STI and BBV Passmed

Question 1

Gonorrhoea is caused by the Gram-negative diplococcus Neisseria gonorrhoae.

How does it present differently in men and women?
What local complications can arise?

Answer 1

males: urethral discharge, dysuria
females: cervicitis e.g. leading to vaginal discharge

Local complications that may develop include urethral strictures, epididymitis and salpingitis

Question 2

What is the major systemic complication of gonorrhea? How does it present?

Answer 2

Disseminated gonococcal infection (DGI)

Initially there may be a classic triad of symptoms: tenosynovitis, migratory polyarthritis and dermatitis.

Later complications include septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)

It is the most common cause of septic arthritis in young adults

Question 3

How is gonorrhea treated?

Answer 3

The first-line treatment is a single dose of IM ceftriaxone 1g
(But if the organism is sensitive to ciprofloxacin then oral ciprofloxacin 500mg should be given)

if ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg + oral azithromycin 2g should be used

Question 4

All patients with gonorrhoea should have ‘test of cure’ due to high abx resistance. What is used for this?

Answer 4

with NAAT if asymptomatic or cultures if symptomatic

Question 5

How can genital herpes be diagnosed?

Answer 5

clinical diagnosis or viral PCR swab from lesion

Question 6

How should genital herpes in pregnancy be managed?

Answer 6

Elective C-section at term is advised if a primary attack of herpes occurs at greater than 28 weeks gestation (3rd trimester)
Oral aciclovir 400 mg TDS (three times daily) should be taken until delivery

Women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low

Question 7

How is asymptomatic bacteriuria in pregnancy managed?

Answer 7

Immediate tx with abx

Question 8

HIV seroconversion occurs about 3-12 weeks after initial infection. How does it present if symptomatic?

Answer 8

Like glandular fever

sore throat
lymphadenopathy
malaise, myalgia, arthralgia
diarrhoea
maculopapular rash and mouth ulcers
rarely meningoencephalitis

antibodies to HIV may not be present
HIV PCR and p24 antigen tests can confirm diagnosis

Question 9

When should asymptomatic patients be screened for HIV?

Answer 9

4 weeks following potential exposure

Question 10

What is the first line for HIV testing?

Answer 10

combination tests (HIV p24 antigen and HIV antibody) are now standard for the diagnosis and screening of HIV
- if the combined test is positive it should be repeated to confirm the diagnosis

Question 11

Name some key AIDS defining illnesses

Answer 11

Kaposi’s sarcoma (caused by human herpes virus 8)
PCP
CMV
Candidiasis (oesophageal or bronchial)
Lymphoma
TB

Question 12

How can HIV be monitored?

Answer 12

CD4 count ( 500-1200 is normal, under 200 is end stage /AIDS)

Viral Load

Question 13

How should HIV be managed?

Answer 13

Antiretroviral therapy (ART) involves a combination of at least 3 drugs, typically 2 nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI).

This combination both decreases viral replication but also reduces the risk of viral resistance emerging

patients should start ART as soon as they have been diagnosed, rather than waiting until a particular CD4 count

NRTI: zidovudine (AZT), abacavir, emtricitabine, didanosine, lamivudine, stavudine, zalcitabine, tenofovir

PI: indinavir, nelfinavir, ritonavir, saquinavir

NNRTI: nevirapine, efavirenz

Question 14

What is a chancre?

Answer 14

Painless indurated lesion characteristic of the primary stage of syphilis

Question 15

Most common complication of gonorrhoea?

Answer 15

Infertility secondary to PID

Question 16

Most common cause of PID?

Answer 16

Chlamydia
(gonorrhoea second)

Question 17

Common causes of genital ulcers?

Answer 17

painful: herpes much more common than chancroid
painless: syphilis more common than lymphogranuloma venereum

Question 18

Most common cause of genital warts (90%)?

Answer 18

HPV 6 & 11

Question 19

What is BV?

Answer 19

Bacterial vaginosis (BV) is an overgrowth of predominately anaerobic organisms e.g. Gardnerella vaginalis which = a fall in aerobic lactobacilli that produce lactic acid→ raised vaginal pH

Fishy/offensive discharge or can be asymptomatic

Question 20

Risk factors for BV?

Answer 20

multiple sexual partners
excessive vaginal cleaning
recent abx
smoking
copper coil

Question 21

How can BV be investigated?

Answer 21

vaginal pH testing from swab - above 4.5 = BV
vaginal swab for microscopy = clue cells

Question 22

How can BV be treated?

Answer 22

metronidazole orally or by vaginal gel

Question 23

Complications of BV?

Answer 23

increased risk of getting STIs

complications in pregnancy:
miscarriage
preterm delivery / PPROM
low birth weight
chorioamnionitis

Question 24

Man returns from trip abroad with maculopapular rash and flu-like illness→

Answer 24

think HIV seroconversion

Question 25

Tx for pubic lice (Phthirus pubis)?

Answer 25

malathion lotion or permethrin cream (insecticides) Both should be applied to the whole body and washed off after 12 hours repeat after a week

Question 26

Chlamydia is the most prevalent STI in the UK and is caused by Chlamydia trachomatis. How does it present in men and women? Investigation? Tx?

Answer 26

women: cervicitis (discharge, bleeding), dysuria men: urethral discharge, dysuria often ASYMPTOMATIC Investigation: for women: the vulvovaginal swab is first-line for men: the urine test is first-line Chlamydia testing should be carried out two weeks after a possible exposure Tx: doxycycline (7 day course) if pregnant then azithromycin, erythromycin or amoxicillin may be used (azithromycin 1g stat preferable)

Question 27

Findings on examination of chlamydia?

Answer 27

pelvic or abdo tenderness cervical motion tenderness inflamed cervix purulent discharge

Question 28

Complications of infection with chlamydia?

Answer 28

PID chronic pelvic pain infertility, ectopic pregnancy conjunctivitis lymphogranuloma venerum reactive arthritis

Question 29

What is lymphogranuloma venerum ?

Answer 29

condition affecting lymphoid tissue around area infected w chlamydia commonest in MSM painless ulcer > lymphadenitis > proctitis

Question 30

Supportive management of genital herpes?

Answer 30

saline bathing analgesia topical anaesthetic agents e.g. lidocaine

Question 31

What PEP should be given post hep B and hep C exposure?

Answer 31

Hep B known responder to vaccine : booster vaccine non-repsonder to vaccine : hepatitis B immune globulin (HBIG) and booster Hep C monthly PCR - if seroconversion then interferon +/- ribavirin

Question 32

What PEP should be given post HIV exposure?

Answer 32

low-risk incidents such as human bites don’t require post-exposure prophylaxis high-risk incidents like needle stick injuries should be treated with a combo of oral antiretrovirals (e.g. Tenofovir, lopinavir and ritonavir) ASAP for 4 weeks with serological testing at 12 weeks following completion

Question 33

Where should swabs for chlamydia and gonorrhoea in women be taken from?

Answer 33

the vulvo-vaginal area (introitus)

Question 34

Fever, loin pain, nausea and vomiting → Management?

Answer 34

acute pyelonephritis obtain a MSU sample and then start on cefalexin for 14 days ( or IV ceftriaxone in hospital)

Question 35

Appropriate next step after needlestick injury?

Answer 35

Bleed and wash the wound Ask a colleague to complete a risk assessment and take the patient’s blood as they will be able to be objective Inform occupational health

Question 36

What is Trichomonas vaginalis? Presentation? Tx?

Answer 36

STI caused by flagellated protozoan parasite vaginal discharge: offensive, yellow/green, frothy strawberry cervix pH > 4.5 in men is usually asymptomatic but may cause urethritis tx: metronidazole for 5-7 days

Question 37

HIV + proctitis ?

Answer 37

Lymphogranuloma venereum

Question 38

most common non-immune cause of foetal hydrops in pregnancy? what is the immune cause?

Answer 38

Parvovirus B19 (Immune is Rh disease)

Question 39

Painless genital pustule → ulcer → painful inguinal lymphadenopathy → proctocolitis =

Answer 39

lymphogranuloma venereum - caused by three serovars of Chlamydia trachomatis

Question 40

When should reinfection with syphilis be suspected?

Answer 40

if the RPR rises by 4-fold or more

Question 41

Urethritis in a male, negative for Gonorrhoea and Chlamydia →

Answer 41

?Mycoplasma genitalium

Question 42

Vaginal candidiasis or thrush refers to a vaginal yeast infection, most commonly with Candida albicans. What are the risk factors?

Answer 42

pregnancy poorly controlled diabetes immunosuppression broad spectrum abx

Question 43

How does candidiasis present?

Answer 43

thick, white 'cottage cheese' discharge vulval / vaginal itching or soreness dyspareunia

Question 44

What pH would you expect in candidias?

Answer 44

<4.5 (as opposed to >4.5 in trichomonas or BV)

Question 45

How can candidiasis be treated?

Answer 45

antifungal cream e.g. clotrimazole (with applicator) antifungal pessary e.g. clotrimazole oral antifungal e.g. fluconazole can use Canesten Duo (OTC tablet + cream)

Question 46

What is mycoplasma genitalium? How is it investigated and managed?

Answer 46

STI that causes non-gonococcal urethritis Ix: NAAT - first urine sample in men, vaginal swabs in women Mx: doxycycline 100mg BD for 7 days, then azithromycin

Question 47

Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum. What are the primary features?

Answer 47

chancre - painless ulcer at the site of sexual contact local non-tender lymphadenopathy

Question 48

What are the secondary features of syphilis?

Answer 48

occurs 6-10 weeks after primary infection systemic symptoms: fevers, lymphadenopathy rash on trunk, palms and soles buccal 'snail track' ulcers condylomata lata (painless, warty lesions on the genitalia )

Question 49

What is Argyll-Robertson pupil?

Answer 49

tertiary feature of syphilis suggests neurosyphilis constricted pupil that accommodates when focusing on near objects but does not react to light

Question 50

How can syphilis be treated?

Answer 50

single dose IM benzathine benzylpencillin

Question 51

Risk factors for HIV?

Answer 51

multiple sexual partners, high-risk sexual practices such as ‘chemsex’, history of other STI IVDU from area with high HIV prevalence MSM / female sexual contacts of MSM trans women sex workers blood transfusions, transplants, or other risk-prone procedures in countries without rigorous procedures for HIV screening occupational exposure such as a needle stick injury