SEXUALLY TRANSMITTED
DISEASES
Case studies
2015 WV Public Health Symposium
Objectives
To review:
• Important STD’s using a case-based
approach
• Treatment and Follow up
• Clinical presentation, diagnostic work-up of
selected STD’s
• CDC 2015 STD Guidelines
Case 1
• 37 y.o. man recently returned from a trip
to Thailand
– Reports a penile ulcer
• Physical exam:
– Afebrile, no rash or lymphadenopathy
– Ulcer at base of penis, 1 X 1.5 cm, no
urethral discharge
What is the differential diagnosis?
Case 1 (cont’d)
Differential Diagnosis:
– Syphilis
– Herpes simplex
– Chancroid
Less likely: Lymphogranuloma venereum (LGV)
Granuloma inguinale
What tests should be ordered?
Case 1 (cont’d)
Tests to order:
– RPR
– HIV test
Consider also:
– Tzanck smear
– HSV-PCR test
Case 1 (cont’d)
• Management (Awaiting test results)?
Case 1 (cont’d)
• Treat for syphilis empirically:
Benzathine penicillin IM 2.4 mU
• Also consider empiric treatment for
chancroid because prevalent in Far East
and so difficult to confirm diagnosis
(Rx: azithromycin)
• Screen for other STD’s: Chlamydia &
gonorrhea
Case 1 (cont’d)
Results:
RPR (+) 1:2
PPA (MHA-TP): positive
HIV Ab: negative
Diagnosis:
Primary syphilis
Syphilis
• Primary: Ulcer, single or multiple, usually
painless
• Secondary: Many manifestations
(ex. Rash, lymphadenopathy, fever, etc.)
• Latent: only serologic tests (+),
asymptomatic
• Tertiary: Neurological, CV
Syphilis
• All stages need treatment
• RPR titer should fall
• PPA (MHA-TP) or FTA-stays (+) for life
* What if patient is allergic to penicillin?
Management of Syphilis in
Penicillin-Allergic Patient
• Penicillin is preferred treatment for all
patients and all stages of Syphilis
• Pregnant Patients - If allergic to
penicillin, always desensitize them to
penicillin
Case 2
• 30 y.o. sexually active woman developed
nausea, vomiting, fever, and right upper
quadrant pain
– Liver enzymes mildly elevated; mildly WBC
– Urinalysis normal
Differential diagnosis?
Case 2 (cont’d)
Consider:
• Fitz-Hugh Curtis Syndrome
(Perihepatitis from N. gonorrhoeae or
Chlamydia trachomatis)
• Cholecystitis
• Hepatitis
Work up?
Case 2 (cont’d)
Diagnostic Workup:
• Blood cultures
• Pelvic exam
• Cervical swab for DNA - probe – Chlamydia and N.
gonorrhoeae; throat and rectal cultures
• Hepatitis serologies
• Right upper quadrant ultrasound
• HIV test; RPR
Empiric Therapy of Fitz-Hugh Curtis Syndrome
(perihepatitis)?
Case 2 (cont’d)
Treatment:
• Treat as for Disseminated Gonococcal
Infection with IV Ceftriaxone AND
• Give Azithromycin OR Doxycycline for
possibility of Chlamydia infection
Follow up: HIV test, RPR, treat sexual
partners, counseling
Case 2 (cont’d)
Disseminated Gonococcal Infection
• Monoarticular arthritis/tenosynovitis
[sometimes with pustular/hemorrhagic
skin lesion(s)]
• Perihepatitis
• Endocarditis (rare)
• Meningitis (rare)
Treat with IV ceftriaxone
Case 3
• 17 year old female adolescent presented
with 3 day history of back and abdominal
pain, fever
– Chills, anorexia 1 day PTA
– No vomiting, hematuria, dysuria, vaginal
discharge or bowel complaints
– LMP 2 weeks prior, was normal
– Sexually active, reported condom use
Case 3 (cont’d)
• PE: Flushed, uncomfortable
– T 38.3°C, HR 115, BP 120/70, RR 16
– Tender in right & left lower quadrants with
guarding but no rebound
– Pelvic: purulent cervical discharge &
cervical motion tenderness
– No adnexal masses
– Stool heme negative
Case 3 (cont’d)
• Cervical swab
– NAAT for Chlamydia, N. gonorrhea
• HIV Ab test
• RPR
• Pregnancy test - negative
Diagnosis?
Case 3 (cont’d)
Pelvic Inflammatory Disease
• Diagnosis: clinical
• Treatment:
Parenteral: Cefoxitin & Doxycycline OR
Clindamycin + gentamicin
IM/Oral: Either Ceftriaxone or Cefoxitin
with Probenecid plus Doxycycline (+
Flagyl)
Case 3 (cont’d)
• This same patient, one month later,
presents with low grade fever, headache,
and 3 painful, shallow genital ulcers
Differential Diagnosis?
What would you do?
Case 3 (cont’d)
• HSV-PCR test (swab) positive
Diagnosis: Herpes simplex genitalis, also
probable aseptic meningitis
• Treat with acyclovir
• Is there any value to testing Ab for
HSV-1 and HSV-2?
Case 4
• A 38 y.o. woman presents for a routine
pelvic and PAP smear
– Asymptomatic; no lesions and no discharge
– PAP results: “atypical squamous cells of
undetermined significance”
What should be done?
Case 4 (cont’d)
Plans:
• Colposcopy
• Consider HPV (Human Papillomavirus)
Testing (Typing) on cervical cells
Colposcopy reveals high grade squamous
intraepithelial lesion
HPV tests (+) for type 18
What should you do and what should you
tell the patient?
Case 4 (cont’d)
• HPV types 16 and 18 (also 31, 33, 35) are a
strong risk factor for cervical dysplasia/
carcinoma
– Her lesion may progress to malignancy
– If a smoker, she needs to stop
– She needs gynecological management according to
the grade of lesion – e.g., cryotherapy, surgery, etc.,
close follow up
What if she had only visible genital warts causing
pruritis?
Case 4 (cont’d)
Visible genital warts:
• Caused by HPV serotypes of 6, 11
• These do not increase pt’s risk of cervical
dysplasia/carcinoma
• Various treatments available:
– Patient-administered – podophyllin (NOT in
pregnancy); Imiquimod
– Provider-administered – cryotherapy; laser
• No treatment eradicates the virus
• HPV vaccine for prevention
Summary
1. Genital ulcers – caused by HSV; Syphilis;
chancroid; LGV; Granuloma inguinale
(HSV can also cause aseptic meningitis)
2. N. gonorrhoeae – causes cervicitis, urethritis,
also perihepatitis in women; DGI
Rx: Ceftriaxone
Beware of quinolone resistance
Chlamydia trachomatis – can also cause
cervicitis, urethritis, and perihepatitis
Summary (cont’d)
3. Parenteral Penicillin best drug for all patients
with syphilis
4. HPV – serotypes 6 & 11 genital warts
*serotypes 16, 18, 31, 33, 35 – associated
with cervical dysplasia, cancer
5. Both ulcerative STDs AND those causing
urethritis, cervicitis facilitate HIV
transmission
6. When you test for one STD, screen for the
other STD’s also and screen/treat contacts.
