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In the name of God. Sexually Transmitted Infections Ataei Behrooz,MD.MPH Medical University Isfahan Department of Infectious Diseases 2011.

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Presentation on theme: "In the name of God. Sexually Transmitted Infections Ataei Behrooz,MD.MPH Medical University Isfahan Department of Infectious Diseases 2011."— Presentation transcript:

1 In the name of God

2 Sexually Transmitted Infections Ataei Behrooz,MD.MPH Medical University Isfahan Department of Infectious Diseases 2011

3 The name of this group of diseases was changed from “venereal diseases” to “sexually transmitted diseases” or “STDs” Now many persons call them “sexually transmitted infections or “STIs.”

4 Sexually Transmitted Infections A STI is an infection that is transmitted through sexually activity

5 Importance of STIs Most neglected area of healthcare in developing countries (vaginitis, cervicitis and PID) Major cause of infertility in both females and males

6 Importance of STIs Account for up to 40% of gynecologic hospital admissions Cofactor in HIV and HBV transmission STDs are almost as common as malaria: 333 million new cases each year

7 Importance of STIs Infertility: – % of males with untreated chlamydia and gonorrhea – % of females with untreated PID (8 - 20% of females with untreated gonorrhea develop PID) Increased risk of HBV and HIV/AIDS transmission

8 STDs are a Significant Problem The consequences of untreated STDs –Ectopic pregnancy (7-10 times increased risk in women with history of PID) –Increased risk of cervical cancer –Chronic abdominal pain (18% of females with a history of PID)


10 BACTERIA Neisseria gonorrhoeae gonorrheaNeisseria gonorrhoeae Chlamydia trachomatis chlamydiaChlamydia trachomatis Treponema pallidum SyphilisTreponema pallidum Hemophilus ducreyi ChancroidHemophilus ducreyi Calymmatobacterium granulomatis Donovanosis (granuloma inguinale)Calymmatobacterium granulomatis Gardnerella vaginalis Gardnerella-associated ("nonspecific") vaginosis OTHERRS :eg. Mycoplasma hominis,Ureaplasma urealyticum

11 VIRUSES Herpes simplex virus Human papilloma virus Hepatitis B virus HIV (AIDS) Cytomegalovirus Molluscum contagiosum virus

12 PROTOZOAL Trichomonas vaginalis Trichomonal vaginitis Entamoeba histolytica Amebiasis in homosexual men Giardia lamblia Giardiasis in homosexual men

13 FUNGI ?Candida albicans Vulvovaginitis, balanitis ECTOPARASITES Phthirius pubis Pubic lice infestation Sarcoptes scabiei ScabiesSarcoptes scabiei


15 Epidemiology HSV has a world wide distribution Humans are the only reservoir of infection Spread by direct contact with infected secretions HSV – 2 more frequent cause of genital infection Major risk of infections 14 – 29 yrs Sero prevalence rates in general papulation 22%

16 Pathogenesis Incubation period 2 – 7 days HSV replicates with in epithelial cells and lyses them Producing thin – walled vesicle Multi nucleated cells with intra nuclear inclusions Regional lymph nodes, enlarged and tender often bilateral

17 HSV also migrates along sensory neurons to sensory ganglia (latent state) Virus migrate back to skin along sensory nerves (Reactivation)

18 Clinical presentation : primary infection In male : Painful vesicle on the glans or penile shaft on erythematous base persist 7 – 14 days In female : painful vesicle on the vulva, perineum, buttocks, cervix or vagina Vaginal discharge frequently Inguinal adenopathy, fever, malaise

19 Recurrent : Grouped vesicles on erthematous base, painful few systemic symptom last days

20 Diagnosis : Appearance of characteristic vesicles is strongly suggestive of HSV infection Tzanck smear (66% sensitive) Tissue culture isolation (gold standard) HSV-2 Antigen Four fold rise in antibodies to HSV-2 (for primary)

21 Treatment Acyclovir (topical, oral, IV ) shorten course of HSV infection Do not prevent latent stage Can not prevent recurrence Prophylactic oral acyclovir (4 -6 yrs) decrease frequency symptomatic recurrences (60% to 80%) Valacyclovir, famcyclovir

22 Shedding of HSV active cervical or vulvar lesions late in pregnancy is indication for cesarean section

23 Recommended Treatment First clinical episode: Acyclovir 400 mg orally 5 times a day for 7-10 days, or famciclovir 250 mg orally 3 times a day for 7-10 days, or valacyclovir 1 g orally 2 times a day for 7-10 days.

24 Recommended Treatment Recurrent episodes : A cyclovir 400 mg orally 3 times a day for 5 days, or 800 mg orally 2 times a day for 5 days or famciclovir 125 mg orally 2 times a day for 5 days

25 Syphilis

26 Epidemiology cases in U.S per year Caused by treponema pallidium Primary syphilis occurs mostly in sexually active 15 – 30 yrs 50% sexual contacts of a patient with primary syphilis infected Incubation period days (21 days)

27 Pathogenesis Treponema pallidium penetrate intact mucous membrane or abraded skin

28 Primary lesion Chancre: Papule that ulcerates, painless, border raised, firm, ulcer indurated,base smooth, usually single, may be genital or almost anywhere, persists 3-6wk,leaving thin, atrophic scar


30 Adenopathy 1 wk after chancre appears, bilateral or unilateral; firm, discrete, movable, no overlying skin changes, painless, nonsuppurative; may persist for months

31 Secondary syphilis 6 – 8 weeks after chancre Skin, mucous membranes, lymph node involved Skin lesion, macular, papular, pustular, follicular, or nodular Generalized, symmetrical In moist intertriginous areas large, pale, flat papules coalesce (condylomata lata)

32 Mucous patches, pain less grayish – white erosion Malaise, anorexia, weight loss fever, sore throat, arthralgias, Generalized, non tender, discrete adenopathy Hepatitis, gasteritis, nephritis, meningitis


34 Late syphilis After 1 to 10 yrs in 15% of untreated patient. Skin gumma (respond) Borne, liver, cardio vascular or CNS gumma Progressive cardiovascular syphilis within 10yrs more than 10% untreated patient CNS syphilis in 8%, 5 to 35 yrs after primary infection Tabes dorsalis, general paresis, meningovascular

35 Diagnosis

36 LABORATORY DIAGNOSIS Direct Examination for Spirochetes In primary, secondary, and early congenital syphilis, the darkfield examination or immunofluorescent staining of mucocutaneous lesions is the quickest and most direct laboratory method of establishing the diagnosis.


38 The standard nontreponemal test is the VDRL slide test. It is now most often used to monitor a patient's response to therapy. Most laboratories and blood banks have adapted a modification for routine screening for syphilis: the

39 rapid plasma reagin (RPR) card test, the automated reagin test (ART), or the toluidine red unheated syphilis test (TRUST). A prozone phenomenon occurs in up to 2% of infected

40 These tests are inexpensive, reliable, and easy to perform. They have utility for screening sera and in areas of high prevalence (e.g., southeastern United States) should still be used to screen hospital admissions. Also, they have great utility as a gauge of the success of treatment.



43 Specific Treponemal Tests These tests would be relatively expensive as screening tests, their principal use is to verify a positive nontreponemal reaginic test result. Once positive, the patient usually remains positive for life

44 In summary, the reaginic antibody tests (RPR, VDRL, ART) are used for screening large numbers of sera, the specific treponemal tests (TPHA, MHA-TP, FTA-abs) for confirming the diagnosis, and the quantitative nontreponemal antibody tests (RPR, VDRL) for assessing the adequacy of therapy.

45 Reversion to a non reactive status may occur in up to 10% of patients, especially in those who are treated early.

46 Treatment


48 Jarisch-Herxheimer Reaction Systemic reaction Resembling gram negative sepsis Usual1y begins I to 2 hours after the initial treatment of syphilis with effective antibiotics, especial1y penicillin.

49 Follow after treatment Every patient who is treated for syphilis should be sero negative or sero fast with a low fixed titer before termination of follow – up if not therapy should be repeated

50 Abrupt onset of fever, chills, myalgias, headache, tachycardia, hyperventilation, vasodilation with flushing, Varying degrees of obtundation, and mild hypotension. Particularly common when secondary syphilis is treated (70% to 90%) but can occur in any stage (10% to 25%).

51 Lasts from 12 to 24 hours and has been wel1 correlated with the release from the spirochetes.

52 prevented or treated with an anti-inflammatory agent such as aspirin every 4 hours for a period of 24 to 48 hours. Prednisone can also abort the reaction, and one dose of 60 mg PO or IV should be given as adjunctive therapy to JH patients with cardiovascular or symptomatic neurosyphilis and to pregnant patients to avoid catastrophic consequences.

53 2000 cases in U.S. per year, caused by Haemophilus ducreyi Chancroid

54 Incubation 3-5 days; vesicle or papule to pustule to ulcer; soft, not indurate; very painful Primary lesion

55 1 wk after primary in 50%; painful, unilateral (two thirds), suppurative Adenopathy

56 Systemic features: None

57 Organism in Gram stain of pus; can be cultured (75%) but direct yields highest from lymph node. Rx: ceftriaxone, 250 mg once 1M, or ciprofloxocin, 500 mg twice daily for 3 days Diagnosis / treatment

58 Lymphogranuloma venereum cases per year in U.S., due to Chlamydia trachomatis

59 Primary lesion Incubation 5-21 days; painless papule,vesicle, ulcer, evanescent (2-3 days), noted only 10-40%

60 Adenopathy 5-21 days after primary, one third bilateral, tender, matted iliac / femoral “groove sign”; multiple abscesses; coalescent, caseating, supportive, sinus tracts; thick yellow pus; fistulas; strictures; genital ulcerations

61 Fever, arthritis, pericarditis, proctitis, meningoencephalitis. kerataconjunctivitis. Preauricular adenopathy, edema of eyelids, erythema nodosum Systemic features

62 LGV CF positive 85%-90% (1-3 wk); must have high titer(>1:6), cross- reacts with other Chlamydia; also positive STS, rheumatoid factor, cryoglobulins/

63 Rx:Doxycycline,100mg twice daily for 7 days

64 Granuloma inguinale 50 cases in U.S. per year, caused by Calymmatobacterium gronulomatis

65 Incubation 9-50 days; at least one painless papule that gradually ulcerates; ulcers are large (l-4cm),irregular, non tender; with thickened, rolled margins and beefy red tissue of base older portions of ulcer show depigmented scarring, white advancing edge contains new papules

66 No true adenopathy; in one fifth, subcutoneous spread through lymphatics leads to indurated swelling or abscesses of groin (“pseudobuboes”) adenopathy

67 Metastatic infection of bones, joints, liver

68 Scraping or deep curetting at actively extending border; Wright or Giemso stain reveals short, plump, bipolar staining; “Donovan's bodies in macrophage vacuoles/ Rx: tetracycline, 2 g/day for 21 days Diagnosis / treatment

69 genital warts, frequent, caused by human papillomavirus Condyloma acuminatum

70 Characteristic large,soft, fleshy, cauliflower-like excrescences around vulva, glans, urethral orifice anus, perineum Primary lesion

71 None adenopathy

72 None per se; association with cervical dysplasia/ neoplasia

73 Chief importance is distinction from syphilis and chancroid/ Rx: topical podophyllin ± cryosurgery, laser resection Diagnosis / treatment

74 Urethritis

75 GONORRHEA Epidemiology Particular risk factors 1.Urban habitat 2.Low socioeconomic status 3.Un married status 4.Unprotected sexual contacts 50% of females intercourse with a male with gonococcal, urethritis developed symptomatic infection

76 For male 20% A symptomatic infection of male important factor transmission (40%) Co infection with C. trachomatis(30% to 40%) Group B blood increases susceptibility

77 Etiology Neisseria gonorrhea is a gram – Negative, kidney bean shaped diplococcus

78 Clinical presentation Incubation period : 2 to 7 days In male : purulent discharge urethritis and severe Dysuria In female cervicitis : coptous yellow vaginal discharge

79 Females also may develop urethritis with dysuria and frequency Anorectal gonorrhea occurs in both homo sexual males and hetero sexual female Extragenital dissemination occurs in 1% male and 3% female (Arthritis – dermatitis syndrome)

80 Laboratory diagnosis 1.Gram stain (intracellular diplococci) 2.Culter 3.DNA probe


82 Culture A single culture on antibiotic-containing selective medium, such as modified Thayer-Martin agar, has a sensitivity of 95% or more for urethral specimens from men with symptomatic urethritis 80% to 90% for endocervical infection in women.

83 Non gonococcal urethritis (NGU) NGU predominate in higher socioeconomic Chlamydia trachomatis causes 30 to 50% of NGU Chlanmydia – Negative NGU U.urealyticum, trichomonas vaginals

84 Clinical syndromes Incubation period 7 – 14 days Urethral discharge, itching, dysuria Discharge is not spontaneous Discharge apparent after milking urethra in morning Mucopurulent discharge consist of thin, cloudy fluid with purulent specks C. trachomatis common cause epididymitis in male 35 yrs age.




88 Initial Treatment for Patient and Partners Treat gonorrhea (unless excluded): plusTreat chlamydial infection: Ceftriaxone, 125 mg IM; or Azithromycin, 1 g PO; or Cefpodoxime, 400 mg PO; or Doxycycline, 100 mg bid for 7 days Cefixime, 400 mg PO

89 Alternative regimens Ceftizoxime (500 mg IM, single dose) or Cefotaxime (500 mg IM, single dose) or Spectinomycin (2 g IM, single dose) or Cefotetan (1 g IM, single dose) plus probenecid (1 g PO, single dose) or Cefoxitin (2 g IM, single dose) plus probenecid (1 g PO, single dose)


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