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Sexually Transmitted Infections: Diagnosis and Management

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Sexually Transmitted Infections: Diagnosis and Management SEXUALLY TRANSMITTED INFECTIONS: DIAGNOSIS AND MANAGEMENT STEPHANIE N. TAYLOR, MD LSUHSC SECTION OF INFECTIOUS DISEASES MEDICAL DIRECTOR, DELGADO CENTER PERSONAL HEALTH CENTER NEW ORLEANS, LA INTRODUCTION Ê Tremendous Public Health Problem Ê AtitdAn estimated 15 m illion AiAmericans acqu ire an STD each year Ê $10 billion dollars in healthcare costs per year Ê Substantial morbidity/mortality Ê Ulcerative and non-ulcerative STDs associated with increased HIV transmission STI PRINCIPLES Ê Counseling – HIV infection, abstinence, and “safer sex” practices Ê STD Screening of asymptomatic individuals and those with symptoms Ê Patients with one STD often have another Ê Partners should be evaluated and treated empirically at the time of presentation STI PRINCIPLES Ê Serologic testing for syphilis should be done in all patients Ê HIV t esti ng sh ould be s trong ly encouraged in all patients (New CDC Recommendation for “Opt-Out” testing) Ê STDs are associated with HIV transmission Major STI Pathogens Ê Bacteria Ê Viruses Ê HSV I & II, HPV, Ê Neisseria HBV, HIV , gonorrhoeae, molluscum Haemophilus ducreyi, Ê Protozoa GdGardnere lla vag inali s Ê Trichomonas Ê Spirochetes vaginalis Ê Fungi Ê Treponema pa llidum Ê Candida albicans Ê Chlamydia Ê Ectoparasites Ê Chlamy dia Ê Phthiris pubis, trachomatis Sarcoptes scabei MAJOR STI SYNDROMES Ê GENITAL ULCER DISEASE Ê URETHRITIS/CERVICITIS Ê PELVIC INFLAMMATORY DISEASE Ê VAGINITIS Ê OTHER VIRAL STDs Ê ECTOPARASITES GENITAL ULCER DISEASE Differential Diagnosis: Ê STIs Ê Syphilis, Herpes, Chancroid Ê LGV, Granuloma inguinale Ê Non-STIs Ê Trauma, fixed drug eruption, neoplasia Ê Aphthous ulcers, non-STD infection, Ê Behçet’s Syndrome – Oral and/or genital ulcers (not alone), cutaneous lesions, uveitis, arthritis , phlebitis Ê Reiter’s Syndrome – arthritis, conjunctivitis, urethritis, circinate balanitis, keratoderma blennorrhagicum Primary and secondary syphilis — Rates by state: United States and outlying areas, 2008 2.8 VT 1.8 0.7 0.0 0.8 NH 1.5 0.7 2.2 MA 3.3 RI 1.7 0.5 010.1 1.2 636.3 0.6 2.1 CT 1.0 NJ 2.6 0.5 2.2 0.8 3.0 3.1 DE 1.9 0.9 4.3 2.2 MD 6.7 6.0 2.6 0.7 3.4 1.1 3.8 DC 24.8 2.2 Guam 3.5 3.2 6.7 Rate per 100,000 5.0 2.4 2.2 7.3 2.2 population 9.7 9.6 6.3 <=0.2 5.9 (n= 4) 16.5 0.1 0.21-2.2 (n= 23) 2.3 5.7 >2.2 (n= 27) Puerto Rico 4.2 Note: The total rate of P&S syphilis for the United StatesVirgin and Is. 0.0 outlying areas (Guam, Puerto Rico and Virgin Islands) was 4.5 per 100,000 population. The Healthy People 2010 target is 0.2 case per 100,000 population. Primary and secondary syphilis — Rates by county: United States, 2008 Rate per 100,000 population <=0.2 (n= 2,184) 0.21-2.2 (n= 373) >2.2 (n= 584) Note: In 2008, 2,180 (69.3%) of 3,141 counties in the U.S. reported no cases of P&S syphilis. Primary and secondary syphilis — Age- and sex-specific rates: United States, 2008 Men Rate (per 100,000 population) Women 20 16 12 8 4 0Age 0 4 8 12 16 20 0.110-14 0.2 5.315-19 3.0 17.3 20-24 5.1 17.2 25- 29 3.9 15.030-34 2.5 14.735-39 2.3 14.440-44 1.8 838.3 45- 54 111.1 2.655-64 0.3 0.665+ 0.0 7.6Total 1.5 Primary and secondary syphilis — Male-to- female rate ratios: United States, 1981–2006 Male-Female rate ratio 10:1 8:1 6:1 4:1 2:1 0 1997 98 99 2000 01 02 03 04 05 06 Primary and secondary syphilis — Male-to- female rate ratios: United States, 1989–2008 Rate (per 100,000 population) Rate Ratio (log scale) 25 16:1 Male Rate Female Rate Total Rate 20 MlMale-to- Fema le Rate Rat io 8:1 15 4:1 10 2:1 5 0 1:1 1989 91 93 95 97 99 2001 03 05 07 Primary and secondary syphilis — Rates by region: United States, 1999–2008 Rate (per 100,000 population) 10 West Midwest 8 Northeast South 6 4 2 0 1999 2000 01 02 03 04 05 06 07 08 Primary and secondary syphilis — Rates by race/ethnicity:United States, 1999 –2008 Rate (per 100,000 population) 40 American Indian/AK Native Asian/Pacific Islander Black 32 Hispanic White 24 16 8 0 1999 2000 01 02 03 04 05 06 07 08 Primary and secondary syphilis — Reported cases* by stage and sexual orientation, 2008 Cases 5000 Primary Secondary 3750 2500 1250 0 HtHeterosexua lMl Men Women MSM† *20% of reported male cases with P&S syphilis were missing sex of sex partner information. †MSM denotes men who have sex with men. Primary and secondary syphilis — Cases by sexual orientation and race/ethnicity, 2008 Cases 3000 White Black 2250 Hispanic Other 1500 750 0 ‡ Heterosexual Men Women MSM Primary and secondary syphilis — Cases by source and sex: United States, 1999–2008 Cases (in thousands) 8 non-STD Clinic Male 7 non-STD Clinic Female STD Clinic Male STD Clinic Female 6 5 4 3 2 1 0 1999 2000 01 02 03 04 05 06 07 08 Congenital syphilis (CS) — Cases for infants <1 year of age and rates of primary and secondary syphilis among women: United States, 1999–2008 CS cases (in thousands) P&S rate (per 100,000 women) 0.8 4 CS Cases P&S Rate 0.6 3 0.4 2 0.2 1 000.0 0 1999 00 01 02 03 04 05 06 07 08 Conggypyenital Syphilis Rates by Race/Ethnicity Congenital Syphilis by State Parish vs. National Rates 2008 Ê National Rate – 4.5 cases/100,000 Ê Jefferson Parish – 11.6 cases/100,000 Ê Orleans Parish – 38.9 cases/100,000 Ê National Goal < 0.4 cases/100,000 Early Syphilis – Region 1 by Parish 2008 Early Syphilis – Region 1 by Parish 2009 1st Six Months of 2009 SYPHILIS STAGING INFECTION (3 WEEKS) PRIMARY CHANCRE (1-3 MONTHS) SECONDARY (1-3 MONTHS / 60-90%) LATENCY (2-50 YEARS) 70% 30% LIFETIME LATENCY TERTIARY PRIMARY SYPHILIS Ê Incubation period 3-90 days Ê Begins as a macule/papule that erodes into a clean based, painless, indurated ulcer with smooth, firm borders Ê Usually singular but can be multiple Ê Goes unnoticed in 15-30% of patients Ê If untreated, will heal in 1-5 weeks PRIMARY SYPHILIS PRIMARY SYPHILIS PRIMARY SYPHILIS SECONDARY SYPHILIS Ê Hematogenous dissemination Ê Skin Rash (90%) - Maculopapular, or pustular lesions involving the palms and soles. Condyloma lata. Ê Mucous Membranes (70%) - Lesions include mucous patches, erosions, aphthous ulcers. Ê Constitutional symptoms (70%) - Fever, malaise, pharyngitis, anorexia, weight loss, andhlid arthralgias. Ê CNS - HA, meningitis, uveitis, tinnitis. SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS SECONDARY SYPHILIS Adenopathy Patchy Alopecia SECONDARY SYPHILIS Condyloma lata SECONDARY SYPHILIS Condyloma lata LATENT SYPHILIS Ê Period during which there is no clinical evidence of disease Ê Serological tests are positive Ê Arbitrarily divided into “early latent” (infection occurred within the last year) or “late latent” TERTIARY SYPHILIS Ê Slowly progressive disease - affects any organ system and produces clinical illness years after initial infection Ê NEUROSYPHILIS - meningitis, general paresis, optic neuritis ( ↑ WBCs, + CSF VDRL, ↑ Prot.) Ê CARDIOVASCULAR - aortic aneurysm, aortic regurgiiitation Ê GUMMATOUS - large indurated lesions of skin, GI tract, mouth DIAGNOSIS Ê Darkfield examination of material from a moist lilesion – 70-80% sensitive Ê Serologic Tests Ê Non-treponemal – RPR, VDRL, ART Ê Treponemal – FTA-ABS, TPHA, IgG Ê Silver stain of bioppysy material Ê DNA Methods (PCR, etc.) SEROLOGIC TESTS Ê REMEMBER!!! Ê No serologic test for syphilis can make a diagnosis by itself, or distinguish between active (never treated or inadequately treated) syphilis and inactive (adequately treated) syphilis Ê Must be coupled with a careful history and a thorough physical examination before a diagnosis can be made BIOLOGIC FALSE POSITIVE Ê Antibodies to phospholipid produced in other disorders Ê Positive non-specific test (VDRL, RPR) Ê Not confirmed with specific test (or negative TPHA, etc.) Ê Seen in a number of conditions such as lupus, drug reactions, narcotic drug use, TB, pregnancy, hepatitis, rheumatoid arthritis, etc. Syphilis: 2006 CDC STD Treatment Guidelines Ê Primary, Secondary, and Early Latent Ê Benzathine penicillin 2.4 MU IM X 1 Ê PCN a llerg ic– Doxy. 100 mg po bid f or 14 days Ê Late Latent Ê Benzathine ppqenicillin 2.4 MU IM q wk. x 3 weeks Ê PCN allergic – Doxy. 100 mg po bid x 4 weeks Ê Neuro-Syphilis – Ê AiC3Aqueous crystalline PCN 3-44104 MU IV q 4 hrs 10-14 days – PCN Allergic need to be desensitized Ê Special Circumstances Ê Pregnant and PCN allergic – desensitize and treat Ê HIV – Same tx. for stage of syphilis in non-HIV pt. CHANCROID Ê ETIOLOGY Ê EPIDEMIOLOGY Ê Haemophilus ducreyi Ê Seen more commonly in third world Ê Fastidious organism countries difficult to isolate Ê Less than 1,000 cases Ê Requires seen in the U.S. ,but suppltdlemented outbrea ks or chocolate agar and epidemics have been seen 5% CO2 for growth CLINICAL MANIFESTATIONS Ê Incubation period 5-7 days Ê A papule develops initially but goes on to erode itintoapaiflinful,soft,and non-idindura tdted ulcer Ê 50% of patients will develop painful local adenoppyathy which may suppurateorrupture CHANCROID Genital Ulcer with Inguinal Buboes in 50% Chancroid: 2006 CDC STD Treatment Guidelines Ê Azithromyygcin 1 gm orally yg single dose Ê Ceftriaxone 250 mggg IM single dose Ê Ciprofloxacin 500 mg po bid for 3 days Ê Erythromycin base 500 mg po qid for 7 days GENITAL HERPES Ê Most common cause of genital ulcer disease in N.A.
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