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1
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2
MINOR STDS So You Think These are Minor
Infections!

• Presented by
• Charles L. Heaton, MD
• Professor of Dermatology
• University of Cincinnati
• College of Medicine

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The Problems for Todays Review

• Trichomonas vaginalis
• Molluscum contagiosum
• Lymphogranuloma venereum
• Granuloma inguinale

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TRICHOMONAS VAGINALIS
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TRICHOMONAS VAGINALIS

• The most common non-viral STD
• Etiology Trichomonas vaginalis - a flagellated
  protozoan
• Incubation 4 to 28 days
• Diagnosis - Clinical
• Asymptomatic - infrequent in females
  - frequently in males
• continued

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TRICHOMONAS VAGINALIS

• Diagnosis - Clinical
• Acute
• Females
• Pruritus of vulvae
• Vulvar erythema edema
• Malodorous, frothy-gray cervical vaginal
  discharge
• Strawberry cervix
• Dyspareunia
• continued

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TRICHOMONAS VAGINALIS
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TRICHOMONAS VAGINALIS
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TRICHOMONAS VAGINALIS
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TRICHOMONAS VAGINALIS
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TRICHOMONAS VAGINALIS
TRICHOMONAS ORALIS
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TRICHOMONAS VAGINALIS

• Diagnosis - Clinical
• Acute
• Males
• Leukorrhea - rule out chlamydia
• Urethral itch
• Urethral irritation
• continued

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TRICHOMONAS VAGINALIS

• Diagnosis - Clinical
• Subacute to chronic in females
• Bartholinitis skeneitis
• Salpingitis

continued
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TRICHOMONAS VAGINALIS

• Diagnosis - Clinical
• Perinatal
• Preterm delivery
• Low birth weight
• Pneumonia
• Bronchitis
• Oral ulcerations
• continued

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TRICHOMONAS VAGINALIS

• Diagnosis - Clinical
• Subacute to chronic in males
• Prostatitis
• Epididymitis
• Urethral strictures
• continued

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TRICHOMONAS VAGINALIS

• Diagnosis - Laboratory
• Wet mounts (75 sensitivity)
• Urinary sediment (75 sensitivity)
• Culture - 10 to 12 days
• PCR
• Sensitivity 95
• Specificity 98
• continued

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TRICHOMONAS VAGINALIS

• Diagnosis -Laboratory
• Elisa
• Sensitivity 82
• Specificity 73
• Direct FA
• Sensitivity 85
• Specificity 99
• continued

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TRICHOMONAS VAGINALIS

• Diagnosis -Laboratory
• Culture
• Sensitivity - Diamonds media 95
• Sensitivity - Hollander media 95

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TRICHOMONAS VAGINALIS

• Treatment - Females and Males
• Drug of choice
• Metronidazole, 2 grams once or 250 mg tid or 375
  mg bid po x 7 days
• Tinidazole, 2 grams once
• Similar to metronidazole but not marketed USA
• As effective as metronidazole better tolerated
• Ornidazole, similar to tinidazole used outside
  USA
• continued

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TRICHOMONAS VAGINALIS

• Treatment - Females and Males
• Special considerations
• Metronidazole contraindicated for first trimester
  pregnant patients
• If alcohol consumed metronidazole can produce
  antabuse effect
• Candida albican vaginitis can develop in some
  patients treated with metronidazole
• continued

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TRICHOMONAS VAGINALIS

• Treatment - Females and Males
• Special consideration
• Treat sexual partners simultaneously to reduce
  failure prevent exogenous reinfection
• Neonatal infections (over 4th week of life) can
  be treated with metronidazole 10-30 mg/kg qd x
  5-8 days

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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM

• Etiology Poxviruses (Nakano group 2)
• Incubation 1 week to 6 months with average being
  14-50 days
• Asymptomatic carrier Probably exists but no firm
  data
• Reservoir Probably human

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MOLLUSCUM CONTAGIOSUM

• Diagnosis - Clinical
• Children
• Pink, dome-shaped and umbilicated papules
• Face, eyelids, trunk, proximal extremities
• Young adults
• Pink, dome-shaped and umbilicated papules
• Older lesions may be verrucous
• Lower abdominal wall, pubis, proximal inner
  thighs, genitalia continued

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MOLLUSCUM CONTAGIOSM

• Diagnosis - Clinical
• Immune compromised (esp. HIV/AIDS)
• Confluent large umbilicated papules and nodules
• Frequently on the face
• May occur on mucous membranes (mouth nose)
• continued

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MOLLUSCUM CONTAGIOSUM

• Diagnosis - Clinical
• Spontaneous resolution - via trauma frequently
• With pustules clinically
• With foreign body reaction histologically
• Laboratory
• Biopsy - Henderson-Peterson bodies
• Serology - negative

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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
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MOLLUSCUM (HENDERSON- PETERSON BODIES)
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MOLLUSCUM(HENDERSON- PETERSON BODIES)
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MOLLUSCUM CONTAGIOSUM

• Treatment
• Removal - curettage
• Destruction
• Cryotherapy - chemical irritation coagulation
• Electrodesiccation - light
• Medication
• Tretinoin
• Imiquimod

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MOLLUSCUM CONTAGIOSUM

• Sexual partners
• Examine
• Remove any clinical lesions

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LYMPHOGRANULOMAVENEREUM
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LYMPHOGRANULOMA VENEREUM

• Etiology Chlamydia trachomatis var
  lymphogranulomatosis
• Incubation Approximately 30 days
• Diagnosis - Clinical
• Primary lesion
• Small chancriform lesion - infrequent
• continued

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Chlamydia Life Cycle
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LYMPHOGRANULOMA VENEREUM
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LYMPHOGRANULOMA VENEREUM
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LYMPHOGRANULOMA VENEREUM

• Diagnosis - Clinical
• Secondary lesion
• Regional adenopathy
• Nodes very tender
• Nodes fluctuant
• Protocolitis ? vaginal anal sex
• continued

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LYMPHOGRANULOMA VENEREUM
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LYMPHOGRANULOMA VENEREUM
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LYMPHOGRANULOMA VENEREUM

• Diagnosis - Clinical
• Late untreated
• Large bowel obstruction
• Sigmoid
• Rectal

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LYMPHOGRANULOMA VENEREUM
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LYMPHOGRANULOMA VENEREUM
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LYMPHOGRANULOMA VENEREUM
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LYMPHOGRANULOMA VENEREUM

• Laboratory
• Chlamydia Serotypes L1, L2, L3

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LYMPHOMARANULOMA VENEREUM

• Treatment
• Aspiration - drainage of bubos
• Preferred antibiotic
• Doxycyline, 100 mg po bid x 21 days
• Alternatives
• Erythromycin, 500 mg po qid x 21 days
• Sulfisoxazole, 500 mg po qid x 21 days
• continued

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LYMPHOGRANULOMA VENEREUM

• Treatment
• Expected responses to antibiotics
• 50 healed ulcers 7 days
• 80 healed ulcers 14 days
• 100 healed ulcers 28 days
• Relapse rate 3-5
• Pregnancy - erythromycin regimen

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LYMPHOGRANULOMA VENEREUM

• Sexual partners
• Examine
• Serotest
• Treat prospectively
• Report to health authority - required in most
  states - check with your health authority

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GRANULOMA INGUINALE
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GRANULOMA INGUINALE

• Etiology Calymmatobacterium granulomatis
• Incubation 30-50 days, maybe longer
• Sex Ratio Male/Female -10/1
• Infectivity Rate 12-52
• Geographic - worldwide
  - tropics particularly

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GRANULOMA INGUINALE

• Clinical Forms
• Ulcerovegative - most common
• Hypertrophic or verrucous
• Necrotic
• Cicatricial
• Rare Dissemination

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GRANULOMA INGUINALE
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GRANULOMA INGUINALE
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GRANULOMA INGUINALE
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GRANULOMA INGUINALE
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GRANULOMA INGUINALE
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GRANULOMA INGUINALE
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GRANULOMA INGUINALE
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GRANULOMA INGUINALE

• Complications
• Pseudobuboes
• Elephantiasis
• Squamous cell carcinoma
• Dissemination

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GRANULOMA INGUINALE

• Diagnosis - Clinical
• Histology
• Donovan bodies - mononuclear cells with straight
  or bent rods that have deep staining poles
• Cytology - scrapings
• Biopsy
• Wrights-Giemsas stains
• Silver stain
  continued

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GRANULOMA INGUINALE
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GRANULOMA INGUINALE
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GRANULOMA INGUINALE

• Diagnosis - Clinical
• Serology - negative
• Culture - not clinically useful

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GRANULMONA INGUINALE

• Differential Diagnoses
• Histology
• Histoplasmosis
• Leishmaniasis
• Rhinoscleroma
  continued

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GRANULOMA INGUINALE

• Differential Diagnosis
• Clinically
• Squamous cell carcinoma
• Syphilis
• Lupus vulgaris
• Pyoderma gangrenosum

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GRANULOMA INGUINALE

• Treatment
• Tetracycline Hcl - 500 mg qid x 10-30 days
• Trimethoprim-Sulfamethoxazole - 500 mg qid x
  14-21 days
• Erythromycin (in pregnancy) - 500 mg qid x 14-21
  days
  continued

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GRANULOMA INGUINALE

• Treatment
• Gentamycin - 40 mg IM every 12 hours x 21 days
• Ampicillin - 500 mg every 6 hours x 21 days
• Fluoroquinolones, ie Ciprofloxacin
• Debridement and topical care

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DIFFERENTIAL DIAGNOSIS
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GRANULOMA INGUINALE
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CHANCRE
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EXOPHITIC CHANCRE
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Rule out SQUAMOUS CELL CA
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PEMPHAGUSFOLACEOUS
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SQUAMOUS CELL CA
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CHANCRE
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SQUAMOUS CELL CA
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MINOR STDs

• For More Information
• Cincinnati STD/HIV
• Prevention Training Center
• 1-800-459-2820

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MINOR STDsThe End

• Charles L. Heaton, MD
• Professor of Dermatology
• University of Cincinnati
• College of Medicine

83
To get your CME swww.stdptc.uc.edu

• Click on the title of this lecture. First timer
  users please register returning users log in.
• Chose the title of this lecture to access the
  evaluation. When you finish the evaluation you
  will be able to print your certificate.