STIs part 2 (HIV syphilis) Flashcards
what are genital warts caused by?
- sexually transmitted HPV subtype 6 and 11
- (occasionally 16 and 18 but associated with malignant potential)
who is most likely to get florid lesions in genital warts?
- DM
- pregnancy
- OCP
- smoking
- immunosuppression
what is the incubation period for genital warts?
what do genital warts look like?
how do they feel on palpation?
- up to 8 months
- pink papular lesions, single or multiple, keratotic or plaques
- multiple raised papillomatous lesions, feel hard to touch and are irregular
what investigations would you perform for genital warts?
- biopsy atypical lesions
- cervical smear and cytology
- colposcopy and biopsy cervical lesions
- STI screen
how can genital warts be managed?
- ablation (<6 and keratinised)
- immune modulation (imiquimod cream)
- surgical:
curettage, excision - advice on cervical smears and eliminating sexual contacts
how might vaginal warts affect pregnancy?
what are the complications of vaginal warts?
- consider LSCS only if large vaginal introitus lesions
- infection of confluent lesions, CIN, cervical carcinoma
what organism is syphilis caused by?
who is most at risk?
- treponema pallidum
- re-emerged in MSM, many with HIV
how does primary stage syphilis present?
- chancre- at site inoculation, small painless ulcer, indurated with exudate
- may be on anal margin, tonsils, lips or nipples
- incubation period a few weeks
how does secondary stage represent?
- widespread maculopapular rash, palms, soles, generalised
- mouth ulcers
- alopecia
- systemic symptoms: headaches, malaise, fever, meningitis, CN nerve dysfunction
how does tertiary stage present?
- neurosyphilis (dementia, meningeal involvement)
- cardiovascular symptoms
- latent stage: positive blood test, no symptoms
what investigations would you do?
- take sample from open skin lesions to do microscopy
- serology
- syphilis PCR
- STI screen, especially HIV
what is the management of syphilis?
neurosyphilis?
- benzathine penicillin 2.4g IM
- procaine benzylpenicillin, 750mg for 10 days
what are the complications of syphilis in pregnancy?
- pregnant women with untreated syphilis 70-100% infants infected
- 1/3 chance of stillbirth if infected
- growth problems up to 2 years
- all pregnant women with positive serology should be treated for syphilis
- outcome depends on gestational age infection acquired
what is the pathology of HIV?
- kills CD-4 cells
- HIV 1 most common
- reverse transcriptase RNA inserted into DNA and causes latent infection
what is the normal CD4 range?
what is the timecourse of HIV?
- 500-1500
- infection, seroconversion (acute illness), asymptomatic, HIV related illness, AIDS , death
what happens in seroconversion in HIV?
- initial massive proliferation of viral load, body can not cope and drops CD4
- body recovers and makes more CD4 cells
- HIV RNA conc increases, CD4 conc decreases, then they become symptomatic
what are the risk factors to ask about?
- sex worker
- MSM
- unprotected sex with foreign people
- IVDU
what are the symptoms of seroconversion?
- occurs 2-6 weeks after exposure
- only 60% of people get it
- glandular fever like symptoms:
- sore throat
- fever
- lymphadenopathy, malaise and lethargy, arthralgia/myalgia
- rash (maculopapular on trunk)
- ulcers on mouth and penis
What would make you think HIV in a patient presenting with another problem?
- atypical
- severe
- recurrent
what are the aids related malignancies?
- Kaposi sarcoma
- non-hodgkins lymphoma
- invasive cervical carcinoma
- (all NHL patients should be screened for HIV)
10% of them will get a malignancy
what are the bacterial conditions which are AIDS defining in people with HIV?
fungal?
- TB
- recurrent pneumonia
- salmonella septicaemia
- mycobacterium avid complex (MAC)
- candidiasis (oesophageal, bronchial, tracheal, lungs)
- pneumocystis pneumonia
what viral infections are associated with it?
parasitic infections associated with it?
- CMV (retinitis, liver, spleen, glands)
- HSV
- cerebral toxoplasmosis
- cryptosporidiosis
- leishmaniasis
What is HAART?
- the use of at least 3 anti- HIV drugs from at least 2 different drug classes
- two nucleoside reverse transcriptase inhibitors (NRTIs)
- one non nucleoside reverse transcriptase inhibitor (NNRTIs)
what is the aim with viral load?
what may affect viral load coming down?
- it should be kept below 50
- monitor treatment to make sure it is coming down
- compliance,over 95% of people who are 100% compliant will have an undetectable viral load
what is an adverse side effect of HAART?
There are interactions between many steroids and HAART, which one does not have an adverse reaction with ritonavir?
- Cushings disease
- beclomethasone (other cause cushings)
what common drug does ritonavir/ cobiscistat interact with?
what does rilpivirine interact with?
- CYP3A4 pathway (simvastatin)
- causes rhabdomyolysis
- PPIs contraindicated
what may happen to HAART in drug interactions?
- causes decreased conc allowing the virus to replicate with low drug levels, leading to drug resistance
when should HAART be offered in the UK?
what is the guidance on who should be tested for HIV?
- CD4 <350 (before AIDS) and treatment minimises risk of transmission
- all people with an STI
- all people with risk >1 in 1000
- anyone in high risk groups
- all patients with clinical indicator disease
What are they looking for in an HIV blood test?
- blood test takes 2 weeks to come back
- (tests for antibody and antigen)
- antibody takes 4 weeks to develop
what other test can be done in HIV?
- point of care testing
- measure viral load
name 2 NRTIs?
- zidovudine/ lamivudine/ tenofovir
when should you start HAART in pregnancy?
what is the disadvantage of starting HAART?
- any CD4 count, to reduce transmission
- on it for the rest of your life, co-pharmacy, side effects
what are the most common side effects of HAART?
why?
- bone marrow suppression
- kidney and liver toxicity
- insulin resistance
- interferes with metabolic pathways by affecting mitochondrial activity
what are the drug interactions of HAART?
- all p450 interacting drugs
what does the viral load have to be for the mother to have a normal delivery?
what does the baby get?
what other precaution must be taken?
- <50
- give neonatal PEP for 4 weeks
- no breastfeeding
when should PEP be given?
what else can be done for prevention?
- anyone who has had sex with a high risk person in last 72 hours
- PreP
- male circumcision in 60% of cases
