Sexually transmitted infections

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Sexually transmitted infections

• Mary Horgan M.D.
• Cork University Hospital

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Major STD syndromes

• Genital ulcer disease
• Urethritis/cervicitis
• Vaginitis/vaginosis
• Exophytic processes
• Ectoparasitic infestations
• Systemic STD syndromes

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Genital ulcer disease

• Genital herpes (HSV)
• Syphilis (T. pallidum)
• Chancroid (H. ducreyi)
• Lymphogranuloma venereum (rare)
• Granuloma inguinale (rare)

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Genital ulcer disease

• Conditions characterised by ulcers which are
  usually sexually transmitted
• Multiple causes can co-exist

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Staging of syphilis

• Primary
• Secondary
• Latent
• Early latent
• Late latent 1 year
• Late (tertiary) - includes neurosyphilis

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Primary syphilis

• The first manifestation of infection
• Characterized by development of chancre
• Incubation period
• average 3 wks. from time of exposure
• range 9 - 90 days
• Chancre occurs at site of bacterial invasion

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Chancre characteristics

• Indurated
• Painless
• Raised border
• Red, smooth base
• Scant serous secretions
• Indolent, punched out appearance

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Chancre characteristics

• Regional lymphadenopathy is common
• inguinal nodes if genital lesions present
• cervical nodes if oropharyngeal lesions present
• Chancre usually (but not always) precedes
  development of secondary symptoms
• Chancre typically resolves in 3 - 6 weeks without
  treatment

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Secondary syphilis

• Evidence of systemic spread of infection
• Characterized by rash, other skin and mucous
  membrane lesions
• Typically develops 3 - 6 weeks following
  development of primary lesions (chancre)

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Rash characteristics

• Maculopapular eruption
• classic palmar -plantar distribution
• may occur on face, back, trunk, arms, legs
• Rash may also manifest as
• macular or erythematous eruption
• papular lesions
• pustular lesions (infrequent)
• annular lesions

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Rash characteristics

• Mucous patches affecting mucous membrane
  surfaces
• Facial nickel and dime lesions
• Patchy alopecia (hair-loss)
• moth-eaten appearance

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Systemic signs and symptoms

• Flu-like syndrome
• Weight loss
• Anemia, elevated ESR
• Lymphadenopathy
• Hepatosplenomegaly

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Latent syphilis

• Serologic evidence of infection without clinical
  manifestations
• positive blood test for syphilis
• no primary or secondary lesions
• no evidence of tertiary disease
• Early vs. late latent syphilis
• early infection of less than 1 years duration
• late infection of greater than 1 years
  duration

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Treatment Recommendations

• Early syphilis
• all primary infections
• all secondary infections
• early latent infection (
• Benzathine PCN-G (Bicillin-LA) 2.4 million units
  IM single dose

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Treatment Recommendations

• Late disease
• Late latent syphilis (1 years duration)
• Benzathine PCN-G (Bicillin-LA) 2.4 million units
  IM q week x 3 doses

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Treatment Recommendations

• Penicillin-allergic patients
• Doxycycline 100mg po BID x 14 days
• (28 days if late disease), OR
• Tetracycline 500mg po QID x 14 days
• (28 days if late disease)

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Neurosyphilis

• The manifestations of CNS syphilis were readily
  recognized by physicians practicing 30 or 40
  years ago. However they are unfamiliar to many
  physicians today given the relative rarity of
  this condition

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Neurosyphilis

• Asymptomatic
• no clinical manifestations
• defined by presence of CNS abnormalities
  including
• WBC 5/mm3, mostly lymphs
• elevated protein
• reactive CSF-VDRL
• may progress to overt neurosyphilis

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Parenchymatous neurosyphilis

• General paresis
• also known as paretic neurosyphilis, dementia
  paralytica, and general paralysis of the insane
• T. pallidum directly invades the cerebrum
• early symptoms memory loss, irritability,
  personality changes, headache, insomnia
• late symptoms defective judgment, emotional
  lability, lack of insight, confusion,
  disorientation, delusions, paranoia, seizures

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Parenchymatous neurosyphilis

• General paresis
• neurologic findings include
• Argyll Robertson pupils
• slurred speech
• expressionless face
• tremors

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Congenital syphilis

• Acquistion of syphilis by the fetus or newborn
  infant
• Vertical transmission from mother
• Transplacental (during pregnancy)
• Perinatal acquisition (at time of birth)
• Significant cause of spontaneous abortion (up to
  50 in infected mothers)

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Congenital syphilis

• Early clinical signs and symptoms include
• hepatomegaly
• splenomegaly
• anemia, jaundice
• skin rash / petechiate
• persistent nasal discharge (snuffles)
• abnormal bone development (osteochondritis)
• pseudoparalysis

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Cardiovascular syphilis

• Cause of thoracic aortic aneurysm
• aortic valvular insufficiency
• Also may involve coronary arteries
• Pathogenesis is through endarteritis of the vasa
  vasorum of aorta
• Lesions may erode through chest wall or rupture
  spontaneously

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Treatment of tertiary syphilis

• Treatment of gummatous lesions will prevent
  further destruction
• Treament will not restore tissue which has
  already been destroyed

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Laboratory tests for syphilis

• Confirm clinical suspicion of disease
• Screen populations at risk
• Monitor response to therapy
• Determine treatment failure and need for lumbar
  puncture

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Types of laboratory tests

• Direct examination of lesion material
• darkfield microscopy
• Serologic testing of blood samples
• non-treponemal tests (screening)
• treponemal tests (confirmatory)
• Other
• direct fluorescent antibody (DFA)
• histologic staining (biopsy)

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Darkfield microscopy

• Extremely specific for T. pallidum
• Test of choice for moist genital ulcers
• Offers immediate diagnosis
• Opportunity for immediate treatment

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Serologic tests for syphilis

• A blood test
• Detects antibody in serum
• Requires blood sample centrifugation
• Requires laboratory processing
• Follow universal precautions at every step

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Syphilis - Non-treponemal tests

• Used for screening large samples
• Cardiolipin-cholesterol-lecithin antigen
• Sensitive but not 100 specific
• Two tests commonly available
• Rapid Plasma Reagin test (RPR)
• Venereal Disease Research Laboratory test
  (VDRL)

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Non-treponemal test sensitivity

• Test 1o 2o EL LL
• VDRL 78 100 95 71
• RPR 86 100 98 73

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False-positive RPR / VDRL

• General population 1-2
• IV drug users 10
• Transient false-positive
• pregnancy
• febrile illnesses
• Chronic false-positive
• autoimmune disorders, aging

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Syphilis - Treponemal tests

• Used for confirmation of infection
• Detects antibodies against T. pallidum cellular
  components
• More expensive, more specific
• Commonly available tests include
• Fluorescent Treponemal Antibody Absorption
  (FTA-ABS)
• Microhemagglutination Assay (MHA-TP)
• T. pallidum particle agglutination (TP-PA)

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Interpreting treponemal tests

• 86 of syphilis cases remain reactive for life
• Not used to monitor efficacy of treatment or
  reinfection
• 1 false-positive rate in general pop.
• Negative test on CSF excludes neurosyphilis

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Syphilis serology

• Problems
• How do you ascertain who is infectious?
• How do you ascertain who should be tracked for
  partner notification?

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Summary

• Neurosyphilis, congenital syphilis and tertiary
  syphilis are difficult to diagnose
• These conditions cause serious long-term
  morbidity and mortality
• High index of suspicion for syphilis is required
  when dealing with populations at risk

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Genital herpes

• 90 of primary infection is subclinical
• Most common in adolescence and young adults
• Neonatal infection via birth canal
• disseminated
• CNS
• skin, eye, mouth (SEM)
• occurs with primary secondary infection

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Genital Herpes

• Primary infection first exposure to HSV type 1
  or 2
• Initial infection first exposure to HSV-2 but
  previous infection with HSV-1
• some antibody cross protection
• generally not as severe as primary infection
• Recurrent infection known prior outbreaks
• usually precipitated by stress, trauma,
  pregnancy, menses, fever, systemic illness

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Genital herpes primary infection

• Usually painful with prodrome
• Incubation period 2-20 days (mean 6d)
• Duration 1-3 weeks
• Presents as painful vesicles or ulcers
• Initial infection is usually associated with
• lymphadenopathy
• fever, headaches
• myalgias
• urethritis, cervicitis
• urinary retention

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Genital infectionrecurrent infection

• 80 have recurrences but frequency varies
• Usually at same site as primary infection
• Less severe than primary infection

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Genital herpes Diagnosis

• Clinical features
• Viral culture
• HSV PCR

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Genital herpes treatment

• Acyclovir or derivatives are drugs of choice
• Available in oral, parenteral and topical forms
• Primary infection
• ACV 400mg tid for 10 days
• Recurrent infection
• ACV 400mg tid for 5 days
• Chronic suppressive therapy consider for 6
  episodes/year with
• ACV 400mg bd for one year

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Urethritis/cervicitis

• Gonorrhoea (N. gonorrhoeae)
• Chlamydia trachomatis
• Mycoplasma hominis
• Ureaplasma urealyticum

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The urethra

• Common pathway for urine and semen
• Columnar epithelial lining
• Primary site of infection for GC and chlamydia
• Possible site of infection for
• mycoplasma hominis
• Trichomonas
• Ureaplasma

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Urethritis

• Inflammatory response of urethra
• infection of urethra
• WBC is primary inflammatory response
• organisms may also be seen
• Symptoms
• dysuria
• discharge (purulent or mucoid)
• WBC

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Urethral specimen collection

• Patient should not void for 2hours before
  specimen collection\
• Swab inserted 1-2cm into distal urethra and
  rotated 1-2 turns
• Smear swab onto glass slide
• Inoculate swab onto chocolate and NY agar
• Second swab for chlamydiazyme

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Cervicitis

• Cervicitis is the female counterpart of
  urethritis
• inflammatory response of cervix
• reflects infection of T zone
• WBC is primary inflammatory response and
  organisms may be seen as in GC

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Cervicitis

• Caused by
• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Mycoplasma hominis
• Ureaplasma
• Trichomonas
• Characterised by
• discharge
• dysuria
• dyspareunia

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Other causes of cervical inflammation

• HSV
• Trichomonas
• Candidiasis
• Foreign body
• Ectopy, OCP and menses

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Endocervical swab collection

• Visualise cervical os
• Insert swab and rotate several times
• Observe colour of swab
• Smear swab lightly on glass slide
• Inoculate on chocolate and NY agar
• Second swab for chlamydiazyme as above

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Chlamydia trachomatis

• Common cause of cervicitis and urethritis
• Obligate intracellular organism
• May cause
• PID and sequelae
• Reiters syndrome
• Neonatal eye infection and pneumonia
• Diagnosis by
• culture
• non-culture techniques
• urine-based screening

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Treatment of Chlamydia trachomatis

• Treat with
• Azithromycin 1G po one dose
• If no access to microscopy treat for coinfection
• See CDC recommendations for alternatives for
• allergies
• pregnancy
• reinfection
• less expensive regimens

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Gonorrhoea

• Gram - intracellular diplococci
• Cause urethritis, cervicitis, proctitis and
  pharyngitis
• Disseminated gonococcal infection
• Associated with PID and its sequelae
• Neonatal infection e.g. conjunctivitis

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Treatment of GC

• Effective therapy includes a regimen that covers
  coinfection with chlamydia and GC
• Treat with
• Ciprofloxacin 500mg one dose
• Azithromycin 1G one dose
• For alternatives see CDC guidelines on www.cdc.gov

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Evaluation of sex partners

• Treat regular and potential source partners as
  per index case
• Symptomatic patients
• refer all patients within past 30 days
• Asymptomatic patients
• refer all patients within past 60 days
• Treat all partners who have objective evidence of
  infection
• Full STD screen should be done on all patients

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Vaginitis/vaginosis

• Bacterial vaginosis
• Trichomoniasis
• Yeast vaginitis

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Bacterial vaginosis

• Malodorous vaginal discharge /- pruritis
• Homogenous, non-viscous milky white D/C
• Caused by gardnerella, mycoplasma and anaerobes
• Absence of normal flora like lactobacillus
  appears to correlate with its development
• Not sexually transmitted but more common in
  sexually active women

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Bacterial vaginosis

• Vaginal pH 4.5
• Positive whiff test
• fishy odour on addition of 10 KOH
• Presence of clue cells on microscopy
• Homogenous discharge on examination

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Bacterial vaginosis

• Infection may induce preterm labour
• Treatment
• Metronidazole 400mg bd for 7 days
• avoid during first trimester of pregnancy
• No indication to treat sexual partner

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Trichomoniasis

• Caused by a protozoa, Trichomonas vaginalis
• Profuse, purulent, malodorous discharge
• May be associated with dysuria and irritation
• Examination shows petechiae on cervix
  (strawberry cervix)

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Trichomoniasis diagnosis

• Motile trichomonads on saline wet prep of vaginal
  exudate
• Vaginal pH 4.5
• Culture (not routinely done)

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Trichomoniasis treatment

• Metronidazole 2.0G one dose
• Sexual abstinence until symptoms resolve
• Treatment of sexual contacts is necessary since
  the infection is sexually transmitted

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Vulvovaginal candidiasis

• Usually not a sexually transmitted infection
• 66 caused by Candida albicans
• Presents with
• vulval pruritis
• vaginal discharge
• dysuria

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Vulvovaginal candidiasis diagnosis and treatment

• pH
• Fungal elements on 10 KOH prep
• Treat with
• intravaginal imidazole cream or pessary
• Fluconazole 150mg one dose

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Pelvic Inflammatory Disease