Sexually transmitted infections (STI) • •I. classical – venereal diseases • • 1) syphilis (lues) • 2) gonorrhea (clap,drip) • 3) chancroid - ulcus molle • 4) lymphogranuloma venereum • 5) granuloma inguinale • •II. non-venereal STDs • 1)Non-specific UGI - chlamydia, • mycoplasma, ureaplasma etc. • + trichomoniasis • + bacterial vaginosis •2) viral STD – HIV,hepatitis,genital herpes • genital warts, molusca •3) parasitic – scabies, phtiriasis • 00007+ 1) Syphilis spirocheta Causative organism: Treponema pallidum Schaudinnfritz Epidemiology •transfer: sexual intercourse (acquired sy) • non-sexual transfer • (transfusion, injury) • • from mother to child • (congenital sy) • •IP 21 days (9-90 d) Primary syphilis •after incubation period of 3 weeks • hard chancre – indurated base • sometimes atypical, multiple or • superficial (primary syphilitic lesion) • •after 4-5 days reg. lymphadenopathy • •after 2-3 w (within 8 w) chancre heals • with a scar •sometimes latency follows Typical chancre 0093 003 Atypical multiple erosions 0093 005 Multiple lesions 0093 006 Primary syphilitis lesions in a female 0093 007 Oral lesions 0093 008 Oral lesions 0093 009 Oral lesions 0093 010 Perianal chancre Secondary syphilis •Starts usually after 9-10 th week, •untreated lasts for 5-6 months, then latency, •Reccurences are possible within 2-5 years • •Reccurent rashes (syphilids) - noninfectious • - macular syphilid (roseola syphilitica) • - papular/papulosquamous syphilid • (lichen syphiliticus) • - palmoplantar syphilid (clavi syphilitici) • - papulocrustous, papuloerrosive • syphilid, pustular syphilid • Roseola syphilitica 0093 011 Lichen syphiliticus 0093 012 Palmoplantar syphilid syfilis 016 Leucoderma syphiliticum 0093 014 Alopecia areolaris 0093 013 •Mucous membranes lesions • (highly contagious !!!!) • • - condylomata lata • - mucous patches • - syphilitic angina • • • • condylomata lata 0093 015 condylomata lata 096 002 condylomata lata 096 003 condylomata lata 096 004 condylomata lata 096 005 condylomata lata 096 007 mucous patches 096 006 syphilitic angina 096 008 Latent Syphilis • •No clinical features (either on the skin, mucous membranes or in internal organs) •just positive serology •longest between 2th and 3rd stage • •after 3-5 but even 10-15 years in 1/3 patients with untreated syphilis progression to 3rd stage • Tertiary Syphilis •Noninfectious, • lesions not containing viable treponemas • •Clinics: • 1) tuberous syphilis • 2) gummata : skin (specif. granuloma) • : organs • tongue, bones- hard palate, • nose and parenchymal • organs – liver, lungs etc. • tuberous syphilis 096 010 Gummata 096 009 gumma of the hard palate with perforation 096 012 •3) Visceral sy : bones • syphilitic periostitis,osteomyelitis • : parenchymal organs • interstit. inflammation- liver,parotides,testes… • •4) KV syphilis : mesaortitis --> aneurysma • endarteritis of coronary vessels • insufficiency of aortal valve • neurosyphilis •Meningovascular damage • - intracranial hypertension • - focal symptoms similar to cerebral stroke •Degeneration of neurons • -general paresis of the insane • disturbances of memory, intetellect, attention, • discernment, moods, depressions, agitation, • dementn states with megalomanic deliria • trembling, dysarthria • neurosyphilis • - tabes dorsalis • sclerosis of the posterior columns of spinal chord • •Progressive ataxia (specific walk, + Romberg sign) •Absent deep tendon reflexes ( but positive Babinski sign) •Argyll-Robertson pupils – no reaction to light •Shooting pains •Sphincter disorders, impotence •Charcot‘s joints – damaged due to a lack of sensation •Trofic defects - malum perforans Congenital Syphilis •Transplacental transfer • conditions - mother has TP in • the blood • - permeable placenta • (rarely before the end of 1st trimester) • • • implications: treated sy – healthy child • non- treated early sy - abortion in 6-7 m • non treated late sy – early congenital sy • - late cong. syphilis • - healthy child • • Early congenital Sy •atrophic newborn •yellow-grey colour (anemia, jaundice) •hepatosplenomegaly •pneumonia alba •general. lymphadenopathy •pemphigus syphiliticus blisters on palms & soles •papulosquamous lesions • • • • pemphigus syphiliticus 096 015 Papuloerrosive lesions,coryza syphilitica 096 011 Early congenital Sy •coryza syphilitica rhinitis •Parrot lines – rhagades--> scars around mouth •30% mucous patches •condylomata lata •Bone damage: saddle nose • palate perforation • frontal bossing • sabre shins saddle nose 096 016 Late congenital Sy • after 2 years of age •Hutchinsons trias: • - barrel incisors • - interstitial keratitis • - 8 th nerve deafness •saddle nose, frontal bossing, sabre shins •effusions to joints /Clutton joints/ •sometimes gummata on the skin •rarely internal organs involvement: hepatosplenomegaly,KV syphilis- mesaortitis •neuro sy – disorders of speech and intellect • • Barrel incisors, diasthema 096 014 Barrel incisors,diasthema 096 013 saddle nose 096 017 Diagnosis of syphilis •Direct examination • •Ulcer or other mucous membranes lesions • I) dark field microscopy Technique: –Massage of the ulcer with a plastic loop, –Picking up the fluid with the loop to a drop of saline solution –Put on a slide –Slowly moving shining spiral structures –in dark field /5 to 15 um, 10 to 20 spirals/ –differentiation from non pathogenic – treponemas/T. macro,microdentium etc./ – –II) DFATP (DIF – Ab against TP), –III ) PCR • Treponema-pallidum-picture • Serology • • 1) nonspecific reactions - antigen is cardiolipin • • 1906 Bordet Wassermann - KFR (BWR) • flocculation reactions (RRR ,VDRL ) • • - screening reaction • • - positive since 5th week after infection • • - sometimes biologic false positivity • –Acute (< 6 months) gravidity, spirochetal infections (leptospirosis), viral infections (mononucleosis, rubella,chicken pox) –Chronic (> 6 months) - chronic infections (leprosy, TBC, malaria), autoimmune disorders(SLE), malignancies, drug abuse • 2) specific reactions – antigen is TP • • • 1949 Nelson TPIT TP immobilization test, not performed now • •FTA-Abs. Test (IgM)(Fluorescent Treponemal Antibody) •Specific confirmation test, positive since 3rd week • •TPHA Test (S-IgM SPHA)(Treponema Pallidum Haemagglutination) sheep ery coated with TP antigens • Screening and confirmation test, positive since 4th week • •ELISA IgM, IgG - confirmation test, early positivity •Westernblot - confirmation test, more accurate than ELISA • •screening – RRR, TPHA, confirmatory – ELISA, WB, FTA ABS Treatment of syphilis •Recent sy: P-PNC G 1,5 -3 mil U im. • 1 week, at the end 1 application of • benzathin PNC 2,4 mil U im. • •Late sy : P-PNC G 1,5-3 mil U. 2 weeks , • then benzathin PNC 3 x á 1 week • •Neurosyphilis: crystalic PNC 18-24mil U/d iv • •allergy : TTC, macrolids – not so effective! • cephalosporins Complications of treatment of syphilis • •Jarisch – Herrxheimer‘s reaction • • •Rupture of the aneurysma of aorta 2) Gonorrhea •pathogen: Neisseria gonorrhoeae •G- diplococcus, 0,8-1,6 um •Acute purulent inflammation of the mucous membranes of urogenital tract (but also rectum,conjunctiva…) •no immunity develops! •transfer: sexual intercourse, • rarely during delivery • exceptionally via objects •IP: 2-6 days ( 1-14 d) Clinical picture • Acute go in men • •Discharge and dysuria •complications: balanitis,balanoposthitis,phimosis, • paraphimosis • Tysonitis, Littreitis, periurethritis, • cavernitis, cowperitis • Ascending infection • prostatitis,epididymitis, seminal vesiculitis • cystitis, ureteritis, pyelonephritis, • sepsis, metastatic complications Acute go in men 096 018 Gonococcal sepsis •Epizodic fever, polyarthritis, •Hemorrhagic ,pustular rashes •Metastatic complications • -mostly knee - gonarthritis • (empyema, perforation, ankylosis), • less often other joints – sterno-clavicular •Pneumonia •Endokarditis,myositis • Chronic gonorrhea in men • •Gonococci hidden in small glands •or in prostate, •Spare milky discharge- ’bonjour drop’ •consequences: stricture of urethra, fimosis, sterility • Acute gonorrhea in women •Urethritis •Cervicitis • •Complications: bartholinitis, paraurethritis,cystitis, • endometritis, salpingitis, adnexitis • peritonitis,perihepatitis, pyelonephritis, sepsis, metastatic complications • Chronic gonorrhea in women • mostly asymptomatic course • inf. hidden in small glands • after intercourse, menses, alcohol intake egestion of cocci and infection of sexual partner • •consequences: sterility, risk of ectopic pregnancy, • chronic PID /pelvic inflam. disease/ 00005+ diagnostics •Microscopy •taking of samples with a loop •smear – spred on a glass slide,heat fixation and Gram staining •Culture – blood agar • t 36 dC, CO2 rich atm. • gray colonies -identification –oxidase reaction and others - ATB sensitivity (PNC, cefalosporins, TTC) • -Serology: unreliable - -PCR • • Extragenital go •Go conjunctivitis • neonatal • adult • •Rectal go • primary • secondary • •Pharyngeal go 096 019 Treatment of gonorrhea •Acute non complicated go: • ceftriaxone 1g i.m. • (+ azithromycine 2g (single dose) • doxycycline 7-10 days 2x100 mg • spectinomycine 2g i.m. • •Complicated, chronic go: • better to treat during hospitalization • ceftriaxone 3-7 days 1g i.m. 3) Chancroid 096 020 Chancroid - Ulcus molle •Causative org.: Hemophilus Ducreyi •short G- rod •IP: 3-5 days ( 1-14 days) •epidemiology: Africa, India, Carribean •No immunity •Clinics: painful ulcer with undermined border,mostly innner aspect of the foreskin •Within 3 weeks lymphadenopathy(bubo) colliquation, fistulas • Chancroid • •Dg: microscopy • described as schools of fish • • culture : blood agar enriched with • vancomycine and 1% izovitalex • •Th: Azithromycine 1g 3 days • Cephalosporins – ceftriaxone 1 g i.m. • Ciprofloxacine 2 x 500 mg 1 week • 4) Lymphogranuloma venereum •cause: chlamydia - serovars L1-3 •IP: 1-3 weeks ( 3-30 days) •Epidemiology: Asia,Africa,India,South Am. •Veneral disease affecting lymphatics •Clinic: small ulcer •Healed within 1 week •After 1-6 weeks regional lymphadenopathy,colliquation,fistulas, healing with scars •consequences: lymphoedema of penis, vulva Lymphogranuloma venereum DSC_0413.JPG Lymphogranuloma venereum 096 026 Lymphogranuloma venereum • •Dg: – serology KFR (titer > 1:64 or • 4 x increase and higher) • – microimmunofluorescence • - culture - expensive • - PCR •Th: doxycycline 2x100mg 3 weeks, • ery 4x500mg 3w, azitro 1g 3 w • surgery of abscesses 5) Granuloma inguinale •Cause: Klebsiella - formerly: Calymmatobacterium granulomatis •G- small oval microorganism • grows intracellularly in macrophages •epidemiology: SE India,N. Guinea, Carribean,South Africa, Australia •IP: 2weeks – 2 months •clinics: chronic ulcerative vegetating • often large ulcers Granuloma inguinale 27531tn.jpg Granuloma inguinale •Dg: • – microscopy- Wright or Giemsa staining: • G-oval bodies inside macrophages, • -culture – difficult -serology (x Kl. Rhinoscleromatis) -PCR • •Th: streptomycine 1g im. 2-3w • azithromycine 1g weekly 4w • doxycycline 2x 100mg 3 w is gis II ) Other STDs • 1) non-specific UG infections • •Most common agents: –Chlamydia trachomatis (D - K) 50% –Mycoplasma, Ureaplasma 20-30% –Trichomonas vaginalis < 5% –Bacterial urethritis <2% –Candida < 2% –Herpes simplex < 2% –Unknown 10 % Chlamydia G- immobile bacteria, round-shaped obligate intracellular parasites lack cytochromes IP 10-20 days chlamydie Serovariants : •serovariant: A-C …. trachoma •serovariant :L1-L3….lymph. vener. •serovariant :D-K … urog. infections • •women: cervicitis (50% asymptom.) • urethritis (mostly asymptomatic) • proctitis • endometritis, salpingitis • PID, infertility •Men: • •Mucopurulent urethritis (10-50%symptomatic) •Epididymitis, prostatitis •Reiter sy: • -starts as urethritis or balanitis circinata • -after 10 -30 days .: arthritis (95%) • conjunctivitis 25-50%) • rashes (10%) • lesions similar to pustular • psoriasis or EEM • • diagnostics •Chlamydia trachomatis (D-K) • microscopy- Giemsa stain • direct IF with monoclonal. Ab, • culture on cell cultures (Mc Koy) • PCR, LCR • • serology - ELISA, KFR, IIF • (unreliable, follow the Ab titre dynamics) Treatment of chlamydial infections • •Doxycycline 2x100 mg 7-10 days •or azitromycine 1g mg 1-3 days •or chinolones 2x 250 mg 5 days • /ofloxacine,ciprofloxacine/ • pregnancy : erythromycine • PID: clindamycine+ gentamycine • or ciprofloxacine+ metronidazole Mycoplasmata, ureaplasmata •M. genitalium, (hominis, fermentans) •(Ureaplasma urealyticum) •Lack cell wall,immobile, ectoparasites •Dg: culture, mycoplasma agar, PCR •Clinical picture: • men: 70 % symptomatic chron. urethritis, • serous discharge, sterile leukocyturia • compl. prostatitis,pyelonefritis,Reiter sy • women : mostly asymptomatic infection: • urethritis, vaginitis, cervicitis, endometritis, • spontaneous abortions •Th: azitromycine 500 mg, then 250 mg until day 5 Trichomoniasis trichomtrophozoiit trichomgiemsa Trichomonas vaginalis – flagellated protozoan - transfer during sex but also via objects /sponges, wet towels/ clinics: women – vaginitis – foamy vaginal discharge dysuria , dyspareunia men – mostly asymptomatic course or mild dysuria dg: mikroscopy -native preparate culture th: metronidazole 1x2g or 2x500mg 1 week 2) Viral STDs • •genital herpes – HSV 1,2 • •genital warts – HPV (6,7,11,16,18) • •molusca contagiosa – poxvirus a) Genital herpes •Causative agent HSV II : 70-90%, • HSV I : 10-30% •Clinical picture: • primoinfection :herpetic blisters-->polycyklic • erosions, very painful,enlarged lymphnodes, • healing 2 to 6 weeks • reccurent infection: approx. 80%, • in women more severe course • asymptomatic infection – carriers • •! Infection in pregnancy ! Genital herpes 096 021 Genital herpes •Dg: clinical appearance • serology : KFR, ELISA,WB • ( culture ) ( PCR ) • •Th: according to the extent- iv. ACV 5mg/kg • p.o. ACV 200-400 mg 5xd • or valacyklovir,famyciclovir • cidofovir •Reccur. infection: prolonged supressive th: •ACV 3x200 or 2x400 mg at least 3months b) Genital warts •Cause: HPV • > 200 types • •83% HPV 6 and 11, •6% HPV 16 a 18 •IP 1-6 months •Some related to cervical carcinoma •vaccination 096 022 Genital warts •Dg: •Clinical appearance • •PCR • •Histology •akantosis, •papilomatosis, •koilocytes = • (hyperchromic nucleus, perinuclear halo) • 096 023 Genital warts •Th: •excision, abrasion •Cryoth., electrocoag. •podophylin tct • podofylotoxin • ( Wartec crm ) •Imiquimod 5% crm • (Aldara) •Vaccination • • 096 024 c) Moluscum contagiosum •cause: poxvirus • MCV1,2 •transfer: •direct contact - among chilren •during sex. intercourse- in young adults around 20 y •No itch, spontaneous regression •Dg: clinics,(histology) •Th: excision, abrasion • cryotherapy • iodine • • 096 025 Moluscum contagiosum IMG_1507 3) Parasitic STD • 1) Phtiriasis (crabs) • •cause:phtirus pubis • = pubic louse (crab) • •Size: approx 2mm • smaller than head or body louse • •IP approx. 30 days • • • • • 00493+ a) Phtiriasis •itching in pubic region ( or in axillary hairs ) • •Nits attached to the hairs just as head lice • •Maculae coeruleae • = violaceous macules • result from the bite •Dg: clinical picture • •Th: ivermectin 0,5% • malathion 0,5% •top. dimethicon • • • • • • • • • • • filcky b) Scabies •Causative agent: • Sarcoptes scabiei • (scabies mite) •Makes burrows in stratum corneum •Feeds with tissue fluid •Size: cca 0,3 mm •IP: 2-6 weeks •Transfer: direct contact indirectly • via linen, underwear, • in cheap hotels,lodging-houses • hospices,retirement houses • among homeless people , • even health-care workers ! • • 00511+ 00512+ Scabies • •clinics: small papules, • doubled • pruritus at night •Predilection:interdigital spaces -fingers, anterior axillary fold,around umbilicus, genitalia • •Dg: clinical appearance • microscopy •Th: topical - permethrine • (Infectoscab) • sulphuric oinment • systemic:ivermectin •!!! Hygienic measures !!! infekční 067 infekční 072