Sexually transmitted Infections. Diagnosis & Treatment 2017

Transcription

1 Sexually transmitted Infections. Diagnosis & Treatment 2017 Filip Moerman Infectiology CHR Citadelle Liège Institute of Tropical Medicine Antwerp Bande 23/11/ 2017.

2 Overview (all STI) Syphilis (! = important) [U] U=ulcer Chancroid (\ = not important) [U] Chlamydia (+ Lymphogranuloma Venereum[\] [U] ) (!) Granuloma Inguinale (\) Gonorrhea (!) Genital mycoplasmas (\); Ureaplasma urealyticum (\): NGU Trichomoniasis (!) Candidiasis (STI+/ ) (!) Herpes genitalis (!) [U] Human Papillomavirus (HPV) (!) Hepatitis B/C (MST+/ ) (!) HIV / AIDS (!!!) Scabies (!) Pediculosis pubis (pou du pubis) (!)

3 ATTENTION! Genitals might be a first localisation of a simple skin disease. Before you reveal to a patient the diagnosis of an STI, be sure about it. Some of these diseases could be transmitted nonsexually as well! Herpes, Syphilis and HIV have a negative image and hence are a source of worries for young & old ALWAYS to add with every treatment: partner(s) also to be treated and abstain from sex for some days!

4 Men and women may have different opinions about sexual life

5 Sexuality is a complex issue

6 The importance of STI is clear: they are cofactors for transmission of HIV. The vulnerability to acquire HIV increases significantly when an STI is present (passively and actively).

7 ...ONE CANNOT EXPLAIN THE HIV PANDEMIC WITHOUT TAKING INTO ACCOUNT STI!!! (STI Inflammation)

8 THESE REMAIN IMPORTANT

9 Syphilis Organism: Treponema pallidum 3 waves Primary: Sjanker (ulcer) Secundary: disseminated infection Tertiary: late syphilis

10 Syphilis. Incubation = one week to 3 months. Serology becomes positive 1 to 4 weeks AFTER the primary ulcer. 30% asymptomatic! Route of transmission: all sexual contacts! Even kissing. 50% probability of infection from a positive source. Oral lesions very contagious. Organism: Treponema pallidum Clinical and serological evolution different (extreme, nontypical) within HIV+ people.

11 exposure primary incubation (10-90 days) primary syphilis early neurosyphilis secundary incubation (4-10 weeks after appearance chancre) recurrence 24% 25% secundary syphilis early latent syphilis (asymptomatic) (1year or less postinfectious) central nervous system invasion 25-60% asymp toma tic symptomatic 5% meningitis cranial neuritis ocular meningovascular late latent syphilis (asymptomatic) (>1 year postinfectious) tertiary syphilis tertiary syphilis cardiovascular 10% (20-30y postinfection) gummata 15% (1-46y postinfection) late neurosyphilis general paresis tabes dorsalis 2-5% (2-30y) 2-9% (3-50y)

12 Syphilis: early phase (I) Primary syphilis: +/ Ulcer* ( sjanker ): different locations: anus, penis, vagina, lips, mouth, tongue, fingers. Painless, but recent literature says not always +/ lymph nodes. *the lesion of primary syphilis occurs at the initial site of inoculation.

13 Primary syphilis: hard sjanker

14 Syphilis: secundary phase (I) +/ All possible skin symptoms (erythema, papulae, alopecia, erosions, ulcers); typical: palmoplantar erythema. Rarely itchy. +/ gegeneralised lymph nodes. +/ general symptoms: fever, fatigue, myalgias, eye infections, arthritis, periostitis (typical fibula pain because of periostitis)... The person remains contagious.

15 Secundary syphilis, can also be.. Fever of Unknown origin Hepatitis (!) Periostitis/osteomyelitis Condylomata lata Glomerulonephritis Alopecia

16 In an HIV+ pt Syphilis, secundary.

17 Secundary syphilis

18 He who knows syphilis, knows medicine Sir William Osler

19 Syphilis: latent phase (II) Early latent: 2 to 4 years. Sometimes skin symptoms, lymph nodes, sometimes nothing. Late latent: 3 to 5 years. The persoon is no longer contagious (exception: MTCT in utero!)

20 Syphilis: late / tertiary phase (III) (\) About 5 to 20% develops: Cardiac syphilis: aortic valve disease: CAVE Neurosyphilis: epileptic attacks, vertigo, insomnia, aphasia, hemiplegia, Argyll Robertson,... Can be early in HIV Gummata. The majority, however, has a benign syndrome.

21 Neurosyphilis Asymptomatic Meningitis (lymphocytic meningitis) Meningovascular (CVA like) Cranial nerve paresis (VII, VIII) Eye involvement (uveitis, vitritis, ) Tabes dorsalis Gummata Dementia paralytica

22 Syphilis can trigger dementia!

23 Late syphilis Destruction of bones, brain, blood vessels, skin,

24 Diagnosis Organism: No direct culture Dark field microscopy (chancre) (PCR) Biopsy (Whartin Starry) (Rabbit Infectivity Test) Serology Non treponemal tests (VDRL, RPR) Treponemal tests (TPHA, TPPA, FTA abs)

25 Serology

26 Neurosyphilis: diagnosis (CT/MRI) LP: lymphocytic meningitis (cave irrelevant in early syphilis) RPR/VDRL on CSF: sens 30%, spec 100% TPHA on CSF: high sens, low spec (diffusion) Positive serology + clinical argument Good patient selection Neurologisc/ocular complaints Treatment failure HIV and latent syphilis (+ high RPR, + lage CD4?)

27 What in HIV? HIV asymptomatic lymphocytic meningitis (pleiocytosis) Higher risk of developing neurosyphilis? Risk on over/undertreatment Need of clear guidelines

28 Data sources: Ministery of Public Health, Flemish Community, French Community, Primary and secundary syphilis cases, mandatory notification, Belgium,

29 Incidence of syphilis Syfilis prov. Antwerpen Vlaanderen Koen DeSchrijver, Filip Moerman: gezondheidsinspectie Prov A pen

30 Syphilis cases per sex and sexual orientation, Sentinel Network of Clinicians, Belgium, Oct.-Jan. periods, Number of syphilis diagnoses Period 1 Period 2 Period 3 Period 4 Period 5 MSM Hetero M Women I P H

31 One night with Venus and the rest of your life with mercury

32 Actual treatment standards Early syphilis 1 x 2.4 MU Benzathine penicillin IM Latent syphilis 3 x 2.4 MU Benzathine penicillin IM Neurosyphilis d IV Benzylpenicillin Alternatives: Procaine penicillin IM, ceftriaxone, azithromycin, doxycyclin?desensitisation for penicillin

33 Chancroid (ulcus molle) Haemophilus ducreyi. Rare in Europe. Exclusion diagnosis (DD syphilis!). Resembles syphilis*. R/ Azithromycine 1 g. *In theory syphilis PAINLESS ulcer and chancroid PAINFUL ulcer (as herpes).

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35 Chlamydia Chlamydia trachomatis Cause of NGU ; urethral syndrome (urethral discharge and pyuria +/ pain) or vaginal fluor 70 à80% asymptomatic! (esp women) T incub = 1 to 3 weeks (compare to gono & syph:!) Transmission: unprotected sexual contacts, also oral. Complications: LGV (serovar L2), Bartholinitis, PID, arthritis, infertility, EUG, rectocolitis, epididymitis, M. Reiter,... Diagnosis via PCR / Serologie

36 Chlamydia Treatment Azithromycin 1 (2!) g PO or doxycycline 2 x 100 mg/d 7 d*** 3 weeks+ in LGV Erythromycin and quinolones are alternatives Test for gonorrhea!!

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38 Diagnosis of Chlamydia via PCR

39 Lymphogranuloma venereum

40 Gonorrhea GU Neisseria gonorrhoeae. Cause of urethritis: Men: dysuria +/ fluor; 20% asymptom. Complic: strictures, epididymitis, urethral rupture Women: 70% asymptom! 30% fluor vaginal/urethral. Complic: PID. Sometimes oropharyngeal.

41 Incidence of gonorrhee Gonorroe prov. Antwerpen Vlaanderen Koen DeSchrijver, Filip Moerman: gezondheidsinspectie Prov A pen

42 Susceptibility to antimicrobials among N. gonorrhoeae strains Belgium. Strains examined Ciprofloxacine Spectino Ceftriaxone n % n % n % susceptible low level resistance high level resistance susceptible low level resistance susceptible not susceptible

43 Gonococcal resistance in The Netherlands reported by 25 laboratories Betalactams Tetracyclines Quinolone s Cephalosporin Year Isolates : N % R % R % R % R Source: Increase of gonococcal quinolone resistance in the Netherlands from

44 Gonorrhea T incub. = 2 to 14 days. Transmission: unprotected sexual contacts, even oral. Diagnosis: men: microscopy (RO) + culture / AB gram women: idem but cervix PCR (!)

45 Treatment of Gonorrhea Recommended Ceftriaxone 1g IM (+ Azithro!) Quinolones (ciprofloxacin 500 mg, ofloxacin 400 mg, levofloxacin 250 mg) NO LONGER! Alternatives: Azithromycin 2 g is effective (cost, GI tolerance), 1 gm not recommended possible rapid emergence of antimicrobial resistance Spectinomycine 2 g IM If cephalo allergic, does not treat pharyngeal gonorrhea

46 Gonorrhea

47 2016 new European Guideline on the management of NGU*** Patrick HORNER, et al. Int J STD AIDS online first, published on May 4, 2016 as doi:10,1177/

48 What is new? Gonorrhea approach remains as it is NO longer Azithro (or preferrably not), but Doxy; in case of M. genitalium even 10 days. Lymecycline is alternative (300 BD 10/7, as Tetralysal; no photosensitivity) Why? Because Resistance with Azithro towards M. genitalium Other causes becoming increasingly prevalent:

49 Up to 50% is Chlamydia, up to 30% is M. genitalium, up to 20% can be due to U. urealyticum, up to 10% is T. vaginalis, up to 5% can be viral (HSV, Adeno), in which case Conjunctivitis may appear. Test all of them with PCR NGU: never forget its complications! Epididymitis, Reactive arthritis

50 Trichomoniasis (protozoal) Trichomonas vaginalis ( self limiting in men; woman is carrier) Very frequent, esp in Africa. Benign (rarely complications, exc LBW [?]); could cause a white yellow milky fluor (men rarely symptomatic; women up to 50% asympt). Transmission: sex + toilet seats (?). D/direct microscopy. R/Metronidazole.

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52 Candidiasis (is no [rarely] STI!) Candida albicans [sugar, heat, moist] CAVE: if very frequent: think about: corticotherapy, AB therapy, diabetes (!), HIV, pregnancy,...! The main cause of vaginal itching! Causes a yoghurt like fluor +/ erythema. In men sometimes frightening! D/clinical; mycology R/Fluconazole or Miconazole.

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54 Herpes simplex II (en I!) Herpes Genitalis Frequent and really a nuissance! (lifelong); infection possible from people that are not symptomatic! Clinically: eryhtema, later vesicles, then small and very painfull ulcers which tend to dry. Often many lesions. Dyspareunia. Can be very extensive in HIV+ people. Sometimes (1 inf) fever, meningo encephalitis, headache, radiculomyositis,...

55 Herpes Genitalis (2) Transmission: all kinds of sex, even kissing. Some will never get it, but partners of HSV+ people must know that it will be almost inevitable. T inc = 2 à12 dagen but... D/PCR +/ serology (culture) R/Aciclovir sometimes preventively on a daily basis. +/ same virus: zona, varicella!

56 Herpes Genitalis (mostly HSV II).

57 Human Papillomavirus Infections HPV type 6, 11, 16, 18, 31, 33, 35, 42. Clinically: warts. PROVEN role in the pathogenesis of cervical cancer (certain subtypes) and some oral cancers; can be very serious in HIV+! Transmission: all forms of sexual contact incl kissing, but also via towels, bed sheats, underwear and close body contact. In general VERY contagious! T incub. = 2 weeks to 1 year!! Disappears in 2+ years. D/clinical +/ serotyping (epidemiologic context.) R/cryo (N2), cauterisation, Fluoro uracil, podophyline, laser, surgery, ZnSO4, (interferon).

58 Genital warts (HPV).

59 Hepatitis B/C

60 Scabies ( la gale ) Sarcoptes scabiei. Transmission via close body contact* incl blankets, clothes Itching +++ typically worse at night. Interdigital only in a later stadium. Eruptions can surinfect. Rash = hypersensitive reaction! Clinical diagnosis (rarely biopsy) R/crème permethrine, lindane of crotamiton +/ Ivermectine + antihistam. Rub well for at least 12 hrs entire body. Repeat after 24u. Tincub = 2 5 weeks. Very frequent in Africa, esp young people*; preval 100% in prisoners.

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62 Sarcoptes scabiei

63 Pubic lice (pou du pubis) Phthirus pubis. Transmission close body contact but often sexually, exceptionally via towels. T incub. = 2 5 days. Very annoying; you cannot scratch in your trousers a whole day Possible eczematisation and surinfection. R/pyrethrines, lindane (spray, lotion, crème) (vb. Para plus spray)

64 Pubic lice.

65 Phthirus pubis.

66 REITER s syndrome Exclusion diagnosis! NGU +/ eye symptoms +/ synovitis Chronic inflammation Reassure your patient R/ASA+++

67 Chemsex, PrEP, Slaming Definitions Often all three together: London, A dam, Brussels, Berlin, Paris. Will extend! Ethical conflict, the HIV world divided Where are the condoms? Prof Mike Youle tought us an eye opener in Barcelona 9/2015: sex and recreational drugs in high educated people!

68 Gina, Tina and Miauw miauw Gina: gamma OH butteric acid: Liquid XTC Tina: crystal / Ice / Crystal Methamphetamine Miauw miauw: Mephedrone (Cathenone group) All can be sniffed or injected (HCV danger!) Adherence decreases, interactions with RTV and CBCstat (HIV treatment) 3cc of Gina can kill, esp if with ethyl, RTV, CBCstat!

69 Mephedrone Often injected Cocaine like effect Available via internet cheap Extremely addictive Called bath salt or miauw miauw A film on Meth/Ice exists: Chemsex (you tube)

70 Crystal Meth PO, IV (EXTREMELY dangerous), Snif Slaming reduces pain (cfr my patient) Addiction after 1 use only!! Possible: amnesia, epilepsy, anxiousness, CVA, Endocarditis, insomnia, desinhibition with high libido, paranoia, tooth decay, depression, agression, conc difficulties, mucositis/δskin Difficult to stop once addicted Meth at work, to have sex, to go out,

71 Risk factors for erectile dysfunction Aging Smoking Depression Psychological factors Hypertension Diabetes Hyperlipidemia Prostate surgery Medications