GUM Flashcards
What is HIV?
Human immunodeficiency virus
RNA retrovirus - HIV-1 most common
virus enters and destroys the CD4 T helper cells of the immune system
What is AIDS?
Acquired immunodeficiency syndrome which occurs as HIV infection progresses and the person becomes immunodeficient. leads to opportunistic infection
now mostly known as late-stage HIV
what is the progression of contracting HIV
initial flu-like illness occurs within few weeks of infection. infection is then asymptomatic until condition progresses to immunodeficiency
immunodeficient patients develop AIDS-defining illnesses and opportunistic infections - potentially years after initial infection
how is HIV transmitted?
- Unprotected anal, vaginal or oral sexual activity
- Mother to child at any stage of pregnancy, birth or breastfeeding - vertical transmission
- Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, eg through sharing needles, needle-stick injuries or blood splashed in an eye
NOT KISSING
AIDS-defining illnesses associated with end-stage HIV infection occur where the CD4 count has dropped to a level that allows for unusual opportunistic infection and malignancies. what are some examples?
- Kaposi’s sarcoma
- Pneumocystis jirovecii pneumonia (PCP)
- Cytomegalovirus infection
- Candidiasis (oesophageal or bronchial)
- Lymphomas
- Tuberculosis
how should be screened for HIV?
almost everyone who is admitted to hospital with an infectious disease, regardless of risk factors
risk factors = test
how long can it take for a person to develop antibodies to HIV for and what implications does this have for testing?
up to 3 months
HIV antibody tests can be negative for 3 months following exposure so a repeat test is necessary if initial test is negative within 3 months of exposure
how long can it take for a person to develop antibodies to HIV for and what implications does this have for testing?
up to 3 months
HIV antibody tests can be negative for 3 months following exposure so a repeat test is necessary if initial test is negative within 3 months of exposure
do patients require formal counselling or education before an HIV test?
no
document verbal consent
what is the screening test for HIV?
antibody testing
blood test - can be self test sample which then gets posted to lab
testing for p24 antigen can give a positive result earlier in the infection
PCR testing for HIV RNA levels tests directly for number of viral copies in blood giving viral load
how is HIV monitored?
CD4 count
Viral Load (VL)
what us the CD4 count?
number of CD4 cells in the blood
these cells are destroyed by the virus so the lower the count, the higher the risk of opportunistic infection
what is the normal range for CD4 count and what is considered to be end-stage HIV (AIDS)
500-1200 cells/mm3 normal range
under 200 cells/mm3 is considered end stage
what is the viral load?
number of copies of HIV RNA per ml of blood
‘undetectable’ refers to viral load below the labs recordable range - usually 50-100 copies/ml
how is HIV treated?
combination of antiretroviral therapy (ART)
ART offered to everyone with a diagnosis of HIV irrespective of viral load or CD4 count
BHIVA guidelines recommend starting regime of 2 NRTIs plus a third agent
what is the aim of HIV treatment?
achieve a normal CD4 count and undetectable viral load
when a patient has a normal CD4 and an undetectable viral load on ART, treat their physical health problems as you would an HIV negative patient
HAART stands for highly active anti-retrovirus therapy. what are some examples?
- Protease inhibitors (PIs)
- Integrase inhibitors (IIs)
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
- Entry inhibitors (EIs)
what are some additional managements for patients with HIV?
prophylactic co-trimoxazole given to pt with CD4 under 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP)
close monitoring of cardiovascular risk factors and blood lipids as increased risk of cardiovascular disease
yearly cervical smears for women as predisposes to HPV infection
vaccination up to date - influenza, pneumococcal, hepatitis A&B, tetanus, diptheria, poilio BUT AVOID live vaccines
what sexual health advice can you give to couples regarding HIV?
advise condoms and dams for oral sex even if both positive
if VL is undetectable, transmission through unprotected sex is unheard of but not impossible
partners should have regular HIV tests
what advice can you give couples trying to conceive?
where undetectable viral load, unprotected sex and pregnancy may be considered
also possible to conceive safely through techniques like sperm washing and IVF
when can a woman with HIV have a normal vaginal delivery?
viral load < 50 copies/ml
what is cs needed in women with HIV?
Considered in patients with >50 copies
All women with >400 copies/ml
what should be given during the CS if viral load is unknown or there are >10000 copies/ml?
IV zidovudine
an antiviral medication
what prophylaxis treatment is given to the baby and what is given at what viral loads?
- Low-risk babies (viral load is < 50 copies per ml) = zidovudine for 4 weeks
- High-risk babies (viral load is > 50 copies / ml) = zidovudine, lamivudine and nevirapine for 4 weeks
what is the deal with breastfeeding with HIV?
can be transmitted during breastfeeding even if mothers viral load is undetectable
breastfeeding NOT recommended
what is Post-exposure prophylaxis for HIV?
used after exposure to HIV to reduce risk of transmission
not 100% effective and must be commenced within 72 hours
sooner it is started = better outcome
risk assessment of the probability of developing HIV should be balanced against side effects of PEP
what does PEP involve?
combination of ART therapy
current regime is Truvada and Raltegravir for 28 days
when a person has been exposed to HIV when should they have a test?
immediately and a minimum of 3 moths after exposure to confirm negative status
what is PID?
inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix
what are the terms for inflammation of the endometrium, fallopian tubes, ovaries, connective tissue and peritoneal membrane?
Endometritis is inflammation of the endometrium
Salpingitis is inflammation of the fallopian tubes
Oophoritis is inflammation of the ovaries
Parametritis is inflammation of the parametrium, which is the connective tissue around the uterus
Peritonitis is inflammation of the peritoneal membrane
what are the 3 main STI causes of PID?
- Neisseria gonorrhoeae - more severe PID
- Chlamydia trachomatis
- Mycoplasma genitalium
What are some non PID caused by non-STIs?
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae (a bacteria often associated with respiratory infections)
- Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)
what are the risk factors for PID?
- Not using barrier contraception
- Multiple sexual partners
- Younger age
- Existing sexually transmitted infections
- Previous pelvic inflammatory disease
- Intrauterine device (e.g. copper coil)
how do women present wIth PID?
- Pelvic or lower abdominal pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- Pain during sex (dyspareunia)
- Fever
- Dysuria
What may be seen on examination of a women with PID?
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
Patients may have a fever and other signs of sepsis.
What investigations are done for PID?
- NAAT swabs for gonorrhoea and chlamydia
- NAAT swabs for Mycoplasma genitalium if available
- HIV test
- Syphilis test
A high vaginal swab for bacterial vaginosis, candidiasis and trichomoniasis
Microscope to look for pus cells on swabs from vagina or endocervix - absence of pus cells = exclude PID
pregnancy test in sexually active women with lower abdo pain
inflammatory markers
how is PID managed?
ref to GUM
antibiotics started empirically before swab results obtained to avoid delay and complications
abx will depend on local guideliens
eg
- A single dose of IM ceftriaxone 1g - to cover gonorrhoea
- Doxycycline 100mg BD for 14 days - to cover chlamydia and Mycoplasma genitalium
- Metronidazole 400mg BD for 14 days - to cover anaerobes such as Gardnerella vaginalis
how is PID managed?
ref to GUM
antibiotics started empirically before swab results obtained to avoid delay and complications
abx will depend on local guideliens
eg
- A single dose of IM ceftriaxone 1g - to cover gonorrhoea
- Doxycycline 100mg BD for 14 days - to cover chlamydia and Mycoplasma genitalium
- Metronidazole 400mg BD for 14 days - to cover anaerobes such as Gardnerella vaginalis
signs of sepsis - IV abx, admission
what are some complications fo PID?
- Sepsis
- Abscess
- Infertility
- Chronic pelvic pain
- Ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
What is Fitz-High-Curtis Syndrome?
inflammation and infection of the liver capsule (Glisson’s capsule) = adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
right sided upper quadrant pain - can be referred to right should tip as there is diaphragmatic irritation
laparoscopy to visualise and treat the adhesions
What is bacterial vaginosis?
Overgrowth of anaerobic bacteria in the vagina
NOT sexually transmitted
Caused by loss of lactobacilli in the vagina
Increases risk of STI
describe the microbes involved in bacterial vaginosis?
LACK of lactobacilli (produce lactic acid) which keep vagina acidic preventing overgrowth of bacteria
Rise in pH = anaerobic bacteria multiply
(Gardnerella vaginalis (most common), Mycoplasma hominis, Prevotella species)
what are risk factors for developing BV?
- Multiple sexual partners
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
how does BV present?
- Fishy smelling watery grey or white discharge
- ½ of women are asymptomatic
- Absence of itching, irritation, and pain
how is BV investigated?
Test vaginal pH (3.5-4.5)
Charcoal swab for microscopy (high vaginal or low vagina)
what is seen on microscopy for BV?
Clue cells on microscopy (epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis)
what is the treatment for BV?
Metronidazole – targets anaerobic, Given orally or vaginal gel
Clindamycin is alternative
Check for additional pelvic infections (C & G)
Provide info about reducing risk in the future – avoiding irritation or cleaning with soaps that will disrupt flora
AVOID ALCOHOL WITH METRONIDAZOLE – disulfiram like reaction
what are the complications of BV?
- Increased risk of STI (C, G & HIV)
- Miscarriage
- Preterm delivery
- Premature rupture of membranes
- Chorioamnionitis
- Low birth weight
- Postpartum endometritis
What is candidiasis?
Vaginal infection with a yeast of the Candida family
what microbe is involved with candidiasis?
Candida albicans
Colonise vagina without causing symptoms and then progresses to infection when right environment occurs eg pregnancy or following broad spec abx
what are the risk factors for developing candidiasis
- Increased oestrogen (higher in pregnancy, lower pre-puberty, and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids)
- Broad-spectrum antibiotics
how does candidiasis present?
- Thick, white discharge that does not typically smell
- Vulval itching, irritation and discomfort
- Severe infection – erythema, fissures, oedema, dyspareunia, dysuria, excoriation
what investigations are done for candidiasis?
- Test vaginal pH using swab and pH paper helpful for differentiating between candida (pH <4.5), BV and trichomonas (pH >4.5)
- Charcoal swabs with microscopy to confirm diagnosis
how is candidiasis managed?
Antifungal cream – clotrimazole
Antifungal pessary – clotrimazole
Oral antifungal tablets – fluconazole
(Single dose of cream 5g of 10% at hight
Single dose of clotrimazole pessary 500mg at night
3 doses of clotrimazole pessary 200mg over 3 nights
Single dose of fluconazole 150mg)
Canesten Duo – OTC single fluconazole tablet and clotrimazole cream
what are the complications of candidiasis?
recurrent infections
what is chlamydia?
most commonly sexually transmitted infection in the UK
largely asymptomatic and can still transmit it with no symptoms
what organism causes chlamydia?
Chlamydia trachomatis is a gram-negative bacteria
Intracellular organism
what are risk factors for chlamydia?
Young
Sexually active
Multiple partners
what are the symptoms of chlamydia in women?
- Abnormal vaginal discharge
- Pelvic pain
- Abnormal vaginal bleeding
- Dyspareunia
- Dysuria
- Cervical excitation (exam)
- Inflamed cervix (exam)
what are the symptoms of chlamydia in men?
- Urethral discharge/discomfort
- Dysuria
- Epididiymo-orchitis
- Reactive arthritis
what are some anorectal symptoms of chlamydia?
discomfort, discharge, bleeding, change in bowel habits
what investigations are done for chlamydia?
NAAT swabs
how is chlamydia treated?
1st line for uncomplicated chlamydia infection – doxycycline 100mg BD for 7 days
Abstain from sex for 7 days of Tx for all partners to reduce reinfection
Refer to GUM for contact tracing and partner notification
Prevention for future advice
how is chlamydia treated in pregnancy and breastfeeeding?
- Azithromycin 1g stat then 500mg once a day for 2 days
- Erythromycin 500mg four times daily for 7 days
- Erythromycin 500mg twice daily for 14 days
- Amoxicillin 500mg three times daily for 7 days
what are some general complications of chlamydia?
- PID
- Chronic pelvic pain
- Infertility
- Ectopic pregnancy
- Epididymo-orchitis
- Conjunctivitis
- Lymphogranuloma venereum
- Reactive arthritis
what are some pregnancy related complications of chlamydia?
- Preterm delivery
- Premature rupture of membranes
- Low birth weight
- Postpartum endometritis
- Neonatal infection
what is Gonorrhoea?
Sexually transmitted infection
90% men and 50% of women are symptomatic
what microbe is associated with Gonorrhoea?
Neisseria gonorrhoeae
Gram negative diplococcus bacteria
Infects mucous membranes with columnar epithelium, such as endocervix in women, urethra, rectum, conjunctiva, and pharynx
Spreads via contact with mucous secretions from infected areas
what are some risk factors for contracting gonorrhoea?
young
sexually active
lots of sexual partners
how does gonorrhoea present in women?
Odourless purulent discharge, possibly yellow or green
Dysuria
Pelvic pain
how does Gonorrhoea present in men?
Odourless purulent discharge, possibly green or yellow
Dysuria
Testicular pain or swelling
what other symptoms may be associated with gonorrhoea?
rectal infection - anal or rectal discomfot, discharge, often asymptomatic
pharyngeal infection - sore throat, asymtpomatic
prostatitis - perineal pain, urinary symptoms, prostate tenderness,
conjunctivitis - erythema, purulent discharge
what investigations are done for Gonorrhoea?
NAAT
Endocervical, vulvovaginal, urethral swabs, first catch urine sample
Rectal and pharyngeal swab are recommended in all MSM
NATAT is just for checking presence of gonococcal infection by looking for gonococcal DNA or RNA - Do not provide info about specific bacteria and their antibiotic sensitivities - need charcoal for ms&c
what are the complications of gonorrhoea?
- PID
- Chronic pelvic pain
- Infertility
- Epididymo-orchitis
- Prostatitis in men
- Conjunctivitis
- Urethral strictures
- Disseminated gonococcal infection
- Skin lesions
- Fitz-Hugh-Curtis syndrome
- Septic arthritis
- Endocarditis
- Gonococcal conjunctivitis in a neonate – ophthalmia neonatorum
what is disseminated gonococcal infection?
complication of untreated gonococcal infection where bacteria spreads to skin and joints
what does Disseminated Gonococcal Infection cause?
- various non-specific skin lesions
- Polyarthralgia (joint aches and pains)
- Migratory polyarthritis (arthritis that moves between joints)
- Tenosynovitis
- Systemic symptoms such as fever and fatigue
what is mycoplasma genitalium?
bacteria that causes non-gonococcal urethritis - STI
what investigations are done for mycoplasma genitalium?
NAAT to look specifically for DNA/RNA of the bacteria
As traditional cultures are not helpful for isolating MG as it is slow-growing organism
- First urine sample in morning for men
- Vaginal swabs for women
how is Mycoplasma Genitalium managed?
Doxycycline followed by azithromycin
Doxycycline 100mg BD for 7days
Azithromycin 1g stat then 500mg OD for 2 days
Moxifloxacin – alternative or in complicated infections
Azithromycin used alone in pregnancy and breastfeeding
what can Mycoplasma Genitalium lead to?
- Urethritis
- Epididymitis
- Cervicitis
- Endometritis
- Pelvic inflammatory disease
- Reactive arthritis
- Preterm delivery in pregnancy
- Tubal infertility
what is trichomoniasis?
Type of parasite spread through sexual intercourse
a protozoan (single-celled organism with flagella)
Lives in urethra of men and women and vagina in women
how does trichomoniasis present?
Vaginal discharge – frothy and yellow/green, can have fishy smell
Itching
Dysuria
Dyspareunia
Balanitis – inflammation of gland penis
what is seen on examination of a patient with trichomoniasis?
strawberry cervix caused by inflammation relating to the trichomonas infection, tiny haemorrhages across surface of the cervix
pH will be raised, above 4.5, like BV
what investigations are done on trichomoniasis?
Charcoal swab with microscopy
Swab from posterior fornix or low vaginal swab
Urethral swab or first catch urine in men
how is trichomoniasis managed?
Refer to GUM
Metronidazole
what are the complications of trichomoniasis?
Increases risk of contracting HIV, BV, cervical cancer, PID, pregnancy related complications
what are the 2 types of swabs?
charcoal swabs
NAAT - nucleic acid amplification tests
what can you test for with a charcoal swab?
- BV
- Candidiasis
- Gonorrhoeae
- Trichomonas vaginalis
- GBS
what can you do with a charcoal swab?
allows for microscopy, culture and sensitivities
what can NAAT test for?
chlamydia and Gonorrhoea
what does NAAT test for?
checks directly for DNA/RNA of the organism
what does NAAT test for?
checks directly for DNA/RNA of the organism
what is lymphogranuloma venereum? who is it most common it?
condition affecting the lymphoid tissue around the site of infection with chlamydia
most common is MSM
what are the 3 stages of lymphogranuloma venereum?
- Primary stage – painless ulcer – on the penis, vaginal wall, or rectum
- Secondary stage – lymphadenitis, swelling inflammation and pain in the lymph nodes infected with bacteria, inguinal or femoral lymph nodes may be affected
- Tertiary stage – involves inflammation of the rectum and anus, proctocolitis leads to anal pain, change in bowel habit, tenesmus, and discharge
how is Lymphogranuloma Venereum treated?
treated with doxycycline 100mg BD for 21 days
what is chlamydial conjunctivitis?
chlamydia affecting the conjunctiva of the eye
how does one contract chlamydial conjunctivitis?
genital fluid comes into contact with the eye - hand to eye spread
how does Chlamydial conjunctivitis present?
chronic erythema, irritation, discharge lasting more than 2 weeks, unilateral
Chlamydia can affect neonates when mothers are infected with chlamydia - chlamydial conjunctivitis
herpes and syphilis on notes
