STIs

Question 1

HPV: definition, Transmission, Pathophys, Risks, & Types

Answer 1

• Definition: group of non-enveloped DNA viruses that specifically infect human epithelial cells of the skin & mucus membrane; 90% of HPV infx are asymptomatic and clear within 3 years
• Transmission:
  
  • contact with infected epithelial cells (sexual contact or birth)
• Pathophys:
  
  • HPV → uncontrolled cell growth of epithelial cells → warts & lesions; transformation to carcinomas dependent on HPV type & cofactors
• Risks:
  
  • Immune compromised, HIV, Pregnancy, tobacco use associated with persistent infection
• Types:
  
  • HPV Type 6 & 11: ~90% of warts, low risk
  • HPV Type 16 & 18: ~70% cervical cancer, ~90% of anal cancers, high risk

Question 2

HPV: S/sxs, PE, Dx & Tx

Answer 2

• S/sxs:
  
  • many = asymptomatic
  • Condylomata acuminata: skin-colored, range in size, cauliflower-like look to their surface, verrucous papules & plaques
  • Painless but may cause itching, burning, or bleeding
• Dx:
  
  • Clinical diagnosis is usually sufficient for anogenital warts
  • Molecular DNA test = definitive dx
  • PAP smear, acetic acid tests
  • Bethesda system** **for cervical cytology
• Tx:
  
  • Prophylaxis:
    
    • condom use
    • HPV vaccine
    • limit sexual contact
  • Management:
    
    • Salicylic acid: to remove warts
    • Liquid nitrogen cryotherapy Laser Removal
  • Meds:
    
    • Imiquimod 3.75% cream daily at bedtime for up to 8 weeks.
    • Podofilox 0.5% solution or gel TID for 3 days, with 4 days of no therapy that follows. Repeat PRN up to 4 cycles.
    • Sinecatechins 15% ointment, apply TID until complete clearance of warts is achieved. No longer than 4 months

Question 3

Bethesda System for Cervical Cytology

Answer 3

used to diagnose cervical cancer

• Types of Readings:
  
  • Normal Intraepithelial
  • Cell Abnormalities
    
    • →Squamous Intraepithelial Cell Abnormality
    • → ASCUS: atypical cells of undetermined significance
    • → LSIL: low-grade squamous intraepithelial lesions (CIN-I)
    • HSIL: high-grade squamous intraepithelial lesion (CIN II-III)
    • Squamous Cell Carcinoma

Question 4

Cervical Screening PAP testing and HPV testing

Answer 4

• used to test for cervical cytologic abnormalities
• Prior HPV testing should not prevent pap testing and screening
• Co-testing: HPV testing with a pap test → HPV testing is not completed in pts < 25 years old
• Age 21-29 yo q3 years
• Age 30-65 yo → cervical cytology alone q 3 years, high-risk HPV testing alone q 5 years, cervical cytology in combo with high risk HPV testing q 5 years

Question 5

Who do you NOT screen for cervical abnormalities?

Answer 5

• 65 yo+
• healthy people <21 years of age
• people with hysterectomy due to non-cancerous reasons

Question 6

Chlamydia

Answer 6

• Definition: gram-negative bacteria that resembles both a bacteria & a virus → lacks a peptidoglycan cell wall
• Chlamydia trachomatis = MCC of bacterial STIs in the US
• S/sxs:
  
  • Most women = asymptomatic
  • yellow/foul smelling mucopurulent discharge
  • Pruritus, Dysuria, Dyspareunia, Hematuria
  • Males: urethritis, proctitis, epididymitis
• Dx:
  
  • Nucleic Acid Amplification Test: gold standard, detects DNA in sample
    
    • → remains positive up to 21-30 days after successful tx
  • Giemsa stain: lacks murein (peptidoglycan) so a normal Gram stain is not effective
• Tx:
  
  • Azithromycin 1g PO x 1 dose OR doxycycline 100mg BID x 7 days
  • Tx for gonorrhea: ceftriaxone 500 mg IM x 1 dose
  • **all partners within past 60 days should receive testing & empiric testing
  • ** repeat testing in 3 months even if asymptomatic → checking for reinfection, NOT test of cure
  • Abstain from sex for 7 days following completion of tx AND sxs have resolved

Question 7

When can you Tx for Chlamydia alone while awaiting test results?

Answer 7

• Known exposure to CT only
• Cervicitis, and no concern for PID AND:
  
  • low local prevalence of GC AND
  • No/low risk factors for GC acquisition AND
  • no/low concern for loss to f/u

Question 8

Lymphogranuloma Venereum (LGV)

Answer 8

• Definition:
  
  • disease caused by Disease caused by Chlamydia. trachomatis serovars L1, L2, or L3
  • MC seen with rectal infection
• s/sxs:
  
  • Characterized by adenopathy: inguinal (anogenital infx) or cervical (oropharyngeal infx)
  • More likely to have systemic symptoms: fever, chills myalgias
    *

Question 9

Gonorrhea

Answer 9

• Definition:
  
  • gram-negative diplococci that infect humans
• Transmission:
  
  • sexual contact (male to female = most effective form of distribution), mother to child during birth
• S/sxs:
  
  • Males:
    
    • Dysuria
    • -Urethral Discharge: purulent or bloody
  • Females:
    
    • Thick, white, purulent vaginal or urethral discharge
    • Dysuria
  • Rectal Infections: pain defecation, purulent discharge
  • Pharyngitis: pharyngeal exudate
• Dx:
  
  • Nucleic Acid Amplification Test (NAAT): gold standard, detects DNA in sample
    
    • → remains positive up to 21-30 days after successful tx
  • Gram stain: stains pink
  • Culture: chocolate agar or Thayer-Martin medium, sensitive and specific
  • For people with vulvas/vaginas: vaginal swab = more sensitive than urine sample
• Tx:
  
  • *May treat pre-emptively
  • Ceftriaxone 500 mg IM x 1 dose for people weighing <150 kg, or 1g IM >/= 150 kg (alternatives gemifloxacin or gentamicin)
  • Treat for chlamydia:
    
    • Azithromycin 1g PO x 1 dose OR doxycycline 100mg BID x 7 days
  • **all partners within past 60 days should receive testing & empiric testing
  • ** repeat testing in 3 months even if asymptomatic → checking for reinfection, NOT test of cure
  • Abstain from sex for 7 days following completion of tx AND sxs have resolved

Question 10

Genital Herpes (HSV)

Answer 10

• Definition:
  
  • group of enveloped, double stranded DNA viruses
• Most cases of recurrent genital herpes are caused by HSV2 & oral herpes by HSV1 (but there is a lot of crossover)
• S/sxs:
  
  • Usually asymptomatic (but may shed virus)
  • Painful genital ulcers preceded by prodromal symptoms (burning, paresthesias, numbness)
  • Fever, malaise, dysuria, inguinal lymphadenopathy
• PE:
  
  • Multiple, shallow, tender ulcers
  • Grouped vesicles on erythematous base
  • Inguinal lymphadenopathy
• Dx:
  
  • PCR (NAAT): test of choice
  • HSV-1 serology (NOT recommended for general population)
  • Viral Cultures
  • Tzanck smear: multinucleated giant cells → not recommended anymore
• Tx:
  
  • **DO NOT WAIT FOR CONFIRMATORY LAB RESULTS**
  • Antivirals (With dosing for initial outbreak):
    
    • Valacyclovir 1g BID 7-10 days, acyclovir 400 mg TID 7-10 days, Famciclovir 250mg PO TID 7-10 days
    • *Reduce pain & speed up healing
  • docosanol (Abreeva OTC)

Question 11

When is HSV serology useful?

Answer 11

• pt with recurrent or atypical genital sxs with a negative HSV PCR or cx results
• pt with a clinical dx of genital herpes without laboratory PCR or cx confirmation
• pt with a sex partner who has HSV

Question 12

Episodic vs Suppressive Tx of HSV

Answer 12

• Episodic:
  
  • start at 1st sign of prodromal sxs or within 24 hours of lesion onset; give rx in advance to have at home
• Suppressive:
  
  • daily dosing reduces frequencies of recurrences; reduces viral shedding & risk of transmission; no “minimum” frequency of recurrence is required to meet indications for suppressive therapy
    
    • → different dosing!

Question 13

Syphilis: Definition, Transmission

Answer 13

• Definition:
  
  • chronic infection caused by Treponema pallidum → spirochete, does not hold stain; resistant to phagocytosis
• More common in men who have sex with men 41.6%
• Transmission:
  
  • body fluids (cut/breaks in external genitalia or mouth, sexual contact, contaminated needles, direct contact with skin lesion), congenital (crosses placenta in the 1st trimester → possible stillbirth)
• Does NOT stain with gram stain.

Question 14

Primary, Secondary, Latent, & Tertiary Syphilis S/sxs & PE

Answer 14

• Primary Syphilis:
  
  • painless chancre with punched out appearance and raised indurated edges appears 10-90 days after contact and resolves spontaneously within 2-8 wks after appearance
  • Regional lymphadenopathy
  • atypical presentation of multiple ulcers and rash
• Secondary Syphilis:
  
  • 1-3 months = most infectious stage)
  • Rash on Palms and Soles
    
    • → also on trunk
  • Mucocutaneous lesions, lymphadenopathy
  • Condyloma Lata : large raised, grey to white lesions = high level spirochetes
  • Alopecia: “moth eaten scalp”, eyebrows, beard
  • Hepatitis: mild transaminitis, elevated alk phos
• Latent Syphilis:
  
  • Cardiac/vascular involvement
  • gummatous lesions
  • Neurological –tabes dorsalis and paresis
  • no visible signs or sxs
  • Stages:
    
    • *Early: 1 year post infection
    • *Late: >1 year post infection
• Tertiary (Late): 1-20 years
  
  • Gumma: granulomas on skin
  • Neurosyphilis: HA, meningitis, dementia, vision/hearing loss
  • bes Dorsalis: wasting of back of spinal cord)
  • CV syphilis: aortitis
  • Argyll-Robertson Pupil: loses light constriction reflex, accommodation intact

Question 15

Syphilis Dx

Answer 15

• Non-Treponemal Tests:
  
  • may indicate activity of infx and may remain positive at low level even after tx
  • RPR: rapid plasma reagin
  • VDRL-Venereal Disease Research Lab
• Treponemal Tests:
  
  • always remain POSITIVE even if infx has been adequately treated
  • FTA-ABS: fluorescent treponemal ab absorption
  • TPPA: treponema particle agglutination assay
  • EIA: enzyme immunoassay
• Dark Field Microscopy:
  
  • identifies spirochetes in chancres

Question 16

Syphilis Tx

Answer 16

*Penicillin: tx of choice for all stages*

• Primary Syphilis:
  
  • tx should be given if clinical dx is made
  • 4-fold increase in RPR titer within 12 mos
  • report of contact with confirmed positive partner regardless of sxs
  • Benzathine (Bicillin) PCN G 2.4 mu IM x1 (this is the long-acting form of penicillin)
    
    • Doxycycline 100mg BID x 14 days as alternative
• Avoid sex contact for 10 days after tx
• Early Latent <12 months
  
  • bicillin LA 2.4 mu IM x 1
    
    • Alt: Doxycycline 100mg BID x 14 days
• Late Latent: > 12 months
  
  • Bicillin LA 2.4 mu IM x 3 weekly doses
  • alt for PCN allergy: DOxy 100 mg BID x 28 days
    
    • →many recommend desensitization so that PCN can be used

**positive test result = must be reported to public health department

→ pt advised to notify partners to seek testing & tx

Question 17

Jarisch-Herxheimer Reaction

Answer 17

• Definition:
  
  • acute self-limited febrile rxn after tx for syphilis (any spirochete)
    
    • occurs in 10-35% of pts
  • MC = after tx of early syphilis
• Pathophys:
  
  • Caused by phagocytosis of PMNs and presence of Cytokines
• S/sxs:
  
  • Fever, chills, rigors, diaphoresis, hypotension, worsening rash
  • Rarely: meningitis, respiratory distress, renal/hepatic dysfunction-uterine contractions in pregnancy

Question 18

Indications for PrEP

Answer 18

• Patients who may have an HIV positive partner
• Pts with 1+ sex partners with unknown status
• Patients with STIs within the last 6 months
• Pts must be confirmed HIV negative
• Pts with an eGFR >30
• Eligibility and monitoring guidelines need to be followed to minimize risk of med SEs or missing possible new HIV infx

Question 19

Medications used in PrEP

Answer 19

• Truvada (emtricitabine + tenofovir disoproxil/TDF)
  
  • → daily pill that can reduce HIV acquisition by 90%
• Descovy (emtricitabine + tenofovir alafenamide/TAF)
  
  • →once daily pill that can reduce HIV acquisition by >90%
    
    • →Not for ppl at risk from receptive vaginal sex
• Cabotegravir (injection)
  
  • →initial dose + 4 weeks later another injection, then every 8 weeks thereafter ( 3, 5, 7 etc.)

Question 20

PrEP vs PEP

Answer 20

Question 21

Fitz-Hugh-Curtis Syndrome

Answer 21

• Chronic manifestation of pelvic inflammatory disease
• RUQ pain: associated with a perihepatitis that does not affect the liver parenchyma, just causes inflammation of the capsule of the liver