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Dip GUM > Systemic presentations of STIs > Flashcards

Systemic presentations of STIs Flashcards

1
Q

What is PID

A

Inflammation and infection arising from endocervix
Leading to endometritis, salpingitis, oophoritis and pelvic peritonitis.
Often due to chalmydia, gonorrhoea or BV

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2
Q

Symptoms of PID

A 
Lower abdo / pelvic pain
Abnormal PV discharge 
Deep dyspareunia
Pyrexia >38
Altered bleeding - HMB, PCB, IMB He
Secondary dysmenorrhoea
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3
Q

Outpatient treatment of PID

A

Ceftriaxone 1g IM STAT
and doxycycline 100mg BD 14/7
and metronidazole 400mg BD 14/7

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4
Q

When is hospitalisation indicated for PID

A 
Severe infection
Adnexal mass ? Abscess
Sepsis
Poor response to treatment
Severe pain requiring strong analgesics
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5
Q

Cause of PID

A

usually ascending infection from endocervix
causing endometritis / salpingitis / parametritis / oophoriti / tubo-ovarian abcess / pelvic peritonitis

Common causative agents = gonorrhoea and chlamydia
Mycoplasma genitalium

Other organisms commonly found which may be implicated
Gardnerella vaginalis
anaerobes (including Prevotella, Atopobium, Leptotrichia)

Pathogen negative PID is common

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6
Q

Commonest cause of PID

A

Chlamydia = commonest identified cause

Other organisms commonly found which may be implicated
Gardnerella vaginalis
anaerobes (including Prevotella, Atopobium, Leptotrichia) Mycoplasma genitalium

Pathogen negative PID is common

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7
Q

What effect does insertion of an IUCD have on PID risk

A

increases the risk of developing PID

only for 4-6 weeks after insertion

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8
Q

Signs of PID

A

Lower abdominal tenderness - usually bilateral
Adnexal tenderness on bimanual
+/- tender mass
cervical motion tenderness
fever (>38°C) in moderate to severe disease

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9
Q

In which patients is the risk of PID highest?

A

women under 25
not using barrier contraception
new sexual partner

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10
Q

diagnosis of PID

A

Clinical

based on examination findings

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11
Q

Complications of PID

A

Fitz-Hugh Curtis syndrome

tubo-ovarian abscess

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12
Q

Impact of HIV on PID

A

May have more severe symptoms associated with PID
Respond well to standard antibiotic therapy
No change in treatment indicated

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13
Q

what is Fitz-Hugh Curtis syndrome

A

right upper quadrant pain
associated with perihepatitis
hepatic adhesions

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14
Q

Which patients with PID should be suspected of having a tubo-ovarian abscess

A

Systemically unwell
Palpation of an adnexal mass
Lack of response to therapy

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15
Q

Should an IUCD be removed in a patient with PID?

A

For mild to moderate PID - leave the IUCD in situ
review after 48-72 hours
Remove if no significant clinical improvement

decision to remove IUD balanced against the risk of pregnancy

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16
Q

what tests are indicated for a patient with a clincal diagnosis of PID

A 
Pregnancy test
Chlamydia
Gonorrhoea
Mycoplasma Genitalium 
If moderate / severe - CRP, WCC
USS if abscess / hydrosalpinx suspected
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17
Q

Differential diagnosis of PID

A
  • ectopic pregnancy
  • acute appendicitis
  • endometriosis
  • complications of an ovarian cyst e.g. torsion or rupture
  • urinary tract infection
  • irritable bowel syndrome
  • Acute bowel infection or diverticular disease
  • functional pain - longstanding symptoms
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18
Q

what proportion of women with acute appendicitis have cervical motion tenderness

A

1 / 4

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19
Q

Advice for women treated for PID regarding future fertility

A

Following treatment fertility is usually maintained
There remains a risk of future infertility / chronic pelvic pain / ectopic pregnancy
More severe disease = greater risk
Repeat episodes of PID = an exponential increase in the risk
The earlier treatment is given the lower the risk

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20
Q

Alternative treatment options for PID

A

Ofloxacin 400mg PO BD
AND metronidazole 400mg PO BD for 14 days

or

Moxifloxacin 400mg PO OD 14 days

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21
Q

treatment of M genitalium associated PID

A

Moxifloxacin 400mg PO OD 14 days

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22
Q

Inpatient treatment of PID

A 
IV ceftriaxone 2g daily 
AND IV doxycycline 100mg BD daily 
followed by 
PO doxycycline 100mg BD 
AND PO oral metronidazole 400mg BD 
total of 14 days
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23
Q

Alternative inpatient treatment of PID

A 
IV clindamycin 900mg TDS 
AND IV gentamicin (2mg/kg loading dose)
then 1.5mg/kg TDS\
followed by 
PO clindamycin 450mg QDS 
OR PO doxycycline 100mg BD
AND  PO metronidazole 400mg BD 
total of 14 days

or IV ofloxacin 400mg BD plus IV metronidazole 500mg TDS 14 days
or IV ciprofloxacin 200mg BD plus IV doxycycline 100mg BD plus IV metronidazole 500mg TDS 14 days

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24
Q

When treating severe PID with IV therapy when can the switch to oral treatment be made

A

IV therapy continued until 24 hours after clinical improvement
then switched to oral

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25
Q

Risks associated with PID in pregnancy

A

uncommon

increase in maternal and fetal morbidity

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26
Q

Surgical Management of PID

A

Laparoscopy - dividing adhesions / draining pelvic abscesses

Ultrasound guided aspiration of pelvic fluid collections = less invasive

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27
Q

Follow up for patients treated for PID

A 
Review at 72 hours iif moderate or severe symptoms o
Review at 2-4 weeks 
to ensure:
• response to treatment
• compliance with antibiotics
• PN complete
• repeat pregnancy test
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28
Q

Timeframe for repeating mycoplasma genitalium test after treating M. gen PID

A

4 weeks

to ensure microbiological clearance

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29
Q

What empirical treatment should be offered to male sexual partners of women with PID

A

doxycycline 100mg BD for 1 week

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30
Q

What is the look back period for PN for women with PID

A

6 months before symptom onset

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31
Q

Possible causes of epidiymo-orchitis

A

STIs
Urinary infection
Mumps
Consider tuberculous epididymo-orchitis (high prevalence countries /previous TB / immunodeficiency)
Behcet’s disease
amiodarone treatment
Rare infective causes - brucella and fungi incl candida

32
Q

Treatment of epididymo-orchitis

Suspected STI related

A

If epididymo-orchitis most likely due to any STI:
- Ceftriaxone 1g IM STAT
AND - Doxycycline 100mg PO BD 10-14 days

If most probably non-gonococcal cause could consider:
- Doxycycline 100mg PO BD 10-14 days
or
Ofloxacin 200mg PO BD 14 days

33
Q

What is epididymo-orchitis

A

clinical syndrome

Pain, swelling and inflammation of the epididymis +/- testes

34
Q

Commonest aetiology of epididymo-orchitis in under 35s

A

most often a sexually transmitted pathogen

such as Chlamydia or gonorrhoea

35
Q

Commonest aetiology of epididymo-orchitis in over 35s

A

most often non-sexually transmitted
Gram negative enteric organisms
causing urinary tract infections
Risks include recent instrumentation / catheterisation

36
Q

What additional investigations are recommended for men with epididymo-orchitis caused by gram negative enteric organisms

A

Further investigations of the urinary tract

anatomical or functional abnormalities are common in this group

37
Q

What % of men with mumps develop epididymo-orchitis

A

up to 40% of post-pubertal males

Mumps epidemic in 2005

38
Q

risk factors for tuberculous epididymo-orchitis

A

rare presentation

  • patients from high prevalence countries
  • previous history of TB
  • immunodeficiency

usually as a result of disseminated infection
commonly associated with renal TB

TB epididymitis - noted as a complication of BCG instillation for treatment of bladder carcinoma

39
Q

Does mycoplasma genitalium cause epididymo-orchitis?

A

Yes

Test men with epididymo-orchitis for mycoplasma genitalium

40
Q

What % of UK TB cases are extra-pulmonary

A

40-45% of TB cases in the UK

41
Q

Does Ureaplasma urealyticum cause epididymo-orchitis?

A

Often found in men with epididymo-orchitis

BUT Evidence lacking to support causation

42
Q

Symptoms of epididymo-orchitis

A

characteristically = unilateral scrotal pain and swelling
relatively acute onset
+/- urethritis or urethral discharge

43
Q

What is the most important differential diagnosis of epididymo-orchitis

A

Torsion of the spermatic cord (testicular torsion)

surgical emergency

44
Q

What is the timeframe for surgery for testicular torsion

A

testicular salvage surgery IS REQUIRED WITHIN 6 HOURS becomes decreasingly likely with time

45
Q

Symptoms of mumps

A

headache
fever
characteristic unilateral / bilateral parotid swelling
7-10 days later - unilateral testicular swelling
+/- epididymitis

46
Q

Symptoms suggestive of tuberculous epididymo-orchitis

A 
subacute / chronic onset 
painless or painful scrotal swelling 
\+/- associated systemic symptoms of tuberculosis 
\+/- scrotal sinus 
\+/-thickened scrotal skin
47
Q

Signs of epididymo-orchitis

A

Tenderness to palpation
Palpable swelling of epididymis - starting with tail at the lower pole - spreading towards the head
+/- involvement of the testicle

Possibly
o urethral discharge
o secondary hydrocoele
o erythema / oedema of the scrotum
o pyrexia
48
Q

Complications of epididymo-orchitis

A

More common in uropathogen related epididymo-orchitis than STI causes
• Reactive hydrocoele
• Abscess formation
• Infarction of the testicle
• Infertility - poorly understood relationship

Mumps epididymo-orchitis can lead to testicular atrophy.

49
Q

Of those with bilateral orchitis what % will have reduced fertility

A

13%

50
Q

Diagnosis of epididymo-orchitis and cause

A

STI testing
• Gram stained urethral smear
• Urethral swab for gonorrhoea culture
• FPU or urethral swab for NAATs - gonorrhoea / chlamydia
• MCS of MSU for bacteria
• urine dipstick - nitrite and leucocyte

KUB USS + urologist RV - if confirmed UTI cause

51
Q

Test for confirming diagnosis of mumps epididymo-orchitis

A

mumps IgM / IgG serology

52
Q

Investigation for tuberculous epididymo-orchitis

A

3x early morning urines
for AAFB - not always positive in TB epididymitis
IV urography
renal tract USS
biopsy of the site
CXR to exclude / confirm co- existing respiratory involvement

53
Q

General advice for management of epididymo-orchitis

A

Rest
Analgesia
Scrotal support
NSAIDs
Abstain from sexual intercourse until they and
partner(s) completed treatment and follow-up - if STI cause

54
Q

Treatment of epididymo-orchitis most probably due to enteric organisms

A
  • Ofloxacin 200mg PO BD 14 days
    or
  • Ciprofloxacin 500mg PO BD 10 days
55
Q

Are corticosteroids beneficial in the treatment of acute epididymo-orchitis

A

no

56
Q

Treatment of severe epididymo-orchitis or epididymo-orchitis with features of sepsis

A

in-patient management
fluid and electrolytes
IV antibiotics

  • cefuroxime 1.5g TDS
    +/- Gentamicin for 3-5 days
57
Q

Treatment of epididymo-orchitis of all causes where the patient is allergic to cephalosporins and/or tetracyclines

A

Ofloxacin 200mg PO BD 14 days

58
Q

PN for epididymo-orchitis

A

Partner notification and empirical treatment
for all patients with epididymo-orchitis due to gonorrhoea / chlamydia / NGU or / indeterminate aetiology and MSU negative

59
Q

Follow-up of epididymo-orchitis

A

Review at 3 days
If no improvement - review diagnosis and therapy re-evaluated
Further follow-up at 2 weeks - assess compliance, PN and improvement of symptoms.
TOC if GC +ve

If minimal improvement in swelling - arrange USS or surgical assessment

60
Q

Differential diagnosis in suspected epididymo-orchitis which does not improve with antibiotics

A 
testicular ischaemia / infarction 
testicular / epididymal tumour 
alternative infectious aetiologies - TB, mumps or rarer infective cause
non-infective causes 
progression to an abscess
61
Q

Aetiology of reactive arthritis

A

sterile inflammation
of synovial membrane / tendons / fascia
triggered by an infection at a distant site
usually GI or STI

62
Q

What is the name of reactive arthritis caused by and STI

A

sexually acquired reactive arthritis
= SARA

Includes sexually acquired Reiter’s syndrome

63
Q

What is Reiter’s syndrome

A

the triad of urethritis, arthritis and conjunctivitis

+/- other cutaneous / mucous membrane lesions
- keratoderma blennorrhagic / circinate balanitis/vulvitis, uveitis / oral ulceration / cardiac or neurological involvement

64
Q

Most common causes of SARA

A

urethritis or cervicitis
Most common = Chlamydia - 35-69% of cases
Gonorrhoeae - up to 16%
Ureaplasma urealyticum - a few cases

65
Q

Mechanism of SARA

A

not fully known
Immune response to uro­genital micro­-organisms
Synovial fluid cultures are negative for organisms
An intrasynovial immune response to the organisms occurs

Intra-articular bacterial antigen has been found in the joints
Synovitis is mediated by proinflammatory cytokine

66
Q

What is the implication of possession of the HLA­B27 gene in relation to SARA

A

HLA­B27 gene increases susceptibility to SARA

up to 50x

67
Q

What history may be associated with a patient with SARA

A

past or family history of spondyloarthritis or iritis

Sexual intercourse - usually with a new partner - within 3 months prior to the onset of arthritis

68
Q

Symptoms of SARA

A

Arthritis within 30 days of sexual contact
Recent urethral discharge +/- dysuria
Pain +/- swelling and stiffness, at one or more joints
Esp knees, ankles and feet
Pain and stiffness at entheses - esp posterior / plantar aspect of the heels
Enthesitis / fasciitis
Painful movements - tenosynovitis
Low back pain / stiffness
Irritable eyes +/- redness / photophobia / reduced visual acuity
Conjunctivitis
Iritis is less common
Systemic symptoms - malaise / fatigue / fever

69
Q

Signs of SARA

A 
Genital infection
Arthritis 
Enthesopathy
Tenosynovitis. 
Acute sacro­-iliitis
Conjunctivitis
Psoriasiform rash 
nail dystrophy
Heart lesions usually asymptomatic - tachycardia, LV dilatation, pericarditis, aortic valve disease 
Renal pathology - proteinuria / microhaematuria / aseptic pyuria
70
Q

Complications of SARA

A

Majority = self­ limiting

complications of SARA are principally due to aggressive
arthritis - more likely with a HLA­B27 gene

  • chronic symptoms
  • Erosive joint damage
  • Persistent locomotor disability
  • cataract formation - from nadequately treated / recurrent uveitis
71
Q

What is the mean duration of first episode of SARA

A

4­ - 6 months
followed by full recovery

50% have recurrent episodes at variable intervals

72
Q

Diagnosis of SARA

A

3 components.
· Typical clinical features of spondyloarthropathy.
· Evidence of genito­urinary infection
· Investigation of specificity and activity of arthritis

73
Q

General advice for the management of SARA

A

self­-limiting disease
Avoid sexual intercourse - including oral sex - until treatment completed and follow­up for any STI
Rest
NSAIDS

74
Q

Essential investigations for SARA

A 
- STI screening
HIV test
ESR or CRP
FBC
Urinalysis
75
Q

Additional investigations which are often useful in SARA

A 
LFTS
U+Es
HLA­B27.
X­rays - affected joints + sacro­iliac joints.
ECG.
Echo

Ophthalmic evaluation including slit lamp

sometimes useful

  • Blood cultures.
  • Stool culture (if enteritic ReA is suspected).
  • USS of affected joints / entheses.
  • MRI of sacro­iliac joints
  • Synovial fluid analysis - cell count / Gram stain / crystals / culture.
  • Synovial biopsy
  • Exclusion tests - rheumatoid factor / autoantibodies (SLE) / plasma urate (gout), CXR + serum ACE level (sarcoidosis)
76
Q

Management of SARA

A 
Treat STI 
Rest
NSAIDS
Physiotherapy
Ice packs
Intra-a­rticular corticosteroid injections
77
Q

Management of moderate / severe SARA

or failure of first line treatment

A
  • Systemic corticosteroids +/- osteoporosis prophylaxis.
  • Sulphasalazine / Methotrexate / Azathioprine - If disabling symptoms persist 3+ months or erosive joint damage
  • Gold salts and ­D-penicillamine - occasionally used for persistent polyarthritis
  • Biological agents - TNF alpha blockers - use for
    treating ReA is anecdotal - possible they may re­activate
    the infective trigger

Dip GUM (27 decks)

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