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DR10.1-11 | Sexually Transmitted Diseases — Practice Quiz
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A 24-year-old man presents to a NACO STI clinic with profuse purulent urethral discharge for 3 days. The NACO syndromic kit most appropriate for his management is:
Correct. Kit 1 (grey) is the urethral discharge kit, designed to simultaneously treat GC (Neisseria gonorrhoeae) and NGU (Chlamydia trachomatis) in a single patient contact.
Urethral discharge in a male maps to NACO Kit 1 (grey), which simultaneously covers gonococcal and chlamydial infection — the two commonest co-infecting organisms — at a single visit.
Incorrect. Map the syndrome first: purulent urethral discharge in a male is the urethral discharge syndrome → NACO Kit 1 (grey). Kit 2 is for vaginal discharge, Kit 3 for non-herpetic genital ulcer, Kit 6 for inguinal bubo.
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The VDRL test is reactive at 1:32 in a patient with a painless indurated genital ulcer and non-tender bilateral inguinal lymphadenopathy. Which statement about follow-up serology is MOST accurate?
Correct. A fourfold (two-dilution) drop in non-treponemal titre by 6 months is the standard criterion for adequate treatment response. VDRL 1:32 → 1:8 at 6 months would indicate success.
Non-treponemal tests (VDRL/RPR) track disease activity and their titre should fall fourfold by 6 months post-treatment. Treponemal tests (TPHA/FTA-ABS) remain reactive for life and cannot monitor treatment response.
Incorrect. Remember: VDRL/RPR are non-treponemal tests that reflect disease activity and fall with treatment. TPHA/FTA-ABS are treponemal tests that remain reactive for life — they confirm past infection but cannot monitor treatment.
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A 28-year-old woman presents with a painful, soft, ragged ulcer at the vulva with a tender fluctuant left inguinal node. She is pregnant at 14 weeks. Which is the SAFEST single-dose treatment for the genital ulcer?
Correct. Azithromycin 1 g oral single dose is active against H. ducreyi, is safe in pregnancy (category B/compatible), and achieves high tissue levels.
The clinical picture (painful, soft, ragged ulcer with tender fluctuant inguinal node) is chancroid (Haemophilus ducreyi). Azithromycin 1 g single dose is effective, safe in pregnancy, and preferred. Ciprofloxacin and doxycycline are avoided in pregnancy.
Incorrect. The ulcer is chancroid. Ciprofloxacin is avoided in pregnancy (cartilage concerns), doxycycline is contraindicated in pregnancy (fetal bone/dental effects). Erythromycin is an alternative but is multi-dose — azithromycin is preferred single-dose.
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In taking a sexual history using the 5 Ps framework, which domain specifically enquires about the gender of partners and number of concurrent partners?
Correct. 'Partners' captures number of partners in the past 3-6 months, their gender, and whether relationships are concurrent — all key risk-stratification data.
The 5 Ps are: Partners (number, gender, concurrency), Practices (sexual practices — oral/anal/vaginal), Protection from STIs (condom use), Past history of STIs, and Pregnancy intention.
Incorrect. Recall the 5 Ps: Partners (who and how many), Practices (what sexual acts), Protection (condom use), Past STI history, Pregnancy intention. Gender and concurrency of partners fall under 'Partners'.
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A 30-year-old man with known syphilis is 4 weeks into benzathine penicillin G treatment. He develops fever, rigors, and worsening rash within 2-4 hours of injection. The MOST likely explanation is:
Correct. The Jarisch-Herxheimer reaction occurs within 2-12 hours of the FIRST dose, causes fever, chills, headache, and worsening rash, and is due to cytokine release from spirochaete lysis — not penicillin allergy.
The Jarisch-Herxheimer reaction is a self-limiting febrile response occurring within 2-12 hours of the first dose of anti-syphilitic treatment, caused by the sudden release of spirochaetal antigens during lysis. It is not anaphylaxis and is managed with reassurance and antipyretics.
Incorrect. Anaphylaxis to penicillin is immediate (within minutes), urticarial, and responds to adrenaline. A timed febrile flare with rash hours after the first injection of anti-syphilitic therapy is the classic Jarisch-Herxheimer reaction.
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A patient presents with a 3-week history of a painless, beefy-red, non-ulcerative genital lesion that bleeds to touch. Inguinal lymph nodes are normal. Tissue smear shows intracytoplasmic Donovan bodies. The MOST likely diagnosis is:
Correct. Donovanosis — beefy-red, hypertrophic, non-ulcerative, bleeds on touch, normal lymph nodes ('pseudobubo' forms under skin, NOT in nodes), Donovan bodies on smear. Caused by Klebsiella granulomatis.
Donovanosis (granuloma inguinale) presents as a beefy-red, non-tender, hypertrophic lesion that bleeds easily and shows Donovan bodies (intracytoplasmic inclusion bodies in mononuclear cells) on Giemsa stain. The causative organism is Klebsiella granulomatis.
Incorrect. Donovan bodies in intracytoplasmic inclusions are pathognomonic for donovanosis (Klebsiella granulomatis). LGV primarily causes inguinal bubo. Condylomata lata are moist, flat, white warty plaques. Chancroid is a painful, soft ulcer.
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Which urethral smear finding is diagnostic of gonococcal urethritis (specificity >95% in symptomatic males)?
Correct. Intracellular (within PMNs) Gram-negative diplococci = diagnostic of GC in symptomatic males. This finding justifies syndromic treatment that covers both GC and NGU.
Intracellular Gram-negative diplococci (IGNC) in a urethral smear from a symptomatic male have >95% specificity for gonococcal urethritis. Extracellular diplococci are less specific. NGU is defined by leucocytes without organisms.
Incorrect. Neisseria gonorrhoeae is a Gram-negative diplococcus (paired kidney-bean-shaped cocci). The key diagnostic feature is their intracellular location (inside PMNs) — this distinguishes active gonococcal infection from non-specific carriage.
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A 22-year-old woman presents with profuse, frothy, yellow-green vaginal discharge and vulval pruritus. pH strip shows vaginal pH 5.5. Which bedside test will MOST likely confirm the diagnosis?
Correct. Frothy yellow-green discharge + pH 5.5 + saline wet mount showing motile flagellated trichomonads = Trichomonas vaginalis. The motility is the key — organisms become non-motile at room temperature, so examine promptly.
Frothy yellow-green discharge with pH >4.5 points to Trichomonas vaginalis. Motile trichomonads on saline wet mount confirm the diagnosis. Candida shows pseudohyphae on KOH; BV shows clue cells and a positive whiff test at pH >4.5.
Incorrect. Match the clues: frothy, yellow-green, high pH → Trichomonas vaginalis → saline wet mount for motile trichomonads. Pseudohyphae on KOH = Candida (cottage-cheese, low pH). Clue cells + whiff = BV (grey, fishy, high pH).
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A pregnant woman at 32 weeks is found to have reactive VDRL (1:8) and positive TPHA. She is allergic to penicillin. Which is the MOST appropriate management?
Correct. In pregnancy, penicillin is the ONLY drug with proven fetal-protective efficacy. Penicillin desensitisation is the indicated approach when the pregnant patient is penicillin-allergic — no alternative antibiotic substitutes.
In a pregnant woman with syphilis, penicillin is the ONLY agent proven to treat both maternal infection and protect the fetus from congenital syphilis. If allergic, the protocol is penicillin desensitisation then benzathine penicillin G — not substitution with doxycycline (contraindicated in pregnancy) or azithromycin (T. pallidum azithromycin resistance reported; not reliably protective for fetus).
Incorrect. This is a critical point: in a pregnant woman with syphilis, doxycycline is contraindicated, azithromycin is insufficient (fetal protection unproven, resistance emerging), and ceftriaxone has limited published evidence for fetal protection. Desensitise and use penicillin.
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A 26-year-old man presents with soft, flesh-coloured, cauliflower-like anogenital papules. VDRL test is negative. Which finding would be the MOST important reason to refer him for colposcopy of his sexual partner?
Correct. The cauliflower-like warts are condylomata acuminata (low-risk HPV 6/11). The partner's cervix may carry high-risk HPV 16/18 asymptomatically, and colposcopy detects subclinical CIN that warrants follow-up.
Genital warts are caused by low-risk HPV 6/11. However, sexual partners may be co-infected with high-risk HPV 16/18, which cause subclinical cervical intraepithelial neoplasia (CIN). Colposcopy for the female partner is warranted. Acetowhitening indicates HPV infection but does not confirm malignancy.
Incorrect. The visible warts are low-risk HPV 6/11 (non-oncogenic). The concern for the female partner is co-infection with high-risk HPV 16/18 causing subclinical cervical disease — detected on colposcopy. Acetowhitening does not mean malignancy.
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Which statement BEST describes the key advantage of syndromic case management over laboratory-confirmed diagnosis in the Indian primary care setting?
Correct. Same-visit treatment eliminates the return-visit gap where most patients default. This is the central public-health rationale for the NACO syndromic approach in India.
The primary advantage of syndromic management is same-visit treatment — especially important where laboratory infrastructure is absent and patients often default between first visit and result collection. The trade-off is reduced specificity (some overtreatment), which is accepted to maximise coverage.
Incorrect. Syndromic management treats multiple probable pathogens simultaneously — this is LESS specific than targeted therapy, not more. Its strength is immediacy and coverage, not precision. Partner management is still required.
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A 29-year-old woman presents with thin, grey, homogeneous vaginal discharge with a pH of 5.0 and a positive whiff test. Saline wet mount reveals clue cells. Which organism is the PRIMARY driver of this pathological state?
Correct. BV is a dysbiosis — Gardnerella + anaerobes replace Lactobacillus. Clue cells (vaginal epithelial cells studded with coccobacilli) + positive whiff + pH >4.5 = Amsel criteria met. Treatment: metronidazole.
Bacterial vaginosis (BV) is a polymicrobial dysbiosis in which normal Lactobacillus is replaced by Gardnerella vaginalis and anaerobes. Diagnosis requires 3 of 4 Amsel criteria: grey discharge, pH >4.5, positive whiff test, clue cells on wet mount.
Incorrect. Candida causes curdy white discharge with LOW pH (<4.5) and pseudohyphae on KOH. Trichomonas causes frothy yellow-green discharge with motile organisms on wet mount. Chlamydia causes mucopurulent cervicitis. BV is characterised by clue cells, high pH, and positive whiff test.
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