Sexually transmitted infections. Part II

Sexually Transmitted
Infections
By: Maria Carmela L. Domocmat, RN, MSN
Nurse Instructor
Northern Luzon Adventist College

Diseases Characterized by Diseases Characterized by
Ulcerations Vaginal Discharge
Chancroid Bacterial Vaginosis
Trichomoniasis
Genital HSV Infections
Vulvovaginal Candidiasis
Granuloma Inguinale
(Donovanosis) Human Papillomavirus (HPV)
Infection
Lymphogranuloma Venereum
Genital Warts
Syphilis
Hepatitis A, B, C
Diseases Characterized by Sexually transmitted enteric
Urethritis or Cervicitis infections
Chlamydial Infections Proctitis, Proctocolitis, and
Gonococcal Infections Enteritis
Ectoparasitic Infections
Scabies
Pediculosis Pubis

Overview
Maria Carmela L.Domocmat, RN, MSN

› Chancroid
› Genital HSV Infections
› Granuloma Inguinale (Donovanosis),
› Lymphogranuloma Venereum
› Syphilis


http://www.webmd.com/sexual-conditions/slideshow-std-pictures-and-
http://www.webmd.com/sexual-conditions/slideshow-std-pictures-and-facts


Chancroid is caused by Haemophilus
ducreyi a, a small, gram-negative,
facultative anaerobic bacillus.
It produces a cytocidal distending toxin
that appears to be responsible for its toxic
effects.
Cofactor of HIV transmission, syphilis and
HSV


usually from 3 to 5
days
may extend up to 2
weeks

Incubation period

transmitted sexually by direct contact
with purulent lesions
by autoinoculation to nonsexual sites such
as the eye and skin.
can be transmitted as long as the original
sore or oozing lymph node remains
infected with the bacteria.

MOT

Initially papules or pustules
Multiple painful, irregular, deep genital ulcers
Inguinal lymphadenopathy or buboes
(swelling of the lymph nodes)

s/s

Culture of H. ducreyi

The differential
diagnosis proved to be
chancroid, caused by
Haemophilus ducreyi,
and not syphilis.

. Dx

Chancroid of the Penis Chancroid of the Labia


IM, single dose
Oral azithromycin
Ceftriaxone
Oral
Ciprofloxacin
Erythromycin
Sexual partners within 10 days before onset
of s/s should also be treated
Chancroid ulcers typically improve within 3 to
7 days after institution of therapy and healing
is usually complete in 2 weeks.
http://www.ncbi.nlm.nih.gov/books/NBK25605/

Treatment

Drain fluctuant lymph nodes by either
needle aspiration or incision.


Syphilis, herpes simplex virus (HSV), and
HIV testing and counseling are essential
to diagnose those patients who are
coinfected with this disease.


Rupture of buboes, with subsequent
scarring and/or chronic sinus tract
drainage
Phimosis (the foreskin cannot be fully
retracted over the glans penis) and
balanoposthitis (or balanitis is an
inflammation of the foreskin and head of
the penis)

Complications


At least 50 million persons in the United
States have genital HSV infection
estimated that 1.6 million new cases
occur each year.
Most persons infected with HSV-2 have
not been diagnosed.


Two types of a viral infection
characterized by periodic outbreaks of
painful sores. Stress, sunburn, and certain
foods are the primary causes of a herpes
outbreak.

Herpes simplex

Both herpes simplex virus-1 and virus-2
may be transmitted through sex, or by
kissing or touching any affected area.
Possible by fomites (e.g., towels)
Newborn vaginal delivery

MOT

Fetal demise due to HSV

Genital Herpes
Organism: Herpes
simplex II (90% of
cases) & Herpes
simplex I, viruses

Maria Carmela L.Domocmat,
RN, MSN

from five to twenty days

Incubation Period

Herpes simplex virus-1 usually shows up
as cold sores or blisters.
Herpes simplex virus-2
some are asymptomatic
Early symptoms can include
burning sensation in the genitals,
low back pain,
dysuria, and
flu-like symptoms.

Symptoms:

A short while later, small red bumps may
appear around the genitals or on the
mouth;
later these bumps become painful blisters
which then crust over, form a scab, and
heal.
symptoms go away but reappear since the
virus stays in the body

Symptoms:

Herpes genitalis

Genital Herpes
Maculopapular herpetic rash on the penile shaft and corona of the
glans penis.

Herpes simplex keratitis
is a serious viral infection.
It may cause repeated attacks that are
triggered by stress, esposure to sunlight, or
any condition that impairs the immune system.

Herpes simplex keratitis

Infectivity:
Washing with soap people can infect
and water readily others when they
inactivates HSV; have symptoms &
therefore fomite some times when
transmission is they do not
unlikely.

Maria Carmela L.Domocmat,
RN, MSN

Visual – lesions
Viral culture
Confirm the dx
Most accurate if specimens are obtained within
48 hrs of 1st outbreak of blisters
Direct immunofluorescence staining
Antigen detection testing of vesicualar
exudate
Pap smear

Dx

Decrease discomfort
Promote healing without secondary
infection
Decrease viral shedding
Prevent infection transmission

Goals of treatment

Treatment
No cure
Drugs help decrease severity of
symptoms, promote healing, and
decrease recurrent outbreaks


Genital Herpes:
Acyclovir 200-400mg TID x 10 days
Famciclovir (Famvir)
Valacyclovir (Valtex)

Herpes prophylaxis: Acyclovir 200-400mg
BID
Herpes zoster (shingles): Acyclovir 800mg 5
times a day for 10 days

use Betadine on lesions to dry & prevent
secondary infections

Treatment

Oral analgesics
Local anesthetic sprays
Ice packs or warm compress to lesions
Sitz bath – 3-4x/day
Increase fluid intake
Frequent urination
Pour water over genitalia while voiding, or
encourage voiding while sitting in tub of water or
standing in shower
Catheterize as necessary
Wear loose-fitting nonsynthetic undergarments

Reduce pain

When vesicles rupture release highly contagious
exudate
Wash hands thoroughly after contact with lesion
Genital hygiene
Keep skin clean and dry
Wear gloves when applying ointment
Avoid touching eyes
Avoid sex when (+) with lesion
Use latex or polyurethane condoms
Launder towels that have direct contact with
lesion; separate towels and other personal items
of client

Prevent reinfection

Emphasize risk of fetal infection to both
male and female clients
A condom can prevent herpes
transmission during vaginal or anal sex,
but oral contact with genitals or open
sores anywhere can spread the disease.

Health educ

While herpes is not life-threatening, and
not all people who have it suffer from
outbreaks
disseminated infections
Meningitis
Transverse myelitis
Risk for spontaneous abortion
Predispose carcinoma of cervix

Complications

HSV Vesicles


Aka: donovanosis Incubation period
initially described 1 to 12 weeks
by Donovan over a
century ago

Granuloma Inguinale

bacterium was classified in 1913
as Calymmatobacterium granulomatis.
the molecular structure of the causative
organism was similar to Klebsiella species
and reclassified the gram-negative
pleomorphic bacillus as Klebsiella
granulomatis.


About half of infected men and women
have sores in the anal area.
Small, beefy-red bumps appear on the
genitals or around the anus.
The skin gradually wears away, and the
bumps turn into raised, beefy-red,
velvety nodules called granulation tissue.
usually painless, but they bleed easily if
injured.
without lymphadenopathy

S/S
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001660/

The disease slowly spreads and destroys genital
tissue.
Tissue damage may spread to the area where
the legs meet the torso. This area is called the
inguinal folds.
The genitals and the skin around them lose skin
color.
In its early stages, it may be hard to tell the
difference between donovanosis and chancroid
In the later stages, donovanosis may look like
advanced genital cancers, lymphogranuloma
venereum, and anogenital cutaneous amebiasis

S/S
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001660/

causative organism - difficult to culture,
diagnosis requires visualization of dark-
staining Donovan bodies on tissue crush
preparation or biopsy
Culture of tissue sample (hard to do and
not routinely available)
Scrapings or punch biopsy of lesion
Microscopic identification of Donovan’s bodies
from edge scraping of lesions

Dx

sexual contact; however, it is
hypothesized to have low infectious
capabilities because repeated exposure is
necessary for clinical infection to occur.
may also be obtained through the fecal
route
or by passage through an infected birth
canal.

MOT

Donovanosis
or granuloma inguinale


Antibiotics are used to treat donovanosis.
To cure the condition requires long-term
treatment.
Most treatment courses run 3 weeks or
until the sores have completely healed.
A follow-up examination is important
because the disease can reappear after it
seems to be cured.

Treatment

Doxycycline 100 mg orally BID for at
least 3 weeks and until all lesions have
completely healed

Recommended Regimen

Azithromycin 1 g orally once per week for at least 3 weeks and
until all lesions have completely healed
OR
Ciprofloxacin 750 mg orally BID for at least 3 weeks and until
all lesions have completely healed
OR
Erythromycin base 500 mg orally four times a day for at least 3
weeks and until all lesions have completely healed
OR
Trimethoprim-sulfamethoxazole one double-strength (160
mg/800 mg) tablet orally twice a day for at least 3 weeks and
until all lesions have completely healed
The addition of an aminoglycoside (e.g., gentamicin 1 mg/kg IV
every 8 hours) to these regimens can be considered if
improvement is not evident within the first few days of therapy.

Alternative Regimens

Genital damage and scarring
Loss of skin color in genital area
Permanent genital swelling due to scarring

Complications

Treat partners within 60 days before dx.

Health educ

LYMPHOGRANULOMA
VENERUEM (LGV)

AKA:
lymphopahia
venerea
tropical bubo,
climatic bubo,
strumous bubo,
poradenitis
inguinales,
Durand-Nicolas-
Favre disease,
lymphogranuloma
inguinale

Lymphogranuloma venereum


is a chronic (long-term) infection of the
lymphatic system caused by three
different types of the
bacterium Chlamydia trachomatis.
serovars L1, L2, or L3
not caused by the same bacteria that cause
genital chlamydia
more common in men than women. The
main risk factor is being HIV-positive.

Causes, incidence, and risk factors

3 to 30 days

Incubation period

Tender, enlarged, inflamed inguinal and/or
femoral lymphadenopathy -typically unilateral.
Both sides – “groove sign”
Can drain, ulcerate and scar
Or recede
self-limited genital ulcer or papule sometimes
occurs at the site of inoculation.
However, by the time patients seek care, the lesions
have often disappeared.
Marked external genital deformity

Symptoms

Rectal exposure in women or MSM can
result in proctocolitis,
including mucoid and/or hemorrhagic rectal
discharge,
anal pain,
constipation,
fever,
and/or tenesmus (painful bowel movements)

Symptoms

Diagnosis is based on
clinical suspicion,
epidemiologic information,
and the exclusion of other etiologies for proctocolitis,
inguinal lymphadenopathy, or genital or rectal ulcers.
C. trachomatis testing also should be conducted,
if available.
Genital and lymph node specimens (i.e., lesion
swab or bubo aspirate) can be tested for C.
trachomatis by culture, direct
immunofluorescence, or nucleic acid detection.
Chlamydia serology

Dx tests

Treatment cures infection and prevents
ongoing tissue damage, although tissue
reaction to the infection can result in
scarring.
Buboes
aspiration through intact skin or incision and
drainage to prevent the formation of
inguinal/femoral ulcerations.
Doxycycline is the preferred treatment

Treatment


Recommended Regimen
Doxycycline 100 mg orally twice a day for 21 days
Alternative Regimen
Erythromycin , 500 mg orally 4x/day for 21 days
Although clinical data are lacking, Azithromycin
1 g orally once weekly for 3 weeks is probably
effective based on its chlamydial antimicrobial
activity.
Fluoroquinolone-based treatments might also
be effective, but extended treatment intervals are
likely required.

Treatment


Management of Sex Partners
Persons who have had sexual contact with a
patient who has LGV within the 60 days before
onset of the patient’s symptoms should be
examined, tested for urethral or cervical
chlamydial infection,
and treated with a chlamydia regimen
(azithromycin 1 gm orally single dose
or doxycycline 100 mg orally twice a day for 7
days).

Treatment


Pregnancy
Pregnant and lactating women should be
treated with erythromycin.
Azithromycin might prove useful for treatment
of LGV in pregnancy, but no published data are
available regarding its safety and efficacy.
Doxycycline is contraindicated in pregnant
women.

Special Considerations

HIV Infection
Persons with both LGV and HIV infection
should receive the same regimens as those
who are HIV negative. Prolonged therapy might
be required, and delay in resolution of
symptoms might occur.

Special Considerations

Abnormal connections between the
rectum and vagina
Brain inflammation (very rare)
Infections in the joints, eyes, heart, or
liver
Long-term inflammation and swelling of
the genitals
Scarring and narrowing of the rectum
Complications can occur many years after
you are first infected.

Complications

LGV is an invasive, systemic infection
If not treated early LGV proctocolitis can
lead to chronic, colorectal fistulas and
strictures. Genital and colorectal LGV
lesions can also develop secondary
bacterial infection or can be coinfected
with other sexually and nonsexually
transmitted pathogens.

Complications


Treponema pallidum bacterium.

Secondary syphilis is the most contagious of all
the stages, and is characterized by a systemic
spread of the


Stages

Genital chancre
Chancre – an oval ulcer with a raised
firm border that does not bleed readily
and is painless unless infected
Develop at site of inoculation (i.e., genitalia,
anus, mouth)
Occurs abt 4 wks after initial infection
If untreated – heals spontaneously in 4 to 6
wks
Leave thin, atrophic scar

Primary syphilis


Syphilitic Ulcer


Lymphadenopathy near the chancre
Nodes – painless, firm, discrete


Develops when primary is untreated
6 to 8 wks after infection
Generalized rash – maculopapular and
nonpruritic rash
Usually on palm, sole
Infectious
Generalized nontender, discrete
Lymphadenopathy
Mucous patches
Gray, superficial patches on mucous membranes
in mouth

Secondary syphilis

Secondary Syphilis: includes multiple
lesions located on the penis and scrotum.

The secondary
maculopapular rash
usually causes no
itching, and can
appear as the
chancre, or
chancres found
during the primary
stage of syphilis are
healing, or several
weeks after the
chancres have
healed.

syphilis can cause
painless ulcers
(know as chancres)
to appear on the
penis, or at the
place where the
syphilis bacteria
entered the
body.(Credit: M
Rein/CDC)

Syphilis chancre

can cause painless
ulcers (known as
chancres) to appear
on the vagina, or at
the place where the
syphilis bacteria
entered the
body.(Credit: CDC)

Syphilis

Condylomata lata
Broad-based flat papules
Develop in warm, moist body areas (i.e.,
labia, anus corners of mouth)
Highly contagious
General flu-like manifestations
Patchy hair loss from eyebrows and
scalp (alopecia)
Usually disappear after 2 to 6 wks

Secondary syphilis

Condylomata lata

secondary stage syphilis can
include flat, warty-looking
growths on the vulva and
around the anus.(Credit: CDC)


Client is seroreactive but shows no
evidence of disease
non infectious except transplacental
spread or BT
Not sexually transmitted this time
Occurs 1 to 2 yrs after primary lesion,
can last as long as 50 yrs
More than half remain at this stage

Latent syphilis


Occurs 1 to 35 yrs after primary infection
Devastating, irreversible complications
Chronic bone and joint inflammation
Cardiovascular problems (e.g., aneurysms,
valvular involvement)
Granulomatous lesions (gummas) on any part of
the body
Ophthalmic, auditory, CNS problems
Noninfectious
Terminal if untreated

Tertiary

Tertiary neurosyphilis presents with symptoms of
meningitis or with focal deficits consistent with
stroke.
The mnemonic device "PARESIS" is an aid to
recall the following types of symptoms:
Personality
Affect
Reflexes (e.g., hyperactive)
Eye (e.g., Argyll Robertson pupils)
Sensorium (e.g., illusions, delusions, hallucinations)
Intellect (e.g., decreased recent memory, orientation,
judgment, insight)
Speech abnormalities

Tertiary

gummas observed in tertiary
syphilis

oral, anal, or vaginal sex, or via intimate
touching or kissing.
Mothers can pass it to their babies by
touching syphilis sores (chancres) and
then touching the baby.

MOT

One week to three months

Incubation Period

Dark-filed microscopy (DFA)
Lesions scraped and causative organism identified
Serologic tests
Indirect test that detect antibodies
Venereal disease research laboratory (VDRL)
Rapid plasma reagin (RPR)
Fluorescent treponemal antibody absorptions
(FTA-ABS) test
Treponema pallidum particle agglutination (TP-
PA)

Dx tests

Dark-filed
microscopy (DFA)
Lesions scraped
and causative
organism
identified

Diagnostic tests

T. pallidum cannot be Advantages of
viewed by normal darkfield microscopy:
light microscopy. Definitive immediate
Darkfield microscopy diagnosis (useful in
primary and secondary
can identify T. disease).
pallidum with its Rapid results.
spiral shape, 10-14
coils, corkscrew
motion, and a total
length of 6-20
micrometers.

Darkfield microscopy


An experienced microscopist and specialized
equipment (often not available outside of a
specialized clinic) are required.
Confusion with other pathogenic or nonpathogenic
spirochetes may occur. Generally not recommended
on oral lesions because of specificity problem with
nonpathogenic spirochetes in the oral cavity.
It must be performed immediately because motility is
important to identification. The sensitivity of darkfield
microscopy decreases as the lesion heals.
Possibility of false-negatives increases with use of
topical substances such as soap and water, antibiotic
ointments, etc.

Disadvantages of darkfield
microscopy:

Serologic tests
Indirect test that detect antibodies
Note: antibodies are not present in serum until
4 wks after the appearance of chancre

Diagnostic tests

Venereal disease research laboratory
(VDRL)

Rapid plasma reagin (RPR)
Uses antigen to detect the antibody
relatively specific for Treponema pallidum

Diagnostic tests: Serologic tests

Fluorescent treponemal antibody
absorptions (FTA-ABS) test

Treponema pallidum particle
agglutination (TP-PA)

Diagnostic tests: Serologic tests

Direct fluorescent
antibody - T.
pallidum (DFA-TP)
identifies T.
pallidum on direct
lesion smear by
immunofluorescence
using polyclonal
antiserum or
monoclonal antibody.

Direct fluorescent antibody


Primary, secondary, Primary, secondary
tertiary syphilis syphilis
Benzathine Abstain from
penicillin G 2.4 sexual contact at
mU, IM, one dose least 1 month
Doxycycline or after treatment
tetracycline 100
mg, PO, 2-3 times
a day for 14 days.

Treatment


Latent syphilis
Three weekly penicillin injections
Neurosyphilis – IV aqueous crystalline
penicillin G

Treatment:


Adults

Primary, secondary, and early latent
syphilis without neurologic involvement:
Benzathine penicillin G, IM, 2.4 million
units in a single dose

If penicillin allergic (one of the
following):
Doxycycline 100 mg orally twice
daily for 2 weeks
Tetracycline 500 mg orally 4 times
daily for 2 weeks


Adults

Late latent or latent syphilis of unknown
duration without neurologic involvement:

•Benzathine penicillin G 7.2 million units
total, administered as 3 doses of 2.4
million units IM each at 1-week intervals

If penicillin allergic (one of the following):
Doxycycline 100 mg orally twice
daily for 28 days
Tetracycline 500 mg orally 4 times
daily for 28 days

Adults

Tertiary (late) syphilis without neurologic
involvement:
Benzathine penicillin G 7.2 million units total,
administered as three doses of 2.4 million units IM
each at 1-week intervals

If penicillin allergic:
Treat according to treatment for late latent
syphilis.

Neurosyphilis:
Aqueous crystalline penicillin G 18-24 million units
per day, administered as 3-4 million units IV every 4
hours or continuous infusion for 10-14 days IV

Alternative regimen (if compliance can be ensured):

Procaine penicillin 2.4 million units IM once daily
PLUS
Probenecid 500 mg orally 4 times a day, both for 10-14 days


is a self-limited reaction to anti-
treponemal therapy.
characterized by fever, malaise, nausea,
and vomiting.
may be associated with chills and
exacerbation of secondary rash.
This reaction occurs within 24 hours after
therapy and usually resolves within 24
hours.

Jarisch-
Jarisch-Herxheimer Reaction


Patients should be warned that it is not an
allergic reaction to penicillin and that it can
be treated with symptomatic support.
It occurs more frequently after treatment
with penicillin and treatment of early syphilis,
especially at the secondary stage.
Pregnant women should be informed that
treatment for syphilis may precipitate early
labor and that they should notify an
obstetrician if problems develop.

Jarisch-
Jarisch-Herxheimer Reaction


serious damage to A fetus is at
the brain and the particular risk if the
nervous system; mother doesn't
mental seek treatment;
deterioration; the chances for
a loss of balance, stillbirth and serious
vision, and birth defects,
sensation; including blindness,
leg pain; and are very high.
heart disease.

Complications: Untreated syphilis
can lead to

Irreversible blindness
Mental illness
Paralysis
Heart disease
death

Complications

caused by transplacental transmission of
spirochetes;
the transmission rate approaches 100%.
Perinatal death may result from
congenital infection in more than 40% of
affected, untreated pregnancies.

Congenital syphilis

Among survivors, manifestations have
traditionally been divided into early and
late stages.
Manifestations are defined as early if they
appear in the first 2 years of life and late
if they develop after age 2 years.

Congenital syphilis

Syphilis in pregnancy can lead to spontaneous
abortion, stillbirth, premature delivery, or
perinatal death. It can also cause significant
morbidity during infancy, childhood, and
adolescence. A very strict follow-up of pregnant
women before delivery and an active approach to
identify and treat exposed neonates born to
infected mothers are strongly recommended.
A study in Nigeria has demonstrated the
usefulness of syphilis screening during pregnancy
and recommended that syphilis screening should
be continued as part of routine antenatal testing

Syphilis in pregnancy

Hutchinson's teeth notched,
narrow-edged permanent incisors,
sometimes but not always a sign of
congenital syphilis.


Early manifestations of congenital
infection vary and involve multiple organ
systems.
The most striking lesions affect the
mucocutaneous tissues and bones.
Mucous patches, rhinitis, and
condylomatous lesions are highly
characteristic features of mucous
membrane involvement in congenital
syphilis.

Early onset congenital syphilis

Nasal fluid is highly infectious. Snuffles are
followed quickly by a diffuse maculopapular
desquamative rash that involves extensive
sloughing of the epithelium, particularly on
the palms and soles and around the mouth
and anus. In contrast to acquired syphilis, a
vesicular rash and bullae may develop. These
lesions are highly infectious.
Hepatomegaly is reported in almost 100% of
cases, and biochemical evidence of liver
dysfunction is usually observed.

Early onset congenital syphilis

syphilisScarring from the early systemic
disease causes late manifestations of
congenital syphilis.
Manifestations include neurosyphilis and
involvement of the teeth, bones, eyes,
and the eighth cranial nerve.

Late-
Late-onset congenital

http://www.nzma.org.nz/journal/120-1250/2448/content01.jpg

Congenital syphilis

HIV infected persons with early stage syphilis
should receive a single IM dose of 2.4mu of
benzathine penicillin
Some specialists suggest that HIV-infected
persons with primary or secondary syphilis
receive additional treatments (e.g.,
benzathine penicillin G administered at 1-
week intervals for 3 weeks, as recommended
for late syphilis). However, the benefit of this
approach remain unproven

Syphilis and HIV/Other STDs


All patients who have syphilis should
be tested for HIV infection.
Persons with primary or secondary
syphilis who live in areas with a high
prevalence of HIV should be retested for
HIV after 3 months if the first HIV test
result was negative.
Consider screening persons with syphilis
for other STDs.

Syphilis and HIV/Other STDs


Sexually transmitted infections. Part II

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