Sexually Transmitted Infection

What causes the skin to be in herpes?

Very tender

HSV1 is usually what?

Herpes labialis (oral/cold sores)

HSV2 is usually what?

Genital herpes

Which groups of people can herpes cause serious illness?

Pregnancy and immunocompromised

What are some signs and symptoms of initial outbreak?

Worse

Painful lesions

Abrupt onset

Fever

Anorexia

Malaise

Tender regional lymphadenopathy

When do herpes symptoms subside?

10-14 days

How long does viral shedding occur for herpes?

3 weeks or more

Herpes labialis (HSV-1) prodrome?

Pain, burning, tingling, and pruritus 6-36 hours prior to appearance of vesicle

What type of rashes do HSV1 have?

Erythematous papules

Rapidly develop into vesicles

Become pustular and ulcerate

What are the symptoms of Herpes genitalis (HSV-2)?

More severe than type 1

Especially in women

Herpetic vesicles appear on or near the external genitalia

Vesicles rupture

◦ Leave exquisitely tender ulcers

◦ The vaginal mucosa is inflamed and edematous

◦ Cervical involvement 70-80% of patients

◦ Characterized by ulcerative cervical mucosa

What % of patients will have a reoccurrence of herpes?

90% of patients within the first 12 months

◦ PAINFUL lesions

◦ No fever or constitutional symptoms

◦ The lesions heal in 8-10 days

◦ Viral shedding lasts an average 2-5 days

◦ HSV-2: The symptoms are more severe - especially in women

How to diagnose herpes?

PCR or Tzanck smear

What is the treatment of herpes?

Acyclovir (Zovirax)

How can healthcare workers prevent new HSV infections?

Universal precautions

What is proven effective in reducing transmission in HSV2?

Valacyclovir

What is the most common STI worldwide?

Condyloma Acuminata (HPV)

What are the most common types of HPV?

HPV 6 or HPV 11

Virtually all cases of cervical cancer are due to what?

HPV infection 16 and 18

What is a sign and symptom of HPV?

◦ A lump in the genital region - "a wart"

◦ Flesh colored growths

◦ May itch

◦ May bleed (if irritated)

◦ May appear erythematous

◦ Can be pedunculated

◦ Usually is a discrete papillary growth

◦ Arise from a single stalk

How do you diagnose HPV?

Generally, a clinical diagnosis

Papanicolaou (Pap) test of the cervix

Biopsy

What is the treatment of HPV surgically?

Cryotherapy - most common

What are treatment of HPV medically?

Trichloroacetic acid

Podofilox (Condylox)

How do you prevent HPV?

Gardasil 9 (HPV vaccine)

What is HPV vaccination NOT USED for?

Treatment of active warts

What is the recommended age for HPV vaccination? What is not?

11-12 years

>27 years

What are complications of HPV?

Development of cervical dysplasia and cancer

Penile and esophageal cancer

What is urethritis?

Gonococcal urethritis (20%): Neisseria gonorrhoeae

Nongonococcal urehtritis (80%): Chlamydia trachomatis

What are complications of urethritis & cervicitis?

◦ Urethral stricture

◦ Lymphangitis

◦ Periurethral abscess

◦ Tuboovarian abscess

◦ PID - pelvic inflammatory disease

◦ Sterility

What are signs and symptoms of men in gonococcal urethritis/cervicitis?

◦ Mucopurulent urethral/rectal discharge

◦ Unilateral epididymal tenderness and swelling

What are signs and symptoms of women in gonococcal urethritis/cervicitis?

◦ Mucopurulent cervical/vaginal discharge

◦ Cervical motion tenderness

◦ Adnexal tenderness

◦ Lower abdominal tenderness

◦ Asymptomatic in up to 50%

What are some extragenital GC infections?

Conjunctivitis in new borns from untreated mothers

Disseminated gonococcal infection

- purulent arthritis

- triad of tenosynovitis, dermatitis, and polyarthralgias

What are screening for high-risk patients of gonorrhea?

HIV infections

Sexually active women <25 years

New or several sex partners

MSM

How to diagnose gonorrhea?

Nucleic acid amplification testing (NAAT) is the test of choice

How to treeat gonorrhea?

High dose ceftriaxone IM

Concurrent treatment for C. trachomatis

- doxycycline

- azithromycin (but has increasing resistance)

What should you do if they have gonorrhea regarding differentials?

ALWAYS treat empirically for chlamydia if positive for gonorrhea

What is the most common reported bacterial infection in the US?

Chlamydia trachomatis

How are symptoms presented in chlamydia?

Asymptomatic

>50% males

>80% females

Risk factors of chlamydia?

◦ Young age: <25 years

◦ New sex partner in past 3 months

◦ History of previous Chlamydia trachomatis infection

◦ Inconsistent condom use

◦ Socioeconomic disadvantaged

What happens to women with chlamydia?

Genitourinary tract infection (cervis most common)

Fitz-Hugh-Curtis syndrome (perihepatitis)

- inflammation of liver capsule

- RUQ pain, normal liver enzymes

Complications of pregnancy

What happens to men with chlamydia?

Urethritis

- mucoid or watery urethral discharge

- dysuria

Epididymitis

- unilateral testicular pain

Prostatitis

- may be cause of chronic prostatitis

Proctitis

- primarily MSM

What are common clinical syndromes in both men and women?

◦ Conjunctivitis: Direct inoculation with infected genital infections

◦ Pharyngitis: C. trachomatis not thought to cause pharyngitis, but may

be reservoir

◦ Genital lymphogranuloma venereum (LGV): Large inguinal

lymphadenopathy

◦ Reactive arthritis/reactive arthritis triad (RAT): Reactive arthritis,

with or without conjunctivitis/uveitis and cervicitis/urethritis

How do you test for chlamydia?

NAAT - Nucleic Acid Amplification Testing

What is screening for chlamydia?

◦ Sexually active women < 25 annual screening

◦ Pregnancy

◦ Women >25 based on risk factors

◦ Men who have sex with men (MSM)

◦ HIV infected

What is treatment of chlamydia?

Doxycycline

Azithromycin

What are some clinical manifestations of trichomonas vaginalis in women?

◦ Commonly presents as a thin, purulent, malodorous vaginal

discharge

◦ May have dysuria, dyspareunia, lower abdominal pain

◦ May be worse with menstruation

◦ Pregnancy: Can cause PROM, preterm labor, low birth weight

What are some clinical manifestations of trichomonas vaginalis in men?

Urethral discharge, dysuria

How to diagnose trichomonas vaginalis?

Wet prep, spun down urine, NAAT test (gold standard)

How to treat trichomonas vaginalis?

Metronidazole (Flagyl)

What acuase Lymphogranuloma Venereum?

Chlamydia trachomatis types L1-L3

What are the 3 stages of infection of LGV?

◦ Primary infection: Genital ulcer

◦ Secondary infection: Extension into regional lymph nodes

◦ Inguinal syndrome

◦ Anorectal symptoms

◦ Late lymphogranuloma venereum (LGV)

What happens in the first stage of LGV?

◦ Occurs within 3-12 days after inoculation

◦ Small, painless papule or pustule

◦ May erode to form a small herpetiform ulcer

◦ Differentiator: No pain with LGV lesion

◦ Heals rapidly without scarring

◦ Men: Lesion on the penis or scrotum

◦ Women: Vaginal wall, posterior cervix, or vulva

◦ Initial lesion (especially in women) can go unnoticed

What happens in the inguinal syndrome in second stage of LGV?

◦ Begins 2-6 weeks after the primary lesion

◦ "Buboes" - usually unilateral, painful lymph node that can

rupture

◦ Classic "groove" sign

◦ 1/3 of all men and when most men are diagnosed

◦ Women do not usually have classic presentation and therefore are not diagnosed as often

What happens in the anorectal syndrome in second stage of LGV?

More common in women and MSM

◦ Inflammatory mass present in the rectum and retroperitoneum

◦ May present with proctocolitis (rectal d/c, anal pain, constipation,

fever, and/or tenesmus)

◦ Complications - chronic colorectal fissures and strictures

What happens in late LGV?

◦ Fibrosis and strictures in anogenital tract

◦ Complications - genital elephantiasis, anal fistulae and strictures,

frozen pelvis, and infertility

How to diagnose LGV?

NAAT

How do you treat LGV?

Doxycycline

Needle aspirate or I&D the buboes

What is treponema pallidum? (syphilis)

Spirochete

Human is the sole natural host

What is primary syphilis?

21 days after infection

What is secondary syphilis?

Weeks to few months after infection

What is late syphilis?

Anytime from 1 to 30 years after infection

What is congenital syphilis?

Via placenta

What is the sign and symptoms of primary syphilis?

PAINLESS papule at site of inoculation that ulcerates

Chancre is swarming with spirochetes

Associated with regional non tender lymphadenopathy

Heals without treatment in 3 to 6 weeks

What are signs and symptoms of secondary syphilis?

Constitutional symptoms

Lymphadenopathy - posterior cervical, axillary, inguinal, femoral regions (epitrochlear nodes suggestive of Dx)

Rash - involves entire trunk and extremities, including the palms and soles

Moth eaten alopecia

What are other findings of secondary syphilis?

GI findings - Syphilitic hepatitis (high alkaline phosphatase), GI tract ulcerations

MS abnormalities - Synovitis, osteitis, and periostitis

Renal abnormalities - Mild transient albuminuria, nephrotic syndrome, or acute nephritis with hypertension and acute renal failure

Neurological findings - Headache or meningitis, CN deficits,

meningovascular disease, or stroke

Ocular findings -Uveitis, retinal necrosis, and optic neuritis

◦ Diminished visual acuity

◦ Involvement of the eye in patients with syphilis should be considered a manifestation of neurosyphilis

Does the rash in secondary syphilis hurt or itch? How long does it persist?

No, persist for months

What is important to differentiate in latent syphilis?

◦ Patients with late latent disease are not considered infectious to their recent sexual contacts since they do not have lesions that can transmit disease

◦ Patients with early latent syphilis may have transmitted T. pallidum to their sexual partners through lesions that were recently active, but are no longer present

◦ Pregnant women with latent syphilis can transmit T. Pallidum to their fetus for up to 4 years

What can happen in tertiary syphilis?

Gummatous disease

Cardiovascular syphilis (aortitis)

What is neurosyphilis associated with? (What stage)

Tertiary syphilis

What do early forms of tertiary syphilis affect?

CSF, meninges, and vasculature

Symptomatic meningitis

Ocular syphilis

Otosyphilis

Meningovascular syphilis

What do late forms of tertiary syphilis affect?

General paresis

Tabes dorsalis

- Argyll-Robertson pupil

What is an early sign of congenital syphilis?

Snuffles, later characteristic is Hutchinson's teeth

How do you diagnose early syphilis?

Dark field microscopy of samples from the chancre lesion and serologic tests

How do you diagnose secondary and tertiary syphilis?

Serologic tests (RPR)

How do you treat syphilis?

IM Penicillin

If allergic,

Doxycycline or ceftriaxone

Desensitization to Penicillin

What is vaginitis most common in?

Adult women

What is vaginitis uncommon in?

Prepubertal girls

What type of infection is bacterial vaginosis?

Polymicrobial

What % of d/c cases does bacterial vaginosis account for?

40-50%

What are signs and symptoms of bacterial vaginosis?

◦ 50-75% asymptomatic

◦ Abnormal vaginal discharge

◦ Unpleasant odor

◦ Strong fish-like odor, especially after intercourse and during menses

◦ Usually off-white, thin, and homogenous

◦ May be associated with acute cervicitis

How to diagnose bacterial vaginosis?

Amsel criteria

3 out of 4 must be met

Who do you treat with bacterial vaginosis?

All women who are symptomatic

If they are non pregnant, what drug of choice for bacterial vaginosis?

Metronidazole (Flaygl)

Metronidazole gel (MetroGel)

Clindamycin 2% cream

If they are pregnant, what drug do you give for bacterial vaginosis?

Metronidazole

Clindamycin (Celocin)

What is pregnancy risk of bacterial vaginosis in pregnant asymptomatic?

Preterm birth with BV linked to preterm labor due to chorioamnionitis

What is the causative organism of chancroid?

Haemophilus ducreyi

What is a symptom of chancroid?

PAINFUL genital ulcers

Erythematous papule that rapidly evolves into pustule, which erodes into 1-2 cm diameter ulcer

How to diagnose chancroid?

Clinical diagnosis, gram stain and culture, PCR

How to treat chancroid?

Azithromycin or ceftriaxone

What are complications of chancroid?

Ruptures of buboes

Phismosis and balanoposthitis