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Sexually
TransmittedTransmitted
Infections&Infections&
MANAGEMENT4nursesMANAGEMENT4nursesMANAGEMENT4nursesMANAGEMENT4nurse...
STDs
• STDs are diseases and infections which
are capable of being spread from
person to person through:
– sexual intercou...
STD CLASSIFICATION
1. BACTERIAL
2. VIRAL2. VIRAL
3. PROTOZOAL
4. FUNGAL
5. ECTOPARASITES
WALTER WASWA,BSC.MLS 3
BACTERIA
a) Neisseria gonorrhea
b) Chlamydia trachomatis
c) Treponema pallidumc) Treponema pallidum
d) Hemophilus ducreyi-...
VIRAL
a) HERPES SIMPLEX VIRUS (Genital
Herpes)
b) HPV Genital Warts
c) HBVc) HBV
d) HIV
e) CYTOMEGALOVIRUS
f) MOLLUSCUM CO...
protozoan
a) TRICHOMONA
S VAGINALIS
b) ENTOMOEBA
HISTOLYTICAHISTOLYTICA
(HOMOsexual)
c) GIARDIA
LAMBLIA
(HOMOsexual)WALTER...
fungal
Candida albican-
vulvovaginitis
WALTER WASWA,BSC.MLS 7
ECTOPARASITE
a) Phthirius
pubis-pubic
lice
infestation
WALTER WASWA,BSC.MLS 8
infestation
b) Sarcoptes
scabiei-
scabies
WHY SHOULD NURSES STUDY STDS
1. Major cause of infertility in men and women
2. Co factor in HIV and HBV
3. Common as malar...
CHLAMYDIA
• Chlamydia trachomatis
• Small intracellular bacteria
• MOST COMMON STD
• FEMALES OUTNUMBER MALES 6:1
• Cervix ...
CHLAMYDIA
• If asymptomatic-discharge ,painful
urination ,lower abdominal pain,
bleeding, fever and nauseableeding, fever ...
Laboratory Tests for ChlamydiaLaboratory Tests for Chlamydia
• Tissue culture has been the standard
– Specificity approach...
Laboratory Tests for Chlamydia
(continued)
• DNA amplification assays
–polymerase chain reaction (PCR)
–ligase chain react...
Chlamydia Direct Fluorescent
Antibody (DFA)
14
Source: Centers for Disease Control and Prevention
WALTER WASWA,BSC.MLS
Healthy/unhealthy cervix
WALTER WASWA,BSC.MLS 15
Mucopurulent Cervicitis
16Source: Seattle STD/HIV Prevention Training CenterWALTER WASWA,BSC.MLS
CHLAMYDIA/COMPLICATION
• Urethratis
• Epididymitis
• Proctitis
• Cervicitis
• Endometritis
• Salpingitis
• Perihepatitis
•...
LAB DIAGNOSTICS
• Direct fluorescent antibody
• Enzyme immunoassay
• DNA PROBE• DNA PROBE
• Cell culture
• DNA amplication...
CHLAMYDIA/treatment
• Doxycycline
100m orally 2
times day fortimes day for
seven days
• Azithromycin 1g
orally
WALTER WASW...
GONORRHEA
-females
• Gonococcal cervicitis-slightl yellow-green discharge or
vulvar irritation
-Males-Males
• Gonococcal u...
GONORHOEA
• Gram negative
WALTER WASWA,BSC.MLS 21
GONORRHEA
• Mucus membranes affected
include cervix,anus,throata nd
the eyesthe eyes
• The bacteria attacks the cervix
as ...
GONORRHEA
• Symptoms are thick discharge,
burning urination and severe
menstrual or abdominal crampsmenstrual or abdominal...
GONORRHEA
COMPLICATIONS
1. Urethritis
2. Epididymitis
3. Proctitis
4. Endometritis4. Endometritis
5. Cervicitis
6. Salping...
GONORRHEA
Consequences
• Female:PID with sterility,ectopic
pregnancy,severe pelvic pain,infantpregnancy,severe pelvic pain...
GONORRHEA
• Transmitted to eyes,anus,throat
may enter the blood stream and
invade joints,heart,liver and CNSinvade joints,...
GONORRHEA/drugs
• Azithromycin igm daily/
doxycycline 100mg
twice daily
• Ceftriaxone 125mgCeftriaxone 125mg
IM/4OOmg oral...
Diagnosis not Easy
• Three levels of diagnosis are
defined on the basis of clinical
findings or the results of
laboratory ...
Diagnosis of GonorrhoeaDiagnosis of Gonorrhoea
• Suggestive diagnosis is defined by
the presence of:
1. A mucopurulent end...
2.Presumptive diagnosis of gonorrhoea is made
on the basis of one of the following three
criteria:
• Typical gram-negative...
3. Definitive diagnosis of gonorrhoea
requires:
• Confirmation of isolates by biochemical,
enzymatic, serologic, or nuclei...
Newer Methods in Diagnosis of
Gonorrhoea
• Detection of N. gonorrhoea by a
nonculture laboratory test (Antigen
detection t...
NONGONOCOCAL URETHRITIS
• Female-few or no
symptoms,may itch,urinary
burning,mild vaginal
discharge of pus
• Male-penile d...
SYPHILISSYPHILIS –– THETHE ““““““““GREAT IMITATORGREAT IMITATOR””””””””
• Infectious Dose: ~57 organisms1
• Incubation Per...
Primary SyphilisPrimary Syphilis
WALTER WASWA,BSC.MLS 35
Primary Syphilis - Chancre
WALTER WASWA,BSC.MLS 36
Primary Syphilis - Chancre
WALTER WASWA,BSC.MLS 37
Primary Syphilis Chancre
38
Source: Florida STD/HIV Prevention Training Center
WALTER WASWA,BSC.MLS
Secondary Syphilis Rash
Sores
39
Source: Florida STD/HIV Prevention Training Center
WALTER WASWA,BSC.MLS
Secondary Syphilis Rash
40
Source: Florida STD/HIV Prevention Training Center
WALTER WASWA,BSC.MLS
Secondary Syphilis Rash
41
Source: Cincinnati STD/HIV Prevention Training Center
WALTER WASWA,BSC.MLS
Secondary Syphilis
42
Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas
WALTER WASWA,BSC.MLS
Congenital Syphilis
• Congenital syphilis
usually occurs following
vertical transmission of
T. pallidum from the
infected ...
First /(primary)Stage Syphilis
Chancres (shangker) (painless open
sore) appear on the body.
They disappear in about 14They...
If gone untreated…
Third/tertiary Stage Syphilis
• Transmission to sex
partners and newborns
• Nerve and brain damage
• Bl...
SYPHILIS
Symptoms
• Inflamed
cervix/PID;spread to
prostate/epididymis,rar
CondylomataCondylomata
LataLata
prostate/epididy...
Diagnosis of Syphilis
• History and clinical examination.
• Evaluation based on three factors:
–Clinical findings.
– Demon...
Laboratory Diagnosis of Syphilis
The Uncommon Methods
1.Rabbit Infectivity Test (RIT)
– High Sensitivity and Specificity
–...
• RPR and VDRL are agglutination assays
Reagin
Serologic Tests for Syphilis:
Non-Treponemal Assays
Cardiolipin
Charcoal
Se...
6.VDRL
• VDRL (venereal disease research laboratories)
- It is useful for the screening, diagnosis and follow up.
- The re...
7.RPR
• Test Procedure:
– Serum or plasma added to circle on card and spread.
– One drop of antigen from a needle capable ...
Every Pregnant women Needs
Screening
WALTER WASWA,BSC.MLS 52
VIRAL STDS
1.HSV
2.HPV2.HPV
3.HBV
4.HIV
WALTER WASWA,BSC.MLS 53
HPV
• Recurrent,incurable
viral disease
• HSV-2=genital herpes
• 80%asymptomatic• 80%asymptomatic
WALTER WASWA,BSC.MLS 54
HSV
• HSV-1 cold sores,blisters,primarily
around the mouth and affects 80%
of all adults
• HSV-2 genital herpes infects 1:...
HSV
WALTER WASWA,BSC.MLS 56
HSV 2
• Active phase may include itching ,burning , swelling
and flu like symptoms
• Appearance of small painful blisters ...
HSV 2
• No cure
• Acyclovir is prescribed form minimizing the
discomfort
• Sexual activity should be avoided when sores ar...
HPV
• Ref to 70 different viruses a third of which causes
genital problems
• Common in 40% of sexually active women in the...
HPV
• HPV
16,18,31,45=CERVICAL
CANCER
• Genital warts affect 1 %Genital warts affect 1 %
of sexually active adult
• 75% of...
HPV
• No cure for HPV although lessions can be removed
• Methods include cyrotherapy, chemicals and laser
therapy
• HPV is...
HPV
• TREATMENT
• Patient apply podofilox 0.5% solution or gel
• Cryotherapy
• Podophyllin resin 10-25%• Podophyllin resin...
HBV
• Transmission as HIV
• Bloodborne, sex, tattoo, eearpiercings, injection and ocupuncture
• Easily transmitted than HI...
HBV
• Present in body fluids
• Severe HBV include jaundice and may result in
prolonged illness or death
WALTER WASWA,BSC.M...
HIV
• Retrovirus that targets and destroys helper T-4
cells that assist the immune response to disease
WALTER WASWA,BSC.ML...
Beginning of HIV/AIDS
• The first published article related to AIDS
was in 1981. The principal author’s name
was Michael G...
Discovery of HIV infection.
• In 1982, the term Acquired Immune Deficiency
Syndrome is used for the first time. The name w...
History of HIV
•• The HIV virus first came to light during theThe HIV virus first came to light during the
early 1980’s.ea...
What is Human Immune DeficiencyWhat is Human Immune Deficiency
VirusVirus
•• Genus RetroviridaeGenus Retroviridae
•• Lenti...
What is Human ImmuneWhat is Human Immune
Deficiency VirusDeficiency Virus
•• These contain RNA, the genetic material ofThe...
Origin of AIDS; controversial, similar
to SIV
71WALTER WASWA,BSC.MLS
WALTER WASWA,BSC.MLS 72
Family : Retroviridae
Subfamily : Lentivirus
• RNA virus, 120nm in
diameter
• Envelope gp160; gp120 &
gp41
• Icosahedral s...
Types of HIVTypes of HIV
WALTER WASWA,BSC.MLS 74
WALTER WASWA,BSC.MLS 75
Subtype C is Major type in India
• Subtype C is
predominant in
Southern and East
Africa, India and Nepal.
It has caused th...
Resistance
• The virus are inactivated in 10 minutes at 600c and in seconds
at 1000c
• At room temperature survive for sev...
HIV Replication
– Attachment
– Penetration
– Uncoating
– Reverse Transcription– Reverse Transcription
– Integration
– Repl...
Life Cycle of HIV
1. Attachment: Virus binds to surface molecule
(CD4) of T helper cells and macrophages.
• Coreceptors: R...
HIV Life Cycle: Attachment Requires CD4 ReceptorHIV Life Cycle: Attachment Requires CD4 Receptor
plus a Coreceptorplus a C...
• The HIV receptor
•• Gp160Gp160 is composed ofis composed of gp41gp41 andand gp120gp120 and forms theand forms the
recept...
The HIV ReceptorThe HIV Receptor
WALTER WASWA,BSC.MLS 82
Lifecycle of HIV
HIV particles enter the body in a fluid as it can notHIV particles enter the body in a fluid as it can no...
Life Cycle of HIV
3. Reverse Transcription: Viral RNA is
converted into DNA by unique enzyme
reverse transcriptase.
Revers...
WALTER WASWA,BSC.MLS 85
Infection spread throughout the BodyInfection spread throughout the Body
• Within the inflammatory cells of the infection ...
Effects of HIV on the immune systemEffects of HIV on the immune system
3 areas:3 areas:
1. Destruction of CD4+ T cells pop...
2.Host’s immune responses2.Host’s immune responses
•• Both humoral and cellBoth humoral and cell--mediated immune response...
Blood and Body fluids contain HighBlood and Body fluids contain High
concentration of Viral particlesconcentration of Vira...
Low concentrations of HIVLow concentrations of HIV
It is highly unlikely you will be infected
if you come into contact wit...
High Risk Populations:
1. Males, homosexuals & bisexuals
2. IV drug users
3. Improperly screened transfusion recipients
4....
How is HIV Spread?
• ANY type of sexual activity (highest risk)
• Sharing used drug needles
• Pregnancy-from mother to chi...
HIV in Body FluidsHIV in Body Fluids
Semen
11,000 Vaginal
Fluid
7,000
Blood
18,000
Amniotic
Fluid
4,000 Saliva
1
Average n...
Transmission
• Vaginal Intercourse
• Anal Intercourse (10x higher infection rate than
vaginal intercourse because of tissu...
Window Period
• This is the period of time after becoming
infected when an HIV test is negative
• 90 percent of cases test...
Pathogenesis of HIV / AIDSPathogenesis of HIV / AIDS
Infected TInfected T--CellCell
HIV
Virus
T-Cell
HIV Infected
T-Cell
N...
• Immune responses fail to eradicate all viruses.
• Viral load is maintained at low level
• Continuous decline of CD4+ T c...
Immune defects due to HIV infectionImmune defects due to HIV infection
B cellsB cells –– impaired humoral responseimpaired...
CDC Classification of HIV
• Category 1: > 500 cells/mm3 (or CD4% > 28%)
• Category 2: 200-499 cells/mm3 (or CD4% 14% -
• 2...
normal
Slightly
Acute HIV disease
Exposure to
HIV
Clinical latency period
competence
Progression of HIV infection
Progress...
WHO clinical case definition for AIDS in
South-East Asia
• WHO clinical case definition for AIDS in South-East Asia
Clinic...
WHO clinical case definition for AIDS in SouthWHO clinical case definition for AIDS in South--
East AsiaEast Asia
• Dissem...
Stage 1Stage 1 -- PrimaryPrimary
• Short, flu-like illness - occurs one to six weeks
after infection
• no symptoms at all
...
Stage 2Stage 2Stage 2 ---- AsymptomaticAsymptomaticAsymptomaticAsymptomatic
• Lasts for an average of ten years
• This sta...
- Symptomatic
• The symptoms are mild
• The immune system deteriorates• The immune system deteriorates
• Emergence of oppo...
- HIV AIDS
• The immune
system weakens
• The illnesses• The illnesses
become more
severe leading to
an AIDS diagnosis
WALT...
Progression to AIDSProgression to AIDS
•• During the latency period, lymph nodes and the spleen areDuring the latency peri...
•• FinalFinal stage of HIV infectionstage of HIV infection -- AIDSAIDS
•• Occurs when the destruction of peripheral lympho...
Opportunistic Infections
109WALTER WASWA,BSC.MLS
-to-Baby
• Before Birth
• During Birth• During Birth
• Postpartum
–After the birth
WALTER WASWA,BSC.MLS 110
How is HIV not spread?How is HIV not spread?
• Shaking hands
• Hugging
• Swimming pools• Swimming pools
• Toilet seats
• I...
THE NATIONAL HIV TESTING POLICYTHE NATIONAL HIV TESTING POLICY
• No individual should be made to undergo a
mandatory testi...
Pre--test Counseling explain to individualstest Counseling explain to individuals
• Transmission
• Prevention
• Risk Facto...
Post--test Counselingtest Counseling
• Clarifies test
results
• Need for
additional testingadditional testing
• Promotion ...
Three types of tests
(i) Screening tests - ELISA and simple/rapid
tests.
(ii) Confirmatory or supplemental tests-
Western ...
Diagnosis of HIV
•• Initial test for HIV is an indirect ELISA testInitial test for HIV is an indirect ELISA test
•• Econom...
Absence of Antibodies to do not confirm
absence of HIV infection
•• Absence of antibody, as in ‘window period’ does notAbs...
EIA/ELISA
Test
PositiveNegative
Repeat
Positive
HIV Testing
No HIV Exposure
Low Risk
HIV Exposure
High Risk
Run IFA
Confir...
Diagnosis of HIV
•• Positive or indeterminate ELISA tests for antiPositive or indeterminate ELISA tests for anti--HIV anti...
Indirect ELISA test
WALTER WASWA,BSC.MLS 120
Western blot Test
•• Confirms HIV infectionConfirms HIV infection
•• Proteins are separated by electrophoresisProteins are...
Western BlottingWestern Blotting
•• A discrete protein band represents theA discrete protein band represents the
specific ...
HIV Western blot
WALTER WASWA,BSC.MLS 123
Rapid Tests
•• ADVANTAGESADVANTAGES::
• quicker to perform
– do not require batching
– do not require specialised equipmen...
The ‘Window period’ Aware of
it
Follows acute infection with HIV, before HIV
antibodies can be detected in the patient’s
b...
Paediatric HIV Testing
Infants born to HIV infected mothers will have
antibodies to HIV in their serum as a result of:
– m...
Treatment of HIVTreatment of HIV
•• Eradication of HIV infection not possible with currently availableEradication of HIV i...
Antiretroviral DrugsAntiretroviral Drugs
•• Significant declines in AIDS related morbidity and mortality are seenSignifica...
Therapeutic OptionsTherapeutic Options
•• Combination of RT inhibitors protease inhibitorsCombination of RT inhibitors pro...
AIDS (Pregnancy & AIDS)
• Zidovudine(AZT) – recommended for px of maternal
fetal HIV transmission & administered after 14
...
Antiretroviral DrugsAntiretroviral DrugsAntiretroviral DrugsAntiretroviral Drugs
• Nucleoside Reverse Transcriptase inhibi...
Prevention and control of HIVPrevention and control of HIV
• Education
• Prevention of blood born HIV transmission
• Anti ...
HIV Occupational ExposureHIV Occupational Exposure
• Review facility policy and report the incident
• Medical follow-up is...
HIV NonHIV Non--Occupational ExposureOccupational Exposure
• No data exists on the efficacy of antiretroviral
medication a...
Play safePlay safe
• Use the common
sense
Be faithful to one
partner,partner,
Use Condom.
• Antiretroviral
drugs
• Caesare...
AbstinenceAbstinenceAbstinence
• It is the only 100 %
effective method of
not acquiring
HIV/AIDS.
• Refraining from
sexual...
Monogamous relationshipMonogamous relationshipMonogamous relationship
• A mutually monogamous (only one sex partner)
relat...
Sex EducationSex Education –– Best option to PreventBest option to Prevent AIDSAIDS
Move from Past to FutureMove from Past...
World AIDS DayWorld AIDS Day,,
• World AIDS Day, observed December 1 each
year, is dedicated to raising awareness of the
A...
TRICHOMONIASIS
• Single celled protozoa
• Men and women can be infected
• Remains dormant in asymptomatic women
• Causes v...
CANDIDIASIS
• NOT sexually transmitted
Symptoms
a) Itching
b) Dischargeb) Discharge
c) Burning/irritation
• Pregnant women...
Bacteria vaginosis
• Discharge is white and ordorous
Symptoms
• Cervicitis
• PID
• Pospartum endometritis• Pospartum endom...
ECTOPARASITE
• Pubic lice
• Thru sexual contact/infected clothing
• Symptoms: little to severe itchiness• Symptoms: little...
ECTOPARASITES
• Scabies:close physical /sexual
contact/infected clothing
• Symptoms
• small.,red rash arround primary
lesi...
Treponema pallidum – The Agent of Syphilis
• Spirochete
• Obligate human parasite
• Transmission
– Sexual
– Trans-placenta...
Pelvic Inflammatory Disease (PID)
• l0%-20% women with GC develop PID
• In Europe and North America, higher proportion of ...
Chancroid
• The combination of a painful genital ulcer and
tender Suppurative inguinal adenopathy suggests
the diagnosis o...
Chancroid
• 3) the clinical presentation,
appearance of genital ulcers and,
if present, regional
lymphadenopathy are typic...
Chancroid
• A definitive diagnosis of Chancroid
requires the identification of H.
ducreyi on special culture media thatduc...
Granuloma Inguinale (Donovanosis)Granuloma Inguinale (Donovanosis)
• Granuloma inguinale is a genital ulcerative
disease c...
Granuloma Inguinale
(Donovanosis)
• Clinically, the disease is commonly
characterized as painless, slowly progressive
ulce...
Granuloma Inguinale
(Donovanosis)
• The causative organism is difficult to culture,
and diagnosis requires visualization o...
Lymph granulomaLymph granuloma VenereumVenereum
• Lymph granuloma venereum (LGV) is
caused by C. trachomatis serovars L1, ...
Lymph granuloma Venereum
• Diagnosis is based on clinical suspicion,
epidemiologic information, and the
exclusion of other...
Lymph granuloma Venereum
• Genital and lymph node specimens (i.e., lesion
swab or bubo aspirate) can be tested for C.
trac...
Lymph granuloma Venereum
• chlamydia serology (complement fixation
titers >1:64) can support the diagnosis of LGV
in the a...
Trichomoniasis• An estimated 5 million new cases occur each year in women and men.
• Occurs in vagina of women so may be s...
Consequences of untreated STD
• Ectopic pregnancy
• Increased risk of cervical cancer
• Chronic abdominal pain
• Children ...
PREVENTION of STIs
• Abstinence give 100% effective method to
prevention
• Avoid multiple partners
• Condoms/spermicides• ...
WHY IS STI CONTROL DIFFICULT
• Many people carry the infections
without knowing it
WALTER WASWA,BSC.MLS 160
Life at Risk with Sexually Transmitted Infections
Best Choice Play safe
WALTER WASWA,BSC.MLS 161
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STD&HIV AIDS FOR KRCHN NORTH COAST MEDICAL TRAINING COLLEGE LECTURES

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This is a lecture to Nursing students (KRCHN) course lecture on sexually transmitted infections and management

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STD&HIV AIDS FOR KRCHN NORTH COAST MEDICAL TRAINING COLLEGE LECTURES

  1. 1. Sexually TransmittedTransmitted Infections&Infections& MANAGEMENT4nursesMANAGEMENT4nursesMANAGEMENT4nursesMANAGEMENT4nurses Common Diseases WALTER WASWA,BSC.MLS WALTER WASWA,BSC.MLS 1
  2. 2. STDs • STDs are diseases and infections which are capable of being spread from person to person through: – sexual intercourse –oral-genital contact or in non-sexual ways. –IV drug –Congenitally transmitted WALTER WASWA,BSC.MLS 2
  3. 3. STD CLASSIFICATION 1. BACTERIAL 2. VIRAL2. VIRAL 3. PROTOZOAL 4. FUNGAL 5. ECTOPARASITES WALTER WASWA,BSC.MLS 3
  4. 4. BACTERIA a) Neisseria gonorrhea b) Chlamydia trachomatis c) Treponema pallidumc) Treponema pallidum d) Hemophilus ducreyi-chancroid e) Calymmatobacterium granulomatis- granuloma inguinae f) Gardnerella vaginalis WALTER WASWA,BSC.MLS 4
  5. 5. VIRAL a) HERPES SIMPLEX VIRUS (Genital Herpes) b) HPV Genital Warts c) HBVc) HBV d) HIV e) CYTOMEGALOVIRUS f) MOLLUSCUM CONTAGIOSUM VURUS g) (HSV-2) WALTER WASWA,BSC.MLS 5
  6. 6. protozoan a) TRICHOMONA S VAGINALIS b) ENTOMOEBA HISTOLYTICAHISTOLYTICA (HOMOsexual) c) GIARDIA LAMBLIA (HOMOsexual)WALTER WASWA,BSC.MLS 6
  7. 7. fungal Candida albican- vulvovaginitis WALTER WASWA,BSC.MLS 7
  8. 8. ECTOPARASITE a) Phthirius pubis-pubic lice infestation WALTER WASWA,BSC.MLS 8 infestation b) Sarcoptes scabiei- scabies
  9. 9. WHY SHOULD NURSES STUDY STDS 1. Major cause of infertility in men and women 2. Co factor in HIV and HBV 3. Common as malaria 333m cases every year WALTER WASWA,BSC.MLS 9
  10. 10. CHLAMYDIA • Chlamydia trachomatis • Small intracellular bacteria • MOST COMMON STD • FEMALES OUTNUMBER MALES 6:1 • Cervix is the site of infection• Cervix is the site of infection • Most women are asymptomatic until the pain and fever from PID occur • Potential to transmit to newborn during delivery – Conjunctivitis, pneumonia WALTER WASWA,BSC.MLS 10
  11. 11. CHLAMYDIA • If asymptomatic-discharge ,painful urination ,lower abdominal pain, bleeding, fever and nauseableeding, fever and nausea • Complication include cervicitis, infertility, salpinitis, ectopic pregnancy, stillbirths, reactive arthritis WALTER WASWA,BSC.MLS 11
  12. 12. Laboratory Tests for ChlamydiaLaboratory Tests for Chlamydia • Tissue culture has been the standard – Specificity approaching 100% – Sensitivity ranges from 60% to 90% • Non-amplified tests – Enzyme Immunoassay (EIA), e.g. Chlamydiazyme • sensitivity and specificity of 85% and 97% respectively Drips 12 • sensitivity and specificity of 85% and 97% respectively • useful for high volume screening • false positives – Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace- 2 • sensitivities ranging from 75% to 100%; specificities greater than 95% • detects chlamydial ribosomal RNA • able to detect gonorrhea and chlamydia from one swab • need for large amounts of sample DNA WALTER WASWA,BSC.MLS
  13. 13. Laboratory Tests for Chlamydia (continued) • DNA amplification assays –polymerase chain reaction (PCR) –ligase chain reaction (LCR) 13 • Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100% • LCR ability to detect chlamydia in first void urine WALTER WASWA,BSC.MLS
  14. 14. Chlamydia Direct Fluorescent Antibody (DFA) 14 Source: Centers for Disease Control and Prevention WALTER WASWA,BSC.MLS
  15. 15. Healthy/unhealthy cervix WALTER WASWA,BSC.MLS 15
  16. 16. Mucopurulent Cervicitis 16Source: Seattle STD/HIV Prevention Training CenterWALTER WASWA,BSC.MLS
  17. 17. CHLAMYDIA/COMPLICATION • Urethratis • Epididymitis • Proctitis • Cervicitis • Endometritis • Salpingitis • Perihepatitis • Otitis media in infants • Cervicitis WALTER WASWA,BSC.MLS 17 • Otitis media in infants • Inclusion conjuctivitis • sterility
  18. 18. LAB DIAGNOSTICS • Direct fluorescent antibody • Enzyme immunoassay • DNA PROBE• DNA PROBE • Cell culture • DNA amplication WALTER WASWA,BSC.MLS 18
  19. 19. CHLAMYDIA/treatment • Doxycycline 100m orally 2 times day fortimes day for seven days • Azithromycin 1g orally WALTER WASWA,BSC.MLS 19
  20. 20. GONORRHEA -females • Gonococcal cervicitis-slightl yellow-green discharge or vulvar irritation -Males-Males • Gonococcal urethritis,odorous cloudy discharge,urianary burning ,swollen ,tender lymph glands in groins WALTER WASWA,BSC.MLS 20
  21. 21. GONORHOEA • Gram negative WALTER WASWA,BSC.MLS 21
  22. 22. GONORRHEA • Mucus membranes affected include cervix,anus,throata nd the eyesthe eyes • The bacteria attacks the cervix as first site of infection WALTER WASWA,BSC.MLS 22
  23. 23. GONORRHEA • Symptoms are thick discharge, burning urination and severe menstrual or abdominal crampsmenstrual or abdominal cramps • 10-40% of women develop PID • Untreated gonorrhea can result in arthritis, dermatitis and tenosynivitis WALTER WASWA,BSC.MLS 23
  24. 24. GONORRHEA COMPLICATIONS 1. Urethritis 2. Epididymitis 3. Proctitis 4. Endometritis4. Endometritis 5. Cervicitis 6. Salpingitis 7. Pharyngitis 8. Conjuctivitis 9. Amniotic infection syndrome 10. Disseminated gonococcal WALTER WASWA,BSC.MLS 24
  25. 25. GONORRHEA Consequences • Female:PID with sterility,ectopic pregnancy,severe pelvic pain,infantpregnancy,severe pelvic pain,infant conjuctivitis • Male: • Prostate absesses with fever,difficult urination,epididymitis with sterility WALTER WASWA,BSC.MLS 25
  26. 26. GONORRHEA • Transmitted to eyes,anus,throat may enter the blood stream and invade joints,heart,liver and CNSinvade joints,heart,liver and CNS • Treatment:special treatment resistant bacteria may require special treatment WALTER WASWA,BSC.MLS 26
  27. 27. GONORRHEA/drugs • Azithromycin igm daily/ doxycycline 100mg twice daily • Ceftriaxone 125mgCeftriaxone 125mg IM/4OOmg orally • is the best treatment99.1% WALTER WASWA,BSC.MLS 27
  28. 28. Diagnosis not Easy • Three levels of diagnosis are defined on the basis of clinical findings or the results of laboratory diagnostic tests. A findings or the results of laboratory diagnostic tests. A definitive diagnosis of gonorrhoea must be obtained for medico legal purposes. WALTER WASWA,BSC.MLS 28
  29. 29. Diagnosis of GonorrhoeaDiagnosis of Gonorrhoea • Suggestive diagnosis is defined by the presence of: 1. A mucopurulent endocervical or1. A mucopurulent endocervical or urethral exudate on physical examination and sexual exposure to a person infected with N. gonorrhoea. WALTER WASWA,BSC.MLS 29
  30. 30. 2.Presumptive diagnosis of gonorrhoea is made on the basis of one of the following three criteria: • Typical gram-negative intracellular diplococci on microscopic examination of a smear of urethral exudate from men or endocervical secretions from women*; • Growth of a gram-negative, oxidase-positive• Growth of a gram-negative, oxidase-positive diplococcus, from the urethra (men) or endocervix (women), on a selective culture medium, and demonstration of typical colonial morphology, positive oxidase reaction, and typical gram- negative morphology; WALTER WASWA,BSC.MLS 30
  31. 31. 3. Definitive diagnosis of gonorrhoea requires: • Confirmation of isolates by biochemical, enzymatic, serologic, or nucleic acid testing e.g., carbohydrate utilization, rapid enzyme substrate tests, serologic methods such as cosubstrate tests, serologic methods such as co agglutination or fluorescent antibody tests supplemented with additional tests that will ensure accurate identification of isolates, or a DNA probe culture confirmation technique. WALTER WASWA,BSC.MLS 31
  32. 32. Newer Methods in Diagnosis of Gonorrhoea • Detection of N. gonorrhoea by a nonculture laboratory test (Antigen detection test (e.g., Gonozymedetection test (e.g., Gonozyme [Abbott]), direct specimen nucleic acid probe test (e.g., Pace II [GenProbe]), nucleic acid amplification test (e.g., LCR [Abbott]). WALTER WASWA,BSC.MLS 32
  33. 33. NONGONOCOCAL URETHRITIS • Female-few or no symptoms,may itch,urinary burning,mild vaginal discharge of pus • Male-penile discharge,urinary burning • Etiology: – 20-40% C. trachomatis – 20-30% genital mycoplasmas (Ureaplasma urealyticum, Mycoplasma genitalium) – Occasional Trichomonas vaginalis, HSV – Unknown in ~50% cases burning WALTER WASWA,BSC.MLS 33 – Unknown in ~50% cases • Sx: Mild dysuria, mucoid discharge • Dx: Urethral smear ≥ 5 PMNs (usually ≥15)/OI field Urine microscopic ≥ 10 PMNs/HPF Leukocyte esterase (+)
  34. 34. SYPHILISSYPHILIS –– THETHE ““““““““GREAT IMITATORGREAT IMITATOR”””””””” • Infectious Dose: ~57 organisms1 • Incubation Period – 21 days (median) • 3 clinical stages of syphilis – Primary: • Painless sore (chancre) at inoculation sitesite – Secondary: • Rash, Fever, Lymphadenopathy, Malaise – Tertiary/Latent: • CNS invasion, organ damage • “The physician that knows syphilis knows medicine.” – Sir William Osler 6 WALTER WASWA,BSC.MLS 34
  35. 35. Primary SyphilisPrimary Syphilis WALTER WASWA,BSC.MLS 35
  36. 36. Primary Syphilis - Chancre WALTER WASWA,BSC.MLS 36
  37. 37. Primary Syphilis - Chancre WALTER WASWA,BSC.MLS 37
  38. 38. Primary Syphilis Chancre 38 Source: Florida STD/HIV Prevention Training Center WALTER WASWA,BSC.MLS
  39. 39. Secondary Syphilis Rash Sores 39 Source: Florida STD/HIV Prevention Training Center WALTER WASWA,BSC.MLS
  40. 40. Secondary Syphilis Rash 40 Source: Florida STD/HIV Prevention Training Center WALTER WASWA,BSC.MLS
  41. 41. Secondary Syphilis Rash 41 Source: Cincinnati STD/HIV Prevention Training Center WALTER WASWA,BSC.MLS
  42. 42. Secondary Syphilis 42 Source: Diepgen TL, Yihune G et al. Dermatology Online Atlas WALTER WASWA,BSC.MLS
  43. 43. Congenital Syphilis • Congenital syphilis usually occurs following vertical transmission of T. pallidum from the infected mother to theinfected mother to the fetus in utero, but neonates may also be infected during passage through the infected birth canal at delivery. WALTER WASWA,BSC.MLS 43
  44. 44. First /(primary)Stage Syphilis Chancres (shangker) (painless open sore) appear on the body. They disappear in about 14They disappear in about 14 days. Signs Appearance of red painless sore on mouth,fingers,reproductive organs in priamry syphilis- chancers
  45. 45. If gone untreated… Third/tertiary Stage Syphilis • Transmission to sex partners and newborns • Nerve and brain damage • Blindness • Physical damage• Physical damage • Death • Tertiary syphilis linked to HIV • Destructive lesion,organ destruction,meningitis Degenerative lesions called gummas appear as a result of hypersensitivity
  46. 46. SYPHILIS Symptoms • Inflamed cervix/PID;spread to prostate/epididymis,rar CondylomataCondylomata LataLata prostate/epididymis,rar e cases of arthritis Treatment • Doxycline or erthromycin WALTER WASWA,BSC.MLS 46
  47. 47. Diagnosis of Syphilis • History and clinical examination. • Evaluation based on three factors: –Clinical findings. – Demonstration of spirochetes in clinical specimen. – Present of antibodies in blood or cerebrospinal fluid. • More than one test should be performed. • No serological test can distinguish between other Treponemal infections. WALTER WASWA,BSC.MLS 47
  48. 48. Laboratory Diagnosis of Syphilis The Uncommon Methods 1.Rabbit Infectivity Test (RIT) – High Sensitivity and Specificity – Long turn-around-time – Limited to research settings 2.Dark Field Microscopy http://www.els.net – Useful only during primary infection – Technician expertise required 3.Immunostaining – Direct fluorescent antibody or silver stain 4.Polymerase Chain Reaction (PCR) – Not commercial available textbookofbacteriology.net 7WALTER WASWA,BSC.MLS 48
  49. 49. • RPR and VDRL are agglutination assays Reagin Serologic Tests for Syphilis: Non-Treponemal Assays Cardiolipin Charcoal Serum or CSF 11WALTER WASWA,BSC.MLS 49
  50. 50. 6.VDRL • VDRL (venereal disease research laboratories) - It is useful for the screening, diagnosis and follow up. - The results can be qualitative or qualitative • Each preparation of antigen suspension should first be examined by testing with known positive or negative serum controls. • The antigen particles appear as short rod forms at magnification of about 100x. Aggregation of these particles into large or small clumps is interpreted as degrees of positivity • Reactive on left, non-reactive on right WALTER WASWA,BSC.MLS 50
  51. 51. 7.RPR • Test Procedure: – Serum or plasma added to circle on card and spread. – One drop of antigen from a needle capable of delivering 60 drops/mL is added. – Rotate at 100 rpms/minute for 8 minutes. – Results are read macroscopically.– Results are read macroscopically. • Daily quality control: – 20 gauge needle checked for delivery of 60 drops/mL – Rotator checked for 100 rpms/minute – Room temperature must be 23-29 C. – Three levels of control must be run and give appropriate results. • RPR appears to be more sensitive than the VDRL. WALTER WASWA,BSC.MLS 51
  52. 52. Every Pregnant women Needs Screening WALTER WASWA,BSC.MLS 52
  53. 53. VIRAL STDS 1.HSV 2.HPV2.HPV 3.HBV 4.HIV WALTER WASWA,BSC.MLS 53
  54. 54. HPV • Recurrent,incurable viral disease • HSV-2=genital herpes • 80%asymptomatic• 80%asymptomatic WALTER WASWA,BSC.MLS 54
  55. 55. HSV • HSV-1 cold sores,blisters,primarily around the mouth and affects 80% of all adults • HSV-2 genital herpes infects 1:6• HSV-2 genital herpes infects 1:6 adult • Contagious through direct skin contact particularly oral and genital areas WALTER WASWA,BSC.MLS 55
  56. 56. HSV WALTER WASWA,BSC.MLS 56
  57. 57. HSV 2 • Active phase may include itching ,burning , swelling and flu like symptoms • Appearance of small painful blisters of genitals rupture, crust over and healrupture, crust over and heal • The virus travels down nerve to ganglia near spine and reamins dormant until another outbreak and virus travels up nerve to skin • Control difficult because 75% are unaware they are infected WALTER WASWA,BSC.MLS 57
  58. 58. HSV 2 • No cure • Acyclovir is prescribed form minimizing the discomfort • Sexual activity should be avoided when sores are activeactive • Antiviral drugs neither eradicate latent virus nor affect the risk, frequency or severity of recurrences • Treatment • On first clinical episode • Acyclovir 400mg orally 5 times a day for 7-10 days WALTER WASWA,BSC.MLS 58
  59. 59. HPV • Ref to 70 different viruses a third of which causes genital problems • Common in 40% of sexually active women in their 20’s • A small percentage develop genital warts which can• A small percentage develop genital warts which can lead to a precancerous condition • Spread through direct contact on vaginal/and are anal area • Warts remain undetected when located inside the vagina/cervix/anus WALTER WASWA,BSC.MLS 59
  60. 60. HPV • HPV 16,18,31,45=CERVICAL CANCER • Genital warts affect 1 %Genital warts affect 1 % of sexually active adult • 75% of adult have been infected with greater than one type 0f HPV WALTER WASWA,BSC.MLS 60
  61. 61. HPV • No cure for HPV although lessions can be removed • Methods include cyrotherapy, chemicals and laser therapy • HPV is associated with cervical cancer or cervical• HPV is associated with cervical cancer or cervical dysplasia • Early detection reduces mortality • Also linked to cancers of the cavity WALTER WASWA,BSC.MLS 61
  62. 62. HPV • TREATMENT • Patient apply podofilox 0.5% solution or gel • Cryotherapy • Podophyllin resin 10-25%• Podophyllin resin 10-25% • Sugery, intralesional interferon, laser WALTER WASWA,BSC.MLS 62
  63. 63. HBV • Transmission as HIV • Bloodborne, sex, tattoo, eearpiercings, injection and ocupuncture • Easily transmitted than HIV • Almost 95% of person with HBV recover • Vaccination of health personnels • RISK GRP• RISK GRP • Hemodialysis pts • Injectable drug users • Health workers • Infants born of mothers infected • Gay men • Sexually active heterosexuals WALTER WASWA,BSC.MLS 63
  64. 64. HBV • Present in body fluids • Severe HBV include jaundice and may result in prolonged illness or death WALTER WASWA,BSC.MLS 64
  65. 65. HIV • Retrovirus that targets and destroys helper T-4 cells that assist the immune response to disease WALTER WASWA,BSC.MLS 65
  66. 66. Beginning of HIV/AIDS • The first published article related to AIDS was in 1981. The principal author’s name was Michael Gottlieb and it appeared in the Morbidity and Mortality Weeklythe Morbidity and Mortality Weekly Report for June 5th. This article reported that there was a random increase in pneumocystis carinii pneumonia (PCP), a rare lung infection. WALTER WASWA,BSC.MLS 66
  67. 67. Discovery of HIV infection. • In 1982, the term Acquired Immune Deficiency Syndrome is used for the first time. The name was designated by the CDC. • In 1983, French scientists at the Institute Pasteur found a new virus that they called lymphadenopathy-found a new virus that they called lymphadenopathy- associated virus or LAV. About a year later, Dr. Robert Gallo, of the National Cancer institute discovered HLTV-III. The first discovery was made in France at the Institute Pasteur, but shared credit is given to Dr. Robert Gallo, the discoverer of AIDS and his French counterparts for discovering HIV on April 23, 1984. WALTER WASWA,BSC.MLS 67
  68. 68. History of HIV •• The HIV virus first came to light during theThe HIV virus first came to light during the early 1980’s.early 1980’s. •• A number of healthy gay men in New YorkA number of healthy gay men in New York began to develop rare opportunistic infectionsbegan to develop rare opportunistic infectionsbegan to develop rare opportunistic infectionsbegan to develop rare opportunistic infections & cancers, that were resistant to treatment.& cancers, that were resistant to treatment. •• One such viral opportunistic infection isOne such viral opportunistic infection is cytomegalovirus that causes blindness &cytomegalovirus that causes blindness & inflammation of the coloninflammation of the colon WALTER WASWA,BSC.MLS 68
  69. 69. What is Human Immune DeficiencyWhat is Human Immune Deficiency VirusVirus •• Genus RetroviridaeGenus Retroviridae •• Lentivirus, which literally means slow virusLentivirus, which literally means slow virus -- it takesit takes such a long time to develop adverse effects in thesuch a long time to develop adverse effects in the body.body.body.body. •• This virus attacks the immune systemThis virus attacks the immune system •• There are two strainsThere are two strains –– HIV 1 & HIV 2HIV 1 & HIV 2 WALTER WASWA,BSC.MLS 69
  70. 70. What is Human ImmuneWhat is Human Immune Deficiency VirusDeficiency Virus •• These contain RNA, the genetic material ofThese contain RNA, the genetic material of HIVHIV •• The outer layer of the HIV virus cell is coveredThe outer layer of the HIV virus cell is covered in coat proteins, which can bind to certainin coat proteins, which can bind to certainin coat proteins, which can bind to certainin coat proteins, which can bind to certain WBCs. This allows the virus to enter the cell,WBCs. This allows the virus to enter the cell, where it alters the DNA.where it alters the DNA. •• The virus infects and destroys the CD4 lymphocytesThe virus infects and destroys the CD4 lymphocytes which are critical to the body’s immune response.which are critical to the body’s immune response. WALTER WASWA,BSC.MLS 70
  71. 71. Origin of AIDS; controversial, similar to SIV 71WALTER WASWA,BSC.MLS
  72. 72. WALTER WASWA,BSC.MLS 72
  73. 73. Family : Retroviridae Subfamily : Lentivirus • RNA virus, 120nm in diameter • Envelope gp160; gp120 & gp41 • Icosahedral symmetryIcosahedral symmetry • Nucelocapsid – Outer matrix protein (p17) – Major capsid protein (p24) – Nuclear protein (p7) • Diploid RNA with several copies of reverse transcriptase WALTER WASWA,BSC.MLS 73
  74. 74. Types of HIVTypes of HIV WALTER WASWA,BSC.MLS 74
  75. 75. WALTER WASWA,BSC.MLS 75
  76. 76. Subtype C is Major type in India • Subtype C is predominant in Southern and East Africa, India and Nepal. It has caused theIt has caused the world's worst HIV epidemics and is responsible for around half of all infections. WALTER WASWA,BSC.MLS 76
  77. 77. Resistance • The virus are inactivated in 10 minutes at 600c and in seconds at 1000c • At room temperature survive for seven days • HIV are inactivated in 10 minutes by treatment with 50% ethanolethanol • 35% Isopropanol. • 0.5% Lysol and paraformaldehyde • 0.3% hydrogen • 10% house hold bleach • Hypochlorite solution at 0.5% • 2% Glutaraldehyde WALTER WASWA,BSC.MLS 77
  78. 78. HIV Replication – Attachment – Penetration – Uncoating – Reverse Transcription– Reverse Transcription – Integration – Replication – Assembly – Release WALTER WASWA,BSC.MLS 78
  79. 79. Life Cycle of HIV 1. Attachment: Virus binds to surface molecule (CD4) of T helper cells and macrophages. • Coreceptors: Required for HIV infection. • CXCR4 and CCR5 mutants are resistant to infection. 2. Fusion: Viral envelope fuses with cell2. Fusion: Viral envelope fuses with cell membrane, releasing contents into the cell. WALTER WASWA,BSC.MLS 79
  80. 80. HIV Life Cycle: Attachment Requires CD4 ReceptorHIV Life Cycle: Attachment Requires CD4 Receptor plus a Coreceptorplus a Coreceptor WALTER WASWA,BSC.MLS 80
  81. 81. • The HIV receptor •• Gp160Gp160 is composed ofis composed of gp41gp41 andand gp120gp120 and forms theand forms the receptor for binding to the host cell (CD4 positive cells).receptor for binding to the host cell (CD4 positive cells). •• The gp41 portion is half embedded in the membraneThe gp41 portion is half embedded in the membrane envelope and interacts with gp120 portion on theenvelope and interacts with gp120 portion on the The gp41 portion is half embedded in the membraneThe gp41 portion is half embedded in the membrane envelope and interacts with gp120 portion on theenvelope and interacts with gp120 portion on the exterior side of the membrane.exterior side of the membrane. •• Each receptor is composed of 3 subunits of gp41 and 3Each receptor is composed of 3 subunits of gp41 and 3 subunits of gp120.subunits of gp120. WALTER WASWA,BSC.MLS 81
  82. 82. The HIV ReceptorThe HIV Receptor WALTER WASWA,BSC.MLS 82
  83. 83. Lifecycle of HIV HIV particles enter the body in a fluid as it can notHIV particles enter the body in a fluid as it can not survive without a support medium.survive without a support medium. The virus targets any cell expressing CD4, including TThe virus targets any cell expressing CD4, including T helper cells, macrophages, dendritic cells andhelper cells, macrophages, dendritic cells and monocytes.monocytes. WALTER WASWA,BSC.MLS 83
  84. 84. Life Cycle of HIV 3. Reverse Transcription: Viral RNA is converted into DNA by unique enzyme reverse transcriptase. Reverse transcriptase RNA ---------------------> DNARNA ---------------------> DNA Reverse transcriptase is the target of several HIV drugs: AZT, ddI, and ddC. WALTER WASWA,BSC.MLS 84
  85. 85. WALTER WASWA,BSC.MLS 85
  86. 86. Infection spread throughout the BodyInfection spread throughout the Body • Within the inflammatory cells of the infection (T cells) • Site of replication shifts to lymphoid tissues: • Lymph nodes • Spleen• Spleen • Liver • Bone marrow • Macrophages and Langerhans cells become reservoirs and sites of • replication but do not die themselves. WALTER WASWA,BSC.MLS 86
  87. 87. Effects of HIV on the immune systemEffects of HIV on the immune system 3 areas:3 areas: 1. Destruction of CD4+ T cells population1. Destruction of CD4+ T cells population 2. Immune effects due to HIV infection2. Immune effects due to HIV infection 3. Progression of HIV infection to AIDS3. Progression of HIV infection to AIDS WALTER WASWA,BSC.MLS 87
  88. 88. 2.Host’s immune responses2.Host’s immune responses •• Both humoral and cellBoth humoral and cell--mediated immune responsesmediated immune responses partially control the viral production but in thispartially control the viral production but in this process they destroy the infected CD4+T cells,process they destroy the infected CD4+T cells, leading to a gradual decline of CD4+ T cellsleading to a gradual decline of CD4+ T cells HIVHIV--specific CTLs kill infected CD4+ T cellsspecific CTLs kill infected CD4+ T cells•• HIVHIV--specific CTLs kill infected CD4+ T cellsspecific CTLs kill infected CD4+ T cells •• Antibodies that recognize a variety of HIV antigensAntibodies that recognize a variety of HIV antigens are producedare produced -- Antibody dependent cellAntibody dependent cell--mediatedmediated cytotoxicitycytotoxicity •• Apoptosis of infected cellsApoptosis of infected cells WALTER WASWA,BSC.MLS 88
  89. 89. Blood and Body fluids contain HighBlood and Body fluids contain High concentration of Viral particlesconcentration of Viral particles • Blood • Semen/Vaginal fluids (as high asfluids (as high as blood) • Breast milk • Pus from sores WALTER WASWA,BSC.MLS 89
  90. 90. Low concentrations of HIVLow concentrations of HIV It is highly unlikely you will be infected if you come into contact with: • Sweat • Tears• Tears • Urine • Saliva (-highly possible if blood from mouth sores is present) WALTER WASWA,BSC.MLS 90
  91. 91. High Risk Populations: 1. Males, homosexuals & bisexuals 2. IV drug users 3. Improperly screened transfusion recipients 4. Sexual partners of persons infected with HIV 5. Infants of HIV –infected mothers WALTER WASWA,BSC.MLS 91
  92. 92. How is HIV Spread? • ANY type of sexual activity (highest risk) • Sharing used drug needles • Pregnancy-from mother to child • Sharing razors- if blood is present• Sharing razors- if blood is present • Kissing- if even the smallest amount of blood is present. (-membranes of mouth are thin enough for HIV to enter straight into the body.) • Tattoos/body piercing if equipment is not clean. WALTER WASWA,BSC.MLS 92
  93. 93. HIV in Body FluidsHIV in Body Fluids Semen 11,000 Vaginal Fluid 7,000 Blood 18,000 Amniotic Fluid 4,000 Saliva 1 Average number of HIV particles in 1 ml of these body fluidsWALTER WASWA,BSC.MLS 93
  94. 94. Transmission • Vaginal Intercourse • Anal Intercourse (10x higher infection rate than vaginal intercourse because of tissue tear is higher • Oral Intercourse • Blood Transfusion (risk greater than 90% if sample is• Blood Transfusion (risk greater than 90% if sample is already infected) • Needles (tattoos, injections) • Infected mother to the infant through: • Pregnancy (placenta), Birth, and breastfeeding WALTER WASWA,BSC.MLS 94
  95. 95. Window Period • This is the period of time after becoming infected when an HIV test is negative • 90 percent of cases test positive within three• 90 percent of cases test positive within three months of exposure • 10 percent of cases test positive within three to six months of exposure WALTER WASWA,BSC.MLS 95
  96. 96. Pathogenesis of HIV / AIDSPathogenesis of HIV / AIDS Infected TInfected T--CellCell HIV Virus T-Cell HIV Infected T-Cell New HIV Virus WALTER WASWA,BSC.MLS 96
  97. 97. • Immune responses fail to eradicate all viruses. • Viral load is maintained at low level • Continuous decline of CD4+ T cells WALTER WASWA,BSC.MLS 97
  98. 98. Immune defects due to HIV infectionImmune defects due to HIV infection B cellsB cells –– impaired humoral responseimpaired humoral response •• BB--cell hyper reactivitycell hyper reactivity •• Polyclonal hypergammaglobulinemia due to enhanced nonspecificPolyclonal hypergammaglobulinemia due to enhanced nonspecific IgG and IgA production.IgG and IgA production. •• Impaired AbImpaired Ab--isotype switching and inability to respond toisotype switching and inability to respond to specific antigen.specific antigen. •• High incidence of BHigh incidence of B--cell lymphomascell lymphomas•• High incidence of BHigh incidence of B--cell lymphomascell lymphomas Lymph nodesLymph nodes •• HIV kills cells in the lymph nodesHIV kills cells in the lymph nodes •• Early HIV infection: destruction of dendritic cellsEarly HIV infection: destruction of dendritic cells •• Late stage: extensive damage, tissue necrosis, a loss of follicularLate stage: extensive damage, tissue necrosis, a loss of follicular dendritic cells and germinal centres.dendritic cells and germinal centres. •• An inability to trap Ag or support activation of T+B cellsAn inability to trap Ag or support activation of T+B cells WALTER WASWA,BSC.MLS 98
  99. 99. CDC Classification of HIV • Category 1: > 500 cells/mm3 (or CD4% > 28%) • Category 2: 200-499 cells/mm3 (or CD4% 14% - • 28%)• 28%) • Category 3: < 200 cells/mm3 (or CD4% < 14%)(CD4+ T-lymphocyte counts per microliter of blood) WALTER WASWA,BSC.MLS 99
  100. 100. normal Slightly Acute HIV disease Exposure to HIV Clinical latency period competence Progression of HIV infection Progression of HIV infection •• After initial infection withAfter initial infection with HIV, there is usually anHIV, there is usually an acute fluacute flu--like illness.like illness. •• This illness may includeThis illness may include •• FeverFever •• HeadacheHeadache •• TirednessTiredness Severely impaired Abnormal Slightly reduced Time Clinical latency period -declining CD4+ T cell amount AIDS Immunecompetence Opportunistic infections •• TirednessTiredness •• Enlarged lymph nodesEnlarged lymph nodes •• But after this mostBut after this most individuals are clinicallyindividuals are clinically asymptomatic for years.asymptomatic for years. This is called the clinicalThis is called the clinical latency period.latency period. WALTER WASWA,BSC.MLS 100
  101. 101. WHO clinical case definition for AIDS in South-East Asia • WHO clinical case definition for AIDS in South-East Asia Clinical AIDS in an adult is defined as an individual who has been identified as meeting the two criteria A and B below: A. Positive test for HIV infection by two tests based on preferably two different antigens. B. Any one of the following criteria: • - Weight loss of 10% body weight or cachexia, not known to be due to a condition unrelated to HIV infection - Chronic diarrhoea of one month's duration, intermittent or constant WALTER WASWA,BSC.MLS 101
  102. 102. WHO clinical case definition for AIDS in SouthWHO clinical case definition for AIDS in South-- East AsiaEast Asia • Disseminated, miliary or extra pulmonary tuberculosis • Candidiasis of the oesophagus; diagnosable as dysphasia, odynophagia and oral Candidiasisdysphasia, odynophagia and oral Candidiasis • Neurological impairment restricting daily activities, not known to be due to a condition unrelated to HIV (e.g. trauma) • Kaposi's sarcoma. WALTER WASWA,BSC.MLS 102
  103. 103. Stage 1Stage 1 -- PrimaryPrimary • Short, flu-like illness - occurs one to six weeks after infection • no symptoms at all • Infected person can infect other people• Infected person can infect other people WALTER WASWA,BSC.MLS 103
  104. 104. Stage 2Stage 2Stage 2 ---- AsymptomaticAsymptomaticAsymptomaticAsymptomatic • Lasts for an average of ten years • This stage is free from symptoms • There may be swollen glands• There may be swollen glands • The level of HIV in the blood drops to very low levels • HIV antibodies are detectable in the blood WALTER WASWA,BSC.MLS 104
  105. 105. - Symptomatic • The symptoms are mild • The immune system deteriorates• The immune system deteriorates • Emergence of opportunistic infections and cancers WALTER WASWA,BSC.MLS 105
  106. 106. - HIV AIDS • The immune system weakens • The illnesses• The illnesses become more severe leading to an AIDS diagnosis WALTER WASWA,BSC.MLS 106
  107. 107. Progression to AIDSProgression to AIDS •• During the latency period, lymph nodes and the spleen areDuring the latency period, lymph nodes and the spleen are sites of continuous HIV replication and cell destruction.sites of continuous HIV replication and cell destruction. •• The immune system remains competent at handling mostThe immune system remains competent at handling most infections with opportunistic microbes but the number ofinfections with opportunistic microbes but the number of CD4+ T cells steadily declines.CD4+ T cells steadily declines. Symptoms often experienced months to years before the onsetSymptoms often experienced months to years before the onset of AIDS.of AIDS. •• Lack of energyLack of energy •• Weight lossWeight loss •• Frequent fevers and sweatsFrequent fevers and sweats •• Persistent or frequent yeast infectionsPersistent or frequent yeast infections •• Persistent skin rashesPersistent skin rashes •• Dysfunction of CNSDysfunction of CNS WALTER WASWA,BSC.MLS 107
  108. 108. •• FinalFinal stage of HIV infectionstage of HIV infection -- AIDSAIDS •• Occurs when the destruction of peripheral lymphoid tissue isOccurs when the destruction of peripheral lymphoid tissue is complete and the blood CD4+ T cell count drops belowcomplete and the blood CD4+ T cell count drops below 200200 cells/mmcells/mm33. (Healthy adults usually have CD4+ T. (Healthy adults usually have CD4+ T--cell counts ofcell counts of 1,000 or more).1,000 or more). •• AIDSAIDS –– acquired immunodeficiency syndromeacquired immunodeficiency syndrome –– is marked byis marked by Progression to AIDSProgression to AIDS •• AIDSAIDS –– acquired immunodeficiency syndromeacquired immunodeficiency syndrome –– is marked byis marked by development of various opportunistic infections and malignancies.development of various opportunistic infections and malignancies. •• The level of virus in the blood and CD4+ T cell count can predictThe level of virus in the blood and CD4+ T cell count can predict the risk of developing AIDS. Vthe risk of developing AIDS. Voral titers often accelerate asoral titers often accelerate as the patient progresses towards AIDS.the patient progresses towards AIDS. •• Without treatment, at least 50% of people infected with HIVWithout treatment, at least 50% of people infected with HIV will develop AIDS within ten years.will develop AIDS within ten years. WALTER WASWA,BSC.MLS 108
  109. 109. Opportunistic Infections 109WALTER WASWA,BSC.MLS
  110. 110. -to-Baby • Before Birth • During Birth• During Birth • Postpartum –After the birth WALTER WASWA,BSC.MLS 110
  111. 111. How is HIV not spread?How is HIV not spread? • Shaking hands • Hugging • Swimming pools• Swimming pools • Toilet seats • Insect bites • Donating blood WALTER WASWA,BSC.MLS 111
  112. 112. THE NATIONAL HIV TESTING POLICYTHE NATIONAL HIV TESTING POLICY • No individual should be made to undergo a mandatory testing for HIV • No mandatory HIV testing should be imposed as a precondition for - Employment - Providing health care services and facilities- Providing health care services and facilities • Any HIV testing must be accompanied by a pretest and posttest counseling services (through VCTC) • Testing without consent – hindrance to the control of the epidemic WALTER WASWA,BSC.MLS 112
  113. 113. Pre--test Counseling explain to individualstest Counseling explain to individuals • Transmission • Prevention • Risk Factors • Voluntary &• Voluntary & Confidential • Report ability of Positive Test Results WALTER WASWA,BSC.MLS 113
  114. 114. Post--test Counselingtest Counseling • Clarifies test results • Need for additional testingadditional testing • Promotion of safe behavior • Release of results WALTER WASWA,BSC.MLS 114
  115. 115. Three types of tests (i) Screening tests - ELISA and simple/rapid tests. (ii) Confirmatory or supplemental tests- Western Blot assay.Western Blot assay. (iii) Nucleic acid and antigen screening tests. Polymerase chain reaction (PCR), Ligase chain reaction (LCR), Nucleic acid based Sequence assays (NASBA) and some ELISA tests. WALTER WASWA,BSC.MLS 115
  116. 116. Diagnosis of HIV •• Initial test for HIV is an indirect ELISA testInitial test for HIV is an indirect ELISA test •• Economic, rapid, performed easily, high sensitivityEconomic, rapid, performed easily, high sensitivity and specificityand specificity •• Detects antiDetects anti--HIV antibodies in patient serumHIV antibodies in patient serum•• Detects antiDetects anti--HIV antibodies in patient serumHIV antibodies in patient serum •• Antibodies are generally detectable within 3Antibodies are generally detectable within 3 months of infectionmonths of infection •• Antibodies are typically directed at the envelopeAntibodies are typically directed at the envelope glycoproteins (gp120 and gp41)glycoproteins (gp120 and gp41) WALTER WASWA,BSC.MLS 116
  117. 117. Absence of Antibodies to do not confirm absence of HIV infection •• Absence of antibody, as in ‘window period’ does notAbsence of antibody, as in ‘window period’ does not exclude the presence of the virus which can beexclude the presence of the virus which can be detected by PCR amplification approx. ten days afterdetected by PCR amplification approx. ten days after infectioninfection •• ‘Window period’‘Window period’ –– time between infection andtime between infection and detection of serological viral markerdetection of serological viral marker •• Direct ELISA for p24 antigen canDirect ELISA for p24 antigen can also be usedalso be used although the false negative rate is higheralthough the false negative rate is higher WALTER WASWA,BSC.MLS 117
  118. 118. EIA/ELISA Test PositiveNegative Repeat Positive HIV Testing No HIV Exposure Low Risk HIV Exposure High Risk Run IFA Confirmation Positive Positive End Testing Repeat ELISA Every 3 months for 1 year Negative PositiveNegativeIndeterminate Repeat at 2-4 months Repeat at 3 weeks Low Risk High Risk Negative HIV + Repeat every 6 months for continued High risk behavior WALTER WASWA,BSC.MLS 118
  119. 119. Diagnosis of HIV •• Positive or indeterminate ELISA tests for antiPositive or indeterminate ELISA tests for anti--HIV antibodiesHIV antibodies are confirmed by immunoblotting (Western Blotting) whichare confirmed by immunoblotting (Western Blotting) which identifies specific HIV virus proteinsidentifies specific HIV virus proteins •• PCR can also be usedPCR can also be used•• PCR can also be usedPCR can also be used •• Detects proDetects pro--viral DNA or viral RNAviral DNA or viral RNA •• It is highly sensitive and specific but is more costly thanIt is highly sensitive and specific but is more costly than ELISAELISA •• Can be used to test infants born to HIVCan be used to test infants born to HIV--infected mothersinfected mothers WALTER WASWA,BSC.MLS 119
  120. 120. Indirect ELISA test WALTER WASWA,BSC.MLS 120
  121. 121. Western blot Test •• Confirms HIV infectionConfirms HIV infection •• Proteins are separated by electrophoresisProteins are separated by electrophoresis and transferred to a nitrocelluloseand transferred to a nitrocellulose membrane by the passage of an electricmembrane by the passage of an electric currentcurrentcurrentcurrent •• The proteins are treated with antibodiesThe proteins are treated with antibodies •• Similar to ELISA technique, addition ofSimilar to ELISA technique, addition of secondary antibodies with an enzymesecondary antibodies with an enzyme attached allows the use of colour to detectattached allows the use of colour to detect a particular proteina particular protein WALTER WASWA,BSC.MLS 121
  122. 122. Western BlottingWestern Blotting •• A discrete protein band represents theA discrete protein band represents the specific antigen that the antibody recognizesspecific antigen that the antibody recognizes •• The bands from a positive Western blot areThe bands from a positive Western blot are from antibodies binding to specific proteinsfrom antibodies binding to specific proteins and glycoprotein's from the HIV virusand glycoprotein's from the HIV virus from antibodies binding to specific proteinsfrom antibodies binding to specific proteins and glycoprotein's from the HIV virusand glycoprotein's from the HIV virus •• The CDC recommends that the blot should beThe CDC recommends that the blot should be positive for two of the p24, gp41 andpositive for two of the p24, gp41 and gp120/160 markers (gp160 is the precursorgp120/160 markers (gp160 is the precursor form of gp41 and gp120, the envelope protein)form of gp41 and gp120, the envelope protein) WALTER WASWA,BSC.MLS 122
  123. 123. HIV Western blot WALTER WASWA,BSC.MLS 123
  124. 124. Rapid Tests •• ADVANTAGESADVANTAGES:: • quicker to perform – do not require batching – do not require specialised equipment or– do not require specialised equipment or trained personnel – results delivered on the same day • Only ‘WHO recommended’ Rapid HIV antibody tests should be used to ensure quality. WALTER WASWA,BSC.MLS 124
  125. 125. The ‘Window period’ Aware of it Follows acute infection with HIV, before HIV antibodies can be detected in the patient’s blood stream. • Patient is highly infectious, despite testing HIVPatient is highly infectious, despite testing HIV antibody negative, HIV is replicating rapidly in all body compartments. • Typically up to 12 weeks duration but may be shorter in more sensitive HIV antibody assays. WALTER WASWA,BSC.MLS 125
  126. 126. Paediatric HIV Testing Infants born to HIV infected mothers will have antibodies to HIV in their serum as a result of: – maternal-fetal transfer during pregnancy – delivery– delivery – breast-feeding they may not necessarily be infected ! WALTER WASWA,BSC.MLS 126
  127. 127. Treatment of HIVTreatment of HIV •• Eradication of HIV infection not possible with currently availableEradication of HIV infection not possible with currently available drugsdrugs •• Viral replication can not be completely suppressedViral replication can not be completely suppressed •• Latently infected CD4+ T cells established at early stageLatently infected CD4+ T cells established at early stage •• Goals of antiretroviral therapy are to:Goals of antiretroviral therapy are to: -- Suppress viral replicationSuppress viral replication-- Suppress viral replicationSuppress viral replication -- Restore and/or preserve immune functionRestore and/or preserve immune function -- Improve quality of lifeImprove quality of life -- Reduce HIVReduce HIV--associated morbidity and mortalityassociated morbidity and mortality •• Combinations of antiretroviral drugs are usedCombinations of antiretroviral drugs are used •• Referred to as HAART (highly active antiretroviral therapy)Referred to as HAART (highly active antiretroviral therapy) •• Suppress levels of plasma viraemia for long periodsSuppress levels of plasma viraemia for long periods •• Plasma viraemia is a strong prognostic factor in HIV infectionPlasma viraemia is a strong prognostic factor in HIV infection WALTER WASWA,BSC.MLS 127
  128. 128. Antiretroviral DrugsAntiretroviral Drugs •• Significant declines in AIDS related morbidity and mortality are seenSignificant declines in AIDS related morbidity and mortality are seen as a result of HAARTas a result of HAART •• Several strategies for development of effective antiviral drugsSeveral strategies for development of effective antiviral drugs •• Potential therapies based on knowledge of the way in which HIVPotential therapies based on knowledge of the way in which HIV gains access into the cells and its method of replicationgains access into the cells and its method of replicationgains access into the cells and its method of replicationgains access into the cells and its method of replication •• Targets for therapeutic antiTargets for therapeutic anti--retroviral drugs:retroviral drugs: -- Inhibiting reverse transcriptionInhibiting reverse transcription -- Inhibiting proteasesInhibiting proteases -- Inhibiting integrateInhibiting integrate –– interferes with integration of viralinterferes with integration of viral DNA into host genomeDNA into host genome -- Inhibiting fusionInhibiting fusion –– prevents virus from fusing with host cellprevents virus from fusing with host cell WALTER WASWA,BSC.MLS 128
  129. 129. Therapeutic OptionsTherapeutic Options •• Combination of RT inhibitors protease inhibitorsCombination of RT inhibitors protease inhibitors results in potent antiresults in potent anti--viral activityviral activity •• In most cases, two nucleoside analogues and oneIn most cases, two nucleoside analogues and one protease inhibitor are taken togetherprotease inhibitor are taken togetherprotease inhibitor are taken togetherprotease inhibitor are taken together •• HAART lowers plasma viral loads in many cases toHAART lowers plasma viral loads in many cases to levels not detectable by current methodslevels not detectable by current methods •• Has improved the health of AIDS patients to theHas improved the health of AIDS patients to the point that they can function at a normal levelpoint that they can function at a normal level WALTER WASWA,BSC.MLS 129
  130. 130. AIDS (Pregnancy & AIDS) • Zidovudine(AZT) – recommended for px of maternal fetal HIV transmission & administered after 14 months AOG (PO meds); IVIT during labor;/ neonate post birth for 6 wks. Restrict breastfeeding –infant/neonate is seen byRestrict breastfeeding –infant/neonate is seen by physician at birth, 1 wk. or 2 wks., a mos., 2 mos., & 4 mos. of life * Neonate- asymptomatic for 1st several yrs. Of life & monitored for early sign of immunodeficiency WALTER WASWA,BSC.MLS 130
  131. 131. Antiretroviral DrugsAntiretroviral DrugsAntiretroviral DrugsAntiretroviral Drugs • Nucleoside Reverse Transcriptase inhibitors – AZT (Zidovudine) • Non-Nucleoside Transcriptase inhibitors – Viramune (Nevirapine)– Viramune (Nevirapine) • Protease inhibitors – Norvir (Ritonavir) WALTER WASWA,BSC.MLS 131
  132. 132. Prevention and control of HIVPrevention and control of HIV • Education • Prevention of blood born HIV transmission • Anti Retro Viral treatment • Combination therapy• Combination therapy • Post exposure prophylaxis • Specific prophylaxis • Primary health care WALTER WASWA,BSC.MLS 132
  133. 133. HIV Occupational ExposureHIV Occupational Exposure • Review facility policy and report the incident • Medical follow-up is necessary to determine the exposure risk and course of treatment • Baseline and follow-up HIV testingBaseline and follow-up HIV testing • Four week course of medication initiated one to two hours after exposure • AZT (200mg)-TID +lamivudine(3TC)(150mg)BID x 4days • Nelfinavir (750 mg) TID ,AZT/3TC • Exposure precautions practiced WALTER WASWA,BSC.MLS 133
  134. 134. HIV NonHIV Non--Occupational ExposureOccupational Exposure • No data exists on the efficacy of antiretroviral medication after non-occupational exposures PREVENTIONPREVENTION ------ FIRSTFIRST • The health care provider and patient may decide to use antiretroviral therapy after weighing the risks and benefits • Antiretroviral should not be used for those with low-risk transmissions or exposures occurring more than 72 hours after exposure WALTER WASWA,BSC.MLS 134
  135. 135. Play safePlay safe • Use the common sense Be faithful to one partner,partner, Use Condom. • Antiretroviral drugs • Caesarean delivery WALTER WASWA,BSC.MLS 135
  136. 136. AbstinenceAbstinenceAbstinence • It is the only 100 % effective method of not acquiring HIV/AIDS. • Refraining from sexual contact: oral, anal, or vaginal. • Refraining from intravenous drug use WALTER WASWA,BSC.MLS 136
  137. 137. Monogamous relationshipMonogamous relationshipMonogamous relationship • A mutually monogamous (only one sex partner) relationship with a person who is not infected with HIV • HIV testing before intercourse is necessary to proveHIV testing before intercourse is necessary to prove your partner is not infected WALTER WASWA,BSC.MLS 137
  138. 138. Sex EducationSex Education –– Best option to PreventBest option to Prevent AIDSAIDS Move from Past to FutureMove from Past to Future WALTER WASWA,BSC.MLS 138
  139. 139. World AIDS DayWorld AIDS Day,, • World AIDS Day, observed December 1 each year, is dedicated to raising awareness of the AIDS pandemic caused by the spread of HIV infection. It is common to hold memorials toinfection. It is common to hold memorials to honour persons who have died from HIV/AIDS on this day. Government and health officials also observe the event, often with speeches or forums on the AIDS topics. WALTER WASWA,BSC.MLS 139
  140. 140. TRICHOMONIASIS • Single celled protozoa • Men and women can be infected • Remains dormant in asymptomatic women • Causes vaginal irritation,itching, and difuse• Causes vaginal irritation,itching, and difuse malodorous dischare in symptomatic women • Women may see red spots on the vaginal walls • Most men are asymptomatic • Both partner must be treated WALTER WASWA,BSC.MLS 140
  141. 141. CANDIDIASIS • NOT sexually transmitted Symptoms a) Itching b) Dischargeb) Discharge c) Burning/irritation • Pregnant women, diebetes, obesity, suppressed immunity, antibiotics, corticosteroids or birth control pills commonly experience yeast infection WALTER WASWA,BSC.MLS 141
  142. 142. Bacteria vaginosis • Discharge is white and ordorous Symptoms • Cervicitis • PID • Pospartum endometritis• Pospartum endometritis • Proamture labour • Recurring UTI TREATMENT • Oral,cream,or gel application of flagyl • Male partner also treated if infection recurs WALTER WASWA,BSC.MLS 142
  143. 143. ECTOPARASITE • Pubic lice • Thru sexual contact/infected clothing • Symptoms: little to severe itchiness• Symptoms: little to severe itchiness • Treatment:pyrinate • Clean clothing/no sharing inner pants WALTER WASWA,BSC.MLS 143
  144. 144. ECTOPARASITES • Scabies:close physical /sexual contact/infected clothing • Symptoms • small.,red rash arround primary lesion,intense itching esp.night • Treatment:topical scabicide,clean clothing WALTER WASWA,BSC.MLS 144
  145. 145. Treponema pallidum – The Agent of Syphilis • Spirochete • Obligate human parasite • Transmission – Sexual – Trans-placental– Trans-placental – Percutaneous following contact with infectious lesions – Blood Transfusion • No reported cases of transmission since 1964 5WALTER WASWA,BSC.MLS 145
  146. 146. Pelvic Inflammatory Disease (PID) • l0%-20% women with GC develop PID • In Europe and North America, higher proportion of C. trachomatis than N. gonorrhoeae in women with symptoms of PID • CDC minimal criteria Drips 146 • CDC minimal criteria – uterine adnexal tenderness, cervical motion tenderness • Other symptoms include – endocervical discharge, fever, lower abd. pain • Complications: – Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia – 7X risk of ectopic pregnancy with 1 episode PID – chronic pelvic pain in 18% WALTER WASWA,BSC.MLS
  147. 147. Chancroid • The combination of a painful genital ulcer and tender Suppurative inguinal adenopathy suggests the diagnosis of Chancroid A probable diagnosis of Chancroid, for both clinical and surveillance purposes, can be made if all of the following criteria are met: purposes, can be made if all of the following criteria are met: 1) the patient has one or more painful genital ulcers; 2) the patient has no evidence of T. pallidum infection by dark field examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers; WALTER WASWA,BSC.MLS 147
  148. 148. Chancroid • 3) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for if present, regional lymphadenopathy are typical for Chancroid; and 4) a test for HSV performed on the ulcer exudate is negative. WALTER WASWA,BSC.MLS 148
  149. 149. Chancroid • A definitive diagnosis of Chancroid requires the identification of H. ducreyi on special culture media thatducreyi on special culture media that is not widely available from commercial sources; even when these media are used, sensitivity is <80% (145). WALTER WASWA,BSC.MLS 149
  150. 150. Granuloma Inguinale (Donovanosis)Granuloma Inguinale (Donovanosis) • Granuloma inguinale is a genital ulcerative disease caused by the intracellular gram- negative bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium(formerly known as Calymmatobacterium granulomatis). The disease occurs rarely in the United States, although it is endemic in some tropical and developing areas, including India; Papua, New Guinea; the Caribbean; central Australia; and southern Africa (192,193). WALTER WASWA,BSC.MLS 150
  151. 151. Granuloma Inguinale (Donovanosis) • Clinically, the disease is commonly characterized as painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy;without regional lymphadenopathy; subcutaneous granulomas (pseudoboboes) might also occur. The lesions are highly vascular (i.e., beefy red appearance) and bleed easily on contact. WALTER WASWA,BSC.MLS 151
  152. 152. Granuloma Inguinale (Donovanosis) • The causative organism is difficult to culture, and diagnosis requires visualization of dark- staining Donovan bodies on tissue crush preparation or biopsy. No FDA-clearedpreparation or biopsy. No FDA-cleared molecular tests for the detection of K. granulomatis DNA exist, but such an assay might be useful when undertaken by laboratories that have conducted a CLIA verification study. WALTER WASWA,BSC.MLS 152
  153. 153. Lymph granulomaLymph granuloma VenereumVenereum • Lymph granuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3 . The most common clinical manifestation of LGV amongmanifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. WALTER WASWA,BSC.MLS 153
  154. 154. Lymph granuloma Venereum • Diagnosis is based on clinical suspicion, epidemiologic information, and the exclusion of other Aetiologies for proctocolitis, inguinal lymphadenopathy,proctocolitis, inguinal lymphadenopathy, or genital or rectal ulcers. C. trachomatis testing also should be conducted, if available. WALTER WASWA,BSC.MLS 154
  155. 155. Lymph granuloma Venereum • Genital and lymph node specimens (i.e., lesion swab or bubo aspirate) can be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection. NAATs for C. trachomatis are not FDA-cleared for testing rectal specimens, although some NAATs for C. trachomatis are not FDA-cleared for testing rectal specimens, although some laboratories have performed the CLIA validation studies that are needed to provide results for clinical management. Additional molecular procedures (e.g., PCR-based genotyping) can be used to differentiate LGV from non-LGV C. trachomatis, but these are not widely available. WALTER WASWA,BSC.MLS 155
  156. 156. Lymph granuloma Venereum • chlamydia serology (complement fixation titers >1:64) can support the diagnosis of LGV in the appropriate clinical context. Comparative data between types of serologicComparative data between types of serologic tests are lacking, and the diagnostic utility of serologic methods other than complement fixation and some micro immunofluorescence procedures has not been established. WALTER WASWA,BSC.MLS 156
  157. 157. Trichomoniasis• An estimated 5 million new cases occur each year in women and men. • Occurs in vagina of women so may be sexually transmitted to men using infected washcloths and towels. • It is transmitted to the baby during delivery. • It also can occur in the urethra (carries urine to penis) in men, doesn’t have symptoms usually. SYMPTOMS: Appear within 5 to 28 days of exposureAppear within 5 to 28 days of exposure Women usually have a vaginal discharge that FEMALE SYMPTOMS: Itching and burning at the outside of the opening of the vagina and vulva. Painful and frequent urination Heavy, unpleasant smelling greenish, yellow discharge MALE SYMPTOMS: Usually nothing, or discomfort in urethra, inflamed head of the penis. WALTER WASWA,BSC.MLS 157
  158. 158. Consequences of untreated STD • Ectopic pregnancy • Increased risk of cervical cancer • Chronic abdominal pain • Children can be infected at birth causing• Children can be infected at birth causing blindness ns damage/death WALTER WASWA,BSC.MLS 158
  159. 159. PREVENTION of STIs • Abstinence give 100% effective method to prevention • Avoid multiple partners • Condoms/spermicides• Condoms/spermicides • Most STI can be treated • All STI can be prevented • Early diagnosis and treatment can decrease the possibility of serious complications such as infertility in both men and women WALTER WASWA,BSC.MLS 159
  160. 160. WHY IS STI CONTROL DIFFICULT • Many people carry the infections without knowing it WALTER WASWA,BSC.MLS 160
  161. 161. Life at Risk with Sexually Transmitted Infections Best Choice Play safe WALTER WASWA,BSC.MLS 161

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