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STD Overview

STD Overview. Sam Brown-Parks, MD, MPH July 17, 2008. Overview. Bacterial Chlamydia Gonorrhea Syphilis Viral HSV HPV HIV Parasitic Trichomonas. Chlamydia. Chlamydia Trachomatis most common treatable bacterial STD 2.8 Million Americans/ year

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STD Overview

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  1. STD Overview Sam Brown-Parks, MD, MPH July 17, 2008

  2. Overview • Bacterial • Chlamydia • Gonorrhea • Syphilis • Viral • HSV • HPV • HIV • Parasitic • Trichomonas

  3. Chlamydia • Chlamydia Trachomatis • most common treatable bacterial STD • 2.8 Million Americans/ year • Transmission: vaginal, anal, oral, perinatal • “Silent” infection- no sx • 75% of women • 50% of men

  4. WOMEN Increased Vag D/C (due to inflammation) +/- Urinary freq/ Dysuria Abdominal Pain Dyspaurenia Menstrual irregularity MEN White to watery penile discharge Dysuria ? No symptoms? Chlamydia: Signs & Symptoms

  5. Chlamydia: Complications • PID • Infertility/ Ectopic Pregnancy • Chronic Pelvic Pain • Reiters Syndrome • Inflammation of eyes, joints, rash • Appendicitis?

  6. Wet Prep with increased WBCs & Bacteria with + physical findings Vaginal/ Urethral DNA probe (with GC) Urine testing Azithromycin 1gm* Rescreen positives in 3 months after treatment + Concomitant tx for GC Testing & Treatment

  7. Gonorrhea • Neisseria gonorrhoeae • Intracellular gm+ diplococci • >700,000 cases in US per year • Transmission: vaginal, anal, oral, perinatal • Often asymptomatic • Can take up to 30 days after infection

  8. WOMEN Often Mild Dysuria Vaginal discharge Irregular bleeding Dyspaurenia MEN Dysuria White, yellow or green penile discharge Swollen, painful testicles Gonorrhea: Signs & Symptoms

  9. Gonorrhea: Complications • PID • Epididymitis • Infertility • Ectopic Pregnancy • Disseminated Gonococcal Disease • Arthritis, dermatitis, endometritis • Increased spread of HIV (contraction and transmission)

  10. Wet Prep with increased WBCs & Bacteria with + physical findings Vaginal/ Urethral DNA probe (with Chlamydia) Urine testing Ceftriaxone 125mg IM* or Cefixime 400mg po* Plus concomitant tx for Chlamydia Testing & Treatment

  11. Syphilis • Treponema pallidum • The “great imitator” • 36,000 cases in 2006 • Transmission: vaginal, anal, oral, perinatal • Increasing number of new cases • Fulton Co #5, DeKalb #11 (2006) • 64% cases involved MSM

  12. Syphilis: Signs & Symptoms • Many are asymptomatic or unaware of lesions at time of transmission • Primary: firm, round, small painless chancre • Usually develop sx 10-90 d after infection (mean 21) • Lasts 3-6 weeks, resolves without treatment • Secondary:can develop in weeks, months • Rash: rough, reddish brown on palms/ soles • +/- fever, +LNs, sore throat, patchy hair loss, h/a,weight loss, muscle aches, and fatigue • Resolves without tx

  13. Syphilis: Signs & Symptoms • Tertiary (latent) Syphilis • Begins as soon as rash disappears • Sx may not develop for 10-20 years • 15% of untreated cases will develop Neurosyphilis • Ataxia, imbalance • Paralysis, numbness • Blindness • Dementia, death

  14. With Chancre: Dark Field Examination Secondary: RPR If +, EIA If +/- FTA-ABS Tertiary: CSF tested <2 years (early latent) Benzathine PCN x 1 Doxycycline if allergic >2 years (late latent) Procaine PCN q wk x3 Neuro findings: PCN IV q 4 hours x 2 wk Testing & Treatment

  15. Viral STDs

  16. Genital Herpes Simplex • Very prevalent STD: 20% in >12yo in US • Most due to HSV-2, occasionally HSV-1 • 1.6M new cases per year in US • Transmitted by Genital-Genital contact or Genital-oral contact as well as through birth canal

  17. Herpes: Signs & Symptoms • Most are asymptomatic • Primary Outbreak (within 2 wks of transmission) • Pruritic, Painful vesicles -> shallow ulceration • Fever, malaise prodrome • Lymphadenopathy • Dysuria • Secondary Outbreaks • Less severe • Decrease in freq over time for most

  18. Herpes: Complications • Recurrent outbreaks with asymptomatic shedding • Dissemination with immunosuppression • Neonatal transmission • Rarely intrauterine infection (congenital herpes)

  19. Viral Culture PCR Antibody testing First Outbreak Acyclovir 400 TID 10d Valcyclovir 1000 BID 10d Famcyclovir 250 TID 10d Recurrent Outbreaks Suppression Valtrex 1000 Qday or 500 QD if <10 /yr Test & Treatment

  20. Human Papilloma Virus • >100 types (including all warts) • Most common STD in US • 20 Million Americans infected • 50% of sexually active people acquire HPV in their lives • Low-risk (Warts): 6 lower risk strains • #6,11 most likely to cause genital warts • High-risk (Cervical CA): 13 high risk strains • #16,18 cause 70% of cervical cancers

  21. HPV: Signs & Symptoms • Usually NONE • Genital warty growths

  22. Only as part of cervical (Pap) testing No Male screening available 80% are cleared without treatment within 2 years Abnormal Pap with +HPV -> colposcopy Warts Topicals Cryotherapy LASER/ Surgical Tests & Treatment

  23. HPV: Complications • Cervical Dysplasia • Urethral Obstruction (uncommon) • High Grade Dysplasia of Anal, perineal tissue in immunocompromised

  24. HPV: Prevention • Condoms • moderate protection • Site dependent • Can still spread skin to skin • Vaccine • 4 strains (6,11,16,18) • Girls ages 9-26 • 3 shots (0, 2, 6 months)

  25. Human Immunodeficiency Virus • First reported in 1981 • Infects cells with CD4 receptors • Causes cell death -> Immunosuppression • >1M Americans HIV+ (1/4 unknown) • Men>Women • Blacks>Hispanics>Whites • AIDS= CD4<200 • 980,000 AIDS cases in US since 1981

  26. Reported Cases of AIDS in Georgia, 1993-2000 Number of Cases 1993 2156 1994 2247 1995 2170 1996 2029 1997 1549 1998 1442 1999 1299 2000 1170

  27. HIV: Transmission • Virus can enter through any mucosal surface • Virus can be found in blood, semen, breast milk, saliva (no evidence of transmission in saliva). • Can be spread Mother to child during pregnancy and delivery. • Risk of infection is greatly increased when infected with other STDs

  28. HIV: Symptoms • Early: 2-8 weeks of infection***highly infectious • Fatigue • Fever • Headache • Enlarged LNs • Later: Up to 10 years after initial infection • PID that does not respond to tx • Persistent yeast infections • Persistent skin rashes or flaky skin • Short term memory loss

  29. + AB 1-3 months after exposure ELISA x2 and Western Blot confirm Should retest again 6 wks after exposure Reverse Transcriptase Inhibitors Triple Therapy=HAART Testing & Treatment

  30. Parasites

  31. Trichomonas • Single cell protozoan, Trichomonas vaginalis • Most prevalent parasite in N. America • Women>Men • 7.4 Million new cases per year • Transmitted penis-vagina or vulva-vulva

  32. Men Most asymptomatic Some men with transient Dysuria Mild Discharge Women Green frothy discharge Vaginal itching Dysuria Dyspaurenia Lower Abdominal Pain Occurs 5-28 d of exposure Trichomonas: Signs & Symptoms

  33. Wet Prep Can see small, red ulcerations on vaginal wall or cervix or strawberry cervix Culture or PCR for men Vaginal pH >5 Metronidazole 2gm single dose 500mg BID x7d Need to treat sex partner(s) Tests and Treatment

  34. Complications • Increase susceptibility to HIV • Preterm labor • Low birth weight infants • Epididymitis, prostatitis

  35. Reportable STDs in Georgia • Syphilis link • Chlamydia • Gonorrhea • Chancroid • HIV

  36. COMMON ERRONEOUS ASSUMPTIONS OF PATIENTS 1. I know exactly where I got this disease. 2. I got this disease from my last sexual partner. 3. When my symptoms are gone, my infection is cured. 4. My symptoms are not from an STD, but from other causes (i.e., stress, chemical burns, zipper trauma, or menstrual cramps)

  37. COMMON ERRONEOUS ASSUMPTIONS OF PHYSICIANS 1. Sexual experience implies sexual knowledge. 2. The definition of “sex” is vaginal intercourse only. 3. Women usually have few sexual partners, while men have several. 4. Physician responsibility ends with the diagnosis and treatment of the disease.

  38. Case • 17 yo female recently sexually active • c/o vaginal lesions • No fevers, chills • +fatigue

  39. The End

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