STI

MCQ
 KEY POINTS

• Caused by Treponema Pallidum (Spirochete)

• Enters through breaks and abrasions in the skin and mucosa
• Primary Syphilis : Painless Chancre
• Secondary Syphilis : Diffuse skin rash, mucocutaneous lesions and
lymphadenopathy
• Tertiary Syphilis : Gumma, Cardiac, ophthalmic, auditory, meningitis,
neurosyphilis
• Latent Syphilis : Asymptomatic patient found to have positive screening
- Late Latent syphilis : Unknown duration
- Early Latent syphilis : within 90 days of exposure
 PRIMARY SYPHILIS- CHANCER

• Painless Clean Smooth shallow based ulcer with smooth borders

• Usually in the genital tract but can be present anywhere on the body

• Many women cannot see the chancer on the perineum or in the vagina so it goes

unnoticed until they have secondary syphilis

• Single Lesion!

• Heals slowly over 4-6 weeks

 PRIMARY SYPHILIS- DIAGNOSIS

• Dark Field microscopy is the only test that diagnosis syphilis specifically but rarely
used clinically

• The diagnosis is typically made clinically (CHANCRE) + 2 Lab tests:

-Non-treponemal tests : RPR or VRDL (Screening)

Purpose: Screening + Monitor tx efficacy (Titers should show 4 fold decrease)

- Treponemal specific: FT-ABS (Confirmatory)

N.B : After resolution the non-treponemal tests will be non-reactive but the FT-ABS
remains positive for life

A negative FT-ABS does not rule out syphilis because it may be transiently negative
 PRIMARY SYPHILIS- TREATMENT

• Single does of Intramuscular Benzathine penicillin G 2.4 million units

• Follow the patient with non-treponemal test to monitor resolution because FT-ABS
will always remain positive.
• Non-treponemal test titer should decrease by four-fold at 6 months
• Repeat also at 12 months
• A titer of 1:4 is considered successful treatment

“Patients with syphilis should be followed with repeat non-

treponemal tests and clinical examination at 6 and 12 months”
 PRIMARY SYPHILIS- TREATMENT IN HIV
PATIENTS

• This is a special category because :

- Higher risk of neurological complication
 Should be evaluated every 3 months, starting after the
treatment
 PRIMARY SYPHILIS- TREATMENT
FAILURE

• For patients with treatment failure  Need to rule out

neurosyphilis (CSF)
• Give weekly benzathine pen G intramuscularly for 3 doses as
long as the CSF excludes neurosyphilis
 SECONDARY SYPHILIS

• Fever, myalgia, headache, rash (Palms and Soles)

• Over 2-10 weeks of untreated primary syphilis
 TERTIARY SYPHILIS

• After secondary syphilis can remain latent for years and then
present as tertiary syphilis
• Neurological & Cardiac Complications
 SYPHILIS IN PREGNANCY

• Can be transmitted :
- Transplacental
- Direct contact with lesion during birth
 SYPHILIS IN PREGNANCY -ULTRASOUND

• Placentomegaly, hydrops, fetal growth restriction

 SYPHILIS IN PREGNANCY- OUTCOMES

• Stillbirth, prematurity, neonatal death

• Congenital infections : Blindness, deafness, abnormal teeth and
bone
• Neonate can have hepatosplenomegaly, rhinorrhea, SGA,
maculopapular rash
 SYPHILIS IN PREGNANCY- SCREENING

• Screen ALL women in the first trimester

• Women who live in high risk areas should be tested again in
the third trimester at 28 and 32 weeks
 TX OF ADVANCED SYPHILIS

• PRIMARY + SECONDARY SYPHILIS :

Single dose of Benzathine Penicillin G
• Patients with latent syphilis of unknown duration require 3 or more
doses
• If a patient skips a dose the treatment must be re-initiated
• Monitor response at 6-12 months
• Some pregnant women might not have the fourfold decline and
require additional monitoring
• Intravenous aqueous penicillin is used in patients with signs or
symptoms of neurosyphilis, such as loss of muscle function,
generalized paresis, or seizures.
 SYPHILIS IN PREGNANCY- ALLERGIES TO
PENICILLIN

• Benzathine pen G is the only effective treatment

• If allergic should be desensitized
• Monitor for treatment failure and re-infection at 6months, 12
months and 24 months post-treatment
• Repeat titers at 28weeks
 ALLERGY IN NON-PREGNANT

• In nonpregnant penicillin-allergic patients, other

antibiotics such as tetracyclines, azithromycin, and
cephalosporins (including ceftriaxone) are acceptable,
but these medications are not considered adequate
during pregnancy.
 JARISCH–HERXHEIMER
REACTION

• Acute reaction that can occur in the first 24 hours after

treatment
• Fever, headache, myalgias, premature labor
• In pregnancy it presents as preterm contractions, decreased
fetal movement and late decelerations
 CHLAMYDIA -BACKGROUND

• Most frequently reported genital infection disease in the US

• Asymptomatic presentation is common  Diagnosis relies on screening

rather than clinical presentation

 CHLAMYDIA -DIAGNOSIS

• Nucleic Acid Amplification test – NAAT

• Can be conducted on urine and endocervical sample

 CHLAMYDIA -SCREENING

• PPV and NPV depend on prevalence

• Screening sexually active women younger than 24 years of age
• If older than 24 with risk factors : STI history, multiple or new partner 
SCREEN
• Prevalence is high in certain populations :
1- African American
2- Hispanics
3- Incarcerated
4-Military recruits
5- STI clinics
 CHLAMYDIA -TREATMENT

• Azithromycin dihydrate/doxycycline BID for 7days

• Test of cure :
- Women who are suspected to be reinfected
- Did not complete their antibiotics course
- Pregnant
• If done, should be done more than 3 weeks after treatment
because it can remain false positive if done before