Prof. Omayma Mohammad

1. Sexually Transmitted Diseases Venereal Diseases Prof. Omayma Mohammad

2. 1- Gonorrhea Causative agent: Neisseria gonorrhea. Morphology: • gram-ve kidney-shaped diplococci. • in pathological specimens, the organism appears intracellularly in pus cells and extracellularly. Cultural characters: • Grows best on enriched media as chocolate agar and Thayer-Marten agar (chocolate agar containing antibiotics to suppress normal flora). • Aerobic and needs 5-10% CO2 for growth at 37ºC for 24-48 hours.

3. Gm-stained smear of pathological discharge

4. Gm stain from colonies Gm-ve diplococci

5. Morphology of N. gonorrhea on chocolate agar

6. Biochemical reactions: • Oxidase positive. • Ferment glucose. • Does not ferment maltose or sucrose (in contrary to N. meningitidis and N. sicca). Antigenic structure and virulence factors: Gonococci are antigenically heterogeneous and capable of changing their surface structure invitro and may be invivo to avoid host defense

7. 1- Pili: Important virulence factor as they mediate i- attachment to host cells. ii- resistance to phagocytosis. iii- Antigenic heterogeneity: According to antigenic variation of pilus protein (pilin), gonococci are classified to about 100 serotypes. 2- OPa: surface proteins help in the attachment to host cells. 3-Lipoolygosaccharides (LOS) (Endotoxin): Toxicity in gonococcal infection is largely due to toxic effect of LOS. 4- IgA1 protease: Inactivates secretory IgA. 5- Por proteins: several types, play role in antigenic diversity

8. Pathogenesis: Invasive organism - Gonococci attack mucus membranes of the genitourinary tract, eye (ophthalmianeonatorum), anorectal area and throat producing acute suppuration and tissue invasion. This is followed by chronic inflammation and fibrosis. - Invasion of blood stream (bacteremia) and disseminated gonococcal infections (DGI) leads to skin lesions (hemorrhagic papules and pustules), tenosynoviitis and suppurative arthritis , usually the knees, ankles and wrists. • Gonococcal endocarditis is uncommon but sever.

9. Occurrence of DGIs depends on: 1- certain strains of gonococci cause DGI more frequently than others. These strains are characterized by: • Resistant to bactericidal action of serum. • Marked sensitivity to penicillin. • Need arginin, uracil and hypoxanthin for growth. 2- persons deficient in complement components C6- C9 (as woman during menses and pregnancy) are at risk of DGI.

10. Gonococcal Pathogenesis:

11. Clinically: In females: • The primary infection is in the endocervix and extends to the vagina and urethra. There will be a mucopurulent discharge. • The paraurethral and Bartholin glands are usually involved. • Infection may extend to salpingitis, fibrosis and obliteration of the tubes (PID, pelvic inflammatory disease) → infertility In males: • Gonorrheal urethritis. • Acute case is characterized by copious discharge. • chronic case by morning drops. - Infection may extend to cause prostatitis and epididymitis.

12. Lab Diagnosis:Specimen: - In females: cervical swab in acute and chronic infection. - In males: urethral discharge in acute infection and morning drops in chronic infection. A- Gram stain. B- Culture on chocolate agar or modified Thayer- Marten agar. - Cultured plates are incubated aerobically at 36ºC for 24-48 hours in presence of 5% CO2. - Suspected colonies are identified by: 1- morphology 2-gram stain 3- oxidase test 4-Sugar fermentation C- Gonococcal antigens in the specimen can be detected by ELISA and DNA probe. Serological diagnosis: - by detection of specific antibodies to gonococcal pilin and outer proteins by ELISA.

13. 2-Syphilis Causative organism: Treponema pallidum which is a spirochete that belongs to the family treponemataceae, group spirochetes. Morphology: - long slender, spiral-shaped bacilli. - actively motile by axial endoflagellae which lies between the peptidoglycan layer and an outer sheath. • can not be stained with gram stain, but can be visualized by dark ground microscopy and can be stained by IFT and Fontana stain.

14. Morphology of Treponema pallidum Treponema pallidum smear Stained by silver impregnation Technique (Fontana Stain)

15. Dark-ground microscopy IF staining

16. culture: • It has never been cultured on artificial media or tissue culture. • The non-pathogenic treponema (Reiter strain) can be grown anaerobically in broth enriched with serum. • The pathogenic Nicola΄s strain can grow in the testicles of the rabbits. • In whole blood or plasma stored at 4ºC, the organism remain viable for at least 24 hours (important in blood transfusion).

17. Antigenic structure - The antigen make up is not exactly known, but human with syphilis develops: 1- antibodies capable of staining T. pallidum by indirect IF, immobilizing live motile organism. 2- antibody-like substance, reagin, which gives positive CF (complement fixation) and flocculation tests with aqueous suspension of cardiolipin extracted from normal mammalian heart tissue

18. Ways of transmission of syphilis A- Acquired syphilis: • Is mainly a sexually transmitted disease. • Can be acquired as a clinical hazard in hands of doctors and nurses by contact with patients. • It can be rarely transmitted by blood transfusion of fresh blood. B- Congenital syphilis: • A pregnant woman can transmit the organism to the fetus through the placenta,

19. Clinical stages of acquired SyphilisPrimary syphilis:- Appear 3 weeks after exposure to infection. Pathogenesis: invasion - T. pallidum can penetrate intact mucus membrane or damaged skin or through hair follicles causing the characteristic lesion of primary syphilis. Then there is a rapid systemic spread via the blood and lymphatics. - The lesion begins as a papule which breaks down to form an ulcer with clean base (chancre). - The site of the lesion is usually the skin and mm of external genitalia (vulva and vagina in females, glans penis and penis in males), but may be intrarectal, perianal or oral. - Primary lesion usually heals spontaneously.

21. Secondary syphilis: - Appear 6-10 weeks after appearance of the chancre. - It is characterized by lesions that follow systemic spread via the blood and lymphatics : 1- fever. 2- maculopapular rash any where in the body, notably in the palm and sole. 3- moist papule in anogenital region; codylomalata. 4- mucus patches in the mouth. - T. pallidum is found in large number in the lesions of primary and secondary syphilis. 5- During this phase there may be also syphilitic meningitis, chorioretinitis, nephritis (immune complex type), or periostitis.

22. maculopapular rash in the palm maculopapular rash in the body mucus patches in the mouth codyloma lata

23. Tertiary syphilis - About 30% of cases of early syphilis may progress to complete cure without treatment. - About 30% of untreated infection remain latent. - The remainder cases progress to tertiary syphilis. - Tertiary syphilis is characterized by rare T. pallidum in the lesions. Lesions: 1- appearance of granulomatous lesions (gummas) in skin, bones and liver. 2- degenerative changes in CNS, meningeovascular syphilis, paresis, tapes dorsalis. 3- cardiovascular lesions aortitis, aortic aneurysm, aortic valve insufficiency.

24. Syphilitic gummas in skin

25. Lab diagnosis of syphilis I- Detection of T. pallidum in lesions: Serous exudate from lesions of 1ry and 2ry stages is examined by: 1- wet film for dark ground microscopy. 2- IFT using fluorescein-labelledantitreponemal antibodies. 3- staining with silver impregnation technique (Fontana stain). II- Serological diagnosis: A- non-treponemal antigen tests: • detect the reagin antibody that react with a non-specific antigen, cardiolipin, which is an alcohol extract of beef heart muscle supplemented with lecithin and cholesterol. • Reagin is a mixture of IgG and IgM that appear 2-3 weeks in the patient serum and 4-8 weeks in the CSF after exposure to infection.

26. Non-treponemal antigen tests include: 1-Flocculation tests: VDRL and RPR (rapid plasma reagin) tests. 2- CFT, complement fixation test (Wasserman test). They are characterized by: - Non-specific and can lead to false positive results. - Become negative 6-18 months after effective treatment, so can be used to follow up the effect of treatment. - They are mainly used for screening and epidemiological studies because they are sheep, rapid and simple.

27. B- Treponemal antigen tests: - Highly specific and sensitive tests as they use T. pallidum as the antigen. - But they are complex and expensive, so used mainly for confirmation of diagnosis. -They remain positive for life, so cannot be used to judge the efficacy of treatment. 1- Fluorescent treponema antibody test (FTA). The presence of IgM FTA in the blood of a new-borne is good evidence of in-utero infection. 2-Treponema pallidumhemagglutination (TPHA). 3- T. pallidum Particle Agglutination Assay (TPPA)

28. 3- Lymphogranulomavenerium Causative organism: Chlamydia trachomatis serotypes L1-L3. Lesion: - The initial lesion is a painless papule on the external genitalia, which ulcerates. - The inguinal L.N. enlarge (pubos), suppurate and the pus is drained through the overlying skin. • Healing by scaring leads to strictures and lymphatic obstruction→ elephantiasis of labia and scrotum.

29. Pubos

30. Chlamydia • Chlamydia are intracellular parasites that are considered as gram –v bacteria. • They lack the mechanism for production of metabolic energy and can not synthesize ATP → energy parasite. • According to outer membrane proteins, chlamydia are classified into number of serotypes from A-L:- - A,B,C cause trachoma. - D-K cause occulogenital diseases, non-gonococcal urethritis, cervicitis and PID. - L1-L3 cause LGV.

31. Developmental cycle of Chlamydia There are 2 forms of the organism: • the elementary body (EB): the infective form. It is taken by the host cell after attachment by phagocytosis-like process. *it enlarges inside the cell forming the reticulate body (RB). *RB grows inside the cell and divides by binary fission forming large number of EBs that are seen as inclusion bodies. *EBs are released by a process reversible to phagocytosis to infect new cells.

32. Developmental cycle of Chlamydia

33. Lab Diagnosis • Smears from the lesion and aspirate from the LN stained by Giemsa or IF to see the intracytoplasmic inclusions. • Direct detection of chlamydial antigens in the specimen using specific monoclonal antibodies by ELISA or IFT. • Direct detection of nucleic acid by PCR and DNA probes. • Isolation in tissue culture. • Serological diagnosis, to detect specific IgM or high titer of IgG by ELISA or IFT.

34. 4- Non-gonococcal urethritis Causative agent: - Chlamydia trachomatis serotypes D-K. In females → cervicitis, salpingitis and pelvic inflammatory disease (PID). It can lead to infertility. In males → urethritis and epididymitis. - Infection of the new borne during birth causes inclusion conjunctivitis. Lab diagnosis: as in case of LGV. Other causes of non-gonococcalurethritis in males: 1- Mycoplasma (Ureaplasmaurealyticum, M. genitalium). 2- Gardnerellavaginalis 3- Trichomonasvaginalis 4- Herpes Simplex virus

35. 5- Chancroid Causative organism: Hemophilus ducreyi. • Gram –v short rods or coccobacilli. • Facultative anaerobe, grow on chocolate agar, needs 5% CO2 during incubation at 37ºC. • Needs X factor (hemin) but not V factor (NAD) for growth (H. influenza needs both X and V factors). Chancroid is characterized by soft ulcer on the external genitalia,regional LN are enlarged and painful.

36. Diagnosis: 1- Scraping from the lesion or aspirate from the enlarged lymph nodes:- a- gram stained smear. b- culture on chocolate agar. 2- Serological diagnosis

37. 6- Mycoplasma hominis Belong to the family mycoplasmataceae that includes:- Genus: Mycoplasma • Species: M. pneumoniae • Species: M. hominis • Species: M. genitalium Genus: Ureaplasma • Species: U. urealyticum In females: M. hominis causes cervicitis, salpingitis, tubo- ovarian abscess (PID), post partum fever. It may play a role in bacterial vaginosis. In males:U. urealyticum, M. genitalium and hominis cause non- gonococcalurethritis that may be complicated by epididymitis.

38. Characters of Mycoplasma - Smallest free-living bacteria (0.2 - 0.8 :m) - Facultative anaerobes, except M. pneumoniae → strict aerobe - Lack a complete cell wall Thus, they can assume multiple shapes including round, pear shaped and even filamentous. - The only bacteria that contain sterol in the cell membrane. - require complex media containing sterols for growth and for membrane synthesis - they can not be treated with penicillin or cephalosporin, Why?

39. Lab diagnosis: • Culture of the specimen on specific media→ fried egg appearance. • Direct detection of Mycoplasma antigen in the specimens by IFT and PCR. • Serological diagnosis: detection of specific IgM or rising titer of IgG in the patient serum.

40. 7- Granuloma inguinale (granuloma contagiosa)Donovanosis • is a chronic, ulcerative, granulomatous disease of the skin and lymphatics. Causative agent:Calymmatobacteriumgranulomatis is a Gram –ve capsulated rods with characteristic bipolar staining (Donovan bodies). • The bacteria invade and multiply in mononuclear cells and liberated when cells rupture. CP: • Initially the lesions are papules, almost always on the genitalia, that tend to ulcerate slowly. • Patients develop subcutaneous granulomas in the inguinal regions; they do not usually involve the lymph nodes, so called pseudo-buboes.

41. Diagnosis: • the nature of the lesion (nodules which erode to form painless, beefy, granulomatous ulcers). • The organism is difficult to culture. • Smear from the lesion stained with Giemsa shows the enlarged mononuclear cells containing vacuoles filled with the organism (Donovan bodies).

42. Candida vulvovaginitisMycotic vulvovaginitis • Candida albicans is found as a part of normal flora in the vagina in 25% of women. • Yeast fungus, in pathological specimens pseudohypha are seen. Strongly gm +ve. Pathogenesis: - Factors that are responsible for pathogenicity of the fungus are: diabetes, pregnancy, immunosuppression, antibiotics, contraceptive pills, cystic fibrosis and poor feminine hygiene. There will be excessive growth of the fungus. - The condition may be complicated by urethritis and dysuria.

43. Manifestation: • A thick, curd like white vaginal discharge • intense pruritis of the vulva • pH of the discharge is < 4.5 • erythematous vagina and labia Diagnosis: 1- clinical manifestation. 2- gram stain of vaginal discharge. 3- culture on Sabouraud agar

44. Gm stain of vaginal discharge in case of mycotic vulvovaginitis Shows: gm+ve candida yeast and pseudohyphae

46. Colonies of Candida albicans on Sabouraud dextrose agar

47. Candida infection of male genitalia candida balanitis • Can be recovered from the coronal sulcus in the absence of clinical infection. - The strains are usually the same in both partners • Diabetes plays an important role in the pathogenicity of candida and candida balanitis may be the representing symptom. • Clinically, there is glazed non-purulent surface, slightly scaling edge. Eroded pustule may occur. Recurrent infection causes fibrosis and fissuring. Lab diagnosis: Gram stain and culture.

48. Non-specific vaginitis (bacterial vaginosis) The commonest cause of vaginal discharge. - It is due to complex inter-relationship between Gardenerellavaginalis (small aerobic gm-v bacilli or coccobacilli) and anaerobic bacteria as Mobiluncus. - Mycoplasma hominis may play a role. • The discharge is thin, white-gray, adherent and has fishy odor. • Fishy odor is accentuated by addition of 10% KOH. • pH > 4.5 (5.5) - Itching is minimal or absent. • Microscopically→ clue cells, which are epithelial cells adherent to them the involved organisms.

49. Clue cells Clue cell: vaginal epithelium cells adherent to it Gardenerella vaginalis which are gm-ve coccobacilli.