Infective genital ulcer disease:-

كلية الطب ? جامعة بابل المرحلة الخامسة د-نسرين مالك
gynaecology

infective genital ulcer disease:-

i-genital herpes:-genital herpes is a sexual transmitted disease caused by the herpes simplex virus (hsv), of which there are two types. type 1 (hsv-1) usually causes oral herpes, an infection of the lips , mouth, pharynx, and eyes. symptoms are commonly known as cold sores or fever blisters, which associated with burning or itching. herpes simplex virus type 2 (hsv-2) causes most cases of genital herpes infections. however, hsv-1 has increased in frequency and is estimated to be responsible for up to 30 to 40 percent of new genital hsv infections ,as hsv-1 can spread from the mouth to the genitals during oral sex. still, in most cases, genital herpes is caused by the second type of herpes virus (hsv-2) .

types of infections:- the clinical designations of genital hsv infection are: primary, non primary first episode, and recurrent .
primary infection:- refers to infection in a patient without preexisting antibodies to hsv-1 or hsv-2.
non-primary :-first episode infection refers to the acquisition of genital hsv-1 in a patient with preexisting antibodies to hsv-2 or the acquisition of genital hsv-2 in a patient with preexisting antibodies to hsv-1.
recurrent infection :- refers to reactivation of genital hsv in which the hsv type recovered in the lesion is the same type as antibodies in the serum.
each of these types can be either symptomatic (with prodromal symptoms or active genital lesions) or asymptomatic (with subclinical shedding of virus without lesions).

clinical manifestation:-primary herpes presents up to 3 weeks after acquisition. there is usually wide spread involvement of the vulva, vagina and the cervix can also be affected .painful vesicles develop, which coalesce into multiple ulcers. peri-urethral involvement may cause severe pain , and can cause urinary retention this may also be partly due to involvement of the sacral nerves.

diagnosis:-hsv infection can be diagnosed by viral culture, polymerase chain reaction (pcr), direct fluorescent antibody testing.
treatment:-
primary infection :- treatment include analgesia and bathing in salt water. lignocaine gel can be applied to particular sore areas. antiviral treatment stops viral replication, and healing occurs the following week.
although first episode genital hsv is self-limited, we recommend acyclovir therapy (200 mg po five times daily for 5 days) to reduce the duration of active lesions and viral shedding.
recurrent infection :-among non-pregnant patients, antiviral therapy of recurrent episodes is most likely to be effective if started within the first 24 hours when prodromal symptoms arise( like burning). long term suppressive therapy (400 mg po twice daily) this is considerably reduces the frequency of attacks specially for those how have more than 6-8 attacks per year ,although they can still occur and the infection can still be transmitted to partners.
using a latex barrier (condom ) during sex may protect from herpes, but only if it covers the area where the virus is shedding, and should avoid the sex if there is visible sores on the genitalia.

ii-syphilis:-
syphilis is a chronic infection caused by the bacterium treponema pallidum. syphilis is a highly contagious disease spread primarily by sexual activity, including oral and anal sex. occasionally, the disease can be passed to another person through prolonged kissing or close bodily contact. although this disease is spread from sores, the vast majority of those sores go unrecognized. the infected person is often unaware of the disease and unknowingly passes it on to his or her sexual partner. pregnant women with the disease can spread it to their baby. this disease, called congenital syphilis, can cause abnormalities or even death to the child.
syphilis cannot be spread by toilet seats, door knobs, swimming pools, hot tubs, bath tubs, shared clothing, or eating.
the manifestations of disease are occurring in any one individual in three distinct stages over time:-
incubating syphilis:- the median incubation period before clinical manifestations is 21 days (range 3 to 90 days).
primary syphilis :- the first manifestation of syphilis is a papule, which is typically painless, at the site of inoculation. this soon ulcerates to produce the classic chancre(s) of primary syphilis, a 1 to 2 centimeter painless ulcer with a raised, indurated margin that may be genital or extragenital. the ulcer is associated with mild to moderate regional lymphadenopathy that is often bilateral. chancres heal spontaneously within three to six weeks, even in the absence of treatment.

secondary syphilis :- secondary syphilis is a disseminated systemic process that begins six weeks to six months after the appearance of the chancre in approximately 25 percent of untreated patients. a generalized maculopapular skin rash involving the palms and soles and mucous membranes, but usually sparing the face, is characteristic of this stage of the infection. generalized lymphadenopathy accompanies the skin rash. additional clinical features include fever, pharyngitis, weight loss, and large genital lesions called condylomata lata. although spirochetes can be found in the cerebrospinal fluid (csf) of around 40 to 50 percent of patients with early syphilis , neurologic manifestations are rare. the rash of secondary syphilis typically resolves spontaneously within two to six weeks.
latent syphilis :- latent disease is usually subclinical, although clinical relapses may occur. syphilis is rarely transmitted during the latent phase, with the exception of perinatal transmission during pregnancy.
tertiary syphilis:- tertiary syphilis occurs in approximately one-third of untreated patients, but is now rarely seen since most patients are treated either deliberately or inadvertently when receiving penicillin for other indications. tertiary syphilis is characterized by slowly progressive signs and symptoms. clinical manifestations include gumma formation, cardiovascular disease, and/or cns changes (neurosyphilis). such manifestations usually develop 5 to 20 years after the disease has become latent.
diagnosis:-
1-darkfield microscopy:- diagnosis requires the demonstration of morphologically compatible organisms that display the characteristic motility associated with t. pallidum. a positive slide has delicate, corkscrew-shaped organisms with rigid, tightly wound spirals that move via a forward and backward motion with rotation about the longitudinal axis.
2-serologic testing :- two types of serologic testing are available: specific treponemal and non-treponemal antibody tests.
a-treponemal antibody tests (eg, fluorescent treponemal antibody absorption [fta-abs] test, the microhemagglutination assay for antibodies to treponema pallidum [mha-tp], and the treponema pallidum particle agglutination assay [tppa]) are confirmatory tests that detect antibodies specifically directed at treponemal cellular components. these tests are sensitive and specific, but expensive and correlate poorly with disease activity, since they remain positive despite treatment.
b-nontreponemal antibody tests (eg, venereal disease research laboratory [vdrl] test and the rapid plasma reagin [rpr] test) are performed on serum and used as the screening test for syphilis in most settings.
3-cerebrospinal fluid examination :- csf examination is essential if there is any clinical evidence
to suggest neurosyphilis.


treatment:-
penicillin is the gold standard for the treatment of syphilis in both pregnant and non pregnant individuals. procaine penicillin 1.2 million units daily , intramuscularly ,for 12 days.or benzathine penicillin 2.4 mu by intramuscular injection, repeated after 7 days.
penicillin allergy :- non pregnant women with a history of penicillin allergy may be treated with alternative antibioticseg, erythromycin (500 mg four times per day for 14 das), or tetracycline(100 mg twice per day for 14 days) , there is lack sufficient data regarding efficacy of, ceftriaxone and azithromycin therefore, they are not recommended . the only satisfactory treatment for penicillin-allergic pregnant patients with syphilis is desensitization followed by penicillin therapy,because the tetracycline is contraindicated, and the erythromycin is not transfer through the placenta and therefore it can not treat the affected fetus.
if the infection have been present for more than 1 year , treatment is extended to 21 days for penicillin regimens and 28 days for oral regimens.

iii-tropical genital ulcer disease:
1-lymphogranuloma venereum:- lymphogranuloma venereum (lgv) is an uncommon sexually transmitted disease (std) caused by chlamydia trachomatis serovars (l1-l3). lgv is endemic in certain areas of africa, southeast asia, india, the caribbean, and south america.in the early stages there is often a small superficial ulcer that can slowly increase in size but often goes unnoticed, more obvious are the enlarged nodes, which become compressed by the inguinal ligament leading to groove sign. the nodes can become matted together and discharging pus. the diagnosis can be confirmed serologically by a complement fixation test.
the complete treatment of patients with lgv includes appropriate antimicrobial coverage and drainage of infected buboes.the recommended medical treatment for lgv involves one of the following antibiotic regimens:doxycycline 100 mg orally twice daily for 21 days, or erythromycin base 500 mg orally four times per day for 21 days.
2-chancroid:-chanchroid is an infection caused by haemophilus ducreyi, which is a fastidious gram-negative coccobacillus bacteria.the chancroid is sexually transmitted disease.
it starts with small shallow ulcers, which are usually multiple and painful. the edges are irregular and there is localized lymphadenopathy.the sores may persist for several months and the glands can suppurate through the skin, diagnosis by culture .treatment is by.doxycyclin, azithromycin, and a third-generation cephalosporin like ceftriaxone.
3-granuloma inguinale(donovanosis):- granuloma inguinale (also known as donovanosis) is a bacterial disease caused by klebsiella granulomatis characterized by ulcerative genital lesions. it is endemic in india.it is usually a slowly progressive infection starting with discrete papules on the skin or vulva which can enlarge to form beefy red painful ulcers. these spread slowly around the genital and perineum. as they heal, fibrosis can develop , which may lead to lymphoedema and elephantiasis.diagnosis is confirmed by biopsy or crush preparation in which donovan bodies are visible. treatment is by doxycycline 100 mg orally twice per day, or azithromycin 1 g orally once per week or ciprofloxacin 750 mg orally twice a day or erythromycin base 500 mg orally four times a day or trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a day. all antibiotic regimens should last for at least 3 weeks and until all lesions have completely healed. normally, the infection will begin to subside within a week of treatment, but the full treatment period must be followed to minimize the possibility of relapse.
other viral infections:-
1-human papilloma virus (hpv):-
human papillomavirus (hpv) causes condyloma acuminata (genital warts) which is the most common sexually transmitted virus in the united states. it infects the epithelial layer (the outer layer) of the skin and mucous membranes. hpv is spread by direct skin-to-skin contact, including sexual intercourse, oral sex, anal sex, or any other contact involving the genital area (eg, hand to genital contact). it is not possible to become infected with hpv by touching a toilet seat.
there are many different types of hpv. some types can cause health problems including genital warts caused by hpv type 6-11 viruses that have little oncogenic potential, or cause cancers as a result of infection with hpv type 16-18. but there are vaccines that can stop these health problems from happening.
routine screening for women aged 21 to 65 years old by doing pap can result in reduction of cervical cancer.
symptomes:- rarely, women with genital warts have itching, burning, or tenderness in the genital area, depending upon the number of warts and their location. however, most women with warts do not have any symptoms at all. warts appear skin-colored or pink, and may be smooth and flat or raised with a rough texture. they are usually located on the labia or at the opening of the vagina.
treatment :-cryotherapy, or application of podophyllin once or twice a week for up to 6 weeks. but this drug is contraindicated during pregnancy.
2-molluscum contagiosum:-this poxvirus produces painless , pearly lesions with a dimple ,up to 5 mm in diameter. these are common in childhood and clear after a few months.adults may acquire infection during sexual intercourse, and the lesions can mistaken for genital wart. treatment is by cryotherapy,or curettage or application of phenol.
3-human immunodeficiency virus (hiv):-
hiv (human immunodeficiency virus) is a virus that attacks the immune system, the body s natural defense system. both the virus and the infection it cause what is called hiv.

pathogenesis:- hiv has several targets including dendritic cells, macrophages, and cd4+ t cells.
target cells hiv-1 most often enters the host through the genital mucosa. the viral envelope protein (glycoprotein (gp)-120) binds to the cd4 molecule on dendritic cells. interstitial dendritic cells are found in cervicovaginal epithelium as well as tonsillar and adenoidal tissue, which may serve as initial target cells in infection transmitted via genital-oral sex .
transmission of hiv during primary infection has been associated with unprotected anal intercourse, the number of sexual contacts, and high rates ofother acute sexually transmitted diseases.vertical transmission occurs in 25-40 per cent of pregnancies if there are no interventions to reduce the risk. the minority of these infection occur during gestation, and the majority of infections occur during parturition.
breast feeding accounts for transmission in up to 15 per cent of pregnancies.

three interventions have been shown to reduce the risk of vertical transmission of hiv:-
1- antiviral medication prescribed during the later half of pregnancy , and to the neonate for 6 weeks.
2-elective c\s.
3- avoidance of breast feeding.
if all three interventions are undertaken the risk of transmission is less than 1 per cent.

clinical manifestations:-a variety of symptoms and signs may be seen in association with acute hiv infection. published series consistently report that the most common findings are fever, lymphadenopathy, sore throat, mucocutaneous lesions, myalgia/arthralgia, diarrhea, headache, nausea/vomiting, and weight loss . none of these findings is specific, but several features, especially the duration of symptoms and the presence of mucocutaneous ulcers, are suggestive of the diagnosis.

laboratory features:- a number of nonspecific laboratory findings are associated with primary hiv infection:-
white blood count :-initially, there is a fall in the total white blood cell count. in one study, for example, the leukocyte count dropingped to a low of 960/µl nine days after the onset of symptoms .thereafter, the total leukocyte count begins to recover due to an expansion of lymphocytes. cd8+ lymphocytes increase at a faster rate than cd4+ t cells, resulting in a persistent inversion of the normal cd4+:cd8+ ratio to less than 1.0.
other :-elevation of liver associated enzymes, mild anemia and thrombocytopenia have all been reported in association with primary hiv infection.

treatment:-antiviral medication are:-
1- nucleoside analogue reverse transcriptase inhibitors, such as zidovudine or didinasine.
2- a non - nucleoside reverse transcriptase inhibitors, such as nevirapine.
3- protease inhibitor , such as nelfinavir.