STIs Flashcards
(221 cards)
1
Q
What is the most common bacterial STi in the UK and worldwide?
A
Chlamydia
2
Q
How common is chlamydia in the UK in females?
A
Approximately 1 in 10 females
3
Q
Outline the features of the bacteria that causes chlamydia?
What is the incubation time?
A
It’s an obligate, intracellular, gram negative bacteria
Called chlamydia trachomatis
7-21 days
4
Q
How is chlamydia spread?
A
Primarily through penetrative sex
Can occur via autoinoculation or splashing from genital fluids
5
Q
What does chlamydia cause inflammation of in men and women?
A
Men - urethra (can affect epididymis or testicles also)
Women - urethra or cervix (if it goes further up its PID)
Both - rectum, conjunctiva, nasopharynx
6
Q
What is the difference between an uncomplicated and a complicated chlamydia infection?
A
Uncomplicated - not ascended to upper genital tract
Complicated - spread to upper genital tract causing PID in women and epididymo-orchitis
7
Q
Risk factors for chlamydia
A
Age <25
New sexual partner
>1 sexual partner in the last year
Lack of consistent condom use
8
Q
In what % of pt is chlamydia asymptomatic in?
A
70% of women
50% of men
9
Q
Symptoms of chlamydia in sexually active females?
A
Increased, purulent vaginal discharge
PCB or IMB
Deep dyspareunia
Dysuria
Pelvic pain and tenderness
Cervical motion tenderness
An inflamed or friable cervix which may bleed on contact
10
Q
Symptoms of chlamydia in sexually active men ?
A
Tend to be very mild
Dysuria
Mucopurulent urethral discharge
Urethral discomfort or urethritis
Epididymo-orchitis
Reactive arthritis
11
Q
Symptoms of rectal chlamydia?
A
Usually asymptomatic
May be anal discharge or discomfort
12
Q
Symptoms of chlamydial conjunctivitis?
A
2 weeks or more of unilateral erythema, irritation and discharge
13
Q
What type of test do we use to confirm a chlamydia diagnosis?
A
Nuclear acid amplification test (NAAT)
Checks directly for DNA or RNA of the organism
14
Q
Confirming a diagnosis of chlamydia in women?
A
Vulvovaginal swab is sample of choice - inserting swab 5cm into vagina and gently rotating for 10-30 seconds
(Endocervical swab can be taken but less sensitive, or first catch urine sample can be taken if woman prefers)
15
Q
Confirming a diagnosis of chlamydia in men?
A
First catch urine sample is the specimens of choice (hold urine in bladder for at least an hour and catch the first 20ml)
(Alternative is urethral swab)
16
Q
Who should have rectal swabs taken for lymphogranuloma venereum?
A
Those who engage in high risk sexual activities (e.g. anal intercourse) and are symptmatic
All HIV positive men who have sex with men with a positive chlamydia test at any other site
17
Q
How do we manage chlamydia?
A
First line doxycycline 100mg TDS for 7 days
(2:Azithromycin or 3:erythromycin)
Strongly encourage screening for other STIs - gonorrhoea, syphilis, HIV
Advise pt that their current partner must also be treated to reduce risk of re-infection and onwards transmission
Avoid all sexual intercourse until both they and their partners have completed treatment
Encourage pt to tell previous contacts
18
Q
Why is doxycycline now the preferred antibiotic for treating chlamydia instead of azithromycin?
A
Due to concerns about mycoplasma genitalium which is an infection that often coexists in pts with chlamydia and there is evidence of rising levels of macrolide resistance
19
Q
How long back should you encourage the pt with positive chlamydia to tell their contacts?
A
Men with urethral symptms - 4 weeks prior to onset of symptoms -> all contacts since
Asymptomatic men and all women - all contacts from the last 6 months or the most recent sexual partner
20
Q
What should you offer to all the contact sof a positive chlamydia pt?
A
Treatment before the results of their swabs are back
Treat with doxycycline
21
Q
Whats first line antibiotic for pregnant women with chlamydia?
A
Azithromycin
22
Q
Which pt who are positive for chlamydia require referral to genitourinary medicine (GUM)?
A
If no response to first line treatment
If pelvic inflammatory disease or epididymo-orchitis is suspected
If pregnant
If recurrent cases
23
Q
Who should be offered a test of cure for chlamydia?
A
If pregnant
poor compliance is suspected
Or if symptoms persist
24
Q
Who should be offered repeat chlamydia testing after Tx for chlamydia? When? Why?
A
Under 25s
3-6 months after finishing Tx
To check for re-infection
25
Prognosis of chlamydia?
Untreated infections may persist or resolve spontaneously
Clearance increases with duration of untreated infection - 50% will resolve within 12 months of diagnosis
However, if left untreated they may result in serious complications
26
Complications of chlamydia?
PID in women
Epididymo-orchitis in men
Lymphogranuloma venereum
Sexually acquired reactive arthritis (SARA)
Perihepatitis / Fitz-Hugh-Curtis syndrome
Adverse outcomes in pregnancy
27
% of women with untreated chlamydia infection that will get PID?
16%
28
What is lymphogranuloma venereum? Who is it most common in? What are the 3 stages?
An ulcerative condition of the genital area caused by chlamydia trachomatis serovars L1, L2, L3 - primarily an infection of the lymphatics
Most common in MSM and men with HIV
Primary stage - small painless pustule which later forms an ulcer on penis, vaginal wall or rectum
Secondary stage - painful lymphadenopathy inguinal and femoral
Tertiary stage - inflammation of rectum and anus which causes anal pain, change in bowel habit, tenesmus and discharge
29
what is sexually-acquired reactive arthritis? What proportion are caused by a chlamydia infection?
A HLA-B27 associated seronegative spondyloarthropathy
It’s inflammation of the synovial membranes, fascia and tendons triggered by an infection at another site
2/3rds of cases are due to a chlamydia infection
30
What is Fitz-Hugh-Curtis syndrome? Symptoms? Investigation?
perihepatitis - a chronic manifestation of PID
inflammation of the liver Glisson’s capsule, without the involvement of the liver parenchyma. This leads to adhesions between the liver and the periosteum.
Right upper quadrant pain, abdominal distension and other signs of peritonitis
Confirm chlamydia or gonorrhoea infection. Laparoscopy can be used to confirm and to remove adhesions by adhesiolysis
31
What adverse outcomes in preganncy can chlamydia infection have?
Increased risk of infertility
Increased risk of PROM, pre-term delivery, LBW, ectopic pregnancy
Increased risk of intrapartum pyrexia and late post-partum endometritis
Infections of eyes, lungs, nasopharynx, genitals in neonate due to exposure in birth canal during delivery
32
Outline screening for chlamydia?
All sexual partners of those with proven/suspected chlamydia infection
All sexually active adult s<25 annually, or more frequently if changed partner
All pt with concerns about sexual exposure
Under 25s who have been treated for chlamydia in the last 3-6 months
People who have had 2 or more sexual partners in the previous 12 months
All women seeking termination of pregnancy
All pt attending GUM clinics
33
Triad of symptoms in Behcet’s syndrome?
Oral ulcers
Genital ulcers
Anterior uveitis
34
Features of Behçet’s syndrome?
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
35
Features of reactive arthritis?
Asymmetrical oligoarthitis of lower limbs
Dactylitis
Symptoms of urethritis
Eye - conjunctivitis or anterior uveitis
Skin - circinate balanitis or keratoderma blenorrhagica
“Can’t see, pee or climb a tree”
36
When does reactive arthritis typically develop after an initial infection?
How long do symptoms last?
4 weeks
Symptoms generally last 4-6 months
37
What is the second most common bacterial STI worldwide and in the UK?
Gonorrhoea
38
What are the key characteristics of the bacteria that causes gonorrhoea? Incubation period?
Neisseria gonorrhoea
Gram-negative diplococcus
2-5 days
39
What can neisseria gonorrhoea infect?
Mucous membranes with columnar epithelium
E.g. endocervix, urethra, rectum, conjunctiva, pharynx
40
How is gonorrhoea transmitted>
By direct inoculation of secretions from 1 mucous membrane to another
In infants it usually results from exposure to infected cervical exudates at birth
41
Risk factors gonorrhoea?
Age 15-24
New sexual contact in the last year or more than 1 sexual contact in the last year
Inconsistent condom use
Men who have sex with men
Current or PMHx STI
History of sexual abuse
Deprivation
42
How often is gonorrhoea asymptomatic in men and women?
Men - 10%
Women 50%
I.e. it is more likely to be symptmatic than pt with chlamydia
43
How does gonorrhoea present in a female with…
A urethral infection?
An endocervical infection?
Urethral - dysuria but no urinary frequency
Endocervical - altered/increased discharge, pelvic pain and sometimes IMB or menorrhagia or dyspareunia
44
How does gonorrhoea present in a male?
As a urethral infection:
- purulent urethral discharge which is typically green or yellow
- dysuria
- epididymo-orchitis although this is more rare
45
How does gonorrhoea rectal and pharyngeal infections present?
Both commonly asymptomatic
Rectal can present with anorectal discomfort and discharge
Pharyngeal can present with a sore throat
46
How do we diagnose gonorrhoea?
NAAT testing using vulvovaginal swabs in women or first-pass urine specimen in men
Also take specimens for culture for susceptibility testing prior to treatment
(Consider rectal and pharyngeal sampling on MSM)
47
How do we ass gonorrhoea?
Thorough history
Examine whole genital area
Assess foe extra-genital infection
Consider screening for other STIs and HIV
Diagnostic testing - NAAT and culture for susceptibility testing
48
Antibiotic choice for gonorrhoea?
If antimicrobial susceptibility is known and it is sensitive to ciprofloxacin then use ciproflox 500mg orally as a single dose
If antimicrobial suscepbility is not known, or pt is pregnant - ceftriaxone 1g IM as a single dose
(This is because resistance to ciproflox in the Uk is 36% - in real practice most of the time ceftriaxone is given_
49
How do we manage gonorrhoea?
Tx with antibiotics
Encourage partner notification
Follow up after 1 week and do a test of cure
Abstain from any sexual activity for 7 days to reduce risk of re-infection
Provide advice about ways to prevent future infections
50
What should you do if you try to manage a gonorrhoea case with ceftriaxone and it fails treatment?
Report this to PHE!!!
51
Which sexual contacts of gonorrhoea should be notified?
For men with symptomatic urethral infections - all sexual partners in preceding 2 weeks of their most recent partner if >2 weeks
For everyone else - all partners in preceding 3 months
52
How should you manage contacts of gonorrhoea?
If presenting after 14 days of exposure the test and if this is positive treat
If presenting within 14 days then use clinical judgement to decide whether to start empirical treatment or not
53
Prognosis of gonorrhoea?
Would resolve spontaneously in most women
If left untreated in both men and women it may result in severe complications
54
Complications of gonorrhoea?
Men:
Epididymitis or orchitis
Prostatitis
Infertility
Urethral strictures
Infection of mullerian or Cowper glands
Women:
PID
Peritoneal spread, including perihepatitis absess
Pregnancy complications - spontaneous abortion, prem labour, PROM, perinatal mortality, Gonococcal conjunctivitis of the newborn
Both:
Disseminated Gonococcal infection
55
What is disseminated Gonococcal infection? What symptoms does it cause?
Haematogenous spread from the primary infection
Triad: tenosynovitis, migratory polyarthritis, dermatitis
Can also cause systemic symptms
Later complications: septic arthritis, endocarditis, perihepatitis, Gonococcal meningitis
56
Most common cause of septic arthritis in young, sexually-active adults?
Neisseria gonorrhoea
57
Why can gonorrhoea cause infertility?
As it can lead to local complications such as urethral strictures, epididymitis and salpingitis in men, or PID in women
58
Why is gonorrhoea more likely to disseminated than chlamydia?
It’s pathogenicity and characteristic features makes it more able to invade mucosal linings more aggressively
59
What is urethritis?
What are the 2 categories?
A term usually reserved for men
Inflammation of urethra that can be caused by a sexually transmitted infection
Gonococcal and non-gonococcal urethritis (latter is also referred to as non-specific urethritis)
60
Common causes of non-specific urethritis?
Chlamydia trachomatis
Ureaplasma urealyticum
Mycoplasma genitalium
61
How do we investigate urethritis in men?
Urethral swab and gram staining - look for presence of leukocytes and gram negative diplodocus
NAAT test for chlamydia using urine test
62
Symptoms of urethritis?
Dysuria and or urethral discharge
Asymptomatic in 30% of men
63
Complications of urethritis?
Epididymitis
Subfertility
Reactive arthritis
64
Management of urethritis?
Oral doxycycline for 7 days or single dose of oral azithromycin
65
What is mycoplasma genitalium?
A bacteria that can cause non-specific urethritis
It’s an STI
It can lead to urethritis, epididymitis, cervix it is, endometritis, PID, reactive arthritis, preterm delivery, tubal infertility
66
How do we manage uncomplicated genital infections of mycoplasma genitalium?
Doxycycline 100mg twice daily for 7 days then; Azithromycin 1g stat then 500mg once a day for 2 days
(Moxifloxacin if complicated!)
67
What is pelvic inflammatory disease?
Infection and inflammation of the female pelvic organs - uterus, fallopian tubes, ovaries, surrounding peritoneum
It is usually as a result of an ascending infection from the endocervix
68
Causative organisms of pelvic inflammatory disease?
Chlamydia trachomatis most commonly
Neisseria gonorrhoea
Mycoplasma genitalium
Less commonly - gardnerella vaginalis, H.influenza, E.coli
69
What is salpingitis?
Inflammation of fallopian tubes
70
What is Oophoritis?
Inflammation of ovaries
71
What is parametritis?
Inflammation of the parametrium -
fibrous and fatty connective tissue that surrounds the uterus and separates the supravaginal portion of the cervix from the bladder
72
Symptoms of PID?
Low bilateral abdominal pain
Deep dyspareunia
Dysuria
Menstrual irregularities - secondary dysmenorrhea, IMB, PCB, menorrhagia
Abnormal vaginal mucopurulent discharge
Systemic - fever, n&v, malaise if severe
73
Signs of PID?
Adnexal tenderness, cervical motion tenderness, uterine tenderness on bimanual vaginal exam
Abnormal cervical or vaginal mucopurulent discharge and cervical friability on speculum exam
74
Investigations PID?
Pregnancy test to exclude ectopic pregnancy
Vulvovaginal swabs for chlamydia and gonorrhea
High vaginal swabs for trichomonas, Candida, BV
Assess for endocervical or vaginal pus cels under microscope on a wet-mont vaginal smear
Bloods - leukocytosis, ESR/CRP elevated, HIV, hepatitis and syphilis serology as part of STI screen
Laparoscopy may be done is severe or diagnostic uncertainty
Sometimes endocervical USS is done to rule out DDx
75
Management PID?
NSAIDs
After swabs start empirical antibiotics
Refer to GUM
Contact tracing
Test of cure if needed and review within 72 hours and then again 2-4 weeks after completing Tx
Advise on future use of barrier contraception
76
Antibiotic choice for PID? What is mycoplasma genitalium tests positive?
Ceftriaxone 1g single IM + oral doxycycline 100mg TDS + oral metronidazole 400mg TDS for 14 days
If positive then start moxifloxacin
77
Explain the empirical antibiotic choices for PID
Ceftriazone covers gonorrhoea
Doxycycline covers chlamydia and MG
Metronidazole covers anaerobes such as gardnerella vaginalis
78
Can you leave the IUD in if you have PID?
If PID is mild and she is clinically improving within 48-72 hours then yes
Better short term clinical outcomes if its removed. Remmeber if you remove it you may need to provide some emergency contraception
79
Complications PID?
Perihepaitits in 10%
Tubal infertility may be 10-20% after a single episode
Chronic pelvic pain due to scarring and adhesions
Ectopic pregnancy risk increases
Pelvic peritonitis and sepsis
Tubo-ovarian abscess
80
What is trichomoniasis?
A sexually transmitted infection caused by trichomonas vaginalis which is a highly motile, flagelated protozoean
Transmission is almost exclusively through sexual intercourse. Vertical transmission can occur during vaginal delivery
Men - organism found in urethra
Women - found in vagina, urethra, paraurethral glands
81
What is the most common non-viral STI in the world
Trichomoniaiss
82
What % of cases of trichomoniasis are in women?
90%
83
Symptoms of trichomoniasis in women?
50% asymptomatic
Frothy and yellow-green vaginal discharge
Fishy odour to discharge
Vulval itching
Dysuria
Dyspareunia
84
What will the cervix look like on examination in trichomoniasis?
Colpotis muscularis - strawberry appearance caused by tiny haemorrhages across the cervical surface in cervicitis
85
Sympotms trichomoniasis in men?
15-50% asymptomatic
Urethral discharge
Dysuria
Ureinary frequency, balanitis can also occur
86
Investigations trichomoniaiss
Vaginal discharge pH >4.5
Women - high vaginal swabs from posterior fornix
Men - urethral swab or first-void urine
Culture and microscopy of a wet mount shows motile trophozoites
Test for other STIs
87
Management trichomoniasis?
Oral metronidazole 400-500mg TDS 5-7 days
Treat contacts from previous 4 weeks
Follow up
Sexual abstinence for at least a week
88
Complications trichomoniasis
Perinatal - preterm, LBW
• Predisposition to maternal postpartum sepsis
• Facilitation of HIV transmission by damaging the vaginal mucosa
• PID
• Alterations to normal vaginal flora, increasing susceptibility to BV
• Increased risk of cervical cancer, esp in women co-infected with HPV
• Infertility
• Acute and chronic prostatitis
• Increased risk of prostate cancer
89
Characteristic features of treponema pallidum?
Cause of syphilis
Gram negative
Obligate
Spirochete bacterium
90
How is syphilis transmitted?
Vaginal, anal, oral sex
Vertically during pregnancy
Sharing needles/blood products
Skin if open
91
Incubation period syphilis?
9-90 days - average 21
92
What are pt with HIV who are co-infected with syphilis at increased risk of?
Neurological complications - neurosyphilis
93
What are the stages of syphilis? When do they occur?
Primary syphilis ~21 days after infection
Secondary syphilis - 4-12 weeks after appearance of primary syphilis
Early + late latent syphilis
Tertiary syphilis >2 years later
94
What is primary syphilis?
Occurs 9-90 days after exposure
Presents with a syphilitic chancre at the site of infection entering the body as spirochetes destroy the skin
95
What is tertiary syphilis?
A type 4 hypersensitivity reaction that typically occurs 15-40 yeas after initial infection
A T-cell ed immune response to the spirochetes in the organs
Causes many serious complications
96
Symptoms of primary syphilis?
Chancre - painless, indurated ulcer with a clean base and sharp border. Often genital but can be extra-genital e.g. hands, mouth (may not be seen in women as it may be on the cervix)
Local lymphadenopathy
Lasts weeks-months
(This stage wont occur if spirochetes entered blood directly e.g. blood transfusion error)
97
Symptoms secondary syphilis?
Non-pruritis maculopapular rash trunk -> palms of hands and soles of feet
Condylomata lata in moist areas e.g. perianal, vulval, axilla
Patchy Lesions on oral mucosa
Syphilitic Alopecia
Systemic - generalised lymphadenaopthy, fever, malaise, headache, hepatitis, splenomegaly, glomerulonephritis
Lasts weeks-months
98
Why does secondary syphilis cause a rash?
As spirochetes attach to and infect the endothelial cells of blood vessels near the skin
99
What are condylomata lata?
Moist wart-like lesions
100
Symptoms tertiary syphilis?
Cardiovascular - most commonly aortic aneurysms,
Gummas
Ocular - most commonly Argyll Robertson pupil
Neurosyphuls - tabes dorsalis, general paresis, stroke-like symptoms
101
What are gummas in tertiary syphilis?
Granulomatous lesions that occur when there’s a huge gathering of immune cells in response to spirochetes ad this causes a centre of coagulative necrosis
102
What is tabes dorsalis?
The consequences of neurosyohilis - the slow demyelination of the neural tracts primarily in the dorsal root ganglia of the spinal cord
Causes lightening pains, paraesthesia, pupillary change, absent reflexes/propioception/vibration sense
103
Investigations syphilis?
Dark field microscopy or PCR of swabs taken from original chancre to directly visualise T.pallidum spirochetes
Non-treponemal tests e.g. rapid plasma reagin test, venereal disease research laboratory test
Treponemal-specific tests e.g. T.pallidum enzyme immunoassay or T.pallidum haemagglutination test
All positive tests must be confirmed with a different serological test
Negative tests should be repeated at 6 and 12 weeks
104
Why are non-treponemal tests non-specific?
Not specific for syphilis so may result in false positives. This is because they assess the quantities of anti-Cardiolipin antibodies being produced but Cardiolipin is also released by damaged cells in our bodies
105
Causes of false positive non-treponemal test for syphilis?
Pregnancy
SLE
Anti-phospholipid syndrome
TB
Leprosy
Malaria
HIV
106
Why are treponemal-specific tests specific?
As they look for antibodies that target T.pallidum specifically
107
What are the 3 antigens of syphilis spirochetes?
Group specific i.e. on all treponema’s
Species-specific i..e on all T.pallidum
Cardiolipin
108
What does a positive non-treponemal test + positive treponemal test indicate?
Active syphilis infection
109
What does a positive non-treponemal test + negative treponemal test indicate?
False positive syphilis result
110
What does a negative non-treponemal test + positive treponemal test indicate?
A successfully treated syphilis - this is because non-treponemal tests become negative after Tx
111
Management syphilis
Refer to GUM
Full sexual health screen
Single deep IM benzathine penicillin
Non-treponemal titres should be monitored after Tx to assess response (4 fold decline is considered adequate)
Contact tracing, prevention of future infection, advise for sexual abstinence for a while
112
What is A Jarisch-Herxheimer reaction? Cause?
A reaction in pt infected by spirochetes who undergo antibiotic Tx
Causes a fever, rash and tachycardia within a few hours of a antibiotic being given
Thought to be caused by the release of endotoxins following bacterial death
113
Symptoms congenital sepsis?
Early disease (first 2 years): fever, irritability, poor feeding, failure to thrive, maculopapular rash
Late disease (>2 years) - Hutchinson’s teeth, mulberry molars, rhagades, snuffles, keratitis, saber shins, saddle nose, deafness, blindness, hepatosplenomegaly, developmental delay and neurological problems
114
What is syphilis in pregnancy associated with?
Multiple adverse outcomes e.g. hydrops, preterm, LBW, foetal loss, congenital syphilis in the newborn
115
What are Hutchinson’s teeth?
Small, widely spaced teeth with notches on their biting surface
Sign of congenital syphilis
116
What are mulberry molars?
Multiple, rounded enamel cusps on the permanent 1st molars
Sign of congenital syphilis
117
What are rhagades?
Linear cracks and scars found at the angle of the nose and mouth
Sign of congenital syphilis
118
What are saber shins?
Anterior bowing of the tibia
Sign of congenital syphilis (or rickets)
119
What is a saddle nose?
The collapse of the bridge of the nose, creating a concave or saddle-shaped appearance. Caused by inflammation and damage to the nasal septum
Associated with congenital syphilis
120
What can cause genital ulcers?
Herpes simplex virus
Syphilis - chancre
Chancroid caused by haemophilus ducreyi
Lymphogranuloma venereum caused by chlamydia trachomatis
Behçet’s disease
Granulomas inguinale caused by klebsiella granulomatis
121
What strains of HPV cause genital warts?
6 and 11
122
Medical term for genital warts?
Condylomata accuminata
123
What do HPV genital warts look like?
They can appear on their own or in a group (groups of warts can look like a cauliflower)
feel soft or firm
Tend to be small 2-5mm each
be white, red, skin-coloured, or darker than the surrounding skin
They do not usually cause symptoms but sometimes they may be painful, itchy or bleed.
124
How do we treat genital warts?
Topical podophyllum - arrests mitosis in metaphase
Cryotherapy - liquid nitrogen application
Second line - imiquimod cream
125
What type of virus is herpes simplex?
An enveloped double stranded DNA virus
126
What do HSV-1 and HSV-2 cause?
They can both cause genital or oral herpes but…
HSV-1 is more commonly associated with oral-labial herpes and genital herpes
HSV-2 is more likely to cause recurrent genital herpes infection
127
What is the primary herpes simplex infection?
The first time either HSV-1 or HSV-2 is acquired with no pre-existing antibodies to either virus
Can last up to 3 weeks
Often more severe then following recurrent episodes
128
What happens to the herpes simplex virus after the primary infection?
The virus becomes latent in the trigeminal nerve ganglion in the case of oral herpes, and sacral nerve ganglia in the case of genital herpes
129
What is recurrent genital herpes?
Clinical symptms of genital herpes due to reactivation of pre-existing HSV-1 or HSV-2 infection after. A latent period
130
How is HSV transmutted?
It’s acquired at mucosal surfaces or breaks in the skin, by direct contact with infected secretions.
This is usually through sexual contact with HSV02 usually through vaginal/anal sex and HSV-1 through Oro-genital sex
Note it can be acquired with contact with lesions at other sites e.g. autoannoculation
HSV-1 is commonly transmitted in childhood via direct contact with infected secretions entering via skin or mucous membranes e.g. kissing or sharing utensils
131
Incubation period for herpes?
2-21 days
132
How often is HSV-1 the cause of oral herpes?
>90% of cases
Very for HSV-2 to cause it but not impossible
133
Features of herpes?
Cold sores
Gingivostomatitis
Genital blisters
Dysuria
vaginal or urethral discharge
Headache, malaise fever - these systemic symptoms are more common with initial infection
Herpes keratitis
Herpetic whitlow
Herpes gladiatorum
134
What is herpes gingivostomatitis?
Infection of gums and lips caused mostly by HSV-1
Often has a prodrome of fever, general malaise, sore throat, lymphadenaopthy
135
Where do cold sores tend to appear?
Bottoms lip, unilateral
136
What do cold sores look like?
What prodrome might they have?
They are tiny, fluid-filled blisters on and around the lips. These blisters are often grouped together in patches. After the blisters break, a scab forms that can last several days.
Burning, tingling, pain, itching or paraesthesia may occur before where the cold sore will appear
137
What is herpetic whitlow?
Herpes infection of finger
Tends to infect the top of the finger
swelling and pain in your finger
blisters or sores on your finger
skin becoming red or darker than your usual skin tone
feeling generally unwell and having a high temperature
138
What do herpes genital ulcers look like?
Multiple painful crops of genital blisters which quickly burst to leave erosions and ulcers
On the external genitalia, perineum or perianal region
Prodrom tingling or burning may occur up to 48 hours before in recurrent episodes
139
What is herpes gladiatorum?
Herpes infection of the skin
Common in wrestlers due to transmission by skin-to-skin contact
Not necessarily classed as an STI but can be a complication of oro-genital herpes
140
Triggers for recurrent herpes outbreak
Exposure to prolonged bright UV light
Physical or emotional stress
Fatigue
Fever
Menstruation
Immunosuppression
Temperature extremes
Trauma to the area
Dental or surgical procedures
141
Diagnosis of herpes?
Viral swab from the base of a nano genital lesion - PCR or NAAT testing
Consider screening for other STIs
142
Management of herpes?
Self care measures
Advise to abstain from sexual activity until lesions have cleared
Oral antivirals within 5 days of starting an episode - aciclovir
Some pt with frequent exacerbations may benefit from long term prophylactic aciclovir
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Self care measures for herpes?
Saline bathing - promotes healing, eases symptoms, prevents secondary infections
Analgesia
Topical petroleum jelly or anaesthetic e.g. before passing urine to help with dysuria
Increase fluid intake (dilutes urine)
Avoid wearing tight clothing
Avoiding trigger factora
144
Prognosis of HSV?
A chronic condition with variable frequency of recurrence
HSV 2 - on average 4-5 recurrences a year
HSV-1 - on average 2-3 recurrences a year
Symptoms are typically worst in the primary infection and reduce in severity and frequency overtime
145
Complications herpes simplex infection?
Psychosocial
Secondary infections e.g. candida or streptococcus sp
Herpetic whitlow
Balanitis
Urinary retention (rare but if virus infects S2-S4)
Herpes proctitis in MSM
Systemic infections particuarly if immunocomporimised e.g. meningitis or encephalitis
Neonatal HSV
Dehydration (from poor intake due to painful swallowing, or from fever)
Eczema herpticum
Eye disease e.g. herpetic keratitis
Herpes gladiatorum
Herpes sycosis of the beard area
Erythema multiforme
Pneumonia, tracheobronchitis etc
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What is bacterial vaginosis?
Dysbiosis of the vagina characterised by overgrowth of predominantly anaerobic organism e.g. gardnerella vaginalis, and low lactobilli.
This results in less lactic acid produced so pH rises
The more alakline the environment the more the anaerobic bacterial will multiply
147
Vaginal pH in bacterial vaginosis?
>4.5
148
Normal vagina pH?
3.8-4.5
149
Is bacterial vaginosis considered an STI?
No however it is said to be sexually-associated because it mainly occurs amongst sexually active women
150
Epidemiology of BV
Most common cause of abnormal vaginal discharge in women of childbearing age
In 23-39% of population
Much more common in black women
151
Factors that increase risk of BV?
Being sexually active
Multiple male sexual partners
Women who have sex with women - concordant vaginal floral
Sexua;l relationships with >1 person
Recent change in s3xual partner
Certain sexual behaviours e.g. anal or oral sex followed by vaginal penetration
Not using condoms and menstruation - semen and menstruatal blood create an alkaline environment which encourages the growth of BV organisms
Douching e.g. vaginal washes, bubble baths
Seropositive for HSV2
Copper IUD
Smoking cigarettes
Poor genital hygeiene e.g. infrequent change of underwear
152
Factors that reduce the risk of BV?
Circumcised partners
Consistent condom use
Hormonal contraceptive may be protective
153
Presentation of BV
50% a symptmatic
Fishy smelling thin, grey/white discharge that is not itchy or sore
154
Investigations BV
Speculum and swab discharge from lateral vaginal wall
Test pH of discharge
If the diagnosis can’t be made then send a discharge sample to lab for gram staining and microscopy
Test for other STIs
155
What cells would be seen on microscopy in BV in a vaginal discharge specimen?
Clue cells - cervical epithelial cells that have bacteria stuck in them causing a fuzzy appearance
156
What criteria is used to diagnose BV?
Amsel’s criteria
157
Amsel’s criteria
3 of the 4:
- thin, white homogenous discharge
- clue cells on microscopy
- vaginal pH >4.5
- positive whiff test - addition of potassium hydroxide results in a fishy odour
158
Outline the whiff test for BV
Apply potassium hydroxide to a sample of vaginal discharge
In BV there are lots of anaerobic bacteria which produce amines. When the amines react with KOH they produce a fishy odour
159
Tx of BV
Asymptomatic - no Tx required
If symptmatic - advise to avoid contributing factors + prescribe oral metronidazole 400mg TD for 5-7 days
160
Relapse rate after Tx of BV
>50% within 3 months
161
Complications BV
Increased risk of acquiring STIs - 2 fold risk of hIV, chlamydia, gonorrhoea, HSV-2 and a 9 fold risk of trichomoniasis
Pregnancy - late miscarriage, preterm labour and delivery, spontaneous abortion, LBW, postpartum endometritis, post-surgical infections
Subclinical PID
Recurrence
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Why does BV increase the risk of STIs?
BV causes Dysbiosis of the vagina which can make it more favorable for the growth and survival of other pathogens, including sexually transmitted bacteria.
The acidic environment maintained by lactobacilli in a healthy vagina helps protect against infections, and when this balance is disrupted, the risk of infection may rise.
May impair the immune response
While BV is not classified as a sexually transmitted infection itself, there is evidence that sexual activity, especially with new or multiple partners, may be associated with an increased risk of BV, but also STIs
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What is vaginal candidiasis?
Genital thrush
Symptomatic inflammation of the vagina or vulva caused by a superficial fungal infection - usually by yeasts that belong to the genus candida
Note: candida yeasts are a part of the normal flora of female genital tract but overgrowth can cause issues
164
What causes vaginal candidiasS?
Candida albicans - 80-89%
Candida glabrata - 5%
Other candida cause the rest
165
What is recurrent vaginal candidiasis?
4 or more symptomatic episodes in 1 year with at least 2 of these episodes being confirmed by microscopy or culture
166
How common is vaginal candidiasis?
Up to 75% of women will be affected at some point in their lifetime
167
Risk factors vaginal candidiasis?
Antibiotic use in the last 3 months
Local irritants - soaps, shampoos, douching
Uncontrolled diabetes mellitus
Other causes of immunosuppression e.g. HIV, corticosteroid use
Increased oestrogen - COCP, reproductive age, pregnancy
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Symptoms vaginal candidiasS?
Cottage cheese appearing, non-offensive discharge
Vulvitis: superficial dyspareunia or dysuria
Itching vulva
Vulva erythema, fissuring or satellite lesions may be seen
169
Investigtaions vaginal candidiasis?
Examination of external genitalia
High vaginal swab of vaginal secretions for microscopy - not routinely indicated as can be diagnosed based on clinical features
Consider HbA1c testing to exclude DM in severe/recurrent cases
Consider STI screening
170
Self-management measures for vaginal candidiasis?
Simple emollients as soap substitutes to wash and moisturise the vulval area
Avoid contact with soaps, shampoos, bubble baths etc
Avoid vaginal douching
Avoid wearing tight-fitting or non-absorbent clothing
Avoid use of complementary therapies e.g. yoghurt or tea tree oil
171
Tx of vaginal candidiasis?
Optimise management of underlying condition if relevant e.g. DM
Antifungal drug treatment - fluconazole 150mg oral capsule single dose
If vulval symptoms - topical imidazole in addition
If signs of severe infection advise to repeat antifungal drug Tx after 72 hours (so day 1 and day 4)
172
Tx of vaginal candidiasis in pregnant women ?
clotrimazole pessary 500mg intravaginally at night for up to 7 consecutive nights first-line
173
Management of recurrent vaginal candidiasS?
Check compliance with previous Tx
Confirm diagnosis - high vaginal swab MC&S
Consider testing for diabetes
Exclude DDx
Consider use of an induction-maintenance regime e.g. oral fluconazole every 3 days for 3 doses followed by oral fluconazole weekly for 6 months
174
Complications vaginal candidias?
Tx failure
Recurrent infection
Reduced QOL and psychosexual diffiuclties
Candidia balanitis - rare!
175
What is primary HIV infection
Seroconversion
10 days - 6 weeks after infection
Symptomatic in 60-80% of pt
Typically presents as a glandular fever-type illness
Increased symptmatic severity is associated with poorer long term prognosis
Viral load in this stage is very high and person is very infectious
176
What is the asymptomatic phase of HIV
Begins after the flu-like symptoms of the primary infection revolves
Duration of this phase varies widely between people with some progressing to AIDS stage in 1-2 years (rapid progressors) and some maintaining effective immune function for > 10 years (slow progressors)
177
What is advanced HIV disease ”AIDS”?
When the number of CD4 cells is less than 200 cells per microlitre, and certain opportunistic infections and malignancies develop – these conditions are known as AIDS defining illnesses
178
Prevalence of HIV globally
In 2020 to 39,000,000 people living with HIV, 1.3 million for newly infected, and 630,000 people died of aids related illness.
African regions are most severely affected with over 2/3 of all people living with HIV globally being from here
Between 2000, and 2018 new HIV infections fell by 37% and HIV related deaths fell by 45% – this is because of the more widespread use of ART
179
Prevalence of HIV in the UK
At the end of 2018, 104,000 people living with HIV 7500 of these being unaware of the infection.
50,000 women who have sex with men and 48,600 W heterosexual beings.
New diagnoses of HIV are declining
The success of the antenatal HIV screening program for pregnant woman, has meant that mother to child transmission of HIV in the UK has almost been eliminated
180
Transmission of HIV
The virus is present in cell containing bodily fluids. E.g. blood semen vagina secretions breastmilk amniotic fluid, pleural effusions and CSF
Transmitted from affected bodily fluids, e.g. sexual activity, vertically, by inoculation, e.g. contaminated, needles, or blood products
181
Risk factors for HIV
Having a current or former partner infected with HIV
From an area of high HIV prevalence.
Men have sex with men.
Female sexual contact of men have sex with men.
Trans-woman.
Most for sexual partners, engaging in high-risk sexual practices, history of other STIs
History of injecting drugs.
Current or previous sex workers.
Raped
Blood transfusions, transplants and other risk prone procedures in the countries without vigourous procedures for HIV screening
Occupational exposure, e.g. needlestick injury
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Symptoms of primary HIV infection
Sore throat, lymphadenopathy, myalgia, malaise, arthralgia, diarrhoea, maculopapular, rash mouth ulcers (glandular, fever-like illness)
May present with common symptoms of infection, is that unusually severe, prolonged, recurrent or unexplained
May present with conditions related to immuno suppression, for example, candidiasis, or shingles
Lymphadenopathy of unknown origin
Pyrexia of unknown, origin, or sweats
Or it may present with weight loss >10 kg
183
Examples of AIDS defining illnesses
Pneumocystis pneumonia (PCP)
Kaposi's sarcoma
Cryptococcal meningitis
Cerebral toxoplasmosis
Cerebral lymphoma
CMV retinitis
HIV-related encephalopathy
Disseminated or extrapulmonary TB
Chronic intestinal cryptosporidiosis
Chronic herpes simplex infection (especially oral or genital ulcers lasting for more than a month or bronchitis, pneumonitis, or esophagitis at any site)
Invasive cervical cancer
Lymphoma (certain types)
184
Respiratory conditions associated with HIV
Pneumocystis pneumonia
Tuberculosis.
Atypical mycobacterial disease.
185
Neurological and visual conditions associated with HIV
Cryptococcal meningitis
Cerebral toxoplasmosis
Cerebral lymphoma
Cytomegalovirus retinitis
186
Cancer associated with HIV
Lymphoma
Kaposi’s sarcoma
Cervical cancer
187
Skin conditions associated with HIV
Fungal skin and nail infections.
Viral infections e.g. HSV, molluscum, contagiosum, shingles and warts.
Bacterial infection e.g. impetigo, and folliculitis
Seborrhoeic, dermatitis, and psoriasis
188
Oral conditions associated with HIV
Oral candidiasis
aphthous ulcers
Oral hairy leukoplakia
Kaposi’s sarcoma
Gingivitis.
Dental abscess
189
Gastrointestinal diseases associated with HIV
Oesophageal candidiasis
Diarrhoea.
Hepatitis B and C
190
Genital conditions associated with HIV
Genital candida, genital, herpes, genital warts
191
Investigating HIV
combination tests (HIV p24 antigen and HIV antibody) are now standard for the diagnosis and screening of HIV
if the combined test is positive it should be repeated to confirm the diagnosis
some centres may also test the viral load (HIV RNA levels) if HIV is suspected at the same time
testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure
after an initial negative result when testing for HIV in an asymptomatic patient, offer a repeat test at 12 weeks
192
When can we test for HIV antibodies?
How can we test for it?
may not be present in early infection, but most people develop antibodies to HIV at 4-6 weeks but 99% do by 3 months
usually consists of both a screening ELISA (Enzyme Linked Immuno-Sorbent Assay) test and a confirmatory Western Blot Assay
193
What is p24 antigen?
When can we test for it?
a viral core protein that appears early in the blood as the viral RNA levels rise
usually positive from about 1 week to 3 - 4 weeks after infection with HIV
194
How do we monitor HIV?
Testing the CD4 count - the lower the count for higher the risk of opportunistic infections
195
Normal range of CD4 cells
>500cells/mm3
196
What test do we do with a viral load in HIV patients?
Test for HIV RNA per ml of blood
Reflects rates viral replication measured using a PCR test.
And undetectable load means the level is < than the recordable range. (<20copies/ml)
When viral load is the supressed through ART, CD4 counts recover, and the risk of HIV–related opportunistic infections, and cancers decline
197
Infections at CD4 count 400-500?
Small risk of opportunistic infection
Hodgkin lymphoma and cervical cancer
198
Infections at CD4 count 350-400?
Bacterial skin infections, recurrent bacterial chest, infections, tuberculosis, oropharyngeal candidiasis, fungal infections, sebhorreic dermatitis
Likely to be having sweats and lymphadenopathy 
199
Infections at CD4 count 200-350?
Oral hairy leukoplakia, shingles, pneumocystis, pneumonia, persistent HSV infection, non-Hodgkin lymphoma.
Likely to have weight loss. 
200
Infections at CD4 count 100-200?
Oesophageal, candidiasis, histoplasmosis, cerebral, toxoplasmosis, cryptococcal, meningitis, cryptosporidiosis, Kaposi’s sarcoma.
Likely to have diarrhoea and wasting of muscles. 
201
Infections at CD4 count <100?
Atypical, mycobacterium infections, cytomegalovirus infections, progressive, multifocal, leukoencephalopathy, primary cerebral lymphoma.
Likely to have HIV dementia
202
Management of HIV
Antiretroviral therapy is offered to everyone irrespective of the viral load or CD4 count, and should be started as soon as the person is diagnosed with HIV
Involves a combination of at least three drugs : this is usually to nucleoside reverse transcriptase inhibitors, and either a protease inhibitor, or a non-nucleoside, reverse transcriptase inhibitors
(2 NRTI + either PI or NNRTI)
203
Why do we use a combination of at least three drugs when treating HIV
It decreases viral replication, but also reduces the risk of viral resistance 
204
Aim of HIV treatment
To achieve in normal CD4 count, and an undetectable viral load
205
What is additional management should HIV patients with CD4 count <200 have?
Prophylactic cotrimoxazole to protect against pneumocystis pneumonia (PCP)
206
Monitoring screening and vaccines should HIV patients have
Close monitoring of cardiovascular risk factors as HIV infection increases the risk of CVD
Annual cervical smears as HIV increases risk of HPV and cervical cancer
Vaccinations should be up-to-date, but avoid live vaccines - influenza, pneumococcal, shingles, hep B, HPV, Tdap
207
Types of HIV drugs
Entry inhibitors
Nucleoside reverse transcriptase inhibitors.
Non-nucleoside reverse transcriptase inhibitors
Protease inhibitors
Integrase inhibitors.
208
Example of entry inhibitor drugs used in HIV, and how do they work
Maraviroc (CCR5 inhibitor) or enfuvirtide (fusion inhibtior)
Prevent HIV from entering infecting immune cells
209
Examples of nucleoside reverse transcriptase inhibitors
abacavir, emtricitabine, lamivudine, tenofovir alafenamide fumarate, tenofovir disoproxil fumarate, and zidovudine
210
Side-effects of nucleoside reverse transcriptase inhibitors
Peripheral neuropathy - all
Tenofovir can cause renal impairment and osteoporosis
211
Examples of non-nucleoside reverse transcriptase inhibitors
doravirine, efavirenz, etravirine, nevirapine, and rilpivirine
212
Examples of protease inhibitors to Tx HIV
atazanavir, darunavir, fosamprenavir, lopinavir, ritonavir, and saquinavir
213
Side effects of protease inhibitors to Tx HIV
Diabetes
Hyperlipidaemia
Buffalo hump
Central obesity
P450 enzyme inhibition - esp ritonavir
Indinavir can also cause renal stones and asymptomatic hyperbilirubinaemia
214
Examples of integrase inhibitords to treat HIV
How do they work
bictegravir, cabotegravir, dolutegravir, elvitegravir, and raltegravir
They block the action of integrase which inserts the viral genome into the DNA of the host cell
215
Preventing vertical transmission of HIV
Viral load <50 - normal vaginal delivery
Viral load 50-400 - consider pre-labour C-section
Viral load >400 - pre-labour C-section recommended
Viral load >1000 - IV zidovudine as an infusion during labour and delivery
Prophylaxis:
Low risk babies (viral load of mum <50) - give zidovudine for 2-4 weeks prophylaxis
High risk babies give zidovudine, lamivudine and nevirapine for 4 weeks
Avoid breast feeding
216
What is PEP?
Post-exposure prophylaxis for HIV
Used after exposure to reduce the risk of transmission
Not 100% effective but can reduce transmission risk by 80%
Must be commenced within 72 hours but should be in the first few hours where possible
Current regimen is emtricitabine + tenofovir (truvada) + raltegravir for 28 days
Serological testing at 12 weeks following completion
217
What is PrEP?
Pre-exposure prophylaxis for HIV
Taken before exposure to reduce the risk of transmission
Usual regimen - truvada which is emtricitabine and tenofovir
1 tablet is taken a day for at least 7 days before you have sex.
If the pt wants to start taking daily PrEP but thinks they may have sex within the first 7 days, they can take 2 tablets at least 2 hours before you have sex, and then continue to take 1 tablet each day.
218
Prognosis HIV
Advances in ART mean HIV is now a manageable chronic disease and people living with it who are adherent and clinically responding to ART can expect a normal or near-normal life span
The most important factor in reducing morality is early diagnosis
Without ART, CD4 count slowly declines eventually resulting in the development of constitutional symptoms, opportunistic infections and malignancies associated with advanced HIV disease
219
Settings where there are opportunities for sexual health promotion?
Healthcare facilities
Community outreach programmes
Educational institutions
Online platforms
220
How can substance abuse and STIs be linked?
Impaired judgement
High-risk behaviours
Shared drug-use equipment e.g. sharing needles
Reduced inhibitions
Transactional sex
Substance abuse can be associated with barriers to accessing healthcare services so they may be less likely to seek help for STIs
Mental health issues which may make them more vulnerable to risky sexual behaviours
221
Causes of abnormal vagina; discharge?
BV
Vaginal candidiasis
Trichomoniasis
Endocervical infections - chlamydia or gonorrhoea
Others:
Retained foreign body e.g. tampon, condom
Inflammation due to allergy or irritation caused by substances e.g. lubes
Tumours
Atrophic vaginitis in post-menopausal women
Cervical ectopy or polyps
Fistulae
Recent childbirth
Physiological - changes around menstrual cycle, during pregnancy, after menopause
