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IM - Infectious Disease - GU and STDs

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tonystep1's version from 2017-08-08 04:35

INFECTIONS OF THE GENITOURINARY TRACT CLINICAL FEATURES

Question Answer
Lower Urinary Tract InfectionsDysuria-commonly expressed as burning on urination // Frequency // Urgency // Suprapubic tenderness // Gross hematuria is sometimes present // In lower UTis, fever is characteristically absent.
PyelonephritisFever, chills // Flank pain // Symptoms of cystitis (may or may not be present) // Nausea, vomiting, and diarrhea (sometimes present) // Fever with tachycardia // Patients generally appear more ill than patients with cystitis // Costovertebral angle tenderness-unilateral or bilateral //Abdominal tenderness may be present on examination.
Acute prostatitisFever, chills-Patients may appear toxic. // Irritative voiding symptoms-Dysuria, frequency, and urgency are common. // Perineal pain, low back pain, and urinary retention may be present as well.
Chronic prostatitisPatients may be asymptomatic. Patients do not appear ill. Fever is uncommon. // Patients frequently have recurrent UTls with irritative voiding and obstructive urinary symptoms // There is dull, poorly localized pain in the lower back, perineal, scrotal, or suprapubic region.
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DIAGNOSIS OF INFECTIONS OF THE GENITOURINARY TRACT

Question Answer
Dipstick urinalysis of UTIPositive urine leukocyte esterase test // Positive nitrite test for presence of bacteria (gram-negative)
Urinalysis Criteria for UTIBacteriuria: > l organism per oil-immersion field. Bacteriuria without WBCs may reflect contamination and is not a reliable indicator of infection // Pyuria: >8 WBC/HPF
Urine Gram stain for UTIA count of > 105 organisms/mL represents significant bacteriuria.
Urinary for PyleonephritisLook for pyuria, bacteriuria, and leukocyte casts. // hematuria and mild proteinuria may be present. //
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TREATMENT OF GENITOURINARY TRACT INFECTIONS

Question Answer
Acute uncomplicated cystitis-i.e., nonpregnant womenUse empiric treatment with oral TMP/SMX (Bactrim) for 3 days // if sulfa allergic use fluoroquinolone (ciprofloxacin) for 3 days is appropriate
Pregnant women with UTITreat with ampicillin, amoxicillin, or oral cephalosporins for 7 to 10 days. // Avoid fluoroquinolones (can cause fetal arthropathy)
UTis in menUse empiric treatment with oral TMP/SMX (Bactrim) for 3 days.
Recurrent UTIsIf relapse occurs within 2 weeks of cessation of treatment, continue treatment for 2 more weeks and obtain a urine culture // If the patient has more than two UTis per year, give chemoprophylaxis // Single dose of TMP/SMX after intercourse or at first signs of symptoms // Alternative low-dose prophylactic antibiotics, e.g., low-dose TMP/SMX, for 6 months
For uncomplicated pyelonephritisTMP/SMX or a fluoroquinolone for 10 to 14 days is effective for most gram negative rods // Amoxicillin is appropriate for gram-positive cocci (enterococci,S . saprophyticus).
For complicated pyelonephritisHospitalize the patient and give IV fluids. // Start with parenteral antibiotics (broad-spectrum) ampicillin plus gentamicin or ciprofloxacin are common initial choices.
Acute prostatitis if severe hospitalize the patient and initiate IV antibiotics.
Chronic prostatitisTreat with a fluoroquinolone. For chronic bacterial prostatitis, a prolonged course is recommended but does not guarantee complete eradication.
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SEXUALLY TRANSMITTED DISEASES (STDs) CLINICAL FEATURES

Question Answer
ChlamydiaMany cases are asymptomatic (80% of women, 50% of men). // Men who are symptomatic may have any of the following: dysuria,purulent urethral, discharge, scrotal pain and swelling, and fever // Women who are symptomatic may have purulent urethral discharge, intermenstrual or postcoital bleeding, and dysuria.
Gonorrhea in menGonorrhea is asymptomatic in up to 10% of carriers. These asymptomatic carriers can still transmit the disease. // Most men have symptoms involving the urethra-e.g. , purulent discharge, dysuria, erythema and edema of urethral meatus, and frequency of urination
Gonorrhea in womenMost women are asymptomatic or have few symptoms // Women may have symptoms of cervicitis or urethritis-e.g., purulent discharge dysuria, intermenstrual bleeding, and dyspareunia
Disseminated gonococcal infection(occurs in l% to 2% of cases; more common in women)-possible findings // Fever, arthralgias, tenosynovitis (of hands and feet) // Migratory polyarthritis/septic arthritis, endocarditis, or even meningitis // Skin rash (usually on distal extremities)
HIV Primary infectionA mononucleosis-like syndrome about 2 to 4 weeks after exposure to HIV // Duration of the illness is brief (3 days to 2 weeks).// Symptoms include fever, sweats, malaise, lethargy, headaches, arthralgias/myalgias diarrhea, sore throat, lymphadenopathy, and a truncal maculopapular rash.
Asymptomatic infection HIV(seropositive, but no clinical evidence of HIV infection) CD4 counts are normal (>500/mm3) . // Longest phase (lasts 4 to 7 years, but varies widely, especially with treatment)
Symptomatic HIV infection (pre-AIDS)First evidence of immune system dysfunction // Without treatment, this phase lasts about l to 3 years // Persistent generalized lymphadenopathy // Localized fungal infections (e.g. , on fingernails, toes, mouth) // Recalcitrant vaginal yeast and trichomonal infections in women // Oral hairy leukoplakia on the tongue // Skin manifestations that include seborrheic dermatitis, psoriasis exacerbations, molluscum, and warts Constitutional symptoms (night sweats, weight loss, and diarrhea)
AIDS PulmonaryMarked immune suppression leads to disseminated opportunistic infections and malignancies. // Pulmonary -- Community accquired bacterial pneumonia , Pneumocystis pneumonia (PCP) , Tuberculosis , CMV or MAC increased risk when the CD4 count <50
AIDS Neurological featuresAIDS dementia // Toxoplasmosis Symptoms both of a mass lesion (discrete deficits, headache) and of encephalitis (fever, altered mental status) CT scan or MRI shows characteristic findings: multiple (more than three) contrast enhanced mass lesions in the basal ganglia and subcortical white matter. // Cryptococcal meningitis Diagnosed by identifying organisms in CSF by cryptococcal antigen, culture, or staining with India ink // Other CNS infections Bacterial meningitis, histoplasmosis, CMV, progressive multifocal leukoencephalopathy (PML), HSV, neurosyphil is, TB // Noninfectious CNS diseases CNS lymphoma, CVA, metabolic encephalopathies
AIDS Gastrointestinal featuresDiarrhea - Most common G l complaint; caused by a variety of pathogens Antibiotic therapy is also a common cause. // Oral lesions - Oral thrush (candidiasis), HSV or CMV (ulcers), oral hairy leukoplakia (EBV infection) Kaposi's sarcoma // Esophageal involvement Candidiasis is most common cause of dysphagia; also CMV and HSV-seen with CD4 counts <100 // Anorectal disease Proctitis-Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, HSV
AIDS Dermatological features Kaposi's sarcoma - More common in homosexual men than in other groups , Painless, raised brown-black or purple papules (common sites: face, chest, genitals, oral cavity) , Widespread dissemination can occur. // Infections HSV infections, molluscum contagiosum, secondary syphil is, warts, shingles, and many other skin conditions/infections occur with higher frequency.
AIDS CMV infectionCommon cause of serious opportunistic viral disease // Disseminated disease is common and usually involves the Gl or pulmonary systems // Most important manifestation is retinitis-unilateral visual loss that can become bilateral if untreated (seen in 5% to 1 0% of AIDS patients) // Colitis and esophagitis are other findings.
HSV-1 Primary infection is usually asymptomatic and often goes unnoticed // When symptomatic, primary infection is associated with systemic manifestations (e.g. , fevers, malaise) as well as oral lesions // Oral lesions involve groups of vesicles on patches of erythematous skin. Herpes labialis (cold sores) are most common on the lips (usually painful, heal in 2 to 6 weeks)
HSV-2 Primary infectionConstitutional symptoms (e.g. , fever, headache, malaise) often present in primary infection. // HSV-2 presents with painful genital vesicles or pustules // Other findings are tender inguinal lymphadenopathy and vaginal and/or urethral discharge.
Disseminated HSVUsually limited to immunocompromised patients // May result in encephalitis, meningitis, keratitis, chorioretinitis, pneumonitis and esophagitis
Neonatal HSV (vertical transmission at time of delivery)is associated with congenital malformations, intrauterine growth retardation (IUGR), chorioamnionitis, and even neonatal death.
HSV Ocular diseaseEither form of herpes simplex can cause keratitis, blepharitis, and keratoconjunctivitis.
Syphilis Primary stage Chancre-a painless, crater-like lesion that appears on the genitalia 3 to 4 weeks after exposure // Heals in 14 weeks, even without therapy // Highly infectious-Anyone who touches the lesion can transmit the infection.
Syphilis Secondary stageThis may develop 4 to 8 weeks after the chancre has healed. A maculopapular rash is the most characteristic finding in this stage.// Other possible manifestations: flu-like illness, aseptic meningitis, hepatitis // Patients are contagious during this stage. // About one-third of untreated patients with secondary syphilis develop latent syphilis
Syphilis Latent StageLatent stage is defined as the presence of positive serologic test results in the absence of clinical signs or symptoms. // Two-thirds of these patients remain asymptomatic; one-third develop tertiary syphilis.
Syphilis Tertiary stageOne-third of untreated syphilis patients in the latent phase enter this stage. // It occurs years after the development of the primary infection (up to 40 years later). // Major manifestations include cardiovascular syphilis, neurosyphilis, and gummas (subcutaneous granulomas). // Neurosyphilis is characterized by dementia, personality changes, and tabes dorsalis (posterior column degeneration) // It is very rare nowadays due to treatment with penicillin.
ChancroidNo systemic illness // painful genital ulcer(s) that can be deep with ragged borders and with a purulent base // unilateral tender inguinal lymphadenopathy ("buboes") that appears 1 to 2 weeks after ulcer
Lymphogranuloma venereumpainless ulcer at the site of inoculation that may go unnoticed // few weeks later, tender inguinal lymphadenopathy (usually unilateral) and constitutional symptoms develop.// If untreated, proctocolitis may develop with perianal fissures and rectal stricture; obstruction of lymphatics may lead to elephantiasis of genitals.
Pediculosis Pubis (Pubic Lice)Severe pruritus in the genital region is characteristic. Other hairy areas of the body can be involved.
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SEXUALLY TRANSMITTED DISEASE DIAGNOSIS

Question Answer
ChlamydiaDiagnostic tests include culture, enzyme immunoassay, and molecular tests such as PCR. Serologic tests are not used for Chlamydia. // Molecular diagnostic tests are replacing culture as the screening test of choice due to higher sensitivity. // Sexually active adolescents (particularly females) should be screened for chlamydia! infection even if they are asymptomatic.
GonorrheaGram stain of urethral discharge showing organisms within leukocytes is highly specific for gonorrhea. // Obtain cultures in all cases-in men from the urethra; in women from the endocervix. May treat empirically because culture results take l to 2 days to return. // Consider testing for syphilis and HIV // Obtain blood cultures if disease has disseminated.
HIVEnzyme-linked immunosorbent assay (ELISA) method Screening test for detecting antibody to HIV; becomes positive 1 to 12 weeks after infection // Western blot test is a specific test used to confirm a positive result on an ELISA test.
AIDSDepends principally on the identification of an indicator condition or on finding in an HIV-1-seropositive patient a CD4-cell count lower than 200. // AIDS Indicator Diseases
Herpes SimplexTzanck smear-quickest test This shows multinucleated giant cells // Culture of HSV is the gold standard of diagnosis // Direct fluorescent assay and ELISA 80% sensitive Results available within minutes to hours
SyphilisDarkfield microscopy (definitive diagnostic test)-examines a sample of the chancre with visualization of spirochetes // Nontreponemal tests-RPR, VDRL (most commonly used) (ideal for screening) // Treponemal tests-FTA-ABS, MHA-TP Not for screening, just for confirmation of a positive nontreponemal test // All patients should be tested for HIV infection
ChancroidDiagnosis is made clinically. // Rule out syphilis and HSV and consider testing for HIV // Painful genital ulcer(s) // Tender lymphadenopathy
Lymphogranuloma venereumDiagnosis is made by serologic tests (complement fixation, immunofluorescence) .
Pediculosis Pubis (Pubic Lice)Diagnosis is made by examination of hair under microscope (or possibly with the naked eye)-identification of adult lice or nits.
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TREATMENT OF SEXUALLY TRANSMITTED DISEASES

Question Answer
ChlamydiaAzithromycin (oral one dose) or doxycycline (oral for 7 days) // Treat all sexual partners.
GonorrheaCeftriaxone (IM, one dose) is preferred because it is also effective against syphilis. // Also give azithromycin (one dose) or doxycycline (for 7 days) to cover coexistent chlamydia! infection
HIVTriple-drug regimens known as HAART use two nucleoside reverse transcriptase inhibitors and either of the following: A nonnucleoside reverse transcriptase inhibitor or protease inhibitor // Monitor the response to treatment using plasma HIV RNA load-the goal is to reduce the viral load to undetectable levels.
Herpes SimplexThere is no cure available for either type of herpes simplex // Mucocutaneous disease Treat with oral and/or topical acyclovir for 7 to 10 days // Oral acyclovir may be given as prophylaxis for patients with frequent recurrences. // Foscarnet may be given for resistant disease in immunocompromised patients.
SyphilisBenzathine penicillin g (one dose IM) is the preferred agent. If the patient is allergic to penicillin, give oral antibiotics (doxycycline, tetracycline) for 2 weeks. // Repeat nontreponemal tests every 3 months to ensure adequate response to treatment. Titers should decrease fourfold within 6 months. If they do not, that may signal treatment failure or reinfection.
Late latent syphilis or tertiary syphilisgive penicillin in three doses IM once per week.
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