Syndromic Approach to Sexually Transmitted Diseases


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Syndromic Approach to Sexually Transmitted Diseases

  1. 1. STDs Dr. Alaa Hassan MBBCh, MSc, MD Consultant, Community medicine and public Health
  2. 2. • Although STDs are caused by many different organisms, these organisms only give rise to a limited number of syndromes. • A syndrome is simply a group of the symptoms of which a patient complains, and the signs observed during examination.
  3. 3. Diseases presenting mainly as genital ulcer
  4. 4. 1.Syphilis • Caused by Treponema pallidum • Syphilis infection is characterized by stages, and accurate staging is vital to determine appropriate therapy
  5. 5. Primary SyphilisPrimary Syphilis • Characterized by the appearance of a painless, indurated ulcer— the chancrethe chancre —occurring 10 days to 3 months after infection with T pallidum. • The chancre usually heals by 4–6 weeks, although associated painless bilateral lymphadenopathy may persist for months.
  6. 6. Primary syphilis - chancre
  7. 7. Primary syphilis - chancre
  8. 8. Secondary syphilisSecondary syphilis • Symmetric mucocutaneous (macular, papular, papulosquamous, or pustular lesions) with generalized nontender lymphadenopathy. • In moist skin areas such as the perianal or vulvar regions, papules may become superficially eroded to form pink or whitish condylomatacondylomata latalata. • Constitutional symptoms such as fever, malaise, and weight loss occur commonly. • Less common complications include meningitis, hepatitis, arthritis, nephropathy, and iridocyclitis.
  9. 9. 10 Secondary Syphilis Rash Source: Florida STD/HIV Prevention Training Center
  10. 10. 11 Secondary Syphilis: Generalized Body Rash Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
  11. 11. 12 Secondary Syphilis Rash Source: Florida STD/HIV Prevention Training Center
  12. 12. 13 Secondary Syphilis Rash Source: Cincinnati STD/HIV Prevention Training Center
  13. 13. 14 Secondary Syphilis – Condylomata Lata Source: Florida STD/HIV Prevention Training Center
  14. 14. Latent syphilisLatent syphilis • is diagnosed in persons with serologic evidence of syphilis infection without other current evidence of disease. • "Early" latent syphilis is defined as infection for less than 1 year. • Asymptomatic patients with known infection of more than 1 year are classified as having late latent syphilis.
  15. 15. Tertiary syphilisTertiary syphilis • is diagnosed in patients with – syphilitic aortitis, and – one or more gummas, a syphilitic granuloma. • Patients are infectious during primary, secondary, and early latent stages of syphilis.
  16. 16. Late syphilis - serpiginous gummata of forearm
  17. 17. Cardiovascular syphilis - narrowing of coronary ostia in aortus
  18. 18. Congenital syphilis - mucous patches
  19. 19. Congenital syphilis - - Hutchinson’s teeth
  20. 20. Congenital syphilis - perforation of palate
  21. 21. Lab DiagnosisLab Diagnosis • Positive darkfield examination or direct fluorescent antibody tests of lesion exudates definitively diagnose primary syphilis. • More typically, syphilis is diagnosed by positive results of both a – Nontreponemal test (VDRL or RPR) and a – Treponemal test (T pallidum particle agglutination [TP-PA] or FTA- ABS). • Nontreponemal tests titers generally rise and fall in response to T pallidum infection and treatment, respectively, and usually return to normal (negative) following treatment, although some individuals remain "serofast" and have persistent low positive titers. • Treponemal tests usually yield persistent positive results throughout the patient's life following infection with T pallidum. Treponemal test titers do not correlate with disease activity or treatment.
  22. 22. Syphilis - Treponema pallidum on darkfield
  23. 23. 24 2.Genital Herpes Simplex • Caused by HSV-2: 80-90%, HSV-1: 10-20% • Primary infection commonly asymptomatic; symptomatic cases sometimes severe, prolonged, systemic manifestations • Vesicles ⇒ painful ulcerations ⇒ crusting • Recurrence potential • Diagnosis: – Culture – Serology (Western blot) – PCR
  24. 24. 25 Genital Herpes Simplex in Females Source: Centers for Disease Control and Prevention
  25. 25. 26 Genital Herpes Simplex Source: Florida STD/HIV Prevention Training Center
  26. 26. 3.Chancroid • Caused by Haemophilus ducreyi. • Definitive diagnosis is difficult, requiring identification of H ducreyi on special culture medium that is not readily available.
  27. 27. Chancroid - gram stain of H. ducreyi
  28. 28. Chancroid Male - regional adenopathy
  29. 29. 4.Lymphogranuloma venereum • is caused by serovariants L1, L2, and L3 of C trachomatis. • The small ulcer arising at the site of infection is often unnoticed or unreported. • The most common clinical presentation is painful unilateral lymphadenopathy. • Rectal exposure may result in proctocolitis (mucus or hemorrhagic rectal discharge, anal pain, constipation, fever, or tenesmus). • Diagnosis rests on clinical suspicion, epidemiologic information, exclusion of other etiologies, and C trachomatis tests.
  30. 30. LGV lymphadenopathy
  31. 31. 5.Granuloma inguinale • or donovanosis is caused by Calymmatobacterium granulomatis, • The bacterium does not grow on standard culture media; diagnosis rests on demonstration of so-called Donovan bodies in a tissue specimen. • Causes painless, progressive, beefy red, highly vascular lesions without lymphadenopathy.
  32. 32. Granuloma inguinale, Donovan bodies
  33. 33. Granuloma inguinale, male
  34. 34. Granuloma inguinale, female
  35. 35. Herpes Syphilis Chancroid Lymphogranuloma Venereum Granuloma Inguinale Appearance Often purulent "Clean" Purulent May be purulent "Beefy," hemorrhagic Number Usually multiple Single Often multiple Single or multiple Multiple Pain Yes No Yes Ulcer: no Nodes: yes No Preceded by Papule, then vesicle Papule Papule Papule; ulcer often unnoticed Nodule(s) Adenopathy Painful with primary outbreak Painless Painful; may suppurate Painful; may suppurate No, unless secondary bacterial infection Systemic symptoms Often with primary outbreak Usually not Occasionally Usually not No
  36. 36. Urethral Discharge
  37. 37. 38 Gonorrhea • 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
  38. 38. 39 Gonorrhea Gram Stain Source: Cincinnati STD/HIV Prevention Training Center
  39. 39. 40 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)/field Urine microscopic ≥ 10 PMNs/HPF Leukocyte esterase (+)
  40. 40. 41 Chlamydia Life Cycle Source: California STD/HIV Prevention Training Center
  41. 41. Scrotal Swelling (Epididymitis) • The cause of epididymitis varies with age. • It is most commonly due to • gonorrhea or C trachomatis in men 35 years of age or younger, • gram-negative enteric organisms in men 35 years of age or older who engage in unprotected insertive anal intercourse, who have undergone recent urologic surgery, or who have anatomic abnormalities. • Patients usually present with unilateral testicular pain and inflammation with onset over several days. • The laboratory evaluation of suspected epididymitis is essentially the same as for urethritis, and includes Gram stain, culture or antigen test, and serologic testing for HIV and syphilis.
  42. 42. Vaginitis
  43. 43. 1.VulvoVaginal candidiasis • Vulvovaginal candidiasis (VVC) is typically caused by C albicans, although occasionally other species are identified. • More than 75% of all women will have at least one episode of VVC during their lifetime. • The diagnosis is presumed if the patient has vulvovaginal pruritus and erythema with or without a white discharge, and is confirmed by wet mount or KOH preparation showing yeast or pseudohyphae, or culture showing a yeast species.
  44. 44. • VVC is not usually acquired through sexual intercourse; • treatment of sex partners is not recommended but may be considered in women who have recurrent infection. • Some male sex partners have balanitis and may benefit from topical antifungal agents.
  45. 45. 2.Trichomonas vaginalis • Vaginitis due to T vaginalis presents with a thin, yellow or yellow-green frothy malodorous discharge and vulvar irritation that may worsen following menstruation. • Diagnosis can often be made via prompt examination of a freshly obtained wet mount, which reveals the motile trichomonads. • Partners of women with trichomonas infection require treatment; although men are usually asymptomatic, they will reinfect female partners if untreated.
  46. 46. 3.Bacterial vaginosis • Bacterial vaginosis arises when normal vaginal bacteria are replaced with an overgrowth of anaerobic bacteria. Although not thought to be an STD, it is associated with having multiple sex partners or a new sex partner.. • Diagnosis can be based on the presence of three of four clinical criteria: – (1) a thin, homogeneous vaginal discharge, – (2) a vaginal pH value of more than 4.5, – (3) a positive KOH test, and – (4) the presence of clue cells in a wet mount preparation.
  47. 47. Vaginitis Diagnostic Test Candida albicans Trichomonas vaginalis Bacterial Vaginosis pH <4.5 >4.5 KOH to slide Yeast or pseudohyphae Amine or "fishy" odor Saline to slide Yeast or pseudohyphae Motile T vaginalis organisms "Clue" cells Culture Yeast species T vaginalis Nonspecific (not recommended)
  48. 48. Cervicitis • Cervicitis is characterized by purulent discharge from the endocervix, which may or may not be associated with vaginal discharge or cervical bleeding.
  49. 49. 50 Normal Cervix Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center
  50. 50. 51 Chlamydia Cervicitis Source: St. Louis STD/HIV Prevention Training Center
  51. 51. 52 Mucopurulent Cervicitis Source: Seattle STD/HIV Prevention Training Center
  52. 52. Pelvic inflammatory disease • PID is defined as inflammation of the upper genital tract, including pelvic peritonitis, endometritis, salpingitis, and tuboovarian abscess due to infection with – gonorrhea, – C trachomatis, or – vaginal or bowel flora. • Lower abdominal tenderness and uterine, adnexal, or cervical motion tenderness without other explanation of illness is sufficient to diagnose PID.
  53. 53. • Other criteria enhance the specificity of the diagnosis: – Fever higher than 38.3 °C (101 °F). – Abnormal cervical or vaginal discharge. – Abundant WBCs in saline microscopy of vaginal secretions. – Elevated sedimentation rate. – Elevated C-reactive protein. – Cervical infection with gonorrhea or C trachomatis.
  54. 54. 55 Pelvic Inflammatory Disease Source: Cincinnati STD/HIV Prevention Training Center
  55. 55. 56 C. trachomatis Infection (PID( Drips Source: Patton, D.L. University of Washington, Seattle, Washington Normal Human Fallopian Tube Tissue PID Infection
  56. 56. Genital warts
  57. 57. 58 HPV • Infection is generally indicated by the detection of HPV DNA • HPV infection is causally associated with cervical cancer and probably other anogenital squamous cell cancers (e.g. anal, penile, vulvar, vaginal) • Over 99% of cervical cancers have HPV DNA detected within the tumor • Routine Pap smear screening ensures early detection (and treatment) of pre-cancerous lesions
  58. 58. 59 Perianal Wart Source: Cincinnati STD/HIV Prevention Training Center HPV and Cervical Cancer
  59. 59. 60 HPV Warts on the Thigh Source: Cincinnati STD/HIV Prevention Training Center HPV and Cervical Cancer
  60. 60. 61 Possible HPV on the Tongue Source: Cincinnati STD/HIV Prevention Training Center HPV and Cervical Cancer
  61. 61. Molluscum Contagiosum • Molluscum contagiosum appears in individuals of all ages and from all races, but has been reported more commonly in the white population and in males. • Lesions are due to infection with poxviruspoxvirus, which is transmitted through direct skin contact, as occurs among children in a nursery school and among adults during sexual activity. • Diagnosis is typically based on inspection, which reveals dimpled or umbilicated flesh-colored or pearly papules several millimeters in diameter • Lesions usually resolve spontaneously within months of appearance, but can be treated with cryotherapy, cautery, curettage, or removal of the lesion's core, with or without local anesthesia.
  62. 62. Molluscum contagiosum, vulva and thighs
  63. 63. Molluscum contagiosum