Transcript 1% (if treated)

Sexually Transmitted
Diseases
David W. Haas, M.D.
Division of Infectious Diseases
Vanderbilt University School of Medicine
Nashville, Tennessee
Case Presentation
• 19 YO male c/o burning on urination,
yellow discharge on underwear.
• Has otherwise been well.
– What are likely diagnoses?
– What tests should be done?
– What treatment may be needed?
– Anything else to do?
Gonococcal Urethritis
• Incubation 1-10 days
• Can’t differentiate from chlamydia by
symptoms
• Most infections are symptomatic
• May persist without continued symptoms
Acute Epididymitis
• Young men
– Chlamydia (most common)
– Gonococcus
• Old men
– Gram (-) enterics
– Pseudomonas
Localized Gonococcal Infections
• Anorectal infection
– Culture often (+) in women with cervical GC
– Treatment failures detected at rectum
• Pharyngeal infection
– Orogenital exposure
• Pelvic inflammatory disease
– Cervix doesn’t predict upper tract GC
– 20% risk of infertility
• Perihepatitis (Fitz-Hugh-Curtis syndrome)
Disseminated Gonococcal Infection
Joint involvement
Number
Sites
Character
Cells
Culture
Papules/pustules
Blood culture
Arthritis-dermatitis
syndrome
Septic arthritis
several
Knee, elbow, wrist,
ankle
1 or 2
Knee, elbow, wrist,
ankle
Tenosynovitis
Frank arthritis
<20,000 WBC/mm3
Negative
>50,000WBC/mm3
Often positive
5-40
Absent
Often positive
Negative
Diagnosis of Gonorrhea
• Culture
– Rapidly inoculate media
– Thayer-Martin, others
• DNA probes or DNA amplification
– If used, culture unnecessary
• Gram stain
– Gram (-) diplococci
– Many leukocytes
Treatment of Uncomplicated Gonorrhea
(urethra, cervix, pharynx, rectum)
•
•
•
•
•
•
Ceftriaxone (125mg IM x 1 dose)
Cefixime (400mg PO x 1 dose)
Cefpodoxime (400mg PO x 1 dose)
Ciprofloxacin (500mg PO x 1 dose)
Gatifloxacin (400mg PO x 1 dose)
Levofloxacin (250mg PO x 1 dose)
+
• Azithromycin 1g po x 1 dose
• Doxycycline 100mg q12h po x 7 days
OR
OR
OR
OR
OR
OR
Treatment of Gonorrhea
General Considerations
•
•
•
•
Reculture all (+) sites at 4-7 days
Consider reculture os rectal canal in women
Examine and culture sexual contacts
Treat sexual contacts regardless
Chlamydia trachomatis
Genital Disease
• Urethritis in men
– Isolated with 20% of GC cases
– Isolated in 40% of NGU
– Asymptomatic infection common
• Epididymitis
• Cervicitis
• Pelvic inflammatory disease
– Infertility risk 10%
– Perihepatitis
Diagnosing C. trachomatis Infection
• Gram stain
– 4 WBC’s per oil-immersion field
– No organisms seen
• Rapid methods
– DNA probes or PCR
• Culture
– Costly, not generally done
Case Presentation
• 19 YO male c/o burning on urination,
yellow discharge on underwear.
• Has otherwise been well.
– What are likely diagnoses?
– What tests should be done?
– What treatment may be needed?
– Anything else to do?
Syphilis
Stage
Onset
• Primary
3 weeks
• Secondary
2-8 weeks
• Latent
>8 weeks
• Late
years
“Classic” Syphilitic Chancre
•
•
•
•
•
Painless
Raised borders
No exudate
At inoculation site
Rarely seen by physician
Secondary Syphilis
• Rash
– Variable, palms & soles
• Fever
• Diffuse lymphadenopathy
• Patchy alopecia
• Mucous patches
• Condyloma lata
Darkfield Examination for Syphilis
1.
2.
3.
4.
Abrade lesion with dry gauze
Obtain serous exudate
Place on slide with coverslip
View motile spirochetes
•
Great for primary and secondary
syphilis, not for oral lesions
Syphilis Serology
Primary
Nontreponemal
tests
(VDRL & RPR)
Specific
treponemal tests
(FTA-Abs,
MHA-TP, TPHA)
Secondary
Late
75%
99%
1%
(if treated)
75%
100%
95%
Who with Latent Syphilis
Needs a Spinal Tap?
•
•
•
•
Neurologic symptoms
Failure of RPR to fall with therapy
RPR 1:32
Inability to give penicillin
If CSF abnormal, treat for neurosyphilis
Treating Syphilis
• Primary and Secondary
– Benzathine PCN 2.4 million units IM x 1
– (Ceftriaxone 1g qd IV or IM x 8-10 d)
– (Doxycycline 100mg q12h x 14 d)
– Anticipate Jarisch-Herxheimer
• Latent (>1 year duration)
– Benzathine PCN 2.4mil units IM weekly x 3
– (Doxycycline 100mg q12h x 28 d)
Treating Neurosyphilis
– Pen G 2-4 million units IV q4h x 10-14 d
– (Procaine Pen G 2.4 mil units IM q24h +
probenacid 500 mg PO qid x 14 days)
– (Ceftriaxone 1g IV or IM qd x 14 d)
Genital Herpes - Initial
Episode
• Painful vesicles or pustules which
ulcerate
• Fever, headache, myalgias
• Tender inguinal adenopathy
• Extragenital vesicles common
• Pharyngitis, aseptic meningitis, urethritis
occasional
Genital Herpes - Recurrent
•
•
•
•
90% recur in first year
Average 5 per year initially
Less severe than first episode
Avoid sex until lesions heal
Diagnosing Genital Herpes
• Diagnosis often clinical
• Cytology (Tzank prep) shows
– Scrape lesion
– Spear to microscope slide
– Stain with Pap or Wright-Giemsa
– See multinucleated giant cells
• Culture
– Swab lesion
– To viral transport media
– Cytopathic effect in 1-4 days
Treating Genital Herpes
• Initial
– Acyclovir 400mg po q8h x 7-10 days
– Valacyclovir 1g po q12h x 10 days
– Famciclivir 250mg po q8h x 7-10 days
• Recurrent (Often not treated)
– Acyclovir 400mg q8h x 5 days
– Valacyclovir 500mg po q12h x 3 days
– Famciclivir 125mg po q12h x 5 days
• Chronic suppression
– Acyclovir 400mg q12h
– Valacyclovir 1g po q24h
– Famciclivir 250mg po q12h
Sexually Transmitted
Diseases