Z

IM Penicillin Follow titers

Biopsy

Presume chancroid

Figure 56-1. Algorithm for assessment of vulvar ulcers.

years are infected. The two types of this virus are HSV-1 and HSV-2. Type 1 usually causes infections in the oral region and type 2 in the genital region; however, cross-infection may occur. Recurrence is greater with HSV-2. The primary episode usually is a systemic as well as a local disease, with the patient often complaining of fever or general malaise. Local infection typically induces paresthesias before vesicles erupt on a red base. After the primary episode, the recurrent disease is local, with less severe symptoms. Recurrent herpes ulcers are small and superficial and usually do not scar. The best diagnostic test is viral culture. Rarely the infections are sufficiently severe to warrant hospitalization, such as with encephalopathy or urinary retention. Treatment for immunosuppressed individuals often requires intravenous acyclovir therapy; oral acyclovir is effective in suppressing frequent recurrences.

Syphilis, caused by the bacteria Treponema pallidum, may induce a chronic infection. The organism is extremely tightly wound and is too thin to be seen on light microscopy. The typical incubation period is 10 to 90 days. The disease can be divided into primary, secondary, latent, and tertiary stages. Primary syphilis classically presents as the indurated, nontender chancre. The ulcer usually arises 3 weeks after exposure and disappears spontaneously after

2 to 6 weeks without therapy. Nontreponemal tests (i.e.. RPR or VDRL) sometimes do not become positive with the appearance of chancre: if the serology is negative in the face of a painless ulcer, then dark-field microscopy is the best diagnostic step.

Secondary syphilis usually is systemic, occurring about 9 weeks after the primary chancre. The classic macular papular rash may occur anywhere on the body but usually on the palms and soles of the feet, or the flat lesion of condylomata lata on the vulva may be seen (Figure 56-2). These lesions have a high concentration of spirochetes.

Latency of varying duration occurs after secondary disease. If untreated, approximately one third of women may proceed into tertiary syphilis, which may affect the cardiovascular system or central nervous system. Optic atrophy, tabes dorsalis, and aortic aneurysms are some manifestations. Penicillin is the treatment of choice for syphilis. Because of the long replication time, prolonged therapy is required. For example, the long-acting penicillin benzathine penicillin G is often used. One injection of 2.4 million units intramuscularly is standard treatment of early disease (primary, secondary, and latent up to 1-yr duration). Patients with late latent syphilis (greater than I yr) should be treated with a total of 7.2 million units intramuscularly divided as 2.4 million units every week for a total of three courses. For women allergic to penicillin, oral erythromycin or doxycycline may be used (Table 56-1). In pregnancy, penicillin is the only known effective treatment for preventing congenital syphilis.

Neurosyphilis requires more intensive therapy, usually intravenous penicillin in the hospital.

After therapy, the nontreponemal test is followed quantitatively every

3 months for at least 1 yr. An appropriate response is a fourfold fall in titers in

Figure 56-2. Genital condyloma lata of secondary syphilis. (Reproduced with permission from Cunningham FG, et al. Williams obstetrics, 21st ed. New York: McGraw-Hill, 2001:14X7.)

3 months and a negative titer in 1 year. When the titer does not fall appropriately, one possible etiology is neurosyphilis, which may be diagnosed by lumbar puncture.

Chancroid is a sexually transmitted disease, usually manifesting as a soft, tender ulcer of the vulva. It is more common in males than females. The typical ulcer is tender, with ragged edges on a necrotic base. Tender lym-phadenopathy may coexist with these infections. The etiologic organism is Haemophilus ducreyi, a small gram-negative rod. Gram stain usually reveals the classic "school of fish." After ruling out syphilis and herpes, chancroid should be suspected. Biopsy and/or culture help to establish the diagnosis. Treatment includes oral azithromycin or intramuscular ceftriaxone.

Table 56-1

TREATMENT OF SYPHILIS

Table 56-1

TREATMENT OF SYPHILIS

DURATION

TREATMENT

Primary, secondary, early latent (<1 yr)

Penicillin 2.4 M units IM

Late latent (>1 yr) or unknown duration

Penicillin 2.4 M units IM

every week x 3 doses

Neurosyphilis

IV Penicillin x 4-6 doses

Data from ihe CDC 2002 Guidelines for treatment of sexually transmitted diseases.

Data from ihe CDC 2002 Guidelines for treatment of sexually transmitted diseases.

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