SEXUALLY TRANSMITTED

INFECTIONSNadine M McGraw PA-C MHS

STD/STI INCLUDE Chancroid Lymphogranuloma venereum Herpes Syphilis HPV Gonorrhea Chlamydia Pubic lice HIV Hepatitis Trichomoniasis

CHANCROID An STD characterized by painful genital

ulcerations and inflammatory inguinal adenopathy

Haemophilus ducreyi is causative organism.

It is uncommon in the United States but found worldwide, endemic in developing countries

What is the difference between a chancre and chancroid?

CHANCROID

Incidence/Prevalence in USA: 28 cases reported in 2009. Actual numbers felt to be greater due to underreporting of cases and difficulty with diagnosis.

Predominant age: Teenagers and adults

Predominant sex: Male > Female

Signs and Symptoms

• Tender genital papule that ulcerates after 24 hours (little round lumps)

• Irregular edged, painful ulcer(s) Ulcers may be 1 mm to 5 cm in size

• Ulcers may occur on the shaft of the penis, glans and meatus in men

• Ulcers in women most commonly occur in labia majora but also seen in labia minora, perineum, thigh, and cervix

• Painful inguinal adenopathy with abscess formation in 30% of patients

• Atypical presentations include folliculitis and foreskin abscess

DIAGNOSIS Not quite a diagnosis of exclusion,

however no PCR test is available and you must culture H. ducrey on special media usually not readily available. Therefore, you rule out other ulcerations including herpes and syphilis first.

“A probable diagnosis of chancroid, for both clinical and surveillance purposes, can be made if all of the following criteria are met: 1) the patient has one or more painful genital ulcers; 2) the patient has no evidence of T. pallidum infection by darkfield examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers; 3) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for chancroid; and 4) a test for HSV performed on the ulcer exudate is negative.” from the CDC

TREATMENTRecommended Regimens Azithromycin 1 g orally in a single dose OR Ceftriaxone 250 mg intramuscularly (IM) in a

single dose OR Ciprofloxacin* 500 mg orally twice a day for 3

days* OR Erythromycin base 500 mg orally three times

a day for 7 days * Ciprofloxacin is contraindicated for pregnant

and lactating women.

LYMPHOGRANULOMA VENEREUM

Rare, systemic STD caused by the 3 most virulent strains of Chlamydia! (L1, L2, L3)

Usually a disease of the tropics

Tender unilateral node - inguinal

3 stages - primary, secondary & tertiary Groove sign Poupart’s ligament

SIGNS AND SYMPTOMS Primary: Superficial lesions such as papules,

vesicles, ulcers or erosions appear on the external genitalia 3 days to 3 weeks after exposure. Lesions are painless and disappear in a few days leaving no scar.

Secondary: fever, chills, regional lymphadenopathy-week to months after primary, buboes begin as a mass of firm, tender, enlarged nodes. Buboes usually unilateral and involve overlying skin with erythema and adhesions.

Tertiary: anogenital stage, proctitis, perirectal abscesses

DX AND TX Culture pus

from buboes, check for chlamydia

Treat with doxy or emycin

HERPES Viral infection HSV I and HSV II what is the difference?

Exposure to virusSubclinical

Primary Infection

Systemic

Oral/Genital – Cutaneous – Genital

Latency

Recurrent Infections

SIGNS AND SXS Initial infection will have

lymphadenopathy, fever, maliase then outbreak

Painful ulcerations or vessicles erupt

Usually a “tingling” or burning feeling prior to outbreak

Females may present with burning with urination and “UTI” symptoms

DIAGNOSIS OF HSV Serologic testing for HSV I and II

IGM and IGG

Viral culture of ulceration for typing as wellMust be kept on ice and to lab ASAP

With viral treatment, remember topical treatments to prevent secondary infections

TREATMENT OF HSV Initial outbreak

Valtrex (valacyclovir) 1000 mg PO q 12 X 7-10 days Begin within 48 to 72 hrs of onset

acyclovir 400 mg po TID X 7-10 days

Recurrence Valtrex

500 mg po q 12 X 3 days Begin within 24 hrs of onset

acyclovir 400 mg poi TID X 5

Suppression Valtrex

1000 mg po qd, or 500 mg po qd if less than 5/year acyclovir

400 mg po BID

GONORRHEA- Bacteria: Neisseria gonorrhoeae Often asymptomatic as well, screen at paps,

if symptoms discharge, dysuria Diagnosed with cervical culture, urethral

swab or urine culture Treatment: ??? Cephalosporins or quinolones SUPERGONORRHEA

The new MRSA/VRE http://

abcnews.go.com/Health/Wellness/super-gonorrhea-scientists-discover-antibiotic-resistant-std/story?id=14027745

Requires test of cure!

CHLAMYDIA MOST FREQUENTLY REPORTED STI IN

US! Bacteria: Chlamydia trachomatis Many times asymptomatic, screen at

paps for high risk women. If symptoms: discharge, dysuria, lymphadenopathy.

PID is major complication of Chlamydia Diagnosed by cervical culture, urethral

swab or urine culture Treatment azithromycin or doxy Need a test of cure!

HPV Management Issues

Systemic virus- high incidence of recurrence

Laser Rx can aeroslize viral particles and place OR personnel at risk

Local Rx TCA Podophyline Cautery N2O

SYPHILIS Bacterial infection caused by Treponema

pallidum with 4 stages Primary: painless ulcer or chancre Secondary: skin rash, mucocutaneous

lesions, and lymphadenopathy), neurologic infection (i.e., cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, loss of vibration sense, and auditory or ophthalmic abnormalities)

Latent Tertiary: neurosyphilis cardiac or

gummatous lesions

SECONDARY SYPHILIS

DIAGNOSIS AND TREATMENT A presumptive diagnosis of syphilis is possible

with the use of two types of serologic tests: 1) nontreponemal tests (e.g., Venereal Disease Research Laboratory [VDRL] and RPR) and 2) treponemal tests (e.g., fluorescent treponemal antibody absorbed [FTA-ABS] tests, the T. pallidum passive particle agglutination [TP-PA] assay, various EIAs, and chemiluminescence immunoassays).

Darkfield testing for T. pallidum If you order the RPR and it is positive, the lab

will typically do the VDRL Penicillin is drug of choice, azithromycin may be

used

THE WRAP UP If anyone is positive for one STI look for

all others! PREVENTION PREVENTION PREVENTION!

REFERENCES http://

www.cdc.gov/std/treatment/2010/genital-ulcers.htm#chancroid