GUM medicine - done Flashcards
1
Q
What is BV?
A
Overgrowth of bacteria in the vagina, specifically anaerobic bacteria – not an STI
2
Q
What is BV caused by?
A
Loss of lactobacilli “friendly bacteria” in the vagina
3
Q
What risk does BV put women in?
A
Developing STIs
4
Q
What are lactobacilli? What its function?
A
The main component of the healthy vaginal bacterial flora - produces lactic acid which keeps the vaginal pH low (under 4.5)
5
Q
What does the acidic environment in the vagina do?
A
Prevents other bacteria from overgrowing
6
Q
What happens when the pH of the vagina rises?
A
More alkaline environment enables anaerobic bacteria to multiply
7
Q
Which examples of anaerobic bacteria are there?
A
Gardnerella vaginalis (most common)
Mycoplasma hominis
Prevotella species
8
Q
What are the risk factors for BV?
A
Multiple sexual partners (although it is not sexually transmitted)
Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
Recent antibiotics
Smoking
Copper coil
9
Q
What to ask when taking a history for BV?
A
Use of soaps to clean the vagina
Vaginal douching
10
Q
What is the presenting feature of BV?
A
Fishy-smelling watery grey or white vaginal discharge (half of women are asymptomatic)
11
Q
What would suggest a diagnosis other than BV?
A
Itching, irritation and pain are not associated with BV and suggest an alternative cause
12
Q
How can the typical discharge of BV be confirmed?
A
Speculum examination – high vaginal swab can be done
Examination is not always required where the symptoms are typical and the woman is low risk of STIs
13
Q
What are the investigations for BV?
A
Vaginal pH can be tested using a swab and pH paper
14
Q
What is the normal pH of the vagina?
A
3.5-4.5 (BV occurs with a pH above 4.5)
15
Q
What type of swab is used for BV?
A
Standard charcoal swab – high vaginal swab
16
Q
How does BV appear on microscopy?
A
“Clue cells” – epithelial cells from the cervix that have bacteria stuck inside them – usually Gardnerella vaginalis
17
Q
What is the management of BV?
A
Asymptomatic BV doesn’t usually require treatment
Symptomatic BV treated with metronidazole
18
Q
How is metronidazole given?
A
Orally or by vaginal gel
19
Q
What is an alternative to metronidazole for BV?
A
Clindamycin an alternative but less optimal antibiotic choice
20
Q
How to avoid BV?
A
Avoid vaginal douching or cleaning with soaps
21
Q
What advice to give when prescribing metronidazole?
A
Avoid alcohol for the duration of treatment as it causes a “disulfiram-like reaction” with nausea and vomiting, flushing and sometimes shock and angioedema
22
Q
What complications is BV associated with in pregnant women?
A
Miscarriage
Preterm delivery
Premature rupture of membranes
Chorioamnionitis
Low birth weight
Postpartum endometritis
23
Q
What is the other name for “thrush”
A
Vaginal candidiasis
24
Q
What is vaginal candidiasis?
A
Vaginal infection with a yeast of the candida family – most commonly candida albicans
25
What are some risk factors for thrush?
**Increased oestrogen** (higher in pregnancy, lower pre-puberty and post-menopause)
**Poorly controlled diabetes**
**Immunosuppression** (e.g. using corticosteroids)
**Broad-spectrum antibiotics**
26
How does vaginal candidiasis present?
**Thick white discharge** which doesn’t typically smell
## Footnote
**Vulval and vaginal itching, irritation or discomfort**
27
What can severe vaginal candidiasis lead to?
**Erythema**
**Fissures**
**Oedema**
**Pain during sex** (dyspareunia)
**Dysuria**
**Excoriation**
28
What are the investigations for thrush?
Often **treatment for thrush** is started impirically, based on presentation
29
How can the pH of a vaginal differentiate between different infections?
**BV and Trichomonas** (pH \> 4.5)
**Candidiasis** (pH \< 4.5)
30
What can confirm the diagnosis of thrush?
**Charcoal swab** with microscopy
31
What are the management options for thrush?
**Antifungal medications:**
Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator
Antifungal pessary (i.e. clotrimazole)
Oral antifungal tablets (i.e. fluconazole)
32
What are the **different options for doses / regimes** of **antifungal** medications?
A single dose of **intravaginal clotrimazole cream (5g of 10% cream) at night**
A **single** dose of **clotrimazole pessary (500mg) at night**
**Three doses** of **clotrimazole pessaries (200mg) over three nights**
A single dose of **fluconazole (150mg)**
33
What is canesten duo?
**Over the counter treatment for thrush**, containing:
**Single fluconazole tablet**
**Clotrimazole cream** to use externally for symptoms
34
What advice needs to be given to women using antifungal creams and pessaries?
Can **damage condoms** and **prevent spermicides from working** – alternative **contraception is needed for at least 5 days** after use
35
What type of bacteria is chlamydia trachomatis?
**Gram-negative bacteria**
36
How does chlamydia replicate?
**Enters and replicates within cells** before rupturing the cell and spreading to others (**intracellular organism**)
37
What is the National Chlamydia Screening Programme?
A programme aimed to **screen every sexually** active person **under 25 years of age** for chalamydia **annually or when they change their sexual partner** – everyone who tests positively should have a **re-test three months** after treatment to **ensure they have not contracted chlamydia again**, rather than to check that the treatment has worked
38
What are patients tested for when they attend a GUM clinic ?
**Chlamydia**
**Gonorrhoea**
**Syphilis** (blood test)
**HIV** (blood test)
39
What are the two kinds of swabs used for sexual health screening?
**Charcoal swabs**
Nucleic acid amplification test **(NAAT) swabs**
40
What type of testing do charcoal swabs allow for?
**Microscopy** (looking at sample under a microscope), **culture** (growing the organism) and **sensitivities** (testing which antibiotics are effective)
41
What do charcoal swabs look like?
**Long cotton bud** which go into a tube with a **black transport medium at the end** (amines transport medium – keeps microorganisms alive during transport)
42
What does microscopy involve?
**Gram staining and examination** under a microscope
43
Where are samples taken from for charcoal swabs?
**Endocervical** swabs
**High vaginal** swabs
44
What infections can charcoal swabs confirm?
**Bacterial vaginosis**
**Candidiasis**
**Gonorrhoeae** (specifically endocervical swab)
**Trichomonas vaginalis** (specifically a swab from the posterior fornix)
Other bacteria, such as **group B streptococcus (GBS)**
45
What infection is NAAT specifically testing for?
**Chlamydia** and **gonorrhoea** - testing directly for the DNA or RNA of the organism
46
What samples can NAAT testing use?
Endocervical swab
Vulvovaginal swab (self taken)
First-catch urine sample
(in order of preference)
47
What samples can be taken from men for NAAT testing?
**First-catch urine**
**Urethral swab**
48
What swabs can be taken to diagnose chlamydia in the rectum and throat?
**Rectal** and **pharyngeal** NAAT swabs
49
How to confirm a diagnosis of gonorrhoea after a positive NAAT test?
Endocervical charcoal swab is required for microscopy, culture and sensitivities
50
What presentations suggest chlamydia in women?
**- Abnormal vaginal discharge**
- **Pelvic pain**
- **Abnormal vaginal bleeding** (intermenstrual or postcoital)
- **Painful sex** (dyspareunia)
- **Painful urination** (dysuria)
51
What presentation suggests chlamydia in a man?
- **Urethral discharge**
- **Painful urination** (dysuria)
- **Epididymo-orchitis**
- **Reactive arthritis**
52
How would **rectal chlamydia** and **lymphogranuloma venereum** present?
Anorectal symptoms - discomfort, discharge, bleeding and change in bowel habits
53
What are the examination findings in chlamydia?
- Pelvic or abdo tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
54
What tests are used to diagnose chlamydia?
Nucleic acid amplification tests (NAAT)
55
Where are samples for NAAT testing for chlamydia taken from?
**Vulvovaginal swab**
**Endocervical swab**
**First-catch urine** sample (in women or men)
**Urethral swab in men**
**Rectal swab** (after anal sex)
**Pharyngeal swab** (after oral sex)
56
What is the first line treatment for uncomplicated chlamydia?
**Docycycline** 100mg twice a day for 10 days
57
Why is a single dose of 1g of azathioprine no longer recommended first line for chlamydia?
**Mycoplasma genitalium resistance** to azithromycin and
**Less effective** for **rectal chlamydia infection**
58
What medications can be given to pregnant women with **chlamydia**?
**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
59
When is a **test of cure** used for clamydia?
- Rectal cases of chlamydia
- Pregnancy
- Symptoms persist
60
What should form part of management after testing positive for chlamydia?
**Abstain from sex for seven days of treatment** of all partners to **reduce the risk of re-infection**
**Refer** all patients to genitourinary medicine (**GUM**) **for contact tracing and notification of sexual partners**
Test for and treat any other sexually transmitted infections
**Provide advice about ways to prevent future infection**
**Consider safeguarding issues** and sexual abuse in children and young people
61
What are the possible complications from infection with chlamydia?
**Pelvic inflammatory disease**
**Chronic pelvic pain**
**Infertility**
**Ectopic pregnancy**
**Epididymo-orchitis**
**Conjunctivitis**
**Lymphogranuloma venereum**
**Reactive arthritis**
62
What are the pregnancy related complications after infection with chlamydia?
**Preterm delivery**
**Premature rupture** of membranes
**Low birth weight**
Postpartum **endometritis**
**Neonatal infection** (conjunctivitis and pneumonia)
63
What is lymphogranuloma venereum?
Condition **affecting the lymphoid tissue** around the **site of** infection with **chlamydia** - most common in **MSM**
64
How many stages are there of Lymphogranuloma Venereum?
3 stages
65
What is the **primary** stage of LGV?
**Painless ulcer** (primary lesion) - occuring on the **penis in men, vaginal wall** in women or **rectum** after anal sex
66
What is the second stage of LGV?
Involves **lymphadenitis** - swelling, inflammation and pain in the lymph nodes infected with the bacteria (inguinal or femoral)
67
What is the 3rd stage of LGV?
Inflammation of the rectum (**proctitis**) and anus
68
What may **proctocolitis** in the 3rd stage of LGV lead to?
- Anal pain
- Change in bowel habits
- **Tenesmus**
- Discharge
69
What is tenesmus?
Feeling of needing to empty the bowels even after completing a bowel motion
70
What is the first line treatment for LGV?
**Doxycycline** 100mg twice daily for 21 days
71
What are alternatives to Doxy for LGV?
Erythromycin
Azithromycin
Ofloxacin
72
How does chlamydial conjunctivits occur?
When genital fluid comes into contact with the eye
73
How does chlamydial conjunctivitis present?
Chronic erythema
Irritation
Discharge lasting more than 2 weeks
Usually unilateral
74
What can present similarily to chlamydial conjunctivitis?
**Gonococcal** conjunctivitis
75
What type of bacteria is Neisseria Gonorrhoeae?
Gram negative diplococcus bacteria
76
Where does gonorrhoea infect?
Infects **mucous membranes** with a **columnar epithelium** e.g. **endocervix**, **urethra**, **rectum**, **conjunctiva** and **pharynx**
77
What increases the risk of gonorrhoea?
Being:
Young
Sexually active
Having multiple partners
Having other STIs
78
What is the problem with treating gonorrhoea?
High level of **antibiotic resistance** - traditionally **ciprofloxacin** or **azithromycin** was used to treat gonorrhoea - there are now high levels of **abx resistance**
79
How does Gonorrhoea present in women?
More likely to be symptomatic than infection with chlamydia:
**Odourless purulent discharge**, possibly green/yellow
**Dysuria**
**Pelvic pain**
80
How does gonorrhoea present in men?
- Odourless purulent discharge, possibly green or yellow
- Dysuria
- Testicular pain or swelling (**epididymo-orchitis**)
81
How does rectal infection with gonorrhoea present?
Anal or rectal discomfort and discharge - often asymptomatic
82
How does pharyneal infection with gonorrhoea present?
Possible **sore throat** but otherwise **asy****mptomatic**
83
How does prostatitis caused by gonorrhoea present?
**Perineal pain, urinary symptoms and prostate** tenderness
84
How is gonorrhoea diagnosed?
NAAT testing to detect the RNA or DNA of gonorrhoea
85
Where are samples taken from for the diagnosis of gonorrhoea?
**Endocervical**, **vulvovaginal** or **urethral** swabs or in **first catch urine sample**
86
What samples for gonorrhoea are advised in MSM?
**Rectal** and **pharyngeal** in all MSM and in those with **risk factors** (e.g. **anal and oral sex**)
87
Why are endocervical swabs taken for MSC for gonorrhoea?
To provide information on the specific bacteria, antibiotic **sensitivities** and **resistance**
88
What is included in the management of patients who test positive for gonorrhoea?
Referre to GUM clinics to **coordinate testing, treatment and contact tracing** - management depends on whether antibiotic sensitivities are known
89
What are the antibiotics of choice for gonorrhoea?
Uncomplicated:
- Single dose of **intramuscular ceftriaxone 1g** if the sensitivites are NOT known
- Single dose of **oral ciprofloxacin** 500mg if the sensitivites are known
90
What follow up should patients with gonorrhoea have?
Follow-up test of cure - with NAAT testing if they are symptomatic or cultures where they are symptomatic:
* 72 hours after treatment for culture
* 7 days after treatment for RNA NATT
* 14 days after treatment for DNA NATT
91
What are the other factors to consider around gonorrhoea?
- Abstain from sex for 7 days to **reduce re-infection**
- Test for and **treat other STIs**
- Provide **advice about ways to prevent future infection**
- Consider **safeguarding issues** and **sexual abuse** in children and young people
92
What are some complications of gonorrhoea?
Pelvic inflammatory disease
Chronic pelvic pain
Infertility
Epididymo-orchitis (men)
**Prostatitis** (men)
**Conjunctivitis**
Urethral **strictures**
**Disseminated gonococcal infection**
**Skin lesions**
**Fitz-Hugh-Curtis** syndrome
**Septic arthritis**
**Endocarditis**
93
What is a key complication to remember of gonorrhoea in pregnancy?
**Gonococcal conjunctivitis** in a neonate - contracted from the mother during birth - called **ophthalmia neonatorum** - medical emergency and associated with **sepsis**, **perforation of the eye** and **blindness**
94
What is **disseminated gonococcal infection**?
Complication of untreated gonococcal infection where the **bacteria spreads to the skin and joints**
95
What does **disseminated gonococcal infection** cause?
- Various non-specific **skin lesions**
- **Polyarthralgia** (joint aches and pains)
- **Migratory polyarthritis** (arthritis which moves between joints)
- **Tenosynovitis**
- **Systemic symptoms** such as fever and fatigue
96
What is **mycoplasma ginitalium** (MG)?
A bacteria which causes **non-gonococcal urethritis** - STI
97
What is a concern with mycoplasma genitalium?
Developing problems with **antibiotic resistance,** particularly with **azithromycin**
98
How does MG present?
Many cases do not cause symptoms - **urethritis** is a **key feature**
99
What complications may infection with **mycoplasma genitalum** lead to?
**Urethritis**
Epididym**itis**
Cervic**itis**
Endometr**itis**
Pelvic inflammatory disease
Reactive arthr**itis**
Preterm delivery in pregnancy
Tubal infertility
100
What are the investigations for **mycoplasma genitalium**?
Traditional **cultures** are **not helpful** in isolating MG as it is a **very slow growing** organism. Therefore testing involves **nucleic acid amplification tests** (NAAT) to look specifically for the DNA or RNA of the bacteria
101
What samples are recommended for testing for MG?
- **First urine sample** in the morning for men
- **Vaginal swabs** (can be self taken) for women
102
What else should **positive samples** be **tested for?**
**Macrolide resistance** and performing a **test of cure** after treatment
103
What is the management for MG?
Course of **doxycycline** followed by **azithromycin** for uncomplicated genital infections
- **Doxycycline** 100mg twice daily for 7 days then;
- **Azithromycin** 1g stat then **500mg** once a day for **2 days** (unless it is known to be resistant to macrolides)
104
What can be used to treat complicated infections of MG?
**Moxifloxacin**
105
What is used to treat MG in pregnancy and breastfeefing?
**Azithromycin** alone (doxycyclin is contraindicated)
106
What is PID?
**Inflammation** and **infection** of the **organs of the pelvis** caused by **infection spreading up** through the **cervix**
107
What can PID result in?
**Tubular infertility** and **chronic pelvice pain**
108
What is endometritis?
**Inflammation of the endometrium**
109
What is salpingitis?
Inflammation of the fallopian tubes
110
What is oophoritis?
**Inflammation of the ovaries**
111
What is **parametritis**?
Inflammation of the **parametrium** (connective tissue around the uterus)
112
What is **peritonitis**?
Inflammation of the **peritoneal membrane**
113
What are the causes of PID?
**Neisseria gonorrhoeae** tends to produce more severe PID
## Footnote
**Chlamydia trachomatis**
**Mycoplasma genitalium**
114
What else can **PID** be caused by?
**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)
115
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**)
116
How does PID present?
**Pelvic or lower abdominal pain**
Abnormal **vaginal discharge**
Abnormal **bleeding** (intermenstrual or postcoital)
Pain during sex (**dyspareunia**)
**Fever**
**Dysuria**
117
What are the **examination findings of PID**?
Pelvic **tenderness**
**Cervical motion tenderness** (cervical excitation)
Inflamed cervix (**cervicitis**)
Purulent **discharge**
(Fever and other signs of sepsis)
118
What are the investigations for PID?
Testing for causative organisms and other STIs:
NAAT swab for **gonorrhoea** and **chlamydia**
NAAT swab for **mycoplasma genitalium**
**HIV** test
**Syphilis** test
High vaginal swab for **BV, candidiasis and trichomonias**
**Microscope for pus cells** on swabs from vagina or endocervix
Pregnancy test to exclude **ectopic pregnancy**
**Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis**
119
What is the management of PID?
Refer patients to **GUM** specialist service for contact tracing
Start **antibiotics empirically** (according to guidelines)
An example regieme:
- Single dose of **intramuscular ceftriaxone** 1g (to cover gonorrhoea)
- **Doxycycline** 100mg twice daily for 10 days (to cover chlamydia and mycoplasma genitalium)
- **Metronidazole** 400mg twice daily for 14 days (to cover **anaerobes** such as **gardnerella vaginalis**)
**Ceftriaxone and doxy** will cover other bacteria e.g. H. influenzae and E.Coli
120
When may PID patients require admission for IV abx / managment?
Signs of sepsis
Pregnant
Drainage of pelvic abscess
121
What are some complications of PID?
**Sepsis**
**Abscess**
**Infertility**
**Chronic pelvic pain**
**Ectopic pregnancy**
**Fitz-Hugh-Curtis syndrome**
122
What is Fitz-Hugh-Curtis syndrome?
Complication of PID caused by **inflammation and infection of the liver capsule** (**Glisson's capsule**) leading to adhesions between the liver and peritoneum
123
How does Fitz-Hugh-Curtis syndrome happen?
**Bacteria spreads from pelvis** via peritoneal cavity, lymphatic system or blood
124
What are the symptoms of Fitz-High-Curtis syndrome?
Right upper quadrant pain that can be referred to the right shoulder tip if there is **diaphragmatic irritation**
125
How is Fitz-Hugh-Curtis syndrome treated?
LAparoscopy to visualise and treat adhesions by **adhesiolysis**
126
What is **trichomonas vaginalis**?
Type of parasite spread through sexual intercourse - classed as a **protozoan** and is a single celled organism with **flagella**
127
What are flagella and there are they on trichomonas?
Appendages stretching from the body, similar to limbs
**Four flagella at the front** and a **single flagellum at the back** giving a characteristic appearance to the organism
128
What are the flagella used for in trichomonas?
**Attaching to tissues** and **causing damage**
129
Where does **trichomonas live**?
Urethra of men and women and vagina
130
What does trichomonas increase the risk of?
**Contracting HIV** by **damaging the vaginal mucosa**
**Bacterial vaginosis**
**Cervical cancer**
**Pelvic inflammatory disease**
**Pregnancy-related complications** such as preterm delivery.
131
How does trichomonas infection present?
50% of cases are asymptomatic, when they do occur:
* Vaginal discharge
* Itching
* Dysuria (painful urination)
* Dyspareunia (painful sex)
* Balanitis (inflammation to the glans penis)
132
How is the vaginal discharge in trichomonas?
**Frothy and yellow-green** (may have fishy smell)
133
How does the cervix appear in trichomonas?
"**Strawberry cervix**" (aka **colpitis macularis**) - cervicitis
Tiny haemorrhages across surface of the cervix, giving the **appearance of a strawberry**
134
What is the pH like in trichomonas?
Raised pH (above 4.5) similar to BV
135
How is a diagnosis of trichomonas made?
Standard **charcoal swab** with **microscopy** (examination under a microscope)
Swabs taken from the **posterior fornix of the vagina** (behind the cervix) in women
**Self taken low vaginal swab** may be used as an alternative
**Urethral swab** or **first-catch urine** is used in men
136
What is the treatment of trichomonas infection?
**Metronidazole**
137
What does the **herpes simplex virus** cause?
Both **cold sores** (**herpes labialis**) and **genital herpes**
138
What are the two main strains of the herpes virus?
**HSV-1**
**HSV-2**
(many people are infected without any symptoms)
139
Where does the virus remain latent after initial infection?
Associated **sensory nerve ganglia** - typically the **trigeminal nerve ganglion** with **cold sores** and the **sacral nerve ganglia** with genital herpes
140
What other things can the herpes simplex virus cause?
**Aphthous ulcers**
**Herpes keratitis** (inflammation of the cornea of the eye)
**Herpetic whitlow** (a painful skin lesion on a finger or thumb)
141
How is the herpes simplex virus spread?
Through **direct contact** with **affected mucous membranes** or **viral shedding** in **mucous secretions** - virus can be spread even when no symptoms are present
142
When is asymptomatic shedding of HSV most common?
In first 12 months of infection and where recurrent symptoms are present
143
Which form of the virus typically causes **genital herpes**?
**HSV-2**
144
How does genital herpes present?
Initial presentation is the most severe:
* **Ulcers** or blistering lesions affecting the genital area
* **Neuropathic** type pain (tingling, burning or shooting)
* **Flu-like** symptoms (e.g. fatigue and headaches)
* **Dysuria** (painful urination)
* **Inguinal lymphadenopathy**
145
Up to how long can an initial infection of genital herpes last?
3 weeks - **recurrent episodes are usually milder**
146
How is a diagnosis of herpes made?
Can be made **clinically** based on the history and examination findings
**Viral PCR** swab from a lesion can confirm the diagnosis and causative organism
147
What is the management of genital herpes?
Referal to a **genitourinary medicine** specialist service
**Aciclovir** to treat geniral herpes (alternatives are valaciclovir and famciclovir)
148
What are some additional measures for treating genital herpes?
**Paracetamol**
Topical **lidocaine 2% gel (**e.g. Instillagel)
**Cleaning** with warm salt water
Topical **vaseline**
Additional **oral fluids**
**Wear loose clothing**
**Avoid intercourse** with symptoms
149
Does genital herpes cause pregnancy-related issues or complications of congenital abnormalities?
Not known to
150
What is the main issue to genital herpes during pregnancy?
Risk of **neonatal herpes simplex infection** contracted during labour and deliver - **high morbidity and mortality** (however **passive** immunity to the virus as antibodies can cross the placenta into the fetus)
151
What is the management of genital herpes based upon?
Whether it is **primary infection** or **recurrent genital herpes**
152
Is aciclovir harmful in pregnancy?
Not known to be
153
How is **primary genital herpes** contracted **before 28 weeks gestation**?
**Aciclovir** during the initial infection then **followed by regular prophylactic aciclivir** starting **from 36 weeks gestation** onwards to reduce the risk of genital lesions during labout and delivery
154
How will having genital herpes during pregancy affect the management?
Asymptomatic at delivery **can have a vaginal delivery** (provided \> 6 weeks after initial infection)
**C-Section** is recommended when symptoms are present
155
How is primary genital herpes which is contracted after 28 weeks during pregnancy treated?
Aciclovir during the initial infection followed immediately by **regular prophylactic aciclovir**
**C-Section is recommended** in **all cases** to reduce the risk of **neonatal infection**
156
How is **recurrent genital herpes** treated in pregnancy?
**Regular** **prophylactic aciclovir** is considered **from 36 weeks gestation** to **reduce the risk of symptoms** at the **time of delivery**
Carries a low risk of neonatal infection (0-3%) even if the lesions are present suring delivery
157
What does HIV stand for?
Human immunodeficiency virus
158
What does AIDS stand for?
**Acquired immunodeficiency syndrome**
159
What is AIDS now referred to as?
**Late-stage HIV**
160
What type of virus is HIV?
**RNA retrovirus**
161
What is the most common type of HIV?
**HIV-1** (HIV-2 is rare outside West Africa)
162
What cells does HIV affect?
**CD4 T-helper cells** of the immune system
163
How does an infection with HIV present?
Initial **seroconversion** flu-like illness within the first few weeks of infection - then **asymptomatic** until the condition **progresses** to **immunodeficiency** - where **AIDS-definiing illnesses** and oppourtunic infections occur - potentially **years after the initial infection**
164
How is HIV transmitted?
**Unprotected** anal, vaginal or oral **sexual** activity
**Mother to child** at any **stage of pregnancy**, birth or breastfeeding (called vertical transmission)
**Mucous membrane, blood or open wound exposure** to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye
165
What are some AIDS definining illnesses?
**Kaposi’s** sarcoma
**Pneumocystis jirovecii pneumonia** (PCP)
**Cytomegalovirus infection**
**Candidiasis** (oesophageal or bronchial)
**Lymphomas**
**Tuberculosis**
166
How is **HIV screened** for?
Everyone admitted to hospital with an infectious disease is tested for HIV
Up to **3 months** to **develop** **antibodies** to the virus after infection
**HIV antibody tests can be negative** for three months following exposure
167
Do patients still require formal counselling or education before a test for HIV?
168
What testing is typical for HIV?
**Antibody testing** - simple blood test
Testing for the **p24 antigen** can give a positive result earlier in the infection
**PCR testing** for the **HIV RNA** levels tests directly for the **number of viral copies** in the blood giving a **viral load**
169
How is HIV disease monitored?
CD4 count
Viral load
170
What does the CD4 count tell you about the HIV infection?
These cells are **destroyed by the virus**
500-1200 cells/mm3 is the normal range
\<200 cells/mm3 is considered **end stage HIV** and puts the patient at high risk of **opportunistic infections**
171
How is the **viral load** used to monitor HIV?
Number of copies of **HIV RNA** per ml of blood
"**Undetectable**" refers to a viral load below the lab's recordable range (usually 50-100 copies / ml)
Can be in the **hundreds and thousands** in untreated HIV
172
Who manage patients with HIV?
Specialist HIV, infectious disease or GUM centres manage patients with HIV
173
How is HIV treated with **antiretroviral therapy**?
ART is offered to **everyone** with a **diagnosis** of HIV irrespective or **viral load** or **CD4 count**
Specialist **blood tests** can **establish the resistance** or each HIV strain to different medications
174
What is HIV treatment aimed at?
Achieve a **normal CD4 count** and **undetectable viral load**
175
How would you treat physical health problems (e.g. routine chest infection) on patients with **normal CD4** and an **undetectable viral load on ART?**
As you would a HIV negative patient - check for medication interactions
176
What are the different classes of HAART medications which work slightly different on the virus?
**Protease inhibitors** (PIs)
**Integrase inhibitors** (IIs)
**Nucleoside reverse transcriptase inhibitors** (NRTIs)
**Non-nucleoside reverse transcriptase inhibitors** (NNRTIs)
**Entry inhibitors** (EIs)
177
What forms part of the additional managment for a patient with **diagnosed HIV?**
- Prophylactic **co-trimoxazole** (septrin) is given to patients with a CD4 of under 200/mm3 to protect against **PCP**
- Patients with HIV have increased risk of developing CVD so close monitoring of **risk factors** and **blood lipids** - appropriate treatment (e.g. statins) may be required to reduce their risk of **developing CVD**
- Yearly **cervical smears** for women with HIV as it predisposes patients to developing **HPV and cervical cancer**
- **Vaccinations** up to date, including influenza, pneumococcal, hep A and B, tetanus, diptheria and poli vaccines - patients should **avoid live vaccines**
178
If both partners are HIV positive, do they still need to use condoms?
Yes for **vaginal and anal sex and dams for oral sex**
If the viral load is undetectable then transmission through unprotected six is unheard of - even in extensive studies - infection is **not impossible**
179
How may patients who are HIV positive concieve safely?
Techniques like **sperm washing** and **IVF**
180
How may a HIV positive mother give birth?
The **mother’s viral load will determine** the mode of delivery:
**Normal vaginal delivery** is recommended for women with a **viral load \< 50 copies / ml**
**Caesarean section** is considered in patients **with \> 50 copies copies / ml and in all women with \> 400 copies / ml**
**IV zidovudine should be given during the caesarean if the viral load is unknown or there are \> 10000 copies / ml**
181
What prophylaxis against HIV for newborns is there?
Depends on mothers viral load:
**Low-risk babies**, where the mother’s **viral load is \< 50 copies** per ml, are given **zidovudine** for **four** weeks
**High-risk babies**, where the mother’s viral load is **\> 50 copies** / ml, are given **zidovudine, lamivudine and nevirapine for four weeks**
182
Can HIV be transmitted during breast feeding?
**Yes,** even if the mother's viral load is undetectable
183
What is the window of oppourtinity for post-exposure prophylaxis for HIV?
Less than 72 hours - it's **not 100% effective**
Risk assessment of probability of developing HIV balanced against the **side effects of PEP**
184
What does PEP for HIV involve?
Combination of ART therapy, current regime:
- **Truvada** (emtricitabine and tenofovir) and **raltegravir** for 28 days
185
Post HIV exposure, when are HIV tests done?
**Immediately** and also a **minimum** of **three months** after exposure to **confirm a negative status** - individuals should **abstain** from unprotected sexual activity for a minimum of three months until **confirmed as negative**
186
What bacteria causes syphillis?
**Treponema pallidum**
187
What type of bacteria is treponema pallidum?
**Spirochete** - type of **spiral-shaped bacteria** - gets in through skin or mucous membranes, replicates and then disseminates throughout the body
**Mainly an STI**
188
How long is the incubation period for syphillis?
**21 days** on average
189
How can syphillis be contracted?
**Oral, vaginal or anal sex** involving **direct contact with an infected area**
**Vertical transmission from mother to baby** during pregnancy
**Intravenous drug use**
**Blood transfusions and other transplants** (although this is rare due to screening of blood products)
190
Whar are the different stages / types of syphillis?
Primary
Secondary
Latent
Tertiary
Neurosyphilis
191
What is primary syphilis?
Painless ulcer called a **chancre** at the **original site of infection** (usually on the genitals)
192
What is **secondary syphilis**?
Systemic symptoms, particularly of the **skin and mucous membranes** - symptoms can **result after 3-12 weeks** and the patient can enter the latent stage
193
What is **latent syphilis?**
Latent syphilis occurs **after the secondary stage** of syphilis where **symptoms disappear and the patient becomes asymptomatic** despite still being infected
194
When does **early latent syphilis occur**?
Within 2 years of the initial infection and **late latent syphilis** occurs **from 2 years after the initial infection onwards**
195
What is **tertiary syphilis?**
Occurs many years after the initial infection, affects many organs of the body particularly with the **development** of the **gummas** and cardiovascular and **neurological complications**
196
What is **neurosyphillis**, when does it occur?
If the infection involves the CNS, presenting with neurological symptoms
197
How does **primary syphilis present**?
A painless genital ulcer (**chancre**) tending to resolve over 3-8 weeks
## Footnote
**Local lymphadenopathy**
198
How does **secondary syphilis** present?
Typically starts after the chancre is healed:
**Maculopapular rash**
**Condylomata lata** (grey wart-like lesions around the genitals and anus)
Low-grade **fever**
**Lymphadenopathy**
**Alopecia** (localised hair loss)
**Oral lesions**
199
How does tertiary syphilis present?
**Gummatous lesions** (gummas are granulomatous lesions that can affect the skin, organs and bones)
## Footnote
**Aortic aneurysms**
**Neurosyphilis**
200
How does neurosyphilis present?
**Headache**
**Altered behaviour**
**Dementia**
**Tabes dorsalis** (demyelination affecting the spinal cord posterior columns)
**Ocular syphilis** (affecting the eyes)
**Paralysis**
**Sensory impairment**
201
What is **argyll-robertson pupil**?
A specific finding in neurosyphilis
A **constricted pupil** which **accommodates** when focusing on a near object **but doesn't react to light** - often irregularly shaped - commonly called a 'prostitutes pupil'
202
How is a diagnosis of syphilis made?
**Antibody testing** for antibodies to the **T.pallidum** bacteria can be used as a screening test - then referred to a specialist GUM centre for further testing
Samples can be tested for T. pallidum with:
**Dark field microscopy**
**Polymerase chain reaction** (PCR)
203
Which tests can be used to assess the **quantity** **of antibodies** being produced by the body to an infection with syphilis?
**Rapid plasma reagin** (RPR) and **venereal disease research laboratory** (VDRL) (non-specific but sensitive)
Higher number indicates a greater chance of active disease
204
How do the PRP and VDRL quantify syphilis infection?
**Tests involve introducing a sample of serum** to a solution containing antigens and assessing the reaction. A more significant reaction suggests a higher quantity of antibodies
Non-specific so often produce **false positives**
205
What does the management of a patient with syphilis involve?
Full screening for other STIs
Advice about avoiding sexual activity until treated
Contact tracing
Prevention of future infections
206
What is the standard medication for syphilis?
**Single** **deep intramuscular dose** of **benzathine benzylpenicillin** (penicillin)
207
What are alternative medications for syphilis e.g. late syphilis and neurosyphilis?
**Ceftriaxone**
**Amoxicillin**
**Doxycycline**
