Pediatric Primary Care (97 page)

H.  Follow up.

1.  Test of cure for uncomplicated gonococcal infection not indicated.

2.  Persistent infection may be due to reinfected or untreated co-infection with chlamydia.

I.  Complications.

1.  PID.

2.  Tubal scarring.

3.  Infertility.

4.  Ectopic pregnancy.

5.  Hematogenous spread causing skin and joint syndrome.

J.  Education.

1.  Partners need to be evaluated and treated.

2.  Encourage use of condom.

3.  Screen for other STIs (chlamydia, HIV, syphilis, hepatitis B).

VII. SYPHILIS

A.  Etiology.

1.  Person-to-person transmission of spirochete,
Treponema pallidum.

2.  Incubation is 10–90 days.

B.  Occurrence.

1.  Rare in much of industrialized world but problem in large U.S. urban areas and the rural South.

C.  Clinical manifestations.

1.  Primary: painless, indurated ulcers (chancres) at site of inoculation, within 3 weeks of exposure.

2.  Secondary: 1–2 months later, generalized maculopapular rash (includes palms and soles), fever, malaise, headache, lymphadenopathy.

3.  Hypertrophic, papular lesions (condyloma lata) in moist areas of vulva or anus.

4.  Latent: seroreactivity but no clinical manifestations of syphilis, may last years.

a.  Early latent: acquired in last year.

b.  Late latent: acquired more than 1 year ago or unknown duration.

5.  Tertiary: may be many years after acquiring infection; features major organ damage.

6.  Neurosyphilis: central nervous system (CNS) disease can occur during any stage of syphilis; examine cerebrospinal fluid in patients with neurologic involvement.

D.  Physical findings.

1.  Primary: chancre at site of inoculation, painless ulcer.

2.  Secondary: maculopapular rash, generalized, including palms/soles, condyloma lata.

3.  Neurosyphilis: abnormal neurologic exam.

E.  Diagnostic tests.

1.  Positive dark-field exam is definitive for syphilis but may not be readily available.

2.  Nontreponemal tests (VDRL, RPR) are quantitative, testing activity, treatment response. Same lab should measure subsequent tests to ensure reliability. Tests may become negative 2 years after treatment.

3.  Treponemal tests (FTA-ABS, TP-PA) must confirm nontreponemal test.

4.  Tests usually positive for life. Other spirochetal disease causes positive test (yaws, pinta, leptospirosis, rat-bite fever, Lyme disease).

F.  Differential diagnosis.

1.  Rash of secondary syphilis can be confused with pityriasis rosea, making blood evaluation important for sexually active adolescents diagnosed with pityriasis.

G.  Treatment.

1.  Recommended regimen for adults.

a.  Primary, secondary, and early latent:

•  Penicillin G benzathine, 2.4 million units IM single dose (preferred), OR

•  If penicillin allergic, not pregnant: doxycycline 100 mg PO bid for 14 days, OR tetracycline 500 mg PO qid for 14 days.

b.  Late latent, latent of unknown duration, tertiary or neurosyphilis, HIV-positive and pregnant patients refer to CDC guidelines for treatment. Note: Patients allergic to penicillin should be desensitized.

H.  Follow up.

1.  Evaluate blood tests for early-acquired syphilis at 3, 6, and 12 months.

2.  Add 24-month test for persons with syphilis of 1 year duration.

I.  Complications.

1.  Untreated syphilis causes damage to most body organs over time, infects partners.

2.  Co-infection with HIV, other STIs.

3.  Infected pregnant women pass along syphilis to fetus, resulting in stillbirth, hydrops fetalis, or prematurity. Infants may suffer numerous complications.

4.  Jarisch-Herxheimer reaction (acute, febrile reaction with headache myalgia) may occur in first 24 hours after treatment (occurs most with patients being treated for early syphilis). Antipyretics may be used but may not prevent this reaction.

J.  Education.

1.  Sexual partners must be treated. Public health department finds contacts anonymously.

2.  HIV status should be checked. If negative, recheck in 3 months.

3.  Safer sex counseling.

VIII. TRICHOMONIASIS

A.  Etiology.

1.
Trichomonas vaginalis
is a flagellated protozoan.

B.  Occurrence.

1.  Primarily sexually transmitted, may coexist with other STIs.

C.  Clinical manifestations.

1.  Most males have no symptoms.

2.  Females may have profuse, pruritic, malodorous, yellow-green vaginal discharge or no symptoms at all.

3.  Incubation period: 4–28 days.

D.  Physical findings.

1.  Females: frothy white, yellow-green vaginal discharge with erythematous vaginal mucosa and friable “strawberry cervix.”

E.  Diagnostic tests.

1.  On wet mount, trichomonad has jerky motion and lashing flagella.

F.  Differential diagnosis.

1.  Other STIs such as gonorrhea and chlamydia could be cause of discharge.

2.  Monilia could be cause of pruritus.

G.  Treatment.

1.  Recommended regimen: metronidazole 2 g dose PO, OR

2.  Tinidazole 2 g orally in a single dose, OR

3.  Alternative regimen: metronidazole 500 mg PO bid for 7 days.

H.  Follow up.

1.  None needed unless discharge persists.

I.  Complications.

1.  If no response to initial treatment, may repeat metronidazole 1 g bid for 7 days OR 2 g daily for 3–5 days. If treatment failure occurs twice with metronidazole 2 g single dose, treat with metronidazole 500 PO bid for 7 days OR or tinidazole 2 g PO for 5 days.

2.  In rare cases where infection persists despite treatment of patient and partner, CDC may be helpful in looking at resistance of organism.

J.  Education.

1.  Treat partners even if no symptoms.

2.  Patients should abstain from sex until they and any partners are treated and asymptomatic.

3.  Safer sex counseling.

4.  Screen for other STIs.

5.  No alcohol consumption for 48 hours due to disulfiram-like effects of metronidazole (flushing, pulsating headache, violent vomiting, restlessness).

IX. VULVOVAGINITIS

A.  Etiology.

1.  Bacterial vaginosis is syndrome found in sexually active females caused by changes in vaginal flora. Normal vaginal ecosystem is disrupted by increases in
Gardnerella vaginalis, Mycoplasma hominis, Ureaplasma
species, anaerobic bacteria, and marked decrease in lactobacillus species.

2.  Incubation is unknown.

B.  Occurrence.

1.  Common, may occur with other infections.

2.  Although not proven to be sexually transmitted, it is uncommon in sexually inexperienced females.

C.  Clinical manifestations.

1.  May have no symptoms.

2.  White, homogenous, adherent vaginal discharge with fishy odor.

D.  Physical findings.

1.  White, malodorous vaginal discharge.