Sexually Transmitted Infections
Sexually Transmitted Infections
Sexually Transmitted Infections
Transmitted Diseases
Common Diseases
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STDs
STDs are diseases and infections which are capable of being spread from person to person through:
sexual intercourse oral-genital contact or in non-sexual ways. IV drug Congenitally transmitted
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Common STIs
Chlamydia Gonorrhea Genital Herpes (HSV-2) Genital Warts (HPV) Hepatitis B
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STDs of Concern
Actually, all of them Sores (ulcers)
Syphilis Genital herpes (HSV-2, HSV-1)
Sores
Painless
Syphilis Lymphogranuloma venereum Granuloma inguinale
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Transmission Sexual Trans-placental Percutaneous following contact with infectious lesions Blood Transfusion No reported cases of transmission since 1964
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Primary:
Painless sore (chancre) at inoculation site Secondary: Rash, Fever, Lymphadenopathy, Malaise Tertiary/Latent: CNS invasion, organ damage The physician that knows syphilis knows medicine. Sir William Osler
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Primary Syphilis
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S o r e s
Sores
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Sores
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Secondary Syphilis
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Sores
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Congenital Syphilis
Congenital syphilis usually occurs following vertical transmission of T. pallidum from the infected mother to the fetus in utero, but neonates may also be infected during passage through the infected birth canal at delivery.
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DIAGNOSIS OF SYPHILIS
1. History and clinical examination. 2. Dark-field microscopy: special technique use to demonstrate the spirochete as shiny motile spiral structures with a dark background. The specimen includes oozing from the lesion or sometimes L.N. aspirate. It is usually positive in the primary and secondary stages and it is most useful in the primary stage when the serological tests are still negative.
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Laboratory Testing
Direct examination of clinical specimen by dark-field microscopy or fluorescent antibody testing of sample. Non-specific or non-treponemal serological test to detect reagin, utilized as screening test only. Specific Treponemal antibody tests are used as a confirmatory test for a positive reagin test.
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Diagnosis of Syphilis
Evaluation based on three factors: Clinical findings.
Demonstration of spirochetes in clinical specimen. Present of antibodies in blood or cerebrospinal fluid.
More than one test should be performed. No serological test can distinguish between other Treponemal infections.
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Immunostaining
Direct fluorescent antibody or silver stain
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Non-specific or lipoidal tests A. VDRL (venereal disease research laboratories) - It is useful for the screening, diagnosis and follow up. - The results can be qualitative or qualitative
1. Acute type: usually low titre and dont persist for more than 6 months 2. Chronic type: usually last for more than 6 months B. Rapid plasma reagin test. C. Wasserman test not used more
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Serology
A. Reiter protein complement fixation test. B. Fluorescent Treponemal antibody/absorption test, FTA/ABS. the most specific and most sensitive . C. Treponema pallidum
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VDRL
Each preparation of antigen suspension should first be examined by testing with known positive or negative serum controls. The antigen particles appear as short rod forms at magnification of about 100x. Aggregation of these particles into large or small clumps is interpreted as degrees of positivity Reactive on left, non-reactive on right
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RPR
Test Procedure:
Serum or plasma added to circle on card and spread. One drop of antigen from a needle capable of delivering 60 drops/mL is added. Rotate at 100 rpms/minute for 8 minutes. Results are read macroscopically.
Non-Treponemal Tests:
Advantages
Rapid turnaround time Minutes Inexpensive No specialized instrumentation required Usually revert to negative following therapy Can be used to monitor response to therapy
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Non-Treponemal Tests:
Limitations
Results are subjective Intra- and Inter-laboratory variability Non-specific False positive results can result from other infectious or non-infectious conditions EBV, Lupus, etc. Limited sensitivity in early/primary syphilis and in late/latent syphilis Low throughput Problematic for high volume laboratories
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Non-Treponemal Tests:
Limitations, continued
Possibility for prozone effect High levels of antibody may inhibit the agglutination reaction To identify prozone, labs must serially dilute samples
Undilute
1:2
1:4
1:8
1:16
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Principle: Infection leads to production of specific antibodies directed against T. pallidum Treponemal tests detect IgG or total IgM/IgG antibodies directed against T. pallidum
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Treponemal Assays:
Advantages
High Specificity Possibly higher sensitivity during early and late syphilis stages compared to non-treponemal tests Newer Methods Objective result interpretation Automation option High throughput High reproducibility/precision
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Fluorescent Treponemal Antibody Absorption Test (FTA-ABS) Diluted, heat inactivated serum added to Reiters strain of T. pallidum to remove cross reactivity due to other Treponemes. Slides are coated with Nichols strain of T. pallidum and add absorbed patient serum.
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Treponemal Assays:
Limitations
Remain positive despite treatment Cannot be used to monitor response to therapy Conventional Methods Subjective interpretation requiring technician expertise to read Newer Methods Expensive instrumentation Higher cost/test
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Traditional Algorithm
Non-treponemal test (e.g., RPR) Reactive Treponemal test (e.g., FTA) Non-reactive Negative for syphilis
Reactive Syphilis
Non-reactive
Advantages: Results show good correlation with disease status Rapid, inexpensive screening method Excellent option for laboratory with small throughput Recommended by the CDC
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Traditional Algorithm
Non-treponemal test (e.g., RPR) Reactive Treponemal test (e.g., FTA) Non-reactive Negative for syphilis
Reactive Syphilis
Non-reactive
Disadvantages: Manual (RPR) and subjective interpretation Screening method is non-specific and may lead to false-positive results Not suitable for high throughput laboratories Potentially lower sensitivity for detecting early syphilis and late/latent disease
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Reverse Algorithm
Treponemal test (eg, EIA) Reactive Non-Treponemal test (eg, RPR) Non-reactive Negative for syphilis
Reactive Syphilis
Evaluation Required*
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Sores
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Drips
Gonorrhea Nongonococcal urethritis Chlamydia Mucopurulent cervicitis Trichomonas vaginitis and urethritis Candidiasis
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Gonorrhea
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Diagnosis of Gonorrhoea
Suggestive diagnosis is defined by the presence of: A mucopurulent endocervical or urethral exudate on physical examination and sexual exposure to a person infected with N. gonorrhoea.
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Presumptive diagnosis of gonorrhoea is made on the basis of one of the following three criteria:
Typical gram-negative intracellular diplococci on microscopic examination of a smear of urethral exudate from men or endocervical secretions from women*; Growth of a gram-negative, oxidase-positive diplococcus, from the urethra (men) or endocervix (women), on a selective culture medium, and demonstration of typical colonial morphology, positive oxidase reaction, and typical gram- negative morphology;
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Gonorrhoea
Detection of N. gonorrhoea by a nonculture laboratory test (Antigen detection test (e.g., Gonozyme [Abbott]), direct specimen nucleic acid probe test (e.g., Pace II [GenProbe]), nucleic acid amplification test (e.g., LCR [Abbott]).
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Drips
Nongonococcal Urethritis
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 (+) 72
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Chlamydia
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Chlamydia
Chlamydia is an infection of the penis, vagina, throat, or tube that carries urine. Chlamydia is caused by bacteria (a kind of germ). You get it by having sex with someone who has Chlamydia. Chlamydia can be spread by the vagina, penis, mouth, or anus.
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Chlamydia
Too many people are continuing to have unsafe sex, put themselves at risk of STIs and the serious consequences associated with infection, including infertility. "On-going investment in programmes to increase sexual health awareness, condom use and testing, particularly for groups at most risk, is vital.
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Chlamydia trachomatis
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
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Normal Cervix
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Chlamydia Cervicitis
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Mucopurulent Cervicitis
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Drips
Non-amplified tests
Enzyme Immunoassay (EIA), e.g. Chlamydiazyme
sensitivity and specificity of 85% and 97% respectively useful for high volume screening false positives
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Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100% LCR ability to detect chlamydia in first void urine
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Drips
Complications:
Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia 7X risk of ectopic pregnancy with 1 episode PID chronic pelvic pain in 18%
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Chancroid
The combination of a painful genital ulcer and tender Suppurative inguinal adenopathy suggests the diagnosis of Chancroid A probable diagnosis of Chancroid, for both clinical and surveillance purposes, can be made if all of the following criteria are met: 1) the patient has one or more painful genital ulcers; 2) the patient has no evidence of T. pallidum infection by dark field examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers;
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Chancroid
3) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for Chancroid; and 4) a test for HSV performed on the ulcer exudate is negative.
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Chancroid
A definitive diagnosis of Chancroid requires the identification of H. ducreyi on special culture media that is not widely available from commercial sources; even when these media are used, sensitivity is <80% (145).
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An estimated 5 million new cases occur each year in women and men. Occurs in vagina of women so may be sexually transmitted to men using infected washcloths and towels. It is transmitted to the baby during delivery. It also can occur in the urethra (carries urine to penis) in men, doesnt have symptoms usually. SYMPTOMS: Appear within 5 to 28 days of exposure Women usually have a vaginal discharge that FEMALE SYMPTOMS: Itching and burning at the outside of the opening of the vagina and vulva. Painful and frequent urination Heavy, unpleasant smelling greenish, yellow discharge MALE SYMPTOMS: Usually nothing, or discomfort in urethra, inflamed head of the penis.
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Trichomoniasis
Bacterial Vaginitis
Controversy: STD - yes or no Need for treatment
1980: only if patient complains 2002: increased risk of:
Preterm birth / premature rupture of membranes Amniotic fluid infection Chorioamnionitis / Postpartum endometritis Pelvic inflammatory disease Postsurgical infection Cervical intraepithelial neoplasia Mucopurulent cervicitis Acquisition of HIV Dr.T.V.Rao infection MD
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Life at Risk with Sexually Transmitted Infections Best Choice Play safe
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Email
[email protected]
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