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DR10.1-11 | Sexually Transmitted Diseases — PBL Case

CLINICAL SETTING

You are the medical officer at a NACO-affiliated STI clinic attached to a District Hospital in Tamil Nadu. It is a Tuesday morning. Two patients — a 28-year-old man (Senthil) and his 24-year-old wife (Kavitha) — have arrived together requesting help. They have agreed to be seen sequentially, and the husband insists on being present during both consultations. You must navigate both the clinical and confidentiality dimensions of this encounter.

Trigger 1: Senthil's Complaint

Senthil works as a long-haul lorry driver on the Chennai–Bengaluru route. He presents with a painless sore on his penis for 3 weeks and painless swelling of both groins. He noticed the sore while bathing. He denies pain, fever, or dysuria. He has not sought treatment previously and hoped it would resolve. On direct questioning using a non-judgmental approach, he discloses that he had a single unprotected encounter with a commercial sex worker 5 weeks ago; his wife is unaware. He uses condoms 'sometimes'. On examination: single, indurated, painless ulcer 1.2 cm diameter on the coronal sulcus with a clean base; bilateral non-tender, rubbery inguinal lymphadenopathy. There are no vesicles or pustules.

DISCUSSION POINTS

  • What is the differential diagnosis for a single, painless, indurated genital ulcer? What clinical features distinguish this from chancroid and herpes genitalis?
  • What two categories of serological tests would you order for syphilis, and what does each category measure? When would you expect VDRL and TPHA to be reactive in the course of this disease?
  • Senthil's wife is in the waiting room and wants to know what is wrong. What are your obligations around confidentiality and partner notification? How would you use the 5 Ps framework to counsel Senthil before speaking with her?
  • If the bedside VDRL is reactive at 1:16 and TPHA is positive, what stage of syphilis does this represent and what is the first-line treatment — drug, dose, route, and frequency?
Click to reveal Trigger 2: Kavitha's Consultation — A Different Problem (discuss previous trigger first!)

Trigger 2: Kavitha's Consultation — A Different Problem

You now see Kavitha. She presents with a yellowish-white penile-shaped discharge (she had an unrelated genital wart-like lesion noticed first, see below). Primarily she reports two separate problems: (A) a 2-week history of urethral-like irritation that on further probing turns out to be vaginal pruritus with a thick, curdy white discharge and vulval redness; and (B) a single soft, flesh-coloured, cauliflower-like growth at the right labium minus for the past month, which is non-tender and has been growing slowly. She denies any other partners. On examination: vulval erythema and satellite lesions, thick white discharge on speculum, vaginal pH 3.9, KOH prep shows pseudohyphae and budding yeast. The labial lesion is a soft, pedunculated, cauliflower-like papule with a negative acetowhitening on 5% acetic acid at the base. VDRL from Kavitha: non-reactive.

DISCUSSION POINTS

  • Kavitha has two simultaneous diagnoses. Identify each, state the key confirmatory finding for each, and explain how you differentiate the cauliflower-like labial lesion from condylomata lata given that her VDRL is non-reactive.
  • For the vaginal infection: state the drug, dose, route, and duration of first-line treatment. Are there any restrictions if Kavitha were in her first trimester of pregnancy?
  • For the genital wart: which HPV types are responsible? Outline two first-line treatment options, noting which is patient-applied and which is provider-applied. What safety instruction must you give regarding pregnancy?
  • Does Kavitha's genital wart diagnosis oblige Senthil to receive any additional investigation or treatment beyond his syphilis regimen? Justify your answer.
Click to reveal Trigger 3: Urethral Discharge — A Walk-in Patient (discuss previous trigger first!)

Trigger 3: Urethral Discharge — A Walk-in Patient

While finalising Senthil and Kavitha's prescriptions, a 22-year-old male student (Arjun) walks in to the clinic. He reports a 5-day history of copious, creamy-yellow urethral discharge and significant dysuria. He has one regular partner and reports one unprotected encounter with a different partner 9 days ago at a college event. Examination reveals a milky-white discharge expressed from the meatus. The laboratory is currently processing a previous sample, and the Gram stain result will be available in 30 minutes. The NACO Kit 1 (grey) is in stock.

DISCUSSION POINTS

  • Should you wait for the Gram stain result before treating Arjun, or dispense Kit 1 immediately? Justify using the principles of syndromic management. What is the one additional organism that Kit 1 empirically covers beyond the Gram stain–visible pathogen?
  • When the Gram stain result arrives showing intracellular Gram-negative diplococci in PMNs, how does this change (or not change) your management?
  • Arjun asks whether his regular partner and his encounter partner need treatment. Walk through the contact management component of the 4 Cs for both.
  • Arjun returns in 7 days with persistent mild discharge. His repeat smear shows no intracellular diplococci but >5 PMNs per high-power field. What is the diagnosis, what organism is most likely, and how do you manage this?
Click to reveal Trigger 4: Integration — Programme and Ethical Dimensions (discuss previous trigger first!)

Trigger 4: Integration — Programme and Ethical Dimensions

At the end of the clinic session, the clinic supervisor asks you to reflect on the three cases managed that morning. She asks a series of integrating questions to consolidate your learning and identify practice-level gaps.

DISCUSSION POINTS

  • Across all three cases you managed three different NACO syndromes. List each syndrome, its NACO kit colour, and the key organisms empirically covered. Which two syndromes required simultaneous dual-organism coverage and why?
  • Senthil did not use a condom reliably and had multiple partners. How would you conduct a risk-stratified HIV pre-test counselling session with him, using the 5 Ps framework, without disclosing his history to Kavitha?
  • The clinic supervisor raises the issue of antimicrobial resistance: ciprofloxacin-resistant Neisseria gonorrhoeae has been detected in the district. How does this affect empirical kit selection, and what would you need to know about Kit 1 composition to ensure it remains effective?
  • Identify one strength and one limitation of syndromic management that you observed across today's cases. What programme-level change would you advocate to address the limitation?