STI 1 and 2

Question 1

What are the 5 “P”s of taking a good sexual history?

Answer 1

partners
practices
protection from STDs
past STDs 
precaution of pregnancy

Question 2

Why is it important for all patients with an STD to be evaluated for HIV?

Answer 2

many STDs facilitate the transmission of HIV:
Chlamydia
Gonorrhoeae
BV
HSV 1,2
Syphilis
Chancroid
Granuloma inguinal (Klebsiella granluomatosis)

Question 3

Is the immunity due to prior infection durable in the case of STIs?

Answer 3

no, in general, prior infection does not protrect against re-infection

Question 4

Define cervicitis.

Answer 4

visible purulent endocervical exudate and/or sustained endocervical bleeding induced by gentle passage of a cotton swab through the cervical os

Question 5

Contrast the presentation of gonococcal and nongonococcal uretheritis.

Answer 5

gonococcal infection incubation is less than 4 days, presents with severe dysuria and the discharge is profuse yellow or green

NGU incubation is in the range of 7-14d, with mild dysuria and slight discharge that is gray (minor)

Question 6

Describe the diagnostic tests that would differentiate GU and NGU.

Answer 6

GU: gram stain shows many WBC with intracellular gram negative diplococci

NGU: gram stain shows WBC and no diplococci (suggestive for C. trachomatis)

both show > WBC per oil immersion or >10 WBC on first void UA of AM (alternate PCR of urethral swab or urine specimen)

Question 7

What is the standard tx. for GU and NGU.

Answer 7

GU: ceftriaone 250 IM plus: azithromycin 1000mg PO x1 OR doxycycline 100mg PO BIDx 7

NGU: Azithromycin 1g PO x1 or doxycycline 100mg BID x 7d

this regimen also treats for chlamydia

Question 8

What are the suite of recommendations that usually accompany STI treatment.

Answer 8

abstain from sex for 7d
notify partners for eval, tx and testing
test for other STDs including HIV
repeat testing recommended in 3-6mo

Question 9

What is the clinical presentation of mucopurulent cervicitis?

Answer 9

common that patient is asymptomatic, symptoms can include abnormal vaginal discharge and intermetnstrual bleeding (esp. after sex)

Question 10

Name important criteria and considerations for diagnosis of mucopurulent cervicitis?

Answer 10

at least one of the major diagnostic criteria: mucopurulent endocervical exudate or sustained endocervical bleeding induced by passage of a cotton swab

gram stain or NAAT of cervical, vaginal or urine specimens can be helpful

MUST ALWAYS evaluate for upper tract disease (PID)

Question 11

When is test of cure recommended in the treatment of mucopurulent cervicitis?

Answer 11

if the patient is pregnant

if the GC regimen did not include cefrtriaxone

Question 12

Which STI are women and men more likely to get based on gender

Answer 12

women 2.5x more likely to get Chlamydia
women have a higher incidence of Gonorrhea
men have a greater incidence of Syphilis

Question 13

What is the target for Chlamydia screening?

Answer 13

annal screening for women <25yo, highest rates seen in women ages 15-24

Question 14

Describe the pathogenesis of Chlamydia.

Answer 14

C. trachomatis is an intracellular bacterial pathogen that infects urethral, rectal, cervical, and upper reproductive tract epithelial cells, epidermal cells in men and conjunction and pulmonary columnar cells

C. trachomatis reproduces through and elementary (enters and /reticulate body lifecycle

Question 15

Contrast complication of Chlamydia in men and women

Answer 15

men: epidiymitis, prostatitis and reactive arthritis

Women: PID, tubal infertility, ectopic pregnancy, chronic pelvic pain

Question 16

Discuss the presentation of neonatal infection with chlamydia and its treatment.

Answer 16

Neonatal inclusion conjunctivitis occurs within 5-12d of birth and requires ORAL antibiotics

Neonatal C. trachomatis pneumonia occurs within 8 weeks of birth and requires ORAL antibiotics

perinatal screening can eliminate 90% of infections

Question 17

What is the standard treatment for chlmydia?

Answer 17

Azithromycin 1g PO x1
OR
Doxycycline 100mg PO BIDx7d

Question 18

Describe the risk of transmission man > woman vs. woman > man for gonorrhea

Answer 18

male > female 50-70% per exposure

female > male 20% per exposure

Question 19

Describe the gram stain of N. gonorrhea.

Answer 19

intracellular bacterial pathogen that is a diplococcus with prominent pilli

** it is important to gram stain and culture all sites of sexual contact

Question 20

Who is more likely to be asymptomatic with N. gonorrhoeae, men or women?

Answer 20

men <10% asymptomatic

women up to 80% asymptomatic

Question 21

Describe the symptoms of Pharyngeal and anorectal gonorrhea

Answer 21

pharyngeal gonorrhea is almost always asymptomatic

anorectal gonorrhea presents with pruritus, tenasmus, discharge and bleeding

Question 22

Describe the presentation of the two syndromes associated with disseminated gonoccocal infection.

Answer 22

1. Arthritits-Dermatitis: additive, asymmetric polyarthritis, papules and pustules on extremities
2. Septic Arthritis: usually involves 1 joint, often the knee

Question 23

How is gonococcal conjunctivitis prevented in newborns?

Answer 23

prevented at birth with erythromycin ointment, if not treated ophthalmia neonatorum can lead to blindness

associated symptoms include scalp abscesses, meningitis and bacterial sepsis

Question 24

What is the 1st line treatment of N. gonorrhea?

Answer 24

ceftriaxone 250 mg IM x1 + azithromycin 1000mg PO x1 or doxycycline 100mg PO BID x7d

alternate regimens replace ceftriaxone with cefixime (increasing resistance) or azithromycin 2g PO x1 followed by test of cure in those with cephalosporin allergy

DGI will require hospitalization and longer course of cephalosporins with antibiotic susceptibility testing

Question 25

Define pelvic inflammatory disease.

Answer 25

any combination of cervicitis, endometritis, salpingitis, turbo-ovarian abscess, and peritonitis including peri-hepatitis (Fitx-Hugh-Curtis Syndrome) classically a polymicrobial infection that can include C. trachomatis, N. gonorrhoeae + bacteria that are a normal part of the vaginal flora

Question 26

Name non-sexual causes of PID.

Answer 26

within the 1st three weeks of insertion of IUD | douching- changes the vaginal flora and forces bacteria into the upper reproductive tract

Question 27

Of women who are symptomatic (only ⅓ of those infected) what are symptoms of PID?

Answer 27

lower abdominal pain, fever, vaginal discharge with foul odor, dysuria, painful intercourse and peri hepatitis pain

Question 28

How is dx of PID made?

Answer 28

lineal diagnosis based on cervical motion tenderness or uterine tenderness or adnexal tenderness WITH WBC in vaginal secretion or mucopurulent cervititis

Question 29

What are the keys to management of PID given that the dx. is made clinically and is assumed to be polymicrobial? (2)

Answer 29

broad antibiotics are needed | antibiotics should be started as soon as dx.

Question 30

What are complication os PID and how can it be prevented?

Answer 30

tubal infertility (increases with #epidsodes) ectopic pregnancy chronic pelvic pain prevented by screening for chlamydia

Question 31

Describe the pathogenesis of BV

Answer 31

an undefined chance promotes the replacement of lactobacillus species (produces hydrogen peroxide) with high concentrations of G. vaginalis and other anaerobic bacteria apparent by the presence of clue cells (highly stippled cytoplasm)

Question 32

What is the presentation of BV?

Answer 32

vaginal discharge that is gray, whitish ad has a fish odor there is no inflammation of the vaginal was and endocervix (if present due to another cause- BC increases the risk for acquisition of other STI)

Question 33

How do you diagnose BV?

Answer 33

gram stain is the gold standard (notes the relative concentration of lactobacilli to other bacteria) which not often used in clinic Clinically meet 3 of 4 criteria 1. homogenous, thin, whitish gray discharge that coats vaginal walls 2. positive whiff test when KOH is added to vaginal discharge 3. vaginal pH >4.5 5. clue cell: vaginal epithelial cells coated with cocobacilli

Question 34

Who should be recommended treatment of BV and what is the management

Answer 34

all pregnant women should be treated- prevent PROM, early labor, preterm birth and postpartum endometritis; symptomatic women should be treated but male partners do not need to be treated metronidazole 500mg PO BID for 7d or metronidazole gell or clindamycin cream intravaginally QID 5-7d

Question 35

What organisms should be considered for genital ulcer disease?

Answer 35

``` H. ducreyi (Chancroid) K. granulates (Donovanosis) C. trachomatis (L1-3) T. palladium (Syphillis) HSV ```

Question 36

Contrast primary infection and non-primary 1st episode of HSV.

Answer 36

primary infection is usually asymptomatic or can include symptoms of 1st episode without antibodies non-primary 1st episode: fever, headache, malaise, myalgia, pain and itching, dysuria, tender inguinal adenopathy tender widely spaced bilateral ulcers in various stages (vesicles, pustules, ulcers) that develop over 4-10d

Question 37

How is HSV diagnosed?

Answer 37

usually by clinical appearance of lesion, can be confirmed by PCR, or type specific IgG antibodies culture will show cytopathic effects, Tzanch prep was used historically

Question 38

How is HSV treated

Answer 38

acyclovir, famciclovir and valacyclovir can be used as suppressive or episodic therapy- suppressive therapy decreases shedding and decreases but does not eliminate transmission

Question 39

What is the most important risk factor for neonatal transmission?

Answer 39

acquisition of primary HSV infection during pregnancy is the greatest risk to fetus- contact with infected secretion at birth can result in cutaneous lesions and invasion of the CNS to cause encephalitis new onset of HSV requires antiviral tx and lesions at the time of delivery indicates cesarian section targeted screening can be done for pregnant woman and partner

Question 40

Describe the pathogenesis of Syphilis.

Answer 40

T. palladium penetrates intact mucosa or gains access through abraded membranes it enters blood stream and lymphatics to disseminate throughout the body creates the classic obliterative endarteritis cutaneous lesions contain many oraganisms

Question 41

Describe the clinical manifestation of primary syphilis.

Answer 41

painless ulcer (chancre) that develops at the site of inoculation, associated with LAD within 90d of exposure and takes 2-8wks to heal

Question 42

Describe the clinical manifestation of secondary syphillis.

Answer 42

constitutional symptoms and lesions fever chills, malaise, poor appetite rashes: maculopaular or pustular rash (VERY INFECTIOUS), alopecia, mucous patches (mucosa) and condyloma lata (painless plaques in intertriginous areas) **key rash on palms and soles of the feet

Question 43

What is the difference between latent and tertiary syphilis?

Answer 43

latent syphilis onset after resolution of secondary syphilis (relapses occur in early latent> late latent) tertiary syphilis progresses to neural (tabies dorsalis) and vascular destruction; gummatous: granulomatous inflammation and destruction of tissue can effect the bones and mucocutaneous tissue

Question 44

Describe dianosis of syphilis.

Answer 44

darkfield shows spiral organism, serology remains the mainstay of dx.

Question 45

How do you treat syphilis?

Answer 45

penicillin is the drug of choice for all stages of syphillis, even those with penicillin allergy or pregnant women; duration of therapy depends on the stage of syphilis partners within 90d should be notified

Question 46

What is the gram stain of Chancroid? What is the clinical presentation

Answer 46

H. ducreyi is a gram negative coccobacillus that presents with painful ulcer with ragged and undermined edges that bleeds easily 50% will have enlarged inguinal LN (bubos) which can spontaneously rupture

Question 47

What is the clinical criteria for Chancroid and how is it treated?

Answer 47

all for dx: > 1 painful ulcer, appearance of ulcer c/w chancroid, no evidence of syphilis or HSV tx. with Azithromycin 1g PO x1 or ceftriaxone 250 mg IM x 1

Question 48

What is the organism and presentation of Granuloma inguinale?

Answer 48

Klebsiella granulomatis found largely in tropical regions presents with painless, beefy red ulcer with rolled edges and bleeds easily (no LAD, no bubos) untreated lesions can lead to extensive scarring

Question 49

How is Granuloma inguinale dx and how is it treated?

Answer 49

donavan bodies in mononclear cells is diagnostic, treat with doxycycline 100mg PO BID until all lesions are healed

Question 50

What is the organism and stages of lymphogranuloma venereum?

Answer 50

LGV is due to C. trachomatis, associated with groove sign stages 1. painless ulcer 2. bubo- mostly unilateral- groove sign, 3. scarring dx. clinically, with aspiration of bubo and serology; tx. with doxycyline for 21d

Question 51

Which subtypes of HPV cause integration of viral DS DNA into the host genome?

Answer 51

types 16 and 18 (oncogenic)

Question 52

What are symptoms of recurrent respriatory papilomatosis?

Answer 52

HPV 6 and 11 causes altered cry, hoarsness, stridor and respiratory distress

Question 53

List ectoparasites that can be transmitted sexually with their treatment.

Answer 53

pediculosis pubis: public lice- permethrin cream/ decontaminate clothing and bedding sarcoptes scabiei- scabies (note burrows)- treated with permethrin cream or ivermectin PO