Sexually Transmitted Diseases(stds)

Sexually Transmitted Diseases(STDs)

Li Xiao-hong Dept. of Dermatology The first affiliated hospital of zhengzhou university

Definition of STDs STDs are a group of infectious diseases, the pathogens of which are transmitted through sexual contact.

Standard STDs Disease Syphilis Primary Secondary Tertiary Gonorrhea Chancroid Lymphogranuloma Venereum Granuloma inguinale

Causative agent Incubation period Tremonema pallidum 3 weeks 7-8 weeks ≥ 3-5 years Neisseria gonorrheae 3-5 days Hemophilus ducreyi 3-14 days Chlamydia trachoma2-6 weeks tis Calymmatobacterium Days to several granulomatis months

The Routes of STDs’ Transmission 

Infection through sexual behavior Direct contact Indirect contact

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Blood born transmission Latrogenic infection Intrauterine fetal infection Infection from birth canal Other routes of transmission Artificial insemination Organ transplantation Insect’s bite Tattoo

The number of reported STD Patients in China (1985-1998)

Prevention of STDs Early sex education  Have safe sex mutual monogamy Using condoms  Detection of the asymptomatically infected persons  Effective diagnosis and treatment  Pre-exposure vaccination 

Syphilis

Definition

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Syphilis is an inflammatory process, caused by the spirochete treponema pallidum, that tends to evolve through three stages: Primary stage: a solitary chancre. Secondary stage: wide-spread macules and papules on skin and mucous membranes, signs and symptoms of systemic disease. Tertiary stage: gummas in the skin and destructive lesions also in the bones, eyes, brain, and elsewhere, resulting in debilitation and often death.

Highlights in the hostory of Syphilis 1905-Shaodinn and Hoffman discovered the spirochete Treponima pallidum  1906-Wassermann, Neisser, and Bruck developed serologic tests for syphilis  1909-Paul Ehrlich introduced organic arsenicals (Salvarsan) for therapy  1943-First penicillin therapy of syphilis was tried 

The Pathogen of Syphilis Treponima pallidum(T. pallidum)  A spiral spirochete 4-14 spirals Entire length: 5-20μm  Characteristic motility A projection in the direction of the long axis A rotation on its long axis A bending or twisting from side to side

Laboratory Test of Syphilis 

Examination of T. Pallidum Darkfield examination Direct fluorescent antibody test Silver stain PCR

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Serologic Tests Nontreponemal test: VDRL, RPR Treponemal test: MHA-TP, FTA-ABS

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Examination of CSF Cell count: >10WBCs/mm3 Total protein Nontreponemal serology

T. Pallidum (Darkfield examination)

T. Pallidum (Direct fluorescent antibody test)

T. Pallidum (Silver stain)

Expected Positive Serologic Reactions in Patients with Various Stages of Syphilis Expected positive results(%) Stage of Syphilis

Primary Secondary Latent Late

Nnotreponemal tests (VDRL, RPR)

70 100 72 77

Treponemal tests (FTA-ABS)

90 100 97 95

The Stages of Syphilis Acquired Acquired Syphilis Syphilis

Congenital Congenital Syphilis Syphilis

Early Early Earlyacquired acquired Primary Primarysyphilis syphilis Chancre Chancre Earlycongenital congenitalsyphilis syphilis Syphlis(Duration Secondary syphilis Early secondary syphilis (Age ≤2 years old) Syphlis(Duration Secondary syphilis Early secondary syphilis (Age ≤2 years old) ≤≤22years) Relapsing years) Relapsingsecondary secondarysyphilis syphilis Early latent syphilis Early latent syphilis Late Benign Lateacquired acquired Benigntertiary tertiarysyphilis syphilis Syphilis(Duration Syphilis(Duration >2 Late >2years) years) Latecardiovascular cardiovascularsyphilis syphilis Late neurosyphilis Late neurosyphilis Late Latelatent latentsyphilis syphilis

Late Latecongenital congenitalsyphilis syphilis Benign Benigncongenital congenitalsyphilis syphilis (Age>2 years old) (Age>2 years old) Late Latecardiovascular cardiovascularsyphilis syphilis Late neurosyphilis Late neurosyphilis Latent Latentcongenital congenitalsyphilis syphilis

The Course of Syphilis Infection Incubation Relapsing secondary syphilis Secondary syphilis Primary syphilis

Late neurosyphilis(10%) Late cardiovascular syphilis(10%) Late benign syphilis(15%)

Latent syphilis(25-30%) Early syphilis Late syphilis Year

2

Spontaneously recovery (25-30%) 10

15

Primary Syphilis Clinical Features  Chancre  Regional lymphadenopathy(Bubo)

Chancre  

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Incubation period: 18-21days Location: Genital: 90% Extragenital: 10% Number: usually only one

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Characters of the lesion A elevated papule with eroded surface Exuding a serous fluid Indurated, I,e, having a cartilage-like consistency Painless

Regional lymphadenopathy(Bubo) Enlarged  Firm  Nontender  Don’t suppurate  Painless 

Diagnosis

Darkfield examination: positive  Serologic tests: Early primary syphilis: negative Late primary syphilis: positive 

Differential Diagnosis Herpes simplex  Traumatic ulcer  Chancroid  Erythroplasia of Queyrat  Anal fissure  Ulcerated mucosal tuberculosis 

Secondary Syphilis Cutaneous lesions with many morphologic forms  Mild systemic involvement 

Cutaneous Lesions(Syphilids) Characters  Early eruptions: symmetrical generalized, superficial, nondestructive, exanthematic, transient and macular. Later eruptions: polymorphous maculopapular or papular lesions, and less often scaly, pustular, or pigmented.  The severity varies widely.  The presence of lesions on the palms and soles is strongly suggestive.  Serologic test: 100% positive.

Syphilids Syphilids of of Secondary Secondary Syphilis Syphilis Syphilids Syphilids Measles-like Measles-likesyphilid: syphilid: Monomorphic Monomorphicmacular macularexanthem exanthem Papular Papularsyphilid syphilid: : Yellow Yellowbrown brownmacules maculesand andpapules, papules, especially especiallyfavoring favoringthe thepalms palmsand andsoles,but soles,butmay maybe beon onthe thetrunk trunk Papulosquamous Papulosquamoussyphilis: syphilis: Polymorphic Polymorphicappearance, appearance,often oftenannular annularininblacks; blacks;may mayoccur occuraround aroundhair hairline; line; Can Canresemble resemblepsoriasis psoriasis Pustular Pustularand andpapalopustular papalopustularexanthem: exanthem: Pustules Pustulesininthe thenasolabial nasolabialfold foldand andcorners cornersofofthe themouth; mouth;usually usuallynot notassociated associatedwith withfever fever

Other Important Skin and Mucous Membrane Manifestations Condylomata lata  On folds of moist skin  Broad and flat papule with a smooth, moist, weeping, gray surface  Teem with trepomema

Mucous patch  On mucous membrane of mouth and on the genitalia  Macerated, grayish, eroded erosions  Teem with treponema

Systemic Involvement in Secondary Syphilis    

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Widespread lymphodenopathy Multiple pulmonary nodular infiltrates Hepatitis, gastritis or gastric ulceration, Glomerulomephritis

Meningitis, Bell’s palsy Sensorineural hearing loss Iritis, anterior uveitis, optic neuritis Periostitis, osteomyelitis, polyarthritis, tonosyrovitis

Diagnosis of Secondary Syphilis Serologic tests: 100% positive  Darkfield examination: positive with moist lesions  Pathology study: rich in plasma cells, often with intense perivascular inflammation 

Measles-like syphilid

Papulosquamous syphilis

Papular syphilid

Pustular and papalopustular exanthem

Typical slightly scaly ham-colored macules on the palms and soles

Condylomata lata

Mucous patch

Sensorineural hearing loss

Tertiary Syphilis

Usually ulcerated cutaneous lesions  Severe systemic involvement, which may be fatal 

Benign Tertiary Syphilis 

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Tertiary cutaneous syphilis Nodular syphilids Gumma Late osseous syphilis Saddle nose Charcot joint Bone pain at night Tertiary syphilitic ocutopathy Retinochoroiditis Outer layer scleritis

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Neurosyphilis Meningitis Tabes dorsalis Progressive general paralysis

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Late cardiovascular syphilis Aortic insufficiency Coronary disease Aortic aneurysm

Diagnosis of Tertiary Syphilis

Darkfield examination: 100% negative  Serologic test(including CSF serology): positive(70%)  Pathologic study: may be diagnostic(necrosis, granulomas and plasma cell) 

Differential Diagnosis Lupus vulgaris: destruction slower  Mycosis fungoides Identified by biopsy and  Lepromatous leprosy negative serology  Sarcoidosis 

Latent Syphilis Asymptomatic  Normal CSF  Positive specific serologic tests for syphilis  Having infectivity  Among the untreated latent syphilitic patient, 30% of them would develop complication of late syphilis 

Congenital Syphilis Early congenital syphilis  Late congenital syphilis  Latent congenital syphilis 

Early Congenital Syphilis Consistent with acquired secondary syphilis, but more severer  Characters Snuffles Syphilitic pemphigus Parenichia Radial scaring Parrot’s pseudoparalysis 

Late Congenital Syphilis 

Inflammatory late congenital syphilis Interstitial keratitis Perisynovitis(Clutton’s joints) Tabes dorsalis and generalized paresis

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Stigmata Hutchinson’s teeth, mulberry molar Saddle nose, corneal scars Saber shins Rhgades of the lips Hutchinson’s triad: Hutchinson’s teeth, opacities of the cornea and eighth nerve deafness

Diagnosis of Congenital Syphilis 

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A complete physical examination for findings of congenital syphilis Nontreponemal serology at the infant’s sera(not cord blood) CNS evaluation Long-bone x-ray evaluation Pathologic evaluation of the placenta using antitreponemal antibody staining Determination of specific antitrepimemal IgM

Rhgades of the lips

Hutchinson’s teeth, mulberry molar

Interstitial keratitis

Treatment of Syphilis (1) Primary, secondary and early latent syphilis

First line treatment option

Benzathine penicillin G 2.4 million units IM at a single dose

Penicillin Allergy

Doxycycline 100 mg orally twice a day for two weeks or Tetrocycline 500 mg orally four times daily for two weeks

Treatment of Syphilis (2) Late and late latent syphilis

First line treatment option

Benzathine penicillin G 2.4 million units IM weekly for 3

Penicillin Allergy

Doxycycline 100 mg orally twice a day for 30 days

weeks

or Tetrocycline 500 mg orally four times daily for 30 days

Treatment of Syphilis (3) Neurosyphilis First line Penicilin G crystalline 2-4 million units intravenously every treatment options 4 hours 10-14 days or Penicillin G procaine 2.4 million units IM daily plus probenecid 500 mg orally four times daily, both for 10-14 days plus Benzathine penicillin G 2.4 million units IM weekly for 3 weeks

Penicillin Allergy

Desensatization and treatment with penillin

Treatment of Syphilis (4) Congenital syphilis Infant

Penicilin G crystalline 100.000-50,000 units/kg/day intravenously for 10-14 days or Penicillin G procaine 50.000 units IM daily for 10-14 days plus Benzathine penicillin G 2.4 million units IM weekly for 3 weeks

Older Children

Penicilin G crystalline 200.000-300,000 units/kg/day IM or intravenously for 10-14 days

Treatment of Syphilis (5) For detail information about treatment of syphilis, please see:  The CDC 1998 Guidelines for the Treatment of Sexually Transmitted Diseases at: http://www.cdc.gov/nchstp/dstd/1998_STD_ Guidlines/1998_guidelines_for_the_treatment.htm  European STD Guidelines at: http://www.iusti.org/sti/European_Guidelines.pdf

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