Sexually Transmitted Diseases

David W. Haas, M.D.Division of Infectious Diseases

Vanderbilt University School of MedicineNashville, 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

Arthritis-dermatitis syndrome

Septic arthritis

Joint involvement

Number several 1 or 2

Sites Knee, elbow, wrist, ankle

Knee, elbow, wrist, ankle

Character Tenosynovitis Frank arthritis

Cells <20,000 WBC/mm3 >50,000WBC/mm3

Culture Negative Often positive

Papules/pustules 5-40 Absent

Blood culture 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) OR• Cefixime (400mg PO x 1 dose) OR• Cefpodoxime (400mg PO x 1 dose) OR• Ciprofloxacin (500mg PO x 1 dose) OR• Gatifloxacin (400mg PO x 1 dose) OR• Levofloxacin (250mg PO x 1 dose)

+• Azithromycin 1g po x 1 dose OR• Doxycycline 100mg q12h po x 7 days

Treatment of GonorrheaGeneral 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 trachomatisGenital 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

• Primary

• Secondary

• Latent

• Late

Onset

3 weeks

2-8 weeks

>8 weeks

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. Abrade lesion with dry gauze

2. Obtain serous exudate

3. Place on slide with coverslip

4. View motile spirochetes

• Great for primary and secondary syphilis, not for oral lesions

Syphilis Serology

Primary Secondary Late

Nontreponemal tests

(VDRL & RPR)75% 99%

1%

(if treated)

Specific treponemal tests

(FTA-Abs,

MHA-TP, TPHA)

75% 100% 95%

Who with Latent SyphilisNeeds 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