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Sexually Transmitted Diseases
Prof.Dr.Fehmi Tabak
Cerrahpasa Medical Faculty
Department of Infectious Diseases
8 Aralık 2010
Topics
• Background Information
• “Sores”
• “Drips”
• Role of STDs in HIV Transmission
2
Background Information
3
Background
Epidemiology
4
Syndromes
•
•
•
•
•
Urethritis
Genital ulcer adenopathy syndrome
Mucopurulent cervicitis
Pelvic inflamatuar diseases (PID)
Vaginitis
Background
STDs of Concern
• “Sores” (ulcers)
– Syphilis
– Genital herpes (HSV-2, HSV-1)
– Others uncommon in the Turkey
• Lymphogranuloma venereum
• Chancroid
• Granuloma inguinale
6
Background
STDs of Concern (continued)
• “Drips” (discharges)
–
–
–
–
–
–
Gonorrhea
Chlamydia
Nongonococcal urethritis
Mucopurulent cervicitis
Trichomonas vaginitis / urethritis
Candidiasis (vulvovaginal, less problems in men)
• Other major concerns
– Genital HPV (especially type 16, 18) and Cervical
Cancer
7
“Sores”
Syphilis
Genital Herpes (HSV-2, HSV-1)
8
Genital Ulcer Diseases –
Does It Hurt?
Sores
• Painful
– Chancroid
– Genital herpes simplex
• Painless
– Syphilis
– Lymphogranuloma venereum
– Granuloma inguinale
9
Primary Syphilis - Clinical
Manifestations
Sores
• Incubation: 10-90 days (average 3 weeks)
• Chancre
– Early: macule/papule  erodes
– Late: clean based, painless, indurated ulcer with
smooth firm borders
– Unnoticed in 15-30% of patients
– Resolves in 1-5 weeks
– HIGHLY INFECTIOUS
10
Primary Syphilis
-Chancre
-LAP
Sores
11
Secondary Syphilis - Clinical
Manifestations
Sores
• Represents hematogenous dissemination of
spirochetes
• Usually 2-8 weeks after chancre appears
• Findings:
–
–
–
–
rash - whole body (includes palms/soles)
mucous patches
condylomata lata - HIGHLY INFECTIOUS
constitutional symptoms
• Sn/Sx resolve in 2-10 weeks
12
Secondary Syphilis
•
•
•
•
•
•
•
•
Rash
Generalized LAP
Condylomata lata
CNS involvement
Fever
Glomerulonephritis
Hepatitis
Artralgia
Sores
Secondary Syphilis Rash
Source: Florida STD/HIV Prevention Training Center
14
Sores
Secondary Syphilis: Generalized
Body Rash
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
15
Sores
Secondary Syphilis Rash
Source: Florida STD/HIV Prevention Training Center
16
Sores
Secondary Syphilis Rash
Source: Cincinnati STD/HIV Prevention Training Center
17
Sores
Secondary Syphilis
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas
18
Secondary Syphilis –
Condylomata Lata
Source: Florida STD/HIV Prevention Training Center
Sores
19
Tersier and late syphilis
• Gom (Syphilitic
granulomas)
• CNS and CVS
involvement
Syphilis
• Latent syphilis
Serology (+), Clinic (-)
Varies from several months to several years
More duration less infectivity
Early (<2 years) Late (>2 years)
• Neurosyphilis
Any neurological symptom or sign
Syphilis - Diagnose
• Dark field
microscopy
• Serology
Syphilis - Diagnose
• Non-spesific
serological tests
• VDRL
• RPR
• Spesific serological
tests
•
•
•
•
FTA-ABS
TPHA
MHA-TP
ELISA
- The only positive thing of my life
is my VDRL test!!!
Sores
Genital Herpes Simplex - Clinical
Manifestations
• Direct contact – may be with
asymptomatic shedding
• Primary infection commonly
asymptomatic; symptomatic
cases sometimes severe,
prolonged, systemic
manifestations
• Vesicles  painful ulcerations
 crusting
• Recurrence a potential
• Diagnosis:
–
–
–
–
Tzanck smear
Culture
Serology (Western blot)
PCR
24
Sores
Epidemiology of Genital Herpes
• One of the 3 most common STDs, increased 30%
from late 70s to early 90s
• 25% of US population by age 35
• HSV-2: 80-90%, HSV-1: 10-20% (majority of
infections in some regions)
• Most cases subclinical
• Transmission primarily from subclinical infection
• Complications: neonatal transmission, enhanced
HIV transmission, psychosocial issues
25
Sores
Genital Herpes Simplex
26
Sores
Genital Herpes Simplex in Females
Source: Centers for Disease Control and Prevention
27
“Drips”
Gonorrhea
Nongonococcal urethritis
Chlamydia
Mucopurulent cervicitis
Trichomonas vaginitis and urethritis
Candidiasis
28
Drips
Gonorrhea - Clinical Manifestations
• Urethritis - male
–
–
–
–
Incubation: 1-14 d (usually 2-5 d)
Sx: Dysuria and urethral discharge (5% asymptomatic)
Dx: Gram stain urethral smear (+) > 98% culture
Complications
• Urogenital infection - female
–
–
–
–
Endocervical canal primary site
70-90% also colonize urethra
Incubation: unclear; sx usually in l0 d
Sx: majority asymptomatic; may have vaginal discharge,
dysuria, urination, labial pain/swelling, abd. pain
– Dx: Gram stain smear (+) 50-70% culture
– Complications
29
Urethritis
Gonococcic
IP
2-7 days
Nongonococcic
10-21 days
Initial
Acute
Subacute
Discharge
Yellow,
profuse
Moderate
Less, açık
renkli
Mild
Dysuria
Urethral discharge
Drips
Gonorrhea
Source: Florida STD/HIV Prevention Training Center
32
Drips
Gonorrhea Gram Stain
Source: Cincinnati STD/HIV Prevention Training Center
33
Drips
Nongonococcal Urethritis
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas
34
Drips
Nongonococcal Urethritis
• Etiology:
– 20-40% C. trachomatis
– 20-30% genital mycoplasmas (Ureaplasma
urealyticum, Mycoplasma genitalium)
– Occasional Trichomonas vaginalis, HSV
– Unknown in ~50% cases
• Sx: Mild dysuria, mucoid discharge
• Dx: Urethral smear  5 PMNs (usually 15)/OI
field
Urine microscopic  10 PMNs/HPF
Leukocyte esterase (+)
35
Drips
Chlamydia Life Cycle
Source: California STD/HIV Prevention Training Center
36
Drips
Chlamydia trachomatis
• Responsible for causing:
–
–
–
–
–
Cervicitis,
Urethritis
Proctitis
Lymphogranuloma venereum
Pelvic inflammatory disease
• Potential to transmit to newborn during delivery
– Conjunctivitis, pneumonia
37
Lymphogranuloma venereum
LGV
GROOVE’ s SIGN
Drips
Normal Cervix
Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center
39
Drips
Chlamydia Cervicitis
Source: St. Louis STD/HIV Prevention Training Center
40
Drips
Mucopurulent Cervicitis
Source: Seattle STD/HIV Prevention Training Center
41
Drips
Laboratory Tests for Chlamydia
• Tissue culture has been the standard
– Specificity approaching 100%
– Sensitivity ranges from 60% to 90%
• Non-amplified tests
– Enzyme Immunoassay (EIA), e.g. Chlamydiazyme
• sensitivity and specificity of 85% and 97% respectively
• useful for high volume screening
• false positives
– Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2
• sensitivities ranging from 75% to 100%; specificities greater than
95%
• detects chlamydial ribosomal RNA
• able to detect gonorrhea and chlamydia from one swab
• need for large amounts of sample DNA
42
Drips
Laboratory Tests for Chlamydia
(continued)
• DNA amplification assays
– polymerase chain reaction (PCR)
– ligase chain reaction (LCR)
• Sensitivities with PCR and LCR 95% and 8598% respectively; specificity approaches 100%
• LCR ability to detect chlamydia in first void urine
43
Drips
Chlamydia Direct Fluorescent Antibody
(DFA)
Source: Centers for Disease Control and Prevention
44
Drips
Pelvic Inflammatory Disease (PID)
• l0%-20% women with GC develop PID
• In Europe and North America, higher proportion of C. trachomatis
than N. gonorrhoeae in women with symptoms of PID
• CDC minimal criteria
– uterine adnexal tenderness, cervical motion tenderness
• Other symptoms include
– endocervical discharge, fever, lower abd. pain
• Complications:
– Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia
– 7X risk of ectopic pregnancy with 1 episode PID
– chronic pelvic pain in 18%
45
HPV and Cervical Cancer
46
HPV and Cervical Cancer
HPV and Cervical Cancer
• Infection is generally indicated by the
detection of HPV DNA
• HPV infection is causally associated with
cervical cancer and probably other anogenital
squamous cell cancers (e.g. anal, penile,
vulvar, vaginal)
• Over 99% of cervical cancers have HPV DNA
detected within the tumor
• Routine Pap smear screening ensures early
detection (and treatment) of pre-cancerous
lesions
47
HPV and Cervical Cancer
Estimates for HPV-Associated Cancers
• Cervical cancer:
– In the U.S., an estimated 14,000
cases and 5,000 deaths
– Worldwide, an estimated 450,000
cases and 200,000 deaths
48
HPV and Cervical Cancer
Perianal Wart
Source: Cincinnati STD/HIV Prevention Training Center
49
HPV and Cervical Cancer
HPV Penile Warts
Source: Cincinnati STD/HIV Prevention Training Center
50
HIV Infection
• Infection of immun system
• Seen oppurtunistic infections
and neoplastic diseases in the
last stage
Transmission Risks
Transmission
Sexual activity
Risk
Anal sex
HIV+M M/F
1/3-1/10
Vaginal sex
HIV+M F
1/75-1/100
Vaginal sex
HIV+F
Oral sex
-
M
1/300-1/1000
????
HBV Infection
HBV
• Carrier
: 2-3.000.000
• CHB (25%) : 500-750.000
• Cihrosis and HCC(ex)/year :
5000
CHB – Epidemiology
1/3 - %5
HBsAg Prevalance
1/3-%5
8% -HİGH
2-7% - Moderate
<2% - Low
Genital siğiller
• HPV (human papilloma
virus) etkendir
• Erkek ve kadın genital
bölgesinde ve anus
çevresinde sert, ağrısız,
küçük siğillerdir.
• •Virüsün 6 ve 11. alt tipleri
dış genital bölgede;
• •16, 18 ve 31. alt tipleri ise,
servikal displazi ve
karsinomla ilişkilidir.
Korunma yolları
•Şüpheli cinsel temastan kaçının
•Tek eşliliğe yönelin
•Riskli kişilere HBV aşısı uygulayın
•Kondom kullanın
•Uyuşturucu ve alkol aldıktan sonra
şüpheli cinsel temastan kaçının