Author
Dina Strachan, MD
Assistant Clinical Professor of Dermatology, Columbia University College of Physicians and Surgeons
Director, Aglow Dermatology
New York, NY
Disclosure: Dina Strachan, MD, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Robert A. Schwartz, MD
Professor and Head, Dermatology
Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health
UMDNJ-New Jersey Medical School
Newark, New Jersey
Disclosure: Robert A. Schwartz, MD, has disclosed no relevant financial relationships.
Sexually transmitted diseases (STDs) are an unfortunately common occurrence despite aggressive educational efforts encouraging safe sexual practice. Although STDs are best known for their anogenital manifestations, most infections also have secondary manifestations involving the skin, eyes, oral cavity, or other locations. Many of these lesions can be readily mistaken and, if not properly identified, can lead to significant morbidity. The image shown is from an HIV-positive patient and demonstrates multiple condylomas (arrows) from human papilloma virus infection, the virus most commonly associated with anogenital warts.
Gonorrhea is a purulent infection of the mucous membranes caused by Neisseria gonorrhoeae, a gram negative, intracellular diplococcus. It is colloquially referred to as the clap or the drip. It can be transmitted sexually through vaginal, anal or oral intercourse or perinatally. In the latter situation it may be first evident as conjunctivitis). The infection in men causes anterior urethritis which is usually symptomatic, resulting in dysuria and urethral discharge (shown). Repeat, or untreated infections, can lead to urethral strictures.
The infection is asymptomatic in women 50% of the time. Symptoms include dysuria, vaginal discharge, bleeding between periods, and swelling of the labial folds. Retrograde spread of the gram positive diplococcal organism in women may result in pelvic inflammatory disease (PID), chronic pelvic pain, infertility, and ectopic pregnancy. Fitz-Hugh-Curtis syndrome is when PID is accompanied by right upper quadrant pain resulting from inflammation of the peritoneum around the liver. Laparoscopy may reveal thin adhesions, termed "violin strings," in the abdomen due to chronic inflammation (shown).
Gonococcal infection in neonates occurs during vaginal delivery and usually presents as a purulent conjunctivitis. The prevalence of this infection and its complications, such as corneal erosion, perforation, and blindness, has been significantly decreased with application of silver nitrate or erythromycin eye drops at birth. Although in the United States it is less common than chlamydia as a cause of conjunctivitis in newborns, gonorrhea is more aggressive (shown). Newborns with sexually transmitted infections should undergo evaluation for other sexually transmitted diseases such as HIV.
Hematogenous spread of N gonorrhea occurs in up to 3% of patients with gonorrhea. Patients with HIV, systemic lupus erythematosus, complement deficiencies, and those who are pregnant or menstruating are particularly vulnerable. Multiple organ systems can be involved, resulting in septic arthritis, dermatitis, endocarditis, meningitis, osteomyelitis, and septic shock. Pictured is an acral pustule of disseminated gonococcemia. Gram-negative intracellular diplococci would be present on a gram stain of the contents. Image courtesy of the Centers for Disease Control and Prevention (CDC).
Genital herpes is one of the most common sexually transmitted diseases. It is caused by either herpes simplex virus 1 (HSV 1) or herpes simplex virus 2 (HSV 2). Although HSV-2 is more frequently associated with genital infection and HSV-1 with orofacial disease, crossover does occur. Asymptomatic infection is most common. Viral shedding and transmission takes place in the absence of lesions. The classic presentation is grouped vesicles or erosions on a base of erythema (shown) -- these lesions may take 2 weeks to resolve. Image courtesy of the CDC.
In some infected persons with HSV, there may be only nonspecific itching, burning or redness in the genital area. Recurrent buttocks lesions may be a sign of genital infection. Genital herpes infection tends to be chronic and recurrent. It is more common in women and may increase transmission of other sexually transmitted infections such as HIV. Autoinfection to other areas of the body may occur. The image shown is from a 7-year-old child with periocular herpes simplex and an established history of recurrent herpes labialis. Image courtesy of the CDC.
Human papilloma virus (HPV) infection causes a variety of anogenital diseases in sexually active adults, including condylomata acuminata (shown), bowenoid papulosis, cervical cancer and some anal cancer. Subclinical infection is common. Warts may be found on the external genitalia, perineum, perianal area, and the adjacent areas of skin. Lesions may be just a few millimeters or present as large, cauliflower-like growths several centimeters in size. They may be flesh-colored, pink, brown, or white and may appear macerated in the moist mucosal area of the genitalia (vs the keratotic lesions seen on other areas).
Extra-anogenital HPV spread of condyloma acuminata is uncommon, but may be found in patients on renal dialysis, with HIV, and after solid organ transplantation. Intraoral eruptions have a similar cauliflower appearance to the venereal warts. They typically develop on the nonkeratinized mucosa. Oral-genital intercourse is the presumed means of contact for many patients with partners who have genital lesions. Image courtesy of the CDC.
Known as "the great imitator," syphilis has a variety of skin and systemic manifestations. It is transmitted by the spirochete Treponema pallidum and goes through primary, secondary, and tertiary stages. The classic lesion of primary syphilis is a painless, rubbery ulcer (chancre) with raised edges which typically occurs 21 days after inoculation (shown). Multiple primary lesions may occur in HIV-infected individuals or as "kissing lesions" on opposing skin surfaces. If the lesion becomes secondarily infected with bacteria, it may become painful. Regional lymphadenopathy (buboes) may be present.
Secondary syphilis, resulting from multiplication and spread of spirochetes to the skin and other tissues, may present with patchy hair loss, skin eruptions, fever, malaise, pharyngitis, and eye symptoms. A generalized, scaly, papulonodular eruption is the most common manifestation of secondary syphilis. The lesions are usually 1 cm in size and can range in color from pink or reddish-brown to violaceous. Although typically nonpruritic, the presence of itch does not rule out syphilis.
The presence of lesions on the palms and soles helps distinguish secondary syphilis from other papulosquamous eruptions such as guttate psoriasis, pityriasis rosea, sarcoidosis and lichen planus. The classic "copper-penny lesions" are reddish brown, scaly papules on the palms (shown) and soles. Condylomata lata are painless, white lesions of secondary syphilis that present in the anogenital area. Condylomata lata may be confused with genital warts. All lesions of secondary syphilis are highly contagious.
Tertiary syphilis, or gummatous syphilis, involves the skin or visceral organs. Gummas may be single or multiple and the liver and skeleton are commonly affected. Characteristic symptoms are fever, jaundice, anemia, and nocturnal bone pains. There are 3 forms of neurosyphilis. Meningovascular syphilis causes obliterative endarteritis and perivascular inflammation. Paretic syphilis results in widespread parenchymal involvement and atrophy. Tabes dorsalis causes demyelination of the posterior columns of the spinal cord (black arrows), leading to ataxia and loss of pain sensation, proprioception, and deep tendon reflexes. This causes the classic wide-based gait and postular instability. Image courtesy of the CDC.
Congenital syphilis may produce a number of complications. Inflammation of the corneal connective tissue produces interstitial keratitis, leading to diffuse stromal haze and blindness in late-staged congenital syphilis (shown). Early and late stage congenital syphilis is differentiated by 2 years of age. Other potential congenital complications include deafness, paroxysmal cold hemoglobinuria, mulberry molars, Hutchinson incisors, hemorrhagic rhinitis, hepatosplenomegaly, glomerulonephritis, and hydrops. There are a variety of laboratory and diagnostic tests, including dark-field microscopy (immediate), histology, direct fluorescence antibody test (DFA-TP), rapid plasma reagin (RPR), and Venereal Disease Research Laboratory (VDRL) used to detect syphilis. Image courtesy of the CDC.
Molluscum contagiosum is a common, self-limited viral skin infection caused by a poxvirus that is spread via skin-to-skin contact. It is common in nongenital skin in the pediatric population, but in adults is typically a sexually transmitted disease. The typical lesion is an umbilicated, dome-shaped, flesh-colored or pink papule that may persist for 8 weeks or more. Inflammation may accompany spontaneous resolution, raising false concern of secondary infection. Treatment is usually physical destruction with substances such as liquid nitrogen, cantharidin, salicylic acid, and trichloroacetic acid. Imiquimod, an immune response modifier, is also sometimes used, as is physical removal (curettage, manual extrusion). Recently, some botanical substances have also been shown to facilitate clearance.
Chancroid is caused by the gram-negative bacterium Haemophilus ducreyi, which is seen as a "school of fish" on gram stain. Although endemic in many developing countries, outside of prostitution, chancroid is rare in the industrialized world. Men are much more likely to be infected. Unlike with primary syphilis, chancroid tends to produce multiple soft and painful ulcers with ragged, undermined borders (shown). There may also be a gray membrane over the lesions. There are no systemic manifestations. Chancroid infection is a risk factor for both acquiring and transmitting HIV. Image courtesy of the CDC.
Granuloma inguinale, or donovanosis, is another cause of genital ulcer disease seen more commonly in the tropics. It is caused by gram-negative pleomorphic bacillus, Klebsiella granulomatis, thought to have low infectious capabilities, frequently requiring repeat exposure for clinical infection to occur. Lesions start out as papules or nodules usually in the genital region, and are sometimes mistaken for lymph nodes (pseudobuboes). They eventually evolve into painless, beefy red ulcers with raised edges (shown). The ulcers expand and may cause local destruction.
Granuloma inguinale may also result in lymphedema. Autoinoculation with donovanosis is common and dissemination does occur in about 6% of cases. The image shown is a case of disseminated donovanosis of the ankle. In rare cases, hematogenous dissemination to the spleen, lungs, liver, bones, and orbits may occur and lead to death. Definitive diagnosis is made when Donovan bodies, which are intracellular bacteria, are detected on microscopy.
Lymphgranuloma venereum (LVG) is caused by infection with Chlamydia trachomatis L1, L2 (most common), and L3 serotypes. Like syphilis, it is characterized by 3 states, the first being the presence of a small, painless, often undiscovered papule. During the second stage lymph node involvement results in the formation of painful buboes. Enlargement of lymph nodes above and below the inguinal ligament result in the classic "groove sign." Untreated, rectal fistulas may form, especially in women, resulting in scarring and chronic lymphatic obstruction. With anogenital-rectal involvement, LVG may be confused with Crohn's disease. A 3-week course of either doxycycline or erythromycin may be required. Buboes may require surgical drainage.
Author
Dina Strachan, MD
Assistant Clinical Professor of Dermatology, Columbia University College of Physicians and Surgeons
Director, Aglow Dermatology
New York, NY
Disclosure: Dina Strachan, MD, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Robert A. Schwartz, MD
Professor and Head, Dermatology
Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health
UMDNJ-New Jersey Medical School
Newark, New Jersey
Disclosure: Robert A. Schwartz, MD, has disclosed no relevant financial relationships.
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