Could it be an STI?

Dr Neelam Doshi

Thanks to Stuart Atkin at Gold coast Sexual Health clinic for clinical case pictures
 Kate: JHO
Monday Ophthalmology
Patient
Gonococcal presentation
 Gonorrhoea

• Neisseria gonorrhoeae
• Lower genital tract, rectum, oropharynx and eyes
• Incubation period : within a 1 week ( 1-2 days)
• Males: Purulent urethral discharge, dysuria, frequency, 50% assymptomatic
• Females: 90% mild- asymptomatic infection
– vaginal discharge, dysuria, dyspareunia, abnormal menses

• Investigations: M&CS of infected secretions,

– Rapid screening test : Urine NAAT/PCR-less invasive, dual organisms tested, costly, false positive, no
antibiotic sensitivity
• Smears/Swabs for culture: urethral, cervical, rectal, throat ,eye
• Gram stain: typical intracellular gram negative diplococci
 Gonorrhoea
• Treatment:
– Penicillin, Ciprofloxacin, Tetracycline - Increasing resistance
– Cefixime( single dose), Ceftriaxone, Cefotaxime, Spectinomycin,
– Repeat cultures after a week to confirm Rx effectiveness
– Rule out or co treat with azithromycin for Chlamydia infection

• Prognosis:
Delay in treatment leads to complications
Males: Eipididymo-orchitis, prostatitis, urethral stricture

Females: Salpingo-oophoritis, pelvic inflammatory diseases, infertility

• Prevention:
• Use of condoms
• Contact tracing and treatment
Tuesday: Gastroenterology
Patient one - Proctitis
Patient two:proctocolitis
 Chlamydia trachomatis
• Most common: Non gonococcal STI

• Silent epidemic –asymptomatic

• Highly infective > 50 % chance of transmission after

one sex (0.3% for HIV )

• Early diagnosis : NAAT’s (PCR) ,Not cultured by

routine methods

• Highest notifiable diseases in Australia since 2009

– Indigenous population NT, parts of Queensland and WA
Gram negative obligate Intracellular pathogen .2 forms : dimorphic growth cycle
Elementary body (EB) : Infectious to columnar epithelial cells mainly ….receptor mediated
endocytosis….differentiate into metabolic active form (Reticulate Body RB) ---Replication form ---EB progeny
 Classification : 4 species
• C . trachomatis : Oculo genital
– Serovar L1 L2 L3 : LGV
– Serovar : A B Ba C : Ocular trachoma
– Serovar D-K : Oculo genital
• C. pneumoniae : Respiratory
• C. psittaci: Veterinary /Zoonotic
• C. pecorum: Veterinary
 Clinical features (Chlamydia)
15-29 years age group
Women Men

• Asymptomatic (80%) • Asymptomatic (50%),

•Post coital or •Urethral discharge
intermittent bleeding •Dysuria
•Lower abdominal pain •Proctitis
•Purulent vaginal
discharge
 Diagnosis (Chlamydia)
Men – Urine(morning sample) first part of urine and urethral discharge
swab
Women – Endo cervical swab, urine, vaginal swabs
Self collection kits for urine or low vaginal swabs

Screening : Nucleic acid amplification techniques like PCR detects the

cryptic plasmid in urine or secretions

Slow to grow as obligate intracellular and special tissue culture cells

needed
Tissue culture cells: Genital swabs√ urine ×
IMF: Chlamydial inclusion bodies in tissue cell culture
using labelled monoclonal antibodies
 Treatment (Chlamydia)
• Azithromycin 1 g stat single dose .
• Doxycycline 100 mg bd for 7 days
• Ofloxacin

• Abstain from unprotected sex for a week

 Complications: high morbidity
untreated 5-10% go for complications
•Females :
– Pelvic inflammatory disease
– Infertility (25%)
– Ectopic pregnancy(15%)
– Premature delivery/IUGR
•Males:
– Proctocolitis
– Epididymoorchitis, Prostatitis, Reactive arthritis(HLA B
27)
Wednesday : Dermatology
 Patient one
painless ulcer for 2 weeks
Patient two

Painful inguinal lymph

node
 LGV-Lymphogranuloma
venereum
• C . trachomatis :Genital
– Serovar L1 L2 L3 : LGV
• Restricted areas: Africa, Asia, South and
Central America
• Australian cases 5 /year and are acquired
overseas-Notifiable in few states in
Australia
• Men who have sex with men
 Clinical presentation LGV
IP 4 weeks
Starts as painless genital ulcer
Ulcer heals and goes unnoticed as painless
4-6 weeks later painful inguinal lymph nodes ( Bubo )
Discharging lymphnodes
 LGV-Diagnosis
• Pus / genital swab for PCR
• Active lesions : Biopsy
– Granulomatous lesion

• Treatment as for chlamydia infection

Thursday : Surgery
 Patient
Painful penile ulcer with enlarged tender inguinal lymph node
 Chancroid –Haemophilus
ducreyi
• Gram negative rod
• IP:3 d- 2 weeks
• Red and soft base ulcer- Soft chancre
• Painful
• Irregular ulcers with pus
• LN’s +++
 Chancroid –Daignosis
• Aspirate gram stain-gram negative bacilli
• Growth :×, takes 9 days
• Multiplex PCR √ to rule out coexisting STI’s

• Treatment
– Azithromycin 1 g stat OR
– Ciprofloxacin OR
– Ceftriaxone
 Chancroid
• Tropical/sub tropical countries-
Asia/Africa/Carribean
• Prostitutes
• Cofactor in HIV / STI transmission
• Notifiable in Australia but very rare
Friday: Gynecology
 Patient one
34 yo female with thin frothy copious discharge
 HE stain

Trichomonas Vaginalis

• Parasite
• Flagellated pear
shaped protozoan

Wet prep in clinic

 Trichomoniasis
• Most common STI
• IP: 4-28 days
• Vaginal discharge – white thin frothy
• Men: urethritis
• Treat both partners simultaneously with
oral metronidazole for 7 days as
– asymptomatic carriers
– High recurrence rate
 Patient 2
Bacterial Vaginosis
Gardnerella Vaginalis
Reproductive age females
Greyish thin (serous) fishy discharge
Vulval soreness but no itching
Hay’s criteria: 4
pH >4.5 ( normal vaginal pH is around 4, acidic to keep bacterial growth low )
+ whiffs test (fishy odour with KOH)
clue cells
↓in lactobacilli
 Treatment
• Not sexually transmitted
• Douching, perfumed bath salts a risk factor
• Complication: Premature labour in pregnancy.
• Metronidazole 400 mg tds 7d
 Patient 3
Foul, thick curd like discharge in a patient who is known
diabetic
• •
 Candida ……
• Foul, thick curd like discharge
• Immunosupressed
DM, Stress, recent antibiotics
• Topical Nystatin gel 7 d.
• Fluconazole orally if severe
• Look for co- morbidities.
Saturday: A and E
Patient one
Patient two:
 Syphilis - Treponema pallidum
• Thin coiled highly motile bacteria
• Fastidious growth, cannot survive drying or disinfectants
• Transmission : through skin abrasion or mucous
membrane from close contact of an infected person, not
through fomites
• Vertical transmission
• Incubation period: 2-4 weeks (3 weeks av. ) as multiply
slowly
4 stages:
Primary, secondary, tertiary, late or quaternary syphilis
Only some show all 4 stages

T. pallidum on dark field microscopy

 Primary syphilis
• Primary lesion:
– Papule that breaks down into a hard base,
painless, punched out ulcer = Hard chancre
genital-penis/cervix or extra-genital rectum, lip,
hands

• Regional lymph nodes- enlarged, rubbery and

painless

• Lesions heal spontaneously in 2-6 weeks,

hence go unnoticed
 Secondary syphilis
• 2-10 weeks after primary chancre
• Spread through lymphatics and blood stream
• Generalised maculopapular rash, palms and soles
involved
• Generalised lymphadenopathy, fever, malaise
• Highly infectious stage
• Heal spontaneously

Latent syphillis
Asymptomatic for 3-30 while organisms dormant in liver
spleen or CNS
Secondary syphilis – maculopapular
rash
Secondary syphilis
 Tertiary syphilis
• 3 to 30 years after primary lesion in 30% cases
• Gumma: granulomatous nodules in skin, mucous membrane or
bones
• Gumma break down to form punched out ulcers

Late Syphilis
2 main forms
Cardiovascular syphilis: Aortic aneurysm
Neurosyphilis:
Paresis, Tabes dorsalis, General paralysis of insane
 Diagnosis
Mainly serological : 2 types
•Nonspecific tests ( non treponemal ): SCREENING
– Detect antibody like substance reagin and not trepenemal antibodies hence non
specific tests
– VDRL
– RPR
•Specific tests: CONFORMATORY tests as detect treponemal antibodies
– TPPA, FTA-ABS, ELISA

•Serological tests need to be properly interpreted with signs and symptoms to

determine clinical status as these tests cannot differentiate between past and
recent infection

Treatment:
IM benzathine/Procaine Penicillin, Ceftraixone or oral Doxycycline
Diagnosis: baby panda
* No residents were
harmed in the
preparation of this
lecture
 Never underestimate human behaviour!!

• Infections transmitted through sexual behaviours

– Vaginal
– Oral
– Anal
 STI’s
• 5 out of 10 CDC notifications are STI’s
Chlamydia Gonorrhoea, Syphillis, HepB, HIV

• Public health ( epidemiological) implication

Coexist , Rising Antimicrobial resistance
 Common STI’s ( Red –STI covered )
Bacterial : Chlamydia
Chancroid
Lymphogranuloma venereum (LGV)
Non gonococcal
Donovanosis

Gonorrhoea (NGO)

Syphilis (chancre)
Shigella,Campylocater

Parasitic: Trichomonads , Giardia, Amoebiasis

Viral: HPV (Human papilloma virus)

HSV (Herpes simplex virus)
Hepatitis (Hepatitis B/C virus)
HIV 1/2 (Human immunodeficiency virus)

Fungal: Candidiasis (thrush)

Arthropod infestations:
Pediculosis pubis
Scabies
 Risk factors
• Age: 15 - 30 y.
• Early sexual activity
• Low education level , poor healthcare facility
• Contraceptives: Barrier used less and OC pills used more
• Multiple partners / high risk partners
• Increased international mobility
• Recreational drug use, prostitution, alcohol
• Asymptomatic carriers: multiple infections coexist .
 Sexual Health Services
• Primary / Secondary / Tertiary care
Keys aspects in STI
– Confidentiality
– Privacy
– Contact tracing
– Coexisting infections
 History
• Sexual History
a. To establish the potential source
b. Risk Assessment

• Menstrual, contraception and obstetric history .

• Drug history –allergy, contraceptives

• P/M/H
 Sexual History - detailed
• Number and types of sexual contacts
(genital/genital, oral/genital, anal/genital,
oral/anal) with dates
• Partner’s sex
• regular or casual partner
• Use of condoms / other contraception's
• Previous history of STI’s including dates and
treatment received
• HIV testing and HBV vaccination status
• Travel history
 Presentation to clinics
Asymptomatic Contacts

Symptomatic
Discharge: vaginal / urethral, vulval/perineal soreness.
Genital ulcers, warts
Urinary tract symptoms
Fever, pain, itch, rash, joint pains and eye symptoms
 Examination of the patient
• General examination: mouth
throat, skin and lymph
nodes .
• Inguinal, genital and peri-anal areas
• Groins - lymphadenopathy
• External genitalia- look for erythema,
fissures, ulcers, chancres, pigmented or
hypo pigmented areas and warts
• Signs of skin trauma .
 Men
• Foreskin retracted - balanitis, ulceration,
warts or tumours
• Urethral meatus –redness , discharge
• Scrotal , testes and epididymis .
• Rectal examination / proctoscopy –If rectal
symptoms or those who practise ano-
receptive intercourse
• Peri-anal lesions
• Regional lymph nodes
 Causes of urethral discharge
Infective Non-infective

Neisseria gonorrhoeae Physical or chemical trauma

Chlamydia trachomatis Urethral stricture
Mycoplasma genitalium Non-specific (unknown
Ureaplasma urealyticum aetiology)
Trichomonas vaginalis
Human papillomavirus
Herpes simplex virus
Urinary tract infection (rare)
Treponema pallidum
(meatal chancre)
 Causes of genital ulceration
Infective Non-infective

Syphilis Behcet’s syndrome

Primary chancre Toxic epidermal necrolysis
Secondary mucous patches Stevens-Johnson Syndrome
Tertiary gumma Carcinoma
Chancroid Trauma
LGV
Donovanosis
Herpes simplex (primary or
recurrent)
Herpes zoster
 Women
• Vulval -Bartholin’s glands
• Walls of vagina for warts
• Cervix -ulceration, discharge, bleeding and ectopy

• Bimanual pelvic examination-adnexal tenderness or

masses, cervical tenderness, the position, size and
mobility of the uterus

• Rectal examination and procotscopy performed if the

patient has symptoms or practises ano-receptive
intercourse
 Causes of Vaginal discharge
Infective Non-infective
Bacterial vaginosis
Candida albicans Cervical polyps
Trichomonas vaginalis Neoplasms
Chlamydia trachomatis Retained products
Neisseria gonorrhoeae (e.g. tampons)
Herpes simplex Chemical irritation
 STI – Lab investigations
• Discharge/swab
– grams stain MCS
– Wet preps
• Urine: PCR
• Serology
• Molecular PCR/NAAT
Representative sample
Quick transport
Proper storage
Take home message…….