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what is the cause of genital herpes?
- HSV2
- but also HSV1 due to oro-genital route
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what is transmission of genital herpes?
- sexual
- vertical especially if active infection at time of delivery
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which age and gender has highest rates of genital herpes?
20-24 yo females
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how does genital herpes present?
- shallow painful ulcers
- may coalesce
- associated painful regional lymphadenopathy (inguinal)
- discharge
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how long does it take for the ulcers to heal?
10-14 days
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how else may women present with a primary attack of genital herpes?
urinary retention
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what else may the herpes ulcers be associated with?
- fever
- headache
- myalgia
- =constitutional symptoms
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if a mother is known to have active genital herpes, what should be done and why?
- have c-seciton
- as neonatal HSV can result in encephalitis, meningo-encephalitis, conjunctivitis
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what Ix is done to detect HSV?
- swabs of ulcer, vesicular fluid
- culture, PCR
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what is Rx of genital herpes?
- aciclovir
- symptom relief: soak in warm salty water
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what advise do you give if pt has genital herpes?
sexual abstinence whenever lesions are present or the tingling sensation indicating imminent presentation as condoms may not cover all areas affected
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what is prognosis difference between HSV 1& 2?
- HSV1: recurrence less, 1 or 2 in lifetime
- HSV2: fortnightly recurrence in first year
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for genital herpes, where does the HSV stay dormant in latency?
- sacral sensory root ganglia
- S2-5
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how have i caught herpes if my partner does not have symptoms?
2/3 people who contract the virus catch it from someone who is asymptomatic
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can i catch herpes from a toilet seat?
HSV can only survive for a short time away from body so no
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what brings on an attack of herpes?
- when latent virus is reactivated
- factors: local trauma, UV light, immunocompromised eg HIV or malignancy
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will all the attacks of herpes be painful?
- 1st symptomatic attack of herpes is usually the worst
- subsequent attacks are shorter and less painful
- use painkillers eg codeine phosphate or salt baths
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do i need to treat each attack?
usually only initial episode of genital herpes is treated with antivirals as treatment of subsequent attacks has little influence on symptoms and duration
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whats main difference in presentation between primary and recurrent infection?
primary: systemic symptoms, lack of previous symptoms, new sexual partner
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why dysuria in genital herpes?
- urine over an ulcer
- inflammation on urethra during primary episode
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why discharge in genital herpes? and which type of infection?
- intense cervicitis in females with HSV
- so if able to look at cervix: inflamed and mucopurulent discharge
- primary infection
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what is differential for genital ulceration?
- herpes
- primary or secondary syphilis
- chancroid
- LGV
- donovanosis = granuloma inguinale
- herpes zoster
- apthosis
- behcets
- drug eruptions
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non infectious causes of genital ulcers?
- Behcets disease: genital oral eye joint
- drug eruptions
- skin diseases
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if a patient in UK presented with painful genital ulcers
- HSV
- syphilis
- other routine STI screen
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what would make you think an ulcer is syphilis?
- painless
- solitary ulcer on penis
- feel base of ulcer: firm hard feeling = induration
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how do you differentiate chancroid from syphilis (CHANCRE)?
- chancroid: soft
- syphilis: hard
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pattern of inguinal gland involvement
- herpes: small shotty nodes
- syphilis: large rubbery non tender node
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female pt with pair of ulcers close to anus?
- syphilis
- doesn't have to be solitary, can be pair esp where skinfold
- = kissing ulcer
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what is dark ground microscopy?
specimen to special microscope - black background and see spirochetes against black background.
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what is the quickest way of confirming syphilis?
- dark ground microscopy - quickest way to confirm syphilis
- but now doing less with PCR
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multiple small painful ulcers with pus like base?
chancroid
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what is difference between chancroid and herpes?
- pattern of inguinal node involvmeent
- chancroid: abscess in groin requiring incision and drainage
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what is cause of chancroid? organism
haemophilus ducreyi G-ve rod
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Rx for syphilis?
benzathene penicilin for syphilis?
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2 bacterial causes of gen ulcer?
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what is and causes LGV?
- lymphogranuloma venereum
- chlamydia trachomatis: specific strain L123
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2 patterns of presentation of LGV?
- classic: small ulcer (size of herpes) which is transient and disappears quickly, present at stage when organism already in LN - intense inflammation
- current: outbreak of LGV in europe - gay HIV+ men present with proctitis. don't SEE LN involvement but they are internally. mimics IBC
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what is the difference between most chlamydias and the ones that cause LGV?
the LGV ones are very invasive
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what does LGV in MSM mimic?
- IBD inflammatory bowel disease
- even at histological level
- bad cos treat IBD with steroids which makes LGV worse and HIV worse
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what is Rx for LGV?
3 weeks doxycycline
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what causes granuloma inguinale
- intracellular Klebsiella granulomatis
- tropics - papua new guinea, india
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what is pathogenesis of granuloma inguinale?
ulcer into lymphatics and LN and erupts through overlying skin - hypertrophic granulomatous lesions in groins
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what is differential for granuloma inguinale?
secondary syphilis: condylomata lata
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how would you manage someone with acute primary HSV infection?
- very painful and distressing
- tell pt: viral infection so will resolve spontaneously
- aciclovir: 5times a day for 5 days
- primary episode: accelerate healing, sooner the treat the better, if delay for 48 hours not much benefit
- analgesia: NSAID, topical lidocaine if v severe pain
- urethritis can be v painful: pass urine into warm bath water
- psychological support as lifelong infection, cant eliminate
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what is complication of primary HSV?
- urinary retention
- need catheterisation for 24-48 hours
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what is value of giving ACV in recurrent episode of HSV?
recurrent episode: less value of ACV, may reduce duration for half a day
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when do you use ACV for recurrent disease?
- suppression
- if > 6/year
- give for up to 1 year
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how would you follow up herpes patient?
- complete STI screen
- HSV culture result - prognosis
- info about HSV and special services
- partner management - transmission issues, couple counselling in herpes clinics
- measure serology
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'where has the infection come from?'
- new partner: usually within 14 days of sex
- or previous partner and now suddenly immunosuppressed so show it eg HIV
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can they spread infection while in acute primary phase?
- yes and
- don't go near neonates eg nurses - dangerous to neonates
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can you autoinnoculate infection? eg touch genital then touch eye
no
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what is herpetic whitlow?
infection on finger nail - paronychia
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how prevent transmission?
- not to have sex due to asymptomatic shedding
- once diagnosed with herpes can shed intermittently for rest of life, most heavily during active lesions
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how effective is condom use?
- recommended but not great protection
- on male shedding from glans: protection is ok
- female from vulval area: only protect male shaft of penis
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how do you assess susceptibility of new partners to get HSV from an infeced one?
- type specific serology
- if same Ab then risk is negligible
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what 3 ways can transmission be reduced?
- condoms
- sexual abstinence during episodes
- aciclovir
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what does TINEA CRURIS look like?
- red confluent patches
- in creases of groin and natal cleft
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how do you treat TINEA CRURIS?
- topical antifungal and steroid cream
- partner does not need to be tested or treated
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how do you treat scabies?
- topical malathion from neck down
- wash all worn clothes, towels, bed linen
- Rx sexual partner and household contact
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which 3 genital lesions can you get from travelling?
- chancroid
- granuloma inguinale
- lymphogranuloma venereum
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I have never had penetrative sex, how did I catch warts?
transmitted through microabrasions in skin/skin contact
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how common is HPV?
very common 10-20% of 15-49 year olds have genital tract HPV DNA but only 10% have skin lesions
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symptoms of warts?
- usually no physical discomfort unless perianal or large growths may cause irritation or soreness
- urethral anal or cervical warts may cause bleeding
- urethral warts may disrupt urinary stream
-
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When will the warts go away?
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When did I catch the warts?
- infectious even if not visible
- period of infectiousness varies from weeks to few years
- 95% HPV negative after 2 years of infection
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Why doesn’t my partner have warts?
incubation 2 weeks to 9 months, can be longer
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I read on the internet that I shouldn’t smoke if I have warts, why is that?
smokers respond less to treatment
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Will my warts come back?
1/3 recur in first 3 months
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Will the warts affect my fertility?
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Will condoms protect future partners from infection?
condoms reduce but not prevent transmission as skin around the penis will be affected
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Because I have warts will I have cervical cancer?
- no as different strains of HPV
- 6, 11 for warts
- 16, 18 for cervical cancer
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I have heard there is a vaccine for warts is that true?
yes in the quadrivalent vaccine: 6, 11, 16, 18 (gardasil)
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I am pregnant will my baby catch my warts?
no
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what % of adults have antibodies to HSV1?
80%
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what % of adults have antibodies to HSV2?
10-80%
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what % of those with HSV2 antibodies remember previous symptoms?
<10%
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how is genital herpes transmitted?
- skin to skin contact
- NOT GENITAL FLUIDS
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when is genital herpes a problem in pregnancy?
if it is the first episode of herpes during pregnancy then can harm baby
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how may a patient present in A&E with genital herpes?
urinary retention secondary to herpes
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