Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Sexuality - Sexually Transmitted Infections - Cases (B3)

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Go to sexuality - stis - urethritis/cervicitis
Go to sexuality - stis - vaginitis
Go to sexuality - stis - pelvic pain
Go to sexuality - stis - genital ulcers
Go to sexuality - stis - genital growths
Go back to sexuality - stis - overview

Cases

Case 1

15 year old adolescent females comes to the emergency room with 3-4 days of fatigue, sore throat, low grade fever and a rash.

Question
What would be important to ask on the history?

Answer
Important history information would include:

  • Other systemic symptoms: None, there is no cough or GI symptoms
  • Contact with ill individuals: No one sick in family or friends
  • Medications: She denies being on any medications
  • Sexual history: She is reluctant to discuss her sexual history in the emergency room as her mother is in waiting room. You reassure her of confidentiality and she mentions that she has had two sexual partners that were both consensual and she occasionally uses condoms.
  • History of STDs and contraception: She has no history of STDs, no symptoms of vaginal infection.
  • Drug history: She denies any drugs except occasional cigarettes on the weekend
  • History of last menstrual period: Two weeks ago and was her menstrual period was normal

Question
What would be especially important to review on her physical examination?

Answer

  • HEENT exam: She has no nasal discharge and her ear canals/TMs are normal. She has erythematous pharynx with slight exudate.
  • Lymph nodes: She has anterior cervical lymphadenopathy
  • Chest/cardiac exam: Clear lung fields, cardiac exam is normal with no murmurs
  • Skin exam: She has the following diffuse rash
    Secondary Syphilis Rash
    click for full-size image
  • Pelvic examination: She refuses at this time.

Question
What is your differential diagnosis?

Answer

  • Strep pharyngitis/scarlet fever
  • Mononucleosis other other minor viral infection
  • Secondary syphilis

Question
What tests would you order?

Answer

  • CBC - The CBC might help with mononucelosis showing lymphocytosis and abnormal lymphocytes. Her CBC showed hemoglobin of 12.0 gm/l and her WBC was 11,000 with no lymphocytosis or abnormal lymphocytes.
  • Monospot - Negative
  • Strep throat culture or rapid strep test
  • VDRL or RPR
  • If available, urine screen for gonorrhea and chlamydia

You send off throat culture, RPR and urine screen for GC and CT.


Question
Would you treat her at this point and if so, with what? 

Answer
You decide that scarlet fever is real possibility and because of their living area and difficulty in getting her back to the clinic and a question of reliability, you give her a penicillin injection.

It is also possible that she could have very early mononucleosis and she has not yet developed either a positive monospot or a lymphocytosis.

In about 40 minutes, she has shaking chills.


Question
What are the possibilities to explain this?

Answer
One possibility might be an allergic reaction to the medication. However, another explanation might be that she has secondary syphilis and she is having a Jarisch-Herxheimer reaction. This follows treating an individual for syphilis and is an immune reaction after the spirochetes are being lyzed. The reaction occurs within 2 hours after treatment in 50% of patients with primary syphilis, 90% with secondary syphilis, and 25% with early latent syphilis. The reaction consists of fever and chills, myalgias, headache, elevated neutrophil count, and tachycardia. The reaction usually last up to 12-24 hours and treatment is usually with reassurance.

She is referred to your office in two days for follow-up. At that time you notice the following hand rash that you missed on the first visit.

Palmar Rash
click for full-size image

You also get back her RPR which is positive and her urine GC and CT which are negative.


Question
What are important therapeutic issues at this time?

Answer:

  • Ordering quantitative VDRL to be able to follow her titers after therapy
  • Treating her with Bicillin to treat her active syphilis. Bicillin is required as longer serum levels of a low dose of penicillin are required to treat syphilis.
  • Discussing the possibility of HIV testing
  • Discussing contraceptive options
  • Discussing how much she is willing to discuss with her mother or father about her condition and contraceptive options.
  • Discussing the need for a pelvic examination
  • Discussing follow-up on above items.
  • Discussing the mandatory reporting requirement of the syphilis to the public health department and the need to treat sexual partners.

Case 2

17 year old male comes into your office complaining of 4 days of burning on urination.

Question
What are important history questions?

Answer
Important history information would include:

  • Presence of penile discharge: Small amount for 3 day
  • History of prior STDs or UTIs: None
  • Other symptoms: Except for dysuria and discharge, there are none
  • Current medications: On topical acne medications
  • Sexual history: He has had three partners in past 6-12 months and occasionally uses condoms.
  • History of STDs: No history of prior STDs
  • Drug history: Occasional use of alcohol and marijuana

Question
What would be important items on the physical examination?

Answer

  • Lymph nodes: There is no adenopathy
  • Skin exam: No rashes or lesions
  • Careful genital examination: There are no penile lesions, there is no swelling or tenderness of the testes. There is slight clear penile discharge seen below

Male adolescent with urethral discharge
click for full-size image


Question
What would be your next steps?

Answer

  • Gram stain the discharge :
    White cells are seen with over 5 white cells per high power field. No bacteria seen. Since the individual has both a urethral discharge and white cells on gram stain, there would be no need for either leukocyte esterase test or examining urinary sediment as at this point, you have made a clinical diagnosis of urethritis. If there was no discharge, then examining the urine would be helpful.
  • Testing for Gonorrhea and chlamydia via either culture or LCR/PCR techniques.
    Depending on availability, cost etc one could chose culture or amplification techniques. If there was no medical coverage and cost was a problem, one could treat the teen presumptively without culture.

Question
What would be your therapeutic interventions?

Answers

  • Treatment with a regimen that covers both gonorrhea and chlamydia. If one was in an area with very low prevalence of gonorrhea and one was testing for gonorrhea, one could treat only for chlamydia, in view of the negative gram-stain, and await the gonorrhea test.
  • Discussion of HIV testing
  • Discussion of contraception and need for more consistent condom use
  • Discussion of treatment of his sexual partners.

Case 3

A 17 year old female comes in to office complaining of 4 days of vaginal itching and burning.

Question
What would be important to ask on the history?

Answer
Important history information would include:

  • Prior history of vaginal infections: None
  • Other symptoms: None
  • Sexual history: She has had one boyfriend for six months and has been on OCPs for five months and does not use condoms.
  • History of STDs: She has no history of prior STDs
  • Medications: She denies being on any medications
  • Drug history: None
  • History of last menstrual period: One week ago and her menses was normal.

Question
What would be especially important to review on her physical examination?

Answer:

  • Skin exam: She has no rashes
  • Pelvic examination: Exam shows no lesions on external genitalia. On vaginal exam, you see the following discharge

Discharge from "trich" infection
click for full-size image

The cervix has normal ectropion. There is no cervical motion tenderness, no adnexal masses and no uterine or adnexal tenderness. There is no inguinal adenopathy.


Question
What is your differential diagnosis?

Answer
She appears to have a vaginal infection. The most common types are candida, trichomonas or bacterial vaginosis. The latter usually is not associated with much itching and burning so is less likely. The discharge is more characteristic of trichomonas vaginalis vaginitis being yellowish and bubbly versus a more cottage cheese appearance.


Question
What tests would you order?

Answer

  • Wet mount:
  • Cervical gonorrhea and chlamydia test
  • RPR
  • Pap smear

The wet mount is seen below


Question
What is your diagnosis?

Answer
Given the appearance of the discharge and given the wet mount that has both white cells and what appears like a trichomonas organism, the diagnosis is likely trichomonas vaginalis vaginitis.


Question
What are important therapeutic issues at this time?

Answer

  • Ordering metronidazole to treat her
  • Discussing the treatment of sexual partners
  • Discussing the possibility of HIV testing
  • Discussing contraceptive options including the more consistent use of condoms
  • Discussing a follow-up appointment

MATCH THE SLIDES SHOWN BELOW WITH THE MOST LIKELY DIAGNOSES

Diagnoses

  • Genital warts
  • Primary syphilis
  • Herpes simplex
  • Pink pearly penile papules
  • Chancroid
  • LGV
  • Molluscum contagiosum
  • Scabies

Lesions

1)

2) 1 one week painful lesions
pink pearly penile pauples
3) 1 week painless lesion 4) painless lesions

Answers

Lesion 1: pink pearly penile papules
Lesion 2: Herpes simplex
Lesion 3: syphilis
Lesion 4 Molluscum contagiosum

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