2- HIV/ STI

Question 1

What are the highest risk cateogories for HIV?

Answer 1

Male-to-male sex, heterosexual sex, IV drug use

Question 2

What portion of the immune system is targeted by HIV?

Answer 2

CD4 T cells (enhance immune response)

Question 3

HIV is transmitted via what body fluids of an infected individual? (6)

Answer 3

Blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, breast milk

Question 4

How is HIV transmitted from the body fluids of an HIV postive individual?

Answer 4

Contact with mucous membrane or damaged tissue, or directly injected into bloodstream

Question 5

What are the routes of transmission for HIV?

Answer 5

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)

Question 6

What occurs prior to the clinical latency phase of HIV disease progression?

Answer 6

Acute HIV syndrome- wide dissemination of virus, seeding of lymphoid organs, body has not had a chance to respond

Question 7

HIV RNA copies increase as the disease progresses. What occurs in the body after primary infection, acute HIV syndrome, and clinical latency?

Answer 7

Constitutional sxs → opportunistic diseases → death

Question 8

How does the body respond to acute HIV syndrome (occurs after primary infection)?

Answer 8

Immune system response (CD4 count increases after large decrease) then decline again as disease progresses

Question 9

What are the 4 stages of HIV?

Answer 9

1. Primary infection (acute HIV)
2. Clinical latency (chronic infection)
3. Symptomatic HIV (chronic infection)
4. AIDS

Question 10

Acute HIV occurs 2-6 weeks after exposure. How will a pt present?

Answer 10

Mono/ flu-like sxs (dx often missed)

Pt highly infectious

Question 11

How will routine HIV Ab tests appear during acute HIV (stage 1 of disease)?

Answer 11

Negative

(but HIV antigen measurable and viral load very high)

Question 12

Pt with acute HIV (stage 1 of disease) will present with non-specific sxs with the exception of what?

Answer 12

Rash (upper trunk, neck, face), and mucocutaneous ulcers

Question 13

What occurs in clinical latency (stage 2 of HIV) as immune system begins to respond to infection and acute illness resolves?

Answer 13

Patient seroconverts (becoming Ab positive)

Question 14

What happens to the viral load during the clinical latency stage of HIV (stage 2)?

Answer 14

Decreases to “set point” then slowly rises over time

Question 15

How will a pt typically present during the clinical latency stage of HIV and how long will this last?

Answer 15

Asx, ~10 years

Question 16

What occurs in the symptomatic infection stage of HIV disease (stage 3)?

Answer 16

Immune system deteriorates

(CD4 count decreases as HIV RNA viral load increases)

Question 17

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?

Answer 17

Symptomatic infection stage of HIV

Question 18

How do you define the progression of HIV to AIDS?

Answer 18

• CD4 T cell count < 200 cells/ mcL OR
• HIV + 1/27 AIDS defining conditions

Question 19

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?

Answer 19

Pneumocystis jiroveci pneumonia

Dx via exam of sputum sample

(also have elevated LDH)

Question 20

What is the tx for penumocystitis jiroveci pneumonia (AIDS related opportunistic infection)?

Answer 20

Bactrim DS + supportive care

Question 21

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?

Answer 21

Toxoplasmosis

Dx via contrast-enhancing lesions on brain CT/ MRI

(also seropositive for Toxoplasmosis)

Question 22

What is the tx for toxoplasmosis (AIDS related opportunistic infection)?

Answer 22

Sulfadiazine and pyrimethamine

Question 23

AIDS presenting with pneumocystitis jiroveci pneumonia likely has CD4 T cell count of what?

Answer 23

< 200

Question 24

AIDS presenting with toxoplasmosis likely has CD4 T cell count of what?

Answer 24

< 100

Question 25

AIDS presenting with MAC likely has CD4 T cell count of what?

Answer 25

\< 50

Question 26

AIDS presenting with cytomegalovirus (CMV) retinits likely has CD4 T cell count of what?

Answer 26

\< 50

Question 27

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?

Answer 27

MAC Dx with AFB stain (+) (also pos. sputum and blood cultures)

Question 28

What is the tx for MAC (AIDS related opportunistic infection)?

Answer 28

Combo therapy (macrolide + ethambutol)

Question 29

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?

Answer 29

Cytomegalovirus (CMV) retinitis Dx with visualization of perivascular hemorrhages, white fluffy exudates on fundoscopic exam (also seropositive for CMV)

Question 30

What is the tx for cytomegalovirus (CMV) retinitis (AIDS related opportunistic infection)?

Answer 30

IV gangcyclovir

Question 31

What candida infections are a/w AIDS and how are they treated?

Answer 31

Esophageal candidiasis or recurrent vaginal candidiasis Tx with Diflucan or other azole

Question 32

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?

Answer 32

Kaposi's sarcoma (multifocal, widespread, associated lymphadenopathy)

Question 33

While there are many antiretroviral therapies (ART) for HIV, what is important to know?

Answer 33

Many HIV meds are a/w significant SEs and drug interactions

Question 34

Who should be screened for HIV?

Answer 34

**Everyone** 13-64 yo, TB tx initiation, STD, high risk pts (annual screening), pregnant women

Question 35

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

Answer 35

Established HIV

Question 36

When should dx testing be performed for HIV?

Answer 36

Opportunistic infections and TB, sxs consistent with either established or acute HIV

Question 37

What is the test of choice for screening and diagnostic testing of HIV?

Answer 37

Combination HIV antibody and antigen testing (also aval: HIV Ab test, rapid HIV tests)

Question 38

If you suspect acute HIV and you on;y test for the antibody, what is likely to happen?

Answer 38

You will miss acute HIV (USE COMBO TEST or order HIV RNA test)

Question 39

Who should be treated for HIV?

Answer 39

Everyone (including acute/ early infection) + refer asap

Question 40

What is performed prior to initiation of ART for HIV to help guide treatment selection?

Answer 40

Genotypic drug resistance

Question 41

What is the goal of HIV treatment?

Answer 41

Suppress plasma HIV-1 RNA levels to undectable levels (\< 200 copies/ mL), reduce transmission (consistently undectable = prevents transmission)

Question 42

What is the protocol for post-exposure prophylaxis (PEP) for HIV?

Answer 42

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)

Question 43

What can be prescribed to prevent HIV for people at risk?

Answer 43

Pre-exposure prophylaxis (PrEP) = Truvada

Question 44

In patients with HIV what is considered a "normal" CD4 T cell count and at what levels do they typically "do well"?

Answer 44

N = 600-1200 Do well @ ≥ 350

Question 45

In seeing patients with HIV, medications being taken for prophylaxis are a clue to what?

Answer 45

CD4 T cell count Diflucan = cocci = CD4 \< 250 Bactrim = pneumocystis jiroveci/ toxoplasma gondii encephalitis = CD4 \< 100-200

Question 46

What is the causative organism of syphilis?

Answer 46

Treponema pallidum

Question 47

How is syphilis transmitted?

Answer 47

Direct contact w/ infection lesion → enters skin and creates **painless** chancre

Question 48

What are the stages of syphilis?

Answer 48

Primary, secondary, latent, tertiary

Question 49

Pt presents with painless chancre that persists for 4-6 weeks then resolves. What are you concerned for?

Answer 49

Primary syphilis (at location where syphilis entered body)

Question 50

What are the most common manifestations of secondary syphilis?

Answer 50

Rash, condyloma lata, mucous patches

Question 51

Pt presents w/ non-pruritic rash on the palms and soles of foot. What stage of syphilis are you concerned for?

Answer 51

Secondary

Question 52

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?

Answer 52

Condyloma lata, secondary

Question 53

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?

Answer 53

Mucous patches, secondary

Question 54

How long does secondary syphilis generally persist before latent phase?

Answer 54

2-6 weeks

Question 55

In what stage of syphilis is the disease asx, no longer sexually transmittable, and persists for years?

Answer 55

Latent

Question 56

Although most pts do not develop tertiary syphilis, when does it typically appear and what areas of the body can be affected?

Answer 56

10-30 yrs after initial infection Damage to heart, blood vessels, brain, nervous system

Question 57

Pt presents with paralysis, difficulty with coordination, dementia, as well as changes in vision and blindness. What syphilis complications are you concerned for?

Answer 57

Neurosyphilis and ocular syphilis (can occur at any stage)

Question 58

How is syphilis diagnosed?

Answer 58

Serology (blood test) * RPR and VDRL both non-treponemal antibody tests * (High) Titer indicates disease activity * Confirm w/ treponemal Ab test (FTA-ABS)

Question 59

What is the caution for a low titer with RPR and VDRL (non-treponemal antibody tests) for syphilis dx?

Answer 59

May be false positive

Question 60

How do you confirm the dx of neurosyphilis or ocular syphilis?

Answer 60

Lumbar puncture and perform VDRL on spinal fluid (refer to neurologist)

Question 61

Who is treated for syphilis?

Answer 61

Everybody (test + treat sexual partners)

Question 62

What is the tx for syphilis?

Answer 62

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

Question 63

What is the tx for syphilis if pt has PCN allergy? (typical tx = Benzathine pen G)

Answer 63

Oral azithro or oral doxy (except if HIV or pregnant- then use PCN, but consider desensitization)

Question 64

Untreated syphilis during pregnancy (congenital syphilis), esp early syphilis can lead to what complications?

Answer 64

Stillbirth, neonatal death, infant disorders (deafness, neuro impairment, bone deformities)

Question 65

How is congenital syphilis prevented?

Answer 65

Screen pregnant women at 1st prenatal visit | (if high risk, f/u screens @ 28 weeks and delivery, monitor tx)

Question 66

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?

Answer 66

``` Lymphogranuloma venereum (LGV) Tx = doxy ``` (must r/o syphilis and contact county health dept)

Question 67

Pt presents with painful, tender, genital ulcer with foul-smelling discharge and inguinal adenitis. What are you concerned for?

Answer 67

Chancroid (must r/o syphilis and HSV, contact county health dept, consider presumptive tx)

Question 68

What is the tx for chancroid once you have r/o syphilis and HSV?

Answer 68

Azithro, ceftriaxone, cipro

Question 69

What is the causative organism of LGV (lymphogranuloma venereum)?

Answer 69

Serotype of chlamydia trachomatis

Question 70

What is the causative organism of chancroid?

Answer 70

H. ducreyi