STIs Flashcards
When you touch each other…
you will get pregnant, and you will die.
Risk factors for STIs
unmarried residence in an urban area new sex partners multiple sex partners history of a prior STI illicit drug use contact with sex workers young age (15-24) african american admission to correctional facility or juvenile detention center meeting partners on the internet
What are the potential etiologies for a patient with a genital ulcer?
STI- HSV, syphilis, chancroid, LGV
noninfectious- Behcet’s disease, fixed drug reactions and trauma
Herpes Simplex Virus (HSV)
causative agents
types of infection
HSV-1 and HSV-2
Types
- Primary: infection in a patient without antibodies to HSV1 or HSV-2 (has lesions but not abys)
- Nonprimary: first episode infection due to acquiring genital HSV-1 w/ preexisting antibodies to HSV-2 or vice versa
- Recurrent: reactivation of genital herpes in which the HSV type recovered in the lesion is the same type as the antibodies recovered in the serum
HSV Sx
primary
nonprimary
recurrent
primary
- highly variable from symptomatic to asymptomatic
- sx tend to be more severe in women
- systemic sx, local pain/itching, dysuria (d/t urinary retention or more rarely to lumbosacral radiculomyelitis), lymphadenopathy
nonprimary
-less symptomatic than first episode
recurrent
-less severe/shorter duration
asymptomatic shedding
HSV
transmission
Dx
HIGHLY transmittable via the oral-genital route
-remember, any break in the skin gives you an increased chance of HIV
Dx
- viral cultrue if active lesions present
- PCR: more sensitive
- direct fluorescent
- serology: type-specific antibody testing of serum, helps determine if the pt is at risk of acquisition, determines if a patient has had evidence of prior infection
- CAN do screening for HSV
HSV
tx drugs
therapy for primary genital infections
therapy for recurrent disease
- Acyclovir (Zovirax)
- Famcyclovir (famvir)
- valacyclovir (valtrax)
Primary HSV
- should be treated within 72 hours
- decreases duration of sx, increases healing of lesions, decreases viral shedding
- analgesics may be required/ sitz baths helpful
Recurrent disease
- chronic suppressive therapy: expensive and may not be covered by all insurance carriers
- episodic therapy: start at the first sign of prodromal sx, usually take for three days
- no intervention
What is the most common mode of transmission of HSV?
From direct contact of the fetus with infected vaginal secretions during delivery
What is used to treat HSV in pregnancy?
Acyclovir
When do we do a prophylactic C-section?
If the mother has active HSV lesions in the birth canal.
Do NOT do if infected mother has:
- no active lesions
- lesions that have crusted
- active nongenital HSV lesions (cold sores)
**Maternal immunity is important
Does HSV always appear right away?
No, it could take years to show up.
-pts need to be educated that they may not have acquired the infection recently and that there had not necessarily been infidelity in a monogamous partner
Syphilis Causative agent Culture? Serological tests available who to screen?
Treponema palidum
Cannot be cultured! Can be seen with DARKFIELD microscopy. Instead, do serological test.
Serological tests-
Nontreponemal: VDRL, RPR, TRUST/ reported as titers
Treponemal: (reported as reactive or nonreactive)
Screen
- patient with suspected disease
- high risk populations (pts with other STIs, multiple sex partners)
- routine screening of pregnant women
- commercial sex workers
- all sexually active HIV- infected patients at least annually; more frequent screening for those w/ multiple sex partners and unprotected intercourse
What do you do when you diagnose a pt with syphilis?
offer HIV testing and counseling
It is a reportable infection in the US
Syphilis transmission
Primary and secondary syphilis produce chancres, mucous patches, and condyloma lata
spread by kissing or touching a person who had active lesions on the lips, oral cavity, breasts, or genitals
can be passed through the placenta
Primary syphilis
incubation period
sx
incubation period of 2-3 weeks from inoculation- a papule forms and soon ulcerates to the chancre
chancre is usually painless, they heal spontaneously 3-6 weeks even without treatment
Usually bilateral lymphadenopathy
Secondary syphilis
sx
-Weeks to a few months later 25% of people w/ untreated infections will develop systemic illness
sx:
- rash: any form BUT vesicular, INCLUDES THE PALMS/SOLES
- grey/white lesions in warm moist areas- condyloma lata
- systemic sx
- lymphadenopathy
- alopecia (patchy)
- hepatitis
- GI abnormalities
- musculoskeletal and renal abnormallities
- ocular disease
Tertiary Syphilis
sx
1-25 years after secondary syphillis:
- early tertiaty syphilis presents = 1 year
- Late tertiary syphilis presents > 1 year from initial infection
Systems involved
- subcutaneous tissues (gumma)- granuloma
- CV: ascending thoracic aorta becomes dilated aortic valve regurgitation occurs
- CNS: (most common)
- -early: meningitis, meningiovascular disease
- -late: general paresis, tabes dorsalis, ocular, otosyphilis
What do you do when you suspect Neurospyhilis?
a Lumbar puncture!
CSF findings:
-lymphocytic pleocytosis
-elevated protein
+ a serological test like CSF-VDRL, and or FTA-ABS
**need to follow CSF during treatment to make sure there is a response
Treatment for early syphilis
For primary, secondary syphilis and early latent:
2.4 million units of PEN G
-for pcn allergy pts, preferred drug is doxy 100mg BID for 14 days
Treatment for late syphilis
-pts with gummas or CV invlvment need to have an LP to r/o neurosyphilis before treatment
if they have localized disease:
- 2.4 million units of PEN G IM weekly for 3 weeks
- Gumma will resolve
- it will only halt progession of CV disease and some prefer to treat CV disease like neurosyphilis
tx of neurosyphilis
- IV PEN G
- pts who are allergic to PCN should undergo PCN desensitization since PCN G is the DOC for treating neurosyphilis and an allergist should be consulted
- non-penicillin regimens are not recommended for pts with neurosyphilis
monitoring
- pts need to be reexamined at 6 weeks and 12 months after tx
- a titer should be drawn just prior to starting tx and the same test and lab should be used for follow up
Human Papillomavirus (HPV) manifestations
Double-stranded DNA viruses Papillomavirus genus
manifestations
- genital warts (condyloma acuminatum)
- bowenoid papules and Bowen’s disease
- giant condyloma (Buschke-Lowenstein tumors) (huge genital warts)
- Intraepithelial neoplasia and/or carcinoma of the vagina, vulva, cervix, anus, or penis
- Plays a role in squamous cell carcinomas of the head and neck particularly the oral cavity
What HPV strains cause cancer? warts?
HPV 16 and HPV 18 account for 70% of all cervical cancers worldwide
HPV 6 and HPV 11 cause about 90% of genital warts
Paradigm of cervical carcinogenesis
*most HPV infections usually resolve within 6-12 months (including the carcinogenic HPV genotypes)
- HPV acquisition
- HPV persistence
- progression of persisting infection to precancerous lesion
- local invasion
What is the most common viral sexually transmitted disease in the US?
Anogenital warts (HPV)
-persistent infections especially with other risk factors (such as HIV) can result in the development of squamous cell carcinoma
Anogenital warts
sx
asymptomatic
pruritis, burning
bleeding
tenderness, pain
discharge (women)
large condylomata can interfere w/ defecation, intercourse, and vaginal delivery
lesions in the proximal anal canal may cause strictures
Anogenital warts
Dx
- dx made by visual inspection
- document extent of involvement by PE,, anoscopy, sigmoidoscopy, colposcopy, and or vaginal speculum exam
- 5% acetic acid (vinegar) causes lesions to turn white
- consider bx when dx is uncertain or presence of atypical features or lesions that do not respond to tx
Anogenital warts
Tx
- spontaneous regression occurs 20-30% cases
- all therapies have a 30-70% recurrence rate
Ablative
- podophylliin (contraindicated in pregnancy)
- imiguimod (aldara)- also used for IEN vulva/anus
- Trichloroacetic acid (applied by provider)
- 5-fluoruracil (5-FU) (applied by provider)
- Intralesional injected alpha interferon
Excisional
- cryotherapy
- laser therapy: requires anesthesia/risk of scarring
- with knife or scissors: requires anesthesia, risk of infection and hemorrhage, need to send specimen to path
What are the three main causes of urethritis in males?
Gonorrhea
- usually can get discharge w/milking the urethra
- Urethral swab will be positive for WBCs and GRAM NEGATIVE INTRACELLULAR DIPLOCOCCI
Chlamydia
-commonly concurrent
Trichomonas vaginalis
-the cause of “nongonococcal urethritis” (NGU)
Trichomonas vaginalis
- causes?
- presentation in women? (because men can be infected with this)
- causes 20-35% of vaginitis in symptomatic women
- always sexually transmitted
Presentation
- can be asymptomatic carrier
- purulent, malodorous, thin discharge (70%)
- burning, pruritus
- dysuria, frequency- urethral involvement
- dyspareunia, postcoital bleeding
Trichomoniasis
dx
vaginal swab
- wet mount for microscopy in normal saline
- can see trichomonads– diagnostic
"Classic"- green, frothy, foul-smelling discharge Elevated pH (>4.5) and increased PMNs Culture on diamonds medium: not readily available and takes up to 7 days for results
Trichomoniasis
tx
- flagyl: single oral dose of 2 grams, 500 mg BID for 7 days (if recurrent infection)
- no intercourse until all parties have been treated!
Trichomoniasis in Men
Sx
dx
tx
sx- usually transient, asymptomatic
dx- no definitive diagnostic tests
tx- usually because of positive female dx or empirically for NGU (because sx are typical for urethritis)
Neisseria gonorrhoeae
Manifestations (women/men)
- second most commonly reported communicable disease in US
- increasing abx resistance!
Manifestations
women: any portion of the genital tract (PID), most commonly the cervix, urethritis
men: urethritis, epididymitis, proctisis
Oropharyngeal infections: frequently asymptomatic
What is DGI?
How does it manifest?
Disseminated Gonococcal Infection
-occurs in 1-3% of infected patients, more common in women
Manifestation:
Triad
-tenosynovitis (inflammation and swelling of a tendon), multiple tendons are inflamed (small joints)
-dermatitis, painless lesions, few in number, transient
-polyarthralgias
Purulent arthritis without skin lesions:
-knees, wrists, and ankles most common joints, typically asymmetric, sometimes overlaps with triad
Gonorrhea
dx
- culture can be difficult
- gram stain: used primarily in dx of urethritis in men
- NAAT (nucleic acid amplification testing): optimal method for dx, not approved for nongenital sites (culture those)
Gonorrhea
tx
250 mg IM Ceftriaxone single dose
PLUS *to cover for chlamydia
1 gram single dose of Azithromycin (zithromax)
Watch them take it in the office
If allergic to ceftriaxone can give azithromycin 2 gr single dose
Epididymitis
tx
In men
Chlamydia trachomitis
facts
manifestations in women
manifestations in men
- Most common STI in the US
- small gram negative organism, obligate intracellular parasite
- immunity to infection is not long-lived hence reinfection or persistent infection is common
manifestations
- asymptomatic! (typically)
- cervicitis
- urethritis
- PID
- if left untreated, can increase risk of premature rupture of membranes and low birth weight, newborns can develop conjunctivitis and pneumonia (when mother is untreated)
Men
- urethritis
- proctitis (uncommon)
- epididymitis
Chlamydia
tx
*often coexists w/ gonorrhea so treat for both!!!
first line agents: -azithromycin (zithromax) 1 gr single dose -doxycycline 100mg BID for 7 days Second line agents: -Ofloxacin/levofloxacin for 7 days
Chlamydia
dx
- culture
- NAAT (gold standard)
- antigen detection
- genetic probe
- chlamydia rapid testing (under development)
What are the reportable infections?
Syphilis, DIG, and chlamydia
What do you screen for routinely in pregnancy?
chlamydia gonorrhea syphilis hep B Offer test for HIV take history for HSV PAP done to assess for HPV
Don’t let youre affection give you an infection
Put some protection on that erection
