A Discussion About Sexually Transmitted Diseases

Case 1 A.J. is a 16y/o woman who presents to Teen Clinic w/ cc: low abdominal pain x2 days. She’s also experienced some burning with urination x4 days, tactile fevers x1 day. She thinks she may have had a little more vaginal d/c than usual recently. She can’t recall the number of sexual partners she’s had, but has been with a new partner for about 3 wks. She has had occasional unprotected sex.

Speculum exam reveals…

Chlamydia Most common STD  ~4 million cases /year in the US alone. Rates of Chlamydia are highest in adolescent women, and drop off steeply in the early 20’s. Risk factors: young age, black race, multiple sex partners, recent new partner, h/o STD, and low rate of barrier contraceptive usage. Usually asymptomatic in women, symptomatic in men.

Clinical Findings in Chlamydia Asymptomatic infection is common among both women and men. Cervicitis is the most common chlamydial syndrome  vaginal d/c, lower abdominal pain are most common sx. Dysuria may be present. PID can be the presenting sx. Signs: Mucopurulent cervical d/c, cervical friability/ edema. In men: if symptomatic, may present as urethritis, epididymitis or prostatitis. Signs: penile d/c, unilateral scrotal pain/edema.

Sequelae of Chlamydia Approximately 30% of women w/ chlamydia will develop PID if left untreated. Increased incidence of ectopic pregnancy after chlamydia infection PID due to CT has higher rates of subsequent infertility. Can develop perihepatitis (Fitzhugh-Curtis Syndrome)

Diagnosis of Chlamydia Historically – cell culture, DFA or ELISA Now Ligase Chain Rxn (LCR) is standard of care. Can be done on cervical swab or urine (less invasive). LCR: sensitivity = 90-95%, specificity = ~100%! CDC recommends annual chlamydia screening of all sexually active women <25 y/o, even if asymptomatic.

Treatment of Chlamydia Recommended Regimens: Azithromycin 1g po x1, or Doxycycline 100mg po BID x7 days. Alternative Regimens: Erythromycin base 500mg po QID X7days Erythromycin ethylsuccinate 800mg po QID x7days Ofloxacin 300mg po BID x7days Levofloxacin 500mg po qd x7days

Other Considerations If recommended regimen is used for treatment, no test-of-cure is necessary unless sx persist or reinfxn suspected or patient is pregnant. Patient’s sex partners must be treated if sexual contact within 60 days of sx.

Case 2 L.T. is a 37 y/o man who presents to your clinic with cc: right testicular pain x3 days. He also describes some whitish penile d/c since yesterday and mild burning w/ urination. No F/C/N/V or abdominal pain. L.T. is concerned re: new sexual partner who was “a little shady”, and wants to be tested for STDs.

Physical exam reveals…

Gonorrhea General Considerations Most affected women are asymptomatic, while most men are symptomatic. After exposure, 20-50% of men and 60-90% of women become infected. Without therapy, 10-17% of women develop pelvic inflammatory disease (PID). Approximately 10-30% patients infected with Gonorrhea are co-infected with Chlamydia.

Clinical Findings in Gonorrhea Women: If symptomatic  localized to lower genitourinary tract and include: Urinary frequency and dysuria Itching, burning or purulent d/c from vulva, vagina, cervix or urethera. Men: About 90% of men are symptomatic 82% purulent penile d/c, 53% dysuria Unilateral epididymitis, proctatitis possible. Disseminated infection possible – usually a triad of polyarthralgias, tenosynovitis and dermatitis.

Work Up of Gonorrhea Diagnosis Culture = “gold standard”. 65-85% sensitive in asymptomatic pts, 100% specific. Gram stain. Only 60% sensitive in symptomatic women, 100% sensitive in symptomatic men. LCR (urine or swab) 50-95% sensitive, 100% specific. High prevalence of co-infection with other STDs (esp. Chlamydia) important to do complete STD screen!

Treatment for Gonorrhea Recommended Regimen: Cefixime 400mg po x1 or, Ceftriaxone 125mg IM x1 or, Ciprofloxacin 500mg po x1 or, Ofloxacin 400mg po x1 or, Levofloxacin 250mg po x1 PLUS…for presumed co-infxn w/ chlamydia: Azithromycin 1g po x1 or, Doxycycline 100mg po BID x7 days

Other Considerations Gonorrhea is a reportable disease. Patient’s sex partners within 60 days of the onset of symptoms must also be treated, both for Gonorrhea and Chlamydia. According to the CDC, if uncomplicated gonorrhea is treated w/ recommended regimen, no test-of-cure is necessary.

Case 3 M.W. is a 18 y/o man who presents to Planned Parenthood w/ cc: “rash”. He seems quite anxious as he tells you about the painful lesion on his penis which started about 5 days ago. It began w/ burning pain, then small blisters appeared. He picked at a few of the blisters, and then the area began to erode into an ulcer-like lesion. It’s still quite painful and oozing sero-sanguinous fluid.

Doc, it really hurts a lot!

Genital Herpes Simplex Virus HSV is the most prevalent cause of genital ulcers. Genital HSV is a recurrent, life-long viral infection. About 85% of cases of genital HSV are due to HSV-2, however HSV-1 can also cause genital lesions. At least 50 million people in the US have genital HSV. Most pts infected w/ HSV-2 are asymptomatic, but shed virus intermittently.

Clinical Findings in Genital HSV Primary infxn – Usually more severe than secondary, but can also be asymptomatic. Prodromal sx of burning, itching, tingling Vesicular eruption follows, then erodes into painful ulcers in genital region. Bilateral inguinal adenopathy, fever and malaise can accompany severe infxns. Lesions persist for 2-6 weeks Secondary infxn – may be asymptomatic, or less severe presentation of above w/out systemic sx.

Diagnosis of HSV HSV cell culture of “fresh” lesion, preferably still in the vesicular state. Serology – type-specific serology, usually takes ~21 days to develop antibodies (sensitivity = 80-96%, specificity >96%). IgM suggestive of new infxn (1/2 life ~ 6wks). IgG suggestive of chronic infxn. PCR – Not yet widely available, but probably will become new standard (highly sensitive and specific).

Treatment of Genital HSV Primary Infxn: Acyclovir 400mg po TID x7-10 days, or Famciclovir 250mg TID x7-10 days, or Valacyclovir 1g BID x7-10 days. Topical lidocaine may be used for analgesia. Recurrent Infxn: episodic therapy (w/ each outbreak) Acyclovir 400mg po TID x5 days, or Famciclovir 125mg BID x5 days, or Valacyclovir 500mg BID x3-5 days. Suppressive Therapy: (Pts w/ >6 outbreaks/yr) Acyclovir 400mg BID (~$30/ 1 month supply) Famcyclovir 250 mg BID (~$200/ 1 month supply) Valacyclovir 1gm qd (~$100/ 1 month supply)

Other Considerations Genital HSV-2 has much higher recurrence rate than genital HSV-1, so serologic testing may be useful in tx. Approximately 50% of pts will have recurrence w/in 6 months of primary infxn. Suppressive Tx prolongs interval to recurrence, modestly reduces duration of viral shedding. Patient counseling is critical! Asymptomatic shedding Need to inform potential new partners Risks w/ pregnancy and delivery, etc… Development of an HSV-2 vaccine is underway.

Another painful ulcer…

Chancroid Endemic in several areas in the US, but occurs more frequently in Africa, West Indies and SE Asia. Usually sexually transmitted Incubation period is short: lesion usually appears w/in 3-5 days after exposure. ~10% of pts w/ chancroid are co-infected w/ HSV or syphilis.

Clinical Findings in Chancroid Lesion starts as erythematous papule, evolves into a pustule which then erodes into a painful ulcer. Infected pts many have more than 1 ulcer. Typical ulcer is 1 to 2cm in diameter, has erythematous base w/ clearly demarcated, raised borders. Inguinal lymphadenitis occurs ~50% of cases. Nodes my become fluctulant and drain pus.

Diagnosis of Chancroid Definitive Dx requires positive culture for H. ducreyi on special cx media that is not widely available. (Sensitivity only ~80%). Presumptive Dx via clinical criteria: Painful genital ulcers, +/- inguinal LAN. Negative for T. pallidum (syphilis) w/ darkfield exam or serology. HSV culture of lesion is negative. PCR test in development not yet widely available.

Treatment of Chancroid Successful treatment for chancroid cures the infection, resolves clinical sx and prevents transmission. Recommended Regimen: Azithromycin 1g po x1, or Ceftriaxone 250mg IM x1, or Ciprofloxacin 500mg po BID x3 days, or Erythromycin 500mg TID x 7 days. Sex partners must be tx’d regardless of sx if sexual contact w/in 10 days prior to sx onset. Chancroid is a reportable disease.

What about a painless genital ulcer?

Syphilis Systemic disease caused by Treponema Pallidum. “Mini-epidemic” in the 1980’s to early 90’s w/ 20.3 cases per 100,000 population. Incidence declining w/ 2.2 cases per 100,000 population in 2000. Highest US incidence in southeast. Black:Caucasian incidence ~30:1.

Clinical Findings in Syphilis Primary Infxn: painless ulcer at the site of infection. Secondary Infxn (relapsing episodes are possible for up to 5 yrs after primary): skin rash (symmetric eruption of trunk, extremities including palms and soles) Mucocutaneous ulcer-like lesions Systemic rubbery/painless lymphadenopathy Wide array of neurologic abnormalities

Clinical Findings, continued Latent Syphilis: period during which serology is positive, but patients lack clinical manifestations. Tertiary Syphilis: Advanced infection presenting w/ cardiac, ophthalmic, auditory abnormalities, gummatous lesions, advanced neurologic manifestations.

Diagnosis of Syphilis The chancre of primary syphilis is best diagnosed w/ darkfield microscopy. Secondary or latent phase are best diagnosed with serology: Nontreponemal tests: VDRL and RPR Many causes of false positive Become non-reactive 2-3 yr after treatment. Treponemal tests: FTA-abs and TP-pa More specific than non-treponemal tests. Generally remain reactive for life.

Treatment of Syphilis Primary & Secondary: Early Latent: Benzathine penicillin G 2.4 million U. IM x1 Doxycycline 100mg po BID x14 days, or Tetracycline 500mg po QID x14 days. Early Latent: Benzathine penicillin G 2.4 million U IM x1 Late Latent and Tertiary: Benzathine penicillin G 2. million U IM x3 q weekly interval.

Doctor, I’ve got these bumps…

Genital Human Papilloma Virus Condyloma acuminatum (anogenital warts) Diagnosis is clinical Treatment is cryothearpy w/ liquid nitrogen, Condoylox 0.5% soln. BID x3d q 4d x4,or Aldara 5% cream qod x<4months. Cervical HPV Screening via regular Pap smears. Diagnosis via Pap smear, HPV serotyping, colposcopy w/ or s/ biopsy. Treatment: cryotherapy, surgical excision, curretage, or electrosurgery.

Hepatitis B Estimated that there are 300 milion HBV carriers in the world, 1.25 million in the US Sexual transmission is the most common mechanism of transmission  accounts for >50% new cases in the US. Percutaneous transmission (IVDU, tatoos, accupuncture, sharing razors/toothbrush) Incubation time is 6 wks to 6 mos after exposure.

Diagnosis & Treatment of HBV Diagnosis is via serology. Treatment/Prevention: Postexposure tx w/ HBIG, plus vaccination with HBV vaccine w/in 14 days after exposure Vaccination of all household members. Vaccination of all high risk individuals (eg. healthcare workers, IVD users, pts w/ hx of STD, pts who have sex w/ IVD users, men who have sex w/ men.

Human Immunodeficiency Virus Overview Risk factors include unprotected sex multiple sexual partners, hx of other STDs, men who have sex w/ men, pts who have sex w/ IVD users, IVD use, perinatal exposure to infected mom. Progression of disease varies. From exposure to development of AIDS – few months to 17 yrs (median=10yrs)

Testing for HIV Should be offered to all pts presenting for evaluation of STD, as wellas to all pts with risk factors. Informed consent required prior to testing. Both pre-test and post-test counseling is an integral part of testing procedure. Tests: ELISA as screening. Western Blot or immunofluorescent assay (IFA) as confirmatory tests.

References Centers for Disease Control: Morbidity & Mortality Weekly Report. “Sexually Transmitted Diseases Treatment Guidelines 2002”. 10 May 2002, Vol. 51, No. RR-6. DeCherney, Pernoll. Current: Obstetric & Gynecologic Diagnosis & Treatment. 8th Ed. (McGraw Hill, Lange: New York). www.uptodate.com database topics related to sexually transmitted diseases. Primary Care Medicine: Office Evaluation and Management of the Adult Patient, 3rd Ed. Goroll, May & Mulley. Lippincot-Raven:New York, 1995. Tierney, McPhee, Papadakis. Current: Medical Diagnosis & Treatment, 40th Ed. (McGraw Hill, Lange:New York, 2001) http://www.cdc.gov/nchstp/dstd/dstdp.html www.aafp.org