Sexually Transmitted Diseases pdf - All Lectures

Sexually Transmitted Diseases
(STDS)

STI versus STD----

• STI – Infections acquired through sexual

intercourse (may be symptomatic or
asymptomatic)

• STD – Symptomatic disease acquired through

sexual intercourse

• STI is most commonly used because it applies

to both symptomatic and asymptomatic
infections

Sexually Transmitted disease
presentation:

o Genital ulcers or sores
o Urethral discharge
o Vaginal discharge
o Lower abdominal pain
o Inguinal bubo
o Scrotal swelling
o Rectal or pharyngeal inflammation
o papules

Types and their pathogenic causes

Disease

Cause

Bacterial

Gonorrhea

Neisseria gonorrhoeae

Vaginitis

Gardnerella vaginalis, Anaerobes

Chancroid

Haemophilus ducreyi

Granuloma inguinale
(Donovanosis)

Calymmatobacterium

granulomatosis

Types and their pathogenic causes

Disease

Cause

Spirochaetes

Syphilis

Treponema pallidum

Chlamydia

Non-specific urethritis

Chlamydia trachomatis type D - K

Lymphogranuloma

venereum

Chlamydia trachomatos type L

1,2,3.

Types and their pathogenic causes

Disease

Cause

Mycoplasma

Pelvic inflammatory

disease

Mycoplasma hominis

Non-specific urethritis

Ureaplasma urealyticum

* Not always sexually transmitted

Types and their pathogenic causes

Disease

Cause

Protozoa

Trichomoniasis

Trichomonas vaginalis

Dysentery*

Entamoeba histolytica

Diarrhoea*

Giardia lamblia

Fungi

Vaginal thrush

Candida albicans

Not always sexually transmitted

Types and their pathogenic causes

Disease

Cause

Ectoparasites

Pubic lice

Phthirius pubis

Genital scabies

Sarcoptes scabiei

Viruses

AIDS

HIV

Genital herpes

Herpes simplex, type 2 (and 1)

Warts

Papilloma viruses types 6,11,16 &

18)

Hepatitis*

Hepatitis B

Gonorrhea

• It is bacterial infection caused by Neisseria

gonorrhoeae a gram- negative, infects columnar or
cuboidal epithelium.

• Site of infection: the organism can survive only in

blood and on mucosal surfaces including the urethra,
endocervix, rectum, pharynx, conjunctiva.

Most

common sites:

Cervix (cervicitis) or vagina in the female
Urethra (urethritis) or penis in the male

• Mode of infection: almost always by sexual intercourse.

Greater efficiency of transmission from male to female

• Gonorrhea can also be spread from mother to child

during birth.

IN MEN:

➢ Urethritis; Epididymitis

➢ Most infections among men are acute and

symptomatic with purulent discharge &
dysuria (painful urination) after 2-5 day
incubation period

➢ The most common cause of urethritis

among men are Neisseria and Chlamydia.

IN WOMEN:

➢ Cervicitis; Vaginitis; Pelvic Inflammatory Disease

(PID); Disseminated Gonococcal Infection (DGI)

➢ Women often asymptomatic ; Often untreated

until PID complications develop.

➢ PID:

• Progressive infection that harms a women’s reproductive

system. Can lead to sterility, ectopic pregnancy and
chronic pain - treated or not.

• Caused by chlamydia and gonorrhea.
• Symptoms - long and painful periods, discharge, low

abdominal pain, fever, chills, nausea, vomiting, pain
during intercourse.

IN WOMEN

(cont.)

➢ Disseminated Gonococcal Infection (DGI):

• Result of gonococcal bacteremia
• Often skin lesions
• Petechiae (hemorrhagic spots)
• Pustules on extremities
• Arthralgias
• Tenosynovitis
• Septic arthritis
• Occasional complications: Hepatitis; Rarely

endocarditis or meningitis

Gonorrhea

Females

1. 50% risk of infection after

single exposure

2. Asymptomatic infections

frequently not diagnosed

3. Genital infection primary

site is cervix (cervicitis),
but vagina, urethra, rectum
can be colonized

4. Ascending infections in 10-

20% including salpingitis,
tubo-ovarian abscesses,
pelvic inflammatory
disease (PID) , chronic
infections can lead to
sterility

Males
1. 20% risk of infection

after single exposure

2. Most initially

symptomatic (95%
acute)

3. Genital infection

generally restricted to
urethra (urethritis) with
purulent discharge and
dysuria

4. Rare complications may

include epididymitis,
prostatitis, and
periurethral abscesses

Gonorrhea

Females
5. Disseminated infections

more common, including
septicemia, infection of
skin and joints (1-3%)

6. Can infect infant at

childbirth (conjunctivitis,
ophthalmia neonatorum)

Males
5. Disseminated infections

are very rare

6. More common in

homosexual/bisexual\
heterosexual

Extragenital gonorrhea:
oRectal Gonorrhea:
oGonococcal Pharyngitis:
oDisseminated Gonococcal Infection (Arthiritis-Dermatitis
Syndrome):

Gonococcal Urethritis

Diagnosis:

• Gram's stain: the presence of intracellular

diplococci within polymorphonuclear
leukocytes→presumptive diagnosis

• Culture →gold slandered for diagnosis
• Nucleic acid amplification tests: have high

sensitivity, and they also test for C.trachomatis.

• serologic test: non-available; all patients should

have a serologic test for syphilis and HIV.

Treatment

• the standard therapy recommended in

uncomplicated infections of the urethra,
cervix, rectum, or pharynx in nonpregnant
adults is a single dose of 250mg of ceftriaxone

Plus (if Chlamydia is not Ruled Out ).
• Azithromycin 1 g in a single dose or
• Doxycycline 100 mg twice daily for 7 days

Treatment

• Alternative:
• Spectinomycin 2g IM in one dose
• Ciprofloxacin 500mg orally in one dose
• Norfloxacin 800mg orally in one dose
• Cefotaxime 1g in one dose
(To all these: Plus if Chlamydia is not Ruled Out ).
• Azithromycin 1 g in a single dose or
• Doxycycline 100 mg twice daily for 7 days

Nongonococcal Urethritis (NGU)

• The diagnosis, as the name implies, used to be one of

exclusion. Any urethral inflammation not caused by
gonorrhea

Organisms:
• Genital chlamydial is responsible for about half of NGU
• Ureaplasma urealyticum and mycoplasma genitalium

cause 10-30% of NGU

• Herpes viruses, T. vaginalis, haemophilus species, and

anaerobic bacteria account less than 10% of cases

• One third of cases, no infectious cause can be found.

males. NGU begins 7-28 days after sexual contact with
a smarting sensation while urinating and a mucoid
discharge.

females. The sign and symptoms in females are
more nonspecific; may be present mucopurulent
discharge.
Treatment: azithromycin 1gm orally in a single
dose or doxycycline 100mg orally twice a day for 7
days. Alternative: erythromycin 500mg orally four
times a day for 7 days.

Nongonococcal Urethritis

Gonococcal
urethritis

NGU

3-5 days

7-28 days

Incubation
period

Abrupt

gradual

Onset

Burning

Smarting feeling

dysuria

Purulent

Mucoid or purulent

discharge

Gram-negative
intracellular
diplococci

Polymorphonuclear
leukocytes

Gram stain

Syphilis

• Also known as lues, is a contagious, sexually-

transmitted disease caused by the spirochete

Treponema Pallidum.

• The spirochete enters through the skin or mucous

membranes, on which the primary

manifestations are seen

• In congenital syphilis the treponema crosses the

placenta and infects the fetus.

• Route of infection: sexual contact (most

important); congenital; acquired by transfusion of

blood; accidental

Stages (untreated syphilis)

Primary S: localized infection at site of inoculation

(chancre)

Secondary S: disseminated infection

Latent S: no clinical sign or symptoms (seropositive)

-Early latent S: less than one year duration
-Late latent S: greater than one year duration
4.       Syphilis of unknown duration
5.       Late (tertiary) S: cutaneous, vascular, neurologic findings
6.       Congenital S: acquired in utero
Risk of transmission: during primary, secondary, and early

latent stages of disease. The patient is most infectious

during the first and second year of infection

Primary Syphilis; Chancre (primary stage)

• Primary syphilis manifests as a single, painless, clean-

based ulcer . Chancres are usually solitary.

• The lesion usually appears within 3 weeks of

infection (can range from 10-90 days)

• In women the labia and vagina wall are most often

affected, but the cervix may also be involved

• In men: glans of penis, penile shaft, or scrotum
• Can also occur on lips or tongue (infected orally) or in

rectum/anus (infected through anal intercourse)

Primary Syphilis; Chancre (primary stage)

• Non tender regional adenopathy.
• On palpation between two fingers, a cartilage-

hard consistency is sensed

Glans of penis

labia

Course: if left untreated heal spontaneously with scarring
in 3-6 weeks and secondary syphilis appear
Diagnosis: clinical suspicion, conformed by dark filed
examination. Serologically negative.
DD: any genital lesion, primary syphilis should be
considered until ruled out clinically and by specific test

Chancre & Chancroid

chancre

chancroid

Cause

Spirochete in
the serum

Ducrey bacillus in the smear

incubation

3 weeks

4-7 days

Pain

painless

Painful

inflammation

Has no
surrounding
inflammator
y zone

large surrounding

inflammatory zone

Edge

It is not
undermined

It is undermined

Lesions

Usually
single

Multiple

palpation

Cartilage
hard

Soft to the touch

The surface

Has dark,
velvety red
without
membrane

Yellowish red with membrane

adenopathy

Bilateral
usually

Usually unilateral

Secondary syphilis

➢ Appears 2-6 months after primary infection and 2-10

weeks after primary chancre.

➢ Lesions: Usually diffuse non-pruritic, indurated rash,

including palms & soles.

➢ the lesions of secondary S have certain characteristics

that differentiate them from other cutaneous diseases:

• There is little or no fever at the onset
• Lesions are noninflammatory, develop slowly, and may

persist for weeks or months

• Pain or itching is minimal or absent
• There is a marked tendency to polymorphism
• Color resembling a "clean-cut ham" or having a

coppery tint

• Lesions have variety of shapes

Types of lesions:

• Macular eruption
• Papular eruption
• Papulosquamous syphilids
• Follicular or lichenoid syphilids
• Annular syphilids

• Condylomata lata: Formed by coalescence of large, pale, flat-

topped papules. Occur in warm, moist areas such as the
perineum. Highly infectious. often mushroom-like mass. They are
not covered by the digitate elevations characteristic of venereal
warts (condylomata acuminata). This later is true verruca,
caused by human papillomavirus.

• Mucosal lesions: ~ 30% of secondary syphilis patients develop

mucous patch

• Note. All cutaneous lesions of secondary syphilis are infectious;

therefore, if you do not know what is, do not touch. Cellular
immune processes are responsible for the cutaneous
manifestations of secondary syphilis.

Alopecia areata

Diagnosis. Clinical suspicion confirmed by dark-filed
examination and\or serology (STS).
DD. syphilis has long been known as the 'great imitator'
because the various cutaneous manifestation may
simulate almost any cutaneous or systemic disease.

The rash may be confused with:
Pityriasis rosea (usually has a herald patch and lesions
seen along lines of skin cleavage)
Drug eruptions
Acute febrile exanthems
Psoriasis
Lichen planus
Scabies
The mucous patch may be confused with oral thrush

Latent Syphilis

• During this latent period there are no clinical

signs of syphilis, but the serologic tests are
reactive. During the early latent period
infectivity persists: for at least 2 years a
women with early latent S may infect her
unborn child.

• Is divided into early (less than one year

duration) and late (greater than one year
duration).

Tertiary Syphilis

• Tertiary S most often occur 3-5 years after infection.

16% of untreated patients will develop tertiary lesions
of the skin, mucous membranes, bone, or joints and
heal with scarring

• Treponema are usually not found by darkfiled

examination. Systemic disease also develop including
cardiovascular disease, CNS lesions.

• Two main types; Nodular syphilid and the Gumma
• Diagnosis: clinical finding, confirmed by STS and

biopsy; darkfiled examination is always negative.

• DD: TB, malignancy, lymphoma.

Congenital Syphilis

• Prenatal syphilis acquired in utero

• Infection through the placenta usually does not occur

before the fourth month, so treatment of the mother

before this time will almost always prevent infection in

the fetus.

• If infection occurs after the fourth month 40% risk of

fetal death

Most neonates with congenital syphilis are normal at

birth.

• Early congenital syphilis; lesions occurring within first

two years of life

• Late congenital syphilis; lesion occur after two years

Early Congenital Syphilis

• Neonates is usually premature, marasmic, fretful,

and dehydrated. The face is pinched and drawn,
resembling that an old man or women.
Multisystem disease is characteristic

• Snuffles, a form of rhinitis, is the most frequent

and often the first specific finding. In persistent
and progressive cases ulceration develop that
may involve the bones and cause perforation of
the septum or development of saddle nose,
which are important stigmata later in the disease

• Cutaneous lesions, resemble those of acquired

secondary S. with exaggeration

Late Congenital Syphilis

• Symptoms and signs of late congenital S become more

evident after age 5 years. The most important signs are:

➢ Frontal bosses (bony prominences of the forhead).
➢ Saddle nose
➢ Short maxilla
➢ High arched palate
➢ Mulberry molars (more than four small cusps on a narrow

first lower molar of the second dentition).

➢ Hutchinson's teeth (peg-shaped upper central incisors of

the permanent dentition that appear after age 6 years)

Late Congenital Syphilis

➢Higouménaki's sign (unilateral enlargement of

the sternoclavicular portion of the clavicle as
end result of periostitis)

➢Rhagades (linear scars radiating from the

angle of the eyes, nose, mouth, and anus)

➢Hutchinson's triad (Hutchinson's teeth,

interstitial keratitis, and cranial nerve V111
deafness) is considered pathognomonic of late
congenital syphilis.

Serologic Tests for Syphilis

There are two types of STS
• Nontreponemal test or classic reaction:

detects antibodies against phospholipids
antigens

• Treponemal test or specific test: detects

antibodies direct against T.Pallidum.

The use of one type is not sufficient for

diagnosis

Nontreponemal test

• Correlate with disease activity (reported

quantitatively);

• they are:
• Rapid plasma reagin (RPR).
• Veneral disease research laboratory (VDRL).

Treponemal test

• Correlate poorly with disease activity.
• Remains positive lifetime, regardless of

treatment.

• They are:
• Microhemagglutination assay for T.pallidum

(MHA-TP)

• Fluorescent treponemal antibody absorption

(FTA-ABS)

• T-pallidum particle agglutination (TP-PA)

Biologic False-Positive Tests Results (BFP)

The term BFP is used to denote a positive STS in

persons with no history or clinical evidence of
syphilis; two types:

• Acute BFP reactions are defined as those that

revert to negative in less than 6 months, may
result in; vaccinations, pregnancy, infections
(hepatitis, measles, typhoid, varicella, influenza,
malaria)

• Chronic BFP reactions positive test persist for

more than than 6 months, seen in: connective
tissue diseases, chronic liver disease, multiple
blood transfusion, and advancing age.

Treatment

• Penicillin remains the drug of choice for treatment of

all stages of syphilis.

Patients with primary, secondary, or early latent syphilis

of less than 1 year duration:

recommended treatment: Benzathine penicillin G. 2.4

million units IM in one dose.

alternative treatment in nonpregnant, penicillin allergic:
• Tetracycline 500mg orally four times a day for 2 weeks
• Doxycycline 100mg orally twice a day for 2 weeks.
• Ceftriaxone 1g IM or IV for 8-10 days
• Azithromycin 2g as a single oral dose

Treatment

Patients with late latent syphilis of more than one year

duration

• recommended treatment: Benzathine penicillin G. 2.4

MU IM once a week for 3 weeks

alternative treatment in nonpregnant, penicillin allergic:
• Tetracycline 500mg orally four times a day for 30 days
• Doxycycline 100mg orally twice a day for 30 days
Pregnant women with syphilis should be treated with

penicillin in doses appropriate for the stage of

syphilis. Pregnant women who allergic to penicillin

should be skin tested and desensitized if test results

are positive.

CHANCROID (Venereal/Soft Sore)

▪ Tropical sexually transmitted disease caused by Haemophillus

ducreyi, a gram negative bacterium.

▪ It is endemic in Africa, Asia and South America
▪ Men outnumber women many fold.
▪ After a one week incubation period a papule develops which

becomes a pustule and then an ulcer, which is
characteristically very painful.

▪ One or more deep or superficial tender ulcer on the genitalia,

and painful adenitis in 50% which may suppurate, are
characteristic of the disease.

▪ 50% of cases have a painful adenopathy with development of

bubos - inflamed lymph nodes with pus and necrosis, fixed to
the skin. There is no systemic component

CHANCROID (Venereal/Soft Sore)

• Diagnosis: the combination of a painful ulcer

with tender inguinal adenopathy is suggestive,
and when accompanied by suppurative
inguinal adenopathy , is almost
pathognomonic.

• In the absence of treatment, the chancroid

lesion can persist for months to years.

• Treatment is with cotrimoxazole or

erythromycin.

Granuloma Inguinale

• Granuloma inguinale is a mildly contagious, chronic,

granulomatous, locally destructive disease characterized by

progressive, indolent, serpiginous ulcerations of the groins,

pubes, genitalia, and anus.

• No adenopathy. Inguinal swellings are not lymphadenitis

but represent subcutaneous perilymphatic granulomatous

lesions

• Etiology: Granuloma inguinale is caused by the Gram-

negative bacterium Calymmatobacterium granulomatosis

• The exact mode of transmission of infection is

undetermined. Venereal but also nonvenereal transmition

occurs

Granuloma Inguinale

• Preferred treatment:

– Doxycycline 100 mg twice a day for 3 weeks

• Alternate Treatments:

– Azithromycin 1 gm weekly for 3 weeks
– Ciprofloxacin 750 mg twice a day for 3 weeks
– Erythromycin 500 mg four times a day for 3 weeks

LYMPHO GRANULOMA VENEREUM

is a tropical sexually transmitted disease

caused by Chlamydia trachomatis

• Endemic in Africa, India, SE Asia, South

America and the Caribbean,

• Men affected more commonly than

women, principally between the age 20

to 30 years.

LYMPHO GRANULOMA VENEREUM

• Three stages to the disease:
1) An asymptomatic ulcer which resolves rapidly
2) An inguinal syndrome, between 1 week and 6

months later, with adenopathy (lymph nodes are

painful) and bubo development.

• There is often systemic illness and malaise
3) Proctocolitis regional abscess or fistula,

resulting in regional strictures, e.g. rectal

strictures

• Diagnosis is by serology and intradermal skin test

with LGV antigen - Frei's test.

• Treated with tetracyclines or erythromycin.

CHANCROID (Venereal/Soft Sore)

Granuloma Inguinale

LYMPHO GRANULOMA VENEREUM