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					STDs I – Genital Lesions
Tisha Titus Family & Preventive Medicine April 5, 2007

Genital Lesion STDs
• • • • • Chancroid Genital Herpes Lymphogranuloma Venereum (LGV) Granuloma Inguinale Syphilis

• Human Papillomavirus (HPV) • Molluscum Contagiosum

Herpes 1 lesion # of lesions Border Depth Base Secretions Induration Pain Regional LAD
Vesicle

Syphilis
Papule chancre

Chancroid
Erythematous

LGV
Papule, pustule or vesicle Usually one Variable Superficial Variable

Granuloma Inguinale
papule

Multiple may coalesce Erythematous Superficial Red & smooth

Usually one Sharply demarcated Superficial Red & smooth; cardboard like Serous Present Rare

Usually 1-3 Erythematous; undermined Excavated Yellow to gray

Single or multiple Rolled & elevated Elevated Red & rough

Serous None Common; prodrome of tingling Tender; firm, discrete

Purulent hemorrhagic Rare Often

Variable None Variable

Rare; may be hemorrhagic Present Rare

Non-tender, firm, discrete

Tender; may suppurate

Tender; may suppurate

Psuedoadenopathy

Herpes Etiologic agent Incubation US incidence Initial Sx
HSV II At least 36 hours 500,000 new cases/yr Small genital vesicles, painful urination Anti-virals No cure SA, stillbirth, birth defects

Syphilis
Trepnema pallidum 9-90 days 40,000 cases/yr Hard chancre at infection site followed by body rash Antibiotics

Chancroid
Hemophilus ducreyi 1-3 days 3,000 cases/yr Soft, painful chancre

LGV
Chlamydia trachomatis 3-21 days 250 cases/yr Initial small ulcer followed by enlarging nodes Antibiotics

Granuloma inguinale
Klebsiella granulomatis 9-50 days Relatively rare Chancre at infection site

Treatment

Antibiotics

Antibiotics

Complications

Death, insanity, sterility, heart disease Condom, washing

Scarring, tissue damage, possible  risk of AIDS Condom, washing, circumcision

(M) - Genital elephantiasis (F) – rectal strictures Condom, washing, circumcision

Possible  risk of AIDS

Protection

Condoms; avoid sex during flare-ups

Condom, washing, circumcision

Pt complains of genital ulcer/warts

Vesicular lesion; Hx of recurrent vesicular lesion

No

Solitary painless ulcer?

Yes No Tx for herpes

Yes

No Tx for syphilis & chancroid

Tx for syphilis

Wart?

Yes Improving in 7 days? Tx for HPV Yes No Tx for syphilis & chancroid No Tx for chancroid Improving in 7 days? Improving in 7 days?

Yes
No Repeat chancroid Tx

Yes

Referral to specialist

No

Improving in 7 days?

Yes

Clinical cure

CDC Prevention & Control
1. Education & counseling of those at risk 2. Identification of asymptomatic infections and symptomatic infections in persons not likely to seek care 3. Effective diagnosis & treatment 4. Evaluation, treatment & counseling of partners 5. Pre-exposure vaccinations (HBV, HAV, HPV)

Eliciting information
1. 2. 3. 4. 5. Partners Prevention of pregnancy Protection from STDs Practices Past history of STDs

Chancroid

Chancroid in the US
• • • • • Discrete outbreaks Few endemic areas Cofactor for HIV transmission 10% will also have T. pallidum or HSV Probable diagnosis
– 1+ painful ulcers – No T. pallidum or HSV from exudate – Genital ulcers & LAD

Chancroid Treatment
• • • • Azithromycin 1 gm PO single dose OR Ceftriaxone 250 mg IM single dose OR Ciprofloxacin 500 mg PO BID x 3 days OR Erythromycin base 500 mg PO TID x 7 days

• Test for HIV at diagnosis • Retest for syphilis & HIV 3 months post diagnosis

Genital Herpes

HSV in the US
• 50 million in the US • 50% of first episodes are HSV-1; subsequent infections usually HSV-2 • Many with HSV-2 are unrecognized • Cell culture (limited usefulness) • PCR (not FDA approved) • Glycoprotein G-based type specific assay (Herpeselect, Biokit HSV-2 & SureVue HSV-2)

HSV First Episode Treatment
• • • • Acyclovir 400 mg PO TID x 7-10 days OR Acyclovir 200 mg PO PID x 7-10 days OR Famciclovir 250 mg PO TID x 7-10 days OR Valacyclovir 1 gm PO BID x 7-10 days

• Asymptomatic shedding • Patient education

HSV Suppression Therapy
• • • • Acyclovir 400 mg PO BID OR Famciclovir 250 mg PO BID OR Valacyclovir 500 mg PO QD* OR Valacyclovir 1 gm PO QD

•  frequency of recurrences in 70-80% in patients w/ 6+ outbreaks annually • * less effective for frequent recurrences

HSV Recurrent Treatment
• • • • • • Acyclovir 400 mg PO TID x 5 days OR Acyclovir 800 mg PO BID x 5 days OR Famciclovir 125 mg PO BID x 5 days OR Famciclovir 1 gm PO BID x 1 day OR Valacyclovir 500 mg PO BID x 3 days OR Valacyclovir 1 gm PO QD x 3 days

• Initiate in prodrome or within 1 day of new lesions

Severe HSV
• Disseminated infection, pneumonitis, hepatitis or CNS complications • Acyclovir 5-10 mg/kg IV Q8 hours x 2-7 days (until clinical improvement) • Subsequent PO therapy for combined total of 10 days

HSV Special Considerations
• HIV suppressive therapy
– Acyclovir 400-800 mg PO BID-TID OR – Famciclovir 500 mg PO BID OR – Valacyclovir 500 mg PO BID

• HIV re-infection treatment
– Acyclovir 400 mg PO TID x 5-10 days OR – Famciclovir 500 mg PO BID x 5-10 days OR – Valacyclovir 1 gm PO BID x 5-10 days

HSV Special Considerations
• Pregnancy (vertical transmission)
– Transmission as high as 30-50% if recent infection – <1% for those w. recurrent infections – Medication safety not established, treatment is recommended to prevent vertical transmission – Active lesions = C-section

• Neonatal herpes
– Acyclovir 20 mg/kg IV Q8 hours x 14-21 days

Lymphogranuloma Venereum

LGV in the US
• C trachomatis serovariants L1, L2, & L3 • Invasive & systemic  chronic fistulas & strictures • Ulcer is self limiting; often gone by the time care is sought • Culture, direct immunofluorescence, nucleic acid detection (NAAT) or serology • Genotyping for serovars

LGV Treatment
• Doxycycline 100 mg PO BID x 21 days OR • Erythromycin base 500 mg PO QID x 21 days* • Data lacking for Azithromycin 1 gm weekly for 3 weeks • Sex partners:
– Azithromycin 1 gm PO single dose OR – Docycycline 100 mg PO BID x 7 days

• *Erythromycin for pregnant women

Granuloma Inguinale

GI in the US
• AKA: Donovanosis • Rare • Diagnose by dark-staining Donovan bodies on crush tissue prep or biopsy • No FDA cleared PCR • Calymmatobacterium granulomatis (previously)

GI Treatment
• Doxycycline 100 mg PO BID x 3 weeks+ OR • • • • Azithromycin 1 gm PO Q week x 3 weeks+ OR Ciprofloxacin 750 mg PO BID x 3 weeks+ OR Erythromycin base 500 mg PO QID x 3 weeks+* OR TMP-SMX DS (160mg/800mg) one PO BID x 3 weeks+

• + treat until all lesions are healed • * for use in pregnant women

Syphilis

Syphilis in the US
Systemic: primary, secondary, tertiary, latent Presumptive tests: VDRL, RPR, FTA-ABS, & TP-TA Definitive test: DFA of exudate or tissue AB titers do not correlate with Dz activity Penicillin G preferred for all stages Jarisch-Herxheimer RXN -fever, HA, & myalgia w/i 24 hours of treatment • All should be tested for HIV at diagnosis & again at 3 months if first test negative • • • • • •

Syphilis: Sex Partner Evaluation
• Exposure <90 days prior to any diagnosis: treat presumptively • Exposure >90 days prior to any diagnosis: treat presumptively if serologic tests not available & follow-up uncertain • Long term partner of latent syphilis patient: evaluate clinically & serologically - treat accordingly

o 1

&

o 2

Syphilis Treatment

Adults: • Benzathine Pen G 2.4 million units IM once Children: • Benzathine Pen G 50,000 units/kg IM once PCN Allergy • Doxycycline 100 mg PO BID x 14 days OR • Tetracycline 500 mg PO QID x 14 days OR • Desensitize & use PCN

Latent Syphilis Treatment
Adults Early • Benzathine Pen G 2.4 million unts IM once Adults Late or Unknown • Benzathine Pen G 2.4 million units IM Q week x 3 weeks Children Early • Benzathine Pen G 50,0000 units/kg IM once Children Late or Unknown • Benxathine Pen G 50,000 units/kg Q week x 3 weeks

Latent Syphilis Treatment
• PCN allergy regimens
– Doxycycline 100 mg PO BID x 28 days OR – Tetracycline 500 mg PO QID x 28 days

• Requires close clinical and serologic follow-up • Can also desensitize & treat with PCN

o 3

Syphilis Treatment

• Benzathine Pen G 2.4 million units IM Q week x 3 weeks • Gumma & CV symptoms only • All should have CSF exam before Tx initiation • If PCN allergy - treat as per latent alternatives

Neurosyphilis Treatment
• Aqueous crystalline Pen G 18-24 million units QD continuous infusion x 10-14 days OR • Aqueous crystalline Pen G 3-4 million units IV Q4 hours x 10-14 days OR • Procaine PCN 2.4 million units IM QD AND • Probenecid 500 mg PO QID x 10-14 days OR • Ceftriaxone 2 gm QD IM or IV x 10-14 days

Syphilis & HIV
• 1o, 2o & early latent treatments are the same as for non-HIV 1o & 2o treatments • Evaluate for treatment failure at 3, 6, 9, 12 & 24 months • Treatment failure  CSF exam & re-treatment • Use of PCN alternatives not well studied desensitize • Late & unknown latent variants require CSF exam before treatment

Syphilis & Pregnancy
• All women should be screened in first trimester • Reactive treponemal screen  confirmatory nontreponemal titer • Poor prenatal care areas  RPR card test & treatment • High prevalence areas - serologic testing at 28 & 32 weeks & delivery • Test all mothers of stillbirths after 20 weeks • Jarisch-Herxheimer RXN premature labor & fetal distress • No proven alternative to PCN - desensitize

Congenital Syphilis
• Prevention & detection depends on Dx in pregnant women
– Serologic testing at 28 wks & delivery – Treatment of partners to prevent re-infection – All tested for HIV

• Routine testing of newborn sera or cord blood not recommended • Ab transfer  serology interpretation issues • RPR or VDRL on newborn sera

Human Papilloma Virus (HPV)

HPV in the US
• 100 variants; 30 genital • Mostly asymptomatic, unrecognized or subclinical • Warts: 6 & 11 • Cancer: 16, 18, 31, 33 & 35 • Definitive: viral nucleic acid or capsid protein • Same treatment regimens for HIV patients

Patient Applied Wart Treatments
• Podofilox 0.5% solution or gel*
– Apply BID x 4 days then 4 days without – Repeat up to 4 cycles – No greater than 10cm2 or 5ml/day

• Imiquimod 5% cream*
– Once daily at HS, 3x / week for up to 16 weeks – Wash 6-10 hours after application – Safety in pregnancy not established

Provider Administered Wart Tx
• Cryotherapy – Liquid nitrogen or cryoprobe – Repeat every 1-2 weeks

• Podophyllin resin 10-25%*
– Apply to each wart; air dry - repeat weekly – Less than 10cm2 or 0.5ml per application

• TCA/BCA 80-90%
– Apply to each wart; air dry til frosty - repeat weekly

• Surgical removal • Intralesional interferon or laser surgery (alternatives)

Other Wart Treatments
Cevical • Cryotherapy • TCA/BCA Anal • Cryotherapy • TCA/BCA 80-90% • Surgical removal Pregnancy • Cryotherapy • TCA/BCA

Urethral meatus • Cryotherapy • Podophyllin 10-25%

Molluscum Contagiosum

MC in the US
• • • • • Poxvirus Common in children Anywhere but palms & soles Not of great PH significance Chronic (months to years) but lesions self resolve without scarring

MC Treatments
• Not completely necessary - self limiting • Surgical - possible scarring
– – – – Scraping Decoring Freezing Needle electrosurgery

• Wart removal medications - possible scarring

References
• • • • www.DermAtlas.com www.Healthac.org CDC MMWR Aug 4, 2006 vol 55 No RR-11 http://www.nlm.nih.gov/medlineplus/ency/arti cle/000826.htm


				
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