Danger Between the Sheets: Life Threatening Complications of STI's

Transcription

1 Danger Between the Sheets: Life Threatening Complications of STI's Ryan Misek, DO, FACOEP, FACEP Clinical Associate Professor Course Director of Emergency Medicine Core Faculty, Emergency Medicine Residency Midwestern University/Chicago College of Osteopathic Medicine

2 Disclosures I have no relevant financial relationship with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity.

3 Objectives 1. Discuss life threatening complications of STIs. 2. Determine treatment and management of these complications. 3. Illustrate key physical exam findings of potentially critical complications of STIs.

4 STI Background Infections commonly spread by sexual activity, especially vaginal intercourse, anal sex and oral sex. >30 types of bacteria, viruses, & parasites WHO billion people have STIs (other than HIV) Lancet M syphilis, GC/chlamydia or Trich WHO M new STIs/year in US CDC 2012 nonhiv STIs 108,000 deaths (2015) Lancet 2016

5 Historical Perspective 1555 BC: Ebers papyrus PID described, adhesions on mummies BC: Mummy Amunet Inner thigh tattoos protect vs. STIs Sandal oil to treat urethritis

6 Pelvic Inflammatory Disease Spectrum of disorders of female upper genital tract: Endometritis, salpingitis, peritonitis, & tubo-ovarian abscess 750,000 cases/yr in US Complications in 25% of cases: Sepsis (#1 serious infection in WCBA) Infertility (30%) 1 episode (15%), 2 (35%), 3+ (75%) Westrom 1975 Ectopic (50%) 6-10 fold risk, 10% ectopic risk after PID Williams 3rd ed. Chronic Pain (15-20%)

7 Pelvic Inflammatory Disease Ascending infection, Polymicrobial Most common organisms: C. trachomatis N. gonorrhoeae Can be caused by nonsexually acquired organisms

8 Risk Factors of PID Young age Multiple sexual partners Cigarette smoking Menses *IUDs (only 3 weeks after insertion) ~50% patients without identifiable risk factors

9 Clinical Features of PID Abdominal pain = Most Common Symptom Dyspareunia, bleeding, discharge, fever Lower abdominal tenderness, CMT/adnexal tenderness, fever ⅔ cases Atypical or Silent PID (unrecognized) 10% perihepatitis (Fitz-Hugh-Curtis) syndrome

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11 Diagnosis of PID Laparoscopy = Gold Standard Clinical examination sensitivity 65-90% CDC recommends Empirical treatment: Sexually active + Pelvic/Lower abdominal pain (w/o other identifiable cause) Cervical motion tenderness Adnexal tenderness Uterine tenderness

12 Treatment of PID

13 Inpatient Criteria Surgical emergencies (appy) cannot be excluded Pregnant Failure of outpatient therapy Failure to respond to PO abx Failure to tolerate outpatient regimen Severe illness, nausea/vomiting, or high fever Tubo-ovarian abscess

14 Parenteral Treatments

15 Tubo-Ovarian Abscess Abscess on fallopian tube, ovary or adjacent organs Complication of PID 3-16% Consider if PID fails treatment HIV+ with PID = high risk for TOA Polymicrobial infection ( anaerobes) Tubo-Ovarian Complex (not walled off like abscess) More responsive to antibiotics

16 Signs & Symptoms TOA Fever & Leukocytosis (60-80%) Lower abdominal/pelvic pain (90%) Vaginal discharge

17 Diagnosis of TOA Clinical Ultrasound = Imaging of Choice CT Diagnostic laparoscopy

18 Treatment of TOA Parenteral antibiotics (same as for PID) Surgical intervention if unresponsive to ABx or rupture Laparoscopy IR drainage Abscesses 8cm may need surgical intervention 1st Ruptured TOA = Surgical Emergency Goals: abscess drainage, excision of necrotic tissues, & peritoneal cavity irrigation Torsion of TOA = Surgical Emergency Doppler US false neg if only tube torsed

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20 Disseminated Gonorrhea 0.5-3% of GC infections Fever, malaise, leukocytosis Female > Male Arthritis dermatitis syndrome (most common) Arthritis: asymmetric polyarthralgias of distal joints two joints Dermatitis: discrete papules & hemorrhagic pustules on extremities, 5-40 lesions Necrotic pustules on an erythematous base, tender

21 Gonococcal Disease Gram stain, 95% sensitive for male urethritis Not sensitive for other sites Culture, PCR Test for chlamydia coinfection Suspected disseminated gonococcus Culture urethra, cervix, pharynx, rectum, affected joints Increase sensitivity Unroof skin lesions lesions for culture 21

22 Gonococcal Disease Treat for presumed C. trachomatis coinfection Urethritis, cervicitis, proctitis: Ceftriaxone 250mg IM x1 & treatment for chlamydia Epididymitis Ceftriaxone 250mg IM x1 & doxycycline 100mg PO BID10d Bacteremia Cefotaxime 1g IV q8hrs & doxycycline 100 mg IV q8hrs PID, disseminated gonococcus Hospitalization (some cases of PID) Ceftriaxone 1 g IV qd & doxycycline 100mg BID x10d 22

23 Gonococcal Endocarditis 1-2% of Disseminated Gonococcal Infections >50% patients require valve surgery Mortality rate = 19% Despite appropriate medical & surgical treatment

24 MDR Gonorrhea 400,000 reported cases of gonorrhea/year CDC estimates actually 820,000 new infections/yr 30% resistant to 1 drug 2006: 5 treatment options for GC 2018: Only 1 remains

25 MDR Gonorrhea Resistant to Azithromycin & Ceftriaxone Sensitive to Ertapenem

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29 Syphilis Treponema pallidum, spirochete Sexually transmitted (HIV coinfection & MSM) Signs & Symptoms Primary syphilis Small papule at inoculation site (10-90d) Chancre painless, indurated ulcer (1-2cm) Nontender inguinal adenopathy 29

30 Secondary Syphilis (25% untreated) 6-20 weeks postexposure Fever, chills, malaise, weight loss, lymphadenopathy Rash Great Masquerader, variable appearance Typical: macular/papular, symmetric, trunk, extremities, palms & soles, 0.5-2cm red-brown lesions, pustular Condyloma lata: Large, raised gray/white lesions, moist areas & mucosa Alopecia, hepatitis, synovitis, nephrotic syndrome Anterior uveitis, chorioretinitis syphilitic meningitis 30

31 Condyloma lata 31

32 Tertiary Syphilis (25-40% untreated) Gummatous syphilis Large skin ulcers or heaped up granulomatous tissue Cardiovascular syphilis Dilated aorta, aortic regurgitation, with murmur or CHF Coronary artery narrowing, thrombosis Neurosyphilis Meningitis: within 1 year of primary infection Headache, stiff neck, AMS, uveitis + vision impairment Meningovascular: infectious arteritis, ischemic stroke, spinal cord infarct Suspect in young person with ischemic stroke 32

33 Gumma / Argyll Robertson Pupil 33

34 Tertiary Syphilis General paresis: year latency Progressive memory & judgment deficits, dementia Psychosis, dysarthria, facial and limb hypotonia, tremors Tabes dorsalis: 20-year latency Posterior columns of the spinal cord vibration, fine touch, proprioception Ataxia, lancinating pain (sudden brief stabs of pain), paresthesias, epigastric pain, nausea & vomiting Argyll Robertson pupil: accommodates, nonreactive Constricts with accommodation Doesn t react to light 34

35 Diagnosis of Syphilis Dark-field microscopy Nontreponemal test: RPR or VDRL sensitive, nonspecific, inexpensive Treponemal specific test: FTA-ABS or TPPA Confirmatory, high specificity for treponemals, expensive CSF: Meningitis, focal neuro findings, ophthalmic, tertiary syphilis, or HIV with low CD4 WBC cells/µl, protein mg/dl CSF VDRL, CSF FTA-ABS 35

36 Diagnosis of Syphilis Primary: Dark-field microscopy Secondary: Serologic studies or Dark-field Tertiary: Confirmed by serologic HIV coinfection: False-negative FTA-ABS 36

37 Syphilis Treatment 2637 BC: Treatment with mercury Chinese emperor recommendation 1776: Fumigation 1800: Sweating

38 Treatment of Syphilis Primary, secondary or early latent Latent = seroreactivity without evidence of disease Early latent = acquired within past year Benzathine penicillin G 2.4 million Units IM x1 Doxycycline 100 mg PO two times a day for 14 days Reexamine in 6 months (clinically & repeat VDRL/RPR) +/- HIV testing Late latent, unknown duration Benzathine penicillin G 2 to 4 million units IM weekly for 3 weeks (highly preferred) or Doxycycline 100 mg PO for 30 days 38

39 Treatment of Syphilis Neurosyphilis Aqueous crystalline penicillin G IV 3-4M u q 4 hrs x 14d or Procaine penicillin 2.4M u IM daily + Probenecid 500 mg PO qid x 14d Jarisch Herxheimer reaction: fever, headache, myalgias within 24 hours of treatment for syphilis. Treat with antipyretics 39

40 HSV Encephalitis 1 in 500,000 population/year HSV-1 (90%), 57% US adults HSV-2 (10%), sexual contact ⅓ HSE from primary infection Temporal lobe electrical changes Diagnosis: CSF PCR Treatment: Acyclovir 10mg/kg 30% mortality when treated 70% mortality rate without treatment Survivors have severe neurological damage

41 HSV Pneumonitis

42 Hepatitis Hepatitis A Virus Fecal-Oral route; MSM, IVDU, travel outside US Hepatitis B Virus Parenteral exposure & intimate contact; IVDU, MSM Hepatitis D coinfection + HBV Fulminant hepatitis Hepatitis C Virus IVDU, >20 sex partners, blood transfusion pre % co-infection in HIV+ Chronic infection 90% Chronic Liver Disease 10-20% 3.2M Chronic HCV in US Chronic Liver Disease 20 years later Cirrhosis/Death

43 Fulminant Hepatitis Acute onset hepatic failure & encephalopathy Timeframe = days HBV + HDV coinfection = most common Can occur with all of the causative viruses Incidence = 1-2% of all cases Hallmarks = AMS, spontaneous mucosal bleeding

44 Hepatitis PEP HAV: Immune Serum Globulin 0.02ml/kg HBV: If HBsAG+, none needed. If nonimmune: HBIG IM x 1 + Hep B Vaccine Series HCV: None recommended HDV: Same as HBV

45 HIV 45

46 HIV & AIDS Opportunistic infections Neoplasms Death CD4 <200 + AIDS-defining illness = AIDS

47 Infection Prophylaxis Pneumocystis jiroveci pneumonia (PCP) CD4+ <200 cells/µl or oropharyngeal candidiasis TMP/SMX Toxoplasma gondii encephalitis Toxoplasma IgG + AND CD4+ <100 cells/µl TMP/SMX Disseminated Mycobacterium avium complex (MAC) CD4+ <200 cells/µl AND active MAC ruled out Azithromycin/Clarithromycin

48 HIV PEP Pre-PEP needlestick risk 1 in 300 (0.33%) No cases through intact skin Splash injury 1 in 1000 (0.09%) High Risk Hollow-Bore needle + visible blood Percutaneous injury from needle in source s vein/artery Goal: Initiate PEP 1-2hrs post exposure Efficacy of PEP greatly decreases > 24-36hrs

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50 HIV PEP 3-drug regimen for 28 days Toftenofovir DF 300 mg AND emtricitabine 200 mg (Truvada ) once daily AND raltegravir 400 mg twice daily Or dolutegravir 50 mg once daily

51 What can kill you? PID TOA Torsion of TOA Fulminant Hepatitis HIV AIDS Syphilis Disseminated Gonococcal Infection Multi-drug Resistant Gonorrhea