T4: STDs and Syphilis

Question 1

List 3 main causes of genital discharge

List 2 non-gonococcal causes of discharge

Answer 1

1. Neisessia gonorrhea
2. Chlamydia trachomatis
3. Trichomonas vaginalis

Non-gonococcal: Mycoplasma genitalium, ureaplasma urealyticum

Question 2

A patient comes in with genital ulceration. What are the 5 ddx?

Answer 2

1. HSV
2. Syphilis
3. Haemophilus ducreyi
4. Chlamydia
5. Klebsiella granulomatis (Granuloma inguinale)

Question 3

A patient comes in with a wart: What are your 4 Ddx?

Answer 3

1. HPV
2. Conylomata lata (syphilis)
3. Molluscum contangiosum
4. scabies

Question 4

What is the approach that we use in managing STIs and what are the pros and cons of this approach?

Answer 4

Syndromic management
Pros- saves time, increase access, saves cost, doesn’t require resources
Cons- not targeted, against antibiotic stewardship, allergies, need to follow up

Question 5

You are about to discharge a patient with an STI. When will you see this patient again (as a general rule) and what is the exception to this rule and why?

Answer 5

See them 1 week later except for if they have PID (72 hours later or earlier due to risk of sepsis)

Question 6

What are the complications of STIs in women?

• Acute
• Chronic

Answer 6

Acute- PID (Chlamydia and gonorrhea), endometritis, dyspareunia, disseminated infection and pregnancy (neonatal disease, chorioamnionitis, PTL)
Chronic- chronic pelvic pain and adhesions, cervical Ca, infertility, recurrent miscarriages, ectopic pregnancy, psychosocial

Question 7

What are the complications of STIs in men?
Acute
Chronic

Answer 7

Acute- More localized» epididymo-orchitis, prostatitis, urethritis, periurethral abscess, dissemination
Chronic- fistulae formation and urethral strictures

Question 8

Given that we follow a syndromic approach when dealing with STIs- list 7 syndromes that we work with

Answer 8

1. Discharge syndromes- MUS, VDS
2. Genital ulceration syndromes
3. Warts
4. LAP
5. Scrotal swelling
6. Pubic lice
7. Bubos

Question 9

SCROTAL SWELLING

• You have a patient presenting with scrotal swelling. Besides the infectious causes- list 4 ddx and state the general management for these
• List 2 infectious causes of scrotal swelling
• Given the causative organisms, describe management (2)

Answer 9

• Malignancy, hernia, testicular torsion, hydrocele and you refer these patients to surgery
• Gonorrhoea, chlamydia
• Gonorrhea- ceftriaxone, Chlamydia- azithromycin

Question 10

BUBO

• Define a bubo
• Given its location: list 4 ddx (excluding infection)
• List 2 causative organisms for a bubo (infectious) and therefore, describe the management of it

Answer 10

• A bubo is a tender, unilateral inguinal lymphadenopathy
• Abscess, aneurysm, lymph nodes, hernia
• Haemophilus ducreyi and chlamydia trachomanis. Management= Azithromycin. If abscess- drain every 72 hours and if it persists= refer.

Question 11

PUBIC LICE

• Name the causative organism
• In which areas of the body will you see pubic lice?
• List 3 symptoms
• The differential diagnosis is __. State how this differs from pubic lice (2)
• Describe the management of pubic lice

Answer 11

• Phirus pubis
• Pubis, perianal, eyelashes
• itching, red papules, bacterial superinfection
• scabies. They differ in location. Scabies= skin, pubis- hair
• Management: Benzyl benzoate. Wash all contaminated linen and iron them. if eyelashes are involved= petroleum jelly for 10 days

Question 12

LOWER ABDOMINAL PAIN

• Given the location of LAP, there are 4 main groups of Ddx. List there and give differentials
• Name the scale we use for PID and thereafter, explain each of the 5 stages and management therefore
• Describe the management of LAP

Answer 12

• pregnancy-related- ectopic pregnancy, endometritis
• gynecological: ovarian torsion, cysts, chronic endometritis, ovarian cancer
• abdominal/ intestinal: appendicitis, IBS, IBD, colitis, constipation
• urinary tract: cystitis, pyelonephritis, acute urinary retention
• We use the Glansville staging.
  Stage 1- endometritis and salpingitis no peritonitis
  stage 2- salpingitis and peritonitis
  stage 3- salpingitis and occlusion
  stage 4- tubulo ovarian/ fallopian torsion
  stage 5- respiratory symptoms> preserve life

So you first exclude the differential diagnoses. If they screen positive for the ddx- refer to gynecology (if severely ill- put an IV line and administer ceftriaxone and metronidazole and refer)
If they just have LAP with or without discharge (none of the ddx)- you screen for a UTI. If they have a UTI- treat for UTI but if not: give ceftriaxone, azithromycin, and metronidazole (discharge syndromes management)

Question 13

WART RELATED SYNDROMES
- Account for the decrease in the incidence of HPV
- HPV has ONCOGENIC and BENIGN strains- name these
- Your differential diagnosis when you see a wart-like lesion is condylomata lata. What test will you use to exclude this?
- Wart can resolve spontaneously. But in which instances do we want to interfere and why?
Name 2 complications of warts
Describe the management of warts

Answer 13

• Vaccines for HOV given in Grade 4 learners (girls)
• Oncogenic- 16, 18. Benign- 6,11
• Do an RPR
• Pregnancy as it may cause obstructed labor
• laryngeal papilloma and infect the infant passing down the birth canal
• Management can be surgical (cryoablation, excision, laser ablation, electrocautery) or medical (immunotherapy- interferons, cytotoxic (fluorouracil, trichloroacetic acid), podophyllotoxin - not for use in pregnancy)

Question 14

GUS

- List 5 differential diagnoses for GUS

Answer 14

HSV
Syphilis
H ducreyi
Granuloma inguinale (Klebsiella granulomatosis)
Chlamydia (L1-L3)

Question 15

Which organism best describe:

• NO pain
• NO lymph
• Breakdown into a beefy ulcer with rolled-up edges, bleeds easily

Answer 15

Klebsiella inguinale (granuloma inguinale)

Question 16

Which organism best describe

• NO pain
• Lymph present bilaterally
• clean base, clear edges, margins are red and indurated

Answer 16

Syphilis

Question 17

Which organism best describe
NO pain
Lymph unilaterally
superficial 
groove sign

Answer 17

Chlamydia trachomatis

Question 18

Pain present
Lymphs and bubo
multiple vesicles, pus; edges ragged, red, not indurated
inguinal lymph» abscess

Answer 18

Haemophilus ducreyi

Question 19

Pain ulcers
tender local lymphadenopathy (inguinal)
May have a headache, dysuria, or subclinical

Answer 19

HSV

Question 20

Genital ulceration syndromes- management

• Which drug should you give in an HIV + patient (or unknown RVD status) with genital ulceration?
• You have a male who has had sex in the past 3 months and is HIV + AND has a genital ulcer- how do you treat him?
• You have a pregnant woman who presents with a genital ulcer and has had sex in the past 3 months but is HIV -. How do you treat her?
• You have a patient with genital ulceration who has not had sex in the past 3 months and is HIV -. What is your working diagnosis?
• All of the above-mentioned patients need to be followed up 6 months later. which test should you do at the follow-up?

Answer 20

• Acyclovir
• Doxycycline + acyclovir
• Benzylpenicillin (or amoxicillin or probenecid acid if benzylpenicillin is not available)
• I will consider genital herpes as a dx. Emphasize HIV testing
  Do an RPR 6 months later

Question 21

DISCHARGE SYNDROMES
State whether this refers to gonococcal or non-gonococcal causes

pruritus, dysuria, discharge, mucous strands in urine

(IT IS VERY HARD TO DIFFERENTIATE)

Answer 21

non-gonococcal

Question 22

DISCHARGE SYNDROMES
State whether this refers to gonococcal or non-gonococcal causes

Acute, abrupt onset, discharge, dysuria, and frank/ purulent discharge

Answer 22

Gonococcal

Question 23

You see a male patient who presents with discharge and dysuria. He tells you that his girlfriend has a VDS. What is your management?

Answer 23

Give him single-dose IM ceftriaxone and oral azithromycin AND oral metronidazole

Question 24

You see a male patient who presents with discharge and dysuria. He also tells you that he is allergic to penicillin. What is your management?

In which 3 ways will you confirm that a patient has penicillin allergy?

You follow this patient up a week later and he states that, despite adhering to the medication, the discharge persists. What drug do you give him?

Answer 24

I will omit ceftriaxone. I will double the dose of azithromycin (2g)

angioedema, bronchospasm, anaphylactic shock

gentamicin + 2g Azithromycin

Question 25

A 20-year-old presents to you with discharge and dysuria. What is the first condition to exclude?

Answer 25

LAP

Question 26

A 20-year-old presents to you with discharge and dysuria. She does not have LAP. She tells you that she is not sexually active. How do you manage her?

Answer 26

Assess for candida and bacterial vaginosis and follow up in 7 days (it could also be physiological) [treatment would be metronidazole or clotrimazole]

Question 27

A pregnant 24-year-old presents to you with discharge and dysuria. She does not have LAP. How do you manage her? On PV, you notice that her vulva is red, scratched, and inflamed with a curd-like discharge. What will you add to your management? And if symptoms persist?

Answer 27

Give- ceftriaxone, azithromycin, metronidazole Add clotrimazole vaginal cream or pessary Give metronidazole for 7 days

Question 28

SYPHILIS - True or false: syphilis has been decreasing in incidence over the years - Why, as a doctor, is it important to know about syphilis? - Name the causative organism and 2 diagnostic techniques for it - How is it transmitted?

Answer 28

- False (increasing incidence) - High prevalence, mortality, and morbidity, MTCT, easy to Rx - Treponema pallidum, serology, and dark field microscopy - Horizontally (sex, blood-borne)and vertically (from week 9= transplacental, not via breastfeeding unless there is a lesion on the breast)

Question 29

SYPHILIS - What does latent mean? - Describe the classification of syphilis - If you are unsure of the stage of syphilis the patient is in, what do you do? - Differentiate between early latent and late latent syphilis

Answer 29

- Latent= clinically inapparent infection - Early syphilis>> primary, secondary, early latent & Late syphilis>> late latent, tertiary - Treat as late - early= < 1 year, late= > 1 year

Question 30

``` PRIMARY SYPHILIS - What is characteristic of primary syphilis? Describe it - When does it appear? - How long does it last? -What happens if untreated? - Using the following terms- describe the sequelae of primary syphilis (These are not in order) chanre>> papule>> ulcer>> macule ```

Answer 30

- chancre- painless ulcer, indurated raised borders, red base, bilateral lymphadenopathy - Appears ~21 days after exposure (9-90 days) - Lasts 3-8 weeks - Progresses if untreated>> blood - macule>> papule >> ulcer>> chancre

Question 31

SECONDARY SYPHILIS - What characterizes secondary syphilis - There are a number of symptoms (which often resolve spontaneously even without treatment). They belong to the following classifications, explain each - Rash - Alopecia - Lymphadenopathy - Constitutional - GIT - Renal - MSK - CNS - Ocular

Answer 31

- Spirochetaemia - Rash: maculopapular even on palms and soles, diffuse: on trunk and extremities, mucosal surfaces. Condylomata lata: moist areas, highly infectious. HIV+>> lues maligna: non-resolving ulceration - Alopecia: Moth-like on hair, eyebrows, beard - Lymphadenopathy: epitrochlear is very suggestive, non/ minimally tender, usually generalized - Constitutional- fever, malaise, headache, myalgia, sore throat, LOW. GIT: Hepatitis (raised ALP, ALT, and AST), lesions in GIT mucosa Renal- nephrotic syndrome, acute nephritis with hypertension> acute renal failure MSK: synovitis, osteitis, periostitis CNS: meningitis, CN palsies, meningovascular disease, stoke Ocular- ant/post/ panuveitis. Treat as neurosyphilis

Question 32

TERTIARY SYPHILIS - When does tertiary syphilis occur? - In this stage, there is tissue damage- account for it - At this stage, there are 3 main categories of presentations. Name and explain each one briefly

Answer 32

- Occurs 3-10 years later in a third of untreated syphilis - Gummatous: granulomatous lesions on the skin/ muscle, viscera (brian, abdo), and bone Cardiovascular: syphilitic aortitis and endarteritis obliterans CNS: Tabes dorsalis and General paresis of the insane

Question 33

TERTIARY SYPHILIS - Using the DORSALIS mnemonic, describe the morphology of tabes dorsalis - Describe Argyl-Robertson eyes

Answer 33

``` Dorsal column degeneration (chronic inflammatory changes in the parenchyma) Orthopedic pain(Charcot's joints) Reflexes decreased (deep tendon) Shooting pain (lighting pains) Argyl-Robertson eyes (ptosis) Locomotor ataxia (high stomping gait, bladder incontinence) Impaired proprioception Syphilis ``` Small pupil, does not respond to the light, normal response to accommodation and convergence, dilates imperfectly to mydriasis, does not dilate in response to painful stimuli

Question 34

``` TERTIARY SYPHILIS Define GPI Describe General paresis of the insane - Symptoms - Signs ```

Answer 34

- Progressive dementing illness - Symptoms: Behaviour, personality, judgment impairment. Forgetfulness, occasional psychosis - Signs: dysarthria, intention tremor, brain atrophy on CT, hypotonia of face and limb

Question 35

NEUROSYPHILIS 1. Classify neurosyphilis and explain each category 2. In terms of syphilis Dx- Name 2 tests used and 2 tests not used.

Answer 35

- Asymptomatic: Abnormal CSF but signs and symptoms absent - Acute syphilitic meningitis: Early invasion. Meningeal symptoms, CN palsies, acute transverse myelitis - Menignovascular syphilis: MCA (aphasia, neglect, homonymous hemianopia, gaze palsy towards lesion, contralateral paresis) involvement. Presents with strokes. Focal arteritis leads to focal infarcts. Endarteritis of small vessels with perivascular inflammation. Status epilepticus and memory impairment. Prodrome: insomnia, headache, emotional lability - Parenchhymous syphilis: Tabes dorsalis and GPI

Question 36

NEUROSYPHILIS - Describe the traditional algorithm for syphilis testing - Name two non-specific tests and their advantages and disadvantages - Name the 2 specific tests and their advantages

Answer 36

- We first start with non-specific (non-treponemal) tests and do specific tests - RPR and VDRL. They are quantitative (titre, RPR> 1:16 +). Very sensitive (may give false +). Tells you about an active disease, can take time to be + - FTA-ABS and TPHA- Qualitative (+/-), very specific, positive for life

Question 37

NEUROSYPHILIS - TRUE OR FALSE: neurosyphilis only occurs in tertiary syphilis - In terms of diagnosis, we use CSF which is the opposite of serum: explain how so - TRUE OR FALSE: a negative PCR excludes neurosyphilis - Describe the CSF of neurosyphilis - Explain the role of contact tracing here - Describe the treatment of early vs late syphilis (and in a case of allergy?)

Answer 37

- False, neurosyphilis can occur at any stage - RPR and VDRL (specific, so if +, that is diagnostic, if negative, does not exclude) and FTA-ABS and ELISA/ TPHA are sensitive (if negative, excludes) - False - high bacteria, low glucose - Contact tracing is NB, even if the partner is seronegative. Presumptive Rx. - Early: 1-week benzathine penicillin (one IM stat dose), Late: 3 doses of benzathine penicillin (weekly) - Give doxycycline in allergy

Question 38

NEUROSYPHILIS - Describe the treatment of neurosyphilis - For how long do CSF abnormalities persist? - When do you do a follow-up RPR? - Steroids are not used in SA for neurosyphilis. What is the advantage of their use?

Answer 38

- IV or IM penicillin, 10-14 days - persist for months - 3 months later= RPR - Prevent nerve deafness, optic atrophy, interstitial keratitis

Question 39

NEUROSYPHILIS - What is a Jarisch-Herxheimer reaction? - Describe the symptoms and treatment thereof - On special occasions, it can be devastating- explain

Answer 39

- This is a reaction where the dying spirochetes release inflammatory mediators>> cytokines after administration of an effective agent - Fever, myalgia, headache, worsening of the lesion, headache>> give antipyrexia and analgesia - Devastating if: localised form: ocular, neuro, CVS; Aneurysm>> rupture>> death or in pregnancy: PRM (PTL)

Question 40

NEONATAL SYPHILIS - What do you do if the mother's RPR is + - Explain how syphilis is diagnosed - Describe the syphilitic placenta

Answer 40

- Give 10-day parenteral penicillin and follow up until negative - Dx when the mother has RPR+ and clinically and if the baby's serology shows 4X the maternal RPR - Large, thick, pale, necrotizing fasciitis