Chapter 80 Sexually Transmitted Diseases
Clinical Case Problem 1: A 24-Year-Old Woman with Diffuse Abdominal Pain
Select the best answer to the following questions
1. What is the most likely diagnosis in this patient?
2. What is the most appropriate intervention for this patient?
3. If hospitalization is chosen for this patient, which of the following is an acceptable first-line parenteral regimen for her condition?
4. If outpatient management is chosen for this patient, which of the following is an acceptable first-line treatment of mild to moderate PID according to the 2010 Centers for Disease Control and Prevention (CDC) guidelines?
5. Which of the following statements regarding the relationship between combined oral contraceptive pills (OCPs) and this patient’s condition is true?
6. Which of the following organisms is not associated with the condition described in this case?
7. All of the following are direct risk factors for PID except
8. Which of the following is (are) a complication(s) of disseminated gonococcal infection (DGI)?
Clinical Case Problem 2: A 19-Year-Old Woman with Complaints of Vaginal Discharge
9. As recommended by the CDC’s STI treatment guidelines (2010), which of the following is first-line treatment of this patient’s condition?
10. The U.S. Preventive Services Task Force (USPSTF) recommends that the following women be screened for chlamydial disease:
Clinical Case Problem 3: A 24-Year-Old Man with Dysuria
11. The patient’s urethral Gram stain reveals 20 WBCs per high-power field. There are no intracellular gram-negative diplococci seen. What is the most likely diagnosis in this patient?
12. What is the most likely organism causing this condition?
13. What is first-line treatment of this patient’s condition?
14. You prescribe an appropriate antibiotic regimen for this patient and his current sexual partner. He returns to your office stating that he and his partner have completed the recommended treatment. They have been in a monogamous relationship since then. His symptoms have resolved completely. He wants to know if further testing can be done to make sure the “infection is gone.” You advise him that
Clinical Case Problem 4: A 23-Year-Old Female Graduate Student Presents for Her Annual Exam
Clinical Case Problem 5: A 25-Year-Old Woman with Vulvar “Growths”
17. What is the most likely diagnosis in this patient?
18. All of the following are acceptable treatments of this condition except
19. The patient should be counseled that
20. Which of the following statements about syphilis is true?
21. Which of the following statements about syphilis testing is true?
22. What is the treatment of choice in patients who are not allergic to penicillin for primary, secondary, or early latent syphilis (syphilis acquired within the preceding year without evidence of disease)?
Clinical Case Problem 6: A 24-Year-Old Woman with Genital Lesions
23. You tell the patient the most likely diagnosis is
24. Which of the following statements concerning the patient’s condition is false?
25. Which of the following statements about human immunodeficiency virus (HIV) is false?
26. Which of the following accurately describes the natural history of HIV infection?
Clinical Case Management Problem
Discuss risk factors for hepatitis B and preventive strategies to reduce transmission.
Answers
1. b. This patient meets diagnostic criteria for acute PID. The clinical diagnosis of acute PID is imprecise, and episodes of PID often go unrecognized. Clinicians need to maintain a low threshold of suspicion and consider epidemiologic factors in diagnosis of PID. Patients who are young, have multiple sexual partners, live in high-prevalence areas for gonorrhea or Chlamydia, do not use barrier contraception, and have a history of prior PID are at highest risk. According to the 2010 CDC STI treatment guidelines, empirical treatment of PID should be initiated in young, sexually active women who report pelvic or lower abdominal pain when no other cause of the pain can be identified and the following minimal diagnostic criteria are met: cervical motion tenderness, or uterine tenderness, or adnexal tenderness. Supportive criteria include the following: (1) oral temperature higher than 101° F (>38.3° C), (2) abnormal cervical or vaginal mucopurulent discharge, (3) the presence of WBCs on wet prep, (4) elevated erythrocyte sedimentation rate, (5) elevated C-reactive protein, or (6) documentation of cervical infection with N. gonorrhoeae or C. trachomatis. More invasive studies, such as endometrial biopsy to document endometritis, laparoscopy, or transvaginal ultrasonography to document tubal disease, are sometimes necessary in select cases to confirm diagnosis.
The differential diagnosis of acute PID is broad and includes disorders of any of the three organ systems within the pelvis: (1) the reproductive tract (adnexal torsion, ectopic pregnancy, and threatened abortion), (2) the gastrointestinal tract (appendicitis, diverticulitis, and regional ileitis), and (3) the urinary tract (cystitis and pyelonephritis). The patient in Clinical Case Problem 1 most likely has acute PID given her history and examination findings. The presence of vaginal discharge and pelvic findings make acute appendicitis less likely. Uncomplicated cervicitis does not present with systemic symptoms. The negative pregnancy test result makes ectopic pregnancy or threatened abortion unlikely. Pregnancy should be ruled out in all women of reproductive age presenting with abdominal and pelvic symptoms.
2. a. Early treatment of acute PID decreases the probability of tubal scarring and subsequent infertility. The incidence of infertility is 15% after one episode of untreated or inadequately treated PID. In the past, it was generally advocated to hospitalize all patients for parenteral antibiotics to ensure successful eradication of infection. However, there are no data available to support that inpatient treatment results in better outcomes than outpatient treatment or that benefits exceed cost. In practice, the decision for hospitalization is made on an individual basis, depending on severity of disease and patient factors such as compliance. The CDC suggests hospitalization in the following circumstances: (1) observation for potential surgical emergencies that cannot be excluded (e.g., appendicitis); (2) pregnant patients; (3) failed outpatient treatment; (4) severe illness, such as high temperature, nausea, or vomiting; or (5) the presence of a tubo-ovarian abscess. In this patient’s case, her high fever, nausea, and vomiting would be an indication for hospitalization for parenteral antibiotics. Laparoscopy is not performed routinely for suspected PID.
3. b. The treatment of acute PID should include broad-spectrum coverage for N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative bacteria, and streptococci. The 2010 CDC STI treatment guidelines recommend the following as acceptable regimens for parenteral treatment of PID: (1) cefotetan 2 g IV every 12 hours or cefoxitin 2 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours or (2) clindamycin 900 mg IV every 8 hours plus gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours. Parenteral therapy should continue for at least 24 hours after clinical improvement, at which time the transition can be made to oral antibiotics.
4. a. The CDC no longer recommends fluoroquinolones as first-line treatment of gonorrhea infections and associated conditions because of the emergence of fluoroquinolone-resistant strains of N. gonorrhoeae. Therefore, the preferred treatment of uncomplicated adult gonococcal urethritis, cervicitis, or proctitis is as follows: (1) ceftriaxone 250 mg IM in a single dose or (2) cefixime 400 mg orally in a single dose plus treatment for chlamydia if chlamydial infection is not ruled out (e.g., azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice a day for 7 days).
Following the same logic, recommended outpatient regimens for PID include the following:
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