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Episode #5 – Adventures from STI Clinic

5 Cover Art (1500)

Summary

Dr. Anu Hazra leads us through a medley of cases in STI clinic.

Credits

Host: Sara Dong

Guest: Anu Hazra

Writing/Producing/Editing/Cover Art: Sara Dong

Infographics: Elise Merchant, Sara Dong

Our Guests

Anu Hazra, MD

Twitter

Dr. Anu Hazra is an Assistant Professor in the Section of Infectious Diseases and Global Health at the University of Chicago and Director of STI Services at the Chicago Center of HIV Elimination.  In addition to his work at UofC, he is also co-Medical Director of Howard Brown Health’s 55th Street Clinic. Howard Brown Health is a prominent federally qualified health center specializing in the needs of LGBTQ people living in the Midwest.

 

His research centers around sexually transmitted infections and their impact on sexual and gender minorities as well as other vulnerable populations living on the South Side of Chicago. These interests are complemented by his clinical work in complex HIV management, PrEP care, Hepatitis C management, gender affirming hormone therapy, high resolution anoscopy, treatment of opioid use disorder, as well as medical education.  Above all else, he is passionate about the equitable delivery of healthcare to LGBTQ people of color.

Elise Merchant, MD

Twitter

Dr. Elise Merchant is now an ID attending at Tufts.  She completed my adult Infectious Diseases Fellow at Beth Israel Deaconess Medical Center. She grew up in Montana, but moved to New England to study Anthropology and Biology at Brown University, then attended medical school at Tufts University School of Medicine. She stayed on at Tufts Medical Center for Internal Medicine residency and a chief resident year, before moving across town to BIDMC for fellowship, where she completed additional training in the Clinician Educator Track.

Her interests include medical education, HIV, and sexually transmitted infections. She also love board games, fantasy novels, dabbling in art, consuming caffeine, and hanging out with my cat, Ollivander.

Culture

Anu likes to catch up on Real Housewives of NYC to relax!

Consult Notes

One-liners

  1. 25 yo previously healthy male with persistent urethral discharge who was found to have Mycoplasma genitalium infection.
  2. 40 yo male with painless penile ulcer, pain in buttocks, and inability to urinate who was diagnosed with HSV-related lumbosacral radiculitis (sometimes known as Elsberg syndrome)
  3. 20 yo transgender female with well controlled HIV presented with a tender right cervical/neck mass and found to have cervical lymphogranuloma venereum.
  4. 16 yo female with pelvic inflammatory disease

Key Points

Jump to:

How to take a comprehensive sexual history and create a comfortable environment

  • Practice makes perfect! Hone your language over time
  • Context matters: in a STI clinic, patients are more prepared for the questions, but in other settings they might not have thought about it
  • Start with a preamble emphasizing sexual health:
      • “Hey, I’m going to spend a few minutes talking about your sexual health, because your sexual health is part of your general health itself”.
      • Defuse concerns about invasion of privacy
      • Then give patients a beat to talk and consent to the conversation, or defer it.
  • Ask open-ended questions:
      • “Tell me about your sex life”
      • “What are your biggest concerns about your sexual health?”
      • “Are you satisfied with your sexual health? How is your current sex life similar or different from what you think your ideal sex life would be?”
        • This can often open up a conversation about dysphoria with sex or intimate partner violence
  • Let the patient lead, and probe with questions.
      • “Besides the people you’ve discussed, is there anyone else? Tell me about your other sexual partners.”
      • “Tell me what you do to protect yourself against HIV or STIs. What would you do to take even better care of your sexual health?”
  • You can use the 5 Ps to help you remember important topics: partners, practices, protection, past STIs, prevention of pregnancy
      • Partners:
        • Try: “Tell me about your sexual partners.” or “What are the genders of your sexual partners?”
        • “Do you have sex with men, women, or both?” can be gendering and lead you to miss things
      • Practices:
        • “To understand your risk of STIs, I need to understand what kinds of sex you have”
        • Reflect the language patients use
          • Avoid overly complex language
          • If patients are using language you don’t typically use, it’s okay to follow them.
        • Use specific questions that spell out the practices:
          • “Do you have penis in vagina sex? Penis in butt sex?”
          • Ask about other types of sexual behavior – oral sex, receptive anal sex 
      • Protections from STIs: 
        • Condoms, PrEP, PEP
        • Vaccination
        • Partner services
      • Past history of STIs
      • Planning or prevention of pregnancy 
  • After getting information, discuss a course of action: “Based on what we talked about, I think these types of tests would be beneficial”

Some resources:

Approach to urethritis

What about a patient who returns due to recurrent or persistent symptoms after treatment for urethritis?

  • Considerations might include:
    • Poor adherence with treatment regimen
    • Reinfection
    • Antimicrobial resistance
    • Involvement of another organism.  Think about M.genitalium or in MSW, Trichomonas

Let’s talk about Mycoplasma genitalium!

Genital ulcers

  • Classically genital ulcers are broken into painless or painful:
      • Painless: 
          • Syphilis (Treponema pallidum)
          • Early LGV (Chlamydia trachomatic serovars L1-3)
          • Donovanosis (granuloma inguinale; Klebsiella granulomatis)
      • Painful: 
          • HSV-1 and -2
          • Chancroid (Haemophilus ducreyi)
  • The ddx also includes:
      • Non-STIs: TB, amebiasis, leishmaniasis
      • Non-infectious: Lipschutz ulcer, fixed drug reaction, Behcet, Crohns disease, trauma
  • Patients don’t always read the textbook though!
      • Syphilitic chancres can become superinfected and painful
      • Reports of non-painful HSV penile ulcers
  • Keys to figuring out the cause of genital ulcers:
      • Symptoms.  In addition to the painful/painless noted above, investigate if they have constitutional symptoms (which may point to HSV, secondary syphilis, LGV)
      • Sexual history
      • Geographic location and travel
      • Medications
      • Physical exam: appearance of ulcers, presence of lymphadenopathy, other findings

We discussed the importance of differentiating dysuria vs inability to urinate due to acute urinary retention.  What to think about with the inability to urinate in this STI setting:

  • Infections may start with dysuria but progress to urinary retention over time, particularly in: prostatitis or prostatic abscess, cystitis, gonorrhea or chlamydia with urethral abscess
  • Neurological condition is likely going to have urinary retention from the onset of symptoms
    • Don’t forget about cauda equina syndrome
    • Think about complicated HSV or VZV infection
    • Epidural abscess
  • Mechanical obstruction or trauma, such as penile fracture or urethral obstruction
  • Anticholinergic medications

We presented a case of complicated HSV infection: HSV lumbosacral radiculitis

  • Complicated HSV infection can lead to lumbosacral radiculitis, which could be related to primary or reactivation disease.  This is sometimes known as Elsberg syndrome
  • Elsberg syndrome describes acute or subacute bilateral lumbosacral radiculitis, often accompanied by localized myelitis.  This complication can be transient, but might require urinary catheterization temporarily

A quick notes on HSV diagnosis

  • HSV PCR swab of an ulcer is the preferred diagnostic test / gold standard.  You can also do viral culture in some cases, which allows for resistance testing
  • Serologic testing reflects if patient has EVER had exposure, but doesn’t tell you if active disease
    • Type-specific HSV serologic assays can be helpful in specific situations with high clinical suspicion:
      • Recurrence of lesions with negative PCR or culture
      • Signs of genital HSV with no laboratory confirmation
      • Partner with known genital herpes
    • Serologic two-step testing:  Commercially available immunoassays often have poor sensitivity and are false positive at low index values (<3.0-3.5).  May need a confirmatory test with a different antigen.  
      • HSV2 infection should not be diagnosed with EIA <3.5 without confirmation, but 
      • EIA >=3.5 is sufficient for diagnosis without confirmation

Some of Anu’s tips to approach to sexual health for TGNC people

  • Have some perspective
    • Many transgender people have experienced violence, including sexual violence
    • Many transgender people have had prior negative experiences with the medical-industrial complex and may view medical providers as gatekeepers to the care that they need or desire
    • Any transference is not personal, but based on lived experiences, and should be interpreted as such!
  • Allow the patient to retain control throughout the encounter
    • Greet patient while they are dressed
    • If genital exam is required
      • Focus only on organs that are present and possibly at risk of infection based on history
      • Explain to patient why genital exam is required
      • Verbally walk patients through steps of the exam to allow mental preparation
      • Offer choices and decision-making ability
        • Empower the patient to say no to any part of the exam!
          • Empiric treatment without exam is an option
  • Trans-inclusive and gender-affirming EMR is important as well!  EMR should be organ system-based, and reflect patient’s current anatomy

In case 3, Anu discussed the differential diagnosis of cervical lymphadenopathy in people living with HIV.  Here is a list of the many possibilities:

  • Bacterial 
      • Primary and secondary syphilis (typically not irregular or with necrotic center like the podcast case)
      • Staph or Strep infection
      • Bartonella
      • Tularemia
      • Lemierre’s syndrome – septic thrombophlebitis might look like cervical chain LAD
      • Mycobacterial: TB/Scrofula (especially if history of homelessness or incarceration); NTM
      • Others: LGV, Brucella, Leptospira, Yersinia/Plague
  • Viral
      • Adenovirus
      • CMV, EBV
      • VZV
      • Rubella, measles, mumps (if not vaccinated)
      • Dengue
  • Fungal
      • Histoplasma
      • Coccidioidomycosis
      • Blastomycosis
      • Cryptococcosis
  • Parasitic 
      • Toxoplasma
  • Malignancies or lymphoproliferative diseases
      • Lymphoma (diffuse large B-cell) or leukemia
      • Kaposi’s sarcoma (if low CD4)
      • Castleman’s disease
      • Skin neoplasms (SCC)
      • Metastatic disease
  • Others:
      • Kikuchi disease
      • Sarcoidosis, amyloidosis, lupus, Stills disease
      • Serum sickness; drug reaction; IgG4-related disease
  •  

Lymphogranuloma venereum (LGV)

This was a unique case of cervical infection with LGV.  A few facts about cervical or oropharyngeal LGV:

We’ll end with pelvic inflammatory disease

Other miscellaneous mentions and notes:

Episode Art & Infographics

Goal

Listeners will be able to describe the initial evaluation and management of urethritis, M.genitalium and LGV infection, and pelvic inflammatory disease.

Learning Objectives

After listening to this episode, listeners will be able to: 

  • List the recommended first-line treatment for pelvic inflammatory disease, gonococcal urethritis, M.genitalium and LGV infections.
  • Summarize the differential diagnosis of cervical lymphadenopathy in a patient living with HIV
  • Describe the differential diagnosis of genital ulcers
  • Take a comprehensive sexual history
  • Describe basic characteristics of quality care for transgender individuals

Disclosures

Our guest (Anu Hazra) as well as the Febrile podcast and hosts report no relevant financial disclosures.

Citation

Hazra, A., Dong, S.  “#5: Adventures from STI clinic”. Febrile: A Cultured Podcast.  https://player.captivate.fm/episode/de5461dc-b355-4290-be53-33c763900f34

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