STDs, GPs

1. STDs
Dr. Alaa Hassan
MBBCh, MSc, MD
Consultant, Community
medicine and public Health

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.

4. Diseases presenting mainly as genital ulcer

5. 1.Syphilis
• Caused by Treponema pallidum
• Syphilis infection is characterized by stages,
and accurate staging is vital to determine
appropriate therapy

6. 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.

7. Primary syphilis - chancre

8. Primary syphilis - chancre

9. 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.

10. 10
Secondary Syphilis Rash
Source: Florida STD/HIV Prevention Training Center

11. 11
Secondary Syphilis: Generalized Body
Rash
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

12. 12
Secondary Syphilis Rash
Source: Florida STD/HIV Prevention Training Center

13. 13
Secondary Syphilis Rash
Source: Cincinnati STD/HIV Prevention Training Center

14. 14
Secondary Syphilis – Condylomata Lata
Source: Florida STD/HIV Prevention Training Center

15. 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.

16. 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.

17. Late syphilis - serpiginous gummata of
forearm

18. Cardiovascular syphilis - narrowing of
coronary ostia in aortus

19. Congenital syphilis - mucous patches

20. Congenital syphilis - - Hutchinson’s
teeth

21. Congenital syphilis - perforation of
palate

22. 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.

23. Syphilis - Treponema pallidum on
darkfield

24. 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

25. 25
Genital Herpes Simplex in Females
Source: Centers for Disease Control and Prevention

26. 26
Genital Herpes Simplex
Source: Florida STD/HIV Prevention Training Center

27. 3.Chancroid
• Caused by Haemophilus ducreyi.
• Definitive diagnosis is difficult, requiring
identification of H ducreyi on special culture
medium that is not readily available.

28. Chancroid - gram stain of H. ducreyi

29. Chancroid Male - regional adenopathy

30. 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.

31. LGV lymphadenopathy

32. 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.

33. Granuloma inguinale, Donovan bodies

34. Granuloma inguinale, male

35. Granuloma inguinale, female

36. 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

37. Urethral Discharge

38. 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

39. 39
Gonorrhea Gram Stain
Source: Cincinnati STD/HIV Prevention Training Center

40. 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 (+)

41. 41
Chlamydia Life Cycle
Source: California STD/HIV Prevention Training Center

42. 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.

43. Vaginitis

44. 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.

45. • 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.

46. 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.

47. 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.

48. 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)

49. Cervicitis
• Cervicitis is characterized by purulent
discharge from the endocervix, which may or
may not be associated with vaginal discharge
or cervical bleeding.

50. 50
Normal Cervix
Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center

51. 51
Chlamydia Cervicitis
Source: St. Louis STD/HIV Prevention Training Center

52. 52
Mucopurulent Cervicitis
Source: Seattle STD/HIV Prevention Training Center

53. 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.

54. • 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.

55. 55
Pelvic Inflammatory Disease
Source: Cincinnati STD/HIV Prevention Training Center

56. 56
C. trachomatis Infection (PID(
Drips
Source: Patton, D.L. University of Washington, Seattle, Washington
Normal Human
Fallopian Tube Tissue PID Infection

57. Genital warts

58. 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

59. 59
Perianal Wart
Source: Cincinnati STD/HIV Prevention Training Center
HPV and Cervical Cancer

60. 60
HPV Warts on the Thigh
Source: Cincinnati STD/HIV Prevention Training Center
HPV and Cervical Cancer

61. 61
Possible HPV on the Tongue
Source: Cincinnati STD/HIV Prevention Training Center
HPV and Cervical Cancer

62. 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.

63. Molluscum contagiosum, vulva and
thighs

64. Molluscum contagiosum