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1、Sexually transmitted infections,Mary Horgan M.D. Cork University Hospital,Major STD syndromes,Genital ulcer disease Urethritis/cervicitis Vaginitis/vaginosis Exophytic processes Ectoparasitic infestations Systemic STD syndromes,Genital ulcer disease,Genital herpes (HSV) Syphilis (T. pallidum) Chancr
2、oid (H. ducreyi) Lymphogranuloma venereum (rare) Granuloma inguinale (rare),Genital ulcer disease,Conditions characterised by ulcers which are usually sexually transmitted Multiple causes can co-exist,Staging of syphilis,Primary Secondary Latent Early latent: 1 year Late (tertiary) - includes neuros
3、yphilis,Primary syphilis,The first manifestation of infection Characterized by development of chancre Incubation period average 3 wks. from time of exposure range 9 - 90 days Chancre occurs at site of bacterial invasion,Chancre characteristics,Indurated Painless Raised border Red, smooth base Scant
4、serous secretions Indolent, “punched out” appearance,Chancre characteristics,Regional lymphadenopathy is common inguinal nodes if genital lesions present cervical nodes if oropharyngeal lesions present Chancre usually (but not always) precedes development of secondary symptoms Chancre typically reso
5、lves in 3 - 6 weeks without treatment,Secondary syphilis,Evidence of systemic spread of infection Characterized by rash, other skin and mucous membrane lesions Typically develops 3 - 6 weeks following development of primary lesions (chancre),Rash characteristics,Maculopapular eruption classic palmar
6、 -plantar distribution may occur on face, back, trunk, arms, legs Rash may also manifest as macular or erythematous eruption papular lesions pustular lesions (infrequent) annular lesions,Rash characteristics,“Mucous patches” affecting mucous membrane surfaces Facial “nickel and dime” lesions Patchy
7、alopecia (hair-loss) “moth-eaten” appearance,Systemic signs and symptoms,Flu-like syndrome Weight loss Anemia, elevated ESR Lymphadenopathy Hepatosplenomegaly,Latent syphilis,Serologic evidence of infection without clinical manifestations positive blood test for syphilis no primary or secondary lesi
8、ons no evidence of tertiary disease Early vs. late latent syphilis early: infection of less than 1 years duration late: infection of greater than 1 years duration,Treatment Recommendations,Early syphilis all primary infections all secondary infections early latent infection ( 1 years duration) *Benz
9、athine PCN-G (Bicillin-LA) 2.4 million units IM single dose,Treatment Recommendations,Late disease 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
10、(28 days if late disease), OR Tetracycline 500mg po QID x 14 days (28 days if late disease),Neurosyphilis,The 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 con
11、dition,Neurosyphilis,Asymptomatic no clinical manifestations defined by presence of CNS abnormalities including: WBC 5/mm3, mostly lymphs elevated protein reactive CSF-VDRL may progress to overt neurosyphilis,Parenchymatous neurosyphilis,General paresis also known as paretic neurosyphilis, dementia
12、paralytica, and general paralysis of the insane T. pallidum directly invades the cerebrum early symptoms: memory loss, irritability, personality changes, headache, insomnia late symptoms: defective judgment, emotional lability, lack of insight, confusion, disorientation, delusions, paranoia, seizure
13、s,Parenchymatous neurosyphilis,General paresis neurologic findings include: Argyll Robertson pupils slurred speech expressionless face tremors,Congenital syphilis,Acquistion of syphilis by the fetus or newborn infant Vertical transmission from mother Transplacental (during pregnancy) Perinatal acqui
14、sition (at time of birth) Significant cause of spontaneous abortion (up to 50% in infected mothers),Congenital syphilis,Early clinical signs and symptoms include: hepatomegaly splenomegaly anemia, jaundice skin rash / petechiate persistent nasal discharge (“snuffles”) abnormal bone development (oste
15、ochondritis) pseudoparalysis,Cardiovascular syphilis,Cause of thoracic aortic aneurysm aortic valvular insufficiency Also may involve coronary arteries Pathogenesis is through endarteritis of the vasa vasorum of aorta Lesions may erode through chest wall or rupture spontaneously,Treatment of tertiar
16、y syphilis,Treatment of gummatous lesions will prevent further destruction Treament will not restore tissue which has already been destroyed,Laboratory tests for syphilis,Confirm clinical suspicion of disease Screen populations at risk Monitor response to therapy Determine treatment failure and need
17、 for lumbar puncture,Types of laboratory tests,Direct examination of lesion material darkfield microscopy Serologic testing of blood samples non-treponemal tests (screening) treponemal tests (confirmatory) Other direct fluorescent antibody (DFA) histologic staining (biopsy),Darkfield microscopy,Extr
18、emely specific for T. pallidum Test of choice for moist genital ulcers Offers immediate diagnosis Opportunity for immediate treatment,Serologic tests for syphilis,“A blood test” Detects antibody in serum Requires blood sample centrifugation Requires laboratory processing Follow universal precautions
19、 at every step,Syphilis - Non-treponemal tests,Used for screening large samples Cardiolipin-cholesterol-lecithin antigen Sensitive but not 100% specific Two tests commonly available Rapid Plasma Reagin test (RPR) Venereal Disease Research Laboratory test (VDRL),Non-treponemal test sensitivity,Test 1
20、o 2o EL LL VDRL 78% 100% 95% 71% RPR 86% 100% 98% 73%,False-positive RPR / VDRL,General population: 1-2% IV drug users: 10% Transient false-positive pregnancy febrile illnesses Chronic false-positive autoimmune disorders, aging,Syphilis - Treponemal tests,Used for confirmation of infection Detects a
21、ntibodies against T. pallidum cellular components More expensive, more specific Commonly available tests include: Fluorescent Treponemal Antibody Absorption (FTA-ABS) Microhemagglutination Assay (MHA-TP) T. pallidum particle agglutination (TP-PA),Interpreting treponemal tests,86% of syphilis cases r
22、emain reactive for life Not used to monitor efficacy of treatment or reinfection 1% false-positive rate in general pop. Negative test on CSF excludes neurosyphilis,Syphilis serology,Problems: How do you ascertain who is infectious? How do you ascertain who should be tracked for partner notification?
23、,Summary,Neurosyphilis, congenital syphilis and tertiary syphilis are difficult to diagnose These conditions cause serious long-term morbidity and mortality High index of suspicion for syphilis is required when dealing with populations at risk,Genital herpes,90% of primary infection is subclinical M
24、ost common in adolescence and young adults Neonatal infection via birth canal disseminated CNS skin, eye, mouth (SEM) occurs with primary secondary infection,Genital Herpes,Primary infection: first exposure to HSV type 1 or 2 Initial infection: first exposure to HSV-2 but previous infection with HSV
25、-1 some antibody cross protection generally not as severe as primary infection Recurrent infection: known prior outbreaks usually precipitated by stress, trauma, pregnancy, menses, fever, systemic illness,Genital herpes: primary infection,Usually painful with prodrome Incubation period: 2-20 days (m
26、ean 6d) Duration 1-3 weeks Presents as painful vesicles or ulcers Initial infection is usually associated with lymphadenopathy fever, headaches myalgias urethritis, cervicitis urinary retention,Genital infection: recurrent infection,80% have recurrences but frequency varies Usually at same site as p
27、rimary infection Less severe than primary infection,Genital herpes: Diagnosis,Clinical features Viral culture HSV PCR,Genital herpes: treatment,Acyclovir or derivatives are drugs of choice Available in oral, parenteral and topical forms Primary infection ACV 400mg tid for 10 days Recurrent infection
28、 ACV 400mg tid for 5 days Chronic suppressive therapy: consider for 6 episodes/year with ACV 400mg bd for one year,Urethritis/cervicitis,Gonorrhoea (N. gonorrhoeae) Chlamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum,The urethra,Common pathway for urine and semen Columnar epithelial lini
29、ng Primary site of infection for GC and chlamydia Possible site of infection for mycoplasma hominis Trichomonas Ureaplasma,Urethritis,Inflammatory response of urethra infection of urethra WBC is primary inflammatory response organisms may also be seen Symptoms dysuria discharge (purulent or mucoid)
30、WBC,Urethral specimen collection,Patient should not void for 2hours before specimen collection Swab inserted 1-2cm into distal urethra and rotated 1-2 turns Smear swab onto glass slide Inoculate swab onto chocolate and NY agar Second swab for chlamydiazyme,Cervicitis,Cervicitis is the female counter
31、part of urethritis inflammatory response of cervix reflects infection of T zone WBC is primary inflammatory response and organisms may be seen as in GC,Cervicitis,Caused by Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasma hominis Ureaplasma Trichomonas Characterised by discharge dysuria dyspar
32、eunia,Other causes of cervical inflammation,HSV Trichomonas Candidiasis Foreign body Ectopy, OCP and menses,Endocervical swab collection,Visualise cervical os Insert swab and rotate several times Observe colour of swab Smear swab lightly on glass slide Inoculate on chocolate and NY agar Second swab
33、for chlamydiazyme as above,Chlamydia trachomatis,Common cause of cervicitis and urethritis Obligate intracellular organism May cause PID and sequelae Reiters syndrome Neonatal eye infection and pneumonia Diagnosis by culture non-culture techniques urine-based screening,Treatment of Chlamydia trachom
34、atis,Treat with Azithromycin 1G po one dose If no access to microscopy treat for coinfection See CDC recommendations for alternatives for allergies pregnancy reinfection less expensive regimens,Gonorrhoea,Gram - intracellular diplococci Cause urethritis, cervicitis, proctitis and pharyngitis Dissemi
35、nated gonococcal infection Associated with PID and its sequelae Neonatal infection e.g. conjunctivitis,Treatment of GC,Effective therapy includes a regimen that covers coinfection with chlamydia and GC Treat with Ciprofloxacin 500mg one dose Azithromycin 1G one dose For alternatives see CDC guidelin
36、es on www.cdc.gov,Evaluation of sex partners,Treat regular and potential source partners as per index case Symptomatic patients refer all patients within past 30 days Asymptomatic patients refer all patients within past 60 days Treat all partners who have objective evidence of infection Full STD scr
37、een should be done on all patients,Vaginitis/vaginosis,Bacterial vaginosis Trichomoniasis Yeast vaginitis,Bacterial vaginosis,Malodorous vaginal discharge +/- pruritis Homogenous, non-viscous milky white D/C Caused by gardnerella, mycoplasma and anaerobes Absence of normal flora like lactobacillus a
38、ppears to correlate with its development Not sexually transmitted but more common in sexually active women,Bacterial vaginosis,Vaginal pH 4.5 Positive whiff test fishy odour on addition of 10% KOH Presence of clue cells on microscopy Homogenous discharge on examination,Bacterial vaginosis,Infection
39、may induce preterm labour Treatment Metronidazole 400mg bd for 7 days avoid during first trimester of pregnancy No indication to treat sexual partner,Trichomoniasis,Caused by a protozoa, Trichomonas vaginalis Profuse, purulent, malodorous discharge May be associated with dysuria and irritation Exami
40、nation shows petechiae on cervix (“strawberry cervix”),Trichomoniasis: diagnosis,Motile trichomonads on saline wet prep of vaginal exudate Vaginal pH 4.5 Culture (not routinely done),Trichomoniasis: treatment,Metronidazole 2.0G one dose Sexual abstinence until symptoms resolve Treatment of sexual co
41、ntacts is necessary since the infection is sexually transmitted,Vulvovaginal candidiasis,Usually not a sexually transmitted infection 66% caused by Candida albicans Presents with vulval pruritis vaginal discharge dysuria,Vulvovaginal candidiasis: diagnosis and treatment,pH 4.5 Fungal elements on 10% KOH prep Treat with intravaginal imidazole cream or pessary Fluconazole 150mg one dose,Pelvic Inflammatory Disease,