HERPES

TRICHOMONAS

SYPHILLIS

CHLAMYDIA

GONORRHEA

BACTERIAL VAGINOSIS

PID

20 MILLION AMERICANS A YEAR NEW STI,

ALMOST HALF BETWEEN AGE 15-24

COST 16 BILLION ANNUALLY

INFERTILITY CAN RESULT IN WOMEN

MPORTANCE OF HISTORY TAKING

COMMONEST STI IN US

MOST IN SEXUALLY ACTIVE YOUNG WOMEN

COMPLICATIONS

PID

CHRONIC PELVIC PAIN

FALLOPIAN SCARRING

INFERTILITY

INCUBATION PERIOD 7-21 DAYS

WOMEN 15-24 HIGHEST

MEN 25-29

BLACKS HIGHEST

NEW OR MULTIPLE SEX PARTNERS

PREVIOUS OR COEXISTING STI

INCONSISTENT CONDOM USE

SEX FOR MONEY OR DRUGS

INCARCERATION

RECTAL C.T. IN MSM > RISK OF HIV ACQUISITION

INTRACELLULAR BACTERIUM WITH cell wall and ribosomes similar to those of gram-negative organisms.

3 STRAINS INFECT HUMANS C. trachomatis, C. pneumoniae, and C. psittaci.

C TRACHOMATIS CAUSES

clinical infection caused by C. trachomatis is usually determined by the outer membrane protein A (OmpA—also known as the major outer membrane protein [MOMP]), which can be determined based on serology (OmpA serovar)

OROPHARYNGEAL , GENITAL RECTAL AND CONJUNCTIVAL INFECTIONS, PNA IN NEWBORNS,

INFECTS COLUMNAR EPITHELIAL CELLS AT MUCOSAL SITES, BECOMES CHRONIC

CT HAS A GRAM NEGATIVE LIKE CELL WALL

TRANSMISSION RATE PER ACT IS 10%, VERTICAL TRANS ( M TO BABY ) 50%

INCUBATION PERIOD 7-21 DAYS

WOMEN

CERVICITIS

CAN BE MUCOPURULENT , VAGUE ABD DISCOMFORT SPOTTING

CAN BE ASYMPTOMATIC

URETHRITIS

DYSURIA AND FREQUENCY -MIMICS CYSTITIS

PID

SPREADS FROM CERVIX TO ENDOMETRIUM FALLOPIAN TUBES OVARIES

LEADS TO PID 10% EACH YEAR, CAN LEAD TO:

TUBAL SCARRING

INFERTILITY

ECTOPIC PREGNANCY

PERIHEPATITIS- FITZ HUGH CURTIS SYNDROME N,V,FEVER,RUQ PAIN +PID

SERIOUS COMPLICATIONS RARE IN MEN

BUT CAN BE:

EPIDYDIMITIS

PROCTITIS

PROCTITIS- REACTIVE ARTHRITIS

MOST IS

URETHRITIS- HETEROSEXUAL MEN- DYSURIA + DISCHARGE CLEAR MUCOID

MUCOPURULENT < THAN GONORRHEA

EPIDYDMITIS-UNILATERAL SCROTAL PAIN, EPIDIDYMAL SWELLING, TENDERNESS, CAN HAVE URETHRAL DISCHARGE ???2WHHBCS PER HIGH POWER FIELD ON GRAM STAIN OF SPECIMEN

70% OF STI EPIDIDYMITIS IS CT

HAND TO EYE TRANSMISSION

OROPHARYNGEAL :

ASYMPTOMATIC, OR PHARYNGITIS /TONSILLITIS

RECTAL

MEN AND WOMEN ( AUTOINCOCULATE FROM VAGINAL SECRETIONS

DISCHARGE TENESMUS PROCTITIS FEVER-ANOSCOPY

LYMPHOGRANULOMA VENEREUM ( RARER) NEEDS LGV SPECIFIC MOLECULAR TESTING

LGV-RARE, OCCUR IN MSM W HIV

CAN GET INGUINAL LYMPHADENOPATHY WITH NODES CALLED “BUBOES” THAT SUPPURATE

REACTIVE ARTHRITIS -REITERS SYNDROME : GET CONJUNCITIVITS URETHRITIS OLIGOARTHRITIS SKIN LESIONS AND CIRCINATE BALANITIS

SCREENING

ALL SEXUALLY ACTIVE WOMEN UNDER 25 ANNUAL

OVER 25 WITH NEW OR MULTIPLE PARTNERS ANNUAL

ALL PREGNANT WOMEN <25

ALL PREGNANT WOMEN > 25 AT RISK OR PARTNER W STI

RETEST FOR ABOVE IN 3RD TRIMESTER

TEST OF CURE 4 WEEKS AFTER TREATMENT, AND 3 MONTHS AFTER RX

MEN:

NOT RECOMMENDED SCREENING , ONLY IF COMMUNITY PREVALENCE HIGH, JAILS STI CLINICS

MSM

ALL MEN HAVE ANNUAL SCREENING

URETHRAL AND RECTAL SITES URINE NAAT AND RECTAL NAAT IF EXPOSED

3-6 MONTHLY IF TAKE PREP , W HIV OR MULTIPLE PARTNERS

DOXY 100 BID X 7 DAYS

AZITHROMYCIN 1 GM PO X 1 DOSE

LEVAQUIN 500 MG PO OD X 7 DAYS

PREGNANT WOMEN CANT HAVE A TETRACYLINE

USE

AZITHROMYCIN 1G ORALLY IN SINGLE DOSE

OR AMOXICILLIN 3 X DAY FOR 7 DAYS

LVG

DOXY 100 BID FOR 21 DAYS

3 MONTH FOLLOW UP AND REPEAT TESTING FOR REINFECTION, STIL SYMPTOMATIC OR RECURRENCE

PARTNERS

ALL PARTNERS IN 60 DAYS PRIOR TO ONSET OF SYMPTOMS SHOULD BE REFERRED FOR EVAL, TEST AND PRESUMPTIVE TREATMENT OF CT.

IF NO SEX PARTNER WITHIN 60 DAYS THEN LAST ARTNER

PARTNER TREATED RIGHT AWAY WITHOUT WAITING FOR TEST RESULT AS MAY NOT TURN UP FOR SECOND VISIT

PURPOSE OF TESTING IS TO PERFORM COUNSELLING AND SCREENING FOR OTHER STIS

USE OF EXPEDITED PARTNER THERAPY EPT - IF REFUSE DIAGNOSES PARTNER CAN DELIVER THIER TREATMENT TO THEM .USE OF EPT ON MSM SHARED DECISION-SHOULD BE TESTED FOR OTHER STIS

RESUMPTION OF SEX

AFTER COMPLETING DOXY

OR 7 DAYS AFTER SINGLE DOSE AZITHROMYCIN

UROGENITAL SYMPTOMS HAVE RESOLVED

PARTNER HAS COMPLETED TREATMENT

PARTNER NOTIFICATION

FOLLOW UP TESTING 3 MONTHS

COMPLICATIONS - EVEN IF TREATED CAN HAVE LONG TERM SEQUELAE IN WOMEN -COUNSEL

COUNSEL- LESS PARTNERS, ALWAYS USE CONDOM , ROUTINE SCREENING

SECOND MOST COMMON STI

GRAM NEGATIVE DIVIDES BY BINARY FISSION( LIKE PROKARYOCYTE CELLS AND ECOLI -PAIR DAUGHTER CELLS),APPEARS AS PAIRS-PIC G ATTACHES TO EPITHELIAL CELLS

1-14 days

NEISSERIA GONORRHOEAE,SEX OR VERTICAL TRANS

SEX ACTIVE PERSONS 20-29

RECENT TREND OF INCREASED INFECTIONS

HIGHLY TREATABLE

INITIALLY ASYMPTOMATIC

INCIDENCE

> MALES MSM FROM 2012 TO 2020 127% INCREASE IN MEN

HIGHEST RATE IN BLACKS

RISK FACTORS SAME AS FOR CHLAMYDIA

TRANSMISSION RATE FROM 50-70 %TO A FEMALE W EJACULATION, OTHER WAY ROUND 20%

UROGENITAL, RECTAL PHARYNGEAL CONJUNCTIVITIS , RARELY DISSEMINATED

INCUBATION 1-14 DAYS

CAUSES PID TUBAL INFERTILITY AND ECTOPIC PREGNANCY IN WOMEN

MEN

URETHRITIS

OVERT SYMPTOMATIC MOST 2-5 DAYS - MUCOPURULENT OR PURULENT W DYSURIA

ANORECTAL

ASYMPTOMATIC OR PROCTITIS W CONSTIPATION,PAINLESS PURULENT DISCHARGE TENESMUS-ANOSCOPY

EPIDIYMITIS INFREQUENT BUT PRESENTS WITH URETHRITIS

vaginal discharge,

intermenstrual bleeding,

dysuria

lower abdominal pain,

dyspareunia

BARTHOLIN GLAND INFECTION

PID

PERIHEPATITIS

NAAT multiple gram-negative intracellular diplococci.

ENDOCERVICAL '

URETHRAL

URINE

VAGINAL SOME

RECTAL AND PHARYNGEAL

POC NAAT SELF COLLECTED IN CLINCIAL SETTING

GRAM STAIN ON MALE WITH PURULENT DISCHARGE IS COMMON HIGH SPEC AND SENS.EXCEPT FOR ASYMPTOMATIC MALES

CULTURE

PHASIING OUT

SEX ABUSE NEED TO KEEP SPECIMEN, CONSULT FOR CLIA NAAT TESTING

WOMEN

ROUTINE ALL SEXUALLY ACTIVE WOMEN < 25

> 25 W RISKS

SCREEN FOR RECTAL AND PHARNYGEAL SHARED DECISION MAKIING

PREGNANT

ALL < 25 AND RISK > 25

RESTEST 3RD TRIMESTER

HETEROSEXUAL MEN- NO ROUTINE SCREENING

MSM

ANNUALLY AT LEAST -3-6 MONTHS HIGH RISK OR HIV, CHLAMYDIA

URINE RECTAL AND PHARYNGEAL NAAT

< 150 KGS CEFTRIAXONE 500MG IM X 1

> 150 KGS = 1 GM

PHARYNGEAL NG A TEST OF CURE RECOMMENDED AFTER 7-14 DAYS

W CHLAMYDIA DOXY 100 BID X 7

W CT PREGNANT AZIMTHROM 1 GRAM

ALTERNATIVE IF NO CEFTRIAXONE

GENT 240 IM X 1 DOSE + AZITHROMYCIN 2G ORALLY X 1 DOSE

OR CEFIXIMME 800 MG ORALLY X 1 DOSE

MOST TREATMENT FAILURES ARE FROM REINFECTION

EPT IS ORAL CEFIXIME 800 MG DELIVERED SCRIPT TO PARNTER, ADD DOXY IF SUSPECT CT, PREGNANT AZITHROM 1 GM X 1

EPT CONTRAINDICATED IF PARTNER HAS PID SYMPTOMS

COUNSELING SAME AS CT

TREPONEMA PALLIDUM spirochete bacterium that is transmitted primarily through sexual activity or with vertical transmission during pregnancy

PROGRESSIVE DX primary, secondary, latent, and tertiary), with episodes of active clinical disease interrupted by periods of latent infection; neurologic manifestations can occur at any of these stages

Corkscrew-shaped, motile microaerophilic bacterium that cannot be viewed by normal light microscopy

Persons who acquire T. pallidum are contagious to their sex partners throughout the primary and secondary stages of infection—when lesions or rash are present.[14,16] Although sexual transmission of T. pallidum usually results from contact at genital mucous membranes, it can also occur at other body areas, including the mouth, anorectal areas, and cutaneous lesions.

“the great imitator” because so many of the signs and symptoms may be difficult to differentiate from those of other diseases.[

SYPH CAN GO TO CIRC, LYMPH AND CNS

PRIMARY PAINLESS CHANCRE AT SITE OF INOCULATION

ALOPECIA

LYMPHADENOPATHY

MALAISE FEVER

MUCOUS PATECHES FLAT IN ORAL CAVITY

CONDYLOMATA LATA

VISCERAL -LIVER KIDNEY LUNGS SPLEEN

USU NEPHRITIS OR HEPATITIS W HIGH ALK PHOS

2-50 YEARS PROGRESS IF UNTREATED

GUMMATOUS LESIONS

TABES DORSALIS

PSYCHIATRIC , DEMENTIA SCHIZOPHRENIA

CARDIOVASCULAR SYPHILIS aortic valve regurgitation

NEUROSYPHILIS

EARLY ASEPTIC MENINGITIS LIKE SYMPTOMS CRANIAL NERVE 11, VI AND VIII

LATE PARESIS AND TABES DORSALIS, OCULAR SYPHILIS

ocular

bad stuff

see pptx sti

OCULAR SYPHILIS OCCURS ANY STAGE

UVEITIS AND OTHERS

syphilis who have ocular complaints should have a complete cranial nerve evaluation and receive a referral to an ophthalmologist for an immediate evaluation

OTOSYPHILIS -HEARING LOSS TINNITUS VERTIGO -REFER OTOLARYNGOLOGIST

CONGENITAL -VERTICAL TRANSMISSION VIA FETUS OR DELIVERY

MANY DISORDERS INCLUDING HUTCHINSONS TEETH AND PALATAL PERFORATION

CHALLENGING FOR ACTIVE PRIOR AND ABSENCE OF INFECTION

DIRECT DETECTION

DARK FIELD MICROSCOPY

PCR NO FDA APPROVED TEST YET

DIRECT FLUORESCENT ANTIBODY TEST

TISSUE STAINING

SEROLOGIC

NEED BOTH TREP AND NON TREP FOR DX AS EACH HAS MAJOR LIMITATIONS

NON TREPONEMAL NON SPECIFIC DONE FIRST, IF + DO TREP

****NOTE RECENT TRENDTO DO TREPONOMAL FIRST*

(VDRL AND RPR) MEASURE ANTIBODIES AGAINST LIPOIDAL ANTIGENS - THE TWO GIVE A RATIO

A FOURFOLD CHANGE IN TITER eg 1:16TO 1:4 OR FROM 1:8 TO 1:32 IS SIGNIFICANT

TREPONEMAL ( TPPA,tp-EIA AND CIA, FTA-ABS

) MEASURE ANTIBODIES AGAINST T PALLIDUM

IGG SOME HAVE IGM AND

SEROLOGIC TESTING HAS HIGHEST YIELD FOR 2NDRY, EARLY MAY NOT SHOW

FALSE POSITIVES - IF PREGNANT, AUTOIMMUNE, VD, LEPROSY MALARIA

NEUROSYPHILIS

SEROLOGICAL TESTS POSITIVE NEED LUMBAR PUNCTURE CSF VDRL> SPEC BUT < SENS, SO IF NEG GET CSF FTA-ABS

LAW STATES ALL SYPHILIS CASES STATE REPORTABLE BY CLINICIAN LAB OR BOTH

ALL PREGNANT WOMEN SEROLOGIC TEST AT FIRST VISIT

AT RISK COMMUNITY OR RIS RETEST AT 28 WEEKS

ANY WOMAN W STILLBORN AFTER 20 WEEKS GESTATION

MSM ANNUAL SCREENING

EVERY 3-6 MONTHS IF HIGH RISK

HIV +

ANNUAL

EVERY 3-6 MONTHS IF HIGH RISK

JAIL

OPT OUT ANNUAL

PEN G parenteral at all stages

BENZTHINE PENICILLIN G

2.4 MILLION UNITS IM X 1

PCN ALLERGY

DOXYCYCLIN 100 MG QID X 14 DAYS

TETRACYCLINE 500 MG QID X 14 DAYS

PREGNANT ??

EARLY LATENT - SAME RX

LATE LATENT OR UNKNOWN DATE OF ORIGIN- SAME RX BUT X 3 DOSES AT 1 WEEK INTERVALS FOR 7.2 MILLLION UNITS

ALLERGY:

DOXYCYCLIN 100 MG QID X 28 DAYS

TETRACYCLINE 500 MG QID X 28 DAYS

TERTIARY - SAME AS LATE LATENT FOR PCN .CSF FIRST TO CHECK FOR NEUROSYPHILIS

NEURO DIFFERENT RX

PRIMARY AND SECONDARY

NO HIV

6 AND 12 MONTHS LOOKF OR FOURFOLD DECREASE NON TREP

HIV 3, 6,9,12,24MONTHS

LATENT

6,12,24 -NO HIV

HIV 6,12,18,24

SEX PARTNERS

IN GENERAL TRANSMISSION ONLY OCCURS WHEN SYPHILIS PERSON HAS MUCOCUTANEOUS LESIONS

90 DAYS PRIOR PARTNERS,

TREAT PRESUMTIVELY IF UNLIKELY TO RETURN FOR TEST RESULTS

NO EPT

NO SEX UNTIL MUCOSAL LESIONS HEALED, 7 DAY POST RX, SEX PARTNERS TREATED

• In the United States, reported cases of syphilis, including congenital syphilis, have steadily increased in recent years. Epidemiologic features associated with increased reported rates of syphilis include male sex, age 25-34 years, MSM, persons with HIV, and persons who are Black.

• Syphilis is a systemic infection caused by Treponema pallidum, and in the absence of treatment, this disease can progress in stages. Untreated syphilis is characterized by episodes of active clinical manifestations interrupted by periods of asymptomatic latent infection. Neurosyphilis, ocular syphilis, and otosyphilis can occur during any stage of infection.

• Untreated syphilis in pregnancy can lead to devastating consequences, including stillbirth, neonatal death, and congenital syphilis.

• The laboratory diagnosis of syphilis is challenging and requires using a combination of clinical criteria and laboratory tests (both treponemal and nontreponemal tests) to differentiate active infection, prior infection, and absence of infection.

• The serologic diagnosis of syphilis employs two major algorithms: (1) the traditional screening method that uses a nontreponemal assay as the initial test, or (2) a reverse sequence screening method that uses a treponemal antibody test as the initial test. 

• Screening for syphilis is recommended in all pregnant women, men who have sex with men, persons with HIV, and other groups at increased risk for acquisition of syphilis.

• Penicillin G, administered parenterally, is the preferred drug for treating all stages of syphilis and is effective in resolving clinical symptoms associated with primary and secondary syphilis, as well as preventing late sequelae. The dosing of penicillin depends on the stage of disease; neurologic, ocular, and otosyphilis require more intensive therapy. 

• The Jarisch-Herxheimer reaction is a self-limited reaction that can occur after initiation of anti-treponemal therapy; it is characterized by fever, malaise, nausea, vomiting, chills, and exacerbation of a secondary syphilis rash.

• For a person diagnosed with primary, secondary, or early latent syphilis, all of their sex partners within the prior 90 days should undergo evaluation and treatment of syphilis; if no sexual contacts occurred in the 90 days prior to the diagnosis, then the most recent sex partner should have evaluation and presumptive treatment.

• All persons treated for syphilis should have follow-up monitoring with nontreponemal testing to evaluate response to treatment.

NORMAL PH 3.8 - 4.5

MICROBIOTA HAS LACTOBACILLUS LACTIC ACID AND H202

• MOST COMMON BACTERIAL VAGINOSIS , VULVOVAGINAL CANDIDIASIS, AND TRICHOMONIASIS

• trophic vaginitis

• Desquamative inflammatory vaginitis

• Foreign bodies (e.g. retained tampons)

• Genital herpes

• Lichen simplex chronicus

• Lichen sclerosis

• Local or systemic allergic reactions (e.g. spermicides, deodorants, drug reactions)

• Mucopurulent cervicitis

• Normal physiologic variation

• Vulvar vestibulitis

• 
  

MENSTRUAL CYCLE

SEX HISTORY INCLUDING GENDERS

VAGINAL HYGIENE - EG DOUCHING

UNDERLYING MEDICAL CONDITIONS

PHYSICAL

ASSESS CERVIX R/O CERVICITIS

INSPECTION OF DISCHARGE COLOR VISCOSITY ADHERENCE TO WALLS, ODOR

SPECIMEN COLLECTION

SALINE WET MOUNT

KOH TEST CANDIDIASIS

AND WHIFF TEST-UNBELIEVABLE -STRONG FISHY ODOR = BACTERIAL VAGINOSIS

PH LITMUS TEST

> 4.5 = B. VAGINOSIS CAN BE TRICHOMONIASIS

VAGINAL GRAM STAIN B. VAG OR CANDIDIASIS

CULTURE

NAAT- B VAG , CANDIDA AND TRICHOM

COMMON

HAVE TO BE SEXUALLY ACTIVE

ASSOC WITH > NUMBER SEXUAL PARTNERS ,DOUCHING AND HSV2, SEX TOYS

HIGHER COLONISATION IN MEN W EXTRA MARITAL RELATIONSHIPS THAN MONOGAMOUS

LOSS OF LACTOBACILLUS = DYSBIOSIS AND INFLAMMATION,

USU GARDNERELLA ASSOC W SEXUAL EXPOSURE - CREATES BIOFILM

LEADS TO ELEVATED PH

PID -NEED MORE STUDIES

OBSTETRIC COMPLICATIONS POST OP INFECTION, LATE MISCARRIAGE, PREMATURE DELIVERY

RISK OF ACQUIRING STIS

AMSEL CRITERIA

• Vaginal pH greater than 4.5, which is the most sensitive but least specific sign

• Figure 5. Bacterial Vaginosis—Clue Cells

  The presence of “clue cells” (bacterial clumping that obscures the borders of vaginal epithelial cells) (Figure 5) in at least 20% of vaginal epithelial cells per high power field viewed on saline microscopy

• Positive amine, “whiff” or “fishy odor” test (liberation of biologic amines with or without the addition of 10% KOH)

• Homogeneous, nonviscous, milky-white discharge adherent to the vaginal walls

LAB

VAGNIAL GRAM STAIN W CLUE CELLS GOLD STANDARD-NOT U SED OFTEN

OSOM BV BLUE TEST

AFFIRM VPIII

NAAT

PTIMA BV AND BD MAX ARER FDA APPROVED

NOT RECOMMENDED UNLESS PRE OBS SURGICAL PROCEDURE

TREATMENT

METRONIDAZOLE 500 MG BID FOR 7 DAYS

METRO GEL 0.75% INTRA VAG OD X 5 DAY

CLINDAMYCIN 2% QHS X 7 DAY

TRICHOMONAS VAGINALIS PROTOZOA MOST COMMON CURABLE WORLDWIDE

Single-celled flagellated anaerobic protozoan parasite.

FROTHY GRAY OR YELLOW GREEN DISCHARGE

ITCH

STRAWBERRY CERVIX

MEN

USU ASYMPTOMATIC

URETHRAL INFECTION,

PROSTATIS

EPIDIDYMITIS

NAAT

WET MOUNT AND CULTURE USED LESS

POC TESTING

SCREENING NOT DONE ROUTINELY *ONLY HIGH RISK WOMEN

RX

WOMEN

METRONIDAZOLE 500 MG BID X 7 DAYS NO ALCOHOL RULE HAS CHANGED

OR ALTERNATE FOR MEN AND WOMEN

TINIDAZOLE2G PO X 1 DOSE

MEN

METRONIDAZOLE 2 G PO X 1 DOSE

ALLERGIES

REFER TO ALLERGIST

OR

INTRAVAG BORIC ACID OR PAROMOMYCIN CREAM

2ND LINE

METRONIDAZOLE 2 G OD X 7 DAYS

3RDLINE

SPECIAL KIT FROM CDC 5 NITROIMIDAZOLE DRUG RESISTANCE TESTING

HI DOSE TINIDAZOLE 1 GRM 3 X DAY + PARAMNOMYCIN CREAM X 14 DAYS

SECX PARTNERS

60 DAYS BEFORE

7 DAYS AFTER TREATMENT

PRGNANT WOMEN METRONIDAZOLE, NOT TINIDAZOLE

YEAST INFECTION

NOT STI

VERY COMMON

RECURRENT:

HIV

DM

PREGNANCY

ABX

STEROIDS

HRT

SALINE WET MOUNT OR KOH

CULTURE

NOT PCR

TREAMENT

OTC CREAMS

CLOTRIMAZOLE 1% 7-14 DYS

2% X 3DAYS

MICONAZOLE 2% X 7 DAYSOR SUPP

TIOCONAZOLE OINTMENT 6.5 % SINGLE DOSE

FLUCONAZOLE PO 150 MG X 1 DOSE

• Avoid douching.

• Avoid unnecessary antibiotic use.

• Avoid repeated courses of self-administered, over-the-counter antifungal therapy in settings where no laboratory diagnosis has been confirmed.

• Complete the full course of any prescribed therapy.

• Optimize the management of other concurrent illnesses, such as diabetes mellitus and HIV.

MAJORITYHSV 2 AND LESSER HSV 1

CAN BE VERTICAL TRANSMISSION ESP IN THIRD TRIMESTER IST OUTBREAK

MOST PREVALENT STI IN US

MOST COMMON IN BLACKS

DOUBLE STRANDED DNA CAUSES CHRONIC INFECTION, HAS LATENCY

ENTERS THORUGH SKIN CRACK OR MMEMBRANE

TRANSPORTS TO NERVE ENDINGS -PERIPHERAL AXONS-TO GANGLIA , BECOMES LATENT IN GANGLIA SO ITS NOT CLEARED BY NEURONAL APOPTOSIS , CAN STAY IN GANGLION, GANGLION BECOMES LIFELONG RESERVOIR FOR VIRUS, CAN REACTIVATE ANYTIME

INCREASING FREQUENCY

YOUNG WOMEN

MSM

COLLEGE STUDENTS-HAS PREPLACED HSV 2 AS LEADING FIRST EPISODE GENITAL OUTBREAK

GENITAL-GENITAL OR ORAL SEX

THEORY

LESS HSV1 ORAL EXPOSURE AS KIDS,MORE ORAL SEX THESE DAYS

THOUGTH TO BE NEURONAL STRESS

SHEDDING OCCURS

CAN GET SYMPTOMATIC IN GENITAL, BUTTOCKS THIGHS -ANYWHERE THROUGHOUT THE DISTRIBUTION INNERVATED BY THE SACRAL GANGLIA , SHEDDING THROUGHOUT GENITAL REGION

NEW KNOWLEDGE, SHEDDING OCCURS MOST DAYS, BUT CD8 + T LYMPHOCYTES CONTAIN THE SHEDDING

HSV 2 REACTIVATION RECRUITS CD4 CELLS, WHICH CAN SERVE AS TARGET CELLS FOR HIV 1

INFECTION HIGHER MAN TO WOMAN-OF COURSE

THOSE WITH STRONG HSV SPECIFIC T CELL RESPONSES HAVE LESS RECURRENCE

USU OCCURS IN 4 DAYS FROM EXPOSURE

KNOWN CAUSES OF REACTIVATION TRAUMA FEVER, UV LIGHT, PHYSICAL /EMOTIONAL STRESS, IMMUNOSUPPRESION, FATIGUE, MENSES, SEX

PRIMARY EPSIODE:

FIRST EPXOSURE ( NO ANTIBODY)

FIRST EXPOSURE TO ONE TYPE ALREADY HAS OTHER VIRAL TYPE (HSV 1 OR 2)

PRIOR ASYMPTOMATIC ACQUISITION OF SAME TYPE ( ALREADY HAS ANTIBODY)

SYMPTOMS

SEVERE BILATERAL GENITAL ULCERS,

ITCHING

DYSURIA

DISCHARGE

INGUINAL TENDER ADENOPATHY

NO ANTIVIRAL-LASTS 2-3 WEEKS

VIRAL SHEDDING 10-12 DAYS

FEVER

MYALGIA

HEADACHE 3-5 DAYS LATER

CERVICITIS ULCERATIVE LESIONS ERYHTEMA FRIABILITY ON EXAM

SOMEONE WHO HAS HSV 1 AS CHILD WILL GET MILDER PRIMARY SYMPTOM IF THEY ACQUIRE HSV 2 A ADULT, PRESUMABLE CROSS IMMUNITY PROTECTION

PRODROMAL PAIN FROM HSV RTRAVELLING ALONG AXON 12-24 HOURS BEFORE

MILD LOCALISED SYMPTOMS- VESICLES OR PUSTULES,

PROGRESS TO WET ULCER

CRUST OVER

HSV 2 4-5 OUTBREAKS A YEAR

HSV 1 1 OUTBREAK A YEAR

80 % OF PERSONS SEROPOSITIVE FOR HSV 2 HAVE NEVER RECEIVED A DIAGNOSIS

20% OF THOSE NEVER HAD A SYMPTOM OR ON CERVIC

60% HAD VERY MILD SYMPTOM/MISDIAGNOSED-ALOT HAVE HSV 1 ALREADY

ASEPTIC MENINGITIS 10% OF ALL CASES

RARE:

SACRAL PARASTHESIAS , RADICULAR PAIN, TRANSVERSE MYELITIS, DISSEMINATED INFECTION

LUMINANT HEPATITIS

60% OF HIV HAVE HSV

MORE SEVERE AND CHRONIC LESIONS

CD4 COUNT LESS THAN 100 CELLS/MM OFTEN HAVE NON HEALING ULCERS

CAN DEVELOP ACYCLOVIR RESISTANT HSV. IRONICALLY GET MORE SHEDDING, ANTERETROVIRAL THERAPY CAN CAUSE INITIAL INCREASE IN ULCERS

HSV FACILITATES BOTH ACQUISITION AND TRANSMISSION OF HIV,HIV RISK INCREASES 2 FOLD IF HAVE HSV 2 INFECTION

WHY ?

HIV CAN BE PRESENT IN HERPES ULCERATION

AND HSV REACTIVATION INCREASES RATE OF HIV TRANSCRIPTION >HIV RNA LEVELS

THIS IS ALL HSV 2 ONLY

NAAT BEST( PCR)

SEROLOGICAL TESTING, TYPE SPECIFIC AND TYPE COMMON

TYPE SPECIFIC HSV 2 OR HSV

HSV 2 ARE USUALLY SEXUALLY AQUIRED-RARELY HSV 2 CAUSES ORAL ULCERS,'

SO HSV 2 ANTIBODY MEANS ANOGENITAL INFECTION

ANTIBODIES REMAIN INDEFINITELY USES ELISA IGG TESTING

POSTIVIE TESTING REQUIRES SECOND TEST,DUE TO FALSE POSITIVE,

LOW FALSE NEGATIVE EXCEPT WITH EARLY INFECTION

NOT RECOMMENDED FOR GENERAL POPULATION

EXCEPTIONS

THOSE WHO HAVE SYMPTOMS AND NOT DIAGNOSED

ATYPICAL GENITAL SYMPTOMS WIHT NEGATIVE PCR

SEX PARTNER WITH GENITAL HERPES

HIV

MSM-ROUTINE IF STATUS UNKNOWN

PRESENTING WITH ANOTHER STI, MULTIPLE SEX PARTNER10 OR MORE

PRMARY OUTBREAK LESSER DOSE THAN HZV

ACYCLOVIR 400 MG PO 3XDAY FOR 7-10 DAYS

FAMCYCLOVIR 250 MG POTID 7-10 DAYS

VALACYCLOVIR 1 GRAM PO BID 7-10 DAYS

PRIMARY OUTBREAK 7-10 DAY COURSE

START EMPIRICALLY

CAN EXTEND IF SYMPTOMATIC AFTER 10 DAYS

RECURRENCE

AYCLOVIR 800 MG PO BID FOR 5 DAYS/ TID FOR 2 DAYS

FAMCICLOVIR 1 GM PO BID X 1 DAY/500 MG BID FOR 2 DAYS/125 BID FOR 5 DAYS

VALACYCLOVIR 500 MG BID FOR 3 DAYS/1 GM OD FOR 5 DAYS

IV FOR SEVERE HSV DISEASE OR DISSEMINATED INFECTION, HEPTATITIS, MENINGITIS

TRANSMISSION HIGHEST IF NEWLY ACQUIRED IN PREGNANCY

ESPECIALLY LATE, HIGHEST IF OUTBREAK AND SHEDDING DURING PREGNANCY

SUPPRESSIVE ANTIVIRAL THERAPY

DISCLOSURE OF STATUS

CONSISTENT CONDOM USE

ALL REDUCE TRANSMISSION

When counseling persons with symptomatic HSV-2 genital herpes infection, the provider should discuss the following:

• The natural history of the disease, with emphasis on the potential for recurrent episodes, asymptomatic viral shedding, and the attendant risks for sexual transmission of HSV to occur during asymptomatic periods (asymptomatic viral shedding is most frequent during the first 12 months after acquiring HSV-2).

• The effectiveness of daily suppressive antiviral therapy for preventing symptomatic recurrent episodes of genital herpes for persons experiencing a first episode or recurrent genital herpes.

• The effectiveness of daily use of valacyclovir in reducing risk for transmission of HSV-2 among persons without HIV and use of episodic therapy to shorten the duration of recurrent episodes.

• The importance of informing current sex partners about genital herpes and informing future partners before initiating a sexual relationship.

• The importance of abstaining from sexual activity with uninfected partners when lesions or prodromal symptoms are present.

• The effectiveness of male latex condoms, which when used consistently and correctly can reduce, but not eliminate, the risk for genital herpes transmission.

• The type-specific serologic testing of partners of persons with symptomatic HSV-2 genital herpes to determine whether such partners are already HSV seropositive or whether risk for acquiring HSV exists.

• The low risk for neonatal HSV except when genital herpes is acquired late in pregnancy or if prodrome or lesions are present at delivery.

• The increased risk for HIV acquisition among HSV-2 seropositive persons who are exposed to HIV.

• The lack of effectiveness of episodic or suppressive therapy among persons with HIV to reduce risk for transmission to partners who might be at risk for HSV-2 acquisition.

• Genital herpes is the leading cause of genital ulcer disease worldwide and one of the most prevalent sexually transmitted infections in the United States.

• Genital herpes is a chronic viral infection predominantly caused by HSV-2; it is characterized by periods of latency punctuated by periods of viral shedding.

• More than 85% of persons with genital herpes are unaware of their infection, and asymptomatic shedding of HSV accounts for most transmitted genital HSV infections.

• To make a clinical diagnosis of genital herpes, a direct viral test (preferably PCR) should be performed on a sample taken from a lesion.

• Routine serologic screening for genital herpes is not recommended for the general population, but type-specific serologic screening for HSV-2 may be indicated in certain situations.

• When type-specific serologic testing is indicated, a two-step process should be utilized to confirm low index value (less than or equal to 3.0) on initial EIA-ENZYME IMMUNOSASSAY -LOOKS FOR ANTIBODIES or CLIA testing.

• Antiviral therapy with acyclovir, valacyclovir, or famciclovir can be used intermittently for each episode of genital herpes (episodic therapy) and to prevent recurrent outbreaks (suppressive therapy).

• Among persons without HIV, daily suppressive therapy with valacyclovir prevents recurrent outbreaks of genital herpes and reduces transmission of HSV-2 to sex partners.

• Prophylactic therapy with acyclovir or valacyclovir beginning at 36 weeks of gestation should be offered to all women with a history of genital herpes since it has been shown to reduce the risk of HSV recurrence at delivery and thereby reduce the need for a cesarean delivery.

• Counseling plays an integral role in the management of a patient diagnosed with HSV infection, given the significant morbidity attributed to the psychological burden of HSV related to the need for behavior change and for disclosure to sexual partners.