STIs

Question 1

Single papule -> shallow, painless, nonexudative ulcer with indurated edges

BILATERAL INGUINAL LYMPHADENOPATHY!

Answer 1

Primary syphilis
(Painless genital ulcer + bilateral inguinal lymphadenopathy = almost always syphilis)

-> Empiric PCN even if RPR negative

Question 2

Diffuse maculopapular rash that begins on trunk, extends to extremities, and involves palms and soles

Answer 2

Secondary syphilis (1-2mo after chancre)

Question 3

Most sensitive test for syphilis

Answer 3

Treponema tests (FTA-ABS)
(TP-PA, MHA-TP, TP-EIA)

Question 4

Sensitivity of VDRL/RPR?

Answer 4

These are non-treponemal tests.

Can miss ~25% of primary syphilis.

Question 5

Causes of false VDRL

Answer 5

Viruses
Drugs / IV use
Rheumatic fever, Rheumatoid arthritis
SLE/Lepropsy

Question 6

Epitrochlear lymphadenopathy

Answer 6

Pathognomonic for secondary syphilis

Question 7

Grey mucosal patches

Answer 7

Secondary syphilis

Question 8

Condyloma lata

Answer 8

Secondary syphilis

Question 9

Treatment of primary or secondary syphilis

Answer 9

One dose of IM penicillin G benzathine

Question 10

Tenosynovitis, polyarthralgia, skin rash (few pustules) on trunks and extremities (but can spare palms and soles?)

Answer 10

Disseminated gonococcus

Question 11

Painful genital ulcers with erythematous base, well-demarcated borders, purulent exudate, +/- necrotic
+ inguinal lymphadenopathy

Answer 11

Hemophilus ducreyi (chancroid)

Question 12

Painless papule becomes beefy-red ulcer with characteristic rolled edge of granulation tissue

Answer 12

Klebsiella granulomatis

Granuloma inguinale

Question 13

Painless transient papule or shallow ulcer on genitals (can progress to painful swelling of inguinal nodes)

Answer 13

lymphogranuloma venereum (chlamydia)

Question 14

Tx chlamydia

Answer 14

Doxycycline x7 days
Or azithromycin once
(Use azithromycin or amoxicillin in pregnant patients)

Question 15

Dx of gonorrhea

Answer 15

Gram stain and culture is gold standard for any site (pharynx, cervix, urethra, anus)
Nucleic acid amplification tests can be sent on penile/vaginal tissue or from urine

Question 16

Treatment of gonorrhea

Answer 16

IM Centriaxone AND PO azithromycin (regardless of whether chlamydia is present)
Don’t use fluoroquinolones due to emerging resistance

Question 17

Treatment of disseminated gonorrhea

Answer 17

IV ceftriaxone for at least 24 hours

Empiric azithromycin or doxycycline for chlamydia tx

Question 18

Treatment for syphilis if severe penicillin allergy?

Answer 18

Doxycycline

If CNS syphilis or pregnant, then can desensitize then give penicillin

Question 19

3 causes of painless genital lesions?

Answer 19

Syphilis
Lymphogranuloma venereum (chlamydia)
Granuloma inguinale (klebsiella granulomatis) -> but lymphadenopathy is rare, and is very rare in the US

Note that chancroid (H ducreyi) IS painful!!!

Question 20

3 causes of painFUL genital lesions

Answer 20

Chancroid (H ducreyi)
Herpes (vesicular)
Behest (vasculitis -> oral and sometimes genital ulcers)