STI Cases 1. A 17year-old female is seen in your clinic for a primary care visit. She has complaints today only of tension headaches that occur on a weekly basis, She otherwise has no PMHX, no significant family history, no medications or allergies. She is using condoms for birth control and has never has a gynecologic exam. What STI screening is indicated? 2. A 26 year-old woman is examined in the Emergency Department for a painful swelling on her labia for 2-3 days. What is the likely diagnosis? What STI's is associated with this condition? 3. A 24 year-old patient returns to your clinic to discuss her Pap smear. This was her third annual exam. Previous paps have been negative, but this pap shows CIN I. What do you tell her about HPV? What should she tell her partner about HPV? What further tests are indicated? Would you do testing for HPV? 4. A 21-year male student presents to your clinic with genital ulceration and inguinal lymphadenopathy. What is your differential? 5. A 30 year-old male patient presents to your clinic for routine health maintenance. Social history is remarkable for > 10 lifetime male partners. He reports condom use~90%. What further questions would you ask? What screening tests would you offer him? Any other treatments? 6. A 22 year-old male presents to your clinic with a bump just above his penis. He has recently had unprotected sex with a new partner and is quite concerned about a STI. He says he want to be tested for "everything". What is the differential of the papule? What further history do you need? What screening tests do you offer him? Update on STI's I. The scope of the problem 49% of high school students have had sexual intercourse1 8.3% before age 13 16.2% with more that four partners 58% used condom with last intercourse 24.8% used alcohol or drugs with last intercourse 72%-86% of college students have had sexual intercourse2,3 7.8% engaged in anonymous sex 34.5% had 6 or more lifetime partners 29.6% used condom with last intercourse 16.6% used alcohol or drugs with last intercourse II. Risk assessment Components of Individualized Risk Assessment for HIV (and other STI's)5 • Number of lifetime sexual partners • Sexual activities-Vaginal, Anal(receptive and insertive), and oral sex • Sex or needle sharing with individuals known to be HIV positive • Sharing needles or having sex with persons who share needles • Personal history of STI's or hepatitis • Sex with persons who have STI's-especially genital lesions • Current STI symptoms • Sex in exchange for drugs, money, or other inducement • Use of substance in connection with sexual activity • History of HIV antibody testing and results • Condom use • Birth control methods • +PPD • Clinical Symptoms suggesting HIV infection • Immunization status for Hepatitis B III. Infections A. Chlamydia Nonmotile, Gram-negative intracellular bacteria. Transmitted sexually-semen and mucus Predilection for columnar epithelium(found in younger women with cervical ectopy) Epidemiology 3-5 million symptomatic case annually Greatest number among sexually active females ages 12-19(40% of all cases) Clinical Manifestations Male 25-50% asymptomatic Incubation 7-21 days Urethritis-30-50% Epidydimitis-50% Proctitis-15% ? Prostatitis Reiters Female 70% asymptomatic. Cervicitis-Mucopurulent discharge, edematous friable cervix, increased menstrual flow, break through bleeding Urethritis Bartholinitis PID-leading cause Perihepatitis Salpingitis Infertility-contributes to 50% of cases Infant-Stillbirth, conjunctivitis, pneumonia • Screening Culture Antigen detection kits Amplified DNA Assays-PCR, LCR, SDA etc… Newest assays validated for urine specimens-may be more effective in men Sen.- 82-100% Spec 98-100% Women Sexually active and under age 25 Have more than one sexual partner, regardless of age Have had a STI in the past, regardless of age Do not use condoms consistently, regardless of age Men-no evidence for routine screening of asymptomatic men • Treatment Cervicitis/Urethritis-Also treat for concomitant GC infection Azithromycin 1gm Doxycycline 100mg BID for 7-10 days Ofloxacin 300 mg BID x 7 days Erythromycin 333 MG TID x 7-10 days-Recommended during pregnancy Adolescents are at high risk for reinfection B. Gonorrhea Gram negative Neisseria gonorrhoeae Predilection for columnar epithelium-increased risk with cervical ectopy • Epidemiology 650,000 annual cases- rates have been rising in last several years Rates rising among MSM-13% of cases Contributes to spread of HIV 60% of cases occur among people aged 15-24 • Clinical Manifestations Asymptomatic- account for 50% of infections Women Infection rate 60-90% after single exposure Endocervicitis-edematous and friable cervix Urethritis Labial Swelling Bartholinitis-2nd most common complication Endometritis Salpingitis-complicates 15-30% of cases Perihepatitis Men Infection rate 20-35% after single female exposure Urethritis Epididymitis-occurs in 10-30% of untreated men Prostatitis-rare Both Pharyngitis-90% asymptomatic. Can be persistent reservoir for infection Proctitis High degree of concomitant infection of pharynx, rectum and genital tract Disseminated-Need to culture all orifices-rectal, genital, pharyngeal Septic Joint-Knees most common. Synovial fluid positive 30-50%. Arthritis-Dermatitis-fever, chills, arthritis, tenosynovitis, + blood cultures (2050%), rash-hemorrhagic pustules on trunk, arms, hands and feet Conjunctivitis Infant-conjunctivitis, scalp abscess, pneumonia Screening/Diagnosis Gram stain-100% sens for urethrits in symptomatic menCulture DNA probe First catch urine LE Asymptomatic high-risk women and high-risk pregnant women • Treatment-Treat for concomitant Chlamydia infection Uncomplicated infection Ceftriaxone 125 mg IM x1 Cefixime 400 mg po x1-Not recommended for pharyngeal infection Cipro 500 mg po x1( Rising flouroquinolone resistance worldwide->50% in SE Asia) Ofloxacin 400 mg po x 1 C. Human Papilloma Virus • Epidemiology 75% of reproductive-age adults have been infected/15% currently infected Highest infection rates among young women 14% of college women are infected annually/45% at college health service routine exam 5.5 million new cases annually-most asymptomatic 30 subtypes-90% of infections caused by 6 and 11 6,11,42,43, 44 benign. Cause disease that regresses. Low-risk group 31, 33, 35, 39, 51, 52-15% of cervical cancers. High risk group 16, 18, 45, 56, 58, 59, 68-80% of cervical cancers. High risk group Usually, but not always sexually transmitted • Clinical manifestations Cervical Neoplasm Low-risk group 60% spontaneously resolve High-risk group- 10-15% untreated will progress to invasive cervical cancer. Accounts for most all cervical cancers Condyloma Acuminata- vulva, penis, scrotum, urethra, perineum. anal/rectal. Co-infection with HIV leads to increased disease severity Infant-Respiratory papillomatosis Screening No routine or universal screening recommended New recommendations may recommend perhaps for ASCUS pap Hybrid capture II-DNA probe for high-risk subtypes. Sen. 90% • Treatment External genital warts Aldara 5%induces cytokines Apply 3 X/week over entire involved area. Lower recurrence rates. Cryotherapy Laser therapy Podophyllin/Podofilox TCA/BCA D. Syphilis Treponema pallidum Transmitted in bodily fluids and direct contact Increases HIV transmission rate 2-5 fold • Epidemiology 1999-6657 Primary and secondary cases, 556 cases of congenital syphillis Increasing rates among MSM Highest rates among 20-29 year-old women and 35-39 year-old men • Clinical Manifestations Primary-painless ulcer-usually single. Assoc with lymphadenopathy-incubation 21 days. Secondary-occurs 6-8 weeks after infection. Rash-may be pruritic. Can look like anything, condylomata lata, lymph node enlargement, spotty alopecia. Late/Latent-Aortitis, neurosyphillis, gummas Infant-50% transmission rate. • Screening/diagnosis All pregnant women All persons at increased risk of infection Non-treponemal Tests-used for screening and to follow response to therapy RPR-Qualitative VDRL-Quantitative. Use to follow response to treatment Treponemal Tests-used for confirmation. Stay positive for life FTA-ABS MHA-TP TPI- • Treatment Primary Penicillin G 2.4 million IU IM Need to document a fourfold drop in VDRL titer at 6 months Jarisch-Herxheimer Reaction- occurs in 50% of primary syphillis and 90% of secondary syphillis within two hours of treatment. Fever, tachycardia, myalgias, headache, leukocytosis Screen for HIV and other STI's E. Herpes Simplex Virus • Epidemiology 1 million new infections annually-25-50% in adolescents Women-25% seroprevalence HSV-2 Men-20% seroprevalence HSV Whites-17%-growing most rapidly among white teens AA-45% Transmitted by direct contact, intercourse not necessary. Barrier methods only partly effective 10% annual transmission in sero-discordant couples Asymptomatic shedding-3% of infected individuals9 Risk factor for HIV infection • Clinical Manifestations Asymptomatic 50-70% Primary Infection HSV-1 1/3;HSV-2 2/3. Single or multiple vesicles on erythematous base anywhere on genital skin. Assoc with tender inguinal LAD, fever, malaise. Ulcerate and heal in 2-4 weeks Recurrent-decreased severity. Heals in 1-2 weeks. Usually unilateral. More likely with HSV-2. 90% had at least one recurrence, 38%>5 recurrences, 20%> 10 recurrences. Median 4. Decrease after first year Prodrome-tingling, shooting pain in legs and hips, pruritis. Culture-70-90%% sensitive with active lesions DFA- Sen. 70-90% Aseptic Meningitis-33% women, 10% men Extragenital lesions-autoinoculation Proctitis Cervicitis- 90% of primary infections. Complications-necrotizing cervitcitis Pharyngitis Perinatal infection-encephalitis, hepatitis, DIC etc… • Screening Not routinely recommended • Treatment Primary Acyclovir 400mg TID or 200 mg 5X/day X 7-10 days Valacyclovir 1 gm BID X 7-10 days Famcyclovir 250 mg TID X 7-10 days Recurrent Acyclovir 400mg TID or 200 mg 5X/day or 800 mg BID X 5 days Valacyclovir 500 gm BID X 5 days Famcyclovir 125 mg BID X 5 days Suppression-Consider after multiple recurrences (>6). Plan 1-year course Acyclovir- 400 mg BID X 1 year Valacyclovir 250 mg BID or 500 mg or 1 gm QD Famacyclovir 250 mg BID F. HIV • Epidemiology-20% of individuals with HIV became infected during adolescence 1999-MSM-46% Heterosexuals-30% IDU-18% MSM/IDU-3% 54% AA, 19% hispanic, 18% white; 50% under age 25, 70% male4 • Screening -Only 70% of HIV infected people know they are infected4 Guide to clinical preventive services-19962 - Offer to all persons at increased risk-persons with STD's, IVDA, gay and bisexual men, hemophiliacs, sexual partners of high risk individuals, pregnant women, active - - TB, occupational exposure, health care workers at risk, donors, persons who request the test because they consider themselves at risk. Consider testing-persons who received blood between 1977-1985, heterosexual persons with noncompliance with condoms and more than 1 sexual partner in the last 1 year, prostitutes. Insufficient evidence to recommend for or against routine screening in persons without identified risk factors. • Risk Assessment-Need to consider setting prevalence and behavioral risk - Recommend for all patients in settings of increased behavioral risk-STD clinics, clinics for MSM, shelters, correctional facilities - Recommend for most persons in settings of high prevalence( >1%) - In settings with low prevalence and low behavioral risk- offer on the basis of risk screening and to any patient requesting testing. • Special groups Pregnant women Acute occupational exposure Acute non-occupational exposure • Elisa and Western Blot- Available as serum, rapid serum, home dried blood spot, oral fluid or urine-based assay. Standard assays look for HIV-1. Rapid Tests-only preliminary positive at time of testing-must be confirmed. Benefit of informing positive patients otherwise lost to follow-up. Most indicated in clinics with low return rates.8 Detectable 6-12 weeks in majority of patients. Detectable in 95% at 6 months. Sources of false negatives-agammaglobulinemia, immunosuppression, replacement transfusions, HIV subtypes, O strains and HIV-2. Sources of indeterminate-early partial sero-conversion, advanced HIV infection, crossreacting alloantibodies from pregnancy or transfusion, organ transplantation, autoantibodies, HIV-2 infection. HIV-2 and HIV-1 non-B infection testing may be indicated in certain situation • Post-exposure treatment Initiate in after unprotected receptive and insertive anal and vaginal intercourse with a partner who is or is likely to be HIV infected. Can offer with receptive fellatio. Need baseline negative HIV Assure commitment to safer sexual practices Initiate within 72 hours. 4 week prophylaxic regimen. Monitor for signs or symptoms of acute HIV infection-send p24 and/or viral load. G. Hepatitis B Epidemiology 200,000 infections per year. Highest incidence ages 25-39 120,000 are sexually acquired Prevention Routine vaccination of adolescents age 11-12 not previously vaccinated6 Adolescents older than age 12 at increased risk of Hep. B infection Multiple sexual partners(> 1 in last 6 months) Use injected drugs MSM Sexual or household contact with Hep BsAg positive individual Health care workers Residents of institutions On hemodialysis Travel to Hep B endemic area for greater than 6 months H. Hep. A-routine vaccination for MSM I. Molluscum Contagiosum Molluscum contagiosum virus- pox virus Transmitted by touching lesion Causes small raised papules with central keratotic plug Large numbers or giant facial lesions-think HIV infection Can treat by removal-will spontaneously regress J. Pediculosis Pubis Pruritic papules and macules in genital area. Presence of lice or nits. Treat with lindane or permethrin. May need second treatment. IV. Clinical syndromes A. Genital Ulcers/Lymphadenopathy Syphillis HSV Chancroid-culture for Haemophilus ducreyi. Tender genital papules which become purulent and ulcerates. Assoc. with tender lymphadenopathy and "bulbo". Diagnosis by culture Transmitted by touching infected lesion. Treat with Azithro, CFTX, Cipro, or EES Lymphogranuloma venereum(LGV)-caused by chlamydia trachomatis Painless papule which ulcerates. Followed by lymphadenopathy. May lead to fistulae formation. Diagnosis by titers. Treat with Doxycycline, EES, or Sulfisoxazole. Granuloma inguinale- "Donovanosis" calymmatobacterium granulomstis May require biopsy for diagnosis B. Pelvic inflammatory disease-polymicrobial Chlamydia-5-50% Gonorrhea Anaerobes R/o tubo-ovarian abscess, ovarian torsion, ovarian cyst, appendicitis, ectopic pregnancy Leads to 6-10 fold increased risk of ectopic pregnancy 25% infertile after 1 episode/50% infertile after 3 episode C. Urethritis Chlamydia-30-50% Gonnorrhea U. urealyticum 20-40% Trichomonas vaginalis 2-5% HSV D. Epididymitis Chlamydia-50% Chlamydia/GC GC alone Enteric organism-> age 35, MSM TB-uncommon E. Vaginitis 15-20% Trichomonas-5 million cases per year. Usually sexually transmitted 40-50%-Bacterial Vaginosis. Not usually sexually transmitted. 20-25%-Candidiasis. Occasionally sexually transmitted Treat partner for recurrent BV or vaginal candidiasis. References 1. Youth Risk Behavior Surveillance- United States, 1999. MMWR Vol. 49. No SS-5 June 9, 2000. 2. "Screening for Human Immunodeficiency Virus." Guide to Clinical Preventive Services. 2nd ed. Baltimore (MD): Williams and Wilkins; 1996. 303-24. 3. Youth Risk Behavior Surveillance: National College Health Risk Behavior Survey-- United States, 1995. MMWR Vol. 46. No SS-6 November 14, 1997 4. "HIV Prevention Strategic Plan through 2005" U.S Department of Health and Human Services. CDC. January 2001. 5. "HIV Counseling, Testing, and Referral Standards and Guidelines." U.S Department of Health and Human Services. CDC. May 1994 6. "Immunization of Adolescents: recommendations of the Advisory Committee on Immunization Practices, the American Academy if Pediatrics, the American Academy of Family Physicians, and the American Medical Association." Pediatrics 99(3):479-488, 1997 7. 1998 Guidelines for the Treatment of Sexually Transmitted Diseases. MMWR Vol. 47. No RR-1 January 23, 1998 8. Update: HIV Counseling and Testing Using Rapid Tests-United States, 1995" MMWR 47(11); 211-215. 9. Gilson, R.J. and A. Mindel. "Sexually Transmitted Infections." BMJ 2001;322(7295): 11601164 10. Management of Possible Sexual, Injecting-Drug-Use, or Other Nonoccupational Exposure to HIV, Including Considerations Related to Antiviral Therapy. MMWR Vol. 47. No. RR-17 September 25, 1998. 11. Katz, M.H. and J.L. Gerberding. “ The Care of Persons with Recent Sexual Exposure to HIV.” Annals of Intern Med. 1998;128:306-312.