Micro Images

Question 1

A patient complaining of discharge has this appearance on pelvic exam. How do you treat?

Answer 1

Metronidazole for pt AND PARTNER

(Frothy yellow discharge = trich = protozoa = metronidazole)

Question 2

Tx?

Answer 2

Cephalosporin + azithro or doxy to cover Chlamydia

(Ox + = GC)

Question 3

List at least two tests you would run on a patient with this finding.

Answer 3

US/CT/MRI looking for aortic aneurysm

Neurological tests

(This is a gumma of tertiary syphilis for which aortic aneurysms and dementia are common manifestations; serological testing is not very useful in this late stage)

Question 4

Complication of this condition?

Answer 4

Respiratory distress, causing a 3% mortality rate per year in patients with infantile laryngeal papillomas due to HPV

Question 5

Causative agent?

Answer 5

Chlamydia trachomatis L1-L3

(LGV)

Question 6

Pt presents with headache and fever. Culture of CSF reveals this finding. Dx?

Answer 6

HSV meningitis

(Cytopathic effect = HSV; presentation + ability to culture from CSF = meningitis; CSF culture usually negative if HSV encephalitis)

Question 7

Cytology of this lesion would reveal:

Answer 7

Multinucleated giant cells with inclusions

(Tzank cells; multiple vesicles on a red base = HSV)

Question 8

“Ouch, it hurts”.

Dx?

Answer 8

Chancroid

(H. ducreyi)

Question 9

This finding is unlikely in which stage of the disease caused by this organism?

Answer 9

Tertiary syphilis

(Dark field microscopy = T. pallidum; few spirochetes can be detected in lesions of tertiary syphilis)

Question 10

“It burns when I urinate.” Dx?

Answer 10

Ct urethritis

(Milky D/C + dysuria = Ct)

Question 11

A patient complaining of discharge has this finding on pelvic exam. What is the most appropriate diagnostic test?

Answer 11

Wet mount to look for trich

(Colpitis macularis = “strawberry cervix”; think trich!!)

Question 12

Which stage of life cycle is the organism in this image in?

Answer 12

Latency

(Koilocytes = HPV infected epithelial cells, which are non-permissive cells where HPV lies latent)

Question 13

How would you make a definitive diagnosis of the suspected organism?

Answer 13

KOH prep

(Vulvovaginal Candidiasis = budding yeast causing white discharge + diaper-rash appearance)

Question 14

What caused this?

Answer 14

Congenital HSV

(This is eczema herpeticum)

Question 15

What physical exam finding is unique among STDs to this disease?

Answer 15

Vulvar fissuring

(Caused by edematous response to Candida)

Question 16

Microscopic examination of this patient’s discharge would likely reveal:

Answer 16

Clue cells

Gram - rods (Gardnerella)

(White, adherent discharge coating the cervix = BV)

Question 17

Which cell type causes the lesion found here?

Answer 17

Keratinocytes

(HPV replicates in keratinocytes = permissive cells; latent in germinal cells = non-permissive cells)

Question 18

What would the causative agent of these lesions look like on gram stain?

Answer 18

Wouldn’t see it on gram stain

(Keratitis [inflammation of cornea] caused by congenital syphilis or HSV 1; T. pallidum too thin for gram stain = must use dark field microscopy; obviously HSV doesn’t gram stain)

Question 19

Dx?

Answer 19

Hutchison teeth due to congenital syphilis

Question 20

Your gynecology attending calls you into a room during a colposcopy to ask what you think of this finding. You say….

Answer 20

When treated with acetic acid and viewed with a colposcope, dysplastic cells become white, so this is likely cervical dysplasia, 90% of which is caused by HPV!

Question 21

A patient complains of a rash on his back and arms. PMH is non-contributory except he mentions he had a small “sore” on his penis a few months ago that didn’t bother him and went away fairly quickly. You decide to biopsy one of the lesions on his back to confirm your suspicion. What do you expect to see on gram stain?

Answer 21

Nothing!

(Syphilis does not gram stain; instead you would do dark field microscopy like the image)

Question 22

How would you treat this?

Answer 22

Removal

Question 23

Dx?

Answer 23

Chlamydia trachomatis

(Cytoplasmic inclusion bodies [vacuoles containing bugs] = Ct)

Question 24

This is a possible complication of which STD? How would the patient present?

Answer 24

Chlamydial cervicitis/urethritis (or LGV?)

Repetitive staccato cough, peripheral eosinophilia, no fever or wheezing

(Infantile pneumonia; notice bilateral infiltrates + hyperinflation)

Question 25

A female patient presents with severe pain and deformity of her hands. PMH is insignificant except a distant GC infection that was successfully treated. Xray reveals this finding. What is your diagnosis?

Answer 25

Reiter's syndrome (Aseptic arthritis that can follow Ct, GC, or bacterial enterocolitis infections)

Question 26

Dx?

Answer 26

Gingivostomatitis due to HSV 1

Question 27

Dx?

Answer 27

Verruca plana/HPV

Question 28

This finding is a common complication of:

Answer 28

Tertiary syphilis (Aortic aneurysm of ascending arch)

Question 29

Dx?

Answer 29

Congenital syphilis (Saber shins)

Question 30

A patient present with this finding and insists that it's nonpainful. How would you definitely diagnose it and what would be your subsequent treatment?

Answer 30

RPR/VDRL, FTA-Abs, dark field microscopy PCN (Nonpainful genital ulcer = syphilis until proven otherwise)

Question 31

Dx?

Answer 31

HSV encephalitis (Usually due to HSV 1; white areas = inflammed)

Question 32

The pH of this discharge would be:

Answer 32

\> 4.5 (Colpitis macularis [strawberry cervix] + frothy yellow discharge = trich]

Question 33

Tx?

Answer 33

PCN (Moth-eaten hair = secondary syphilis)

Question 34

How would you treat a patient with this finding on cytology?

Answer 34

Acyclovir or similar (Tzank smear - multinucleated giant cells with inclusions = **_HSV_**)

Question 35

"It burns when I urinate." Dx?

Answer 35

Gonococcal urethritis (Purulent D/C + dysuria = GC)

Question 36

PE finding?

Answer 36

Fish-smell discharge with KOH (Clue cells = epithelial cells with adherent **_Gardnerella_** = bacterial vaginosis)

Question 37

DDx?

Answer 37

GC Chlamydia (Ophthalmia neonatorum)

Question 38

What do you suspect is "tree man"'s condition?

Answer 38

Epidermodysplasia verruciformis (Genetic defect in cellular immunity leading to multiple warts on face, trunk, and limbs beginning in childhood)

Question 39

Presentation?

Answer 39

White, clumpy discharge Vulvar itching Vulvar erythema, edema, fissuring (Budding yeasts = Candida)

Question 40

Your patient's chart states he is in for an "ulcer" in his mouth. His vitals are 130/80, 38.5, 16, 82. When you go to shake his hand upon entering the room, you notice this.... What is the next step in management?

Answer 40

RPR or VDRL serological testing (Mucosal ulcer + fever + rash on hands indicates **_secondary syphilis_**; sensitive non-treponemal tests are performed initially then confirmed with more specific but expensive treponemal tests like FTA-abs tests)

Question 41

Inhibiting the process below would be an effective means of treatment for which of the sexually transmitted organisms we discussed?

Answer 41

GC, syphilis, H. ducreyi, Gardnerella (This is the MOA of beta-lactams; Ct = IC; Ureaplasma = no cell wall; rest are fungi or protozoa; remember Gardnerella is actually treated with metronidazole)

Question 42

Causative agent?

Answer 42

HSV 1 (Vesicles on erythematous base on finger = **_herpetic whitlow_** = HSV 1)