Mark Maynards SGR on STDs

1. SGR Presentation by
Mark Maynard, DO
KoalaNeel
Chlamydia

2. STD
SGR Presentation by
Mark Maynard, DO

3. Time
?Abx

4. Aggressive
Symptom
Highly
Infectious
Explosive
Treponema
Aggressive
Symptom
Highly
Infectious
Explosive
Treponema

6. STDs
Chlam
GC
Trich
HSV
Syphilis
Rarities
Chancroid
LGV
Granuloma Inguinale
HPV
Others
BV
Candida

7.  Most freq reported
 Asymptomatic
 50% Men, 70%Women
 Clinical
 Men
▪ Urethritis, epididymitis
▪ Proctitis, Reiter syndrome
 Women
▪ Cervicitis,Vag discharge,
spotting, dysuria
▪ 20% PID  ectopic,
infertility

8.  Dx
 Prefered NAAT
▪ Swab, Urine
▪ Sn 90%, Sp 99%
 Tx
 Azithro 1 g PO x 1
 Alt: Doxy 100 mg BID
 Compliance  Cure
 PDPT (partner delivered
partnerTx)
 Q: Legal inTx?
 STD Clinic
 No sex until 7 days afterTx
 Re-infection higher PID
rate
 Dr Homewreaker

9.  Q: LAP + CMT + Discharge
= ?
 PID
 Min Dx Criteria
▪ Uterine or adnexal tenderness
▪ CMT
 Improved Sp
▪ Temp > 38
▪ Cervical discharge
▪ WBC, ESR, CRP
▪ TVUS: thick tubes/fluid,TOA
 Tx:
 Ceftriaxone 250 IM plus Doxy
100 BID x 14 d
 Single dose = FAIL
 Epididymitis
 Dysuria
 Pyuria
 US doppler
 Tx:
 Age < 40 (same as PID)
▪ Ceftriaxone, Doxy
 Age > 40
▪ Cipro

10.  23 yo M, new partner,
c/o discharge
 Dx ?
 Tx?
 One more thing doc…
“Achy joints, chills, bug
bites”
 VS:T 38.1, HR 112
 Dx andTx?

11.  2nd most common
 Clinical
 Most asymptomatic
 Men:
▪ Purulent discharge
 Women:
▪ Asymptomatic until PID
▪ Cervicitis
 Proctitis and Pharyngitis

12.  Q: rash + knee pain +
sexually active = Dx?
 Disseminated GC (arthritis-
dermatitis syndrome)
 Rare: 3%
 Petechial or pustular rash
 Asymmetric arthralgias,
septic arthritis
 Fever
 Difficult to Dx
 Cx lesions
 BCx
 Dispo?

13.  Dx:
 NAAT, Gram stain
 Tx:
 Ceftriaxone 250 mg IM x 1
 Or Cefixime 400 mg PO x 1
 No sex for 7 days after tx

14.  Both cause discharge
 Test for both
 Treat for both
 Both can ascend (PID,
Epididymitis)
 Both partners needTx

15.  Clinical
 Asymptomatic
▪ Women 25%
▪ Men 90%
 Difficult to control
spread
 Women:
▪ Vulvar irritation, thin
discharge (70%)
▪ Yellow-green, froth (rare)
▪ Exam: inflamed vag
mucosa, punctate
hemorrhages

16.  Men
▪ Asymptomatic
▪ May have urethritis
 Dx:
 Wet prep: motile
trichamonads (Sn 70%)
 Stay motile 10-20 min
 Tx:
 Metro 2 g PO x 1
 Avoid alcohol
 Metro Gel (Don’t use)
 Asymptomatic?
 Still treat
 Cure rate 90%

17. STDs
Chlam
GC
Trich
HSV
Syphilis
Rarities
Chancroid
LGV
Granuloma InguinaleHPV
Others
BV
Candida

18.  23 yo F, no PMH,
dysuria and vaginal
burning/itching.
 Gluc 75
 UA:
 14WBC, Squam City
 External Exam
 Dx?
 Tx?

19.  Lifelong
 Primary: “First is the
Worst”
 Asymptomatic Rate
 Prodrome
 Rash
 papule vesicles on
erythematous base
erode/crust heal.
 Uniform size
 Dx:
 Clinical or serologic
 Tzanck smear ?

20.  Tx:
 No cure, shortens course,
Dec viral sheading
 Primary:
 Acyclovir 400 mg POTID x
10 d
 Immunocomp  IV
 Recurrent  Lower
dose/duration

21.  26 yo M, “groin sore” x
3 days, not painful,
new sexual partner 3
wks ago, no travel
 No discharge, single
ulcer, no adenopathy
 Dx?
 Tx?
 Q: Labs?
 RPR Negative

22.  Treponema pallidum
 Clinical Stages:
 1°: PainLESS Chancre
 2°:Variable Rash
 3°: CNS,Vasc, Skin
▪ Badness
 Neurosyphilis
▪ Occurs at ANY stage
▪ CSF forVDRL

23. 30%

24.  Dx:
 Depends on stage
 EarlyDarkfield
 LateRPR
 Tests
 Nontreponemal AbTest
▪ RPR,VDRL
▪ Screening tests
▪ Tx  RPRTiter decreases
▪ 4-fold decrease =Tx success
 Treponemal AbTest
▪ Confirmatory test
▪ FTA-ABS
▪ Stays positive afterTx
 Tx:
 Primary/Secondary:
 Pen G Benzathine 2.4 million
units IM x 1
 Bicillin?
 Latent/Tertiary
 Pen G Benzathine 2.4 million
units weekly x 3
 Pregnant
 IV Pen G
 If Pen allergic Desensitize

25. RPR/VDRLDarkfield FTA-ABS

26.  Haemophilus ducreyi
 PainFULL
 Ulcer + lymphadenitis
 Clinical:
 Erythematous papule 
erosion/ulcer/pustular
 Inguinal drainage

27.  Dx:
 Clinical
 DDx: HSV (vesicular),
Syphilis (painless)
 Tx:
 Aspiration or I&D
▪ Prevents fistulas
 Azithro 1 g PO x 1

28.  Lymphogranuloma
venereum
 Chlamydia trachomatis
 L1, L2, L3
 Aka: tropical bubo.
 Rare in US
 Painless chancre (never
noticed)
 Unilateral inguinal
lymphadenopathy
(Bubo), purple hue,
“Groove”

29.  Dx:
 Clinical (travel to
Caribbean, S. America,
Africa)
 Tests not widely
available
 Tx:
 Doxy 100 mg BID x 21 d
 Complications
 Lymph obstruction 
elephantiasis
LGV
ro
o
v
e

30.  Klebsiella granulomatis
 Looks Horrible, Pt feels
fine
 Very rare in US.
 India, southern Africa,
Pacific nations
 Classic painless “beefy
red”, bleeds easily
 Not very contagious,
req’s multiple exposures

31.  Dx:
 Difficult to culture,
Tissue biopsy
 Tx:
 Doxy 100 BID x 21 d (or
untill resolved)

32.  PainLESS
 Syphilis
 Granuloma Inguinale
 PainFULL
 HSV (Vesicle)
 Chancroid (Ulcer & LAD)
 LGV (Bubo)
 Tx:
 HSV Acyclovir
 Syphilis Pen G
Benzithine
 Chanchroid  Azithro
 LGV and GI  Doxy

34.  STD-ER, its our job
 PID = Sex Active + CMT/Adnexal +/- DC
 Test for HIV
 Syphilis Dx: Early Darkfield, Late RPR
 Look Beyond the Genitals
 When in doubt,TREAT IT!
 TzanckYou for Listening

35.  http://koalaland.com.au/chlamydia
 http://www.dshs.state.tx.us/hivstd/ept/
 http://www.cdc.gov/std/treatment/2010/default.htm
 http://www.cdc.gov/std/chlamydia/default.htm
 http://www.cdc.gov/std/gonorrhea/default.htm
 http://www.cdc.gov/std/herpes/default.htm
 http://www.cdc.gov/std/trichomonas/default.htm
 http://www.cdc.gov/std/syphilis/default.htm
 Nobay F, Promes S. SexuallyTransmitted Diseases. In:Tintinalli JE, Stapczynski
JS, Ma, OJ, Cline DM, editors.Tintinalli’s Emergency Medicine. 7 th ed. NewYork:
McGraw-Hill; 2011.
 Birnbaumer DM. SexuallyTransmitted Diseases. In: Rosen's Emergency Medicine:
Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2013
 Workowski KA, Berman S: Sexually transmitted diseases treatment guidelines.
MMWR Morb Mortal Weekly Rep 2006 Aug 4;(55);22-30
 Miller JN:Value and limitations of nontreponemal and treponemal tests in the
laboratory diagnosis of syphilis.Clin Obstet Gynecol 1975 Mar 18;18(1);191-203
 http://www.mayomedicallaboratories.com/test-
catalog/Clinical+and+Interpretive/9056