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Image from the CDC | Wikimedia Commons.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

The above image demonstrates a tongue chancre in a patient with primary stage syphilis.

Sexually transmitted infections (STIs) include some of the most common infectious diseases affecting Americans, and their incidence is increasing.[1] There were more than 2 million cases of chlamydia, gonorrhea, and syphilis reported to the Centers for Disease Control and Prevention (CDC) in 2016, representing the highest number of annual cases of any condition ever reported.[1] The majority of these cases (around 1.6 million) were chlamydia.

The CDC (2016) estimates that there are 20 million new STIs in the United States each year, with persons aged 15-24 years accounting for 50% of new infections. This does not include cases of STIs that go undiagnosed or unreported. STIs alone incur approximately $16 billion in direct medical costs annually.[2] As derived from 2013 data, the estimated total number of STIs in the United States is more than 110 million.[3]

Although STIs are best known for their anogenital manifestations, most infections also have other manifestations, which may involve the skin, eyes, oral cavity, or other areas.

Image from Dr. P. Marazzi | Science Source.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Gonorrhea

Epidemiology and presentation

A gonorrhea-associated mucopurulent discharge from the penis is shown above.

Gonorrhea, colloquially referred to as "the clap," is the second most common notable disease in the United States, with 468,514 cases reported in 2016.[1,4] It is estimated that a similar number of unreported cases also exist.[1,4] Accounting for unreported cases, an estimated 820,000 new gonococcal infections occur in the United States each year.

The term gonorrhea refers to an infection of the mucous membranes caused by Neisseria gonorrhoeae, a gram-negative, intracellular diplococcus that can be transmitted sexually through vaginal, anal, and oral intercourse, as well as perinatally.[4,5]

Genital infections are the most common manifestation of gonorrhea, and cases are often asymptomatic or present with nonspecific symptoms that may mimic other bladder or vaginal infections. Delayed diagnosis is not uncommon and can lead to complications associated with untreated infection. Women are more likely to be asymptomatic, but when they do have symptoms, they commonly present within 10 days of exposure. The most common sites of infection in women are the endocervix and the urethra.[6]

Men with gonorrhea typically present 1-14 days after exposure with urethritis and copious mucopurulent discharge from the penis.[4] This may progress to epididymitis, which often causes testicular or scrotal pain.

Rectal infection may occur in both men and women; symptoms include, but are not limited to, rectal pain, painful bowel movements, discharge, soreness, and bleeding.

Image from the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Diagnosis and treatment

The image shows penile discharge, as well as an overlying pyodermal lesion on the glans penis.

Nucleic acid amplification testing (NAAT) is the preferred examination for the diagnosis of gonorrhea. Any assessment for gonorrhea should also include testing for chlamydia, as coinfection is common. Administration of a cephalosporin (typically ceftriaxone) and azithromycin or doxycycline is necessary to effectively treat gonorrhea and cover for possible coinfection with chlamydia.[7] This regimen is recommended even if testing for chlamydia is negative.

Images courtesy of Andrade-Filho Jde S. Rev Inst Med Trop Sao Paulo. 2013;55(6):435-6. [Open access.] PMID: 24213201, PMCID: PMC4105096, and Taylor PK. Bristol Royal Infirmary, Bristol, England; 1995.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Complications

Thin adhesions (above left), often described as similar in appearance to violin strings, may develop in the abdomen due to chronic inflammation from gonorrhea-associated pelvic inflammatory disease (PID).

PID is a dangerous complication of gonorrhea infection in women, occurring in about 10-20% of those infected with cervical gonorrhea. Women infected with gonorrhea are more likely than men to be asymptomatic, and therefore, their infection may go undetected until it progresses to PID.[6] Acute symptomatic PID is characterized by the sudden onset of lower abdominal pain, pelvic organ tenderness, and inflammation of the genital tract. Fever, chills, and mucopurulent discharge from the cervix are common accompanying findings.[6, 8] Prompt diagnosis and treatment is critical, as PID can cause long term adverse sequelae. These include tuboovarian abscesses, chronic pelvic pain, infertility, and increased risk for ectopic pregnancy as a result of scarring and adhesions that occur when inflamed tissues heal.[8]

Another complication of PID is perihepatitis (Fitz-Hugh–Curtis Syndrome); this develops from inflammation of the Glisson capsule, a fibrous layer that surrounds the liver and, in perihepatitis, results in right upper quadrant pain.[6,8] Laparoscopy in PID may reveal the above-mentioned thin adhesions in the abdomen caused by chronic inflammation.

Image from Medscape.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Maternal-fetal transmission

Transmission of gonorrhea during the birthing process commonly presents as a purulent conjunctivitis in the newborn (ophthalmia neonatorum, shown).[1,7]

Gonococcal infection during pregnancy has been associated with premature rupture of membranes (PROM), chorioamnionitis, preterm birth, and spontaneous abortion. The eye, however, is the most frequent site of newborn gonococcal infection.

Ophthalmia neonatorum refers to infection of the eye in a newborn. Infection can cause purulent conjunctivitis with swelling of the eyelids, and if not treated, further ophthalmic complications such as corneal ulceration, perforation, and blindness.[9] Lack of treatment can allow the infection to spread to the blood stream, brain, and spinal cord.

The incidence of ophthalmia neonatorium has significantly decreased due to maternal screening for STIs, as well as the application of prophylactic antibiotic ointments to the eyes of newborns within the first hour of life.

Image from J Pledger | the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

The above image provides another example of conjunctivitis in the newborn (ophthalmia neonatorum).

Gonorrhea is less common than chlamydia as a cause of newborn conjunctivitis in the United States; however, gonorrhea causes more aggressive ophthalmic disease. Coinfection of N gonorrhoeae with Chlamydia trachomatis is a frequent occurrence; therefore, simultaneous evaluation for chlamydia should always occur.[7] Newborns with these infections should undergo evaluation for other STIs too, such as human immunodeficiency virus (HIV) infection.

Image from Dr Wiesner | the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Systemic complications

An acral pustule associated with disseminated gonococcemia is seen above.

Hematogenous spread of N gonorrhoeae (disseminated gonococcal infection [DGI], shown) occurs in up to 3% of US patients with gonorrhea.[10]

Women have historically been affected by DGI more than men; however, with the increasing prevalence of gonorrhea among men, the ratio has recently been reversing. Patients with HIV infection, systemic lupus erythematosus, or complement deficiencies, or those who are pregnant or have menstruated recently, are particularly vulnerable to systemic infection.[10]

Two clinical syndromes of DGI have been characterized: the first consists of purulent arthritis without associated skin lesions, and the second consists of tenosynovitis, polyarthralgias, and dermatitis (also called arthritis-dermatitis syndrome). Skin findings of disseminated gonococcemia typically consist of painless petechial or pustular acral lesions.[7] Gram-negative intracellular diplococci may be present on a Gram stain of the lesion's contents.

Rare complications include endocarditis, osteomyelitis, vasculitis and meningitis.[6,7]

Image from Drs NJ Fiumara and Gavin Hart | the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Genital Herpes

Epidemiology and presentation

The classic skin finding of genital herpes is an eruption of grouped vesicles or erosions on a base of surrounding erythema in the genital or anal region (shown). These lesions may take 2-4 weeks to resolve.[11]

This infection is caused by either herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2). Although HSV-1 is more frequently associated with orofacial disease, and HSV-2 with genital infection, recent studies have demonstrated that a significant proportion of new onset genital herpes is due to HSV-1.[11,12,13]

Between 2007 and 2010, it was reported by the CDC that about 15.5% of people aged 14-49 were HSV-2 seropositive. Of these individuals, 87.4% had never been told by a health-care provider that they had herpes.[14]

Asymptomatic infection is most common, and viral shedding and transmission can take place in the absence of lesions.[11] However, the classic presentation of genital herpes can include a number of symptoms, including dysuria, fever, tender lymphadenopathy, and headache.

Image from Dr P. Marazzi | Science Source.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Genital herpes lesions on the vulva are shown in the above image.

Most individuals with genital herpes may be asymptomatic, while others may experience only mild, nonspecific symptoms (ie, itching, burning, or redness in the genital area).[11]

Primary infections are typically more severe than recurrent outbreaks and can present with painful genital ulcers, dysuria, lymphadenopathy, and systemic symptoms, including fevers, headache, and malaise.[15]

Following a primary outbreak, recurrent lesions may occur outside of the genital and anal areas (ie, buttocks, lower back, etc) and at times are confused with shingles. Approximately half of individuals with recurrent herpes recognize a prodrome prior to an outbreak, characterized by tingling or shooting pains in the area hours to days before lesions erupt. Systemic symptoms are uncommon with recurrent outbreaks.[11] HSV infection may increase transmission of other STIs, such as HIV (two- to four-fold increased risk).[11]

Image from Medscape.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Maternal-fetal transmission

Vertical transmission of genital herpes may occur during childbirth and is an estimated complication in 1 out of every 3200-10,000 live births.[16,17] Neonatal infection can present as skin, eye, and mouth disease (shown); central nervous system disease; or disseminated disease. Symptoms range from localized vesicular eruptions to multisystem organ failure and death.[14]

Image from GalliasM | Wikimedia Commons.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Human Papillomavirus

Epidemiology and presentation

The above image demonstrates throat warts resulting from human papillomavirus (HPV) infection.

HPV infection is the most common STI in the United States.[18] Globally, HPV affects hundreds of millions of people, with an estimated prevalence of 10% of all women.[19] It has been estimated as well that at least 80% of sexually active women and men are exposed to HPV at least once in their lifetime. However, speculation has also been made that almost all sexually active adults have been infected with HPV, a discrepancy that may result from the fact that HPV infections can resolve on their own and therefore may be missed despite routine testing.[18]

As a result of some HPV infections, male and female adolescents, as well as adults, can develop benign and malignant neoplasms, including condylomata acuminata, bowenoid papulosis, cervical cancer, and some anal cancers.[18,19] The most common oncogenic strains of HPV are 16 and 18.[19-21]

Image from Wikimedia Commons.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Small condylomata on the scrotum are shown above.

Subclinical infection is common in HPV infection. However, a classic presentation of the disorder typically involves the appearance of warts in the external genitalia, perineum, and/or perianal area, as well as in the adjacent areas of skin.[20,21] Lesions may be just a few millimeters in size or large, cauliflower-like tumors several centimeters in size.[20] They may be flesh colored, pink, brown, or white and may appear macerated in the moist mucosal area of the genitalia (versus the keratotic lesions seen in other areas).

Image courtesy of Shaher Theeb, MD | Medscape Consult.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

This image demonstrates an unusual presentation of HPV in a 23-month-old boy who presented with perianal warts that had been increasing in number since he was 8 months old.

Image from Sol Silverman, Jr, DDS | the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Oral human papillomavirus

The same types of HPV that can infect the genital area can lead to warts in the mouth and throat (shown). If the infecting strain of HPV is considered high risk, the warts may progress to cancer of the head and/or neck.[19]

Approximately 10% of men and 3.6% of women have oral HPV.[22] The presence of HPV-16 in the oral cavity has been associated with oropharyngeal cancer, and around 1% of those with oral HPV are infected with this strain. HPV is estimated to cause approximately 12,885 oropharyngeal cancers yearly.[19,22,23]

Intraoral eruptions have a similar cauliflower appearance to venereal warts and typically develop on nonkeratinized mucosa. Oral-genital intercourse is the means by which genital HPV leads to oral HPV.

Image courtesy of Rose Yin Geist | Medscape.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Vaccination

The above image demonstrates a squamous papilloma on the lateral border of the tongue in a patient with HPV.

There are three approved HPV vaccines in the United States, all given in three doses: a bivalent vaccine (Cervarix) that targets HPV-16 and -18 (responsible for 70% of cervical cancers),[20] a quadrivalent vaccine (Gardasil) for HPV types 6 and 11 (responsible for 90% of genital warts) and 16 and 18,[20] and a nine-valent vaccine (Gardasil 9) for HPV types 6 and 11 and for oncogenic HPV types 16, 18, 31, 33, 45, 52 and 58.[24] The nine-valent vaccine may prevent about 90% of cervical, vulvar, vaginal, and anal cancers; the additional five HPV types not covered by the vaccines account for about 20% of cervical cancers.[24] The most recent HPV vaccination recommendations can be found at: http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html.[25]

Image from Drs. Gavin Hart and NJ Fiumara | the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Syphilis

Epidemiology and presentation

A rubbery syphilitic ulcer (chancre) with raised edges is shown above.

Syphilis is known as "the great imitator/pretender/imposter," because those who are infected progress through multiple stages of the disease, all of which have a variety of skin and systemic manifestations that can mimic other diseases.[26,27] Syphilis is transmitted via person-to-person contact of sores infected with the spirochete Treponema pallidum.[26] The infection progresses through primary, secondary, latent, and late/tertiary stages if untreated.[26,27] In 2016, there were 88,042 new cases of syphilis, including 27,814 cases of primary and secondary syphilis (the most infectious stages).[26]

The classic lesion of primary syphilis is a painless, rubbery ulcer (chancre) with raised edges, which typically occurs 21 days after inoculation.[26-28] Regional lymphadenopathy may occur. The chancre typically lasts 3 to 6 weeks and may heal faster with treatment.

Although chancres are typically solitary, multiple primary lesions may occur in HIV-infected individuals or as "kissing" lesions on opposing skin surfaces.

Image courtesy of DermNet New Zealand.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

A diffuse papulosquamous eruption is the most common skin manifestation of secondary syphilis (shown above).[29] This typically occurs within weeks to months after the development of the chancre of primary syphilis. The lesions associated with secondary syphilis are usually 1 cm in size; involve the trunk and extremities, as well as the palms and soles; and can range in color from pink or reddish brown to violaceous. The rash may also include mucosal surfaces and characteristically appears as raised, grey to white papules called condyloma lata.[26]

Secondary syphilis results from multiplication the T pallidum spirochetes and their spread to the skin and other tissues within weeks to months after initial inoculation. Systemic symptoms that can be present in secondary syphilis include fever, headache, malaise, anorexia, sore throat, patchy hair loss, myalgias, weight loss, and adenopathy. The kidneys, liver, and joints may also be affected.

Image courtesy of DermNet New Zealand.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Shown above is an example of condyloma lata affecting the umbilicus.

In secondary syphilis, condyloma lata also can occur in moist areas in the groin, inner thighs, armpits, or umbilicus or underneath the breasts.[26,29] In the absence of treatment, the rash will resolve within several weeks but may recur during the following two years of disease progression.[30]

Image from Medscape.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Shown is another example of a rash due to secondary syphilis.

Image from Susan Lindsley | the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

The presence of lesions on the palms and soles helps to distinguish secondary syphilis from other papulosquamous eruptions, such as guttate psoriasis, pityriasis rosea, sarcoidosis, and lichen planus. The classic "copper penny" lesions of syphilis are reddish brown, scaly papules on the palms (shown) and soles.[26] However, while the presence of the classic palmar/plantar rash can be helpful, secondary syphilis often occurs without this characteristic finding.

Lesions of secondary syphilis are highly contagious, and therefore a high index of suspicion is necessary to successfully make a diagnosis, initiate treatment, and prevent further transmission.

Latent syphilis follows the disappearance of primary and secondary syphilis symptoms (early latent: infection ≤1 year ago; late latent: infection >1 year ago).[26,29] In this stage, the infection is asymptomatic; however, serologic tests are still positive. If untreated, the infection will eventually progress to late or tertiary syphilis.

Image from DoubleVision | Science Source.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Late syphilis

Late syphilis encompasses cardiovascular syphilis (especially aortitis), gummatous syphilis, and neurosyphilis (specifically tabes dorsalis and general paresis). Tertiary syphilis specifically refers to either cardiovascular or gummatous syphilis.[31]

Gummatous syphilis (shown) is very uncommon and describes a granulomatous reaction occurring anywhere, including in the skin, bones, or internal organs. Cardiovascular syphilis typically causes vasculitis in the vasa vasorum, leading to weakening of the wall of the aortic root. Inflammation of the ascending thoracic aorta can result in aortic dilation and aortic regurgitation.[26] The onset typically occurs over a long period of time and can be difficult to detect as patients typically present with an asymptomatic murmur.[31]

Neurosyphilis is typically classified as either early neurosyphilis or late neurosyphilis. Early neurosyphilis encompasses an asymptomatic state, as well as syphilitic meningitis, meningovascular syphilis, and syphilis involving the eyes and ears.[27] Late neurosyphilis encompasses tabes dorsalis and general paresis.

Image from J Pledger | the CDC | Wikimedia Commons.

31 Signs of Sexually Transmitted Infections

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Gummatous syphilis

Gummatous syphilis is very uncommon and typically presents in immunocompromised HIV-infected individuals. Gummas normally occur in the skin and bones; however, they may also involve the internal organs. They appear as ulcers or granulomatous lesions (shown) with a round, irregular shape.[30]

Image from Susan Lindsley, VD | the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Congenital syphilis

Interstitial keratitis, a complication of late-stage congenital syphilis, is shown above.

Rates of congenital syphilis fluctuated between 8 and 12 cases per 100,000 live births between the years 2005 and 2015.[1,32] More than 600 cases of congenital syphilis were reported in 2016, resulting in more than 40 deaths[1].

Sixty to 90% of neonates with congenital syphilis are asymptomatic at birth and, if left untreated, are vulnerable to various complications, including death.[26] Early and late stages are differentiated by age of onset of clinical manifestations. The onset of early stage congenital syphilis is within 2 years of age, in contrast to late-stage congenital syphilis, which presents after this 2-year timeframe.[33] The most common findings among symptomatic infants at birth include hepatomegaly, jaundice, nasal discharge, generalized lymphadenopathy, skeletal abnormalities, and rash.[33]

The manifestations of late-stage syphilis are typically the result of chronic scarring and persistent inflammation from earlier infection. In late-stage congenital syphilis, corneal connective tissue inflammation causes interstitial keratitis, leading to a diffuse stromal haze (shown) and blindness.[34]

Image from Susan Lindsley | the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Other late-stage congenital syphilis complications include frontal bossing, saddle nose, short maxilla, sensorineural hearing loss, paroxysmal cold hemoglobinuria, mulberry molars, notched Hutchinson incisors (shown), gummas, intellectual disability and/or hydrocephalus, and anterior bowing of the shins ("saber shins").[33]

To prevent the transmission of syphilis to newborns, pregnant women should be screened for syphilis at entry into prenatal care. Women at high risk or who live in communities with a high prevalence of congenital syphilis should also be screened at 28 weeks and again at delivery.[32]

Image from Dr. Norman Cole | the CDC.

31 Signs of Sexually Transmitted Infections

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Diagnosis and treatment

A newborn displaying signs of congenital syphilis is shown.

The gold standard for the diagnosis of syphilis is direct visualization with darkfield microscopy; however this approach is rarely used today. Instead, there are two types of blood tests available to diagnose syphilis: nontreponemal and treponemal tests. Nontreponemal tests are nonspecific and have traditionally been used for initial screening due to low cost and ease of testing.

Any person with a reactive nontreponemal test should receive a follow-up treponemal test to confirm diagnosis. Penicillin is the treatment of choice for all stages of syphilis.[26,29,33]

Image from Dr. P. Marazzi | Science Source.

31 Signs of Sexually Transmitted Infections

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Molluscum Contagiosum

Molluscum contagiosum is a common, self-limited viral skin infection caused by a poxvirus that is spread via skin-to-skin contact.[35] It is a common finding on nongenital skin in the pediatric population. In adults, however, it can be an STI. The typical lesion is an umbilicated, dome-shaped, flesh-colored or pink papule (shown) that may persist for 6 months or longer. In immunocompetent patients, lesions usually occur locally and spontaneously resolve within months.[35,36]

First-line therapy typically involves physical destruction with substances such as liquid nitrogen, cantharidin, salicylic acid, podophyllotoxin and trichloroacetic acid.[35] Imiquimod, an immune-response modulator, is also sometimes used, as is physical removal (curettage, manual extrusion).

Image from the CDC.

31 Signs of Sexually Transmitted Infections

Dina Strachan, MD | October 31, 2018 | Contributor Information

Chancroid

Epidemiology

Chancroid is caused by the gram-negative bacterium Haemophilus ducreyi,[37] which is seen as a "school of fish," "railroad tracks," (shown) or "fingerprints" (parallel rows) on Gram stain.[38] Although endemic in many developing countries, chancroid is increasingly uncommon in the industrialized world and requires networks with high sex partner change rates (ie, sex work) to be maintained.[37] There were only seven cases of chancroid in the United States reported to the CDC in 2016. It is unclear if the incidence of chancroid has decreased to such low numbers or if this represents lack of testing. Men are three times more likely to be infected than women, although it is not clear if this is a true discrepancy or a result of ease of diagnosis in males.[37,38]

Image from Dr. Pirozzi.| the CDC.

31 Signs of Sexually Transmitted Infections

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Presentation

Unlike 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.[37] Inguinal lymphadenitis may also occur, and involved nodes may undergo liquefaction and present as painful, fluctuant buboes.[38] Typically, there are no systemic manifestations associated with the infection.

Image from J Pledger | the CDC.

31 Signs of Sexually Transmitted Infections

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Diagnosis and treatment

Tender, unilateral lymph node involvement may be present in chancroid (shown).[39]

Diagnosis of chancroid requires the identification of the pathogen H ducreyi on culture media that is typically not available from commercial sources. There are no polymerase chain reaction (PCR) tests approved by the US Food and Drug Administration (FDA) for the bacteria (although there are a few laboratories that offer PCR testing). Therefore, the diagnosis is typically made clinically when there are multiple painful ulcers and regional lymphadenopathy and when syphilis and HSV infection have been ruled out.[40]

Although the infection can be cleared with short courses of azithromycin, ceftriaxone, erythromycin, or ciprofloxacin, buboes should be drained either via needle aspiration or preferably with incision and drainage.[39,40] Within 3 days of therapy, symptoms should improve.

Chancroid infection is a risk factor for both acquiring and transmitting HIV; coinfection with syphilis may also occur. Therefore, screening for these diseases as well as other STIs is important.[39,40]

Image from Dr Tabua, Chief Medical Officer, and Joe Miller; Port Moresby, Papua, New Guinea | the CDC.

31 Signs of Sexually Transmitted Infections

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Granuloma Inguinale

An ulcerated lesion in granuloma inguinale is shown above.

Granuloma inguinale, or donovanosis, is a slowly progressive genital ulcer disease caused by the facultative intracellular gram-negative bacterium Klebsiella granulomatis. The disease is rare in the United States but is endemic in India, Papua New Guinea, the Caribbean, central Australia, and southern Africa.[41,42]

Granuloma inguinale is thought to require repeat exposure for clinical infection to occur, and while it is primarily transmitted sexually, it can be passed on through nonsexual contact.[43]

Lesions typically appear as papules or nodules, usually in the genital region, that ulcerate and evolve into painless, beefy red ulcers with raised edges (shown). The lesions are typically highly vascularized and tend to bleed, and bacterial superinfection may occur. Lesions are commonly associated with pseudobuboes, due to granulomatous involvement of the subcutaneous tissue.[43]

Diagnosis requires visualization of dark-staining Donovan bodies from a biopsy or tissue sample; there are currently no FDA-approved molecular tests to detect the pathogen.[42]

Prolonged treatment with at least three weeks of azithromycin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, or erythromycin therapy is required, and even after effective therapy, relapse may occur within 6-18 months.[42]

Image from Dr Tabua, Chief Medical Officer, and Joe Miller; Port Moresby, Papua, New Guinea | the CDC.

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Disseminated disease

The image shows a case of disseminated donovanosis of the ankle.

Severe cases of granuloma inguinale may result in lymphedema and, in rare cases, hematogenous dissemination to the spleen, lungs, liver, bones, and orbits.[43] If untreated, it is not uncommon for lymphatic obstruction to occur, causing elephantiasis of the genitalia.

Image from Wikimedia Commons.

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Chlamydia

Epidemiology and presentation

The above image demonstrates a chlamydia infection of the cervix.

C trachomatis infection is the United States' most frequently reported infectious disorder. (HPV infection is actually more common, but unlike chlamydia, its reporting is not mandated.) Serovars D-K cause genital infection. The characteristic clinical picture of chlamydia frequently overlaps that of gonorrhea, and often the two syndromes cannot be differentiated without diagnostic testing.[44]

Among infected women, the cervix is most commonly affected; however, urethritis is also a common symptom. If left untreated, multiple sequelae can occur, including PID, ectopic pregnancy, and infertility (similar to the complications caused by PID from gonococcal infection). PID caused by C trachomatis is associated with higher rates of infertility, ectopic pregnancy, and chronic pelvic pain than is PID caused by N gonorrhea. Perihepatitis (Fitz-Hugh–Curtis syndrome) may also occur.[44]

Image from Wikimedia Commons.

31 Signs of Sexually Transmitted Infections

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Conjunctivitis due to chlamydia infection is shown above.

If symptomatic, men with chlamydia infection commonly present with urethritis and may also experience a mucoid or watery discharge from the urethra. The discharge is typically scant, in contrast to the copious purulent discharge that typically occurs with gonococcal infection. Epididymitis may occur and typically presents with unilateral testicular pain and tenderness. Prostatitis and proctitis may be present; however, anorectal disease is more commonly caused by the L1-L3 serovars.[44,45]

Men and women can experience conjunctivitis, pharyngitis, and lymphogranuloma venereum as clinical manifestations of chlamydia infection.

Diagnosis and treatment

The diagnostic test of choice is nucleic acid amplification testing (NAAT) of vaginal swabs for women and urine samples for men. Screening of all sexually active women below age 25 is recommended, as is screening of women who are over age 25 and at higher risk for infection.[44]

Treatment with doxycycline or azithromycin is recommended for infected individuals and all of their sex partners.[44]

Image from Herbert L Fred, MD, and Hendrik A van Dijk | Wikimedia Commons.

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Lymphogranuloma Venereum

Lymphogranuloma venereum (LGV) is caused by infection with C trachomatis serotypes L1, L2 (most common), and L3. "Classic" LGV initially presents with a genital ulcer or inflammatory reaction at the site of inoculation, which heals within a few days. The second stage of infection appears 2-6 weeks later, with unilateral (but sometimes bilateral) inguinal and femoral lymphadenopathy, resulting in the "groove" sign (shown).

While rectal LGV may be asymptomatic, individuals exposed through receptive anal sex may present with symptoms and signs of proctocolitis, characterized by bleeding, tenesmus, and fever. Outbreaks of LGV proctitis have been described in the homosexual male population and can be confused with inflammatory bowel disease.

Untreated LGV will progress to a late stage of the disease. Manifestations of this stage are secondary to scarring and include genital elephantiasis, anal fistulae and strictures, infertility, and frozen pelvis.[46] The diagnosis is made clinically and with testing for C trachomatis nucleic acid. Additional molecular procedures can differentiate LGV from non-LGV strains of C trachomatis.

If LGV is the suspected diagnosis, treatment should begin as soon as possible with a 3-week course of doxycycline, which cures the infection and prevents additional damage to tissues.[46]

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Cerebrovascular Accident: A Stroke of Misfortune

troke is the fifth leading cause of death and the leading cause of adult disability in the US. Learn more about recognizing its variable presentation and instituting effective and urgent treatment.Slideshows, October 17, 2018
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Gonorrhea

Gonorrhea is a purulent infection of the mucous membrane surfaces caused by Neisseria gonorrhoeae. N gonorrhoeae is spread by sexual contact or through transmission during childbirth.Medscape Drugs & Diseases, September 07, 2018
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Chlamydia (Chlamydial Genitourinary Infections)

Chlamydial infection can cause disease in many organ systems, including the genitourinary tract. Chlamydiae are small gram-negative obligate intracellular microorganisms that preferentially infect squamocolumnar epithelial cells.Medscape Drugs & Diseases, September 25, 2018
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