Bacterial Diseases of the Reproductive System

Prostatitis

Prostatitis is an inflammation of the prostate which can be caused by bacteria.

Learning Objectives

Define the symptoms, diagnostic tests and treatments used for prostatitis

Key Takeaways

Key Points

  • Bacteria can cause acute and chronic prostatitis.
  • Acute prostatitis is a serious condition that needs immediate treatment with antibiotics. If treated promptly complications are rare.
  • Chronic prostatitis is a rare disease that is harder to treat and has high recurrence rate. In the case of remission, combinations of antibiotics may be a better therapy than a single antibiotic.

Key Terms

  • bactericidal: An agent that kills bacteria.
  • bacteriostatic: A drug that prevents bacterial growth and reproduction but does not necessarily kill them. When it is removed from the environment the bacteria start growing again.
  • cystitis: An inflammation of the urinary bladder.

Prostatitis is an inflammation of the prostate which can be caused by bacteria. Bacterial infections can cause both acute and chronic prostatitis.

Symptoms and diagnosis

Acute prostatitis is relatively easy to diagnose because it presents the general infection symptoms which may include: fever, chills, groin and lower back pain, issues during urination, and general body aches. The prostate is usually enlarged. Testing of urine samples reveals the presence of bacteria and white blood cells. Blood samples can contain bacteria. White blood cells counts are elevated in the complete blood count.

Chronic prostatitis is a rare condition. It usually causes intermittent urinary tract infections (UTIs) which can lead to cystitis. Sometimes there are no symptoms. The diagnosis is made after culturing urine or prostate liquid. Semen analysis can also be used for diagnosis it. PSA (prostate specific antigen) levels may be elevated.

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Histologic image of chronic prostatitis: The single gland on the left is healthy, while the glands on the right are inflamed

INFECTIOUS AGENTS

Common bacteria that cause acute prostatitis include gram negative bacteria such as Escherichia coli, Klebsiella, Proteus, Enterobacter, Pseudomonas, as well as gram positive bacteria such as Staphylococcus aureus. E. coli is the major infectious agent that causes chronic prostatitis.

TREATMENT

Acute prostatitis is a serious condition that requires immediate treatment to prevent complications such as sepsis. The antibiotics of choice should be bactericidal (e.g., quinolone) not bacteriostatic (e.g., tetracycline) if the infection is life-threatening. Other commonly used antibiotics are doxycycline and ciprofloxacin. Severe infections may require hospitalization, while milder cases (no sepsis) can be treated with antibiotic administration combined with bed rest at home. The infection is usually cured successfully with antibiotics and the recovery is complete without further complications. Treatment of chronic prostatitis requires courses of antibiotic administration for one to two months or a longer course with low doses. The recurrence of the disease is high. In these cases higher success rates of treatment are achieved when a combination of antibiotics is used. Animal studies have shown that E. coli extract with cranberry can prevent chronic prostatitis. The choice of antibiotic for chronic prostatitis also depends on its ability to penetrate the prostatic capsule. Good penetrators of the barrier are quinolones, doxycycline, macrolides and sulfas (Bactrim). In the case of acute prostatitis, the prostate-blood barrier is damaged by the infection so the penetrating ability of the antibiotic is not as important.

Prostatitis

Prostatitis is an inflammation of the prostate which can be caused by bacteria.

Learning Objectives

Define the symptoms, diagnostic tests and treatments used for prostatitis

Key Takeaways

Key Points

  • Bacteria can cause acute and chronic prostatitis.
  • Acute prostatitis is a serious condition that needs immediate treatment with antibiotics. If treated promptly complications are rare.
  • Chronic prostatitis is a rare disease that is harder to treat and has high recurrence rate. In the case of remission, combinations of antibiotics may be a better therapy than a single antibiotic.

Key Terms

  • bactericidal: An agent that kills bacteria.
  • bacteriostatic: A drug that prevents bacterial growth and reproduction but does not necessarily kill them. When it is removed from the environment the bacteria start growing again.
  • cystitis: An inflammation of the urinary bladder.

Prostatitis is an inflammation of the prostate which can be caused by bacteria. Bacterial infections can cause both acute and chronic prostatitis.

Symptoms and diagnosis

Acute prostatitis is relatively easy to diagnose because it presents the general infection symptoms which may include: fever, chills, groin and lower back pain, issues during urination, and general body aches. The prostate is usually enlarged. Testing of urine samples reveals the presence of bacteria and white blood cells. Blood samples can contain bacteria. White blood cells counts are elevated in the complete blood count.

Chronic prostatitis is a rare condition. It usually causes intermittent urinary tract infections (UTIs) which can lead to cystitis. Sometimes there are no symptoms. The diagnosis is made after culturing urine or prostate liquid. Semen analysis can also be used for diagnosis it. PSA (prostate specific antigen) levels may be elevated.

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Histologic image of chronic prostatitis: The single gland on the left is healthy, while the glands on the right are inflamed

INFECTIOUS AGENTS

Common bacteria that cause acute prostatitis include gram negative bacteria such as Escherichia coli, Klebsiella, Proteus, Enterobacter, Pseudomonas, as well as gram positive bacteria such as Staphylococcus aureus. E. coli is the major infectious agent that causes chronic prostatitis.

TREATMENT

Acute prostatitis is a serious condition that requires immediate treatment to prevent complications such as sepsis. The antibiotics of choice should be bactericidal (e.g., quinolone) not bacteriostatic (e.g., tetracycline) if the infection is life-threatening. Other commonly used antibiotics are doxycycline and ciprofloxacin. Severe infections may require hospitalization, while milder cases (no sepsis) can be treated with antibiotic administration combined with bed rest at home. The infection is usually cured successfully with antibiotics and the recovery is complete without further complications. Treatment of chronic prostatitis requires courses of antibiotic administration for one to two months or a longer course with low doses. The recurrence of the disease is high. In these cases higher success rates of treatment are achieved when a combination of antibiotics is used. Animal studies have shown that E. coli extract with cranberry can prevent chronic prostatitis. The choice of antibiotic for chronic prostatitis also depends on its ability to penetrate the prostatic capsule. Good penetrators of the barrier are quinolones, doxycycline, macrolides and sulfas (Bactrim). In the case of acute prostatitis, the prostate-blood barrier is damaged by the infection so the penetrating ability of the antibiotic is not as important.

Gonorrhea

Gonorrhea (also colloquially known as the clap) is a common human sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae.

Learning Objectives

Describe gonorrhea

Key Takeaways

Key Points

  • The usual symptoms of gonorrhea in men are burning with urination and penile discharge.
  • Women with gonorrhea, on the other hand, are asymptomatic half the time or have vaginal discharge and pelvic pain.
  • If gonorrhea is left untreated, it may spread locally causing epididymitis or pelvic inflammatory disease or throughout the body, affecting joints and heart valves.Treatment is commonly with ceftriaxone as antibiotic resistance has developed to many previously used medications.

Key Terms

  • ceftriaxone: A synthetic cephalosporin antibiotic used to treat gonorrhea.

Gonorrhea (also colloquially known as the clap) is a common human sexually transmitted infection. The usual symptoms in men are burning with urination and penile discharge. Women, on the other hand, are asymptomatic half the time or have vaginal discharge and pelvic pain. In both men and women if gonorrhea is left untreated, it may spread locally causing epididymitis or pelvic inflammatory disease or throughout the body, affecting joints and heart valves.Treatment is commonly with ceftriaxone as antibiotic resistance has developed to many previously used medications. In 2011, there were reports of some strains of gonorrhea showing resistance to ceftriaxone. Half of women with gonorrhea are asymptomatic while others have vaginal discharge, lower abdominal pain or pain with intercourse.

The most common male symptoms are urethritis associated with burning with urination and discharge from the penis. Either sex may also acquire gonorrhea of the throat from performing oral sex on an infected partner, usually a male partner. Such infection is asymptomatic in 90% of cases, and produces a sore throat in the remaining 10%. The incubation period is 2 to 14 days with most of these symptoms occurring between 4–6 days after being infected. Rarely, gonorrhea may cause skin lesions and joint infection (pain and swelling in the joints) after traveling through the blood stream. Very rarely it may settle in the heart causing endocarditis or in the spinal column causing meningitis (both are more likely among individuals with suppressed immune systems, however).

CAUSE

Gonorrhea is caused by the bacteria Neisseria gonorrhoeae. The infection is transmitted from one person to another through vaginal, oral, or anal sex. Men have a 20% risk of getting the infection from a single act of vaginal intercourse with an infected woman. The risk for men who have sex with men is higher. Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with an infected man. A mother may transmit gonorrhea to her newborn during childbirth; when affecting the infant’s eyes, it is referred to as ophthalmia neonatorum. It cannot be spread by toilets or bathrooms.

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Neisseria gonorrhoeae: Neisseria gonorrhoeae cultured on two different media types and presented in stereoscopic 3d.

Nongonococcal Urethritis (NGU)

Nongonococcal urethritis (NGU) is an urethral inflammation that is not caused by Neisseria gonorrhoeae.

Learning Objectives

Recognize the symptoms, causes and treatments for nongonococcal urethritis (NGU)

Key Takeaways

Key Points

  • The general symptoms are pain on urination, frequent urination, and white or cloudy discharge.
  • It can be caused by many infectious agents, with the most common being chlamydia.
  • Since many different infectious agents can be causing NGU, the initial treatment should be with a broad spectrum antibiotic.

Key Terms

  • epididymitis: An inflammation of the epididymis, a structure in the testicles where sperm matures.

Nongonococcal urethritis (NGU) is a urethral inflammation that is not caused by Neisseria gonorrhoeae, a classification used by doctors for treatment purposes. The general symptoms are pain on urination, frequent need to urinate and white or cloudy discharge. The most common symptoms unique to men are discharge from the penis, itching, and tenderness. In women, the symptoms include vaginal discharge, abdominal pain. If irregular menstrual bleeding is present it may indicate that the infection has progressed into pelvic inflammatory disease.

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Azithromycin: The structure of azithromycin, a microlide antibiotic used to treat NGU.

Diagnosing NGU is based on the lack of Neisseria gonorrhoeae in laboratory testsin a patient with urethritis. In men, it can be diagnosed with Gram staining of urethral discharge; the same is not true for women, since they may have other Gram negative bacteria that are part of their normal vaginal microflora. There are multiple infectious agents that can cause nongonococcal inflammation of the urethra. The most common bacterial agent is Chlamydia trachomatis (about a quarter to half of all NGU cases), though others include Ureaplasma urealyticum, Haemophilus vaginalis and Mycoplasma genitalium. Viral infections can be caused sometimes by the Herpes simplex virus or adenovirus. Parasites such as Trichomonas vaginalis can cause inflammation too, although rarely. NGU can be caused by reasons different than infection, such as the use of some chemicals or physical injuries. Since many different infectious agents can be causing NGU, the initial treatment should be with a broad spectrum antibiotic. Studies indicate that therapies with doxycycline or azithromycin with tinidazole can be more effective than doxycycline or azithromycin alone. Sexual partners of infected patients should be treated as well. Prompt treatment is critical in both men and women. Women are at risk of developing pelvic inflammatory disease (PID), while in men the infection can progress to epididymitis and cause infertility.

Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease (PID) is an inflammation of the female reproductive organs that is most often caused by infection.

Learning Objectives

Describe the causes, symptoms and long-term effects of pelvic inflammatory disease

Key Takeaways

Key Points

  • Different agents can cause the infection but the most common are Chlamydia trachomatis and Neisseria gonorrhoeae.
  • PID can cause permanent damage to the affected organs leading to issues such as infertility and chronic pelvic pain.
  • Single antibiotics or combinations of antibiotics are used for the treatment of PID.

Key Terms

  • ectopic: Being out of place, such as a pregnancy occurring inside the fallopian tubes instead of the uterus.
  • pelvic inflammatory disease: inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs
  • asymptomatic: not exhibiting any symptoms of disease.

Pelvic inflammatory disease (PID) is an inflammation of the uterus, fallopian tubes and/or the ovaries. It is most often caused by a sexually transmitted infection (STI) but there are other predisposing conditions (e.g., postpartum period, the use of intrauterine device). It should be treated promptly to avoid serious complications like scarring and adhesions which can cause infertility, ectopic pregnancy and chronic pelvic pain.

Symptoms and diagnosis

PID can be asymptomatic or present with acute symptoms. About two thirds of patients whose laparoscopies indicated a previous PID were unaware of it. Asymptomatic infections should be treated as well, since they can still cause permanent damage to the reproductive tract.

Symptoms include fever, lower abdominal pain, unusual discharge, irregular menstrual bleeding, painful intercourse.

Different tests can be used for diagnosis such as pelvic ultrasound and laboratory tests for STIs. Usually, more than one test is needed for proper diagnosis. Early diagnosis and treatment are critical to limit the spread of the infection to the lower part of the tract and to avoid long term consequences.

Infectious agents

PID can be caused by many different infectious agents like viruses, fungi or bacteria. The most common infectious agents are Chlamydia trachomatis and Neisseria gonorrhoeae which are sexually transmitted.

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Pap smear with Chlamydia: Cells of Chlamydia are visible in the vacuoles. Magnification 500x, stained with hematoxylin and eosin stain (HE)

The normal vaginal flora can also cause PID under certain circumstances. Co-infection with multiple species is also possible.

Treatment

The primary mode of therapy is an antibiotic regimen. In serious cases, intravenous administration of drugs may be necessary. Usually, improvement of symptoms should be noticed within a few days.

Sexual partners of patients with PID should be treated as well. Some of the most commonly used antibiotics and combinations of antibiotics are: cefoxitin or cefotetan plus doxycycline, cefoxitin plus doxycycline, clindamycin plus gentamycin, ampicillin and sublactam plus doxycycline.

Syphilis

Syphilis is a sexually transmitted infection (STI) caused by the bacterium Treponema pallidum.

Learning Objectives

Describe syphilis, its affect on the spinal cord, and its methods of transmission

Key Takeaways

Key Points

  • In addition to sexual contact, syphilis may also be transmitted from mother to child during pregnancy or at birth, resulting in congenital syphilis.
  • Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person, and usually presents with a single skin ulceration called a chancre.
  • Secondary syphilis occurs approximately four to 10 weeks after the primary infection and may present as a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles of the feet.
  • Primary syphilis typically presents with a single skin ulceration called a chancre.
  • Neurosyphilis refers to a syphilis infection that affects the central nervous system, and cardiovascular syphilis affects the cardiovascular system.
  • Blood tests for syphilis are either treponemal or nontreponemal.
  • The Tuskegee syphilis study, where African American men in rural Alabama were told they were receiving free health care and instead were given syphilis in order to study its symptoms and progression, is one of the most infamous cases of questionable medical ethics in US history.

Key Terms

  • congenital syphilis: syphilis present in utero and at birth
  • Treponema pallidum: A Gram-negative spirochaete bacterium with subspecies that cause treponemal diseases such as syphilis, bejel, pinta, and yaws.
  • chancre: A skin lesion, sometimes associated with certain contagious diseases like syphilis.
  • syphilis: a disease spread via sexual activity, caused by the bacterium Treponema pallidum
  • syphilis: A disease spread via sexual activity, caused by the bacterium Treponema pallidum.

Syphilis

Syphilis is a sexually transmitted infection (STI) caused by the spirochete bacterium Treponema pallidum.

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Electron Microscopy of Treponema Pallidum: This electron micrograph shows Treponema pallidum on cultures of cotton-tail rabbit epithelium cells (Sf1Ep). It is the causative agent of syphilis.

FOUR STAGES OF SYPHILIS

The signs and symptoms of syphilis vary depending on which of the four stages it presents (primary, secondary, latent, or tertiary). The primary stage classically presents itself with a single chancre (a firm, painless, non-itchy skin ulceration) as shown in. Secondary syphilis shows itself with a diffuse rash that frequently involves the palms of the hands and soles of the feet. Latent syphilis displays little to no symptoms, and neurosyphilis (tertiary) can result in neurological and cardiac symptoms because the syphilis has been undiagnosed or untreated for many years.

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Secondary Syphilitic Infection on the Posterior Aspect of the Torso: Dermatologic manifestations are the hallmark of secondary syphilis. Copper-red papules are most common, but macular, pustular, acneiform, psoriasiform, nodular, annular, or follicular variants can appear. The lesions characteristically do not itch, but may itch in some patients.

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Primary Syphilitic Infection of the Finger: The chancre is usually firm, round, small, and painless, appearing at the spot where syphilis entered the body. It lasts three to six weeks and heals on its own. If adequate treatment is not administered, the infection progresses to the secondary stage.

DIAGNOSIS AND TREATMENT

Diagnosis is usually via blood tests, but the bacteria can also be visualized under a microscope. Syphilis can be effectively treated with antibiotics, specifically the preferred intramuscular penicillin G (given intravenously for neurosyphilis), or else ceftriaxone, and in those who have a severe penicillin allergy, oral doxycycline or azithromycin.

Syphilis is believed to have infected 12 million people globally in 1999, with more than 90 percent of cases in the developing world. Rates decreased dramatically after the widespread availability of penicillin in the 1940s. However, rates of infection have increased since the turn of the century in many countries, often in combination with human immunodeficiency virus (HIV). By some accounts, this has been attributed, in part, to unsafe sexual practices among men who have sex with men, increased promiscuity among all genders, prostitution, and decreasing use of barrier protection.

PRIMARY SYPHILIS

Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person. Approximately three to 90 days after the initial exposure (average 21 days) a skin lesion, called a chancre, appears at the point of contact. This chancre is classically a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders between 0.3 and 3.0 cm in size. However, the lesion may take on almost any form. In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer. Occasionally, multiple lesions may be present, with multiple lesions more common when co-infected with HIV. Lesions may be painful or tender (in 30 percent of those infected), and they may occur outside of the genitals (2 to 7 percent). The lesion may persist for three to six weeks without treatment.

SECONDARY SYPHILIS

Secondary syphilis occurs approximately four to 10 weeks after the primary infection. While secondary disease is known for the many different ways it can manifest, symptoms most commonly involve the skin, mucous membranes, and lymph nodes. There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles of the feet. The rash may become maculopapular or pustular. It may form flat, broad, whitish, wart-like lesions known as condyloma latum on mucous membranes. All of these lesions harbor bacteria and are infectious.

Other symptoms may include fever, sore throat, malaise, weight loss, hair loss, and headache. Rare manifestations include hepatitis, kidney disease, arthritis, periostitis, optic neuritis, uveitis, and interstitial keratitis. The acute symptoms usually resolve after three to six weeks; however, about 25 percent of people may experience a recurrence of secondary symptoms.

NEUROSYPHILIS

Neurosyphilis occurs when syphilis is left untreated from many years. The brain and spinal cord become infected with the syphilis bacterium, Treponema pallidum, during the secondary stage of infection and can remain latent for 10 to 20 years after the initial infection. Eventually, this infection begins to damage the tissues of the brain and spinal cord, resulting in neurosyphilis. Neurosyphilis is characterized by neurological and psychiatric symptoms, such as confusion, blindness, abnormal gait and dementia. Left untreated, neurosyphilis symptoms will worsen over time and can lead to death. Treatment for neurosyphilis is the same as any other stage of syphilis, requiring only a short course of penicillin.

TRANSMISSION AND PREVENTION

Syphilis is transmitted primarily by sexual contact or during pregnancy from a mother to her fetus. The spirochete is able to pass through intact mucous membranes or compromised skin. Therefore, it is transmissible by kissing, or oral, vaginal, and anal sex. Approximately 30 to 60 percent of those exposed to primary or secondary syphilis will get the disease. It can be transmitted via blood products, but, many countries test for it, and thus the risk is low. The risk of transmission from sharing needles appears limited. Syphilis cannot be contracted through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing.

As of 2010, there is no vaccine effective for prevention. Abstinence from intimate physical contact with an infected person is effective at reducing the transmission of syphilis, as is the proper use of a latex condom. However, condom use does not completely eliminate the risk.

Genital Ulcer Diseases

Genital ulcers are skin ulcers on the genital area caused by sexually transmitted diseases or noninfectious conditions.

Learning Objectives

List the causes and symptoms of genital ulcers

Key Takeaways

Key Points

  • The most common STDs that present with genital ulcers are genital herpes, syphilis, chlamydia and chancroid.
  • Other than ulceration, enlarged lymph nodes in the groin area may be present, along with blisters and sores.
  • To improve the outcome, treatment often starts before identification is complete, with medications chosen based on symptoms and epidemiological circumstances.

Key Terms

  • Behcet’s syndrome: Behcet’s syndrome, or Behcet’s disease, is an immune disorder that leads to inflammation of the blood vessels. Common symptoms include mouth and genital ulcers, as well as ocular issues.

Genital ulcers are skin ulcers located on the genital area and can be caused by a number of sexually transmitted diseases or other noninfectious conditions such as yeasts, trauma, lupus, rheumatoid arthritis or Behcet’s syndrome.

Sexually Transmitted Genital Ulcers

When the reason for a genital ulcer is an infection, it can be caused by a number of sexually transmitted diseases. Among the most common are Herpes simplex virus (HSV), the genital herpes agent; Treponema pallidum, that causes syphilis; Chlamydia trachomatis, the cause of chlamydia; and Haemophilus ducreyi, the chancroid agent. In the United States, the most common reasons for genital ulcers in young and sexually active patients are genital herpes and syphilis.

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Genital Ulcers: Ulcers caused by genital herpes.

Symptoms and Diagnosis

Genital ulcers can be painful or painless depending on the type of infection. Their appearance can be slightly different from one disease to another. Other than ulceration, enlarged lymph nodes in the groin area can be present, along with blisters and sores. Proper diagnosis cannot be obtained solely through examination and medical history. Testing for a specific infectious agent depends on the likelihood of its presence. In the U.S., testing is recommended for syphilis (by serology and darkfield microscopy) and HSV (culture, serology or PCR), and in cases of chancroid outbreaks or based on the medical history, for the presence of Haemophilus ducreyi. In about 25% of the cases, the reason for the ulcer will not be identified by laboratory testing. Syphilis, genital herpes and chancroid have all been associated with increasing the risk for HIV transmission. The CDC recommends routine HIV screening for all patients who present with genital ulcers.

Treatment

Since the ulcers are symptoms of a number of infectious agents, the treatment is chosen according to the disease agent if it can be identified. Quite often, therapy has to start before identification is complete in order to decrease the chances for transmission and to increase the probability of successful treatment. The choice of medication is made, after careful examination of the symptoms and all epidemiological circumstances, based on the most likely causative agent.

Lymphogranuloma Venereum

Lymphogranuloma venereum (LGV) is a sexually transmitted disease which causes an infection of the lymph nodes.

Learning Objectives

Outline the causes and disease stages for lymphogranuloma venereum (LGV)

Key Takeaways

Key Points

  • The infectious agents are a few serovars of Chlamydia trachomatis: L1, L2, L2a, L2b and L3.
  • The symptoms of LGV include enlarged and inflamed lymph nodes and lymph passages as well as infection of the surrounding tissues in the genital and abdominal areas.
  • Treatment of LGV includes antibiotics and may require drainage of inflamed nodes.

Key Terms

  • serovar: A group of microorganisms (viruses or bacteria), belonging to the same species, that are characterized by the presence of a specific antigen on their surface.
  • bubo: An inflamed swelling of a lymph node, especially in the armpit or the groin, due to an infection such as bubonic plague, gonorrhea, tuberculosis or syphilis.

Lymphogranuloma venereum (LGV) is a sexually transmitted disease which was considered rare in the developed world until about a decade ago. LGV is an infection of the lymph nodes. The infectious agent enters the body through breaks in the skin or through the epithelial layer of mucous membranes.

Infectious Agents

The infectious agents are a few serovars of Chlamydia trachomatis: L1, L2, L2a, L2b and L3.

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Chlamydiae Life Cycle: Basic diagram of the life cycle of the Chlamydiae. The infectious agents of Lymphogranuloma venereum are a few serovars of Chlamydia trachomatis: L1, L2, L2a, L2b and L3.

Symptoms and Diagnosis

The general symptoms may include fever, malaise and decreased appetite. The disease progresses in stages. In the primary stage, symptoms appear within days after infection. The first symptom is usually painless ulcers at the contact area.The secondary stage can manifest from days to months later. The infectious agent spreads to the lymph nodes through the lymphatic drainage pathways, causing inflammation of the lymph nodes and lymphatic channels. In males with genital infection, these symptoms will usually be in the inguinal or/and femoral areas. In women, an inflammation of the cervix, the fallopian tubes or/and peritonitis may appear as well as inflammation and infection of the lymphatic system. If the infection started in the anal area, it may cause inflammation of the rectum or the colonic mucosa, presenting with symptoms such as anorectal pain, discharge, abdominal cramps and diarrhea.

The enlarged lymph nodes are called buboes and are painful, inflamed and can fixate to the skin. These changes can further progress to necrosis, abscesses and fistulas. As healing starts, fibrosis may occur in the inflamed areas and cause obstruction of the lymphatic system and edema. The fibrosis and edema are considered the third stage of LGV and are mainly permanent. Diagnosis is made after serological analysis and exclusion of other reasons for genital ulcers and lymphatic issues. Culturing is also used for identification of serotypes. Other tests include direct fluorescent antibody analysis (DFA) and PCR tests.

Treatment

Treatment is performed with antibiotics, usually tetracycline, doxycycline or erythromycin. Sometimes drainage of the buboes or abscesses is performed as well. Prognosis is best if treatment starts early in the infection process. Severe complications include bowel obstruction or perforation, which can lead to death.

Group B Streptococcus Colonization

Group B streptococcus is part of the natural microflora in some people, but can sometimes cause life-threatening infections.

Learning Objectives

Describe the pathogenic characteristics, symptoms and diagnostic test used for Group B streptococcus (GBS)

Key Takeaways

Key Points

  • The most vulnerable groups of people to infection are newborns, the elderly, and people with compromised immune system.
  • To prevent infections in infants, many countries routinely screen pregnant women for GBS in the third trimester.
  • GBS infection is treated with antibiotics, with penicillin and ampicillin as the primary choice.

Key Terms

  • sepsis: A life-threatening medical condition caused by a severe inflammatory response of the human body triggered by the presence of an infectious agent.

Group B Streptococcus Colonization

Group B streptococcus (GBS), also called streptococcus agalactiae or simply strep B, is part of the natural genital and intestinal microflora in some people. Studies indicate that as many as 40% of women can be carriers. It is usually harmless but under certain circumstances (in newborns, the elderly, and in people with compromised immune systems) it can cause life-threatening infections. The bacteria is gram-positive streptococcus, and possesses the group B antigen from the Lancefield classification. Its infectivity is due to the presence of a antiphagocytic polysaccharide capsule. If a pregnant woman is a carrier of strep B, the baby can become infected during vaginal delivery.

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The CAMP Test: The collected sample is streaked on a blood agar plate (vertical streaks) next to staphylococcus aureus culture (horizontal streak). Strep B has weak hemolytic activity, which is enhanced substantially (arrow-like area) when streaked next to s. aureus. The reason for that is the interaction between the CAMP factor from strep B and the s. aureus hemolysin.

Symptoms and diagnosis

Healthy adults are usually asymptomatic carriers of the bacteria. Sometimes it can manifest with urinary tract infections (UTIs) in both pregnant and nonpregnant women. In newborns, the first symptoms are breathing difficulties and pneumonia, which can progress to meningitis and sepsis. In elderly people, it can cause pneumonia and/or UTI and is linked to congestive heart failure. A number of different tests are used as diagnostic tools. Screening pregnant women for GBS, usually in the third trimester, is currently routine in many countries. In the cases of positive status, antibiotics are administered during labor to substantially lower the risk of infection for the baby. This strategy has lead to a significant drop in the rates of infant infection in these countries. A very common diagnostic test is the CAMP test named after the three people that discovered it. Sometimes, before plating, enrichment of the gathered probe is performed. This includes sample growth in special medium that will favor its growth over the other bacteria collected with the specimen. The method of enrichment followed by the CAMP tests is currently the gold standard for GBS diagnosis. It lowers significantly the rates of false negatives. However, culturing takes days and is not feasible if labor starts before screening was completed or in cases when it was not performed at all. The best diagnostic tool will allow identification during labor. PCR techniques are faster but they are still complicated and not fast enough to be used widely for diagnostics once labor has started. TreatmentPregnant women who are carriers of GBS are administered penicillin or ampicillin during labor. These antibiotics are the primary choice for GBS therapy in general, since the bacteria are becoming increasingly resistant to many other common antibiotics.

Chancroid (Soft Chancre)

Chancroid is a sexually transmitted disease caused by Haemophilus ducreyi.

Learning Objectives

Recognize the symptoms, causes and treatment for chancroid

Key Takeaways

Key Points

  • Chancroid is becoming rarer worldwide but there are sporadic outbreaks even in countries where it is uncommon.
  • The most common symptoms for chancroid are enlarged lymph nodes and painful, bleeding ulcers with distinctive characteristics.
  • Chancroid is treated with single doses of antibiotics like azythromycin or ceftriaxone, or with erythromycin for a week.

Key Terms

  • fastidious: Microorganisms that are difficult to culture since they need specific nutrients in their medium to grow.
  • lymphadenopathy: An abnormal enlargement of the lymph nodes

Chancroid (soft chancre) is a sexually transmitted disease and can only be spread through sexual contact. It is becoming rarer worldwide with sporadic outbreaks in countries where it is uncommon. This disease is a risk factor for HIV infection.

Infectious Agent

Chancroid is caused by Haemophilus ducreyi, a gram-negative fastidious organism. It enters the body through breaks in the skin.

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Haemophilus ducreyi: A microscopic image of the bacteria that causes chancroid. The stain used is Gentian Violet and the bacteria are bacilli organized in chains.

Symptoms and Diagnosis

The incubation period of chancroid is between one to fourteen days. The area of infection gets inflamed as cells of the immune system gather to fight the invading organism. Between 30-60% of the patients can also develop lymphadenopathy. Quite often, these enlarged lymph nodes can rupture through the skin and produce draining abscesses.The first symptoms after infection are small painless bumps which quickly become painful ulcers. These ulcers can be quite different in size. The base of the ulcers is usually covered in a gray or yellow substance and bleeds easily. They are typically located in specific ares for men and women. Men often have only one ulcer while women present with multiple ulcers. Women have other symptoms as well such as pain during urination and intercourse. For proper diagnosis, the other two infectious agents that can present with similar although not identical ulcers need to be excluded. Tests for the identification of Treponema pallidium (causes syphilis) and HSV (Herpes Simplex Virus, type 2) may be performed to exclude the possibility that ulcers are caused by those agents instead of Haemophilus ducreyi. For identification, samples from patients are cultured on chocolate agar. Even though serological and genetic tests can be used for identification, they are not widely used and culturing is the main tool for identifying Haemophilus ducreyi.

Treatment

Chancroid is treated with single doses of antibiotics like azythromycin or ceftriaxone, or with erythromycin for a week.

Bacterial Vaginosis

Bacterial vaginosis (BV) is a condition of disrupted balance of the vaginal microflora.

Learning Objectives

Describe the symptoms, causes and methods of diagnosis for bacterial vaginosis

Key Takeaways

Key Points

  • The most common symptom is white or gray discharge, that can be thin, with fish-like odor (especially strong after intercourse).
  • Common bacterial species that can overgrow and cause symptoms of BV are Gardnerella vaginalis, Mobiluncus, Bacteroides and Mycoplasma.
  • The treatment regimen is most often metronidizole (for seven days) or clindamycin. BV has high recurrence rates.

Key Terms

  • recurrence: The returning of a disease that was already treated successfuly.

Bacterial vaginosis (BV) is a condition where the vaginal microflora in women have become disrupted. BV is not a typical sexually transmitted disease since women who have never had sexual contact can suffer from this condition, too. However, having sex with a new partner or multiple partners increases the risk of getting BV but it is unclear how and why that happens. BV is a very common condition and it is estimated that about 1 in 3 women will develop it in their lifetime.

Symptoms and diagnosis

Bacterial vaginosis may be completely asymptomatic. The most common symptom is white or gray discharge, that can be thin, with fish-like odor (especially strong after intercourse). Sometimes itching outside of the vagina or/and burning during urination can also be present. For diagnosis in the clinical practice, a swab from the vaginal wall is obtained and examined with a few different tests called the Amsel criteria:

  • the discharge should be thin, white, yellow and homogenous
  • clue cells must be present in the specimen when observed under the microscope
  • pH > 4.5
  • the release of fishy odor after the addition of 10% KOH to the specimen

At least three of these tests have to be positive for conclusive diagnosis. Alternative tests can be performed as well and they usually involve Gram staining of the specimen and observing the types of bacteria present in it. Infectious agentsThe normal vaginal microflora contains many species with Lactobacillus as the dominant representative. Some Lactobacilli produce hydrogen peroxide which can prevent the overgrowth of bacteria that will disturb the balance and cause BV. Some of the bacteria that will produce BV symptoms are Gardnerella vaginalis, Mobiluncus, Bacteroides, and Mycoplasma. Factors that are known to disturb the balance are: antibiotics, pH imbalance (douching can alter vaginal pH), psychosocial stress, iron deficiency anemia in pregnant women and women with STD.

Women who already have BV are at increased risk for sexually transmitted diseases including HIV. Bacterial vaginosis during pregnancy increases the risk of premature birth. TreatmentThe treatment regimen is most often metronidizole (for seven days) or clindamycin. The treatment is usually successful but BV has high rates of recurrence. Treatment of male sex partners is usually not recommended but BV can be transferred to female sex partners.

Chlamydia

Chlamydia infection is a common sexually transmitted infection (STI) in humans caused by the bacterium Chlamydia trachomatis.

Learning Objectives

Describe the effects of chlamydia in men and women

Key Takeaways

Key Points

  • Chlamydia infection is one of the most common sexually transmitted infections worldwide; it is estimated that about 1 million individuals in the United States are infected with chlamydia.
  • Between half and three-quarters of all women who have a chlamydia infection of the cervix (cervicitis) have no symptoms and do not know that they are infected.
  • C. trachomatis infection can be effectively cured with antibiotics once it is detected. Current guidelines recommend azithromycin, doxycycline, erythromycin, or ofloxacin.Agents recommended for pregnant women include erythromycin or amoxicillin.

Key Terms

  • azithromycin: A macrolide antibiotic derived from erythromycin.
  • sexually transmitted disease: any of various diseases that are usually contracted through sexual contact

Chlamydia infection (from the Greek meaning “cloak”) is a common sexually transmitted infection (STI) in humans caused by the bacterium Chlamydia trachomatis. The term Chlamydia infection can also refer to infection caused by any species belonging to the bacterial family Chlamydiaceae. C. trachomatis is found only in humans.

image

Chlamydia: Pap smear showing C. trachomatis (H&E stain).

Chlamydia is a major infectious cause of human genital and eye disease. Chlamydia infection is one of the most common sexually transmitted infections worldwide; it is estimated that about 1 million individuals in the United States are infected with chlamydia. C. trachomatis is naturally found living only inside human cells. Chlamydia can be transmitted during vaginal, anal, or oral sex, and can be passed from an infected mother to her baby during vaginal childbirth. Between half and three-quarters of all women who have a chlamydia infection of the cervix (cervicitis) have no symptoms and do not know that they are infected. In men, infection of the urethra (urethritis) is usually symptomatic, causing a white discharge from the penis with or without pain on urinating (dysuria).

Occasionally, the condition spreads to the upper genital tract in women (causing pelvic inflammatory disease ) or to the epididymis in men (causing epididymitis). If untreated, chlamydial infections can cause serious reproductive and other health problems with both short-term and long-term consequences.

Genital disease

Chlamydial cervicitis in a female patient characterized by mucopurulent cervical discharge, erythema, and inflammation. Male patients may develop a white, cloudy or watery discharge from the tip of the penis.

Women

Chlamydial infection of the neck of the womb (cervicitis) is a sexually transmitted infection which is asymptomatic for about 50-70% of women infected with the disease. The infection can be passed through vaginal, anal, or oral sex. Of those who have an asymptomatic infection that is not detected by their doctor, approximately half will develop pelvic inflammatory disease (PID), a generic term for infection of the uterus, fallopian tubes, and/or ovaries. PID can cause scarring inside the reproductive organs, which can later cause serious complications, including chronic pelvic pain, difficulty becoming pregnant, ectopic (tubal) pregnancy, and other dangerous complications of pregnancy.Chlamydia is known as the “Silent Epidemic” because in women, it may not cause any symptoms in 75% of cases, and can linger for months or years before being discovered. Symptoms that may occur include unusual vaginal bleeding or discharge, pain in the abdomen, painful sexual intercourse (dyspareunia), fever, painful urination or the urge to urinate more frequently than usual (urinary urgency).

Men

In men, chlamydia shows symptoms of infectious urethritis (inflammation of the urethra) in about 50% of cases. Symptoms that may occur include: a painful or burning sensation when urinating, an unusual discharge from the penis, swollen or tender testicles, or fever. Discharge, or the purulent exudate, is generally less viscous and lighter in color than for gonorrhea. If left untreated, it is possible for chlamydia in men to spread to the testicles causing epididymitis, which in rare cases can cause sterility if not treated within 6 to 8 weeks. Chlamydia is also a potential cause of prostatitis in men, although the exact relevance in prostatitis is difficult to ascertain due to possible contamination from urethritis.

Treatment

C. trachomatis infection can be effectively cured with antibiotics once it is detected. Current guidelines recommend azithromycin, doxycycline, erythromycin, or ofloxacin. Agents recommended for pregnant women include erythromycin or amoxicillin.

An option for treating partners of patients ( index cases ) diagnosed with chlamydia or gonorrhea is patient-delivered partner therapy (PDT or PDPT), which is the clinical practice of treating the sex partners of index cases by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.