Gyn Infections


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  • Gyn Infections

    2. 2. GYNECOLOGICAL INFECTIONS GENERAL DX CONSIDERATIONS Symptoms : Discharge, fever & abd./pelvic pain Age group : Adult, Pre-adolescent or geriatric Past Medical History : Diabetes, cancer or HIV Sexual history: Known & unknown Medications : Recent antibiotics Etiologies : Viral, bacterial, fungal or parasitic Location : External, lower &/or upper tract Previous infections : Primary or re-occurrence Bleeding : Location of bleeding/relationship to cycle
    3. 3. DIAGNOSTIC APPROACH Vaginal Discharge (Leukorrhea) Volume, frequency & duration Nature clear, bloody, color & viscosity Location of irritation, pruritus, odor Pain-external discomfort PQRST Constitutional symptoms Presence of fever, nausea, or vomiting Previous episodes/current exposures Pregnancy. infertility Social Issues
    4. 4. DIAGNOSTIC TESTS Cultures: GC, Chlamydia, Viral Smears: PAP, wet mount, KOH prep & Gram stain Vaginal pH- acetic acid prep KOH Whiff test Urinalysis Blood test: CBC, SMA, RPR, Hepatitis & HIV Rare: Cervical biopsy or Pelvic U/S
    5. 5. GYNECOLOICAL INFECTIONS Lower tract Vulvovaginitis: aka Vaginitis/Vulvitis Vaginosis Upper tract Cervicitis, endometritis, salpingitis, pelvic inflammatory disease
    6. 6. VULVOVAGINITIS <ul><li>Remember: </li></ul><ul><li>- Vaginal/pelvic infections can be from secondary or mixed organisms or co- infections which increase risks and virulence </li></ul><ul><li>- Previous infections increase risks </li></ul><ul><li>- Compound presentation </li></ul>
    7. 7. VULVOVAGINITIS <ul><li>Definition </li></ul><ul><li>Inflammation involving the vulva and the vagina </li></ul><ul><li>Presenting with symptoms of vaginal discharge , itching, burning, dyspareunia, or foul odor </li></ul><ul><li>Patient can also present asymptomatic </li></ul><ul><li>One of the most common gynecological problems in adult women. </li></ul><ul><li>Evaluation in office simple and treatment effective </li></ul>
    8. 8. <ul><li>Categorized as four conditions : </li></ul><ul><ul><li>Candida (yeast) vulvovaginitis </li></ul></ul><ul><ul><li>Bacterial Vaginosis </li></ul></ul><ul><ul><li>Trichomonas vulvovaginitis </li></ul></ul><ul><ul><li>Atrophic vaginalis </li></ul></ul>Common vulvovaginal infections
    9. 9. Vaginal Normal Flora <ul><li>Normal vaginal discharge white, odorless </li></ul><ul><ul><li>pH of 3.5 to 4.2 </li></ul></ul><ul><li>Discharge copious enough to pool in the posterior fornix. </li></ul><ul><ul><li>Many bacteria normal flora </li></ul></ul><ul><ul><ul><li>Most common is lactobacillus acidophillus </li></ul></ul></ul><ul><ul><ul><li>Inhibits growth of other bacteria maintain normal flora </li></ul></ul></ul>
    10. 10. Vaginal Normal Flora <ul><li>Lactobacilli Escherichia coli </li></ul><ul><li>Peptococci Clostridium spp. </li></ul><ul><li>Gardnerella vaginalis Enterococcus </li></ul><ul><li>Group B Streptococci </li></ul><ul><li>Staphylococcus Aureus </li></ul><ul><li>Candida spp. </li></ul>
    11. 12. Bacterial Vaginosis <ul><li>Polymicrobial disease </li></ul><ul><ul><li>Overgrowth of garderella vaginalis and other anaerobes decrease of Lactobacilli </li></ul></ul><ul><ul><li>Increased malodorous vaginal discharge </li></ul></ul><ul><ul><li>“ Fishy” amine odor with 10% P Hydroxide </li></ul></ul><ul><ul><li>Not sexually transmitted </li></ul></ul><ul><ul><li>Wet mount + clue cells </li></ul></ul><ul><ul><li>Vaginal culture not useful </li></ul></ul>
    12. 13. Gram stain
    13. 17. Bacterial Vaginosis Treatment <ul><li>Symptomatic patients treat </li></ul><ul><li>Asymptomatic patients consider tx </li></ul><ul><li>Metronidazole 500 mg po bid *7days </li></ul><ul><li>Metronidazole gel 0.75% 5g bid*5days </li></ul><ul><li>Clindamycin cream 2% 5g qd*days </li></ul><ul><li>Metronidazole 2g po one dose </li></ul><ul><li>Clindamycin 300mg po bid * 7 days </li></ul>
    14. 18. Trichomonas Vaginalis <ul><li>Unicellular flagellate protozoa </li></ul><ul><li>Infection of the vagina, Skene’s ducts and the lower urinary tract in women </li></ul><ul><li>In men infect the lower genitourinary tract. </li></ul><ul><li>Transmission is through coitus </li></ul>
    15. 19. Trichomonas vaginalis Signs and Symptoms <ul><li>Malodorous frothy yellow-green discharge </li></ul><ul><li>Pruritus </li></ul><ul><li>Diffuse vaginal erythema </li></ul><ul><li>Red petechiael or macular lesions on the cervix </li></ul>
    16. 20. Trichomonas Vaginalis Diagnosis & Treatment <ul><li>Wet mount saline + flagella </li></ul><ul><li>Culture Gold standard 95% accurate </li></ul><ul><li>Metronidazole 2g single dose </li></ul><ul><li>Metronidazole 500 mg po bid *7days </li></ul><ul><li>Sexual partner should be treated even if asymptomatic </li></ul>
    17. 26. Vulvovaginal Candidiasis <ul><li>AKA; Yeast vulvovaginitis, Candida Albacans, Yeast infection </li></ul><ul><li>Causative Organism : Candida spp </li></ul><ul><li>Predisposing factors : Pregnancy, diabetes, broad spectrum antibiotic, corticosteroids, heat, moisture, occlusive clothing, HIV, chronic debilitation. </li></ul><ul><li>70 to 80% of women will have vulvovaginal candidiasis </li></ul>
    18. 27. Vulvovaginal Candidiasis Signs and Symptoms <ul><li>Vulvovaginal erythema, pruritus, whit curd-like, cheesy vaginal discharge </li></ul><ul><li>No odor </li></ul><ul><li>Burning sensation may be associated with urination </li></ul>
    19. 31. Vulvovaginal Candidiasis Diagnosis and Treatment <ul><li>Diagnosis: based on history, clinical findings </li></ul><ul><li>10% KOH solution + filaments and spores (pseudohyphae) </li></ul><ul><li>Treatment: Control underlying disease </li></ul><ul><li>Treat symptomatic patients </li></ul><ul><li>Clotrimazole 500 mg single dose </li></ul><ul><li>Fluconazole 150mg single dose </li></ul><ul><li>Clotrimazole 2 100 mg tab vaginally*3days </li></ul><ul><li>Miconazole 200mg vaginal supp * 3 days </li></ul><ul><li>Terconazole 0.8% cream 5g supp * 3 days </li></ul>
    20. 34. Atrophic Vaginitis <ul><li>Etiology : Estrogen defficiency </li></ul><ul><li>Postmenopausal women </li></ul><ul><li>Thinning of the vaginal mucosa and epithelium alteration in vaginal pH 5 to 7 predisposes vagina to trauma and infections </li></ul>
    21. 35. Atrophic Vaginitis Signs and Symptoms <ul><li>Vaginal dryness, dyspareunia </li></ul><ul><li>Spotting, vaginal irritation </li></ul><ul><li>Itching, burning </li></ul><ul><li>Diagnosis : Wet mount increase polymorphonuclear cells and parabasal epithelial cells </li></ul>
    22. 36. Atrophic Vaginitis Treatment <ul><li>Estradiol vaginal ring q 90 days </li></ul><ul><li>Vagifem 1 tab intravaginal qd*2 weeks </li></ul><ul><li>Then 2*wk* 3 to 6 mths </li></ul><ul><li>Warning: contraindicated in hx of breast or endometrial cancer </li></ul>
    23. 37. VIRAL INFECTIONS Herpes simplex - Typically caused by HSV Type 2 (STD) can be by Type 1 - Never total resolution Chronic & Recurrent - External infection easier to diagnosis & more symptomatic - Pain may be prodromal in nature - Rarely systemic - Viral shedding for 7-10 days - Requires tissue culture confirmation
    24. 38. Herpes simplex - Initial infection with severe pain, pruritus & burning, frequency & dysuria. Asymptomatic shedding common - Initial with more symptoms & have a longer duration 2 – 6 weeks - Recurrent infections usually with less lesions milder presentation, heal faster. - Progressively shorter varying duration
    25. 39. <ul><li>Herpes simplex </li></ul><ul><li>Physical findings : </li></ul><ul><li>Initial infection with painful small grouped vesicles usually appear external genitalia </li></ul><ul><li>A manifestation of primary infection in women may be aseptic meningitis </li></ul><ul><li>- May have non purulent cervicitis </li></ul>
    26. 40. Herpes simplex Treatment: Primary infection- Acyclovir, Valacyclovir & Famciclovir for 7 -10 days Recurrent infection- Same meds but for 5 days Local measures- Topical antifungals, Monsel solution or trichloroacetic acid. Hospitalize if severe for IV antiviral, sedation & analgesia If systemic or if immunosuppressed will need IV for 5-7 days or until resolved
    27. 41. <ul><li>Herpes simplex </li></ul><ul><li>Pregnant Treatment: </li></ul><ul><li>All antiviral are class C drugs and given only in severe systemic cases </li></ul><ul><li>50% transmission rate to infant if vaginally delivered with active lesions which carries significant morbidity and 80% mortality </li></ul><ul><li>Active lesion with intact membranes deliver via C/S </li></ul><ul><li>Inactive lesion & asymptomatic may vaginally deliver </li></ul><ul><li>If ROM baby will need NICU admission for IV antiviral therapy pending cultures. </li></ul>
    28. 49. VIRAL INFECTIONS Condyloma Acuminatum <ul><li>HUMAN PAPILLOMA VIRUS (HPV) </li></ul><ul><li>- 46 different HPV serotypes </li></ul><ul><li>- Incubation period is 3 months </li></ul><ul><li>- May regress spontaneously, recur, persist, or </li></ul><ul><li>undergo malignant transformation </li></ul><ul><li>STD transmissible </li></ul><ul><li>Divided into low risk or high risk depending on association with cervical CA </li></ul>
    29. 50. <ul><li>HUMAN PAPILLOMAVIRUS </li></ul><ul><li>- Increase with immunosupression, OBCP, </li></ul><ul><li>smoking, & coinfection with herpes </li></ul><ul><li>- May proliferate profusely in pregnancy </li></ul><ul><li>- 40-95% CIN PAP have HPV DNA </li></ul><ul><li>Strong association with cervical CA </li></ul><ul><li>80-90 % invasive CA contain HPV DNA </li></ul><ul><li>CIN increases with number of partners </li></ul>
    30. 51. <ul><li>HUMAN PAPILLOMA VIRUS </li></ul><ul><li>Physical findings </li></ul><ul><li>Presence of scattered flesh colored or hyperpigmented condylomata acuminata growths present in any part of the vulval or perineal skin. May also occur within the introitus, in the vagina, and on the cervix. </li></ul><ul><li>May form large cauliflower-like masses </li></ul><ul><li>Itching may be present </li></ul>
    31. 52. <ul><li>HUMAN PAPILLOMA VIRUS </li></ul><ul><li>Diagnosis </li></ul><ul><li>- PAP smear </li></ul><ul><li>- Colposcopy with acetic acid </li></ul><ul><li>Punch biopsy, endocervical sampling </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Condyloma Lata </li></ul>
    32. 53. HUMAN PAPILLOMA VIRUS Treatment -Topical salicylic acid products Imiquimod 5% cream 3*wk bedtime max 16 wks Podofilox 0.5% solutionor podophyllin resin 10 to 25% solution twice daily * 3days hiatus 4 days Local sharp excision for large pedunculated lesion Laser vaporization, cryotherapy for small lesions Electrocauterization Hysterectomy for high grade changes Prognosis unpredictable
    33. 54. HPV in Pregnancy <ul><li>May grow rapidly in pregnancy </li></ul><ul><li>May bleed during vaginal delivery and predispose newborn to laryngeal papillomatosis or genital warts. </li></ul><ul><li>If diagnose early in pregnancy treat prior to delivery if treatment not successful must consider C section. </li></ul>
    34. 61. GONOCOCCAL INFECTIONS <ul><li>Etiology : </li></ul><ul><li>Neisseria gonorrhoeae gram-negative diplococcal organism commonly sexually transmitted </li></ul><ul><li>- Over 1million cases/year. Greatest incidence 15 to 29 age group </li></ul><ul><li>- Incubation period 3-5 days </li></ul><ul><li>Ascending infection from: cervix/endocervix to the surface of the uterine edometrium, out to the mucosa of the fallopian tubes, spreads to the ovaries. </li></ul><ul><li>Bartholinitis, anorectal, pharyngitis, conjunctivitis, Disseminated infection, vulvovaginitis in childdren </li></ul>
    35. 62. GONOCOCCAL INFECTIONS <ul><li>Symptoms </li></ul><ul><li>Often asymptomatic in women </li></ul><ul><li>Becomes symptomatic in women often during or just after menses </li></ul><ul><li>Patient will present with complaints of: </li></ul><ul><li>Dysuria, urinary frequency, urgency, rectal discomfort </li></ul><ul><li>Purulent and profuse vaginal discharge, pruritus, dysuria </li></ul><ul><li>- Pelvic, lower abdominal pain may be present </li></ul><ul><li>- Bartholin glands pain & unilateral swelling </li></ul><ul><li>- May have systemic infection i.e. eye & arthritis </li></ul>
    36. 63. GONOCOCCAL INFECTION SYMPTOMS <ul><li>Anal itching, discharge, pain, bleeding </li></ul><ul><li>Fever, malaise, pharyngitis, dermatitis, arthritis in disseminated infection </li></ul><ul><li>Conjunctivitis by autoinoculation </li></ul>
    37. 66. GONOCOCCAL INFECTIONS <ul><li>Diagnostic Test </li></ul><ul><li>-Gram stain– intracellular diplococci 97% specific </li></ul><ul><li>Endocervical culture 80 to 90% sensitive </li></ul><ul><li>Blood culture with disseminated gonorrhea 25% + </li></ul><ul><li>Joint aspiration and culture of effusion </li></ul><ul><li>Serologic test for syphilis </li></ul>
    38. 73. GONOCOCCAL INFECTIONS TREATMENT - Drug resistant common - Uncomplicated gonorrhea non pregnant patients: Ceftriaxone 125mgIM x 1 Ciprofloxacin 500mg PO X 1 Ofloxacin 400 mg PO X 1 Also Doxycycline 100 mg po bid X 7 days Azithromycin 1g PO X 1 In pregnant patients: Ceftriaxone 250mgIM x 1 Spectinomycin 2g IM X 1 Also: Erythromycin 500mg PO qid X 7days Amoxacillin 500mg po tid X 7 days
    39. 74. GONOCOCCAL INFECTIONS TREATMENT <ul><li>Bacteremia and Arthritis </li></ul><ul><li>IV cephalosporin followed by PO upon DX. </li></ul><ul><li>Gonococcal meningitis and endocarditis </li></ul><ul><li>10 to 14 days IV cephalosporin, Pen G or chloramphenicol </li></ul>
    40. 75. CHLAMYDIAL INFECTION <ul><li>Etiology: </li></ul><ul><li>Chlamydia trachomatis; obligatory intracellular bacterium </li></ul><ul><li>The most prevalent STD in the US </li></ul><ul><li>Most common bacterial STD in women </li></ul><ul><li>Predisposing factors: multiple partners </li></ul><ul><li>young active women, lower socioeconomic </li></ul><ul><li>Incubation period 6 to 14 days </li></ul>
    41. 76. CHLAMYDIAL INFECTIONS <ul><li>Symptoms </li></ul><ul><li>- Often asymptomatic </li></ul><ul><li>- Mucopurulent vaginal discharge, pruritus, </li></ul><ul><li>dysuria, hypertrophic cervical inflammation </li></ul><ul><li>- Pelvic/abdominal pain </li></ul><ul><li>Abnormal vaginal bleeding </li></ul><ul><li>Cervical friability </li></ul><ul><li>Systemic manifestations: Fever, chills, nausea, vomiting, anorexia, Fitz-Hugh-Curtis syndrome </li></ul><ul><li>- Lymphogranuloma venereum </li></ul>
    42. 80. CHLAMYDIAL INFECTIONS <ul><li>Diagnostic Test </li></ul><ul><li>Endocervical cell culture 3 to7 days </li></ul><ul><li>CDC recommendation: urethra, rectum, vagina in children </li></ul><ul><li>-ELISA test 90% sensitive 97% specific </li></ul>
    43. 81. Inclusion cells
    44. 84. CHLAMYDIAL INFECTIONS Treatment - Doxycycline bid X 7 days - Macroides alternative if PCN allergic In pregnancy : Erythromycin 500 mg PO qidX7 Amoxicillin 500mgPO tidX10d - Must assume & treat PID coinfection - Lymphogranuloma venereum Tx for 21 days
    45. 85. Pelvic Inflammatory Disease <ul><li>Definition. </li></ul><ul><li>Inflammation of the upper genital tract including the fallopian tubes,(salpingitis) the uterus(myometrium myometritis, the endometrium, endometritis), the ovaries (oophoritis) and the broad ligament (parametritis) </li></ul><ul><li>Commonly PID refers to Salpingitis </li></ul>
    46. 86. Pelvic Inflammatory Disease <ul><li>Epidemiology: Steady increase in both incidence and hospitalization for PID. </li></ul><ul><li>Each year over one million women in the US </li></ul><ul><li>Often polymicrobial , ascending </li></ul><ul><li>Risk factors: younger age < 25Y/O </li></ul><ul><li>Multiple sexual partners 5X </li></ul><ul><li>Intrauterine device (IUD) to 2 to 3X </li></ul><ul><li>Transcervical instrumentation </li></ul>
    47. 87. Pelvic Inflammatory Disease <ul><li>Degree of urgency of the illness </li></ul><ul><li>Not usually life threatening unless complicated by ruptured TOA </li></ul><ul><li>Incidence of TOA in PID is about 15% </li></ul><ul><li>Presence of TOA may require surgical intervention if therapy fails or rupture occurs </li></ul>
    48. 88. Pelvic Inflammatory Disease <ul><li>Gonococcus adheres to non-ciliated epithelial cells in the fallopian tubes, major damage is to the ciliated epithelial cells by the toxic effect of cytokines. This inflammatory reaction results in scarring and tubal adhesions. </li></ul><ul><li>Primary chlamydia infection usually is self-limited and associted with mild to moderate tubal inflammation, but repeated infections can result in permanent tissue damage. </li></ul>
    49. 89. Diagnosis <ul><li>Signs and Symptoms </li></ul><ul><li>Abdominal, pelvic pain, Abnormal vaginal discharge/bleeding, fever 101 or higher, chills, nausea, vomiting, anorexia, urinary symptoms </li></ul><ul><li>Patient may present with signs of septic shock THINK TOA </li></ul>
    50. 90. Diagnosis <ul><li>ON PE: </li></ul><ul><li>Abdominal tenderness , guarding, rebound, rigid or board–like in TOA </li></ul><ul><li>On pelvic, Purulent vaginal discharge </li></ul><ul><li>Tender to cervical motion, purulent discharge through the cervical os. </li></ul><ul><li>Uterus and adnexal tenderness, pyosalpinx or hydrosalpinx is present </li></ul>
    51. 91. Diagnostic testing <ul><li>CBC with differential </li></ul><ul><li>ESR> 20mm/hr in 75% of PID cases </li></ul><ul><li>In severe cases start IV, foley, record I&O </li></ul><ul><li>Urine hCG or Beta hCG </li></ul><ul><li>Laparoscopy most accurate </li></ul><ul><li>Ultrasound crucial in detecting TOA </li></ul><ul><li>Vaginal wet smear gram stain, white blood cell count helpful but non specific </li></ul><ul><li>Culture for Chlamydia or Gonorrhoeae </li></ul>
    52. 92. Pelvic Inflammatory Disease <ul><li>The clinical criteria for the diagnosis of PID can be divided into major and minor criteria. </li></ul><ul><li>Major criteria must all be present: </li></ul><ul><li>Abdominal tenderness </li></ul><ul><li>Cervical motion tenderness </li></ul><ul><li>Adnexal tenderness </li></ul><ul><li>Minor criteria one or more of the following: Fever (>38Cor 100.4F) </li></ul><ul><li>Leukocytosis( >10,000 cell/mm) </li></ul><ul><li>Purulent fluid from peritoneal cavity </li></ul><ul><li>Pelvic abscess on exam or sonogram </li></ul>
    53. 93. Pelvic Inflammatory Disease <ul><li>Treatment </li></ul><ul><li>Hospitalization based on: </li></ul><ul><li>Severity of the clinical illness </li></ul><ul><li>Patient compliance with an outpatient regimen </li></ul><ul><li>Anaerobic infection and certainty of the diagnosis. </li></ul>
    54. 94. Pelvic Inflammatory Disease <ul><li>In-patient treatment for: History of IUD use </li></ul><ul><li>Pelvic mass, sepsis, nulliparity, pregnancy, inability to R/O surgical emergencies, intolerance of outpatient therapy. </li></ul><ul><li>Treat PID as polymicrobial </li></ul><ul><li>Recommended outpatient regimens include: cefoxitin 2gIM with probenecid 1 g PO or Ceftriaxone 250 mg IM </li></ul><ul><li>In addition one of the following: </li></ul><ul><li>Doxycycline 100mg PO bidX 10 to 14 days Tetracycline 500mg PO QID 10 to 14 days </li></ul><ul><li>Erythromycin 500 mgPO QID </li></ul>
    55. 95. In-patient regimen <ul><li>Cefoxitin 2gIV q 6hrs or Cefotetan 2gIV q 12hrs plus </li></ul><ul><li>Doxycycline 100mg IV or PO q 12 hrs </li></ul><ul><li>Alternative: </li></ul><ul><li>Clindamycin 900mg IV q 8hrs plus </li></ul><ul><li>Gentamicin 2mg/kg IV loading dose followed by 1.5 mg/kg Ivq 8 hrs. </li></ul><ul><li>PO Follow-up include Doxycycline or Clindamycin 450mg qid </li></ul>
    56. 96. Pelvic Inflammatory Disease <ul><li>Evaluate the sexual partner for treatment. Laparoscopy in patients with uncertain diagnosis, to lyse adhesions, drain the abscess. </li></ul><ul><li>Laparotomy in cases of ruptured TOA </li></ul><ul><li>Complications include infertility and ectopic pregnancy due to adhesions. Fitz-Hugh-Curtis syndrome involves perihepatitis and peritonitis. </li></ul>
    57. 97. SYPHILIS <ul><li>- Etiology- Treponema pallidum spirochete </li></ul><ul><li>Infection by direct contact through inoculation </li></ul><ul><li>Increase across the board since the 1990’s </li></ul><ul><li>Inner city urban and rural areas use of drugs </li></ul><ul><li>Most common in 15-30 age group </li></ul><ul><li>-Sensitive indicator for STD transmission </li></ul><ul><li>Incubation period: Primary 10 to 90 days </li></ul><ul><li>Secondary average 6 weeks </li></ul><ul><li>Latent four to 20 years later </li></ul>
    58. 98. SYPHILIS <ul><li>Symptoms </li></ul><ul><li>Primary infection: </li></ul><ul><li>Hard, painless chancre which spontaneous resolution 3-6 weeks </li></ul><ul><li>Secondary: </li></ul><ul><li>Systemic disease last 2 to 6 wks </li></ul><ul><li>Lymphadenopathy, skin rash, vulva condylomata lata </li></ul><ul><li>Latent phase last 2 to 20 yrs </li></ul>
    59. 99. Symptoms Continue <ul><li>Tertiary infection: </li></ul><ul><li>Without treatment 1/3 will develop tertiary syphilis </li></ul><ul><li>Progressive damage to the CNS </li></ul><ul><li>Damage to the musculoskeletal system </li></ul><ul><li>Tabes dorsalis, generalizedparesis, aortic aneurysm, gummata of soft tissues and bones </li></ul>
    60. 100. SYPHILIS Diagnostic Test - Serologic Test VDRL/RPR - Treponemal antibody test FTA rate from 16.2-100/100,000 - Darkfield exam - May need CSF test
    61. 103. SYPHILIS Treatment - Penicillin is treatment of choice - If pregnant will need desensitization if allergic - Jarisch-Herxheimer reaction is a flu like reaction secondary to pyrogen release from treponemes - Doxycycline/Macroides as alternative (not as effective)