STDs Flashcards
1
Q
etiology of chlamydia
A
- chlamydiaceae trachomatis
- obligate intracellular w/ gram negative like cell wall
2
Q
MC infected w/ chlamydia
A
AA females 15-24 yo
3
Q
different serotypes of chlamydia
A
- A, B, C: trachoma (eye)
- D-K: mucosal surfaces
- L1, L2, L3: lymphogranuloma venerum (LGV)
4
Q
lymphogranuloma venerum (LGV)
A
- small, often asx genital skin lesion then regional lymphadenopathy in groin/pelvis
- Lesions heal with scarring, can have persistent sinus tracts
- Severe proctitis if aq. via anal sex
- Same dx testing as general
- Tx: Doxy 100 mg PO BID X 21 days or erythromycin 500 mg PO QID X 21 days
5
Q
Transmission of chlamydia
A
- Mucosal contact: vag, oral, anal sex
- Highly contagious (partner infection rate >50%)
- Can pass sexual (genital) or vertical (perinatal)
- Perinatal: neonatal conjunctivitis or pneumonia
- Increases risk of acquiring HIV d/t mucosal inflammation
- Sig asymptomatic carriers
- Reinfection common
6
Q
Chlamydia screening
A
yearly if sexually active and <25 yo
7
Q
S/S of chlamydia in women
A
- Cervicitis: clear to thick yellow discharge and abnl vag bleeding
- Urethritis: dysuria-pyuria (but no wbc), abd pain, fever
(80% asymptomatic)
8
Q
S/S of chlamydia in men
A
- > 50% asx
- Urethritis MC: clear, yellowish, white discharge. Dried secretions at urethral meatus
- Proctitis, dysuria, urinary freq or urgency
- Complications: epididymitis and reactive arthritis
9
Q
PE of chlamydia
A
- Female: thick, mucopurulent discharge in cervical os
- Male: mucoid/watery urethral discharge
10
Q
Labs for chlamydia
A
Nucleic acid amplification tests (NAATs) PCR DNA probe
- urine or bodily fluid
- MC used, very accurate
Culture/gram stain
- Culture swab from site of infection
- Tx empirically, can take 24-48 hrs for results
ELISA
- looks for antigens to pathogen
- less accurate than culture but second most specific
11
Q
Tx of chlamydia
A
- Azithromycin: 1 g once (not for QT prolongation, meds for arrhythmia)
12
Q
Special points to note about chlamydia
A
- Must report to health dept
- If exposed or you think positive, treat!
- Treat all sex partners if have had sexual contact during 60 days preceding onset of sx/dx
- Abstain from sex 7 days after last day of tx
- Check for gonorrhea – 40%F and 20%M co infected
- Retesting recommended 3 mos after therapy d/t high rates reinfection
- MSM screened annually for urethral or rectal infection
- MSM + HIV or risky behavior = 3 month screening
13
Q
PID associated with chlamydia
A
- from ascending infection
- Chronic abd pain d/t adhesions of ovaries and fallopian tubes
- Inc chance of ectopic preg X7-10
- Untreated = fertility
- Fitz-Hugh-Curtis sx: (inflammation of liver capsule, RUQ pain, abnl LFTs)
- Reactive arthritis
14
Q
Reiter syndrome / reactive arthritis d/t chlamydia
A
- 2 to immune-mediated response to chlamydia
- Sx: asymmetric polyarthritis, urethritis, conjunctivitis
- RF/HLA-B27 negative
- “can’t see, can’t pee, can’t climb a tree”
15
Q
etiology of gonorrhea
A
- neisseria gonorrhoeae
- gram neg. diplococci
- incubation 1-14 days or 2-5 days
16
Q
MC infected w/ gonorrhea
A
15-24 yo F
17
Q
transmission of gonorrhea
A
- Mucosal contact during vaginal, oral, anal sex
- can affect any part of body/organs/mucous membranes
- Easy transmission: single encounter with infected partner = infection 50-70% of the time!
18
Q
screening of gonorrhea
A
Annual if sexually active & <25 yo
19
Q
S/S of gonorrhea in female
A
- most asx
- urethritis
- cervicitis
- thin, purulent**, mild odor discharge
20
Q
S/S of gonorrhea in male
A
- most sx urethritis: burning on urination, purulent/mucopurulent discharge
- Acute epididymitis: unilateral testicle pain/swelling, prostatitis, cystitis
21
Q
other sx associated w/ gonorrhea
A
- Rectal: often asx. Rectal pain, pruritis, tenesmus, rectal discharge. Bloody diarrhea. Rectal infection
- Oropharyngeal: often asx, can cause mild-severe dysphagia and discomfort
- Eye: most often unilateral if 2 to self-inoculation, purulent discharge, conjunctivitis, can = blindness
22
Q
Labs for gonorrhea
A
same as chlamydia
23
Q
tx of gonorrhea
A
Dual therapy:
- Rocephin 250 mg IM once + Azithromycin 1 gm PO once
- Alt: cefixime + azithromycin
- pain relief for epididymitis, PID, DGI
24
Q
special points to note about gonorrhea
A
- Must report to health department
- If exposed or you think positive, treat!
- Screen if asx but partner known infection
- Untreated can lead to accessory gland infection (Bartholin, skene)
- PID
- Fitz-Hugh-Curtis sx (inflammation of liver capsule, RUQ pain, abnl LFTs)
- Test of cure not necessary with dual treatment, is recommended if used alt meds
25
Disseminated Gonorrhea Infection (DGI)
- d/t untreated gonorrhea that spreads to blood
- arthritis, tenosynovitis, dermatitis + any of the following:
• Fever
• Skin change: rash on torso, limb, palm, sole. Abscess formation
• Joint: polyarthralgia, purulent arthritis (knee MC)
• CNS: meningeal sx, decreased mental status
• Cardiac: murmur, tachy, endocarditis, embolic lesions
26
Tx of DGI
Ceftriaxone 1 g IM and Azithromycin 1 g PO daily X 7 days
27
Etiology of trichomonas
- T. vaginalis
- oval shaped, flagellated protozoa (swimming football)
- Incubation days to weeks
28
screening for trchomonas
Screen all positive pts for other STIs
29
Transmission of trichomonas
- F
- M
- Women: vagina, cervix, urethra, bladder, Bartholin and Skene glands
- Men: anterior urethra and prostate
30
S/S of trich in women
- 70% sx
- copious, frothy, watery, yellow-green vag discharge
- dysuria
- vag irritation
- Vulvar edema
- +/- abd pain
- Strawberry cervix**
31
Labs for trich
- Wet mount prep: visualize T. vaginalis on slide
- Culture
- NAAT
- DNA probe
32
Tx of trich
- Metronidzaole 2 g PO Once (avoid etoh)
Alternatives:
- Metro 500 mg PO BID X 7 days
- Tinidazole 2 g PO once
33
Special points to note about trich
- Complications: PID
- Pregnancy: 30% more likely to deliver preterm or low birth weight infant. Avoid metronidazole in first trimester (teratogenic risk)
- Recommend retest sexually active women 3 months after treatment
- Up to 53% women with HIV also have t. vaginalis. Screen at initial HIV visit, cure rate better with Metro 500 mg BID x 7 days
34
etiology of syphilis
- Treponema pallidum
- spirochete bacterium (corkscrew-shaped)
- Must use dark field microscopy
35
transmission of syphilis
- Dz progresses in stages
- Congenital transmission = congenital syphilis
- MSM are majority of new cases, higher rates of abx resistance
- Enters body via abrasions on skin/mucous membranes during sexual contact OR transplacentally during pregnancy
- Disseminates via circulatory system (incl. lymph)
- CNS invasion may occur in any stage
36
primary syphilis infection
- Ulcer or chancre on penis or vagina
• Painless, indurated, clean base. Can have multiple lesions
• Highly infectious but heals spontaneously within 3-6 weeks
- Most contagious stage (primary and secondary)
37
secondary syphilis infection
- Secondary lesions several weeks after primary chancre, may persist weeks to months
- Mucocutaneous
- Manifestations
• Skin rash – nickel/dime sized, generalized over body, palms/soles
• Lymphadenopathy 50-80%
• Malaise, alopecia
• Condylomata lata***
- Serologic tests usually highest titer
38
Tertiary (late) syphilis infection
- approx. 30% untreated progress within 1-20 years
- Rare bc of abx
- Mannifestations:
• Gummatous lesions***
• Cardiovascular syphilis
39
Latent syphilis infection
- Host suppresses infection, no lesions clinically apparent
- Only evidence is positive serologic test
- Occurs between 1 and 2 stage, between 2 relapses, after 2 stage
- Early latent < 1 year duration
- Late latent ≥ 1 year duration
40
Neurosyphilis infection
- Invasion of CNS
- Can occur at any stage, may occur decades after infection
- Can be asx
- Tabes dorsalis
41
Congenital syphilis
- May = stillbirth, neonatal death, infant disorder (deaf, neuro impairment, bone deformities)
- May occur during any stage of syphilis, risk higher during primary and secondary
- Fetal infection can occur at any trimester
- Spectrum of severity
• Only severe cases clinically apparent at birth
• Early lesions (MC): <2 yo, usually inflammatory
• Late lesions: >2 yo, usually immunologic and destructive
- Hutchinson teeth, palate deformities
42
Dx of syphilis
- Hx and PE
- Biopsy: direct visualization of spirochete from lesion exudate or tissue
via dark field microscopy
- Tertiary: LP with VRDL
43
Blood tests for syphilis
- treponemal
- RPR
- VDRL
- FTA-ABS
- MHA-TP
44
treponemal test for syphilis
qualitative, measures ab vs. T. pallidum ag
45
RPR blood test
- faster than VDRL
- detects ab vs cardiolipin-lecithin-cholesterol antigen****
- NOT specific for T. pallidum
- positive or negative screen
- + within 7 days of exposure
- Titer decrease with time +/- tx
46
VDRL blood test
- slower than RPR
- stndrd for CSF testing
- same ab as RPR
- reported as ratio (1:4)
- 4 rise = active infection***
- failure of titer to dec 4X is new infection or tx failure
47
FTA-ABS or MHA-TP tests
- very specific, confirms positive RPR or VDRL
| - Neg test of CSF excludes neurosyphilis
48
Tx of primary, secondary and early latent syphilis
- Benzathine penicillin G 2.4M units IM once
- Penicillin allergic:
• Doxy 100 mg PO BID X 14D
• Tetra 500 mg PO QID X 14D
49
Tx of late latent and tertiary syphilis
- Benzathine penicillin G 2.4M units IM once weekly X 3 weeks
- Penicillin allergic:
• Doxy 100 mg PO BID X 28D
• Tetra 500 mg PO QID X 28D
50
Tx of neurosyphilis
- Aqueous crystalline penicillin G IV q 4hr or continuous IV infusion 10-14D
- compliance ensured: procaine penicillin IM daily X 10-14D + Probenecid 500 mg PO QID X 10-14D
51
Jarisch-Herxheimer Rxn
self-limited rxn to antitreponemal therapy
- fever, malaise, nv, chills, exacerbation of secondary rash
- within 24 hrs of tx
- NOT allergic rxn to penicillin
- MC after tx with penicillin and tx of early syphilis
52
infection/etiology of chancroid
- Haemophilus ducreyi: Gram-neg streptobacillus
- Bacteria via sexual contact
- incubation: 1-2 days after intercourse
- Small bump – ulcer in one day
- uncommon in US
- MC developing countries, low socioeconomic areas, commercial sex workers
53
S/S of chancroid
- Painful ulcer
- 3-50 mm diameter
- Shaft penis/labia
- M – once ulcer
- F – multiple ulcers
- tender suppurative inguinal adenopathy
- soft edges
- base covered with gray or yellowish-gray material
- bleeds easily if scraped
54
Dx of chancroid
- Culture lesion: definitive dx
- Combo of painful genital ulcer and tender suppurative inguinal adenopathy suggests dx of chancroid
- r/o syphilis:
• t. pallidum with darkfield microscopy
• Neg serologic tests
- Neg HSV PCR and HSV culture if ulcer
55
Tx of chancroid
- Azithromycin 1 g PO once
- Ceftriaxone 250 mg IM once
- Ciprofloxacin 500 mg PO BID X 3D
- Erythromycin 500 mg PO TID X 7D
56
Special points to note about chancroid
- f/u 3-7days after tx initiation
- Tx partners regardless of sx (all pt 10 days before lesion appeared)
- Can scar
- No documented adverse rxn while pregnant
- Common in HIV pts, if dx chancroid, test for HIB
57
in comparing chancre vs. chancroid, what characteristics do they share?
- Pustules at site of inoculation, progress to ulcerated lesions
1-2 cm diameter
- Appear on genitals of infected pts
- Present at multiple sites and with multiple lesions
58
in comparing chancre vs. chancroid, how do they differ?
Chancre:
- Painless
- Non-exudative
- Hard (indurated) edges
- Heal spontaneously w/in 3-6 weeks, even w/o tx
Chancroid:
- Painful
- Grey or yellow purulent exudate
- Soft edge
59
infection/etiology of genital herpes
- Herpes simplex virus 1 and 2
- leading cause of genital ulcer dz
- HSV-1: MC cold sore/fever blister
- HSV-2: MC genital herpes
* * but either can cause lesions in all locations!
- Chronic, life-long
- Can xmit from asx host
60
Risk factors for genital herpes
```
Genital HSV-2:
- F>M, AA, older age
- Higher with more sexual partners
Genital HSV-1:
- Young women (college students)
- MSM
```
61
transmission of genital herpes
- Close contact with person shedding virus at mucosal /epithelial surface or genital/oral secretions
- genital:genital, oral:genital, genital:oral
- HSV2: MC asymptomatic shedding, often person unaware infected
62
S/S of herpes
- Often asx
- Primary infection/outbreak 2D to 2W after intercourse
- Primary outbreak most diffuse and painful
- Considered primary if infected with HSV1 or 2 and NO ab of either type
- Ab appear 12 weeks after
- Decr appetite, fever, malaise, musc ache, groin lymphadenopathy
63
S/S of primary genital herpes
- Severe, multiple, bilateral genital ulcers
- Prodrome before outbreak
- Blisters break, leave painful, shallow ulcer. Crust over and heal 7-14D
- dysuria
- Vag/urethra discharge
- Tender inguinal adenopathy
- F: shedding from cervix in 80-90% primary infections. Cervix appears abnl with ulcerative lesions, erythema, friable
- Infection of urethra/meatus = clear
64
S/S of non-primary genital herpes
- HSV1 or 2 infection w/ pre-existing ab to the other strain
- Milder than primary (cross immunity protection)
- weeks to months after primary
65
Dx of herpes
- Viral culture
- PCR for HSV DNA
- IG testing for either strain
IgG – old infection
IgM – new infection
- Tzanck Test
Scrape vesicle base to look for Tzanck cells*** (giant cells with multiple nuclei). Stain with Wright’s stain
66
Tx of primary herpes
- Acyclovir 400 mg PO TID X 7-10D
- Acyclovir 200 mg PO 5 times a day X 7-10 days
- Famciclovir 250 mg PO TID X 7-10D
- Valacyclovir 1 g PO BID X 7-10D
* extend tx if no improvement in 10 days
67
Tx of secondary herpes
- Acyclovir 400 mg PO TID X 5-10D
- Famciclovir 500 mg PO BID X 5-10D
- Valacyclovir 1 g PO BID X 5-10D
68
suppression tx of herpes
- Acyclovir 400-800 mg PO BID-TID
- Famciclovir 500 mg PO BID
- Valacyclovir 500 mg PO BID
69
Special points to note about herpes
- Sexual transmission thought to be higher from M → F than F → M
- Can be transmitted perinatally at time of delivery (mucosal or skin contact)
- Fomite transmission is unlikely, autotransmission can occur from genital to other mucocutaneous sites, fingers, eyes’
- Can get Herpetic whitlow (fingers)
70
Severe HSV
- Hospitalization + IV acyclovir if: severe, complications (disseminated infection, pneumonitis, hepatitis), CNS complications
- Followed by outpt PO antivirals for min 10 days total therapy
71
HSV counseling
- Inform current and future partners
- Can transmit during asx periods
- Remain abstinent with uninfected partners when lesions or prodromal sx are present
- Male latex condoms might reduce risk of transmission
72
Pregnancy and HSV
- Transmission is high if mom is infected at time of delivery (30-50%)
- Transmission is low for moms with hx of HSV on suppression meds during delivery
- 3rd trimester, abstain from sex with people known to be infected
- CAN deliver vaginally w/o sx or prodrome
- C-section if lesions at onset of labor
- Acyclovir is drug of choice during pregnancy
73
infection/etiology of HPV
- Many sub types,
- Type that causes warts ≠ the kind that causes cancer
- Type 6 & 11 90% of warts
- 27% sexually active people, 45% between 14-19 yo
- Onset 4 mo after contact
74
transmission of HPV
- Highly contagious (contact = 70% chance will be infected)
- Spread via skin-to-skin contact
- Viral particles penetrate skin and mucosal surfaces through microscopic abrasions in genital area
75
S/S of HPV
- Occur in clusters
- Very tiny to large masses (condyloma acuminate)
- Look like small stalks:
F: outside (MC)/inside vagina, cervix, anus
M: tip of penis, shaft, scrotum, anus
Rare: in mouth/throat
76
Dx of HPV
- PE
- acetic acid turns condyloma white = positive
- Biopsy
77
Tx of HPV
- $$ and not always effective
- Podofilox cream – 1st line
- Aldara – alt option
- Liquid nitrogen cyrotherapy
- Derm referall
78
Cervical CA associated w/ HPV
- Strains 16 & 18 cause about 70% of cancers.
- 27,000 affected ea year
- Cervical, vaginal, vulvar cancer in W, penile ca in men. Also anal and throat cancer
- Almost all cervical cancer is caused by HPV
79
HPV vaccine
- Rec for preteen boys and girls 11-12, protection prior to virus exposure.
- Series of shots over several months
Gardasil:
- HPV 6, 11, 16, 18
Gardasil 9:
- Same as Gardasil + high risk strains: 31, 33, 45, 52, 58
Cervarix:
- HPV 16 & 18
- No coverage vs. genital wart strains
80
what is the MC gyn complaint?
vaginosis
81
MC causes of vaginosis
* Trichomonas vaginalis
* Candidiasis
* Bacterial vaginosis
* Atrophic vaginitis
82
nl vaginal pH (postmenarchal and premenopausal)
3. 8 - 4.2
| * if disturbed = overgrowth of pathogens
83
factors that alter the vaginal environment
```
• Fem hygiene products
• Contraceptives
• Vag medications
• Abx
• STIs
• Sexual intercourse
• Stress
- Recurrent infections → irritiation, excoriation, scarring → sexual dysfunction & facilitation of transmission of other STIs
- Psychosocial/emotional stress common
```
84
S/s of vaginosis
- Irritation of genital area
- Discharge: white, gray, watery, foamy
- Inflammation of labia minora/majora & perineal area
- Dysuria
- Dyspareunia
- Foul/fishy vaginal odor
85
infection/etiology of bacterial vaginosis
- Gardnerella vaginosis MC
| - NOT STI but caused by sexual intercourse
86
RF for bacterial vaginosis
```
- F partners of F with BC 80% chance of infection
• Rough sex
• Douching
• Hot baths
• Frequent intercourse
• Change in sex partner
• Cunnilingus
• Concomitant STIs
• Pregnancy
```
87
S/S of bacterial vaginosis
- Thin white or gray discharge
- Foul fishy odor
- Clue cells (globs of bacteria stuck to vaginal cell walls)
- Dysuria, vaginal erythema, irritation, pruritis
- Positive “whiff test” when vaginal discharge combined with KOH
- Vag pH >4.5
88
Dx of bacterial vaginosis
Saline wet mount (wet prep):
- Vag discharge on slide with NaCL
- Clue cells: vag epithelial cells with rods and cocci bacteria
- decrease number lactobacilli
- no WBCs***
KOH prep:
- Vag discharge on slide with 10% KOH
- Whiff test: fish odor dt release of amines = positive test
89
Tx of bacterial vaginosis
- Metronidazole
- Clindamycin gel
- Recurrent: standing orders
90
infection/etiology of vaginal candidiasis
- Candida species (MC C. albicans)
| - NOT STI but seeded by a man
91
RFs of vaginal vandidiasis
* Oral contraceptive use
* IUD
* Young at first intercourse
* Frequent intercourse
* Cunnilingus
* DM
* HIV, immunocompromised-
* Abx use
* Pregnancy
92
S/S of vaginal candidiasis
- Vulvar/vaginal erythema/swelling
- Burning and itching**
- Curd-like vaginal discharge** (vomit)
- Vulvar dysuria** – burning when urine in contact with vulva skin
- Cervix appears nl
- Dyspareunia
93
Dx of vaginal candidiasis
Saline wet mount (wet prep):
- hyphae and budding yeast
KOH prep:
- budding yeast and hyphae easier to see bc KOH kills bacteria
94
Tx of vaginal candidiasis
- Diflucan 150 mg PO once
| - repeat in one week of no improvement
95
infection/etiology of PID
- Orgs ascending to upper female genital tract from vagina/cervix
- MC pathogens:
Chlamydia trachomatis
Neisseria gonorrhoeae
96
prevention of PID
- education/counseling
- Change in sexual behavior
- Use of prevention services
- Effective dx, tx, counseling
- Eval, tx, counseling of partners
97
RFs for PID
- Young
- Multiple sex partners
- IUD
- Hx of PID
98
complications of PID
- Sepsis
- Ectopic pregnancy
- Tubal occlusion with infertility
- Fitz-Hugh-Curtis sx
99
S/S of PID
- Abd pain
- Vag discharge
- Low back pain
- Irregular vaginal bleeding
Pelvic exam:
- Cervical motion tenderness****
- Mucopurulent cervical discharge
- Uterine tenderness
- Adnexal tenderness (bilateral)
- Toxic sx: fever, nv, severe pain
100
Dx. of PID
Urinalysis:
- r/o cystitis and pyelonephritis
Cultures:
- Gonorrhea and chlamydia
Pregnancy test:
- Preg until proven otherwise
- PID is MC incorrect dx of ectopic pregnancy
- PID rare in pregnancy but can occur in first 12 weeks gestation
Wet prep:
- PID rare without coexisting purulent endocervical infection
- Look for numerous WBCs
101
Tx of PID
- Doxycycline
- Azithromycin
- If tubual/ovarian abcess – include clindamycin or metronidazole
- Remove IUD if present
