wsmithv's version from 2015-11-08 01:14

Scabies, Pediculosis, Warts


Question Answer
ScabiesFound in web spaces between fingers and toes or at elbows or genitalia. Found in nipples or near genitals. Burrows visible (they dig) but smaller than pediculosis. scrape and magnify. treat with permetrhin. widespread disease is "crusted" or hyperkeratotic and responds to ivermectin; sever disease (often in immunocompromised) needs repeated dosing.
PediculosisCrabs. DX on visualization. Found on hair-bearing areas (axilla, pubis). causes itching. visible on surface. TX= pemerthrin; lindae is euqal in efficacy but more toxic (neurotoxic, seizures in kids)
Genital Warts TXremove by physical means: cryotherapy with liquid nitrogen, surgery for large ones, laser, melt with podophyllin or trichloroacetic acid. Imiquimod (applied locally by patient; immunostimulant that leads to sloughing off)
Molluscum ContagiosumViral infection of mucous membranes with flesh-colored dome-shpaed and pearly lesions) DX on visual. NO TESTS.
Genital WartsCondylomata acuminata. papillomavirus. diagnose on visual. WRONG ANSWERS ARE biopsy, serology, stain, smear, culture
WHEN IS DESENSITIZATION THE ANSWERNeruosyphilis and pregnancy only
Jarisch-Herxheimer ReactionFever, Headache, myalgias after Tx for syphilis. NO DANGER. just uncomfortable. Give aspirin and antipyretics. it will pass



Question Answer
TX of tertiary syphilisIV penicillin (G) and desensitization if allergic. Oral doxycycline if penicillin allergy
Tx of secondary syphilissingle IM injection of penicillin (benzathine). Oral doxycycline if penicillin allergy
TX of primary syphilissingle IM injection of penicillin (benzathine)
False Positives of VDRL, RPRinfection, older age, injection drug use and AIDS, malaria, antiphospholipid syndrome, and endocarditis (reagent in VDRL is phospholipid and cardiolipen hence last two). Titers are reliable at > 1:8. lower titer is more often false positive. higher titer (>1:32) are rarely false positive. so higher more likely correct
Sensitivity of DX Tests by Stageprimary VDRL or RPR 75%-85%, FTA-ABS 95%; secondary VDRK or RPR 99%, FTA-ABS 100%, tertiary: VDRL or RPR 95%, FTA-ABS 98%
Tertiary Syphilis presentationneurosyphilis features meningovascular (stroke from vasculitis), tabes dorsalis (loss of position and vibratory sense, incontinence, cranial nerve - involves posterior column like B12 def), general paresis (memory and personality changes), argyll robertson pupil (reacts to accomodation, but not to light). also has aortitis (aortic regurgitation, aortic aneurysm) and gummas (skin and bone lesions)
Secondary Syphilis presentationrash (palm and soles, can be general), alopecia areata (hariless in patchy areas), mucous patches, condylomata lata (wart-like lesions, not CONDYLOMATA ACCUMINATA = genital warts/hpv)
Primary Syphilis presentation and TXpainless genital ulcer with heaped-up indurated edges (becomes painful if it becomes secondarily infected with bacteria). Painless adenopathy. Chancres will heal spontaneously even without treatment, but penicillin is used to prevent later stages.

HSV and general UGD


Best Initial Step for clear vesicles of HSV :Oral acylovir. While tzanck prep is best initial and viral culture is most accurate, it is unnecessary if clear vesicles. TOPICAL ACYCLOVIR IS WORTHLESS
Question Answer
Dark-field MicroscopyMOST ACCURATE FOR SYPHILIS If positive for spirochetes no further testing for syphilis is necessary
UGD Tx Lympohgranuloma venereumDoxycycline
UGD Tx HSVAcyclovir, valacyclovir, famciclovir, foscarnet for acyclovir-resistant HSV (acyclovir, valacyclovir, famciclovir work through thymidine kinase pathway, not gancyclovir and not foscarnet)
UGD Tx ChancroidAzithromycin (single dose)
UGD TX SyphilisSingle dose of intramuscular benzathine penicillin. Doxycyline if penicillin allergic.
UGD Tests HSV Tzanck prep = best initial. Viral culture is most accurate
UGD Tests Lymphogranuloma venereumcomplement fixation titers in blood, NAAT on swab. CAUSED BY CHLAMYDIA, which won't stain because intracellular
UGD Tests ChancroidStain and culture on specialized media (pelomorphic gram-negative cocobacillus)
UGD Tests SyphilisDark-field microscopy (best initial in primary and most accurate), VDRL or RPR (75% sensitive in primary), FTA or MHA-TP (confirmatory)
Ulcerative Genital Disease Most Likely DXoften impossible to determine because all have inguinal adenopathy, so question has to tell you something special. So: painless ucler = syphilis; painful ulcer = Chancroid (H dureyi. "It hurts me; I do cry."); LYMPH nodes tender and suppurative = LYMPHogranuloma venereum; Vesicles prior to ulcer and painful = Herpes

PID, Cervicitis, and Urethritis


Question Answer
PID TX testscombination for gonorrhea and chlamydia. INPATIENT = cefoxitin or cefotetan combined with doxycycline. OUTPATIENT: ceftriaxone and doxycycline (possible with metronidazole). If anaphylaxis to penicillin then OUTPATIENT = levofloxacin and metronidazole OR INPATIENT: clindamycin and gentamicin
PID DX testscervical swab for culture, DNA probe, or NAAT. These tests clarify need for treating partner. Culture is preferred for N. Gon to determine resistance. Cervical Testing is NOT THE MOST ACCURATE Test for PID. Most accurate is Laparoscopy ONLY NEEDED IF Dx unclear, symptoms persist despite therapy, recurrent episodes for unclear reasons
PID next best stepexclude ectopic pregancy with pregnancy test
PID Presentationlower abdominal tenderness, lower abdominal pain, fever, cervical motion tenderness (bimanual exam), leukocytosis (not essential)
CervicitisPresentation: Cervical discharge and strawberry cervix. DX and TX are same except self-admin vaginal swab for NAAT (most accurate and [I think] best initial). NOT SWAB by gyno.
Urethritis TXCombination of 1 for gonorrhea (Cefixime or Ceftriaxone) and 1 for Chlamydia (Azithromycin or Doxycycline). NOT Quinolones b/c of resistance.
Other causesMycoplasma genitalium, Ureaplasma
Urethritis DX testBest initial: Men = Urethral Swab for Grab stain and WBCs (looking for intracellular gram-neg diplococci = N. Gonorrhoeae). Most Accurate Urethral Culture (voided) for nucleic acid amplification test (NAAT) = a DNA probe for Gonorrhoeae and Chlamydia). Women can do self-admin vaginal swab for NAAT.
What is the Most likely Dx? Urethritis v. CystitisBoth give dysuria, urinary frequency and burning. Cystitis does not give discharge while urethritis does.