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Syndromic management of STI
1. DEBRE BIRHAN UNIVERSITY
COLLEGE OF MEDICINE
Syndromic approach for
management of STI
and PID
Presenter - Zelalem Mekonnen
Modulator- Dr. Adissu (Gynecologist & Obstetrician)
February 2013 E.C
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2. Objectives
Define Sexually transmitted diseases
Recognize approaches to STI Case Management
Understand the syndromic approach for the
management of different STIs syndromes
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3. Sexually transmitted infections
Is diverse group of infections, caused by different types of
microbial agents, that are frequently transmitted by sexual
contact.
Other modes of transmission include: mother-to-child, blood
transfusions, or other contact with blood or fomites
STIs have public health importance because of their
magnitude, potential complications and their interaction
with HIV/AIDS.
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4. Epidemiology of STIs
According to 2016 EDHS 4% of women and men
age 15-49 reported having an STI and/or
symptoms of an STI in the past 12 months
Among men, the percentage was 6% in Oromiya,
and 5% in Harari compared to less than 1% in the
Tigray and Benishangul-Gumuz.
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5. Interaction of STIs and HIV
STIs enhance the sexual transmission of HIV
through
I. primarily cause ulcers disrupt the integrity of the skin
barrier
II. Cause inflammation (gonorrhea, trichomoniasis, and
chlamydial infections)
III. Increase viral shedding & increase susceptibility to
HIV
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6. CONT…
HIV infection affects STIs through
1. HIV alters susceptibility of STI pathogens to
antibiotics
2. Increased susceptibility to STIs among
immune suppressed individuals
3. The clinical features of various types of STIs
are influenced when there is co-infection
with HIV.
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7. Approaches to STI Case
Management
Three diagnostic approaches:
Etiologic approach.
Clinical approach
Syndromic approach
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8. 1. Etiologic approach
Identifying the causative agent using laboratory tests
& giving treatment targeting to the pathogen identified.
2. Clinical approach
Uses clinical experience to identify symptoms which
are typical for a specific STI, then giving treatment
targeted, to the suspected pathogen
3. Syndromic approach
Identification of clinical syndrome and giving
treatment targeting all the locally known pathogens
which can cause the syndrome
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9. Etiologic approach
Advantages
Accurate diagnosis, accurate
treatment,
Proper use of antibiotics
Decreases over treatment and
antibiotic resistance).
Better way to diagnose and treat
asymptomatic infections
Disadvantages
Needs lab support and
expertise
Expensive and it is time
consuming
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10. Clinical approach
Advantages
Saves time for
patients
Reduces lab
expenses
Disadvantages
Requires high clinical skill
Mixed infections often
overlooked
Doesn’t identify
asymptomatic STIs
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11. Syndromic approach
Advantages
Complete STI care
offered at first visit
Simple, rapid and
inexpensive
Patients treated for
possible mixed infections
Accessible to a broad
range of health workers
Disadvantages
Over treatment with
antibiotics,
There is risk of creating
antibiotic resistance
Decreased compliance
There is also increased
cost of drugs.
Moreover asymptomatic
infection missed.
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12. Cont..
Health care providers should undertake the
following measures besides treating individual
patients
i. Partner notification and management
ii. Condom promotion and supply
iii. Health education and risk reduction counseling
iv. Linkage with HIV counseling and testing
v. Follow-up visits for patients with STI
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14. 1. Urethral discharge syndrome
is the presence of abnormal secretions from the distal
part of the urethra
it is the characteristic manifestation of urethritis
urethral discharge is accompanied by burning
sensations (dysuria) during micturition.
Person with urethral discharge can also have increased
frequency and urgency of urination and itching
sensation of urethra.
The appearance of the discharge can be purulent or
mucoid, clear, white, or yellowish-green
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15. Etiology
Neisseria gonorrhea (81%)
Chlamydia trachomatis (36.8%).
other causative micro-organisms are mycoplasma
genitalium,Trichomonas vaginalis, and
Ureaplasma urealyticum.
Most of the time urethral discharge is due to
mixed infection of Neisseria gonorrhea and
Chlamydia trachomatis
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16. Clinical manifestations
N. gonorrhea has usually an acute onset with profuse and
purulent discharge
C. trachomatis has sub-acute onset with scant
mucopurulent discharge.
Common signs and symptoms are burning sensation during
micturition, urgency and frequency of urination with itching
sensation of the urethra.
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17. The signs and symptoms of complications of the
syndrome are testicular pain and swelling, arthritis,
polyarthralgia, tenosynovitis, skin lesions and
constitutional symptoms.
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18. CONT..
Acute complications
i. Disseminated gonococci syndrome
ii. Perihepatitis
iii. Acute epididymo-orchitis
Chronic complications
1. Urethral stricture
2. Infertility
3. Reiter’s syndrome (arthritis, conjunctivitis, and
nonspecific urethritis)
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19. TREATMENT
Ceftriaxone 250mg IM stat/ Spectinomycin 2 gm IM
stat
Plus
Azithromycin 1gm po stat/Doxycycline 100 mg po Bid
for 7 days/Tetracycline 500 mg po Qid for 7
days/Erythromycin 500 mg po Qid for 7 days in cases of
contraindications for Tetracycline (children and
pregnancy)
The preferred regimen is Ceftriaxone 250mg IM stat
plus Azithromycin 1gm po stat
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20. 2. Genital ulcer syndrome
is an open sore or a break in the continuity of the
skin or mucous membrane of the genitalia
ETIOLOGY
Herpes simplex virus, (HSV-1 and HSV-2)
Treponema pallidum
Haemophilius ducreyia
Chlamydia trachomatis
Klebsiella granulomatis (donovanosis)
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22. Common sites in male are glance penis, prepuce and
penile shaft
In women are vulva, perineum, vagina and cervix and can
cause occasionally severe vulvo- vaginitis and necrotizing
cervicitis
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23. complications of genital ulcer syndrome
Granulomatous lesions (Gummas) on the skin,
liver, bones, or other organs
Tabes dorsalis and dementia, often with paranoid
features
Aortic aneurysm and aortic valve insufficiency
Phimosis in men
Destruction of the penis or auto amputation
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24. TREATMENT
1. Treatment for Non- Vesicular Genital Ulcer
Benzathine penicillin 2.4 million units IM stat /Doxycycline(in penicillin allergy) 100mg
bid for 14 days plus
Ciprofloxacin 500mg bid orally for 3 days /Erythromycin 500mg tab qid for 7 days
plus
Acyclovir 400mg Tid orally for 10 days (or 200mg five times per day of 10 day)
2. Treatment for Vesicular, multiple or recurrent genital ulcer
Acyclovir 200 mg five times per day for 10 days
Or
Acyclovir 400 mg tid for 7 days
3. Treatment for recurrent infection: Acyclovir 400 mg tid for 7 days
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25. 3. Vaginal discharge syndrome
Normal vaginal discharge is white mucoid, odor
less &nonirritant, thin or thick based on menstrual
cycle.
Abnormal in color, odor and amount accompanied
by pruritus- pathological
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26. Etiology
The most common causes of vaginal discharge syndrome are
Neisseria gonorrhea
Chlamydia trachomatis
Candida albicans
Trichomonas vaginalis
Gardnerella vaginalis
Bacterial vaginosis (Gardnerella vaginalis) is the leading
cause of vaginal discharge in Ethiopia followed by
candidiasis, trichomoniasis, gonococcal and chlamydia
cervicitis
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27. CLINICAL MANIFESTATIONS
Thin, homogenous whitish discharge with fishy
odor
Thick, profuse, malodorous, yellow-green, frothy
itchy
Purulent exudate from the cervical Os
White , thick and curd like discharge coating the
walls of the vagina
Vulvo-vaginal pruritus, irritation of vulva,
dyspareunia, dysuria, and frequency of urination.
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28. Physical examination
Dry congestion of the vulva with discharge.
Signs of cervicitis during speculum examination
which are redness and contact bleeding from the
cervix, spotting and endo cervical discharge
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29. COMPLICATIONS
Pelvic Inflammatory Disease (PID)
Peritonitis and intra-abdominal abscess
Adhesions and intestinal obstruction
Ectopic pregnancy
Premature Rupture of Membrane (PROM)
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31. CONT..
Common risk factors for development of vaginal
discharge syndrome secondary to cervicitis:
The presences of one or more risk factor suggest
cervicitis
• Multiple sexual partners in the last 3 month
• New sexual partner in the last 3 month
• Ever traded sex
• Age below 25 years
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32. Risk Assessment Positive Risk Assessment Negative
Ceftriaxone 250mg IM stat/ Spectinomycin
2gm IM stat
Plus
Azithromycin 1gm po stat/Doxycycline 100 mg
po Bid for 7 days
Plus
Metronidazole 500 mg Bid for 7 days
If discharge is white or curd-like add
Clotrimazole vaginal pessary 200 mg at bed
time for 3 days
Note: The preferred regimen is Ceftriaxone
250mg IM stat plus Azithromycin 1gm po stat
plus Metronidazole 500 mg bid for 7 days.
Metronidazole 500 mg bid for 7
days
If discharge is white or curd-like
add Clotrimazole vaginal pessary
200 mg at bed time for 3 days
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33. 4. Lower abdominal pain/ (PID)
Clinical syndrome resulting from ascending infection
from the cervix and/or vagina.
Inflammatory disorders of the upper female genital
tract, including endometritis, salpingitis, tubo-ovarian
abscess and pelvic peritonitis.
The inflammation may also spread to the liver, spleen
or appendix.
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34. CONT..
The vast majority of PID with or without pelvic
abscess improves with antibiotics alone and the fever
usually subsides in less than 72 hours.
Failure to improve within 72 hours after antibiotic
treatment indicates failure of medical treatment and the
patient should be referred for surgical evaluation and
treatment.
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35. ETIOLOGY
PID is frequently poly-microbial.
The commonest pathogens associated with PID, which are
transmitted sexually, are C. trachomatis & N. gonorrhea.
Other causes which may or may not be transmitted sexually
include:
Mycoplasma genitalium
E. coli
H. influenza
Streptococcus
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36. Risk factors
AGE
Adolescent girls are at significant risk for development of
acute salpingitis
The incidence of acute PID decreases with advancing age.
Due to greater endocervical exposure in the
ectocervix of adolescents
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37. IUCD
Multiple case-controlled studies have shown an
increased risk of acute PID in women who used an
IUD.
It has been estimated that IUCD users have a
threefold to fivefold increased risk for
development of acute PID
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38. Surgical procedures of the female genital
tract
About 15% of pelvic infections occur after
procedures that break the cervical mucous barrier.
UGTI associated with first-trimester
abortions is about 1 in 200 cases
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39. Previous acute PID
Due to the sexual habits of the woman involved,
such as reinfection from an untreated male partner
or genital tract damage from the initial infection.
may be the loss of natural protective mechanisms
of the fallopian tube lining against
microorganisms.
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40. Frequent sexual activity,
early onset of sexual activity,
multiple sex partners, and a
recent new sex partner are associated with risk for
developing PID.
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41. PID protective factors
OCP
Mechanism of protection- probably due to:
cervical mucus thickening
short menstrual flow period- shorter interval for
bacterial invasion
ovulation inhibition no nidus for abscess
formation on ovary
Barrier contraceptives ( mechanical and
chemical)- 60% decrease with consistent use
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42. Hegar criteria for the Diagnosis
if one major plus two minor or
Two major criteria.
Major criteria
1. Cervical motion tenderness
2. Uterine tenderness
3.Adnexal tenderness.
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43. Minor criteria
One or more of minor criteria can be used to
diagnosis of PID:
• oral temperature >101°F (>38.3°C);
• abnormal cervical mucopurulent discharge
• presence of abundant numbers of WBC on saline
microscopy of vaginal fluid;
• elevated erythrocyte sedimentation rate;
• elevated C-reactive protein; and
• laboratory documentation of cervical infection
with N. gonorrhoeae or C. trachomatis.
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47. Fitz-Hugh-Curtis syndrome
Perihepatic inflammation and adhesions, develop in 1% -
10%
RUQ pain,pleuritic pain,& RUQ tenderness.
Mistakenly diagnosed as either acute cholecystitis or
pneumonia
Due to vascular or transperitoneal dissemination of either N.
gonorrhoeae or C. trachomatis to produce the perihepatic
inflammation.
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48. For outpatient For inpatient
Ceftriaxone 250 mg IM stat
/Spectinomycin 2gm i.m stat
Plus
Azithromycin 1gmpo stat/Doxycycline
100 mg po b.i.d for 14 days
Plus
Metronidazole 500 mg po b.i.d for 14
days
Admit if there is no improvement
within 72 hours
Note : The preferred regimen is
Ceftriaxone 250mg IM stat plus
Azithromycin 1gm po stat plus
Metronidazole 500 mg bid for 14 days
Ceftriaxone 250 mg i.m/i.v
/Spectinomycin 2 gm i.m bid
Plus
Azithromycin 1gm po daily
/Doxycycline 100 mg po b.i.d for 14
days
Plus
Metronidazole 500 mg po b.i.d for
14 days
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49. Hospitalization of patients with acute PID
should be seriously considered when:
surgical emergencies such as appendicitis
and ectopic pregnancy cannot be exclude
pelvic abscess is suspected
severe illness precludes management on an
outpatient basis
CONT..
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50. CONT..
The patient is pregnant
The patient is unable to follow or tolerate an
outpatient regimen
Patient has failed to respond to outpatient therapy.
PID in HIV patients
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52. Tubo-ovarian Abscess
Tubo-ovarian abscess (a mass consisting primarily of an
abscess cavity within an anatomically defined structure
such as the ovary), pyosalpinx
TOA is diagnosed when a patient with PID has a pelvic
mass that is palpable during bimanual examination.
About 75% of women with tubo-ovarian abscess respond to
antimicrobial therapy alone
Failure of medical therapy suggests the need for drainage of
the abscess
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53. Evaluation
Laparoscopy
limited as a method of diagnosing the early stages of
PID,
It is important to R/O non-PID surgical emergencies,
such as appendicitis, endometriosis
Laparoscopy strongly indicated for patients who are not
responding to therapy to
confirm the diagnosis,
obtain cultures from the cul-de-sac or
fallopian tubes, and drain pus if necessary
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54. Ultrasonography
Ultrasound is helpful in distinguishing an adnexal
mass, especially in patients who demonstrate a
lack of response to antimicrobial therapy in the
initial 48 to 72 hours of therapy.
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55. 5. Scrotal swelling syndrome
Caused by trauma, tumor, and torsion of the testis or
inflammation of the epididymis.
Mostly the inflammation of the epididymis is caused
by STD.
Among patients who are younger than 35 years, the
swelling is likely to be caused by sexually transmitted
infection.
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56. ETIOLOGY SCROTAL SWELLING
SYNDROME
Infectious scrotal swelling caused by:
N. gonorrhea
C. trachomatis
T. pallidum
Mumps virus
Filarial disease
Non-infectious cause
Testicular torsion,
trauma,
Incarcerated inguinal hernia
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57. CLINICAL MANIFESTATIONS
OF SCROTAL SWELLING
Pain and swelling of the scrotum
Tender and hot scrotum on palpation
Edema and erythema of the scrotum
Dysuria
frequency and urethral discharge
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58. COMPLICATIONS OF SCROTAL
SWELLING SYNDROME
• Destruction and scarring of testicular tissues
• Infertility
• Impotence
• Prostatitis
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60. 6. Inguinal bubo syndrome
(Swollen glands)
Is swelling of inguinal lymph nodes as a result of
STIs
ETIOLOGY
Chlamydia trachomatis (L1, L2 and L3)
Treponema pallidum
Haemophilius ducreyi
Klebsiella granulomatis (donovanosis)
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61. CLINICAL MANIFESTATIONS
Constitutional symptoms of fever, headache
Tender unilateral or bilateral lymphadenopathy
forms a classical “groove sign” in the inguinal area
Fluctuant abscess formation which form coalesce
mass (bubo)
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63. COMPLICATIONS
Fistula or sinus formation
Multiple draining sinus
Extensive ulceration of genitalia
Extensive scarring
Chronic untreated LGV may result in
lymphatic obstruction, elephantiasis of the
genitalia.
Note: surgical incisions are contraindicated; instead
aspirate pus with needle through the health skin.
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65. 7. NEONATAL CONJUNCTIVITIS
Ocular redness, swelling and drainage which may be
purulent due to pathogenic agents or irritant chemicals in
infants less than 4 weeks of age.
Common etiologic causes of neonatal conjunctivitis are:
N. gonorrhea
C. trachomatis
S. pneumoniae
H. influenzae
S. aureus
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66. COMMON RISK FACTORS OF NEONATAL
CONJUNCTIVITIS
I. Maternal infection with STI
II. Exposure of the infant to infectious organisms
III. Inadequacy of ocular prophylaxis immediately after birth
IV. Premature rupture of membrane
V. Ocular trauma during delivery
VI. Prematurity
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67. CLINICAL MANIFESTATIONS
Red and edematous conjunctiva
Edematous eye lead
Discharge which may be purulent
Orbital cellulitis in more serious cases
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69. PREVENTION OF NEONATAL CONJUNCTIVITIS
1. Wiping the baby’s both eyes with dry and clean
cotton cloth as soon as the baby is born.
2. Apply 1% tetracycline eye ointment into the eyes
of the newborn infant.
3. Properly open the eye of the infant and place the
ointment on the lower conjunctival sacs.
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71. Syphilis in pregnancy
is a systemic infection caused by the spirochete
Treponema pallidum, which is of particular
concern during pregnancy because of the risk of
transplacental infection of the fetus.
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72. In Ethiopia, syphilis prevalence among ANC follow
up in 2012 was 1%, indicating a low prevalence of
syphilis in pregnant women
RPR >5% indicates high prevalence.
All pregnant women: screen at the first prenatal
encounter
Women at high risk of infection: repeat screening at
28 to 32 weeks and at delivery
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73. The stage of syphilis is clinically important
because it impacts the treatment regimen and the
risk of vertical transmission
1. Primary syphilis
Papule, painless, at the site of inoculation.
Ulcerates to produce the classic chancre of primary
syphilis, a 1 to 2 cm painless ulcer
Associated with mild to moderate regional
lymphadenopathy that is often bilateral.
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74. Cont.
Chancres heal within 3 to 6wk, even in the absence
of treatment.
The primary stage of syphilis missed in women b/c
the lesion is on vaginal or cervical mucosa
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75. 2. Secondary syphilis
Disseminated begins 6wk to 6 months after the
appearance of the chancre
A generalized maculopapular skin rash palms, soles
& mucous membranes
Sparing the face, is characteristic of this stage of the
infection.
Generalized lymphadenopathy accompanies the skin
rash..
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78. Cont.
fever, pharyngitis, weight loss, and large genital
lesions called condylomata lata..
The rash typically resolves within 2 to 6wks
Secondary syphilis is commonly the stage when
women present to a health care provider
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79. 3. Latent syphilis
asymptomatic.
untreated, patients will have signs & symptoms of
secondary or late syphilis.
latent syphilis may transmit the infection to the
fetus
early latency -the first year following secondary
syphilis
late latency - >1 years
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80. 4. Tertiary (late) syphilis
one-third of untreated patients
Tertiary syphilis is characterized by slowly
progressive signs and symptoms
Gumma formation & cardiovascular disease.
5 to 20 years after the disease has become latent.
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81. Laboratory
I. Dark field microscopy
II. Nontreponemal
RPR (rapid plasma reagin) test
standard VDRL slide test
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83. Preferred regimen
I. A single dose of benzathine penicillin G 2.4 million
units intramuscularly for women with primary,
secondary, or early latent disease
II. Late latent, tertiary, and disease of unknown duration,
three doses of benzathine penicillin G 2.4 million
unit intramuscularly at weekly
If a dose is missed for more than 14 days, the full
three-dose course of therapy should be started again
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84. References
1. Ethiopian National guidelines for the management
of sexually transmitted infections using the
syndromic approach ;February, 2015
2. Te Lindes operative gynecology 11th edition
3. Up-todate 17.1
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