1. 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.

2. 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

3. 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.

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

5. 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.

6. 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.

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

8. 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

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

10. Syphilis

11. 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

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

13. 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)

14. 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

15. 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

16. 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 ????

17. 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 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

18. Herpes Simplex

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

20. 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

21. 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

22. Chancroid

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

24. 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

25. Lymphogranuloma Venereum

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

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

28. Granuloma Inguinale (Donovanosis)

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

30. 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

31. The other STI’s

32. Neisseria gonorrhea

33. 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

34. 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

35. Chlamydia trachomatis

36. 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)

37. Non-gonococcal urethritis

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

39. 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)

40. Human papilloma virus

41. 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

42. HPV
Not usually transmitted from mother to newborn

43. Ectoparasites

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

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

46. Scabies
Norwegian Scabies
aggressive
HIV
Treat with
ivermectin