CHAPTER 18
SEXUALLY TRANSMITTED DISEASES
（性行為感染症）
I. Definition
A large group of infections produced by different Microorganisms including spirochetes, chlamydia, bacteria, mycoplasma, protozoa, fungi, parasites, and viruses via sexual contact.
A. Syphilis（梅毒）
1. Efilogy: Treponema pallidum
2. Classification of Clinical Disease
a. Clinical manifestation:
1) primary stage (chancre, 硬性下疳)
2) secondary stage(skin rash)
3) latent stage (a positive serological test in the absence of the secondary symptoms)
4) tertiary stage (cardiovascular syphilis and neurosyphilis)
b. Epidemiologic classification:
1) early phase (the first 2 years after infection)
2) late phase (more than 2 years' duration)
3. Primary syphilis
- Incubation period: 21 days (average)
- Physical Examination
a. Skin finding
1) Chancre: Inflammatory papule, followed later by a single and painless erosion, having a smooth, clean base with raised, indurated borders, associated with a scanty, serous exsudate
2) Distribution: the site of inoculation (penis and vulva etc.)
b. General finding: Painless regional lymphadenopathy
1) Diagnossis; Dark-field and serologic examinations
2) Differential Diagnosis：genital herpes infection（陰部ヘルペス）, chancroid（軟性下疳）, trauma（外傷）, lymphogranuloma venereum（鼠径リンパ肉芽腫症）, erosive balanitis or vulvitis（糜燗性包皮炎または外陰部炎）, squamous cell carcinoma of the penis（陰茎扁平上皮癌）, Bechet's disease, fixed drug eruption（固定薬疹）, lichen planus（扁平苔癬）, psoriasis（乾癬）, Reiter's syndrome, superficial or deep mycotic infection（浅在性または深在性真菌感染症）
3) Histopathology: Vascular change（endoarteritis, 心内膜炎 and periarteris, 動脈周囲炎）
4. Secondary syphilis
- 2 to 6 months after infection
- Physical Examination
a. Skin finding: Macular, papular, papulosquamous, follicular, pustular, or nodular varieties occur, with many forms often appearing simultaneously.
1) Macular lesion（roseola syphilitica, 梅毒性薔薇疹）
The earliest of the secondary skin manifestation Nonpruritic and nonscaling oval spots
2) Papular lesion（papular syphilides, 丘疹性梅毒）
The most frequent lesion
3) Follicular lesion（miliary papular syphilides, 粟粒丘疹性梅毒）
Pinhead to pinpoint in size, erythematous papule
4) Papulosquamous lesion
Raised with flat surface, discoid and scaling, red and indurated lesion (a psoriasiform appearance)
5) Condyloma lata（扁平コンジローマ）
Lesions begin as papule but become flattened, macerated, and covered with a thick mucoid exudate. papilomatosis, vegetations and foul odor
6) Pustular lesion
7) Mucous membrane lesion
Papules are characteristically rounded, flat, gray, superficially ulcerated, and teeming with spirochetes.
b. General finding
1) Malaise, appetite loss, hoarseness, mild weight loss, headache,myalgia, arthralgia and low-grade fever
2) Lymphadenopathy and spleen enlargement
3) Hepatitis, gastritis and periostitis
4) Eye involvement:uveitis, iridocyclitis, choroidoretinitis and combined occlusion of the central retinal vein and artery due to vasculitis
c. Diagnosis
1) Dark-field examination and serologic test（暗視野法と血清学的検査）
2) Histologic examination of tissue using silver stains or immuno-fluorescence for the detection of spirochetes
d. Differential Diagnosis
1) Macular rash: drug eruptions, rubella, rubeola, viral exanthema, pityriasis rosea
2) Papular change: psoriasis, lichen planus, acne, scabies
3) Condyloma lata: impetigo, fungal infection, condyloma acumiatum, balanitis, ulcerated hemorrhoid, psoriasis, herpes simplex
e. Histopathology
1) Endothelial swelling of superficial capillary
2) Infiltrate of plasma cells and lymphocytes
5. Latent syphilis（潜伏梅毒）
a. Latent syphilis is defined in an individual who has a repeatedly reactive serologic test for syphilis that is confirmed by a specific treponemal test in the absence of signs and symptoms of disease.
b. A pregnant woman with latent disease can infect her fetus.
6. Tertiary syphilis（第３期梅毒）
- Physical Examination
a. Skin finding
1) Nodular and noduloulcerative lesion（tubercular syphilides, 結節性梅毒）
2) Gumma（ゴム腫）
3) Mucous membrane lesion
(a) Chronic intestitial glossitis（舌炎）
(b) Desruction of the nasal bone and cartilage（saddle nose, 鞍鼻）
b. General finding
1) Cardiovascular syphilis（心血管梅毒）: aortic insufficiency and aneurysm
2) Neurosyphilis（中枢神経梅毒）: acute meningitis and chronic meningoencephalitis
7. Prenatal syphilis (congenital syphilis)（先天梅毒）
・ Prenatal syphilis is defined as syphilis transmitted by the mother to the fetus in utero.
・ The clinical manifestations of prenatal syphilis are divided into early prenatal syphilis (appearing before age 2) and late prenatal syphilis (after age 2).
a. Early prenatal syphilis
1) Dead, macerated fetuses of spontaneous abortions and stillbirths may result as well as babies dying soon after birth due to early severe disease.
2) When disease is obvious at birth, a mortality rate is 50%.
3) Skin finding; bullous lesion（syphilitic pemphigus, 梅毒性天疱瘡）.
4) General finding:
(1) Infants were small for date and presented with marasmus, pot belly, withered eye, old man face and pseudoparalysis of Parrot（パローの仮生麻痺）.
(2) Hepatosplenomegaly and osteochondritis（肝脾腫と骨軟骨炎）CNS involvemnt (40-50% of patients)
b. Late prenatal syphilis
1) Saddle nose（鞍鼻）
2) Frontal bossae（前頭部突出）
3) Short maxillae（矮小上顎）
4) Relative protuberance of the mandible (bulldog jaw)（下顎の比較的突出）
5) High arched palate（高口蓋弓）
6) Rhagades（パロー溝）
7) Sabre shin（サーベル状脛骨）
8) Mulberry molar（桑の実状大臼歯）
9) Hutchinson's triad（ハッチンソン三徴候）: Hutchinson's teeth（ハッチンソン歯牙）, interstitial keratitis（実質角膜炎）, eighth nerve deafness（第８神経性難聴）
8. Serology of Syphilis
a. Nontreponemal antigen test or Serologic tests of syphilis (STS)
Nonspecific antibodies are measured by tests that employ cardiolipin-lecithin as antigen.
1) Complement fixation test
(a) Wassermann test
(b) Ogata test
2) Flocculation test
(a) Kahn's test
(b) Venereal Disease Research Laboratory test (VDRL)
= glass slide test
(c) Rapid Plasma Reagin card test (RPR)
b. Treponemal antigen test
Specific anti-treponemal antibodies are measured using assays that require the whole organism or its components as the antigen.
1) Treponema pallidum immobilization test (TPI)
2) T.P. complement fixation test (TPCF)
3) Reiter protein CF test (RPCF)
4) Fluorescent treponemal antibody test (FTA)
5) T.P. hemagglutination test (TPHA)
6) FTA absorption test (FTA-ABS)
7) IgM-FTA-ABS test
8) IgM-solid phase hemabsorption test (IgM-SPHA)
9. Biological false-positive reaction (BFP)（生物学的偽陽性反応）
a. BFP reactors for the reaginic tests are defined as patients in whom one or more of these tests (VDRL, Wassermann, RPR) are repeatedly positive, but in whom tests for anti-treponemal antibody (FTA and/orTPHA test) are negative.
b. Cause of BFP
Pregnancy, Smallpox vaccination, Mycoplasma pneumonia, Measles, Mumps, Infectious mononucleosis, Narcotic addict, SLE, RA, Hashimoto's thyroiditis, Elderly population, Leprosy, Type B-hepatitis, Hepatic cirrhosis, Polyarteritis nodosa, Malignant tumors, Technical error.
※ These comparative ractivities on serologic tests (STS, TPHA, FTA-ABS) are correlated with the clinical stage of disease.
※ STS are used as indicator of the effect of an anti-syphilitic treatment.
※ The greatest importance of treponemal antigen test is its specificity, making it possible to distinguish BFP STS reactions from genuine positive.
10. Treatment
a. Intramuscular injection treatment for primary syphilis for later stage
|
benzathine penicillin G |
600,000 units daily |
600,000 units daily |
|
aqueous procaine PC-G |
for 5 days |
for 10〜20 days |
b. Oral treatment program
|
PC-G or PC-V (Bicillin G or V)
|
1.2〜2.4 million units for 2 week〜 |
| Erythromycin |
1.2〜1.6 g/day for 1〜2 month |
|
Minomycin |
200 mg/day for 1〜2 month |
c. Jarisch-Herxheimer reaction
1) 2−12hr after the first injection of Penicillin or other antisyphilitic drugs with astrong treponemicidal effect,a pronunced febrile reaction.
2) It resolves usually within 18 to 24 hrs.
3) Nothing is known for certain about the cause of this reaction.
B. Chancroid（軟性下疳）
1. Etiology: Chancroid is a venereal disease caused by the Gram-negative bacillus Haemophilus ducrei.
2. Clinical features
a. After an incubation period of 2-5 days, a small, red papule develops and rapidly becomes pustular and then breaks down leaving a small, soft, nonindurated, sharply circumscribed ulceration.
b. In contrast of syphilis, the ulcer of chancroid is tender and sometimes painful. About a week after the appearance of the ulcer, Inguinal lymphnodes are enlarged and tender and may suppurate and break down.
3. Diagnosis
a. H.ducreyi may be identified in smears from the ulcer.
b. H.ducreyi may be isolated by direct inoculation onto a solid culture medium consisting of a chocolate agar plate.
4. Treatment
Antibiotics (Cephalosporin etc)
C. Lymphogranuloma Venereum（鼠径リンパ肉芽腫症）
1. Etiology: Chlamydia trachomatis
2. Clinical features:
a. A small papulo-vesicle develops on the external genitalia, and heals rapidly.
b. Inguinal lymphadenopathy is hard and tender.
c. The major late manifestation is rectal stricture.
a. In women, late scarring, fistulas, ulceration, and elephantiasis of the perineum, called esthiomene, may require radical surgical intervention.
3. Diagnosis
a. Frei test
b. Isolation and identification of the organism by culture for Chlamydia.
4. Treatment: tetracycline and minocycline
D. Minor sexually transmitted diseases
1. Candidiasis (Vaginal candidiasis)（外陰部カンジダ症）
Etiology: Candida albicans
Treatment: topical and systemic imidazoles
2. Genital warts (Condyloma acuminatum)（尖圭コンジローマ）
Etiology: human papilloma viruses type 6, 11, 16, and 18
3. Trichomoniasis（トリコモナス症）
Etiology: Trichomonas vaginalis
Treatment: metronidazole
4. Genital herpes simplex（陰部単純性疱疹）
5. Pediculosis pubis（毛ジラミ症）
6. Scabies（疥癬）