Sexually Transmitted Sexually Transmitted DiseasesDiseases

STD = transmitted mostly STD = transmitted mostly by means of sexually contactby means of sexually contact

I. Bacterial STD (reportable) - syphilis, gonorrhoea, chancroid (ulcus molle), lymphogranuloma venereum, granuloma inguinale

II. Other bacterial infections (nonspecific, non-gonococcal) – Chlamydia, Mycoplasma, rarely Streptococci, Enterococci, Gardnerella vag.…

III. Mycotic inf. = Yeasts – C.albicans…

IV. Parasitic inf. - scabies, crab louse…

V. Viral inf. – genital herpes, genital warts, molluscum contagiosum, AIDS, CMV, hepatitis viruses…

VI. Protozoal inf. – trichomoniasis, Giardia lamblia…

Syphilis (luesSyphilis (lues)) caused bycaused by Treponema palliduTreponema pallidumm

I. Direct mikroscopic identification (only some lesions):

dark-field examinationSpecial microscope ► substage with special lens - transmitts only marginal rays beyond objective = dark

field ► insert of slide with sample → rays bend in

objective → shiny objects (spiral-shape)

dark field microscopy

Syphilis (luesSyphilis (lues)) caused bycaused by Treponema palliduTreponema pallidumm

II. Serology (blood) ● nonspecific rections (antigen = cardiolipin) BWR (complement fixation r.), RRR (Rapid Reagin Reaction –

flocculation r.), VDRL (Venereal Disease Research Laboratory – flocculation reaction)

(high degree od sensitivity, low degree of specifity, tendency to diminish without treatment)

● specific (treponemal) reactions (antigen = T.pallidum)

19S-IgM-SPHA (IgM, 2nd wk), FTA-ABS (indirect

immunofluorescence, IgM, 2nd wk), TPHA (IgG, 4th-5th wk) TPIT (immobilization – not longer employed, 7th-9th wk) III. cerebro-spinal fluid (lumbar puncture)

Syphilis acquisita (aquired) Course of an untreated syphilis

Terciární stádium

- s. of organs

- neurosyfilis

PRIMARY S. TERTIARY S.SECONDARY S.

Syphilis primariaSyphilis primaria 3 weeks after exposure

a primary lesion develops at the site of initial contact (a papule → painless erosion), extragenital primary lesions (5%)

unilateral painless lymphadenopathy occurs in 1 to 2 weeks

the untreated lesion heals spontaneously (with scarring) in 3 to 6 weeks

Syphilis secundaria in 9 weeks after contact → dissemination of T.pallidum to all organs (guided by flu-like syndrom or asymptomatic)

more often bilaterally symmetric macular, papular or psoriasiform rash (minimal pain or itching), involvement of palms and soles…

condylomata lata (moist anal wartlike papules, highly infectious!)

in mouth „papulae mucosae oris“ (highly infectious!)

alopecia syphilitica areolaris (irregular, „moth eaten“) or diffusa

Latent syphilis Latent syphilis (aquired)(aquired)

Is defined as a period after active infection, signs and symptoms are absent but in which serological results remain positive.

Patients in early latent stage (2 years) can be infectious.

Positive serological findings decrease and finally become negative (late latent syphilis).

Or they can progress to tertiary syphilis. The transition to late tertiary syphilis can last 10, 20

or more years.

Syphilis terciariaSyphilis terciaria

+ gummata (granulomatous lesions, livid red, brown, with central necrosis and discharge) anywhere on the skin, in the oral cavity, in bones…

+ cardiovascular involvement (endarteritis of the coronary vessels, aneurysm of the ascending aorta…)

+ syphilis CNS (s. cerebrospinalis, endarteritis, gummata, meningitis)

Progressive paralysis(general paresis, psychiatric

and neurologic symptoms)

Tabes dorsalis (locomotor ataxia, damage of joints, trophic ulceration

on the feet…)

Neurosyphilis (metalues)Neurosyphilis (metalues)

Congenital syphilisCongenital syphilis

T.pallidum can be transmitted by an infected mother to the fetus, but not before the fourth month of pregnancy (cardiovascular circulation is quite mature).

The fetus is at the greatest risk when maternal syphilis is less then 2 years duration (in early secondary stage of mother´s infection).

The ability of the mother to infect the fetus decreases (but never disappears).

Syphilis congenita RECENSSyphilis congenita RECENS

Early congenital s. becomes symptomatic during the first 2 years of life, 50% (with clinical signs at birth) die.

The stigmata include: maculopapular, vesicular rash, desquamating erythema of palms and soles, rhinitis, iritis, osteochondritis…

Syphilis congenita RECENSSyphilis congenita RECENS

vesicular rash osteochondritis

Syphilis congenita TARDA

Late congenital s. signs become after 5 to 10 years of life.

Saddle nose, short maxilla, Hutchinson´s teeth (peg-shaped upper central incisors), Hutchinson´s triad (H.teeth, keratitis, the VIIIth nerve deafness), „sabre tibia“ (anterior bowing and thickening of tibia)

Or can be without symptoms!

THERAPYTHERAPY

Primary, secondary, early latent s.- benzathine benzylPNC 2,4 M i.m. - 1x- procain benzylPNC 1,2 M i.m. - 10days- doxycycline, erythromycin 2g/d orally - 15 days

Late latent s.- benzathine benzylPNC 2,4 M i.m 2,4 M/weekly i.m.- in 3 dose - prokain PNC G – 2 M/denně i.m. 15 daysNeurosyphilis – crystalline PNC (14 days) - doxycycline orally for 30 daysCongenital s. - benzathine PNC 50 tis.j./kg/den – 1- 10days - spiramycin 50-100mg/kg/den 14 daysIn pregnancy - PNC, erythromycine (15days)

Clinical findings:

o an incubation period 3-5 days

o In MEN: burning, frequent urination, purulent discharge, some people only complain of mild dysuria with mucoid urethral discharge. Untreated infection can spread to the prostate, seminal vesicles, testicles…

o In WOMEN: asymptomatic infection or symptoms of mild urethritis, nonspecific vaginal discharge (endocervical infection), cervical erosions, inflammatory changes of Bartholin´s gland. Infection can spread and involve uterus, fallopian tubes, ovary…

Gonorrhoea (drip, clap) Gonorrhoea (drip, clap) G- microbe G- microbe Neisseria gonorrhoeaeNeisseria gonorrhoeae

GonorrhoeaGonorrhoea

Clinical findings:

o Extragenital gonorrhoea includes involvement of rectum, pharyngs, conjuctiva.

o Disseminated GO – polyarthritis, dermatitis (palms), or endocarditis, meningitis.

o COMPLICATION (result of untreated infection) - sterility in men and women, - ectopic pregnancy in women, - neonatal ocular gonorrhoea can be aquired via intrauterine infection or most often during childbirth

Gonorrhoea (drip, clap) Gonorrhoea (drip, clap) G- microbeG- microbe Neisseria gonorrhoeaeNeisseria gonorrhoeae

▪ culture – on „chocholate“ agar (shiny gray colonies)

▪ PCR, DNA hybridization, DIF… direct identification, not used routinely

Therapy: ampicillin, amoxicillin (3g orally in a single dos), ceftriaxone (250 mg intramuscular injection), doxycycline (200mg/day for 7 days)…In case of complication ATB inj., more days.

Diagnostics: ▪ mikroscopy (smear of urethra,endo-

cervical canal, rectum or conjuctiva…) - gram-stained (or methylene blue stained)

Chancroid (ulcus molle, soft chancre) Chancroid (ulcus molle, soft chancre) Haemophilus Ducreyi (G-rod) Haemophilus Ducreyi (G-rod)

Incidence: tropical Africa, south-east Asia, south and central America, India

Clinical findings:

an incubation period - 3 to 5 days

a painful (unlike syphilis), red papule, rapidly becomes ulcer (deep, bleeds easily, spreads laterally, with yellow-gray exudate), unilateral or bilateral painful lymphadenopathy

Chancroid (ulcus molle, soft chancre) Chancroid (ulcus molle, soft chancre) Haemophilus Ducreyi (G-rod) Haemophilus Ducreyi (G-rod)

Dg.: microskopy - gram-stained

(when swab is rolled in one direction → bacteria form parallel chains = „school of fish arrangement)

culture (special agar), PCR Therapy: erythromycin, trimethoprim-

sulfamethoxazol by mouth for 10 days, amoxycillin-clavulan acid for 7 days…

Lymphogranuloma inguinale (venereum)Lymphogranuloma inguinale (venereum)Chlamydia trachomatis - Chlamydia trachomatis - serotypes serotypes L1-L3L1-L3

Clinical findings: an incubation period 5 - 21 days painless erosion, especially

inguinal lymphadenopathy

lymph nodes become fluctuant, ulcerate, discharge purulent material → lymfatic obstruction → chronic edema of the external genitals is a late manifestation inflammation of the

lymfatic system

Incidence: is most common in Africa, Asia, south Am.

Lymphogranuloma inguinale (venereum)Lymphogranuloma inguinale (venereum)Chlamydia trachomatis - Chlamydia trachomatis - serotypes serotypes L1-L3L1-L3

Dg.: • PCR• culture (special tissue)• microskopy (IF), • serology (ELISA, IF...)

Therapy

doxycycline, erythromycin for 3 weeks

Incidence: is most common in Africa, Asia, south Am.

Granuloma (venereum) inguinaleGranuloma (venereum) inguinale Calymmatobacterium (Donovania) Calymmatobacterium (Donovania)

granulomatis (G-)granulomatis (G-)

Incidence: is most prevalent in New Guinea, India, subtropical regions

Clinical finding: red ulceration, with granulation tissue, spread widely…

Dg: PCR histological exam. (G- „Donovan´s bodies“)C.g. is very difficult for culture, no serologic testing is available.

Therapydoxycycline, erythromycin, trimethoprim-sulfamethoxazol…

YEASTSYEASTS Candida albicans, C. tropicans, C. crusei, Candida albicans, C. tropicans, C. crusei,

Torulopsis glabrata (G+)Torulopsis glabrata (G+)

Incidence: worldwide frequent

Clinical findings:

discharge, burning, itching

Dg.: microscopy (Gram+)

culture (Sabouraud´s agar)

Therapy

antimycotics (vaginal, drugs)

Evidence: most common STD(often coinfection with N.gonorrhoeae)Dg.: mikroskopy (wet mount exam. or dark-field microskopy

– movable flagellates) culture (special liquid or firm medium, simultaneously - a culture for GO)

Therapyornidazol (1500mg – a single dose), metronidazole 2x250mg/10 days Both partners should be treated

at the same time.

TrichomoniasisTrichomoniasisprotozoan Trichomonas vaginalis (Donné)protozoan Trichomonas vaginalis (Donné)

Chlamydial InfectionsChlamydial InfectionsG- microbe G- microbe Chlamydia trachomatis Chlamydia trachomatis serotyp serotyp

D-KD-K

Clinical findings: mucoid discharge

Dg.: microskopy (Giemsa staining, DIF – intracellular parasites, material from urethral or cervical scrapings)

PCR (from urine) (x culture and serology plays a minor role) Therapy doxycycline, TTC, erythromycin, sulfonamide – 7 days

Condylomata accuminata (genital Condylomata accuminata (genital warts)warts)

Papilloma virus – HPV typ 6Papilloma virus – HPV typ 6

Clinical findings: cauliflower-like or small pearly papule,

painless, itching

Dg.: histological examin.

PCR, DIF

Therapy: Podophylotoxin,

LN, laser, imiquimod,

surgical intervention…

Pediculosis pubisPediculosis pubisparasiteparasite Phthirius pubis Phthirius pubis

(crab louse)(crab louse)

Clinical findings: lice and nits (pubic hairs, other hairy sites can be affected, after bite small blue-gray macules = „maculae coeruleae“), itching

Diagnostic: clinical findings

microscopy (lice and nits)Therapy…hexachlorcyklohexan, permethrin, 4% carbaryl, 100% dimeticone…

Necessary: to treat both partners, to repeat the treatment.

AIDSAIDS (Acquired Immunodeficiency Syndrome)(Acquired Immunodeficiency Syndrome)

• Indirect methods (antibodies)

- tests for screening (quick tests - ELISA, IF,…)

- tests for confirmation (e.g.Western Blot)

• Direct methods: p24 antigen test, PCR…

Other investigation and therapy → in special centre.

• ALL sexuall partners should be examined!