Sexually Transmitted Diseases

1
Sexually Transmitted Diseases

• By Jonathan Phillips, D.O.

2
Introduction
3
Introduction

• STDs are a major public health problem in
  developed and developing countries.
• Complications of untreated STDs include genital
  tract infections, infertility, cervical cancer,
  and enhanced transmission and acquisition of the
  HIV.

4
Sexually Transmitted Diseases

• Ulcerative
• Chancroid
• Syphilis
• Mucopurulent
• Chlamydia
• Gonorrhea
• Viral Infections
• HPV
• HIV
• Molluscum contagissum

5
Syphilis
6
Syphilis

• Haemophilus ducreyi
• aka soft chancre
• predominantly male disease
• gram negative rod
• school of fish clusters
• genital tract of humans
• requires X factor only

7
Syphilis Chancre
8
Pathogenesis

• 1 week, see small erythematous papule
• painful, friable ulcer develops
• lymphadenopathy from spread to inguinal lymph
  nodes
• may rupture
• exudates highly contagious

9
Treponema pallidum

• spirochete
• corkscrew type motility
• axial filaments
• bundles of periplasmic flagella
• need silver staining to see
• dark field microscopy
• cannot culture on artificial media

10
Treponema pallidum
11
Transmission

• sexual contact - abraded skin or mucous
• oral, anal sex
• congenital
• primary or secondary stage generally
• prior to 18th wk. gestation rare
• secondary disease w/latent infection

12
Primary stage

• 3 weeks incubation
• Chancre (hard)
• painless
• indurated
• well circumscribed ulcer
• Regional lymphadenopathy

13
Primary Stage
14
Secondary Stage

• septicemia from infected foci
• extracellular multiplication induces a chronic
  inflammatory response
• generalized lymphadenopathy
• generalized maculopapular rash
• condylomas
• soft, fleshy papules in genital region
• moth-eaten alopecia

15
Secondary Stage
16
Rash of Secondary Syphilis

• On body
• Unique found on soles of feet, palms of hands
• Description
• Copper penny macules or papules

17
Secondary syphilis - condyloma latum

• Condylomata lata
• Associated with syphilis
• Described as soft, fleshy papules
• Condylomata acuminata
• Associated with HPV
• Described as soft, flesh-colored, verrucous
  papules

18
Condyloma latum
19
Latent stage

• 3 weeks to 3 mos. after secondary stage
• Early latent - lt1 year duration
• Late latent - gt1 year duration
• Can transmit to fetus
• May last 3 to 30 years

20
Tertiary stage

• waning of immunity - w/i mos. to 50 yrs. later
• treponemes invade CNS, CV system, eye, skin,
  other internal organs
• Neurosyphilis - symptoms
• destruction of
• brain parenchyma (paresis)
• dorsal roots of spinal cord (tabes)
• or both (taboparesis)
• meningitis
• optic atrophy

21
Tertiary Stage
22
Cardiovascular - symptoms

• thoracic aortic aneurysm
• aortitis
• aortic endocarditis
• Other organs, skin, bone
• benign gummas
• destructive, granulomatous, non-progressive
  lesions
• treponemes rarely found in the lesions

23
Tertiary transmission

• does not occur
• congenital transmission rare

24
AIDS and HIV patients

• higher prevalence of recurrent secondary syphilis
• more rapid progression to CNS
• Early congenital syphilis (birth to 2)
• extensive cutaneous lesions
• snuffles
• osteochondritis of long bones
• anemia, hepatosplenomegaly, CNS disease

25
Late congenital syphilis (gt2)

• interstitial keratitis
• 8th nerve deafness
• notched and spaced incisors, raspberry molars
• sabre shins
• saddle nose
• cutaneous gummas

26
Congenital Syphilis
27
Laboratory diagnosis

• darkfield microscopy
• nontreponemal tests - RPR, VDRL
• treponemal test - FTA-ABS, MHA-TP
• CSF (acquired and congenital neurosyphilis)
• VDRL
• inc. cell count, elevated total protein

28
Treatment/Prevention

• penicillin
• reportable, trace contacts

29
Chlamydia trachomatis
30
Chlamydia trachomatis

• Obligate intracellular bacterium
• Cell wall lacks peptidoglycan
• Life cycle contains elementary bodies, reticulate
  bodies
• Require source of ATP from host
• Most prevalent STD in US
• Many co-infected with gonorrhea
• Only source humans

31
Chlamydia trachomatis
32
Chlamydia Pathogenesis

• Infection asymptomatic initially
• Host develops acute inflammatory response
• Watery discharge
• Males-diseminate into epididymis
• Female fallopian tubes into peritoneal cavity
• Newborns- mucopurulent conjunctivitis 1-2 weeks
  after delivery
• Neonatal pneumonia

33
Chlamydia-Laboratory

• Scant urethral discharge
• PMN with no GC seen
• Nucleic acid probe and amplification
• ELISA ,DFA

34
Treatment

• Tetracycline or doxycycline
• Neonates-ophthalmic ointment-0.5 erythromycin,
  1 tetracycline

35
Neisseria gonorrhea
36
Neisseria gonorrhea

• Gram negative cocci, kidney bean shaped
• Seen intracellularly in PMN on gram stain
• Second leading cause of sterility in females- C.
  trachomatis is first
• Primary disease-acute urethritis, proctitis,
  pharygitis, ophthalmia neonatorum, acute
  cervicitis or vulvovaginitis

37
Neisseria gonorrhea
38
Neisseria

• Males
• 2-8 day incubation
• Burning and frequency of urination
• Purulent creamy yellow discharge
• Females
• Fever and abdominal pain
• Mucopurulent discharge
• Burning and frequency

39
Neisseria gonorrhea
40
Neisseria

• Disseminated gonococcal infections
• Arthritis and tenosynovitis
• Rare-endocarditis and meningitis
• Laboratory
• Male-gram stain
• Female-culture and ID

41
Neisseria-Treatment

• Ceftriaxone single dose
• Add doxcycline for co-infection with chlamydia
• Neonates-drops at birth
• 0.5 erythromycin
• 1 tetracycline or 1 silver nitrate

42
Trichomoniasis
43
Trichomoniasis

• Parasitic infection caused by T. vaginalis
• Profuse, malodorous, purulent discharge
• And cervical petechiae
• Dx motile trichomonads on wet mount
• TX Flagyl 2.0 grams single dose.

44
Trichomoniasis
45
Candidiasis
46
Candidiasis

• Presents thick, cottage cheese like discharge,
  pruritus, and external dysuria.
• Dx thick vaginal discharge
• Fungal elements on KOH prep
• TX clotrimazole vaginal cream or
  suppository,100mg for 7 days or 200mg 3 days or
  fluconazole 150mg PO singe dose.

47
Candidiasis
48
Ectoparasitic crabs
49
Ectoparasitic crabs

• Phthirus pubis
• Presents pruritis and inflammation
• Dx crab lice and eggs
• TX lidane 1 shampoo for 4 min., permethrin 1
  crème rinse 10 minites

50
Ectoparasitic crabs
51
Viral infections
52
Review of HIV

• HIV-1
• Principal cause of AIDS
• HIV-2
• Less virulent
• Slower progression to AIDS
• Endemic in W. Africa, spread throughout Asia

53
(No Transcript)
54
HIV

• RNA virus
• RNA nucleoprotein core (nucleocapsid) surrounded
  by lipid envelope
• Protein spikes virally encoded
• Enzymes
• Protease
• Reverse transcriptase
• Integrase

55
Infected cells

• CD4 receptor bearing cells
• Macrophages
• Monocytes
• Dendritic cells
• T helper cells
• TH cell must be activated for replication and
  cell destruction to occur

56
Infection process

• Gp120 involved in binding to CD4
• For fusion must also bind co-receptor
• Chemokine receptors
• CCR5
• CXCR4
• Infection affected by levels of those receptors
• Expression may be upregulated by OI
• Gp41 mediates fusion

57
CCR5

• Macrophage tropic
• Expressed on
• Dendritic cells
• Macrophages
• T cells
• More commonly associated with primary infection
• Do not require high levels of CD4 on cells
  infected

58
CXCR4

• Lymphocyte tropic
• Only expressed on T cells
• In approx. 50 of cases phenotype switches from
  CCR5 to CXCR4 late in infection
• Rapid decline in CD4 count
• Progression to AIDS

59
Mutation in CCR5

• Homozygous mutant for CCR5
• Deletion of 32 bp
• Nonfunctional protein produced
• Confers macrophage-tropic resistance
• Caucasian populations only thus far
• Heterozygous
• Decreased production, some resistance

60
(No Transcript)
61
HIV
Immune cells
CNS
Mild CNS illness (self-limiting aseptic
meningoencephalitis)
Mild illness (mononucleosis-like)
Partial control of virus replication Patient
remains well
Persistent lymphadenophathy, weight loss, fever,
oral candidiasis, diarrhea
Subacute encephalitis, dementia Opportunistic CNS
infections
Still well
AIDS Opportunistic infections
62
(No Transcript)
63
Papillomaviruses
64
Papillomaviruses

• All dsDNA viruses
• All induce hyperplastic epithelial lesions
• gt70 types, 25 types STDs
• Have tissue and cell specificity
• Epithelia of skin and mucous membranes
• Potential to progress to malignancy

65
Papillomaviruses
66
Infection

• Incubation period 1-6 months
• Enter basal cells, as cell approaches surface it
  starts replicating
• Some cells virus remains latent
• Immumocompromised patient see reactivation

67
HPV infections

• Anogenital warts condyloma acuminata
• Usually benign
• Often regress spontaneously

68
Condylomata acuminata

• Venereal warts
• Multiple with satellite lesions
• Location
• External genitalia
• Vagina, cervix
• Perianal

69
Condyloma Acuminata
70
Differentiate from syphilis

• Condylomata lata (syphilis)
• Flatter
• More greyish
• Scrape lesion, do darkfield
• Condylomata accuminata
• Flat warts of cervix culposcopy or biopsy
• Strongly associated with cervical cancer

71
HPV 16, 18

• Found in 90 of cervical cancers
• May not form visible wart

72
HPV

• Subclinical carriage common
• Visualize by staining with 5 acetic acid
• Stain white
• acetowhite lesions
• Biopsy to rule out other inflammatory conditions

73
HPV
74
Subclinical Infections

• Acetic acid application to cervix, vagina, or
  penis
• 40-80 of male partners of women with warts are
  infected
• 60-80 of lesions identified as HPV on biopsy

75
Treatment-HPV

• Liquid nitrogen
• Podophyllin
• Imiquimod

76
(No Transcript)
77
(No Transcript)
78
Herpes simplex virus

• HSV-1 commonly upper body lesions
• HSV-2 genital tract infections
• Either can infect and cause similar lesions at
  both sites

79
Herpes simplex virus
80
Herpes simplex virus
81
Epidemiology

• Estimated 20 of young adults in US are infected
  with HSV-2
• 70 to 90 of patients have asymptomatic initial
  and recurrent infections
• Recurrence decreases over time

82
Clinical features

• Lesions typically appear 3-7 days after exposure
• Lesions
• vesicular,
• grouped,
• have erythematous base
• Dewdrop on a rose petal
• Painful

83
Clinical Features
84
Clinical features

• Lesions clear by crusting over
• Primary disease lasts about 3 weeks
• Virus travels up sensory nerve endings
• Latent infection
• Dorsal root ganglion

85
Recurrence

• 90 of infected symptomatic individuals have
• Average about 4 to 8 times/year
• Triggers include stress, hormonal changes, fever
• Prodrome may include itching, tingling, or burning

86
Sequelae

• Congenital spread
• Transmission to fetus less than with primary
  infection
• Neonatal disseminated herpes
• Encephalitis
• Aseptic meningitis or encephalitis

87
Laboratory diagnosis

• Tzanck smear
• Smear of fresh vesicular lesion
• Stain with Wright-Giemsa stain
• Look for multinucleated giant cells
• Cell culture
• PCR

88
Treatment

• Acyclovir, 400mg TID 7-10 days
• Valacyclovir 500mg BID 5 days
• Famciclovir 125mg BID 5 days

89
Molluscum contagiosum
90
Molluscum contagiosum

• Benign
• Large DNA virus
• Dome-shaped with central umbilication
• Pearly flesh colored
• Treatment-rare
• Excisional curettage or cryotherapy

91
Molluscum contagiosum
92
Organism lesions typically Size Painful
Primary Syphilis Single, indurated border Uniform if gt1 No
Chancroid Multiple, jagged edges Various sizes Yes
Donovanosis Beefy red lesions, white border No
Herpes genitalis Multiple with erythematous border Uniform Yes
93
Competency Exam
94
Question 1

• 1. Leading cause of sterility in women?
• A. HPV
• B. Gonorrhea
• C. Chlamydia
• D. Syphilis

95
Question 1

• 1. Leading cause of sterility in women?
• A. HPV
• B. Gonorrhea
• C. Chlamydia
• D. Syphilis

96
Question 2

• Which is not true of Haemophilas ducreyi?
• A. aka soft chance
• B. school of fish clusters
• C. predominantly male
• D. Gram positive cocci

97
Question 2

• Which is not true of Haemophilas ducreyi?
• A. aka soft chance
• B. school of fish clusters
• C. predominantly male
• D. Gram positive cocci

98
Question 3

• Which is not true of primary stage syphilis?
• A. Painful
• B. Well circumscribed ulcer
• C. Regional lymphadenopathy
• D. 3 weeks incubation

99
Question 3

• Which is not true of primary stage syphilis?
• A. Painful
• B. Well circumscribed ulcer
• C. Regional lymphadenopathy
• D. 3 weeks incubation

100
End of Lecture

• This lecture will be made available on the
  Internal Medicine Website
• http//IM.Official.ws