Systemic presentation of STIs Flashcards
What are the essential investigations required in SARA?
Full screening for STIs, including HIV. ESR/CRP Or Plasma viscosity (PLV). FBC Urinalysis.
What investigations are often useful in SARA?
Liver and kidney function tests.
HLAB27.
Xrays of affected joints and sacroiliac joints. Electrocardiogram.
Echocardiogram.
Ophthalmic evaluation including slit lamp assessment.
What is the aetiology of SARA?
Chlamydia is the commonest identifiable cause of NGU and SARA - 35-69% of cases
Neisseria gonorrhoeae- 16%
Ureaplasma urealyticum- minority
Mechanism of CT causing inflammatory process in joints in SARA?
CT persists in the synovium in an aberrant form with repressed synthesis of the major outer membrane protein (MOMP) and active production of heat shock protein
This contributes to the inflammatory response.
Causes of STI keratitis?
Keraitis is inflammation of cornea
More common in HIV Viral- HSV/VZV are most common Bacterial- rare but severe Fungal- rare in HIV candida albicans/parapsilosis
Symptoms- eye pain, photophobia, discharge, FB sensation
Diagnosis- slit lamp +/- viral PCR
Epidydimo orchitis
1st and 2nd line treatments
If likely STI-
Ceftriaxone 500mg IM single dose
Plus Doxycycline 100mg po BD 10-14 days
If GC unlikely
Doxycycline 100mg po bd 10-14 days
or Ofloxacin 200mg bd 14 days
EO likely non STI (?enteric organisms)
Ofloxacin 200mg po bd 14 days
Or Ciprofloxacin 500mg bd 10 days
List of SH related notifiable diseases/ infections to PHE
Acute encephalitis/meningitis Neisseria meningitidis Infectious bloody diarrhoea Malaria Measles/mums/rubella Tetanus Tuberculosis Typhus Yellow fever Campylobacter spp Giardia lamblia Haemophilus influenzae Hepatitis A, B, C, delta, and E viruses Legionella spp Polio virus Salmonella spp Shigella spp Streptococcus pneumoniae/ pyogenes Varicella zoster virus Vibrio cholerae Yersinia pestis
Is HIV a notifiable disease in the UK?
No
Risk of infertility % with 1st, 2nd and 3rd episodes of PID?
16%- 1st
20% - 2nd
40% 3rd
What are CV complications with SARA?
Usually asymptomatic Tachycardia Left ventricular dilatation Rarely pericarditis Aortic valve disease may occur.
Electrocardiographic abnormalities, including conduction delay, are recorded in 5-14% of patients
Example of some features in SARA?
Urethritis/proctitis/cervicitis Endocarditis Conjunctivitis Keratoderma blenorrhagica Arthritis Tenosynovitis Sacroilitis Entesopathy Psoriaform rasm Renal disease- GN/IGA nephropathy Thrombophlebitis Fever/weight loss
What is the 1st line outpatient treatment for PID?
Intramuscular ceftriaxone 1g single dose plus Oral doxycycline 100mg BD for 14 days plus Oral metronidazole 400mg BD for 14 days
OR
Oral ofloxacin 400mg BD for 14 days
plus
Oral metronidazole 400mg BD for 14 days
OR
Oral moxifloxacin 400mg OD for 14 days
What is the 2nd line outpatient treatment for PID?
IM ceftriaxone 1 g immediately
PLUS
Oral azithromycin 1 g/week for 2 weeks
1st line inpatient treatment for PID?
IV until 24 hours after clinical improvement -then switched to oral.
Intravenous ceftriaxone 2g daily
PLUS Intravenous doxycycline 100mg BD (oral if tolerated)
Followed by:
Oral doxycycline 100mg BD for 14 days
PLUS Oral metronidazole 400mg BD for 14 days
OR
Intravenous clindamycin 900mg TID
PLUS Intravenous gentamicin 2mg/kg loading dose followed by 1.5mg/kg TID
Followed by:
Oral clindamycin 450mg QID to complete 14 days OR oral doxycycline 100mg BD to complete 14 days
PLUS
Oral metronidazole 400mg BD to complete 14 days
Treatment of SARA?
Treating underlying infection does not affect course of complications but rely treatment may decrease risk of relapsing arthritis in those with previous hx of reactive arthritis
Treatment of SARA if enteric cause?
Short term antibiotics do not appear to alter the course of Reiter’s
Treatment of arthritis in SARA?
Rest
NSAIDs
Prednisolone if poly arthritis
Chronic arthritis- suflasalazine, methotrexate, azathioprine
TNF alpha
Level of evidence for use of moxifloxacin in PID?
level 1A
Treatment of GC in eye?
Ceftriaxone 1mg IM 3 days
Or
Spectinomycin 2g IM daily for 3 days
Treatment of disseminated GC?
Assess for endocarditis or meningitis
Ceftriaxone 1g IM (or IV) daily
Or cefotaxime 1g IV 8 hourly
Or ciprofloxacin 500mg IV 12 hourly
Or spectinomycin 2g IM 12 hourly
Disseminated gonorrhoea?
Rash
Tenosynovitis
Arthralgia
Very rarely endocarditis, meningitis and osteomyelitis, hepatitis
How does GC spread to cause disseminated GC?
Haematogenously
Is DGI more common in men or women?
3 x more common in women
Systemic symptoms of DGI?
Systemic symptoms include:
Fever
Malaise
Joint pain/swelling
Skin rash
DGI and cardiac involvement interesting fact!
Before the advent of antibiotic therapy, gonorrhoea was the single most common cause of bacterial endocarditis.
How does DGI manifest in joints?
Purulent arthritis without skin lesions. This may be symmetrical and affects the knees, wrists or ankles
Tenosynovitis/dermatitis/polyarthralgia syndrome. This is usually asymmetrical
Most commonly affects feet, hands and knee
Dermatological DGI where does it present?
Skin lesions are found mainly on the extremities and spare the scalp, face and mucous membranes.
What does skin DGI look like?
Macules 1-2 mm in diameter evolve through papular, vesicular and pustular stages with central haemorrhage preceding necrosis and desquamation.
The spots are painless and usually number less than 10.
A dark, haemosiderin, stain may be seen at resolution.
Sensitivity of NAAT to diagnose GC in synovial fluid of joints?
NAAT testing on synovial fluid resulting in an overall NAAT sensitivity of 73.3%
