HIV, STI, Atypical Mycobacterial And Fungal Diseases Flashcards
HIV (transmission)
Transmission: Sex, IDU, mother to child, breast feeding
Health care setting: dirty needle stick, organ transplant, Artificial insemination, contact with bloody bodily fluids
HIV (initial symptoms)
Occur 2-6 weeks post exposure, May last 2-4 weeks after onset
Flu-like:
Fever, rash, fatigue, pharyngitis, lymphadenopathy, myalgia, mucocutaneous ulceration, headache
(Should be highly suspicious if all are present)
HIV (testing)
Antibody screening 3-8 weeks after infection
-Testing too early could result in a false.
Negative
US primary is HIV 1 testing, some test HIV2
ELISA (highly sensitive, screening test) followed by Western Blot (specific, confirmatory)
HIV (background)
Lentivirus
possible origin from Africa
HIV 1 is prominent in the US
HIV 2 is prominent in Africa (less pathogenic)
HIV progresses into Acquired Immune Deficiency Syndrome (AIDS)
HIV (Progression)
Exposure
- (3-8 week) window of no immune response
Acute
-Flu-like symptoms, High infectivity
Asymptomatic
12 months to median 11 yrs before AIDS develops
HIV replication present during all stages of infection and progressively reduce CD4 lymphocytes
AIDS
-When CD4 counts fall below 200:
fever, weight loss, diarrhea, cough, shortness of breath, and oral candidiasis as the disease progresses-a cute
-Pneumonia, toxoplasmosis, TB, mycobacterium avium disease
HIV (Tests 1)
ELISA with confirmatory WB
Orasure HIV 1 Oral specimen
- oral fluid
- non clinician
- if positive, we need a confirmatory test
Oraquick Advance HIV 1/2 (Rapid) test
- can be outside clinic
- results from finger stick or VP in 20-40 mins
- Need to confirm with WB
HIV (tests 2)
NAAT
P 24 antigen
- can detect p24 protein (antigen) in 2 weeks
- lacks both sensitivity and specificity
- use in conjunction with antibody tests early
PCR for viral load
- can detect 11 days after infection
- newborn testing
- monitor therapeutic response to to
- most sensitive
HIV (who is tested)
The CDC recommends screening for pts 13-64 years in all health-care settings.
HIV (work-up)
hx
Sexual and substance abuse, vaccine, previous STD’s, travel
Through physical including Gynecological for women.
Tests
CD4 count, and viral load, other STI’s, CBC, blood Chem
HIV/AIDS (opportunistic infections)
Toxoplasma gondii encephalitis Cryptosporidiosis Disseminated Mycobacterium Avium Complex (MAC) disease Bacterial Enteric Infections Syphilis Mucocutaneous Candidiasis Cryptococcosis Histoplasmosis Coccidioidomycosis Cytomegalovirus Disease Herpes Simplex Virus Disease HHV-6 and HHV-7 Disease Varicella-Zoster Virus Diseases Human Papillomavirus Disease
Candidiasis (background)
Candida albicans
Yeast-like fungi
Risk factors: immunosuppressed, antibiotic use, diet, stress
Candidiasis (affected areas)
Superficial mucocutaneous: oral, vaginal, diaper area candidiasis, etc.
Can also be invasive, esophageal candidiasis in AIDS, systemic dissemination, etc
May involve virtually any organ
Candidiasis (transmission)
Human and animal reservoirs, but frequently found in environment
Candidiasis (Dx)
Diagnosis: depends on site
Superficial: wet mount looking for hyphae, pseudohyphae or budding yeast
May also do blood cultures, urine cultures, biopsies
Candidiasis (Tx)
Most healthy people do not show symptoms
topical antifungal agents for superficial infections
Systemic (invasive) infections – parenteral antifungals such as fluconazole
Histoplasmosis (background)
Histoplasma capsulatum is a fungus, that grows as a yeast at body temperatures in mammals
Endemic in OH, MO and MS River Valley, acidic soil in these areas provides growth media
Histoplasmosis (transmission)
Bats can be infected and spread infection
Contaminated soil may be a risk for years, as well as airborne spores
Associated with renovation, construction activities
Histoplasmosis (Symptoms)
Healthy people who are exposed are typically asymptomatic, Sometimes see chronic granulomas (calcified nodes and nodules on CXR
Flu-like symptoms with erythema nodosum (raised red dots on lower legs)
Immunocompromised: initially is pulmonary, may get systemic spread and manifestations such as CNS, liver, spleen, and rheumatologic, ocular, and hematologic systems
Histoplasmosis (progression)
If symptomatic, initial illness often flu-like & limited duration
Fever & chills, inspiratory chest pain and cough, joint pain, mouth sores & erythema nodosum on lower legs
If goes on to chronic phase, may develop or continue to have chest pain, cough, SOB, fever and sweating
In rare cases, may disseminate and cause inflammation in pericaridium, meninges, high fever
Histoplasmosis (Dx)
CXR, chest CT Bronchoscopy Biopsy Blood/urine for antigens or antibodies Spinal Tap if suspect infected CSF
Histoplasmosis (Tx)
Usually clears up without treatment
If symptoms last > 1 month, typically will need antifungal therapy: Amphotericin B, itraconazole, and ketoconazole
Cytomegalovirus (CMV) (background)
Common virus, nearly everyone infected with it but most people usually asymptomatic
Lifetime infection once infected, virus dormant in most cases
Cytomegalovirus(CMV) (transmission)
Transmission: Congenital (born with it) or perinatal (acquired via breast feeding)
Spread via body fluids: blood, saliva, urine, semen and breast milk
Lifetime infection once infected, virus dormant in most cases
Kids in daycare
Primary infection during first exposure
-can be go through periods of inactivity
Cytomegalovirus (Symptoms)
Congenital infection (serious illness)
Jaundice, rash, low birth weight, splenomegaly, hepatomegaly & hepatic dysfunction, seizures
Immunocompromised persons may develop infection in many organs
In HIV, often see CMV retinitis/uveitis or CMV diarrhea (GI track ulceration)
Also, pneumonia, encephalitis and behavioral changes, hepatitis, seizures & coma – and ultimately, death in some persons
Healthy people can also become ill with CMV, but rarer
Can develop a mono-like syndrome or other illnesses/symptoms as noted above
Cytomegalovirus (Tx)
No curative treatment for CMV, generally healthy adults and children not treated, but immunocompromised will get antivirals
Prevention is key!
Personal hygiene, avoid contact with body fluids/passing body fluids to others, appropriate disposal of infected items, don’t share glasses/kitchen utensils, safe sex
Gonorrhea (background)
Sexually transmitted infection (STI) caused by Neisseria
Highest rates among teens, young adults and African Americans
Gonorrhea (Transmission)
sexual contact or via childbirth
Gonorrhea (symptoms (males))
Symptoms vary
Men may be asymptomatic, experience dysuria or have a penile discharge (1-14 days after exposure)
Can develop epididymitis if untreated, and rarely, sterility
Gonorrhea (symptoms (females))
typically asymptomatic or low-grade symptoms like dysuria, increased vaginal discharge or bleeding between periods
Potentially serious complications if left untreated – PID/abscess and be at increased risk for ectopic pregnancy, infertility
Gonorrhea (additional symptoms)
Anal infections
May be asymptomatic, or have bleeding, burning, discharge
Throat infections
May be asymptomatic or have sore throat
Can occasionally get disseminated infection of bloodstream or joints (arthritis), potentially life-threatening
May disseminate infection to blood stream and joints (arthritis)
Gonorrhea (associated illnesses)
Increased risk of transmitting or being infected with HIV
Chlamydia
Gonorrhea (who is tested)
Testing – anyone who is sexually active is at risk (vaginal, anal, oral)
Those with symptoms, pregnant women or those with a partner who has recently tested positive
Those with a positive test need to be tested for other STIs
Chlamydia testing often done in conjunction
Gonorrhea (tests)
Tests: culture, gram stain, DNA probe with amplification
Screening (including pregnant women) or diagnostic
Specimen: swab of discharge or secretion: cervix, urethra, penis, anus, or throat
Testing for Chlamydia trachomatis typically done concurrently since similar symptoms
If positive, partner also needs testing/treatment
In NC, law allows EPT – “expedited partner treatment”
Gonorrhea (Tx)
Antibiotic treatment for those with positive tests
Antibiotic resistant strains of gonorrhea increasing so if still symptomatic after a few days of treatment, may need to f/u with provider
Fluoroquinolone resistance has developed
Oral cephalosporins no longer recommended as a single drug for treatment;
Syphilis (background)
Bacterial STI caused by Treponema pallidium
AKA “ the great imitator”
Stages classified as primary, secondary and late/latent
Syphilis (Transmission)
Transmission: direct contact with a syphilis lesion
Vagina, penis, anus, rectum, mouth
Can also be transmitted by pregnant woman to child
Not spread by contact with inanimate objects
Syphilis (Signs/symptoms)(primary)
Heralded by “chancre”, a firm, round, painless lesion, which may be single (entry point) or multiple
Incubation 10-90 days (median: 21)
Chancre/s typically heal w/o treatment in 3-6 weeks, but infection progresses if not treated
Syphilis (signs and symptoms)(secondary)
Development of non-pruritic body rash after chancre heals
Appearance of rash varies from faint to reddish brown spots, but unlike many rashes, affects palms of hands and soles of feet
May have associated symptoms: fever, lymphadenopathy, sore throat, patchy hair loss, headaches, weight loss, muscle aches, fatigue
Will resolve with or without treatment but will progress to late/latent stage
Syphilis (signs and symptoms) (latent)
Without treatment of infection, will develop latent disease (asymptomatic but seropositive)
About 15% will go on to develop late syphilis, may occur 10-20 years after initial infection acquired
Manifestations: internal organ damage: brain, CNS, eyes, heart & vascular system, liver, bones, and joints
Dementia, paralysis, gradual blindness, coordination difficulty, …can cause death
Syphilis (Testing)
Screening: Venereal Disease Research Lab (VDRL) or rapid plasma reagent (RPR) tests
Diagnosis: Fluorescent treponemal antibody absorption test (FTA-ABS) and Treponema pallidum particle agglutination assay (TPPA)
Specimens: scraping from chancre, blood, or CSF (latent syphilis) sample depending on test and stage of disease
Syphilis (Associated Illnesses)
2-5 X increased risk for HIV infection
Chancre increases risk to transmit infection to others or to be exposed from a HIV+ person
Syphilis (Tx)
Treatment – parenteral penicillin (dose & type depends on stage)
Can become re-infected, no immunity after infection
Prevention is key
Condoms can help, but may not cover infected area
Avoid drug/alcohol use that may lead to risky behavior
Chlamydia (background)
Bacterial STI caused by Chlamydia trachomatis
Chlamydia (Transmission)
Transmission – oral, anal or vaginal sex or via vaginal childbirth when pregnant woman infected
Increased risk with greater number of partners
Teen girls and young women at greatest risk due to immature (open) cervix
Chlamydia (symptoms)
Women: asymptomatic, or may depend on infection: vaginal discharge, dysuria or if spreads to fallopian tubes may develop fever, abdominal pain, low back pain, nausea, pain during intercourse, bleeding between periods
Can spread to rectum
Men: penile discharge, dysuria, pain or pruritus around meatus
Male to male receptive sex: rectal pain, discharge bleeding with chlamydial infection
Either men or women can develop oral chlamydia
Chlamydia (Testing)
Specimen: sample or secretion from the infected area, such as the cervix, urethra, penis, anus, or throat (or urine for molecular testing)
Preferred: nucleic acid amplification tests (NAAT) due to high sensitivity & specificity of molecular testing
Other: direct fluorescent antibody (DFA) stain, DNA probe (less sensitive than NAAT), rapid test being evaluated for widespread use
Typically done in conjuction with n. gonorrhoeae testing
Chlamydia (progression)
Untreated infection in women can lead to PID, ectopic pregnancy, infertility
Also increases risk of developing HIV if exposed
Recommended annual screening for all women
Chlamydial pneumonia (PNA), and conjunctivitis, could result in premature delivery in pregnant women
Chlamydia (Tx)
Treatment: Azithromycin (single dose) or doxycycline (1 week course)
Sex partners need treatment
In NC, can provide expedited partner treatment
Recommended that retesting occur 3 months after treatment, even if partner treated
Tx chlamydia alone, but for gonorhhea, treat both chlamydia and gonorhhea
Herpes Simplex (General)
Herpes Virus family
50+ different viruses
4 are pathogenic to humans
HSV, VZV, EBV, CMV
Herpes simplex HSV-1: mouth & lips HSV-2: anogenital Herpes Whitlow (infection under culture as a result of contact with oral lesion) Other: buttocks, trunk
Herpes Simplex (progression)
Dx: grouped small & uniform vesicles on erythematous base that Vesicles typically preceded by 1-2 days of tingling, burning, itching. May have low grade fever & malaise
Commonly recurs in same area; rate recurrence varies
UV light, trauma & systemic changes may predispose
Viral shedding occurs until crusted in 4 -7 days, contagious until lesions healed
Course is 5 -14 days per episode, typically heal without scarring
Fluid in lesion is contagious, not the lesions
Herpes Simplex (Dx)
clinical signs & symptoms, PCR or culture
Differential diagnosis:
Herpes Zoster
Impetigo (cold sore- like lesions)
Apthous ulcers
Herpes Simplex (Tx)
Symptomatic – goal is to relieve discomfort and promote healing
Antivirals: Acyclovir (zovirax) Available in topical, oral or IV, depending Acyclovir MOA: decrease viral shedding, new lesion formation & promotes healing
Complications:
Can disseminate in immunocompromised
Pregnant women
Neonatal disseminated disease
Herpes Zoster (General)
Varicella Zaoster virus (chicken pox) this is a.k.a. shingles.
Rash follows nervous pathway
Most common in people over 60
Herpes Zoster (S &Sx)
Pain/ itching, fever, headache, fatigue before presentation of rash
Rash follow never paths (dermatomes)
Herpes Zoster (Dx)
Clinically Dx
PCR, Dircet fluorescence antibody (DFA) test
Differential
Herpes symplex , insect bites, need to rule out HIV
Herpes Zoster (Tx)
Self-limited, pain relief, anti-viral to shorten the course, tx of secondary infections, oral and antibacterials for secondary infections.
Vaccine preventable (after the age of 60)
HPV (general)
Human Papilloma Virus
Most common STI in the US
40 types that can affect males and females
90% of the cases will clear within 2 years
May cause cancer (warts, cervical, anal, (mouth, throat in males)
HPV (transmission)
Sexual contact including oral and genital
HPV (Tx)
Vaccine preventable in children
Gardicill protects against cervical cancer, warts, and other cancers in males and females.
Cervarix protects against cervical cancer
There is a new Gardicil 9 that protects against everything.
Currently no to, but warts and lesions can be treated
HPV (Tests)
N test for males
Atypical Mycobacterial Bacteria (general)
Greater recognition due to improvement of diagnostic testing which can distinguish Mycobacterium tuberculosis from other mycobacterium
Increased infections with HIV
Non-tuberculous mycobacteria (NTB) classified on growth rates
Rapidly growing further classified as pigmented or non-pigmented
M. fortuitum reservoirs – soil, water, mammals, marine life
Aypical Mycobacteria (M, Fortuitum)
Most commonly causes skin, bone and joint disease
In both immunocompetent and immunosuppressed
Also: nosocomial disease outbreaks (e.g., sternal wound infections, plastic surgery wound infections, post-injection abscesses) & pseudo-outbreaks
Rarely, pulmonary disease
Atypical Mycobacterial (M. Fortuitum) Dx
Diagnosis: recovery of organism from wound or tissue w/o alternative explanation
For pulmonary disease: sputum for acid fast bacteria X 3, CXR evidence
M. Fortuitum (TX)
Guided by antimicrobial susceptibility
M. Fortuitum (progression)
Disease typically chronic but progressive.
Atypical Mycobacteria -MAC (general)
Mycobacterium Avium Complex (MAC)
M. avium and M. intracellulare
Several different syndromes:
In children, cervical lymphadenitis
In HIV+ persons, disseminated disease
Less commonly: In immunocompetent persons, pneumonia
Incidence unknown, not nationally reportable but decreasing incidence with HIV disease due to HAART therapy and antimicrobial prophylaxis
Atypical Mycobacteria-MAC (transmission)
Etiology: environmental Air, food, water Many types of animals can be infected Cows, dogs, pigs, chickens, birds, etc. Not spread between persons
Atypical Mycobacteria-MAC (symptoms)
Symptoms: may include night sweats, weight loss, abdominal pain, fatigue, diarrhea, and anemia
Typically affects HIV+ persons when CD4
Atypical Mycobacteria-MAC (Dx)
Diagnosis: usually culture
AFB smear and CXR showing lymphadenopathy may be added as needed
Atypical Mycobacteria-MAC (Tx)
Includes at least 2 antimicrobials, one of which should be either clarithromycin or azithromycin
Second drug is usually ethambutol
Helmiinth Infections (General)
Helminth infections caused by soil-transmitted helminths (STHs) are common infections in poverty ridden area
Most common in Americas, China, E. Asia and Sub-Saharan Africa
4 most common STHs are: roundworms (Ascaris lumbricoides), whipworms (Trichuris trichiura), and the anthropophilic hookworms (Necator americanus and Ancylostoma duodenale)
Iron deficiency anemia and protein malnutrition linked to hookworm disease
Helminth Infections (general 2 )
Disproportionate burden: most people have a few worms, 20% of populations carries 80% worm burden
Children disproportionately infected, except for hook worms which are more common in adults
Helminth Infections (transmission)
transmission via soil contaminated with egg-carrying feces, association with poverty, poor sanitation, and lack of clean water
Endemic areas factors: warmth & moisture
Risk factor for adults with hookworms: agricultural occupations
Helminth Infections (Tx)
Treatment: period deworming with antihelminth drugs: mebendazole and albendazole
High re-infection rates
Education & improved sanitation are key prevention factors, use of latrines, good personal hygiene
Periodic deworming of populations necessary to help minimize morbidity and mortality
Often administered in schools, “simplicity and safety”
Pinworms (general)
Caused by Enterobius vermicularis
Incidence: common! Estimated to be 40 million infections in US annually
Most commonly occurs in 5-10 year olds, though can occur in anyone
Pinworms (transmission)
Human is only natural host, not animals
May be spread in crowded living conditions, between family members
Can get under fingernails and spread to others, and objects which may indirectly spread infections, can also become infected by ingestion of eggs
Pinworms (Sx)
Most common symptom: itching around anus, worse at night, inflammatory response, can get secondary infection at times
Rarely can migrate to vagina or urinary tract
Do not see systemic symptoms
Pinworms (Dx)
Diagnosis: visual identification
Yellow white “thread”,
Pinworms (Tx)
Treatment: albendazole or mebendazole
Initial dose, and then repeated X 1 to prevent reinfection from eggs
Often treat based on symptoms, don’t need lab confirmation
Often treat entire families at same time
Also need to launder bedding and toys every 3-7 days for 3 weeks, careful washing of hands after using the bathroom, daily laundering of pajamas/underwear for 2 weeks
