STIs Flashcards
What is the genome of Herpes simplex virus?
Enveloped, large ds DNA virus
____ is the most common etiology of sexually transmitted genital ulcers
Herpes Simplex Virus
How does a primary herpes infection present?
Can be severe including painful ulcers, dysuria, fever, tender LAD, and HA
Ulcers typically last around 3 weeks
What does HSV do after primary infection?
HSV establihses a latent state followed by viral reactivation and recurrent local disease (note that genital disease resides latently in sacral ganglia)
How does recurrent HSV infection present/
Can be mildly symptomatic or asymptomatic and lesions tend to only last around 10 days
How is HSV diagnosed?
PCR of lesions is gold standard. If you have an intact vesicle, want some of the fluid underneath for PCR
- viral culture is about 50% sensitive
- Serology
Tzanck smear (no longer used- below)
Tzanck smear for HSV
Shows multinucleated giant cells from lesion scarpings- has a low specificity and sensivity and cannot differentiate HSV 1 from 2
T or F. Only PCR or viral culture can tell if a lesion is HSV 1 or 2
T.
How is HSV treated?
There is no cure, but acyclovir and valacyclovir when given within 72 hrs of lesion appearance may decrease the duration and severity of illness. Simialrly, chronic suppression via daily medication can decrease frequency of recurrences and the potential to spread disease to a partner
What causes Syphillis?
Trepneoma pallidum
Describe Trepneoma pallidum
This is a spirochete that is too thin to see on gram stain, so most commonly visualized via darkfield screening (below)
How does primary syphillis present?
Typically as a painless chancre, a shallow ulcer with a clean base and rolled edges, located at the site of treponemal invasion.
When do chancres typically appear?
About 3 weeks after infection
T or F. Syphillis chancres heal with or without therapy
T.
Remember that chancres can arise at any site but are always at the site of primary treponemal entry
How does secondary syphilis present?
This typically occurs about 2-10 weeks after chancre appearance in untreated people and is marked by nonpainful maculopapular rash, that may also be scaly or pustular (can look like anything!)
Where are 2ndary syphillis rashes most commonly found?
palms or soles
What are some other potential symptoms of 2ndary syphillis?
Condylomata lata formation in the anogential region, axillae, and inner thighs
- LAD, fever, and malaise
- Silvery-grey superficial erosions or mucous patches on oropharyngeal and genital mucuous membranes
How do the sores/patches/lesions of 2ndary syphillis progress?
They typically last a few weeks then resolve with or without treatment
condyloma lata is more smooth, whereas warts are more cauliflower like (HPV caused)
How common is teritary syphillis?
Occurs in about 1/3 of untreated of pts, usually after a latent period of 5+ years
What are the CV manifestations of teritary syphillis?
Syphilitic aortitis leading to slowly progressive dilation of the aortic root and arch, which causes aortic valve insufficiency and aneurysms of the proximal aorta
What are the CNS manfiestations of tertiary syphillis?
This can be symptomatic or not. CNS abnormalities can include:
- pleocytosis (increased CNS inflammatory cells-mainly mononuclear)
- elevated CNS protein
- positive VDRL
- Meningovascular infection (chronic meningitis)
- cerebral gummas
- dementia
- rarely tabes dorsalis
What are cerebral gummas?
mass lesions composed of plasma cells. These can also occur in bone, skin, and mucuous membranes!
What is tabes dorsalis?
slow degeneration of nerves in dorsal columns manifested as broad-based ataxia, strokes, and parethesias. Again, this is very, very, very rare today
What is an Argyll Robertson pupil?
Argyll Robertson pupils (AR pupils or, colloquially, “prostitute’s pupils”) are bilateral small pupils that reduce in size on a near object (i.e., they accommodate), but do not constrict when exposed to bright light (i.e., they do not react to light). They are a highly specific sign of neurosyphilis; however, Argyll Robertson pupils may also be a sign of diabetic neuropathy.
What are the main ways to diagnose syphillis?
Nontreponemal and treponemal tests
What are the two nontreponemal tests?
These measure Abs to cardiolipin, a phospholipid found in trepenoma pallidum
RPD: rapid plasma reagent
VDRL: venereal disease research laboratory
These are used for screening
What are the treponemal tests?
These are more specific and measure AB specific to t. pallidum and are used for confirmation of screening tests
FTA-ABS: Flourescent treponemal AB absorption
TP-PA: T. pallidum particle agglutination assay
MHA-TP: Microhemoagglutination test for ab to T. pallidum
Other diagnosis strategies for syphillis?
Darkfield microscopy
How is primary, secondary, and latent syphillis treated?
IM penicllin G benzathine
How is teritary syphillis treated?
IV Penicillin G for 10-14 days
How should syphillis be treated if the pt. has a penicllin allergy?
If the pt is pregnant, it doesnt matter- you will have to desensitize them and use PCN
BUT, if they are not and the infection is not serious, you can use Doxycycline and monitor closely in follow up
What is a Jarisch-Herxheimer rxn?
This can occur during treatment (typically of secondary syphillis) with penicillin and presents as an acute febrile raction to meds with HA and myalgias within the first 24 hrs of treatment.
What is thought to cause a a Jarisch-Herxheimer rxn?
Thought to be due to killed bacteria releasing pyrogens, however not completely understood
What causes lymphogranulomas venereum (LGV)?
L1, L2, and L3 serovars of Chlmydia trachomatis
What is LGV?
It is classified as a genital ulcer disease but is predominately a disease of lymphatic tissue resulting from direct extension from the primary infection site to draining lymph nodes
How does LGV commonly present?
As a small painless genital ulcer that heals spontaneously within a few days. 2-6 weeks later, pts. can develop painful inguinal or femoral LAD with systemic symptoms. Boboes, which are painful inguinal nodes, can also form and rupture
What is another complication of LGV?
Anorectal syndrome which is marked by inflammatory masses/swelling in the rectum.
How does Anorectal syndrome present?
Pts. can present with proctocolitis (can be occult +) with rectal discharge, anal pain, constipation, fever, and/or tenesmus
Complications include chronic colorectal fistulas and strictures
What is tenesmus?
a clinical symptom, where there is a feeling of constantly needing to pass stools, despite an empty colon.
Bottom: colonscopy showing anorectal LGV
What is a ‘groove’ sign?
hallmark of LGV- painful LAD seperated by the inguinal ligament
How is LGV diagnosed?
Diagnosis is difficult. If available, nucleic acid amplification testing on genital, lymph node specimens (lesion swab or bubo aspirate), or rectal specimens is best- not available that often. Typically, the diagnosis is clinical (i.e. if pt. is MSM with rectal bleeding- treat empirically)
Serology can also be used but not good sensitivty and specificity
What is the Tx for LGV?
Doxycycline 100 mg BID for 21 days
What causes Chancroid?
Haemophilis ducreyi, a gram-negative rod
How does chanroid present?
–Erythematous papule rapidly evolves into a pustule which erodes into an ulcer. More than one ulcer is common.
–Ulcer is quite painful with erythematous base. Yellow or gray exudate covering the base is common.
How common is inguinal lymphadenitis in Chancroid?
Present in half of men, and less common in women (lymph nodes may also rupture). HOWEVER, in Chancroid the ulcer is more painful, larger, and multiple and is the main player in the tissue while the main player in LVG may be lymphatic involvement
What is the cause of Grnauloma inguinale (aka donovanosis)?
Klebsiella granulomatis
Where Donovanosis most common?
India, Caribbean, South America, Australia, Papa New Guinea
Describe donovanosis?
This disease is marked by beefy, red vascular ulcers with rolled edges that are PAINLESS
There might also be pseudo-buboes present in the inguinal area that feel like swollen lymph nodes but are actually subQ granulation that is eventually broken down and replaced by ulcers
Describe the structure of Chlamydia trachomatis D-K?
obligate intracellular bacteria lacking a cell wall
how does clyamydia trachomatis replicate?
An infectious, but metabolically inactive elementary body is taken up by the muscosal epithelial cells. After internalization the elementary body is surrounded by an endosomal membrane to form an inclusion. Within the inclusion, the elementary body turns into a reticulate body, which is more metabolically active that divides by binnary fission. Within 40-48 hrs the reticulate body transforms back into an elementary body that are released from the vacuole
If there is interferon present in the cell, intracellular will non-replicate within the cell
What is the most common bacterial cause of sexually transmitted genital infections?
Chlamydia
How does chylamydia MOST commonly manifest?
majority are asymptomatic, providing an ongoign reservoir for future infection
How does symptomatic chlamydia present in women?
Again women are mostly asymptomatic, with the cervi being the more commonly affected site and up to 8% of women showing no signs or symptoms
If symptoms are present, they are most commonly in the form of mucupurulent endocervical discharge, friable cervix, or edematous ectopy (erosion) seen in 10-20% of pts. OR urethritis that presents with dysuria and frequency
-Bartholinitis can also occur
UA with chlamydia would show what?
pyruia but not bacteriuria
how does chlamydia present in men?
40-95% of men can be aymptomatic, but if symptoms are present they are most commonly:
Urethritis (most common cause of nongonococcal urethritis in men)- this is typically accompanied by a mucoid or watery urethral discharge often only seen upon milking the urethra and dysuria
What are some other potential manifestations of Chlamydia in men?
Epididymitis can occur, which is marked by unilateral testicular pain, tenderness, hydrocele, or palpable swelling
Procitis, which is inflammation of the distal rectal mucosa (remember, LGV can also cause this)
Other potential chlamydia manifestations in men AND women?
conjunctivits and pharyngitis
Inflammation of the vulva can also occur in women
How is Chlamydia diagnosed?
Nucleic acid amplication testing on urine or cervical/urethral specimen
How is Chlamydia treated?
Azithromycin 1 gm single dose or
Doxycycline 100 mg BID x 7 days
Describe Neisseria gonorrhoeae
This is an oxidase positive gram negative diplococcous
It ferments lactose and produces IgA protease
Gonorrhoeae is the ____ most commonly reported communicable disease in the US
2nd (chlamydia is no. 1)
How does the clap present in women?
cervicitis which is asymptomatic the majority of times. There can be vaginal pruritis and/or mucopurulent discahrge. Some women have also reported:
- intermenstrual bleeding or menorrhagia
- urethritis with typical symptoms
- Bartholinitis
Soooo clamydia and gonorrhoeae look very similar when pts. exhibit symptoms
How does the clap present in men?
-urethritis, up to 60% asymptomatic (a little more often symptomatic than chlamydia). Can have discahrge present spontaneously, which can be purulent or mucopurulent in color and copious in amount (compared to chlamydia)
epididymitis
What other symptoms of the clap can occur in both men AND women?
- proctitis- mostly asymptomatic, but may have tenesmus, anorectal pain, anorectal bleeding or discharge
- pharyngitis
- DGI
T or F. This is no significant immunity to N. gonorrhoeae due to its antigenic variation
T.
How can gonorrhea be diagnosed?
NAAT on urine, cervical.urethral specimen, throat swab, or anal swab can all be used
T or F. N. gonorrhoeae can grow on Thayer Martin media
T.
How would N. gonorrheae be treated?
ceftriaxone 250 mg IM x 1 dose
plus Azithromycin 1 gm PO x one dose for possible additional activity against N. gonorrhoeae and for treatment of potential chlamydia infection (resistance is on the rise!!)
How is Trichomoniasis?
A parasite (flagellate) that is the MOST common non-viral sexually transmitted disease worldwide
Where does trich primarily infect?
squamous epithelium in the urogenital tract: vagina, urethra, and paraurethral glands. Can also infect the cervix, bladder, and prostate.
How does trich present in women?
Women can be anywhere from asymptomatic to producing purulent, mlodorous, thin discharge associated with burning, pruritis, dysuria, lower abdominal pain, and dyspareunia
Postcoital bleeding can also occur
What might you see on a physical exam of a woman with Trich?
vulvar and vaginal mucosa erythema. A minority get green-yellow frothy discharge.
Also, cervical hemorrhage may lead to the presence of a strawberry cervix
How do men with trich present?
The vast majority are asymptomatic but mild urethritis can occur with watery discharge
How is Trich diagnosed?
NAAT is the gold standard.
Other options include wet mount (cheap but not sensitive)- the presence of motile trichomonads is diagnostic
What is tx. of trichomoniasis?
metronidazole 2 gm PO x 1 dose (or tinidazole) AND must treat the partner
Describe ureaplasma urealyticum
This belongs to the family Mycoplasmataceae, does not have a cell wall, and is a facultative anaerobe
What disease does ureaplasma urealyticum cause?
Associated with male nongonococcal urethritis
How is the Tx for ureaplasma urealyticum?
Doxycycline
Describe Candida
This is a budding yeast that uses pseudohyphae for invasion. This is NOT an STI and is a normal part of the flora but can cause infection especially in the setting of ABX therapy, immunosuppression, and diabetes mellitus
What diseases can Candida cause?
Vulvovaginitis (recurrences are very common)
Oral thrush (in babies and HIV pts.) and candida-esophagitis in AIDS pts.
Typically presents as itchiness and irritation in the vulva and sometimes a thick, curd-like discharge
How is Candida diagnosed?
KOH prep looking for yeast
How is Candida treated?
Oral fluconazole or topical imidazole cream (miconazole, and clotrinazole)
What is the most common cause of vaginal discharge in women of childbearing age?
Bacterial vaginosis
What causes BV?
Mainly Gardnerella vaginalis, a pleomorphic, anaerobic, gram-variable rod
What causes Gardnerella vaginalis to cause BV?
It represents a complex change in vaginal flora marked by a reduction in the concentration of lactobacilli and increased in anaerobes. The mechanism of floral imbalance is unclear
How does BV present?
gray or white thin homogeneous vaginal discharge with fishy odor. Not painful or pruritic
T or F. BV is NOT and STI but is associated with sexual activity as a risk factor
T. Women who dont have sex dont get BV
How is BV diagnosed?
The presence of clue cells under misroscopy and a positive whiff test, which is the smell of fish after adding a drop of 10% KOH to a sample of the vaginal discharge
How is BV treated?
Metronidazole 500mg BID x7 days
Clue cells are vag epithelial studded with adherent coccobacilli best seen at the edge of the cell
Describe the genome of HPV
Non-enveloped, circular dsDNS virus
Describe the common manifestations of different strains of HPV
There are at least 100 types, 30 of which infect the female genital tract), and:
HPV1-4 most commonly cause skin warts
HPV 6 and 11 cause genital warts or CIN that does not progress to cervical cancer
High risk strains include HPV 16,18,31, and 33
Where can HPV cause cancer?
cervix, anal, head, and neck
_____ is the most important risk factor in the development of cervical cancer
High-risk HPV
How does HPV typically progress?
On average, up to 50% of HPV infections are tranisent and are eliminated within 8 mos, and 90% are cleared within 2 yrs
How does HPV present histo wise?
HPV infects squamous epithelial cells and induces perinuclear cytoplasmic vacuoles called koilocytes, that may also show nuclear enlargemnet, nuclear membrane contour irregularity, and peri-nuclear halos
How is the genome of HPV different between non-malignant tumors and malignant tumors?
In non-malignant tumors, the genome is circular, full-length, and does not integrate into the host cell chromosomes, while in malignant tumors, a partial genome that has lost the E2 gene is integrated, resulting in high level expression of E6 and E7.
What do E6 and E7 do?
E6 leads to degradation of p53 and E7 inactivates the RB protein, both leading to loss of cell cycle control
T or F. Even though cervical cancer has been clearly linked to cervical cancer, its presence alone is not enough to cause cervical cancer
T. Other factors such as host immune status determine whether or not transformation will occur
How does HPV cause condyloma acuminatum?
HPV infects the basal keratinocyte of the epidermis presumably through disruptions of the mucosal surface of the skin. At this location, the virus remains latent in the cell at low copy numbers. As the epidermal cells differentiate and migrate to the surface, the viral cells proliferate so that they are in high number by the keratinocyte layer, which causes disruption of the normal skin and wart formation
How is HPV most commonly spread?
Skin to skin contact and not blood bourne infection. Cell-mediated immunity probably plays a significant role in disease/warty regression
Condlyloma lata will be white, while these are cauliflower and flesh colored
What would be the follow up to an abnormal pap smear?
Colposcopy and biopsy
What are the complications of HSV?
CNS infections (encephalitis or meningitis)
Congenital or in utero infection leads to disseminated disease and/or encephalitis
What are the complications of HPV?
Cervical, head/neck, and anal cancers
What are the complications of syphillis in pregnancy?
Below you can see snuffles in a baby born with syphillis, which is heavy sinus drainage from the nose and a woman with saddle nose
Pts can also be deaf if they contract syphillis in utero
What are some of the complications of gonorrhea?
Ophthalmia neonatorum (below)- eye has purulent conjunctivitis with perfuse exudate and swelling of the eyelids. Without tx, infection can spread from the epithelial layers into the conjunctiva and cornea leading to visual impairment
What are some of the congenital complications of chlamydia?
reactive arthritis (arthritis, uvetis, and urethritis)- aka Reiter syndrome
What are some of the complications of congenital chlamydia?
Ophthalmia neonatorum
Infant pneumonia (5-30%)- seen at around 4-12 weeks of age
What is pelvic inflammatory disease?
A complication of untreated gonorrhea or chlamydia that is defined as an acute or subclinical ifnection of the upper genital tract in women, involving any or all of the uterus, fallopian tubes, and ovaries
It can result in endometritis, salpingitis, oophoritis, periphepatitis, and/or tubo-ovarian abscess
What is the majorty of PID caused by?
The vast majority are caused by sexually-transmitted pathogens or BV associated pathogens like Gardrenella
What are the symptoms of PID?
lower abdominal pain (cardinal symptom). Can worsen during sex or with jarring movements
How would PID present on a physical exam?
Cervical motion (chandelier sign) and/or uterine or adnexal tenderness on bimanual pelvic exam
Purulent endocervical or vaginal discharge is common
What is Fit-Hugh Curtis Syndrome?
Aka perihepatitis, this occurs in the setting of PID, and is defined as inflammation of the liver capsule and peritoneal surfaces of the anterior RUQ
How common is perihepatitis in women with PID?
It occurs in 10% of women with PID and is characterized by RUQ pain that increases with deep inspiration (aka pleuritic) that can be referred to the right shoulder
T or F. ALT/AST are highly elevated in perihepatitis?
F. only minimally elevated because only the capsule is invovled
Aka violin-string adhesions
How would PID be treated?
Most pts. with PID can be treated outpatient but some have to be treated in patient?
How would outpt. PID be treated?
Cefoxitin IM with probenicid x 1 dose plus Doxy PO x 14 days OR
Ceftriaxone IM x1 dose plus Doxy x 14 days (if gonorrhea is suspected or confirmed)
How would inpt. PID be treated?
Cefoxitin IV plus Doxy
