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Syphilis

Syphilis. Primary Secondary Tertiary. Primary syphilis. Probability = 50% after sexual encounter with a patient with active syphilis Incubation period 10-90 days Chancre arises at site of spirochetal entry a painless ulcerated lesion with a raised border and indurated base

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Syphilis

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  1. Syphilis Primary Secondary Tertiary

  2. Primary syphilis • Probability = 50% after sexual encounter with a patient with active syphilis • Incubation period 10-90 days • Chancre arises at site of spirochetal entry a painless ulcerated lesion with a raised border and indurated base • Resolves on its own in 3-6 weeks

  3. Secondary syphilis • Disseminated spread of spirochetes all over the body • 2-4 weeks after primary infection resolves • 90% skin and mucous lesions Rash begins on trunk and proximal extremities and spreads outward. Pruritic esp on palms and soles • Generalized lymphadenopathy 85% • Fever and malaise 70 %

  4. Tertiary syphilis • 33% will progress to this stage if untreated • Cardiovascular ( Aortic Insufficiency Aneurysm) • CNS (tabes Dorsalis, optic atrophy, Argyle-Robertson pupil • Musculoskeletal

  5. Diagnostic Testing • Darkfield testing • Serologic testing Nonspecific (VDRL RPR ) with titer Specific (MHATP FTSAb)

  6. Spinal tap for syphilis • Neurological symptoms • Ophthalmic symptoms • Tertiary syphilis • Treatment failure • HIV or other immunosuppressed patient with late latent or unknown length of infection

  7. Treatment • Primary: Benzathine PenG 2.4 mil units IM or Doxycycline 100mg BID for 2 weeks • Secondary (<1 year) Same as Primary (> 1 year) Benz PenG 2.4 mill units IM qweek for 3 weeks or Doxycycline 100mg bid for 4 weeks • Tertiary Cardiovascular same as late secondary CNS PenG 3-4 mill units IV q 4 hr

  8. Treatment • All patients with a primary contact • All patients with a positive darkfield • All patients with serologic evidence of syphilis • Previously treated patients with a 4 fold rise in titer

  9. Sexually transmitted diseases • 3 mill adolescents acquire STD yearly • Changing emphasis old GC and syphilis new chlamydia, HSV, HPV and HIV • Newer infections are more difficult to treat or cause chronic disease HIV AIDS HPV Genital Cancer HSV recurrent infections

  10. Sexually transmitted diseases • More serious consequences in women genital cancer with HPV Decreased reproductive capacity from tube damage during infection complications of pregnancy - spontaneous abortion, still births, preterm births, chorioamnionitis, low birth weight transmission to the fetus (HIV, syphilis, HSV, CMV HBV)

  11. Gonorrhea • Symptoms discharge, abnormal bleeding, pelvic pain • 40-60 % have symptoms (asymptomatic more common in women) • Incubation period less than 10 days

  12. Disseminated GC • Early: Arthritis (migratory) tenosynovitis and dermatitis • Late: arthritis, perihepatitis, osteomyelitis, pericarditis, endocarditis, meningitis

  13. Diagnosis of GC Male gram stain or culture. Gram stain positive in 90-95 % if symptoms Female Gram Stain or culture Gram stain only positive in 50-70 %

  14. Treatment of GC • Rocephin 250 mg single dose • Doxycycline 100 mg bid • Zithromax 1 gram po

  15. Chancroid • Acute ulcerative disease often associated with inguinal adenopathy (bubo) • Causative agent H Ducreyi (gram neg rod) • Lesions generally limited to genital sites • Incubation period 3-10 days

  16. Chancroid • Small papule at site of entry surrounded by a zone of erythema. Within 2-3 days the lesions become pustular or vesiculopustular and ulcerate • Classic ulcer is superficial and shallow with a ragged edge. The base of the ulcer is covered with a necrotic exudate This ulcer is painful unlike syphilis

  17. Chancroid • In 50 % of cases a bubo develops 7-10 days after the initial lesion. Tender inflammatory If untreated it will rupture forming a large ulcer

  18. Chancroid Treatment • Zithromax 1 gram po • Rocephin 250 mg IM • Cipro 500 mg po bid for 3 days

  19. LGV • LGV is an infection caused by Chlamydia Trachomatis L1L2L3 • Primary infection of the lymphatic tissue • Infection spreads from lymph node into adjacent tissue. Lymph nodes enlarge, necrose and form abscesses • Long term complication is destruction of lymphatic tissues with resulting edema

  20. Diagnosis and Treatment of LGV • Diagnosis: PCR of chlamydial antigen from aspirated or draining pus • Treatment: Doxycycline 100mg bid for 21 days

  21. HPV • Papova viral family (double stranded DNA) • Requires squamous epithelium to grow • Causes genital and skin warts • Important because the virus is implicated in anogenital cancer (90% of cancer of the anogenital tract have HPV DNA present) • Treatment is aimed at eradication of the wart but does not eliminate the virus

  22. Examination of the Male GU Tract • Most common finding is mass a) all masses arising from testicle are cancer b) masses arising from spermatic cord structures are non cancerous

  23. Torsion • Torsion – twisting of testis on spermatic cord resulting in a strangulation of blood supply • Most common age 12-20 • Acute onset unilateral pain and swelling of testis. May be difficult to differentiate from epididymitis. Sono with color flow doppler to differentiate

  24. Hydrocele • Fluid collection between tunica vaginalis and testis. Patients present with progressive swelling and discomfort on the involved side of the scrotom. Diagnosis made with sono

  25. Varicocele • Enlarged tortuous spermatic vein above the testicle usually on left. Typically this decreases in size when supine

  26. Herpes • HSV1 or HSV2 • Primary infections painful pustular or ulcerative lesions occurring 8 –16 days after contact. Systemic symptoms are common and include fever headache and myalgias • Treatment Zovirax Famvir

  27. Epididymitis • Onset of pain is usually more gradual than torsion • Typically sex related • Sono to help differentiate from torsion • Treatment doxycycline for 10 days, bactrim or levaquin

  28. Scrotal Infections • Cellulitis • Abscess Skin only or involves or even originates from infection from one of the primary intrascrotal organs. Consider admission if diabetic or significant systemic symptoms • Fourniers gangrene- polymicrobial inf of subcutaneous tissues that originates from 1 of 3 sites. Skin, Urethra, and Rectum

  29. Abnormal Genital Bleeding • Rule out pregnancy • Localize bleeding to uterine cavity • Stabilize with fluid – Blood as needed • Conjugated estrogen 20 mg iv or BCP • Follow up with gynecology • Referral for all postmenopausal patients

  30. Criteria for Diagnosis of PID All 3 must be present Abdominal tenderness Cervical Motion Tenderness Adnexal Tenderness One of these must be present positive gram stain temp>38 WBC > 10 Inflammatory mass on exam or sono

  31. Treatment of PID • Consider admission if future fertility is an issue or systemic symptoms • Outpatient – Rocephin250 IM plus doxycycline 100mg bid for 10 days • Inpatient – Cefoxitin 2 gm IV every 6 hr or Cefotetan 2 gm IV every 12 hr followed by doxycycline 10mg bid for 10 days

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