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1、Sexually transmitted infectionsMary Horgan M.D.Cork University HospitalMajor STD syndromeszGenital ulcer diseasezUrethritis/cervicitiszVaginitis/vaginosiszExophytic processeszEctoparasitic infestationszSystemic STD syndromesGenital ulcer diseasezGenital herpes (HSV)zSyphilis (T. pallidum)zChancroid
2、(H. ducreyi)zLymphogranuloma venereum (rare)zGranuloma inguinale (rare)Genital ulcer diseasezConditions characterised by ulcers which are usually sexually transmittedzMultiple causes can co-existStaging of syphiliszPrimaryzSecondaryzLatentyEarly latent: 1 year zLate (tertiary) - includes neurosyphil
3、isPrimary syphiliszThe first manifestation of infectionzCharacterized by development of chancrezIncubation periodyaverage 3 wks. from time of exposureyrange 9 - 90 dayszChancre occurs at site of bacterial invasionChancre characteristics zInduratedzPainlesszRaised borderzRed, smooth basezScant serous
4、 secretionszIndolent, “punched out” appearanceChancre characteristicszRegional lymphadenopathy is commonyinguinal nodes if genital lesions presentycervical nodes if oropharyngeal lesions presentzChancre usually (but not always) precedes development of secondary symptomszChancre typically resolves in
5、 3 - 6 weeks without treatmentSecondary syphiliszEvidence of systemic spread of infectionzCharacterized by rash, other skin and mucous membrane lesionszTypically develops 3 - 6 weeks following development of primary lesions (chancre)Rash characteristicszMaculopapular eruptionyclassic palmar -plantar
6、 distributionymay occur on face, back, trunk, arms, legszRash may also manifest asymacular or erythematous eruptionypapular lesionsypustular lesions (infrequent)yannular lesionsRash characteristicsz“Mucous patches” affecting mucous membrane surfaceszFacial “nickel and dime” lesionszPatchy alopecia (
7、hair-loss)y“moth-eaten” appearanceSystemic signs and symptomszFlu-like syndromezWeight losszAnemia, elevated ESRzLymphadenopathyzHepatosplenomegalyLatent syphiliszSerologic evidence of infection without clinical manifestationsypositive blood test for syphilisyno primary or secondary lesionsyno evide
8、nce of tertiary diseasezEarly vs. late latent syphilisyearly: infection of less than 1 years durationylate: infection of greater than 1 years duration Treatment RecommendationszEarly syphilisyall primary infectionsyall secondary infectionsyearly latent infection (1 years duration)*Benzathine PCN-G (
9、Bicillin-LA) 2.4 million units IM q week x 3 dosesTreatment Recommendations zPenicillin-allergic patients:yDoxycycline 100mg po BID x 14 days (28 days if late disease), ORyTetracycline 500mg po QID x 14 days(28 days if late disease)NeurosyphiliszThe manifestations of CNS syphilis were readily recogn
10、ized by physicians practicing 30 or 40 years ago. However they are unfamiliar to many physicians today given the relative rarity of this conditionNeurosyphiliszAsymptomaticyno clinical manifestationsydefined by presence of CNS abnormalities including:xWBC 5/mm3, mostly lymphsxelevated proteinxreacti
11、ve CSF-VDRLymay progress to overt neurosyphilisParenchymatous neurosyphiliszGeneral paresis yalso known as paretic neurosyphilis, dementia paralytica, and general paralysis of the insaneyT. pallidum directly invades the cerebrumxearly symptoms: memory loss, irritability, personality changes, headach
12、e, insomniaxlate symptoms: defective judgment, emotional lability, lack of insight, confusion, disorientation, delusions, paranoia, seizuresParenchymatous neurosyphiliszGeneral paresis yneurologic findings include: xArgyll Robertson pupilsxslurred speechxexpressionless facextremorsCongenital syphili
13、szAcquistion of syphilis by the fetus or newborn infantzVertical transmission from motheryTransplacental (during pregnancy)yPerinatal acquisition (at time of birth)zSignificant cause of spontaneous abortion (up to 50% in infected mothers)Congenital syphiliszEarly clinical signs and symptoms include:
14、yhepatomegalyysplenomegalyyanemia, jaundiceyskin rash / petechiateypersistent nasal discharge (“snuffles”)yabnormal bone development (osteochondritis)ypseudoparalysisCardiovascular syphiliszCause of thoracic aortic aneurysmyaortic valvular insufficiencyzAlso may involve coronary arterieszPathogenesi
15、s is through endarteritis of the vasa vasorum of aortazLesions may erode through chest wall or rupture spontaneouslyTreatment of tertiary syphiliszTreatment of gummatous lesions will prevent further destruction zTreament will not restore tissue which has already been destroyedLaboratory tests for sy
16、philiszConfirm clinical suspicion of diseasezScreen populations at riskzMonitor response to therapyzDetermine treatment failure and need for lumbar punctureTypes of laboratory testszDirect examination of lesion materialydarkfield microscopyzSerologic testing of blood samplesynon-treponemal tests (sc
17、reening)ytreponemal tests (confirmatory)zOtherydirect fluorescent antibody (DFA)yhistologic staining (biopsy)Darkfield microscopyzExtremely specific for T. pallidumzTest of choice for moist genital ulcerszOffers immediate diagnosiszOpportunity for immediate treatmentSerologic tests for syphilisz“A b
18、lood test”zDetects antibody in serumzRequires blood sample centrifugationzRequires laboratory processingzFollow universal precautions at every stepSyphilis - Non-treponemal testszUsed for screening large sampleszCardiolipin-cholesterol-lecithin antigenzSensitive but not 100% specificzTwo tests commo
19、nly availableyRapid Plasma Reagin test (RPR)yVenereal Disease Research Laboratory test (VDRL)Non-treponemal test sensitivity Test 1o 2o EL LLVDRL78% 100%95% 71%RPR86% 100%98% 73%False-positive RPR / VDRLzGeneral population: 1-2%zIV drug users: 10%zTransient false-positiveypregnancyyfebrile illnesses
20、zChronic false-positiveyautoimmune disorders, agingSyphilis - Treponemal testszUsed for confirmation of infectionzDetects antibodies against T. pallidum cellular componentszMore expensive, more specificzCommonly available tests include:yFluorescent Treponemal Antibody Absorption (FTA-ABS)yMicrohemag
21、glutination Assay (MHA-TP)yT. pallidum particle agglutination (TP-PA)Interpreting treponemal testsz86% of syphilis cases remain reactive for lifezNot used to monitor efficacy of treatment or reinfectionz1% false-positive rate in general pop.zNegative test on CSF excludes neurosyphilis Syphilis serol
22、ogyProblems:How do you ascertain who is infectious?How do you ascertain who should be tracked for partner notification?SummaryzNeurosyphilis, congenital syphilis and tertiary syphilis are difficult to diagnosezThese conditions cause serious long-term morbidity and mortalityzHigh index of suspicion f
23、or syphilis is required when dealing with populations at riskGenital herpesz90% of primary infection is subclinicalzMost common in adolescence and young adultszNeonatal infection via birth canalydisseminatedyCNSyskin, eye, mouth (SEM)yoccurs with primary secondary infectionGenital HerpeszPrimary inf
24、ection: first exposure to HSV type 1 or 2zInitial infection: first exposure to HSV-2 but previous infection with HSV-1ysome antibody cross protectionygenerally not as severe as primary infectionzRecurrent infection: known prior outbreaksyusually precipitated by stress, trauma, pregnancy, menses, fev
25、er, systemic illnessGenital herpes: primary infectionzUsually painful with prodromezIncubation period: 2-20 days (mean 6d)zDuration 1-3 weekszPresents as painful vesicles or ulcerszInitial infection is usually associated withylymphadenopathyyfever, headachesymyalgiasyurethritis, cervicitisyurinary r
26、etentionGenital infection:recurrent infectionz80% have recurrences but frequency varieszUsually at same site as primary infectionzLess severe than primary infectionGenital herpes: DiagnosiszClinical featureszViral culturezHSV PCRGenital herpes: treatmentzAcyclovir or derivatives are drugs of choicez
27、Available in oral, parenteral and topical formszPrimary infectionyACV 400mg tid for 10 dayszRecurrent infectionyACV 400mg tid for 5 dayszChronic suppressive therapy: consider for 6 episodes/year withyACV 400mg bd for one year Urethritis/cervicitiszGonorrhoea (N. gonorrhoeae)zChlamydia trachomatiszMy
28、coplasma hominiszUreaplasma urealyticumThe urethrazCommon pathway for urine and semenzColumnar epithelial liningzPrimary site of infection for GC and chlamydiazPossible site of infection for ymycoplasma hominisyTrichomonasyUreaplasmaUrethritiszInflammatory response of urethrazinfection of urethrazWB
29、C is primary inflammatory responsezorganisms may also be seenzSymptomsydysuriaydischarge (purulent or mucoid)yWBCUrethral specimen collectionzPatient should not void for 2hours before specimen collectionzSwab inserted 1-2cm into distal urethra and rotated 1-2 turnszSmear swab onto glass slidezInocul
30、ate swab onto chocolate and NY agarzSecond swab for chlamydiazymeCervicitiszCervicitis is the female counterpart of urethritiszinflammatory response of cervixzreflects infection of T zonezWBC is primary inflammatory response and organisms may be seen as in GCCervicitiszCaused byyNeisseria gonorrhoea
31、eyChlamydia trachomatisyMycoplasma hominisyUreaplasma yTrichomonaszCharacterised byydischarge ydysuriaydyspareuniaOther causes of cervical inflammationzHSVzTrichomonaszCandidiasiszForeign bodyzEctopy, OCP and mensesEndocervical swab collectionzVisualise cervical oszInsert swab and rotate several tim
32、eszObserve colour of swabzSmear swab lightly on glass slidezInoculate on chocolate and NY agarzSecond swab for chlamydiazyme as aboveChlamydia trachomatiszCommon cause of cervicitis and urethritiszObligate intracellular organismzMay cause yPID and sequelaeyReiters syndromeyNeonatal eye infection and
33、 pneumoniazDiagnosis byycultureynon-culture techniquesyurine-based screeningTreatment of Chlamydia trachomatiszTreat withyAzithromycin 1G po one dosezIf no access to microscopy treat for coinfectionzSee CDC recommendations for alternatives for yallergiesypregnancyyreinfectionyless expensive regimens
34、GonorrhoeazGram - intracellular diplococcizCause urethritis, cervicitis, proctitis and pharyngitiszDisseminated gonococcal infectionzAssociated with PID and its sequelaezNeonatal infection e.g. conjunctivitisTreatment of GCzEffective therapy includes a regimen that covers coinfection with chlamydia
35、and GCzTreat withyCiprofloxacin 500mg one doseyAzithromycin 1G one dosezFor alternatives see CDC guidelines on www.cdc.govEvaluation of sex partnerszTreat regular and potential source partners as per index casezSymptomatic patientsyrefer all patients within past 30 dayszAsymptomatic patientsyrefer a
36、ll patients within past 60 dayszTreat all partners who have objective evidence of infectionzFull STD screen should be done on all patientsVaginitis/vaginosiszBacterial vaginosiszTrichomoniasiszYeast vaginitisBacterial vaginosiszMalodorous vaginal discharge +/- pruritiszHomogenous, non-viscous milky
37、white D/CzCaused by gardnerella, mycoplasma and anaerobeszAbsence of normal flora like lactobacillus appears to correlate with its developmentzNot sexually transmitted but more common in sexually active womenBacterial vaginosiszVaginal pH 4.5zPositive whiff testyfishy odour on addition of 10% KOHzPr
38、esence of clue cells on microscopyzHomogenous discharge on examinationBacterial vaginosiszInfection may induce preterm labourzTreatmentyMetronidazole 400mg bd for 7 daysyavoid during first trimester of pregnancyzNo indication to treat sexual partnerTrichomoniasiszCaused by a protozoa, Trichomonas va
39、ginaliszProfuse, purulent, malodorous dischargezMay be associated with dysuria and irritationzExamination shows petechiae on cervix (“strawberry cervix”)Trichomoniasis: diagnosiszMotile trichomonads on saline wet prep of vaginal exudatezVaginal pH 4.5zCulture (not routinely done)Trichomoniasis: trea
40、tmentzMetronidazole 2.0G one dosezSexual abstinence until symptoms resolvezTreatment of sexual contacts is necessary since the infection is sexually transmittedVulvovaginal candidiasiszUsually not a sexually transmitted infectionz66% caused by Candida albicanszPresents withyvulval pruritisyvaginal dischargeydysuriaVulvovaginal candidiasis: diagnosis and treatmentzpH 4.5zFungal elements on 10% KOH prepzTreat with yintravaginal imidazole cream or pessaryyFluconazole 150mg one dosePelvic Inflammatory Disease
