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Fig. 15.5 Gonococcal ophthalmia neonatorum. From McMillan A, Scott GR.
https://t.me/medicina_free
Sexually transmitted infections: a colour guide. Edinburgh: Churchill Livingstone,
Elsevier Ltd; 2000.
erythromycin (with penicillin for the baby at birth because it crosses the
placenta poorly), or intramuscular ceftriaxone 500 mg daily for 10 days
(2 g daily for late infection/neurosyphilis).
Treatment reactions
Anaphylaxis. Penicillin is a common cause; adrenaline and resuscita-
tion equipment should be immediately to hand (p. 183).
Jarisch Herxheimer reaction. This is an acute febrile reaction that
follows treatment and is characterised by headache, malaise and
myalgia; it resolves within 24 hours. It is common in early syphilis
and rare in late syphilis. Fetal distress or premature labour can occur
in pregnancy. The reaction may also cause worsening of neurological (cerebral artery occlusion) or ophthalmic (uveitis, optic neuritis)
disease, myocardial ischaemia (inammation of the coronary ostia)
and laryngeal stenosis (swelling of a gumma). Prednisolone
40–60 mg daily for 3 days is recommended to prevent the reaction
in patients with these forms of the disease; antibiotic treatment can
be started 24 hours after the rst steroid dose. In high-risk situations
the rst antibiotic dose should be given in hospital.
Procaine reaction. Fear of impending death occurs immediately after
the accidental intravenous injection of procaine penicillin and may
be associated with short-lived hallucinations or ts. Aspiration before
any intramuscular injection is mandatory.
Gonorrhoea
Gonorrhoea is caused by the Gram-negative diplococcus Neisseria
gonorrhoeae and usually involves columnar epithelium in the lower gen-
ital tract, rectum, pharynx and eyes. Transmission is usually the result
of vaginal, anal or oral sex. Gonococcal conjunctivitis may be caused
by accidental infection from contaminated ngers. Untreated mothers
may infect babies during delivery, resulting in ophthalmia neonatorum
(Fig. 15.5).
Clinical features
The incubation period is usually 2–10 days. Infection of the male urethra
causes urethral discharge and dysuria; only a minority are asymptomatic.
The female urethra, paraurethral glands/ducts, Bartholin's glands/ducts
or endocervical canal may be infected, but about 80% of women are
asymptomatic. There may be vaginal discharge or dysuria but these
symptoms may be due to co-existing infections, such as chlamydia
(see below), trichomoniasis or candidiasis. Intermenstrual or post-coital
Sexu al ly tr ansmi tted bacte rial in fecti ons 379
15.9 Complications of delayed therapy in gonorrhoea
Acute prostatitis
Epididymo-orchitis
Bartholin’s gland abscess
Pelvic inammatory disease (may lead to infertility or ectopic pregnancy)
Disseminated gonococcal infection
bleeding suggests involvement of the cervix and lower abdominal/pelvic
pain and dyspareunia suggests that the infection has ascended to the
upper genital tract (PID)
Rectal infection is seen in MSM and in women due either to anal sex
or to contamination from a urogenital site. It is usually asymptomatic but
may present with anal discomfort, discharge or rectal bleeding.
Clinical examination may show no abnormality, but mucopurulent or
purulent urethral discharge may be seen at infected sites. This is often
obvious at the male urethra (p. 372). Discharge may be expressed from
the female urethra, paraurethral ducts or Bartholin's ducts. The cervix
may be inamed, with mucopurulent discharge and contact bleeding.
Proctoscopy may reveal either no abnormality, or clinical evidence of
proctitis (p. 375) such as inamed rectal mucosa and mucopus.
Pharyngeal gonorrhoea is usually symptomless and is largely attributed to receptive orogenital sex. Gonococcal conjunctivitis is an uncommon complication of adults and neonates, presenting with purulent
discharge from the eye(s), severe inammation of the conjunctivae and
oedema of the eyelids, pain and photophobia. Conjunctivitis must be
treated urgently to prevent corneal damage.
Other complications arise if diagnosis or treatment is delayed
(Box 15.9). Disseminated gonococcal infection (DGI) is rare. Symptoms
include arthritis of one or more joints, pustular skin lesions, tenosynovitis
and fever. Gonococcal endocarditis has been described.
Investigations
Gram-negative diplococci may be seen on microscopy of smears from
infected sites (see Fig. 15.1). Pharyngeal smears are not helpful due to
the presence of commensal Neisseria spp., which have the same microscopic appearance. Nucleic acid amplication tests (NAAT) are a widely
used diagnostic test (see Box 15.1), with culture on selective medium in
positive cases for antibiotic sensitivity surveillance. Nucleic acid probes
for specic antibody resistance mutations (e.g. to ciprooxacin) are
increasingly available, with the prospect of whole-genome sequencing
in the near future.
Management of adults
Neisseria gonorrhoeae is a highly adaptable organism and has developed high-level resistance to a range of antibiotics over time, with
frequent changes to recommended antibiotics and dosage. Multi-drugresistant gonorrhoea (MDRGC) has emerged as a signicant concern in
recent years. Current UK treatment recommendations are for a single
1g dose of IM ceftriaxone. Longer courses of antibiotics are required for
complicated infection. NAAT-based antibiotic sensitivity testing available
at the time of diagnosis offers the possibility of selective use of antibiotics
previously rendered unsuitable for blind treatment (see Box 15.10).
The partner(s) of patients with gonorrhoea should be seen as soon
as possible.
Chlamydial infection
Chlamydia is transmitted and presents in a similar way to gonorrhoea.
In women, the cervix and urethra are commonly involved. Infection is
asymptomatic in about 80%, but may cause intermenstrual and/or
post-coital bleeding, dysuria or vaginal discharge. Lower abdominal pain
and dyspareunia are features of PID. Examination may reveal mucopurulent cervicitis, contact bleeding from the cervix, evidence of PID or
no obvious clinical signs.
15
380 S EXU A LLY T R AN S MIT T ED IN F E CT I ON S
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15.10 Treatment of uncomplicated anogenital gonorrhoea
Uncomplicated anogenital or pharyngeal infection
Ceftriaxone 1 g IM as a single dose
Ciprooxacin 500 mg orally as a single dose
1,2
Pregnancy and breastfeeding
Ceftriaxone 1 g IM as a single dose
Spectinomycin 2 g IM stat
3
Disseminated gonorrhoea
Ceftriaxone 1 g IM or IV once daily or
Cefotaxime 1 g IV 3 times daily
Switched to an oral alternative according to sensitivities after 48 hrs
and continued for 7 days
1
Contraindicated in pregnancy and breastfeeding.
(NAAT) or culture-based sensitivity testing shows sensitivity at all sites.
(IM = intramuscular; IV = intravenous)
2
Only where nucleic acid amplication test
3
Not routinely available.
15.11 Treatment of chlamydial infection
Uncomplicated infection
First choice: Doxycycline 100 mg orally twice daily for 7 days
1
Second choice: Azithromycin 1 g orally as a single dose followed by 500 mg once
daily for 2 days
Infection with possible complications (epididymo-orchitis, PID, SARA)
First choice: Doxycycline 100 mg orally twice daily for 14 days
Second choice: Ooxacin 400 mg orally twice daily for 14 days
1
Contraindicated in pregnancy and breastfeeding.
possible organisms.
about rare permanent and disabling side-effects.
(PID = pelvic inammatory disease; SARA = sexually acquired reactive arthritis)
3
Quinolones are now less commonly used rst line because of concerns
2
With additional antibiotics to cover other
2
1
3
Other complications include perihepatitis (Fitz-Hugh–Curtis syndrome,
p. 856), chronic pelvic pain, conjunctivitis and sexually acquired reactive arthritis (SARA) (p. 1035). Perinatal transmission may lead to ophthalmia neonatorum and/or pneumonia in the neonate. The majority of
chlamydial infections clear spontaneously without treatment but others
persist. The individual’s risk of ‘silent’ tubal damage and subsequent
infertility or ectopic pregnancy following asymptomatic chlamydial infection is low, but is a concern because of the high prevalence of chlamydial
infection in the sexually active population.
In men, urethral symptoms are usually milder than those of gonorrhoea
and may be absent in over 50% of cases. Conjunctivitis is also milder
than in gonorrhoea; pharyngitis does not occur, although chlamydia is
detected in pharyngeal samples in a small proportion of individuals. The
incubation period varies from 1 week to a few months. Without treatment, symptoms may resolve but the patient remains infectious for several months. Complications, such as epididymo-orchitis and SARA are
rare. Sexually transmitted pathogens, such as chlamydia or gonococci,
are usually responsible for epididymo-orchitis in men aged less than
35 years, whereas bacteria such as Gram-negative enteric organisms
are more commonly implicated in older men.
Treatments for chlamydia (Box 15.11) are also used for empirical treatment of NGU. Antibiotic resistance has not yet been a signicant issue.
Sexual partners should be traced and may be tested and/or treated epidemiologically depending on circumstances. Technologies supporting
testing, treatment and partner notication for chlamydia include appbased notication systems and electronic treatment vouchers which can
be redeemed at community pharmacies.
Mycoplasma genitalium
Mycoplasma genitalium is strongly associated with NGU (p. 372) and
is implicated in the pathogenesis of PID. Its role in the development of
other STI syndromes is not clear. A very high proportion of M. genita-
lium isolates in the UK are resistant to macrolides. This has led to doxycycline replacing azithromycin as the rst choice empirical treatment of
chlamydial infection and NGU. Where azithromycin is used, the multiple-dose regimen shown in Box 15.11 is preferred over a single dose
because this may be both more effective and reduce the risk of macrolide resistance developing in M. genitalium
Other sexually transmitted bacterial infections
Chancroid, granuloma inguinale and LGV as causes of genital ulcers in
the tropics are described in Box 15.12. LGV now much more commonly
presents as proctitis in MSM, having been acquired in Europe (p. 375).
Sexually transmitted viral infections
Genital herpes simplex
Infection with herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2)
produces a wide spectrum of clinical problems (p. 290), and facilitates
the transmission of untreated HIV. Herpes is usually acquired sexually
(vaginal, anal, orogenital or oro-anal), but perinatal transmission to the
neonate may also occur. Primary infection at the site of HSV entry may
be symptomatic or asymptomatic. HSV then establishes latency in local
sensory ganglia, intermittently reactivating to cause either symptomatic
or asymptomatic recurrences at the same site with viral shedding, during
which transmission may occur. Most transmissions are thought to originate from people unaware of their infection. Although HSV-1 is classically associated with orolabial herpes and HSV-2 with anogenital herpes,
HSV-1 accounts for more than 50% of anogenital infections in the UK.
Clinical features
Symptomatic episodes usually involve the external genitalia with irritable vesicles that soon rupture to form small, tender ulcers which scab
and heal without scarring (Fig. 15.6 and see Fig. 15.3). A symptomatic
episode at the time of acquisition is usually the most severe, but may
occasionally be delayed following asymptomatic primary infection.
Constitutional symptoms such as fever, headache and malaise are common. Complications, such as urinary retention due to autonomic neuropathy, and aseptic meningitis, are occasionally seen. Inguinal lymph
nodes become enlarged and tender, and there may be nerve root pain in
the 2nd and 3rd sacral dermatomes. Lesions at other sites (e.g. urethra,
vagina, cervix, perianal area, anus or rectum) may cause dysuria, urethral
or vaginal discharge, or anal, perianal or rectal pain. First episodes usually heal within 2–4 weeks without treatment; recurrences are similar but
usually milder and of shorter duration than the initial attack
Extragenital lesions may develop at other sites, such as the buttock,
nger or eye, due to auto-inoculation.
HSV-1 and HSV-2 episodes are clinically identical, but recurrences
occur more often in HSV-2 infection and their frequency tends to
decrease more slowly with time. Prodromal symptoms, such as irritation
or burning at the affected site, or neuralgic pain affecting buttocks, legs
or hips often occur prior to a symptomatic recurrence.
Diagnosis
Swabs are taken from vesicular uid or ulcers for detection of HSV-1
and 2 DNA by NAAT. Type-specic antibody tests for HSV-1 and 2 are
available but not routinely used for diagnosis.
Management
First episode
Oral antiviral treatment will shorten the duration of symptoms if started
within 5 days of the beginning of the episode, or while lesions are still
forming. Occasionally, intravenous therapy may be indicated if oral
Sexu al ly tr ansmi tted viral infe ct ions 381
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15.12 Salient features of lymphogranuloma venereum, chancroid and granuloma inguinale (Donovanosis)
Infection and
distribution Organism
Lymphogranuloma venereum (LGV)
E/W Africa, India,
SE Asia, S America,
Caribbean
Chlamydia
trachomatis types
L1, 2, 3
Incubation
period Genital lesion Lymph nodes Diagnosis Management
3–30 days Small, transient,
painless ulcer,
vesicle, papule; often
unnoticed
Tender, usually
unilateral, matted,
suppurative bubo;
inguinal/femoral
nodes involved
Chancroid
Africa, Asia, Central
and S America
Haemophilus
ducreyi (short
Gram-negative
bacillus)
3–10 days Single or multiple
painful ulcers with
ragged undermined
edges
As above but
unilocular,
suppurative bubo;
inguinal nodes
involved in ~50%
Granuloma inguinale
Australia, India,
Caribbean, S Africa,
S America, Papua
New Guinea
Klebsiella
granulomatis
(Donovan bodies)
3–40 days Ulcers or hypertrophic
granulomatous
lesions; usually
4
painless
Initial swelling of
inguinal nodes, then
spread of infection
to form abscess or
ulceration through
adjacent skin
N.B. Partners of patients with LGV, chancroid and granuloma inguinale should be investigated and treated, even if asymptomatic.
1
LGV acquired as a rectal infection in MSM commonly presents as proctitis.
and breastfeeding has not been fully assessed.
(IM = intramuscular; NAAT = nucleic acid amplication test)
4
Mother-to-baby transmission of granuloma inguinale may rarely occur.
2
Doxycycline and ciprooxacin are contraindicated in pregnancy and breastfeeding.
Swab from ulcer
or bubo pus for
Chlamydia, NAAT
with LGV subtypes if
1
positive
Microscopy and
culture of scrapings
from ulcer or pus
from bubo
Microscopy of
cellular material for
intracellular bipolarstaining Donovan
bodies
Doxycycline2 100 mg
twice daily orally for 21
days or
Erythromycin 500mg
orally 4 times daily
Azithromycin3 1 g orally
once or
Ceftriaxone 250mg IM
once or
Ciprooxacin2 500mg
orally twice daily for
3 days
Azithromycin
3
1 g orally
weekly or 500mg orally
daily or
Doxycycline2 100mg
orally twice daily or
Ceftriaxone 1 g IM daily
3
The safety of azithromycin in pregnancy
15
Fig. 15.6 Herpetic ulceration of the vulva. From McMillan A, Scott GR. Sexually
transmitted infections: a colour guide. Edinburgh: Churchill Livingstone, Elsevier Ltd;
2000
therapy is poorly tolerated or aseptic meningitis occurs. Many possible
oral dosage regimens are used, including:
aciclovir 400 mg 3 times daily for 5 days
valaciclovir 500 mg twice daily for 5 days.
Topical and oral analgesia is helpful and patients are advised to use a
warm shower spray to ease urination. Catheterisation via the suprapubic route is occasionally required for urinary retention. Treatment may be
continued for longer than 5 days if new lesions develop.
Recurrent genital herpes
Symptomatic recurrences are usually mild and may require no specic
treatment other than saline bathing, although the psychosexual impact
of herpes stigma in a minority of patients should be considered. For more
severe or prolonged episodes, patient-initiated treatment within 24 hours
of onset, with one of the following oral regimens, should reduce the duration of the recurrence:
aciclovir 800 mg 3 times daily for 2 days
valaciclovir 500 mg twice daily for 5 days.
In a few patients, treatment started at the onset of prodromal symptoms may abort recurrence.
Those with recurrences that are severe and/or frequent may benet
from suppressive therapy. Daily treatment should be given for a minimum
of 1 year before stopping to assess recurrence rate. The rate of decay in
frequency of recurrence is low, so only about 20% of patients will experience signicantly reduced rates. For others, resumption of suppressive therapy is justied. Aciclovir 400 mg twice daily is most commonly
prescribed.
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Management in pregnancy
The risk of disseminated infection is increased in pregnancy, particularly
in the third trimester. A pregnant woman with no previous anogenital
herpes and a partner with a history of HSV infection should be advised
on avoiding acquisition, which may include consistent condom use during pregnancy to reduce genital-to-genital transmission. Antibody testing can identify the type-specic HSV serostatus of a woman and her
partner and inform the advice given. Treatment with aciclovir is usually
offered for genital herpes acquired during pregnancy after appropriate
discussion; although aciclovir is not licensed for use in pregnancy in the
UK, there is considerable clinical evidence to support its safety.
Vaginal delivery is routine in most women with herpes in pregnancy.
Caesarean section is sometimes considered if there is a recurrence at the
beginning of labour, although the risk of neonatal herpes through vaginal
transmission is very low. Caesarean section is often recommended if primary infection occurs after 34 weeks because the risk of viral shedding
in labour is very high and the antibody response to HSV which develops
in the mother and protects the neonate by transplacental transmission
may not have fully developed.
Human papillomavirus and anogenital warts
Human papillomavirus (HPV) subtypes (p. 1091) that preferentially infect
the genital skin and are mainly sexually transmitted include benign genotypes (HPV-6 and 11) causing anogenital warts as well as genotypes
such as 16 and 18, which do not cause genital warts but are associated
with cervical, vulval, penile and anal intra-epithelial neoplasia (CIN, VIN,
PIN and AIN) and the associated invasive cancers, as well as with cancers of the oropharynx. HPV is commonly transmitted through non-penetrative sex so affects individuals from the early years of adolescence
onwards. Asymptomatic infection without any clinical sequelae is usual
with all subtypes and infection with multiple subtypes is common.
Clinical features
Anogenital warts caused by HPV may be single or multiple, exophytic, papular or at. Rarely, a giant condyloma (Buschke–Löwenstein
tumour) develops, with local tissue destruction. Because of the association with intra-epithelial neoplasia, warts with an atypical appearance
should be biopsied. Perianal warts (p. 370) are more common in MSM,
but are also found in women and in heterosexual men. In pregnancy,
warts may dramatically increase in size and number, making treatment
difcult. Rarely, they are large enough to obstruct labour so delivery by
caesarean section is required. Perinatal transmission of HPV occasionally leads to anogenital warts and rarely to laryngeal papillomas in the
neonate.
Management
The use of condoms can help prevent the transmission of HPV to noninfected partners, but as condoms do not cover all of the genital
skin, protection is incomplete. Vaccination against genital HPV infection
is routine in many countries. There are three types of vaccine:
A bivalent vaccine offers protection against HPV types 16 and
18, which account for approximately 75% of cervical cancers in
the UK.
A quadrivalent vaccine offers additional protection against HPV
types 6 and 11, which account for over 90% of genital warts.
A nonavalent vaccine protects against ve additional high-risk types
(31, 33, 45, 52 and 58).
All vaccines have been shown to be highly effective in the prevention
of cervical intra-epithelial neoplasia in young women, and the quadrivalent and nonavalent vaccines have also been demonstrated to be highly
effective in protecting against HPV-associated genital warts. HPV vaccination is usually administered prior to the onset of sexual activity, typically
at age 11–13, in a course of three injections. In the UK, vaccination has
Fig. 15.7 Molluscum contagiosum of the shaft of the penis. From McMillan
A, Scott GR. Sexually transmitted infections: a colour guide. Edinburgh: Churchill
Livingstone, Elsevier Ltd; 2000.
been offered to girls since 2007 (with quadrivalent vaccine from 2012)
and the recommendation was extended to boys from 2020.
Benign anogenital warts sometimes resolve spontaneously without
treatment and in the vast majority of cases are a harmless, if sometimes
distressing, inconvenience. Topical self-administered treatments commonly prescribed for use at home include:
Podophyllotoxin, 0.5% solution or 0.15% cream (contraindicated in
pregnancy)
Imiquimod cream (contraindicated in pregnancy), also used in the
treatment of HPV-associated intra-epithelial neoplasia
Catephen, an extract of the green tea plant, Camellia sinensis
Ablative therapies, usually performed by a clinician, are sometimes
used rst line or for warts that are keratinised, extensive or resistant to
topical treatment.
Cryotherapy using liquid nitrogen to freeze warty tissue often requires
repeated clinic visits, although home cryotherapy is available. It is
one of the few options for treatment of warts in pregnancy.
Hyfrecation – surgical electrofulguration using the heat from an electric
current to destroy tissue – is suitable for external and internal warts.
Surgical removal may be used to excise extensive and/or refractory
warts, especially pedunculated perianal lesions, under local or general anaesthesia.
Molluscum contagiosum
Infection by molluscum contagiosum virus, both sexual and non-sexual,
produces esh-coloured, umbilicated, hemispherical papules usually up
to 5 mm in diameter after an incubation period of 3–12 weeks (Fig. 15.7).
Lesions are often multiple and, once established in an individual, may
spread by auto-inoculation. Infection in childhood is common; many
individuals are immune by adulthood. If not, sexually acquired infection
causes lesions on the genitalia, lower abdomen and upper thighs. The
diagnosis is usually clinical. Typically, lesions persist for several months
before spontaneous resolution occurs. Treatment regimens are therefore
cosmetic; they include cryotherapy, hyfrecation or topical applications of
0.15% podophyllotoxin cream (contraindicated in pregnancy). The hard,
pearly central core of each lesion can be removed using a needle and
results in resolution, but this carries a risk of scarring.
Fu r th e r i n fo r ma t i on 383
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Viral hepatitis
The hepatitis viruses A–D (p. 884) may be sexually transmitted:
Hepatitis A (HAV). Enteric infection may be transmitted through
insertive oro-anal, digital-anal sex or peno-anal sex. Outbreaks of
hepatitis A occur in MSM populations, most recently across Europe
in 2016–18.
Hepatitis B (HBV). Hepatitis B is highly transmissible through all
forms of penetrative sex, including oral sex, and is seen more commonly in groups with higher rates of partner change including sex
workers and MSM, or with partners from endemic areas. Hepatitis D
(HDV) may also be sexually transmitted.
Hepatitis C (HCV). Hepatitis C is much less transmissible through
sex than HBV. Sex involving mucosal trauma (such as anal sex)
carries a higher risk and sexually transmitted HCV is seen more
commonly in MSM, particularly those co-infected with HIV, than in
other populations.
Active immunisation against HAV and HBV should be offered to susceptible people at risk of infection. Many STI clinics offer a combined
HAV and HBV vaccine to all MSM.
Partner notication, for testing and advice on preventing onward
transmission, is offered to all those diagnosed with sexually transmitted
viral hepatitis, with vaccination for HAV and HBV. No active or passive
immunisation is available for protection against HCV but the consistent
use of condoms is likely to protect susceptible partners until the index
patient is able to complete treatment.
Further information
Books and journal articles
Mitchell L, Howe B, Ashley Price D, eds. Oxford handbook of genitourinary
medicine, HIV, and sexual health, 3rd edn. Oxford: Oxford University Press;
2018.
Website
bashh.org/guidelines British Association for Sexual Health and HIV; updates on
treatment of all STIs.
15
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Multiple Choice Questions
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15.1. The preferred treatment for uncomplicated chlamydial infection
has changed from single dose azithromycin to a 7-day course
of doxycycline primarily because of concerns about the
development of antimicrobial resistance in which organism?
A. Chlamydia trachomatis
B. Mycoplasma genitalium
C. Haemophilus ducreyi
D. Treponema pallidum
E. Trichomonas vaginalis
Answer: B.
Rates of macrolide resistance in Mycoplasma genitalium in the UK
are thought to be around 40%, probably driven by the widespread use
of single dose azithromycin for the treatment of chlamydial infection in
sexually active individuals. Treatment of antibiotic resistant M. genitalium
in symptomatic individuals such as men with non-gonococcal urethritis
(NGU) can be difcult. Azithromycin has never been a rst-line treatment
for syphilis in the UK, but resistance does occur in Treponema pallidum.
Azithromycin is a potential treatment for chancroid and resistance in
Haemophilus ducreyi is not currently widely reported.
15.2. A 49-year-old woman who has had two new male partners in the
past 4 weeks presents to her general practitioner with vaginal
discharge having a ‘shy’ smell which is worse after sex. She
has had 3 days of intermenstrual bleeding which is unusual,
but no abdominal or pelvic pain. On examination a thin grey
discharge is seen without evidence of vulvitis. The optimal
management plan is:
A. Empirical treatment for bacterial vaginosis (BV) with
clindamycin cream and a cervical smear test
B. Swabs for NAAT for gonorrhoea and chlamydia and await
results
C. High vaginal swab for microscopy for Trichomonas vaginalis
(TV) and bacterial vaginosis and empirical treatment with oral
metronidazole
D. Swabs for NAAT testing for gonorrhoea, chlamydia and
Trichomonas vaginalis and empirical treatment with oral
metronidazole.
E. Treatment with IM ceftriaxone, oral doxycycline and
metronidazole for possible gonococcal, chlamydial, TV or BV
infection
Answer: D.
The commonest cause of a vaginal discharge with smell is bacterial vaginosis. BV does not cause inammation or cervical bleeding.
Intermenstrual bleeding is common in perimenopausal women. In a
postmenopausal woman it may be a cause for concern but STIs should
be excluded before investigating other causes. STIs have a much higher
prevalence in young people but are seen in older sexually active individuals, particularly those with multiple partners. Both gonorrhoea and
chlamydial infection cause cervicitis so should be excluded. Trichomonas
vaginalis does not usually cause a cervicitis without signicant vaginal
inammation and vulvititis, but should also be considered. NAAT testing
for TV is not universally available but may be possible. Empirical treatment with metronidazole will usually cure both TV and BV. Syndromic
management – giving treatment to cover all possible infections – would
not usually be a preferred approach where testing is available unless
there were symptoms and signs of ascending infection (pelvic inammatory disease).
15.3. A 21-year-old woman presented to a walk-in sexual health clinic
complaining of a painful rash on her vulva for the past 4 days,
which she had not had before. She said that 7 days ago she had
left her male partner because he had disclosed that he had been
having sex with several other partners, both male and female,
during their relationship so she would like testing for other STI.
She uses recreational drugs and occasionally injects. She does
not have a current sexual partner.
On examination you identied a vesicular rash on her vulva that
you diagnosed clinically as genital herpes, for which you treated
her empirically with oral aciclovir 400 mg 3 times daily for 5 days.
She had no symptoms or signs to suggest other STI or BBV
infection. You carried out relevant diagnostic tests and full testing
for other STI and BBV. She returns to the clinic a few days later
to see a Health Adviser, who telephones to ask your advice on
management and advises of the following results:
PCR for Chlamydia trachomatis – positive
HIV1 Ag/Ab test – negative
PCR for Neisseria gonorrhoeae – negative
Hepatitis B surface antigen (HBsAg) – negative
Hepatitis B core antibody (anti-HBc) – positive
Hepatitis C antibody – positive
PCR of vesicle uid for herpes simplex virus type 1
(HSV1) – negative
PCR of vesicle uid for herpes simplex virus type 2
(HSV2) – positive
Treponema pallidum EIA – positive
Which one of the following actions would be appropriate on the
basis of the above results?
A. Advise treatment with oral azithromycin 1 g orally followed by
500 mg once daily for 2 days
B. Send a further blood sample for hepatitis B PCR (viral load)
C. Send a further blood sample for hepatitis C PCR (viral load)
D. Initiate suppressive therapy for HSV 2 with aciclovir 400 mg
12-hourly for 3 months
E. Advise treatment with a single dose of 2.4 megaunits of long-
acting intramuscular benzathine benzylpenicillin
Answer: C.
The positive Chlamydia PCR indicates current infection. However, the
recommended treatment is with doxycycline rather than azithromycin,
to take into account possible coexisting infection with macrolide-resistant Mycoplasma genitalium. The positive anti-HBc indicates past infection with hepatitis B and the negative HBsAg indicates an absence of
current infection; there is therefore no indication to test her viral load.
The positive hepatitis C antibodies are a marker of either current or past
infection so should be investigated further by hepatitis C PCR, which, if
positive, would indicate current infection. A rst episode of genital herpes
is usually treated with a 5-day course of aciclovir; longer-term suppressive therapy is reserved for patients who have severe and/or frequent
recurrences. The T. pallidum EIA is a screening test for both IgG and
IgM, so may indicate either past or current infection; therefore further
investigation is necessary (with T. pallidum IgM and a non-treponemal
test) rather than treatment for syphilis.
15.4. A 23-year-old man presents for the rst time to a specialist
sexual health service with a 4-day history of dysuria and purulent
urethral discharge. He has had condomless insertive vaginal, oral
and anal sex with three female sexual partners over the last 3
weeks. Direct microscopy of a Gram-stained sample of urethral
discharge shows many pus cells and Gram-negative intracellular
diplococci. The preferred management plan is:
A. Take samples for gonorrhoea NAAT testing and culture from
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the urethra, and blood for HIV and syphilis serology, treat
empirically for urethral gonorrhoea with IM ceftriaxone 1 g
single dose and notify the most recent female partner
B. Take samples for NAAT testing for Neisseria gonorrhoea and
Chlamydia trachomatis from the urethra and pharynx, along
with cultures for gonococcal antimicrobial sensitivities and
HIV and syphilis serology. Treat for suspected gonorrhoea
with IM ceftriaxone 1 g single dose. Obtain details of three
recent partners for partner notication
C. Take samples for NAAT testing for Neisseria gonorrhoea
and Chlamydia trachomatis from the urethra and pharynx
and blood for HIV and syphilis serology and treat with oral
doxycycline 100 mg twice daily for 7 days for possible
chlamydial infection. Treat for gonorrhoea and notify partners
depending upon antimicrobial sensitivity results.
D. Take samples for NAAT testing and culture for gonococcal
antimicrobial sensitivities from the urethra, treat for both
gonorrhoea and chlamydial infection and notify all three
recent partners
E. Perform NAAT testing for Neisseria gonorrhoea and
Chlamydia trachomatis from the urethra, pharynx and rectum
along with cultures for gonococcal antimicrobial sensitivities
and blood for HIV and syphilis serology. Treat for suspected
gonorrhoea with IM ceftriaxone 1 g single dose. Obtain
details of the most recent partner for partner notication.
Answer: B.
Gram-stained microscopy has high sensitivity and specicity for the
diagnosis of urethral gonorrhoea in men. Immediate treatment with ceftriaxone 1 g IM single dose on the basis of a presumptive diagnosis is
appropriate but treatment for possible co-existing chlamydial infection is
not routinely given. Resistance to ceftriaxone remains rare but is a major
concern, so optimal management includes culture for antimicrobial sensitivity which should be taken from all potentially exposed sites, which
would usually include the rectum in women and MSM but not in menwho-have-sex-with-women (MSW). Testing for HIV and syphilis should be
part of routine testing for STI in all cases in all individuals. Symptoms of
urethral gonorrhoea in men usually develop within 7 days of contact with
an infected individual, however in symptomatic men all partners within the
last 4 weeks would usually be traced for testing and/or treatment.
DE Newby
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NR Grubb
16
Cardiology
Clinical examination of the cardiovascular system 386
Functional anatomy and physiology 388
Anatomy 388
Physiology 389
Investigation of cardiovascular disease 391
Electrocardiogram 391
Cardiac biomarkers 393
Chest X-ray 394
Echocardiography 394
Computed tomography 395
Magnetic resonance imaging 396
Cardiac catheterisation 396
Electrophysiology 397
Radionuclide imaging 397
Presenting problems in cardiovascular disease 397
Chest pain on exertion 398
Severe prolonged chest pain 398
Breathlessness 398
Syncope 398
Palpitation 399
Cardiac arrest 399
Abnormal heart sounds 400
Heart failure 401
Cardiac arrhythmias 408
Principles of management of cardiac arrhythmias 419
Anti-arrhythmic drugs 419
Non-pharmacological treatments 421
Coronary artery disease 424
Angina pectoris 426
Acute coronary syndrome 431
Non-cardiac surgery in patients with heart disease 439
Peripheral arterial disease 440
Diseases of the aorta 442
Aortic aneurysm 442
Aortic dissection 444
Aortitis 445
Marfan syndrome 445
Coarctation of the aorta 446
Hypertension 446
Diseases of the heart valves 451
Rheumatic heart disease 451
Mitral valve disease 453
Aortic valve disease 457
Tricuspid valve disease 460
Pulmonary valve disease 461
Prosthetic valves 462
Infective endocarditis 462
Congenital heart disease 465
Diseases of the myocardium 472
Myocarditis 472
Cardiomyopathy 473
Cardiac tumours 476
Diseases of the pericardium 476
386 CA R DIO L OG Y
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Clinical examination of the cardiovascular system
6
Face, mouth and eyes
Pallor
Central cyanosis
Dental caries
Fundi (retinopathy)
Stigmata of
hyperlipidaemia
and thyroid disease
Poor oral hygiene in a
Malar flush
5 7
Jugular venous pulse
(see opposite)
Height
Waveform
6
5
Jugular venous pulse
patient with infective
endocarditis
7
8
4
Carotid pulses
4
Volume
Character
Bruits
(see opposite)
3
9
10
Blood pressure
3
2
2
Radial pulse
Rate
Rhythm
1
Hands
Clubbing
Splinter haemorrhages
and other stigmata of
infective endocarditis
1
11
12
Xanthelasma
Precordium
Inspect
Palpate
(see opposite)
8
Auscultation
(see opposite)
9
Back
Lung crepitations
Sacral oedema
10
Abdomen
Hepatomegaly
Ascites
Aortic aneurysm
Bruits
11
Tendon xanthomas
(hyperlipidaemia)
12
Femoral pulses
Radio-femoral delay
Bruits
Splinter haemorrhage
Cyanosis and clubbing in a
patient with complex cyanotic
congenital heart disease
Insets (Splinter haemorrhage, jugular venous pulse, malar ush, tendon xanthomas) From Newby D, Grubb N. Cardiology: an illustrated colour text. Edinburgh: Churchill Livingstone,
Elsevier Ltd; 2005.
Observation
Symptoms and well-being
Breathlessness
Distress etc.
Body habitus
Body mass (obesity, cachexia)
Marfan and other syndromes
Tissue perfusion
Skin temperature
Sweating
Urine output
13
13
Legs
Peripheral pulses
Oedema
Vasculitis in a
patient with
infective
endocarditis
Peripheral
oedema in a
patient with
congestive
cardiac failure
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