Transcript STD_PRACTICAL final (2)COMbINED SESSTION

Reproductive block
2014
Prof kambal
Dr.Ali M Somily
Dr.Malak El-Hazmi
Objectives
 Name various etiological agents causing sexually
transmitted diseases
 Describe the clinical presentations of sexually
transmitted diseases
 Discuss the microbiological and no microbiological
methods for diagnosis of sexually transmitted diseases
 Outline the management of sexually transmitted
diseases .
Four Classes of STD’s
1- VirusesHerps
HIV
Hepatitis B
Human papilloma virus
2- Bacterial
Syphilis
Gonorrhea
Chlamydia
Chancroid
Mycoplasma hominis
Ureaplasma urealyticum
3- Fungus
Yeast – Candida
albicans
4- Parasites
Trichomonas
Ectoparasites
Phithrus pubis Pubic louse
Sarcoptes scabiei
Bacterial STDs
Case 1
 A 23-year-old alcoholic and drugs (cocaine) addict
single male arrived from his trip to South East Asia six
months ago. He gave history of multiple sexual
partners. Two months ago he developed ulcer on his
penis which disappeared compeletly. A full physical
notes a rash on both her palms and her soles
?
What are the possible causes
for his presentation
 Treponema Pallidum
 Herpes Simplex Virus 2
 Haemophilus Ducreyi
How could you differentiate between them
based on s/s of the patient?
Ulcer
Etiology
Ulcer
Lymphadeno Systemic
pathy (Babo)
Chancroid
Haemophilus
Ducreyi
Wet , painful
Inguinal
tender
Present
Chancer
Treponema
Pallidum
Dry, painless
and raised
margin
Inguinal part
of generalize
disease
Depends on
stage
Ulcerated
Vesicles
Herpes Simplex
Virus 2
Multiple
shallow
painful
Occasionally
present
In primary
 syphilis is a disease caused by a corkscrew-shaped
bacterium (a spirochete) called Treponema
pallidum. It causes disease when it penetrates
broken skin of the genitals or the mucous
membranes of the mouth or anus.
 It can also be passed from an infected person
through an open cut or wound and from mother to
child.
 Symptoms: 3-staged disease
Primary syphilis
Painless penile chancre in primary
syphilis due to Treponema pallidum:
primary syphilis infection vagina ulcers
 The lesion are sampled and identified through
dark-field microscopy
2nd stage - or secondary syphilis .
 This stage occurs in about 6-8 weeks after formation of sore
if the chancre is not marked and the patient untreated
 Typically, general signs appear: fever, the aches , headache ,
a tiredness , a rash as well as lesions on the palms of the
hands and soles (feet), glossitis (lesions in the tongue), the
lesions contain the bacteria, they are highly contagious
secondary syphilis.
A
B
Mucous patches (A and B) are superficial mucosal
erosions seen in secondary syphilis. They can be found on
any mucosal surface and are highly infectious
Base on the finding, what is the most likely diagnosis?
Briefly outline the management of this patient?
 Dx;
Primary syphilis
 Rx;
Benzathine penicillin IM---allergy
Doxycycline
Patient Counseling and Education
He should be tested for other STD especially HIV
3rd stage or Tertiary / Acute stage
This is the final stage in which the symptoms show no or
minor cure despite seeking treatment. Syphilis symptom if
left untreated it will then continue and often goes on to
damage the nervous system and the heart, weakens bones
& joints leading to death
None of these third stage gummas or ulcers will heal to
their original state
Tertiary / Acute stage
In the central nervous system it can affect the spinal column,
resulting in a condition called tabes dorsalis. This condition causes
postural instability with a staggering wide base gait that can damage
the joints of the leg.
The condition shown is called
Charcot's knee.
tertiary syphilis with gumma
distruction of nose
Identification of T. pallidum - Direct
Microscopy
Dark field showing Treponema pallidum:
A dark field analysis of fluid from a lesion of
primary or secondary syphilis is considered
the gold standard for diagnosing syphilis
Silver Stain
Spirochetes may be seen in biopsy specimens
of suspicious lesions such as palmar macular
rash or gummatous lesions
Case 1:
A 36-year-old female presented with a chief complaint of rash all over the body, of
15 days duration, associated with severe itching. On detailed history, the patient
stated that the rash started asymptomatic on the right forearm, and later became
generalized. The patient applied some native medications and developed
generalized itching and presented with a picture of contact irritant dermatitis in the
form of papules, vesicles, and scaling, all over the body. The patient was treated for
the same with a combination of topical steroids and antihistamines. The patient had
little symptomatic relief with this. The patient's rash was persistent in the form of
macules, papules, and scaling. A thorough examination revealed the presence of few
lesions on the genitalia mainly on the labia majora which were flat topped papules
and the patient also had a mucous patch over the hard palate [. Thus, secondary
syphilis was strongly suspected and the patient was subjected for Venereal Disease
Research Laboratory (VDRL) testing. The VDRL testing was non-reactive. As the
suspicion of secondary syphilis was high
As the suspicion of secondary syphilis was high, what
further evaluation would you request to exclude or
confirm syphilis?
-Request for repeat VDRL test, with higher dilution
as false negative results will occur due to. Prozone phenomenon in
the excess of antibody( high concenteration in serum)
- Also request specific Treponemal antigen tests e.g. FTA-Abs , ELIS
-
Briefly outline the management of this patient
secondary treatment consists in two intramuscular
of penicillin injections at weekly intervals.
treatment effectiveness will be verified on the
serology at : 3, 6 , 12 month for the drop of titers.
Discussion
Prozone phenomenon is an immunological event, relying on an antigen-antibody
interaction such as in rapid plasma reagin (RPR) or VDRL. [3] An agglutination or
precipitation reaction will be positive (i.e., visible through lattice formation) when
the optimal ratio of the antigen antibody yields an insoluble precipitate that is
visible, thus rendering the test positive. [4]
The zone of equivalence defines this optimal ratio. In the zone of the antibody
excess (prozone) or antigen excess (post zone), false negative results will occur. [4]
The prozone phenomenon in the setting of syphilis may become prevalent
because of the current acquired immunodeficiency syndrome (AIDS) epidemic. [2]
As syphilis and HIV mutually increase the chance of contracting other diseases,
B-cell behavior can lead to hyper-responsiveness to antigenic stimulation, leading
to excess antibody production. [5]
Treatment of syphilis
The treatment of syphilis is variable depending on the stage of
the disease:
At the primary stage: the minute treatment: a single injection of
penicillin 2.4 million iu intramuscularly (except againstindication) is made and the patient will be cured once the canker
is gone, it will not secondary syphilis or tertiary.
Stage secondary treatment consists in two 2.4 million iu
intramuscular injections at weekly intervals. Syphilis will also be
cured, treatment effectiveness will be verified on the serology.
In the tertiary stage, the treatment is longer. The effectiveness of
treatment is monitored on the evolution of HIV
Case 2
 A 35-year-old Pilipino married male presented to the
emergency room complaining of dysuria for the last
24-hour and noted some "pus-like" drainage in his
underwear and the tip of his penis.
Urethral Discharge in Gonorrhea)
Ophthalmia : 2-7 days after birth with
Bloody, green or serosanguineous discharge
What are the possible causes for his presentation?
Organisms
Urethritis
Gonococcal
Urethritis
Neisseria
gonorrhoeae
Purulent discharge
Non-gonococcal
urethritis
Chlamydia
trachomatis
Mucopurulent
Others
•Trichomonas
vaginatis
•Mycoplasma
genitalium
What investigations do you like to order for him?
Explain how those investigations would help you?
GCU
Organisms
Smear/Culture
Neisseria
gonorrhoeae
Gram-ve diplococci
& cellpus /
Selective media
NGCU Chlamydia
trachomatis
Others
Trichomonas
vaginalis
Mycoplasma
genitalium
Immunological
tests
Molecular
testing
+ve
Pus cell/McCoy
Cell culture
DFA
+ve
Wet mount;
pus &TV/
Culture
Pus cell /
Special media
culture
EIA
+ve
EIA
+ve
This Gram-stained specimen from uretheral discharge reveals N. gonorrhoeae
intracellular diplococci, leading to a positive diagnosis of gonorrhea
Base on the finding, what is the most
likely diagnosis? Briefly outline the
management of this patient?
Symptoms
In both genders, gonorrhea spreads through the bloodstream
to other organs, causing infection and inflammation of the
joints (gonococcal arthritis), the heart (gonococcal
endocarditis), or covering the brain (gonococcal meningitis).
Some adults get eye infections by rubbing eyes after touching
infected genitals
Neisseria gonorrhoeae growing on heated
blood agar (Chocolate Agar)
Neisseria gonorrhoeae requires a rich growth
medium, such as heated blood agar
(Chocolate Agar) and an atmosphere
containing 5-10% carbon dioxide. Even so,
it may take up to 48 hours to get colonies
of the size seen above.
G.C. Sel Agar with L.C.A.T
Enriched and selective; contains
antibiotics colistin (kills gramnegative coliforms), vancomycin
(kills gram-positives), nystatin
(kills fungi
Case 3
 A 24-year-old female noted vaginal itching and
irritation with a discharge. Previously, she developed a
yeast infection that was treated with over-the-counter
medications and resolved. Thinking that this was
recurrence, she again self-treated. This time, however,
the symptoms did not resolve.
What are the possible causes
for her presentation
Bacterial vaginosis
Candida vaginitis
Trichomonas vaginalis
Allergic vaginitis
Chlamydia trachomatis
Neisseria gonorrhoeae
What investigations would you like to order for her?
Explain how those investigations would help you?
PH
Whiff Gram stain /
test
Bacterial
vaginosis
Candida
vaginitis
Trichomonas
vaginatis
Wet prep
Culture
Immunologic/
molecular test
Chlamydia: is currently one of the most common and
widespread bacterial STDs
Spread During unprotected sex.
Symptoms: Occur within 7-21 days of infection.
Men: Clear thick discharge from Penis, burning during
urination
Women: Painful Urination, itching, burning or bleeding from
vagina may have vaginal discharge, dysuria, urination, labial
pain/swelling, abd. Pain
• Chlamydia: is currently one of the most
common and widespread bacterial STDs
• Spread During unprotected sex.
• Responsible for causing cervicitis, urethritis,
proctitis, lymphogranuloma venereum, and
pelvic inflammatory disease
• Potential to transmit to newborn during
delivery
Conjunctivitis, pneumonia
• Symptoms: Occur within 7-21 days of
infection.
• Men: Clear thin discharge from Penis,
burning during urination
• Women: Painful Urination, itching,
burning or bleeding from vagina.
Chlamydia - Laboratory Diagnosis
Tissue culture has been the standard
Non-amplified tests
Enzyme Immunoassay (EIA), e.g.Chlamydiazyme
Nucleic Acid Hybridization (NA Probe), e.g.
Gen-Probe Pace-2
detects chlamydial ribosomal RNA
able to detect gonorrhea and chlamydia from
one swab
DNA amplification assays
polymerase chain reaction (PCR)
ligase chain reaction (LCR)
LCR ability to detect chlamydia in first void urine
What investigations you like to order for her?
Explain how those investigations would help you?
PH
Bacterial
>4.5
Whiff Gram stain /
test
Wet prep
+++
Clue cells
Culture
molecular test
Not helpful DNA Probe
vaginosis
Candida
(gardnerella vaginalis)
<4.5
-
vaginitis
Trichomonas
vaginalis
Immunologic/
Yeast and
Candida
DNA Probe
Motile
EIA
pseudohyphae
>4.5
+-
Trichomonas
Trophozoi DNA Probe
tes
Chlamydia - Laboratory Diagnosis
2- Culture This McCoy cell
1- Chlamydia Direct
monolayer micrograph reveals a number
Fluorescent Antibody (DFA)
of intracellular
C. trachomatis inclusion bodies
Elementery bodies
inclusion bodies
Chlamydia - Laboratory Diagnosis
A sexually transmitted disease caused by a bacterium Haemophilus ducreyi)
characterized by a genital ulcer (sometimes called a soft chancre) that begins
as a tender pimple surrounded by a reddened area.
It is more commonly seen in men than women, particularly uncircumcised
males . Chancroid is spread by having unprotected sex.
Some symptoms include:
sores or raised bumps on the genitals which eventually if untreated,
becomes filled with pus and eventually ruptures leaving a painful
sore/ulcer.
The bacteria may also infect the lymph glands in the groin. These glands
may become enlarged, hard and painful.
In Women, ulcers appear on the genitals, painful urination and painful
intercourse
Chancroids are contagious as long as the person as open sores. 2 to 3
Following is the Gram-stained smear of
from genital ulcer of a 25 –year old male
 The organism MOST likely causing the ulcers is ;
1. Treponema pallidum
2. Herpes Simplex Virus 2
3. Haemophilus ducreyi
4. Gonorrhea
CDC / Center for Disease Control and Prevention/
Division of STD Prevention
Regional adenopathy
Chancroid
Diagnosis:
No blood test is available to diagnose
chancroid, so the diagnosis is usually made
on clinical grounds after a physical exam.
She presented to her family physician for management.
On examination there is a bad odor along with a frothy
discharge and strawberry cervix.
Swab of the secretions was taken in order to perform
tests.
“Strawberry cervix”
Source: Claire
E. Stevens/Seattle STD/HIV Prevention Training Center at the University of51Washi
Wet prep/ Gram stain
A wet mount of the swab demonstrates "swimming" Motile Trophozoites .
Base on the finding, what is the most likely diagnosis?
Briefly outline the management this case?
 Dx;
Trichomoniasis
 Rx;
Metronidazole
Husband should be treated
No sex until they are cured
Patient Counseling and Education
STDs- Ectoparasitic Infestations
Lice in Pubic Area
STDs- Ectoparasitic Infestations
Scabies causing eczema-like
Scabies (under the skin crabs)
hand condition
How do you diagnose HIV
infection ?
Serological profile of HIV infection
DIAGNOSIS
1. Serological test:
-
Screening assay
(routine ELISA/rapid)
Detection Ag or Ab
Confirmatory assay
(Western blot, RIBA, LIA)
2. Direct Methods:
PCR
NA detection
(early inf ,neoate inf, monitor Rx )
Genital herpes
Neonatal herpes infection
1- ELISA:
serum sample is analyzed for
detection the IgM Ab.
2- Direct immunofluorescence (IF):
scraping of the base lesion sample is
analyzed for detection the Ag.
3- Polymerase chain reaction (PCR):
CSF sample in case of neonatal
herpes.
4- Tissue culture:
vesicle fluid sample is cultured in
cell line (Vero or Hep-2 cells) and
then identified by the following:
- Observe the viral CPE
- Direct immunofluorescence (IF)
Genital warts
Diagnosis
• External genital warts can be easily diagnosed by
medical examination.
• Internal genital warts can be visualized by colposcopy.
Lab diagnosis:
1- Polymerase chain reaction (PCR) is
used to detect
HPV DNA.
2- Pap-smear test is used to identify
abnormal epithelial cells of the cervix
(cervical dysplasia).
3- In-situ DNA hybridization is used for
HPV genotyping.
THE END