Transcript “sexually transmitted infections or “STIs.

In the name of God
Sexually Transmitted Infections
Ataei Behrooz,MD.MPH
Medical University Isfahan
Department of Infectious Diseases
2011
• The name of this group of diseases was changed
from “venereal diseases” to “sexually transmitted
diseases” or “STDs”
• Now many persons call them “sexually
transmitted infections or “STIs.”
Sexually Transmitted Infections
A STI is an infection that is transmitted
through sexually activity
Importance of STIs
• Most neglected area of healthcare
in developing countries (vaginitis,
cervicitis and PID)
• Major cause of infertility in both
females and males
Importance of STIs
• Account for up to 40% of gynecologic
hospital admissions
• Cofactor in HIV and HBV transmission
• STDs are almost as common as malaria:
333 million new cases each year
Importance of STIs
• Infertility:
– 20-40% of males with untreated chlamydia and
gonorrhea
– 55-85% of females with untreated PID
(8-20% of females with untreated gonorrhea develop PID)
• Increased risk of HBV and HIV/AIDS
transmission
STDs are a Significant Problem
The consequences of untreated STDs
– Ectopic pregnancy (7-10 times increased
risk in women with history of PID)
– Increased risk of cervical cancer
– Chronic abdominal pain (18% of females
with a history of PID)
STIs - classification
• BACTERIAL
• VIRAL
• PROTOZOAL
• FUNGAL
• ECTOPARASITES
BACTERIA
• Neisseria gonorrhoeae gonorrhea
• Chlamydia trachomatis chlamydia
• Treponema pallidum
Syphilis
• Hemophilus ducreyi Chancroid
• Calymmatobacterium granulomatis Donovanosis (granuloma
inguinale)
• Gardnerella vaginalis
Gardnerella-associated ("nonspecific")
vaginosis
• OTHERRS :eg. Mycoplasma hominis ,Ureaplasma urealyticum
VIRUSES
•
•
•
•
•
•
Herpes simplex virus
Human papilloma virus
Hepatitis B virus
HIV (AIDS)
Cytomegalovirus
Molluscum contagiosum virus
PROTOZOAL
• Trichomonas vaginalis Trichomonal vaginitis
• Entamoeba histolytica Amebiasis
in homosexual men
• Giardia lamblia
in homosexual men
Giardiasis
FUNGI
?Candida albicans Vulvovaginitis, balanitis
ECTOPARASITES
• Phthirius pubis Pubic lice infestation
• Sarcoptes scabiei Scabies
HERPES SIMPLEX
VIRUS Infection
Epidemiology
• HSV has a world wide distribution
• Humans are the only reservoir of infection
• Spread by direct contact with infected secretions
• HSV – 2 more frequent cause of genital infection
• Major risk of infections 14 – 29 yrs
• Sero prevalence rates in general papulation 22%
Pathogenesis
• Incubation period 2 – 7 days
• HSV replicates with in epithelial cells and lyses
them
• Producing thin – walled vesicle
• Multi nucleated cells with intra nuclear
inclusions
• Regional lymph nodes, enlarged and tender
often bilateral
• HSV also migrates along sensory
neurons to sensory ganglia (latent
state)
• Virus migrate back to skin along sensory
nerves (Reactivation)
Clinical presentation : primary infection
• In male :
• Painful vesicle on the glans or penile shaft
on erythematous base persist 7 – 14 days
• In female : painful vesicle on the vulva,
perineum, buttocks, cervix or vagina
• Vaginal discharge frequently
• Inguinal adenopathy, fever, malaise
Recurrent :
Grouped vesicles on erthematous base,
painful few systemic symptom last 3 -10 days
Diagnosis :
• Appearance of characteristic vesicles is strongly
suggestive of HSV infection
• Tzanck smear (66% sensitive)
• Tissue culture isolation (gold standard)
• HSV-2 Antigen
• Four fold rise in antibodies to HSV-2 (for primary)
Treatment
• Acyclovir (topical, oral, IV) shorten course of
HSV infection
• Do not prevent latent stage
• Can not prevent recurrence
• Prophylactic oral acyclovir (4 -6 yrs)
decrease frequency symptomatic recurrences
(60% to 80%)
• Valacyclovir, famcyclovir
• Shedding of HSV active cervical or
vulvar lesions late in pregnancy is
indication for cesarean section
Recommended Treatment
• First clinical episode:
Acyclovir 400 mg orally 5 times a day
for 7-10 days, or famciclovir 250 mg
orally 3 times a day for 7-10 days, or
valacyclovir 1 g orally 2 times a day for
7-10 days.
Recommended Treatment
• Recurrent episodes:
Acyclovir 400
mg orally 3 times a
day for 5 days, or 800 mg orally 2
times a day for 5 days or
famciclovir 125 mg orally 2 times
a day for 5 days
Syphilis
Epidemiology
• 90000 cases in U.S per year
• Caused by treponema pallidium
• Primary syphilis occurs mostly in sexually
active 15 – 30 yrs
• 50% sexual contacts of a patient with
primary syphilis infected
• Incubation period 10 -90 days (21 days)
Pathogenesis
• Treponema pallidium penetrate intact
mucous membrane or abraded skin
Primary lesion
• Chancre:
• Papule that ulcerates, painless, border
raised, firm, ulcer indurated,base smooth,
usually single, may be genital or almost
anywhere, persists 3-6wk,leaving thin,
atrophic scar
Adenopathy
• 1 wk after chancre appears, bilateral or
unilateral; firm, discrete, movable, no
overlying skin changes, painless,
nonsuppurative; may persist for months
Secondary syphilis
• 6 – 8 weeks after chancre
• Skin, mucous membranes, lymph node
involved
• Skin lesion, macular, papular, pustular,
follicular, or nodular
• Generalized, symmetrical
• In moist intertriginous areas large, pale, flat
papules coalesce (condylomata lata)
• Mucous patches, pain less grayish –
white erosion
• Malaise, anorexia, weight loss fever,
sore throat, arthralgias,
• Generalized, non tender, discrete
adenopathy
• Hepatitis, gasteritis, nephritis ,
meningitis
Late syphilis
• After 1 to 10 yrs in 15% of untreated patient.
• Skin gumma (respond)
• Borne, liver, cardio vascular or CNS gumma
• Progressive cardiovascular syphilis within 10yrs
more than 10% untreated patient
• CNS syphilis in 8%, 5 to 35 yrs after primary
infection
• Tabes dorsalis, general paresis, meningovascular
Diagnosis
LABORATORY DIAGNOSIS
• Direct Examination for Spirochetes
In primary, secondary, and early congenital
syphilis, the darkfield examination
• or immunofluorescent staining of
mucocutaneous lesions is the quickest and
most direct laboratory method of establishing
the diagnosis.
• The standard nontreponemal test is the
VDRL slide test.
• It is now most often used to monitor a
patient's response to therapy.
• Most laboratories and blood banks have
adapted a modification for routine screening
for syphilis: the
• rapid plasma reagin (RPR) card test, the
automated reagin test (ART), or the
toluidine red unheated syphilis test
(TRUST).
• A prozone phenomenon occurs in up to 2%
of infected
• These tests are inexpensive, reliable, and easy
to perform.
• They have utility for screening sera and in
areas of high prevalence (e.g., southeastern
United States) should still be used to screen
hospital admissions.
• Also, they have great utility as a gauge of the
success of treatment.
Specific Treponemal Tests
• These tests would be relatively expensive as
screening tests,
• their principal use is to verify a positive
nontreponemal reaginic test result.
• Once positive, the patient usually remains
positive for life
• In summary, the reaginic antibody tests
(RPR, VDRL, ART) are
• used for screening large numbers of sera, the
specific treponemal tests
• (TPHA, MHA-TP, FTA-abs) for confirming
the diagnosis, and the
• quantitative nontreponemal antibody tests
(RPR, VDRL) for assessing the adequacy of
therapy.
• Reversion to a non reactive status may
occur in up to 10% of patients, especially
in those who are treated early.
Treatment
Jarisch-Herxheimer Reaction
• Systemic reaction
• Resembling gram negative sepsis
• Usual1y begins I to 2 hours after the
initial treatment of syphilis with effective
antibiotics, especial1y penicillin.
Follow after treatment
• Every patient who is treated for syphilis
should be sero negative or sero fast with a
low fixed titer before termination of follow
– up if not therapy should be repeated
• Abrupt onset of fever, chills, myalgias,
headache, tachycardia, hyperventilation,
vasodilation with flushing,
• Varying degrees of obtundation, and mild
hypotension.
• Particularly common when secondary
syphilis is treated (70% to 90%) but can
occur in any stage (10% to 25%).
• Lasts from 12 to 24 hours
• and has been wel1 correlated with the
release from the spirochetes .
• prevented or treated with an anti-inflammatory
agent such as aspirin every 4 hours for a period of
24 to 48 hours.
• Prednisone can also abort the reaction, and one dose
of 60 mg PO or IV should be given as adjunctive
therapy
• to JH patients with cardiovascular or symptomatic
neurosyphilis
• and to pregnant patients to avoid catastrophic
consequences.
Chancroid
• 2000 cases in U.S. per year, caused by
Haemophilus ducreyi
Primary lesion
• Incubation 3-5 days; vesicle or papule to pustule
to ulcer; soft, not indurate; very painful
Adenopathy
• 1 wk after primary in 50%; painful,
unilateral (two thirds), suppurative
Systemic features:
None
Diagnosis / treatment
• Organism in Gram stain of pus; can
be cultured (75%) but direct yields
highest from lymph node.
• Rx: ceftriaxone, 250 mg once 1M, or
ciprofloxocin, 500 mg twice daily for
3 days
Lymphogranuloma venereum
• 600-1000 cases per year in U.S., due to
Chlamydia trachomatis
Primary lesion
• Incubation 5-21 days; painless
papule,vesicle, ulcer, evanescent (2-3
days), noted only 10-40%
Adenopathy
• 5-21 days after primary, one third bilateral,
tender, matted iliac / femoral “groove sign”;
• multiple abscesses; coalescent, caseating,
supportive, sinus tracts; thick yellow pus;
fistulas; strictures; genital ulcerations
Systemic features
• Fever, arthritis, pericarditis, proctitis,
meningoencephalitis. kerataconjunctivitis.
Preauricular adenopathy, edema of eyelids,
erythema nodosum
• LGV CF positive 85%-90% (1-3 wk);
must have high titer(>1:6), crossreacts with other Chlamydia; also
positive STS, rheumatoid factor,
cryoglobulins/
• Rx:Doxycycline,100mg twice
daily for 7 days
Granuloma inguinale
• 50 cases in U.S. per year, caused by
Calymmatobacterium gronulomatis
• Incubation 9-50 days;
• at least one painless papule that gradually
ulcerates; ulcers are large (l-4cm),irregular, non
tender; with thickened, rolled margins and beefy
red tissue of base older portions of ulcer show
depigmented scarring, white advancing edge
contains new papules
adenopathy
• No true adenopathy; in one fifth, subcutoneous
spread through lymphatics leads to indurated
swelling or abscesses of groin
(“pseudobuboes”)
Metastatic infection of
bones, joints, liver
Diagnosis / treatment
• Scraping or deep curetting at actively extending
border; Wright or Giemso stain reveals short,
plump, bipolar staining; “Donovan's bodies in
macrophage vacuoles/
• Rx: tetracycline, 2 g/day for 21 days
Condyloma acuminatum
• genital warts, frequent, caused by
human papillomavirus
Primary lesion
• Characteristic large ,soft, fleshy,
cauliflower-like excrescences around vulva,
glans, urethral orifice anus, perineum
adenopathy
None
• None per se; association with cervical
dysplasia/ neoplasia
Diagnosis / treatment
• Chief importance is distinction from
syphilis and chancroid/
• Rx: topical podophyllin ± cryosurgery, laser
resection
Urethritis
GONORRHEA
Epidemiology
• Particular risk factors
1.
2.
3.
4.
Urban habitat
Low socioeconomic status
Un married status
Unprotected sexual contacts
• 50% of females intercourse with a male with
gonococcal, urethritis developed
symptomatic infection
• For male 20%
• A symptomatic infection of male important
factor transmission (40%)
• Co infection with C. trachomatis(30% to 40%)
• Group B blood increases susceptibility
Etiology
• Neisseria gonorrhea is a gram –
Negative, kidney bean shaped
diplococcus
Clinical presentation
• Incubation period : 2 to 7 days
• In male : purulent discharge
urethritis and severe Dysuria
• In female cervicitis : coptous yellow
vaginal discharge
• Females also may develop urethritis with
dysuria and frequency
• Anorectal gonorrhea occurs in both
homo sexual males and hetero sexual
female
• Extragenital dissemination occurs in 1%
male and 3% female (Arthritis –
dermatitis syndrome)
Laboratory diagnosis
1. Gram stain (intracellular diplococci)
2. Culter
3. DNA probe
Culture
• A single culture on antibiotic-containing
selective medium, such as
• modified Thayer-Martin agar, has a sensitivity
of 95% or more for urethral specimens from
men with symptomatic urethritis
• 80% to 90% for endocervical infection in
women.
Non gonococcal urethritis (NGU)
• NGU predominate in higher socioeconomic
• Chlamydia trachomatis causes 30 to 50% of
NGU
• Chlanmydia – Negative NGU
U.urealyticum, trichomonas vaginals
Clinical syndromes
• Incubation period 7 – 14 days
• Urethral discharge, itching, dysuria
• Discharge is not spontaneous
• Discharge apparent after milking urethra in
morning
• Mucopurulent discharge consist of thin, cloudy
fluid with purulent specks
• C. trachomatis common cause epididymitis in
male 35 yrs age.
Initial Treatment for Patient and
Partners
Treat gonorrhea (unless excluded):
plus
Treat chlamydial infection:
Ceftriaxone, 125 mg IM; or
Azithromycin, 1 g PO; or
Cefpodoxime, 400 mg PO; or
Doxycycline, 100 mg bid for 7
days
Cefixime, 400 mg PO
Alternative regimens
• Ceftizoxime (500 mg IM, single dose)
• or
• Cefotaxime (500 mg IM, single dose)
• or
• Spectinomycin (2 g IM, single dose)
• or
• Cefotetan (1 g IM, single dose) plus probenecid (1 g PO, single
dose)
• or
• Cefoxitin (2 g IM, single dose) plus probenecid (1 g PO, single dose)