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Sexually Transmitted Diseases
David W. Haas, M.D.Division of Infectious Diseases
Vanderbilt University School of MedicineNashville, 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
Arthritis-dermatitis syndrome
Septic arthritis
Joint involvement
Number several 1 or 2
Sites Knee, elbow, wrist, ankle
Knee, elbow, wrist, ankle
Character Tenosynovitis Frank arthritis
Cells <20,000 WBC/mm3 >50,000WBC/mm3
Culture Negative Often positive
Papules/pustules 5-40 Absent
Blood culture 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) OR• Cefixime (400mg PO x 1 dose) OR• Cefpodoxime (400mg PO x 1 dose) OR• Ciprofloxacin (500mg PO x 1 dose) OR• Gatifloxacin (400mg PO x 1 dose) OR• Levofloxacin (250mg PO x 1 dose)
+• Azithromycin 1g po x 1 dose OR• Doxycycline 100mg q12h po x 7 days
Treatment of GonorrheaGeneral 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 trachomatisGenital 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
• Primary
• Secondary
• Latent
• Late
Onset
3 weeks
2-8 weeks
>8 weeks
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. Abrade lesion with dry gauze
2. Obtain serous exudate
3. Place on slide with coverslip
4. View motile spirochetes
• Great for primary and secondary syphilis, not for oral lesions
Syphilis Serology
Primary Secondary Late
Nontreponemal tests
(VDRL & RPR)75% 99%
1%
(if treated)
Specific treponemal tests
(FTA-Abs,
MHA-TP, TPHA)
75% 100% 95%
Who with Latent SyphilisNeeds 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