GUM Flashcards
What is HIV?
Human immunodeficiency virus
RNA retrovirus - HIV-1 most common
virus enters and destroys the CD4 T helper cells of the immune system
What is AIDS?
Acquired immunodeficiency syndrome which occurs as HIV infection progresses and the person becomes immunodeficient. leads to opportunistic infection
now mostly known as late-stage HIV
what is the progression of contracting HIV
initial flu-like illness occurs within few weeks of infection. infection is then asymptomatic until condition progresses to immunodeficiency
immunodeficient patients develop AIDS-defining illnesses and opportunistic infections - potentially years after initial infection
how is HIV transmitted?
- Unprotected anal, vaginal or oral sexual activity
- Mother to child at any stage of pregnancy, birth or breastfeeding - vertical transmission
- Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, eg through sharing needles, needle-stick injuries or blood splashed in an eye
NOT KISSING
AIDS-defining illnesses associated with end-stage HIV infection occur where the CD4 count has dropped to a level that allows for unusual opportunistic infection and malignancies. what are some examples?
- Kaposi’s sarcoma
- Pneumocystis jirovecii pneumonia (PCP)
- Cytomegalovirus infection
- Candidiasis (oesophageal or bronchial)
- Lymphomas
- Tuberculosis
how should be screened for HIV?
almost everyone who is admitted to hospital with an infectious disease, regardless of risk factors
risk factors = test
how long can it take for a person to develop antibodies to HIV for and what implications does this have for testing?
up to 3 months
HIV antibody tests can be negative for 3 months following exposure so a repeat test is necessary if initial test is negative within 3 months of exposure
how long can it take for a person to develop antibodies to HIV for and what implications does this have for testing?
up to 3 months
HIV antibody tests can be negative for 3 months following exposure so a repeat test is necessary if initial test is negative within 3 months of exposure
do patients require formal counselling or education before an HIV test?
no
document verbal consent
what is the screening test for HIV?
antibody testing
blood test - can be self test sample which then gets posted to lab
testing for p24 antigen can give a positive result earlier in the infection
PCR testing for HIV RNA levels tests directly for number of viral copies in blood giving viral load
how is HIV monitored?
CD4 count
Viral Load (VL)
what us the CD4 count?
number of CD4 cells in the blood
these cells are destroyed by the virus so the lower the count, the higher the risk of opportunistic infection
what is the normal range for CD4 count and what is considered to be end-stage HIV (AIDS)
500-1200 cells/mm3 normal range
under 200 cells/mm3 is considered end stage
what is the viral load?
number of copies of HIV RNA per ml of blood
‘undetectable’ refers to viral load below the labs recordable range - usually 50-100 copies/ml
how is HIV treated?
combination of antiretroviral therapy (ART)
ART offered to everyone with a diagnosis of HIV irrespective of viral load or CD4 count
BHIVA guidelines recommend starting regime of 2 NRTIs plus a third agent
what is the aim of HIV treatment?
achieve a normal CD4 count and undetectable viral load
when a patient has a normal CD4 and an undetectable viral load on ART, treat their physical health problems as you would an HIV negative patient
HAART stands for highly active anti-retrovirus therapy. what are some examples?
- Protease inhibitors (PIs)
- Integrase inhibitors (IIs)
- Nucleoside reverse transcriptase inhibitors (NRTIs)
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
- Entry inhibitors (EIs)
what are some additional managements for patients with HIV?
prophylactic co-trimoxazole given to pt with CD4 under 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP)
close monitoring of cardiovascular risk factors and blood lipids as increased risk of cardiovascular disease
yearly cervical smears for women as predisposes to HPV infection
vaccination up to date - influenza, pneumococcal, hepatitis A&B, tetanus, diptheria, poilio BUT AVOID live vaccines
what sexual health advice can you give to couples regarding HIV?
advise condoms and dams for oral sex even if both positive
if VL is undetectable, transmission through unprotected sex is unheard of but not impossible
partners should have regular HIV tests
what advice can you give couples trying to conceive?
where undetectable viral load, unprotected sex and pregnancy may be considered
also possible to conceive safely through techniques like sperm washing and IVF
when can a woman with HIV have a normal vaginal delivery?
viral load < 50 copies/ml
what is cs needed in women with HIV?
Considered in patients with >50 copies
All women with >400 copies/ml
what should be given during the CS if viral load is unknown or there are >10000 copies/ml?
IV zidovudine
an antiviral medication
what prophylaxis treatment is given to the baby and what is given at what viral loads?
- Low-risk babies (viral load is < 50 copies per ml) = zidovudine for 4 weeks
- High-risk babies (viral load is > 50 copies / ml) = zidovudine, lamivudine and nevirapine for 4 weeks
what is the deal with breastfeeding with HIV?
can be transmitted during breastfeeding even if mothers viral load is undetectable
breastfeeding NOT recommended
what is Post-exposure prophylaxis for HIV?
used after exposure to HIV to reduce risk of transmission
not 100% effective and must be commenced within 72 hours
sooner it is started = better outcome
risk assessment of the probability of developing HIV should be balanced against side effects of PEP
what does PEP involve?
combination of ART therapy
current regime is Truvada and Raltegravir for 28 days
when a person has been exposed to HIV when should they have a test?
immediately and a minimum of 3 moths after exposure to confirm negative status
what is PID?
inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix
what are the terms for inflammation of the endometrium, fallopian tubes, ovaries, connective tissue and peritoneal membrane?
Endometritis is inflammation of the endometrium
Salpingitis is inflammation of the fallopian tubes
Oophoritis is inflammation of the ovaries
Parametritis is inflammation of the parametrium, which is the connective tissue around the uterus
Peritonitis is inflammation of the peritoneal membrane
what are the 3 main STI causes of PID?
- Neisseria gonorrhoeae - more severe PID
- Chlamydia trachomatis
- Mycoplasma genitalium
What are some non PID caused by non-STIs?
- Gardnerella vaginalis (associated with bacterial vaginosis)
- Haemophilus influenzae (a bacteria often associated with respiratory infections)
- Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)
what are the risk factors for PID?
- Not using barrier contraception
- Multiple sexual partners
- Younger age
- Existing sexually transmitted infections
- Previous pelvic inflammatory disease
- Intrauterine device (e.g. copper coil)
how do women present wIth PID?
- Pelvic or lower abdominal pain
- Abnormal vaginal discharge
- Abnormal bleeding (intermenstrual or postcoital)
- Pain during sex (dyspareunia)
- Fever
- Dysuria
What may be seen on examination of a women with PID?
- Pelvic tenderness
- Cervical motion tenderness (cervical excitation)
- Inflamed cervix (cervicitis)
- Purulent discharge
Patients may have a fever and other signs of sepsis.
What investigations are done for PID?
- NAAT swabs for gonorrhoea and chlamydia
- NAAT swabs for Mycoplasma genitalium if available
- HIV test
- Syphilis test
A high vaginal swab for bacterial vaginosis, candidiasis and trichomoniasis
Microscope to look for pus cells on swabs from vagina or endocervix - absence of pus cells = exclude PID
pregnancy test in sexually active women with lower abdo pain
inflammatory markers
how is PID managed?
ref to GUM
antibiotics started empirically before swab results obtained to avoid delay and complications
abx will depend on local guideliens
eg
- A single dose of IM ceftriaxone 1g - to cover gonorrhoea
- Doxycycline 100mg BD for 14 days - to cover chlamydia and Mycoplasma genitalium
- Metronidazole 400mg BD for 14 days - to cover anaerobes such as Gardnerella vaginalis
how is PID managed?
ref to GUM
antibiotics started empirically before swab results obtained to avoid delay and complications
abx will depend on local guideliens
eg
- A single dose of IM ceftriaxone 1g - to cover gonorrhoea
- Doxycycline 100mg BD for 14 days - to cover chlamydia and Mycoplasma genitalium
- Metronidazole 400mg BD for 14 days - to cover anaerobes such as Gardnerella vaginalis
signs of sepsis - IV abx, admission
what are some complications fo PID?
- Sepsis
- Abscess
- Infertility
- Chronic pelvic pain
- Ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
What is Fitz-High-Curtis Syndrome?
inflammation and infection of the liver capsule (Glisson’s capsule) = adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
right sided upper quadrant pain - can be referred to right should tip as there is diaphragmatic irritation
laparoscopy to visualise and treat the adhesions
what is seen on microscopy for BV?
Clue cells on microscopy (epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis)
what is seen on examination of a patient with trichomoniasis?
strawberry cervix caused by inflammation relating to the trichomonas infection, tiny haemorrhages across surface of the cervix
pH will be raised, above 4.5, like BV
