Board Review STD’s (+++) Josh Johnson, PGY III

Judith says:

• Multiple STD’s frequently occur together

• When an STD is suspected treat for gonorrhea and chlamydial infection

Chlamydia Trachomatis

• Signs and Symptoms:– Urethritis and cervcitis, watery

• Females 80% asymptomatic– Mucopurlent cervcitis– PID– Can lead to infertility

• Males 50% asymptomatic– Watery discharge

– Treatment• Azithromycin / Doxycycline• Erythromycin in pregnancy• Treat Partners

Reiters Syndrome

• Reactive arthritis associated with immune response to Chlamydia

• Conjunctivitis• Urethrrits• Asymmetric polyarthrits

• Can’t see, Can’t pee and Can’t climb a tree.

Lympogranuloma Venereum

• Sub type of Chlamydia (L1 and L3)• Rare in the US• Signs and Symptoms

– Primary• Genital uclers

– Secondary• 7-30 days after ulcers

• Buboes: Unilateral PAINFUL adenopathy

– Treatment• Doxycyline or Erythromycin

Nisseria Gonorrhea (g- diplo)• 2-8 days after sex

– Men: milky/yellow discharge and dysuria

– Females: asymptomatic , lower

abdominal pain, dysuria, PID–Can get other places

• Eyes• Epididymitis- Orchitis• Anus• Throat• Bartholonian Cyst• Disseminated

– Treatment• Ceftriaxone (no FQ)

Disseminated Gonococcal Infection

• Rash– Hemorrhagic pustules on erythematous

base• Bactermemia

– Meningitis, endocarditits• Oligoarticular arthritis

• Knees most common

• Tenosynovits• ADMIT IV ABX

– And treat partner

Trichomoniasis

• Protozoan• Female

– Itchy, foul odor, yellow green (rarely)

– Vaginal pH>4.5– Strawberry cervix

• Wetmount• Avoid sex for 1 week after

abx• Metronidazole 2gm x 1

Syphylis (Treponema pallidum)

• Primary:– Painless genital chancre– Heals in 4-8 weeks – VDRL not helpful yet…

• Secondary:– 2-10 weeks later– Rash (palms/soles), CNS, Liver… anything

• Tertiary– Years later– Granulomatous lesions, meningitis, dementia,

tabes dorsalis and thoracic aneurysm

– Tabes Dorsalis (syphilitic myelopathy• Demylenation of dorsal columns of spinal cord• Loss of vibration, 2 point touch and ataxia

• Diagnosis• VDRL or RPR• Confirm with a FTA-ABS

• Treatment– PCN 2.4 million units – Possibity Jarisch-Herxheimer reaction:

• Spirochetes die in mass quantities • Fevers, rigors, hypotension

Chancroid• Developing countries• Haemophilus Ducreyi• PAINFUL genital ulcers and PAINFUL

lymphadenitis • Look for other STD’s (herpes and

syphilis• Treatment

– Azithro– Ceftriaxone– Ciprofloxacin– Erythromycin

Pelvic Inflammatory Disease

• Polymicrobal• Risk factors• Signs/symptoms

– Lower abdominal pain– Cervical motion tenderness– Fever

• Complications– Infertility– Ectopic pregnancy

Fitz-Hugh-Curtis Syndrome

• Inflammation of the hepatic capsule and diaphragm:

Herpes Simplex Virus

• ~25% have it• Transmitted via direct contact • Painful shallow ulcers or vesicles• Shedding can occur in asymptomatic patients

• Lives in your spinal cord for life• Brought out by stress• Dx clinical or by PCR

– Old school Tzanck smear

• Treat with Acyc- Famci- or Valacyclovir

Botulism • Botulinum toxin inhibits acetylcholine

release at neuromuscular junction, causing paralysis

• Three main presentations of botulism: – 1) foodborne (canned foods, honey)– 2) infant (most common)– 3) wound (IV drug user, dirty wounds)

• D's of botulism: diplopia, droopy eyes (ptosis) dilated pupils, dry mouth, dysphonia, dysarthria

• Botulism treatment: botulinum antitoxin from CDC, consider early intubation, supportive care

Anthrax

• Endospores (Gram + rods)• No Human-Human Spread• Weapons of mass destruction• 3 types

– Intestinal and oropharyngeal– Cutaneous – Pulmonary

anthrax• Cutaneous

– Puritic but not painful

– Animal hair/wool/hide exposure

– tx Doxy, cipro• Intestinal (rarest)

– Dysentery – ~60% mortality

• Pulmonary• Wide mediastium• No infiltrates • 100% mortality if not

treated in 24 hours• Tx with Floroquinlones

Diptheria (Corynebacterium diptheriae)

• Humans via Respirations• Diptheritic membrane

– Pseudomembrane– Bleeds when scraped– Smells like “wet mouse”

• Endotoxin– Produces membrane– Hemotogenous spread

• Myocarditis (2/3) and neuropathies (descending)

• TX: PCN or erythromycin– Booster to all contacts