Simple notes in STDs (sexually transmitted diseases)

they are a group of diseases that trnsmitted sexually and they are of many causes:

1-bacterial:gonorrhea , syphilis , chlamydia

2-fungal: candidiasis

3-viral:herpes zoster virus , herpes simplex virus , HIV

4-parasite: trichomanis vaginalis , scabies , pediculosis pubis.




Gonorrhea...:

definition:

it's a purulent inflammation of mucous membrane surfaces caused by Neisseria gonorrhea


incubation period:

5 days in men , 2 weeks in females.


Clinical presentation:

in males.... urethral discomfort , dysuria , discharge.

In females... discharge from endocervicitis is the most common presenting symptom, the discharge is discribed as thin , purulent and mildy odorous .

In neonates... ophthalmia neonatorum.


Investigations:

gram stain culture


treatment

1-ceftriaxone(Rocephin)-- 125-250mg IM once

2-ciprofloxacin(Cipro)--- 500mg PO once for uncomplicated urogenital or rectal infections.

3-spectinomycin 2g IM once

4-doxycyclin (vibramycine)200 mg/day for 7 days






Syphilis....:

definition:

it's achronic systemic veneral disease with multiple clinical presentations and charactrized by episodes in active disease( 1ry,2ry,3ry stages) caused by a spirochete called treponema pallidum , and syphilis transmitted by 3 ways from intimate contact and blood transfusion transplacentally from infected mother to her fetus.


INCUBATION PERIOD :

It varies from 9 to 90 days (usually 2-4 weeks)



CLINICAL FEATURES:

1-Primary syphilis

The characteristic feature is the chancre which is usually a solitary and painless ulcer with indurated base. It can occur at penis, vulva esp. fourchette, cervix, and extragenital areas like anus or lip. Inguinal lymphadenopathy is also common. The enlarged lymph nodes are usually discrete, non-tender and rubbery in consistency.

2-Secondary syphilis

This stage usually occurs 6-8 weeks after chancre. The characteristic features include:

1) generalized, symmetrical and non-pruritic papulosquamous rash characteristically affecting palms and soles

2) generalized lymphadenopathy

3) mucosal ulcerations (mucosal patches, snail-track ulcer) over genitalia and mouth

4) condylomata lata at perianal area and mouth

5) patchy alopecia

6) systemic: fever, malaise, anorexia, weight loss and anaemia

3-Tertiary syphilis

1) Cardiovascular syphilis (3A) - It usually occurs after a latent period of 10-20 or more years.

a) Angina pectoris due to coronal ostial stenosis

b) Aortic incompetence

c) Aortic aneurysm (ascending aorta is the commonest site)

2) Neurosyphilis

a) Asymptomatic neurosyphilis

There is no clinical abnormality but abnormal CSF.

b) Meningovascular neurosypilis

It usually occurs 3-7 years after infection, affecting cerebral and/or spinal meninges.

c) General paralysis of insane (GPI)

This usually occurs 10-20 years or more after infection. The clinical features include dementia with recent memory loss, loss of insight, euphoria with delusion of grandeur, tremor, spastic paraparesis, convulsions, incontinence and finally bedridden.

d) Tabes dorsalis

Similarly this occurs 10-20 years or more after infection. The clinical features include lightning pain in legs, paraesthesia, sensory ataxia (positive rombergism and ataxic gait), sensory loss in proprioception and vibration, deep pain in Achilles tendon, absent reflexes, overflow incontinence, Argyll Robertson pupils, optic atrophy, Charcot's joints and visceral crises.

e) Ocular syphilis

The typical features are ocular atrophy, optic neuritis, chorioretinitis with pepper and salt fundus.

3) Gummatous syphilis (benign tertiary syphilis)

This is due to granulomatous lesions affecting skin, bone and mucosae (mouth, palate, pharynx, nasal septum). Rarely liver, brain and spinal cord are involved as well.

4-Congenital Syphilis

Congenital syphilis is transmitted in utero after the first 16 weeks of pregnancy, therefore it is usually not a cause of abortion during the first trimester. The infected child born later in a family usually has less severe syphilis. Again, it has been divided according to the arbitrary dividing line of two years into early and late types.



INVESTIGATIONS:

1-Dark Ground Examination (DGE) (dark field elemnation test)

2-Serological Tests

3-Lumbar Puncture

4-Others (depends on clinical suspicion)

Chest X-Ray, Electrocardiography, Echocardiography, Cardiac catheterization, biopsy of gumma



TREATMENT:

Primary, Secondary & Early Latent Syphilis

1) Procaine penicillin (Servipen)

1.2 megaunit IMI qd x 10 days
Before holidays: Benzathine penicillin 1.2 to 2.4 megaunit is to be given (i.e. 0.6 megaunit/day according to length of holiday) to cover the holiday.

2) Benzathine penicillin (Penadur)

2.4 megaunit IMI weekly x 3 weeks (half into each side of buttock)

For patient who is sensitive to penicillin:

3) Tetracycline 500 mg qid x 2 weeks

4) Erythromycin 500 mg qid x 2 weeks

5) Doxycycline 100 mg bd x 2 weeks

Pregnant woman with syphilis:

1) Penicillin or erythromycin, No tetracycline
(Probenecid, if used, requires special precaution)

2) Reply letter to MCH from SYPSH head-office

3) After treatment, quantitative measure of VDRL monthly till delivery

4) Retreat the patient if there is serological evidence of reinfection or relapse

5) Follow-up three weeks after delivery together with her baby

Precautions in Treatment

1) Risk of anaphylaxis

a) ask for history of penicillin allergy

b) resuscitation facilities should be available

c) Penicillin test

500 ml N.S. + one megaunit soluble penicillin
Inject 0.1 ml hypodermal (200 units)
Read 15 minutes later, wheal >5 mm positive

This test has limited value as a negative test does not exclude the chance of anaphylactic reaction. It is still done in Social Hygiene Service for medicolegal reason.

d) After injection, observe the patient in the clinic for at least 30 minutes.

2) Jarisch-Herxheimer reaction

This reaction usually occurs within 12 hours after the first dose of treatment. It is believed to be due to hypersensitivity reaction to killed treponeme and their liberated toxins. In early syphilis, this reaction is common but harmless. Patient usually has flu-like symptoms, feverishness, chills and malaise. However, patient should be warned beforehand and symptomatic treatment like paracetamol may be necessary. In late syphilis, this reaction is uncommon but dangerous, causing morbidity and even death. Steroid cover before treatment is therefore important.


HEALTH EDUCATION

Health education is given to patients in the anti-VD office in Social Hygiene Clinic. Preventive measures are taught as well.


CONTACT TRACING

Again this is done by the health visitors of anti-VD office.

Examination and treatment of sexual contacts are important steps in the control of spread of sexually transmitted diseases. In early syphilis, contacts of preceding three to six months should be traced. Those who have contact within three months should be treated even without symptom and sign. In late syphilis, spouse or regular sex partners should be screened, and in mother, her children as well. However, they should be treated only when the diagnosis has been established. It must be emphasized again that the screening of all these contacts should be voluntary and confidential.







Refrence: :Dr. L.Y. CHONG



(Social Hygiene Handbook - 2nd Edition )

HIV....:

what are the stages of HIV ?

Stage one: subclinical a symptomatic infections

stage two: Aids related complex(ARC)

weight loss + lymphodenopathy +cutanous

lesions

stage three: full blown Aids



what are skin manifestation of Aids?

1- hairy oral leukoplakia

2- herpes simplex virus

3-recurrent candidiasis

4-seborrheac dermatitis

5- acute onset psoriasis

6- kapsois sarcoma



INVESTIGATIONS

1) HIV antibody test

Methods used locally:

a) ELISA (enzyme linked immunosorbent assay)

This is a very sensitive test for screening purpose, but it may sometimes give a false positive result.

b) Western Blot

In this test, there is electrophoretic separation of viral proteins into a characteristic profile. It is used for confirmatory purpose.

There is cross reactivity between HIV-1 and HIV-2 infection, therefore specific test for HIV-2 antibody for patient from west Africa would be needed. Seroconversion usually occurs within three weeks to three months after infection. However, a small proportion (<5%) of HIV-infected patients may remain seronegative.

2) Tests for immune function

a) T lymphocyte subsets test

T-helper cell (T4/CD4), T-suppressor cell (T8/CD8)

b) p24 antigen, anti-p24 antibody

c) Immunoglobulin level

d) Delayed cutaneous hypersensitivity test

3) Tests for other systems: depend on the clinical suspicion


MANAGEMENT

Both the preventive measures and the specific therapies are equally important in the management of HIV infection.

1) Prevention

Health education
Practice of safe sex
Precautions when dealing with patients' body fluid
Screening of blood or blood products for transfusion, organs for transplantation
Screening for high risk group

2) Counselling and education

Precautions to prevent further spread
Psychological support

3) Specific and supportive treatment

Specific anti-HIV therapy: AZT, ddI, ddC, Ribavirin
Treatment of opportunistic infections
Treatment of malignancy
Symptomatic relief
Nursing care
Immunotherapy (potential HIV vaccine)
Social support


Practice in Social Hygiene Clinic concerning HIV infection:

1) All patients who attend Social Hygiene Clinics (except skin cases) would have screening for HIV antibody. Informed consent would be obtained before the test. Acceptance or refusal of the test must be documented in the record.

2) Strict confidentiality is emphasized. Only consultant, medical officer in-charge and nursing officer in-charge of the clinic could have access to the records of the HIV-positive patients. Staffs who involved in handling the patient would be informed to take adequate precautions and keep strict confidentiality.

3) Counselling (including pretest counselling) and health education in the anti-VD office.

4) All HIV-positive patients would be referred to AIDS unit of Special Preventive Programme of Department of Health for further management. Doctor's referral letter would be given to the patient directly, and nursing officer in-charge would arrange appointment with the staff of AIDS unit in Yaumatei Clinic.


Precautions when perform minor operations in HIV-positive patients and disinfection procedures in Social Hygiene Service:

1) Protective barriers during minor operations: gloves, masks, protective goggles, gowns and aprons.

2) Used needles should be recapped with recapping device. Disposed the used needles in a puncture resistant sharp box which should be labelled "Blood Precaution" before sending to incineration.

3) Laboratory specimens should be kept in leak-proof containers with secure lids and "biohazard" label.

4) Surfaces contaminated by blood or body fluid should be mopped up using disposable towels with gloved hands. The area should than be cleaned with sodium hypochlorite (household bleach) (1,000-10,000 ppm).

5) Laundry items should be double bagged and labelled to warn cleaning staff.

6) Instruments or reusable items should be totally immersed in water and sent for autoclave (80-100o C x 10 minutes) or decontamination by chemical disinfectants. For heat-sensitive device, used 2% glutaraldehyde (Cidex) x 10 minutes.


Procedure for management of needlestick injury:

1) First aid is important. Express blood from the wound, wash immediately and thoroughly with soap and water.

2) Injured staff should report to his/her officer-in-charge or unit head.

3) Measure the HIV-Ab and hepatitis-Ag and Ab of the injured and the patient (with consent).

4) The injured staff should preferably attend the Accident & Emergency Department or the Viral Hepatitis Preventive Service in Yaumatei Clinic, especially when post-exposure prophylaxis for hepatitis-B and HIV infection are considered.

Counselling and education in anti-VD office to patients who attend Social Hygiene Clinic:

To prevent sexual transmission of HIV infection, the following advice would be given by the health nurses in this office:

1) Avoid promiscuity, decrease number of sexual partners, avoid casual sexual partners.

2) Advised on safe sex such as avoiding exchange of body fluid during sexual activity with potential HIV carriers, avoiding anal sex, and proper use of condom.

3) Encourage the prostitutes to come for regular check up in female Social Hygiene Clinics.

4) Trace the HIV-positive cases for follow up and refer to Special Medical Consultation Clinic.


AIDS programs in Hong Kong:

1) Special Preventive Program of Department of Health

2) Screening program in Social Hygiene Service

3) Various programs are planned and implemented through the advice of Advisory Council on AIDS (Committee on Education and Publicity on AIDS + Scientific Working Group on AIDS) e.g. Unlinked anonymous urine screening for patient in various selected population

4) Screening for blood donors in the Hong Kong Red Cross Blood Transfusion Service

5) Screening for semen donors in the Family Planning Association.

6) Various programs are planned and run by the government assisted or non-government organization e.g. The Hong Kong AIDS Foundation and the AIDS Concern.