Dr Arvind M.

Kurhade
MBBS ; MD.
Lecturer , Medical Microbiology [ Clinical ] .
F .M . S . ; U . W . I .
 How the STDs spread? Anal sex

STDs spread in several ways , besides sexual intercourse.

Skin to Skin contact with infected areas , including

thighs , scrotum , vulva , penis , anus.

Touching below the waist

(infected areas)

Oral sex infected genitals to mouth or infected mouth

to genitals

Kissing infected mouth area.

Eye Infections (gonorrhea , Chlamydia , herpes) Genital Region (entire region
can be infected especially for
herpes , syphilis )
Oral region ( herpes , syphilis , gonorrhea )

Finger spread (to self or others)

Gonorrhoea
Neisseria Gonorrhoeae
Epidemiology Gonorrhoea=
 Significant public health problem with underestimated
incidence. Less reported cases - Community

High Incidence in some groups defined by

geography , age , sexual risk behavior - sex worker.

Asymptomatic carriage is major Reservoir

 4

PATHOGENESIS
Transmission & virulence factor
Transmission
Sexually transmitted - pyogenic infection - of Urethra
& Uterine Cervix.

Efficiently transmitted by:

Male to female via semen
 Female to male urethra
Rectal intercourse ( Anal sex )
Pharyngeal infection ( Oral sex )
Perinatal transmission ( Mother to Infant )

Gonorrhea associated with increased transmission of

And susceptibility to HIV infection
Virulence factors : -
Pili / Fimbriae : - Initial attachment to the cell surface with
Fimbriae / Pili: ( Adherence ) to the Urethral mucosa .

Capsule :- ( Polyphosphate capsule ) - Prevents phagocytosis

 Por protein ( protein I ) : Protects the phagocytosed bacteria from
intracellular killing .

Opa protein ( Protein II ): Allows tight attachment to host cells &

bacteria migrates into epithelial cells & multiplies.

Rmp protein ( Reduction modifiable protein ) = ( Protein III ) :

Stimulates production of antibodies that block serum bactericidal
activity against gonococci .

Incubation period 2-8 days.

Pathology & Clinical findings
In Men
 Urethritis Mucopurulent discharge
Chronic urethritis Stricture formation
Multiple discharging sinuses ( Water can perineum )
In WomenCervicitis ,
Vaginitis ( Prepubertal girls )
Endometritis - Uterus
Salphingitis
PID

( As a rule women are carriers of this infection )

Pathology & Clinical Manifestations:
Epididymitis -
 Symptoms : Unilateral
Testicular pain & swelling.

Infrequent but commonest

local complication in
males.

Usually associated with

subclinical urethritis
Swollen or Tender Testicles
Pathology & Clinical Manifestations-Cervicitis
Non - specific symptoms:
Abnormal vaginal discharge ,
Inter menstrual bleeding , Dysuria ,
Lower abdominal pain .

Clinical findings: Mucopurulent or

purulent cervical discharge , easily
induced Cervical bleeding.

50% of women with clinical

cervicitis have no symptoms.
 Symptoms may occur within 8
- 10 days of infection.
10

Pathology & Clinical

manifestation contd
Pharyngitis
Conjunctivitis-Autoinoculation

Disseminated Gonococcal
Infection ( DGI ) in 1-3%
Fever , Polyarthritis .
 Pustular-hemorrhagic skin rash
Pathological Manifestation in New Born
Non venereal - Neonates may become infected through
passage of the birth canal.

i) Gonococcal Ophthalmia Neonatorum - if

untreated
Blindness
Prevention: by Instillation of Tetracycline /
Erythromycin / Silver nitrate in conjunctival sac of New
Born .
 Complications in Women
Bartholin abscess
Pelvic Inflammatory Disease ( P I D ) 10
- 20 % ( Women with Endocervical
gonorrhea ) .
Acute Infection:
Salpingitis , Tubo-ovarian abscess ,
Endometritis , Bartholin abscess .

Chronic Infection:
Ectopic pregnancy , Infertility .

May be Asymptomatic OR
 May present with - Lower abdominal pain , Discharge ,
Irregular menstrual bleeding & Fever

LAB DIAGNOSIS
N . gONORRHOEAE
Specimen for Smear , Morphology , Culture &
Biochemical study
Pus

Secretions / discharge from : Urethra , Cervix,

 Synovial fluid from Joints in Disse. Gono. Infection

Swab from : Rectum , Conjunctiva , Throat

N. gonorrhoeae Microscopy - Gram stain
Gram negative -Diplococci
MORPHOLOGY:
In purulent material -
Organisms mainly Intracellular (
within Polymorphs - some may be
loaded with as many as 100
Cocci.)
Nonmotile Gram ve
Diplococci ( kidney shaped )
(pairs of cocci)- Bean shaped
adjacent sides concave.
 Fimbriae / Pilli on the surface.Responsible-for-
Adherence toUrethral mucosa .
Outer surface of cocci covered with loosely associated
Micro Capsule ( Slime ) Prevents Phagocytosis .
Culture:- Blood agar / Chocolate agar * 5-10% CO2
Chocolate agar [ heated blood
(brown)]
Modified Thayer Martin Enriched media with lysed blood &
antibiotic Selective for N. g. especially when specimen is from
vagina & rectum having other bacteria too which are inhibited.
Colistin: Inhibits Gram-ve flora (N. gonorrhoeae & N.
meningitidis
resistant to colistin , most saprophytic After 48 hrs of incubation
species :Small , Convex , Glistening ,
Soft , Mucoid Colonies.
of
Neisseria susceptible )
Vancomycin: Inhibits
Gram+ve. Nystatin:
Inhibits yeast flora.
 Trimethoprim: Inhibits swarming Proteus.
Biochemical
N gonorrhhoea - oxidase positive

reaction
Oxidase Test: Positive (
+ve ) .
Oxidase reagent -
Tetramethyl- para
 phenylene diamine hydrochloride.
Filter paper soaked with fresh oxidase reagent.
Gonococci ferments only
Glucose with Acid production.
Does not ferment other sugars.
Catalase positive .
Nucleic Acid Amplification Test
Essays for direct detection of N. gonorrhoeae in Genito
urinary specimen.
The specificity & sensitivity of the Test is very High.
Advantage : Better detection & rapid result.
 SEROLOGICAL TEST - Useful in chronic cases & in
metastatic lesions.
Includes : R.I.A.( Radio Immuno Assay ) & ELISA
Treatment:
Drug Resistance common - Chromosomally mediated &
Plasmid mediated to penicillin ( Lactamase producing ).
C.D.C. - U.S.A .- Recommends the Treatment of
Uncomplicated Genital & Rectal Infection by the use of :

Ceftriaxon 125 mg single IM OR

Cefrofloxacin 500 mg OR
 Ofloxacin 400 mg single oral dose + Doxycycline 100 mg
twice daily orally for 7 days.
Alternative to Doxycycline include Erythromycin 1 gm or
Azithromycin 1 gm single oral dose for 7 days.
Prevention

Early detection of cases & Tracing of contact Health

education & Other general measures.

 Barrier method with Condom can greatly reduce the
Transmission of Infection.

Avoid Multiple Sexual Partners.

Promotion of safe sex & individual counselling

Treponema
Trepos = to turn Nema = thread
Relatively short , slender with fine spirals & pointed or
rounded ends

Pathogenic - T. pallidum , T. pertenue , T. carateum

Taxonomy
 Domain: Bacteria
Phylum: Spirochaetes Order:
Spirochetales
Family: Spirochaetaceae
Genus: Treponema Species:
pallidum
Spirochaetes Associated
Human Diseases
Genus Species Disease
Treponema T.pallidum Syphilis
T. pertenue Yaws
T. Carateum Pinta

Borrelia B.burgdorferi Lyme disease (Borreliosis)

B.recurrentis Epidemic relapsing fever
B.vincentee Vincents angina

Leptospira L.interrogans Leptospirosis

(Weils Disease)
Epidemiology of Syphilis
TRANSMISSION : By Direct Sexual contact &
Transplacentally ( Congenital Syphilis ).
Hospital personnel , Laboratory staff & Blood transfusion
recipient may contract disease Accidentally. Sharing of
needles by IV Drug users.

INCIDENCE : Increasing = Infected person may remain

Contagious - During early Syphilis.
Late syphilis is not usually contagious.
Worldwide estimated 12 million new cases Annually.
 Syphilitic lesions are the portal for HIV Transmission.
Pathogenesis & Virulence Factor :-
T. pallidum penetrates mucous surface or abraded skin & travel
to draining Lymph node in about 30 min , where they Multiply
during incubation period .
The Treponema invades the lymphatics & disseminates in the blood
stream ; adheres to endothelial cells.
Incubation period - 3 weeks - ( 10 - 90 days ).
Primary lesion end-arteritis Endothelial scarring Intense
Inflammatory reaction & tissue necrosis Replacement fibrosis
Iry Chancre Ulcers heals but spirochetes disseminate.
*Virulence Factors * :-
 Outer membrane protein Promote adherence of T . Pallidum to
surface of host cell .
Enzyme hyaluronidase Facilitates perivascular infiltration .
Fibronectin Prevents phagocytosis of T.Pallidum by macrophages
Clinical stages of Syphilis
Stage Description Symptoms and Signs
Primary
Contagious Chancre (a small, usually painless skin sore ) , regional
lymphadenopathy
Secondary Contagious Rashes , sores on mucous membranes , hair loss , fever , Occurs weeks to
months condolamata lata.
after the primary stage
Latent Asymptomatic ; not Positive serologic tests contagious

Symptomatic; not Cardiovascular syphilis and neurosyphilis ; Late benign

Late or tertiary contagious Gummatous .

Congenital
Early Symptomatic Rhinitis develops followed by maculopapular rash
Occurring up to age 2 yr
Late Symptomatic
Occurring later in life
Hutchinson's teeth , eye or bone abnormalities
A painless sore called a chancre develops where the spirochete entered the body.

The sore may be located on the genitals , lips , anus , or other area of direct contact

The chancre will last 1- 5 weeks ( on average 3 weeks ) & heal without treatment
The person can transmit the infection very easily during this stage
Secondary Syphilis
Seen 6 weeks to 6 months after
primary chancre
The skin rash:
Diffuse ,
Often with a superficial scale
(papulosquamous).
May leave residual pigmentation

Condylomata Lata:
Painless mucosal warty erosion.
Occur in warm , moist areas such as the
perineum & genitals . Highly infectious
.

Mucosal lesions:
 ~ 30% of Secondary syphilis patients develop mucous patch (slightly raised ,
oval area covered by a grayish white membrane , with a pink base that
does not bleed ). Painless Lymphadenopathy .
Highly infectious .

Latent Syphilis
Positive syphilis serology without clinical signs of syphilis. ( Serological
test +ve. )

It begins with the end of secondary syphilis & may last for a lifetime.
Is divided into early & late latency.

Early latent: The first year after the

resolution of primary or secondary lesions
or a reactive serological test for
syphilis -without any clinical symptoms (
asymptomatic )
Late latent: Usually not
infectious, except for
the pregnant woman,
who may transmit
infection to her fetus.
1/3 of untreated pts will
proceed to tertiary
syphilis
LATE SYPHILIS -Tertiary Syphilis
The destructive stage of the disease.(It takes 3 -10
years ).
Lesions develop in skin , bone , & any visceral organs.
The main types are:
Late benign (Gummatous)
Cardiovascular &
Neurosyphilis
Can be crippling & life threatening
Blindness , deafness , deformity , lack of co-ordination
, paralysis , dementia may occur
 Usually very slowly progressive but
some neurologic syndromes may
develop suddenly due to endarteritis &
thrombosis in the CNS .
Late syphilis is Non-infectious.
Congenital Syphilis
Results from Transplacental Infection about 10 - 15
weeks of Gestation.
 The infection occurs in Foetus from I ry & II ry
Infection of Mother.

Abortion , neonatal mortality & late mental or

physical problems resulting from the active disease

Lab diagnosis of syphilis

Specimen Tissue fluid - expressed from early
 surface lesions for demonstration of spirochete.
*Most appropriate diagnostic test = Dark field
microscopy of ulcer discharge ( Painless , indurated
ulcer on glans - exuded clear serum discharge )
Blood serum for serological tests.
Treponema pallidum can not be cultured in clinical
laboratory.
Direct Demonstration of Trepanoma:
A) Dark Ground Microscopy
Elongated , motile , flexible , twisted spirally , thin , delicate with
tapering ends.
 10 - 14 m long & 0.1 - 0.2 m
wide , 10 regular spirals which
are sharp & angular at regular
interval of 1 um . *
Dark field microscopy of ulcer
discharge ( Most appropriate
diagnostic test )

Actively mobile , exhibiting

rotation around long axis ,
backward & forward
movements & flexion of whole
body.
B) Stained preparation
For direct demonstration of T.
Pallidum.
Smear made from exudate & stained by silver
impregnation method ( Fontanas stain ) or
fluorescein labelled antibody test ( Direct
fluorescent
Antibody test ) DFA - TP test.
Serological Tests
To detect antibody directed against lipid ( cardiolipin ) called
as A) Nontreponemal tests ( Reagin ) Standard And
antibodies against specific Treponemal antigen are K/as
B) Treponemal tests.(Specific )

Standard/non treponemal Specific- Treponemal Tests

Reagin tests

a. Venereal Disease Research a.. Fluorescent treponemal antibody

Laboratory Test VDRL absorption Test (FTA ABS ) b. Rapid
Plasma Reagin(RPR ) b. T.Pallidum immobilization test
 ( TPI)
c. Toludine Red Unheated Serum c. T.Pallidum Haemeagglutination
Test (TRUST) test (TPHA)

Reagin ( Non-specific ) Antibody Tests

VDRL Test : Antigen used is cardiolipin
i.e.purified lipid extract of beef heart with lecithin
and cholesterol.

RPR Test ( Rapid plasma reagin ) : modification of

VDRL carbon ( charcoal ) & choline
 TRUST Test : modification of RPR ( Ag more
stable ) Toludine red - unheated serum card test

VDRL Test ( Venereal Disease Research

Laboratory , New York , USA .

Reactive Non- reactive

Biological False Positive Test :VDRL
1% of Normal sera show BFP
 Acute BFP reaction in Acute infection : such as
Measles , Infectious mononucleosis , Mycoplasma
pneumonae , Malaria .

Chronic BFP reaction in : SLE ( Systemic Lupus

Erythematosus ) , Leprosy , Polyarthritis nodosa ,
Rheumatic disorder .
Group Specific Treponemal Tests
Employ Reiter Treponemes :- live or killed extract
of
 Virulent Nichols strain of - T. pallidum , maintained in
Rabbit testes

FTA ABS test Flurescent treponema antibody

Absorption test
TPHA test Tre.palli.haemagglutination assay test
TPI test Treponema pallidum immobilisation test

FTAABS Test Used for congenital syphilis ( IgM )

& used as a standard reference test
TPHA Test
- ve +ve
Prevention & Treatment of Syphilis
Penicillin remains drug of choice
WHO monitors treatment recommendations
 7 10 days continuously for early stage
At least 21 days continuously beyond the early stage

Prevention with barrier methods ( e.g.: Condoms )

Prophylactic treatment of contacts identified

through Epidemiological Tracing .

Treatment : -
For Early stage Inj. Benzathine Penicillin G
 For Late stage weekly injection for 3 weeks

For those allergic to penicillin :. Erythromycin ,

Tetracycline or
Ceftriaxone

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