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STD's

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19. Okt 2014

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1
•Sexually Transmitted
Diseases
• Its your health.
• Protect yourself.

• DR.KUNJAN H SHAH
• MODERATOR:
• DR. M.C BANSAL
• DR.PADMA NAGPAL.
2

STI versus STD
• STI – Infections acquired through sexual
intercourse (may be symptomatic or
asymptomatic)
• STD – Symptom...

Classic venereal diseases
• Diseases which spread mainly though sexual
intercourse were named classics venereal
diseases i...

Sexually transmitted disease(STD)
• In 1975,the Term “ sexually
transmitted disease” was given for a
a series of transmiss...

• • Nongonococcal urethritis
• • Vaginitis
• • Genital herpes
• • Molluscum contagiosum
• • Condyloma acuminatum
• • Trich...

Incidence Of STD
7
• 20-25 % of college students across the country have
either been infected with an STD or transmitted a...

8
• In a study conducted in 2001 by the Center for
Disease Control and Prevention, research
concluded that risky sexual be...

NORMAL FLORA ---Vagina
9
• Lactobacillus acidophilus
• Diphtheroids
• Candida

NORMAL Ph AND DISCHARGE
10
• pH 3.8 – 4.2
• Normal discharge
– White
– Odorless
– Seen in dependent areas
– Composed of ba...

11
The incidence of sexually
transmitted disease
• �STD is growing very fast not
only in advancing countries but
also in a...

12
• STDs are a series of transmissible diseases
which is contacted though sexual activity and
also through indirect conta...

Worldwide Burden of Disease
• STIs/RTIs cause a large proportion of the global
burden of ill-health.
• WHO estimates that ...

Worldwide Burden of Disease
• Transmission and prevalence (how
common they are) are influenced by social
and economic fact...

15
Iatrogenic infections are more common
where there are many STIs, and where
health care providers do not have the
traini...

Estimated New Cases of Curable*
STIs Among Adults
16

17
Prevalence and Incidence of STIs
• Higher among urban residents, unmarried,
and young adults
• Differs between countrie...

18
25 years and
older Under 25
years old
63% of all STDs occur in people less than 2563% of all STDs occur in people less ...

19
• Poverty
• Lack of education
• Social inequity
• Inadequate access to health care
• Gender-power imbalances
• Cultural...

Estimated Burden of STD in
U.S.
• STD Incidence Prevalence
• Chlamydia 3 million ---
• Gonorrhea 650,000 ---
• Syphilis 70...

2008 National STD Prevention Conference
Confronting Challenges, Applying Solutions
Chicago, Illinois March 10-13, 2008
• 2...

Route of transmission
• sexual behaviour (directly dissemination) the
main mode of transmission, account for
above 95% of ...

Spread of STD
23
• Skin to Skin contact with
infected areas, including
thighs, scrotum, vulva, penis,
anus
• Touching belo...

24
WOMEN AT RISK THE X FACTOR
• STDs OFTEN
ASYMPTOMATIC
– 75-90% WOMEN WITH
CHLAMYDIA
– 50-70% MEN WITH
CHLAMYDIA
• PID
≤ ...

25
TEENS & SEX
STD TESTS IN ADOLESCENT
CLINICS
• AT-RISK GROUP
– MULTIPLE SEX PARTNERS
– UNPROTECTED SEX
– CONTRACEPTIVE U...

Maternal-Fetal Transmission
Maternal-Infant Transmission
• HIV
• Herpes
• Gonorrhea
• Chlamydia
• Syphilis
26

Consequences of STD
–Some STDs are incurable--
HIV
–Some STDs cause cancer---
HPV
–Some STDs can cause
complications that ...

STD increases HIV susceptibility
• STD causes infection and desquamation of
squamous or columnar cells producing an
inflam...

STD increases HIV transmission
For a person with HIV, having an STD:
• Brings inflammatory cells loaded with HIV to
the ge...

• Clinical manifestation of
common STDs
30

31
How Symptomatic are STIs?

Signs or Symptoms of Sexually
Transmitted Infection
32

33
Common Symptoms for Girls
Some symptoms you may have are:
• Sores, bumps or blisters near genitals,
anus (butt hole) or...

34
Some common symptoms ----
• Sores, bumps or blisters near genitals,
anus or mouth
• Burning or pain when urinate (pee)
...

35
Two Basic Types of STDsTwo Basic Types of STDs
BACTERIA
Gonorrhea
Syphilis
Chlamydia
Chancroid
Spirochete---
Syphilis
•...

• PARASITES:T.VAGINALIS
• FUNGAL: CANDIDIASIS
36

Syphilis
• Syphilis is caused by the treponema palidum.
• Mainly infected though sexual behaviour or
placental infection. ...

Spirochetes
39
• Spirochetes include 3 genera pathognomic
for humans:
• Treponema Pallidum : Venereal
Syphilis,YAWS,pinta
...

Spirochete--
40

MORPHOLOGY
41
• Thin delicate organism with tapering ends
• Measures: 6-15 um x .2um
• Trilaminar cytoplasmic membrane
sur...

PATHOGENESIS
42
• Rapidly penetrates intact mucous membrane ,
skin abrasion
• Enters lymphatic's & blood to produce
system...

Etiopathogenesis; The pathogen is
treponema pallidum.
It is also called Spirochaete
pallida.
43

Spirochetes---
44

Clinical manifestation--Syphilis
• �Acquired syphilis
• �Primary syphilis
• �Secondary syphilis
• �Tertiary syphilis
• �Co...

46
BE AWARE OF IT!!!!!
Up to 50% of people don’t know they have it.
Symptoms may be mild or painless or nearly invisible. ...

Primary syphilis
MAIN feature of is chancre
• �hardness as cartilage
• �single or several
• �without subjective symptom
• ...

48
• Symptoms usually appear 10-90 days after
contact.
• An infected person gets a sore (chancre), which
may be
painful at...

49
Primary chancre on
Prepuce Chancre under prepuce

PRIMARY SYPHILIS-CHANCRE OF
ANUS
51

Secondary syphilis
• Clinical manifestation of secondary syphilis
• Pleomorphism of the lesions: macula�
maculopapule�papu...

Secondary Syphilis
53
• 2nd
stage lasts 3-6 weeks.
• After the chancre comes a copper-colored
skin rash which may appear o...

Secondary Syphilis
• Clinical characteristic of secondary
• syphilis
• �The eruptions are pantomorphia,
generalized,
• hav...

SKIN RASH OVER PALMS
55

RASH ON FOOT
56

2ND
STAGE-PAPULO SQUAMOUS
RASH
57

2ND
STAGE-PAPULOPUSTULAR
RASH
58

SECONDARY SYPHILIS-
ALOPECIA
59

• RASH OVER SOLE OF FOOT
60

Infective Syphilitic Sodden ,moist,
painless peri anal condyloma lata
61

2nd
stage
62

ULCERATING GUMMA OF
FOREARM 2ND
STAGE
63

65
• All symptoms disappear so that the victim
thinks he/she is cured.
• If not received treatment the bacterium
remains i...

66
Late syphilis - serpiginous gumma
of forearm

Tertiary syphilis
• � 2 years after infection, the latest can be
20years.
• The constituent ratio was about 30% in all
syp...

68
Cardiovascular syphilis -
narrowing of coronary Ostia in
aortas

NEUROSYPHILIS- - spirochetes in
neural tissue
69

Tertiary Syphilis
• Clinical characteristic of tertiary syphilis
• �Several lesion, asymmetry distributed, it is
hard to f...

ULCERATING GUMMA
71

72
• The results of the internal damage from the 3rd
stage shows up many years later.
• Ten, twenty, even thirty years aft...

Syphilis Congenita
• Syphilis congenita is acquired from a
mother with early syphilis. It is generally
believed that syphi...

CLINICALLY...
74
• Maculopapular rash ,Vesicles ,Bulla
• Snuffles ,Mucous patches in oropharynx.
Cavity
• Hepatosplenomega...

Congenital Syphilis----
76
LATE MANIFESTATIONS
 Hutchinson teeth ,Mulberry molars
 Interstitial keratitis ,VIII nerve de...

CONGENITAL SYPHILIS-MUCOUS
PATCH
78

PALATAL PERFORATION-
CONG.SYPHILIS
80

Congenital Syphilis---
• Clinical characteristic of syphilis congenita
� No sulcus chancre occurred, already in the
second...

Congenital Syphilis
83

Congenital Syphilis
84

HUTCHISON’S TEETH
85

TEETH ABNORMALITY IN
CONGENITAL SYPHILIS
86

OTHER Organ’s involvement in
Syphilis (Acquired)
87
• Renal :glomerulonephritis, nephrotic
syndrome
• Liver: hepatitis
• B...

88
•Pregnancy
complications:
• Preterm labor
• Spontaneous abortion
• Stillbirth
•Neonatal
complications: (March of
Dimes,...

SYPHILIS & PREGNANCY
89
• Vertical transmission as early as 6 wks
POG
• Clinical manifestations apparent after 16
wks POG
...

Syphilis And Pregnancy---
90
• There is no adverse effects on mother during
pregnancy
• All pregnant women to be screened
...

96
TEST ANTIGEN INTERPRETATION
VDRL (CSF)
Screen
CARDIOLIPIN
CHOLESTEROL
TRUE POSITIVE
RPR TITER >1:2
VDRL TITER >1:2
FA...

Serological tests for syphilis
97
TEST
SENSITIVITY BY STAGE OF
SYPHILIS (%)
SPECIFICITY
(%)
10
20
LATENT LATE
VDRL
78
(74-...

Cong syphilis--Diagnostic
criteria's
98
• Dark field microscopy
• Silver staining
• Immunoflourescence
• PCR
• IgMb wester...

Rx acco. To stage of disease
99
Stages OfStages Of
SyphilisSyphilis
Patient without PenicillinPatient without Penicillin
A...

Monitoring therapy
100
• Monthly VDRL titers during pregnancy
• 3,6 ,9,12 months after therapy thereafter
• Disease of mor...

101

102

Gonorrhea
103

Gonorrhoea
104

105
• Each year approximately 650,000 people in
the United States are infected with
gonorrhea
• People get gonorrhea from ...

Facts to know...
• The vaginal squamous epithelium is
resistant to gonococcus.
• The diplococci attack the columnar
epithe...

107
• Most of those infected show no
symptoms.
• If symptoms do occur, they usually appear
within 2 days to 4 weeks of exp...

108

Clinical manifestation of
gonorrhoea
• �Gonorrhoea in male patients
• �Gonorrhoea in female patients
• �Gonorrhoea in neon...

Gonorrhoea in male patients
• Incubation period is 1-10 days (3-5 days
average )
• Begins with frequent micturation , urge...

complication
• Prostitis
• Epididymitis
• Vesiculitis’
• Uretharal stricture
• developed in later stage
111

Gonococci urethritis
112

Gonococcal fistula in penis
113

Urethritis with balanitis
114

Double gonococcal fistula of penis
115

Orchiditis and scrotal swelling
116

117
Epididymitis: leads to sterility

Symptoms of Gonorrhoea in
Females.
• Women catch this infection from her sex partner
and often remain asymptomatic.
• May ...

Gonorrhoea in female pt.
119
Gonococcal cervicitis– thick yellow pus discharge through and
superficial erosion

BARTHOLIN ABCESS
120

complication
• Pelvic inflammation
• �Bartholinitis
• �Endometritis
• �Salpingitis---Hydro / pyo salpinx—To mass
• Parisal...

Gonorrhoea in neonates / infant
and prepubertal girls.
• � Ophthalmia neonatorum occurs with in 2-3
days after birth ---if...

Gonococal Conjunctivitis
123

GONOCCOCAL EYE
124

125
Gonococcal ophthalmia

Gonococcal pus discharge in pre
pubertal girl
126

Disseminated gonorrhea - skin
lesion
127

others
• �Gonorrhea of rectum and throat
• Caused by heterosexual or homosexual
• sore or red throat due to gonorrhea in t...

129
Salpingitis,
Tubo-ovarian
abscess,
Hydrosalpinx,
partial or complete
tubal block---
Ectopic pregnancy
/ infertility.
A...

130
•Pregnancy
complications:
• Chorioamnionitis
• Intrauterine growth
restriction (IUGR)
• Pelvic abscess or
Bartholin’s ...

Non Gonococcal Urithritis
• NonGonococcaI Urethritis
• �nongonococcal urethritis has obvious
symptom of urethritis, but go...

Non Gonococcal Urithritis
132
• An inflammation or infection of the urethra (the tube that carries
the urine from the blad...

Clinical feature
• Delitescence is 1-3 weeks, manifestation in
male patients is urethritis which is lighter
than gonococca...

134
NGU
Gonococcal

Intra cellular Gram Negetive
Diplococci
135

Urithrits (N.G .)
136

Investigation and Rx Of
Gonococcaql ? Non Gonococcal ?
137

CHLAMYDIA
138

CHLAMYDIA
139
THE MOST COMMON BACTERIAL STD WITH
3 TO 5 MILLION CASES PER YEAR ONLY IN
USA
One of the most common causes o...

140
Girls
8%-35%
Boys
8%-22%
Chlamydia can infect 20-40% of some sexually active groups
Teenage Infection Rtes: Highest of...

141

142
• Is a small gram negative bacteria,an obligate
intracellular parasite,appears as
intracytoplasmic inclusion bodies.
•...

143

144
MALES
• Thin, watery, or milky DISCHARGE from penis
• Pain or BURNING during urination
• Frequent URGE to urinate
• Ma...

Extra Genital Chlamydia
145
Oral –Chlamydia Infection

146
HARMFUL EFFECTS OF CHLAMYDIAHARMFUL EFFECTS OF CHLAMYDIA
Pelvic Inflammatory Disease, Epididymitis,
and Infertility – ...

147
• Arthritis with Chlamydial
infection

Eye with chlymadia
148

Eye with chlymadia
149

Chlymadia cervicitis
150

Opthalmia neonatorum
151

152
• Skin lesions
with
Chlamydial
infection

153

154

155
•Pregnancy
complications:
• PID
• Postpartum or
postabortion
endometritis and
salpingitis
• Preterm delivery
• PROM
• ...

156
LABORATORY DIAGNOSIS
SEXUALLY TRANSMITTED
DISEASES- chlymadia and
gonorrhea

Chlymadia and gonorrhea
157
•
WHEN TO COLLECT………
ENDOCERVIX OR VAGINAL
SPECIMENS

158
ENDOCERVIX VAGINA
Normal pH 7.0 <4.5
Cell Type COLUMNAR
EPITHELIAL
SQUAMOUS
EPITHELIAL
Pathogens Chlamydia
trachomatis...

LAB. Diagnosis---- of chlamydia
159
• Nuclic Acid AMPLIFICATION
– URINE SCREEN
• DIRECT FLUORESCENT AB
• DNA PROBES [DNA A...

LABORATORY TEST
160
GRAM STAIN CULTURE URINE NAA
GC
GRAM – DIPLOCOCCI
(bean-shaped)
SENSITIVITY - MALES
 95-99%
Symptomat...

• So for gonorrhea,
• 1gram stain:>30 pmn/hpf in 5 fields indicates
mucopurulant cervicitis
• 2presence of intacellular di...

URINE NAAT TESTING
162
• NON-INVASIVE, PAINLESS!!!
• AUTOMATION
• TURNAROUND TIME
4 hrs
• SCREENING IS RECOMMENDED
CDC, ...

163

164
• CULTURE - THE GOLD STANDARD
– PHARYNX & ANUS IN MALES & FEMALES
– VAGINA FEMALES
– URETHRA MALES
• NOT RECOMMENDED
–...

165
• CULTURES FROM ALL SITES OF
PENETRATION
• OR
• FDA APPROVED NAAT
– 2 NAATs (different targets)
– both must be positiv...

166

167

GONORRHEA Rx
168
Uncomplicated Gonorrhea[CDC GUIDELINE]
 Cefixime 400mg PO single dose
OR
 Ceftriaxone 125 mg IM single ...

169
Disseminated infection[CDC GUIDELINE]
**Ceftriaxone 1g IV every 24 hrs
OR
 Cefotaxime 1 g iv 8 hrly OR CEFTIZOXIME
1g...

170
Estimated penicillin resistant cases of gonorrhea in USA
- 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000
198...

GENITAL HERPES
( HSV )
175

Genital herpes
• �Genital herpes is a kind of
common
sexually transmitted disease
caused by herpes simplex virus
II though...

Hsv epidemiology
177
• By age 50, >90% people have HSV-1
antibodies
• Prevalence correlates with socioeconomic
status
• HS...

HSV----TYPES
• 8 human herpesviruses (HHVs)
• α-herpesviruses include :
– Herpes simplex virus (HSV)-1
– Herpes simplex vi...

179
• Most people have no symptoms. The first
outbreak typically occurs 2 weeks after
exposure. The virus stays in the bod...

Herpes Simplex-- Tiny , Multiple ,
Painful Vesicles on Glans penis
180

HERPES Simplex---- Extra Genital
181

182
HSV-1(COLD-SORE) Spread also
by sharing razors,towels etc

HSV CERVICITIS
183

HSV Spectrum of Disease
184
• Persistent ulcerative HSV infections are very
common in AIDS
• Candida and HSV often occur i...

HSV FEMALE –small vesicles
185

PRIMARY HERPES MALE
186

RECURRENT HERPES MALE
187

• Fever, malaise, myalgia, pain, itching,
dysuria, vaginal and urethral discharge
• Tender inguinal adenopathy, widely-spa...

SKIN LESION
189

FINGER WITH HERPES
190

ORAL HERPES
191

192
First-time outbreaks are the most severe and most
painful, and it takes form 1 to 3 weeks for the sores to
heal over.
...

This was an outbreak of herpes
genitalis manifested as blistering
around the vaginal introitus due to
the HSV-2 virus.
193

194
Extensive Herpes Simplex Ulcers

195

Recurrent genital herpes
196
• Recurrent in 1-4 months after the
• extinction of lesions of Primary genital
• herpes
• � S...

197
• High frequency of reactivation
• Increased severity
• Widespread local extension
• Higher incidence of dissemination...

198
•Coalescence of herpes genitalis
“micro-ulcers”.
HSV circumferential ulcer

HSV & PREGNANCY
199
• Maternal complication: Cesarean delivery if
there are prodromes or active lesions
when the woman goe...

200

NEONATAL HERPES
201

202
Higher risk of cervical cancer,
need more frequent Pap smears
and doctor’s visits to detect it
HARMFUL EFFECTS of HERP...

203
HSV Diagnosis
• Clinical – characteristic multiple vesicular
lesions or ulcers
• Staining of scrapings from base of le...

204

205
• Primary infection
– Acyclovir 200 mg PO 5x/day for 7-14 days,
or
– Acyclovir 400mg PO tid for 7-14 days, or
– Famcic...

206

CHANCHROID (SOFT SORE )
207

208

CHANCROID
209
• Appears mostly in urban areas.
• Is a cofactor for HIV infection.about 10
percent persons who have soft so...

chancroid
• �Chancroid is an
acute,autoinoculable,ulcerative kind of
sexually transmitted disease caused by gram
negative ...

Chancroid - gram stain of H.
ducrey.
211

Clinical Features of Soft sore-
H.Ducrye Bacilli Infection
• Clinical feature
• � Delitescence: 2-3 days
• �subjective sym...

CHANCROID ULCERS
213

214

Chancroid Male - regional
adenopathy
215

Chancroid - ruptured node
216

Haemophyllus ducrey Bacilli
217

Soft sore---
• Complication
• �lymphadenitis
• �lymphangitis occurred in phallosome
• �leak of urethra
• �ankylo-urethria
...

DIAGNOSIS
• GRAM STAIN: from ulcer base may show
gram negative strepto bacilliu lying in
clusters either in leucocyte or o...

Probable diagnosis by...
• 1. painful genital ulcer
• 2regional lymphedenopathy typical of
chancroid
• 3no evidence of t. ...

TREATMENT ACCO. TO WHO AND
CDC GUIDELINES
• T.AZITHRO 1GM ORALLY STAT SINGLE
DOSE
• OR
• INJ.CEFTRIAXONE 250 MG IM STAT SI...

FOLLOW UP
• AFTER 7 DAYS.IF NO SYMPTOMATIC
IMPROVEMENT,THEN DIAGNOSIS MAY BE
WRONG OR PT IS COINFECTED WITH
ANOTHER STD.
•...

LYMPHOGRANNULOMA VENERUM
223

224

MANY SYNONYMS
• TROPICAL BUBO
• CLIMACTIC BUBO
• PORADENITIS INGUINALE
• DURAND-NICOLAS-FAVRE DISEASE
• LYMPHOPATHIA VENER...

Venereal lymphogranuloma
• Lymphogranuloma venereum is also called
• Lymphogranuloma inguinale� fourth
venereal disease. I...

Etiopathogenisis----
• �pathogen--- L1�L2�L3 Chlamydia
• trachomatis
• � Chlamydia trachomatis is the main
pathogen which ...

228
LGV primary lesion

229
Chronic lymphogranuloma
venereum in female. Genital
elephantiasis---Asthimone

Clinical feature
• �Delitescence: 1-4 weeks,1week for average
• �Early symptom: ulcers
• �intermediate stage symptom: slot...

MALE FEMALE
231

Advanced Stage of LGV---
• �advanced stage symptom: elephantiasis
• proctostenosis.
• �constitutional symptom:
lymphadenec...

LGV LYMPHEDENOPATHY
233

234

LGV extending to anal area
236

Grannuloma Inguinale
237

238
Granuloma inguinale, Donovan
bodies

DIAGNOSIS
• FREI TEST;INTRADERMAL TEST, NOW
HISTORICAL
• COMPLEMENT FIXATION: MORE SENSETIVE
THEN FREI TEST BUT HAS CROSS
...

MANAGEMENT
• ACCO. TO CDC: DOXY 100 BD FOR 21 DAYS
ALTERNATIVE REGIMEN:ERYTHROMYCIN
BASE 500 MG Q.I.D FOR 21 DAYS[choice i...

241

242
Granuloma inguinale, chronic
destructive lesion

243
• Granuloma inguinale with
both active and healed lesions

244

245

246

HPV
247
• INCIDENCE
– MOST PREVALENT STD IN COLLEGE WOMEN
• CLINICAL IMPRESSION
– VISIBLE GENITAL WARTS CALLED
CONDYLOMA A...

?
248
33%
Estimated 24 to 40 million cases today, with
1 million NEW cases per year, mostly in
people under 25 years old.
...

?
249
• HPV infects the ENTIRE GENITAL REGION ---Including the
vulva, penis, cervix, thighs, scrotum, anus, mouth, and
thr...

HPV
250
• DOUBLE
STRANDED
• DNA
• VIRUS
• HIGH RISK-
ONCOGENIC
• 16,18,31,33

?
• Condylomata acumlnata, also called genital
warts ,is induced by papillomavirus
• �Pathogen:
Papillomavirus, has above ...

252

253
Signs and Symptoms of HPV
(Genital Warts)
• Most people with HPV do not develop
symptoms. Certain types of HPV can
cau...

254

Genital wart
255
• Usually the warts look like tiny
cauliflowers, but sometimes they are flat.
• The warts may cause itchi...

HPV- PREGNANCY ,NEWBORN
256
• Pregnancy complications:
– Cesarean delivery
• Neonatal complications:
– Acquires infection ...

Condyloma acuminata, penile
257

Condyloma Acuminata---Vulva
258

Condyloma acuminata, vulva
259

Condyloma acuminata, vaginal
wall
260

Condyloma acuminata, anal
261

Condyloma acuminata, meatal
262

263

264

HPV-Diagnosis
265
• HYBRID CAPTURE PROBE
– Sensitivity: 84-100%
– Specificity: 74-95%
• PCR FROM CERVICAL SPECIMENS
• DX I...

266

267

268

269

270

271

272
ACQUIREDIMMUNODEFICIENCY
SYNDROME (AIDS)

HIV AND AIDS
273
• AIDS is one of the most deadly diseases in
history.
• AIDS is caused by HIV (Human
immunodeficiency vir...

274

275
Human immunodeficiency virus 1 & 2.
• Belongs to retrovirus RNA family.
• Destroyed by sterlization at 56 degee C.For ...

276
• HIV can be transmitted from an infected
person to another person through blood,
semen, vaginal fluids, and breast mi...

277
• Many people do not know they have it.
• Symptoms may not appear for up to 10 years.
• Some people may feel and look ...

Sources of HIV Infection in Men
and Women in the United States
278

279

Stages of HIV
280

HIV V/S IMMUNE SYSTEM
281
• HIV is a retrovirus that targets CD4+
T-cells, depleting the number of cells and
impairing cel...

SYMPTOMS OF AIDS
282
• Extreme weakness
and fatigue
• Rapid weight loss
• Frequent fevers with
not explanation
• Heavy swe...

283
Kaposi’s sarcoma
(Cancer associated with AIDS)

284
Oral Thrush (yeast infection)
Common infection associated with AIDS

285
Oral Leukoplakia

286
How is HIV treated?
• There is NO cure.
• If you think you or your partner may have HIV
or AIDS you need to see a heal...

HIV TESTING:PREGNANT WOMAN
287
• Include HIV testing in routine prenatal screening.
• Screen after the woman is informed t...

POST TEST
COUNCEILLING,SEROPOSITIVE
WOMEN
288
• Most HIV+ women are diagnosed during
childbearing years (CDC, 2002e; 2002f...

POST TEST
COUNCELLING,SERONEGATIVE
WOMEN
289
• Seronegative women should receive
counseling and education about behavior
c...

HIV IN PREGNANCY
290
• The baseline rate of perinatal HIV
transmission without prophylactic therapy is
approximately 25 pe...

HIV IN PREGNANCY CONTI...
291
• Cesarean delivery is recommended as an
intervention to prevent perinatal HIV
transmission ...

292
HIV-Reproductive Health
Concerns
• Passing an STI to a fetus or newborn
– Potentially life-threatening health
conditio...

HIV-PREGNANCY,NEWBORN
293
• Pregnancy complications: Gradual loss of
immune function
– Inability to fight disease
– Increa...

294
• STD LINKAGE WITH HIV
• Syphilis +++
• Chancroid +++
• Chlamydia ++
• Gonorrhoea ++
• Trichomonas +
• Herpes simplex ...

HIV TREATMENT RESOURCE
295
•For free, 24-hour clinical advice for treating
HIV-infected pregnant women and their infants,
...

ART(ANTI RETROVIRAL
THERAPY)
296
• Effective ART uses a combination of
antiretroviral therapies (cART) that slow viral
rep...

ART CONTI...
297
•Eleven anti-HIV drugs are approved for use
with pregnant women (Perinatal HIV Guidelines Working
Group, ...

298
Prevention of Opportunistic
Infections
• A single dose of double-strength
trimethoprim-sulfamethoxazole (Septra,
Bactr...

Molluscum contagiosum
299

300
Molluscum contagiosum, vulva
and thighs

301
Molluscum contagiosum, penis

302

303
CLINICAL SYNDROME
COMPARISON
SYNDROME DISCHARGE ODOR PRESENTATION
Trichomonasis Watery, thin,
gray, alkaline
homogeneo...

304
BacterialBacterial
vaginosisvaginosis
TrichomonasTrichomonas
vaginitisvaginitis
CandidalCandidal
vaginitisvaginitis
Va...

305
THE FISHY ODOR IN VIVO
• NORMAL VAGINAL FLORA
– H2O2 Producing Lactobacilli ⇒ lactic acid
⇓ pH (<4.5)
• BACTERIAL VAGI...

BV
306
• Symptoms:
– Malodorous
discharge
– Abdominal pain
– Irregular /
prolonged
menses
• Risk factors:
– Douches
– New ...

BV
307
• Pelvic examination
– Homogenous, malodorous, yellow,
white/grey fishy/ musty discharge
adherent to the vaginal wa...

BV
308
• Three of the four criteria to be met for
diagnosis: (Amsel’s criteria)
– Homogenous, grey- white non-
inflammator...

NUGENT SCORING
309
• Gram staining system of vaginal smears
to diagnose Bacterial vaginosis.
• Lactobacillus Morphotypes L...

310
BV DIAGNOSED
FACTS TO CONSIDER
• PREGNANT WOMEN
– AFFECT 15-20% PREGNANT WOMEN
– AMNIOTIC FLUID INFECTION
– POSTPARTUM...

BV
311
• Gram stain – vaginal discharge
Positive -- less than 4 lactobaccili/ oil
immersion field.
• Treatment
– Tab Metro...

312
• Treatment …contd/…Treatment …contd/…
• Alternative regimens
– Clindamycin ovules 100 mg intravaginally qhs
3 days
– ...

313
BV: Pregnancy and Newborns (CDC,
2006b; Koumans et al., 2002)
•Pregnancy
complications:
• Chorioamnionitis
• Miscarria...

TRICHOMONIASIS
314
• Tetraflagellated motile protozoon
• Anterior nucleus, anterolateral undulating
membrane & prominent a...

315
• Man is the only known host
• Usually infest vagina & urethra but may
involve endocervix
• Commonest infection leadin...

316
• Prevalence
– Approx 15-20% of all women & 3-10% of all
men harbor the organism
– Two peaks – sexually active young w...

317
• Source of Infection
– Transmitted through sexual intercourse
– Primary reservoir – female
– Vector- male
– Spontaneo...

TRICHOMONIASIS CONTI...
• Trichomoniasis
– Caused by a protozoan
– Half of American men and women carry
this organism
– Ma...

319
• Factors affecting growth
– Mature vaginal epithelium
– Elevated vaginal pH
• Progesterone dominant states
• Intravag...

320
• Histopathology
– Superficial inflammatory reaction
– Patchy blood vessel dilatation
– Proliferation of surface epith...

Parasites: Trichomonas vaginalis
321

322
• Sometimes called “trich” it is a parasite that
can be passed from person to person during
sexual intercourse.
• One ...

323
• Asymptomatic tricomoniasis
– Accounts for 70% cases
– No signs & symptoms

324
• Symptomatic
– Severe itching
– Redness and swelling
– Tenderness
– Dyspareunia
– Dysuria and urinary frequency
– Rar...

325
• Vaginal discharge
– Profuse
– Frothy
– Grey/ greenish
– and malodorous

326

327
• Diagnosis
– Avoid topical vaginal preparation for 48 h
prior
– Wet smear

328
TRICHOMONAS VAGINITIS
LAB TESTS
• WET MOUNT
URINE OR VAGINAL SECRETION MUST
BE VIEWED IMMEDIATELY
TRANSPORT INSTABIL...

329

330
• Diagnosis (contd)
• Culture
– Stuart or thioglycollate media
– Diamond’s or Lowe’s media

331
• On examination
– Erythema, edema and tenderness
– Subepithelial hyperemia
– Punctate submucosal hemorrhages
-strawbe...

332

TRICHOMONAS CONTI…..
333
• Chronic- symptomatic
– Long H/o intermittent vulvovaginitis
– Slight to moderate discharge
– No...

TRICHOMONIASIS
334
FACTS TO CONSIDER
• THIRD MOST COMMON OF THE VAGINITIDES
• THOUGHT TO FACILITATE HIV TRANSMISSION
• PRE...

TRICHOMONIASIS
335
Recommended regimenRecommended regimen
Metronidazole 2 gm orally in a single dose
Alternative regimenAl...

336
Trichomoniasis
Treatment Failure
• Re-treat with metronidazole 500 mg twice
daily for 7 days
• If repeated failure occ...

337
Trichomoniasis
Management of Sex Partners
• Sex partners should be treated
• Avoid intercourse until therapy is comple...

CANDIDIASIS
• Candidiasis (moniliasis)
– Yeast-like fungus caused by Candida
albicans
– Symptoms: severe itching, burning,...

339
• Dimorphic, gram positive fungus
• 41% women harbor one or more species of
candida as normal flora
• >400 strains ide...

340

341
• Accounts for 70-80% vulvovaginitis cases
• Candida vaginitis is not a STD
• Optimum pH 4-4.5

342
Symptoms & signs:
– Thick, white, curdy or flocculent discharge.
– Itching – before and after menses - most
prominent ...

343
• ETIOLOGIC AGENT
– 85-95% CANDIDA ALBICANS
– CANDIDA GLABRATA
• LESS SUSCEPTIBLE
TO AZOLES
• HIV INFECTED
• FREQUENCY...

CANDIDA VAGINITIS
344
• Omaha classification of vulvovaginal
candidiasis
• Genesis I
– Primary vulvovaginal candidiasis
• ...

345
• Omaha classification (contd)
• Genesis III
– Systemically influenced vulvovaginal
candidiasis
• A Pregnancy, high do...

CANDIDA
346
• Diagnosis
• KOH preparation
• Vaginal swab for culture and sensitivity:
– Culture medium
• Biggy agar --- Br...

347
• Treatment:Treatment:
Azoles are the mainstay of treatment.
– Uncomplicated infections:
• 3-7 days intravaginal cream...

348
TreatmentTreatment
Butaconazole 2% cream 5gm intravaginal -3d
Butaconazole 2% cream (SR) 5gm intravaginal –
single app...

349
• Oral therapy with fluconazole 150 mg SD has
same efficacy as 3- and 7-day courses of the
azole containing topical ag...

350
• Chronic recurrent candidiasis is treated
with
– Fluconazole 100-150 mg/week or 100-
150 mg /month for six months
– I...

351
• Treatment of male partner
• Usually not necessary unless he has candidal
balanitis or uncircumcised

Lice
• Pubic lice
– “Crabs”
– Eggs nest in clothing, furniture and linens
352

Lice
353

354
• Pubic lice are called “crabs” because they
look like crabs.
• Crabs are frequently the color and size of
small freck...

355
• Pubic lice are tiny insects that can crawl
from the pubic hair of one person to the
pubic hair of another person dur...

356

357
Crabs –
under microscope

HAV
358
• The most common form of hepatitis
• Acquired through a fecal-oral route
• No perinatal transmission (Sinclair, 2...

359
Hepatitis B
• Hepatitis is a disease of the liver.
• Hepatitis B is transmitted person to person
through blood and bod...

360
Estimated 300,000 cases in
the USA each year
(CDC MMWR 39
(NO.RR-1), 1990)
5,000 to 6,000 DEATHS
per year due to HBV
3...

361
Sexual transmission, both heterosexual and homosexual, is
now the most common risk factor, and accounts for at least
3...

362
You can get vaccinated at your doctor’s office or
local Health Department
Three shots are needed (boosters 1 month apa...

HCV
363
•HCV is the most common chronic blood-borne
infection in the U.S. An estimated 2.7 million
persons are chronically...

HCV;PREGNANACY AND
NEWBORN
364
• Neonatal complications: 5 of every 100
infants exposed become infected, most often
during...

365

366

367

368

369

370

371

372

373

Diagnosis & treatment of STIs
• Over 30 different organisms can cause STIs
• Many infections have similar symptoms &
signs...

375
Diagnosis & treatment of STIs
STI diagnosis where lab tests not available:
the syndromic approach
to STI case manageme...

376
PRINCIPLES OF STI/RTI CASE
MANAGEMENT
• Correctly diagnosing and treating
symptomatic patients
• Providing patient edu...

377
STEPS OF CLINICAL CASE
MANAGEMENT
1. History taking
2. Clinical examination
3. Laboratory tests
4. Diagnosis
5. Treatm...

378
APPROACHES TO STI/RTI CASE
MANAGEMENT
1. Traditional clinical approach
2. Laboratory-assisted approach
3. Syndromic ma...

379
TRADITIONAL CLINICAL
APPROACH: ADVANTAGES
• Simple
• Inexpensive
• Can be used in any setting
• Immediate diagnosis.
•...

380
TRADITIONAL CLINICAL APPROACH:
LIMITATIONS
1. Diagnosis is often incorrect or
incomplete (especially in mixed
infectio...

381
LABORATORY-ASSISTED
APPROACH: ADVANTAGES
1. Possible to get an exact diagnosis using
laboratory tests
2. Avoids over-t...

382
LABORATORY-ASSISTED APPROACH:
LIMITATIONS
1. Expensive
2. Trained laboratory technicians are
needed
3. Infrastructure ...

383
SYNDROMIC MANAGEMENT
APPROACH
1. Diagnosis is based on the identification of
syndromes which are a combination of the
...

384
SYNDROMIC MANAGEMENT:
ADVANTAGES
1. Fast—the patient is diagnosed and treated in one
visit
2. Highly effective for sel...

385
SYNDROMIC MANAGEMENT:
LIMITATIONS
1. Not useful in asymptomatic individuals
2. Over-treatment if patient has only one
...

Traditional clinical
approach
Lab. assisted approach Syndromic approach
Interviews patient for
symptoms
Interviews patient...

Symptoms Syndrome Common STIs/RTIs
Urethral discharge Urethral discharge
syndrome
Gonorrhoea, chlamydia,
trichomoniasis
Ge...

Symptoms Syndrome RTIs/STIs
Vaginal discharge Vaginal cervical discharge
syndrome
Cervicitis: gonorrhoea,
chlamydia, trich...

389
1. Determine the clinical problem
2. Pick up appropriate flowchart by looking at the
clinical problem box at the top
3...

390
IDENTIFYING APPROPRIATE
SYNDROMIC MANAGEMENT
FLOWCHARTS
• Case studies
• Read the case
• Look at the symptoms of the p...

391
ROLE OF DOCTORS IN SYNDROMIC
MANAGEMENT
• Use syndromic management for providing correct and
complete cure to STI/RTI ...

392
1. STI clients hesitant to approach doctors
2. Often choose far-off doctors
3. Do not prefer to revisit
4. First visit...

393
The syndromic approach
• Developed by WHO
• Does not require laboratory tests
• Tested in many countries since 1970’s
...

394
The syndromic approach
• STIs grouped into 7 main categories, according to
symptoms and signs
• Each category is calle...

© Teaching-aids at low cost

396
© Teaching-aids at low cost

© Teaching-aids at low cost

© Teaching-aids at low cost

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© Teaching-aids at low cost

© Teaching-aids at low cost

© Teaching-aids at low cost

403
©Teaching-aids at low cost

404
The syndromic approach to STIs
Principles of syndromic management:
• Recognize the syndrome
• The syndrome could be ca...

405
Syndromic approach - advantages
• No laboratory tests needed:
– reduces costs
– patient does not have to wait for resu...

406
Syndromic approach - challenges
• Many STIs are asymptomatic
• Vaginal discharge is not necessarily the result of
an S...

407
The syndromic approach to STIs
In spite of its limitations,
the syndromic approach is at present
the most realistic op...

408
STIs in conflict settings
Syndromic approach included in:
• MISP
• Sphere
• IASC Guidelines for HIV/AIDS Interventions...

• “Syndromic Management” contrasts with
“Etiologic Management.” Whereas etiologic
management focuses on identifying and tr...

Syndromic Approach to STI
Management
• Identification of clinical syndrome
• Giving treatment targeting all the locally
kn...

History of the STI Patient
• Presenting symptoms
• Previous diagnosis of STI
• Sexual history
• Symptoms and diagnosis in ...

Talking about STIs with Patients
• Important to understand the patient’s
perspective on talking about sex
– Embarrassed
– ...

Building Rapport
• Begin with a non-medical interaction
• Create an atmosphere that is open and
supportive
• Practice “act...

Common STI Syndromes
• Urethral discharge or burning on urination in
men
• Vaginal discharge
• Genital ulcer in men and wo...

Genital Ulcer Syndrome
415
Patient complains of genital ulcer
Take history & examine
Vesicles or recurrence
Treat for HSV,...

Genital Ulcer Disease:
Differential Diagnosis
• Herpes simplex
• Syphilis
• Chancroid
• Lymphogranuloma venereum
• Granulo...

Differential Diagnosis?
417
Syphilitic chancre, showing well-
demarcated boundary and clean
ulcer base (in contrast to cha...

Differential Diagnosis?
418
• This is also syphilis, but varies
from classic appearance of a
single ulcer.
• Up to 40% of ...

Differential Diagnosis?
419
•Genital Ulcer

Differential Diagnosis?
420
Genital ulcer disease caused by
multiple pathogens

Differential Diagnosis?
421

Differential Diagnosis?
422
•Scabies excoriations. Although
not typically thought of as a cause
of GUD, patient scratching...

Genital Ulcer Disease Treatment
• Recommended treatment for non-vesicular
genital ulcer
– Benzanthine penicilline 2.4 mill...

424
Urethral Discharge Syndrome

425
• Chlamydia
• Gonorrhea
• Mycoplasma hominis
• Ureaplasma urealyticum
• Hemophilus & Parahemophilus spp.
• Other bacte...

426
Urethral Discharge Syndrome
Patient complains
of urethral discharge
or dysuria
Take history
& do P/E; milk urethra
if ...

427
Recommended Treatment for
Urethral Discharge and Burning
on Urination
• Ciprofloxacin 500 mg po stat, or
• Spectinomyc...

428
Take history
and examine
Does history
confirm reinfection
or poor compliance?
Treat for trichomonas
vaginalis
•Educate...

429
Patient complains
of vaginal discharge or
vulval itching/ burning
Take history, examine patient
(external speculum and...

430
Vaginal Discharge
• Common causes:
– Neisseria gonorrhea
– Chlamydia trachomatis
– Trichomonas vaginalis
– Gardnerella...

431
Recommended Treatment for
Vaginal Discharge
Risk Assessment Negative for
STI
Risk Assessment Positive
for STI
Ciproflo...

RISK ASSESMENT OF STI
• If assessment of risk for STI is positive (i.e.
multiple sexual partners, recent unprotected
sex, ...

Lower Abdominal Pain
• Common etiologies:
– Sexually transmitted: Neisseria gonorrhea,
Chlamydia trachomatis, Mycoplasma
h...

434
Lower Abdominal Pain
Patient complains of
lower abdominal pain
Take history including gynecological
And examine (abdom...

Recommended Treatment
• Out patient Inpatient
• Ciprofloxacin 500mg
• PO bid for 7 days, OR
• Spectinomycin 2gm IM
stat pl...

436
Neonatal Conjunctivitis
• Infection of the eyes of the neonate as a result of
genital infection of the mother, transmi...

437
Neonatal Conjunctivitis
Neonate presents with eye discharge
Take history and examine child
Purulent conjunctivitis pre...

438
• Common STI causes of scrotal swelling are
similar to those of urethral discharge
– Neisseria gonorrhea
– Chlamydia t...

439
• Patient
complains of
• scrotal swelling
or pain
Take history, examine,
offer HIV test
Scrotal swelling or
pain prese...

440
Scrotal Swelling
Recommended Therapy
• Ciprofloxacin 500mg PO stat,
or
• Spectinomycin 2gm IM stat
plus
• Doxycycline ...

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Syndromic management of sexually transmitted disease

MonicapreetKaur

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