LYMPHOGRANULOMA VENEREUM SEXUAL TRANSMITTED DISEASES

LYMPHOGRANULOMA VENEREUM [LGV] SEXUAL TRANSMITTED DISEASES [STDs]


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LGV is a sexual infectious disease, which produces specific involvement with acute and chronic inflammation of the lymph channels and nodes of the genital and rectum. The disease is transmitted by sexual contact.
Early manifestations include an evanescent genital lesion followed by sub-acute regional lymphadenitis progressing to suppuration and sinus formation.
Later, progressive inflammatory disease of the local lymphatics and surrounding tissues leads to lymph-edema, ulceration and disfigurement of the genitals, and to proctitis, perianal fistulas and rectal stricture.

Etiology, the cause of the disease:
The causative agents of LGV is chlamydia trachomatis. LGV strains are unique: they are usually invasive, produce disease in lymphatic tissue, and grow in cell culture systems and macrophages. LGV microorganism is pathogenic for the chick embryo and produces meningo-encephalitis on intra-cerebral inoculation into mice.

Epidemiology, the spread of the disease:
• Although LGV was long considered a disease of warm climates, there is ample evidence of its world-wide distribution.
• Most common sexually transmitted diseases [STDs] world-wide estimated incidence 92 million in 1999, and in the United States is about 4 million cases per year in 2002.
• As with other venereal diseases, the prevalence of the infection is determined by the promiscuity of the population and is greatest in young adults. Clinical spectrum parallels that of Neisseria gonorrhea is about 40 %..
• Infertility due to fallopian tube scarring has been strongly linked to antecedent Chlamydia trachomatis infection.

Symptoms and signs
:
• After a variable incubation period of from 3 to 20 days, an initial lesion such as vesicular, popular or ulcerative may occur at the site of infection. Most commonly, the first evidence of the disease is involvement of the inguinal lymph nodes beginning 2 weeks to 3 months after exposure, the primary lesion having been unnoticed or absent.
• The inguinal adenitis, unilateral or bilateral, is a sub-acute diffuse process affecting the entire chain of lymph nodes, an often the femoral group as well, producing the “the sign of the groove”.
• Urethritis, epidydimitis, proctitis in the male; cervicitis, salpingitis, and pelvic inflammatory disease [PID] in the female.
Chlamydia trachomatis is recovered from the urethra of up to 70 % of men.
Late manifestations of LGV include disfiguring lesions of the external genitals [elephantiasis] and the anorectal syndrome which is initiated early in the disease by proctitis with tenesmus and a bloody or purulent discharge. Later, chronic cicatrizing inflammation of the rectum and peri-rectal tissues leads to obstipation.
Benign anorectal stricture, contracture, or stenosis results from trauma or infection. It is a common problem of women and may cause difficulty in achieving or completing a bowel movement, pain, and small or ribbon-like stools.
.
Diagnosis:
• Isolation of the organism in cell culture; the Frei test and the complement fixation test are positive.
• Chlamydial antigens or nucleic acid can be detected by direct immuno-fluorescent antibody[DFA] slide tests.
• In LGV, aspirate fluctuant buboes through normal skin for testing. Detection of antibody in serum or in local secretions is of limited usefulness except in LGV.

Treatment:
• Ofloxacin [400 mg per oral twice daily for 14 days]; plus metronidazole [500 mg per oral twice daily for 14 days]
• LGV treatment: Doxycycline [100 mg per oral twice daily] or erythromycin base [500 mg 4 times daily] for at least 3 weeks.
• Trachoma and adult inclusion conjunctivitis treatment: Public health programs consists of mass application of tetracycline or erythromycin ophthalmic ointment into the eyes of all children in affected communities for 21-60 days.
• Tetracycline 500 mg 4 times daily, combined with sulfonamides 3 gram daily for 3-6 weeks may prove more effective than either alone.



Prevention:
Avoidance of illicit sexual contact is the surest of all preventive methods.
The standard rubber condom is effective but protects covered parts only. The exposed parts should be washed with soap and water as soon after contact as possible. This applies to both sexes.

INFECTIONS OF TRICHOMONIASIS SEXUAL TRANSMITTED

4. TRICHOMONIASIS INFECTIONS SEXUAL TRANSMITTED DISEASES

Etiology or the cause of a disease
• Trichomonas vaginalis is a venereal infection in most instances. The cervix, urethra, and bladder may be involved secondary. The vaginal organisms can often be trace to the male partner, who harbors the flagellate beneath the prepuce or in the urethra.
• Unsolicited reporting of vaginal discharge or leucorrhea suggests vaginitis or trichomoniasis.
Symptoms and signs
• Vulvitis in the adult may be associated with trichomonas vaginalis or candida infections of the vagina, particularly during pregnancy. Leucorrhea due to trichomonas vaginalis infection usually occurs as a diffuse vaginitis [infection of vagina] characterized by a thin, yellow-green, occasionally frothy discharge with a fetid odor. Numerous red points [like strawberry patches], which rarely bleed, are scattered over the vaginal surface and cervical surface.
• Typical symptoms are profuse purulent vaginal discharge and vulva itching
• Inflammation of vulva, vaginal epithelium, and servix.

Diagnose
Microscopy: Leucocytes; motile trichomonads seen in 80 to 90 % of
symptomatic patients, less often in the absence of symptoms
The new DNA probe test [the Affirm test] can detect trichomonas vaginalis
Complications
Trichomonas vaginalis infections of vagina is often followed by chronic cervicitis, a
major factor in infertility. Urinary tract trichomoniasis may cause troublesome
symptoms.

Treatment
Tinidazol [generic, Fasigyn brand] 500 mg/tablet per oral , if body weight less than
60 kg, the dose 3 tablets once daily for 4 days; if the body weight more than 60 kg the
dose 4 tablets once daily for 3 days; or
Metronidazole [generic, Flagyl brand] 5oomg/tablet per oral the same dose with the
Fasigyn.

Prevention
The husband should use a condom if infection or re-infection is likely. Sexual
promiscuity and borrowing of douche tips, underclothing, or other possibly
contaminated articles should be avoided.

SYPHILIS SEXUAL TRANSMITTED INFECTIONS

3. SYPHILIS SEXUAL TRANSMITTED INFECTIONS

The cause of syphilis and epidemiology:
Syphilis is an acute and chronic, contagious, venereal granulomatous infection due to Treponema pallidum, Since almost any disease may be mimicked by syphilis in one of its 3 clinical stages. Although infection usually occurs during intercourse, transfer of treponema pallidum by infected blood and plasma, and passage from the mother to the fetus through the placenta [congenital syphilis], and blood transfusion are possible. Extra-genital infection such as tongue, lips, breast may also occur.
The organism cannot survive outside the body tissues and fluids, and infection other than through direct personal contact or through blood products is
One-half of sexual contacts of persons with infectious syphilis become infected.
Symptoms and signs depend on the stages of syphilis:
• Primary syphilis: History of contact with an infected individual 1-4 weeks prior to appearance of primary lesion. Primary lesion: chancre at site of inoculation [labia, cervix, anal canal, rectum, mouth or penis in men] may be single or multiple .Regional lymph nodes on one or both sides are often rubbery, discrete, and non-tender.
• Secondary syphilis: Usually occurs 7-10 weeks after exposure to the disease. There is often evidence of systemic involvement with fever, generalized lymphadenitis, non-pruritic maculopapular dermatitis, naso-pharyngitis, laryngitis conjunctivitis, arthralgia, and mucous patches. Primary chancre may still be present. Lesions are widely distributed over the trunk and extremities, including the palms and soles. In most intertriginous areas, papules can enlarge and erode to produce broad, highly infectious lesions called condylomata lata.
• Latent syphilis: Often follows inadequate or improper therapy. Early latent, less than 4 years; late latent, more than 4 years. An intermediate phase after secondary lesions have disappeared and while tertiary symptoms are not yet evident. Latent syphilis offers no clinical evidence of signs other than the positive syphilis serology test. Only latent syphilis develops after the first year of infection. However, women with latent syphilis can infect the fetus in uterus.
• Tertiary Late syphilis: Involvement may be diffuse, may be confined to certain organ systems or localized as discrete lesions [gummata] in any and all tissues.
1. Muco-cutaneous: Gummatous lesions of the skin and mucous membranes.
2. Osseous: Diffuse lesions of bones and joints with periostitis, arthritis, synovitis,
and osteomyelitis.
3. Ocular: Conjunctivitis, iritis, uveitis, keratitis and retinitis.
4. Cardiovascular: Uncomplicated aortitis, aortic regurgitation, and aneurism.
5. Central nervous system disease a continuum throughout syphilis. Meningeal
findings, including headache, nausea, vomiting change in mental status and
neck stiffness present within one year of infection. Tabes dorsalis with clinical
signs: ataxia, pains of varying character and location, visual disturbance,
sphincter and sexual disturbances, hyporeflexia, diminution of vibration and
position sense.
6. Late benign syphilis [gumma]: usually solitary lesions showing granulomatous inflammation with central necrosis are found most often in the skin and skeletal system, mouth, upper respiratory tract, liver and stomach.

Diagnosis
• Dark-field microscopy of lesions exudates or direct fluorescent antibody t.reponema pallidum[DFA-TP] test in fixed smears from suspect lesions.
• Treponemal serologic tests: agglutination assay and the fluorescent treponemal antibody-absorbed test.Result remain positive even after successful treatment.
• Patients with syphilis should be evaluated for HIV disease.

Treatment:
• Primary, secondary, or early latent: Repository penicillin 600 000 units IM daily for ten days, or penicllin G benzathine [single dose of 2.4 million Unit IM]. Patients with confirmed Penicillin Allergy: Tetracycline hydrochloride [500 mg per oral 4 times daily] or Doxycycline [100 mg per oral twice daily] for 2 weeks.
• Late latent, cardiovascular or benign tertiary : Lumbar puncture, if cerebrospinal fluid [CSP] normal : Penicillin G benzathine [2.4 million Unit IM weekly for 3 weeks. CSV abnormal: Treat as neurosyphilis.
• Neuro-syphilis : Aqueous penicillin G [18-24 million Unit IV, given as 3-4 million Unit every 4 hours or continuous infusion] for 10-14 days.
• Syphilis in pregnancy: According to stage; desensitization and treatment with penicillin.

Prevention:
• Avoidance of illicit sexual contact is the surest of all preventive methods.
• The standard rubber condom is effective but protects covered parts only. The exposed parts should be washed with soap and water as soon after contact as possible. This applies to both sexes.
• If there is known exposure to infectious syphilis, abortive penicillin therapy may be used. Give 1.2 million units of repository penicillin IM in one dose, or penicillin G 1-2 million units IV.

GONORRHEA VENEREAL INFECTIONS

GONORRHEA VENEREAL DISEASES

Gonorrhea is estimated the most prevalent of the acute sexual transmitted infectious diseases. Among the venereal diseases it is by far the most prevalent, occurring seven times more frequently than syphilis. Gonorrhea involves not only the infected person,but often the innocent in tragic consequence.

In any consideration of gonorrhea from the medical or public health standpoint, the facts logically arrange themselves into 4 distinct categories:

[1].Gonorrhea in the male; [2] gonorrhea in the adult female;[3] gonorrhea vulvo-vaginitis in children; and [4] gonorrhea ophthalmia neonatorium. The cause or etiology of gonorrhea is gram-negative diplococcus, Neisseria gonorrhea, non-motile, non-spore-forming bacteria that grow in pairs and are shaped like coffee beans.

Epidemiology or the spread of the diseases:
In fiscal 1949 there were reported to the United States Public Health Services 331 700 cases of gonorrhea ; and 362 000 cases reported in the United States in 2002; actual case numbers higher. This, in spite of its great incidence and in view of the fact that the prevalence and complications of the disease have not much change
· U.S. incidence of 120 cases per 100 000 population—the highest among industrialized nations
· 75 % of cases in 20-24 age group, highest risk among sexually active 15-19 year-old women and among African Americans.
· Efficient male to female transmission; 40-60 % rate with a single unprotected encounter; 20 % rate to women who practice fellatio with infected partners.
· Drug-resistant strains are widespread. Penicillin, ampicillin, and tetracycline are no longer reliable agents.
Source: Dennis L. Kasper, MD et al. Harrison’s Manual of Medicine, McGraw Hill, International Edition, 2005, p 399.

Symptoms and signs :


Gonorrhea in the adult male is characterized by an acute urethritis with painful urination and purulent urethral discharge. The incubation period is 2-7 days. Uncommon complications include epidydimitis, proctitis, penile edema, balanitis in uncircumcised men.
Gonorrhea in female begins in the urethra, vagina, and vaginal glands and is characterized by painful urination and purulent discharge. Commonly the infection spreads to the uterus, tubes and other pelvic structures. Incubation period is about 10 days. Co-infection with Chlamydia trachomatis is seen up to 40 % of genital gonorrhea infections.
Anorectal gonorrhea: spreads from cervical exudates in women; rates in homosexual men decreasing in the last era. Strains in this population tend to be more resistant to antibiotics.
Pharyngeal gonorrhea: usually resulting from oral-genital sexual exposure; almost always coexist with genital infection.
Ocular gonorrhea: caused by auto-inoculation; swollen eye lids, hyperemia, profuse purulent discharge, occasional corneal ulceration and perforation.
Gonorrhea in pregnancy: Salpingitis and pelvic inflammatory diseases in first trimester can cause fetal loss, Third trimester can cause premature delivery, neonatal sepsis and death.
Gonorrheal arthritis: Arthritis presents with painful joints in conjunction with tenosynovitis, skin lesions, and poly-arthritis of knees, elbows and distal joints. Suppurative arthritis affects one or two joints most often knees, wrists, ankles, and elbows.

Gonorrhea vulvovaginitis in children: This in an inflammatory process involving the urogenital tract in female,chiefly the vulva and vagina,characterized by swelling and redness of the mucous membranes and by purulent discharges of varying degree.

Ophthalmia Neonatorium: It includes every type of purulent inflammation of the conjunctiva which occurs during the first 3 weeks of a baby's life. This is an acute infection caused by a variety of infectious agents. In the past a great of majority of this infections was due to the gonococcus.The incidense of gonorrhea ophthalmia neonatorium is difficult to find to day, since the introduction of the Crede silver nitrate method of prophylaxis.


Diagnosis: Laboratory examinations: male, smear and culture of material obtained from the urethral meatus [opening] will demonstrate the causative organism; intracellular gram-negative diplococcus. Smear and culture of urethral and vaginal discharges should be performed.

Treatment for gonorrheal infections:
· Treatment of uncomplicated infection of the cervix, urethra, pharynx, or rectum:
Ceftriaxone [125 mg IM, single dose]or; Ciprofloxacin [500 mg per oral, single dose] or: Ofloxacin [400 mg per oral, single dose] or Doxycycline [100 mg per oral twice daily for 7 days]
· Treatment of complicated infections: Ceftriaxone [one gram IM, single dose] or; Ofloxacin [400 mg per oral twice daily for 14 days].

CURABLE SEXUAL TRANSMITTED INFECTIONS

CURABLE SEXUAL TRANSMITTED INFECTIONS [STIs]

THE SITUATIONS







Reproductive tract infections, which include sexually transmitted infections, threaten health both directly and indirectly. Complications from reproductive tract infections can be serious. Pelvic inflammatory diseases, for example, can cause infertility, ectopic pregnancy, and chronic pain. A mother with syphilis exposes her children to a risk of pneumonia, premature birth, low birth weight and blindness. And human papillomavirus [HPV] infection is strongly link to a risk of cervical cancer.
Some 340 million cases of curable STIs, caused mainly by bacteria, are estimatetd to occur world wide every year, the majority in developing countries. In many countries, STIs are among the top 5 conditions to which men and women sek care and thus constitute a considerable drain of resource-strapped health services.

Table: Estimated annual incidence of curable
Sexually transmitted diseases worldwide
Disease…………………New cases [million]
Gonorrhea..……………………..62
Chlamydial infection..………92
Syphilis…………………………..12
Trichomoniasis………………174
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Total…………………………....340

Table:…Estimated annual incidence and rate of STIs
In the age 15-49 by region and worldwide in 1999

==================================
Region……………….New cases/year..Incidence/1000
……………………..…..[x1000]…….......15-49 year-olds

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North America…………...14 000……….90
Latin America and
The Caribbean………......38 000……..146
Western Europe………….17 000……….84
Eastern Europe and
…central Asia……………..22 000……..107
East Asia and the
Pacific………………….......18 000……….22
South and south-east
Asia…………………..........151 000……..158
Australia……………………...1000………..91
North Africa and the
Middle East……………...10 000………61
Sub-Saharan Africa…..69 000……257
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Total……………………...340 000…….112

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Source: World Health Organization, Geneva. 2002, p 32

What are the PROBLEMS?

What are the causes of STIs?
Can we treat and prevent the STIs ? Yes, we can.
How to treat and to prevent the STIs?

PROBLEM SOLVING OR SOLUTION

The answer of the questions as the solution of the problems of the STIs diseases will be described in the following below: