Sexually Transmitted Infections😍

• Donovanosis:
• Grand party in Club (Kleb Granulo) mnemonic - refer micro
• Right Don () → aka False Bob (Pseudobuoes)
• Rolls (Rolled edges) in Club (Klebsiella), eat beef (red beefy)
• Has no Pain (Painless), but bleeds (bleed on touch)
• Put bodies → Donovan bodies
• Takes a long day to come
• why right (Wright Giemsa)?
• He kills with safety pin (safety pin appearance) painlessly

• Syphillis
• It was dark (dark field),
• Button hole → Felt
• hard (hard chancre) and rubbery (rubbery LN) d*** → did it Bilaterally (B/L LN)
• But no pain (Ulcer and LN painless)

• LGV
• LGTV → Keep Neat (NAAT) → From Dogs (Doxy)
• Only Painless ulcer with Painful Buboes (U/L)

• Chance with his Wife (Chancroid and Herpes)
• Multiple people (Multiple lesions)
• Painful sex (Painful)
• Cried (H ducreyi) → Soft (Soft chancre)
• HSV → Vesicles

• Black → Bubo

• Ulcer → White/Blue

• Herpes → Red

• Partner Rx
• Urethral and scrotal swelling, ulcer → treat partners
• Cervical d/d → treat partners when symptomatic
• Vaginal d/d → only trichomonas only when symptomatic
• Non herpetic Ulcer → last 3 months partners
• Herpetic Ulcer → no partner Rx
• PID → Rx partner with kit 1 (Patient kit 6)
• Bubo → All partners for last 3 weeks → BAD (Bubo, azithro, Doxy)

• Mnemonic:
• Buschke Ollendrof → in Condyloma Lata
• Buschke Lowenstein tumor → Condyloma Accuminata

NOTE: Cervix : Corpus Ratio

• Note: Cervix is longer than uterus (corpus) before puberty.

Age	Cervix : Corpus Ratio
At birth	1 : 1
Before puberty	2 : 1
At puberty	1 : 2
Reproductive age	1 : 3 or 1 : 4
Menopause	1 : 1 (Organ atrophy)

• T. Pallidium

• Venereal syphilis: STD

• Incubation period: 9 - 90 days

Syphilis Stages and Diagnosis

Guidelines for Follow-up

• Follow-up at 6, 12 and 24 months

• Mnemonic:
• Buschke Ollendrof → in Condyloma Lata
• Buschke Lowenstein tumor → Condyloma Accuminata

NOTE: Cervix : Corpus Ratio

• Note: Cervix is longer than uterus (corpus) before puberty.

Age	Cervix : Corpus Ratio
At birth	1 : 1
Before puberty	2 : 1
At puberty	1 : 2
Reproductive age	1 : 3 or 1 : 4
Menopause	1 : 1 (Organ atrophy)

Hutchinson's Triad (Mnemonic: ENT):

• Late manifestation of congenital syphilis.

• E (Eye):
• Interstitial Keratitis.

• N (Nerve):
• 8th Nerve Deafness.
• SNHL

• T (Teeth):
• Hutchinson's Teeth.
• Notching of incisors

• Others features include:
• Saddle nose (Olympic brow)
• Mulberry molars.
• Running nose.
• Clutton's joints.

Hutchinson's

• H → Herpes Zoster Ophthalmicus

• U → subUngual Melanoma (superficial spreading melanoma)
• Hutchinson sign

• T → Triad → congenital syphillis
• Peg shaped teeth
• Interstitial Keratitis (IK + SNHL)
• SNHL

• CH → Chauffeur's Fracture/Backfire Fracture
• Intra articular #

• Son → looking older → Hutchison Gilford
• LMN A gene defect (laminopathy).
• Progeria (onset: Child)

• PUPIL → Hutchinson Pupil
• Herniation of uncus (medial temporal lobe) → compresses ipsilateral CN III → same side pupillary dilatation.
• Kernohan’s notch phenomenon:
• False localizing sign
• Ipsilateral pupil dilatation
• Ipsilateral UMN palsy

Investigations:

Dark field microscope

• Cannot be stained with Geimsa

• Most sensitive and specific (for primary stage, chancre/lymph node).

• Spiral, slender, wavy organisms (spirochetes).

• Reflect the light transmitted by organism

Silver impregnation:

• Fontana Stain - fluid/films

• Levaditi stain: tissue

• silver pyrates live near fountain

Serological Diagnosis

Reagin Tests (Non-Treponemal Tests) (Non-specific)

• Become positive later

• Become negative → Helps in monitoring

• Includes
• Wasserman test (Complement Fixation Test)
• Kahn test
• VDRL
• RPR
• TRUST
• UST
• RST

VDRL

• Purified lipid extract of beef heart + lecithin + cholesterol

• Use all samples - blood as well as CSF

• IOC for Neurosyphilis → CSF sample

Treponemal Tests (Specific)

• Become positive first

• Do not help in monitoring

• Most Specific blood test: 
• FTA-ABS > TPPA

• Earliest Positive: 
• IgM Capita > FTA-ABS

• Most Sensitive: 
• IgM Capita > FTA-ABS

• Screening: 
• VDRL or RPR (RPR cards for field).

• IOC
• Primary Syphilis: DGM.
• Secondary Syphilis: FTA-ABS.
• Tertiary Syphilis: Enzyme Immunoassay.
• Neurosyphilis: CSF Examination.

• Monitoring Activity: VDRL

Treatment:

• Standard: Injection Benzathine Penicillin.
• Adult Dose:
• 2.4 million units IM single dose (1.2M each buttock).
• Duration:
• Single dose: Primary, Secondary, Early Latent.
• Three doses (weekly): Late Latent, CVS, Benign Tertiary.
• Child Dose: 
• 50,000 units/kg IM
• up to adult dose

• Special Cases (Cannot cross barriers):
• Neurosyphilis, Congenital Syphilis:
• Drug of Choice: Aqueous Crystalline Penicillin IV.
• Alternative: Procaine Penicillin + Probenecid.

• Allergic to penicillin:
• Desensitize the patient
• because Penicillin is the most effective drug ????
• Doxycyline

• In pregnancy

 

• Mnemonic: Ooi Oii → Cry → Baby
• Hint thannitt mullum (Muller hinton)
• Schoolil (school of fish) povum,
• railway trackil (rail road track) kuda nadakum,
• chocolate thinnond horse (chocolate horse blood) ride cheyyum

Ulcer Characteristics:

• Soft chancre

• painful soft genital ulcers.

• Non-indurated base.

• Floor with yellow necrotic tissue

• Undermined edges.

• Bleeds on touch.

Lymphadenopathy: 

• Unilateral and tender

• Suppurative LN → Buboes

Gram Stain: 

• Gram negative bacilli in chains
• "School of Fish"
• "Rail Road Track”

Investigation of Choice: 

• Culture
• Mueller Hinton Agar + chocolate horse blood
• supplemented with isovitalex and fetal calf serum

Treatment:

• Single Dose T. Azithromycin 1 gram.

• If unavailable: 
• Ceftriaxone 250 mg IM.

Important Information

• In syphilis - hard – painless chancre

• Ulcer Characteristics:
• Multiple, painful.
• Vesicles and coalescing erosions (ulcers not typical).

• Incubation: Short (2-7 days)

• Episodes:
• Primary: More painful, severe.
• Recurrent: Less painful, severe, intense.

• Latent in dorsal root ganglion

• Lymphadenopathy: Bilateral painful.

Herpetic Keratitis

• Treatment:
• 3% Acyclovir eye ointment (not drops)
• Steroids are contraindicated.
• Eye drops 1st → Ointment 15 mins later.
• If ointment is applied first:
• It creates a barrier.
• Prevents absorption of the eye drop.

---

NOTE

Similar terms	Seen in
Dendritic ulcer	HSV 1 Corneal ulcer
Pseudodendrites	Acanthameba
Pseudodendritic ulcer	Varicella Zoster

Diagnosis of Herpetic Infections:

EEG

• Periodic lateralized epileptiform discharge (PLED)
• Seen in HSV encephalitis
• Mnemonic: His wife → Period late → she seizures

Lab Diagnosis

• Tzanck smear → Lipschultz bodies

• Skin scrapings can be used

• Geimsa staining
• Cytopathic effect = 3M
• Multinucleated
• Molding
• Margination

• Mc coy culture

Tzanck Smear:

• Mnemonic: HSV → His Wife → Has Giant boobs (Multinucleated giant cell) and good lips (Lipschultz) → She wears tank top (Tzank) → She goes to Gym too (Giemsa stain). She becomes a target for others (Target lesions → erythema multiforme)

• For cytology

• Unroof vesicle/bulla or scrape erosion base

• Stain with Giemsa stain

• See: Large multinucleated giant cell (feature of HSV infection)

• Also some acantholytic cells

Gold Standard:

• PCR (differentiates HSV 1 & 2).

Treatment of HSV Infection:

• Treatment available: 
• Acyclovir
• Valacyclovir
• Famciclovir

• Primary infection:

Antiviral	Dosage	Duration	Total/day
Acyclovir	200 mg x five times a day OR 400 mg 3 times/day.	7 to 10 days	1g
Valacyclovir	1 g x twice times a day	7 to 10 days	2g

• Recurrent infection:

Antiviral	Dosage	Duration	Total/day
Acyclovir	400 mg x three times a day	5 days	1.2 g
Valacyclovir	1 g x twice times a day	5 days	3 g

• If > 6 recurrences/year: 
• suppressive treatment (daily)

• If Acyclovir resistant:
• Use Foscarnet and Cidofovir

Hutchinson's

• H → Herpes Zoster Ophthalmicus

• U → subUngual Melanoma (superficial spreading melanoma)
• Hutchinson sign

• T → Triad → congenital syphillis
• Peg shaped teeth
• Interstitial Keratitis (IK + SNHL)
• SNHL

• CH → Chauffeur's Fracture/Backfire Fracture
• Intra articular #

• Son → looking older → Hutchison Gilford
• LMN A gene defect (laminopathy).
• Progeria (onset: Child)

• PUPIL → Hutchinson Pupil
• Herniation of uncus (medial temporal lobe) → compresses ipsilateral CN III → same side pupillary dilatation.
• Kernohan’s notch phenomenon:
• False localizing sign
• Ipsilateral pupil dilatation
• Ipsilateral UMN palsy

• Donovanosis:
• Grand party in Club (Kleb Granulo) mnemonic - refer micro
• Right Don () → aka False Bob (Pseudobuoes)
• Rolls (Rolled edges) in Club (Klebsiella), eat beef (red beefy)
• Has no Pain (Painless), but bleeds (bleed on touch)
• Put bodies → Donovan bodies
• Takes a long day to come
• why right (Wright Giemsa)?
• He kills with safety pin (safety pin appearance) painlessly

• Syphillis
• It was dark (dark field),
• Button hole → Felt
• hard (hard chancre) and rubbery (rubbery LN) d*** → did it Bilaterally (B/L LN)
• But no pain (Ulcer and LN painless)

• LGV
• LGTV → Keep Neat (NAAT) → From Dogs (Doxy)
• Only Painless ulcer with Painful Buboes (U/L)

• Chance with his Wife (Chancroid and Herpes)
• Multiple people (Multiple lesions)
• Painful sex (Painful)
• Cried (H ducreyi) → Soft (Soft chancre)
• HSV → Vesicles

• Black → Bubo

• Ulcer → White/Blue

• Herpes → Red

• Partner Rx
• Urethral and scrotal swelling, ulcer → treat partners
• Cervical d/d → treat partners when symptomatic
• Vaginal d/d → only trichomonas only when symptomatic
• Non herpetic Ulcer → last 3 months partners
• Herpetic Ulcer → no partner Rx
• PID → Rx partner with kit 1 (Patient kit 6)
• Bubo → All partners for last 3 weeks → BAD (Bubo, azithro, Doxy)

 

Neisseria meningitidis

• Clinical features:
• Pyogenic meningitis.

• Meningococcal vaccine:
• Protects against serotypes A, C, Y, W135.
• Does not protect against serotype B.

Neisseria Gonorrhoeae

• Clinical features:
• Ophthalmia neonatorum.
• Urethritis (most common in males).
• Cervicitis (most common in females).
• Watercan perineum (multiple discharging sinuses).

• Complications:
• Disseminated gonococcal infection (DGI).
• A/w PORB1a.

• Fitz-Hugh-Curtis syndrome
• perihepatitis
• Also seen in Chlamydia trachomatis infections.
• Trac (trachomatis ) gone (Gonorrhoeae) fits (Fitz-Hugh-Curtis syndrome varum

Modified Thayer-Martin medium

• Contains Vancomycin, Colistin, Nystatin, and Trimethoprim.

• Most common cause of STD and NGU.

• Infective stage: Trophozoite only.

• Diagnostic stage: No cyst formed.

• In males
• Cystitis, Prosthetitis, Urethritis

• Females: Strawberry cervix, greenish discharge.

 

• South delhi fashionable aunti → has No sister (No cyst) → love diamond () and strawberries () and lash () → jerk and twitch ()

Trophozoite:

• Pear shaped

• 1 nucleus.

• 4 anterior flagella.

• 1 posterior flagellum with an undulating membrane.

Diagnosis:

• Shows twitching / jerky motility.

• Sample: Discharge sample.

• PAP smear can be used.

• Microscopy: Only trophozoites.

Culture:

• Lash cysteine hydrolysate serum

• Diamond medium.

Treatment:

• DOC: Metronidazole.

• Partner must be treated.

Actinomyces Israelii:

• It is acid-fast.

• Microscopy: Filamentous organism.

• Appearances: "Ball of cotton," "ball of wool," "dust bunnies," or "Gupta bodies".

• A/w oral cervical actinomycosis triad
• Woody hard swelling
• Multiple discharging sinuses
• Sulfur granules

• A/w chronic osteomyelitis of mandible

• Associated with:
• PID
• IUCD → Copper T

STI Kits (Syndromic Management)

• Mnemonic: "Great Girls Will Buy Red Yellow Bags."

Miscellaneous

• Most common cause of PID in virgin females: Genital TB
• Hematogenous spread
• Affect Ampulla

Culture medium for Chlamydia

• Urethral discharge shows no organism on Gram staining

• McCoy cell culture

• Iodine stained inclusion bodies on microscopy

• “McCoy () Cat Chases (Chlamydia) Iodine () Fish.”Investigation:

• NAAT

• CFT