Transcript STD’s - Cleveland Clinic

STD’s
JANUARY 26, 2006
DR. GABRIN
Chlamydia Trachomatis
• Causes urethritis, epididymitis/orchitis,
proctitis, and Reiter’s syndrome in men
• Urethritis, cervicitis, PID, and infertility in
women
• Conjunctivitis in both sexes
• Commonly asymptomatic
Chlamydia
• 1-3 week incubation period
• Symptoms-urinary burning, urethral
discharge, vaginal d/c, vaginal irritation
and pain, scrotal pain, abdominal/pelvic
pain
• Dx-swabs utilizing direct
immunofluorescence, ELISA, or DNA
probes- 70-95% sensitive
Chlamydia
• Treatment
• Azithromycin 1 gram po x 1 dose or
doxycycline 100mg po bid x 7 days
• Avoid sexual contact for 7 days
• Sexual partners within 60 days should be
treated
• Treatment for possible gonorrhea
coinfection should be given
Gonococcal Infections
• Neisseria Gonorrhoreae- gram neg
diplococcus
• Causes urethritis, cervicitis, PID, and
infertility in women
• Urethritis, epididymitis/orchitis and
prostatitis in men
• Symptomatic pharyngitis, conjuctivitis, and
proctitis are rare
Gonococcal Infections
• Symptoms-dysuria, urethral discharge,
vaginal d/c, scrotal/epididymal pain,
abdominal/pelvic pain, and occasional
peritonitis
• Rectal infection/procititis can occur in both
sexes
• Incubation period- 1-2 weeks
• Asymptomatic infection is common
Gonococcal Infections
• 80-90% of men develop sx’s within 2
weeks-most commonly dysuria and
purulent penile discharge
• Dissemination of gonorrhea occurs in 2%
of patients with untreated primary infection
Disseminated GC
• 1st stage- febrile bacteremic stage,
multiple scattered skin lesions primarily on
extremities-palms and soles
• 2nd stage-initial sx’s subside followed by
monoarticular arthritis, with purulent
synovial fluid
• Dx often clinical- cultures 20-50%positive
• Treatment - IV rocephin
Gonococcal Infections
• Uncomplicated GC• Dx-swab with culture
• Rx-single dose of oral cefixime or
fluroquinolone, or IM ceftriaxone
• Pregnant pt- treat with cephalosporin or
2gram spectinomycin IM
• Treat for chlamydial coinfection
• Avoid sexual contact for 7 days
Trichomoniasis Vaginalis
• Flagellated protozoan-causes vaginitis
with discharge, urethritis with dysuria, and
occasional abd pain.
• Men usually asymptomatic-occ. Dysuria
• Pregnant women at increased risk or
PROM, preterm delivery and low birth
weight
Trichomoniasis
• Incubation 3 to 28 days
• Dx-wet prep reveals flagellated motile
parasites—60-70% sensitive
• Rx-Metronidazole 2gram x 1 dose
• Metronidazole-class C no great studies
that show single dose will be teratogenic
• CDC indicates that Metronidazole can be
used in pregnant women x 1 dose.
Genital Warts
• Human Papillomavirus(HPV)-DNA viruses
that are transmitted by direct contact and
cause venereal or anogenital warts
• Incubation period-1-8months
• Genital warts- begin as flesh colored
papules or cauliflower-like projections that
can form condyloma acuminata
Genital Warts
• Warts- commonly occur on urethra,
frenulum, penis and perianal regions in
men
• Women- occur at posterior introitus and
labia, vagina, cervix and spread to
perineum
Genital Warts
• Dx-clinical but may be confirmed with skin
biopsy or soaking area with dilute aceitic
acid for 3 minutes are will turn dull graywhite color.
• Treatment- topical podophyllin, imiquimod
cream, or cryotherapy
• Refer patients to derm, uro, or ob-gyn
Syphillis
• Treponema pallidum-spirochete
transmitted through direct contact at
mucous membranes or nonintact skin
• Classic syphillis- 3 stages-primary,
secondary, and tertiary
Syphillis
• Primary Syphillis
• Painless chancre or ulcer with indurated
borders on penis, vulva or other areas of
sexual contact
• Appears around 3 weeks after contact
• Primary chancre heals over 3-6 weeks
• Usually no constitutional symptoms
Syphillis
• Secondary syphillis
• 3-6 weeks after primary chancre heals
• Includes lymphadenopathy and nonpruitic
polymorphous rash which starts on trunk
or flexor surface of extremities and
involves palms and soles
• Fever, malaise, headache, sore throat,
and condyloma lata
• Spontaneously resolves
Syphillis
• Tertiary syphillis- develops in 1/3 of
patients with untreated secondary syphillis
• Peripheral neuropathy(tabes dorsalis),
meningitis, dementia, aortitis with valve
insufficiency and thoracic aortic aneursym
Syphillis
• Dx-dark-field microscopy in eary stages
• Serologic- RPR or VDRL, become positive
about 14 days after primary chancre
appears
• FTA-ABS-more sensitive and specific
• RX-Penicillin
Herpes Simplex
• HSV-2 or less commonly HSV-1 can cause
genital infection via transmission through
direct contact with mucosal srufaces or
nonintact skin
• Primary infections- incubation period 7-10
days—painful clusters of vesicular or
pustular lesion on a red base
• Ulcerate after 3-5 days often accompanied
by lymphadenopathy
Herpes Simplex
• Systemic sx’s- common with primary infection
• Fever, headache, myalgias, tender inguinal
adenopathy and dysuria, urinary retention and
aseptic meningitis
• Primary illness lasts 2-3 weeks if untreated
• Virus remains latent and sheds in urogenital
secretions
• Secondary or recurrent infection occurs in 6090% of patients
Herpes Simplex
• Dx-clinical or using tzank smear of
vesicular fluid
• Rx- acyclovir for 7-10 days
• Severe cases may require hospitalization
with IV acyclovir
• Recurrent herpes- 5days or oral acyclovir,
valacyclovir, or famciclovir
Chancroid
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Haemophilus ducreyi-gram neg. bacillus
Common in tropics
10% coinfected with HSV or treponema
Incuabtion 4-10 days
Tender papule on erythematous base on
external genitalia-enlarges to form painful
purulent ulcer
• May have “kissing lesions” on adjacent
skin from autoinoculation
Chancroid
• Primary inguinal adenopathy(usually
unilateral) occurs in half of untreated
patients 1-2 weeks after primary infection
• May form mass of matted nodes(bubo)spontaneous suppurate and drain
Chancroid
• Dx-clinical but may occasionally culture
• Rx- ceftriaxone, azithromycin, cipro, or
erythromycin.
• Buboes may be aspirated to relieve pain
from swelling-do non excise
Lymphgranuloma Venerum
• LGV caused by Chlamydia trachomatisuncommon in US
• Primary lesion-painless papule or vesicle
on genitals 5-21 days after exposure
• Heals spontaneously
Lymphgranuloma Venerum
• Weeks to months after primary lesion
heals- painful inguinal adenopathy-60%
unilateral
• Buboes form-overlying skin often gets
purplish hue
• Scarring of bubo may leave linear
depression parallel to inguinal
ligament=groove sign
Lymphgranuloma Venerum
• Dx- serologic testing, culture of aspirated
material
• Rx-Doxycycline 100mg bid for 21 days
• Mild untreated cases can resolve in 8-12
weeks
• Late sequellae include scarring; urethral,
vaginal and anal strictures; and
occaionally lymphatic obstruction
HIV Infection
• Epidemiology- UN-Aids program predicts by
2020, HIV will be responsible for 1/3 of all
infections disease related deaths worldwide
• In US, CDC estimates 40,000 new HIV
infections occur each year
• Risk factors- homosexuality or bisexuality, iv
drug use, heterosexual exposure, blood
tranfusion prior to 1985 and maternal-neonatal
transmission
HIV
• RNA retrovirus-attacks host cells involved in
immune function- CD4 T lymphocytes
• Causes lymphopenia, CD4 defecits, and
autoimmune phenomena.
• Profound defects in cellular immunity result in
opportunistic infections and neoplasms
• Transmission via semen, vaginal secretions,
blood or blood products, breast milk, and
transplacental transmission in utero
HIV
• Acute HIV infection-flu-like symptoms
often goes unrecognized occurs in 50-90%
of patients
• Exposure to onset-2-4 weeks
• Most common sxs- fever, fatigue, sore
throat, rash, headache, and
lymphadenopathy
• Other sx’s-myalgias, diarrhea, and weight
loss
HIV
• Seroconversion-detectable antibody
response- 3-8 weeks after infection
• Long asymptomatic period only with
possible generalized lymphadenopathy
• Mean incubation time from exposure to
development of AIDS is 8.23 years for
adults and 1.97 years for children under 5
years of age
HIV
• Constitutional sx’s-common
• Fever, wt loss, and malaise- account for
majority of HIV-related er visits
• CBC, cultures, UA, LFT’s, CXR, serologic
testing for syphillis, cryptococcus,
toxoplasmosis, CMV and
coccidioidomycosis
• LP consider for neuro signs or FUO
HIV
• Pulmonary complications-common reason
for ER visit
• Cough, hemoptysis, SOB and chest pain
• Most common in HIV- CAP, PCP, TB,
CMV, Cryptococcus neoformans, and
neoplasms
• PCP- treat with bactrim
HIV
• Neurologic complications
• CNS disease occurs in 90% of patients
with AIDS
• CT and LP for any neuro signs or
symptoms
• Most common-AIDs dementia,
Toxoplasma gondii, Cryptococcus
neoformans- fever, focal deficits, altered
mental status or seizures.
HIV
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ED care and disposition
Universal precautions
Respiratory isolation for suspected TB
ABC’s
Start antibiotics early
HIV
• Be aware of opportunistic infections
• CMV- IV ganciclovir or foscarnet
• Opthalmologic CMV- ganciclovir implant
pulus oral ganciclovir
• PCP- TMP-SMX 20/100 mg/kg/d x 3
weeks
• TB- isoniazid, rifaburin, pyrazinamide and
streptomycin
HIV
• Toxoplasmosis-pyrimehamine plus
sulfadiazine plus folinic acid
• Cryptococcosis- amphotericin B IV and
then switch to fluconazole daily for 8-10
weeks
• Thrush- clotrimazole 10mg trochesor
nystatin 500,000 unit gargle 5x/day
HIV
• Get ID involved and get person admitted.
• Handle the acute stuff
Questions
• 1. How many new HIV infections the US each year
• A. 15 B. 40,000 C. 1,000,000 D. 500,000
• 2. What is the treatment for HSV
• A. Spontaneously resolves B. Levaquin C. Acylcovir D. Bactrim
• 3. True or False You should treat for gonorrhea and chlamydia as
coninfections
• 4. The treatments for chlamydia and gonorrhea are
• A. valtrex B. Zithromax/rocephin C. Fluconazole D. Douching
• 5. True or False-- Treatment for BV is flagyl