Prevalence of HIV published in CDC 2008 (1999-2006)
- Adults aged 18-49 yrs: 5/1000
- Men 7/1000
- Women 2/1000
- Non Hispanic black population:2/100
- Men 2.6/100
- Womem 1.5/100
- Mexican American population; 3/1000
AIDS in prenatal setting
- Maternal antibody is passed to the baby
- with no prenatal treatment only 20-30% will be truly infected but 100% will have antibody positive
What study is good to diagnose AIDS in neonates?
- PCR for HIV DNA
- HIV RNA assays
What is the best time to test for neonates?
- 14-21 days
- 1-2 mo
- 4-6 mo
- confirm with antibody test at 12-18 mo
When do you suspect HIV in infants 1st year of life?
- Chronic Candidiasis
- Persistent lymphadenoopathy
What is evidence of severe immunesuppression in infants?
- <12 mo < 750 CD4 (<15 %)
- 1-5 yrs < 500 CD4 (< 15 %)
- >6 yrs < 200 CD4 (<15 %)
what is the most common opportunistic infection in HIV pts?
Pneumocystis jirovenci (carinii)
Xray finding in Pneumocytis jirovenci?
- minimal to diffususe interstitial disease
- Dx; finding cysts or trophozoites forms in BAL or induced sputum specimens
tx; TMP/SMX for 21 days (15-20mg/kg/d div q6h IV or PO)
if PaO2 less than 70 mmHg give Prednisone 1mg/kg PO BID and taper after 5 days.
Who needs prophylaxis for PCP?
- Any prior history of PCP
- birth to 4-6 weeks, HIV exposed; no prophylaxis
- 4-6 weeks to 4mo HIV inderterminate or +; prophylaxis
- 4-12 mo
- HIV indeterminate:prophylaxis
- HIV infection reasonably excluded; NO prophylaxis
- 1-5 yrs infected:CD4 + < 500 or <15 %
- 6yrs- adult HIV infected: CD4 + <200 or 15 %
What medicine you use for prophylaxis?
TMP/SMX three times a week or Dapsone 100mg one daily if cant tolerate TMP/SMX.
Check for G6PD deficiency if using dapsone
Tuberculosis and HIV
- PPD > 5mm induration= + PPD
- IF negative never rules out infection
- treat TB the same as in non HIV patients
- 4 DRUG REGIMEN (INH, RIF,PZA and etambutol or streptomycin)
Criteria for initation of antiretroviral therapy based on age of the Child
- < 12 mo TREAT ALL
- 1 to 5 years symptomatic or CD4 <25% and HIV RNA > 100,000
- 5 years: Symptomatic or CD4 < 350
- Consider for asymptomatic and CD4 > 350 and HIV RNA > 100,000
Most common side effects of antiretroviral therapy?
- Lamivudine 3TC- pancreatitis
- ddI- pancreatitis
- Abacavir- hypersensitivity reaction
- If any of these occur on therapy you must STOP
- and NEVER rechallenge patient; Causes DEATH
- Screen for HLA B*5701
- Nevirapine- rash
- Efavirenz- teratogenic...DO NOT use around pregnancy.
- Adolescent female must stop.
Bottom line in treatment of HIV to remember...
- throw out any answer that has ZDV(AZT)/D4T combined
- ddC in the answer
- except an infant born to a mother with HIV positive ZDV(AZT) unless the child is proven to be HIV-infected, then use the standard 3-drug therapy.
When to swith medicines in HIV?
- clinical progression
- DRUG TOXICITY
- laboratory markers of disease progression
- inability to suppress viral load to undetectable levels after 4-6mo of therapy
- return of detectsble viral load after being undetectable for a period of time
- decline in CD4 cells
when you need post exposure prophylaxis for HIV?
- If the fluid was bloddy and the skin integrity was compromised
- give ZDV,3TC +/- lopinavir/ritonavir for 4 weeks
Neisseria Ghonorrhoeae medium of growth
Thayer Martin or Chocolate agar
gonorrhoea features in Men
- 2-7 days after exposure develop discharge
- urethral irritation, erythema, dysuria
- assymptomatic infection in 5-60% and can persists if untreated
- local manisfestations can include epididymitis, prostatitis, periurethral abscess and penile lymphangitis
Gonorrhoea features in female;
- 1-14 days incbation period
- Endocervix is most frequent primary site
- assymptomatic infection is more common
- Endocervical discharge, dysuria,urinary frequency, mestrual irregularities
- Cervical erythema, friability, mucopurulent discharge on exam.
what is called the perihepatitis of ghonorreal infxn?
Disseminated Gonococcal Infection (DGI)?
- Leading cause of acute septic arthritis in young adults
- Menstruation may trigger dissemination
- Terminal complement deficiencies at increased risk.
- Urethral, Cervical, Rectal
- Ceftriaxone 125 mg IM x 1 dose
- allergic pts; spectinomycin
- Bacteremia, Arthritis, Disseminated
- Ceftriaxone 1g IV daysx 7-10 days or for 2-3 days followed by either;
- cefexime 400mg PO bid or
- cefpodoxime 400mg PO bid; to complete 7-10 days of therapy.
- Ceftriaxone 250mg IM x 1 dose
- doxycycline 100mg bid x 14 days
PID guidelines for Hospitalization?
- Surgical emergencies
- Suspected pelvic/tubo-ovarian abscess
- uncertain diagnosis
- N/V precluding oral therapy
- failure to respond to oral agents in 24-48 hrs
- chlamydia in 20-30% of men with GC
- Chlamydia causes 30-50% of non-gonoccocal urethritis
- Chlamydia causes 2/3 of epididymitis in young men
- Chlamydia in 30-60% of women co-infected with GC
- Chlamydia in 1/3 of cervix and/or fallopian tubes of laparoscopically verified PID
Diagnosis Chlamydia infections?
leukocyte urethral exudate with >4 PMN's on Gram Stain of urethral swab without organism is correlated with Chlamydial NGU
what is lymphogranuloma venerum?
- 3 days to 3 weeks of exposure
- a small painless vesicle or papule/ulcer appears at the site of initial contact (1/3 of patients only)
- 2-6 weeks after exposure;
- regional lymphadenopathy develops. Painful periadenitis occurs with matted nodes and inflamed overlying skin
- supuration occurs with fistula formation.
Describe 2nd and 3rd stage of lymphogranuloma venerum?
- 2nd stage;
- Fever, Chills, headache, myalgias,
- Can get aseptic meningitis, meningoencephalitis, conjunctivitis, hepatitis,arthritis
- 3rd stage;
- Chronic ulcerative/infiltrative local structures, fibrosis, strictures, impaired lymphatic flow with resulting genital elephantiasis
Describe Mucopurulent Cervicitis (chlamydia)
- yellow or creamy discharge from cervix
- gram stain + for WBCs
- Similar symptoms to GC
- > 10 PMN's/HPF on Gram stained smear of cervical mucous correlates with Chlamydia if GC is ruled out
PID- probably as common as a cause as GC
Diagnosis of Chlamydia?
- Detection of elementary bodies by giemsa or immunofluorecent staining with monoclonal antibody; most sensitive
- Chlamydiazyme and MicroTrak; rapid assays for detection of Chlamydia in clinical specimens
- Serologic 4 fold rise in antibody titer or IgM
Treatment of Chlamydia?
- Urethritis, Cervicitis, Conjunctivitis, Proctitis
- azithromycin 1 gm x 1 dose or doxycycline 100mg PO Bid x 7 days
- Pregnant women
- azithromycin 1 gm x 1 dose or amoxicillin 500 mg tid x 7 days
- Doxycycline 100 mg PO bid x 21 days
Mycoplasma infxns; Ureaplasma Urealyticum
- "fried egg" appearance on solid media
- found in 50% healthy adults
- non gonococccal urethritis; most likely the etiology
- Prostatitis; both found in symptomatic men
- PID; M. hominis in 10% of acute salpingitis.
how to treat mycoplasma hominis?
same as chlamydia
painless skin lesion; chancre?
- primary syphilis
- develops at site of inoculation on average 21 days after exposure
- incubation period can range from 10-90 days
- Skin lesions are painless.
- hematogenous dissemination of treponema pallidum
- fever, malaise, generalized lymphadenopathy
- rash- macular, papular, annular, or follicular
- alopecia, condylomata lata mucous patches
diagnosis of syphilis
- VDRL or RPR for initial screen
- confirm; FTA ABS (fluorescent treponemal ab absorbed)
- MHA-TP (microhemagglutination assay for ab to T pallidum
- Darkfield microscopy showing T pallidum from a clinical specimen.
Central Nervous system syphilis
- meningeal syphilis
- hearing loss, facial weakness, visual disturbances
- meningovascular syphilis
- Focal CNS ischemia or stroke.