STD Syndromes

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STD Syndromes Powered By Docstoc
					  Overview of Sexually
  Transmitted Diseases
       Rebecca A. Lillis, M.D.
Assistant Professor of Medicine, Section of
            Infectious Diseases
          LSUHSC, New Orleans
               DISCLOSURE

• I have no financial interests or other
  relationship with manufacturers of commercial
  products, suppliers of commercial services, or
  commercial supporters. My presentation will
  not include any discussion of the unlabeled use
  of a product or a product under investigational
  use.
                Major STDs
Type of Agent   Name                    Disease
     Viruses    Human Papillomavirus    Warts
                Herpes Simplex          Herpes
                Hepatitis B             Hepatitis
                HIV                     AIDS
     Bacteria   Chlamydia               Chlamydia
                Neisseria Gonorrheae    Gonorrhea
                Treponema pallidum      Syphilis
                Hemophilus ducreyi      Chancroid
      Fungi     Candida albicans        Candidiasis
     Protozoa   Trichomonas vaginalis   Trichomoniasis
      Insects   Sarcoptes scabii        Scabies
                      Syphilis

• Cause: Spirochete - Treponema pallidum
• Symptoms: Genital ulcer, rash
• Diagnosis:
  – Dark Field exam
  – Blood test: RPR, VDRL,MHA-TP, IgG
• Complications:
  – Late syphilis
  – Congenital syphilis
  – HIV transmission
• Treatment - Penicillin
                      Syphilis
            Stages and Manifestations

Early Syphilis - 1st 12 months
  Primary -       Genital ulcer (chancre)
  Secondary - Generalized rash (palms & soles)
                  Oral and genital lesions
                  Alopecia
  Early latent - No signs or symptoms

Late latent - Years

Late - Neurosyphilis
       Cardiovascular syphilis
         Syphilis: Treatment

• Early syphilis
  • Benzathine penicillin G (Bicillin L-A)
    2.4 million units IM x 1
• Late latent
  • Benzathine penicillin G 2.4 million units
    IM per week x 3
• Neurosyphilis and cardiovascular syphilis
  • Intravenous penicillin G
     P&S Syphilis, Louisiana vs. U.S.
                                    1981-1999
     Cases/100,000
80

                                           Louisiana
60



40



20
                                                   U.S.
            Year 2000 Objective
 0
 1987   1988   1989   1990   1991   1992    1993   1994   1995   1996   1997   1998   1999

                                    Year of Report
Primary and secondary syphilis — Rates: United States, 1970–2004 and the
                       Healthy People 2010 target


Rate (per 100,000 population)
  25

                                P&S Syphilis
  20                            2010 Target

  15


  10


   5


   0

         1970      73       76        79       82   85   88   91     94      97     2000    03

    Note: The Healthy People 2010 target for P&S syphilis is 0.2 case per 100,000 population.
    Louisiana rate 7.34 cases/ 100,000 is highest in nation for 2004
         P&S Syphilis Cases in Louisiana
         Actual cases and projection to elimination goal
       Cases of P&S syphilis
3500

3000

2500

2000

1500

1000

 500

   0
       1991    1993      1995   1997     1999    2001   2003   2005
                                Year of Report
Rates of Syphilis in Industrialized Countries

 Country            P&S Cases      Rate
 Canada                248          0.8
 England               117          0.4
 Sweden                52           0.6
 Denmark               39           0.7

 U.S. (1996)         11,387         4.3


 U.S. (1998)          6,993         2.6


 U.S. (2005 goal)     1,000         0.4
Causes of Genital Ulcers

      ) Herpes

      ) Syphilis

      ) Chancroid
                 Herpes

• Herpes Simplex Virus (HSV) I and II
• Symptoms: Painful blisters that recur
• Complications (rare):
  – Spread to infants at delivery
  – Severe infections in AIDS patients
        Herpes: Treatment

) No cure
) Antivirals shorten duration, reduce
  frequency and severity of recurrences
  5 Acyclovir (Zovirax)
  5 Famcyclovir (Famvir)
  5 Valcyclovir (Valtrex)
) Different dosages for initial treatment vs.
  recurrent or suppressive treatment
                 Chancroid

• Cause: Hemophilus ducreyi
  – Epidemiology: Uncommon in U.S., occurs in
    outbreaks
• Symptoms:
  – Painful sore (may be multiple) that looks like
    chancre
• Male:female ratio 10:1
• Treatment: Azithromycin, Ceftriaxone
  Causes of Genital Ulcers

) Herpes
  5Painful, blister - ulcer, shallow,
   multiple, recurrent
) Syphilis
  5Painless, single, not recurrent
) Chancroid
  5Painful, single or multiple, not
   recurrent
Causes of Urethral or Cervical Discharge


            ) Gonorrhea


            ) Chlamydia
                Gonorrhea

• Cause: Neisseria gonorrheae
• Symptoms:
  – Men - painful discharge from urethra
  – Women - cervical discharge
    • often no symptoms
• Complications:
  – Women - Pelvic Inflammatory Disease (PID)
    Infertility, ectopic pregnancy
  - Infants - Eye infection "ophthalmia
    neonatorum"
  Tests for Gonorrhea

) Culture

) Gram Stain

) Non-culture tests
  5 DNA Probe test (GenProbe)
  5 PCR/LCR test
                Chlamydia

• Cause: Chlamydia trachomatis
• Symptoms:
  – Men – scant clear discharge from urethra
  – Women - cervical discharge
    • Usually no symptoms for men or women
• Complications:
  – Women - Pelvic Inflammatory Disease (PID)
    Infertility, ectopic pregnancy
  - Infants – Pneumonia at 6 week age, eye
    infection
        Tests for Chlamydia

) Culture
) Non-culture tests
  5 DFA test
  5 EIA
     5Lab -Chlamydiazyme, Microtrak, others
     5Rapid - Clearview, TestPack, SureCell
  5 DNA Probe test (GenProbe)
  5 PCR and LCR tests
 Sensitivity of Different Tests for Chlamydia

              Test type

 PCR/LCR


    Culture


       DFA


DNA Probe


        EIA

              1           10      100      1000      10000      100000   1000000
                               Number of organisms detectable
    Gonorrhea: Treatment

) Antibiotics for gonorrhea
  5 Cefixime (Suprax) 400 mg PO x 1

  5 Ciprofloxacin (Cipro) 500 mg PO x 1

  5 Azithromycin (Zithromax) 2 gm PO x 1

  5 Ceftriaxone (Rocephin) 125 mg IM x 1

) Always treat for chlamydia also
    Chlamydia: Treatment

) Azithromycin 1 gm PO x 1

) Doxycycline 100 mg PO BID x 7 days
                             Rates of STDs
                             Louisiana, 1992-1999
      Cases/100,000
500


400
                                                   Chlamydia
300

                                                          Gonorrhea
200


100
                                         P&S Syphilis
   0
   1992       1993        1994    1995     1996    1997      1998     1999
                                  Year of Report

 *projected from first 8 months
                  Chlamydia — Rates: United States, 1984–2004
      Louisiana’s rate for 2004 was 488.26 per 100,000, third highest in the nation


Rate (per 100,000 population)
   350


   280


   210


   140


    70


     0

           1984        86       88     90       92       94        96       98      2000   02   04


               Note: As of January 2000, all 50 states and the District of Columbia had
               regulations requiring the reporting of chlamydia cases.
              Gonorrhea — Rates: United States, 1970–2004
 Louisiana’s rate for 2004 was 235.46 per 100,000 – second highest in the
                                  nation


Rate (per 100,000 population)
   500
                                                                                    Gonorrhea
                                                                                    2010 Target
   400


   300


   200


   100


     0

           1970      73         76   79   82    85      88     91      94     97     2000     03


          Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000
          population.
Rates of Gonorrhea and Chlamydia by Agegroup
                                   Louisiana, 1999
            Cases per 100,000
2,500
               Chlamydia        Gonorrhea

2,000


1,500


1,000


  500


        0
             5-9   10-14   15-19    20-24    25-34   35-44   45-54   55-64   65+
                                            Age Group
    Vaginitis

) Candidiasis

) Trichomoniasis

) Bacterial vaginosis
              Trichomoniasis

•   Cause: Trichomonas vaginalis (protozoan)
•   Symptoms: Frothy white vaginal discharge
•   Diagnosis: Trich. on wet mount
•   Complications:
    – ? Increased HIV transmission
• Treatment: Metronidazole (Flagyl)
• Very high recurrence rate after treatment
         Bacterial Vaginosis

• Cause: Increase in Gardnerella vaginalis &
  others, decrease in lactobacilli
• Symptoms: Malodorous vaginal discharge
• Diagnosis:
  – Clue cells on wet mount
  – Positive "whiff test"
• Complications: Premature delivery
• Treatment: Metronidazole (Flagyl)
• High recurrence rate after treatment
               Candidiasis

• Cause: Candida albicans
• Not an STD
• Symptoms: Cheesy white adherent
  discharge
• Treatment:
  – Fluconazole (Diflucan)
  – Terconazole (Terazol)
  – OTC creams
Differentiating Among Causes of Vaginitis


) Candidiasis
  5 Discharge is thick, adherent
) Trichomoniasis
  5 Frothy discharge
  5 Protozoa on wet prep
) Bacterial vaginosis
  5 Thick, clear-white malodorous discharge
  5 Clue cells on wet prep
      Treatment of Vaginitis

) Candidiasis
  5 Diflucan 150 mg PO x 1
) Trichomoniasis
  5 Metronidazole (Flagyl) 2 gm PO
) Bacterial Vaginosis
  5 Metronidazole (Flagyl) 500 mg BID x 7
    days
         Syndromic Treatment for STDs
                  Most common situations


) Genital ulcer - treat for syphilis
   5 Benzathine penicillin 2.4 million units IM
) Urethral discharge/cervical discharge - treat for gonorrhea
  and chlamydia
   5 Cefixime 400 mg or Cipro 500 mg AND
   5 Azithromycin 1.0 gm or Doxycycline 100 mg b.i.d. x 7
     days
) Vaginal discharge in female - treat for trichomoniasis and
  bacterial vaginosis
   5 Metronidazole 2 gm
  Prevention Counseling

) Get partners treated

) Decrease number of partners

) Use a condom every time

				
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