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PPC2 Exam 1 > STIs: Testing, Cervicitis, PDI, Ulcers/HSV, HPV > Flashcards

STIs: Testing, Cervicitis, PDI, Ulcers/HSV, HPV Flashcards

1
Q

STIs Characterized by Genital Ulcers (5)

A
  1. Herpes simplex
  2. Syphilis
  3. Chancroid – Mainly found among sex workers
  4. Granuloma inguinales
  5. Lymphogranuloma venereum
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2
Q

Non-Ulcer Organisms (6)

A
  1. Chlamydia
  2. Gonorrhea
  3. Human Papilloma virus
  4. T. Vaginalis
  5. Vaccine preventable STI’s (Ex: Hepatitis B)
  6. HIV infection
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3
Q

Screening Sexually Active Adolescents

A

Annual screening done with urine at least once a year, particularly if young age and sexually active

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4
Q

USPHS/CDC Recommended Screening

A
  1. Annual screen for Chlamydia if under 25.

2. High risk women should be screened for GC as well.

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5
Q

High risk screening (7)

A
  1. Previous STI
  2. Young age and sexually active
  3. Multiple sexual partners
  4. Inconsistent or erratic condom use
  5. New partners since last screened.
  6. Partners of IV drug users, rape
  7. Sex in exchange for good or services
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6
Q

Screening for men having sex with men (MSM) (7)

A
  1. HIV serology
  2. Syphilis serology
  3. Urethral infection (insertive intercourse),
    • Gonorrhea/chlamydia
    • (nucleic acid amplification–urine is preferred
  4. Rectal infection (receptive anal intercourse),
    • Gonorrhea/chlamydia–nucleic acid amplification) –
  5. Pharyngeal infection (receptive oral intercourse),
    • Gonorrhea–nucleic acid amplification)
  6. Hepatitis A, B (vaccination if nonimmune) –
  7. Sexual transmission of Hepatitis C (MSM with HIV)
  8. Recent or concurrent STI and HIV
    • More frequent STI screening dependent on risk behavior (3-6 months)
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7
Q

Nucleic Acid Amplification Test (NAAT)

A
  1. Amplify DNA over 1 million fold
  2. Most sensitive tests for C. trachomatis infection
  3. NAATs that are FDA-cleared for use with vaginal swab specimens and urine specimens
    o Provider or self-collected (equivalent to provider).
  4. Optimal urogenital specimen types for chlamydia screening using NAAT include first catch-urine (men) and vaginal swabs (women)
  5. Rectal and oropharyngeal C. trachomatis infection in persons engaging in receptive anal or oral intercourse can be diagnosed by testing at the anatomic site of exposure.
    - NAATs are not FDA-cleared for use with rectal or oropharyngeal swab specimens.
    - But NAATs have been demonstrated to have improved sensitivity and specificity compared with culture for the detection of C. trachomatis at rectal sites and at oropharyngeal sites among men
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8
Q

NAAT TESTS (4)

A
  1. APTIMA (Gen‐Probe)*
    - Transcription‐mediated amplification (TMA)
    - Older test not as effective as NAAT
  2. Cobas Amplicor (Roche)
    - Polymerase chain reaction (PCR)
  3. BD ProbeTec ET (Becton, Dickson)*
    - Strand displacement amplification (SDA)
  4. All offer combined test for GC and chlamydia
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9
Q

Urine Testing (6)

A
  1. All NAAT approved for urine testing for chlamydia in both genders
  2. TMA, SDA approved for urine testing for gonorrhea in both genders
  3. PCR is approved for urine testing for GC in males only
  4. Appropriate for asymptomatic males and females for both GC and Chlamydia
  5. Appropriate for symptomatic males
  6. Symptomatic females should have more complete evaluation
    * They must have a pelvic exam done to check for PID or an abscess
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10
Q

Urine Testing: First Catch Specimen (5)

A
  1. Must be one hour since last void
  2. NOT CLEAN Catch! → you want the first urine specimen
  3. First 5‐10 of urine stream collected in sterile specimen cup
  4. The patient voids the rest of the urine in the toilet
  5. May be left for 24 hours at room temperatures
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11
Q

Vaginal Swabs (4)

A
  1. Equivalent sensitivity to endocervical swabs in most students
  2. Equivalence between physician collected and patient collected
  3. Minimal difference between dry specimen and those in buffer
  4. Most show superiority to urine
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12
Q

Cervicitis

A
  1. Non‐specific symptoms: abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia
  2. Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding
  3. 50% of women with clinical cervicitis have no symptoms
  4. Incubation period unclear, but symptoms may occur within 10 days of infection
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13
Q

PID Incidence (3)

A
  1. Commonly associated with symptoms
  2. l0%‐20% women with GC develop PID
  3. In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID
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14
Q

PID Minimal Criteria (2)

A
  1. Uterine adnexal tenderness

2. Cervical motion tenderness

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15
Q

PID Other Symptoms and Complications (3,3)

A

Other symptoms include

  1. Endocervical discharge
  2. Fever
  3. Lower abdominal pain

Complications:

  1. Infertility: 15%‐24% with 1 episode PID secondary to GC or chlamydia
  2. 7X risk of ectopic pregnancy with 1 episode PID
  3. Chronic pelvic pain in 18%
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16
Q

Trichomonas Vaginalis (5)

A
  1. Trichomoniasis is the most prevalent nonviral sexually transmitted infection in the United States, affecting an estimated 3.7 million persons (CDC 2015)
  2. Flagellated anaerobic protozoa
  3. Only protozoan that infects the genital tract
  4. T. vaginalis has four free flagellae and one flagella embedded in an undulating membrane.
  5. Flagellae are responsible for the jerky motility of this organism that is seen under a microscope.
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17
Q

Trichomonas Vaginalis Prevalence (4)

A
  1. Most infected persons (70%–85%) have minimal or no symptoms, and untreated infections might last for months to years
  2. 13% of black women are affected compared with 1.8% of non-Hispanic white women
  3. Affects >11% of women aged ≥40 years
    •26% of symptomatic women and 6% of asymptomatic women in STD clinic patients
    •9% to 32% of incarcerated women
    • 2%–9% of incarcerated men
  4. MSM: Low prevalence
18
Q

Trichomonas Vaginalis Risk Factors (4)

A
  1. Multiple sexual partners
  2. Low SE status
  3. History of STDs
  4. Lack of condom use
19
Q

Infection with Trichomonas vaginalis is associated with (4)

A
  1. Adverse pregnancy outcomes, including premature rupture of membranes and pre-term labor
  2. Pelvic inflammatory disease
  3. Increased risk for HIV infection
  4. If + for T. vaginalis, should test for HIV (CDC, 2015)
20
Q

Diagnosis of Trichomonas Vaginalis: Wet Mount (

A
  1. Trichomonads may closely resemble white blood cells (WBCs), especially if the specimen is old (the trichomonads become sluggish).
  2. Must be done within one hour
  3. Motility is required for positive identification.
  4. Vaginal pH >4.5
  5. Sensitivity of wet mount is low (51%–65%) in vaginal specimens
  6. Lower in specimens from men (e.g., urethral specimens, urine sediment, and semen)
  7. Need to use highly sensitive and specific tests
21
Q

Gold standard Diagnosis of Trichomonas Vaginalis

A

Culture!

22
Q

NAAT TESTS FOR T. Vaginalis (4)

A
  1. In women, NAAT is highly sensitive, detecting 3 to 5 times more T. vaginalis infections than wet-mount microscopy (poor sensitivity (51%–65%)
    • APTIMA T. vaginalis assay
    • FDA-cleared-vaginal, endocervical, or urine specimens from women
    • In men, the sensitivity of self-collected penile-meatal swabs (80%) was higher than that of urine (39%)
  2. BD Probe Tec TV Qx Amplified DNA Assay
    • FDA-cleared for detection of T. vaginalis from endocervical, vaginal, or urine specimens from women
  3. OSOM Trichomonas Rapid Test (Sekisui Diagnostics, Framingham, MA
    • Point of care, approximately 10 minutes, with sensitivity 82%–95% and specificity 97%–100%
  4. Affirm VP III (Becton Dickinson, Sparks, MD),
    • DNA hybridization probe test that evaluates for T. vaginalis, G. vaginalis, and Candida albicans
23
Q

T. Vaginalis treatments (3)

A
  1. Metronidazole 2g orally in a single dose
    OR
  2. Tinidazole 2g orally in a single dose
  3. Alternative Regimen: Metronidazole 500 mg twice a day for 7 days
24
Q

Genital Ulcer Disease: Painful (2) vs. Painless (3)

A

Painful

  1. Chancroid
  2. Genital herpes simplex → pain= classic sign of herpes simplex

Painless

  1. Syphilis → painless ulcers = most common sign of syphilis
  2. Lymphogranuloma venereum
  3. Granuloma inguinale
25
Q

Genital Herpes Simplex Manifestations (4)

A
  1. Direct contact – may be with asymptomatic shedding
  2. Primary infection commonly asymptomatic; symptomatic cases sometimes severe, prolonged, systemic manifestations
  3. Vesicles → painful ulcerations → crusting
  4. Recurrence a potential
26
Q

Genital Herpes Simplex Dx (3)

A

i. Culture
ii. Serology (Western blot)
iii. PCR

27
Q

Genital Herpes Simplex Transmission (4)

A
  1. HSV‐2 is transmitted sexually and perinatally.
  2. Most sexual transmission occurs while source case is asymptomatic.
  3. Efficiency of sexual transmission is greater from men to women than from women to men
    i. Women are more susceptible
  4. Incubation period after acquisition is 2‐12 days (average is 4 days).
28
Q

Genital Herpes Simplex Pathology (4)

A
  1. The virus remains latent indefinitely.
    i. Will break out in the same area that it has before
  2. Reactivation, precipitated by multiple known and unknown factors, induces viral replication.
  3. The re‐activated virus may cause a cutaneous outbreak of herpetic lesions.
  4. Up to 90% of persons seropositive for HSV‐2 antibody have no clinical history of anogenital herpes outbreaks.
29
Q

Genital Herpes Simplex First Clinical Episode (6)

A

“Primary infection”

  1. First infection ever with either HSV‐1 or HSV‐2
  2. Primary disease is more severe than recurrent disease
  3. No antibody present when symptoms appear
  4. Characterized by multiple lesions that are more severe, last longer, and have higher titers of virus than recurrent infections
  5. Illness lasts 2‐4 weeks
  6. Often associated with systemic symptoms including fever, headache, malaise, and myalgia
30
Q

Genital herpes simplex lesion progression

A

papules → vesicles → pustules → ulcers → crusts → healed

31
Q

Genital Herpes Simplex Recurrent Infection (2)

A
  1. Disease usually mild and short in duration

2. Antibody present when symptoms appear

32
Q

Genital Herpes Simplex Asymptomatic infection (2)

A
  1. No known history of clinical outbreaks

2. Serum antibody is present

33
Q

Recurrent Infection without Treatment

A
  1. Prodromal symptoms (localized tingling, irritation) in ~50% begin 12‐24 hours before lesions
  2. Illness lasts 5‐10 days
    a. First episode can last for up to three weeks
  3. Symptoms tend to be milder, less severe than in primary infection
  4. Usually there are no systemic symptoms
  5. HSV‐2 primary infection more prone to recur than HSV‐1 primary infection
  6. Want to use acyclovir for symptomatic shedding
    a. Over 16 years old though → use valcyclovir
34
Q

Asymptomatic Viral Shedding (2)

A
  1. Acyclovir chemo-suppression dramatically reduces shedding.
  2. Most common sites of asymptomatic shedding are vulva and perianal areas in women and penile skin and perianal area in men.
35
Q

Genital Herpes Simplex – Virologic Tests: Viral Culturing (2)

A

GOLD STANDARD

  1. Preferred test for patients with genital ulcers or other mucocutaneous lesions
  2. Sensitivity is low in recurrent disease
36
Q

Genital Herpes Simplex – Virologic Tests: ELISA (3)

A
  1. Type specific serologic tests
    - HerpeSelect HSV-2 ELISA may be false + at low index values (1.2-3.5)
    - Confirm with Biokit or Western Blot
  2. HerpeSelect HSV-1 ELISA insensitive for HSV-1 (80%)
    - Head to head comparison of type specific assays vs. Western BlotCytology (Tzanck or Pap)
  3. Insensitive and nonspecific and should not be relied on for HSV diagnosis
37
Q

Genital Herpes Simplex – Virologic Tests: PCR

A

Preferred test for detecting HSV in spinal fluid

38
Q

Genital Herpes Simplex – Virologic Tests: Type Specific Serology Tests (5)

A
  1. Type‐specific and nonspecific antibodies to HSV develop during the first several weeks following infection and persist indefinitely.
  2. Presence of HSV‐2 antibody usually indicates anogenital infection.
  3. Presence of HSV‐1 does not distinguish anogenital from orolabial infection.
  4. Culture medium must be refrigerated
  5. Results come back w/i 48 hours but treat before results
39
Q

Antiviral Medications for HSV (4)

A

Systemic antiviral chemotherapy includes 3 oral medications:

  1. Acyclovir
  2. Valcyclovir
  3. Famciclovir
  4. Topical antiviral treatment has minimal clinical benefit and is not recommended.
40
Q

HSV Patient Counseling and Education (5)

A

Counseling should include:

  1. Nature of the infection
  2. Transmission - Importance of using condoms
  3. Treatment issues
  4. Risk‐reduction strategies
  5. Emphasize potential for recurrent episodes, asymptomatic viral shedding, and sexual transmission.
41
Q

HPV First Line Treatments (3)

A
  1. Imiquimod (3.75%) applied daily for genital warts
  2. Case reports of inflammatory responses to 5% imiquimod
  3. Worsened inflammatory and autoimmune skin disease
42
Q

HPV Alternative Treatments (3)

A
  1. Podophyllin resin 10-25%, reports of systemic toxicity (including death)
  2. No clear efficacy benefit when compared with podophyllotoxin
  3. Contraindicated in pregnancy

PPC2 Exam 1 (13 decks)

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