Question 1 A 70yo F presents for evaluation of positive serologies for syphilis and progressive memory difficulty. She began having problems with leaving the stove on, so her daughter brought her in to be evaluated. She has a normal physical exam. Here Trepia is positive and her RPR is 1:4.

Question 1 What is the next appropriate step in evaluating this patient? Repeat RPR in 6mo Treat with IM penicillin Treat with IV penicillin CSF exam with LP

Question 2 A 22yo M presents with penile discharge. He has had the discharge for 2d and had some burning with urination the day before. The discharge is thick and yellow. He is sexually active with women. He has no other symptoms and his past medical history is unremarkable. He has no allergies to medications.

Question 2 Which is the most appropriate treatment? Ceftriaxone and azithromycin Doxycycline Ciprofloxacin Ceftriaxone

Question 3 A 25yo male presents for evaluation of a rash on his penis. He notices small bumps for the past few months but they have gotten larger and he is worried about them getting worse and heard they can cause cancer. The rash is shown below.

Question 3 You diagnose him with genital warts Question 3 You diagnose him with genital warts. What is the best recommendation for this patient? He can have these removed by a dermatologist without risk of recurrence. He doesn’t need the HPV vaccine because he is male. He doesn’t need the HPV vaccine because the serotypes of genital warts are not high risk. He should get the HPV vaccine.

Sexually Transmitted Infections Board Review February 3, 2018 Kelli Williams, MD Division of Infectious Diseases University of Cincinnati

Overview Ones you can see (ulcerative) Ones you can’t (other) Syphilis HSV Chancroid Lymphogranuloma venereum Granuloma Inguinale Ones you can’t (other) Gonorrhea Chlamydia NGU HPV Ectoparasites

Pain and Genital Ulcer Disease Which ulcers are painful? HSV Chancroid Which ulcers are painless? Syphilis Lymphogranuloma venereum (but lymphadenopathy is painful) Granuloma Inguinale

Syphilis

Primary Syphilis (Early) Treponema pallidum Painless ulcer at site of exposure - 3wk incubation - heaped up borders - clean base - resolves in 3-6wk May have negative testing

Secondary Syphilis (Early) Diffuse rash Palms and soles Associated LAD, fever, malaise, sore throat Alopecia Uveitis, hearing loss

Neurologic Complications Can occur during any stage Can be either asymptomatic or symptomatic Symptomatic early neurosyphilis Occurs within the first year after infection Mainly among HIV + persons Presents as meningitis Symptomatic late neurosyphilis (tertiary)

Tertiary Syphilis (Late Neurosyphilis) Neurovascular (>10yrs after infection) Tabes Dorsalis Shooting pains, lancinating, ataxia, CN abnormalities General Paresis dementia, psychosis, Argyl Robertson pupil Gummas CV Aorta myocarditis

Latent Syphilis (Early, Late, Unknown) Asymptomatic Treatment based on stage: Early stages: LA-benzathine PCN 2.4mu IM once Doxycycline 100mg po bid x14days Late or Unknown: LA-benzathine PCN 2.4mu IM qwk x3 Doxycycline 100mg po bid x 28days

Testing Non-treponemal tests: RPR or VDRL Screening test False positive: age pregnancy autoimmune viral infections Positive result must be confirmed with treponemal test False negative: Prozone effect Too early in infection May decline over time Used for monitoring response to therapy: Four-fold decline after treatment Treponemal tests: MHA-TP, TPPA, FTA-Abs, EIAs, CIA Confirmatory test Will remain positive for life False positive: other treponemal infections (yaws) Lyme disease Darkfield 70% sensitive CSF tests 50% sensitive (highly specific) +Trepia/ - RPR/ + FTA ????

Treatment Early: (primary, secondary, or early latent) LA-benzathine PCN 2.4mu IM once Doxycycline 100mg po bid x14days Late latent or Unknown: LA-benzathine PCN 2.4mu IM qwk x3 Doxycycline 100mg po bid x 28days Neurosyphilis: PenG 3-4mu q4hrx 10-14 days Pregnant patients must be treated with penicillin Jarisch- Herxheimer reaction may occur within 6hrs of therapy; symptoms may include fevers, chills, and hypotension, treat with antipyretics only

Herpes Simplex

HSV HSV 1 and 2 can cause genital lesions Multiple painful superficial blisters/vesicles with erythematous base

Testing Tzanck smear: Culture Antigen detection PCR 40% sensitive Culture 30-80% sensitive Antigen detection ~70% sensitive PCR >90% sensitive Serologic tests not routinely used

Vertical Transmission Vertical transmission is based on primary vs recurrent infection at time of delivery Primary infection: up to 50% Recurrent infection: <1% Route of delivery depends on presence of lesions at time of delivery Acyclovir is sometimes used in mothers with history of HSV

Chancroid

Chancroid More common in southern US Caused by Hemophilus ducreyi Ulcer is painful, indurated, ragged (kissing lesions) Associated suppurative inguinal LAD

Chancroid Diagnosis: Treatment: Culture azithromycin 1 gram once ceftriaxone 250 mg IM x 1 erythromycin and ciprofloxacin Treat all partners in the preceding 60 days

Lymphogranuloma Venereum

Lymphogranuloma Venereum Chlamydia trachomatous L1-3 Short lived, painless ulcer associated with painful LAD; “groove sign” Can cause proctitis in MSM

Lymphogranuloma Venereum Diagnosis: NAATs do not distinguish serotypes Serology not definitive Therapy: doxycycline x21days Azithromycin 1 g po q week x 3 weeks

Granuloma Inguinale (Donovanosis)

Granuloma Inguinale Painless serpiginous ulcer red with white border Can progress and be destructive

Granuloma Inguinale Not common in US, found in SE Asia, Australia, Southern Africa Caused by Klebsiella granulomatis Diagnosis: biopsy Treatment: doxycycline x21days Azithromycin 1 g po qweek x 3 T/S and ciprofloxacin

The other STI’s

Neisseria gonorrhea

Neisseria gonorrhea Can cause urethritis, cervicitis, vaginitis, PID, rectal disease, pharyngitis Diagnosis: NAAT, cx Test of cure (2wk) particularly if using a 2nd line agent Treatment: Ceftriaxone + azithro/doxycycline Azithromycin Resistance FQ Oral cephalosporins

Neisseria gonorrhea Disseminated Gonococcal Infection Skin lesions Arthralgias Tenosynovitis Septic arthritis (usually monoarticular) Fitzhugh-Curtis Syndrome: perihepatitis RF: Terminal complement deficiency Most cases of pharyngeal and rectal gonococcal infections are ASYMPTOMATIC

Chlamydia trachomatis

Chlamydia trachomatis Serotypes D-K cause urethritis/ cervicitis/ vaginitis/ PID/ proctitis Can be asymptomatic as well routine screening Already discussed serotypes L1-3 cause LGV Diagnosis: NAAT Treatment: Azithromycin once Doxycycline x7d Associated with Reactive Arthritis (urethritis, conjunctivitis, arthritis, skin lesions)

Non-gonococcal urethritis

Non-gonococcal urethritis (besides CT) Etiologies: Mycoplasma genitalium Trichomonas vaginalis HSV, adenovirus ? Ureaplasma urealyticum and U. parvum Treatment: Azithromcyin or doxycyline

Trichomonas vaginalis Symptomatology: Women: vaginitis, urethritis or cystitis Has been associated with cervical neoplasia, atypical PID, cuff cellulitis, infertility, preterm birth and PROM Increased susceptibility to HIV infection Men: prostatitis, balanoposthitis, epididymitis May be related to infertility and prostate cancer Newborns: fever, respiratory problems, urinary tract infection, nasal discharge, and, in girls, vaginal discharge Diagnosis: wet mount, cx, NAAT Treatment: Metronidazole or tinidazole Unclear if treatment in asymptomatic pregnant women improves above outcomes (so not routine to test)

Human papilloma virus

HPV High risk (types16, 18) and low-risk types 16 & 18 cause ~70% of cervical cancers Low-risk types lead to genital warts Vaccine recommended for women (girls) 9-26yo and men (boys) from 11-26yo Treatment: meant to alleviate pain/bleeding associated with warts or psychological effects Cryodestructive therapy Immune-mediated therapy Surgery

HPV Not usually transmitted from mother to newborn

Ectoparasites

Pubic Lice Pthirus pubis= crabs Treatment: Permethrin topical Ivermectin Treat partners

Scabies Sarcoptes scabei Symptoms: Diagnosis: Treatment: Severe itching at night Diagnosis: Visualization of burrows Treatment: Permethrin Ivermectin Lindane

Scabies Norwegian Scabies aggressive HIV Treat with ivermectin