CASE SYNTHESIS

REPRO Module Case 1

QUIAPO, Ivy Concepcion B.
02-09-17

DR. ALEX DY
Preceptor
 ID:PT, 34 y/o,
male, married, life
guard from Anislag, Pertinent Data:
Daraga Age: Age-specific diseases; sexually active
period; middle-adulthood period
Gender: Gender-specific diseases
Married: one partner? Multiple partner?
Partner in the last 3 months? Sexual activity?
Work: Nature of work? Shifting? Hygienic
practices?
 OPQRST
Onset? When did it started? How frequent
CC: Penile was it? Is it continuous or intermittent?
Discharge of 2 Palliative and provocative factors? When
does it gets worst?
weeks duration What are the characteristics of the penile
discharge? What is its color, composition,
appearance and odor?
DDx: Is it painful? If yes, does it radiate to any
part of your body? Are there any
Urethritis or related
associated symptoms?
diseases (STD)
In a pain scale, how will you rate the pain?
When did it started? Did it start abruptly
or in progression? During when does it
appear?
HPI
2 weeks: pain upon
urination;
clear to yellowish
penile discharge;
drinks 2-3 L of DDx
water
Urethritis and related
1 day: thick and diseases
yellowish to Gonorrhea
greenish discharge; Chlamydia
(-) testiclular pain
1 month: (+) dysuria; (-)
fever, flank
pain, tea colored
urine

PMH
(-) HPN, DM, BA
S/P tonsillectomy (2012) Hx of trauma or accidents?
adult? What age?
UTI (Jan 2012)
Data Needed:
What are the symptoms
experienced in UTI last
2012?
Hx of chilhood illnesses (eg,
mumps)?
Screening tests?
Psych hx?
Recurrent tonsilitis might
be a sign of infection (STD)
Family Hx Data Needed
(+) HPN, DM both sides Previous STD?
Contact with known STD?
Social Hx
Partners, need to be tested
(+) smoking 2-5/day x 5yrs = 1.25 Unprotected sex
pack years MSM
Occasional alcoholic beverage Sexual activities: oral,
drinker
genital, anal?
Lifeguard for 8 years
Married for 3 years Nature of work?
Several female sexual partners
(2016)
Denies relationship with same sex
Denies practice with oral sex
PE:
VS: BP: 120/80 HR: 86 Normal
RR: 16cpm Temp: 37.7 C

HEENT:
DDx:
(+) aphthous ulcer 5cm in diameter,
right buccal mucosa Syphilis
(+) penile discharge (thick yellowish) Gonorrhea
(+) scrotal tenderness
(+) palpable lymph nodes on the
inguinal area, bilateral
U/A:
INFECTION
Lt. yellow
Pus cells 10-15/hpf
RBC 0-13
Sp. Gravity 1.030
Protein none

DDx:
Grams stain of discharge:
- Gonorrhea
(+) gram negative diplococci
RPR & VDRL
- Awaiting result
Rx:
1. Ceftriaxone 250mg/IM as single dose
2. Azithromycin 500mg/cap, 1 cap OD x 3 doses
Sexually Transmitted
Diseases (STD)
Initial rate of spread of any STI Efforts to prevent and control STIs
within a population: aim to:

1. rate of sexual exposure of 1. decrease the rate of sexual

susceptible to infectious exposure of susceptibles to
people infected persons

2. efficiency of transmission 2. to decrease the duration of

per exposure infectivity

3. duration of infectivity of 3. to decrease the efficiency of

those infected transmission
Sexually transmitted herpes
simplex virus (HSV)
infections now CAUSE MOST
GENITAL ULCER DISEASE
throughout the world Ongoing epidemic of
methamphetamine use,
gonorrhea, syphilis, and
Genital HPV remains the MOST
chlamydial infection have had
COMMON SEXUALLY
a remarkable resurgence
TRANSMITTED PATHOGEN in the
among MSM in North
US
America and Europe

Chlamydia trachomatis
infection has been increasing
steadily (MSM and African
Americans)
 MANAGEMENT OF COMMON SEXUALLY
TRANSMITTED DISEASE (STD) SYNDROME

1.Risk assessment
2.Clinical assessment
3.Diagnostic testing or screening
4.Treatment
5.Prevention
 MANAGEMENT OF COMMON SEXUALLY
TRANSMITTED DISEASE (STD) SYNDROME

RISK ASSESSMENT
guides detection and interpretation of symptoms that could
reflect an STD
decisions on screening or prophylactic/preventive
treatment
risk reduction counseling and intervention (e.g., hepatitis B
vaccination)
treatment of partners of patients with known infections
 MANAGEMENT OF COMMON SEXUALLY
TRANSMITTED DISEASE (STD) SYNDROME

CLINICAL ASSESSMENT
elicitation of information on specific current symptoms and signs of STDs
Confirmatory diagnostic tests
for persons with symptoms or signs
Screening tests
for those without symptoms or signs
 MANAGEMENT OF COMMON SEXUALLY
TRANSMITTED DISEASE (STD) SYNDROME
CLINICAL ASSESSMENT Grams stain of
urethral discharge for
men with urethral
microscopic examination discharge
culture Rapid plasma reagin
antigen detection tests test for genital ulcer
nucleic acid amplification tests
(NAATs) 4 Cs of prevention and control:
Contact tracing
serology
Ensuring compliance with
therapy
All adults should be screened for Counseling on risk reduction
infection with HIV-1 at least once Condom promotion and provision
and more frequently
URETHRITIS IN MEN
 URETHRITIS IN MEN

produces urethral discharge, dysuria, or both,

usually without frequency of urination

Causes include Neisseria gonorrhoeae, C. trachomatis,

Mycoplasma genitalium, Ureaplasma urealyticum,
Trichomonas vaginalis, HSV, and adenovirus
C. trachomatis caused ~3040% of cases of
nongonococcal urethritis (NGU), particularly in
heterosexual men

Coliform bacteria can cause urethritis in men

who practice insertive anal intercourse.
 APPROACH TO PATIENT

1. Establish the presence of 2. Evaluate for complications or

urethritis.
a Grams-stained smear of an
anterior urethral specimen
obtained by passage of a small
urethrogenital swab 23 cm into
the urethra
reveals 5 neutrophils per 1000
field in areas containing cells
alternative diagnoses
r/o epididymitis and systemic
complications, such as
disseminated gonococcal
infection (DGI) and reactive
arthritis
 APPROACH TO PATIENT
3. Evaluate for gonococcal and
chlamydial infection.
Absence of typical gram-
negative diplococci on Grams-
stained smear of urethral
exudate containing
inflammatory cells
warrants a preliminary
diagnosis of NGU
4. Treat urethritis promptly while test results
are pending.
Azithromycin or doxycyclin
if Grams stain does not reveal gonococci,
urethritis is treated with a regimen effective
for NGU
Parenteral cephalosporin therapy & oral
azithromycin
If gonococci are demonstrated by Grams stain
or if no diagnostic tests are performed to
exclude gonorrhea definitively
 DIFFERENTIAL DIAGNOSIS

CHLAMYDIA GONORRHEA

SYPHILIS
Chlamydia
 ETIOLOGIC AGENTS: Chlamydiae
Obligate intracellular bacteria: cannot reproduce outside their host cell

C. trachomatis C. pneumoniae C. psittaci C. pecorum

Produces compact Produces Produces

intracytoplasmic intracytoplasmic intracytoplasmic
inclusions that lack inclusions that lack inclusions that lack
glycogen; inhibited by glycogen; resistant to glycogen; resistant to
sulfonamides sulfonamides sulfonamides

Lympogranuloma C. psittaci
Trachoma
venereum (LGV) C. felis
Occular
Infection of C. abortus
trachoma
Urogenital lymphatics
and lymph
infections
nodes
 Chlamydia trachomatis INFECTIONS:
CLINICAL MANIFESTATION
NONGONOCOCCAL AND POSTGONOCOCCAL URETHRITIS

Etiology: C. trachomatis most common cause of NGU and PGU

*Ureaplasma urealyticum, Mycoplasma genitalium, Trichomonas vaginalis, Herpes simplex virus other causes
Risk factor: young age
Prevalence: highest at 20-24y/o; less among men who have sex with men (MSM) vs heterosexual
Symptoms: urethral discharge (whitish, mucoid), dysuria, urethral itching
Physical Examination: meatal erythema and tenderness
Diagnosis: documentation of leukocytic urethral exudate; exclusion of Gonorrhea by Gram staining or culture
Laboratory Tests: pyuria (15 leukocytes/400x microscopic field)
(+) leukocyte esterase test
increased leukocytes (Gram-stained smear from urogenital swab 1-2cm into the anterior urethra)
Treatment regimen: Combination therapy with tetracycline, doxocycline or azithromycin
Gonorrhea
 TREATMENT: Chlamydia
Treatment (uncomplicated
chlamydial infections) (7 Pregnancy
days) Amoxicillin (7
days)
Tetracycline
CONS 500mg TID
500mg QID Other
Expensive
Doxycycline flouroquinolon
PROS
CI for
100mg BID es are CI
As effective as pregnancy
Erythromycin
Erythromycin
500mg QID Fewer GI
Azythromycin reactions
1g OD For poor
compliance
Flouroquinolone
For sexual
Ofloxacin 300mg BID partners of Drug resistance is not
Levofloxacin 500mg OD infected pts observed in C. trachomatis
 GONORRHEA: CLINICAL MANIFESTATION
Discharge:
Initially: scant and
Major Symptom: mucoid
Urethral discharge 2-3 days: profuse
ACUTE and dysuria, usually and purulent
URETHRITIS: most without urinary
common clinical frequency or urgency
manifestation of Grams staining:
gonorrhea in men PMNs and gram-
Strains of the PorB.1A negative intracellular
serotype: mild and monococci and
asymptomatic diplococci
Incubation urethritis > PorB.1B
period: 27 strains
days
 GONORRHEA: LABORATORY DIAGNOSIS

Men: Grams staining of urethral exudates

highly specific and sensitive in males
only ~50% sensitive in diagnosing gonococcal cervicitis
samples: Dacron or rayon swabs
inoculated onto a Thayer-Martin or other gonococcal selective
medium for culture
process all samples immediately (gonococci dont tolerate
drying)
Stuart or Amies medium (within 6 h)
CM with self-contained CO2-generating systems (such as the
JEMBEC or Gono-Pak systems) (for longer holding periods)
GONORRHEA: TREATMENT
GONORRHEA: LABORATORY DIAGNOSIS
 Syphilis
chronic systemic infection caused by
Treponema pallidum subspecies pallidum
 SYPHILIS: NATURAL COURSE
Penetrates intact Course of the disease
mucous membrane Blood from a patient with
Microscopic abrasion in
skin incubating or early syphilis
INFECTIOUS
Generation time - ~30 hours
Enter lymphatics and
blood Incubation period inversely
proportional to number of
organisms inoculated
Systemic infection and 107/g before clinically lesion
metastatic lesion long
before the appearance appears
of primary lesion Median incubation period - ~21
days (500 1000 inoculum)
SYPHILIS: PATHOGENESIS AND CLINICAL COURSE
 SYPHILIS: CLINICAL MANIFESTATIONS
PRIMARY SYPHILIS
PRIMARY CHANCRE

single painless papule that

rapidly becomes eroded and
usually becomes indurated,
cartilaginous consistency on
palpation of the edge of the
base of the ulcer (hard chancre)
Heterosexual penis
MSM anal canal, rectum,
mouth, external genitalia
Women cervix and labia
Heals within 4-6 weeks (range 2-
12 weeks)
 SYPHILIS: CLINICAL MANIFESTATIONS
PRIMARY SYPHILIS
Haemophilus
CHANCROID
Treponema CHANCROID
ducreyi
pallidum Painful
Painless
Typically multiple
Typically single
Regional
Regional
uniateral
bilateral
lymphadenopath
lymphadenopat
y
hy Soft chancre
Hard chancre
soft based with
hard base with
undermined
sloping edges
edges
Heals
SYPHILIS: CLINICAL MANIFESTATIONS
SECONDARY SYPHILIS
6 8 weeks after the chancre heals

(although primary and secondary
may overlap)
Some may enter latent stage without
secondary lesions
May also be found in aqueous humor
and CSF
Invades the CNS during the first
weeks or months (detected CSF
abnormalities in the secondary
syphilis)
Secondary manifestations despite
high antibodies immune evasion
 SYPHILIS: CLINICAL MANIFESTATIONS
SECONDARY SYPHILIS
MUCOCUTANEOUS LESIONS
Macular, papular, papulosquamous,
and occasionaly pustular syphilides
Pale red or pink, nonpuritic discrete
macules on trunk and proximal areas
papular lesions distributed widely
that frequently involve palms and
soles
Lues maligna severe necrotic lesions
HIV-infected individuals
CONDYLOMATA
Involvement ofLATA
hair follicles patchy
alopecia
Broad, moist, pink or gray-white,
highly infectious lesions
Warm, moist, intertriginous areas
(perianal, vulva, scrotum)
 SYPHILIS: CLINICAL MANIFESTATIONS
TERTIARY (LATE) SYPHILIS

Late benign syphilis

(gumma)
granulomatous lesion
Cardiovascular syphilis
involving vasa
vasorum of the
ascending aorta and
resulting in aneurysm;
MOST COMMON cause
of death
 TREATMENT: Syphilis

DRUG OF CHOICE (ALL STAGES): PENICILLIN G

long exposure d/t slow rate of multiplication
no evidence of penicillin resistance in T. pallidum

Other effective anibiotics:

Tetracyclines & Cephalosporins

Aminoglycosides & Spectinomycin: inhibit T.

pallidum in very large doses

Azithromycin: effective oral agent and requires

careful follow-up
 TREATMENT: Syphilis

SECONDARYSYP TERTIARY (LATE)

EARLY SYPHILIS
HILIS SYPHILIS
MOST WIDELY USED FOR CSF EXAM SHOULD BE DONE
CSF NORMAL/NOT
EARLY SYPHILIS:
PENICILLIN G BENZATHINE EXAMINED: CSF NORMAL:
Penicillin G
Penicillin G
Benzathine
Single dose: 2.4m units
recommended
Benzathine
CSF ABNORMAL:
Preventive Treatment: Treatment for neurosyphillis
pts exposed to infectious
syphilis w/in 3 mos CSF ABNORMAL:
Clinical Responses
95% effective; clinical Treatment for
relapse may occur (HIV)
HIV patients: CSF Exam
neurosyphillis Benign Tertiary Syphilis: good

recommended esp w/ CD4+ CV Syphilis: poor d/t aortic
T cell count of 350 /L aneurysm and aortic regurgitation--
cannot be reversed by antibiotics
 TREATMENT: Syphilis

ASYMPTOMATIC/SYMPTOMATIC
NEUROSYPHILIS:
AQUEOUS PENICILLIN

Penicillin allergy:
ASYMPTOMATIC/SYM Penicillin G Benzathine: no detectable
Skin Testing
PTOMATIC concentrations in CSF and SHOULD NOT Desensitization
NEUROSYPHILIS: BE GIVEN FOR NEUROSYPHILIS Treatment w/
AQUEOUS
PENICILLIN AsymptomaticNeurosyphilis: may Penicillin
relapse--higher in pts w/ HIV
Menigeal Syphilis: treatment w/ penicillin
is good but if w/ existing parenchymal
damage, arrest dse progression
Ceftriaxone may be used
 DIFFERENTIAL DIAGNOSIS

CHLAMYDIA GONORRHEA

SYPHILIS