Sexually transmitted diseases

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Sexually transmitted diseases

• Charles S. Bryan, M.D.
• November 30, 2007

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Here me, ambitious souls, Sex is the curse of
life!

• --Margaret Fuller Slack in Spoon River
  Anthology, by Edgar Lee Masters

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Genital ulcer disease overview

• Herpes simplex virus the most common caused in
  sexually active young adults in U.S.
  
• Treponema pallidum an important consideration in
  nearly all situations. Think syphilis!
  
• Chancroid uncommon in most areas of U.S. common
  in developing countries
  
• Lymphogranuloma venerum small ulcers, prominent
  lymphadenopathy
  
• Granuloma inguinale largely a tropical disease

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Whats your diagnosis?
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Herpesviruses

• HSV-1 and HSV-2
• Cytomegalovirus (CMV)
• Varicella-zoster virus (VZV)
• Epstein-Barr virus (EBV)
• HSV6 (A B) roseola, other conditions
• HSV7 role in disease unclear
• HSV8 Kaposi sarcoma

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Genital herpes

• 90 HSV-2, 10 HSV-1
• Estimated 400,000 episodes of primary infection
  and 20 million or more recurrent infections each
  year
  
• 20 of U.S. population between 15 and 40 have
  antibodies (any without history)

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Genital herpes (2)

• Recurrent herpes simplex pain, psychological
  distress in some (but not most) patients
  
• Maternal-infant transmission 50 mortality to
  newborn
  
• Concern that HSV ulcers may facilitate HIV
  transmission

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Genital herpes diagnosis

• Clinical diagnosis classically grouped
  vesicular, pustular, and ulcerative lesions
  
• Laboratory 90 sensitivity in vesiculopustular
  stage (culture, direct immunofluoresence, antigen
  detection)Serology little clinical value

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Primary genital herpes

• Lasts 2 to 3 weeks, with large numbers of skin
  lesions plus mucosal involvement (urethritis,
  cervicitis) and adenopathy
  
• Systemic manifestations occur including aseptic
  meningitis
  
• Urinary and fecal retention also occurs

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Recurrent genital herpes

• Mildly symptomatic to frankly subclinical
• Systemic and mucosal manifestations are not
  present
  
• Fewer lesions than in primary episodes illness
  usually only a few days

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Whats your diagnosis?
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Syphilis serology

• RPR (VDRL) is positive in 70 of primary, 99 of
  secondary, and 56 of late (tertiary) patients
  with syphilis
  
• Specific treponemal tests (FTA-ABS, MHA-TP, TPI)
  lose positive predictive value when done on
  low-prevalence populations
  
• Successful Rx of early syphilis should decrease
  RPR by 8-fold at 6 months

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Syphilis some current perspectives

• HIV epidemic patients do not respond uniformly
  to antibiotics
  
• Demographics occurs especially in
  African-Americans
  
• Congenital syphilis higher now than at any time
  since the 1940s

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Syphilis stages

• Primary chancre
• Secondary spirochetemia, immune complexes
• Latent positive serology without manifestations
• Tertiary (late) slowly progressive inflammatory
  disease (notably aorta, CNS)
  
• Congenital

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Course of syphilis
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Secondary syphilis
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Some causes of BFP reactions

• Infections (numerous)
• Connective tissue disorders
• Chronic liver disease
• Drug addiction
• Pregnancy
• Aging

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Whats your diagnosis?
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Chancroid

• Hemophilus ducreyi schools of fish
• Soft chancre soft and painful (the opposite of
  syphilis, which is hard and painless)
  ragged-appearing with undermined edge, often on
  prepuce frenulum of men, labia and vestibule of
  women
• Rule out syphilis in every case

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Whats your diagnosis?
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Lymphogranuloma venereum

• Mainly caused by Chlamydia trachomatis serovars
  L1, L2, L3
  
• Painless vesicle, papule, or ulcer is easily
  overlooked
  
• Prominent inguinal lymphadenopathy with groove
  sign
  
• Late fibrosis, lymphatic obstruction

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Lymphogranuloma venereum

• Mainly caused by Chlamydia trachomatis serovars
  L1, L2, L3
  
• Painless vesicle, papule, or ulcer is easily
  overlooked
  
• Prominent inguinal lymphadenopathy with groove
  sign
  
• Late fibrosis, lymphatic obstruction

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Whats your diagnosis?
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Granuloma inguinale

• Calymmatobacterium granulomatis
• Uncommon (
• Small painless papule or nodule evolves into
  beefy red, exuberant heaped up ulcer with
  satin-like surface
  
• Donovan bodies bipolar-staining safety pins

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Whats your diagnosis?
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Neisseria gonorrhoeae

• Acute anterior urethritis in men Readily easily
  diagnosed (Grams stain)
  
• Endocervicitis in women Easily missed
  consequences can be tragic
  
• Rectal Likewise, nonspecific
• Pharyngitis Difficult to treat

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Neisseria gonorrhoeae (2)

• Modified Thayer-Martin medium vancomycin,
  colistin, nystatin, trimethoprim
  
• Plate out promptly Gonococci dont tolerate
  drying!
  
• Many strains have relative or absolute
  requirement for added C02 or HC03

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Neisseria gonorrhoeae (3)

• Pili facilitate attachment, impede phagocytosis
• Lipopolysaccharide marked endotoxin activity
  local cytopathic effect
  
• IgA protease cleaves IgA-1 subclass of
  immunoglobulins

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Neisseria gonorrhoeae (4)

• Porin (Por, formerly protein I) may facilitate
  endocytosis
  
• Opacity proteins (Opa, formerly protein II)
  contribute to attachment to human cells
  
• Reduction-modifiable protein (Rmp, formerly
  protein III stimulates blocking antibodies that
  reduce serum bactericidal activity

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Epidemiology of gonorrhea

• Peak 468 cases per 100,000 population (1 in 200
  people) in 1975
  
• female-to-male transmission 20 per episode,
  rising to 60-80 after 4 or more exposures
  
• male-to-female (less well-studied) about 50 per
  contact, rising to 90 after 3 exposures

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Pathology of gonorrhea

• Infects columnar or cuboidal epithelium
• Attachment to pili (mediated in part by pili and
  Opa) followed 24-48 hours later by penetration
  
• Vigorous PMN response with sloughing, development
  of microabscesses, exudation of pus

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Acute anterior urethritis in men

• Usual purulent urethral discharge after 2 to 7
  day incubation period
  
• 1/4 of men scant discharge
• Only 1 to 5 of men are asymptomatic
• 20 to 30 of heterosexual men are coinfected with
  Chlamydia
  
• Acute epididymitis now uncommon

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Uncomplicated genital infection in women

• Mainly endocervical canal (urethra colonized in
  70 to 90)
  
• Symptoms Increased vaginal discharge, dysuria,
  intermenstrual bleeding, menorrhagia
  
• Up to 90 may be asymptomatic
• Signs are subtle!

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Uncomplicated genital infection in women (2)

• Abdominal or pelvic pain usually (but not always)
  indicates salpingitis
  
• Physical exam purulent or mucopurulent cervical
  exudate but can be nonspecific
  
• Coinfection (e.g., Chlamydia, Trichomonas,
  Candida, Gardnerella, HSV-2) is common (and
  confusing)

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Anorectal gonorrhea

• Positive rectal cultures in up to 40 of women
  and 40 of gay men with uncomplicated gonorrhea
  but usually asymptomatic (as few as 10 have
  symptoms, but easily overlooked)
• Rectum only site of infection in 5 of women, 40
  of gay men

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Anorectal gonorrhea (2)

• Acute proctitis anal pruritus, tenesmus,
  purulent discharge, rectal bleeding
  
• Anoscopy exudate, inflammatory changes
• Infection with Chlamydia, HSV-2, other pathogens
  can produce similar findings

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Pharyngeal gonorrhea

• Positive throat cultures 3 to 7 of heterosexual
  men, 10 to 25 of gay men, 10 to 20 of women
  with gonorrhea 90 are asymptomatic
  
• Only rarely is pharynx the only site of
  infection wisdom of cultures thus debatable
  
• Can cause symptomatic pharyngitis

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P.I.D.

• P.I.D. Acute pelvic inflammatory disease
• Various combinations of endometritis,
  salpingitis, tuboovarian abscess, pelvic
  peritonitis
  
• Infertility 15 to 20 after one episode, 50 to
  80 after 3 or more episodes

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P.I.D. (2)

• Most consistent symptom lower abdominal pain,
  usually bilateral
  
• Often follows onset of menses by a few days
• 2/3rds of patients show fever, leukocytosis,
  elevated ESR
  
• Gonococcal PID more overt than chlamydial

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What is the likely clinical scenario for this
patient?
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Disseminated gonococcal infection

• Results from gonococccal bacteremia uncommon (3 of patients)
  
• Most common manifestation arthritis-dermatitis
  syndrome fever, leukocytosis, skin lesions,
  tenosynovitis, polyarthralgias, and/or
  oligoarthritis

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Disseminated gonococcal infection (2)

• Uncommon endocarditis, meningitis,
  perihepatitis
  
• Rare pneumonia, ARDS, osteomyelitis
• Strains causing disseminated infection tend to be
  sensitive to penicillin but resistant to
  bactericidal action of serum

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Whats your diagnosis?
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Chlamydia trachomatis

• 4 to 5 million new cases in U.S. each year most
  common bacterial STD. High rates especially in
  adolescents, African-Americans
  
• Antibodies to C. trachomatis present in 75 of
  women who are infertile due to tubal instruction
  vs. 25 of controls

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Chlamydia trachomatis (2)

• Infects same mucosal sites as N. gonorrheae
  (urethra, cervix, rectum, conjunctiva) and can
  also cause epididymitis, PID, ectopic pregnancy
  
• Asymptomatic infections during pregnancy can
  cause neonatal conjunctivitis and pneumonia

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Laboratory diagnosis of chlamydia infection

• Cell cultures are not widely available and are
  costly
  
• Antigen detection systems (ELISA,
  immunofluorescent) 60 to 90 sensitive, 98 to
  99 specific versus culture
  
• DNA tests (LCR or PCR) seem to be most sensitive
  and specific non-culture tests to date

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Chlamydia urethritis in men

• Only 1 of 8 infected men followed without Rx
  developed symptoms
  
• However, C. trachomatis causes 30-50 of
  symptomatic nongonococcal urethritis and an even
  higher proportion of postgonococcal urethritis
  
• Incidence exceeds gonococcal urethritis by at
  least 2 to 1

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Chlamydia urethritis (2)

• White, gray, or sometimes clear discharge
• Grams stain average of 4 or more WBCs/oil
  field per HPF (but this criterion misses 1/4 of
  cases)
  
• Complications epididymitis reactive arthritis
  including Reiters syndrome transmission to women

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Chlamydia infection in women

• Acute urethral syndrome (one of several causes)
• Mucopurulent cervicitis (presumptive diagnosis
  yellow or green mucopus 10 WBCs/hpf friable
  cervix) seems to enhance likelihood of HIV
  transmission

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Chlamydia in women (2)

• P.I.D. -- Chlamydia may cause up to 1/2 of cases
  in the U.S. each year (on average, Chlamydia are
  isolated in about 20 of cases)
  
• Ectopic pregnancy 80 have antibodies to
  Chlamydia
  
• Risk to neonates inclusion conjunctivitis,
  pneumonia

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