Sexually Transmitted Infections – Viruses
Herpes Simplex Virus, Human Papillomavirus, Molluscum
Contagiosum
1.
Herpes Simplex Virus
a.
Herpes Simplex Virus 1 and 2
b.
Symptoms
i. Highly
variable, and depend on the course of infection, and whether it is a primary,
recurrent, or non-primary infection
1.
Primary Infection
a.
Systemic symptoms of fever, headache, malaise,
myalgias
b.
Local symptoms of pain, dysuria, tender
lymphadenopathy
c.
Painful genital ulcers: pustular vesicular
lesions on an erythematous base which ulcerate and the crust over
2.
Recurrent Infection
a.
Common
b.
Less severe than primary or non-primary infection
c.
Systemic infections or symptoms are atypical
3.
Non-Primary Infection
a.
An initial outbreak of an HSV serotype in a
patient who had a prior HSV infection with a different serotype
b.
Severity is generally less than a primary
infection, but worse than recurrent infection, and may or may not have systemic
symptoms
ii. Extragenital
Manifestations
1.
Meningitis
a.
Altered mental status, LP finds pleocytosis with
predominantly lymphocytes, normal CSF glucose concentration
b.
May be recurrent, and if so, may or may not
appear at the time of genital lesions
2.
Disseminated HSV
a.
Typically seen in immunocompromised individuals,
includes visceral manifestations
i. Pneumonitis,
Esophagitis, Hepatitis, Chorioretinitis, Keratitis
3.
Proctitis
c.
Transmission
i. Direct
contact, either from lesions during outbreaks, or from asymptomatic viral
shedding
d.
Testing
i. Viral
Culture
1.
May be performed if the lesion is intact; the
provider will unroof the vescicle and the sample of fluid is collected
ii. PCR
1.
Higher sensitivity than cultures, and may detect
asymptomatic shedding.
2.
Obtained from genital ulcers or mucocutaneous
sites
3.
Test of choice for CSF
iii. Tzanck
Smear
1.
Multinucleated giant cells
iv. Direct
Fluorescent Antibody
1.
Rapid test to detect HSV in specimen
v. Serology
1.
Type-Specific Antibodies
2.
May be negative in primary infections
3.
Useful if the patient didn’t receive a workup
during the outbreak, or if the HSV culture is negative
4.
Also used to determine partner susceptibility
vi. Asymptomatic
Screening
1.
Not recommended given low specificity and high
false-positive rates
e.
Treatment
i. General
Principles
1.
Prompt initiation of treatment reduces pain,
length of outbreak, decrease time of viral shedding
ii. Primary
Outbreak
1.
First Line
a.
Acyclovir 400mg TID x7-10d
b.
Valacyclovir 1000mg BID x7-10d
c.
Famciclovir 250mg TID x7-10d
2.
Disseminated HSV, CNS involvement, or
complicated HSV may require IV antiviral
a.
Acyclovir 5-10mg/kg IV q8h x2-7d, then PO
therapy to complete 10d course
iii. Further
Therapy
1.
Consider adherence, costs, partner
seropositivity, and psychosocial impact of recurrent infections and medications
when selecting therapy
2.
No therapy
3.
Episodic
a.
Patient is given script and instructed to take
medication when prodromal symptoms begin
b.
First Line
i. Acyclovir
800mg TID x2d, 800mg BID x5d, 400mg TID x5
ii. Famciclovir
1000mg BID x1d, 125mg BID x5d, 500mg X1d f/b 250mg BID x2d
iii. Valacyclovir
500mg BID x3d, 1000mg QD x5d
4.
Chronic
a.
Daily administration
b.
Often used for those with frequent outbreaks
(often defined as >10 outbreaks per year), and those with seronegative
partners
c.
First Line
i. Acyclovir
400mg BID
ii. Famciclovir
250mg BID
iii. Valacyclovir
500mg QD or 1000mg QD
5.
Immunosuppresed
a.
Treatment duration and doses are generally
higher
b.
HIV patients who have better HIV control
demonstrate fewer outbreaks
iv. Pregnancy
1.
Generally, all outbreaks are treated in
pregnancy, and women are placed on suppression
2.
Routine suppression is performed at 36 weeks
3.
Acyclovir or Valacyclovir are used in pregnancy
4.
Vertical Transmission
a.
Often acquired via the genital tract during
labor and delivery, with greatest risk from primary infections
b.
Neonate may present with localized infection of
skin/eyes/mouth, CNS, or disseminated illness
2.
Human Papillomavirus
a.
Most commonly transmitted STI, at least 80% of
all sexually active individuals get at least one strain of HPV in their
lifetime
i. ~360,000
new cases of genital warts, ~10,300 cervical cancers
b.
Symptoms
i. Linked
to a variety of conditions
1.
Malignancy
a.
Cervical Cancer
i. Many
strains are considered ‘High-Risk’, the highest risk include HPV 16, 18, 31, 33
b.
Anal Cancer
i. A/w
HPV 16
ii. Most
commonly seen in MSM population
c.
Penile Cancer
i. A/w
HPV 16
d.
Head/Neck Cancers
i. Can
be seen in surgeons who perform laser procedures
2.
Warts
a.
Nongenital
i. Very
common, and present as common warts, plantar warts, and flat warts
ii. Laryngeal
papillomatosis
b.
Genital
i. A/w
HPV 6 and 11
c.
Natural History
i. Many
people are infected by HPV, and the majority of immunocompetent individuals
clear the infection spontaneously and without sequelae
ii. If
the infection is not cleared, it may progress to dysplasia and invasion, over a
period of many years
d.
Prevention
i. HPV
vaccination
1.
Current Nonavalent, Quadrivalent, and Bivalent
vaccines exists
a.
Nonavalent: HPV strains for genital warts (HPV 6
and 11) as well as the 7 most common strains for causing cervical cancer
2.
Series of three vaccines, age 9-26, given at 0,
1-2m, and 6m.
a.
Series does not need to be restarted if
interrupted
3.
Can be given if patient has begun sexual
activity
4.
Not recommended during pregnancy
5.
Ok to administer in immunocompromised
e.
Transmission
i. Sexual
contact, not necessarily prevented by condom use
f.
Cervical Cancer Screening
i. Age
<21: No screening, regardless of sexual history
ii. Age
21-29: Cytology every 3 years, HPV testing if ASCUS
iii. Age
30-65: Cotesting every 5 years, or Cytology every 3 years
iv. Age
>65: No screening. Or, if h/o CIN2 or greater, continue routine screening
for 20 years.
v. After
Hysterectomy: No screening. Or, if h/o CIN2 or greater, continue routine
screening for 20 years.
vi. If
vaccinated against HPV: No effect on screening or management
3.
Molluscum Contagiosum
a.
Poxvirus
b.
Symptoms
i. Chronic,
localized infection manifested by flesh-colored, dome-shaped papules with a
central umbilication.
ii. Any
skin surface except palms/soles.
iii. Dermatitis
may occur surrounding a papule, with an eczematous patch/plaque, and therefore
exacerbate infection via scratching.
c.
Transmission: Direct skin contact,
athletes, children, shaving.
i. In
adults, genital papules are classified as sexually-transmitted.
ii. Molluscum
is a common infection in children, and anogenital lesions are typically not
sexually-transmitted but are a consequence of auto-innoculation.
d.
Diagnosis: Clinical.
e.
Clinical Course: Immunocompetent
patients resolve lesions in a few months, and the infection is usually cleared
within a year.
i. In
immunocompromised patients, disseminated molluscum may occur - it is an AIDS
defining lesion.
ii. Extensive
lesions should prompt immunological evaluation.
f.
Treatment:
i. Principles
of Treatment
1.
Prior to treatment, a full skin
examination should be performed to identify all lesions.
2.
Treatment is recommended in
immunocompromised individuals, and in those with sexually-transmitted
infections.
3.
Insufficient evidence that any
treatment is effective.
ii. Cryotherapy
1.
SE’s: scars, hypopigmentation
iii. Curettage
1.
Benefit of being rapid and
immediate
2.
SE’s: bleeding, scarring
iv. Cantharidin
1.
Applied by physician, then washed off
2-6hrs later or upon blistering, repeated q2-4wks
2.
Avoid on face, genitals
3.
SE’s: pain, burning, pruritis,
scarring
v. Podophyllotoxin
1.
Safety not established in young
children
2.
SE’s: erythema, pruritis,
inflammation, erosions
vi. For
severe cases in immunocompromised individuals:
1.
Interferon-alpha
a.
SE’s: flu-like symptoms
2.
Cedofovir
a.
SE’s: nephrotoxicity
Image from BBC
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