1. Gonorrhea, trichomoniasis, chlamidiosis, candidal and mycotic affection of the skin.
Lector: Shkilna M.

2. CONTENT Signs and Symptoms of Gonorrhea.
Microbiology/Pathology of Neisseria gonorrhea.
Signs and Symptoms of Gonorrhea.
Complications of gonococci infection .
Disseminated Gonococci Infection.
Diagnosis and treatment of Gonococci Infection.
Chlamydia Infections in Women, Men, and Neonates.
Signs and Symptoms of Chlamydia.
Diagnosis and treatment of Chlamydia.
Signs and Symptoms of Trichomoniasis.
Diagnosis and treatment of Trichomoniasis.

3. What is gonorrhea?
Gonorrhea is a very common sexually transmitted disease, caused by a bacteria that easily grows and multiplies in warm, moist areas of the reproductive tract such as the cervix, the uterus, the fallopian tubes, and the urethra. This bacterium can also grow in the mouth, throat, eyes, and anus.

4. Infection
Gonorrhea is spread through contact with the penis, vagina, mouth, or anus.
Ejaculation does not have to occur for infection to occur.
Gonorrhea can also be spread from mother to baby during delivery. This may cause blindness, joint infection, or a life-threatening blood infection in the baby.
People who have had
gonorrhea and were
treated may become
infected again .

5. Microbiology/Pathology
Etiologic agent: Neisseria gonorrhoeae .
Was discovered in 1879 by A. Neisser in suppurative discharges. In 1885 E. Bumm isolated a pure culture of the organism and studied it in detail.
Gram-negative intracellular diplococcus.
Infects mucus-secreting epithelial cells.
Evades host response through alteration of surface structures. 5

6. Gonorrhea: Gram Stain of Urethral Discharge
On Gram stained slides, in gonococcal infection, the following are seen:
Polymorphs.
Gram-negative kidney-shaped extracellular and intracellular diplococci (ICDC). 6

7. Gram stain of urethral discharge showing gram negative, intracellular diplococci.

8. Incubation Period -1-14 days.
Gonorrhea
Incubation Period days.
Men have a 20% risk of getting the infection from a single act of vaginal intercourse with a woman infected with gonorrhea. The risk for men who have sex with men (MSM) is higher.
Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with a man infected with gonorrhea.
An infected mother may transmit gonorrhea to her newborn during childbirth, a condition known as ophthalmia neonatorum

9. Signs and Symptoms For men: Many men experience no symptoms
Burning while urinating
White, yellow, or green
discharge from penis
Painful or swollen testicles
Many men experience no symptoms
Some have symptoms 2-5 days after infection, but they can take up to 30 days to appear

10. Signs and Symptoms For women: Pain or burning while urinating
Increased vaginal discharge
Irregular bleeding
Symptoms are often mild, but most women have no symptoms at all
Even when symptoms do occur, they are often mistaken for a bladder or vaginal infection

11. Gonococcal Bartholinitis
Tender swollen Bartholin’s gland with purulent discharge
Infection at other sites common

12. Bartholin’s Abscess Painful swollen Bartholin’s glands
Fluctuant, tender
May have expressible purulent discharge

13. Complications of gonococcal infection in males :
Chronic complications:
Urethral stricture.
Infertility.
Acute complications:
Infection of the glands .
Ascending infection (prostatitis, cystitis, epididyrnitis).
Infection of adjoining structures (periurethral abscess and infection of median raphe).

14. Complications in Women
Accessory gland infection
Bartholin’s glands
Skene’s glands
Pelvic Inflammatory Disease (PID)
May be asymptomatic
May present with lower abdominal pain, discharge, irregular menstrual bleeding and fever
Fitz-Hugh-Curtis Syndrome
Perihepatitis

15. DISSEMINATED GONORRHEA CLINICAL PRESENTATION

16. Gonococcal Ophthalmia in the Adult
Marked chemosis and tearing
Typically purulent discharge, erythema

17. Gonococcal Ophthalmia in the Adult
Conjunctival erythema and discharge

18. Disseminated Gonococcal Infection
Gonococcal bacteremia
Sources of infection include symptomatic and asymptomatic infections of pharynx, urethra, cervix
Occurs in < 5% of GC-infected patients
More common in females

19. DGI Clinical Manifestations
“Dermatitis-arthritis syndrome”
Arthritis: 90%
Characterized by fever, chills, skin lesions, arthralgias, tenosynovitis
Less commonly, hepatitis, myocarditis, endocarditis, meningitis
Rash characterized as macular or papular, pustular, hemorrhagic or necrotic, mostly on distal extremities

20. DGI Skin Lesion
Necrotic, grayish central lesion on erythematous base

21. DGI Skin Lesion
Papular and pustular lesions on the foot

22. DGI Skin Lesion
Small painful midpalmar lesion on an erythematous base

23. DGI Skin Lesion
Pustular erythematous lesions

24. DGI Differential Diagnosis
Meningococcemia
Staphylococcal sepsis or endocarditis
Other bacterial septicemias
Acute HIV infection
Thrombocytopenia & arthritis
Hepatitis B prodrome
Reiter’s Syndrome
Juvenile Rheumatoid Arthritis
Lyme disease

25. Gonococcal Complications in Pregnancy
Postpartum endometritis
Septic abortions
Post-abortal PID
Possible role in:
Gestational bleeding
Preterm labor and delivery
Premature rupture of membranes

26. Gonococcal Ophthalmia Neonatorum
Lid edema, erythema and marked purulent discharge
Preventable with ophthalmic ointment

27. Diagnosis
A doctor or a nurse can obtain a sample from parts of the body likely to be infected, such as the cervix, urethra, rectum, or throat, and send it to a lab for analysis.
Gonorrhea present in the cervix or urethra can be diagnosed through a urine sample.
A Gram stain is a quick lab test that can be done in a clinic or doctor’s office. This test allows the doctor to see the gonorrhea bacterium under a microscope and can be done for men and women.

28. GC Culture Specimen Streaking Cervical and Urethral

29. GC Culture After 24 Hours

30. Treatment Several antibiotics can successfully cure gonorrhea
However, drug-resistant strains of gonorrhea are increasing in many areas of the world, including the United States.
Successful treatment is becoming more difficult.
Because many people with gonorrhea also have Chlamydia, antibiotics for both infections are usually given together.
In women, gonorrhea is a common cause of pelvic inflammatory disease (PID).

31. Chlamydia

32. What is Chlamydia?
Chlamydia, which is caused by the bacterium Chlamydia trachomatis, is the most frequently reported sexually transmitted disease in the United States.
Chlamydia is known as a “silent disease” because about ¾ of infected women and ½ of infected men have no symptoms.
Chlamydia can damage a woman’s reproductive organs. Serious complications that cause irreversible damage, such as infertility, can occur before a woman ever recognizes a problem and before any symptoms occur.

33. Infection
Chlamydia can be transmitted during vaginal, anal, or oral sex.
Women are frequently re-infected if their sex partners are not treated
Chlamydia can also be passed from an infected mother to her baby during vaginal childbirth. Untreated chlamydia can lead to premature childbirth, and chlamydial infections of the eyes and respiratory tracts. Also, chlamydia is the leading cause of early infant pneumonia and conjunctivitis (pink eye) in newborns.
People who have had chlamydia and were treated may become infected again.

34. Chlamydia Infections in Women, Men, and Neonates
Genitals
Cervicitis
PID
Urethritis
Eye (Conjunctivitis)
Throat (Pharyngitis)
Rectum
(Proctitis)
Eye (conjunctivitis)
Lungs (pneumonia)
Genitals
(Urethritis)
(Epididymitis)
Rectum(Proctitis)
Throat (Pharyngitis)
Eye(Conjunctivitis)
Systemic
(Reiter’s Syndrome)
70-80% ASYMPTOMATIC
>50% ASYMPTOMATIC

35. Signs and Symptoms Initial infection is of the cervix and urethra:
If symptoms do occur, they usually appear 1-3 weeks after exposure.
For women:
Initial infection is of the cervix and urethra:
Abnormal vaginal discharge
Burning while urinating
Infection spreads from cervix to fallopian tubes:
Lower abdominal pain
Low back pain
Nausea
Fever
Painful intercourse
Irregular bleeding
Cervical infection can spread to the rectum

36. Signs and Symptoms For men: Rectal infection:
Discharge from penis
Burning while urinating
Burning and itching around opening of penis
Rectal infection:
Rectal pain
Discharge
Bleeding
Throat infections can also occur through oral sex

37. CHLAMYDIA UNUSUAL PRESENTATIONS
Trachoma
Inclusion conjunctivitis
Lymphogranuloma venereum

38. TRACHOMA

39. INCLUSION CONJUNCTIVITS

40. LGV CLINICAL MANIFESTATIONS

41. Diagnosis Laboratory tests are done to diagnose chlamydia
Some are performed using a urine test
Other require a specimen from the penis or cervix

42. Complications

43. Treatment
There are several antibiotics that can successfully treat and cure chlamydia
Most common: Azithromycin (single dose) & Doxycycline (twice daily for a week)
To avoid re-infection, persons with chlamydia should abstain from sexual intercourse until they and their partners have completed treatment.
In women, untreated chlamydia can spread to the uterus or fallopian tubes and cause pelvic inflammatory disease (PID).
Up to 40% of women with untreated chlamydia develop PID.
PID can cause permanent damage, leading to chronic pelvic pain, infertility, and potentially fatal ectopic pregnancies.

44. Trichomoniasis

46. Symptoms
Between 10% and 50% of women infected with T. Vaginalis are asymptomatic.
Symptoms usually appear within 5 to 28 days of exposure.
Symptoms are nonspecific and cannot be used to differentiate trichomoniasis from other genital infections.

47. Profuse Watery Vaginal Discharge in Trichomoniasis

48. Proportion of asymptomatic trichomoniasis
73%
Women
77%
asymptomatic
Men
The majority of men in the study were asymptomatic, denying penile discharge or itching, dysuria and lower abdominal pain. In contrast the majority of women with trichomoniasis were symptomatic, complaining of vaginal discharge or itching, dysuria or lower abdominal pain.
Symptoms included penile or vaginal discharge or itching, dysuria, or lower abdominal pain. 48

49. Clinical Aspects Persistant vaginitis, 50% asympotmatic.
Discharge 75%.
Vulvar itching and burning 50%.
Dyspareunia 50%.
Dysurea 50%.
Bad odor 10%.
Strawberry cervix.
Males:
Urethritis and Prostatitis.
Asymptomatic.
Dysurea.
Non purulent discharge.
Non gonococcal urethritis.

50. Diagnosis Clinical picture. Microscopic morphology (wet mount)
Male vs female.
Antigen detection.
Look for other venereal diseases.

51. Wet mount microscopy
Performed on vaginal swab specimens (or male urine sediment) resuspended in a drop or 2 of saline
Organisms must be viable and motile
Must be performed within 15 minutes of specimen collection
% sensitivity with expert microscopist

52. T. vaginalis culture
Trich grows best in microaerophilic or anaerobic environments
CO2 incubator or anaerobe jars, ºC, pH
Diamond’s medium with antifungal and antibacterial additives
InPouch™ TV (Biomed)
Cultures examined daily for up to 5 days
Sensitivity estimates:
% in women
< % in men

53. InPouch TV cultures from men require long incubation periods
0.8 * [
Women (vaginal swabs)
0.6
Men (urine, semen or
urethral swabs)
Proportion of positive cultures
0.4 * [
* P < 0.002
The contrast in the performance of the InPouch TV culture system in specimens from women and men in the study was striking. Positive cultures from men took significantly longer to become positive than did positive vaginal swab cultures. Whereas greater than 70% of vaginal swab cultures from women with trichomoniasis were positive by the first day after inoculation, only 32% of positive male cultures were positive on day 1. Cultures from men with trichomoniasis frequently did not become positive until later days of incubation. Six percent of positive specimens from men did not become positive until the last day cultures were read, 5 days after inoculation, compared to fewer than 1% of positive cultures from women in the study.
0.2 * [
0.0 1 2 3 4 5
Time after inoculation (days) 53

54. Rapid antigen detection
Dipstick from Genzyme
Antibodies on stick capture T. vaginalis antigen in specimen
Sensitivity slightly better than wet mount microscopy ~80%
Only validated in women

55. Treatment of Trichomoniasis
Metronidazole 2 gm orally once
Metronidazole 500 mg orally twice daily x 7 days
Metrogel NOT recommended;
< 50% efficacious than oral regimens 55

56. Tinidazole Tinidazole 2 gm orally once also recommended regimen
Clinical trials found cure rates between % in women, 83% in men.
Compared to metronidazole, tinidazole has:
Higher clinical and microbiological cure rates
Less frequent side effects

57. Treatment during Pregnancy and Lactation
Metronidazole 2gm orally once
Tinidazole safety NOT well evaluated (category C)
Breast-feeding
Metronidazole - withhold breastfeeding during treatment and for hours after last dose
Tinidazole – withhold breastfeeding during treatment and for 3 days after last dose

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