Genital Infections & STDs - L06 - 09/30

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Which infectious organisms produce discharge?
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Terms in this set (52)
Which infectious organisms produce discharge?
Gardenerella Vaginalis
Candida Albicans
Trichomonas vaginalis
Chlamydia Trachomatis
Neisseria Gonorrhoeae
Which infectious organisms produce ulcers?
Treponema Pallidum
Haemophilus Ducreyi
Chlamydia Trachomatis
Herpes Simplex Virus 2
Which infectious organisms produces both discharge and ulcers
Chlamydia Trachomatis
What is normal vaginal flora?
G (+) Lactobacillus sp. Facultative or strict anaerobic rod found in the mouth, stomach, GI, GU. Can cause opportunistics infections

Viridan Streptococci, Yeast, Staphylococci
Normal Vaginal pH
3.8-4.5
What are the most common infections of women of reproductive age?
Bacterial Vaginosis
Vulvovaginal Candidiasis (VVC)
What organisms cause vaginitis or vaginosis? Which are STDs?
Bacterial vaginosis, Candidiasis, and trichomonas (STD)
Vaginal Infections> Bacterial Vaginosis

1. Discharge

2. pH

3. Specific Tests

4. G Stain

5. Clinical Presentation

6. Causative agent
1. Thin greyish white uniformly adherent

2. > 4.5

3. (+) Amine "Whiff" Test

4. Clue Cells

5. No pain, pruritus, or dysuria, no increase in PMN's, Malodor, & vaginal discharge

6. Gardnerella Vaginalis
Describe an amine or whiff test
Drops of KOH added to vaginal discharge. Fishy odor = (+). Indicative of trichomoniasis or BV
What is a clue cell
Vaginal cell w/ bacteria stuck to it
Is BV an STD?No; part of normal flora but causes a disturbance of the vaginal microbial ecosystemHow would apple cider affect BV?Acidity would bring vaginal pH back downHow would the application of yogurt affect BV?Replenish the normal flora of the vaginaVulvovaginal Candidiasis 1. Causative Agent: 2. Endo/ exogenous 3. Opportunistic? 4. Discharge 5. pH 6. Specific Test 7. Diagnosis 8. Clinical Presentation 9. Treatment1. Candida Albicans 2. Endogenous 3. Opportunistic 4. Cottage Cheese (uniformly adherent) 5. Normal 6. KOH Prep Wet Prep Yeast cell w/ budding hyphae Few PMNs 7. Germ tubes & pseudohyphae on cornmeal agar, CHROMagar, Sabouraud Dextrose 8. Pruritus (itching), burning sensation, normal cervix, erythema, swelling of labia and vulva 9. Azoles & Echinocandins (fungins)Describe the MOA of AzolesInhibits synthesis of ergosterol by inhibiting lanosterol 14-𝜶-demethylase; disrupts protein synthesisDescribe the MOA of EchinocandinsCaspofungin and Micafungin inhibit synthesis of 1,3β-glucans required for fungal cell wallTrichomonas Vaginalis 1. Characteristics (aero/anaer, motility, organism type) 2. Discharge 3. pH 4. Specific Tests 5. Trichomoniasis Presentation 6. Clinical Presentations1. Anaerobic, flagellated, protozoa 2. Frothy Yellowish green discharge 3. > 4.5 4. - (+) Whiff Test - Wet prep (visualize trichomonas, large # of PMNs) - Nucleic acid probe assay - Gram stain 5. Strawberry cervix - localized hemorrhages on cervix and vagina 6. Bad odor, pruritus, dysuria, vaginal soreness, dyspareunia, slight urethral discharge in malesWhat organisms cause vaginal discharges?Gardnerella Vaginalis Candida Albicans TrichomonasWhat organisms cause cervical discharges?Neisseria gonorrhoeae Chlamydia TrachomatisWhat is cervicitisAn often silent infection that causes the inflammation of columnar and subepithelium of endocervixWhat is pelvic inflammatory disease? Symptoms?Infection of the female reproductive organs caused by STD complication. Abdominal pain, irregular or painful periods, high fever, pain during sexCervical Infection / PID > Chlamydia Trachomatis 1. Characteristics - Intra/ Extracellular - Cell wall - Energy dependence 2. Virulence factors 3. Virulence 4. Laboratory Diagnosis 5. Treatment1. - Intracellular - Cell wall lacks peptidoglycan - Requires host ATP 2. - Intracellular growth - Prevention of phagolysosomal fusion 3. Attachment; EB's restricted to nonciliated, columnar, cuboidal, and transitional epithelial cells 4. - Fluorescent Antibody staining of genital specimens, conjunctival scrapings - Culture (Most Specific) - ElISA, NAAT 5. Can't treat with beta lactams b/c no cell wall but can inhibit protein synthesis via azithromycinDescribe the replication cycle of chlamydia trachomatisElementary Body attaches > endocytosis > differentiates into reticulate body > multiplies > differentiates back into EB > released back into adjacent cellsDescribe the Chlamydia Trachomatis Elementary Body?Metabolically inert Resistant to harsh environment No peptidoglycan Double layer outer membraneDescribe the Chlamydia Trachomatis Reticulate Body?Metabolically active Noninfectious stage Binary fissionDescribe cervicitis and urethritis in women with chlamydia trachomatis70% are asymptomatic Dysuria, vaginal discharge, vaginal pruritus Mucopurulent watery discharge Easily induced bleeding of cervixDescribe complications associated with chlamydia trachomatis pathogenesisTravels up the fallopian tubes into the peritoneal cavity resulting in Salpingitis and/ or PIDWhat is Salpingitis (Chlamydia trachomatis)?severe inflammatory response in the fallopian tubes Most serious complication Range from silent infection to sever: Fever, lower abdominal pain, tenderness of uterusDescribe the symptoms associated w/ chlamydia trachomatis infection in malesUrethritis, conjunctivitis, mucocutaneous lesions, & polyarthritis involving the joints of spine and sacroiliac joints where the spine attaches to the pelvisDescribe the symptoms associated w/ chlamydia trachomatis infection in newbornsPneumonia, pneumonitis, mucopurulent conjunctivitis 1-2 weeks after deliveryCervical Infections/ PID > Neisseria Gonorrhoeae > Virulence Factors 1. Capsule? 2. Pili Importance in Immunity 3. Porin 4. LOS (Lipooligosaccharide) 5. Iron Acquisition1. Yes has it a capsule 2. Attachment; high antigenic and phase variation with resistance from neutrophils 3. Can be activated via antigenic variation - Porin A: N. Meningitidis - Porin B: N Gonorrhoeae, activity necessary for survival, prevents phagolysosomal fusion, helps w/ entry to epithelial cells 4. Similar to LPS endotoxin, elicits intense immune response 5. Lactoferrin-binding proteins bind to host transferrin. Essential for growth and metabolism solely in humansCervical Infections/ PID > Neisseria Gonorrhoeae 1. Female Cervicitis/ Urethritis 2. Female Invasion 3. Male urethritis 4. Male invasion1a. Burning frequency of urination. 1b. Mucopurulent discharge. 1c. Fever and abdominal pain 2a. Fallopian tubes 2b. Can cause salpingitis, tubo-ovarian abscesses, PID, sterility or ectopic pregnancy 3. 2-8 day incubation > Burning & frequent urination > purulent creamy yellow discharge 4. anterior > posterior urethra > cowper's glands results in fibrosis (scarring causes narrowing in urethra), possible sterilityCervical Infections/ PID > Neisseria Gonorrhoeae Disseminated Gonococcal Infection (DGI) 1. What is it? 2. Growth requirements? 3. Highly sensitive to? 4. Strains resistant to? 5. Gonococcemia 6. Newborns1. Systemic spread of infection > LOS toxicity resulting in chills, fever, malaise, rash 2. Requires arginine hypoxanthine, and uracil for growth 3. Penicillin 4. Bactericidal activity of blood (Can't get killed by the blood) 5. Migratory arthralgia, arthritis, tenosynovitis 6. Ophthalmia/ neonatorum (conjunctivitis)Cervical Infections/ PID > Neisseria Gonorrhoeae Lab diagnosis 1. Samples Processed: Male/ Female/ Both 2. NAAT 3. Media + environment 4. Treatment1a. Females: Culture, ID, NAAT 1b. Males: G stain only 1c. Other sites: Culture, ID, NAAT 2. Swab of cervical/ urethral discharge or urine 3. In CO2 enriched atmosphere: - Thayer Martin, NYC Media, - Transgrow, Jembec Plate, - chocolate( doesn't grow on blood agar) 4. Ceftriaxone (one dose) - Co-treatment with azithromycin or doxycycline for chlamydia -Neonates drops at birth required by law (erythromycin, tetracycline, silver nitrate)Which gram stain would be seen with Chlamydia? Gonorrhoea?A. Chlamydia B. GonorrhoeaSummary of Discharges Gonorrhea Chlamydia BV Candida Trichomonas- Gonorrhea - Mucopurulent/ Yellow - Chlamydia - Watery Mucopurulent - BV - Thin greyish white uniformly adherent - Candida - Cottage cheese - Trichomonas - Frothy/ yellowish greenG Stain visible? BV Candida Chlamydia Gonorrhoea TrichomonasBV - Visible Candida - Visible Chlamydia - Difficult Gonorrhoea - Visible Trichomonas - Difficult1. Which organisms can grow in culture? 2. Cannot?1a. Candida - Sabouraud 1b. Gonorrhoea - Chocolate, Thayer Martin, NYC 2. Chlamydia, BV & TrichomonasPMNS 1. BV 2. Candida 3. Chlamydia 4. Gonorrhoea 5. TrichomonasBV - NO Candida - NO Chlamydia - Yes Gonorrhoea - Yes Trichomonas - YesUlcerative Diseases > Treponema Pallidum (Syphilis) 1. What does it look like? Motility? Stain? Culture? 2. Transmission1. Thin spirochete with corkscrew type motility cannot be seen on gram stain so use silver stain or dark field microscopy. Can't culture because needs host to survive 2. Sexual contact, congenital, secondary disease w/ infectious rashUlcerative Diseases > Treponema Pallidum (Syphilis) Stages1. Primary Stage - Located at site of inoculation - 3 weeks of incubation - Hard painless indurated chancre - Regional lymphadenopathy - Heals in 1-6 weeks 2. Secondary Stage - Infectious Disseminated Rash & Fever - Enters blood - Copper penny macules/ Rash found on soles and palms and rest of body - Moth Alopecia - Condylomata Lata: Soft fleshy infectious papules in skin folds/ mucosal surfaces - Resolves in a few weeks and enters latent stage 3. Tertiary Stage (Affects CNS, Cardiovascular, and organs) - CNS: Argyll Robertson Pupil - Cardio: Thoracic aortic aneurysm - Other organs, skin, bone: Gummas (destructive lesion)Ulcerative Diseases > Treponema Pallidum (Syphilis) Congenital 1. Transmission 2. Symptoms 2a. Early < 2 yrs 2b. Late > 2yrs 3. Treatment1. Transplacental, Primary/ Secondary, infectious lesion 2. Usually asymptomatic. Hepatomegaly, Jaundice, Nasal discharge, Rash, Skeletal abnormalities 2a. Cutaneous lesions and snuffles/ rhinitis 2b. Frontal bossing, saddle nose, short maxilla, protuberant mandible, - keratitis (blindness) - sabre shins - Hutchinson's incisors/ raspberry molars - Gummas 3. Can treat within first 3 months of life, but keratitis and sabre shins may occur laterUlcerative Diseases > Treponema Pallidum (Syphilis) Lab DiagnosisDark field Microscopy Nontreponemal tests (RPR, VDRL). Quick and cheap - RPR (Rapid Plasma Reagin): test for cardiolipin; may give false positive; can use to track - VDRL Treponemal Test (Specific antibodies) - FTA-ABS - Fluorescent -TP-PA/ MH-TP microhemagglutination * can't track b/c antibodies always present *False positive includes immunocompromised, pregnant women, neonate of infected mother CSF (acquired & congenital neurosyphilis): VDRLUlcerative Diseases > Treponema Pallidum (Syphilis) Treatment + Pregnant women testPenicillin - any stage Allergies: Doxycycline/ tetracycline If mother is reactive to RPR or VDRL gives treatment regardless of infant signs If unknown/ non-reactive. Start treatment while awaiting results. If reactive - continue. If not - stop.Ulcerative Diseases > Chlamydia Trachomatis SerovarsB, D-K Genitourinary L1-3 - Lymphogranuloma VenereumUlcerative Diseases > Chlamydia Trachomatis > LGV 1. Rare in... 2. More likely in men 3. Diagnosis1. US buy highly prevalent in Africa, Asia, S. America 2. Who have sex with men 3a. Fluorescent Antibody stain of genital specimens, conjunctival scrapings 3b. ELISA, NAATUlcerative Diseases > Chlamydia Trachomatis >LGV StagesPrimary Lesion: Generally painless papule, heals quickly (non-indurated herpetiform ulcer) Secondary Stage: - Acute lymphadenitis w/ bubo formation (painful) - Spread to draining lymph - Fever/ systemic infection - Hemorrhagic proctitis after anal Tertiary stage (rare) - Genital ulcers, fistulas, rectal strictures, genital elephantiasis - result of inflammatory responseUlcerative Diseases > Haemophilus Ducreyi 1. G stain + shape 2. Chancre? 3. Sex prevalence 4. Grouping1. G(-) Rod 2. Soft 3. Males 4. School of fish/ Railroad tracksUlcerative Diseases > Haemophilus Ducreyi 1. Pathogenesis 2. Culture 3. Epidemiology 4. Diagnosis1. starts as small erythematous papule > 1-4 very painful ulcers within 3-5 weeks w/ ragged borders covered w/ yellow or grey necrotic purulent exudate > spreads to lymph 2. Requires supplemented GC medium at 33º for 7+ days. Oxidase (+) 3. Underreported, minority populations, heterosexuals, female sex workers 4. Culture from lesion but diagnose by exclusion since negative darkfield, syphilis serology, and HSVUlcerative Diseases > HSV-2 0. Genome enveloped 1. Characteristic feature 2. Disease Presentation 3. Pregnancy 4. Diagnosis0. DS DNA, Enveloped 1. Painful vesicular lesion (dewdrop on a rose petal) 2a. 4-7 days after contact: Papules, painful itching & burning, dysuria, fever, headache 2b. 2-3 weeks: new lesions, old lesions become ulcers that eventually heal 2c. Recurrent episodes 3. Safer to do C-section to keep from infection 4. Tzanck smear; multinucleated & cowdry inclusion bodyViral Infections > HPV 1. Genome, envelope 2. Genotypes & tissue tropism 3. Progression to cancer 4. Risk Factors 5. Detection 6. Vaccine a. Contents b. Who? c. schedule d. impact1. DS DNA, nonenveloped 2a. Genital Warts: HPV 6 or 11 2b. Cancer: HPV 16, 18 3. Infection > Episomal virus production > integrated DNA > cancer 4. Unprotected sex, close skin contact, smoking, cervical cancer, immunosuppression, more sex 5. Pap smear (koilocytes), HPV DNA/ RNA (better specificity) testing 6. Gardasil a. Mimics viral capsid b. Women over 25 c. 2 doses before 15, 3 after, and 3 for immunocompromised d. decrease in cases seenHIV CD4 Count Organisms & Cases> 500 Community acquired - More likely to acquire bacterial pneumonia, have HSV & zoster reactivation 200-500 Tuberculosis < 200 1. Pneumocystis jiroveci 2. Cryptosporidium 3. Candida 4. Fungal pneumonia < 100 1. Toxoplasmosis 2. Candidal, HSV or CMV esophagitis < 50 1. Cytomegalovirus 2. Cryptococcus 3. Mycobacterium avium complex 4. Primary CNS lymphoma (EBV)