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STD Overview. Sam Brown-Parks, MD, MPH July 17, 2008. Overview. Bacterial Chlamydia Gonorrhea Syphilis Viral HSV HPV HIV Parasitic Trichomonas. Chlamydia. Chlamydia Trachomatis most common treatable bacterial STD 2.8 Million Americans/ year

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std overview

STD Overview

Sam Brown-Parks, MD, MPH

July 17, 2008

overview
Overview
  • Bacterial
    • Chlamydia
    • Gonorrhea
    • Syphilis
  • Viral
    • HSV
    • HPV
    • HIV
  • Parasitic
    • Trichomonas
chlamydia
Chlamydia
  • Chlamydia Trachomatis
  • most common treatable bacterial STD
    • 2.8 Million Americans/ year
  • Transmission: vaginal, anal, oral, perinatal
  • “Silent” infection- no sx
    • 75% of women
    • 50% of men
chlamydia signs symptoms
WOMEN

Increased Vag D/C (due to inflammation)

+/- Urinary freq/ Dysuria

Abdominal Pain

Dyspaurenia

Menstrual irregularity

MEN

White to watery penile discharge

Dysuria

? No symptoms?

Chlamydia: Signs & Symptoms
chlamydia complications
Chlamydia: Complications
  • PID
  • Infertility/ Ectopic Pregnancy
  • Chronic Pelvic Pain
  • Reiters Syndrome
    • Inflammation of eyes, joints, rash
  • Appendicitis?
testing treatment
Wet Prep with increased WBCs & Bacteria with + physical findings

Vaginal/ Urethral DNA probe (with GC)

Urine testing

Azithromycin 1gm*

Rescreen positives in 3 months after treatment

+ Concomitant tx for GC

Testing & Treatment
gonorrhea
Gonorrhea
  • Neisseria gonorrhoeae
  • Intracellular gm+ diplococci
  • >700,000 cases in US per year
  • Transmission: vaginal, anal, oral, perinatal
  • Often asymptomatic
  • Can take up to 30 days after infection
gonorrhea signs symptoms
WOMEN

Often Mild

Dysuria

Vaginal discharge

Irregular bleeding

Dyspaurenia

MEN

Dysuria

White, yellow or green penile discharge

Swollen, painful testicles

Gonorrhea: Signs & Symptoms
gonorrhea complications
Gonorrhea: Complications
  • PID
  • Epididymitis
  • Infertility
  • Ectopic Pregnancy
  • Disseminated Gonococcal Disease
    • Arthritis, dermatitis, endometritis
  • Increased spread of HIV (contraction and transmission)
testing treatment1
Wet Prep with increased WBCs & Bacteria with + physical findings

Vaginal/ Urethral DNA probe (with Chlamydia)

Urine testing

Ceftriaxone 125mg IM*

or

Cefixime 400mg po*

Plus concomitant tx for Chlamydia

Testing & Treatment
syphilis
Syphilis
  • Treponema pallidum
  • The “great imitator”
  • 36,000 cases in 2006
  • Transmission: vaginal, anal, oral, perinatal
  • Increasing number of new cases
    • Fulton Co #5, DeKalb #11 (2006)
    • 64% cases involved MSM
syphilis signs symptoms
Syphilis: Signs & Symptoms
  • Many are asymptomatic or

unaware of lesions at time of transmission

  • Primary: firm, round, small painless chancre
    • Usually develop sx 10-90 d after infection (mean 21)
    • Lasts 3-6 weeks, resolves without treatment
  • Secondary:can develop in weeks, months
    • Rash: rough, reddish brown on palms/ soles
    • +/- fever, +LNs, sore throat, patchy hair loss, h/a,weight loss, muscle aches, and fatigue
    • Resolves without tx
syphilis signs symptoms1
Syphilis: Signs & Symptoms
  • Tertiary (latent) Syphilis
    • Begins as soon as rash disappears
    • Sx may not develop for 10-20 years
    • 15% of untreated cases will develop Neurosyphilis
      • Ataxia, imbalance
      • Paralysis, numbness
      • Blindness
      • Dementia, death
testing treatment2
With Chancre: Dark Field Examination

Secondary:

RPR

If +, EIA

If +/- FTA-ABS

Tertiary:

CSF tested

<2 years (early latent)

Benzathine PCN x 1

Doxycycline if allergic

>2 years (late latent)

Procaine PCN q wk x3

Neuro findings: PCN IV q 4 hours x 2 wk

Testing & Treatment
genital herpes simplex
Genital Herpes Simplex
  • Very prevalent STD: 20% in >12yo in US
  • Most due to HSV-2, occasionally HSV-1
  • 1.6M new cases per year in US
  • Transmitted by Genital-Genital contact or Genital-oral contact as well as through birth canal
herpes signs symptoms
Herpes: Signs & Symptoms
  • Most are asymptomatic
  • Primary Outbreak (within 2 wks of transmission)
    • Pruritic, Painful vesicles -> shallow ulceration
    • Fever, malaise prodrome
    • Lymphadenopathy
    • Dysuria
  • Secondary Outbreaks
    • Less severe
    • Decrease in freq over time for most
herpes complications
Herpes: Complications
  • Recurrent outbreaks with asymptomatic shedding
  • Dissemination with immunosuppression
  • Neonatal transmission
  • Rarely intrauterine infection (congenital herpes)
test treatment
Viral Culture

PCR

Antibody testing

First Outbreak

Acyclovir 400 TID 10d

Valcyclovir 1000 BID 10d

Famcyclovir 250 TID 10d

Recurrent Outbreaks

Suppression

Valtrex 1000 Qday

or 500 QD if <10 /yr

Test & Treatment
human papilloma virus
Human Papilloma Virus
  • >100 types (including all warts)
  • Most common STD in US
    • 20 Million Americans infected
    • 50% of sexually active people acquire HPV in their lives
  • Low-risk (Warts): 6 lower risk strains
    • #6,11 most likely to cause genital warts
  • High-risk (Cervical CA): 13 high risk strains
    • #16,18 cause 70% of cervical cancers
hpv signs symptoms
HPV: Signs & Symptoms
  • Usually NONE
  • Genital warty growths
tests treatment
Only as part of cervical (Pap) testing

No Male screening available

80% are cleared without treatment within 2 years

Abnormal Pap with +HPV -> colposcopy

Warts

Topicals

Cryotherapy

LASER/ Surgical

Tests & Treatment
hpv complications
HPV: Complications
  • Cervical Dysplasia
  • Urethral Obstruction (uncommon)
  • High Grade Dysplasia of Anal, perineal tissue in immunocompromised
hpv prevention
HPV: Prevention
  • Condoms
    • moderate protection
    • Site dependent
    • Can still spread skin to skin
  • Vaccine
    • 4 strains (6,11,16,18)
    • Girls ages 9-26
    • 3 shots (0, 2, 6 months)
human immunodeficiency virus
Human Immunodeficiency Virus
  • First reported in 1981
  • Infects cells with CD4 receptors
  • Causes cell death -> Immunosuppression
  • >1M Americans HIV+ (1/4 unknown)
    • Men>Women
    • Blacks>Hispanics>Whites
  • AIDS= CD4<200
    • 980,000 AIDS cases in US since 1981
reported cases of aids in georgia 1993 2000
Reported Cases of AIDS in Georgia, 1993-2000

Number of Cases

1993 2156

1994 2247

1995 2170

1996 2029

1997 1549

1998 1442

1999 1299

2000 1170

hiv transmission
HIV: Transmission
  • Virus can enter through any mucosal surface
  • Virus can be found in blood, semen, breast milk, saliva (no evidence of transmission in saliva).
  • Can be spread Mother to child during pregnancy and delivery.
  • Risk of infection is greatly increased when infected with other STDs
hiv symptoms
HIV: Symptoms
  • Early: 2-8 weeks of infection***highly infectious
    • Fatigue
    • Fever
    • Headache
    • Enlarged LNs
  • Later: Up to 10 years after initial infection
    • PID that does not respond to tx
    • Persistent yeast infections
    • Persistent skin rashes or flaky skin
    • Short term memory loss
testing treatment3
+ AB 1-3 months after exposure

ELISA x2 and Western Blot confirm

Should retest again 6 wks after exposure

Reverse Transcriptase Inhibitors

Triple Therapy=HAART

Testing & Treatment
trichomonas
Trichomonas
  • Single cell protozoan, Trichomonas vaginalis
  • Most prevalent parasite in N. America
  • Women>Men
  • 7.4 Million new cases per year
  • Transmitted penis-vagina or vulva-vulva
trichomonas signs symptoms
Men

Most asymptomatic

Some men with transient

Dysuria

Mild Discharge

Women

Green frothy discharge

Vaginal itching

Dysuria

Dyspaurenia

Lower Abdominal Pain

Occurs 5-28 d of exposure

Trichomonas: Signs & Symptoms
tests and treatment
Wet Prep

Can see small, red ulcerations on vaginal wall or cervix or strawberry cervix

Culture or PCR for men

Vaginal pH >5

Metronidazole

2gm single dose

500mg BID x7d

Need to treat sex partner(s)

Tests and Treatment
complications
Complications
  • Increase susceptibility to HIV
  • Preterm labor
  • Low birth weight infants
  • Epididymitis, prostatitis
reportable stds in georgia
Reportable STDs in Georgia
  • Syphilis link
  • Chlamydia
  • Gonorrhea
  • Chancroid
  • HIV
common erroneous assumptions of patients
COMMON ERRONEOUS ASSUMPTIONS OF PATIENTS

1. I know exactly where I got this disease.

2. I got this disease from my last sexual partner.

3. When my symptoms are gone, my infection is cured.

4. My symptoms are not from an STD, but from other causes (i.e., stress, chemical

burns, zipper trauma, or menstrual cramps)

common erroneous assumptions of physicians
COMMON ERRONEOUS ASSUMPTIONS OF PHYSICIANS

1. Sexual experience implies sexual knowledge.

2. The definition of “sex” is vaginal intercourse only.

3. Women usually have few sexual partners, while men have several.

4. Physician responsibility ends with the diagnosis and treatment of the disease.

slide41
Case
  • 17 yo female recently sexually active
  • c/o vaginal lesions
  • No fevers, chills
  • +fatigue