Dr.T.V.
Rao MD
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Dr.T.V.Rao MD
What is a Sexually Transmitted Infection or STI?
STIs are infections that are spread from person to person through intimate sexual contact. STIs are dangerous because they are easily spread and it is hard to tell just by looking who has an STI. 1 in 4 sexually active teens has an STI ?.
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STDs
STDs are diseases and infections which are capable of being spread from person to person through:
sexual intercourse oral-genital contact or in non-sexual ways. IV drugs
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Four Classes of STDs
Bacterial Fungus Parasites
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Viruses- NOT curable ?
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Common STIs
Chlamydia Gonorrhea Genital Herpes (HSV-2) Genital Warts (HPV) Hepatitis B
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HIV and AIDS Pubic Lice Syphilis
Trichomoniasis
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What are some common
Symptoms of STIs?
The symptoms vary among the different types of STIs. Some examples of common symptoms include:
Unusual discharge from the penis or vagina Sores or warts on the genital area Burning while urinating Itching and redness in the genital area Anal itching, soreness, or bleeding
If having any of these symptoms or think you might have an STI, talk to your health care provider.
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STIs in Women
Women are more vulnerable biologically, culturally, socioeconomically Most are asymptomatic (no symptoms)in women
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STDs of Concern
Actually, all of them Sores (ulcers) Syphilis
Genital herpes (HSV-2, HSV-1) Others uncommon in the U.S.
Lymph granuloma venereum Chancroid Granuloma inguinale
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STDs of Concern (continued)
Drips (discharges) Gonorrhea Chlamydia Nongonococcal urethritis / mucopurulent cervicitis Trichomonas vaginitis / urethritis Candidiasis (vulvovaginal, less problems in men)
Other major concerns
Genital HPV (especially type 16, 18) and Cervical Cancer
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Scientifically known as the gonococcus, or Neisseria gonorrhea
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Signs & Symptoms
Most infected women have no symptoms Include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods
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NEISSERIA GONORRHOEAE
3rd most common STD i It is a G-ve diplococci Infects the endocervix mucopurulent cervicitis Majority of infections are asymptomatic It is a leading cause of PID Dx endocervical culture N gonorrhea & chlamydia coexist in 50% of patients Rx ceftriaxone 125 mg IM cefixime 400 mg PO Followed by Rx for chlamydia Husband should be treated Can cause purulent conjunctivitis of the newborn
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Gonorrhea - Clinical
Manifestations
Urethritis - male
Incubation: 1-14 d (usually 2-5 d) Sx: Dysuria and urethral discharge (5% asymptomatic) Dx: Gram stain urethral smear (+) > 98% culture Complications
Urogenital infection - female
Endocervical canal primary site 70-90% also colonize urethra Incubation: unclear; sx usually in l0 d Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain Dx: Gram stain smear (+) 50-70% culture Complications
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Gonorrhea
Source: Florida STD/HIV Prevention Training Center
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Gonorrhea
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Gonorrhea Gram Stain
Source: Cincinnati STD/HIV Prevention Training Center
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Effects on Pregnancy
Can also be spread from mother to child during birth Can cause fertility problems, birth defects, skin problems, arthritis, blood poisoning, and heart and brain infections
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Nongonococcal Urethritis
Etiology:
20-40% C. trachomatis 20-30% genital mycoplasmas (Urea plasma urealyticum, Mycoplasma genitalium) Occasional Trichomonas vaginalis, HSV Unknown in ~50% cases
Sx: Mild dysuria, mucoid discharge Dx: Urethral smear 5 PMNs (usually 15)/OI field Urine microscopic 10 PMNs/HPF Leukocyte esterase (+)
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Treatment
Several antibiotics can successfully cure gonorrhea Because of drug-resistance the successful treatment o single shot of ceftriaxone 125 mg or a single dose of cefixime 400 mg taken by mouth are currently the recommended antibiotic treatment
Azithromycin (Zithromax) 2g in a single dose may be used for people who have severe allergic reactions to ceftriaxone, cefixime, or penicillin.f gonorrhea is becoming more difficult
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Bacterial Vaginitis
Controversy: STD - yes or no
Need for treatment
1980: only if patient complains 2002: increased risk of:
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Preterm birth / premature rupture of membranes Amniotic fluid infection Chorioamnionitis / Postpartum endometritis Pelvic inflammatory disease Postsurgical infection Cervical intraepithelial neoplasia Mucopurulent cervicitis Acquisition of HIV infection
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SYPHILIS
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About Syphilis
Researchers tracing origins(CBC, 5:03) Incidence
US: 13,997 in 2009
Top 13 states = 75% of cases per CDC Data by sex (males on the increase, females on the decrease) 285 - men, 4 - women
King County: 289 early syphilis cases in 2010 Over 90% among men (MSM)
Caused by bacteria, therefore curable Transmission via vaginal, oral, anal sex
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Source: 2009 King County STD Epidemiology Report
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Syphilis Symptoms
Syphilis is a multi-stage disorder:
Primary stage - painless, infectious chancre
Several days-few months after infection Genitals, mouth, rectum, other areas Sometimes there is no chancre Ulcer heals; many may think there is no problem Illustration: male (MayoClinic) Photos: oral male, female, mix (CDC, Univ. of South Carolina
Integrated Biomedical Sciences; University of Quebec; Cincinnati STD/HIV Prevention Training Center; istdpictures.com)
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Primary Syphilis Clinical Manifestations
Incubation: 10-90 days (average 3 weeks) Chancre
Early: macule/papule erodes Late: clean based, painless, indurated ulcer with smooth firm borders Unnoticed in 15-30% of patients Resolves in 1-5 weeks HIGHLY INFECTIOUS
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Sores
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Primary Syphilis Chancre
Source: Florida STD/HIV Prevention Training Center
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Primary Syphilis
Source: Centers for Disease Control and Prevention
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Syphilis Symptoms
Secondary stage Infectious rash
3-6 weeks following infection Hands, soles of feet; other areas Fever and flu-like symptoms may also be apparent Rash typically heals after several weeks
Condylomata Lata
Wart-like lesions (on female, male, CDC)
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Secondary Syphilis Clinical Manifestations
Represents haematogenous dissemination of spirochetes Usually 2-8 weeks after chancre appears Findings:
rash - whole body (includes palms/soles) mucous patches Condylomata lata - HIGHLY INFECTIOUS constitutional symptoms
Sn/Sx resolve in 2-10 weeks
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Secondary Syphilis Rash
Source: Florida STD/HIV Prevention Training Center
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Secondary Syphilis: Generalized Body Rash
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
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Secondary Syphilis Rash
Source: Cincinnati STD/HIV Prevention Training Center
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Syphilis
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Syphilis Symptoms
Latent Stage
Infection hides in body, often central nervous system Infected person can remain in this stage for years There may be no symptoms for a long time Disease begins to attack organs Latent further divided into early, late, or unknown stages based on when infection occurred
Late/Tertiary Stage
Severe symptoms develop: paralysis/numbness; blindness; heart disease; dementia
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Secondary Syphilis
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas
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Syphilis Treatment
Penicillin or other antibiotics Communicate with all sex partners regarding syphilis Refrain from sexual activity until infection is gone Condoms may help prevent syphilis transmission
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Chancroid
A sexually transmitted disease caused by a bacterium.
More commonly seen in men than women, particularly uncircumcised males Chancroid is spread by having unprotected anal, vaginal or oral sex. Some symptoms include: sores or raised bumps on the genitals which eventually if untreated, becomes filled with pus and eventually ruptures leaving a painful sore/ulcer. The bacterial may also infect the lymph glands in the groin. These glands may become enlarged, hard and painful. In Women, ulcers appear on the genitals, painful urination and painful intercourse Chancroids are contagious as long as the person as open sores. The open sores contain bacteria and any contact with these sores can result in infection. Chancroids may be treated with certain antibiotics. The ulcers generally heal within 2 to 3 weeks.
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Chancroid ulcers
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Regional adenopathy
CDC / Center for Disease Control and Prevention/ Division of STD Prevention
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Chlamydia
Bacterial Infection Spread During unprotected anal, vaginal, or oral sex. Symptoms: Occur within 7-21 days of infection. Men: Clear thick discharge from Penis, burning during urination Women: Painful Urination, itching, burning or bleeding from vagina.
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Chlamydia trachomatis
More than three million new cases annually Responsible for causing cervicitis, urethritis, proctitis, lymphogranuloma venereum, and pelvic inflammatory disease Direct and indirect cost of chlamydial infections run into billions of dollars Potential to transmit to newborn during delivery
Conjunctivitis, pneumonia
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Chlamydia
Chlamydia is one of the most common STIs, infecting an estimated 1 in 6 teens. An infected person with no symptoms can still pass the disease to others, or have serious complications. Symptoms in a male may include: a slight discharge (drip) from the penis, and a tingling sensation or pain with urination. A female may experience irregular bleeding, pain during intercourse, a vaginal discharge, belly pain, or pain with urination. Untreated chlamydia can lead to fertility problems. This disease can also be passed to babies during birth. Chlamydia is treated with antibiotics To prevent chlamydia use latex or plastic condoms each time you have sex.
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Chlamydia
Four million new cases occur each year SYMPTOMS: fever, weight loss for no reason, swollen glands, fatigue, diarrhea, white spots on the mouth. FEMALE SYMPTOMS: Vaginal discharge (white or grey) or burning with urination Lower abdominal pain Bleeding between menstrual periods. Low-grade fever (later symptom) MALE SYMPTOMS: Discharge from the penis and/or burning when urinating Burning and itching around the opening of the penis Pain and swelling in the testicles Low grade fever (associated with epididymitis inflammation of the testicles)
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Chlamydia
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Chlamydia Cervicitis
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Source: St. Louis STD/HIV Prevention Training Center
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Chlamydia Complications
Conjunctivitis in newborn (eye drops given) Reiters Disease (sensitive photos) Pelvic Inflammatory Disease (PID Illustration) Infection Disease-causing organisms migrate to uterus, fallopian tubes, ovaries Untreated, PID leads to scarring, pelvic pain, tubal pregnancy, infertility Treatment includes antibiotics Approximately 1 million women affected each year Approximately 100,000 women become infertile each year )
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Chlamydia Complications
Epididymitis
600,000 cases a year Inflammation of epididymis
Tube located in back of testicle Holds maturing sperm
Disease-causing microbe enters urethra, travels Symptoms include fever, pain, discharge, swelling Treatment includes antibiotics, STD treatment if applicable Chronic epididymitis does not threaten fertility
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Lymphogranuloma venereum
From different chlamydia bacteria More prevalent in Asia, Africa, South America, but increasing in North America; now required to be reported in WA Per DOH, six cases in 20082009 Painless pimple or lesion on genitals Infection spreads to lymph 12-01-2013 Dr.T.V.Rao MD tissue
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Lymphogranuloma Venerum (LGV)
Complication of Chlamydia
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CDC / Center for Disease Control and Prevention/ Division of STD Prevention
Herpes
Simplex Virus (HSV-2), which is related to the viruses that belongs to the same family of viruses that cause chicken pox and shingles
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About Herpes
Transmission via vaginal, oral, anal sex Transmission of virus can also occur through fingers (touching a sore, then touching a membrane) Transmission of virus possible when no sores present Transmission to fetus possible, but not typically if herpes was contracted before pregnancy
If pregnant woman contracts herpes toward end of pregnancy, transmission to fetus more likely If pregnant woman has active herpes, Cesarean performed
Transmission may occur outside body contact, but no proof
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HERPES GENITALIS
It is a recurrent sexually transmitted disease Caused by Herpes simplex virus HSV-1 10% of genital lesions HSV-2 90% of genital lesions HSV-1 & 2 also infect the orofacial skin in reversed % The virus causes prolonged lifelong infection of the nerve cells of the affected area 1-PRIMARY (FIRST) INFECTION multiple vesicles which will ulcerate forming shallow superficial ulcers over the external genitalia There is often simultaneous involvement of the vagina & cx
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Herpes Symptoms
Most common symptom is blisters
First (primary) outbreak occurs within a few weeks of contact May continue for a couple weeks, longer for those with compromised immune system May feel painful, itchy, tingle/burn
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HERPES GENITALIS
It causes severe pain, itching, vaginal discharge & painful urination urine retention that may require catheterization Associated with fever, general malaise & headache It takes 2-4 weeks to heal
2-SECONDARY (RECURRENT ) HERPES
The viruses that are already present in the nerve cells will be reactivated by various stresses such as generalized illness, menses, emotional stress or trauma It is less painful, circumscribed, not associated with generalized symptoms & lasts an average of 7 days
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Herpes
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Oral Herpes
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Source: CDC/NCHSTP/Division of STD, STD Clinical Slides
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Oral Herpes
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Herpes Simplex Oralis
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patient age: 15 years, patient sex: male
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Herpes Simplex 1 & 2
45 million people in the United States ages 12 and older have herpes 1 out of 5 of the total adolescent and adult population, are infected with Herpes Simplex
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Primary Herpes, vulva
CDC / Center for Disease Control and Prevention/ Division of STD Prevention
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Genital Herpes Simplex Clinical Manifestations
Direct contact may be with asymptomatic shedding Primary infection commonly asymptomatic; symptomatic cases sometimes severe, prolonged, systemic manifestations Vesicles painful ulcerations crusting Recurrence a potential Diagnosis:
Culture Serology (Western blot) PCR
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HERPES GENITALIS
There may be an association between the Herpes virus & precancerous & cancerous conditions of the genital tract . The virus has been detected in in squamous cell carcinoma of the cx vagina & vulva It was not proven to a causative factor for these cancer Transmission of AIDS virus is increased in the presence of genital ulcers caused by infections such as Herpes or Syphilis
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Herpes Type 2 (HSV-2)
Cause lesions around and on the genital areas Bumps form on the lips and sometimes in the mouth, tongue, and throat Blisters crust over and heal within 10-16 days
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Sores
Epidemiology of Genital Herpes
One of the 3 most common STDs, increased 30% from late 70s to early 90s 25% of US population by age 35 HSV-2: 80-90%, HSV-1: 10-20% (majority of infections in some regions) Most cases subclinical Transmission primarily from subclinical infection Complications: neonatal transmission, enhanced HIV transmission, psychosocial issues
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Genital Herpes Simplex
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas
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Genital Herpes Simplex
Source: CDC/NCHSTP/Division of STD, STD Clinical Slides
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Genital Herpes Simplex
Source: Florida STD/HIV Prevention Training Center
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Effects on Pregnancy
Type 2 Viral shedding from cervix, vagina, vulva plays the primary role in transmitting the disease from mother to infant About 60% of newborns infected and not treated will die or be severely damaged
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HERPES GENITALIS
Dx
to
Viral culture of a suspicious lesion Blood test for detection of antibodies helpful
Dx asymptomatic individuals or to confirm a past infection
Rx Acyclovir 200mg orally 5 times /day for 10 days duration of ulcerative lesions Improve the symptoms Used for 1ry infection -2ry infection no Rx -Supportive care keeping the area clean & dry xylocaine jelly Applying compresses Tylenol
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HERPES GENITALIS
Patients with recurrence 6 years prophylactic Acyclovir 400 mg twice a day To reduce sexual transmission couples should avoid direct sexual contact (by abstinence or using condom) when the infected individual has a lesion or experiencing a prodrome tingling, itching, or pain felt before the recurrent lesion appear 1ry infection in pregnancy close to delivery risk of transmission to the newborn 50% If the mother have active lesions elective CS should be performed Infection to the newborn is devastating disseminated infection with CNS involvement & 50% mortality
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LYMPHGRANULOMA VENEREUM A disease of Tropical Countries
Caused by Chlamydia trachomatis, serotype L1,2,3 A chronic infection of the lymphatic tissue : 5:1 Incubation period 4-21 days Involves : Vulva most frequent site Cx, urethra, rectum 3 phases of the disease -Primary phase Shallow , painless ulcer of the vestibule, labia or perirectal Heals without Rx -Secondary phase 1-4 wk after 1ry Painful lymphadenopathy in the inguinal or perirectal areas
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LYMPHGRANULOMA VENEREUM
2/3 unilateral adenopathy Systemic symptoms malaise & fever Tertiary phase -The nodes enlarged, tender , matted together & adherent to the overlaying skin bubos -7-15 days the bubo rupture spontaneously multiple draining sinuses & fistulas -Extensive tissue destruction of the genitalia & anorectal region elephantiasis, multiple fistulas & stricture Treatment -Doxycycline 100 mg bd for 21 days
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GRANULOMA INGUINALE (DONOVANOSIS) A disease of Tropical Countries
Caused by G-ve , nonmotile , encapsulated rod Calymmatobacterium granulomatous Transmitted sexually & by close nonsexual contact Incubation period 1-12 wk Dx Donovan bodies in specimen taken from the ulcers dark staining bacteria with safety pin appearance in the cytoplasm of mononuclear cells Painless red ulcer with fresh granulation tissue Multiple ulcers of the vulva destroy normal vulvar architecture scarring & lymphatic obstruction marked enlargement of the vulva Rx Tatracycline 500 mg qid for 3 wk
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Known as Human Papillomavirus
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20 million people are currently infected with HPV Very common amongst sexually active college students
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Human Papillomavirus (HPV)
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Human Papilloma Virus
Known as Genital Warts.
NOT Curable!!!
It causes growths
of tiny, skincolored, cauliflower-like warts to appear on the penis, vulva, vagina, and the cervix, in or around the anus or the throat. Spread by sexual or skin to skin contact with someone who has HPV. Symptoms: Irritation or itching in both men and women. HPV is extremely dangerous for women because it can lead to cervical cancer. Warts caused by HPV are treated with an ointment, laser surgery, burning it with acid or freezing it with liquid nitrogen!
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Signs & Symptoms
Most common manifestation of HPV is warts Includes warts on skin such as plantar warts or in the genital area, known as genital warts
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HPV Penile Warts
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Source: Cincinnati STD/HIV Prevention Training Center
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Condylomata acuminata, anal
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Signs & Symptoms
May be associated with discomfort such as itching, burning, or tenderness in the genital area Most women with HPV do not have any symptoms at all
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Signs & Symptoms
Include fever, general muscle aches, swollen lymph nodes in the neck, flu-like symptoms Increased salivation and sometimes bleeding in the mouth
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Treatment
No effective treatment Warts may be treated with agents designed to reduce or remove the warts, including creams, oral medications, or surgery The infection usually goes away without treatment, but for high risk HPV
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HPV and Cervical Cancer
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HPV and Cervical Cancer
HPV and Cervical Cancer
Infection is generally indicated by the detection of HPV DNA HPV infection is causally associated with cervical cancer and probably other anogenital squamous cell cancers (e.g. anal, penile, vulvar, vaginal) Over 99% of cervical cancers have HPV DNA detected within the tumor Routine Pap smear screening ensures early detection (and treatment) of pre-cancerous lesions
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HIV-Human Immunodeficiency Virus AIDS-Acquired Immune Deficiency Syndrome
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HIV/AIDS
HIV is the virus that causes AIDS The definition of AIDS relates to CD4+ T-cells Count Healthy adults usually have CD4+ T-cell counts of 1,000 or more Aids and some HIV sufferers have less than 200 CD4+ T-cells
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Modes of Transmission
blood blood products sexual fluids People can be infected and NOT look sick or even have AIDS but can still transmit HIV
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Signs & Symptoms
rapid weight loss dry cough recurring fever or profuse night sweats profound and unexplained fatigue swollen lymph glands diarrhea white spots or unusual blemishes on the tongue, in the mouth, or in the throat
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Effects of Pregnancy
70% transmission occurs at the time of delivery 30% amount occurs antenatally (before delivery) A significant contributor to transmission is breastfeeding
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TREATMENT IN PREGNANCY
Zidovudine monotherapy vertical transmission 25% 8% Standard triple therapy should be offered Zidovudine should be included in the Rx to prevent perinatal transmission Zidovudine IV intrapartum to the neonate for the first 6 wk of life Elective CS recommended if -Women did not receive antiretroviral therapy -Monotherapy -Detectable viral load > 500 RNA copies /ml -Viral load determination not done -No prenatal care
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AIDS-related Opportunistic Infections
Kaposis Sarcoma Yeast Infections
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Treatment
Antiviral drugs drugs that boost the immune system have allowed many people with HIV to resist infections, stay healthy, and prolong their lives, but these medications are not a cure
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STD/HIV Inter-Relationships
STD increases HIV susceptibility
STD causes infection and desquamation of squamous or columnar cells producing an inflammatory response Results in increased number of HIV target cells (lymphocytes) on mucous membrane surfaces and a portal of entry for HIV
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STD increases HIV transmission
For a person with HIV, having an STD: Brings inflammatory cells loaded with HIV to the genital tract Increases HIV viral shedding from mucous membranes
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HEPATITIS
Hepatitis A, B, and C all can be transmitted sexually Hepatitis B is the most common & its sexual transmission is the most efficient Hepatitis A & B can be prevented by vaccination Sexual transmission accounts for 45% of new cases Hepatitis B immunoglobulin's post exposure prophylaxis within 14 days Pregnant mothers with Hepatitis B transmit the infection to their infants during or after birth Newborn infant should receive Immunoglobulin's + Vaccination within 12 hrs of birth
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Parasitic Infection of the vagina in women and urethra in men. Mostly passed through sexual contact. It is also spread through damp towels, bathing suits or wash clothes shared with an infected person. There are frequently no symptoms.
Men: discharge from penis, mild discomfort in penis and swelling in genitalia. Women: green to yellow discharge with bad odor, vaginal itching, painful urination, inflammation in genitals. Sometimes in lower abdomen.
Trichomoniasis can usually be cured with the prescription drug, metronidazole, given by mouth in a single dose
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TRICHOMONIASIS
Caused by a protozoan Trichomonas vaginalis Symptoms diffuse malodorous yellowish green discharge vulvar irritation Dx microscopy of vaginal secretion sensitivity 60-70% culture more sensitive Rx Metronidazole 2 gm orally single dose Husband should be treated & they should avoid intercourse until they are cured Vaginal Trichomoniasis has been associated with adverse pregnancy outcome PROM, preterm delivery & low BWt. Metronidazole is safe in pregnancy
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PID(Pelvic Inflammatory Disease)
Caused by a complication of bacterial vaginosis and/or gonorrhea/chlamydia. Sexually active women aged 1525 are at highest risk for developing PID. A womans genital tract becomes inflamed and infected causing swelling, scarring, fever and pain. PID is a major cause for infertility. Symptoms: Abdominal and pelvic pain, vaginal bleeding, discharge and pain during sex.
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Candidiasis
The 2nd most common cause of vaginal irritation or vaginitis and can also occur on male genitals. It can also appear in the mouth and throat as white sores. Contrary to popular belief, Candidiasis is rarely transmitted by sexual contact. It is generally passes by Everyone has this fungus on and inside their bodies. Most of the time it is harmless and keeps the bacterial levels in your body in check, but if there is an overgrowth of this fungus it can lead to a variety of problems Some symptoms include: In Women: A thick white discharge that looks like cottage cheese, itching and burning as well as a rash on the outer lips of the vagina. In Men: Soreness, itching and redness of the head of the penis, scrotum and foreskin. (Uncircumcised men are more likely to develop yeast because it thrives in moist areas)
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An
Infections with Trichomoniasis and Candia
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SCABIES
Scabies is a fairly common infectious disease of the skin caused by a mite. Scabies mites burrow into the skin producing pimple-like irritations or burrows. Scabies mites are transferred by direct skin-to-skin contact. Indirect transfer from undergarments or bedclothes can occur only if these have been contaminated by infected people immediately beforehand. Scabies can also be transmitted during sexual contact. The most prominent symptom of scabies is intense itching particularly at night. The areas of the skin most affected by scabies include the webs and sides of the fingers, around the wrists, elbows and armpits, waist, thighs, genitalia, nipples, breasts and lower buttocks. Skin lotions are available through a physician's prescription for the treatment of scabies.
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ECTOPARASITIC INFESTATION PEDICULOSIS PUBIS
Humans are the only reservoir for pubic lice Can be transmitted by sexual & close nonsexual contact Pruritus is the most common symptom Rx Washing the area with pediculicide formulations Washing the clothes & linens with very hot water
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Scabies (under the skin crabs)
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Scabies (under the skin crabs)
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What STD screening tests would you order?
1. 2.
Urine for GC and CT and syphilis serology Urine for GC and CT and syphilis and HSV-2 serology Urine and rectal GC and CT tests, pharyngeal GC, and syphilis serology Urine, rectal and pharyngeal GC and CT, and syphilis and HSV-2 serology
39% 39%
3.
4.
17%
6%
STI Prevention
Abstain from sexual intercourse vaginal, oral, or anal Be in a monogamous relationship with an uninfected partner
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Reduce Number of Partners Get to know the Person Get tested together Try celibacy Learn about HIV/STDs together Talk to your partner about what you know How many can you think of?
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Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World from Various WEB RESSOURCES
Email [email protected]
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