Infections of the Genital Tract

1. Infections of the Genital Tract Karl Bolintiam Francine Lu Roberto Sioco

2. Outline • Infections of the lower genital tract • Infections of the Vulva • Vaginitis • Toxic Shock Syndrome • Cervicitis • Infections of the upper genital tract • Endometritis • Pelvic Inflammatory Disease • Actinomyces Infection • Tuberculosis

3. Toxic Shock Syndrome

4. Toxic shock syndrome (TSS) • an acute, febrile illness produced by a bacterial exotoxin, with a fulminating downhill course involving dysfunction of multiple organ systems • abrupt onset and rapidity • may develop rapid onset of hypotension associated with multiorgan system failure • develop from a site of bacterial colonization rather than from an infection

5. Toxic shock syndrome (TSS) • used to be related to menstruation and tampon use • more likely with use of higher absorbency tampons, several cycle days of tampons, and kept a single tampon in for a longer period of time • NonmenstrualTSS may be a sequela of focal staphylococcal infection of the skin and subcutaneous tissue • often following a surgical procedure

6. Classical TSS • the woman must be colonized or infected with S. aureus • the bacteria must produce TSS toxin-1 (TSST-1) or related toxins • the toxins must have a route of entry into the systemic circulation. • Interestingly, approximately 85% of adult females have antibodies against TSST-1 • women with menstrual-related TSS do not respond immunologically to TSST-1 as do women with nonmenstrual-related TSS.

7. Pathophysiology • signs and symptoms of TSS are produced by the exotoxin named toxin-1 • toxins act as “superantigens.” • activate up to 20% of T cells at once, resulting in massive cytokine production. • primary effects of toxin-1: • increased vascular permeability and thus profuse leaking of fluid (capillary leak) from the intravascular compartment into the interstitial space • profound loss of vasomotor tone, resulting in decreased peripheral resistance. • Exotoxinis believed to be absorbed directly from the vagina, as blood cultures are rarely positive for S. aureus in a woman with TSS • microulcerationsproduced by use of tampons systemic circulation

8. Clinical Manifestations • Wide range of symptoms but should have high index of suspicion for TSS in a woman who has an unexplained fever and a rash during or immediately following her menstrual period • prodromal flu-like illness for the first 24 hours. • days 2-4 of the menstrual period: • abrupt onset of a high temperature • headache, myalgia, sore throat, vomiting, diarrhea, a generalized skin rash, and often hypotension • formefruste: low-grade fever and dizziness rather than hypotension

9. Clinical Manifestations • Skin changes: most characteristic manifestation • first 48 hours: rash appears similar to an intense sunburn. • Next few days: the erythema will become more macular and look like a drug-related rash. • Days 12 to 15: fine, flaky, desquamation of skin over the face and trunk with sloughing of the entire skin thickness of the palms and soles • vaginal mucosa is hyperemic during the initial phase of the syndrome

10. Clinical Manifestations • tenderness of the external genitalia and vagina on pelvic exam • Myalgia, vomiting, and diarrhea

12. Diagnosis • CBC, Urinalysis, PT/PTT • Blood chem • Crea, FBS, BUN, transaminases • cervical, vaginal, and blood cultures for S. aureus

14. Management • First eliminate the hypotension produced by the exotoxin • IVF given while pressure and volume dynamics are monitored with a pulmonary artery catheter. • Mechanical ventilation is required for women who develop adult respiratory distress syndrome. • wash out the vagina with saline or dilute iodine solution to diminish the amount of exotoxin that may be absorbed into the systemic circulation • Drain and debride skin infection if that is the focus

15. Treatment • clindamycin 600 mg IV every 8 hours • PLUS: nafcillinor oxacillin 2 g IV every 4 hours, • and most experts recommend a 1- to 2-week course of therapy with an antistaphyloccocal agent such as clindamycin or dicloxacillin even in the absence of positive S. aureusculture • Include aminoglycoside for gram negative coverage (sepsis), if diagnosis is questionable

16. Endometritis

17. Endometritis • Usually coexists with salpingitis • But patients with endometritis alone had distinct risk factors: • douching in last 30 days • current IUD in place • in days 1 to 7 of menstrual cycle

18. Endometritis • Gold standard diagnosis: endometrial biopsy. • At least one plasma cell per 120× field of endometrial stroma combined with five or more neutrophils in the superficial endometrial epithelium per 400× field • In severe cases: diffuse lymphocytes and plasma cells in the endometrial stroma or stromal necrosis may be present.

19. Endometritis • May be subclinical • May not have signs of salpingitis as well (no cervical motion or adnexal or uterine tenderness) • High clinical suspicion • Risk factors: • young age (20 to 22 years old in most studies) • abnormal uterine bleeding (menorrhagia or metrorrhagia) • menstrual cycle day less than 14 • douching in last 30 days • history of prior PID

20. Pathogens • C. trachomatis, N. gonorrhoeae, bacterial vaginosis, M. genitalium, and Trichomonasvaginalis • in women with current N. gonorrhoeae or C. trachomatis infection, endometritis was apparent in 43% of women with a history of prior PID and 23% in women without prior PID. • suggestive of possible immunologic memory. • may not have an isolated pathogen.

21. Treatment • same as outpatient salpingitistreatment • should last 14 days. • Addition of metronidazole if with bacterial vaginosis.

22. 2010 CDC guidelines for PID

23. Tuberculosis

24. Tuberculosis • primarily chronic salpingitis and chronic endometritis • frequent cause of chronic PID and infertility in other parts of the world • Usually in premenopausal women • either Mycobacterium tuberculosis or M. bovis

25. Tuberculosis • primary site of infection: usually the lung. • spread hematogenouslyoviduct. • Primary and predominant site of pelvic TB • Subsequent spread to the endometrium and less commonly to the ovaries.

26. Clinical Manifestations • insidious or rapidly progressing • similar to the chronic sequelae of nontuberculous acute PID • Usually infertility and abnormal uterine bleeding • Mild-to-moderate chronic abdominal and pelvic pain • Ascites

27. Clinical Manifestations • May be asymptomatic, could also have normal pelvic exam findings • PE: mild adnexal tenderness and bilateral adnexalmasses • inability to manipulate the adnexa because of scarring and fixation.

28. Diagnosis • Suspect in patients not responding to conventional antibiotic therapy for acute bacterial PID. • Positive tuberculin skin test • +/- CXR findings

29. Diagnosis • endometrial biopsy late in the secretory phase of the cycle • Portion sent for culture and animal inoculation • remaining portion examined histologically. • classic giant cells, granulomas, and caseous necrosis confirm the diagnosis

30. Diagnosis • Characteristic changes on laparotomy: distal ends of the oviduct remain everted, producing a “tobacco pouch” appearance

31. Management • chest radiographic examination, IV pyelogram, serial gastric washings, and urine cultures • Treatment: 5-drug regimen for MDR-TB • Surgery reserved for: • persistent pelvic masses, • some women with resistant organisms, • women older than 40 • women whose endometrial cultures remain positive