Download MBBS Dermatology PPT 14 Introduction Stis Syphilis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Dermatology PPT 14 Introduction Stis Syphilis Lecture Notes

Introduction to Sexual y

Transmitted Infections (STIs);



The sexual y transmitted infections (STIs; earlier k/a
STDs or VDs) are a group of communicable infections /
diseases that are transmitted by sexual contact &
caused by a wide range of bacterial, viral, protozoal,
fungal agents & ectoparasites
Transformation in STIs

? List of pathogens which are sexual y transmitted has

expanded from `5 classical' venereal diseases (VDs)
to include more than 20 agents including viral

? Shift to clinical syndromes associated with STIs

Classification of STI agents

1. Bacterial Agents
? Treponema pal idum - Syphilis
? Haemophilus ducreyi - Chancroid
? Calymmatobacterium granulomatis - Donovanosis
? Bacterial Vaginosis - caused by various microbial


? Neisseria gonorrhoea - Gonococcal Urethritis and

other manifestations

? Chlamydia trachomatis ? Non-Gonococcal Urethritis


? Mycoplasma hominis - NGU
? Ureaplasma urealyticum - NGU
Classification of STI agents

2. Viral Agents
? Herpes simplex virus 2 or 1 (HSV 2 & 1) - Herpes


? Hepatitis B virus
? Human Papil oma Virus - Warts
? Molluscum Contagiosum Virus- Mol uscum


? Human Immunodeficiency Virus (HIV) - AIDS

Classification of STI agents

3. Protozoal agents
? Entamoeba histolytica ? Amoebiasis
? Giardia lamblia ? Giardiasis
? Trichomonas vaginalis ? Vaginitis
Classification of STI agents

4. Fungal agents
? Candida albicans - Candidal Vaginitis
5. Ectoparasites
? Phthirus pubis - Pediculosis
? Sarcoptes scabiei - Scabies


? General history (Demography)
? Contact of an STI
? Onset, character, periodicity, duration & relation to

sexual intercourse & urination

? Anogenital discharge / dysuria / hematuria
? Dyspareunia / pelvic pain
? Ulcers, lumps, rashes or itching

? Past medical and STI history
? Medications, al ergies (emphasise antibiotics) &


? Any STI in sexual partner(s)
? Last menstrual period
? Vaccination history
? Obstetric history (h / o abortions)
? Any history of injecting drug abuse, what drug, how


? Any history of tattooing or blood product exposure

Sexual History

? Number of exposure (Single, multiple)
? Number of sexual partner(s)
? Date of last sexual exposure
? Sex of partner(s) and history of male to male

contact (MSM)

? Type of intercourse ? oral, vaginal, anal
? Protected / unprotected exposure
History for HIV

? H/o Recurrent diarrhoea
? H/o Fever
? H/o Loss of weight
? H/o Genital ulcer disease
? H/o Blood transfusion
? H/o Herpes zoster
? H/o Opportunistic infections


? Exposure of abdomen, genitals and thighs is


Inspect for:

? Rashes
? Lumps
? Ulcers
? Discharge
? Smel

Inspect for:

? Pubic hair for lice & nits
? Skin of the face, trunk, forearms, palms & the oral


? Palpate: Lymph nodes

Examination - Men

? Penis
? External meatus
? Retracted foreskin
? Perianal area
? Lymph nodes examination
? Per-rectal (P / R) examination
? Palpation of scrotum & expression of any discharge

from the urethra.

? Proctoscopy
Examination - Women

? External genitalia
? Perineum
? Perianal area
? Lymph nodes examination
? Speculum examination of vagina & cervix
? Bimanual pelvic examination
? Oral cavity

Systemic Examination

? Cardiovascular

? Respiratory

? Gastrointestinal (liver, spleen)

? Central Nervous

? Urinary

? Musculoskeletal

? Caused by Treponema pal idum subsp. pal idum
? T. pal idum - a fine, motile, spiral organism,

measuring 6-15 m in length & 0.09 to 0.18 m in

thickness with characteristic motility

? It has regular spirals which helps in differentiating

from other non-pathogenic treponemes

? Cannot be grown on culture media


Moderate to high probability of transmission:
? Sexual contact
? Infected blood
? Trans-placental route
? Accidental to medical personnel


Attachment to host cel s

Corkscrew movement & travel to lymph nodes

In perivascular lymphatics cause endarteritis obliterans

Loss of blood supply

Genital ulcer

Primary syphilis

? Stage from infection to the healing of the chancre

? Incubation period- 9-90 days

After this time there is ulcer formation
Primary syphilis

? Single, painless, wel -defined, `Hunterian' ulcer with

clean looking granulation tissue on floor

? Indurated, button-like

? Hard chancre - heals with scar even without


Primary syphilis

Sites of ulcer
? Genital (90-95%)
Coronal sulcus, glans, frenulum, prepuce, shaft of

penis in male
Cervix, labia, vulva, urethral orifice in females

? Extra-genital (5-10%):
Commonest site is the lips

Combination of clinical & Laboratory investigation

? DGI-serum from ulcer / aspirate from lymph node

? VDRL / RPR- Negative til one week after appearance

of ulcer.

Positive by 4 weeks

Natural History

Gjestland (1955)- a fol ow-up study of 1147 cases (the Oslo


? 24% -mucocutaneous relapses
? 11% died of syphilis
? 16% - benign late manifestations (usual y cutaneous)

nodules or gummata

? 10% cardiovascular syphilitic lesions
? 6% - neurosyphilis.
? Conclusion: Long before penicil in was introduced, at

least 60% of people with syphilis lived & died without

developing serious symptoms (Rook's 2010)
Secondary Syphilis

? 6-8 weeks after appearance of primary chancre

? Systemic disease

? Constitutional features like sore throat, malaise, fever

& joint pain may accompany the lesions

Secondary Syphilis

? Common signs are:
- Skin rash (75-100%)
- Lymphadenopathy (50-86%)
- Mucosal lesions (6-30%)

Secondary Syphilis

? Non-itchy lesions general y
? Macular, papular, nodular, pustular, annular lesions

may occur

? Condyloma lata
? Split papules at angles of mouth
? Corona veneris
? Moth eaten alopecia
? Mucosal lesions - mucous patches (snail-track ulcers)
? The `great-imitator'


? VDRL / RPR - Almost always positive
- False negative (in some cases)
- False positive (in some cases)
? Specific tests: TPHA / TPPA may remain reactive

throughout the life
Latent syphilis

? Persistent seropositivity with clinical latency
? Fol owing resolution of primary or secondary stage

latency occurs & continues as such in 60-70% of


? Less than 2 years: Early
? More than 2 years: Late

Tertiary Syphilis

? After a period of latency of up to 20 years,

manifestations of late syphilis can occur

Characteristic lesion is the gumma
? A deep granulomatous process involving the

epidermis secondarily

? Causes punched out ulcerative lesions with white

necrotic slough on the floor

? On lower leg, scalp, face, sternal area
Tertiary Syphilis

Develops 10-30 years after infection - so in middle / old

age; more in men
? Aortitis (ascending aorta)
? Aortic aneurysm sudden death due to rupture
? Coronary ostial stenosis

Tertiary Syphilis

? In any patient with syphilis, CSF lymphocytosis, an

elevated CSF protein level or a reactive VDRL test

would suggest neuro-syphilis & must be treated

? Asymptomatic neurosyphilis
? Meningeal neurosyphilis -usual y has its onset during

secondary disease; characterized by symptoms of

headache, confusion, nausea & vomiting, neck

stiffness & photophobia. Cranial nerve palsies cause

unilateral or bilateral facial weakness &

sensorineural deafness
? Meningovascular syphilis - occurs most frequently

between 4 and 7 years after infection. The clinical

features of hemiparesis, seizures & aphasia reflect

multiple areas of infarction from diffuse arteritis.

? Gummatous neurosyphilis - results in features typical of a

intracranial space-occupying lesion.

? Parenchymatous syphilis : general paralysis (GPI) from

parenchymatous disease of the brain used to occur 10?

20 years after infection. The onset is insidious with subtle

deterioration in cognitive function & psychiatric

symptoms that mimic those of other mental disorders.
? Tabetic neurosyphilis was the most common form of

neurosyphilis in the pre-antibiotic era, with an onset 15?

25 years after primary infection. The most characteristic

symptom is of lightning pains- sudden paroxysms of

lancinating pain affecting the lower limbs.

? Other early symptoms include paraesthesia, progressive

ataxia, & bowel & bladder dysfunction.

Treatment of Syphilis & STIs

? CDC guidelines: updated regularly and reviewed

thoroughly every 4 years

? Others:
Syphilis treatment

Primary, Secondary, Early Latent
? Recommended regimen (CDC)

Inj. Benzathine Penicil in G,
2.4 mil ion units IM stat after test dose


Late Latent Syphilis

? Recommended regimen
Inj. Benzathine penicil in G 2.4 mil ion units IM AST at

one week intervals x 3 doses

? Recommended regimen
Aqueous crystal ine penicil in G, 18-24 mil ion units

daily administered as 3-4 mil ion units IV every 4 hours

for 10-14 days

Alternative regimen for penicillin

allergic patients

? Doxycycline (100 mg) BD

? Erythromycin (500mg) QDS

? Tetracycline (500mg) QDS

Duration of treatment

? Early syphilis : 15 days

? Late syphilis : 30 days
? Pregnancy: Only penicil in G
? If patient al ergic: desensitize

? CDC: Guidelines (Dr G. O. Wendel, Jr., et al. N Engl J

Med. 1985)
The Jarisch-Herxheimer reaction

? The Jarisch-Herxheimer reaction is an acute febrile

reaction frequently accompanied by headache, myalgia,

fever, & other symptoms that can occur within the first

24 hours after the initiation of any therapy for syphilis.

? Antipyretics can be used to manage symptoms
? The reaction might induce early labor or cause fetal

distress in pregnant women, but this should not prevent

or delay therapy

Thank you

This post was last modified on 07 April 2022