Can HSV-1 cause the first episode of genital herpes?
Yes, however, the majority of infections is due to HSV-2
The majority of genital herpes infections are transmitted by persons unaware that they have the infection or who are asymptomatic when transmission occurs. True or false?
True
What is fomite transmission?
This route requires an inanimate object to carry a pathogen from one susceptible animal to another.
Is fomite transmission likely to occur with HSV?
Unlikely because soap and water inactivates HSV
HSV remains latent in the paraspinous ganglia and is reactivated by________?
Trauma, fever, ultraviolet light, stress, and unknown factors
When would HSV-2 antibodies be present in a patient with a newly acquired case of HSV-2?
It may take from 3 weeks to a few month for antibodies to appear
A patient is concerned that over the weekend they may have been exposed to HSV-2 and want to be tested. Will serum antibodies be present?
No
Primary infections with HSV-2 tend to be moderate to severe and the herpetic lesions are often (bilateral or unilateral)?
Bilateral
How do the lesions progress in an HSV infection?
Papules→vesicles→pustules→ulcers→crusts→healed
Describe the systemic manifestations that can occur with an initial HSV-2 infection.
Fever, headache, malaise, myalgia, & urinary retention in women
What are the local symptoms of an initial infection with HSV-2?
Pain, itching, dysuria, vaginal discharge, and adenopathy
What percent of patient with an initial acquisition of HSV-2 have inguinal adenopathy?
80% have firm, nonfluctuant tender nodes
How long do the genital lesions from an initial HSV-2 infection persist?
On average 11-12 days
Can HSV-2 infection cause dysuria?
Yes, 80% of women report dysuria
Describe the prodrome for a recurrent HSV-2 infection
Localized tingling and irritation
Are recurrent episodes of HSV-2 shorter than in a primary infection?
Yes. The lesion lasts 4-6 days with milder symptoms
What percentage of patients with a symptomatic HSV-2 infection will have a recurrence in the first 12 months of infection
90%
How many occurrences would you expect in the first year of HSV-2 infection?
The median recurrence rate is 4.5 per year
Is it true that the frequency of recurrences of HSV-2 decreases over time?
Yes
Does antiviral suppressive therapy eradicate viral HSV-2 shedding?
No, however, it dramatically reduces viral shedding
Is screening for HSV-1 or HSV-2 in the general population indicated?
No
What is the preferred test for HSV if lesions are present?
Viral culture
All patients with genital ulcers should be tested for__________?
Syphilis
What drugs are used to treat HSV?
Acyclovir, valacyclovir, famciclovir
Is topical treatment of HSV recommended?
No
What dose of valacyclovir is recommended for treatment of the first clinical episode of HSV-2?
1 gram orally every 12 hours for 7-10 days
Suppressive therapy can reduce the frequency of genital herpes recurrences by________%
70-80%
When would suppressive therapy for HSV-2 be suggested?
With frequent recurrences (>6 per year)
The dose for suppressive therapy of HSV-2 infection with valacyclovir is______?
500 mg- 1000 mg daily
Why is valacyclovir preferred in the management of HSV-2 infections?
The dosing is less frequent and thus more convenient
The dose for episodic therapy for recurrent infection of HSV-2 infection with valacyclovir is______?
500 mg every 12 hours for 3 days or 1000 mg daily for 5 days
Can episodic treatment of HSV-2 shorten the duration of recurrent episodes?
Yes if started within 1 day of lesion onset
Do genital ulcers from HSV-2 infection increase the risk of HIV infection?
Yes
Why is it important to ask women about HSV prior to delivery?
HSV can be transmitted to the baby
Can HSV-2 infection cause cancer?
N0
Can a woman with HSV-2 infection deliver vaginally if she has no signs of herpetic lesions or prodrome at the onset of labor?
Yes
Approximately how many types of HPV can infect the genital tract?
More than 30 types of HPV are sexually transmitted
Genital HPV types are divided into two groups based on their association with_____________?
Cervical cancer
What are the two types of HPV infection classification?
Low-risk and high risk
Do low risk types of HPV cause cervical cancer?
No
Which type of HPV cause genital warts?
Low-risk HPV (6 and 11)
Which HPV types are considered high risk or oncogenic?
16, 18, 31, 33, 35, 39, 45
Is it true that most genital HPV infections (high risk or low risk) are transient, asymptomatic, and have no clinical consequences?
Yes, most HPV infections go away on their own
Is HPV a reportable condition?
No, however genital warts are reportable in some states
What approximate percentage of the population acquire genital HPV infection at some point in their lives?
50-80%
Can HPV be transmitted by fomites?
Fomite transmission of HPV has never been documented
Is HPV more likely to be detected in HIV-infected individuals?
Immune-suppressed individuals are at higher risk of infection with HPV
What are other risk factors for genital HPV infection?
Smoking, oral contraceptive use, poor nutrition and lack of circumcision of male partners
Which of the HPV types are oncogenic and account for more than half of the HPV types found in anogenital cancer?
HPV types 16 and 18
Which of the HPV types cause visible genital warts?
HPV types 6 and 11
Do visible genital HPV warts cause cancer?
No
Most women with an effective immune response will clear a new cervical HPV infection in approximately__________years?
2
What is the most important risk factor for precancerous (high-grade) cervical cell changes and cervical cancer in women with HPV infection?
HPV infection that persists
What are the factors associated with persistent HPV infection?
Older age, high-risk HPV types, and immune suppression
Recurrent respiratory papillomatosis is a rare condition of respiratory tract warts in a baby due to HPV transmitted during delivery. Which type of HPV is associated with this condition?
HPV types 6 and 11
Where do genital warts most commonly appear?
In areas of coital friction
Can HPV types causing genital warts cause lesions on oral, upper GI, and ocular locations?
Yes
How is the diagnosis of genital warts usually made?
By visual inspection
Is colposcopy recommended if genital warts are present?
No
Should you screen for other STIs in patients with newly diagnosed genital warts?
Yes
Can genital warts recur once they are treated?
There is a 20-50% recurrence rate at 3-6 months after treatment
Why should genital warts in preadolescent children be evaluated?
There is a likelihood of sexual abuse
How do you detect cervical cell abnormalities caused by HPV infection?
By Pap test, colposcopy, or biopsy
What are the Bethesda System classifications of cervical cellular abnormalities?
ASC-US, ASC-H, LSIL, HSIL
Which of the above classifications is associated with a persistent infection with a high-risk HPV and has a higher risk for progression to cervical cancer?
High-grade squamous intraepithelial lesion (HSIL)
Risk factors that increase the risk of developing cervical cancer include all of the following except: Early age of first intercourse (16 years or younger), multiple partners, active or passive smoking, long term use of oral contraceptives, high number of pregnancies, immune suppression and co-infection with other STIs.
All of these increase the risk of cervical cancer
Most women with high-risk HPV types have (normal or abnormal) Pap test results?
Normal
What is the definitive diagnosis of HPV?
HPV DNA testing of cells scraped from the surface of the cervix
When is colposcopy or biopsy indicated?
When lesions are visible on the cervix or Pap is HSIL
What is one of the CDC-recommended patient applied regimens for external genital warts?
Podofilox 0.5% bid for 4 days, skip 4 days, and repeat for up to 4 cycles
Is there a limit on the amount of podofilox that can be used daily?
Use no more that 0.5mL per day
Imiquimod 5% cream (Aldara) is used 3 times a week for up to 16 weeks to treat genital warts. The patient should be instructed to wash the area with soap and water ______hours after the daily treatment?
6-10
Can Imiquimod or podofilox be used to treat genital warts during pregnancy?
No
Provider-administered regimens for external genital warts include_________?
Cryotherapy, podophyllin resin, trichloroacetic acid or surgical removal
Does a woman with genital warts need to increase the frequency of Pap testing?
No
Are condoms effective in preventing transmission of genital HPV infection?
Condoms can decrease but not prevent transmission
Does treating genital warts reduce infectivity?
It is not known
Which vaccine has been shown to decrease the risk of cervical cancer?
Gardasil
Which type of HPV does Gardasil confer protection?
HPV types 6, 11, 16, and 18
Is Gardasil approved in males?
Yes
Does Gardasil protect from genital warts?
It confers protection against 90% of genital warts cases
At what age is it recommended to give Gardasil?
Girls and boys as young as 9 can get vaccinated
What is the schedule for vaccination with Gardasil?
Given intramuscularly at 0, 2 and 6 months
How long should you observe a patient for syncope after administration of Gardasil?
15 minutes
Can Gardasil be given during pregnancy?
Safety during pregnancy has not been established
Is chlamydia a reportable infection?
Chlamydia is reportable in all 50 states
The rate of chlamydia among African Americans is (higher or lower) than the rate among whites?
The rate of chlamydia is about 8 times higher in African Americans
Why are adolescent females more susceptible to chlamydia?
Risky sexual behavior and cervical ectopy are risk factors
What is cervical ectopy?
The presence of columnar epithelial cells present in younger females
Why are adolescents using oral contraceptives at higher risk for chlamydia infections?
Oral contraceptives contribute to cervical ectopy
When there is vertical transmission of chlamydia (perinatal), exposed babies can contract____________?
Conjunctivitis and pneumonia
Do individuals with chlamydia infection have symptoms?
Greater than 50% are asymptomatic
Describe the clinical manifestations of chlamydia (if present).
Mucopurulent, mucoid or clear urethral discharge, and dysuria
What are the uncommon complications in men with chlamydia infections?
Epididymitis, and Reiter’s syndrome (rare)
What are the clinical manifestations of epididymitis?
Fever, scrotal and epididymal pain and swelling
What are the characteristic manifestations of Reiter’s syndrome?
Conjunctivitis, urethritis, oligoarthritis, and skin lesions
When present, what are some of the signs and symptoms of cervicitis due to chlamydia?
Mucopurulent endocervical discharge, edema, erythema, and cervical friability
Can women with chlamydia infections be distinguished from uninfected women by clinical examination?
No
Is the Pap test a sensitive or specific indicator of chlamydial infection?
No
Can women with chlamydia have dysuria?
Yes, 50% of women have chlamydia in both the cervix and urethra
What are some of the complications from chlamydia infection in women?
How does conjunctivitis result from chlamydia infection?
Autoinoculation from infected genitalia
Are the new nucleic acid amplification tests (NAATs) that use swabs or urine samples sensitive and specific
Yes
What is the CDC recommendation for treatment of chlamydia?
Azithromycin 1 g orally in a single dose, OR
Doxycycline 100 mg orally twice daily for 7 days
A pregnant woman with chlamydia could be treated with_________?
Azithromycin 1 g orally in a single dose, OR
Amoxicillin 500 mg orally 3 times a day for 7 days
Can doxycycline be used to treat chlamydial infections in pregnant women?
No, doxycycline is not used in pregnancy
When would you need to retest a pregnant woman who was treated for chlamydia?
Three weeks after completion of therapy
Do you need to retest all women after treatment for chlamydia?
Yes, retest at 3-4 months for reinfection
Does screening for chlamydia reduce the incidence of PID?
Yes, by more than 50%
How often should sexually active women age 25 years and under should be screened for chlamydia?
Annually
When are pregnant women screened for chlamydia?
At the first prenatal visit and in the 3rd trimester if <25 years old or at increased risk
Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the __________ days preceding the onset of symptoms or diagnosis of chlamydia?
60
Patients should be advised to abstain from sexual intercourse until partners are treated and for _________ days after a single dose of azithromycin or until completion of a_________day regimen.
7
Does the CDC recommend treating patient’s with cervicitis for both chlamydia and gonorrhea?
yes
Are women with a history of STIs at higher risk for ectopic pregnancies?
yes
Which region of the U.S. has the highest rates of gonorrhea (GC)?
Southeast U.S.
What type of organism is Neisseria gonorrhea?
Gram-negative diplococcus
What are the screening recommendations for GC?
Screen sexually active girls and women < 25 years of age annually
Is it recommended to screen pregnant women for GC?
Yes
Is it recommended to screen men who have sex with men (MSM) for STIs?
Yes
Are patients with gonorrhea more susceptible to HIV?
Yes
What are the potential complications from GC in women?
Infertility, ectopic pregnancy, and chronic pelvic pain
What are the clinical manifestations of GC in men?
Urethritis, epididymitis, purulent or clear or cloudy discharge, and dysuria
Is it possible to be asymptomatic with a GC infection?
10% of males with GC are asymptomatic
What are the non specific manifestations of GC cervicitis in women?
Mucopurulent or purulent cervical discharge, and easily induced cervical bleeding (friability)
Is it possible to be asymptomatic when cervicitis is present?
Yes, 50% of women with clinical cervicitis have no symptoms
What are the potential complications from GC infections in women?
Accessory gland infection, PID, and perihepatitis
What other parts of the body can become infected with GC?
Rectum, pharynx, eyes and the blood
What are the clinical manifestations of disseminated gonococcal infection?
Skin lesions, arthralgias, arthritis, hepatitis, myocarditis, endocarditis, and meningitis
How is GC diagnosed if sexual abuse is suspected?
Culture is the legal standard
Why is it important to treat for both GC and chlamydia?
There is a high rate of coinfection
What is the recommended treatment for GC?
Ceftriaxone (Rocephin) 250 mg IM X 1 and 1 gram of azithromycin
Why are ceftriaxone and azithromycin recommended for the treatment of GC
Using both antibiotics decreases the incidence of resitant organisms
Can you use an oral agent to treat GC?
Cefixime (Suprax) 400 X 1 and azithromycin together
Are fluoroquinolones recommended for gonorrhea therapy in the U.S?
No
Do you need to perform a “test of cure” after treatment of chlamydia or GC?
Yes, new recommendations include a retest at 3 months
What is expedited partner treatment (EPT)?
Providing medication or prescription for partners of infected patients
Can you provide EPT in the state of Florida?
No
When can sexual partners resume activity after being diagnosed with GC?
When therapy is completed and both partners no longer have symptoms
Syphilis (Treponema pallidum) remains an important problem in the southern region of the U.S. and areas where there are large populations of_____________?
Men who have sex with men (MSM)
Can you culture the organism that causes syphilis?
It can not be cultured in vitro or seen by normal light microscopy
What is the painless skin lesion produced by the primary syphilis infection?
Chancre
What is the progression of the chancre?
Macule→ papule→ ulcer→spontaneous healing in 1-6 weeks
Are serologic tests for syphilis positive during early primary infection of syphilis?
Not always
Serologic test are the highest during the (primary or secondary) stages of syphilis?
Secondary
In the secondary stage of syphilis a___________appears in 75-100% of the cases?
Rash
Describe a syphilitic rash.
Nonpruritic macular, papular rash, may appear on the palms and soles
What are other clinical manifestations of secondary syphilis?
Lymphadenopathy, malaise, mucous patches, wart-like papules, and alopecia
Does neurosyphilis occur during the primary or secondary stage of syphilis?
T. pallidum can invade the CNS at any of the stages
What are the clinical manifestations of neurosyphilis?
Paresis, cranial nerve involvement, tabes dorsales, stroke-like symptoms with seizure
____________ is a syphilitic myelopathy complication of untreated syphilis that involves muscle weakness and abnormal sensations. It consists of abnormal sensations, often called "lightning pains", difficulty walking, loss of coordination, loss of reflexes, muscle weakness and wide-based gait (the person walks with the legs far apart).
Tabes dorsales
What are gummas lesions?
Lesions that occur in late syphilis which destroy tissue, cartilage and bone
Why is it important to do a neurological exam in a patient with syphilis?
CN II, III, VI, VII, and VIII can be affected in neurosyphilis
Why is it important to examine the abdomen in a patient with syphilis?
Liver evolvement with late syphilis can cause liver tenderness or splenomegaly
Which type of syphilis looks similar to genital warts caused by HPV?
Condylomata lata occurs in late syphilis
What are some of the lab tests used to diagnosis syphilis?
VDRL, RPR, FTA-ABS
Is it adequate to diagnose syphilis from a VRDL or RPR (nontreponemal) test?
A treponemal test such as FTA-ABS or TP-PA is needed for confirmation
What are some of the disorders that can cause false positive serologic tests for syphilis?
Patients with late syphilis that have neurological or ophthalmic signs should have evaluation of the__________?
Cerebral spinal fluid (CSF)
What is the treatment for primary, secondary, or early late syphilis?
Benzathine penicillin G. 2.4 units IM in a single dose
How would you treat a patient with syphilis that was allergic to PCN?
Doxycycline 100 mg bid for 14 days
What is the treatment for latent syphilis?
Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals
What is the follow up for syphilis infections?
Reexamine at 6 months with follow up titers
What are the indicators of treatment failure with syphilis?
Persistent or recurring symptoms, sustained 4 fold increase in titers, no drop in titers
When should pregnant women be screened?
At the beginning and near end of term
Why should you test for syphilis in women with stillbirth deliveries?
Syphilis in utero can cause fetal demise
Is it true that patients with syphilis should be advised that they may have positive treponemal and nontreponemal serologic tests for life?
Yes
Can douching be a risk factor for PID?
Yes
Most cases of PID are polymicrobial. What are the most common pathogens?
N. gonorrhoeae: recovered from cervix in 30%-80% of women with PID
C. trachomatis: recovered from cervix in 20%-40% of women with PID
N. gonorrhoeae and C. trachomatis are present in combination in approximately 25%-75% of patients
Approximately 25% of women with a single episode of PID will experience sequelae. Describe the sequelae.
Ectopic pregnancy, infertility, or chronic pelvic pain
A woman with 3 episodes of PID has a _________% chance of becoming infertile due to the infection?
50%
What are the diagnostic criteria for PID?
Uterine tenderness, or adnexal tenderness, or cervical motion tenderness
What is one of the CDC-recommended treatments for PID?
Cetriaxone 250 mg IM in a single dose, PLUS doxycycline 100 mg orally 2 times a day for 14 days ,with or without metronidazole 500 mg orally 2 times a day for 14 days
When would hospitalization be necessary for treatment of PID
Severe illness, nausea and vomiting, high fever or tubo-ovarian abscess
Should pregnant women and patients with HIV infection with low CD4 counts who have PID be hospitalized?
Yes
Patients treated for PID should demonstrate substantial improvement within _______ hours?
72
Do you need to rescreen patients treated for PID?
Rescreening is recommended at 4-6 weeks
Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the________ days preceding the patient’s onset of symptoms.
60
How long is the oral treatment for PID?
14 days
It is important to continue parenteral antibiotics for PID for at least 24 hours after substantial clinical improvement occurs and also to complete a total of_________ days therapy with oral agents
14
Vaginitis is characterized by________?
Vaginal discharge, vulvar itching, irritation, and odor
What are the three most common types of vaginitis?
Bacterial vaginosis (40%-45%), vulvovaginal candidiasis (20%-25%), and trichomoniasis (15%-20%)
Is bacterial vaginosis (BV) currently considered a sexually transmitted disease?
No, but acquisition appears to be related to sexual activity
Does douching increase the risk of BV?
Yes
Which organism in the vagina keeps the pH acidic and inhibits the growth of other bacterial species?
Lactobacilli
BV correlates with a decrease or loss of protective_______?
Lactobacilli
Signs/symptoms of___________when present include: malodorous (fishy smelling) vaginal discharge, reported more commonly after vaginal intercourse and after completion of menses.
BV
The presence of “clue cells” is one of the diagnostic criteria for__________?
BV
What are clue cells?
Bacteria clumping upon the borders of epithelial cells obscuring the borders of the epithelial cell
What is the normal pH of the vagina?
3.8-4.2
The vaginal pH in a patient with BV or trichomoniasis is (higher or lower) than normal?
Higher (greater that 4.5)
The “whiff” test is the liberation of biologic amines with or without the addition of 10% KOH and is diagnostic of___________?
BV
Why do women with BV notice excess odor during coitus?
Coitus can liberate the biologic amines to create the odor
What is one of the CDC recommended treatments for BV?
Metronidazole 500 mg orally twice a day for 7 days, OR metronidazole gel 0.75%, daily for 5 days
Should pregnant women be treated for BV?
Yes, and screening is also recommended during pregnancy
Is therapy recommended for male partners of women with BV?
No
Should female partners of women with BV be treated?
Yes, if BV is present
Can BV recur?
The recurrence rate is 20%-40% after one month
Does data support yogurt therapy or exogenous oral lactobacillus treatment for BV?
No
Should women be screened and treated for BV prior to surgical abortion or hysterectomy?
Yes
Vulvovaginal Candidiasis (VVC) is caused by overgrowth of_______?
