List I - Core Conditions Flashcards
Which cells are affected by HIV?
- CD4+ T Lymphocytes
When is a person diagnosed with AIDS?
- When CD4+ T Lymphocyte drops below 200
What is p24 in relation to HIV?
- An antigen detected before HIV Ab following exposure
How many people in the UK have HIV?
- 101,200
How many people in the UK with HIV are on antiretroviral treatment?
- 96%
How is HIV transmitted?
- UPSI with an infected person
Which factors increase the risk of transmitting HIV?
- Type of sex
- Receptive anal intercourse>receptive vaginal intercourse>insertive anal intercourse>insertive vaginal intercourse
- Trauma: sexual assault, fisting
- Presence of STIs and genital infections
- HSV
- Gonorrhoea
- Syphilis
- BV
How is HIV contracted to the baby in the antenatal period?
- Linked to maternal uncontrolled HIV
* Opt-out antenatal screening in UK since 2001
How is HIV contracted to the baby in the intra-partum period?
- Linked to undiagnosed/uncontrolled maternal HIV
- C-section can reduce the risk of HIV with other medications
- If HIV is controlled, women can have a vaginal delivery
How is HIV contracted to the baby in the post-partum period?
- Linked to breast feeding especially uncontrolled HIV
* Women who really wish to breast feed can be supported to do so
How can HIV transmission be managed with IVDU?
- HIV does not survive long outside the body
- IVDU at risk of other BBV also
- Refer to needle exchange programme
- Refer to local addiction services
What is the occupational risk of HIV transmission?
- Needle stick injury or mucosal exposure
- Follow local protocol for needle stick injury
- Risk assessment of the donor and recipient by uninvolved clinician
- Obtain consent to screen blood for HIV
- Assess recipient’s eligibility to commence PEP for HIV
- Time is critical - do not delay assessment
- Have follow up by occupational health
How might primary HIV infection or seroconversion present?
- Diagnosis within 6 months
- Recent negative HIV result supports diagnosis
- Fever
- Rash
- Pharyngitis
- Lymphadenopathy
- Very high viral load=>very infectious
What is the asymptomatic stage of HIV?
- Varies from person to person from 5 to 10 years
- Only way to tell is to test
- Opt out routine screening would maximise opportunities
- Although asymptomatic- ongoing viral replication causes immune system damage (chronic inflammatory state)
How might symptomatic HIV present?
- Non-specific persistent lymphadenopathy, fever, myalgia, diarrhoea
- Skin lesions, folliculitis, multi-site herpes zoster, seborrhoeic dermatitis
- Oral lesions, candidiasis, oral hairy leukoplakia
- Recurrent bacterial infections, pneumonia, impetigo
- Abnormal blood results - lymphopenia, thrombocytopenia
What are the problems faced with advanced HIV?
- Linked to low CD4 count (T- lymphocyte)
- Patients more likely to get opportunistic infections and certain cancers e.g. B cell lymphoma
- Late stage diagnosis has worse outcomes
- Lower CD4=greater damage to the immune system
- Less chance of immune system recovery
- Increased rates of morbidity and mortality compared to CD4>350 at diagnosis
What are the investigations for HIV?
Routine: - U&E, LFT, FBC, lipid/bone profile, glucose Serology: - Hepatitis A, B, C, syphilis HIV viral load: - Informs of disease progression CD4 count HIV drug resistance profile
What is the treatment for HIV?
- Treatable chronic condition, not curable
- Highly active antiretroviral treatment dramatically improves prognosis - 3 drugs in combination
- Patient commitment is essential (poor compliance can result in resistance
- Life long treatment
- Treatment interruptions result in poorer outcomes
What is the aim of treatment?
- To maintain an undetectable viral load (below 50)
What are the side effects of HIV drugs?
- Generally well tolerated
- Older classes have side effects - no longer an issue for most
- Switch patients to newer if necessary
- Monitor in HIV clinic
Which factors might affect adherence to HIV treatment?
Patient related: - Commitment - Religious/health beliefs - Need to hide HIV - Substance misuse - Depression - Absence of symptoms - No routine Provider related: - Provision of adherence support e.g. pill box - Patient education Regimen related: - Dosing frequency - Pill burden - Need to take with food - Compatibility with life style - Side effects?
Which drugs interact with HAART?
- Steroids
- Statins
- Anti-anxiety
- Anticoagulants
- Chemotherapy drugs
- Anti-TB drugs
- Recreational drugs
- Antacids and multivitamins
Liverpool drug interaction checker
Who can be tested for HIV?
- Anyone - no need for specialist counselling
What are the benefits of a negative test result?
- Reassurance
- Motivation to maintain risk minimising behaviours
- Exclude HIV from differential diagnosis
What are the benefits of knowing a positive HIV result?
- Effective treatment reduces morbidity and mortality
- Earlier treatment = better prognosis
- HIV infection may alter treatment for co-existing medical conditions
- Reduce risk of onward transmission
- More control over who to tell before they become seriously ill and have no choice
What are the window times for testing HIV?
- p24 antigen detected 2-4 wks after infection
- HIV antibody 4-8 wks
- 4th generation (Ag/Ab) HIV test will detect the majority of infected patients by 4 weeks after an exposure
- If risk
What are the pros and cons of bedside HIV testing?
- Rapid results in front of patient
- Quick to perform and good for needle phobic patients
- Cons - some are 3rd generation so only pick up antibodies not the antigen (12 week window period)
- Reactive tests require a laboratory venous sample for results confirmation
What are the pros and cons of the venous blood sample in clotted tube test?
- Accurate
* But result is not instant
After a positive HIV result and breaking the bad news, what should be advised?
- Assess need for on-going psychological support
- Briefly explain HIV
- Explain how it can be transmitted and how to protect against this
- Refer patients to an HIV specialist clinic
- Multidisciplinary care
What is the mainstay of treatment for HIV?
- Treatment as prevention
- Aim is to reduce viral load to undetectable levels
- At this level there is effectively no risk of transmitting HIV to a sex partner
What are the preventative methods for HIV negative people?
- Condom use
- PrPEP
- Does not protect against other STI’s
- Taken before, during and after sex
What can be given to people exposed to HIV to prevent them getting infected?
- PEP - Post Exposure Prophylaxis
- Needs to be taken within 72 hours of risk
- Take for 28 days
- Can be obtained from sexual health clinics or A&E
- Need for baseline HIV test and monitoring
How is HIV transmitted in pregnancy?
- Mother to child transmission
- In pregnancy
- Labour and delivery
- Breast feeding
How is HIV managed in pregnancy?
- Routine antenatal screening (opt-out)
- Positives discussed at MDT
- PEP for baby for 4 weeks after birth
- Formula feeding
What types of influenza virus are there?
- 3 types
* A, B, and C which account for the majority of clinical disease
How is the influenza vaccine different in the one given to children vs given to the elderly and at risk groups?
- Children = live vaccine
* Elderly and at risk groups = inactivated vaccine
What are the 3 main points regarding the children’s influenza vaccine?
- Given intra-nasally
- First dose is given at 2-3 years then annually after that
- It is a live vaccine
What other points are important regarding the influenza vaccine in children?
- Children traditionally offered the flu vaccine e.g. asthmatics will now be given intranasal vaccine unless this is inappropriate e.g. immunosuppressed - in this case they should be given the inactivated injectable vaccine
- Only children aged 2-9 years who have not received an influenza vaccine before need 2 doses
- It is more effective than the injectable vaccine
What are the contraindications for the live influenza vaccine in children?
- Immunocompromised
- Aged <2 years
- Current febrile illness or blocked nose/rhinorrhoea
- Current wheeze (e.g. ongoing viral induced wheeze/asthma) or history of severe asthma (BTS step 4)
- Egg allergy
- Pregnancy/breast feeding
- If the child is taking aspirin e.g. for Kawasaki disease due to risk of Reye’s syndrome
What are the possible side effects of the live influenza vaccine in children?
- Blocked nose/rhinorrhoea
- Headache
- Anorexia
What type of influenza vaccines are offered to adults and at risk groups?
- Current vaccines are trivalent and consist of two subtypes of influenza A and one subtype of influenza B
What is the recommendation for the influenza vaccination for the elderly and at risk groups?
- Department of Health recommends annual influenza vaccination for all people older than 65 years and those older than 6 months if they have:
- Chronic respiratory disease (including asthma)
- Chronic heart disease (heart failure, ischaemic heart disease, including hypertension)
- CKD
- Chronic liver disease: cirrhosis, biliary atresia, chronic hepatitis
- Chronic neurological disease (stroke, TIA)
- Diabetes mellitus
- Immunosuppression due to disease or treatment (e.g. HIV)
- Asplenia or splenic dysfunction
- Pregnant women
- Adults with a BMI >40kg/m2
Others at risk include:
- Health and social care staff involved in patient care
- People living in long stay residential care homes
- Carers of the elderly or disabled whose welfare may be at risk if the carer becomes ill
What are the key points regarding the influenza vaccine administered to the elderly and at risk groups?
- It is inactivated so cannot cause influenza - minority will develop fever and malaise which may last 1-2 days
- Should be stored at between +2 and +8c and shielded from light
- Contraindications include hypersensitivity to egg protein
- Vaccination is around 75% effective in adults, although decreases in the elderly
- Takes around 10-14 days after immunisation before antibody levels are at protective levels
What is the virus that causes measles?
- RNA Paramyxovirus
How is measles spread?
- Respiratory droplets
When is measles infective?
- Incubation period = 10-14 days
* Infective from prodrome until 4 days after rash starts
What are the features of measles?
- Prodrome: irritable, conjunctivitis, fever
- Koplik spots (before rash) = white spots on buccal mucosa
- Rash - starts behind the ears then to the whole body, discrete maculopapular rash becoming blotchy and confluent
What investigations can be done to diagnose measles?
- IgM antibodies can be detected within a few days of the rash onset
What is the management for measles?
- Mainly supportive
- Admission may be considered in immunosuppressed or pregnant patients
- Notifiable disease therefore public health England need to be informed
What are the complications of measles?
- Otitis media - most common
- Pneumonia - most common cause of death from measles
- Encephalitis - typically occurs 1-2 weeks following the onset of the illness
- Subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness
- Febrile convulsions
- Keratoconjunctivitis, corneal ulceration
- Diarrhoea
- Increased incidence of appendicitis
- Myocarditis
How should contacts of a person who has measles be managed?
- If a child not immunised against measles comes into contact with measles then they should be offered the MMR (vaccine induced antibody develops faster than natural infection)
- Should be given within 72 hours of contact
How does the rash spread in measles?
- Starts behind the ears then spreads to the whole body
What is mumps?
- An acute infectious disease caused by a paramyxovirus
- Characterised by bilateral parotid swelling
- Spread by respiratory droplets or saliva
When is mumps most infectious?
- From around 1 - 2 days before the onset of symptoms, to about 9 days afterwards
- May be asymptomatic in 15-20% of people
- Asymptomatic mumps infection is common in children
- Nearly all people develop lifelong immunity to mumps after one episode of infection
- 1 - 2% of cases are thought to be reinfections
How do patients with mumps present clinically?
- Parotitis (swollen parotid glands) — this is present in 95% of symptomatic cases.
- Typically 1 parotid gland is affected first, reaching a maximal size after 2-3 days, ear lobe over the affected gland may be deflected up
- Gland may be tender to touch
- Non-specific symptoms of fever, headache, malaise, muscle ache, and loss of appetite.
- Epididymo-orchitis — affects up to 38% of infected men. Unilateral mumps epididymo-orchitis can significantly, but only transiently, diminish the sperm count, mobility, and morphology. Bilateral mumps epididymo-orchitis occurs in 15–30% of affected men and causes infertility in 30–87% of them.
- Oophoritis occurs in about 7% of women, but rarely causes infertility or premature menopause.
What are the potential complications of mumps?
- Aseptic meningitis.
- Transient hearing loss.
- Pancreatitis.
- Rarer complications include other central nervous system disorders (such as cerebellar ataxia, facial palsy, transverse myelitis, and Guillain–Barre syndrome), thyroiditis, mastitis, prostatitis, hepatitis, and thrombocytopenia
Is mumps a notifiable disease?
- Yes - any suspicion of infection with mumps, the local health protection unit should be notified
How should patients be advised in relation to mumps infection?
People should be advised that:
- Mumps is usually a self limiting condition, will usually resolve over 1-2 weeks with no long term consequences, antibiotics not required
- To rest, drink adequate fluids and take paracetamol or ibuprofen for symptomatic pain relief (avoid aspirin in children younger than 16 years)
- Apply warm or cold packs to the parotid gland as it may ease the discomfort
- Stay off school or work for 5 days after the initial development of parotitis
When is it appropriate to admit people to hospital or refer for specialist advice when they have a mumps infection?
- Signs of mumps encephalitis (altered consciousness, focal neurological signs or seizures)
- Person develops mumps meningitis (severe headache, neck ache, high fever, lethargy and vomiting)
- Following epididymo-orchitis (particularly if bilateral), a man has an abnormal semen analysis or is experiencing infertility
What additional management should be offered to people who have been in contact with possible mumps?
- People should be offered immunisation with the combined MMR vaccine if they are not already immunised, unless they are pregnant, or severely immunocompromised
What is Rubella?
- Single stranded RNA virus from the Togaviridae family
- Transmission occurs through direct contact with an infected person or droplet spread from nasopharyngeal secretions
- The rubella virus replicates in the respiratory mucosa and local lymph nodes and is then spread haematologically to the rest of the body (including the placenta and fetus in the pregnant women)
- Also known as German measles is a viral infection spread by direct contact with an infected person or by droplet from respiratory secretions
