STDs-Shapiro Flashcards
1
Q
T/F There is a test to check for all STDs.
A
False.
2
Q
T/F Women tend to have fewer symptoms than men & seek care later for STDs & therefore have greater complications.
A
True.
3
Q
Which is more common transmission?
Men–>Women
Women–>Men?
A
Men–>Women
4
Q
Diseases characterized by urethritis & cervicitis.
A
Gonococcal infections
Chlamydial infections
Nongonococcal urethritis
5
Q
Diseases characterized by vaginal discharge.
A
Bacterial Vaginosis
Trichomonasis
Vulvovaginal Candidiasis
6
Q
Diseases Characterized by Ulcerations.
A
Chancroid and Syphilis
Genital herpes Infections (HSV-2 and HSV-1)
Granuloma inguinale
7
Q
Other genitourinary infections?
A
pelvic inflammatory disease–catch it b/c can cause sterility.
Genital warts–is it HPV? think of cancer.
8
Q
What is the most common STI in men & women?
A
urethritis & cervicitis
urethral inflammation
either gonococcal or nongonococcal
**can have more than 1 type.
9
Q
What is gonococcal urethritis caused by?
A
N. gonorrhea
10
Q
What is nongonococcal urethritis caused by?
A
Chlamydia trachomatis (20-50%) Ureaplasma urealyticum (20-80%) Mycoplasma genitalium (10-30%) Trichomonas vaginalis (1-70%)
11
Q
Give characteristics of gonococcal urethritis.
A
gram neg. non-motile non-spore forming diplococci oxidase-pos. found w/i neutrophils requires CO2, special media can't use cotton swabs (fatty acids inhibit this)
12
Q
What are the clinical features of gonococcal urethritis?
A
affects urethra birth--eye of infant incubation period: 2-5 days intense burning, fever, malaise can be clear or purulent discharge sometimes asymptomatic
13
Q
What does gonococcal urethritis present like in women?
A
can be asymptomatic
urethritis symptoms–scanty, mucopurulent cervical discharge, vaginal pruritis, dysuria
primary site–endocervical canal
14
Q
What are some complications of gonococcal urethritis?
A
disseminated gonoccocal infection acute arthritis-dermatitis syndrome gonococcal arthritis!!! endocarditis meningitis
15
Q
If you suspect a man has urethritis, what do you test them for?
A
gonorrhea
chlamydia
if gram stain is neg. for gram neg. diplococci then they don’t have gonorrhea.
16
Q
T/F Do the same gram stain for cervix as you do for urethritis in men suspected to have N. gonorrhea infection.
A
False. Different for cervix.
17
Q
Which is more common–culture or PCR/nucleic acid amplification?
A
molecular testing more common now.
18
Q
What is the treatment for gonococcal urethritis/cervicitis?
A
ceftriaxone (one injection) w/ azithromycin or doxycycline (oral pills-chlamydia)
test for other STDs
recommend cessation of sexual activity until clearing of STD.
treat both partners!!
19
Q
What are the symptoms of a local infection of chlamydia in men? Complications?
A
conjunctivitis urethritis prostatitis proctitis More rare complications: Reiter's syndrome, epididymitis, chronic arthritis, infertility
20
Q
What are the symptoms of a local infection, complications of chlamydia in women?
A
conjunctivitis urethritis cervicitis proctitis Complications: endometritis salpingitis perihepatitis reiter's syndrome infertility ectopic pregnancy chronic pelvic pain chronic arthritis
21
Q
What are the symptoms of chlamydia in infants?
A
conjunctivitis pneumonitis pharyngitis rhinitis Complications: chronic lung disease
22
Q
How do you check for chlamydia?
A
requires living cells to penetrate & multiply
gram neg. obligate intracellular bacterium that preferentially infects squamo-columnar epithelium.
incubation period: 1-3 weeks.
23
Q
What are the symptoms of chlamydia?
A
low grade urethritis w/ moderate mucoid or mucopurulent urethral discharge & variable dysuria
24
Q
What can ureaplasma urealyticum cause?
A
Transmitted by sexual contact.
In males causes urethritis, proctitis
In females causes cervicitis & vaginitis
25
What can mycoplasma genitalium cause?
Accounts for 30% of sexually transmitted urethritis.
More common organism in C. trachomatis negative urethritis.
Common in recurrent urethritis.
26
What adenovirus/HSV cause?
viral urethritis
27
What is cervicitis?
inflammation of cervix from gonorrhea or chlamydia
**can be acute or chronic
antibiotics treat
28
What are the 2 cells types of the cervix?
Cervix has two types of cells: flat, squamous cells and glandular cells, which secrete mucus
29
What is acute cervicitis?
Two major diagnostic signs of acute cervicitis:
A purulent and mucopurulent endocervical exudate visible in the endocervical canal
Sustained cervical bleeding easily induced by gentle passage of a cotton swab through the cervix
May be asymptomatic but some women complain of an abnormal vaginal discharge and intermenstrual vaginal bleeding.
30
How do you diagnose acute cervicitis?
mucopurulent cervicitis is defined as gross evidence of purulent material from an inflamed cervix along with 10 or more polymorphonuclear (PMN) leukocytes per microscopic field (oil immersion).
31
What's the deal with chronic cervicitis?
Leukorrhea may be the main symptoms, purulent-variable in color.
Other signs: bleeding, itching, irritation in the external genital; pain during intercourse.
Cervical polyps: small, smooth, red, fingerlike growth in the passage extending from the uterus.
32
What are some diseases characterized by vaginal discharge?
Bacterial Vaginosis
Trichomonasis
Vulvovaginal Candidiasis
33
What's the deal with bacterial vaginosis?
A condition where the normal balance of bacteria in the vagina is disrupted and replaced by an outgrowth of certain bacteria. It is accompanied by discharge, odor, pain, itching and burning.
BV can be diagnosed by the use of clinical criteria or Gram stain. Clinical criteria requires three of the following:
Homogenous, thin, white discharge that smoothly coats the vaginal wall.
Presence of clue cells (epithelial cells with borders obscured by small bacteria.
pH of the vaginal fluid >4.5
Fishy odor of vaginal discharge before or after addition of 10% KOH (whiff test).
34
How is BV transmitted?
Females with no sexual exposure-significantly lower prevalence.
Women who use condoms- decreased prevalence of BV.
Women with new or multiple sex partners have higher prevalence of BV.
Gardnerella vaginalis has been detected as one of a number of the causative agents of BV.
Decrease or absence of Lactobacillus spp. causes increase in pH.
Overgrowth of anaerobes associated with increased enzymes that breakdown vaginal peptides into amines, which cause malodors.
35
How do you go about diagnosing vaginal discharge?
wet mount
culture of vaginal secretions
DNA probe
36
What shows you that you have BV on a wet mount?
clue cells--epithelial cells w/ bacteria.
| 20% for diagnosis.
37
What causes trichomoniasis?
Caused by Trichomonas vaginalis, a flagellated protozoan parasite with numerous strains, some more virulent than others.
38
How does trichomoniasis present in women? men?
Many infected women have symptoms characterized by a diffuse, malodorous, yellow green vaginal discharge with vulvar irritation.
In males, colonizes male urethra-mostly asymptomatic but can cause NGU.
39
What are the signs/ symptoms of trichomoniasis?
Increased vaginal discharge, often profuse (extremely frothy, foul smelling).
Vaginal Itching, irritation and pain.
Patchy redness on the genitals including labia and vagina.
Painful dysuria, if urine touches the inflamed tissues.
Trichomonads can be cultured and identified with rapid assays; often seen on Pap smear
Vaginal pH >5.0
DNA probes.
40
What's the deal with vulvovaginal candiasis?
Most commonly caused by C. albicans (80 to 90% of the time), though other species such as C. glabrata and C. tropicalis are also seen.
10 to 20% of women have asymptomatic colonization with C. albicans.
Symptoms include pruritis, dysuria, and thick curdy discharge
Not a sexually-transmitted infection
41
How do you diagnose candidiasis?
KOH wet mount is best means of diagnosis, specificity of 97%.
Vaginal cultures: can be performed in patients with persistent or recurrent symptoms.
Recurrent infection is defined as four or more infections in one year.
Oral and topical therapies have equal efficacy rates.
42
3 most common causes of vaginitis?
1. BV
2. candidasis
3. trichomoniasis
43
causes of genital ulcers?
Chancroid: Haemophilus ducreyi Syphilis: Treponema pallidum
Genital HSV Infections: HSV-2 and HSV1
Granuloma inguinale: Klebsiella granulomatis
44
What's the deal with chancroid?
Caused by Haemophilus ducreyi (difficult to isolate).
| A papule develops initially but goes on to erode into a painful ulcer.
45
different stages of syphilis? treponema palladium
primary-chancre, local lymph nodes
secondary--see in skin, rashes, fever, malaise, LAD
tertiary--cardiovascular, neuro
congenital
46
when is syphilis most contagious? How is it transmitted?
sexually & vertically
| most contagious during primary & secondary stages
47
What's the deal w/ treponema pallidum?
corkscrew-shaped
motile microaerophilic bacterium
can't be cultured in vitro or viewed w/ normal microscopy
48
How does treponema become disseminated?
via bloodstream & lymphatics
| can also invade CNS
49
Tell me more about the chancre in primary syphilis.
Progresses from macule to papule to ulcer;
Typically painless, indurated, and has a clean base;
Highly infectious;
Heals spontaneously within 3 to 6 weeks; and
Multiple lesions can occur.
50
Which pop. has the highest rates of syphilis?
men having sex with men
51
T/FSerologic tests for syphilis may not be positive during early primary syphilis.
True.
52
What are the clinical manifestations of secondary syphilis?
```
Mucocutaneous lesions most common
Clinical Manifestations:
Rash (75%–100%)
Lymphadenopathy (50%–86%)
Malaise
Mucous patches (6%–30%)
Condylomata lata (10%–20%)
Alopecia (5%)
Liver and kidney involvement can occur
Splenomegaly is occasionally present
```
53
Serologic tests are usu highest in titer during which stage of syphilis?
secondary syphilis
54
How can you view treponema?
electron micrograph
| darkfield microscopy
55
What happens with latent syphilis?
asymptomatic
can only tell b/c of a pos. serologic test
can happen b/w 1 & 2nd stages or after 2nd stage
early latent: 1 yr
56
What is neurosyphilis?
Occurs when T. pallidum invades the central nervous system (CNS)
May occur at any stage of syphilis
Can be asymptomatic
early neurosyphilis: months-yrs after infection
can occur decades later
don't forget about ocular involvement
57
T/F Condylomata lata don't have many spirochetes in them.
False. Have a zillion in them!
58
Neural tissue with silver stain may reveal what?
spirochetes syphilis!
59
What happens in tabes dorsal is of neurosyphilis?
lack of sensation, proprioception
slapping gait
think of syphilis when you have a patient w/ constantly broken ankle or something: diabetes, congenital inability to feel pain, syringomyelia, syphilis.
60
What % of patients progress from secondary to tertiary stage?
30% w/i 1-20 years
rare b/c of antibiotics
here you get gummatous lesions
cardiovascular syphilis-enlarged aorta & aortic regurg
61
What happens in congenital syphilis?
vertical transmission
complications: stillbirth, death, deafness, neurologic impairment, bone deformities
higher risk for primary & secondary stages
62
Early & late congenital syphilis lesions?
Early lesions (most common): Infants 2 years old; tend to be immunologic and destructive
63
What are some things you want to check on PE when you suspect syphilis?
```
Oral cavity
Lymph nodes
Skin of torso
Palms and soles
Genitalia and perianal area
Neurologic examination
Abdomen
```
64
Lab diagnosis of syphilis?
Identification of Treponema pallidum in lesion exudate or tissue:
Darkfield microscopy (rarely available)
Tests to detect T. pallidum
Serologic tests to allow a presumptive diagnosis:
Nontreponemal tests
Treponemal tests
65
What do you look for in dark field?
morphology & motility of spirochetes
66
What are the 2 types of syphilis serologic tests?
treponemal (qualitative)
| nontreponemal (qualitative & quantitative)
67
What are the principles of nontreponemal serologic tests?
Measure antibody directed against a cardiolipin-lecithin-cholesterol antigen
Not specific for T. pallidum
Titers usually correlate with disease activity and results are reported quantitatively
May be reactive for life, referred to as “serofast”
Nontreponemal tests include VDRL(venereal disease research lab-spinal fluid), RPR
68
What are the advantages/disadvantages of nontreponemal serologic tests?
easy/inexpensive
| false pos.
69
What are the principles of treponemal serological tests?
Principles
Measure antibody directed against T. pallidum antigens
Qualitative
Usually reactive for life
Titers should not be used to assess treatment response
Treponemal tests include TP-PA, FTA-ABS, EIA
70
How do you diagnose latent syphilis?
Documented seroconversion or 4-fold increase in comparison with a serologic titer
Unequivocal symptoms of primary or secondary syphilis reported by patient
Contact to an infectious case of syphilis
Only possible exposure occurred within past 12 months
71
What are some indications for CSF exam?
Neurologic or ophthalmic signs or symptoms
Evidence of active tertiary syphilis (e.g., gummatous lesions)
Treatment failure
HIV infection with a CD4 count ≤350 and/or a nontreponemal serologic test titer of ≥1:32
72
HOw do you diagnose neurosyphilis?
VDRL-CSF-diagnostic for neurosyphilis
reactive serologic test
CSF cell count/protein (leukocytes elevated>5)
73
T/F Syphilis & HIV infection commonly co-exist?
True.
74
When should you biopsy the rash of a syphilis patient?
when you think they have syphilis, but have neg. serologic tests
75
How do you treat syphilis?
Benzathine penicillin G 2.4 million units intramuscularly in a single dose (Bicillin L-A®)
If can't take penicillin: doxycycline, tetracycline
76
What is the treatment for neurosyphilis?
Aqueous crystalline penicillin G 18–24 million units per day, administered as 3–4 million units intravenously every 4 hours or continuous infusion for 10 to14 days intravenously
OR procaine penicillin
77
How do you treat syphilis in pregnancy?
penicillin
| difficult if they are allergic.
78
What is the jarisch-herxheimer reaction?
Fever, malaise, nausea/vomiting; may be associated with chills and exacerbation of secondary rash
after being treated for syphilis w/ penicillin. Lysis of their spirochetes.
NOT an allergic rxn.
Can cause early labor. Can use antipyretics to treat.
79
T/F All patients who have HIV should be tested for syphilis. And vice versa.
True.
80
What should you check for at f/u?
6-12 months later
f/u titers
if they had neurosyphilis: repeat CSF exam @ 6 mo intervals
81
T/F Syphilis is resistant to penicillin now.
False.
82
When you do say...the treatment for syphilis has failed?
Persistent or recurring clinical signs or symptoms
Sustained 4-fold increase in titer
Titer fails to show a 4-fold decrease within 6–12 months
Retreat and re-evaluate for HIV infection.
CSF examination can be considered.
83
When should you test a pregnant woman for syphilis?
high prevalence communities--twice during 3rd trimester, @ 28 wks, and delivery
any woman who delivers stillborn infant after 20wks gestation.
84
What is the most common cause of genital ulceration?
genital herpes, HSV infections
get mucocutaneous infection & retrograde migration along sensory nerves
latency in dorsal root & trigeminal ganglia
85
Which type of HSV causes genital herpes?
HSV-1: most infections are orolabial, 20% genital
| HSV-2: almost always genital, orolabial rare
86
Tell me more about HSV-2/genital herpes.
```
80-90% due to HSV-2
Short incubation period.
Erythema, blisters, ulcerations
First episode is severe
Multiple painful vesicles, shallow ulcers, heals in 2-3 weeks
Recurrences: Less severe lesions
80% people have recurrences
HIV infection or immune suppression increases reactivation.
```
87
Other features of HSV-2 infection?
```
3-weeks illness
Multiple lesions, mucosal involvement.
Pain may be severe.
Lymphadenopathy is common.
Systemic symptoms are common
Headache is common: viral meningitis may occur in primary genital infections.
```
88
What are features of recurrent genital herpes?
5-10 days
Fewer lesions, mucosal involvement is uncommon.
Lymphadenopathy is uncommon.
Systemic symptoms are uncommon.
89
When do you see the most relapses for genital herpes?
the first year 4-5X for HSV-2
| can shed virus even when not having an outbreak
90
How do you diagnose genital herpes?
Microscopy direct immunofluorescence can be done on the day collected
Tissue culture followed by immunofluorescent staining (one to several days to positive result)
Real time PCR can distinguish HSV-1 from HSV-2
Type specific serology: ELISA and Western blot
91
How do you treat genital herpes?
acyclovir (resistance via thymidine kinase gene mutation)
valaciclovir
famciclovir
**all analogs of guanosine
92
What does thymidine kinase do?
converts THM to THMP w/ conversion of ATP-->ADP.
93
What is granuloma inguinale?
Granuloma Inguinale is a genital ulcerative disease caused by intracellular gram negative bacterium Klebsiella granulomatis
seen in tropical countries, spread via sex
painless lesions, highly vascular (bleed easily)
no regional LAD
94
How do you diagnose granuloma inguinale?
```
1-12 weeks after contact w/ bacterium.
small beefy red bumps on genitals
can look like a chancroid
culture the tissue, biopsy
antibiotics used to treat.
```
95
What is pelvic inflammatory disease?
Pelvic Inflammatory Disease comprise a spectrum of inflammatory disorders of upper female genital tract.
10-20% women with gonorrheal or chlamydial infection develop PID.
Usually refers to ascending infection from cervix/vagina.
Other agents causing vaginosis and urethritis can cause PID.
Symptoms: low fever, abdominal pain, uterine tenderness, can cause infertility
96
How do you diagnose & treat PID?
Endocervical discharge testing for N. gonorrhoeae and C. trachomatis.
Broad-spectrum antimicrobial are given, oral in mild cases, iv in hospitalized ones
Patients should be advised to rest for 1-3 days until symptoms resolves.
Abstain from sexual intercourse.
97
What is the most commonly acquired STD?
genital warts from HPV
from types 6 & 11 if genital.
from types 16 & 18 on cervix.
98
What are the screening methods for HPV/cancer?
pap smear
cytology
HPV-based DNA testing
start screening when women are sexually active.
perform annually in women under 30 if sexually active, esp if HPV+
99
What are the symptoms of warts?
The morphologic characteristics of cutaneous or genital warts.
Symptoms: pruritis, burning, vaginal bleeding and post-coital bleeding.
Frequent recurrences.
Warts may be pigmented, fixed to underlying tissues.
100
What's the deal with the HPV vaccine?
```
Approved for use in men and women.
Recommended age 11-12.
3 vaccine series (0, 1-2, 6 months).
Efficacy varies
Efficacy in 90+ percentile for reduction of type specific dysplacia.
Targets HPV 6/11 and 16/18
Based on primary capsid proteins
```
101
What is the structure of HPV?
nonenveloped double-stranded DNA virus
102
What percentage of cervical cancers are associated w/ HPV?
>95%
103
What is the pathway from HPV to invasive cancer?
```
transient infection
HPV infection
persistent infection
low grade dysplasia
high grade dysplasia
invasive cancer
```
104
What is the cervical transformation zone?
area of immature metaplasia b/w original & current squamocolumnar junction
99% HPV genital cancers arise w/i transformation zone of cervix
105
>90% of anogenital warts are caused by what type of HPV?
6 & 11
106
If you use podofilox or laser treatment-->what is the recurrence rate of genital warts?
as low as 5%
107
How can you treat HPV infections?
imiquimod: cell-mediated immune response modifier, interferon production
podophyllin resin: cytotoxic & antimitotic
TCA: protein coagulation of wart issues
surgery: cryotherapy, excision
108
What is lymphogranuloma venereum?
Lymphogranuloma venereum is a sexually-transmitted infection caused by a different serotype of C. trachomatis.
Starts as a small painless sore on the penis, vagina or rectum, pain may last for 30 days followed by swollen, painful lymph nodes in the groin area.
Anal bleeding may occur, which appears 2-6 weeks after infection.
Infection can cause diarrhea and abdominal pain.
most common in tropical areas.
109
How do you diagnose lymphogranuloma venereum?
```
oozing, abnormal connection in rectal area
lymph nodes swollen in groin
swelling of vulva or labia in women
**biopsy a lymph node
perform lab test for chlamydia
```
110
How do you treat lymphogranuloma venereum?
tetracycline
doxycycline
erythromycin
