Transcript Name that Lesion It`s Catchy!

It’s Catchy!
Creepy
Crawlers/
Lumpy Bumpys
Pediatric
Pearls
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It Burns!
Name that
Lesion
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A 26 year old woman presents to ED
with fever, chills, nausea, dysuria, lower
abdominal pain, and vaginal discharge.
 What is the diagnosis?
 Name 2 causes.
 Name 2 complications.
Pelvic Inflammatory Disease
 A spectrum of infections of the female genital tract
that includes endometritis, salpingitis, tubo-ovarian
abscess, and perotinitis.
 Caused by an ascending infection from the vagina or
cervix. Most commonly chlamydia or gonorrhea.
 Most common serious infection in women.
Complications include sepsis, perihepatitis (FitzHugh-Curtis), infertility, chronic pelvic pain and
ectopic pregnangy.
PID History and Physical Exam
 History may include bilateral lower abdo pain, low
back pain, vaginal discharge, and irregular vaginal
bleeding in a sexually active woman. May have
systemic/toxic symptoms of fever, nausea, vomiting,
chills.
 Exam may show tender lower abdomen, mucopurulent
cervical discharge, cervical motion tenderness, uterine
tenderness, adnexal tenderness.
PID work-up and treatment
 Should do pregnancy test, urinalysis and urine culture,
and cervical cultures or urine for GC and chlamydia.
 Consider testing for other STIs (HIV, syphilis).
 Toxic, pregnant, or patients with tubo-ovarian abscess
should be admitted.
 Outpatient treatment is usually one dose of IM
ceftriaxone and a 2 week course of PO doxycycline.
 Should discuss safe sex, abstinence until treatment
completion, and referral of partners for treatment.
A 30 y.o. man presents to ED with
dysuria and urethral discharge,
myalgias and conjunctivitis.
 What is the likely diagnosis?
 What is one cause?
Urethritis
 Inflammation of the urethra is most commonly caused
by STIs and is classified as gonococcal urethritis (GCU)
or non-gonococcal urethritis (NGU).
 NGU is associated with reactive arthritis.
 GCU is usually abrupt in onset over 3-4 days, NGU can
have a more insidious onset of symptoms.
 History may include urethral discharge, dysuria,
hematuria, urethral pruritis and painful intercourse in
a sexually active male. Ask about
arthritis/conjunctivitis and systemic symptoms.
Urethritis cont…
 Exam may show an inflammed urethral meatus and/or
urethral discharge. The urethra can be milked to try
and express discharge.
 Look for other STI lesions as well.
 Work-up should include urethral swabs or urine for
GC/chlamydia and screening for other STIs.
 Treatment is a single IM dose of ceftriaxone and either
a single oral dose of azythromicin or a one week course
of oral doxycycline.
A 35 y.o. woman presents to ED with a
vaginal pruritis and increased vaginal
discharge.
 What is the likely diagnosis?
 What are 2 possible causes?
Vulvovaginitis
 Inflammation of the vulva and vagina. Diagnosis is
based on the presence of symptoms of a change in
vaginal discharge and/or vulvovaginal discomfort.
 Bacterial vaginosis resulting from a loss of normal
vaginal lactobacilli is the cause in 40-50% of cases.
 Candidiasis accounts for 20-25% and trichomoniasis
accounts for 15-20%.
 Chemical irritation and poor hygiene are also
contributing factors.
Vulvovaginitis
 Physical exam may show erythema and edema of the
vulva and vagina, discharge that may be foul, thin and
grey, white , yellow or green, and/or curd-like. Vaginal
foreign bodies may be seen.
 Work-up should include vaginal pH, and microscopy
for wet mount and KOH testing.
 Cultures/swabs for trichomonas, yeast, and STIs may
be considered.
Clinical Elements
Symptoms
Signs
Microscopy
Bacterial Vaginosis
Trichomoniasis
Vaginal Candidiasis
Vaginal odor
+
+/-
-
Vaginal discharge
Thin, gray, homogenous
Green-yellow
White, curdlike
Vulvar irritation
+/-
+
+
Dyspareunia
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+
-
Vulvar erythema
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+/-
+/-
Bubbles in vaginal fluid
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+/-
-
Strawberry cervix
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+/-
-
Clue cells
+
-
-
Motile protozoa
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+
-
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+
Saline wet mount
KOH test
Pseudohyphae
A 13 y.o. boy presents to ED with
dysuria, urinary frequency, urgency,
scrotal pain and swelling.
 What is the most likely diagnosis?
 What are 2 causes?
 What do you need to rule out?
A 13 y.o. boy presents to ED with dysuria,
urinary frequency, urgency, scrotal pain and
swelling.
 What is the most likely diagnosis?
 What are 2 causes?
 What do you need to rule out?
Epididymitis
 Inflammation of the epididymis, most commonly
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caused by infection.
In sexually active men it’s usually from gonorrhea or
chlamydia. In the non-sexually active population it’s
most commonly caused by e.coli.
Most common cause of scrotal inflammation.
Need to rule out testicular torsion in any presentation
of testicular pain.
Symptoms usually progress over 24 hours and can
include scrotal pain, swelling, urinary frequency,
urgency, dysuria, nausea, fever, chills, and discharge.
Epididymitis
 Exam may show edematous tender epididimus,
erythematous/edematous scrotum, may have scrotal
abscess. May see urethral discharge.
 Prehn sign= scrotal elevation relieves pain in
epididimytis but not in torsion. But it’s not reliable.
 Work-up may include urinalysis/culture, urine for GC
and chlamydia, gram stain/culture of any discharge,
ESR/CRP may help differentiate from torsion if it’s
elevated. U/S may help distinguish from torsion.
 Treatment is with antibiotics. Septra for non-sexually
active patients, ceftriaxone and doxycycline for
sexually active.
A 32 y.o. man presents to ED with fever,
chills, dysuria, urinary frequency,
urgency, hesitancy, and incomplete
voiding.
 What’s the likely diagnosis?
 What is one possible physical exam finding?
 What is one possible cause?
Bacterial Prostatitis
 Inflammation of the prostate most commonly caused
by sexually transmitted bacteria.
 Symptoms can include fever, chills, malaise,
arthralgias, myalgias, perineal pain, dysuria, urinary
frequency, urgency, nocturia, hesitancy, incomplete
voiding, weak stream, lower back and abdominal pain,
and urethral discharge.
Bacterial Prostatitis
 Exam may show a tender, nodular, hot, boggy, or
normal prostate on DRE. May have suprapubic
abdominal pain.
 Potential causes include gonorrhea, chlamydia,
trichomonas, e.coli, and other gram negative bacteria.
 Urine culture may identify the causative agent.
 Patients should be admitted if any systemic symptoms
are present. Otherwise treatment can be a 2-4 week
course of PO abx. Septra or floroquinolones are
options but also need to treat for GC/chlamydia if
they’re suspected.
Balanitis/Balanopsthitis
 Inflammation of the glans of the penis, +/- foreskin
inflammation.
 Occurs in up to 3% of uncircumcised males.
 History of penile discharge, inability to retract
foreskin, tenderness and itching of glans.
 Exam shows erythema/edema of glans/foreskin,
discharge, ulcerations, phimosis.
Balanitis/Balanopsthitis
 In adults most common underlying condition seen
with it is diabetes. Can also be from poor hygiene,
chemical irritants, etc.
 Infectious causes include candida, HPV, gardnerella,
syphilis, trichomonas, strep.
 Work-up with culture of discharge, glucose check, wet
mount, syphilis serology.
 Treatment depends if it’s infectious and what the
infectious agent is.
Herpes Simplex Virus
 HSV is very common. Approximately 65% of the
United States population is seropositive for HSV-1 by
the fourth decade of life and 25% for HSV-2.
 Primary infections can be asymptomatic or have
symptoms of local pain, tingling, itching, and burning
and then the development of the typical lesions which
are vesicular or ulcerative on an erythematous base.
 After primary infection the infection becomes latent in
the sacral sensory ganglia.
 The viruses become reactivated secondary to a wide
variety of stimuli and secondary infection can occur.
Herpes Simplex Virus
 Lesions coalesce and then heal over the next several weeks.
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Tender bilateral lymphadenopathy occurs with genital
lesions.
Viral culture from skin vesicles can be done to help
establish diagnosis.
A pregnant woman near term should be referred to
obstetrics.
Antivirals can inhibit virus replication and suppress clinical
manifestations but are not a cure. Rates of relapse are
similar in treated and untreated patients.
Genital HSV should be treated with a 10 day course of oral
acyclovir.
Patients should be advised to be abstinent when lesions are
present and use condoms all the time.
Chancre
 The characteristic lesion seen in primary syphilis.
 Develops after an incubation period of 3-6 weeks.
 Frequently solitary, may be multiple. Sometimes seen
as "kissing" lesions on opposing skin surfaces, for
example, the labia.
 The lesion has a punched-out base and rolled edges
and is highly infectious. It resolves 4-6 weeks after it
forms and does not typically leave a scar.
Chancroid
 Sexually transmitted infection caused by Haemophilus
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ducreyi, characterized by painful ulcers, bubo formation
(swelling of lymph nodes), and painful inguinal
lymphadenopathy.
Uncommon in North America but much more common in
Africa and part of Asia- take a travel hx.
Much more common in men than women.
Organisms enter through breaks in the skin on the genitals,
and an erythematous papule forms, becoming a pustule in
2-3 days.
The pustule ulcerates in a matter of weeks, and
lymphadenopathy also usually is seen.
Painful inguinal lymphadenopathy or bubo formation is
present in 50% of patients.
Chancroid
 Diagnosis is made clinically based on the patient
having one or more painful ulcers (ulcers with painful
adenopathy are pathognomonic) with no evidence of
syphilis or herpes simplex virus.
 For treatment, ulcers should be cleaned and buboes
should have I & D.
 Treatment is a single dose of PO azithromycin or a
single dose of IM ceftriaxone.
 Should test for HIV, syphilis, and other STIs.
Perianal Group A Strep
 Perianal Group A Strep is one of the causes of
vulvovaginitis, most commonly seen in children.
 Usually results in a beefy red perineal area that is
edematous and tender and has well defined margins.
 Fissures, drainage, and hemorrhagic spotting may be
present.
 Diagnosis is made by bacterial culture of the area.
 Treatment involves topical antibiotic treatment with
mupirocin or erythromycin, or oral penicillin V.
What is the most common
bacterial STI in North America, and
what are 2 possible physical exam
findings?
Chlamydia
 Caused by Chlamydia trachomatis bacterium, has an
overall prevalence of 5% in North America.
 The incubation period is 1-3 weeks. Approximately
50% of infected males and 80% of infected females are
asymptomatic, but infection may cause a
mucopurulent cervicitis in females and urethritis in
males.
 Forty percent of women and 20% of men with
chlamydial infection are co-infected with gonorrhea.
Chlamydia
 On exam may find mucopurulent urethral discharge, rectal
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discharge, cervical/vaginal discharge, or epididymal
tenderness/swelling.
Cervical motion tenderness, adnexal tenderness, and lower
abdominal pain are also common.
Can test by doing nucleic acid amplification to detect
chlamydial DNA either in urine or with a genital swab.
Should also test for pregnancy and other STIs.
Treatment is a single oral dose of azythromycin or 7 days of
doxycycline. Consult gyne for severe PID or if patient is
pregnant.
Contact partners for treatment as well.
Should also treat for co-infection with gonorrhea.
What is the second most common
bacterial STI in North America and
name 2 associated diseases?
Gonorrhea
 Gonorrhea is a purulent infection of mucous
membrane surfaces caused by a sexually transmitted
microorganism, Neisseria gonorrhoeae.
 Retrograde spread of the organisms occurs in as many
as 20% of women with cervicitis, often resulting in
PID.
 Epididymitis or epididymo-orchitis may occur in men
after gonococcal urethritis.
 Disseminated gonococcal infection (DGI) occurs
following approximately 1% of genital infections.
Gonorrhea
 Most common symptoms in men are dysuria and
urethral discharge. Women usually have vaginal
discharge as main symptom.
 On exam may find mucopurulent urethral discharge,
rectal discharge, cervical/vaginal discharge or
epididymal tenderness/swelling.
 Cervical motion tenderness, adnexal tenderness, and
lower abdominal pain are also common.
Gonorrhea
 Can test with a culture of discharge or with nucleic
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acid amplification for DNA in urine or swabs of
infected areas.
Should also test for syphilis and Chlamydia and look
for signs of other STIs on exam.
Consult gyne for severe PID or pregnant women.
Treat with a single dose of PO cefixime or IM
ceftriaxone.
Also treat for Chlamydia.
Partners need to be referred for treatment.
What is the most common
presentation of HSV-2 infection
and what percentage of patients
present that way?
Herpes Simplex Virus
 80% of patients with primary HSV-2 infection are
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asymptomatic.
Approximately 65% of the United States population is
seropositive for HSV-1 by the fourth decade of life and 25%
for HSV-2.
Primary infections can be symptomatic with symptoms of
local pain, tingling, itching, and burning and then the
development of the typical lesions which are vesicular or
ulcerative on an erythematous base.
After primary infection the infection becomes latent in the
sacral sensory ganglia.
The viruses become reactivated secondary to a wide variety
of stimuli and secondary infection can occur.
Herpes Simplex Virus
 Lesions coalesce and then heal over the next several weeks.

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
Tender bilateral lymphadenopathy occurs with genital
lesions.
Viral culture from skin vesicles can be done to help
establish diagnosis.
A pregnant woman near term should be referred to
obstetrics.
Antivirals can inhibit virus replication and suppress clinical
manifestations but are not a cure. Rates of relapse are
similar in treated and untreated patients.
Genital HSV should be treated with a 10 day course of oral
acyclovir.
Patients should be advised to be abstinent when lesions are
present and use condoms all the time.
What is the most common parasitic
STI and how is it treated?
Trichomoniasis
 Trichomoniasis is a nonreportable STI caused by the
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parasite Trichomonas vaginalis.
-The prevalence in women is about 2.5%.
In females, vaginitis is the most common manifestation of
infection. Other complications include infection of the
adnexa, endometrium, and Skene and Bartholin glands.
Males are usually asymptomatic. When symptoms are
present, they usually manifest as urethritis.
Infection with T vaginalis is a marker of high-risk sexual
behavior. Co-infection with other STDs is common.
Trichomoniasis
 Presenting signs and symptoms may include
vaginal or urethral discharge, odor, irritation, itch,
dysuria, abdominal pain, and dyspareunia.
 In males, if symptomatic, there is usually only
scant, thin discharge.
 If suspected should check vaginal pH and do
microscopy for wet mount.
 Should also test for pregnancy and other STIs.
 A single oral dose of metronidazole is the
treatment.
What is the cause of syphilis and
how is it treated?
Syphilis
 Syphilis is an STI caused by the spirochete Treponema pallidum.
 It penetrates abraded skin or intact mucous membranes easily
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and disseminates rapidly, via the blood vessels and lymphatics.
Primary syphilis is characterized by the development of a
painless chancre at the site of transmission after an incubation
period of 3-6 weeks.
Secondary syphilis develops about 4-10 weeks after the
appearance of the primary lesion and has a wide range of
presentations.
Systemic manifestations include malaise, fever, myalgias,
arthralgias, lymphadenopathy, and rash.
The rash of secondary syphilis typically consists of macular
lesions symmetrically distributed over the body and may involve
the palms, soles, and oral mucosae.
Another skin findings of secondary syphilis is condylomata
latum.
Syphilis
 Latent syphilis is a stage at which the features of
secondary syphilis have resolved, though patients
remain seroreactive.
 About one third of untreated latent syphilis
patients go on to develop tertiary syphilis, whereas the
rest remain asymptomatic.
 Prevalence of approximately 3 per 100,000 in US.
 Occurs more commonly in men than women.
Syphilis
 Serology is the best test. Should have a nontreponemal test first
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like VRDL and RPR. These are very sensitive for detecting
secondary and tertiary syphilis, a bit less sensitive for primary
syphilis.
Because of the possibility of false-positive results, confirmation
for any positive nontreponemal test should follow with a more
specific treponemal test like the treponemal antibody absorption
test.
Patients with confirmed syphilis should be tested for other STIs
including HIV.
Treatment for syphilis symptoms present less than 1 year is
penicillin G benzathine one dose IM.
Follow-up VDRLs need to be done to look for clearance.
Partners should be contacted and tested. Safe sex should be
encouraged.
Crabs (pubic lice)
 A sexually transmitted ectoparasite that lives on the body.
 Most common symptoms is itching.
 The crab louse is found firmly attached to the base of the
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pubic hair. Nits may also be found.
Pubic lice may spread to hair around the anus, abdomen,
axillae, chest, and eyelashes.
Bluish grey macules, may be seen on the abdomen or
thighs and are secondary to the bites of the crab louse.
30% of patients with crabs have a second STI so they
should be investigated for other STIs.
Chemical pediculicides are the mainstay of therapy.
Treatment should be repeated in 7-10 days (the time
needed for the eggs to hatch).
Shaving of the hair is also an option.
Genital Warts (Condyloma
Acuminata)
 Caused by low risk strains of HPV.
 Is the most common STI. Annual incidence is 1% and
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lifetime prevalence is 50% in sexually active individuals.
2/3 of people who had sex with someone with active lesions
will develop warts within 3 months.
Present as painless bumps, pruritis, and discharge. Usually
multiple lesions in more than one area. May have coital
bleeding.
Most commonly seen on the penile glans and shaft in men
and the vulvovaginal and cervical areas in women.
Eruptions can be pearly, filiform, fungating, cauliflower or
plaque-like.
Genital Warts
 The only work-up needed may be to test for other
associated STIs.
 If visible genital warts are left untreated, they can
undergo spontaneous resolution, increase in size,
increase in number, or remain unchanged.
 Complete resolution of lesions after 2 years occurs in
75% of individuals without intervention.
 No treatment can be offered in ED but you can
consider gyne referral if persistent, especially because
of risk of malignant transformation.
Bartholin Gland Abscess
 Bartholin glands are two glands that secrete mucous to
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moisturize the surface of the vaginal mucosa.
Can get cysts from the ducts being blocked or abscesses
from a cyst or the gland getting infected.
Infections are not usually related to STIs.
Approximately 2% of women will have bartholin gland
swelling.
History of a cyst is usually of painless labial swelling,
possible dysparunia.
An abscess can have acute painful unilateral labial swelling,
pain with walking/sitting, dysparunia, and fever.
There may be a history of pain relief with rupture of
abscess.
Bartholin Gland Abscess
 Exam shows a fluctuant labial mass, tender if it’s abscessed.
 May have discharge if it’s ruptured (non-purulent if it’s a
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cyst).
For abscess e.coli is most commonly found, staph and strep
too. GC and chlamydia are possible.
No work-up is usually needed.
A simply cyst can be treated with sitz baths TID to promote
resolution or rupture of cyst.
Abscesses usually need I & D.
If it’s recurrent or unusaual may warrant a gyne referral.
Condyloma Lata
 Condyloma lata is a genital manifestation of secondary
syphilis.
 Can be confused with genital warts.
 The lesions exude highly infectious fluid and the
patient will often have other constitutional symptoms
of secondary syphilis including malaise, fever,
myalgias, arthralgias, lymphadenopathy, and rash.
Lymphogranuloma Venerum
 LGV is an infection of the lymphatics caused by some types
of Chlamydia trachomatis.
 The primary lesion occurs 3-21 days after exposure and is a
painless papule, shallow erosion, ulcer, or grouping of
lesions with a herpetiform appearance. Can occur on the
glans, urethra, penis shaft, or scrotum, in the vagina or on
the vulva.
 The second stage begins about 10-30 days later with the
formation of enlarged, tender regional lymph nodes known
as buboes and there may be constitutional symptoms.
 The nodes frequently abscess and rupture.
Lymphogranuloma Venerum
 The third stage is when proctocolitis develops, but
most don’t progress to this stage.
 LGV is uncommon in north America but endemic in
parts of Africa and Asia so take a travel history.
 Can test for Chlamydia, although you need a more
specific test to look for the serovars that cause LGV.
 Can also try culturing the abscess fluid if you aspirate
it.
 Treatment includes heat, NSAIDs, +/- aspiration of
bubo and 3 weeks of oral doxycycline or erythromycin.
A 4 year old girl presents to ED with
anal and vulvar pruritis, sometimes
waking her up at night.
 What is the most likely diagnosis?
 What is the treatment?
Pinworms
 Most common symptom is anal pruritis but the
infection can spread to the vulva and be easily
confused with vulvovaginitis.
 The pale-colored female pinworm may be visibly seen
in the perianal region.
 A specimen is best obtained by dabbing the stretched,
unwashed perianal folds in the early morning with
cellophane tape and affixing on to a slide.
 Treatment is not necessary although strict
handwashing should be advised. If it’s symptomatic
then treatment with anti-helmenthics is an option.