82 - Sexually Transmittable infxns incl CME Flashcards
(83 cards)
1
Q
Outside of T. pallidum subspp. pallidum, what are 3 more endemic spirochetes and the disease they cause?
A
T.carateum - pinta (karate monks on beans) T. pallidum subsp. endemicum - endemic syphilis T. pallidum subsp. pertenue - yaws (yoyos are persistent)
2
Q
is Treponema gram + or -
A
spirochete, not clasified as gram + or -
3
Q
what popln’s are at risk of syphilis ?
A
M>>>F transgender females MSM (esp previous syphilis, online dating, metamphetamine use) AA and Hispanic
4
Q
syphilis: transmission?
A
sexual: condyloma lata, chancre or mucous patch touching skin of recipient vertical transmission blood borne
5
Q
% of transmission of syphilis post sex?
A
33%
6
Q
stages of syphilis - CME
A
primary secondary early non-primary non-secondary late syphilis
7
Q
which stage do neurosyphilis, otic and ocular syphilis belong to?
A
any stage
8
Q
stages of syphilis - Bologna?
A
primary secondary early latent < 1 yr late latent > 1 yr tertiary
9
Q
what do each of the stages represent in terms of immunology and systems affected?
A
1’ - Th1 response, macrophages destructing treponemes, localized 2’ - hematogenous and lymphatc spread + immune complexes 3’ - ++++ cellular immune reactivity
10
Q
timing of primary syphilis? name of manifestation?
A
chancre @inoculation 21 days post exposure
11
Q
clinical of chancre?
A
painless indurated ulcer with raised border dory flop (foreskin flips over at once when retraced) regional LAD can be anywhere (fingers, nipples, any mucosal site) = primary inoculation site heals w/scar in 3+ weeks
12
Q
syphilid - defn’?
A
any manifestation of syphilis outside of primary
13
Q
give 7 cutan. forms of secondary syphilis?
A
AAA FFLiPPP’N syphilis Alopecia - moth eaten Annular - scaly, favours oral commisures, scalp, palms and soles Acral pebbles Frambesiform - raspberry like Follicular papules - folliculitis-like Lichenoid Leonine facies Leukoderma - “venereal necklace”, trunk lues maligna Pustular - miliary, acneiform, varioliform, echthymiform, impetiginoid Psorisiform Nodular Condyloma Lata Exanthem corymbiform - central plaque with ring of papules clavi syphillitici
14
Q
what is the manifestation of neurosyphilis?
A
general paresis, tabes dorsalis, optic atrophy
15
Q
what is included in tables dorsalis?
A
decreased DTR in legs, pupil irregularities = Argyll Robertson (nearby reflex ok but not light), vibratory loss, ataxia, loss of pain and position sensation
16
Q
how many patients progress to 2’? 3’?
A
2- pretty much all 3 - 1/3
17
Q
timing of 2’ syphilis?
A
3 weeks post primary (3-12 weeks)
18
Q
symptoms of 2’ syphilis?
A
sore throat arthralgias LNA fevers rash malaise
19
Q
classic presentation of 2’ syphilis?
A
scaly exanthem on trunk and extremities, clasically scaly macules patches w/ “colarette of scale”
20
Q
what is condyloma lata?
A
moist papules in the areas of apposition (under breasts, axilla, anogenital, medial thighs), +++ contagious
21
Q
most contagious lesions in syphilis?
A
condyloma lata mucous patches chancre
22
Q
classic mucosal manifestation of 2’ syphilis? - give 3
A
arcuate mucous patches, forming “snail track ulcers” or white leukoplakia-like plaques “split papules” mucous patches at oral commisures” also painless tongue nodules, bullous-erosive lesions like PV, non-specific shallow ulcers
23
Q
classic alopecia in syphilis?
A
“moth eaten” >>>> AA like or diffuse
24
Q
nail changes in syphilis? - give 5
A
brittleness, onycholysis,onychomadesis, beau lines, paronychia, tranverse grooves, splitting, pitting
25
what is lues maligna? risks?
ulcers with heaped up border or necrotic plaques (anywhere) w/ systemic symptoms like fevers and LNA risks: HIV with low CD4, malnutrition, alcohol abuse, MSM, DM, previous syphilis,
26
how do you treat lues maligna?
self-resolves in 4-12 weeks if untreated, or treat as rest
27
what is early non-primary non-secondary syphilis per CME?
infections diagnosed only based on serology with no s&s, acquired w/i 1 year
28
2 cutaneous types of 3 syphilis per CME?
gummatous noduloulcerative
29
timing of 3' syphilis?
years to decades
30
common organs in 3' syphilis per CME?
cardiac - aortitis +- coronary vessel dz bone - osteitis other tissues
31
risk factors for neurosyphilis? (any stage per CME)
male, young, MSM, HIV may be symptomatic or asymptomatic
32
should you tap spine of any patient with syphilis?
only if symptomatic on history and neural exam (always do neural) - including otic and ocular if + refer for optho assessment
33
would you treat syphilis in HIV differently?
no, but higher rate of CNS syphilis and treatment resistance
34
3' syphilis manifestations per Bologna?
50% - gumma (MC) - locally destructive lesions of skin, bones, liver and other organs 25% - cardiovascular 25% - neurosyphilis
35
7 manifestations of congenital syphilis?
easiest: frontal bossing, rhagades, mulberry mollars, hutchinson teeth, mulberry mollars, 8th nerve deafness, saddle nose head down frontal bossing of Parrot keratitis +- corneal ulcers \* (reason for erythromycin drops in all newborns) saddle nose high arched palate +- perf mulberry mollars notched incisor teeth\* ++ caries due to defective enamel hearing loss \* rhagades - radial periorificial scars winged scapula thickening of medial clavicle - Higoumenakis' sign Clutton's joings - painless synovitis and effusion of the knees Saber shins - tibial bowing \* Hutchinson triad
36
4 classifications of neurosyphilis (Bologna)?
Asymptomatic Meningeal Parenchymatous Gummatous
37
What 2 tests (1 of 2) are required by CDC for definitive dx of primary syphilis? secondary syphilis?
PCR or darkfield microscopy (for either)
38
What are components of syphilis exam (JAAD)?
ROS - general, CNS, GI, MSK, psych exam: cranial nerve motor - strenghts nuchal rigidity DTR
39
2 direct detection methods for Treponemes?
PCR Darkfield
40
4 non-treponemal tests?
US(s)R does not TRUST USA's tests of VDRL and RPR USR - unheated serum reagin TRUST - toluidine red unheated serum test VDRL - venereal disease research laboratory RPR - rapid plasma reagin
41
How do treponemal tests work ? advantages?
MotherF)()\*)(\*TTreponema IgM and IgG Ab specific to T. pallidum proteins - better in early infections, detectable 2-4 weeks post exposure lifelong positive
42
5 treponemal tests?
MotherF&&&& TTreponema TPHA - T.pall Hemaaglutinnation essay MHA-TP - microhemagluttination Assay for Ab to TP TP-PA - TP passive particle Agglutination assay FTA - ABs - fluorescent treponemal antibody absorption assay EIA - enzyme immunoassay IgG - ELISA IgM - EIA Clia - chemiluminescence immunoassay My Ha TP TPpa TpHa catches my Farts-A Clearly MHA - TP TPPA TP - HA FTA CLIA
43
How do non-treponemal tests work?
NON-TREPONEMAL – Ab to “reagin” = measure tissue damage by detecting antibodies to cardiolipin, lecithin, cholesterol (N components of human cells - \> ?T. pallidum binds to and converts these to antigens or T. pallidum damages host cells = \>leak in these ); titre: most dilute serum that still yields a reactive test; ex.1:16 means test is reactive after 4 dilutions (1x2x2x2x2) if ++ reactive in spite of therapy, called serofast reactions, most common in HIV false positive – see table false negative – early or late infection, and with prozone phenomenon (Ab so high, the test cannot form normal Ag-Ab lattice, so cannot visualize positive test : ie so thick no space to react =\> reactive after serial dilutions); prozone phenomenon a/w pregnancy, HIV, neurosyphilis and +++ dz burden
44
H&E of syphilis
Classic: psoriasiform hyperplasia sponge vacuolar changes elongation of retes parakeratosis lymphocyte exocytosis necrotic keratinos plasma cells present can look like MF or lymphoma b/c of lymphocyte exocytosis (aka epidermophism) lues maligna: endarteritis obliterans of dermal vessels with ischemic necrosis; spirochetes absent or sparse on stain gumma: +++ caseating necrosis H&E: spirochetes with silver or immunohistochemical stain 2 clues: endothelial cell swelling and proliferation dermal infiltration by lymphocytes and plasma cells silver stains, like Warthin-Starry - \> low specificity =\> immunohisto preferred (more sensitive (71-100%)
45
Reasons why treponemal or non-treponemal tests false positive ?
memorize for both: advanced age autoimmune dz like SLE IVDU Pregnancy immunizations Infections: EBV, leprosy, TB, pinta, yaws, etc
46
How do you dx syphilis? reportable or not?
- all patients need both non-treponemal and treponemal test; - if non-treponemal test already performed, JAAD still recommends repeat nontreponemal test on the day of treatment to enable evaluation of serologic response to tx - report to public health - establish stage of dx - assess for presence of neurosyphilis, ocular syphilis or otic syphilis o refer for CSF if pt either has: signs or symptoms of neurosyphilis, otic syphilis or ocular syphilis suspected treatment failure tertiary syphilis o if ocular sx refer to optho - give benzathine penicillin G – penicillin formation with long half life - benzathine penicillin G is only therapy recommended for both pregnant people and fetus – pregnant patients must be desensitized and treated with penicillin even if allergic
47
whats Jarish - Herxheimer rxn?
- beware of Jarish-Herxheimer reaction o w/i 1 day of tx o fever, headache, myalgia, possible worsening rash o ?spirochette destruction causing release of lipoproteins, immune complex formation, cytokine cascade o resolves spontaneously, typically within 24 hrs o tx with antipyretics and hydration o can induce early labour
48
how far back do you need to notify partners?
- ensure sexual health needs met o screen for other STDs and HIV o sexual vaccines o preexposure prophylaxis: CDC recommends HIV testing for all pts with syphilis who are not known to have HIV and syphilis dx within 6 months is criterion for initializing HIV preexposure prophylaxis o partner notify: primary: 3 months + duration of symptoms secondary: 6 months + duration of symptms early non-primary non-secondary : 1 year abstain from sex for 1+ week until symptoms fully resolve o report
49
how do you monitor response to tx in syphilis?
- follow up to ensure response o serologic response: 4x or greater decline in non-treponemal titres
50
definition of treatment failure in syphilis?
o treatment failure: 1 year for HIV negative pts w/ primary or secondary 2 yrs for HIV negative pts with early nonprimary nonsecondary syphilis 2 years for HIV infected pts with primary or secondary
51
when should you screen for syphilis?
- screening recommendations (TABLE) o pregnant: all pregnant women at first prenatal visit, rescreen in 3rd trimester and delivery if high risk o MSM: annually if sexually active, and every 3-6 months if increased risk o HIV: if sexually active, screen at first HIV evaluation and annually
52
how soon should you follow-up on your syphilis patient?
CDC: 6 and 12 months for uncomplicated, 3, 6, 9, 12 and 24 if HIV+ 3˚: q6 months for 3 years
53
Tx for 1', 2' or early non-primary non-secondary in non-pregnant non-penicillin allergic?
benzathine penicillin G 2.4 M IMx 1
54
Tx for 1', 2' or early non-primary non-secondary in pregnant non-penicillin allergic?
benzathine penicillin G 2.4 M U IM x 1
55
Tx for 1', 2' or early non-primary non-secondary in non-pregnant penicillin allergic?
doxycycline 100 mg BID x 14 days tetracycline 500 mg QID x 14 d ceftriaxone azitromycin
56
Tx for 1', 2' or early non-primary non-secondary in pregnant penicillin allergic?
desensitize and treat with 2.4 M U IM x 1
57
Tx of unknown duration or late syphilis non-pregnant non-penicillin allergic?
benzathine penicillin G 2.4 IM x OW x 3 weeks
58
Tx of unknown duration or late syphilis pregnant non-penicillin allergic?
benzathine penicillin G 2.4 IM x OW x 3 weeks
59
Tx of unknown duration or late syphilis non-pregnant penicillin allergic?
doxycycline 100 mg BID x 28 days tetracycline 500 mg QID x 28 days ceftriaxone (no azithromycin here) x time from 1'
60
Tx of unknown duration or late syphilis pregnant non-penicillin allergic?
desensitize and treat with 2.4 M U IM OW x 3 weeks
61
Tx for neurosyphilis, ocular syphilis or otic syphilis, pregnant or non-pregnant
aqueous penicillin G 24 MU (10x previous) divided into doses Q4 hrs x 14 days can do procaine penicillin 2.4 MU IM OD + probenecid 500 mg PO Q6 hrs x 14 d
62
Tx for neurosyphilis, ocular syphilis or otic syphilis, pregnant or non-pregnant pen allergic
sensitize and treat with aqueous penicillin G 24 MU (10x previous) divided into doses Q4 hrs x 14 days can do procaine penicillin 2.4 MU IM OD + probenecid 500 mg PO Q6 hrs x 14 d
63
Organism that causes Gonorrhea? Gram +/-? appearance?
Neisseria gonorrhea
gram - diplococci
needs iron to grow
64
incubation of Neisseria gonorrhea?
2-5 days
65
Classic clinical findings in W/M (Gonorrhea)?
## Footnote
_men_: ≤10% asymptomatic, gonococcal urethritis w/ dysuria and ++ pus; in ¼ sx only w/urethral manipulation “stripping”; resolves w/o tx in 6 months
_women_: 50% asymptomatic; © cervical canal; d/c (++ yellow), dysuria, intermenstrual bleeding, menorrhagia, Bartolins swelling
_men_: ≤10% asymptomatic, gonococcal urethritis w/ dysuria and ++ pus; in ¼ sx only w/urethral manipulation “stripping”; resolves w/o tx in 6 months
_women_: 50% asymptomatic; © cervical canal; d/c (++ yellow), dysuria, intermenstrual bleeding, menorrhagia, Bartolins swelling
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4 systemic manifestations of Gonorrhea?
1. **pharyngeal** (post oral, usually asymptomatic)
2. **rectal** (+- proctitis, rectal d/c, pruritis, tenesmus)
3. **gonococcal ophthalmia** (incl ophthalmia neonatorum aka purulent conjunctivitis, can progress to severe keratitis and **blindness** -\> reason for erythromycin drops)
4. **arthritis-dermatosis syndrome** (gonococcemia) – 1%
risk factors: menstruation (a/w menses), C5-C9 deficiendy
_fever + joint pain + paucilesional eruption_ of hemorrhagic pustules
gonococcal tenosynovitis © knees, elbows, wrists, ankles, +- overlying erythema
cutaneous: scattered pustules, necrotic due to embolic septic vasculitis, distal extremities, contain gonococci
67
Clinical manifestation of arthritis-dermatosis syndrome?
arthritis-dermatosis syndrome (gonococcemia) – 1%
risk factors: menstruation (a/w menses), C5-C9 deficiendy
fever + joint pain + paucilesional eruption of hemorrhagic pustules
gonococcal tenosynovitis © knees, elbows, wrists, ankles, +- overlying erythema
cutaneous: scattered pustules, necrotic due to embolic septic vasculitis, distal extremities, contain gonococ
68
Gonorrhea - list 5 complications?
_complications: ascending gonorrhea:_ M = epididymitis, prostatitis, vesiculitis
F= acute salpingitis or **PID** (10-20%) -\> infertility, chronic pelvic pain, ectopic
extragenital:
69
Gonorrhea tx?
**Ceftriaxone 250mg IM x 1 AND azithromycin 1 g PO x 1**
(also tx Chlamydia)
if **disseminated**: IV ceftriaxone **1 g Q12 hrs x 7 days** + 1 g azithromycin PO x 1
neonatal/opthalmia neonatorum: ceftriaxone **50 mg/kg IV x 1 dose**
70
Gonorrhea - histo?
gram or methylene blue stain of smear = **gram -ve diplococci within neutrophils**
71
Chancroid - bacteria?
*Haemophilus ducreyi*
72
Chancroid - clinical?
incubation **3-10 d** =\> papule w/erythema -\> pustule -\> painful ulcer w/ soft undermined edges (may have few due to apposition)
“**septic sore”:** pus trapped within skin of penile shaft w/o obvious ulcer
coinfection w/ HSV or syphilis classic
painful inguinal lymphadenitis (buboes), unilateral \>\> bilateral, may ulcerate/rupture
gram- anaerobic
sexual contact w/ infected F w/ genital ulcers (infxs x 45d)
73
Chancroid - histo findings?
3 zones of inflammation:
1 – necrotic debris, fibrin, neuts
2- granulation tissue
3- deepest – lymphocytes and plasmas; + gram neg stain rare
“school of fish” or “railroad track” pattern of gram - bacilli
74
Chancroid - tx?
**Ceftriaxone 250mg** **IM × 1**
Azithromycin 1 g PO × 1
Cipro 500 mg bid × 3 days (c/I in pregnancy)
heals w/i 14 days
75
Bacteria for lymphogranuloma venereum? incubation? sites?
*Chlamydia trachomatis*
(L1–3 serotypes)
©lymph tissue of genitals/rectum
incubation 3-12 d
76
Lymphogranuloma venereum: clinical stages and organs affected in each?
_Stage I_: initial infection of genital mucosa: herpetiform lesion at site of exposure -\> rapid healing; a/w lymphangitis +- cervicitis/urethrtitis/proctocolitis (all rare)
_Stage II: Inguinal syndrome:_ unilateral inguinal LNA (bubo) w/overlying erythema à firm -\> enlarges and ++ painful; skin develops bluish discoloration-\> ruptures with suppuration thru ++ sinus tract w/ bubos and +- PIDà heals
_Stage III (M-yrs): ano-genito-rectal syndrome:_ proctocolitis + intenstinal/perirectal lymph hyperplasia -\> local abscesses, anal fistulas, rectofabinal fistulas, rectal strictures and stenosis
Other manifestations (in table)
* urethra-genito-perineal syndrome
* erythema nodosum
* peno-scrotal elephantiasis
submaxillary or cervixal lymphadenopathy associated with oropharyngeal lesions
77
Lymphogranuloma venereum : H&E/culture?
Giemsa stain: **Gamma-Favre bodies** = organisms within histiocytes
neuts, histiocytes, plasma, multinucleated giant cells
\> **stellate abscesses** characteristic in LNs
dx via PCR \>\> tissue culture (need L1-3 serotypes to get LGV)
r/o chancroid, cat scratch, lymphoma, mycobacterial infections Crohn, symphilis, HIV
78
Lymphogranuloma venereum Tx? (N, preggo, HIV)
For **3 weeks:**
**doxycycline** **100 mg bid**
erythromycin base 500mg qid (pregnancy)
examine/treat **partners if w/I 30 days**
HIV pts = \> longer course
79
Organism in granuloma inguinale?
Klebsiella granulomatosis
80
Clinical presentation of Granuloma Inguinale?
painless SubQ papule or nodule à +++ vascular, beefy, bleed easily -\> ulcerates -\> foul exudate
men: prepuce aka foreskin, glans, frenulum, coronal sulcus
women: vulva
rare lymphadenopathy; does not heal without treatment
extragenital possible – any organ, © bones
incubation 1 day-1 year, ave 3 weeks
ddx: 2’ syphilis esp. condylomata lata, carcinoma, amebiasis, TB, dimorphic fungal, pyoderma Vegetans, Crohn disease, PG
81
Histo of Granuloma Inguinale?
**ulceration w/ +++ granulation tissue**
**pseudoepitheliomatous hyperplasia**
**++ histiocytes, plasmas, few lymphs in dermis, +- neut abscesses**
**Donovan bodies =** parasitized histiocyte; stain bipolar
DDx = **His GiRL Pen**elope
**His**toplasmosis (histoplasma capsulatum)
**G**ranuloma **I**nguinale
**R**hinoscleroma (Klebsiella rhinoscleromatis)
**L**eishmaniasis
**P**encillosis
82
Tx in Granuloma Inguinale?
**azithromycin 1 g weekly** or 500 mg OD x 3 weeks and until all lesions healed
examine sexual partner w/i 60 days of onset or if symptomatic
relapses can occur
83
