STIs Flashcards
probable dx of chancroid
Clinical findings compatible with the diagnosis plus negative darkfield microscopic examination for Treponema pallidum (chancre), negative serologic test for syphilis, and negative culture for herpes simplex virus (HSV) or a clinical presentation not typical for herpes.
Incubation period of chancroid
4-10 days
understanding dilution
**changes in titer- a titer should be obtained just before initiating therapy (ideally on 1st day of tx) since titers can increase dramatically over a few days between dx of syphilis and treatment initiation***
Incubation of chlamydia in women
7-14 days following infection
recurrent hsv
reactivation of genital hsv in which the hsv type recovered in the lesion isthe same as the antibodies in the serum
tx hsv2
acyclovir, valacylovir, famciclovir will decrease frequency and the duration of recurrences. Can do suppressive therapy of 500mg a day of Valtrex since 33% of the time you are pre-prodromal and begin viral shedding. Episodic is 1000mg Valtrex daily x 3 days.
treatment for syphilis
abx tx must be prolonged since T. pallidum divides slowly (average is 1 doubling vivo per day) tx in early and late stages- single dose of benzathine penicillin G (2.4 million units IM) this provides low but persistent serum levels of penicillin and is standard for therapy for primary, secondary, pr early latent syphilis
Chancre
Painless ulcer on the shaft of the penis or the labia dx with venereal syphilis. 1-2cm in diameter and raised, smooth, sharply defined borders. Chancre is concave in the center.
Symptoms of extensive condyloma acuminatum involving vulva
vaginal discharge, pruritis, bleeding, burning, tenderness, pain
s/s PID in women
abd pain, abnormal vaginal bleeding, dyspareunia. Nongonococcal salpingitis may be febrile and more ill. Bartholinitis. Complications w pregnancy
Advantages for azithromycin in tx chlamydia
intracellular and tissue penetration, single dose due to half life of 5-7 days, can be used in pregnant patients
Infection of H. ducreyi leads to
erythematous papule which rapidly evolves into a pustule that erodes into an ulcer
Women with gonorrhea
Can be isolated to the urethra in 90% of cases, may only have urinary s/s of dysuria, urgency, frequency. Worry about PID and Cervicitis.
Aldera
cream BID to penetrate lesions that are obvious. If lesions are inside rectum need colorectal surgery
Questioning and ROS
critical in syphilis. 12 months has massive meaning- be very accurate. be redundant in your questioning to get the correct information
Use of cephalosporins in gonn
used because of non cephalosporin resistance. Uncomplicated use ceftriaxone 250mg IM plus Azithromycin 1gram to cover for chlamydia or can do 100mg Doxy BID x 7 days instead which is for azithromycin intolerant patients and for cases of epididymtsis or proctitis
Treat chancroid
one dose Azithromycin 1g PO or Rochephin 250mg IM - less desirable, Cipro 500mg PO BID x 3 days
Tx Chancre
Heals 4-6 weeks even w out treatment. Primary syphillus tx is PCN G IM. PCN allergy use Doxy or Tetracycline.
diagnostic work up of primary syphilis
- diagnosis can be made by dark- field examination which has a high specificity for T. pallidum
(since this test is not readily available, dx is generally based on clinical suspicion and a positive RPR serology which occurs in 85% of primary cases)
Quinolones in tx Chlamydia
Ofloxacin and Levofloxacin are highly effective but need a full week of therapy and are more expensive, they CANT BE USED IN PREGNANT OR LACTATING WOMEN and can not be used in ADOLESCENTS YOUNGER THAN 18 D/T BONE ABNORMALITIES. Oflaxacin 300mg PO BID x 7 days. Levofloxacin 500mg PO once daily x 7 days. Only good for non pregnant and older who cannot tolerate first line therapy of doxycycline or azithromycin
false positive nontreponemal tests have been associated with?
pregnancy, IV drug use, TB, and rickettsial infection
Skin lesions in disseminated gonorrhea
Fever with painful joints, tender necrotic ulcers painful pustular gonn, painless is syphillus… hemorrhagic vesicopustule of the web space of the hand and sole of foot… fever with necrotic vesicles on arms and legs, tender purpuric papules on right leg with fever and joint pain
Cutaneous manifestations of gonorrhea
can have penile ulcers, purulent discharge of the urethra will also be present. Penile edema can be present painless swelling. More common in young boys. Skin lesions are in disseminated gonococcal infection with typical small pustular skin lesion
pregnant women can transmit T. Pallidum to their fetus (ie, congenital infection) for up to ?
for up to 4 years
what should be ordered if late syphilis is suspected?
spinal tap
a confirmed 4 fold increase in the non- treponomal titer signifies?
treatment failure, so need re- treatment (but definitive criteria for cure or failure have not been established)
trepnoemal tests
Treponemal tests have historically been more complex and expensive to perform; **they have traditionally been used as confirmatory tests for syphilis** when the nontreponemal tests are reactive nemal infect
Description of Behcets syndrome
painful “punched- out” apthous- type ulcers with rolled borders and necrotic bases on the patient’s penis
ulcers erupt in a cyclical pattern that may persist for several weeks
Male symptoms of chlamydia
Penile discharge, burning with urination, burning and itching around penile opening
what is considered a significant change reflective of a response to tx of syphilis (when talking about titers)?
a 4 fold decline in titer, equivalent to a change of 2 dilutions (i.e. from 1:16 to 1:4 or from 1:32 to 1:8) is considered a significant change
Chancroid treatment
Also tx for syphillus due to frequent coinfection. Tx options include erythromycin, bactrim, cipro, rochephin, azithromycin. Proven chancroid: 1 g PO Azithromycin or IM Rocephin. Examine and treat the sex partners for chancroids.
need what 2 lab tests for syphilis
RPR (non treponemal) and FTA (treponemal) if both positive- true case
important distinctions of stages of syphilis
primary: ulcer or chancre at the infection site
secondary: manifestations include (not limited to) skin rash, mucocutaneous lesions, and lymphadenopathy
tertiary: cardiac or opthalmic manifestations, auditory abnormalities
latent infections: those lacking clinical manifestations are detected by serologic testing
Genital warts the where and why
Women - primarily caused by vaginal intercourse or from receptive anal or extension of vulvar infection. men - preputial cavity or penile shaft through heterosexual or homosexual contact. Increase risk with increased partners. Symptoms vary depending on number of lesions and location.
Podofilox
stretch skin and put acid into the lesion BID 4 days on and 3 days off for 4 weeks
what is this?
chancre of primary syphilis
What is this?
If > 3 herpes outbreaks each year screen for
HIV
Chlamydia trachomatis in Women
Most common BACTERIAL cause of STIs. Most women are asymptomatic. If infected at the cervix have 0 s/s. Pyuria but no bacteriuria suspect chlamydia infection of the urethra.
Most efficient initial treatment for warts
Podofilox - a teaching moment
Typical chanchroid ulcer size
1-2cm diameter
What is this?
a chancre d/t syphilis is an ulcerative lesion that is often painlass and has an indurated character. They arrive at the site of initial inoculation of the organism.
the most common manifestations of late syphilis, when do they appear?
- central nervous system involvement (neurosyphilis)
- cardiovascular syphilis (especially aortitis)
- gummatous syphilis (very uncommon in the present era)
They appear at any time from 1 to 30 years after primary infection
Invasive infections of gonorrhea
endocarditis, menigitis, disseminated gonococcal infection can all lead to morbidity
Incubation of chlamydia in men
5-10 days following infection
Clinical sydromes common in women and men
conjunctivitis, pharyngitis, genital lymphogranuloma venereum
treponemal tests include
Fluorescent treponemal antibody absorption (FTA- ABS) Microhemagglutination test for antibodies to T. pallidum (MHA- TP) T. pallidum particle agglutination assay (TP- PA ) T. pallidum enzyme immunoassay (TP- EIA)
probable late latent phase of syphilis
syphilis must also be asymptomatic and have serologic and have serologic evidence of disease. However- NO evidence of that the disease was acquired within the last 12 months.
They don’t know when they got it.
Always rule this out when treating an STI
Pregnancy.
treatment for late syphilis
requires 3 doses of 2.4 million units benzathine penicillin G IM each at one week intervals. Neurosyphilis (considered late) requires IV therapy with penicillin (IV penicillin G, 3- 4 million units Q4 or 18-24 million units per day by continuous infusion for 10 to 14 days)
incubation period of syphilis?
varies from 10 to 90 days (average about 3 weeks)
diagnosis of secondary syphilis
- screening for syphilis is achieved by the rapid plasma reagin (RPR) or the venereal disease research lab test (VDRL)
- all positive tests should be confirmed with tluorescent treponemal antibody (FTA)
what is this?
primary syphilis chancre
neurosyphilis
- CNS involvement can occur during any stage of syphilis
- pts who have clinical evidence of neurologic involvement with syphilis (cognitive dysfuntion, motor or sensory deficits, opthalmic or auditory symptoms, cranial nerve palsies and symptoms or signs of meningitis) should have a CSF examination
- syphilitic uveitis or other ocular manifestations frequently are associated with neurosyphilis
Incubation of chlamydia
7-14 days following infection
Making the dx of Chlamydia
silent disease, 3/4 women no s/s, 1/2 men no s.s. If + s/s, usually 3 weeks after exposure. Dx with nucleic acid amplification testing for the genitourinary tract. use vaginal swabs for women, first catch urine for men
mucous patches of secondary syphilis
could appear on a variety of mucous membranes
(highly infectious)
Treatment for secondary syphilis
- treatment for early disease (primary and secondary for less than 1 year) is 1 dose of IV benzathine penicillin G
- for late disease, PCN G is given once a week for 3 weeks.
- follow up includes RPR at 3, 6, and 12 months to assess respinse to treatment
Refer this since condylomata to surgery
1-2cm at the base - can burn the stalks off by colorectal surgery
lymphadenitis with chanchroid
follow up in 7-10 days, this is from the infection itself, if after treatment and still enlarged need to rule out lymphoma
Herpes clinical designations
primary, nonprimary first episode, and recurrent. underrecognized because infection is subclinical.
what is behcet’s syndrome?
- it is an inflammatory, multisystem syndrome of recurrent apthous ulcers affecting the mouth, skin, eyes, and/or genitals.
- it may also be associated with synovitis, thrombophlebitits, or neurological disorders
Treatment for warts that can be self administered
podofilox 0.5%
treatment of primary syphilis
Benzathine penicillin G 2.4 million units IM in one dose
Alternative tx in the PCN- allergic consists of doxycycline 100mg PO BID for 2 weeks.
(RPR testing should be repeated 3, 6, and 12 month intervals until there is a fourfold drop in titer.)
Female genital herpres simplex virus
very painful, open moist infectious, can use lidocaine paste
DX Condylomata
visual inspection, can do exam with anoscopy, sigmoidscopy, colposcopy or vaginal speculum exam as appropriate. Can put 5% acetic acid to turn lesions white but not specific. Can biopsy if uncertain. If anal lesions need a DRE and to send to colorectal surgery, do DRE with pt on all 4s.
Female s/s chlamydia
Cervix and urethra are initially infected, if they do have s.s it is usually abnormal vaginal discharge or a burning sensation when urinating. if fallopian tubes infected may have abd pain, low back pain, nausea, fever, pain during intercourse, can spread to rectum from the cervix. Can have rectal or oral pain, discharge, bleeding.
Quinolones in tx Chlamydia
Ofloxacin and Levofloxacin are highly effective but need a full week of therapy and are more expensive, they CANT BE USED IN PREGNANT OR LACTATING WOMEN and can not be used in ADOLESCENTS YOUNGER THAN 18 D/T BONE ABNORMALITIES. Oflaxacin 300mg PO BID x 7 days. Levofloxacin 500mg PO once daily x 7 days. Only good for non pregnant and older who cannot tolerate first line therapy of doxycycline or azithromycin
MSM extragenital infections of gonorrhea
pharynx and rectum
Patients with chancroid should be also treated for what?
Co -infection w T. pallidum - causative agent of syphillus.
description of primary syphilis
- 2-3 mm ulcer on the distal shaft of the penis with an indurated, raised, firm border
- scant exudate at the ulcer base
- ulcers are relatively painless unless secondarily infected
- regional nonsupportive adenopathy generally develops in 50- 85% of patients within one week.
perianal condyloma acuminatum
around rectum, can be itchy, leading to autoinoculation from scratching
understanding the serologic evidence- probable early latent syphilis
A. Patients without a past diagnosis of syphilis must have a reactive nontreponemal test (eg, VDRL, RPR, or equivalent serologic methods) *AND* a reactive treponemal test (eg, F TA-ABS, TP- PA, EIA, CIA, or equivalent serologic methods) B. Patients with a prior history of syphilis must have a current nontreponemal test titer that demonstrates a **fourfold or greater** increase from the last nontreponemal test titer. • Accurate history of the last 12 months is critical
Men with gonorrhea
Symptomatic urogenital gonococcal infections in men include urethritis and epididymitis. Discharge spontaneously from the urethral meatus, purulent or mucopurulent in color and copius. Scrotal heaviness until ejaculation. Profuse penile discharge with dysuria 5 days after unprotected sex. Gram stain of discharge shows polymorphonuclear gram negative diplococci. Can be from oral sex w someone with tonsil gonorrhea too.
Dx Chancre
sample the chancre. Treponema pallidum, a corkscrew organism under DARKFIELD microscopy. RPR and VRDL serological syphillus tests – is nonreactive in 25 percent. FTA-ABS TEST IS DEFINITIVE.
Chancroid
Hemophilus ducreyi needs to be detected to be a true chancroid, a small, fastidious negative rod isolated from the lesion. Penile ulcer due to chancroid which is accompanied by marked inguinal lymphadenitis. Definite dx is when you isolate H. ducreyi from the lesion.
Chlamydia trachomatis
Most common bacterial cause of STIs. Most women are asymptomatic. If infected at the cervix have 0 s/s. Pyuria but no bacteriuria suspect chlamydia infection of the urethra.
Chlamydia - the what in Men - Caused by, s/s,
C. trachomatis is the most common cause of non-gonococcal urethritis in men. Watery, urethral discharge, prominent dysuria. In contrast to copious, purulent green soup discharge found in gonorrhea w a shorter incubation period of 2-7 days.
probable early latent syphilis
considered “probable” if a patient has no clincal signs or symptoms of syphilis and has serologic evidence of T. pallidum infection that was aquired within the last 12 months
believed to be potentially infectious
Must consider these conditions when treating chlamydia in men
Epididymitis, prostatitis, proctitis because is changes abx course takes longer to get through enlarged prostate
Chlamydia transmission
Transmission: oral sex, vaginal sex, anal sex, mother to child during birth, greater with greater number of sex partners. Sex partners need to be evaluated.
drawbacks of doxy in tx chlamydia
costs less but there are supply shortages, may not be compliant week long and BID
Gonococcal infection - the what
Bacterial gram negative coccus Neisseria gonorrhoeae, major cause of morbidity worldwide. In men can cause urethritis and in women cervicitis. In women: can result in PID, ectopic pregnancy, infertility and chronic pelvic pain
Selcting abx for gonorrhea what other disease should you treat?
Chlamydia, esp since it is asymptomatic in women
Warts inside mouth tx
burn off by dental surgery
latent syphilis aquired within the preceding 12 months is referred to as ?
early latent syphilis. (all other cases are either late latent or latent of unknown duration)
Genital warts (Condylomata acuminata - anogenital warts) the What
most common VIRAL STI in the united states. Incubation 3 weeks to 8 months. Most are transient and clear within 2 years. Increase risk for anogenital cancers. Passed sexually. Contact transmission, spread from fomites, digital/anal, oral/anal, digital/vaginal. Gardasil provides protection as warts lead to HPV.
HSV1
herpes labialis, vesicle lesions of the oral mucosa cold sores, can also be in the genitalia, liver, lung, eye and central nervous system. need a good hx to dx. confirm with lab testing
what can syphilis be compared to ?
proteus- changed shape to avoid attention. Protean means as mutable and adaptable as the mythological shepard.
Complications of gonn in men
penile lymphangitis, penile edema - bulls head clap - periurethral abscess, post inflammatory strictures, epididymitis. Can spread to rectum or phaynx
Primary hsv
infection in a patient without preexisting antibodies to either hsv1 or hsv2
nonprimary hsv
acquisition of genital hsv-1 in a patient with preexisting antibodies to hsv2 or vice versa ie a patient with prior orolabial herpes and subsequent development of hsv1 antibody response then develops genital herpes due to hsv2 exposure
WBC w Urethritis in Gonorrhea
>5 with s/s urethritis
understanding the serologic evidence- probable late latent syphilis
A person with “probable” late latent syphilis must also be asymptomatic and have serologic evidence of disease as described for **probable early latent** • There is no evidence that the disease was acquired within the last 12 months
description of secondary syphilis
- erythmatous, non- pruritic papules on back, torso and palms consistent with secondary syphils
- normally appears around 6 weeks after the inital lesion (chancre)
- often accompanied by flu- like illness, hepatosplenomegaly and lymphadenopathy
- lesions vary widely causing the axiom “the great imitator”
- usually erythematous or pink, papular and occur diffusely, notably on the palms and soles
Diagnostic workup of HSV2
Confirmed by VIRAL CULTURES. Use culture to confirm first episode since antibodies take weeks to develop.
Recurrence of s/s chlamydia
after initial resolution need a repeat test for chlamydia and other STIs causing urethritis or cervicitis such as gonorrhea or BV.
Who developed serologic testing for syphilis?
Wasserman in 1906
probably dx of chanchroid
one or more probably ulcers, no evidence of t pallidium by darkfield exam of ulcer exudate or serologic testing, clinically presents as chancroid, HSV on ulcer is negative
treatment for behcet’s syndrom
topical tx of ulcers with glucocorticosteroids and oral NSAIDS for pain relief are mainstays of treatment.
HSV2 Vaginitis
Grouped vesicular lesions on an erythematous base on the vulva. 70-90% of cases of genital herpes are caused by HSV2. HIGHLY CONTAGIOUS. Characterized by recurrent outbreaks of grouped vesicles on an inflammed red base. CLASSIC PRODROME of burning or itching, with flu like symptoms followed by an outbreak of vesicles
Pregnant tx with gonn
dual therapy: Ceftriaxone plus Azithromycin, avoid Doxy
diagnostic work up for behcet’s syndrome
diagnosis based upon clinical presentation; recurrent ulcers with at least 2 other systems affected
Gonococcal conjunctivitis the when
Autoinoculation from anogenital source. Can lead to an outbreak from fomites, vectors, person to person non sexual contact, Mainly affects infants born to untreated mothers
Clinical designations of HSV
Primay, nonprimary first episode, recurrent
immune modulator agents for warts
aldara and interferon – needs repeat applications
C. trachomatis is highly susceptible to
tetracyclines and macrolides. first line: azithromax 1gm single dose or doxy 100mg PO BID x 7 days if adherent and not pregnant
