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DR10.1-11 | Sexually Transmitted Diseases — Graded Quiz
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A 34-year-old truck driver presents to a Primary Health Centre at 6 pm with purulent penile discharge for 4 days and dysuria. The laboratory is closed. The PHC stocks NACO kits. The MOST appropriate immediate action is:
Correct. The core principle: treat at first contact, cover all probable organisms, manage the partner. Kit 1 covers GC + NGU. This is exactly the NACO rationale.
Syndromic management is precisely designed for the no-laboratory scenario. The correct action is to dispense Kit 1 (grey) at first contact — treating both GC and NGU simultaneously — and include partner management. Delaying or referring negates the purpose of syndromic management.
Incorrect. Waiting for lab results or referral creates the default gap that syndromic management was designed to prevent. A single antibiotic without chlamydial cover is insufficient. Dispense Kit 1 now and arrange partner management.
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A 19-year-old woman presents with a painful vulval ulcer 5 days after unprotected intercourse. On examination there are two adjacent soft, ragged ulcers with undermined edges and a tender right inguinal node. VDRL is non-reactive. The MOST appropriate NACO kit is:
Correct. The painful, soft, ragged ulcer with tender adenopathy is a non-herpetic genital ulcer (chancroid). NACO Kit 3 (blue) treats both probable pathogens (H. ducreyi and T. pallidum empirically).
Painful, soft, ragged ulcers with tender inguinal adenopathy = chancroid (non-herpetic genital ulcer). NACO Kit 3 (blue) covers non-herpetic GUD, which includes empirical cover for both chancroid and syphilis. Kit 4 (red) is for vesicular herpetic ulcers.
Incorrect. Identify the syndrome first: painful soft ragged ulcer → non-herpetic GUD → Kit 3 (blue). Kit 4 is for vesicular/herpetic ulcers. Kit 6 is for inguinal bubo without significant ulcer. Kit 1 is for urethral discharge.
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A 44-year-old woman has reactive VDRL at 1:4 and positive TPHA. She has no symptoms or signs. She cannot recall any previous treatment for syphilis. She is not pregnant. How long ago she acquired the infection is unknown. The MOST appropriate treatment regimen is:
Correct. Unknown duration latent syphilis = treat as late latent: 3 weekly doses of benzathine penicillin G 2.4 MU IM. The principle is: when in doubt, use the longer course.
When the duration of latent syphilis is unknown, treat as late latent (>2 years): benzathine penicillin G 2.4 MU IM once weekly for 3 doses (7.2 MU total). Single-dose is only appropriate for confirmed early latent (<2 years). Neurosyphilis requires IV penicillin.
Incorrect. The key staging rule: if duration is unknown, default to late-latent treatment (3 weekly doses). Single dose is for confirmed early latent (<2 years). Neurosyphilis requires IV penicillin, not IM. Doxycycline is an alternative for early latent only, not late latent.
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During a per-speculum examination of a woman with vaginal discharge, you note a strawberry cervix (punctate haemorrhages on the cervix). The pH is 5.8. Which diagnosis is MOST consistent with this finding?
Correct. Strawberry cervix is the classic colposcopic sign of T. vaginalis (seen in about 5-15% of cases). Elevated pH, frothy discharge, and cervical punctation → T. vaginalis. Treat with metronidazole and include partner.
Strawberry cervix (colpitis macularis) — punctate haemorrhages on cervical epithelium — is a classic, though uncommon, finding of Trichomonas vaginalis. The combination of frothy discharge, elevated pH, and strawberry cervix is pathognomonic.
Incorrect. BV does not cause cervical haemorrhages — it is a vaginal dysbiosis without cervicitis. Candida causes vulval inflammation and no cervical lesion. Chlamydia causes a friable, mucopurulent cervicitis but without the strawberry punctation of Trichomonas.
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A 31-year-old man presents with a 3-week history of painless inguinal lymphadenopathy that is now fluctuant. He recalls a small transient penile papule 6 weeks ago that healed on its own. The MOST likely diagnosis and treatment are:
Correct. LGV: primary papule heals quickly → secondary stage bubo (painful, fluctuant inguinal lymphadenopathy) weeks later. Doxycycline 100 mg BD × 21 days is the treatment of choice.
Classic LGV presentation: a self-healing primary papule/ulcer followed by inguinal bubo in the secondary stage. Caused by C. trachomatis L1-3. Treatment is doxycycline 100 mg BD for 21 days. The fluctuant node may need aspiration (not incision) to prevent chronic sinus.
Incorrect. The sequence of self-healing primary lesion → bubo weeks later is the LGV progression (C. trachomatis L1-3). Chancroid has a simultaneous painful ulcer + bubo. Syphilis bubo is non-tender. Donovanosis does not primarily cause lymphadenopathy — it causes a subcutaneous pseudobubo.
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While examining a male patient with a suspected genital ulcer, the foreskin cannot be retracted due to phimosis. The MOST appropriate immediate action is:
Correct. Examine what is accessible, document the limitation clearly, and treat syndromically. Forcible retraction risks paraphimosis. Deferring treatment loses the patient. Blind swab insertion risks injury.
Phimosis that conceals a possible sub-preputial ulcer must be handled with careful external inspection and documentation. Forcible retraction causes pain and paraphimosis. The syndromic kit should be administered based on available clinical evidence — this is a known NACO teaching point.
Incorrect. Do not force the foreskin — phimosis with attempted retraction causes paraphimosis. Do not defer treatment completely. The genital ulcer examination skill explicitly teaches: if access is limited, document it and treat based on the available clinical picture using syndromic management.
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A 27-year-old HIV-positive man on ART presents with recurrent grouped vesicular ulcers on the penis for the past 6 months, occurring approximately monthly. The MOST appropriate long-term management strategy is:
Correct. Suppressive acyclovir is indicated for frequent recurrences (≥6/year) and especially in HIV-positive patients. Daily therapy also reduces — but does not eliminate — asymptomatic viral shedding and transmission risk.
Recurrent genital herpes (HSV-2) with 6+ episodes per year, or in an immunocompromised patient, warrants daily suppressive antiviral therapy (acyclovir 400 mg BD or valacyclovir 500 mg OD). This reduces frequency, severity, and asymptomatic viral shedding. Asymptomatic shedding occurs between episodes.
Incorrect. Episodic therapy alone is appropriate for infrequent recurrences. With monthly recurrences in an immunocompromised patient, suppressive daily therapy is standard. Penicillin is inactive against HSV. Asymptomatic shedding occurs between episodes — this is a key counselling point.
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A 25-year-old woman presents with flat, moist, grey-white warty lesions at the vulva and perianal area. VDRL is reactive at 1:16. Which treatment is CONTRAINDICATED in this patient?
Correct. These are condylomata lata (secondary syphilis) — not HPV warts. Podophyllin is a treatment for HPV condylomata acuminata and is inappropriate (and harmful) for syphilitic lesions. Treat with benzathine penicillin G.
The flat, moist, grey-white warty lesions with a reactive VDRL are condylomata lata — manifestations of secondary syphilis, NOT condylomata acuminata (HPV warts). Treatment is benzathine penicillin G, not podophyllin. The two safety reflexes for genital warts: always do VDRL to exclude condylomata lata before applying podophyllin.
Incorrect. The flat, moist, grey-white lesions with reactive VDRL 1:16 are condylomata lata of secondary syphilis — not HPV warts. Podophyllin applied to condylomata lata is a diagnostic error with no therapeutic benefit and systemic toxicity risk.
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A 35-year-old pregnant woman at 10 weeks gestation has a reactive VDRL (1:32) and positive TPHA. She reports no penicillin allergy. The MOST appropriate treatment is:
Correct. Syphilis in pregnancy must be treated urgently with benzathine penicillin G (the only agent with proven fetal-protective efficacy). Do not defer — each week of delay increases congenital syphilis risk.
In pregnancy, benzathine penicillin G is the ONLY treatment proven to prevent congenital syphilis — it must be given promptly regardless of gestational age. Erythromycin does not reliably cross the placenta and is inadequate for fetal treatment. Azithromycin is not recommended. The Jarisch-Herxheimer reaction in pregnancy is a reason for monitoring, not for delaying treatment.
Incorrect. Erythromycin does not reliably cross the placenta — the fetus remains untreated. Azithromycin is not proven safe for fetal protection. Deferring treatment dramatically increases congenital syphilis risk. Treat now with penicillin.
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A 23-year-old woman presents with vaginal discharge. On NACO risk stratification she scores high-risk (she is under 21 with multiple partners). Which of the following is the correct approach to prescribing NACO Kit 2 (green)?
Correct. NACO Kit 2 (green) is designed for vaginal discharge with risk stratification built in. A high-risk woman receives the complete empirical coverage including GC/chlamydia cervical component — single visit, no culture required.
The NACO vaginal discharge syndromic approach (Kit 2, green) uses risk stratification: low-risk women receive treatment for BV and Trichomonas; high-risk women (younger age, multiple partners, symptomatic cervical findings) also receive coverage for GC and chlamydia in the cervical component. Full kit dispensing is appropriate here.
Incorrect. Syndromic management specifically avoids step-by-step escalation that requires multiple visits. A high-risk woman with vaginal discharge should receive the full Kit 2 empirical coverage at first contact — not sequential single-agent trials.
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After treating a male patient with urethral discharge, which component of the NACO '4 Cs' is SPECIFICALLY aimed at reducing reinfection from the source contact?
Correct. Contact management (treating partners) directly interrupts the reinfection cycle. Without partner treatment, the treated patient returns to a source that re-infects them.
The 4 Cs are: Counselling, Compliance, Condom promotion, and Contact management. Contact management — treating the index patient's sexual partner(s) — is the specific intervention that breaks the reinfection cycle by treating the source.
Incorrect. All 4 Cs matter, but the one specifically aimed at preventing reinfection FROM the partner is contact management — treating the partner removes the source of reinfection. Counselling, condom use, and compliance matter but do not directly treat the partner.
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A neonate born to a mother with untreated late latent syphilis at delivery presents at 3 weeks with a maculopapular rash on the palms and soles, rhinitis, and hepatomegaly. VDRL from the neonate is reactive at 1:8. The MOST appropriate treatment is:
Correct. Symptomatic neonatal congenital syphilis requires aqueous crystalline penicillin G IV for 10-14 days (or procaine penicillin G IM as an alternative) — not benzathine penicillin G alone, which may miss CNS involvement.
Symptomatic congenital syphilis in a neonate requires aqueous crystalline penicillin G IV (or procaine penicillin G IM) for 10-14 days. Benzathine penicillin G alone is inadequate for symptomatic congenital syphilis because it does not achieve the CNS drug levels needed. Doxycycline is contraindicated in neonates.
Incorrect. Symptomatic congenital syphilis needs IV/IM aqueous crystalline penicillin for CNS penetration — benzathine penicillin G is insufficient for symptomatic neonatal disease (inadequate CSF levels). Doxycycline is absolutely contraindicated in neonates. Erythromycin does not reliably treat congenital syphilis.
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