T. pallidum subspecies pallidum (referred to hereafter as T. pallidum), a thin spiral organism, has a cell body surrounded by a trilaminar cytoplasmic membrane, a delicate peptidoglycan layer providing some structural rigidity, and a lipid-rich outer membrane containing relatively few integral membrane proteins. Endoflagella wind around the cell body in the periplasmic space and are responsible for motility
In heterosexual men the chancre is usually located on the penis, whereas in homosexual men it may be found in the anal canal or rectum, in the mouth, or on the external genitalia. In women, common primary sites are the cervix and labia. Consequently, primary syphilis goes unrecognized in women and homosexual men more often than in heterosexual men.The clinical appearance depends on the number of treponemes inoculated and on the immunologic status of the patient. A large inoculum produces a dark-field-positive ulcerative lesion in nonimmune volunteers but may produce a small dark-field-negative papule, an asymptomatic but seropositive latent infection, or no response at all in some individuals with a history of syphilis. A small inoculum may produce only a papular lesion, even in nonimmune individuals. Therefore, syphilis should be considered even in the evaluation of trivial or atypical dark-field-negative genital lesions.
The eruption may be very subtle, and 25% of patients with a discernible rash may be unaware that they have dermatologic manifestations.In warm, moist, intertriginous areas (commonly the perianal region, vulva, and scrotum), papules can enlarge to produce broad, moist, pink or gray-white, highly infectious lesions [condylomatalata (see Fig. e7-20)] in 10% of patients with secondary syphilis. Superficial mucosal erosions (mucous patches) occur in 10–15% of patients and commonly involve the oral or genital mucosa
Positive serologic tests for syphilis, together with a normal CSF examination and the absence of clinical manifestations of syphilis, indicate a diagnosis of latent syphilis in an untreated person. The diagnosis is often suspected on the basis of a history of primary or secondary lesions, a history of exposure to syphilis, or the delivery of an infant with congenital syphilis
Benign nodular tertiary syphilis
Most experts agree that neurosyphilis is more common in HIV-infected persons, while immunocompetent patients with untreated latent syphilis and normal CSF probably run a very low risk of subsequent neurosyphilis. In several recent studies, neurosyphilis was associated with a rapid plasma reagin titer of 1:32, regardless of clinical stage or HIV infection status.
The last category includes general paresis and tabesdorsalis. The onset of symptoms usually occurs <1 year after infection for meningeal syphilis, up to 10 years after infection for meningovascular syphilis, at 20 years for general paresis, and at 25–30 years for tabesdorsalis.personality, affect, reflexes (hyperactive), eye (e.g., Argyll Robertson pupils), sensorium (illusions, delusions, hallucinations), intellect (a decrease in recent memory and in the capacity for orientation, calculations, judgment, and insight), and speech
Trophic joint degeneration (Charcot's joints) and perforating ulceration of the feet can result from loss of pain sensation. The small, irregular Argyll Robertson pupil, a feature of both tabesdorsalis and paresis, reacts to accommodation but not to light. Optic atrophy also occurs frequently in association with tabes.
Linear calcification of the ascending aorta on chest x-ray films suggests asymptomatic syphilitic aortitis, as arteriosclerosis seldom produces this sign. Syphilitic aneurysms—usually saccular, occasionally fusiform—do not lead to dissection. Only 1 in 10 aortic aneurysms of syphilitic origin involves the abdominal aorta.
The RPR and VDRL tests are recommended for screening or for quantitation of serum antibody. The titer reflects disease activity, rising during the evolution of early syphilis and often exceeding 1:32 in secondary syphilis. After therapy for early syphilis, a persistent fall by fourfold or more (e.g., a decline from 1:32 to 1:8) is considered an adequate response
Treponemal tests measure antibodies to native or recombinant T. pallidum antigens both of which are more sensitive for primary syphilis than the previously used hemagglutination testsWhen used to confirm positive nontreponemal test results, treponemal tests have a very high positive predictive value for diagnosis of syphilisbased largely on reactivity to recombinant antigens, have also been developed. Treponemal EIAs have been approved as confirmatory tests and, because of their ease of automation, are now used for screening purposes by some large laboratories.For practical purposes, most clinicians need to be familiar with three uses of serologic tests for syphilis: (1) screening or diagnosis (RPR or VDRL), (2) quantitative measurement of antibody to assess clinical syphilis activity or to monitor response to therapy (RPR or VDRL), and (3) confirmation of a syphilis diagnosis in a patient with a reactive RPR or VDRL test (FTA-ABS, TPPA, EIA
The efficacy of penicillin against syphilis remains undiminished after60 years of use, and there is no evidence of penicillin resistance in T. pallidum. Other antibiotics effective in syphilis include the tetracyclines and the cephalosporins. Aminoglycosides and spectinomycin inhibit T. pallidum only in very large doses, and the sulfonamides and the quinolones are inactive. Azithromycin has shown significant promise as an effective oral agent against T pallidum
If untreated, infections at these sites can lead to local complications such as endometritis, salpingitis, tuboovarian abscess, bartholinitis, peritonitis, and perihepatitis in female patients; periurethritis and epididymitis in male patients; and ophthalmianeonatorum in newborns.
The discharge initially is scant and mucoid but becomes profuse and purulent within a day or two. Gram's stain of the urethral discharge may reveal PMNs and gram-negative intracellular monococci and diplococci. The clinical manifestations of gonococcalurethritis are usually more severe and overt than those of nongonococcalurethritis, including urethritis caused by Chlamydia trachomatis
Because Gram's stain is not sensitive for the diagnosis of gonorrhea in women, specimens should be submitted for culture or a nonculture assay Gonococcal infection may extend deep enough to produce dyspareunia and lower abdominal or back pain. In such cases, it is imperative to consider a diagnosis of pelvic inflammatory disease (PID) and to administer treatment for that disease
The vaginal mucosa of healthy women is lined by stratified squamous epithelium and is rarely infected by N. gonorrhoeae. However, gonococcalvaginitis can occur in anestrogenic women (e.g., prepubertal girls and postmenopausal women), in whom the vaginal stratified squamous epithelium is often thinned down to the basilar layer, which can be infected by N. gonorrhoeae
The rectum is the sole site of infection in only 5% of women with gonorrhea. Such women are usually asymptomatic but occasionally have acute proctitis manifested by anorectal pain or pruritus, tenesmus, purulent rectal discharge, and rectal bleedingAmong men who have sex with men (MSM), the frequency of gonococcal infection, including rectal infection, fell by 90% throughout the United States in the early 1980s, but a resurgence of gonorrhea among MSM has been documented in several cities since the 1990s. Gonococcal isolates from the rectum of MSM tend to be more resistant to antimicrobial agents than are gonococcal isolates from other sites.
The designation PGU refers to NGU developing in men 2–3 weeks after treatment of gonococcal urethritis with single doses of agents such as penicillin or cephalosporins, which lack antimicrobial activity against chlamydiae. Since current treatment regimens for gonorrhea have evolved and now include combination therapy with tetracycline, doxycycline, or azithromycin—all of which are effective against concomitant chlamydial infection—both the incidence of PGU and the causative role of C. trachomatis in this syndrome have declined.C. trachomatis urethritis is generally less severe than gonococcal urethritis, although in any individual patient these two forms of urethritis cannot reliably be differentiated solely on clinical grounds. Symptoms include urethral discharge (often whitish and mucoid rather than frankly purulent), dysuria, and urethral itching. Physical examination may reveal meatal erythema and tenderness as well as a urethral exudate that is often demonstrable only by stripping of the urethra.
The condition usually presents as unilateral scrotal pain with tenderness, swelling, and fever in a young man, often occurring in association with chlamydial urethritis
C. trachomatis has been isolated from synovial biopsy samples from 15 of 29 patients in a number of small series and from a smaller proportion of synovial fluid specimens.Mild bilateral conjunctivitis, iritis, keratitis, or uveitis is sometimes present but lasts for only a few days. Finally, dermatologic manifestations occur in up to 50% of patients. The initial lesions—usually papules with a central yellow spot—most often involve the soles and palms and, in 25% of patients, eventually epithelialize and thicken to produce keratodermablenorrhagicum
A Papanicolaou smear shows increased numbers of neutrophils as well as a characteristic pattern of mononuclear inflammatory cells including plasma cells, transformed lymphocytes, and histiocytes. Cervical biopsy shows a predominantly mononuclear cell infiltrate of the subepithelialstroma. Clinical experience and collaborative studies indicate that a cutoff of >30 polymorphonuclear leukocytes (PMNs)/1000x field in a gram-stained smear of cervical mucus correlates best with chlamydial or gonococcal cervicitis
LGV strains of C. trachomatis have occasionally been recovered from genital ulcers and from the urethra of men and the endocervix of women who present with inguinal adenopathy; these areas may be the primary sites of infection in some cases. Proctitis is more common among people who practice receptive anal intercourse, and an elevated white blood cell count in anorectal smears may predict LGV in these patients. Ulcer formation may facilitate transmission of HIV infection and other sexually transmitted and blood-borne diseases
The nodes are initially discrete, but progressive periadenitis results in a matted mass of nodes that becomes fluctuant and suppurative. The overlying skin becomes fixed, inflamed, and thin, and multiple draining fistulas finally develop. Extensive enlargement of chains of inguinal nodes above and below the inguinal ligament ("the sign of the groove") is not specific and, although not uncommon, is documented in only a minority of casesMassive pelvic lymphadenopathy may lead to exploratory laparotomy
A single 1-g oral dose of azithromycin is as effective as a 7-day course of doxycycline for the treatment of uncomplicated genital C. trachomatis infections in adults. Azithromycin causes fewer adverse gastrointestinal reactions than do older macrolides such as erythromycin. The single-dose regimen of azithromycin has great appeal for the treatment of patients with uncomplicated chlamydial infection (especially those without symptoms and those with a likelihood of poor compliance) and of the sexual partners of infected patients
in gonococcal infection, such a smear usually reveals gram-negative intracellular diplococci as well. Alternatively, the centrifuged sediment of the first 20–30 mL of voided urine—ideally collected as the first morning specimen—can be examined for inflammatory cells, either by microscopy showing 10 leukocytes per high-power field or by the leukocyte esterase test. Patients with symptoms who lack objective evidence of urethritis may have functional rather than organic problems and generally do not benefit from repeated courses of antibiotics
For hospitalized patients, the following two parenteral regimens have given nearly identical results in a multicenter randomized trial:Doxycycline (100 mg twice daily, given IV or PO) plus cefotetan (2 g IV every 12 h) or cefoxitin (2 g IV every6 h): Administration of these drugs should be continued by the IV route for at least 48 h after the patient's condition improves and then followed with oral doxycycline (100 mg twice daily) to complete 14 days of therapy.Clindamycin (900 mg IV every 8 h) plus gentamicin(2 mg/kg IV or IM, followed by 1.5 mg/kg every 8 h) in patients with normal renal function: Once-daily dosing of gentamicin (with combination of the total daily dose into a single daily dose) has not been evaluated in PID but has been efficacious in other serious infections and could be substituted. Treatment with these drugs should be continued for at least 48 h after the patient's condition improves and then followed with oral doxycycline (100 mg twice daily) or clindamycin (450 mg four times daily) to complete 14 days of therapy. In cases with tuboovarian abscess, clindamycin rather than doxycycline for continued therapy provides better coverage for anaerobic infection.
Sexually transmitted infections comp
Jeffrey A. Verona MDDepartment of Internal MedicineChinese General Hospital and Medical CenterSEXUALLY TRANSMITTED INFECTIONS
STI• In all societies, STIs rank among the most common of all infectiousdiseases, with >30 infections now classified as predominantly sexuallytransmitted or as frequently sexually transmissible• Certain STIs, such as syphilis, gonorrhea, HIV infection, hepatitis B,and chancroid, are most concentrated within "core populations"characterized by high rates of partner change, multiple concurrentpartners, or "dense," highly connected sexual networks—e.g.,involving sex workers and their clients, some men who have sex withmen (MSM), and persons involved in the use of illicit drugs,particularly crack cocaine and methamphetamine
SYPHILIS• a chronic systemic infection caused by Treponema pallidum subspeciespallidum, is usually sexually transmitted and is characterized by episodesof active disease interrupted by periods of latency• After an incubation period averaging 2–6 weeks, a primary lesion appears,often associated with regional lymphadenopathy• secondary stage, associated with generalized mucocutaneous lesions andgeneralized lymphadenopathy, is followed by a latent period of subclinicalinfection lasting years or decades• In about one-third of untreated cases, the tertiary stage appears,characterized by progressive destructive mucocutaneous, musculoskeletal,or parenchymal lesions; aortitis; or late CNS manifestations.
CLINICAL MANIFESTATIONPrimary SyphilisThe typical primary chancre usually begins as a single painless papule that rapidlybecomes eroded and usually becomes indurated, with a characteristic cartilaginousconsistency on palpation of the edge and base of the ulcer. Multiple primary lesionsare seen in a minority of patients
Regional (usually inguinal) lymphadenopathy accompanies the primary syphiliticlesion, appearing within 1 week of lesion onset. The nodes are firm,nonsuppurative, and painless. Inguinal lymphadenopathy is bilateral and mayoccur with anal as well as with external genital chancres. The chancre generallyheals within 4–6 weeks (range, 2–12 weeks), but lymphadenopathy may persistfor months.
Secondary Syphilis• The protean manifestations of the secondary stage usually includemucocutaneous lesions and generalized nontender lymphadenopathy• The skin rash consists of macular, papular, papulosquamous, andoccasionally pustular syphilides; often more than one form is presentsimultaneously. Initial lesions are pale red or pink, nonpruritic, discretemacules distributed on the trunk and proximal extremities; these maculesprogress to papular lesions that are distributed widely and that frequentlyinvolve the palms and soles
• Constitutional symptoms that may accompany or precede secondary syphilisinclude sore throat (15–30%), fever (5–8%), weight loss (2–20%), malaise (25%),anorexia (2–10%), headache (10%), and meningismus (5%).• Acute meningitis occurs in only 1–2% of cases, but CSF cell and proteinconcentrations are increased in up to 40% of cases, and T. pallidum has beenrecovered from CSF during primary and secondary syphilis in 30% of cases; thelatter finding is often but not always associated with other CSF abnormalities.• Less common complications of secondary syphilis include hepatitis, nephropathy,gastrointestinal involvement (hypertrophic gastritis, patchy proctitis, or arectosigmoid mass), arthritis, and periostitis. Ocular findings that suggestsecondary syphilis include pupillary abnormalities and optic neuritis as well asthe classic iritis or uveitis.
Latent SyphilisEarly latent syphilis is limited to the first year after infection,whereas Late latent syphilis is defined as that of 1 years (orunknown) duration.T. pallidum may still seed the bloodstream intermittently during thelatent stage, and pregnant women with latent syphilis may infectthe fetus in utero. Moreover, syphilis has been transmitted throughblood transfusion or organ donation from patients with latentsyphilis
ASYMPTOMATIC NEUROSYPHILIS• The diagnosis of asymptomatic neurosyphilis is made in patientswho lack neurologic symptoms and signs but who have CSFabnormalities including mononuclear pleocytosis, increased proteinconcentrations, or CSF reactivity in the Venereal Disease ResearchLaboratory test.• Although the prognostic implications of these findings in earlysyphilis are uncertain, it may be appropriate to conclude that evenpatients with early syphilis who have such findings do indeed haveasymptomatic neurosyphilis and should be treated for neurosyphilis;such treatment is particularly important in patients with concurrentHIV infection
SYMPTOMATIC NEUROSYPHILIS• The major clinical categories of symptomatic neurosyphilis include meningeal,meningovascular, and parenchymatous syphilis• Meningeal syphilis may present as headache, nausea, vomiting, neck stiffness,cranial nerve involvement, seizures, and changes in mental status.• Meningovascular syphilis reflects meningitis together with inflammatoryvasculitis of small, medium, or large vessels. The most common presentation isa stroke syndrome involving the middle cerebral artery of a relatively youngadult.• manifestations of general paresis reflect widespread late parenchymal damage
Tabes dorsalis is a late manifestation of syphilis that presents assymptoms and signs of demyelination of the posterior columns,dorsal roots, and dorsal root ganglia.• Symptoms include ataxic wide-based gait and foot drop;paresthesia; bladder disturbances; impotence; areflexia; andloss of positional, deep-pain, and temperature sensations
CARDIOVASCULAR SYPHILIS• Cardiovascular manifestations, usually appearing 10–40 years afterinfection, are attributable to endarteritis obliterans of the vasa vasorum,which provide the blood supply to large vessels• Cardiovascular involvement results in uncomplicated aortitis, aorticregurgitation, saccular aneurysm (usually of the ascending aorta), orcoronary ostial stenosis.
LATE BENIGN SYPHILIS (GUMMA)• Gummas are usually solitary lesions ranging from microscopic to severalcentimeters in diameter. Histologic examination shows a granulomatousinflammation, with a central area of necrosis due to endarteritis obliterans• Common sites include the skin and skeletal system; however, any organ (includingthe brain) may be involved.• Gummas of the skin produce indolent, painless, indurated nodular or ulcerativelesions that may resemble other chronic granulomatous conditions, includingtuberculosis, sarcoidosis, leprosy, and deep fungal infections.• Skeletal gummas most frequently involve the long bones, although any bone may beaffected. Upper respiratory gummas can lead to perforation of the nasal septum orpalate
LABORATORY EXAMINATIONSDemonstration of the Organism• T. pallidum cannot be detected by culture• Dark-field microscopy and immunofluorescence antibody staininghave been used to identify this spirochete in samples from moistlesions such as chancres or condylomata lata• Tissue treponemes can be demonstrated more reliably in researchlaboratories by PCR or by immunofluorescence orimmunohistochemical methods using specific monoclonal orpolyclonal antibodies to T. pallidum
SEROLOGIC TEST FOR SYPHILIS• two types of serologic test for syphilis: nontreponemal andtreponemal• most widely used nontreponemal antibody tests for syphilis arethe rapid plasma reagin (RPR) and Venereal Disease ResearchLaboratory (VDRL) tests, which measure IgG and IgM directedagainst a cardiolipin-lecithin-cholesterol antigen complex• The RPR test is easier to perform and uses unheated serum; it isthe test of choice for rapid serologic diagnosis in a clinical settingand can be automated• The VDRL test remains the standard for examining CSF
• Treponemal tests: fluorescent treponemal antibody–absorbed (FTA-ABS) testand the T. pallidum particle agglutination (TPPA) test.• Treponemal immunochromatographic strip (ICS) tests and enzymeimmunoassays (EIAs)• Most clinicians need to be familiar with three uses of serologic tests for syphilis:• (1) screening or diagnosis (RPR or VDRL)• (2) quantitative measurement of antibody to assess clinical syphilis activityor to monitor response to therapy (RPR or VDRL)• (3) confirmation of a syphilis diagnosis in a patient with a reactive RPR orVDRL test (FTA-ABS, TPPA, EIA)
TREATMENT• Penicillin G is the drug of choice for all stages of syphilis• T. pallidum is killed by very low concentrations of penicillin G,although a long period of exposure to penicillin is requiredbecause of the unusually slow rate of multiplication of theorganism.• Other antibiotics: tetracyclines; cephalosporins;aminoglycosides; spectinomycin; azithromycin
is a sexually transmitted infection (STI) of epitheliumand commonly manifests as cervicitis, urethritis,proctitis, and conjunctivitis
• Neisseria gonorrhoeae is a gram-negative, nonmotile,non-spore-forming organism that grows singly and inpairs• are distinguished from other neisseriae by their ability togrow on selective media and to utilize glucose but notmaltose, sucrose, or lactose.
• Gonorrhea is transmitted from males to femalesmore efficiently than in the opposite direction
GONOCOCCAL INFECTIONS IN MALES• Acute urethritis is the most common clinicalmanifestation of gonorrhea in males• usual incubation period after exposure is 2–7 days• Urethral discharge and dysuria, usually withouturinary frequency or urgency, are the majorsymptoms
Local complications of gonococcal urethritis edema of the penis due to dorsal lymphangitis orthrombophlebitis submucous inflammatory "soft" infiltration of the urethral wall periurethral abscess or fistula inflammation or abscess of Cowpers gland seminalvesiculitis
GONOCOCCAL INFECTIONS IN FEMALESGonococcal CervicitisMucopurulent cervicitis is the most common STI diagnosis inAmerican women(caused by N. gonorrhoeae, C. trachomatis,and other organisms)symptoms usually develop within 10 days of infection and are moreacute and intense than those of chlamydial cervicitis
• N. gonorrhoeae may be recovered from theurethra and rectum of women with cervicitis, butthese are rarely the only infected sites
PHYSICAL EXAMINATION• a mucopurulent discharge (mucopus) issuing fromthe cervical os• Edematous and friable cervical ectopy as well asendocervical bleeding induced by gentle swabbingare more often seen in chlamydial infection• Gonococcal infection may extend deep enough toproduce dyspareunia and lower abdominal or backpain
GONOCOCCAL VAGINITIS• gonococcal vaginitis can occur in anestrogenic women(e.g. Prepubertal girls and postmenopausal women)• vaginal mucosa is red and edematous, and an abundantpurulent discharge is present
ANORECTAL GONORRHEA• Because the female anatomy permits the spreadof cervical exudate to the rectum, N. gonorrhoeaeis sometimes recovered from the rectum of womenwith uncomplicated gonococcal cervicitis.
PHARYNGEAL GONORRHEA• mode of acquisition is oral-genital sexualexposure, with fellatio being a more efficientmeans of transmission than cunnilingus• Most cases resolve spontaneously, andtransmission from the pharynx to sexual contactsis rare
OCULAR GONORRHEA IN ADULTS• Infection may result in a markedly swollen eyelid,severe hyperemia and chemosis, and a profusepurulent discharge• usually results from autoinoculation from aninfected genital site
GONOCOCCAL ARTHRITIS• results from gonococcal bacteremia• DGI strains resist the bactericidal action of human serumand generally do not incite inflammation at genital sites,probably because of limited generation of chemotacticfactors
• Menstruation is a risk factor for dissemination, andapproximately two-thirds of cases of DGI are in women. Inabout half of affected women, symptoms of DGI beginwithin 7 days of onset of menses.• Complement deficiencies, especially of the componentsinvolved in the assembly of the membrane attack complex(C5 through C9), predispose to neisserial bacteremia
• clinical manifestations of DGI have sometimes been classified intotwo stages:• a bacteremic stage, which is less common today• a joint-localized stage with suppurative arthritis• Patients in the bacteremic stage have higher temperatures, andchills more frequently accompany their fever. Painful joints arecommon and often occur together with tenosynovitis and skinlesions. Polyarthralgias usually include the knees, elbows, andmore distal joints; the axial skeleton is generally spared.
• Oculogenital infections due to C. trachomatis serovars D–Kare transmitted during sexual contact or from mother tobaby during childbirth and are associated with manysyndromes:cervicitis, salpingitis, acute urethral syndrome,endometritis, ectopic pregnancy, infertility, and PID in femalepatientsurethritis, proctitis, and epididymitis in male patientsconjunctivitis and pneumonia in infants
• the LGV serovars (L1, L2, and L3) cause LGV, an invasive sexuallytransmitted disease (STD) characterized by acute lymphadenitis with buboformation and/or acute hemorrhagic proctitis
CLINICAL MANIFESTATIONS:NON GONOCCOCAL AND POST GONOCOCCALURETHRITIS• C. trachomatis is the most common cause of nongonococcalurethritis (NGU) and postgonococcal urethritis (PGU)• The cause of most of the remaining cases of NGU is uncertain, butrecent evidence suggests that Ureaplasma urealyticum, Mycoplasmagenitalium,Trichomonas vaginalis, and herpes simplex virus (HSV)cause some cases• NGU is diagnosed by documentation of a leukocytic urethral exudateand by exclusion of gonorrhea by Gram—s staining or culture
EPIDIDYMITIS• Chlamydial urethritis may be followed by acute epididymitis, butthis condition is rare, generally occurring in sexually activepatients <35 years of age• The possibility of testicular tumor or chronic infection (e.g.,tuberculosis) should be excluded when a patient with unilateralintrascrotal pain and swelling does not respond to appropriateantimicrobial therapy
REACTIVE ARTHRITIS• Reactive arthritis (formerly known as Reiter—s syndrome) consists of conjunctivitis,urethritis (or, in female patients, cervicitis), arthritis, and characteristic mucocutaneouslesions• most common type of peripheral inflammatory arthritis in young men• Antibodies to C. trachomatis have also been detected in 46–67% of patients withreactive arthritis, and Chlamydia-specific cell-mediated immunity has beendocumented in 72%• NGU is the initial manifestation of reactive arthritis in 80% of patients, typicallyoccurring within 14 days after sexual exposure. The urethritis may be mild and mayeven go unnoticed by the patient• The knees are most frequently involved; next most commonly affected are the anklesand small joints of the feet. Sacroiliitis, either symmetrical or asymmetrical, isdocumented in two-thirds of patients
MUCOPURULENT CERVICITIS• Cervicitis is usually characterized by the presence of a mucopurulentdischarge, with >20 neutrophils per microscopic field visible in strandsof cervical mucus in a thinly smeared, gram-stained preparation ofendocervical exudate.• Hypertrophic ectopy of the cervix may also be evident as an edematousarea near the cervical os that is congested and bleeds easily on minortrauma (e.g., when a specimen is collected with a swab).• A Papanicolaou smear shows increased numbers of neutrophils as wellas a characteristic pattern of mononuclear inflammatory cells includingplasma cells, transformed lymphocytes, and histiocytes.
PELVIC INFLAMMATORY DISEASE• Inflammation of sections of the fallopian tube is often referred to assalpingitis or PID• PID occurs via ascending intraluminal spread of C. trachomatis orN.gonorrhoeae from the lower genital tract. Mucopurulent cervicitis isoften followed by endometritis, endosalpingitis, and finally pelvicperitonitis• Chronic untreated endometrial and tubal inflammation can result intubal scarring, impaired tubal function, tubal occlusion, and infertilityeven among women who report no prior treatment for PID
LYMPHOGRANULOMA VENEREUM• C. trachomatis serovars L1, L2, and L3 cause LGV, an invasive systemic STD.• The peak incidence of LGV corresponds with the age of greatest sexual activity:the second and third decades of life.• LGV was described in association with a concurrent increase in heterosexualinfection with HIV. Reports of outbreaks with the newly identified variant L2b inEurope, Australia, and the United States indicate that LGV is becoming moreprevalent among MSM. These cases have usually presented as hemorrhagicproctocolitis in HIV-positive men.• LGV begins as a small painless papule that tends to ulcerate at the site ofinoculation, often escaping attention
• The most common presenting picture in heterosexual men and womenis the inguinal syndrome, which is characterized by painful inguinallymphadenopathy beginning 2–6 weeks after presumed exposure;• inguinal adenopathy is unilateral in two-thirds of cases, and palpableenlargement of the iliac and femoral nodes is often evident on thesame side as the enlarged inguinal nodes.• Constitutional symptoms are common during the stage of regionallymphadenopathy and, in cases of proctitis, may include fever, chills,headache, meningismus, anorexia, myalgias, and arthralgias
• A 7-day course of tetracycline (500 mg four times daily), doxycycline (100 mgtwice daily), erythromycin (500 mg four times daily), or a fluoroquinolone(ofloxacin, 300 mg twice daily; or levofloxacin, 500 mg/d) can be used fortreatment of uncomplicated chlamydial infections• Amoxicillin (500 mg three times daily for 7 days) can also be given topregnant women. The fluoroquinolones are contraindicated in pregnancy.• A 2-week course of treatment is recommended for complicated chlamydialinfections (e.g., PID, epididymitis) and at least a 3-week course ofdoxycycline (100 mg orally twice daily) or erythromycin base (500 mg orallyfour times daily) for LGV.
URETHRITIS IN MEN• Causes include Neisseria gonorrhoeae, C. trachomatis, Mycoplasma genitalium,Ureaplasma urealyticum, Trichomonas vaginalis, HSV, and adenovirus.• Establish the presence of urethritis• If proximal-to-distal "milking" of the urethra does not express a purulent ormucopurulent discharge, even after the patient has not voided for several hours(or preferably overnight), a Grams-stained smear of overt discharge or of ananterior urethral specimen obtained by passage of a small urethrogenital swab 2–3 cm into the urethra usually reveals 5 neutrophils per 1000x field in areascontaining cells;• in gonococcal infection, such a smear usually reveals gram-negative intracellulardiplococci as well.
EPIDIDYMITIS• Acute epididymitis, almost always unilateral, produces pain, swelling,and tenderness of the epididymis, with or without symptoms or signsof urethritis• In sexually active men under age 35, acute epididymitis is causedmost frequently by C. trachomatis and less commonly by N.gonorrhoeae and is usually associated with overt or subclinicalurethritis.• Acute epididymitis occurring in older men or following urinary tractinstrumentation is usually caused by urinary pathogens.
• Ceftriaxone (250 mg as a single dose IM) followed by doxycycline(100 mg by mouth twice daily for 10 days) constitutes effectivetreatment for epididymitis caused by N. gonorrhoeae or C.trachomatis• Fluoroquinolones are no longer recommended for treatment ofgonorrhea in the United States because of the emergence of resistantstrains of N. gonorrhoeae, especially (but not only) among MSM
PELVIC INFLAMMATORY DISEASE• refers to infection that ascends from the cervix or vagina to involve theendometrium and/or fallopian tubes• Infection can extend beyond the reproductive tract to cause pelvicperitonitis, generalized peritonitis, perihepatitis, perisplenitis, or pelvicabscess• agents most often implicated in acute PID include the primary causesof endocervicitis (e.g., N. gonorrhoeae and C. trachomatis)• PID is most often caused byN. Gonorrhoeae where there is a highincidence of gonorrhea
• Important risk factors for acute PID include the presence ofendocervical infection or bacterial vaginosis, a history ofsalpingitis or of recent vaginal douching, and recent insertion ofan IUD.• Certain other iatrogenic factors, such as dilatation and curettageor cesarean section, can increase the risk of PID, especiallyamong women with endocervical gonococcal or chlamydialinfection or bacterial vaginosis