STI

Question 1

tx duration of prostatitis

Answer 1

• 4-6 weeks
• if tx for less and sx persist - retreat with appropriate abx for adequate duration
• if doesn’t respond, order transrectal u/s to eval for abscess

Question 2

Tx proctitis

Answer 2

• Generally: CRO 250 x1 + doxy x7 days
• Tx for LGV ifmod-severe or if: bloody dc, perianal ulcers, mucosal ulcers
• Tx for HSV if: painful perianal ulcers/mucosal ulcers

Question 3

Common (and uncommon) causes of proctitis/proctocolitis

Answer 3

Common: gonorrhea, chlaymdia (D-K, L1-L3), syphilis, HSV (especially among HIV+)

Uncommon: campy, shigella, entamoeba, CMV, Giardia (mainly enteritis, esp among MSM)

Question 4

Tx of epididymitis

Answer 4

• CRO 250mg IM x1 + doxy x10 days
• levo instead of doxy in older men or MSM (higher likelihood of enteric organisms like E coli)

Question 5

Tx of PID

Answer 5

CRO 250mg IM x1 + doxy x14 days +/- metronidazole x14 days

Question 6

Amsel’s criteria

Answer 6

(for BV)

• Discharge
• pH > 4.5
• clue cells
• amine odor w/ KOH

Question 7

Tx of Trich

Answer 7

Previously has been metro 2g PO x1. Now metronidazole 500mg PO BID x7 days (new recs) OR tinidazole 2g PO x1. Tx Partner (can do just 2g x1)!

– 5% strains have low-level resistance

If fails: tinidazole 2g PO daily x5 days OR metro 2g PO daily x5 days

**Tinidazole = incr level in genital tract + longer 1/2-life + few SEs (but $$$)

Question 8

Tx for M genitalium

Answer 8

• Azithro 1g PO x1 (<50% success rate) > doxy x7 days (~30% success rate)
• if azithro fails - moxi x7-14 days (many will still fail, as emerging R to quinolones)
• If macrolide and quinolone-R: pristinamycin has been effective

Question 9

If person fails to respond to tx for NGU, what to think of…

Answer 9

• Reinfection
• M genitalium that didn’t respond - there is rx resistance
• Trich (rare in MSM) - tx w/ metro
• HSV

Question 10

Etiologies, dx, and tx of non-gonococcal urethritis

Answer 10

• Etiologies: Chl (25%), M genitalium (30%), trich, ureaplasma (controversial), anaerobes, enterobacterales, Haemophilus, adenovirus
• Dx: Gm stain of urethral secretions = >2WBC; first void urine = +LE, >10WBC from spun specimen
• Tx: doxy x7 days or azitrho 1g PO x1

Question 11

RF for disseminated gonococcal infection

Answer 11

• terminal complement deficiency
• (can be acq in pts with SLE)

Question 12

Presentation of disseminated gonococcal infection

Answer 12

Often: petechial/pustular rash (<12 lesions), asym arthalgia, tenosynovitis, monoarticular septic arthritis

Occasionally: perihepatitis, endocarditis, meningitis

Question 13

Tx of Chlamydia trachomatis

Answer 13

(depends on serotype)

• D-K: azithro 1g PO x1 OR doxy x7D
• L1-3 (or mod-sev disease): doxy x3wks (pref) OR azithro 1g PO qWeek x3 weeks

**does NOT require TOC

Question 14

MCC epididymitis

Answer 14

Chlaymidia (gonorrhea 2nd MCC)

Question 15

Chlamydia tranchomatis

• A, B, Ba, C -
• D-K -
• L1-L3 -

Answer 15

• A, B, Ba, C - common cause of blindness WW
• D-K - GU and ocular
• L1-3 - LGV

Question 16

Annual screening recommendations for STI

Answer 16

• GC/C - all sexually active persons <25yo (or older with risk factors)
• Trich - only in HIV+, no screening in HIV-
• no recs for BV, HSV

Question 17

Chart of all GUD

Answer 17

Question 18

Dx/Tx of Granuloma Inguinale

Answer 18

(Kleb granulomatis)
*NOT endemic in US. Seen in SE Asia, S Africa

• tissue bx → Donovan bodies with WGS
• Tx - doxy x3wks OR azithro 1g PO qWk x3 (or bactrim or cipro). Can add aminoglycoside if slow to improve

Question 19

Dx/Tx of chancroid

Answer 19

(H ducreyi)
*10% co-infected w HSV or syphilis.
**Bacterial superinfection common

• Gram stain =”school of fish”. Culture (80% sens). PCR great, but not widely available
• Azithro 1g PO x1 OR CRO 250mg IM x1
• TREAT ALL PARTNERS IN LAST 2mos

Question 20

Dx/Tx of LGV

Answer 20

• Multiplex PCR for specific serotypes (routine NAAT do not distinguish b/w D-K and L1-3)
  
  • if available: molecular testing for ompA
• serology = supportive, not dx. 4-fold rise of IgM/G OR IgM>1:64 IgG>1:256 = active infection.
• Tx: doxy x3wk or azithro 1g PO qWk x3wk

Question 21

Answer 21

LGV

Question 22

STI a/w proctitis

Answer 22

LGV (Chlamydia trachomatis L1-3)

• rectal pain, tenesmus, rectal bleeding/dx
• may be mistaken for IBD on histo (so can syphilis, btw)

Question 23

dx of syphilis

Answer 23

• genital ulcers (primary syphilis) - darkfield microscopy with 70% sensitivity
• secondary/early latent - serology with ~100% sensitivity (non-trep titers decline over time even w/o tx)
• neuro - CSF RPR/VDRL highly specific but VERY insensitive; CSF trep are very sensitive but not specific (high FP!).

Question 24

+EIA/-RPR/+FTA Abs

Answer 24

(trep/non-trep/trep)

1. past and adequately tx syphilis
2. had syphilis in past, but NOT adequately tx (RPR can become NR w/o tx over time)
3. early syphilis with EIA+ before RPR (super rare)
4. prozone reaction in secondary syphilis (RPR = FN)

Question 25

Typical ocular and audio manifestations of syphilis

Answer 25

_Ocular (any stage, any portion of the eye)_ * Classic: uveitis, neuroretinitis (secondary stage) * Interstitial keratitis (both congenital and acquired) _Ears - sensorineural hearing loss + vestibular complaints_ *\*\*CSF often normal in these cases (though + in ocular \> ear)*

Question 26

typical CV manifestations of syphilis

Answer 26

*(usually 15-30yrs after latency)* * Ao aneurysm * AI * coronary a stenosis * myocarditis

Question 27

Neuro manifestations of syphilis

Answer 27

_Early_ - w/in 1st yr, mainly among HIV pts. Presents as meningitis (basilar often, with CN abnormalities) * **meningovascular** - endarteritis of small vessels in meninges/brain/spinal cord --\> strokes/seizures _Late_ - ~10yrs after primary * **parenchymatous** - destruction of nerve cells --\> tabes dorsalis (paresthesias, ataxia, CN abn), general paresis (dementia, psychosis, slurring speech)

Question 28

mild elevation of aminotransferases w/ disproportionately high AP (often in the thousands)

Answer 28

think of syphilis

Question 29

short-lived, **painless** genital ulcer **painful suppurative inguinal LAD** **groove sign** (swollen matted LNs along inguinal ligament)

Answer 29

LGV

Question 30

**painless** progressive/destructive ulcers "**serpiginous**" **w/o** regional LAD **beefy red w/ white border** **highly vascular**

Answer 30

granuloma inguinale

Question 31

**painful, indurated, "ragged"** genital ulcers **tender/suppurative inguinal LAD** (50%) **kissing lesions** on thigh (d/t self-inoculation)

Answer 31

Chancroid (H ducryei)

Question 32

multiple, **painful**, superficial **vesicular or ulcerative** lesions **erythematous base**

Answer 32

HSV

Question 33

single, **painless** ulcer/chancre at inoculation site **heaped-up borders** **clean base** painless bilateral LAD

Answer 33

syphilis

Question 34

Painless genital ulcers

Answer 34

* syphilis *(irl, but not on boards, \>30% will have multiple painful lesions)* * LGV (but with **painful LAD**) * granuloma inguinale

Question 35

painful genital ulcers

Answer 35

* HSV * chancroid (H ducryei)

Question 36

Culture requirements for gonorrhea

Answer 36

* nonsterile site - Thayer-Martin agar * sterile site - chocolate agar requires CO₂ enrichment

Question 37

Virulence factors of N gonorrhoeae

Answer 37

* type IV pili - attachesto mucosal epithelial cells and PMNs * doesn't elicit protective immune response * antigenic variation → express different surface Ags, helping evade Ab response

Question 38

Pap recs

Answer 38

* q3yrs for 21-29yo * q3yrs or q5 w/ HPV testinf for 30-65yo