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Anais Brasileiros de Dermatologia
Print version ISSN 0365-0596On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.2 Rio de Janeiro Mar./Apr. 2009
http://dx.doi.org/10.1590/S0365-05962009000200008
REVIEW ARTICLE
Approach in sexually transmitted diseases
Walter Belda JuniorI; Ricardo ShiratsuII; Valdir PintoIII
IResponsible for the Department of
Sexually Transmitted Diseases /AIDS, Brazilian Society of Dermatology. Post-doctorate
Degree in Dermatology, Universidade Estadual de Campinas (UNICAMP). Assistant
Professor, Ph.D., Department of Dermatology, Faculdade de Medicina da Universidade
de Sao Paulo (FMUSP) Sao Paulo (SP), Brazil.
IIVolunteer Assistant Professor, Department of Dermatology, Universidade
Federal de São Paulo (UNIFESP) Sao Paulo (SP), Brazil
IIIMinistry of Health. National Program of Sexually Transmitted Diseases
ABSTRACT
Nowadays, sexually transmitted diseases are one of the most common public health issues. Among its consequences are the possibility of transmission from mother to baby which may cause miscarriages and congenital disease, male and female infertility, and the increase of HIV infection risk. Therefore, the main goal of these guidelines is to contribute to the improvement of the treatment for sexually transmitted diseases patients by presenting to the medical community how today's science stands on the matter and also what the recommendation for diagnosing and treating a patient are.
Keywords: Chancroid; Gonorrhea; Granuloma inguinale; Lymphogranuloma venereum; Sexually transmitted disease; Sexually transmitted disease/diagnosis; Sexually transmitted disease/etiology; Sexually transmitted disease/therapy
INTRODUCTION
In 1999, the World Health Organization (WHO) estimated a total of 340 million new cases of curable sexually transmitted diseases (STD) per year all over the world among subjects aged 15 to 49 years amounting to 10 to 12 million cases in Brazil. Other some millions of incurable STD (viral), including genital herpes, human papilloma virus infections, hepatitis B and HIV infections occur annually 1.
Among women with untreated infections by gonorrhea/ Chlamydia, 10 to 40% develop pelvic inflammatory disease (PID). Among them, more than 25% will become infertile considering that the rate of infertility caused by non-infectious causes is estimated 3 to 7%. Studies conducted in developed countries indicate that women who have had PID are six to ten times more likely to have ectopic pregnancy, being that ectopic pregnancy contributes to more than 15% of maternal death 2.
Spontaneous abortions, stillbirths, low birth weight, congenital and perinatal infections are associated with untreated STD in pregnancy 3. Among men, Chlamydia has become an important cause of fertility if not properly treated 4, 5, 6.
Despite that, sexually transmitted diseases have only regained importance as a public health issue after the AIDS epidemics. Studies have shown that people with STD and non-ulcerative genital infections have 5 to 10 times higher risk to get infected by HIV, which is 18 times higher for those with ulcerative diseases 7.
Conversely, if HIV holder also has STD, HIV will be more easily transmitted to his partners. The mean concentration of HIV in seminal liquid is eight times greater in men with urethritis, without any difference in serum concentration. After treatment, seminal concentration is comparable again 8. HIV is also present in cervical-vaginal concentration in a frequency twice higher among women with gonorrhea, three times greater in the presence of Chlamydia and four times greater if there is ulceration of cervix or vagina 9. Bacterial vaginosis of endogenous origin doubles the risk of HIV infection, and it has significant implications in the gestational period, increasing the risk of prematurity and puerperal infection 10, 11, 12.
Notifiable STD in Brazil are AIDS, HIV in pregnancy and exposed child, syphilis in pregnancy and congenital syphilis. To other STD, there is no system of required notification and the absence of population study hinders the visibility of the problem and the implementation of priority interventions and assessment of their effectiveness 13.
MAIN CLINICAL SYNDROMES ACQUIRED SYPHILIS Chronic infectious disease, transmitted by sexual intercourse
and sometimes by the placenta. It is characterized by long periods of clinical
remission and the capacity to reach multiple organic systems, producing skin,
mucosa, cardiovascular and nervous lesions. Etiology Epidemiology Transmission Transmission takes place by direct contact with open lesions,
transfusion of blood contaminated with acquired syphilis and via transplacental
transmission in congenital syphilis. Treponema is capable of penetrating through
normal skin and mucosa, but its penetration is facilitated when there is continuity
solution. It quickly multiplies on the infected epithelium, and by lymphatic
route it attacks the regional ganglia, where it is also quickly multiplies.
Its dissemination is also immediate by hematogenic route. Thus, it invades the
whole organism, and even when symptoms are local, generalized infection takes
few hours. There are reports of accidental inoculation by manipulation of contaminated
lesions by physicians, dentists and laboratory technicians. Clinical Manifestations Laboratory Work Up Darkfield microscopy The possibility of negative results in the test may be
related to: - patient using local or systemic anti-treponema medication Serologic Tests: Non-Treponemic tests (cardiolipidic or reagins) Given that they are non-treponemic reactions, they are
not specific and in addition to being positive for other treponematosis such
as bouba and pinta, they may be present in other diseases than syphilis; in
such cases they are named biological false-positive serologic reactions, whose
main causes are: 1. Error in execution of the technique Infectious mononucleosis 3. Chronic causes Rheumatoid arthritis The most widely used tests are: Management Thus, the recommended dose for recent syphilis management
(primary, secondary and latent with less than one year of progression) is Penicillin
Benzathine 2.400.000 IU, intramuscular, single dose. For latent, late, cutaneous
and cardiovascular syphilis, the recommendation is Penicillin Benzathine 7.200.000
IU, intramuscular, divided into three weekly doses of 2.400.000 IU. In cases
of allergy to penicillin, the following therapeutic regimens are recommended:
recent syphilis - Doxycycline 100 mg PO, BID for 15 days; Tetracycline 500 mg
PO, TID for 15 days; Erythromycin 500 mg PO, TID for 15 days and, Ceftriaxone
250 mg IM/day for 10 days. In latent, late, cutaneous and cardiovascular syphilis:
Doxycycline 100 mg PO, BID for 4 weeks; Tetracycline 500 mg PO, TID for four
weeks and, erythromycin 500 mg PO, TID for 4 weeks. Some authors suggest the
use of azythromycin to treat syphilis, but there are reports of therapeutic
failures. 18, 19, 19 Cure Control GONORRHEA It is an infectious-contagious disease, pandemic, inter-human,
caused by diplococcus (Neisseria gonorrhoeae) and sexual transmission, even
though it may exceptionally be caused by indirect contamination, but it does
not provide immunity. In general, it is a urethral or uterine cervix infection
that may propagate to glands and neighboring organs by ascending route; in some
few cases, primary local infection is extra-genital, causing conjunctivitis,
ophthalmia, pharyngitis and anoretitis. Similarly to any infectious process,
it is not always localized because depending on the immune status of the host,
it may lead to sepsis and general and systemic manifestations. Epidemiology Etiological agent Clinical Manifestations In women, most cases are simpler, translated only as endocervicitis
21. Complications in men: Complication in women: EXTRA-GENITAL GONORRHEA Ophthalmic: It is characterized by conjunctivitis,
initially serous, which becomes progressively purulent, viscous, yellowish,
followed by palpebral and conjuctival edema. Rectal: The main symptoms are tenesmus, anal pruritus,
painful evacuation and mucous-purulent rectal secretion. Rectoscopy may show
purple and edematous mucosa, recovered with abundant suppuration with multiple
erosions. GONOCOCCAL PHARYNGITIS Disseminated Differential diagnosis Laboratory Work Up 2) Culture: enriched and selective means are recommended,
which ensures growth and development of neisseria. They require CO2 atmosphere
of about 3-5% and humidity rate of 90% at temperature of 35.5º C to 36.5º C.
23,24 Among the most used culture media there are modified Thayer-Martin,
Martin Lewis and NYC (New York City). 25 Management Canchroid Sexually transmitted disease, of acute progression, caused
by gram-negative bacillus and clinically characterized by the presence of painful
ulcerations of varied sizes, irregular margins and frequently involved by bright
erythematous halo located in the genital, anal or anogenital regions, followed
or not by satellite adenopathy. Epidemiology Etiology Clinical Manifestations Differential diagnosis Laboratory Work Up 2) Culture: it is difficult to grow the bacteria, even
when using the best media available. The most recommended media are Nairobi,
Johannesburg and enriched agar chocolate. The addition of vancomycin antibiotic
in the enriched agar chocolate medium intends to inhibit the growth of gram
positive bacteria, normally present in the collected clinical sample .33,34,35 Management LYMPHOGRANULOMA VENEREUM Lymphogranuloma venereum (LGV) is an infectious contagious
disease of inflammatory and invasive nature of the urogenital tract that is
caused by Chlamydia trachomatis. In many parts of the world, VLG has become
an important cause of anogenital disease among men who have sex with other men
41. LGV is caused by invasive serotypes L1, L2 and L3 of Chlamydia
trachomatis in contrast with serotypes A-C of this agent, which cause ocular
infection, such as trachoma, and the more common serotypes D-K that cause genital
infections 42. Epidemiology LGV is a relatively rare disease in industrialized countries,
but it is endemic in parts of Africa, Asia, South America and the Caribbean
43. The incidence of infection by Chlamydia trachomatis after
sexual contact is unknown, but probably it is smaller than gonorrhea and canchroid.
The peak of incidence of the infection is between the second and third decades
of life, the most active period of the sexual life. The period of sexual transmissibility
in infected men is about three weeks after the regression of the primary lesion.
Among women, the period of transmission is unknown, but it may probably last
for months, given that the cervix can remain indefinitely infected 44. Clinical Manifestations Two adenomegalias separated by Poupart ligament are characteristics
of this disease. Male homosexuals and women after sexual anal intercourse may
develop hemorrhagic proctitis or proctocolitis in acute stages of LGV. Primary
symptoms are anal pruritus, mucoid rectal secretion and localized pain. The
clinical landmark of anorectal LGV is revealed next: rectal muco-purulent secretion
44. Proctitis may generate diarrhea or constipation, and in classical
proctitis, tenesmus is detected. The tertiary stage refers to late complications
that affect the rectum and the genitals, including elephantiasis. These late
complications are more common among women and are named esthiomene 46. Differential diagnosis Laboratory Work Up Alternatively, Chlamydia trachomatis may be identified
by direct microscopic fluorescence using a conjugate of monoclonal antibodies
in the material collected from the blister or ulceration. This method requires
fluorescence microscope as well and a highly trained technician to execute and
interpret the test 43. Management Other drugs may be used, such as chloramphenicol, rifampicin
and Thiamphenicol. DONOVANOSIS Donovanosis is a chronic, progressive and indolent bacterial
disease that affects preferably the skin and genital and perigenital mucosa.
It is frequently associated with sexual transmission, but it has low infectivity. Etiology Epidemiology It is a disease that affects almost exclusively adults
in the age range 20-40 years. Cases in children are frequently associated with
contact with affected adults, not necessarily by sexual abuse. Clinical Manifestations Clinical manifestation starts with papules or subcutaneous
nodules that may progress with superficial ulceration. They grow slowly, without
causing pain, and become more definite, granulomatous, with centrifugal and
serpiginous character, easily bleeding. They may be self-inoculated and multiple.
Typically, there is no adenitis in donovanosis. In addition to anal and perianal
region, the other areas of extragenital involvement are: lips, gums, jugal mucosa,
mandible, palate, pharynx, larynx, neck, nose, ophthalmic region, scalp, chest
(infra-mammary sulci), axilla, abdomen, arms, legs, bones (especially the tibia).
Oral lesions are the most frequent ones, and teeth losses indicate bone impairment
50, 51. Dissemination to abdominal cavity, intestines, spleen, liver,
lungs, uterus and ovaries has already been reported and it is more frequently
seen in endemic areas. Laboratory Work Up In addition to clinical pathology exam, transmission electron
microscopy may be used to assess the ultrastructural characteristics of K. granulomatis
of different species. The culture of the agent is difficult and it is not available
as a routine. The combined culture with mono-layer cells has been described
using human monocytes, Hep-2 cells and peritoneal macrophages of mice 52. The
gene detection technique using polymerase chain reaction (PCR) that enables
reclassification of donovanosis agent has its diagnostic application restricted
to programs to eradicate the disease 53, 54. Management The following therapeutic regimes are recommended: 1)
Azythromycin 1 g PO in the first day, followed by 500 mg PO/day or Doxycycline
200 mg PO/day up to clinical cure. 2) Doxycycline 200 mg PO/day up to clinical
cure. 3) Erythromycin 2 g PO/day up to clinical cure. 4) Tetracycline 2 g PO/day
up to clinical cure. 5) Sulfamethoxazole/Trimethoprim (400/800) 2 pills PO twice
a day for at least 14 days. Other antibiotics may also be used with satisfactory
therapeutic responses, such as ceftriaxone, norfloxacin, trovofloxacin and Thiamphenicol
49,50,55,56,57. To pregnant patients and positive HIV subjects, we
should consider the addition of aminoglycoside since the beginning of treatment. Essential complementary actions 1) To counsel and provide tests for anti-HIV, VDRL serology
and hepatitis B and C; If it is not possible to define the correct etiological
diagnosis of the process, it is recommended to use the syndromic approach advocated
by the Ministry of Health, as shown below. Syndromic approach in genital ulcers Flow chart
of genital ulcers (Figure 1).56 For the first episode of genital herpes, start treatment
as early as possible with Acyclovir 200 mg, 4/4 h, five times a day for 7 days
or 400 mg PO, TID for seven days OR Valacyclovir 1 g PO BID for 7 days OR Famciclovir
250 mg PO, TID for seven days. In cases of recurrent genital herpes, start early
management with Acyclovir 400 mg PO, TID for 5 days OR Valacyclovir 500 mg PO,
BID for five days OR Famciclovir 125 mg PO, BID for 5 days. In the absence of vesicle lesions, we recommended preventive
treatment for the two most frequent causes of genital ulcers primary
syphilis and canchroid, with Penicillin G Benzathine 2.4 million IU, intramuscular,
single dose + azythromycin 1 g PO single dose OR ciprofloxacin 500 mg PO, BID
for 3 days OR erythromycin estearate 500 mg PO, QID for 7 days. If lesions last more than 4 weeks, start suspecting of
donovanosis, lymphogranuloma venereum or neoplasm. Refer to or perform a biopsy
for investigation. Simultaneously, start treatment for donovanosis - Doxycycline
200 mg/day PO until clinical cure OR azythromycin 1 g PO single dose, followed
by 500 mg PO/day for 3 weeks. REFERENCES
- chancre older than 3 weeks of progression
- non-representative sample
- non-syphilitic process
2. Acute causes
Viral Pneumonia
Infectious hepatitis
Herpes simples and zoster
Measles
Lymphogranuloma Venereum
Vaccination (yellow fever and typhoid fever)
Pregnancy
To establish the definite diagnosis of syphilis and owing
to limitations of non-treponemic tests, it is necessary to confirm it using specific
tests based on detection of antibodies against Treponema pallidum. These tests
include direct immunofluorescence test (FTA-abs); the treponema immobilization
(TPI) test; treponema hemagglutination test (TPHA), and more recently enzyme immunoassays
(EIA) 16, 17.
Systemic lupus erythematosus
Autoimmune hemolytic anemia
Nodous periartheritis
Thyroiditis
Chronic hepatitis
Hansen's disease
Tuberculosis
Leptospirosis
Malaria
Visceral leishmaniasis
Treponemic tests
2. Reiter Protein Complement Fixation (RPCF)
3. FTA-200
4. FTA-abs (Fluorescent Treponemal Antibody-absorbed Test)
5. Treponema pallidum Hemagglutination (TPHA)
6. IgM-TPHA
Balanoposthitis
Stones that cross to the urethra
Spontaneous perineal pain
Prostatitis
Epididymitis
Cystitis
Bartholinitis
Adnexitis
It affects on average 10% to 20% of the subjects who practice
oral sex with partners who have gonococcal urethritis.
2) To vaccinate against hepatitis B if the patient is younger than 30 years;
3) To suspend sexual intercourse until treatment is finished and symptoms have
disappeared;
4) To emphasize constant use of condoms.
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How to cite this article: Belda Jr. W, Shiratsu R, Pinto
V. Abordagem nas doenças sexualmente transmissíveis. An Bras Dermatol.
2009;84(2):151-59.
Mailing Address:
Walter Belda Junior
Av. Açocê, 162- Moema
04075 020 São Paulo - SP
Tel./fax: 55 11 50515141
E-mail: walterbelda@uol.com.br