INFECTIOUS DISEASES
STIs
Dr. Sharif Raihan
MRCP (PACES Candidate)
FCPS MEDICINE (Mid-term)
FCPS HEPATOLOGY (Final part)
BCS (Health), IMO (DMCH)
Infectious diseases -15
QSN
1. Principal of infectious diseases – 4 QSN ( 2
SBA + 2 MCQ )
2. HIV – 2 QSN (1 SBA + 1 MCQ)
3. STI – 2 QSN (1 SBA + 1 MCQ)
4. SYSTEMIC DISEASES – 7 QSN ( 3 SBA + 4
MCQ )
STD
Genital ulcer
Urethral discharge
Vaginal discharge
Genital Warts
Genital Ulcer
Painful Painless
Herpes simplex Syphilis
Chancroid
LGV
Behcet's Disease
Granuloma
Malignancy
Inguinale
Painful Genital ulcer
Diseases Ulcer Inguinal lymph Organism
node
Genital herpes Multiple Enlarged Herpes simplex
Painful Tender virus
Vesicular
Oro-genital
Behcet’s disease Oro-genital Inflammatory
Rheumatological
disease
Chancroid Single/Multiple Tender Haemophilus
Painful ducreyi
Undermined
raged edge
Malignency Metastatic / Unknown primary
Squamus cell
Painless Genital ulcer
Disease Genital Inguinal Organism
Ulcer Lymph node
Syphilis Painless Painless Treponema
pallidum
LGV Painless Painful/Tender Chlamydia
trachomatis
Granuloma Painless Tender (Abscess) Klebsiella spp .
inguinale
Discharge
Vaginal -- Candidiasis
-- Trichomoniasis
-- Bacterial vaginosis
.Urethral -- Gonorrhoea
-- Chlamydia
Vaginal discharge
Itching Color of Other Organism Disease
discharge features
Present Curdy white Low pH Candida Candidiasis
albician
Present Yellow/Green Trichomonas Trichomoniasis
vaginalis
Abssent Whitish High pH Gardnerella Bacterial
Fishy smell Clue cell on vaginalis vaginosis
microscopy
Clue cell
Urethral discharge
Gonorrhoea - Purulant discharge
Chlamydia - Watery discharge
Genital Warts
Known as Condylomata accuminata
Caused by HPV Types 6 & 11 are benign.
Types 16 & 18 causes Cervical Cancer
Features:
Small fleshy protuberances, slightly pigmented.
May bleed or itch
Herpes Simplex Virus
2 strains: HSV-1 and HSV-2
HSV-1 accounted for oral lesions (cold sores)
HSV-2 for genital lesion
Features:
Primary infection: gingivostomatitis
Cold sores
Painful genital ulceration (tingling of the genitalia,
and shooting pains)
Irritable vesicles, tender ulcers on external genitalia.
Urethral/vaginal/anal discharge or perianal/rectal
pain.
Constitutional symptom (fever, headache and
malaise)
Enlarged & tender inguinal lymph nodes
Diagnosis:
Swab from vesicular fluid or ulcers for detection of
DNA by PCR or tissue culture and typing
Management:
Gingivostomatitis: oral acyclovir, chlorhexidine
mouthwash.
Cold sores: topical acyclovir
Genital herpes:
I. Oral acyclovir.
II. If frequent exacerbations (>6 episodes/year) -
prophylactic Rx with oral acyclovir for 3 months.
Chancroid
Haemophilus ducreyi (Gram-negative bacillus)
Erythematous papule, pustule & ulcer on external
genitalia
Single or multiple painful genital ulcers associated with
unilateral, painful inguinal LN enlargement.
Ulcers with ragged undermined edges
Microscopy & culture - scrapings from ulcer or pus from
bubo.
Azithromycin 1g orally once or Ceftriaxone 250 mg IM
once or Ciprofloxacin2 500 mg twice daily orally for 3 days.
Behcet's syndrome
• Multisystem vasculitis disorder
• Autoimmune mediated inflammation of the
arteries and veins.
• Aetiology has yet to be elucidated.
• Associated with HLA B5 ,HLA B51.
Features:
Triad :
Oral ulcers
Genital ulcers
Anterior uveitis
Thrombophlebitis and DVT.
Arthritis (asymmetrical, large joints)
Neurological involvement: severe occipital headache.
GIT: Abd pain, diarrhoea, colitis.
Erythema nodosum.
Diagnosis:
Based on clinical findings
Positive pathergy test is the non-specific hyper-
reactivity of the skin following minor trauma, and is
specific to Behçet's disease.
Rx: Steroids + Azathioprine.
Syphilis
Spirochaete -Treponema pallidum
Primary, secondary and tertiary stages
Incubation period= 9-90 days.
Primary Stage:
Primary lesion or chancre in the genital area.
Dull red macule develops, becomes papular and
then erodes to indurated ulcer (chancre).
Inguinal lymph nodes may become moderately
enlarged, mobile, discrete and rubbery.
Chancre and the lymph nodes are both painless and
non-tender
EX: A 25-year-old man presents with a single, painless,
indurated ulcer on his penile shaft for the past one
week. Several small, painless, inguinal lymph nodes
were palpable bilaterally. His last unprotected sexual
encounter was with a prostitute 3 weeks prior to
presentation >>> Chancre of 1ry Syphilis.
Diagnosis of primary syphilis may be confirmed
either with dark field microscopy of secretions from
the ulcer or with serology.
NB: Bacterial culture of secretions from the ulcer is
incorrect since Treponema pallidum cannot be
cultured on routine bacterial culture media
Secondary features:
1. Occurs 1-6 months after primary infection.
2. Systemic symptoms: fevers, painless generalized
lymphadenopathy.
3. Generalized symmetrical rash on trunk, palms
and soles
4. Buccal 'snail track' ulcers (30%)
5. Condylomata lata.
Snail track ulcer
Condylomata lata
Tertiary features:
(cardio-syphilis & Neuro-syphilis)
Occurs up to 10-25 years following the original
inoculation.
Gummas
Cardiovascular syphilis: Aortic aneurysms, Aortic
regurgitation, Aortitis & Angina.
Neurosyphilis:
GPI (General paralysis of the insane): Gradual onset
confusion, Hallucinations, Tremors, Fits, Cognitive
impairment, Hyperreflexia, and Argyll-Robertson pupils.
TD (Tabes dorsalis)
Ankle reflex absent + planter
extensor
(CMFAST)
Gumma
Features of congenital syphilis:
Blunted upper incisor teeth
deafness
Keratitis
Sabre shins
Saddle nose found in
Congenital Syphilis
Down syndrome
Wegner’s granulomatosis
Leprosy
Hutchinson teeth & sabre
shin
Investigation:
Serological tests can be divided into:
Cardiolipin tests (not treponeme specific):
1. VDRL (Becomes negative after treatment)
2. RPR.
Treponemal specific antibody tests:
1. TPHA (Remains positive all the life even after treatment)
False positive VDRL
• Acute false positive in
Infectious mononucleosis
Chicken pox
Malaria
• Chronic false positive – Autoimmune disease(SLE)
• Others – HIV, Pregnancy
False negative VDRL
• Secondary syphilis ( Prozone phenomena)
Management:
Benzyl-penicillin long-acting 2.4 million units single
IM injection.
Alternatives: doxycycline
The Jarisch-Herxheimer reaction:
There will be Fever, rash, hypotension, tachycardia
after first dose of antibiotic. It is thought to be due to
the release of endotoxins following bacterial death
and typically occurs within a few hours of treatment.
Present in
Syphilis
Rickettsial
Lyme
Q fever.
Procaine reaction.
• Fear of impending death occurs immediately after
the accidental IV injection of procaine penicillin and
may be associated with hallucinations or fits.
• Symptoms are short-lived, but verbal assurance and
sometimes physical restraint are needed.
• Prevented by aspiration before intramuscular
injection to ensure that needle is not in a blood
vessel.
Chancre Chancroid
Treponema pallidum Haemophilus ducreyi
Painless ulcer Painful ulcer
Hard indurated edge Soft, ragged edge
Heal spontaneously within 3-6 wks. Grey or yellow purulent exudate
even if no ttt.
Chancre Chancroid
Lymphogranuloma
Venereum
Chlamydia trachomatis.
Gay men, especially HIV-positive men
Groov sign present
Rx: Azithromycin - treatment of choice.
Gonorrhoea
Gram negative diplococcus Neisseria gonorrhoea
Mucous membrane surface, typically genitourinary but also rectum and
pharynx.
Features:
Males: mucopurulent or purulent urethral discharge.
Females: Pus may be expressed from urethra, paraurethral ducts or
Bartholin’s ducts.
Rectal and pharyngeal infection is usually asymptomatic.
Co-existent infection with Chlamydia is extremely common in patient
with gonorrhoea.
Local complications:
Urethral strictures,
epididymitis and
salpingitis (hence may lead to infertility).
Management:
Treatment of choice for Gonorrhoea.
Options include Ceftriaxone 500 mg IM plus
Azithromycin 1 gm oral.
Cefixime 400mg PO (single dose)
Ciprofloxacin 500mg PO
Disseminated gonococcal infection (DGI):
1) Fever
2) Tenosynovitis
3) Arthritis
4) Pastular skin rash (maculopapular or vesicular)
The treatment for NGU is
5) Doxycycline 100 mg twice a day for seven days or
6) Azithromycin 1 g stat. Erythromycin is second line.
• EX: Pt with gonorrhoea and received ceftriaxone
250 mg IM single dose, but unfortunately his
symptoms have not resolved. What is the most
likely explanation? >> Co-existent infection with
Chlamydia.
Chlamydia
Chlamydia is the most prevalent sexually transmitted
infection and is caused by Chlamydia trachomatis, an
obligate intracellular pathogen.
Features:
Asymptomatic in around 80% of women and 50% of
men.
Women: cervicitis (discharge, bleeding), dysuria.
Men: urethral discharge, dysuria & acute epididymitis
(D.D. Torsion testis).
Investigation:
Chlamydial Nuclear acid amplification tests
(NAATs) - investigation of choice.
First void urine sample, vulvovaginal swab or
cervical swab
• EX: A 20-year-old man presents with dysuria and a
urethral discharge. Gram staining of the urethral
discharge demonstrates neutrophils but no
bacteria.
The most likely causative organism >>> Chlamydia
trachomatis
SBA PEARL
1) Greenish vaginal dischagre with itching – T. vaginalis
2) Curdy white V. discharge with itching – Candidiasis
3) Clear, fishy smell, non itchy But clue cell present – B.
vaginosis
4) Thick purulent urethral discharge – Gonorrhoea
5) Thin purulent urethral discharge – Chlamydia
6) Painful genital ulcer with vesicular eruption- HSV
7) Painful genital ulcer with tender
lymphadenopathy-Chancroid
8) Painless genital ulcer with painless
lymphadenopathy- Syphilis
1. A 23-year-old male presents with a purulent
urethral discharge. A sample of the discharge is
shown to be a Gram negative diplococcus. What is
the most appropriate antimicrobial therapy?
• a) Oral ciprofloxacin for 7 days
• b) Oral penicillin V for 7 days
• c) Oral doxycycline for 7 days
• d) Oral azithromycin stat dose
• e) Intramuscular ceftriaxone stat dose + oral
azithromycin stat dose6
2. A 22-year-old female presents with an offensive
vaginal discharge. History and examination
findings are consistent with a diagnosis of
bacterial vaginosis. What is the most appropriate
initial management?
• a) Oral azithromycin
• b) Topical hydrocortisone
• c) Oral metronidazole
• d) Clotrimazole pessary
• e) Advice regarding hygiene and cotton underwear
3. A 34-year-old man presents with a widespread
maculopapular rash and mouth ulcers. Two
months ago he presented to the local GUM clinic
after developing a painless penile ulcer. At the
time he was noted to have painless inguinal
lymphadenopathy. Which one of the following
organisms is most likely to be responsible?
• a) Lymphogranuloma venereum
• b) Herpes simplex virus type 2
• c) Treponema pallidum ( Primary syphilis)
• d) Haemophilus ducreyi
• e) Treponema pallidum ( Secondary syphilis)
10. A 23-year-old medical student is seen in a genitourinary
medicine clinic for a painless lesion on the glans of his penis. He
describes a 2-week history of the lesion that started as a small
erythematous papule and has now progressed to ulceration.
This was associated with fevers, sweats and general malaise. He
has returned from his elective in the Caribbean and admits to
an episode of unprotected sex with a local resident.
• On examination there was a 1x2cm painless ulcer on the glans of
his penis. You note groove sign with lymphadenopathy above and
below the left inguinal ligament only.
• What organism is cause of the patients presentation?
• a) Treponema pallidum
• b) Chlamydia trachomatis
• c) Haemophilus ducreyi
• d) Klebsiella
• e) Gonorrhoea
