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Dip GUM > Ulcerative diseases > Flashcards

Ulcerative diseases Flashcards

1
Q

causative organism of donovanosis

A

Klebsiella granulomatis (Originally identified as Calymmatobacterium granulomatis)

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2
Q

Transmission of donovanosis

A

sexual transmission - questioned Most cases = 20–40-year age group

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3
Q

clinical features of donovanosis

A

firm papule or subcutaneous nodule Which later ulcerates 90% affects genitals 6% extrag-genital Lymphadenitis uncommon. Dissemination rare

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4
Q

what 4 types of donovanosis are described classically

A
  1. Ulcerogranulomatous = most common; non-tender, fleshy, exuberant, single or multiple, beefy red ulcers, bleed readily when touched.
  2. Hypertrophic / verrucous type = ulcer or growth with raised irregular edge
  3. Necrotic = usually deep foul-smelling ulcer, tissue destruction
  4. Sclerotic = extensive fibrous and scar tissue
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5
Q

What extra-genital sites may donovanosis affect?

A

lips gums cheek palate pharynx Atypical cases in children - affecting face

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6
Q

What areas may secondary spread of donovanosis affect?

A

secondary spread to liver and bone usually associated with pregnancy and cervical lesions

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7
Q

What is the effect of pregnancy on donovanosis infection

A

Secondary spread is more likely Lesions grow more rapidly

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8
Q

Diagnosis of donovanosis

A

Direct microscopy - Giemsa stain tissue smears large mononuclear cells with intracytoplasmic cysts filled with deeply-stained Gram-negative Donovan bodies.

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9
Q

Treatment of dononvanosis

A

Azithromycin 1g PO weekly or 500mg daily for three weeks or until lesions completely healed

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10
Q

Alternative treatment options for donovanosis

A
  1. 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
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11
Q

Treatment of dononvanosis in pregnancy

A

Erythromycin 500mg QDS PO o Could use Azithromycin 1 g weekly

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12
Q

Partner notification for donovanosis

A

all sexual contacts in the last six months offered examination for possible lesions

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13
Q

Follow-up for patients treated for donovanosis

A

follow up until lesions have healed completely

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14
Q

Diagnosis of LGV

A
  • Clinical suspicion - signsof proctocolitis, inguinal lymphadenopathy and hx of genital ulcer - Positive CT NAATs tested for LGV DNA - Exclude other STIs
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15
Q

Culture sensitivity for LGV

A

75-85%

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16
Q

What specimen sampling sites should be used for CT NAATS for LGV testing?

A

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

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17
Q

What blood borne virus infections have a high rate of association with LGV infection?

A
  • HIV - HCV High rates of incident infections in LGV infected MSM Offer risk reduction advice
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18
Q

Treatment of LGV

A

1st choice: Doxycycline 100 mg BD PO 21 days 2nd choice: Erythromycin 500mg QDS PO 21 days Alternative: Azithromycin 1g weekly for 3 weeks

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19
Q

why is a longer course of treatment recommended for LGV than for chlamydia?

A

The rationale relates to the sys- temic nature of LGV infection

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20
Q

What accompanying measures should be taken during antibiotic treatment of LGV

A
  • 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
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21
Q

Treatment of LGV in pregnancy

A

Erythromycin 500mg QDS PO 21 days AVOID doxycycline Azithromycin 1g weekly for 3 weeks can be considered TOC

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22
Q

Contact tracing look back period for LGV

A

Sexual contacts within 4 weeks before onset of the symptoms Last 3 months if asymptomatic Examine, test and offer empirical treatment for 21 days

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23
Q

Follow up of patients with LGV

A

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

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24
Q

Is a routine TOC recommended for LGV

A

No Unless pregnant or breastfeeding Or concerns about treatment completion

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25
Q

Management of patients with fibrotic lesions or fistulae caused by LGV

A

antibiotic therapy to treat infection and surgical repair (including reconstructive genital surgery)

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26
Q

What is the causative organism of chancroid

A

Haemophilius ducreyi

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27
Q

What type of bacteria is Haemophilius ducreyi

A

Gram-negative facultative anaerobic coccobacillus in the family Pasteurellacae

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28
Q

Clinical features of chancroid

A

ano-genital ulceration lymphadenitis progression to bubo formation

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29
Q

Transmission of chancroid

A

Sexual transmission Usually requires a break in the skin

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30
Q

Incubation period of chancroid

A

4–7 days

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31
Q

Prodromal symptoms of chancroid

A

no prodromal symptoms

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32
Q

Classical appearance of a chancroid ulcer

A

ragged undermined edge grey or yellow base bleeds when touched. painful single or multiple

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33
Q

What are the usual sites of chancroid infection in men?

A

-the prepuce - coronal sulcus - frenulum - glans

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34
Q

What are the usual sites of chancroid infection in women?

A
  • labia minora - fourchette. Uncommon = vaginal wall and cervix
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35
Q

Can extra-genital chancroid

A

rare - fingers - breasts - inner thighs

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36
Q

Can H. ducreyi become systemically disseminated

A

No

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37
Q

Clinical variants of chancroid

A

giant phagadenic ulcers dwarf chancroid (similar to herpes) follicular chancroid single painless ulcers (like syphilis)

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38
Q

What proportion of patients with chancroid have painful inguinal lymphadenopathy

A

50% of male cases less common in women

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39
Q

Complications of chancroid

A

Mostly seen in men - phimosis - partial loss of tissue - Healed ulcers may cause tissue contraction - Mild constitutional symptoms

40
Q

Does H. ducreyi infection offer secondary protective immunity

A

no

41
Q

Diagnosis of chancroid

A

DNA PCR Culture - of ulcer base / or undermined edges material Microscopy - Gram-negative coccobacilli

42
Q

Treatment of chancroid

A

Azithromycin 1g PO STAT or Ceftriaxone 250mg IM STAT or Ciprofloxacin 500mg PO BD 3 days or Erythromycin 500mg PO QDS 7 days

43
Q

Treatment of chancroid for HIV positive patients

A

Ciprofloxacin 500mg PO BD 3 days or Erythromycin 500mg PO QDS 7 days

44
Q

Treatment of chancroid in pregnancy or breastfeeding

A

Erythromycin 500mg PO QDS 7 days or Ceftriaxone 250mg IM STAT AVOID ciprofloxacin

45
Q

What are the adverse effects of chancroid on pregnancy outcome or fetal development

A

None reported

46
Q

Partner notification look back window for chancroid

A

sexual contacts within 10 days before symptoms + empirical treatment

47
Q

What are the three stages of LGV

A

Primary lesion Secondary lesions, lymphadenitis or lymphadenopathy or bubo Tertiary stage or the genito-anorectal syndrome

48
Q

incubation period of LGV

A

extremely variable range 3– 30 days

49
Q

Presentation of the primary lesion of LGV

A

Primary lesion may be transient and imperceptible Painless papule / pustule / shallow erosion / ulcer

50
Q

Presentation of LGV proctitis

A

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

51
Q

Presentation of pharyngeal LGV

A

less common symptomatic ulceration pharyngitis symptomatic carriage at this site

52
Q

What proportion of rectal LGV cases are asymptomatic

A

up to 95%

53
Q

what secondary lesions may arise from LGV infection?

A

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

54
Q

In what timeframe does lymphadenopathy commonly follow the primary lesion

A

Lymphadenopathy commonly follows the primary lesion by 10–30 days

55
Q

Features of the tertiary stage of LGV

A

proctitis proctocolitis mimicking Crohn’s disease fistulae strictures chronic granulomatous disfiguring fibrosis and scarring

56
Q

what causes the tertiary stage of LGV

A

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

57
Q

Long term complications of LGV

A

destruction of lymph nodes may cause genital lymphoedema (elephantiasis) persistent suppuration pyoderma association with rectal cancer reported

58
Q

Symptoms of herpes simplex

A

Localised pain Ulcerations / vesicles May be asymptomatic systemic symptoms - fever + myalgia (more common with primary HSV)

59
Q

Signs of herpes simplex

A

Painful ulcerations / blistering and ulceration Tender inguinal lymphadenitis

60
Q

Complications of HSV

A

Superinfection of lesions with candida or streptococcal species Autonomic neuropathy, resulting in urinary retention. Autoinoculation to fingers / adjacent skin Aseptic meningitis

61
Q

Treatment of herpes simplex

A

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

62
Q

What proportion of patients with HSV-associated proctitis have external anal ulceration

A

Only 32% of MSM with HSV-associated proctitis have visible external anal ulceratio

63
Q

What proportion of patients with HSV-associated proctitis have external anal ulceration

A

Only 32% of MSM with HSV-associated proctitis have visible external anal ulceration

64
Q

Define ‘initial episode’ of genital HSV

A

First episode with either HSV-1 or HSV-2

65
Q

What is the difference between an initial episode of genital HSV and primary infection with genital HSV

A

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

66
Q

define: Recurrent episode of genital HSV

A

A recurrence of clinical symptoms due to reactivation of pre-existent HSV-1 or HSV-2 infection after a period of latency

67
Q

Which type of HSV is most common cause of genital herpes in the UK

A

HSV-1 the usual cause of oro-labial herpes now the most common cause of genital herpes in the UK

68
Q

Which type of HSV is more likely to cause recurrent anogenital symptoms

A

HSV-2 more likely to cause recurrent anogenital symptoms historically was the most common cause of genital herpes in the UK - not anymore

69
Q

what proportion of people develop symptoms at the time of acquisition of HSV

A

1/3 develop symptoms at the time of acquisition of HSV-2.

70
Q

What is the incubation period for herpes simplex

A

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.

71
Q

What impact does prior infection with HSV-1 have on manifestations of HSV-2

A

Prior infection with HSV-1 modifies the clinical manifestations of first infection by HSV-2 usually making symptoms less severe

72
Q

What type of HSV are the majority of adult infections with HSV caused by in the UK?

A

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)

73
Q

Natural history of HSV after primary infection

A

Virus becomes latent in local sensory ganglia Periodically reactivating to cause symptomatic lesions or asymptomatic, infectious, viral shedding.

74
Q

what is the usual recurrence rate for genital herpes after a symptomatic first episode

A

4 recurrences per year for HSV-2 1 recurrence per year for HSV-1 Recurrence rates decline over time in most people

75
Q

What genital regions may HSV be shed from asymptomatically

A

HSV can be shed asymptomatically from - external genitalia, - anorectum, - cervix - urethra.

76
Q

What impact does HIV have on HSV viral shedding

A

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

77
Q

Diagnosis of genital HSV

A

HSV demonstrated in swabs taken from the base of the anogenital lesion or the rectal mucosa

78
Q

When should HSV typing be obtained and why

A

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

79
Q

When may HSV serology be useful?

A
  • 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
80
Q

General advice for management of genital herpes

A

Saline bathing Analgesia Topical anaesthetic agents, e.g. 5% lidocaine ointment

81
Q

What is the recommended timeframe for initiating antivirals for HSV

A

within 5 days of start of episode while new lesions are forming of if systemic symptoms persist

82
Q

What is the impact of antiviral treatment for HSV

A

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

83
Q

When is IV treatment for HSV indicated?

A

Only when the patient cannot swallow or tolerate oral medication due to vomiting

84
Q

When may antivirals for the management of HSV be indicated for longer than the standard 5 days?

A

If new lesions are still appearing at 5 days or if systemic symptoms are still present or if complications have occurred.

85
Q

When may inpatient treatment be indicated for HSV

A

For complications such as: urinary retention meningism severe constitutional symptoms

86
Q

Which antivirals are recommended for episodic treatment of HSV - dose and duration

A

Short-course therapies recommended Aciclovir 800 mg TDS 2 days Famciclovir 1 g BD 1 day Valaciclovir 500 mg BD 3 days

87
Q

When is suppressive antiviral therapy indicated for recurrent HSV

A

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

88
Q

Which dose and drug are recommended for suppressive antiviral therapy for recurrent HSV

A

Recommended regimens . Aciclovir 400 mg BD . Aciclovir 200 mg QDS . Famciclovir 250 mg BD . Valaciclovir 500 mg OD

89
Q

Which medical conditions require dose adjustment of Aciclovir?

A

severe renal disease

90
Q

Management of a patient who experiences breakthrough recurrences of HSV whilst on suppressive treatment

A

Increase the daily dosage e.g. aciclovir 400 mg three times daily

91
Q

What is the recommended maximum time to continue HSV suppressive treatment before reassessing recurrence frequency?

A

discontinue suppressive treatment after a maximum of 1 year to reassess recurrence frequency.

92
Q

What should we advise patients when stopping suppressive treatment for HSV?

A

A rebound recurrence often occurs when ending suppression. This does not indicate the rate of future ongoing recurrences

93
Q

What does haemophilus ducreyi cause

A

Chancroid

94
Q

Symptoms of Chancroid

A

Painful shallow multiple ulcers Regional lymphadenopathy + suppuration

95
Q

What causes granuloma inguinale

A

Klebsiella granulomatosis

96
Q

Sexually transmitted causes of genital ulcers

A

herpes simplex syphilis chancroid granuloma inguinale (Donovanosis) LGV

Dip GUM (27 decks)

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