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Flashcards in Sexual Health Deck (17):
1

What are the indications for HIV testing?

Respiratory: TB, PCP, Bacterial pneumonia, aspergillosis

Neurology: Cerebral toxoplasmosis, primary cerebral lymphoma, cryptococcal meningitis, progressive multifocal leucoencphalopathy, aseptic meningitis, Guillain-Barré syndrome, transverse myelitis, dementia, peripheral neuropathy, SOL, cerebral abscess

Dermatology: Kaposi's sarcoma, severe seborrhoeic dermatitis, severe psoriasis, multidermatomal or recurrent herpes zoster

Gastroenterology: persistent cryptosporidiosis, oral candidiasis, oral hairy leukoplakia, chronic diarrhoea, weight loss, hep B/C

Oncology: non-hodgkin's lymphoma, anal cancer, lung cancer, semi normal, head and neck cancer, Hodgkin's lymphoma, castlemans disease

Gynaecology: CIN or Cervical cancer

Haematology: thrombocytopenia, neutropenia, lymphopenia

Ophthalmology: cytomegalovirus retinitis, unexplained retinopathy

ENT: lymphadenopathy, chronic parotitis

Other: PUO, STI,



2

What are the types of HIV test?

POCT: window period of 6-12wks, fingerprint test that allows results within minutes.

Antibody/antigen test: blood test with window period of 4-6wks, results in 1 wk

3

What are some of the high HIV prevalence countries?

Sub-Saharan Africa, South America, South East Asia.

4

Describe Lymphogranuloma Venereum (LGV), its symptoms, tests, and treatment.

Due to infection with chlamydia trachomatis that infect mononuclear phagocytes. Largely occurs in MSM presenting with proctitis.

Symptoms: usually present with painless papule or shallow ulcer, tender inguinal lymphadenopathy. Secondary disease progresses to systemic upset (fever, headache, nausea, lethargy) and gross swelling of inguinal lymph nodes

Tests: full STI screening, PCR for definitive diagnosis

Treatment: Doxycycline 100mg BD for 21days
-buboes may be drained percutaneously to relieve symptoms.

5

Describe Syphillis, its symptoms, tests, and management.

A sexually transmitted disease caused by the spirochaete Treponema Pallidum. Higher risk in MSM.

Primary features: Chancre (painless ulcerations the site of sexual contact, entry point for spirochaete), local non-tender lymphadenopathy.

Secondary features: 6-10wks after primary infection, scaly rash on trunk, palm and soles, malaise, lymphadenopathy, fevers, tonsillitis, buccal 'snail track' ulcers, condylomata lata (flat papules around/beyond genitals)

Tertiary features: follows after 2yrs of latency. Gummas (granulomatous lesions of the skin and bones), ascending aortic aneurysm, general paresis of insane (dementia psychoses), tabes dorsalis (ataxia, numb legs chest and bridge of nose, lighting pains, argyll-Robertson pupil) neurosyphillis.

Congenital features: blunted upper incisors teeth, Rhagades (linear scars at angle of mouth) keratitis, saddle nose, Saber shins, deafness. Hutchinsons triad = keratitis, deafness and pointed teeth.

Tests: Treponeme specific e.g. EIA (+ve 12-21days), TPPA (+ve 21-28days). Non-treponemal tests e.g. RPR (Tests for cardiolipin antibodies +ve after 28days)

Management:
-Benzylpenicllin + probenecid, or doxycycline
-beware Jarisch-herxheimer reaction is sometimes seen following treatment, fever rash, tachycardia after first does of antiobiotics it is thought to be due to the release of endotoxins following bacterial, consider steroids but do not stop treatment.

6

Describe Gonorrhoea, its symptoms, and management.

An sexually transmitted disease that can lead to urethral structure and infertility.

Symptoms:
-Men resent with urethral pus +/- dysuria, tenesmus, proctitis +/- discharge PR e.g. If homosexual
-Women often asymptomatic, or present with van giant discharge, dysuria, proctitis.

Management:
-encourage safe sex and trace contacts
-ceftriaxone + management for chlamydia (azithromycin stat or doxycycline for 7 days)

7

Describe Chlamydia, It's symptoms, investigations, and management

Chlamydia is a small intracellular gram-negative bacteria that can cause, ocular infection (trachoma), genitourinary infection, and Lymphogranuloma Venereum). Most commonly diagnosed bacterial sexually transmitted STI in UK.

Symptoms:
-Female include vaginal discharge, dysuria, lower abdominal pain, fever, intermenstrual or postcoital bleeding, dyspareunia, cervical excitation.
-Male include urethritis, dysuria, urethral discharge, epididymis-orchitis presenting at unilateral testicular pain +/- swelling. Fever.

Investigations: Urine sample and Nucleic acid amplification test (NAAT)

Management:
-Doxycycline 100mg BD for 7days (CI in pregnancy)
-Single dose of 1g of azithromycin
-contact tracing
-test for other STIs

8

What are the main groups of Anti-retrovirals and give some examples.

Nucleoside Reverse Transcriptase Inhibitors (NRTIs):
-Zidovudine (AZT) first HIV drug. SEs include anaemia, low WCC, GI disturbance, fever, rash, myalgia, stop if deranged LFT, heptatomegaly, lactic acidosis.
-Didanosine SEs pancreatitis, Hyperuricaemia, GI disturbance, Liver failure, optic nerve changes.
-Lamivudane (3TC) is well tolerated. Similar but less common SEs as AZT.
-Emtricitabine (FTC) is like Lamivudane but active against Hep B.
-Stavudine (d4T) stop if neuropathy or deranged liver function can be used first line instead of AZT reduced anaemia
-tenofavir SEs as AZT
-Abacavir (ABC) qSE hepatitis, lactic acidosis, hypersensitivity syndrome, rash, fever, vomiting.

Protease Inhibitors:
-Saquinavir SEs oral ulcers paraesthesiae, myalgia, beaches, dizziness, pruritis, rash, pancreatitis.

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs):
-Nevirapine (NVP) SEs Steven-johnsons, toxic epidermal necrolysis, hepatitis
-efavirenz (EFV) SEs rash, insomnia, dizziness, avoid in pregnancy preferred if concurrent TB
-Rilpivirine new

Intergrase Strand Transfer Inhibitors (InSTIs):
-Raltegravr, elvitegravir, dolutegravir, SEs GI upset, insomnia

Once-a-day tablets (combination regimens):
-Atripla, Eviplera, Stribild, Kivexa/Epzicom

9

What are some common AIDs defining illnesses?

-Candidiasis (Oral or Oeosphageal)
-Cervical carcinoma (invasive)
-Candidiasis of bronchi, trachea or lungs.
-Lymphoma
-Coccidioidomycosis, disseminated or extrapulmonary.
-Mycobacterium avium complex (MAC) or M. kansasii, disseminated or extrapulmonary.
-Cryptococcosis, extrapulmonary.
-Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary).
-Cryptosporidiosis, chronic intestinal (>1 month's duration).
-Cytomegalovirus (CMV) disease (other than liver, spleen or nodes).
-Pneumocystis jirovecii pneumonia.
-CMV retinitis (with loss of vision).
-Pneumonia, recurrent or bacterial.
-Encephalopathy e.g. CMV, Toxoplasmosis
-Progressive multifocal leukoencephalopathy.
-Herpes simplex: chronic ulcer(s) (>1 month's duration); or bronchitis, pneumonitis or oesophagitis.
-Salmonella septicaemia, recurrent.
-Histoplasmosis, disseminated or extrapulmonary.
-Toxoplasmosis of brain.
-Wasting syndrome due to HIV.
-Kaposi's sarcoma.

10

Describe Progressive multifocal Leukoencephalopathy (PML), its symptoms and investigations

Widespread demyelination due to infection of olifodendrocytes by JC virus (a polyoma DNA virus).

Symptoms: Subacute onset, behavioural changes, speech/motor/visual impairment.

Investigations: CT shows Single or mutiple brain lesions, no mass effect usually non-enhancing. MRI is better high-signal demyelinating White matter lesions are seen.

11

What are the possible causes of a pancytopenia in a patient with HIV.

Infiltrative: TB, Histoplasmosis, Cryptococcus, Pneumocystosis, Non-Hodgkin lymphoma, myeloma

Myelosuppresion: Usually medication related e.g. Dapsone for PCP prophylaxis, Nucleoside reverse transcriptase inhibitors particularly AZT, TB medication such as isoniazid, rifabutin, rifampicin. Anti-fungal e.g. Amphotericin B

Colony stimulating factors may have a role in treatment, bone marrow biopsy and blood culture can help differentiate.

12

Describe Trichomonas Vaginitis, its features, and management.

Common cause of vaginal discharge, mostly sexually transmitted caused by trichomonas vaginalis.

Features: Frothy, green-yellow, foul-smelling discharge, vaginal soreness, dyspareunia, post-coital bleeding.

Management:
-Metronidazole for both partners.

13

What are the differentials for a genital ulcer?

Primary syphilis chancre
Chancroid
Herpes
Lymphogranuloma venerum
Granuloma inguinale

14

Describe Chancroid, the features, and management.

Caused by H. Ducreyi

Features: Multiple, soft deep, tender ulcers with pus, painful fluctuant lymphadenopathy.

Management: Cotrimoxazole
Buboes should be drained,

15

What are the immunological changes seen in progressive HIV?

-Reduction in CD4 Count
-Increase in B2-microglobulin
-Decreased IL-2 production
-Polyclonal B-cell activation
-Decreased NK cell function
-Reduced delayed hypersensitivity responses

16

Describe Donovanosis, its features, and management.

Aka Granuloma inguinale, a bacterial disease caused by klebsiella granulomatis.

Features: small painless nodules occur around day 10-40, later the burst creating open fleshy oozing lesions. Then infections spread mutilating the infected tissue. (Beefy red ulcer) Rolled edge. Presence of Donovan bodies which are rod shaped val organisms seen in the cytoplasm of mononuclear phagocytes in tissue samples.

Management:
Azithroycin or doxycycline or erythromycin or co-trimoxazole for 3 weeks

17

What type of anaemia does Emtricitabine (Anti-retroviral) cause?

Red cell hypoplasia.