STD's

Question 1

List the sexually transmitted diseases

Answer 1

Chlamydia
Ghonnorhea
Trichinomas vaginalis
PID
Genital herpes
Genital warts
HIV
Syphillis

Question 2

What causes genital herpes

Answer 2

Herpes simplex virus.

transmitted via skin-to-skin contact -vaginal, anal or oral sex

virus can lie dormant until it recurs later in life causing recurrent outbreaks.

Question 3

Pathophysiology behind genital herpes

Answer 3

Two types of HSV
HSV1: Genital & Oral herpes
HSV2: Genital herpes

HSV enters the body through small cracks in the skin or through the mucous membranes of mouth, vagina, rectum, urethra or under the foreskin.

After infecting the surface, the virus travels up the nearest nerve to the ganglion and remains there.

Remains dormant for long, as here it cannot be reached by the immune system.

During the reactivation of the virus, it travels back down the nerve onto the surface of the genitals once again to cause a symptomatic outbreak.

Question 4

How does HSV spread even when people are unaware of infection

Answer 4

Asymptomatic shedding

When the virus multiplies and becomes transmissible without stimulating an immune response from the host and thus no symptoms are present

HSV is notorious for this and up to 1/3 of all transmissions occur this way

Question 5

Risk Factors for genital herpes

Answer 5

multiple sexual partners

oral sex with a partner suffering from cold sores

Barrier contraception reduces risk but transmission is still possible especially by areas not covered by condoms e.g. THIGHS

Question 6

Sx of genital herpes

Answer 6

Primary infection symptoms

Secondary (recurrent) infection symptoms

Cold sores

Question 7

Primary infection symptoms of herpes

Answer 7

1)Small red blisters around the genitals that are very painful and can form open sores
HEAL AFTER 20 DAYS
-F: vulva, clitoris, buttocks and anus
-M: penis n same
2) Vaginal or penile discharge
3) Flu-like symptoms, fever, muscle aches
4) Itchy genitals

Question 8

Secondary (recurrent) infection symptoms of herpes

Answer 8

recurrent outbreaks are shorter and less severe and over time outbreaks usually reduce in severity and length.

due to antibody production increasing recognition of the virus and increasing the effectiveness of response.

1) Burning and itching around the genitals
2) Painful red blisters around the genitals

Question 9

Cold sores

Answer 9

They are mainly caused by HSV-1 and can be occasionally caused by HSV-2.

painful lesions around the mouth and nose that last between [[7-10 days]].

usually dormant with outbreaks occurring up to a few times a year.

If someone suffering from cold sores gives oral sex to a partner, the partner is at risk of contracting genital herpes as a result.

The dormant aspect of the infection means people may contract herpes from a partner without knowing. As a result this can make a diagnosis of genital herpes quite shocking and very difficult for a patient.

Question 10

Dx of genital herpes

Answer 10

Genital ulcer sx

1) aphthous ulcers
2) varicella-zoster virus
3) trauma

[[more than 5 outbreaks]] of genital herpes in one year

indicate a weakened immune system and therefore an underlying diagnosis of HIV.

Question 11

Dg of herpes

Answer 11

History
– sexual partners,
- history of cold sores
- history of any other STIs.

Swab from the open sore –

• This swab will be tested for the presence of HSV and - -PCR can differentiate between type 1 and 2.
• Even if this swab is negative, the diagnosis of herpes can still be made later on if flare-ups persist.

Other Sti
- screen for other possible std’s especially if history is suggestive

Question 12

Management of genital herpes

Answer 12

Primary infection

1) Aciclovir:: reducing the number and size of the lesions caused by HSV
2) sexual health advice
- no sex during outbreaks
- disclose it to recent/ current partners

Recurrent outbreaks

1) [[Episodic rx]] w/ aciclovir whenever outbreaks occur
2) Over the counter painkillers, petroleum jelly and ice packs

Over 5 outbreaks a year // Severe outbreaks
-Suppressive rx : daily doses of aciclovir to prevent new outbreaks.

Question 13

What happens to a woman with Genital herpes who gets pregnant

Answer 13

The mother should maintain rx w/ Aciclovir but the baby should be protected from acquiring the infection due to the antibodies she will pass to the foetus through the placenta.

c/S can be offered as the risk of the baby acquiring HSV transvaginally is 0-3%

Question 14

What happens if a mother contracts Herpes herself in the last trimester of pregnancy

Answer 14

more dangerous for the baby as the mother has not produced antibodies to pass onto the growing foetus.

baby is a lot more likely to contract herpes during vaginal birth (2/5 chance) and so a caesarean section is recommended in this circumstance.

Question 15

3 Forms of neonatal herpes

Answer 15

1) SEM:=skin, eyes and mouth herpes
2) DIS= disseminated herpes affecting the internal organs!
3) CNS herpes = affecting the nervous system and the brain and can lead to !!encephalitis!!

Aciclovir is sufficient for SEM herpes but mortality is estimated to be much higher for DIS and CNS herpes, especially if undiagnosed for some time.

Question 16

What are genital warts

Answer 16

benign epithelial or mucosal outgrowths caused by DNA human papilloma virus (HPV).

Question 17

How many types of HPV are there

Answer 17

over 100 types of the human papilloma virus, responsible for different types of warts.

More than 40 types of HPV have been associated with anogenital warts (condyloma acuminatum)

however HPV6 and HPV11 are responsible for roughly 90% of cases.

Question 18

Pathophysiology of genital warts

Answer 18

spread through skin-to-skin contact during vaginal and anal sexual intercourse,

however penetrative sex is not necessary for transmission!!
——In rare cases it can be passed on from the hand to genitals, during oral sex and to the neonate during delivery.

It is important to note that condoms do not fully protect against HPV as not all skin is covered e.g. the inner thighs just like herpes

virus penetrates the epithelial barrier and !!infects basal keratinocytes!!!.

Within the keratinocyte the virus replicates resulting in multiplication of the keratinocyte and this rapid growth manifests as lesions.

Question 19

Risk Factors for genital warts

Sim to other std’s and cervical cancer

Answer 19

Early age at first sexual intercourse
Multiple partners
Immunosuppression
Smoking
Diabetes associated with persistence of warts

Question 20

Clinical Features of genital warts

Answer 20

Onset of weeks to years
painless, fleshy growths that can be soft or hard and can be singular or multiple.

Can also cause extragenital lesions in oral cavity, larynx, conjunctivae and the nasal cavity.

Most are assyx and spontaneously resolve

Question 21

Dx of genital warts

Answer 21

Vestibular papillomatosis:
-projections of the vestibular epithelium or labia minora
Dx sx: non-viral and not sexually transmitted
Dx dg: Application of acetic acid does not change their colour – HPV lesions turn whitish.

Molluscum contagiosum: viral infection causing small firm raised papules on the skin.

Question 22

What is vestibular papilomatosis

Answer 22

https://www.healthline.com/health/vestibular-papillomatosis

Question 23

Dg work up of genital warts

Answer 23

Colposcopy and biopsy IF neoplasms suggested

Vaginal speculum

Proctoscopy - Anal lesions

Question 24

Rx of genital warts

Answer 24

Lesion usually resolve especially postpartum

2 types: Topical rx & Physical ablation

Question 25

Topical rx

Answer 25

Podophyllotoxin: twice daily for 3 days followed by 4 days rest (4-5 cycles) Clusters of small warts, better for non-keratinised lesions Imiquimod: 3 times weekly and wash off after 6-10 hours (up to 16 wks) Larger warts, particularly keratinised warts

Question 26

C.I on topical rx of warts

Answer 26

Topical treatments may weaken latex condoms. They are also contraindicated in pregnancy and breastfeeding, and may cause local inflammation.

Question 27

Physical ablation for rx of warts

Answer 27

Excision: Pedunculated/large warts or small hard warts -surgical removal under local anaesthetic Cryotherapy: Multiple small warts -freezing using liquid nitrogen usually repeated weekly (consider alternative treatment if no response after 4 weeks) Electrosurgery: Large warts that have failed to respond to topical treatment -excision removes the majority of the wart and then an electric current is passed through a metal loop pressed against the wart to remove any remaining part Laser surgery: Difficult to access warts e.g. inside the anus -a laser is used to burn the warts under local or general anaesthetic.

Question 28

Vaccination against HPV

Answer 28

HPV vaccine is offered to all girls aged 12-13. This was introduced in 2008 and the vaccine originally protected against the high risk HPV types 16 and 18, however since 2012 the vaccine Gardasil® additionally protects against the most common types HPV 6 and 11. The vaccine is most beneficial if administered before first sexual contact. It is argued that only immunising females will not necessarily protect males and herd immunity will not apply to men who have sex with men. In some countries, Gardasil is administered to both males and females.

Question 29

How does HPV affect pregnancy

Answer 29

HPV is not associated with miscarriage, premature birth or other pregnancy complications. due to the hormonal changes associated with pregnancy, genital warts may multiply or enlarge. Treatment is to reduce the burden of lesions so that during childbirth the neonate’s exposure is reduced. physical ablation methods are preferred during pregnancy .

Question 30

Can HPV be transmitted to the baby

Answer 30

The risk of transmission to the neonate during birth is extremely low If transmission does occur then the immune system will usually clear the virus in rare cases the baby may develop respiratory papillomatosis!!! where genital warts develop in the throat.

Question 31

What is HIV

Answer 31

human immunodeficiency virus (HIV). a single stranded RNA retrovirus that infects and replicates within the human immune system using host [[CD4]] cells. Without treatment, destruction of the immune system can lead to acquired immune deficiency syndrome (AIDS).

Question 32

Pathophysiology of HIV

Answer 32

penetrates the host CD4 cell and empties its contents. viral RNA are converted into double stranded DNA by reverse transcriptase, and combined with the host DNA using the enzyme integrase. The viral DNA is read, creating viral protein chains and the immature virus pushes out of the cell [retaining some cell membrane] virus becomes mature when the protease cuts the viral protein chains, to create a working virus. The t helper cell is destroyed during this process.

Question 33

What changes viral RNA. To DNA in Host CD4 cells

Answer 33

reverse transcriptase

Question 34

What enzyme integrates viral DNA into host DNA after conversion

Answer 34

enzyme integrase.

Question 35

What enzyme causes the maturation of the HIV virus

Answer 35

Protease during the cleavage of viral proteins and subsequent death of CD4 cells

Question 36

How do CD4 levels change in response to HIV A normal range for CD4 cells is about 500-1,500.

Answer 36

Initial phase -CD4 levels fall in response to the initial, rapid replication of HIV – and at this stage a person is extremely infectious. This is marked by flu like symptoms d/2 seroconversion Latent phase begins after months- years -patientinitially be asymptomatic, but with CD4 levels falling and viral load increasing, they may become more susceptible to infections and can later become symptomatic AIDS - over an average of 10 years, - CD4 drops to below 200

Question 37

What are the four ways HIV is transmitted

Answer 37

Unprotected sexual contact – vaginal, anal or oral. Sharing of injecting equipment. Medical procedures – blood products, skin grafts, organ donation and artificial insemination. Vertical transmission – from mother to child in utero, during childbirth or breast feeding.

Question 38

Risk groups for HIV

Answer 38

Men who have sex with men Intravenous drug users Those in high prevalence areas Those who have had unprotected sex with a partner who has lived or travelled in Africa

Question 39

Classification of Sx of HIV

Answer 39

Seroconversion Illness Symptomatic HIV AIDS sx

Question 40

List the seroconversion illness sx

Answer 40

2-6 weeks after exposure, patients may experience a non-specific, flu-like illness. Features include: ``` Fever Muscle aches Malaise Lymphadenopathy Maculopapular rash Pharyngitis ``` Latent phase follows

Question 41

List the sx of symptomatic HIV

Answer 41

After the latent phase Weight loss High temperatures Diarrhoea Frequent minor opportunistic infections, e.g. herpes zoster or candidiasis

Question 42

AIDS defining illnesses

Answer 42

pnuemocystis jiroveci pnuemonia, non-Hodgkin’s lymphoma, TB.

Question 43

Dg work up of HIV

Answer 43

ELISA test for serum/salivary HIV antibodies and p24 antigen. give reliable results 4-6 weeks after exposure.

Question 44

Rx of HIV

Answer 44

Highly active antiretroviral therapy (HAART) - does not cure HIV, but aims to reduce the viral load to undetectable levels in the serum. - patient must keep taking the drugs for the rest of their lives. Non-adherence to HAART can result in resistance mutations which make treatment difficult or impossible. Combination drugs classes combine to 1x/day tablets: nucleoside reverse transcriptase inhibitors (NRTIs) protease inhibitors (PIs) non-nucleoside reverse transcriptase inhibitors (NNRTIs) integrase strand transfer inhibitors (InSTIs) Psychological support Regular monitoring POST EXPOSURE PROPHYLAXIS

Question 45

Which regular tests are included in HIV monitoring

Answer 45

``` CD4 count HIV viral load FBC Urinalysis ALT, AST and bilirubin Patients may also require pregnancy testing, and in treatment failure, resistance testing. ```

Question 46

What is post exposure prophylaxis

Answer 46

Rx for when a pt has as suspects exposure to the HIV within the last 72 hrs to lower the risk of becoming infected. 1 month course of Truvada (one tablet daily) + Raltegravir (one tablet twice daily)

Question 47

Can HIV be transmitted to the baby ?

Answer 47

Yes. It can be transmitted in utero Can be transmitted during delivery and transmitted during through breastfeeding.

Question 48

How is HIV transmission to the baby prevented

Answer 48

Antenatal antiretroviral therapy during pregnancy and delivery Avoidance of breastfeeding Neonatal post-exposure prophylaxis

Question 49

Can HIV mothers deliver transvaginally

Answer 49

yes if the serum load is undetectable in the mother

Question 50

what is the risk of transission to the baby w/ and w/o rx

Answer 50

w/ rx adherance: <1%. w/o rx: greater than 1 in 4

Question 51

what is syphillis

Answer 51

exually transmitted infection caused by the spirochete gram-negative bacterium Treponema pallidum subspecies pallidum.

Question 52

types of syphillis

Answer 52

Other subspecies of Treponemes are responsible for non-sexually transmitted diseases such as Bejel, a chronic skin and tissue disease, Yaws, a disease of the bones and joints, and Pinta, a skin disease. Unlike syphilis, these diseases are transmitted by any close contact (sexual or not) and do not pass from mother to fetus.

Question 53

pathophys of syphillis

Answer 53

1)primary syphilis occurs when -motile Treponema pallidum enters through a break in the skin or through intact mucous membranes. The bacteria divide and an infectious hard ulcer (CHANCRE) subsequently forms at the site of contact after an incubation period of 2-3 weeks. This is the first stage of acquired symptomatic syphilis:. If left untreated, T. pallidum can persist and cause systemic damage via OBLITERATING ARTERITIS This is where endothelial cells of the vessels excessively proliferate causing the lumen of the vessels to become narrowed. This can then result in ischaemia at the tissues supplied by these arteries which leads to the symptoms associated with syphilis.

Question 54

sx of syphillis classification

Answer 54

congenital acquired : early (up to 2 years) / late - assyx(latent) - sxxx 1) primary 2) secondary 3) tertiary

Question 55

dg of syphillis

Answer 55

Dark ground microscopy of chancre fluid- detects spirochaete in primary syphilis PCR testing of swab from active lesion Serology: 1) Treponemal tests – assess for exposure to treponemes necessarily syphilis) - Treponemal ELISA (IgG/IgM) – remains positive for life - TPPA or TPHA – remain positive for life 2) Non-treponemal tests: - RPR/VDRL: rises in early disease; falling titres indicate successful treatment or progression to late disease. False positives can occur in inflammatory conditions or during pregnancy. - Lumbar puncture: CSF antibody tests in neurosyphilis

Question 56

rx of syphillis

Answer 56

Penicillin is the treatment of choice. others - avoid sexual contact of any kind, or exposure of other people to active lesions until the condition has been successfully treated - Contact tracing (ppl recently contacted) - Screening for other STIs - Follow-up serology to determine response to treatment

Question 57

what is Jarisch Herxheimer reaction!!!!

Answer 57

inflammatory response secondary to death of treponemes, and results in a flu-like illness within 24 hours of treatment supportive measures suff neuro/cardivascular syph: oral steroids

Question 58

preg of syphillis

Answer 58

antenatal syphillis screening should be done as it can be transferred to the fetus causing 1. miscarriage 2. stillbirth 3. pre-term labour 4. Congenital syphilis

Question 59

spread of syphillis

Answer 59

sexual transmission, the infection can also be transmitted from mother to fetus via the placenta (congenital syphilis) and through infected blood products.

Question 60

rf of syphillis

Answer 60

Engaging in unprotected sex – especially with high risk partners. Multiple sexual partners. Men who have sex with men (MSM). HIV infection.

Question 61

primary syphillis

Answer 61

1) papule (slightly elevated lesion with no fluid) will appear before ulcerating into a CHANCRE at the site of inoculation - a painless singular, hard and non-itchy ulcer - typically develops 9-90 days post infection on a genital site e.g. penis, scrotum, anus, rectum, labia or cervix. However, chancres may be atypical in that they can appear at other sites e.g. oral, be multiple and painful. Classically chancres

Question 62

when does a chancre heal

Answer 62

heal within 3-10 weeks with or without symptoms but may persist during secondary syphilis.

Question 63

when does Secondary syphilis occur

Answer 63

develops 3 months post infection

Question 64

sx of Secondary syphilis

Answer 64

Skin rash – hands and soles of the feet (not usually itchy or painful) Fever Malaise Arthralgia Weight loss Headaches Condylomata lata- elevated plaques like warts at moist areas of skin e.g. inner thighs, anogenital region, axillae Painless lymphadenopathy Silvery-gray mucous membrane lesions – oral, pharyngeal, genital

Question 65

what phase comes immediatley after secondary syphillis

Answer 65

LATENT PHASE comes after secondary phase

Question 66

Tertiary syphilis | 3 subtypes

Answer 66

gummatous syphilis, neurosyphilis cardiovascular syphilis

Question 67

what is Gummatous syphilis

Answer 67

Granulomas can form in bone, skin, mucous membranes of the upper respiratory tract, mouth and viscera or connective tissue e.g. lung, liver, testis. Patients at this stage are non-infectious.

Question 68

what is Neurosyphilis

Answer 68

Tabes dorsalis – ataxia, numb legs, absence of deep tendon reflexes, lightning pains, loss of pain and temperature sensation, skin and joint damage. Dementia – cognitive impairment, mood alterations, psychosis. Meningovascular complications – cranial nerve palsies, stroke, cerebral gummas. Argyll Robertson pupil – pupil is constricted and unreactive to light, but reacts to accommodation.

Question 69

what is Cardiovascular syphilis:

Answer 69

Aortic regurgitation due to aortic valvulitis (diastolic murmur), also aortic root dilatation. Angina due to stenosis of the coronary ostia. Dilation and calcification of the ascending aorta.

Question 70

how do you treat syphillis in pts w/ peniccilin allergy

Answer 70

advise penicillin desensitisation

Question 71

rx for early syph

Answer 71

Benzathine penicillin 2.4 MU IM single dose.

Question 72

rx for late syph

Answer 72

Benzathine penicillin 2.4 MU IM 3 doses at weekly intervals

Question 73

rx for neurosyphillis

Answer 73

Procaine penicillin or Benzylpenicillin

Question 74

what is the presentation of Congenital syphillis

Answer 74

saddle nose, rashes, fever and failure to gain weight.

Question 75

list the non treponemal tests

Answer 75

VDRL: rises in early disease; falling titres indicate successful treatment or progression to late disease. False positives can occur in inflammatory conditions or during pregnancy. -Lumbar puncture: CSF antibody tests in neurosyphilis

Question 76

what is the venereal disease research laboratory (VDRL) test

Answer 76

checks for the antibodies your body makes in response to antigens produced by cells damaged by the bacteria

Question 77

What is a rapid plasma reagin (RPR) test?

Answer 77

detecting the nonspecific antibodies that your body produces while fighting the infection

Question 78

what is the Treponema pallidum particle agglutination assay (TPPA test)

Answer 78

indirect agglutination assay used for detection and titration of antibodies against the causative agent of syphilis,