Showing posts with label STD. Show all posts
Showing posts with label STD. Show all posts

29 September 2009

Syphilis



Syphilis
by: Erik Austin, D.O., M.P.H.

Syphilis
* AKA lues
* Contagious, sexually transmitted disease caused by the
* Spirochete: Treponema pallidum
* Enters through skin or mucous membrane where primary manifestations are seen

Treponema pallidum
* Spiral spirochete that is mobile
* # of spirals varies from 4 to 14
* Length is 5 to 20 microns
* Can be seen on fresh primary or secondary lesions by darkfield microscopy or fluorescent antibody techniques

Syphilis epidemiology
* Major health problem throughout world
* 2.6 cases per 100,000 in 1999 in the US
* Lowest level ever recorded
* Concentrated in 28 counties in the SE U.S.
* Mainly gay men and crack cocaine users
* Enhances risk of transmission of HIV
* HIV testing recommended in all patients with syphilis
* Reportable disease

Serologic Tests
* Testing reveals patients immune status not whether they are currently infected
* Non-treponemal antigen test uses lipoidal antigens rather than T. pallidum or components of it
* RPR = rapid plasma reagin
* VDRL = Venereal Disease Research Laboratory
* Positive within 5 to 6 weeks after infection
* Strongly positive in secondary phase
* Strength of reaction is stated in dilutions
* May become negative with treatment or over decades
* MHA-TP: microhemagglutination assay for T. pallidum
* FTA-ABS: fluorescent treponemal antibody absorption test
* All positive nontreponemal test results should be confirmed with a specific treponemal test
* Treponemal tests become positive early, useful in confirming primary syphilis
* Remain positive for life, useful in diagnosing late disease
* Treatment results in loss of positivity in 13-24% of patients

Biologic False-Positive Test Results
* Positive test with no history or clinical evidence of syphilis
* Acute BFP: those that revert to negative in less than 6 months
* Chronic BFP: those that persist > 6 months

BFP Test Results in Syphilis
* Acute BFP
* Vaccinations
* Infections
* pregnancy
* Chronic BFP
* Connective tissue disease (SLE)
* Liver disease
* Blood transfusions
* IVDA

Cutaneous Syphilis
* Chancre is usually the first cutaneous lesion
* 18 to 21 days after infection
* Round indurated papule with an eroded surface that exudes a serous fluid
* Usually painless and heals without scarring

Chancre
* Inguinal adenopathy 1-2 weeks after chancre
* Generally occur singly, but may be multiple
* Diameter mm to cm

Chancres
* In women, the genital chancre is less often observed due to location within the vagina and cervix
* Edema of labia may occur
* Untreated, the chancre heals spontaneously in 1 to 4 months
* Constitutional symptoms begin just as chancres disappear
* Extragenital chancre: may be larger, frequently on lips, rarely tongue, tonsil, breast, finger, anus.

Chancre Histology
* Ulcer covered by neutrophils and fibrin
* Dense infiltrate of lymphocytes and and plasma cells
* Spirochetes seen with with silver stains; Warthin-Starry
* Direct fluorescent antibody tissue test (DFAT-TP) = serous exudate collected on a slide sent for exam

Serology
* Nontreponemal tests positive 50%
* Treponemal tests positive 90%
* Positivity depends upon duration of infection, if chancre has been present for several weeks, test is usually positive

Chancre vs. Chancroid
* Incubation 3 weeks
* Painless
* Hard
* Lymphadenopathy may be bilateral, nontender, nonsuppurative
* Incubation 4-7 days
* Painful
* Soft
* Lymphadenopathy unilateral, tender, suppurative

DDx in Syphilis
* Chancroid - multiple lesions, may coexist with chancre, must r/o syphilis
* Granuloma Inguinale - indurated nodule that erodes, soft red granulation tissue, Donovan bodies in macrophages with Wright or Giemsa stain
* Lymphogranuloma Venereum - small, painless, superficial non indurated ulcer, primary lesions followed in 7 to 30 days by adenopathy
* HSV - grouped vesicles, burning pain

Secondary Syphilis
* Skin manifestations in 80% called syphilids
* Symmetric, generalized, superficial, macular - later papular, pustular
* May affect face, shoulders, flanks, palms and soles, anal or genital areas

Secondary Syphilis Macular Eruptions
* Exanthematic erythema 6-8 weeks after chancre - may last hours to months
* Round, slightly scaly ham-colored macules
* Pain and pruritus may be present
* Generalized adenopathy

Secondary Syphilis Papular Eruptions
* Occurs on face and flexures of arms, legs, and trunk
* Yellowish-red spots may appear on palmar and plantar surfaces
* Ollendorf’s sign = tender papule
* May produce a psoriasiform eruption
* May appear as minute scale-capped papules
* Tend to be disseminated, but may be localized, asymmetrical, configurate, hypertrophic or confluent.
* Annular syphilid - mimics sarcoidosis and is more common in blacks
* Pustular syphilid – rare - face, trunk, extremities red small crust-covered ulceration
* Rupial syphilid - superficial ulceration is covered with a pile of terraced crusts resembling an oyster shell.
* Lues Maligna - rare, severe ulcerations, pustules, or rupioid lesions, accompanied by severe constitutional symptoms.
* Condylomata lata - papular mass, weeping, gray 1-3cm, groin, anus (not vegetative like condylomata acuminata)
* Syphilitic alopecia - irregular, scalp has a moth-eaten appearance 5% of pts

Secondary Syphilis Mucous Membrane
* Present in 1/3 of secondary syphilis
* Most common is “syphilitic sore throat”
* Diffuse pharyngitis, hoarseness
* Tongue may show patches of desquamation of papillae
* Ulcerations of tongue and lips in late stages
* Mucous patches are the most characteristic mucous membrane lesions; macerated, flat. Grayish, rounded erosions covered by a delicate, soggy membrane.

Secondary Syphilis Systemic Involvement
* Lymphadenopathy common.
* Acute glomerulonephritis, gastritis, proctitis, hepatitis, meningitis, iritis, uveitis, optic neuritis, Bell’s palsy, pulmonary nodular infiltrates, osteomyelitis, polyarthritis.

Secondary Syphilis Diagnosis
* Nontreponemal serologic tests for syphilis are strongly reactive (seronegativity rarely in AIDS)
* Spirochetes on darkfield exam

Secondary Syphilis DDx “Great Imitator”
* Pityriasis rosea
* Drug eruptions (pruritic)
* Lichen planus; Wickham’s striae, Koebner’s, pruritic
* Psoriasis; no adenopathy
* Sarcoidosis; need serology and silver staining of biopsy
* Infectious mononucleosis, false pos RPR
* Geographic tongue
* Aphthous stomatitis

Latent Syphilis
* After the lesions of secondary syphilis have involuted, a latent period occurs where the patient has no clinical signs, but positive serological tests
* May last a few months or a lifetime
* 60-70% of pts that are untreated remain asymptomatic for life
* Women may infect unborn child for 2 years
Late Syphilis
* Defined by CDC as infection of greater than 1 years duration
* Tertiary Cutaneous Syphilis
* Late Osseous Syphilis
* Neurosyphilis
* Late Cardiovascular Syphilis

Tertiary Cutaneous Syphilis
* Tertiary syphilids usually occur 3-5 years after infection
* 16% of untreated pts will develop lesions of skin, mucous membrane, bone or joints
* Skin lesions are localized, destructive, heal with scarring

Tertiary Syphilids
* Two main types; Nodular syphilid and the Gumma
* Nodular - reddish brown firm papules or nodules 2mm or larger, scales.
* Gumma - larger

Nodular Tertiary Syphilid
* Lesions tend to form rings and undergo involution as new lesions develop
* Characteristic circular or serpiginous pattern
* “kidney-shaped” lesion occurs on the extensor surfaces of the arms and on back
* Patches have scars and fresh ulcerated lesions
* Process may last for years, slowly marching across large areas of skin

Gumma
* May occur as unilateral, isolated, single or disseminated lesions, or serpiginous
* May be restricted to the skin, or originate in deeper tissues, and break down the skin
* Lesions begin as small nodules, enlarge to several centimeters
* Central necrosis, deep ulcer with a gummy base, most frequent site is lower legs

Diagnosis of Tertiary Syphilis
* Histopathology - tuberculoid granules with multinucleated giant cells
* Nontreponemal tests (VDRL, RPR) positive in 75%
* Treponemal tests (FTA-ABS, MHA-TP, TPI) positive in nearly 100%
* Darkfield negative, PCR may be positive

DDx Tertiary Syphilis
* R/O tumors; SCCA tongue, leukemic infiltrates, sarcoidosis
* Ulcerated syphilids resemble scrofula, atypical mycobacterium, sporotrichosis, blastomycosis
* Mycosis fungoides (CTCL) has eczema and pruritus
* Perforation of hard palate and septum

Late Osseous Syphilis
* Gummatous lesions can involve the periosteum and bone
* Head, face, tibia
* Periostitis, osteomyelitis, osteitis, gummatous osteoarthritis
* “Osteocope” - bone pain often at night
* Charcot joint - loss of contours of joint, hypermobility, painless
* Associated with tabes dorsalis

Neurosyphilis
* CNS involvement with syphilis can occur at any stage
* Most are asymptomatic; CSF shows pleocytosis
* 4-10% of untreated pts will develop neurosyphilis

Early Neurosyphilis
* First year of infection - meningeal
* Headache, stiff neck, cranial nerve disorders, seizures, delirium, increased ICP

Meningovascular Neurosyphilis
* 4-7 years after infection
* Thrombosis of vessels in the CNS
* Hemiplegia, aphasia, hemianopsia, transverse myelitis, progressive muscular atrophy
* CN palsies; CN IIX, III, IV, VI
* “Argyll Robertson Pupil” accommodates, but doesn’t react

Late Neurosyphilis
* Parenchymatous neurosyphilis occurs more than 10 years after infection
* Two classical patterns; Tabes Dorsalis, and General Paresis

Tabes Dorsalis
* Degeneration of the dorsal roots of the spinal nerves and posterior columns of the the spinal cord
* Gastric crisis with severe pain and vomiting is most common
* Pain, urination problems, paresthesias, ataxia, diplopia, vertigo, deafness
* Signs: Argyll Robertson pupil, reduced lower cord reflexes, Romberg sign, sensory loss, atonic bladder, Charcot’s joints, optic atrophy
* Personality changes, memory loss, apathy, megalomania, delusions, dementia

Late Cardiovascular Syphilis
* Occurs in 10% of untreated pts
* Aortitis, aortic insufficiency, coronary disease, aortic aneurysm

Congenital Syphilis
* Prenatal syphilis acquired in utero
* Infection through the placenta usually does not occur before the fourth month, so treatment of the mother before this time will almost always prevent infection in the fetus.
* If infection occurs after the fourth month 40% risk of fetal death

* 40% of pregnancies in women with untreated early syphilis will result in a syphilitic infant.
* Most neonates with congenital syphilis are normal at birth.
* Early congenital syphilis - lesions occurring within first two years of life
* Late congenital syphilis - lesion occur after two years

Early Congenital Syphilis
* Cutaneous manifestations appear most commonly during 3rd week
* Snuffles (a form of Rhinitis) is most frequent, bloody drainage, ulcers may develop, later septal perfs
* 30-60% of infants develop cutaneous lesions similar to secondary syphilis
* Red to copper maculopapular, become large, scaling, pustules, crusting
* Face, arms, buttocks, legs, palms and soles

Early Congenital Syphilis
* Face, perineum, and intertriginous areas, usually fissured lesions resembling mucous patches. Radial scarring results leading to Rhagades
* Bone lesions occur in 70-80% , epiphysitis is common and causes pain on motion, leading to infant refusing to move; Parrot’s pseudoparalysis.
* Radiologic features of the bone lesions in congenital syphilis during the first 6 months are characteristic.
* Bone lesions occur at the epiphyseal ends of long bones.
* Lymphadenopathy, hepatomegaly, nephrotic syndrome, meningitis, nerve palsies may all occur

Late Congenital Syphilis
* Lesions are two types - malformations of tissue affected at critical growth periods (Stigmata) and persistent inflammatory foci
* Inflammatory - lesions of the cornea, bones, and central nervous system, i.e., interstitial keratitis in 20-50%, perisynovitis of knees (Clutton’s joints), tabes dorsalis, seizures, and paresis

Late Congenital Syphilis
* Malformations (Stigmata) - destructive effects leave scars or developmental defects
* Hutchinson’s Triad - Changes in incisors, corneal scars, and eighth nerve deafness
* Also, saber shins, rhagades of the lips, saddle nose, mulberry molars

Hutchinson’s Teeth
* Malformation of the central upper incisors that appears in the second or permanent teeth. Teeth are cylindrical rather than flattened, cutting edge narrower than base, notch may develop
* Mulberry molar - first molar hyperplastic, flat occlusal surface covered with knobs representing abortive cusps

Treatment of Syphilis
* PCN is drug of choice for treatment of all stages of syphilis.
* HIV testing is recommended in all patients
* If less than one year; 2.4M U of Benzathine PCN G
* PCN-allergic; Tetracycline 500mg QID for 14 days

Jarisch- Herxheimer Reaction
* Febrile reaction occurs after the initial dose of antisyphilitic tx, 60-90% of pts
* 6-8 hours after dose - chills, fever, myalgia, increase in inflammation (neurosyphilis)

Treatment of Sex Partners
* Persons exposed to a patient with early syphilis within the previous 3 months should be treated, even if seronegative
* Single dose azithromycin effective in treating incubating syphilis

Serologic Testing after Tx
* VDRL or RPR repeated every 3 months in first year, every 6 months in second year, than annually
* A fourfold decrease in titer should be seen at 6 months, if not then 3 weekly PCN IM injections
* Response for latent syphilis is slower, 12-24 months
* If not responding; HIV and CSF testing repeated
* Pts with late syphilis may be “serofast”, and titers may not improve
* Neurosyphilis pts should have CSF every 6 months

Syphilis and HIV
* Most HIV pts exhibit the classic clinical manifestations and course, and respond similarly to tx
* More likely to present with secondary syphilis and have a persistent chancre

Yaws
* Treponema pallidum subsp. Pertenue
* Endemic in some tropical, rural regions
* Overcrowding, poor hygiene, transmitted by contact with infected lesions
* Children, disabling course, affects skin, bones, and joints

Early Yaws
* Primary papule or group of papules appear at site of inoculation after 3 week incubation period, initial lesion becomes larger and crusted (Mother Yaw, maman pian )
* Feet, legs, buttocks, face, not genitals
* Mother yaw disappears after a few months
* Secondary Yaws – appears weeks or months after mother yaw appears. May be smaller and appear around primary lesion; may be annular (ringworm yaws)
* Condylomata may develop around body orifices and creases
* Palms and soles may form hyperkeratotic plaques leading to a painful crab-like gait (crab yaws)

Late Yaws
* 10% progress to late stage where gummas occur
* Ulcer with clean edges that tend to fuse to form con figurate and serpiginous patterns similar to tertiary syphilis
* Bone, joint, saddle nose, saber shin, Gangosa (destruction of palate and nose)
* Diagnosis = Darkfield, VDRL or RPR

Endemic Syphilis (Bejel)
* Bejel is a Bedouin term for nonvenereal treponematosis, nomadic tribes of North Africa, Southwest Asia, Eastern Mediterranean
* T. pallidum subsp. Endemicum
* Usually occurs in childhood through skin contact
* May affect the skin, oral mucosa, and skeletal system

Bejel
* Primary lesions rare, probably go undetected in the oral mucosa
* Secondary oral lesions - shallow, painless ulcers, laryngitis
* Condyloma of axillae and groin, lymphadenopathy, osteoperiostitis causes night leg pain
* Untreated secondary bejel heals in 6-9 months
* Tertiary stage - gummatous ulcerations of the skin, nasopharynx, and bone.
* Neuro - uveitis, choritis, optic atrophy

Pinta
* T. carateum; nonvenereal, endemic
* Only skin lesions occur
* All ages, Brazilian rain forest
* Primary Stage - 7 to 60 days after inoculation. Lesion begins as a tiny red papules and become an elevated erythematous infiltrated plaque 10cm in diameter over 2-3 months. Legs -satellite lesions, no erosion or ulceration as in chancres.
* Secondary Stage - 5 months to 1 year
* Small, scaling papules that enlarge and coalesce – affects extremities and face
* Red to blue, black with postinflammatory hyperpigmentation
* Nontreponemal tests reactive in 60%
* Late Dyschromic Stage - young adults – may appear as hyperpigmented and depigmented macules resembling vitiligo
* Face, waist, wrist, trochanteric areas
* Histo - acanthosis, lichenoid, spirochetes in epidermis

Treatment of Yaws, Bejel, and Pinta
* Benzathine PCN G 1.2 to 2.4 M units IM
* Tetracycline 500mg QID for adults
* EES 10mg/kg children QID for 14 days
Nonvenereal Treponematoses
* Yaws
* Endemic Syphilis
* Pinta

Treatment
* Syphilis >1year; 2.4M PCN G weekly for 3 weeks Pcn-allergic; Tetra 500mg QID for 30 days
* Neurosyphilis; IV
* Infant 100,000 to 150,000 units/kg/day Procaine PCN BID for first seven days of life

Syphilis.ppt

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05 July 2009

Sexually Transmitted Diseases What’s New?



Sexually Transmitted Diseases What’s New?
By:Linda Creegan, FNP
California STD/HIV Prevention Training Center


Common STDs

* Humanpapilloma Virus
* Trichomoniasis
* Chlamydia
* Genital herpes
* Gonorrhea
* Hepatitis B
* Syphilis

Overview of Complications of Sexually Transmitted Diseases

Fetal Wastage*
Low Birthweight*
Congenital Infection*
Upper Tract Infection
Systemic Infection
STDs
Infertility
Ectopic Pregnancy*
Chronic Pelvic Pain
HIV Infection*
Cervical Cancer*
* Potentially Fatal
Increased Transmission of HIV in the Presence of Other STDs
* Transmission increased 3-5 times
* Increased susceptibility
* Increased infectiousness
Chlamydia
Gonorrhea
Risk Factors
Recommendations
Syphilis
P&S Syphilis
Genital Herpes
Herpes simplex virus type 2
Genital Warts
What’s New with Chlamydia Infection?
Chlamydia Infections in Women and Neonates
Genital Chlamydia in Women: Complications
Untreated genital CT infection
Ectopic pregnancy
Infertility
Chronic pelvic pain
Public Health Approaches to Chlamydia Control
Chlamydia Screening & Treatment
CT Screening Cost-Effective
Chlamydia Screening Recommendations
Chlamydia Testing Current Diagnostic Methods
Chlamydia Testing Nucleic Acid Amplification Tests
Hybrid Capture
Genital Chlamydia Diagnostic Tests
Sensitivity
Urine-Based CT Tests
Cost Effectiveness of NAAT
Chlamydia Follow-up
Is Test-of-Cure Necessary?
Chlamydia Partner Management
What’s New with Gonorrhea?
Gonorrhea Infection
Gonorrhea Clinical Presentation
Gonorrhea Complications
Gonorrhea Diagnosis
Gonorrhea Anal and Pharyngeal Infections
Gonorrhea Treatment
Uncomplicated Genital and Rectal Infections,
Non-Pregnant Adults
GC Partner Management
Use of Fluoroquinolones to Treat GC Infection:Recommendations
GC LCR Screening
Gonorrhea Screening Recommendations
What’s New with Syphilis?
Syphilis Elimination Public Health Importance
National Plan for Syphilis Elimination Five Key Strategies
Understanding STD Trends in MSM
Syphilis Management in HIV Co-Infected Patients
Syphilis Diagnostic Testing
Syphilis New Therapies
What’ s New with Genital Herpes?
Herpes: Overview
Genital Herpes Infection Epidemiology
HSV-2 Seropositivity
Human Herpesvirus Family
Genital Herpes Transmission
Genital Herpes Natural History
Genital Herpes Categories of Infection
Genital Herpes First Clinical Episodes
Genital Herpes Reactivation of Virus
Genital Herpes Educating to Recognize Symptoms
Genital Herpes Patient’s Perception of Etiology
Genital Herpes Asymptomatic Shedding
Genital Herpes Spectrum of Presentations
Neonatal Herpes Infection
Herpes Transmission in Pregnancy
Herpes Diagnostic Tests
Herpes Diagnosis Serologic Tests
HSV Serology Testing
Genital Herpes Principles of Treatment
Antiviral Medications for Uncomplicated HSV
Genital Herpes What’s New in Treatment?
Genital Herpes Treatment in Pregnancy
Genital Herpes Vaccine Development
Dermal HPVs
Thin-Layer Pap Preparations
ThinPrep Pap Specimen Collection
ThinPrep Pap Test
HPV DNA Tests
Utility of HPV Testing
Conduct HPV test on stored specimen
HPV Disease Management of HIV Infected MSM
Prevention of Genital HPV Infection and Sequelae:
Abnormal Flora in Bacterial Vaginosis (BV)
BV: Complications in Pregnancy
BV: Diagnostic Criteria
Amsel Criteria
BV: Screening in Pregnancy
BV: Treatment Non-Pregnant Women
Trichomoniasis
Trichomoniasis: Diagnosis
Culture System for T. vaginalis
Trichomoniasis Treatment During Pregnancy
Recommended regimen:
Trichomoniasis
Role in Urethritis

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05 May 2009

Sexually Transmitted Diseases



Sexually Transmitted Diseases
Presentation lecture by:Marci Putnam

Case study
Chlamydia
Clinical Findings in Chlamydia
Sequelae of Chlamydia
Diagnosis of Chlamydia
Treatment of Chlamydia
Other Considerations

Case study 2
Gonorrhea
General Considerations
Clinical Findings in Gonorrhea
Work Up of Gonorrhea
* Diagnosis
Treatment for Gonorrhea
Other Considerations

Case 3

Genital Herpes Simplex Virus
Clinical Findings in Genital HSV
Diagnosis of HSV
Treatment of Genital HSV
Other Considerations


Chancroid
Clinical Findings in Chancroid
Diagnosis of Chancroid
Treatment of Chancroid

What about a painless genital ulcer?
Syphilis
Clinical Findings in Syphilis
Diagnosis of Syphilis
Treatment of Syphilis

Genital Human Papilloma Virus
Hepatitis B
Diagnosis & Treatment of HBV
Human Immunodeficiency Virus Overview
Testing for HIV

References

* Centers for Disease Control: Morbidity & Mortality Weekly Report. “Sexually Transmitted Diseases Treatment Guidelines 2002”. 10 May 2002, Vol. 51, No. RR-6.
* DeCherney, Pernoll. Current: Obstetric & Gynecologic Diagnosis & Treatment. 8th Ed. (McGraw Hill, Lange: New York).
* www.uptodate.com database topics related to sexually transmitted diseases.
* Primary Care Medicine: Office Evaluation and Management of the Adult Patient, 3rd Ed. Goroll, May & Mulley. Lippincot-Raven:New York, 1995.
* Tierney, McPhee, Papadakis. Current: Medical Diagnosis & Treatment, 40th Ed. (McGraw Hill, Lange:New York, 2001)
* http://www.cdc.gov/nchstp/dstd/dstdp.html
* www.aafp.org

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STDs – Genital Lesions



STDs – Genital Lesions
Presentation lecture by:Tisha Titus
Family & Preventive Medicine

Genital Lesion STDs
* Chancroid
* Genital Herpes
* Lymphogranuloma Venereum (LGV)
* Granuloma Inguinale
* Syphilis
* Human Papillomavirus (HPV)
* Molluscum Contagiosum

Psuedo-adenopathy
Regional LAD
Common; prodrome of tingling
Purulent hemorrhagic
Erythematous; undermined
Possible risk of AIDS
(M) - Genital elephantiasis
(F) – rectal strictures
Scarring, tissue damage, possible risk of AIDS
Death, insanity, sterility, heart disease
SA, stillbirth, birth defects
Treatment
Chancre at infection site
Klebsiella granulomatis
Chlamydia trachomatis
Hemophilus ducreyi
Trepnema pallidum
HSV II
Etiologic agent
Granuloma inguinale
LGV
Chancroid
Syphilis
Herpes
Pt complains of genital ulcer/warts
Clinical cure
Referral to specialist
CDC Prevention & Control
Eliciting information
Chancroid
Chancroid Treatment
Genital Herpes
HSV First Episode Treatment
HSV Suppression Therapy
HSV Recurrent Treatment
Severe HSV
HSV Special Considerations
Lymphogranuloma Venereum
LGV Treatment
Granuloma Inguinale
GI Treatment
Syphilis
Syphilis: Sex Partner Evaluation
Syphilis Treatment
PCN Allergy
Latent Syphilis Treatment
Adults Early
Neurosyphilis Treatment
Syphilis & HIV
Syphilis & Pregnancy
Congenital Syphilis
Human Papilloma Virus (HPV)
Patient Applied Wart Treatments
Provider Administered Wart Tx
Other Wart Treatments
Cevical
Urethral meatus
Anal
Pregnancy
Molluscum Contagiosum
MC Treatments
References

* www.DermAtlas.com
* www.Healthac.org
* CDC MMWR Aug 4, 2006 vol 55 No RR-11
* http://www.nlm.nih.gov/medlineplus/ency/article/000826.htm

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