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Clin Med III Unit 2 > 6 HIV Syphilis and Others > Flashcards

6 HIV Syphilis and Others Flashcards

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1
Q

Why is HIV considered a retrovirus?

A

It uses reverse transcriptase for reverse transcription (turning its RNA into DNA) —> integrates its genetic material into host cell DNA —> new virus produced

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2
Q

What is the difference between HIV-1 and HIV-2?

A

HIV-1 is the virus primarily responsible for AIDS, and the one you will see in the US

HIV-2 is isolated in W. Africa, similar in genetic sequence but less aggressive

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3
Q

What are HIV’s targets in our body?

A

T cells - particularly CD4 T cells (Helper T cells)

Also infects B lymphocytes and macrophages (other types of WBCs) but it’s the T cells we care about

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4
Q

What are lymphocytes?

A

WBCs that defend against Protozoa, fungi, certain intracellular bacteria, and viruses

Include B cells and T cells

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5
Q

What do B cells do?

A

Make antibodies to attack antigens

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6
Q

What do T cells do?

A

T4 cells (CD4) are the helper T cells - enhance immune response, tell B cells to make antibodies

T8 cells (CD8) are the killer T cells - destroy foreign agents

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7
Q

HIV replication occurs in ….

A

Activated CD4 cells

  1. HIV particle fuses to CD4 component of T cell
  2. HIV incorporates into host T cell (use of reverse transcriptase)
  3. New copies of HIV are released
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8
Q

Routes of transmission for HIV

A

Sexual transmission (exchange of infected body fluids)

Injected drug use

Occupational injury (ie needlestick)

Blood products (risk now 1:1,000,000)

HIV-infected mom to infant (risk 15-40% if mother untreated)

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9
Q

HIV is NOT spread by…

A

Casual contact

Requires infectious body fluid PLUS port of entry

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10
Q

Comparative risk of HIV transmission:

Insertive vaginal intercourse

A

1/10,000

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11
Q

Comparative risk of HIV transmission:

Receptive vaginal intercourse

A

1/1,000

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12
Q

Comparative risk of HIV transmission:

Receptive anal intercourse

A

1/50

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13
Q

Comparative risk of HIV transmission:

Shared drug needle

A

1/150

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14
Q

Comparative risk of HIV transmission:

Occupational needlestick

A

1/300

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15
Q

Primary (acute) HIV infection occurs ______ after exposure

A

2-6 weeks

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16
Q

How do 50-90% of patients with acute HIV infection present?

A

With a mono-like or flu-like illness

Lasts ~2 weeks and resolves spontaneously

Super easy to miss if you aren’t thinking about it

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17
Q

A patient with primary acute HIV will have a ______ HIV Ab test

A

Negative

Viral load is extremely high but body hasn’t made any antibodies yet

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18
Q

When is an HIV+ patient most infectious?

A

During acute primary infection 😬

If you don’t Dx them right, they are highly likely to transmit to partner(s)

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19
Q

Clinical SSx of primary HIV infection

A 
Fever
Adenopathy
Sore throat
Rash***
Mucocutaneous ulcers***
Myalgia
Arthralgia
H/A
N/V/D

Looks a lot like the flu or mono, right?!

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20
Q

Lab findings for primary HIV infection

A

Elevated transaminases (LFTs)
Slight Leukopenia
Slight anemia
Thrombocytopenia

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21
Q

What is clinical latency for HIV?

A

Begins as the immune system responds to infection (acute illness resolves)

Patient seroconverts - now their Ab test will be positive

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22
Q

HIV infected patients will usually seroconvert within…

A

3 months

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23
Q

What happens to a patient’s HIV viral load when they are in clinical latency?

A

Decreases to a “set point” then slowly rises over time

HIV remains active in lymph nodes

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24
Q

What happens to a patient’s CD4 count during clinical latency?

A

CD4 T cell count slowly declines

Patient does pretty well though until CD4 <200

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25
How long does clinical latency last in HIV?
Patients can remain asymptomatic (or minor LAD) for an average of 10 years Approx 5% are long term nonprogressors
26
What happens as an HIV+ patient’s immune system deteriorates?
Lymph nodes and tissue damaged - “burnt out” Virus may mutate and become more pathogenic Body fails to keep up replacement of CD4 cells HIV RNA viral load increases while CD4 count decreases This is the SYMPTOMATIC INFECTION phase
27
SSx of HIV
``` Fever Night sweats LAD Fatigue/malaise Arthralgias Weight loss Oral hairy leukoplakia****** (latent EBV) Thrush Prolonged diarrhea Cervical dysplasia (latent HPV) Skin disorders (molluscum, dermatophytes, seborrheic dermatitis) Kaposi’s sarcoma****** Recurrent HZV ITP ```
28
Definition of Progression to AIDS
CD4 T cell count <200 cell/mcL OR HIV+ AND 1 of 27 AIDS defining conditions (regardless of CD4 count)
29
What are some examples of AIDS defining conditions
Pneumocystis jiroveci (PCP) pneumonia Toxoplasmosis of the brain Mycobacterium avium complex, disseminated CMV in specific organs Candidiasis of esophagus, trachea, bronchi/lungs Kaposi’s sarcoma Invasive cervical cancer
30
Opportunistic pneumonia common in AIDS patients
Pneumocystis jiroveci pneumonia (PCP) Causative organism is an airborne fungus Can be a reactivated dormant infection
31
Clinical presentation of PCP
Nonspecific resp symptoms: fever, cough, SOB May result in severe hypoxemia CXR shows diffuse or perihilar infiltrates8
32
How is PCP diagnosed?
Via exam of sputum sample Lab: elevated LDH (serum lactate dehydrogenase) in 95%
33
First line treatment for PCP
Bactrim DS (trimethoprim-sulfamethoxazole) and supportive care
34
What is the most common intracranial lesion in HIV patients?
Encephalitis caused by toxoplasmosis Usually a reactivated infection
35
What is the causative agent of toxoplasmosis?
Toxoplasma gondii
36
How is toxoplasmosis acquired?
Via ingestion - cat feces, contaminated raw food, or utensils Immunocompetent patients rarely have symptoms
37
Clinical presentation of toxoplasmosis in HIV patients
HA Focal neurological deficits Seizures AMS Can also cause retinitis, pneumonitis
38
How is Toxoplasmosis diagnosed?
Multiple contrast-enhancing lesions on brain CT or MRI Seropositive for toxoplasmosis
39
What is the clinical presentation of Mycobacterium avium complex?
May cause pulmonary infection in immunocompetent patients Causes systemic disease in advanced HIV - night sweats, weight loss, abdominal pain, diarrhea, anemia Causative agent: Mycobacterium avium or Mycobacterium intracellulare
40
What is the mode of transmission for MAC?
Bacteria found in soil and dust —> inhaled or ingested —> systemic infection in HIV pt
41
How is MAC diagnosed?
Sputum acid fast bacillus (AFB) stain positive Positive sputum cultures Positive blood cultures
42
Most common retinal infection in AIDS patients
CMV retinitis Caused by Cytomegalovirus, a herpes virus common in the general population
43
How is CMV transmitted?
Blood Sexually Perinatally It’s super duper common in the general pop
44
Clinical presentation of CMV retinitis
Pt complains of visual disturbances Characterized by perivascular hemorrhages, white fluffy exudates on fundoscopic exam If left untreated, can lead to blindness
45
What is the important thing to know about candidiasis in HIV patients?
The more invasive the candida, the lower the associated CD4 count Esophageal candidiasis, thrush, and recurrent vaginal candidiasis should all be red flags
46
What is Kaposi’s sarcoma?
Vascular neoplasm Classic Kaposi’s: found in elderly Eastern European and mediterranean males AIDS-related Kaposi’s: most frequent in homosexual men - lesions generally multifocal and widespread, with associated LAD May occur at any CD4 T cell count
47
Who should get screened for HIV?
Everyone 13-64 with voluntary opt-out Anyone in whom TB treatment is being initiated At each presentation for an STD Annually in patients at risk - more often for MSM Pregnant women
48
What things should trigger diagnostic HIV testing?
Opportunistic infections (ie fungal) and TB Sx consistent with established HIV: Weight loss, recurrent fever, night sweats, extreme tiredness, LAD, diarrhea > 1 week, sores of mouth/anus/genitals, PNA, unexplained neuro Sx Sx consistent with acute HIV
49
What tests do we use for HIV screening and diagnostic testing?
HIV antibody test - only detects HIV 4-12 weeks after infection, once patient seroconverts Rapid HIV tests (saliva or blood) - a (+) requires confirmation Combination HIV Ab and antigen testing
50
What will happen if you suspect acute HIV and you only test for antibody?
You’ll miss it Then they’ll go out and infect someone else and you’ll feel terrible
51
Can minors get HIV tests in AZ without parents knowing?
They can access STD testing without parental consent but HIV is not explicitly included
52
__________ is recommended for all with HIV, including those with acute/early infection
Antiretroviral therapy (ART) Clinical trial data suggest that individuals treated during early infection experience immunologic and virologic benefits
53
________ testing should be performed prior to initiation of ART
Genotypic drug resistance testing - it will help guide selection of ART
54
What is the treatment goal in HIV?
Suppress plasma HIV-1 RNA levels to undetectable AND prevent transmission
55
Where should you refer patients?
HIVAZ.ORG
56
When should you be concerned about possible HIV exposure?
Unprotected sex with someone who tells you they have HIV (or you think may have HIV) Condom broke or fell off during sex Rape or sexual assault Work-related exposure to HIV (ie needle stick) Sharing needles to inject any type of drug
57
If utilizing post exposure prophylaxis, it must be started within _____
72 hours of exposure
58
What is PrEP?
Pre-Exposure Prophylaxis Daily med (Truvada) that may be prescribed by HIV specialist or PCP to prevent contraction of HIV for those at risk
59
Normal CD4 count is _________
500-1400
60
You may see ____ and _____ at any CD4 count
Thrush Kaposi’s sarcoma
61
Once an HIV patient’s CD4 count is <400, you should...
Start Bactrim DS prophylaxis for PCP
62
Once a patient’s CD4 is <100, you should
Ensure they are on Bactrim DS prophylaxis for toxoplasma gondii (if they aren’t on it already for PCP - WHICH THEY SHOULD BE)
63
Once a patient’s CD4 is <50, you should...
Start Azithromycin prophylaxis for disseminated MAC
64
What is the causative organism for Syphilis?
Treponema pallidum
65
Syphilis is transmitted through...
Direct contact with infected lesion (usually genitals, anus, lips, mouth) Bacteria enter the skin and in 10-90 days create a painless chancre
66
What are the different stages of syphilis?
``` Primary Secondary Latent Tertiary Neurosyphilis Ocular Syphilis ```
67
Clinical presentation of Primary Syphilis
PAINLESS chancre appears at location syphilis entered the body Persists for 4-6 weeks then resolves
68
Clinical presentation of secondary syphilis
Many possible manifestations Rash (very common) Condyloma lata Mucous patches Pt may also have systemic Sx such as malaise, LAD Generally persists 2-6 weeks then enters latency
69
What is the 2˚ syphilis rash like?
Usually non-pruritic Characteristically on palms and soles of feet Not contagious
70
What is condyloma lata?
Moist, heaped, wart-like papules Occur in intertriginous areas (ie gluteal folds, perineum, perianal area) Highly contagious
71
What are the mucous patches associated with secondary syphilis?
Painless flat patches involving the oral cavity, pharynx, genitals - not painful (pt might not be aware of them) Occur in 6-30% of cases Highly infectious
72
Clinical presentation of latent syphilis
Asymptomatic (duh) No longer sexually transmittable May persist for years
73
Clinical presentation of tertiary syphilis
Most do not develop tertiary syphilis, but is does in ~15% of those who are UNTREATED Can appear 10-30 years after initial infection Can damage heart, blood vessels, brain, and nervous system
74
What is neurosyphilis?
Can occur at any stage of the disease Paralysis, difficulty with coordination, dementia
75
What is ocular syphilis?
Changes in vision, blindness associated with syphilis Can occur at any stage
76
How is syphilis diagnosed?
Bacteria (from chancre) visible on microscopy (not commonly used) Serology • Rapid Plasma Reagan (RPR) or Venereal Disease Research Lab (VDRL) test - both are antibody tests • Titer indicates disease activity (low 1:4, high 1:128) • Low titer may be a false positive from another illness • Confirm RPR with treponemal antibody test: FTA-ABS
77
What additional diagnostic studies do you need if neurosyphilis or ocular syphilis are suspected?
LP with VDRL on spinal fluid to confirm Refer to neurologist
78
What is the standard treatment for syphilis?
Benzathine pen G 2.4mu IM x 1 Additional doses required if syphilis present for >1 year (3 doses at 1 week intervals)
79
Syphilis treatment for PCN allergic patients
Oral Azithromycin or oral doxycycline Exception: treat HIV patients and pregnant patients with PCN (REFER)
80
What do you need to do after treating your syphilic patient?
Check RPR titer to confirm treatment success at 3, 6, 12, and 24 months (4 fold decrease = adequate response)
81
Why do we want to treat pregnant mothers for syphilis with pen G regardless of their allergy?
PREVENT CONGENITAL SYPHILIS
82
What is congenital syphilis?
Untreated syphilis during pregnancy esp in early syphilis can lead to stillbirth, neonatal death, or infant disorders such as deafness, neuro impairment and bone deformities
83
How do we prevent congenital syphilis?
Screen all pregnant women at 1st prenatal visit If risk is high, screen and obtain sexual history again at 28 was and at delivery If pregnant pt is PCN allergic, consider desensitization with oral PCN Monitor serology closely to confirm successful treatment
84
What is the causative organism for Lymphogranuloma venereum (LGV)?
Chlamydia trachomatis
85
LGV is rare in the US but when diagnosed it usually occurs in ...
MSM
86
Clinical presentation fo Lymphogranuloma venereum
Causes systemic infection Unilateral inguinal bubo Self-limited genital ulcer or papule at site of inoculation Anal discharge and rectal bleeding
87
What do you do to diagnose LGV?
R/o syphilis If LGV suspected, contact county health dept May be able to do genital, rectal, or lymph node specimen swab for Chlamydia
88
Treatment for Lymphogranuloma venereum
Erythromycin or Doxycycline
89
Causative organism for chancroid
Haemophilus ducreyi
90
Clinical presentation of chancroid
Painful TENDER genital ulcer Lesion produces foul-smelling discharge (it’s contagious) Inguinal amenities (buboes) If suspected: • R/o syphilis • contact county health department - requires special culture
91
Treatment for chancroid
Azithromycin, ceftriaxone, or ciprofloxacin

Clin Med III Unit 2 (6 decks)

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