Chlamydia Trachomatis

Chlamydia Trachomatis

• Risky sexual practices, impaired mucous membranes, history of STIs, and exposure during birth are risk factors.
• Ocular complications include ophthalmia neonatorum (conjunctivitis) which may lead to blindness.
• Genitourinary complications in biologically female individuals include PID, infertility, proctitis, cervicitis, urethritis, ectopic pregnancy.
• Epididymo-orchitis occurs in biologically male individuals.
• Other complications include chlamydial pneumonia, bronchitis, and perihepatitis (Fitz-Hugh-Curtis syndrome).
• This increases the risk of acquiring and transmitting HIV.
• Individuals may be asymptomatic
• 70% of biologically female individuals and >50% of biologically male individuals are asymptomatic.
• Symptoms in biologically female individuals include bartholinitis, cervicitis, endometritis, salpingitis, urethritis (dysuria, pyuria), PID, perihepatitis, and post-coital or intermenstrual bleeding.
• Symptoms in biologically male individuals include urethritis (dysuria, watery/mucoid discharge).
• Rectal infections are usually asymptomatic but can cause anorectal discomfort and discharge.
• Diagnosis is via Nucleic Acid Amplification Test (NAAT)
• NAAT identifies specific microbes from swab or urine samples.
• If using urine samples, collect 15-20ml of the first void, not mid-stream.
• First-line antibiotic treatment includes doxycycline 100mg PO for 7 days (contraindicated in pregnancy) or azithromycin 1g PO on day 1, then 500mg PO on days 2 and 3.
• Azithromycin is the first-line treatment in pregnancy.
• Notify all sexual partners for testing and treatment.
• Discuss safe sexual practices to avoid infections.

Syphilis (Treponema Pallidum)

• Risk factors include unprotected sex, multiple sexual partners, biologically male sex, MSM, IVDU, and existing STIs (especially HIV).
• Cardiovascular complications include syphilitic aortic aneurysm, dilated aorta, aortic regurgitation, and coronary artery narrowing.
• Congenital syphilis complications include hemolytic anemia, deafness, keratitis, periostitis, hepatosplenomegaly, and pseudoparalysis.
• Neurosyphilis complications include dementia, meningitis, brain/spinal cord infarction/ischemia, seizures, tabes dorsalis (muscle weakness, locomotor ataxia, reduced proprioception), paralytic dementia, facial and limb hypotonia, intention tremors, forgetfulness, and personality changes.
• Ocular syphilis complications include uveitis, viritis, retinitis, optic neuropathy, blindness, reduced acuity, and Argyll Robertson pupil.
• Otosyphilis complications include hearing loss and tinnitus.
• Primary syphilis is characterized by a chancre (painless ulcer at the inoculation site) that is usually firm, round, and painless.
• The chancre heals irrespective of treatment, but treatment prevents progression to the secondary stage.
• Secondary syphilis may be asymptomatic.
• Symptoms include a diffuse rough reddish-brown maculopapular rash on extremities.
• Raised grey-whitish lesions on mucous membranes and condylomata lata (wart-like lesions on genitals in 1/3 of secondary syphilis patients) are other symptoms.
• Myalgia, fatigue, lymphadenopathy, fever, and "moth-eaten" alopecia can also occur.
• Secondary syphilis can resolve without treatment, but treatment prevents progression.
• Latent syphilis involves positive serology without symptoms.
• Tertiary (late) syphilis involves gummas (non-cancerous granulomatous growths on internal organs, bones, skin, more common in those with HIV).
• Evidence of organ involvement such as Charcot joints and aortitis are evident.
• Diagnosis includes a blood test for serology
• Syphilis IgM tests are done for very early infections, and HIV and other infections are also tested.
• Some labs can test for Treponema on swabs using NAAT
• Lumbar puncture and CSF examination are done for neurological signs.
• History and physical examination are crucial, with repeat testing a few weeks later if initially negative.
• Treatment involves antibiotics such as parenteral (IM/IV) penicillin G.
• Doxycycline, tetracycline, or ceftriaxone are used if there is a penicillin allergy.
• Notify all sexual partners for testing and treatment.
• Discuss safe sexual practices and how to avoid infections.

Herpes Simplex Virus

• Risk factors include contact with infected individuals, immunosuppression, high-risk sexual behavior, vertical transmission during pregnancy/childbirth, and mucosal surfaces/skin breaks.
• Complications include neonatal HSV infection, meningitis, encephalitis, acute retinal necrosis, uveitis, keratitis, esophagitis, secondary infection of lesions (Candida, Strep), and urinary retention.
• Herpes labialis (oral) presents with painful ulcers around the mouth, high fever, sore throat, pharyngeal edema, myalgia, and cervical lymphadenopathy.
• Recurrent oral infections involve pain, burning, tingling, and vesicle formation.
• Genital herpes presents with ulceration and vesicles.
• Ulceration and vesicles occur on the vulva, cervix, vagina, penis shaft/glans, perineum, and buttocks
• Consider topical anesthetics like lidocaine 5% ointment.
• Oral analgesia and antivirals are treatments.
• Check BASHH guidelines or BNF for the most up-to-date antiviral regimen.
• Aciclovir 200mg PO 5 times daily for 5/7 OR aciclovir 400mg TDS for 5/7.
• Valaciclovir or famciclovir are also options.
• There is no evidence for courses longer than 5 days.
• Partner notification and safe sex practice discussions are necessary.

Neisseria Gonorrhoea

• Gram-negative diplococcus primarily enters the body through unprotected sex and can invade the bloodstream (disseminated gonococcemia) or transmit perinatally.
• Risk factors include unprotected sex, risky sexual behaviors, multiple partners, MSM, low educational/socioeconomic levels, substance abuse, and previous infection history.
• Complications include epididymitis, prostatitis, penile lymphadenitis, urethral strictures, pelvic inflammatory disease, and gonococcal ophthalmia neonatorum (corneal scarring/perforation, blindness).
• 50-80% of biologically female patients are asymptomatic.
• Biologically male patients are rarely asymptomatic.
• Symptoms include urethritis (dysuria, urgency, purulent foul-smelling urethral discharge).
• Cervicitis presents with lower abdominal discomfort, dyspareunia, vaginal pruritus, and foul-smelling vaginal discharge.
• Proctitis presents with anal pruritus, tenesmus, rectal fullness, constipation, purulent anorectal discharge, and bleeding.
• Pharyngitis can occur with sore throat and swollen lymph nodes
• Disseminated gonococcemia leads to fever, chills, malaise, polyarthralgia, tenosynovitis, and postural/vesiculopustular lesions.
• Gonococcal ophthalmia neonatorum presents with purulent conjunctival discharge, swollen eyelids, conjunctival hyperemia, and chemosis.
• Diagnosis requires detection of N. gonorrhoeae at an infected site by nucleic acid amplification tests (NAAT) or culture.
• Treatment involves ceftriaxone 1g intramuscularly as a single dose when antimicrobial susceptibility is unknown.
• Ciprofloxacin 500mg orally as a single dose, if antimicrobial susceptibility is known prior to treatment.

HIV

• Lentivirus genus infection characterized by immune cell targeting, immunodeficiency, immunocompromise, and progression to AIDS.
• Infection targets CD4+ cells (T-lymphocytes, monocytes, macrophages), causing replication and spreading which reduces CD4+ cells and results in immunodeficiency.
• Transmission occurs via sexual contact, parenteral routes (IV drug use or contaminated blood infusions), and vertical routes (in utero).
• Risk factors include West African residence, MSM, risky sexual behaviors, IV drug use, hemophiliacs, blood component recipients, and maternal infection in utero.
• Complications include opportunistic infections, secondary malignancies, AIDS, and neuropsychiatric disease.
• Acute retroviral syndrome presents as a self-resolving flu-like syndrome with myalgia, fever, weight loss, fatigue, and coryza.
• Chronic infection presents variably as asymptomatic or with minor infections like oral/vaginal candidiasis, HZV, or Mycobacterial tuberculosis
• AIDS leads to persistent fever (>1 week), fatigue, weight loss, diarrhea, generalized lymphadenopathy, serious opportunistic infections, and secondary neoplasms like Kaposi's Sarcoma.
• Neuropsychiatric diseases include delirium, major depression, mania, schizophrenia, post-traumatic stress disorder, substance abuse, addiction, and dementia ('AIDS Dementia Complex') caused by cytomegalovirus encephalitis, progressive multifocal leukoencephalopathy, cerebral toxoplasmosis, cryptococcal meningitis, or CNS lymphoma.
• Diagnosis uses laboratory-based tests on patient venipuncture samples (largely 4th generation tests) and point-of-care tests (largely 3rd generation tests).
• Antiretroviral therapy is the treatment.

Hepatitis B and D

• Hepatitis B is a DNA virus of the Hepadaviridae family targeting hepatocytes in the periportal area (zone 1) with an incubation period of 6 weeks to 6 months.
• Hepatitis D is an incomplete RNA virus with an incubation period of 6-24 weeks which is not a part of the Hepadnaviridae family.
• Risk factors include IV drug use, healthcare work, high-risk sexual behaviors, anal intercourse, previous HIV/hepatitis infection, and high prevalence in sub-Saharan Africa primarily due to perinatal transmission.
• Complications include hepatocellular carcinoma, fulminant hepatitis, liver cirrhosis, hepatic encephalopathy, hepatorenal syndrome, and bleeding diathesis.
• Acute hepatitis presents with non-specific symptoms like fever, malaise, and nausea.
• It can begin as anicteric (no jaundice) or progress to icteric hepatitis with hepatomegaly, right upper quadrant pain, jaundice (30%), dark-colored urine, and pale stools.
• Chronic hepatitis is mostly asymptomatic or non-specific until end-stage disease, with exacerbations that may lead to acute hepatitis.
• Jaundice, splenomegaly, ascites, encephalopathy, and extrahepatic symptoms (arthritis, glomerulonephritis, rash, fever) are also symptomatic.
• Blood tests diagnose with viral DNA detection (PCR etc), deranged Liver Function Tests (LFTs), raised ALT + AST (ALT>AST), raised alpha-fetoprotein, raised bilirubin, and decreased albumin.
• A deranged coagulation screen aids diagnosis.
• Serology tests (Hep B surface antigen (HBsAg), Hep B surface antibodies (Anti-HBs), IgM/IgG antibodies against hepatitis B core antigen (IgM anti-HBc/IgG anti-HBc) are diagnostic.
• Liver biopsy indicates acute with mononuclear infiltrate, pericentral inflammation, necrosis, and eosinophilic hepatocytes.
• Liver biopsy indicates chronic with fibrosis, nodule formation, mononuclear portal infiltrate, and some hepatocytes.
• Treatment includes antiviral monotherapy for severe acute hepatitis, pre-existing liver disease, concomitant hepatitis C/D, immunocompromised individuals, and elderly individuals.
• Acute hepatitis treatment is post-exposure prophylaxis (HBV vaccine + immunoglobulin), supportive care (fluid therapy + nutrition), and Pegylated Interferon Alpha (Hepatitis D).
• Chronic hepatitis requires combination therapy and consideration of liver transplant for chronic Hepatitis D.
• Acute Liver Failure treatment is fluid resuscitation, nutritional support, antiviral therapies, and consideration of liver transplant for ALF in Hepatitis D.

HPV

• DNA virus causing cutaneous and mucosal infections, results in verrucae (warts) with over 200 known types.
• Over 40 types are transmitted via sexual contact via skin-to-skin contact when breaks in the epithelium are present.
• Risk factors include epithelial trauma, walking barefoot, occupational hazards (meat, poultry, fish handlers), use of communal showers, smoking, early age of first sexual intercourse, multiple sexual partners, uncircumcised males, and immunocompromised states (especially HIV/AIDS).
• Risk of malignancy with certain HPV infection types.
• Verruca vulgaris (common wart) is caused by HPV types 2 and 4, presents with a cauliflower-like raised surface usually on hands/feet/elbows/knees and can be subungual/periungual and painful.
• Verruca plantaris is caused by HPV type 1, located on the soles of feet and can be painful when walking.
• Verruca plana (flat warts) is caused by HPV types 3, 20, 28, and located on the face, arms, and forehead, commonly found in children and adolescents.
• Condyloma acuminatum (anogenital warts) is caused by types 6, 11, 15, 16 and 18.
• Types 16 & 18 cause 90% of all genital warts and 70% of all cervical cancers.
• Type 16 can cause anal cancer, oropharyngeal, vaginal, penile, and vulvar cancer.
• Laryngeal papillomatosis is caused by types 6 and 11 which occur in the larynx and respiratory tract.
• Genetic testing via PCR detects viral load.
• Immunohistochemistry with biomarker detection.
• Cytology of cervical lesions leads to colposcopy and biopsy if positive.
• Cutaneous warts may resolve spontaneously and are treated with topical salicylic acid or fluorouracil 5%.
• Anogenital warts can be treated.
• External genital warts: podofilox solution/gel, sinecatechins ointment, imiquimod cream
• External or Internal genital warts: Cyotherapy, trichloroacetic acid, bichloroacetic acid, or surgical removal
• Prevention includes HPV vaccine (Gardasil [quadrivalent], Cervarix [bivalent] administered before primary infection occurs (9-13 years old), cervical cancer screening (pap smear), barrier contraception, and decreasing the numbers of sexual partners

PID

• Infection and inflammation of the upper genital tract in biologically female individuals.
• Usually secondary to chlamydia, gonorrhea, or vaginal flora infection.
• Bacterial vaginosis is present in 2/3rds of PID cases.
• This is associated with endometriosis, salpingitis, oophoritis, peritonitis, perihepatitis, and tubo-ovarian abscesses.
• PID is more common in individuals who are biologically female, under 25 years, and sexually active.
• Risk factors include multiple sexual partners, partners with STIs, personal history of PID/STI, unprotected sexual intercourse, and cervix instrumentation (e.g., termination of pregnancy).
• Complications include recurrent PID, hydrosalpinx, pyosalpinx, chronic pelvic pain, infertility, ectopic pregnancy, and ovarian cancer.
• Acute symptomatic PID includes bilateral lower abdominal/pelvic pain that has an abrupt onset during or post menstruation, is constant + aching, and worsens during sexual intercourse or movement.
• Acute PID also includes abdominal/pelvic organ tenderness, feeling of fullness, intermenstrual/postcoital bleeding, dysuria, low-grade fever, rebound tenderness, fever, and decreased bowel sounds (severe cases).
• Chronic PID leads to low-grade fever and weight loss.
• Perihepatitis (Fitz-Hugh-Curtis syndrome) presents with RUQ pain + tenderness.
• Diagnosis may include imaging, lab tests, and speculum examination
• Imaging includes pelvic/abdominal ultrasound, which may show fluid-filled fallopian tubes with cogwheel sign, endometrium wall thickening, and tubo-ovarian abscess.
• Lab tests include vaginal discharge microscopy, NAATs for STI, tissue biopsy, and inflammatory markers (leukocytosis, raised CRP/ESR).
• Broad-spectrum antibiotic therapy, antiemetics, antipyretics, and analgesia are given.
• Prevention includes barrier contraception and abstinence.