who are likely to have poor treatment compliance or are unlikely to return for follow-up, azithromycin, which is given as a single dose, is preferred to doxycycline, which is taken twice daily for 7 days. In addition, tetracyclines should be avoided in pregnancy.
7. The use of criteria to identify women among a low-prevalence population who are at increased risk for chlamydial infections, to test these women for cervical chlamydial infections, and to treat those who are found to be infected has significantly reduced the incidence of PID in a low-prevalence population. Adolescent inner-city females are a very high-prevalence population for C. trachomatis, and on the basis of a prospective longitudinal study, the screening of all sexually active adolescent females every 6 months has been advocated. Similarly, the high prevalence of both chlamydial and gonococcal infection in women entering jails and adolescents entering juvenile detention centers suggests that screening of these women may be worthwhile.
Untreated lower genital tract infections in women may lead not only to PID but to complications of PID, including infertility, ectopic pregnancy, and chronic pelvic pain, as noted above.
REFERENCES
1. Bolan GA, Sparling PF, Wasserheit JN. 2012. The emerging threat of untreatable gonococcal infection. N Engl J Med 366:485–487.
2. Burstein GR, Gaydos CA, Diener-West M, Howell MR, Zenilman JM, Quinn TC. 1998. Incident Chlamydia trachomatis infections among inner-city adolescent females. JAMA 280:521–526.
3. Centers for Disease Control and Prevention (CDC). 1999. High prevalence of chlamydial and gonococcal infection in women entering jails and juvenile detention centers—Chicago, Birmingham, and San Francisco, 1998. MMWR Morb Mortal Wkly Rep 48:793–796.
4. Centers for Disease Control and Prevention (CDC). 2012. Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep 10:590–594.
5. Katz AR, Effler PV, Ohye RG, Brouillet B, Lee MV, Whiticar PM. 2004. False-positive gonorrhea test results with a nucleic acid amplification test: the impact of low prevalence on positive predictive value. Clin Infect Dis 38:814–819.
6. Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. 1996. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 334:1362–1366.
7. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). 2010. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 59:1–116.
CASE 4
The patient was a 20-year-old female who presented to the emergency room with a 4-day history of fever, chills, and myalgia. Two days prior to this she had noted painful genital lesions. On the day of admission she developed headache, photophobia, and a stiff neck. Previously she had been in good health. She admitted to being sexually active but had no history of sexually transmitted infections.
On physical examination, she was alert and oriented. Her vital signs were normal except for a temperature of 38.5°C (101.3°F); pulse rate was 80 beats/min, and blood pressure was 130/80 mm Hg. A general examination was unremarkable except for slight nuchal rigidity. Her throat was clear, and there was no lymphadenopathy. A pelvic examination revealed extensive vesicular and ulcerative lesions on the left labia minora and majora with marked edema. The cervix had exophytic (outward-growing) necrotic ulcerations.
General laboratory tests were unremarkable. A vaginal swab was collected for Neisseria gonorrhoeae and Chlamydia trachomatis nucleic acid amplification test (NAAT), a swab of the lesions was sent for herpes simplex virus (HSV) NAAT, and an RPR (rapid plasma reagin) was performed. A lumbar puncture was also done, which had a normal opening pressure. The cerebrospinal fluid (CSF) showed a mild pleocytosis with a leukocyte count of 41/μl with 21% polymorphonuclear leukocytes and 79% mononuclear cells, a glucose level of 46 mg/dl, and a protein level of 68 mg/dl (slightly elevated). The RPR and a CSF VDRL test were negative. A NAAT was positive from the lesion as well as from her CSF. The patient’s condition improved after 2 days of intravenous therapy. She was discharged home on oral medication.
1 1. What is the differential diagnosis of ulcerative genital lesions? Which rapid test was used so that specific therapy could be started?
2 2. Which complication of her underlying illness did she develop?
3 3. If she had been pregnant at the time of her infection, for what would her fetus be at risk?
4 4. Briefly describe the natural history of this infection.
5 5. Briefly describe the epidemiology of the agent causing her infection.
6 6. There are two different serotypes of the agent causing her infection. What similarities do they share and what are the differences between these agents?
CASE 4 CASE DISCUSSION
1. In the United States, the most likely diagnosis is either genital herpes or syphilis. In studies of patients with genital lesions in the industrialized world, HSV is the most frequently recovered agent. Other agents that are common causes of genital lesions include Haemophilus ducreyi (the etiologic agent of chancroid), human papillomavirus (genital warts), and the lymphogranuloma venereum-causing serotypes of C. trachomatis. Genital herpes lesions are painful, whereas lesions due to Treponema pallidum are usually painless. Genital infections such as chancroid or lymphogranuloma venereum can result in painful or painless ulcers, respectively, but they often result in suppurative lymphadenopathy. The diagnosis of HSV infection can be confirmed by swabbing the base of the lesion and performing either viral culture or NAAT. Using a shell vial culture technique, the virus can usually be detected within 24 hours. However, detection of HSV antigen by immunofluorescence or DNA from the lesion by NAAT is more rapid than culture. In addition, NAAT testing of lesions may be more sensitive than culture, though it is critical to monitor for laboratory contamination since these specimens contain high viral titers. To date, there is only one FDA-cleared NAAT for HSV, which is only approved for vaginal lesion swabs. Tzanck preparations, in which smears taken from the edge of the lesion are examined for the presence of cells showing pathologic changes consistent with HSV infection, can also be used in the diagnosis of genital lesions. This technique, although inexpensive, lacks both the sensitivity and specificity of culture, immunofluorescence, or NAAT. HSV was detected in this patient by an HSV NAAT performed on a swab of her genital lesion, which was positive for HSV-2.
2. Among women with primary genital herpes due to HSV-2, approximately one in three will have self-limited, aseptic meningitis. These patients typically have a pleocytosis with a lymphocytic predominance and an elevated protein level, as was seen in this case. In this clinical setting, CSF would not always be obtained. A NAAT was positive from the lesion as well as from her CSF. While HSV NAAT testing on lesions performs similarly to culture, NAAT testing on CSF is much more sensitive than culture. When CSF cultures were standard laboratory practice, the rate of isolation of HSV-2 was 0.5 to 3.0% in patients with aseptic meningitis. Now that NAAT testing of CSF is the reference method, the rate of detection of HSV-2 has increased to 5 to 17%.
3. Her fetus would be at risk for neonatal
