STI II

Question 1

Cervicitis

Answer 1

Characterised by mucopurulent discharge from the endocaervical canal plus inflamed, edematous, friable ectropian.

Commonly associated with coexisting urethral infection, and with a history of dysuria.

Question 2

Cervicitis caustive organisms

Answer 2

• Chlamydia trachomatis D-K serovars* (most common)
• Gonococcalinfection
• HSV
• Trichomonas vaginalis
• Anaerobes

Question 3

Specimen collection for cervicitis

Answer 3

• High vaginal swab
• Endocervical swab (+/- urethral swab)
• Collect first pass urine for PCR

Question 4

Urethritis

Answer 4

Characterised by urethral discharge and meatal inflammation

Question 5

Urethritis causative organisms

Answer 5

– Gonococcus
– Chlamydia trachomatis
– And others
• Ureaplasma urealyticum 
• Mycoplasmahominis
• Trichomonas vaginalis
• HSV

Question 6

Urethritis specimen collection

Answer 6

• Urethral; +/- pharyngeal; and anorectal swabs

* First pass urine (for PCR)

Question 7

PID definition

Answer 7

Inflammation and infection of the upper genital tract in women, typically involving the endometrium, fallopian tubes, ovaries and surrounding structures.

Question 8

PID aetiology

Answer 8

• Ascending spread of micro-organisms from the vagina or cervix to the upper genital tract
• Common causative agents: C. trachomatis (+/- N. gonorrhoeae); hence, often polymicrobial flora*

Question 9

Causes of non surgically-acquired PID

Answer 9

Increase susceptibility to endogenous vaginal flora following mechanical disruption of the cervical barrier by:
Pregnancy termination; delivery; surgical procedures, or following insertion of IUCD (intra uterine contraceptive device)

Question 10

PID clinical symptoms

Answer 10

– Lower abdo pain/ discomfort
– Vaginal discharge
– Abnormal vaginal bleeding
– Dyspareunia (pain on intercourse)
– Nausea (severe disease)

Question 11

PID complications

Answer 11

– 20% infertility
– 20% chronic pelvic pain
– 10% ectopic pregnancy

Question 12

PID clinical signs

Answer 12

– Lower abdo tenderness/ guarding/rebound
– Adnexal tenderness
– Cervical motion tenderness
– Raised temperature

Question 13

Neisseria spp.

Answer 13

Gram negative, aerobic, cocci (diplococci)

Question 14

Neisseria gonorrhoea epidemiology and transmission

Answer 14

• Occurs naturally only in humans
• Infection rates: males = females
• Peak incidence of infection: 15 to 24 years of age
• Asymptomatic carriers are a major reservoir
– Half of infected women are symptomatic
– Most infected men are symptomatic
• Carrier state also dependent on site of infection:
– Rectal and pharyngeal infections are more likely to be asymptomatic

Question 15

Risk factors associated with Neisseria gonorrhoea infection

Answer 15

• Low socio-economic status
• Urban residence
• Unmarried status
• Race/Ethnicity
• Men who have sex with men (MSM)
• Prostitution
• History of STDs
• Hormonal contraception
• Unprotected intercourse - Male: 20% single exposure 80% multiple exposures. Female: >80% single exposure
• High risk partners
• Drug use

Question 16

Presentation Neisseria gonorrhoea in males

Answer 16

After 2-7 days (range 1-14 days) incubation, symptoms and signs include:
– Urethritis (+ discharge 90-95%)
– Dysuria
– Asymptomatic (5%)
– Ascending infection* (10%; see next slide)

Question 17

Presentation Neisseria gonorrhoea in women

Answer 17

After ~ 8-10 days incubation, symptoms and signs include:
– Cervicitis (+ thin, purulent, unpleasant smelling discharge 20-75%)
– Urethritis (70-90%)
– Bartholin’s gland infection (30%)
– Abdominal/pelvic pain
– Abnormal intra-menstrual bleeds
– Ascending infection* (10-20%; see next slide )
– NOTE: symptoms and signs can mimic thrush/cystitis

Question 18

Complications of Neisseria gonorrhoea in men

Answer 18

Ascending infection:
– Epididymitis 
– Prostatitis
– Urethral stricture
– Periurethral abscess

Question 19

Complications of Neisseria gonorrhoea in women

Answer 19

Ascending infection often results in PID (pelvic inflammatory disease) associated with:
– Salpingitis
– Endometritis
– Tubo-ovarian abscess
(ectopic pregnancy)

Question 20

Gonococcemia

Answer 20

Complication of Neisseria gonorrhoea (septicaemia). It causes disseminated infections of the skin and joints (1-3% of infected women, and much lower percentage of infected
men)

Symptoms and signs include:
– Fever
– Migratory arthalgias
– Suppurative arthritis in the wrists, knees, and ankles
– Pustular rash on an erythmatous base over the extremeties but not on head and trunk

Question 21

ophthalmia neonatorum

Answer 21

Complication of Neisseria Gonorrhoea. Purulent conjunctivitis in newborns infected during vaginal delivery

Question 22

Anorectal gonorrhoea

Answer 22

Complication of gonorrhoea. Commonly MSWM.

Question 23

Neisseria gonorrhoea laboratory diagnosis

Answer 23

For culture: specimens collected by swabbing the cervix, urethra, rectum, and throat
Important : use Dacron or rayon swabs NOT calcium alginate (toxins) or cotton
Transport medium is usually chocolate agar with swift delivery to the lab
Do NOT refrigerate

First pass urine for PCR

Question 24

Chlamydia trachomatis

Answer 24

Infections restricted to humans

Question 25

Chlamydia trachomatis clinical manifestations

Answer 25

1. Trachoma (chronic keratoconjunctivitis) 2. Adult inclusion conjunctivitis 3. Neonatal conjunctivitis 4. Infant pneumonia 5. Urogenital infections (females) 6. Urogenital infection (men) 7. Lymphogranuloma venereum (LGV)

Question 26

Chronic keratoconjunctivitis (trachoma)

Answer 26

C. trachomatis Leading cause of blindness in endemic areas, including North and sub-saharan Africa; Middle- east; Southern Asia; and South America ``` Predominantly affects young children Transmitted via: • Eye to eye by droplets • Contaminated hands, clothing • Flies • Respiratory droplets and faeces ```

Question 27

Adult inclusion conjunctivitis

Answer 27

C. trachomatis • Occurs in people ~ 18- 30 years old • Genital infection usually precedes eye involvement • Transmission is thought to occur via auto- inoculation Characterised by mucopurulent discharge; keratitis, and corneal scarring over time.

Question 28

Neonatal conjunctivitis

Answer 28

C. trachomatis ``` Acquired during passage of the infant through infected birth canal After 5 to 12 days of incubation: – Eyelids swell – Hyperemia – Copious purulent discharge ```

Question 29

Infant pneumonia

Answer 29

C. trachomatis * Onset usually 2 to 3 weeks after birth, characterised by: * Rhinitis * Staccato cough * Afebrile throughout illness * Radiographic signs of infection can persist for months

Question 30

Urogenital infections with C. trachomatis clinical symptoms in women

Answer 30

``` 80% infected women are asymptomatic; when symptomatic: – Bartholinitis – Cervicitis – Endometritis – Perihepatitis – Proctitis – Salpingitis – Urethritis (can occur with or without concurrent cervical infection often associated with mucopurulent discharge) ```

Question 31

Urogenital infections with C. trachomatis clinical symptoms in men

Answer 31

* Most often symptomatic * Urethritis with purulent discharge * Proctitis * Reiter’s syndrome (urethritis;; conjunctivitis;; polyarthritis; and mucocutaneous lesions)

Question 32

Lymphogranuloma venereum (LGV)

Answer 32

``` 1st Stage (1 to 4 weeks after infection) characterised by: • Painless lesion (papule or ulcer) at site of infection (penis; urethra; scrotum; vaginal wall; endocervix, and vulva) ``` 2nd Stage (1 to 4 weeks after infection) characterised by: • Swelling and inflammation of lymph nodes • Infected lymph nodes can be painful giving rise to fluctuant buboes that can enlarge and rupture Systemic symptoms characterised by: • Fever • Chills • Headache, myalgias, arthralgias

Question 33

C. trachomatis laboratory diagnosis

Answer 33

* Specimens: collected from site of infection (urethra; endocervix; rectum; oropharynx, and conjunctiva) * PCR- amplification of specific sequence of the 16S ribosomal RNA

Question 34

Non-gonococcal urethritis (NGU)

Answer 34

Mycoplasma and ureplasma

Question 35

Genital mycoplasma epidemiology

Answer 35

Ureaplasma spp/ M. hominis/ M. genitalium • Colonise the vagina and cervix of adult women – 40-80% (Ureaplasma spp) – 21-58% (M. hominis) – ≤ 1% (M. genitalium) • Colonisation in males is much lower than in females • Frequency of colonization increases after puberty

Question 36

Genital mycoplasma clinical manifestations

Answer 36

Ureaplasma spp/ M. hominis • Simple colonisation of the vagina and cervix of adult pregnant women is not usually associated with disease • But presence of Ureaplasma spp and to a lesser extent M. hominis in placental membrane or amniotic fluid associated with: Chorioamnionitis, Preterm birth, Neonatal disorders (perinatal pneumonia and sepsis in preterm infants) • Both Ureaplasma spp/ M. hominis associated with postpartum fever ``` M. hominis • Pelvic inflammatory disease (PID) • Pyelonephritis • Bacterial vaginosis • NGU (25% of cases) ``` ``` M. genitalium • Cervicitis • Endometritis • PID • Tubal infertility ```

Question 37

Laboratory diagnosis genital mycoplasma

Answer 37

Ureaplasma/M. hominis/M. genitalium: • Specimens: collected from site of infection (urethra, vagina,endocervix, urine, abscess material, prostatic secretions, and semen, for example) • Culture? • PCR