HIV/GUM Teaching day Flashcards
What are the causes of abnormal vaginal discharge?
sexually transmitted infections, bacterial vaginosis, candidiasis, retained foreign body (e.g. tampon or condom)
What are some causes for post-coital vaginal bleeding?
(vaginal bleeding after sexual intercourse): cervical ectropion, cervicitis caused by sexually transmitted infections, vulvovaginal atrophy, cervical cancer
What are the causes of intermenstrual vaginal bleeding?
physiological (ovulation), contraception (progesterone depot), sexually transmitted infections, polyps and fibroids, and malignancy (e.g. uterine cancer, cervical cancer, vaginal cancer)
What are some causes of post-menstrual bleeding?
vaginal atrophy, sexually transmitted infections, hormone replacement therapy and malignancy (e.g. uterine cancer, cervical cancer and vaginal cancer)
What are some causes of dyspaneunia?
(Pain during sex)
sexually transmitted infections, vaginal atrophy, endometriosis.
What are some causes of abdominal and pelvic pain?
pelvic inflammatory disease, urinary tract infection, ectopic pregnancy, ruptured ovarian cyst, endometriosis, and ovarian torsion
What are some causes of vulval skin changes/itching/lesions?
vulval candidiasis, genital warts, genital herpes, syphilis (chancre), vaginal atrophy, lichen sclerosis and vulval malignancy
What needs to be asked in terms of somebody’s genital discharge?
Volume
Colour
Consistency
Smell
What is mycoplasma gentalium?
A bacteria that causes a STI
Causes discharge, pain on urination, pain in testicles, burning or itching in urethra
Diagnosis: PCR from urine
What is the most common cause of non-gonococcal urethritis?
Chlamydia
Which STI’s can you see under a microscope?
Gonorrhoea - will show lots of pus
Not Chlamydia
What is balanitis?
Penile tip swelling
- Will appear swollen, itchy, and painful
Most common cause is bad hygiene in uncircumcised men (smegma irritation)
Treatment: hygiene and emollients
Why might you want a midstream urine sample?
Midstream investigates the contents of the bladder so used to investigate a UTI
The first bit of urine will be from the urethra, so is useful for STI diagnosis
What is the cause of urethral discharge in men?
STI
What is the treatment for chlamydia
2 Doses of doxycycline per day (morning and night) for a week
No sex for a week because it takes that long to clear
If vomits, drug wont work and further therapy will be needed
What is scabies?
Itchy rash caused by mites spread through skin to skin contact
Treated with creams and lotions
What is epididyal-orchitis?
When the epididymis becomes inflamed and spread to the whole testicle
Treated with antibiotics
What is lichen sclerosis?
Itchy white patches on the genitals
What is the presentation of a gonorrhoea infection?
Sometimes no symptoms
Thick green or yellow discharge
Pain urinating
Bleeding between periods
What is the presentation of a chlamydia infection?
Urethritis
Mucoid or watery urethral discharge
Painful urination
Epididymitis (with or without symptomatic urethritis) with unilateral testicular pain
Tenderness and swelling
Abnormal vaginal bleeding
Chancre
Chlamydia can infect the rectum
What is trichomonas vaginalis?
A STI caused by a parasite
Frequently asymptomatic
Purulent, frothy discharge
Vulvar and cervical lesions
Abdominal pain
Dysuria
Dyspareunia
Itching
What is pelvic inflammatory disease?
When and infection spread to upper female reproductive system
Normally there is a mucus plug at the cervix to prevents pathogen from ascending
What are the symptoms of pelvic inflammatory disease (PID)?
- Bilateral lower abdominal pain
- Deep dyspareunia
- Abnormal vaginal bleeding
- Abnormal discharge
- Systemic symptoms like fever, nausea, and vomiting
What are the signs of PID during examination?
- Lower abdominal tenderness
- Purulent cervical discharge
- Cervical motion tenderness
- Uterine tenderness
- Mass
- Fever
What are the complications of PID?
- Ectopic pregnancy
- Infertility, worse with recurrent PID due to scarring
- Chronic PID
- Chronic pain due to adhesions
What is the treatment for PID?
Don’t delay treatment, start the triple treatment early:
- Ceftriaxone IM stat dose (gonorrhoea)
- Issues with needle phobia - Doxycycline 14 days (chlamydia)
- Teratogenic, so don’t give with suspicion of pregnancy - Metronidazole for 7-14 days (anaerobes)
- Interacts with alcohol
What is Gillick competence?
Assesses if young person is mature enough to consent to medical decisions
What are Fraser guidelines?
Apply to under 16’s requesting contraception and sexual health treatment without parental permission or knowledge
What extra questions are asked to under 18’s is sexual health?
- Where do you live?
- What are you relationships like?
- What do you do during the day? Are you going to school or truanting?
- Are you involved in other young people organisations Eg. CAHMS
What is the McCormack pain scale?
Assesses abdominal and pelvic rebound tenderness in quadrants
Maximal score is 36
What are some differentials for a rash?
- Primary HIV infection
- Syphilis
- Drug reaction
- Viral illness
- Skin disease
What are the main symptoms of an acute HIV infection (seroconversion disease)?
- Systemic fever and weight loss
- Malaise
- Headache
- Rash
- Myalgia
- Mouth sores
- Nausea and vomiting
What is the difference of presentation of primary vs secondary syphilis?
Primary: single chancre
Secondary: multiple cutaneous lesions
Tertiary: Systemic involvement
What is a chancre?
A firm painless lesions that oozes fluid that contains syphilis bacteria. It heals after 1-5 weeks but infection remains
Appears where the bacteria entered the body
Lymph nodes nearby may be inflamed
What is a NAAT test?
Nucleic acid amplification test
Can be used to diagnose STI’s
What is the Jarisch-Herxheimer reaction?
Fever, headache, malaise, rigors, and joint pains lasting several hours after beginning syphilis treatment
- Controlled with analgesics and rest
Patients need to be alerted of this possibility
What is the Procaine reaction?
A reaction to procaine penicillin (used for neurosyphilis)
A sensation of impending doom and hallucinations lasting 30mins. it’s self-limiting
What tests are done to STI’s?
- NAAT test for gonorrhoea and chlamydia
It’s highly sensitive but doesn’t give info about antimicrobial sensitivities - Culture for gonorrhoea
Poor sensitivity but gives information about antimicrobial sensitivities - PCR test for herpes, syphilis, and mycoplasma
It’s sensitive and easy, but expensive
Which investigations are done for men having sex with men with symptoms?
Multiple sites need to be covered in case not all areas are positive
Oropharynx: gonorrhoea, chlamydia
Urethral: gonorrhoea, chlamydia
Rectal: Gonorrhoea, chlamydia
Blood: HIV, syphilis, hepatitis
What happens if somebody has neurosyphilis symptoms but is allergic to penicillin?
Ceftriaxone daily because doxycycline doesn’t cross the blood brain barrier
What is the management for bacterial STI’s?
- Partner notification
- Abstinence during treatment
- Education about STI’s and transmission to prevent recurrence
- Preventative measures: vaccine or PrEP
- 3 monthly testing
What are the differentials for genital ulcers?
Herpes simplex
- No cure, symptoms managed with acyclovir
- Causes multiple, painful ulcers with erythematosus
Syphilis
- Treated with antibiotics
- Causes a single, painless ulcer
What is chem sex?
Sex using drugs
What are the benefits and issues of chem sex?
Benefits
- Allows you to go on for longer
- Disinhibits to allow more experiences
- Enhances sexual experience
- Forget internalised homophobia
Issues
- Risky sexual behaviour
- Blood born viruses
- Non-consensual sex
- Risk of dependency and overdose
- Forget to take meds like PrEP
- Unable to enjoy sober sex
What is the management of pneumocystis jirovecii (PCP)?
- Oxygen
- Antibiotics (co-trimoxazole is broad spectrum so also covers fungus)
- Corticosteroids improve prognosis
What is immune reconstitution inflammatory syndrome (IRIS)?
A hyperinflammatory response that occurs in the first six months of treatment of HIV/AIDS patients, a potential complication of the use of highly active antiretroviral therapy (HAART)
- A weak immune system leads to many opportunistic infections that HAART can reveal and cause a shock to the body
Which white blood cell will specifically be low in HIV?
Lymphocytes
How is PCP diagnosed?
A sputum sample
- But PCP tends to cause a dry cough and breathlessness so difficult
X-ray shows ground-glass appearance but this is non-specific
Will hear crackles on auscultation
What are the risks of beginning antiretroviral therapy following hospitalisation?
Risks:
- Polypharmacy causing overlapping side effects
- Immune reconstitution inflammatory syndrome
Usually wait 1 week, treat infection, then start HIV treatment
What are some complications of a PCP infection in HIV?
- Pneumothorax
- IRIS
- Unresponsive infection
Other: DVT due to immobility
What is the issue with HIV and Hep B co-infection?
Causes an accelerated progression of liver disease, including increased risks for hepatocellular carcinoma, and liver-related mortality
Also PrEP stops the Hep B treatment from working so they need to be immune to Hep B before beginning PrEP
How is HIV monitored?
- Check viral load 2-4 weeks after beginning the treatment
- Monitor side effect and organ functions
- Then yearly monitoring, usually electronic
How can HIV be diagnosed in clinic?
Pin prick test or oral version
Takes up to 20mins for results
What is the risk of HIV transmission between anal and vaginal sex?
Anal has higher risk
Receptive (being bottom person) has higher risk because of tears and injuries
How does circumcision reduce the risk of transmission of STI’s?
It removes the receptor cells reducing the surface area that comes into contact with mucosa for transmission
What are the side effects of PEP?
- Nausea
- Fatigue
- Headaches
- Loss of appetite
- Dizziness
- Trouble sleeping
- Linked to psychological effects
Last during the first week of treatment
How does PrEP work?
Prevents the HIV getting into the body and replicating by blocking enzymes
What is the ipergay method of taking PrEP?
Take 2 doses 24 hours before the sex, and then continue for 2 days after the last sex
This is effective
What are the different types of antiretroviral drugs?
Most commonly used:
- Integrase strand transfer inhibitors
- Nucleotide reverse transcriptase inhibitors
Others:
- Non-nucleotide reverse transcriptase inhibitors
- Fusion inhibitors
- CCR5 antagonists
- Protease inhibitors
- Post-attachment inhibitors
How does HIV increase risk of heart disease?
It effects the endothelium of vessels and chronic disease causes long-term inflammation
Also associated with high cholesterol
What are the fungal opportunistic infections of HIV?
- PCP (pneumocystis pneumoniae)
- Oesophageal thrush
- Cryptococcus (meningitis)
- Histoplasmosis (lung infection)
What are the viral opportunistic infections of HIV?
- EBV (Lymphoma)
- Kaposis sarcoma
- HPV
- CMV (retinitis)
- Polyomavirus JC (multifocal leukoencephalopathy (PML))
What is multifocal leukoencephalopathy (PML)?
A demyelinating virus of the CNS
Most are affected, gets bad in immunosuppressed people (HIV)
What are some opportunistic bacterial infections of HIV?
- TB
- Pneumonia
- Mycobacterium avium complex (MAC)
What is Mycobacterium avium complex (MAC)?
A respiratory infection that mimics presentation of lymphoma
Causes disseminated disease in immunosuppressed
What are some opportunistic parasitic infections of HIV?
- Cryptosporidiosis (chronic diarrhoea)
- Toxoplasmosis (spreads to brain causing neuro symptoms)
What are the features of PCP in HIV?
- Progresses within weeks
- Breathlessness on exertion leading to desaturation
- Dry cough (can’t take sputum sample to diagnose)
What is the presentation of Cryptococcal meningitis in HIV?
- Positional headache (raised ICP)
- Blurred vision
- Fever
- Papilledema (diagnostic)
How does cryptococcus cause raised ICP?
Its blocks the coracoid plexus to stop resorption of CSF leading to raised ICP
How can raised ICP caused by cryptococcus be managed?
- Prescribe antifungals
- Therapeutic lumbar puncture
- Shunt if uncontrolled
Which 2 organisms are the most common cause of meningitis in HIV?
- Cryptococcus
- Neisseria meningitidis (vaccine available)
What is Creon?
Used for pancreatic insufficiency to replace digestive enzymes
What is oral hairy leukoplakia?
White, streaky patches on the tongue triggered by EBV
Most common in HIV
