Sexually Transmitted Diseases. by dr Jeffri.pdf
JeffriWahyudi
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Sep 08, 2024
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About This Presentation
Sexually Infection
Slide Content
Syphilis
In 1494 : An outbreak of syphilis in Europe occurred in Naples,
Italy, during a French invasion (Italian War of 1494–98).
"French disease“
"Great Pox"
Italy, during a French invasion (Italian War of 1494–98).
"French disease“
"Great Pox"
In 1530, Girolamo Fracastoro, The Italian
physician and poet, was first used the name
"syphilis" (the name of a character of the
pastoral who suffer from the Great Pox).
The exact origin of syphilis is disputed.
•Columbian hypotheses:
“hypotheses proposes that syphilis
was carried from the Americas to
Europe by the returning crewmen
from Christopher Columbus's voyage
to the Americas”
•Pre-Columbian hypotheses
“hypothesis says that syphilis existed
in Europe previously, but went
unrecognized until shortly after
Columbus' return”.
https://en.wikipedia.org/wiki/
physician and poet, was first used the name
"syphilis" (the name of a character of the
pastoral who suffer from the Great Pox).
The exact origin of syphilis is disputed.
•Columbian hypotheses:
“hypotheses proposes that syphilis
was carried from the Americas to
Europe by the returning crewmen
from Christopher Columbus's voyage
to the Americas”
•Pre-Columbian hypotheses
“hypothesis says that syphilis existed
in Europe previously, but went
unrecognized until shortly after
Columbus' return”.
https://en.wikipedia.org/wiki/
The causative organism, Treponema pallidum, was first identified
by Fritz Schaudinn and Erich Hoffmann in 1905.
wellcomeimages.org https://en.wikipedia.org/wiki/Fritz_Schaudinn
by Fritz Schaudinn and Erich Hoffmann in 1905.
wellcomeimages.org https://en.wikipedia.org/wiki/Fritz_Schaudinn
Syphilis is caused by Treponema pallidum
• A Gram-negative, thin, motile, spiral shaped
bacterium in the order Spirochaetales.
• Incubation period ~3 wk ( 10–90 days )
Transmission mode
1. Sexual contact with infected lesion or body fluid ( most common )
2. Tranplacental ( less common )
3. Blood tranfusion ( rare )
4. Accidental inoculation ( rare )
• A Gram-negative, thin, motile, spiral shaped
bacterium in the order Spirochaetales.
• Incubation period ~3 wk ( 10–90 days )
Transmission mode
1. Sexual contact with infected lesion or body fluid ( most common )
2. Tranplacental ( less common )
3. Blood tranfusion ( rare )
4. Accidental inoculation ( rare )
Pathology and Pathogenesis of Syphilis
The organisms enter the body via minute abrasions of epithelial cell
linings, by penetrating mucous membranes or via hair follicles, and
then there is a rapid systemic spread via the blood and lymphatics.
Treponema pallidum has been termed a 'stealth pathogen' because
of its lack of surface proteins.
Because of this lack of proteins, creating a vaccine has been
impossible.
The organisms enter the body via minute abrasions of epithelial cell
linings, by penetrating mucous membranes or via hair follicles, and
then there is a rapid systemic spread via the blood and lymphatics.
Treponema pallidum has been termed a 'stealth pathogen' because
of its lack of surface proteins.
Because of this lack of proteins, creating a vaccine has been
impossible.
Prevalence of syphilis in Thailand during 2005 – 2014
Per 100,000 pop
year 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
prevalence
2.50 2.43 2.53 2.23 3.27 2.85 3.62 3.17 3.62 4.89
cases
1,557 1,521 1,592 1,408 2,076 1,814 2,313 2,037 2,319 3,134
0
1
2
3
4
5
6
2005200620072008200920102011201220132014
Syphilis
prevalence…
Per 100,000 pop
year 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
prevalence
2.50 2.43 2.53 2.23 3.27 2.85 3.62 3.17 3.62 4.89
cases
1,557 1,521 1,592 1,408 2,076 1,814 2,313 2,037 2,319 3,134
0
1
2
3
4
5
6
2005200620072008200920102011201220132014
Syphilis
prevalence…
USA
Percentage of Syphilis cases in MSM clinic, Bangrak hospital ( 2004 – 2013 )
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
MSW
MSM
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
MSW
MSM
อายุ
ราย
Syphilis cases by age group during 2005 – 2014
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
<14 11 10 10 14 18 11 8 12 21 29
15-24 297 291 286 245 410 367 473 425 554 801
25-34 463 358 430 325 553 413 536 438 486 664
35-44 346 365 361 340 482 401 532 433 419 597
0
100
200
300
400
500
600
700
800
900
2548 2549 2550 2551 2552 2553 2554 2555 2556 2557
<14
15-24
25-34
35-44
อายุ
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
ราย
Syphilis cases by age group during 2005 – 2014
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
<14 11 10 10 14 18 11 8 12 21 29
15-24 297 291 286 245 410 367 473 425 554 801
25-34 463 358 430 325 553 413 536 438 486 664
35-44 346 365 361 340 482 401 532 433 419 597
0
100
200
300
400
500
600
700
800
900
2548 2549 2550 2551 2552 2553 2554 2555 2556 2557
<14
15-24
25-34
35-44
อายุ
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Manifestations of syphilis
Syphilis has 3 distinct stages and a latency stage between the
second and third stages
•Primary Syphilis
•Secondary Syphilis
The Latency Stage
•Tertiary Syphilis
Syphilis has 3 distinct stages and a latency stage between the
second and third stages
•Primary Syphilis
•Secondary Syphilis
The Latency Stage
•Tertiary Syphilis
Principal lesion = Hard chancre
o Syphilitic chancres are indurated
o Painless
o Highly infectious
o Occur anywhere on the body
o Heal in 3-6 weeks.
( Hard chancre and regional lymphadenitis ) Primary syphilis
o Syphilitic chancres are indurated
o Painless
o Highly infectious
o Occur anywhere on the body
o Heal in 3-6 weeks.
( Hard chancre and regional lymphadenitis ) Primary syphilis
Secondary syphilis
- Begin 6-8 weeks after the appearance of the initial chancre
- The principal manifestations of 2°syphilis are skin and mucous
membrane lesions, as well as manifestations of systemic disease
- Malaise
- Anorexia
- Headache
- Sore throat
- Arthralgia
- Low grade fever
- Generalized lymphadenopathy
- 2° syphilis lasts 2-6 weeks before the patient enters the latent phase
- There is a high bacteremia during secondary syphilis
- Begin 6-8 weeks after the appearance of the initial chancre
- The principal manifestations of 2°syphilis are skin and mucous
membrane lesions, as well as manifestations of systemic disease
- Malaise
- Anorexia
- Headache
- Sore throat
- Arthralgia
- Low grade fever
- Generalized lymphadenopathy
- 2° syphilis lasts 2-6 weeks before the patient enters the latent phase
- There is a high bacteremia during secondary syphilis
Secondary syphilis
Condyloma lata
Condyloma lata
Secondary Syphilis in MSM
Differential diagnosis
The skin rash of secondary syphilis may be confused with
•Pityriasis rosea
•Psoriasis
http://www.webmd.com/skin-problems-and-treatments/toc-
image-picture-of-pityriasis-rosea
http://www.dermalex.co.uk/wp-content/themes/elogix/images/psoriasis_guttate.jpg
The skin rash of secondary syphilis may be confused with
•Pityriasis rosea
•Psoriasis
http://www.webmd.com/skin-problems-and-treatments/toc-
image-picture-of-pityriasis-rosea
http://www.dermalex.co.uk/wp-content/themes/elogix/images/psoriasis_guttate.jpg
Differential diagnosis
•Erythema multiforme
•Drug eruption
http://images.medicinenet.com/images/image_collection/pediatrics/erythema-
multiforme-13-8.jpg
http://mydermpath.com/index.
•Erythema multiforme
•Drug eruption
http://images.medicinenet.com/images/image_collection/pediatrics/erythema-
multiforme-13-8.jpg
http://mydermpath.com/index.
Patchy alopecia
Mucous patches
Mucous patches
Latent syphilis – Asymptomatic
– Detectable by abnormal serologic test results
Definition: persons with serological evidence for syphilis who have
never received treatment for this disease and who have no clinical
manifestations are said to have latent syphilis.
Early latent syphilis ( infection onset ≤ 1 yr.)
Late latent syphilis ( infection onset ≥ 1 yr. or unknown duration)
1/3 slowly progress to 3 ° syphilis
The rest remain asymptomatic
– Detectable by abnormal serologic test results
Definition: persons with serological evidence for syphilis who have
never received treatment for this disease and who have no clinical
manifestations are said to have latent syphilis.
Early latent syphilis ( infection onset ≤ 1 yr.)
Late latent syphilis ( infection onset ≥ 1 yr. or unknown duration)
1/3 slowly progress to 3 ° syphilis
The rest remain asymptomatic
Tertiary or late syphilis is a noncontagious but
highly destructive phase of syphilis which may take
many years to develop; it may manifest itself in 3 forms:
•Late benign or gummatous syphilis
•Cardiovascular syphilis
• Neurosyphilis
highly destructive phase of syphilis which may take
many years to develop; it may manifest itself in 3 forms:
•Late benign or gummatous syphilis
•Cardiovascular syphilis
• Neurosyphilis
•1 - 20 years from the acute infection to clinical onset of the late or
tertiary stages of disease.
•In the preantibiotic era, about one-third of untreated infections
were followed by tertiary syphilis.
•In the antibiotic era, all but neurosyphilis are now curiosities in the
developed world, probably because of the effects of intermittent
antibiotics on the development of gummas and cardiovascular
disease.
tertiary stages of disease.
•In the preantibiotic era, about one-third of untreated infections
were followed by tertiary syphilis.
•In the antibiotic era, all but neurosyphilis are now curiosities in the
developed world, probably because of the effects of intermittent
antibiotics on the development of gummas and cardiovascular
disease.
Late benign syphilis
http://www.google.co.th/imgres?imgurl=http://jeffreysterlingmd.files.wordpress.com/
2013/09/syphilis3.jpg&imgrefurl=http://jeffreysterlingmd.com/tag/rash/&h=643&w=
971&tbnid=F60UcM8AxpkLRM:&docid=6Dtdh1rwFKD67M&ei=WfM1Vp -
6BKW2mwXNv4mQAQ&tbm=isch&ved=0CCQQMygJMAlqFQoTCN_Kx8OL78gC
FSXbpgodzV8CEg
http://www.google.co.th/imgres?imgurl=http://jeffreysterlingmd.files.wordpress.com/
2013/09/syphilis3.jpg&imgrefurl=http://jeffreysterlingmd.com/tag/rash/&h=643&w=
971&tbnid=F60UcM8AxpkLRM:&docid=6Dtdh1rwFKD67M&ei=WfM1Vp -
6BKW2mwXNv4mQAQ&tbm=isch&ved=0CCQQMygJMAlqFQoTCN_Kx8OL78gC
FSXbpgodzV8CEg
Late benign or gummatous syphilis
www.studyblue.com
http://phil.cdc.gov/phil/details.asp?pid=2381
www.studyblue.com
http://phil.cdc.gov/phil/details.asp?pid=2381
Stage of Syphilis
Primary ( Chancre )
Contact ( 1/3 become infected )
Secondary
10 – 90 d
Early latent
( 1 yr from contact )
Relapsing ( in 25% )
Late latent
(≥ 1 yr )
Tertiary ( 1/3 )
Late benign ( 16 % )
Cardiovascular ( 9.6 % )
Neuro Sy ( 6.5 % )
3 – 12 wk
4 – 12 wk
Early Syphilis
Late Syphilis Remission ( 2/3)
4 – 6wk
av. 3 wk
Primary ( Chancre )
Contact ( 1/3 become infected )
Secondary
10 – 90 d
Early latent
( 1 yr from contact )
Relapsing ( in 25% )
Late latent
(≥ 1 yr )
Tertiary ( 1/3 )
Late benign ( 16 % )
Cardiovascular ( 9.6 % )
Neuro Sy ( 6.5 % )
3 – 12 wk
4 – 12 wk
Early Syphilis
Late Syphilis Remission ( 2/3)
4 – 6wk
av. 3 wk
Symptomatic VS Asymptomatic periods of Syphilis
4–6 wks 4–6 wks
4–6 wks 4–6 wks
Diagnostic Tests for Syphilis
Microscopy :
Dark field illumination
Culture :
Not used
Serology :
Nontreponemal = VDRL
RPR
Treponemal tests = FTA-ABS
TPHA
Hard chancre
Condyloma lata
Microscopy :
Dark field illumination
Culture :
Not used
Serology :
Nontreponemal = VDRL
RPR
Treponemal tests = FTA-ABS
TPHA
Hard chancre
Condyloma lata
Treponema pallidum under Dark-field microscopy
Diagnostic test of choice in Chancre and some lesion of secondary syphilis (
Condyloma lata and Mucous patch )
Diagnostic test of choice in Chancre and some lesion of secondary syphilis (
Condyloma lata and Mucous patch )
Serology
1. Nontreponemal test :
Use for screening and to follow therapeutic response
- VDRL
- RPR
2. Treponemal tests :
Use to confirm reactive nontreponemal test result
- FTA-ABS
- TPHA
1. Nontreponemal test :
Use for screening and to follow therapeutic response
- VDRL
- RPR
2. Treponemal tests :
Use to confirm reactive nontreponemal test result
- FTA-ABS
- TPHA
Measure IgG and IgM antibodies developed against lipids
from damaged cells during the early stage of the disease.
The antigen used for the nontreponemal tests is cardiolipin
(derived from beef heart).
The two tests used commonly
1. Venereal Disease Research Laboratory ( VDRL )
2. Rapid plasma reagin ( RPR )
Both tests measure coagulation of cardiolipin antigen by the
patient's serum.
Nontreponemal tests
from damaged cells during the early stage of the disease.
The antigen used for the nontreponemal tests is cardiolipin
(derived from beef heart).
The two tests used commonly
1. Venereal Disease Research Laboratory ( VDRL )
2. Rapid plasma reagin ( RPR )
Both tests measure coagulation of cardiolipin antigen by the
patient's serum.
Nontreponemal tests
VDRL become reactive 4-5 wk after infection and revert to
negative during late latency ( 25-30% of cases ).
Result are reported quantitatively as a titer of the sample dilution.
The highest dilution give a positive result is report as “ titer “
A high titer (≥ 1:32 ) indicate active disease
A low titer (≤ 1:8 ) may remain unchanged for year
after therapy of late syphilis
After treatment, the titer should decline 4-fold with in 6 mo
in primary/secondary syphilis or within 24 mo. in latent syphilis
(e.g., from 1:16 to 1:4 or lower ).
negative during late latency ( 25-30% of cases ).
Result are reported quantitatively as a titer of the sample dilution.
The highest dilution give a positive result is report as “ titer “
A high titer (≥ 1:32 ) indicate active disease
A low titer (≤ 1:8 ) may remain unchanged for year
after therapy of late syphilis
After treatment, the titer should decline 4-fold with in 6 mo
in primary/secondary syphilis or within 24 mo. in latent syphilis
(e.g., from 1:16 to 1:4 or lower ).
Treponemal tests
The tests most commonly used are
1. Fluorescent Treponemal Antibody Absorption (FTA-ABS)
2. T. pallidum hemagglultination assay (TPHA)
• Specific antibody tests used to confirm positive reactions with the
VDRL or RPR tests.
• Can be positive before the nontreponemal tests become positive
in early syphilis.
• May also remain positive when the nonspecific tests revert to
negative in some patients who have late syphilis.
The TPHA is technically easier to perform and interpret than the
FTA-ABS tests.
The tests most commonly used are
1. Fluorescent Treponemal Antibody Absorption (FTA-ABS)
2. T. pallidum hemagglultination assay (TPHA)
• Specific antibody tests used to confirm positive reactions with the
VDRL or RPR tests.
• Can be positive before the nontreponemal tests become positive
in early syphilis.
• May also remain positive when the nonspecific tests revert to
negative in some patients who have late syphilis.
The TPHA is technically easier to perform and interpret than the
FTA-ABS tests.
FTB-ABS
• FTB-ABS is the most sensitive serological test in primary syphilis
• Reactivity begin during 3
rd
wk of infection
• Reactivity usually continue even after treament
• False negative result is very rare
FTA-ABS
• FTB-ABS is the most sensitive serological test in primary syphilis
• Reactivity begin during 3
rd
wk of infection
• Reactivity usually continue even after treament
• False negative result is very rare
FTA-ABS
Non
Reactive
Reactive
Nontreponemal
tests
( VDRL/ RPR)
Treponemal
tests
(FTA -ABS / TPHA)
Interpretation
+ +
- +
+ -
Interpretation of Different Serological Tests in Syphilis
Treated syphilis
Late latent syphilis
Prozone phenomenon
Syphilis
tests
( VDRL/ RPR)
Treponemal
tests
(FTA -ABS / TPHA)
Interpretation
+ +
- +
+ -
Interpretation of Different Serological Tests in Syphilis
Treated syphilis
Late latent syphilis
Prozone phenomenon
Syphilis
The prozone phenomenon
• A false negative response resulting from
overwhelming antibody titers.
• The prozone effect is most often associated with
secondary syphilis,
HIV co-infection.
• The incidence of prozone phenomenon to be
between 0.2 - 2%, higher
in the HIV population.
• A false negative response resulting from
overwhelming antibody titers.
• The prozone effect is most often associated with
secondary syphilis,
HIV co-infection.
• The incidence of prozone phenomenon to be
between 0.2 - 2%, higher
in the HIV population.
Nontreponemal
tests
( VDRL/ RPR )
Treponemal
tests
(FTA -ABS / TPHA)
Interpretation
+ +
- +
+ -
Interpretation of Different Serological Tests in Syphilis
Treated syphilis
Late latent syphilis
Prozone phenomenon
Syphilis
Biological false positive VDRL
tests
( VDRL/ RPR )
Treponemal
tests
(FTA -ABS / TPHA)
Interpretation
+ +
- +
+ -
Interpretation of Different Serological Tests in Syphilis
Treated syphilis
Late latent syphilis
Prozone phenomenon
Syphilis
Biological false positive VDRL
Biological false positive VDRL
Biological false positive VDRL
Stage of Syphilis
Primary ( Chancre )
Secondary
Early latent
( 1 yr from contact )
Late latent
(≥ 1 yr )
Tertiary ( 1/3 )
3 – 12 wk
4 – 12 wk
Remission ( 2/3)
( Life-long latency )
Contact
3 wk. ( 10 – 90 d)
VDRL/
RPR
FTA -
ABS
TPHA
- + -
+ + +
+ + +
- + +
VDRL/
RPR
FTA -
ABS
TPHA
- + -
+ + +
+ + +
- + +
- + / -
+ /-
Primary ( Chancre )
Secondary
Early latent
( 1 yr from contact )
Late latent
(≥ 1 yr )
Tertiary ( 1/3 )
3 – 12 wk
4 – 12 wk
Remission ( 2/3)
( Life-long latency )
Contact
3 wk. ( 10 – 90 d)
VDRL/
RPR
FTA -
ABS
TPHA
- + -
+ + +
+ + +
- + +
VDRL/
RPR
FTA -
ABS
TPHA
- + -
+ + +
+ + +
- + +
- + / -
+ /-
Stage of Syphilis
Primary ( Chancre )
Secondary
Early latent
( 1 yr from contact )
Late latent
(≥ 1 yr )
Tertiary ( 1/3 )
3 – 12 wk
4 – 12 wk
Remission ( 2/3
( Life-long latency )
VDRL/
RPR
FTA -
ABS
TPH
A
- + -
+ + +
+ + +
- + +
+ +
+
Contact
3 wk. ( 10 – 90 d)
Cardiovascular Syphilis
Late benign Syphilis
Neuro Syphilis
1 -2 yr.
CNS invasion
Transient Asymptomatic Meningitis
Meningovascular
Parenchymatous
Gummatous
5 – 10 yr.
15- 20 yr
Primary ( Chancre )
Secondary
Early latent
( 1 yr from contact )
Late latent
(≥ 1 yr )
Tertiary ( 1/3 )
3 – 12 wk
4 – 12 wk
Remission ( 2/3
( Life-long latency )
VDRL/
RPR
FTA -
ABS
TPH
A
- + -
+ + +
+ + +
- + +
+ +
+
Contact
3 wk. ( 10 – 90 d)
Cardiovascular Syphilis
Late benign Syphilis
Neuro Syphilis
1 -2 yr.
CNS invasion
Transient Asymptomatic Meningitis
Meningovascular
Parenchymatous
Gummatous
5 – 10 yr.
15- 20 yr
Other types of treponemal tests for syphilis
• Immunochromatography test (Rapid test)
• Treponemal Enzyme Immunoassay (EIA)
• Chemiluminescence Immunoassay (CIA)
• IgG immunoblot test for T. pallidum (Western blot)
• Immunochromatography test (Rapid test)
• Treponemal Enzyme Immunoassay (EIA)
• Chemiluminescence Immunoassay (CIA)
• IgG immunoblot test for T. pallidum (Western blot)
Algorithm for screening for syphilis
•Traditional algorithm for screening syphilis
Nontreponemal test
(VDRL /RPR)
Treponemal test
(TPHA, FTS-ABS,etc )
Syphilis
Not syphilis
Not syphilis
Positive
Negative
Positive
Negative
•Traditional algorithm for screening syphilis
Nontreponemal test
(VDRL /RPR)
Treponemal test
(TPHA, FTS-ABS,etc )
Syphilis
Not syphilis
Not syphilis
Positive
Negative
Positive
Negative
Algorithm for screening for syphilis
•Reverse sequence for screening syphilis
•Reverse sequence for screening syphilis
Stage of Syphilis
Primary ( Chancre )
Secondary
Early latent
( 1 yr from contact )
Late latent
(≥ 1 yr )
Tertiary ( 1/3 )
3 – 12 wk
4 – 12 wk
Early Syphilis
Late
Syphilis
Remission ( 2/3)
Contact
3 wk. ( 10 – 90 d)
Primary ( Chancre )
Secondary
Early latent
( 1 yr from contact )
Late latent
(≥ 1 yr )
Tertiary ( 1/3 )
3 – 12 wk
4 – 12 wk
Early Syphilis
Late
Syphilis
Remission ( 2/3)
Contact
3 wk. ( 10 – 90 d)
Treatment
Early syphilis : Primary syphilis
Secondary syphilis
Early latent syphilis
= Benzathine pen G 2.4 million units IM single dose
Penicillin Allergy
• Doxycycline 100 mg orally twice daily for 14 days
• Tetracycline 500 mg four times daily for 14 days
• Ceftriaxone 1 g daily, IM or IV for 10–14 days is effective for treating early
syphilis
• The optimal dose and duration of ceftriaxone therapy have not been defined
Early syphilis : Primary syphilis
Secondary syphilis
Early latent syphilis
= Benzathine pen G 2.4 million units IM single dose
Penicillin Allergy
• Doxycycline 100 mg orally twice daily for 14 days
• Tetracycline 500 mg four times daily for 14 days
• Ceftriaxone 1 g daily, IM or IV for 10–14 days is effective for treating early
syphilis
• The optimal dose and duration of ceftriaxone therapy have not been defined
Treatment
Late latent syphilis
Tertiary syphilis with normal CSF examination
= Benzathine pen G 2.4 million units IM weekly * 3 weeks
Penicillin Allergy
The only acceptable alternatives for the treatment :
- Doxycycline 100 mg orally twice daily for 28 days
- Tetracycline 500 mg orally four times daily for 28 days
( - Ceftriaxone might be effective
- The optimal dose and duration have not been defined )
Late latent syphilis
Tertiary syphilis with normal CSF examination
= Benzathine pen G 2.4 million units IM weekly * 3 weeks
Penicillin Allergy
The only acceptable alternatives for the treatment :
- Doxycycline 100 mg orally twice daily for 28 days
- Tetracycline 500 mg orally four times daily for 28 days
( - Ceftriaxone might be effective
- The optimal dose and duration have not been defined )
http://www.wired.com/2009/08/0831chemotherapy-syphilis/
1907 : German physician Paul Ehrlich and Japanese student Sahachiro Hata produced their
preparation of an arsenobenzene compound (Salvarsan).
To kill syphilis but too toxic for use in humans because the drug could cause severe
tissue damage and even death if not injected directly into a vein.
1907 : German physician Paul Ehrlich and Japanese student Sahachiro Hata produced their
preparation of an arsenobenzene compound (Salvarsan).
To kill syphilis but too toxic for use in humans because the drug could cause severe
tissue damage and even death if not injected directly into a vein.
1928 : Sir Alexander Fleming
accidental discovery and isolation of
penicillin marks the start of modern
antibiotics.
http://www.thestar.com/news/insight/2007/05/06/penicillins_discovery.html
Penicillin's discovery
1940 : Penicillin replaced Salvarsan as the syphilis treatment of choice.
accidental discovery and isolation of
penicillin marks the start of modern
antibiotics.
http://www.thestar.com/news/insight/2007/05/06/penicillins_discovery.html
Penicillin's discovery
1940 : Penicillin replaced Salvarsan as the syphilis treatment of choice.
Neurosyphilis
1.Asymptomatic
2.Acute syphilitic meningitis
3.Meningovascular syphilis
4.Parenchymatous
5. Gummatous
Early neurosyphilis
Late neurosyphilis
5 – 12 yrs after infection.
15- 20 yrs ( 20 - 25 yrs ) after infection.
3 -7 months. ( 6 yrs.) after infection
After infection
1.Asymptomatic
2.Acute syphilitic meningitis
3.Meningovascular syphilis
4.Parenchymatous
5. Gummatous
Early neurosyphilis
Late neurosyphilis
5 – 12 yrs after infection.
15- 20 yrs ( 20 - 25 yrs ) after infection.
3 -7 months. ( 6 yrs.) after infection
After infection
Cerebrospinal fluid findings in neurosyphilis:
•Microscopy: lymphocytes > 5/mm
3
- Persons with HIV infection, CSF leukocyte count usually is elevated,
using a higher cutoff (>20 WBC/ mm3) might improve the specificity
of neurosyphilis diagnosis.
•Biochemistry::elevated protein levels (protein > 0.4 gm/l)
•Serology:
CSF VDRL : reactive => indicate neurosyphilis (specific)
but negative in 70% of neurosyphilis
CSF FTA or TPHA = unreliable because of false positive
negative test excludes neurosyphilis
•Microscopy: lymphocytes > 5/mm
3
- Persons with HIV infection, CSF leukocyte count usually is elevated,
using a higher cutoff (>20 WBC/ mm3) might improve the specificity
of neurosyphilis diagnosis.
•Biochemistry::elevated protein levels (protein > 0.4 gm/l)
•Serology:
CSF VDRL : reactive => indicate neurosyphilis (specific)
but negative in 70% of neurosyphilis
CSF FTA or TPHA = unreliable because of false positive
negative test excludes neurosyphilis
Indications for Lumbar Puncture (CDC Guidelines for 2002 and 2006)
• Neurologic/ophthalmic signs
• Late syphilis
• Treatment failure
• Patient with HIV infection and late latent syphilis or syphilis of unknown duration
The 2002 CDC guidelines mention that some specialists recommend lumbar
puncture in patients with latent syphilis and a serum RPR titer of ≥ 1:32 and
the 2006 guidelines state that this is also an option in patients with HIV infection
and a CD4+ count of ≤ 350/L.
The 2015 CDC guidelines : Not mention
2014 European Guideline on the Management of Syphilis:
Situations for exclusion of asymptomatic neurosyphilis:
- HIV positive patients with late syphilis and CD4+ cells ≤ 350/mm3 and/or
a serum VDRL/RPR titre >1:32
- in case of serological failure
- in case of use of alternative treatment (tetracyclines) during late syphils.
• Neurologic/ophthalmic signs
• Late syphilis
• Treatment failure
• Patient with HIV infection and late latent syphilis or syphilis of unknown duration
The 2002 CDC guidelines mention that some specialists recommend lumbar
puncture in patients with latent syphilis and a serum RPR titer of ≥ 1:32 and
the 2006 guidelines state that this is also an option in patients with HIV infection
and a CD4+ count of ≤ 350/L.
The 2015 CDC guidelines : Not mention
2014 European Guideline on the Management of Syphilis:
Situations for exclusion of asymptomatic neurosyphilis:
- HIV positive patients with late syphilis and CD4+ cells ≤ 350/mm3 and/or
a serum VDRL/RPR titre >1:32
- in case of serological failure
- in case of use of alternative treatment (tetracyclines) during late syphils.
Recommended Regimen :
Aqueous crystalline penicillin G 18–24 million units per day,
administered as 3–4 million units IV every 4 hours or continuous infusion,
for 10–14 days
Alternative Regimen :
Procaine penicillin 2.4 million units IM once daily
PLUS both for 10–14 days
Probenecid 500 mg orally four times a day
Treatment of Neurosyphilis
Aqueous crystalline penicillin G 18–24 million units per day,
administered as 3–4 million units IV every 4 hours or continuous infusion,
for 10–14 days
Alternative Regimen :
Procaine penicillin 2.4 million units IM once daily
PLUS both for 10–14 days
Probenecid 500 mg orally four times a day
Treatment of Neurosyphilis
•CSF examination should be repeated every 6 months until the cell
count is normal.
•Follow-up CSF-VDRL or CSF protein also can be used to evaluate
changes after therapy; however, changes in these two parameters
occur more slowly than cell counts, and persistent abnormalities
might be less important.
•Leukocyte count is a sensitive measure of the effectiveness of
therapy.
•If the cell count has not decreased after 6 months, or if the CSF cell
count or protein is not normal after 2 years, retreatment should be
considered.
Follow-up( Neurosyphilis)
count is normal.
•Follow-up CSF-VDRL or CSF protein also can be used to evaluate
changes after therapy; however, changes in these two parameters
occur more slowly than cell counts, and persistent abnormalities
might be less important.
•Leukocyte count is a sensitive measure of the effectiveness of
therapy.
•If the cell count has not decreased after 6 months, or if the CSF cell
count or protein is not normal after 2 years, retreatment should be
considered.
Follow-up( Neurosyphilis)
Case 1
•A 15 year old girl comes into clinic due to skin lesions
on her forehead and feet for 1 months.
•She has been sexually active with a truck driver guy 3
months ago, and reports not using condoms.
•She came here and wants to be checked for what skin
disease she had.
•A 15 year old girl comes into clinic due to skin lesions
on her forehead and feet for 1 months.
•She has been sexually active with a truck driver guy 3
months ago, and reports not using condoms.
•She came here and wants to be checked for what skin
disease she had.
Skin lesions on her
forehead and feet.
forehead and feet.
Skin lesions on her genitalia
Condyloma lata
Condyloma lata
Dark-field Illumination test for Condyloma lata
Treponema pallidum
Treponema pallidum
Diagnosis : Secondary Syphilis
VDRL = 1 : 32
TPHA = Reactive
FTA-ABS = Reactive
Treatment : Benzathine penicillin G 2.4 mU IM single dose
VDRL = 1 : 32
TPHA = Reactive
FTA-ABS = Reactive
Treatment : Benzathine penicillin G 2.4 mU IM single dose
2 mo. After treatment
After treatment
Case 2
•A 16 year old female comes into the clinic with a
complaint of vaginal lesions for one month.
•She is sexually active with >10 sex partners, using
condoms “less of the time”.
•The lesions are described as thick, flesh, skin tumor-
like on her genital area.
•A 16 year old female comes into the clinic with a
complaint of vaginal lesions for one month.
•She is sexually active with >10 sex partners, using
condoms “less of the time”.
•The lesions are described as thick, flesh, skin tumor-
like on her genital area.
Human papilloma virus
T. pallidum
Condyloma Acuminata
Secondary syphilis
Podophyllin 25% or TCA 80-90 %
Benzathine penicillin G
T. pallidum
Condyloma Acuminata
Secondary syphilis
Podophyllin 25% or TCA 80-90 %
Benzathine penicillin G
5 mo. After treatment
DISCAR URETRA dan
FLUOR ALBUS
FLUOR ALBUS
Pemeriksaan IMS
•ANAMNESIS
•Keluhan saat datang
•Riwayat seksual (coitus suspectus) :
• a. kontak seksual, di dlm/luar nikah, gonta- ganti
pasangan (kontak seksual multipel)
• b. kontak dg pasangan setelah gejala
• c. frekuensi hub sex dan jenis
• (homo/hetero)
• d. cara hub (genital, anal, oral)
• e. apakah psngan jg menderita
• keluhan sama.
•ANAMNESIS
•Keluhan saat datang
•Riwayat seksual (coitus suspectus) :
• a. kontak seksual, di dlm/luar nikah, gonta- ganti
pasangan (kontak seksual multipel)
• b. kontak dg pasangan setelah gejala
• c. frekuensi hub sex dan jenis
• (homo/hetero)
• d. cara hub (genital, anal, oral)
• e. apakah psngan jg menderita
• keluhan sama.
•Riwayat peny dahulu yg berhub dg kontak seksual
•Riwayat keluarga ( IMS lwt penularan ibu kpd bayi)
•Keluhan yg berkaitan dg komplikasi krn IMS misal : PID krn cervicitis
GO
•Riwayat alergi obat
•Riwayat keluarga ( IMS lwt penularan ibu kpd bayi)
•Keluhan yg berkaitan dg komplikasi krn IMS misal : PID krn cervicitis
GO
•Riwayat alergi obat
Pemeriksaan Fisik
•INSPEKSI dan PALPASI
•Pada pria :
• Lbih mudah krn terdpt 1 kesatuan saluran genital & organ
mudah diraba
•Pada wanita :
•Harus dg spekulum krn organ
•Genital tdp di rongga pelvis
•INSPEKSI dan PALPASI
•Pada pria :
• Lbih mudah krn terdpt 1 kesatuan saluran genital & organ
mudah diraba
•Pada wanita :
•Harus dg spekulum krn organ
•Genital tdp di rongga pelvis
Gonnorhea
•Pada laki-laki Uretritis GO, pd wanita Cervicitis GO
•Penyebab
• kuman Neisseria Gonorrhoea, disebut juga
gonokokus, berbentuk diplokokus.
•Kuman ini menyerang selaput lendir dari :
•Vagina, saluran kencing dan daerah rahim/ leher rahim.
•Saluran tuba fallopi.
•Anus dan rektum.
•Kelopak mata.
•Tenggorokan.
•Pada laki-laki Uretritis GO, pd wanita Cervicitis GO
•Penyebab
• kuman Neisseria Gonorrhoea, disebut juga
gonokokus, berbentuk diplokokus.
•Kuman ini menyerang selaput lendir dari :
•Vagina, saluran kencing dan daerah rahim/ leher rahim.
•Saluran tuba fallopi.
•Anus dan rektum.
•Kelopak mata.
•Tenggorokan.
Neisseria gonorrhoeae
•Gram negative diplococcus
•Non motile
•Non spore forming
•Some types have independent chromosomal mutation,
resulted resistance to penicillin, tetracyclin and
spectinomycin
•No resistance has yet been reported to ceftriaxone
•Gram negative diplococcus
•Non motile
•Non spore forming
•Some types have independent chromosomal mutation,
resulted resistance to penicillin, tetracyclin and
spectinomycin
•No resistance has yet been reported to ceftriaxone
Clinical Manifestations
•Urethral infection in men
•Urogenital infection in women
•Rectal infection
•Pharyngeal infection
•Urethral infection in men
•Urogenital infection in women
•Rectal infection
•Pharyngeal infection
Tanda Dan Gejala
•Penularan melalui oral, anal dan vaginal seks. Hampir 90% penderita
GO pd wanita tidak memperlihatkan keluhan dan gejala.
•Lelaki
•Keluar cairan putih kekuning-kuningan melalui penis.
•Terasa panas dan nyeri pada waktu kencing.
•Sering buang air kecil.
•Terjadi pembengkakan pada
• testis
•Penularan melalui oral, anal dan vaginal seks. Hampir 90% penderita
GO pd wanita tidak memperlihatkan keluhan dan gejala.
•Lelaki
•Keluar cairan putih kekuning-kuningan melalui penis.
•Terasa panas dan nyeri pada waktu kencing.
•Sering buang air kecil.
•Terjadi pembengkakan pada
• testis
Tanda dan gejala
•Perempuan
•Pengeluaran cairan vagina tidak seperti biasa.
•Panas dan nyeri saat kencing.
•Keluhan dan gejala terkadang belum tampak meskipun sudah menular ke
saluran tuba fallopi.
•Bila gx sdh meluas ke PID (Pelvic Inflamatory Disease) sering timbul :
•Nyeri perut & pinggang bagian bawah.
•Nyeri sewaktu hubungan seksual.
•Perdarahan mell vagina diantara siklus haid.
•Mual-mual.
•Terdapat infeksi rektum atau anus.
•Perempuan
•Pengeluaran cairan vagina tidak seperti biasa.
•Panas dan nyeri saat kencing.
•Keluhan dan gejala terkadang belum tampak meskipun sudah menular ke
saluran tuba fallopi.
•Bila gx sdh meluas ke PID (Pelvic Inflamatory Disease) sering timbul :
•Nyeri perut & pinggang bagian bawah.
•Nyeri sewaktu hubungan seksual.
•Perdarahan mell vagina diantara siklus haid.
•Mual-mual.
•Terdapat infeksi rektum atau anus.
KOMPLIKASI GO
•Bila GO tidak diobati maka ± 1% dari lelaki dan wanita, akan terjadi
DGI atau Dessiminated Gonorrhoe Infection. Tanda dan
gejalanya berupa demam, bercak di kulit, persendian bengkak dan
nyeri (FRANK ATHRITIS), peradangan pada dinding rongga jantung,
peradangan selaput pembungkus otak serta meningitis.
•Bila GO tidak diobati maka ± 1% dari lelaki dan wanita, akan terjadi
DGI atau Dessiminated Gonorrhoe Infection. Tanda dan
gejalanya berupa demam, bercak di kulit, persendian bengkak dan
nyeri (FRANK ATHRITIS), peradangan pada dinding rongga jantung,
peradangan selaput pembungkus otak serta meningitis.
Komplikasi pada pria
Epididymitis
Penile lymphangitis
Generalized penile edema
Urethral stricture
Periurethral abscesses
Epididymitis
Penile lymphangitis
Generalized penile edema
Urethral stricture
Periurethral abscesses
Komplikasi pada wanita
Acute salphingitis
Pelvic inflammatory disease
Infertility
Ectopic pregnancy
Bartholin’s gland abscess
Acute salphingitis
Pelvic inflammatory disease
Infertility
Ectopic pregnancy
Bartholin’s gland abscess
Treatment : Uncomplicated GO
•Ceftriaxone 250 mg i.m once
•Cefixime 400 mg orally once
•Cyprofloxacin 500 mg once
•Ofloxacin 400 mg once
Plus
Coinfection with C. Trachomatis
Doxycycline 100 mg orally 2 times a day for 7 days
Alternative regimen :
azythromicyn 1 gr SD
•Ceftriaxone 250 mg i.m once
•Cefixime 400 mg orally once
•Cyprofloxacin 500 mg once
•Ofloxacin 400 mg once
Plus
Coinfection with C. Trachomatis
Doxycycline 100 mg orally 2 times a day for 7 days
Alternative regimen :
azythromicyn 1 gr SD
Treatment
Disseminated Gonococcal Infection :
•Hospitalization
•Ceftriaxone 1 gr/24 hours for 7 days
Or
•Cefotaxime 1 gr/8 hours i.v
•Ceftizoxime 1gr/8 hours i.v
•Spectinomycin 2 gr/12 hours
for a week
Disseminated Gonococcal Infection :
•Hospitalization
•Ceftriaxone 1 gr/24 hours for 7 days
Or
•Cefotaxime 1 gr/8 hours i.v
•Ceftizoxime 1gr/8 hours i.v
•Spectinomycin 2 gr/12 hours
for a week
Treatment
Gonococcal Meningitis :
Ceftriaxone 1 – 2 gr/12
hours for 14 days
Gonococcal Endocarditis :
At least 4 weeks
Gonococcal Meningitis :
Ceftriaxone 1 – 2 gr/12
hours for 14 days
Gonococcal Endocarditis :
At least 4 weeks
Chlamydia Trachomatis Infection in
The Adults
Etiologic agent :
Chlamydia trachomatis strain D – K
•Obligate intracelluler
•An unique growth cycle :
Elementary body
Reticulate body
The Adults
Etiologic agent :
Chlamydia trachomatis strain D – K
•Obligate intracelluler
•An unique growth cycle :
Elementary body
Reticulate body
Clinical Manifestations
•Men :
1.Disuria ringan
2.Polakisuria
3.Discar seropurulen
Reiter’s syndrome :
a)Uretritis
b)Conjunctivitis
c)Arthritis
d)Mucocutaneous lesion
•Men :
1.Disuria ringan
2.Polakisuria
3.Discar seropurulen
Reiter’s syndrome :
a)Uretritis
b)Conjunctivitis
c)Arthritis
d)Mucocutaneous lesion
Clinical Manifestations
•Women :
1.Asimptomatik
2.Disuria ringan
3.Sering kencing
4.Nyeri di daerah pelvis
5.Disparenia
•Women :
1.Asimptomatik
2.Disuria ringan
3.Sering kencing
4.Nyeri di daerah pelvis
5.Disparenia
Treatment
Recomended regimen :
•Doxycycline 100 mg twice for 7
days
•Azithromycin 1 gr orally once
Alternative regimen :
•Ofloxacin 200 mg twice for 7 days
•Erythromycin base 500 mg q.i.d
for 7 days
•Erythromycin ethyl succinate 500
mg q.i.d for 7 days
Recomended regimen :
•Doxycycline 100 mg twice for 7
days
•Azithromycin 1 gr orally once
Alternative regimen :
•Ofloxacin 200 mg twice for 7 days
•Erythromycin base 500 mg q.i.d
for 7 days
•Erythromycin ethyl succinate 500
mg q.i.d for 7 days
FLUOR ALBUS
•KANDIDIASIS VULVOVAGINA
•TRICHOMONAS VAGINALIS
•BACTERIAL VAGINOSIS
•KANDIDIASIS VULVOVAGINA
•TRICHOMONAS VAGINALIS
•BACTERIAL VAGINOSIS
Vulvovaginal Candidiasis
Etiologic agent :
Yeast family : Candida spp.,
C. Albicans
Predisposing factors :
•Pregnancy
•Oral contraceptives
•Diabetes mellitus
•Antibiotics
Etiologic agent :
Yeast family : Candida spp.,
C. Albicans
Predisposing factors :
•Pregnancy
•Oral contraceptives
•Diabetes mellitus
•Antibiotics
Clinical Manifestations
•Acute pruritus and vaginal
discharge, ph < 4,5
•As typically cottage cheese
like
•Acute pruritus and vaginal
discharge, ph < 4,5
•As typically cottage cheese
like
Treatment
Recomended treatment :
•Miconazole nitrat (vaginal supp) 200 mg at bed
time for 3 days
•Clotrimazole (vaginal tab) 200 mg at bed time for
3 days
•Bufoconazole (2% cream 5 gr) intravaginally at
bed time for 3 days
•Terconazole (80 mg supp) at bed time for 3 days
Recomended treatment :
•Miconazole nitrat (vaginal supp) 200 mg at bed
time for 3 days
•Clotrimazole (vaginal tab) 200 mg at bed time for
3 days
•Bufoconazole (2% cream 5 gr) intravaginally at
bed time for 3 days
•Terconazole (80 mg supp) at bed time for 3 days
Treatment
ORAL :
•Fluconazole 150 mg orally single dose
•Itraconazole 400 mg orally single dose
•Itraconazole 100 mg b.i.d for 3 days
ORAL :
•Fluconazole 150 mg orally single dose
•Itraconazole 400 mg orally single dose
•Itraconazole 100 mg b.i.d for 3 days
Trichomoniasis
Penyebab : T. vaginalis
Keluhan
1.Tdk ada
2.Discar berbau,
iritasi/gatal.
3.Dispareunia
4.Disuria
5.Rasa tdk enak
perut bawah
Gejala
1.Tdk ada
2.Eritema vulva
difus
3.Discar >> kuning,
hijau, berbusa
4.Inflamsi dind vag
5.Strawberry
Cervix
Penyebab : T. vaginalis
Keluhan
1.Tdk ada
2.Discar berbau,
iritasi/gatal.
3.Dispareunia
4.Disuria
5.Rasa tdk enak
perut bawah
Gejala
1.Tdk ada
2.Eritema vulva
difus
3.Discar >> kuning,
hijau, berbusa
4.Inflamsi dind vag
5.Strawberry
Cervix
Foamy discharge
Strawberry cervix
Jenis pemeriksaan
•pH 4,5 - 7
•Sniff test positif
•Dg sediaan basah (NaCl) pergerakan trichomonas khas
•Fluorescent antibodi
•Pap smear
•pH 4,5 - 7
•Sniff test positif
•Dg sediaan basah (NaCl) pergerakan trichomonas khas
•Fluorescent antibodi
•Pap smear
Terapi
•Metronidazol 2 gram dosis tunggal
•Metronidazol 2 x 0,5 gr selama 7 hari
•Klindamisin 2 x 300mg slm 7 hari
•Metronidazol 2 gram dosis tunggal
•Metronidazol 2 x 0,5 gr selama 7 hari
•Klindamisin 2 x 300mg slm 7 hari
Bakterial Vaginosis
•Penyebab : Gardnerella vaginalis, Bacteroides Spp, Mycoplasma
hominis
•Dpt tanpa gejala
•Tes amin dg KOH 10% Bau spt ikan (amin yg menguap)
•pH > 7,2
•Sekret menggumpal wrn putih atau keabu-abuan melekat pd dinding
vag.
•Clue cells pd mikroskop
•Penyebab : Gardnerella vaginalis, Bacteroides Spp, Mycoplasma
hominis
•Dpt tanpa gejala
•Tes amin dg KOH 10% Bau spt ikan (amin yg menguap)
•pH > 7,2
•Sekret menggumpal wrn putih atau keabu-abuan melekat pd dinding
vag.
•Clue cells pd mikroskop
Clue cells: squamous epithelial
cells covered primarily with
gardnerella which then take on
this fuzzy appearance called
"clue cell" as seen on wet mount
of vaginal fluid.
antibiotic therapy:
metronidazole or clindamycin for 7 days
cells covered primarily with
gardnerella which then take on
this fuzzy appearance called
"clue cell" as seen on wet mount
of vaginal fluid.
antibiotic therapy:
metronidazole or clindamycin for 7 days
Differential Diagnosis of Vaginal Infections
Diagnostic
Criteria
Normal
Bacterial
Vaginosis
Vaginitis
Trichomo
nas
Cand.
Vulvova
g
Vaginal pH 3.8 - 4.2 > 4.5 4.5
< 4.5
(usually)
Discharge
White,thin,
flocculent
Thick, white
(milky),
gray
Yellow, green,
foamy
White, curdy,
"cottage
cheese"
Amine odor
"whiff"
test
Absent fishy fishy Absent
Miroscopic
Lactobacilli,
epithelial
cells
Clue cells,
adherent
cocci, no
WBC's
Trichomonads,
WBC's
>10/hpf
Budding
yeast,
hyphae,
pseudohy
phae
Diagnostic
Criteria
Normal
Bacterial
Vaginosis
Vaginitis
Trichomo
nas
Cand.
Vulvova
g
Vaginal pH 3.8 - 4.2 > 4.5 4.5
< 4.5
(usually)
Discharge
White,thin,
flocculent
Thick, white
(milky),
gray
Yellow, green,
foamy
White, curdy,
"cottage
cheese"
Amine odor
"whiff"
test
Absent fishy fishy Absent
Miroscopic
Lactobacilli,
epithelial
cells
Clue cells,
adherent
cocci, no
WBC's
Trichomonads,
WBC's
>10/hpf
Budding
yeast,
hyphae,
pseudohy
phae
GENITAL ULCERS
Non-STD
STD
Trauma/abrasions
Aphthous ulcer
Fixed Drug Eruption
Erythema Multiforme
Lymphogranuloma
venererum (LGV)
Candidiasis
Herpes Primary syphilis
or
Chancre
Chancroid
Genital ulcer adenopathy syndrome
OR
Genital ulcer disease, GUD
STD risk behavior
Carcinoma
Non-STD
STD
Trauma/abrasions
Aphthous ulcer
Fixed Drug Eruption
Erythema Multiforme
Lymphogranuloma
venererum (LGV)
Candidiasis
Herpes Primary syphilis
or
Chancre
Chancroid
Genital ulcer adenopathy syndrome
OR
Genital ulcer disease, GUD
STD risk behavior
Carcinoma
• STD ulcers :
Genital herpes: Herpes Simplex Virus
Type 1 and Type 2
Primary syphilis: Treponema pallidum
Chancroid: Haemophilus ducreyi
Lymphogranuloma venereum (LGV):
Chlamydia trachomatis serovars L1-L3
Granuloma inguinale (Donovanosis):
Calymmatobacterium granulomatis
Genital herpes: Herpes Simplex Virus
Type 1 and Type 2
Primary syphilis: Treponema pallidum
Chancroid: Haemophilus ducreyi
Lymphogranuloma venereum (LGV):
Chlamydia trachomatis serovars L1-L3
Granuloma inguinale (Donovanosis):
Calymmatobacterium granulomatis
• Non STD causes :
Aphthous ulcers
Behcet’s syndrome
Fixed drug eruption
Trauma
Abrasions.
• No etiology is found in ~20-40 % of GUD cases.
Most likely related to the sensitivity of the laboratory tests .
( affected by self-medication, duration of lesion, technology of the test )
Aphthous ulcers
Behcet’s syndrome
Fixed drug eruption
Trauma
Abrasions.
• No etiology is found in ~20-40 % of GUD cases.
Most likely related to the sensitivity of the laboratory tests .
( affected by self-medication, duration of lesion, technology of the test )
Year 2001 2007 2012 2013
Country Netherlands South Africa Zambia Brazil
Number of patients with
genital ulcers
372 605 200 434
HSV ( Herpes )
53.6 %
26.1 %
28.5%
58.5%
T. pallidum ( Syphilis )
3.3% 5.8% 11.5% 8.3%
H. ducreyi ( Chancroid )
5.2% 1.7% 0 0
C. tachomatis ( LGV )
0 1.3 % 3% 0
No microorganisms was
detected
37% 55% 32.5%
Cause of genital ulcers by regions
Country Netherlands South Africa Zambia Brazil
Number of patients with
genital ulcers
372 605 200 434
HSV ( Herpes )
53.6 %
26.1 %
28.5%
58.5%
T. pallidum ( Syphilis )
3.3% 5.8% 11.5% 8.3%
H. ducreyi ( Chancroid )
5.2% 1.7% 0 0
C. tachomatis ( LGV )
0 1.3 % 3% 0
No microorganisms was
detected
37% 55% 32.5%
Cause of genital ulcers by regions
Genital Ulcer-HIV Interactions : Epidemiological synergy in the genital tract
Genital ulcers facilitate HIV shedding by:
• bleeding during sexual intercourse
• increasing HIV concentration in genital fluids
Genital ulcers increase susceptibility to HIV by:
• disrupting mucosal integrity
• increasing presence and activation of HIV
susceptible cells
Genital ulcers facilitate HIV shedding by:
• bleeding during sexual intercourse
• increasing HIV concentration in genital fluids
Genital ulcers increase susceptibility to HIV by:
• disrupting mucosal integrity
• increasing presence and activation of HIV
susceptible cells
1. Genital Herpes ( Herpes genitalis)
Herpes simplex virus (HSV)
• HSV-1 : - primarily transmitted by nonvenereal routes.
- following contact with infected saliva.
- facial and oropharyngeal infections.
• HSV-2 : - usually transmitted sexually or maternally to newborn
infants.
- genital herpes and neonatal infections.
Herpes simplex virus (HSV)
• HSV-1 : - primarily transmitted by nonvenereal routes.
- following contact with infected saliva.
- facial and oropharyngeal infections.
• HSV-2 : - usually transmitted sexually or maternally to newborn
infants.
- genital herpes and neonatal infections.
Pathogenesis
• The virus is introduced into the genital mucosa by sexual contact with
an HSV infected partner.
Symptomatic and asymptomatic HSV infected sexual partners can spread
the infection to an uninfected partner.
• Viral replication induces an erythematous papule that swells into a
fluid-filled vesicle.
Eventually these vesicles rupture to leave small ulcers covered with a
grayish exudate.
• The virus is introduced into the genital mucosa by sexual contact with
an HSV infected partner.
Symptomatic and asymptomatic HSV infected sexual partners can spread
the infection to an uninfected partner.
• Viral replication induces an erythematous papule that swells into a
fluid-filled vesicle.
Eventually these vesicles rupture to leave small ulcers covered with a
grayish exudate.
• During primary infections, there is extensive viremia and regional
lymphadenopathy .
• Local interferon, specific antibody and CMI will curtail virus replication. --
The lesions healing take place over a peroid of 1 – 2 weeks but new lesion
may continue to develop over a peroid of 6 weeks.
• The virus invades local nerve endings, ascends the axons, and establishes
latency in the sacral ganglia.
• This is the usual source of recurrence because the virus reactivates, travels
down the axon, and causes new lesions in the epidermis.
lymphadenopathy .
• Local interferon, specific antibody and CMI will curtail virus replication. --
The lesions healing take place over a peroid of 1 – 2 weeks but new lesion
may continue to develop over a peroid of 6 weeks.
• The virus invades local nerve endings, ascends the axons, and establishes
latency in the sacral ganglia.
• This is the usual source of recurrence because the virus reactivates, travels
down the axon, and causes new lesions in the epidermis.
http://images.slideplayer.com/16/4957679/slides/slide_40.jpg
http://www.thelancet.com/cms/attachment/2000990587/2003651400/gr2.jpg
http://www.thelancet.com/cms/attachment/2000990587/2003651400/gr2.jpg
Clinical Manifestations
• Incubation period of 2-7 days (2-21 days).
• Initial manifestations include local pain, tenderness, itching sensation,
dysuria, and in females, a profuse, watery vaginal discharge.
• Initial lesions are papules on a red erythematous base but they rapidly
develop into vesicles and later ulcers covered with a grayish exudate.
• Incubation period of 2-7 days (2-21 days).
• Initial manifestations include local pain, tenderness, itching sensation,
dysuria, and in females, a profuse, watery vaginal discharge.
• Initial lesions are papules on a red erythematous base but they rapidly
develop into vesicles and later ulcers covered with a grayish exudate.
• In females the vesicles
develop on labia majora
and minora, vaginal mucosa,
cervix, and perineal region.
• In males the lesions typically appear
on the glans penis, the prepuce, and
the shaft of the penis.
• lesions are self-limiting and heal
in about 3 weeks.
develop on labia majora
and minora, vaginal mucosa,
cervix, and perineal region.
• In males the lesions typically appear
on the glans penis, the prepuce, and
the shaft of the penis.
• lesions are self-limiting and heal
in about 3 weeks.
Diagnosis of HSV
Definitive: Herpes simplex virus identified on culture or
polymerase chain reaction testing of ulcer scraping
or vesicle fluid aspirate.
Presumptive: Typical lesions and any of the following factors:
- Previously known outbreak.
- Positive Tzanck smear of ulcer scraping.
- Exclusion of other causes of ulcers.
- Fourfold increase in acute and convalescent
antibody titer results. (in a first-time infection)
Definitive: Herpes simplex virus identified on culture or
polymerase chain reaction testing of ulcer scraping
or vesicle fluid aspirate.
Presumptive: Typical lesions and any of the following factors:
- Previously known outbreak.
- Positive Tzanck smear of ulcer scraping.
- Exclusion of other causes of ulcers.
- Fourfold increase in acute and convalescent
antibody titer results. (in a first-time infection)
- Tzanck smear -- Scrape off cells from the base of the ulcer and look for
eosinophilic intra nuclear inclusion bodies and multi-nucleated giant cells.
A positive prep reveals multinucleated
giant cells with jigsaw-puzzle nuclei in
addition to acantholytic balloon cells .
A positive prep will confirm viral infection,
but is not virus-specific.
Cytology (Tzank or Pap): insensitive and nonspecific method of diagnosing
genital
lesions.
eosinophilic intra nuclear inclusion bodies and multi-nucleated giant cells.
A positive prep reveals multinucleated
giant cells with jigsaw-puzzle nuclei in
addition to acantholytic balloon cells .
A positive prep will confirm viral infection,
but is not virus-specific.
Cytology (Tzank or Pap): insensitive and nonspecific method of diagnosing
genital
lesions.
2. Primary Syphilis
Treponema pallidum
• The spiral shaped morphology and characteristic motility pattern
( spin around their longitudinal axis in a corkscrew type manner)
are important for diagnosis via darkfield microscopy
• The primary lesion of syphilis, called a “chancre”, is the stage
characterized by genital ulcer disease.
• Recent outbreaks in men who have sex with men (MSM),
particularly among MSM co-infected with HIV.
Treponema pallidum
• The spiral shaped morphology and characteristic motility pattern
( spin around their longitudinal axis in a corkscrew type manner)
are important for diagnosis via darkfield microscopy
• The primary lesion of syphilis, called a “chancre”, is the stage
characterized by genital ulcer disease.
• Recent outbreaks in men who have sex with men (MSM),
particularly among MSM co-infected with HIV.
Pathogenesis of Syphilis
• The organisms enter the body via minute
abrasions of epithelial cell linings, by
penetrating mucous membranes.
• Then there is a rapid systemic spread via
the blood and lymphatics.
• The most prominent histologic features
are vascular changes caused by
endarteritis and periarteritis.
• The organisms enter the body via minute
abrasions of epithelial cell linings, by
penetrating mucous membranes.
• Then there is a rapid systemic spread via
the blood and lymphatics.
• The most prominent histologic features
are vascular changes caused by
endarteritis and periarteritis.
Clinical Manifestations
• Incubation period of approximately 3 weeks ( 10-90 days, referred
to as the incubation phase of syphilis ), the principal lesion, a hard
chancre, develops.
• Syphilitic chancres are indurated
( hard chancre )
Highly infectious
Occur anywhere on the body
Painless
Chancres will heal in 3-6 weeks.
• Regional lymphadenopathy adjacent to the chancre may develop during
primary syphilis. The nodes are firm, nonsuppurative.
It may persist for months, despite healing of the chancre.
• Incubation period of approximately 3 weeks ( 10-90 days, referred
to as the incubation phase of syphilis ), the principal lesion, a hard
chancre, develops.
• Syphilitic chancres are indurated
( hard chancre )
Highly infectious
Occur anywhere on the body
Painless
Chancres will heal in 3-6 weeks.
• Regional lymphadenopathy adjacent to the chancre may develop during
primary syphilis. The nodes are firm, nonsuppurative.
It may persist for months, despite healing of the chancre.
Diagnosis of syphilis
- Evaluation of presenting signs and symptoms as well as contact history.
- Darkfield examination of exudative
material in syphilitic lesions.
- Serological approaches using
treponemal or nontreponemal tests.
- Nontreponemal tests : measure anti-treponemal antibody using
cardiolipin lecithin as an antigen rather than the actual bacterial antigens.
75-85% sensitive in primary syphilis.
- VDRL (Venereal Disease Research Laboratories)
- RPR (Rapid Plasma Reagin)
- Treponemal antigen tests : ( antigens derived directly from T. pallidum )
More sensitive than the nontreponemal tests in primary syphilis.
- FTA-ABS ( Fluorescent treponemal antibody-absorption test )
- TPHA ( Treponema pallidum hemagglutination assay )
- Evaluation of presenting signs and symptoms as well as contact history.
- Darkfield examination of exudative
material in syphilitic lesions.
- Serological approaches using
treponemal or nontreponemal tests.
- Nontreponemal tests : measure anti-treponemal antibody using
cardiolipin lecithin as an antigen rather than the actual bacterial antigens.
75-85% sensitive in primary syphilis.
- VDRL (Venereal Disease Research Laboratories)
- RPR (Rapid Plasma Reagin)
- Treponemal antigen tests : ( antigens derived directly from T. pallidum )
More sensitive than the nontreponemal tests in primary syphilis.
- FTA-ABS ( Fluorescent treponemal antibody-absorption test )
- TPHA ( Treponema pallidum hemagglutination assay )
Definitive: Treponema pallidum identified on darkfield
microscopy or direct fluorescent antibody testing of a
chancre, condylomata lata or mucous patches.
Presumptive: Positive result on serologic nontreponemal testing
( VDRL or RPR ) that is confirmed with a positive
result on serologic treponemal testing ( FTA-ABS,
TPHA)
Diagnosis of syphilis
microscopy or direct fluorescent antibody testing of a
chancre, condylomata lata or mucous patches.
Presumptive: Positive result on serologic nontreponemal testing
( VDRL or RPR ) that is confirmed with a positive
result on serologic treponemal testing ( FTA-ABS,
TPHA)
Diagnosis of syphilis
3. Chancroid
Haemophilus ducreyi
• A Gram-negative bacilus
• The organism enters the body
through skin abrasions.
• It induces a papule or pustular which ulcerates.
• H ducreyi produces a potent cytolethal distending toxin, which is an important
virulence factor in the pathogenesis of chancroid, probably slow healing of
ulcers.
Haemophilus ducreyi
• A Gram-negative bacilus
• The organism enters the body
through skin abrasions.
• It induces a papule or pustular which ulcerates.
• H ducreyi produces a potent cytolethal distending toxin, which is an important
virulence factor in the pathogenesis of chancroid, probably slow healing of
ulcers.
Clinical Manifestations
- Incubation period of 3-7days
after exposure.
- In contrast to the syphilis chancre,
the chancroid is extremely painful.
- The ulcer enlarges, develops ragged undermined borders.
- The chancroid lacks induration and is referred to as a soft chancre.
- Initially the lesion is typically solitary but by autoinoculation multiple
lesions develop.
- Accompanying chancroid development is an acute, painful inflammatory
inguinal lymphadenopathy in > 50% of cases.
http://emedicine.medscape.com/article/1052141-overview
- Incubation period of 3-7days
after exposure.
- In contrast to the syphilis chancre,
the chancroid is extremely painful.
- The ulcer enlarges, develops ragged undermined borders.
- The chancroid lacks induration and is referred to as a soft chancre.
- Initially the lesion is typically solitary but by autoinoculation multiple
lesions develop.
- Accompanying chancroid development is an acute, painful inflammatory
inguinal lymphadenopathy in > 50% of cases.
http://emedicine.medscape.com/article/1052141-overview
Definitive: H. ducreyi identified on culture
Presumptive: - Painful genital ulcer or ulcers with regional
lymphadenopathy.
- No evidence of T. pallidum infection at least 7 days
after ulcer onset.
- Testing negative for Herpes simplex virus.
Gram stain suggestive of Haemophilus ducreyi
(gram-negative, slender rod or coccobacillus
in a “school of fish” pattern)
.
Diagnosis of Chancroid
Presumptive: - Painful genital ulcer or ulcers with regional
lymphadenopathy.
- No evidence of T. pallidum infection at least 7 days
after ulcer onset.
- Testing negative for Herpes simplex virus.
Gram stain suggestive of Haemophilus ducreyi
(gram-negative, slender rod or coccobacillus
in a “school of fish” pattern)
.
Diagnosis of Chancroid
4. Lymphogranuloma venereum:
Chlamydia trachomatis
serovars L1, L2, and L3.
- There are 2 main serologically distinct groups of Chlamydia that involve STIs.
- C. trachomatis serovars D–K cause Nongonococal urethritis.
- The LGV chlamydias belong to the C. trachomatis serovars L1, L2, and L3.
Chlamydia trachomatis
serovars L1, L2, and L3.
- There are 2 main serologically distinct groups of Chlamydia that involve STIs.
- C. trachomatis serovars D–K cause Nongonococal urethritis.
- The LGV chlamydias belong to the C. trachomatis serovars L1, L2, and L3.
Pathogenesis
• Chlamydia enter the body through small breaks or abrasions in the skin
and induce a local genital lesion as well as regional lymph node
involvement.
• The essential pathologic process is thrombolymphangitis and perilymphangitis
with spread of the inflammatory process
from infected lymph nodes into the
surrounding tissue.
• Inguinal lymphadenopathy is extensive
and may split the inguinal mass into 1/2s
separated by Poupart's ligament,
producing an almost pathognomonic
Groove sign for LGV.
• Chlamydia enter the body through small breaks or abrasions in the skin
and induce a local genital lesion as well as regional lymph node
involvement.
• The essential pathologic process is thrombolymphangitis and perilymphangitis
with spread of the inflammatory process
from infected lymph nodes into the
surrounding tissue.
• Inguinal lymphadenopathy is extensive
and may split the inguinal mass into 1/2s
separated by Poupart's ligament,
producing an almost pathognomonic
Groove sign for LGV.
Clinical Manifestations
• Incubation period : 3 - 30 days
• LGV occurs in 3 stages.
• Primary lesion: is marked by the formation of
a painless papulovesicle and ulceration at the
site of inoculation(small, shallow, painless, genital
or rectal papule or ulcer; no induration),
usually very transitory ( heal within a few days )
and often goes unnoticed.
• Inguinal syndrome: characterized by
painful inguinal lymphadenitis and associated
constitutional symptoms.
• Incubation period : 3 - 30 days
• LGV occurs in 3 stages.
• Primary lesion: is marked by the formation of
a painless papulovesicle and ulceration at the
site of inoculation(small, shallow, painless, genital
or rectal papule or ulcer; no induration),
usually very transitory ( heal within a few days )
and often goes unnoticed.
• Inguinal syndrome: characterized by
painful inguinal lymphadenitis and associated
constitutional symptoms.
•Anogenitorectal syndrome : occurs years after the initial
infection.
- The subacute manifestations of this syndrome are proctocolitis
(rectal bleeding, pain, or discharge; ulcerative proctitis;
constipation or tenesmus) and hyperplasia of intestinal and
perirectal lymphatic tissue.
- The chronic or late manifestations
are perirectal abscesses,
ischiorectal and rectovaginal
fistulas, anal fistulas, and
rectal stricture or stenosis.
www.studyblue.com
infection.
- The subacute manifestations of this syndrome are proctocolitis
(rectal bleeding, pain, or discharge; ulcerative proctitis;
constipation or tenesmus) and hyperplasia of intestinal and
perirectal lymphatic tissue.
- The chronic or late manifestations
are perirectal abscesses,
ischiorectal and rectovaginal
fistulas, anal fistulas, and
rectal stricture or stenosis.
www.studyblue.com
http://clinicalgate.com/perirectal-abscess-and-fistula-in-ano/
www.webmd.com
www.siamhealth.net
www.webmd.com
www.siamhealth.net
Definitive: Chlamydia trachomatis serotype L1, L2, or L3 culture,
identified from clinical specimen
or
Immunofluorescence demonstrating inclusion
bodies in leukocytes of an inguinal lymph node (bubo)
aspirate
or
Microimmunofluorescence positive for
lymphogranuloma venereum strain of C. trachomatis
Presumptive: - Clinical suspicion
- Community prevalence
- Exclusion of other causes of proctocolitis,
inguinal lymphadenopathy, or genital ulcers.
Diagnosis of LGV
identified from clinical specimen
or
Immunofluorescence demonstrating inclusion
bodies in leukocytes of an inguinal lymph node (bubo)
aspirate
or
Microimmunofluorescence positive for
lymphogranuloma venereum strain of C. trachomatis
Presumptive: - Clinical suspicion
- Community prevalence
- Exclusion of other causes of proctocolitis,
inguinal lymphadenopathy, or genital ulcers.
Diagnosis of LGV
Clinical Features of STD Genital Ulcers
Genital Herpes Primary Syphilis Chancroid LGV
Etiologic agent HSV-1 & HSV-2 T. pallidum H. ducreyi C. trachomatis
L1, L2, L3
Incubation
period
2-7 days 10-90 days
(avg. 21 days)
3-10 days
(avg. 4-7 days)
3 days-6 weeks
Presenting
lesion
Vesicles Ulcer Chancre Ulcer/bubo Ulcer/bubo
Number and
distribution of
lesions
Multiple Usually one Single or
multiple
Usually single,
transient
Diameter 1-2 mm 5-15 mm Variable 2-10 mm
Genital Herpes Primary Syphilis Chancroid LGV
Etiologic agent HSV-1 & HSV-2 T. pallidum H. ducreyi C. trachomatis
L1, L2, L3
Incubation
period
2-7 days 10-90 days
(avg. 21 days)
3-10 days
(avg. 4-7 days)
3 days-6 weeks
Presenting
lesion
Vesicles Ulcer Chancre Ulcer/bubo Ulcer/bubo
Number and
distribution of
lesions
Multiple Usually one Single or
multiple
Usually single,
transient
Diameter 1-2 mm 5-15 mm Variable 2-10 mm
Genital Herpes
Primary Syphilis Chancroid LGV
Edges Erythematous Sharply
demarcated,
elevated, round,
or oval
Undermined,
ragged, irregular
Elevated, irregular
Depth Superficial Superficial or
deep
Excavated, deep Superficial or
deep
Base Serous,
erythematous,
Smooth, non-
purulent
Necrotic,
generally
purulent, bleeds
easily
Variable
Clinical Features of STD Genital Ulcers
Primary Syphilis Chancroid LGV
Edges Erythematous Sharply
demarcated,
elevated, round,
or oval
Undermined,
ragged, irregular
Elevated, irregular
Depth Superficial Superficial or
deep
Excavated, deep Superficial or
deep
Base Serous,
erythematous,
Smooth, non-
purulent
Necrotic,
generally
purulent, bleeds
easily
Variable
Clinical Features of STD Genital Ulcers
Genital Herpes
Primary Syphilis Chancroid LGV
Induration None Usually present None Occasionally
present
Pain Painful Painless
Painful, severe Variable
Lymph-
adenopathy
Usually present in
primary infection,
and absent in
recurrences
Firm, non-tender,
bilateral
Tender, may
suppurate,
usually unilateral
Tender, may
suppurate,
usually unilateral
Clinical Features of STD Genital Ulcers
Primary Syphilis Chancroid LGV
Induration None Usually present None Occasionally
present
Pain Painful Painless
Painful, severe Variable
Lymph-
adenopathy
Usually present in
primary infection,
and absent in
recurrences
Firm, non-tender,
bilateral
Tender, may
suppurate,
usually unilateral
Tender, may
suppurate,
usually unilateral
Clinical Features of STD Genital Ulcers
Genital Herpes
Primary Syphilis Chancroid LGV
Diagnostic Test • Tzanck test
• PCR
• Cell culture
• Darkfield
examinations
• TPHA : +
• VDRL, RPR : +
• Microscopy
• PCR
• culture of H.
ducreyi
•Cell culture
Clinical Features of STD Genital Ulcers
Primary Syphilis Chancroid LGV
Diagnostic Test • Tzanck test
• PCR
• Cell culture
• Darkfield
examinations
• TPHA : +
• VDRL, RPR : +
• Microscopy
• PCR
• culture of H.
ducreyi
•Cell culture
Clinical Features of STD Genital Ulcers
Genital Herpes
Primary Syphilis Chancroid LGV
Diagnostic clue Painful, vesicular
lesions --multi-
superficial ulcer
Painless,
indurated border
Extremely
painful deep
ulceration,
ragged
undermined
edge
painless ulcer,
heal within a few
days
“ Groove sign ”
Treatment Acyclovir Benzathine pen G
alternative
Doxycycline
Tetracycline
Erythromycin
Ceftriaxone
Ciprofloxacin
Erythromycin
Azithromycin
Doxycycline
Erythromycin
Clinical Features of STD Genital Ulcers
Primary Syphilis Chancroid LGV
Diagnostic clue Painful, vesicular
lesions --multi-
superficial ulcer
Painless,
indurated border
Extremely
painful deep
ulceration,
ragged
undermined
edge
painless ulcer,
heal within a few
days
“ Groove sign ”
Treatment Acyclovir Benzathine pen G
alternative
Doxycycline
Tetracycline
Erythromycin
Ceftriaxone
Ciprofloxacin
Erythromycin
Azithromycin
Doxycycline
Erythromycin
Clinical Features of STD Genital Ulcers
1. Primary syphilis :
Benzathine penicillin G 2.4 million units IM in a single dose
Alternatives
Doxycycline 100 mg 2x/day for 14 days
OR
Tetracycline 500 mg orally 4x/day for 14 days
2. Genital herpes :
• Acyclovir 400 mg orally 3x/day for 7-10 days ………1st clinical episode
200 mg orally 5x/day for 7-10 days ………1
st
clinical episode
Acyclovir 400 mg orally 3x/day for 5 days …………….Recurrence
* US-CDC : Sexually Transmitted Diseases Treatment Guidelines, 2015
Treatment
Benzathine penicillin G 2.4 million units IM in a single dose
Alternatives
Doxycycline 100 mg 2x/day for 14 days
OR
Tetracycline 500 mg orally 4x/day for 14 days
2. Genital herpes :
• Acyclovir 400 mg orally 3x/day for 7-10 days ………1st clinical episode
200 mg orally 5x/day for 7-10 days ………1
st
clinical episode
Acyclovir 400 mg orally 3x/day for 5 days …………….Recurrence
* US-CDC : Sexually Transmitted Diseases Treatment Guidelines, 2015
Treatment
3. Chancroid :
Azithromycin 1 gm p.o. single dose
or
Ceftriaxone 250mg IM single dose
or
Ciprofloxacin 500mg p.o. BID X 3 days
or
Erythromycin base 500mg p.o. TID X 7 days
4. LGV :
Doxycycline 100 mg orally 2x/day for 21 days
Erythromycin 500 mg orally 4x/day for 21 days
* US-CDC : Sexually Transmitted Diseases Treatment Guidelines, 2015
Treatment
Azithromycin 1 gm p.o. single dose
or
Ceftriaxone 250mg IM single dose
or
Ciprofloxacin 500mg p.o. BID X 3 days
or
Erythromycin base 500mg p.o. TID X 7 days
4. LGV :
Doxycycline 100 mg orally 2x/day for 21 days
Erythromycin 500 mg orally 4x/day for 21 days
* US-CDC : Sexually Transmitted Diseases Treatment Guidelines, 2015
Treatment
Hypertrophic HSV Genitalis in HIV-Infected
* Holmes A et al. Clin Infect Dis. 2007;44:e96-e99
* Holmes A et al. Clin Infect Dis. 2007;44:e96-e99
Non–STD genital ulcers
Trauma / Abrasions
Aphthous ulcer
Fixed Drug Eruption
Erythema Multiforme
Candidiasis
Carcinoma
Trauma / Abrasions
Aphthous ulcer
Fixed Drug Eruption
Erythema Multiforme
Candidiasis
Carcinoma
Traumatic ulcers
Usually develop quickly ( 24 hours ) after sexual intercourse
( unlike infectious ulcerations, which have incubation periods of days – weeks )
Trauma Split Frenulum
Traumatic lesions are usually the result of forced sexual intercourse or
excessively vigorous sex, including oral sex
The lesions often appear as abrasions rather than true ulcers
Usually develop quickly ( 24 hours ) after sexual intercourse
( unlike infectious ulcerations, which have incubation periods of days – weeks )
Trauma Split Frenulum
Traumatic lesions are usually the result of forced sexual intercourse or
excessively vigorous sex, including oral sex
The lesions often appear as abrasions rather than true ulcers
Trauma penile ulcer
Zipper entrapment injuries of the penis
Zipper entrapment injuries of the penis
• A 72-year-old man with DM, HT.
• Presented 4 days following an episode of fellatio performed by a prostitute.
• Superficial trauma from dental devices (braces).
• After 2 days, developed multiple erosions, rapidly coalesced into an
extensive, extremely painful ulcer covered with necrotic debris.
• Presented 4 days following an episode of fellatio performed by a prostitute.
• Superficial trauma from dental devices (braces).
• After 2 days, developed multiple erosions, rapidly coalesced into an
extensive, extremely painful ulcer covered with necrotic debris.
Darkfield examination
Viral culture for herpes simplex
Chancroid culture
Serologic test for syphilis
All negative or nonreactive
• Tissue obtained from the ulcer grew
abundant of “ Eikenella corrodens “.
• E. corrodens is a Gram-negative facultative anaerobic bacillus,
commensal of the human mouth and upper respiratory tract.
www.proprofs.com
Viral culture for herpes simplex
Chancroid culture
Serologic test for syphilis
All negative or nonreactive
• Tissue obtained from the ulcer grew
abundant of “ Eikenella corrodens “.
• E. corrodens is a Gram-negative facultative anaerobic bacillus,
commensal of the human mouth and upper respiratory tract.
www.proprofs.com
* Ted Rosen MD , Dermatology Online Journal 11 (2): 18 , Baylor College of Medicine, Department of Dermatology, Houston.
Diagnosis : Penile ulcer from traumatic orogenital contact
• Treatment : Ceftriaxone 250 mg, intramuscular
+
Amoxicillin-clavulanate 500 mg twice daily for 14 days
• HIV done 6 months later were negative.
Diagnosis : Penile ulcer from traumatic orogenital contact
• Treatment : Ceftriaxone 250 mg, intramuscular
+
Amoxicillin-clavulanate 500 mg twice daily for 14 days
• HIV done 6 months later were negative.
Anal fissures
The cause can be trauma, hard stools, constipation and
receptive anal intercourse
The cause can be trauma, hard stools, constipation and
receptive anal intercourse
Candidiasis
Vulval candidiasis may
occasionally cause fissuring,
which may be mistaken for
genital herpes.
Vulval candidiasis may
occasionally cause fissuring,
which may be mistaken for
genital herpes.
Fixed drug eruption following Doxycycline
Fixed Drug Eruption
Fixed Drug Eruption
Fixed drug eruption
- The major causative agents of fixed drug eruption include antibiotics,
antiepileptics, nonsteroidal anti-inflammatory agents
- The most common cause is co-trimoxazole.
- Other drugs were
tetracycline, doxycycline
phenylbutazone, paracetamol, mefenamic acid
diclofenac, indomethacin, ibuprofen, buprofen
metronidazole, tinidazole
amoxycillin
griseofulvin
phenobarbitone
allopurinol
orphenadrine
albendazole
dextromethorphan
- The major causative agents of fixed drug eruption include antibiotics,
antiepileptics, nonsteroidal anti-inflammatory agents
- The most common cause is co-trimoxazole.
- Other drugs were
tetracycline, doxycycline
phenylbutazone, paracetamol, mefenamic acid
diclofenac, indomethacin, ibuprofen, buprofen
metronidazole, tinidazole
amoxycillin
griseofulvin
phenobarbitone
allopurinol
orphenadrine
albendazole
dextromethorphan
Erythema multiforme following Cotrimoxazole
Erythema Multiforme
Erythema Multiforme
shallow, well-defined ulcer with a fibrinous (yellow-white) base
Aphthous ulcer
Aphthous ulcer
The cause of aphthous ulcer is unknown
- Inflammatory disorders triggered by exogenous factors
- Microbial antigens --- induce an autoimmune process
- Stress
- Vitamin deficiency
Aphthous ulcers affecting the vulva, sudden onset with acute painful ulcers
Recurrent, genital and oral ulceration
Treatment : - Pain relief ( EMLA, Naproxen, Acetominophen )
- Anti-inflammatory (Clobetasol 0.05% ointment, Prednisone)
- Antibiotics for superimposed infection
- Inflammatory disorders triggered by exogenous factors
- Microbial antigens --- induce an autoimmune process
- Stress
- Vitamin deficiency
Aphthous ulcers affecting the vulva, sudden onset with acute painful ulcers
Recurrent, genital and oral ulceration
Treatment : - Pain relief ( EMLA, Naproxen, Acetominophen )
- Anti-inflammatory (Clobetasol 0.05% ointment, Prednisone)
- Antibiotics for superimposed infection
Cancer
Genital wart
Human papillomavirus (HPV)
HPV type
Associated disease
6, 11, 40, 42, 43, 44, 54, 61,
70, 72, 81
( low risk )
•Genital wart
•Low-grade cervical lesions
16, 18, 31, 33, 35, 45, 52, 58
( high risk )
•Low-grade cervical lesions
•High-grade cervical and other
anogenital lesions
•Cervical and other anogenital
cancers
Human papillomavirus (HPV)
HPV type
Associated disease
6, 11, 40, 42, 43, 44, 54, 61,
70, 72, 81
( low risk )
•Genital wart
•Low-grade cervical lesions
16, 18, 31, 33, 35, 45, 52, 58
( high risk )
•Low-grade cervical lesions
•High-grade cervical and other
anogenital lesions
•Cervical and other anogenital
cancers
Predominantly associated with sexual activity, including
- vaginal intercourse
- anal intercourse
- oral sex
- a nonpenetrative sexual activity (genital-genital contact).
Likely requires contact with viable HPV and microtrauma to skin or mucous
membranes to establish infection.
Can occur from asymptomatic and subclinically infected patients.
Treatment of warts or cervical cellular abnormalities may reduce the size, but
does not eliminate infectiousness.
Transmission by fomites has never been documented.
Transmission of Genital HPV
- vaginal intercourse
- anal intercourse
- oral sex
- a nonpenetrative sexual activity (genital-genital contact).
Likely requires contact with viable HPV and microtrauma to skin or mucous
membranes to establish infection.
Can occur from asymptomatic and subclinically infected patients.
Treatment of warts or cervical cellular abnormalities may reduce the size, but
does not eliminate infectiousness.
Transmission by fomites has never been documented.
Transmission of Genital HPV
Rarely, genital HPV infection with low-risk types is transmitted from mother to
newborn during delivery and can cause respiratory tract warts in the child,
known as juvenile-onset recurrent respiratory papillomatosis (JORRP).
Estimates of the incidence rate of JORRP are range from 0.4–1.2 cases per
100,000 children.
Condoms might reduce the risk for HPV-associated diseases (e.g. genital warts
and cervical cancer).
- Consistent and correct condom use also may reduce the risk for genital
HPV acquisition.
- HPV infection can occur in areas that are not covered or protected by a
condom (e.g., scrotum, vulva, or perianus).
Transmission of Genital HPV
Program and Training Branch, Division of STD Prevention, CDC.
newborn during delivery and can cause respiratory tract warts in the child,
known as juvenile-onset recurrent respiratory papillomatosis (JORRP).
Estimates of the incidence rate of JORRP are range from 0.4–1.2 cases per
100,000 children.
Condoms might reduce the risk for HPV-associated diseases (e.g. genital warts
and cervical cancer).
- Consistent and correct condom use also may reduce the risk for genital
HPV acquisition.
- HPV infection can occur in areas that are not covered or protected by a
condom (e.g., scrotum, vulva, or perianus).
Transmission of Genital HPV
Program and Training Branch, Division of STD Prevention, CDC.
Risk Factors for Women
Risk factors consistently associated with genital HPV infection in women
oYoung age
oSexual behavior
-Risk increases with increasing number of sex partners
-Early age of first sexual intercourse
-Sexual behavior of sex partners
oRisk increases for women whose sex partners have had multiple sex
partners.
oImmune status
- HPV is more likely to be detected in immunosuppressed person.
Risk Factors for Men
- Greater number of recent and lifetime sex partners.
- Being uncircumcised increases risk.
Risk factors consistently associated with genital HPV infection in women
oYoung age
oSexual behavior
-Risk increases with increasing number of sex partners
-Early age of first sexual intercourse
-Sexual behavior of sex partners
oRisk increases for women whose sex partners have had multiple sex
partners.
oImmune status
- HPV is more likely to be detected in immunosuppressed person.
Risk Factors for Men
- Greater number of recent and lifetime sex partners.
- Being uncircumcised increases risk.
Transmission mode of Genital HPV
Oral sex
+ Patients with oral condylomata will have
concomitant genital or anal warts, and most give a
history of oral sex.
Penile-vagina
++
Most genital warts occur on the penis, scrotum,
urethral meatus, and perianal area in men and on
the introitis, vulva, perineum, and perianal area in
women.
Penile-anus
+++
Men who have anal intercourse may also have a
higher risk of HPV.
Nonsexual
( fomite )
-
Transmission by fomites (inanimate objects such as
environmental surfaces and clothing) has never
been documented.
Non penetrative Sex
( hand-genital, foreplay )
+
Digital transmission may occur. HPV can be
transmitted with non-penetrative sexual activity.
Vertical Transmission
(transplacenta, birth canal)
+
Although rare, perinatal transmission does occur.
Infants born to women with genital warts during
pregnancy develop laryngeal papillomatosis, and
perinatal transmission appears to play a role in cases
of condylomata developing within the first week of
life.
Oral sex
+ Patients with oral condylomata will have
concomitant genital or anal warts, and most give a
history of oral sex.
Penile-vagina
++
Most genital warts occur on the penis, scrotum,
urethral meatus, and perianal area in men and on
the introitis, vulva, perineum, and perianal area in
women.
Penile-anus
+++
Men who have anal intercourse may also have a
higher risk of HPV.
Nonsexual
( fomite )
-
Transmission by fomites (inanimate objects such as
environmental surfaces and clothing) has never
been documented.
Non penetrative Sex
( hand-genital, foreplay )
+
Digital transmission may occur. HPV can be
transmitted with non-penetrative sexual activity.
Vertical Transmission
(transplacenta, birth canal)
+
Although rare, perinatal transmission does occur.
Infants born to women with genital warts during
pregnancy develop laryngeal papillomatosis, and
perinatal transmission appears to play a role in cases
of condylomata developing within the first week of
life.
Natural History of HPV
Most infections are transient, asymptomatic or subclinical, and
have no clinical consequences in immunocompetent individuals.
• Time to development of clinical manifestations is unclear, but
most likely:
o 3 weeks to months for genital warts.
o Several months to years for cervical cellular abnormalities.
o Decades for cervical cancers.
• 70% of HPV infections clear within 1 year.
• 90% of HPV infections clear within 2 years.
• The gradual development of an effective immune response is
thought to be the likely mechanism for HPV DNA clearance.
Most infections are transient, asymptomatic or subclinical, and
have no clinical consequences in immunocompetent individuals.
• Time to development of clinical manifestations is unclear, but
most likely:
o 3 weeks to months for genital warts.
o Several months to years for cervical cellular abnormalities.
o Decades for cervical cancers.
• 70% of HPV infections clear within 1 year.
• 90% of HPV infections clear within 2 years.
• The gradual development of an effective immune response is
thought to be the likely mechanism for HPV DNA clearance.
Natural History of HPV (continued)
• Persistent HPV infection is infection that is not cleared by the
immune system and is characterized by persistently detectable
type-specific HPV DNA.
o Persistent oncogenic HPV infection is the most important
risk factor for precancerous (high-grade) cervical cellular
changes and cervical cancer.
o Factors associated with persistent infection include:
- older age
- certain HPV types
- immune suppression
• Persistent HPV infection is infection that is not cleared by the
immune system and is characterized by persistently detectable
type-specific HPV DNA.
o Persistent oncogenic HPV infection is the most important
risk factor for precancerous (high-grade) cervical cellular
changes and cervical cancer.
o Factors associated with persistent infection include:
- older age
- certain HPV types
- immune suppression
Clinical course and manifestations:
1. Latent HPV infection: Do not have any detectable warts or other
HPV disease and probably have HPV in
very low numbers per infected cell.
2. Subclinical HPV : Changes cannot be seen with the "naked eye."
The most common "subclinical change" is
intraepithelial neoplasia of the cervix (cervical
dysplasia, CIN 1,2 or 3).
3. Clinical HPV: Genital warts and precancerous changes.
- Condyloma acuminata
- Condyloma planum
- Cancer
1. Latent HPV infection: Do not have any detectable warts or other
HPV disease and probably have HPV in
very low numbers per infected cell.
2. Subclinical HPV : Changes cannot be seen with the "naked eye."
The most common "subclinical change" is
intraepithelial neoplasia of the cervix (cervical
dysplasia, CIN 1,2 or 3).
3. Clinical HPV: Genital warts and precancerous changes.
- Condyloma acuminata
- Condyloma planum
- Cancer
Four morphologic types of genital warts:
1. Condylomata acuminata, which have a
cauliflower-like appearance.
2. Papular warts, which are flesh-colored,
domeshaped papules, usually 1–4 mm in
diameter.
1. Condylomata acuminata, which have a
cauliflower-like appearance.
2. Papular warts, which are flesh-colored,
domeshaped papules, usually 1–4 mm in
diameter.
3. Keratotic warts, which have a thick,
crust-like layer and may resemble
common skin warts or seborrheic
keratosis.
4. Flat-topped papules, which
appear macular to slightly raised.
crust-like layer and may resemble
common skin warts or seborrheic
keratosis.
4. Flat-topped papules, which
appear macular to slightly raised.
http://escapesoutheast-digital.com/can-genital-warts-can-uterine-polyps-disappear-on-their-own/
Urinary obstruction may be the initial problem when the wart
involves the urethral opening.
Urinary obstruction may be the initial problem when the wart
involves the urethral opening.
http://escapesoutheast-digital.com/pregnant-with-hpv-genital-warts/
Oral warts
Oral warts
- Intra-anal warts ( extended into the anus up to the dentate line )
are observed in patients who have had receptive anal intercourse.
-These warts are distinct from perianal warts, which can occur in
men and women who do not have a history of anal sex.
are observed in patients who have had receptive anal intercourse.
-These warts are distinct from perianal warts, which can occur in
men and women who do not have a history of anal sex.
http://www.ispub.com/journal/the_internet_journal_of_gynecology_and_obstetrics/volumee-a-case-report.html
Genital warts in HIV infection
Genital warts in HIV infection
Diagnosis of genital warts: is made by visual inspection based on the
appearance of the lesions.
- Sometimes, lesions are only visible with an enhancing technique
called acetowhitening.
- Application of 3% - 5% acetic acid solution to the area of suspicion
for about 5-10 minutes then the infected areas will turn white.
- However, acetic acid application is not a specific test for HPV
infection, and the specificity and sensitivity of this procedure for
screening have not been defined.
- Therefore, the routine use of this procedure for screening to detect
HPV infection is not recommended *
- A biopsy can be performed if the lesion appears unusual or recurs
after treatment.
* * CDC Treatment Guidelines
appearance of the lesions.
- Sometimes, lesions are only visible with an enhancing technique
called acetowhitening.
- Application of 3% - 5% acetic acid solution to the area of suspicion
for about 5-10 minutes then the infected areas will turn white.
- However, acetic acid application is not a specific test for HPV
infection, and the specificity and sensitivity of this procedure for
screening have not been defined.
- Therefore, the routine use of this procedure for screening to detect
HPV infection is not recommended *
- A biopsy can be performed if the lesion appears unusual or recurs
after treatment.
* * CDC Treatment Guidelines
Recommended Regimens for External Genital Warts
Podophyllin resin 10%–25% in a compound tincture of
benzoin.
A small amount should be applied to each wart and allowed
to air dry ( washed off 1–4 hours after application to reduce
local irritation ).
The treatment can be repeated weekly, if necessary.
The safety of podophyllin during pregnancy has not been
established.
Podophyllin resin 10%–25% in a compound tincture of
benzoin.
A small amount should be applied to each wart and allowed
to air dry ( washed off 1–4 hours after application to reduce
local irritation ).
The treatment can be repeated weekly, if necessary.
The safety of podophyllin during pregnancy has not been
established.
Trichloroacetic acid (TCA) 80%–90%
A small amount should be applied only to the warts and
allowed to dry, at which time a white “frosting” develops
If an excess amount of acid is applied, the treated area
should be powdered with talc, sodium bicarbonate, or
liquid soap preparations to remove unreacted acid.
This treatment can be repeated weekly, if necessary.
A small amount should be applied only to the warts and
allowed to dry, at which time a white “frosting” develops
If an excess amount of acid is applied, the treated area
should be powdered with talc, sodium bicarbonate, or
liquid soap preparations to remove unreacted acid.
This treatment can be repeated weekly, if necessary.
Imiquimod 5% cream, apply once daily at bedtime, three
times a week for up to 16 weeks.
The treatment area should be washed with soap and water
6–10 hours after the application.
The safety of imiquimod during pregnancy has not been
established.
Cryotherapy with liquid nitrogen or cryoprobe
Repeat applications every 1–2 weeks.
Surgical removal either by tangential scissor excision,
tangential shave excision, curettage, or electrosurgery.
times a week for up to 16 weeks.
The treatment area should be washed with soap and water
6–10 hours after the application.
The safety of imiquimod during pregnancy has not been
established.
Cryotherapy with liquid nitrogen or cryoprobe
Repeat applications every 1–2 weeks.
Surgical removal either by tangential scissor excision,
tangential shave excision, curettage, or electrosurgery.
Regimen
Location
External
genitalia
Urethral
meatus
Vagina
Uterine
cervix
Perianal
Intraanal/
Rectal
Podophyllin resin
10%–25%
TCA 80%–90%
Imiquimod 5%
cream
= can use
= should not use
Safety of use at different sites
Location
External
genitalia
Urethral
meatus
Vagina
Uterine
cervix
Perianal
Intraanal/
Rectal
Podophyllin resin
10%–25%
TCA 80%–90%
Imiquimod 5%
cream
= can use
= should not use
Safety of use at different sites
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Categories
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