In the news March Madness?

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1 Infectious Disease in Dermatology: Sexually Transmitted Diseases (other than syphilis) Whitney A. High, MD, JD, MEng Associate Professor, Dermatology & Pathology Director of Dermatopathology (Dermatology) University of Colorado Health Sciences Center March 4, 2017 Orlando, FL DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY WHITNEY A. HIGH, MD, JD, MEng SEXAULLY TRANSMITTED DISEASES I do not have any relevant relationships with industry to disclose. In the news March Madness? 110 million STDs in U.S million were new infections ~50% in <24 year olds Human papillomavirus (HPV) was #1 >$17 billion dollar/year cost in treating just the new infections The top 5 colleges for STD rates Per We are seeing a doubling and tripling of rates of chlamydia and syphilis in persons >50 years old. 1

2 Commonly Discussed STD s Viral Herpes HPV HIV Protozoal/Infestations Trichomonas Scabies Pubic Lice Bacterial Syphilis Chlamydia/LGV Gonorrhea Chancroid Granuloma inguinale Herpes Incubation ~ 5 days 70-80% of cases are subclinical Grouped vesicles erosions/ulcerations Diagnosis - clinical, Tzanck prep, biopsy, immunofluorescence, viral culture, PCR Antibodies not useful in acute setting antibodies not made immediately titers don t correspond to disease activity Case 46 y/o HIV(+) male Painful genital ulcer Enlarging x 12 months Failed 6 courses of ACV Off HAART x 2 months Prior HSV culture by ID was neg. Histology 20x 2

3 CD20 Stain 40x HSV Stain Laboratory analysis: patient with lesions Test Sensitivity (%) Specificity (%) Comments Clinical diagnosis False (-) Viral culture - Primary - Crusted - Recurrent EtOH & Iodine Chronic & Recurrent Temperature & Humidity 10x 20x 40x PCR (+) HSV II Cx (+) ACV resistant strain PCR Immunofluoresence >95 >99 Useful & reliable False (-) Rapid, useful Diagnosis: Acyclovir resistant HSV II infection Cytology: Tzanck test If other tests unavailable US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 2004; , Two Situations for ACV Resistance: discontinued culture for these viruses PCR on swabs from lesions Same day results 1. HIV-positive (4-7%) 2. BM transplant (2-9%) General Population % 3

4 Montreal Gazette October 19, 1983 Vaccine on Horizon? Future success? New plasmid-based DNA vaccine for promiscuous Guinea pigs. Therapeutic Vaccine Patients with 40% reduction in mean viral shedding from baseline (p<0.001) maintained for six months (p<0.001). A new class of drug Helicaseprimase inhibitor On hold in 2013 for unexplained dermal and hematologic findings in a toxicology study of monkeys Condyloma > 150 HPV subtypes ~ 40 cause anogenital infections HPV 6,11 >90% condyloma HPV 16,18 cervical cancer interrupt function of p53 & Rb 4

5 Examined: 29 vulvar verruca in girls (< 5 y/o) HPV 2 in 41% HPV 6/11 in 59% 275 vulvar verruca in women HPV 6/11 in 94% HPV 2 in 3% other HPV 3% Vaccines Gardasil (Merck) new 9-valent form 6, 11, 16, 18, 31, 33, 45, 52, and 58 genital warts/cervical CA aluminum adjuvant Cervarix (GlaxoSmithKline) HPV 16/18 (bivalent) proprietary adjuvant longer lasting/therapeutic use? 2/27/2012 AAP Recommends Boys and girls 11 or 12 y/o Girls y/o (if not already given) Boys y/o (if not already given) Boys y/o may get (weaker data) Special emphasis on MSM population Painful Nodule at Site of Vaccination 5

6 New Side Effects of HPV Drugs Macrophagic Myofasciitis (MMF) Controversial entity Localized granulomatous phenomenon? A systemic autoimmune disease? From about a half dozen reports of: vitiligo vitiligo-like depigmentation FDA reports : 68 reports of dyspigmentation Should be added to consent/counseling Gonorrhea Gram negative diplococci Neisseria gonorrhoeae Common cause of purulent d/c in men Often asymptomatic cervicitis May also involve: oropharynx conjunctiva pelvic inflammatory disease (20%) disseminated disease (1%) Disseminated Gonococcemia 0.5 3% of all cases Days to weeks afterwards Common after menses Migratory polyarthritis Gunmetal pustules Periarticular lesions Lesions asymptomatic, resolve in 4-7 days Trends in GC Treatment CDC surveillance: first saw resistance to fluoroquinolones HI/CA increasing resistance to cefixime in western USA superbug strain (H041) in Japan resistant to all cephalosporins Always treat or exclude CT! 6

7 500x resistance to all known cephalosporins Ceftriaxone or cefixime, with concomitant treatment for CT. Treatment of Gonorrhea Chlamydia Intracellular GN organism C. trachomatis Different serovars may yield: non-gonococcal urthrethritis (D-K) lymphogranuloma venereum (L 1-3 ) Cannot be easily cultured Treatment of NGU: azithromycin 1 gm OTD doxycycline 100 mg BID x 7 days (21 days for LGV) Case 23 y/o man 2 weeks of rash on penis and sore knee Last partner reported had an STD Kataria et al. AAFP,

8 Treatment of Chlamydia Chancroid Chancroid Haemophilus ducreyi (GN coccobacillus) Multiple, painful, ragged ulcerations Can have buboe formation Most common in sub-saharan Africa Typically diagnosed with Gram stain schools of fish or railroad tracks Treatment azithromycin, fluoroquinolones Immune-effector cells in chancroid show increased expression of CCR5 and CXCR4 than do cells in other ulcers. (both of these receptors are involved in entrance of HIV) Treatment of Chancroid Case Prostitute in hospital S/P NSVD Heaped, beefy plaque x 6 years Still working in the Callao community!!! 8

9 The Crush Prep Tissue transferred to slide Crushed with 2nd slide Parasitized macrophages and white blood cells Granuloma Inguinale AKA - Donovanosis Calymmatobacterium granulomatis Intracellular GNB (actually Klebsiella spp.) Treat with long term doxycyline (also TMP/SMX, cipro, azithro, EES) Use a prolonged course of ~21 days Relapse may occur up to 18 months later Silver Stain Treatment of GI/Donovanosis 9

10 Scabies Sarcoptes scabiei var hominis Arachnid (8 legs) Ubiquitous First visualized in 1687 in Italy Often occurs in 30 year epidemics Last epidemic from 1960 s still continuing Wrist area Scabies Clinical Real world results of a good scabies prep Penile Nodules Scabies Crusted Variant (HIV patient) Scabies Treatment Topical - 5% permethrin (Elimite ) neck to toes for 6-14 hours then wash-off may repeat in 1 week clean linens & bag anything not laundered Ivermectin (Stromectol ) mcg/kg (#5 or #6 3 mg tabs) +/- repeat in 1 week favorite for crusted scabies (+/- topical) 10

11 Pubic Lice Pubic Lice Clinical Pthirus pubis Visible to the naked eye Blood meals from pubic area Secondary changes from scratching Maculae cerulea from lice saliva How do I diagnose pubic lice? CAREFULLY Cut hair, place on slide, add mineral oil & coverslip Pubic Lice Also Effect Eyelashes Pubic Lice Treatment Topical meds: permethrin 1-5% (short contact) malathion 0.5% (flammable) Oral meds: ivermectin 200 mcg/kg OTD For eyelashes: smother with white petrolatum (ophtho. grade) anti-cholinesterase eye drops abroad In the end, the best protection against STDs well maybe not always. 11