L13: STIs Flashcards
Make antibodies to attack antigens
B cells
Lymphocytes
WBCs that defends against protozoa, fungi, certain intracellular bacteria, and viruses
T4 cells
Helper T cells: enhance immune response, tell B cells to make Abs
T8 cells
killer T cells: destroy foreign agents
HIV is a _____
Retrovirus→ uses reverse transcriptase→ RNA→ incorporated into host cell DNA
HIV targets
CD4 T cells (helper)
B lymphocytes
Macrophages
An untreated HIV mom has a ____ risk of passing it to her infant
15-40%
Primary HIV infection
Acute retroviral syndrome”
Onset 2-6 weeks after exposure→ mono-like or flu-like illness→ resolves in 2 weeks
Routine HIV Ab test (-)
HIV RNA viral load measurable→ >100,000
Highly infectious→ diagnose to limit transmission to others
Primary HIV infection symptoms
Fever LAD sore throat *rash* → upper trunk, neck, face, *mucocutaneous ulcers* myalgia/arthralgia HA N/V/D
Primary HIV infection labs
Elevated transaminases
Anemia
Leukopenia
Thrombocytopenia
Clinical latency
mmune system responds→ seroconversion with 3 months
Viral load decreases to set point, slowly rises over time
HIV remains active in lymph nodes
CD4 count slowly declines
Asymptomatic, or LAD
Stage lasts ~10 years, approximately 5% a long term nonprogressors
Symptomatic HIV infection
Immune system deteriorates 1. Lymph nodes & tissue damages 2. +/- Virus mutates→ more pathogenic 3. Body fails to keep up replacement of CD4 cells ◦ HIV RNA viral load ↑ ◦ CD4 cell count ↓
Symptomatic HIV infection symptoms
Fever, Night sweats, LAD Fatigue/malaise, Arthralgias Weight loss, Prolonged diarrhea Mouth disorders ◦ Oral hairy leukoplakia* (viral - EBV) ◦ Thrush Cervical dysplasia (HPV) Skin disorders ◦ Molluscum ◦ Chronic dermatophyte infection ◦ Seborrheic dermatitis Kaposi’s sarcoma* Recurrent HZV Idiopathic thrombocytopenia
AIDS is defined as
CD4<200
OR
AIDS defining condition
Who should get screened for HIV?
Everyone 13-64 years old→ voluntary opt-out testing TB treatment initiation Each presentation for STD Annually→ high risk→ MSM Pregnant women
Who should get diagnostic testing (not screening) for HIV?
Opportunistic infections, TB
Symptomatic for acute HIV (acute retroviral syndrome)
Symptomatic for established HIV: weight loss, fever, night sweats, tiredness, LAD, Diarrhea > 1 weeks, sores of mouth, anus, genitals, pneumonia, unexplained neurologic symptoms
HIV antibody test
Screening but only detect after seroconversion→ 4-12 weeks after
MISSES PRIMARY HIV INFECTION
Rapid HIV tests
Saliva or blood
(+) test requires confirmation
Combination HIV antibody + antigen testing
Tests for acute + established HIV
HIV RNA test
Tests for Acute HIV (high) + latency (lower)
Airborne fungus
Reactivated dormant infection
Pneumocystis jiroveci pneumonia (PCP)
formerly called Pneumocystis carinii
CMV is
Herpes virus
CMV transmission
Blood
Sex
Perinatal
Reactivated infection
Ingestion of cat feces, raw contaminated food/utensils
Immunocompetent pts don’t have symptom
Toxoplasmosis
Toxoplasma gondii is a
single celled parasite
Mycobacterium avium complex is either _____ or _______
Mycobacterium avium or mycobacterium intracellulare
Mycobacterium avium complex transmission
bacteria found in soil and dust is inhaled or ingested
Recurrent vaginal or esophageal infection
More invasive infection→ lower CD4+ count
Candidiasis
Vascular neoplasm which can occur at any CD4 T cell count
Kaposi’s sarcoma
Classic Kaposi’s sarcoma, which is not AIDS related, is seen in:
elderly Eastern European and Mediterranean males
Kaposi’s sarcoma presentation
Multifocal and widespread lesions
LAD
CMV retinitis presentation
Most common retinal infection in AIDS
Visual disturbances→ blindness (untreated)
CMV retinitis diagnosis
Fundoscopic exam→ perivascular hemorrhages, white fluffy exudates (cotton wool spots)
Seropositive for CMV
Mycobacterium avium complex presentation
Systemic disease→ night sweats, weight loss, abdominal pain, diarrhea, anemia
Mycobacterium avium complex diagnosis
(+) Sputum acid fast bacillus
(+) sputum cultures
(+) blood cultures
Toxoplasmosis presentation
Causes encephalitis
Most common intracranial lesion in HIV+
HA, focal neuro deficits, AMS
+/- Retinitis, pneumonitis
Toxoplasmosis diagnosis
Brain CT or MRI→ multiple contrast enhancing lesions
Seropositive for toxoplasmosis
Pneumocystis jiroveci pneumonia presentation
Fever, cough, SOB
Severe hypoxemia
Pneumocystis jiroveci pneumonia diagnosis
Sputum sample
CXR→ diffuse or perihilar infiltrates
Elevated LDH
Pneumocystis jiroveci pneumonia treatment
TMP-SMX (bactrim)
HIV management
Antiretroviral therapy (ART) *Clinical trial data suggest that individuals treated during early infection experience immunologic + virologic benefits→ refer ASAP
Genotypic drug resistance testing→ before starting regimen to guid selection of drug
Willing / able to commit to lifelong treatment with strict adherence
May postpone therapy, can be decided on case-by-case basis, but should start as soon as ready/possible
Treatment goal→ suppress plasma HIV-1 RNA levels to undetectable + prevent transmission
Truvada
PrEP
Can a primary care provider prescribe Truvada to be taken daily?
Yes
HIV specialists do too
How quickly do you have to take POST-exposure prophylaxis?
72 hours
Normal CD4 T cell count is
500-1400 cells per cubic/mm
What could be seen at a normal CD4 T cell count?
Thrush Kaposi sarcoma (at any count)
At what CD4 T cell count do people “do very well)
Greater than or equal to 350
At what CD4 count are opportunistic infections seen?
CD4 < 200
Must consider prophylaxis for anyone with AIDS
CD4 T cell < 200 prophylaxis
Bactrim DS→ prophylaxis for Pneumocystis jiroveci pneumonia
CD4 T cell < 100 prophylaxis
Bactrim DS→ prophylaxis for Toxoplasma gondii encephalitis
CD4 T cell < 50 prophylaxis
Azithromycin→ prophylaxis for disseminated Mycobacterium avium complex (MAC)
Syphilis progression
Primary→ Secondary→ Latent→ Tertiary
Primary syphilis
Painless chancre appears at location where syphilis entered body→ Persists for 4-6 wks, then resolves
Secondary syphilis
Rash (very common)
• Non-pruritic
• Characteristically on palms & soles of feet
• Not contagious
Condyloma lata
• Moist, heaped, wart-like papules
• Intertriginous areas (most commonly gluteal folds, perineum, perianal area)
• Highly contagious
Mucous patches
• Painless flat patches involving the oral cavity, pharynx, genitals(pt may be unaware)
• Highly infectious
Systemic Symptoms→ Malaise, LAD
Latent syphilis
Occurs 2-6 weeks after secondary syphilis
asymptomatic
lasts years
non contagious
Congenital syphilis
Especially early syphilis
stillbirth, neonatal death, or infant
disorders such as deafness, neurologic impairment, and bone deformities
Which 2 skin manifestations of secondary syphilis are contagious, and which one is not?
Contagious: condyloma lata, mucous patches
Noncontagious: rash
Tertiary syphilis
Most do not develop tertiary syphilis
Appear 10-30 yrs after initial infection
Can damage heart, blood vessels, brain, nervous system
Neurosyphilis
paralysis, difficulty with coordination, dementia
Ocular syphilis
changes in vision, blindness
Screen pregnant women at 1st prenatal visit
High risk→ screen + obtain sexual history again at 28 wks + at delivery
PCN allergic→ desensitization with oral PCN
Monitor serology closely to confirm successful treatment
Syphilis diagnosis
Bacteria from chancre→ under dark field microscopy (NOT widely available)
Serology→ antibody tests
Rapid Plasma Reagin (RPR) or venereal disease research laboratory test (VDRL) test
Titer indicates disease activity
Low titer = 1:4; higher titer may be 1:128
Low titer may be a false positive
False positive can occur from: autoimmune disease, illness, possibly pregnancy
Confirm RPR with treponemal antibody test: FTA-ABS*
(Fluorescent treponemal antibody absorption)
If neurosyphilis or ocular syphilis are suspected
Must do LP (lumbar puncture) and perform VDRL on spinal fluid
Refer to neurologist
Syphilis treatment
Test + treat sexual partners
Benzathine pen G 2.4 mu IM x 1
→ Additional doses required if syphilis present for > 1 yr→ 3 doses at 1-week intervals
Obtain pt history + contact County Health Dept for advice
(have record if pt in system)
PCN allergic pts→ oral azithromycin or oral doxycycline
HIV or pregnant→ get PCN even if they’re allergic, must be sensitized
Check RPR titer to confirm treatment success→ 3, 6, 12, 24 months)
◦ 4 fold decrease = adequate response
Benzathine pen G 2.4 mu IM x 1
syphilis treatment
Syphilis treatment if PCN allergy
oral azithromycin or oral doxycycline
Lymphogranuloma venereum
Serotype pf Chlamydia trachomatis
Rare in the US, more common in MSM
Chancroid
Haemophilus ducreyi
Sporadic outbreaks in US
Lymphogranuloma venereum presentation
Systemic infection
Unilateral inguinal bubo
Self limited ulcer/papule at site of inoculation
Anal discharge + rectal bleeding
Lymphogranuloma venereum treatment
Erythromycin
Doxycycline
Chancroid presentation
Painful tender genital ulcer Lesion produces foul smelling, contagious discharge Inguinal adenitis (buboes)
Chancroid treatment
Azithromycin
Ceftriaxone
Ciprofloxacin
Chancroid diagnosis
Rule out syphilis + HSV
Contact County Health Department→ requires special culture, may treat presumptively
Lymphogranuloma venereum diagnosis
Rule out syphilis
Contact Country Health Department
+/- genital, rectal or lymph node specimen swab
