1. Bacterial STDs

2. Chancroid Haemophilus ducreyi 4-7 day incubation
Painful soft genital ulcers with membrane and surrounding inflammatory zone
Painful, mostly unilateral, inguinal adenitis (bubo) which may suppurate
Azithromycin, erythromycin, ceftriaxone, ciprofloxacin

3. Granuloma inguinale (donovanosis)
Klebsiella granulomatis
Non-tender, vegetative, hypertrophic, soft, beefy red, gradually enlarging ulcer
Sinuses, hypertrophic scars, esthiomene
Absent lymphatic involvement
Donovan bodies within histiocytes, Giemsa stain

4. Lymphogranuloma venereum
Chlamydia trachomatis L1, L2, L3
Herpetiform vesicle or erosion, to painless shallow ulcer which heals in a few days
2 weeks later, lymphadenopathy resulting in a tender bubo causing the groove sign, possible fistulas
Proctitis, pararectal bubos, rectal strictures
Esthiomene
Cutaneous eruptions, arthritis, constitutional symptoms, conjunctivitis
Doxycycline, erythromycin

5. Gonococcus Neisseria gonorrhoea Gonorrhea: urethral discharge
Primary gonococcal dermatitis: grouped pustules on finger
Gonococcemia: vesiculopustular – purpuric eruption, fever, arthralgia, tenosynovitis, liver abnormalities, carditis, meningitis
Ceftriaxone, cefixime, cefotaxime
Doxycycline or azithromycin for coexistent chlamydia

6. Syphilis T. pallidum Non-treponemal tests: RPR & VDRL
Treponemal tests: EIA, TPPA, MHA-TPA, FTA-ABS
Prozone phenomenon: false negative with high titer when serum undiluted
Biologic false positive (acute from other infection, chronic in autoimmune disease)

7. Primary syphilis Chancre 3 weeks after infection
Painless, indurated, eroded papule
Firm, non-tender, lymphadenopathy
Heal spontaneously in 1-4 months
Phagedenic chancre: severe destruction
Edema indurativum
Chancre redux: relapse

8. Secondary syphilis
Generalized shotty adenopathy; posterior cervical, axillary, epitrochlear
Macular exanthem
Papular eruption
Palms & soles
Ham or copper-colored
Papulosquamous, follicular, lichenoid, annular, corymbose, pustular, rupial, ulcerative
Condyloma lata
Syphilitic alopecia
Pharyngitis, mucous patches

9. Latent & Late Syphilis
60-70% untreated infections remain latent and asymptomatic for life
Early latent: < 1 yr
Late latent: > 1 yr or unknown
Late cardiovascular: aortitis

10. Tertiary cutaneous syphilis
3-5 years after infection
15% of untreated will develop lesions
Nodular, noduloulcerative, tubercular
Serpiginous; arms, back, face
Gummas
Unilateral, ulcerated plaque on leg
Tongue
Ulcers, smooth atrophy, macroglossia

11. Late osseus syphilis Gummas involve periosteum of bone
Head, face, tibia
Periostitis, osteomyelitis, osteitis, osteoarthritis
Osteocope (bone pain) at night
Charcot joint of knees and ankles

12. Neurosyphilis CSF pleocytosis, VDRL, FTA Greater with high RPR
5-10% of untreated
CSF evaluation if:
any neurologic, auditory, ophthalmic signs
RPR > 1:32 if HIV +
Latent syphilis with HIV
Tertiary syphilis

13. Neurosyphilis Early meningitis Meningovascular: thrombotic
Late parenchymatous
Tabes dorsalis: gastric crisis, Argyll Robertson pupils, Romberg sign
Paresis: encephalopathic

14. Congenital syphilis Early (First 2 years) 3 weeks – 3 months
Snuffles rhinitis, septal perforation, saddle nose
Morbilliform eruption
Syphilitic pemphigus (bullae or desquamation)
Fissured lesions and radial scarring, leading to rhagades
Condylomata lata
Epiphysitis, parrot pseudoparalysis
Lymphadenopathy and hepatosplenomegaly
CNS involvement

15. Congenital syphilis Late (after 2 years) Interstitial keratitis
Perisynovitis (Clutton joints) around knees
Gummas
CNS: seizures
Hutchinson triad: incisor teeth, corneal opacities, eighth nerve deafness
Saber shins, rhagades of lips, saddle nose, mulberry molars, Higoumenaki’s sign of clavicle

16. Treatment of Syphilis
Primary, secondary, early latent: 2.4 benzathine penicillin G x 1
Non-pregnant, HIV-negative, penicillin-allergic: doxycycline for 2 weeks
Macrolide resistance, avoid Azithromycin
Late latent: pen G x 1 for 3 weeks or doxy for 4 weeks

17. Treatment of Syphilis Neurosyphilis: Pen IV or IM for 2 weeks
Desensitize if penicillin allergy in neurosyphilis
Jarisch-Herxheimer reaction: chills, fever, exaggerated inflammatory reaction
Treat sexual partners exposed within 90 days
At-risk partners: 3 months + duration of primary, 6 months + duration of secondary, 1 year for latent

18. Treatment of Syphilis
RPR every 3 months in first year, every 6 months in second year, yearly thereafter
Expect 4X decrease in RPR, 6 months after therapy

19. Syphilis & HIV Genital ulcers enhance risk of acquiring HIV
More likely to present with secondary and persistent chancre
Non-treponemal tests higher titer
Increased risk of neurosyphilis
Desensitize if allergic to penicillin
CSF exam in latent syphilis, RPR > 1:32
Penicillin to treat all HIV-infected contacts