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SCREENING, DIAGNOSIS, AND TREATMENT OF SEXUALLY TRANSMITTED DISEASES IN PRIMARY CARE SETTINGS (14HC03)

Bonnie Richards, DO, BSN, Patricia Mason, BS, PHA and Sindy M. Paul, MD, MPH, FACPM

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GRANULOMA INGUINALE (DONOVANOSIS)

The last three STDs – granuloma inguinale, lymphogranuloma venereum and chancroid—are all relatively rare, but included in this article as they are reportable diseases in the state of New Jersey. The first of the three is granuloma inguinale, which is a genital ulcerative disease caused by the intracellular gram-negative bacterium Klebsiella granulomatis.

Epidemiology

The disease is commonly found in tropical and subtropical areas such as Southeast India, Guyana, and New Guinea. However, it can sometimes occur in the United States, typically in the Southeast. There are about 100 cases reported per year in the United States. Men are affected more than twice as often as women.

Symptoms

The disease is commonly characterized as painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lyphadenopathy; subcutaneous granulomas (pseudoboboes) might also occur. The lesions are highly vascular (i.e., beefy red appearance) and bleed easily on contact. The clinical presentation also can include hypertrophic, necrotic, or sclerotic variants. Extragenital infection can occur with extension of infection to the pelvis, or it can disseminate to intraabdominal organs, bones, or the mouth. The lesions also can develop secondary bacterial infection and can coexist with other sexually transmitted pathogens.

Diagnosis

The causative organism is difficult to culture, and diagnosis requires visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy.

Treatment

CDC-recommended treatment:

  • Doxycycline 100mg orally twice a day for at least 3 weeks and until all lesions have completely healed

Treatment of Partners

Persons who have had sexual contact with a patient who has granuloma inguinale within the 60 days before onset of the patient’s symptoms should be examined and offered therapy.

Special populations

Pregnancy: Pregnant and lactating women should be treated with the erythromycin regimen, and consideration should be given to the addition of a parenteral aminoglycoside (e.g., gentamicin 1 mg/kg IV every 8 hours) if improvement is not evident within the first few days of therapy.

HIV Infection: Provide the same regimen as for those who are HIV-negative; consider the addition of a parenteral aminoglycoside (e.g., gentamicin).

Follow Up

Patients should be followed clinically until signs and symptoms have resolved.


LYMPHOGRANULOMA VENEREUM

Lymphogranuloma venereum
Acknowledgement: Dermatology Online Journal 12 (7): 14

Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars.

Epidemiology

LGV was primarily endemic in heterosexuals in areas of East and West Africa, India, parts of Southeast Asia, and the Caribbean. Although previously rare in the U.S. and Europe, since 2003 LGV infection has been increasingly reported in developed countries, primarily in men who have sex with men. The largest outbreak reports were from New York City and the United Kingdom.

Symptoms

The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. A self-limited genital ulcer or papule sometimes occurs at the site of inoculation. However, by the time patients seek care, the lesions have often disappeared. Rectal exposure in women or MSM can result in proctocolitis, including mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and/or tenesmus. LGV is an invasive, systemic infection, and if it is not treated early, LGV proctocolitis can lead to chronic, colorectal fistulas and strictures. Genital and colorectal LGV lesions can also develop secondary bacterial infection or can be coinfected with other sexually and non-sexually transmitted pathogens.

Diagnosis

Diagnosis is based on clinical suspicion, epidemiologic information, and the exclusion of other etiologies for proctocolitis, inguinal lymphadenopathy, or genital or rectal ulcers. C. trachomatis testing also should be conducted, if available.

Genital and lymph node specimens (i.e., lesion swab or bubo aspirate) can be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection.

Treatment

CDC-recommended treatment:

  • Doxycycline 100 mg orally twice a day for 21 days

Treatment of Partners

Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient’s symptoms should be examined, tested for urethral or cervical chlamydial infection, and treated with a chlamydia regimen (azithromycin 1 gm orally single dose or doxycycline 100 mg orally twice a day for 7 days).

Special populations

Pregnancy: Treat pregnant and lactating women with erythromycin.

HIV Infection: Provide the same regimen as for those who are HIV negative. Prolonged therapy might be required. The vast majority of MSM who acquired LGV in the U.S. outbreak were also HIV-infected. This is a major public health concern since enhanced shedding of HIV during clinical proctitis could increase the risk of HIV transmission to uninfected.

Follow Up

Patients should be followed clinically until signs and symptoms have resolved.


CHANCROID

Chancroid ulcer
Acknowledgement: Connie Celum, Walter Stamm

Epidemiology

The number of reported cases of chancroid has declined steadily in the United States, from 4,986 cases in 1987 to 243 cases in 1997. In the early and mid-1990s, most epidemics of chancroid in the United States occurred in urban areas and were associated with crack cocaine use and prostitution. When infection does occur, it is usually associated with sporadic outbreaks.

Symptoms

The combination of a painful genital ulcer and tender suppurative inguinal adenopathy suggests the diagnosis of chancroid.

Diagnosis

A definitive diagnosis of chancroid requires the identification of H. ducreyi on special culture media that is not widely available from commercial sources; even when these media are used, sensitivity is <80%.

A probable diagnosis of chancroid, for both clinical and surveillance purposes, can be made if all of the following criteria are met: 1) the patient has one or more painful genital ulcers; 2) the patient has no evidence of T. pallidum infection by darkfield examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers; 3) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for chancroid; and 4) a test for HSV performed on the ulcer exudate is negative

Treatment

  • Azithromycin 1 g orally in a single dose, or
  • Ceftriaxone 250mg intramuscularly (IM) in a single dose, or
  • Ciprofloxacin 500mg orally twice a day for 3 days, (Ciprofloxacin is
    contraindicated for pregnant and lactating women), or
  • Erythromycin base 500mg orally three times a day for 7 days

Treatment of Partners

Regardless of whether symptoms of the disease are present, sex partners of
patients who have chancroid should be examined and treated if they had
sexual contact with the patient during the 10 days preceding the patient’s
onset of symptoms.

Special populations

Pregnancy: No adverse effects of chancroid on pregnancy outcome have
been reported.

HIV Infection: HIV-infected patients who have chancroid should be
monitored closely because they are more likely to experience treatment
failure and to have ulcers that heal more slowly. HIV-infected patients
might require repeated or longer courses of therapy, and treatment failures
can occur with any regimen.

Follow Up

Patients should be re-examined 3–7 days after initiation of therapy. If no
clinical improvement is evident, consider whether 1) the diagnosis is correct,
2) the patient is coinfected with another STD, 3) the patient is infected with
HIV, 4) the treatment was not used as instructed, or 5) the H. ducreyi strain
causing the infection is resistant to the prescribed antimicrobial.

CONCLUSION

The STDs discussed in this paper are among the more commonly encountered or reportable in the state of New Jersey; however there are others that should be considered in the at-risk patient. The role of the PCP includes sexual history taking and STD/HIV prevention counseling with all patients. As the potential complications of an untreated infection can be devastating, it is important to recognize and treat STDs as early as possible. As the gatekeepers of health services, PCPs will likely be the first to see a patient with an STD. Their role in the diagnosis, treatment, and especially the prevention of STDs underpins a national strategy to reduce STD infections and ensure the sexual health of the individual client.


 
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