Atlas of Sexually Transmitted Diseases and AIDS: Expert Consult, 4e

383 Pages·2010·210.21 MB·English

by  Stephen A. Morse

ATLAS OF SEXUALLY TRANSMITTED DISEASES
AND AIDS
Commissioning Editor: Sue Hodgson
Development Editor: Nani Clansey
Editorial Assistant: Poppy Garraway/Rachael Harrison
Project Manager: Sruthi Viswam
Design: Charles Gray
Illustration Manager: Bruce Hogarth
Illustrator: Maurice Murphy/Antbits
Marketing Manager(s) (UK/USA): Helena Mutak
ATLAS OF SEXUALLY TRANSMITTED DISEASES
AND AIDS
FOURTH EDITION
Stephen A. Morse King K. Holmes
MSPH, PhD MD, PhD
Associate Director for Environmental Microbiology, William H. Foege Chair and Professor,
National Center for Emerging Department of Global Health,
and Zoonotic Infectious Diseases, Schools of Medicine and Public Health,
Centers for Disease Control and Prevention, Director, Center for AIDS and STD,
Atlanta, USA University of Washington,
Seattle, USA
Ronald C. Ballard Adele A. Moreland
PhD MD, FAAD
Chief, Laboratory Reference and Research Branch, Senior Staff, Department of Dermatology,
Division of STD Prevention, Lahey Clinic Medical Center,
National Center for HIV/AIDS, Viral Hepatitis, Burlington, Massachusetts
STD and TB Prevention, USA
Centers for Disease Control and Prevention
Atlanta, USA
An imprint of Elsevier Limited
© 2010, Elsevier Limited. All rights reserved.
First edition 1990
Second edition 1996
Third edition 2003
The right of Stephen A. Morse, Ronald C. Ballard, King K. Holmes and Adele A. Moreland to be identi-
fied as editors of this work has been asserted by them in accordance with the Copyright, Designs and
Patents Act 1988.
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary. Practitioners and researchers must always rely on their own experience and
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To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
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contained in the material herein.
ISBN-13: 9780702040603
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Atlas of sexually transmitted diseases and AIDS.—4th ed.
1. Sexually transmitted diseases–Atlases. 2. AIDS (Disease)–Atlases.
I. Morse, Stephen A.
616.9′51′00222-dc22
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
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Contributors
Ronald C. Ballard PhD David L. Cox PhD
Chief, Laboratory Reference and Research Branch Microbiologist, Laboratory Reference and Research Branch
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Division of STD Prevention National Center for HIV/AIDS, Viral
Prevention Hepatitis STD and TB Prevention
Centers for Disease Control and Prevention Centers for Disease Control and Prevention
Atlanta, USA Atlanta, USA
Consuelo M. Beck-Sague MD, FAAP, FASM Shireesha Dhanireddy MD
Assistant Professor, Department of Epidemiology and Public Assistant Professor of Medicine
Health, University of Miami School of Medicine Division of Allergy and Infectious Diseases
Miami, USA University of Washington
Harborview Medical Center
Francis Bowden
MBBS, MD, FRACP, FAChSHM Seattle, USA
Professor of Medicine,
Infectious Diseases and Sexual Health Physician Kenneth L. Dominguez MD, MPH
Australian National University Medical Microbiologist, Commander, USPHS
The Canberra Hospital National Center for HIV/AIDS, Viral Hepatitis, STD and TB
Canberra, Australia Prevention
Centers for Disease Control and Prevention
William A. Bower
MD, FIDSA Atlanta, USA
Commander, U.S. Public Health Service
Office of Blood, Organ, and other Tissue Safety John M. Douglas Jr MD
Division of Healthcare Quality Promotion, Senior Medical Advisor
National Center for Emerging and Zoonotic Infectious Diseases National Center for HIV/AIDS, Viral Hepatitis, STD and TB
Centers for Disease Control and Prevention Prevention
Atlanta, USA Centers for Disease Control and Prevention
Atlanta, USA
Cheng-Yen Chen
PhD
Microbiologist, Kevin A. Fenton MD, PhD, FFPH
Laboratory Reference and Research Branch Director, National Center for HIV/AIDS, Viral
Division of STD Prevention Hepatitis, STD and TB Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Centers for Disease Control and Prevention
Prevention Atlanta, USA
Centers for Disease Control and Prevention
Atlanta, USA Charlotte A. Gaydos
MS, MPH, DrPH
Professor of Medicine
Robert W. Coombs
MD, PhD
Department of Medicine
Professor of Laboratory Medicine and Medicine Division of Infectious Diseases
Department of Laboratory Medicine Johns Hopkins Medical Institutions
Harborview Medical Center Baltimore, USA
University of Washington
Seattle, USA
vii
 CCoonnttrriibbuuttoorrss CCoonnttrriibbuuttoorrss
Robert D. Harrington David Lewis
MD FRCP(UK), PhD, DTM&H
Professor, Allergy & Infectious Diseases, Medicine Head of the Sexually Transmitted Infections Reference Centre
Harborview Medical Center National Institute for Communicable Diseases,
University of Washington Sandringham, South Africa
Seattle, USA Honorary Associate Professor,
Department of Internal Medicine
Sharon L. Hillier PhD University of the Witwatersrand,
Professor of Microbiology South Africa
Department of Obstetrics, Gynecology & Honorary Associate Professor,
Reproductive Sciences Division of Medical Microbiology
University of Pittsburgh School of Medicine University of Cape Town, South Africa
Pittsburgh, USA
Lourdes Mahilum-Tapay
PhD
Dale Hu MD, MPH Research Associate
Epidemiologist, Department of Haematology
Division of Viral Hepatitis University of Cambridge
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Cambridge, UK
Prevention
Jeanne M. Marrazzo
Centers for Disease Control and Prevention MD, MPH
Atlanta, USA Associate Professor, Medicine/Division of Allergy and
Infectious Diseases
Catherine A. Ison PhD, FRCPath Medical Director,
Professor Seattle STD/HIV Prevention Training Center
Director of Sexually Transmitted Bacteria Reference Laboratory University of Washington
Health Protection Agency Centre for Infections Seattle, USA
Visiting Professor of Investigative Science and Infectious Disease
Adele A. Moreland
Epidemiology MD, FAAD
Imperial College London Senior Staff, Department of Dermatology
Sexually Transmitted Bacteria Reference Laboratory Lahey Clinic Medical Center
Health Protection Agency Centre for Infections Burlington, Massachusetts
London, UK USA
Jørgen S. Jensen Stephen A. Morse
MD, PhD, DMedSci MSPH, PhD
Mycoplasma Laboratory Associate Director for Environmental Microbiology
Statens Serum Institut National Center for Emerging and Zoonotic Infectious Diseases
Copenhagen, Denmark Centers for Disease Control and Prevention
Atlanta, USA
Christine Johnston
MD, MPH
Rhoda A. Morrow
Acting Instructor of Medicine PhD
Division of Infectious Diseases Professor
University of Washington Department of Laboratory Medicine
Virology Research Clinic University of Washington, Seattle, WA
Seattle, USA Affiliate Investigator, Clinical Research
Fred Hutchinson Cancer Research Center
Peter K. Kohl, FRCP Lon Seattle, USA
Professor of Dermatology,
Francis J. Ndowa
Director MB, ChB, Dip Derm, Dip GU Med
Department of Dermatology and Venereology Medical Officer
Vivantes Klinikum Neukölln Department of Reproductive Health and Research
Academic Teaching Hospital of Charite World Health Organisation
University Medicine Berlin Geneva, Switzerland
Berlin, Germany
Winnie W. Ooi
MD, DMD, MPH
Helen H. Lee
PhD Assistant Professor of Medicine
Associate Professor of Medical Biotechnology Department of Infectious Diseases
Department of Haematology Tufts University School of Medicine
University of Cambridge Lahey Clinic Medical Center
Cambridge, UK Burlington, USA
viii
CCoonnttrriibbuuttoorrss CCoonnttrriibbuuttoorrss
John R. Papp, David Taylor-Robinson
PhD PhD
Microbiologist Emeritus Professor of Genitourinary Microbiology and Medicine
Laboratory Reference and Research Branch, Division of Medicine
Division of STD Prevention Imperial College of Science, Technology and Medicine
National Center for HIV/AIDS, Viral Hepatitis, STD and TB St Mary’s Hospital
Prevention London, UK
Centers for Disease Control and Prevention
Atlanta, USA Magnus Unemo PhD
Associate Professor of Clinical Microbiology
Jorma Paavonen
MD National Reference Laboratory for Pathogenic Neisseria
Professor of Obstetrics and Gynecology Department of Clinical Microbiology
Department of Obstetrics and Gynecology Orebro University Hospital
University of Helsinki Orebro, Sweden
Helsinki, Finland
Elizabeth Unger
PhD, MD
Alan Pillay,
PhD Chronic Viral Diseases Branch
Microbiologist Division of High-Consequence Pathogens and Pathology
Laboratory Reference and Research Branch National Center for Emerging and Zoonotic Infectious Diseases
Division of STD Prevention Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Atlanta, USA
Prevention
Centers for Disease Control and Prevention Anna Wald, MD, MPH
Atlanta, USA Professor, Medicine/Allergy & Infectious Diseases;
Epidemiology Virology Research Clinic
Angela J. Robinson
MBBS, FRCP University of Washington
Consultant in Sexual Health Seattle, USA
Department of Genitourinary Medicine
Mortimer Market Centre John Ward PhD
London, UK Director, Division of Viral Hepatitis
National Center for HIV/AIDS, Viral Hepatitis, STD and TB
Jack D. Sobel,
MD Prevention
Professor of Internal Medicine Centers for Disease Control and Prevention
Chief, Division of Infectious Diseases Atlanta, USA
Wayne State University School of Medicine
Harper University Hospital Harold Wiesenfeld MD, CM
Detroit, USA Associate Professor,
Department of Obstetrics, Gynecology and Reproductive Sciences
Stanley Spinola
MD University of Pittsburgh School of Medicine
Director, Division of Infectious Diseases, Pittsburgh, USA
David H. Jacobs Professor of Infectious Diseases,
Professor of Medicine,
Mircrobiology and Immunology,
Pathology and Laboratory Medicine
Indiana University School of Medicine
Indianapolis, USA
ix
Preface
Experience alone does not produce an expert clinician or laboratory combine succinct text with a wealth of photographs and helpful
scientist. The expert must be able to distinguish the relevant from the illustrations to distill essential, practical information into a uniquely
irrelevant in the face of new knowledge and emerging technologies accessible format. Specialists and generalists alike can literally com-
in the clinical and laboratory disciplines. The bewildered beginner plete the book in a day and, like the editors, will learn dozens of
needs a practical synthesis of the essential facts, the classical together important new findings and approaches (while relearning many old
with atypical clinical manifestations of disease and application of the ones!). They will find this a very useful resource to return to, again
most appropriate clinical techniques, laboratory tests and therapies. and again, while teachers in the field will be able to use the illustra-
This fourth edition of the Atlas of Sexually Transmitted Diseases and tions in electronic form to enhance their presentations. The format
AIDS again presents an enormous amount of well-illustrated, up-to- will also aid the student or trainee to understand and assimilate new
date and practical material on the most common (and several uncom- information more rapidly, because it is so richly illustrated and so
mon) sexually transmitted infections. The first chapter reviews genital clearly presented.
anatomy and examination, and includes dermatological conditions We believe that the Atlas will provide an additional perspective on
which may be confused with STDs. The chapters following cover the the subject to both novice and expert, both as a quick reference and
etiological agents, epidemiology, clinical manifestations, laboratory as an additional, pictorial resource when studying for board examina-
diagnosis and current treatment recommendations for sexually trans- tions or applying new, innovative diagnostic tests.
mitted infections, including opportunistic infections associated with Stephen A Morse
AIDS. Ronald C Ballard
We thank each of the authors of this edition of the Atlas, who were King K Holmes
selected on the basis of their outstanding reputations as clinicians, Adele A Moreland
researchers, and teachers. It is gratifying that they have been able to
xi
Acknowledgements
We would like to recognize and express deep gratitude to the late We would like to thank Sue Hodgson and Nani Clansey at Elsevier
Sumner E (Sam) Thompson, MD and Sidney Olansky, MD for their Publishing for their help and enthusiasm in tackling this project. We
inspiration, teaching, clinical expertise and hard work. Dr Thompson would also like to express our thanks to the authors of previous edi-
inspired us to tackle this project and was a co-editor of the first tions for their contributions, which were responsible for the success
edition of this Atlas of Sexually Transmitted Diseases. His clinical of earlier editions of the Atlas. We would also like to acknowledge
vision inspired physicians, medical students and clinicians at Emory the contributions made by Samuel K Sarafian, PhD (d1996) Sandra
University and its affiliates. Dr Sidney Olansky transmitted his vast Larsen, PhD (d2001) and Walter Stamm, MD (d2009) for their con-
knowledge and love of dermatology and syphilology to all those tributions to previous editions of the Atlas and to the fields of STDs
he taught. His long associations with the Fulton County Health and HIV/AIDS.
Department in conjunction with his teaching in the Dermatology Stephen A Morse
Department at Emory University stimulated remarkable interest in Ronald C Ballard
STDs at Emory and the inspiration to produce the first edition of King K Holmes
this book. Adele A Moreland
xiii
1 
Genital and Dermatologic Examination
A. Moreland and P. Kohl
proximal to the corona. The tip distal to the corona is termed the glans penis. A
INTRODUCTION
varying number of smooth or slightly pebbly flesh-colored papules in one or two
orderly rows may rim some or all of the corona; these are a normal variant called
Skin changes (cutaneous disorders) of the genital skin may be assumed either by ‘pearly penile papules’. They may be mistaken for condylomata (HPV) but histo-
patient or physician to be of a sexually transmitted nature because of their loca- logically are angiofibromas (Fig. 1.3).2 The urethral meatus is usually located on
tion. This chapter will review genital anatomy and examination, and general the posterior or undersurface of the glans and should be carefully examined for
principles of dermatologic examination. The latter will include common cutane- discharge, ulcers, or growths such as condylomata.
ous disorders of the genitalia that are not sexually transmitted, but that may be The skin of the scrotum is thin and more deeply pigmented than the surround-
seen in a sexually transmitted disease (STD) clinic or be mistaken for a STD. ing skin. Scrotal skin is closely adherent to the underlying dartos muscle, which
gives it a rugose wrinkled appearance with contraction of the muscle (e.g. at rest
in younger individuals, and in the cold at all ages). The scrotum has numerous
pilosebaceous, eccrine and apocrine glands. Hair is sparse and coarse.3
GENITAL ANATOMY AND EXAMINATION
Gentle palpation of the testes, spermatic cord and epididymis within the scrotal
sac will reveal any tenderness or masses which may indicate infection. The
The examination of both the male and female genital region should begin below scrotum should be raised to examine the perineal skin between the scrotum and
the umbilicus at the mons pubis. It is generally unsatisfactory to try to evaluate the anus. Sparse, coarse hair covers the skin up to the anal mucosa and sweat and
a partially clothed patient, because important ancillary findings (e.g. lymph sebaceous glands are present.
nodes) may be missed. The patient should be undressed below the waist and
gowned or draped; the gloved physician then exposes the lower abdomen, but-
Anus and rectum
tocks and genitalia in a systematic manner. Exam table stirrups afford better
visualization of the genitalia and perianal area in either sex, and should be used
The folds of the anus are hairless and should be examined for hemorrhoids, fis-
if available. Inspect the inguinal folds, noting erythema or scaling and palpating
sures, ulcers, erosions, and growths. By gentle pressure with a gloved finger the
for nodes. Examine pubic hair for nits, lice, papules of molluscum contagiosum,
rectal mucosa can be palpated for tenderness, ulcers, discharge, or masses beyond
folliculitis, human papillomavirus (HPV), or scabies burrows. Other skin lesions
the anal sphincter.
such as blisters (herpesvirus, HSV) or scaly plaques (tinea, syphilis) should be
noted, as well as ulcerations anywhere on the genitalia, abdomen or buttocks. At
the inferior midline near the male penis or female clitoris, the hair becomes more
sparse. FEMALE GENITAL EXAMINATION
The vulva
MALE GENITAL EXAMINATION
The female genitalia are shown in Fig. 1.4. The commonest diagnostic error in
evaluation of the vulva is failure to systematically examine the area. Patients may
Penis and scrotum
be unaware of proper terminology and anatomy and refer to all areas of the
female genital anatomy as vaginal. The vulva is the area between the mons pubis
Male genital anatomy is shown in Fig. 1.1. Deep pigmentation is usual on the
and the perineum bounded by the inguinal folds. For all genital complaints the
shaft of the penis and the hair is almost absent. A few minute yellowish papules
examination routinely proceeds in the same way from the labia majora inward
may be seen (Fig. 1.2). These are pilosebaceous units (sometimes a vestigial hair
to assure recognition of the range of normal anatomic variations. During the
and its associated oil gland). Sweat glands are also present on the base, shaft and
examination, the physician can reassure the patient by verbalizing normal find-
glans of the penis.
ings, and an office hand-mirror may help communication between patient and
The redundant prepuce (foreskin) projects over the glans where sebaceous
physician regarding specific areas of concern.
glands (of Tyson) secrete a keratinous material called smegma which may accu-
mulate between the prepuce and glans in an uncircumcised male.1 The inner
surface of the prepuce has a moist appearance, much like a mucous membrane. The labia majora
Scattered sebaceous glands empty directly to the surface of the glans and are not
associated with hair follicles. The plump paired labia majora fuse anteriorly at the mons pubis and posteriorly
The firm raised ridge encircling the shaft of the penis near the distal tip is merge with the perineal area. They are bounded laterally by the intertriginous
termed the corona of the penis. The coronal sulcus, a slight depression, lies folds and are covered laterally by coarse hair. Sweat and sebaceous glands are
©2010 Elsevier Ltd
1
DOI: 10.1016/B978-0-7020-4060-3.00001-6