Disseminated Gonococcal Infection
Disseminated gonococcal infections are generalised infections resulting from haematogenous (bloodborne) spread of the bacterium. Migratory polyarthritis, arthralgia and tenosynovitis are the most common findings. Arthritis is the most common component of disseminated gonococcal infection. There are fever, chills and skin lesions that start as papules and become pustules. Endocarditis (infection of the heart) is seen in 1-2% of cases. In rectal gonorrhoea (in the last part of the bowel), there is pain, discharge and bleeding from the rectum. Sometimes the infection also settles in the pharynx, where it usually causes no symptoms. Pharyngeal and rectal infections are known to be more resistant to treatment. Perihepatitis (Fitz-Hugh-Curtis syndrome) should be considered in patients who develop pain that increases with coughing, bending forward and deep breathing and radiates to the right shoulder, together with fever, nausea and vomiting.
Granuloma Inguinale
When talking about sexually transmitted infections, one cannot fail to mention "DONOVANOSIS", one of the most common sexually transmitted diseases in less developed countries. This disease is seen most often in the tropical and subtropical regions of Africa and Asia. It is not very contagious and is transmitted through repeated contact. Although it is not common in our country (Turkey), it can be missed because it is not well known. It is not common in Europe and developed countries.
What Causes It?
It is caused by a bacterium formerly known as Klebsiella granulomatis, now called "Calymmatobacterium granulomatis".
What are the signs?
* Small lumps on the reproductive (genital) organs that grow slowly and insidiously and gradually turn into sores.
* The edges of the sore are white, and its base is red and raised.
What are the risk factors?
* Tourism
* Travel
* Multiple sexual partners
* Poverty
* Same-sex sexual contact
How is it diagnosed?
The diagnosis can be made by seeing the typical sore and identifying "Donovan bodies" in samples taken from it stained with Giemsa, Wright and Leishman stains, or by pathological examination of the sore. Today, indirect fluorescence tests and PCR tests have been developed, making diagnosis easier for us.
How is it treated?
Azithromycin is given by mouth, 1 gram on the first day and then 0.5 gram a day, for at least 3 weeks. If necessary (if it recurs), the duration must be extended. Alternatively, tetracycline 4x0.5 g or doxycycline 2x100 mg can be given by mouth for 3 weeks.
What is genital herpes?
Genital herpes is a viral disease caused by HSV (herpes simplex virus), belonging to the group of sexually transmitted diseases, and spread through contact of the mucous membranes of the mouth, vagina or genital area. Genital herpes is an infection affecting the genital areas (the penis in men, the vulva and vagina in women) and the surrounding area (buttocks and anus).
What causes genital herpes?
Two types of herpes simplex virus cause genital lesions: HSV-1 and HSV-2.
HSV-1 most often causes blisters around the mouth, while HSV-2 causes genital sores or lesions around the anus. Outbreaks of herpes are closely related to the immune system. In women whose immune system is weakened (due to stress, infection or medication), the disease is more frequent and prolonged.
Herpes simplex virus type 1 (HSV-1)
This virus is mostly seen as an infection of the lips, mouth and face. It is the most common form of herpes simplex, and many people contract it in childhood. HSV-1 often causes sores and blisters in the mouth or eye infections (particularly of the conjunctiva and cornea). It can also cause infection of the brain (meningoencephalitis). It is transmitted through contact with infected saliva. In adult life, 30-90% of people have developed antibodies. It is more common in communities with lower socio-economic status.
Herpes simplex virus type 2 (HSV-2)
This virus is usually transmitted through sexual intercourse. Symptoms take the form of ulcers and sores in the genital area. However, some people with HSV-2 may have no symptoms. Oral-genital contact can cause cross-infection with type 1 and type 2; in other words, you can get genital herpes from your mouth and oral herpes from your genital area.
Genital herpes spreads only through direct person-to-person contact. It is believed that 60% of sexually active adults carry the disease.
HIV Infection
HIV (Human Immunodeficiency Virus) infection is a chronic infectious disease in which the immune system is progressively suppressed by the causative virus.
The virus that causes the disease (HIV) is a retrovirus belonging to the lentivirus family. Retroviruses are enveloped viruses containing single-stranded RNA. Through the enzyme reverse transcriptase, they convert their genetic material into double-stranded DNA and integrate it into the host chromosome.
On the surface of human lymphocytes there are specific glycoproteins involved in cell activity and function. Lymphocytes carrying the CD4 cell-surface antigen are cells that help immunological reactions. CD4+ lymphocytes are also the primary targets of HIV infection. Over the course of HIV infection, the CD4+ T-cell count progressively falls, and as a result the opportunistic infections and cancers characteristic of AIDS appear.
After the virus is acquired, the disease follows certain stages. Below, the course of the disease is described first, followed by the clinical findings in the various organ systems seen during the disease and the treatment of the disease.
I. CLINICAL COURSE OF HIV INFECTION
The natural course of HIV infection is examined in seven stages.
1. Transmission of the virus
2. Primary HIV infection (acute HIV infection)
3. Seroconversion (antibody formation)
4. Asymptomatic period
5. Early symptomatic period
6. Late symptomatic period (AIDS)
7. Advanced stage
1. Transmission of the Virus:
HIV/AIDS is transmitted mainly in three important ways:
a. Sexual transmission:
HIV/AIDS is transmitted through all types of sexual contact (homosexual, heterosexual, oral, vaginal or anal). A single sexual contact with a person carrying the virus is enough for transmission. The more sexual contacts with people infected with HIV, the higher the likelihood of transmission. The risk of transmission is higher in sexual contact with people who have multiple sexual partners, change partners frequently, inject drugs, or have to receive frequent blood transfusions because of conditions such as haemophilia, other bleeding disorders or chronic kidney disease. Oral, vaginal and anal sexual contact differ in terms of transmission risk; the risk is higher with anal sex.
b. Transmission through blood and blood products:
Because the virus is present in large amounts in the blood, the disease can be transmitted when blood and blood products taken from people carrying the virus are used in another person. However, once antibodies against the virus could be detected in blood in 1985, testing blood and blood products for HIV before giving them to patients became a legal requirement. As a result, transmission by this route fell dramatically in subsequent years.
However, transmission through people who inject drugs sharing the same needle/syringe is being seen at increasing rates.
c. Mother-to-child transmission:
HIV can pass from mother to baby during pregnancy, during delivery and through breastfeeding. However, this rate of 20-30% can be reduced to 8-10% by starting the HIV-positive mother on antiretroviral (virus-suppressing) medication, giving the same medication to the baby after birth, and performing an elective caesarean section.
2. Primary HIV infection (acute HIV infection):
Within 1-6 weeks of entering the body, HIV causes an acute infection during its first period of replication. In this period the clinical findings are variable and not specific to HIV infection. The symptoms and their frequencies are reported as follows: fever (96%), enlarged lymph nodes (lymphadenopathy) (74%), pharyngitis (70%), skin rashes (70%), muscle or joint pain (54%), diarrhoea (32%), headache (32%), nausea and vomiting (27%), enlargement of the liver and spleen (14%), oral thrush (12%). In some cases, nervous system findings such as meningitis and encephalitis are found. All these findings resolve within 2-4 weeks without the need for treatment. The person is infectious from the acute infection period onwards.
3. Seroconversion:
After the virus enters the body, antibodies against HIV develop within 6-12 weeks in 95% of cases. These antibodies do not prevent the disease from progressing, but they are important for diagnosis. This period is called the "seroconversion period". Until the antibodies develop, the virus is present in the blood and the patient is infectious.
4. Asymptomatic Period:
After the seroconversion period, infected people enter the "asymptomatic period". During this period they have no signs or symptoms, but they are infectious. The asymptomatic period lasts 6.5-13 years (on average 8-10 years). However, 20-30% of cases can move on to the next period within an average of 1.5-5 years. Factors affecting this duration are the route by which the virus was acquired, the patient's age and the virulence of the virus. In those who acquired it through transfusion, the viral load is higher, so the period is 6 years, while in homosexual men who acquired the virus through sexual contact it extends to 10-12 years.
Physical examination is usually normal during this period. In 40-50% of cases, generalised lymphadenopathy may be found on examination. Enlarged lymph nodes can also be seen in various diseases other than HIV infection. To attribute them to HIV infection, the lymph node enlargement must be in at least two separate areas other than the groin, measure 0.5-2 cm in diameter and remain enlarged for longer than 3 months. Clinically, this period is a latent period. However, the virus continues to replicate in the lymphatic tissues and the CD4 cell count falls progressively.
5. Early Symptomatic Period:
This is the period when the symptoms that first lead patients to see a doctor begin. The most common signs and symptoms are weakness, headache, weight loss of more than 10% of body weight, fever of unknown cause, diarrhoea lasting longer than a month that cannot be treated, seborrhoeic dermatitis (a disease with scaling of the skin), widespread and frequent herpes virus infections and fungal infections of the mouth.
Along with a CD4 cell count, the viral load, which shows the amount of virus in the blood, should be measured, and treatment should be planned according to these parameters.
6. Late Symptomatic Period (AIDS):
In this period the immune deficiency becomes very marked, and opportunistic infections or cancers may appear. Although in common usage all HIV-related diseases are generally referred to as AIDS, in fact all the stages after the virus enters the body are HIV infection, and the final stage of this is AIDS. The AIDS-defining illnesses are certain infectious diseases caused by parasites, viruses and fungi that do not cause disease in people with an intact immune system, or do so only very rarely in special circumstances, and certain special types of cancer such as Kaposi sarcoma and brain lymphoma.
Particularly in this period, the diagnosis, treatment and prophylaxis (preventive treatment) of opportunistic infections are important.
7. Advanced Stage
Cytomegalovirus (CMV) retinitis, a viral infection of the retina of the eye, may be seen. In patients who have reached this stage, the appearance of a new AIDS-defining illness within an average of 2 years cannot be prevented, despite antiretroviral treatment.
Molluscum Contagiosum
Molluscum contagiosum is a common and relatively harmless viral skin infection. It is contagious and can be passed on through direct contact with another person. It is more common in children and young adults, but it can appear at any age.
What causes molluscum contagiosum?
Molluscum contagiosum is caused by a virus that is passed on through close contact with a person who has the infection or through shared towels and linen. The rash appears after an incubation period of a few weeks. It is more frequent and widespread in people with atopic eczema. Sometimes, numerous molluscum contagiosum lesions can develop in people whose immune system is suppressed for any reason (for example, those receiving immunosuppressive treatment). However, the great majority of people with molluscum contagiosum are healthy.
What are the treatment options?
• The lesions can be frozen with liquid nitrogen (cryotherapy) at intervals until they disappear.
• Some simple measures can make the lesions become inflamed and then disappear. These consist of piercing the lesions with a sharp needle and squeezing them with tweezers. A numbing cream can be used before this procedure.
• The lesions can be scraped away with a sharp instrument (curettage).
• Lesions on the eyelids should be managed by an ophthalmologist.
PEDICULOSIS PUBIS (PUBIC LICE, CRAB LICE)
Cause, Clinical Features and Diagnosis
The pubic louse (Pediculosis pubis) is a segmented parasite 1-4 mm long, with a pointed head and claws for clinging to pubic hair. This parasite is usually seen in people who have many sexual partners, live communally in crowded conditions and do not follow rules of hygiene. The infestation is usually limited to the pubic hair area and around the anus. However, it can also settle in the armpits and other hairy areas of the body. People infested with this parasite complain of itching, which can be severe.
A probable diagnosis is made on the basis of the patient's history and clinical assessment (papules or damaged skin in the itchy area). The diagnosis can be confirmed by seeing lice or eggs attached to the hairs in the genital area and examining them under a microscope.
The lice eggs hatch within a week and reach full maturity after about 8-10 days. Pubic lice are mostly transmitted through sexual intercourse. Warm, crowded environments increase person-to-person transmission. Lice and their eggs remain transmissible for as long as they stay alive on the infested person or on that person's clothing.
Treatment
- Permethrin (1%) is applied to the infested area, left for 10 minutes and then washed off, OR
- Lindane 1% shampoo is applied to the infested area, left for 4 minutes and then washed off, OR
- Pyrethrins with piperonyl butoxide are applied to the infested area, left for 10 minutes and then washed off.
Lindane is not used in pregnant or breastfeeding women or in children under 2 years of age.
Sexual partners should be treated in the same way.
Pediculosis of the eyelashes can be treated by applying an ophthalmic ointment to the lid margins twice a day for 10 days. With these methods, the lice or nits are deprived of air and suffocate. The medicines used should not be applied to the eye itself. Clothing and bed sheets used by the patient in the last 2 days should be washed, dried and ironed.
Prevention
- Sexual contact with infested people should be avoided, and items such as clothing and bedding used by them should not be touched.
- Public education should stress that laundry washed communally must be washed in hot water at 55°C for 20 minutes and always ironed after washing.