STI's Flashcards
“5 P’s” of sexual history
Partners Practice Past history of STI Pregnancy plans Protection from STI
*ask about partner’s hx and partners too
Chlamydia commonly co-infected with _________.
gonorrhea
Non-reportable STI
HPV
Signs of HPV infection
most asymptomatic
genital warts main sign
- smooth papules
- flat papules
- Kerratotic warts (resemble common wart)
Main HPV treatment
Podofilox 0.5% gel applied to warts BID x 3 days
HPV transmission
skin to skin contact
sex primarily (but doesn’t have to be) - intercourse, genital contact
fomites???
How to prevent condylomata acuminata and cervical cancer?
HPV vaccine (quadrivalent 6, 11, 16, 18 = Gardisil)
When is HPV vaccine given? shot series?
recommended in males 11 or 12 yo (can be given 9-26 yo)
3 shot series: dose 1, then 2 mon, then 6 mon
2 kinds of herpes
HSV 1 = oral
HSV 2 = genital
Most common STI in the U.S.
HPV
When should genital warts be biopsied?
- atypical appearance of warts
- pt immunocompromised
- warts don’t resolve or worsen with standard treatment
- persistent ulceration/bleeding
herpes transmission
sexual and vertical (mother to fetus)
HSV-1 symptoms
cold sores or fever blisters
Progression of herpes lesions
burning/stinging skin -> papules -> painful vesicles -> fills with pus -> ulcers -> crusts -> healed
herpes keratitis
complication of HSV-1 where it gets on eye; emergency because may cause blindness
vesicular lesions on tip of nose & dendritic lesions on eye
Complications of HSV
blindness neonatal herpes herpes encephalitis aseptic meningitis radicular pain
Recurrence of herpes triggered by what?
stress, fatigue, exposure to sun, skin trauma
Gold standard diagnosis for HSV
viral culture of lesion (can be typed but doesn’t change tx)
Best HSV treatment for first episode, episodic, and chronic suppression?
First episode (w/i 24 hrs of sx’s):
◦ Acyclovir 800 mg TID x 7-10 d
◦ Valacyclovir 1000 mg BID x 7-10 d
Episodic; 1-5 days:
◦ Acyclovir x 3-5 d
◦ Valacyclovir x 5 d
◦ Famciclovir x 1 d
Chronic suppression (1-2 per month); year:
◦ Acyclovir (safe for 5 yrs)
◦ Famiciclovir (1 yr)
◦ Valacyclovir (1 yr)
What test is no longer used as gold standard for herpes?
Tzanck smear
Most commonly reported notifiable disease in U.S.? 2nd most common?
- Chlamydia
2. Gonorrea
Age group most affected by chlamydia and gonnorhea
20-24 yo
transmission of chlamydia
body fluids; highly transmissible
Signs/sx of Chlamydia
85% asymptomatic
mild dysuria, burning urination, watery penile discharge, conjunctivitis, erythematous oropharynx, joint pain (Reiters syndrome), abd pain
How to dx Chlamydia and Gonorrhea?
nucleic acid amplification (NAAT) of dirty urine or of swab
culture (kids and used in all legal matters)
Chlamydia treatment
Azithromycin 1 g PO x 1 dose (doxy if allergic)
ALWAYS treat for gonorrhea too!
TREAT PARTNER
Patient education about STIs
Discuss prevention strategies: abstinence, monogamy, limit # of sex partners, barrier methods
Sex partners should be evaluated, tested, and treated if they had sexual contact with STI patient during what time frame?
previous 60 days
STI’s with vertical transmission
herpes, gonorrhea, syphilis
Urban residence is a risk factor for what STI?
Gonorrhea
Signs of Gonorrhea
urethritis epididymitis (scrotal pain, edema) yellow discharge of erythema of oropharynx proctitis (common MSM) prostatitis
STI with yellow purulent discharge of urethra and erythematous throat?
Gonorrhea
Differences in discharge of Chlamydia and Gonorrhea
Chlamydia - mucoid watery
Gonorrhea - yellow purulent
Rare and serious complication of Gonorrhea
DGI = disseminated gonococcal infection
red maculopapular skin lesions, arthralgias, tenosynovitis, arthritis, hepatitis, myocarditis, endocarditis, and meningitis
ADMIT!
Gonorrhea treatment
Ceftriaxone 250 mg IM x 1 dose
PLUS Azithromycin 1 g to cover for Chlamydia
Treat partners
Etiology of trichomoniasis
T. vaginalis (protozoa)
Trichomoniasis treatment
Metronidazole 2 g PO x 1 dose
No ETOH x 24 hrs after treatment
Man who is asx, but has grayish green penile discharge with some mild dysuria
Trichomoniasis
How to dx Trich
Wet mount - trophozoites with tail on microscope
culture to confirm
How long to wait after STI treatment to return to sex?
7 days after post treatment or until both partners no longer have sx’s
Patient history and symptoms that indicate Granuloma Inguinale
- Live in tropical or developing country
- initially painless ulcer that later becomes painful (beefy red, discharge)
- scars from lesions
Donovan bodies on biopsy =
Granuloma Inguinale
Granuloma Inguinale treatment
Doxy or Bactrim x 3-4 wks
- Painless ulcer on penis
- Purple painful inguinal lymph nodes (=Bubos)
Lymphogranuloma Venereum
How to test for Lymphogranuloma Venereum?
culture lesion or bubo aspiration
Lymphogranuloma Venereum treatment
Doxy
STI’s seen in South America and Caribbean? (in addiction to Asia and Africa)
Lymphogranuloma Venereum
PAINFUL genital ulcers. Commonly seen in Asia, Africa, and Caribbean.
Chancroid
Chancroid treatment
Cefriaxone IM or Azithromycin
Who needs to be treated for STI with longer course?
HIV+
STI’s with bubos
Chancroid and Lymphogranuloma Venereum
bluish/red lesions in pubic region with areas of excoriation. What should you look for?
pubic lice
Pubic lice treatment
Permethrin (Elimite) rinse 1% x 10 min OR cream 5% x 8 hr
Healthy young adult comes in with pearly, umbilicated papules on groin region.
Molluscum Contagiousum
Etiology of Molluscum Contagiosum
Pox virus
Molluscum Contagiousum treatment
Imiquimod (Aldara) 5% x 1-3 mon on lesions
Cryotherapy, curettage, or electrodessication if painful
What STI is known as “great masquerader?” Why?
Syphilis
variable presentations
All patients with syphilis should be tested for ______.
HIV
Most STI’s highest in ages 20-24, but _______ is slightly older 25-29.
Syphilis
Signs of primary syphilis?
Lesion appears 10-20 days (can be up to 90 days) after infection
CHANCRE = painless lesion with smooth raised border and clean non-necrotic base
Heals spontaneously within 1-6 wks
Signs of secondary syphilis?
Occur 3-6 weeks after primary chancre
Rash on palms, soles, face; Lymphadenopathy; mucocutaneous lesions
Timing of primary and secondary syphilis
Primary appears 10-20 days (can be up to 90 days) after infection
Secondary occur 3-6 weeks after primary chancre
primary and secondary may overlap (chancre AND Mucocutaneous lesions)
NEVER go back to primary. only one onset of Chancre
When can latent syphilis occur?
- between primary and secondary stages
- between secondary relapses
- after secondary stage
Duration of early and late latent syphilis
Early latent: < 1 year
Late latent: >/= 1 year
Hallmarks of tertiary (late) syphilis
1-20 years after infection
Gummatous lesions: destruction of nasal bone/septum
Cardiovascular Syphilis: aneurysms, aortic regurg, Coronary Artery Disease
tabes dorsalis =
syphilitic myelopathy seen in later neurosyphilis
What are signs that syphilis has crossed into CNS (Neurosyphilis)?
Early NS (mon-yrs) cranial nerve dysfunction, meningitis, stroke, altered mental status, loss of vibration sense, and auditory or ophthalmic abnormalities
Late NS (yrs-decades; very rare) tabes dorsalis (syphilitic myelopathy) dementia paralytica = emotional lability, delusions, inappropriate social or moral behavior, megalomania
How to analyze fluid of lesions from suspected syphilis?
Darkfield Microscopy:
+ if treponemes seen
Direct Fluorescent Antibody – T. Pallidum (DFA TP)
+ if treponeme seen
Comparable to Darkfield
1-2 day turnaround
Serologic tests for syphilis
Nontremponemal: VDRL, RPR
Tremponemal: FTA-ABS (fluorescent treponemal antibody absorption test)
Best way to dx syphilis if Chancre/lesion present
Darkfield Microscopy + RPR (or VDRL)
Best way to dx syphilis if no lesion present
RPR (or VDRL)
and
FTA-ABS, TP-PA or EIA
Criteria for early latent syphilis
+ testing within last 12 months
4-fold increase in comparison with titer obtained within year preceding your eval
Unequivocal symptoms of primary or secondary syphilis reported by patient in past 12 months
Contact with a partner with a documented case of Syphilis
When to test for neurosyphilis?
Neurologic or ophthalmic signs
Evidence of active tertiary syphilis (e.g., aortitis, gumma, and iritis)
Treatment failure
HIV infection with late latent syphilis or syphilis of unknown duration
How to test for neurosyphilis?
Serology positive + VDRL-CSF + LP (elevated protein levels in CSF)
Primary, Secondary, and early latent syphilis treatment
IM Benzathine penicillin G 2.4 million units x 1 dose
- if PCN allergic, then doxy or tetracycline
Treatment of neurosyphilis
Hospitalization with IV abx
Aqueous crystalline PCN G
Treatment of late latent (or latent unknown duration) and tertiary syphilis
IM Benzathine penicillin G x 3 doses
Self-limited reaction to anti-treponemal (syphilis) therapy; includes fever, malaise, N/V, rash…
Jarisch-Herxheimer Reaction
Syphilis titers usually highest at what stage of disease?
secondary syphilis
What phase of syphilis can neurosyphilis occur?
can occur at any stage
If HPV is a clinical diagnosis, how do we rule out the possibility of it being a wart from syphillis?
HPV lesions are painful vesicular lesions on an erythematous base
Syphilitic lesions are an open sore (chancre) that is painless
Primary a clinical differentiating, but may do HSV culture of the lesion and order an RPR/VDRL
What labs confirm primary syphilis?
T. pallidum on Darkfield microscopy
RPR and serology tests may be unreactive
How to treat syphilis in pregnant mother with allergy to PCN?
desensitized in the hospital and treated with penicillin; prevents vertical transmission
no alternative med
How should syphilis be followed up if lesion seems to be healing and no ADRs to therapy?
- Repeat HIV antibody test at 3 months
- VDRL or RPR 6 and 12 months after therapy (measure response to therapy)
How should gonorrhea and chlamydia patient’s sexual partners be managed?
test and treat all contacts within prior 60 days
most recent partner should ALWAYS be treated regardless of of time or test results
avoid intercourse until therapy completed
