Download STD Syndromes

Overview of Sexually
Transmitted Diseases
Rebecca A. Lillis, M.D.
Assistant Professor of Medicine, Section of
Infectious Diseases
LSUHSC, New Orleans
DISCLOSURE
• I have no financial interests or other
relationship with manufacturers of commercial
products, suppliers of commercial services, or
commercial supporters. My presentation will
not include any discussion of the unlabeled use
of a product or a product under investigational
use.
Major STDs
Type of Agent
Viruses
Bacteria
Fungi
Protozoa
Insects
Name
Disease
Human Papillomavirus
Warts
Herpes Simplex
Herpes
Hepatitis B
Hepatitis
HIV
AIDS
Chlamydia
Chlamydia
Neisseria Gonorrheae
Gonorrhea
Treponema pallidum
Syphilis
Hemophilus ducreyi
Chancroid
Candida albicans
Candidiasis
Trichomonas vaginalis
Trichomoniasis
Sarcoptes scabii
Scabies
Syphilis
• Cause: Spirochete - Treponema pallidum
• Symptoms: Genital ulcer, rash
• Diagnosis:
– Dark Field exam
– Blood test: RPR, VDRL,MHA-TP, IgG
• Complications:
– Late syphilis
– Congenital syphilis
– HIV transmission
• Treatment - Penicillin
Syphilis
Stages and Manifestations
Early Syphilis - 1st 12 months
Primary Genital ulcer (chancre)
Secondary - Generalized rash (palms & soles)
Oral and genital lesions
Alopecia
Early latent - No signs or symptoms
Late latent - Years
Late - Neurosyphilis
Cardiovascular syphilis
Syphilis: Treatment
• Early syphilis
• Benzathine penicillin G (Bicillin L-A)
2.4 million units IM x 1
• Late latent
• Benzathine penicillin G 2.4 million units
IM per week x 3
• Neurosyphilis and cardiovascular syphilis
• Intravenous penicillin G
P&S Syphilis, Louisiana vs. U.S.
1981-1999
Cases/100,000
80
Louisiana
60
40
20
U.S.
Year 2000 Objective
0
1987
1988
1989
1990
1991
1992
1993
1994
Year of Report
1995
1996
1997
1998
1999
Primary and secondary syphilis — Rates: United States, 1970–2004 and the
Healthy People 2010 target
Rate (per 100,000 population)
25
P&S Syphilis
2010 Target
20
15
10
5
0
1970
73
76
79
82
85
88
91
94
97
2000
03
Note: The Healthy People 2010 target for P&S syphilis is 0.2 case per 100,000 population.
Louisiana rate 7.34 cases/ 100,000 is highest in nation for 2004
P&S Syphilis Cases in Louisiana
Actual cases and projection to elimination goal
3500
Cases of P&S syphilis
3000
2500
2000
1500
1000
500
0
1991
1993
1995
1997
1999
Year of Report
2001
2003
2005
Rates of Syphilis in Industrialized Countries
Country
P&S Cases
Rate
Canada
248
0.8
England
117
0.4
Sweden
52
0.6
Denmark
39
0.7
U.S. (1996)
11,387
4.3
U.S. (1998)
6,993
2.6
U.S. (2005 goal)
1,000
0.4
Causes of Genital Ulcers
) Herpes
) Syphilis
) Chancroid
Herpes
• Herpes Simplex Virus (HSV) I and II
• Symptoms: Painful blisters that recur
• Complications (rare):
– Spread to infants at delivery
– Severe infections in AIDS patients
Herpes: Treatment
) No cure
) Antivirals shorten duration, reduce
frequency and severity of recurrences
5 Acyclovir (Zovirax)
5 Famcyclovir (Famvir)
5 Valcyclovir (Valtrex)
) Different dosages for initial treatment vs.
recurrent or suppressive treatment
Chancroid
• Cause: Hemophilus ducreyi
– Epidemiology: Uncommon in U.S., occurs in
outbreaks
• Symptoms:
– Painful sore (may be multiple) that looks like
chancre
• Male:female ratio 10:1
• Treatment: Azithromycin, Ceftriaxone
Causes of Genital Ulcers
) Herpes
5Painful, blister - ulcer, shallow,
multiple, recurrent
) Syphilis
5Painless, single, not recurrent
) Chancroid
5Painful, single or multiple, not
recurrent
Causes of Urethral or Cervical Discharge
) Gonorrhea
) Chlamydia
Gonorrhea
• Cause: Neisseria gonorrheae
• Symptoms:
– Men - painful discharge from urethra
– Women - cervical discharge
• often no symptoms
• Complications:
– Women - Pelvic Inflammatory Disease (PID)
Infertility, ectopic pregnancy
- Infants - Eye infection "ophthalmia
neonatorum"
Tests for Gonorrhea
) Culture
) Gram Stain
) Non-culture tests
5 DNA Probe test (GenProbe)
5 PCR/LCR test
Chlamydia
• Cause: Chlamydia trachomatis
• Symptoms:
– Men – scant clear discharge from urethra
– Women - cervical discharge
• Usually no symptoms for men or women
• Complications:
– Women - Pelvic Inflammatory Disease (PID)
Infertility, ectopic pregnancy
- Infants – Pneumonia at 6 week age, eye
infection
Tests for Chlamydia
) Culture
) Non-culture tests
5 DFA test
5 EIA
5Lab -Chlamydiazyme, Microtrak, others
5Rapid - Clearview, TestPack, SureCell
5 DNA Probe test (GenProbe)
5 PCR and LCR tests
Sensitivity of Different Tests for Chlamydia
Test type
PCR/LCR
Culture
DFA
DNA Probe
EIA
1
10
100
1000
10000
Number of organisms detectable
100000
1000000
Gonorrhea: Treatment
) Antibiotics for gonorrhea
5 Cefixime (Suprax) 400 mg PO x 1
5 Ciprofloxacin (Cipro) 500 mg PO x 1
5 Azithromycin (Zithromax) 2 gm PO x 1
5 Ceftriaxone (Rocephin) 125 mg IM x 1
) Always treat for chlamydia also
Chlamydia: Treatment
) Azithromycin 1 gm PO x 1
) Doxycycline 100 mg PO BID x 7 days
Rates of STDs
Louisiana, 1992-1999
500
Cases/100,000
400
Chlamydia
300
Gonorrhea
200
100
P&S Syphilis
0
1992
1993
1994
1995
1996
Year of Report
*projected from first 8 months
1997
1998
1999
Chlamydia — Rates: United States, 1984–2004
Louisiana’s rate for 2004 was 488.26 per 100,000, third highest in the nation
Rate (per 100,000 population)
350
280
210
140
70
0
1984
86
88
90
92
94
96
98
2000
Note: As of January 2000, all 50 states and the District of Columbia had
regulations requiring the reporting of chlamydia cases.
02
04
Gonorrhea — Rates: United States, 1970–2004
Louisiana’s rate for 2004 was 235.46 per 100,000 – second highest in the
nation
Rate (per 100,000 population)
500
Gonorrhea
2010 Target
400
300
200
100
0
1970
73
76
79
82
85
88
91
94
97
2000
Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000
population.
03
Rates of Gonorrhea and Chlamydia by Agegroup
Louisiana, 1999
Cases per 100,000
2,500
Chlamydia
Gonorrhea
2,000
1,500
1,000
500
0
5-9
10-14
15-19
20-24
25-34
35-44
Age Group
45-54
55-64
65+
Vaginitis
) Candidiasis
) Trichomoniasis
) Bacterial vaginosis
Trichomoniasis
•
•
•
•
Cause: Trichomonas vaginalis (protozoan)
Symptoms: Frothy white vaginal discharge
Diagnosis: Trich. on wet mount
Complications:
– ? Increased HIV transmission
• Treatment: Metronidazole (Flagyl)
• Very high recurrence rate after treatment
Bacterial Vaginosis
• Cause: Increase in Gardnerella vaginalis &
others, decrease in lactobacilli
• Symptoms: Malodorous vaginal discharge
• Diagnosis:
– Clue cells on wet mount
– Positive "whiff test"
• Complications: Premature delivery
• Treatment: Metronidazole (Flagyl)
• High recurrence rate after treatment
Candidiasis
• Cause: Candida albicans
• Not an STD
• Symptoms: Cheesy white adherent
discharge
• Treatment:
– Fluconazole (Diflucan)
– Terconazole (Terazol)
– OTC creams
Differentiating Among Causes of Vaginitis
) Candidiasis
5 Discharge is thick, adherent
) Trichomoniasis
5 Frothy discharge
5 Protozoa on wet prep
) Bacterial vaginosis
5 Thick, clear-white malodorous discharge
5 Clue cells on wet prep
Treatment of Vaginitis
) Candidiasis
5 Diflucan 150 mg PO x 1
) Trichomoniasis
5 Metronidazole (Flagyl) 2 gm PO
) Bacterial Vaginosis
5 Metronidazole (Flagyl) 500 mg BID x 7
days
Syndromic Treatment for STDs
Most common situations
) Genital ulcer - treat for syphilis
5 Benzathine penicillin 2.4 million units IM
) Urethral discharge/cervical discharge - treat for gonorrhea
and chlamydia
5 Cefixime 400 mg or Cipro 500 mg AND
5 Azithromycin 1.0 gm or Doxycycline 100 mg b.i.d. x 7
days
) Vaginal discharge in female - treat for trichomoniasis and
bacterial vaginosis
5 Metronidazole 2 gm
Prevention Counseling
) Get partners treated
) Decrease number of partners
) Use a condom every time