STDs

Question 1

Treponema pallidum (Syphilis)

Answer 1

STD Specifics: * Ulcers
Features:”* Microaerophile
* Spirochete
*No LPS
*Motile
Cannot be cultured
* Slow growth rate
* Incubation period = 3-90 days (med 3 wk)”
Diseases/Symptoms:
“ Primary: single chancre that heals within 3-6 wk (not always painful, painful w secondary infection), reg lymphadenopathy
*Secondary: (2-6 mo after primary or 2-10 wk after primary chancre) generalized lymphadenopathy, iritis, optic neuritis, uveitis, recurrent eruptions, maculopapular rash, condyloma lata
* Latent: Positive Ab test, but no clinical symptoms
- Early (< 1 yr): infectious, relapses
- Late (>1 yr): resistance to reinfection, but can pass on to fetus or via transfused blood
* Tertiary/Late: inflammatory disease that can affect any organ 1-20 yr after initial infection; NOT infectious
- CV: Aneurysm of ascending aorta
- Gummatous: gummas form
- Leutic periostitis: inflammation of periosteum
*Early Neurosyphilis: first year after infection; HA, confusion, stiff neck, impaired vision, meningovascular
* Late Neurosyphilis: Decades later; paresis (loss of voluntary movement), dementia, tabes dorsalis, incontinence”
Diagnosis:
“Direct Visualization
* Darkfield microscopy
* Immunofluorescent stain of lesions (not oral, naturally occuring bacteria can cause false pos)

Serology
* RPR (non-treponemal)
* VDRL: Measures IgM/IgG against Ag complex; Ab titers correlate with disease activity (non-treponemal)
* FTA-Abs/TP-PA: measures Ab against T pallidum Ag; used to verify non-trep tests; pts usually remain pos for life”
Treatment:
“*Penicillin (IV form to treat neurosyphilis)
* Doxycycline (if allergic to penicillin)

Tx of partner
*Within 90 days of diagnosis: tx with penicillin even w neg result (same w late latent disease but high titer in partner)
*> 90 days: no tx with neg result
* Long term partners of those with late latent: evaluate serologically & clinically

F/U
*Titers should show 4 fold decrease in 6-12 mo”

Question 2

Haemophilus ducreyi/Chancroid

Answer 2

STD Specifics: “Ulcers, PID”
Features:Chancroid: PAINFUL genital ulcer & tender suppurative inguinal lymphadenopathy
Diseases/Symptoms: “ Microscopy/Ag detection are NOT sensitive nor specific &PCR is NOT FDA approved

All of the following met:
1+ painful ulcers
* Darkfield & serology negative for syphilis
* Negative HSV (ulcer exudate)
* Clinical presentation of genital ulcer + adenopathy”
Diagnosis:
“ Azithromycin, ceftriaxone, ciprofloxacin, erythromycin
* Sex partners should be examined & treated if sexual contact w pt 10 days preceding onset of symptoms”
Treatment:

Question 3

“Klebsiella granulomatis
(Granuloma inguinale/ Donovanosis)”

Answer 3

STD Specifics: Ulcers
Features:”* Intracellular
* Difficult to culture
*Donovan bodies
* Endemic to tropical & developing areas”
Diseases/Symptoms: “Granuloma Inguinale (Donovanosis): PAINLESS, slowly progressive ulcers on genitals or perineum without regional lymphadenopathy
* Subcutaneous granulomas (pseudouboes)
* Highly vascular lesions that bleed easily
*Can present as hypertrophic, necrotic or sclerotic
*Extragenital extension to pelvis, intra-abdominal organs, bones, mouth”
Diagnosis:
* Visualization of Donovan bodies on crush specimen or biopsy
Treatment:
*Azithromycin, doxcycline, cipro, erythro, TMP-SMX for at least 3 wk

Question 4

“Chlamydia trachomatis L1-L3
(LGV)”

Answer 4

STD Specifics:
“*Ulcers
* Urethritis
*Cervicitis
*PID
Epididymitis”
Features:
“ Aerobe
*No peptidoglycan
*Non-motile
*Ob intracellular
* Giemsa stain”
Diseases/Symptoms:
“Lymphogranuloma Venereum (LGV): L1, L2, L3
*Self-limited papule/ulcer
* Inguinal or femoral lymphadenopathy (unilateral)
* Rectal exposure can result in proctocolitis

• Urethritis: discharge, dysuria, pruritus
  Cervicitis: discharge, intermenstrual bleeding”
  Diagnosis:
  “ Genital/LN specimens can be cultured, direct immunofluorescence, NAAT
  Serology”
  Treatment:
  “LGV: Doxycycline
• Urethritis:Azithromycin or doxycycline
  *Pregnant: Azithromycin only”

Question 5

HSV-1/2

Answer 5

STD Specifics:
“*Ulcers
*Cervicitis”
Features:
“Herpes Virus Family

• dsDNA, linear
  *Enveloped
  *Cowdry bodies: Intranuclear eosinophilic inclusion bodies (also in CMV/VZV)
• Tzank smear w multinucleated giant cells (same as VZV)”
  Diseases/Symptoms:
  “Above the waist (1) symptoms vs below the waist (2)
  Herpetic whitlow: painful hand vesicle/wart; common in dentists

Genital Herpes:
* Most with HIV-2 have not been diagnosed with genital herpes, but shed virus in genital tract
HSV-1 increasing in first episodes of anogenital herpes (MSM, young women)
Cervicitis: discharge, intermenstrual bleeding”
Diagnosis:
“ PCR (gold standard)
* Cell culture has low sensitivity that declines as healing occurs
* Cowdry intranuclear inclusion bodies”
Treatment:
“*First episode: Acyclovir, Famcyclovir, or Valacyclovir (10 day course, extend if healing incomplete)
*Recurrent: Higher doses of above antivirals for shorter courses
* Suppressive therapy: reduces frequency of recurrence”

Question 6

Gonorrhea

Answer 6

STD Specifics:
“Urethritis
* Cervicitis
* PID
* Epidydimitis”
Features:
“ Aerobe
*Non-motile
* Non spore forming
* Oxidase +
*Kidney bean shape
*Varies surface antigens”
Diseases/Symptoms:
“Gonorrhea:
* Women more asymptomatic than men
* Can cause disseminated disease
* Urethritis: discharge, dysuria, pruritus
*Cervicitis: discharge, intermenstrual bleeding”
Diagnosis:
Cervicitis: gram stain, wet mount, NAAT, culture, PCR
Treatment:
“ Ceftriaxone (uncomplicated GC of cervix, urethra, rectum)
*Doxyclcine for chlamydia if not excluded”

Question 7

Trichomonas vaginalis

Answer 7

STD Specifics:
“*Urethritis
*Cervicitis
*Vaginal discharge”
Features:
Diseases/Symptoms:
“Trichomoniasis: Itching, burning, pain on intercourse, thick yellow-green discharge, vulvar or vaginal redness; 80% women symptomatic, men usually asymptomatic

• Men: Urethritis w discharge, dysuria, pruritus
• Women:Cervicitis w foul smelling discharge, intermenstrual bleeding (strawberry cervix)”
  Diagnosis:
  Wet mound (motile trophozoites), Pelvic exam (strawberry cervix with punctate hemorrhages)
  Treatment:
  Metronidazole (pt + partner)

Question 8

Vulvovaginal candidiasis

Answer 8

STD Specifics:
Vaginal discharge
Features:
“Vaginal infections do not occur when pH > 4
* Dimorphic* (opp)
*Yeast w/ pseudohyphae at cold temp
Mold w/ germ tubes & true hyphae at warm temp”
Diseases/Symptoms:
“Thick white discharge
* Pruritus
* Edema
* Excoriations”
Diagnosis:
KOH wet mount
Treatment:
“ Fluconazole
*Intravaginal antifungals”

Question 9

HPV

Answer 9

STD Specifics:
Epididymitis
Features:
“ dsDNA
* Naked
circular genome
* > 100 types (most important are 6, 11, 16, 18, 31, 33)
* Predilection for stratified squamous epithelium”
Diseases/Symptoms:
“Most common STD; Most infections are self-limited, asymptomatic or unrecognized
* Oncogenic or high risk infection are responsible for cervical, penile, vulvar, vaginal & oropharyngeal cancers + precancers
* Condyloma acuminatum: non-oncogenic (HPV 6, 11)”
Diagnosis:
“* Pap smear: cervical cancer screening; sample cervical cells from transformation zone where outer squamous meet inner columnar
Koilocytes: Large, dense, wrinkled nucleus w perinuclear halos”
Treatment:
“Condyloma acuminatum: Imiquimod, podophyllin, trichloroacetic acid, cryotherapy or surgery

• Gardasil Vaccine: inactivated subunit that treats HIV 6, 11, 16, 18 to prevent STDs by targetting capsid proteins (9-45 yo)
  
  • HPV L1: capsid protein; Ag used
  • 11-12 yo: 2 doses (6-12 mo), can start at 9 yo
  • 15+ yo: 3 doses”

Question 10

Pelvic Inflammatory Disease (PID)

Answer 10

STD Specifics:
“*STDs (GC, chlamydia)
*Vaginal flora (anaerobes, G. vaginalis, H. influenzae, GBS, GN rods)”
Features:
Diseases/Symptoms:
“Spectrum of inflammatory disorders of upper female genital tract
* Abnormal bleeding
*Dyspareunia
* Vaginal discharge
*Cervical motion, uterine or adnexal tenderness”
Diagnosis:
Treatment:
*Ceftriaxone + doxycycline

Question 11

Bacterial Vaginosis

Answer 11

STD Specifics:
“* Polymicrobial clinical syndrome
* Lactobacillus replaced with anaerobic organisms”
Features:
Diseases/Symptoms:
“*Homogenous, thin, white discharge coating vaginal walls
* Clue cell: squamous epithelial cell coated with bacteria
*pH > 4.5
Fishy odor (KOH Whiff test)”
Diagnosis:
“ Gram stain/wet mount
Clinical criteria (at least 3 of the symptoms)”
Treatment: Metronidazole or clindamycin cream intravaginally

Question 12

Epididymitis

Answer 12

STD Specifics:
“N. gonorrhoeae
* C. trachomatis
* Enteric organisms”
Features:
Diseases/Symptoms:
“Unilateral testicular pain & tenderness
* Hydrocele & palpable swelling of epidymis
* Tender/swollen spermatic cord”
Diagnosis:
Treatment:“*Ceftriaxone + doxycycline (GC + chlamydia)
*Levofloxacin (enteric)”