STIs

Question 1

STIs

Answer 1

• Sexually transmitted infections are a major public health concern, with infections often being asymptomatic and leading to various complications

Question 2

Chlamydia

Answer 2

• Most common bacterial cause of STIs
• Small gram negative bacterium

Question 3

Chlamydia transmission

Answer 3

• Chlamydia is transmitted through sexual contact with the penis, vagina, mouth, or anus of an infected partner.
• Can also be transmitted from mother child during delivery

Question 4

Chlamydia Symptoms women

Answer 4

• Most people with chlamydia are aysmptomatic, making diagnosis and treatment difficult
• Clincial syndromes in women:
  
  • Cervicitis - usually asymptomatic but may have mucopurulent endocervical discharge and easily induced endocervical bleeding
  • Urethritis - Pyuria, dysuria, and urinary frequency
  • Proctitis - rectal pain, discharge, and/or bleeding
  • PID - Chylamydia can move up the reproductive tract and result in PID. May present with symptoms of abdominal or pelivc pain, cervical motions and adnexal tenderness. It can result in tubal infertility, ectopic pregnancy, and chronic pelvic pain
  • Perihepatitis - occassionally patients may develop perihepatitis, an inflammation of the liver capsule and adjacent peritoneal surface.

Question 5

Pregnancy complications Chlamydia

Answer 5

• Infection during pregnancy can increase risk for pemature reputure of membranes and preterm deliveries

Question 6

Chlamydia Symptoms Men

Answer 6

• Most men with chlamydia are asymptomatic
• Clinical Syndromes:
  
  • Urethritis - mostly asymptomatic, but may present with mucoid or watery urethral discharge and dysuria
  • Epididymitis - present with unilateral testicular pain and tenderness, hydrocele, and palpable swelling of the epididymis
  • Prostatitis - present with dysuria, urinary dysfunction, pain with ejaculation and pelvic pain
  • Proctitis - inflmmation of distal rectal mucosa. May present with anorectal pain, discharge, trenesmus, rectal bledding, and constipation.
  • Reactive arthritis (very uncommon) - arthritis, uveitis, and urethritis

Question 7

Chlamydia syndromes common to both men and women

Answer 7

• Conjuncitvitis - chlamydia can infect the epithelial cells of the conjunctiva. Generall occurs through direct contract with genital secretions.
• Pharyngitis - not a major cause of pharyngitis, but chlamydia has been detected in the pharynx
• Genital lymphogranuloma venereum - infection of inguinal lymph nodes

Question 8

Treatment Chlamydia

Answer 8

• Chlamydia is very susceptible to tetracyclines and macrolides
  
  • First line agents: Doxycyclin anad azithromycin
• Treatment in pregnant women
  
  • Treatment of pregnant women prevents transmission to infant during passage through the birth canal. The recommended treatment is azithromycin
  • In pregnant women follow up is extremely important as cure rates tend to be lower when compared to non-pregnant women

Question 9

Gonorrhea

Answer 9

• Neisseria gonorrhea is a major cause of morbidity amoung sexually active people
• Gram negative diplococci bacteria
• There is growing resistance to several antimcrobials

Question 10

Gonorrhea Transmission

Answer 10

• Gonorrhea is transmitted through sexual contact with the penis, vagina, mouth, or anus of an infected partner.
• Gonorrhea can also be spread perinatally from mother to baby during childbirth.

Question 11

Gonorrhea symptoms women

Answer 11

• Most women with gonorrhea are aysptomatic
• Clinical syndromes:
  
  • Cervicitis - uterine cervix is the most common site of mucosal infection in gonorrhea. If symptomatic may present with vaginal pruritus, mucopurulent discharge, intermenstrual bleeding, or menorrhagia
  • Urethritis - typically aysmptomatic. if symptoms do occur they tend to be dysuria, urinary urgency, and urinary frequency
  • PID - occurs in 10-20% of infected woemn
  • Perihepatitis
  • Bartholinitis - symptomatuc involvement of Bartholins glands (located behind the labia). May occur in ~6% of infected women. Symptoms include perilabial pain and dirchage, edema of the labia, and enlargement and tenderness of the gland.

Question 12

Gonorrhea complications pregnancy

Answer 12

• Gonorrhea infection in pregnancy has been associated with chorioamnionitis, premature rupture of membranes, preterm birth, low birth weight, and spontaneous abortion. Transmission to the baby may also occur in 30-50% of cases. Infected newborns may have conjunctivitis, pharyngitis, arthritis, and gonococcemia.

Question 13

Gonorrhea symptoms men

Answer 13

• Many are symptomatic
• Syndromes
  
  • Urethritis - discharge (may be purulent or mucopurulent in colour) and copious in amount. Rarely you may see penile lymphangitis, penile edema, periurethral abscesses and postinflammatory urethral strictures
  • Epididymitis - unilateral testicular pain and swelling

Question 14

Extragential infection gonorrhea

Answer 14

• Gonorrhea can infect the pharynx and rectum, althoug these infections tend to be asymptomatic. Rarely, bacteremic spread from a mucosal site and resultant disseminated infection can occur. Finally, gonorrhea can cause aggressive conjuncitvitis in adults and adolescents that can be transmitted through non-sexual contact.

Question 15

Gonorrhea Treatment

Answer 15

• Treament is becoming more difficult with increased rates of antibiotic resistance.
• Due to increasing resistance to sulfonamides, penicillins, tetracyclines and gluoroquinolones, thrid generation cephalosporines are considered first line monotherapy
• Preferred treatment for uncomplicated infection:
  
  • Ceftriaxone IM + azithromycin (for possilbe additional activity of gonorrhea as well as for treatment for potential chlamydia co-infection)
  • These treatment can also be used my pregnant women
• All women should be retested following treatment within 3 months. Pregnant women who are at high risk for reinfection should be tested against during the third trimester.

Question 16

Trichomoniasis

Answer 16

• A genitourinary infection caused by the protozoan Trichomonas Vaginalis
• Most common nonviral STI
• Women are affected more often than men

Question 17

Trichomoniasis Transmission

Answer 17

• Almost always sexually transmitted.
• Women can get the infection from both women and men, while men typically acquire the infection from women and generally don’t transmit it to men
• It’s not common for the parasite to infect other body parts, like the hands, mouth, or anus.
• Can be transferred to infants during childbirth

Question 18

Clinical Features Trichomoniasis women

Answer 18

• Disease can range from an acute, severe, inflammatory disease, to an asymptomatic carrier
• Signs and symptoms:
  
  • Purulent, malodorous, thick dircharge
  • Burning
  • Pruitis
  • Dysuria
  • Frequency
  • Lower abdominal pain
  • Dyspareunia
  • Postcoital Bleeding
• Physical Exam:
  
  • Erythemia of vulva and vaginal mucosa
  • Green-yellow, frothy, malodorous discharge
  • Puncate hemorrhages on vagina and cervix

Question 19

Consequences of trichomoniasis

Answer 19

• Nonpregnant women - if untreated it may progress to urethritis or cystitis. May also lead to cerival neoplasia, posthysterectomy cuff cellulitis or abscess, PID in HIV infected women, and infertility. May also increase susceptibility in acquiring HIV
• Pregnant women - infection during pregnancy is associated with adverse health outcomes including premature rupture of membranes, preterm delviery, and delivery of a low birth weight infant
• Newborns - infants may contract the infection during delivery. Neonates may present with fever, respiratory problems, urinary tract infection, nasal discharge, and vaginal discharge. Asymptomatic infants do not requrie treatment as spontaneous resolution will occur

Question 20

Clincal Features Trichomoniasis men

Answer 20

• In men, T. Vaginalis tends to be asymptomatic and infection often has spontaneous resolution.
• Symptoms (if present):
  
  • Clear or mucopurulent discharge
  • Dysuria
  • Pruritis
  • Burning sensation after intercourse

Question 21

Treatment Trichomoniasis

Answer 21

• Treament in indicated for symptomatic and asymptomatic women and men
• 5 - nitroimidazole - only class of drugs that provide curative therapy
  
  • Metronidazole or tinidazole
• Women should be retested after treatment as reinfection rates are hug
• Pregnant women should be given metronidazole as tinidazole has not yet be proven safe in pregnancy

Question 22

Bacterial Vaginosis

Answer 22

• A clincial condition characterized by a shift in vaginal flora away from lactobacillus and towards a more diverse bacteria species, including anaerobic gram negative rods.
  
  • Hydrogen producing lactobacilli are important in preventing overgrowth of naturally occuring vaginal anaerobes. When lactobacilli are lost, pH increases, and overgrowth of anaerobes occurs
• Most common cause of vaginal discharge in women of childbearing age

Question 23

Risk factors of Bacterial Vaginosis

Answer 23

• Sexual activity - evidence suggests it is sexually transmitted, however, it is not yet classified as an STI
• Other STIs - presence of STI seems to be associated with increased risk of bacterial vaginosis
• Race and ethnicity - higher rates have been reported in minority populations

Question 24

Clinical Featues of Bacterial Vaginosis

Answer 24

• 50-75% of women are asymptomatic
• Symptoms:
  
  • Vaginal discharge - off-white, think, and homogeneous
  • Vaginal odour - unpleasant “fishy smell”

Question 25

Consequences of Bacterial Vaginosis Infection

Answer 25

• Pregnant women are at high risk for preterm delivery
• Can result in endomentrial bacterial colonization, plasma-cell endometritis, postpartum fever, posthysterectomy vaginal cuff cellulitis, postabortal infection
• Risk factor for HIV acquisition and infection
• Risk factor for acquisition of hepes simplex virus type 2, gonorrhea, chlamydia, and trichomoniasis

Question 26

Treatment Bacterial Vaginosis

Answer 26

• Treatment is indicated for symptom relief and to prevent postoperative infection in those with asymptomatic infection prior to abortion or hysterectomy
• Resolves spontaneously in 1/3 of nonpregnant and 1/2 of pregnant women
• Nonpregnant symptomatic women - can used oral metronidazole or clindamycin to resolve symptoms
• Pregnant asymptomatic women - despite increased risk of preterm birth it is not recommended to routinely screen asymptomatic women for bacterial vaginosis

Question 27

Syphilis

Answer 27

• Infection caused by bacerium Treponema Pallidum (gram negative corkscrew bacteria)
• Most cases are sexually transmitted

Question 28

Syphilis Transmission

Answer 28

• Usually transmitted through direct contract with infectious lesions during sex (lesions must be open)
• Primary syphilis - presence of sores - very infectious
• Secondary syphilis - skin rashes and/or mucous membrane lesions - less infectious
• Early latent syphilis - still infectious due to recently active lesions
• Readily crosses the placenta and infects the fetus
• T. Pallidum can infection wherever inoculation occurs - syphilis can spread by touching a person who has active lesions on the lips, oral cavity, breasts, or genitals

Question 29

Hepatitis A

Answer 29

• Infctious disease of the liver caused by hepatitis A virus
• Acute condition (does not cause chronic liver disease)
• Transmission: fecal-oral either by person to person contact or by ingestion of contaminated food or water. Can also be transmitted sexually, especially among women who have sex with men.

Question 30

Hepatitis A Pathogenesis

Answer 30

• After ingestion HAV survives gastric acid, moves to the small intestine and reaches the liver via the portal vein. From here, the virus replicates in the hepatocyte cytoplasm.
• Immune system mediates cell damage as it tries to remove the virus.
• Incubation of the virus is usally 2-4 weeks with complete recovery within 2-6 months

Question 31

Clinical Features Hepatitis A

Answer 31

• <2 years old = asymptomatic
• Older = symptomatic (generally ill for about 8 weeks)
  
  • Common = fatigue, asthenia (abnormal physical weakness or lack of energy), anorexia, nausea, vomiting, and abdominal pain.
  • Less common = fever, headache, arthralgia, myalgia, and diarrhea
  • Cholestatic jaundice
  • Acute liver failure (rare)

Question 32

Diagnosis Hepatitis A

Answer 32

• High AST
• High ALT
• anti HAV IgM - indicates acute infection
• HAV IgG antibody - indicates patient is now immune or is in process of developing immunity

Question 33

Treatment hepatitis A

Answer 33

• Supporative symptomatic care
• Hospitalization for severe hepatitis/liver failure
• Prevention - vaccination

Question 34

Hepatitis B

Answer 34

• An infection of the liver caused by hepatitis B virus (HBV)
  
  • An incurable chronic infection
• Transmission:
  
  • Vertical (mother to child)
  • Parenteral (blood to blood)
  • Sexually transmitted

Question 35

Acute vs. chronic infection hepatitis B

Answer 35

• >90% of exposed infants and children become chronically infected
• >90% of exposed immunocompetent individuals clear the virus spontaneously
• Acute HBV rarely leads to liver failure. Chronic HBV can progress to end-stage lvier disease
• Chronic infection is also a significant risk factor for liver cancer.

Question 36

Pathogeneous Hepatitis B

Answer 36

• Virus enters liver and is allowed to grow (immune tolerant phase). Next, the immune system can either win (inactive hepatitis) or the virus can continue to grow resulting in progressive fibrosis and eventual cirrhosis.

Question 37

Diagnosis Hepatitis B

Answer 37

• HBsAg - indicated current infection (acute or chronic)
• anti-HBs - indicates immunity
• anti-HBc IgG - indicated either past or current infection
• anti-HBc IgM - indicates acute infection

Question 38

Treatment Hepatitis B

Answer 38

• Primary goal of hepatitis B therapy is to prevent cirrhosis, liver cancer, and death.
  
  • Interferone is the strandard treatment. However, the virus integrates into the genome of the hepatocytes meaning you can never truly get rid of the virus.
• Prevention - vaccination

Question 39

Hepatitis C

Answer 39

• Viral infection of the liver caused by hepatitis C virus
• 80% of people who get infected will become chronically infected. However, 20% will clear the infection spontaneously
• Acute HCV tends to be asymptomatic (most don’t seek treatment)
• Chronic HCV is usally asymptomatic, but patients may have non-specific symptoms.
  
  • Can progress to advance liver disease and cirrhosis. Increases risk for liver cancer.
• Transmission:
  
  • Parenternal (blood to blood)
  • Sexual (less risk)
  • Vertical (less risk)

Question 40

Hepatitis C diagnosis

Answer 40

• HCV Ab - positive test indicates current or past infection
• HCV RNA - positive test confirms active/current infection

Question 41

Treatment Hepatitis C

Answer 41

• Hepatits C is now a curable disease
• Direct acting antivirals disrupts life cycle of the virus and suppresses viral replication (Hep C virus does not integrate into the genome, making it curable).