“Sores or Chancre”

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 “Sores”

•Syphilis
•Genital herpes (HSV-2, HSV-1)
•Others uncommon in the U.S.
•Lymphogranuloma venereum
•Chancroid
•Granuloma inguinale

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Background Info you need to know:
LN and rash terms
Lesions or rashes
•Macule: Small, flat, non-palpable lesion (<1
cm). Non-palpable. Example: Freckle
•Papule: Small, elevated, palpable lesion (<1
cm). Example: Wart
•Nodule: Small bump (<1 cm) with
significant deep component (must be
palpated to appreciate). Example: Enlarged
lymph node
•Vesicle: Small fluid-containing lesion (<1
cm). Example: Blister
•Bulla: Large fluid-containing lesion (> 1
cm). Example: Blister
 Sores

Genital Ulcer Diseases –

Does It Hurt?
•Painless
•Syphilis
•Lymphogranuloma venereum
•Granuloma inguinale (Donvanosis)
•Painful
•Genital herpes simplex
•Chancroid

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Treponema pallidum
•Spirochete
•Corkscrew movement
•Gram negative
•Can not be cultured
•Grown in rabbits
•Can not tolerate environment:
very fragile
•Observed by Darkfield or
Fluorescent microscopy
•Must use special stains: Giemsa
and Fontana
T. pallidum
•Slow replication, 3 week incubation period
•Avoids immune response by coating itself with lipids
•Dying or Dead organisms induce the host response
which is responsible for the tissue damage
Transmission and Pathology

•Penetration:
•Through skin & mucous membranes during sexual contact
•transplacentally
•Dissemination:
•Travels via the lymphatic system to regional lymph nodes where
they replicate and then throughout the body via the blood stream
•Invasion of the CNS can occur during any stage of syphilis
Three stages of Syphilis
Primary Syphilis
•Initial Contact - Skin to Skin
•Replication at site
•Result is a primary chancre from
host response at site of infection
•Hard, shallow, painless ulcer
•Lasts 10 days -3 months
•Spirochetes replicate in LN
•Enlarged inguinal nodes
 Sores
Primary Syphilis
Clinical Manifestations
•Chancre
•Early: macule/papule or a superficial erosion
(surface sore)
•Late: clean based, painless, indurated ulcer
with smooth firm borders
•Unnoticed in 15-30% of patients
•Resolves in 1-5 weeks
•HIGHLY INFECTIOUS
Early Syphilis – Diagnosis and Treatment
Diagnosis:
Clinical presentation
Darkfield
Serology

Treatment:
Penicillin G
 Syphilis Serology-Read Chpt.21
•Non-treponemal tests
•VDRL (Venereal Disease
Research Laboratory) •Treponemal tests
•RPR (Rapid Plasma Reagin)
•TRUST (Toluidine Red
Unheated Serum Test)
•USR (Unheated Serum
Reagin)
•TP-PA (Treponema Pallidum
Particle Agglutination)
•FTA-abs (Fluorescent
Treponemal Antibody -
Absorbed)
•EIA (Enzyme Immunoassay)
 Sores

Secondary Syphilis - Clinical Manifestations

•dissemination of spirochetes and replication in LN,
liver, joints, muscles, skin, & mucous membranes
•Usually 2-8 weeks after chancre appears
•Findings:
•Flu-like symptoms
•rash - whole body (includes palms/soles)
•mucous patches
•condylomata lata (wart-like lesions on gentials)
• HIGHLY INFECTIOUS
•Patchy hair loss
•Sn/Sx resolve in 2-10 weeks
 Sores

Secondary Syphilis Rash

Source: Florida STD/HIV Prevention Training Center

Latent and Tertiary syphilis
Latent 3-30 yrs
•Bacteria are dormant in spleen & liver
Tertiary syphilis
•Approximately 30% of untreated patients progress to the
tertiary stage within 1 to 20 years
•Rare because of the widespread availability and use of
antibiotics
•Manifestations
•Gummatous lesions
•Cardiovascular syphilis
•Immune damage-irreversible
Neurosyphilis
•Occurs when T. pallidum invades the CNS
•May occur at any stage of syphilis
•Can be asymptomatic
•Early neurosyphilis occurs months to few years after
infection
•Clinical manifestations include acute syphilitic meningitis, ocular
involvement
•Late neurosyphilis occurs decades after infection; rare
•Insanity, dementia, paralysis - dementia paralytica
•Co-infection with HIV may allow this to develop in 6 months

Neurosyphilis –
Spirochetes in Neural Tissue
Congenital
Syphilis
•Massive invasion of fetus
•Many stillborn or Die shortly after birth
•Manifestations
•Cutaneous and mucocutaneous lesions
•“Snuffles”, infectious mucoid discharge
•Abnormal bone development
•Saddle nose
•Hutchinson’s incisors (notched)
•Moon teeth (dome shape 1st molar)
•Interstitial keratitis (corneal scarring)
Lymphogranuloma venereum (LGV)
•L1, L2, or L3 serovars of C. trachomatis
•Mainly in Africa, Asia, and South America
•The primary lesion is an ulcerating papule at the site of
infection appearing after 1-4 weeks
•Flu-like symptoms
•Painless ulcer heals but the infection travels to LN and
causes LN swelling
•Abscesses called inguinal buboes discharge through skin
and are painful
•Chronic granulomatous reactions
•Ano or genital elephantiasis
•Treatment: Doxycycline
Donovanosis: Granuloma inguinale or
vernerum
•Klebsiella granulomatis
•G- rods
•More common in subtropics like
Caribbean, New Guinea, India and
central Australia
•Smears of ulcer exudate and stain with
Wright’s stain or Giemsa stain
•Look for Donovan bodies in
mononuclear cells
 Symptoms of Donvanosis
•Symptoms can occur 1 to 12 weeks after
contact.
•Half of infected men and women have
sores in the anal area.
•Small, beefy-red bumps appear on the
genitals or around the anus.
•The bumps turn into raised, beefy-red,
velvety nodules called granulation tissue.
•These granulomas are usually painless, but
they bleed easily if injured.
•The disease slowly spreads and destroys
Treatment: Doxycycline
genital tissue.
•The genitals and the skin around them lose
Herpes simplex viruses
Herpes simplex virus type 1
•Traditionally associated with cold sores/fever
blisters
•Latent infection; virus persists in nerve tissue
HSV-1-replication
•HSV infects mucosal
epithelial cells resulting in
replication.
•Virus enters innervating
sensory neurons, and
nucleocapsids are
transported to the
neuronal cell body.
•The viral DNA is released
into the neuronal nucleus
and circularizes.
•Circular viral DNA persists
in the neuronal cell
nucleus, and the latency-
HSV-2
Herpes Simplex Virus 2: Genital Herpes
Most people are Asymptomatic!
If symptomatic:
•3-7 days after infection, a lesion
occurs and develops into a painful
shallow ulcer
•LN become swollen and in some
fever, malaise, and headaches
•2 weeks for ulcer to heal but the
virus has traveled to the dorsal root
ganglion neurons establishing a
latent infection
•75% chance of transmission during
active stage
 Sores
Genital Herpes Simplex - Clinical Manifestations
•Transmission through direct contact – usually during
asymptomatic shedding!
•Recurrence a potential
HSV: Diagnosis and Treatment
Diagnosis:
PCR
Culture
Serology (Type-specific; Western blot)

Treatment:
Acyclovir
Valacyclovir
Famciclovir
Chancroid Chancroid ulcers

•Haemophilus ducreyi
•Painful genital ulcers
•Lymphadenitis
•Differs from syphilis by pain
•Similar to herpes but larger and more
ragged Auto-inoculation produces “kissing
•Confused with Donovanosis ulcers”
•Most common genital ulcer in Asia Scarring during healing may
and Africa produce a Saxophone penis
•There is a dense inflammatory
exudate with PMNs
•Erythromycin is the most common
treatment
Human Papillomavirus
(commonly called Genital Warts)
•HPV Types 6,11,12,16,18,31 are
sexually transmitted
•Incubation Period: 3 weeks—9
months
•HPV infection is causally
associated with cervical cancer
and probably other anal, penile,
vulvar, vaginal cancers
•Over 99% of cervical cancers
have HPV DNA detected within
the tumor
 HPV
•Transmission: skin-to-skin contact
•High-risk (16, 18 etc) vs low-risk (6, 11 etc) types
•Low-risk types: genital warts
•High-risk HPV infection is causally associated with cervical cancer
and other anogenital squamous cell cancers (e.g. anal, penile,
vulvar, vaginal)

•Diagnosis: Clinical exam, cytology, nucleic acid

amplification methods (in conjunction with cytology for
high-risk HPV types)
•Treatment: Topical and destructive modalities

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 HPV: Epidemiology
•Among sexually active women*:
•>50% have been infected with one or
more genital types
•15% have current infection
•50-75% of these are high-risk
•1% have genital warts

*Koutsky. Am J Med 1997; Koutsky et al. Sex Trans Dis 1999. Svare et al JID 1997, Wideroff et al JID 1996;
*#Ho et al. NEJM. 1998
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Common Symptoms of Genital Warts
•The symptoms may include
single or multiple fleshy
growths around the penis,
vagina, anus, urethra
•They may be small, flat,
flesh-colored bumps or tiny,
cauliflower-like bumps
•They may also include:
itching, bleeding, or burning,
and pain
•The symptoms may recur
from time to time
 HPV
Complications of Genital Warts
(if untreated)
•It may destroy body tissue around the genitals and
anus
•It may lead to cancer of the cervix in women
HPV: Prevention
•Non-vaccine modalities:
•Decrease number of partners
•Condoms
•70% reduction in newly sexually active college women when
partners consistently used condoms
•Shown to reduce incident infection, associated with lower rate
of cervical cancer and associated with regression of HPV-related
cervical and penile lesions
•Microbicides
•Treatment of warts
 HPV Vaccines - Females

CervarixTM – GSK
•HPV 16 and 18
•0, 1, 6mo dosing
•Females 10-25yrs
•Approved 10/09 GiardasilTM - Merck
•HPV types 6,11,16,18
•0, 2, 6mo dosing
•Females 9-26yrs
•Approved 6/06

Efficacy approximately 100% against

precancerous lesions caused by specific
types in the vaccine!
Gardasil for Males
•Initial study demonstrated 90+% efficacy for
preventing external lesions caused by HPV types 6,
11, 16 and 18 in men 16-26y
•FDA approved (10/09) for males 9-26 for
prevention of genital warts
Gardasil for Anal Cancer Prevention

•HPV associated with approximately 90% of anal

cancer
•Vaccine approved for new indication December 22,
2010
•Males and females 9-26 years of age
•Prevention of anal cancer and associated
precancerous lesions caused by HPV types 6, 11, 16,
18
On your own-HIV and Crab Louse