REMIER REVIEW SS P RE Your Success is our Passion Premier Review USMLE Step 3 Review Course November 30, 2008 Infectious Diseases N.D. Agrawal, MD hn ©2008 by Premier Review, USMLE Step3 Review Course. All rights reserved. No part of this may be reported or transmitted in any form or by any means without the permission of the Premier accepted practices. However, the authors are not responsible for ertors oF omissions or any cons from application ofthe information in this hand out and make no warranty, express or implied, with respect to the contents of the material Copyright, Premier Review. Please DO NOT copy. Copying these material is violation of copyright lawUSMLE Step 3 Review Course PREMIER REVIEW November 30, 2008 Nee) Your Success is our Passion Infectious Disease N. D. Agrawal, MD Sexually Transmitted Diseases + Gonorrhea + Chlamyd + Syphi + Chaneroid + Genital Herpes HIV + Lympho granuloma venerum + Granuloma inguinale Gonorrhea / Chlamydia + In gonorrhea, discharge per urethra is purulent. In Chlamydia, mucoid or watery. * Gonorrhea Gram stain (Gram-ve Intracellular Diplococei), DNA probe, Culture (Using Thayer Martin Medium is Gold standard), Nucleic acid amplification (NAAT) {using either Polyme (PCR), Transcription mediated amplification (TMA), or Standard displacement amplification (SDA) provides rapid result but expensive, although it is most sensitive and specific test for N. gonorthoeae and is recommended by the Centers for Disease Control and Prevention. Another advantage of NAATS is the ability to perform testing on urine as well as urethral specimens} + Chlamydia-> Genetic Probe (mostly used), Culture (Rarely used as requires tissue culture), Nucleic acid amplification (NAAT) {Gold standard, using either Polymerase chain reaction (PCR), Transcription ‘mediated amplification (TMA), or Standard displacement amplification (SDA)}, Antigen detection, ‘Treatment + Cefiriaxone 125 mg IM one dose + Doxy + 100mg BID PO x 7 days or + Cefiriaxone IM+ Azithromycin 1gm (DOC for pregnant patient) “Preferred tt by pt.” \d Doxy or Azithromycin for Chlamydia} + Alternative treatment for Gonorrhea: Oral cefixime or Oral 2 gram Azithromycin or spectinomycin + Penicillin Allergic patients- instead of Ceftriaxone give Spectinomycin IM (Can be used in pregnaney) + Pregnant pt.: Ceftriaxone IM + Instead of Doxycycline use Erythromycin Base or Azithromycin or Amoxicillin + Currently spectinomyein is not available in USA (Available outside USA) and CDC Azithromycin for Gonorrhea as concerned about rapid resistance. So in patient ourages use of allergic to penicillin may be the only option at present is desensitization with cephalosporin, Although CDC is working with drug companies to make. Spectinomycin available. + Try to treat pl. sexual partner also to prevent reinfection °S: Patient with mucopurulent discharge per urethra Make a note of allergy in the history Examine patient: ER: Focal physical (General, skin, HEENT, heart, lung Clinic: Full physical abdomen, lymph nodes, Genitalia) Copyright, Premier Review, Please DO NOY copy. Copying this material is violation of copyright la 1USMLE Step 3 Review Course KA) PREMIER REVIEW ‘November 30, 2008 = Your Success is our Passion Infectious Disease N. D. Agrawal, MD. ‘There is no other positive finding on exam except mucopurulent discharge per urethra. Clinical diagnosis is Gonorrhea or Chlamydia Order labs: Pregnancy test (In female), PCR Chlamydia urine, PCR gonorrhea urine CBC, CHEM 8, urine analysis, VDRL., HIV test (ELISA) Note: We don’t have to wait for all these results it takes 2 days for PCR results, Order treatment: Ceftriaxone, Intramuscular, one time + Doxy, oral , continuous: If Pregnant patient: Cefiriaxone, Intramuscular, one time + Azithromyein, oral, one time Ifallergic to Penicillin; Desensitization or skin test Counselling: Safe sex, Sexual partner needs treatment Change location to home, schedule to come back in one or two week. End of ease: Diagnosis: Gonorrhea/Chlamydia Primary Syphilis * Caused by Spirochete, Treponema Pallidum * Lesion begins as painless papular lesion on which later on ulcerate to produce ulcer with raised. indurated margin called chancre. Chanere is usually single associated with painless inguinal lymphadenopathy, with firm rubbery consistency. If this ulcer is not noticed, heals spontaneously in three to six weeks without treatment * Investigation: Dark field microscopy (serologie test may be negative in 30% patients) + Treatment: Benzathine Penicillin 2.4 million unit IM XI dose or Doxycycline PO X 2 week. Secondary syphilis + Usually if primary syphilis is untreated, 25% of patients develop secondary syphilis in weeks to months. + C/P- Rash generalized maculopapular including palm and sole, generalized lymphadenopathy. elevated liver enzymes, alopecia, Condyloma lata- Flat, velvety. gray to white lesion in perineal area Investigation: + Serological test: + Non Treponemal- VDRL (Venereal disease research laboratory test), RPR (Rapid Plasma Re: Preferred, as inexpensive + Treponemal test- done if non treponemal test is positive, as this is more specific and confirmatory test. Once ive, remains positive for most of the patients. ‘ent Treponemal antibody absorption test (FTA-ABS) + Microhemagglutination test for antibodies to Treponema Pallidum (MHA- TP) ‘Treatment- Benz. Penicillin 2.4 MU IM x 1 dose or Doxyeyeline x 2 weeks tes) ccs: + Patient with painless single genital ulcer, no discharge + Make a note of allergy in history * Examine: ER: Focal: (General, skin, HEENT, heart, lung, abdomen, lymph nodes, Genitalia) Clinic: Full Copyright, Premier Review, Please DO NOT copy. Copying this material is violation oF copyright law