Board Review of STI for Internal Medicine and Pediatrics for UCAYA

1. STI Board Review: Journey
through PREP and MKSAP
Mike Guyton, MD
Assistant Clinical Professor/Academic
Faculty in General Pediatrics

2. Outline
• Quick Epidemiology
– CDC Facts
• Pediatric Board Presence
• Internal Medicine Board Presence

3. STI’s in the US
• The US ranks first among developed nations in the
rate of STI’s1
– In addition to teen pregnancies
• IN 2000, HPV was estimated as the most
prevalent STI in 15-24yo’s as a population2
– Followed by Trichomonas > Chlamydia > Herpes >
Gonorrhea > HIV > Syphilis
• Rates of some STI’s have been increasing
– Between 2000-2003, rates of GC/Ch infections has
increased by 14% in women 15-19, and about 35% in
men 15-19 2

4. STD Quick Facts from the CDC 9
• FACT: 19 million new infections occur every year in the US
• FACT: STD’s cost the US HealthCare System $17 billion
yearly
• FACT: Untreated STD’s cause 24,000 women in the US to
become infertile yearly
• FACT: While young people only represent 25% of the
sexually experienced population in the US, they account for
almost 50% of newly diagnosed STD infections

5. PREP
• A 28-year-old woman who is positive for human immunodeficiency
virus and has a history of intravenous drug use delivers a 2,300-g
term infant. She had only two prenatal visits, and she was being
treated for Chlamydia infection at the time of delivery. Physical
examination of the infant reveals facial edema, erythema and
scaling of the palms and soles clear rhinorrhea, and
hepatosplenomegaly. Of the following, the MOST likely cause of this
infant's signs and symptoms is infection with
• A.) Candida albicans
• B.) Chlamydia trachomatis
• C.) Pneumocystis jiroveci
• D.) Streptococcus agalactiae
• E.) Treponema pallidum

6. PREP
• A 28-year-old woman who is positive for human immunodeficiency
virus and has a history of intravenous drug use delivers a 2,300-g
term infant. She had only two prenatal visits, and she was being
treated for Chlamydia infection at the time of delivery. Physical
examination of the infant reveals facial edema, erythema and
scaling of the palms and soles clear rhinorrhea, and
hepatosplenomegaly. Of the following, the MOST likely cause of this
infant's signs and symptoms is infection with
• A.) Candida albicans
• B.) Chlamydia trachomatis
• C.) Pneumocystis jiroveci
• D.) Streptococcus agalactiae
• E.) Treponema pallidum

7. Congenital Syphilis
• Results from the hematogenous spread of the organism, T.
pallidum, from mother to fetus through the placenta
– Greatest risk of transmission to the infant is when mom acquires
the disease during or shortly before pregnancy 3
– Infection early can lead to: stillbirth, hydrops fetalis, prematurity,
neonatal death
• Obvious signs may not be present at birth
– May develop in the neonatal period, weeks, months, or even
years later 3
• The earlier the onset of symptoms, the poorer the prognosis
for the infant 3
– When mom is seronegative, delayed onset of symptoms seems
to be more likely

8. Congenital Syphilis: Early Findings
Common Findings
– IUGR
– HSM
– Direct/Indirect
Hyperbilirubinemia
– Coombs-negative Hemolytic
Anemia
– Thrombocytopenia
– Generalized LAN
– Mucocutaneous Lesions
Distinct Findings
• Snuffles
• Skeletal Changes
• Placental Villitis
• Osteochondritis
• Periostitis
• CNS findings
– Monocytosis with normal
glucose and mod. Elevated
protein

9. Congenital Syphilis: Late Findings
• Dental Findings
– Hutchinson Teeth
– Mulberry Molars
• Ocular Findings
– Interstitial Keratitis
• Skeletal Findings
– Sabre Shin, Frontal
Bossing
– Saddle Nose
Deformity
– Palatal Perforation
– Clutton Joints
– Higoumenakis’ Sign
• CNS findings
– Eighth Nerve
Deafness
• Cutaneous Findings
– Rhagades
• Cognitive Findings
– Mental Retardation

11. PREP
• A 15-year-old girl complains of vaginal pruritus and a discharge that has
worsened over the past 2 weeks. Past medical history reveals a recent
urinary tract infection that was treated with an antibiotic. She says she has
a monogamous relationship with her boyfriend, so they do not use
condoms, and he has no symptoms. Physical examination reveals normal-
appearing external genitalia and a discharge visible at her introitus. On
speculum examination, she has a frothy discharge in her vagina and a
normal-appearing cervix. Results of her bimanual examination are normal.
You obtain a normal saline wet mount of the discharge. Of the following,
the MOST important next step, in addition to prescribing medications, is to
• A.) discuss treatment for the boyfriend
• B.) encourage the practice of douching
• C.) repeat the urine culture
• D.) notify the public health department
• E.) obtain pelvic ultrasound

12. Wet Prep

13. PREP
• A 15-year-old girl complains of vaginal pruritus and a discharge that has
worsened over the past 2 weeks. Past medical history reveals a recent
urinary tract infection that was treated with an antibiotic. She says she has
a monogamous relationship with her boyfriend, so they do not use
condoms, and he has no symptoms. Physical examination reveals normal-
appearing external genitalia and a discharge visible at her introitus. On
speculum examination, she has a frothy discharge in her vagina and a
normal-appearing cervix. Results of her bimanual examination are normal.
You obtain a normal saline wet mount of the discharge. Of the following,
the MOST important next step, in addition to prescribing medications, is to
• A.) discuss treatment for the boyfriend
• B.) encourage the practice of douching
• C.) repeat the urine culture
• D.) notify the public health department
• E.) obtain pelvic ultrasound

14. PREP
• A 15-year-old girl complains of vaginal pruritus and a discharge that has
worsened over the past 2 weeks. Past medical history reveals a recent
urinary tract infection that was treated with an antibiotic. She says she has
a monogamous relationship with her boyfriend, so they do not use
condoms, and he has no symptoms. Physical examination reveals normal-
appearing external genitalia and a discharge visible at her introitus. On
speculum examination, she has a frothy discharge in her vagina and a
normal-appearing cervix. Results of her bimanual examination are normal.
You obtain a normal saline wet mount of the discharge. Of the following,
the MOST important next step, in addition to prescribing medications, is to
• A.) discuss treatment for the boyfriend
• B.) encourage the practice of douching
• C.) repeat the urine culture
• D.) notify the public health department
• E.) obtain pelvic ultrasound

15. Vaginal Discharge
• Can be physiologic or Inflammatory Leukorrhea
– Physiologic tends to be more clear/slightly yellow and
creamy in consistency 2
– Begins at onset of puberty and ends after menopause,
due to estrogen influence
• Often, color and consistency are clues to
diagnosis
• Important to be able to distinguish which
discharge needs which treatment

16. Adapted from Zitelli Atlas of Pediatric Diagnosis
Physiologic Candida Chlamydia Gonorrhea Trichomonas Bacterial
Vaginosis
HSV
Appearance White/Gray/Cle
ar/ Mucoid
White,
curdlike,
plaques
Mucopus at
cervix,
clear/bloody
discharge
Yellow/greenis
h discharge
Gray/yellow/gr
een,
malodorous,
frothy
Gray/white/
homogenous,
thin
Serous
Vaginal
Irritation
None, typically yes Not usual Not usual yes rare yes
pH <4.5 <4.5 variable <4.5 >4.5 >4.5 <4.5
Micro Epithelial cells,
lactobacilli, few
WBC
WBC’s,
pseudohyp-
hae with
budding yeast
Increased
WBC
Greatly
increased WBC
Greatly
increased WBC,
motile
trichomonads
Few WBC, but
clue cells
present
Greatly
increased
WBC
Clinical
Symptoms
none Itching,
dysuria,dy-
spareunia
Urethritis, PID,
perihepatitis
Urethritis, PID,
systemic
illness, proctitis
Vulvar itching,
prominent
dysuria, pelvic
discomfort
Fish-like odor LAN, pain

17. Vaginal Discharge: Treatments 8
• Candida:
– Fluconazole 150mg po x 1
• Chlamydia:
– Azithromycin 1g po x1
– Doxycycline 100mg po BID x 7d
– Levofloxacin 500mg po qd x 7d
• Gonorrhea:
– Ceftriaxone 250mg IM x1 plus Azithromycin 1g po x1 or Doxycycline
100mg po BID x 7 days
• Trichomonas:
– Metronidazole/Tinidazole 2g po x1
– Metronidazole 500mg po BID x 7d
• Bacterial Vaginosis:
– Resolves spontaneously in up to 1/3 non-preg/ ½ preg women
– Metronidazole 500mg po BID x 7d
– Topical Clindamycin Cream (5g cream of 100mg Clinda) qhs x 7d
– Clindamycin 300mg po BID x 7d

19. PREP
• As an adjunct to abstinence education, you are asked about the
value of starting a 'virginity pledge' program in your neighborhood
school. You meet with the school staff to educate them on the pros
and cons. Of the following, evidence suggests that the MOST likely
outcome of such programs is that
• A.) formal pledges are more effective than informal pledges
• B.) most pledgers abstain from oral sex
• C.) pledgers and non-pledgers have similar STI rates is sexually active
• D.) pledgers are more likely than non-pledgers to abstain from
vaginal intercourse
• E.) pledgers are more likely than non-pledgers to use condoms when
they become sexually active

20. PREP
• As an adjunct to abstinence education, you are asked about the
value of starting a 'virginity pledge' program in your neighborhood
school. You meet with the school staff to educate them on the pros
and cons. Of the following, evidence suggests that the MOST likely
outcome of such programs is that
• A.) formal pledges are more effective than informal pledges
• B.) most pledgers abstain from oral sex
• C.) pledgers and non-pledgers have similar STI rates is sexually active
• D.) pledgers are more likely than non-pledgers to abstain from
vaginal intercourse
• E.) pledgers are more likely than non-pledgers to use condoms when
they become sexually active

21. Abstinence Programs
• Amazingly Controversial topic across the US
– Debate over abstinence-only programs vs comprehensive sex-ed vs
comprehensive with preference for abstinence
• Many factors have been investigated 1
– Socio-economics
– Educational Attainment of Teens
– Ethnic Composition
– Medicaid Waivers for family planning
• Much Healthcare Cost associated with results of such programs
– An estimated $9.1 billion cost to taxpayers in 2004 from teen child
bearing (compared to first birth at 20yrs or older) 1
In this study (Stanger-Hall), a comprehensive sex and/or STD education
that includes abstinence as the desired behavior correlated with the lowest
teen pregnancy rates across the states

22. Self-Reported Abstinence and STI’s
• Retrospective Study conducted collecting data from the
National Longitudinal Study of Adolescent Health
– N=14,012 young adults
• Of all participants, 964 tested positive for 1 of 3 STI’s
(Chlamydia, Gonorrhea, Trichomonas) 4
– 838 reported sex with at least 1 partner within 12 months
– 118 reported no sex within the past 12 months
– 60 reported no history of penile/vaginal sex ever (~6%)
• This means that more than 10% of those tested had
discrepancy in their reporting 4
– Still, self reported sex increased odds of testing positive by
2 fold.

23. MKSAP
• A 25-year-old man is evaluated in the emergency department for a
3-day history of scrotal pain without fever. Medical history is
unremarkable, and he takes no medications. The patient is
frequently sexually active with women and never has sex with men.
On physical examination, vital signs, including temperature, are
normal. Genitourinary examination discloses a purulent urethral
discharge and right-sided scrotal swelling and tenderness, especially
superior to the right testis. Duplex Doppler ultrasonography of the
scrotum shows normal-sized testes and a swollen right epididymis
with normal blood flow.
• A.) Ampicillin and Gentamicin
• B.) Azithromycin
• C.) Ceftriaxone and Doxycycline
• D.) Ofloxacin

24. MKSAP
• A 25-year-old man is evaluated in the emergency department for a
3-day history of scrotal pain without fever. Medical history is
unremarkable, and he takes no medications. The patient is
frequently sexually active with women and never has sex with men.
On physical examination, vital signs, including temperature, are
normal. Genitourinary examination discloses a purulent urethral
discharge and right-sided scrotal swelling and tenderness, especially
superior to the right testis. Duplex Doppler ultrasonography of the
scrotum shows normal-sized testes and a swollen right epididymis
with normal blood flow.
• A.) Ampicillin and Gentamicin
• B.) Azithromycin
• C.) Ceftriaxone and Doxycycline
• D.) Ofloxacin

25. Epididymitis
• Acute/Subacute inflammation of the epididymis
– Peak occurrence in adolescence, but also seen in older men 5
• Sx can include dysuria, increased urgency/frequency, fever, pyuria, and
leukocytosis
– Pain usually posterior/superior aspect of testicle 5
• Doppler Blood flow often done emergently in some ER’s
– Can be normal to increased 5
• Treatment depends on age 6
– Presumptive treatment for GC/Ch in men <35yrs with
tenderness/swelling on exam
– Tx for men >35 aimed at E. coli and Enterococcus organisms
• Typically use a Fluroquinolone (Levoquin 500mg po qd x 10 days)

26. MKSAP
• An 18-year-old woman has a 3-day history of fever, headache, and
painful sores in the genital area. The patient has no previous history
of genital lesions. Medical history is unremarkable, and her only
medication is an oral contraceptive agent. She does not use
condoms. On physical examination, temperature is 38.1 °C (100.6
°F); other vital signs are normal. There are no signs of meningismus.
Tender ulcerative lesions with a yellow crusted roof cover the labia
bilaterally and the vaginal introitus.
• A.) Chancroid
• B.) Genital Herpes Simplex Virus Infection
• C.) Primary Syphilis
• D.) Vulvovaginal Candidiasis

27. MKSAP
• An 18-year-old woman has a 3-day history of fever, headache, and
painful sores in the genital area. The patient has no previous history
of genital lesions. Medical history is unremarkable, and her only
medication is an oral contraceptive agent. She does not use
condoms. On physical examination, temperature is 38.1 °C (100.6
°F); other vital signs are normal. There are no signs of meningismus.
Tender ulcerative lesions with a yellow crusted roof cover the labia
bilaterally and the vaginal introitus.
• A.) Chancroid
• B.) Genital Herpes Simplex Virus Infection
• C.) Primary Syphilis
• D.) Vulvovaginal Candidiasis

28. Genital Herpes
• Belongs to the Genital Ulcer Syndromes 2
– HSV, T. pallidum, and H. ducreyi
• HSV2 is predominant, with increasing HSV1 genital
occurrence in females 2
• Lesions begin as vesicles, which then rupture to form
painful ulcers
– Usually occurring as clusters
• Occurs as a Primary Outbreak, Recurrent Outbreak,
and Latent Infection
– Primary outbreak last 2-3 weeks and often associated
with systemic symptoms (fever, malaise, dysuria)
– Recurrent Outbreaks usually are shorter, 7-12 days
• HSV has a high infectivity and high recurrence rate
– Infectivity 75-80% with active infection 3
– HSV1 Recurrence: 60%; HSV2 Recurrence: 90% 3

29. Genital Herpes: Treatment
• Treatment differs based on type of
infection
– Primary: 7
• Acyclovir 400mg po TID x 7-10 days
• Acyclovir 200mg po 5x daily x 7-10 days
• Famciclovir 250mg TID x 7-10 days
• Valacyclovir 1g BID x 7-10 days
– Recurrent: 8
• Valacyclovir 500mg BID x 3 days
– Suppression: 8
• Valacyclovir 1g po qday (can be 500mg daily if
<9 recurrences/year)
– 500mg BID if immunoompromised

31. MKSAP
• A 40-year-old man is hospitalized with a 1-day history of left upper extremity
weakness. The patient was treated for gonorrhea when he was 17 years old. On
physical examination, he is awake and alert. Vital signs, including temperature, are
normal. Motor strength is 2/5 in the left upper extremity, and deep tendon reflexes
are brisker in the left upper extremity than in the right. Motor strength and reflexes
are normal on the right. The remainder of the neurologic examination is normal.
CT scan of the head is normal. Lumbar puncture is performed, and cerebrospinal
fluid findings indicate a leukocyte count of 48/µL (48 × 106/L) with 100%
mononuclear cells, a protein level of 82 mg/dL (820 mg/L), and a glucose
concentration of 62 mg/dL (3.4 mmol/L) (plasma glucose, normal); there are no
erythrocytes, and the VDRL is pending. A rapid plasma reagin test for syphilis is
reactive at a 1:256 dilution, and a fluorescent treponemal antibody absorbtion
(FTA-ABS) assay is also reactive. A rapid HIV test is negative.
• A.) Amoxicillin and Probenecid, orally for 21 days
• B.) Aqueous PCN, IV for 10-14 days
• C.) Azithromycin, orally in a single dose
• D.) Benzathine PCN G, IM in a single dose

32. MKSAP
• A 40-year-old man is hospitalized with a 1-day history of left upper extremity
weakness. The patient was treated for gonorrhea when he was 17 years old. On
physical examination, he is awake and alert. Vital signs, including temperature, are
normal. Motor strength is 2/5 in the left upper extremity, and deep tendon reflexes
are brisker in the left upper extremity than in the right. Motor strength and reflexes
are normal on the right. The remainder of the neurologic examination is normal.
CT scan of the head is normal. Lumbar puncture is performed, and cerebrospinal
fluid findings indicate a leukocyte count of 48/µL (48 × 106/L) with 100%
mononuclear cells, a protein level of 82 mg/dL (820 mg/L), and a glucose
concentration of 62 mg/dL (3.4 mmol/L) (plasma glucose, normal); there are no
erythrocytes, and the VDRL is pending. A rapid plasma reagin test for syphilis is
reactive at a 1:256 dilution, and a fluorescent treponemal antibody absorbtion
(FTA-ABS) assay is also reactive. A rapid HIV test is negative.
• A.) Amoxicillin and Probenecid, orally for 21 days
• B.) Aqueous PCN, IV for 10-14 days
• C.) Azithromycin, orally in a single dose
• D.) Benzathine PCN G, IM in a single dose

33. Syphilis: History
• Very Common in Europe in the 18th and 19th Century
with controversial theories on how it was introduced 10
– Columbian vs Pre-Columbian Theory
– Other names: The French Disease, The Great Pox
• Initial treatments were often worse than the disease
– Included inorganic Mercury, then Salvarsan, followed then
by PCN 10
• Largely represented in historical artwork and literature
– Called “The Great Imitator” by Sir William Osler

34. Gerard de Lairesse
Painted by Rembrandt in 1665

35. Syphilis: Epidemiology
• Most current cases remain in the developing
world
• In the developed world, including US, rates have
been increasing since 2000 among certain groups
– Particularly MSM, but stable in women in the US
• Untreated mortality can be as high as 58% 10
• Syphilis infection increases the risk of infection
with HIV 2-5x 10
– Co-infection very common

36. Syphilis: Primary Infection
• Lesion typically appears 2-3 weeks after
exposure
– Painless, firm, indurated, clean smooth base
• May resolve without intervention due to
immune response 5
• Infection is widely disseminated when first
ulceration appears
• Causative Organism: Treponema pallidum

37. Syphilis: Secondary Stage
• Weeks-Months after primary disease
– Could also coincide with primary ulceration
• Maculopapular rash of the palms and soles
– 60% of all patients 5
• Constitutional and Systemic Symptoms may also occur
– Generalized LAN, Fatigue, Fever, Malaise
– Hepatitis, Glomerulonephritis, Aseptic Meningitis
• Diagnosis darkfield microscopy from lesion or reactive
serologies 5
• Risk of transmission highest in Primary/Secondary
phases

38. Syphilis: Tertiary Stage
• Years to decades after initial infection
• Tends to be more systemic to visceral organs 5
– Gummas (inflammatory tumors) of any visceral organ
– Brain and Spinal Cord Destruction by the organism
(General Paresis and Tabes Dorsalis)
– Cardiovascular syphilis
• 10-30 years after initial infection
• Syphilitic aortitis with aneurysm formation
• Neurosyphilis can be in this stage of syphilis, or
any other stage 5

39. Syphilis: Treatment
• Primary/Secondary/early latent 5
– Benzathine PCN G, 2.4 MU, IM x 1
– 2nd: Doxy 100mg po BID x 14d; Ceftriaxone 1g/d IV/IM x 8-
10 days
• Late latent/ latent of UD 5
– Benzathine PCN G, 2.4 MU, IM weekly x 3 doses
– 2nd: Doxy 100mg po BID x 28 days
• Neurosyphilis 5
– Aqueous PCN G, 18-24 MU/d (3-4 U IV q4 or continuous
for 10-14 days)
– 2nd: Procaine PCN, 2.4 MU IM qday with Probenecid
500mg po QID for 10-14 days

41. References
• 1.) Stanger-Hall et al. Abstinence-Only Education and Teen Pregnancy
Rates: Why We Need Comprehensive Sex Education in the U.S. PLoS
ONE. 6 (10), e24658; 2011
• 2.) Nelson Textbook of Pediatrics
• 3.) Zitelli, Basil J et al. Zitelli and Davis’ Atlas of Pediatric Physical
Diagnosis: 6th E. ELSEVIER Saunders Publication. 2012
• 4.) DiClemente et al. Association Between Sexually Transmitted Diseases
and Young Adults’ Self-Reported Abstinence. Pediatrics. 127 (2), 208-
213; 2011
• 5.) American College of Physicians. MKSAP 15: Infectious Disease. 2009.
• 6.) American College of Physicians. MKSAP 15: General Internal
Medicine. 2009
• 7.) Goldstein, Mark. The MassGeneral Hospital for Children Adolescent
Medicine Handbook. Springer Publications. 2011
• 8.) Lexicomp Online Pharmaceutical Reference.
• 9.) The Center for Disease Control: 2010 STD Surveillance.
http://www.cdc.gov
• 10.) Wikipedia: Syphilis. http://en.wikipedia.org/wiki/Syphilis