2.  Large group of obligated intracellular parasites  Coccobacille resemble bacteria (egg shape short thick)  Bacterial endotoxins causes infections  Three species:  Chlamydia trachomatis  Chlamydia psittaci  Chlamydia pneumonia

3.  Nongonococal Urethritis (NGU)  Trachoma  Lymphogranuloma venereum

4.  An infection of the urethra  Usually contacted sexually  Neisseria gonorrhea is the most famous bacterium causing urethritis, but not the most common.  Urethritis not caused by Neisseria gonorrhea is called (NGU)

5. Epidemiology  Not due to the bacterium Neisseria gonorrhoeae  Most common STDs in the USA over 10 million Americans infected  Causal agents include - Chlamydia Trachomatis - Mycoplasma genitalium - Ureaplasma urealyticum  Manifested in male as a urethritis and in female as a cervicitis

6. S & S  Clinical manisfestations of urethritis are usually indistinguishable from gonorrhea and include  An opaque discharge with moderate or scanty quantity  Urethral discharge  Burning on urination

7. Dx  The diagnosis of chlamydial disease has been clinical  By smear and culture

8. Tmt  Tetracycline 500mg four times a day  Doxycycline 100mg twice a day  Erythromycin is an alternative drug and is the drug of choice for the newborn and pregnant women  Partner must also be treated

9. Preventive measures  Health and sex education with emphasis on use of a condom during sexual intercourse

10. Epidemiology  Acute Chlamydial disease of the eye  Worldwide, occuring as an endemic disease  Infectious agent  Chlamydia trachomatis serotypes A-C Related to lymphogranuloma venerum Psittacosis  Most contagious in its early stages

11. S & S  Sudden onset with pain  Photophobia  Blurred vision  Occasionally low-grade fever, headache, malaise and tender preauricular lymphadenopathy

13. Dx  Eye swabs  Conjunctival scrapings

14. Tmt  Doxycycline 100mg bid x 4 weeks  Tetracycline or erythromycin 250mg six times/day  Azithromycin 20mg/kg single-dose therapy

15. Preventive Measures  Education on the need for personal hygiene  Improve basic sanitation including  Availability and use of soap and water  Avoid common-use of towels  Provide adequate case-findings and treatment facilities with emphasis on preschool children  Conduct epidemiologic investigation

16. Epidemiology  Most found in tropical and subtropical areas. Endemic in Asia and Africa  Caused by Chlamydia trachomatis types L1-L3  Acute and chronic sexually transmitted chlamydial disease  Characterized by a transitory primary lesion followed by suppurative lymphadenitis and lymphangitis and serious local complications

17. S & S  First symptom is usually a unilateral, tender enlargement of the inguinal lymph node  Patient may complain  Fever,chills  Malaise  Headaches  Joints pain  Anorexia  Vomitting

19. Dx  Made by demonstration of chlamydial organisms by IFA,EIA,DNA probe,PCR,  Culture of bubo aspirate  Specific micro-IFA serologic test

20. Tmt  Tetracycline 0.25-0.5g four times daily x 21 days  Doxycycline 0.1g twice daily x 21 days  Erythromycin 500mg four times a day x 21 days  Azithromycin 1g orally once weekly x 3/52  Trimethoprim-sulfamethoxazole 160/800mg twice daily x 21 days

21. Preventive measures  Preventive measures are those for sexually transmitted diseases:  Patients should be advised to abstain from sexual intercourse until all lesions are healed  Investigation of contacts and source of infection of all identified sexual contacts  Report to local health authority

23. Epidemiology  Mycoplasmas are pleomorphic, nonmotile microorganisms without cell walls  Smallest independently living organisms Three species are pathogenic to humans  Ureaplasma urealyticum  Mycoplasma hominis  Mycoplasma pneumoniae

24.  Pneumonia  Otitis  Urethritis

25. Epidemiology  Worldwide; sporadic, endemic and occasionally epidemic  Caused by Mycoplasmal pneumoniae  Spread involves close contact or airborne droplets. Attaches to and destroys ciliated epithelial cells of the respiratory tract mucosa  « Mycoplasmal pneumoniae » is the most common pathogen of lung infections

26. S & S  Initial symptoms ressemble influenza  Onset is gradual with  Headache  Malaise  Cough (often paroxysmal )  Substernal pain ( not pleuritic )  Characteristic feature is High fever with bradycardia and diarrhea is common

27. Dx  Diagnosis is based on a rise in antibody titers between acute and convalescent sera  Use of serologic assays (most practical method to confirm); Single elevated IgM  Fourfold rise in titer with peak titer > 1:64  Chest X-Ray shows a patchy bronchopneumonia in the lower lobes

28. Tmt  Tetracycline 500 mg po q 6 hrs for adults  Erythromycin 30 to 50 mg/kg/day for children < 8 yr  Clarithromycin & Azithromycin also effective

29. Preventive Measures  Avoid crowded living and sleeping quarters whenever possible, especially in institutions, barracks, and ships  Report to local health authority, obligatory report of epidemics

30. Epidemiology  Ureaplasma urealyticum and M. hominis are common parasitic microorganisms of the genital tract  Their transmission = sexual activity  Mycoplasma can opportunistically cause inflammation of the reproductive organs of males and females

31. S & S (Men)  Generally appear between 7 and 28 days after intercourse  Usually with mild dysuria and discomfort in the urethra and a clear to mucopurulent discharge  Discharge is frequently more marked in the morning 

32. S & S (Men cont’d)  Meatus may be red with evidence of the dried secretions on underclothes  Occasionnally onset is more acute with dysuria frequency and a copious purulent discharge simulating typical gonococcal urethritis  Proctitis and pharyngitis may develop after rectal and orogenital contact

33. S & S (Women)  Most women are asymptomatic  Vaginal discharge, dysuria, frequency, pelvic pain, and dyspareunia as well as symptoms of proctitis and pharyngitis may occur  Cervicitis with yellow, mucopurulent exudate and cervical ectopy are characteristic 

34. Diagnosis (Men)  Gram-stained slides of the urethral discharge  In mild cases, evidence of urethritis may require examination of urine  If the Dx is in doubt, examination is made on first-voided, morning urine  If infection is present, urethral swabbing usually produces enough material for laboratory examination to confirm Dx 

35. Diagnosis (Women)  Detection of mycoplasma or ureaplasma is currently impractical  Screening for gonococcal co-infections is routine

36. Treatment  Uncomplicated infections are treated with oral administration of either  azithromycin 1g once or  ofloxacin 300 mg bid, tetracycline 500 mg q 6 h or  doxycycline 100 mg bid for 7 days

37. Treatment  Patients who relapse or who develop complications require longer courses  tetracycline 500 mg po q 6 h or  doxycycline 100 mg po bid for 21 to 28 days  In pregnant women  erythromycin 500 mg po q 6 h for at least 7 days should be substituted for tetracycline

38. Prevention  Patients should be advised to abstain from sexual intercourse until treatment is completed and their partners examined and treated  Treated persons should be re-examined and tested for persisting or recurring infection at 8 to 12 wk

39.  Occasionnally, bullae will be seen on the tympanic membrane  Although it is taught that this represents infection with Mycoplasma pneumoniae, most cases involve more common pathogens.

40. DISEASES OF MYCOPLASMS Table 4 DISEASE OR SYMPTOM AGENTHOST Primary atypical pneumonia Mycoplasma pneumoniae Man Genital infection Mycoplasma genitalium Man Rheumatoid arthritis Mycoplasma fermentans Man * Nongonococcal urethritis (NGU) Ureaplasma urealyticum Man * Stillbirth Mycoplasma hominis Man * Spontaneous abortion Mycoplasma hominis Man * Infertility Mycoplasma hominis Man *

41. Variety of diseases manifested by a sudden onset of  Fever.......1-several week  Malaise  Prostration  Peripheral vasculitis  Characteristic rashes  S & S vary from mild to severe

42.  Q fever  Rocky mountain spotted fever  Typhus group

43. Epidemiology  Worldwide in its distribution  Characterized by sudden onset of fever, headache, malaise and interstitial pneumonitis  Acute disease caused by Coxiella burnetii (Rickettsia burnetii )  Transmission is usually by inhalation  Can also be contracted by ingesting infective raw milk

44. S & S  Incubation period varies from 9 to 28 days and averages 18 to 21 days  Onset is abrupt  Fever  Severe headache  Chills  Severe malaise

45. S & S  Myalgia  Chest pain  Nonproductive cough and pneumonia develop during 2nd week  No Rash

46. Dx  Laboratory findings  Elevated liver function occasionally leucocytosis  Diagnosis rise in compliment-fixing atobodies  Isolation of C burnetii is possible (shell-vial technique )  Serum ELISAis also available

47. Dx  Imaging  Radiographs of the chest show patchy pulmonary infiltrates, otfen more prominent than the physical signs

48. Tmt  Tetracycline 250mg q 4 or 6 h  Doxyccycline 100mg twice a day  Chloramphenicol 50mg/kg/daily in 4 divided doses given q 6 h  In acute disease, treatment should be continued until the patient has been afebrile for about 5 days

49. Preventive measures  Educating the public on sources of infection  Pasteurizing milk from cows, goats and sheep  Immunisation with inactivated vaccine prepared from C burnetii

50. Epidemiology  Exposure to tick bite in endemic area  Mode of transmission is usually by bite of an infected tick  An acute febrile disease caused by Rickettsia rickettsii  Producing  High fever  Cough  Rash

51. S & S  Symptoms begin with  Fever  Chills  Headache  Malaise  Rash appears first on the wrist & ankle then spreading to the arms, legs and trunk

53. Dx  Based on serologic response to specific agent  Rickettsia have been identified in skin biopsies using Indirect Fluorescent antibody test  Laboratory confirmation by agglutination of proteus OX19 and OX2 and by specific antibodies with complement fixation and immunoflorescence

54. Tmt  Chloramphenicol 25-50mg/kg/d orally or intravenously in four divided doses  Doxycycline 200mg daily orally or intravenously  Treatment is given for 7 days or through the third day of defervescence

55. Preventive measures  Best means of prevention remains the avoidance of tick-infected habitats  Protective clothing  Tick-repellent chemicals  Removal of tick at frequent intervals

56.  Epidemic Typhus  Endemic Typhus  Scrub Typhus

57. Epidemiology  Also called Louse- borne typhus  Prevalent worldwide  Acute, severe, febrile disease caused by Rickettsia prowazekii  Transmission via louse feces  Characterized by prolonged high fever, intractable headache & maculopapular rash

58. Symptoms begin with  Prodromal malaise  Cough  Headache  Arthralgia  Chest Pain Followed by an abrupt onset of  Chills  Prolonged & high fever  Prostration with flu-like symptoms  Delirium & Stupor  Macular rash

60. Tmt  Tetracycline 25 mg / kg / d in four divided doses for 4 days  Chloramphenicol 50-100 mg / kg /d in four divided doses for 4 days  Doxycycline 5 mg / kg as a single dose

61. Preventive measures  Apply an effective residual insecticide powder at appropriate intervals by hands or power blower to clothes and persons of populations living under favoring lousiness  Improve living conditions with provisions for bathing and washing clothes  Immunize susceptible persons or groups entering typhus area

62. Epidemiology  Also called Murine Typhus or Flea-Borne Typhus  Worldwide,case tend to be scattered, but with a high proportion reported from Texas  An acute febrile disease simular to but milder than epidemic typhus caused by Rickettsua typhy (R. mooseri)  Transmitted to humans by rat fleas

63. S & S  Gradual onset, fever and rash are shorter in duration, and the symptoms are less severe than in the epidemic typhus  Symptoms may mimic measles, rubella and roseola  Rash is maculopapular and concentrated on the trunk and fades rapidly

64. Dx  Clinical differentiation from Rocky Moutain Spotted Fever is established by the early seasonal onset of it and the character of rash  Complement-fixing or immunofluorescent antobodies can be detected in the patient serum with specific R. Typhi antigens

65. Tmt  Tetracycline 25-50 mg / kg / d in four divided doses  Chloramphenicol 50-75 mg / kg / d in four divide doses  Antibiotic treatment is indicated through 3 full days of defervescence

66. Preventive measures Control of rats and ectoparasites (rat fleas) with insecticides, rat poisons and rat-proofing buildings  Case report obligatory in most states (USA) and countries

67. Epidemiology  Also called Mite-borne typhus fever  Exposure to mites in endemic area of Southeast Asia, the western Pacific and Australia  Caused by Rickettsia tsutsugamushi (R. orientalis)  Characterized by fever, a macular rash and lymphadenopathy  Human infection follows a chigger (mite larva) bite

68. S & S  After incubation period of 6 to 21 days  Malaise  Chills  Fever  Severe headache  Backache  Macular papular rash primarily on the trunk  Frequent pneumonitis, encephalitis and cardiac failure

69. Dx  Made by isolation of the infectious agent by inoculating the patient ’s blood into mice.  Fluorescein-labeled antirickettsial assays or commercial dot-blot ELISA dipstick assays are convenient  PCR may be the most sensitive test

70. Tmt  Docycycline 100mg twice a day for 3 days  Chloramphenicol 25 mg / kg / d in four doses for 7 days  Azythromycin is the drug of choice for children, pregnant women, and patient with refractory disease

71. Preventive measures  Impregnating clothes and blankets with miticidal chemicals  Application of mite repellents to exposed skin surfaces  Eliminate mites from the specific sites by application of chlorinated hydrocarbons to ground and vegetation in environs camps, mine buildings and other populated zones in endemic areas

72.  Syphilis  Lyme disease  Relapsing fever

73. Epidemiology  Contagious systemic disease caused by the « spirochete Triponema pallidum »  Characterized by sequential clinical stages and by years of latency  Infection is usually transmitted by sexual contact  Cross placental barrier after 10th week of gestation

74. Epidemiology (cont)  Motile slender spiral shape  Capable of infecting any organ / tissue in the body  Enters the mucous membranes or skin, reaches the regional lymph nodes and disseminates throughout the body

75. S & S  Primary stage  Chancre, regional lymphadenopathy  Secondary stage  Rash on palm and soles  Condyloma latum  CNS,eyes,bones kidneys and joints can be involved  Asymptomatic  Late Latent ( Hidden)  25% may relapse to 2 stage  or Tertiary stage  Symptomatic but not contagious

76. Dx  Clinical history and physical examination  Serologic tests  Investigation of sexual contact  If appropriate  Darkfield examination of fluids from lesions  CSF tests  Radiologic examination  Two classes of serologic tests for syphilis (STS)  Veneral Disease Research Laboratory (VDRL)  Rapid Plasma Reagent ( RPR)

77. Tmt  Penicillin is the antibiotic of choice for all stages of syphilis  A serum level of 0.003IU/ml for 6 to 8 days is required to cure early infectious syphilis  Benzathine penicillin G 2.4 million UIM once produces a satisfactory blood level for 2 wk (1.2 million U/ each buttock)  Two additional injections of 2.4 million U q 7 days should be given for secondary and latent syphilis

78. Preventive measures  General health promotion measures, health and sex education  Protect the community by preventing and controlling STD in prostitutes and their clients  Provide facilities for early diagnosis and treatment  Report to local health authority  Investigation of contacts and source of infection of all identified sexual contacts of confirmed cases of early syphilis should receive treatment

79. Epidemiology  Caused by a spirochete, Borrelia burgdorferi, transmitted primarily by deer tick of the Ixodes scapularis.  It is an inflammatory disorder causing a rash, Erythema Migrans (EM) or Erythema Chronicum Migrans (ECM)  May be followed weeks to months later by neurologic, cardiac and joints abnormalities

80. Erythema chronicum migrams (ECM) starts off as a red (erythematous) flat round rash, wich spreads out (or migrate) over time

81. S & S  Erythema migrans, the hallmark and best clinical indicator of Lyme disease  Begin as a red macule or papule, usually on the proximal portion of an extremity or on the trunk, between 3 to 32 days after tick bite (75% of patients)  Musculoskeletal flu-like syndrome commonly accompanies erythema

83. Dx  Based on both clinical manifestation and laboratory findings  Essentials of diagnosis  Erythema Migrans  Headache of stiff neck  Arthralgia, arthritis and myalgia  Laboratory confirmation require detection of specific antibodies of B burgdoferi in serum

84. Tmt:EM stage  Tetracycline 250mg 4 times daily for 10 to 30 days  Doxycycline 100mg twice daily for 10 to 30 days  Erythromycin can be used in those who are allergic to penicillin or cannot take tetracyclines  Later manifestations of the disease require longer courses of therapy and intravenous therapy

85. Epidemiology  Acute disease caused by several species of Borrelia spirochetes  Infectious organism is a spirochete, Borrelia recurrentis  Transmitted by lice or ticks  Characterized by recurrent febrile episodes lasting 3 to 5 days, separated by intervals of apparent recovery

86. S & S  Sudden chills mark the onset  Followed by  High Fever  Tachycardia  Severe headache  Vomiting  Muscle and joint pain  Often delirium  Erythematous macular or purpuric rash (Trunk & extremities)

87. Dx  Suggested by the recurrent fever  Confirmed by the appearance of spirochetes in the blood during a febrile episode  Spirochetes may be seen on darkfield examination or Wright ’s or Giemsa-stained thick and thin blood smear

88. Tmt  For louse-borne relapsing fever  Tetracycline or Erythromycin 0.5 g po as a single dose  Procaine penicillin G 400,000-600,000 U IM (1 dose)  Doxycycline 100 mg po bid for 5 to 10 days also effective  For tick-borne relapsing fever  Tetracycline or Erythromycin 0.5 g po four times/day for 5 to 10 days

89. Preventive measures  Control lice by measures prescibed for louse-borne typhus fever  Control ticks by measures prescribed for Rocky Moutain spotted fever  Use personal protection measures, including repellents on clothing and bedding for persons with exposure in endemic foci

90. Preventive measures  Control lice by measures prescibed for louse-borne typhus fever  Control ticks by measures prescribed for Rocky Moutain spotted fever  Use personal protection measures, including repellents on clothing and bedding for persons with exposure in endemic foci

91.  Question?