HSV, genital ulcers, chlamydia, gonorrhea, proctitis

Question 1

How to decrease HSV transmission in discordant couples

Answer 1

behavior and education - education about asymptomatic viral shedding.

consistent condom use (esp male to female transmission),

abstinence with prodromal symptoms and active lesions even with condoms

Question 2

Serological testing for HSV

Answer 2

required for pt who is not previously diagnosed or previously confirmed with HSV

Test partner for susceptibility for HSV1 and HSV2

Question 3

how to prevent HSV transmission to partner (medical tx)

Answer 3

daily valacyclovir (best studied once daily dosing)

daily acyclovir (more affordable)

helps to reduce asymptomatic viral shedding, decreases number of outbreaks and shortens outbreak duration.

Question 4

small vesicles or ulcers on a erythematous base and see mild LAD

Answer 4

HSV, these are painful

Question 5

larger deep ulcers with gray yellow exudate well demarcated borders and soft friable base with severe LAD that may suppurate

Answer 5

Haemophilus ducreyi (chancroid) and this is painful

Question 6

chancroid is a painful

Answer 6

larger deep ulcer that is well demarcated and may have severe LAD that may suppurate seen from haemophilius ducreyi

Question 7

single painless ulcer with regular borders and hard base

Answer 7

syphilis (painless) and it’s a chancre

Question 8

small shallow ulcers that are often missed can progress to be painful and fluctuant adenitis

Answer 8

chlamydia trachomatis serovars L1-3 these are painless

Question 9

lymphogranuloma venereum is also caused by

Answer 9

chlamydia trachomatis these can progress to painful fluctuant adenitis (buboes)

Question 10

what test should always be ordered if someone has a genital ulcer

Answer 10

check HIV

Question 11

lymphogranuloma venereum can have

Answer 11

regional lymph node suppuration and matting and develop sinus tracts. This is from Chlamydia trachomatis serovars L1-3

Question 12

infectious genital ulcers chart

Answer 12

Question 13

how does a tuboovarian abscess present?

Answer 13

acute lower abdominal pain, fever, and chills

see purulent cervical discharge.

Question 14

Why do we not retest pts for chlamydia within 3 weeks after being treated for chlamydia

Answer 14

because NAAT can create false positives. NAAT for chlamydia can detect living and dead organisms.

Question 15

Chlamydia trachomatis presentation in women

Answer 15

Question 16

When to screen women for chlamydia trachomatis?

Answer 16

initial prenatal visit

age<25

age >25 with risk factors (multiple sex partners, sex workers)

Question 17

clinical features of a chlamydia trachomatis infection

Answer 17

asymptomatic (most commonly)

cervicitis (post coital bleeding, purulent cervical discharge)

urethritis (sterile pyuria)

PID and perihepatitis (Fitz-Hugh-Curtis syndrome)

Question 18

How to diagnose chlamydia trachomatis?

Answer 18

Nucleic acid amplification testing( NAAT) PCR from cervical swabs

Question 19

Treatment of chlamydia is

Answer 19

azithromycin OR doxycyline

STI testing for HIV and Neisseria gonorrhea

Question 20

how to follow up for test of cure for chlamydia?

Answer 20

test of cure 3 weeks after tx during pregnancy

test for reinfection 3-6 months after treatment

Question 21

What is first line diagnostic test for chlamydia?

Can you have a false positive ?

Answer 21

NAAT or nucleic acid amplication testing for chlamydia trachomatis is more sensitive and specific than culture methods and is preferred for diagnosis of chlamydial infection.

Can have false positive test within 3 weeks of initial treatment because the tests detects both living and dead organisms.

test of cure is not indicated if the chlamydia infection is treated with first line antibiotics and resistance is low.

Question 22

pt develops sudden onset inability to move her left side of face- left sided facial drooping, facial asymmetry and loss of left nasolabial fold. unable to fully close left eye wrinkle forehead or nose and inflate left cheek or show her teeth. NO other neurological complaints. NO travel, illness, rashes or tick bites. what is this?

How to treat?

What also to consider in differential?

Answer 22

sudden onset bell’s palsy and this is a result of HSV reactivation.

Generally 70-85% recover within 3 weeks but prednisone given 3 days of symptom onset improves recovery. Some also suggest valacyclovir can help with pts who have SEVERE facial paralysis.

ALso consider HIV, lyme dx, space occupying lesions (sarcoid or tumor or cholesteatoma or Sjogren’s syndrome).

Question 23

Acute cervicitis

what causes it?

What is it’s clinical presentation

Answer 23

Question 24

What happens if you don’t treat acute cervicitis?

Answer 24

can cause pelvic inflammatory disease or PID with sequelae like infertility, ectopic pregnancy and chronic pelvic pain.

In pregnant women it can cuse: spontaneous abortion, preterm labor from rupture of membranes or neonatal conjunctivitis

Question 25

what is the clinical presentation of pts who have acute cervicitis?

Answer 25

see asymptomatic, mucopurulent discharge, post coital or intermenstrual bleeding, or friable cervix.

Question 26

how to diagnose acute cervicitis?

Answer 26

nucleic acid amplification testing (NAAT) for chlamydia or gonorrhea but also need testing for vaginosis and trichomoniasis. Guidelines recommend empiric treatment (not waiting for test results) for pt and sex partners with azithromycin and ceftriaxone for gonorrhea and chlamydia. Repeat testing is recommended in 3-6 months after treatment in pts with high reoccurrence.

Question 27

do we ever get cervical gram stain to diagnose chlamydia or gonorrhea?

Answer 27

no because it has poor sensitivity for diagnosing gonorrhea

Question 28

Sexually transmitted proctitis what causes it? What are the symptoms?

Answer 28

Question 29

tenesmus, purulent discharge and small volume stools with blood is

Answer 29

proctitis Can be due to UC, radiation tx, and infections - like neisseria gonorrhea which is the most common cause for this in anal receptive intercourse.

Question 30

how to diagnose pts who have proctitis?

Answer 30

purulent discharge should be cultured and sent for gram stain, Tzanck prep, and culture for HSV, PCR for chlamydia trachomatis. Also check for RPR and HIV.

Question 31

differential for vaginitis and chart

Answer 31

Question 32

What is this?

Answer 32

This **vulvovaginal candidiasis** - this is normal vaginal flora and seen commonly. But it can have overgrowth and invasion into the vaginal cells which creates symptomatic vulvovaginal candidiasis. see vaginal discharge, pruritis, dysuria and dyspareunia. Exam will show vaginal discharge and clumpy white discharge. See pseudohyphae and budding yeast on wet mount microscopy.

Question 33

what does this smear show?

Answer 33

bacterial vaginosis- diagnosed with 3 out of 4 cirtiera are present -see thin gray vaginal discharge vaginal pH \>4.5 amine odor after applicaiton of potassium hydroxide (whiff test) clue cells (epithelial cells covered in bacteria) on wet mount microscopy

Question 34

Treatment of bacterial vaginosis is:

Answer 34

oral or vaginal metronidazole ## Footnote can use clindamycin also self limiting condition

Question 35

erythema and infalmmation of vulvuovaginal area and see this on smear

Answer 35

This is trichomonas vaginitis Treatment is metronidazole and must treat partner

Question 36

treatment of vulvovaginal candidasis

Answer 36

can occur after antibiotic use see vulvaginal pruritis, thick white clumpy discharge with this on wet mount (pseudohyphae) tx with fluconazole

Question 37

what is uncomplicated vulvovaginal candidiasis?

Answer 37

less than 3 episodes per year of VVC immunocompetent mild symptoms

Question 38

Treatment of uncomplicated vulvovaginal candidiasis Treatment of complicated vulvovaginal candidiasis

Answer 38

Treatment for uncomplicated vulvovaginal candidiasis is **single course of oral (fluconazole) or topical (miconazole or clotrimazole)** antifungal agent. Complicated infections need **longer treatment** other than Candida albicans

Question 39

Diagnosis of HSV

Answer 39

**1st line - get a PCR testing or NAAT** (nucleic acid amplification testing) by taking a sample by rotating swab firmly on the ulcer base after a vesicle is unroofed or from a lesion that has been ulcerated in less than 24 hrs. **2nd line -** can get **viral culture** if not able to do PCR NAAT for HSV. direct fluorescence antibody - not as sensitive as NAAT type specific serological tests should not be obtained to confirm diagnosis.

Question 40

what is done for HIV testing?

Answer 40

**1.** this screens serum for **HIV antibodies** + **antigen screening** at the same time as initial ELISA test Basically looking at HIV antibodies **(ELISA for HIV1/HIV2) and HIV p24 antigen** **rationale**: pts in _window period_ where they are infected but not producing antibodies at high enough level to be detected will be missed. The antigen/antibody combination had a low false positive rate. **confirmatory testing is**: with a **HIV1/2 antibody differentiation immunoassay** - if intermediate, then get **HIV RNA testing by PCR.** if HIV1/HIV2 antibody differentiation immunoassay is _positive-_ confirms _infection._ If _negative_ HIV1/HIV2 antibody differentiation, get **HIV RNA testing by PCR**. If that is positive, then it confirms HIV infection.

Question 41

Treatment of PID (pelvic inflammatory disease) Parentarel therapy oral/ IM therapy

Answer 41

**parenteral therapy: cefotetan** 2g IV q12h or **cefoxitin** 2g IV q6h + **doxycycline** 100 mg IV or PO q12h or clindamycin 900 mg IV q8h + gentamicin 2mg/kg IV followed by a 1.5 mg/kg IV q8h **PO/IM therapy:** **ceftriaxone 250 mg IM single dose** + **doxycycline 100 mg PO bid for 14 days** with or without **metronidazole 500 mg PO bid for 14 days** or cefoxitin 2g IM single dose with probenecid 1 g PO + doxycycline 100 mg PO bid for 14 days with or without metronidazole 500 mg PO bid for 14 days

Question 42

how to screen and diagnose chlamydia?

Answer 42

NAAT or nucleic acid amplification testing **1st catch urine** (for men and women) **endocervical** (for women) and **urethral** (for men) **swabs** **_also screen for Neiserria gonorrhea too._** chlamydia can also cause oropharyngeal and rectal infection and so evaluate based on sexual practice.

Question 43

empiric treatment for chlamydia/gonorrhea cervicitis and urethritis

Answer 43

**ceftriaxone 250 mg IM single dose** + **azithromycin 1 gram PO _single dose_** **ceftriaxone 250 mg IM single dose** + **doxycycline 100 mg bid for _7 days_** if can't use azithromycin. \*cefixime 400 mg PO single dose if cannot use ceftriaxone.

Question 44

Treatment of epididymitis?

Answer 44

**ceftriaxone 250 mg IM single dose** + **doxycycline 100 mg PO bid for 10 days** if due to chlamydia/gonorrhea **ceftriaxone 250 mg single dose** + **levofloxacin 500 mg PO daily** (or ofloxacin 300 mg PO bid for 10 days) - if infection was **chlamydia/gonorrhea and *_enteric organisms (insertive anal sex)_***

Question 45

Do we test for cure in chlamydia and gonorrhea?

Answer 45

**No,** not for routine pts but **if pregnant** _pt should be tested for cure._ **No,** except if you treated **pharyngeal gonorrhea** _and used an alternate antibiotic regimen then you should test for cure_. All pts with gonorrhea and chlamydia _should be retested in 3 months_ or next appointment due high risk for reinfection.

Question 46

in disseminated gonorrhea, what must be done for culture isolates?

Answer 46

all N. gonorrhea **_isolates should be tested for antimicrobial susceptibility_.** **all suspected disseminated gonococcal infections should have cultures** performed on **blood, joint fluid** (if arthritis is present), **purulent skin lesions** (if present) and **CSF** (if meningitis is present) **NAAT is always preferred;** swab all potential sites of exposure (genital, pharyngeal, rectal). culture has poor sensitivity. disseminated gonococcal infection has: arthritis, dermatitis, endocarditis or meningitis)

Question 47

HPV strains that cause cervical and anal cancer?

Answer 47

HPV 16 18 31

Question 48

pt has multiple myeloma and on bortezomib. What do you do?

Answer 48

**bortezomib** - has risk for herpes zoster reactivation so needs prophylaxis with **acyclovir.**

Question 49

man presents with scrotal swelling, pain, and dysuria. sexually active with both men and women. no prior trauma. Has fever, HR 101 and vital signs are normal. has right hemiscrotum that is edematous, tender to palpation of the superolateral aspect. scrotal pain lessens with elevation of scrotum. No penile discharge. NAAT of chlamydia and gonorrhea are pending. what to treat with?

Answer 49

Treat with **ceftriaxone + levofloxacin** pt has insertive anal sex. Need to cover for both chlamydia, gonorrhea, and enteric bacteria (of rectum) so need **levofloxacin** and not doxycycline.

Question 50

epididymitis symptoms

Answer 50

fever, erythema, swelling of the hemiscrotum and tendereness to palpation near epididymitis see urinary symptoms **Prehn's sign -** alleviation of pain with elevation of testicle or scrotum - supports epididymitis.

Question 51

what is the Prehn's sign?

Answer 51

**Prehn's sign -** alleviation of pain with elevation of testicle or scrotum - supports epididymitis. epididymitis has a bimodal distrubtion men \<35 yrs and \>55 years old. Men \<35 yrs STI from chlamydia and gonorrhea Men \>55 yrs those who practice insertive anal intercourse, E coli, enterobacteriaceae and pseudomonas.