Ulcerative diseases Flashcards
causative organism of donovanosis
Klebsiella granulomatis (Originally identified as Calymmatobacterium granulomatis)
Transmission of donovanosis
sexual transmission - questioned Most cases = 20–40-year age group
clinical features of donovanosis
firm papule or subcutaneous nodule Which later ulcerates 90% affects genitals 6% extrag-genital Lymphadenitis uncommon. Dissemination rare
what 4 types of donovanosis are described classically
- Ulcerogranulomatous = most common; non-tender, fleshy, exuberant, single or multiple, beefy red ulcers, bleed readily when touched.
- Hypertrophic / verrucous type = ulcer or growth with raised irregular edge
- Necrotic = usually deep foul-smelling ulcer, tissue destruction
- Sclerotic = extensive fibrous and scar tissue
What extra-genital sites may donovanosis affect?
lips gums cheek palate pharynx Atypical cases in children - affecting face
What areas may secondary spread of donovanosis affect?
secondary spread to liver and bone usually associated with pregnancy and cervical lesions
What is the effect of pregnancy on donovanosis infection
Secondary spread is more likely Lesions grow more rapidly
Diagnosis of donovanosis
Direct microscopy - Giemsa stain tissue smears large mononuclear cells with intracytoplasmic cysts filled with deeply-stained Gram-negative Donovan bodies.
Treatment of dononvanosis
Azithromycin 1g PO weekly or 500mg daily for three weeks or until lesions completely healed
Alternative treatment options for donovanosis
- Co-trimoxazole 160/800mg BD PO 2. Doxycycline 100mg BD PO: 1 3. Erythromycin 500mg QDS PO 4. Gentamicin 1 mg/kg every 8h IV ALL for 3 weeks or until lesions completely healed
Treatment of dononvanosis in pregnancy
Erythromycin 500mg QDS PO o Could use Azithromycin 1 g weekly
Partner notification for donovanosis
all sexual contacts in the last six months offered examination for possible lesions
Follow-up for patients treated for donovanosis
follow up until lesions have healed completely
Diagnosis of LGV
- Clinical suspicion - signsof proctocolitis, inguinal lymphadenopathy and hx of genital ulcer - Positive CT NAATs tested for LGV DNA - Exclude other STIs
Culture sensitivity for LGV
75-85%
What specimen sampling sites should be used for CT NAATS for LGV testing?
Chlamydiae = intracellular - aim to collect cellular materialfrom: • Ulcer base exudate • rectal mucosa • Aspiration of lymph node or bubo • Rectal / pharyngeal swabs • Urethral swab or FPU if urethritis present
What blood borne virus infections have a high rate of association with LGV infection?
- HIV - HCV High rates of incident infections in LGV infected MSM Offer risk reduction advice
Treatment of LGV
1st choice: Doxycycline 100 mg BD PO 21 days 2nd choice: Erythromycin 500mg QDS PO 21 days Alternative: Azithromycin 1g weekly for 3 weeks
why is a longer course of treatment recommended for LGV than for chlamydia?
The rationale relates to the sys- temic nature of LGV infection
What accompanying measures should be taken during antibiotic treatment of LGV
- Aspirate fluctuant buboes through healthy adjacent skin. Surgical incision usually contraindicated due to risk of complication such as sinus formation. - Provide adequate analgesia for LGV as it may be painful
Treatment of LGV in pregnancy
Erythromycin 500mg QDS PO 21 days AVOID doxycycline Azithromycin 1g weekly for 3 weeks can be considered TOC
Contact tracing look back period for LGV
Sexual contacts within 4 weeks before onset of the symptoms Last 3 months if asymptomatic Examine, test and offer empirical treatment for 21 days
Follow up of patients with LGV
FU All patients clinically until signs and symptoms resolved usually = 1– 2 weeks may take 3–6 weeks for longstanding infections check adequate PN complete +/- FU blood testing - syphilis, Hep B, C and HIV done
Is a routine TOC recommended for LGV
No Unless pregnant or breastfeeding Or concerns about treatment completion
Management of patients with fibrotic lesions or fistulae caused by LGV
antibiotic therapy to treat infection and surgical repair (including reconstructive genital surgery)
What is the causative organism of chancroid
Haemophilius ducreyi
What type of bacteria is Haemophilius ducreyi
Gram-negative facultative anaerobic coccobacillus in the family Pasteurellacae
Clinical features of chancroid
ano-genital ulceration lymphadenitis progression to bubo formation
Transmission of chancroid
Sexual transmission Usually requires a break in the skin
Incubation period of chancroid
4–7 days
Prodromal symptoms of chancroid
no prodromal symptoms
Classical appearance of a chancroid ulcer
ragged undermined edge grey or yellow base bleeds when touched. painful single or multiple
What are the usual sites of chancroid infection in men?
-the prepuce - coronal sulcus - frenulum - glans
What are the usual sites of chancroid infection in women?
- labia minora - fourchette. Uncommon = vaginal wall and cervix
Can extra-genital chancroid
rare - fingers - breasts - inner thighs
Can H. ducreyi become systemically disseminated
No
Clinical variants of chancroid
giant phagadenic ulcers dwarf chancroid (similar to herpes) follicular chancroid single painless ulcers (like syphilis)
What proportion of patients with chancroid have painful inguinal lymphadenopathy
50% of male cases less common in women
Complications of chancroid
Mostly seen in men - phimosis - partial loss of tissue - Healed ulcers may cause tissue contraction - Mild constitutional symptoms
Does H. ducreyi infection offer secondary protective immunity
no
Diagnosis of chancroid
DNA PCR Culture - of ulcer base / or undermined edges material Microscopy - Gram-negative coccobacilli
Treatment of chancroid
Azithromycin 1g PO STAT or Ceftriaxone 250mg IM STAT or Ciprofloxacin 500mg PO BD 3 days or Erythromycin 500mg PO QDS 7 days
Treatment of chancroid for HIV positive patients
Ciprofloxacin 500mg PO BD 3 days or Erythromycin 500mg PO QDS 7 days
Treatment of chancroid in pregnancy or breastfeeding
Erythromycin 500mg PO QDS 7 days or Ceftriaxone 250mg IM STAT AVOID ciprofloxacin
What are the adverse effects of chancroid on pregnancy outcome or fetal development
None reported
Partner notification look back window for chancroid
sexual contacts within 10 days before symptoms + empirical treatment
What are the three stages of LGV
Primary lesion Secondary lesions, lymphadenitis or lymphadenopathy or bubo Tertiary stage or the genito-anorectal syndrome
incubation period of LGV
extremely variable range 3– 30 days
Presentation of the primary lesion of LGV
Primary lesion may be transient and imperceptible Painless papule / pustule / shallow erosion / ulcer
Presentation of LGV proctitis
Haemorrhagic proctitis = primary manifestation rectal pain anorectal bleeding mucoid and/or haemopurulent rectal discharge tenesmus constipation symptoms of lower GI inflammation Some report fever / malaise
Presentation of pharyngeal LGV
less common symptomatic ulceration pharyngitis symptomatic carriage at this site
What proportion of rectal LGV cases are asymptomatic
up to 95%
what secondary lesions may arise from LGV infection?
Tender inguinal / femoral lymphadenopathy lymph node chain may become matted periadenitis bubo formation Buboes may ulcerate and discharge pus +/- create chronic fistulae. systemic spread associated with fever / arthritis / pneumonitis / perihepatitis Reactive arthritis
In what timeframe does lymphadenopathy commonly follow the primary lesion
Lymphadenopathy commonly follows the primary lesion by 10–30 days
Features of the tertiary stage of LGV
proctitis proctocolitis mimicking Crohn’s disease fistulae strictures chronic granulomatous disfiguring fibrosis and scarring
what causes the tertiary stage of LGV
persistence or progressive spread of chlamydia trachomatis in anogenital tissues Chronic inflammatory response Destruction of tissue in the involved areas Most recover after secondary stage
Long term complications of LGV
destruction of lymph nodes may cause genital lymphoedema (elephantiasis) persistent suppuration pyoderma association with rectal cancer reported
Symptoms of herpes simplex
Localised pain Ulcerations / vesicles May be asymptomatic systemic symptoms - fever + myalgia (more common with primary HSV)
Signs of herpes simplex
Painful ulcerations / blistering and ulceration Tender inguinal lymphadenitis
Complications of HSV
Superinfection of lesions with candida or streptococcal species Autonomic neuropathy, resulting in urinary retention. Autoinoculation to fingers / adjacent skin Aseptic meningitis
Treatment of herpes simplex
preferred regimens = Aciclovir 400 mg TDS for 5/7 OR Valaciclovir 500 mg BD 5/7 Alternative regimens: Aciclovir 200 mg five x day for 5/7 Famciclovir 250 mg TDS for 5/7
What proportion of patients with HSV-associated proctitis have external anal ulceration
Only 32% of MSM with HSV-associated proctitis have visible external anal ulceratio
What proportion of patients with HSV-associated proctitis have external anal ulceration
Only 32% of MSM with HSV-associated proctitis have visible external anal ulceration
Define ‘initial episode’ of genital HSV
First episode with either HSV-1 or HSV-2
What is the difference between an initial episode of genital HSV and primary infection with genital HSV
The initial episode is the first episode with either HSV 1 or 2 It is subcalssifcied as either primary or non-primary dependant upon If the person had prior exposure to the other type Primary infection = first infection with either HSV-1 or HSV-2 and no pre-existing antibodies to either type. Non-primary infection = first infection with either HSV- 1 or HSV-2 in an individual with pre-existing antibodies to the other type
define: Recurrent episode of genital HSV
A recurrence of clinical symptoms due to reactivation of pre-existent HSV-1 or HSV-2 infection after a period of latency
Which type of HSV is most common cause of genital herpes in the UK
HSV-1 the usual cause of oro-labial herpes now the most common cause of genital herpes in the UK
Which type of HSV is more likely to cause recurrent anogenital symptoms
HSV-2 more likely to cause recurrent anogenital symptoms historically was the most common cause of genital herpes in the UK - not anymore
what proportion of people develop symptoms at the time of acquisition of HSV
1/3 develop symptoms at the time of acquisition of HSV-2.
What is the incubation period for herpes simplex
Incubation period from acquisition to first clinical signs and symptoms ranges from 2 days to 2 weeks only 1/3 have symptoms at time of infection the majority of infections are acquired subclinically.
What impact does prior infection with HSV-1 have on manifestations of HSV-2
Prior infection with HSV-1 modifies the clinical manifestations of first infection by HSV-2 usually making symptoms less severe
What type of HSV are the majority of adult infections with HSV caused by in the UK?
The majority are due to HSV-1 in the UK The probability of HSV-1 rather than HSV-2 is greater at younger age (women <50 years, men <35years)
Natural history of HSV after primary infection
Virus becomes latent in local sensory ganglia Periodically reactivating to cause symptomatic lesions or asymptomatic, infectious, viral shedding.
what is the usual recurrence rate for genital herpes after a symptomatic first episode
4 recurrences per year for HSV-2 1 recurrence per year for HSV-1 Recurrence rates decline over time in most people
What genital regions may HSV be shed from asymptomatically
HSV can be shed asymptomatically from - external genitalia, - anorectum, - cervix - urethra.
What impact does HIV have on HSV viral shedding
HIV-positive HSV-2 seropositive individuals have higher rates of symptomatic and asymptomatic HSV shedding. Particularly with low CD4 counts or those also seropositive for HSV-1
Diagnosis of genital HSV
HSV demonstrated in swabs taken from the base of the anogenital lesion or the rectal mucosa
When should HSV typing be obtained and why
Virus typing to differentiate HSV-1 and HSV-2 should be obtained in all patients with newly diagnosed genital herpes Essential for diagnosis, prognosis, counselling, and management
When may HSV serology be useful?
- Recurrent genital disease of unknown cause - Counselling patients with initial HSV episode, including pregnant women - Investigating asymptomatic partners of patients with genital herpes, including pregnant partners / planning pregnancy
General advice for management of genital herpes
Saline bathing Analgesia Topical anaesthetic agents, e.g. 5% lidocaine ointment
What is the recommended timeframe for initiating antivirals for HSV
within 5 days of start of episode while new lesions are forming of if systemic symptoms persist
What is the impact of antiviral treatment for HSV
Aciclovir, valaciclovir, and famciclovir all reduce the severity and duration of episodes Does not alter the natural history of the disease or the frequency / severity of subsequent recurrences
When is IV treatment for HSV indicated?
Only when the patient cannot swallow or tolerate oral medication due to vomiting
When may antivirals for the management of HSV be indicated for longer than the standard 5 days?
If new lesions are still appearing at 5 days or if systemic symptoms are still present or if complications have occurred.
When may inpatient treatment be indicated for HSV
For complications such as: urinary retention meningism severe constitutional symptoms
Which antivirals are recommended for episodic treatment of HSV - dose and duration
Short-course therapies recommended Aciclovir 800 mg TDS 2 days Famciclovir 1 g BD 1 day Valaciclovir 500 mg BD 3 days
When is suppressive antiviral therapy indicated for recurrent HSV
Patients who have at least six recurrences per year. Such patients have fewer or no episodes on suppressive Patients suffering from psychological morbidity or significant anxiety
Which dose and drug are recommended for suppressive antiviral therapy for recurrent HSV
Recommended regimens . Aciclovir 400 mg BD . Aciclovir 200 mg QDS . Famciclovir 250 mg BD . Valaciclovir 500 mg OD
Which medical conditions require dose adjustment of Aciclovir?
severe renal disease
Management of a patient who experiences breakthrough recurrences of HSV whilst on suppressive treatment
Increase the daily dosage e.g. aciclovir 400 mg three times daily
What is the recommended maximum time to continue HSV suppressive treatment before reassessing recurrence frequency?
discontinue suppressive treatment after a maximum of 1 year to reassess recurrence frequency.
What should we advise patients when stopping suppressive treatment for HSV?
A rebound recurrence often occurs when ending suppression. This does not indicate the rate of future ongoing recurrences
What does haemophilus ducreyi cause
Chancroid
Symptoms of Chancroid
Painful shallow multiple ulcers Regional lymphadenopathy + suppuration
What causes granuloma inguinale
Klebsiella granulomatosis
Sexually transmitted causes of genital ulcers
herpes simplex syphilis chancroid granuloma inguinale (Donovanosis) LGV
