1. Can HSV-1 cause the first episode of genital herpes?
    Yes, however, the majority of infections is due to HSV-2
  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?
  3. What is fomite transmission?
    This route requires an inanimate object to carry a pathogen from one susceptible animal to another.
  4. Is fomite transmission likely to occur with HSV?
    Unlikely because soap and water inactivates HSV
  5. HSV remains latent in the paraspinous ganglia and is reactivated by________?
    Trauma, fever, ultraviolet light, stress, and unknown factors
  6. 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
  7. 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?
  8. Primary infections with HSV-2 tend to be moderate to severe and the herpetic lesions are often (bilateral or unilateral)?
  9. How do the lesions progress in an HSV infection?
  10. Describe the systemic manifestations that can occur with an initial HSV-2 infection.
    Fever, headache, malaise, myalgia, & urinary retention in women
  11. What are the local symptoms of an initial infection with HSV-2?
    Pain, itching, dysuria, vaginal discharge, and adenopathy
  12. What percent of patient with an initial acquisition of HSV-2 have inguinal adenopathy?
    80% have firm, nonfluctuant tender nodes
  13. How long do the genital lesions from an initial HSV-2 infection persist?
    On average 11-12 days
  14. Can HSV-2 infection cause dysuria?
    Yes, 80% of women report dysuria
  15. Describe the prodrome for a recurrent HSV-2 infection
    Localized tingling and irritation
  16. Are recurrent episodes of HSV-2 shorter than in a primary infection?
    Yes. The lesion lasts 4-6 days with milder symptoms
  17. What percentage of patients with a symptomatic HSV-2 infection will have a recurrence in the first 12 months of infection
  18. How many occurrences would you expect in the first year of HSV-2 infection?
    The median recurrence rate is 4.5 per year
  19. Is it true that the frequency of recurrences of HSV-2 decreases over time?
  20. Does antiviral suppressive therapy eradicate viral HSV-2 shedding?
    No, however, it dramatically reduces viral shedding
  21. Is screening for HSV-1 or HSV-2 in the general population indicated?
  22. What is the preferred test for HSV if lesions are present?
    Viral culture
  23. All patients with genital ulcers should be tested for__________?
  24. What drugs are used to treat HSV?
    Acyclovir, valacyclovir, famciclovir
  25. Is topical treatment of HSV recommended?
  26. 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
  27. Suppressive therapy can reduce the frequency of genital herpes recurrences by________%
  28. When would suppressive therapy for HSV-2 be suggested?
    With frequent recurrences (>6 per year)
  29. The dose for suppressive therapy of HSV-2 infection with valacyclovir is______?
    500 mg- 1000 mg daily
  30. Why is valacyclovir preferred in the management of HSV-2 infections?
    The dosing is less frequent and thus more convenient
  31. 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
  32. Can episodic treatment of HSV-2 shorten the duration of recurrent episodes?
    Yes if started within 1 day of lesion onset
  33. Do genital ulcers from HSV-2 infection increase the risk of HIV infection?
  34. Why is it important to ask women about HSV prior to delivery?
    HSV can be transmitted to the baby
  35. Can HSV-2 infection cause cancer?
  36. Can a woman with HSV-2 infection deliver vaginally if she has no signs of herpetic lesions or prodrome at the onset of labor?
  37. Approximately how many types of HPV can infect the genital tract?
    More than 30 types of HPV are sexually transmitted
  38. Genital HPV types are divided into two groups based on their association with_____________?
    Cervical cancer
  39. What are the two types of HPV infection classification?
    Low-risk and high risk
  40. Do low risk types of HPV cause cervical cancer?
  41. Which type of HPV cause genital warts?
    Low-risk HPV (6 and 11)
  42. Which HPV types are considered high risk or oncogenic?
    16, 18, 31, 33, 35, 39, 45
  43. 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
  44. Is HPV a reportable condition?
    No, however genital warts are reportable in some states
  45. What approximate percentage of the population acquire genital HPV infection at some point in their lives?
  46. Can HPV be transmitted by fomites?
    Fomite transmission of HPV has never been documented
  47. Is HPV more likely to be detected in HIV-infected individuals?
    Immune-suppressed individuals are at higher risk of infection with HPV
  48. What are other risk factors for genital HPV infection?
    Smoking, oral contraceptive use, poor nutrition and lack of circumcision of male partners
  49. 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
  50. Which of the HPV types cause visible genital warts?
    HPV types 6 and 11
  51. Do visible genital HPV warts cause cancer?
  52. Most women with an effective immune response will clear a new cervical HPV infection in approximately__________years?
  53. 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
  54. What are the factors associated with persistent HPV infection?
    Older age, high-risk HPV types, and immune suppression
  55. 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
  56. Where do genital warts most commonly appear?
    In areas of coital friction
  57. Can HPV types causing genital warts cause lesions on oral, upper GI, and ocular locations?
  58. How is the diagnosis of genital warts usually made?
    By visual inspection
  59. Is colposcopy recommended if genital warts are present?
  60. Should you screen for other STIs in patients with newly diagnosed genital warts?
  61. Can genital warts recur once they are treated?
    There is a 20-50% recurrence rate at 3-6 months after treatment
  62. Why should genital warts in preadolescent children be evaluated?
    There is a likelihood of sexual abuse
  63. How do you detect cervical cell abnormalities caused by HPV infection?
    By Pap test, colposcopy, or biopsy
  64. What are the Bethesda System classifications of cervical cellular abnormalities?
  65. 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)
  66. 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
  67. Most women with high-risk HPV types have (normal or abnormal) Pap test results?
  68. What is the definitive diagnosis of HPV?
    HPV DNA testing of cells scraped from the surface of the cervix
  69. When is colposcopy or biopsy indicated?
    When lesions are visible on the cervix or Pap is HSIL
  70. 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
  71. Is there a limit on the amount of podofilox that can be used daily?
    Use no more that 0.5mL per day
  72. 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?
  73. Can Imiquimod or podofilox be used to treat genital warts during pregnancy?
  74. Provider-administered regimens for external genital warts include_________?
    Cryotherapy, podophyllin resin, trichloroacetic acid or surgical removal
  75. Does a woman with genital warts need to increase the frequency of Pap testing?
  76. Are condoms effective in preventing transmission of genital HPV infection?
    Condoms can decrease but not prevent transmission
  77. Does treating genital warts reduce infectivity?
    It is not known
  78. Which vaccine has been shown to decrease the risk of cervical cancer?
  79. Which type of HPV does Gardasil confer protection?
    HPV types 6, 11, 16, and 18
  80. Is Gardasil approved in males?
  81. Does Gardasil protect from genital warts?
    It confers protection against 90% of genital warts cases
  82. At what age is it recommended to give Gardasil?
    Girls and boys as young as 9 can get vaccinated
  83. What is the schedule for vaccination with Gardasil?
    Given intramuscularly at 0, 2 and 6 months
  84. How long should you observe a patient for syncope after administration of Gardasil?
    15 minutes
  85. Can Gardasil be given during pregnancy?
    Safety during pregnancy has not been established
  86. Is chlamydia a reportable infection?
    Chlamydia is reportable in all 50 states
  87. 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
  88. Why are adolescent females more susceptible to chlamydia?
    Risky sexual behavior and cervical ectopy are risk factors
  89. What is cervical ectopy?
    The presence of columnar epithelial cells present in younger females
  90. Why are adolescents using oral contraceptives at higher risk for chlamydia infections?
    Oral contraceptives contribute to cervical ectopy
  91. When there is vertical transmission of chlamydia (perinatal), exposed babies can contract____________?
    Conjunctivitis and pneumonia
  92. Do individuals with chlamydia infection have symptoms?
    Greater than 50% are asymptomatic
  93. Describe the clinical manifestations of chlamydia (if present).
    Mucopurulent, mucoid or clear urethral discharge, and dysuria
  94. What are the uncommon complications in men with chlamydia infections?
    Epididymitis, and Reiter’s syndrome (rare)
  95. What are the clinical manifestations of epididymitis?
    Fever, scrotal and epididymal pain and swelling
  96. What are the characteristic manifestations of Reiter’s syndrome?
    Conjunctivitis, urethritis, oligoarthritis, and skin lesions
  97. When present, what are some of the signs and symptoms of cervicitis due to chlamydia?
    Mucopurulent endocervical discharge, edema, erythema, and cervical friability
  98. Can women with chlamydia infections be distinguished from uninfected women by clinical examination?
  99. Is the Pap test a sensitive or specific indicator of chlamydial infection?
  100. Can women with chlamydia have dysuria?
    Yes, 50% of women have chlamydia in both the cervix and urethra
  101. What are some of the complications from chlamydia infection in women?
    PID, endometritis, salpingitis, & perihepatitis (Fitz-Hugh-Curtis syndrome)
  102. How does conjunctivitis result from chlamydia infection?
    Autoinoculation from infected genitalia
  103. Are the new nucleic acid amplification tests (NAATs) that use swabs or urine samples sensitive and specific
  104. 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
  105. 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
  106. Can doxycycline be used to treat chlamydial infections in pregnant women?
    No, doxycycline is not used in pregnancy
  107. When would you need to retest a pregnant woman who was treated for chlamydia?
    Three weeks after completion of therapy
  108. Do you need to retest all women after treatment for chlamydia?
    Yes, retest at 3-4 months for reinfection
  109. Does screening for chlamydia reduce the incidence of PID?
    Yes, by more than 50%
  110. How often should sexually active women age 25 years and under should be screened for chlamydia?
  111. 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
  112. 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?
  113. 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.
  114. Does the CDC recommend treating patient’s with cervicitis for both chlamydia and gonorrhea?
  115. Are women with a history of STIs at higher risk for ectopic pregnancies?
  116. Which region of the U.S. has the highest rates of gonorrhea (GC)?
    Southeast U.S.
  117. What type of organism is Neisseria gonorrhea?
    Gram-negative diplococcus
  118. What are the screening recommendations for GC?
    Screen sexually active girls and women < 25 years of age annually
  119. Is it recommended to screen pregnant women for GC?
  120. Is it recommended to screen men who have sex with men (MSM) for STIs?
  121. Are patients with gonorrhea more susceptible to HIV?
  122. What are the potential complications from GC in women?
    Infertility, ectopic pregnancy, and chronic pelvic pain
  123. What are the clinical manifestations of GC in men?
    Urethritis, epididymitis, purulent or clear or cloudy discharge, and dysuria
  124. Is it possible to be asymptomatic with a GC infection?
    10% of males with GC are asymptomatic
  125. What are the non specific manifestations of GC cervicitis in women?
    Abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia
  126. What are the clinical findings of GC cervicitis?
    Mucopurulent or purulent cervical discharge, and easily induced cervical bleeding (friability)
  127. Is it possible to be asymptomatic when cervicitis is present?
    Yes, 50% of women with clinical cervicitis have no symptoms
  128. What are the potential complications from GC infections in women?
    Accessory gland infection, PID, and perihepatitis
  129. What other parts of the body can become infected with GC?
    Rectum, pharynx, eyes and the blood
  130. What are the clinical manifestations of disseminated gonococcal infection?
    Skin lesions, arthralgias, arthritis, hepatitis, myocarditis, endocarditis, and meningitis
  131. How is GC diagnosed if sexual abuse is suspected?
    Culture is the legal standard
  132. Why is it important to treat for both GC and chlamydia?
    There is a high rate of coinfection
  133. What is the recommended treatment for GC?
    Ceftriaxone (Rocephin) 250 mg IM X 1 and 1 gram of azithromycin
  134. Why are ceftriaxone and azithromycin recommended for the treatment of GC
    Using both antibiotics decreases the incidence of resitant organisms
  135. Can you use an oral agent to treat GC?
    Cefixime (Suprax) 400 X 1 and azithromycin together
  136. Are fluoroquinolones recommended for gonorrhea therapy in the U.S?
  137. Do you need to perform a “test of cure” after treatment of chlamydia or GC?
    Yes, new recommendations include a retest at 3 months
  138. What is expedited partner treatment (EPT)?
    Providing medication or prescription for partners of infected patients
  139. Can you provide EPT in the state of Florida?
  140. When can sexual partners resume activity after being diagnosed with GC?
    When therapy is completed and both partners no longer have symptoms
  141. 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)
  142. Can you culture the organism that causes syphilis?
    It can not be cultured in vitro or seen by normal light microscopy
  143. What is the painless skin lesion produced by the primary syphilis infection?
  144. What is the progression of the chancre?
    Macule→ papule→ ulcer→spontaneous healing in 1-6 weeks
  145. Are serologic tests for syphilis positive during early primary infection of syphilis?
    Not always
  146. Serologic test are the highest during the (primary or secondary) stages of syphilis?
  147. In the secondary stage of syphilis a___________appears in 75-100% of the cases?
  148. Describe a syphilitic rash.
    Nonpruritic macular, papular rash, may appear on the palms and soles
  149. What are other clinical manifestations of secondary syphilis?
    Lymphadenopathy, malaise, mucous patches, wart-like papules, and alopecia
  150. Does neurosyphilis occur during the primary or secondary stage of syphilis?
    T. pallidum can invade the CNS at any of the stages
  151. What are the clinical manifestations of neurosyphilis?
    Paresis, cranial nerve involvement, tabes dorsales, stroke-like symptoms with seizure
  152. ____________ 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
  153. What are gummas lesions?
    Lesions that occur in late syphilis which destroy tissue, cartilage and bone
  154. 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
  155. Why is it important to examine the abdomen in a patient with syphilis?
    Liver evolvement with late syphilis can cause liver tenderness or splenomegaly
  156. Which type of syphilis looks similar to genital warts caused by HPV?
    Condylomata lata occurs in late syphilis
  157. What are some of the lab tests used to diagnosis syphilis?
  158. 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
  159. What are some of the disorders that can cause false positive serologic tests for syphilis?
    Autoimmune disease, skin diseases, drug abuse, fever, malaria, pinta, yaws, pregnancy, recent immunizations
  160. Patients with late syphilis that have neurological or ophthalmic signs should have evaluation of the__________?
    Cerebral spinal fluid (CSF)
  161. What is the treatment for primary, secondary, or early late syphilis?
    Benzathine penicillin G. 2.4 units IM in a single dose
  162. How would you treat a patient with syphilis that was allergic to PCN?
    Doxycycline 100 mg bid for 14 days
  163. 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
  164. What is the follow up for syphilis infections?
    Reexamine at 6 months with follow up titers
  165. What are the indicators of treatment failure with syphilis?
    Persistent or recurring symptoms, sustained 4 fold increase in titers, no drop in titers
  166. When should pregnant women be screened?
    At the beginning and near end of term
  167. Why should you test for syphilis in women with stillbirth deliveries?
    Syphilis in utero can cause fetal demise
  168. Is it true that patients with syphilis should be advised that they may have positive treponemal and nontreponemal serologic tests for life?
  169. Can douching be a risk factor for PID?
  170. 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
  171. Approximately 25% of women with a single episode of PID will experience sequelae. Describe the sequelae.
    Ectopic pregnancy, infertility, or chronic pelvic pain
  172. A woman with 3 episodes of PID has a _________% chance of becoming infertile due to the infection?
  173. What are the diagnostic criteria for PID?
    Uterine tenderness, or adnexal tenderness, or cervical motion tenderness
  174. 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
  175. When would hospitalization be necessary for treatment of PID
    Severe illness, nausea and vomiting, high fever or tubo-ovarian abscess
  176. Should pregnant women and patients with HIV infection with low CD4 counts who have PID be hospitalized?
  177. Patients treated for PID should demonstrate substantial improvement within _______ hours?
  178. Do you need to rescreen patients treated for PID?
    Rescreening is recommended at 4-6 weeks
  179. 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.
  180. How long is the oral treatment for PID?
    14 days
  181. 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
  182. Vaginitis is characterized by________?
    Vaginal discharge, vulvar itching, irritation, and odor
  183. What are the three most common types of vaginitis?
    Bacterial vaginosis (40%-45%), vulvovaginal candidiasis (20%-25%), and trichomoniasis (15%-20%)
  184. Is bacterial vaginosis (BV) currently considered a sexually transmitted disease?
    No, but acquisition appears to be related to sexual activity
  185. Does douching increase the risk of BV?
  186. Which organism in the vagina keeps the pH acidic and inhibits the growth of other bacterial species?
  187. BV correlates with a decrease or loss of protective_______?
  188. Signs/symptoms of___________when present include: malodorous (fishy smelling) vaginal discharge, reported more commonly after vaginal intercourse and after completion of menses.
  189. The presence of “clue cells” is one of the diagnostic criteria for__________?
  190. What are clue cells?
    Bacteria clumping upon the borders of epithelial cells obscuring the borders of the epithelial cell
  191. What is the normal pH of the vagina?
  192. The vaginal pH in a patient with BV or trichomoniasis is (higher or lower) than normal?
    Higher (greater that 4.5)
  193. The “whiff” test is the liberation of biologic amines with or without the addition of 10% KOH and is diagnostic of___________?
  194. Why do women with BV notice excess odor during coitus?
    Coitus can liberate the biologic amines to create the odor
  195. 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
  196. Should pregnant women be treated for BV?
    Yes, and screening is also recommended during pregnancy
  197. Is therapy recommended for male partners of women with BV?
  198. Should female partners of women with BV be treated?
    Yes, if BV is present
  199. Can BV recur?
    The recurrence rate is 20%-40% after one month
  200. Does data support yogurt therapy or exogenous oral lactobacillus treatment for BV?
  201. Should women be screened and treated for BV prior to surgical abortion or hysterectomy?
  202. Vulvovaginal Candidiasis (VVC) is caused by overgrowth of_______?
    C. albicans and other non-albicans species
  203. Describe the discharge associated with VVC.
    Thick, white, curdy vaginal discharge ("cottage cheese-like")
  204. What can be seen on wet mount in a patient with VVC?
    Pseudohyphae (mycelia) and/or budding yeast (conidia) on KOH or saline wet prep
  205. Antifungal creams can be used for 3-7 days to treat VVC. What is the oral treatment for VCC?
    Fluconazole 150 mg oral tablet, 1 tablet in a single dose
  206. What is the recommended treatment for severe or recurrent VVC?
    100mg, 150 mg, or 200mg oral dose of fluconazole repeated 3 days later
  207. Can you treat a pregnant woman with oral fluconazole?
    No, it is contraindicated. Use the topical preparations
  208. Is VVC acquired through sexual intercourse?
  209. Is treatment of sex partners recommended in patients with VVC?
    No but it may be considered in women who have recurrent infection
  210. What measures can be done to reduce the incidence of VVC?
    Avoid douching, avoid unnecessary antibiotic use, and complete course of treatment
  211. Is trichomoniasis sexually transmitted?
  212. Cervical petechiae ("strawberry cervix") is a classic presentation and occurs in <2% of cases of____________?
  213. Trichomonas vaginalis is a flagellated anaerobic _________that infects the genital tract.
  214. A vaginal pH >4.5 is often present with trichomonas infection. Is this a (higher or lower) pH than normal?
  215. Describe the signs and symptoms of trichomoniasis in women.
    Frothy gray or yellow-green vaginal discharge and pruritus
  216. What is seen on the wet mount in patient’s with trichomoniasis?
    Motile trichomonads
  217. Is fomite transmission frequent with Trichomonas vaginalis?
    No, it is sexually transmitted
  218. What is one of the CDC recommended treatments for trichomonas?
    Metronidazole 2 g orally in a single dose OR tinidazole 2 g orally in a single dose
  219. Can metronidazole be used to treat trichomonas in pregnancy?
  220. Do sexual partners need to be treated in patients with trichomonas?
  221. Should patients with trichomonas be instructed to avoid sex until they and their sex partners are cured or asymptomatic?
  222. Can alcohol be consumed while taking metronidazole?
    No-vomiting will occur
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