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Flashcards in STIs Deck (91):
1

List the ABCDEs of preventing the spread of STIs

Abstinence
Barrier protection
Contacts
Drug therapy
Education and counseling

2

List infections that can facilitate the transmission of HIV

Chlamydia trachomatis
Neisseria gonorrhoeae
Bacterial vaginosis
Genital HSV-1 and HSV-2
Treponema pallidum
Haemophilus ducreyi
Klebsiella granulomatis
Chlamydia trachomatis L1, L2, L3- lymphogranuloma venereum or LGV

3

Chancroid is caused by

Haemophilus ducreyi

4

Granuloma inguinale or Donovanosis is caused by

Klebsiella granulomatosis

5

List causes of non-gonococcal urethritis in men

Chlamydia trachomatis
Mycoplasma genitalium
Ureaplasma urealyticum
Trichomonas vaginalis (uncommon)
Enteric GNRs (uncommon, consider if hx of insertive anal intercourse)
HSV
Unknown- 30% of urethritis

6

Compare and contrast urethritis caused by Neisseria gonorrhoeae vs non-gonococcal urethritis

Gonococcus:
- incubation less than 4 days
- discharge will be profuse and yellow
- dysuria is severe

NGU:
- incubation 7-14 days
- slight grey or clear discharge
- moderate, intermittent dysuria

7

Describe the diagnostic work up for urethritis in men

- physical exam
- gram stain of urethral discharge (high sensitivity and specificity if symptomatic)
- urinalysis
- nucleic acid amplification test

8

Describe the gram stain seen in gonococcal urethritis

WBCs
Gram negative intraceullular diplococci

9

Describe what is seen on urinalysis in gonococcal urethritis

WBCs and positive for leukocyte esterase

Must be first a.m. voided urine

10

All patients empirically treated for gonococcus should also be treated for _______

chlamydia

11

How can non-gonococcal urethritis be treated?

Azithromycin 1x po
Doxycycline bid 7 days

12

Other than medication, what measures must be taken to treat urethritis?

-Abstain from sex for 7 days
- partner notification and testing (partners within last 60 days)
- test for STDs including HIV, syphilis
- test of cure not recommended
- follow up testing in 3-6 months

13

What is a complication of Chlamydia trachomatis in men?

epididymitis
reactive arthritis

14

List causes of mucopurulent cervicitis in women

gonococcal: Neisseria gonorrhoaea

non-gonococcal:
Chlamydia trachomatus
Mycoplasma genitalium
Trichomonas vaginalis
bacterial vaginosis
HSV1 and HSV2
frequent douching

15

What are common presentations of mucopurulent cervicitis in women?

often asymptomatic
abnormal vaginal discharge
intermenstrual bleeding
bleeding after intercourse

16

What are the two main diagnostic features of mucopurulent cervicitis in women?

1. Purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab
2. sustained endocervical bleeding induced by gentle passage of a cotton swab through the cervical os

17

In general, in mucopurulent cervicitis, endocervical bleeding is (painful/ painless)

painless

pain suggests diagnosis of PID

18

All women who seek medical attention for cervicitis must also be evaluated for _____

PID

Cervicitis can be a sign of upper genital tract disease

19

In a women with cervicitis, what other conditions should be tested for?

PID
Chlamydia trachomatis and Neisseria gonorrhoeae with sensitive and specific testing- NAAT of cervical specimins
Trichomonas vaginalis by microscopy and culture
Bacterial vaginosis
Other STIs- HIV, syphilis

20

What is a complication of cervicitis in women?

PID

21

Pregnant women can pass Chlamydia trachomatis to their infant during delivery, causing _________ or _______

neonatal inclusion conjunctivitis/ opthalmia neonatorium
or
neonatal C. trachomatis pneumonia

22

__________ is the most common bacterial STI in the US

Chlamydia trachomatis

23

Who should be screened annually for chlamydia?

Sexually active women < 25 years old

Highest rates of infection in men and women 14-24 years old

24

Why are teens and younger women at increased risk of contracting chlamydia?

The cervix is not fully mature

25

What cells can be infected by chlamydia?

- squamocolumnar cells of the endocervix and upper genital tract
- epithelial cells in the urethra and rectum
- epididymal cells
- conjunctival cells and pulmonary columnar cells of neonates

26

Up to 70% of women have asymptomatic ______ infection

chlamydia

27

List complications of chlamydia infection in men

epididymitis
prostatitis
reactive arthritis

28

List complications of chlamydia infection in women

PID
tubal infertility
ectopic pregnancy
chronic pelvic pain

29

Contrast how proctitis occurs from chlamydia in MSM vs in women

MSM- direct inoculation
women- secondary spread from cervical secretions

30

True or false: infection with chlamydia can cause impaired fertility in men

false, only in women

31

List complications of chlamydia infection in pregnancy

- neonatal inclusion conjunctivitis/ opthalmia neonatorium (develops within 12 days of birth)
- neonatal trachomatis pneumonia (develops within 8 weeks)

32

How are neonatal inclusion conjunctivitis and C. trachomatis pneumonia due to chlamydia treated?

Systemic antibiotics

33

How can neonatal chlamydia infection be prevented?

Perinatal screening

34

List specimens that can be used to diagnose chlamydia infection by NAAT

men: urethral swab
women: endocervical swab, vaginal swab
both: urine, rectal swab

35

What groups should be routinely screened for chlamydia?

sexually active women < 25
women with high risk factors
all pregnant women
** high risk men presenting to STI clinics, correctional facilities, etc

36

How is chlamydia treated?

azithromycin 1 dose
doxycycline bid for 7 days

37

_________ is the second most common bacterial STI in the US

Neisseria gonorrhoeae

38

Describe symptoms of gonococcal urethritis in men

onset 4 days after exposure
most men are symptomatic- purulent discharge, dysuria

39

Describe symptoms of gonococcal cervicitis in women

very often asymptomatic, possible bleeding with intercourse

40

List complications of gonococcus in men

epididymitis
disseminated gonococcal infection

41

List complications of gonococcus in women

PID
disseminated gonococcal infection
tubal infertility
ectopic pregnancy
chronic pelvic pain

42

List the two syndromes that comprise disseminated gonococcal infection

1. arthritis/ dermatitis syndrome- migratory, additive arthritis and cutaneous papules and pustules on the extremities
2. gonococcal septic arthritis

43

List complications of gonococcal infection in pregnancy

opthalmia neonatorum, conjunctivitis within 2 days of delivery- can be prevented at birth with erythromycin ointment- contrast to chlamydia

other complications: scalp abscess, meningitis, bacterial sepsis

44

List samples that can be used for diagnosis of gonococcal infection

NAAT: urine, vaginal swab, endocervical swab, urethral swab

Culture: rectal swab, pharyngeal swab

45

What groups should be targeted for gonococcal screening?

high risk

46

How is gonococcus treated?

First Line
- Ceftriaxone IM 1 dose PLUS azithromycin 1 dose
- Ceftriaxone IM 1 dose PLUS doxycycline bid for 7 days

Alternatives:
- cefixime 1 dose plus azithromycin 1 dose
- cefixime 1 dose plus doxycycline bid for 7 days
**increasing resistance against cefixime so must test for cure with those regimens within 1 week of therapy

47

List risk factors for PID

teens
multiple sexual partners
new sexual partner
prior PID
IUD insertion
douching

48

Describe the pathogenesis of PID

Polymicrobial infection, direct extension of microorganisms from the vagina or endocervix to upper reproductive
structure leads to scar tissue formation
Scar tissue blocks normal movement of egg from falopian tube to uterus, leading to infertility or ectopic pregnancy

49

List symptoms of PID

lower abdominal pain
fever
vaginal discharge with foul odor
painful intercourse
dysuria
intermenstrual bleeding
Fitz-Hugh-Curtis syndrome of upper quadrant peri-hepatitis

50

How is PID diagnosed?

Clinical suspicion is key
- cervical motion tenderness, uterine tenderness, adnexal tenderness
AND
- presence of WBCs in vaginal secretions or mucopurulent cervicitis

Supportive findings: bacterial vaginosis, fever, elevated ESR or CRP

51

How is PID treated?

broad spectrum antibiotics including activity against Chlamydia trachomatis and Neisseria gonorrhoeae as well as strep, GNRs, anaerobes
testing for HIV, syphilis

52

What are sequelae of PID?

ectopic pregnancy
chronic pelvic pain

53

How can PID be prevented?

screening for chlamydia

54

_________ is the most common cause of vaginal discharge in the US

bacterial vaginosis

55

Describe the pathogenesis of bacterial vaginosis

Replacement of lactobacillus (produce H2O2) with anaerobic bacteria

Can be a risk factor for acquisition of other STIs and post-operative infections

56

List risk factors for bacterial vaginosis

Multiple male or female sexual partners
New sex partner
Lack of condom use
Douching
Lack of vaginal Lactobacillus sp.


**BV increases the risk for acquisition of HIV, C. trachomatis, N. gonorrhoeae, HSV 2

57

Describe clinical exam findings in bacterial vaginosis

white or grey discharge with fishy odor
wall contains grey homogenous discharge
no inflammation of vaginal wall or cervix and no tenderness (BV does not cause PID, cervicitis, or cervical/ uterine/ adnexal tenderness, if inflammation is present there are two diagnoses)

58

How is bacterial vaginosis diagnosed?

Must meet 3 of 4
- homogenous thin white discharge with fishy odor
- positive whiff test with 10% KOH
- vaginal pH > 4.5
- wet mount of vaginal fluid shows clue cells (epithelial cells coated with coccobacilli)

59

How is bacterial vaginosis treated?

Metronidazole or clindamycin
avoid intercourse

60

What are complications of bacterial vaginosis?

Increased risk of other STIs
Increased risk of post-op complications
Can cause PROM, early labor, preterm birth, postpartum endometritis

61

List 5 infectious causes of genital ulcers

Haemophilus ducreyi (chancroid)
Klebsiella granulomatis (donovanosis)
Chlamydia trachomatis L1, L2, L3 (LGV)
Treponema palladum (syphilis)
HSV

62

Describe the epidemiology of HSV

50 million people with genital infection, 1/5 adolescents and adults
more common in women

63

HSV-1 replicates in the _____ ganglia; HSV-2 replicates in the _____ ganglia

HSV1 in trigeminal
HSV2 in sacral

64

Describe the pathophysiology of genital HSV infection

HSV penetrates mucosal surfaces to replicate in the epidermis and dermis. The virus enters nerve cells, is transported within the neuron to bodies of ganglia
After initial infection, the virus
remains latent in the ganglia (episomal, not integrated into the host DNA).
During reactivation, the virus spreads to skin and mucosal surfaces by peripheral sensory nerves, which can result in asymptomatic shedding or formation of new blisters.

65

Describe primary HSV infection, non-primary first episodes, and recurrence

Primary: symptomatic or asymptomatic infection with no antibodies developed

Non-primary first episode: fever, headache, malaise, myalgia with local ulcers and adenopathy

Recurrence: subsequent episodes tend to be milder, resolve faster, and decline over 5+ years

66

How are HSV1 and HSV2 diagnosed?

PCR
Serologic assays
cell culture- cytopathic effect, lower sensitivity than PCR
Tzanck prep- giant cells with inclusions, not specific

67

How is genital herpes treated?

Acyclovir, Valacyclovir, Famciclovir.

All people get therapy for first episode
Then can chose episodic or suppressive therapy

68

What are complications of HSV in pregnancy?

Greatest risk if HSV is acquired during pregnancy
Neonatal transmission via infected vaginal secretions during birth

Prevention: acyclovir starting at 36 weeks, avoid intercourse with positive partners during 3rd trimester; delivery by Cesarean if lesions are present at delivery

69

Syphilis is caused by ______

treponema pallidum, a spirochete

70

Describe the pathogenesis of syphilis

T. pallidum penetrates mucous membranes then enters the bloodstream and lymphatics to widely disseminate throughout the body. Disseminated disease lasts until a sufficient immune response develops to control T. pallidum replication.
The incubation period is directly proportional to the size of the inoculum and clinical lesions appear when 10^7 organisms/ mg tissue

71

The pathologic lesion characteristic for all stages of syphilis is _____

obliterative endarteritis

72

Describe the stages of syphilis

1. Primary syphilis: development of chancre at sit of inoculation with painless lymphadenopathy
2. Secondary syphilis: constitutional symptoms plus rash (palms and soles), condyloma lata, mucous patches, alopecia, syphilitic rash
Latent syphilis: symptoms disappear. In early syphilis, there can be relapses of mucocutaneous symptoms but no relapses in late latent syphilis
3. Tertiary syphilis: involvement of neural and vascular tissue, gummatous local tissue damage

73

List complications of congenital syphilis

Greatest risk early in infection when there is spirochetemia
late abortion, still birth, neonatal death, neonatla disease

74

How is syphilis diagnosed?

Serology, PCR
Two different serologic methods must be used for diagnosis
- nontreponemal: VDRL, RPR, used to monitor response to therapy; will decline with therapeutic success
- treponemal: TPA-ABS, TPPA, TPHA, MHA-TP; used as confirmation of diagnosis and will remain positive for life

75

How is syphilis treated?

penicillin
- 1 IM dose if Primary, secondary, early latent
- 1x weekly doses for late latent, tertiary
- IV for neurosyphilis

76

The etiologic agent of granuloma inguinale (also known as Donovanosis) is _______, which is an encapsulated gram-negative rod that infects mononuclear cells

Klebsiella granulomatis

77

Describe the presentation of granuloma inguinale

The initial lesion is a small, painless papule or nodule that begins within 1-3 months after sexual exposure and develops into a beefy red, granulomatous ulcer with rolled edges and bleeds easily on contact

Lesions are NOT painful and there is no lyphadenopathy or bubo formation

78

How is granuloma inguinale diagnosed and treated?

Diagnosis based on clinical presentation, biopsy shows Donovan bodies in mononuclear cells

Tx= doxycyclin bid for ~3 weeks until lesions heal

79

________ are the etiologic agents of lymphogranuloma venerum

Chlamydia trachomatis serovars L1, L2, L3

80

Describe the stages of lymphogranuloma venereum

Primary stage: painless papule or pustule that develops into an ulcer that is often unnoticed
and resolves on its own (painless, self-limited ulcer).

Secondary stage: Painful inguinal of femoral lymphadenopathy (bubo) that is usually
unilateral, can be above and below the inguinal ligament (groove sign)

Tertiary stage: chronic inflammation of untreated infection leads to fibrosis of tissues and obstruction of lymphatics (elephantiasis) and widespread destruction of external genitalia

81

How is lymphogranuloma venereum diagnosed and treated?

Diagnosis: presentation and serology, aspiration of bubo

Tx= doxycyclin bid for 21 days

82

Which serotypes of HPV are high risk for cancer? Which cause genital warts?

16 and 18 are oncogneic
6 and 11 cause cancer

83

Describe the pathogenesis of genital warts

HPV DNA does NOT integrate into the host genome and replicates as extrachromosomal DNA in the nucleus of infected keratinocytes. HPV
infection begins with entry into the basal keratinocytes of the stratum basale. As the basal
cells divide, differentiate and progress to the surface, HPV replicates and induces
excessive proliferation of non-basal epithelial layers (e.g. stratum spinosum, stratum
granulosum, stratum corneum) to result in warts.

84

Describe the pathogenesis of HPV malignancy

HPV DNA is generally integrated into the host genome and induces basal cells to undergo excessive replication, which results in accumulation of deleterious mutations that result in dysplasia and progression to
malignancy

85

What is a complication of infection with HPV during childbirth?

Recurrent respiratory papillomatosis (RRP): occurs following inhalation of HPV-infected secretions during childbirth

result in altered cry, hoarseness, stridor and respiratory distress.

Most common HPV
genotypes to cause RRP= 6 and 11.

86

List treatments for genital warts

Patient applied: imiquimod, podofilox, sinectachin
Provider administrated: liquid nitrogen, podophyllin, trichloroacetic acid, bichloroacetic acid, surgical

Prevention: 2 vaccine options (quadrivalent and bivalent)

87

What is appropriate treatment for pediculosis pubis?

Pubic lice
permethrin cream + decontamination of bedding and clothing
evaluate for other STIs

88

_______ is usually sexually transmitted in adults but not in children

Sarcoptes scabiei- scabies

89

What is appropriate treatment of scabies?

Permethrin cream + decontamination of bedding and clothing

90

List the 5 P's of taking a sexual history

Partners
Practices
Protection from STDs
Past history of STDs
Prevention of pregnancy

91

In chlamydia infection, the _____ body is the infectious particle that infects the cell. The ______ body replicates within the cell. The ____ body assembles and exits the cell

Elementary body- enters and exits
Reticulate body- replicates within the cell