LABORATORY DIAGNOSIS OF SEXUALLY TRANSMITTED DISEASES

GAYATHRI KUMBALATARA
MEDICAL OFFICER LAB NATIONAL REFERENCE LAB STD & HIV

SEXUALLY TRANSMISSIBLE DISEASE AGENTS

BACTERIAL Neisseria gonorrhoeae Chlamydia trachomatis Treponema pallidum Haemophilus ducreyi Mycoplasma hominis Ureaplasma urealyticum Calymmatobacterium granulomatis Gardnerella vaginelis Shigella spp. Campylobacter spp. Group B streptococci VIRAL Herpes simplex virus Cytomegalo virus Human herpes virus 6 Hepatitis B virus Hepatitis C virus Human papilloma virus Molluscum contagiosum HIV - 1 HIV - 2 HTLV - I HTLV - II

SEXUALLY TRANSMITTED DISEASE AGENTS Cont.

PROTOZOAL Trichomonas vaginalis Entamoeba histolytica Giardia lamblia FUNGAL Candida albicans

PARASITIC Phthirus pubis Sarcoptes scabiei Enterobius vermicularis

different organisms show common signs and symptoms ( SYNDROME)

vaginal discharge vaginitis cervicitis urethral discharge Trichomoniasis Candidiasis Bacterial vaginosis Gonorrhoea Chlamydia Gonorrhoea Chlamydia

genital ulcer

Genital herpes Syphilis Chancroid

GI, LGV

SYPHILIS
Caused by

Treponema pallidum

subspecies pallidum

a spirochaete
can not be cultured in artificial media or on tissue culture not easily stained has characteristic movements can survive in blood at 2-6 0c for 48 to 72 hours

Treponema pallidum on darkfield

LABORATORY TESTS
Demonstration of pathogen (only when lesions are present) -Dark ground microscopy -Direct fluorescent antibody test (DFA-TP) specimen- tissue fluid from primary chancre, IIry syphilis and early congenital syphilis Serological tests ( STS) -Nonspecific nontreponemal Ab test -Specific treponemal Ab test

N0N SPECIFIC TESTS Ag - cardiolipin Ab - antilipoidal Commonly used tests :These tests are used :VDRL , RPR

as screening tests to monitor disease activity to monitor response to therapy Test principle :- floccular type agglutination qualitative and quantitative assessment Biological false positive :acute chronic viral infections auto immune diseases immunizations pregnancy

SPECIFIC TESTS Ag - T . pallidum Ab - antitreponemal Commonly used tests :- TPHA( T.pallidum haemagglutination) FTA-Abs (Fluorescent treponemal antibody absorption test) FTA-Abs IgM These tests are used
Test principle :-

as confirmatory tests positivity remains lifelong TPHA-haemagglutination FTA-Abs indirect immunofluorescent

ELISA PCR WB-investigational

:-

RECENT ADVANCES :-

GENITAL HERPES Caused by Herpes simplex virus type 2 (HSV 2) (rarely by type 1 )

Clinical manifestation shallow painful ulcers complications Lab tests : Direct detection - smear for giant cells antigen detection by ELISA electron microscopy PCR Culture - tissue culture Detection of antibodies - ELISA,IFA,RPHA

CHANCROID Caused by

Haemophilus ducreyi

Clinical manifestations - deep painful ulcers (soft chancre) inguinal bubo

Specimen swab from ulcer or pus from bubo

Lab tests Microscopy - Gram stain : gram negative bacilli school (shoal) of fish appearance Culture - on special media with vancomycin Not commonly seen in Sri Lanka now.

GRANULOMA INGUINALE Caused by - Calymmatobacterium granulomatis Clinical manifestations deep ulcer specimen biopsy from base or edge of ulcer Lab tests : -

Histology Crushed smear stain with Giemsa or Leishman stain Donovan bodies short, pink, bipolar, encapsulated rods lying in vacuoles of mononuclear cell

LYMPHOGRANULOMA VENERUM
Caused by Chlamydia trachomatis serovars L1-L3 Clinical manifestations - papule -> ulcer , lymphangitis, lymphadenitis,fistulas,strictures Specimen infected tissue and pus from bubo Lab tests : Culture Antigen detection Serology DNA probes

vaginal discharge

vaginitis -

Trichomoniasis Candidiasis Bacterial vaginosis Gonorrhoea Chlamydia Gonorrhoea Chlamydia

cervicitis -

urethral discharge

TRICHOMONIASIS Caused by Trichomonas vaginalis Clinical manifestations mild urethritis in men vulvo-vaginitis Specimen vaginal swab Lab tests : Wet smear motile flagellated protozoa Dry smear Leishman stain Culture

CANDIDIASIS
Caused by - Candida albicans

Clinical manifestations- vulvo-vaginitis balanitis Specimen vaginal swab Lab tests : wet mount with 10% KOH Gram stain Culture

BACTERIAL VAGINOSIS
Caused by Gardnerella vaginalis

Clinical manifestation vaginal discharge

Specimen - vaginal swab

Lab tests : vaginal pH > 4.5 amine (Whiff) test presence of clue cells absence of Lactobcilli Culture

vaginal discharge

vaginitis cervicitis -

Trichomoniasis Candidiasis Bacterial vaginosis Gonorrhoea Chlamydia Gonorrhoea Chlamydia

urethral discharge

Clinical Spectrum Of Gonorrhoea

Symtomatic Urethritis,, Cervicitis, Proctitis, Pharyngitis, Bartholinitis, Conjunctivits

Asymptomatic , Ux, Endo Cx, Rectum, Pharynx

Local complications Salphingitis, Epidymitis, Bartholin Abscess, Penile Oedema, Peri Urethral Abscess

DGI

GONORRHOEA
Caused by Neisseria gonorrhoeae

Clinical manifestations urethritis cervicitis vulvo-vaginitis ophthalmia neonatorum rectal gonorrhoea pharyngeal gonorrhoea

Complications epididymo-orchitis endometritis pelvic inflammatory disease prostatitis arthritis endocarditis

Specimen urethral or cervical swab ( preparation of smears and inoculation of cultures best done at bed side )

Lab Diagnosis of gonorrhoea

Presumptive diagnosis
Gram stained smear Intracellular gram negative diplococci

Sensitivity 95% for symtomatic males 50- 70% for females

Lab tests :-

Culture - on Thayer Martin medium New York City medium etc. transport in Amies transport medium -further identification by biochemicals
Antibiotic susceptibility testing - Disk diffusion test - Beta lactamase test - Minimum inhibitory concentration (MIC)

CHLAMYDIA
Caused by Chlamydia trachomatis serovar D - K

Clinical manifestations non gonococcal urethritis post gonococcal urethritis (15-30%) epididymo-orchitis cervicitis endometritis salpingitis pelvic inflammatory disease ophthalmia neonatorum
Specimen - urethral, cervical or eye swab first voided urine

Lab tests Gram stain of urethral swab , > 5 PMNL/ 1000 x - or early morning smear : EMS - or sediment of first voided urine with >15 PMNL/ 400 x Culture most sensitive and specific - tissue culture on McCoy cell line Detection of Antigen - ELISA - Direct immunofluorescence - PCR Serology is not usually used