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PPC2 Exam 1 > STIs: Syphilis, Chancroid, Chlamydia > Flashcards

STIs: Syphilis, Chancroid, Chlamydia Flashcards

1
Q

Syphilis Definition (5)

A
  1. An infection caused by Treponema pallidum that can be acquired in adolescents and congenitally in infants.
  2. Congenital infection occurs by transplacental transmission of T. pallidum, a spirochete.
  3. Facilitates infection with HIV (Centers for Disease Control [CDC], 2015
  4. Disease progresses in stages
  5. Serologic tests for syphilis may not be positive during early primary syphilis
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2
Q

Primary Syphilis – Clinical Manifestations (6)

A
  1. Incubation: 10‐90 days (average 3 weeks)

Chancre:

  1. Early: macule/papule erodes
  2. Late: clean based, painless, indurated ulcer with smooth firm borders
  3. Unnoticed in 15‐30% of patients
  4. Resolves in 1‐5 weeks
  5. HIGHLY INFECTIOUS
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3
Q

Primary Syphilis Pathology: Penetration (2)

A
  1. T. pallidum enters the body via skin and mucous membranes through abrasions during sexual contact
  2. Also transmitted transplacentally (vertical transmission)
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4
Q

Primary Syphilis Pathology: Dissemination (2)

A
  1. Travels via the lymphatic system to regional lymph nodes and then throughout the body via the blood stream
  2. Invasion of the CNS can occur during any stage of syphilis
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5
Q

Testing for Syphilis (3)

A
  1. Direct visualization of spirochete by dark field microscopy; direct fluorescent antibody test for Treponema pallidum
  2. Nontreponemal tests—Venereal Disease Research Laboratory microscopic slide test (VDRL); Rapid plasma reagin (RPR)
  3. Treponemal test—fluorescent treponemal antibody absorbed; microhemagglutination assay for antibody to Treponema pallidum (TP‐PA or FTA‐ABS)
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6
Q

Nontreponemal Serologic Tests for Syphilis Advantages (5)

A
  1. Rapid and inexpensive
  2. Easy to perform and can be done in clinic or office
  3. Quantitative
  4. Used to follow response to therapy
  5. Can be used to evaluate possible reinfection
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7
Q

Nontreponemal Serologic Tests for Syphilis Disadvantages (3)

A
  1. May be insensitive in certain stages
  2. False‐positive reactions may occur
  3. Prozone effect may cause a false‐negative reaction (rare)
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8
Q

Nontreponemal Serologic Tests for Syphilis Principles (3)

A
  1. Measure antibody directed against T. pallidum antigens
  2. Qualitative
  3. Usually reactive for life
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9
Q

Sensitivity of Serological Tests of Untreated Syphilis (3)

A
  1. As the disease gets worse, the VDRL becomes positive
  2. In the early stages it may not be positive → can cause you to miss primary syphillis
    a. Rolled edge ulcer that is non-painful – both the patient and test can miss it
    b. As rash develops and hands and feet show typical syphilis – test will be accurate
  3. Autoimmune diseases, pregnancy, lepracy, drug users, etc. may cause positive tests
    a. Recent immunizatiosn can also cause positive VDRL – false positives can occur so TPPA should also be performed to back-up the VDRL
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10
Q

secondary syphilis (5)

A
  1. Secondary lesions occur 3 to 6 weeks after the primary chancre appears; may persist for weeks to months
  2. Primary and secondary stages may overlap
  3. Mucocutaneous lesions most common
  4. Serologic tests are usually highest in titer during this stage
  5. Will have acral distribution → hands & feet!
    * Also palmar/plantar rash
    * Diamond-nickel lesions
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11
Q

Secondary Syphilis Manifestations (6)

A
  1. Rash (75%‐100%)
  2. Lymphadenopathy (50%‐86%)
    • One of the signs of congenital syphilis is baby with large lymph nodes!
  3. Malaise
  4. Mucous patches (6%‐30%)
  5. Condylomata lata (10%‐20%)
    • Painless, mucosal, and warty erosions which are flat, velvety, moist and broad base in nature. They tend to develop in warm, moist sites of the genitals and perineum
  6. Alopecia (5%)
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12
Q

Syphilis Review (Primary vs. Secondary vs. Latent)

A
  1. Primary syphilis infection: Ulcers or chancre at the infection site
  2. Secondary syphilis: Manifestations that include, but are not limited to, skin rash, mucocutaneous lesions, and lymphadenopathy), or tertiary syphilis (i.e., cardiac, gummatous lesions, tabes dorsalis, and general paresis).
  3. Latent infections (i.e., those lacking clinical manifestations) are detected by serologic testing.
    * Latent syphilis acquired within the preceding year is referred to as early latent syphilis
    * All other cases of latent syphilis are late latent syphilis or syphilis of unknown duration.
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13
Q

Latent Syphilis (5)

A
  1. Host suppresses the infection enough so that no lesions are clinically apparent
    * There is a period where the host suppresses the response so it goes unknown
  2. Only evidence is positive serologic test for syphilis
  3. May occur between primary and secondary stages, between secondary relapses, and after secondary stage
  4. Categories:
    o Early latent: <1year duration
    o Late latent: > 1 year duration
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14
Q

Neurosyphilis (5)

A
  1. Occurs when T. pallidum invades the CNS
  2. May occur at any stage of syphilis
  3. Can be asymptomatic
  4. Early neurosyphilis occurs a few months to a few years after infection
    o Clinical manifestations include acute syphilitic meningitis, meningovascular syphilis, ocular involvement
  5. Late neurosyphilis occurs decades after infection and is rarely seen
    o Clinical manifestations include general paresis, tabes dorsalis, ocular involvement
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15
Q

Syphilis Transmission (4)

A
  1. Transmission to the baby is something commonly seen in cities with poor healthcare
  2. More common when a mother has primary and secondary infection, rather than latent infection
  3. Maternal risk factors are lack of prenatal care and cocaine abuse.
  4. Can be contracted at any stage of pregnancy, intrauterine infection can result in fetal death, stillbirth, prematurity or clinical congenital disease
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16
Q

Early Congenital Syphilis (9)

A
  1. May be asymptomatic
  2. Multi‐organ involvement: Hematologic, mucous membrane, musculoskeletal, CNS, eye, renal, GI (AAP, 2015)
  3. Low birth weight/prematurity
  4. Rhinitis (snuffles), mucous patches
  5. Jaundice with elevated liver enzymes
  6. Lymphadenopathy with Coombs‐negative hemolytic anemia
  7. Osteochondritis which causes resistance to movement (Pseudoparalysis of Parrot)
    a. Will have abnormal moro reflex with this
  8. Rash similar secondary syphilis with desquamation of hands/feet
  9. CNS abnormalities
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17
Q

Late Congenital Syphilis (4)

A
  1. Symptoms result from chronic inflammation of CNS, bone, teeth
  2. Bony changes with anterior tibial bowing prominence of forehead
  3. Dental changes with Hutchinson (Peg shaped) teeth with lower molars with excessive cusps, enamel defects
  4. Can have defects of the palate
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18
Q

Follow-Up for Congenital Syphilis (5)

A
  1. Follow-up examinations and serologic testing (i.e., a nontreponemal test) of infants and children treated for congenital syphilis after the neonatal period (30 days of age)
    o Every 3 months until the test becomes nonreactive or the titer has decreased fourfold.
  2. The serologic response after therapy might be slower for infants and children than neonates.
  3. If these titers increase at any point for more than 2 weeks or do not decrease fourfold after 12–18 months, the infant or child should be evaluated (through CSF examination), treated with a 10-day course of parenteral penicillin G, and managed in consultation with an expert.
  4. Treponemal tests
    o Not used as the results are qualitative and persist after treatment
    o There is passive transfer of maternal IgG treponemal antibody might persist for at least 15 months after delivery
  5. If positive at birth but titers are low, closely watch over the next couple of months that titers are dropping
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19
Q

Congenital Syphilis: Reactive Serologic Tests in Infant Older than One Month (3)

A
  1. Review maternal serology to determine if the child has congenital or acquired syphilis.
  2. Treatment consists of:
    Aqueous crystalline penicillin G 200,000–300,000 units/kg/day IV, administered as 50,000 units/kg every 4–6 hours for 10 days
  3. Follow‐up as above for infected neonates (CDC, 2015)
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20
Q

Congenital Syphilis: Infants and Children Aged ≥1 Month with Reactive Serological Tests (3)

A
  1. Review the maternal serology to assess whether they have congenital or acquired syphilis
  2. Any infant or child at risk for congenital syphilis: Needs full evaluation and HIV test
    * Cord bloods can miss the patient due to window of negativity – so always test again if previously negative and at risk!
  3. Recommended Regimen
    o Aqueous crystalline penicillin G 200,000–300,000 units/kg/day IV, administered as 50,000 units/kg every 4–6 hours for 10 days
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21
Q

Jarisch‐Herxheimer Reaction (5)

A
  1. Self‐limited reaction to anti‐treponemal therapy
    o Fever, malaise, nausea/vomiting; may be associated with chills and exacerbation of secondary rash 

  2. Occurs within 24 hours after therapy 

  3. Not an allergic reaction to penicillin; not an allergic reaction, but a reaction to the tx

  4. More frequent after treatment with penicillin and treatment of early syphilis 

  5. Pregnant women should be informed of this possible reaction, that it may precipitate early labor, and to call obstetrician if problems.
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22
Q

Treatment of Syphilis (3)

A
  1. Benzathine Procaine penicillin CR 2.4 mu IM x 1
    * It is the CR type
    * This is the treatment of choice for primary or secondary syphilis

Enhanced IM+oral alternative regimens:
2. Regimens of doxycycline 100 mg orally twice daily for 14 days or tetracycline (500 mg four times daily for 14 days)
3. Azithromycin 2 gm (A2058G mutation/too many treatment failure)
^ Above alternatives should not be used in MSM, persons with HIV, or pregnant women

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23
Q

Chancroid (4)

A
  1. Dirty lesion infected with haemophilis ducreyi
  2. Found in sex workers, MSM, high promiscuity
  3. Haemophilus Ducreyi
    * One or more painful ulcers
    * Suppurative inguinal adenopathy
    * Negative dark field or serologic testing of syphilis
  4. High rates of coinfection with HIV and T. Palladium
24
Q

Chancroid Treatment (4)

A
  1. Azithromycin one gram orally in a single dose
    * May cause vomiting
  2. Ceftriaxone 250mg IM single dose
    * Dr. John’s preferred treatment…
  3. Ciprofloxacin 500mg orally twice a day for 3 days
  4. Erythromycin base 500mg orally qid for 7 days
25
Q

Chlamydia Overview (6)

A
  1. Chlamydia trachomatis
  2. Estimated 3 million cases in U.S. annually 

  3. Most common sexually transmitted infectious disease, and the prevalence is highest in persons aged ≤25 years

  4. Reported rates 3 times higher in females than in males
  5. Sexually transmitted chlamidya is C.trachomatis
    * This is the only one that will be seen in STIs
  6. The other types are lung infections/diffeerent species
26
Q

Chlamydia Risk Factors (6)

A
  1. Adolescence
  2. New or multiple sex partners
  3. History of STD infection
  4. Presence of another STD
  5. Oral contraceptive user
    i. Less likely to worry about barrier protection
  6. Lack of barrier contraception
27
Q

Chlamydia Transmission (6)

A
  1. Transmission is sexual or vertical
  2. Highly transmissible
  3. Incubation period 7‐21 days
  4. Significant asymptomatic reservoir exists in the population
  5. Re‐infection is common
  6. Perinatal transmission results in neonatal conjunctivitis in 30%‐50% of exposed babies
28
Q

Chlamydia Microbiology (4)

A
  1. Obligatory intracellular bacteria
    i. Once it affects the columnar epithelial cells on the exocervix, it replicates and has two forms in the life cycle
  2. Infect columnar epithelial cells
  3. Survive by replication that results in the death of the cell
  4. Takes on two forms in its life cycle:
    i. Elementary body (EB)
    ii. Reticulate body (RB)
29
Q

C. Trichomonas in Men (Local Infection, Complications, Sequelae)

A

Local Infection: conjunctivitis, urethritis, prostatitis

Complications: reiter’s syndrome, epididymitis

Sequelae: chronic arthritis (rare), infertility (rare)

30
Q

C. Trichomonas in Women (Local Infection, Complications, Sequelae)

A

Local Infection: conjunctivitis, urethritis, cervicitis, proctitis

Complications: endometritis, salpingitis, perihepatitis, reiter’s syndrome

Sequelae: infertility, ectopic pregnancy, chronic pelvic pain, chronic arthritis (rare)

31
Q

C. Trichomonas in Infants (Local Infection, Complications, Sequelae)

A

Local Infection: conjunctivitis, pneumonitis, pharyngitis, rhinitis

Complications: chronic lung disease?

Sequelae: rare, if any

32
Q

General Info about C. trachomatis Infection in Men (4)

A
  1. Urethritis–One cause of non‐gonococcal urethritis (NGU)
  2. Majority (>50%) asymptomatic
  3. Symptoms/signs if present: mucoid or clear urethral discharge, dysuria
  4. Incubation period unknown (probably 5‐10 days in symptomatic infection)
33
Q

C. trachomatis Infection Complications in Men (2 with descriptions)

A
  1. Epididymitis
    - Infection/inflammation of epididymis
  2. Reactive arthritis (Reiter Syndrome)
    - Acute arthritis/arthralgia,
    - Lower Uro‐genital tract inflammation‐ Urethritis
    - Mucocutaneous inflammatory lesions
    - Conjunctivitis, fever, malaise, anorexia, and weight loss.
    - Most acute cases will resolve in 2‐6 months
    - Rarely occurs in women
34
Q

General: C. trachomatis Infection in Women (2 main symptoms)

A
  1. Cervicitis
    •Majority (70%‐80%) are asymptomatic
    •Local signs of infection, when present, include:
    •Mucopurulent endocervical discharge
    •Edematous cervical ectopy with erythema and friability
  2. Urethritis
    •Usually asymptomatic
    •Signs/symptoms, when present, include dysuria, frequency, pyuria
35
Q

C. trachomatis Complications in Women (3 with descriptions)

A
  1. Pelvic Inflammatory Disease (PID)
    • Salpingitis
    • Endometritis
  2. Perihepatitis (Fitz‐Hugh‐Curtis Syndrome)
    • Violin sting adhesion between the liver and anterior abdominal well
    • Hallmark
    • Onset of upper abdominal pain usually follows lower abdominal pain but can precede it
    • Less then 50% have elevated liver enzymes
    • GC and Chlamydia can both cause this
    • If someone comes in with RUQ pain you must consider this as a differential if they are sexually active!!
  3. Reiter’s Syndrome (rare in women)
36
Q

General: C. trachomatis Infections in Infants and Children (3)

A
  1. Usually occurs when the mother has never had prenatal care
  2. Perinatal clinical manifestations:
    • Inclusion conjunctivitis
    • Pneumonia
3. Pre‐adolescent males and females: 
•Urogenital infections
•Usually asymptomatic*
•Vertical transmission
•Sexual abuse=Hallmark; If a pre-adolescent has Chlamydia then it is sexual abuse unless proven otherwise!
37
Q

C. trachomatis Cultures (5)

A
  1. Historically the “gold standard”
  2. Variable sensitivity (50%-80%)
    • Specificity approaching 100%
    • Sensitivity ranges from 60% to 90%
  3. High specificity
  4. Use in legal investigations
  5. Not suitable for widespread screening
38
Q

C. trachomatis Serology (2)

A
  1. Rarely used for uncomplicated infections

2. Comparative data between types of serologic test are lacking

39
Q

C. trachomatis Non-amplifiedtests Lab Tests (3)

A
  1. Directfluorescentantibody (DFA)
  2. Detects intact bacteria with a fluorescent antibody
  3. Variety of specimen sites
40
Q

C. trachomatis Enzyme Immunoassay (EIA), e.g. Chlamydiazyme (4)

A
  1. Detects bacterial antigens with an enzyme-labeled antibody
  2. Sensitivity and specificity of 85% and 97% respectively
    * Meaning if it is negative, the patient doesn’t have the disease
  3. Useful for high volume screening
  4. False positives – so therefore not used anymore since NAAT tests
41
Q

C. trachomatis NAAT e.g. Gen-Probe Pace-2 (5)

A
  1. Detects specific DNA or RNA sequences of C. trachomatis and N. gonorrhoeae
  2. Sensitivities ranging from 75% to 100%; specificities greater than 95%
  3. Detects chlamydial ribosomal RNA
  4. Able to detect gonorrhea and chlamydia from one swab
  5. Need for large amounts of sample DNA
42
Q

NAATs (4)

A
  1. Urine for men and women is cleared; not cleared for pharyngeal swabs
  2. NAATs amplify and detect organism-specific genomic or plasmid DNA or rRNA Commercially available NAATs include:
    o Becton Dickinson BDProbe Tec®
    o Gen-Probe AmpCT, Aptima®
    o Roche Amplicor®
  3. Can detect N. gonorrhoeae in the same specimen
  4. Significantly more sensitivity than other tests
43
Q

FDA NAATs Approved for…(4)

A
  1. Urethral swabs from men
  2. Cervical swabs
  3. Urine from men and women
  4. SOMETIMES vaginal swabs
44
Q

FDA NAATs Not Approved for…(3)

A
  1. Rectal
  2. Pharyngeal
  3. (some laboratories have met regulatory requirements)
45
Q

C. trachomatis DNA Amplification Assays (4)

A
  1. Polymerase chain reaction (PCR)
  2. Ligase chain reaction (LCR)
  3. Sensitivities with PCR and LCR 95% and 85‐98% respectively; specificity approaches 100%
  4. LCR ability to detect chlamydia in first void urine
46
Q

Treatment of Genital Chlamydia Infection (4)

A
  1. Meta-analysis of 23 RCTs (through 2012):
    o1065 individuals treated with azithromycin, 850 with doxycycline
  2. Pooled cure rates: doxy 97.5%, azithromycin 94.4%
  3. Pooled estimate favored doxy
    o(2.2% - 2.7% more efficacious) especially in men
  4. Conclusion: doxy marginally superior to azithromycin
47
Q

Treatment of Uncomplicated Genital Chlamydial Infections: First Line (2)

A

Azithromycin 1 g orally in a single dose
OR

Doxycycline 100 mg orally twice daily for 7 days
*Compliance issue since it’s taken for 7 days, but good alternative

48
Q

Second Line/Alternative Treatments of Uncomplicated Genital Chlamydial Infections (4)

A
  1. Erythromycin base 500 mg orally 4 times a day for 7 days, OR
  2. Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days, OR
  3. Ofloxacin 300 mg orally twice a day for 7 days, OR
  4. Levofloxacin 500 mg orally once a day for 7 days
49
Q

Treatment of Neonatal Conjunctivitis and/or Pneumonia (3)

A
  1. Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days
  2. Warning about Pyloric stenosis
  3. 80% effective with second treatment needed
50
Q

Treatment of Chlamydia Infection in Children: children who weigh <45g

A

Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days


51
Q

Treatment of Chlamydia Infection in Children: children who weigh >45g but are <8 years old

A

Azithromycin 1 g orally in a single dose

52
Q

Treatment of Chlamydia Infection in Children: children >8 years old

A

Azithromycin 1 g orally in a single dose
OR
Doxycycline 100 mg orally twice a day for 7 days

53
Q

Chlamydia Partner Management: Sex Partners (3) and Reporting (2)

A

Sex partners
1. Evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding the onset of symptoms or diagnosis of chlamydia.

  1. Aloud to do expedited partner therapy on patients and partners that come in with Chlamydia
  2. Meaning you can write a prescription for every partner that your patient has (in NY state) and can write a letter saying the partner has been exposed to an STD

Reporting

  1. Chlamydia is a reportable STD in all states
  2. Report cases to the local or state STD program.
54
Q

Prevention counseling for Chlamydia: Nature of Infection (2) and Transmission Issues (2)

A

Nature of the infection

  1. Chlamydia is commonly asymptomatic in men and women
  2. In women, there is an increased risk of upper reproductive tract damage with re‐infection.

Transmission issues

  1. Effective treatment of chlamydia may reduce HIV transmission and acquisition.
  2. Abstain from sexual intercourse until partners are treated and for 7 days after a single dose of azithromycin or until completion of a 7‐day regimen. **
55
Q

Chlamydia test of cure (2)

A
  1. No Test-of-cure to detect therapeutic failure (i.e., repeat testing 3–4 weeks after completing therapy) if the appropriate therapy is given unless the symptoms persist, or reinfection is suspected.
  2. Use of chlamydial NAATs at <3 weeks after completion of therapy is not recommended because the continued presence of nonviable organisms.

PPC2 Exam 1 (13 decks)

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