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4th Year > GUM > Flashcards

GUM Flashcards

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1
Q

HSV 1 and 2 causing anogenital/oral infections

A

HSV 1 is most commonly associated with oral infection (coldsores), and is now the most common cause of anogenital infections in the UK

HSV 2 can cause oral but is mostly associated with anogenital infections, it is the most common cause of recurrent anogenital infections.

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2
Q

R/Fs for HSV transmission?

A

Multiple sexual partners

Prev STI

Unprotected sexual encounters

Multiple sexual partners

Early age of sexual first contact

MSM

Female gender

HIV infection

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3
Q

Primary infection presentation of HSV?

A

The first time the virus presents, may be asymptomatic

Febrile flu symptoms (5-7 days)

Tingling neuropathic pain in buttocks/genital area

Painful blisters and ulcers

Tender lymph nodes

Local oedema

Dysuria

Vaginal/urethral discharge

Can last up to four weeks.

Usually bilateral lesions

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4
Q

Presentation of recurrent HSV infection?

A

Usually unilateral

Last about 10 days, usually mild and may be self-limiting

Can be asymptomatic shedding (infective at this point)

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5
Q

Tests for HSV?

A

Viral culture
Swab & PCR

Serology (however take 12 weeks after primary infection)

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6
Q

HSV infection management?

A

Supportive:

  • Saline bathing
  • Oral analgesics
  • Lidocaine gel/cream
  • Pee while in a bath

Antiretroviral:
- Topicals not very good and not recommended

Primary: Acyclovir (400mg TDS) 5d
Recurrence: Acyclovir 800mg TDS 2d
Suppressive: Acyclovir 400mg BD PO

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7
Q

Types of HPV?

A

120 HPV types, 30 cause anogenital infection

16 & 18 are oncogenic (cervical cancer risk)

Non oncogenic (warts) 6 & 11

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8
Q

Difference in keratinised and non-keratinised genital warts?

A

Non-keratinised arise from areas of mucosa i.e. urethra, anus and vagina

Keratinised arise from keratinised epithelium (e.g. coronal sulcus (bit just below foreskin, labia)

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9
Q

Management of warts?

A

Should be referred to sexual health clinic always, as can more accurately test for other STIs, and may be able to contact trace.

All treat growth, not HPV infection:

Podophyllotoxin self application:

  • Non-keratinised warts
  • NO IN PREGNANCY

Imiquimod:

  • Kertinised/non-keratinised
  • NO PREGNANCY
  • Expensive
  • Hyper/hypopigmentation

Physical ablation (Hyfrecation, cryo and excision)
- safe in pregnancy
-

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10
Q

R/Fs for HPV infection

A

Smoking

Multiple sexual partners

Early loss of virginity

Other STIs

Anoreceptive intercourse

Manual sexual practices (fisting, fingering)

Immunosuppression

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11
Q

Viral STIs?

A 
HPV
HSV
HIV
Molluscum contagiosum
EBV 
Hepatitis (A-E)
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12
Q

What cells does HIV bind to?

A

CD4 positive cells, this includes t-helper cells, macrophages, monocytes and neural cells.

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13
Q

What specific marker predicts risk of progression to AIDS in HIV+ individuals?

A

Viral load.

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14
Q

Stages of HIV infection?

A

Seroconversion illness

  • initial presentation, 4-6 weeks after infection
  • Triad of Rash, Fever and pharyngitis
  • Increased inflammatory markers

Asymptomatic
- Can have lymphadenopathy

Symptomatic

  • Fever, diarrhoea, weight loss, night sweats
  • Opportunistic infections

AIDS:
- severe immunodeficiency

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15
Q

Investigations?

A

Detection of anti-HIV antibodies (ELISA) - diagnostic

Viral load assessment

FBC: may see anaemia, thrombocytopaenia, lymphocytopaenia, reduced CD4 cell count.

Raised ESR,

Assess for other infections and other STIs

CXR & cervical smear

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16
Q

Three satges of HIV infection and their CD4 count?

A

Early CD4 > 500

Symptomatic CD4 200-499

Complications 50-199

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17
Q

Some complications typically associated with a CD4 count 50-200?

A

Oral & oesophageal candidiasis

Cervical dysplasia (cervix)

PCP pneumonia

Kaposi sarcoma/lymphoma

Mycobacteria avium intercellulare

Histoplasmosis

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18
Q

What infection can seriously complicate treatment of AIDS?

A

Hepatitis

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19
Q

Late stage complications in HIV?

A

Cervical cancer

CMV retinitis

Disseminated mycobacterium avium intercellulare

Cerebral toxoplasmosis

Primary brain lymphoma

Multifocal leuko-encephalopathy and dementia

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20
Q

General management of HIV+ patients?

A

Make early diagnosis

ART (anti-retroviral Therapy)

Prophylaxis if CD4 < 200

Reduce transmission

prevent and treat long term complications

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21
Q

General categories of ART drugs in HIV?

A

Entry inhibitors

NRTIs (nucleoside reverse transcriptase inhibitors)

Non-NRTIs

Protease inhibitors

Integrase inhibitors

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22
Q

Prevention for HIV?

A

Behavioural:

  • Condoms
  • Abstinence
  • Sero-sorting

Medical:

  • Circumcision
  • Treatment as prevention
  • Prevention of mother to child transmission
  • PEP/PEPSE (post exposure prophylaxis)
  • PREP (pre exposure prophylaxis)
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23
Q

How effective is treatment as prevention?

A

Pretty effective about 96% has no transmission

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24
Q

In occupational needle stick injury what factors may make you consider PEP?

A

Deep injury
Visible blood on device
Injury with needle been in artery or vein
Terminal HIV related illness/ high viral load
Large volume blood transferred

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25
Time window for PEP?
72 hours
26
6 point plan for STIs?
Make diagnosis Treat infection Exclude other infections Screen contacts Test of cure Patient education
27
HIV Risk Factors?
``` MSM IVDU Large HIV infection prevalence in area where they are from Been paid/paid for sex Condomless sex Partner positive (Illicit drugs) ```
28
Causative organism for gonorrhoea?
Neisseria gonorrhoea
29
Complications of gonorrhoea infection?
Complications worse in women Dissemination PID (infertility) Conjunctivitis Perihepatitis Bartholin's abscess
30
Diagnosis of gonorrhoea?
Nucleic acid (urine/swab) Culture Microscopy (only really if urethritis)
31
Areas gonorrhoea and chlamydia may infect?
Rectum Urethra Pharyngeal Endocervical (in women)
32
Genital gonorrhoea presentation?
- discharge (80% in men) - dysuria (can be bad) - proctitis Women can be asymptomatic (50-70%), small number have pelvic pain.
33
Management of gonorrhoea?
6 point plan Diagnose: NAAT (nucleic acid) Treat: check local sensitivities, however: ceftriaxone 500mg IM stat plus azithromycin 1 g orally stat. Screen for others (60% will have) Contact tracing TOC (>72 hours culture, 2 weeks NAAT) Educate (condoms etc.)
34
Causative organism for chlamydia?
Chlamydia trachomatis
35
Chlamydia and Gonorrhoea gram positive or negative?
Negative
36
Chlamydia symptoms?
Can often be asymptomatic Female: - Discharge - Dysuria - Vague lower abdo pain - Fever - Deep dyspareunia Men: Classically urethritis with dysuria and urethral discharge or unilateral testicular pain & swelling (epididymo-orchitis) Can also be rectal, pharyngeal and present as reactive arthritis.
37
Chlamydia signs?
Female: - inflamed cervix - discharge - abdo tenderness - adnexal tenderness (uterine pain) - cervical excitation Male: - Epididymal tenderness. - Mucoid or mucopurulent discharge. - Perineal fullness due to prostatitis.
38
Testing for chlamydia?
NAATS tests First catch urine for men Vulvovaginal swab for women
39
Treatment for chlamydia?
1g STAT azithromycin Doxy 100mg BD for 7 days
40
What is mycoplasma genitalium?
Very low grade bacterium causing similar problems to chlamydia, picked up on NAATS, hard to culture.
41
Causative organism of syphilis?
Treponema Pallidum
42
Complications of chlamydia?
``` Endometritis Salpingitis PID Infertility (need a few infections) Ectopic preg Fitz-curtis (abdominal pain - perihepatitis) Reactive arthritis ```
43
What is NSU?
non-gonococcal, non-chlamydial urethritis Normally due to Mycoplasma
44
Risks of chlamydia in pregnancy?
Transmission to the newborn: - eyes - chlamydial pneumonitis
45
Symptoms of chlamydial pneumonitis in the newborn?
Staccato cough Failure to thrive Tachypnoea
46
Disseminated gonococcal infection presentation?
Rare Females Fever, rash Arthritis, tendonitis
47
Genital lump Ddx?
Normal anatomy Sebaceous cyst, or other benign cause STIs: - Molluscum - Warts - Papular or nodular phase: Syphilis, LGV, Scabies, Herpes)
48
Procto-colitis causative organisms? When does this occur? What does it cause?
Generally in MSM populations, through oro-anal contact Cause bowel symptoms Giardia, shigella, Entamoeba
49
What is TV (simply)?
TV is an STI caused by Trichomonas vaginalis (protozoa)
50
What causes syphilis?
Treponema pallidum
51
What is cervical inra-epithelial neoplasia (CIN)?
Premalignant squamous cell lesion
52
Three settings in which Molluscum contagiosum occur?
Routine physical contact - Most common (90% in GPs) - Children <15yrs - Face, Neck Trunk or limbs STI - young adults Immunocompromised - Serious infection, often on face and neck
53
What is LGV?
Lymphogranuloma venereum: - complication of certain (tropical) types of chlamydial infection where the infection spreads to the inguinal lymph nodes.
54
Features of Molluscum lesions?
- 1-30 lesions in clusters - Occassionally itch/discomfort - Projecting, pearly, umbilicated, round lesions with erethematous edge
55
Management of Molluscum?
Warn about formites and autoinoculation Often no treatment, however can podophylotoxin, imiquimod, cryo it.
56
How is molluscum diagnosis made?
Clinically
57
Progression of herpes lesions?
1. Erythema and (possibly) swelling of skin 2. Vesicles and pustules 3. Ulcers 4. Scabbing 5. Healed skin
58
Management of HSV in pregnancy?
1st episode in 3rd trimester: - Oral Acyclovir 400mg TDS until delivery - C-section If acquired before pregnancy or in 1st/2nd trimester then can deliver vaginally, considering prophylaxis from 36weeks: acyclovir 400mg TDS
59
HSV complications in pregnancy?
Disease in skin/eye/mouth: - with treatment <2% neuro-ocular morbidity Disease in CNS causing encephalitis: - 6% mortality, 70% neuro morbidity Disseminated: - Mortality 30% with treatment, neuro morbidity 17%
60
Stages of syphilis?
Primary: - painless ulcer (chancre), lymphadenopathy, serology can be negative. Secondary: - Mucosal lesions - Rash - Arthralgia - Lymphadenopathy - Meningitis - Iritis - CN palsy Latent: - Asymptomatic, detectable on serology Tertiary: (after 4 years) - CVS syphilis: Aortoi aneurysm, Aortic regurg, - Neurosyphilis
61
How do you diagnose syphilis?
Microscopy (in primary) Antigen assay (EIAs) (IgM, in acute infection, not very accurate) Non-specific VDRL/RPR Specific: TPPA/TPHA Specific remains positive for life Non-specific is useful for monitoring the disease activity, if negative then not infectious and: - Very early infection, or; - Old infection (treated)
62
Tx for syphilis?
Penicillin, IM preferred if allergic then doxy
63
Tropical STIs?
Chancroid - haemophilus ducreyi - Soft ulcer unlike syphilis LGV - Chalydial subtypes Donovanosis - Bacterial disease caused by Klebsiella granulomatis
64
Vaginal discharge Ddx?
Infective STIs: - TV - HSV - Gonorrhoea - Chlamydia Infective non-STI: - BV - vulvovaginal candiasis From the vagina: - Vaginitis - malignancy From cervix: - Ectopy - Polyp - Malignancy From endometrium: - Malignancy - Polyp
65
What is BV?
Bacterial vaginosis: - Imbalance in normal vagina flora - not considered to be an STI Overgrowth of anaerobic bacteria with a pH rise
66
BV R/Fs?
- Smoking - Vaginal Douching ``` UPSI Change of partner Receptive cunnilingus Presence of STI WSW Increased lifetime partners ```
67
Presentation of BV?
50% fishy discharge 50% asymptomatic Not assoc. w/ soreness, itching or irritation
68
Complications of BV in pregnancy?
Late miscarriage Preterm PROM Post partum endometriosis Routine screening not recommended
69
Diagnosis of BV?
Ison Hay criteria Gram stained microscopy: - Loss of lactobacilli - Mixed increased growth
70
Tx for BV?
Tx if: - risk of ascending infection - Symptomatic women Oral metronidazole 400mg BD 5d For recurrent BV: - Vaginal metronidazole gel twice a week
71
Most common causative organism of vulvovaginal candidiasis?
Candida albicans
72
Symptoms in Vulvovaginal Candidiasis?
``` Vaginal itch Vaginal discharge Vulval soreness External dysuria Superficial dyspareunia ```
73
Diagnosis of thrush?
Microscopy Culture
74
Tx for thrush?
Antifungal topical imidazole, e.g. clotrimazole 500mg pessary stat +/- cream OR Oral fluconazole 150mg stat
75
Treatment of recurrent candidiasis?
Speciated fungal culture (to identify species) Vulval care emolients and soap substitute medication: - Fluconazole 150mg every 72hrs 3x (eradication) - prophylactic fluconazole weekly for 6/52
76
TV common symptoms?
Females: - Vaginal discharge - Vaginal itch - Dysuria - offensive odour Males: - Urethral discharge - Dysuria 10-50% asymptomatic (both sexes)
77
Complications of TV in pregnancy? What should you do?
Preterm Low birth weight Post partum sepsis Treatment doesn't improve complication risk, and is risky itself.
78
TV diagnosis?
Microscopy Culture NAAT
79
Management of TV?
6 point plan Metronidazole 500mg bd 5d/ 2g stat Screen and contact trace (4/52)
80
What is epididymo-orchitis (epididymitis) Presentation?
Inflammation of the epididymides and/or testicular inflammation triggered by an infectious agent Usually unilateral (but may be bilateral) - scrotal swelling, erythema and pain. O/E: testicular discomfort, tender swollen epididymis
81
Cause of epididymitis?
Gonorrhoea, chlamydia E coli, enterobacteriaceae (>35, ?structural abnormality) M. tuberculosis (rare) - chronic epididymitis
82
Epididymitis Tx?
Doxy 100mg bd 14d
83
What is pediculosis?
Lice there are two types, genital and body (corporis & capitus)
84
Stages of genital lice?
The nit The nymph The adult
85
Clinical features of pediculosis?
Infests thighs, perineum, abdo, axilla also eyebrows and lashes Symptoms: - intense irritation & movement noticed - blue macules, black spots, lice & nits
86
Pediculosis management?
6 step plan Medication: - Malathion 0.5% - In pregnancy: Permethrin 1% All body hair treated and left for 12 hours, then repeated 1 week later Wash clothes and bed linen at 50 Full STI screen
87
Presentation of scabies?
Symptoms result from a hypersensitivity reaction Pruritis (itch - worse at night) Eczematous looking lesions Burrows (fine grey channels) Indurated (hard) nodules
88
How is scabies transmitted?
Prolonged skin-skin contact Formite spread Sexually transmitted
89
What is norweigan scabies?
Highly contagious form, found in elderly and immunocompromised, kyperkeratotic lesions.
90
Scabies management?
Permethrin 5% Malathion 0.5% lotion Apply to body from neck down and leave for 12 hours Wash linen and clothes at 50 Treat partner and household contacts of 8 weeks
91
Why worry about asymptomatic STIs in MSM?
increased likelihood of HIV transmission
92
LGV proctolitis problems?
Proctocolitis with scarring adhesions and fistula formation Histologically indistinguishable from IBD
93
Hepatitis types associated with MSM?
Hep A - outbreaks in MSM, but prevalence similar to population. Not routinely vaccinated for. Hep B - All MSM should be vaccinated Hep C - Current MSM outbreak, associated with traumatic sexual practices & cocaine, majority HIV+
94
Chemsex drugs?
MDMA, Ketamine, Mephedrone, Crystal meth and GHB/GBL.
95
2 situations where confidentiality can be breeched in GUM?
Beastiality Court order
96
Non-STI causes of genital ulceration?
Trauma Apthosis Erythema multiforme Behcets disease
97
STIs that cause genital ulceration?
``` Herpes Syphilis LGV Chancroid Donovanosis ```
98
STIs with vaccines?
Hep A/B, HPV
99
What other conditions can give rise to a false positive syphilis test?
Lupus/autoimmune Acute febrile illness Autoimmune
100
Clinical features of congenital syphilis?
Hutchinsons teeth Keratitis Deafness
101
Drugs in PREP?
tenofovir and emtricitabine, tablet is truvada One pill a day
102
What treatment for warts is unsuitable for people with dark skin?
Cryo
103
What determines your choice of treatment for warts?
Site Keratinised/non-keratinised Number Pregnant or not Patient choice Pigment of skin

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