Transcript Slide 1

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All patients being evaluated for STDs should be
offered counseling and testing for HIV
Asymptomatic women with risk factors for STDs
should be screened for gonococcal or chlamydial
infection during their annual pelvic examination
and cervical cytology should be obtained
Females between the ages of 9 - 26 years should
be offered HPV vaccination
Pregnant women should be screened for
chlamydia, HIV, hepatitis B, and syphilis
infections
Risk factors for STDs include
 Young age (15 to 24 years old)
 African-American race
 Unmarried status
 Geographical residence
 New sex partner in past 60 days
 Multiple sexual partners
 History of a prior STD
 Illicit drug use
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Partners
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“Do you have sex with men, women or both?”
“In the past 6 months how many sexual partners have you
had?”
Prevention of Pregnancy
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“Are you or your partner trying to get pregnant?”
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“What do you do to protect yourself from STDs?”
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“Do you use protection every time?”
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“Have you ever had STD in the past?”
Protection from STDs
Practices
Past Hx of STDs
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C. trachomatis: small gram-negative
bacterium
the rates are highest in adolescent women
Although the majority of women are
asymptomatic, clinical manifestations range
from cervicitis to PID
The incubation period of symptomatic
disease ranges from 7 to 14 days.
Cervicitis
 cervical infection is the most common chlamydial syndrome
 More than 50 % are asymptomatic
 Symptoms:
◦ vaginal discharge
◦ poorly differentiated abdominal pain
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Physical examination may reveal
◦ mucopurulent cervical discharge
◦ cervical friability
◦ cervical edema
Endocervical ulcers also may be seen.
Chlamydial infection of the female urethra often accompanies
cervicitis. Women with urethral infection complain of typical
symptoms UTI
◦ Frequency, dysuria, occasionally lower abdominal pain.
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Perihepatitis (Fitzhugh-Curtis syndrome) —
Occasionally, patients with chlamydia infection
develop perihepatitis, an inflammation of the liver
capsule and adjacent peritoneal surfaces.
PID — Will occur in approx. 30% of women with
chlamydia infection, if left untreated
PID caused by gonorrhea may be more symptomatic
but PID caused by trichomatis causes higher rates of
subsequent infertility
In Pregnancy — Untreated chlamydia infection can
increase the risk for premature rupture of the
membranes and low birth weight. If the mother is
untreated, 20 to 50 percent of newborns will develop
conjunctivitis, and 10 to 20 percent will develop
pneumonia
CHLAMYDIAL URETHRITIS
 Presentation
◦ mucoid or watery discharge
◦ Dysuria
◦ Incubation period is variable but is typically 5 to 10 days
after exposure
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Gram stain of urethral secretions demonstrate
◦ >5 WBC/hpf.
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Positive leukocyte esterase test on first-void urine or
microscopic examination of first-void urine sediment
demonstrating >10 WBC/hpf.
Treatment: same as women cervicitis
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Drugs of choice
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Alternatives
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Infection in pregnancy
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Alternatives
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◦ Azithromycin 1 g oral once OR
◦ Doxycycline•Δ 100 mg oral twice daily for 7 days
◦ OfloxacinΔ 300 mg oral twice daily for 7 days
◦ LevofloxacinΔ 500 mg oral daily for 7 days
◦ Erythromycin◊ 500 mg oral four times daily for 7 days
◦ Azithromycin 1 g oral once OR
◦ Amoxicillin 500 mg oral three times daily for seven days
◦ Erythromycin◊ 500 mg oral four times daily for seven days
Public health issues — Sexual partners are often
asymptomatic and, unless treated, will reinfect the index
patient or spread infection to other partners.
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Gonorrhea aka "the clap,"
common bacterial STD
In general it infects the same organs as
chlamydia, and has similar long-term effects
In women can involve any portion of the
genital tract, the oropharynx or become
disseminated
often asymptomatic compared to men
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Cervical infection — MC site of infection is
the cervix.
◦ Approx. 50 % are asymptomatic
◦ Symptoms:
 vaginal pruritis and/or
 mucopurulent discharge
◦ On examination:
 the cervix may appear normal or
 show signs of frank discharge
 Cervical mucosa is often friable
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Urethritis - can occur in the absence of pelvic
inflammatory disease and is responsible for
up to 10 % of cases of dysuria among innercity women
Anorectal infection and proctitis - The vast
majority are asymptomatic. Only 3 % present
with symptoms including anal itching, rectal
discharge, rectal fullness and painful
defecation
PID — occurs in approximately 10 to 40 % of
women with cervical gonorrhea
CLINICAL MANIFESTATIONS
◦ can involve any part of the genital tract, either
alone or in combination with other sites. Genital
infections are generally symptomatic
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Urethritis – Symptoms
◦ penile discharge often present spontaneously at the
urethral meatus,
◦ purulent or mucopurulent in color
◦ Dysuria
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Epididymitis - Unilateral testicular pain and
swelling may be the sole presenting
complaints of men with epididymitis
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Culture - "gold standard" for the diagnosis
using a modified Thayer-Martin medium.
Gram stain is only 60 % sensitive in
symptomatic women compared with 95
percent in symptomatic men
DNA amplification techniques - available but
much more expensive
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Cervical, urethral and anorectal infection
◦ Ceftriaxone 125 mg IM once OR
◦ Cefixime 400 mg orally once
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If allergic to Penicillin
◦ azithromycin (2 grams as a single oral dose)
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Pharyngeal infection
Ceftriaxone 125 mg IM once
In Pregnancy — Quinolones and tetracyclines
should not be used. Pregnant women with
uncomplicated gonorrheal infection should be
treated with a recommended cephalosporin
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Chronic infection caused by Treponema pallidum
Transmission usually occurs via direct contact with an
infectious lesion during sex.
The early lesions of primary and secondary syphilis
including chancres, mucous patches, and condyloma
lata, are very infectious.
It has been estimated that transmission occurs in
approximately one-third of patients exposed to these
lesions.
Syphilis can also be spread by kissing or touching a
person who has active lesions on the lips, oral cavity,
breasts, or genitals.
The infection can also be acquired by passage
through the placenta
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After an average incubation period of 2 to 3
weeks, a painless papule appears at the site of
inoculation
Papule ulcerates to produce the classic chancre
of primary syphilis, a one to two centimeter ulcer
with a raised, indurated margin
Chancres heal spontaneously within three to six
weeks even in the absence of treatment
Since the ulcer is painless, many patients do not
seek medical attention, a feature that enhances
the likelihood of transmission
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Secondary syphilis — Weeks to months later,
approx. 25 % of individuals with untreated
infection will develop a systemic illness
◦ Rash - most characteristic finding can take any
form, except vesicular lesions. Classically it is a
diffuse, symmetric macular or papular eruption
involving the entire trunk and extremities, including
the palms and soles
◦ Systemic symptoms include fever, headache,
malaise, anorexia, sore throat, myalgias, and weight
loss.
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As with all stages of the disease, diagnosis of
early syphilis is complicated because the
organism has never been cultivated in vitro.
The chancre of primary syphilis is best
diagnosed by darkfield microscopy
Secondary syphilis is reliably diagnosed by
serologic testing.
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Early Syphilis can be treated by penicillin,
doxycycline, azithromycin, and ceftriaxone
For Primary or early latent syphilis benzathine
penicillin G, should be administered as a single
dose.
In patients with severe penicillin allergy
alternative include doxycycline or azithromycin
Patient monitoring: All patients should be
reexamined clinically and serologically at six and
12 months after treatment. A fourfold reduction
in titer of the nontreponemal antibody test is
considered evidence of an appropriate response.
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MC STD in sexually active young women
organism is the flagellated protozoan trichomonas
vaginalis, which may be found in the vagina, urethra, and
paraurethral glands of infected women.
Other sites include cervix, Bartholin's and Skene's glands.
Humans are the only natural host of T. vaginalis.
Commonly mistaken for yeast infection or bacterial
vaginosis since the symptoms are similar
Symptons include:
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frothy discharge
strong vaginal odor
pain on intercourse
irritation and itching
Men can get trichomoniasis too, but they don't tend to have
symptoms
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In women ranges from an asymptomatic carrier state to a
severe, acute, inflammatory disease
Physical examination often reveals
◦ erythema of the vulva and vaginal mucosa
◦ the classic green-yellow frothy discharge is present in 10 – 30%
◦ Punctate hemorrhages may be visible on the vagina and cervix
("strawberry cervix", 2 % of cases).
In pregnant women infection is associated with premature
rupture of the membranes and preterm delivery
Infants born to infected mothers may contract infection
during delivery. Signs and symptoms in neonates may
include fever, respiratory problems, urinary tract infection,
nasal discharge, and, in girls, vaginal discharge
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The presence of motile trichomonads on wet
mount is diagnostic of infection
Culture on Diamond's medium has a high
sensitivity (95 percent) and specificity (>95
percent)
Rapid antigen and nucleic acid amplification
tests are available but expensive
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Patients should be instructed to avoid
intercourse until they and their partners have
completed treatment and are asymptomatic,
which generally takes about a week
After single dose therapy or treatment of
asymptomatic patients, the couple should
abstain from intercourse until BOTH partners
have waited at least seven days since taking
the last antibiotic dose.
Herpes Simplex
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HSV-1 is associated with oropharynx lesions
HSV-2 is associated with lesions of genitalia
Transmission:
◦ Through active ulcerations or shedding of virus
from mucous membranes
◦ HSV-1 usually acquired in childhood (80% of adults
have been infected)
◦ HSV-2 incidence has increased in recent years
◦ Asymptomatic or unrecognized symptoms of
genital herpes is still contagious
Herpes Simplex
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Pathophysiology:
◦ HSV replicates in dermis/epidermis and travels via
sensory nerves to DRG
◦ Resides as a latent infection until reactivated where
it goes to peripheral nerves
Herpes Simplex
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Clinical Features of HSV-1
◦ Systemic manifestations (fever, malaise, headache)
◦ Vesicular lesions on patches of erythematous skin
◦ Herpes labialis aka cold sores are common on lips
 Usually painful; heal in 2-6 weeks
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Clinical Features of HSV-2
◦ Primary lesion is more severe and prolonged than
recurrent episodes
◦ Painful genital vesicles or pustules
◦ Tender inguinal lymphadenopathy
◦ Vaginal/urethral discharge
Herpes Simplex
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Disseminated HSV
◦ Limited to immunocompromised patients
◦ Encephalitis, meningitis, keratitis, chorioretinitis,
pneumonitis, esophagitis
◦ Rarely pregnant women can develop disseminated
HSV, which can be fatal to mother and fetus
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Neonatal HSV
◦ Congenital malformations, IUGR, chorioamnionitis,
neonatal death
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Ocular Disease
◦ Keratitis, blepharitis, keratoconjunctivitis
Herpes Simplex
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Diagnosis
◦ Usually made clinically
◦ Confirmed by Tzanck smear
 Swabbing the base of ulcer and staining with Wright’s
stain shows multinucleated giant cells
◦ Culture is the gold standard
 Swab the base of ulcer; results available within 2-3 days
◦ Fluorecent assay and ELISA
 80% sensitivity; results available within mins to hours
Herpes Simplex
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Treatment
◦ No cure; symptomatic relief and reduces symptoms
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Mucocutaneous disease
◦ Oral and/or topical acyclovir for 7-10 days
◦ Valacyclovir and Famciclovir have better
bioavailablity
◦ Oral acyclovir for prophylaxis
◦ Foscarnet for resistant disease in
immunocompromised
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Disseminated HSV
◦ Hospital admission; parenteral acyclovir
HPV
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General characteristics
◦ Warts are transmitted via skin-to-skin contact and genital
warts via sexual contact
Types
◦ Most common wart (verruca vulgaris): elbows, knees,
fingers, palms
◦ Flat wart (V. plana): flesh-colored or whitish hyperkeratotic
surface
◦ Plantar wart (V. plantaris): foot pain on pressure areas
◦ Anogenital wart (Condyloma acuminatum): most common
STD associated with HPV 6 and 11
◦ HPV 16 and 18 leads to cervical cancer
◦ Single or multiple soft, fleshy growths on genitalia,
perineum, anus
HPV
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Clinical Features
◦ Warts are asymptomatic unless “bumped”
◦ Plantar warts can be painful during walking
◦ Warts can also bleed
◦ Warts are unsightly and can be disfiguring
Treatment
◦ Freezing lesion with liquid nitrogen applied on a cotton
swab
◦ Salicylic acid (Compound W) applied for weeks
◦ 5-FU cream & retinoic acid cream for flat warts
◦ Surgical excision or laser therapy
◦ Podophyllin for genital warts
HIV
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General characteristics
◦ High risk individuals: homosexual or bisexual men, IVDA,
transfusion recipients before 1985, contacts with HIV-positive
people, unborn/newborn babies of positive mothers
◦ Mortality secondary to opportunistic infections
Transmission
◦ Sexual or parenteral
◦ Fluids: semen, blood, breast milk, vaginal fluid
◦ Pathophysiology:
 Virus attaches to CD4, enters the cell, uncoats, and transcribes
the RNA to DNA by reverse transcriptase
 Activated CD4 cells produce billions of viral particles
 Virus enters the lytic stage of infection resulting in CD4
destruction; eventual depletion of CD4 cells leading to
weakened cellular immunity
HIV
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Primary infection
◦ Mononucleosis-like syndrome 2-4 weeks after
exposure lasting 3 days to 2 weeks
◦ Sx: fever, sweats, lethargy, headaches, diarrhea,
arthralgias, lymphadenopathy,
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Asymptomatic infection
◦ Seropositive w/o clinical evidence
◦ Normal CD4 counts (>500/mm3)
◦ Longest phase lasting 4-7 years
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Symptomatic infection (pre-AIDS)
◦ First evidence of immune system dysfunction
◦ Phase lasts 1-3 years without treatment
HIV
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Other s/s
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Persistent lymphadenopathy
Localized fungal infections
Vaginal yeast; trichomonal infections
Oral hairy luekoplakia on tongue
Seborrheic dermatitis, psoriasis exacerbation, warts
AIDS
◦ Disseminated opportunistic infections/malignancies
◦ CD4 < 200 cells/mm3
◦ Includes pulmonary, GI, neurologic, cutaneous, and
systemic symptoms
HIV
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Pulmonary:
◦ Community acquired bacterial pneumonia, PCP, TB, CMV,
MAC, crytococcus, histoplasmosis, Kaposi’s
Nervous:
◦ AIDS dementia, toxoplasmosis, cryptococcal meningitis,
CNS lymphoma, encephalopathies
GI
◦ Diarrhea, oral lesions, dysphagia due to candidiasis,
anorectal disease
Dermatologic:
◦ Kaposi’s sarcoma, other infections
Misc:
◦ CMV, MAC< HIV-1 wasting syndrome, Malignancies
HIV
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Diagnosis of HIV infection
◦ ELISA method = screening test detecting Abs
 Becomes positive 1-12 weeks after infection
 Negative ELISA excludes HIV (99% sensitivity)
◦ Western blot = confirmatory test if positive ELISA
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Diagnosis of AIDS
◦ CD4 count lower than 200 or identification of an
indicator condition aka AIDS defining illnesses
HIV
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Antiretroviral therapy
◦ Indications: symptomatic regardless of CD4 count or
asymptomatic patients with CD4 < 500
◦ HAART = 2 NRTI + 1 NNRTI or 1 PI
◦ Monitor tx response using plasma HIV RNA load (goal is to
reduce viral load to undetectable loads)
◦ HAART usually is continued in pregnancy
Opportunistic infection prophylaxis
◦ P. carinii – TMP/SMX
◦ TB – yearly PPD screen; INH + pyridoxine if positive
◦ MAC – clarithromycin/azithromycin for prophylaxis
◦ Toxoplasmosis – TMP/SMX
Vaccinations (NO LIVE-VIRUS VACCINES)
References
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Agabegi, S.S. & Agabegi E. Step-up to
Medicine. Lippincott Williams & Williams Inc.
2008. 2nd edition.