9. Robbins: Chapter 22 Vulva, Vagina and Cervix Flashcards

(85 cards)

1
Q

Embryologically, how are fallopian tubes formed?

A

Upper portions of mullerian ducts do not fuse.

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2
Q

When the LOWER portion of the mullerian ducts fuse, what does this form?

A
  1. uterus
  2. cervix
  3. upper vagina
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3
Q
  • Endometriosis is a _______-derived lesion
A

Mullerian

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4
Q

Persistance of the mesonephric ducts form what?

A
  1. Gartner duct cysts = Epithelial inclusions in the cervix and vagina t
  2. Paratubal cysts = Epithelial inclusions next to the ovaries, tubes, and uterus;
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5
Q

What type of epithelium lines the female genital tract and the surface of the ovary?

A

Coelomic epithelium (mesothelium)

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6
Q

Buzzwords for the following common CURABLE STIs (include types in discharge, if possible)

  1. Chlamydia trachomatis
  2. Neisseria gonorrhea
  3. Trichomonas vaginalis
  4. Gardnerella vaginalis
  5. Ureaplasma urealyticum, mycoplasma hominis
A
  1. Chlamydia trachomatis =
    1. pelvic inflammatory disease;
    2. Serous discharge
  2. Neisseria gonorrhea =
    1. Pelvic inflammatory disease (most serious complication of gonorrhea in women);
    2. Purulent discharge
    3. Gram (-) diplococci within neutrophils (PMNs)
  3. Trichomonas vaginalis
    1. Large, ovoid protozoa w flagella;
    2. Yellow, frothy discharge;
    3. “Strawberry cervix”
  4. Gardnerella vaginalis
    1. Gram (-) baccili
    2. Main cause of bacterial vaginosis
    3. Thin grey/green fishy discharge
  5. Ureaplasma urealyticum, mycoplasma hominis
    1. Seen in pre-term deliveries
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7
Q

Which infections of the female genital tract cause:

  1. Discomfort, without serious complications
  2. Infertility
  3. Occur if bb is delivered pre-term
A
  1. Candida, Trichomonas, Gardnerella
  2. Gonorrhea and chylamydia
  3. Ureaplasma urityiculum and mycoplasma homonis
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8
Q

Herpes Simplex Virus (HSV)

  • Commonly involves: _______
  • _____ => oropharyngeal infection
  • _____ => infection in the genital mucos and skin.
A
  • Cervix > vagina > vulva
  • HSV1 => oropharyngeal infection
  • HSV2 => infection of the genital mucosa and skin
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9
Q

How does HSV (herpes simplex virus) present?

A
  1. Lesions on cervix > vagina > vulva
    1. 1/3 of newly infected females show painful red papules 3-7 days after infection with fever, malaise, and tender inguinal lymph nodes
    2. => vesicles
    3. => coalesce into painful ulcers
      1. ​If on cervix or vagina: + purulent discharge & pain
      2. If on vulva: easily seen
      3. If next to urethra: dysuria
    4. => spontaneously in 1-3 weeks
    5. => however, infection remains latent in lumbosacral ganglia
    6. => reactivated due to stress, trauma, UV light, hormonal changes (skin & mucosal lesions
  2. Purulent discharge
  3. Pelvic pain
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10
Q

ALL males with HSV are _____.

A

Symptomatic

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11
Q

HSV

  • Contains what intranuclear inclusions?
  • Morphology?
A
  • Cowdry bodies
  • Morphology
    1. Ulcer is often biopsied
    2. Desquamated (peeling) of epithelium with acute inflammation at the ulcer bed
    3. Multinucleated squamous cells
    4. “Ground glass” eosinophilic to basophilic viral inclusions (viral cytopathic effect)
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12
Q

Recurrences of HSV is MUCH more common in who?

A

Immunocompromised → meningitis, hepatitis, pneumonitis

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13
Q

Detection of anti-HSV antibodies to (Smith antigen) in the serum = _______

A

recurrent/latent infection

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14
Q
  1. _______ have higher susceptibility to HSV
  2. Previous infection with HSV-1 ___ risk of infection with HSV-2
  3. HSV-2 infection enhances acquisition and transmission of ____
A
  • Females
  • HIV-1
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15
Q

HSV1 is a major cause of what in the US?

A
  1. Corneal blindness
  2. Fatal sporadic encephalitis
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16
Q

HSV-2 infection in the neonate may be mild, but more commonly what course does it follow and what’s affected?

A
  • More commonly is fulminating
  • Generalized LAD, splenomegaly, and necrotic foci throught the lungs, liver, adrenals and CNS
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17
Q

What can be used to ID herpes simplex virus (HSV)?

A
  1. Tzank smear, look for cytopathic effect (multinucleation).
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18
Q

What is the gravest consequence of HSV infection?

A

Transmission to the neonate during birth (active and primary/initial infection) is assoc. w/ high mortality rate

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19
Q

What is Molluscum contagiosum virus?

Which type is most often prevelent and sexually transmitted?

A
  • Poxvirus of the skin and mucus membranes with 4 subtypes
  • Most prevelant = MCV1
  • Most sexually trasnmitted = MCV2
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20
Q

What family of viruses is Molluscum contagiosum; what is unique about its replication?

A
  • Poxvirus; linear dsDNA virus
  • ONLY DNA virus to replicate in the cytoplasm
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21
Q

What is the characteristic appearance of the papules seen w/ Molluscum contagiosum infection?

A
  1. Pearly, dome-shaped w/ dimpled umbilicated center
  2. Central waxy core has cells w/ cytoplasmic viral inclusion bodies (Guarnieri bodies)
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22
Q

How is Molluscum contagiosum (poxvirus) diagnosed in children (2-12) and adults?

A
  • Children (2-12 years old): Direct contact or shared items (towels) and is most common on the trunk, arms & legs. Think of sexual abuse if seen in genitals in kids.
  • Adults: sexually transmitted and seen on genitals, lower abdomen, buttocks, inner thighs
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23
Q

Vulvovaginal candidiasis is common in who?

A
  1. T2DM**
  2. Pregnant
  3. ABX
  4. Defects in NADPH or MPO
  5. Burn patients or indwelling cartheter
  6. Neutroptenia/TH17 defects
  7. HIV
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24
Q

Which sign’s and sx’s are common to Candida vaginitis?

A
  1. Yeast infection (not a STI)
    1. Thick, curd like discharge (“cottage cheese-like”)
    2. Intense itching, erythema, swelling
  2. If severe=> ulcerate
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25
What is the characteristic morphology of **Candida**?
Pseudohyphae and budding yeast
26
How is the diagnosis of **Candida vaginitis** made; which stain and what's seen?
* 1. **Inspection** * 2. **KOH wet mount:** pseudospores or filamentous fungal hyphae * **3. Pap smear**
27
What is the most common **curable STI?**
**Trichomonas vaginalis**
28
**_Trichomonas vaginalis_** * Symptoms? * Diagnosis?
1. Sx 1. **Yellow, frothy discharge** 2. **Strawberry cervix** =\> dilation of cervical vessels (colpscopic appearance) 3. **Dyuria/dysparenia (pain during sex)** 2. Diagnosis 1. **Methylene blue wet mount:** motile trophozoites with corkscew motility
29
What is the main cause of **bacerial vaginosis/vaginitis?**
**Gardnerella vaginalis (**Gram - baccilis)
30
What is the typical presentation of **Gardnerella vaginalis**?
1. Present w/ **thin, green-GRAY, discharge** w/ **fishy smell** 2. If pregnant, can cause **premature labor\***
31
What will a **pap smear** of pt with **Gardnerella vaginalis** show?
Superficial and intermediate **squamous cells** covered with shaggy coating of **coccobacilli (clue cells)**
32
Which test for **Gardnerella vaginalis** will enhance the fishy odor?
**Amine whiff test**: mix discharge w/ 10% KOH
33
_**Ureaplasma urealyticum** & **Mycoplasma hominis**_ * Symptoms * Morphology
* Sx * 1. Vagininitis/cervicitis * Morphology * Fried egg appearance
34
What 2 STIs cause **Pelvic Inflammatory Disease** (infection that begins in the vulva/vagina =\> upward involve most female genital system, causing pelvic pain, adnexal tenderness, fever and vaginal discharge).
1. Chlamydia trachomitis (serotypes D-K) 2. Neisseria gonorrheae
35
What is symptom is common between [**N. gonorhheae** and **C. trachomatis]**?
BOTH are often **ASYMPTOMATIC** in women
36
Most common STI in the world
**Chlamydia trachomatis**
37
**_Chlamydia trachomatis_** * Type of bacteria * Presentation * Diagnosis
* Gram (-) obligate intracellar bacteria * **Sx** * Usually asymptomatic (50%) * Mucopurulent/serous discharge (containing mainly neutrophils) * PID * **Diagnose**: Nucleic Acid Amplification Test (NAAT)
38
What are the 2 forms that **Chlamydia trachomatis** exists in during its life cycle and characteristic of each?
1. **- Elementary body** = infectious, inactive form, that is taken up by the host cell 2. - **Reticulate body** = active form, uses host ATP and AA's to replicate
39
What is **PID**?
1. **Infection that begins in the vulva or vagina** and spreads upward to involve most of the structures of the female genital system. 2. Fever, pelvic RUQ pain, adnexel tenderness and vaginal discharge
40
**Pelvic inflammatory disease** that occurs after [spontaneous/induced abortions] and [normal/abnormal deliveries] are referred to as what; most commonly caused by what organisms?
* - Puerperal infections -* infections that occur after childbirth/abortions - Typically polymicrobial: staphylococci, streptococci, coliforms, and Clostridium perfringens
41
How does PID causes by gonococcal infections differ from that caused by staphylococcis, streptococci, and other puerperal invaders; which is more often assoc. w/ bacteremia?
**- Gonococcal shows** marked acute inflammation of mucosal surfaces; spread upward to involve fallopian tubes (acute supportive salpingitis) and tubo-ovarian region, but spares the endometrium. **- Puerperal invaders** have less mucosal involvement and more inflammation of deeper layers; spread via lymph and veins; _bacteremia_ is a more frequent complication
42
Which part of the female genital tract does **Gonococcal infections** usually not affect?
**Endometrium**
43
What are the acute vs. chronic complications which may arise from **PID**?
**Acute** = * Peritonitis and bacteremia ----\> [endocarditis, meningitis, and suppurative arthritis] - **Chronic** = 1. Infertility and tubal obstruction, ectopic preg., pelvic pain, and intestinal obstruction 2. Fitz-Hugh Curtis syndrome
44
What is a **rare complication** of **PID** that occurs almost exlusively in **women**?
**Fitz-High Curtis Syndrome** = inflammation of the liver capsule the creates adhesion, most often due to Gonorrhea.
45
STIs that form Ulcers
1. **Granuloma inguinale** 2. **Chancroid** 3. Chlamydia serovars L1-L3 =\> **lymphogranuloma venereum** 4. **Treponema pallidum (syphilis)**
46
**Lymphogranuloma venereum** is caused by what organism?
**L1-3 serotypes** of **Chalmydia trachomatis**
47
**Lymphogranuloma venereum** is endemic where? Sporadic where?
1. **Endemic** = Parts of Asia, Africaa, the Caribbean, and S. America 2. **Sporadic =** US/Western Europe
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How is **Lymphogranuloma Venereum** diagnosed in active and chronic cases?
* Active = organism is seen in biopsy or smears of exudate * Chronc cases = Ab to chylamdia L1-3
49
Presentation of **Lymphogranuloma venereum**
1. **Begins as painless ulcer** at the site of contact 2. =\> progresses to **painful swollen lymph nodes** 3. **=\>** leading to **genital elephantiasis i**n late stage
50
What is the leading cause o**f preventable infectious blindness?**
**Trachoma**, caused by **chlamydia** (types A, B, Ba, and C)
51
Which organism is responsible for causing **chancroid (soft chancre)** in both males and females; what is its morphology and gram stain?
**Haemophilus ducreyi** = Gram (-) coccobacillus
52
Where is **Haemophilus ducreyi (=\> chancroids)** seen most commonly?
* Most common cause of **genital ulcers** in **Africa** and **SE Asia**
53
Who is **Haemophilus ducreyi (=\> soft chancroids)** most commonly seen in?
1. **lower SES** 2. **Men** who have frequent **sex with** **prostitutes**
54
Where do most ulcers associated w/ **H. ducreyi** develop in females; are they painful or painless? Other SX:
1. Begins: **PAINFUL erythematous papule** on vagina or periurethral area 2. Erodes over a a few days to make an 1. **=\> multiple, non-indurated, painful ulcer (chancroid)** 3. Within 1-2 weeks, 50% pts **get enlarged, tender regional LN (buboes)** 4. \*Haemophilus ducreyi (it's so painful, you "do cry")
55
How does the **H. ducreyi ulcer (chancroid)** *differ* from that of *syphillis*; what is seen morphologically at the base of the ulcer?
- **Chancroids** =\> multiple non-indurated painful ulcers ; base will have a yellow-grey exudate - **Syphillus** =\> single, hard, indurated painful ulcers
56
Microscopically how does the ulcer of **chancroid (H. ducreyi)** appear?
1. Superficial zone of **neutrophilic debris + fibrin** 2. Underneath =\> **granulation tissue** with areas of **necrosis** and **thrombosed vessels**
57
**_Haemophilus ducreyi (painful chancroids)_** * Causes painful, genital ulcers in Africa and SE Asia, where it probably serves as an important cofactor for \_\_\_\_\_\_\_\_ * Why are they often **underdiagnosed**?
* **HIV** * Hard to grow in culture and PCR-based tests are not always available
58
Which organism is associated with **granuloma inguinale (donovanosis)** in both males and females; what is its gram stain and morphology?
* **Klebsiella granulomatis** = Encapsulated_, gram (-) coccobacillus_
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**_Granuloma Inguinale_** * Endemic * Uncommon
* Endemic = Rural areas in some deloping country * Uncommon = US/Western Europe
60
What are **Granuloma Inguinale**?
Soft**, painless genital ulcers** of the **pharynx/oral mucosa without lymphadopathy.** - base: granulation like tissue.
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How does the lesion of **granuloma inguinale** begin and how does it progress over time?
1. R**aised papular lesion** on moist stratified squamous epithelium of genitals 2. **=\> Soft painless ulcer** with granulation tissue at the base.
62
**Untreated** Granuloma Inguinale
* Scarring =\> lymphatic obstruction =\> lymphedema =\> **elephantiasis of the external genetalia**
63
ID **Granuloma Inguinale**
1. **Giemsa-stain:** MO with encapsulated coccobacilli (Donovan bodies) 2. *Wartharin - Starry Silver stains* can also be used
64
What is one major difference about the pathogenesis of H. ducreyi and K. granulomatis?
* **H. ducreyi** often has regional LN involvement; become large and tender * **- K. granulomatis** typically spares the regional LN's
65
What is the **microaerophilic spirochete** that causes syphillis?
**T. pallidum**
66
**T. Pallidum** Type of bacetria
Flagellated, **Gram (-),** slender corkscrew-shaped (or spiral) spirochete
67
**T. pallidum** * Pathogenesis (in all stages) * is too slender to be gram stained so what is used for visualization?
* Proliferative **endarteritis** of small vessels surrounded by **plasma cells** * Cant gram-stain, so **Dark field micrscopy (Silver stain)** and **immunofluorescence** techniques
68
How are the following ID'd 1. Granuloma inguinale 2. Chancroid 3. Chlamydia serovars L1-L3 =\> lymphogranuloma venereum 4. Treponema pallidum (syphilis)
1. Granuloma inguinale 2. Chancroid 3. Chlamydia serovars L1-L3 =\> lymphogranuloma venereum 4. Treponema pallidum (syphilis): 1. Darkfield microscopy (silver stain) or immunoflurouecnce (bc cant gramstain/culture)
69
**Primary syphillis** occurs about 3 weeks after infection and is characterized by what?
**Single, painless, non-tender chancre (wart)** at the cervix, vaginal wall, or anus * indurated edge; _contagious_; heals spontaneously 3-6 weeks but progresses because painless and is typically left untreated
70
**2-10 weeks afte**r untreated primary syphilis the pt enters 2nd stage of syphillis which is characterized by what?
1. - **Maculopapular (copper-colored rash)** on palms and soles of feet 2. - **Condyloma lata** = flat wart like perianal and mucous membrane lesions that are very infectious 3. - Mild fever + LAD + malaise + weight loss = common 4. - Asymptomatic neurosyphillis may develop
71
How long is the typical **latent period** between secondary syphillis and tertiary syphillis?
**5+ years** without clinical sx
72
What are the main manifestations of **tertiary syphillis** that may occur alone or in combination?
1. Benign tertiary syphillis (aka gummas): soft growths with necrotic centers 2. Cardiovascular syphillis 3. Neurosyphillis
73
What is the characteristic finding of benign tertiary syphillis and what are the signs/sx's?
- **Gummas** in bone, skin, and mucous membranes of upper airway and mouth = nodular lesions - Skeletal involvement causes pain, tenderness, and swelling + pathologic fractures - Skin/mucous membranes w/ nodular or, rarely, destructive, ulcerative lesions
74
What is seen on histological examination of a gumma associated with tertiary syphillis?
Centers of coagulated, necrotic material and marginscomposed of plump, palisading macrophages and fibroblasts surrounded by large numbers of mononuclear leukocytes, mainly plasma cells
75
The later manifestations of **congenital syphillis** inculde what distinct triad?
1. - Interstital keratitis 2. - Hutchinson teeth 3. - CN VIII deafness
76
**N. Gonrrhea** * bacterial characteristics * ID
* Phagocytosed gram (-) diplococci within neutrophils/PMNs (intracellular) * Thayer-Martin Agar
77
**_HPV_** * Presentation * Causes cancer where? * Infects what cells? * Cells infected with HPV are called? * ID'd how?
* **Multiple warty lesions** on the perineum and around the anus in low-risk types 6 and 11 * Cervix squamous cell carcinoma\>\>\>\> vagina \> vulva * Basal keratinocytes (stem cells) of genital mucosal epithelium and delivers genome to nucleus * **Squamous cells with koilocytosis** = krinkled nucleus with clear area around it that looks like a raisin d/t E5 promotes viral replication
78
With STD can cause **cervical dysplasia and cancer;** as well as **vuvlvar and vaginal cancer** in females? Name the precursor lesions
HPV * Vulva = vulvar intraepithelial neoplasia (VIN) * Vagina = VaIN * Cervix = CIN
79
**HPV** and **herpes virus** are associated with what type of inflammatory response?
**Cytopathic-cytoproliferative reactions**
80
Candidias occurs due to what?
Change in local flora (microbiome) of the vagina; usually lactinobacillus
81
Name the infection: 1. Intranuclear basophilic "owl eye" inclusions 2. Corkscrew shaped bacteria (spirochetes) 3. Elementary and reticulate bodies 4. Ground glass intranuclear inclusions 5. Squamous cells with koilocytosis
1. asdasd 2. asd 3. sd 4. HSV 5. HPV
82
Are the following lesions single or multiple 1. Chancroids 2. HSV 3. Candidiasis 4. Granumoma inguinale 5. Syphillis 6. Secondary syphillus 7. Lymphogranuloma venereum
1. Chancroids = **single** (non-granulomatous) 2. HSV = **multiple** 3. Candidiasis = **single** 4. Granumoma inguinale = **single** (granulomatous) 5. Syphillis = **single** (non-granulomatous) 6. Secondary syphillus = **multiple** 7. Lymphogranuloma venereum = **single** (granulomatous)
83
Which HPV strains have the highest risk of causing genital cancer??
**16** and **18**
84
**_What is the mechanism of HPV?_** * HPV 6 inhibits p53 =\> continous replication HPV7 inhibits p21 and RB
* HPV 6 inhibits p53 =\> continous replication * HPV7 inhibits p21 and RB * inhibition of p21 =\> increased expression of CDK4/cyclin D =\> inhibits RB-E2F * Inhibition of RB-E2F * =\> immortilization; increased cell proliferation; genomic instability
85