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Pediatric Resident Academic Half Day March 21, 2013 Dr. A. Bates, PGY 5 Pediatric Pediatric Resident Academic Half Day March 21, 2013 Dr. A. Bates, PGY 5 Pediatric Infectious Disease Fellow

http: //www. youtube. com/watch? v=D 4 Y 3 QXOZY 6 E http: //www. youtube. com/watch? v=D 4 Y 3 QXOZY 6 E

Background World Health Organization 2005: • Sexually transmitted infections among adolescents: the need for Background World Health Organization 2005: • Sexually transmitted infections among adolescents: the need for adequate health services • • Since the International Conference on Population and Development in Cairo in 1994, recognition of young people’s specific sexual and reproductive health needs has gradually increased

Background • • Attempts to date to promote the sexual health of young people Background • • Attempts to date to promote the sexual health of young people have tended to focus on prevention, education and counselling for those who are not yet sexually active While the provision of health services to those who have already engaged in unprotected sexual activity and faced the consequences, including pregnancy, STIs or sexual violence, has lagged behind

Background challenges - global and local • • increasing populations • antimicrobial resistance • Background challenges - global and local • • increasing populations • antimicrobial resistance • global travel • co-infections

Objectives recognize common sexually transmitted infections in adolescents create a general management plan special Objectives recognize common sexually transmitted infections in adolescents create a general management plan special circumstances: HIV Post exposure prophylaxis sexual abuse

What is a sexually transmitted Infection The term STI (Sexually Transmitted Infection) is now What is a sexually transmitted Infection The term STI (Sexually Transmitted Infection) is now commonly used in the place of STD (Sexually Transmitted Disease) it is more encompassing it includes infections that may be asymptomatic

What is happening on the Canadian Front? three nationally reportable STIs chlamydia, gonorrhea and What is happening on the Canadian Front? three nationally reportable STIs chlamydia, gonorrhea and syphilis increasing rate of all three infections since 1997

Epidemiology 15 -24 yo represent ~ 25% of the sexually experienced population they acquire Epidemiology 15 -24 yo represent ~ 25% of the sexually experienced population they acquire ~ half of all new STDs Compared with older adults, sexually active adolescents aged 15– 19 years and young adults aged 20– 24 years are at higher risk of acquiring STDs for a combination of behavioral, biological, and cultural reasons.

Epidemiology multiple factors involved adolescent females have an increased susceptibility to Chlamydia trachomatis because Epidemiology multiple factors involved adolescent females have an increased susceptibility to Chlamydia trachomatis because of increased cervical ectopy multiple barriers lack of transport, discomfort with the facility/service design, concerns re: confidentiality

Canadian Stats 2009 Chlamydia AB - 366 cases/100 000 ppl Rates (per 100 000) Canadian Stats 2009 Chlamydia AB - 366 cases/100 000 ppl Rates (per 100 000) 10 -14 yo - 29. 1 15 -19 1041. 7 20 -24 yo - 1373. 8 steadily increasing in Canada since 1997

Canadian Stats 2009 Gonorrhea AB - 42 cases/100 000 ppl Rates (per 100 000) Canadian Stats 2009 Gonorrhea AB - 42 cases/100 000 ppl Rates (per 100 000) 10 -14 yo - 3. 8; 15 -19 102. 5 20 -24 yo - 145. 2 from 1997 -2004 - rate has increased by ~ 94% resistance - quinolones (up to 15. 7% in 2005)

Canadian Stats 2009 Syphilis 15 -19 yo - 52 cases 20 -24 yo - Canadian Stats 2009 Syphilis 15 -19 yo - 52 cases 20 -24 yo - 193 cases previously rare - by 2006 in Canada - incrased to 1 493 cases (regional outbreaks) risk groups - MSM (HIV positive and neg) sex workers and their clients acquisition in endemic regions

Further Epidemiology of Canadian STIs HPV - very common not reportable so true incidence Further Epidemiology of Canadian STIs HPV - very common not reportable so true incidence not known Most affected - adolescent and young adult woment and ment HSV - 1 & 2 - common not reportable but seroprevalence indicate rates of at least 20% very common in both adolescent and adult men and women (women > men)

Why the Increase? better diagnostics (NAATs) suboptimal youth awareness and knowledge of risk-reduction behaviours Why the Increase? better diagnostics (NAATs) suboptimal youth awareness and knowledge of risk-reduction behaviours sex is occurring at an early age (and longer throughout life) high rates of serially monogamous relationships adolescents (and public in general) have a poor understanding of transmission risks vaginal, anal and oral “party drugs” are increasingly linked to unsafe sexual behaviours

Why the Increase? other unique factors with adolescents where do they get there education Why the Increase? other unique factors with adolescents where do they get there education from? where do they get testing/treatment from? social factors - peer pressure, games, etc.

Approach Primary prevention Secondary prevention Approach Primary prevention Secondary prevention

Approach Primary prevention aims to prevent exposure identify at-risk individuals thorough assessments patient centred Approach Primary prevention aims to prevent exposure identify at-risk individuals thorough assessments patient centred counselling education

Approach Secondary prevention reduction of STI prevalence detection of infection in at-risk populations counselling Approach Secondary prevention reduction of STI prevalence detection of infection in at-risk populations counselling timely partner notification and treating infected individuals and contacts goal: preventing and/or limiting further spread

Which Statement Is True? 1) The presence of an acute infection can increase the Which Statement Is True? 1) The presence of an acute infection can increase the risk of co-infection 2) Sequelae of women from untreated CT/GC can include infertility 3) Persistent HPV infections plays a role in cervical dysplasia and carcinoma 4) Chronic viral STI (i. e. HSV) can have long standing negative impacts on patient’s psychosocial well-being 5) All the above

Which Statement Is True? 1) The presence of an acute infection can increase the Which Statement Is True? 1) The presence of an acute infection can increase the risk of co-infection (ie chancre and HIV) 2) Sequelae of women from untreated CT/GC can include infertility (chronic pelvic pain, ectopic pregnancy, PID) 3) Persistent HPV infections plays a role in cervical dysplasia and carcinoma (role for vaccine) 4) Chronic viral STI (i. e. HSV) can have long standing negative impacts on patient’s psychosocial well-being 5) All the above

Approach to Adolescents with Sexually Transmitted Infections History Exam Investigations Managements Approach to Adolescents with Sexually Transmitted Infections History Exam Investigations Managements

HISTORY think about STI risk factors. . . HISTORY think about STI risk factors. . .

STI Risk Factors sexual contact with a person with a known STI sexually active STI Risk Factors sexual contact with a person with a known STI sexually active youth under 25 yo new sexual pertner or more than 2 in the past year serially monogamous relationships no contraception or SOLE use of non-barrier contraception IVDU substance use - ETOH, rec Rx (esp if assoc with having sex)

STI Risk Factors engaging in unsafe sexual practices (sharing sex toys, sex with blood STI Risk Factors engaging in unsafe sexual practices (sharing sex toys, sex with blood exchange, unprotected sex - oral/genital/anal) sex workers survival sex street involvement, homelessness anonymous sexual partnering (rave party, internet, bathhouse) victims of sexual assault/abuse previous STI

History very thorough HEADDSSS history confidentiality empathy non judgemental focused sexual history History very thorough HEADDSSS history confidentiality empathy non judgemental focused sexual history

Sexual History Patient comfort genital signs and symptoms systemic symptoms fever discharge weight loss Sexual History Patient comfort genital signs and symptoms systemic symptoms fever discharge weight loss dysuria lymphadenopathy abdominal pain testicular pain rashes and lesions prevention immunizations, condoms Rx treatments, allergies

Sexual History relationships: are you sexually active now or have you ever been? incl Sexual History relationships: are you sexually active now or have you ever been? incl oral, and vaginal do you have any concerns about sexual or relationship violence or abuse?

Sexual History sexual risk behaviour number of partners sexual preference, orientation sexual activities - Sexual History sexual risk behaviour number of partners sexual preference, orientation sexual activities - give or receive oral sex? anal sex? personal risk - sex with people from other countries, bathhouses, travelling use of condoms?

Sexual History STI history have you ever been tested for an STI/HIV? last screening Sexual History STI history have you ever been tested for an STI/HIV? last screening date? have you ever had an STI in the past? if yes, what and when? how long have symptoms been on going

Sexual History Reproductive health history use of contraception? frequency? problems? ever been pregnant? used Sexual History Reproductive health history use of contraception? frequency? problems? ever been pregnant? used emergency contraception?

Other High Risk Behaviors Substance use ETOH, IVDU, sex while intoxicated tattoos or piercings Other High Risk Behaviors Substance use ETOH, IVDU, sex while intoxicated tattoos or piercings Psychosocial history traded sex for money, drugs, shelter? paid for sex? forced to have sex? sexually abused (mentally, physically) have a home? live with anyone other than family? Encounters with the law

Exam Common to both sexes systemic signs - weight loss, fever, enlarged LNs mucocutaneous Exam Common to both sexes systemic signs - weight loss, fever, enlarged LNs mucocutaneous regions (incl pharynx) external genitalia - lesions, inflammations, genital d/c, anatomical irreg perianal inspection

Exam adolescent males palpate scrotal contents (attn to epididymis) retract foreskin to inspect the Exam adolescent males palpate scrotal contents (attn to epididymis) retract foreskin to inspect the glans “milk” the urethra - discharge adolescent females separate labia - visualize vaginal orifice speculum exam - cervix, vaginal walls bimanual exam - uterine or adnexal masses or tenderness

Investigations Urine - first void - CT/GC (NAATs) Serum - Syphilis EIA/RPR anti-HIV 1/2 Investigations Urine - first void - CT/GC (NAATs) Serum - Syphilis EIA/RPR anti-HIV 1/2 antibodies Hep. Bs Ag, Hep. Bs Ab Hep. C Ab Hep. A Ab Cervix: Endocervical canal - swab for CT and GC culture/NAAT (12 cm - columnar epithelial cells); direct inoculate for N. gonorrhoeae onto culture plate or transport medium Exocervical samples - HSV, HPV

Investigations Lesions vesicles - deroof and swab - HSV PCR ulcers - HSV PCR; Investigations Lesions vesicles - deroof and swab - HSV PCR ulcers - HSV PCR; Syphilis - dark field microscopy, PCR, DFA/IFA Pharynx - posterior pharynx and tonsillar crypts (culture) Rectum - CT, GC, HSV

Investigations Urethra thin, dry flex swab, moistened (3 -4 cm males; 1 -2 cm Investigations Urethra thin, dry flex swab, moistened (3 -4 cm males; 1 -2 cm females) rotate slowly -> prepare a slide; inoculate on culture/transport medium “milking” penis 3 -4 x helps Vaginal collect pooled vaginal secretions; or swab in posterior fornix (usually done during speculum exam) Warts/Other HPV infections scrape exocervical for superficial epithelial cells; use cytobrushes to collect from squamo-columnar junction HPV DNA

Post Test Counselling organism/syndrome specific advise education about transmission, safer sex practices case reporting Post Test Counselling organism/syndrome specific advise education about transmission, safer sex practices case reporting requirements partner notification use of motivational interviewing strategies (both primary and secondary prevention)

Common Signs/Symptoms Common Signs/Symptoms

Which of the Statements are True? 1) patients with organisms causing urethritis almost always Which of the Statements are True? 1) patients with organisms causing urethritis almost always have symptoms 2) patients should abstain from unprotected sex until 7 days after starting treatment 3) when collecting urine for NAAT for CT/GC, collection of mid-stream urine is recommended 4) if abuse is suspected, NAAT testing is sufficient

Which of the Statements are True? 1) patients with organisms causing urethritis almost always Which of the Statements are True? 1) patients with organisms causing urethritis almost always have symptoms - up to 25% are asymptomatic (esp NGU) 2) patients should abstain from unprotected sex until 7 days after starting treatment 3) when collecting urine for NAAT for CT/GC, collection of mid-stream urine is recommended - first-catch urine 4) if abuse is suspected, NAAT testing is sufficient need a culture

Asymptomatic Neisseria gonorrhoaea Chlamydia trachomatis Syphilis HSV 1 & 2 HPV HIV Viral hepatitis Asymptomatic Neisseria gonorrhoaea Chlamydia trachomatis Syphilis HSV 1 & 2 HPV HIV Viral hepatitis

Urethritis urethral discharge burning on urination irritation of the distal urethra or meatus meatal Urethritis urethral discharge burning on urination irritation of the distal urethra or meatus meatal erythema Gonococcal urethritis - urethritis develops 2 to 6 days NGU urethritis - 1 to 5 wks (avg 2 -3) after acquisition

Urethritis Pathogens Urethritis Pathogens

Urethritis Pathogens N. gonorrhea C. trachomatis Trichomonas vaginalis HSV Mycoplasma genitalium Ureaplasma urealyticum * Urethritis Pathogens N. gonorrhea C. trachomatis Trichomonas vaginalis HSV Mycoplasma genitalium Ureaplasma urealyticum * Adenovirus * Candida albicans

Chlamydia Background caused by Chlamydia trachomatis serovars D to K under diagnosed usual incubation Chlamydia Background caused by Chlamydia trachomatis serovars D to K under diagnosed usual incubation is 2 to 3 wks (up to 6 wks) without treatment, infection can persist for many months individuals with N. gonorrhea are usually co-infected with C. trachomatis Screen sexually active females under 25 years

Chlamydia Signs/Symptoms females - most often asymptomatic; cervicitis, vaginal discharge, dysuria, conjunctivitis males - Chlamydia Signs/Symptoms females - most often asymptomatic; cervicitis, vaginal discharge, dysuria, conjunctivitis males - often asymptomatic; urethral discharge, urethritis, dysuria, conjunctivitis, proctitis neonates/infants - conjunctivitis in neonates; pneumonia in infants < 6 months

Chlamydia Testing NAATs are the most sensitive and specific done on urine, urethral and Chlamydia Testing NAATs are the most sensitive and specific done on urine, urethral and cervical (blood and mucus can affect test) culture preferred for medico-legal purposes and recommended for throat specimens serology not useful for acute genital chlamydial infections conjunctival swab for culture, DFA

Chlamydia Treatment Preferred: Azithromycin 1 g PO x 1 or Doxy 100 mg PO Chlamydia Treatment Preferred: Azithromycin 1 g PO x 1 or Doxy 100 mg PO BID x 7/7 Infants with conjunctivitis: need systemic treatment - Erythromycin x 14 d (can use Azithro once > 1 mo)

Chlamydia Aftermath Major sequelae: female - PID, ectopic pregnancy, chronic pelvic pain, reactive arthritis, Chlamydia Aftermath Major sequelae: female - PID, ectopic pregnancy, chronic pelvic pain, reactive arthritis, infertility males - epididymo-orchitis, reactive arthritis

Chlamydia Followup Test of cure not routine Required if: poor compliance alternative Tx used Chlamydia Followup Test of cure not routine Required if: poor compliance alternative Tx used prepubertal children pregnant women done at 3 -4 wks (avoid FP)

Gonnorhea Background Neisseria gonorrhea, gram negative diplococci concerns of drug resistance quinolones - not Gonnorhea Background Neisseria gonorrhea, gram negative diplococci concerns of drug resistance quinolones - not recommended in Canada (> 3 -5% R) incubation - 2 to 7 days most affected 15 -19 yo females and 20 -24 yo males

Gonnorhea Signs/Symptoms Neonates/Infants - Ophthalmia, neonatal AF infection and disseminated gonococcal infection (sepsis) Females Gonnorhea Signs/Symptoms Neonates/Infants - Ophthalmia, neonatal AF infection and disseminated gonococcal infection (sepsis) Females - cervicitis, PID, urethritis, perihepatitis, batholinitis Males - urethritis, epididymitis Both - pharyngeal infection, conjunctivitis, disseminated infection - arthritis, dermatitis, endocarditis, meningitis

Gonnorhea Testing gram stain - 95% sense/spec on urethral specimens young males; 45 -65% Gonnorhea Testing gram stain - 95% sense/spec on urethral specimens young males; 45 -65% sense and 90% spec on endocervical specimens CULTURE - susceptibilities sexual abuse/assault, pharynx, blood (disseminated) treatment failure NAATs - cervical, urethral swabs, urine; some for vaginal swabs URINE preferred no serology

Gonnorhea Treatment 2012 PHAC STI Low risk* - Cefixime 800 mg PO x 1 Gonnorhea Treatment 2012 PHAC STI Low risk* - Cefixime 800 mg PO x 1 High risk* - MSM, treatment failures - Ceftriaxone 250 mg IM x 1 Fluoroquinolones ONLY IF susceptibility testing demonstrates susceptible local R is < 5% and TOC can be done Tx all patients for Chlamydia

Gonnorhea Followup Test of cure all pharyngeal infections persistent symptoms or signs post-Tx those Gonnorhea Followup Test of cure all pharyngeal infections persistent symptoms or signs post-Tx those treated with alternative regimen cases linked to drug resistant/Tx failures treated with the same antibiotic sexual abuse, neonates

Gonnorhea Aftermath Sequelae females - PID, infertility, ectopic pregnancy, chronic pelvic pain, reactive arthritis, Gonnorhea Aftermath Sequelae females - PID, infertility, ectopic pregnancy, chronic pelvic pain, reactive arthritis, disseminated gonococcal infection males - epididymo-orchitis, reactive arthritis, infertility (rare), disseminated gonococcal infection

Which of the statements re: PID is True? 1) the most common infectious cause Which of the statements re: PID is True? 1) the most common infectious cause of lower abdominal pain in young women is cystitis 2) Most PID is associated with more than one organism 3) Most cases of PID present to ER 4) There is no long-term sequelae from PID

Which of the statements re: PID is True? 1) the most common infectious cause Which of the statements re: PID is True? 1) the most common infectious cause of lower abdominal pain in young women is cystitis - PID 2) Most PID is associated with more than one organism 3) Most cases of PID present to ER - 2/3 go unrecognized and underreported 4) There is no long-term sequelae from PID - tubal factor infertility, ectopic preg, chronic pelvic pain directly related to number of episodes

Pelvic Inflammatory Disease lower abdominal pain and fever deep dyspareunia abnormal bleeding Bimanual exam Pelvic Inflammatory Disease lower abdominal pain and fever deep dyspareunia abnormal bleeding Bimanual exam - cervical motion tenderness, adenexal tenderness and/or mass RUQ pain cervicitis

Pelvic Inflammatory Disease PATHOGENS? ? Pelvic Inflammatory Disease PATHOGENS? ?

Pelvic Inflammatory Disease STI - Chlamydia, Gonorrhea, (HSV and Trich - rare) Endogenous - Pelvic Inflammatory Disease STI - Chlamydia, Gonorrhea, (HSV and Trich - rare) Endogenous - Genital tract mycoplasma - M genitalium, U urealyticum Anaerobic - Bacteroides, Peptostreptococcus, Prevotella Facultative (aerobic) - E coli, Gardnerella vaginalis, Streptococcus sp, H influenzae

Pelvic Inflammatory Disease cervical swab - gram stain and gonorrhea culture; CT NAAT or Pelvic Inflammatory Disease cervical swab - gram stain and gonorrhea culture; CT NAAT or culture Urine +/- serum b. HCG r/o ectopic pregnancy following ESR/CRP pelvic u/s vaginal swab - culture, gram stain, p. H, whiff test and wet mount**

Pelvic Inflammatory Disease GOALS 1) control acute infection 2) prevent long-term sequelae Cover - Pelvic Inflammatory Disease GOALS 1) control acute infection 2) prevent long-term sequelae Cover - CT, GC, GNEB, streptococci +/- anaerobic 1) IV Cefoxitin PLUS PO Doxy 2) IV Clindamycin PLUS Gentamicin 3) IV Cipro PLUS Doxy +/- Metro PO step down to complete 14 days with Doxycycline ** Doxy and fluoroquinolones CI in pregnancy

Pelvic Inflammatory Disease When to Hospitalize surgical emergencies (appendicitis) cannot be excluded patient is Pelvic Inflammatory Disease When to Hospitalize surgical emergencies (appendicitis) cannot be excluded patient is pregnant patient does not respond clinically to PO Abx patient is unable to follow/tolerate outpatient PO regimen severe illness, nausea and vomiting or high fever tubo-ovarian abscess ** HIV ** youth/adolescents - poor compliance

Vaginal Discharge – a few words vaginal discharge, odor, vaginal/vulvar pruritus/erythema, dysuria Etiology: Bacterial Vaginal Discharge – a few words vaginal discharge, odor, vaginal/vulvar pruritus/erythema, dysuria Etiology: Bacterial Vaginosis Vulvovagnial candidiasis Trichomonas If high STI risk - send urine or cervical swab for CT/GC NAAT (or culture)

BREAK TIME 5 minute stretch break. . BREAK TIME 5 minute stretch break. .

Which statement is false? • 1) About 70 -80% of genital ulcers are due Which statement is false? • 1) About 70 -80% of genital ulcers are due to HSV-1 and HSV-2 • 2) Syphilis is only a concern in men who have sex with men (MSM) • 3) Genital ulcer disease in sexually active teens can be associated with 2 or more pathogens • 4) There are other non-infectious conditions causing genital ulcers that need to be on the differential.

Which statement is false? • 1) About 70 -80% of genital ulcers are due Which statement is false? • 1) About 70 -80% of genital ulcers are due to HSV-1 and HSV-2 • 2) Syphilis is only a concern in men who have sex with men (MSM) • 3) Genital ulcer disease in sexually active teens can be associated with 2 or more pathogens • 4) There are other non-infectious conditions causing genital ulcers that need to be on the differential.

Genital Ulcers • Description of the lesion - erosive vs. pustular, vesicles, papules, inguinal Genital Ulcers • Description of the lesion - erosive vs. pustular, vesicles, papules, inguinal lymphadenopathy • location • indurated • painful • associated symptoms

Pathogens Genital Ulcers Pathogens Genital Ulcers

Pathogens of Genital Ulcers • Painful • Painless Pathogens of Genital Ulcers • Painful • Painless

Pathogens of Genital Ulcers • Painful - Herpes simplex virus 1 and 2 • Pathogens of Genital Ulcers • Painful - Herpes simplex virus 1 and 2 • Haemophilus ducreyi (Chancroid) • Painless - Treponema pallidum (Syphilis) • C. trachomatis (LGV serovars - L 1, L 2, L 3) - painless papule -> ulcer • Klebsiella granulomatis (granuloma inguinale or donovanosis)

Genital HSV 1 & 2 • herpes - greek - “to creep” • ds. Genital HSV 1 & 2 • herpes - greek - “to creep” • ds. DNA virus - mucocutaneous, CNS, visceral infections • latent in neuronal cells --> reactivation --> reoccurrence of lesions (genital - sacral nerve root) • infectious - while asymptomatic usually ~ 2 d (greater than woman), active lesions • incubation - avg 6 days

Genital HSV 1 & 2 • SITE - boxer short area for both sexes Genital HSV 1 & 2 • SITE - boxer short area for both sexes • males - glans, prepuce, penile shaft, anus and rectum (for MSM) • women - cervix, vulva, vagina, perineum, legs and buttocks

Genital HSV 1 & 2 • grouped vesicles evolving toward superficial circular ulcers on Genital HSV 1 & 2 • grouped vesicles evolving toward superficial circular ulcers on an erythematous base • smooth margin and base • ulcers are painful and/ore pruritis • genital pain • constitutional (MC with primary infection) • enlarged, non-fluctuant and tender LNs • fever, malaise, pharyngitis

Genital HSV 1 & 2 • Viral culture • NAATs - CSF, vesicle fluid, Genital HSV 1 & 2 • Viral culture • NAATs - CSF, vesicle fluid, ulcer swabs • Tzanck smear cytology, Ag detection - poor accuracy • Antibody tests - HSV 1&2 (12 wks post primary) • a) patients with apparent first-episode genital herpes with neg culture/NAAT • b) ID of a seropositive preg woman with no history of herpes • c) counselling HSV serologically discordant couples

Genital HSV 1 & 2 • Treatment: • Primary - Acyclovir 200 mg PO Genital HSV 1 & 2 • Treatment: • Primary - Acyclovir 200 mg PO 5 x/d for 5 -10 days or Valacyclovir 1 g PO BID x 10/7 • Secondary - Valacyclovir 500 mg PO BID x 3/7 • Prophylaxis - Valacyclovir 500 mg PO OD (double up x 3/7 with outbreak)

Neonatal Herpes • CNS, disseminated or SEM disease • highest risk in primary infection Neonatal Herpes • CNS, disseminated or SEM disease • highest risk in primary infection of mom • 50% with primary and 2 -8% with recurrent • c-section if active lesions • suppression in third trimester to mom • Tx with Acyclovir IV 21 d for CNS and disseminated and 14 d for SEM • Prophylaxis to babes after infection is still controversial

Which statement is false? • 1) All babies born to mom’s with a lifetime Which statement is false? • 1) All babies born to mom’s with a lifetime history of syphilis (even if Tx before pregnancy) require serology • 2) 2/3 of babies born with congenital syphilis are asymptomatic • 3) ulcers carry spirochetes and are infectious • 4) Adequate Tx of syphilis is a fourfold drop in RPR titre at 6 months

Which statement is false? • 1) All babies born to mom’s with a lifetime Which statement is false? • 1) All babies born to mom’s with a lifetime history of syphilis (even if Tx before pregnancy) require serology • 2) 2/3 of babies born with congenital syphilis are asymptomatic • 3) ulcers carry spirochetes and are infectious • 4) Adequate Tx of syphilis is a fourfold drop in RPR titre at 6 months (ie 1: 32 to 1: 8)

Syphilis • Spirochete – Treponema pallidum • Motile, corkscrew-shaped, microaerophilic • present in serous Syphilis • Spirochete – Treponema pallidum • Motile, corkscrew-shaped, microaerophilic • present in serous secretions from lesions • other endemic spirochetes • yaws (Caribbean), pinta (Central America), or bejel • Lyme disease

Syphilis • Primary - painless, indurated, single (70%) ulcer • firm, enlarged, non-fluctuant, non-tender Syphilis • Primary - painless, indurated, single (70%) ulcer • firm, enlarged, non-fluctuant, non-tender lymphadenopathy • incubation avg 3 wks (up to 3 mo) • Secondary • rash, fever, malaise, lymphadenopathy, mucus lsions, condyloma lata, patchy or diffuse alopecia, meningitis, headaches, uveitis, retinits • incubation 2 - 12 wks (up to 6 mo)

Syphilis • Latent asymptomatic • early vs. late • Tertiary • cardiovascular - aortic Syphilis • Latent asymptomatic • early vs. late • Tertiary • cardiovascular - aortic aneurysm, AR, coronary a. ostialstenosis - 10 -30 y • neurosyphilis - asymptomatic to headaches, vertigo, personality changes, dementia, ataxia, argyll-robertson pupil (<2 y to 20 y) • gumma - tissue destruction of any organ (most 15 yrs)

Syphilis • Lesions - primary, secondary, congenital - infectious • darkfield exam - spirochetes Syphilis • Lesions - primary, secondary, congenital - infectious • darkfield exam - spirochetes • direct/indirect fluorescent antibody • PCR

Syphilis • Serum (positive in 2 -4 wks from exposure) • Treponemal - Syphilis Syphilis • Serum (positive in 2 -4 wks from exposure) • Treponemal - Syphilis EIA/INNO-Lia/FTA-ABS/TPPA (highly sensitive, less specific) • Non-treponemal testing - RPR/VDRL/TRUST - false positives • CSF - usual tests PLUS VDRL

Syphilis • Knowledge of previous RPR/INNO-Lia & EIA as well as treatment is useful Syphilis • Knowledge of previous RPR/INNO-Lia & EIA as well as treatment is useful • Pos EIA and RPR reactive with clinical signs and symptoms --> treat • Primary, secondary, early latent - IM Benzathine penicillin G 2. 4 million units x 1 • Late latent, unknown, tertiary - IM Pen G weekly x 3 doses • Neurosyphilis - Pen G 3 -4 million units q 3 -4 h x 10 -14 d

Syphilis • Antibodies are life long (EIA positive) • some patients stay serofast (low Syphilis • Antibodies are life long (EIA positive) • some patients stay serofast (low RPR 1: 1 and 1: 2 titres, but not actively infected) • if not 4 fold decrease, require rpt Tx • Penicillin desensitization indication

Congenital Syphilis • highest risk in primary and secondary syphilis (80%) especially in 2 Congenital Syphilis • highest risk in primary and secondary syphilis (80%) especially in 2 nd trimester • early (onset < 2 y) - 2/3 may be asymptomatic • hydrops/stillbirth, fulminant disseminated infection, mucocutaneous lesions, osteochondritis, anemia, HSM, neurosyphilis, necrotizing funisitis • late (onset > 2 y + persistent) - interstitial keratitis, lymphadenopathy, HSM, bone involvement, anemia, Hutchinson’s teeth, Mullberry molars, neurosyphilis

Congenital Syphilis Congenital Syphilis

Congenital Syphilis • if mom treated before pregnancy and not reinfected don’t do anything Congenital Syphilis • if mom treated before pregnancy and not reinfected don’t do anything with baby • if mom infected during pregnancy and adequately treated (> 4 wks b/f delivery) - assess signs/symptoms x 3 mo; RPR 0, 3, 6, 18 mo • NO Tx • NO further w/u

Congenital Syphilis • mom inadequately treated, not treated, or baby RPR > 4 fold Congenital Syphilis • mom inadequately treated, not treated, or baby RPR > 4 fold mom’s or reactive at 12 mo • close f/u • Treat 10 d IV Pen G crystalline • RPR 0, 3, 6, and 18 mo • Xray long bones, CBC, CSF, ophtho and hearing

Congenital Syphilis • unconventional treatment of mom in pregnancy, not a confirmation RPR done, Congenital Syphilis • unconventional treatment of mom in pregnancy, not a confirmation RPR done, treated within 4 wks delivery • full exam • assess risk - may treat • RPR 0, 1, 2, 3, 6, 12, 18 mo • usually do full w/u • if not treated

Just a few more viruses… Just a few more viruses…

Human Papillomavirus • DNA virus • one of the most common STIs • MC Human Papillomavirus • DNA virus • one of the most common STIs • MC condylomata acuminata - 6 and 11 • High risk precancerous/cancerous lesions - 16, 18 (31, 33, 45, 58, 59) • 70% of adult population will have at least one genital HPV infection over their lifetime • women 15 -49 routine cervical cancer screen Ontario prev of high risk HPV 12. 7% • often acquired early (15 -19 yo)

Human Papillomavirus • Diagnosis • External genital warts - clinical Dx (typical location, appearance) Human Papillomavirus • Diagnosis • External genital warts - clinical Dx (typical location, appearance) • get worse in pregnancy, other defects of CMI • Tx • Cryotherapy - local liquid nitrogen • Imiquimod - topical • Podofilox

Human Papillomavirus • most infections (>80%) clear spontaneously within 18 months • 15 -19 Human Papillomavirus • most infections (>80%) clear spontaneously within 18 months • 15 -19 yo in US, external genital warts were noted in 1% of sexually active adults • infection of one HPV genotype DOES NOT protect against others • Gardasil ** • avg of 20 yrs from acquiring high risk genotype to detection of cervical cancer

Which statement is true? • 1) patients with HIV must disclose to their partners Which statement is true? • 1) patients with HIV must disclose to their partners their HIV status • 2) Babies born to HIV infected moms have a 5% chance of acquiring HIV • 3) Sexual transmission of HIV is enhanced by the presence of other STIs • 4) All sexual abuse/assault patients should be started on PEP

Which statement is true? • 1) patients with HIV must disclose to their partners Which statement is true? • 1) patients with HIV must disclose to their partners their HIV status • 2) Babies born to HIV infected moms have a 5% chance of acquiring HIV • 3) Sexual transmission of HIV is enhanced by the presence of other STIs • 4) All sexual abuse/assault patients should be started on PEP

Human Immunodeficiency Virus • Prevention • Education • Identifying those at risk • Testing Human Immunodeficiency Virus • Prevention • Education • Identifying those at risk • Testing • HAART • vertical transmission • PEP • risk assessment • started ASAP, less effective if after 72 hrs

Human Immunodeficiency Virus • Clinical Dx • primary or acute HIV – “mono-like” illness Human Immunodeficiency Virus • Clinical Dx • primary or acute HIV – “mono-like” illness • fever > 80% • arthralgia/myalgia, rash, lymphadenopathy, sore throat, fatigue, headache - 40 -80% • oral ulcers and/or genital ulcers, wt loss, n/v or diarrhea - 10 -40% • chronic asymptomatic HIV infection • chronic symptomatic HIV infection

HIV in children HIV in children

Human Immunodeficiency Virus • infants/children • FTT • lymphopenia • chronic diarrhea • opportunistic Human Immunodeficiency Virus • infants/children • FTT • lymphopenia • chronic diarrhea • opportunistic infections • more ill from usual childhood infections

Human Immunodeficiency Virus • POC testing and STAT ELISA testing • serum - EIA Human Immunodeficiency Virus • POC testing and STAT ELISA testing • serum - EIA (detect antibodies by 3 wks after infection, but can take up to 6 months) • p 24 Ag - included in the most recent 4 th gen. testing • positives - confirmed using a different EIA & Western blot • PCR - babies born to HIV infected mothers • RNA 10 days after infection) • DNA shows virus integration • Quantitative PCR - Viral Load testing • Genotyping - drug resistance • ** CD 4 and VL NOT used as screening

Human Immunodeficiency Virus • Diagnosis in pregnancy is important! • undetectable VL in pregnancy Human Immunodeficiency Virus • Diagnosis in pregnancy is important! • undetectable VL in pregnancy • AZT x 6 wks after birth to babe • no breast feeding • < 1%

Sexual Abuse • needs to be considered in prepubertal children with genital, rectal, or Sexual Abuse • needs to be considered in prepubertal children with genital, rectal, or pharyngeal chlamydia or gonorrhea infection • need a Test of Cure at 3 -4 wks after completion of Tx • genital warts present in a child older than 18 months (particularly > 2 y)

Sexual Abuse • HIV serology • Hep. Bs. Ag and Ab • Hep C Sexual Abuse • HIV serology • Hep. Bs. Ag and Ab • Hep C Ab • Syphilis EIA • cultures - Chlamydia, Gonorrhea

Review • Chlamydia trachomatis • Neisseria Gonorrhea • Genital Herpes (HSV 1 & 2) Review • Chlamydia trachomatis • Neisseria Gonorrhea • Genital Herpes (HSV 1 & 2) • Syphilis (congenital syphilis) • Genital warts (HPV) • HIV • Sexual Abuse

Resources • CDC website • PHAC 2012 STI guidelines • CPS position statements Resources • CDC website • PHAC 2012 STI guidelines • CPS position statements

Questions? Questions?