STI Flashcards
HIV modes of transmission
Sexual Parenteral Vertical
Pathophysiology of HIV
RNA retrovirus infect all cells expressing the T4(CD4) antigen -CD4 -B-cells -Macrophages Causes immunodeficiency, Autoimmunity, Allergic reactions
Progression of HIV to AIDS
AIDS is defined as a presence of an Opportunistic infections or CD4<200cells
Opportunistic infections with HIV/AIDS
Kaposi Sarcoma:Purple skin lesions Pneumocystis jeroveci:PNA, hypoxia, dry cough Toxoplasmosis: Focal neuro deficits, brain mass/lesion Cryptococcus neoformans: meningitis like picture(fungal) TB
CD4 count<500 OI
TB Kaposi Sarcoma
CD4 count<200 OI
Pneumocytosis Toxoplasmosis Cryptococcosis
CD4 count<50 OI
Disseminated MAC infection (Mycobacterium Adium complex) Histoplasmosis
Preferred HIV Test/screen
ELISA(HIV Enzyme Linked ImmunoSorbent Assay) 50%positive after 22 days 95% positive after 6 weeks Must be confirmed
Confirmatory Test for HIV
Western Blot Specificity when combined with ELISA>99.99% Indeterminate results with: -early HIV -HIV-2 -Influenza vaccine -Autoimmune disease -Pregnancy -Recent tetanus toxoid admin
Easy and quick test for HIV
HIV Rapid Antibody Test Screen for HIV, 10-20 minute results, performed with minimal training *Needs to be confirmed by ELISA and Western Blot
CBC in screening for HIV/AIDS
Anemia of chronic disease Neutropenia Thrombocytopenia(Advanced HIV infection)
Absolute CD4 lymphocyte count CD4 lymphocyte percentage
Most widely used predictor of HIV progression risk of progression to an AIDs OIis high with CD4 <200 or ,14% Folllowed Q3 months or sooner if change in status
Best test to help diagnose acute HIV infection
HIV viral load
HIV viral load test
Acute HIV diagnosis Correlate with. Disease progression Used to measure response to antiretrovirals
Screening criteria for HIV/AIDS
USPSTF recommends screening on adolescents and adults 15-65. Increase range if at increased risk Even if no risk recommend at least testing once No implied consent, make it clear ordering an HIV test
Goals of treatment for an HIV Pt
Viral Supression** OI prophylaxis Preventative considerations -cervical/rectal cancer screening -Vaccinations(Need CD4 count >200) -CAD and lipids -mental health/social support
When do you start antiretrovirals
As soon as the Pt is ready to start and be compliant, regardless of CD4 or viral count
Immune reconstitution
Immune system will rev up after antivirals are started and CD4 count starts to rise. It will begin attacking some bugs that it hadn’t and Pt’s might see symptoms(symptomatic support and reassurance)
Perihilar infiltrates-
Batwing appearance chest x-ray, of Pneumocystis jiroveci
Antiretroviral treatment should start asap because:
-Prevents further transmission -RCT’s x2 have proven benefit -additional health benefits(HIV virus does more damage than just immune system)
Antiretroviral drug selection based on:
-Viral genotype(resistance patterns) -Pt comorbid conditions *Pysch *Liver/renal disease *Hep B -Pt med interactions -Baseline viral load -HLA-B5701 status(Abacavir RXN) and G6PD RXN
Antiretroviral drug points to know
-Therapy must be 3 or more drugs(only 2 from same class) -Resistance is common(if Pt misses just a few doses virus can become resistant)
Nucleoside reverse transcriptase inhibitors (NRTIs or Nukes)
MOA-Prevent viral RNA from being transcribed into DNA Side Effects-associated with lactic acidosis, hepatic steatosis(fatty liver), and lipodystrophy(abnormal distribution of fat) Special-can also treat Hep B Monitor- Need to test for HLAB-5701 Abacavir Example-Emtricitabine
Non-nucleoside Revers transcriptase inhibitors (NNRTIs or Nonnukes)
MOA-Prevent viral RNA from being transcribed into DNA Side effects- rash(SJS) Has significant drug RXNs works best with viral load<100,000
Protease inhibitors (PIs)
MOA-Prevents replicated viruses from being released from a cell Side effects-Dyslipidemia, hyperglycemia, insulin resistance, lipodystrophy CYP system RXN-proton pump inhibitors and statins are most notorious Paired with a booster drug to increase absorption
Integrase inhibitors
MOA-Prevent Viral DNA from integrating into host DNA Side effects-abnormal dreams, N/V/D, rash, LFTs(don’t give to psych pt) Needs renal adjustments Some need a booster or pharmacokinetic enhancer *cobicistat
Fusion Inhibitor (FI) and Chemokine Coreceptor Antagonist (CCR-5)
MOA-Prevents viral fusion/binding to the cell Not first line-newer drugs Side effects- FI-injection site RXN, neutropenia, pneumonia CCR-5-Hepatitis, pneumonia, myalgias, many drug interactions Often seen as last resort for Pt’s with significant resistance
Factors that contribute to ARV drug resistance
-Medication non-adherence -Decreased absorption -drug interactions
Principles of HAART (Highly active antiretroviral therapy
***VIRAL SUPPRESSION***** -prevent future transmission -restore immune function -reduce HIV associated morbidities
Post exposure prophylaxis
Healthcare and non occupational exposure -3 drug treatment -28 days of treatment -Baseline and follow up labs(Up to a year)
Chlamydia ETiology/pathology
Chlamydia Trachomatis
Infects cell walls until bursts open
MC bacterial STI om US
Chlamydia Sx
M-mucoid discharge urethritis
Commonly asymptomatic especially females
Urethritis
PID
Cervicitis(strawberry cervix)
Proctitis
Mucoid discharge
Mild dysuria
Chlamydia Dx and complications
Vaginal swab and urine preferred
Cervical, urethral and liquid pap
Complaints
NAAT(nucleic amplification test)
Can cause infertility, conjunctivitis, PNA
Chlamydia treatment/prevention
Azithromycin 1gm x1dose
Doxycycline 100mg BID x 10 days
retest in 3 weeks
Screen annually in women <24
Gonorrhea ETi/transmission
Gonococcal
1-14 d incubation period in men/unclear in women possibly 10days
Autoinocculation
5 Ps of STI risk assessment
Past STDs
Partners
Practices
Prevention
Pregnancy plans/prevention
Gonorrhea symptoms
M-urethritis-yellowish white discharge
F-Majority asymptomatic, extragenital infection, may have urogenital infection(vaginitis, vaginal discharge, labia pain, swelling, abd pain)
Gonorrhea Diagnostics
Gram - diplococci
Specimen types(Vaginal swab, urine, cervical, urethral, liquid pap)
Culture
Nucleic acid amp[lification test
gonorrhea complications
Pelvic inflammatory disease can cause infertility
Gonorrhea treatment and prevention
Ceftiaxone 250mg IM +doxycycline or Azythromycin(has high resistance treat with 2 abx)
Screen annualy women <24
Trichomoniasis Vaginalis
Parasite-pear shaped-trichomonas vaginalis
Transmission-Sex
Sx-Most asymptomatic-vaginal discharge-frothy yellow/green, vulvovaginal discomfort, pruritis, dysuria,
Men-Asymptomatic, urethritis, scant discharge
Ddx-bacterial vaginosis
Dx-wet mount-vaginal swab, pH>4.5, Fishy odor after KOH, motile
Complications-perinatal complications, increase HIV transmission
Treatment-Metronidazole 2 g PO x1, Tinidazole 2 gram PO x1
Syphilis “The Great Imposter”ETi, transmission and Sx
Treponema pallidum-spirochete
Multiple stages primary, secondary, latent,and tertiary and Congenital
Primary incubation period 10-90 days
Transmission-unprotected sex(Vag,oral,anal), verticle
primary Sx-Painless chancre, hard indurated ulcer forms at site, Lymphadenopathy in1-2 weeks heals with scaring 1-5 weeks
Secondary Sx- 6 weeks after chancre, copper tinted lesions, maculopapular often on palms and soles as well as body, flu-like prodrome, lymphadenopathy, hepatosplenomegaly, Condylomata Lata- wart like moist lesion near chancre highly contagious
Latent Sx-no sores/rash relapse is possible, early latent<1yr, late<1yr, late has lower transmission
Tertiary sx: Occurs 1-20 yrs later, heart, brain, other organs, Gummas-granulomas on skin, bones and joints, neurosyphilis
Syphilis Diagnosis, complications, treatment and prevention
Dx-Dark field microscopy, screening-nontreponemal serology test(rapid plasma reagent)VDRL, confirm tests-FTA-ABS, TP-PA
Complications-Heart disease, blindness, brain damage, still birth, infertility, Congenital birth defects(ToRCHS), faciltates HIV
Treatment-Consult ID, Report to MDH,
Upto early latent-Benzathine Pen G 2.4 million units IM x1 dose
Late/tertiaryBenzathine PenG 2.4 million units IM weekly x 3 weeks
Screening- all pregnant women at 1st prenatal visit, 28 weeks and at delivery
High risk individuals should also be screened
HSV 1&2
HSV1 oral cold sore
HSV2 MC-
Primary outbreak-most severe
recurrence less severe
Transmission by sexual contact, verticle(ToRCHS)
Sx- small painful, grouped vesicles at site of contact–>pustules–>erosions/ulcers–>crust/heal in 2-6 weeks
Tingling burning prodrome, flu like symptoms, regional lymphadenopathy
Dx-Viral culture(unroofed vesicle-gold standard), PCR, more sensitive, Serology, tzank smear-multinucleated giant cells, immunofluorescence Ag
Treat- Oral antivirals started within 72 hrs of onset Valcyclovir$$$$less often, Acyclovir$ more frequent
Educated on Sx and chronicity, transmission, partner notification OB risks
Chancroid
ETI-Haemophilus ducreyi-grem neg streptobacillus
Sexual contact- skin contact, autoinnoclation-uncommon in US
Sx- Acute painful red papule at contact site–>pustule–>ruptures yellow grey exudate
BUBO formation(enlarged lymphnodes/inguinal adenitis(Pathognomic) Deep ulcer, bleeds easily
Dx-Swab exudateGram neg rods(school of fish) PCR confirmation Clinical diag based on exclusion of HSV and Syphilis
Treat-REPORT to MDH-treat suspicion dont wait for culture
Azithromycin 1 gram PO x 1
Ceftriaxone 250mg IMx1
Condyloma Acuminata
Genital Warts
Human Papilloma virus HPV
MC cause of STI
Type 6 and 11 MC
Trans-sex, skin contact and vertical
Sx- Tiny painless papules–>evolve into soft smooth velvety fleshy skin tags
Can coalesce into califlower likeregions
Spread quickly over mucosa
Suspect Child abuse if found in kids
DDX-Molluscum contagiosum, Acrochordons
Dx-H&P, biopsy and send to pathology(cancer)
Complications-Cancer-penile, cervical, anal, Head and neck
Treat- Multiple visits, no cure-cryotherapy, laser, electrocauter
Topicals-Acetic acid wash, podofilox, Imiquimod(cream)
Vaccine-Gardisil age 9-14 and 15-26
Education and support-partner infection
