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Syphilis and HIV Management in the Primary Care Setting

Syphilis and HIV Management in the Primary Care Setting. Jonathan Vilasier Iralu, MD, FACP NAIHS Infectious Disease Consultant. Syphilis Overview. Sexually transmitted disease Caused by Treponema pallidum, a microaerophillic, corkscrew shaped bacteria HIV positive patients have

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Syphilis and HIV Management in the Primary Care Setting

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  1. Syphilis and HIV Management inthe Primary Care Setting Jonathan Vilasier Iralu, MD, FACP NAIHS Infectious Disease Consultant

  2. Syphilis Overview Sexually transmitted disease Caused by Treponema pallidum, a microaerophillic, corkscrew shaped bacteria HIV positive patients have More constitutional symptoms More organ involvement Worse rashes

  3. Syphilis Epidemiology Transmission by Sexual contact Passage through placenta Kissing or other contact with active lesion Transfusion of blood Accidental direct inoculation

  4. Syphilis Pathophysiology T pallidum divides every 30 to 33 hours Invades locally but disseminates widely 30% of 58 patients with early syphilis in one study had organisms isolatable from CSF Local lesions are marked by plasma cell, lymphocyte and histiocyte infiltration first then capillary proliferation and finally, necrosis with ulceration.

  5. Primary Syphilis Findings Primary Syphilis(21 day incubation) Chancre (heals 3-6 weeks) Regional lymphadenopathy (starts 1 wk later) RPR/VDRL positive in 78% (74-87% range) HIV positive patients have multiple chancres in 25% of cases

  6. Syphilis Clinical Stages Secondary Syphilis(2-8 weeks post chancre) palmar/plantar rash macular, papulosquamous, pustular syphilides condylomata lata/mucous patches alopecia (alopecia areata) Pharyngitis, epitrochlear adenopathy,myalgia, weight loss, aseptic meningitis 1-2%, proteinuria, hepatitis, uveitis RPR/VDRL positive in 100% of cases

  7. Secondary syphilis and HIV Ulceronodular syphilis and Lues Maligna are more common HIV positive patients are more likely to have simultaneous overlap of secondary syphilis with primary syphilis

  8. Latent Syphilis Early Latent Syphilis Seroconversion within the last year primary or secondary lues within 1 year Contact of a primary, secondary or EL case Late Latent Syphilis: present > 1 year Latent Syphilis of Unknown Duration

  9. Neurosyphilis Meningovascular (infarction) Stroke syndromes (aphasia, hemiparesis, seizures) Parenchymal (neuron destruction) Tabes dorsalis (foot slap, wide based gait, lightning pains, (+) Romberg, Charcot Joints) General paresis (Personality, Affect, Reflexes, Eye, Sensorium, Intellect, Speech) Other:Gunbarrel sight (optic atrophy), uveitis, CN VII and VIII palsy, syphilitic otitis (deafness and tinnitus)

  10. Neurosyphilis and HIV 23% of HIV positive vs 10% of HIV negative patients get neurosyphilis HIV causes more rapid progression to neurosyphilis (3-fold increase if CD4< 350) Uveitis, especially with bilateral involvement is more frequent in HIV-positive patients

  11. Other Tertiary Syphilis Dx Cardiac Syphilis Aortitis-endarteritis obliterans of vasa vasorum Saccular aortic aneurysm Secondary aortic insufficiency Aortitis may develop more rapidly if HIV (+) but is rare since syphilis is usually diagnosed early in HIV Benign Gummatous Syphilis Develop in 10 years if HIV negative Develop in months if HIV positive

  12. Syphilis Diagnosis in the HIV (+) False positive RPR/VDRL seen in HIV positive patients 11% of the time. False negative VDRL seen in 7.3% of HIV positive patients with latent syphilis

  13. Syphilis Management Primary and secondary Syphilis Dark-field exam of skin lesions if available Draw RPR and HIV serology Administer Benzathine penicillin 2.4 mU IM R/O optic/neurosyphilis if symptomatic Check RPR at 6 and 12 months- if < 4-fold drop at 6 months, LP, re-check HIV and re-treat with three weekly doses of LAB.

  14. Syphilis Management Latent Syphilis Check RPR (reflex MHA TP) and HIV test Careful genital exam LP if symptomatic, tertiary lesion, treatment failure or HIV positive and late unknown duration. Give Benzathine PCN 2.4 mU IM once if early latent, weekly x3 if late latent or unknown duration.

  15. Syphilis Management Latent syphilis follow-up RPR at 6, 12 and 24 months LP and retreat if titer rises 4 fold titer fails to fall 4 fold by 12-24 months Signs or symptoms of syphilis recur

  16. Syphilis Management Neurosyphilis: PCN G 18-24 mU IV/day for 10-14 days Procaine 2.4 mU IM/day plus Probenecid 500 mg po QID for 10-24 days. LP every 6 months until cell count normal Cardiac or Gummatous syphilis Benzathine PCN 2.4 mU IM q wk x 3

  17. Syphilis Special Considerations Pregnancy Treat as appropriate for stage with penicillin Fetal Ultrasound and HIV test Beware Jarisch-Herxheimer reaction

  18. Syphilis Treatment: HIV Positive Treat exactly as for HIV negative low threshhold for LP- 3 schools of thought: LP all syphilis cases LP all latent and late syphilis cases but reserve LP in 1o & 2o syphilis for patients with CD4 count < 350 or RPR titer > 1:32 Only LP if symptomatic with focal neuro exam Check RPR every 3 months (not 6 months)

  19. Acute Retroviral Syndrome • Fever 96% • Adenopathy 74% • Pharyngitis 70% • Rash 70% • Myalgias 54% • Diarrhea 32% • Headache 32% • N & V 27% • HSM 14% • Thrush 12% • Weight loss 13% • Neurologic Sx 12%

  20. Acute Retroviral Syndrome • Who should be treated? • DHHS considers treatment “Optional” • CIII recommendation • Many patients can delay Rx for years • Baseline drug resistance assays should be sent • Boosted protease inhibitor regimens are preferred

  21. Acute Retroviral Syndrome • Treat with the usual 3 drug combinations • Follow the CD4 and Viral Load q 3-4 months • Duration: • Studies underway • Continue indefinitely?

  22. Post exposure prophylaxis(PEP) for Health Care Workers Risk 0.3% per incident Risky: deep wounds, large volumes or high viral load Median seroconversion in 46 days (x = 65) 95% seroconvert by 6 months Retrospective case control study: Zidovudine administered to exposed HCW’s 81% decrease in HIV transmission per exposure

  23. Recommended PEP drugs • Nucleoside/tide Reverse Transcriptase Inhibitors • Zidovudine/Lamivudine • Tenofovir/Emtricitabine • Protease Inhibitor • Lopinavir/ritonavir

  24. Post exposure prophylaxis Health Care Workers • PEP is best started immediately • Call PEP-Hotline if > 24-36 hr delay • PEP should be given for 4 weeks. • Followup testing at 6 weeks, 12 weeks and 6 months is necessary on the HCW. • PEP Hotline 1-888-448-4911

  25. Non occupational HIV Exposure • Risk of transmission- needle exposure: • 0.67% per episode of intravenous puncture • 0.4% per episode of percutaneous puncture • Risk of transmission-sexual exposure: • 1-3% for receptive anal contact • 0.1-0.2% for receptive vaginal contact • < 0.1% risk with insertive vaginal contact

  26. Non occupational HIV Exposure • Offer PEP if source is HIV positive • Mucous membrane, non-intact skin, or percutaneous exposure to bodily fluids • Receptive and insertive vaginal and anal intercourse • Receptive oral intercourse with ejaculation • Eye exposures to seminal fluid • Start therapy if exposure occurred < 72 hrs ago

  27. Non occupational HIV Exposure • How to handle non-occupational exposure • Evaluate for other STD’s • Contraception if indicated • Evaluate IDUs for HBV and HCV • Check HIV Ab at 0, 6 weeks, 12 weeks, 6 months • Counseling for risk reduction

  28. Fever Differential Diagnosis • M. avium Bacteremia • Miliary Tuberculosis • Disseminated Pneumocystis • Cryptococcosis • Disseminated Coccidioidomycosis • Bacillary Angiomatosis • CMV • Non-Hodgkin’s Lymphoma

  29. Initial Fever Evaluation • CMP, CBC, CXR, Blood Cultures • Bactec Blood Culture • PPD skin test • Lumbar Puncture • Sputum induction for PCP and AFB • Dilated fundoscopic exam

  30. Fever Evaluation continued • Abdominal CT • Bone Marrow • Consider: • Liver biopsy • Skin biopsy • Endoscopy

  31. M. avium Review • Patients present with fever, sweats and diarrhea. • Cachexia, hepatosplenomegaly and lymphadenopathy are often seen. • Cytopenias and elevated alkaline phosphatase are commonly seen.

  32. MAC Diagnostics • Bactec Blood cultures in NM and AZ. • Other helpful cultures • Bone Marrow • Gut • Sputum and stool Cx are not reliable.

  33. MAC Therapeutics • Basic Therapy • Clarithromycin 500 mg po BID • Plus • Ethambutol 15-20 mg/kg po QD • Addition of Rifabutin 300 to 450 mg po QD is optional • Azithro- is better than clarithro- if on HAART

  34. MAC Therapeutics • Salvage Regimen • Amikacin 10 mg/kg iv QD or 22 mg/kg iv TIW • plus either • Ciprofloxacin 500 mg po BID • or • Rifabutin 300-450 mg po QD

  35. Pulmonary Infiltrate Differential • Bacterial pneumonia • Tuberculosis • M kansasii • Pneumocystis • Toxoplasmosis • Cryptococcosis • Coccidioidomycosis • Blastomycosis • Aspergillosis • Strongyloidiasis • CMV • VZV • Kaposi’s Sarcoma • Lymphoma • Lymphocytic Interstitial Pneumonitis

  36. Initial evaluation of infiltrates • Routine Gram stain and culture • Blood cultures • Sputum AFB smear and culture X 3 • Induced sputum for PCP immunofluorescence

  37. Pulmonary Infiltrate Therapy • Typical pneumonia, CD4 > 200 • -Third generation cephalosporin plus a macrolide • Atypical pneumonia, CD4 < 200 • Trimethoprim/Sulfa plus a cephalosporin plus a macrolide

  38. Further Infiltrate evaluation • What to do next if routine tests are negative • Bronchoalveolar Lavage • Transbronchial lung biopsy • Transcutaneous lung biopsy

  39. PCP Review • Biology • Now officially called Pneumocystis jiroveci • Now officially a fungus • Diagnosis • Induced sputa are useful in an experienced lab (not in the IHS) • BAL specimen for PCP immunofluorescence is diagnositic • BAL for GMS/PAS stain useful on the Rez • PCP PCR of sputum or BAL • b-D Glucan blood assay

  40. PCP Review • Treatment Options: • TMP-Sulfa 5 mg/kg IV or po q 8 hrs for 21 days • Use adjunctive steroids if hypoxic • Alternate RX: • Trimethoprim-Dapsone • Primaquine/Clindamycin • Pentamidine IV • Atovaquone

  41. Diarrhea • Chronic • CMV • Microsporidia • Cryptosporidia • MAC • Isospora • Cyclospora • Giardia • Acute • Shigella • Salmonella • Campylobacter • C. Difficile

  42. Diarrhea • Bloody • Shigella • Salmonella • Campylobacter • C. difficile • CMV • Entamoeba • Watery • Microsporidia • Cryptosporidia • MAC • Isospora • Giardia • Entamoeba • Cyclospora

  43. Diarrhea work up • Initial evaluation • CBC, electrolytes, BUN, Creatinine, LFTS • Routine stool culture • Clostridium difficile toxin assay • Stool Ova and Parasites exam • Stool Trichrome stain • Stool Modified AFB Stain

  44. Diarrhea workup • Further workup • Upper endoscopy with small bowel Bx. • Colonoscopy with Bx.

  45. Diarrhea Treatment Specific agents • Cryptosporidia Paromomycin, Azithromycin • Microsporidia Fumagillin, Albendazole • Chronic diarrhea due to cryptosporidiosis and microsporidiosis are now usually treated with HAART and not a specific agent

  46. Differential for paralysis in AIDS • Brain • Toxoplasmosis • Lymphoma • TB • Cryptococcosis • Nocardia • Brain abscess • PML • Upper motor neuron • Vacuolar myelopathy • TB • Lymphoma • Epidural abscess • Lower Motor Neuron • CIDP • Mononeuritis multiplex • CMV polyradiculopathy

  47. Evaluation for paralysis in AIDS • Initial ER work-up • Head CT scan with contrast • Lumbar Puncture • MTb, EBV, Toxo, JC Virus PCRs • Crypto Ag • VDRL • Routine, AFB, Fungal Culture • Cytology

  48. Evaluation for paralysis in AIDS • Further work-up • MRI of brain or spine • NCV/EMG • PET-CT

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