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Bacterial STDs

Bacterial STDs. 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.

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Bacterial STDs

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  1. Bacterial STDs

  2. Chancroid • Haemophilusducreyi • 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) • Klebsiellagranulomatis • Non-tender, vegetative, hypertrophic, soft, beefy red, gradually enlarging ulcer • Sinuses, hypertrophic scars, esthiomene • Absent lymphatic involvement • Donovan bodies within histiocytes, Giemsa stain

  4. Lymphogranulomavenereum • 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, pararectalbubos, 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 shottyadenopathy; posterior cervical, axillary, epitrochlear • Macular exanthem • Papular eruption • Palms & soles • Ham or copper-colored • Papulosquamous, follicular, lichenoid, annular, corymbose, pustular, rupial, ulcerative • Condylomalata • 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 • Tabesdorsalis: 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 • Condylomatalata • 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

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