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Image from Dr. Lance Liotta Laboratory | Wikimedia Commons.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

The above Pap smear reveals Chlamydia trachomatis, the bacterium that causes chlamydia, in cellular vacuoles.

Sexually transmitted infections (STIs) include some of the most common infectious diseases affecting Americans, and despite awareness campaigns, their incidence continues to rise.[1-3] There were more than 2.4 million cases of chlamydia, gonorrhea, and syphilis reported to the Centers for Disease Control and Prevention (CDC) in 2018. The majority of these cases were chlamydia infections, which, at 1.8 million, had increased 19% since 2014.[1]

The CDC estimates that there are 19 million new STIs in the United States each year, with persons aged 15-24 years accounting for 50% of new infections.[1] This does not include cases of STIs that go undiagnosed or unreported.

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

Image from Dr. P. Marazzi | Science Source.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

Gonorrhea

Epidemiology and presentation

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

Gonorrhea, colloquially referred to as "the clap," was responsible for a reported 583,407 STI cases in the United States in 2018.[1,4] It is estimated that a similar number of unreported cases also exist, with the total number perhaps reaching over 1 million annually.[1,4]

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]

While genital infections are the most common manifestation of gonorrhea, asymptomatic cases or nonspecific symptoms that may mimic other bladder or vaginal infections are frequent. 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 men and women; symptoms include, but are not limited to, rectal pain, painful bowel movements, discharge, soreness, and bleeding.

Image from the CDC.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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 preferred and is commonly available as a swab or urine test. Any assessment for gonorrhea should concurrently test for chlamydia, as coinfection is common.

Globally, increasing antibiotic resistance poses a rising threat to the treatment of gonorrhea. The cephalosporins (ceftriaxone or cefixime) are currently first-line therapeutic agents, although in the United States, the dual therapy approach was adopted in 2010, with the CDC adding azithromycin (or doxycycline) to the regimen to shield ceftriaxone from resistance and to ensure that patients are also covered for chlamydia.[7] This regimen is recommended even if testing for chlamydia is negative.

Image courtesy of Medscape.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

Complications

Thin adhesions (above), 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, the 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 findings.[6,8] Prompt diagnosis and treatment is critical, as PID can cause long-term adverse sequelae, including 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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

Maternal-fetal transmission

Gonococcal infection during pregnancy has been associated with premature rupture of membranes (PROM), chorioamnionitis, low birth weight, and spontaneous abortion. Transmission of gonorrhea during the birthing process commonly presents days later as a purulent conjunctivitis in the newborn (ophthalmia neonatorum, shown).[1,7]

Ophthalmia neonatorum can cause purulent conjunctivitis with swelling of the eyelids, and if not treated, further ophthalmic complications such as corneal ulceration, perforation, and blindness can occur.[9] Lack of treatment can lead to systemic infections, including sepsis and meningitis.

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

Image from J Pledger | the CDC.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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 additional STIs, including human immunodeficiency virus (HIV) infection.

Image from Dr Wiesner | the CDC.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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, studies have demonstrated that HSV-1 also commonly causes genital infections.[11-13]

Approximately 65% and 25% of the United States population is seropositive for HSV-1 and HSV-2, respectively, by the fourth decade of life, with women being infected more frequently with HSV-2 than men.[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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

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

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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

Maternal-fetal transmission

Vertical transmission of genital herpes may occur during childbirth and is a complication in an estimated 1 out of every 3,200-10,000 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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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% in all women.[19] Moreover, it is a known cause of cervical cancer, the fourth most common cause of cancer in women. It is estimated that 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, some anal cancers, and, as mentioned, cervical cancer.[18,19] The most common oncogenic strains of HPV are 16 and 18.[19-21]

Image from Wikimedia Commons.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

This image demonstrates an unusual manifestation 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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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 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 (about 1% of cases) in the oral cavity has been associated with oropharyngeal cancer, with HPV being estimated to cause around 12,885 oropharyngeal cancers annually.[19,22,23]

Intraoral eruptions have a cauliflower appearance similar to that of 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.

Signs of 9 Sexually Transmitted Diseases

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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, 11 (responsible for 90% of genital warts),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 (with a Swedish study published in October 2020 indicating that the quadrivalent vaccine also can reduce the incidence of cervical cancer); the additional five HPV types not covered by the vaccines account for about 20% of cervical cancers.[24][25] The most recent HPV vaccination recommendations can be found at: https://www.cdc.gov/vaccines/vpd/hpv/index.html.[26]

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

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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.[27,28] Syphilis is transmitted via person-to-person contact of sores infected with the spirochete Treponema pallidum.[27] If untreated, the infection progresses through primary, secondary, latent, and late/tertiary stages.[27,28] Accounting for all such stages, there were 115,045 cases of syphilis newly diagnosed in 2018, including 35,063 cases of primary and secondary syphilis (the most infectious stages) and 1,306 cases of congenital syphilis.[27]

The classic lesion of primary syphilis is a painless, rubbery ulcer (chancre) with raised edges, which typically occurs 21 days after inoculation.[27-29] Regional lymphadenopathy may occur. The chancre typically lasts 3-6 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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

A diffuse papulosquamous eruption (shown above) is the most common skin manifestation of secondary syphilis.[30] 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, characteristically appearing as raised, gray to white papules called condyloma lata.[27]

Secondary syphilis results from multiplication of 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.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

An example of condyloma lata affecting the umbilicus is shown above.

In secondary syphilis, condyloma lata can also occur in moist areas in the groin, inner thighs, armpits, or umbilicus or underneath the breasts.[27,30] In the absence of treatment, the rash will resolve within several weeks but may recur during the subsequent 2 years of disease progression.[31]

Image from Medscape.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | Contributor Information

Another example of a rash due to secondary syphilis is shown.

Image from Susan Lindsley | the CDC.

Signs of 9 Sexually Transmitted Diseases

Dina Strachan, MD | October 7, 2020 | 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.[27] 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).[27,30] 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.

Signs of 9 Sexually Transmitted Diseases

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Late syphilis

Late syphilis encompasses cardiovascular syphilis (especially aortitis), gummatous syphilis, and neurosyphilis. Tertiary syphilis specifically refers to either cardiovascular or gummatous syphilis.[32]

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.[27] The onset typically occurs over a long period of time and can be difficult to detect, as patients typically present with an asymptomatic murmur.[32]

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.[28] Late neurosyphilis encompasses tabes dorsalis and general paresis.

Image from J Pledger | the CDC | Wikimedia Commons.

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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.[31]

Image from Susan Lindsley, VD | the CDC.

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Congenital syphilis

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

Rates of congenital syphilis have continued to increase over the past decade, rising to 33 cases per 100,000 live births in 2018.[1,2,33] More than 1,300 cases of congenital syphilis were reported in 2018 (up 40% from 2017).[1,2]

Sixty to 90% of neonates with congenital syphilis are asymptomatic at birth and, if left untreated, are vulnerable to serious health complications, including death.[27] 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 time frame.[34] The most common findings among symptomatic infants at birth include rash, nasal discharge, jaundice, generalized lymphadenopathy, hepatomegaly, and skeletal abnormalities.[34]

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.[35]

Image from Susan Lindsley | the CDC.

Signs of 9 Sexually Transmitted Diseases

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Other complications occurring in late-stage congenital syphilis 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").[34]

To prevent the transmission of syphilis to newborns, pregnant women should be screened for syphilis early in pregnancy. 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.[33]

Image from Dr. Norman Cole | the CDC.

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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 remains the treatment of choice for all stages of syphilis.[27,30,34]

Image from Dr. P. Marazzi | Science Source.

Signs of 9 Sexually Transmitted Diseases

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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.[36] 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, well-demarcated, 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.[36,37]

First-line therapy typically involves physical destruction with substances such as liquid nitrogen, cantharidin, salicylic acid, podophyllotoxin, and trichloroacetic acid.[36] Imiquimod, an immune-response modulator, is also sometimes used, as is physical removal (curettage, manual extrusion).

Image from the CDC.

Signs of 9 Sexually Transmitted Diseases

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Chancroid

Epidemiology

Chancroid is caused by the gram-negative bacterium Haemophilus ducreyi,[38] which is seen as a "school of fish," "railroad tracks," (shown) or "fingerprints" (parallel rows) on Gram stain.[39] 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/trafficking) to be maintained.[38] There were only three cases of chancroid in the United States reported to the CDC in 2018. 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.[38-40]

Image from Dr. Pirozzi.| the CDC.

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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.[38] Inguinal lymphadenitis may also occur, and involved nodes may undergo liquefaction and present as painful, fluctuant buboes.[39] Typically, there are no systemic manifestations associated with the infection.

Image from J Pledger | the CDC.

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Diagnosis and treatment

Tender, unilateral lymph node involvement may be present in chancroid (shown).[41]

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 commonly made clinically when there are multiple painful ulcers and regional lymphadenopathy and when syphilis and HSV infection have been ruled out.[42]

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.[41,42] Within 3 days of therapy, symptoms should improve.

Chancroid infection is a risk factor for acquiring and transmitting HIV. Coinfection with syphilis may also occur. Therefore, screening for these diseases, as well as other STIs, is essential.[41,42]

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

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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.[43,44]

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.[45]

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.[45]

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.[44]

Prolonged treatment with at least 3 weeks of azithromycin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, or erythromycin therapy is required. Even after effective therapy, however, relapses may occur within 6-18 months.[44]

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.[45] 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, with 1.8 million cases reported in 2018.[1] (HPV infection is more common, but unlike with chlamydia, reporting is not mandated.) Serovars D-K cause genital infections. The characteristic clinical picture of chlamydia frequently overlaps that of gonorrhea, and often the two diseases cannot be differentiated without diagnostic testing.[46]

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. 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.[46]

Image from Wikimedia Commons.

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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.[46,47]

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

Diagnosis and treatment

The diagnostic test of choice for chlamydia 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.[46]

Treatment with doxycycline or azithromycin is recommended for infected individuals and their sex partners.[46] Persons who are infected should refrain from sexual activity for 7 days after the completion of their treatment.

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

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Lymphogranuloma Venereum

LGV is caused by infection with C trachomatis serovars 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.[48] The diagnosis is made clinically and through 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.[48]

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Human Papillomavirus (HPV)

Human papillomavirus (HPV) produces epithelial tumors of the skin and mucous membranes.Medscape Drugs & Diseases, Feb 2020
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Molluscum Contagiosum

Molluscum contagiosum virus causes a benign viral infection that is largely (if not exclusively) a disease of humans.Medscape Drugs & Diseases, Sep 2020
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