Download Sexually Transmitted Diseases (STD)

Sexually Transmitted Diseases *
(STDS)
* Sexually Transmitted
Diseases (STD)
Very important entity of diseases all
result from sex problems (abnormal
or illegal) and since there is a strong
association between venereal
diseases and dermatology; we –will
study this subject in dermatology,
also because patient with venereal
diseases may present initially to
dermatological clinics.
*Pathogens:
*
Bacterial:
* Neisseria Gonorrhoeae →Gonorrhea
* Chlamydia Trachomatis →Trachoma
* Mycoplasma Hominis →Post Partum Fever
* Ureaplasma Urealiticum→Non-gonococcal urethritis
* Mycoplasma Genitalium→ Non-gonococcal urethritis
* Treponema Pallidum→Syphilis
* Gardnerella Vaginalis→Bacterial Vaginosis
* Haemophilius Ducreyi→Chancroid
* Shigella→Shigellosis in homosexual
*
Viruses:
* HIV→AIDS
* Herpes Simplex→ Genital Herpes Simplex
* Human Papillomavirus→Condyloma accuminata, laryngeal
papilloma, vulvar papilloma, carcinoma
* Hepatitis B,C→acute or chronic hepatitis,
* Epstein-Barr virus (EBV)→infectious mononucleosis
* Poxvirus→ molluscum contagiosum
* Cytomegalovirus (CMV)→retinitis,colitis,encephalitis (HIV)
* Human herpesvirus→Kaposi sarcoma
* Parasitic:
* Entamoeba histolytica→Amebiasis cutis
* Trichomonas vaginalis→Trichomoniasis
* Pthirius pubis→pediculosis pubis
* Sarcoptes scabiei→scabies
* Fungi: Candida albicans→candidiasis
* Clinical manifestations
→localized
→systemic
*Localized manifestations:
* Pruritus: Causes of itching: scabies, pediculosis pubis,
trichomoniasis, candida albicans,
* Ulcer on genitalia: syphilis, chancroid, herpes, lymphogranoloma
venerum,
* Mass on genitalia: venereal wart (condylomata acuminate),
syphilitic condylomata lata, molluscum contagiosum
* Discharge: urethral (Gonorrhea, non-specific urethritis,
Escherichia coli, candidiasis)
* Systemic manifestations:
* Secondary rash of syphilis
* Jaundice (hepatitis virus): generalized itching
* AIDS
* Disseminated gonorrhea
*
*Gonorrhea
* It is bacterial infection caused by Neisseria gonorrhoeae a gramnegative, 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, and prepubertal vaginal tract. It does not
survive on the stratified epithelium of the skin and postpubertal
vaginal tract. It can disseminated locally and systemically.
* Mode of infection: almost always by sexual intercourse.
* Diagnosis:
1. Gram's stain: the presence of intracellular diplococci within
polymorphonuclear leukocytes→presumptive diagnosis
2.
3.
culture →gold slandered for diagnosis
4.
serologic test: non-available; all patients should have a
serologic test for syphilis and HIV.
Nucleic acid amplification tests: have high sensitivity, and
they also test for C.trachomatis.
* Genital Infection In Males
* Urethritis: after a 3-5 days incubation period, most infected men
have a sudden onset of burning, frequent urination, and a yellow
thick, purulent urethral discharge.
* Some of patients have long period of incubation and they then
complain only of mild dysuria with a mucoid urethral discharge as
observed in nongonococcal urethritis or become chronic carriers,
acting as women without symptoms.
* Complications: epididymitis, seminal vesiculitis, and prostatitis.
* Genital Infection In Females
* The majority of female with gonorrhea are asymptomatic.While
the urethra and rectum are often involved, the locus of infection
is endocervix.
* Cervicitis: may appear normal or with nonspecific pale yellow
vaginal discharge or it may show marked inflammatory changes
with erosions and pus exuding from the ostium Skene's glands,
which lie on either side of the urinary meatus.
* Urethritis: begins with variable intensity of frequency and
dysuria.
* Bartholin Ducts: the Bartholin ducts, which open on the inner
surfaces of the labia minora near the vaginal opening, if
infected, show a drop of pus at the gland orifice.
* After occlusion of the infected duct, the patient complains of
swelling and discomfort while walking or sitting.
* Pelvic Inflammatory Disease (PID)
* PID or salpingitis, is infection of the uterus, fallopian tubes, and
adjacent pelvic structures. Organism spread to these from the
cervix and vagina. most cases caused by C. trachomatis and\or N.
gonorrhoeae
* Other causes: microorganism of the normal vaginal flora,
micoplasma hominis and ureaplasma urealyticum.
* Risk factors: age (under 20) years, previous PID, vaginal
douching, and bacterial vaginosis.
* Clinical presentation: symptoms range from minimal lower
abdominal pain usually bilateral to severe pain accompanied by
peritoneal signs. PID is an important cause of infertility.
* Extragenital Gonorrhea
* Rectal Gonorrhea: is acquired by anal intercourse or by
contamination from genital gonorrhea.
Gonococcal Pharyngitis: gonococcal pharingitis is acquired by
oral exposure and rarely by kissing. Most cases are asymptomatic.
* Disseminated Gnonococcal Infection (Arthiritis-Dermatitis
Syndrome): DGI is the most common cause of acute septic
arthritis in adult. The classic triad is dermatitis, tenosynovitis,
and migratory polyarthritis.
* 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 doxycycline 100mg
twice daily for 7 days (for Chlamydia).
* Alternative:
* Spectinomycin 2g IM in one dose
* Ciprofloxacin 500mg orally in one dose
* Norfloxacin 800mg orally in one dose
* Ceftizoxime 500mg IM in one dose
* Cefotaxime 1g in one dose
* To all these doxycycline 100 mg twice daily for 7 days.
* Nongonococcal Urethritis (NGU)
* The diagnosis, as the name implies, used to be one of exclusion.
* 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.
* Nongonococcal Urethritis in males. NGU
begins 7-28 days after sexual contact with a
smarting sensation while urinating and a
mucoid discharge.
NGU
Gonococcal urethritis
Incubation period
7-28 days
3-5 days
Onset
gradual
Abrupt
dysuria
Smarting
feeling
Burning
discharge
Mucoid
purulent
Gram stain
Polymorphonuc
lear leukocytes
or
Purulent
Gram-negative
diplococci
intracellular
Nongonococcal Urethritis in 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.
* Reiter Syndrome (Reactive Arthritis with
Conjunctivitis\Urethritis\Diarrhea): the syndrome is a
characteristic clinical triad of urethritis, conjunctivitis, and
arthritis. The skin involvement commonly begins with small
guttate, hyperkeratotic, crusted, or pustular of the genitals,
palms, or soles.
Syphilis*
*Syphilis
*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 ar
seen. In congenital syphilis the treponema crosses
the placenta and infects the fetus.
*Routes of infection:
*1) sexual contact (most important)
*2) congenital
* 3)acquired by transfusion of blood
* 4)accidental
* Stages (untreated syphilis)
1.
2.
3.
4.
5.
6.
7.
8.
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
Syphilis of unknown duration
Late (tertiary) S: cutaneous, vascular, neurologic
findings
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); after an incubation
period of 10-90 days chancre develop; it is a
acquired by direct contact with an infectious
lesion of the skin or the moist surface of the
mouth, anus, or vagina. Chancres are usually
solitary, but multiple lesions are not
uncommon.
*
*The lesions begins as a papule that undergo
ischemic necrosis and erodes, forming a 0.32.0cm, painless, hard, indurated ulcer; the
base is clean, with serous discharge. On
palpation between two fingers, a cartilage-hard
consistency is sensed. The regional lymph nodes
on one or both sides are enlarged.
*Diagnosis: clinical suspicion, conformed by
dark filed examination.
*DD: any genital lesion, primary syphilis should
be considered until ruled out clinically and by
specific test.
Cause
incubation
Pain
inflammation
Edge
Lesions
palpation
The surface
adenopathy
chancre
Spirochete in
the serum
3 weeks
painless
Has no
surrounding
inflammatory
zone
It is not
undermined
Usually single
Cartilage hard
chancroid
Ducrey bacillus in the smear
Has dark,
velvety red
without
membrane
Bilateral
usually
Yellowish red with membrane
4-7 days
Painful
large surrounding inflammatory
zone
It is undermined
Multiple
Soft to the touch
Chancre & Chancroid *
Usually unilateral
* Course: if left untreated heal spontaneously
with scarring in 3-6 weeks and secondary
syphilis appear
*Secondary syphilis
*Cutaneous lesions: also called syphilids, appears 2-6
months after primary infection and 2-10 weeks after
primary chancre.
*Lesions: 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
* Types of lesions:
* Macular eruption. The most common. The
appearance of an exanthematic erythema extends
rapidly; appears on the sides of the trunk, about
the navel, and on the inner surfaces of the
extremities.
* Papular eruption. The most common and also most
easily recognized. Papules are distributed on the
face, flexures of the arms and lower legs, over the
trunk, and classically there are lesions on the palms
and soles.
* Split papules are hypertrophic , fissured
papules that form in the creases of alae nasi
and at the oral commissures.
* Papulosquamous syphilids. sometimes have
features of psoriasiform eruption.
* Follicular or lichenoid syphilids.
* Annular syphilids like sarcoidosis
*Condylomata lata is a papular, relatively broad and flat,
located on folds of moist skin, especially about the genitalia
and anus; they may become hypertrophic and, instead of
infiltrating deeply, protrude above the surface, forming a
soft, red, often mushroom-like mass. They are not covered
by the digitate elevations characteristic of venereal warts
(condylomata acuminate). This later is true verruca,
caused by human papillomavirus.
*Syphilitic alopecia is irregularly distributed so that the
scalp has a moth-eaten appearance.
*Mucous membrane. The most common mucosal lesion is
syphilitic sore throat, diffuse pharyngitis that may be
associated with tonsillitis or laryngitis. Mucous patches
which are macerated, teem with treponema, on the tonsils,
tongue, gums, lips, or in the genitalia.
* Systemic involvement generalized lymphadenopathy
* 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.
* 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.
* 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.
* Tertiary Cutaneous 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: noduloulcerative syphilid and
the gumma.
* Gumma (latin: Gum), the term describes the
rubbery lump or deep granulomatous lesion,
found in the subcutaneous tissue, having a
tendency for necrosis and ulceration.
* Diagnosis: clinical finding, confirmed by STS
and biopsy; darkfiled examination is always
negative.
* DD: TB, malignancy, lymphoma.
* Congenital Syphilis
* Prenatal S is acquired in utero from the
mother, who usually has early syphilis.
Transmission of the T. pallidum across the
placenta may occur at any age of pregnancy,
but the lesions generally develop after the
fourth month of gestation, when fetal
immunologic competence begins to develop; so
treatment of the mother prior to this time will
almost always prevent infection in the fetus.
* In untreated cases, may appear: (1) stillbirth
(2) infants die shortly after birth (3) without
symptoms at birth, but will have late
symptomatic congenital syphilis a few weeks
after birth or at puberty; for this reason
prenatal syphilis is divided into early and late
congenital syphilis.
* Early Congenital Syphilis
* Early Congenital Syphilis is defined as syphilis acquired in utero
that becomes symptomatic during the first 2 years of life.
* -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. (the destructive
effects of syphilis often leave scars or development defects
called stigmata)
* -Cutaneous lesions of congenital S 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)
* 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
1) Nontreponemal test or classic reaction: detects
antibodies against phospholipids antigens
2) 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) and venereal disease research
laboratory (VDRL)
* -Treponemal test correlate poorly with disease
activity and remains positive lifetime,
regardless of treatment; they are:
* Microhemagglutination assay for T.pallidum
(MHA-TP)
* Fluorescent treponemal antibody absorption(FTAABS)
* 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
*
* Treatment
* Penicillin remains the drug of choice for
treatment of all stages of syphilis.
1) 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
* 2)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
* 3) 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 (Soft Chancre)
* It is an infectious, ulcerative, STD caused by the
Gram-negative bacillus Haemophilus ducreyi (
the Ducrey bacillus).
* One or more deep or superficial tender ulcer on
the genitalia, and painful adenitis in 50% which
may suppurate, are characteristic of the disease.
Men outnumber women many fold.
* After an incubation period of 3-5 days, a
painful, red papule appears at the site of
contact and rapidly becomes pustular and
ruptures to form an irregular-shaped ulcer with
a red halo. The ulcer is deep, bleeds easily,
and spread laterally, burrowing under the skin
and giving the lesion an undermined edge. The
ulcers are highly infectious, and multiple
lesions appear on the genitals from
autoinoculation, heal with scarring.
* Unilateral or bilateral inguinal lymphadenopathy develops , after
1 week of the onset of disease, and may rupture spontaneously.
* Diagnosis: the combination of a painful ulcer with tender
inguinal adenopathy is suggestive, and when accompanied by
suppurative inguinal adenopathy , is almost pathognomonic.
* Probable diagnosis is made when all the following criteria are
met:
* One or more painful genital ulcers are present
* There is no evidence of T.pallidum infection
* The clinical features of chancroid
* A test result for herpes simplex is negative
* DD: most frequent mistaken is herpes progenitalis which have
recurrent grouped vesicles at the same time
* Treatment:
* -recommended: one dose of either azithromycin
1gm orally or ceftriaxone 250mg IM.
* -alternative: ciprofloxacin 500mg orally twice
daily for 3 days
* Erythromycin 500mg four times daily for 7 days
* Granuloma Inguinale (Donovanosis)
* Granuloma inguinale is a mildly contagious, chronic, granulomatous,
locally destructive disease characterized by progressive, indolent,
serpiginous ulcerations of the groins, pubes, genitalia, and anus.
* -The disease begins as single or multiple subcutaneous nodules,
which erode through the skin to produce clean, sharply defined
lesions, which are usually painless.
* -Inguinal swellings are not lymphadenitis but represent
subcutaneous perilymphatic granulomatous lesions that may
eventually break through the skin, causing sinus formation.
Complications include elephantiasis, stricture, and pelvic
abscess.
* Site: genitalia (90%), inguinal (10%), anal (1-5%).
* The incubation time is unknown, 2-3 weeks most common.
* Etiology: Granuloma inguinale is caused by the Gram-negative
bacterium klebsiella granulomatis. The exact mode of
transmission of infection is undetermined. Venereal but also
nonvenereal transmition occurs.
* Diagnosis is confirmed by finding the organism (Donovan bodies)
in the lesions, will be found within mononuclear cells.
* DD: granuloma inguinale may be confused with ulceration of the
groin caused by syphilis or carcinoma, but it is differentiated
from these disease by its long duration and slow course, by the
absence of lymphatic involvement, and, in the case of syphilis,
by a negative test and failure to respond to antisyphilitic
treatment.
* Recommended Treatment:
* Trimethoprim-sulfamethoxazole, one tablet
orally twice a day
* Doxycycline, 100mg orally twice a day
* Alternative Treatment:
* Ciprofloxacin, 750mg orally twice a day
* Erythromycin 500mg four times a day
* Azithromycin, 1g orally once a week
* -All for 3 weeks
Thank you
Thank you*