Sexually

Transmitted Diseases
Common Diseases
Dr.T.V.Rao MD

Dr.T.V.Rao MD 1
 What are Sexually Transmitted
Diseases
• STD’s are infections that are spread from
person to person through intimate sexual
contact.
• STD’s are dangerous because they are
easily spread and it is hard to tell just by
looking who has an STD.
• 1 in 4 teenagers has an STD.(Western
Statistics)
Dr.T.V.Rao MD 2
 STDs
• STDs are diseases and infections which
are capable of being spread from
person to person through:
– sexual intercourse
– oral-genital contact or in non-sexual ways.
– IV drug
– Congenitally transmitted

Dr.T.V.Rao MD 3
 Common STI’s
• Chlamydia • HIV and AIDS
• Gonorrhea • Pubic Lice
• Genital Herpes • Syphilis
(HSV-2)
• Trichomoniasis
• Genital Warts
(HPV)
• Hepatitis B
Dr.T.V.Rao MD 4
 STD’s of Concern
• Actually, all of them
• “Sores” (ulcers)
– Syphilis
– Genital herpes (HSV-2, HSV-1)
– Others uncommon in the U.S.
• Lymphogranuloma venereum
• Chancroid
• Granuloma inguinale

Dr.T.V.Rao MD 5
 Do Patients Want to Know?
About STD’s
• 92.4% wanted to know if they were
infected
• 90.8% wanted to know if their
partners were infected
• 65% expected the test as part of STD
screening
Dr.T.V.Rao MD 6
 STDs of Concern (continued)
• “Drips” (discharges)
– Gonorrhea
– Chlamydia
– Nongonococcal urethritis / mucopurulent cervicitis
– Trichomonas vaginitis / urethritis
– Candidiasis (vulvovaginal, less problems in men)
• Other major concerns
– Genital HPV (especially type 16, 18) and Cervical
Cancer

Dr.T.V.Rao MD 7
 Sores
Genital Ulcer Diseases –
Does It Hurt?
• Painful
– Chancroid
– Genital herpes simplex
• Painless
– Syphilis
– Lymphogranuloma venereum
– Granuloma inguinale

Dr.T.V.Rao MD 8
 Treponema pallidum – The Agent of Syphilis

• Spirochete
• Obligate human parasite
• Transmission
– Sexual
– Trans-placental
– Percutaneous following contact with
infectious lesions
– Blood Transfusion
• No reported cases of transmission
since 1964
5 MD
Dr.T.V.Rao 9
 Syphilis – The “Great Imitator”
• Infectious Dose: ~57 organisms1
• Incubation Period – 21 days (median)
• 3 clinical stages of syphilis
– Primary:
• Painless sore (chancre) at inoculation site
– Secondary:
• Rash, Fever, Lymphadenopathy, Malaise
– Tertiary/Latent:
• CNS invasion, organ damage
• “The physician that knows syphilis knows
medicine.”
– Sir William Osler
Dr.T.V.Rao MD 10
6
 Primary Syphilis - Clinical
Manifestations
• Incubation: 10-90 days (average 3 weeks)
• Chancre
– Early: macule/papule erodes
– Late: clean based, painless, indurated ulcer with
smooth firm borders
– Unnoticed in 15-30% of patients
– Resolves in 1-5 weeks
– HIGHLY INFECTIOUS

Dr.T.V.Rao MD 11
Primary Syphilis

Dr.T.V.Rao MD 12
Primary Syphilis - Chancre

Dr.T.V.Rao MD 13
Primary Syphilis - Chancre

Dr.T.V.Rao MD 14
 Primary Syphilis Chancre

Dr.T.V.Rao MD 15
Source: Florida STD/HIV Prevention Training Center
 s

Primary Syphilis Chancre e

r
o
S
• Represents haematogenous dissemination
of spirochetes
• Usually 2-8 weeks after chancre appears
• Findings:
– rash - whole body (includes palms/soles)
– mucous patches
– Condylomata lata - HIGHLY INFECTIOUS
– constitutional symptoms
• Sn/Sx resolve in 2-10 weeks
Dr.T.V.Rao MD 16
 Sores

Secondary Syphilis Rash

Dr.T.V.Rao MD 17
Source: Florida STD/HIV Prevention Training Center
 Sores
Secondary Syphilis: Generalized
Body Rash

Dr.T.V.Rao MD 18
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
 Secondary Syphilis Rash

Dr.T.V.Rao MD 19
Source: Florida STD/HIV Prevention Training Center
 Secondary Syphilis Rash

Dr.T.V.Rao MD 20
Source: Cincinnati STD/HIV Prevention Training Center
 Secondary Syphilis

Dr.T.V.Rao MD 21
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas
 Sores
Secondary Syphilis
Condylomata Lata

Dr.T.V.Rao MD 22
Source: Florida STD/HIV Prevention Training Center
 Congenital Syphilis
• Congenital syphilis
usually occurs following
vertical transmission of
T. pallidum from the
infected mother to the
fetus in utero, but
neonates may also be
infected during passage
through the infected
birth canal at delivery.

Dr.T.V.Rao MD 23
 DIAGNOSIS OF SYPHILIS
1. History and clinical examination.
2. Dark-field microscopy: special technique
use to demonstrate the spirochete as shiny
motile spiral structures with a dark
background.
• The specimen includes oozing from the
lesion or sometimes L.N. aspirate. It is
usually positive in the primary and
secondary stages and it is most useful in
the primary stage when the serological
tests are still negative.
Dr.T.V.Rao MD 24
 Laboratory Testing
• Direct examination of clinical specimen
by dark-field microscopy or fluorescent
antibody testing of sample.
• Non-specific or non-treponemal
serological test to detect reagin, utilized
as screening test only.
• Specific Treponemal antibody tests are
used as a confirmatory test for a positive
reagin test.
Dr.T.V.Rao MD 25
 Diagnosis of Syphilis
• Evaluation based on three factors:
– Clinical findings.
– Demonstration of spirochetes in clinical specimen.
– Present of antibodies in blood or cerebrospinal
fluid.
• More than one test should be performed.
• No serological test can distinguish between
other Treponemal infections.
Dr.T.V.Rao MD 26
 Provisional Diagnosis of Syphilis

• A presumptive diagnosis
is possible with
sequential serologic tests
(e.g. VDRL, RPR), using
the same testing method
each time. A fourfold
change in titer (e.g. from
1:8 to 1:32) is usually
considered to be clinically
significant. Confirmatory
tests should be
performed

Dr.T.V.Rao MD 27
 Other Diagnostic Tests
• Serological tests of
syphilis.
• Biopsy rarely
needed. It shows
endarteritis
obliterans with
inflammatory
reaction containing
a plenty of plasma
cells. Granuloma
may found in
tertiary syphilis.

Dr.T.V.Rao MD 28
 Laboratory Diagnosis of Syphilis
The Uncommon Methods
• Rabbit Infectivity Test (RIT)
http://www.els.net

– High Sensitivity and Specificity

– Long turn-around-time
– Limited to research settings
• Dark Field Microscopy
– Useful only during primary infection
– Technician expertise required
• Immunostaining
– Direct fluorescent antibody or silver stain
• Polymerase Chain Reaction (PCR)
– Not commercial available
textbookofbacteriology.net

7 MD
Dr.T.V.Rao 29
 SERLOGICAL TESTS OF SYPHILIS:
STS
• Non-specific or lipoidal tests
• A. VDRL (venereal disease research laboratories)
- It is useful for the screening, diagnosis and
follow up.
- The results can be qualitative or qualitative
False positive results
• 1. Acute type: usually low titre and don’t persist for
more than 6 months
• 2. Chronic type: usually last for more than 6
months
• B. Rapid plasma reagin test.
• C. Wasserman test not used more
Dr.T.V.Rao MD 30
Laboratory Diagnosis of Syphilis
The Common Methods
• Serology
–Mainstay for syphilis
testing
–Two classes of serologic
tests
• Non-treponemal
• Treponemal
8 MD
Dr.T.V.Rao 31
 Specific serological tests of
Syphilis
• A. Reiter protein complement fixation
test.
• B. Fluorescent Treponemal
antibody/absorption test, FTA/ABS. the
most specific and most sensitive .
• C. Treponema pallidum
haemagglutination test- TPHA- D.
Treponema pallidum immobilization test-
TPI Dr.T.V.Rao MD 32
 Serologic Tests for Syphilis:
Non-Treponemal Assays
• Principle:
– T. pallidum infection leads to the production of reagin
• Reagin – Antibodies to substances released from
cells damaged by T. pallidum
– Reagin reacts with cardiolipin
• Cardiolipin – a phospholipid component of certain
eukaryotic and prokaryotic membranes
• Examples of non-treponemal tests:
– Rapid Plasma Reagin (RPR)
– Venereal Disease Research Laboratory (VDRL)

9 MD
Dr.T.V.Rao 33
 Serologic Tests for Syphilis:
Non-Treponemal Assays
• RPR and VDRL are agglutination assays

Charcoal

Cardiolipin

10 MD
Dr.T.V.Rao 34
 Serologic Tests for Syphilis:
Non-Treponemal Assays
• RPR and VDRL are agglutination assays

Charcoal
Cardiolipin
Reagin

Serum
or
CSF

11 MD
Dr.T.V.Rao 35
 VDRL

• Each preparation of antigen suspension should first be examined by

testing with known positive or negative serum controls.
• The antigen particles appear as short rod forms at magnification of about
100x. Aggregation of these particles into large or small clumps is
interpreted as degrees of positivity
• Reactive on left, non-reactive on right
Dr.T.V.Rao MD 36
 Rapid Plasma Reagin Test - RPR
• General screening test, can be adapted to
automation.
• CANNOT be performed on CSF.
• Antigen
– VDRL cardiolipin antigen is modified with choline chloride
to make it more stable
– attached to charcoal particles to allow macroscopic
reading
– antigen comes prepared and is very stable.
• Serum or plasma may be used for testing, serum is
not heated.

Dr.T.V.Rao MD 37
 RPR
• Test Procedure:
– Serum or plasma added to circle on card and spread.
– One drop of antigen from a needle capable of delivering 60 drops/mL
is added.
– Rotate at 100 rpms/minute for 8 minutes.
– Results are read macroscopically.
• Daily quality control:
– 20 gauge needle checked for delivery of 60 drops/mL
– Rotator checked for 100 rpms/minute
– Room temperature must be 23-29 C.
– Three levels of control must be run and give appropriate results.
• RPR appears to be more sensitive than the VDRL.

Dr.T.V.Rao MD 38
 Treponema pallidum haemagglutination
(TPHA)
• Adapted to micro
techniques (MHA-TP)
• Tanned sheep RBCs
are coated with T.
pallidum antigen from
Nichol’s strain.
• Agglutination of the
RBCs is a positive
result.
Dr.T.V.Rao MD 39
 Non-Treponemal Tests:
Advantages
• Rapid turnaround time – Minutes
• Inexpensive
• No specialized instrumentation
required
• Usually revert to negative following
therapy
–Can be used to monitor response
to therapy
12 MD
Dr.T.V.Rao 40
 Non-Treponemal Tests:
Limitations
• Results are subjective
– Intra- and Inter-laboratory variability
• Non-specific
– False positive results can result from other
infectious or non-infectious conditions
• EBV, Lupus, etc.
• Limited sensitivity in early/primary syphilis and in
late/latent syphilis
• Low throughput
– Problematic for high volume laboratories
13 MD
Dr.T.V.Rao 41
 Non-Treponemal Tests:
Limitations, continued
• Possibility for prozone effect
– High levels of antibody may inhibit the
agglutination reaction
– To identify prozone, labs must serially dilute
samples

Undilute 1:2 1:4 1:8 1:16

14 MD
Dr.T.V.Rao 42
 Serologic Tests for Syphilis:
Treponemal Assays
• Principle:
–Infection leads to production of
specific antibodies directed
against T. pallidum
• Treponemal tests detect IgG or
total IgM/IgG antibodies directed
against T. pallidum
15 MD
Dr.T.V.Rao 43
 Serologic Tests for Syphilis:
Treponemal Assays
• Microhemagglutination assay (MHA)
• Fluorescent treponemal antibody (FTA-ABS)
• Treponema pallidum particle agglutination (TP-PA)
• Enzyme Immunoassay (EIA)
• Multiplex Flow Immunoassay (MFI)
FTA-ABS TP-PA Conventional EIA

www.mastgrp.biz
Yellow wells = positive

16 MD
Dr.T.V.Rao 44
 Treponemal Assays:
Advantages
• High Specificity
• Possibly higher sensitivity during early
and late syphilis stages compared to
non-treponemal tests
• Newer Methods
– Objective result interpretation
– Automation option
– High throughput
– High reproducibility/precision
20 MD
Dr.T.V.Rao 45
 Fluorescent Treponemal Antibody
Absorption Test (FTA-ABS)
• Diluted, heat inactivated serum
added to Reiter’s strain of T.
pallidum to remove cross
reactivity due to other
Treponemes.
• Slides are coated with Nichol’s
strain of T. pallidum and add
absorbed patient serum.
Dr.T.V.Rao MD 46
 Fluorescent Treponemal Antibody
Absorption Test (FTA-ABS)
• Slides are washed, and incubated with
antibody bound to a fluorescent tag.
• After washing the slides are examined for
fluorescence.
• Requires experienced personnel to read.
• Highly sensitive and specific, but time
consuming to perform.
Dr.T.V.Rao MD 47
 Treponemal Assays:
Limitations
• Remain positive despite treatment
– Cannot be used to monitor response to
therapy
• Conventional Methods
– Subjective interpretation requiring
technician expertise to read
• Newer Methods
– Expensive instrumentation
– Higher cost/test
21 MD
Dr.T.V.Rao 48
 Traditional Algorithm
Non-treponemal test (e.g., RPR)
Reactive Non-reactive

Treponemal test (e.g., FTA) Negative for syphilis

Reactive Non-reactive

Syphilis Negative for syphilis

Advantages:
– Results show good correlation with disease status
– Rapid, inexpensive screening method
– Excellent option for laboratory with small throughput
– Recommended by the CDC

24 MD
Dr.T.V.Rao 49
 Traditional Algorithm
Non-treponemal test (e.g., RPR)
Reactive Non-reactive

Treponemal test (e.g., FTA) Negative for syphilis

Reactive Non-reactive

Syphilis Negative for syphilis

Disadvantages:
– Manual (RPR) and subjective interpretation
– Screening method is non-specific and may lead to false-positive
results
– Not suitable for high throughput laboratories
– Potentially lower sensitivity for detecting early syphilis and
late/latent disease

25 MD
Dr.T.V.Rao 50
 Reverse Algorithm
Treponemal test (eg, EIA)
Reactive Non-reactive

Non-Treponemal test (eg, RPR) Negative for syphilis

Reactive Non-reactive

Syphilis Second Treponemal Test (e.g., TP-PA)

Reactive Non-reactive

Evaluation Required* Negative for syphilis

27 MD
Dr.T.V.Rao 51
Every Pregnant women Needs
Screening

Dr.T.V.Rao MD 52
Genital Herpes Simplex

Dr.T.V.Rao MD 53
Genital Herpes Simplex - Clinical
Manifestations
• Direct contact – may be with asymptomatic shedding
• Primary infection commonly asymptomatic; symptomatic
cases sometimes severe, prolonged, systemic
manifestations
• Vesicles painful ulcerations crusting
• Recurrence a potential
• Diagnosis:
– Culture
– Serology (Western blot)
– PCR

Dr.T.V.Rao MD 54
 Epidemiology of Genital Herpes
• One of the 3 most common STDs, increased
30% from late 70s to early 90s
• 25% of US population by age 35
• HSV-2: 80-90%, HSV-1: 10-20% (majority of
infections in some regions)
• Most cases subclinical
• Transmission primarily from subclinical
infection
• Complications: neonatal
transmission, enhanced HIV
Dr.T.V.Rao MD 55
 Sores

Underdiagnoses of Genital Herpes

• 779 women attending STD clinic

• 372 genital herpes diagnosis:
– 363 HSV-2 antibody positive
– 9 HSV-1 culture positive lesions
• Of the 372 diagnosed with genital herpes
– 82 (22%) symptomatic
– 14 (4%) viral shedding without symptoms
– 60 (14%) history of symptoms
– 216 (58%) HSV-2 antibody without viral shedding or
history of symptoms
Dr.T.V.Rao MD 56
 Genital Herpes Simplex

Dr.T.V.Rao MD 57
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas
 Genital Herpes Simplex

Dr.T.V.Rao MD 58
Source: CDC/NCHSTP/Division of STD, STD Clinical Slides
 “Drips”
–Gonorrhea
–Nongonococcal urethritis
–Chlamydia
–Mucopurulent cervicitis
–Trichomonas vaginitis and
urethritis
–Candidiasis Dr.T.V.Rao MD 59
 Gonorrhea -
Clinical Manifestations
• Urethritis - male
– Incubation: 1-14 d (usually 2-5 d)
– Sx: Dysuria and urethral discharge (5% asymptomatic)
– Dx: Gram stain urethral smear (+) > 98% culture
– Complications
• Urogenital infection - female
– Endocervical canal primary site
– 70-90% also colonize urethra
– Incubation: unclear; sx usually in l0 d
– Sx: majority asymptomatic; may have vaginal
discharge, dysuria, urination, labial pain/swelling, abd. pain
– Dx: Gram stain smear (+) 50-70% culture
– Complications
Dr.T.V.Rao MD 60
 Gonorrhea

Dr.T.V.Rao MD 61
Source: Florida STD/HIV Prevention Training Center
 Gonorrhea Gram Stain

Dr.T.V.Rao MD 62
Source: Cincinnati STD/HIV Prevention Training Center
 Diagnosis not Easy
• Three levels of diagnosis are
defined on the basis of clinical
findings or the results of
laboratory diagnostic tests. A
definitive diagnosis of
gonorrhoea must be obtained for
medico legal purposes.
Dr.T.V.Rao MD 63
 Diagnosis of Gonorrhoea
• Suggestive diagnosis is defined by
the presence of:
• A mucopurulent endocervical or
urethral exudate on physical
examination and sexual exposure to
a person infected with N.
gonorrhoea.
Dr.T.V.Rao MD 64
 Presumptive diagnosis of gonorrhoea is made
on the basis of one of the following three
criteria:
• Typical gram-negative intracellular diplococci on
microscopic examination of a smear of urethral
exudate from men or endocervical secretions
from women*;
• Growth of a gram-negative, oxidase-positive
diplococcus, from the urethra (men) or
endocervix (women), on a selective culture
medium, and demonstration of typical colonial
morphology, positive oxidase reaction, and
typical gram- negative morphology;

Dr.T.V.Rao MD 65
Presumptive Diagnosis of Gonorrhoea

• The observation of gram-

negative, intracellular diplococci on
microscopic examination of
endocervical secretions from women
must be supported by a positive
result from a test from either 2 or 3
to make a laboratory diagnosis of
“presumptive N. gonorrhoea.”
Dr.T.V.Rao MD 66
 Definitive diagnosis of
gonorrhoea requires:
• Isolation of N. gonorrhoea from sites of
exposure
(e.g., urethra, endocervix, throat, rectu
m) by culture (usually a selective
medium) and demonstrating typical
colonial morphology, positive oxidase
reaction, and typical gram-negative
morphology
•
Dr.T.V.Rao MD 67
 Definitive diagnosis of gonorrhoea
requires:
• Confirmation of isolates by
biochemical, enzymatic, serologic, or nucleic
acid testing e.g., carbohydrate
utilization, rapid enzyme substrate
tests, serologic methods such as
coagglutination or fluorescent antibody tests
supplemented with additional tests that will
ensure accurate identification of isolates, or a
DNA probe culture confirmation technique.
Dr.T.V.Rao MD 68
 Newer Methods in Diagnosis of
Gonorrhoea
• Detection of N. gonorrhoea by a
nonculture laboratory test (Antigen
detection test (e.g., Gonozyme
[Abbott]), direct specimen nucleic
acid probe test (e.g., Pace II
[GenProbe]), nucleic acid
amplification test (e.g., LCR
[Abbott]). Dr.T.V.Rao MD 69
 Definitive diagnosis of
gonorrhoea requires:

• Isolation of N. gonorrhoea from sites of

exposure
(e.g., urethra, endocervix, throat, rectum) by
culture (usually a selective medium) and
demonstrating typical colonial
morphology, positive oxidase reaction, and
typical gram-negative morphology and

Dr.T.V.Rao MD 70
 Definitive diagnosis of gonorrhoea
requires:
• Confirmation of isolates by
biochemical, enzymatic, serologic, or nucleic
acid testing e.g., carbohydrate
utilization, rapid enzyme substrate
tests, serologic methods such as
coagglutination or fluorescent antibody tests
supplemented with additional tests that will
ensure accurate identification of isolates, or a
DNA probe culture confirmation technique.
Dr.T.V.Rao MD 71
 Drips

Nongonococcal Urethritis
• Etiology:
– 20-40% C. trachomatis
– 20-30% genital mycoplasmas (Ureaplasma
urealyticum, Mycoplasma genitalium)
– Occasional Trichomonas vaginalis, HSV
– Unknown in ~50% cases
• Sx: Mild dysuria, mucoid discharge
• Dx: Urethral smear 5 PMNs (usually 15)/OI
field
Urine microscopic 10 PMNs/HPF
Leukocyte esterase (+)
Dr.T.V.Rao MD 72
Chlamydia

Dr.T.V.Rao MD 73
 Chlamydia
• Chlamydia is an infection of the
penis, vagina, throat, or tube that
carries urine.
• Chlamydia is caused by bacteria (a kind
of germ).
• You get it by having sex with someone
who has Chlamydia.
• Chlamydia can be spread by the
vagina, penis, mouth, or anus.
Dr.T.V.Rao MD 74
 Chlamydia
• Too many people are continuing to have
unsafe sex, put themselves at risk of STIs and
the serious consequences associated with
infection, including infertility.
• "On-going investment in programmes to
increase sexual health awareness, condom use
and testing, particularly for groups at most
risk, is vital.

Dr.T.V.Rao MD 75
 Chlamydia trachomatis
• More than three million new cases annually
• Responsible for causing cervicitis, urethritis,
Proctitis, lymphogranuloma venereum, and
pelvic inflammatory disease
• Direct and indirect cost of chlamydial
infections run into billions of dollars
• Potential to transmit to newborn during
delivery
– Conjunctivitis, pneumonia

Dr.T.V.Rao MD 76
 Normal Cervix

Source: Claire E. Stevens, Seattle STD/HIV Prevention

Dr.T.V.Rao MD Training Center 77
 Chlamydia Cervicitis

Dr.T.V.Rao MD 78
Source: St. Louis STD/HIV Prevention Training Center
 Mucopurulent Cervicitis

Dr.T.V.Rao MD 79
Source: Seattle STD/HIV Prevention Training Center
 Drips

Laboratory Tests for Chlamydia

• Tissue culture has been the standard
– Specificity approaching 100%
– Sensitivity ranges from 60% to 90%
• Non-amplified tests
– Enzyme Immunoassay (EIA), e.g. Chlamydiazyme
• sensitivity and specificity of 85% and 97% respectively
• useful for high volume screening
• false positives
– Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-
2
• sensitivities ranging from 75% to 100%; specificities greater than
95%
• detects chlamydial ribosomal RNA
• able to detect gonorrhea and chlamydia from one swab
• need for large amounts of sample DNA
Dr.T.V.Rao MD 80
 Laboratory Tests for Chlamydia
(continued)
• DNA amplification assays
– polymerase chain reaction (PCR)
– ligase chain reaction (LCR)
• Sensitivities with PCR and LCR 95% and
85-98% respectively; specificity
approaches 100%
• LCR ability to detect chlamydia in first
void urine
Dr.T.V.Rao MD 81
 Chlamydia Direct Fluorescent
Antibody (DFA)

Dr.T.V.Rao MD 82
Source: Centers for Disease Control and Prevention
 Drips

Pelvic Inflammatory Disease (PID)

• l0%-20% women with GC develop PID
• In Europe and North America, higher proportion of C.
trachomatis than N. gonorrhoeae in women with
symptoms of PID
• CDC minimal criteria
– uterine adnexal tenderness, cervical motion tenderness
• Other symptoms include
– endocervical discharge, fever, lower abd. pain
• Complications:
– Infertility: 15%-24% with 1 episode PID secondary to GC or
chlamydia
– 7X risk of ectopic pregnancy with 1 episode PID
– chronic pelvic pain in 18%
Dr.T.V.Rao MD 83
 Chancroid
• The combination of a painful genital ulcer and
tender Suppurative inguinal adenopathy suggests
the diagnosis of Chancroid 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 dark field examination of ulcer
exudate or by a serologic test for syphilis
performed at least 7 days after onset of ulcers;
Dr.T.V.Rao MD 84
 Chancroid
• 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.
Dr.T.V.Rao MD 85
 Chancroid
• 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% (145).
Dr.T.V.Rao MD 86
 Granuloma Inguinale (Donovanosis)
• Granuloma inguinale is a genital ulcerative
disease caused by the intracellular gram-
negative bacterium Klebsiella granulomatis
(formerly known as Calymmatobacterium
granulomatis). The disease occurs rarely in the
United States, although it is endemic in some
tropical and developing areas, including India;
Papua, New Guinea; the Caribbean; central
Australia; and southern Africa (192,193).
Dr.T.V.Rao MD 87
 Granuloma Inguinale
(Donovanosis)
• Clinically, the disease is commonly
characterized as painless, slowly progressive
ulcerative lesions on the genitals or perineum
without regional lymphadenopathy;
subcutaneous granulomas (pseudoboboes)
might also occur. The lesions are highly
vascular (i.e., beefy red appearance) and
bleed easily on contact.

Dr.T.V.Rao MD 88
 Granuloma Inguinale
(Donovanosis)
• The causative organism is difficult to
culture, and diagnosis requires visualization of
dark-staining Donovan bodies on tissue crush
preparation or biopsy. No FDA-cleared
molecular tests for the detection of K.
granulomatis DNA exist, but such an assay
might be useful when undertaken by
laboratories that have conducted a CLIA
verification study.
Dr.T.V.Rao MD 89
 Lymph granuloma Venereum
• Lymph granuloma venereum (LGV) is
caused by C. trachomatis serovars
L1, L2, or L3 . The most common clinical
manifestation of LGV among
heterosexuals is tender inguinal and/or
femoral lymphadenopathy that is
typically unilateral.

Dr.T.V.Rao MD 90
 Lymph granuloma Venereum
• Diagnosis is based on clinical
suspicion, epidemiologic
information, and the exclusion of other
Aetiologies for proctocolitis, inguinal
lymphadenopathy, or genital or rectal
ulcers. C. trachomatis testing also should
be conducted, if available.

Dr.T.V.Rao MD 91
 Lymph granuloma Venereum
• 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.
NAATs for C. trachomatis are not FDA-cleared for
testing rectal specimens, although some
laboratories have performed the CLIA validation
studies that are needed to provide results for
clinical management. Additional molecular
procedures (e.g., PCR-based genotyping) can be
used to differentiate LGV from non-LGV C.
trachomatis, but these are not widely available.
Dr.T.V.Rao MD 92
 Lymph granuloma Venereum
• chlamydia serology (complement fixation
titers >1:64) can support the diagnosis of LGV
in the appropriate clinical context.
Comparative data between types of serologic
tests are lacking, and the diagnostic utility of
serologic methods other than complement
fixation and some micro immunofluorescence
procedures has not been established.

Dr.T.V.Rao MD 93
•
Trichomoniasis
An estimated 5 million new cases occur each year in women and men.
• Occurs in vagina of women so may be sexually transmitted to men using infected
washcloths and towels.
• It is transmitted to the baby during delivery.
• It also can occur in the urethra (carries urine to penis) in men, doesn’t have
symptoms usually.

SYMPTOMS:
Appear within 5 to 28 days of exposure
Women usually have a vaginal discharge that
FEMALE SYMPTOMS:
Itching and burning at the outside of the opening of the
vagina and vulva.
Painful and frequent urination
Heavy, unpleasant smelling greenish, yellow discharge
MALE SYMPTOMS:
Usually nothing, or discomfort in urethra, inflamed head of
the penis.

Dr.T.V.Rao MD 94
 Bacterial Vaginitis
• Controversy: STD - yes or no
• Need for treatment
– 1980: only if patient complains
– 2002: increased risk of:
• Preterm birth / premature rupture of membranes
• Amniotic fluid infection
• Chorioamnionitis / Postpartum endometritis
• Pelvic inflammatory disease
• Postsurgical infection
• Cervical intraepithelial neoplasia
• Mucopurulent cervicitis
• Acquisition of HIV Dr.T.V.Rao
infection MD 95
Life at Risk with Sexually Transmitted Infections
Best Choice Play safe

Dr.T.V.Rao MD 96
• Programme Created by Dr.T.V.Rao MD
for Medical and Paramedical Students in
the Developing World
• Email
• doctortvrao@gmail.com

Dr.T.V.Rao MD 97