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1、Sexually transmitted infections,Mary Horgan M.D.Cork University Hospital,Major STD syndromes,Genital ulcer diseaseUrethritis/cervicitisVaginitis/vaginosisExophytic processesEctoparasitic infestationsSystemic STD syndromes,Genital ulcer disease,Genital herpes(HSV)Syphilis(T.pallidum)Chancroid(H.ducre
2、yi)Lymphogranuloma venereum(rare)Granuloma inguinale(rare),Genital ulcer disease,Conditions characterised by ulcers which are usually sexually transmittedMultiple causes can co-exist,Staging of syphilis,PrimarySecondaryLatentEarly latent:1 year Late(tertiary)-includes neurosyphilis,Primary syphilis,
3、The first manifestation of infectionCharacterized by development of chancreIncubation periodaverage 3 wks.from time of exposurerange 9-90 daysChancre occurs at site of bacterial invasion,Chancre characteristics,InduratedPainlessRaised borderRed,smooth baseScant serous secretionsIndolent,“punched out
4、”appearance,Chancre characteristics,Regional lymphadenopathy is commoninguinal nodes if genital lesions presentcervical nodes if oropharyngeal lesions presentChancre usually(but not always)precedes development of secondary symptomsChancre typically resolves in 3-6 weeks without treatment,Secondary s
5、yphilis,Evidence of systemic spread of infectionCharacterized by rash,other skin and mucous membrane lesionsTypically develops 3-6 weeks following development of primary lesions(chancre),Rash characteristics,Maculopapular eruptionclassic palmar-plantar distributionmay occur on face,back,trunk,arms,l
6、egsRash may also manifest asmacular or erythematous eruptionpapular lesionspustular lesions(infrequent)annular lesions,Rash characteristics,“Mucous patches”affecting mucous membrane surfacesFacial“nickel and dime”lesionsPatchy alopecia(hair-loss)“moth-eaten”appearance,Systemic signs and symptoms,Flu
7、-like syndromeWeight lossAnemia,elevated ESRLymphadenopathyHepatosplenomegaly,Latent syphilis,Serologic evidence of infection without clinical manifestationspositive blood test for syphilisno primary or secondary lesionsno evidence of tertiary diseaseEarly vs.late latent syphilisearly:infection of l
8、ess than 1 years durationlate:infection of greater than 1 years duration,Treatment Recommendations,Early syphilisall primary infectionsall secondary infectionsearly latent infection(1 years duration)*Benzathine PCN-G(Bicillin-LA)2.4 million units IM single dose,Treatment Recommendations,Late disease
9、 Late latent syphilis(1 years duration)*Benzathine PCN-G(Bicillin-LA)2.4 million units IM q week x 3 doses,Treatment Recommendations,Penicillin-allergic patients:Doxycycline 100mg po BID x 14 days(28 days if late disease),ORTetracycline 500mg po QID x 14 days(28 days if late disease),Neurosyphilis,T
10、he manifestations of CNS syphilis were readily recognized by physicians practicing 30 or 40 years ago.However they are unfamiliar to many physicians today given the relative rarity of this condition,Neurosyphilis,Asymptomaticno clinical manifestationsdefined by presence of CNS abnormalities includin
11、g:WBC 5/mm3,mostly lymphselevated proteinreactive CSF-VDRLmay progress to overt neurosyphilis,Parenchymatous neurosyphilis,General paresis also known as paretic neurosyphilis,dementia paralytica,and general paralysis of the insaneT.pallidum directly invades the cerebrumearly symptoms:memory loss,irr
12、itability,personality changes,headache,insomnialate symptoms:defective judgment,emotional lability,lack of insight,confusion,disorientation,delusions,paranoia,seizures,Parenchymatous neurosyphilis,General paresis neurologic findings include:Argyll Robertson pupilsslurred speechexpressionless facetre
13、mors,Congenital syphilis,Acquistion of syphilis by the fetus or newborn infantVertical transmission from motherTransplacental(during pregnancy)Perinatal acquisition(at time of birth)Significant cause of spontaneous abortion(up to 50%in infected mothers),Congenital syphilis,Early clinical signs and s
14、ymptoms include:hepatomegalysplenomegalyanemia,jaundiceskin rash/petechiatepersistent nasal discharge(“snuffles”)abnormal bone development(osteochondritis)pseudoparalysis,Cardiovascular syphilis,Cause of thoracic aortic aneurysmaortic valvular insufficiencyAlso may involve coronary arteriesPathogene
15、sis is through endarteritis of the vasa vasorum of aortaLesions may erode through chest wall or rupture spontaneously,Treatment of tertiary syphilis,Treatment of gummatous lesions will prevent further destruction Treament will not restore tissue which has already been destroyed,Laboratory tests for
16、syphilis,Confirm clinical suspicion of diseaseScreen populations at riskMonitor response to therapyDetermine treatment failure and need for lumbar puncture,Types of laboratory tests,Direct examination of lesion materialdarkfield microscopySerologic testing of blood samplesnon-treponemal tests(screen
17、ing)treponemal tests(confirmatory)Otherdirect fluorescent antibody(DFA)histologic staining(biopsy),Darkfield microscopy,Extremely specific for T.pallidumTest of choice for moist genital ulcersOffers immediate diagnosisOpportunity for immediate treatment,Serologic tests for syphilis,“A blood test”Det
18、ects antibody in serumRequires blood sample centrifugationRequires laboratory processingFollow universal precautions at every step,Syphilis-Non-treponemal tests,Used for screening large samplesCardiolipin-cholesterol-lecithin antigenSensitive but not 100%specificTwo tests commonly availableRapid Pla
19、sma Reagin test(RPR)Venereal Disease Research Laboratory test(VDRL),Non-treponemal test sensitivity,Test 1o 2o EL LLVDRL78%100%95%71%RPR86%100%98%73%,False-positive RPR/VDRL,General population:1-2%IV drug users:10%Transient false-positivepregnancyfebrile illnessesChronic false-positiveautoimmune dis
20、orders,aging,Syphilis-Treponemal tests,Used for confirmation of infectionDetects antibodies against T.pallidum cellular componentsMore expensive,more specificCommonly available tests include:Fluorescent Treponemal Antibody Absorption(FTA-ABS)Microhemagglutination Assay(MHA-TP)T.pallidum particle agg
21、lutination(TP-PA),Interpreting treponemal tests,86%of syphilis cases remain reactive for lifeNot used to monitor efficacy of treatment or reinfection1%false-positive rate in general pop.Negative test on CSF excludes neurosyphilis,Syphilis serology,Problems:How do you ascertain who is infectious?How
22、do you ascertain who should be tracked for partner notification?,Summary,Neurosyphilis,congenital syphilis and tertiary syphilis are difficult to diagnoseThese conditions cause serious long-term morbidity and mortalityHigh index of suspicion for syphilis is required when dealing with populations at
23、risk,Genital herpes,90%of primary infection is subclinicalMost common in adolescence and young adultsNeonatal infection via birth canaldisseminatedCNSskin,eye,mouth(SEM)occurs with primary secondary infection,Genital Herpes,Primary infection:first exposure to HSV type 1 or 2Initial infection:first e
24、xposure to HSV-2 but previous infection with HSV-1some antibody cross protectiongenerally not as severe as primary infectionRecurrent infection:known prior outbreaksusually precipitated by stress,trauma,pregnancy,menses,fever,systemic illness,Genital herpes:primary infection,Usually painful with pro
25、dromeIncubation period:2-20 days(mean 6d)Duration 1-3 weeksPresents as painful vesicles or ulcersInitial infection is usually associated withlymphadenopathyfever,headachesmyalgiasurethritis,cervicitisurinary retention,Genital infection:recurrent infection,80%have recurrences but frequency variesUsua
26、lly at same site as primary infectionLess severe than primary infection,Genital herpes:Diagnosis,Clinical featuresViral cultureHSV PCR,Genital herpes:treatment,Acyclovir or derivatives are drugs of choiceAvailable in oral,parenteral and topical formsPrimary infectionACV 400mg tid for 10 daysRecurren
27、t infectionACV 400mg tid for 5 daysChronic suppressive therapy:consider for 6 episodes/year withACV 400mg bd for one year,Urethritis/cervicitis,Gonorrhoea(N.gonorrhoeae)Chlamydia trachomatisMycoplasma hominisUreaplasma urealyticum,The urethra,Common pathway for urine and semenColumnar epithelial lin
28、ingPrimary site of infection for GC and chlamydiaPossible site of infection for mycoplasma hominisTrichomonasUreaplasma,Urethritis,Inflammatory response of urethrainfection of urethraWBC is primary inflammatory responseorganisms may also be seenSymptomsdysuriadischarge(purulent or mucoid)WBC,Urethra
29、l specimen collection,Patient should not void for 2hours before specimen collectionSwab inserted 1-2cm into distal urethra and rotated 1-2 turnsSmear swab onto glass slideInoculate swab onto chocolate and NY agarSecond swab for chlamydiazyme,Cervicitis,Cervicitis is the female counterpart of urethri
30、tisinflammatory response of cervixreflects infection of T zoneWBC is primary inflammatory response and organisms may be seen as in GC,Cervicitis,Caused byNeisseria gonorrhoeaeChlamydia trachomatisMycoplasma hominisUreaplasma TrichomonasCharacterised bydischarge dysuriadyspareunia,Other causes of cer
31、vical inflammation,HSVTrichomonasCandidiasisForeign bodyEctopy,OCP and menses,Endocervical swab collection,Visualise cervical osInsert swab and rotate several timesObserve colour of swabSmear swab lightly on glass slideInoculate on chocolate and NY agarSecond swab for chlamydiazyme as above,Chlamydi
32、a trachomatis,Common cause of cervicitis and urethritisObligate intracellular organismMay cause PID and sequelaeReiters syndromeNeonatal eye infection and pneumoniaDiagnosis byculturenon-culture techniquesurine-based screening,Treatment of Chlamydia trachomatis,Treat withAzithromycin 1G po one doseI
33、f no access to microscopy treat for coinfectionSee CDC recommendations for alternatives for allergiespregnancyreinfectionless expensive regimens,Gonorrhoea,Gram-intracellular diplococciCause urethritis,cervicitis,proctitis and pharyngitisDisseminated gonococcal infectionAssociated with PID and its s
34、equelaeNeonatal infection e.g.conjunctivitis,Treatment of GC,Effective therapy includes a regimen that covers coinfection with chlamydia and GCTreat withCiprofloxacin 500mg one doseAzithromycin 1G one doseFor alternatives see CDC guidelines on www.cdc.gov,Evaluation of sex partners,Treat regular and
35、 potential source partners as per index caseSymptomatic patientsrefer all patients within past 30 daysAsymptomatic patientsrefer all patients within past 60 daysTreat all partners who have objective evidence of infectionFull STD screen should be done on all patients,Vaginitis/vaginosis,Bacterial vag
36、inosisTrichomoniasisYeast vaginitis,Bacterial vaginosis,Malodorous vaginal discharge+/-pruritisHomogenous,non-viscous milky white D/CCaused by gardnerella,mycoplasma and anaerobesAbsence of normal flora like lactobacillus appears to correlate with its developmentNot sexually transmitted but more com
37、mon in sexually active women,Bacterial vaginosis,Vaginal pH 4.5Positive whiff testfishy odour on addition of 10%KOHPresence of clue cells on microscopyHomogenous discharge on examination,Bacterial vaginosis,Infection may induce preterm labourTreatmentMetronidazole 400mg bd for 7 daysavoid during fir
38、st trimester of pregnancyNo indication to treat sexual partner,Trichomoniasis,Caused by a protozoa,Trichomonas vaginalisProfuse,purulent,malodorous dischargeMay be associated with dysuria and irritationExamination shows petechiae on cervix(“strawberry cervix”),Trichomoniasis:diagnosis,Motile trichom
39、onads on saline wet prep of vaginal exudateVaginal pH 4.5Culture(not routinely done),Trichomoniasis:treatment,Metronidazole 2.0G one doseSexual abstinence until symptoms resolveTreatment of sexual contacts is necessary since the infection is sexually transmitted,Vulvovaginal candidiasis,Usually not
40、a sexually transmitted infection66%caused by Candida albicansPresents withvulval pruritisvaginal dischargedysuria,Vulvovaginal candidiasis:diagnosis and treatment,pH 4.5Fungal elements on 10%KOH prepTreat with intravaginal imidazole cream or pessaryFluconazole 150mg one dose,Pelvic Inflammatory Disease,
