STIs Flashcards
Impact of STIs?
- sterility, cancer, and death
RFs for STIs
- unmarried
- residence in urban area
- new sex partners
- multiple sex partners (concurrent)
- history of a prior STI
- illicit drug use
- contact with sex workers
- young age (15-24)
- African-American race
- admission to correctional facility or juvenile detention center
- meeting partners on the internet
Causes of genital ulcers (STI and noninfectious etiology)
STI:
- HSV
- Treponema pallidum (syphilis)
- Haemophilus ducreyi (chancroid)
- chlamydia trachomatis (lymphogranuloma venereum; LGV)
noninfectious etiology:
Behcet’s disease
fixed drug reactions and trauma
HSV infection -> causative agents
- causative agents: HSV- 1 and HSV-2
- no longer separated into genital and oral
- both serotypes can cause either type of infection
Very common: 50 mill people in US - frequently under-recognized b/c infection is often subclinical
Types of HSV infection
Primary: infection in a pt w/o abs to HSV-1 or HSV-2
nonprimary: 1st episode infection due to acquiring HSV-1 w/ preexisting abs 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 abs recovered in the serum
Symptoms of HSV infection
- Primary: highly variable from very symptomatic to asymptomatic
- sxs tend to be more severe in women than in men
- systemic sxs, local pain/itching, dysuria, lymphadenopathy
- Dysuria can be due to acute urinary retention or more rarely to lumbosacral radiculomyelitis
nonprimary: less symptomatic than first episode
recurrent: less severe, shorter duration
- asymptomatic shedding
- if women get in cervix or vagina it could go unnoticed, shedding virus without lesions
Transmission of HSV
- highly transmittable
- can be transmitted by oral-genital contact
- greater risk of acquiring HSV w/ male source
- 70% of transmission occurred during periods of asymptomatic shedding
- condom use 50% decline in transmission
- HSV -2 genital ulcer disease has been linked to an increased risk for acquiring HIV-1 infection (any break in the skin increases risk of HIV)
Dx HSV
- viral culture: if active lesions present
- PCR: more sensitive
- Direct fluorescent ab
serology:
- type-specific ab testing of serum
- helps to determine if the pt is at risk of acquisition
- determines if pt has hard evidence of prior infection
- can do screening for HSV
Tx of HSV
drugs:
acyclovir
Famcilovir -> more bioavailable
Valacyclovir -> more bioavailable/BID
primary genital HSV: should be treated (w/in 72 hours) - decreases duration of symptoms - 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 1st sign of prodromal symptoms usually take for 3 days
- no intervention
HSV in pregnancy
- most common mode of transmission is from direct contact of fetus w/ infected vaginal secretions during delivery
- Maternal immunity is impt: if mother contracted HSV before pregnancy -> have abs that will transfer to baby
- biggest risk: if mother contracted HSV while pregnant
- Acyclovir can be used to tx a primary infection
prophylactic C-section: do if active lesions at birth canal, not recommended if mother has no active lesions or if lesions have crusted at time of delivery (or have feeling of prodromal sxs), not recommended if have active nongenital HSV lesions
Prevention of HSV
- counseling!!!
- pts need to be educated that they may not have acquired the infection recenetly and that there has not necessarily been infidelity in a monogamous partner
- education on recurrences
- monogamous partner testing
- telling future sexual partners
Syphilis causative agent and tests available?
- Treponema palidum
can’t be cultured, can be seen with dark field microscopy - serologic tests available: nontreponemal: VDRL, RPR, TRUST/ reported as titers
treponemal: reported as reactive or nonreactive: - fluorescent treponemal ab absorption
- microhemagglutination test for abs to T. palidum
- Treponema palidum particle agglutination assay
- Treponema pallidum enzyme immunoassay
Who should be screened for Syphilis?
- pt with suspected disease
- screening high risk populations (pts with other STIs, persons with multiple sex partners)
- routine screening of pregnant women
- commercial sex workers
- all sexually active HIV infected pts at least annually, more frequent screening for those w/ multiple sex partners and unprotected intercourse
What is syphilis associated with?
- reportable infection in the U.S.
- number of cases increasing since 2001: primarily in MSM (HIV pop not using protection, syphilis started to spread then branched out into other populations
- also in heterosexual pop.
- *It is associated with an increased risk for acquisition and transmission of HIV
- all pts who are dx with syphilis should be offered HIV testing and counseling
Transmission of Syphilis?
- Primary and secondary syphilis produce chancres, mucous patches and condyloma lata
- estimated transmission occurs in 30% exposed to someone who is infected
- syphilis can be spread by kissing or touching a person who has active lesions on the lips, oral cavities, breasts or genitals
- it can be acquired through passage through the placenta
Primary syphilis characteristics
- incubation period of 2-3 weeks from inoculation - a papule forms and soon ulcerates to the chancre
- chancre is usually painless
- usually there is bilateral lymphadenopathy
- chancres heal spontaneously within 3-6 weeks even without tx
- widespread dissemination of the organism occurs at the same time
Secondary syphilis characteristics
- weeks to a few months later 25% of people with untreated infections will develop systemic illness:
- rash: any form BUT vesicular, includes palms and soles.
- Gray/white lesions warm moist areas -> condyloma lata
- systemic sxs
- lymphadenopathy
- alopecia (patchy)
- hepatitis
- GI abnormalities ( can be misdx as lymphoma)
- musculoskeletal and renal abnormalities
- ocular disease
Tertiary syphilis characteristics
- 1-25 years after secondary syphilis: early tertiary syphilis presents = year
- late tertiary syphilis presents > 1 year from initial infection
systems involved:
-subcutaneous tissue (gumma) - granulomas
-CV: ascending thoracic aorta becomes dilated aortic valve regurgitation occurs.
CNS (most common):
early: meningitis, meningiovascular disease
late: general paresis, tabes dorsalis, ocular, otosyphilis
Characteristics of neurosyphilis
- when suspected need to do a lumbar puncture
CSF findings: lymphocytic pleocytosis, elevated protein, + CSF-VDRL and or FTA-ABS
Need to follow CSF during tx to make sure there is a response (lumbar punctures)
Tx of early syphilis
For primary, secondary syphilis and early latent:
- 2.4 mill units of benzathine PCN G IM
- for PCN allergies DOC: doxy 100 mg BID for 14 days
- tetracycline, azithro, and ceftriaxone are other alternatives although not well documented.
Tx for late syphilis
- pts with gumbos or CV involvement need to have a LP to r/o neurosyphilis tx
- if they have localized disease tx is:
- 2.4 mill units of benzathine pin G IM weeks for 3 weeks
- gumma will resolve
- it will only halt progression of CV disease and some prefer to treat CV disease like neurosyphilis
Tx for neurosyphilis
- IV PCN G either 3-4 mill units q 4 hrs or 18-24 mill units per day by continuous infusion for 10-14 days
- pts who are allergic to PCN should undergo desensitization since PCN G is doc for tx neurosyphilis and an allergist should be consulted
- non-pcn regimens are not recommended for pts w/ documents neurosyphilis
Monitoring tx of syphilis
- pts need to be reexamined clinically and serologically at 6 and 12 months after tx
- a fourfold reduction in titer of the nontreponemal ab test is evidence of a response to therapy
- a titer should be drawn just prior to starting tx and the same test and lab should be used for f/u
- Think tx failure or reinfection if not getting better
HPV who it infects
- double stranded DNA viruses Papillomavirus genus
- Human HPV only infects humans
- more than 100 types of HPV
- 75-80% sexually active adults will acquire genital tract HPV b/f age of 50
How does HPV manifest?
- genital warts (condyloma acuminatum)
- Bowenoid papule and Bowen’s disease
- Giant condyloma (Buschke-Lowenstein tumors)
- 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 in the oral cavity
HPV genotypes
- over 40 mucosal HPV genotypes infect lower female genital tract
- carcinogenic types HPV16 & HPV18 account for 70% of all cervical cancers worldwide
- HPV6 and HPV11 cause about 90% of genital warts
Natural hx of HPV
- most HPV infections usually resolve w/in 6-12 months (Including the carcinogenic HPV genotypes)
- paradigm of cervical carcinogenesis:
- HPV acquisition
- HPV persistence
- Progression of persisting infection to precancerous lesion
- local invasion
Anogenital warts
- most common viral STI disease in the U.S.
- 67% of pts -> women
- persistent infection especially w/ other risk factors (such as infection w/ HIV) can result in development of squamous cell carcinoma
- acquisition is related to sexual activity
- Fomites can also spread the virus
Sxs of anogenital warts
- depends on number, size, and location
- asx
- pruritus, burning
- bleeding
- tenderness, pain
- discharge (women)
- large condylomata can interfere with defecation intercourse and vaginal delivery
- lesions in proximal anal canal may cause strictures
Dx of anogenital warts
- usually made by visual inspection
- document extent of involvement by PE, anoscopy, sigmoidosopy, colposcopy (looks at vagina and cervix), and/or vaginal speculum exam
- 5% acetic acid causes lesions to turn white
- biopsy can be considered:
when dx is uncertain or presence of atypical features - lesions that don’t respond to tx
Tx of anogenital warts
- spontaneous regression occurs 20-30% of cases
- al therapies have a 30-70% recurrence rate
ablative:
Podophyllin (CI in pregnancy)
Imiguimod (Aldara)
Trichloroacetic acid
5-fluoruracil (5-FU) - intralesional injected alpha interferon
Excisional:
cryotherapy (freezing) - laser therapy: reqrs anesthesia/ risk of scarring
- excisional procedures w. knif or scissors: reqrs anesthesia, risks of infection and hemorrhage, need to send specimen to path
Prevention of HPV
- gardisil 9:
16, 18, 31, 33, 45, 52, 58 (cancers: cervical, vulva, penile, vaginal, throat)
6 and 11 -> anogenital warts
recommendations for vaccine:
- 9-26 in women
- 9-15 in males
monitoring of women with pap smears currently recommended, needs to continue
Urethritis in Men causes?
- 3 main causes:
gonorrhea: common cause - usually can get discharge w/ milking the urethra, urethral swab: +WBC & +gram negative intracellular diplococci
- chlamydia: common concurrent infection or may be primary
- Trichomonas vaginalis: cause of nongonococcal urethritis (NGU)
Trichomonas vaginalis
- accounts for 20-35% of vaginitis dx in sx women in primary care settings
- flagellated protozoan, humans only natural host
- Trichomoniasis:
- always sexually transmitted
- assoc w/ high prevalence of coinfection w/ other STIs
- organism can be ID in 30-40% of male sex partners of infected women
Trichomoniasis presentation in women
- asymptomatic carrier state
- symptomatic cases:
purulent, malodorous, thin discharge (70%) - burning, pruritus
- dysuria, frequency -> urethral involvement
- dyspareunia, postcoital bleeding
Dx of trichomoniasis
- vaginal swab: wet mount for microscopy in normal saline
- can see motile trichomonads (dx)
- classic: green, frothy, foul-smelling discharge (4.5) & increased PMNs
- culture on diamond’s media: test not readily available, takes up to 7 days for results
Trichomoniasis tx
- Metronidazole (Flagyl):
single oral dose of 2 gems
500 mg BID for 7 days (if recurrent infection) - metranidazole tx for symptomatic pregnant women (if not sx -> not tx)
- male partners need to be tx for maximal cure rates in women
- no intercourse until all parties are tx
Trichomoniasis in men
- usually transient q/ spontaneous resolution and asx
- sxs are typical for urethritis
- no definitive dx tests: low yield with swabs for motile organisms
- tx is usually b/c of + female dx or empirically for NGU
Neisseria gonorrhea
- 2nd most commonly reported communicable disease in U.S.
- trend toward decreasing infections, lowest 1970s
highest rates among: adolescents/ young adults minorities persons living in the SE U.S - increasing abx resistance
Gonorrhea manifestations
- women: any portion of the genital tract (PID -> causes infertilitry, abscesses), most common site is the cervix, urethritis
- men: urethritis, epididymitis, proctitis (anal region)
- oropharyngeal infections: frequently asymptomatic
Disseminated gonococcal infection (DGI)
- occurs in 1-3% of pts infected
- 3x more common in women than in men
- hx of recent symptomatic genital infection is uncommon
- asymptomatic mucosal infection predisposes
- pt w/ decreased immunity more at risk: pregnancy, SLE, complement deficiencies
Manifestation of DGI
- triad: tenosynovitis, dermatitis, polyarthralgias:
acutely systemic signs/sxs occur
multiple tendons are inflamed (small joints)
skin: painless lesions, few in #, transient
purulent arthritis w/o skin lesions:
- knees. wrist, and ankles most common joints
- typically asymmetric, sometimes there is overlap with triad
(joint will become septic if you don’t tap and tx)
Dx of gonorrhea
culture: can be difficult-> organism fastidious
gram stain: used primarily dx of urethritis in men
Nucleic acid amplification testing (NAAT):
recommended as optimal method for dx
amplifies N. gonorrhoeae DNA or RNA sequences using various techniques
- samples: endocervix, vagina, urine, urethra in men
- not approved for nongenital sites (culture those)
Tx of Gonorrhea
- ceftriaxone preferred tx: resistance emerging -> 250 mg IM single dose
+ (to cover tx of chlamydia)
azithro 1 gram single dose or
doxy 100 mg BID for 7 days except in pregnant women - give in office
- if allergic to ceftriaxone can give azithro 2 g single dose
alt: cefotaxime and cefoxitin w/ probenecid
Epididymitis tx
in men if intolerance to doxy then can use azithro > but f/u evals are needed
Chlamydia trachomitits
- small gram - organism, oblique intracellular parasite
- immunity to infection isn’t long lived hence reinfection or persistent infection is common
- 4,000,000 cases in women are estimated to occur annually in U.S. -> making it the most common STI
- prevalence in men more difficult to determine -> common to screen women and tx men empirically
- chlamydia is on the rise in both genders
Clincial manifestations of chlamydia in women
- asymptomatic, common presentation, usually picked up on routine check or culture
- cervicitis
- urethritis
- PID: 30% of women w/ chlamydia will develop PID if left untx
pregnancy: if left untx can increase risk of premature rupture of membranes and low birth weight
- newborns can develop conjunctivitis and pneumonia (when mother untx)
Chlamydia tx
- often coexists w/ gonorrhea so tx for both
- 1st line agents: azithro: 1 g single dose
- or doxy: 100 mg BID for 7 days (cheap)
2nd line agents: expensive and CIs:
- ofloxacin for 7 days
- levofloxacin for 7 days
- test for cure in pregnant pts
chlamydia manifestations in men
urethritis
epididymitis: men
Dx of chlamydia
- culture
- NAAT: vaginal, urethral, urine specimens (gold std)
- AG detection: swab from cervix/ urethra
- genetic probe: swab from cervix/ urethra
- chlamydia rapid testing: under development
- reportable infection
Pregnancy routine early screening for what?
- chlamydia
- gonorrhea
- syphilis
- Hep B
- offered test for HIV
- take hx for HSV
- pap done to assess for HPV
STI prevention
- ID those at high risk and screen
- HIV positive persons need to be screened for other STIs
- counsel safe sex behavior and protection especially those who are most likely to engage in risky behavior
