STI: ulcerative lesions

Question 1

Herpes simplex 1 and 2

Answer 1

• Transmission: inoculation of mucous membrane and/or broken skin
• Leads to life-long infection w/ shedding (ASx) and latency/recurrence
• Most ppl are ASx, but symptoms include painful ulcers, tender LNs, fever, flu-like Sxs
• Dx based on clinical findings, viral culture of lesion, and serology
• Rx for first episode: acyclovir (or other anti-virals) for 7-10 days
• 90% have recurrent lesions in first year, recurrences decrease over time
• Daily suppression (for pts w/ >6 episodes/yr) also consists of antivirals

Question 2

Syphilis (treponema pallidum)

Answer 2

• Spirochete acquired by sexual contact, congenital transmission, contact w/ active lesion
• Syphilis is a disease primarily in men
• Progression: primary-> secondary-> latent-> tertiary

Question 3

Primary and secondary syphilis

Answer 3

• Incubation is around 21 days, presents as chancre (single or multiple painless lesions) and regional LAD, heals in 3-6 wks
• Secondary syphilis begins 2-8 wks after chancre, characterized by fever, malaise, generalized LAD, rash (usually macular or maculopapular), CNS involvement
• 1/3rd of secondary syphilis pts get condylomata lata: wart-like lesions (painless) on genitals that are highly infectious

Question 4

Tertiary syphilis 1

Answer 4

• About 1/3rd of pts w/ secondary syphilis will progress to tertiary syphilis, which consists mostly of CV Sxs (aortitis), gumma, and neurosyphilis
• CV syphilis: aortitis increases risk of Ao dissection/aneurysm
• Gumma: inflammatory nodules
• Neurosyphilis: acute syphilitic meningitis, latent neurosyphilis, cerebrovascular syphilis, general paresis, tabes dorsalis
• Possible to have ASx neurosyphilis (abnormal CSF findings but no neuro signs) early on (secondary syphilis)

Question 5

Tertiary syphilis 2

Answer 5

• Cerebrovascular syphilis leads to infarction of cerebral vessels (incubation period 5-12 yrs)
• General paresis: meningoencephalitis w/ invasion of cerebellum (average latent period: 15-20 yrs)
• Early Sxs: irritability, memory loss, personality changes
• Late Sxs: emotional lability, defective judgement, delusions of grandeur, paranoia
• Argyl-robertson pupil: accommodates but doesn’t react to light (common in neurosyphilis)
• Tabes dorsalis: pain shooting up legs (lancinating pain), ataxia

Question 6

Dx of syphilis

Answer 6

• Primary: darkfield examination (doesn’t stain w/ H&E), serology not positive until secondary
• Secondary: serology and clinical
• Latent: serology only (no clinical evidence)
• Tertiary: clinical, serology, path

Question 7

Serologic Dx of syphilis

Answer 7

• Either non-treponemal (non-specific) Abs, or specific tremponemal tests
• Non-treponemal Ab test (RPR): Ab directed against cardiolipin, titer correlates w/ disease activity
• Should become negative 1 yrs after Rx
• Specific treponemal Ab tests: assay presence of several Abs to specific treponemal Ags
• Titers do not correlate w/ activity of disease, are positive for life
• For Dxing syphilis, first use treponemal-specific Ab tests (if negative they don’t have syphilis), then if positive confirm w/ RPR (if RPR is positive they have syphilis)
• If RPR is negative it could be past exposure and Rx, early or latent syphilis, or false + treponemal test

Question 8

Rx of syphilis

Answer 8

• Early (primary, secondary, or early latent): benzathine PCN IM 1x
• Late syphilis (late latent, gummata, cardiovascular): benzathine PCN IM weekly for 3 wks
• Alternatives: doxycycline
• Neurosyphilis: aqeous crystalline penicillin q 4 hrs for 10-14 days

Question 9

Less common causes of genital ulcerations 1

Answer 9

• Chancroid (haemophilus ducreyi): GN coccobacillus, uncommon in US, incubation 5-7 days
• Physical findings: tender genital papule (chancroid is painful) that becomes pustular that erodes into painful ragged ulcer (looks like HSV)
• Tender regional LAD present
• LGV: lymphogranuloma venereum caused by LGV serovars of chlamydia, common in africa, asia, and south america
• Incubation period of 1-4 wks, primary lesion is papule or ulcer (small, painless) w/ systemic signs that heals in a few days

Question 10

Less common causes of genital ulcerations 2

Answer 10

• Second stage (2-6 wks later): inflammation and swelling of inguinal lymph nodes (buboes), can rupture into fistulas, again accompainied by systemic signs
• This stage may lead to chronic ulcers, fistulas, and/or strictures
• Granuloma inguinale (calymmatobacterium): GN bacillus found mostly in tropics
• Initial small papule that ulcerates to form painless ulcer w/ rolled edges and a surface that bleeds easily w/ contact
• There is spontaneous healing and scar formation-> gross deformities, lesions can be found in genital area and rectum
• Dx via clinical + histo exam of Bx w/ staining showing Donavan bodies