Sexually transmitted diseases (STD)  - PowerPoint Presentation

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Sexually transmitted diseases (STD) 

By...

-Alaa

aloqaily

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Sexually transmitted diseases (STD) 

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Most common organisms and diseases :

STI Testing

• Vaginal swab

• Tests for bacterial vaginosis,

trichomoniasis, candida

• Cervical swab

• Tests for gonorrhea and chlamydia

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1)

Gonorrhoea

 

 second most common bacterial STD.

 bacteria Neisseria

gonorrhoea

  .

Complains:

 -Rectal infection  

 -pharyngeal infection  

  -Ophthalmic infection       

-neonatal infection: occurs when the mother has endocervical infection at the time of delivery and cause ophthalmia neonatorum.

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Clinical features :

asymptomatic in up to 50% of cases 

 vaginal discharge

 -mucopurulent discharge

 - the most common symptom and the patients may experience

lower abdominal pain

in up to 25% 

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Examination :

 Mucopurulent cervical discharge 

is seen on speculum exam. Cervical motion tenderness is common with bimanual pelvic exam.  Vulvovaginitis is seen on inspection. 

 Petechial skin lesions, septic arthritis, and rarely, endocarditis or meningitis, may demonstrate with disseminated gonorrhea.

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Complications:

 -increased risk of coinfection

 with chlamydia 50%. -increased risk of preterm rupture of membranes and preterm birth. -Ascending infection may result in PID .

*Rarely, haematogenous spread... disseminated gonococcal infection 

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Mucopurulent cervical discharge

Gonococcemia

Gonococcemia

Diagnosis

-culture .

-

NAAT (Nucleic-acid amplification tests) tests are highly sensitive and specific

-Indication for Testing :

1)symptomatic women

2)those who have another STI

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Treatment

• single dose of

ceftriaxone

250 mg IM plus

azithromycin 1 g PO

• if pregnant: above regimen or 2 g spectinomycin IM plus azithromycin 1 g PO (avoid quinolones)• also treat chlamydia, because of high rate of co-infection

• treat partners

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2)Chlamydia:

 the

most common bacterial STI

, in women under 25 years old. 

By

Chlamydia trachomatis

: it is an obligate intracellular organism.

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 Clinical features :

• asymptomatic (80% of women)

• muco-purulent endocervical discharge• urethral syndrome: dysuria, frequency, pyuria, no bacteria on culture• pelvic pain

•AUB.• symptomatic sexual partner

If pregnant

 Is often asymptomatic. But it maybe associated with :

 1-Preterm rupture of membranes

 2-Preterm delivery 

3-low birth weight

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 Transmission to the fetus at the time of delivery causing

  

conjunctivitis and pneumonia.

 -Examination :

mucopurulent

cervical discharge. 

Urethral and cervical motion tenderness may or may not be noted.

 -Diagnosis :

PCR-DNA.

• cervical culture

• obligate intracellular parasite:

tissue culture is the definitive standard

.

• urine and vaginal tests now available, which are equally or more effective than cervical culture

*NAAT tests . 

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Treatment :

 Treated by

 azithromycin or doxycycline; simultaneous treatment of current and recent sexual partners

is required.test of cure for chlamydia required in pregnancy (cure rates lower in pregnant patients)

…...retest 3-4 wk after initiation of therapy.Screening...• high risk groups• during pregnancy

• with initiation of OCP (independent risk factor)

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Genital warts

(

Condyloma acuminatum) The most common overall STD In women as well as the most common viral STD

– benign epithelial tumors caused by HPV infection ,Very common – There are over 100 genotypes of HPV and

types 6 and 11 cause over 90% of genital warts (that cause Condyloma acuminatum)

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 – oncogenic genotypes including types -16 and 18- but these cause anogenital dysplasia , cervical and vulvar cancer, not warts.

 – characteristic appearance is a : 

pedunculated , soft papule that progress into a cauliflower-like mass. – M.C site of lesions is the cervix

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Clinical presentation 

 mostly It is subclinical and resolve spontaneously.

 HPV infection persists and results in warts and precancerous lesions

...pain, odor and bleeding only when lesions become large or infected. 

 Risk factors: 

immunosuppression, DM, pregnancy

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Management

 – 

Prevention: HPV vaccination is available as a bivalent (against types 16 and 18) or quadrivalent (types 6, 11, 16 and 18) vaccine 

Treatment:

 – 1) Ablative therapies such as application of liquid nitrogen(cryotherapy) or surgical techniques

 – 2) patient-applied topical therapies, like podofilox gel(anti-mitotic)*in pregnancy treatment is limited to ablative options 

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Trichomonas Vagin

itis 

Clinical features : vaginal discharge associated with itching, burning, and pain with intercourse.Asymptomatic in 50% 

of women. evidence of an association with pregnancy outcome: preterm birth, low birthweight and maternal postpartum sepsis.

Trichomoniasis

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Diagnosis

1.Speculum Examination :

The vaginal epithelium is frequently edematous and inflamed.Vaginal discharge is typically

frothy and green.

The erythematous cervix may demonstrate

the characteristic

“strawberry

”

appearance.

Vaginal

pH is elevated >4.5

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2.Testing :

Gold standard is a nucleic acid amplification test (NAAT) 

 indicated in symptomatic women.3.Wet Mount : 

Microscopic examination reveals actively motile “trichomonads” on a saline preparation. WBCs are seen.

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“Strawberry” cervix

Vaginal discharge is typically frothy and green

Management :

The treatment of choice is

oral metronidazole

for both the patient and her sexual partner. Vaginal metronidazole gel has a 50% failure rate.

Metronidazole is safe to use during pregnancy, including the first trimester.

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Syphillis

By  

Treponema pallidum. transmission: Direct contact with secretions from an infective lesion or via transplacental passage of the bacteria during pregnancy.

◦ Syphilis can be acquired or congenitally. ◦ Syphilis can present in one of four different stages

: primary, secondary, latent and tertiary, and may also occur congenitally.◦ Both types have early and latent phases. 

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Primary stage: 

(average 21 days)

 -

chancers

  appears at the point of contact it is a single, genital painless lesion.- regional lymphadenopathy ,,,,unnoticed.

-serological tests usually negative, local infection only- This resolves within a few weeks

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Secondary syphillis

: ...6 weeks to 6 months after infection(can resolve spontaneously)

malaise, anorexia, headache, diffuse lymphadenopathy generalized maculopapular rashcondylomata lata: anogenital, broad-based fleshy grey lesions

 serological tests usually positive _darkfield+_

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Tertiary syphilis:

 3 to 15 years after the initial infection.

 Without treatment, a third of infected people develop tertiary disease.

People with

tertiary syphilis are not infectious.

-may involve any organ system

-

neurological

:

tabes

dorsalis, general paresis

 -

cardiovascular

: aortic aneurysm, dilated aortic root

 -

vulvar

gumma

: nodules that enlarge, ulcerate and become necrotic (rare)

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 Congenital syphilis

◦  

miscarriage,(IUGR), fetal hydrops,

congenital syphilis

, stillbirth, preterm birth and neonatal death. 

 Common symptoms that develop over the first couple of years of life include …..hepatosplenomegaly (70%), rash (70%), fever (40%), neurosyphilis (20%), and lung inflammation (20%).

 If untreated, late congenital syphilis may occur in 40%, including saddle nose,

 

Hutchinson's incisors and macerated skin.

. 

-treatment with penicillin improves the outcome for the fetus.

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Investigations• aspiration of ulcer serum or node...

darkfield microscopy (most sensitive and specific diagnostic test for syphilis)spirochetes

• non-treponemal screening tests (VDRL, RPR); nonreactive after treatment, can be positive withother conditions• specific anti-treponemal antibody tests (FTA-ABS, MHA-TP, TP-PA)

 confirmatory tests; remain reactive for life (even after adequate treatment)

None of these serological tests will detect syphilis in its incubation stage, which may last for an 

average of 25 days.

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Prevention :• Vaginal delivery is appropriate with cesarean section only for obstetric indications. 

• avoiding multiple sexual partners, and promote use of barrier contraceptives.

Management :Benzathine penicillin 2.4 million units IM × 1 is given in pregnancy to ensure adequate antibiotic levels in the fetus. Other antibiotics do not cross the placenta well. Even if the gravida is penicillin-allergic, she should still be given a full penicillin dose using an oral desensitization regimen under controlled conditions.

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Starts within 1-2h

Lasts for 24-48h

Pt... fever, headache, myalgia, hypotension, uterine contractions

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HSV

◦

most common ulcerative STI. 

◦  

90% are HSV-2, 10% are HSV-1

.

Primary herpes...systematic

syx

: fever, malaise, adenopathy, diffuse genital lesions

multiple, painful, shallow ulcerations with small vesicles appear 7-10 d after initial infection

Recurrent herpes...to dorsal rote ganglia, not systematic 

mostly

 asymptomatic, although the individual may still be infectious, and subsequent

recurrences may be symptomatic

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Investigations

• viral culture

preferred in patients with ulcer present, however decreased sensitivity as lesions heal.• cytologic smear (Tzanck smear)

  multinucleated giant cells, acidophilic intranuclear inclusion bodies• type specific serologic tests for antibodies to HSV-1 and HSV-2 

• HSV DNA PCR

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Neonatal herpes

◦ mortality rate of up to 30% and consequent life long neurological morbidity in up to 70% .

 ◦ It is acquired during delivery if the mother has infection within the third trimester and especially the last 6 weeks

mode of delivery ... 

caesarean section

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◦ If there was 

recurrent infections

 in the mother, IgG from the mother can cross the placenta to the fetus and can protect him from infection. 

Treatment...

acyclovir

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HIV 

  modes of transmission??The infected patient develops  (AIDS). 

death caused by overwhelming infection from opportunistic diseases.

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Fetal infection: 

Transplacental infection occurs + vertical transmission .

azidothymidine (AZT) prophylaxis, the vertical transmission rate drops from 30% to 10% with vaginal delivery. With elective cesarean section

without membrane rupture the perinatal infection rate <5%.  Treatment. ...Combination triple anti-viral HAART

therapy for all HIV-positive... low CD4 counts and high RNA viral loads, making infection through a vaginal delivery much more likely. 

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 Neonatal infection: 

At birth neonates of HIV-positive women will have positive HIV

tests from transplacental passive IgG passage. HIV-infected breast milk can potentially transmit the disease to the newborn. Progression from HIV to AIDS in infants is

more rapid than in adults....

avoid breast feeding .

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 Maternal infection:

 Pregnancy does not enhance progression to AIDS.

 Antiviral prophylaxis:  Infected pregnant women should take triple-drug therapy including the drug zidovudine (ZDV) as part of their drug regimen, starting at 14 weeks and continuing throughout pregnancy, intrapartum, and after delivery.

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 Mode of delivery: 

Vaginal delivery should be planned at

39 weeks, with the following guidelines:-Avoid amniotomy. -Do not use scalp electrodes.-Avoid forceps or vacuum delivery.-Use gentle neonatal resuscitation

-If viral load ≥1,000 copies/mL, offer cesarean section at 38 weeks without amniocentesis.

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Treatment...

 Combination triple anti-viral HAART

therapy for all HIV-positive pregnant mother, this includes 2 nucleotide reverse transcriptase inhibitors (NRTIs) with an NNRTI or a protease inhibitor (e.g., zidovudine, lamivudine, or ritonavir). 

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Hepatitis B virus

Transmission ? – Most infections are asyptomatic

 – Diagnosis: serology for hepatitis B core antibody or HBsAg

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Maternal infection

–mostly Asymptomatic infection.

 HBsAg

is the screening test ...if positive, follow up with complete hepatitis panel & liver enzymes assessing for active or chronic hepatitis .

– Acute hepatitis: presents with RUQP. 

Lab tests show elevated bilirubin and liver enzymes.

Most patients recover normal liver function.

 – Chronic hepatitis: RUQP Can lead to cirrhosis and hepatocellular carcinoma 

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Vaginal delivery is indicated unless obstetric indication for CS.

Avoid scalp electrodes in labor as well as scalp needles in the nursery.

 Neonates of HBsAg-positive mothers...should receive passive immunization with hepatitis B immunoglobulin (HBIg) and active immunization with hepatitis B vaccine ….After that Breast feeding is acceptable

HBsAg-negative mothers at high risk... should receive HBIg

passive immunization. Active immunization is safe in pregnancy because the agent is a killed virus

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Fetal infection – Transplacental transmission is rare

– The main route of transmission is exposure to infected secretions during vaginal delivery

 – There is no risk for transmission if the mother has positive antibody test but negative HBsAg test

Treatment

No specific treatment for acute hepatitis

–

Interferon or lamivudine

for chronic hepatitis

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Neonatal infection

 – Neonatal HBV develops in only

10% of HBsAg-positive mothers

, of those infected ;

80% of them will develop chronic hepatitis.

Management as mentioned above

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Chancroid

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