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Kuliah Infeksi Menular Seksual

(IMS )
Oleh : dr Kristina Nadeak SpKK ( K )

Penyakit penyakit yang dapat ditularkan melalui


infeksi menular seksual

Sifilis
Gonore
Uretritis non spesifik
Trikomoniasis
Chancroid
Lymfogranuloma venereum
Donovanosis
Herpes genital
Vaginosis Bakterial
Kandidosis /Kandidiasis vulvovaginal
Kondiloma Akuminata
Hepatitis-B
Sitomegalovirus
Epstein-Barr Virus Infeksi
Pedikulosis pubis
Scabies
Intestinal Protozoa
HIV
Molluscum kontangiosum

Nama penyakit

Jan 2004 sd des 2008

Jan sd des 2009

Jan sd juni 2010

Jlh

persen

Jlh

persen

Jlh

persen

sifilis

31

11,83

10

7,94

6,86

gonore

42

16,03

31

24,60

23

22,55

UNS/IGNS

55

20,99

19

15,08

17

16,67

Kondiloma Akuminata

43

16,41

27

21,43

23

22,55

chancroid

1,91

1,59

1,96

Herpes genital

15

5,73

3,18

1,96

Trikomonisasis
Vaginalis

2,67

2,38

2,94

Moluskum kontangiosum

1,15

1,59

1,96

HIV+ s

O,76

2,38

1,96

HIV + KA

1,91

6,35

6,86

Bakterial vaginosis

15

5,73

6,35

2,94

KVV

39

14,89

7,14

11

10,78

total

262

126

102

GONORE
Etiologi: Neisseria gonorrhoeae

:
Pria 1- 5 hari
Wanita sulit diketahui oleh
Masa inkubasi

karena sering asimtomatik .

Gejala klinis
Pria

Subj : rasa gatal, panas


disekitar OUE, nyeri kencing
Obj : duh tubuh uretra,kental,
putih atau kuning,kadangkadang mukoid atau
mukopurulen,eritema
atau edema pada meatus
.Terkadang dijumpai pem.kel
limfe inguinal bilateral .

Wanita sering asimtomatik,


bila ada duh tubuh serviks
purulen atau mukopurulen,
kadang-kadang disertai
eksudat purulen dari uretra
atau kelenjar Bartholin.
Komplikasi :
Pria epididimitisinfertilitas
Wanita adneksitiskehamilan
ektopik, infertilitas.
Lab : Gram stain
KulturThayer-Martin
,

Infeksi genital non spesifik/ uretritis non


spesifik
Etiologi: tersering Chlamydia
trachomatis.
Masa inkubasi:
Pria 1- 3 minggu atau lebih lama
Wanita sulit diketahui mungkin 1-4
minggu.
Gejala klinis :
Pria duh tubuh uretra, mukoid atau
mukopurulen,kadang-kadang purulen
dapat disertai eritema meatus.
Wanita duh tubuh serviks mukopurulen,ektopia serviks, serviks
mudah berdarah.

Komplikasi :
Pria epididimitis infertilitas.
Wanita adneksitiskehamilan
Ektopik,infertilitas.
Lab :
PriaGramlekosit > 5/ Lpd.
wanitaGramlekosit> 30/Lpd.
( -) N.Go,Trich,C.Vag atau negatif
Kuman penyebab.

SIFILIS

Etiologi : T.Pallidum ( spiral)


Masa inkubasi : 10-90 hari ( 3 minggu).
Gejala Klinis :
Primerulkus soliter,bulat atau lonjong,
dasar bersih,dengan indurasi,tidak ada rasa
nyeri. Kelenjar getah bening membesar,
umumnya bilateral, kenyal,tidak ada nyeri,
dan tidak disertai eritema. Tidak ada gejala
sistemik.1-5 miggu.
Sekunder (2mgg- 6 bulan) berbagai ruam
pada kulit, selaput lendir dan organ tubuh,
Dapat disertai demam, malaise.

Sifilis laten(-) klinis, pem


serologis reaktif.
Sifilis lanjut :
Tertier ( gumma)benigna
Neurosifilis : asimtomatis
simtomatis
Sifilis kardiovaskuler.
Lab : Lapangan gelap(dark field).
Mikroskop fluoresensi.
Penentuan antibodi ( serum)
VDRL & TPHA

Chancroid ( ulkus mole)


Etiologi :Haemophilus ducreyi.
Masa inkubasi : 2- 35 hari.
Gambaran klinis
:ulkus( multiple) ,sangat nyeri,tepi
tidak rata dan bergaung,berbatas
tegas.Dasar ulkus
rapuh,kotor,mudah
berdarah,nekrotik.
Pembesaran kel limfe inguinal dan
sakit Bubo formation.
(-)gejala sistemik.

Lab :
Peng Gram,Wright,Unnapapanheim atau Giemsa.
Test ELISA.

Granuloma inguinale( Donovanosis)


Etiologi :Calymmatobacterium
granulomatis.
Masa inkubasi :2 minggu -3
bulan.
Gambaran klinis : ulkus dan
ulsera meluas dan pada
dasarnya terdapat jaringan
granulasi (ulcus granulomatous).
Lab : preparat apus dgn zat
warna Giemsabadan Donovan
Histologi badan 2 Donovan.

Limfogranuloma venereum(LGV)
Mengenai sistim saluran pembuluh
limfe dan kelenjar limfe( genital,
inguinal, anus dan rektum).
Etiologi : C.trachomatis serovars
L1,L2dan L3.
Masa inkubasi : 3-20 hari .
Gambaran klinis :Limfadenitis
inguinal yang unilateral, nyeri
Didahului lesi primer( erosi atau
ulkus dangkal atau vesikel atau
papel ).
Greeblatts sign,ettage bubo.
Gejala sistemik :demam,anoreksia.

Komplikasi:
Sindrom anorektal.
Sindrom genital
( Esthiomene).
Lab: Pengecatan Giemsa
dari pus
bubo.
serologi :complement
fixation
test,titer 1:1024
kultur jaringan.

Herpes genital
Etiologi : Herpes simplex virus,
umumnya tipe 2.
Masa inkubasi :
Biasanya 2-10 hari,dapat sampai
3 minggu .
Gejala klinis :
Herpes genital primerdiawali
dengan papul vesikel ulkus/
erosi multiple berkelompok,
diatas dasar eritematosa,sangat
nyeri dan edema di inguinal,
limfadenopati bilateral,dan kenyal
,disertai gejala sistemik.

Herpes genital rekurens


umumnya lesi tidak sebanyak
pada lesi rimer,dan keluhan tidak
seberat lesi primer.
Lab : tes Tzank.
kultur jaringan.
ELISA

Cytomegalovirus ( CMV)
Twentieth centuryhistologic appearance fatal
infection newborns
Enlarge cells with viral inclusion
> 50% of individual in most populations
throughouts the world demonstrate serological
evidence of prior CMV infection.

Morphology

.Member of the beta subfamily of the herpesviridae ,also


includes HHV-6, HHV -7.
Infect many other mamalian species( mice ,rats, guinea
pigs and nonhuman primates ).
The CMV virion is 200nm in size and contain large double stranded
DNA genome encased in an icosahedral capsid.
70 viral proteinViral glycoproteinkey determinant in mediating &
entry of the virus into the cell.
Genome contain 230 thousand base pairs of DNA.
ability to persist in a latent state for life time of infected
individual

Morphology

These viruses have a long reproductive cycle and the infection


progress slowly in culture.
The infected cells frequently become enlarged ( cytomegalia).

The virus can maintened in latent form in secretory glands,


lymphoreticular cells, kidneys, and other tissue.

Epidemiology
Is a ubiquitous virus,as evidence infection :
*person of all ages ( u.s) 5-30 %children will be CMV seropositif by
5 0r 6 years age.
- adolesnce 40% & increase by 1% per year .
*socioeconomic group
* geographic locales

Transmissi
sexually transmissible infection based on several lines of
evidence : heterosexuals
* CMV seroprevalence among male partners of CMV
seropositive women than of CMV seronegative women ( 74% vs
31%) .
* Prevalence of CMV seropositivity in sexually active women ( age
of 15-30 years) was greater than than in celibate women

Among women,predictor of CMVseropositivity included :


- young age at time of first sexual intercourse
- greater number of lifetime sexual partners
- the presence of other STDS
* out break of CMV-associated mononucleosis was documented
among sex partners but did not affect non sexually active person.
* clinical observasi most frequenstly and in greater titers from
cervical secretion and semen than from outer sources.

HOMOSEXUAL MEN
* first documentation San francisco ( 1970-early 1980 )
STDclinic,the
rate of CMVseropositivity in homoseksual men was 93,5% :54,3 % in
heteroseksual.
* Urinary excretion of CMV was found > in homoseksual men than
heterosexual,( 7,4% vs 0%).
* infection wiith multiple strains of CMV has been documented in homo
sexual men with and without HIV/AIDS

Excretion of CMV was found > in semen (34,6) :urine (7,7) and
semen harbored virus for longer periods of time than urine ( 22
months vs 9 months).

Transmission
Via BLOOD PRODUCTS and TRANSPLANTED ORGANS
CONGENITAL AND NEONATAL INFECTION
* three different routes : . Transplacentalreactivation
( 20-40%).
. Intrapartumlokal viral shedding.
50% of infant born to the 2-28 % 0f women who shedCMV
from vagina or cervix at time of delivery will become infected.
. Breast milk ( 30-70% of seropositive
women).

Clinical manifestations
Infection in immunocompetent
Symtomatic disease in otherwise healthy individual is
uncommon .
Primary infection can result in a mononucleosis like
syndrome :
Fever
lymphadenophaty
Pharingitis
Peripheral blood lymphocytosis

Clinical manifestation
Infection in the immunocompromised
In immunocompromised individual, primary infection or reactivation
of latent virus can be life-threatening .
. Retinitis
.polyradiculopathy :ascending lower-extremity
weakness
.meningoencephalitis
.esophageal ulceration .colitis
.sclerosing cholangitis

Congenital infection are common and can result in


serious life long sequelae .
The possibility that subclinical CMV infection contributes
to chronic diseases such as atherosclerosis

Neonates
Cytomegalic inclusion disease fatal
( jaundice,hepato splenomegaly,trombositopeni and CNS
involvement ).
Sensorineural hearing

lDiagnosis
* Cultur
* Antigen detection peripheral blood leukocytes detection of the
CMV pp65 tegumen protein.
* Polymerase chain reaction.
* Histopathology
owl eye nuclear inclusion.

Treatment

Antiviral agents :
Ganciclovir
a nucleoside analogue of guanosine.
as a competitive inhibitor of deoxyguanosin
triphosphate.
Valganciclovir
Valine ester of ganciclovir.
much greater bioavalaibility compare to oral ganciclovir.
Foscarnet
Cidofovir
Cytogam : high-titer CMV-immune globulin
Fomivirsen.

Epstein-Barr virus ( EBV) infection

Most people become infected with EBV, which is often asymtomatic


but commonly causes infectious mononucleosis.

EBV initially infects epithelial cells (mucosa epithelium) and or


B cell in lymphoid tissues in the oropharynx( glandular
fever),The virus disseminates throunghout the lymphoreticular
system.

Which is primarily transmitted by saliva

Implicated in oncogenesis :
( Transforming cells)

*Burkitts lymphoma
*Nasopharyngeal Ca.
*Hodgkins disease]
*B-Lymphoproliferativ
disorders

Virus classification :

Group : Group I ( ds DNA )


Family : Herpesviridae
Subfamily :Gammaherpesvirinae
Genus : Lymhocrytovirus
Species :Human herpesvirus 4 ( HHV-4)

Epidemiology

Primary exposure often occurs in the first years of life,and this


infections usually cause no symtoms.
In the United States and other developed countries,many persons
are not infected with EBV in their childhood years. When infection
with EBV occurs during adolescence or young adulthood ,it causes
infectious mononucleosis 35% to 50% of the time .

Prevalence of EBV DNA in cervical samples from women attending


sexually transmitted diseases clinic ranges from 28 % to 40% .

Study of koilocytotic lesion of vulvaEBV DNA was detected in


almost half of vulvar biopsies :11% of cell samples from normal
vulvar mucosa contain EBV DNA..

Epidemiology
In healthy,sexual active uncircumcised men, EBV DNA was
detected from coronal sulcus of the gland penis in 13% of study
participants.
Forty-eight percent of EBV seropositive men with uretral discharges
secondary to gonococcal infection had EBV DNA detected in their
genital tract secretions.

Infact, infectious EBV can recovered from genital mucosa of


women with acute infectious mononucleosis,suggesting that
virus is either conveyed from the oropharing to distant mucosa
site by trafficking EBV-infected lymphocytes or that infection
has been iniated by introduction of exogenous virus at that
anatomic site .

Transmission

Transmission EBV :
Kissing
sexual transmission : number of sexual partner.
after acquisition of a new
sexual partner .
blood transfusion
tissue transplantation

Clinical manifestation

Primary EBV infection in infancy or early childhood is usually


subclinical, but when delayed until the second decade of life, it
manifest as infection mononucleosis in up to 50% of patients.
Characteristic triad : fever , headache , general malaise
pharingitis
} lasting for1 to4 weeks.
lymphadenopathy

Clinical manifestation

The greater frequency of symtomatic infection in adolescence may


relate not to age but rather to a
larger inoculum of transmitted
virus and the ensuing T cell reaction

Serologic test
*normal to moderatedly elevated white blood cell count.
*Increased total number of lymphocytes,greater than 10 %
atypical lymphocytes.
*Positive reaction to a monospot test
*Positive paul-Bunnell heterophile antibody

KONDILOMA AKUMINATA
Etiologi :Human papilloma
virus.
Masa inkubasi :1-8 bulan,
rata-rata 2-3 bulan.
Gejala klinis:
Ada tiga bentuk :
1.Bentuk datar ( flat )
2.Bentuk papul
3.Bentuk verukosa
Terutama pada daerah yang
lembab.
Pada wanita dapat menimbul
kan kanker mulut rahim .

Pem penunjang :
Test asam asetat 5%
Kolposkopi
Histopatologi

MOLUSKUM KONTAGIOSUM
Etiologi : virus moluskum
kontagiosum
(VMK).
Masa inkubasi :1 migg-6 bulan,ratarata 2-3 bulan .
Lab : histologi

Trikomoniasis
Etiologi :Trichomonas vaginalis
Masa inkubasi :3-28 hari.
Gejala klinis :
Duh tubuh vagina homogen,
banyak,purulen,kadang-kadang
berbusa,mukosa vagina eritema,
berbau seperti ikan busuk, PH
vagina 5,0
Komplikasi :
Pada wanita hamil dapat
menyebabkan partus prematur,
bayi berat badan lahir rendah.

Lab :Sediaan langsung


(basah).
Kultur pada media Feinberg
atau Kupferberg.

Kandidosis vulvovaginal
Etiologi :Candida albicans.
Gejala klinis :
Pruritus vulva, inflamasi pada
introitus dan labia, disertai
edema atau fisura,duh tubuh
vagina berdumpal,putih,kadangkadang dapat kental, atau
kekuningan,PH vagina 4,5.

Lab :Pem mikroskopik dari


sekret vagina dengan sediaan
basah KOH 10% atau dengan
pewarnaan Gram.

Vaginosis Bakterial
Etiologi :pergantian Lactoba
sillus Spp dengan bakteri
anaerob dalam konsentrasi
tinggi(Bacteriodes,Mobiluncu
s),Gardnerella vaginalis dan
Mycoplasma hominis.
Masa inkubasi :belum pasti,
Diperkirakan beberapa hari
sampai 4 minggu .
Gejala klinis :
Vagina berbau amis terutama
setelah senggama, duh tubuh
vagina tidak terlalu banyak,
Homogen,putih keabu-abuan,

melekat pada dinding vagina,


tidak ada tanda inflamasi.
PH vagina 4,7 ; tes amin ( +).
Komplikasi : pada wanita
hamil dapat menyebabkan
ketuban pecah dini, kelahiran
prematur,bayi berat badan lahir
rendah.
Amsel et al kriteria ( 3 dari 4) :
1.Cairan vagina homogen.
2.PH vagina 4,5
3.Sekret vag berbau spt ikan
busuk.
4.Adanya clue cells

Skabies
Etiologi : Sarcoptes scabies Var
hominis.
Masa inkubasi :2-4 minggu .
Gambaran klinis :
Pruritus pada malam hari merupakan
gejala skabies utama,dan adanya
terowongan ( kunikuli). Lesi berupa
Vesikel,papel urtika dan dan lain-lain,
pada penis bentuk khas berupa nodul
coklat kemerahan yang gatal pada
daerah tertutup dan sering disertai lesi
ulseratif dan pioderma.

Komplikasi :
Infeksi sekunder,spt : lesi ulseratif
dan pioderma.

Pedikulosis Pubis

Etiologi :Phthirus pubis.


Gambaran klinis :
Gatal,pada daerah gigitan
dijumpai maculae cerulae.
terdapat daerah
dada,abdomen dan paha
atas.
Dijumpai kutu dewasa atau
telur kutu.

Intestinal Protozoa

Umumnya penularan melalui oral-fecal tetapi pada kaum


homoseksual ( MSM ) penularan dapat melalui hubungan kelamin
yaitu genital ke anal .
Intestinal protozoa ( protozoa usus ) yang paling sering dijumpai
karena penularan seksual adalah : Entamoeba histolytica dan
Giardia Lamblia ,
sedangkan Crystosporidium sering menjadi masalah besar
pada penderita AIDS

Manifestasi klinis

Diare
Perut bagian atas kram dan sakit
Bloating (gembung)
Flatulence ( perut gembung )
Berat badan menurun
Jarang : vomiting ,nausea dan fever
Dilaporkan : Vaginits
Proctitis

HIV
HIV adalah Human Immunodeficiency Virus .
Di klasifikasi dalam famili Retroviridae ,sub family Lentiviridae
Terdiri : Inti dan Envelop .
Inti : Enzim reverse transcriptase,RNA
protein P7,P8,enzim
Capsid : P24,25 dan P17,18.
Envelop:Gp120 dan Gp 41 .
. Dalam RNA ada Gen Utama : GAG
,Pol,dan Env
Gen tambahan : Tat,Rev, Vpr, Nef,Vpu, Vif.

Tropisma

HIV spesifik , selektif tinggi terhadap sel limfosit T-helper ( CD4+)


dan sel yang mampu mengekspresikan reseptor CD4 seperti
astrosit, migroglia , monosit- makrofag ,Langerhan,s ,dendritik .

Penularan

Hubungan seksual : homoseksual dan heteroseksual


Horizontal : tranfusi darah , jarum suntik yang tercemar, tato .
Vertikal : Transplasenta , ASI .

Manifestasi klinis

Manifestasi gejala dan tanda dari HIV dapat doibagi menjadi 4


tahap.
Pertama

Kedua

: tahap infeksi akut tidak spesifik .


muncul 6 minggu pertama setelah paparan HIV
( demam, rasa letih ,nyeri otot dan sendi ,nyeri telan dan
pembesaran kelenjar getah bening dapat juga disertai
meningitis aseptik ).
: tahap asimtomatis gejala dan keluhan hilang.
berlangsung 6 minggu hingga beberapa bulan bahkan
tahun setelah infeksi.
Internalisasi HIV ke intraseluler aktivitas masih normal

Ketiga

: tahap simtomatis gejala dan keluhan lebih spesifik

dengan gradasi sedang sampai berat .


Berat badan tidak sampai 10 % , selaput mulut terjadi
sariawan , infeksi saluran nafas bagian atas.
dapat melakukan aktivitas meskipun terganggu .
Keempat :Tahap AIDS .
penurunan berat badan > 10 %
diare > 1 bulan
panas yang tidak diketahui sebabnya lebih dari satu bulan.
kandidiasis oral , oral hairy leukoplakia ,TBC paru,
pneumonia bakteri , infeksi sekunder ( p pneumokistik
karinii ),toksoplasmosis otak, virus citomegalo, v.herpes,
histoplasmosis,koksidiomikosis ,keganasan ,dermatitis HIV
penderita berbaring ditempat tidur > 12 jam /hari .

Fase infeksi akut

Makula eritem dan papula .


Jumlah limfosit T > 500 sel /mm
kemudian akan mengalami
penurunan setelah 6 minggu
terinfeksi .

Daftar Kepustakaan

1.Departemen Kesehatan Republik Indonesia Direktorat Jenderal


Pemberantasan Penyakit Menular dan Penyehatan Lingkungan .
Pedoman Penatalaksanaan Infeksi Menular seksual, Jakarta 2004

2 HolmesKK, MardhPA, SparlingPF and Wiesnert PJ . Sexually


Transmitted Diseases 4th ed. New york : Mc Graw Hill 2008 .
.

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