Presentation include some details on genital ulcers and typical features, differential diagnosis, causing organisms, diagnosis and treatment.
Presentation prepaired and done by 3rd year medical students of Faculty of Medicine, University of Ruhuna, Sri Lanka during STI appointment under the guidance of Consultant Venereologist, STI clinic Mahamodara, Galle.
Done by
Dias P G N J
Dilanka I W G M
Dinuraji K S H
2. GENITAL ULCER,
Defined as single or multiple vesicular, ulcerative or
erosive lesions of the genital area, with or without
inguinal lymphadenopathy, cause by number of sexually
transmitted infections and non sexually transmitted
conditions.
4. Cause by Treponema pallidum
Transmission –Sexual
Verticle (in utero/during passage)
Blood transfusion(rarely)
3 stages
Primary, Secondary & Tertiary
Syphilis
5. Primary Syphilis
Primary lesion or “chancre” develops at the site of
inoculation
Chancre
progresses from macule to papule to
ulcer
typically painless, indurated and has a
clean base(no necrosis)
highly infectious
heals spontaneously within 3-6 weeks
multiple lesions can occur
Regional lymphadenopathy
Classically rubbery painless bilaterally
6. Secondary syphilis
Secondary lesions occur several(2-12weeks) after primary chancre appears
Lasts weeks to months
Clinical manifestations
skin and mucous membranes
• macular or pustular rash(can occur throughout the body- centripetal and
can occur soles and palms)
• condylamata lata (in between skin folds)
• alopecia
Systemic
• lymphadenopathy
• malaise
• arthralgia
• fever
7. Latent syphilis
Positive serological tests without clinically apparent disease
In between 2ry and tertiary
early latent
less than 2 year duration
high chance of relapses
Late latent
2 year or more than 2 year
relapses unlikely
8. Tertiary syphilis
May develop decades later
30% of untreated patients progress to tertiary stage
Manifestations
• Gummatous lesions
granulomatous inflammation in skin, bones
or mucocutaneous tissues
• Cardiovascular syphilis
• Neurosyphilis
acute syphilitic meningitis
ocular involvements
general of paresis insane
tabes dorasalis
9. Congenital syphilis
• Occurs due to transplacental transmission and during
delivery from infected birth canal.
• Can occur during any stage of syphilis.
• Risk is much higher during 1ry and 2ry syphilis, present as a
bullous rash
• Fatal infection can occur during any trimester of pregnancy.
10. Diagnosis
Clinical history
symptoms suggestive of primary syphilis
(painless ulcer)
previous history of syphilis
unprotected risky sexual exposer
Examination
painless, indurated hard ulcer
regional lymphadenopathy
11. Laboratory Diagnosis
Direct microscopy
Fresh exudate from the primary chancre should be examined under Dark field
microscopy immediately after collection
look for T. pallidum morphology and motility.
• thin delicate helically coil corkscrew shape organism.
• rapid rotation around its long axis and slow forward- backward motion.
13. TREATMENT
Benzathine penicillin G 2.4MU i.m single dose
Alternative treatment,
In penicillin allergy & Non Pregnant
• Doxycycline 100mg bd for 2 weeks or
• Tetracycline 500mg 4 times/ day for 2 weeks
Contact Tracing & Epidemiological Treatment should be done
14. Prevention
• Contact tracing and epidemiological treatment.
• Screening pregnant women at least at 1st prenatal visit.
• In high prevalence communities or patients at risk, test twice during 3rd trimester
and at delivery.
• Safe sex
15. Genital Herpes
Organism - Herpes simplex virus
Most common cause of genital ulceration
Two types 1. HSV 1 infection
2. HSV 2 infection(most common type)
Transmission
Sexually
oral, vaginal and anal intercourse
Non sexually
contact with herpes ulcer, saliva or genital secretions
16. CLINICAL FEATURES
Local pain, tenderness, itching
Papules on a red erythematous base
• rapidly develop into vesicles which ulcerate.
• superficial non indurated tender ulcer with
erythematous edges.
• painful shallow multiple ulcers.
• heal in about 3weeks.
Can be associated with fever and regional
lymphadenopathy
Can cause urethritis
Recurrences are common
17. Complications
• Encephalitis
• Neuralgia
• Urinary retention
• Pharyngitis-oral sex
• Extra genital lesions-auto inoculation
• Can be a co factor with HPV for development
of cervical cancer
During pregnancy
• trans placental transmission
• Result in stillbirth or teratogenic effect
• High risk if acquired near the time of
delivery
• Risk is low in recurrences
18. Diagnosis
Direct smear for giant cell
Tzanck smear-Tzank cells can be seen
specimen- swab taken from the base
of ulcers or vesicle fluid
Virus isolation in cell culture
Genome detection
HSV DNA detection using PCR
Serological tests
ELISA-HSV specific IgG
NOT DIAGNOSTIC
19. Management
Primary Episodes
Acyclovir 400mg oral tds for 7-10days
or
Valacycolvir 1g oral bd for 7-10days
Recurrent Episodes
Episodic therapy
Acyclovir 400mg oral tds for 5days
or
Valacycolvir 500mg oral bd for 3days
Suppressive therapy (for 1 year)
Acyclovir 400mg oral bd
or
Valacyclovir 1g oral once a day
20. Prevention
Avoid contact with lesions
ware gloves
Safe sex
Prevent neonatal herpes
EL-LSCS for mothers with active infection(genital ulcers at
the time of delivery -4weeks)
21. Lymphogranuloma Venereum(LGV)
Organism – Chlamydia trachomatis( L1, L2, L3 serotypes)
I P 3-30 days
Endemic in certain areas(Africa, southeast Asia, India, South America)
Clinical features
Primary stage
Small painless and vesicular lesion
ulcer at the site of infection
usually single
elevated irregular edges
superficial or deep
may have fever, headache and myalgia
22. Secondary Stage
marked inflammation in draining lymph node
enlarged nodes become painful(buboes-collection of
inflamed lymph nodes) and can rupture
Tertiary Stage
genital lymphedema destructive lesions
Rectal exposure in women or MSM can result in proctocolitis
Mucoid and/or hemorrhagic rectal discharge, anal pain, constipation,
tenesmus
If untreated early
can lead to chronic colorectal fistulas and strictures
23. Diagnosis
Nucleic acid amplification test for LGV serova- PCR
Serological tests(not reliable )
1. complement fixation test
2. Microimmunoflurescent test
Cell culture
Cytology
swabs from genital lesions and lymph
node aspirate for the presence of cells with
inclusion bodies (stain with iodine)
(Other STI should be exclude)
24. Treatment
Doxycycline 100mg bd for 21 days
or
Erythromycin 500mg four times daily 21 days
Epidemiological treatment to the partner
Abstain from the sex till the patient and the partner complete
the treatment
Surgical drain some times require
25. Chancroid
Organism - Haemophilus ducreyi
Distribution-Less common
prevalent in Africa & Asia
Co-infection with syphilis
Incubation period : 3-10 days
Clinical manifestation
painful non indurated soft ulcer
tender suppurative inguinal lymphadenopathy
26. ULCER
Common sites- men-prepuce & frenulum
women-labia majora/minora & perinium
Initial lesion is a pustule or papule
Then breakdown into a ulcer
Can be single or multiple
Irregular borders
Base-gray or yellowish grey material
Painful soft ulcer
Bleed easily
No induration
27. Diagnosis
Microscopy – gram stain
show the characteristic Gram-negative
coccobacilli resembling rail road tracks or
school of fish
specimens
scraping from the base of ulcer, lymph node
aspiration
Culture on special culture media with X factor
PCR
Antigen detection and serology(for rearch purposes)
28. Treatment
Azithromycin-1g oral single dose
or
Ceftriaxone-250mg IM single dose
or
Ciprofloxacin 500mg oral bd for 3days
or
Erythromycin 500mg oral tds for 7 days
Contact tracing and epidemiological treatment
29. Granuloma Inguinale(Donovanosis)
Organism – Klebsiella granulomatis
` gram negative bacilli with characteristic bipolar staining
I.P. 1-12 weeks
Distribution-Less common now.
But endemic in tropics & subtropics.
Eg, Caribbean, South India
30. ULCERS
• Initially small painless nodules
• Slowly progressive ulcerative lesions without regional lymphadenopathy
• Then they burst creating open, fleshy, oozing ulcer
• Progressed by internal and external tissue destruction
• Lesions are highly vascular bleed easily on contact
• Characteristic rolled edge of granulation tissue
31. Diagnosis
Visualization of dark staining Donovan bodies(numerous bacilli in the cytoplasm of
macrophages demonstrated with Giemsa or silver stain) on tissue crushed perforations
or biopsy from base or edge of the ulcer
Organism difficult to culture
PCR
32. Treatment
Doxycycline-100 mg oral bd for at least 3 weeks or until all lesions have
completely heal
Alternative regimes
Azithromycin 1g oral once per weeks at least 3 weeks
or
Ciprofloxacin 750mg oral bd for at least 3 weeks
Partners should also be examined & treated
Epidemiological treatment
33. References...
• Kumar and Clark's clinical medicine 9th edition.
• Medical microbiology Greenwood 18th edition.
• ABC of sexually Transmitted Infections 5th edition.
• www.medscape.com
• www.cdc.gov
• www.bash.org