Sexually Transmitted Diseases Prof Dr Fehmi Tabak Cerrahpasa

Sexually Transmitted Diseases Prof. Dr. Fehmi Tabak Cerrahpasa Medical Faculty Department of Infectious Diseases 8 Aralık 2010

Topics • Background Information • “Sores” • “Drips” • Role of STDs in HIV Transmission 2

Background Information 3

Background Epidemiology 4

Syndromes • • • Urethritis Genital ulcer adenopathy syndrome Mucopurulent cervicitis Pelvic inflamatuar diseases (PID) Vaginitis

Background STDs of Concern • “Sores” (ulcers) – Syphilis – Genital herpes (HSV-2, HSV-1) – Others uncommon in the Turkey • Lymphogranuloma venereum • Chancroid • Granuloma inguinale 6

Background 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 7

“Sores” Syphilis Genital Herpes (HSV-2, HSV-1) 8

Genital Ulcer Diseases – Does It Hurt? Sores • Painful – Chancroid – Genital herpes simplex • Painless – Syphilis – Lymphogranuloma venereum – Granuloma inguinale 9

Primary Syphilis - Clinical Manifestations Sores • 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 10

Primary Syphilis -Chancre -LAP Sores 11

Secondary Syphilis - Clinical Manifestations Sores • Represents hematogenous 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 12

Secondary Syphilis • • Rash Generalized LAP Condylomata lata CNS involvement Fever Glomerulonephritis Hepatitis Artralgia

Sores Secondary Syphilis Rash Source: Florida STD/HIV Prevention Training Center 14

Sores Secondary Syphilis: Generalized Body Rash Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides 15

Sores Secondary Syphilis Rash Source: Florida STD/HIV Prevention Training Center 16

Sores Secondary Syphilis Rash Source: Cincinnati STD/HIV Prevention Training Center 17

Sores Secondary Syphilis Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 18

Secondary Syphilis – Condylomata Lata Source: Florida STD/HIV Prevention Training Center Sores 19

Tersier and late syphilis • Gom (Syphilitic granulomas) • CNS and CVS involvement

Syphilis • Latent syphilis Serology (+), Clinic (-) Varies from several months to several years More duration less infectivity Early (<2 years) Late (>2 years) • Neurosyphilis Any neurological symptom or sign

Syphilis - Diagnose • Dark field microscopy • Serology

Syphilis - Diagnose • Non-spesific serological tests • VDRL • RPR • Spesific serological tests • • FTA-ABS TPHA MHA-TP ELISA - The only positive thing of my life is my VDRL test!!!

Sores 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: – – Tzanck smear Culture Serology (Western blot) PCR 24

Sores Epidemiology of Genital Herpes • One of the 3 most common STDs, increased 30% from late 70 s to early 90 s • 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 25

Sores Genital Herpes Simplex 26

Sores Genital Herpes Simplex in Females Source: Centers for Disease Control and Prevention 27

“Drips” Gonorrhea Nongonococcal urethritis Chlamydia Mucopurulent cervicitis Trichomonas vaginitis and urethritis Candidiasis 28

Drips 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 l 0 d Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain – Dx: Gram stain smear (+) 50 -70% culture – Complications 29

Urethritis

Urethral discharge

Drips Gonorrhea Source: Florida STD/HIV Prevention Training Center 32

Drips Gonorrhea Gram Stain Source: Cincinnati STD/HIV Prevention Training Center 33

Drips Nongonococcal Urethritis Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas 34

Drips Nongonococcal Urethritis • Etiology: – 20 -40% C. trachomatis – 20 -30% genital mycoplasmas (Ureaplasma 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 (+) 35

Drips Chlamydia Life Cycle Source: California STD/HIV Prevention Training Center 36

Drips Chlamydia trachomatis • Responsible for causing: – – – Cervicitis, Urethritis Proctitis Lymphogranuloma venereum Pelvic inflammatory disease • Potential to transmit to newborn during delivery – Conjunctivitis, pneumonia 37

Lymphogranuloma venereum LGV GROOVE’ s SIGN

Drips Normal Cervix Source: Claire E. Stevens, Seattle STD/HIV Prevention Training Center 39

Drips Chlamydia Cervicitis Source: St. Louis STD/HIV Prevention Training Center 40

Drips Mucopurulent Cervicitis Source: Seattle STD/HIV Prevention Training Center 41

Drips Laboratory Tests for Chlamydia • Tissue culture has been the standard – Specificity approaching 100% – Sensitivity ranges from 60% to 90% • Non-amplified tests – Enzyme Immunoassay (EIA), e. g. Chlamydiazyme • sensitivity and specificity of 85% and 97% respectively • useful for high volume screening • false positives – Nucleic Acid Hybridization (NA Probe), e. g. Gen-Probe Pace-2 • sensitivities ranging from 75% to 100%; specificities greater than 95% • detects chlamydial ribosomal RNA • able to detect gonorrhea and chlamydia from one swab • need for large amounts of sample DNA 42

Drips Laboratory Tests for Chlamydia (continued) • DNA amplification assays – polymerase chain reaction (PCR) – ligase chain reaction (LCR) • Sensitivities with PCR and LCR 95% and 8598% respectively; specificity approaches 100% • LCR ability to detect chlamydia in first void urine 43

Drips Chlamydia Direct Fluorescent Antibody (DFA) Source: Centers for Disease Control and Prevention 44

Drips Pelvic Inflammatory Disease (PID) • l 0%-20% women with GC develop PID • In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID • CDC minimal criteria – uterine adnexal tenderness, cervical motion tenderness • Other symptoms include – endocervical discharge, fever, lower abd. pain • Complications: – Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia – 7 X risk of ectopic pregnancy with 1 episode PID – chronic pelvic pain in 18% 45

HPV and Cervical Cancer 46

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 47

HPV and Cervical Cancer Estimates for HPV-Associated Cancers • Cervical cancer: – In the U. S. , an estimated 14, 000 cases and 5, 000 deaths – Worldwide, an estimated 450, 000 cases and 200, 000 deaths 48

HPV and Cervical Cancer Perianal Wart Source: Cincinnati STD/HIV Prevention Training Center 49

HPV and Cervical Cancer HPV Penile Warts Source: Cincinnati STD/HIV Prevention Training Center 50

HIV Infection • Infection of immun system • Seen oppurtunistic infections and neoplastic diseases in the last stage

Transmission Risks

HBV Infection

HBV • Carrier : 2 -3. 000 • CHB (25%) : 500 -750. 000 • Cihrosis and HCC(ex)/year : 5000

CHB – Epidemiology 1/3 - %5 HBs. Ag Prevalance 1/3 -%5 8% -HİGH 2 -7% - Moderate <2% - Low

Genital siğiller • HPV (human papilloma virus) etkendir • Erkek ve kadın genital bölgesinde ve anus çevresinde sert, ağrısız, küçük siğillerdir. • • Virüsün 6 ve 11. alt tipleri dış genital bölgede; • • 16, 18 ve 31. alt tipleri ise, servikal displazi ve karsinomla ilişkilidir.

Korunma yolları • Şüpheli cinsel temastan kaçının • Tek eşliliğe yönelin • Riskli kişilere HBV aşısı uygulayın • Kondom kullanın • Uyuşturucu ve alkol aldıktan sonra şüpheli cinsel temastan kaçının