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probable dx of chancroid

Clinical findings compatible with the diagnosis plus negative darkfield microscopic examination for Treponema pallidum (chancre), negative serologic test for syphilis, and negative culture for herpes simplex virus (HSV) or a clinical presentation not typical for herpes.


Incubation period of chancroid

4-10 days


understanding dilution

**changes in titer- a titer should be obtained just before initiating therapy (ideally on 1st day of tx) since titers can increase dramatically over a few days between dx of syphilis and treatment initiation***


Incubation of chlamydia in women

7-14 days following infection


recurrent hsv

reactivation of genital hsv in which the hsv type recovered in the lesion isthe same as the antibodies in the serum


tx hsv2

acyclovir, valacylovir, famciclovir will decrease frequency and the duration of recurrences. Can do suppressive therapy of 500mg a day of Valtrex since 33% of the time you are pre-prodromal and begin viral shedding. Episodic is 1000mg Valtrex daily x 3 days.


treatment for syphilis

abx tx must be prolonged since T. pallidum divides slowly (average is 1 doubling vivo per day) tx in early and late stages- single dose of benzathine penicillin G (2.4 million units IM) this provides low but persistent serum levels of penicillin and is standard for therapy for primary, secondary, pr early latent syphilis



Painless ulcer on the shaft of the penis or the labia dx with venereal syphilis. 1-2cm in diameter and raised, smooth, sharply defined borders. Chancre is concave in the center.


Symptoms of extensive condyloma acuminatum involving vulva

vaginal discharge, pruritis, bleeding, burning, tenderness, pain


s/s PID in women

abd pain, abnormal vaginal bleeding, dyspareunia. Nongonococcal salpingitis may be febrile and more ill. Bartholinitis. Complications w pregnancy


Advantages for azithromycin in tx chlamydia

intracellular and tissue penetration, single dose due to half life of 5-7 days, can be used in pregnant patients


Infection of H. ducreyi leads to

erythematous papule which rapidly evolves into a pustule that erodes into an ulcer


Women with gonorrhea

Can be isolated to the urethra in 90% of cases, may only have urinary s/s of dysuria, urgency, frequency. Worry about PID and Cervicitis.



cream BID to penetrate lesions that are obvious. If lesions are inside rectum need colorectal surgery


Questioning and ROS

critical in syphilis. 12 months has massive meaning- be very accurate. be redundant in your questioning to get the correct information


Use of cephalosporins in gonn

used because of non cephalosporin resistance. Uncomplicated use ceftriaxone 250mg IM plus Azithromycin 1gram to cover for chlamydia or can do 100mg Doxy BID x 7 days instead which is for azithromycin intolerant patients and for cases of epididymtsis or proctitis


Treat chancroid

one dose Azithromycin 1g PO or Rochephin 250mg IM - less desirable, Cipro 500mg PO BID x 3 days


Tx Chancre

Heals 4-6 weeks even w out treatment. Primary syphillus tx is PCN G IM. PCN allergy use Doxy or Tetracycline.


diagnostic work up of primary syphilis

- diagnosis can be made by dark- field examination which has a high specificity for T. pallidum
 (since this test is not readily available, dx is generally based on clinical suspicion and a positive RPR serology which occurs in 85% of primary cases)


Quinolones in tx Chlamydia

Ofloxacin and Levofloxacin are highly effective but need a full week of therapy and are more expensive, they CANT BE USED IN PREGNANT OR LACTATING WOMEN and can not be used in ADOLESCENTS YOUNGER THAN 18 D/T BONE ABNORMALITIES. Oflaxacin 300mg PO BID x 7 days. Levofloxacin 500mg PO once daily x 7 days. Only good for non pregnant and older who cannot tolerate first line therapy of doxycycline or azithromycin


false positive nontreponemal tests have been associated with?

pregnancy, IV drug use, TB, and rickettsial infection


Skin lesions in disseminated gonorrhea

Fever with painful joints, tender necrotic ulcers painful pustular gonn, painless is syphillus... hemorrhagic vesicopustule of the web space of the hand and sole of foot... fever with necrotic vesicles on arms and legs, tender purpuric papules on right leg with fever and joint pain


Cutaneous manifestations of gonorrhea

can have penile ulcers, purulent discharge of the urethra will also be present. Penile edema can be present painless swelling. More common in young boys. Skin lesions are in disseminated gonococcal infection with typical small pustular skin lesion


pregnant women can transmit T. Pallidum to their fetus (ie, congenital infection) for up to ?

for up to 4 years


what should be ordered if late syphilis is suspected?

spinal tap


a confirmed 4 fold increase in the non- treponomal titer signifies?

treatment failure, so need re- treatment (but definitive criteria for cure or failure have not been established)


trepnoemal tests

Treponemal tests have historically been more complex and expensive to perform; **they have traditionally been used as confirmatory tests for syphilis** when the nontreponemal tests are reactive nemal infect


Description of Behcets syndrome

painful "punched- out" apthous- type ulcers with rolled borders and necrotic bases on the patient's penis

ulcers erupt in a cyclical pattern that may persist for several weeks



Male symptoms of chlamydia

Penile discharge, burning with urination, burning and itching around penile opening


what is considered a significant change reflective of a response to tx of syphilis (when talking about titers)?

a 4 fold decline in titer, equivalent to a change of 2 dilutions (i.e. from 1:16 to 1:4 or from 1:32 to 1:8) is considered a significant change


Chancroid treatment

Also tx for syphillus due to frequent coinfection. Tx options include erythromycin, bactrim, cipro, rochephin, azithromycin. Proven chancroid: 1 g PO Azithromycin or IM Rocephin. Examine and treat the sex partners for chancroids.


need what 2 lab tests for syphilis

RPR (non treponemal) and FTA (treponemal) if both positive- true case


important distinctions of stages of syphilis

primary: ulcer or chancre at the infection site

secondary: manifestations include (not limited to) skin rash, mucocutaneous lesions, and lymphadenopathy

tertiary: cardiac or opthalmic manifestations, auditory abnormalities

latent infections: those lacking clinical manifestations are detected by serologic testing


Genital warts the where and why

Women - primarily caused by vaginal intercourse or from receptive anal or extension of vulvar infection. men - preputial cavity or penile shaft through heterosexual or homosexual contact. Increase risk with increased partners. Symptoms vary depending on number of lesions and location.



stretch skin and put acid into the lesion BID 4 days on and 3 days off for 4 weeks


what is this?

chancre of primary syphilis


What is this?


If > 3 herpes outbreaks each year screen for



Chlamydia trachomatis in Women

Most common BACTERIAL cause of STIs. Most women are asymptomatic. If infected at the cervix have 0 s/s. Pyuria but no bacteriuria suspect chlamydia infection of the urethra.


Most efficient initial treatment for warts

Podofilox - a teaching moment


Typical chanchroid ulcer size

1-2cm diameter


What is this?

a chancre d/t syphilis is an ulcerative lesion that is often painlass and has an indurated character. They arrive at the site of initial inoculation of the organism.

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the most common manifestations of late syphilis, when do they appear?

- central nervous system involvement (neurosyphilis)

- cardiovascular syphilis (especially aortitis)

- gummatous syphilis (very uncommon in the present era)

They appear at any time from 1 to 30 years after primary infection


Invasive infections of gonorrhea

endocarditis, menigitis, disseminated gonococcal infection can all lead to morbidity


Incubation of chlamydia in men

5-10 days following infection


Clinical sydromes common in women and men

conjunctivitis, pharyngitis, genital lymphogranuloma venereum


treponemal tests include

Fluorescent treponemal antibody absorption (FTA- ABS) Microhemagglutination test for antibodies to T. pallidum (MHA- TP) T. pallidum particle agglutination assay (TP- PA ) T. pallidum enzyme immunoassay (TP- EIA)


probable late latent phase of syphilis

syphilis must also be asymptomatic and have serologic and have serologic evidence of disease. However- NO evidence of that the disease was acquired within the last 12 months.

They don't know when they got it.


Always rule this out when treating an STI



treatment for late syphilis

requires 3 doses of 2.4 million units benzathine penicillin G IM each at one week intervals. Neurosyphilis (considered late) requires IV therapy with penicillin (IV penicillin G, 3- 4 million units Q4 or 18-24 million units per day by continuous infusion for 10 to 14 days)


incubation period of syphilis?

varies from 10 to 90 days (average about 3 weeks)


diagnosis of secondary syphilis

- screening for syphilis is achieved by the rapid plasma reagin (RPR) or the venereal disease research lab test (VDRL)

- all positive tests should be confirmed with tluorescent treponemal antibody (FTA)



what is this?

primary syphilis chancre



- CNS involvement can occur during any stage of syphilis

- pts who have clinical evidence of neurologic involvement with syphilis (cognitive dysfuntion, motor or sensory deficits, opthalmic or auditory symptoms, cranial nerve palsies and symptoms or signs of meningitis) should have a CSF examination

-syphilitic uveitis or other ocular manifestations frequently are associated with neurosyphilis


Incubation of chlamydia

7-14 days following infection


Making the dx of Chlamydia

silent disease, 3/4 women no s/s, 1/2 men no s.s. If + s/s, usually 3 weeks after exposure. Dx with nucleic acid amplification testing for the genitourinary tract. use vaginal swabs for women, first catch urine for men


mucous patches of secondary syphilis

could appear on a variety of mucous membranes

(highly infectious)

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Treatment for secondary syphilis

-treatment for early disease (primary and secondary for less than 1 year) is 1 dose of IV benzathine penicillin G

- for late disease, PCN G is given once a week for 3 weeks.

- follow up includes RPR at 3, 6, and 12 months to assess respinse to treatment


Refer this since condylomata to surgery

1-2cm at the base - can burn the stalks off by colorectal surgery


lymphadenitis with chanchroid

follow up in 7-10 days, this is from the infection itself, if after treatment and still enlarged need to rule out lymphoma


Herpes clinical designations

primary, nonprimary first episode, and recurrent. underrecognized because infection is subclinical.


what is behcet's syndrome?

- it is an inflammatory, multisystem syndrome of recurrent apthous ulcers affecting the mouth, skin, eyes, and/or genitals.

- it may also be associated with synovitis, thrombophlebitits, or neurological disorders


Treatment for warts that can be self administered

podofilox 0.5%


treatment of primary syphilis

Benzathine penicillin G 2.4 million units IM in one dose

Alternative tx in the PCN- allergic consists of doxycycline 100mg PO BID for 2 weeks.

(RPR testing should be repeated 3, 6, and 12 month intervals until there is a fourfold drop in titer.)


Female genital herpres simplex virus

very painful, open moist infectious, can use lidocaine paste


DX Condylomata

visual inspection, can do exam with anoscopy, sigmoidscopy, colposcopy or vaginal speculum exam as appropriate. Can put 5% acetic acid to turn lesions white but not specific. Can biopsy if uncertain. If anal lesions need a DRE and to send to colorectal surgery, do DRE with pt on all 4s.


Female s/s chlamydia

Cervix and urethra are initially infected, if they do have s.s it is usually abnormal vaginal discharge or a burning sensation when urinating. if fallopian tubes infected may have abd pain, low back pain, nausea, fever, pain during intercourse, can spread to rectum from the cervix. Can have rectal or oral pain, discharge, bleeding.


Quinolones in tx Chlamydia

Ofloxacin and Levofloxacin are highly effective but need a full week of therapy and are more expensive, they CANT BE USED IN PREGNANT OR LACTATING WOMEN and can not be used in ADOLESCENTS YOUNGER THAN 18 D/T BONE ABNORMALITIES. Oflaxacin 300mg PO BID x 7 days. Levofloxacin 500mg PO once daily x 7 days. Only good for non pregnant and older who cannot tolerate first line therapy of doxycycline or azithromycin


MSM extragenital infections of gonorrhea

pharynx and rectum


Patients with chancroid should be also treated for what?

Co -infection w T. pallidum - causative agent of syphillus.


description of primary syphilis

- 2-3 mm ulcer on the distal shaft of the penis with an indurated, raised, firm border

- scant exudate at the ulcer base

- ulcers are relatively painless unless secondarily infected

- regional nonsupportive adenopathy generally develops in 50- 85% of patients within one week.


perianal condyloma acuminatum

around rectum, can be itchy, leading to autoinoculation from scratching


understanding the serologic evidence- probable early latent syphilis

A. Patients without a past diagnosis of syphilis must have a reactive nontreponemal test (eg, VDRL, RPR, or equivalent serologic methods) *AND* a reactive treponemal test (eg, F TA-ABS, TP- PA, EIA, CIA, or equivalent serologic methods) B. Patients with a prior history of syphilis must have a current nontreponemal test titer that demonstrates a **fourfold or greater** increase from the last nontreponemal test titer. • Accurate history of the last 12 months is critical


Men with gonorrhea

Symptomatic urogenital gonococcal infections in men include urethritis and epididymitis. Discharge spontaneously from the urethral meatus, purulent or mucopurulent in color and copius. Scrotal heaviness until ejaculation. Profuse penile discharge with dysuria 5 days after unprotected sex. Gram stain of discharge shows polymorphonuclear gram negative diplococci. Can be from oral sex w someone with tonsil gonorrhea too.


Dx Chancre

sample the chancre. Treponema pallidum, a corkscrew organism under DARKFIELD microscopy. RPR and VRDL serological syphillus tests -- is nonreactive in 25 percent. FTA-ABS TEST IS DEFINITIVE.



Hemophilus ducreyi needs to be detected to be a true chancroid, a small, fastidious negative rod isolated from the lesion. Penile ulcer due to chancroid which is accompanied by marked inguinal lymphadenitis. Definite dx is when you isolate H. ducreyi from the lesion.


Chlamydia trachomatis

Most common bacterial cause of STIs. Most women are asymptomatic. If infected at the cervix have 0 s/s. Pyuria but no bacteriuria suspect chlamydia infection of the urethra.


Chlamydia - the what in Men - Caused by, s/s,

C. trachomatis is the most common cause of non-gonococcal urethritis in men. Watery, urethral discharge, prominent dysuria. In contrast to copious, purulent green soup discharge found in gonorrhea w a shorter incubation period of 2-7 days.

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probable early latent syphilis

considered "probable" if a patient has no clincal signs or symptoms of syphilis and has serologic evidence of T. pallidum infection that was aquired within the last 12 months

believed to be potentially infectious


Must consider these conditions when treating chlamydia in men

Epididymitis, prostatitis, proctitis because is changes abx course takes longer to get through enlarged prostate


Chlamydia transmission

Transmission: oral sex, vaginal sex, anal sex, mother to child during birth, greater with greater number of sex partners. Sex partners need to be evaluated.


drawbacks of doxy in tx chlamydia

costs less but there are supply shortages, may not be compliant week long and BID


Gonococcal infection - the what

Bacterial gram negative coccus Neisseria gonorrhoeae, major cause of morbidity worldwide. In men can cause urethritis and in women cervicitis. In women: can result in PID, ectopic pregnancy, infertility and chronic pelvic pain


Selcting abx for gonorrhea what other disease should you treat?

Chlamydia, esp since it is asymptomatic in women


Warts inside mouth tx

burn off by dental surgery


latent syphilis aquired within the preceding 12 months is referred to as ?

early latent syphilis. (all other cases are either late latent or latent of unknown duration)


Genital warts (Condylomata acuminata - anogenital warts) the What

most common VIRAL STI in the united states. Incubation 3 weeks to 8 months. Most are transient and clear within 2 years. Increase risk for anogenital cancers. Passed sexually. Contact transmission, spread from fomites, digital/anal, oral/anal, digital/vaginal. Gardasil provides protection as warts lead to HPV.



herpes labialis, vesicle lesions of the oral mucosa cold sores, can also be in the genitalia, liver, lung, eye and central nervous system. need a good hx to dx. confirm with lab testing


what can syphilis be compared to ?

proteus- changed shape to avoid attention. Protean means as mutable and adaptable as the mythological shepard.


Complications of gonn in men

penile lymphangitis, penile edema - bulls head clap - periurethral abscess, post inflammatory strictures, epididymitis. Can spread to rectum or phaynx


Primary hsv

infection in a patient without preexisting antibodies to either hsv1 or hsv2


nonprimary hsv

acquisition of genital hsv-1 in a patient with preexisting antibodies to hsv2 or vice versa ie a patient with prior orolabial herpes and subsequent development of hsv1 antibody response then develops genital herpes due to hsv2 exposure


WBC w Urethritis in Gonorrhea

>5 with s/s urethritis


understanding the serologic evidence- probable late latent syphilis

A person with "probable" late latent syphilis must also be asymptomatic and have serologic evidence of disease as described for **probable early latent** • There is no evidence that the disease was acquired within the last 12 months


description of secondary syphilis

- erythmatous, non- pruritic papules on back, torso and palms consistent with secondary syphils

- normally appears around 6 weeks after the inital lesion (chancre)

- often accompanied by flu- like illness, hepatosplenomegaly and lymphadenopathy

- lesions vary widely causing the axiom "the great imitator"

-usually erythematous or pink, papular and occur diffusely, notably on the palms and soles



Diagnostic workup of HSV2

Confirmed by VIRAL CULTURES. Use culture to confirm first episode since antibodies take weeks to develop.


Recurrence of s/s chlamydia

after initial resolution need a repeat test for chlamydia and other STIs causing urethritis or cervicitis such as gonorrhea or BV.


Who developed serologic testing for syphilis?

Wasserman in 1906


probably dx of chanchroid

one or more probably ulcers, no evidence of t pallidium by darkfield exam of ulcer exudate or serologic testing, clinically presents as chancroid, HSV on ulcer is negative


treatment for behcet's syndrom

topical tx of ulcers with glucocorticosteroids and oral NSAIDS for pain relief are mainstays of treatment.


HSV2 Vaginitis

Grouped vesicular lesions on an erythematous base on the vulva. 70-90% of cases of genital herpes are caused by HSV2. HIGHLY CONTAGIOUS. Characterized by recurrent outbreaks of grouped vesicles on an inflammed red base. CLASSIC PRODROME of burning or itching, with flu like symptoms followed by an outbreak of vesicles


Pregnant tx with gonn

dual therapy: Ceftriaxone plus Azithromycin, avoid Doxy


diagnostic work up for behcet's syndrome

diagnosis based upon clinical presentation; recurrent ulcers with at least 2 other systems affected


Gonococcal conjunctivitis the when

Autoinoculation from anogenital source. Can lead to an outbreak from fomites, vectors, person to person non sexual contact, Mainly affects infants born to untreated mothers


Clinical designations of HSV

Primay, nonprimary first episode, recurrent


immune modulator agents for warts

aldara and interferon -- needs repeat applications


C. trachomatis is highly susceptible to

tetracyclines and macrolides. first line: azithromax 1gm single dose or doxy 100mg PO BID x 7 days if adherent and not pregnant