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1. It Burns! Name that Lesion It’s Catchy! Creepy Crawlers/ Lumpy Bumpys Pediatric Pearls 100 100 100 100 100 200 200 200 200 200 300 300 300 300 300 400 400 400 400 400 500 500 500 500 500

2. A 26 year old woman presents to ED with fever, chills, nausea, dysuria, lower abdominal pain, and vaginal discharge. • What is the diagnosis? • Name 2 causes. • Name 2 complications.

3. Pelvic Inflammatory Disease • A spectrum of infections of the female genital tract that includes endometritis, salpingitis, tubo-ovarian abscess, and perotinitis. • Caused by an ascending infection from the vagina or cervix. Most commonly chlamydia or gonorrhea. • Most common serious infection in women. Complications include sepsis, perihepatitis (Fitz-Hugh-Curtis), infertility, chronic pelvic pain and ectopic pregnangy.

4. PID History and Physical Exam • History may include bilateral lower abdo pain, low back pain, vaginal discharge, and irregular vaginal bleeding in a sexually active woman. May have systemic/toxic symptoms of fever, nausea, vomiting, chills. • Exam may show tender lower abdomen, mucopurulent cervical discharge, cervical motion tenderness, uterine tenderness, adnexal tenderness.

5. PID work-up and treatment • Should do pregnancy test, urinalysis and urine culture, and cervical cultures or urine for GC and chlamydia. • Consider testing for other STIs (HIV, syphilis). • Toxic, pregnant, or patients with tubo-ovarian abscess should be admitted. • Outpatient treatment is usually one dose of IM ceftriaxone and a 2 week course of PO doxycycline. • Should discuss safe sex, abstinence until treatment completion, and referral of partners for treatment.

7. A 30 y.o. man presents to ED with dysuria and urethral discharge, myalgias and conjunctivitis. • What is the likely diagnosis? • What is one cause?

8. Urethritis • Inflammation of the urethra is most commonly caused by STIs and is classified as gonococcal urethritis (GCU) or non-gonococcal urethritis (NGU). • NGU is associated with reactive arthritis. • GCU is usually abrupt in onset over 3-4 days, NGU can have a more insidious onset of symptoms. • History may include urethral discharge, dysuria, hematuria, urethral pruritis and painful intercourse in a sexually active male. Ask about arthritis/conjunctivitis and systemic symptoms.

9. Urethritis cont… • Exam may show an inflammed urethral meatus and/or urethral discharge. The urethra can be milked to try and express discharge. • Look for other STI lesions as well. • Work-up should include urethral swabs or urine for GC/chlamydia and screening for other STIs. • Treatment is a single IM dose of ceftriaxone and either a single oral dose of azythromicin or a one week course of oral doxycycline.

11. A 35 y.o. woman presents to ED with a vaginal pruritis and increased vaginal discharge. • What is the likely diagnosis? • What are 2 possible causes?

12. Vulvovaginitis • Inflammation of the vulva and vagina. Diagnosis is based on the presence of symptoms of a change in vaginal discharge and/or vulvovaginal discomfort. • Bacterial vaginosis resulting from a loss of normal vaginal lactobacilli is the cause in 40-50% of cases. • Candidiasis accounts for 20-25% and trichomoniasis accounts for 15-20%. • Chemical irritation and poor hygiene are also contributing factors.

13. Vulvovaginitis • Physical exam may show erythema and edema of the vulva and vagina, discharge that may be foul, thin and grey, white , yellow or green, and/or curd-like. Vaginal foreign bodies may be seen. • Work-up should include vaginal pH, and microscopy for wet mount and KOH testing. • Cultures/swabs for trichomonas, yeast, and STIs may be considered.

16. A 13 y.o. boy presents to ED with dysuria, urinary frequency, urgency, scrotal pain and swelling. • What is the most likely diagnosis? • What are 2 causes? • What do you need to rule out?

17. A 13 y.o. boy presents to ED with dysuria, urinary frequency, urgency, scrotal pain and swelling. • What is the most likely diagnosis? • What are 2 causes? • What do you need to rule out?

18. Epididymitis • Inflammation of the epididymis, most commonly caused by infection. • In sexually active men it’s usually from gonorrhea or chlamydia. In the non-sexually active population it’s most commonly caused by e.coli. • Most common cause of scrotal inflammation. • Need to rule out testicular torsion in any presentation of testicular pain. • Symptoms usually progress over 24 hours and can include scrotal pain, swelling, urinary frequency, urgency, dysuria, nausea, fever, chills, and discharge.

19. Epididymitis • Exam may show edematous tender epididimus, erythematous/edematous scrotum, may have scrotal abscess. May see urethral discharge. • Prehn sign= scrotal elevation relieves pain in epididimytis but not in torsion. But it’s not reliable. • Work-up may include urinalysis/culture, urine for GC and chlamydia, gram stain/culture of any discharge, ESR/CRP may help differentiate from torsion if it’s elevated. U/S may help distinguish from torsion. • Treatment is with antibiotics. Septra for non-sexually active patients, ceftriaxone and doxycycline for sexually active.

21. A 32 y.o. man presents to ED with fever, chills, dysuria, urinary frequency, urgency, hesitancy, and incomplete voiding. • What’s the likely diagnosis? • What is one possible physical exam finding? • What is one possible cause?

22. Bacterial Prostatitis • Inflammation of the prostate most commonly caused by sexually transmitted bacteria. • Symptoms can include fever, chills, malaise, arthralgias, myalgias, perineal pain, dysuria, urinary frequency, urgency, nocturia, hesitancy, incomplete voiding, weak stream, lower back and abdominal pain, and urethral discharge.

23. Bacterial Prostatitis • Exam may show a tender, nodular, hot, boggy, or normal prostate on DRE. May have suprapubic abdominal pain. • Potential causes include gonorrhea, chlamydia, trichomonas, e.coli, and other gram negative bacteria. • Urine culture may identify the causative agent. • Patients should be admitted if any systemic symptoms are present. Otherwise treatment can be a 2-4 week course of PO abx. Septra or floroquinolones are options but also need to treat for GC/chlamydia if they’re suspected.

26. Balanitis/Balanopsthitis • Inflammation of the glans of the penis, +/- foreskin inflammation. • Occurs in up to 3% of uncircumcised males. • History of penile discharge, inability to retract foreskin, tenderness and itching of glans. • Exam shows erythema/edema of glans/foreskin, discharge, ulcerations, phimosis.

27. Balanitis/Balanopsthitis • In adults most common underlying condition seen with it is diabetes. Can also be from poor hygiene, chemical irritants, etc. • Infectious causes include candida, HPV, gardnerella, syphilis, trichomonas, strep. • Work-up with culture of discharge, glucose check, wet mount, syphilis serology. • Treatment depends if it’s infectious and what the infectious agent is.

30. Herpes Simplex Virus • HSV is very common. Approximately 65% of the United States population is seropositive for HSV-1 by the fourth decade of life and 25% for HSV-2. • Primary infections can be asymptomatic or have symptoms of local pain, tingling, itching, and burning and then the development of the typical lesions which are vesicular or ulcerative on an erythematous base. • After primary infection the infection becomes latent in the sacral sensory ganglia. • The viruses become reactivated secondary to a wide variety of stimuli and secondary infection can occur.

31. Herpes Simplex Virus • Lesions coalesce and then heal over the next several weeks. Tender bilateral lymphadenopathy occurs with genital lesions. • Viral culture from skin vesicles can be done to help establish diagnosis. • A pregnant woman near term should be referred to obstetrics. • Antivirals can inhibit virus replication and suppress clinical manifestations but are not a cure. Rates of relapse are similar in treated and untreated patients. • Genital HSV should be treated with a 10 day course of oral acyclovir. • Patients should be advised to be abstinent when lesions are present and use condoms all the time.

34. Chancre • The characteristic lesion seen in primary syphilis. • Develops after an incubation period of 3-6 weeks. • Frequently solitary, may be multiple. Sometimes seen as "kissing" lesions on opposing skin surfaces, for example, the labia. • The lesion has a punched-out base and rolled edges and is highly infectious. It resolves 4-6 weeks after it forms and does not typically leave a scar.

37. Chancroid • Sexually transmitted infection caused by Haemophilusducreyi, characterized by painful ulcers, bubo formation (swelling of lymph nodes), and painful inguinal lymphadenopathy. • Uncommon in North America but much more common in Africa and part of Asia- take a travel hx. • Much more common in men than women. • Organisms enter through breaks in the skin on the genitals, and an erythematous papule forms, becoming a pustule in 2-3 days. • The pustule ulcerates in a matter of weeks, and lymphadenopathy also usually is seen. • Painful inguinal lymphadenopathy or bubo formation is present in 50% of patients.

38. Chancroid • Diagnosis is made clinically based on the patient having one or more painful ulcers (ulcers with painful adenopathy are pathognomonic) with no evidence of syphilis or herpes simplex virus. • For treatment, ulcers should be cleaned and buboes should have I & D. • Treatment is a single dose of PO azithromycin or a single dose of IM ceftriaxone. • Should test for HIV, syphilis, and other STIs.

41. Perianal Group A Strep • Perianal Group A Strep is one of the causes of vulvovaginitis, most commonly seen in children. • Usually results in a beefy red perineal area that is edematous and tender and has well defined margins. • Fissures, drainage, and hemorrhagic spotting may be present. • Diagnosis is made by bacterial culture of the area. • Treatment involves topical antibiotic treatment with mupirocin or erythromycin, or oral penicillin V.

43. What is the most common bacterial STI in North America, and what are 2 possible physical exam findings?

44. Chlamydia • Caused by Chlamydia trachomatis bacterium, has an overall prevalence of 5% in North America. • The incubation period is 1-3 weeks. Approximately 50% of infected males and 80% of infected females are asymptomatic, but infection may cause a mucopurulent cervicitis in females and urethritis in males. • Forty percent of women and 20% of men with chlamydial infection are co-infected with gonorrhea.

45. Chlamydia • On exam may find mucopurulent urethral discharge, rectal discharge, cervical/vaginal discharge, or epididymal tenderness/swelling. • Cervical motion tenderness, adnexal tenderness, and lower abdominal pain are also common. • Can test by doing nucleic acid amplification to detect chlamydial DNA either in urine or with a genital swab. • Should also test for pregnancy and other STIs. • Treatment is a single oral dose of azythromycin or 7 days of doxycycline. Consult gyne for severe PID or if patient is pregnant. • Contact partners for treatment as well. • Should also treat for co-infection with gonorrhea.

47. What is the second most common bacterial STI in North America and name 2 associated diseases?

48. Gonorrhea • Gonorrhea is a purulent infection of mucous membrane surfaces caused by a sexually transmitted microorganism, Neisseria gonorrhoeae. • Retrograde spread of the organisms occurs in as many as 20% of women with cervicitis, often resulting in PID. • Epididymitis or epididymo-orchitis may occur in men after gonococcal urethritis. • Disseminated gonococcal infection (DGI) occurs following approximately 1% of genital infections.

49. Gonorrhea • Most common symptoms in men are dysuria and urethral discharge. Women usually have vaginal discharge as main symptom. • On exam may find mucopurulent urethral discharge, rectal discharge, cervical/vaginal discharge or epididymal tenderness/swelling. • Cervical motion tenderness, adnexal tenderness, and lower abdominal pain are also common.

50. Gonorrhea • Can test with a culture of discharge or with nucleic acid amplification for DNA in urine or swabs of infected areas. • Should also test for syphilis and Chlamydia and look for signs of other STIs on exam. • Consult gyne for severe PID or pregnant women. • Treat with a single dose of PO cefixime or IM ceftriaxone. • Also treat for Chlamydia. • Partners need to be referred for treatment.