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Toronto Notes 2019 Gynecological Infections
Treatment
• firstepisode:acyclovir200mgPOfivetimesdailyx7-10days,orfamciclovir250mgPOTIDx7-10 days or valacyclovir 1g PO BID x 7-10 days
• recurrentepisode:
■ acyclovir 400 mg PO TID x 5 days, valacylovir 1 g PO OD x 5 days or famciclovir 250 mg PO BID x
5 days
• dailysuppressivetherapy
■ consider for >6 recurrences per yr or recurrence every 2 mo
■ acyclovir 400 mg PO bid or valacyclovir 500 mg PO OD or valacyclovir 1 g PO OD or famciclovir
250 mg PO bid
• severedisease:IVacyclovir5-10mg/kgIVq8hx2-7doruntilclinicalimprovementobservedfollowed
by oral antiviral therapy to complete 10 d of therapy total
• educationregardingtransmission:avoidsexualcontactfromonsetofprodromeuntillesionshave
cleared, use barrier contraception
SYPHILIS Etiology
• Treponemapallidum
Classifications
• primarysyphilis
■ 3-4 wk after exposure
■ painless chancre on vulva, vagina, or cervix
■ painless inguinal lymphadenopathy
■ serological tests usually negative, local infection only
• secondarysyphilis(canresolvespontaneously)
■ 2-6 mo after initial infection
■ nonspecific symptoms: malaise, anorexia, headache, diffuse lymphadenopathy ■ generalized maculopapular rash: palms, soles, trunk, limbs
■ condylomata lata: anogenital, broad-based fleshy grey lesions
■ serological tests usually positive
• latentsyphilis
■ no clinical manifestations; detected by serology only
• tertiarysyphilis
■ may involve any organ system
■ neurological: tabes dorsalis, general paresis
■ cardiovascular: aortic aneurysm, dilated aortic root
■ vulvar gumma: nodules that enlarge, ulcerate, and become necrotic (rare)
• congenitalsyphilis
■ may cause fetal anomalies, stillbirths, or neonatal death
Investigations
• aspirationofulcerserumornode
• darkfieldmicroscopy(mostsensitiveandspecificdiagnostictestforsyphilis)–lookforspirochetes
• non-treponemalscreeningtests(VDRL,RPR);non-reactiveaftertreatment,canbepositivewithother
conditions
• specificanti-treponemalantibodytests(FTA-ABS,MHA-TP,TP-PA)
■ confirmatory tests; remain reactive for life (even after adequate treatment)
Treatment
• reportabledisease,partnersshouldbereferredfortreatment
• treatmentofprimary,secondary,latentsyphilisof<1yrduration
■ benzathinepenicillinG2.4millionunitsIMsingledose • treatmentoflatentsyphilisof>1yrduration
■ benzathinepenicillinG2.4millionunitsIMq1wkx3wk • treatmentofneurosyphilis
■ IVaqueouspenicillinG3-4millionunitsIMq4hx10-14d • screening
■ high risk groups
■ in pregnancy (see Obstetrics, Table Infections During Pregnancy, OB29)
Complications
• ifuntreated,1/3willexperiencelatecomplications
HIV
• seeInfectiousDiseases,ID27
Gynecology GY29
Epidemiology of Genital Ulcers
HSV 70-80% 1o Syphilis 5% Chancroid <1% (Haemophilus ducreyi)