STI Cases

STI Cases
1.
A 17year-old female is seen in your clinic for a primary care visit. She has complaints today only of
tension headaches that occur on a weekly basis, She otherwise has no PMHX, no significant family
history, no medications or allergies. She is using condoms for birth control and has never has a
gynecologic exam.
What STI screening is indicated?
2.
A 26 year-old woman is examined in the Emergency Department for a painful swelling on her labia for
2-3 days.
What is the likely diagnosis?
What STI's is associated with this condition?
3.
A 24 year-old patient returns to your clinic to discuss her Pap smear. This was her third annual exam.
Previous paps have been negative, but this pap shows CIN I.
What do you tell her about HPV?
What should she tell her partner about HPV?
What further tests are indicated? Would you do testing for HPV?
4.
A 21-year male student presents to your clinic with genital ulceration and inguinal lymphadenopathy.
What is your differential?
5.
A 30 year-old male patient presents to your clinic for routine health maintenance. Social history is
remarkable for > 10 lifetime male partners. He reports condom use~90%.
What further questions would you ask?
What screening tests would you offer him?
Any other treatments?
6.
A 22 year-old male presents to your clinic with a bump just above his penis. He has recently had
unprotected sex with a new partner and is quite concerned about a STI. He says he want to be tested
for "everything".
What is the differential of the papule?
What further history do you need?
What screening tests do you offer him?
Update on STI's
I.
The scope of the problem
49% of high school students have had sexual intercourse1
8.3% before age 13
16.2% with more that four partners
58% used condom with last intercourse
24.8% used alcohol or drugs with last intercourse
72%-86% of college students have had sexual intercourse2,3
7.8% engaged in anonymous sex
34.5% had 6 or more lifetime partners
29.6% used condom with last intercourse
16.6% used alcohol or drugs with last intercourse
II.
Risk assessment
Components of Individualized Risk Assessment for HIV (and other STI's)5
• Number of lifetime sexual partners
• Sexual activities-Vaginal, Anal(receptive and insertive), and oral sex
• Sex or needle sharing with individuals known to be HIV positive
• Sharing needles or having sex with persons who share needles
• Personal history of STI's or hepatitis
• Sex with persons who have STI's-especially genital lesions
• Current STI symptoms
• Sex in exchange for drugs, money, or other inducement
• Use of substance in connection with sexual activity
• History of HIV antibody testing and results
• Condom use
• Birth control methods
• +PPD
• Clinical Symptoms suggesting HIV infection
• Immunization status for Hepatitis B
III.
Infections
A. Chlamydia
Nonmotile, Gram-negative intracellular bacteria.
Transmitted sexually-semen and mucus
Predilection for columnar epithelium(found in younger women with cervical ectopy)
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Epidemiology
3-5 million symptomatic case annually
Greatest number among sexually active females ages 12-19(40% of all cases)
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Clinical Manifestations
Male
25-50% asymptomatic
Incubation 7-21 days
Urethritis-30-50%
Epidydimitis-50%
Proctitis-15%
? Prostatitis
Reiters
Female 70% asymptomatic.
Cervicitis-Mucopurulent discharge, edematous friable cervix, increased menstrual flow,
break through bleeding
Urethritis
Bartholinitis
PID-leading cause
Perihepatitis
Salpingitis
Infertility-contributes to 50% of cases
Infant-Stillbirth, conjunctivitis, pneumonia
•
Screening
Culture
Antigen detection kits
Amplified DNA Assays-PCR, LCR, SDA etc…
Newest assays validated for urine specimens-may be more effective in men
Sen.- 82-100%
Spec 98-100%
Women
Sexually active and under age 25
Have more than one sexual partner, regardless of age
Have had a STI in the past, regardless of age
Do not use condoms consistently, regardless of age
Men-no evidence for routine screening of asymptomatic men
•
Treatment
Cervicitis/Urethritis-Also treat for concomitant GC infection
Azithromycin 1gm
Doxycycline 100mg BID for 7-10 days
Ofloxacin 300 mg BID x 7 days
Erythromycin 333 MG TID x 7-10 days-Recommended during pregnancy
Adolescents are at high risk for reinfection
B. Gonorrhea
Gram negative Neisseria gonorrhoeae
Predilection for columnar epithelium-increased risk with cervical ectopy
•
Epidemiology
650,000 annual cases- rates have been rising in last several years
Rates rising among MSM-13% of cases
Contributes to spread of HIV
60% of cases occur among people aged 15-24
•
Clinical Manifestations
Asymptomatic- account for 50% of infections
Women Infection rate 60-90% after single exposure
Endocervicitis-edematous and friable cervix
Urethritis
Labial Swelling
Bartholinitis-2nd most common complication
Endometritis
Salpingitis-complicates 15-30% of cases
Perihepatitis
Men
Infection rate 20-35% after single female exposure
Urethritis
Epididymitis-occurs in 10-30% of untreated men
Prostatitis-rare
Both
Pharyngitis-90% asymptomatic. Can be persistent reservoir for infection
Proctitis
High degree of concomitant infection of pharynx, rectum and genital tract
Disseminated-Need to culture all orifices-rectal, genital, pharyngeal
Septic Joint-Knees most common. Synovial fluid positive 30-50%.
Arthritis-Dermatitis-fever, chills, arthritis, tenosynovitis, + blood cultures (2050%), rash-hemorrhagic pustules on trunk, arms, hands and feet
Conjunctivitis
Infant-conjunctivitis, scalp abscess, pneumonia
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Screening/Diagnosis
Gram stain-100% sens for urethrits in symptomatic menCulture
DNA probe
First catch urine LE
Asymptomatic high-risk women and high-risk pregnant women
•
Treatment-Treat for concomitant Chlamydia infection
Uncomplicated infection
Ceftriaxone 125 mg IM x1
Cefixime 400 mg po x1-Not recommended for pharyngeal infection
Cipro 500 mg po x1( Rising flouroquinolone resistance worldwide->50% in SE Asia)
Ofloxacin 400 mg po x 1
C. Human Papilloma Virus
•
Epidemiology
75% of reproductive-age adults have been infected/15% currently infected
Highest infection rates among young women
14% of college women are infected annually/45% at college health service routine exam
5.5 million new cases annually-most asymptomatic
30 subtypes-90% of infections caused by 6 and 11
6,11,42,43, 44 benign. Cause disease that regresses. Low-risk group
31, 33, 35, 39, 51, 52-15% of cervical cancers. High risk group
16, 18, 45, 56, 58, 59, 68-80% of cervical cancers. High risk group
Usually, but not always sexually transmitted
•
Clinical manifestations
Cervical Neoplasm
Low-risk group 60% spontaneously resolve
High-risk group- 10-15% untreated will progress to invasive cervical cancer. Accounts
for most all cervical cancers
Condyloma Acuminata- vulva, penis, scrotum, urethra, perineum. anal/rectal.
Co-infection with HIV leads to increased disease severity
Infant-Respiratory papillomatosis
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Screening
No routine or universal screening recommended
New recommendations may recommend perhaps for ASCUS pap
Hybrid capture II-DNA probe for high-risk subtypes. Sen. 90%
•
Treatment
External genital warts
Aldara 5%induces cytokines
Apply 3 X/week over entire involved area. Lower recurrence rates.
Cryotherapy
Laser therapy
Podophyllin/Podofilox
TCA/BCA
D. Syphilis
Treponema pallidum
Transmitted in bodily fluids and direct contact
Increases HIV transmission rate 2-5 fold
•
Epidemiology
1999-6657 Primary and secondary cases, 556 cases of congenital syphillis
Increasing rates among MSM
Highest rates among 20-29 year-old women and 35-39 year-old men
•
Clinical Manifestations
Primary-painless ulcer-usually single. Assoc with lymphadenopathy-incubation 21 days.
Secondary-occurs 6-8 weeks after infection. Rash-may be pruritic. Can look like anything,
condylomata lata, lymph node enlargement, spotty alopecia.
Late/Latent-Aortitis, neurosyphillis, gummas
Infant-50% transmission rate.
•
Screening/diagnosis
All pregnant women
All persons at increased risk of infection
Non-treponemal Tests-used for screening and to follow response to therapy
RPR-Qualitative
VDRL-Quantitative. Use to follow response to treatment
Treponemal Tests-used for confirmation. Stay positive for life
FTA-ABS
MHA-TP
TPI-
•
Treatment
Primary
Penicillin G 2.4 million IU IM
Need to document a fourfold drop in VDRL titer at 6 months
Jarisch-Herxheimer Reaction- occurs in 50% of primary syphillis and 90% of secondary syphillis
within two hours of treatment. Fever, tachycardia, myalgias, headache, leukocytosis
Screen for HIV and other STI's
E. Herpes Simplex Virus
•
Epidemiology
1 million new infections annually-25-50% in adolescents
Women-25% seroprevalence HSV-2
Men-20% seroprevalence HSV
Whites-17%-growing most rapidly among white teens
AA-45%
Transmitted by direct contact, intercourse not necessary. Barrier methods only partly effective
10% annual transmission in sero-discordant couples
Asymptomatic shedding-3% of infected individuals9
Risk factor for HIV infection
•
Clinical Manifestations
Asymptomatic 50-70%
Primary Infection HSV-1 1/3;HSV-2 2/3.
Single or multiple vesicles on erythematous base anywhere on genital skin. Assoc with tender
inguinal LAD, fever, malaise. Ulcerate and heal in 2-4 weeks
Recurrent-decreased severity. Heals in 1-2 weeks. Usually unilateral. More likely with HSV-2.
90% had at least one recurrence, 38%>5 recurrences, 20%> 10 recurrences. Median 4. Decrease
after first year
Prodrome-tingling, shooting pain in legs and hips, pruritis.
Culture-70-90%% sensitive with active lesions
DFA- Sen. 70-90%
Aseptic Meningitis-33% women, 10% men
Extragenital lesions-autoinoculation
Proctitis
Cervicitis- 90% of primary infections. Complications-necrotizing cervitcitis
Pharyngitis
Perinatal infection-encephalitis, hepatitis, DIC etc…
•
Screening
Not routinely recommended
•
Treatment
Primary
Acyclovir 400mg TID or 200 mg 5X/day X 7-10 days
Valacyclovir 1 gm BID X 7-10 days
Famcyclovir 250 mg TID X 7-10 days
Recurrent
Acyclovir 400mg TID or 200 mg 5X/day or 800 mg BID X 5 days
Valacyclovir 500 gm BID X 5 days
Famcyclovir 125 mg BID X 5 days
Suppression-Consider after multiple recurrences (>6). Plan 1-year course
Acyclovir- 400 mg BID X 1 year
Valacyclovir 250 mg BID or 500 mg or 1 gm QD
Famacyclovir 250 mg BID
F. HIV
•
Epidemiology-20% of individuals with HIV became infected during adolescence
1999-MSM-46%
Heterosexuals-30%
IDU-18%
MSM/IDU-3%
54% AA, 19% hispanic, 18% white; 50% under age 25, 70% male4
•
Screening -Only 70% of HIV infected people know they are infected4
Guide to clinical preventive services-19962
- Offer to all persons at increased risk-persons with STD's, IVDA, gay and bisexual
men, hemophiliacs, sexual partners of high risk individuals, pregnant women, active
-
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TB, occupational exposure, health care workers at risk, donors, persons who request
the test because they consider themselves at risk.
Consider testing-persons who received blood between 1977-1985, heterosexual
persons with noncompliance with condoms and more than 1 sexual partner in the last
1 year, prostitutes.
Insufficient evidence to recommend for or against routine screening in persons
without identified risk factors.
•
Risk Assessment-Need to consider setting prevalence and behavioral risk
- Recommend for all patients in settings of increased behavioral risk-STD clinics,
clinics for MSM, shelters, correctional facilities
- Recommend for most persons in settings of high prevalence( >1%)
- In settings with low prevalence and low behavioral risk- offer on the basis of risk
screening and to any patient requesting testing.
•
Special groups
Pregnant women
Acute occupational exposure
Acute non-occupational exposure
•
Elisa and Western Blot- Available as serum, rapid serum, home dried blood spot, oral fluid or
urine-based assay. Standard assays look for HIV-1.
Rapid Tests-only preliminary positive at time of testing-must be confirmed. Benefit of
informing positive patients otherwise lost to follow-up. Most indicated in clinics with low
return rates.8
Detectable 6-12 weeks in majority of patients. Detectable in 95% at 6 months.
Sources of false negatives-agammaglobulinemia, immunosuppression, replacement
transfusions, HIV subtypes, O strains and HIV-2.
Sources of indeterminate-early partial sero-conversion, advanced HIV infection, crossreacting alloantibodies from pregnancy or transfusion, organ transplantation, autoantibodies,
HIV-2 infection.
HIV-2 and HIV-1 non-B infection testing may be indicated in certain situation
•
Post-exposure treatment
Initiate in after unprotected receptive and insertive anal and vaginal intercourse with a
partner who is or is likely to be HIV infected. Can offer with receptive fellatio.
Need baseline negative HIV
Assure commitment to safer sexual practices
Initiate within 72 hours.
4 week prophylaxic regimen.
Monitor for signs or symptoms of acute HIV infection-send p24 and/or viral load.
G. Hepatitis B
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Epidemiology
200,000 infections per year. Highest incidence ages 25-39
120,000 are sexually acquired
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Prevention
Routine vaccination of adolescents age 11-12 not previously vaccinated6
Adolescents older than age 12 at increased risk of Hep. B infection
ƒ Multiple sexual partners(> 1 in last 6 months)
ƒ Use injected drugs
ƒ MSM
ƒ Sexual or household contact with Hep BsAg positive individual
ƒ Health care workers
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Residents of institutions
On hemodialysis
Travel to Hep B endemic area for greater than 6 months
H. Hep. A-routine vaccination for MSM
I.
Molluscum Contagiosum
Molluscum contagiosum virus- pox virus
Transmitted by touching lesion
Causes small raised papules with central keratotic plug
Large numbers or giant facial lesions-think HIV infection
Can treat by removal-will spontaneously regress
J.
Pediculosis Pubis
Pruritic papules and macules in genital area. Presence of lice or nits.
Treat with lindane or permethrin. May need second treatment.
IV.
Clinical syndromes
A. Genital Ulcers/Lymphadenopathy
ƒ Syphillis
ƒ HSV
ƒ Chancroid-culture for Haemophilus ducreyi. Tender genital papules which
become purulent and ulcerates. Assoc. with tender lymphadenopathy and
"bulbo". Diagnosis by culture
Transmitted by touching infected lesion. Treat with Azithro, CFTX, Cipro,
or EES
ƒ Lymphogranuloma venereum(LGV)-caused by chlamydia trachomatis
Painless papule which ulcerates. Followed by lymphadenopathy. May lead
to fistulae formation.
Diagnosis by titers. Treat with Doxycycline, EES, or Sulfisoxazole.
ƒ Granuloma inguinale- "Donovanosis" calymmatobacterium granulomstis
May require biopsy for diagnosis
B. Pelvic inflammatory disease-polymicrobial
Chlamydia-5-50%
Gonorrhea
Anaerobes
R/o tubo-ovarian abscess, ovarian torsion, ovarian cyst, appendicitis, ectopic pregnancy
Leads to 6-10 fold increased risk of ectopic pregnancy
25% infertile after 1 episode/50% infertile after 3 episode
C. Urethritis
Chlamydia-30-50%
Gonnorrhea
U. urealyticum 20-40%
Trichomonas vaginalis 2-5%
HSV
D. Epididymitis
Chlamydia-50%
Chlamydia/GC
GC alone
Enteric organism-> age 35, MSM
TB-uncommon
E. Vaginitis
15-20% Trichomonas-5 million cases per year. Usually sexually transmitted
40-50%-Bacterial Vaginosis. Not usually sexually transmitted.
20-25%-Candidiasis. Occasionally sexually transmitted
Treat partner for recurrent BV or vaginal candidiasis.
References
1.
Youth Risk Behavior Surveillance- United States, 1999. MMWR Vol. 49. No SS-5 June 9,
2000.
2. "Screening for Human Immunodeficiency Virus." Guide to Clinical Preventive Services. 2nd
ed. Baltimore (MD): Williams and Wilkins; 1996. 303-24.
3. Youth Risk Behavior Surveillance: National College Health Risk Behavior Survey-- United
States, 1995. MMWR Vol. 46. No SS-6 November 14, 1997
4. "HIV Prevention Strategic Plan through 2005" U.S Department of Health and Human
Services. CDC. January 2001.
5. "HIV Counseling, Testing, and Referral Standards and Guidelines." U.S Department of
Health and Human Services. CDC. May 1994
6. "Immunization of Adolescents: recommendations of the Advisory Committee on
Immunization Practices, the American Academy if Pediatrics, the American Academy of
Family Physicians, and the American Medical Association." Pediatrics 99(3):479-488, 1997
7. 1998 Guidelines for the Treatment of Sexually Transmitted Diseases. MMWR Vol. 47. No
RR-1 January 23, 1998
8. Update: HIV Counseling and Testing Using Rapid Tests-United States, 1995" MMWR
47(11); 211-215.
9. Gilson, R.J. and A. Mindel. "Sexually Transmitted Infections." BMJ 2001;322(7295): 11601164
10. Management of Possible Sexual, Injecting-Drug-Use, or Other Nonoccupational Exposure to
HIV, Including Considerations Related to Antiviral Therapy. MMWR Vol. 47. No. RR-17
September 25, 1998.
11. Katz, M.H. and J.L. Gerberding. “ The Care of Persons with Recent Sexual Exposure to
HIV.” Annals of Intern Med. 1998;128:306-312.