Sexually Transmitted Diseases

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Sexually Transmitted Diseases

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Sexually Transmitted Diseases

  1. 1. Sexually Transmitted Diseases Common Diseases Dr.T.V.Rao MD Dr.T.V.Rao MD 1
  2. 2. What are Sexually Transmitted Diseases • STD’s are infections that are spread from person to person through intimate sexual contact. • STD’s are dangerous because they are easily spread and it is hard to tell just by looking who has an STD. • 1 in 4 teenagers has an STD.(Western Statistics) Dr.T.V.Rao MD 2
  3. 3. STDs • STDs are diseases and infections which are capable of being spread from person to person through: – sexual intercourse – oral-genital contact or in non-sexual ways. – IV drug – Congenitally transmitted Dr.T.V.Rao MD 3
  4. 4. Common STI’s • Chlamydia • Gonorrhea • Genital Herpes (HSV-2) • Genital Warts (HPV) • Hepatitis B • • • • Dr.T.V.Rao MD HIV and AIDS Pubic Lice Syphilis Trichomoniasis 4
  5. 5. STD’s of Concern • Actually, all of them • “Sores” (ulcers) – Syphilis – Genital herpes (HSV-2, HSV-1) – Others uncommon in the U.S. • Lymphogranuloma venereum • Chancroid • Granuloma inguinale Dr.T.V.Rao MD 5
  6. 6. Do Patients Want to Know? About STD’s • 92.4% wanted to know if they were infected • 90.8% wanted to know if their partners were infected • 65% expected the test as part of STD screening Dr.T.V.Rao MD 6
  7. 7. STDs of Concern (continued) • “Drips” (discharges) – Gonorrhea – Chlamydia – Nongonococcal urethritis / mucopurulent cervicitis – Trichomonas vaginitis / urethritis – Candidiasis (vulvovaginal, less problems in men) • Other major concerns – Genital HPV (especially type 16, 18) and Cervical Cancer Dr.T.V.Rao MD 7
  8. 8. Genital Ulcer Diseases – Does It Hurt? Sores • Painful – Chancroid – Genital herpes simplex • Painless – Syphilis – Lymphogranuloma venereum – Granuloma inguinale Dr.T.V.Rao MD 8
  9. 9. Treponema pallidum – The Agent of Syphilis • Spirochete • Obligate human parasite • Transmission – Sexual – Trans-placental – Percutaneous following contact with infectious lesions – Blood Transfusion • No reported cases of transmission since 1964 Dr.T.V.Rao MD 5 9
  10. 10. Syphilis – The “Great Imitator” • Infectious Dose: ~57 organisms1 • Incubation Period – 21 days (median) • 3 clinical stages of syphilis – Primary: • Painless sore (chancre) at inoculation site – Secondary: • Rash, Fever, Lymphadenopathy, Malaise – Tertiary/Latent: • CNS invasion, organ damage • “The physician that knows syphilis knows medicine.” – Sir William Osler Dr.T.V.Rao MD 6 10
  11. 11. Primary Syphilis - Clinical Manifestations • Incubation: 10-90 days (average 3 weeks) • Chancre – Early: macule/papule erodes – Late: clean based, painless, indurated ulcer with smooth firm borders – Unnoticed in 15-30% of patients – Resolves in 1-5 weeks – HIGHLY INFECTIOUS Dr.T.V.Rao MD 11
  12. 12. Primary Syphilis Dr.T.V.Rao MD 12
  13. 13. Primary Syphilis - Chancre Dr.T.V.Rao MD 13
  14. 14. Primary Syphilis - Chancre Dr.T.V.Rao MD 14
  15. 15. Primary Syphilis Chancre Dr.T.V.Rao MD Source: Florida STD/HIV Prevention Training Center 15
  16. 16. S o r e s Primary Syphilis Chancre • Represents haematogenous dissemination of spirochetes • Usually 2-8 weeks after chancre appears • Findings: – rash - whole body (includes palms/soles) – mucous patches – Condylomata lata - HIGHLY INFECTIOUS – constitutional symptoms • Sn/Sx resolve in 2-10 weeks Dr.T.V.Rao MD 16
  17. 17. Sores Secondary Syphilis Rash Dr.T.V.Rao MD Source: Florida STD/HIV Prevention Training Center 17
  18. 18. Sores Secondary Syphilis: Generalized Body Rash Dr.T.V.Rao MD Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides 18
  19. 19. Secondary Syphilis Rash Dr.T.V.Rao MD Source: Florida STD/HIV Prevention Training Center 19
  20. 20. Secondary Syphilis Rash Dr.T.V.Rao MD Source: Cincinnati STD/HIV Prevention Training Center 20
  21. 21. Secondary Syphilis Dr.T.V.Rao MD Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 21
  22. 22. Secondary Syphilis Condylomata Lata Dr.T.V.Rao MD Source: Florida STD/HIV Prevention Training Center Sores 22
  23. 23. Congenital Syphilis • Congenital syphilis usually occurs following vertical transmission of T. pallidum from the infected mother to the fetus in utero, but neonates may also be infected during passage through the infected birth canal at delivery. Dr.T.V.Rao MD 23
  24. 24. DIAGNOSIS OF SYPHILIS 1. History and clinical examination. 2. Dark-field microscopy: special technique use to demonstrate the spirochete as shiny motile spiral structures with a dark background. • The specimen includes oozing from the lesion or sometimes L.N. aspirate. It is usually positive in the primary and secondary stages and it is most useful in the primary stage when the serological tests are still negative. Dr.T.V.Rao MD 24
  25. 25. Laboratory Testing • Direct examination of clinical specimen by dark-field microscopy or fluorescent antibody testing of sample. • Non-specific or non-treponemal serological test to detect reagin, utilized as screening test only. • Specific Treponemal antibody tests are used as a confirmatory test for a positive reagin test. Dr.T.V.Rao MD 25
  26. 26. Diagnosis of Syphilis • Evaluation based on three factors: – Clinical findings. – Demonstration of spirochetes in clinical specimen. – Present of antibodies in blood or cerebrospinal fluid. • More than one test should be performed. • No serological test can distinguish between other Treponemal infections. Dr.T.V.Rao MD 26
  27. 27. Provisional Diagnosis of Syphilis • A presumptive diagnosis is possible with sequential serologic tests (e.g. VDRL, RPR), using the same testing method each time. A fourfold change in titer (e.g. from 1:8 to 1:32) is usually considered to be clinically significant. Confirmatory tests should be performed Dr.T.V.Rao MD 27
  28. 28. Other Diagnostic Tests • Serological tests of syphilis. • Biopsy rarely needed. It shows endarteritis obliterans with inflammatory reaction containing a plenty of plasma cells. Granuloma may found in tertiary syphilis. Dr.T.V.Rao MD 28
  29. 29. Laboratory Diagnosis of Syphilis The Uncommon Methods • Rabbit Infectivity Test (RIT) http://www.els.net – High Sensitivity and Specificity – Long turn-around-time – Limited to research settings • Dark Field Microscopy – Useful only during primary infection – Technician expertise required • Immunostaining – Direct fluorescent antibody or silver stain • Polymerase Chain Reaction (PCR) – Not commercial available textbookofbacteriology.net Dr.T.V.Rao MD 7 29
  30. 30. SERLOGICAL TESTS OF SYPHILIS: STS Non-specific or lipoidal tests • A. VDRL (venereal disease research laboratories) - It is useful for the screening, diagnosis and follow up. - The results can be qualitative or qualitative • False positive results • 1. Acute type: usually low titre and don’t persist for more than 6 months • 2. Chronic type: usually last for more than 6 months • B. Rapid plasma reagin test. • C. Wasserman test not used more Dr.T.V.Rao MD 30
  31. 31. Laboratory Diagnosis of Syphilis The Common Methods • Serology –Mainstay for syphilis testing –Two classes of serologic tests • Non-treponemal • Treponemal Dr.T.V.Rao MD 8 31
  32. 32. Specific serological tests of Syphilis • A. Reiter protein complement fixation test. • B. Fluorescent Treponemal antibody/absorption test, FTA/ABS. the most specific and most sensitive . • C. Treponema pallidum haemagglutination test- TPHA- D. Treponema pallidum immobilization testTPI Dr.T.V.Rao MD 32
  33. 33. Serologic Tests for Syphilis: Non-Treponemal Assays • Principle: – T. pallidum infection leads to the production of reagin • Reagin – Antibodies to substances released from cells damaged by T. pallidum – Reagin reacts with cardiolipin • Cardiolipin – a phospholipid component of certain eukaryotic and prokaryotic membranes • Examples of non-treponemal tests: – Rapid Plasma Reagin (RPR) – Venereal Disease Research Laboratory (VDRL) Dr.T.V.Rao MD 9 33
  34. 34. Serologic Tests for Syphilis: Non-Treponemal Assays • RPR and VDRL are agglutination assays Charcoal Cardiolipin Dr.T.V.Rao MD 10 34
  35. 35. Serologic Tests for Syphilis: Non-Treponemal Assays • RPR and VDRL are agglutination assays Charcoal Cardiolipin Reagin Serum or CSF Dr.T.V.Rao MD 11 35
  36. 36. VDRL • Each preparation of antigen suspension should first be examined by testing with known positive or negative serum controls. • The antigen particles appear as short rod forms at magnification of about 100x. Aggregation of these particles into large or small clumps is interpreted as degrees of positivity • Reactive on left, non-reactive on right Dr.T.V.Rao MD 36
  37. 37. Rapid Plasma Reagin Test - RPR • General screening test, can be adapted to automation. • CANNOT be performed on CSF. • Antigen – VDRL cardiolipin antigen is modified with choline chloride to make it more stable – attached to charcoal particles to allow macroscopic reading – antigen comes prepared and is very stable. • Serum or plasma may be used for testing, serum is not heated. Dr.T.V.Rao MD 37
  38. 38. RPR • Test Procedure: – Serum or plasma added to circle on card and spread. – One drop of antigen from a needle capable of delivering 60 drops/mL is added. – Rotate at 100 rpms/minute for 8 minutes. – Results are read macroscopically. • Daily quality control: – – – – 20 gauge needle checked for delivery of 60 drops/mL Rotator checked for 100 rpms/minute Room temperature must be 23-29 C. Three levels of control must be run and give appropriate results. • RPR appears to be more sensitive than the VDRL. Dr.T.V.Rao MD 38
  39. 39. Treponema pallidum haemagglutination (TPHA) • Adapted to micro techniques (MHA-TP) • Tanned sheep RBCs are coated with T. pallidum antigen from Nichol’s strain. • Agglutination of the RBCs is a positive result. Dr.T.V.Rao MD 39
  40. 40. Non-Treponemal Tests: Advantages • Rapid turnaround time – Minutes • Inexpensive • No specialized instrumentation required • Usually revert to negative following therapy –Can be used to monitor response to therapy Dr.T.V.Rao MD 12 40
  41. 41. Non-Treponemal Tests: Limitations • Results are subjective – Intra- and Inter-laboratory variability • Non-specific – False positive results can result from other infectious or non-infectious conditions • EBV, Lupus, etc. • Limited sensitivity in early/primary syphilis and in late/latent syphilis • Low throughput – Problematic for high volume laboratories Dr.T.V.Rao MD 13 41
  42. 42. Non-Treponemal Tests: Limitations, continued • Possibility for prozone effect – High levels of antibody may inhibit the agglutination reaction – To identify prozone, labs must serially dilute samples Undilute 1:2 1:4 Dr.T.V.Rao MD 14 1:8 1:16 42
  43. 43. Serologic Tests for Syphilis: Treponemal Assays • Principle: –Infection leads to production of specific antibodies directed against T. pallidum • Treponemal tests detect IgG or total IgM/IgG antibodies directed against T. pallidum Dr.T.V.Rao MD 15 43
  44. 44. Serologic Tests for Syphilis: Treponemal Assays • • • • • Microhemagglutination assay (MHA) Fluorescent treponemal antibody (FTA-ABS) Treponema pallidum particle agglutination (TP-PA) Enzyme Immunoassay (EIA) Multiplex Flow Immunoassay (MFI) FTA-ABS TP-PA Conventional EIA www.mastgrp.biz Yellow wells = positive Dr.T.V.Rao MD 16 44
  45. 45. Treponemal Assays: Advantages • High Specificity • Possibly higher sensitivity during early and late syphilis stages compared to non-treponemal tests • Newer Methods – Objective result interpretation – Automation option – High throughput – High reproducibility/precision Dr.T.V.Rao MD 20 45
  46. 46. Fluorescent Treponemal Antibody Absorption Test (FTA-ABS) • Diluted, heat inactivated serum added to Reiter’s strain of T. pallidum to remove cross reactivity due to other Treponemes. • Slides are coated with Nichol’s strain of T. pallidum and add absorbed patient serum. Dr.T.V.Rao MD 46
  47. 47. Fluorescent Treponemal Antibody Absorption Test (FTA-ABS) • Slides are washed, and incubated with antibody bound to a fluorescent tag. • After washing the slides are examined for fluorescence. • Requires experienced personnel to read. • Highly sensitive and specific, but time consuming to perform. Dr.T.V.Rao MD 47
  48. 48. Treponemal Assays: Limitations • Remain positive despite treatment – Cannot be used to monitor response to therapy • Conventional Methods – Subjective interpretation requiring technician expertise to read • Newer Methods – Expensive instrumentation – Higher cost/test Dr.T.V.Rao MD 21 48
  49. 49. Traditional Algorithm Non-treponemal test (e.g., RPR) Reactive Non-reactive Treponemal test (e.g., FTA) Reactive Syphilis Negative for syphilis Non-reactive Negative for syphilis Advantages: – – – – Results show good correlation with disease status Rapid, inexpensive screening method Excellent option for laboratory with small throughput Recommended by the CDC Dr.T.V.Rao MD 24 49
  50. 50. Traditional Algorithm Non-treponemal test (e.g., RPR) Reactive Non-reactive Treponemal test (e.g., FTA) Reactive Syphilis Negative for syphilis Non-reactive Negative for syphilis Disadvantages: – Manual (RPR) and subjective interpretation – Screening method is non-specific and may lead to false-positive results – Not suitable for high throughput laboratories – Potentially lower sensitivity for detecting early syphilis and late/latent disease Dr.T.V.Rao MD 25 50
  51. 51. Reverse Algorithm Treponemal test (eg, EIA) Reactive Non-reactive Non-Treponemal test (eg, RPR) Reactive Syphilis Negative for syphilis Non-reactive Second Treponemal Test (e.g., TP-PA) Reactive Non-reactive Evaluation Required* Negative for syphilis Dr.T.V.Rao MD 27 51
  52. 52. Every Pregnant women Needs Screening Dr.T.V.Rao MD 52
  53. 53. Genital Herpes Simplex Dr.T.V.Rao MD 53
  54. 54. Genital Herpes Simplex - Clinical Manifestations • Direct contact – may be with asymptomatic shedding • Primary infection commonly asymptomatic; symptomatic cases sometimes severe, prolonged, systemic manifestations • Vesicles painful ulcerations crusting • Recurrence a potential • Diagnosis: – Culture – Serology (Western blot) – PCR Dr.T.V.Rao MD 54
  55. 55. Epidemiology of Genital Herpes • One of the 3 most common STDs, increased 30% from late 70s to early 90s • 25% of US population by age 35 • HSV-2: 80-90%, HSV-1: 10-20% (majority of infections in some regions) • Most cases subclinical • Transmission primarily from subclinical infection • Complications: neonatal transmission, enhanced HIV Dr.T.V.Rao MD 55
  56. 56. Sores Underdiagnoses of Genital Herpes • 779 women attending STD clinic • 372 genital herpes diagnosis: – 363 HSV-2 antibody positive – 9 HSV-1 culture positive lesions • Of the 372 diagnosed with genital herpes – – – – 82 (22%) symptomatic 14 (4%) viral shedding without symptoms 60 (14%) history of symptoms 216 (58%) HSV-2 antibody without viral shedding or history of symptoms Dr.T.V.Rao MD 56
  57. 57. Genital Herpes Simplex Dr.T.V.Rao MD Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 57
  58. 58. Genital Herpes Simplex Dr.T.V.Rao MD Source: CDC/NCHSTP/Division of STD, STD Clinical Slides 58
  59. 59. “Drips” –Gonorrhea –Nongonococcal urethritis –Chlamydia –Mucopurulent cervicitis –Trichomonas vaginitis and urethritis –Candidiasis Dr.T.V.Rao MD 59
  60. 60. Gonorrhea Clinical Manifestations • Urethritis - male – – – – Incubation: 1-14 d (usually 2-5 d) Sx: Dysuria and urethral discharge (5% asymptomatic) Dx: Gram stain urethral smear (+) > 98% culture Complications • Urogenital infection - female – – – – Endocervical canal primary site 70-90% also colonize urethra Incubation: unclear; sx usually in l0 d Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain – Dx: Gram stain smear (+) 50-70% culture – Complications Dr.T.V.Rao MD 60
  61. 61. Gonorrhea Dr.T.V.Rao MD Source: Florida STD/HIV Prevention Training Center 61
  62. 62. Gonorrhea Gram Stain Dr.T.V.Rao MD Source: Cincinnati STD/HIV Prevention Training Center 62
  63. 63. Diagnosis not Easy • Three levels of diagnosis are defined on the basis of clinical findings or the results of laboratory diagnostic tests. A definitive diagnosis of gonorrhoea must be obtained for medico legal purposes. Dr.T.V.Rao MD 63
  64. 64. Diagnosis of Gonorrhoea • Suggestive diagnosis is defined by the presence of: • A mucopurulent endocervical or urethral exudate on physical examination and sexual exposure to a person infected with N. gonorrhoea. Dr.T.V.Rao MD 64
  65. 65. Presumptive diagnosis of gonorrhoea is made on the basis of one of the following three criteria: • Typical gram-negative intracellular diplococci on microscopic examination of a smear of urethral exudate from men or endocervical secretions from women*; • Growth of a gram-negative, oxidase-positive diplococcus, from the urethra (men) or endocervix (women), on a selective culture medium, and demonstration of typical colonial morphology, positive oxidase reaction, and typical gram- negative morphology; Dr.T.V.Rao MD 65
  66. 66. Presumptive Diagnosis of Gonorrhoea • The observation of gramnegative, intracellular diplococci on microscopic examination of endocervical secretions from women must be supported by a positive result from a test from either 2 or 3 to make a laboratory diagnosis of “presumptive N. gonorrhoea.” Dr.T.V.Rao MD 66
  67. 67. Definitive diagnosis of gonorrhoea requires: • Isolation of N. gonorrhoea from sites of exposure (e.g., urethra, endocervix, throat, rectu m) by culture (usually a selective medium) and demonstrating typical colonial morphology, positive oxidase reaction, and typical gram-negative morphology • Dr.T.V.Rao MD 67
  68. 68. Definitive diagnosis of gonorrhoea requires: • Confirmation of isolates by biochemical, enzymatic, serologic, or nucleic acid testing e.g., carbohydrate utilization, rapid enzyme substrate tests, serologic methods such as coagglutination or fluorescent antibody tests supplemented with additional tests that will ensure accurate identification of isolates, or a DNA probe culture confirmation technique. Dr.T.V.Rao MD 68
  69. 69. Newer Methods in Diagnosis of Gonorrhoea • Detection of N. gonorrhoea by a nonculture laboratory test (Antigen detection test (e.g., Gonozyme [Abbott]), direct specimen nucleic acid probe test (e.g., Pace II [GenProbe]), nucleic acid amplification test (e.g., LCR [Abbott]). Dr.T.V.Rao MD 69
  70. 70. Definitive diagnosis of gonorrhoea requires: • Isolation of N. gonorrhoea from sites of exposure (e.g., urethra, endocervix, throat, rectum) by culture (usually a selective medium) and demonstrating typical colonial morphology, positive oxidase reaction, and typical gram-negative morphology and Dr.T.V.Rao MD 70
  71. 71. Definitive diagnosis of gonorrhoea requires: • Confirmation of isolates by biochemical, enzymatic, serologic, or nucleic acid testing e.g., carbohydrate utilization, rapid enzyme substrate tests, serologic methods such as coagglutination or fluorescent antibody tests supplemented with additional tests that will ensure accurate identification of isolates, or a DNA probe culture confirmation technique. Dr.T.V.Rao MD 71
  72. 72. Drips Nongonococcal Urethritis • Etiology: – 20-40% C. trachomatis – 20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium) – Occasional Trichomonas vaginalis, HSV – Unknown in ~50% cases • Sx: Mild dysuria, mucoid discharge • Dx: Urethral smear 5 PMNs (usually 15)/OI field Urine microscopic 10 PMNs/HPF Leukocyte esterase (+) 72 Dr.T.V.Rao MD
  73. 73. Chlamydia Dr.T.V.Rao MD 73
  74. 74. Chlamydia • Chlamydia is an infection of the penis, vagina, throat, or tube that carries urine. • Chlamydia is caused by bacteria (a kind of germ). • You get it by having sex with someone who has Chlamydia. • Chlamydia can be spread by the vagina, penis, mouth, or anus. Dr.T.V.Rao MD 74
  75. 75. Chlamydia • Too many people are continuing to have unsafe sex, put themselves at risk of STIs and the serious consequences associated with infection, including infertility. • "On-going investment in programmes to increase sexual health awareness, condom use and testing, particularly for groups at most risk, is vital. Dr.T.V.Rao MD 75
  76. 76. Chlamydia trachomatis • More than three million new cases annually • Responsible for causing cervicitis, urethritis, Proctitis, lymphogranuloma venereum, and pelvic inflammatory disease • Direct and indirect cost of chlamydial infections run into billions of dollars • Potential to transmit to newborn during delivery – Conjunctivitis, pneumonia Dr.T.V.Rao MD 76
  77. 77. Normal Cervix Dr.T.V.Rao MD Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center 77
  78. 78. Chlamydia Cervicitis Dr.T.V.Rao MD Source: St. Louis STD/HIV Prevention Training Center 78
  79. 79. Mucopurulent Cervicitis Dr.T.V.Rao MD Source: Seattle STD/HIV Prevention Training Center 79
  80. 80. Drips Laboratory Tests for Chlamydia • Tissue culture has been the standard – Specificity approaching 100% – Sensitivity ranges from 60% to 90% • Non-amplified tests – Enzyme Immunoassay (EIA), e.g. Chlamydiazyme • sensitivity and specificity of 85% and 97% respectively • useful for high volume screening • false positives – Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace2 • sensitivities ranging from 75% to 100%; specificities greater than 95% • detects chlamydial ribosomal RNA • able to detect gonorrhea and chlamydia from one swab • need for large amounts of sample DNA Dr.T.V.Rao MD 80
  81. 81. Laboratory Tests for Chlamydia (continued) • DNA amplification assays – polymerase chain reaction (PCR) – ligase chain reaction (LCR) • Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100% • LCR ability to detect chlamydia in first void urine Dr.T.V.Rao MD 81
  82. 82. Chlamydia Direct Fluorescent Antibody (DFA) Dr.T.V.Rao MD Source: Centers for Disease Control and Prevention 82
  83. 83. Drips Pelvic Inflammatory Disease (PID) • l0%-20% women with GC develop PID • In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID • CDC minimal criteria – uterine adnexal tenderness, cervical motion tenderness • Other symptoms include – endocervical discharge, fever, lower abd. pain • Complications: – Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia – 7X risk of ectopic pregnancy with 1 episode PID – chronic pelvic pain in 18% Dr.T.V.Rao MD 83
  84. 84. Chancroid • The combination of a painful genital ulcer and tender Suppurative inguinal adenopathy suggests the diagnosis of Chancroid A probable diagnosis of Chancroid, for both clinical and surveillance purposes, can be made if all of the following criteria are met: 1) the patient has one or more painful genital ulcers; 2) the patient has no evidence of T. pallidum infection by dark field examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers; Dr.T.V.Rao MD 84
  85. 85. Chancroid • 3) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for Chancroid; and 4) a test for HSV performed on the ulcer exudate is negative. Dr.T.V.Rao MD 85
  86. 86. Chancroid • A definitive diagnosis of Chancroid requires the identification of H. ducreyi on special culture media that is not widely available from commercial sources; even when these media are used, sensitivity is <80% (145). Dr.T.V.Rao MD 86
  87. 87. Granuloma Inguinale (Donovanosis) • Granuloma inguinale is a genital ulcerative disease caused by the intracellular gramnegative bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis). The disease occurs rarely in the United States, although it is endemic in some tropical and developing areas, including India; Papua, New Guinea; the Caribbean; central Australia; and southern Africa (192,193). Dr.T.V.Rao MD 87
  88. 88. Granuloma Inguinale (Donovanosis) • Clinically, the disease is commonly characterized as painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy; subcutaneous granulomas (pseudoboboes) might also occur. The lesions are highly vascular (i.e., beefy red appearance) and bleed easily on contact. Dr.T.V.Rao MD 88
  89. 89. Granuloma Inguinale (Donovanosis) • The causative organism is difficult to culture, and diagnosis requires visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy. No FDA-cleared molecular tests for the detection of K. granulomatis DNA exist, but such an assay might be useful when undertaken by laboratories that have conducted a CLIA verification study. Dr.T.V.Rao MD 89
  90. 90. Lymph granuloma Venereum • Lymph granuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3 . The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. Dr.T.V.Rao MD 90
  91. 91. Lymph granuloma Venereum • Diagnosis is based on clinical suspicion, epidemiologic information, and the exclusion of other Aetiologies for proctocolitis, inguinal lymphadenopathy, or genital or rectal ulcers. C. trachomatis testing also should be conducted, if available. Dr.T.V.Rao MD 91
  92. 92. Lymph granuloma Venereum • Genital and lymph node specimens (i.e., lesion swab or bubo aspirate) can be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection. NAATs for C. trachomatis are not FDA-cleared for testing rectal specimens, although some laboratories have performed the CLIA validation studies that are needed to provide results for clinical management. Additional molecular procedures (e.g., PCR-based genotyping) can be used to differentiate LGV from non-LGV C. trachomatis, but these are not widely available. Dr.T.V.Rao MD 92
  93. 93. Lymph granuloma Venereum • chlamydia serology (complement fixation titers >1:64) can support the diagnosis of LGV in the appropriate clinical context. Comparative data between types of serologic tests are lacking, and the diagnostic utility of serologic methods other than complement fixation and some micro immunofluorescence procedures has not been established. Dr.T.V.Rao MD 93
  94. 94. • • • • Trichomoniasis An estimated 5 million new cases occur each year in women and men. Occurs in vagina of women so may be sexually transmitted to men using infected washcloths and towels. It is transmitted to the baby during delivery. It also can occur in the urethra (carries urine to penis) in men, doesn’t have symptoms usually. SYMPTOMS: Appear within 5 to 28 days of exposure Women usually have a vaginal discharge that FEMALE SYMPTOMS: Itching and burning at the outside of the opening of the vagina and vulva. Painful and frequent urination Heavy, unpleasant smelling greenish, yellow discharge MALE SYMPTOMS: Usually nothing, or discomfort in urethra, inflamed head of the penis. Dr.T.V.Rao MD 94
  95. 95. Bacterial Vaginitis • Controversy: STD - yes or no • Need for treatment – 1980: only if patient complains – 2002: increased risk of: • • • • • • • • Preterm birth / premature rupture of membranes Amniotic fluid infection Chorioamnionitis / Postpartum endometritis Pelvic inflammatory disease Postsurgical infection Cervical intraepithelial neoplasia Mucopurulent cervicitis Acquisition of HIV Dr.T.V.Rao MD infection 95
  96. 96. Life at Risk with Sexually Transmitted Infections Best Choice Play safe Dr.T.V.Rao MD 96
  97. 97. • Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World • Email • doctortvrao@gmail.com Dr.T.V.Rao MD 97

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