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

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. CAN PRESENT IN OTHER WAYS TOO

12. 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

13. 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

14. 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

15. 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

16. Chancre Treponema pallidum

17. Chancroid H.ducreyi

18. Vesicles Herpes simplex

19. Vesicles Herpes simplex

20. Syphilis-master of disguises

21. IRREGULAR ULCER WARTY GROWTH

22. 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

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

24. NOT EVERYONE USES THE FRONT DOOR

25. MAJOR STD SYNDROME TWO-URETHRAL DISCHARGE

26. DISCHARGE WATERCAN PERINEUM

27. ULCER WITH DISCHARGE

28. Chlamydia salpingitis
CHEESE BURGER? NO CHLAMYDIA TRACHOMATIS D-K

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

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

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

34. Candida albicans- budding yeasts with pseudohyphae

35. 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

37. 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

38. Differential Diagnosis of Vaginal Infections
Diagnostic Criteria
Normal
Bacterial Vaginosis
Vaginitis Trichomonas
Candida Vulvovaginitis
Vaginal pH
> 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

39. 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)

40. 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

41. OK-RARE PIC OF FEMALE WITH BUBO

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

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

44. Conjunctivitis (Chlamydia trachomatis TRIC)
TRACHOMA INCLUSION CONJUNCTIVITIS

46. Which the commonest STD?

47. WE VERY OFTEN UNDERESTIMATE THE BEST PEOPLE

48. 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

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

50. Antigenic structure

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

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

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

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

56. *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

59. HIV MARKERS

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

62. DEFINITELY NOT THE END