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Syphilis in HIV-Infected Patient

  1. Special Considerations: HIV-Infected Persons, Sex Partners
    1. Treatment with benzathine penicillin G, 2.4 million units IM administered at 1-week intervals for 3 weeks
    2. Penicillin-allergic patients who have primary or secondary syphilis and HIV infection should be managed according to the recommendations for penicillin-allergic, HIV-negative patients.
    3. Send VDRL & HIV. treat the partner of early syphilitic patient.
  2. Chancroid
    Caused by the organism Haemophilus ducreyi.  incubation period - 3 to 7 days.
  3. Clinical Features
    1. The characteristic ulcer is friable, soft, and nonindurated, with ragged undermined margins and surrounding erythema. The lesion is often covered with a gray or yellow necrotic exudates.
    2. After 1 week 50% of patients develop inguinal lymphadenopathy, which is typically painful and unilateral.
    3. A suppurative bubo occurs in 25% of all patients, which may spontaneously rupture and discharge thick pus. This results in a large, deep inguinal ulceration. Autoinoculation may result in the classic kissing lesions.
    4. The diagnosis of chancroid is based on clinical presentation, which may be accurate in only 33% to 53% of cases. Definitive diagnosis is made with culture of the causative organism. even under optimal conditions, culture has an accuracy of less than 80% and is not sensitive enough to detect all cases.
    5. A painful ulceration with tender inguinal lymphadenopathy is suggestive of chancroid, whereas an association with suppurative adenopathy is almost pathognomonic. If diagnosis must rely on clinical morphology, it is important to perform serologic and dark-field examinations for syphilis and culture for herpes, to rule out common causes of genital ulceration.
  4. Chancroid May Have A Variety Of Presentations.
    1. The classic form consists of ulcers ranging in diameter from 3 to 20 mm, with multiple lesions caused by autoinoculation.
    2. Dwarf chancroid presents as single or multiple herpetiform ulcerations, with or without inguinal lymphadenopathy.     
    3. Transient chancroid has an ulcer that rapidly resolves in 4 to 6 days and is followed by suppurative inguinal lymphadenopathy in 10 to 20 days.
    4. The follicular form consists of ulcerations in the pilar apparatus in hair-bearing areas.
    5. Giant chancroid presents as multiple small ulcerations that rapidly expand and coalesce to form a single, large destructive lesion. This form is often associated with inguinal bubo formation.
    6. Phagedenic chancroid results in widespread necrosis and extensive soft tissue destruction of the genitalia. Finally, pseudogranuloma inguinale a form of chancroid that closely resembles granuloma inguinale.
  5. Natural Course and Complications
    1. In about half of the untreated patients, the course is that of spontaneous resolution without complications. Inguinal lymphadenitis referred to as buboes occurs in one-third to one-half due to delay in treatment.
    2. If treatment is further delayed, complications may occur; the bubo may form abscess which ruptures leading to discharging sinuses.
    3. Other complications include phimosis, fistula formation, haemorrhage from erosive lesions and fusospirochetosis.
    4. Healing of the lesions is often followed by scarring which may lead to phimosis.
    5. Secondary anaerobic infection of the lesions may produce phadagenic ulcers and concurrent infection with T. pallidum, Herpes simplex and Chlamydia trachomatis is common.
  6. Investigations
    1. Investigations like viral culture for Herpes simplex; dark ground examination of a smear from the ulcer for T. pallidum and serological tests for syphilis.
    2. Gram-stained smear from the ulcer can also be performed in suitable cases looking for the Gram negative coccobacillary rods which form long trails within mucous strands giving a 'school of fish' appearance. Culture plates containing enriched GC media are useful for cultivation of this fastidious organism, and can be available upon arrangement with the laboratory.
    3. On primary isolation media, growth may be visible at 24 hours but identifiable colonies may not be seen until after 48 to 72 hours of inoculation.
    4. Culture plates should not be discarded as negative until after at least five days of inoculation.
    5. A Gram-stained smear should be performed on colonies suspected of being H. ducreyi. Gram-negative bacilli compatible with H. ducreyi should be biochemically tested.
    6. In contrast to other haemophilus species, H. ducreyi requires hemin (X factor) for growth and thus is positive in the porphyrin test. H ducreyi does not require NAD (V factor) for growth.
    7. The use of specific monoclonal antibodies to detect bacterial antigens is sensitive, specific and less time consuming but are not widely available.
    8. Polymerase chain reaction (PCR) is now also employed to achieve a higher diagnostic accuracy. Biopsy of the ulcer is rarely performed.
  7. Chancroid
    Azithromycin 1 g orally in a single dose,
    Ceftriaxone 250 mg intramuscularly (IM) in a single dose,
    Erythromycin 500 mg orally QID for 7 days
    Bubo aspiration (>5cm)  through surrounding normal skin
  8. Special Considerations:
    HIV Infection- HIV-infected patients may require longer courses of therapy.
    Sex Partners- Should be examined and treated, regardless of whether symptoms of the disease are present, if they had sexual contact with the patient during the 10 days preceding the patient's onset of symptoms.

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