SEXUALLY TRANSMITTED

INFECTIONS - II
 Congenital Syphilis
• Congenital syphilis - syphilis present in utero & at
birth
• Prevention: VDRL at antenatal visit & treatment with
penicillin G
• Transmission across placenta to foetus occurs at any
stage of pregnancy
• Foetal damage does not occur until after fourth month
• Early: birth to 2 years of age
• Late: after 2 years of age
• Stigmata
 Early congenital syphilis
• Asymptomatic; only identified on
routine antenatal screening
• Poor feeding & rhinorrhea (snuffles) – profuse
serous discharge – old man with a cold in head
• Hepatosplenomegaly, skeletal
abnormalities, pneumonia & vesicobullous lesions
known as ‘pemphigus syphiliticus’
 Late congenital syphilis
• Subclinical in about 60% of cases
• Interstitial keratitis (occurs at 5–25 years of age),
eighth-nerve deafness & recurrent arthropathy
• Bilateral knee effusions are known as Clutton's
joints
• Asymptomatic neurosyphilis - in about one-third
of untreated patients; clinical neurosyphilis occurs
in one-quarter of untreated individuals >6 years
age
 Classic Stigmata
• Hutchinson's teeth - centrally notched, widely
spaced, peg-shaped upper central incisors
• Mulberry molars - molars with multiple, poorly
developed cusps
• Saddle nose
• Saber shins
 Treatment
• Penicillin G
 Chancroid / Soft chancre / Ducrey’s
disease
• Acute, autoinoculable STI
• Etiologic agent: Gram negative facultative,
anaerobic bacillus Haemophilus ducreyi
• “School of fish” or “rail road track”
appearance
• Age group: 20-30 years
• Males affected more commonly
 Clinical features
• Incubation period- 3-10 days
• Sites: Frenum, prepuce, coronal sulcus in male
and vulva, vestibule in females
• Painful genital ulcers, non-indurated (soft
chancre/soft sore), bleed on touch
• Edema of prepuce
• Tender inguinal lymphadenopathy (unilateral
in majority), sometimes suppurative
 Investigations
• Microscopy:
• Gram stain – low sensitivity

• Culture - < 80% sensitivity

• Molecular techniques- PCR

 Treatment (CDC)
• Recommended regimen
Azithromycin 1 g orally single dose
or
Ceftriaxone 250 mg IM in a single dose
or
Ciprofloxacin 500 mg twice daily x 3 days
or
Erythromycin base 500 mg orally three times a day x
7 days
 Lymphogranuloma Venereum
(LGV)
• Also k/a tropical bubo or lymphogranuloma
inguinale
• Caused by Chlamydia trachomatis serovars L1,
L2 & L3
• Incubation period – 3-12 days
 Pathogenesis
• Enters through skin abrasions or mucous
membranes  via the lymphatics  multiply
within mononuclear phagocytes in regional
nodes
• Thrombolymphangitis & perilymphangitis
occur
• Necrosis & the formation of stellate abscesses
• Fistulae & sinus tract formation; may be f/b
healing with fibrosis
 Clinical features
Primary stage (Genital)
• Superficial ulceration, which looks like herpes,
is temporary and heals without scarring
• It may not be noticed (GUD with no ulcer)
 Clinical features
Inguinal syndrome (Secondary stage)
• Most common manifestation: bubo
• Occurs - 2-6 weeks later
• More common in males
• Painful inguinal lymphadenitis with associated
constitutional symptoms
• Enlargement of the femoral & inguinal lymph
nodes separated by the inguinal ligament –
“groove sign of Greenblatt”
• Suppuration and sinus formation
 Clinical features
Genital syndrome (Tertiary stage)
• May occur many years later
• Results from fibrosis & lymphatic obstruction
• Penile and scrotal elephantiasis
• Females-elephantiasis of the vulva and clitoris
• Fistulae, chronic ulceration, scarring &
deformity
 Clinical features
• Late complications - include rectal strictures,
chronic rectovaginal & urethral fistulae
• May predispose to malignant change
 Investigations
• Diagnostic method of choice is by nucleic acid
amplification tests (NAAT) & confirmation by
PCR assays for LGV-specific DNA
• Serology:
Complement fixation test – lack sensitivity /
specificity
Microimmunofluorescent (MIF) antibody
testing to the L-serovar
• Frei intradermal test – historical interest only;
based on positive hypersensitivity reaction
 Treatment
• Recommended regimen
Doxycycline 100 mg twice daily for 21 days

• Alternative regimen
Erythromycin base 500 mg four times daily
for 21 days
 Granuloma inguinale /
Donovanosis
Chronic, destructive, granulomatous STI
caused by Gram negative organism
Calymmatobacterium (Klebsiella)
granulomatis
• Incubation period: Not precisely known;
about 50 days in human experimental
inoculation studies
• The organism occurs inside large vacuolated
histiocytes in the form of “closed safety pin”
 Clinical Features
• Initial lesion - a papule or subcutaneous nodule
that ulcerates
• Leads to large beefy-red, non-tender
granulomatous ulcers that bleed easily &
gradually extend
• Secondary infection - result in necrotic, foul-
smelling, deep ulcers
• May be followed by pseudo-elephantiasis
 Investigations
Microscopy:
• Giemsa or Leishman’s stain (crush smear
from ulcer) for Donovan bodies
• Clusters of blue-to-black organisms that
resemble ‘safety pins’ within the vacuoles of
enlarged macrophages
 Treatment
• Recommended regimen
Azithromycin 1 g orally once per week or 500
mg daily for at least 3 weeks and until all
lesions have completely healed
• Alternative regimens
Doxycycline 100 mg orally twice a day
OR Ciprofloxacin 750 mg orally twice a day
OR Erythromycin base 500 mg orally 4 times
a day
OR Trimethoprim-sulfamethoxazole one DS
(160/800 mg) tablet orally twice a day
 Herpes genitalis
• Organism-Herpes simplex virus (HSV-2,
HSV-1)
• Incubation period: 2 days – 2 weeks
• Primary episode: classically a group of
vesicular lesions leading to discrete multiple
painful ulcers
• Penile ulceration are most frequent on the
glans, prepuce and shaft of the penis
• Painful & last for 2–3 weeks if untreated
 Clinical features
• In the female, similar lesions occur on the
external genitalia and mucosa of the vulva,
vagina & cervix
• Pain and dysuria are common
• First episodes are usually more severe than
recurrences
 Investigations
• Microscopy
Tzanck smear – nonspecific, multinucleate
giant cells
• Culture from vesicle fluid
• Detection of viral antigen by
immunofluorescence
• PCR for HSV DNA
 Treatment
• First episode
Acyclovir 400 mg orally three times a day for 7-10
days
Or
Acyclovir 200 mg orally 5 times a day
Or
Valacyclovir 1 g orally twice a day
Or
Famciclovir 250 mg orally three times a day
 Episodic therapy for recurrence
Acyclovir 400 mg orally three times a day for 5
days
Or
Valcyclovir 500 mg orally twice a day for 3 days
Suppressive therapy for recurrence
Acyclovir 400 mg orally twice a day
Or
Valcyclovir 500 mg orally
 Urethritis

• Characterized by findings of PMN leucocytes

in urethral smear or sediment in the first void
urine
- Gonococcal
- Nongonococcal
 Gonorrhea

• Gonorrhea - means “Flow of seed”

• Albert Neisser identified the organism in 1879
• Neisseria gonorrheae - Gram negative
encapsulated aerobic diplococcus with pili
• Incubation period- 2-5 days
 Clinical features
• Acute catarrhal inflammation of genital mucosa
• Men – Inflammation of penile urethra- urethritis
• Burning sensation, dysuria, discharge - yellow,
thick purulent discharge
• Females – 50% may be asymptomatic- cervix
infection
• Lower abdominal pain, vaginal discharge or
dyspareunia
• Throat infection – due to oral sex on an infected
partner- usually asymptomatic; may cause sore
throat
• May spread in ascending manner, causing
prostatitis, epididymitis, salpingo-oophoritis, PID,
later infertility
• DGI- pain and swelling in or around one or
several joints, fever and chills and skin lesions
• Ophthalmia neonatorum – due to infected birth
canal during childbirth
 Investigations
• Gram-stained smear – PMNs with
intra/extracellular G negative diplococci
• Culture – Thayer-Martin medium
• Blood culture – DGI, septicemic
 Treatment
• Recommended regimen
Ceftriaxone 250 mg IM in a single dose
PLUS
Azithromycin 1 g orally in a single dose
Alternative regimen
Cefixime 400 mg orally in a single dose
PLUS
Azithromycin 1 g orally in a single dose
 Nongonococcal Urethritis
Usual causative organisms:
• Chlamydia trachomatis
• Mycoplasma hominis
• Ureaplasma urealyticum
• Trichomonas vaginalis
• May co-exist with gonococcal infection
 Clinical features
• Dysuria with odorless, mucoid, scanty discharge
• No diplococci but abundant PMNs
• > 5 pus cells / oil immersion field
 Treatment
Azithromycin 1 g orally in a single dose
Or
Doxycycline 100 mg orally twice a day for 7 days

WITH (for Trichomonas)

Metronidazole 2 g orally in a single dose
Or
Tinidazole 2 g orally in a single dose
 Vaginitis
Etiology
• Candida albicans and other species of candida

• Trichomonas vaginalis

• Bacterial vaginosis
 Candidal vulvovaginitis
• Normal flora of skin & vagina – symptoms d/t
excessive growth of the yeast
• Balanoposthitis in males

• Risk factors: Pregnancy, DM, HIV infection /

AIDS, repeated courses of broad-spectrum
antibiotics, corticosteroids
• Most cases caused by C. albicans, others by non-
albicans sps e.g., glabrata
 Clinical features

• Pruritus, frequency & burning micturition

• Dyspareunia

• Thick curdy white discharge

• Pre-menstrual flare

• Examination reveals thick cheesy plaques

 Investigations
• 10% KOH mount: Pseudohyphae with budding
yeasts seen
• Vaginal pH is normal (4-4.5)
 Treatment
• Uncomplicated vaginal candidiasis
OTC intravaginal agents
Clotrimazole 1% cream 5 g intravaginally daily for 7-14
days
Or Miconazole 200 mg vaginal suppository one
suppository for 3 days
Or Tioconazole 6.5% ointment 5 g intravaginally in a
single application
Oral agent
Fluconazole 150 mg orally in single dose
 Trichomoniasis
• Caused by Trichomonas vaginalis – a flagellated
anaerobic protozoan
• Itching / burning sensation with dyspareunia &
dysuria in females
• Frothy, foul-smelling yellowish-green vaginal
discharge
• ‘Strawberry cervix’ – petechiae on cervix
• May also cause upto 11-13% cases of NGU in
males – usually asymptomatic
 Investigations
• Saline wet mount: motile trichomonads in vaginal
discharge
• Vaginal pH - >4.5
 Treatment
• Recommended regimen
Metronidazole 2 g orally in a single dose
Or
Tinidazole 2 g orally in a single dose
 Bacterial vaginosis
• A disturbance in vaginal microbial ecosystem
• Caused by a mixed flora - Gardnerella
(Haemophilus) vaginalis, Mycoplasma hominis
and anaerobes
• Causes grey, homogenous discharge with
characteristic fishy odour
• Pruritus - not prominent
 Diagnosis

• ‘Clue cells’ - vaginal epithelial cells coated

with Gardnerella vaginalis (at least 20%)

• Whiff test: fishy odour on adding KOH

• Vaginal pH >4.5
 Treatment
• Recommended regimen
Metronidazole 500 mg orally twice a day for 7 days
OR
Metronidazole gel 0.75%, one applicator (5 g)
intravaginally, once a day for 7 days
OR
Clindamycin cream 2%, one applicator (5 g)
intravaginally at bedtime for 7 days
 Syndromic Management
• Use of clinical algorithms based on an STI
syndrome, the constellation of patient
symptoms and clinical signs, to determine
therapy

• Antimicrobial agents are chosen to cover the

major pathogens responsible for the
particular syndromes in a geographic area
 Essential Components
• Syndromic Diagnosis and Treatment
• Education on Risk reduction
• Condom Promotion
• Partner Notification
• Counseling
• Follow-up

Each component is important for control

 Advantages
Simple, inexpensive, rapid and implemented
on large scale

Requires minimum training and used by

broad range of health providers
 Disadvantages
• Algorithm for vaginal discharge has limitations
e.g., in cases of cervicitis (Chlamydia /
gonococci)

• Over diagnosis and over Rx (multiple

antimicrobials for single infection)

• Selection of resistant pathogens

• Does not address subclinical STI

Urethral Discharge
Urethral Discharge

Examine for Urethral Discharge: Milking of Urethra

Discharge seen No Discharge seen

Rx for Gonorrhea and Chlamydia Any other STI

F/u after 7 days Use appropriate chart

Cured Discharge persists

T/t regimen followed regimen not followed

Refer to higher care Repeat treatment &

Re-evaluate > 7 days
Genital Ulcer

No No
Only vesicles present GUD Educate and counsel

Yes Yes

Treat for Herpes Treat for Chancroid and Syphilis

Treat for Syphilis if VDRL+ Treat for herpes if prevalence more than 30%

No No
Ulcers healed Ulcers improving Refer

Yes Yes

Educate and counsel Continue for 7 more days

Inguinal Bubo
Enlarged or painful inguinal lymph nodes

History & examine

No Ulcer(s) present Yes

Rx for LGV + Chancroid As in genital ulcer chart

14 Days

Responding to treatment No Refer to higher care centre

Yes Presume cured

Vaginal Discharge/ Itch/ Burning

History
No No
Vulvul erythema Any other STI Educate

Yes
Yes
Appropriate chart
Lower abdominal pain
Lower abdominal pain chart
No
Yes
High GC/CT prevalence Treat for Gonococci/Chlamydia/
bacterial Vaginosis/Trichomonas
No
Yes
Treat for bacterial Vulvul edema / erythema Treat for Candida
Vaginosis
and Trichomonas No

Educate
 Treatment (Syndromic approach)
• http://naco.gov.in/sites/default/files/Syndromic
%20Poster_REDUCED.pdf
Thank you