Transcript 2.HIV & STD診斷與治療short-
青少年性病與愛滋病之 診斷與治療
衛生署 疾病管制局 中區傳染病防治醫療網 王任賢 指揮官
HIV/AIDS
Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome 2
What Is HIV/AIDS?
• Acquired immunodeficiency syndrome (AIDS) is caused by the human immunodeficiency virus (HIV).
• HIV attacks and destroys white blood cells, causing a defect in the body ’ s immune system.
• The immune system of an HIV-infected person becomes so weakened that it cannot protect itself from serious infections. When this happens, the person clinically has AIDS.
• AIDS may manifest as early as 2 years or as late as 10 years after infection with HIV.
3
Clinical Spectrum of AIDS
• Group 1: Acute infection 0-3 weeks • Window period: Seroconversion 3-12 weeks • Group 2: Asymptomatic infection 0-10 years • Group 3: Persistent generalized LAP • Group 4: Other HIV-related diseases – Constitutional diseases – Neurological disorders – Opportunistic infections – Secondary neoplasms – Other conditions 4
1200 1100 1000 900
Natural History of HIV Infection Without the Use of Antiretroviral Tx
Primary Infection + Acute HIV syndrome Wide dissemination of virus Seeding of lymphoid organs Opportunistic Diseases Death 10 7 10 6 Clinical latency 800 700 600 500 400 300 200 100 0 0 1 3 Constitutional Symptoms 10 5 10 4 10 3 10 2 Years Weeks Source: Fauci, A., Pantaleo, D., Stanley S., Weismann, D. Annals of Internal Medicine 124: 6754-3, 1996
Signs and Symptoms of AIDS
• Fever of unknown origin • Enlarged lymph glands • Skin rashes and cough • Persistent diarrhea • Severe weight loss • Skin lesions • Loss of appetite and fatigue 6
Signs and Symptoms in HIV Disease
Symptom Pain Tiredness Anxiety Sleep disturbance Mouth sore Sadness Weight loss Nausea
* n=314
Prevalence* 52% 50% 40% 37% 33% 32% 31% 28% Symptom Fever Cough Depression Diarrhea Skin Problem Pruritus Respiratory problem Vomiting Prevalence 27% 27% 24% 24% 24% 23% 22% 20%
J Palliative Care
, 1994: 10(2): 95.
Diagnosis of HIV
Mainly serological • Through antibody testing with ELISA; if positive, confirmation by Western Blot • Culture of blood and tissues • RT-PCR ： mainly for follow up 9
HIV test and counseling
Treatment of HIV Infected Patients
• At present, no drug or therapy can cure AIDS • Availability of anti-AIDS vaccines appears unlikely in the near future • A combination of three antiretrovirals (ARVs) is the gold standard for treatment • ARVs are not universally available, are very expensive and must be administered correctly 13
性病之診斷分類及治療
性病之分類
• • • • • 尿道炎及子宮頸炎 陰部潰瘍 鼠蹊淋巴腫 陰部新生物 全身性感染
男性尿道炎
• • • 症狀 – 分泌物、小便疼痛、尿道口癢 病原菌 – Neisseria gonorrhoeae – Chlamydia trachomatis – Ureaplasma urealyticum ? – Herpes simplex virus – Trichomonas vaginalis 鑑別診斷 – 臨床症狀、潛伏期、 實驗室診斷
確認男性尿道炎
• Urethral Gram-stained smear > 5 PMNs/1,000X • Subjective urethritis symptoms + objective urethral discharge • Only subjective urethritis symptoms avoid urination 4-8 hr & reexamine in 7 days • First 5-10 CC of voided urine + centrifuge Gram-stained sediment > 15 PMNs/500X
尿道炎病患檢
查 • Gram’s stain • Culture for N. gonorrhoeae • Culture for C. trachomatis
Culture for N. gonorrhoeae
• Specimen for culture – male: urethral discharge – female: cervical discharge • Sampling and transportation – cotton in plastic swab & candle jar • Media for growth – chocolate agar – modified Thayer-Martin agar
Culture for C. trachomatis
• Specimen for culture – male: urethral swab – female: swab of cervical cannel • Sampling and transportation – cotton in plastic swab – SPG or 2SP in iced water • Technique for culture – shell vial technique
淋病
• 治療方式： – Routine treatment • ceftriaxone 125 mg IM • cefixime 400 mg PO – Disseminated gonococcal infection (DGI) • ceftriaxone 1 gm IV qd until S/S improve • + cefixime 400 mg PO bid for 10-14 days
淋病
• 通報定義 – 由醫師臨床診斷感染淋病，且符合實驗室 診斷定義者。 – – 實驗室診斷定義：由染色鏡檢或培養分離 出淋菌雙球菌，或使用 PCR 或其他檢驗方 式偵測出淋菌抗原或基因。 需 1 週 內通報。
披衣菌尿道炎及子宮頸炎
• 治療方式： – Routine treatment • azithromycin 1 gm PO, single dose • tetracycline 500 mg q6h for 7 days • ofloxacin 300 mg PO bid for 7 days – Pregnant women • azithromycin 1 gm PO, single dose
尿道炎治療後症狀
• 若治療後，尿道炎症狀持續，該怎麼辦： – – – – 追出性伴侶，並給予治療 重新確認尿道炎的存在 若無尿道炎存在，只需加強病人信心即可 若仍有尿道炎存在，可給予 metronidazole 2 gm PO stat – 慢性攝護腺炎 ( 不可能 )
陰道分泌物之鑑別診斷
• • • • 白帶 (bacterial vaginosis) – high pH, Lactobacilli (-), Whiff test (+), fish odor, clue cell 念珠菌陰道炎 (Candida vaginitis) – 糖尿病、懷孕、避孕藥、長期使用類固醇 陰道滴蟲症 (Trichomonas vaginitis) – 淺綠色泡沫狀分泌物，奇癢無比 子宮頸炎
陰道分泌物之治療
• • • • 白帶 – metronidazole 500 mg PO bid for 7 days 念珠菌陰道炎 – fluconazole 150 mg PO once 陰道滴蟲症 – metronidazole 2 gm PO once 子宮頸炎 – 治療同男性尿道炎
陰部潰瘍
• 原因： – Primary syphilis (chancer) – Chancroid (Hemophilus ducreyi) – Genital herpes – Trauma
陰部潰瘍的鑑別診斷
• 鑑別診斷 – – – – – 外型，是否疼痛 病史 潛伏期 鼠蹊部淋巴腫 實驗室診斷
Specimen preparation in darkfield examination
• Clean up lesion with saline • Scrape lesion gently until exudation, avoid bleeding • Squeeze out exudate & wipe off with slide • Add a drop of saline • Observe in darkfield microscope
梅毒之血清學診斷 (1/2)
• • 當血中 VDRL(+) 時： – – 若 TPHA>1:80, 代表現在或以前曾有梅毒 若 TPHA<1:80, 代表 VDRL(+) 非由梅毒造成 何種情況下表示 梅毒仍有活性 ?
– 有明顯早期梅毒症狀，而血清反應呈陽性 者 – – – 二次血清 STS 有四倍上升者 經 BPN 治療 6 個月後 STS 有四倍下降者 未經治療者，單次血清 VDRL(+),TPHA>1:1280
梅毒之血清學診斷 (2/2)
• • 何種情況下表示 梅毒已沒有活性 ?
– – 經完整 BPN 治療，且沒再接觸梅毒病患者 經完整 BPN 治療， 6 月後 STS 並沒有 4 倍變 動者 – 無症狀病患 ,STS 維持低而穩定的效價時 若您對梅毒的活性有任何疑問時： – 可給予病患 BPN 治療以觀測 STS 的變化， 但在您尚未診斷出有活性梅毒前，請勿輕 易向病患下診斷 。
梅毒
• 治療方式： – 感染梅毒一年以 內 • benzathine penicillin 2.4 MU IM once – 感染梅毒一年以上，無侵犯中樞神經者 • benzathine penicillin 2.4 MU IM qwk X 3 – 感染梅毒一年以上，有侵犯中樞神經者 • aqu PCG 3 MU q4h IV for 10 days + benzathine penicillin 2.4 MU IM qwk X 3
梅毒
• 通報範圍 – – 活性梅毒通報定義：同時符合通報條件 1+2 或僅符合通報條件 3 者。 非活性梅毒通報定義：僅符合通報條件 2 者。
梅毒
• • 通報條件 – 臨床症狀出現硬下疳或全身性梅毒紅疹等 臨床症狀。 – 未曾接受梅毒治療或病史不清楚者， RPR （ + ） 或 VDRL （ + ），且 TPHA=1 ： 320 以上 ( 包括 320) 。 – 曾經接受梅毒治療者， VDRL 價數上升四倍。 需 1 週 內通報。
軟下疳 (chancroid)
• • • • • 潰瘍很痛，而且很髒 病原菌 – Hemophilus ducreyi ，極難培養 診斷 – school of fish appearance in smear 病患多接觸過妓女 治療 – azithromycin 1 gm PO once – ceftriaxone 250 mg IM once
Genital Herpes
• • • 會再發且不會好的病 藥物治療可縮短病變及疼痛時間 藥物沒法治癒此病
傳統陰部疱疹
• 治療方式： – 初次發作 • acyclovir 400 mg PO tid for 7-10 days – 初次發作並侵犯到直腸或膀胱 • acyclovir 400 mg PO 5/D for 7-10 days – 嚴重的再發 • acyclovir 400 mg PO tid for 5 days – 預防性療法 • acyclovir 400 mg PO bid for 1 year
鼠蹊肉芽腫 (lymphogranuloma venerum)
• • • • • • 病原菌 – Chlamydia trachomatis 單獨淋巴腫而沒有潰瘍， groove sign (+) 男：女 =10 ： 1 女性多以陰部水腫或瘺管表現 診斷 – 淋巴結抽取液培養，血清學檢 查 治療 – tetracycline 500 mg q6h for 3 weeks
菜花 (anogenital warts)
• Condylomata acuminata • Human papilloma virus • Cauterization – 30-50% bi- or trichloroacetic acid liquid nitrogen 10% podophyllin resin 1% podophyllotoxin (condylox) carbon dioxide laser
Pelvic inflammatory disease
• Clinical diagnosis by exclusion of ectopic pregnancy and appendicitis • Endogenous – β-lactam/b-lactamase inhibitor • Exogenous – ceftriaxone + azithromycin • Remove IUD