Sexual Disease Case Studies III

STDs: Mycoplasma/Ureaplasma Tests, Infectious Diseases Cases

Conclusions & Confusions

• Few definitive STD Lab Testing facts are known about genital mycoplasma infections. However, some evidence shows these organisms as a cause of NGU, cervicitis, PID, and possibly infertility, as well as pregnancy and neonatal complications.
• M. genitalium may be a true pathogen rather than a commensal organism. Routine exams and treatment for M. genitalium may lower rates of pelvic inflammatory disease and its sequelae.
• Also, no commercial assay is yet available.
• In addition, current data suggests that routine checks and treatment for M. hominis and U. urealyticum will not likely benefit young, healthy patients without symptoms.

The Case for Kendra

• Age 22, comes in for possible UTI symptoms.
• Notes mild dysuria for 3 days. No urgency, frequency or hematuria. Also, no fever or back pain.
• Also, what other history is important to obtain?
• All in all, what lab tests should be ordered?
• Would you treat empirically at this point?
• Has had 2 male partners in the last 3 months, with no protection. Both do not have symptoms.
• In addition, no prior STI or UTI history

 Kendra continued

• Per clinic the STD test protocol, you collect urine for both chlamydia and a UA
• Also, what is the indication for doing chlamydia?
• Should it be a first void, midstream or both?
• Urine for chlamydia must be first-void, “dirty” catch
• UA shows moderate WBCs, no bacteria
• Treated empirically with TMP-SMZ X 3 days
• The next day, her chlamydia result was positive
• In addition, what are the next steps to manage this infection?
• Furthermore, what will you do about her partners?

Chlamydia STD

Treatment 2006 CDC Treatment Guidelines

• Rx: Azithromycin 1 gm single dose OR
• Doxycycline 100 mg BID x 7 days
• Contraindicated during pregnancy
• Effectiveness is equivalent

Provider’s Role to Prevent Reinfection

• STD Test for reinfection:
• Retest 3-4 months after treatment or whenever the patient presents to the clinic within the next 12 month
• Notifying the partner
• Provider referral (report to health dept)
• Patient referral (refers partner to clinic)
• Expedited partner therapy (Rx for partner)
• Expedited Partner Therapy, aka Patient Delivered Partner Therapy
• STD Providers give the patient medication intended for the partner or partners
• Providers write the partner or partner a prescription for medication

CDC suggests New guidance

• Providers should consider including EPT as part of their regular STD Testvcare.
• EPT is a “useful option” to further partner treatment
• Especially for male partners of chlamydia- or gonorrhoea-infected females
• CDC STD Treatment Guidelines suggest EPT as an option for partner treatment among heterosexual persons with chlamydia or gonorrhoea

Chlamydia

Diagnosis

• Nucleic Acid Amplification Test (NAAT)
• Amplifies specific nucleic acid sequences (i.e., DNA)
• Can detect GC and CT in a single specimen

*note: only Aptima and BD ProbeTec QX are FDA-cleared for vaginal specimens

• Self-collected vaginal swabs are suggested.
• First, void urine in women is also acceptable. New guidance
• Does not require viable organisms
• Highly sensitive and specific, >99% in most settings
• Can test endocervical, urethral, urine, or vaginal* specimens

The Case of Ralph

• 23 y.o. Undergrad student presents with dysuria for 1 week. No discharge. Also complains of left index finger pain and swelling for several days.
• In addition, reports the same female partner for the past 7 months. Also, always use condoms. No prior STDs were diagnosed.
• The patient has a history of orofacial herpes.

Ralph continued

Exam:

• Left inguinal adenopathy to 1cm, slightly tender. Penis
• with erythema at meatus. No discharge.
• Erythema from the tip of the finger to the DIP joint. Also, swelling and fluid collection is present in the medial nail fold. Mild pressure yields clear fluid. No regional adenopathy.
• UA: noWBCs, no RBCs, no bacteria

Ralph, continued

• Urine CT NAAT
• Urine culture
• Are there other STD lab tests that should be done?
• Would you treat empirically?
• Azithromycin or doxycycline

And Ralph continued

• Chlamydia test and urine culture were negative
• Also, symptoms resolved without treatment
• Left index finger HSV culture positive, type 1
• In addition, the positive culture result supports the clinical impression that his finger lesion is a herpetic whitlow.
• He presumably inoculated himself by touching an oral or genital lesion
• But wasn’t he immune from prior oral infection?

 Ralph – discussion

• Dysuria, with or without external genital lesions, is a common symptom of genital herpes.
• His dysuria may have been due to herpetic urethritis. He Would need a urethral swab PCR to confirm (pt declined)
• Whether he got this by receiving oral sex from his girlfriend or by auto-inoculation via his finger is unclear.
• Herpes should be considered early in differential UTI symptoms that are atypical, recurrent or persistent.
• HSV-1 is a common cause of genital herpes
• Account for ~50% of GH cases in the ACHA STI survey
• Also, most patients with symptomatic genital HSV-1 have a new primary infection

Herpes:

Who Should I Check? What Should Be Used?

Use culture/PCR when patient…

• Presents with an open lesion (diagnosis)
• Use type-specific serology to…..
• Confirm an uncertain clinical diagnosis
• Also, diagnose patients with atypical or unrecognised
• infection
• Manage partners of persons with genital herpes
• Test patients at higher risk?

What about routine Exams?

 Serologic testing for HSV

• All in all, routine testing of adolescent adults is not suggested (USPSTF, CDC)
• However, testing of persons at higher risk of infection may make sense
• Prevalence increases with age (and sexual experience)
• MSM, HIV+, and contact to partner with HSV all have high rates
• Arguments pro and con:
• Prevalent STD with known complications risks
• Also, low PPV (<50%) in adolescents and young adults
• Confirming results is complex and expensive

USPSTF recommendations 2005. CDC Treatment Guidelines 2006.

In the case of ELISA 

A positive result for HSV-2 antibody means the patient is infected with genital herpes (rarely oral)

Serology

• 4-6 weeks to develop antibodies typically
• No role for IgM testing
• Confirm low values (<3.0) with another test or WB
• WB is not commercially available but can be sent to Univ. of Washington ($250)
• The patient is infectious with genital herpes
• Management is the same as for lesion-based diagnosis

Ryan

Ryan is a 19 y.o. Sophomore. Also, he started having sex with men and came to the clinic for routine STD testing. At present, he’s concerned about a bump near his anus and wonders if it is haemorrhoid. He has had receptive anal intercourse only a few times, most recently about 1 month ago. However, no other symptoms or concerns.

Ryan continued

• Exam: 1cm fissure noted near the anus, not tender, firm edges
• Lab: HSV Herpes PCR swab of the lesion, plus routine STI testing (GC, CT, VDRL, HIV)
• Plan: Reassurance and self-care are suggested.

Ryan continued

• Also, the HSV PCR Test was negative
• VDRL was reactive at 1:64, with a positive TP-PA confirmatory test
• Diagnosis: primary syphilis
• Treatment: Benzathine penicillin G 2.4 million units IM If PCN allergy, then doxycycline X 2 weeks
• Plan follow up VDRL at 3, 6, 12 months

Pearls

• Also, routine testing for syphilis is mostly for MSM, IDU, and pregnant women.
• Strong association with HIV infection (50% HIV+)
• The incidence in other countries may be different
• Also, diagnostic exams are important in the workup of unusual rashes or suspicious lesions (regardless of risk factors)
• Primary syphilis lesions (chancres) are often subtle, usually without pain, and sometimes internal (vaginal, rectal, pharynx). However, syphilis more typically presents as a secondary rash or is found on routine testing.

Is this a yeast infection?

• A 24 y.o. A female college student presents with a complaint of vulvar itching for 3 days. Also, she has had similar symptoms twice in the last year.
• ROS: Acne is being treated with 100 mg of doxycycline daily. She is also on oral contraceptives, has had the same boyfriend for 15 months, and does not use condoms.

Exam:

• Minimal vulvar erythema, with a small superficial fissure noted in a labial fold. Also, vaginal wet prep reveals moderate WBCs, and a few yeasts are present.
• However, how would you manage this patient?
• Additionally, treat for yeast?
• HPV Test for STIs?
• In addition, a viral culture from this lesion was positive for HSV-2.

  Diagnostics

Tests for Herpes

Visual exam alone

• Poor to fair, even with experienced clinician, Viral culture
• Good to very good, especially with the first episode of the disease. Nucleic acid amplification (PCR)
• Highly sensitive and specific, best exam where available Antigen kits, Tzanck smear
• Poor sensitivity and specificity are not suggested
• Serology (gG-based)
• Good to excellent, depending on the timing

Genital Herpes –

Discussion

• Generally, the Herpes Virus is often subtle and goes unrecognised
• Firstly, have a high index of suspicion for herpes and open genital lesions
• Secondly, PCR is the STD Home test of choice for lesion diagnosis
• HSV-2 increases the acquisition risk of HIV 2-5X
• Serology can be useful for evaluation of atypical or recurrent symptoms
• Finally, offer treatment with antivirals to all positive pts