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A Discussion About Sexually Transmitted Diseases

A Discussion About Sexually Transmitted Diseases. Marci Putnam January 2003. Case 1.

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A Discussion About Sexually Transmitted Diseases

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  1. A Discussion AboutSexually Transmitted Diseases Marci Putnam January 2003

  2. Case 1 • A.J. is a 16y/o woman who presents to Teen Clinic w/ cc: low abdominal pain x2 days. She’s also experienced some burning with urination x4 days, tactile fevers x1 day. She thinks she may have had a little more vaginal d/c than usual recently. She can’t recall the number of sexual partners she’s had, but has been with a new partner for about 3 wks. She has had occasional unprotected sex.

  3. Speculum exam reveals…

  4. Chlamydia • Most common STD  ~4 million cases /year in the US alone. • Rates of Chlamydia are highest in adolescent women, and drop off steeply in the early 20’s. • Risk factors: young age, black race, multiple sex partners, recent new partner, h/o STD, and low rate of barrier contraceptive usage. • Usually asymptomatic in women, symptomatic in men.

  5. Clinical Findings in Chlamydia • Asymptomatic infection is common among both women and men. • Cervicitis is the most common chlamydial syndrome  vaginal d/c, lower abdominal pain are most common sx. Dysuria may be present. PID can be the presenting sx. • Signs: Mucopurulent cervical d/c, cervical friability/ edema. • In men: if symptomatic, may present as urethritis, epididymitis or prostatitis. • Signs: penile d/c, unilateral scrotal pain/edema.

  6. Sequelae of Chlamydia • Approximately 30% of women w/ chlamydia will develop PID if left untreated. • Increased incidence of ectopic pregnancy after chlamydia infection • PID due to CT has higher rates of subsequent infertility. • Can develop perihepatitis (Fitzhugh-Curtis Syndrome)

  7. Diagnosis of Chlamydia • Historically – cell culture, DFA or ELISA • Now Ligase Chain Rxn (LCR) is standard of care. Can be done on cervical swab or urine (less invasive). • LCR: sensitivity = 90-95%, specificity = ~100%! • CDC recommends annual chlamydia screening of all sexually active women <25 y/o, even if asymptomatic.

  8. Treatment of Chlamydia • Recommended Regimens: • Azithromycin 1g po x1, or • Doxycycline 100mg po BID x7 days. • Alternative Regimens: • Erythromycin base 500mg po QID X7days • Erythromycin ethylsuccinate 800mg po QID x7days • Ofloxacin 300mg po BID x7days • Levofloxacin 500mg po qd x7days

  9. Other Considerations • If recommended regimen is used for treatment, no test-of-cure is necessary unless sx persist or reinfxn suspected or patient is pregnant. • Patient’s sex partners must be treated if sexual contact within 60 days of sx.

  10. Case 2 • L.T. is a 37 y/o man who presents to your clinic with cc: right testicular pain x3 days. He also describes some whitish penile d/c since yesterday and mild burning w/ urination. No F/C/N/V or abdominal pain. • L.T. is concerned re: new sexual partner who was “a little shady”, and wants to be tested for STDs.

  11. Physical exam reveals…

  12. Gonorrhea General Considerations • Most affected women are asymptomatic, while most men are symptomatic. • After exposure, 20-50% of men and 60-90% of women become infected. • Without therapy, 10-17% of women develop pelvic inflammatory disease (PID). • Approximately 10-30% patients infected with Gonorrhea are co-infected with Chlamydia.

  13. Clinical Findings in Gonorrhea • Women: If symptomatic  localized to lower genitourinary tract and include: • Urinary frequency and dysuria • Itching, burning or purulent d/c from vulva, vagina, cervix or urethera. • Men: About 90% of men are symptomatic • 82% purulent penile d/c, 53% dysuria • Unilateral epididymitis, proctatitis possible. • Disseminated infection possible – usually a triad of polyarthralgias, tenosynovitis and dermatitis.

  14. Work Up of Gonorrhea • Diagnosis • Culture = “gold standard”. 65-85% sensitive in asymptomatic pts, 100% specific. • Gram stain. Only 60% sensitive in symptomatic women, 100% sensitive in symptomatic men. • LCR (urine or swab) 50-95% sensitive, 100% specific. • High prevalence of co-infection with other STDs (esp. Chlamydia) important to do complete STD screen!

  15. Treatment for Gonorrhea • Recommended Regimen: • Cefixime 400mg po x1 or, • Ceftriaxone 125mg IM x1 or, • Ciprofloxacin 500mg po x1 or, • Ofloxacin 400mg po x1 or, • Levofloxacin 250mg po x1 • PLUS…for presumed co-infxn w/ chlamydia: • Azithromycin 1g po x1 or, • Doxycycline 100mg po BID x7 days

  16. Other Considerations • Gonorrhea is a reportable disease. • Patient’s sex partners within 60 days of the onset of symptoms must also be treated, both for Gonorrhea and Chlamydia. • According to the CDC, if uncomplicated gonorrhea is treated w/ recommended regimen, no test-of-cure is necessary.

  17. Case 3 • M.W. is a 18 y/o man who presents to Planned Parenthood w/ cc: “rash”. He seems quite anxious as he tells you about the painful lesion on his penis which started about 5 days ago. It began w/ burning pain, then small blisters appeared. He picked at a few of the blisters, and then the area began to erode into an ulcer-like lesion. It’s still quite painful and oozing sero-sanguinous fluid.

  18. Doc, it really hurts a lot!

  19. Genital Herpes Simplex Virus • HSV is the most prevalent cause of genital ulcers. • Genital HSV is a recurrent, life-long viral infection. • About 85% of cases of genital HSV are due to HSV-2, however HSV-1 can also cause genital lesions. • At least 50 million people in the US have genital HSV. • Most pts infected w/ HSV-2 are asymptomatic, but shed virus intermittently.

  20. Clinical Findings in Genital HSV • Primary infxn – Usually more severe than secondary, but can also be asymptomatic. • Prodromal sx of burning, itching, tingling • Vesicular eruption follows, then erodes into painful ulcers in genital region. • Bilateral inguinal adenopathy, fever and malaise can accompany severe infxns. • Lesions persist for 2-6 weeks • Secondary infxn – may be asymptomatic, or less severe presentation of above w/out systemic sx.

  21. Diagnosis of HSV • HSV cell culture of “fresh” lesion, preferably still in the vesicular state. • Serology – type-specific serology, usually takes ~21 days to develop antibodies (sensitivity = 80-96%, specificity >96%). • IgM suggestive of new infxn (1/2 life ~ 6wks). • IgG suggestive of chronic infxn. • PCR – Not yet widely available, but probably will become new standard (highly sensitive and specific).

  22. Treatment of Genital HSV • Primary Infxn: • Acyclovir 400mg po TID x7-10 days, or • Famciclovir 250mg TID x7-10 days, or • Valacyclovir 1g BID x7-10 days. • Topical lidocaine may be used for analgesia. • Recurrent Infxn: episodic therapy (w/ each outbreak) • Acyclovir 400mg po TID x5 days, or • Famciclovir 125mg BID x5 days, or • Valacyclovir 500mg BID x3-5 days. • Suppressive Therapy: (Pts w/ >6 outbreaks/yr) • Acyclovir 400mg BID (~$30/ 1 month supply) • Famcyclovir 250 mg BID (~$200/ 1 month supply) • Valacyclovir 1gm qd (~$100/ 1 month supply)

  23. Other Considerations • Genital HSV-2 has much higher recurrence rate than genital HSV-1, so serologic testing may be useful in tx. • Approximately 50% of pts will have recurrence w/in 6 months of primary infxn. • Suppressive Tx prolongs interval to recurrence, modestly reduces duration of viral shedding. • Patient counseling is critical! • Asymptomatic shedding • Need to inform potential new partners • Risks w/ pregnancy and delivery, etc… • Development of an HSV-2 vaccine is underway.

  24. Another painful ulcer…

  25. Chancroid • Endemic in several areas in the US, but occurs more frequently in Africa, West Indies and SE Asia. • Usually sexually transmitted • Incubation period is short: lesion usually appears w/in 3-5 days after exposure. • ~10% of pts w/ chancroid are co-infected w/ HSV or syphilis.

  26. Clinical Findings in Chancroid • Lesion starts as erythematous papule, evolves into a pustule which then erodes into a painful ulcer. Infected pts many have more than 1 ulcer. • Typical ulcer is 1 to 2cm in diameter, has erythematous base w/ clearly demarcated, raised borders. • Inguinal lymphadenitis occurs ~50% of cases. Nodes my become fluctulant and drain pus.

  27. Diagnosis of Chancroid • Definitive Dx requires positive culture for H. ducreyi on special cx media that is not widely available. (Sensitivity only ~80%). • Presumptive Dx via clinical criteria: • Painful genital ulcers, +/- inguinal LAN. • Negative for T. pallidum (syphilis) w/ darkfield exam or serology. • HSV culture of lesion is negative. • PCR test in development not yet widely available.

  28. Treatment of Chancroid • Successful treatment for chancroid cures the infection, resolves clinical sx and prevents transmission. • Recommended Regimen: • Azithromycin 1g po x1, or • Ceftriaxone 250mg IM x1, or • Ciprofloxacin 500mg po BID x3 days, or • Erythromycin 500mg TID x 7 days. • Sex partners must be tx’d regardless of sx if sexual contact w/in 10 days prior to sx onset. • Chancroid is a reportable disease.

  29. What about a painless genital ulcer?

  30. Syphilis • Systemic disease caused by Treponema Pallidum. • “Mini-epidemic” in the 1980’s to early 90’s w/ 20.3 cases per 100,000 population. • Incidence declining w/ 2.2 cases per 100,000 population in 2000. • Highest US incidence in southeast. • Black:Caucasian incidence ~30:1.

  31. Clinical Findings in Syphilis • Primary Infxn: painless ulcer at the site of infection. • Secondary Infxn (relapsing episodes are possible for up to 5 yrs after primary): • skin rash (symmetric eruption of trunk, extremities including palms and soles) • Mucocutaneous ulcer-like lesions • Systemic rubbery/painless lymphadenopathy • Wide array of neurologic abnormalities

  32. Clinical Findings, continued • Latent Syphilis: period during which serology is positive, but patients lack clinical manifestations. • Tertiary Syphilis: Advanced infection presenting w/ cardiac, ophthalmic, auditory abnormalities, gummatous lesions, advanced neurologic manifestations.

  33. Diagnosis of Syphilis • The chancre of primary syphilis is best diagnosed w/ darkfield microscopy. • Secondary or latent phase are best diagnosed with serology: • Nontreponemal tests: VDRL and RPR • Many causes of false positive • Become non-reactive 2-3 yr after treatment. • Treponemal tests: FTA-abs and TP-pa • More specific than non-treponemal tests. • Generally remain reactive for life.

  34. Treatment of Syphilis • Primary & Secondary: • Benzathine penicillin G 2.4 million U. IM x1 • Doxycycline 100mg po BID x14 days, or • Tetracycline 500mg po QID x14 days. • Early Latent: • Benzathine penicillin G 2.4 million U IM x1 • Late Latent and Tertiary: • Benzathine penicillin G 2. million U IM x3 q weekly interval.

  35. Doctor, I’ve got these bumps…

  36. Genital Human Papilloma Virus • Condyloma acuminatum (anogenital warts) • Diagnosis is clinical • Treatment is cryothearpy w/ liquid nitrogen, Condoylox 0.5% soln. BID x3d q 4d x4,or Aldara 5% cream qod x<4months. • Cervical HPV • Screening via regular Pap smears. Diagnosis via Pap smear, HPV serotyping, colposcopy w/ or s/ biopsy. • Treatment: cryotherapy, surgical excision, curretage, or electrosurgery.

  37. Hepatitis B • Estimated that there are 300 milion HBV carriers in the world, 1.25 million in the US • Sexual transmission is the most common mechanism of transmission  accounts for >50% new cases in the US. • Percutaneous transmission (IVDU, tatoos, accupuncture, sharing razors/toothbrush) • Incubation time is 6 wks to 6 mos after exposure.

  38. Diagnosis & Treatment of HBV • Diagnosis is via serology. • Treatment/Prevention: • Postexposure tx w/ HBIG, plus vaccination with HBV vaccine w/in 14 days after exposure • Vaccination of all household members. • Vaccination of all high risk individuals (eg. healthcare workers, IVD users, pts w/ hx of STD, pts who have sex w/ IVD users, men who have sex w/ men.

  39. Human Immunodeficiency Virus Overview • Risk factors include unprotected sex multiple sexual partners, hx of other STDs, men who have sex w/ men, pts who have sex w/ IVD users, IVD use, perinatal exposure to infected mom. • Progression of disease varies. From exposure to development of AIDS – few months to 17 yrs (median=10yrs)

  40. Testing for HIV • Should be offered to all pts presenting for evaluation of STD, as wellas to all pts with risk factors. • Informed consent required prior to testing. Both pre-test and post-test counseling is an integral part of testing procedure. • Tests: • ELISA as screening. • Western Blot or immunofluorescent assay (IFA) as confirmatory tests.

  41. References • Centers for Disease Control: Morbidity & Mortality Weekly Report. “Sexually Transmitted Diseases Treatment Guidelines 2002”. 10 May 2002, Vol. 51, No. RR-6. • DeCherney, Pernoll. Current: Obstetric & Gynecologic Diagnosis & Treatment. 8th Ed. (McGraw Hill, Lange: New York). • www.uptodate.com database topics related to sexually transmitted diseases. • Primary Care Medicine: Office Evaluation and Management of the Adult Patient, 3rd Ed. Goroll, May & Mulley. Lippincot-Raven:New York, 1995. • Tierney, McPhee, Papadakis. Current: Medical Diagnosis & Treatment, 40th Ed. (McGraw Hill, Lange:New York, 2001) • http://www.cdc.gov/nchstp/dstd/dstdp.html • www.aafp.org

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