Transcript SEXUALLY TRANSMITTED INFECTIONS

SCENARIO I:



A16-year-old female who presents to her private
gynecologist’s office.
She is complaining of abdominal pain, perineal
itching, and vaginal discharge for 7 days.
Lab. Tests:

DNA probe results: +ve for both:
Gonorrha & Chlamydia.
SEXUALLY TRANSMITTED INFECTIONS:



They are infections whose primary route of
transmission is SEXUAL CONTACT.
Sexually transmitted infections (STIs) are one of the
most well-recognized health problems worldwide.
However, they are difficult to track:
 Asymptomatics.
 Non-exposed
areas.
SEXUALLY TRANSMITTED INFECTIONS:



Most of the published data on the prevalence and
incidence of STIs come from developed countries.
Information about STIs in Islamic, where non-marital sex
and homosexuality are forbidden by religion countries
are limited.
An assumed low prevalence of STIs and religious and
cultural intolerability of non-marital sex and
homosexuality in Islamic countries are expected reasons
for the limited data.
SEXUALLY TRANSMITTED INFECTIONS:

Islamic rules and values are essential and should be
of highest priority for policymakers because of the
potential of such infections to spread particularly
among the youth.
SEXUALLY TRANSMITTED INFECTIONS:

Risk Factors:
 Hx
of previous STI.
 Contact with infected person.
 Sexually active individual  25 years.
 Multiple sexual partners.
 Un-protected sexual intercourse. (No barrier).
 Drug abuse,..
CAUSES
CAUSES:
Viral
•Candida albicans
Fungal
• HSV.
•HPV.
•HBV.
•HIV.
Bacterial
protozoal
• Chancroid.
•Syphilis.
•LGV.
•Granuloma inguinale.
•Chlamydia.
•Gonorrhea.
• Chlamydia trichomatis.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
Painful
• HSV.
•Chancroid.
Painless
STIs without Genital Ulcers
Warts
•Syphilis.
•HPV
•LGV.
•Grauloma inguinale
Drip
“Discharge”
•Chlamydia.
•Gonorrhea.
Others
•HBV.
•HIV.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
Painful
• HSV.
•Chancroid.
Painless
•Syphilis.
•LGV.
•Grauloma inguinale
STIs without Genital Ulcers
CLASSIFICATION:
STIs
STIs with Genital Ulcers
Painful
• HSV.
•Chancroid.
Painless
STIs without Genital Ulcers
HERPES SIMPLEX VIRUS HSV
HSV:

A DNA virus.
The most common cause of
genital ulcer disease.

Contagious.

Transmission:

 Direct
mucus membrane contact.
HSV:

Types: HSV I, HSVII.
HSVI usually causes lesions above the level of umbilicus.
HSVII usually causes lesions below the level of umbilicus.
HSV I
HSV II
HSV:

Symptoms:
Primary:
Latency
-Systemic: viremia.
-Painful skin lesions.
Retrograde Transport
Stress
Reactivation:
Anterograde Transport
Recurrent:
-Localized.
-No systemic manifestations.
HSV:

Clinical Examinations:
 Primary
lesions:
 Systemic:
fever, flu like,…
 Clear vesicles at site of exposure.
 Spontaneously rupture
 shallow painful inflamed
ulcer.
 Recurrent
lesions:
 Localized,
milder.
HSV:

Diagnosis:
 Lab
tests:
 Viral
isolation is the most accurate.
 Serology: ELISA for specific antibodies.
 Cytology:

Multinucleated Gaint Cells.
HSV:

Management:
 Acyclovir
(200 mg PO q24 hrs for 5 days).
 Valacyclovir:  risk of sexual transmission by 50%.
 Famciclovir.
CHANCROID
CHANCROID:

Caused by: Hemophilus ducreyi.

Facilitates transmission of HIV.
Pathophysiology:
Develop within 72 hours
CHANCROID:

Clinical Examinations:
Characterisically
“Ragged Edge Ulcer”.
 Shallow and non-indurated.
 Seen on vulva, vagina or cervix.


Tender inguinal lymphadenopathy may develop.
CHANCROID:

Ragged Edge Ulcer
CHANCROID:

Lab Tests:
 +ve
culture is confirmatory.
 However, this organism is slowly growing… Gram stain
is not reliable.
 Diagnosis is made after ruling out syphilis.

Management:
 Azithromycin.
 Ceftriaxone.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
Painful
• HSV.
•Chancroid.
Painless
STIs without Genital Ulcers
CLASSIFICATION:
STIs
STIs with Genital Ulcers
Painful
Painless
•Syphilis.
•LGV.
•Grauloma inguinale
STIs without Genital Ulcers
SYPHILIS
SYPHILIS:


Caused by: Treponema pallidum.
A motile anerobic spirochete.
SYPHILIS:
Primary Syphilis
Secondary Syphilis
No clinical findings
Latent Syphilis
(Localized Chancre; painless)
-Spirochetemia
-Condyloma Lata; painless
Gumma (CNS, CVS, bone,..)
Tertiary Syphilis
SYPHILIS:

Maternal Syphilis:
 Primary
Syphilis:
Chancre:
“Rolled Edge Ulcer”
•Usually, disappears spontaneously.
SYPHILIS:


Secondary Syphilis:
Condyloma Lata:
Maculopapular rash. (money spots).
•Usually, disappears spontaneously without treatment.
SYPHILIS:

Tertiary syphilis:
Gumma
SYPHILIS:

Diagnosis:
 Non
specific tests:
 VDRL:
If positive, confirmatory tests are requested.
 False +ve with some autoimmune diseases; SLE, APL, …

 Rapid
 Dark

plasma regain test (RPR test).
field Microscopy:
For exudate lesion of chancre in primary syphilis and
condyloma lata in secondary syphilis.
SYPHILIS:

Diagnosis:
 Confirmatory
 Fluorescent
tests:
Titer Antibody-Absorption (FTA-ABS).
 Microhemagglutination assay for antibodies to T. Pallidum
(MHA-TP).
SYPHILIS:

Management:
 Penicillin
G is the drug of choice.
 2.4 million units of Benzathin Penicillin G are given IM.
SYPHILIS:
If a woman is allergic to penicillin??????!!!!!

Non pregnant:

Pregnant:
Tetracycline.
Penicillin + Desensitization
LYMPHOGRANULOMA VENEREUM
LGV…
LGV:

Caused by: L serotype of Chlamydia trichomatis.

Clinical Features:

INITIAL lesion is a PAINLESS ulcer that heals spontaneously.

Few weeks later,
Peri-rectal or inguinal painful lymphadenopathy may develop.
 Classic clinical sign is:
“GROOVE SIGN” or Double Genitocrural Folds.
= A depression between two inflamed groups
of lymph nodes

LGV:
GROOVE SIGN
LGV:

Lab. Tests:


Culture of aspirated fluid from tender lymph nodes.
Management:
Doxycycline, or
 Erythromycine.


Fluctuant nodes SHOULD be ASPIRATED to prevent sinus
formation.
GRANULOMA INGUINALE (DONOVANOSIS)
GRANULOMA INGUINALE :

Caused by: Klebsiella granulomatis.

Not very common:
Not highly contagious.
 Chronic exposure is needed.

GRANULOMA INGUINALE:

Clinical Features:

Initially: Painless vulvar nodules.
Later the nodules burst,
creating open, fleshy, oozing lesions--“BEEFY RED ULCER”

GRANULOMA INGUINALE:
BEEFY RED ULCER
GRANULOMA INGUINALE :

Lab. Tests:

Microscopic examination of ulcer smear:
“DONOVAN BODIES”
--- This is why it is also called:
“ DONOVANOSIS”.
GRANULOMA INGUINALE :

Management:
 Doxycycline.
 Co-trimoxazole.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
STIs without Genital Ulcers
Warts
•HPV
Drip
“Discharge”
•Chlamydia.
•Gonorrhea.
Others
•HBV.
•HIV.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
STIs without Genital Ulcers
Warts
•HPV
Drip
“Discharge”
•Chlamydia.
•Gonorrhea.
Others
•HBV.
•HIV.
CONDYLOMA ACUMINATUM
CONDYLOMA ACUMINATUM:

Caused by: HPV 6, 11.

HPV 16, 18  cervical cancer.

HPV is the most common viral STD worldwide.

Highly infectious.
CONDYLOMA ACUMINATUM:

Clinical Examination:
 Condyloma:
 Cauliflower-like
mass.
 The most common site is the
CERVIX.
CONDYLOMA ACUMINATUM:

Management:
 Podophyllin.
 Imiquimod
cream.
 Tri-chloro-acetic acid.
 Larger
lesions:
 Ablation



 No
therapy:
Cryotherapy.
LASER vaporization.
Surgical excision.
effective systemic therapy is present.
CONDYLOMA ACUMINATUM:

Vaccination:
 Gardasil.
 Cervarix.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
STIs without Genital Ulcers
Warts
•HPV
Drip
“Discharge”
•Chlamydia.
•Gonorrhea.
Others
•HBV.
•HIV.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
STIs without Genital Ulcers
Warts
Drip
“Discharge”
•Chlamydia.
•Gonorrhea.
Others
•HBV.
•HIV.
CHLAMYDIA
CHLAMYDIA:

Caused by: Chlamydia

Obligatory intracellular bacterium.

The most common bacterial STIs in women.


trichomatis.
Infects endocervical and endotubal clumnar epithelium but doesn’t
infect squamous epithelium of the vagina.
Vertical transmission may result in conjunctivitis.
CHLAMYDIA:

Symptoms:
 Most
of chlamydial cervical infections, including even
salpingo-oophoritis, are asymptomatic.

Clinical Examinations:
 Speculum
examination:
 Mucopurulent
 Urethral/
cervical discharge.
cervical motion tenderness
may or may not be present.
CHLAMYDIA:
•OCPs show a 2-fold increase in +ve endocervical
culture for chlamydia.
•However, OCPs DON’T increase risk of chlamydia
PID.
CHLAMYDIA:

Diagnosis:
 In
the past: Culture was the gold standard.
 But, nowadays, new techniques such as NAAT, PCR and
DNA probe assay are the best.

Treatment:
 Azithromycin,
or
 Doxycycline.
 Both
partners should receive the same treatment.
CDC Recommendation Guidelines 2010
GONORRHEA
GONORRHEA:

Caused by: Neisseria gonorrhea.

Gram –ve diplococci bacterium.

Infects cervix, urethra, anal canal, Bartholin glands and
oropharynx.

Vertical transmission--- Neonatal conjunctivitis.

Disseminated infection (1%): septic arthritis, dermatiris,…
GONORRHEA:

Symptoms:
 Lower
genital tract:
 Vulvovaginal discharge, itching, burning, dysuria,
rectal discomfort.
 Upper
genital tract:
 PID: diffuse bilateral abdominal pain, nausea,
vomiting and fever.
GONORRHEA:

Clinical Examination:
 Speculum
examination:
 Mucopurulent
cervical discharge.
 Cervical motion tenderness may be present.
GONORRHEA:

Clinical Examination:
 Bartholin’s
abscess:
GONORRHEA:

Lab. Test:
 Culture

of endocervical mucus is the gold standard.
Management:
 Cover
 Dual

both Gonorrhea and Chlamydia:
therapy:
Cefixime (400mg PO single dose) + (Azithromycin 1g PO single dose).
CDC Recommendation Guidelines 2010
 Bartholin’s
absess:
 Antibiotics,
incised and drained.
GONORRHEA:
 Bartholin’s
absess:
 Antibiotics,
 Incision
and a catheter is
inserted and kept
drained while healing.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
STIs without Genital Ulcers
Warts
Drip
“Discharge”
•Chlamydia.
•Gonorrhea.
Others
•HBV.
•HIV.
CLASSIFICATION:
STIs
STIs with Genital Ulcers
STIs without Genital Ulcers
Warts
Drip
“Discharge”
Others
•HBV.
•HIV.
HBV
HBV:

DNA virus; hepadnaviridae.

Mode of Transmission:
 Body
fluids: blood, semen, vaginal,
or oral secretions, breast milk.
 Vertical transmission.
HBV:

Clinical Features:
 ?????
Acute Hepatitis
90%
Recover
4.5%
Asymptomatic
Carrier
9%
Chronic
1%
Fulminant
4.5% Active
Carrier
HBV:


Lab. Tests:
HBsAg: indicates that the person has an infection with HBV and there
is a risk for transmission.

Anti-HBs: indicate recovery.

Anti-HBc: appear at the onset of acute hepatitis and persist for life.

HBeAg: indicate high risk of infectivity.
HBV:

Treatment:
 Acute
HBV:
 No
specific therapy for acute HBV.
 Supportive.
 Chronic
HBV:
 IFN-α, Lamivudine,
Entacavir, Adefovir, Tenovovir,…
HBV:

Vaccination:
 Passive
 HBIG:
 Active
Immunization:
for HBsAg -ve those who are at high risk for HBV.
Immunization:
 Killed
vaccine. So, it is safe during pregnancy. ???
HBV:

Neonate Immunization:

HBV Vaccine:
 At birth.
 1 month.
 6 months.
HIV
HIV:


RNA; Retroviridae.
Has enzymes:
Reverse transcriptase.
 Protease.
 Integrase.


Transmission:
through body secretions.
 Vertical transmission.


It targets CD4 helper T-Cells.
HIV:
HIV:

Clinical Features:
Acute Viral Syndrome
Asymptomatic (5-7 years)
AIDS
Acute HIV:
Latent:
HIV:

AIDS:

Opportunistic infections:

E.g., CMV, toxoplasmosis, pneumocystitis carinii pneumonia,
T.B,…

Leukemia, lymphoma, Kaposi’s sarocoma.

High frequency of CERVICAL DYSPLASIA and CERVICAL
CARCINOMA.
HIV:

Lab. Tests:

ELISA:


Screening.
Confirmatory tests:

Western blot.

PCR: is the MOST specific.
HIV:

Management:
 Zidovudine:
A
reverse transcriptase inhibitor.
 It is now considered as the standard care.
 Administered to mother during pregnancy.
 It significantly reduces the risk of transmission.
 Multi-therapy:
 HAART
regimen..
 Decreases the risk of transmission to <1%.
 Protease inhibitors e.g., squinavir and indinavir may be
added.
PREVENTION AND CONTROL OF STIs
Principles of Effective STIs Control:
 Barrier
methods: Condom.
 Vaccination.
 Encourage early diagnosis and treatment:
 Encourage
health seeking behaviour.
 Screening..
 Prohibit
illegal sexual relationship.
 Delay onset of sexual intercourse.
 Islamic rules…..
Vaginal Discharge:
Physiologic Vaginal Discharge
Pathologic Vaginal Discharge
Vaginosis
Vaginitis
Vaginal Discharge:
Physiologic Vaginal Discharge
Pathologic Vaginal Discharge
Vaginosis
Vaginitis
Physiologic Vaginal Discharge:


Arises from estrogen predominant
cervucal mucus.
Appearance:

Mostly Anaerobes
Bactroids,
Peptostreptococcus,
Hemophilus, Gardnerella
Thin, clear, white or transparent, nonodorous.
PH= 3.5-4.5.
 Dominant organism: Lactobacilli.


30%
Non-lactobacillus
70%
Lactobacillus
Examination:

No vaginal erythema, no edema, no
itching, or burning.
PH= 3.5 – 4.5
Vaginal Discharge:
Physiologic Vaginal Discharge
Pathologic Vaginal Discharge
Vaginosis
Vaginitis
Vaginal Discharge:
Physiologic Vaginal Discharge
Pathologic Vaginal Discharge
Vaginosis
Vaginitis
Bacterial Vaginosis:
A
condition arising from alteration of normal
flora.
 Characterized


by:
Marked  in lactobacilli.
Significant  in non-lactobacilli (aerobes & anaerobes).
 Vaginal
PH  4.5
Bacterial Vaginosis:
30%
Non-lactobacillus
85%
Non-lactobacillus
Normal
Bactroids,
Peptostreptococcus,
Hemophilus, Gardnerella
70%
Lactobacillus
Vaginosis
Mostly Anaerobes
Mostly Anaerobes
Bactroids,
Peptostreptococcus
Hemophilus,
Gardnerella
15%
Lactobacillus
PH= 3.5 – 4.5
PH  4.5
Bacterial Vaginosis:

Clinical Findings:

Appearance:


Thin, gray, adherent discharge.
Amine or fishy odor. “the commonest complaint”

PH  4.5.

Examination:



No inflammatory changes.
No pain, itching or irritation.
Microscopic Examination:

Clue cells.
Bacterial Vaginosis:

Clue Cells:

Microscopic viewing of the discharge
in saline shows minimal WBCs with clue
cells.

They are vaginal cells covered with
bacteria.
Bacterial Vaginosis:

Whiff Test:


+ve.
Fishy odor when KOH is
applied on discharge.
Bacterial Vaginosis:

Management:

Selected antibiotics are directed at anaerobes”
 Metronidazole, or
 Clindamycin.


Can be used orally, or topically in form of gel.
1 week course.
Vaginal Discharge:
Physiologic Vaginal Discharge
Pathologic Vaginal Discharge
Vaginosis
Vaginitis
Vaginal Discharge:
Physiologic Vaginal Discharge
Pathologic Vaginal Discharge
Vaginosis
Vaginitis
Vaginitis:

A condition arising from an inflammatory response.
It results in symptoms: itching, burning or pain as well as
erythema and edema.


Microscopic examination of the discharge: +ve WBCs.
Causative organisms:
Trichomonas
Candida
TRICHOMONAS VAGINITIS
Trichomonas Vaginitis:

Most common cause of abnormal vaginal discharge worldwide.
However, it is the least common in USA.

Trichomonas vaginitis:

Flagellated motile protozoa.
 Transmission:



Sexually Transmitted.
Infects urogenital system: Vagina and urethra.
Trichomonas Vaginitis:

Clinical Findings:

Symptoms:


Speculum Examination:




Itching, burning, dysparenuia.
Perfuse, frothy, yellow-green,
malodoros discharge.
Vaginal epithelium is erythematous, edematous and inflamed.
Erythematous cervix: strawberry appearance.
Vaginal PH  4.5.
Trichomonas Vaginitis:

Microscopic Examination:


WBCs abundant.
Motile flagellated parasite.
Trichomonas Vaginitis:
Management:
 Mitronidazole 500mg PO bid for 1 week.


Sexual partner should receive treatment.
CANDIDA VAGINITIS
“ MONILIAL VAGINITIS”
Candida Vaginitis:

The 2nd most common cause of abnormal vaginal discharge.

Causitive organism: Candida albican, yeast.

Also, known as “ Monilial Vaginitis”.

Risk Factors:



Uncontrolled DM.
Systemic broad spectrum antibiotics.
Altered immunity: HIV, immunosuppressive agents.
Candida Vaginitis:

Clinical Findings:

Symptoms:


Clinical Examination:
 Thick, curd-like white discharge, no odor.


Itching, burning, dysparenuia.
Vaginal erythema, edema and tenderness.
Vaginal PH  4.5.
Candida Vaginitis:
Candida Vaginitis:

Microscopic Examination:

Abundant WBCs.

Addition of 10% KOH  Pseudohyphae.
Candida Vaginitis:

Management:
 Oral
agents:
 Fluconazole. (150mg, single dose).
 Topical

vaginal agents:
Fungicidal creams “end with –azole”:

Ticonazole, clotrimazole, miconazole, terconazole,……
DISCUSSION….
Problem I:
Patient Snapshot:
-She describes the discharge as
thin, gray with fishy odor.
- Pelvic examination:
no erythema or edema is seen.
1- What is the most likely diagnosis:
a. Physiologic discharge.
b. Bacterial vaginosis.
c. Vaginal candidiasis.
d. Chlamydia cervicitis.
e. Trichomonas vaginitis.
Problem I:
Patient Snapshot:
-She describes the discharge as
thin, gray with fishy odor.
- Pelvic examination:
no erythema or edema is seen.
2- Which of the following would help you to
confirm your diagnosis?
a. Hyphae.
b. Multinucleated gaint cells.
c. Clue cells.
d. Intracellular organisms.
e. Non of the above.
Problem I:
Patient Snapshot:
-She describes the discharge as
thin, gray with fishy odor.
- Pelvic examination:
no erythema or edema is seen.
3- You decided to check vaginal PH to aid in
your diagnosis. You expect it to be:
a. 1.5 – 2.4.
b. 2.5-3.4.
c. 3.5 – 4.5.
d.  4.5.
e. 7.2
Problem I:
Patient Snapshot:
-She describes the discharge as
thin, gray with fishy odor.
- Pelvic examination:
no erythema or edema is seen.
4- What would you use for therapy?
a. Mitronidazole.
b. Fluconazole.
c. Azithromycin.
d. Ampicillin.
e. Acyclovir.
Problem II:
Patient Snapshot:
-she comes today with inguinal
lymphadenopathy with malaise and fever.
The diagnosis is established by:
a. Staining for Donovan bodies.
b. Presence of antibodies to Chlamydia.
c. Positive Frei skin test.
d. Culturing for Hemophilus ducreyi.
e. Culturing for Kelebiella granulomatis.
Thanks…