This document discusses sexually transmitted infections (STIs) caused by Treponema pallidum (syphilis), Neisseria gonorrhoeae (gonorrhea), and Chlamydia trachomatis (chlamydia). It describes the clinical manifestations of primary, secondary, and late syphilis. It also discusses gonococcal and chlamydial infections in males and females, including urethritis, cervicitis, pelvic inflammatory disease, and disseminated gonococcal infection. The document provides details on laboratory testing, treatment, and clinical presentation of these common STIs.
References
Fisherman's Pulmonary Diseases & Disorders 5th ed
Murray & Nadel's Textbook of Respiratory Medicine 6th ed
Croatian & Douglas Respiratory Medicine 5th ed
Harrison's Principle of Internal Medicine 19th edition
NEJM Article
A detailed description of sarcoidosis, pulmonary in specific but also covering the other systems. a rare entity in india or a better way to say, often an overlooked disease.
References
Fisherman's Pulmonary Diseases & Disorders 5th ed
Murray & Nadel's Textbook of Respiratory Medicine 6th ed
Croatian & Douglas Respiratory Medicine 5th ed
Harrison's Principle of Internal Medicine 19th edition
NEJM Article
A detailed description of sarcoidosis, pulmonary in specific but also covering the other systems. a rare entity in india or a better way to say, often an overlooked disease.
Meningitis is a severe CNS pathology and early and appropriate intervention is needed to prevent adverse outcome including mortality and long term complications. This presentation focuses on the different types of meningitis and the appropriate management options
A case presentation of Tuberculous Meningitis. Management Included. This patient had experienced Drug-induced Hepatitis because of prescription reading error
Infections and salivary gland disease in pediatric age: how to manage - Slide...WAidid
The slideset by Professor Susanna Esposito aims at explaining how to manage the salivary gland infections in pediatric age, from pathogenesis, to transmission, treatments and vaccination coverage, that should be urgently increased in Italy as well as in EU Countries.
Meningococci are a type of bacteria that cause serious infections. The most common infection is meningitis, which is an inflammation of the thin tissue that surrounds the brain and spinal cord. Meningococci can also cause other problems, including a serious bloodstream infection called sepsis. In its early stages, you may have flu-like symptoms and a stiff neck. But the disease can progress quickly and can be fatal. Early diagnosis and treatment are extremely important. Lab tests on your blood and cerebrospinal fluid can tell if you have it. Treatment is with antibiotics. Since the infection spreads from person to person, family members may also need to be treated.
A vaccine can prevent meningococcal infections.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Sexually transmitted infections comp
1. Jeffrey A. Verona MD
Department of Internal Medicine
Chinese General Hospital and Medical Center
SEXUALLY TRANSMITTED INFECTIONS
2.
3. STI
• In all societies, STIs rank among the most common of all infectious
diseases, with >30 infections now classified as predominantly sexually
transmitted or as frequently sexually transmissible
• Certain STIs, such as syphilis, gonorrhea, HIV infection, hepatitis B,
and chancroid, are most concentrated within "core populations"
characterized by high rates of partner change, multiple concurrent
partners, or "dense," highly connected sexual networks—e.g.,
involving sex workers and their clients, some men who have sex with
men (MSM), and persons involved in the use of illicit drugs,
particularly crack cocaine and methamphetamine
4.
5.
6. SYPHILIS
• a chronic systemic infection caused by Treponema pallidum subspecies
pallidum, is usually sexually transmitted and is characterized by episodes
of active disease interrupted by periods of latency
• After an incubation period averaging 2–6 weeks, a primary lesion appears,
often associated with regional lymphadenopathy
• secondary stage, associated with generalized mucocutaneous lesions and
generalized lymphadenopathy, is followed by a latent period of subclinical
infection lasting years or decades
• In about one-third of untreated cases, the tertiary stage appears,
characterized by progressive destructive mucocutaneous, musculoskeletal,
or parenchymal lesions; aortitis; or late CNS manifestations.
7. CLINICAL MANIFESTATION
Primary Syphilis
The typical primary chancre usually begins as a single painless papule that rapidly
becomes eroded and usually becomes indurated, with a characteristic cartilaginous
consistency on palpation of the edge and base of the ulcer. Multiple primary lesions
are seen in a minority of patients
8.
9.
10. Regional (usually inguinal) lymphadenopathy accompanies the primary syphilitic
lesion, appearing within 1 week of lesion onset. The nodes are firm,
nonsuppurative, and painless. Inguinal lymphadenopathy is bilateral and may
occur with anal as well as with external genital chancres. The chancre generally
heals within 4–6 weeks (range, 2–12 weeks), but lymphadenopathy may persist
for months.
11. Secondary Syphilis
• The protean manifestations of the secondary stage usually include
mucocutaneous lesions and generalized nontender lymphadenopathy
• The skin rash consists of macular, papular, papulosquamous, and
occasionally pustular syphilides; often more than one form is present
simultaneously. Initial lesions are pale red or pink, nonpruritic, discrete
macules distributed on the trunk and proximal extremities; these macules
progress to papular lesions that are distributed widely and that frequently
involve the palms and soles
12. • Constitutional symptoms that may accompany or precede secondary syphilis
include sore throat (15–30%), fever (5–8%), weight loss (2–20%), malaise (25%),
anorexia (2–10%), headache (10%), and meningismus (5%).
• Acute meningitis occurs in only 1–2% of cases, but CSF cell and protein
concentrations are increased in up to 40% of cases, and T. pallidum has been
recovered from CSF during primary and secondary syphilis in 30% of cases; the
latter finding is often but not always associated with other CSF abnormalities.
• Less common complications of secondary syphilis include hepatitis, nephropathy,
gastrointestinal involvement (hypertrophic gastritis, patchy proctitis, or a
rectosigmoid mass), arthritis, and periostitis. Ocular findings that suggest
secondary syphilis include pupillary abnormalities and optic neuritis as well as
the classic iritis or uveitis.
13. Latent Syphilis
Early latent syphilis is limited to the first year after infection,
whereas Late latent syphilis is defined as that of 1 year's (or
unknown) duration.
T. pallidum may still seed the bloodstream intermittently during the
latent stage, and pregnant women with latent syphilis may infect
the fetus in utero. Moreover, syphilis has been transmitted through
blood transfusion or organ donation from patients with latent
syphilis
14.
15. ASYMPTOMATIC NEUROSYPHILIS
• The diagnosis of asymptomatic neurosyphilis is made in patients
who lack neurologic symptoms and signs but who have CSF
abnormalities including mononuclear pleocytosis, increased protein
concentrations, or CSF reactivity in the Venereal Disease Research
Laboratory test.
• Although the prognostic implications of these findings in early
syphilis are uncertain, it may be appropriate to conclude that even
patients with early syphilis who have such findings do indeed have
asymptomatic neurosyphilis and should be treated for neurosyphilis;
such treatment is particularly important in patients with concurrent
HIV infection
16. SYMPTOMATIC NEUROSYPHILIS
• The major clinical categories of symptomatic neurosyphilis include meningeal,
meningovascular, and parenchymatous syphilis
• Meningeal syphilis may present as headache, nausea, vomiting, neck stiffness,
cranial nerve involvement, seizures, and changes in mental status.
• Meningovascular syphilis reflects meningitis together with inflammatory
vasculitis of small, medium, or large vessels. The most common presentation is
a stroke syndrome involving the middle cerebral artery of a relatively young
adult.
• manifestations of general paresis reflect widespread late parenchymal damage
17. Tabes dorsalis is a late manifestation of syphilis that presents as
symptoms and signs of demyelination of the posterior columns,
dorsal roots, and dorsal root ganglia.
• Symptoms include ataxic wide-based gait and foot drop;
paresthesia; bladder disturbances; impotence; areflexia; and
loss of positional, deep-pain, and temperature sensations
18. CARDIOVASCULAR SYPHILIS
• Cardiovascular manifestations, usually appearing 10–40 years after
infection, are attributable to endarteritis obliterans of the vasa vasorum,
which provide the blood supply to large vessels
• Cardiovascular involvement results in uncomplicated aortitis, aortic
regurgitation, saccular aneurysm (usually of the ascending aorta), or
coronary ostial stenosis.
19. LATE BENIGN SYPHILIS (GUMMA)
• Gummas are usually solitary lesions ranging from microscopic to several
centimeters in diameter. Histologic examination shows a granulomatous
inflammation, with a central area of necrosis due to endarteritis obliterans
• Common sites include the skin and skeletal system; however, any organ (including
the brain) may be involved.
• Gummas of the skin produce indolent, painless, indurated nodular or ulcerative
lesions that may resemble other chronic granulomatous conditions, including
tuberculosis, sarcoidosis, leprosy, and deep fungal infections.
• Skeletal gummas most frequently involve the long bones, although any bone may be
affected. Upper respiratory gummas can lead to perforation of the nasal septum or
palate
20. LABORATORY EXAMINATIONS
Demonstration of the Organism
• T. pallidum cannot be detected by culture
• Dark-field microscopy and immunofluorescence antibody staining
have been used to identify this spirochete in samples from moist
lesions such as chancres or condylomata lata
• Tissue treponemes can be demonstrated more reliably in research
laboratories by PCR or by immunofluorescence or
immunohistochemical methods using specific monoclonal or
polyclonal antibodies to T. pallidum
21. SEROLOGIC TEST FOR SYPHILIS
• two types of serologic test for syphilis: nontreponemal and
treponemal
• most widely used nontreponemal antibody tests for syphilis are
the rapid plasma reagin (RPR) and Venereal Disease Research
Laboratory (VDRL) tests, which measure IgG and IgM directed
against a cardiolipin-lecithin-cholesterol antigen complex
• The RPR test is easier to perform and uses unheated serum; it is
the test of choice for rapid serologic diagnosis in a clinical setting
and can be automated
• The VDRL test remains the standard for examining CSF
22. • Treponemal tests: fluorescent treponemal antibody–absorbed (FTA-ABS) test
and the T. pallidum particle agglutination (TPPA) test.
• Treponemal immunochromatographic strip (ICS) tests and enzyme
immunoassays (EIAs)
• Most clinicians need to be familiar with three uses of serologic tests for syphilis:
• (1) screening or diagnosis (RPR or VDRL)
• (2) quantitative measurement of antibody to assess clinical syphilis activity
or to monitor response to therapy (RPR or VDRL)
• (3) confirmation of a syphilis diagnosis in a patient with a reactive RPR or
VDRL test (FTA-ABS, TPPA, EIA)
23. TREATMENT
• Penicillin G is the drug of choice for all stages of syphilis
• T. pallidum is killed by very low concentrations of penicillin G,
although a long period of exposure to penicillin is required
because of the unusually slow rate of multiplication of the
organism.
• Other antibiotics: tetracyclines; cephalosporins;
aminoglycosides; spectinomycin; azithromycin
24.
25.
26.
27. is a sexually transmitted infection (STI) of epithelium
and commonly manifests as cervicitis, urethritis,
proctitis, and conjunctivitis
28. • Neisseria gonorrhoeae is a gram-negative, nonmotile,
non-spore-forming organism that grows singly and in
pairs
• are distinguished from other neisseriae by their ability to
grow on selective media and to utilize glucose but not
maltose, sucrose, or lactose.
29. • Gonorrhea is transmitted from males to females
more efficiently than in the opposite direction
30. GONOCOCCAL INFECTIONS IN MALES
• Acute urethritis is the most common clinical
manifestation of gonorrhea in males
• usual incubation period after exposure is 2–7 days
• Urethral discharge and dysuria, usually without
urinary frequency or urgency, are the major
symptoms
31. Local complications of gonococcal urethritis
edema of the penis due to dorsal lymphangitis or
thrombophlebitis
submucous inflammatory "soft" infiltration of the urethral wall
periurethral abscess or fistula
inflammation or abscess of Cowper's gland seminal
vesiculitis
32. GONOCOCCAL INFECTIONS IN FEMALES
Gonococcal Cervicitis
Mucopurulent cervicitis is the most common STI diagnosis in
American women
(caused by N. gonorrhoeae, C. trachomatis,
and other organisms)
symptoms usually develop within 10 days of infection and are more
acute and intense than those of chlamydial cervicitis
33. • N. gonorrhoeae may be recovered from the
urethra and rectum of women with cervicitis, but
these are rarely the only infected sites
34. PHYSICAL EXAMINATION
• a mucopurulent discharge (mucopus) issuing from
the cervical os
• Edematous and friable cervical ectopy as well as
endocervical bleeding induced by gentle swabbing
are more often seen in chlamydial infection
• Gonococcal infection may extend deep enough to
produce dyspareunia and lower abdominal or back
pain
35. GONOCOCCAL VAGINITIS
• gonococcal vaginitis can occur in anestrogenic women
(e.g. Prepubertal girls and postmenopausal women)
• vaginal mucosa is red and edematous, and an abundant
purulent discharge is present
36. ANORECTAL GONORRHEA
• Because the female anatomy permits the spread
of cervical exudate to the rectum, N. gonorrhoeae
is sometimes recovered from the rectum of women
with uncomplicated gonococcal cervicitis.
37. PHARYNGEAL GONORRHEA
• mode of acquisition is oral-genital sexual
exposure, with fellatio being a more efficient
means of transmission than cunnilingus
• Most cases resolve spontaneously, and
transmission from the pharynx to sexual contacts
is rare
38. OCULAR GONORRHEA IN ADULTS
• Infection may result in a markedly swollen eyelid,
severe hyperemia and chemosis, and a profuse
purulent discharge
• usually results from autoinoculation from an
infected genital site
39.
40. GONOCOCCAL ARTHRITIS
• results from gonococcal bacteremia
• DGI strains resist the bactericidal action of human serum
and generally do not incite inflammation at genital sites,
probably because of limited generation of chemotactic
factors
41. • Menstruation is a risk factor for dissemination, and
approximately two-thirds of cases of DGI are in women. In
about half of affected women, symptoms of DGI begin
within 7 days of onset of menses.
• Complement deficiencies, especially of the components
involved in the assembly of the membrane attack complex
(C5 through C9), predispose to neisserial bacteremia
42. • clinical manifestations of DGI have sometimes been classified into
two stages:
• a bacteremic stage, which is less common today
• a joint-localized stage with suppurative arthritis
• Patients in the bacteremic stage have higher temperatures, and
chills more frequently accompany their fever. Painful joints are
common and often occur together with tenosynovitis and skin
lesions. Polyarthralgias usually include the knees, elbows, and
more distal joints; the axial skeleton is generally spared.
46. • Oculogenital infections due to C. trachomatis serovars D–K
are transmitted during sexual contact or from mother to
baby during childbirth and are associated with many
syndromes:
cervicitis, salpingitis, acute urethral syndrome,
endometritis, ectopic pregnancy, infertility, and PID in female
patients
urethritis, proctitis, and epididymitis in male patients
conjunctivitis and pneumonia in infants
47. • the LGV serovars (L1, L2, and L3) cause LGV, an invasive sexually
transmitted disease (STD) characterized by acute lymphadenitis with bubo
formation and/or acute hemorrhagic proctitis
48. CLINICAL MANIFESTATIONS:
NON GONOCCOCAL AND POST GONOCOCCAL
URETHRITIS
• C. trachomatis is the most common cause of nongonococcal
urethritis (NGU) and postgonococcal urethritis (PGU)
• The cause of most of the remaining cases of NGU is uncertain, but
recent evidence suggests that Ureaplasma urealyticum, Mycoplasma
genitalium,Trichomonas vaginalis, and herpes simplex virus (HSV)
cause some cases
• NGU is diagnosed by documentation of a leukocytic urethral exudate
and by exclusion of gonorrhea by Gram—s staining or culture
49. EPIDIDYMITIS
• Chlamydial urethritis may be followed by acute epididymitis, but
this condition is rare, generally occurring in sexually active
patients <35 years of age
• The possibility of testicular tumor or chronic infection (e.g.,
tuberculosis) should be excluded when a patient with unilateral
intrascrotal pain and swelling does not respond to appropriate
antimicrobial therapy
50. REACTIVE ARTHRITIS
• Reactive arthritis (formerly known as Reiter—s syndrome) consists of conjunctivitis,
urethritis (or, in female patients, cervicitis), arthritis, and characteristic mucocutaneous
lesions
• most common type of peripheral inflammatory arthritis in young men
• Antibodies to C. trachomatis have also been detected in 46–67% of patients with
reactive arthritis, and Chlamydia-specific cell-mediated immunity has been
documented in 72%
• NGU is the initial manifestation of reactive arthritis in 80% of patients, typically
occurring within 14 days after sexual exposure. The urethritis may be mild and may
even go unnoticed by the patient
• The knees are most frequently involved; next most commonly affected are the ankles
and small joints of the feet. Sacroiliitis, either symmetrical or asymmetrical, is
documented in two-thirds of patients
51. MUCOPURULENT CERVICITIS
• Cervicitis is usually characterized by the presence of a mucopurulent
discharge, with >20 neutrophils per microscopic field visible in strands
of cervical mucus in a thinly smeared, gram-stained preparation of
endocervical exudate.
• Hypertrophic ectopy of the cervix may also be evident as an edematous
area near the cervical os that is congested and bleeds easily on minor
trauma (e.g., when a specimen is collected with a swab).
• A Papanicolaou smear shows increased numbers of neutrophils as well
as a characteristic pattern of mononuclear inflammatory cells including
plasma cells, transformed lymphocytes, and histiocytes.
52.
53. PELVIC INFLAMMATORY DISEASE
• Inflammation of sections of the fallopian tube is often referred to as
salpingitis or PID
• PID occurs via ascending intraluminal spread of C. trachomatis or
N.gonorrhoeae from the lower genital tract. Mucopurulent cervicitis is
often followed by endometritis, endosalpingitis, and finally pelvic
peritonitis
• Chronic untreated endometrial and tubal inflammation can result in
tubal scarring, impaired tubal function, tubal occlusion, and infertility
even among women who report no prior treatment for PID
54. LYMPHOGRANULOMA VENEREUM
• C. trachomatis serovars L1, L2, and L3 cause LGV, an invasive systemic STD.
• The peak incidence of LGV corresponds with the age of greatest sexual activity:
the second and third decades of life.
• LGV was described in association with a concurrent increase in heterosexual
infection with HIV. Reports of outbreaks with the newly identified variant L2b in
Europe, Australia, and the United States indicate that LGV is becoming more
prevalent among MSM. These cases have usually presented as hemorrhagic
proctocolitis in HIV-positive men.
• LGV begins as a small painless papule that tends to ulcerate at the site of
inoculation, often escaping attention
55. • The most common presenting picture in heterosexual men and women
is the inguinal syndrome, which is characterized by painful inguinal
lymphadenopathy beginning 2–6 weeks after presumed exposure;
• inguinal adenopathy is unilateral in two-thirds of cases, and palpable
enlargement of the iliac and femoral nodes is often evident on the
same side as the enlarged inguinal nodes.
• Constitutional symptoms are common during the stage of regional
lymphadenopathy and, in cases of proctitis, may include fever, chills,
headache, meningismus, anorexia, myalgias, and arthralgias
56. • A 7-day course of tetracycline (500 mg four times daily), doxycycline (100 mg
twice daily), erythromycin (500 mg four times daily), or a fluoroquinolone
(ofloxacin, 300 mg twice daily; or levofloxacin, 500 mg/d) can be used for
treatment of uncomplicated chlamydial infections
• Amoxicillin (500 mg three times daily for 7 days) can also be given to
pregnant women. The fluoroquinolones are contraindicated in pregnancy.
• A 2-week course of treatment is recommended for complicated chlamydial
infections (e.g., PID, epididymitis) and at least a 3-week course of
doxycycline (100 mg orally twice daily) or erythromycin base (500 mg orally
four times daily) for LGV.
57. URETHRITIS IN MEN
• Causes include Neisseria gonorrhoeae, C. trachomatis, Mycoplasma genitalium,
Ureaplasma urealyticum, Trichomonas vaginalis, HSV, and adenovirus.
• Establish the presence of urethritis
• If proximal-to-distal "milking" of the urethra does not express a purulent or
mucopurulent discharge, even after the patient has not voided for several hours
(or preferably overnight), a Gram's-stained smear of overt discharge or of an
anterior urethral specimen obtained by passage of a small urethrogenital swab 2–
3 cm into the urethra usually reveals 5 neutrophils per 1000x field in areas
containing cells;
• in gonococcal infection, such a smear usually reveals gram-negative intracellular
diplococci as well.
58.
59. EPIDIDYMITIS
• Acute epididymitis, almost always unilateral, produces pain, swelling,
and tenderness of the epididymis, with or without symptoms or signs
of urethritis
• In sexually active men under age 35, acute epididymitis is caused
most frequently by C. trachomatis and less commonly by N.
gonorrhoeae and is usually associated with overt or subclinical
urethritis.
• Acute epididymitis occurring in older men or following urinary tract
instrumentation is usually caused by urinary pathogens.
60. • Ceftriaxone (250 mg as a single dose IM) followed by doxycycline
(100 mg by mouth twice daily for 10 days) constitutes effective
treatment for epididymitis caused by N. gonorrhoeae or C.
trachomatis
• Fluoroquinolones are no longer recommended for treatment of
gonorrhea in the United States because of the emergence of resistant
strains of N. gonorrhoeae, especially (but not only) among MSM
61. PELVIC INFLAMMATORY DISEASE
• refers to infection that ascends from the cervix or vagina to involve the
endometrium and/or fallopian tubes
• Infection can extend beyond the reproductive tract to cause pelvic
peritonitis, generalized peritonitis, perihepatitis, perisplenitis, or pelvic
abscess
• agents most often implicated in acute PID include the primary causes
of endocervicitis (e.g., N. gonorrhoeae and C. trachomatis)
• PID is most often caused byN. Gonorrhoeae where there is a high
incidence of gonorrhea
62. • Important risk factors for acute PID include the presence of
endocervical infection or bacterial vaginosis, a history of
salpingitis or of recent vaginal douching, and recent insertion of
an IUD.
• Certain other iatrogenic factors, such as dilatation and curettage
or cesarean section, can increase the risk of PID, especially
among women with endocervical gonococcal or chlamydial
infection or bacterial vaginosis
T. pallidum subspecies pallidum (referred to hereafter as T. pallidum), a thin spiral organism, has a cell body surrounded by a trilaminar cytoplasmic membrane, a delicate peptidoglycan layer providing some structural rigidity, and a lipid-rich outer membrane containing relatively few integral membrane proteins. Endoflagella wind around the cell body in the periplasmic space and are responsible for motility
In heterosexual men the chancre is usually located on the penis, whereas in homosexual men it may be found in the anal canal or rectum, in the mouth, or on the external genitalia. In women, common primary sites are the cervix and labia. Consequently, primary syphilis goes unrecognized in women and homosexual men more often than in heterosexual men.The clinical appearance depends on the number of treponemes inoculated and on the immunologic status of the patient. A large inoculum produces a dark-field-positive ulcerative lesion in nonimmune volunteers but may produce a small dark-field-negative papule, an asymptomatic but seropositive latent infection, or no response at all in some individuals with a history of syphilis. A small inoculum may produce only a papular lesion, even in nonimmune individuals. Therefore, syphilis should be considered even in the evaluation of trivial or atypical dark-field-negative genital lesions.
The eruption may be very subtle, and 25% of patients with a discernible rash may be unaware that they have dermatologic manifestations.In warm, moist, intertriginous areas (commonly the perianal region, vulva, and scrotum), papules can enlarge to produce broad, moist, pink or gray-white, highly infectious lesions [condylomatalata (see Fig. e7-20)] in 10% of patients with secondary syphilis. Superficial mucosal erosions (mucous patches) occur in 10–15% of patients and commonly involve the oral or genital mucosa
Positive serologic tests for syphilis, together with a normal CSF examination and the absence of clinical manifestations of syphilis, indicate a diagnosis of latent syphilis in an untreated person. The diagnosis is often suspected on the basis of a history of primary or secondary lesions, a history of exposure to syphilis, or the delivery of an infant with congenital syphilis
Benign nodular tertiary syphilis
Most experts agree that neurosyphilis is more common in HIV-infected persons, while immunocompetent patients with untreated latent syphilis and normal CSF probably run a very low risk of subsequent neurosyphilis. In several recent studies, neurosyphilis was associated with a rapid plasma reagin titer of 1:32, regardless of clinical stage or HIV infection status.
The last category includes general paresis and tabesdorsalis. The onset of symptoms usually occurs <1 year after infection for meningeal syphilis, up to 10 years after infection for meningovascular syphilis, at 20 years for general paresis, and at 25–30 years for tabesdorsalis.personality, affect, reflexes (hyperactive), eye (e.g., Argyll Robertson pupils), sensorium (illusions, delusions, hallucinations), intellect (a decrease in recent memory and in the capacity for orientation, calculations, judgment, and insight), and speech
Trophic joint degeneration (Charcot's joints) and perforating ulceration of the feet can result from loss of pain sensation. The small, irregular Argyll Robertson pupil, a feature of both tabesdorsalis and paresis, reacts to accommodation but not to light. Optic atrophy also occurs frequently in association with tabes.
Linear calcification of the ascending aorta on chest x-ray films suggests asymptomatic syphilitic aortitis, as arteriosclerosis seldom produces this sign. Syphilitic aneurysms—usually saccular, occasionally fusiform—do not lead to dissection. Only 1 in 10 aortic aneurysms of syphilitic origin involves the abdominal aorta.
The RPR and VDRL tests are recommended for screening or for quantitation of serum antibody. The titer reflects disease activity, rising during the evolution of early syphilis and often exceeding 1:32 in secondary syphilis. After therapy for early syphilis, a persistent fall by fourfold or more (e.g., a decline from 1:32 to 1:8) is considered an adequate response
Treponemal tests measure antibodies to native or recombinant T. pallidum antigens both of which are more sensitive for primary syphilis than the previously used hemagglutination testsWhen used to confirm positive nontreponemal test results, treponemal tests have a very high positive predictive value for diagnosis of syphilisbased largely on reactivity to recombinant antigens, have also been developed. Treponemal EIAs have been approved as confirmatory tests and, because of their ease of automation, are now used for screening purposes by some large laboratories.For practical purposes, most clinicians need to be familiar with three uses of serologic tests for syphilis: (1) screening or diagnosis (RPR or VDRL), (2) quantitative measurement of antibody to assess clinical syphilis activity or to monitor response to therapy (RPR or VDRL), and (3) confirmation of a syphilis diagnosis in a patient with a reactive RPR or VDRL test (FTA-ABS, TPPA, EIA
The efficacy of penicillin against syphilis remains undiminished after60 years of use, and there is no evidence of penicillin resistance in T. pallidum. Other antibiotics effective in syphilis include the tetracyclines and the cephalosporins. Aminoglycosides and spectinomycin inhibit T. pallidum only in very large doses, and the sulfonamides and the quinolones are inactive. Azithromycin has shown significant promise as an effective oral agent against T pallidum
If untreated, infections at these sites can lead to local complications such as endometritis, salpingitis, tuboovarian abscess, bartholinitis, peritonitis, and perihepatitis in female patients; periurethritis and epididymitis in male patients; and ophthalmianeonatorum in newborns.
The discharge initially is scant and mucoid but becomes profuse and purulent within a day or two. Gram's stain of the urethral discharge may reveal PMNs and gram-negative intracellular monococci and diplococci. The clinical manifestations of gonococcalurethritis are usually more severe and overt than those of nongonococcalurethritis, including urethritis caused by Chlamydia trachomatis
Because Gram's stain is not sensitive for the diagnosis of gonorrhea in women, specimens should be submitted for culture or a nonculture assay Gonococcal infection may extend deep enough to produce dyspareunia and lower abdominal or back pain. In such cases, it is imperative to consider a diagnosis of pelvic inflammatory disease (PID) and to administer treatment for that disease
The vaginal mucosa of healthy women is lined by stratified squamous epithelium and is rarely infected by N. gonorrhoeae. However, gonococcalvaginitis can occur in anestrogenic women (e.g., prepubertal girls and postmenopausal women), in whom the vaginal stratified squamous epithelium is often thinned down to the basilar layer, which can be infected by N. gonorrhoeae
The rectum is the sole site of infection in only 5% of women with gonorrhea. Such women are usually asymptomatic but occasionally have acute proctitis manifested by anorectal pain or pruritus, tenesmus, purulent rectal discharge, and rectal bleedingAmong men who have sex with men (MSM), the frequency of gonococcal infection, including rectal infection, fell by 90% throughout the United States in the early 1980s, but a resurgence of gonorrhea among MSM has been documented in several cities since the 1990s. Gonococcal isolates from the rectum of MSM tend to be more resistant to antimicrobial agents than are gonococcal isolates from other sites.
The designation PGU refers to NGU developing in men 2–3 weeks after treatment of gonococcal urethritis with single doses of agents such as penicillin or cephalosporins, which lack antimicrobial activity against chlamydiae. Since current treatment regimens for gonorrhea have evolved and now include combination therapy with tetracycline, doxycycline, or azithromycin—all of which are effective against concomitant chlamydial infection—both the incidence of PGU and the causative role of C. trachomatis in this syndrome have declined.C. trachomatis urethritis is generally less severe than gonococcal urethritis, although in any individual patient these two forms of urethritis cannot reliably be differentiated solely on clinical grounds. Symptoms include urethral discharge (often whitish and mucoid rather than frankly purulent), dysuria, and urethral itching. Physical examination may reveal meatal erythema and tenderness as well as a urethral exudate that is often demonstrable only by stripping of the urethra.
The condition usually presents as unilateral scrotal pain with tenderness, swelling, and fever in a young man, often occurring in association with chlamydial urethritis
C. trachomatis has been isolated from synovial biopsy samples from 15 of 29 patients in a number of small series and from a smaller proportion of synovial fluid specimens.Mild bilateral conjunctivitis, iritis, keratitis, or uveitis is sometimes present but lasts for only a few days. Finally, dermatologic manifestations occur in up to 50% of patients. The initial lesions—usually papules with a central yellow spot—most often involve the soles and palms and, in 25% of patients, eventually epithelialize and thicken to produce keratodermablenorrhagicum
A Papanicolaou smear shows increased numbers of neutrophils as well as a characteristic pattern of mononuclear inflammatory cells including plasma cells, transformed lymphocytes, and histiocytes. Cervical biopsy shows a predominantly mononuclear cell infiltrate of the subepithelialstroma. Clinical experience and collaborative studies indicate that a cutoff of >30 polymorphonuclear leukocytes (PMNs)/1000x field in a gram-stained smear of cervical mucus correlates best with chlamydial or gonococcal cervicitis
LGV strains of C. trachomatis have occasionally been recovered from genital ulcers and from the urethra of men and the endocervix of women who present with inguinal adenopathy; these areas may be the primary sites of infection in some cases. Proctitis is more common among people who practice receptive anal intercourse, and an elevated white blood cell count in anorectal smears may predict LGV in these patients. Ulcer formation may facilitate transmission of HIV infection and other sexually transmitted and blood-borne diseases
The nodes are initially discrete, but progressive periadenitis results in a matted mass of nodes that becomes fluctuant and suppurative. The overlying skin becomes fixed, inflamed, and thin, and multiple draining fistulas finally develop. Extensive enlargement of chains of inguinal nodes above and below the inguinal ligament ("the sign of the groove") is not specific and, although not uncommon, is documented in only a minority of casesMassive pelvic lymphadenopathy may lead to exploratory laparotomy
A single 1-g oral dose of azithromycin is as effective as a 7-day course of doxycycline for the treatment of uncomplicated genital C. trachomatis infections in adults. Azithromycin causes fewer adverse gastrointestinal reactions than do older macrolides such as erythromycin. The single-dose regimen of azithromycin has great appeal for the treatment of patients with uncomplicated chlamydial infection (especially those without symptoms and those with a likelihood of poor compliance) and of the sexual partners of infected patients
in gonococcal infection, such a smear usually reveals gram-negative intracellular diplococci as well. Alternatively, the centrifuged sediment of the first 20–30 mL of voided urine—ideally collected as the first morning specimen—can be examined for inflammatory cells, either by microscopy showing 10 leukocytes per high-power field or by the leukocyte esterase test. Patients with symptoms who lack objective evidence of urethritis may have functional rather than organic problems and generally do not benefit from repeated courses of antibiotics
For hospitalized patients, the following two parenteral regimens have given nearly identical results in a multicenter randomized trial:Doxycycline (100 mg twice daily, given IV or PO) plus cefotetan (2 g IV every 12 h) or cefoxitin (2 g IV every6 h): Administration of these drugs should be continued by the IV route for at least 48 h after the patient's condition improves and then followed with oral doxycycline (100 mg twice daily) to complete 14 days of therapy.Clindamycin (900 mg IV every 8 h) plus gentamicin(2 mg/kg IV or IM, followed by 1.5 mg/kg every 8 h) in patients with normal renal function: Once-daily dosing of gentamicin (with combination of the total daily dose into a single daily dose) has not been evaluated in PID but has been efficacious in other serious infections and could be substituted. Treatment with these drugs should be continued for at least 48 h after the patient's condition improves and then followed with oral doxycycline (100 mg twice daily) or clindamycin (450 mg four times daily) to complete 14 days of therapy. In cases with tuboovarian abscess, clindamycin rather than doxycycline for continued therapy provides better coverage for anaerobic infection.