Many infections that are not traditionally considered STIs are sexually transmissible, including those caused by human immunodeficiency virus (HIV), human T cell leukemia viruses types I and II, cytomegalovirus, Epstein-Barr virus, human herpes virus (HHV-6, HHV-7), hepatitis B virus, molluscum contagiosum virus, and Sarcoptes scabiei. The presence of any STI suggests behavior that increases risk for HIV (see Chapter 125), and HIV counseling and testing should be provided to all adolescents with STIs. Acquisition of gonorrhea, syphilis, HSV-2, and trichomoniasis in prepubertal children beyond the neonatal period indicates sexual contact and signifies the need to investigate for possible sexual abuse (see Chapter 22); diagnosis of STIs in infants can represent abuse or perinatal acquisition. The association of sexual abuse with vulvovaginitis and genital HPV infection, which may result from skin or genital HPV types, is less certain.
Direct extension of N. gonorrhoeae, often in combination with C. trachomatis, to the endometrium, fallopian tubes, and peritoneum causes pelvic inflammatory disease (PID). PID complications include tubo-ovarian abscess, perihepatitis (Fitz-Hugh-Curtis syndrome, an inflammation of the liver capsule), and infertility. The differential diagnosis of PID includes ectopic pregnancy, septic abortion, ovarian cyst torsion or rupture, urinary tract infection, appendicitis, mesenteric lymphadenitis, and inflammatory bowel disease. Pelvic ultrasound may detect thickened adnexal structures and is the imaging study of choice to exclude other possible diagnoses. Minimum clinical criteria for diagnosis of PID are lower abdominal tenderness with uterine, adnexal, or cervical motion tenderness. Additional criteria that support the diagnosis are fever, mucopurulent cervix discharge, elevated white blood cell (WBC) count, elevated inflammatory markers, and documented infection with N. gonorrhoeae or C. trachomatis. Adolescents should be hospitalized for treatment if there is uncertainty about the diagnosis; pregnancy; no clinical response to oral therapy within 72 hours; inability to adhere to or tolerate oral therapy; a tubo-ovarian abscess; or severe illness with high fever, nausea, and vomiting. The recommended parenteral treatment for hospitalized patients is cefotetan or cefoxitin, plus doxycycline orally. The recommended ambulatory treatment of PID for younger persons is ceftriaxone (250 mg) in a single intramuscular (IM) dose, plus doxycycline orally for 14 days, with or without metronidazole for 14 days. Follow-up examination should be performed within 72 hours.
N. gonorrhoeae, a gram-negative coccus, is often seen microscopically as diplococci. Gonorrhea is a common STI among adolescents. The highest incidence in the United States is in 15to 24-year-old females and 20to 24-year-old males, and incidence rates differ by race. The organism causes infection at the site of acquisition, which commonly results in mucopurulent cervicitis and urethritis (see Table 116-1), but infection of the rectum and pharynx can also occur. Disseminated gonococcal infections can occur with hematogenous spread and results in petechial or pustular acral skin lesions, asymmetric arthralgia, tenosynovitis or septic arthritis, and, occasionally, endocarditis or meningitis. Perinatal transmission of maternal infection can lead to neonatal sepsis and meningitis (see Chapter 65) and ophthalmia neonatorum (see Chapter 119).