2- HIV/ STI Flashcards
What are the highest risk cateogories for HIV?
Male-to-male sex, heterosexual sex, IV drug use
What portion of the immune system is targeted by HIV?
CD4 T cells (enhance immune response)
HIV is transmitted via what body fluids of an infected individual? (6)
Blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, breast milk
How is HIV transmitted from the body fluids of an HIV postive individual?
Contact with mucous membrane or damaged tissue, or directly injected into bloodstream
What are the routes of transmission for HIV?
Sexual contact, injection drug use, occupational injury, blood products, HIV-infected mom to infant
(risk of mother transmitted to infant decreases if mother being treated)
What occurs prior to the clinical latency phase of HIV disease progression?
Acute HIV syndrome- wide dissemination of virus, seeding of lymphoid organs, body has not had a chance to respond
HIV RNA copies increase as the disease progresses. What occurs in the body after primary infection, acute HIV syndrome, and clinical latency?
Constitutional sxs → opportunistic diseases → death
How does the body respond to acute HIV syndrome (occurs after primary infection)?
Immune system response (CD4 count increases after large decrease) then decline again as disease progresses
What are the 4 stages of HIV?
- Primary infection (acute HIV)
- Clinical latency (chronic infection)
- Symptomatic HIV (chronic infection)
- AIDS
Acute HIV occurs 2-6 weeks after exposure. How will a pt present?
Mono/ flu-like sxs (dx often missed)
Pt highly infectious
How will routine HIV Ab tests appear during acute HIV (stage 1 of disease)?
Negative
(but HIV antigen measurable and viral load very high)
Pt with acute HIV (stage 1 of disease) will present with non-specific sxs with the exception of what?
Rash (upper trunk, neck, face), and mucocutaneous ulcers
What occurs in clinical latency (stage 2 of HIV) as immune system begins to respond to infection and acute illness resolves?
Patient seroconverts (becoming Ab positive)
What happens to the viral load during the clinical latency stage of HIV (stage 2)?
Decreases to “set point” then slowly rises over time
How will a pt typically present during the clinical latency stage of HIV and how long will this last?
Asx, ~10 years
What occurs in the symptomatic infection stage of HIV disease (stage 3)?
Immune system deteriorates
(CD4 count decreases as HIV RNA viral load increases)
Pt presents with mouth disorders such as oral hairy leukoplakia and thrush, Kaposi’s sarcoma, night sweats, prolonged diarrhea, and skin disorders such as molluscum, chronic dermatophyte infection and seb derm. What are you concerned for?
Symptomatic infection stage of HIV
How do you define the progression of HIV to AIDS?
- CD4 T cell count < 200 cells/ mcL OR
- HIV + 1/27 AIDS defining conditions
Pt with AIDS presents with fever, cough, SOB, severe hypoxemia. CXR shows diffuse or perihilar infiltrates. What AIDS related opportunistic infection are you concerned about and how would you confirm your suspected dx?
Pneumocystis jiroveci pneumonia
Dx via exam of sputum sample
(also have elevated LDH)
What is the tx for penumocystitis jiroveci pneumonia (AIDS related opportunistic infection)?
Bactrim DS + supportive care
Pt with AIDS presents with encephalitis (HA, focal neurological deficits, seizures, AMS, +/- retinitis and pneumonitis). What AIDS related opportunistic infection are you concerned about and how would you confirm your suspected dx?
Toxoplasmosis
Dx via contrast-enhancing lesions on brain CT/ MRI
(also seropositive for Toxoplasmosis)
What is the tx for toxoplasmosis (AIDS related opportunistic infection)?
Sulfadiazine and pyrimethamine
AIDS presenting with pneumocystitis jiroveci pneumonia likely has CD4 T cell count of what?
< 200
AIDS presenting with toxoplasmosis likely has CD4 T cell count of what?
< 100
AIDS presenting with MAC likely has CD4 T cell count of what?
< 50
AIDS presenting with cytomegalovirus (CMV) retinits likely has CD4 T cell count of what?
< 50
Pt with AIDS presents with systemic disease including pulmonary infection with night sweats, weight loss, abd pain, diarrhea, and anemia. What AIDS related opportunistic infection are you concerned about and how would you confirm your suspected dx?
MAC
Dx with AFB stain (+)
(also pos. sputum and blood cultures)
What is the tx for MAC (AIDS related opportunistic infection)?
Combo therapy (macrolide + ethambutol)
Pt with AIDS presents with visual disturbances that if left untreated can lead to blindness. What AIDS related opportunistic infection are you concerned about and how would you confirm your suspected dx?
Cytomegalovirus (CMV) retinitis
Dx with visualization of perivascular hemorrhages, white fluffy exudates on fundoscopic exam
(also seropositive for CMV)
What is the tx for cytomegalovirus (CMV) retinitis (AIDS related opportunistic infection)?
IV gangcyclovir
What candida infections are a/w AIDS and how are they treated?
Esophageal candidiasis or recurrent vaginal candidiasis
Tx with Diflucan or other azole
What AIDS related complication is defined as a vascular neoplasm, can occur at any CD4 T cell count, and is most frequent in homosexula men?
Kaposi’s sarcoma
(multifocal, widespread, associated lymphadenopathy)
While there are many antiretroviral therapies (ART) for HIV, what is important to know?
Many HIV meds are a/w significant SEs and drug interactions
Who should be screened for HIV?
Everyone 13-64 yo, TB tx initiation, STD, high risk pts (annual screening), pregnant women
The following sxs are a/w with what?
Weight loss, recurrent fever/ night sweats, extreme tiredness, lymphadenopathy, diarrhea > 1 week, sores of mouth/ anus/ genitals, pneumonia, unexplained neuro sxs
Established HIV
When should dx testing be performed for HIV?
Opportunistic infections and TB, sxs consistent with either established or acute HIV
What is the test of choice for screening and diagnostic testing of HIV?
Combination HIV antibody and antigen testing
(also aval: HIV Ab test, rapid HIV tests)
If you suspect acute HIV and you on;y test for the antibody, what is likely to happen?
You will miss acute HIV
(USE COMBO TEST or order HIV RNA test)
Who should be treated for HIV?
Everyone (including acute/ early infection) + refer asap
What is performed prior to initiation of ART for HIV to help guide treatment selection?
Genotypic drug resistance
What is the goal of HIV treatment?
Suppress plasma HIV-1 RNA levels to undectable levels (< 200 copies/ mL), reduce transmission
(consistently undectable = prevents transmission)
What is the protocol for post-exposure prophylaxis (PEP) for HIV?
Start w/i 72 hrs, 3 drug regimen x 28 days
HIV test at time of exposure, 6 wks, 12 wks (can stop tx if negative)
What can be prescribed to prevent HIV for people at risk?
Pre-exposure prophylaxis (PrEP) = Truvada
In patients with HIV what is considered a “normal” CD4 T cell count and at what levels do they typically “do well”?
N = 600-1200
Do well @ ≥ 350
In seeing patients with HIV, medications being taken for prophylaxis are a clue to what?
CD4 T cell count
Diflucan = cocci = CD4 < 250
Bactrim = pneumocystis jiroveci/ toxoplasma gondii encephalitis = CD4 < 100-200
What is the causative organism of syphilis?
Treponema pallidum
How is syphilis transmitted?
Direct contact w/ infection lesion → enters skin and creates painless chancre
What are the stages of syphilis?
Primary, secondary, latent, tertiary
Pt presents with painless chancre that persists for 4-6 weeks then resolves. What are you concerned for?
Primary syphilis
(at location where syphilis entered body)
What are the most common manifestations of secondary syphilis?
Rash, condyloma lata, mucous patches
Pt presents w/ non-pruritic rash on the palms and soles of foot. What stage of syphilis are you concerned for?
Secondary
Pt presents with moist, heaped, wart-like papules in the intertriginous areas. You believe they are highly contagious. What are these lesions called and what stage of syphilis are you concerned for?
Condyloma lata, secondary
Pt presents with painless, flat patches involving the oral cavity, pharynx, and genitals. You believe they are highly infectious. What are these lesions called and what stage of syphilis are you concerned for?
Mucous patches, secondary
How long does secondary syphilis generally persist before latent phase?
2-6 weeks
In what stage of syphilis is the disease asx, no longer sexually transmittable, and persists for years?
Latent
Although most pts do not develop tertiary syphilis, when does it typically appear and what areas of the body can be affected?
10-30 yrs after initial infection
Damage to heart, blood vessels, brain, nervous system
Pt presents with paralysis, difficulty with coordination, dementia, as well as changes in vision and blindness. What syphilis complications are you concerned for?
Neurosyphilis and ocular syphilis
(can occur at any stage)
How is syphilis diagnosed?
Serology (blood test)
- RPR and VDRL both non-treponemal antibody tests
- (High) Titer indicates disease activity
- Confirm w/ treponemal Ab test (FTA-ABS)
What is the caution for a low titer with RPR and VDRL (non-treponemal antibody tests) for syphilis dx?
May be false positive
How do you confirm the dx of neurosyphilis or ocular syphilis?
Lumbar puncture and perform VDRL on spinal fluid
(refer to neurologist)
Who is treated for syphilis?
Everybody (test + treat sexual partners)
What is the tx for syphilis?
Benzathine pen G - 1 shot (additional doses in > 1 yr)
Contact county health dept
Check RPR titer to confirm tx success at 6, 12, 24 mos
What is the tx for syphilis if pt has PCN allergy?
(typical tx = Benzathine pen G)
Oral azithro or oral doxy
(except if HIV or pregnant- then use PCN, but consider desensitization)
Untreated syphilis during pregnancy (congenital syphilis), esp early syphilis can lead to what complications?
Stillbirth, neonatal death, infant disorders (deafness, neuro impairment, bone deformities)
How is congenital syphilis prevented?
Screen pregnant women at 1st prenatal visit
(if high risk, f/u screens @ 28 weeks and delivery, monitor tx)
Pt presents w/ unilateral inguinal bubo (swollen lymph node), self-limited genital ulcer/ papule at site of innoculation, and anal discharge/ rectal bleeding. What are you concerned for and what is the tx?
Lymphogranuloma venereum (LGV) Tx = doxy
(must r/o syphilis and contact county health dept)
Pt presents with painful, tender, genital ulcer with foul-smelling discharge and inguinal adenitis. What are you concerned for?
Chancroid
(must r/o syphilis and HSV, contact county health dept, consider presumptive tx)
What is the tx for chancroid once you have r/o syphilis and HSV?
Azithro, ceftriaxone, cipro
What is the causative organism of LGV (lymphogranuloma venereum)?
Serotype of chlamydia trachomatis
What is the causative organism of chancroid?
H. ducreyi
