Sexually transmitted infections

Transcription

1 Sexually transmitted infections Dr Caroline CHARLIER-WOERTHER Université Paris Descartes Paris, France

2 Learning objectives Counsel patients about the risk of STD Know how to diagnose and treat a sexuallytransmitted urethritis Know how to diagnose and treat a sexuallytransmitted cervicitis Know how to diagnose and treat syphilis Counsel pregnant women with syphilis

3 Sexually transmitted infections Epidemiology Urethritis Cervicitis Genital ulceration syphilis

4 STI : definition Infections that are most commonly passed through sexual contact: Oral Vaginal Anal Skin-to-skin

5 STI : pathogens involved URETHRITIS Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasma genitalium CERVICITIS Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasma genitalium GENITAL ULCERATION Treponema pallidum Herpes simplex 2 et 1 Haemophilus ducreyi Chlamydia trachomatis Also : HIV HBV, HAV +/- HCV Human Papilloma Virus Scabies Louse

6 STI : epidemiology key messages Increased incidence True rise of incidence Enhanced detection Most cases involve young people Increased resistance to antibiotics (Neisseria gonorrheae, Mycoplasma genitalium)

7 What is the most frequent STD pathogen in Europe? Chlamydia trachomatis Neisseria gonorrhoeae Treponem pallidum

8 What is the most frequent STD pathogen in Europe? Chlamydia trachomatis Neisseria gonorrhoeae Treponem pallidum

9 Chlamydia epidemiology First STI in Europe (3% women years in France) 75% are people years 40% increase btwn 2006 and 2010 (improved detection) ECDC 2012 Annual Report

10 Gonorrhoea 2 nd most frequent STI in Europe 90% are people years 70% are men In France 15% are HIV-infected Increased resistance to antimicrobials ECDC 2012 Annual Report

11 Syphilis Sex ratio 3M: 1F 85% > 24 years In France 50% = HIV-infected ECDC 2012 Annual Report

12 STD Men = urethritis Women = cervicitis Other primary localizations Proctitis Pharyngitis Regional complications Prostatitis gonococcus Epididymo orchitis Other complications Septicemia, arthritis gonococcus Reactive arthritis chlamydia Other primary localizations Proctitis Pharyngitis Regional complications Pelvic inflammatory disease Peritonitis Ectopic pregnancies/infertility chlamydia Other complications Septicemia, arthritis gonococcus Reactive arthritis chlamydia

13 Inflammation of the urethra Urethritis in men Neisseria gonorrheae Chlamydia trachomatis Mycoplasma genitalium Short incubation < 7 days Burning when urinating White discharge No fever < 10% asymptomatic Burning when urinating clear discharge No fever 50% asymptomatic Burning when urinating clear discharge No fever % asymptomatic? Other pathogens rarely involved: Trichomonas vaginalis Herpes simplex Enterobacteria

14 Cervicitis Inflammation of the cervix Neisseria gonorrheae Chlamydia trachomatis Trichomonas vaginalis Vaginal discharge Vaginal bleeding Vaginal pain 60% asymptomatic Vaginal discharge Vaginal bleeding Vaginal pain 90% asymptomatic Vaginal discharge (thin green of yellow) Vaginal pain Vaginal itching 70% asymptomatic

15 Uretritis Uretritis / cervicitis diagnosis Direct examination of the discharge / urethral swab to evidence Neisseria and culture on chocolate agar Fastidious gram negative coffee-bean shaped cocci PCR testing for Neisseria, Chlamydia trachomatis or Mycoplasma genitalium on the first voided urine First voided urine fits for all

16 Cervicitis Uretritis / cervicitis diagnosis Direct examination of the discharge / cervical swab to evidence Neisseria and culture on chocolate agar Fastidious gram negative coffee bean shaped cocci PCR testing for Chlamydia trachomatis on the first voided urine/ discharge / cervical or vaginal swab PCR testing for Mycoplasma genitalium on vaginal swab Vaginal swab suits for all

17 Uretritis / cervicitis principles of treatment Ceftriaxone 500mg IM (N. gonorrhoeae) AND doxycycline 100mg x 2/j 14d (C. trachomatis) Both in each and every case Evaluation response to treatment Clinical evaluation : disappearance of symptoms Evaluate other STI HIV, HBV +/- HAV/ HCV, uretritis? cervicitis? Education about STI and protected sex /HBV vaccine Evaluate all sexual partners within the last 3 months

18 Genital ulceration Syphilis Herpes simplex And also, more rarely, Klebsiella granulomatis Haemophilus ducreyi Trinitycentre.nhs.uk

19 Syphilis Treponema pallidum Spirochete Non cultivable Transmission Sexual contacts Mother-to-child (placenta) Stanford.edu

20 LATE EARLY Syphilis Syphilis stages Primary stage Secondary stage after 4-10 weeks Early latent stage (< 1 year) Late latent stage ( > 1 year) Tertiary stage Incubation = days

21 Primary stage The sore Unique > multiple Painless, firm clean and round At the site of entry Genital / anus/ mouth+++ Adenomegaly 3-6 weeks in treated or untreated patients Syphilis

22 Secondary stage Syphilis 4-10 weeks after the occurrence of the sore Polymorphic skin eruption +++ Soles+++

23 Secondary stage Syphilis 4-10 weeks after the occurrence of the sore Mucous membrane lesions +++ Highly contagious++ Cheilitis

24 Secondary stage 4-10 weeks after the occurrence of the sore Patchy hair loss Fever, pains, tireness Enlarged liver/ spleen Nephrotic syndrome Liver cytolysis the great pretender Syphilis

25 Neurosyphilis During primary / secondary stages Asymptomatic 5% symptomatic Meningitis Cerebral vasculitis Nerve palsy Ophtalmic complications (uveitis/retinitis) During tertiary stages Tabes dorsalis General paresis Syphilis

26 Tertiary stage after 1-30 years in 30% of cases after 30 years Syphilis Cardiovascular 10%: Aortic aneurysm, aortic valve insufficiency Neurological 10%: Tabes dorsalis : slow degeneration of the dorsal column of the spinal cord responsible for proprioception General paresis : chronic meningo-encephalitis with altered motricity and dementia (frontal and temporal cortex) Skin/ bone and joints 10%

27 Syphilis diagnosis Direction examination Darkfied microscopy Sensibility 50% Not in the mouth Direct IF testing Serology Cardiolipidic antigens VDRL= Veneral Disease Reagent Laboratory Treponemic antigens TPHA = Treponema Pallidum Haemagglutination Assay FTA = Fluorescent Treponemal Antibody Test DO NOT DISTINCT STI / NOT STI treponema

28 Syphilis diagnosis

29 Syphilis principles of treatment Early syphilis (< 1 year) Penicillin G : extencillin 1 IM dose (2.4M) Late syphilis (> 1 year) Penicillin G : extencillin 3 IM doses Neurosyphilis : penicillin G IV 15 days

30 Syphilis principles of treatment Evaluation response to treatment Clinical evaluation : disappearance of symptoms Biological evaluation : M3,M6,M12 TPHA : stable VDRL : 2-fold decrease every 3 months Evaluate other STI HIV, HBV +/- HAV/ HCV, urethritis? cervicitis? Education about STI and protected sex/ HBV vaccine Evaluate all sexual partners within the last 3 months

31 Mother to child transmission Syphilis and pregnancy During pregnancy after 16 WG During delivery Mostly at early stages of maternal infection Responsible for Fetal loss : 40% Perinatal mortality : 20% Long term impairment : 20% Newman PlosMed 2013

32 Syphilis and pregnancy en.wikipedia.org

33 Syphilis and pregnancy 1,860,000 pregnant women infected 1/3 of pregnant women not tested worldwide Only 30% women tested and treated in Africa Newman PlosMed 2013

34 N. gonorrhoeae and C. trachomatis specificities

35 Fever Mono/ oligoarthritis Pustular lesions N. gonorrhoea Septicemia Positive blood cultures < 3% of gonorrhoea cases

36 N. gonorrhoeae and pregnancy Increased prematurity Mother to child transmission : 40% Conjunctivitis with purulent discharge (keratitis) Disseminated infection

37 Strictly human disease Intracellular pathogen 19 serovars Chlamydia trachomatis A-C : trachoma D-K: IST L1-L3 : Lymphogranulomatosis venereum

38 Lymphogranuloma venereum Severe ano-rectitis MSM Purulent discharge Bleeding Major pain Adenomegaly Fever Evolution toward pelvic fibrosis Halioua 2006

39 Chlamydia trachomatis and pregnancy Ectopic pregnancy and infertility 1/3 of ectopic pregnancies are related to Chlamydia Mother to child transmission of 70% 50% conjunctivitis 20% delayed interstitial pneumonia (4-12 weeks)

40 Reactive arthritis Mostly men Clinical presentation Urethritis Eye inflammation : conjunctivitis Migratory oligoarthritis (< 5, usually involving the knee or sacroiliac joint) Biological features Negative rheumatoid factor HLAB27 Pathogens involved C. trachomatis N. gonorrhoeae Campylobacter jejuni Salmonella Shigella

41 Pathogens involved in uretritis??

42 2 main infectious causes of genital ulceration?

43 Wikimedia Commons CDC ECDC University of IOWA