26<br />Microbial Diseases of the Urinary and Reproductive Systems<br />
Microbial Diseases of the Urinary and Reproductive Systems<br />Microbes usually enter the urinary system through the uret...
Female Urinary Organs<br />Figure 26.1<br />
Female Reproductive Organs<br />Figure 26.2a<br />
Male Reproductive & Urinary Organs<br />Figure 26.3<br />
Normal Microbiota<br />Urinary bladder and upper urinary tract sterile<br />Lactobacilli predominant in the vagina<br />>1...
Cystitis<br />Usually caused by<br />E. coli<br />S. saprophyticus<br />May also be  caused by<br />Proteus<br />Klebsiell...
UTI<br />Ureteritis = inflammation of ureter (maybe caused by stone in the ureter)<br />Cystitis = inflammation of bladder...
“Bad Stroke”<br />
FACTORS THAT CONTRIBUTE TO UTI<br />FEMALE (PROXIMITY TO THE ANUS, SHORTER URETHRA)<br />POOR HYGIENE<br />UNSAFE SEXUAL P...
S/Sx:<br />PAIN assessment<br />Pain during and after urination = <br />	cystitis<br />Pain after urination = urethritis<b...
Management<br />E. coli (most common C.A.)<br />Increase fluids<br />Warm sitz bath<br />EMPTY the bladder<br />Good hygie...
Leptospirosis<br />Leptospira interrogans<br />Reservoir: Dogs and rats<br />Transmitted by skin/mucosal contact from urin...
Silver Stain of Leptospira interrogans serotype icterohaemorrhagiae<br /><ul><li>Obligate aerobes
Characteristic hooked ends    (like a question mark, thus the      species epithet – interrogans)</li></li></ul><li>Leptos...
(Anicteric leptospirosis) Systemic with aseptic meningitis
(Icteric leptospirosis) Overwhelming disease (Weil’s disease)
Vascular collapse
Thrombocytopenia
Hemorrhage
Hepatic and renal dysfunction</li></ul>NOTE: Icteric refers to jaundice (yellowing of skin and mucus membranes by depositi...
Pathogenesis of Icteric Leptospirosis<br /><ul><li>Leptospirosis, also called Weil’s disease in humans
Direct invasion and replication in tissues
Characterized by an acute febrile jaundice & immune complex glomerulonephritis
Incubation period usually 10-12 days with flu-like illness usually progressing through two clinical stages:</li></ul>Lepto...
Epidemiology of Leptospirosis<br /><ul><li>Mainly a zoonotic disease
Transmitted to humans from a variety of wild and domesticated animal hosts
In USA most common reservoirs rodents (rats), dogs, farm animals and wild animals
Transmitted through breaks in the skin or intact mucus membranes
Indirect contact (soil, water, feed) with infected urine from an animal with leptospiruria
Occupational disease of animal handling</li></li></ul><li>Comparison of Diagnostic Tests for Leptospirosis<br />
Sexually Transmitted Diseases (STDs )<br />Prevented by condoms<br />Treated with antibiotics<br />
Gonorrhea<br />Figure 26.5a<br />
Gonorrhea<br />Neisseria gonorrhoeae<br />Attaches to oral or urogenital mucosa by fimbriae.<br />Females may be asymptoma...
Gonorrhea<br />Figure 26.7<br />
Gonorrhea<br />UN 26.1<br />
Nongonococcal Urethritis<br />Chlamydia trachomatis<br />May be transmitted to a newborn's eyes<br />Painful urination and...
Pelvic Inflammatory Disease<br />N. gonorrhoeae<br />C. trachomatis<br />Can block uterine tubes<br />Chronic abdominal pa...
GONORRHEA<br />Neisseria gonorrhea, gram (+)<br />IP: 3-7 days<br />28<br />Rex Karl S. Teoxon, R.N, M.D<br />
SIGNS AND SYMPTOMS<br />Females: usually asymptomatic or minimal urethral discharge w/ lower abdominal pain<br />Male: Muc...
GONORRHEAMANIFESTATIONS IN MEN<br /><ul><li>Urethritis
Epididymitis
Proctitis
Pharyngitis</li></li></ul><li>GONORRHEACLINICAL PRESENTATION<br />
32<br />
GONORRHEAMANIFESTATIONS IN WOMEN<br /><ul><li>Urethritis
Endocervicitis
Proctitis
PID
Pharyngitis</li></li></ul><li>GONORRHEADISSEMINATED INFECTION<br /><ul><li>Arthritis
Dermatitis
Pericarditis and endocarditis
Meningitis
Perihepatitis</li></li></ul><li>DISSEMINATED GONORRHEACLINICAL PRESENTATION<br />
36<br />Rex Karl S. Teoxon, R.N, M.D<br />
37<br />Rex Karl S. Teoxon, R.N, M.D<br />
38<br />Rex Karl S. Teoxon, R.N, M.D<br />
DIAGNOSIS<br />GSCS of cervical secretions on Thayer Martin medium<br />39<br />Rex Karl S. Teoxon, R.N, M.D<br />
GONORRHEAGRAM STAIN<br />
GONORRHEADIAGNOSIS<br /><ul><li>Clinical examination
Gram stain
Culture
Nucleic acid probes</li></li></ul><li>MANAGEMENT<br />Ceftriaxone (Rocephin) 250 mg IM<br />Ofloxacin (Floxin) 400 mg oral...
GONORRHEASEQUELAE<br /><ul><li>Infertility
Ectopic pregnancy
Chronic pelvic pain</li></li></ul><li>COMPLICATION<br />PID<br />ectopic pregnancy and infertility<br />Peritonitis<br />P...
GONORRHEATREATMENT<br />Patient and partner should be treated<br />Drugs of choice<br />Ceftriaxone<br />Quinolone<br />
CHLAMYDIA <br />Chlamydia trachomatis, gram (-)<br />IP: 2-10 days<br />46<br />Rex Karl S. Teoxon, R.N, M.D<br />
SIGNS AND SYMPTOMS<br />Maybe asymptomatic<br />Gray white discharge, Burning and itchiness at the urethral opening<br />D...
Rex Karl S. Teoxon, R.N, M.D<br />48<br />
49<br />Rex Karl S. Teoxon, R.N, M.D<br />
CHLAMYDIADIAGNOSIS<br />
CHLAMYDIAMANIFESTATIONS IN MEN<br /><ul><li>Urethritis
Proctitis
Epididymitis</li></li></ul><li>CHLAMYDIAMANIFESTATIONS IN WOMEN<br /><ul><li>Urethritis
Endocervicitis
Proctitis
PID
Perihepatitis</li></li></ul><li>MANAGEMENT<br />Doxycycline or Azithromycin<br />Erythromycin and Ofloxacin<br />CX:<br />...
Syphilis<br />Figure 26.9a<br />
Syphilis<br />Treponema pallidum<br />Invades mucosa or through skin breaks.<br />Figure 26.10<br />
Syphilis<br />Direct diagnosis<br />Darkfield microscopic identification of bacteria<br />Staining with fluorescent-labele...
Syphilis<br />Figure 3.6b<br />
Syphilis<br />Primary stage: Chancre at site of infection<br />Secondary: Skin and mucosal rashes<br />Latent period: No s...
Virulence Factors of T. pallidum<br /><ul><li>Outer membrane proteins  promote adherence
Hyaluronidase may facilitate perivascular infiltration
Antiphagocytic coating of  fibronectin
Tissue destruction and lesions are primarily result of host’s immune response (immunopathology)</li></li></ul><li>SYPHILIS...
SYPHILISMECHANISMS OF TRANSMISSION<br /><ul><li>Sexual contact
Perinatal</li></li></ul><li>SYPHILISFREQUENCY<br /><ul><li>Incidence has increased , especially in females aged 15-24 years
Highest prevalence - urban blacks and hispanics</li></li></ul><li>SYPHILISCLASSIFICATION	<br /><ul><li>Primary
Secondary
Latent
Early
Late
Tertiary</li></li></ul><li>SIGNS AND SYMPTOMS<br />Primary (3-6 wks after contact) – nontender lymphadenopathy and chancre...
Pathogenesis of T. pallidum (cont.)<br />Primary Syphilis<br /><ul><li>Primary disease process involves invasion of mucus ...
Occurs prior to development of the primary lesion
10-90 days (usually 3-4 weeks) after initial contact the host mounts an inflammatory response at the site of inoculation r...
Chancre changes from hard to ulcerative with profuse shedding of spirochetes
Swelling of capillary walls & regional lymph nodes w/ draining
Primary lesion heals spontaneously by fibrotic walling-off within two months, leading to false sense of relief</li></li></...
67<br />Rex Karl S. Teoxon, R.N, M.D<br />
68<br />Rex Karl S. Teoxon, R.N, M.D<br />
Pathogenesis of T. pallidum (cont.)<br />Secondary Syphilis<br /><ul><li>Secondary disease 2-10 weeks after primary lesion
Widely disseminated mucocutaneous rash
Secondary lesions of the skin and mucus membranes are highly contagious
Generalized immunological response</li></li></ul><li>SECONDARY SYPHILISPRINCIPAL CLINICAL FINDINGS<br />
Generalized Mucocutaneous Rash of Secondary Syphilis<br />
72<br />Rex Karl S. Teoxon, R.N, M.D<br />
73<br />Rex Karl S. Teoxon, R.N, M.D<br />
SECONDARY SYPHILISPRINCIPAL CLINICAL FINDINGS<br />
LATE STAGE SYPHILISPRINCIPAL CLINICAL MANIFESTATIONS<br />Destructive gummas<br />Aortic valve injury<br />CNS manifestati...
Pathogenesis of T. pallidum (cont.)<br />Latent Stage Syphilis<br /><ul><li>Following secondary disease, host enters laten...
First 4 years = early latent
Subsequent period = late latent
About 40% of late latent patients progress to late tertiary syphilitic disease</li></li></ul><li>Pathogenesis of T. pallid...
Granulomas reflect containment by the immunologic reaction of the host to chronic infection
Late neurosyphilis develops in about 1/6 untreated cases, usually more than 5 years after initial infection
Central nervous system and spinal cord involvement
Dementia, seizures, wasting, etc.
Cardiovascular involvement appears 10-40 years after initial infection with resulting myocardial insufficiency and death</...
79<br />Rex Karl S. Teoxon, R.N, M.D<br />
80<br />Rex Karl S. Teoxon, R.N, M.D<br />
CONGENITAL SYPHILISCLINICAL MANIFESTATIONS<br />Fetal death<br />Growth restriction<br />Multiple anomalies<br />Immediate...
Pathogenesis of T. pallidum (cont.)<br />Congenital Syphilis<br /><ul><li>Congenital syphilis results from transplacental ...
T. pallidumsepticemia in the developing fetus and widespread dissemination
Abortion, neonatal mortality, and late mental or physical problems resulting from scars from the active disease and progre...
SYPHILISDIAGNOSIS<br />Clinical examination<br />Darkfield microscopy<br />Serology<br />VDRL – screening test<br />MHA or...
DIAGNOSIS<br />	Dark-field examination of  lesion- 1st and 2nd stage<br />    Non specific VDRL and RPR<br />    FTA-ABS<b...
Diagnostic Tests for Syphilis<br />(Original Wasserman Test)<br />NOTE: Treponemal antigen tests indicate experience with ...
SYPHILISTREATMENT<br />Patient and sexual partner(s) should be treated<br />Antibiotic therapy<br />Penicillin – preferred...
Prevention & Treatment of Syphilis<br /><ul><li>Penicillin remains drug of choice
WHO monitors treatment recommendations
7-10 days continuously for early stage
At least 21 days continuously beyond the early stage
Prevention with barrier methods (e.g., condoms)
Prophylactic treatment of contacts identified through epidemiological tracing</li></li></ul><li>Lymphogranuloma Venereum (...
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  1. 1. 26<br />Microbial Diseases of the Urinary and Reproductive Systems<br />
  2. 2. Microbial Diseases of the Urinary and Reproductive Systems<br />Microbes usually enter the urinary system through the urethra.<br />Microbes usually enter the reproductive system through the vagina (in females) or urethra (in males).<br />
  3. 3. Female Urinary Organs<br />Figure 26.1<br />
  4. 4. Female Reproductive Organs<br />Figure 26.2a<br />
  5. 5. Male Reproductive & Urinary Organs<br />Figure 26.3<br />
  6. 6.
  7. 7. Normal Microbiota<br />Urinary bladder and upper urinary tract sterile<br />Lactobacilli predominant in the vagina<br />>1,000 bacteria/ml or 100 coliforms/ml of urine indicates infection<br />
  8. 8. Cystitis<br />Usually caused by<br />E. coli<br />S. saprophyticus<br />May also be caused by<br />Proteus<br />Klebsiella<br />Enterococcus<br />Pseudomonas<br />E. coli usually causes pyelonephritis.<br />Antibiotic-sensitivity tests may be required before treatment.<br />
  9. 9. UTI<br />Ureteritis = inflammation of ureter (maybe caused by stone in the ureter)<br />Cystitis = inflammation of bladder (caused by ascending bacterial infection usually E. coli)<br />Urethritis= inflammation of urethra (may lead to prostatitis and epididymitis)<br />
  10. 10. “Bad Stroke”<br />
  11. 11. FACTORS THAT CONTRIBUTE TO UTI<br />FEMALE (PROXIMITY TO THE ANUS, SHORTER URETHRA)<br />POOR HYGIENE<br />UNSAFE SEXUAL PRACTICES<br />BACK TO FRONT STROKE<br />HIGH pH <br />URINARY STASIS<br />KIDNEY STONES<br />OBSTRUCTION OF URINE OUTFLOW<br />
  12. 12. S/Sx:<br />PAIN assessment<br />Pain during and after urination = <br /> cystitis<br />Pain after urination = urethritis<br />Inguinal pain = ureteritis<br />Flank pain = pyelonephritis<br />Inflammatory manifestations <br /> fever and chills<br />Cx:<br />Ascending infection<br />Obstruction (stones/calculi)<br />
  13. 13. Management<br />E. coli (most common C.A.)<br />Increase fluids<br />Warm sitz bath<br />EMPTY the bladder<br />Good hygiene<br />Observe safe sexual practice<br />Front to back stroke<br />Acidify urine (cranberry juice, prune, plums)<br />C/S test before giving antibiotics<br />For urosepsis give aminoglycosides<br />Observe complications<br />
  14. 14. Leptospirosis<br />Leptospira interrogans<br />Reservoir: Dogs and rats<br />Transmitted by skin/mucosal contact from urine-contaminated water<br />Diagnosis: Isolating bacteria or serological tests<br />Figure 26.4<br />
  15. 15. Silver Stain of Leptospira interrogans serotype icterohaemorrhagiae<br /><ul><li>Obligate aerobes
  16. 16. Characteristic hooked ends (like a question mark, thus the species epithet – interrogans)</li></li></ul><li>Leptospirosis Clinical Syndromes<br /><ul><li>Mild virus-like syndrome
  17. 17. (Anicteric leptospirosis) Systemic with aseptic meningitis
  18. 18. (Icteric leptospirosis) Overwhelming disease (Weil’s disease)
  19. 19. Vascular collapse
  20. 20. Thrombocytopenia
  21. 21. Hemorrhage
  22. 22. Hepatic and renal dysfunction</li></ul>NOTE: Icteric refers to jaundice (yellowing of skin and mucus membranes by deposition of bile) and liver involvement<br />
  23. 23. Pathogenesis of Icteric Leptospirosis<br /><ul><li>Leptospirosis, also called Weil’s disease in humans
  24. 24. Direct invasion and replication in tissues
  25. 25. Characterized by an acute febrile jaundice & immune complex glomerulonephritis
  26. 26. Incubation period usually 10-12 days with flu-like illness usually progressing through two clinical stages:</li></ul>Leptospiremia develops rapidly after infection (usually lasts about 7 days) without local lesion<br />Infects the kidneys and organisms are shed in the urine (leptospiruria) with renal failure and death not uncommon<br /><ul><li>Hepatic injury & meningeal irritation is common</li></li></ul><li>Clinical Progression of Icteric (Weil’s Disease) and Anicteric Leptospirosis<br />(pigmented part of eye)<br />
  27. 27. Epidemiology of Leptospirosis<br /><ul><li>Mainly a zoonotic disease
  28. 28. Transmitted to humans from a variety of wild and domesticated animal hosts
  29. 29. In USA most common reservoirs rodents (rats), dogs, farm animals and wild animals
  30. 30. Transmitted through breaks in the skin or intact mucus membranes
  31. 31. Indirect contact (soil, water, feed) with infected urine from an animal with leptospiruria
  32. 32. Occupational disease of animal handling</li></li></ul><li>Comparison of Diagnostic Tests for Leptospirosis<br />
  33. 33. Sexually Transmitted Diseases (STDs )<br />Prevented by condoms<br />Treated with antibiotics<br />
  34. 34. Gonorrhea<br />Figure 26.5a<br />
  35. 35. Gonorrhea<br />Neisseria gonorrhoeae<br />Attaches to oral or urogenital mucosa by fimbriae.<br />Females may be asymptomatic; males have painful urination and pus discharge.<br />Treatment is with antibiotics.<br />If left untreated, may result in<br />Endocarditis<br />Meningitis<br />Arthritis<br />Ophthalmia neonatorum<br />
  36. 36. Gonorrhea<br />Figure 26.7<br />
  37. 37. Gonorrhea<br />UN 26.1<br />
  38. 38. Nongonococcal Urethritis<br />Chlamydia trachomatis<br />May be transmitted to a newborn's eyes<br />Painful urination and watery discharge<br />Mycoplasma hominis<br />Ureaplasma urealyticum<br />
  39. 39. Pelvic Inflammatory Disease<br />N. gonorrhoeae<br />C. trachomatis<br />Can block uterine tubes<br />Chronic abdominal pain<br />
  40. 40. GONORRHEA<br />Neisseria gonorrhea, gram (+)<br />IP: 3-7 days<br />28<br />Rex Karl S. Teoxon, R.N, M.D<br />
  41. 41. SIGNS AND SYMPTOMS<br />Females: usually asymptomatic or minimal urethral discharge w/ lower abdominal pain<br />Male: Mucopurulent discharge, Painful urination<br />29<br />Rex Karl S. Teoxon, R.N, M.D<br />
  42. 42. GONORRHEAMANIFESTATIONS IN MEN<br /><ul><li>Urethritis
  43. 43. Epididymitis
  44. 44. Proctitis
  45. 45. Pharyngitis</li></li></ul><li>GONORRHEACLINICAL PRESENTATION<br />
  46. 46. 32<br />
  47. 47. GONORRHEAMANIFESTATIONS IN WOMEN<br /><ul><li>Urethritis
  48. 48. Endocervicitis
  49. 49. Proctitis
  50. 50. PID
  51. 51. Pharyngitis</li></li></ul><li>GONORRHEADISSEMINATED INFECTION<br /><ul><li>Arthritis
  52. 52. Dermatitis
  53. 53. Pericarditis and endocarditis
  54. 54. Meningitis
  55. 55. Perihepatitis</li></li></ul><li>DISSEMINATED GONORRHEACLINICAL PRESENTATION<br />
  56. 56. 36<br />Rex Karl S. Teoxon, R.N, M.D<br />
  57. 57. 37<br />Rex Karl S. Teoxon, R.N, M.D<br />
  58. 58. 38<br />Rex Karl S. Teoxon, R.N, M.D<br />
  59. 59. DIAGNOSIS<br />GSCS of cervical secretions on Thayer Martin medium<br />39<br />Rex Karl S. Teoxon, R.N, M.D<br />
  60. 60. GONORRHEAGRAM STAIN<br />
  61. 61. GONORRHEADIAGNOSIS<br /><ul><li>Clinical examination
  62. 62. Gram stain
  63. 63. Culture
  64. 64. Nucleic acid probes</li></li></ul><li>MANAGEMENT<br />Ceftriaxone (Rocephin) 250 mg IM<br />Ofloxacin (Floxin) 400 mg orally<br />treat concurrently with Doxycycline or Azithromycin for 50% infected w/ Chlamydia<br />42<br />Rex Karl S. Teoxon, R.N, M.D<br />
  65. 65. GONORRHEASEQUELAE<br /><ul><li>Infertility
  66. 66. Ectopic pregnancy
  67. 67. Chronic pelvic pain</li></li></ul><li>COMPLICATION<br />PID<br />ectopic pregnancy and infertility<br />Peritonitis<br />Perihepatitis<br />Ophthalmia neonatorum<br />Sepsis<br />Arthritis<br />44<br />Rex Karl S. Teoxon, R.N, M.D<br />
  68. 68. GONORRHEATREATMENT<br />Patient and partner should be treated<br />Drugs of choice<br />Ceftriaxone<br />Quinolone<br />
  69. 69. CHLAMYDIA <br />Chlamydia trachomatis, gram (-)<br />IP: 2-10 days<br />46<br />Rex Karl S. Teoxon, R.N, M.D<br />
  70. 70. SIGNS AND SYMPTOMS<br />Maybe asymptomatic<br />Gray white discharge, Burning and itchiness at the urethral opening<br />DX:<br />Gram stain<br />Antigen detection test on cervical smear<br />Urinalysis<br />47<br />Rex Karl S. Teoxon, R.N, M.D<br />
  71. 71. Rex Karl S. Teoxon, R.N, M.D<br />48<br />
  72. 72. 49<br />Rex Karl S. Teoxon, R.N, M.D<br />
  73. 73. CHLAMYDIADIAGNOSIS<br />
  74. 74. CHLAMYDIAMANIFESTATIONS IN MEN<br /><ul><li>Urethritis
  75. 75. Proctitis
  76. 76. Epididymitis</li></li></ul><li>CHLAMYDIAMANIFESTATIONS IN WOMEN<br /><ul><li>Urethritis
  77. 77. Endocervicitis
  78. 78. Proctitis
  79. 79. PID
  80. 80. Perihepatitis</li></li></ul><li>MANAGEMENT<br />Doxycycline or Azithromycin<br />Erythromycin and Ofloxacin<br />CX:<br />PID<br />Ectopic pregnancy<br />Fetus transmittal (vaginal birth)<br />53<br />Rex Karl S. Teoxon, R.N, M.D<br />
  81. 81. Syphilis<br />Figure 26.9a<br />
  82. 82. Syphilis<br />Treponema pallidum<br />Invades mucosa or through skin breaks.<br />Figure 26.10<br />
  83. 83. Syphilis<br />Direct diagnosis<br />Darkfield microscopic identification of bacteria<br />Staining with fluorescent-labeled, monoclonal antibodies<br />Indirect, serological diagnosis<br />VDRL, RPR, ELISA test for reagin-type antibodies using cardiolipid (Ag)<br />FTA-ABS tests for anti-treponemal antibodies<br />
  84. 84. Syphilis<br />Figure 3.6b<br />
  85. 85. Syphilis<br />Primary stage: Chancre at site of infection<br />Secondary: Skin and mucosal rashes<br />Latent period: No symptoms<br />Tertiary: Gummas on many organs<br />Congenital: Neurological damage<br />Primary and secondary stages treated with penicillin<br />
  86. 86. Virulence Factors of T. pallidum<br /><ul><li>Outer membrane proteins promote adherence
  87. 87. Hyaluronidase may facilitate perivascular infiltration
  88. 88. Antiphagocytic coating of fibronectin
  89. 89. Tissue destruction and lesions are primarily result of host’s immune response (immunopathology)</li></li></ul><li>SYPHILIS <br />Treponema pallidum, spirochete<br />IP: 10-90 days<br />60<br />Rex Karl S. Teoxon, R.N, M.D<br />
  90. 90. SYPHILISMECHANISMS OF TRANSMISSION<br /><ul><li>Sexual contact
  91. 91. Perinatal</li></li></ul><li>SYPHILISFREQUENCY<br /><ul><li>Incidence has increased , especially in females aged 15-24 years
  92. 92. Highest prevalence - urban blacks and hispanics</li></li></ul><li>SYPHILISCLASSIFICATION <br /><ul><li>Primary
  93. 93. Secondary
  94. 94. Latent
  95. 95. Early
  96. 96. Late
  97. 97. Tertiary</li></li></ul><li>SIGNS AND SYMPTOMS<br />Primary (3-6 wks after contact) – nontender lymphadenopathy and chancre; most infectious; resolves 4-6 wks<br />Secondary – systemic; generalized macular papular rash including palms and soles and painless wartlike lesions in vulva or scrotum (condylomata lata) and lymphadenopathy<br />Tertiary – (6-40 years) - neurosyphilis/ permanent damage (insanity); gumma (necrotic granulomatous lesions), aortic aneurysm<br />64<br />Rex Karl S. Teoxon, R.N, M.D<br />
  98. 98. Pathogenesis of T. pallidum (cont.)<br />Primary Syphilis<br /><ul><li>Primary disease process involves invasion of mucus membranes, rapid multiplication & wide dissemination through perivascular lymphatics and systemic circulation
  99. 99. Occurs prior to development of the primary lesion
  100. 100. 10-90 days (usually 3-4 weeks) after initial contact the host mounts an inflammatory response at the site of inoculation resulting in the hallmark syphilitic lesion, called the chancre (usually painless)
  101. 101. Chancre changes from hard to ulcerative with profuse shedding of spirochetes
  102. 102. Swelling of capillary walls & regional lymph nodes w/ draining
  103. 103. Primary lesion heals spontaneously by fibrotic walling-off within two months, leading to false sense of relief</li></li></ul><li>PRIMARY SYPHILISPRINCIPAL CLINICAL FINDING<br />
  104. 104. 67<br />Rex Karl S. Teoxon, R.N, M.D<br />
  105. 105. 68<br />Rex Karl S. Teoxon, R.N, M.D<br />
  106. 106. Pathogenesis of T. pallidum (cont.)<br />Secondary Syphilis<br /><ul><li>Secondary disease 2-10 weeks after primary lesion
  107. 107. Widely disseminated mucocutaneous rash
  108. 108. Secondary lesions of the skin and mucus membranes are highly contagious
  109. 109. Generalized immunological response</li></li></ul><li>SECONDARY SYPHILISPRINCIPAL CLINICAL FINDINGS<br />
  110. 110. Generalized Mucocutaneous Rash of Secondary Syphilis<br />
  111. 111. 72<br />Rex Karl S. Teoxon, R.N, M.D<br />
  112. 112. 73<br />Rex Karl S. Teoxon, R.N, M.D<br />
  113. 113. SECONDARY SYPHILISPRINCIPAL CLINICAL FINDINGS<br />
  114. 114. LATE STAGE SYPHILISPRINCIPAL CLINICAL MANIFESTATIONS<br />Destructive gummas<br />Aortic valve injury<br />CNS manifestations<br />Dementia<br />Tabes dorsalis<br />Pupillary abnormalities<br />
  115. 115. Pathogenesis of T. pallidum (cont.)<br />Latent Stage Syphilis<br /><ul><li>Following secondary disease, host enters latent period
  116. 116. First 4 years = early latent
  117. 117. Subsequent period = late latent
  118. 118. About 40% of late latent patients progress to late tertiary syphilitic disease</li></li></ul><li>Pathogenesis of T. pallidum (cont.)<br />Tertiary Syphilis<br /><ul><li>Tertiary syphilis characterized by localized granulomatous dermal lesions (gummas) in which few organisms are present
  119. 119. Granulomas reflect containment by the immunologic reaction of the host to chronic infection
  120. 120. Late neurosyphilis develops in about 1/6 untreated cases, usually more than 5 years after initial infection
  121. 121. Central nervous system and spinal cord involvement
  122. 122. Dementia, seizures, wasting, etc.
  123. 123. Cardiovascular involvement appears 10-40 years after initial infection with resulting myocardial insufficiency and death</li></li></ul><li>LATE STAGE SYPHYLISGUMMAS<br />
  124. 124. 79<br />Rex Karl S. Teoxon, R.N, M.D<br />
  125. 125. 80<br />Rex Karl S. Teoxon, R.N, M.D<br />
  126. 126. CONGENITAL SYPHILISCLINICAL MANIFESTATIONS<br />Fetal death<br />Growth restriction<br />Multiple anomalies<br />Immediately apparent at birth<br />Delayed appearance<br />
  127. 127. Pathogenesis of T. pallidum (cont.)<br />Congenital Syphilis<br /><ul><li>Congenital syphilis results from transplacental infection
  128. 128. T. pallidumsepticemia in the developing fetus and widespread dissemination
  129. 129. Abortion, neonatal mortality, and late mental or physical problems resulting from scars from the active disease and progression of the active disease state</li></li></ul><li>CONGENITAL SYPHILISRISK OF PERINATAL TRANSMISSION<br />%<br />
  130. 130. SYPHILISDIAGNOSIS<br />Clinical examination<br />Darkfield microscopy<br />Serology<br />VDRL – screening test<br />MHA or FTA – confirmatory test<br />
  131. 131. DIAGNOSIS<br /> Dark-field examination of lesion- 1st and 2nd stage<br /> Non specific VDRL and RPR<br /> FTA-ABS<br />Mgmt<br />Primary and secondary - Pen G<br />Tertiary - IV Pen G<br />85<br />Rex Karl S. Teoxon, R.N, M.D<br />
  132. 132. Diagnostic Tests for Syphilis<br />(Original Wasserman Test)<br />NOTE: Treponemal antigen tests indicate experience with a treponemal infection, but cross-react with antigens other than T. pallidum ssp. pallidum. Since pinta and yaws are rare in USA, positive treponemal antigen tests are usually indicative of syphilitic infection.<br />
  133. 133. SYPHILISTREATMENT<br />Patient and sexual partner(s) should be treated<br />Antibiotic therapy<br />Penicillin – preferred in pregnancy<br />Doxycycline<br />Tetracycline<br />
  134. 134. Prevention & Treatment of Syphilis<br /><ul><li>Penicillin remains drug of choice
  135. 135. WHO monitors treatment recommendations
  136. 136. 7-10 days continuously for early stage
  137. 137. At least 21 days continuously beyond the early stage
  138. 138. Prevention with barrier methods (e.g., condoms)
  139. 139. Prophylactic treatment of contacts identified through epidemiological tracing</li></li></ul><li>Lymphogranuloma Venereum (LGV)<br />Chlamydia trachomatis<br />Initial lesion on genitals heals<br />Bacteria spread through lymph causing enlargement of lymph nodes<br />Treatment: Doxycycline<br />
  140. 140. LGVCLINICAL MANIFESTATIONS<br />
  141. 141. CHLAMYDIALGV<br />STD caused by serovars L1, L2, L3<br />Common in Asia, Africa, South America, and the Caribbean<br />Incubation period 3 days to 3 weeks<br />Painless vesicleregional lymphaticsinguinal and femoral adenitis and proctitis<br />
  142. 142. Chancroid (Soft Chancre)<br />Haemophilus ducreyi<br />Ulcer on genitalia<br />May break through surface<br />Infection of lymph nodes<br />Treatment: Erythromycin and ceftriaxone<br />
  143. 143. Bacterial Vaginosis<br />Gardnerella vaginalis<br />Diagnosis by clue cells<br />Treatment: Metronidazole<br />Figure 26.12<br />
  144. 144. DIAGNOSIS<br />Viral culture<br />Pap smear (shows cellular changes)<br />Tzanck smear (scraping of ulcer for staining)<br />94<br />Rex Karl S. Teoxon, R.N, M.D<br />
  145. 145. MANAGEMENT<br />Anti viral – acyclovir (zovirax)<br />CX:<br />Meningitis – mild and self limiting<br />Neonatal infection (vaginal birth)<br />Disseminated with liver involvement<br />Encephalitis<br />Skin, eyes, mouth<br />95<br />Rex Karl S. Teoxon, R.N, M.D<br />
  146. 146. Genital Herpes<br />Herpes simplex virus 2 (Human herpesvirus 2 or HHV–2)<br />Neonatal herpes transmitted to fetus or newborns<br />Recurrences from viruses latent in nerves<br />Suppression: Acyclovir or valacyclovir<br />
  147. 147. HERPES GENITALIS<br />HSV 2<br />Envelop, icosahedral, dsDNA<br />Latent – sacral nerve ganglia<br />97<br />Rex Karl S. Teoxon, R.N, M.D<br />
  148. 148. 98<br />Rex Karl S. Teoxon, R.N, M.D<br />
  149. 149. 99<br />Rex Karl S. Teoxon, R.N, M.D<br />
  150. 150.
  151. 151. SIGNS AND SYMPTOMS<br />Painful sexual intercourse<br />Painful vesicular lesions (cervix, vagina, perineum, glans penis)<br />101<br />Rex Karl S. Teoxon, R.N, M.D<br />
  152. 152. Genital Warts<br />Human papillomaviruses<br />Treatment: Imiquimod to stimulate interferon<br />HPV 16 causes cervical cancer and cancer of the penis.<br />DNA test is needed to detect cancer-causing strains.<br />Vaccination against HPV strains<br />
  153. 153. GENITAL WARTS<br />Condyloma Acuminatum <br />HPV type 6 & 11, papilloma virus<br />103<br />Rex Karl S. Teoxon, R.N, M.D<br />
  154. 154. SIGNS AND SYMPTOMS<br /> Single or multiple soft, fleshy painless growth of the vulva, vagina, cervix, urethra, or anal area, Vaginal bleeding, discharge, odor and dyspareunia<br />DX:<br />Pap smear-shows cellular changes (koilocytosis)<br />Acetic acid swabbing (will whiten lesion)<br />104<br />Rex Karl S. Teoxon, R.N, M.D<br />
  155. 155.
  156. 156.
  157. 157. 107<br />Rex Karl S. Teoxon, R.N, M.D<br />
  158. 158. 108<br />Rex Karl S. Teoxon, R.N, M.D<br />
  159. 159. MANAGEMENT<br />Laser treatment is more effective<br />CX:<br />Neoplasia<br />Neonatal laryngeal papillomatosis (vaginal birth)<br />Rex Karl S. Teoxon, R.N, M.D<br />109<br />
  160. 160. Candidiasis<br />Candida albicans<br />Grows on mucosa of mouth, intestinal tract, and genitourinary tract.<br />NGU in males<br />Vulvovaginal candidiasis<br />Diagnosis is by microscopic identification and culture of yeast.<br />Treatment: Clotrimazole or miconazole.<br />
  161. 161. CANDIDIASIS<br />Moniliasis (oral candidiasis)<br />Vulvovaginal candidiasis<br />Candida albicans (Yeast or fungus)<br />111<br />Rex Karl S. Teoxon, R.N, M.D<br />
  162. 162. SIGNS AND SYMPTOMS<br />Cheesy white discharge<br />Extreme itchiness<br />DX:<br />KOH (wet smear indicate positive result)<br />112<br />Rex Karl S. Teoxon, R.N, M.D<br />
  163. 163. 113<br />Rex Karl S. Teoxon, R.N, M.D<br />
  164. 164.
  165. 165. 115<br />Rex Karl S. Teoxon, R.N, M.D<br />
  166. 166. MANAGEMENT<br />Imidazole, Monistat, Diflucan<br />CX:<br />Oral thrush to baby (vaginal birth)<br />116<br />Rex Karl S. Teoxon, R.N, M.D<br />
  167. 167. Trichomoniasis<br />Trichomonas vaginalis<br />Found in semen or urine of male carriers<br />Vaginal infection causes irritation and profuse discharge.<br />Diagnosis is by microscopic identification of protozoan.<br />Treatment: Metronidazole.<br />Figure 26.15<br />
  168. 168. TRICHOMONIASIS<br />Trichomonas vaginalis<br />parasite<br />118<br />Rex Karl S. Teoxon, R.N, M.D<br />
  169. 169. SIGNS AND SYMPTOMS<br />Females: itching, burning on urination, yellow gray frothy malodorous vaginal discharge, foul smelling<br />Males: usually asymptomatic<br />Dx: microscopic exam of vaginal discharge<br />119<br />Rex Karl S. Teoxon, R.N, M.D<br />
  170. 170. MANAGEMENT<br />Metronidazole (Flagyl)<br />include partners<br />CX: PROM<br />120<br />Rex Karl S. Teoxon, R.N, M.D<br />
  171. 171. Vaginitis and Vaginosis<br />Table UN 26.1<br />
  172. 172. Know Normal!<br />1. Epithelial Cells<br />2. Lactobacilli<br /> - 5 to 15 µ<br />3. WBCs<br /> - Few = NL<br /> - Never > Epi’s<br /> - Many = Inflammation<br /> (Parabasilar Cell) ><br />
  173. 173. Vaginosis - Know 3<br />Bacterial Vaginosis<br /> - FEW or NO LACTOBACILLI<br /> - MANY Coccobacillary Orgs.<br /> = “GARBAGE”<br /> - CLUE CELLS<br /> = CELL EDGE<br /> - FEW WBCs!!!!!!!<br /> - MOBILUNCUS = MOTILE<br />Cytolytic Vaginosis<br /> = “Lactobacillus<br /> Overgrowth Syndrome”<br />- MANY LACTOBACILLI<br /> - 5 to 15 µ<br />
  174. 174. Vaginosis - Know 3<br />3. Lactobacillosis/Leptothrix<br /> - LONG LACTOBACILLI<br /> - 40 to 75 µ<br />
  175. 175. Vaginitis - Know 2+<br />1. Trichomonas<br />2. Candidiasis/Yeast<br /> - Candida albicans 1) Blastospores<br />“CANDIDIASIS” 2) Budding Yeast<br /> 3) Pseudohyphae<br /> - Candida glabrata 1) Blastospores<br />(Torulopsis g.) 2) Budding yeast<br />“YEAST”<br /> Grow is clusters = CUMULI ><br />
  176. 176. Additional Slides - Normals<br />Normal Epithelial Cells with Sharp Borders<br />Normal Lactobacilli - 5 to 15 µ (note size relative to cell nucleus)<br />1. Epithelial Cells<br />2. Lactobacilli<br /> - 5 to 15 µ<br />3. WBCs<br /> - Few = NL<br /> - Never > Epi’s<br /> - Many = Inflammation<br /> (Parabasilar Cell) ><br />
  177. 177. Additional Slides - Clue CellsAND Inflammation of ? Cause<br />1. Epithelial Cells<br />2. Lactobacilli<br /> - 5 to 15 µ<br />3. WBCs<br /> - Few = NL<br /> - Never > Epi’s<br /> - Many = Inflammation<br /> (Parabasilar Cell) ><br />
  178. 178. STD<br />128<br />Rex Karl S. Teoxon, R.N, M.D<br />
  179. 179. HIV and AIDS<br />Retrovirus (HIV1 & HIV2)<br />Attacks and kills CD4+ lymphocytes (T-helper)<br />Capable of replicating in the lymphocytes undetected by the immune system<br />Immunity declines and opportunistic microbes set in<br />No known cure<br />Rex Karl S. Teoxon, R.N, M.D<br />129<br />
  180. 180. 130<br />Rex Karl S. Teoxon, R.N, M.D<br />
  181. 181. MOT<br />Sexual intercourse (oral, vaginal and anal)<br />Exposure to contaminated blood, semen, breast milk and other body fluids<br />Blood Transfusion<br />IV drug use<br />Transplacental<br />Needle stick injuries<br />131<br />Rex Karl S. Teoxon, R.N, M.D<br />
  182. 182. HIGH RISK GROUP<br />Homosexual or bisexual<br />Intravenous drug users<br />BT recipients before 1985<br />Sexual contact with HIV+<br />Babies of mothers who are HIV+<br />Rex Karl S. Teoxon, R.N, M.D<br />132<br />
  183. 183. 133<br />Rex Karl S. Teoxon, R.N, M.D<br />
  184. 184. SIGNS AND SYMPTOMS<br />Acute viral illness (1 mo after initial exposure) – fever, malaise, lymphadenopathy<br />Clinical latency – 8 yrs w/ no sx; towards end, bacterial and skin infections and constitutonal sx – AIDS related complex; CD4 counts 400-200<br />AIDS – 2 yrs; CD4 T lymphocyte < 200 w/ (+) ELISA or Western Blot and opportunistic infections<br />134<br />Rex Karl S. Teoxon, R.N, M.D<br />
  185. 185. DIAGNOSIS<br />HIV+<br />2 consecutive positive ELISA and <br />1 positive Western Blot Test<br />AIDS+<br />HIV+<br />CD4+ count below 200/ml<br />135<br />Rex Karl S. Teoxon, R.N, M.D<br />
  186. 186. SIGNS AND SYMPTOMS<br />Extreme fatigue<br />Intermittent fever<br />Night sweats<br />Chills<br />Lymphadenopathy<br />Enlarged spleen<br />Rex Karl S. Teoxon, R.N, M.D<br />136<br />
  187. 187. SIGNS AND SYMPTOMS<br />Anorexia<br />Weight loss<br />Severe diarrhea<br />Apathy and depression<br />PTB<br />Kaposis sarcoma<br />Pneumocystis carinii<br />AIDS dementia<br />137<br />Rex Karl S. Teoxon, R.N, M.D<br />
  188. 188. 138<br />Rex Karl S. Teoxon, R.N, M.D<br />
  189. 189. MANAGEMENT<br />Nucleoside Reverse Transcriptase Inhibitors NRTI’s<br /> Zidovudine (AZT) – limit viral growth<br />Non-nucleoside Reverse Transcriptase Inhibitors NNRTI’s Ritonavir (Norvir)<br />Prevention of spread (safe sex)<br />Universal precautions<br />Symptomatic intervention and treatment of opportunistic infections<br />Vaccines (influenza and hepa B)<br />139<br />Rex Karl S. Teoxon, R.N, M.D<br />
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