Sexually Transmitted Infections

Front 1

At the outset, two common errors in approaching a patient with an STI should be avoided.

Back 1

The first error is failing to consider that an individual is at risk for an STI. All sexually active persons are at risk, not only because of their own sexual behavior, but because of their sexual partner's behavior as well. Failure to consider risk factors often results in mistakes in diagnosis, inappropriate treatment, poor follow-up of infected sexual contacts, and, ultimately, recurrent or persistent infection.

A second error with STIs is failing to recognize and diagnose co-infection. The most serious co-infection is with HIV. The worldwide epidemic of STIs fuels the global spread of HIV. STIs, most of which can be readily diagnosed and treated, may greatly enhance the transmission of HIV infection. HIV, in turn, may alter the natural history of other STIs.

Front 2

The two most common and sexually transmitted infections in the United States are

Back 2

HSV-2 infection and syphilis.

Front 3

Genital herpes differs from other STIs in its tendency for

Back 3

spontaneous recurrence.

Front 4

HSV: transmission

Back 4

spread by direct contact with infected secretions.

Front 5

what type of HSV is the more frequent cause of genital infections

Back 5

HSV-2 is the more frequent cause of genital infection.
vi. The major risk of infection is in the 14- to 29-year-old cohort and varies with sexual activity.

Front 6

HSV: pathogenesis

Back 6

After exposure, HSV replicates within epithelial cells and lyses them, producing a thin-walled vesicle.

Multinucleated cells are formed with characteristic intranuclear inclusions.

Regional lymph nodes become enlarged and tender.

HSV also migrates along sensory neurons to sensory ganglia, where it assumes a latent state.

Exactly how viral reactivation occurs is uncertain.

During reactivation, the virus appears to migrate back to skin along sensory nerves

Front 7

what is the manifestation symptoms of HSV

Back 7

Genital lesions that develop 2 to 7 days after contact with infected secretions are the manifestation of the clinical illness.

Front 8

Where is HSV found in men

Back 8

In men, painful vesicles usually appear on the glans or penile shaft

Front 9

Where is HSV found in women?

Back 9

in women, they occur on the vulva, perineum, buttocks, cervix, or vagina. A vaginal discharge is frequently present.

Front 10

Many HSV patients describe a characteristic prodrome of

Back 10

tingling or burning for 18 to 36 hours before the appearance of lesions.

Front 11

HSV: Laboratory testing

Back 11

Although clinical features of HSV infection are suggestive diagnostically, these features are insensitive and not specific.

Also, knowing the infection is caused by HSV-1 or -2 is helpful prognostically, as HSV-1 infections are less likely to recur and viral shedding is less.

Diagnosis should be confirmed by laboratory testing.

Isolation of HSV in cell culture is the gold standard for diagnosis, but sensitivity is low.

Additional testing that may be performed includes Tzanck smear (66% sensitive) (see Chapter 93), Papanicolaou smear, immunofluorescent assay for viral antigen, and serologic testing.

Direct antigen detection by means of an enzyme immunoassay test shows greater sensitivity than culture for later-stage HSV lesions and is equivalent to culture for early-stage infection.

This is generally the diagnostic test of choice.

Front 12

Treatment: HSV

Back 12

Antiviral therapy for herpes genitalis has been shown to be beneficial and is the mainstay of management.

Oral acyclovir, valacyclovir, and famciclovir have all been shown to be effective in treatment of symptomatic HSV infection.

Front 13

After primary infection, treatment can follow one of two strategies

Back 13

episodic or chronic daily suppressive treatment

Chronic daily suppressive therapy has been shown to decrease the number of recurrences by 70% to 80% in those with six or more episodes per year.

This strategy has also been shown to decrease transmission of HSV from those infected, although viral shedding may still occur.

Despite the benefits of chronic daily therapy, acquired resistance to acyclovir has been seen occasionally in HIV-infected persons and in other immunocompromised hosts (e.g., after bone marrow transplantation).

HSV most commonly becomes acyclovir resistant through a mutation in the thymidine kinase gene.

Acyclovir-resistant HSV infection is commonly characterized by chronic, progressive mucocutaneous ulcers.

Front 14

Why is sphyilis of unique importance

Back 14

Syphilis is of unique importance among the venereal diseases because early lesions heal without specific therapy; however, serious systemic sequelae of untreated syphilis pose a major risk to the patient, and transplacental infections can occur.

Front 15

Primary syphilis occurs mostly in

Back 15

sexually active 15- to 30-year-old individuals.

Front 16

what is the antibiotic of choice for syphilis

Back 16

pcn

Front 17

syphilis and hiv

Back 17

HIV co-infection is increasing, which poses a serious problem because the mucosal lesions of primary syphilis facilitate transmission of HIV infection Also, HIV appears to accelerate the course of syphilis, with more rapid and frequent involvement of the neurologic system

Front 18

syphilis: pathogenesis

Back 18

Treponema pallidum penetrates intact mucous membranes or abraded skin, reaches the bloodstream by means of the lymphatics, and disseminates.

The incubation period for the primary lesion depends on inoculum size, with a range of 3 to 90 days.

Front 19

If the primary chancre is not treated, secondary syphilis may develop

Back 19

6 to 8 weeks later.

Front 20

what is involved in secondary sphyilis

Back 20

With secondary syphilis, skin, mucous membranes, and lymph nodes are involved.

Front 21

secondary sphyilis: skin involvement

Back 21

A variety of skin manifestations may occur, including macular, papular, papulosquamous, pustular, follicular, or nodular lesions.
Discrete, erythematous, macular lesions over the thorax or hyperpigmented macules on the palms and soles occur most commonly.

In moist intertriginous areas, large, pale, flat-topped papules coalesce to form highly infectious plaques or condylomata lata; darkfield microscopy reveals that these lesions are teeming with spirochetes.

Front 22

secondary syphilis: mucous membrane involvement

Back 22

Mucosal lesions are painless, dull, erythematous patches or grayish-white erosions. These lesions are infectious and darkfield positive as well.

Front 23

secondary syphilis: systemic manifestations

Back 23

Systemic manifestations of secondary syphilis include malaise, anorexia, weight loss, fever, sore throat, arthralgias, and generalized, nontender, discrete adenopathy.

Front 24

syphilis and HIV

Back 24

The natural history of syphilis may be altered by co-infection with HIV; such patients may develop signs and symptoms of secondary syphilis more rapidly, sometimes even before healing of the primary chancre.

Front 25

syphilis: diagnosis

Back 25

Serologic studies are the primary method for diagnosis of syphilis, but the diagnosis may also be made by darkfield examination or direct fluorescent antibody tests of clinical specimens.

Spirochetes can be seen in darkfield preparations of chancres or moist lesions of secondary syphilis.

Front 26

differential diagnosis for primary chancre

Back 26

includes herpes simplex and three conditions that are relatively rare in the United States:

chancroid,
lymphogranuloma venereum (LGV),
and granuloma inguinale.

Front 27

2. Primary
3. Secondary
4. Early latent
5. Healthy contact*

REGIMEN OF CHOICE

Back 27

Benzathine penicillin, 2.4 MU IM once

Front 28

2. Primary
3. Secondary
4. Early latent
5. Healthy contact*

PCN ALLERGY

Back 28

Penicillin desensitization or doxycycline, 100 mg PO twice daily, or tetracycline, 500 mg PO 4 times daily, both for 14 days; some experts recommend ceftriaxone or azithromycin

Front 29

Late latent or latent syphilis of unknown duration

REGIMEN OF CHOICE

Back 29

Benzathine penicillin, 2.4 MU IM per week for 3 wk

Front 30

Late latent or latent syphilis of unknown duration


PCN ALLERGY

Back 30

Penicillin desensitization, no regimen adequately evaluated; doxycycline, 100 mg PO twice daily, or tetracycline, 500 mg 4 times daily, both for 28 days

Front 31

Neurosyphilis

REGIMEN OF CHOICE

Back 31

Aqueous penicillin G, 20 MU IV daily for 10-14 days

Front 32

Neurosyphilis

PCN ALLERGY

Back 32

Penicillin desensitization or ceftriaxone, 2g IV or IM daily for 10-14 days

Front 33

In general, all stages and manifestations of syphilis can be treated with

Back 33

intramuscular benzathine penicillin; however, the presence of neurosyphilis requires modification of this standard therapy.

Front 34

what should be considered in all patients with with latent syphilis or latent syphilis of unknown duration especially if HIV co-infected.

Back 34

lumbar puncture

Front 35

diagnosis of neurosyphilis

Back 35

In absence of other CSF abnormalities, a patient with a persistently positive blood VDRL test result and a positive CSF VDRL test result should be considered to have neurosyphilis and treated accordingly.

Front 36

Jarisch-Herxheimer reaction.

Back 36

After initiation of treatment for syphilis, some patients may develop an acute febrile reaction called a Jarisch-Herxheimer reaction.

This reaction is thought to represent a systemic response to penicillin-induced lysis of spirochetes, and manifestations include fever, myalgias, and headache within 24 hours of treatment.

Antipyretics may be used.

This reaction is especially important in neurosyphilis, as patients may display an acute worsening of original presenting symptoms and signs.

Corticosteroid therapy may be administered for severe reactions.

Front 37

In successfully treated primary syphilis, the VDRL test result should become negative

Back 37

by 2 years after therapy (usually by 6 to 12 months).

The FTA-abs test result, however, often remains positive for life.

Front 38

In secondary syphilis, 75% of adequately treated patients will have a

Back 38

negative serum VDRL test result by 2 years. If the VDRL test result does not become negative or if a low fixed titer is not achieved, lumbar puncture should be performed to evaluate the possibility of asymptomatic neurosyphilis, and the patient should be re-treated with penicillin.

Front 39

All patients with syphilis should be tested for

Back 39

HIV infection.

All individuals infected with HIV should be tested for syphilis.

Front 40

what is the most common STI in the US

Back 40

C. trachomatis

Front 41

what is the second most common STI in the US

Back 41

Neisseria gonorrhoeae

Front 42

N. gonorrhoeae: epidemiological factors

Back 42

It is estimated that 600,000 new infections with N. gonorrhoeae occur each year.

Particular risk factors are urban location, low socioeconomic status, unmarried status, and large numbers of unprotected sexual contacts.

Fifty percent of women having intercourse with a man with gonococcal urethritis will develop symptomatic infection.

The risk for men is 20% after a single sexual contact with an infected woman.

Orogenital contact and anal intercourse also transmit infection.

Both men and women can have this infection and not have symptoms.

In fact, asymptomatic infection of men is an important factor in transmission.

Indeed, untreated patients may remain culture positive and capable of transmitting infection for periods of up to 6 months.

Co-infection with C. trachomatis is observed in up to 30% to 40% of patients with gonorrhea.

Higher rates of gonorrhea are being observed in MSM.

Front 43

Men with gonorrhea generally develop symptoms of

Back 43

urethritis including purulent discharge and severe dysuria.

These symptoms develop 2 to 7 days after sexual contact with an infected partner.

Front 44

Women with gonorrhea generally develop

Back 44

For symptomatic infections, cervicitis is the most frequent manifestation and results in copious, yellow, vaginal discharge.

Front 45

Gonorrhea: diagnosis

Back 45

1. Gram stain and culture, nucleic acid hybridization tests, and nucleic acid amplification tests are available for the diagnosis of N. gonorrhoeae (and C. trachomatis).

2. Growing the organism in culture is currently the only means by which susceptibility testing can be performed, and with resistance to many antibiotic classes developing in N. gonorrhoeae, this becomes important.

Front 46

The current recommendation for the treatment of uncomplicated gonorrhea is

Back 46

ceftriaxone, 125 mg given intramuscularly once, or cefixime, 400 mg orally once

Treatment of gonorrhea should always be followed by a course of doxycycline, 100 mg orally twice daily for 7 days, or azithromycin, 1 g orally as a single dose, to treat possible concurrent chlamydial infection

Front 47

___________ is the most commonly reported infectious disease in the United States

Back 47

Chlamydia is the most commonly reported infectious disease in the United States, and C. trachomatis is implicated in NGU 15% to 50% of the time.

Front 48

chlamydial infections: male symptoms

Back 48

Men and women with chlamydial infections may be asymptomatic.

However, in symptomatic infection, men generally report urethral discharge, itching, and dysuria, which are characteristic complaints indicating urethritis.

It is important to note that the discharge is not spontaneous but becomes apparent after milking the urethra in the morning. The mucopurulent discharge consists of thin, cloudy fluid with purulent specks.

Front 49

chlamydial infections: female symptoms

Back 49

Symptomatic women most commonly report vaginal discharge.

Two thirds of women with mucopurulent cervicitis have chlamydial infection.

Similarly, many women with the acute onset of dysuria, urinary frequency, and pyuria, but sterile urine, have C. trachomatis infection.

Untreated chlamydial infection in women may lead to PID, ectopic pregnancy, and infertility.

Front 50

chylamydial infections: diagnosis

Back 50

Culture, direct immunofluorescence, enzyme immunoassay, and nucleic acid hybridization and amplification tests are available for identification of C. trachomatis.

For diagnosis of cervicitis, nucleic acid amplification is the preferred method, as it is the most sensitive and specific test for Chlamydia.

In addition, this test may be performed on cervical swabs or urine specimens, making it a convenient option in clinics.

The exclusion of gonorrhea relies mainly on Gram-stained preparations of exudates and ultimately culture.

However, a nucleic acid amplification test may be performed for this purpose as well.

Screening for chlamydia at routine gynecologic examinations is now recommended for all women 25 years of age or younger.

Front 51

chylamydial infections: treatment

Back 51

The patient and all sexual contacts should be treated with azithromycin, 1 g orally as a single dose, or doxycycline, 100 mg orally twice daily for 7 days.

Front 52

Candidiasis (generally, Candida albicans): Epidemiology and Pathogenesis

Back 52

Yeast is part of normal flora; overgrowth favored by broad-spectrum antibiotics, high estrogen levels (pregnancy, before menses, oral contraceptives), diabetes mellitus; may be early clue to HIV infection

Front 53

Candidiasis (generally, Candida albicans): Clinical findings

Back 53

Itching, occasional dysuria; little or no urethral discharge; labia pale or erythematous with satellite lesions; vaginal discharge thick, adherent, with white curds; balanitis in 10% of male contacts

Front 54

Candidiasis (generally, Candida albicans): Diagnosis

Back 54

Vaginal pH = 4.5 (normal); negative whiff test; yeast seen on wet mount in 50%; culture positive; rapid tests available

Front 55

Candidiasis (generally, Candida albicans): Treatment

Back 55

Miconazole, butoconazole, terconazole, clotrimazole, nystatin or tioconazole cream or suppository for 3-7 days; fluconazole, 150 mg PO once

Front 56

Trichomonas vaginalis infection: Epidemiology and Pathogenesis

Back 56

STI; incubation 5-28 days; symptoms begin or exacerbate with menses

Front 57

Trichomonas vaginalis infection: Clinical Findings

Back 57

Soreness, irritation, mild dysuria, dyspareunia; copious loose discharge, one fifth yellow-green, one third bubbly

Front 58

Trichomonas vaginalis infection: Diagnosis

Back 58

Elevated pH; wet mount shows large numbers of WBCs, trichomonads; positive whiff test (10% KOH causes fishy odor); rapid tests available

Front 59

Trichomonas vaginalis infection: Treatment

Back 59

Metronidazole, 2 g PO once; tinidazole, 2 g PO once; treat sexual contacts

Front 60

Bacterial vaginosis: Epidemiology and Pathogenesis

Back 60

Replacement of Lactobacillus species with Gardnerella vaginalis, Mycoplasma hominis, and anaerobes (Mobiluncus and Prevotella species); associated with multiple or new partners, douching

Front 61

Bacterial vaginosis: Clinical findings

Back 61

Vaginal odor, little inflammation; mild discharge, grayish, thin, homogeneous with small bubbles

Front 62

Bacterial vaginosis: Diagnosis

Back 62

Elevated pH; positive whiff test; wet prep contains clue cells (vaginal epithelial cells with intracellular coccobacilli), few WBCs; rapid tests available

Front 63

Bacterial vaginosis: Treatment

Back 63

Metronidazole, 500 mg PO twice daily for 7 days; metronidazole gel (0.75%), 5 g intravaginally once daily for 5 days, or clindamycin cream (2%), 5 g intravaginally daily at night for 7 days; do not treat contacts unless recurrent vaginitis

Front 64

_______ is the most important cause of genital warts as well as cervical dysplasia and cancer in women

Back 64

HPV

Front 65

Of importance, there is now a quadrivalent vaccine that protects against infection with HPV types _, __, __, and ___, types most commonly implicated in genital warts and cervical cancer

Back 65

Of importance, there is now a quadrivalent vaccine that protects against infection with HPV types 6, 11, 16, and 18, types most commonly implicated in genital warts and cervical cancer

Front 66

Currently the three-vaccine series is recommended for ____ to _______-year-old girls, with catch-up vaccination offered to female patients aged _____ to _____ years

Back 66

Currently the three-vaccine series is recommended for 11- and 12-year-old girls, with catch-up vaccination offered to female patients aged 13 to 26 years

Front 67

HPV: epidemiological factors

Back 67

More than 100 types of HPV have been identified, and more than 30 can cause genital infection.

Important types include HPV types 6 and 11, which cause the majority of genital warts, and HPV types 16, 18, 31, 33, and 35, which can lead to cervical, vaginal, or anal cancer.

Patients infected with HPV can have more than one type of the HPV virus present simultaneously.

Front 68

HPV: Clinical presentation

Back 68

Genital warts are flat, papular, or pedunculated and are asymptomatic, in general.

However, depending on size and location, warts can be painful, pruritic, and friable.

The natural history of genital warts is benign, but recurrence is common.

Immunocompromised patients such as those with HIV may have warts that are larger in size and number.

Front 69

HPV: Diagnosis

Back 69

aHPV infection may be diagnosed by detection of HPV DNA, RNA, or capsid proteins in cells.

Identification of HPV infection is recommended as part of cervical cancer screening and is used in triage of women with atypical squamous cells of undetermined significance (ASC-US).

Outside of cervical cancer screening, however, routine testing for HPV infection is not recommended.

The diagnosis of genital warts is made by visual inspection and may be confirmed by biopsy.

Biopsy should be performed in any case where the diagnosis is in question, if the warts do not respond or worsen during therapy, if the patient is immunocompromised, or if the warts have any red flag signs such as pigmentation, induration, friability, or ulceration. Specialized testing for HPV infection is generally unnecessary.

Front 70

HPV: treatment

Back 70

Treatment for HPV is not indicated unless a patient has a cervical squamous intraepithelial lesion (SIL) or warts, as subclinical HPV infection frequently resolves spontaneously.

Furthermore, untreated genital warts may also spontaneously resolve.

Therefore the decision to initiate treatment for genital warts needs to be individualized.

Consideration of the following should enter into the decision regarding whether to treat and what modality should be used: number, size, morphology, and location of the warts, patient preference, cost of therapy, convenience, adverse effects, and provider experience.
If treatment is initiated, the goal is to remove visible warts.

Removal of warts may induce a wart-free period but does not guarantee that the HPV virus has been eradicated or that HPV cannot continue to be transmitted.

Front 71

HPV: treatment: external warts

Back 71

For external warts, treatment may be patient or provider applied.

Patient-applied modalities include podofilox 0.5% solution or gel or imiquimod 5% cream.

Podofilox is an antimitotic agent that destroys warts.

Imiquimod stimulates an immune reaction to increase the production of interferon and cytokines, which in turn leads to destruction of the warts.

These agents are applied once or twice daily for a defined period, and then several days of no therapy is allowed.

This cycle may be repeated for several weeks.

Provider-applied modalities include cryotherapy, podophyllin resin 10% to 25%, trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80% to 90%.

Cryotherapy with liquid nitrogen destroys warts by thermal-induced cytolysis.

Podophyllin resin contains several compounds including antimitotic agents.

TCA and BCA are caustic and destroy warts by chemical coagulation of proteins. Damage to adjacent areas of tissue may be encountered if the product is allowed to spread.

A final treatment for eternal warts is surgical removal. Warts may be removed by scissor or shave excision, curettage, electrosurgery, or laser surgery. Surgery offers the advantage of treatment of warts in one visit and is most beneficial for those with a large number of genital warts or warts that cover a large area.

The presence of genital warts is not an indication to increase the frequency of cervical cancer screening or to perform cervical colposcopy. However, for cervical warts, underlying cervical dysplasia needs to be ruled out. Management should occur in conjunction with a specialist.

Front 72

Proctocolitis in Men Who Have Sex with Men

Back 72

Men who practice receptive anal intercourse may have proctitis or proctocolitis, causing anorectal pain, mucoid or bloody discharge, tenesmus, diarrhea, or abdominal pain.

Sigmoidoscopy should be performed, with culture and Gram stain of the discharge.

LGV has been recognized as an important causative agent in this population. If not treated early, LGV may lead to chronic colorectal fistulas and strictures