Bts Altfel de Boli

INFECTII CU TRANSMITERE
SEXUALA
• According to Freud,
along with aggression,
sex is what drives every
action. Humanity, like
every other being on
the planet has an ever
present urge to
reproduce.
SEX IUBIRE
• INSTINCT • COMITTMENT
– UMAN VERSUS ANIMAL
– UMAN VERSUS ANIMAL • FIZIOLOGIC
• PATOLOGIC
• FIZIOLOGIC VERSUS • CONDITIONAT/NECONDITIO
PATOLOGIC NAT
– MALADII?? • DOVADA IUBIRII MAXIME

– INFECTII?? ESTE CAPACITATEA DE A
– FIZIC?? RENUNTA LA PERSOANA
– PSIHIC?? IUBITA
– COMPORTAMENTAL??
• I believe that sex is one of the most
beautiful, natural, wholesome things
that money can buy.” – Tom Clancy
• “Having sex is like playing bridge. If
you don’t have a good partner, you’d
better have a good hand.” Woody
Allen
• “Women might be able to fake
orgasms. But men can fake whole
relationships.” Sharon Stone
• “Women need a reason to have sex.
Men just need a place.” Billy Cristal
• “The sexual life of adult women is a
“dark continent” for psychology” –
Sigmund Freud
• Civilized people cannot fully satisfy
their sexual instinct without love.” –
Bertrand Russell
• Dacă îţi iei nevastă, nu
te căsători doar cu
sexul ei. Pitagora
• Sexul fără dragoste
este doar împerechere.
Dragostea fără sex este
doar filosofie. Mark
Amend
• Singura pornografie în
artă e lipsa de talent.
Eugen Lovinescu
• Sexualitatea nu este ceva pur instinctual; este fără
îndoială o putere creatoare – ea este atât cauza
principală ce stă la baza vieţii noastre individuale,
cât un important factor în cadrul vieţii psihice. Carl
Gustav Jung
• Dragul meu Jung, promite-mi că nu vei abandona
niciodată teoria sexuală. Este cea mai esenţială!
Vezi tu, noi trebuie să facem din ea o dogmă, un
bastion de neclintit împotriva talazului de mâl al
ocultismului. Sigmund Freud
• VIATA ESTE BTS??
• VIATA ESTE MALADIE?
• VIATA ESTE SEX?
• SEXUL ESTE O MALADIE?
• SEXUL ESTE PACAT?
• CE ESTE PACATUL?
• Intr-o lume in care
SEXUL SI RELIGIILE
sexualitatea tinde sa
devina unul dintre cele mai
importante sisteme de • Baptism
referinta, devine aproape
un stereotip sa analizezi • Sex intre/cu minori – Aspru condamnat
acest concept din punct de • Sex premarital – Aspru condamnat
vedere moral.
• Sex extraconjungal – Aspru condamnat
• Divort – Inacceptabil din punct de vedere moral
• Masturbare – Pozitie neclara sau neutra
• Avort – Aspru condamnat
• Contraceptie – Pozitie neclara sau neutra
• Orientare homosexuala – Inacceptabil din punct de vedere moral
• Sex homosexual – Aspru condamnat
• Budism
• Sex intre/cu minori – Inacceptabil din punct de vedere moral

• Sex premarital – Acceptabil din punct de vedere moral
• Sex extraconjungal – Inacceptabil din punct de vedere moral
• Divort – Acceptabil din punct de vedere moral
• Masturbare – da
• Avor t- Pozitie neclara sau neutra
• Contraceptie – da
• Orientare homosexuala – da
• Sex homosexual- Acceptabil din punct de vedere moral
•
• Catolicism • Metodism
• Sex intre/cu minori – Aspru condamnat
• Sex premarital – Aspru condamnat • Sex intre/cu minori – Inacceptabil din punct de vedere moral
• Sex extraconjungal – Aspru condamnat • Sex premarital – Inacceptabil din punct de vedere moral
• Divort – Aspru condamnat • Sex extraconjungal – Inacceptabil din punct de vedere moral
• Masturbare – Inacceptabil din punct de vedere moral • Divort – Acceptabil din punct de vedere moral
• Avort – Aspru condamnat • Masturbare – Pozitie neclara sau neutra
• Contraceptie – Aspru condamnat • Avort – Pozitie neclara sau neutra
• Orientare homosexuala – Pozitie neclara sau neutra • Contraceptie – da
• Sex homosexual – Aspru condamnat • Orientare homosexuala – Acceptabil din punct de vedere
moral
• Ortodoxie
• Sex intre/cu minori – Aspru condamnat

• Sex premarital – Aspru condamnat
• Sex extraconjungal – Aspru condamnat
• Divort – Inacceptabil din punct de vedere moral
• Masturbare – Aspru condamnat
• Avort – Aspru condamnat
• Contraceptie – Aspru condamnat
• Orientare homosexuala – Aspru condamnat
• Islamism • Iudaism
• Sex intre/cu minori – Inacceptabil din punct • Sex intre/cu minori – Inacceptabil din punct
de vedere moral de vedere moral
• Sex premarital – Aspru condamnat • Sex premarital – Acceptabil din punct de
• Sex extraconjungal – Aspru condamnat vedere moral
• Divort – Pozitie neclara sau neutra • Sex extraconjungal- Aspru condamnat
• Masturbare – Inacceptabil din punct de • Divort – Acceptabil din punct de vedere
vedere moral moral
• Avort – Pozitie neclara sau neutra • Masturbare – Pozitie neclara sau neutra
• Contraceptie – da • Avort – Inacceptabil din punct de vedere
• Orientare homosexuala – Aspru condamnat moral
• Sex homosexual – Aspru condamnat • Contraceptie – Acceptabil din punct de
vedere moral
• Orientare homosexuala – Acceptabil din
punct de vedere moral
• CE CONSIDERAM BOALA/INFECTIE/AFECTIUNE
SEXUAL TRANSMISA?
– FIZIC
– PSIHIC
– EMOTIONAL
– COMPORTAMENTAL
– MINTEA/IMAGINATIA UMANA SA FIE DE VINA?
• Human sexual activity, or human sexual
practice or human sexual behavior, is the
manner in which humans experience and
express their sexuality.
• People engage in a variety of sexual acts

from time to time, and for a wide variety of
reasons.
• Sexual activity normally results in sexual

arousal and physiological changes in the
aroused person, some of which are
pronounced while others are more subtle.
• Sexual activity also includes conduct and

activities which are intended to arouse the
sexual interest of another, such as strategies
to find or attract partners (mating and
display behavior), and personal interactions
between individuals, such as flirting and
foreplay.
• Human sexual activity has sociological, cognitive, emotional, behavioral and
biological aspects; this includes personal bonding, shared emotions during sexual
activity, and physiological processes such as the reproductive system, the sex drive
and sexual intercourse and sexual behavior in all its forms.
• In some cultures, sexual activity is considered acceptable only within marriage,

although premarital and extramarital sex are also common.
• Some sexual activities are illegal either universally or in some countries, and some
are considered against the norms of a society.
• For example, sexual assault, as well as sexual activity with a person below some
locally determined age of consent, are criminal offenses in most jurisdictions.
• Sexual activity can be classified in a number of ways.
• It can be divided into acts which involve one person, such as
masturbation, or two or more people such as vaginal sex, anal sex, oral sex
or mutual masturbation.
• If there are more than two participants in the sex act, it may be referred to
as group sex.
• Autoerotic sexual activity can involve use of dildos, vibrators, anal beads,
and other sex toys, though these devices can also be used with a partner.
• Sexual activity can be classified into the gender and sexual orientation of
the participants, as well as by the relationship of the participants. For
example, the relationships can be ones of marriage, intimate partners,
casual sex partners or anonymous. Sexual activity can be regarded as
conventional or as alternative, involving, for example, fetishism, urolagnia,
and/or BDSM activities.[
• Fetishism can take many forms ranging from
the desire for certain body parts, for example
large breasts, armpits or foot worship.
• The object of desire can often be shoes,
boots, lingerie, clothing, leather or rubber
items.
• Sexual activity can also be consensual or
under force or duress, or lawful/illegal or
otherwise contrary to social norms or
generally accepted sexual morals.
• Some non-conventional autoerotic practices
can be dangerous. These include erotic
asphyxiation and self-bondage.
• The potential for injury or even death that
exists while engaging in the partnered
versions of these fetishes (choking and
bondage, respectively) becomes drastically
increased in the autoerotic case due to the
isolation and lack of assistance in the event
of a problem.
• Symptoms of Sexual Disorders
• Dyspareunia
• Erectile Dysfunction (ED)
• Exhibitionism
• Female and Male Orgasmic Disorders
• Female Sexual Arousal Disorder
• Fetishism
• Frotteurism
• Gender Identity Disorder
• Hypoactive Sexual Desire Disorder
• Male Erectile Disorder
• Premature Ejaculation
• Sex Addiction (not a recognized diagnostic category at this time)
• Sexual Masochism and Sadism
• Transvestic Fetishism
• Vaginismus
• Voyeurism
• Sexually transmitted diseases (STD),
also referred to as sexually
transmitted infections (STI) and
venereal diseases (VD), are illnesses
that have a significant probability of
transmission between humans by
means of sexual behavior, including
vaginal intercourse, anal sex and oral
sex. Some STIs can also be contracted
by using IV drug needles after their
use by an infected person, as well as
through any incident involving the
contact of a wound with
contaminated blood or through
childbirth or breastfeeding.
• Sexually transmitted infections
have been well known for
hundreds of years, and
venereology is the branch of
medicine that studies these
diseases. While in the past,
these illnesses have mostly
been referred to as STDs or
VD, in recent years the term
sexually transmitted infections
(STIs) has been preferred, as it
has a broader range of
meaning; a person may be
infected, and may potentially
infect others, without having a
disease.
• Until the 1990s, STIs were commonly known
as venereal diseases, the word venereal
being derived from the Latin word venereus,
and meaning relating to sexual intercourse or
desire, ultimately derived from Venus, the
Roman goddess of love.[Social disease was a
phrase used as a euphemism.
• Sexually transmitted infection is a broader
term than sexually transmitted disease.[An
infection is a colonization by a parasitic
species, which may not cause any adverse
effects. In a disease, the infection leads to
impaired or abnormal function. In either
case, the condition may not exhibit signs or
symptoms.
• Increased understanding of infections like
HPV, which infects a significant portion of
sexually active individuals but cause disease
in only a few has led to increased use of the
term STI.
• Public health officials originally introduced
the term sexually transmitted infection,
which clinicians are increasingly using
alongside the term sexually transmitted
disease in order to distinguish it from the
former.
• STD may refer only to infections that are causing diseases,
or it may be used more loosely as a synonym for STI.
• Most of the time, people do not know that they are
infected with an STI until they are tested or start showing
symptoms of disease.
• Moreover, the term sexually transmissible disease is
sometimes used since it is less restrictive in consideration
of other factors or means of transmission.
• For instance, meningitis is transmissible by means of sexual
contact but is not labeled an STI because sexual contact is
not the primary vector for the pathogens that cause
meningitis.
• This discrepancy is addressed by the
probability of infection by means
other than sexual contact.
• In general, an STI is an infection that
has a negligible probability of
transmission by means other than
sexual contact, but has a realistic
means of transmission by sexual
contact (more sophisticated means—
blood transfusion, sharing of
hypodermic needles—are not taken
into account).
• Thus, one may presume that, if a
person is infected with an STI, e.g.,
chlamydia, gonorrhea, genital herpes,
it was transmitted to him/her by
means of sexual contact.
• The diseases on this list are
most commonly transmitted
solely by sexual activity.
• Many infectious diseases,
including the common cold,
influenza, pneumonia, and
most others that are
transmitted person-to-person
can also be transmitted during
sexual contact, if one person is
infected, due to the close
contact involved.
• However, even though these
diseases may be transmitted
during sex, they are not
considered STIs.
History
• Sexually transmitted diseases (STDs)
have been known since antiquity:
gonorrhoea was certainly described
by the ancient Egyptians, and was
recognized by Greek and Roman
medical writers.
• The prevalence and spread of these
diseases was exacerbated by war or
other travel, and the rise of city
dwelling, with the concomitant
increase of people living in close
proximity to each other.
• By the Middle Ages both gonorrhoea
and syphilis were widespread.
• One view, by no means unchallenged,
was that syphilis was brought to
Europe by Christopher Columbus'
sailors on their return from the New
World.
• The differentiation of the 2 diseases from each other was often a matter
of medical debate, from the sixteenth up until the nineteenth century,
many authors believing that the symptoms of gonorrhoea (clap or gleet)
were the early stages of syphilis (the pox).
• This view was substantiated by the British surgeon John Hunter (1728-93),
who undertook heroic self-experimentation by injecting his own penis
with material taken from a patient with gonorrhoea.
• On developing the signs of syphilis he concluded the two infections were

the same — little realizing that his patient, like many others, actually
suffered from both infections at the same time.
• The main orthodox treatment for syphilis from the Middle Ages until the early years of the
twentieth century consisted of the application of a mercury ointment, a favourite treatment for
skin lesions.
• But sufferers from the disease were particularly susceptible to the blandishments of quacks and
charlatans, and many successful businesses profited during the seventeenth through to the
twentieth centuries from selling useless remedies.
In the middle of the nineteenth century a French physician, Philippe Ricord (1799-1889),
convincingly demonstrated the differentiation of the two main STDs and determined the three
stages — primary, secondary, and tertiary — of syphilis.
• Shortly afterwards Rudolph Virchow (1821-1902) established that syphilis was spread through the
body by the blood, explaining the known cardiovascular, muscular, and psychiatric complications.
• At the turn of the twentieth century up to a third of inmates in mental asylums were reckoned to
be suffering form tertiary syphilis.
• During the nineteenth century an increasing number of public health
measures, usually aimed at prostitutes, were taken to prevent or control
the spread of STDs.
• The Contagious Disease Acts of Great Britain clearly tolerated prostitution,

as they permitted, amongst other regulations, the compulsory
examination and incarceration of infected women, often in the so-called
Lock hospitals.
• A vociferous campaign was mounted by women's groups, civil rights

activists, and members of the medical profession, and the Acts were
repealed in 1886.
• Advances against the diseases were notably improved by the discovery of

their causative microorganisms. That of gonorrhoea was found in 1879
and that of syphilis in 1905.
• Shortly after this the German bacteriologist Paul
Ehrlich (1854-1915) announced the efficacy of
Salvarsan, an arsenic-based treatment for syphilis.
• Also a diagnostic test was devised, which was

enormously important as it allowed the disease to
be detected in sufferers not yet displaying the
symptoms; they could then be advised on how to
prevent or minimize passing on the infection.
• The development of the sulpha drugs and more

potent antibiotics provided a wider range of
effective drugs against these diseases.
• However, it rapidly became apparent that the

provision of appropriate treatments did not
eradicate these diseases, and that public health
advice and personal hygiene education were also
necessary.
• The appearance and world-wide spread of AIDS

(Acquired Immune Deficiency Syndrome), for which
an effective treatment is still unavailable, during the
1980s, has emphasized the complex nature of these
diseases.
Risk per unprotected sexual act with an infected person
Known risks Possible
•Throat chlamydia[6]
•Throat gonorrhea[6] (25–30%) •Hepatitis B (low risk)[9]
Performing oral sex on a man •Herpes (rare) •HIV (0.01%)[10]
•HPV[7] •Hepatitis C (unknown)
•Syphilis[6] (1%)[8]
•Herpes •Throat gonorrhea[6]

Performing oral sex on a woman
•HPV[7] •Throat chlamydia[6]
•Chlamydia
•Gonorrhea[6]
Receiving oral sex—man •HPV
•Herpes
•Syphilis[6] (1%)[8]
•HPV
Receiving oral sex—woman •Herpes •Bacterial Vaginosis[6]
•Gonorrhea[6]
•Chlamydia (30–50%)[9]
•Crabs
•Scabies
•Gonorrhea (22%)[11]
•Hepatitis B
Vaginal sex—man •Hepatitis C
•Herpes (0.07% for HSV-2)[12]
•HIV (0.05%)[10][12]
•HPV (high: around 40-50%)[13]
•Syphilis
•Trichomoniasis
•Chlamydia (30–50%)[9]
•Crabs
•Scabies
•Gonorrhea (47%)[14]
•Hepatitis B (50–70%)
Vaginal sex—woman •Hepatitis C
•Herpes
•HIV (0.1%)[10]
•HPV (high;[9] around 40-50%)[13]
•Syphilis
•Trichomoniasis
•Chlamydia
•Crabs
•Scabies (40%)
•Gonorrhea
Anal sex—insertive •Hepatitis B •Hepatitis C
•Herpes
•HIV (0.62%)[16]
•HPV
•Syphilis (14%)[8]
•Chlamydia
•Crabs
•Scabies
•Gonorrhea
Anal sex—receptive •Hepatitis B •Hepatitis C
•Herpes
•HIV (1.7%)[16]
•HPV
•Syphilis (1.4%)[8]
•Amebiasis
•Cryptosporidiosis (1%)
Anilingus •Giardiasis •HPV (1%)
•Hepatitis A (1%)
•Shigellosis (1%)
• Bacterial
• Chancroid (Haemophilus ducreyi)
• Chlamydia (Chlamydia trachomatis)
• Gonorrhea (Neisseria gonorrhoeae), colloquially known as "the
clap"
• Granuloma inguinale or (Klebsiella granulomatis)
• Syphilis (Treponema pallidum)
• Fungal
• Candidiasis (yeast infection)
• Viral
• Micrograph showing the viral cytopathic effect of herpes (ground
glass nuclear inclusions, multi-nucleation). Pap test. Pap stain.
• Viral hepatitis (Hepatitis B virus)—saliva, venereal fluids.
(Note: Hepatitis A and Hepatitis E are transmitted via the fecal-
oral route; Hepatitis C is rarely sexually transmittable, and the
route of transmission of Hepatitis D (only if infected with B) is
uncertain, but may include sexual transmission
• Herpes simplex (Herpes simplex virus 1, 2) skin and mucosal,
transmissible with or without visible blisters
• HIV (Human Immunodeficiency Virus)—venereal fluids, semen,
breast milk, blood
• HPV (Human Papillomavirus)—skin and mucosal contact. 'High
risk' types of HPV cause almost all cervical cancers, as well as
some anal, penile, and vulvar cancer. Some other types of HPV
cause genital warts.
• Molluscum contagiosum (molluscum contagiosum virus MCV)—
close contact
• Parasites
• Crab louse, colloquially known as "crabs" or "pubic lice" (Pthirus
pubis)
• Scabies (Sarcoptes scabiei)
• Protozoal
• Trichomoniasis (Trichomonas vaginalis), colloquially known as
"trich"
ATITUTIDINI VIS-À-VIS DE ITS
• NONJUDGEMENTAL
• WE ARE DOCTORS AND NOT PRIESTS EVEN IF
PATIENTS DO CONFESS SOMETIMES MORE TO
DOCTORS THEN THEY DO TO THE PRIEST
• BE PREPARED FOR
EVERYTHING
• YOU MAY ENCOUNTER:
NUNS, PRIESTS, SEXUAL
WORKERS, ACTORS,
POLITICIANS, BANKERS ETC
• PAY ATTENTION TO YOUR
MIMIC/VERBAL/NONVERBA
L COMMUNICATION
• CONFIDENTIALITY: FAMILY,
PRESS, COLLEAGUES,
FRIENDS, ENEMIES ETC.
ANAMNESIS
• THOROUGHFULL
• DETAILLED
• UNPERSONAL APPROACH:
LIFE PARTNER
• PROTECTED/UNPROTECTED
SEXUAL INTERCOURSE
• PAY ATTENTION TO
DIFFERENT MEANING OF
TIME: LONG TIME VERSUS
SHORT TIME
ANAMNESIS
• ANAMNESIS IN ITS
MEANS ASKING ABOUT
ALL INVOLVED PERSONS
• YOU CAN’T TAKE AN ITS
THROUGH THE TOILET
LID
• MORE THEN 2
PHYSICAL EXAINATION
• SEPARETELY FOR ALL
INVOLVED PARTIES
• HUSBAND/
WIFE/LOVERS/CONCUBI
N(E)
• ALL NATURAL CAVITIES
• CUTANEOUS AREAS
• SCALP
• CUTANEOUS ADNEXES
WHAT ARE WE LOOKING FOR
• SIGNS: • SYMPTOMS:
– LOCAL: – ASYMPTOMATIC
• ERITHEMATHOUS PLAQUES – VAGINAL/URETRAL PAIN,
AND MACULES PRURITUS, SENSATION OF
• PAPULAR LESION BURNING
• HYPERTROFIC LESIONS – DISCHARGE
• WARTS
– FEVER
• EROSIVE LESIONS/ULCERS
• URETRAL/VAGINAL – MALAISE
DISCHARGE
– GENERAL:
• EXANTHEMATOUS RASH
• MACULO-PAPULAR
LESIONS
• LYMPHADENOPATHY
• The first well-recorded European outbreak of what is now known
as syphilis occurred in 1494 when it broke out among French
troops besieging Naples.
• The disease may have originated from the Columbian Exchange.
• From Naples, the disease swept across Europe, killing more than
five million people.
• As Jared Diamond describes it, "[W]hen syphilis was first

definitely recorded in Europe in 1495, its pustules often covered
the body from the head to the knees, caused flesh to fall from
people's faces, and led to death within a few months," rendering
it far more fatal than it is today. Diamond concludes,"[B]y 1546,
the disease had evolved into the disease with the symptoms so
well known to us today."[
• Prior to the invention of modern medicines, sexually transmitted

diseases were generally incurable, and treatment was limited to
treating the symptoms of the disease.
• The first voluntary hospital for venereal diseases was founded in

1746 at London Lock Hospital.
• Treatment was not always voluntary: in the second half of the

19th century, the Contagious Diseases Act was used to arrest
suspected prostitutes. In 1924, a number of states concluded the
Brussels Agreement, whereby states agreed to provide free or
low-cost medical treatment at ports for merchant seamen with
venereal diseases.
• The first effective treatment for a
sexually transmitted disease was
salvarsan, a treatment for syphilis.
• With the discovery of antibiotics, a
large number of sexually transmitted
diseases became easily curable, and
this, combined with effective public
health campaigns against STDs, led to
a public perception during the 1960s
and 1970s that they have ceased to
be a serious medical threat.
• During this period, the importance of
contact tracing in treating STIs was
recognized.
• By tracing the sexual partners of
infected individuals, testing them for
infection, treating the infected and
tracing their contacts in turn, STI
clinics could effectively suppress
infections in the general population.
• In the 1980s, first genital herpes and then AIDS emerged into the public
consciousness as sexually transmitted diseases that could not be cured by modern
medicine.
• AIDS in particular has a long asymptomatic period—during which time HIV (the
human immunodeficiency virus, which causes AIDS) can replicate and the disease
can be transmitted to others—followed by a symptomatic period, which leads
rapidly to death unless treated. HIV/AIDS entered the United States in about 1969
likely through a single infected immigrant from Haiti.
• Recognition that AIDS threatened a global pandemic led to public information
campaigns and the development of treatments that allow AIDS to be managed by
suppressing the replication of HIV for as long as possible.
• Contact tracing continues to be an important measure, even when diseases are
incurable, as it helps to contain infection.
ARE ITS AN ISSUE IN THE 21ST
CENTURY??
• SWOT is an acronym for Strengths,
Weaknesses, Opportunities, and
Threats .
• It was originally designed by the
Boston Consulting Group (BCG) in
Massachusetts, USA, where Strategic
Managers devised the strategy to
undermine their competitors and
achieved competitive advantage.
• SWOT analysis can be adapted to
scientific research to helps us as
Scientists in formulating strategies
that augment our research and enable
us to understand and devise holistic
strategies to combat emerging and
recalcitrant infectious pathogens.
• When the characteristic capacities
and the gaps have been identified, we
can then devise means of achieving
our goals
STRENGTS IN ITS MANAGEMENT
• KNOWN (IDENTIFIED)
DISEASES
• KNOWN TREATMENT
• HIGH VALUE
EPIDEMIOLOGICAL DATA
• HIGH LEVEL OF AWARENESS
• GOOD EDUCATIONAL
CAMPAIGN
• GOOD PREVENTIVE
MEASURES
• VACCINATION?
WEAKNESS IN ITS MANAGEMENT
• ECONOMICAL CRISIS: LACK OF MONEY
FOR THE PUBLIC HEALTH SYSTEM
• HIGH INCIDENCE IN POOR AND
DEVELOPING COUNTRIES
• LACK OF DATA IN POOR COUNTRIES
• ITS TRANSMITTED THROUGH
CONDOMS: HPV, HEP. C, CHLAMIDIA,
MYCOPLASMA
• RELAXING TENDENCY FOR CONDOM
USE: DECREASE IN HIV MORTALITY;
HAART THERAPY
• HIGH RISK FOR CERVICAL AND
EOSOPAGHEAL/PHARYNX CANCER
OPPORTUNITIES IN ITS MANAGEMENT
• RISING AWARENESS
• EDUCATIONAL
CAMPAIGNS: ITS CAN BE
TRANSMITTED BY ORAL
CONTACT
• DEVELOPING NEW
ANTIBIOTICS
• MONEY FUNDING
STRATEGIES
• PUBLIC HEALTH POLICIES
FOR UNDERDEVELOPED
COUNTRIES
THREADS IN ITS MANAGEMENT
• THE POWER OF LOVE
AND THE WEAKNESS OF
THE HUMAN MIND: THE
NEW RESTLESS AGE
(SEVERAL PARTNERS,
CONCUBIN/E, THE WEAK
MODEL OF THE CLASICAL
FAMILY, THE WEAK
CHURCH)
• DEVELOPING RESISTANCE
TO ANTIBIOTICS
• THE AGING CONCEPT
• In February 2013, CDC published two analyses that provide an in-depth look at the
severe human and economic burden of sexually transmitted infections (STIs) in the
United States.
• CDC’s new estimates show that there are about 20 million new infections in the
United States each year, costing the American healthcare system nearly $16 billion
in direct medical costs alone.
• America’s youth shoulder a substantial burden of these infections. CDC estimates
that half of all new STIs in the country occur among young men and women.
• In addition, CDC published an overall estimate of the number of prevalent STIs in
the nation. Prevalence is the total number of new and existing infections at a given
time.
• CDC’s new data suggest that there are more than 110 million total STIs among
men and women across the nation. CDC’s analyses included eight common STIs:
chlamydia, gonorrhea, hepatitis B virus (HBV), herpes simplex virus type 2 (HSV-2),
human immunodeficiency virus (HIV), human papillomavirus (HPV), syphilis, and
trichomoniasis.
• CDC estimates that there are more than 19.7
million new STIs in the United States each
year. While most of these STIs will not cause
harm, some have the potential to cause
serious health problems, especially if not
diagnosed and treated early. Young people
(ages 15-24) are particularly affected,
accounting for half (50 percent) of all new
STIs, although they represent just 25 percent
of the sexually experienced population.
• While the consequences of untreated STIs are often worse for
young women, the new analysis reveals that the annual number of
new infections is roughly equal among young women and young
men (49 percent of incident STIs occurs among young men, vs. 51
percent among young women).
• Four of the STIs included in the analysis are easily treated and cured
if diagnosed early: chlamydia, gonorrhea, syphilis, and
trichomoniasis. However, too many of these infections go
undetected because they often have no symptoms. But even STIs
that don’t have symptoms can have serious health consequences.
Undiagnosed and untreated chlamydia or gonorrhea, for example,
can put a woman at increased risk of chronic pelvic pain and life-
threatening ectopic pregnancy, and can also increase a woman’s
chance of infertility.
• CDC estimates that HPV accounts for the majority of newly acquired
STIs. While the vast majority (90 percent) of HPV infections will go
away on their own within two years and cause no harm, some of
these infections will take hold and potentially lead to serious
disease, including cervical cancer
• CDC’s analysis suggests
that there are more than
110 million STIs overall
among men and women
nationwide. This estimate
includes both new and
existing infections. Some
prevalent infections –
such as HSV-2 and HIV –
are treatable but lifelong
infections.
• HPV accounts for the
majority of prevalent STIs
in the United States.
While there is no
treatment for the virus
itself, there are
treatments for the serious
diseases that HPV can
cause, and vaccines are
available to prevent some
types of HPV infection
Human papillomavirus (HPV) – The
most common STI
• Human papillomavirus (HPV) – The most common STI: The body’s
immune system clears most HPV naturally within two years (about 90
percent), though some infections persist.
• While there is no treatment for the virus itself, there are treatments for
the serious diseases that HPV can cause, including genital warts, cervical,
and other cancers.
• Most sexually active men and women will get HPV at some point in their
lives. This means that everyone is at risk for the potential outcomes of
HPV and many may benefit from the prevention that the HPV vaccine
provides.
• HPV vaccines are routinely recommended for 11 or 12 year old boys and
girls, and protect against some of the most common types of HPV that can
lead to disease and cancer, including most cervical cancers.
• CDC recommends that all teen girls and women through age 26 get
vaccinated, as well as all teen boys and men through age 21 (and through
age 26 for gay, bisexual, and other men who have sex with men). HPV
vaccines are most effective if they are provided before an individual ever
has sex.
• HSV-2, HBV, and HIV are lifelong
infections that together account
for nearly one-quarter of all
prevalent infections.
• These infections have potentially
severe health consequences. For
example, HSV-2 can lead to
painful chronic infection,
miscarriage or premature birth,
and fatal infection in newborns.
HBV can lead to cirrhosis, a life-
threatening liver disease.
• And HIV damages a person’s
immune system over time,
increasing an infected person’s
susceptibility to a number of
diseases.
• Additionally, nearly 18,000
people in the United States die
with AIDS each year.
STIs Result in Significant Costs to the
U.S. Healthcare System
• STIs place a significant economic
strain on the U.S. healthcare
system.
• CDC conservatively estimates that
the lifetime cost of treating eight
of the most common STIs
contracted in just one year is
$15.6 billion.
• Because some STIs – especially
HIV – require lifelong treatment
and care, they are by far the
costliest. In addition, HPV is
particularly costly due to the
expense of treating HPV-related
cancers.
• However, the annual cost of
curable STIs is also significant
($742 million). Among these,
chlamydia is most common and
therefore the most costly.
Fighting STIs: Prevention, Diagnosis,
and Prompt Treatment
• Treatment Because STIs are preventable, significant
reductions in new infections are not only possible,
they are urgently needed.
• Prevention can minimize the negative, long-term

consequences of STIs and also reduce healthcare
costs.
• The high incidence and overall prevalence of STIs in

the general population suggests that many
Americans are at substantial risk of exposure to STIs,
underscoring the need for STI prevention.
• Abstaining from sex, reducing the number of sexual

partners, and consistently and correctly using
condoms are all effective STI prevention strategies.
• Safe, effective vaccines are also available to prevent

HBV and some types of HPV that cause disease and
cancer.
• And for all individuals who are sexually active –

particularly young people – STI screening and prompt
treatment (if infected) are critical to protect a
person’s health and prevent transmission to others.
CDC’s STI Screening
Recommendations:
• If you are sexually active, be sure to talk to your healthcare provider about STI
testing and which tests may be right for you.
• All adults and adolescents should be tested at least once for HIV.
• Annual chlamydia screening for all sexually active women age 25 and under, as
well as older women with risk factors such as new or multiple sex partners.
• Yearly gonorrhea screening for at-risk sexually active women (e.g., those with new
or multiple sex partners, and women who live in communities with a high burden
of disease).
• Syphilis, HIV, chlamydia, and hepatitis B screening for all pregnant women, and
gonorrhea screening for at-risk pregnant women at the first prenatal visit, to
protect the health of mothers and their infants.
• Trichomoniasis screening should be conducted at least annually for all HIV-infected
women.
• Screening at least once a year for syphilis, chlamydia, gonorrhea, and HIV for all
sexually active gay men, bisexual men, and other men who have sex with men
(MSM).
• MSM who have multiple or anonymous partners should be screened more
frequently for STIs (e.g., at 3 to 6 month intervals).
• In addition, MSM who have sex in conjunction with illicit drug use (particularly
methamphetamine use) or whose sex partners participate in these activities
should be screened more frequently.
APARENTELE POT INSELA
SCREENING ITS
• SANGVIN • URINAR
– TPHA – SUMAR URINA
– VDRL CANTITATIV – UROCULTURA
– TESTE DE REFERINTA (IgM, IgG
FTABS)
• PROBE BIOLOGICE
– HIV
– EX BACTERIOLOGIC SECRETIE
– AgHBs URETRALA/VAGINALA
– AG CHLAMIDIA, MICOPLASMA
– EXSUDAT FARINGIAN
– EX BACTERIOLOGIC SECR
ANALA
– GENOTIPARE HPV
• VAGINAL
• URETRAL
• ANAL
• FARINGIAN
INFECTII CU TRANSMITERE
SEXUALA DE ETIOLOGIE VIRALA
INFECTIA CU HPV
• PAPOVIROZE HIPERPLAZICE
• NEOFORMATIUNI BENIGNE CU EVOLUTIE CRONICA DE
LUNI-ANI
– Veruci vulgare
– Veruci plane juvenile
– Veruci plantare
– Papiloame:
• CORNOASE
• KERATOZICE DIGITATE
• ALE CAVIT BUCALE
– Vegetatii veneriene
– CONDILOAME GIGANTE MUCO-CUTANATE
VEGETATIILE VENERIENE=CONDILOMA
ACUMINATUM
• PAPILOAME VIRALE ALE REGIUNII ANO-
GENITALE
• EXCRESCENTE PAPILIFORME IZOLATE SAU
GRUPATE, ROZ-ROSIETICE, CU SUPRAFATA
ULCERATA IN ZONELE CU SECRETII SI BRUN
KERATOZICE IN ZONELE USCATE
• PEDICULATE SAU SESILE, CU VARFUL DINTAT IN
CREASTA DEN COCOS
VEGETATIILE VENERIENE
• LOCALIZARE;
– LA BARBAT:
• SANT BALANO-PREPUTIAL
• COROANA GLANDULUI
• GLAND
• PREPUT
• TEACA PENISULUI
• MEAT
• INTRAURETRAL
– LA FEMEIE: LABIAL CU SAU FARA INVADAREA VAGINULUI;
URETRA; COL UTERIN
– DACA SUNT CONFLUENTE REALIZEAZA FORMATIUNI DE
MARIMEA UNUI PUMN CONOPIDIFORME, CU SUPRAFATA
NEREGULATA, BRAZDATA DE SANTURI
VEGETATIILE VENERIENE
• ALTE LOCALIZARI:
– PERIANAL; ANAL
– PERIGENITAL
– INGHINO-CRURAL
• TRANSMITERE PE CALE SEXUALA (VEGETATII
VENERIENE) INDIFERENT DACA CONTACTUL
SEXUAL ESTE SAU NU PROTEJAT
• POT APARE SPONTAN LA PURTATORII DE VIRUS SI
LA GRAVIDE PURTATOARE DE VIRUS ANTERIOR
ASIMPTOMATICE
HPV GENITAL
HPV GENITAL
DIAGNOSTIC DIFERENTIAL HPV-
PAPULE HIPERTROFICE PENIENE
DIAGNOSTIC DIFERENTIAL HPV-
CONDILOMA LATA
• TREBUIE DIFERENTIATE DE SIFILIDELE PAPULO-
HIPERTROFICE (CONDILOMA LATA VERSUS
CONDILOMA ACUMINATUM)
• ACESTEA SUNT LOCALIZATE IN ACELEASI REGIUNI:
PAPULE MARI CU SUPRAFATA PLANA SPRE
DEOSEBIRE DE VEGETATII CE AU SUPRAFATA
CONOPIDIFORMA
• SEROLOGIE DE SIFILIS POZITIVA SI T. PALIDUM
PREZENT IN LEZIUNI
• APAR LA PERSOANELE CU IMUNITATE
COMPROMISA
PAPILOMATOZE GIGANTE MUCU-
CUTANATE
• CONDILOMATOZA GIGANTA
PSEUDOEPITELIOMATOASA BUSCHKE
LOEWENSTEIN
• APARE LA ADULTI TINERI: VEG VENERIANA
OBISNUITA CARE IN TIMP DEVINE INFILTRATIE F
INTINSA; VOLUMINOASA SI KERATOZICA CU ZONE
PROFUND INFILTRATIVE SI PUTAND INFILTRA
CORPII CAVERNOSI SI URETRA
• BALANO-PREPUTIAL, LABIAL, VULVAR; PERIANAL
• TREBUIE DIFERENTIAT DE EPITELIOMUL
SPINOCELULAR
PAPILOMATOZA ORALA FLORIDA
• APARE PE PALATUL TARE; GINGII, MUCOASA
JUGALA; LIMBA; FARINGE; BUZE; COMISURI
• VEGETATIE PAPILOMATOASA CU SUPRAFATA
POLIPOIDA MAMELONATA, CONOPIDIFORMA
• LEZIUNI DURE LA PALPARE
• SE POT ULCERA SI SUPRAINFECTA, POT APARE
DURERI SI ADENOPATIE
PAPILOMATOZA ORALA FLORIDA
DIAGNOSTICUL INFECTIEI HPV
• GENOTIPARE/FENOTIPARE HPV:
– LEZ ALE MUCOASEI GENITALE LA FEMEI: DIN
COL/ANAL
– LA BARBATI: LEZ ALE MUCOASEI URETRALE/ANALE
– MUCOASA JUGALA
– RACLAJ AL MUCOASEI CU PRELEVARE DE CELULE
IN A CAROR GENOTIP S-A INCLAVAT GENOTIPUL
VIRAL
TRATAMENTUL INFECTIILOR CU HPV
• TRATAMENT LOCAL:
– LASER CO2, ELECTROCAUTERIZARE,
RADIOCAUTERIZARE; IN ANESTEZIE LOCALA
– ZAPADA CARBONICA, AZOT LICHID
– SUBST CHIMICE: ACID SALICILIC 40%; ACID
TRICLORACETIC 33%
– PTR CONDILOMA ACUMINATUM:
PODOFILINA/PODOFILOTOXINA 25-40% IN TIPIZATE:
UNGUENTE LANOLINA, VASELINA
– 5FU: 5FLUOROURACIL (LEZIUNI PE MEAT)
– ALDARA (IMIQUIMOD) 5% STIMULEAZA SINTEZA
LOCALA DE INTERFERON SI PREVINE RECIDIVELE
• TRATAMENT GENERAL:
– IMUNOSTIMULARE: ISOPRINOZIN 5CP/ZI,
10ZILE/LUNA, 4-5 LUNI CONSECUTIV
– VACCINARE BCG, LEVAMISOL
– DERIVATI DE VITAMINA A (RETINOIZI) SISTEMICI
– ATENTIE LA CONTACT SEXUAL
MOLUSCUM CONTAGIOSUM
• DERMATOVIROZA PROLIFERATIVA, HETERO SI
AUTOINOCULABILA DATA DE UN POXVIRUS DE MARI
DIMENSIUNI CE AFECTEAZA FRECVENT COPII
• MICI TUMORETE EMISFERICE, CU USOARA
OMBILICARE CENTRALA, DE CONSISTENTA FERMA,
CULOARE ALB LAPTOASA, TRANSLUCIDA SAU ROZATA,
CU SUPRAFATA NETEDA
• PRIN PRESIUNE PUTERNICA SAU INTEPARE CU VARFUL
ACULUI/BISTURIULUI SE ENUCLEAZA O SUBSTANTA
PASTOASA GALBEN CENUSIE = GRAUNTII DE
MOLUSCUM = EPIDERM NECROZAT SUB ACTIUNEA
VIRUSULUI
• LEZIUNI MULTIPLE
• ASIMPTOMATICE
• NU LASA IMUNITATE
• SE POT SUPRAINFECTA
• INCUBARE: 2-5 SAPTAMANI
• LOCALIZARE:
– COPII: PE FATA; GAT; PLEOAPE
– ADULT: GENITAL/PERIGENITAL (CONTAGIUNE PRIN
RAPORT SEXUAL)
• TRATAMENT;
– INTEPARE CU SERINGA/ACUL
– CHIURETARE
– ELECTROCAUTERIZARE/LASER CO2
– SE DISTRUG TOATE LEZINULE INTR-O SEDINTA
– DECONTAMINARE HAINE/LENJERIE INTIMA
– LEZIUNI MULTIPLE: TETRACICLINA SAU
ERITROMICINA 7-8 ZILE
– STIMULAREA IMUNITATII: ISOPRINOZIN
EPIDERMONEUROVIROZE
• AFECTEAZA CU PRECADERE TESUTURI CU
ORIGINE ECTODERMICA
• AFINITATE NEURO SI DERMOTROPA
• LEZIUNI CUTANEO-MUCOASE REPREZENTATE
DE VEZICULE GRUPATE
• LATENTA IN ORGANISM CA VIRUS BIOFIT
– HSV1;2
– VIRUS VARICELO-ZOSTERIAN
HERPESUL SIMPLEX
• CEA MAI RASPANDITA INFECTIE VIRALA
• HSV1: LEZIUNI IN JUMATATEA SUPERIOARA A
CORPULUI; HERPES PERIBUCAL
• HSV2: HERPES GENITAL SI PERIGENITAL
• INFECTIA SE TRANSMITE PRIN CONTACT INTIM (SARUT,
CONTACT SEXUAL) DE LA O PERSOANA CU LEZIUNI
ACTIVE SI DE LA PURTATORI APARENTI SANATOSI LA
OAMENI CARE NU AU INTRAT ANTERIOR IN CONTACT
CU VIRUSUL
• SE POATE TRANSMITE SI TRANSPLACENTAR
• AGENTUL PATRUNDE PRIN MUCOASE SAU PRIN
SOLUTIILE DE DISCONTINUITATE DE LA NIVELUL
TEGUMENTULUI
HERPESUL SIMPLEX
• LEZIUNI CUTANEO-MUCOASE: ERUPTII
VEZICULOASE IN BUCHET, CIRCINATE, CU SEMNE
GENERALE FOARTE DISCRETE
• RAR AFECTAREA SIST NERVOS CENTRAL; STARE
SEPTICEMICA
– 1. INFECTIA PRIMARA (intre varsta de 6 luni si 5 ani)
– 2. INFECTIA HERPETICA RECIDIVANTA,
CARACTERISTICI:
• ABSENTA SAU DISCRETIA SIMPTOMELOR;
• DIMENSIUNILE REDUSE ALE ERUPTIEI;
• RESORBTIA SPONTANA IN 7-10 ZILE
PRIMOINFECTIA HERPETICA
• IN PRIMA COPILARIE
• 80-95% FORME ASIMPTOMATICE
• 10% ERUPTIE CUTANEO-MUCOASA
• 5% SIMPTOMATOLOGIE CLINICA
ZGOMOTOASA/GRAVA
• GINGIVO-STOMATITA HERPETICA ACUTA: CEA MAI
FRECVENTA MANIFESTARE LA COPIL (INTRE 1-3ANI)
• SINDROM ERUPTIV VEZICULOS PE MUCOASA:
GINGIVALA; JUGALA; LINGUALA; PALAT; VESTIBULUL
GURII; AMIGDALIAN
• POATE ASOCIA STARE GENERALA ALTERATA, DISFAGIE;
ULCERATII DUREROASE, GALBEN CEROASE SECUNDAR
RUPERII VEZICULELOR INITIALE
• ADENOPATIE SUBMANDIBULARA SAU CERVICALA
DUREROASA
• LA NIVEL CUTANAT: INCUBATIE DE 7-8 ZILE
• INOCULARE DIRECTA A HSV PE PIELEA
NORMALA SAU SECUNDAR UNUI
TRAUMATISM
• FRECVENT PE ZONA DE TRECERE INTRE PIELE
SI MUCOASE: BUZE, NAS, PLEOAPE, GENITAL
• ERUPTIA POATE FI PRECEDATA DE FENOMENE
GENERALE USOARE
• VINDECARE IN 7 ZILE
• LOCALIZARI OFTALMOLOGICE: HERPES
PALPEBRAL; BLEFARITA SI
KERATOCONJUNCTIVITA
• HERPES POSTTRAUMATIC: PE DEGETE LA COPII
CU PRIMOINFECTIE DUPA O INTEPATURA:
PANARITIU HERPETIC
• HERPESUL GENITAL: FOARTE FRECVENT; TREBUIE
DIFERENTIAT DE ALTE BTS (BOLI CU TRANSMITERE
SEXUALA)
• BARBAT: LOCALIZARE: FATA INTERNA PREPUT, SANT
BALANO-PREPUTIAL; GLAND, URETRAL SUB FORMA DE
VEZICULE GRUPATE
• FEMEI: CARCATER PROFUZ CU INTERESAREA VULVEI;
VAGINULUI; COLULUI UTERIN CU EDEM AL LABIILOR MARI
SI MUCOASA VULVO-VAGINALA ROSIE,TUMEFIATA CU
LEZIUNI VEZICULO-EROZIVE NUMEROASE; DUREROASE
• ADENOPATIE INGHINALA BILATERALA DUREROASA
• INOCULARE PRIN CONTACT SEXUAL
HERPES GENITAL
HERPES GENITAL
HERPES GENITAL
HERPES GENITAL
INFECTIA HERPETICA NEONATALA
• LA NOU NASCUTI; FORMA FOARTE GRAVA, UNEORI LETALA
• TRANSMITERE TRANSPLACENTARA DE LA MAMA SAU IN PERIOADA
POSTNATALA
• ERUPTIE HERPETICA LA MAMA APARE LA CATEVA ZILE
ANTEPARTUM DREPT HERPES BANAL SAU STOMATITA HERPETICA
• FRECVENT LA PREMATURI SI SUBNUTRITI
• DEBUT LA 4-6 ZILE POSTPARTUM
– FORMA CUTANATA SI SEPTICEMICA: DEBUT CU FEBRA MARE SI
ERUPTIE HERPETICA CUTANEO-MUCOASA DISEMINATA SI ALTERAREA
STARII GENERALE; LEZIUNILE CUTANEO-MUCOASE SUNT DISCRETE,
PREDOMINAND CELE SEPTICEMICE: HEPATICE (ICTER, CIROZA)
– FORMA MENINGO-ENCEFALITICA
HERPESUL RECIDIVANT
• CARACTERSITICI:
– INTERESEAZA ADULTUL
– DIMENSIUNI REDUSE ALE ERUPTIEI
– OBLIGATORIU CU SEMNE PREMONITORII: DURERE, USTURIME,
ARSURA ETC
– ABSENTA SIMPTOMATOLOGIEI GENERALE
– F RAR FEBRA, DURERE, LIMFANGITA
• FAC RECIDIVE CCA 8-10% DIN PERSOANELE CE AU FACUT
PRIMOINFECTIE SI CARE AU GRAD DE DEFICIENTA IMUNA FATA DE
VIRUS
• RECIDIVE DE OBICEI PE ACELASI LOC CU PRIMOINFECTIA:
PERIBUCAL SAU GENITAL (EXPLICATIE: SCADEREA IMUNITATII SI
CRESTEREA HIPERSENSIBILITATII LOCALE FATA DE VIRUS CU OCAZIA
PRIMEI INFECTII PRECUM SI IN GGL SPINALI UNDE RAMANE
CANTONAT VIRUSUL)
• HERPES GENITAL IN PING-PONG
HERPESUL RECIDIVANT
• DUPA PRIMOINFECTIE HSV VEGETEAZA FARA ACTIVITATE
PATOGENA IN GGL SPINALI AI NERVILOR PERIFERICI; IN
CELULELE SCHWANN ALE NERIVLOR SENZORIALI:
STABILINDU-SE UN ECHILIBRU CE PERMITE HSV
SUPRAVIETUIREA
• FACTORII CARE FAVORIZEAZA RECIDVA: IACRS,
GASTROENTERITE, HEPATITE, MENSTRELE (HERPES
CATAMENIAL), SARCINA, OBOSEALA, STRES PSIHIC, IRITATIE
LOCALA (EXTRACTII DENTARE LABORIOASE, LUCRARI
PROTETICE INCORECTE), EXPUNEREA LA UV, ACTIVITATEA
SEXUALA
• IMUNODEPRESIA POATE FAVORIZA CAZURI SEVERE DE
RECIDIVE
HERPES RECURENT
ETIOPATOGENIE, EPIDEMIOLOGIE,
DIAGNOSTIC
• HSV: 70-200 MICRONI
• 2 TIPURI ANTIGENICE MAJORE (HSV1; HSV2)
• POATE DISEMINA:
– PE CALE HEMATOGENA DUPA MULTIPLICARE LOCALA;
– PRIN CONTIGUITATE DE LA O CELULA LA ALTA;
– NERVOS: CENTRIFUG SAU CENTRIPET
• ANTICORPII LA NASTERE SUNT ANTICORPI MATERNI, TRANSMISI
TRANSPLACENTAR, CARE SE MENTIN PANA LA 4-6 LUNI DE VIATA LA UN TITRU
SIMILAR ADULTULUI; APOI TITRUL SCADE PANA LA 2 ANI SI APOI CRESTE TREPTAT
INAPOI PANA LA 5 ANI
• CONSECINTA: INTRE 6 LUNI-2-5 ANI EXISTA O BARIERA IMUNA CU IMUNITATE
SLABA FATA DE HSV
• LA PRIMOINFECTIE IgG SI IgM ANTIHSV APAR IN ZIUA 5-6 SI CRESC PANA IN ZIUA
15, NEASIGURAND CONSTANT PROTECTIE
• IgG ANTI HSV SUNT PREZENTI LA PANA LA 84-90% DINTRE TINERII PESTE 15 ANI,
OMUL ODATA INFECTAT RAMANE PURTATOR TOATA VIATA
• IN HERPESUL RECIDIVAT CRESTE IgM ANTI HSV DIN ZIUA 5-6 DE INFECTIE CA
ELEMENT DE DIAGNOSTIC PARACLINIC
TRATAMENTUL INFECTIEI HERPETICE
• SCOP:
– EVITAREA INFECTIEI SECUNDARE
– COMBATEREA RECIDIVELOR
– REDUCEREA FENOMENELOR INFLAMATORII SI A DURERII
• TRATAMENTUL LOCAL: ACICLOVIR TOPIC;
– IN RECIDIVE DE LA MOMENTUL APARITIEI
SIMPTOMATOLOGIEI PREMONITORII (DURERE, USTURIME,
ARSURA) DE 5X/ZI MINIM
– ANTISEPTICE: SOL CASTELANI, VIOLET DE GENTIANA,
BETADINA, APA OXIGENATA, RIVANOL ETC
– SOL GLICERINA BORAXATA: (ACID BORIC 3G; LIDOCAINA
FIOLE 4; ERITROMICINA 2G; GLICERINA 30G) IN LEZIUNI
BUCALE
– AFTOLIZOL ETC
• TRATAMENT GENERAL:
– ACICLOVIR (4g/zi); GANCICLOVIR, FOSCARNET ETC
– IN GINGIVOSTOMATITA HERPETICA; AFECT OCULARE,
FORME GRAVE CU ALTERAREA STARII GENERALE ETC
– IN FORMELE RECIDIVANTE CU EPISOADE FRECVENTE
SI SUPARATOARE: DOZA MEDIE 800-1g/zi LUNI DE ZILE
– SE CONTRAINDICA: CORTICOTERAPIA,
DERMATOCORTICOIZII, ROENTGENTERAPIA,
FOTOTERAPIA
– ATENTIE LA PEELING-URI SI TRATAMENTE LASER LA
PACIENTI CE FAC FRECVENT HERPES RECIDIVANT
– ATENTIE LA TERAPIA CU RETINOIZI
• TRATAMENT SUPORTIV:
– ANTIBIOTIC LOCAL SAU GENERAL IN CAZ DE
SUPRAINFECTIE
– TERAPIA DURERII: ASPIRINA, PARACETAMOL,
CODEINA PLUS PARACETAMOL, IBUPROFEN ETC
– ALIMENTATIE SEMILICHIDA
– EVITAREA FACTORILOR DE RECIDIVA
• INFECTII CU TRANSMITERE SEXUALA DE
ETIOLOGIE BACTERIANA
INFECTIA SIFILITICA
Transmitere
Sursa – bolnavul cu leziuni floride (şancru primar şi sifilide
secundare) – prin transmitere directă, sânge, lichid spermatic,
lapte de mamă.
Calea de transmitere
- 98% pe cale sexuală – 1/3 dintre contacţi fac boala.
- Extrasexuală – directă – sărut, muşcătură, înţepătură obiect
medical contaminat, transfuzie sânge infectat, boală
profesională la ginecologi, stomatologi, etc.
- indirect – prosop, pahar, obiecte de ras,
instrumente de suflat – practic inexistent.
- Transplacentar – de la mamă la făt.
Clinic – Sifilis primar
- Incubaţie – 21 zile (limite 10-90);

- La locul de inoculare – leziunea primară (şancru dur sau sifilom) – durează
1 – 6 săptămâni, se vindecă fără cicatrice;
- Clinic – maculă eritematosă → se infiltrază → se erodează central;
- eroziune rotund–ovalară, 1-2 cm, bine delimitat, neted, curat,
lucios, cu secreţie bogată în spirochete, nedureros, bază indurată;
- localizare – genital, extragenital;
- adenopatia satelită – apare la 7 zile după şancru, unilaterală (rar
bilaterală), poliganglionară, nedureroasă, spontan rezolutivă;
- Complicaţii – fimoză, parafimoză, suprainfecţie (devine dureros), edem;
Clinic – Sifilis secundar
- Stadiul de septicemie treponemică;
- La 3 – 6 săptămâni de la apariţia şancrului;
- Manifestări cutaneo-mucoase tranzitorii şi manifestări sistemice;
Sifilide:
- Cutanate – maculare – rozeola – macule rotund-ovalare, roz-pal, 1-2cm, discrete,
nepruriginoase, dispar la vitropresiune;
- papuloase – lenticulare – roşu-arămii, ferme la palpare, scuamă ce
formează guleraş periferic – mai ales palmo-plantar;
- papulo-erozive – în pliuri;
- papulo-scuamoase, foliculare, pustuloase, inelare;
- Mucoase – plăci mucoase nedureroase, erozive;
- condiloma lata – papule hipertrofice, macerate, exudative, se
suprainfectează bacterian şi miros urât, suprafaţă netedă – regiunea genitală şi
pliuri;
- Alopecie în luminişuri sau difuză, modificări unghiale;
- Manifestări sistemice – micropoliadenopatie, splenomegalie, afectare hepatică,
renală, gastrică, oculară, neurologică, etc.
- Sifilidele – evoluţie autolimitată;
Clinic – Sifilis latent
- Netratat, sifilisul secundar trece într-un stadiu asimptomatic, cu teste

serologice pozitive = sifilis latent.
- Starea de latenţă poate dura toată viaţa sau poate fi întreruptă de recăderi
de tip secundar sau terţiar;
- Vechimea infecţiei se determină prin istoric şi teste serologice anterioare:
- sub 2 ani – sifilis latent recent
- peste 2 ani – sifilis latent tardiv
Clinic – Sifilis terţiar
- La 1-20 ani după stadiul secundar; imunitatea şi alergia sunt maxime;

- Cutanat – leziuni localizate, simetrice, cronice, tendinţă distructivă locală,
sărace în treponeme;
- sifilide nodulare şi nodulo-ulcerative;
- gome;
- leziuni mutilante mucoase
- Neurosifilis – tabes, paralizie generală progresivă;
- Cardiovascular – anevrism aortic, coronarită;
- Leziuni osteo-articulare – leziuni osteolitice;
- Gome în orice alte organe;
- Diagnostic – clinic, serologic, histopatologic.
Sifilis congenital
- Transmitere de la mamă la făt - hematogen; după naştere – prin lapte matern;

- Sifilis netratat contactat în timpul naşterii – transmitere 80-100%;
- Sifilis congenital precoce (manif. clinice sub 2 ani) – prematuri, greutate mică,
facies senescent, sifilide, coriza, laringita, hepatospenomegalie, leziuni
osoase;
- Sifilis congenital tardiv (manif. clinice după 2 ani) – sifilide nodulare, ulcerate,
gome, leziuni viscerale, stigmate, distrofii;
- Sifilis serologic – poate evolue spre s. tardiv, s. nervos;
- Diagnostic – VDRL cantitativ mamă şi copil, FTAabs.- IgM;
- Tratament - numai cu Penicilina G 200.000-300.000 u.i./zi fracţionat, i.v. sau
i.m., 10-12 zile;
- Prevenire – control serologic înainte de sarcină, trim. 1, trim. 3 şi la naştere;
Diagnostic
Ultramicroscopia – examinarea la microscop în câmp întunecat a produsului din leziunile
eroziv-ulcerative; microscopul optic – impregnare argentică.
Diagnostic serologic:
- Teste ce pun în evidenţă antigenele lipoidice – atc diagnostici (reagine):
- se pozitivează la 14-20 zile după apariţia sifilom, scad în sifilis terţiar (1 -2 ani);
- utile pt screening şi aprecierea eficacităţii tratament;
- VDRL,RPR - r. de floculare; RBW – r. de fixare complement;
- R. fals pozitive (0,025%) – vaccinări recente, infecţii bacteriene (TBC, scarlatina,
endocardita, etc), virale (MI, gripa, rujeola, hepatita), sarcina, boli autoimune
(colagenoze, hepatite, ciroză hep.), neoplazii avansate, vârsta înaintată, transfuzii
repetate.
- Teste ce pun în evidenţă antigenele proteice – atc specifici:
- sensibilitate şi specificitate mare – confirmarea infecţiei (rar fals poz.);
- TPHA – se pozitivează ~ VDRL, se negativează f. greu;
- FTA, FTAabs.-IgM – se pozitivează primul – pt confirmarea infecţiei la adulţi
seronegativi, pt confirmare sifilis congenital;
- TPI – se pozitivează târziu (50-60 zile), constant pozitiv în s. latent tardiv şi s. terţiar,
mare specificitate, este utilizat pt a lămuri cazurile fals pozitive.
Definiţii de caz
Sifilis primar seronegativ – şancru, evidenţiere T. pallidum prin ultramicroscopie, serologie
negativă;
Sifilis primar seropozitiv – ca şi mai sus + serologie pozitivă;
Sifilis secundar – clinic: manif. de secundarism, serologie pozitivă;
Sifilis terţiar – una sau mai multe dintre manif. clinice: cutanat, osos şi visceral cu excepţia
s. cardiac şi nervos; neurosifilis; sifilis cardio-vascular;
- serologie pozitivă.
Sifilis latent – absenţa manifestărilor clinice de sifilis; lcr şi Rx cardiopulmonar normal;

serologie pozitivă teste treponemice şi netreponemice;
- teste pozitive documentat de mai putin de 2 ani – latent recent;
- teste pozitive nedocumentate sau mai vechi de 2 ani – latent tardiv.
Sifilis congenital – sifilis serologic sau clinic depistat până la vârsta de 2 luni.
Tratament
- Penicilina parenteral – benzatin penicilina, penicilina cristalină,

procainpenicilină;
- Sifilis recent (≤ 2 ani) – penicilinemie eficientă 7–10 zile;
- Sifilis tardiv (> 2 ani) - penicilinemie eficientă 21 – 30 zile.
- Alergie la Penicilină – Doxiciclină, Tetraciclină, Eritromicină.
- Neurosifilis şi sifilis în sarcină – numai Penicilina documentat eficientă.
- Îngrijiri medicale parteneri sexuali;
- Monitorizare postterapeutică – examen clinic şi serologie cantitativă, timp de 2

ani, iniţial la 3 luni în primul an, apoi la 6 luni; dacă titrul testelor
netreponemice nu scade de 4 ori în primele 6 luni – reevaluare, atc anti HIV,
reluarea tratament.
Accidente/incidente ale tepapiei în sifilis
Reacţia Jarisch-Herxheimer – incidenţă > 25%

- În forme active, datorită distrucţiei masive de treponeme şi eliberare de endotoxine;
nu este periculoasă.
- Clinic: - la 6-12 h - febră, cefalee, transpiraţie, congestie a feţei, astenie, exacerbarea
leziunilor – durează 24-48 h;
- Se poate preveni cu Prednison 20-30 mg şi antihistaminice;
- Tratament – numai în formele grave:
- se întrerupe Penicilina 24-48 h
- antitermice, antihistaminice, corticoizi oral.
Paradoxul terapeutic Wile

- Agravarea bruscă a sifilis visceral → insuficienţă cardiacă, IM, AVC, convulsii.
- Explicaţie → rezorbţia rapidă a infiltratului din leziunile viscerale
- Recomandare → în sifilisul visceral se începe tratament în doze mici
Accidente/incidente ale tepapiei în sifilis
Sindromul Hoigné
- Reacţie pseudoanafilactică la Penicilina depozit;
- Clinic – imediat după injecţie – tahicardie, creşterea TA, cianoză, greţuri, vărsături,
acufene, diplopie, senzaţie de panică, comă superficială.
- Explicaţie - microembolii prin cristalele de penicilină nedizolvate care ajung i.v.
- Tratament – de urgenţă – HHC, Miofilin, Papaverină, Diazepam, etc.
Reacţii alergice la Penicilină – 1% din populaţie

- Regulă → testarea cutanată !
- Clinic: tip1 – urticarie şi şoc anafilactic (min. – 2 h)
tip 3 – purpură, eritem polimorf-like, etc. (la 3-5 zile)
pseudoalergice – prin degranularea mastocitelor, datorită substanţelor
anafilactoide (impurităţi).
- Tratament – HHC, Adrenalină, antihistaminice inj., etc
- Este necesar tratamentul cu alt antibiotic sau desensibilizare.
Gonoreea
Neisseria gonnorrheae
- Una dintre cele mai frecvente ITS, de 3 ori mai frecventă la bărbaţi decât la femei;
- Transmitere aproape exclusiv sexuală, excepţional lenjeria murdară;
- Incubaţie – 2-5 zile (1-14 zile);
- Clinic:
Barbaţi – uretrită – secreţie galben-verzuie abundentă, disurie;
- 15% asimptomatici;
- complicaţii locale – abcese periuretrale, balanită, infectarea glande Tyson,
Cowper, Littre, Morgagni;
- complicaţii regionale – prostatita, veziculita, orhiepididimită;
Femei – infecţia iniţială la majoritatea asimptomatică;
- cervicită, uretrită – simptome urinare şi secreţie purulentă –
subdiagnosticată ca şi cistită;
- complicaţii loco-regionale – bartholinita, vulvovaginita, endometrita –
durere, hipermenoree, menoragii, salpingita – sterilitate.
Gonoreea
Gonoreea extragenitală:
- Primară – orofaringiană – după contact sexual orogenital – depozite purulente
amigdaliene, sensibiliatate locală;
- rectală – contact sexual anal – secreţie, sângerăr, tenesme;
- oftalmo-gonoreea nou-născutului – unilaterală, la 1-5 zile de la naştere;
actual se face profilaxie la toţi nou.născuţii;
- Secundară – prin transfer extragenital – conjunctivita gonococică;
- Diseminare hematogenă – artrita gonococică – articulaţie mare;
- endocardita, septicemie, perihepatita, meningita.
Diagnostic – produsul patologic - secreţie uretrală, în absenţă produs de brosaj uretral
sau masaj prostatic);
- secreţie recoltată din colul uterin, uretră, rect faringe;
- frotiu – coloraţie Gram – diplococi Gram neg.
- cultură – metoda cea mai precisă;
- serodiagnosticul – utilă numai în formele de infecţie diseminată.
Gonoreea
Tratament:
- Atenţie la asocierea cu infecţie chlamydiană – se tratează preventiv şi
acesta;
- La cea necomplicată – Ceftriaxon 250mg inj i.m.
- - Ciprofloxacin 500 mg doză unică;
- - Ofloxacin 400 mg doză unică;
- - Spectinomicina 2g inj. i.m.
- - Kanamicină 2 g inj. i.m.
urmate de Doxiciclina 200mg 7 zile sau Eritromicina 2g 7 zile.
Infecţia cu Chlamydia Trachomatis
Chlamydia trachomatis serotipuri D-K
- Cea mai frecventă infecţie transmisă sexual în tările civilizate,
Clinic:
- Bărbaţi – 75 % asimptomatici
- uretrită – incubaţie 7 -21 zile, frecvent asociată cu gonoreea (uretrita
postgonococică);
- epididimită, prostatită, proctită;
- Femei – 70% asimptomatice
- cervicită, endometrită, perihepatită;
- boală inflamatorie pelvină – infertilitate
- transmitere la făt – pneumonie, conjunctivită;
- Diagnostic – serologic – test ELISA – atc antiChlamydia
- imunofluorescenţă directă – atg din secreţie
- cultura, hibridizare ADN-ARN, PCR – scumpe.
- Tratament – Azitromicină 1 g dz. unică
- Doxiciclină 200 mg/zi, Eritromicina 2g/zi, Ofloxacin 2x200mg/zi,
Roxitromicina 4x150mg/zi – 7 zile;
• ALTE INFECTII CU TRANSMITERE SEXUALA
Trichomoniaza
- Boală infecţioasă parazitară a tractului genito-urinar inferior produsă de
Trichomonas vaginalis
- Transmitere – pe cale sexuală, f. rar nevenerian (rezistenţă scăzută în condiţii de
uscăciune;
- Incubaţia – 4 – 21 zile;
- Clinic: - femeie – vulvo-vaginită – secreţie galben-verzuie, neplăcut mirositoare,
eritem, edem, prurit, dispareunie, complicaţii, etc.
- bărbat – uretrită, balanopostită, frecv. asimptomatic;
- Diagnostic – examen secreţie – microscopie optică, cu ser fiziologic, coloraţie
Giemsa;
- Tratament – Metronidazol 2 g dz. unică, Tinidazol 2 g dz. unică;
- Metronidazol 500 mg x 2/zi 7 zile;
- Tinidazol 500 mgx2/zi 5 zile;
+/- tratament local.
+ partener.
- Gravide trim. I – clotrimazol ovule; trim. II, III – Metronidazol oral;

Candidoze
Nu este de obicei o boală transmisă sexual.
- Tratamentul partenerilor trebuie avut în vedere în cazul infecţiei recurente;

- Clinic – vulvo-vaginită;
- balanopostita.
- Diagnostic – examen secreţie + cultură.
- Tratament – imidazoli sau nistatin topic;
- atenţie factori favorizanţi – tratamente cu antibiotice, preparate
vaginale antiseptice, diabet zaharat, imunosupresie, corticoterapie, focar
digestiv, etc.
- sistemic – Fluconazol doză unică; altele numai excepţional.
Hepatite
Agenţi ITS care pot provoca hepatite:
- Virusul hepatitei B (HBV)
- Virusul hepatitei A (HAV)
- Citomegalovirus (CMV)
- T. pallidum
- HIV (sindrom retroviral acut)
- Virusul hepatitei C
Diagnostic – forme simptomatice – astenie, anorexie, febră, icter, etc.
- erupţie urticariană, artralgii, etc.
- creşterea transaminaze.
- forme simptomatice – creşterea transaminaze.
Diagnosticul de pune prin efectuarea şi interpretarea markerilor serologici.

Hepatita virală B
Evaluarea şi tratamentul bolnavilor se efectuează în serviciul de boli

infecţioase.
- Formele cronice - tratament antiviral;
- Bolnavii vor fi consiliaţi să-şi protejeze partenerii sexuali (prezervativ) până
devin neinfecţioşi sau partenerii sunt vaccinaţi cu succes;
- Managementul contacţilor – contact posibil infectant în ultimile 48h:
imunizare pasivă cu imunoglobuline specifice şi vaccinare;
- parteneri sexuali obişnuiţi – testare, urmată de
imunizarea persoanelor susceptibile;
- Vaccinarea nou-născuţilor, a categoriilor cu risc crescut (recomandarea OMS
– vaccinarea universală).
Scabia
Sarcoptes Scabiae
- frecvent ITS la adulţi;
- Clinic → erupţie papuloasă, localizată, escoriaţii lineare de grataj, noduli eritematoşi (organe
genitale, axile, abdomen)
→ prurit accentuat nocturn
- Paraclinic → examen parazitologic direct
- Context epidemiologic
- Tratament (şi al contacţilor)
Lindan 1% contact 8 h;
Benzoat de benzil 25% 3 seri la rând;
Sulf 6 -10% 3 seri la rând
Permetrină cremă 5% aplicaţie unică
Crotamiton 10% 2 – 5 seri al rând
Sugari, copii sub 10 ani, gravide, femei care alăptează:
Benzoat de benzil 10 -15% 3 seri la rând;
Sulf 6% 3 seri la rând
Crotamiton 10% 2 – 5 seri la rând.
- Măsuri auxiliare – hainele şi lenjeria spălate la cel puţin 60ºC sau 3 zile izolate într-un sac de
plastic sau 3 zile aerisite.
Pediculoza pubiană (ftiriaza)
Phtirius pubis
- Se transmite în principal pe cale sexuală, se asociază cu alte ITS;

- Clinic – prurit localizat în zona genitală;
- macule cerulee (pete albăstrui) – patognomonice;
- papulo-vezicule, cruste hematice, elemente de piodermită sau
eczematizare, paraziţi;
- alte localizări – perianal, coapse, barbă, mustăţi, gene, sprâncene.
- Tratament – Lindan 1% şampon 4 min., cremă 8 h;
- piretrine + piperonyl butoxid 10 min., cu reaplicare peste 10 zile;
- măsuri auxiliare de igienă obligatorii.
Infecţia HIV
Virusul imunodeficienţei umane

Sursa de infecţie – persoane infectate HIV indiferent de stadiul sau expresia
clinică a bolii; o persoană infectată rămâne până la sfârşitul vieţii potenţial
infectantă.
Transmitere – prin sânge, spermă, secreţii vaginale;
- Contact sexual;
- Parenteral – transfuzii de sânge şi derivate
- instrumentar medico-chirurgical;
- transplant de organe;
- însămânţare artificială;
- Vertical (risc 13-30%) – in utero, la naştere, prin lapte matern;
Nu se transmite prin salivă, aerosoli, înţepături de insectă.
Infecţia HIV
Clinic
- Infecţia primară – asimptomatică
- 10-20% din cazuri – boală febrilă acută tranzitorie, la 3 – 6
săptămâni de la infecţie;
- După infecţia primară
– infecţie asimptomatică
- limfadenopatie persistentă generalizată – adenopatie în 2 arii ganglionare
extragenitale 3 luni;
- AIDS-related complex
- SIDA manifestă
Diagnostic
- Serologie – ELISA şi Western Blot;
- Izolarea virusului din sănge, lcr, cultură de monocite şi limfocite din sănge;
- Antigen viral p24
- Ly CD4+, CD8+,
- β2 microglobulina serică;
Infecţia HIV
Principale grupe de risc:
- homosexuali;
- Consumatori de droguri;
- Transfuzaţi (hemofilicii)
- Persoane care practică sex în scop comercial.
Testarea HIV
- Indicaţii – persoane care solicită personal testul;
- persoane care aparţin grupelor de risc;
- bolnavi cu semne şi simptome sugestive;
- boli asociate cu infecţia HIV (TBC, ITS);
- sarcină.
- Consiliere pre- şi posttestare;
- Confidenţialitate;
Reglementări legislative
Ordinul Ministerului Sănătăţii nr. 1070/25.08.2004 pentru
aprobarea programului de supraveghere şi control al infecţiilor
cu transmitere sexuală
- Depistarea ITS face parte din activitatea medicală curentă indiferent de specialitate;
- Raportarea ITS este obligatorie pentru toate unităţile sanitare din sectorul public sau
privat;
- ITS cu raportare obligatorie:
- Sifilis
- Infecţia genitală cu Chlamydia trachomatis
- Gonoreea
- Sifilisul se declară numai de către medicul dermato-venerolog (eventual în urma
informării de către medicul de familie sau de altă specialitate);
- Instituirea tratamentului de către alt medic decât medicul D-V se va face numai după
absolvirea unui program de formare în domeniul ITS;
- Asistenţa medicală şi tratamentul persoanelor suspecte şi confirmate cu ITS este
asigurat, indiferent de alte condiţii;
Atribuţii şi sarcini specifice unităţilor sanitare şi personalului
sanitar în prevenirea şi controlul ITS
Dispensare studenţeşti, cabinete şcolare:

- educare, informare, comunicare pt prevenire şi control ITS;
- depistare cazuri suspecte → bilet trimitere D-V;
- examen clinic şi serologic prevăzut de lege;
- urmăreşte tratamentul cf. indicaţii D-V;
- verifică efectuarea control postterapeutic;
- investigaţii epidemiologice pt. depistarea ITS;
- evidenţa elevi/studenţi cu ITS.
Medicul de familie
- consiliere, educaţie sexuală, prevenire ITS;
- depistare ITS;
- supravegherea clinică şi serologică a gravidei;
- investigaţii epidemiologice;
- urmărirea tratamentului ambulatoriu la indicaţiile D-V;
- verifică efectuarea control postterapeutic;
- ţine evidenţa bolnavilor de ITS;
- cei care au efectuat pregătire în acest sens în zone cu
accesabilitate scăzută, pot asigura tratament sindromic cf. Ghid.
Unităţi sanitare cu paturi cu excepţia D-V

- asigură prin laboratoare de serologie, bacteriologie, efectuarea
examene pt. depistarea ITS;
- asigură consul medic D-V din unitate sau din afara ei;
- asigură efectuarea tratament de specialitate prescris de D-V şi
supraveghere clinico-serologică;
- asigură efectuarea examenelor clinice şi prelevarea probelor
biologice pt. studii epidemiologice privind ITS.
Supravegherea epidemiologică a populaţiei generale

- examen medical la angajare sau periodic;
- examen clinic de bilanţ – medicul de familie stabileşte dacă există
risc şi necesită investigaţii;
- examen medical prenupţial – contra cost;
- examen periodic al gravidelor – testare gratuită, la prima
prezentare şi în luna a VII-a;
- testare mamă şi nou-născut;
- examen bilanţ elevi cls. a XII-a şi ultima clasă de postliceală – în
caz de suspiciune;
- donatorii de sânge - obligatoriu.
Supravegherea epidemiologică a populaţiei cu risc
- Contacţii cazurilor de ITS;

- Copiii la intrarea într-un centru de asistenţă socială;
- Persoane cu serologie HIV pozitivă;
- Consumatorii de droguri – la fiecare internare;
- Cei ce prestează sexul în scop comercial – lunar;
La toate cazurile suspecte sau confirmate cu ITS se recomandă

consilierea şi testarea HIV.
CHILD ABUSE
• Maltreatment of children has become a major public health crisis
• Safeguarding the welfare of children is a priority, and it is the moral and ethical
responsibility of healthcare professionals to detect cases of abuse and intervene
appropriately to prevent further harm
• In the United States in 2004, an estimated 3 million reports of child abuse were
investigated by state and local Child Protective Services (CPS) agencies
• Approximately 872,000 cases were eventually substantiated
• An estimated 2000 children die as a result of abuse each year, and the numbers
are increasing
• Children who received an assessment for abuse increased 32.4% between 1990
and 2004
• Medical practitioners play a key role in the recognition of abuse and supply the
vital evidence which assists CPS in substantiating intentional injury.
• Clinicians are often challenged to differentiate findings
attributable to child abuse from accidental injury, benign skin
conditions, or other pathologic disorders with similar
presentations
• Familiarity with medical conditions and cultural practices that

mimic child abuse, combined with a thorough medical and
laboratory evaluation, can facilitate the appropriate diagnosis
• A misdiagnosis can be traumatizing
• Inaccurate diagnoses:
– False-positives = noninflicted injuries or medical conditions who are
incorrectly identified as being abused
– False-negatives = abused children who are not reported to Child
Protected Services
– Significant damage can result from either misdiagnosis, with the latter
having particularly serious repercussions
• Because cutaneous injury represents the most
recognizable and common form of abuse,
dermatologists may be called upon to help
distinguish signs of intentional injury from skin
conditions that mimic maltreatment.
• A combination of individual, familial, and
societal factors contribute to the risk of child
maltreatment:
– Parents’ expectations inconsistent with normal child development
– Parents were abused or neglected themselves
– Family disorganization, dissolution, violence among members, and lack of
external support
– Stressors, such as parental substance abuse, mental illness, unemployment,
and poverty
– Young, single, nonbiological parents
– Poor parent-child relationships and negative interactions
– Poor parental impulse control
– Community violence
• Certain children are more likely than others to be victims of child abuse:
– Young age
• 71% of abused children between the ages of 1 and 12
• Children under the age of 4 are at greatest risk of severe injury, and account for 79% of child
maltreatment fatalities, with infants under 1 year accounting for 44% of deaths
– A history of abuse
• An abused child has a 50% chance of experiencing recurrent abuse and a 10% chance of death
if abuse is not detected at the initial presentation
– Comorbid conditions
• Learning disabilities
• Conduct disorders,
• Chronic illnesses,
• Mental retardation,
• Other handicaps
• Prematurity may be a risk factor for child abuse.
• The most common perpetrators of child abuse in
descending order of frequency:
– fathers,
– mothers’ boyfriends,
– female babysitters,
– mothers
• Parents are the perpetrators in 77% of child
fatalities
• Biological parents are less likely to engage in
severe abuse than parental substitutes, extended
family members, or strangers.
• Among children confirmed by CPS:
– 61% experienced neglect,
– 19% were physically abused,
– 10% were sexually abused,
– 5% were emotionally or psychologically abused
• Physical abuse is the most frequently reported form of child abuse, with skin being
the most commonly injured organ system
• Many experts believe that sexual abuse is the most underreported form of child
maltreatment because of the ‘‘victim secrecy’’ that so often characterizes these
cases
• In addition to frequently experiencing feelings of shame, guilt, and

embarrassment, children often fail to report sexual molestation because of the
fear that such disclosure will lead to even more serious consequences
• A comprehensive history: medical history, trauma, and injury, is absolutely critical
in determining the nature of cutaneous lesions.
• If the child is verbal and the injuries are suspicious of child abuse, it is important to
speak with the child away from the caregivers.
• Simple and age-appropriate language should be used to ask open-ended

questions, such as ‘‘Tell me what happened to your arm?’’
1. Does the history of the injury match the presentation (ie, extensive buttock
bruising and a history of a fall while running)?
2. Is the history vague and lacking in detail?
3. Are conflicting histories given by different family members or caretakers?
4. Could the injury have occurred accidentally, based on the child’s developmental
and activity level (ie, a 1-month-old rolling off the bed)?
5. Does the pattern of injury fit a biomechanical model of trauma that is considered
abusive (ie, handprint bruise on the face)?
6. Does the pattern of injury correspond to that inflicted by an instrument in a
manner that would not occur through play or natural environmental interactions
(ie, loop cord injuries)?
7. Was there a delay in seeking care for anything other than a minor injury?
8. Does the child have a history of multiple injuries?
9. Does the child have a history of repeated emergency department visits?
10. Is the child taking medication, or does the child have a history of a bleeding
disorder?
11. Is there injury to other organ systems (ie, brain, eyes, or skeleton)
PHYSICAL ABUSE
• Bruises
• Abrasions
• Lacerations
• Scratches
• Soft tissue edema
• Strap marks
• Hematomas
• Burns
• Bites.
• Common mimickers of maltreatment include Mongolian spots, bullous
impetigo, erythema multiforme, and Henoch-Schoenlein purpura (HSP)
• Cultural practices may also be misconstrued as abuse.
Extensive bruising in a protected area of the
Noninflicted bruising on anterior bony prominences
acquired through normal play bodY indicative of physical abuse
PHYSICAL ABUSE
• Characteristics that increase the likelihood of
abuse include multiple bruises in clusters
– Uncommon location (typically protected areas, such as the buttocks,
back, trunk, genitalia, inner thighs, cheeks, earlobes, or neck)
– Bruises in a child\9 months of age who is not independently mobile
– Bruising away from bony prominences
– Cutaneous and physical injuries other than bruises
– Multiple bruises in clusters
– Bruises in a defined pattern or those that carry the imprint of an
implementefined pattern, or different stages of healing
PHYSICAL ABUSE
• One proposed method to assist in identifying
tissue injury involves the use of a low light
Wood’s lamp
• When held approximately 10 cm from the
skin, ultraviolet light has been shown to
enhance visualization of faint bruises and soft
tissue injuries not yet apparent to the naked
eye.
PHYSICAL ABUSE
• Dating bruises based on color
– A bruise with any yellow is likely to be[18 hours old
(although the converse, a bruise that has no yellow
is\18 hours old, is not necessarily true)
– Red, blue, purple, or black coloring may occur any
time from 1 hour of bruising until resolution
– Red can be present in bruises no matter their ages
– Bruises of identical age and cause on the same person
may not appear as the same color and may not
change
– at the same rate
PHYSICAL ABUSE
• Factors affecting presentation of bruises:
– Quantity of extravasated blood
– Distance below the surface of the skin
– Severity of blunt force
– Vascularity of the underlying tissue
– Connective tissue support at the site of injury
– Child’s age
– Child’s gender
– Skin pigmentation
– Medications that affect the rate of ecchymosis
dispersion (ie, steroids)
PHYSICAL ABUSE
• Conditions mistaken for inflicted bruising:
– Mongolian spots
– Capillary hemangiomas
– Lymphangiomas
– Ink, dye, or paint stains
– Eczema
– Phytophotodermatitis
– Coagulation disorders (factor VIII and IX deficiencies, von Willebrand disease, idiopathic
thrombocytopenic purpura, leukemia, and salicylate toxicity)
– Hypersensitivity vasculitis
– Hypersensitivity reactions (erythema multiforme, erythema marginatum, and erythema nodosum)
– Purpura fulminans of meningococcemia
– Incontinentia pigmenti (rare)
– Impetigo
– Cafe´-au-lait spots
– Chilblain
– Osteogenesis imperfecta
– Ehlers-Danlos syndrome
Henoch SchoEnlein purpura, localized in the lower extremities, mimicking
the bruising of abuse
PATTERNED INJURIES
Instruments of abuse and
typical signs of skin injury
• Hands or knuckles/fists • Handprints, oval fingermarks on skin, or pinch marks; ‘‘tin

ear syndrome,’’ which includes bruising to pinna, retinal
• Belt or buckle bleeding, and head injury(eg, from a punch)
• Long, broad bands of ecchymoses ending in a horseshoe-
shaped mark caused by buckle; the tongue of the buckle
may cause puncture wounds
• Rope, wire, or cord
• Whip, stick, or paddle • Loop marks, double track marks, or burns
• Fingernails, coat hanger,•• Linear bruises and petechiae, often along the gluteal cleft
Linear excoriations
or hair brush
• Teeth • Bite marks
• Other • Erythematous imprint in shape of a spoon or fly-swatter

Patterned ecchymoses inflicted by a looped cord
BITE MARKS
• Potential for infection
• Document the shape (round, elliptical, or irregular), color, and diameter
(horizontal and vertical) of a bite mark to help identify possible perpetrators.
• Suspected when ecchymoses, abrasions, or lacerations in an elliptical or ovoid
pattern
• Typically a central area of ecchymoses with either of the following patterns:
– (1) positive pressure from the closing of teeth with disruption of small vessels, or
– (2) negative pressure caused by suction, creating surrounding erythema and edema with occasional
petechiae
• Visualized more clearly at 2 to 3 days after the injury because of the decreased
edema and surrounding erythema
• Sequential examinations and photographs should be obtained for evaluation
• Adult bite marks can be differentiated from those of a child by findings such as a
maxillary intercanine distance (the linear distance between the central point of the
cuspid tips) of more than 3 cm and the tooth pattern
• Human bite marks are typically superficial, whereas animal bites may cause deep
punctures or lacerations.
BURNS
• Approximately 6% to 20% of all child abuse cases

• Most abusive burn injuries occur during the
developmentally challenging ages of 1 to 3 years
• Stressors:
– inconsolable crying,
– toilet training,
– physical disabilities increase the likelihood of abuse in
caretakers who are already stressed by limited
emotional and physical resources
Features suggestive of abuse in
burn injuries
• Burns that look older than the history would suggest
• The existence of other injuries (bruises or fractures)
• Symmetrically distributed burns
• Burns localized to the perineum/ buttocks; there is often central sparing of buttocks (doughnut pattern)
• Burns suggestive of immersion: no splash marks, clear tide levels, and demarcated outline of the contacted
surface; stocking- or glove-pattern burn
• Wounds necessitating skin grafting or intensive care
• Sparing of flexor creases
• Burns of posterior head or back
• Multiple burn sites
• Burns consistent with the following mechanisms of injury:
– Brands/contact burns (ie, hot plate)
– Cigarettes or cigarette lighters
– Scalding immersion
– Microwave oven
– Stun guns
– Fork tines
– Light bulb
– Iron or grill markings
Well-demarcated symmetrical burn in the stocking distribution, consistent with
hot water immersion as a form of abuse.
Dunking scald injury with a ‘‘doughnut’’ burn pattern, where the
buttocks are pressed against the cool bottom of the tub
Punched-out ulcerations of 8-mm to 10-mm with superficial purple
crusts and erosions on a nonexpanding base after cigarette burns
Skin conditions that mimic inflicted
burns*
Type of burn Dermatologic mimics
•
• Circular or patterned burn Dermatitis herpetiformis, Impetigo and bullous
impetigo, Phytophotodermatitis, Drug eruption, Fixed
drug eruption, Varicella, Guttate psoriasis, Pityriasis
lichenoides, Insect bites, Contact dermatitis,
Epidermolysis bullosa, Staphylococcal scalded skin
syndrome, Stevens-Johnson syndrome, Pyoderma
gangrenosum, Herpes (zoster or simplex), Pemphigus
• Car seat buckle burns, Chemical burns from home

remedies, Garlic burn (common home remedy),
• Other burns Sunburns, Enuresis blanket burn, Congenital insensitivity
to pain, Nonintentional burns
Ecthyma mimicking cigarette burns of abuse
ALOPECIA
• Resulting from the forceful pulling of hair from the scalp
• Differential diagnosis: tinea capitis, traction alopecia (possibly from hairstyling and tight
braids), trichotillomania, loose anagen hair syndrome, and alopecia areata
• Traumatic alopecia can often be difficult to distinguish from trichotillomania, but

distinguishing characteristics of child abuse typically include signs of trauma with
underlying scalp hematoma, hemorrhage, tenderness, and irregular outlines of
localized hair loss
• Hair breakage and subsequent regrowth is typically at a more regular length than in
chronic trichotillomania.
• Scaling and other signs or inflammation are absent, differentiating traumatic hair loss
from fungal scalp infections
NEGLECT
• Physical neglect is more common than physical abuse and can also present with
cutaneous manifestations
• Neglect defined by the inability of a caregiver to provide for the basic needs of a
child
• Often chronic in nature and can involve inattention to a child’s nutrition, clothing,
shelter, medical care, safety, or education
• Physical signs include marked subcutaneous wasting, severe dermatitis (often

diaper dermatitis), and scaling of the skin caused by chronic avitaminosis and poor
hygiene, often with associated pediculosis capitis
• The child is typically not immunized and has multiple untreated injuries
CULTURAL PRACTICES
• Certain widely practiced folk health remedies

can produce characteristic skin lesions, such as
petechiae, purpura, and hyperpigmentation,
which often mimic physical abuse
• Understanding cultural practices, can help avoid
misdiagnosis and prevent further trauma
• Proper evaluation is necessary, because the use
of cultural practices does not exclude the
potential for child abuse.
• Cupping, Coining, Spooning, Moxibustion, Caida de mollera,
and Salting.
• Cupping to treat ailments including pain, poor appetite, fever,
and congestion
• In dry cupping, a heated cup is inverted on the skin, typically
on a child’s back, creating a suction force from the cooling and
contracting air, which is thought to ‘‘draw out’’ the ailment
• However, circular burns from the heat and central ecchymosis
and petechiae from the suction effect can be mistaken for
abuse
• Wet cupping involves the same application to previously
abraded skin.
Annular ecchymoses caused by the cultural practice
of cupping
• Coining an ancient Vietnamese folk remedy practiced by many Vietnamesee
Americans to treat minor ailments, such as fever, headache, and chills
• Oiled skin is rubbed firmly with the edge of a coin, producing linear erythematous
marks, petechiae, or purpura, usually on the back
• There have been a few reported cases of serious complications from coining that
required skin grafts when the oil on the skin caught fire
• However, most of the complications have been minor burns.
• Quatsha, also known as spooning, is similar to coining and is used in China to rid
the body of illness. This procedure can result in a linear pattern of ecchymosis
when wet skin is rubbed with a porcelain spoon
• Moxibustion is used in Asian cultures to relieve a
variety of symptoms, including fever and
abdominal pain = rolling pieces of moxa herb
(mugwort or Artemisia vulgaris) or yarn into a
small cone, igniting it on the skin over
acupuncture points, and allowing it to burn until
the onset of pain
• Small discrete circular, target-like burns that may
be confused with cigarette burns from child
abuse
Linear purpura and hyperpigmentation caused by
ritual coining
• Caida de mollera refers to the presence of a sunken anterior fontanelle in an infant
that is believed in some MexicaneAmerican subcultures to cause a variety of
symptoms, including poor feeding, irritability, and diarrhea.
• Attempts to correct this condition may involve oral suction over the fontanelle by a
folk healer, slapping of the soles of the feet, or shaking of the infant upside down.
• Therefore, caida de mollera is an improbable cause of shaken baby syndrome.
• Salting, defined as the application of salt to the skin, is an old Turkish custom
thought to improve the health of a newborn’s skin
• Rare cases of epidermolysis, severe hypernatremia, and even death have been
reported in a few infants that had been intermittently salted since birth
SEXUAL ABUSE
• Childhood sexual abuse a problem of epidemic proportions affecting children of all

ages and economic and cultural backgrounds.
• More than 88,000 children were confirmed victims of sexual abuse in the United
States in 2002
• Approximately 1% of children experience some form of sexual abuse each year,
resulting in the victimization of 12% to 25% of girls and 8% to 10% of boys by 18
years of age.
• Of the 3 million cases of child abuse investigated each year, about 20% are
reported as sexual abuse.
• An estimated 90% of sexual abuse is committed by men, with 70% to 90% being
perpetrated by individuals known to the child.
• Family members constitute about 30% to 50% of perpetrators against girls and
10% to 20% against boys
• Adolescents are perpetrators in at least 20% of reported cases
HISTORY
• The history that sets the gold standard in cases of sexual molestation
• Sexually abused children often present to medical personnel with a variety of

symptoms, even though they have not disclosed maltreatment
• The presenting complaints may be nonspecific, such as sleep disturbances,

abdominal pain, enuresis, encopresis, or phobias
• Studies have found that a child with a history of sexual abuse is more likely to
develop inappropriate sexual behaviors manifested by sexual play, masturbation,
seductive or sexually aggressive behavior, and age-inappropriate sexual knowledge
• A child’s disclosure of maltreatment is one of the most important pieces of
information in determining the likelihood of abuse
• When conducting an interview, it is important to maintain a neutral tone of voice

and avoid the use of leading and suggestive questions
• Interview aids, such as anatomical dolls, may be useful in understanding exactly

what type of abuse occurred
• Both age and gender also influence admission, with girls disclosing sexual abuse
more often than boys and older children discussing the account more frequently
than younger children
GIRLS GENITALIA
• The prepubertal hymen has a variety of
configurations that can described as annular,
crescentric, fimbriated, cribiform, septate,
microperforate, or even imperforate, the most
common being crescentric and annular
Normal anogenital findings and
variants
• Periurethral (or vestibular) bands
• Longitudinal intravaginal ridge or column
• Hymenal tag
• Hymenal bump or mound
• Linea vestibularis
• Hymenal cleft/notch in the anterior (superior) half of the hymenal rim, on or above the 3 o’clock to 9
o’clock line, patient supine
• External hymenal ridge
• Septate hymen
• Imperforate hymen
• Microperforate hymen
• Thickened hymen (caused by estrogen, folded ridge, or edema from infection or trauma)
• Failure of midline fusion (perineal groove)
• Groove in the fossa in a pubertal female
• Diastasis ani
• Perianal skin tag
• Increased perianal pigmentation
• Venous congestion in the perianal area
• All girls suspected of possible sexual abuse
should undergo evaluation of the labia
majora, labia minora, introitus, and hymen for
erythema, ecchymoses, lesions, abrasions, or
tears
• In particular, one of the most challenging
aspects of the female genital examination is
evaluation of the hymen
• The appearance of the hymen changes with age in response to hormonal
influences
• Peripartum estrogen causes the newborn’s hymen to have a thick, pale, elastic,
and redundant appearance
• This effect often lasts until 2 to 3 years of age and then reappears at puberty
• During the interim, the prepubertal unestrogenized hymen is typically
characterized as thin, vascular, reddened, and, often, innervated, leading to
increased sensitivity
• The appearance of the hymen also varies, depending on the position of the child
during examination.
• In the majority of children with legal confirmation of sexual abuse, the genital
examination of the abused child rarely differs from that of the nonabused child
• Physical findings are often absent even when the perpetrator admits to
penetration
• Thus, it is not appropriate to interpret a normal genital examination as evidence

that sexually abusive contact did not take place
• The most common explanation:

– physical abuse did not produce visible injury
– an injury occurred which healed completely before a physical examination was
performed
• Studies have reported that the healing process in the anogenital region occurs
relatively quickly
• Two factors correlated significantly with the presence of abnormal genital findings
are the time since the last incident and a history of blood being reported at the
time of molestation. The greater the time interval to examination, the less likely it
is that injuries will be appreciated during the examination
• The Adam’s Sexual Abuse classification scale was initially devised in 1992 in an
effort to maintain consistency in interpretation of genital and anal findings in
children referred for a sexual abuse
Anogenital findings specific for
abuse
• High specificity for abuse
• Acute laceration of the hymen (partial or complete)
• Ecchymosis of hymen
• Perianal lacerations extending into the anal sphincter
• Healed hymenal transaction (area of absent tissue)
• Absence of hymenal tissue
• Newly healed scars in the posterior fourchette of the hymen
• Marked and immediate dilatation of the anus in a knee-chest position, with no
constipation, stool in the vault, or neurologic disorder
• Purulent or malodorous vaginal discharge in a young girl (all discharge should be
cultured for evidence of a sexually transmitted disease)
Transection of the posterior hymenal rim with surrounding erythema and
petechiae, a presentation that is highly specific for sexual abuse
Anogenital findings specific for
abuse
• Moderate specificity for abuse
• Acute lacerations, abrasions, or extensive bruising of the labia, peri-hymenal
tissues, penis, scrotum, or perineum (may be unwitnessed accidental trauma)
• Scar or fresh laceration of posterior fourchette, not involving the hymen
• Hymenal notch or cleft that extends[50% of the inferior hymenal rim
• Perianal scar not in the midline
• Condyloma acuminata in a child older than 3 years of age
• Herpes of the anogenital area beyond the neonatal period
• Marked and immediate dilation of the anus with no stool present in the rectal
vault when the child is examined in the knee-chest position without sedation;
there must be no significant history of encopresis, chronic constipation, or
neurologic deficits
MALE GENITALIA
• Though less common than in girls, sexual abuse in boys is still a major (but under-
recognized) problem
• As in girls, the external genitalia must be evaluated for erythema, ecchymosis,

abrasions, lacerations, and bite patterns
• The urethral meatus may also have lacerations, erythema, and discharge
• Circumferential injuries to the shaft or glans penis in boys are suggestive of abuse
• Penile and anal secretions should be cultured for sexually transmitted diseases,
and anal secretions should be examined for semen if penetration is suspected
PERIANAL REGION
• Normal perianal skin changes commonly found in nonabused children include

erythema and increased pigmentation
• Venous congestion, thickened rugae, anal laxity, fissures, scars, and tags occur with
increased frequency in a sexually abused child, although they are not diagnostic of
abuse
• Scars outside the midline and marked irregularity of the anus are suggestive of
chronic trauma
• Forced anal intercourse can result in abrasions, lacerations, and hematomas;
however, rectal lacerations heal over time and are often difficult to detect
• Laxity of the anus and anal dilatation are consistent with abuse, but can also be
found with neurologic disorders and chronic constipation
• Anal dilatation of any size is considered a normal reflex if stool is present in the
rectal vault or if dilation occurs after the child has been in the prone kneeechest
position for more than 30 seconds
• However, anal dilatation of 20 mm or greater, without stool in the rectal vault, is
highly suspicious for abuse
ORAL CAVITY
• Although the oral cavity is often a site of

sexual abuse in children, visible oral injuries or
infectionsn are not commonly found
• Indications of possible sexual abuse in the oral
cavity include evidence of forced oral
penetration, such as bruising or petechiae of
the hard or soft palate, and tears of the
frenulum
Differential diagnosis of cutaneous findings in sexual
abuse of children
Findings (boys and girls)
• Perineal area • Candidiasis, pinworms, cellulitis, contact
dermatitis, atopic dermatitis, psoriasis,
• Inflammation or erythema Kawasakisyndrome (perianal erythema
commonly precedes the development of the
diagnostic criteria for the disease)
• Syphillis, herpes simplex virus, varicella,
Behc¸et’s disease, bullous pemphigoid
• Ulcer or vesicular rash • Mongolian spots, trauma, HUS, Henoch-
Schoenlein purpura
• Bruising • Encopresis, poor hygiene, pinworms, group A
streptococcal or staphylococcal cellulitis,
irritants, trauma
• Erythema • Constipation, Crohn’s disease, irritation
• Crohn’s disease, medical procedures, result
of fissures; midline scar less suspicious
forabuse
• Anal fissures
• Scarring
Differential diagnosis of cutaneous
findings in sexual abuse of children
• Anogenital warts • Condyloma acuminata (HPV), molluscum
contagiosum, verruca vulgaris, skin tags
• Hemorrhoids, Crohn’s disease, rectal

• Rectal bleeding prolapse, rectal tumors, anal trauma from
penetration
• Relaxation of anal sphincter, perianal

edema from infection or trauma
• Flattened anal folds
• Findings (boys only)

• Hair tourniquet, zipper entrapment injury,
• Penile trauma straddle injury
• Irritants, infection, trauma
• Penile or scrotal erythema

Differential diagnosis of cutaneous
findings in sexual abuse of children
• Nonspecific vulvovaginitis, group A
• Findings (girls only) streptococcal vaginitis, lichen sclerosis,
• Excoriation, bleeding, vascular lesions lichen simplex chronicus, lichen planus,
atopic dermatitis, hemangiomas, vaginal
foreign bodies
• Increased vascularity of the hymen • Local irritants, normal nonestrogenized

and vestibule state
• Scarring • Linea vestibularis (10% of newborns),
female circumcision
• Labial adhesion
• Irritation or rubbing
• Vaginal and urethral findings • Sacrcoma botyroides (form of embryonal
rhabdomyosarcoma resembling a bunch
of grapes protruding from the vagina),
caruncle (erythematous, vascular,
papillary growth in urinary meatus of
females) ureterocoele, urethral prolapse
Mimickers of sexual abuse
• A variety of dermatologic conditions cause ulcers, erythema, friability, or even
bleeding of the perineum; these should be considered when sexual abuse is
suspected.
• The differential diagnosis is extensive, and includes lichen sclerosis et atrophicus,

nonspecific vulvovaginitis, seborrheic dermatitis, atopic or contact dermatitis,
scabies, perianal streptococcal dermatitis, lichen simplex chronicus, lichen planus,
psoriasis, hemangiomas, bullous pemphigoid, Behcet’s disease, and urethral
prolapse
Hypopigmentation and atrophy of lichen sclerosis et atrophicus • Lichen sclerosus et
atrophicus is the most
common skin condition
mistaken for sexual abuse
• It is a benign but chronic
condition of the anogenital
area of girls and rarely of
boys
• Potent topical
corticosteroids are the
mainstay of treatment
• Perineal irritation: contact dermatitis (often caused by diapers), seborrheic
dermatitis, poor hygiene, candidal lesions, and excoriation secondary to pruritus
• Contact dermatitis may result in edema of the penis and foreskin, but a history of
irritant exposure will typically help confirm diagnosis
• Onset of seborrheic dermatitis typically occurs within the first 2 months of life
• Flexural surfaces, such as the inguinal folds, are commonly involved, with sparing
of the mucosa
• In infants, psoriasis typically presents in the diaper region and skin folds, with
erythema and minimal scaling often being the only clinical features
• Inverse psoriasis, occuring in flexural creases, may involve the anogenital area,
axillae, and ear canals
• Though rarely performed, a biopsy can aid in appropriate diagnosis
• Vulvovagnitis : localized pain, dysuria, pruritus, erythema, or discharge, making it
difficult to distinguish from a sexually transmitted infection (STI) caused by sexual
abuse
• The most common cause of vulvovagnitis = irritation secondary to poor hygiene or
even vigorous cleaning during submersion in a bubble bath
• Most cases of vaginitis are not caused by STIs
• Candida vulvovaginitis may occur in the face of predisposing factors, including
antibiotic use, diabetes mellitus, an underlying primary skin disease and
immunosuppression
• Bloody, copious, or fouls melling discharge increases the likelihood of an STI or a
nonvenereal pathogen
• However, vaginal foreign bodies may also present in a similar manner.
• Shigella vaginitis has also been reported to be misdiagnosed as gonorrhea. Shigella
vaginitis is associated with bloody, purulent, or watery discharge and, surprisingly,
diarrhea is not a common associated
Vulvar hemangioma with extensive erythema and ecchymosis mimicking
sexual abuse
• Streptococcal infection of the anus, vagina, penis, and urethra can
raise concern about abuse but be aware of autoinoculation by
contaminated nasopharyngeal secretion
• Children with perianal streptococcal dermatitis often present with
acute onset of anal pruritus and pain with defecation
• The anal mucosa is typically described as edematous,
erythematous, and tender.
• Chronic disease may even lead to fissures, discharge, or
hemorrhagic spotting
• Streptococcal balanitis can present as urethral discharge or
erythema and edema of the foreskin
• Streptococcal vaginitis causes erythema of the mucosa and various
types of discharge ranging from serous, purulent, and blood-tinged
• Sixty percent of children will have a positive swab culture for group
A streptococcus, helping to differentiate infection from abuse.
Assessment of the likelihood of sexual
abuse
• Possible abuse
– Herpes simplex type 1 anogenital lesions (no history of abuse)
– Condyloma acuminata (no history of abuse); condyloma in a child[3-
• Probable abuse
– Positive culture for Chlamydia trachomatis from genital area in a prepubertal child, or cervix in an
adolescent female (not perinatally acquired)
– Positive culture for herpes simplex type 2, from genital or anal lesions (not perinatally acquired)
– Trichomonas infection, diagnosed by wet mount orculture from vaginal swab (not perinatally
acquired)
• Definite evidence of abuse or sexual contact
– Evidence of sperm, semen, or acid phosphatase
– Pregnancy
– Positive cultures for Neisseria gonorrheae from vaginal, urethral, anal, or pharyngeal source (not
perinatally acquired)
– Evidence of syphilis (not perinatally acquired)
– HIV infection (not perinatally acquired or via transfusion of blood products)
Condyloma accuminatum
PSYCHOLOGICAL IMPACT
• The physical scars may heal, but the emotional and psychological sequelae of child
abuse may endure and be more devastating
• It is well known that the skin is a commonly used site for self-inflicted trauma in
both children and adults with psychological problems
• Many of the behavioral disorders seen today are often the result of childhood
maltreatment
• Such psychological trauma may actually be manifested by self-injurious sucking,

biting, or scratching, which have recognizable cutaneous patterns
PLEASE REPORT ASAP

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INFECTII CU TRANSMITERE

– MALADII?? • DOVADA IUBIRII MAXIME

• Sex intre/cu minori – Inacceptabil din punct de vedere moral

• Sex intre/cu minori – Aspru condamnat

• People engage in a variety of sexual acts

• Sexual activity normally results in sexual

• Sexual activity also includes conduct and

• In some cultures, sexual activity is considered acceptable only within marriage,

• On developing the signs of syphilis he concluded the two infections were

• The Contagious Disease Acts of Great Britain clearly tolerated prostitution,

• A vociferous campaign was mounted by women's groups, civil rights

• Advances against the diseases were notably improved by the discovery of

• Also a diagnostic test was devised, which was

• The development of the sulpha drugs and more

• However, it rapidly became apparent that the

• The appearance and world-wide spread of AIDS

Known risks Possible

•Herpes •Throat gonorrhea[6]

• The disease may have originated from the Columbian Exchange.

• As Jared Diamond describes it, "[W]hen syphilis was first

• Prior to the invention of modern medicines, sexually transmitted

• The first voluntary hospital for venereal diseases was founded in

• Treatment was not always voluntary: in the second half of the

• Prevention can minimize the negative, long-term

• The high incidence and overall prevalence of STIs in

• Abstaining from sex, reducing the number of sexual

• Safe, effective vaccines are also available to prevent

• And for all individuals who are sexually active –

- Incubaţie – 21 zile (limite 10-90);

- Netratat, sifilisul secundar trece într-un stadiu asimptomatic, cu teste

- La 1-20 ani după stadiul secundar; imunitatea şi alergia sunt maxime;

- Transmitere de la mamă la făt - hematogen; după naştere – prin lapte matern;

Sifilis secundar – clinic: manif. de secundarism, serologie pozitivă;

Sifilis latent – absenţa manifestărilor clinice de sifilis; lcr şi Rx cardiopulmonar normal;

- Penicilina parenteral – benzatin penicilina, penicilina cristalină,

- Îngrijiri medicale parteneri sexuali;

- Monitorizare postterapeutică – examen clinic şi serologie cantitativă, timp de 2

Reacţia Jarisch-Herxheimer – incidenţă > 25%

Paradoxul terapeutic Wile

Reacţii alergice la Penicilină – 1% din populaţie

- Gravide trim. I – clotrimazol ovule; trim. II, III – Metronidazol oral;

- Tratamentul partenerilor trebuie avut în vedere în cazul infecţiei recurente;

Diagnosticul de pune prin efectuarea şi interpretarea markerilor serologici.

Evaluarea şi tratamentul bolnavilor se efectuează în serviciul de boli

- Se transmite în principal pe cale sexuală, se asociază cu alte ITS;

Virusul imunodeficienţei umane

Dispensare studenţeşti, cabinete şcolare:

Unităţi sanitare cu paturi cu excepţia D-V

Supravegherea epidemiologică a populaţiei generale

- Contacţii cazurilor de ITS;

La toate cazurile suspecte sau confirmate cu ITS se recomandă

• Familiarity with medical conditions and cultural practices that

• In addition to frequently experiencing feelings of shame, guilt, and

• Simple and age-appropriate language should be used to ask open-ended

• Hands or knuckles/fists • Handprints, oval fingermarks on skin, or pinch marks; ‘‘tin

• Other • Erythematous imprint in shape of a spoon or fly-swatter

• Approximately 6% to 20% of all child abuse cases

• Car seat buckle burns, Chemical burns from home

• Resulting from the forceful pulling of hair from the scalp

• Traumatic alopecia can often be difficult to distinguish from trichotillomania, but

• Physical signs include marked subcutaneous wasting, severe dermatitis (often

• Certain widely practiced folk health remedies

• Childhood sexual abuse a problem of epidemic proportions affecting children of all

• Sexually abused children often present to medical personnel with a variety of