C h a p t e r 4 1
Sexually Transmitted Infections
1053
schedules and increased compliance. Episodic interven-
tion reduces the duration of viral shedding and the heal-
ing time for recurrent lesions. For individuals who wish
to prevent transmission to a susceptible partner or wish
to prevent outbreaks, continuous antiviral suppressive
therapy may be advised. These drugs are well tolerated,
with few adverse effects. This long-term suppressive
therapy does not limit latency, and reactivation of the
disease frequently occurs after the drug is discontinued.
In 2002, the FDA approved long-term suppressive ther-
apy with valacyclovir and condom use for the preven-
tion of HSV-2 transmission to an uninfected sexual
partner. Infection with HSV-2 may predispose an indi-
vidual to HIV infection and antiviral therapy does not
reduce this risk.
4
Maternal/Neonatal Transmission
Herpes simplex virus may be transmitted from mother
to child around the time of delivery causing potentially
fatal disease in the newborn.
1,5,14,15
Women who experi-
ence their first genital HSV infection in pregnancy are at
highest risk of transmitting the disease to their newborn.
Disseminated neonatal infection carries high mortality
and morbidity rates. Because of the risk involved, many
authorities recommend that recently acquired HSV
infections in pregnant women be treated with antiviral
drugs (e.g., aciclovir or valaciclovir).
Active infection during labor may necessitate cesar-
ean delivery, ideally before membranes rupture, but this
is not a guarantee that the infant will not acquire infec-
tion. Pregnant women with a known history of HSV-2
infection should be treated with antiviral therapy from
36 weeks until delivery. If there are no active lesions at
the time of labor, vaginal delivery is preferred. Neonatal
HSV is treated with systemic antiviral therapy.
Chancroid
Chancroid is a disease of the external genitalia and
lymph nodes caused by the gram-negative bacterium
Haemophilus ducreyi
.
2,4,11
The disease is most common
in tropical and subtropical regions. It is one of the most
common causes of genital ulcers in less developed coun-
tries, especially in Africa and parts of Asia, where it prob-
ably serves as an important cofactor in the transmission
of HIV infection.
9
This STI has become uncommon in
the United States. However, recent evidence suggests that
chancroid may be underdiagnosed because many STI
clinics do not have the facilities to test for
H. ducreyi
.
Chancroid is highly infectious and is usually transmitted
by sexual intercourse or through skin and mucous mem-
brane abrasions. Autoinoculation may lead to multiple
chancres. Lesions begin as macules, progress to pustules,
and then rupture. On physical examination, lesions
and regional lymphadenopathy (i.e., buboes) may be
found. Secondary infection may cause significant tissue
destruction.
Diagnosis usually is made clinically, but may be con-
firmed through culture. Gram stain rarely is used today
because it is insensitive and nonspecific. There are no
FDA approved PCR tests for
H. ducreyi
.
4
The organism
has shown resistance to treatment with sulfamethoxa-
zole alone and to tetracycline.
4
Lymphogranuloma Venereum
Lymphogranuloma venereum (LGV) is an acute and
chronic venereal disease caused by
Chlamydia tracho
matis
types L1, L2, and L3. The disease, although found
worldwide, has a low incidence outside the tropics.
Most cases reported in the United States are in men.
There appears to be a new variant of L2 that is causing
a resurgence of LGV in Europe and the United States,
particularly in men who have sex with men.
4,11
The lesions of LGV can incubate for a few days to sev-
eral weeks and thereafter cause small, painless papules
or vesicles that may go undetected. An important char-
acteristic of the infection is the early (1 to 4 weeks later)
development of large, tender, and sometimes fluctuant
inguinal lymph nodes called
buboes
. There may be flulike
symptoms with joint pain, rash, weight loss, pneumonitis,
tachycardia, splenomegaly, and proctitis. In later stages of
the disease, a small percentage of affected persons develop
elephantiasis (hypertrophy, edema, and fibrosis of the skin
and subcutaneous tissues) of the external genitalia, caused
by lymphatic obstruction or fibrous strictures of the rec-
tum or urethra from inflammation and scarring. Urethral
involvement may cause pyuria and dysuria. Cervicitis
is a common manifestation of primary LGV in women,
and could extend to perimetritis or salpingitis, which are
known to occur in other chlamydial infections.
4
Anorectal
structures may be compromised to the point of inconti-
nence. Complications of LGV may be minor or extensive,
involving compromise of whole systems or progression to
a cancerous state.
Diagnosis usually is accomplished by a complement
fixation test for LGV-specific
Chlamydia
antibodies.
High titers for this antibody differentiate this group
from other chlamydial subgroups. PCR techniques,
when more widely available, will provide a more practi-
cal, cost-effective tool for diagnosis.
4
Treatment involves
3 weeks of doxycycline, tetracycline, or erythromycin.
4
Because doxycycline is contraindicated in pregnancy,
erythromycin should be used. Surgery may be required
to correct sequelae such as strictures or fistulas or to
drain fluctuant lymph nodes.
SUMMARY CONCEPTS
■■
Sexually transmitted infections (STIs) are spread
by sexual contact and involve both male and
female partners. Portals of entry include the
mouth, genitalia, urinary meatus, rectum, and
skin. All STIs are more common in persons who
have more than one sexual partner, and it is
not uncommon for a person to be concurrently
infected with more than one type of STI.
(continued)
