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Genital ulcer disease

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  • 1. Clinical Presentation, Diagnosis, and Management Dr. Negussie Tegegne,Dr. Negussie Tegegne, DermatovenereologistDermatovenereologist Assistant professorAssistant professor Department of dermatovenereologyDepartment of dermatovenereology FOM, Addis Ababa UniversityFOM, Addis Ababa University Addis AbabaAddis Ababa EthiopiaEthiopia Genital Ulcer Disease
  • 2. Genital Ulcer Disease: Ulcerative, erosive, pustular or vesicular lesions on the genitalia with or without lymphadenopathy DefinitionDefinition
  • 3. A. STD-related etiologies and organisms: 1. Genital herpes: Herpes Simplex Virus Type 1 and Type 2 2. Primary syphilis: Treponema pallidum var. pallidum 3. Chancroid: Haemophilus ducreyi 4. Lymphogranuloma venereum Chlamydia trachomatis serovars L1-L3 (LGV): 5. Granuloma inguinale Calymmatobacterium granulomatis (Donovanosis): Etiology
  • 4. B. Non STD-related etiologies: 1. Non-STD infectious causes of GUD: Candidiasis/balanitis, scabies, common skin infections (e.g. Staph). 2. Non-infectious causes of GUD: aphthous ulcers, Behcet’s syndrome, fixed drug eruption, Reiter’s syndrome, trauma/abrasions. C. No etiology is found in 20% to 30-50% of GUD cases
  • 5. Genital Ulcer Disease (GUD) • Etiologies of GUD – Syphilis – Herpes – Chancroid – Lymphogranuloma venereum – Donovanosis • Clinical management – Etiologic – Syndromic
  • 6. Genital Ulcer Disease (GUD) • Etiologies of GUD – Syphilis – Herpes – Chancroid – Lymphogranuloma venereum – Donovanosis
  • 7. Genital Ulcer Disease (GUD) Genital Ulcer Disease (GUD) • Etiologies of GUD – Syphilis – Herpes – Chancroid – Lymphogranuloma venereum – Donovanosis KAIS 2007: Treponema pallidum Seroprevalence • Women: 1.7% • Men: 1.9%
  • 8. Syphilis: Microbiology • Bacterium • Treponema pallidum subspecies pallidum • Spirochete, spiral, corkscrew shaped • Obligate human pathogen • Cannot be readily cultured in vitro
  • 9. Syphilis: Natural history • Sexual or • Nonsexual contact, - congenital, - occupational, - blood borne • 30–50% risk of infection following exposure • Chancre develops in ~21 days (range, 10–90 days), lasts 2–6 weeks Exposure Primary syphilis→
  • 10. Primary syphilis lesion heals in six weeks due to cell mediated immune response. a. Chancre - Early: macule/papule → erodes - Late: clean based painless, indurated ulcer with smooth firm borders - Unnoticed in 15-30% of patients - Resolves in 2-6 weeks - HIGHLY INFECTIOUS b. Regional lymphadenopathy
  • 11. Syphilis: Natural history Secondary syphilis • Represents hematogenous dissemination of spirochetes • Usually 2-8 weeks after chancre appears • Findings: – rash - whole body (includes palms/soles) – mucous patches – condylomata lata - HIGHLY INFECTIOUS – “Moth-eaten” alopecia – generalized lymphadenopathy – constitutional Systemic symptoms: fever, malaise, etc – Sn/Sx resolve in 2-10 weeks Secondary syphilisExposure Primary syphilis →→
  • 12. Secondary syphilis
  • 13. Syphilis: Natural history • Latent syphilis: no signs or symptoms • Early latent: <1 year (< 2,WHO) • Late latent: >1 year (> 2, WHO) • 25% secondary relapse • Can last 2–20 years Secondary syphilis Primary syphilisExposure Latent syphilis → ←→→→→
  • 14. Syphilis: Natural history Exposure Primary syphilis Secondary syphilis Latent syphilis Teritiary syphilis → → →← → • ~33% develop tertiary disease, if untreated • Can affect heart, bones, nerves, brain
  • 15. Syphilis: Neurosyphilis • Can occur at any stage of disease • Can be asymptomatic • Neurologic or ophthalmic signs and symptoms • Cranial nerve palsies (III, VIII) • Strokes • Meningitis • < 5% of all cases • Neurologic examination is critical
  • 16. Syphilis: Syphilis and HIV infection • Multiple chancres • Overlapping primary and secondary manifestations • Slower decline of serologic titers • Increased HIV viral load and decreased CD4 counts
  • 17. Syphilis: Diagnosis • Clinical suspicion ( presentation) • Rapid tests: Darkfield microscopy • Serology - Non-treponemal tests: RPR / VDRL positive 1 to 4 weeks after appearance of chancre, 6 weeks after exposure - Treponemal tests: TPPA / FTA-ABS / EIA may become positive 1 week earlier than non- treponemal test
  • 18. Syphilis: Indications for CSF analysis • Signs of neurosyphilis • Hearing or vision loss • Tinnitus • Dizziness/imbalance • Cranial nerve abnormalities • Treatment failure • HIV infection and late latent stage • Tertiary disease
  • 19. Syphilis: Treatment of primary, secondary, and early latent syphilis • Penicillin G benzathine 2.4 million units (MU) intramuscular (IM) once • Penicillin-allergic • Non-Pregnant: Doxycycline 100 mg orally twice daily for 14 days • Pregnant: Desensitize, treat with penicillin G benzathine 2.4 MU IM once • Jarisch-Herxheimer reaction • Fever, headache, myalgia within 24 hours of treatment
  • 20. Syphilis: Treatment follow-up • Repeat serologic tests at 3, 6, 12 and 24 months – 4-fold decline in titer at six months consistent with cure • Clinical follow-up • Repeat CSF analysis for neurosyphilis • Screen for HIV infection and other STDs
  • 21. Syphilis: Post-Exposure Treatment • Treat all sex partners within past 90 days • Penicillin G benzathine 2.4 MU IM once • Penicillin allergic • Non-Pregnant: Doxycycline 100 mg po BID x 14 days • Pregnant: Desensitize, treat with penicillin G benzathine 2.4 MU IM once
  • 22. Syphilis: Screening of Pregnant Women • First prenatal visit • 28 weeks
  • 23. Genital Ulcer Disease (GUD) • Etiologies of GUD – Syphilis – Herpes – Chancroid – Lymphogranuloma venereum – Donovanosis KAIS 2007: HSV-2 Seroprevalence • Women: 42% • Men: 26%
  • 24. Genital Herpes • HSV 1 and HSV 2 • establish latent infection in central ganglia • primary outbreak is most severe • reactivation of virus occurs with or without symptoms • reactivation may be asymptomatic or is localized, less severe and of shorter duration
  • 25. Primary Genital Herpes ▪ incubation period- 2 - 21 days  primary infection occurs in HSV antibody negative individuals – painful vesiculo-ulcerative lesions over genital area • More florid presentation • More widespread • More painful - painful inguinal lymph nodes – urinary symptoms – fever, myalgia in 40 to 70% – benign aseptic meningitis in 10 to 30% – 70 - 90% of women will have HSV cervicitis More florid presentation with primary (first) episode • More widespread • More painful • Urination/defection may be difficult • May be HSV-1
  • 26. Non-primary / Recurrent Genital Herpes • recurrent episodes, or first clinical outbreak in HSV antibody positive individual • localized, unilateral, less severe • 98% of recurrences occur in individuals infected with HSV-2 • may be long latency prior to first episode • with recurrence, 12 - 20% of women will have HSV cervicitis
  • 27. Herpes (HSV-2) “Textbook” case • Grouped vesicles on an erythematous (red) base • Painful • Incubation: 4 days (range, 2-12) • Herpes simplex virus-2 (sometimes 1) Grouped vesicles on an erythematous (red) base Not (yet) ulcers – these are vesicles
  • 28. Herpes Vesicles may rupture, leaving “punched out” erosions (areas missing the top layer of the skin) Grouped erosions
  • 29. Vesicles (blisters with clear fluid) Pustules (blisters with yellow fluid) Crust (scab) Herpes Grouped pustules, some with crust, on erythematous base
  • 30. Herpes erosions, circumferential around foreskin Grouped erosions with exudate (discharge) on vulva Herpes
  • 31. More subtle presentation in recurrent disease • May be less painful • Patient may not be aware of outbreak Grouped pustules on hair follicles • Auto-inoculation • No shaving! Grouped erosions Grouped pustules
  • 32. Herpes Chronic presentation in HIV-infected patient • Gluteal cleft • May be resistant to acyclovir • Less common with effective HIV therapies (ART)
  • 33. Genital Ulcer Disease (GUD) • Aetiologies of GUD – Syphilis – Herpes – Chancroid – Lymphogranuloma venereum – Donovanosis
  • 34. Bacterial diseases • Caused by Gram- negative bacillus Haemophilus ducreyi • Begins 1-5 days (up to 14 days) after exposure • One or more deep or superficial tender genital ulcers • Painful inguinal lymph node inflammation (bubo) in 50% • Extragenital disease reported 1. chancroid
  • 35. 2. lymphogranuloma venereum • Caused by Chlamydia trachomatis serovars L1, L2, L3 • Suppurative (pus-draining) inguinal lymph node inflammation with matted lymph nodes, inguinal bubo with ulceration, and constitutional symptoms – Begins 3-20 days after exposure with a painless lesion on the distal penis, vulva, vagina, or cervix – 2 weeks later: enlargement of lymph nodes (1/3 bilateral) – Violaceous color, tender swelling, and skin breakdown1-5 days (up to 14 days) after exposure
  • 36. – Systemic symptoms may occur (malaise, joint pains, conjunctivitis, loss of appetite, weight loss, and fever) – Skin manifestations may include erythema nodosum, erythema multiforme, photosensitivity, and scarlatiniform rashes • LGV can also manifest as proctitis • Leads to sinus formation and scarring→ Lymphedema of the genitalia
  • 37. 3 . granuloma inguinale • Caused by Klebsiella granulomatis • Appear 8-80 days after exposure, usually 2-3 weeks • Begins as single or multiple nodules (bumps) that erode through the skin to produce typically painless lesions • Lesions are typically “vegetative,” beefy red, soft, and bleed readily • 90% of cases involve genital region • Enlarge by auto-inoculation
  • 38. Genital Ulcer Evaluation Diagnosis based on medical history and physical examination often inaccurate - Serologic test for syphilis - Culture/antigen test for herpes simplex - Haemophilus ducreyi culture in settings where chancroid is prevalent - Tests for LGV: CFT, MIF, culture - Biopsy may be useful
  • 39. Treatment

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