Sexually Transmitted Diseases

1. Sexually Transmitted Diseases Peter Tran, D.O Garden City Hospital

2. Objectives • HSV • Chancroid • Syphilis • Lymphogranuloma Venereum • Chlamydia/Gonorrhea • Trichomoniasis • HPV • Molluscom Contagiosum • Scabies • Pubic lice

3. Epidemiology • 15 million new cases reported each year • 65 million infected with incurable viral STD • HPV • Prevalence – 20 million • Incidence – 6.2 million • ½ of all men and women acquire at some point in their lives • At 50 y/o, 80% of women would acquire HPV.

4. Epidemiology • Chlamydia • Rates steadily rising • 2003 – 900,000 cases reported • 2x the reported cases of gonorrhea

5. Chlamydia — Reported rates: United States, 1984–2001

6. Chlamydia — Rates by state: United States and outlying areas, 2001 Note: The total rate of chlamydia for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 275.5 per 100,000 population.

7. Chlamydia — Rates by sex: United States, 1984–2001

8. Chlamydia — Age- and sex-specific rates: United States, 2001

9. Epidemiology • Gonorrhea • Rates have decreased slightly since 1998. • Higher for non-hispanic blacks (24x the rate for whites) • High for homosexual men • Fluoroquinolone resistance increasing • Not recommend in Hawaii and Calif.

10. Gonorrhea — Reported rates: United States, 1970–2001 and the Healthy People year 2010 objective Note: The Healthy People 2010 (HP2010) objective for gonorrhea is 19.0 cases per 100,000 population.

11. Gonorrhea — Rates by state: United States and outlying areas, 2001 Note: The total rate of gonorrhea for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 126.9 per 100,000 population. The Healthy People year 2010 objective is 19.0 per 100,000 population.

12. Gonorrhea — Rates by region: United States, 1981–2001 and the Healthy People year 2010 objective

13. Gonorrhea — Rates by sex: United States, 1981–2001 and the Healthy People year 2010 objective

14. Gonorrhea — Rates by race and ethnicity: United States, 1981–2001 and the Healthy People year 2010 objective

15. Gonorrhea — Age- and sex-specific rates: United States, 2001

16. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2001 Note: Resistant isolates have ciprofloxacin MICs >1 mg/mL. Isolates with intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 mg/mL. Susceptibility to ciprofloxacin was first measured in GISP in 1990.

17. Epidemiology • Syphilis • Rates have remained steady since 2000 • Incidence 2.5/100,000 people in 2003. • 27% increase in males • 21% decrease in females • Higher in southern states and among blacks

18. Primary and secondary syphilis — Reported rates: United States, 1970–2001 and the Healthy People year 2010 objective Note: The Healthy People 2010 (HP2010) objective for primary and secondary syphilis is 0.2 case per 100,000 population.

19. Primary and secondary syphilis — Rates by state: United States and outlying areas, 2001 Note: The total rate of primary and secondary syphilis for the United States and outlying areas (including Guam, Puerto Rico and Virgin Islands) was 2.2 per 100,000 population. The Healthy People year 2010 objective is 0.2 per 100,000 population.

20. Primary and secondary syphilis — Counties with rates above and counties with rates below the Healthy People year 2010 objective: United States, 2001

21. Primary and secondary syphilis — Rates by region: United States, 1981–2001 and the Healthy People year 2010 objective

22. Primary and secondary syphilis — Rates by sex: United States, 1981–2001 and the Healthy People year 2010 objective

23. Primary and secondary syphilis — Rates by race and ethnicity: United States, 1981–2001 and the Healthy People year 2010 objective

24. Primary and secondary syphilis — Age- and sex-specific rates: United States, 2001

25. STD’s with Genital Ulcers

26. HSV • HSV-2 • 50 million in US HSV-1/HSV-2 • 85-90% of cases • HSV-1 • Cold sores • Can also be transmitted during oral sex • Incubation period - 1 week • Typically presents as painful ulcers of the genitalia or anus and bilateral painful inguinal adenopathy. • A group of vesicles on an erythematous base that does not follow a neural distribution is pathognomonic. • Often associated with flu-like symptoms • Urethral lesions can cause retention • Asymptomatic viral shedding can occur 3 months after presentation

27. HSV

28. HSV • Diagnosis • Classic presentation occurs in a small percentage of patient. • Women can present with atypical lesions • abrasions, fissures or itching • Viral culture with subtyping • Sensitivity - 30-95% • Depends on stage of lesion and whether primary or recurrence. • Treatment • Antiviral • acyclovir, valacyclovir, and famciclovir • Used as first episode, episodic or suppressive • If episodic, must be used during the prodrome phase or 1 day of onset of lesions.

29. Chancroid • Caused by H.ducreyi • Most common STD worldwide • M:F – 3:1 • Incubation – 1-3 weeks • 10% are co-infected with HSV or syphilis • Painful, nonindurated ulcer with a friable base. • Can spread laterally by apposition to the inner thighs. • It is associated with inguinal adenopathy that is typically unilateral and tender with tendency to become suppurative and fistulize. • H. ducreyi is fastidious and difficult to culture. • Gram-stain more helpful. • gram-negative streptobacilli, which are usually arranged in short, parallel chains

30. Chancroid

31. Chancroid • Treatment • Azithromycin 1g PO • Rocephin 250mg IM • Cipro 500mg BID 3 days • Erthromycin 500mg qid x 7 days • Treat sexual partners • Relief of inguinal tenderness by I&D/needle aspiration of the buboes.

32. Syphilis • Caused by the spirochete Treponema Pallidum • Direct contact with lesion, body fluids or in utero. • Incubation – 10 days – 3 months • Primary syphilis is characterized by a single painless, indurated ulcer occurring at the site of inoculation that appears about 3 weeks after inoculation and persists for 4 to 6 weeks. • associated with bilateral, nontender inguinal or regional lymphadenopathy • Often goes unnoticed since its asymptomatic and heals without treatment • Latent syphilis • Defined as seroreactivity with no clinical evidence of disease. • Early latent – within 1 year • Late Latent – beyond 1 year or unknown duration

33. Syphilis

34. Secondary Syphilis • Typically presents several months – 2 years from initial infection • Mucocutaneous, constitutional symptoms • Maculopapular rash • Trunks, palms, soles • Generalized nontender lymphadenopathy • Condyloma lata – very infectious

35. Secondary Syphilis

36. Tertiary Syphilis • 1/3 of untreated patients will develop tertiary syphilis • systemic disease that can affect almost any organ or system, especially the cardiovascular, skeletal, and central nervous systems, and skin. Aortitis, meningitis, uveitis, optic neuritis, general paresis, tabes dorsalis, and gummas of the skin and skeleton.

37. Syphilis • Tests • Non-treponemal • RPR & VDRL • Sensitivity (78% and 86% in primary) about 100% in secondary/tertiary. • Correlate with disease activity. • Negative after 1 year • 4-fold decrease titer represents successful Tx • Treponemal • TP-PA • FTA-ABS • + results stay for life. Does not correlate with disease activity.

38. Syphilis • Treatment • Primary/Secondary • 2.4 mil units Benzthiazide PCN G IM • Jarisch-Herxheimer Rxn • Allergic • Doxy 100mg BID x 14 days • Tertiary • Aqueous crystalline PCN G 3-4 mil units IV q4h x 14 days or Procaine PCN G IM 2.4 mil units qd with probenecid 500mg qid x 14 days

39. Lymphogranuloma Venereum • Caused by Chlamydia trachomatis types L1, L2, L3. • Rare in the US. Mostly tropical regions. • Incubation – 3 days – 1 month • Presents as single painless ulcer on the genitalia. • Painful unilateral, suppurative inguinal lymphadenopathy and constitutional symptoms that occur 1 month after ulcer heals. • Can lead to significant tissue damage with anorectal fistula formation, elephantiasis, urethral destruction. • Treatment • Doxycycline 100 bid x 3 weeks • Erythromycin 500mg qid x 3 weeks

40. Lymphogranuloma Venereum

41. Chlamydia Trachomatis • Types D-K • Most common bacterial STD in US and worldwide. • Most common cause of epididymitis in young men. • 40% of untreated infection in women will lead to PID. • Over half of infected men and women are asymptomatic. • Tests • PCR & endocervical or urethral cultures • Can be done on urine samples • Treatment • Primary • Zithromax 1g • Doxycycline • Alternatives • Erythromycin, levaquin, amoxicillin • Treat sexual partners • Treat for gonorrhea coinfection

42. Chlamydia Trachomatis

43. N. Gonorrhea • Caused by intracellular gram-negative diplococci. • Incubation – 1-2 weeks • Symptoms include LUTS and pelvic discomfort or dysuria in women. • Can lead to PID • Rare but can manifests as systemic disease • Reiter’s Syndrome • “Can’t see, can’t pee, can’t climb a tree” (arthritis, urethritis, conjuctivitis) • Often coinfected with C. trachomatis • Tests • PCR/culture • Can be obtained from urine • Treatment • Primary - Rocephin 125mg IM • Flouroquinolones except in parts of Asia, Pacific, Hawaii, Calif. • Pregnancy – Rocephin or Spectinomycin 2gm IM • Treat for coinfection with C. trachomatis • Treat all sexual partners within 2 months of contact

44. N. Gonorrhea

45. Trichomoniasis • Most common STD worldwide • Caused by the flagellated protozoan Trichomonas vaginalis • Incubation – Days – 1 month • ½ of infected women are asymptomatic • Men can present with LUTS/discharge • Clinically presents with frothy white-green foul-smelling vaginal discharge • “strawberry cervix” • Vaginal wet-mount or microscopic exam of urine • Treatment • Flagyl 2g or 500mg

46. Trichomoniasis

47. Genital Warts • Caused by HPV via direct skin-skin contact • Over 100 different types • Type 6,11 are common • Low risk for conversion to invasive carcinoma • Type 16,18,31,33,35,39,45,51 associated with cervical dysplasia and neoplasm in women and SIN in men • >85% of cervical/anal cancer caused by type 16, 18 • Diagnosis • Visual – nontender cauliflower like genital lesions • Acetic acid 3-5% may show subclinical infection • ? Limited cystoscopy for urethral lesions • Treatment • Patient-Applied • Podofilox 0.5% • Imiquimod 5% cream • Physician-Applied • Cryosurgery, laser, electrosurgery, surgical excision, TCA, BCA

48. HPV

49. Molluscum Contagiosum • Caused by MCV-1 virus • Incubation – 2 weeks – 2 months • Considered an STD in adolescents and adults • Diagnosis • Smooth, round, papule 2-5mm with central umbilication • Biopsy • Henderson-Patterson bodies • Treatment • Benign and self-limiting. Lesions usually resolve by 1 year. • Can be treated by cryo, laser, cautery.

50. Molluscum Contagiosum