Reproductive tutorial -

STDs
1. A 34-year-old man presented with a fever for 3 days and blistering
lesions in his external genitalia. He was clinically suspected of having
genital herpes.
Describe the laboratory investigations available to confirm the clinical
diagnosis.
• To confirm diagnosis- Culture methods
• Others – Molecular testing, serology
• Culture methods
o Sample – specimens obtained from vesicular lesions within the
first three days after their appearance.
o Transport- Immediately transport with viral transport medium
(M5 transport medium) specimen should be held at 4 c and
transported to the laboratory within 48h.
• Molecular testing
o Specimen – swabs of genital lesions.
o Most sensitive and specific test.
o Combined HSV and T. pallidum PCR
• Serology
o Type- specific antibody test HSV- 1 and HSV-2.
o Demonstrating seroconversion. (from negative result at the
time of the lesion to positive result 6-12 weeks later)
o IgM detection can be used in diagnosing a new herpes infection,
2. A 30-year-old man presented with a hard indurated non tender ulcer in
his penis for 1 week. A sexually transmitted infection was suspected.
2.1 What is the most probable clinical condition?
• Early syphilis/ primary syphilis

2.2 State the pathogen which causes this condition.

• Treponema pallidum]

2.3 List two other differential diagnosis for this condition.

• Genital Herpes- HSV
• Chancroid – Hemophilus ducreyi
• Lymphogranuloma venereum – Chlamydia trachomaties
• Molluscum contagiosum –

2.4 Briefly describe how you would arrive at a microbiological diagnosis of

the condition mentioned in 1.a.
• Direct microscopic examination- dark field microscope
o From lesions or lymph nodes.
o Diagnosis – characteristic movement > cork- screw motility.
• Non treponemal serological tests – screening
o VDRL
o RPR
• Treponemal serological test – for confirmation.
o TPHA- T. pallidum haem – agglutination test
o TPPA - T. pallidum particle – agglutination test
o ELISA
• Molecular methods – PCR

VDRL Testing

Reactive Non-Reactive

To confirm treponemal
To exclude S4 late
infection TPPA

Reactive Reactive

Serological evidence of No treponemal infections

treponemal infections
 2.5 Outline the management of this patient.
• Benzathine penicillin 2,4 MU single dose IM after sensitivity test.
• Penicillin allergy
o Doxycycline 100mg twice daily for 14 days
o Azithromycin 2g PO stat or azithromycin 200mg daily for 10
days
o Erythromycin 500 qds for 14 days.
3.
3.1. Discuss the clinical manifestations of early-acquired and late-
acquired syphilis
• Early acquired syphilis
o Primary
o Secondary
o Early latent
• Late acquired syphilis
o Late latent
o Tertiary syphilis
▪ Gummatous
▪ Cardiovascular
▪ Neurological

• Primary syphilis
o Painless ulcer – chancre (ano-genital, single ulcer,
characteristic indurated edges with a clean base discharging
clear serum.
o Non tender regional lymphadenopathy
• Secondary syphilis – 3-6 weeks
o Generalized maculo – popular rash on the palms and planter
surfaces of feet
o Patchy alopecia
o Generalized lymphadenopathy
o Condyloma lata – highly contagious, hypertrophic lesions
resembling flat warts in the moist area, such as labia and
perineum, the folds of the fore skin and around the anus
o Painless shallow ulcers - oral, genital
o Hepatitis, glomerulonephritis, splenomegaly
• Early latent syphilis – 2 years
o No clinical manifestations (asymptomatic)
 • Late latent syphilis – more than 2 years
o No clinical manifestations (asymptomatic)
• Tertiary syphilis – 20 to 40 years after initial infection
o Gummatous disease- formation of gummas ( soft tumor like
lesions mainly skin and bones
o Cardiovascular – aortitis ( ascending aorta), aortic
regurgitation, heart failure, aneurysm
o Neurological disease – asymptomatic, meningovascular (focal
arteritis including infarctions or meningeal inflammation),
general paresis, tabes dorsalis

3.2. Describe the advantages and disadvantages of laboratory tests

available to diagnose syphilis
Test Advantage Disadvantage
Direct microscopic- o Direct visualization o Requires specialized
Dark field microscopy o Rapid test equipment and expertise
o Indicates definitive o Not effective to latent
diagnosis syphilis
o False negatives– old lesions,
anti-treponemal treatment,
incorrect methods

Non treponemal o Useful for screening and o False positives – other

serological tests monitoring treatment infections, auto immune
(VDRL, RPR) response. disease or pregnancy.
o Quantitative results o Not specific for syphilis
o Broadly available
o Highly sensitive

Specific treponemal o Highly specific o More expensive

antibody test (TPHA, o Highly sensitive o Can’t monitor treatment
TPPA, ELISA) response

PCR o Highly specific o Expensive

o Highly sensitive o Limited availability
4. A 32-year-old commercial sex worker presented with vaginal discharge for 5
days.
4.1. Name the pathogens likely to cause vagina discharge in the patient.

gonorrhea - Neisseria
gonorrhoeae
cervicitis
non - gonococcal -
chlamydia trachomatis

excessive vaginal
discharge Bacterial vaginosis -
Gardnerella vaginalis

vaginal pathology candida infections

Trichomonas vaginalis

4.2. Discuss the investigation that you would like to perform on this
patient.
• Gonorrhea –
o Urethral discharge (men) or cervical discharge (female)
direct microscopy >>> gram negative diplococci (intra or extra
neutrophilic)
o Culture – high vaginal swab (endocervical swab)
• Chlamydia –
o Culture – not widely available
o Non-culture tests – endocervical craping >> direct
immunofluorescent, PCR, ELISA
• Bacterial vaginosis –
o Direct microscopic >>> clue cells
o Vaginal pH test – pH > 4.5
o KOH Whiff test >> positive amine
• Vulvovaginal candidiasis –
o Direct microscopic
o Culture vaginal swab
• Trichomoniasis-
o Wet prep microscopy – motile protozoa
5. A 30-year-old man presented with a purulent urethral discharge for 2 weeks.
He also complained of dysuria. Gonorrhea was suspected.
5.1. Outline the pathogenesis of this infection.
• Asymptomatic females act as a reservoir. Neisseria
gonorrhoeae is a causative bacterium.
• Transmission through sexual contact with an infected individual.
• N. gonorrhea attach to the epithelial cells of mucosal surfaces
and invade
• It induces local inflammation and damage.
• In male,
o Asymptomatic or painful urination
o Purulent urethral discharge due to local inflammation with
pus formation
o Urinary tract obstruction due to scaring
o Sterility due to scarring of vas deference or damage to
testes
• In female,
o Mostly asymptomatic (reservoir)
o Purulent vaginal discharge due to typical bacteria induced
neutrophils
o Can cause salpingitis, or pelvic
inflammatory disease due to
slowly ascending of infection in
chronic untreated gonorrhea

5.2. Briefly describe how you would arrive at

a microbiological diagnosis.
Sample collection- urethral discharge in
male and cervical discharge in female
• Direct microscopy with gram staining-
gram negative diplococci within
neutrophils. Both intra or extra
neutrophilic diplococci present
• Culture – urethral swab culture in
Thayer- martin agar. It is mandatory
for antibiotic treatment.
5.3. What are the important steps in the management of this patient?
• Antibiotic treatment
o Cefixime 400 mg as a single oral dose
o Ceftriaxone 250 mg IM as single dose for complicated
cases (PID, Epididymo-orchitis)
o Ceftriaxone is drug of choice in ophthalmia neonatorum
• Patient education
o Educate the patient on safe sex practice to prevent
future infections.
o Advice to avoid sex activities until treatment completed
and symptoms resolved
• Partner notification
o Informed all recent sexual partners to check for
gonorrhea.
• Screening for other STDs.

5.4. Discuss the complications likely to occur following this infection.

• Women –
o Pelvic inflammatory disease
o Bartholin’s abscess
o Ectopic pregnancy
o Infertility
• Men –
o Prostatitis
o Urethral strictures
o Sterility
• Neonatal –
o Ophthalmia neonatorum
• Systemic complications –
o Septicemia
6. A 24-year-old pregnant woman was screened for HIV in the 1st trimester,
and she became positive with screening test.
6.1. Outline the testing pathway of HIV.

Initial Screening Test

1. Initial Antibody/Antigen Screening (4th Generation Test)
- Purpose: Detect both HIV-1 and HIV-2 antibodies and the p24
antigen.
- Outcome: If positive, the test indicates a possible HIV infection
but requires confirmatory testing.

Confirmatory Testing
2. Confirmatory Antibody Differentiation Test
- Purpose: Distinguish between HIV-1 and HIV-2 antibodies.
- Outcome: If positive, it confirms the presence of HIV infection. If
indeterminate or negative, further testing is needed.

3. HIV-1 Nucleic Acid Test (NAT)**

- Purpose: Detects HIV RNA to confirm infection and determine
viral load.
- Outcome: Positive result confirms HIV infection. If negative and
the initial test was positive, it may indicate a false-positive initial test
or acute infection with low viral load.

Additional Testing
4. CD4 Count
 - Purpose: Assess immune system function.
- Outcome: Helps determine the stage of the disease and guide
treatment decisions.

5. HIV Viral Load Test

- Purpose: Measure the amount of HIV RNA in the blood.
- Outcome: Helps in monitoring treatment efficacy and disease
progression.

6. Drug Resistance Testing

- Purpose: Identify any resistance to antiretroviral drugs.
- Outcome: Guides the selection of the most effective antiretroviral
therapy (ART) regimen.

Additional Considerations for Pregnancy

7. Counseling and Support
- Purpose: Provide psychological support and education about HIV,
pregnancy, and transmission prevention.
- Outcome: Ensures the woman understands her diagnosis and the
importance of ART adherence.

8. Initiation of Antiretroviral Therapy (ART)

- Purpose: Reduce maternal viral load to undetectable levels to
prevent mother-to-child transmission.
- Outcome: Effective ART can significantly reduce the risk of
transmission during pregnancy, labor, and breastfeeding.

Monitoring During Pregnancy

9. Regular Follow-Up Appointments
- Purpose: Monitor the effectiveness of ART and the health of the
mother and fetus.
- Outcome: Ensure adherence to ART, manage any side effects, and
provide ongoing support.

10. Delivery Planning

- Purpose: Determine the safest mode of delivery to minimize the
risk of HIV transmission.
 - Outcome: Depending on viral load, a cesarean delivery may be
recommended if the viral load is not well controlled.

6.2. Briefly explain the further management of this patient.

Antiretroviral Therapy (ART)

1. Immediate Initiation of ART
- Purpose: To reduce the viral load to undetectable levels, minimizing
the risk of transmission to the baby.
- Regimen: The choice of ART regimen will be tailored to the
patient's needs, considering factors such as drug resistance, potential
side effects, and drug interactions.

Monitoring and Follow-Up

2. Regular Viral Load and CD4 Count Monitoring**
- Frequency: Initially every 1-3 months, then every 3-6 months once
viral load is suppressed.
- Purpose: Ensure the effectiveness of ART and adjust the regimen
if necessary.

3. Adherence Counseling
- Purpose: Ensure the patient understands the importance of
consistent ART adherence to maintain viral suppression.

Pregnancy and Delivery Care

4. Routine Obstetric Care
- Monitoring: Regular prenatal visits to monitor the health of the
mother and fetus.
- Screening: Routine screening for other infections and health
issues.

5. Delivery Planning
- Mode of Delivery: If the viral load is undetectable near delivery,
vaginal delivery may be considered safe. If the viral load is
detectable, a scheduled cesarean delivery may be recommended to
reduce transmission risk.

Prevention of Mother-to-Child Transmission (PMTCT)

6. Intrapartum Care
- IV Zidovudine: Administered during labor if the viral load is
detectable to further reduce transmission risk.

Postpartum Care
7. Neonatal Antiretroviral Prophylaxis
- Regimen: The newborn will receive antiretroviral medication,
typically zidovudine, for 4-6 weeks to reduce the risk of HIV
transmission.

8. Infant HIV Testing

- Testing Schedule: Early testing at 14-21 days, 1-2 months, and 4-6
months of age to determine the infant’s HIV status.

Breastfeeding Guidance
9. Feeding Options
- Recommendation: In settings where formula feeding is safe and
feasible, it may be recommended to avoid breastfeeding. In settings
where breastfeeding is practiced, exclusive breastfeeding with
maternal ART is advised to minimize transmission risk.

Long-Term Follow-Up
10. Ongoing HIV Care
- Continuity of Care: After delivery, the mother should continue
ART and regular HIV care to maintain her health and prevent
transmission in future pregnancies.

11. Support Services

- Psychosocial Support: Counseling and support groups to help the
mother cope with the diagnosis and maintain a healthy lifestyle.
6.3. Briefly explain how you would manage the newborn.

Immediate Post-Birth Care

1. Antiretroviral Prophylaxis
- Regimen: Administer zidovudine (AZT) within 6-12 hours of birth.
The typical regimen is:
- Zidovudine (AZT) syrup (2 mg/kg) orally every 6 hours for 4-6
weeks.
- Additional Medications: If the mother’s viral load was not well
controlled or if she did not receive adequate ART during pregnancy,
additional medications such as nevirapine or a combination regimen may
be used.

HIV Testing
2. Early Diagnostic Testing
- First Test: Perform an HIV PCR test (nucleic acid test) at 14-21
days of age.
- Subsequent Tests: Repeat HIV PCR tests at 1-2 months and again
at 4-6 months of age.
- Antibody Testing: Perform an HIV antibody test at 18 months to
confirm the infant's HIV status definitively.

Feeding Guidelines
3. Feeding Recommendations
- Formula Feeding: In settings where formula feeding is safe and
feasible, it is recommended to avoid breastfeeding to eliminate the
risk of HIV transmission.
- Breastfeeding: In settings where breastfeeding is necessary,
exclusive breastfeeding is recommended for the first 6 months while
the mother continues ART to minimize the risk of transmission.

Monitoring and Follow-Up

4. Regular Health Assessments
- Growth and Development: Monitor the infant’s growth,
development, and overall health regularly.
- Side Effects: Monitor for potential side effects of antiretroviral
medications.
Immunizations
5. Standard Immunizations
- Vaccination Schedule: Follow the standard immunization schedule
for infants, with careful consideration of live vaccines if the infant's
HIV status is confirmed positive.

Long-Term Follow-Up
6. Confirmatory HIV Testing
- Final Confirmation: If all PCR tests are negative, perform a
confirmatory HIV antibody test at 18 months to ensure the infant is
HIV-negative.

7. Ongoing Support
- Parental Education: Educate the parents about the importance of
adherence to prophylactic medications and follow-up appointments.
- Psychosocial Support: Provide support services for the family to
address any psychosocial and emotional needs.