Sexually transmitted Sexually transmitted infections infections

II Non II Non –– Herpetic Genital ulcer Herpetic Genital ulcer 1 1 –– Syphilis : Syphilis :

Is a systemic sexually transmissible infection Is a systemic sexually transmissible infection caused by trepanoma pallidum. caused by trepanoma pallidum.

Other trepanomas include :Other trepanomas include : 1 1 –– T. Paertenue causes Yaws. T. Paertenue causes Yaws. 2 2 –– T. Pallidum endemicum causes endemic syphilis. T. Pallidum endemicum causes endemic syphilis. 3 3 –– T. Carateum causes pinta . T. Carateum causes pinta . The last three ( Tropical Trepanomatosis ) are not The last three ( Tropical Trepanomatosis ) are not

sexually transmitted. sexually transmitted.

Clinical features :Clinical features :

The first manifestation of venereal syphilis is a The first manifestation of venereal syphilis is a painless ulcer ( chancre ) at the site of inoculation. painless ulcer ( chancre ) at the site of inoculation. These can be multiple. The regional lymph nodes These can be multiple. The regional lymph nodes become enlarged.become enlarged.

In women the commonest site for a chancre is on the In women the commonest site for a chancre is on the cervix. It may therefore pass unnoticed. It usually arise cervix. It may therefore pass unnoticed. It usually arise 3-6 weeks after infection. It is painless and resolve 3-6 weeks after infection. It is painless and resolve spontaneously without treatment after a few weeks. It spontaneously without treatment after a few weeks. It has a rubbery consistency and accompanied by inguinal has a rubbery consistency and accompanied by inguinal lymphadenopathy. lymphadenopathy.

Secondary syphilis can appear as the chancre Secondary syphilis can appear as the chancre disappear or up to 6 months later , manifestations by disappear or up to 6 months later , manifestations by systemic eruption, most often a non itching systemic eruption, most often a non itching maculopapular rash. It is symmetrical and involve the maculopapular rash. It is symmetrical and involve the palms of the hands and soles of the feet. More florid palms of the hands and soles of the feet. More florid lesions resembling warts, condylomata lata are seen in lesions resembling warts, condylomata lata are seen in intertriginous areas particularly perianally. Mucous intertriginous areas particularly perianally. Mucous pathos and lines ( snail track ) ulcers are seen on the pathos and lines ( snail track ) ulcers are seen on the mucosal surface. There may be generalize mucosal surface. There may be generalize lyphadenopathy.lyphadenopathy.

0ther manifestations include : 0ther manifestations include :

1 1 –– alopecia. alopecia.

2 2 –– Arthritis. Arthritis.

3 3 –– Meningitis. Meningitis.

Mucous patches, oralMucous patches, oral

Diagnosis :Diagnosis : 1 1 –– Diagnosis of primary syphilis is made by Diagnosis of primary syphilis is made by

demonstrating the organism by dark field microscopy. demonstrating the organism by dark field microscopy. The lesion is cleaned and mildly abraded, so that The lesion is cleaned and mildly abraded, so that clear serum exude from the base, mixed with a drop clear serum exude from the base, mixed with a drop of saline on a microscope slide. Slide viewed under of saline on a microscope slide. Slide viewed under high power ( 3800 X ) using dark field illumination. high power ( 3800 X ) using dark field illumination.

2 2 –– Serological tests : Serological tests : a/ a/ Fluorescent trepanoma Ab ( FTA )Fluorescent trepanoma Ab ( FTA ) Most sensitive and specific test for syphilis. Most sensitive and specific test for syphilis. b/ b/ Trepanoma pallidum haemagglutination assay Trepanoma pallidum haemagglutination assay

( TPHA ) or Trepanoma pallidum agglutination (TPPA )( TPHA ) or Trepanoma pallidum agglutination (TPPA ) c/ c/ Venereal disease reference laboratory ( VDRL ) Venereal disease reference laboratory ( VDRL )

test is a reaginic or non test is a reaginic or non –– specific test. specific test.

d/ d/ Rapid plasmen reagin ( RPR ) tests are used, Rapid plasmen reagin ( RPR ) tests are used, titration done such as 1 in 64 at the threshold of titration done such as 1 in 64 at the threshold of reaction of the test. reaction of the test.

In primary syphilis, however the serological test may all In primary syphilis, however the serological test may all be be ––ve.ve.

3 3 –– Biopsy from lesion, sepcilized stain, such as silver, Biopsy from lesion, sepcilized stain, such as silver, reveal the presence of spirochate. reveal the presence of spirochate.

* In secondary syphilis, the serological tests are * In secondary syphilis, the serological tests are positive with a VDRL titer of usually 1 in 32 or greater. positive with a VDRL titer of usually 1 in 32 or greater.

* Following treatment of primary or secondary * Following treatment of primary or secondary syphilis the titer of VDRL should fall two fold syphilis the titer of VDRL should fall two fold every 3 months, becoming every 3 months, becoming ––ve within 2 years.ve within 2 years.

* Following resolution of secondary syphilis, a * Following resolution of secondary syphilis, a period of latency occurs. No outward period of latency occurs. No outward manifestation of infection, only detected on manifestation of infection, only detected on serological testing. It may relapse up to 2 years serological testing. It may relapse up to 2 years during which Infection can be transmitted to during which Infection can be transmitted to several partners. Called early latent syphilis.several partners. Called early latent syphilis.

* Primary and secondary syphilis are not life * Primary and secondary syphilis are not life threatening. The importance of diagnosis : threatening. The importance of diagnosis :

1 1 –– rest on the risk of late tertiary syphilis, rest on the risk of late tertiary syphilis, neurosyphilis can be manifested within 5 years of neurosyphilis can be manifested within 5 years of infection in the form of menoingovascular syphilis infection in the form of menoingovascular syphilis presents with stroke. This may progress presents with stroke. This may progress subsequently to tabes dorsalis or general paresis subsequently to tabes dorsalis or general paresis of insane . of insane .

2 2 –– Another risk is vertical transmission which may cause Another risk is vertical transmission which may cause intrauterine death ( IUD ) on a severely affected neonate.intrauterine death ( IUD ) on a severely affected neonate.

Less severe infection may present during late childhood with Less severe infection may present during late childhood with the stigmata of congenital syphilis including eighth nerve the stigmata of congenital syphilis including eighth nerve deafness, interstitial keratitis and abnormal teeth. The risk of deafness, interstitial keratitis and abnormal teeth. The risk of congenital infection is highest ( 70% ) with primary and congenital infection is highest ( 70% ) with primary and secondary syphilis. The effect of late congenital infection are not secondary syphilis. The effect of late congenital infection are not prevented unless the mother is treated before 20 weeks of prevented unless the mother is treated before 20 weeks of gestation. gestation.

Treatment :Treatment :

The treatment of choice is penicillin, a variety of The treatment of choice is penicillin, a variety of regimens are used.regimens are used.

1 1 –– Procaine penicillin 1.2 mu daily by IM injection for Procaine penicillin 1.2 mu daily by IM injection for 12 days.12 days.

2 2 –– Benzathine penicilline 2.4 mu by IM injection Benzathine penicilline 2.4 mu by IM injection repeated after 7 days . repeated after 7 days .

3 3 –– Doxycycline 100 mg two times a day for 14 days. Doxycycline 100 mg two times a day for 14 days. 4 4 –– Erythromycine 500 mg four times a day for 14 Erythromycine 500 mg four times a day for 14

days.days. If infection has been present for more than 1 year, If infection has been present for more than 1 year,

treatment is extended for 21 days for penicilline treatment is extended for 21 days for penicilline regimen and 28 days for oral regimen.regimen and 28 days for oral regimen.

In pregnancy the absorption of erythromycin is In pregnancy the absorption of erythromycin is unreliable.unreliable.

Partners notification is essential. Children may need Partners notification is essential. Children may need to be tested, and sibling of congenital infection is to be tested, and sibling of congenital infection is possible.possible.

III Tropical Genital Ulcer Disease :III Tropical Genital Ulcer Disease :

1 1 –– Lymphogranuloma venereum ( LGV ) : Lymphogranuloma venereum ( LGV ) :

LGV is caused by specific serovars ( LLGV is caused by specific serovars ( L11 –– L L33 ) of ) of chlamydia trachomata, found in the far eats, sub chlamydia trachomata, found in the far eats, sub –– saharan Africa and south America.saharan Africa and south America.

In early stages In early stages –– small superficial ulcer that slowly small superficial ulcer that slowly increase in size but often goes unnoticed, more obvious increase in size but often goes unnoticed, more obvious are enlarged LN which become compressed by the are enlarged LN which become compressed by the inguinal ligament leading to the ( Grooving sign ), inguinal ligament leading to the ( Grooving sign ), sometimes matted together and discharge pus, forming sometimes matted together and discharge pus, forming a Bubo. In women sever proctitis can progress to a Bubo. In women sever proctitis can progress to fistulae and stricture. fistulae and stricture.

Diagnosis :Diagnosis :

Confirm serologically by complement fixation test.Confirm serologically by complement fixation test.

Treatment :Treatment : 1 1 –– Doxycycline 100 mg bd for 21 days. Doxycycline 100 mg bd for 21 days.

2 2 –– Erythromycin 500 mg four times a day for 21 Erythromycin 500 mg four times a day for 21

days.days.

2 2 –– Chancroid : Chancroid : Is an infection acquired by Haemophilus ducreyi. Is an infection acquired by Haemophilus ducreyi.

The geographical distribution is similar to LGV. It start The geographical distribution is similar to LGV. It start with small shallow ulcers usually multiple and painful, with small shallow ulcers usually multiple and painful, the edges are irregular and with localized LAP. the edges are irregular and with localized LAP.

The organisms can only be grown on specialized The organisms can only be grown on specialized culture medium and ideally the medium should be culture medium and ideally the medium should be inoculated directly from the patient. Even so it may be inoculated directly from the patient. Even so it may be difficult to obtain a positive culture.difficult to obtain a positive culture.

Treatment : Treatment : 1 1 –– Azithromycine 1 gram . Azithromycine 1 gram .

2 2 –– Ceftriaxone 250 mg IM. Ceftriaxone 250 mg IM.

3 3 –– ciprofluxacine 500 mg twice a day for 3 days. ciprofluxacine 500 mg twice a day for 3 days.

3 3 –– Granuloma inguinale ( Donovanosis ) : Granuloma inguinale ( Donovanosis ) : Caused by Klebsiella granulomatis ( previously know Caused by Klebsiella granulomatis ( previously know

as calymmatobacterium granulomatis ), it is endemic as calymmatobacterium granulomatis ), it is endemic in India, new Guinea and southern Africa.in India, new Guinea and southern Africa.

It start with discreet papules on the skin or vulva It start with discreet papules on the skin or vulva which can enlarge to form a beefy red painful ulcer, which can enlarge to form a beefy red painful ulcer, these may spread slowly around the perineum and the these may spread slowly around the perineum and the genitalia. As healing occur, fibrosis develop which may genitalia. As healing occur, fibrosis develop which may lead to lymphoedema and elephantiasis.lead to lymphoedema and elephantiasis.

Diagnosis :Diagnosis : Confirmed by biopsy or a crush preparation I n which Confirmed by biopsy or a crush preparation I n which

donovan bodies are visible.donovan bodies are visible.

TTreatment :reatment : 1 1 –– Ciprofluxacine 750 mg bd for 21 days minimum. Ciprofluxacine 750 mg bd for 21 days minimum.

2 2 –– Cotrimoxazole 960 mg bd for 21 days minimum. Cotrimoxazole 960 mg bd for 21 days minimum.

3 3 –– Doxycyclline 100 mg bd for 21 days minimum. Doxycyclline 100 mg bd for 21 days minimum.

4 4 –– Erythromycin 500 mg four times a day for 21 days Erythromycin 500 mg four times a day for 21 days minimum. minimum.

Other viral infections :Other viral infections : 1- Human papilloma virus :1- Human papilloma virus : More than 70 different types of human papilloma More than 70 different types of human papilloma

virus ( HPV ) have been described. There are certain virus ( HPV ) have been described. There are certain genital strains preferentially infect the genital mucosa genital strains preferentially infect the genital mucosa and these thought to be sexually transmitted.and these thought to be sexually transmitted.

Infection is often established asymptomatically and Infection is often established asymptomatically and may be carried for years, probably life long. The virus may be carried for years, probably life long. The virus can infect the skin of the vulva, perineum, vagina, can infect the skin of the vulva, perineum, vagina, cervix and rectum. Warts are frequently multiple and cervix and rectum. Warts are frequently multiple and slowly increase in size. They can spread directly to the slowly increase in size. They can spread directly to the perianal skin without anal intercourse being practiced.perianal skin without anal intercourse being practiced.

The majority of genital warts are caused by HPV type The majority of genital warts are caused by HPV type 6-11 which have little oncogenic potential. HPV types 6-11 which have little oncogenic potential. HPV types 16-18 may cause flat warts and have been linked with 16-18 may cause flat warts and have been linked with the development of cervical carcinoma. the development of cervical carcinoma.

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Treatment : Treatment : Visible warts are usually treated with :Visible warts are usually treated with :

1 1 –– Physical methods such as cryotherapy. Physical methods such as cryotherapy.

2 2 –– Application of podophyllin once or twice / week for Application of podophyllin once or twice / week for up to 6 weeks.up to 6 weeks.

3 3 –– Surgical treatment is used for intractable cases, Surgical treatment is used for intractable cases, employing lasers, electrocautery or scissor excision.employing lasers, electrocautery or scissor excision.

Traditionally patients with warts have been advised to Traditionally patients with warts have been advised to use barrier methods of contraception during treatment use barrier methods of contraception during treatment and for the subsequent three months. Sexual partner and for the subsequent three months. Sexual partner should be examined and treated if have warts.should be examined and treated if have warts.

What ever treatment is used, the warts will recur until What ever treatment is used, the warts will recur until the immune response control growth of the warts virus. the immune response control growth of the warts virus. This can take several weeks or even months. This can take several weeks or even months.

2 2 –– Molluscum contagiosum : Molluscum contagiosum : this POX virus produce Painless pearly lesions with a this POX virus produce Painless pearly lesions with a

dimple up to 5 mm in diameter, they are common in dimple up to 5 mm in diameter, they are common in childhood and clear after few months. Adults may childhood and clear after few months. Adults may acquire infection during sexual intercourse and acquire infection during sexual intercourse and sometimes mistaken for genital warts.sometimes mistaken for genital warts.

Treatment : Treatment : Cryotherapy or following curettage and application of Cryotherapy or following curettage and application of

phenol.phenol.

The fluid from the vesicle is infectious and patients The fluid from the vesicle is infectious and patients should be warned not to pick at them. should be warned not to pick at them.

Molluscum contagiosumMolluscum contagiosum

3 3 –– HIV infection : HIV infection : Acquired immune deficiency syndrome ( AIDS )Acquired immune deficiency syndrome ( AIDS )

Was first described in San Francisco in 1983 caused by Was first described in San Francisco in 1983 caused by infection with human immunodeficiency virus ( HIV ) it infection with human immunodeficiency virus ( HIV ) it is a devastating disease because of stigmata of sexual is a devastating disease because of stigmata of sexual transmission and the risk of vertical transmission to transmission and the risk of vertical transmission to children.children.

The onset of immunodeficiency can be manifest in The onset of immunodeficiency can be manifest in any organ system, so that a high index of suspicion any organ system, so that a high index of suspicion required. required.

Virology :Virology : HIV is a retrovirus, single stranded RNA. Reverse HIV is a retrovirus, single stranded RNA. Reverse

transcriptase is carried within the core to enable transcriptase is carried within the core to enable proviral DNA to be produced in an infected cells. It proviral DNA to be produced in an infected cells. It usually bind to CDusually bind to CD4 4 receptors on T receptors on T –– helper helper lymphocytes, macrophages, dendretic cells and lymphocytes, macrophages, dendretic cells and microglia.microglia.

Current antiretrovial drugs target reverse Current antiretrovial drugs target reverse transcriptase or viral protease. The aim of these is to transcriptase or viral protease. The aim of these is to decrease the level of virus in the plasma to zero, with a decrease the level of virus in the plasma to zero, with a combination of anti combination of anti –– retroviral agents. If total retroviral agents. If total suppression not achieve , resistant strain will develop. suppression not achieve , resistant strain will develop.

Diagnosis : Diagnosis :

The test should be performed only with informed The test should be performed only with informed consent from the patient.consent from the patient.

1 1 –– By finding Ab to gp 120. By finding Ab to gp 120.

2 2 –– During seroconversion p24 Ag is detectable in During seroconversion p24 Ag is detectable in serum before Abserum before Abss are produced. are produced.

3 3 –– We monitor the disease by measuring CD We monitor the disease by measuring CD44 lymphocyte level in peripheral blood ( normal level > lymphocyte level in peripheral blood ( normal level > 0.5 /l ).0.5 /l ).

Transmission : Transmission : In developing countries, principally spread through In developing countries, principally spread through

vaginal intercourse.vaginal intercourse.

In developed countries, majority of infection acquired In developed countries, majority of infection acquired through homosexual sex or IV drug use.through homosexual sex or IV drug use.

Natural history and principles of treatment :Natural history and principles of treatment : 20% of infected individuals experience acute 20% of infected individuals experience acute

seroconversion illness a few weeks after acquistion, seroconversion illness a few weeks after acquistion, clinical features include fever, LAP, pharyngitis and clinical features include fever, LAP, pharyngitis and conjunctivitis. conjunctivitis.

Without Antiretroviral the median time to the Without Antiretroviral the median time to the development of AIDS is ten years defined by the onset development of AIDS is ten years defined by the onset of life of life –– threatening opportunistic infection or threatening opportunistic infection or malignancies associated with immune deficiency. malignancies associated with immune deficiency.

Treatment :Treatment : Usually combination of Antiretroviral agents :Usually combination of Antiretroviral agents :

1 1 –– Nucleoside analoque reverse transcriptase inhibitor Nucleoside analoque reverse transcriptase inhibitor such as Zidovidine.such as Zidovidine.

2 2 –– Non Non –– nucleoside reverse transcripotase inhibitor nucleoside reverse transcripotase inhibitor such as Nevirapine.such as Nevirapine.

3 3 –– Protase inhibitor such as Nelfinavir. Protase inhibitor such as Nelfinavir.

Immune deficiency has already occur, treatment and Immune deficiency has already occur, treatment and prevention of opportunistic infection is needed. prevention of opportunistic infection is needed.

Gynecological manifestations of HIV : Gynecological manifestations of HIV : Include :Include :

1 1 –– Persistent warts despite aggressive surgical Persistent warts despite aggressive surgical treatment. treatment.

2 2 –– Chronic HPV, result in development of cervical Chronic HPV, result in development of cervical carcinoma or vulvar intraepithelial neoplasia and carcinoma or vulvar intraepithelial neoplasia and Bowen's disease. So prefer annually pap smear in Bowen's disease. So prefer annually pap smear in women with HIV.women with HIV.

3 3 –– Eruption of secondary herpes may become Eruption of secondary herpes may become widespread, severe and persistent for weeks if not widespread, severe and persistent for weeks if not diagnosed and treated.diagnosed and treated.

4 4 –– Post partum endometritis is common in these Post partum endometritis is common in these women. women.

Kaposi’s sarcoma

(Cancer associated with AIDS)

Oral Thrush (yeast infection)

Common infection associated with AIDS

Oral Leukoplakia

Vertical transmission : Vertical transmission : Occur in 25 Occur in 25 –– 40 % of pregnancies if no intervention 40 % of pregnancies if no intervention

is used to reduce the risk.is used to reduce the risk.

3 interventions have been shown to reduce the risk of 3 interventions have been shown to reduce the risk of vertical transmission : vertical transmission :

1 1 –– Avoid breast feeding ( not in poor countries ) Avoid breast feeding ( not in poor countries )

2 2 –– Elective C/S . Elective C/S .

3 3 –– Antiviral medication prescribed during the latter Antiviral medication prescribed during the latter half of pregnancy and to the neonate for 6 weeks. half of pregnancy and to the neonate for 6 weeks.

By these the risk of transmission, less than 3%.By these the risk of transmission, less than 3%.