STIs Flashcards
What is the #1 STD optometrists see in the US?
chlamydia, largely asymptomatic
What is the #1 symptom of an STD?
asymptomatic
How many people in the US have an STI?
1 in 5 people, 68 million in US
What is the #1 transmitted STD?
HPV, but there is a vaccine
What causes syphilis?
spirochete Treponema Pallidum, a helical bacteria 0.18 microns wide and 5-15 microns long
What barriers can syphilis cross?
placenta, blood brain, blood retinal
How is syphilis most often aquired?
via sexual intercourse, more rarely through blood contact or contact with chancre
How is a spirochete directly observed?
dark field microscopy
What are the stages of syphilis?
primary, secondary, latent, tertiary
What is true of primary syphilis?
all untreated primary will become secondary
How does secondary syphilis progress?
30% of untreated secondary becomes tertiary the rest remain latent, this is where you produce a rash
What happens with late syphilis?
can go back and forth between early and late latency
What is tertiary syphilis?
clinical neurosyphilis, cardiovascular syphilis and late benign dermatological involvement
When can asymptomatic CNS involvement occur in syphilis?
in all untreated cases in any phase of the disease; more likely than not it occurs during later stages
When will an optometrist detect syphilis?
when there is CNS involvement
What is a chancre?
ulcerative, painless active lesion in primary syphilis; upon direct contact enters lymphatics and blood stream and quickly disseminates
How long does it take between incubation and chancre?
3 weeks (range 3 days to 3 months)
How long does spontaneous healing of a chancre take?
2-8 weeks
When does secondary syphilis occur?
2-12 weeks after contact
What are s/s of secondary syphilis?
malaise, papular rash on trunk and extremities, palms of hands and soles of feet, uveitis (ocular involvement 5% of cases)
When is the greatest treponemal load?
secondary syphilis
What are clinical manifestations of syphilis?
rash 75-100% of the time and lymphadenopathy 50-86%; + malaise, mucous patches, condylomata lata (wart like), alopecia, liver and kidney involvement, splenomegaly
What is latent syphilis?
hot suppresses infection but no lesions are clinically apparent, only evidence is a positive serologic test
When may latent syphilis occur?
between primary and secondary stages, between secondary relapses, and after secondary stage
What is early latent?
<1 year duration
What is late latent?
> or equal to 1 year
What is tertiary syphilis?
30% get to tertiary, all organs and tissues of the body may become involved; gummas (granulomatous lesions) are found in cardiovascular and neurological systems
What are cardiovascular complications of tertiary syphilis?
lesions of the aorta and arteries of the CNS; arteritis, ischemia and aortic aneurysms
When does neurosyphilis occur?
at any stage, damage is caused by spirochetes actually damaging CNS
How can neurosyphilis be detected?
+CSF serology, increased protein and leukocytosis
What is syphilitic meningitis?
HA, nausea, stiff neck, confusion, CN palsies
When should you consider syphilitic cerebrovascular disease?
young patients with CV
T/F neurosyphilis is in almost half of individuals in secondary stage
true
What are s/s of neurosyphilis?
general paresis, tabes dorsalis, argyll robertson pupils and cranial nerve involvement
What is the natural history of syphilis?
government paid to have individuals with syphilis and had them deny treatment to those patients to study the course/progression of the disease
What is the order of progression for syphilis?
inoculation, incubation period (1 week), development of primary syphilis and chancre that resolves in 1-6 weeks, early latent period, secondary period with development of rash, late latent phase, tertiary with gummas
Statistics for syphilis
100% of people inoculated from dirty toilet will get primary syphilis; 100% of untx syphilis develops into secondary; 75% of secondary syphilis becomes latent while 30% gets stuck in loop of secondary and latent; 45% with latent develop permanent latency; 30% with permanent latency develop tertiary; 20% with tertiary are incapacitated and 10% die
How is congenital syphilis contracted?
in utero or during passage through birth canal
What are s/s of congenital syphilis?
rhinitis, skin rash, liver infection, interstitial keratitis, hutchinson’s teeth, frontal bossing (square cranium), saddle nose
What is hutchinson’s triad for congenital syphilis?
teeth, interstitial keratitis, CN 8 deafness
What do non-treponemal tests look for?
reagin looks for inflammatory markers of a spirochete found in the body
What are non-treponemal tests?
rapid plasma reagin and venereal disease research laboratory VDRL
What are treponemal specific tests?
specific to the treponemal spirochete; FTA-ABS, MHA-TP, HATTS, TPHA-TP
What is the rapid plasma reagin?
non-specific syphilis associated antibody; low specificity, high sensitivity aka high false positives
What are the multiple antigens for rapid plasma reagin?
cardiolipin, lecithin, cholesterol
What can cause biological false positives for RPR?
infectious mononucleosis, malaria, pregnancy, lupus, RA, drug use
What are RPR results for primary, secondary, and latent/tertiarty syphilis?
(+)titer 4-6 weeks, (+++)titer with highest load almost 100% sensitive, and decreasing titers/sensitivity respectively
What will an adequate treatment of syphilis show?
(-) titer; 4x reduction in titer
What is FTA-ABS?
immunofluorescent assay technique, +/- cross-reactivity with Lyme disease, highly sensitive and specific
T/F FTA-ABS remains positive after treatment
true
Testing interpretation + RPR +FTA-ABS
active syphilis
Testing interpretation - RPR +FTA-ABS
adequately treated or latent/late neurosyphilis
Testing interpretation + RPR - FTA-ABS
biologic false positive
Testing interpretation - RPR - FTA-ABS
no exposure of very recent
When is CSF examination indicated for syphilis?
patients with syphilis who demonstrate any of the following criteria: neurologic or ophthalmic s/s, evidence of active tertiary syphilis, treatment failure, HIV infection with CD4 <350 and/or nontreponemal serologic test titer of > 1:32
T/F any ocular involvement is considered neurosyphilis
true
What is CSF testing in syphilis?
no gold standard, CDC recommends CSF-VDRL
What is the neurosyphilis equation?
CSF leukocytosis + elevated protein + neurological symptoms > 1 year = neurosyphilis
What is a common syphilis treatment?
penicillin G
When do ocular manifestations of syphilis occur?
secondary or tertiary
What are ocular manifestations of syphilis?
conjunctivitis, scleritis, interstitial keratitis, granulomatous uveitis, chorioretinits, retinal vasculitis, arterial occlusion
Diagnosis of ocular syphilis
prompt diagnosis to avoid treatable irreversible vision loss, consider CSF testing, evaluate any anterior uveitis or CN palsy with coincident skin rash
T/F in all cases of syphilis, the possibility of coinfection w/ HIV must be ruled out
true
What is the most common HIV transmission?
unprotected sex with HIV infected partner, also infected blood/breast milk/semen/vaginal fluid coming in contact with mucous membrane or damaged tissue
What are risky behaviors for HIV?
sharing needles
Can HIV be transmitted from mother to child?
yes
HIV 1 vs 2
1 identified in 1985, 2 predominantly found in W Africa with slower progression and milder immunodeficiency
What does the HIV virus do?
retrovirus binds to CD4 glycoprotein molecules (chemokine receptor) on the surface of the target host cells
What is viral load?
ongoing viral replication; higher load correlated with more rapid progression to AIDs
What is CD4 count?
assessment of health of your system; normally 1000 cells/cubic mm (600-1500)
When do CD4 counts drop?
drop progressively in HIV infection, provides an estimate of immunity, cell mediated immunity is critical for protection agains infectious process, involves memory CD4 cells unable to recognize specific pathogen
What characterizes AIDs?
CD4 <200 cells/cubic mm = AIDs
What is the average time for progression to AIDs without therapy?
10-11 years
What is the average time to death following AIDs?
3.7 years
What is the initial/early phase of HIV?
newly infected with no symptoms, acute retroviral syndrome flu-like illness 2-3 weeks following infection with recovery in weeks
What occurs in initial HIV infection?
body mounts immune response by producing antibodies= HIV+ status; seroconversion in 6 weeks to 6 months to develop in 95% of those infected
How are mutations involved in HIV?
during process of viral replication, many mutations are formed which confuses killer T cells CD 8; antibody titers are not sufficient to destroy the replicating virus
What is the chronic phase of HIV?
10-11 years “latent” period, relatively health: progressive deterioration of immune system and viral replication; minor immune dysfunction, abnormal blood studies, minor constitutional problems
When is antiretroviral therapy given?
day 1 of diagnosis, ART patients may live with clinical latency for several decades
What is the crisis phase of HIV?
systemic diagnosis of AIDs, manifestation of an indicator disease + HIV confirmation; CD4 < 200 cells/mm3 with or without an indicator disease
What percent of individuals with AIDs have ocular involvment?
75-100%
When can you detect antibodies for HIV?
6 weeks to 6 months after exposure
What is the viral lode test?
measures # of HIV RNA molecules per mililiter of plasma (want low to reduce progression and transmission)
What is the chance of causing disease progression in 60 months for 20,000 and 200,000 respectively?
1% and 24%
What is the goal for viral load?
as low as possible aka below limit of quantification, typically <25-50
What can a PCR detect?
down to 50 copies of HIV RNA
What are 3 AIDs defining malignancies?
kaposi’s sarcoma, burkitt’s lymphoma, primary CNS lymphoma
What is ART (HAART) therapy?
cocktail of 2 nucleoside reverse transcriptase inhibitors and 1 non-nucleoside reverse transcriptase inhibitor or integrase strand transfer inhibitor or protease inhibitor
What is a NRTI?
nucleoside reverse transcriptase inhibitor; prevents elongation of viral DNA, prevents replication by blocking reverse transcriptase from binding
What is a NNRTI?
non-nucleoside reverse transcriptase inhibitor; bind to a specific area adjacent to the site of the reverse transcriptase enzyme
What is INSTI?
integrase strand transfer inhibitor; blocks HIV’s DNA incorporation into CD4 cell’s DNA
What is PI?
protease inhibitor; case premature release of immature, non-infectious viral particles
What are the names of common ART options?
Biktarvy, Triumeq, Atripla, Genvoya, Complera
What is prophylactic HIV treatment?
pre exposure and post
What is PrEP?
pre-exposure, for high risk groups, once daily med (Truvada and Descovy) aka combo of 2 HIV meds (tenofovir NRTI and emtricitabine NRTI)
What is PEP?
post-exposure, begin within 72 hours, different cocktail
What is oral thrush/candidias?
yeast infection of the mucus membrane lining the mouth and tongue, normal component in oral microbiota –> opportunistic infection in HIV patients
When can you get opportunistic infections?
CD4 500-200 cells/mm3 or ratio of CD4 to lymphocytes less than 30%
What opportunistic infections do you get with 500-200 cells?
thrush, herpes zoster, and hairy leukoplakia
What is hairy leukoplakia?
Epstein Barr, white patch on the side of the tongue
What infection can you get with CD4 200-100?
pneumocystis carinii pneumonia
What is the most significant HIV/AIDs complication?
pneumocystis pneumonia a fungal infection of the lungs
What infections are possible with CD4 less than 100 cells/mm3?
cyptococcosis and cryptosporidiosis
T/F there is CSF involvement with infection and CD4 less than 100
true
What is cyptococcosis?
fungal infection, wound/cutaneous, pulmonary or meninigitis
What is cryptosporidiosis?
parasitic, intestine to diarrhea, need fluid rehydration and electrolytes
What infections are possible with CD4 less than 50 cells?
mycobacterium avium complex, progressive multifocal leukocephalopathy or primary central nervous system lymphoma
What is mycobacterium avium complex?
group of bacteria related to TB; found in soil, food, and water; can infect lungs, bones or intestines and can spread through out body
What is progressive multifocal leukocephalopathy?
secondary to immune suppression as side effect of biologic med for psoriatic arthritis; infection that damages myelin of white matter, fatal
What is conjunctival microvasculopathy?
perilimbal injection, comma shaped vesicles, sludging of the blood columns due to HIV
What are adnexal ocular manifestations of HIV?
molluscum, HZO, primary non-hodgkin
What is immune recovery uveitis?
occurring after onset of ART, in patients with history of inactive CMV
What is HIV retinopathy?
CWS, intraretinal hemes, microaneurysms, IRMA; see a patient back in 3 months
What is ischemic maculopathy?
enlargement of FAZ
What is CMV retinitis?
most common sight threatening opportunistic infection, can lose vision in 48 hours
What is CD4 with CMV?
less than 50
What is acute retinal necrosis syndrome?
peripheral retinitis tx with IV acyclovir
What is progressive outer retinal necrosis syndrome?
posterior pole retinal necrosis leading to NLP
What is ocular toxoplasmosis?
parasitic infection, focal or diffuse, prophylaxis in seropositive patients with low CD4 counts (pyrimethamine-sulfamethoxazole)
What are examples of fungal infections from HIV?
pneumocystic choroidopathy, candidal chorioretinitis, cryptococcus chorioretinits, histopasma chorioretinits
What are bacterial infections with HIV?
syphilis¯_(ツ)_/¯ endogenous bacterial retinitis, mycobacterium TB
When do cranial nerves get involved with neuro-ophthalmic HIV?
50% due to cyptococcal meningitis
What are appropriate disinfectants for HIV?
3% hydrogen peroxide, 70% ethanol, 10% bleach/water solution
What organism is chlamydia?
obligate intracellular parasite
Trachoma and Inclusion Conjunctivitis serotypes
A-C and D-K respectively
What does trachoma produce?
chronic conjunctivitis causing blindness
What is transmission of trachoma?
flies, eye to eye
What are signs of trachoma?
follicular conjunctivitis, Arlt’s line, trichiasis, corneal opacity
What is treatment of trachoma?
SAFE– surgery for entropion, antibiotic zithromax, facial hygiene and environment change
What are urogenital symptoms of chlamydia?
pain areas in lower abdomen, and urogenital system, pain during sex or urination, abnormal discharge or bleeding
What is adult inclusion conjunctivits?
oculogenital disease of conj and genitals, acute follicular conjunctivitis, preauricular lymphadenopathy
What is chlamydial testing?
conj or urethra swab, polymerase chain reaction, urine specimen (gold standard)
What is chlamydia treatment?
azithromycin 1 g single dose, oral doxy, erythromycin, ofloxacin, levofloxacin
What meds are appropriate for chlamydia during pregnancy?
erythromycin and amoxicillin
T/F you must report chlamydia to the health department
true, requires name of individuals who test positive; TN promotes expedited partner delivered therapy
What are signs of ophthalmia neonatorum?
redness, mucopurulent discharge, swelling of lids, conjunctival chemosis, bilateral symptoms
Why do infants lack follicles?
they have not developed lymphoid tissue
What is ophthalmia neonatorum prophylaxis?
erythromycin ung, povidine-iodine, 1% silver nitrate
What are risk factors for gonorrhea?
25 year old, hx of STI, inconsistent condom use, new or multiple sex partners, substance abuse
What bacteria causes gonorrhea?
neisseria gonorrhea, gram negative diplococcus
How does gonorrhea cause infertility?
leading cause of infertility due to infected women developing pelvic inflammatory disease
What are clinical presentations of gonorrhea?
urethritis, cervicitis, proctitis, and conjunctivitis
What can severe gonorrhea cause?
endocarditis, menigitis, myocarditis
What is polyarticular tenosynovitis?
joint inflammation following dissemination of gonorrhea in wrists, ankles, hands, and feet
What is the test of choice for diagnosis of gonorrhea?
culture, nucleic acid amplification test, PCR, or transcription mediated amplification assay
What are ocular signs of gonnococcal keratoconjunctivitis?
marked lid edema, conj hyperemia, copious purulent exudate, preauricular lymphadenopathy, conj membrane
Why must a patient be hospitalized with a corneal ulcer from gonorrhea?
it can penetrate the cornea in 24 hours leading to perforation and endophthalmitis
What is management of gonorrhea?
gentamicin, tobramycin or bacitracin; if corneal involvement then ceftriaxone
What is the ALLOW method?
ask, legitimize, limitations, open up further discussion, work together to develop treatment plan
