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Sexually Transmitted Diseases David W. Haas, M.D. Division of Infectious Diseases Vanderbilt University School of Medicine Nashville, Tennessee Case Presentation • 19 YO male c/o burning on urination, yellow discharge on underwear. • Has otherwise been well. – What are likely diagnoses? – What tests should be done? – What treatment may be needed? – Anything else to do? Gonococcal Urethritis • Incubation 1-10 days • Can’t differentiate from chlamydia by symptoms • Most infections are symptomatic • May persist without continued symptoms Acute Epididymitis • Young men – Chlamydia (most common) – Gonococcus • Old men – Gram (-) enterics – Pseudomonas Localized Gonococcal Infections • Anorectal infection – Culture often (+) in women with cervical GC – Treatment failures detected at rectum • Pharyngeal infection – Orogenital exposure • Pelvic inflammatory disease – Cervix doesn’t predict upper tract GC – 20% risk of infertility • Perihepatitis (Fitz-Hugh-Curtis syndrome) Disseminated Gonococcal Infection Joint involvement Number Sites Character Cells Culture Papules/pustules Blood culture Arthritis-dermatitis syndrome Septic arthritis several Knee, elbow, wrist, ankle 1 or 2 Knee, elbow, wrist, ankle Tenosynovitis Frank arthritis <20,000 WBC/mm3 Negative >50,000WBC/mm3 Often positive 5-40 Absent Often positive Negative Diagnosis of Gonorrhea • Culture – Rapidly inoculate media – Thayer-Martin, others • DNA probes or DNA amplification – If used, culture unnecessary • Gram stain – Gram (-) diplococci – Many leukocytes Treatment of Uncomplicated Gonorrhea (urethra, cervix, pharynx, rectum) • • • • • • Ceftriaxone (125mg IM x 1 dose) Cefixime (400mg PO x 1 dose) Cefpodoxime (400mg PO x 1 dose) Ciprofloxacin (500mg PO x 1 dose) Gatifloxacin (400mg PO x 1 dose) Levofloxacin (250mg PO x 1 dose) + • Azithromycin 1g po x 1 dose • Doxycycline 100mg q12h po x 7 days OR OR OR OR OR OR Treatment of Gonorrhea General Considerations • • • • Reculture all (+) sites at 4-7 days Consider reculture os rectal canal in women Examine and culture sexual contacts Treat sexual contacts regardless Chlamydia trachomatis Genital Disease • Urethritis in men – Isolated with 20% of GC cases – Isolated in 40% of NGU – Asymptomatic infection common • Epididymitis • Cervicitis • Pelvic inflammatory disease – Infertility risk 10% – Perihepatitis Diagnosing C. trachomatis Infection • Gram stain – 4 WBC’s per oil-immersion field – No organisms seen • Rapid methods – DNA probes or PCR • Culture – Costly, not generally done Case Presentation • 19 YO male c/o burning on urination, yellow discharge on underwear. • Has otherwise been well. – What are likely diagnoses? – What tests should be done? – What treatment may be needed? – Anything else to do? Syphilis Stage Onset • Primary 3 weeks • Secondary 2-8 weeks • Latent >8 weeks • Late years “Classic” Syphilitic Chancre • • • • • Painless Raised borders No exudate At inoculation site Rarely seen by physician Secondary Syphilis • Rash – Variable, palms & soles • Fever • Diffuse lymphadenopathy • Patchy alopecia • Mucous patches • Condyloma lata Darkfield Examination for Syphilis 1. 2. 3. 4. Abrade lesion with dry gauze Obtain serous exudate Place on slide with coverslip View motile spirochetes • Great for primary and secondary syphilis, not for oral lesions Syphilis Serology Primary Nontreponemal tests (VDRL & RPR) Specific treponemal tests (FTA-Abs, MHA-TP, TPHA) Secondary Late 75% 99% 1% (if treated) 75% 100% 95% Who with Latent Syphilis Needs a Spinal Tap? • • • • Neurologic symptoms Failure of RPR to fall with therapy RPR 1:32 Inability to give penicillin If CSF abnormal, treat for neurosyphilis Treating Syphilis • Primary and Secondary – Benzathine PCN 2.4 million units IM x 1 – (Ceftriaxone 1g qd IV or IM x 8-10 d) – (Doxycycline 100mg q12h x 14 d) – Anticipate Jarisch-Herxheimer • Latent (>1 year duration) – Benzathine PCN 2.4mil units IM weekly x 3 – (Doxycycline 100mg q12h x 28 d) Treating Neurosyphilis – Pen G 2-4 million units IV q4h x 10-14 d – (Procaine Pen G 2.4 mil units IM q24h + probenacid 500 mg PO qid x 14 days) – (Ceftriaxone 1g IV or IM qd x 14 d) Genital Herpes - Initial Episode • Painful vesicles or pustules which ulcerate • Fever, headache, myalgias • Tender inguinal adenopathy • Extragenital vesicles common • Pharyngitis, aseptic meningitis, urethritis occasional Genital Herpes - Recurrent • • • • 90% recur in first year Average 5 per year initially Less severe than first episode Avoid sex until lesions heal Diagnosing Genital Herpes • Diagnosis often clinical • Cytology (Tzank prep) shows – Scrape lesion – Spear to microscope slide – Stain with Pap or Wright-Giemsa – See multinucleated giant cells • Culture – Swab lesion – To viral transport media – Cytopathic effect in 1-4 days Treating Genital Herpes • Initial – Acyclovir 400mg po q8h x 7-10 days – Valacyclovir 1g po q12h x 10 days – Famciclivir 250mg po q8h x 7-10 days • Recurrent (Often not treated) – Acyclovir 400mg q8h x 5 days – Valacyclovir 500mg po q12h x 3 days – Famciclivir 125mg po q12h x 5 days • Chronic suppression – Acyclovir 400mg q12h – Valacyclovir 1g po q24h – Famciclivir 250mg po q12h Sexually Transmitted Diseases