Sexually transmissible infections-clinical correlation-pop up version STI/STD AFFECTS MORE THAN JUST GENITALS Dr. P. K. Rajesh Clinical Microbiologist, April 2013

KNOW THE CORRECT FULL SPELLING, NO SHORT FORMS Learning outcomes At the end of these TWO lectures, the student should be able to name organisms causing STD and classify them into bacteria, virus, fungi, protozoa discuss the clinical syndromes commonly associated with STD explain the diagnostic protocol to be adopted depending on the presentation of the case interpret data scientifically and rationally act in a mature manner when anybody approaches them for counseling regarding STI or STD KNOW THE CORRECT FULL SPELLING, NO SHORT FORMS SAMPLE COLLECTION MICROSCOPY CULTURE MOLECULAR SEROLOGY ANTIGEN DETECTION

Sexually transmissible… STI is an infectious agent spread from person-to-person through 1) direct body contact 2) contact with infected body fluids; any disease acquired primarily through sexual contact is termed STD Today there are over 20 recognized STD

STD's are mostly CAUSED BY Bacteria gonorrhea, syphilis, chancroid, bacterial vaginosis, donovanosis (PID)- Mycoplasma, Chlamydia, LGV Virus genital herpes, molluscum contagiosum, (HPV - genital warts) (HIV/AIDS); hepatitis B,C. Fungi- candidiasis (thrush) Protozoa -trichomoniasis Insects-scabies, pediculosis pubis (Note all the above are disease names and not the agents name) PELVIC INFLAMMATORY DISEASE IF YOU ARE PLANNING TO BE A DOC DON’T IGNORE THIS SLIDE

The next three slides….. Contains an exhaustive list of organisms, recognized as being transmissible sexually. You do not have to “mug this up” The idea of showing this is to make you think of all possibilities when you deal with such a case. Concentrate on the organisms in bold IF YOU HAVE CUT THIS CLASS AND ARE PLANNING TO MUG MY PPT LATER-PLEASE MUG THIS UP

Disease Organism(s) Acquired Immunodeficiency Syndrome Human immunodeficiency virus (HIV-1 and HIV-2) Bacterial vaginosis Bacteroides spp. Gardnerella vaginalis Mobiluncus spp. Mycoplasma hominis Ureaplasma urealyticum Chancroid Haemophilus ducreyi Chlamydial infections Chlamydia trachomatis Enteric infections Various Gram negative bacteria, Campylobacter fetus, Shigellasp., Escherichia coli, Salmonella sp. Amebiasis Entamoeba histolytica (protozoan) Giardiasis Giardia lamblia (protozoan)

Genital herpes Herpes simplex virus Genital (venereal) warts Venereal warts or condyloma acuminata Human papillomavirus Gonorrhea Neisseria gonorrhoeae donovanosis Calymmatobacterium granulomatis Group B streptococcal infections Streptococcus agalactiae Leukemia/Lymphoma/Myelopathy  HTLV-I and II Lymphogranuloma venereum (LGV***) Chlamydia trachomatis Molluscum contagiosum Molluscum contagiosum virus

NGU or Nongonococcal urethritis* Chlamydia trachomatis, Gardnerella vaginalis, Ureaplasma urealyticum Pelvic Inflammatory Disease (PID)** N. gonorrhoeae- most common , Chlamydia trachomatis- most common,  Anaerobic bacteria (ex. Bacteroides), Facultative Gram negative rods (ex. Escherichia coli), Mycoplasma hominis, Actinomyces israelii Pubic lice, Pediculosis Pediculus humanus and Phthirius pubic Scabies Sarcoptes scabiei var. hominis Syphilis Treponema pallidum Trichomoniasis Trichomonas vaginalis Vaginal yeast infections, Mycotic vulvovaginitis  Candida albicans Viral hepatitis Hepatitis A,B, C, D

Common Pathogen Parade Virus Human immunodeficiency virus Hepatitis A,B, C, D Herpes simplex virus Human papillomavirus Bacteria Chlamydia trachomatis (ATYPICAL BACTERIA) Haemophilus ducreyi (GRAM NEGATIVE COCCOBACILLI) Treponema pallidum (SPIROCHETE) Neisseria gonorrhoeae (GRAM NEGATIVE COCCI) Fungi-Candida albicans Protozoa-Entamoeba histolytica Trichomonas vaginalis REMINDER ALL THESE ORGANISMS HAVE BEEN DEALT WITH BEFORE

Ok docs! plz note STD syndromes Major Ulcer Discharge Painful lymph nodes Minor Abdominal pain Rash THESE WILL BE THE COMMON SYMPTOMS A PERSON WITH STD PRESENTS WITH

CAN PRESENT IN OTHER WAYS TOO

The National Survey on Drug Use and Health (NSDUH), 2005 STD AGE DISTRIBUTION FAD SAD BAD MAD The National Survey on Drug Use and Health (NSDUH), 2005

DON’T DRINK AND ‘DRIVE’ SCREWDRIVER IS A POPULAR COCKTAIL ALCOHOL INCREASES DESIRE BUT REDUCES PERFORMANCE The National Survey on Drug Use and Health (NSDUH), 2005

The National Survey on Drug Use and Health (NSDUH), 2005 ETHNIC DISTRIBUTION ASIANS SURE KNOW HOW TO KEEP SECRETS! DON’T WE? The National Survey on Drug Use and Health (NSDUH), 2005

Uniform size clean base Tender inguinal nodes Std with ulcer Ranking lesion Tenderness Ulcer Lymph node HSV Most common vesicle Tender Uniform size clean base Tender inguinal nodes Syphilis Less common than HSV. chancre Nil Clean base indurated border Rubbery, mildly tender Chancroid Soft sore Painful large, ragged necrotic base, undermined edge Very tender, fluctuant inguinal nodes LGV Donovanosis Rare Bubo Different Clears Progressive indolent Fluctuant inguinal nodes Insignificant THINK OF THESE ORGANISMS IF A PERSON PRESENTS WITH GENITAL ULCER

Chancre Treponema pallidum

Chancroid H.ducreyi

Vesicles Herpes simplex

Vesicles Herpes simplex

Syphilis-master of disguises

IRREGULAR ULCER WARTY GROWTH

REPEAT-THINK OF THESE IF A PERSON PRESENTS WITH ULCER The ulcer flow chart Genital sore or ulcer vesicles- genital herpes (HSV) Painless indurated chancre- syphilis (T.p) Painful soft sore-chancroid (H.d) Key-HSV-Herpes simplex virus T.p- Treponema pallidum H.d- Haemophilus ducreyi REPEAT-THINK OF THESE IF A PERSON PRESENTS WITH ULCER

Amputating ulcer-due to? Entamoeba histolytica- man! Who is the other man?

NOT EVERYONE USES THE FRONT DOOR

MAJOR STD SYNDROME TWO-URETHRAL DISCHARGE

DISCHARGE WATERCAN PERINEUM

ULCER WITH DISCHARGE

Chlamydia salpingitis CHEESE BURGER? NO CHLAMYDIA TRACHOMATIS D-K

Interpret this Gram stain GRAM STAIN OF DISCHARGE-SHOWS INTRACELLULAR DIPLOCOCCI NORMAL BACTERIAL FLORA-EXPECTED IN VAGINA

Gram positive bacilli- any clue? Or is it safety pin shaped

CURDY/CHEESY DISCHARGE-COULD BE CANDIDA-YOU WOULD SEE BUDDING YEASTS ON MICROSCOPY Say cheese- Candida albicans- BUDDING YEASTS

Candida albicans- budding yeasts with pseudohyphae

FROTHY DISCHARGE-TRICHOMONAS YOU CAN SEE ‘FALLING LEAF’ PROTOZOA ON WET MOUNT MICROSCOPY IN THE LOG BOOK OR OSPE DON’T ANSWER “ FOUL SMELLING’’ AS WE ARENT GIVING YOU THIS TO SMELL Frothy foul smelling- Trichomonas vaginalis

The discharge flow chart With ulcer?-use ulcer chart No ulcer-gonorrhea, chlamydia ( abd pain-PID) No ulcer, no abdominal pain trichomoniasis,candidiasis THINK OF THESE IF A PERSON PRESENTS WITH URETHRAL DISCHARGE

Differential Diagnosis of Vaginal Infections Diagnostic Criteria Normal Bacterial Vaginosis Vaginitis Trichomonas Candida Vulvovaginitis Vaginal pH 3.8 - 4.2 > 4.5 4.5 < 4.5 (usually) Discharge White,thin, flocculent WHITE, MILKY FROTHY FOUL SMELLING White, curdy, "cottage cheese"  Microscopic Lactobacilli, epithelial cells Clue cells,adherent cocci, no WBC's Trichomonads, WBC's >10/hpf  Budding yeast, hyphae, pseudohypha

The bubo flow chart Enlarged and or painful genital lymph node ? With ulcer-ulcer flow chart No ulcer-Lymphogranuloma venereum. (Chlamydia trachomatis L1,L2,L3)

Lymph nodes- ? LGV- see BUBO flow chart WHY ALL MALE PICS? BCOS MALES ARE SYMPTOMATIC-FEMALES ARE MOSTLY ASYMPTOMATIC EVEN WITH A CHEESE BURGER FALLOPIAN TUBE

OK-RARE PIC OF FEMALE WITH BUBO

LET THERE BE PAIN-HE SHOULDN’T THINK OF “IT” AGAIN

The scrotal pain flow chart Painful scrotum No history of injury, No retraction/rotation Genital chlamydia (Chlamydia trachomatis D-K)

Conjunctivitis (Chlamydia trachomatis TRIC) TRACHOMA INCLUSION CONJUNCTIVITIS

Which the commonest STD?

WE VERY OFTEN UNDERESTIMATE THE BEST PEOPLE

HIV NOTES TO REVISE JUST TO MAKE YOU UNDERSTAND THAT HIV CAN BE ASKED AS A QUESTION IN YEARS 1,2,3,4,5…….100 OF YOUR MEDICAL LIFE….THANKS

HIV LENTI-RETRO VIRUS RNA,ICOSAHEDRAL ENVELOPED HIV-1,HIV-2 HIV-1 (M,O,N) M-A to K ( Clades)

Antigenic structure

Mode of Spread SEXUAL (Hetero/Homosexual) BLOOD TRANSFUSION VERTICAL (transplacental) (delivery) OCCUPATIONAL (needle stick) (mucosal splashes) SYRINGES/NEEDLES

Pathogenesis RECEPTORS CD4CELLS/MACROPHAGES RNA ENTRY REVERSE TRANSCRIPTASE HOST GENOME BUDS OUT INFECTS OTHER CELLS CD4 COUNTS DROPS

Clinical staging 1)ASYMPTOMATIC (window period) 2)SEROCONVERSION (minor illness) 3)PGL 4)OPPURTUNISTIC CD4 less than 200/Ul Bacterial/Fungal/Parasitic Viral infections

Lab Diagnosis SCREENING ELISA-for Antibodies (ab) CONFIRMATORY Western Blot- (ab) P24 antigen- (ag) PCR/Viral load ACADEMIC Viral culture Resistance

*ELISA can detect antigen and or antibody Myth-ELISA can detect only HIV Truth-ELISA can be used to diagnose any infectious disease* *ELISA can detect antigen and or antibody

HIV MARKERS

A,B,C of HIV prevention Abstinence (wait) Being faithful (spouse/partner) Condom Correct,counselling commonsense

DEFINITELY NOT THE END