Sexually Transmitted Diseases

1. Sexually Transmitted Diseases David W. Haas, M.D. Division of Infectious Diseases Vanderbilt University School of Medicine Nashville, Tennessee

3. Case Presentation • 19 YO male c/o burning on urination, yellow discharge on underwear. • Has otherwise been well. • What are likely diagnoses? • What tests should be done? • What treatment may be needed? • Anything else to do?

5. Gonococcal Urethritis • Incubation 1-10 days • Can’t differentiate from chlamydia by symptoms • Most infections are symptomatic • May persist without continued symptoms

6. Acute Epididymitis • Young men • Chlamydia (most common) • Gonococcus • Old men • Gram (-) enterics • Pseudomonas

7. Localized Gonococcal Infections • Anorectal infection • Culture often (+) in women with cervical GC • Treatment failures detected at rectum • Pharyngeal infection • Orogenital exposure • Pelvic inflammatory disease • Cervix doesn’t predict upper tract GC • 20% risk of infertility • Perihepatitis (Fitz-Hugh-Curtis syndrome)

9. Disseminated Gonococcal Infection

13. Diagnosis of Gonorrhea • Culture • Rapidly inoculate media • Thayer-Martin, others • DNA probes or DNA amplification • If used, culture unnecessary • Gram stain • Gram (-) diplococci • Many leukocytes

15. Treatment of Uncomplicated Gonorrhea (urethra, cervix, pharynx, rectum) • Ceftriaxone (125mg IM x 1 dose) OR • Cefixime (400mg PO x 1 dose) OR • Cefpodoxime (400mg PO x 1 dose) OR • Ciprofloxacin (500mg PO x 1 dose) OR • Gatifloxacin (400mg PO x 1 dose) OR • Levofloxacin (250mg PO x 1 dose) + • Azithromycin 1g po x 1 dose OR • Doxycycline 100mg q12h po x 7 days

16. Treatment of GonorrheaGeneral Considerations • Reculture all (+) sites at 4-7 days • Consider reculture os rectal canal in women • Examine and culture sexual contacts • Treat sexual contacts regardless

17. Chlamydia trachomatisGenital Disease • Urethritis in men • Isolated with 20% of GC cases • Isolated in 40% of NGU • Asymptomatic infection common • Epididymitis • Cervicitis • Pelvic inflammatory disease • Infertility risk 10% • Perihepatitis

18. Diagnosing C. trachomatis Infection • Gram stain • 4 WBC’s per oil-immersion field • No organisms seen • Rapid methods • DNA probes or PCR • Culture • Costly, not generally done

19. Case Presentation • 19 YO male c/o burning on urination, yellow discharge on underwear. • Has otherwise been well. • What are likely diagnoses? • What tests should be done? • What treatment may be needed? • Anything else to do?

21. Stage Primary Secondary Latent Late Onset 3 weeks 2-8 weeks >8 weeks years Syphilis

22. “Classic” Syphilitic Chancre • Painless • Raised borders • No exudate • At inoculation site • Rarely seen by physician

26. Secondary Syphilis • Rash • Variable, palms & soles • Fever • Diffuse lymphadenopathy • Patchy alopecia • Mucous patches • Condyloma lata

33. Darkfield Examination for Syphilis • Abrade lesion with dry gauze • Obtain serous exudate • Place on slide with coverslip • View motile spirochetes • Great for primary and secondary syphilis, not for oral lesions

35. Syphilis Serology

36. Who with Latent SyphilisNeeds a Spinal Tap? • Neurologic symptoms • Failure of RPR to fall with therapy • RPR 1:32 • Inability to give penicillin If CSF abnormal, treat for neurosyphilis

37. Treating Syphilis • Primary and Secondary • Benzathine PCN 2.4 million units IM x 1 • (Ceftriaxone 1g qd IV or IM x 8-10 d) • (Doxycycline 100mg q12h x 14 d) • Anticipate Jarisch-Herxheimer • Latent (>1 year duration) • Benzathine PCN 2.4mil units IM weekly x 3 • (Doxycycline 100mg q12h x 28 d)

38. Treating Neurosyphilis • Pen G 2-4 million units IV q4h x 10-14 d • (Procaine Pen G 2.4 mil units IM q24h + probenacid 500 mg PO qid x 14 days) • (Ceftriaxone 1g IV or IM qd x 14 d)

40. Genital Herpes - Initial Episode • Painful vesicles or pustules which ulcerate • Fever, headache, myalgias • Tender inguinal adenopathy • Extragenital vesicles common • Pharyngitis, aseptic meningitis, urethritis occasional

42. Genital Herpes - Recurrent 90% recur in first year Average 5 per year initially Less severe than first episode Avoid sex until lesions heal

43. Diagnosing Genital Herpes Diagnosis often clinical Cytology (Tzank prep) shows Scrape lesion Spear to microscope slide Stain with Pap or Wright-Giemsa See multinucleated giant cells Culture Swab lesion To viral transport media Cytopathic effect in 1-4 days

45. Treating Genital Herpes Initial Acyclovir 400mg po q8h x 7-10 days Valacyclovir 1g po q12h x 10 days Famciclivir 250mg po q8h x 7-10 days Recurrent (Often not treated) Acyclovir 400mg q8h x 5 days Valacyclovir 500mg po q12h x 3 days Famciclivir 125mg po q12h x 5 days Chronic suppression Acyclovir 400mg q12h Valacyclovir 1g po q24h Famciclivir 250mg po q12h

46. Sexually Transmitted Diseases