1 / 45

성전파성 질환

성전파성 질환. 성빈센트병원 이 승 주. Topics. Background Information “ Drips ” “ Sores ” Role of STDs in HIV Transmission. Background Information. 용어의 변천. Venereal disease (VD) , Jean Fernel (1558) Syphilis, Gonorrhea, Chancroid Lymphogranuloma venereum , Donovanosis

adanne
Download Presentation

성전파성 질환

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. 성전파성 질환 성빈센트병원 이 승 주

  2. Topics • Background Information • “Drips” • “Sores” • Role of STDs in HIV Transmission

  3. Background Information

  4. 용어의 변천 • Venereal disease (VD), Jean Fernel (1558) • Syphilis, Gonorrhea, Chancroid • Lymphogranulomavenereum, Donovanosis • Sexually transmitted disease (STD), WHO (1974) • Nonspecific urethritis, trichomoniasis, genital herpes, genital warts, hepatitis B, and many others • Sexually transmitted infection (STI),(2000-) • Asymptomatic infected people • Reproductive tract infection (RTI) • Bacterial vaginosis

  5. 성병의 증상 및 무증상 감염 Background • “Drips” (discharges) • Gonorrhea • Chlamydia • Nongonococcal urethritis / mucopurulent cervicitis • Trichomonas vaginitis / urethritis • Candidiasis (vulvovaginal, less problems in men)

  6. 성병의 증상 및 무증상 감염 Background • “Sores” (ulcers) • Syphilis • Genital herpes (HSV-2, HSV-1) • Others uncommon in South Korea • Lymphogranuloma venereum • Chancroid • Granuloma inguinale • “Warts” (condyloma) • Genital HPV (Condyloma acuminata) • Asymptomatic infection • Chlamydia

  7. “Drips” Gonorrhea Nongonococcal urethritis Chlamydia Mucopurulent cervicitis Trichomonas vaginitis and urethritis Candidiasis

  8. Gonorrhea - 임상양상 Drips • Urethritis - male • Incubation: 1-14 d (usually 2-5 d) • Sx: Dysuria and urethral discharge (5% asymptomatic) • Dx: Gram stain urethral smear (+) > 98% culture • Complications • Urogenital infection - female • Endocervical canal primary site • 70-90% also colonize urethra • Incubation: unclear; sx usually in l0 d • Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain • Dx: Gram stain smear (+) 50-70% culture • Complications

  9. Gonorrhea Drips Source: Florida STD/HIV Prevention Training Center

  10. Gonorrhea - Gram Stain Drips Source: Cincinnati STD/HIV Prevention Training Center

  11. Nongonococcal Urethritis Drips Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas

  12. Nongonococcal Urethritis Drips • Etiology: • 20-40% C. trachomatis • 20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium) • Occasional Trichomonas vaginalis, HSV • Unknown in ~50% cases • Sx: Mild dysuria, mucoid discharge • Dx: Urethral smear  5 PMNs (usually 15)/OI field Urine microscopic  10 PMNs/HPF Leukocyte esterase (+)

  13. Chlamydia trachomatis Drips • More than three million new cases annually • Responsible for causing cervicitis, urethritis, proctitis, lymphogranuloma venereum, and pelvic inflammatory disease • Direct and indirect cost of chlamydial infections run into billions of dollars • Potential to transmit to newborn during delivery • Conjunctivitis, pneumonia

  14. Laboratory Tests for Chlamydia Drips • Tissue culture has been the standard • Specificity approaching 100% • Sensitivity ranges from 60% to 90% • Non-amplified tests • Enzyme Immunoassay (EIA), e.g. Chlamydiazyme • sensitivity and specificity of 85% and 97% respectively • useful for high volume screening • false positives • Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2 • sensitivities ranging from 75% to 100%; specificities greater than 95% • detects chlamydial ribosomal RNA • able to detect gonorrhea and chlamydia from one swab • need for large amounts of sample DNA

  15. Laboratory Tests for Chlamydia (continued) Drips • Nucleic Acid Amplification Tests (NAATs) • Polymerase chain reaction (PCR) • Ligase chain reaction (LCR) • Strand displacement amplification (SDA) • Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100% • NAATs ability to detect chlamydia in first void urine

  16. PCR의 기술적인 문제점 • 위음성 • 검사자의 실수, 검체 체취의 문제점 • 기술적인 문제 • 환자의 검체 내에 목적으로 하는 핵산의 양이 적을 때 • 목적으로 하는 핵산의 변이 (Mutation) • 억제물질 (inhibitor)의 존재 • 위양성 • 검사자의 실수, 검체 체취의 문제점 • 목적으로 하지 않은 핵산의 증폭 • 오염 (Contamination)

  17. Dead organism • PCR은 살아있는 미생물과 죽은 미생물을 구별할 수 없다. 항생제 등의 치료로 인해 세균이 죽더라도 그 DNA는 존재한다. • 치료완료 후 즉각적인 검사는 dead organism을 검출하여 양성으로 판정하는 문제가 발생할 수 있다. • 따라서 치료 후 F/U PCR 검사는 치료완료 후 최소 3주 이후에 시행한다.

  18. Not a quantitative test • 보통의 PCR 검사는 정량검사가 아닌 정성검사이다. 따라서 PCR은 미생물의 DNA의 존재여부만을 확인하는 것이지 그 미생물의 양을 측정하는 것이 아니다.

  19. Multiplex PCR • 남성 요도염 또는 여성 STI6종 검사 • Neisseria gonorrhoeae • Chlamydia trachomatis • Mycoplasma genitalium • Ureaplasma urealyticum • Mycoplasma hominis (?? Pathogen이 아닐 가능성) • Trichomonas vaginalis • 한 검체로 동시검사하는 장점 • 각 원인균이 동일한 중요성을 가지고 있는가?

  20. Multiplex PCR • 전립선염 15종 • 요도염 6종 • Escherichia coli • Pseudomonas aeruginosa • Enterococcus faecalis • Proteus spp • Staphylococcus aureus • Klebsiella spp • Strepptpcoccus spp • Enterobacter spp • Veillonella spp • 상기 원인균들이 실제 전립선염 원인균으로 작용하고 있는가?

  21. PCR 검사요약 • PCR은 미생물을 직접 검출할 수 있는 민감하고 빠르고 정확한 검사이다. • 하지만, 언제든지 위양성과 위음성과 같은 기술적인 문제점이 발생할 수 있다. • 따라서 엄격한 정도관리 (strict quality control program)가 필요하다. • 검사하는 의사 또는 의료인 • 검사대행업체 • 또한 이러한 이유 때문에 임상적 적용에도 신중을 요한다.

  22. 올바른 검체채취와 검체의 보관 • 모든 검체가 PCR검사에 이용 가능 • 남성 Urethral swab (전용 면봉 및 운반키트가 추천됨) • 여성 Cervical swab (전용 면봉 및 운반키트가 추천됨) • 여성 Vaginal swab (전용 면봉 및 운반키트가 추천됨) • 여성 Self-collected vaginal swab (우편을 통한 집단검진 screening에 주로 이용) • 남성, 여성 Urine (First-voided urine)

  23. Urine • 비침습적 검체로 선호됨 • 단, 다음 사항에 주의 • First-catch voided urine for urethritis • 적어도 2시간 이상 참거나 first morning urine • 검체의 보관은 냉장고에 • 도말검체는 2℃–27℃에서 5일, 2℃–8℃에서 7일간 보관이 가능하며, 소변검체는 상온에서는 24시간, 2℃–8℃에서는 5일까지 보관이 가능

  24. 치료 • Gonorrhea • Spectinomycin 2g IM once • Ceftriaxone 250mg IM once • Chlamydia and other NGU • Azithromycin 1g PO single dose • Doxycyclin 100mg bid for 7 days • Trichomoniasis • Metronidazole 2g PO single dose • Metronidazole 500mg bid for 7 days • 술 먹지 마세요!

  25. Recurrent urethritis • 원인 • 항생제 내성 • 약을 제대로 먹지 않음 • 파트너 치료 안됨 • Trichomonas vaginalis • HSV urethritis • 다른 문제? : urethral foreign bodies, periurethral fistula, abscess • 치료 • Longer duration of treatment • Azithromycin ↔ Doxycycline • Metronidazole 2g PO once

  26. “Sores” Syphilis Genital Herpes (HSV-2, HSV-1)

  27. Genital Ulcer Diseases –Does It Hurt? Sores • Painful • Chancroid • Genital herpes simplex • Painless • Syphilis • Lymphogranuloma venereum • Granuloma inguinale

  28. Syphilis - Clinical course

  29. Primary Syphilis - 임상양상 Sores • Incubation: 10-90 days (average 3 weeks) • Chancre • Early: macule/papule  erodes • Late: clean based, painless, indurated ulcer with smooth firm borders • Unnoticed in 15-30% of patients • Resolves in 1-5 weeks • HIGHLY INFECTIOUS

  30. Primary Syphilis Chancre Sores Source: Florida STD/HIV Prevention Training Center

  31. Secondary Syphilis - 임상양상 Sores • Represents hematogenous dissemination of spirochetes • Usually 2-8 weeks after chancre appears • Findings: • rash - whole body (includes palms/soles) • mucous patches • condylomata lata - HIGHLY INFECTIOUS • constitutional symptoms • Sn/Sx resolve in 2-10 weeks

  32. Secondary Syphilis: Generalized Body Rash Sores Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

  33. Secondary Syphilis Rash Sores Source: Florida STD/HIV Prevention Training Center

  34. Secondary Syphilis –Condylomata Lata Sores Source: Florida STD/HIV Prevention Training Center

  35. Syphilis - Testing Strategies • Routine Screening – • Nontreponemal test + Confirmatory treponemal test • VDRL (or RPR) + TPHA– Best combination • Follow-up & Monitoring after treatment • 치료 전 반드시 titer!! (Nontreponemal test titer ) • VDRL titer or RPR titer • 같은 방법으로 F/U (ex. VDRL  VDRL)

  36. Response of VDRL titer to therapy

  37. Antibody response in Syphilitic infections

  38. Syphilis - Treatment • Benzathine Penicillin G 240만 IU IM (한올제약 마이신주) • Primary, secondary, early latent : once • Late latent or unknown duration : three doses at 1-week interval • Aqueous crystalline Penicillin G IV (근화제약 페니실린지칼륨주) • Neurosyphilis • Doxycycline PO • Tetracycline PO • Ceftriaxone IM or IV • Azithromycin PO

  39. Syphilis - Follow-up • VDRL titer (RPR titer) • Every 3 – 6 months • Until seronegative or serofast  If not, CSF examination • Persistent syphilitic lesion or titer not decreasing (4 folds)  Retreatment

  40. Persistently positive VDRL • Serofast state • Treatment failure: more likely with erythromycin or tetracycline • Reinfection • Biological false-positives

  41. Serofast state • Positive VDRL for life • Fixed low titer • Usually at titers  1:8 • Due to late treatment

  42. Lack of documented adequate treatment • Stable low titer VDRL extending back over years • Usually do not have active syphilis • Consider asymptomatic neurosyphilis • Treat for late latent syphilis

  43. Random positive VDRL • Without any symptoms or prior history of syphilis • Patient’s denial of any exposure • TPHA & VDRL titer • Consider asymptomatic neurosyphilis • Treat for late latent syphilis

  44. 진단서 발급문제 • 가끔 환자들이 취업 때문에 검진을 받은 후 과거의 매독감염 및 치료 Hx. 때문에VDRL이나 RPR이 seronegative로 전환되지 않고 지속되어 곤란해 하면서 진단서를 발급해달라고 오는 경우가 있습니다. • 완치가 확실한 serofast state일 때는 질병코드를 R76.0 또는 R76.9, 혹시 위양성 반응일 때는 R76.2로 잡고 “상승된 항체역가가 관찰되지만 매독 등 다른 질환은 없다”고 써주면 될 것 같습니다. • R76    혈청의 기타 면역학적 이상 소견(Other abnormal immunological findings in serum)   R76.0 상승된 항체역가(Raised antibody titre)   R76.2 매독의 가양성 혈청 시험(False-positive serological test for syphilis)   R76.9 상세불명의 혈청의 면역학적 이상 소견(Abnormal immunological finding  in serum, unspecified)

  45. Syphilis - Summary • Initial screening: VDRL (or RPR) + TPHA • Before treatment: VDRL (or RPR) titer, HIV & other STD tests • Treatment according to the guideline • Follow-up: VDRL (or RPR) titer • If suspicious, but negative, repeat to confirm.

More Related