Sexually Transmitted Diseases

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69

Sexually Transmitted Diseases

In this chapter, five sexually transmitted diseases (STDs) are covered – syphilis, gonorrhea, chancroid, lymphogranuloma venereum (LGV), and granuloma inguinale. Additional more common STDs including herpes simplex infections, molluscum contagiosum, condyloma acuminata, crab lice, and HIV infection are discussed in Chapters 67, 68, 66, 71, and 65, respectively. When one STD is present, a search for others is indicated.

Syphilis (Lues)

Etiologic agent is the spirochete Treponema pallidum; the infection is divided into four phases: primary, secondary, latent, and tertiary (Fig. 69.1), in addition to a congenital form.

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Fig. 69.1 Natural history of untreated syphilis. Chancres spontaneously resolve after a few weeks (see Fig. 69.3). In the group of patients with no recurrence, the rapid plasma reagin (RPR) becomes negative in 50% and remains positive in 50%. Adapted from Rein MF, Musher DM. Late syphilis. In: Rein MF (Ed.), Atlas of Infectious Diseases, Vol. V: Sexually Transmitted Diseases. New York: Current Medicine, 1995:10.1–10.13. Inset figure: Adapted from Morse SA, et al. Atlas of Sexually Transmitted Diseases and AIDS, 3rd ed. London: Mosby; 2003.

Syphilis is 7–8 times more common in men than in women in the United States, and the highest rates are in black and Hispanic individuals and in men who have sex with men (MSM); there is an increased risk of transmission of HIV infection in those with ulcers due to syphilis as well as chancroid or herpes simplex viral infection.

One or more ulcers, usually anogenital, characterize primary syphilis and are referred to as chancres (Fig. 69.2); the ulcers are painless (unless secondarily infected) and upon palpation the base is firm; regional lymphadenopathy may be present (Fig. 69.3).

Secondary syphilis reflects hematogenous dissemination and the skin lesions vary from macular to papulosquamous and from annular to granulomatous (Figs. 69.4 and 69.5); mucosal involvement is common and includes mucous patches, split papules at the angles of the mouth and condyloma lata (Fig. 69.6); usually accompanied by constitutional symptoms (Table 69.1).

Tertiary syphilis is preceded by a latent phase that can last for years (Fig. 69.7); the skin and mucous membranes, as well as the bones, develop gummas (Fig. 69.8), with cardiovascular syphilis and neurosyphilis representing the major causes of death in those who remain untreated.