Download MBBS Dermatology PPT 26 Sexually Transmitted Infections II Lecture Notes

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Congenital Syphilis

? Congenital syphilis - syphilis present in utero & at

birth

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? Prevention: VDRL at antenatal visit & treatment with

penicillin G

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? Transmission across placenta to foetus occurs at any

stage of pregnancy

? Foetal damage does not occur until after fourth month

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? Early: birth to 2 years of age
? Late: after 2 years of age
? Stigmata
Early congenital syphilis

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? Asymptomatic; only identified on

routine antenatal screening

? Poor feeding & rhinorrhea (snuffles) ? profuse

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serous discharge ? old man with a cold in head

? Hepatosplenomegaly, skeletal

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abnormalities, pneumonia & vesicobullous lesions

known as `pemphigus syphiliticus'

Late congenital syphilis

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? Subclinical in about 60% of cases
? Interstitial keratitis (occurs at 5?25 years of age),

eighth-nerve deafness & recurrent arthropathy

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? Bilateral knee effusions are known as Clutton's

joints

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? Asymptomatic neurosyphilis - in about one-third

of untreated patients; clinical neurosyphilis occurs

in one-quarter of untreated individuals >6 years

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age
Classic Stigmata

? Hutchinson's teeth - centrally notched, widely

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spaced, peg-shaped upper central incisors

? Mulberry molars - molars with multiple, poorly

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developed cusps

? Saddle nose
? Saber shins

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Treatment

? Penicillin G
Chancroid / Soft chancre / Ducrey's

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disease

? Acute, autoinoculable STI
? Etiologic agent: Gram negative facultative,

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anaerobic bacillus Haemophilus ducreyi

? "School of fish" or "rail road track"

appearance

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? Age group: 20-30 years
? Males affected more commonly

Clinical features

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? Incubation period- 3-10 days
? Sites: Frenum, prepuce, coronal sulcus in male

and vulva, vestibule in females

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? Painful genital ulcers, non-indurated (soft

chancre/soft sore), bleed on touch

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? Edema of prepuce
? Tender inguinal lymphadenopathy (unilateral

in majority), sometimes suppurative
Investigations

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? Microscopy:
? Gram stain ? low sensitivity

? Culture - < 80% sensitivity

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? Molecular techniques- PCR

Treatment (CDC)

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? Recommended regimen
Azithromycin 1 g orally single dose
or
Ceftriaxone 250 mg IM in a single dose
or

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Ciprofloxacin 500 mg twice daily x 3 days

or

Erythromycin base 500 mg orally three times a day x

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7 days
Lymphogranuloma Venereum

(LGV)

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? Also k/a tropical bubo or lymphogranuloma

inguinale

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? Caused by Chlamydia trachomatis serovars L1,

L2 & L3

? Incubation period ? 3-12 days

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Pathogenesis

? Enters through skin abrasions or mucous

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membranes via the lymphatics multiply

within mononuclear phagocytes in regional

nodes

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? Thrombolymphangitis & perilymphangitis

occur

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? Necrosis & the formation of stellate abscesses
? Fistulae & sinus tract formation; may be f/b

healing with fibrosis
Clinical features

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Primary stage (Genital)
? Superficial ulceration, which looks like herpes,

is temporary and heals without scarring

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? It may not be noticed (GUD with no ulcer)

Clinical features

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Inguinal syndrome (Secondary stage)
? Most common manifestation: bubo
? Occurs - 2-6 weeks later
? More common in males
? Painful inguinal lymphadenitis with associated

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constitutional symptoms

? Enlargement of the femoral & inguinal lymph

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nodes separated by the inguinal ligament ?

"groove sign of Greenblatt"

? Suppuration and sinus formation

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Clinical features

Genital syndrome (Tertiary stage)
? May occur many years later
? Results from fibrosis & lymphatic obstruction

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? Penile and scrotal elephantiasis
? Females-elephantiasis of the vulva and clitoris
? Fistulae, chronic ulceration, scarring &

deformity

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Clinical features

? Late complications - include rectal strictures,

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chronic rectovaginal & urethral fistulae

? May predispose to malignant change
Investigations

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? Diagnostic method of choice is by nucleic acid

amplification tests (NAAT) & confirmation by

PCR assays for LGV-specific DNA

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? Serology:

Complement fixation test ? lack sensitivity /

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specificity
Microimmunofluorescent (MIF) antibody

testing to the L-serovar

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? Frei intradermal test ? historical interest only;

based on positive hypersensitivity reaction

Treatment

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? Recommended regimen

Doxycycline 100 mg twice daily for 21 days

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? Alternative regimen

Erythromycin base 500 mg four times daily

for 21 days

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Granuloma inguinale /

Donovanosis

Chronic, destructive, granulomatous STI

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caused by Gram negative organism

Calymmatobacterium (Klebsiella)

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granulomatis

? Incubation period: Not precisely known;

about 50 days in human experimental

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inoculation studies

? The organism occurs inside large vacuolated

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histiocytes in the form of "closed safety pin"

Clinical Features

? Initial lesion - a papule or subcutaneous nodule

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that ulcerates

? Leads to large beefy-red, non-tender

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granulomatous ulcers that bleed easily &

gradually extend

? Secondary infection - result in necrotic, foul-

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smelling, deep ulcers

? May be followed by pseudo-elephantiasis
Investigations

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Microscopy:
? Giemsa or Leishman's stain (crush smear

from ulcer) for Donovan bodies

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? Clusters of blue-to-black organisms that

resemble `safety pins' within the vacuoles of

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enlarged macrophages

Treatment

? Recommended regimen

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Azithromycin 1 g orally once per week or 500

mg daily for at least 3 weeks and until all

lesions have completely healed

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? Alternative regimens
Doxycycline 100 mg orally twice a day
OR Ciprofloxacin 750 mg orally twice a day
OR Erythromycin base 500 mg orally 4 times a

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day

OR Trimethoprim-sulfamethoxazole one DS

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(160/800 mg) tablet orally twice a day
Herpes genitalis

? Organism-Herpes simplex virus (HSV-2,

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HSV-1)

? Incubation period: 2 days ? 2 weeks
? Primary episode: classically a group of

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vesicular lesions leading to discrete multiple

painful ulcers

? Penile ulceration are most frequent on the

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glans, prepuce and shaft of the penis

? Painful & last for 2?3 weeks if untreated

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Clinical features

? In the female, similar lesions occur on the

external genitalia and mucosa of the vulva,

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vagina & cervix

? Pain and dysuria are common
? First episodes are usually more severe than

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recurrences
Investigations

? Microscopy

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Tzanck smear ? nonspecific, multinucleate

giant cells

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? Culture from vesicle fluid
? Detection of viral antigen by

immunofluorescence

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? PCR for HSV DNA

Treatment

? First episode

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Acyclovir 400 mg orally three times a day for 7-10

days

Or

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Acyclovir 200 mg orally 5 times a day
Or
Valacyclovir 1 g orally twice a day
Or
Famciclovir 250 mg orally three times a day

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Episodic therapy for recurrence

Acyclovir 400 mg orally three times a day for 5 days
Or
Valcyclovir 500 mg orally twice a day for 3 days

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Suppressive therapy for recurrence

Acyclovir 400 mg orally twice a day
Or

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Valcyclovir 500 mg orally
Urethritis

? Characterized by findings of PMN leucocytes

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in urethral smear or sediment in the first void

urine

- Gonococcal

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- Nongonococcal

Gonorrhea

? Gonorrhea - means "Flow of seed"

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? Albert Neisser identified the organism in 1879
? Neisseria gonorrheae - Gram negative

encapsulated aerobic diplococcus with pili

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? Incubation period- 2-5 days
Clinical features

? Acute catarrhal inflammation of genital mucosa
? Men ? Inflammation of penile urethra- urethritis

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? Burning sensation, dysuria, discharge - yellow,

thick purulent discharge

? Females ? 50% may be asymptomatic- cervix

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infection

? Lower abdominal pain, vaginal discharge or

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dyspareunia

? Throat infection ? due to oral sex on an infected

partner- usually asymptomatic; may cause sore

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throat

? May spread in ascending manner, causing

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prostatitis, epididymitis, salpingo-oophoritis, PID,

later infertility

? DGI- pain and swelling in or around one or

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several joints, fever and chills and skin lesions

? Ophthalmia neonatorum ? due to infected birth

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canal during childbirth
Investigations

? Gram-stained smear ? PMNs with

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intra/extracellular G negative diplococci

? Culture ? Thayer-Martin medium
? Blood culture ? DGI, septicemic

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Treatment

? Recommended regimen
Ceftriaxone 250 mg IM in a single dose
PLUS

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Azithromycin 1 g orally in a single dose
Alternative regimen
Cefixime 400 mg orally in a single dose
PLUS
Azithromycin 1 g orally in a single dose

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Nongonococcal Urethritis

Usual causative organisms:
? Chlamydia trachomatis
? Mycoplasma hominis

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? Ureaplasma urealyticum
? Trichomonas vaginalis
? May co-exist with gonococcal infection

Clinical features

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? Dysuria with odorless, mucoid, scanty discharge
? No diplococci but abundant PMNs
? > 5 pus cells / oil immersion field
Treatment

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Azithromycin 1 g orally in a single dose
Or
Doxycycline 100 mg orally twice a day for 7 days

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WITH (for Trichomonas)
Metronidazole 2 g orally in a single dose
Or
Tinidazole 2 g orally in a single dose

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Vaginitis

Etiology

? Candida albicans and other species of candida

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? Trichomonas vaginalis
? Bacterial vaginosis
Candidal vulvovaginitis

? Normal flora of skin & vagina ? symptoms d/t

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excessive growth of the yeast

? Balanoposthitis in males
? Risk factors: Pregnancy, DM, HIV infection /

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AIDS, repeated courses of broad-spectrum
antibiotics, corticosteroids

? Most cases caused by C. albicans, others by non-

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albicans sps e.g., glabrata

Clinical features

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? Pruritus, frequency & burning micturition
? Dyspareunia
? Thick curdy white discharge
? Pre-menstrual flare
? Examination reveals thick cheesy plaques

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Investigations

? 10% KOH mount: Pseudohyphae with budding

yeasts seen

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? Vaginal pH is normal (4-4.5)

Treatment

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? Uncomplicated vaginal candidiasis
OTC intravaginal agents
Clotrimazole 1% cream 5 g intravaginally daily for

7-14 days

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Or Miconazole 200 mg vaginal suppository one

suppository for 3 days

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Or Tioconazole 6.5% ointment 5 g intravaginally in

a single application

Oral agent

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Fluconazole 150 mg orally in single dose
Trichomoniasis

? Caused by Trichomonas vaginalis ? a flagellated

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anaerobic protozoan

? Itching / burning sensation with dyspareunia &

dysuria in females

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? Frothy, foul-smelling yellowish-green vaginal

discharge

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? `Strawberry cervix' ? petechiae on cervix
? May also cause upto 11-13% cases of NGU in

males ? usually asymptomatic

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Investigations

? Saline wet mount: motile trichomonads in vaginal

discharge

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? Vaginal pH - >4.5
Treatment

? Recommended regimen

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Metronidazole 2 g orally in a single dose
Or
Tinidazole 2 g orally in a single dose

Bacterial vaginosis

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? A disturbance in vaginal microbial ecosystem
? Caused by a mixed flora - Gardnerella

(Haemophilus) vaginalis, Mycoplasma hominis

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and anaerobes

? Causes grey, homogenous discharge with

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characteristic fishy odour

? Pruritus - not prominent
Diagnosis

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? `Clue cells' - vaginal epithelial cells coated

with Gardnerella vaginalis (at least 20%)

? Whiff test: fishy odour on adding KOH

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? Vaginal pH >4.5

Treatment

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? Recommended regimen
Metronidazole 500 mg orally twice a day for 7 days
OR
Metronidazole gel 0.75%, one applicator (5 g)

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intravaginally, once a day for 7 days

OR
Clindamycin cream 2%, one applicator (5 g)

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intravaginally at bedtime for 7 days
Syndromic Management

? Use of clinical algorithms based on an STI

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syndrome, the constellation of patient

symptoms and clinical signs, to determine

therapy

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? Antimicrobial agents are chosen to cover the

major pathogens responsible for the particular

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syndromes in a geographic area

Essential Components

? Syndromic Diagnosis and Treatment

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? Education on Risk reduction
? Condom Promotion
? Partner Notification
? Counseling
? Follow-up

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Each component is important for control
Advantages

Simple, inexpensive, rapid and implemented

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on large scale

Requires minimum training and used by

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broad range of health providers

Disadvantages

? Algorithm for vaginal discharge has limitations

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e.g., in cases of cervicitis (Chlamydia / gonococci)

? Over diagnosis and over Rx (multiple

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antimicrobials for single infection)

? Selection of resistant pathogens

? Does not address subclinical STI

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Urethral Discharge

Urethral Discharge

Examine for Urethral Discharge: Milking of Urethra

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Discharge seen

No Discharge seen

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Rx for Gonorrhea and Chlamydia

Any other STI

F/u after 7 days

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Use appropriate chart

Cured

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Discharge persists

T/t regimen followed

regimen not followed

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Refer to higher care

Repeat treatment &

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Re-evaluate > 7 days

Genital Ulcer

No

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No

Only vesicles present

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GUD

Educate and counsel

Yes

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Yes

Treat for Herpes

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Treat for Chancroid and Syphilis

Treat for Syphilis if VDRL+

Treat for herpes if prevalence more than 30%

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No

No

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Ulcers healed

Ulcers improving

Refer

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Yes

Yes

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Educate and counsel

Continue for 7 more days
Inguinal Bubo

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Enlarged or painful inguinal lymph nodes

History & examine

No

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Ulcer(s) present

Yes

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Rx for LGV + Chancroid

As in genital ulcer chart

14 Days

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Responding to treatment

No

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Refer to higher care centre

Yes

Presume cured

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Vaginal Discharge/ Itch/ Burning

History

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No

No

Vulvul erythema

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Any other STI

Educate

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Yes

Yes

Appropriate chart

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Lower abdominal pain

Lower abdominal pain chart

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No

Yes

High GC/CT prevalence

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Treat for Gonococci/Chlamydia/

bacterial Vaginosis/Trichomonas

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No

Treat for bacterial

Yes

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Vulvul edema / erythema

Treat for Candida

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Vaginosis

and Trichomonas

No

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Educate
Thank you