Tarek Mansi. ~19 million new cases every year ~65 million have incurable viral STIs 2/3 in...
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Transcript of Tarek Mansi. ~19 million new cases every year ~65 million have incurable viral STIs 2/3 in...
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SEXUALLY TRANSMITTED INFECTIONS
Tarek Mansi
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Epidemiology and Trends
~19 million new cases every year ~65 million have incurable viral STIs 2/3 in adolescents and young age US: 4 out of 10 top notifiable diseases
(HSV and HPV not reportable) HPV: 50% of sexually active males and
females Gonorrhea: - - 20 times more in non-hispanic blacks - Increased Quinolone resistance
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STI
Sores Drips
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Sores (Ulcers)
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Sexually Transmitted
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Non- sexually Transmitted
Trauma Drug reactions Cancer Behcet’s syndrome Erythema multiforme Psoriasis & Lichen planus
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Herpes Simplex
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Cause: HSV I &II (85-90%) IP: 4-6 days Asymptomatic viral shedding for up to 3
months Diagnosis: - Definitive test: Viral culture, Tzank
smear - Serological tests: IgM and IgG
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Treatment
First clinical episode (7-10d): Acyclovir: 400 mg TID / 200mg 5 times
per day Famciclovir: 250mg BID Valacyclovir: 1g BID TopicalLater on:
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Chancroid
Cause: H. ducreyi IP: 1-21d Difficult to culture Painful ulcers, friable base, shaggy
border, purulet exudate.. Associated with unilateral inguinal lymphadenopathy
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Treatment
Single dose: Azithromycin 1g PO or Ceftriaxone 250mg IM
Ciprofloxacin 500mg BID for 3d F/u 3-7 days. Sexual partner should be examined
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Syphilis
Cause: T. pallidum IP: 10-90 days Immune response: - Non-specific Ab response: Anticariolipin
(VDRL and RPR) - Specific Ab response: anti- Treponemal
Ab FTA-ABS & TP-PA) Diagnosis: - Direct fluorescent Ab and Dark field
microscopy
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Primary (Chancre)
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Secondary
Represents hematogenous dissemination of spirochetes
Usually 2-8 weeks after chancre appears Findings:
rash - whole body (includes palms/soles) mucous patches condylomata lata – in moist areas and HIGHLY
infectious constitutional symptoms FAHM Rarely: Uveitis, iritis, arthritis, periostitis, GN
Symptoms and signs usually resolve in 2-10 weeks
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Tertiary
Late benign (gummatous) syphilis Neuro-syphilis: Tabes dorsalis, Argyll-
Robertson’s pupil, lost proprioreception Cardio-syphilis: Aortitis, aortic aneurysm,
AV insufficiency
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Treatment
1ry, 2ry, early latent: Benzathine Penicillin G 2.4 million IU IM once
- Allergic: doxycycline 100mg BID OR Tetracycline 500mg QID x2wks
Late latent: 2.4 mil. IU once per week X3wks
- Allergic: 4 weeks Jarisch-Herxheimer reaction
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Lymphogranuloma Venereum
Cause: Chlamydia trachomatis (L1, L2, L3)
IP: Variable Groove sign Treatment: - Doxycycline - Erythromycin x 3wks
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DRIPS
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Chlamydia
Cause: Chlamydia trachomatis (D-k) IP: 3-14 days Often coexists with Gonorrhea Most common cause of epididymitis/orchitis in
young men 75% of females are asymptomatic, 40% of
untreated cases develop PID Diagnosis: - Culture - NAAT - EIA, DFA, NAH (non-amplified)
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Treatment: - Azithromycin 1g once - Doxycycl. 100mg BID x7d - Amoxycillin 500mg TID x7d
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Gonorrhea
Cause: N. gonorrhea
IP: 3-14d Diagnosis: - Culture: Thayer-
Martin or Chocolate agar
- G-stain: G-ve diplococci
- NAAT
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Males Females - Fitz-Hugh-Curtis syndrome: Perihepatic
spread of adnexal gonorrhea Disseminated Gonorrhea: fever, rash,
Polyarthritis, Tenosynovitis (lover’s heel) Treatment: - Ceftriaxone 250mg IM once - cefixime 400mg PO once - Allergic: Spectinomycin 2g IM once
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Trichomoniasis
Cause: T. vaginalis (flagellated protozoan) 174 million new cases yearly Males: Usually asymptomatic, Urethritis,
prostatitis (rare) Females: Usually symptomatic.. Vaiginitis
(fishy odorous d/c, ph>4.5), cervicitis (strawberry Cx)
Treatment: - Recommended: Metronidazole OR Tinidazole
2g PO once (x alchohol, x breast fedding) - If failed: metronidazole 500mg PO BID x7d
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Chondyloma Acuminatum
Cause: HPV (ds DNA) Mode of tranmission: skin to skin contact IP: Variable ~3-12 months Many subtypes, 16 &18- 70% of Cx
cancer Most are asymptomatic Diagnosis: Papanicholas stain Biopsy of warts indicated if atypical,
pigmented, indurated, ulcerated, fixed, resistant to Rx
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Treatment Primary goal: To treat visible warts Patient-Applied:
Podofilox 0.5% solution or gelORImiquimod 5% creamORSinecatechins 15% ointment
Provider–Administered:Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1–2 weeks.ORPodophyllin resin 10%–25% in a compound tincture of benzoinORTrichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90%ORSurgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery.
HPV Vaccines : Cervarix and Gardasil Both vaccines protect against the two HPV types (HPV-16 and HPV-18) that cause 70% of cervical cancers and Gardasil protect against (6-11) that causing genital warts .
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Molluscum contagiosum
Cause: MCV (ds DNA) IP: 14-50 days 4 subtypes, clinically
similar - MCV1: USA - MCV2&3: Europe,
Australia, HIV patients
Usually self-limiting. Cautery, TCA, etc. may cause scarring
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Scabies and Pediculosis (lice)
Cause: Sarcoptes scabiei Treatment: - Permethrin cream (5%),
wash off after 8-14 hours - Ivermectin 200 mic/kg
PO, repeated after 2 weeks
- Lindane 1%.. C/I children <2yrs, pregnant & lactating women, extensive dermatitis
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Pediculosis pubis (pubic lice)
Cause: Phthirus pubis Eggs (nits) glued to hair shaft Treatment: - Permethrin 1% - Ivermectin 250mic/kg PO, repeated
after 2 wks - Malathion 0.5% lotion - Topical insecticidal preparations - Kerosene/Oil
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HIV
Cause: HIV 1&2 (retrovirus) IP: variable >3months Urologic manifestations: - Higher risk of renal, penile and testicular
Ca. - Neurologic bladder - Hypogonadism - Protease inhibitors may cause calculi
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PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS
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Expedited Partner Therapy
Treatment of the patient’s partner without referral, e.g. “Partner Package”
CDC 2006 guidelines: Only when other managements are
impractical or fail Not routine in homosexual males (high risk
of undiagnosed HIV) Not in Syphilis Not in partners of females with trich. Vag.
(comorbidity with Gonorrhea and Chlamydia)
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THANK YOU