Self evaluation questions 

Chlamydia trachomatis

1. Gram stain of urethral discharge, in symptomatic men with gonococcal urethritis will be

A. Positive in 95%  

B. Positive in 75%  

C. Positive in 50%  

D. Positive in 25%  

If the gram stain is negative for Gonococcus,  most likely the urethritis is not due to Gonococcus, but you cannot rule it out completely.

2. Major etiology for  nongonococcal  urethritis NGU) is

A. Trichomonas vaginalis

B. Herpes simplex virus

C. U. urealyticum

D. C. trachomatis 

3. Postgonoccccal urethritis. 

A. Postgonococcal urethritis refers to the clinical syndrome in which symptoms recur after treatment for gonorrhea.

B. It is a manifestation of dual urethral infection. 

C. Chlamydia trachomatis has been recovered from 11-50% of men with gonorrhea. 

D. None of the above

E. All of the above

This refers to urethritis that follows within a certain time following treatment of Gonococcal infection, in keeping with the incubation period of the co-existing organism. I see different durations cited, three weeks seems reasonable. If urethritis recurs after 6 months, it will not be considerd as Postgonoccccal urethritis. 

Thereis  high frequency with which dual infections occur, the basis for simultaneously treating Chlamydia trachomatis  with Neisseria Gonorrhea. C trachomatis can be isolated from 20% of males with Gonorrhea.Occasionally, dual infection with ureaplasma may occur. 

4.  Chlamydia species

A. The cell envelope is similar to Gram-negative bacterial types but the outer membrane lacks peptidoglycan.

B. They are obligate intracellular bacteria that fail to grow outside in artificial media. 

C. They are metabolically deficient compared with free-living bacteria, because they require the host-derived ATP for survival. 

D. All of the above

5. Serovarieties of C. trachomatis can cause all of the following infections except

A. Trachoma

B. Nongonococcal urethritis

C. Lymphogranuloma venereum

D. Endocarditis

6. Sites that can be involved with sexually transmitted Chlamydia trachomatis in women. All of the following except 

A.Cervicitis

B. Endometritis

C. Salpingitis 

D. Proctitis

E. Pelvic inflammatory disease

F. Urethra

G. Conjunctiva

Sorry for this silly question. Conjunctival infection is not sexually transmitted. It is hand to eye contact.

7. Serovarieties D-K of  Chlamydia cause inclusion conjunctivitis and infant pneumonia, which is acquired during passage through an infected birth canal.

A. True

B. False

8. Serovarieties L₁, L₂ and L₃ of  Chlamydia cause lymphogranuloma venereum, a sexually transmitted disease.

A. True

B. False

9. Chlamydia trachomatis in men is best treated with

A. Tetracycline (especially doxcycline) 

B. Erythromycin 

B. Azithromycin is effective given as a single dose, but is expensive. 

C. Ciprofloxacin may be used in adults. 

10 Pregnant woman with  Chlamydia trachomatis is best treated with

A. Tetracycline

B. Erythromycin

11. Chlamydia infection is more common in

A. Men

B. Women

 I see different statements from different sources and probably relates to whether we are dealing with symptomatic or asymptomatic infection.

12. Chlamydia infection is more common than Gonorrhea in women

A. True

B. False

  I see different statements from different sources and probably relates to whether we are dealing with symptomatic or asymptomatic infection.

Syphilis

A.  Light microscopy

B. Darkfield microscopy

2. Treponema pallidum can be

A. sustained in vitro cultivation 

B. Requires to be propagated in rabbits or guinea pigs 

Sustained in vitro cultivation of T. pallidum is not currently possible for diagnostic purposes. Investigators have propagated T. pallidum in rabbits or guinea pigs to provide organisms for scientific study, to evaluate new antimicrobial agents or candidate vaccines, or to demonstrate the presence of treponemes in clinical specimens.

3. T. pallidum infection is acquired from direct sexual contact with an individual who has an active primary or secondary syphilitic lesion. 

A. Transmission occurs in approximately one third of such contacts

B. Transmission occurs in approximately half of such contacts

C. Transmission occurs in all such contacts.

4. Less commonly T. pallidum may be spread by: 

A. Sharing of needles by IV drug users 

B. By non-genital contact with a mucosal lesion 

C. Occasional cases result from accidental inoculation of infected material. 

D. Transplacental transmission

E. All of the above

Modern precautions have essentially eliminated blood transfusions as a source of disease  (e.g. infant contact with a maternal chancre) 

5. 50% of the sexual contacts of a patient with primary syphilis become infected.

A. True

B. False

6. In Congenital syphilis 

A. Infection is contracted from an infected mother via transplacental transmission of T. pallidum 

B. In women with untreated early syphilis, 40% of pregnancies result in spontaneous abortion, stillbirths, or perinatal deaths. 

C. Infection can be asymptomatic, especially in the first weeks of life

D. It may have multi-system manifestation, including osteitis, hepatitis, lymphadenopathy, pneumonitis, mucocutaneous lesions, anemia, and hemorrhage. 

E. Late manifestations of congenital syphilis can involve the central nervous system, bones, teeth, eyes, skin and/or cartilage.

F. All of the above

7. Transplacental transmission is most likely to occur in

A. Early stages of maternal syphilis

B. Late stages of maternal syphilis

Untreated syphilis, at any stage of the disease, can be transmitted to the fetus; the rate of transmission is almost 100% during the secondary stage and slowly decreases with increasing duration of disease. Mother with tertiary syphilis is less likely to transmit the infection to fetus.

8. In primary syphilis

A. The primary lesion develops 2 to 10 weeks after infection as an indurated swelling at the site of infection. 

B. The surface necroses to yield a hard-based ulcerated lesion,

C. The chancre is teeming with spirochetes and is highly infectious.

C. Untreated, the lesion heals within 3 to 8 weeks. 

D.  All of the above

The primary lesion is not always apparent.

9. Basic pathologic lesion in primary syphilis is

A. Endarteritis

B. Necrotizing Granuloma

C. Suppurative process

10. The differential for genital ulcers  due to STD should include

A. Herpes Simplex

B. Chancroid

C. Lymphogranuloma venerium

D. Granuloma Inguinale

E. All of the above

Look up the characteristics of ulcers for each of these entities. Fortunately in United states, Chancroid, Lymphogranuloma venerium and Granuloma inguinale are are.

11. Secondary syphilis is highly contagious.

A. True

B. false

12.Immune complexes of antibody, spirochetal components and complement are present in arteriolar walls 

A. True

B. False

They may account for some of he clinical manifestations. 

13. Tertiary syphilis is highly contagious.

A. True

B. False

Late disease is not infectious to others. There are very few organisms in gumma.

14. In the natural history of untreated secondary syphilis, which statement is true

A. Nontreponemal antibody test results revert to negative, possibly the result of spontaneous cure. 

B. Serologic tests remain positive, but no further clinical manifestations appear. 

C. Untreated cases develop tertiary manifestations. 

D. All of the above

• In 25% nontreponemal antibody test results revert to negative, possibly the result of spontaneous cure. 
• In  45%, serologic tests remain positive, but no further clinical manifestations appear. 
• In 30% untreated cases develop tertiary manifestations. 

15.  All of the following can be CNS Tertiary syphilis except

A. Meningitis

B. Tabes dorsalis

C. General paralysis of insane

D. Motor neuron disease

• Meningovascular syphilis involves vascular changes of the meninges associated with increased cells and protein in the cerebrospinal fluid and focal neurologic changes. 
•  In general paresis, there is extensive cortical degeneration of the brain, with mental changes ranging from decreased memory to hallucinations or frank psychosis. 
• Tabes dorsalis involves demyelination of the posterior columns and dorsal roots and damage to dorsal root ganglia. The latter produces ataxia, wide-based gait, foot slap, and loss of the sensations of position, pain, and temperature. 

16. The tertiary syphilis manifestations characteristically occur after 15 to 20 years.

A. True

B. False

A. True

B. False

18. The most characteristic lesion of late cardiovascular syphilis is

A. Aneurysm of the ascending and transverse segments of the aortic arch

B. Aneurysm of the descending aorta

• The most characteristic lesion of late cardiovascular syphilis is the development of an aneurysm of the ascending and transverse segments of the aortic arch as a result of gummatous changes in the middle coat of the aorta and loss of elasticity. 
• This aneurysm can lead to aortic valve incompetence, pressure necrosis of structures adjacent to the aorta, or rupture of the aorta.

A. True

B. False

• The isolated gumma is a granulomatous reaction to T. pallidum infection. .
•  It occurs most often in skin, bones, or joints, but may involve any organ. 
• Clinical manifestations of gumma are similar to those of other mass-producing lesions in the tissues, such as tumors. 
• Too few spirochetes are in the lesions to be demonstrated by microscopic techniques, except in general paresis, when large numbers are found in the cerebral cortex. 

20. In the early stages of syphilis, the patient rapidly becomes immune to re-infection,

A. True

B. False

• In the early stages of syphilis, the patient rapidly becomes immune to re-infection, but immunity is short-lived if the patient is successfully treated. 
• In the later stages, immunity to reinfection is more solid and continues after treatment.
• Syphilis in immunocompromised patients such as those suffering from the- acquired immunodeficiency syndrome may present with unusually aggressive or atypical manifestations.

21. Definitive diagnosis is achieved by identifying spirochetes by 

• microscopic dark field examination
• the VDRL slide test
• the rapid plasma reagin (RPR) test
• direct fluorescent antibody tests of lesion exudate or tissue.

22  Nontreponemal tests  

A.  are diagnostic serologic tests for syphilis

B.  They are screening tests for the diagnosis of syphilis

Nontreponemal tests are non specific and needs to followed by treponemal antibody tests or dark field examination to demonstrate the organism. Cardiolipin tests are nonspecific: they may become false-positive in a variety of autoirnmune diseases or in those involving substance tissue destruction or liver involvement, such as lupus erythernatosus, viral hepatitis, infectious mononucleosis, and malaria. 

A. the VDRL slide test

B. the rapid plasma reagin (RPR) test

C. the automated reagin test (ART)

D. All of the above

24. Non-treponemal tests are used as screening procedures for diagnosis and are confirmed by one of the treponemal tests.

A. True

B. False

25. Treponemal tests,  the fluorescent treponemal antibody absorption tests (FTA-ABS),  involve direct detection of antibody to T. pallidum.  For this purpose the T. pallidum is obtained from 

A. Cultures

B. From rabbits cultivated with T. pallidum. 

Remember, T. pallidum. are not easy to culture.

26. Treponemal tests are valuable confirmatory tests, but they are not helpful in monitoring therapy.

A. True

B. False

Treponemal tests are considerably more specific than those using cardiolipin, but titers of positive tests do not decrease rapidly with cure.

27.Penicillin remains the best-studied and the preferred therapy for syphilis. For early (primary, secondary or latent less than one year) syphilis use

A. penicillin G benzathine 2.4 million units IM once. 

B. penicillin G benzathine 2.4 million units IM weekly for 2 weeks. 

C. penicillin G 2-4 million units IV daily for 10-14 days.

D. penicillin G procaine 50,000 units/kg IM daily for 10-14 days.

For late (more than one year’s duration) cardiovascular or gumma syphilis use penicillin G benzathine 2.4 million units IM weekly for 2 weeks. 

For neurosyphilis use penicillin G 2-4 million units IV daily for 10-14 days.

For congenital syphilis use penicillin G procaine 50,000 units/kg IM daily for 10-14 days.

 28. Routine serologic testing is performed in early pregnancy and should be repeated in the last trimester in women at high risk of acquiring syphilis. 

A. True

B. False

29. The following are manifestations of Tertiary syphilis except

A. Tabes dorsalis

B. Aneurysm of ascending aorta

C. Gumma of bone

D. Mitral incompetence

30. Tertiary syphilis can involve

A. CNS

B. CVS

C. Skin

D. Bones

E. Joints

F. Oral and nasal cavities

G. All of the above

31.  Jarisch-Herxheimer reaction refers to

A. Worsening clinical status following Penicillin therapy

B. A lab phenomenon with treponemal antibody testing

C. Refers to changes in Aorta secondary to obliterative endarteritis of the vasa vasorum in tertiary syphilis

Rapid destruction of spirochetes by penicllin leads to an allergic reaction to spirochetal antigens. It occurs in a small percentage of patients and you should be aware of it. Under certain circumstances, where the reaction is anticipated steroids can be administered concurrently.

Pelvic inflammatory disease (PID)

1.  Microorganisms reach the upper genital tract

A. From direct canalicular spread of organisms from the endocervix to the endometrial and fallopian tube mucosa.

B. by hematogenous spread

2. You need to differentiate PID from 

• Acute appendicitis
• Diverticulitis
• Ectopic pregnancy
• Intraabdominal abscess secondary to perforation of colon
• All of the above

3. The incidence of PID is higher in women with intrauterine devices than in those not using this form of contraception.

A 5 to 10 times higher

B. 100 times higher

C. No relationship

In the first 4 weeks following insertion of IUD the PID can be attributed to IUD. If it occurs later most likely it is due to STD. There is probably an increased incidence of PID, in STD when the patient has an IUD.

4. Name the 2 most common pathogens implicated in PID.

A. Neisseria gonorrhea 

B. Chylamdia trachomatis

C. Anaerobes 

D. Gardinerella vaginalis

5. Antimicrobial agents with activity against gonococci, chlamydia. trachomatis, and anaerobes are used in the treatment of PID. 

A. True

B. False

6. Best regimen for treatment of PID is

A. cefoxitin plus doxycycline

B. clindamycin plus gentamicin

C. ceftriaxone plus doxycycline

D. ciprofloxacin plus clindamycin.

All of these regimens are acceptable.

Neisseria gonorrhea

A. urethra in males 

B. endocervix in females

C. the rectum

D. the eyes

2. The infection is transmitted by sexual contact in the following sites except

A. urethra in females

B. the rectum

C. the oropharynx

D. the eye

The eye infection is from hand to eye contact and not due to sexual contact. Silly question.

3. The reservoir of gonococcal disease in the population

A.  Asymptomatic persons. 

B.  Patients who do not seek treatment may become asymptomatic carriers

C. All of the above

As many as 50% of women and 5% of men will not experience recognizable symptoms. Asymptomatic infection is an important factor in transmission of this disease. Asymptomatic carrier can transmit infection for 6 months.

4. Gram stain is more 90% sensitive and 98% specific in men.

A. True

B. False

5. Antibiotic options are 

A. a single dose of Ceftriaxone 125 mg. IM

B. Cefixime (Suprax) 400 mg p.o. 

C. Ciprofloxacin 500 mg. p.o.

D. Ciprofloxacin 400 mg. p.o.

E. All of the above

A. True

B. false

50% patients with urethritis or cervicitis have concomitant chlamydia infection. Doxycycline 100 mg. Twice daily, or azithromycin 1 gram orally as a single dose, should be given along with one of the above antimicrobials.

7. Is vaccine available for prevention of Neisseria gonorrhea 

A. Yes

B. No

8. If you had Goncocoocal infection and if it was treated properly, one does not have to consider Gonorrhea if the symptoms of urethritis returns. The main differential is between different etiological agents that cause  non-gonococcal urethritis.

A. True

B. False

Reinfection is norm, and it is not unusual for one sexually active patient to have 20 or more discrete infections. Re visit the definition of post gonococcal urethritis. One has to consider dual infections with agents causing non-gonococal urethritis. You need to keep both of these concepts in mind. There is no immunity afforded by Gonorrhea and dual infections are common. If the uretritis recurs within 3 weeks most likely it is due to dual imfection. If it occurs later it could be new gonococcl infection.

9. All sexual contacts with an infected patient will acquire Gonococcal infection.

A. True

B. False

50% of females having intercourse with a male with gonococcal urethritis will develop symptomatic infection. The risk for males is 20% after single contact with an infected female. Here gain the problem of asymptomatic infection. Women may acquire the infection but not be symptomatic and could become a carrier and transmit infection.

10. Fitz-Hugh-Curtsi syndrome is

A. Gonococcal peri-splenitis

B.  Gonococcal peri-hepatitis

C.  Gonococcal peri-renal inflammation

D. Non of the above

Fitz-Hugh-Curtsi syndrome is reported both with Gonococcal and Chlamydia infections. When there is peri-hepatitis, patients will have RUQ pain and tenderness and should not be confused with another disease.

11. In patient suspected of having Gonorrhea, you should culture for Neisseria gonorrhea 

A. Urethral discharge

B. Rectal swab

C. Pharyngeal swab

D. All of the above

Remember Gonorrhea can be in urethra, rectum or pharynx depending on the sexual habit.

12. A VDRL should be obtained routinely in all patients with gonorrhea.

A. True

B. False

You should screen for all sexually transmitted diseases , once you diagnose one STD infection.

13. When arthritis is due to Gonococcal infection, you can always culture the organism form the joint fluid.

A. True

B. False

There are two types of joint manifestations in systemic gonococcal infection. 1. Septic arthritis and 2. "arthritis-dermatitis syndrome". The latter is due to circulating immune complexes (presumed) and the joint fluid may not yield organisms on culture.

14. All of the following has been reported with Gonococcal infection except

A. Septic joint

B. Endocarditis

C. Meningitis

D. Pneumonitis

Gonococcemia rarely may lead to endocarditis, meningitis, myopericarditis or toxic hepatitis. The extragenital dissemination is responsible for these infections.