Sexually Transmitted Diseases David W. Haas, M.D. Division of Infectious Diseases Vanderbilt University School of Medicine Nashville, Tennessee

Case Presentation 19 YO male c/o burning on urination, yellow discharge on underwear. Has otherwise been well. –What are likely diagnoses? –What tests should be done? –What treatment may be needed? –Anything else to do?

Gonococcal Urethritis Incubation 1-10 days Can’t differentiate from chlamydia by symptoms Most infections are symptomatic May persist without continued symptoms

Acute Epididymitis Young men –Chlamydia (most common) –Gonococcus Old men –Gram (-) enterics –Pseudomonas

Localized Gonococcal Infections Anorectal infection –Culture often (+) in women with cervical GC –Treatment failures detected at rectum Pharyngeal infection –Orogenital exposure Pelvic inflammatory disease –Cervix doesn’t predict upper tract GC –20% risk of infertility Perihepatitis (Fitz-Hugh-Curtis syndrome)

Disseminated Gonococcal Infection Arthritis-dermatitis syndrome Septic arthritis Joint involvement Numberseveral1 or 2 SitesKnee, elbow, wrist, ankle CharacterTenosynovitisFrank arthritis Cells<20,000 WBC/mm 3 >50,000WBC/mm 3 CultureNegativeOften positive Papules/pustules5-40Absent Blood cultureOften positiveNegative

Diagnosis of Gonorrhea Culture –Rapidly inoculate media –Thayer-Martin, others DNA probes or DNA amplification –If used, culture unnecessary Gram stain –Gram (-) diplococci –Many leukocytes

Treatment of Uncomplicated Gonorrhea (urethra, cervix, pharynx, rectum) Ceftriaxone (125mg IM x 1 dose)OR Cefixime (400mg PO x 1 dose)OR Cefpodoxime (400mg PO x 1 dose)OR Ciprofloxacin (500mg PO x 1 dose)OR Gatifloxacin (400mg PO x 1 dose)OR Levofloxacin (250mg PO x 1 dose) + Azithromycin 1g po x 1 dose OR Doxycycline 100mg q12h po x 7 days

Treatment of Gonorrhea General Considerations Reculture all (+) sites at 4-7 days Consider reculture os rectal canal in women Examine and culture sexual contacts Treat sexual contacts regardless

Chlamydia trachomatis Genital Disease Urethritis in men –Isolated with 20% of GC cases –Isolated in 40% of NGU –Asymptomatic infection common Epididymitis Cervicitis Pelvic inflammatory disease –Infertility risk 10% –Perihepatitis

Diagnosing C. trachomatis Infection Gram stain –  4 WBC’s per oil-immersion field –No organisms seen Rapid methods –DNA probes or PCR Culture –Costly, not generally done

Case Presentation 19 YO male c/o burning on urination, yellow discharge on underwear. Has otherwise been well. –What are likely diagnoses? –What tests should be done? –What treatment may be needed? –Anything else to do?

Syphilis Stage Primary Secondary Latent Late Onset 3 weeks 2-8 weeks >8 weeks years

“Classic” Syphilitic Chancre Painless Raised borders No exudate At inoculation site Rarely seen by physician

Secondary Syphilis Rash –Variable, palms & soles Fever Diffuse lymphadenopathy Patchy alopecia Mucous patches Condyloma lata

Darkfield Examination for Syphilis 1.Abrade lesion with dry gauze 2.Obtain serous exudate 3.Place on slide with coverslip 4.View motile spirochetes Great for primary and secondary syphilis, not for oral lesions

Syphilis Serology PrimarySecondaryLate Nontreponemal tests (VDRL & RPR) 75%99% 1% (if treated) Specific treponemal tests (FTA-Abs, MHA-TP, TPHA) 75%100%95%

Who with Latent Syphilis Needs a Spinal Tap? Neurologic symptoms Failure of RPR to fall with therapy RPR  1:32 Inability to give penicillin If CSF abnormal, treat for neurosyphilis

Treating Syphilis Primary and Secondary –Benzathine PCN 2.4 million units IM x 1 –(Ceftriaxone 1g qd IV or IM x 8-10 d) –(Doxycycline 100mg q12h x 14 d) –Anticipate Jarisch-Herxheimer Latent (>1 year duration) –Benzathine PCN 2.4mil units IM weekly x 3 –(Doxycycline 100mg q12h x 28 d)

Treating Neurosyphilis –Pen G 2-4 million units IV q4h x d –(Procaine Pen G 2.4 mil units IM q24h + probenacid 500 mg PO qid x 14 days) –(Ceftriaxone 1g IV or IM qd x 14 d)

Genital Herpes - Initial Episode Painful vesicles or pustules which ulcerate Fever, headache, myalgias Tender inguinal adenopathy Extragenital vesicles common Pharyngitis, aseptic meningitis, urethritis occasional

Genital Herpes - Recurrent 90% recur in first year Average 5 per year initially Less severe than first episode Avoid sex until lesions heal

Diagnosing Genital Herpes Diagnosis often clinical Cytology (Tzank prep) shows –Scrape lesion –Spear to microscope slide –Stain with Pap or Wright-Giemsa –See multinucleated giant cells Culture –Swab lesion –To viral transport media –Cytopathic effect in 1-4 days

Treating Genital Herpes Initial –Acyclovir 400mg po q8h x 7-10 days –Valacyclovir 1g po q12h x 10 days –Famciclivir 250mg po q8h x 7-10 days Recurrent ( Often not treated) –Acyclovir 400mg q8h x 5 days –Valacyclovir 500mg po q12h x 3 days –Famciclivir 125mg po q12h x 5 days Chronic suppression –Acyclovir 400mg q12h –Valacyclovir 1g po q24h –Famciclivir 250mg po q12h

Sexually Transmitted Diseases