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GENITAL ULCER DISEASE STEPHANIE N. TAYLOR, MD LSUHSC SECTION OF INFECTIOUS DISEASES MEDICAL DIRECTOR, DELGADO PERSONAL HEALTH CENTER NEW ORLEANS, LA.

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Presentation on theme: "GENITAL ULCER DISEASE STEPHANIE N. TAYLOR, MD LSUHSC SECTION OF INFECTIOUS DISEASES MEDICAL DIRECTOR, DELGADO PERSONAL HEALTH CENTER NEW ORLEANS, LA."— Presentation transcript:

1 GENITAL ULCER DISEASE STEPHANIE N. TAYLOR, MD LSUHSC SECTION OF INFECTIOUS DISEASES MEDICAL DIRECTOR, DELGADO PERSONAL HEALTH CENTER NEW ORLEANS, LA

2 DISCLOSURE ä I have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

3 GENITAL ULCER DISEASE Differential Diagnosis: ä ä STDs   Syphilis, Herpes, Chancroid ä ä LGV, Granuloma inguinale, Ectoparasites (infected) ä ä Non-STDs ä ä Trauma, fixed drug eruption, neoplasia ä ä Aphthous ulcers, non-STD infection, Crohn’s Ds. ä ä Behçet’s Syndrome – Oral and/or genital ulcers (not alone), cutaneous lesions, uveitis, arthritis, phlebitis ä ä Reiter’s Syndrome – arthritis, conjunctivitis, urethritis, circinate balanitis, keratoderma blennorrhagicum

4 Primary and secondary syphilis — Rates by state: United States and outlying areas, 2008 Note: The total rate of P&S syphilis for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 4.5 per 100,000 population. The Healthy People 2010 target is 0.2 case per 100,000 population.

5 Primary and secondary syphilis — Age- and sex-specific rates: United States, 2008

6 Primary and secondary syphilis — Male-to- female rate ratios: United States, 1981–2006

7 Primary and secondary syphilis — Reported cases * by stage and sexual orientation, 2008 * 20% of reported male cases with P&S syphilis were missing sex of sex partner information. † MSM denotes men who have sex with men.

8 Primary and secondary syphilis — Cases by sexual orientation and race/ethnicity, 2008

9 SYPHILIS STAGING INFECTION PRIMARY CHANCRE (3 WEEKS) SECONDARY (1-3 MONTHS) (1-3 MONTHS / 60-90%) LATENCY (2-50 YEARS) 70% 30% LIFETIME LATENCY TERTIARY

10 PRIMARY SYPHILIS

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12 Manifestations of Secondary Syphilis ä ä Rash (may be anywhere or look like anything) ä ä Mucous patches; condylomata lata ä ä Lymphadenopathy ä ä ‘Moth eaten’ alopecia ä ä Systemic symptoms (fever, headache, fatigue, arthralgia/myalgia)

13 SECONDARY SYPHILIS

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16 Adenopathy Patchy Alopecia

17 SECONDARY SYPHILIS Condyloma lata

18 LATENT SYPHILIS ä ä Period during which there is no clinical evidence of disease ä ä Serological tests are positive ä ä Arbitrarily divided into “early latent” (infection occurred within the last year) or “late latent”

19 TERTIARY SYPHILIS ä ä Slowly progressive disease - affects any organ system and produces clinical illness years after initial infection ä ä NEUROSYPHILIS - meningitis, general paresis, optic neuritis (  WBCs, + CSF VDRL,  Prot.) ä ä CARDIOVASCULAR - aortic aneurysm, aortic regurgitation ä ä GUMMATOUS - large indurated lesions of skin, GI tract, mouth

20 DIAGNOSIS ä ä Darkfield examination of material from a moist lesion – 70-80% sensitive ä ä Serologic Tests ä ä Non-treponemal (Non-specific) – RPR, VDRL, ART ä ä Treponemal (Specific) – FTA-ABS, TPHA, IgG ä ä Silver stain of biopsy material ä ä DNA Methods (PCR, etc.)

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22 Specific Serologic Tests (IgG, MHA-TP, FTA-Abs, etc) ä ä Detect antibody to specific treponemal antigens (fewer false positives) ä ä May be negative in primary syphilis (70 – 80% sensitive) ä ä Remain positive for life

23 Non-specific Serologic Tests (RPR, VDRL, ART, etc) ä ä Detect antibody to cardiolipin, cholesterol and lecithin (false positives are possible) ä ä May be negative in primary syphilis (70%– 80% sensitive) but almost always positive in secondary syphilis ä ä Reported as reactive, weakly reactive, non- reactive or may be quantified

24 Non-specific Serologic Tests (RPR, VDRL, ART, etc) Quantification: 1:1 1:2 1:4 1:8 1:16 1:32 1:64 …. 1:512 etc. Titers decrease after successful therapy (re-check at 6 and 12 months) A fourfold decrease (2 dilutions) 6 months after treatment is considered a sign of successful treatment

25 Non-specific Serologic Tests (RPR, VDRL, ART, etc) ä ä Titers should eventually fall to zero (non- reactive) after treatment ä ä 10% – 15% of patients remain “serofast” at a low titer - This can result in problems with test interpretation years later

26 Syphilis: 2006 CDC STD Treatment Guidelines ä ä Primary, Secondary, and Early Latent ä ä Benzathine penicillin 2.4 MU IM ä ä PCN allergic– Doxy. 100 mg po bid for 14 days ä ä Late Latent ä ä Benzathine penicillin 2.4 MU IM q wk. x 3 injections ä ä PCN allergic – Doxy. 100 mg po bid x 4 weeks ä ä Neuro-Syphilis – ä ä Aqueous crystalline PCN 3-4 MU IV q 4 hrs days – PCN Allergic need to be desensitized ä ä Special Circumstances ä ä Pregnant and PCN allergic – desensitize and treat ä ä HIV – Same tx. for stage of syphilis in non-HIV pt.

27 CHANCROID ä ä ETIOLOGY ä ä Haemophilus ducreyi ä ä Fastidious organism difficult to isolate ä ä Requires supplemented chocolate agar and 5% CO 2 for growth ä ä EPIDEMIOLOGY ä Seen more commonly in third world countries ä Only 25 cases reported in the U.S. in 2008, but outbreaks have been seen in the past

28 CLINICAL MANIFESTATIONS ä ä Incubation period 5-7 days ä ä A papule develops initially but goes on to erode into a painful, soft, and non-indurated ulcer ä ä 50% of patients will develop painful local adenopathy which may suppurate or rupture

29 CHANCROID Genital Ulcer with Inguinal Buboes in 50%

30 Chancroid: 2006 CDC STD Treatment Guidelines ä ä Azithromycin 1 gm orally single dose ä ä Ceftriaxone 250 mg IM single dose ä ä Ciprofloxacin 500 mg po bid for 3 days ä ä Erythromycin base 500 mg po qid for 7 days

31 Herpes Simplex Virus - Pathophysiology ä ä Mucocutaneous infection; retrograde migration along sensory nerves; latency in dorsal spinal root or trigeminal ganglia; re-activation and recurrent outbreaks. ä ä HSV–1: most infections are orolabial 20% of new genital herpes cases ä ä HSV-2: almost always genital infection orolabial infection is rare

32 GENITAL HERPES ä ä Most common cause of genital ulcer disease in N.A. ä ä Primary Infection ä ä % due to HSV-2 ä ä Typically most severe, systemic symptoms common ä ä Mult. painful vesicles, shallow ulcers, heal 2-3 wks ä ä Recurrences ä ä Less severe lesions ä ä Shorter duration ä ä Most patients with HSV-2 asymp. or do not recognize symptoms ä ä Asymptomatic viral shedding occurs without outbreaks

33 Genital herpes — Initial visits to physicians’ offices: United States, 1966–2005 Note: The relative standard error for genital herpes estimates range from 20% to 30%. SOURCE: National Disease and Therapeutic Index (IMS Health)

34 Disease Spectrum in HSV-2 Seropositive Persons ä ä 20% - Clinical manifestations are recognized as genital herpes ä ä 60% - Clinical manifestations are not recognized as genital herpes ä ä 20% - Subclinical

35 Genital Herpes Initial Presentations for Care ä ä 20% - True primary infection ä ä 40% - Non-primary first episode of genital HSV ä ä 40% - First clinical manifestations of a prior genital HSV infection (recurrence)

36 Features of Primary HSV-2 Infection ä 3-week illness ä Many lesions, frequently bilateral ä Mucosal involvement is common ä Pain may be severe ä Lymphadenopathy is common ä Systemic symptoms are common

37 HERPES SIMPLEX

38 Features of Recurrent Genital Herpes ä ä 5 – 10 days ä ä Fewer lesions, usually unilateral ä ä Mucosal involvement is uncommon ä ä Lymphadenopathy is uncommon ä ä Systemic symptoms are uncommon

39 RECURRENT HERPES SIMPLEX

40 Recurrence of Herpes Outbreaks ä ä Mean number of outbreaks in first year after initial genital HSV-2 infection: ä ä - men 5.2 outbreaks/year - women4.0 outbreaks/year ä ä Rate declines over time ä ä Rates are lower in genital HSV-1 infection ä ä ? Precipitating factors

41 Subclincal Shedding of HSV ä ä Seen in > 95% of persons with HSV-2 (much less common in genital HSV-1) ä ä More frequent in first year after infection (detected on 5 – 10% of days by culture and 20 – 30% of days by PCR) ä ä Less frequent over time (2 –3% of days) ä ä Responsible for most transmission

42 Diagnosis of Genital Herpes ä ä Clinical diagnosis has good specificity in classic cases but lacks sensitivity due to atypical and subclinical cases ä ä Culture (or DFA) 50 – 70% sensitivity ä ä “Type specific” serologic assays with good sensitivity and specificity are now available

43 Treatment of Genital Herpes ä ä Primary and Non-primary Initial Infections ä ä Treat most patients

44 CDC 2006 STD Treatment Guidelines Treatment of First Episode ä ä Acyclovir 400 mg TID for 7-10 days ä ä Acyclovir 200 mg 5x/day for 7 – 10 days ä ä Valacyclovir 1 g BID for 7 – 10 days ä ä Famciclovir 250 mg TID for 7 – 10 days

45 Treatment of Genital Herpes ä ä Primary and Non-primary Initial Infections - treat most patients ä ä Episodic Recurrences - treatment may have minimal benefit

46 CDC 2006 STD Treatment Guidelines Treatment of Episodic Recurrences ä ä Acyclovir 400 mg TID for 5 days ä ä Acyclovir 800 mg BID for 5 days ä ä Acyclovir 800 mg TID for 2 days ä ä Valacyclovir 500 mg BID for 3 days ä ä Valacyclovir 1000 mg q day for 5 days ä ä Famciclovir 125 mg BID for 5 days ä ä Famciclovir 1000 mg BID for 1 day

47 Treatment of Genital Herpes ä ä Primary and Non-primary Initial Infections - treat most patients ä ä Episodic Recurrences - treatment may have minimal benefit ä ä Suppressive Therapy - indicated when outbreaks are frequent - should be discussed with all patients

48 CDC 2006 STD Treatment Guidelines Suppressive Therapy ä ä Acyclovir 400 mg BID ä ä Valacyclovir 1 g q day ä ä Valacyclovir 500 mg q day ä ä Famciclovir 250 mg BID ä ä Reassess the need for continued therapy

49 HSV STD Treatment Guidelines ä ä Initial Episode ä ä Acyclovir, famcicloivir, or valacyclovir X 7-10 days ä ä Recurrences ä ä Acyclovir, famcicloivir, or valacyclovir X 5 days ä ä 2006 STD Guidelines – add 1, 2 and 3-day regimens ä ä Suppressive Therapy ä ä Indicated for patients with 6 outbreaks a year ä ä Reduces the frequency and asymptomatic shedding

50 Approach to the Patient with GUD ä ä History and exam - if the presentation is “classic” then treat based on your clinical diagnosis ä ä Testing - syphilis serologyand darkfield (if available) - culture or serology for herpes (if available) - HIV testing ä ä If diagnosis is not clear, treat for primary syphilis


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