STDs Flashcards
STDs that increase risk of HIV (7)
Chlamydia, gonorrhea, bacterial vaginosis, herpes, syphilis, chancroid, Klebsiella granulomatosis
Gonococcal urethritis
Incubation period
Dysuria
Discharge
Less than 4 days
Severe
Profuse yellow / green
Incubation period for nongonococcal (chalmydial) urtheritis
7-14 days
Severity of dysuria w/ gonococcus
Severe. Like peeing out glass shards.
Severity of dysuria w/ non gonococcus
Mild / moderate / intermittent.
Type of male discharge w/ gonococcus
Profuse yellow or green
Type of male discharge w/ nongonococcus
Slight, grey, can be mixed w/ mucous. May only be noticed in underwear upon wakening.
What stain is used for urethritis?
Diagnostic criteria
- Gram stain / methylene blue / gentian violet stain of discharge
- > 2 WBC per oil immersion field + gram neg intracellular diplococci (GNID)
- > 2 WBC per oil immersion field w/o GNID = NGU
Diagnosing urethritis (4)
Discharge seen on exam
Gram stain
Urinalysis: >10 WBC/HPF or positive leukocyte esterase (LE) on first void urine
PCR
Treating urethritis
GC
NGU
- N gonorrhoeae: ceftriaxone + azithromycin or doxycycline (if allergic to azithro)
- NGU: azithromycin or doxycycline
- ALL pxs treated for GC should be treated for Chlamydia
What is most common cause of persistent / recurrent NGU? What do you use to treat?
Mycoplasma genitalium is most common cause of persistent / recurrent NGU. Tx w/ azithro
Follow up for urethritis
Repeat testing in 3 months to check for reinfection.
Complications of urethritis (2)
C teach may cause epididymitis or reactive arthritis
Sxs of cervicitis
- Asymptomatic is common
- Sxs include abnormal vaginal discharge and intermenstrual bleeding (especially after sex). Usually NOT painful (pain may indicate PID).
2 most common causes of cervicitis
Neisseria gonorrheae and Chlamydia trachomatis
Diagnosing cervicitis
2 major
3 others
- Major diagnostic criteria (need at least one): (Muco)purulent endocervical exudate or sustained endocervical bleeding induced by cotton swab through os.
- Others – leucorrhea, gram stain, PCR of cervical / vaginal / urine specimens
- Neg gram stain does not rule out
What must always be done in the case of cervicitis?
Must ALWAYS evaluate for upper tract disease (PID), looking for adnexal / uterine tenderness
Treating cervicitis
- Treatment – same as urethritis
- N gonorrhoeae: ceftriaxone + azithromycin or doxycycline (if allergic to azithro)
- NGU: azithromycin or doxycycline
- ALL pxs treated for GC should be treated for Chlamydia
Follow up for cervicitis
- No test of cure, except for pregnancy or if GC regimen did not include ceftriaxone
- Repeat testing at 3-6 months
What is the #1 bacterial STD in the US?
Chlamydia
Pxs at risk of Chlamydia
Women 2x risk. Women under 25 y/o should be screened yearly.
Most common in ages 15-24. South.
AA’s at highest risk.
Serotypes of Chlamydia
- D-K: urethritis, cervicitis, neonatal infection
* L1-L3: lymphogranuloma venerum (LGV)
Elementary Body vs Reticulate Body
- Elementary body (EB) – Enters & Exits the cell
* Reticulate Body (RB) – Replicates in the cell
Gram stain for Chlamydia
Abundant WBCs but not intracellular diplococci (gonorrhea)
What percentage of pxs w/ Chlamydia are asymptomatic?
Men 42%, women 70%
Sxs of Chlamydia
Men: dysuria, discharge, pruritis
Women: discharge, bleeding, painful sex, dysuria
Both: proctitis
Complications of Chlamydia
Men: epididymitis, prostatitis, reactive arthritis
Women: PID (occurs in 20%), tubal infertility, ectopic pregnancy, chronic pelvic pain
Neonatal inclusion conjunctivitis Other name Cause Onset Treatment
- aka Opthalmia neonatorum
- Caused by Chlamydia
- Acquired during birth. Onset 5-12 days after birth.
- Tx w/ oral erythromycin
Neonatal C trach pneumonia
Onset
Associated sxs
Treatment
- Acquired during birth. Onset w/in 8 weeks.
- 50% of pxs will also have conjunctivitis. Peripheral eosinophilia may be present.
- Tx w/ ORAL erythromycin
Diagnosing Chlamydia
Women (3)
Men (2)
Both (1)
- Women – Mucopurulent discharge from cervix, sustained bleeding via cotton swab through os, always evaluate for PID
- Men – gram stain, UA on first void urine looking for nucleic acids
- PCR for both
Screening for Chlamydia
- Annual screening for sexually active women less than 25 y/o, or > 25 y/o w/ risk factors (new partner, poor condom use, sex work)
- Screening in 3rd trimester for pregnant women
- Annual screening for syphilis, Chlamydia, gonorrhea, and HIV for men at adolescent clinics, STD clinics, jail, or MSM
STD screening for men
Annual screening for syphilis, Chlamydia, gonorrhea, and HIV for men at adolescent clinics, STD clinics, jail, or MSM
Treating Chlamydia
Azithromycin or doxycycline
Follow up for Chlamydia
No test of cure unless pregnant
Repeat testing in 3 months
2nd most common bacterial STD in US
Gonorrhea
Epidemiology of gonorrhea
More common in women.
Age 15-24 is highest.
AA’s at highest risk.
South.
Risk of gonorrhea transmission (male vs female)
- Male → female 50-70% per exposure
* Female → male 20% per exposure
Mechanism of gonorrhea infection
Infects columnar / cuboidal epithelium. Pili help w/ attachment. Internalized, then released via basolateral membrane to disseminate.
What percentage of pxs w/ gonorrhea are symptomatic?
Men 90%
Women only 20%
1 complication of gonorrhea in men
Epididymyitis
How common is pharyngeal gonorrhea?
25% of pxs w/ urogenital gonorrhea. Almost always asymptomatic.
Sxs of anorectal gonorrhea (4)
Pruritis, tenesmus, discharge, bleeding
Disseminated Gonoccocal Infection (DGI)
How common?
Underlying predisposition
2 main syndromes
•Occurs in 1-3% of pxs
•13% of complement deficiency
1) Arthritis Dermatitis - asymmetric polyarthritis, papules / pustules (full of bacteria, contagious)
2) Septic arthritis - Usually involves only 1 joint, most often on knee.
Most common presentation of DGI (disseminated gonococcal infection)
Arthritis-dermatitis
Gonococcal conjunctivitis Onset Prevention Treatment Complication
Occurs 2-3 days after birth.
Prevented w/ erythromycin ointment (does not work for Chlamydia)
Treat w/ ceftriaxone
Untreated may cause blindness
4 neonatal gonococcal diseases
Opthalmia neonatorum (aka gonococcal conjunctivitis)
Scalp abscess
Meningitis
Bacterial sepsis
Diagnosing gonorrhea (3)
- GS / MB / GV (gentian violet) / culture. Look for gram neg intracellular diplococci on gram stain
- PCR: superior to culture in asymptomatic pxs
Screening for gonorrhea (4)
- Annual screening for women less than 25 y/o or > 25 y/o w/ risk factors (new partner, poor condom use, sex work). Same as Chlamydia.
- Pregnant women.
- Annual screening for MSM
Treating gonorrhea
- Treatment – always treat for Chlamydia as well, even if there’s no evidence of it.
- Urethritis / cervicitis: Ceftriaxone + azithromycin or doxycycline (if allergic to azithro)
- Disseminated: hospitalization + AB susceptibility testing. Ceftriaxone + azithro
- GC is often resistant to tetracycline, so azithro is preferred to doxy
Definition of PID
Any combo of cervicitis, endometritis, salpingitis, tubo-ovarian abscess, or peritonitis including peri-hepatitis (Fitz-Hugh-Curtis Syndrome)
Fitz-Hugh-Curtis Syndrome
Direct extension of N gon or C trach from fallopian tube to liver). “Violin strings” seen b/w liver capsule and parietal peritoneum.
Bacteria that cause PID
Polymicrobial: C trachomatis or N gonorrhoeae + normal vaginal flora (Strep agalactiae, H flu, E coli, Bacteroides fragilis, Gardnerella vaginalis)
How common is PID in pxs w/ Chlamydia or Gonorrhea?
10-40% of women w/ C trach or N gon develop PID
Risk factors for PID
- Teenagers, new partner, prior episode of PID, IUD (usually w/in first 3 weeks), douching (changing vaginal flora and pushing bacteria up).
- Pxs w/ HIV have higher rate of tubo-ovarian abscess
Sxs of PID (6)
What percentage are asymptomatic?
- Lower abdominal pain, fever, vaginal discharge w/ foul odor, dysuria, painful sex, peri-hepatitis
- 2/3 are asymptomatic
Diagnosing PID 3 Major criteria Supportive findings Imaging Histo
- High index of suspicion is required. Diagnosis is clinical, not lab-based.
- Major criteria (need at least 1): cervical motion tenderness, uterine tenderness, adnexal tenderness
- Supportive findings: WBC vaginal secretions, mucopurulent cervicitis, cervical friability, fever, high ESR / CRP, lab proof of C trach or N gon
- Transvaginal US may show thickened, fluid filled fallopian tubes
- Endometrial biopsy may show endometritis
Treating PID
- Broad spectrum AB’s against C trach, GC, Strep, enteric GNRs, anaerobes. Start as soon as diagnosis is made.
- Partner notification / testing
- No sex until AB’s are finished
- Repeat testing for Chlamydia and gonorrhea in 3 months
Complications of PID
- Infertility – risk increases w/ each episode (15%, 30%, 60%)
- Ectopic pregnancy and chronic pelvic pain
1 cause of vaginal discharge
Bacterial Vaginosis
Risk factors for BV (4)
New partner, poor condom use, douching, loss of lactobacillus species
Cause of BV
Loss of H2O2 producing lactobacillus → increase in Gardnerella vaginalis and anaerobes.
What does BV increase the risk of? (4)
Increased risk of C trach, N gon, HSV2, HIV
Clinical manifestations of BV (3)
- Vaginal discharge – gray / white, FISHY ODOR (mainly occurs after sex or menstruation)
- NO inflammation of vaginal walls / cervix. No cervicitis or tenderness. If tenderness is present, it may indicate coinfection w/ other STD.
- Pregnancy – All pregnant women should be treated due to association w/ premature rupture of membranes (PROM), early labor, preterm birth, and postpartum endometritis.
Diagnosing BV
- Gram stain is gold standard. Used to determine relative concentration of lactobacilli to other bacteria. However, most physicians use clinical criteria.
- Clinical criteria (3/4 must be met)
- Discharge
- Positive “whiff test” w/ addition of 10% KOH to discharge
- Vaginal pH > 4.5 (due to lack of lactobacilli)
- Clue cells – vaginal epithelial cells coated w/ coccobacilli. “Salt and pepper” appearance.
Treating BV
- Metronidazole or clindamycin
- Avoid sex during therapy
- Male partners do NOT need to be treated
Complications of BV
- Does not cause PID, but is associated w/ PID.
* BV increases risk for post-op infection after gyn surgery
5 infections that cause genital ulcers
H ducreyi (Chancroid) K granulomatis (Donovanosis) Lymphogranuloma venereum (C trach L1-3) T palladum Herpes
Most common cause of herpes transmission
Subclinical shedding
Herpes DNA
Remains episomal. Does not integrate.
Herpes primary infection
Asymptomatic is most common
Ab neg
Herpes non-primary 1st episode
- Ab positive
- Systemic sxs: fever, headache, malaise, myalgia
- Local sxs: pain / itching, dysuria, clear urethral discharge, bloody / purulent vaginal discharge, tender inguinal adenopathy, tender ulcers (eventually crust), proctitis
How common is herpes recurrence?
90% in 1st year for HSV2
55% in 1st year for HSV1
Most pxs have 4-5 recurrences / year
Herpes Diagnosis
- PCR is gold standard
- IgG serology: glycoprotein G1 for HSV1. Glycoprotein G2 for HSV2.
- Culture – lower sensitivity than PCR. May see cytopathic effects.
- Tzanck prep – Shows giant cells w/ intranuclear inclusions. Rarely used anymore. Can’t differentiate b/w HSV and VZV.
Tx for pregnant women w/ prior history of herpes
Acyclovir at 36 weeks
Complication of herpes
Increased risk of HIV. Neonatal herpes may be lethal.
Syphilis epidemiology
Much more common in males, especially MSM.
Western / southeastern US
Age 20-29 is highest
Syphilis associated with?
HIV
Syphilis mechanism of invasion
Spirochete – penetrates skin, enters blood / lymphatics to disseminate. Lesions occur in areas with >10^7 organisms / mg tissue.
Hallmark pathologic lesion of syphilis
Obliterative endarteritis
Primary syphilis
- Chancre - painless ulcer, often unnoticed. Multiple if immunocompromised. Heal in 2-8 weeks if untreated.
- Lymphadenopathy
Secondary syphilis (5)
- Constitutional sxs: fever, chills, malaise, poor appetite
- Maculopapular / pustular rash – red / pink, 3-10 mm. Start on trunk / proximal extremities and then spread. Hallmark is on the palms / soles.
- Alopecia of scalp, eyebrows, beard. May be patchy.
- Mucous patches – superficial painless erosion of tongue / lips
- Condyloma lata – painless plaques in intertriginous areas
Tertiary syphilis
- 1/3 of untreated pxs
- Progressive neural / vascular destruction 5-30 years after infection
- Neuro: meninges, brain, eye, ear damage
- Argyll Robertson pupil - Small irregular pupil that accommodates to near vision but does not react to light
- Aneurysm of ascending aorta
- Gummatous: granulomatous inflammation / destruction of bones and mucocutaneous tissues.
Syphilis in pregnancy
- All pregnant women should be screened for syphilis early in pregnancy. Transmission may occur at any time during pregnancy, but is most common early when spirochetemia is most common.
- May result in abortion, still birth, neonatal death, or neonatal disease.
Diagnosing Syphilis
Serology is gold standard
PCR, DFA
Cannot be cultured
Syphilis serology
- Non-treponemal tests: VDRL and RPR are used for screening. If positive, use FTA (fluorescent trichonemal Ab) test. These are also used for monitoring response to therapy.
- Positive diagnosis requires positive nontreponemal and treponemal tests
- Follow efficacy of treatment w/ nontreponemal tests. Don’t use treponemal tests b/c these are positive for life.
Treating syphilis
Testing partners?
- Penicillin is DOC for all stages, even in allergic pxs (desensitize first)
- RPR or VDRL titers are monitored periodically. 4 fold or 2-dilution is significant.
- Partners w/in last 90 days should be presumptively treated. > 90 days should be tested.
Chancroid Cause / morphology Sxs Diagnosis Treatment
- Haemophilus ducreyi. Gram neg coccobacillus.
- Papules → Pustule → Central necrosis → Painful ulcer with ragged & undermined edges that easily bleeds.
- 50% of pxs have enlarged inguinal LN’s (bubos). Usually unilateral. May rupture spontaneously.
- Diagnosis is clinical. Must meet all 4 criteria: at least 1 painful ulcer, looks like a chancroid, no evidence of syphilis or HSV
- Treatment – azithromycin or ceftriaxone
Donovanosis Scientific / unscientific name Morphology / tropism of bug Sxs Diagnosis Treatment
- Klebsiella granulomatis / Granuloma inguinale
- Encapsulated GNR that infects mononuclear cells
- Papule → painless beefy red ulcer with rolled edges and easily bleeds on contact. Usually on penis or labia (not vagina / cervix). No LAD. No bubos. No constitutional sxs. Untreated may cause extensive scarring / lymphatic obstruction → elephantiasis.
- Diagnosis – Clinical appearance and Donovan bodies (bacteria) in mononuclear cells
- Treatment – azithromycin for > 3 weeks.
Lymphogranuloma venereum (LGV)
Cause
Diagnosis
Treatment
- Caused by C trachomatis serovars L1-3
- Diagnosis – clinical presentation, serology, PCR
- Treatment – doxycyclin + / - bubo aspiration
3 stages of LGV
- I (primary): painless papule / ulcer. Self-limited. Often unnoticed.
- II (secondary): painful bubo (usually unilateral; may be above and below the inguinal ligament, known as the GROOVE SIGN).
- III (tertiary): fibrosis / scarring, possible elephantiasis, destruction of external genitalia
What is the most common STD in the US?
HPV
75% of Americans
90% are asymptomatic
Recurrent Respiratory Papillomatosis
HPV 6 / 11 transmitted at childbirth. Altered cry, hoarseness, stridor, respiratory distress.
How long do most HPV infections last?
Most are cleared w/in 2 years
Which HPV genotypes cause warts vs cancer?
6/11 cause warts. No integration.
16 / 18 cause cervical cancer. Does integrate.
Condyloma acuminata
Anogenital warts.
Mainly HPV 6 / 11.
Hyperkeratotic, exophytic papules.
15% of pxs have spontaneous remission in 3-4 months.
HPV Diagnosis
- Anogenital warts – visual inspection
* Cervical HPV infection: pap smear, acetowhitening, colposcopy, biopsy
Pubic lice Bug Sxs Diagnosis Treatment
- Pediculosis pubis
- Pxs notice nits or itching.
- Diagnose by physical exam.
- Tx w/ permethrin 1% cream or pyrethrins (wash off after 10 min)
- Decontaminate bedding / clothing by washing in hot water or dry cleaning
- Tx parters from last 30 days
Scabies Bug Transmission Sxs Treatment
- Sarcoptes scabiei
- Often sexually acquired in adults
- Itching – often worse at night. Hypersensitivity to mite Ags
- Nodules – dark / tender, usually on penis / scrotum. Burrow seen on top.
- Tx w/ permethrin 5% cream applied to entire body neck down (wash off after 8-14 hrs)
- Decontaminate just like lice
- Tx partners from last 30 days
Crusted scabies
Treatment
•Immunocompromised pxs may develop severe form called crusted scabies. Tx w/ Ivermectin.
STDs that can be transmitted via pregnancy (7)
Chlamydia, GC, herpes, syphilis, HIV, Hep B / C, HPV
Non-STD infections that can be transmitted via pregnancy (4)
CMV, Toxoplasma, Rubella, and group B strep
3 common causes of vaginitis
Treat partner?
- BV (most common), vulvovaginal candidiasis, Trichomonas vaginalis
- Partner does not need to be treated for VVC or BV. Yes for Trichomonas.
Which herpes viruses cause meningitis / encephalitis
HSV2 may cause meningitis (photophobia). HSV1 is more likely to cause encephalitis.
