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Flashcards in STIs Deck (44)
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1

When you touch each other...

you will get pregnant, and you will die.

2

Risk factors for STIs

unmarried
residence in an urban area
new sex partners
multiple sex partners
history of a prior STI
illicit drug use
contact with sex workers
young age (15-24)
african american
admission to correctional facility or juvenile detention center
meeting partners on the internet

3

What are the potential etiologies for a patient with a genital ulcer?

STI- HSV, syphilis, chancroid, LGV
noninfectious- Behcet's disease, fixed drug reactions and trauma

4

Herpes Simplex Virus (HSV)
causative agents
types of infection

HSV-1 and HSV-2

Types
-Primary: infection in a patient without antibodies to HSV1 or HSV-2 (has lesions but not abys)
-Nonprimary: first episode infection due to acquiring genital HSV-1 w/ preexisting antibodies to HSV-2 or vice versa
-Recurrent: reactivation of genital herpes in which the HSV type recovered in the lesion is the same type as the antibodies recovered in the serum

5

HSV Sx
primary
nonprimary
recurrent

primary
-highly variable from symptomatic to asymptomatic
-sx tend to be more severe in women
-systemic sx, local pain/itching, dysuria (d/t urinary retention or more rarely to lumbosacral radiculomyelitis), lymphadenopathy

nonprimary
-less symptomatic than first episode

recurrent
-less severe/shorter duration

**asymptomatic shedding**

6

HSV
transmission
Dx

HIGHLY transmittable via the oral-genital route

-remember, any break in the skin gives you an increased chance of HIV

Dx
-viral cultrue if active lesions present
-PCR: more sensitive
-direct fluorescent
-serology: type-specific antibody testing of serum, helps determine if the pt is at risk of acquisition, determines if a patient has had evidence of prior infection
-CAN do screening for HSV

7

HSV
tx drugs
therapy for primary genital infections
therapy for recurrent disease

-Acyclovir (Zovirax)
-Famcyclovir (famvir)
-valacyclovir (valtrax)

Primary HSV
-should be treated within 72 hours
-decreases duration of sx, increases healing of lesions, decreases viral shedding
-analgesics may be required/ sitz baths helpful

Recurrent disease
-chronic suppressive therapy: expensive and may not be covered by all insurance carriers
-episodic therapy: start at the first sign of prodromal sx, usually take for three days
-no intervention

8

What is the most common mode of transmission of HSV?

From direct contact of the fetus with infected vaginal secretions during delivery

9

What is used to treat HSV in pregnancy?

Acyclovir

10

When do we do a prophylactic C-section?

If the mother has active HSV lesions in the birth canal.

Do NOT do if infected mother has:
-no active lesions
-lesions that have crusted
-active nongenital HSV lesions (cold sores)

**Maternal immunity is important

11

Does HSV always appear right away?

No, it could take years to show up.

-pts need to be educated that they may not have acquired the infection recently and that there had not necessarily been infidelity in a monogamous partner

12

Syphilis
Causative agent
Culture?
Serological tests available
who to screen?

Treponema palidum

Cannot be cultured! Can be seen with DARKFIELD microscopy. Instead, do serological test.

Serological tests-
Nontreponemal: VDRL, RPR, TRUST/ reported as titers
Treponemal: (reported as reactive or nonreactive)

Screen
-patient with suspected disease
-high risk populations (pts with other STIs, multiple sex partners)
-routine screening of pregnant women
-commercial sex workers
-all sexually active HIV- infected patients at least annually; more frequent screening for those w/ multiple sex partners and unprotected intercourse

13

What do you do when you diagnose a pt with syphilis?

offer HIV testing and counseling

It is a reportable infection in the US

14

Syphilis transmission

Primary and secondary syphilis produce chancres, mucous patches, and condyloma lata

spread by kissing or touching a person who had active lesions on the lips, oral cavity, breasts, or genitals

can be passed through the placenta

15

Primary syphilis
incubation period
sx

incubation period of 2-3 weeks from inoculation- a papule forms and soon ulcerates to the chancre

chancre is usually painless, they heal spontaneously 3-6 weeks even without treatment

Usually bilateral lymphadenopathy

16

Secondary syphilis
sx

-Weeks to a few months later 25% of people w/ untreated infections will develop systemic illness

sx:
-rash: any form BUT vesicular, INCLUDES THE PALMS/SOLES
-grey/white lesions in warm moist areas- condyloma lata
-systemic sx
-lymphadenopathy
-alopecia (patchy)
-hepatitis
-GI abnormalities
-musculoskeletal and renal abnormallities
-ocular disease

17

Tertiary Syphilis
sx

1-25 years after secondary syphillis:
-early tertiaty syphilis presents = 1 year
-Late tertiary syphilis presents > 1 year from initial infection

Systems involved
-subcutaneous tissues (gumma)- granuloma
-CV: ascending thoracic aorta becomes dilated aortic valve regurgitation occurs
-CNS: (most common)
--early: meningitis, meningiovascular disease
--late: general paresis, tabes dorsalis, ocular, otosyphilis

18

What do you do when you suspect Neurospyhilis?

a Lumbar puncture!

CSF findings:
-lymphocytic pleocytosis
-elevated protein
+ a serological test like CSF-VDRL, and or FTA-ABS

**need to follow CSF during treatment to make sure there is a response

19

Treatment for early syphilis

For primary, secondary syphilis and early latent:
2.4 million units of PEN G

-for pcn allergy pts, preferred drug is doxy 100mg BID for 14 days

20

Treatment for late syphilis

-pts with gummas or CV invlvment need to have an LP to r/o neurosyphilis before treatment

if they have localized disease:
-2.4 million units of PEN G IM weekly for 3 weeks
-Gumma will resolve
-it will only halt progession of CV disease and some prefer to treat CV disease like neurosyphilis

21

tx of neurosyphilis

-IV PEN G
-pts who are allergic to PCN should undergo PCN desensitization since PCN G is the DOC for treating neurosyphilis and an allergist should be consulted
-non-penicillin regimens are not recommended for pts with neurosyphilis

monitoring
-pts need to be reexamined at 6 weeks and 12 months after tx
-a titer should be drawn just prior to starting tx and the same test and lab should be used for follow up

22

Human Papillomavirus (HPV)
manifestations

Double-stranded DNA viruses Papillomavirus genus

manifestations
-genital warts (condyloma acuminatum)
-bowenoid papules and Bowen's disease
-giant condyloma (Buschke-Lowenstein tumors) (huge genital warts)
-Intraepithelial neoplasia and/or carcinoma of the vagina, vulva, cervix, anus, or penis
-Plays a role in squamous cell carcinomas of the head and neck particularly the oral cavity

23

What HPV strains cause cancer? warts?

HPV 16 and HPV 18 account for 70% of all cervical cancers worldwide

HPV 6 and HPV 11 cause about 90% of genital warts

24

Paradigm of cervical carcinogenesis

*most HPV infections usually resolve within 6-12 months (including the carcinogenic HPV genotypes)

-HPV acquisition
-HPV persistence
-progression of persisting infection to precancerous lesion
-local invasion

25

What is the most common viral sexually transmitted disease in the US?

Anogenital warts (HPV)

-persistent infections especially with other risk factors (such as HIV) can result in the development of squamous cell carcinoma

26

Anogenital warts
sx

asymptomatic
pruritis, burning
bleeding
tenderness, pain
discharge (women)
large condylomata can interfere w/ defecation, intercourse, and vaginal delivery
lesions in the proximal anal canal may cause strictures

27

Anogenital warts
Dx

-dx made by visual inspection
-document extent of involvement by PE,, anoscopy, sigmoidoscopy, colposcopy, and or vaginal speculum exam

-5% acetic acid (vinegar) causes lesions to turn white
*consider bx when dx is uncertain or presence of atypical features or lesions that do not respond to tx

28

Anogenital warts
Tx

-spontaneous regression occurs 20-30% cases
-all therapies have a 30-70% recurrence rate

Ablative
-podophylliin (contraindicated in pregnancy)
-imiguimod (aldara)- also used for IEN vulva/anus
-Trichloroacetic acid (applied by provider)
-5-fluoruracil (5-FU) (applied by provider)
-Intralesional injected alpha interferon

Excisional
-cryotherapy
-laser therapy: requires anesthesia/risk of scarring
-with knife or scissors: requires anesthesia, risk of infection and hemorrhage, need to send specimen to path

29

What are the three main causes of urethritis in males?

Gonorrhea
-usually can get discharge w/milking the urethra
-Urethral swab will be positive for WBCs and GRAM NEGATIVE INTRACELLULAR DIPLOCOCCI

Chlamydia
-commonly concurrent

Trichomonas vaginalis
-the cause of "nongonococcal urethritis" (NGU)

30

Trichomonas vaginalis
-causes?
-presentation in women? (because men can be infected with this)

-causes 20-35% of vaginitis in symptomatic women
-always sexually transmitted

Presentation
-can be asymptomatic carrier
-purulent, malodorous, thin discharge (70%)
-burning, pruritus
-dysuria, frequency- urethral involvement
-dyspareunia, postcoital bleeding