1. Jeffrey A. Verona MD
Department of Internal Medicine
Chinese General Hospital and Medical Center
SEXUALLY TRANSMITTED INFECTIONS

3. STI
• In all societies, STIs rank among the most common of all infectious
diseases, with >30 infections now classified as predominantly sexually
transmitted or as frequently sexually transmissible
• Certain STIs, such as syphilis, gonorrhea, HIV infection, hepatitis B,
and chancroid, are most concentrated within "core populations"
characterized by high rates of partner change, multiple concurrent
partners, or "dense," highly connected sexual networks—e.g.,
involving sex workers and their clients, some men who have sex with
men (MSM), and persons involved in the use of illicit drugs,
particularly crack cocaine and methamphetamine

6. SYPHILIS
• a chronic systemic infection caused by Treponema pallidum subspecies
pallidum, is usually sexually transmitted and is characterized by episodes
of active disease interrupted by periods of latency
• After an incubation period averaging 2–6 weeks, a primary lesion appears,
often associated with regional lymphadenopathy
• secondary stage, associated with generalized mucocutaneous lesions and
generalized lymphadenopathy, is followed by a latent period of subclinical
infection lasting years or decades
• In about one-third of untreated cases, the tertiary stage appears,
characterized by progressive destructive mucocutaneous, musculoskeletal,
or parenchymal lesions; aortitis; or late CNS manifestations.

7. CLINICAL MANIFESTATION
Primary Syphilis
The typical primary chancre usually begins as a single painless papule that rapidly
becomes eroded and usually becomes indurated, with a characteristic cartilaginous
consistency on palpation of the edge and base of the ulcer. Multiple primary lesions
are seen in a minority of patients

10. Regional (usually inguinal) lymphadenopathy accompanies the primary syphilitic
lesion, appearing within 1 week of lesion onset. The nodes are firm,
nonsuppurative, and painless. Inguinal lymphadenopathy is bilateral and may
occur with anal as well as with external genital chancres. The chancre generally
heals within 4–6 weeks (range, 2–12 weeks), but lymphadenopathy may persist
for months.

11. Secondary Syphilis
• The protean manifestations of the secondary stage usually include
mucocutaneous lesions and generalized nontender lymphadenopathy
• The skin rash consists of macular, papular, papulosquamous, and
occasionally pustular syphilides; often more than one form is present
simultaneously. Initial lesions are pale red or pink, nonpruritic, discrete
macules distributed on the trunk and proximal extremities; these macules
progress to papular lesions that are distributed widely and that frequently
involve the palms and soles

12. • Constitutional symptoms that may accompany or precede secondary syphilis
include sore throat (15–30%), fever (5–8%), weight loss (2–20%), malaise (25%),
anorexia (2–10%), headache (10%), and meningismus (5%).
• Acute meningitis occurs in only 1–2% of cases, but CSF cell and protein
concentrations are increased in up to 40% of cases, and T. pallidum has been
recovered from CSF during primary and secondary syphilis in 30% of cases; the
latter finding is often but not always associated with other CSF abnormalities.
• Less common complications of secondary syphilis include hepatitis, nephropathy,
gastrointestinal involvement (hypertrophic gastritis, patchy proctitis, or a
rectosigmoid mass), arthritis, and periostitis. Ocular findings that suggest
secondary syphilis include pupillary abnormalities and optic neuritis as well as
the classic iritis or uveitis.

13. Latent Syphilis
Early latent syphilis is limited to the first year after infection,
whereas Late latent syphilis is defined as that of 1 year's (or
unknown) duration.
T. pallidum may still seed the bloodstream intermittently during the
latent stage, and pregnant women with latent syphilis may infect
the fetus in utero. Moreover, syphilis has been transmitted through
blood transfusion or organ donation from patients with latent
syphilis

15. ASYMPTOMATIC NEUROSYPHILIS
• The diagnosis of asymptomatic neurosyphilis is made in patients
who lack neurologic symptoms and signs but who have CSF
abnormalities including mononuclear pleocytosis, increased protein
concentrations, or CSF reactivity in the Venereal Disease Research
Laboratory test.
• Although the prognostic implications of these findings in early
syphilis are uncertain, it may be appropriate to conclude that even
patients with early syphilis who have such findings do indeed have
asymptomatic neurosyphilis and should be treated for neurosyphilis;
such treatment is particularly important in patients with concurrent
HIV infection

16. SYMPTOMATIC NEUROSYPHILIS
• The major clinical categories of symptomatic neurosyphilis include meningeal,
meningovascular, and parenchymatous syphilis
• Meningeal syphilis may present as headache, nausea, vomiting, neck stiffness,
cranial nerve involvement, seizures, and changes in mental status.
• Meningovascular syphilis reflects meningitis together with inflammatory
vasculitis of small, medium, or large vessels. The most common presentation is
a stroke syndrome involving the middle cerebral artery of a relatively young
adult.
• manifestations of general paresis reflect widespread late parenchymal damage

17. Tabes dorsalis is a late manifestation of syphilis that presents as
symptoms and signs of demyelination of the posterior columns,
dorsal roots, and dorsal root ganglia.
• Symptoms include ataxic wide-based gait and foot drop;
paresthesia; bladder disturbances; impotence; areflexia; and
loss of positional, deep-pain, and temperature sensations

18. CARDIOVASCULAR SYPHILIS
• Cardiovascular manifestations, usually appearing 10–40 years after
infection, are attributable to endarteritis obliterans of the vasa vasorum,
which provide the blood supply to large vessels
• Cardiovascular involvement results in uncomplicated aortitis, aortic
regurgitation, saccular aneurysm (usually of the ascending aorta), or
coronary ostial stenosis.

19. LATE BENIGN SYPHILIS (GUMMA)
• Gummas are usually solitary lesions ranging from microscopic to several
centimeters in diameter. Histologic examination shows a granulomatous
inflammation, with a central area of necrosis due to endarteritis obliterans
• Common sites include the skin and skeletal system; however, any organ (including
the brain) may be involved.
• Gummas of the skin produce indolent, painless, indurated nodular or ulcerative
lesions that may resemble other chronic granulomatous conditions, including
tuberculosis, sarcoidosis, leprosy, and deep fungal infections.
• Skeletal gummas most frequently involve the long bones, although any bone may be
affected. Upper respiratory gummas can lead to perforation of the nasal septum or
palate

20. LABORATORY EXAMINATIONS
Demonstration of the Organism
• T. pallidum cannot be detected by culture
• Dark-field microscopy and immunofluorescence antibody staining
have been used to identify this spirochete in samples from moist
lesions such as chancres or condylomata lata
• Tissue treponemes can be demonstrated more reliably in research
laboratories by PCR or by immunofluorescence or
immunohistochemical methods using specific monoclonal or
polyclonal antibodies to T. pallidum

21. SEROLOGIC TEST FOR SYPHILIS
• two types of serologic test for syphilis: nontreponemal and
treponemal
• most widely used nontreponemal antibody tests for syphilis are
the rapid plasma reagin (RPR) and Venereal Disease Research
Laboratory (VDRL) tests, which measure IgG and IgM directed
against a cardiolipin-lecithin-cholesterol antigen complex
• The RPR test is easier to perform and uses unheated serum; it is
the test of choice for rapid serologic diagnosis in a clinical setting
and can be automated
• The VDRL test remains the standard for examining CSF

22. • Treponemal tests: fluorescent treponemal antibody–absorbed (FTA-ABS) test
and the T. pallidum particle agglutination (TPPA) test.
• Treponemal immunochromatographic strip (ICS) tests and enzyme
immunoassays (EIAs)
• Most clinicians need to be familiar with three uses of serologic tests for syphilis:
• (1) screening or diagnosis (RPR or VDRL)
• (2) quantitative measurement of antibody to assess clinical syphilis activity
or to monitor response to therapy (RPR or VDRL)
• (3) confirmation of a syphilis diagnosis in a patient with a reactive RPR or
VDRL test (FTA-ABS, TPPA, EIA)

23. TREATMENT
• Penicillin G is the drug of choice for all stages of syphilis
• T. pallidum is killed by very low concentrations of penicillin G,
although a long period of exposure to penicillin is required
because of the unusually slow rate of multiplication of the
organism.
• Other antibiotics: tetracyclines; cephalosporins;
aminoglycosides; spectinomycin; azithromycin

27. is a sexually transmitted infection (STI) of epithelium
and commonly manifests as cervicitis, urethritis,
proctitis, and conjunctivitis

28. • Neisseria gonorrhoeae is a gram-negative, nonmotile,
non-spore-forming organism that grows singly and in
pairs
• are distinguished from other neisseriae by their ability to
grow on selective media and to utilize glucose but not
maltose, sucrose, or lactose.

29. • Gonorrhea is transmitted from males to females
more efficiently than in the opposite direction

30. GONOCOCCAL INFECTIONS IN MALES
• Acute urethritis is the most common clinical
manifestation of gonorrhea in males
• usual incubation period after exposure is 2–7 days
• Urethral discharge and dysuria, usually without
urinary frequency or urgency, are the major
symptoms

31. Local complications of gonococcal urethritis
 edema of the penis due to dorsal lymphangitis or
thrombophlebitis
 submucous inflammatory "soft" infiltration of the urethral wall
 periurethral abscess or fistula
 inflammation or abscess of Cowper's gland seminal
vesiculitis

32. GONOCOCCAL INFECTIONS IN FEMALES
Gonococcal Cervicitis
Mucopurulent cervicitis is the most common STI diagnosis in
American women
(caused by N. gonorrhoeae, C. trachomatis,
and other organisms)
symptoms usually develop within 10 days of infection and are more
acute and intense than those of chlamydial cervicitis

33. • N. gonorrhoeae may be recovered from the
urethra and rectum of women with cervicitis, but
these are rarely the only infected sites

34. PHYSICAL EXAMINATION
• a mucopurulent discharge (mucopus) issuing from
the cervical os
• Edematous and friable cervical ectopy as well as
endocervical bleeding induced by gentle swabbing
are more often seen in chlamydial infection
• Gonococcal infection may extend deep enough to
produce dyspareunia and lower abdominal or back
pain

35. GONOCOCCAL VAGINITIS
• gonococcal vaginitis can occur in anestrogenic women
(e.g. Prepubertal girls and postmenopausal women)
• vaginal mucosa is red and edematous, and an abundant
purulent discharge is present

36. ANORECTAL GONORRHEA
• Because the female anatomy permits the spread
of cervical exudate to the rectum, N. gonorrhoeae
is sometimes recovered from the rectum of women
with uncomplicated gonococcal cervicitis.

37. PHARYNGEAL GONORRHEA
• mode of acquisition is oral-genital sexual
exposure, with fellatio being a more efficient
means of transmission than cunnilingus
• Most cases resolve spontaneously, and
transmission from the pharynx to sexual contacts
is rare

38. OCULAR GONORRHEA IN ADULTS
• Infection may result in a markedly swollen eyelid,
severe hyperemia and chemosis, and a profuse
purulent discharge
• usually results from autoinoculation from an
infected genital site

40. GONOCOCCAL ARTHRITIS
• results from gonococcal bacteremia
• DGI strains resist the bactericidal action of human serum
and generally do not incite inflammation at genital sites,
probably because of limited generation of chemotactic
factors

41. • Menstruation is a risk factor for dissemination, and
approximately two-thirds of cases of DGI are in women. In
about half of affected women, symptoms of DGI begin
within 7 days of onset of menses.
• Complement deficiencies, especially of the components
involved in the assembly of the membrane attack complex
(C5 through C9), predispose to neisserial bacteremia

42. • clinical manifestations of DGI have sometimes been classified into
two stages:
• a bacteremic stage, which is less common today
• a joint-localized stage with suppurative arthritis
• Patients in the bacteremic stage have higher temperatures, and
chills more frequently accompany their fever. Painful joints are
common and often occur together with tenosynovitis and skin
lesions. Polyarthralgias usually include the knees, elbows, and
more distal joints; the axial skeleton is generally spared.

45. CHLAMYDIA

46. • Oculogenital infections due to C. trachomatis serovars D–K
are transmitted during sexual contact or from mother to
baby during childbirth and are associated with many
syndromes:
cervicitis, salpingitis, acute urethral syndrome,
endometritis, ectopic pregnancy, infertility, and PID in female
patients
urethritis, proctitis, and epididymitis in male patients
conjunctivitis and pneumonia in infants

47. • the LGV serovars (L1, L2, and L3) cause LGV, an invasive sexually
transmitted disease (STD) characterized by acute lymphadenitis with bubo
formation and/or acute hemorrhagic proctitis

48. CLINICAL MANIFESTATIONS:
NON GONOCCOCAL AND POST GONOCOCCAL
URETHRITIS
• C. trachomatis is the most common cause of nongonococcal
urethritis (NGU) and postgonococcal urethritis (PGU)
• The cause of most of the remaining cases of NGU is uncertain, but
recent evidence suggests that Ureaplasma urealyticum, Mycoplasma
genitalium,Trichomonas vaginalis, and herpes simplex virus (HSV)
cause some cases
• NGU is diagnosed by documentation of a leukocytic urethral exudate
and by exclusion of gonorrhea by Gram—s staining or culture

49. EPIDIDYMITIS
• Chlamydial urethritis may be followed by acute epididymitis, but
this condition is rare, generally occurring in sexually active
patients <35 years of age
• The possibility of testicular tumor or chronic infection (e.g.,
tuberculosis) should be excluded when a patient with unilateral
intrascrotal pain and swelling does not respond to appropriate
antimicrobial therapy

50. REACTIVE ARTHRITIS
• Reactive arthritis (formerly known as Reiter—s syndrome) consists of conjunctivitis,
urethritis (or, in female patients, cervicitis), arthritis, and characteristic mucocutaneous
lesions
• most common type of peripheral inflammatory arthritis in young men
• Antibodies to C. trachomatis have also been detected in 46–67% of patients with
reactive arthritis, and Chlamydia-specific cell-mediated immunity has been
documented in 72%
• NGU is the initial manifestation of reactive arthritis in 80% of patients, typically
occurring within 14 days after sexual exposure. The urethritis may be mild and may
even go unnoticed by the patient
• The knees are most frequently involved; next most commonly affected are the ankles
and small joints of the feet. Sacroiliitis, either symmetrical or asymmetrical, is
documented in two-thirds of patients

51. MUCOPURULENT CERVICITIS
• Cervicitis is usually characterized by the presence of a mucopurulent
discharge, with >20 neutrophils per microscopic field visible in strands
of cervical mucus in a thinly smeared, gram-stained preparation of
endocervical exudate.
• Hypertrophic ectopy of the cervix may also be evident as an edematous
area near the cervical os that is congested and bleeds easily on minor
trauma (e.g., when a specimen is collected with a swab).
• A Papanicolaou smear shows increased numbers of neutrophils as well
as a characteristic pattern of mononuclear inflammatory cells including
plasma cells, transformed lymphocytes, and histiocytes.

53. PELVIC INFLAMMATORY DISEASE
• Inflammation of sections of the fallopian tube is often referred to as
salpingitis or PID
• PID occurs via ascending intraluminal spread of C. trachomatis or
N.gonorrhoeae from the lower genital tract. Mucopurulent cervicitis is
often followed by endometritis, endosalpingitis, and finally pelvic
peritonitis
• Chronic untreated endometrial and tubal inflammation can result in
tubal scarring, impaired tubal function, tubal occlusion, and infertility
even among women who report no prior treatment for PID

54. LYMPHOGRANULOMA VENEREUM
• C. trachomatis serovars L1, L2, and L3 cause LGV, an invasive systemic STD.
• The peak incidence of LGV corresponds with the age of greatest sexual activity:
the second and third decades of life.
• LGV was described in association with a concurrent increase in heterosexual
infection with HIV. Reports of outbreaks with the newly identified variant L2b in
Europe, Australia, and the United States indicate that LGV is becoming more
prevalent among MSM. These cases have usually presented as hemorrhagic
proctocolitis in HIV-positive men.
• LGV begins as a small painless papule that tends to ulcerate at the site of
inoculation, often escaping attention

55. • The most common presenting picture in heterosexual men and women
is the inguinal syndrome, which is characterized by painful inguinal
lymphadenopathy beginning 2–6 weeks after presumed exposure;
• inguinal adenopathy is unilateral in two-thirds of cases, and palpable
enlargement of the iliac and femoral nodes is often evident on the
same side as the enlarged inguinal nodes.
• Constitutional symptoms are common during the stage of regional
lymphadenopathy and, in cases of proctitis, may include fever, chills,
headache, meningismus, anorexia, myalgias, and arthralgias

56. • A 7-day course of tetracycline (500 mg four times daily), doxycycline (100 mg
twice daily), erythromycin (500 mg four times daily), or a fluoroquinolone
(ofloxacin, 300 mg twice daily; or levofloxacin, 500 mg/d) can be used for
treatment of uncomplicated chlamydial infections
• Amoxicillin (500 mg three times daily for 7 days) can also be given to
pregnant women. The fluoroquinolones are contraindicated in pregnancy.
• A 2-week course of treatment is recommended for complicated chlamydial
infections (e.g., PID, epididymitis) and at least a 3-week course of
doxycycline (100 mg orally twice daily) or erythromycin base (500 mg orally
four times daily) for LGV.

57. URETHRITIS IN MEN
• Causes include Neisseria gonorrhoeae, C. trachomatis, Mycoplasma genitalium,
Ureaplasma urealyticum, Trichomonas vaginalis, HSV, and adenovirus.
• Establish the presence of urethritis
• If proximal-to-distal "milking" of the urethra does not express a purulent or
mucopurulent discharge, even after the patient has not voided for several hours
(or preferably overnight), a Gram's-stained smear of overt discharge or of an
anterior urethral specimen obtained by passage of a small urethrogenital swab 2–
3 cm into the urethra usually reveals 5 neutrophils per 1000x field in areas
containing cells;
• in gonococcal infection, such a smear usually reveals gram-negative intracellular
diplococci as well.

59. EPIDIDYMITIS
• Acute epididymitis, almost always unilateral, produces pain, swelling,
and tenderness of the epididymis, with or without symptoms or signs
of urethritis
• In sexually active men under age 35, acute epididymitis is caused
most frequently by C. trachomatis and less commonly by N.
gonorrhoeae and is usually associated with overt or subclinical
urethritis.
• Acute epididymitis occurring in older men or following urinary tract
instrumentation is usually caused by urinary pathogens.

60. • Ceftriaxone (250 mg as a single dose IM) followed by doxycycline
(100 mg by mouth twice daily for 10 days) constitutes effective
treatment for epididymitis caused by N. gonorrhoeae or C.
trachomatis
• Fluoroquinolones are no longer recommended for treatment of
gonorrhea in the United States because of the emergence of resistant
strains of N. gonorrhoeae, especially (but not only) among MSM

61. PELVIC INFLAMMATORY DISEASE
• refers to infection that ascends from the cervix or vagina to involve the
endometrium and/or fallopian tubes
• Infection can extend beyond the reproductive tract to cause pelvic
peritonitis, generalized peritonitis, perihepatitis, perisplenitis, or pelvic
abscess
• agents most often implicated in acute PID include the primary causes
of endocervicitis (e.g., N. gonorrhoeae and C. trachomatis)
• PID is most often caused byN. Gonorrhoeae where there is a high
incidence of gonorrhea

62. • Important risk factors for acute PID include the presence of
endocervical infection or bacterial vaginosis, a history of
salpingitis or of recent vaginal douching, and recent insertion of
an IUD.
• Certain other iatrogenic factors, such as dilatation and curettage
or cesarean section, can increase the risk of PID, especially
among women with endocervical gonococcal or chlamydial
infection or bacterial vaginosis

67. GENITAL HERPES

68. CHANCROID

69. LYMPHOGRANULOMA VENEREUM