Concept
Map: Syphilis
1. Al Capone contracted syphilis in his
youth. By the time he was imprisoned in Alcatraz, he was suffering from
syphilis-induced confusion and disorientation. What stage of syphilis did Mr.
Capone have at this time?
Tertiary
2. Which of the following is true of the
latent stage of syphilis infection?
It may never progress to tertiary
syphilis.
3. Which of the following terms does NOT
describe syphilis?
Attenuated
A
burning Question
A 20-year-old woman comes to the local
clinic complaining of lower abdominal pain and sharp burning pain on urination
(dysuria) that has gone on for 1 week. She also complains of mild fever and
chills. Her history and physical reveal that she has had eight sexual partners
in the previous year and has used condoms only on occasion because she has been
taking birth control pills. She has not visited her physician or gynecologist
for 2 years. The clinic physician performs a pelvic exam and sample collection
to determine the causative agent, telling the patient that she likely has
contracted a sexually transmitted infection (STI).
1. Sexually transmitted infections
(STIs) are a significant problem in the world. The symptoms described in the
case thus far are fairly general and may apply to multiple STIs. However, many
STIs can be discerned by other visual signs that accompany the general
symptoms.
**Checking patients for STIs is
difficult because of the wide range of signs and symptoms that may or may not
be present. Many STIs share symptoms. Clinical diagnosis of STIs starts with
looking for the most obvious and commonly seen signs.
On further examination, the physician
finds no obvious external lesions on or around the patient’s genitalia.
However, the physician does note the presence of a discharge.
2. The physician performs a pelvic exam,
which reveals the presence of an abnormal thin, watery vaginal discharge and
inflammation of the cervix. The physician then palpates the abdomen (examines
by touch and pressure) and finds that the uterus, fallopian tubes, and ovaries
are enlarged and tender. The physician takes a swab sample of the cervix and
sends it to the laboratory to determine the causal organism. Light microscopy
and simple staining of the sample in the lab reveal an organism with a very
unique life cycle. The organism is classified as gram-negative, but it stains
very poorly compared to other classic gram-negative STI pathogens. The stain
shows both a nonreplicating, extracellular infectious elementary body and a
replicating, noninfectious reticulate body inside mucosal cells from the
cervical epithelium swab. Based on the symptoms and these new laboratory
findings, which of the following would be the most likely diagnosis for the
patient?
Chlamydia
**The physician makes a clinical
diagnosis of chlamydia. Additionally, the exam shows that the patient has signs
of progressive chlamydial pelvic inflammatory disease (PID).
This just went from bad to worse for the
patient. Untreated STI cases can lead to progression of disease beyond the
borders of the urinary and reproductive tracts, with potentially serious
complications.
3. The two most common STI organisms
associated with PID in the United States are Chlamydia trachomatis and Neisseria
gonorrhoeae. There are many similarities between these STIs. Which of the
following statements comparing chlamydia and gonorrhea are true?
Patients may be coinfected with both
gonorrhea and chlamydia.
Chlamydia is found more often in women,
whereas gonorrhea is found more often in men.
Chlamydia and gonorrhea can infect a
patient and be transmitted without causing obvious symptoms.
**STIs not only are hard to detect, but
also are not mutually exclusive. When a patient has one STI, others may be
“hiding in the shadows.” STIs spread rapidly and can have consequences outside
the urinary and reproductive tracts.
The laboratory needs more time to rule
out a mixed infection but does confirm the presence of Chlamydia. The
patient’s symptoms suggest that this infection has been going on for a while
and has progressed beyond a simple case of Chlamydia urethritis to
pelvic inflammatory disease (PID). As discussed in the above question, these
STIs aren’t just for the genitals anymore!
4. Chlamydia PID is just part of
the overall spectrum of disease caused by Chlamydia organisms. Even
though we now understand more about STIs and their complications, we are still
exploring how the organisms “branch out” beyond just a single infection. Which
of the following diseases have Chlamydia infection as an etiology?
infertility
inclusion conjunctivitis
pneumonia
trachoma
lymphogranuloma venereum (LGV)
cervical cancer
**Mixed STI infections (which may
involve both different species and different strains of the same species) are
able to manifest in an infected patient with more than just the classic “clap”
symptoms. The caregiver should always be aware that more may be going on in the
patient than meets the eye and act appropriately to instruct the patient on
routes of spread the person might not anticipate.
Having identified the STI and potential
consequences, we now need to turn to appropriate treatment for her conditions.
5. Our patient needs antibiotics to
overcome this infection and prevent any further complications. Which of the
following would be the best choice?
a combination therapy of
cephalosporin-class AND macrolide-class
Conclusion
After
3 days of hospitalization for antibiotic therapy, monitoring, and laboratory
testing to assess the function of her reproductive systems, the patient is
released to go home. She is discharged with a short course of antibiotics,
educational materials about STIs (with multiple copies so that she can notify
and inform her partners), and instructions to follow up with her gynecologist
for yearly checkups.
Chapter
26 Reading Questions
1. If a patient is diagnosed with
trichomoniasis, which treatment should be prescribed?
Metronidazole
2. Which disease or microbe is NOT
transmitted across the placenta to the unborn fetus?
ophthalmia neonatorum
**Ophthalmia neonatorum is not
transmitted across the placenta; the infant acquires it during passage through
the birth canal.
Diseases
in Focus Chapter 26 – Male, age 23
Medical History (Hx)
The patient is a 23-year-old male. He is
from Loveland, Colorado. He was admitted to the clinic seeking sexually
transmitted infection (STI) testing. An initial physical examination of the
patient shows several small, blisterlike bumps on his penis. The patient is a
student and also plays drums in a band. He is in a monogamous heterosexual
relationship of six months, and reports consistent use of spermicidal condoms
during intercourse. He estimates that he has sex with his girlfriend roughly
twice a week. He lives in an apartment with one male roommate; however, he
frequently stays at his girlfriend’s house. His most recent travel was a cruise
he and his girlfriend took in Alaska a month ago. Neither he nor his girlfriend
owns any pets. He does not report using any drugs of abuse. He does not have a
family history of genetic disease. He is lactose intolerant. Two weeks ago, he
noticed an unusual tingling sensation in his genitalia. He did not mention it
to his girlfriend, nor did he seek any specific medical attention. He
subsequently began to notice a burning sensation during urination, along with a
few small red bumps resembling pimples at the base of his penis. After a few
days, he noticed that the bumps had multiplied and some had started to become
blisters. At this point, he and his girlfriend decided to seek STI testing. She
is with him upon admittance to the clinic. She has not experienced any similar
symptoms; however, she would also like to be tested as a precautionary measure.
Differential
Diagnoses
Differential
diagnosis is the process of identifying a disease from a list of possible
diseases that fit the information derived from examining a patient. Your job
will be to synthesize information from a patient whose main presenting symptoms
are consistent with a microbial disease of the reproductive system. Use
the Chapter 26 Disease Tables 26.1, 26.3 and Diseases Associated with AIDS and your knowledge
about microbial diseases of the urinary and reproductive systems to identify
the patient's risk factors and symptoms, evaluate diagnostic evidence,
formulate and test a diagnosis about the pathogen responsible for the patient's
woes, and suggest a course of treatment.
1. Identify relevant information
Review the patient's medical history,
and then identify risks and concerns that are relevant to your diagnosis (and
the patient's treatment).
Relevant:
Risk of travel-related disease exposure
Not Relevant:
Age-related risk of disease
Occupational risk of disease
Risk of sexually transmitted infection
Risk of vector-borne disease
Risk of drug-related disease exposure
Risk of genetic/familial disease
Special concerns for treatment
Risk of immunocompromised
**You've reviewed your patient's medical
history. He has traveled recently, which could increase his exposure to novel
pathogens and vector organisms. This does not give you very much to go on,
though; especially since your patient's symptoms suggest that he has an STI.
You decide to try to focus your hypothesis--perhaps if you have a better
understanding of what STIs suit his symptoms, you will be better able to
identify the relevant information in his medical history.
Review
possible diagnoses.
Now
that you have considered the evidence at hand, you should start to build a
hypothesis about what disease your patient has based upon the symptoms he
presents. In the beginning of your diagnostic process you should try to think
broadly and consider any and all reasonable possibilities. You can then narrow
down these possibilities by performing diagnostics that can support or refute
your hypothesis.
2. Given your current information, which
of the following diseases do you think could be responsible for your
patient's symptoms?
genital herpes
**You suspect your patient may have
genital herpes!
3. Select a diagnostic.
You would like to perform some
diagnostics to help you confirm your hypothesis. Which of the following would
you like to do to help you make a diagnosis of genital herpes?
culture of fluid from vesicle
PCR testing on fluid from vesicle
Serology
**You take a blood sample and sample of
cells and fluid from your patient's lesions. You also take a blood sample and
vaginal swab from his girlfriend. You release the couple from the clinic and
let them know that their results will be available in a couple of days. You
decide to order antibody testing, virus cultures, and PCR for your samples.
Which herpes viruses should you focus on, though?
4. Refine your hypothesis
The viruses responsible for genital
herpes belong to the family Herpesviridae. Genital herpes is only one of
several conditions caused by viruses of this family. Eight types of herpesvirus
are currently known to cause disease in humans. Match each type of herpes virus
to the disease it causes.
HHV-1: cold/canker sores, oral herpes,
genital herpes
HHV-2: cold/canker sores, oral herpes,
genital herpes
HHV-3: chicken pox, shingles
HHV-4: infectious mononucleosis
HHV-5: CMV inclusion disease, retinitis
HHV-6: roseola, roseola infantum
(measleslike rash in infants)
HHV-7: roseola, roseola infantum
(measleslike rash in infants)
HHV-8: Kaposi’s sarcoma
** Human herpesvirus 1 and 2 are
responsible for both oral and genital herpes.
5. Of the two strains of virus that
cause genital herpes, which strain is more likely to be responsible for
your patient's outbreak?
herpes simplex virus 2
** Most cases of genital herpes are
caused by HHV-2. You will perform PCR on your patient's sample for both HHV-1
and 2, however.
6. If you assume that this is your
patient's first outbreak and that his condition had an incubation period, when
would you guess that he acquired the virus?
three weeks ago
** If this is your patient's first
outbreak of genital herpes, then you might expect that he contracted the
disease roughly one week before the first onset of symptoms.
7. You would like to ask your patient
about scenarios where he could have contracted the virus. Which of the
following could he have acquired genital herpes from?
skin-to-skin contact with infected oral
or genital area
oral sex
physical contact with an asymptomatic
person with latent genital herpes
unprotected vaginal sex
anal sex
vaginal sex with condom
** Your lab results have returned. Your
patient's viral culture is positive for HHV-2, which your PCR results confirm.
Your patient's girlfriend's results are negative for both HHV-2 and HHV-1,
however. You call your patient and his girlfriend back in, and separately
inform them of their respective diagnoses.
8. Interpret your results
Your patient's girlfriend looks shocked
when you deliver the news. She immediately runs out to your patient,
exclaiming: "How could you cheat on me??!" Your patient stammers that
he hasn't and wouldn't cheat on her. Is it possible that he is telling the
truth?
Yes, he could be telling the truth.
You explain to your patient's girlfriend
that is very possible that he caught the disease long before his current
outbreak. Around 90% of patients with HHV-2 experience recurrences over their
lifetime, and it is not uncommon for initial outbreaks of genital herpes to go
completely unnoticed.
9. Treat the disease
Your patient tries to sheepishly smile
at his girlfriend and reaches out for her. She is still clearly upset, but she
takes his hand and sighs loudly. She turns to you and asks how you plan to cure
her boyfriend. You reply that ______.
you cannot cure your patient's disease
** You inform the couple that while they can manage your
patient's symptoms and outbreaks, he will never truly be "cured" of
the disease.
The
viruses responsible for genital herpes, like all herpesviruses, can remain
latent in the body for long periods of time. After an initial infection, some
people experience sporadic outbreaks as the virus (latent in the trigeminal or
sacral nerve ganglia) becomes active and is transported from the neuron to the
skin. Reactivation appears to be triggered by several factors, including
menstruation, emotional stress, illness, or even vigorous contact with an area
of infection (e.g., scratching an area, or friction from sexual contact).
10. "If I can never be cured, how can I avoid passing the
disease to my girlfriend?" your patient cries.
You
assure him that it is still possible for him maintain a relationship, although
he will potentially have to form some new habits and take some extra
precautions. You recommend that if the pair mutually agrees to continue dating,
then he and/or his girlfriend should ______.
avoid sex when the infected partner is
symptomatic
use additional protection during oral
sex (dental dam, saran wrap)
use a condom during intercourse
take a daily prescription for
valacyclovir
** You inform the couple that with
forethought and proper precautions, they should be able to have the kind of
relationship that suits them both. Although abstinence from sexual activities
is the only method that is 100% effective against the spread of genital herpes,
if the couple decides to pursue a continued sexual relationship, there are
several things they can do to reduce the risk of transmission. While some
methods of safe sex are more effective than others for preventing the spread of
genital herpes, a combination of barrier methods, antiviral drug treatment, and
thoughtful timing of sexual encounters (i.e., no sexual contact during an
active outbreak) can greatly reduce the risk of spreading the disease.
Chapter
26
1. Pyelonephritis may result from
All of the answers are correct.
** systemic infections; ureteritis;
urethritis; cystitis
2. Which of the following is caused by
an opportunistic pathogen?
Candidiasis
3. A urine sample collected directly
from the urinary bladder
is sterile.
4. The most common reportable disease in
the United States is
gonorrhea.
5. Which of the following is NOT a complication
of gonorrhea?
None of the answers are correct; all of
these are potential complications of gonorrhea.
** arthritis; endocarditis; meningitis; pelvic
inflammatory disease
6. Which of the following is the most
difficult to treat with chemotherapeutic agents?
genital herpes
7. Recurring vesicles on the surface of
human skin are symptoms of
genital herpes.
8. Which of the following diseases
causes a skin rash, hair loss, malaise, and fever?
Syphilis
9. Infants born to asymptomatic mothers
with recurrent genital herpes are less likely to acquire herpesvirus at birth
than infants born to newly infected mothers because
maternal antibodies offer protection.
10. Which of the following is greater?
the number of reported cases of
gonorrhea last year
11. A 25-year-old man presented with
fever, malaise, and a rash on his chest, arms, and feet. Which of the following
causative agents is most likely to cause these symptoms?
Treponema
12. Which
of the following is treated with cephalosporins because the organism is
resistant to penicillin and fluoroquinolones?
Neisseria gonorrhoeae
13. Women
and men typically have the same normal microbiota in their reproductive
systems.
FALSE
14. Genital candidiasis is a disease
that only affects women.
FALSE
15. Trichomoniasis is the only known STI
caused by a protozoan.
TRUE
