SEXUALLY TRANSMITTED INFECTION- Symptomatic or asymptomatic infections acquired through sex

SEXUALLY TRANSMITTED DISEASE- Symptomatic disease acquired through sex

 Series of transmissible diseases which infected through sexual activity or indirect contact transmission
 affects both genitourinary apparatus and many organs through lymphatic system or hematogenous
dissemination
 Main hazard to human health

Microorganism Causal agent Disease

VIRUSES Human Papillomavirus Warts
Herpes Simplex virus Herpes
Hep B virus Hepatitis
HIV virus AIDS
BACTERIA Chlamydia trachomatis Chlamydia
Neisseria gonorrhoeae Gonorrhea
Haemophilus ducrevi Chancroid
FUNGI Candida albicans Candidiasis and Balanitis
PROTOZOA Trichomonas vaginalis Trichomoniasis
INSECTS Sarcoptes scabiei Scabies

CAUSES OF GENITAL ULCERS:

Herpes, Syphilis, Chancroid
CAUSES OF URETHRAL or CERVICAL DISCHARGE:
Gonorrhea, Chlamydia
Abnormal: Mucoid
CAUSES OF VAGINITIS:
Candidiasis, trichomoniasis, bacterial vaginosis

SYPHILIS
 Treponema pallidum (Spirochete)
 Multi-stage disorder
 “great imitator”
Primary Stage (3-90 days)
Chancre- main feature
- painless, infectious, hard, single or many
Several days-months after infection
Genitals mouth rectum and other areas
ulcer heals, many might think there is no problem
Secondary stage (4-10 weeks)
infectious rash
3-6 weeks following infection
hands source feed and other areas
fever and flu like symptoms may also be apparent
rash typically heals after several weeks
Condylomata Lata- wart like lesions
gray, raised papules, appear on the vulva or near the anus or in other warm intertriginous region
symptom manifested by illnesses other than syphilis such as condylomata acuminata = differential
diagnosis must be performed
Latent stage
infection hides in body, often CNS
years
may be no symptoms for a long time
disease begins to attack organs
further divided into early late or unknown stages based on when infection occurred
Late/tertiary stage (3-25 years)
severe symptoms develop: paralysis, numbness, blindness, heart disease, dementia

Investigation:
Dark Field Microscopy- demonstrate spirochete as shiny motile spiral structures with a dark background
- Usually positive in primary and secondary stages
Serological Test:
Non-specific: Rapid Plasma Reagin and Veneral Disease Research Laboratory
Specific: Microhemagglutination Assay for Treponema pallidum Antibodies (MHA-TP) and IgG

Treatment:
Early syphilis:
Benzathine penicillin G (Bicillin L-A)- 24 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

HERPES
- Herpes Simplex Virus (HSV) I and II
Symptoms:
Blisters (most common)
First primary outbreak occurs within a few weeks of contact
may continue for a couple of weeks, longer for those with compromised immune system
painful itchy tingle or burn
Flu Like Symptoms: headache, fever, swollen lymph nodes, muscle aches
burning during urination
 HSV-1: “fever blisters” (occasional cold sores on the lips)
small blisters or sores on genitals
 HSV-2: fluid filled blisters that form painful crusted sores in genitals and thighs or buttocks.
Can spread to the lips through oral contact

Complications:
Rare
spread to infants at delivery
severe infections in AIDS patients

Investigations:
Viral Culture- taking a tissue sample or scraping of the sores for examination in the lab
PCR
Blood test

Treatment: no cure!!
Antivirals- shorten duration, reduce frequency and severity of recurrences
 acyclovir (Zovirax)
 Famcyclovir (Famvir)
 Valcyclovir (Valtrex)
Different dosages for initial treatment versus recurrent or suppressive treatment

CHANCROID
 Haemophilus ducreyi
 Results in painful superficial ulcers often with regional lymphadenopathy
 occurs in Asia Africa and Caribbean
 important cofactor of HIV transmission
Clinical Manifestations:
painful sore that looks like chancre with soft edges
male to female ratio 10:1

Symptoms:
Genital Ulceration- ulcers on genitals
 extremely painful in men but may go unnoticed in women as it can develop inside the vagina

Investigation:
Special Culture Media (Chocolate Agar)- for definitive diagnosis

Treatment:
 Azithromycin
 Ceftriaxone
CAUSES OF GENITAL ULCERS:
a. herpes
painful, blister
ulcer, shallow, multiple, recurrent
b. syphilis
Painless
Single, not recurrent
c. Chancroid
Painful
Single or multiple, not recurrent

GONORRHEA “tulo”
 Neisseria gonorrhoeae: coffee-bean shaped, intracellular diplococci, red
Clinical manifestations
Men
Painful discharge from urethra (thick, yellowish-greenish)
Burning while urinating
Women
Pain while urinating
Vaginal discharge (thick, greenish)
Redness of the genital area

Symptoms: Often NO symptoms

Complications
Men
Infants
Epididymitis
Ophthalmia neonatorum
Infertility
Women
PID
Infertility
Ectopic pregnancy

Investigation:
Gram stain
Non-culture test: DNA Probe test (GenProbe) and PCR/LCR test
Culture

Treatment:
Antibiotics also applicable for chlamydia
 Cefixime (Suprax) 400mg PO x 1
 Ciprofloxacin (Cipro) 500mg PO x 1
 Azithromycin (Zithromax) 2gm PO x 1
 Ceftriaxone (Rocephin) 125mg IM x 1

CHLAMYDIA
 Chlamydia trachomatis
Symptoms:
Generally w/n 3 weeks of infection. Often NONE
Men Women
Scant CLEAR DISCHARGE from urethra Cervical discharges
Pain when urinating
Complications:
Women Infants
PID Pneumonia at 6 weeks age
Infertility Eye infection
Ectopic pregnancy

Investigation:
Culture
Non-amplified tests: Enzyme Immunoassay (EIA)- Chlamydiazyme
 Nucleic Acid Hybridization (NA Probe)- Gen-Probe Pace-2
NA amplification assays: PCR and Ligase Chain Reaction (LCR)

Treatment:
Antibiotics
 Azithromycin 1gm PO x 1
 Doxycycline 100mg PO BID x 7 days
 Condoms
 Abstinence

TRICHOMONIASIS
 Trichomonas vaginalis
Symptoms:
Women Men
Stinging in vaginal area Stinging when urinating
STRONG VAGINAL SMELL Penile discharge
Vaginal discharge (frothy, green/yellow, pH 5, WBC, motile trichomonads) Stinging in urethra
Small ulcers on vulva

Complications:
Spread other STDs and STIs
Genital inflammation

Investigation:
Wet mount
Culture

Treatment:
 Metronidazole (Flagyl) 2gm PO
*High recurrence after treatment

BACTERIAL VAGINOSIS
 ↑ Gardnerella vaginalis (bad), decrease in 95% lactobacillus (good)
Clinical manifestations:
Vaginal Pain
Abundant FISHY vaginal discharge
Burning sensation

Complications:
Increases risk of HIV, herpes, chlamydia, gonorrhea
Pregnant: premature birth

Investigations:
Clue cell on wet mount
Clue cell- vaginal cells covered w/ bacteria
Positive “whiff test”
Vaginal pH (≥ 4.5)

Treatment:
 Metronidazole (Flagyl) 500mg BID x 7 days (oral tab)
 Clindamycin (cream)
 Tinidazole (oral tab)
*High recurrence after treatment

CANDIDIASIS
- Candia albicans…..NOT STD
Symptoms:
Cheesy white adherent discharge

Syndromic Treatments for STDs

Genital ulcers Vaginal discharge
Treat for syphilis Treat for trichomoniasis and bacterial vaginosis
Benzathine penicillin 2.4 million units IM Mebendazole 2gm
Urethral/cervical discharge
Treat gonorrhea and chlamydia
Ceftriaxone 400mg or Cipro 500mg AND
Azithromycin 1gm or Doxycycline 100mg BID x 7 days

HPV
- Human Papillomavirus
- VIRUS = INCURABLE
- 200+ strains: 40+ can be sexually transmitted
Clinical manifestations:
Days, weeks, or more after infection
Less common among MEN
Genital warts- most common symptom

Complications:
30 strains cause CERVICAL CANCER
Increase risk of vulvar, anal, penile cancer

Investigation:
Visible: physical exam
Nonvisible:
Vinegar solution test- help identify difficult-to-see FLAT LESIONS
Pap smear- checks for cancer cells
DNA test- recognize DNA of high-risk HPV, expensive

Treatment:
 Topical ointment
 Laser/freezing/burning for smaller warts
 Abstinence
 Condom
 Prophylaxis
o Vaccines: Gardasil 3 injections for high-risk HPV types (6, 11, 16, 18)

HIV/AIDS
AIDS severe symptoms: Weight loss of more than 10% of body weight
Diarrhea lasting longer than a month
Fever lasting for longer a month
Characteristic HIV-1 HIV-2
Infectivity High Low
Virulence High Low
Heterosexual spread Higher Lower
Vertical transmission 20-25% ≤ 5%
Genetic diversity -- Lower
Prevalence Global Africa
Origin Common chimpanzee Sooty Mangabey
Time to AIDS ≤10 years ≥ 20 years

Effects of the virus:

Attacks CD4 T cells
Change composition of WBC
Enables HIV to replicate itself
Weakens immune system
Increases vulnerability to life-threatening illnesses

Main routes of transmission:

Sexual- MAIN mode, 70-80% of cases
Parenteral- Blood transfusions
Vertical/perinatal- Utero, labor, breastfeeding
Physical factors affecting Transmission and Vulnerabilities
Viral Host
Strain of HIV Presence of STI
Viral load Stage of infection
Hereditary to HIV
Phases of HIV
Acute: HIV replicates QUICKLY
Energy req. increase
Asymptomatic
Symptomatic: onset of opportunistic infections
Further increase in nutritional req.
Late symptomatic (full-blown AIDS)
Heightened viral load
Intense weight loss and wasting
Opportunistic infections taking control

Investigation:
WINDOW PERIOD- negative for first 3 months after infection
3 tests to confirm result conflict
Repeat test 3 months after 1st test
FALSE POSITIVE more common in children under 18 months

Types of HIV tests:

BLOOD TEST
EIA or ELISA- most common
Western blot- GOLD standard, more specific, a confirmatory test
Radio-immunobinding assay- expensive, confirmatory when antibodies are low
Dot-blot immunobinding assay- cost-effective rapid screening test
PCR- measures HIV genetic info
URINE TESTS
Test for antibodies in urine
Not as sensitive as blood tests
EIA, Western blot
ORAL FLUID TESTS
Test for antibodies in oral fluids
EIA, Western blot

Treatment:
 NO CURE!!!
 Help slow progression to AIDS, reduce OIs, minimize malnutrition
 ANTIRETROVIRAL THERAPY- most EFFECTIVE using ARV drugs (prevent ↑ in viral load)
o Combination of ARV’s
o Limit replication, delay onset, prevent additional OIs
o Problems: expensive, taken for life, uncomfortable side effects