HIVPhysician Training Course 2002, Christian Medical College, Vellore
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- Title
-
HIVPhysician Training Course 2002,
Christian Medical College, Vellore - extracted text
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HIV Physician Training Course 2002,
Christian Medical College, Vellore
DISTANCE LEARNING COURSE
HIV AND FEVER
Author: Priscilla Rupali
Course Organiser : Anand Zachariah
Distance Learning Expert: Janet Grant, Open University, UK
This course is supported by the European Commission through grant number
IND/B76211/1B/1999/0379 provided to the HIV/STI Prevention and Care Research
Programme of the Population Council India.
MODULE 5
TT
INSTRUCTION SHEET - HIV AND FEVER (MODULE 5)
1. In addition to this module you will find X-ray 5A in separate cover for
activity 5.8.
2. After you complete the module tear: (a) Tutor marked assignment (page
25); (b) the module evaluation form (at the end of the module) and enclose
it the stamped envelop. Send it by registered post by: January 11, 2003.
3. Please write your name and roll number on the tutor marked assignment
before dispatching it.
1
MODULE 5
OVERVIEW
Fever is a common symptom during the course of HIV infection and left
untreated may cause considerable morbidity and death. Fever is usually due to
an underlying infection tl^iat is eminently treatable. These infections may be due
to virulent pathogens (that commonly cause infections in an immunocompetent
host) or opportunistic infections (that affect immunocompromised hosts).
Short duration fevers are usually due to virulent pathogens. The etiology of
prolonged fever is dependent on the stage of the disease. In the early stages of
HIV disease, prolonged fever may be due to an acute sero-converting illness or
virulent infections such as tuberculosis, pneumococcal pneumonia, and typhoid.
In later stages of disease, prolonged fever may be due to opportunistic infections
(such as cryptococossis or toxoplasmosis) as well as virulent pathogens. Non-
infectious causes of fever are less common and include malignancies and drug
fever.
In most cases, fever is associated with symptoms and signs that suggest the
source of fever. However immunosupression may blunt the body's immune
response and alter the typical clinical presentation of an infection. In patients
with advanced HIV infection, fever may be the only evidence of a pathologic
process.
Fever of unknown origin (FUO) is defined as a temperature elevation of 101° F
(38.3° C) or higher for 3 weeks or longer the cause of which is not diagnosed after
1 week of intensive in-hospital investigation. FUO is classified according to the
clinical setting in which it occurs: classical FUO; FUO in neutropenic patients;
FUO in HIV patients; and nosocomial FUO. Not all patients with HIV infection
may fit the above definition and temperature recording at home may be required
to demonstrate fever when it is irregular and remittent. An alternative definition
of FUO in HIV infection is a fever: (a) which has no specific localizing symptom
or sign and (b) which has been present long enough for a self-limited illness to be
ruled out.
2
MODULE 5
Proper management of prolonged fever in HIV infection requires diagnosis of
the underlying cause based on clinical symptoms and the stage of HIV disease.
In contrast to classical FUO, clinical algorithms driven by the presenting
symptoms guide the evaluation of fever. This module will help you to increase
your knowledge about: (a) the various causes of fever; (b) clinical syndromes
associated with fever; (c) and the diagnostic approach and treatment of these
syndromes.
OBJECTIVES
After completion of this module should be able to:
1. List the common causes of fever in Human Immunodeficiency Virus (HIV)
infection.
2. Recognise the different clinical syndromes and the main causative
agents/diseases responsible for them.
3. Use clinical algorithms to diagnose and manage these clinical syndromes.
3
MODULE 5
CONTENTS
Activity 5.1
Title
Short duration fever - I
Reading 5.1
Fever- Short duration and
Time (min)
10
prolonged fever
)
Page
4
30
27^30,31
Activity 5.2
Short Duration Fever - I I
10
6
Activity 5.3
Clinical Evaluation of Prolonged Fever 20
8
Reading 5.3
History in a fever patient
Clinical examination findings in fever
15
28
Activity 5.4
Differential Diagnosis of Fever
15
10
Reading 5.4
Pyrexia of unknown origin-classification
Etiology of fever in HIV infection
15
27,31-32
Activity 5.5
PUO Algorithms
10
12
Reading 5.5
Management algorithms of HIV
Patients with prolonged fever
25
36-38
Activity 5.6
Emperic Therapy
10
14
Reading 5.6
TB in relation to prolonged fever
20
33-35
10
16
Management
10
18
Activity 5.9
Fever and Headache - I
10
20
Activity 5.10
Fever and Headache - II
10
22
Tutor Marked Assignment
60
25
Total estimated study time
280
Prolonged fever- etiological agents
Activity 5.7
Fever and Respiratory Symptoms Differential Diagnosis
Activity 5.8
Fever and Respiratory Symptoms -
4
MODULE 5
The first activity aims at the evaluation of a patient with
short
read
duration
fever.
Before
undertaking
"WHO staging of HIV infection"
duration and prolonged fever"
the
of
management
"Correlation
of
fever
CD4
(pg. 29) ,
27) ,
activity,
"Fever—short
"Clinical rules in
HIV infection"
in
count
(pg.
this
and absolute
30)
(pg-.
lymphocyte
and
count"
31) .
(pg-
ACTIVITY 5.1
SHORT DURATION FEVER (TIME: 10 min)
A 25 year old man from Chittoor presents with fever of one
week
duration
associated with
and rigors.
chills
He
was
diagnosed to have HIV infection after routine screening for
He has been asymptomatic and
blood donation 6 months ago.
ago.
has not suffered from any serious opportunistic infections.
His WBC count done 2 months ago was TC 7000 cells/mm3 and
differential
count:
neutrophils
55%,
lymphocytes
40%,
eosinophils 2%, basophils 2%.
On examination: Weight 70 Kg, well built. No skin or mucous
membrane findings, no lymph nodes enlarged.
Spleen 2 cm. No
cardiovascular, respiratory or neurological findings.
1.
What
is
his
stage
of
HIV
infection
based
on
in
this
patient, - in
the
WHO
staging?
I
2.
List
the
likely
causes
fever
of
order of probability.
1^'
)
)
? t//. I
3. What tests will you order to evaluate the fever?
l/J
)
5
MODULE 5
•^FEEDBACK 5.1
1. What is his stage of HIV infection?
WHO clinical group 1.
Clinically he is asymptomatic and has no clinical signs of immunodeficiency. His absolute
lymphocyte count is 2800 cells/mm3 which approximately correlates to a CD4 count of
>200 cells/mm3.
2. List the likely causes of fever in this patient,in order
of probability.
Malaria
Typhoid
Hepatitis
Viral fever
Since he does not have clinical evidence of immunodeficiency and is presenting with a
short duration fever, the clinical differential diagnosis is the same as in an
immuo comp etent person. The presence of splenomegaly suggests a diagnosis of malaria
or typhoid. Since Chittoor is endemic for malaria, that is the most probable diagnosis.
3. What tests will you order to evaluate the fever?
Total and differential white cell count
Malarial smear - thick and thin
Widal test
Blood culture (if available)
Urine microscopy
6
MODULE 5
ACTIVITY 5.2
SHORT DURATION FEVER- II (TIME: 10 min)
His MP smear is found to be positive for P. vivax.
1. What treatment would you start him on?
2.1s there any role for prophylaxis for malaria for him?
■'A>t. tX'V -
lx.
Xa.-O z^L
C. <T^
7
MODULE 5
/■^FEEDBACK 5.2
His MP smear is found to be positive for P. vivax.
l.What treatment would you start him on?
Chloroquine 600 mg (4 tablets) - Day 1
Chloroquine 600 mg (4 tablets) - Day 2
Chloroquine 300 mg (2 tablets) - Day 3
Primaquine 15 mg OD for 5 days
(NMEP regimen)
2. Is there any role for prophylaxis for malaria for him?
There is no increased risk for the development of malaria in HIV infection. Since he is
residing in an endemic area, there is no role for malaria prophylaxis.
8
MODULE 5
This activity is designed to give you practice in clinical
evaluation
of
a
HIV
infected
person
who
prolonged fever.
Before doing this activity,
in
presenting
a
patient
with
examination findings in fever" (pg.
fever"
presents
wi th
read "History
and
"Clinical
28) in the reader.
ACTIVITY 5.3
CLIINCAL EVALUATION OF PROLONGED FEVER
(TIME: 20 min)
Mr. Vengaih, 35 year old manual labourer from Namakkal, was
diagnosed
to
have
HIV
infection
two
years
ago.
He
presented with symptoms of fever and chills of two months
duration.
1. What are the specific questions you would like to ask in
the history?
2. What are the clinical findings that you would look for?
9
9
MODULE 5
^FEEDBACK 5.3
1. What are the specific questions you would like to ask in
the history?
1. Duration of HIV infection
“
"
would
look
2. Associated symptoms — respiratory, CNS, urinary, abdominal
3. History of tuberculosis and TB treatment
4. Other opportunistic infections
7
5.
Opportunistic Infections prophylaxis
6.
Highly active antiretroviral therapy
7. Co-existent morbidity: Alcoholism, IVDU
2.
What
are
the
clinical
findings
for?
Oral Candida, oral hairy leukoplakia, pigmentation
Significant generalized lymphadenopathy
Skin lesions - nodules, papules
Hepatosplenomegaly, intra-abdominal glands
Respiratory distress, lower respiratory signs
Neck stiffness
Limb weakness
Fundal lesions - haemorrhages
Elevated JVP, heart murmurs
Genital examination - ulcers, glands
Per Rectal examination - prostatic tenderness and fluctuation
that
you
10
MODULE 5
The next exercise focuses on the differential diagnosis of
prolonged fever. Before you undertake the exercisef study:
^Pyrexia of unknown origin-classification" (pg. 27);
^Etiology of fever -correlation to CD4 counts" (pg. 31) and
"Frequency of etiologies of prolonged fever at Vellore (pg.
32) .
Activity 5.4
DIFFERENTIAL DIAGNOSIS OF FEVER
(TIME: 15 min)
9
Mr. Vengaiah was diagnosed to have HIV infection when he
consulted his local GP for recurrent genital ulceration. He
had significant loss of weight and appetite. He had noticed
darkening of skin and loose stools on and off. He also had
occasional headache.
On examination: An emaciated individual, temperature-38°C,
respiratory rate-24/min. Pulse rate-100/min. Darkening of
palms and soles and generalized pruritic papular rash. Two
0.5 x 0.5 cm lymph nodes in the deep cervical region, a few
small
axillary
nodes.
Abdominal
examination-mild
hepatosplenomegaly. CNS examination-no signs of meningeal
irritation, no papilloedema or focal deficits.
1. What is his WHO clinical stage?
on
Based
his
clinical
stage,
what
differential
would you considejc—in order of probability?
Stage -
Interpretation of clinical signs Differential diagnosis -’
0
X-L-y
Tb - KJ.-W,
/'
rv I
YlA-y
.
diagnosis
11
MODULE 5
^FEEDBACK 5.4
i. What is his clinical stage of HIV infection?
Based
on
his
clinical
stage
what
differential
diagnosis
would you consider in order of probability?
Stage
WHO clinical group 3
Interpretation of clinical signs
Pruiritic rash and pigmentation indicate significant immunodeficiency. Generalised
lymphadenopathy and hepatosplenomegaly may indicate the presence of disseminated
TB. The increased respiratory rate may indicate respiratory involvement probably due to
pulmonary TB.
Differential diagnosis:
Disseminated TB
9
"Cryptococcosis
Lymphoma
12
MODULE 5
The next exercise aims
to make you familiar with the PUO
algori thins. Before you do the exercise, study:
Fever, respiratory and central nervous
sys tem algori thins
(pg. 36-38) .
ACTIVITY 5.5
PUO ALGORITHMS
(TIME: 10 min)
1. Which PUO algorithm will you use in Mr. Vengaiah's case
(the patient referred to in Activity 5.3 and 5.4)?
Which tests will you order in correct sequence?
Algorithm
Tests
Step 1
Step 2
Step 3
1
13
MODULE 5
FEEDBACK 5.5
Which algorithm will you use? Which tests will you order in
correct sequence?
Algorithm - Fever algorithm (Figure 1).
Tests:
Step 1- Chest x-ray, sputum AFB
Step 2 - Lymph node FNAC or smear/ ultrasound of the abdomen
Step 3 - Bone marrow
Step 4 - Liver biopsy
The list and order of tests in the algorithm provide a guide to investigation. These may
require modification in the individual case based on clinical judgement.
14
The
next
exercise
aims
empiric therapy in PUO.
''Prolonged
fever
to
MODULE 5
make
you
familiar
wi th
Before you do the exercise,
etiological
agents"
35) and
(pg.
relation to prolonged fever in HIV infection" (pg.
the
study:
yyTB
in
33-34) .
ACTIVITY 5.6
EMPERIC THERAPY
(TIME: 10 min)
Mr. Vengaiah's laboratory reports are as follows:
WBC Total count:
4200 cells/mm3 Neutrophils 75, Lymphocytes
20, Eosinophils 3, basophils 2.
Chest x-ray - Bilateral
hilar
adenopathy,
Sputum AFB -
negative. Lymph node FNAC was non-diagnostic, Ultrasound of
abdomen- multiple hypoechoic areas in the liver and spleen,
no
lymph nodal masses.
specific lesions.
Bone marrow smear
and biopsy no
In view of financial constraints a liver
biopsy was not attempted.
1. What is your interpretation of the findings?
IZV1 (7- f J y
V|
(X)'
--------- -
2 . What
treatment
Cua m4
will
you
“r6
f'o .
7
'-7 //To
start
at
mentioning drug regimens?
3
XH
3
this
point,
15
MODULE 5
' ^FEEDBACK 5.6
l.What is your interpretation of the findings?
There is absolute lymphopenia indicating advanced immunodeficiency. The hilar
adenopathy and hypoechoic lesions suggest a disseminated infiltrative process which IS
probably tuberculosis. Cryptococcal infection is still a possibility but there are no
meningeal signs.
2.What
treatment
will
you
start
at
this
point
mentioning
drug regimens?
The most probable diagnosis in this patient is disseminated tuberculosis for the following
reasons, (a) clinical features point to the diagnosis; and (b) TB is the most common cause
of prolonged fever in HIV infection. The negative result on sputum AFB testing does
not exclude the diagnosis.
The high probability of diagnosis and the negative investigation workup warrant the
initiation of empiric anti-tubercular therapy. He should be followed up carefully to assess
response to therapy. In the case of failure of response further diagnostic evaluation
would be indicated.
This patient should be started on short course chemotherapy. According to the RNTCP
program this patient would fit into Category 3 (seriously ill extra-pulmonary disease-
disseminated TB).
His dmg regimen will be as follows:
2(HRZE)3 4(HR)3 . Rifampicin 450 mg, Isoniazid 600 mg, Pyrazinamide 1500 mg and
Ethambutol 1200 mg thrice weekly for 2 months. Followed by Rifampicin 450 mg.
Isoniazid 600 mg thrice weekly for 4 months.
The principles of drug therapy, drug choice, dose and duration are the same as in a
imu no comp etent patient with tuberculosis. Some physicians would extend the total
duration of treatment up to 1 year.
He was started on empirical anti-tuberculous
which he noted remarkable improvement.
therapy with
16
MODULE 5
This activity takes you through the steps for evaluating a
and respiratory symptoms.
ACTIVITY 5.7
FEVER AND RESPIRATORY SYMPTOMS
DIFFERENTIAL DIAGNOSIS (TIME: 10 min)
Mr. Albert, 45 years old a known case of HIV infection
presents
with complaints of fever,
cough and slowly
progressive breathlessness of 2 weeks duration.
He has lost 10 kg of weight. He has a history of diarrhoea
on and off. There is no history of dimness of vision or
headache.
He received a complete course of tuberculosis treatment 20
years ago for pulmonary TB.
On
examination:
50
Kg.
He
is
tachypneic
at
rest.
Respiratory rate- 40/mt., temperature 37.6° C and blood
pressure 110/70 mm Hg.
On examination of the respiratory
system there are crackles in right infrascapular and —7infraaxillary regions and an occasional wheeze. Central
nervous system, including fundus, was normal.
1.
Write
your
down
probability
and
also
differential
state
the
diagnosis
reasons
in
for
order
your
of
first
diagnosis?
r /s
r
—
Pt^r ixAMo-vyjg) ^'yiA a
■ ^^4 - P'Vy.
. 7
A
L
AW^ryvO'
’Vxo—fyxJtjf,
.■f'J - ^zvx,____
2. What tests will you order to confirm your diagnosis?
P'AJ/tC
^AxU^azAX,'VAX»A^
)
h
I
'
17
MODULE 5
^FEEDBACK 5.7
Write
down
probability
your
and
differential
also
state
the
diagnosis
reasons
in
for
order
your
first
diagnosis ?
Differential diagnosis:
1. Pneumocystis carinii
2. Pulmonary TB-relapse
3. Bacterial pneumonia
Reasons for considering PCP as first diagnosis:
Previous complete TB treatment makes TB less likely.
Symptoms of dry cough, progressive breathlessness, minimal respiratory signs and
respiratory distress make PCP the likely diagnosis.
He has not taken TMP/SMX prophylaxis.
What tests will you order to confirm your diagnosis?
Chest X-ray
Sputum AFB smear and gram stain
Induced sputum with 3% saline for PCP smear (silver staining)
I
Serum LDH
Pulse oximetry
of
18
MODULE 5
ACTIVITY 5.8
FEVER AND RESPIRATORY SYMPTOMSMANAGEMENT (TIME: 10 MIN)
' 7
Pulse oximetry - oxygen saturation 80%
Serum LDH - 800 U/L, Sputum AFB smear - negative
•?
Induced sputum for PCP smear could not be performed.
Chest x-ray- 5-A (in labeled cover)
1.
Write down the abnormalities on the chest x-ray.
the differential diagnosis?
State
"fl
Findings:
' ' C-VerA-cA-x
Differential diagnosis:
1.
2.
3.
4.
7
2.
What
treatment
will
you
start
this
patient
on
(drug,
dose and duration) ?
'"F Gq
3.If
he
failed
to
respond
to
further tests will you require7
the
above
treatment
what
19
MODULE 5
FEEDBACK 5.8
1.Write
down
the
abnormalities
on
the
chest
x-ray.
State
the differential diagnosis?______
Findings: Bilateral diffuse interstitial infiltrates.
Differential diagnosis:
l.PCP
2. TB
3. CMV
4. Cryptococal pneumonia
5. Lymphocytic interstitial pneumonitis
6. Non —Hodgkin’s lymphoma
2. What treatment will you start this patient on?
Co-trimoxazole (TMP 160 mg/SMX 800 mg) 2 tablets three times per day x 21 days.
In the critically ill patient the IV co-trimoxazole may be used (dose TMP 20mg/kg/day
IV q6-8h).
/
This patient has significant hypoxemia based on the pulse oximeter reading and therefore
warrants the initiation of corticosteroid therapy at the following dose:
Prednisolone 40 mg twice daily x 5 days; followed by Prednisolone 40 mg once daily x 5
days; and then followed by Prednisolone 20mg once daily for 11 days.
3.
If
he
failed
to
respond
to
the
above
treatment
what
further tests will you require?
If he fails to respond to the above treatment bronchoscopy and bronchoalveolar lavage
will be required.
Mr.
Albert
responded
combination
which he
he
was
started
on
to
co-trimoxazole
and
received for 21 days.
life
TMP/SMX DS one tablet daily.
long
TMP/SMX
prednisolone
Following this
prophylaxis
with
20
The next
exercise
focuses
on
MODULE 5
the
evaluation of fever and
headache.
ACTIVITY 5.9
FEVER AND HEADACHE -1
Mr.
Sundaram,
37
years
infection 5 years ago,
for
TB
old
He
headache
with
general
physical
stiffness,
fundus
is
and
presents
vomiting
neurological deficits.
to
HIV
have
fever
of
20
days.
On
for
normal
is
on
currently
with
examination
is
diagnosed
received complete anti-TB treatment
1ymphadeni tis
prophylaxis.
was
(TIME: 10 min)
normal.
and
there
3
Bactrim
months
and
examination
his
He
neck
no
has
are
no
focal
He had no sinus tenderness.
What diagnoses will you consider and what tests will you order?
7/>rYK.
-
1w
21
MODULE 5
^'FEEDBACK 5.9
What diagnoses
will
you
consider and what
tests will you
order?
Diagnosis: Chronic meningitis probably due to cryptococcal infection.
Tests:
CSF - opening pressure, total count, sugar, protein, gram stain, India ink, AFB smear.
Routine, AFB and fungal cultures if available.
Chest X-ray and sputum AFB smear and malarial parasite and Para-nasal sinus x-ray.
22
MODULE 5
ACTIVITY 5.10
FEVER AND HEADACHE - II (10 min)
Mr. Sundaram's laboratory reports are as follows:
CSF-
Pressure
180
mm.
Total
cell
count
-100
cells/mm3
Differential cell count - Lymphocytes 96 Neutrophils 4.
Protein
44 mg/dl,
sugar -
53mg/dl,
India Ink
test
negative.
Fungal culture - Cryptococcus Neoformans.
Chest x-ray and sputum AFB negative.
What treatment will
you administer to this patient
(drug,
dose and duration)?
•T
7
'■
(_o'
<•
*^0
23
II
MODULE 5
!!
I
K
II
ft
FEEDBACK510
ii
II
II
What treatment will you give?
I!
II
T. Fluconazole 800 mg stat, followed by 400 mg OD for 8-12 weeks.
I
Then lifelong prophylaxis with Fluconazole 200 mg once daily.
I
Fluconazole may be given to this patient as he has good prognostic features:
consciousness preserved, increased CSF cell count, normal sugar, CSF pressure normal.
I
li
ir
I
li
i
:
j
i
j
ii
i
1
|!
I
I
24
II
MODULE 5
I
1
I
I
NOTES
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27
MODULE 5
READINGS
PYREXIA OF UNKNOWN ORIGIN - CLASSIFICATION (Durack and Street)
CLASSIC
™ HIV______
NEUTROPENIC
NOSOCOMIAL
Patient
<500
Seropositive
Hospitalised
type
neutrophils / mm3
Duration 3 days
3 days
3 days
3 days
hospitalization hospitalization
hospitalization hospitalization
or 3 OP visits
or 4 weeks
Etiologies Infections
Peri-anal
TB
Urinary
Malignancy
infection
MAC
infection
Inflammation Aspergillosis
PCP
Respiratory
Candidemia
Toxoplasmosis infection
Drugs
Phlebitis
MAC- Mycobacterium avium intracellulare
TB - Tuberculosis
PCP - Pneumocystis carinii
SHORT DURATION FEVER AND PROLONGED FEVER
Short duration fever
(<2 weeks)___ ___________
Viral fever
Malaria
Typhoid
Bronchitis / sinusitis
Pneumococcal pneumonia or
bacteremia
Urinary tract infection
Pyogenic skin infections
S. typhimurium septicaemia
Prolonged fever
(>3weeks)______________________
Tuberculosis
Pneumocystis carinii pneumonia
Cryptococcosis
Toxoplasmosis
Disseminated Cytomegalovirus
infection
Disseminated Mycobacterium aviumintracellulare infection
Disseminated herpes infection
Infective endocarditis
Lymphoma
Drug fever
28
MODULE 5
SPECIFIC HISTORY IN A PATIENT PRESENTING WITH FEVER
1. Duration of HIV infection
2. Associated symptoms - respiratory (cough, breathlessness and sputum), CNS
(headache, seizures, limb weakness, visual symptoms), urinary (dyuria),
abdominal (abdominal pain, diarrhea, vomiting and jaundice).
3. History of tuberculosis and TB treatment
4. Other opportunistic infections
5. Opportunistic Infections prophylaxis
6. Highly active antiretroviral therapy
7. Co-existent morbidity - Alcoholism, IVDU
8. History to enable clinical staging - Degree of weight loss, activity level,
mucocutaneous lesions
___________ CLINICAL EXAMINATION FINDINGS IN FEVER
Inference
Findings
Oral Candida, oral hairy leukoplakia, Signs of immunodeficiency
pigmentation____________________
Sinus tenderness and nasal discharge Sinusitis, upper respiratory tract infection
TB, cryptococcosis, lymphoma
Significant generalized
lymphadenopathy_______________
Neck stiffness___________________ Chronic meningitis_________________
Fundal lesions- harmorrhages______ CMV retinitis______________________
Cryptococcosis, nocardiosis, Penicillium
Skin lesions- nodules, papules
infection, TB_______________________
Pneumonia, PCP, TB, Plueral effusion
Respiratory distress, lower
respiratory signs_________________
Infective endocarditis, pericardial effusion
Elevated JVP, heart murmurs______
TB, Lymphoma
Hepatosplenomegaly, intraabdominal glands_______________
STD's__________________
Genital examination-ulcers, glands
Pelvic inflammatory disease
Pelvic examination- forniceal
tenderness_____________________
Prostatic abscess
Per rectal examination- Prostatic
tenderness and fluctuation, peri-anal
abscess________________________
Focal cerebral lesion-toxoplasmosis
Limb weakness
29
MODULE 5
Proposed WHO staging system for patients infected with HIV
Stage 1:
Asymptomatic
Persistent generalised lymphadenopathy
Stage 2:
Weight loss between 5% and 10% of body weight
Minor mucocutaneous manifestations (seborrhoeic dermatitis, prurigo, fungal nail
infections, recurrent oral ulcerations, angular stomatitis)
Herpes zoster within the past five years
Recurrent upper respiratory tract infections (for example, bacterial sinusitis)
And/or
Performance scale 2: symptomatic, normal activity
Stage 3:
Weight loss >10% body weight
Unexplained chronic diarrhoea for longer than one month
Unexplained prolonged fever (intermittent or constant) for longer than one month
Oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis within last year
Severe bacterial infections (for example, pneumonia, pyomyositis)
And/or
Performance scale 3: bedridden for less than 50% of the day during the last month
Clinical stage 4 (AIDS):
HIV wasting syndrome
Pneumocystis carinii pneumonia
Toxoplasmosis of the brain
Cryptosporidiosis with diarrhoea for more than one month
Cryptococcus, extrapulmonary
Cytomegalovirus infection of an organ other than liver, spleen, or lymph nodes
Herpes simplex virus infectionmucocutaneous for more than 1 month or visceral of any
duration
Progressive multifocal leukoencephalopathy
Any disseminated endemic mycosis
Candidiasis of the oesophagus, trachea, bronchi, or lungs
Atypical mycobacteriosis, disseminated
Non-typhoidal salmonella septicaemia
Extrapulmonary tuberculosis
Lymphoma
Kaposi's sarcoma
HIV encephalopathy
And/or
Performance scale 4: bedridden for more than 50% of the day during last month
30
MODULE 5
CLINICAL RULES IN THE MANAGEMENT OF FEVER IN HIV INFECTION
•
Major opportunistic infections are uncommon with a CD4 counts above 200
cells/mm3.
•
Patients with HIV infection and a CD4 count exceeding 500 cells/mm3,
should be evaluated for fever as an immunocompetent host.
•
Patients with CO4 cell counts of 200-500/cu.mm, are at increased risk of
infections caused by
relatively virulent pathogens
that occur in the
immunocompetent hosts as well.
•
Three-fourths of prolonged fevers are due to tuberculosis. Therefore in the
case of a negative diagnostic evaluation, emperic anti-TB treatment is warranted.
•
In the following situations suspect unusual causes of fever:
Prolonged fever
> In a patient who has completed TB treatment
> Occurring at low CD4 count (<50-100 cells/mm3)
> With skin lesions, fundal lesions
> Not responding to emperic anti-TB treatment
> In an IV drug user
•
Approach to short duration fever is similar to an immunocompetent host.
However investigation and emperic therapy may start earlier.
31
MODULE 5
CORRELATION OF CD4 COUNT AND ABSOLUTE LYMPHOCYTE COUNT
Absolute lymphocyte count = WBC total count x Lymphocyte count
•
100
Absolute lymphocyte count (ALC) of 1000 cells/mm3 roughly correlates
•
to a CD4 count 200 cells/ mm3 •
The positive predictive value of ALC < 1000 cells for a diagnosis of AIDS
•
is 88%.
Journal of Association of Physicians of India 1997; 45: (6):455-6.
Etiology of fever in HIV infection - correlation to CD4 counts
CD4 counts
Etiologies of fever
cells /mm3
> 500
Acute retroviral syndrome
Causes of fever in non-immunocompromised patient
200-500
Bacterial pneumonias
Tuberculosis
Herpes zoster
Lymphomas
<200
Pneumocystis Carinii Pneumonia (PCP)
Disseminated/Chronic herpes simplex
Toxoplasmosis
Cryptococcosis
Disseminated histoplasmosis
Tuberculosis(TB) (miliary/extrapulmonary)
<50
Disseminated Cytomegalovirus (CMV)
Disseminated MAC
1
32
MODULE 5
CAUSES OF PROLONGED FEVER IN HIV INFECTION
(STUDY OF 100 PATIENTS AT CMCH, VELLORE FROM REFERENCE 3)
Disseminated TB (definite)
21%
Disseminated TB (presumed)
19%
Pulmonary TB
16%
Extra-pulmonary TB
10%
Pneumocystis Carinii
7%
Cryptococossis
10%
Cerebral Toxoplasmosis
1%
Bacterial pneumonia
2%
Amoebic liver abscess
2%
Disseminated Histoplasmosis
1%
Sinusitis
1%
Spontaneous Peritonitis
1%
Pyogenic meningitis
1%
Malaria
1%
66%
UNUSUSAL CAUSES OF FUO
Drug Fever
•
Usually accompanied by a skin rash.
•
Associated with TMP/SMX, dapsone, penicillin, caphalosporins, phenytoin,
carbamezapine and clindamycin.
•
Resolves within 24-48 hours after withdrawal of drug.
Immune reconstitution Syndrome
•
Patients initiated on HAART may develop fever, leucocytosis,
lymphadenopathy and worsening chest x-ray in the first few weeks to months.
•
This is due to development of a vigorous immune response to sub-clinical
opportunistic infections.
•
It has been frequently reported with MAI and tuberculosis.
33
MODULE 5
TB IN RELATION TO PROLONGED FEVER IN HIV INFECTION
1. The commonest cause of HIV related FUO in India is tuberculosis.
2. Disseminated and extra-pulmonary TB (lymph node, pleural effusion,
abdominal TB) occur frequently with advanced HIV infection.
3. Clinical pointers to a diagnosis of tuberculosis include: hepatosplenomegaly,
weight loss and lymph node enlargement.
4. Abnormal laboratory findings in disseminated TB include: anemia, elevated
alkaline phosphatase and lymphopenia (<1500/mm3).
5. Chest X-ray findings of tuberculosis in HIV infection may be atypical. These
findings include interstitial or lobar infiltrates and lower lobe sub-segmental
infiltrates, hilar and mediastinal lymphadenopathy and pleural effusion.
^6. The principles of chemotherapy of tuberculosis in an HIV infected patient are
the same as an immunocompetent host.
7. There is no evidence that multi-drug resistant (MDR) tuberculosis occurs with
increased frequency in the HIV infected patients in India.
8. In a patient presenting with prolonged fever and a negative physical
examination and laboratory investigation, empiric anti-tuberculosis treatment
may be justified.
9. Disseminated mycobacterium avium intracellulare (MAI) infection is
uncommon in India. Prior tuberculosis could confer immunity against atypical
mycobacteria. It is also possible that patients do not survive till to the stage of
advanced immunodeficiency at which MAI infections occur.
7
34
MODULE 5
TUBERCULOSIS TREATMENT RECOMMENDATIONS
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAM
Categoly of Treatment
Type of patient
Regimen*
Category I
New sputum smear
2(HRZE)3
positive
Seriously ill sputum
4(HR)3
smear negative
Seriously ill extrapulmonary tuberculosis^
Category II
Sputum smear positive
relapse***
Sputum smear positive
2(HRZES)3
1(HRZE)3
5(HRE)3
failure***
Sputum smear positive
treatment after default
Category III
Sputum smear negative
Extra-pulmonary not
2(HRZ)3
4(HR)3
seriously ill__________
* The number before the letters refers to the months of treatment. The subscript
after the letters refers to the number of doses per week. H: Isoniazid (600 mg), R:
Rifampicin (450 mg), Z: Pyrazinamide (1500 mg), E: Ethambutol (1200 mg), S:
Streptomycin (750 mg). Patients weighing more than 60 Kg should receive an
additional dose of Rifampicin of 150 mg. Patients of age > 50 year or weight < 30
Kg should receive streptomycin 500 mg. Patients in category I and II who are
sputum smear positive at the end of the intensive phase of treatment should
receive an additional month of intensive phase of treatment.
** Examples of seriously ill extra-pulmonary TB cases are meningitis,
disseminated TB, tuberculous pericarditis, bilateral and extensive pleurisy,
spinal TB with neurological complications and intestinal and genitourinary TB.
*** In rare and exceptional cases, patients who are smear negative or have extrapulmonary disease can have relapse or failure. The diagnosis in all such cases
should be supported by culture or histological evidence of active tuberculosis. In
these cases the patients should be categorized as "other" and given category II
treatment.
35
_______________ Prolonged Fever - Etiological Agents
Typical Findings___________
________ Diagnosis ____________
Variable: focal infiltrates,
Sputum AFB stain and culture, if no
reticulonodular, cavitary disease, hilar
sputum production - induced
adenopathy, lower and middle lobe
sputum; requires 3-8 weeks for
involvement common, pleural effusion;
growth on conventional media;
early-stage HIV infection-upper lobe
sensitivity of sputum AFB smear cavitary; late-stage HIV-pneumonitis
50%
mid or lower lobes or miliary pattern
with minimal granuloma formation.
Extrapulmonary TB is common - esp.
meningitis, adenopathy______________
M. arium
Chronic or
History- Fever, weight loss, night sweats, Sputum, FOB or induced sputum
Complex
asymptomatic
diarrhea. Examination
AFB stain and culture; must
lymphadenopathy, hepatosplenomegaly
distinguish from MTB; MA may
colonise airways without causing
pulmonary disease.___________
S.Pneumoniae Acute; purulent
Lobar or broncho-pneumonia ± pleural
Blood cultures often positive;
sputum ±
effusion
sputum gram stain, culture
pleurisy______
(sensitivity of culture is 50%).
Cryptococcus
Chronic, sub
Nodule, cavity, diffuse or
Sputum, induced sputum, or FOB
acute or
nodular infiltrates
stain and culture; serum
symptomatic
cryptococcal antigen usually
positive; CSF analysis
indicated if antigen or organism
found at any site.______________
Pneumocystis
Acute or sub
Interstitial infiltrates with characteristic
Induced sputum (mean yield of
Carinii
acute; non
ground glass appearance; negative x-ray 60%) and FOB with BAL (mean
productive
in early stages about 15-20%;
yield of 95%); technical
I cough; dyspnea
expertise is highly variable.
* See Sanford Guide to HIV/AIDS therapy for details of drug doses
Agent
Tuberculosis
(MTB)
Course
Chronic, sub
acute or
asymptomatic
usually has
productive cough
± hemoptysis
MODULE 5
Treatment
See page 34.
Clarithromycin +
ethambutol ±
rifabutin*
Oral: Amoxicillin,
IV: Crystalline
penicillin
Fluconazole
or
Amphotericin B +
Flucytosine*
TMP-SMX or
Pentamad ine
pO2 < 70 mm Hg:
Prednisone*
36
MODULE 5
MANAGEMENT ALGORITHMS FOR HIV-INFECTED
PATIENTS WITH PROLONGED FEVER
Fig.l
Prolonged fever
I;
I
No associated symptoms
& LNE on physical exam
No associated symptoms
& physical exam normal
FNA
US Abdomen
I
I
if cough / dyspnoea
- refer Fig 2
if headache / altered sensorium
- refer Fig 3
I
+ ve
I
Treat
accordingly
LNE
FNA
US :
BM
ATT
Lymphnode enlargement
Fine needle aspiration
Ultrasonography
Bone marrow
: Antituberculous therapy
1
+ ve
- ve
- ve
i
i
Focal
visceral lesions
or LNE
BM smears,
trephine biopsy
culture for AFB
i
f
+ ve
FNA
I
i
Treat
accordingly
f
+ ve
I
i
- ve
Treat
accordingly
i
I
- ve
i
Consider
liver
biopsy or
empirical
ATT
37
MODULE 5
Fig. 2 Prolonged fever and pulmonary symptoms
Chest X-ray
I
Normal
I
Abnormal
I
Sputum AFB
+ ve
- ve
Bilateral
interstitial
infiltrates
I
I
I
ATT
ABG
Consolidation Fibrocavitary or Mediastinal or Miliary
disease
adenopathy
mottling
I
Sputum AFB
staining
Sputum AFB
staining
/\
/\
z
Sputum AFB
staining
+ ve or -ve
Decreased PaO2 Normal PaO2
Treat for
PCP
l
Symptomatic
treatment
+ ve
I
ATT
- ve
+ ve
I
I
ATT
- ve
Treat for ATT
Treat as
PCP
for bacterial
pneumonia
AFB
PaO2
PCP
ABG
: Acid-fast bacilli
: Partial pressure of oxygen (mmHg)
: Pneumocystis carinii pneumonia
: Arterial blood gas
38
MODULE 5
Fig. 3 Prolonged fever and neurological symptoms
Focal clinical signs
I
■4
- ve
+ ve
i
CT
CT scan head
t
I
Multiple ring
enhancing
lesions
Treat for toxoplasma
encephalitis
Basal meningitis
or infarcts
—I
Normal
: Computed tomography
CSF : Cerebrospinal fluid
Ag
: Antigen
CSF analysis
AFB smear & culture,
Normal Abnormal —► Cryptococcal smear,
Ag & culture
I
f
AFB smear & culture, cryptococcal
+ ve
- ve
smear,Ag & culture
I
Clinical improvement in 2 wks
+ ve
I
- ve
Continue treatment
and follow with
suppressive
therapy
+ ve
Treat
accordingly
- ve
Consider
alternative
diagnosis
I
Treat with
antifungals
ATT
39
MODULE 5
REFERENCES
1. USPHS/IDSA (2002) Guidelines for the prevention of opportunistic infections in
persons infected with Human Immunodeficiency Virus- 2002.
http://www.cdc.gov/mmwr/PDF/RR/RR5108.pdf
2.
Rupali P. (1998) Profile of prolonged fever in HIV infection. In M.D dissertation
to the M.G.R Medical University.
3. Sullivan M, Feinberg J. Bartlett JG (1996) Fever in patients with HIV infection.
Infec Dis Clin North Am ; 10 :149-165.
4. World Health Organization (1990) Acquired immune deficiency syndrome
(AIDS): interim proposal for a WHO staging system for HIV-1 infection and
disease. PV/dy Epidemiol Rec 65: 221-228.
i
HIV Physician Training Course 2002,
Christian Medical College, Vellore
DISTANCE LEARNING CQUB.SE
INFECTION CONTROL
&
EXPOSURE PREVENTION
Authors: Cherian T
Mathai E
Perakath B
Course Organiser : Anand Zachariah
Distance Learning Expert: Janet Grant, Open University, UK
This course is supported by the European C
A.'... through grant number
Commission
IND/B762H/1B/1999/0379 provided to the HIV/STI Prevention
and Care
—.........
—J Research
Programme of the Population Council India.
MODULE 6
INSTRUCTION SHEET -INFECTION CONTROL AND EXPOSURE
PREVENTION (MODULE 6)
1. After you complete the module tear: (a) Tutor marked assignment (page
31-32); (b) the module evaluation form (at the end of the module) and
enclose it the stamped envelop. Send it by registered post by: January 18,
2003.
2. Please write your name and roll number on the tutor marked assignment
before dispatching it.
1
MODULE 6
OVERVIEW
Today HIV physicians are faced with the challenge of providing quality HIV care to
patients while also ensuring a safe working environment for the hospital staff. The
HIV epidemic has provided us with a better understanding of the risks from blood
borne pathogen to health care workers. This has helped define approaches to reduce
these risks.
The first case of transmission of HIV infection to a health worker was documented in
1984. Till 1997 there were 95 proven cases and 191 probable cases of occupational
transmission of HIV worldwide. The magnitude of the problem and risks posed by
occupational transmission of Hepatitis B and Hepatitis C is far greater.
The chief risk factors for occupational transmission are: (i) contaminated needle stick
injuries (risk of transmission from needle stick injury 0.3% for HIV, 1.8% for
Hepatitis C and 6-30% for Hepatitis B) and (ii) mucous membrane or non-intact skin
exposures (risk of transmission 0.09% for HIV). Out of the 267 cases of
occupationally acquired HIV in United States, 35% were in nurses, 16% in laboratory
technicians, 10% in physicians and 6% in surgeons.
The Center for Disease Control in 1987 has identified " Universal Precautions" as the
central approach to prevention of transmission of blood borne pathogens. In the
application of universal precautions, all patients and their blood and specified body
fluids are regarded as potentially infectious. The two cardinal principles of universal
precautions are: (i) reduction of exposure to infectious body fluids by use of physical
barriers (gloves, masks, protective eye wear and gown) and (ii) safe disposal of
sharps to prevent needle injuries.
The other important components of a health worker safety program are:
Mandatory hepatitis B vaccination of all health workers at risk
Waste segregation and disposal
Regular worker education
Reporting services for occupational exposures
Provision of post-exposure prophylaxis
Introduction of new safety devices
This module focuses on how to implement these policies at the level of your facilities
and hospitals. The practical aspects of these programs and detailed discussion of
segregation and disposal of wastes and health worker education will be covered
during the Contact Course II.
2
MODULE 6
OBJECTIVES
After completing this module you should be able to:
1. Define the extent of the problem of infections due to blood borne pathogens
among health workers in India and the risks posed by specific pathogens and types
of exposures.
2. Outline the components of a safety program for health care workers to reduce
risks of transmission of blood borne pathogens with specific reference to:
(a) Implementation of universal precautions
(b) Hepatitis B vaccination
(c) Exposure reporting service
(d) Provision of post-exposure prophylaxis.
3. Identify the weaknesses of infection control practice in your set-up and outline
possible strategies to address these weaknesses.
3
MODULE 6
CONTENTS
Activity 6.1
Title
Blood borne pathogen infections
Time (minutes)
10
Page
4
in health workers in India
Reading
Activity 6.2
Occupational exposures in US
Universal precautions- the use
of barriers
20
33-34
20
6
Universal precautions for the
prevention of transmission
10
35-37
Activity 6.3
Infectious Body fluids
5
8
Activity 6.4
Universal precautionssharp disposal
15
10
eading
Prevention of injuries with sharps
Sharps disposal container
10
38
Housekeeping in HIV infection
Hepatitis B vaccination
5
20
12
14
10
10
5
10
10
5
40
56-57
16
41
18
42
5
10
20
43
19
22
20
5
10
10
10
44-48
24
26
56-57
28
10
60
325
49
31
Reading
Activity 6.5
Activity 6.6
Reading 6.6 Hepatitis B immunisation in
health workers
Activity 6.7
Hepatitis B and the health worker
Post-exposure care
Reading 6.7 Handling exposure
Activity 6.8
Post-exposure risk assessment
Reading 6.8 Factors affecting transmission
Risk of occupational transmission
Exposure evaluation - initial tests
Activity 6.9
Filling up an exposure report form
Activity 6.10 Post-exposure prophylaxis -HIV (A)
Reading 6.10 Recommended HIV post-exposure
prophylaxis
Activity 6.11 Post-exposure prophylaxis -HIV (B)
Activity 6.12 Post-exposure prophylaxis-HBV
Reading 6.12 Hepatitis B and the health worker
Activity 6.13 HIV testing for invasive procedures
Reading 6.13 Blood borne pathogen screening
for invasive procedures
TMA
Total estimated study time
4
MODULE 6
This activity is aimed at helping you learn about
the risk of
different types of blood borne exposures and the extent of the
problem
of blood borne pathogen
infection
among
health
among
workers. Please read, "Occupational Exposures
in the United
States"
(pg.
33-34)
in
the reader. After
reading, attempt the following activity.
completing
the
ACTIVITY 6.1
BLOOD BORNE PATHOGEN INFECTIONS IN HEALTH
WORKERS IN INDIA (TIME: 10 MIN.)
1. Based on the below formula given at the end, calculate the
estimated number of seroconversions to HIV, Hepatitis C and
Hepatitis B per year among health workers in India. The data
provided is hypothetical.
Estimated number of needle stick injuries (NSI)in India
900,000 per year.
(This figure is based on the following
assumptions: 600,000 hospital beds in India, 30 injuries/100
beds, 60% of injuries being unreported, 50 % of exposures
being outside the hospital)
Estimated prevalence of blood borne pathogens in hospitalized
patients: HIV 2%, HCV 2%, HBV 4%.
Risk of Infection following contaminated needle stick injury:
HIV 0.3 %; HCV 1.8%; HBV 6%.
Formula:
Estimated number of sero-conversions / year =
No. of NSIx seroprevalence in hospitalx risk of infection
10000
Eg. No. of seroconversions due to HIV = 900,000 x 2 x 0.3
10,000
Calculate the following using the above formula:
Estimated number of seroconversion / year in IndiaHIVSTjC
Hepatitis C
Hepatitis B -
<2/^0
0 y
^0 Y
yo • 2
S'
5
MODULE 6
^FEEDBACKS.!
Estimated number of seroconversions / year to health workers in IndiaHIV - 54
Hepatitis C - 324
Hepatitis B - 2160
The above figures are estimates of seroconversions but may not reflect actual number of
health workers who are infected by blood borne pathogens. They
They are meant to emphasise
the magnitude of risk of blood bome pathogen infection among health workers.
The
following activity will
help you
barriers in universal precautions.
^Universal precautions
learn
about
the
use
of
Before undertaking it read:
for the prevention of transmission
HIV and other blood borne infections" (pg.35-37) ,
of
6
MODULE 6
ACTIVITY 6.2
UNIVERSAL PRECAUTIONS -USE OF BARRIERS
(TIME: 20 MIN.)
Thamarai Selvi,
a 24 years old primigravida has been
married
She is unbooked and comes in labour to
your
for two years.
clinic.
Write
down
contact,
in
the
spray,
table
splash)
infectious body fluids
what
barriers
are
below:
are
(a)
what
likely
to
exposures
take
related to the procedures
appropriate
(gloves,
mask,
place
with
listed;
(b)
eye
wear
gown).
Procedure
Probable means of
Appropriate barriers
exposure to infectious
body fluids
Vaginal examination
Normal vaginal
delivery
Caesarian section
, j
Abdominal ultrasound
Care of the new born
&
(hand
and
7
MODULE 6
^FEEDBACK 6.2
Procedure
Probable means of
Appropriate barriers
exposure to infectious
body fluids
Vaginal examination
Hand contact
Gloves
Normal vaginal delivery
Hand contact
Gloves
Spray
Mask
Splash
Eye wear
Full arm apron
Plastic overshoes
Caesarian section
Hand contact
Gloves
Spray
Mask
Splash
Eye wear
Full arm apron
Plastic overshoes
Abdominal ultrasound
Nil
Nil
Care of the new born
Hand contact
Gloves
Spray
Mask
Splash
Eye wear
Plastic apron
Overshoes
8
MODULE 6
The following activity will help you learn which body
fluids
to consider potentially infectious.
ACTIVITY 6.3
INFECTIOUS BODY FLUIDS (TIME: 5 MIN)
The
ward attender
accidentally spilled urinal
his clothes and hands
was
while emptying it.
undergoing treatment for
meningitis.
The
attender
was
clothing at the
time.
contained small
amount of faeces.
risk
and
assessment
The urine was
for
wearing
and
any
cryptococcal
protective
not blood stained,
1. Is the attender at risk of acquiring HIV infection^
2. What would you advise to the attendant?
/
but
The attendant is sent for
counseling regarding post-exposure
prophylaxis .
J?-
onto
The source patient
HIV infection
not
contents
9
MODULE 6
^FEEDBACK 6.3
1. Is the attendant at risk?
No, the attender is not at risk. Urine and faeces do not require application of universal
precautions and do not pose risks of transmission to the health worker.
_2. What would you advise to the attendant?
The attendee needs to be reassured. It would also be appropriate to review with him the
principles of universal precautions, the need for using barriers and appropriate disposal
of sharps. The attender would be better off wearing gloves and apron while handling
body fluids, equipment or linen soiled with body fluids so as to avoid skin contact. He
needs to check his hands for cuts regularly and to use a bandage as needed. You should
review his Hepatitis B immunisation status.
...
The next activity will help you
you learn
learn about
about preventing
preventing needle
injuries and how to dispose sharps. Attempt the activity after
reading:
"Prevention of injuries with sharps" and "Sharp
Disposal Container" (pg. 38).
10
MODULE 6
ACTIVITY 6.4
UNIVERSAL PRECAUTIONS- SHARP DISPOSAL
(TIME : 15 MIN)
1. List measures to reduce the risk of needle injury during
the following procedures: (a) blood drawing; (b) surgery.
Measures to reduce risk of needle injury
Blood drawing
—’
A/®
■---
Surgery
*
CJ2rC__^
^^-<0
t
C
eV'
f
'X----
K /~^.AAf^/
^C- ^)
1---
Yi z (TV
r
2. Write down a list of things that you
hollow bore needle once it is used.
2.
should not do to a
4.
3. Answer the following questions related to a sharps disposal
container_______
What are three characteristics that a sharps disposal container must have?
l^y-c^ )
Where should a sharps disposal container be placed?
■ UOy____________
What should the colour of a sharps disposal container be and how should it be labelled?
(kjjt
’
When should a sharps disposal container be emptied?
11
MODULE 6
^FEEDBACK 6.4
i.
Blood drawing
Surgery
Measures to reduce risk of needle injury
Gloves
Tourniquet
Avoid recapping
Sharps disposal container on the blood drawing tray
Needles not to be left lying around after the procedure
Use instruments and not hands to grasp needles/sharps
Do not retrieve needles /sharps with hands
Move unused needles/sharps out of the surgical field
Shield scalpel to prevent injury of the assistant
Care with wires and pins
Never pass sharp instruments from hand to hand - use “neutral
zone”
2. Write down a list of things that
hollow bore needle once it is used.
you
should
not
do
1. Do not recap needles.
2. Do not bend or break needles.
3. Do not leave needles lying around.
4. Do not dispose needles in the regular waste bin.
3.___________________ ________
What are three characteristics that a sharps disposal container must have?
Puncture resistance, durability and being leak proof.
Where should a sharps disposal container be placed?
"
’
~
At the site ofuse - in the nursing station, treatment room, operating area, on the injection tray.
It should be placed at table level and be easily accessible.
What should the colour of a sharps disposal container be and how should it be labelled?
Blue with biohazard symbol
When should a sharps disposal container be emptied?
As soon as it is thm-fourthsfull.
to
a
12
This activity will
MODULE 6
about
help you learn
housekeeping
aspects
of nursing a patient with HIV infection.
ACTIVITY 6.5
HOUSEKEEPING IN HIV INFECTION (TIME: 5 MIN.)
Chandy
uneventful
is
an
HIV
affected
appendicectomy.
individual,
He
underwent
an
returning
to
the
he
After
vomited a large amount on the floor.
Tick your choice.
1.Where should he be nursed?
Isolation ward l~
icu O
I
General ward
Single room
2.How will you clean the area?
Wipe dry I---- 1 Cover with Dakins
Clean as usual for any other case
3.What will you do with his unsoiled linen and utensils?
Send for autoclaving F
I
Soak in Dakin’s solution L, .1 Proceed as usual
4.How will you prepare his bed for the next patient?
Wash with a disinfectant U/f Fumigate the room
Proceed as usual F
S.Where will you dispose his wound dressing?
Yellow bag I---- 1
I
Special bag for HIV patients^
9
I
Metal container
I
ward
ia K
13
MODULE 6
^FEEDBACK 6.5
There are no special housekeeping needs for HIV positive individuals without
secondary/opportunistic infections. Universal precautions should apply as with all
patients. Special precautions will depend on the nature of the secondary infection;
e.g. open tuberculosis will need isolation.
1.Where should he be nursed?
Isolation ward
General ward 'I
ICU
Single room
2.How will you clean the area?
Wipe dry CZJ Cover with Dakins
Clean as usual for any other case
3.What will you do with his unsoiled linen and utensils?
Send for autoclaving I
I
Soak in Dakin’s solution I
'i
I Proceed as usual V
4.How will you prepare his bed for the next patient?
Wash with a disinfectant I
I
Fumigate the room
Proceed as usual V
5.Where will you dispose his wound dressing?
Yellow bag V Special bag for HIV patientsl
As for all
infectious
waste
I
Metal container
14
MODULE 6
This activity is aimed at helping you learn about Hepatitis B
vaccination in health workers. Perform the activity after
reading
"Hepatitis B immunisation in health workers"
and the articlef "Hepatitis B and the health worker"
(pg.40)
(pg.
56-
57) .
ACTIVITY 6.6
HEPATITIS B VACCINATION (TIME: 20 MIN.)
Your
has
hospital
requested you
to
devise
an
immunisation
strategy for Hepatitis B vaccination for the staff.
1. Which categories
vaccination to?
of
staff
would
you
provide
hepatitis
B
2 . Is anti-HBc antibody testing required before vaccination to
assess for prior infection?
/
<
Xr-/
<
I1
- f- U
3. What are factors that may lead toi lack
protective antibodies after immunisation?
of development of
rhA.(A.'W_^
4. What is the cost of vaccination for all the staff at risk in
your hospital?____________
No. of staff requiring vaccination -
Total cost of vaccination____
Cost of Shanvac B vaccine (10 ml)
- Rs. 950.40
Cost per person for 3 dose Shanvac vaccination- Rs. 285.
5. What are some strategies to ensure complete vaccination for
all the staff at risk in your hospital?
a.
/)
, •/
b ..
c.r- /"
*
■
c.
15
MODULE 6
^FEEDBACK 6.6
1. Which categories of staff would you provide hepatitis
vaccination to?
B
All staff at risk - doctors, nurses, attendees, sweepers, lab technicians, physiotherapists,
students involved in patient care.
Staff who may not require Hepatitis B vaccination are office staff.
2. Is anti-HBc antibody testing ((evidence
' '
of pior hepatitis
B infection) required before vaccination
----- to assess for
prior infection?____________
No. Routine testing for prior evidence of Hepatitis B infection is not required before
vaccination.
3. What are factors that may lead to lack of development of
protective antibodies after immunisation?
HIV infection
~
Chronic liver disease
Chronic renal failure
Smokers
Persons on immunosuppressive drugs
Persons above 50 years have less adequate antibody production after vaccination.
4. What is the cost of vaccination for all the staff at risk
in your hospital?
No. of staff requiring vaccination - n
Total cost of vaccination (Rs.)- n x 285
5. What are strategies to ensure complete
all the staff at risk in your hospital?
vaccination
for
a. Requirement for pre-employment vaccination.
b. Annual drive with education program.
c. Incentives for vaccination (provide vaccine free upto a certain date and thereafter
charge for it).
16
MODULE 6
This activity aims to enable you to learn the immediate steps
of post-exposure care. Read "Handling’ Exposure" (pg. 41) . After
completing the reading attempt the below activity.
ACTIVITY 6.7
POST-EXPOSURE CARE (TIME: 5 MIN.)
Dr. N. a 30 year old lady doctor drew blood from a patient Mr.
K. Hospital number 3351, with HIV infection and crYptococcal
meningitis.
drawing,
As
she
is
withdrawing
the
needle
after
blood
the patient jerked his hand and the needle pierced
the doctor's gloved hand injuring her index finger. The needle
(a 22 G disposable needle) went deep into her finger and there
was visible blood on the surface of the needle.
1. What immediate steps of action should the doctor take?
1.
2.
3.
4.
5.
4
kJ iO/Lv
<4ZoJtc^J
■acA
I
17
MODULE 6
^FEEDBACK 6.7
1. What immediate steps of action should the doctor take?
1. Remove gloves
2. Go to nearest tap
3. Wash hands with running water expressing blood for 10 minutes,
4. Apply soap or antiseptic as is available.
5. Apply bandage
6. Report the exposure to the reporting authority.
18
This
to
aims
activity
transmission,
factors
enable
MODULE 6
you
to
learn
the
transmission
influencing
from
risk
of
a
HIV
contaminated needle stick injury and tests to be performed at
the initial evaluation of a needle stick injury. Undertake the
after
activity
transmission",
(pg. 42)
reading
"Risk
and
of
"Exposure
the
folowing
:
"Factors
affecting
transmission
occupational
evaluation
initial
tests
of
HIV"
to
be
performed" (pg. 43) .
ACTIVITY 6.8
POST-EXPOSURE RISK ASSESSMENT
(TIME: 10 MIN.)
Dr.
N had removed her gloves immediately after the exposure
and placed her hands under running water expressing blood and
disinfecting it with spirit.
She applied a bandage and then
came to report her exposure to your clinic.
1. What is
your assessment of the risk of transmission of
HIV to Dr. N from this exposure?
2. What
are
the
factors
that
may
increase
the
risk
of
transmission in this case?
1. Risk of transmission of HIV
2. Factors that may increase the risk of transmission:
a.
^7—A'O
b.
c.
d.
3 . What testing would you
Mr. K.
and for Dr. N?
Source patient -
Exposed doctor -
4
>/
advise
for
4^7
the
source
patient
19
MODULE 6
^VFEEDBACK6.8
1. Risk of transmission of HIV - 0.3% (0.2-0.5%)
2.
Factors that may increase the risk of tranmission:
(a) Advanced HIV infection
(b) Hollow bore needle
(c) Needle had been introduced directly into a vein.
(d) Visible blood on the surface of the needle
(e) Deep injury
The only factor that may reduce the risk of transmission is that she was wearing gloves at
the time of the injury.
(f)
What testing would you advise for the source patient and
for doctor who has been exposed?___
Source patient - HbsAg, Hepatitis C serology
Exposed doctor - the appropriate serology for which the source patient is positive in this
case HIV ELISA (the doctor’s blood is drawn and the tests ordered after the patient’s
report is known).
This activity will help you fill up an exposure report form.
ACTIVITY 6.9
FILLING A EXPOSURE REPORT FORM
(TIME: 10 MIN.)
Mr. K (Hospital Number 3351) HbsAg
negative, HCV serologynegative
Dr. N - HIV serology negative Dr. N had received 3 doses of
Hepatitis B vaccination in 2000. No followup anti-HBs test had
been performed.
Fill up the exposure report form for Dr. N.
20
MODULE 6
Index case (source patient)
Name of source patient: Hv
Hospital No.
Diagnosis:
/-by Z
Blood borne pathogen status known before the accident:
HIV
^Yes/ No "Positive / negative
Hepatitis B
Yes/ No" Positive / negative
Hepatitis C
Yes/No v'Positive / negative
Blood screen performed after the accident:
HIV
'^Yes/ No Positive / negative
Hepatitis B -Yes/ No Positive / negative
Hepatitis C v^es/No Positive / negative
Infection status in case of HIV infection (circle) :
Class 1 - Asymptomatic, low viral laod
Class -Csynytomatjc) AIDS, high viral load, acute serocoverting illness
Hospital staff
Name:
Hospital No.: —
Hepatitis B vaccination taken (circle) @aose//P)dose/ 3"‘ dose
Anti-HBs level - (Date
~—
) Level?
aJv >
Blood screen performed after the accident:
HIV
-^es/No Positive / negativev
Hepatitis B > Yes/ No Positive / negative
Hepatitis C
Yes/No Positive / negative
Anti-HBs titre x/¥es / NcM^ositive / negative
Injury
~
“
—----------Sharp injury (describe the device and the nature of the exposurc)Type of device- kiflUw
Visible blood on the surface of devise- Yes7/ No
Device introduced into artery or vein -/Yes / No
Deep injury - Yes / No
Was the health worker gloved: Yes / No
Exposure type - Less severe ( eg.solid bore needle, superficial injury)
More severe (eg. Large bore hollow needle, deep puncture, visible
blood on needle surface, needle inserted into vein/artery)
Mucous membrane or non-intact skin exposure (describe the exposure)
Nature of fluidr
Site of exposure:
Skin Conjunctiva—
Oral mucosaWas the health worker using mask and protective eye-wear- Yes / No
Exposure type
Small volume (ie. A few drops)
Large volume (ie. Major splash)
Was appropriate post-exposure care initiated Yes / No
21
MODULE 6
^^FEEDBACK 6.9
Index case (source patient)
Name of source patient: Mr. K
Hospital No. 3351
Diagnosis: CryptococcalMeningitis
Blood borne pathogen status known before the accident:
HIV
Yes/ No Positive / negative
Hepatitis B
Yes/ No Positive / negative
Hepatitis C
Yes/No Positive / negative
Blood screen performed after the accident:
HIV
Yes/ No Positive / negative
Hepatitis B
Yes/ No Positive / negative
Hepatitis C
Yes/No Positive / negative
Hospital staff
Name:
Dr. N
Hospital No.:
Hepatitis B vaccination taken (circle) :l8t dose/ 2nd dose/ 3rd dose
Anti-HBs level - (Date
) Level: Not done
Blood screen performed after the accident:
HIV
Yes/ No Positive / negative
Hepatitis B
Yes/ No Positive / negative
Hepatitis C
Yes/No Positive / negative
Anti-HBs titre Yes / No Positive / negative
Infection status in case of HIV infection (circle) :
Class 1- Asymptomatic, low viral laod
Class 2 - symptomatic, AIDS, high viral load, acute serocoverting illness_________
Injury
Sharp injury (describe the device and the nature of the exposure)Type of device - Hollow bore needle 22 G needle
Visible blood on the surface of devise- Yes / No
Device introduced into artery or vein - Yes / No
Deep injury - Yes / No
Was the health worker gloved: Yes / No
Exposure type - Less severe ( eg.solid bore needle, superficial injury)
More severe (eg. Large bore hollow needle, deep puncture, visible
blood on needle surface, needle inserted into vein/artery)
Mucous membrane or non-intact skin exposure (describe the exposure)
Nature of fluidSite of exposure:
Skin Conjunctiva
Oral mucosaWas the health worker using mask and protective eye-wear- Yes / No
Exposure type
Small volume (ie. A few drops)
Large volume (ie. Major splash)
Was appropriate post-exposure care initiated Yes / No
22
MODULE 6
The next activity aims to help you learn how to choose and
initiate post-exposure prophylaxis for a health worker who has
had an exposure from an HIV positive source patient, Undertake
the activity after reading:
"Recommended
"Recornmended HIV postexposure
prophylaxis
for percutaneous
injuries",
"Recommended
HIV
postexposure prophylaxis for mucous membrane exposures and
nonintact
skin
exposures",
and
"Basic
Expanded
HIV
Postexposure Prophylaxis Regimens",
” Timing and duration of
PEP,
Primary side
effects associated with an tiretroviral
agents, Monitoring and managing toxicities"f "Counselling of
health workers exposed to HIV positive source",
"Follow-up
testing" (pg. 44-48) in the reader.
ACTIVITY 6.10
POST-EXPOSURE PROPHYLAXIS - HIV (A)
(TIME: 20 MIN.)
Write down in the exposure form what post-exposure prophylaxis
would you advise for Dr. N?
EXPOSURE REPORT FORM (CONTINUED)
Exposure to HIV positive source patient:______
Needle injury:
Exposure type- Less severe / More severe
Mucous membrane or non-intact skin exposure:
Exposure type- Small volume / large volume
HIV infection status of source: Class 1 / Class 2
PEP recommendation:
Basic 2 drug PEP- Consider / Recommend
Expanded 3 drug PEP- Recommend
___________
Drugs advised
Drug
Dose
?
1.
'd)
.A./ .
2.
3.
Side-effects to be monitored for:
Duration
*
1.
k;
A /
Vi
xr/.—
—
'saz
r J vx,A
2.
3.
'
Followup visits:
1.
L
L
2.
Lab tests
TIa-^tvV
M
-
j-
—
i
3. ____ \/ I
Counselling
2.
l/l)
o
s
*
— Vx-VA
-
4.
£/f
23
MODULE 6
^FEEDBACK 6.10
EXPOSURE REPORT FORM (CONTINUED)
Exposure to HIV positive source patient:
Needle injury:
Exposure type- Less severe / More severe
Mucous membrane or non-intact skin exposure:
Exposure type- Small volume / large volume
HIV infection status of source: Class 1 / Class 2
PEP recommendation:
Basic 2 drug PEP Consider / Recommend
Expanded 3 drug PEP
Drugs advised:
Drug
Dose
Duration
1. Indinavir
800 mg q8h (on empty stomach) 4 weeks
2. Zidovudine
300 mg bd
4 weeks
3. Lamivudine
150mgbd
4 weeks
(Alternate basic regimens- Lamivudine + Stavudine or Didanosine + Stavudine)
(Alternate additional drug for expanded regimen- Nelfinavir: or Efavirenz)
Precautions to be taken and side-effects to be monitored for:
Indinavir - On empty stomach with low fat meal, to take large amount of fluids
Nausea, vomiting, increase in bilimbin. Kidney stones. Avoid astimezole, terfenadine,
cisapride, Rifampicin, statins and benzodiazepines
Zidovudine - Headache, nausea, vomiting, malaise, anemia
Followup visits:
Lab tests
1. 2 weeks
Assess for toxicities (blood counts, creatinine,LFT)
1. 6 weeks
HIV serology (other blood tests as needed)
2. 3 months
HIV serology (other blood tests as needed)
3. 6 months
HIV serology
Counselling:
1. Reassure Dr. N- explain that while there are risks, they are really low.
2. Sexual abstinence or use condom with partner for the 6 months of followup.
3. Not to donate blood.
4. Explain regimen, side-effects, drugs to be avoided and need for adherence.
5. To review in case of any symptoms suggestive of an acute seroconverting illness
(fever, lympadenopathy, rash, neurological syndromes).
6. Emphasise to Dr. N that you will be available in case she would like to discuss
anything.
___
__
24
MODULE 6
ACTIVITY 6.11
POST-EXPOSURE PROPHYLAXIS - HIV (B)
(TIME: 10 MIN.)
Mr. N,
a lab technician drew blood from Mr.
R.
and spilled a
drops of blood on his hands after the procedure. He
noticed a superficial cut on the hand on which he spilled
blood. He immediately washed his hands with soap and water and
reported the exposure to you. The post-exposure testing result
showed that R's HIV ELISA is reactive and Mr. N's HIV test is
few
negative.
checkup.
Mr.
R is
asymptomatic and had come for
a
general
Fill up your recommendations for post-exposure prophylaxis for
Mr. N. on the exposure report form.
EXPOSURE REPORT FORM (CONTINUED)
Exposure to HIV positive source patient:
Needle injury:
~
Exposure type- Less severe / More severe
Mucous membrane or non-intact skin exposure:
Exposure type— Small volume / large volume
HIV infection status of source: Cla^L / Class 2
PEP recommendation:
Basic 2 drug PEP ConS\^r / Recommend
Expanded 3 drug PEP
Drugs advised
Drug
Dose
1.
CH)
2.
Duration
1 ’
A
Side-effects to be monitored for:
1.
2.
y___________________ _______
Followup visits:
s/"
1.
2.
3. __________________
Counselling:
1.
2.
3.
4.
“
Lab tests
25
MODULE 6
* ^FEEDBACK 6.11
EXPOSURE REPORT FORM (CONTINUED)
Exposure to HIV positive source patient:
Needle injury:
Exposure type- Less severe / More severe
Mucous membrane or non-intact skin exposure:
Exposure type— Small volume / large volume
HIV infection status of source: Class 1 / Class 2
PEP recommendation:
Basic 2 drug PEP Consider / Recommend
Expanded 3 drug PEP
Drugs advised
Drug
Dose
1. Nil
2.
3. ___________________
Side-effects to be monitored for:
1.
2.
3. ____________________
Followup visits:
Lab tests
1. 6 weeks
HIV ELISA
2. 3 months
HIV ELISA
3. 6 months
HIV ELISA
Duration
Counselling:
Mr. K had a low risk exposure and this needs to be explained to him. While basic
regimen of PEP with 2 drugs can be offered, it need not be recommended. You might
actually dissuade Mr. K from taking PEP as the risk of side effects from PEP may
outweigh any benefit to him. You would advise him to come for follow up.
He needs to wear gloves while drawing blood and apply banadage to cuts. You should
advise sexual abstinence or use of condom with partner, not to donate blood and to
review in case of any symptoms suggestive of an acute seroconverting illness (fever,
lympadenopathy, rash, neurological syndromes).
26
MODULE 6
The next activity aims to help you learn how to choose and
initiate post-exposure prophylaxis for a health worker who has
had an exposure from a Hepatitis B source patient. Undertake
the activity after re-reading: “ Hepatitis B and the health
worker" (pg, 5 6-57) .
ACTIVITY 6.12
POST-EXPOSURE PROPHYLAXIS - HBV
(TIME: 10 MIN.)
Dr. S sustains a needle stick injury with an 18 G needle which
he has used for a road traffic accident patient Mrs. D, for
fluid resuscitation, There was visible blood on the needle and
it had punctured his gloved finger. He washes his hands and
reports the exposure. Mrs. D HbsAg test is positive.
Dr. S
had three dose hepatitis B vaccination 5 years ago and his
anti-HBs titre following the exposure was found to be 8
mIU/ml.
Write down your recommendation for post-exposure
prophylaxis for Dr. S.
EXPOSURE REPORT FORM (CONTINUED)
Exposure to HBSAg positive source patient:
Needle injury
Mucous membrane or non-intact skin exposure:
Vaccination status:
Unvaccinated
Partially vaccinated
Completely vaccinated
Anti-HBs antibody titre after vaccination: < 10 Miu/ml / > 10 Miu/ml / not known
Anti-HBs antibody titre after exposure: c^p^in/ ml / > 10 lU/ml / not known
PEP Recommended
HBIG 0.06 ml/Kg IM
Hepatitis B vaccine booster
Hepatitis B vaccine full course 0,1, 6 months
Followup visits:
Counselling:
A)
za
Lab tests
.• I •/- G S
La - ~ • ..A.,
■'
0
.
<
27
MODULE 6
'^FEEDBACK 6.12
EXPOSURE REPORT FORM (CONTINUED)
Exposure to HBSAg positive source patient:
Needle injury:
Mucous membrane or non-intact skin exposure:
Vaccination status:
Unvaccinated
Partially vaccinated
Completely vaccinated
Anti-HBs antibody titre after vaccination: < 10 Miu/ml / > 10 Miu/ml / not known
Anti-HBs antibody titre after exposure: < 10 mIU/ ml / > 10 lU/ml / not known
PEP Recommended
HBIG 0.06 ml/Kg IM
Hepatitis B vaccine booster
Hepatitis B vaccine full course 0,1, 6 months
Followup visits:
Lab tests
1 month after last dose of vaccine
Anti-HBs level
Counselling:
“
——————______________________
Dr. S should be reassured that the risk may be low as he has had prior vaccination. It is
because of his lower anti-body level that he is being given HBIG and booster
vaccination. No specific behavioural modification or restriction in patient contact is
required.
_______
________
28
MODULE 6
The following exercise t ’
tt"13
help you learn about the debate
on
screening
of blood borne pa thogens
before invasive
procedures.
Read
^Blood borne pathogen
screening
before
invasive procedures" (pg. 49) in
the reader. Then proceed to
the next activity.
ACTIVITY 6.13
HIV TESTING FOR INVASIVE PRCEDURES
(TIME: 10 MIN.)
A 35-year-old lorry cleaner from Namakkal presenting with
a
left sided neck swelling and fever
is found to have matted
lower deep cervical lymph nodes and is
referred for a fine
needle aspiration of the lymph node, The
surgeon who the case
is referred to requests for an HIV test.
1. Is the risk of transmission of blood borne pathogens
to the
health worker while drawing blood for HIV screening
more or
less than the risk of performing aa needle aspiration
.of the
lymph node?
2. In which
situations may HIV
screening be performed
doing an invasive procedure?
•- ..i
s-
J
3. Would precautions would
known to be HIV positive?
V-A
you take if the patient was
before
29
MODULE 6
FEEDBACK 6.13
i.
Is the risk of transmission of blood borne pathogens to the
health worker while drawing blood
for HIV screening more
less
a needle aspiration of the
than the risk of performing
lymph node?
The risk of transmission through a hollow needle used to draw blood is more than the
risk of transmission from a needle used to aspirate tissue. The infectiousness of blood is
greater than aspirated tissue fluid and the needle used for drawing blood can deliver more
innoculum than a fine needle used for the aspiration test.
2. In which situations may HIV screening be performed
before doing an invasive procedure?
Risk prone procedures such as deep pelvic or vascular surgery.
3.
Would precautions
would you take
if the patient
was known to be HIV positive?
Operative precautions do not change based on HIV status and all universal precautions
should be followed irrespective of the results of a positive test. It makes more sense to
invest resources in universal precautions rather than in universal testing.
or
/
30
NOTES
MODULE 6
I
33
MODULE 6
X-V21V
2JREADINGS
OCCUPATIONAL EXPOSURES IN THE UNITED STATES
From the : International Health Care Safety Centre
The following figures were calculated based on 1996 EPINet data (a surveillance
system for needle exposures to health workers in the US). We do not know to what
degree new HIV treatments have affected health care worker risk of HIV infection.
They have probably reduced the risk somewhat since there are now fewer AIDS
patients in hospitals.
We estimated percutaneous injuries and blood and body fluid exposures in one year,
based on:
• 30 injuries per 100 occupied hospital beds reported (from our national EPINet
data for 1996)
• 600,000 occupied hospital beds in the U.S.
r y
• 180,000 injuries in one year reported in hospitals (0.3 x 600,000)
• 39% of incidents not reported (according to surveys conducted in 6 EPINet
hospitals in 1996-1997) = 295,082 injuries occurred in hospitals
• double this figure because 50% of health care workers work outside of hospital
settings (total = 590,164 percutaneous injuries)
• according to EPINet data for 1996, an additional 1/3 of reported exposures (total
= 196,721 mucocutaneous exposures) involve skin/non-intact skin or mucous
membrane contact with blood or at-risk biological substances with can also transmit
HIV, HBV, HCV
• Total annual percutaneous and mucocutaneous exposures to blood or at-risk
biological substances in the U.S. in 1996 = 786,885
----- -
/ (TO
f
Risk of Infection Following a Single HIV, HBV, or HCV-Contaminated Needlestick
or Sharp Instrument Injury
> HIV 0.25% -0.4%
> HBV 6% - 30%-------- •
> HCV 0.4%-1.8%
34
MODULE 6
The CDC estimates that 400 new occupational HBV infections occurred in 1995
among U.S. health care workers, down from 17,000 in 1983. (Arch Intern Med
1997;157:2601-2603)
Assuming that between 1% and 2% of patients are HIV-positive (and therefore that
1% to 2% of needlesticks are HIV-contaminated) between 18 to 35 new occupational
HIV infections would occur from percutaneous injuries each year. Infections
resulting from blood exposures to non-intact skin or mucuous membranes would
add between 2 to 4 cases (based on a transmission rate of .09% for a mucous
membrane exposure).
Assuming that between 2% and 10% of patients are HCV-positive (Dr. Richard
Garvin, Hepatitis Branch, CDC), between 59 to 1,180 new occupational HCV
infections would occur each year. Infections resulting from blood exposures to non
intact skin or mucous membranes would add between 16 to 393 cases (assuming that
the transmission rate was between 0.4% and 1.8% per exposure, with lower limit
from Dr. Giuseppe Ippolito, Italy, 1999).
The consequences of occupational exposure to bloodborne pathogens are not only
infections. Each year, thousands of health care workers are affected by psychological
trauma during months of waiting for notification of serological results. Other
personal consequences can include postponement of childbearing, altering sexual
practices, side effects of prophylactic drugs, infection, chronic disabilities, loss of
employment, denial of worker compensation claims, liver transplant, and premature
death.
From: http://hsc.virginia.edu/medcnti7centers/epinet/cdcestim.html
35
MODULE 6
UNIVERSAL PRECAUTIONS FOR PREVENTION OF TRANSMISSION OF HIV
AND OTHER BLOODBORNE INFECTIONS
"Universal precautions," as defined by CDC, are a set of precautions designed to
prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus
(HBV), and other bloodborne pathogens when providing first aid or health care.
Under universal precautions, blood and certain body fluids of all patients are
considered potentially infectious for HIV, HBV and other bloodborne pathogens.
Universal precautions took the place of and eliminated the need for the isolation
category "Blood and Body Fluid Precautions" in the 1983 CDC Guidelines for
■
-
-—--------------- —
'
—----------------------- ----------- ---------------------
"
'
.
A
Isolation Precautions in Hospitals. However, implementing universal precautions
does not eliminate the need for other isolation precautions, such as droplet
precautions for influenza, airborne isolation for pulmonary tuberculosis, or contact
isolation for methicillin-resistant Staphylococcus aureus.
Universal precautions apply to: blood, other body fluids containing visible blood,
semen, and vaginal secretions. Universal precautions also apply to tissues and to the
following fluids: cerebrospinal, synovial, pleural, peritoneal, pericardial, and
amniotic fluids.
Universal precautions do not apply to: feces, nasal secretions, sputum, sweat, tears,
urine, and vomitus unless they contain visible blood. Universal precautions do not
apply to saliva except when visibly contaminated with blood or in the dental setting
where blood contamination of saliva is predictable.
Universal precautions involve:
1. The use of protective barriers such as gloves, gowns, aprons, masks, or protective
eyewear, which can reduce the risk of exposure of the health care worker's skin or
mucous membranes to potentially infective materials.
2. In addition, under universal precautions, it is recommended that all health care
workers take precautions to prevent injuries caused by needles, scalpels, and other
sharp instruments or devices.
1
36
MODULE 6
1 G-LOVINGf gowning, masking, and other protective barriers
AS PART OF UNIVERSAL PRECAUTIONS
All health care workers should routinely use appropriate barrier precautions to prevent skin
and mucous membrane exposure durmg contact with any patient's blood or body fluids that
require universal precautions.
a. Gloves should be worn:
i. for touching blood and body fluids requiring universal precautions, mucous
membranes, or nonintact skin of all patients
ii. for handling items or surfaces soiled with blood or body fluids to which universal
precautions apply.
in. Gloves should be changed after contact with each patient.
iv. Hands and other skin surfaces should be washed immediately if contaminated
with blood or body fluids requiring universal precautions.
v. Hands should be washed immediately after gloves are removed.
vi. Gloves should reduce the incidence of blood contamination of hands during
phlebotomy, but they cannot prevent penetrating injuries caused by needles or other
sharp instruments. Institutions that judge routine gloving for all phlebotomies is not
necessary should periodically reevaluate their policy. Gloves should always be
available to health care workers who wish to use them for phlebotomy. In addition,
the following general guidelines apply:
Use gloves for performing phlebotomy when the health care worker has cuts.
scratches, or other breaks in his/her skin.
Use gloves in situations where the health care worker judges that hand
contamination with blood may occur, e.g., when performing phlebotomy on an
uncooperative patient.
Use gloves for performing finger and/or heel sticks on infants and children.
Use gloves when persons are receiving training in phlebotomy.
k Masks and protective eyewear or face shields should be
worn by health care
workers to prevent exposure of mucous membranes of the mouth, nose, and eyes
r
/
37
MODULE 6
during procedures that are likely to generate droplets of blood or body fluids
requiring universal precautions.
c. Gowns or aprons should be worn during procedures that are likely to generate
splashes of blood or body fluids requiring universal precautions.
2. PREVENTION OF NEEDLE AND SHARP INJURIES
All health care workers should take precautions to prevent injuries caused by
needles, scalpels, and other sharp instruments or devices during procedures; when
cleaning used instruments; during disposal of used needles; and when handling
sharp instruments after procedures. To prevent needlestick injuries:
a. Needles should not be recapped by hand, purposely bent or broken by hand,
removed from disposable syringes, or otherwise manipulated by hand.
b. After they are used, disposable syringes and needles, scalpel blades, and other
sharp items should be placed in puncture-resistant containers for disposal.
c. The puncture-resistant containers should be located as close as practical to the
use area.
d. All reusable needles should be placed in a puncture-resistant container for
transport to the reprocessing area.
General infection control practices should further minimize the already minute risk
for salivary transmission of HIV. These infection control practices include the use of
gloves for digital examination of mucous membranes and endotracheal suctioning,
handwashing after exposure to saliva, and minimizing the need for emergency
mouth-to-mouth resuscitation by making mouthpieces and other ventilation devices
available for use in areas where the need for resuscitation is predictable.
Although universal precautions do not apply to human breast milk, gloves may be
worn by health care workers in situations where exposures to breast milk might be
frequent, e.g., in breast milk banking.
Adapted from: http://www.cdc.gov/ncidod/hip/BLQOD/UNIVERSA.HTM
38
MODULE 6
PREVENTION OF SHARP INJURIES
The following set of instructions lists measures to prevent needle injuries from
taking place.
1. Procedure related injuries:
a. Blood drawing:
i.
Use tourniquet and gloves
ii.
Take a sharps disposal container on your blood drawing tray
iii.
Avoid keeping your palpating finger on the artery or vein during blood
drawing (as in arterial blood gas)
iv.
Remove the needle and dispose in sharps disposal container before
transferring blood into test tube. An artery clamp or forceps may be used for
removing needle from the syringe and disposing into sharps disposal container,
v.
Do not recap the needle after use.
b. Surgery
i.
Do not pass sharps from hand to hand. Use a neutral area or transit tray.
ii.
Do not retract with hand.
iii.
Do not use hand suturing.
iv.
Avoid needle-hand contact. Never retrieve needles and sharps with fingers.
v.
Move unused sharps out of the surgical field.
vi.
Shield the scalpel when using it to avoid injury to assistants.
vii.
Exercise care with wires and long pins.
viii.
While suturing the needle should be away from the knot. Clamp the needle
and then only cut the suture.
ix.
Wear double gloves while operating.
2. Disposal injuries
a. Never leave unused sharps lying around.
b. Dispose sharps only in the sharps disposal container.
39
MODULE 6
c. Remove and empty sharps disposal container when three-fourths full.
d. Sharps disposal containers need to be emptied with great care.
SHARP DISPOSAL CONTAINERS
1. Functional Criteria: Puncture resistant, durability and leak proof
2. General location and placement:
Sharp containers should be placed at the site of use. They should be readily visible
and within easy horizontal reach of the user. There should not be obstacles between
the sharp container and the site of use.
3. Colour and label: Blue or white translucent colour with biohazard label on the
surface of the container.
4. Emptying: The sharp disposal container should be sent for emptying when it is
three-fourths full.
40
MODULE 6
HEPATITIS B IMMUNISATION IN HEALTH WORKERS
Hepatitis B is the most important occupational blood borne pathogen infection
among health workers. In the United States it was estimated that 17,000 new
Hepatitis B infections occurred in health workers in
1983. With effective
immunisation the number of new Hepatitis B infections in health workers
was
reduced to 400 in 1995.
All health workers at risk of r
exposure to Hepatitis B should be provided
immunisation. The efficacy of 3 doseJ schedule of vaccination is 90-95%. The
vaccination schedule has less efficacy in persons who have HIV infection, chronic
liver disease, chronic renal failure, Diabetes Mellitus, smokers and persons on
immunosuppressive drugs.
Routine prevaccination antibody testing is not required. Antibody testing is
recommended 1-2 months after the third dose of vaccine. Persons who do not
develop adequate antibody titre after the third dose are required to receive a repeat
course of vaccination with three doses. Follow up antibody testing after 2 months of
completion of course and booster vaccination is not required.
Following significant exposure of a vaccinated health worker to a Hepatitis B
positive source patient, anti-HBs testing is required. If antibody levels are
inadequate Hepatitis B immunoglobulin and booster dose of vaccination are to be
administered. This regimen has an efficacy of about 75% in protecting the health
worker against the exposure.
In situations where anti-HBs testing is not available, a reasonable option is:
a. provide complete Hepatitis B vaccination course to all at risk health workers.
b. In case of a significant exposure to Hepatitis B positive source patient-
If the health worker has had a full course of vaccination then the person may be
followed up. If the person does not have documented vaccination record or has not
received a complete course of vaccination, then Hepatitis B immunoglobulin
injection followed by repeat course of vaccination should be advised. In case
Hepatitis B immunoglobulin is not available for a significant exposure in an
unvaccinated or partially vaccinated individual, then institute Hepatitis vaccination
as soon as possible.
41
MODULE 6
HANDLING EXPOSURES
In case of an exposure:
Don't panic.
Stop what you are doing immediately.
Hand over to colleague if needed.
Call for help.
In case of needle stick injury:
1. Remove gloves
2. Go to nearest tap
3. Wash hands with running water expressing blood for 10 minutes.
4. Apply soap or antiseptic as is available.
5. Apply bandage
In case of mucous membrane exposure:
1. Irrigate copiously with water or normal saline for 10 minutes. In case of exposure
to eyes keep your eyelids held open.
2. Do not apply soap or antiseptic.
3. Report exposure to reporting authority.
In case of non-intact skin exposure:
1.
Wash with soap and water or antiseptic.
2.
Report exposure<to reporting authority.
In case of needle stick injury, mucous membrane exposure or non-intact skin
exposures:
Report the exposure as soon as possible so to initiate appropriate post-exposure
prophylaxis.
42
MODULE 6
FACTORS AFFECTING
-TRANSMISSION
SOURCE PATIENT
STATUS
NEEDLE
SOLID I HOLLOW
DEPTH OF INJURY
HCW IMMUNITY
POST-EXPOSURE CARE
POST-EXPSOURE
PROPHYLAXIS
FACTORS AFFECTING TRANSMISSION FROM NEEDLE INJURY
1. Increased innoculum of blooda. Device visibly contaminated with blood
b. Needle had been placed directly in artery or vein
c. Deep injury
d. Hollow bore needle
2. Source patient with increased viral load: Symptomatic disease, AIDS, acute
seroconverting illness
Factors which reduce risk of transmission from a needle stick injury
Post-exposure prophylaxis
RISK OF OCCUPATIONAL TRANSMISSION OF HIV INFECTION
Contaminated needle stick injury - 0.3 % (0.2-0.5%)
Mucous membrane exposure - 0.09% (0.006-0.5%)
43
MODULE 6
EXPOSURE EVALUATION - INITIAL TESTS TO BE PERFORMED
Source patient having no known infection.
1- Tests for source patient
HbsAg, HIV ELISA or rapid test and HCV serology.
2. Tests for exposed health worker
a. Ifsource patient's tests are all negative No tests required for exposed health worker.
b. Ifsource patient HIV test is positive HIV ELISA to be performed for exposed health worker.
c. Ifsource patient HbsAg test is positive and health worker has been partially orfiilly
immunized Anti-HBs titre to be performed for the health worker.
d. If source patient HCV serology test positive HCV serology to be performed for the health worker.
44
MODULE 6
RECOMMENDED HIV POSTEXPOSURE PROPHYLAXIS FOR
PERCUTANEOUS INJURIES
(Vol. 50 / No. RR-11 MMWR pg. 24)
Refer Guidelines and Policies in HIV Care, CMCH pg. 23-27 and note differences in
management.
Exposure
type
Less
severe
More
severe§§
___________ INFECTION STATUS OF SOURCE PATIENT
HIV positive HIV positive Source of
Unknown
HIVClass 1*
Class 2*
unknown
source§
Negative
HIV status
Recommend
basic 2- drug
PEP
Recommend
expanded 3drug PEP
Recommend
expanded 3drug PEP
Recommend
expanded 3drug PEP
1______
Generally,
no
PEP
warranted
Consider 2
drug PEP
in source
with
known risk
factorsft
Generally,
No PEP
no
PEP warranted
warranted
Consider 2
drug PEP**
in settings
where
exposure to
HIV
patients
likely_____
Generally,
Generally,
No PEP
no
PEP no
PEP warranted
warranted
warranted
Consider 2 Consider 2
drug PEP
drug PEP**
in source
in settings
with
where
known risk exposure to
HIV
factorstt
patients
likely_________________
* HIV-Positive, Class 1 —
- asymptomatic
... HIV- •infection
- ■
or known low viral load (e. g., <1,500 RNA
copies/ mL). HIV- Positive, Class 2 — Symptomatic HIV infection, AIDS, acute seroconversion,/ or
known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of
postexposure prophylaxis (PEP) should not be delayed pending expert consultation, and, because
expert consultation alone cannot substitute for face- to- face counseling, resources should be available
to provide immediate evaluation and follow- up care for all exposures.
fSource of unknown HIV status (e. g., deceased source person with no samples available for HIV
testing).
§Unknown source (e. g., a needle from a sharps disposal container).
^Less severe (e. g., solid needle and superficial injury).
** The designation "consider PEP" indicates that PEP is optional and should be based on an
individualized decision between the exposed person and the treating clinician.
tflf PEP is offered and taken and die source is later determined to be HIV- negative?, PEP should be
discontinued.
§§More severe (e. g., large- bore hollow needle, deep puncture, visible blood on device, or needle
used in patient's artery or vein).
45
MODULE 6
RECOMMENDED HIV FQSTEXPOSURE PROPHYLAXIS FOR MUCOUS MEMBRANE
EXPOSURES AND NONINTACT SKIN EXPOSURES
(Vol. 50 / No. RR-11 MMWR Page 25)
Refer Guidelines and Policies in HIV Care, CMCH pg. 23-27 and note differences in
management.
INFECTION STATUS OF SOURCE PATIENT
Exposure
HIV positive
HIV positive Source of
Unknown
HIVtype
Class If
Class 2f
unknown
source^
Negative
HIV status§
Small
Consider
Recommend
Generally,
Generally,
No PEP
volume**
basic 2 drug
basic 2 drug
no
PEP no
PEP warranted
PEP ft
PEP
warranted
warranted
Consider 2
Consider 2
drug PEP ft drug PEP ft
in source
in settings
with known where
risk factorsft exposure to
HIV patients
likely _____
Large
Recommend
Recommend
Generally,
Generally,
No PEP
volume^ H
basic 2- drug expanded 3no
PEP no
PEP warranted
PEP
drug PEP
warranted
warranted
Consider 2
Consider 2
drug PEP ft drug PEP ft
in source
in settings
with known where
risk factors
exposure to
HIV patients
likely______
* For skin exposures, follow- up is indicated only if there is evidence of compromised skin integrity
(e. g., dermatitis, abrasion, or open wound).
tHIV- Positive, Class 1 — asymptomatic HFV infection or known low viral load (e. g., <1,500 RNA
copies/ mL). HIV- Positive, Class 2 —
symptomatic HFV infection, AIDS, acute seroconversion, or known high viral load. If drug resistance
is a concern, obtain expert consultation. Initiation of postexposure prophylaxis (PEP) should not be
delayed pending expert consultation, and, because expert consultation alone cannot substitute for
face- to- face counseling, resources should be available to provide immediate evaluation and follow
up care for all exposures.
§Source of unknown HIV status (e. g., deceased source person with no samples available for HIV
testing).
^Unknown source (e. g., splash from inappropriately disposed blood).
** Small volume (i. e., a few drops).
tfThe designation, “consider PEP/' indicates that PEP is optional and should be based on an
individualized decision between the exposed person and the treating clinician.
§§If PEP is offered and taken and the source is later determined to be HFV- negative, PEP should be
discontinued.
„Large volume (i. e., major blood splash).
46
MODULE 6
BASIC AND EXPANDED HIV PQSTEXPQSURE
PROPHYLAXIS REGIMENS
(Vol. 50 / No. RR-11 MMWR pg. 47)
BASIC REGIMEN
• Zidovudine + Lamivudine
- ZDV: 600 mg per day, in two or three divided doses, and
— 3TC: 150 mg twice daily.
ALTERNATE BASIC REGIMENS
• Lamivudine (3TC) + Stavudine (d4T)
- 3TC: 150 mg twice daily, and
- d4T: 40 mg (if body weight is <60 kg, 30 mg twice daily) twice daily.
• Didanosine (ddl) + Stavudine (d4T)
- ddl: 400 mg (if body weight is <60 kg, 125 mg twice daily) daily, on an empty
stomach.
- d4T: 40 mg (if body weight is <60 kg, 30 mg twice daily) twice daily.
EXPANDED REGIMEN
Basic regimen plus one of the following:
• Indinavir (IDV)
- 800 mg every 8 hours, on an empty stomach.
• Nelfinavir (NFV)
- 750 mg three times daily, with meals or snack, or
- 1250 mg twice daily, with meals or snack.
• Efavirenz (EFV)
- 600 mg daily, at bedtime.
• Abacavir
- 300 mg twice daily.
ANTIRETROVIRAL AGENTS FOR USE AS PEP ONLY WITH EXPERT
CONSULTATION
• Ritonavir
• Saquinavir (SQV)
• Amprenavir (AMP)
• Lopinavir/Ritonavir (KALETRA™)
ANTIRETROVIRAL AGENTS GENERALLY NOT RECOMMENDED FOR USE AS PEP
• Nevirapine (NVP)
47
MODULE 6
TIMING AND DURATION OF PEP
Post-exposure prophylaxis for HIV infection should be initiated as soon as possible after the
exposure preferably within the first 24 hours. However PEP may be started even up to one
week after the exposure. Post-exposure prophylaxis should be administered for 4 weeks if
tolerated.
PRIMARY SIDE EFFECTS ASSOCIATED WITH ANTIRETROVIRAL AGENTS
(Vol. 50 / No. RR-11 MMWR pg. 13)
Nucleoside reverse transcriptase inhibitors (NRTIs)
1. Zidovudine (AZT) anemia, neutropenia, nausea, headache, insomnia, muscle pain and
weakness
'
2. Lamivudine (3TC) abdominal pain, nausea, diarrhea, rash, and pancreatitis
3. Stavudine (d4T) peripheral neuropathy, headache, diarrhea, nausea, insomnia, anorexia
pancreatitis, increased liver function tests (LFTs), anemia, and neutropenia
4. Didanosine (ddl) pancreatitis, lactic acidosis, neuropathy, diarrhea, abdominal pain and
nausea----------------------------------5. Abacavir nausea, diarrhea, anorexia, abdominal pain, fatigue, headache, insomnia, and
hypersensitivity reactions
Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
1. Nevirapine (NVPlrash_(including cases of Stevens-Johnson syndrome), fever, nausea,
headache, hepatitis, and increased LFTs
2. Delavirdine (DLV) rash (including cases of Stevens-Johnson syndrome), nausea, diarrhea.
headache, fatigue, and increased LFTs
3. Efavirenz EFV) rash (including cases of Stevens-Johnson syndrome), insomnia,
somnolence, dizzmess, trouble concentrating, and abnormal dreaming
Protease inhibitors (Pls)
1. Indinavir (IDV) nausea, abdominal pain, nephrolithiasis, and indirect hyperbilirubinemia
Nelfmavir (NFV) diarrhea, nausea, abdominal pain, weakness, and rash
2. Ritonavir (RTV) weakness, diarrhea, nausea, circumoral paresthesia, taste alteration, and
increased cholesterol and triglycerides
3. Saquinavir (SQV) diarrhea, abdominal pain, nausea, hyperglycemia, and increased LFTs
4. Amprenavir (AMP) nausea, diarrhea, rash, circumoral paresthesia, taste alteration, and
depression
5. Lopinavir/Ritonavir (Kaletra™) diarrhea, fatigue, headache, nausea, and increased
cholesterol and triglycerides
MONITORING AND MANAGING TOXICITIES
After initiation of PEP the health worker should be monitored at baseline and after 2 weeks.
Lab testing should include complete blood counts, liver and renal function tests.
They should be advised the importance of completing their regimen.
They should also know the drug side-effects and interactions.
Minor side-effects may be treated symptomatically or with dose adjustment.
Major side-effects may require stoppage or change of drugs.
48
MODULE 6
COUNSELLING OF HEALTH WORKERS EXPOSED TO HIV SOURCE
1. Exposed health workers are under tremendous stress and should be reassured
and gently counseled.
2. While the risks of exposure need to be acknowledged the miniscule nature of
most exposures needs to be emphasized as well the possibility for reducing
the risks through PEP.
3. The pros and cons of taking PEP need to be discussed if it is indicated.
4. If PEP is initiated, then the dosing, side-effects and interactions and the
follow-up schedule need to be clearly explained.
5. The health worker should refrain from sexual activity or use condoms
appropriately during the 6 months after the exposure.
6. They should avoid blood donation during the period of follow-up.
7. The health worker should be advised to seek medical evaluation for any acute
illness occurring during follow-up.
FOLLOW-UP TESTING
(Vol. 50 / No. RR-11 MMWR Page 46)
HBV exposures
• Perform follow-up anti-HBs testing in persons who receive hepatitis B vaccine.
— Test for anti-HBs 1-2 months after last dose of vaccine.
- Anti-HBs response to vaccine cannot be ascertained if HBIG was received in the
previous 3-4 months.
HCV exposures
• Perform baseline and follow-up testing for anti-HCV and alanine amino
transferase (ALT) 4-6 months after exposures.
• Perform HCV RNA at 4-6 weeks if earlier diagnosis of HCV infection desired.
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs) with
supplemental tests.
HIV exposures
• Perform HIV-antibody testing for at least 6 months postexposure (e.g., at
baseline, 6 weeks, 3 months, and 6 months).
• Perform HIV antibody testing if illness compatible with an acute retroviral
syndrome occurs.
• Advise exposed persons to use precautions to prevent secondary transmission
during the follow-up period.
• Evaluate exposed persons taking PEP within 72 hours after exposure and
monitor for drug toxicity for at least 2 weeks.
49
MODULE 6
BLOOD BORNE PATHOGEN SCREENING BEFORE INVASIVE PROCEDURES
There are three possible reasons doctors may order HIV test before invasive
procedures.
1- HIV status alters diagnostic and therapeutic considerations
In certain situations knowledge of the HIV status may alter the diagnostic and
therapeutic considerations.
Eg. In case of renal transplant HIV screening is done on the
the recipient.
recipient. If
If the
the recipient
recipient
had HIV infection, the patient would not tolerate immunosupression and may die of
HIV and not chronic renal failure.
2- Performance of risk prone procedures which pose serious risks to the operating
surgeon
In performance of high-risk procedures, knowledge of the HIV test may allow the
surgeon to alter surgical procedure so as to reduce risk to the operating team.
Eg. Risk prone procedures such as deep pelvic surgery or vascular surgery where
the surgeons operating hands and sharps are placed together but are not visible to
the surgeon. In this situation the surgeon is prone to the risk of sharp injury.
Appropriate precautions need to be taken to prevent injury to the surgeon. In such a
situation HIV testing may be considered as it may reduce the risk of transmission of
HIV infection to the operating surgeon.
3. Performance of procedures which are not in high risk category
HIV testing is not recommended in most invasive procedures, as they do not pose
significant risks to the surgeon. The only method of reducing risks in these
procedures is by following universal precautions for all patients.
There is a perception that knowledge of HIV test may lead to closer adherence to
universal precautions in patients who pose risks to the surgeon. However a study
from San Francisco suggested infection control precautions were no more carefully
observed when HIV test was known to be positive.
Screening for blood borne pathogens requires testing for HIV, Hepatitis B and
Hepatitis C. Screening tests may miss some patients who have infection in the
window period or because of lack of sensitivity of the tests (eg. Hepatitis C). Also
screening may miss unknown blood borne pathogens that we do not know about
today.
A negative blood borne pathogen screen may lead a surgeon to be less careful and
therefore more prone to injury. On the other hand a positive HIV test may lead to the
surgeon to avoid performance of the procedure on the patient. This would reduce
patients' access to medical care and would be ethically unacceptable.
50
MODULE 6
SAFE SURGICAL PRACTICE
While all categories of Health Care Workers (HCW) are at risk of exposure to blood
borne pathogens, surgeons and obstetricians and gynecologists, by the very nature
of their profession, are particularly at risk. General surgeons are higher risk than any
other category of HCW 1.
While this article has focused on HIV transmission, it must be remembered that the
risk of contracting hepatitis B or C is higher than the risk of contracting HIV from
blood contact or sharps injuries with solid or hollow needles 3.Observing the
following precautions will help minimize transmission of these and other unknown
BBP
The risk to a surgeon is dependent on the type and number of operations performed
by the surgeon and the prevalence of HIV in the population. This will vary with the
seroprevalence of the patient population and the surgical injury rate. The frequency
of percutaneous injury has been found in various studies to be about 1 in 40
operations. Based on a probabilistic model, the cumulative lifetime risk to a surgeon
performing 350 operations per year for 30 years is about 1/100 3. For HIV prevalence
of 1 in 100, the cumulative risk is about 1 in 100. When the seroprevalence is 1/10,
the risk may be high as 1 in 5 i.e., the risk increases with increasing prevalence in the
community.
There are five variables that can be altered to reduce the risk of HIV transmission to
a surgeon: I) seroprevalence ii) efficiency of transmission iii) number of operations
performed per year iv) number of years in practice and v) incidence of inoculation.
Of these, the only practical strategy for risk reduction is to modify surgical practice
so as to reduce the incidence of inoculation.
Inoculation during an operation can be substantially decreased by 1) Barrier
protection 2) Alteration of surgical technique to avoid needlestick / sharps injury.
Personal Protective Equipment (PPE): Barrier precautions and PPE are used to
decrease a surgeon’s exposure to blood.
1. Gloves: Glove perforations are common during operations, particularly if
equipment such as drills are being used. Furthermore, surgeons are often unaware
51
MODULE 6
that gloves have perforated and there has been skin contact with blood and body
fluids.
Double gloving is recommended as this has been shown to reduce exposure rates
from 51% to 7%. Double gloving has been criticized as being impractical, decreasing
tactile sensation and dexterity, particularly by older surgeons. It is recommended
that the inner pair be a half size bigger than the size normally worn by the surgeon,
and the outer pair be the usual size. This prevents loss of tactile sensation, air
pockets and pain 3. Polyethylene and vinyl gloves, though resistant to tearing, have
not been shown to decrease exposure to blood.
It should be noted that while gloves protect against blood exposure, they do not
prevent or protect against needle stick or sharps injuries. However, wearing gloves
reduces the amount of blood contact.
If the forearm is likely to be exposed to blood (eg. During manual removal of
placenta), it should also be covered with gloves.
2. Masks: The role of masks has shifted from protecting the patient to protecting the
surgeon. Hence, masks should be secured properly, covering the mouth and nose.
They should be changed, ideally between cases and if soiled with blood. High
filtration, disposable masks provide more protection than cloth masks traditionally
worn. Where large volume splashes are anticipated, a full-face shield is
recommended in addition.
3. Protective eyewear: Protective eyewear is necessary to protect the HCW from
conjunctival contact with blood. Various models are available, the cheapest being
standard glasses with side wings. In India, cheap, easily available varieties are
motorcycle goggles. Motorcycle face shields can be used where large spills are
anticipated, or when the surgeon wears corrective eyewear already. These should be
made available in all operation theatres in adequate numbers.
4. Gowns: Ideally, gowns should be made of impervious material. While these are
commercially available, they are expensive, and single use. A cheaper alternative is
to wear a disposable plastic apron under the conventional cloth gown. While this
protects the chest and abdomen up to mid thigh, the arms are unprotected.
Protection of the arms will require elbow length gloves or disposable barrier sleeves
or specially designed plastic gowns with sleeves. Provision of protection to the arms
52
MODULE 6
is unsatisfactory at present in our practice. An easily adaptable technique using
ordinary gloves is demonstrated in the photographs provided.
5. Footwear: The dorsum of the feet should be covered by impervious footwear that is
thick enough to prevent accidental injuries like blood spills and falling scalpels etc.
A pair of such footwear should be kept exclusively for OR use. These may be
covered with a pair of overshoes to decrease bloodstaining and for ease of cleaning.
(This should not replace impervious foot wear) The overshoes should ideally be of
disposable, impervious material, but cloth overshoes over leather / plastic footwear
is an acceptable alternative in our situation. Knee length rubber boots are advised
where pooling of blood and fluid on the floor is likely, e.g. Caesarean section and
urology.
Thus a "well dressed"ii surgeon in the 21st century would have protective eye wear, a
disposable mask, a plastic apron under the gown (or impervious gowns), double gloves, and
well fitting shoes with an overshoe.
6. One area that is frequently overlooked is that of aerosols created during surgery.
These include CO? laser therapy, laparoscopic surgery, procedures using high-speed
drills etc. It is prudent to assume that such aerosols may be infectious, and effective
smoke evacuation systems should be in place. Laparoscopic surgery is not
contraindicated in HIV positive individuals if aerosols are effectively dealt with.
Masks should be well fitting and of the high filtration variety.
Avoiding sharps injury
Cuts and pricks by scalpels and solid needles are the commonest sharps injuries
encountered by the surgeon and his team. Solid needles are less likely to result in
seroconversion than hollow needles and most literature on this issue is with regard
to hollow needles.
Minor changes in surgical practice and a progressive mindset are necessary to
reduce the chance of intraoperative needle stick injuries.
The following modifications in technique are recommended.
1. Use of forceps or another needle holder to retrieve suture needles from tissues.
While older surgeons, who were trained in an era where needles were reused and
needed to be treated "with respect" often use their fingers to retrieve needles,
younger surgeons and surgeon in training need to be taught to change practice in
53
MODULE 6
order to avoid injury. The most common site of injury is the tip of the index finger of
the non dominant hand.
2. Use of forceps or instruments to hold tissues while suturing / cutting and not the
hand. This is especially important while closing the abdomen after a laparotomy.
3. Avoid attempts to palpate needle tips obscured by tissue or blood. Suck all blood
and retract tissues with retractors, sponge sticks or mops. Assistants should not
enthusiastically mop while the surgeon is suturing.
4. Do not pull needles out towards the non dominant hand or the assistant's hand.
5. Avoid tying sutures with the needle attached to the suture. It is safer, though more
expensive to cut the needle off before tying.
6. Sharp instruments such as mounted needles, cautery tips, staples etc on the table or
patient should be stored on a corner of the Mayo stand or the scrub nurses' trolley
when not in use. Foam and sticky pads are available to store used needles. Magnetic
pads are also available.
7. "Economy of movement". Certain practices need to be relearnt by all members of the
surgical team. It is good practice to make sure that no two people touch the same
sharp instrument at the same time. If they do, it is prudent to ensure that only one
person's hand is moving at any one time. Rapid, jerky movements should be
avoided. If a sharp is placed on the operating field or patient, it should be
accompanied by a verbal warning such as "sharp", "knife" or "cautery". Scrub nurses
have been traditionally taught to pass instruments to surgeons directly. Scrub nurses
should avoid handling suture needles with their fingers and should use instruments
to load them. All sharps should be passed between surgeons and nurses through a
"neutral zone", usually a kidney tray.
8. Where major blood splashes are anticipated, eg. vascular surgery, vascular
anastomoses can be inspected through a Petri dish cover. Irrigation and suction can
also be performed behind such transparent shields.
9. Decreasing the number of personnel in the OR will decrease the opportunities for
exposure.
10. When the patient is known to be seropositive, perhaps the one single factor that
decreases such injuries is an experienced surgeon 4. Assistants should be relaxed, not
angry or anxious and assist without coercion.
54
MODULE 6
11. Improvement in technology. Blunt tipped needles are available though the
"industry" has been reluctant to introduce these in developing economies. Scalpel
blades with blunt tips serve the same purpose as conventional blades.
12. Use of alternative instruments. The use of scalpels and scissors can be reduced
significantly if the surgeon is willing to dissect with the electrocautery hand held
handle, as most American surgeons do. Scissors in place of scalpels for dissection
will reduce the chance of injury. Electrocautery can be used to cut skin, if properly
used. Many institutions have eliminated the use of scalpel blades during surgery 4.
Staplers for bowel anastomoses and skin closure are recommended, but this has to
be weighed against increased costs.
13. Performance of a lesser procedure often suffices in patients known to be
seropositive, eg. Percutaneous drainage of intra abdominal abscess, FNAC instead of
open biopsy, etc.
Thus, in this day and age, it is important that all HCW involved in and around
operating theatres practice their craft with a high degree of discipline and integrity.
55
MODULE 6
REFERENCES
1. CDC (2001) Updated U.S Public Health Service Guidelines for the management
of occupational exposures to HBV, HCV and HIV and recommendations for post
exposure prophylaxis. MMWR 50/No. RR-11:1-54.
2. Hospital Infection Control Committee, Christian Medical College and Hospital
(2001) Guidelines and policies in HIV care.
3. Universal precautions for prevention of transmission of HIV and other blood
borne infections.
http://www.cdc.gov/ncidod/hip/BLOOD/UNIVERSA.I-ITM
4. International Health Care Safety Centre (1998). Annual Number of Occupational
Percutaneous Injuries and Mucocutaneous Exposures to Blood or Potentially
Infective Biological Substances.
http://hsc.virginia.edu/medcntr/centers/epinet/cdcestim.html
5. Immunisation Action Coalition. Hepatitis B and the health care worker
http://www.immunize.org
FURTHER READING
1. CDC(1987) Recommendations for prevention of HIV transmission in health-care
settings. MMWR 36(suppl no. 2S).
2. CDC(1988) Update: Universal precautions for prevention of transmission of
human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens
in health-care settings. MMWR 37:377-388.
6. CDC (1989) Guidelines for prevention of transmission of human
immunodeficiency virus and hepatitis B virus to health-care and public-safety
workers. MMWR 38(S-6):l-36.
7. Lin EY, Burnicardi FC (1994) HIV Infections and Surgeons. World ] Surg; 18(5)753-8.
5. Smoot EC (1998) Practical Precautions for Avoiding Sharp Injuries and Blood
Exposure. Plastic Recons Surg. 101(2): 528-34.
6. Schiff SJ (1990) A surgeon's risk of AIDS. ] Neurosurg 73(5):651-60.
7. Crombleholme WR (1990) HIV Infection. Managing exposure risks for the
Obstetrician / Gynecologist. Obstet Gynecol Clin. North Am. 17 (3): 627-36.
8. Stotter AT, Vipond MN, Guillou PJ (1993) The response of general surgeons to
HIV in England and Wales. Ann R Coll Surg Engl. 75(5): 330-2.
9. Gerberding JL, Littell C, Tarkington A, Brown A, Schecter WP (1990) Risk of
exposure of surgical personnel to patients' blood during surgery at San Francisco
General Hospital. N Engl J Med 322:1788-93.
10. Zuger A, Miles SH. Physicians, AIDS, and occupational risk: Historic traditions
and ethical obligation. JAMA 1987;258:1924-8.
11- http://medocs.ucdavis.edu/osu/421/orthopedic ethics/case 6/case 6.htm
12. Selecting, evaluating and using sharp disposal containers.
http://www.cdc.gov/niosh/sharps
5^
Hepatitis B and the
health care worker
You need more
than hepatitis B shots!
To obtain the ACIP statement
“Immunization of Health-Care Workers”
call (800) 232-2522
CDC answers frequently asked questions
about how to protect health care workers
Harold S. Margolis, MD, pediatrician, is chiefof the Hepatitis Branch, Centersfor Disease Control and
Prevention (CDC), and director ofthe World Health Organization Collaborating Centrefor Research and
Reference in Viral Hepatitis. Linda A. Moyer, RN, is an epidemiologist at the Hepatitis Branch, CDC.
Which workers in the health care setting
need hepatitis B vaccine?
Persons who have a reasonable expectation of be
ing exposed to blood on the job should be offered
hepatitis B vaccine. This does not include recep
tionists, executive directors, billing staff, general
office workers, etc., as these groups would not be
expected to have occupational risk.
What is the appropriate site for
administration of hepatitis B vaccine and
what needle length and gauge should be
used?
The deltoid is recommended for routine intramus
cular vaccination in adults, particularly for hepa
titis B vaccine. The suggested needle size is 1 to
114 inches and 20 to 25 gauge.
A health care worker's (HCW) first dose of
hepatitis B vaccine was four months ago.
Should the series be restarted?
No. The vaccine series does not need to be restarted. The person should receive the second dose
at this time and third dose 2-6 months later. /
HCW is still negative after a second vaccine series,
the HCW is considered a non-responder to hepatitis
B vaccination. The HCW should be counseled that
non-response to the vaccination series most likely
means that the HCW is susceptible to HBV infec
tion. It is possible, however, that the HCW is
chronically infected with HBV and HBsAg testing
should be recommended. Counseling of the HCW
should then be done to discuss what non-response
to the vaccination series means for that specific
HCW and what steps should be taken in the future
to protect his/her health.
How often should anti-HBs titers be drawn
on HCWs who perform invasive procedures?
No healthy person needs to be repeatedly tested
for anti-HBs. Persons who perform invasive pro
cedures should be treated no differently from
other health care workers with respect to anti-HBs
testing. If a health care worker has an exposure
(e.g., needlestick) he or she should be evaluated
^or Pos^exPosure prophylaxis according to current
recommendations (see table below).
Is it safe for HCWs to be vaccinated during
pregnancy?
Yes. Pregnant women in occupations with a high
risk of HBV infection should be vaccinated.
Hepatitis B vaccine contains no components that
have been shown to pose a risk to the fetus at any
time during gestation. However, HBV infection
during pregnancy poses a significant risk to the fe
tus or newborn of perinatal or in utero infection.
Which HCWs need serologic testing after
receiving 3 doses of hepatitis B vaccine ?
Persons at occupational risk of infection and with
continued permucosal or percutaneous exposures
to blood or body fluids (e.g., HCWs with direct
patient contact, HCWs who have the risk of
needlestick or sharps injury, lab workers who
draw and test blood) should be tested after vacci
nation. Testing should be done 1-2 months after
the last dose of vaccine.
What should be done if a HCW's serologic
test comes back negative for anti-HBs?
Repeat the 3-dose series and then test for anti-HBs
1-2 months after the last dose of vaccine. If the
Should a HCW who performs invasive
procedures and who once had a positive antiHBs result be revaccinated if the anti-HBs titer
is rechecked and is less than 10mlU/mL?
No. Postvaccination testing should be done only
I-2 months after the original vaccine series is
completed. Testing showed that the HCW was
protected as a result of the original vaccination
series. Data show that adequate response to the 3dose series of hepatitis B vaccine provides long
term immunologic memory that gives long-term
protection. Only immunocompromised persons
(e.g., hemodialysis, patients, HIV-positive per
sons) need to have anti-HBs testing and booster
doses of vaccine to maintain their anti-HBs con
centrations of at least lOmlU/mL in order to be
protected against HBV infection.
If HCWs were vaccinated for hepatitis B in
the past and not tested for immunity, should
they be tested now?
No. A HCW does not need to be tested unless he
or she has an exposure. If an exposure occurs,
refer to the table below for management guide
lines. In addition to following these guidelines, if
prophylaxis (HBIG and a booster dose of vaccine)
is indicated, the person should receive postvacci
nation testing 3-6 months afterwards. It is neces
sary to do postvaccination testing at 3-6 months
as earlier testing may just measure antibody from
HBIG. This postvaccination anti-HBs test result
should be recorded in the person’s health record.
Recommended postexposure prophylaxis for percutaneous or
permucosal exposure to hepatitis B virus, United States*
Vaccination and antibody
response status of exposed
person
Treatment when source is
Source not tested or status
unknown
HBsAg1 positive
HBsAg negative
HBIG? x 1; inmate HB vaccine
senes3
Initiate HB
vaccine series
Initiate HB vaccine senes
Known responder4
No treatment
No treatment
No treatment
Known non-responder
HBIG x 2 or
No treatment
HBIG x 1 and initiate revaccination
If known high-risk source, treat
as if source were HBsAg positive
Antibody response unknown Test exposed person for anti-HBs5 No treatment
1. If adequate4, no treatment
2. If inadequate4, HBIG x 1
and vaccine booster
Test exposed person for anti-HBs
1 If adequate4, no treatment
2. If inadequate4, initiate
revaccination
Unvaccinated
Previously vaccinated:
1 Hepatitis B surface antigen
2 Hepatitis B immune globulin; dose 0.06 mL/kg
intramuscularly
3 Hepatitis B vaccine
4 Responder is defined as a person with adequate levels
of serum antibody to hepatitis B surface antigen (i.e.,
anti-HBs £10 mIU/mL): inadequate response to vacci
nation defined as serum anti-HBs <10 mIU/mL
5 Antibody to hepatitis B surface antigen
* from "Immunization of Health-Care Workers." MMWR, 1997; 46 (RR-18).
item #P21O9 (3/01)
Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org
i
For a pre-employment physical, a health care
worker states she received all three hepatitis B
vaccine doses as an adolescent. Would you do
a titer?
This is a situation that will become more common
in the future and for which there are no specific
guidelines. A reasonable approach, however, can
be developed from current recommendations.
Currently, CDC recommends postvaccination
testing for antibody to hepatitis B surface antigen
(anti-HBs) 1 -2 months after the last dose of hepa
titis B vaccine for persons vaccinated as health
care workers or in training. This employee was
vaccinated as an adolescent, and postvaccination
testing was not done since it was not indicated at
the time of vaccination.
If the health care worker has written documenta
tion of three doses of vaccine given as an adoles
cent, that should be sufficient to meet the needs of
the employer and the requirements of OSHA
guidelines. Another option would be to test the
person for the presence of anti-HBs, since a per
son vaccinated as an adolescent is still likely to
have detectable antibody. If the person, however,
is anti-HBs negative on testing, that does not mean
s/he was not immunized, since s/he could have
lost detectable antibody over time and still be
protected. If the person is found to be anti-HBs
negative, that status should be recorded on her/his
employee health record along with the vaccination
history. If the health care worker subsequently has
a blood exposure, s/he should follow the current
guidelines for postexposure immunoprophylaxis.
If the health care worker has no written documen
tation of vaccination as an adolescent, the person
should receive the 3-dose vaccine series and antiHBs testing 1-2 months after the full series.
I oversee the employees of a clinic in which all
the health care workers decided to check their
anti-HBs titers (15 employees got tested). Eight
of them had titers less than 10 mIU/mL,
although two of them had previously had
adequate titers. The other seven had not been
previously tested. What should I do?
CDC does not recommend periodic testing for
anti-HBs or booster doses of hepatitis B vaccine
for immune competent persons. When testing is
done as described above, it places the employee
health service in a difficult position. The two
employees who previously had documented ad
equate titers should have nothing done as they are
protected. It also appears that 7 of the 15 employ
ees had adequate levels of anti-HBs when tested.
That leaves 6 employees in which it is not known
if they had previously responded to hepatitis B
vaccination and now have undetectable anti-HBs.
The most helpful approach to define the issue,
would be to give one dose of vaccine to each of the
employees and then test anti-HBs in one month.
For employees with adequate anti-HBs (>10mIU/
mL), nothing more need be done, as they are pro
tected. For employees with inadequate anti-HBs
after one additional dose of vaccine, we would
complete the revaccination series by giving two
more doses of vaccine according to the recom
mended schedule and test 1-2 months after the
third dose of vaccine. If anti-HBs is adequate, they
are protected; if inadequate, they are "non-responders" to the vaccine.
There are several physicians in our group who
have no documentation of having received
hepatitis B vaccine but are relatively sure they
received the doses many years ago. What do
we do now?
Unfortunately, inadequate documentation of vac
cination is common. Even if these physicians
think they may have been fully vaccinated, but it
is not documented, the three-dose vaccination
series should be administered and post-vaccina
tion testing should be performed 1-2 months af
ter the three-dose series. There is no harm in
receiving extra doses of vaccine.
Some might suggest giving only one dose of vac
cine followed by post-vaccination testing. Al
though 30% of previously unvaccinated healthy
adults will have a protective antibody response
after only one dose of vaccine, these individuals
will not have the long-term protection afforded by
the three-dose series.
tation required to ensure valid hepatitis B vacci
nation. If policies are in place and documentation
is not present, revaccination should be instituted.
Care should always be taken to document vaccine
lot, date, manufacturer, route, and vaccine dos
ages. Postvaccination testing results should also
be documented, including the date testing was
performed.
i"m a nurse who received the hepatitis B
vaccine series over 10 years ago and had a
positive follow-up titer. At present, my titer is
negative. What should I do now?
Nothing. Current data show that vaccine-induced
anti-HBs levels may decline over time; however,
immune memory (anamnestic anti-HBs response)
remains intact indefinitely following immuniza
tion. Persons with declining antibody levels are
still protected against clinical illness and chronic
disease. For health care workers with normal
immune status who have demonstrated an antiHBs response following vaccination, booster
doses of vaccine are not recommended nor is
periodic anti-HBs testing. ♦
Keep your own
vaccination history!
Record the dates you received
hepatitis B vaccine, as well as
the results of your postvaccina
tion serology (anti-HBs).
Remember to save records of
any vaccinations you receive so
you don’t have to repeat them.
Each organization (hospital, clinic, etc.) should
develop policies or guidelines as to the documen-
Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org
HIV Physician Training Course 2002,
Christian Medical College, Vellore
DISTANCE LEARNING COTJRSE
HIV
GASTROINTESTINAL SYSTEM
Author: Ashis Mukhopadhyaya
Course Organiser : Anand Zachariah
Distance Learning Expert: Janet Grant, Open University, UK
This course is supported by the European Commission through grant number
IND/B76211/13/1999/0379 provided to the HIV/STI Prevention and Care Research
Programme of the Population Council India.
MODULE 7
A^I^XSTRCjlNIFSTINAI SYSTEM
(MODULE 7)
1. In addition to this module y0„ wiI1 find x.ray „ ln
activity 7.5,
2. After you complete the module tear: (a) Tutor marked assignment (page
30); (b) the module evaluation form (at the end of the moduie) and endose
■t the stamped envelop. Send it by registered post by: January 25, 2003
3. Please write your name and roll number on the tutor marked assignment
before dispatching it
1
MODULE 7
OVERVIEW
This module will help you to improve your knowledge and help you develop
your clinical services in relation to the gastrointestinal manifestations
associated with HIV infection.
The gastrointestinal system is the largest lymphoid system in the human
body. It plays a crucial role in the pathogenesis of AIDS. It may provide a
portal of entry for the virus (eg. HIV infection transmitted through breast
milk).
HIV
infection
of the
gastrointestinal tract results
in
local
immunosuppression as a direct consequence of which the gut is vulnerable to
a variety of opportunistic pathogens.
Ninety percent 90% of HIV patients from developing countries present with
gastrointestinal symptoms. Particular enteric pathogens or neoplasms can
help establish the diagnosis of AIDS.
The most common gastrointestinal presentations are: diarrhoea, dysphagia,
abdominal pain and jaundice. This module will help you learn the clinical
approach to these symptoms by working through a set of clinical problems.
2
MODULE 7
OBJECTIVES
After completion of this module the student should be able to:
1. Describe:
i.
The clinical approach to the evaluation of syndromes of the
gastrointestinal system: (a) odynophagia/ dysphagia; (b) abdominal pain; (c)
diarhoea; (d) jaundice.
ii.
The causative agents of the syndromes.
i.
The diagnostic evaluation of these syndromes.
iii.
The specific treatment of the syndromes and their etiological agents.
2. Apply the clinical algorithms to the evaluation and management of clinical
case problems of gastrointestinal disease.
3
MODULE 7
CONTENTS
Title
Activity 7.1
Approach to dysphagia
Reading 7. J Dysphagia and odynophagia
Time (minutes)
Page
15
5
30
33-36
Activity 7.2
Non-resolving dysphagia
10
7
Activity 7.3
Abdominal pain - Part I
10
9
Reading 7.3 Abdominal pain
30
37-39
Activity 7.4
Abdominal pain - Part II
10
11
Activity 7.5
Abdominal pain - Part III
10
13
Activity 7.6
Diarrhoea - Part I
10
15
Reading 7.6 Diarrhoea
45
40-44
Activity 7.7
Diarrhoea - Part II
10
17
Activity 7.8
Diarrhoea - Part III
10
19
Activity 7.9
Diarrhoea - Part IV
10
21
Activity 7.10 Jaundice - Part I
10
23
Reading 7. JO Hepatic disorders
30
45-49
Activity 7.11 Jaundice - Part II
10
25
Activity 7.12 Jaundice - Part III
10
27
TMA
60
30
Total estimated study time
320
5
MODULE 7
The following exercise will help you learn the approach
to diagnosis and management of a patient presenting with
swallowing difficulty. Read the sectionf"Dysphagia and
Odynophagia" (pg. 33-37) in the reader. After you have
completed the reading you may proceed to the activity.
ACTIVITY 7.1
APPROACH TO DYSPHAGIA (TIME: 15 MINUTES)
Mr. Manu Nair is a forty-five year old engineer working
in a small manufacturing firm in Mumbai. He had an
abdominal surgery ten years ago, during which time he was
transfused one unit of blood. Two years ago he was found
to be HIV seropositive during an annual office health
checkup. He now presents with a history of difficulty in
swallowing and occasional severe pain in the retrosternal
region after swallowing.
1. What is the differential diagnosis that you will
consider in Mr. Nair in order of probability?
'I- — CAy \j
3- _
4.
_ _____ t
:ajx.
Vy______________
2. What additional history would you like to obtain from
Mr. Nair?
T
"
_ .j
2.
3.
/ver
for
when
you
findings
will
you
4. Examine the photograph
your diagnosis?
(Fig.
7-A on page 51) .What is
3. What specific
examine Mr. Nair?
look
1?
2.
3.
4.
5. What treatment will you institute for this patient?
'J-
—
c
/
6
MODULE 7
FEEDBACK 7.1
What is the differential diagnosis that
consider in Mr. Nair in order of probability?
1.
you
will
Mr. Nair has dysphagia and retrosternal pai:
ain suggesting the presence of esophagiits. The
differential diagnosis of this complaint is:
1. Candida esophagitis
2. Herpes esophagitis
3. CMV esophagitis
4. HIV induced esophagitis
5. Drug induced esophagitis
2. What additional history would you like to obtain from
Mr. Nair?_____________
1. Prior history of candidal infection and use of fluconazole.
2. History of visual blurring or bloody diarrhea which may occur with CMV infection.
3. History of use of Doxycycline, AZT or DDC which can cause pill induced esophagitis.
4. Food and fluid intake in the past few days.
3. You are then asked to examine Mr. Nair. What are the
specific things that you will look for in his condition?
1. Curdy white lesions on the surface of the tongue and the buccal mucosa diagnostic of
Candida esophagiits.
2. Grouped vesicular lesions on the surface of the mouth suggestive of herpes stomatitis
and lesions of genital herpes.
3. Fundus examination for large yellow and white lesions with granular borders and
perivascular exudates and haemorrhages suggestive of CMV retinitis (cottage cheese and
ketchup appearance).
4. Sign of malnutrition and dehydration.
4. Examine the photograph (Fig.
your diagnosis?________________
7-A on page 51) . What is
The photo shows curdy white precipitate on the tongue suggestive of candidal infection.
The presence of oral candidiasis in a patient with symptoms of esophagitis usually
indicate the presence of candidal esophagitis.__________________
5. What treatment will you institute for this patient?_____
T. Fluconazole 100-200 mg OD for 2 weeks.
If he has been on regular fluconzole prophylaxis, the dose of fluconazole may be
increased to 400-800 mg daily or changed to Itraconzole solution. If he is unable to
swallow, then Syrup Itraconazole or IV Fluconzolp may be administered till he is able to
swallow.If he is unable to swallow at all then in-patient admission and IV fluids are
required.
7
MODULE 7
The next activity will help you learn about
non-resolving
dysphagia.
ACTIVITY 7.2
NON-RESOLVING DYSPHAGIA (TIME: 10 MINUTES)
Mr.
Nair
initially
improved
after
treatment
with
Fluconazole . However he returns to your clinic because of
recurrence of symptoms.
1. What is your differential diagnosis and which further
tests will you order?
2. Examine the test reports shown in
(page 51) and write down your findings?
Fig.
7-B
and
7-C
c
3. What is
findings ?
4.
What
your
treatment
diagnosis
based
will
administer
you
(drug choice, dose and duration)?
'^A
ch)
v
on
these
to
laboratory
this
patient
8
MODULE 7
^FEEDBACK 7.2
1. What is your differential diagnosis
and which further
tests will you order?
1- Recurrence of Candida esophagitis
2. Herpes
3. CMV
4. HIV induced
The patient needs to be referred for
an upper GI endoscopy.
2. Examine the upper GI e ndoscopy picture in Fig. 7-B and
histopathology of lesion in 7-C (page 51) and write down
your findings?
7’B ’ LarSe fallow superficial ulcers at the distal end of the esophagus.
7-C - The histopathology - numerous owl eye type inclusion bodies
3.
What is your diagnosis
based on these laboratory
findings ?
"The presence of owl eye type inclusion bodies is diagnostic of CMV esophagitis.
4.
What
treatment
will
you
administer
to
this
patient
(drug choice, dose and duration)?
Gancyclovir 5 mg/Kg IV OD (or 6 mg/Kg IV 5 days a week) for 4-6 weeks
The dose needs to be adjusted according to renal functions. The duration of the
induction therapy is longer than for CMV retinitis for which induction therapy is 14-21
days. In patients who are resistant to Gancyclovir, IV Foscarnet may be used.
9
MODULE 7
I’he following exercise will help you lesrn the approach
to diagnosis and management of a patient presenting with
abdominal pain. Read the sectionf"Abdominal pain"(pg. 37—
39) in the reader. After you have completed the reading
you may proceed to the activity.
ACTIVITY 7.3
ABDOMINAL PAIN - PART I (TIME: 10 MINUTES)
37 year old Mr. Kumar a lorry driver, was diagnosed to
have HIV infection 3 years ago when he presented with
candidiasis.
oral
candidiasis.
He
presented
with
complaints
of
moderate to severe upper abdominal pain, with progressive
weight loss and low grade fever for the last 2 months.
1. What history will you elicit from the patient
localise the anatomical site of the pathology?
P-<^W 1 ,x>
^C-tAU-A/'
'
V>4>
2
J
“
to
~'A, ,
-
2.
What
physical
findings
will
you
look
for
in
this
patient?
*
*
■
a
;/
-CX
t
10
MODULE 7
^FEEDBACK 7.3
1. What history will you elicit from the patient
to
localise the anatomical site of the pathology?___________
Stomach and duodenum- burning upper abdominal pain with vomiting soon after food
Pancreas- constant pain in the epigastrium and radiating to the back and relieved on
leaning forward.
Cholecystitis and cholangiti:s- right hypochondria! pain radiating to the scapula and right
shoulder, jaundice, fever
Enteritis- diarrhea and vomiting
Surgical causes (obstruction, perforation and peritonitis)
Progressive abdominal distension, vomiting
2.
What
physical
findings
will
you
look
for
in
this
patient?
Jaundice, tenderness, guarding, rigidity and rebound, Murphy’s sign, liver and spleen,
other masses, shifting dullness and fluid thrill, bowel sounds
11
MODULE 7
ACTIVITY 7.4
ABDOMINAL PAIN
PART II (TIME: 10 MINUTES)
Mr. Kumar complained of upper abdominal pain which
was
fairly constant and radiated to the back.
It was
associated with vomiting which occurred soon after food,
The bowels habits were fairly regular. He had lost about
10 Kg of weight over the last several months. He had no
history of jaundice,
He had been receiving Bactrim
prophylaxis
but
had
not
received
any
anti-viral
treatment. He does not smoke or consume alcohol.
On examination he was looking ill. Pulse rate 90/minute,
Respiratory rate 16/minute, temperature 101° F. Pallor
present, multiple cervical lymph nodes
1.5-2 cm in size,
nodes 1.5-2
Liver 5 cm, Spleen 2 cm
cm. Ill-defined tender and firm
mass
m the epigastrium 4-6 cm in size, Shifting dullness
present.
1. What inference will you draw from the
patient's
description of abdominal pain?
/O'z^e4<AA^L>^v'
2. What inferences can be drawn based on the examination
findings
and
what
are
the
possible
differential
diagnosis?
—/
'C Vaa
’'f
4
‘
CCN?
>
XI
A
,
rXAy<.„-p
3. What tests will you order for Mr. Kumar?
2
l-w
C4»a
/
y
A-/3>/
7 I
12
MODULE 7
^FEEDBACK 7.4
i.
What
inference
will
you
draw
from
the
patient's
description of abdominal jpain?
lhe pain is of pancreatic origin as> it has the characteristic description of upper
abdominal pain radiating to the back. He has
not been exposed to the common drugs
and toxins which results in pancreatitis (alcohof^
■yddl, 3TC and Pentamidine) in a HIV
patient. The pain may be the result of the
mass in the epigastrium which may arise from
the pancreas or structures surrounding the pancreas.
2.
What inferences can be drawn based
on the examination
findings
and
what
are
the
possible
differential
diagnosis?
Finding
Differential diagnosis
Cervical adenopathy
TB, cryptococossis, lymphoma, PGL
Hepatosplenomegaly
TB, cryptococossis
Intraabdominal mass
TB lymphadenitis, lymphoma
Shifting dullness
TB
Sluggish bowel sounds: TB
This patient has generalised lymphadenopathy, hepatosplenomegaly and probably intra
abdominal lymphadenopathy, lire most likely diagnosis are disseminated tuberculosis
and lymphoma. While MAI can present in a similar way it is not common in India and
may not be strongly considered in the differential diagnosis.
3. What tests will you order for Mr. Kumar?
WBC total and differential count
Creatinine, Fasting sugar. Liver function tests^^
Chest x-ray
Fine needle aspiration of lymph node and AFB smear
Ultra-sound of the abdomen
Serum amylase
13
MODULE 7
ACTIVITY7.5
ABDOMINAL PAIN
WBC
total
PART III (TIME: 10 MINUTES)
count
2700
Neutrophils
60,
lymphocytes
12.
function
Liver
Direct bilirubin
monocytes
1.0
U/L,
150 U/L,
IU/L.
Ultrasound
hepatosplenomegaly ,
count
bilirubin
180
cystic
x-ray-
Total
6,
120
multiple
Chest
tests-
bandforms
SCOT
phosphatase
7-1
26,
0.8 mg% ,
Alkaline
(see X-ray
cells/mm3 Differential
SGPT
of
abdomen
peri-pancreatic
free
fluid
present
in x-ray cover).
mediastinal
nodes,
in
the
Serum amylase
adenopathy.
mg%,
abdomen
70
U/L.
Fine
needle
aspiration of cervical nodes- Numerous AFB seen.
1. What is your interpretation of the results
and what
further tests will you order for this patient?
■—y
r
'
’7
-
; •
}
)
Ua J-iV
)
7
f .\ z
j <
Ua L^-f S
^{c ^^1
r
.
)
f,
2. What treatment will you initiate?
14
MODULE 7
^FEEDBACK 7.5
1.
What
is
your
interpretation
of
the
results
and what
further tests will you order for this patient?
This patient has advanced immunodeficiency as indicated by the absolute lymphocyte
count of <1000 cells/mm3. The normal serum amylase rules out acute pancreatitis. The
liver function tests show mild elevation of liver enzymes and alkaline phosphatase which
could be consistent with a diffuse infiltrative process in the liver but does not rule out a
anicteric
hepatitis.
The
chest
x-ray
confirms
the
presence
of generalised
lymphadenopathy. The ultra-sound confirms the presence of hepatosplenomegaly and
intra-abdominal adenopathy with peri-pancreatic involvement and peritoneal free fluid.
The demonstration of acid fast bacilli on the FNAC confirms the process to be due to
disseminated tuberculosis. It does not rule out MAI infection or another co-existent
intra-abdominal process.
The further tests that may be required are AFB culture on the lymph node aspirate. If a
second diagnosis is strongly being considered then ultrasound guided aspiration of the
peri-pancreatic node or peritoneal aspiration should be performed.
2. What treatment will you initiate?
Anti-fB treatment should be initiated with 4 drug regimen. Rifampicin, INAH,
Ethambutol and Pyrazinamide at appropriate doses. Bactrim prophylaxis needs to be
initiated. The abnormal liver function tests are not a contra-indication for initiation of
hepatotoxic anti-TB drugs. However he needs to be carefully monitored for the
development of hepatotoxicity.
J
Mr.
Kumar was treated with IV fluids and anti-TB
treatment with Rifampicin, Isoniazid, Pyrazinamide and
Ehtambutol with which he showed gradual improvement of
At review after 3 months his symptoms had
symptoms.
resolved and he was gaining weight. His AFB culture was
reported as M. tuberculosis.
15
MODULE 7
The foiling exercise Will help you learn the approach
to diagnosis and management of a patient presenting with
diarrhoea. Read the section,"Diarrhoea" (pg.40-44) in the
reader After you have completed the reading you may
proceed to the activity.
ACTIVITY7.6
DIARRHOEA - PART I (TIME: 10 MINUTES)
Mrs. Selvi an asymptomatic HIV positive patient
presented
with small volume stools mixed with blood,
cramping
abdominal pain of 2 days associated with fever.
On examination pulse rate 120 /minute BP 90/70
mm Hg
Temperature 101.5° F Dry tongue Abdomen- mild
periumbilical tenderness
1. What are your inferences based on the history
and
examination?
Vb.-V C
l
/
2. What
patient?
bv'Uv
are
the
likely
causes
of
diarrhoea
in
this
ilt/j) jc^cAy
3. What tests would you like to order for her?
)
4. What treatment will you administer?
-
16
MODULE 7
FEEDBACK 7.6
1- What are
examination?
your
inferences
based
on
the
history
and
This patient has an acute diarrh^nui^T^hfe^
suggestive
of an acute bacillary
ysentery and mild dehydration. She is febrile but there are
no
features
which suggest the
presence of sepsissyndromp
2.
What
are
the
likely
causes
of
diarrhea
patient?
in
this
Shigella sp.
Salmonella typhimurium and enteritidis
Vibrio sp.
Campylobacter jejuni
E. coli
Viruses
Of these Shigella and Campylobacter can
produce a dysenteric illness and are therefore
the likely pathogens.
3. What tests would
you like to order for him?
This patient could be treated without thi
e ald of any laboratory tests. Stool exammatiM
for faecal leucocytes may be done
to confirm the diagnosis of bacillary dysentery. Stool
culture may be performed if facilities are available.
4 . What treatment will
you administer?
Oral rehydration
T. Ciprofloxacin 500 mg BD for 3-7 days.
17
MODULE 7
ACTIVITY 7.7
DIARRHOEA - PART II (TIME: 10 MINUTES)
Mr.
Selvam is a thirty five year old miner from Kolar was
diagnosed to have HIV infection when he presented to his
GP
3
years
ago
with
gonorrhea.
He
now
complains
of
diarrhea occurring 3-5 times
day for the last 4 months
and progressive weight loss,
He has been treated by his
local doctors with several course of antibiotics with out
much relief.
1.
Write
down
the
further
historical
points
that
you
would like to elicit from Mr. Selvam?
—
J
-
< <> ? />!
2 . What specific examination findings would you look for
in Mr. Selvam?
<__ J
J
18
MODULE 7
^FEEDBACK 7.7
1. Write down the further historical
would like to elicit from Mr. Selvam?
CONDITION
points
that
you
QUESTIONS
Small bowel diarrhoea
Large volume
Less frequent
B orb orgymi
Periumbilical pain
Large bowel diarrhoea
Small volume
Frequent
Tenesmus
Hematochezia
Anorectal disease
Rectal pain
Fresh bleeding
Protein energy malnutrition
Weight loss
Leg swelling
Facial puffiness
Vitamin deficiencies
Night blindness
Fissures over angles of mouth
Loss of taste
Tongue burning
Paraesthesias
Mineral deficiencies
Proximal weakness
TB
Fever, respiratory symptoms
Cryptococcal meningitis
Central nervous system symptoms
2. What specific examination findings would you look for
in Mr.
Selvam?____________
General examination- Pallor, Bitot
spots, angular stomatitis, glossitis, pedal oedema,
echymoses,
Respiratory examination- Lower respiratory signs
Neurological signs- Peripheral neuropathy, proximal weakness, fundal signs of CMV
retinitis
[Gastrointestinal system- Abdominal tenderness, peri-anal ulcers
19
MODULE 7
ACTIVITY 7.8
DIARRHOEA PART III (TIME: 10 MINUTES)
■
Selvam
said that
the diarrhoea
was
extremely
troublesome, as it occurred up to six times a day and
about four times in the night as well. The stools were
large volume and watery. He had not noticed any blood or
complained of tenesmus. He often experienced minimal pain
around his umbilicus. He has lost significant weight in
the last month, There is no history of prolonged fever or
respiratory symptoms.
On examination:
Pulse rate 102/minute BP 90/70 mm Hg Weight 4 0 Kg Severe
emaciation.
Pallor , glossitis , angular stomatitis,
koilonychia, pedal oedema present. No jaundice
Abdomen- no hepatosplenomegaly or free fluid, No peri
anal lesions
CNS- ankles jerks are absent, fundus examination
1. What are
examination?
your
inferences
based
on
the
history
and
tl VL4 f
2.
What
are
the
likely
causes
of
diarrhea
this
in
patient?
■■
3. What tests would you like to order for him?
(%>^)
&
)
20
MODULE 7
'^FEEDBACK?.8
1- What are
examination?
your
inferences
based
on
the
and
history
to^dbi^h^?—
weight 4”IcTTron'd0fSh°WS evidence °f protein energy malnutrition (emaciation
2.
What
are
the
likely
causes
of
diarrhea
patient?
in
this
The common
agents: Isospora belli, Cyclospora, Cryptospond.a and Giardia lamblia. However a variety
of other pathogens may cause chronic diarrhea including: Microsporidia, Shigella sp
Salmonella sp.. Vibrio cholera, E. histolytica and Cytomegalovirus. In a proportion oi
patients no pathogen may be found and the diarrhea may be due to HIV enteropathy.
3. What tests would
?
St°01
you like to order for him?
Tnchrome7mdlad fast stain)
Stool culture
Haemoglobin, WBC total count and differential count, blood picture
Jjyer^inctiontests, Electrolyte profile (if possible)
21
MODULE 7
ACTIVITY 7.9
DIARRHOEA PART IV (TIME; 10 MINUTES)
Laboratory reports:
Haemoglobin 7.2g%, WBC count 5200 cells/mm3
Neutrophils 75
Lymphocytes 15 Basophils 3 Monocytes
7 Blood smear
dimorphic
blood
picture
(microcytosis,
occasional
macrocytes
and hypersegmented neutrophils
seen).Liver
function tests- Total bilirubin 1.2 Direct
bilirubin 0.9
total protein 7.0 g/dl globulin 4.5 g/dl SCOT 30 SGPT 40
Alkaline phosphatase 120
Stool examination - see Fig. 7-D (page 52)
Reported to be Isospora belli cysts seen
1. What treatment will you initiate for this patient?
22
MODULE 7
^FEEDBACK 7.9
:•
1. What treatment will you initiate for this patient?
TMP/SMX DS I qid for 10 days
TMP/SMX DS I bd for 3 weeks
Followed by Bactrim DS I OD life long suppression
Rehydration
Nutritional supplementationCalorie, protein, fat (as tolerated)
Ferrous sulphate 200 mg OD to tid as tolerated
Trace element preparation 1 capsule OD
Vitamin B complex I OD
I1
Loperamide I pm
II
II
I
II
n
li
I’
I
I
I
23
MODULE 7
The following exercise will help you learn the approach
to diagnosis and management of a patient presenting with
jaundice. Read the sectionf"Hepatic Disorder" (pg. 45—49)
in the reader. After you have completed the reading you
may proceed to the activity.
ACTIVITY 7.10
JAUNDICE- PART I (TIME: 10 MINUTES)
40-year-old Mr. Das presented to his GP with complaints
of jaundice of 3 months and was referred from Calcutta
after he was found to be HIV positive.
Mr.
Das was
transfused at the time of
an acute
appendicitis 5 years ago. He had been well since then. He
has no history of abusing IV drugs or sexual risk factors
for HIV infection. He has not received any other drugs.
There is no history of low grade fever, weight loss or
respiratory symptoms.
On examination:
Icterus present, loss of axillary hair, pedal oedema
present. Abdomen examination- Liver 4 cm Spleen 2 cm
Free fluid — present
1. What are the inferences of your clinical examination?
2. What lab tests would you order for Mr. Das?
~
, H-c
■
/
■
24
MODULE 7
^FEEDBACK 7.10
1. What are the inferences of your history and clinical
examination?
Mr Das has evidence of a chronic decompensated liver disease (loss of axillary hair
pedal oedema and ascites) probably with chronic active hepatitis (jaundice and
hepatosplenomegaly). This may be Hepatitis B or C induced following the transfusion
that he received 5 years ago.
The absence of significant drug history (anti-TB, anti-viral drugs, anti-epileptics) make
drug induced hepatitis unlikely. Opportunistic infection which cause infiltration of the
liver such as disseminated TB, disseminated MAI and cryptococossis may present
similarly. But the absence of systemic symptoms of fever and progressive weight loss
make these unlikely.
°
__________
2. What lab tests would
Liver function tests
HbsAG
Anti-HCV serology
HIV ELISA
Ultra-sound of the abdomen
you order for Mr. Das?
25
MODULE 7
ACTIVITY 7.11
JAUNDICE- PART II (TIME: 10 MINUTES)
Laboratory reports:
Liver function tests-
Total bilirubin
7 mg/dl Direct bili-rnbi n
protein 6.9 g/dl, Albumin 2.5 g/dl,
5 mg/dl Total
SCOT 450 U/L,
SGPT
350 U/L, Alkaline phosphatase 260 U/L
HbsAg - positive
Ant-HCV serology — positive
HIV ELISA- positive
Ultra-sound abdomen-
Hepatosplenomegaly with free fluid in the abdomen
CD4 count (Capsellia) - 150 cells/ mm3
Viral load (Amplicor assay)- 60,000 copies/ml
1. What is your interpretation of the laboratory reports?
c
C€
7
14 U-v
- A—-y
2. What treatment options are available for Mr. Das?
Hepatitis B-
Hepatitis C
HIV-
7
/ / JXT j
)
OJf I
26
MODULE 7
‘^FEEDBACK 7.11
What is your interpretation of the laboratory reports?
7
mcreased SGOT; SG1>1. and alkaKne phosphatas-
demonstrate the evidence of hepatitis. The low serum albumin and ascites on the
ultrasound show evidence of hepatic decompensation. They confirm the
presence of
chronic active hepatitis which is due to Hepatitis B and C co-infection.
What treatment options are available for Mr.
Hepatitis BInterferon IFN alpha 2b
Lamivudine
Hepatitis CInterferon IFN alpha with Ribavarin
HIV-
HAART
To avoid Pi’s, Nevirapine
To use Lamivudine
Possible regimen- Efavirenz, AZT and Lamivudine
Das?
27
MODULE 7
ACTIVITY 712
JAUNDICE- PART III (TIME: 10 MINUTES)
Mrs. Braganza is a hairdresser from Mumbai. She had gone
to Bangkok seven years ago and had been fascinated by the
tattoing
artistes.
She
got
herself
a
tattoo
and
unfortunately acquired HIV via the infected needle. She
has been a :regular patient and is currently on HAART for
the last two» years. She had cryptococal meningitis seven
months ago and was treated appropriately. 471Z Her last CD4
count was 50/ml.
She was
jaundice in hlsf last visit.
noticed
to
have
minimal
Her LET is as follows:
Total bilirubin 2.6 mg%, Direct bilirubin 1.3mg%, Total
protein 6.8gm%, Albumin 3.2gm%, SCOT 55 U/L, SGPT 60 U/L,
Alkaline Phosphatase 650U/L
1. What are the main .abnormalities on the liver tests?
1.
ha
2.
3.
4.
_/
2.
What is the interpretation of the liver abnormalities?
What are the differential diagnosis of this abnormality?
1.
2 s
2.
M? /i
3.
3. Examine the ultra-sound Figure 7-E (page 52)
down your findings. What is your inference?
L
”
and write
"——————
2.
4. What would be your next line of management?_____
____ c y
28
MODULE 7
FEEDBACK 7.12
What are the main abnorma 1 ities
1. Increased bilirubin
2. Markedly increased alkaline phoph;latase
3. Marginally elevated transaminases
2.
on the liver tests?
What is the interpretation of the liver abnormalities?
What are the differential diagnosis of the LET report?
of the liver. ITe d.fferenF
biliary d.sease presentations include acalculous cholecystitis and AIDS cholangiopathy.
3.
Examine the ultra-sound X-ray 7-E
(Page 52)
j^g^indir^.what is your inference?
52) and write
The ultra-sound shows mtra-hepatic biliary dilatation favouring
a diagnosis of AIDS
cholangiopathy.
4 . What would be
your next line of management?
This Patient needs referral for an ERCP or CT of the abdomen.
29
NOTES
MODULE 7
33
MODULE 7
READINGS
DYSPHAGIA AND ODYNOPHAGIA
The oesophagus is a frequent site of infection by opportunistic infections,
A
large number of pathogens including fungal, bacterial, viral and even
protozoal organisms can cause infectious oesophagitis.
Three pathogens,
Candida, cytomegalovirus and herpes simplex virus cause the majority of
oesophageal infections. In addition, although obscure in pathogenesis, HIV
associated oesophageal ulceration is an important disease condition.
The following table is a list of the important as well as less common disease
conditions causing infectious oesophagitis in HIV patients.
TABLE 1: SPECTRUM OF OESOPHAGEAL INFECTIONS
COMMON
LESS COMMON
Fungi
Candida
Aspergillus
Viral
Cytomegalovirus
Epstein Barr virus
Herpes simplex virus
Bacterial
Bacterial
Tuberculosis
Others
Idiopathic HIV
associated ulcer
34
MODULE 7
COMMON CAUSES OF ESOPHAGITIS
Candida Esophagitis
CMV Esophagitis
Herpes Esophagitis
HIV associated
Esophagitis
Idiopathic
Occurs with
advanced HIV
infection
Etiology
Incidence
Candida albicans
Commonest cause of
esophagitis (64%)
Develops in 20% of
AIDS patients
Cytomegalovirus
Less frequent
Herpes simplex
Infrequent
Clinical features
Substernal dysphagia
Odynophagia
Oral thrush predictive
of Candida
esophagitis
Absence of oral
thrush does not
exclude diagnosis
The diagnosis is based
on clinical suspicion
Glod StandardUpper Gl endoscopy
with histopathological
examination
Substernal pain
Odynophagia
Dysphagia less
common
Associated CMV
retinitis, colitis may be
present.
Odynophagia
Dysphagia
Retrosternal pain
Oral herpetic ulcers
may be present
Diagnosis considered
after ruling out all
other causes of
esophagitis
Upper Gl endoscopy
- Extensive ulcerations
that are large and
deep
Biopsy- Cytopathic
changes
Characteristic
inclusion bodies
Histopathological
examination
Initial phase- discrete
ulcers that coalesce
to form larger ulcers
Viral cultures
EndoscopyModerate to large
ulcers in mid and
distal esophagus
Diagnosis
35
MODULE 7
ALGORITHM FOR ODYNOPHAGIA AND DYSPHAGIA
The first step in the management of odynophagia and dysphagia ia an
empirical trial with oral fluconazole. Further evaluation and treatment
following non-response is as listed in the algorithm below:-
ODYNOPHAGIA - DYSPHAGIA
TWO WEEK EMPIRICAL FLUCONAZOLE
[
RESPONSE
NO RESPONSE
REFER
FOLLOW UP
ENDOjSCOPY
POSITIV E BIOPSY
OR CULTURE
TREAT
APPROPRIATELY
(Wilcox CM etal Gastroenterology 110: 1803-1809, 1996)
NEGATIVE
TRIAL OF
STEROIDS
FOR HIV
ULCERS
36
MODULE 7
TREATMENT OF OESOPHAGITIS
DISEASE
Candidal oesophagitis
TREATMENT
T. Fluconazole 100 mg OD for 2
weeks
In case of non-response increase to
T. Fluconazole 400 mg OD for 2
weeks
Refractory to Fluconazole consider:
Syrup Itraconazole 100 mg bd for 10
days
IV Amphotericin 0.3-0.5 mg/kg/day
CMV oesophagitis
Gancyclovir 5 mg/Kg OD for 3-6
weeks
Herpes oesophagitis
T. Acyclovir 400 mg tid for 5 days
Or Acyclovir 5 mg/kg IV q8h for 5-10
days
Idiopathic HIV oesophagitis
T. Prednisolone 40 mg OD
Taper by 10 mg/week
Total course 4 weeks
Treatment of HIV infection
37
MODULE 7
ABDOMINAL PAIN
The importance of history taking in abdominal pain cannot be ^-emphasized.
It provides important dues in localizing the source of the problem.
The
following are patterns of abdominal pain commonly encountered in clinical
practice.
EVALUATION OF ABDOMINAL PAIN IN AIDS PATIENTS
SYMPTOM COMPLEX
SUSPECT
DIAGNOSTIC TESTS
Dull pain, diarrhea,
Infectious enteritis
Stool parasites, cultures
Peritonitis
Abdominal films
nausea and vomitting
Acute severe pain
Surgical consultation
Right upper quadrant
Cholecystitis
Liver function tests
pain, jaundice
Cholangitis
Ultra-sound abdomen
Epigastric pain with
Pancreatitis
Ultra-sound abdomen
radiation to the back
Serum amylase and
lipase
Subacute pain and
vomiting
Intestinal obstruction
Abdominal films
Barium studies
MODULE 7
38
ABDOMINAL PAIN - DIFFERENTIAL DIAGNOSIS
__ ORGAN
Stomach
MANIFESTATION
Gastritis, ulcer
Small Intestine
Enteritis
Colon
Obstruction
Colitis
Liver
Infiltration
Biliary .tract
Cholecystitis,
cholangitis
Pancreatitis
Pancreas
Messenteric nodes
Peritoneum
Peritonitis, ascites
Intra-abdominal
lymphadenopathy
DISEASE ____
H. pylori, CMV,
lymphoma___________
Enteric pathogens
producing diarrhea (see
pg-)_________________
TB, lymphoma________
Enteric pathogens
producing colitis (see
page)________________
TB, Cryptococossis,
MAC infection________
CMV, Cryptosporidium,
Microsporidium_______
TB, CMV, Drugs
(Didanosine,
Lamivudine, Alcohol,
Pentamidine)_________
TB, Lymphoma, MAC
infection
TB - Tuberculosis
CMV - Cytomegalovirus infection
MAC - Mycobacterium avium intracellulare infection
MANAGEMENT OF ABDOMINAL PAIN
The first decision in the evaluation of abdominal pain is to differentiate
between a medical and surgical cause of abdominal pain. The indications for
surgery are the same in HIV patients as that in the normal population. There
is increased perioperative morbidity in AIDS patients due to their debilitation
and malnutrition. All tissue specimens should be sent for viral, fungal and
mycobacterial culture. The management of medical causes of abdominal pain
is defined by the etiology of the abdominal pain.
39
MODULE 7
ALGORITHM OF MANAGEMENT OF ABDOMINAL PAIN
ABDOMINAL
PAIN
LOCALISATION
I
SURGICAL
CAUSE
Scout films
Non-Obstructed
Barium studies
OBSTRUCTED
PERFORATION
MEDICAL
CAUSE
GASTRIC
Endoscopy
HEPATO
BILIARY
Refer Jaundice
algorithm
(page 47 )
1
CONSERVATIVE
MANAGEMENT
TREATMENT OF
SPECIFIC
ETIOLOGY
EMERGENCY
LAPROTOMY
PANCREATIC
Ultra-sound
Serum amylase
lipase
I
TREAT
APPROPRIATELY
ENTERITIS
Stool parasite
culture
40
MODULE 7
DIARRHOEA
Diarrhoea is the most frequent of gastrointestinal manifestations of AIDS,
seen in up to 50-90% of patients with HIV infection.
The factors that
contribute to this predilection for enteric infections are: (a) immune
dysfunction seen in the intestinal mucosa; (b) nutritional deficiencies; and (c)
achlorhydria and hypochlorhydria.
Diarrhea in HIV infection may be due to multiple pathogens. Organisms
which produce acute diarrhea in the normal population may cause chronic
diarrhea in patients with HIV infection. Response to treatment may be partial
and associated with high recurrence rates.
The principles of therapy are: (a) supportive therapy with fluids, electrolytes
and anti-motility drugs; (b) to use specific antimicrobial therapy against the
pathogen identified.
ACUTE DIARRHOEA
The pathogens causing acute diarrhea in HIV infection are similar to diarrheal
pathogens in the normal population and include Shigella, Salmonella, E. coli,
viruses, Campylobacter, G. lamblia and E. hystolitica infections. Bacterial
infections
are
the
predominant cause of acute
diarrhea.
Bacterial
gastroenteritis may be prolonged and severe in HIV patient. Therefore earlier
initiation of antibiotic therapy in acute diarrhea is required in patients with
HIV infection.
CAUSES OF CHRONIC DIARRHOEA IN HIV PATIENTS AT VELLORE
Protozoa (70%)
Isospora belli
Giardia lamblia
Cryptosporidia
Microspora
Cyclospora
Blastomycosis
Balantidium coli
E.histolyitica
D.fragilis
Bacteria (23%)
Shigella sp.
Salmonella sp.
Aeromonas
Helminths (6%)
S. stercoralis
41
CHRONIC DIARRHOEA IN HIV PATIENTS
VIRUSES
Herpes
Miscrosporidia Cytomegaloviru
simplex
s
Etiology
PROTOZOA (70%)
Cryptosporidia Isospora
belli
Clinical
features
Profuse, non-bloody, watery diarrhea,
abdominal pain, weight loss, nausea
Diagnosis Stool ova and
cystsModified acid
fast stain
Light and
electron
microscopy of
intestinal
biopsy
Stool
ova and
cystsModified
acid fast
stain
Large
spherical
oocytes
MODULE 7
Stool ova and
cysts
Trichrome
stain
Specific
fluorescent
stain
Hemaorrhagic
diarrhea, fever,
weight loss,
abdominal pain,
haematochezia
ColonoscopyDiscrete
haermorrhagic
erosions or
ulcerations
HistopathologyOwl eye
inclusion bodies
BACTERIA (23%)
Shigella
Salmonella
Campylobacter
Recurrent or
Proctitis with
chronic
anorectal
diarrhea, fever,
pain,
bleeding and abdominal pain
mucopurulent and cramps
Protracted
discharge
illness_________
Stool and blood
Stool and
blood culture culture
MYCOBATERIUM
AVIUM INTRACELLULARE_______
Diarrhoea
Abdominal pain
Malabsorption
Fever, weight loss
Hepatosplenomeg
aly
Stool examinationAFB in stools
Endoscopic biopsyAFBin
macrophages
No granuloma
formation
MODULE 7
42
EVALUATION OF DIARRHOEA IN HIV PATIENTS
Prior to evaluation as detailed above, a careful history should be obtained.
Unfortunately the history may not help in establishing a specific diagnosis as
more than one organism may be the cause of diarrhoea. Abdominal cramps,
bloating and nausea suggest gastric and/ or small intestinal involvement seen
with Cryptosporidium, Isospora or Giardia.
characterized by Cryptosporidium.
Severe watery diarrhoea is
Hematochezia implies, colitis, seen in
CMV, Shigella or Campylobacter infection. Tenesmus is seen in bacterial
colitis. Anal intercourse followed by tenesmus and dyschezia suggest herpes,
gonococci or Chlamydial infection leading to proctitis.
STAGE 1
1. Stool culture for Bacteria. E.g. Shigella, Salmonella, Campylolacter and
Clostridium difficile.
2. Stool specimens examined for parasites using saline, iodine. Trichrome, and
acid fast preparations for mycobacteria.
If stage one tests are negative empiric therapy may be considered. If the
empiric therapy fails the patient needs to be referred for stage 2 and 3.
STAGE 2
1. Gastroduodenoscopic or colonoscopic inspection of tissue and biopsy.
2. Biopsy stained with Hematoxylin and Eosin for protozoa, methenamine
silver or Giemsa for fungi, and AFB stains for mycobacteria.
3. Duodenal or colonoscopic biopsy culture for mycobacteria.
4. Duodenal fluid examination for parasites.
STAGE 3
1. Biopsy specimens examined by electron microscopy
The goal of evaluating diarrhoea is to identify a treatable cause with the
minimal work up. There are inter-institutional variations of the expertise
available for diagnosis and this can alter the sensitivity or pick up rate of
various tests. Geographical patterns of infections also may play an important
role in determining yield of pathogens.
43
MODULE 7
TREATMENT OF HIV ASSOCIATED DIARRHOEA
DRUG TREATMENT
Pathogen
Isospora belli
Treatment
TMP/SMX II BD for 2-4 weeks or
TMP/SMX DS I QID for 10 days followed by
TMP/SMX DS I BD for 3 weeks or
Ciprofloxacin 500 mg BD for 7 days
Cryptosporidium
No therapy proven efficacious
parvum
Nitazonoxide 2 G/day or Octreotide
Cyclospora cyatenensis
TMP/SMX DS I QID for 10 days or
TMP/SMX I BD for 3 weeks
Entamoeba histolytica
Metronidazole 750 mg tid for 10 days
Tinidazole 1G q!2h for 3 days
Giardia lamblia
Metronidazole 250 mg tid for 5 days
Microsporidium
Albendazole 400 mg BD for 4 weeks
Campylobacter jejuni
Ciprofloxacin 500 mg BD for 3 days
Azithromycin 500 mg OD for 3 days
Salmonellosis
Ciprofloxacin 750 mg BD for 10-14 days
Shigellosis
Ciprofloxacin 500 mg BD for 3 days
CMV colitis
Gancyclovir 5 mg/ Kg IV q!2h for 3-6 weeks
Herpes simplex
Acyclovir 5 mg/kg IV q8h for 5 days
In countries such as ours where diagnostic facilities may not widely be
available, empirical trial of therapy for patients with chronic diarrhoea may
be indicated. Combinations that have been studied are: (a) Albendazole 800
mg BD for 2 weeks and 0?) TMP/SMX DS II BD for 3 weeks with
Ciprofloxacin 750 mg BD for 1 week. The latter regimen was studied at
CMCH with partial efficacy.
44
MODULE 7
DIAGNOSTIC ALGTORITHM FOR EVALUATION OF DIARRHOEA
Diarrhoea
------------ L
Less than 2 weeks
Acute diarrhoea
□
More than 2 weeks
Chronic diarrhoea
Empirical Ciprofloxacin
If stool tests not available
then empiric therapy
may be considered
j
Stool tor parasites x 3
Stool Culture
750 mo bd x 3 davs
L
Negative
Positive
Empirical antibiotics
Treat appropriately
Not improved
Improved
---■r
I
J
Gaatroacopy/ Sigmoidoscopy
Bioosies for LM. Fluid analysis
..... I
-----
..... _____ »- . :..
Positive
Z
Negative
I
I
Treat appropriately
|
I
Positive
..
Biopsies for EM
—1___
Negative
...
!
Treat appropriately
Symptomatic treatment
45
MODULE 7
HEPATIC DISORDERS
Hepatomegaly with or without jaundice and associated abnormalities of liver
function tests are frequent finding in AIDS patients. These abnormalities may
be due to hepatic parenchymal or biliary diseases.
Hepatic parenchymal diseases in AIDS
1. Infections:
Viruses: Hepatitis C, CMV, Hepatitis B and D
Bacteria: Peliosis hepatis, M.Tuberculosis, MAC
Protozoa: Microsporidium
Fungi: Cryptococcus
2. Drug induced hepatitis:
TMP/SMX,
AZT, DDI, Azole agents, IN AH, Rifampicin, Pyrazinamide,
Tetracyclines, Gancyclovir, Nevirapine, Ritonavir, Saquinavir, Nelfinavir,
Clarithromycin
3. Tumours:
Lymphoma
Drugs and infiltrative diseases
The key diseases that need to be ruled out in AIDS patients are either infective
or drug related. Drug toxicity is more common in patients with AIDS and
stoppage of hepatotoxic drugs should parallel the evaluation of jaundice in
these patients. Diagnosis of infections requires a liver biopsy for obtaining
appropriate histopathology and cultures. Treatment is tailored according to
the specific opportunistic pathogen.
Viral Hepatitis
Hepatitis B and C co-infection are common in HIV infection as their
transmission patterns are similar (Hepatitis B by parenteral and sexual route
and Hepatitis C by the parenteral route). Clinical manifestations of the
46
MODULE 7
hepatotrophic viruses are altered with co-infection. HIV co-infection leads to
reappearance of hepatitis B, increased viral replication, elevated levels of viral
DNA and increased expression of core antigen in the liver. However, the host
response is blunted due to the immunosupressed state and there is very little
inflammation in the liver despite high viral titres. More patients with acute
hepatitis B progress on to develop chronic hepatitis (> 6 months). However
clinical manifestations of chronic hepatitis B are less severe in HIV patients.
On the other hand, in Hepatitis C where the virus is directly cytopathic, co
infection leads to increased viral load and greater hepatic parenchymal injury.
The current recommended treatment of chronic Hepatitis B is with Interferon
or Lamivudine and for Hepatitis C with Interferon with Ribavarin. These
treatments are less effective in patients with HIV infection.
47
ALGORITHM FOR JAUNDICE IN HIV INFECTION
JAUNDICE or
ABNORMAL LIVER TESTS
HEPATITIC PATTERN
Elevated bilirubin and transaminases
J
7
'
ULTRASOUND ABDOMEN
To assess for Wra-hepatic biltary
dilatation
I
:..
DILATED DUCTS
■
--
CHOLESTATIC PATTERN
Elevated biltrubfn
Elevated alkaline phophatase
Viral markers: HBsAg, antl-HCV serology
DRUG TOXICITY
INFECTIONS
i-------- —
|
I
NON DILATED
DUCTS
I
I
J
1
POSITIVE
z-F- REFER
LIVER BIOPSY
....
NEGATIVE;
7
TREAT APPROPRIATELY:
7
STOP HEPATOTOXIC
DRUGS
I
Resolution
REFER
I
No resolutfon
-FLiver biopsy
7
48
MODULE 7
BILIARY DISORDERS
Biliary presentations of gastrointestinal disease are relatively less common.
The conditions which fall within this category are the following:1) Diseases not associated with HIV infection such as gall stone disease and
biliary stricture
2) Acalculous cholecystitis
3) " AIDS cholangiopathy"
ACALCULOUS CHQECYSTITIS
Most of the cases of acalculous cholecystitis are isolated reports. The causes of
acalculous cholecystitis are: Cryptosporidia, Candida albicans. Microsporidia,
Isopora belli. Salmonella enteridis, Campylobacter and CMV infection.
The characateristics of acalculous and calculous cholecystitis are similar: right
upper quadrant or epigastric pain, fever, nausea, vomiting and diarrhoea.
The serum bilirubin is normal, aminotransferases are minimally elevated and
alkalize phosphatase levels are markedly elevated.
Ultrasound reveals a
thickened gall bladder wall, gall bladder dilatation and thickened biliary
ducts and pericholecystic fluid.
Surgical excision of the gall bladder is the definitive treatment of acalculous
cholecystitis. Mortality in patients can increase if there is delay as gangrene
and perforation can set in.
Usually late AIDS patients with malnutrition
develop this condition.
AIDS CHOLANGIOPATHY
This generic term encompasses a range of biliary tract disorders that occur in
patients with AIDS. Four distinct entities are as follows: papillary stenosis;
sclerosing cholangitis;, papillary stenosis and sclerosing cholangitis; and
extrahepatic bile duct stricture. The causes of AIDS cholangiopathy are the
exact same organisms, which cause acalculous cholecystitis. However in 2850 /o of cases no identifiable pathogen or disease can be ascertained. The
clinical symptomatology include epigastric and/or right upper quadrant
pain, fever, vomiting, diarrhoea, weight loss and pruritus are the common
49
MODULE 7
clinical symptoms. The diagnosis is made by CT scan and ERCP. The
treatment of the underlying opportunistic infection forms the basis of
management of AIDS cholangiopathy.
Endoscopic sphincterotomy and
ursodeoxycholic acid have been shown to partially ameliorates symptoms.
50
MODULE 7
REFERENCES
1. Dieterich
D.T,
Poles
M.A,
Cappell
M.S,
Lew
E.A.
(1999)
Gastrointestinal manifestations of HIV disease including peritoneum
and mesentery. In Merigan T.C, Bartlett J.G, Bolognesi D (eds) Textbook
of AIDS Medicine. Williams and Wilkins.
2. Main J, McNair A, Goldin R, Thomas H.C. (1999). Liver Disease and
AIDS In Merigan T.C, Bartlett J.G, Bolognesi D (eds) Textbook of AIDS
Medicine. Williams and Wilkins.
3. Wilcox C.M, Friedman S.L. (1998) Gastrointestinal Manifestations of
Acquired Immunodeficiency Syndrome. In Feldman M, Scharschmidt
B.F, Sleisenger M.H (eds) Gastrointestinal and Liver Disease. Saunders.
4. Smith P.D, Wilcox C.M. (1999) Sastrintestinal Complications of the
Acquired Immunodeficiency Syndrome. In Yamada T, Alpers D.H,
Lame
L,
Owyang
C,
Powell
D.W.
(eds)
Testbook
Gastroenterology.Lippincott Williams and Wilkins.
FURTHER READING
1. Mukhopadhya A, Ramakrishna BS, Kang G, Pulimood AB, Mathan
MM, Zachariah A, Mathai DC. (1999) Enteric pathogens in southern Indian
HIV-infected patients with & without diarrhoea. Indian J Med Res 109:85-9.
2. Kelly P, Lungu F, Keane E, Baggaley R, Kazembe F, Pobee J, Farthing M.
(1996) Albendazole chemotherapy for treatment of diarrhoea in patients
with AIDS in Zambia: a randomised double blind controlled trial. BMJ
312(7040):1187-91
51
Fig. 7-A
Fig. 7-B
Fig. 7-C
MODULE 7
52
Fig. 7-D
Fig. 7-E
MODULE 7
H/V Phz/szczan Training Course 2002,
Christian Medical College, Vellore
DISTANCE LEARNING COURSE
STIs
RTIs
&
HIV
Author: Susanne Abraham
Course Organiser : Anand Zachariah
Distance Learning Expert: Janet Grant Open University, UK
^,Eur0Pean Cession through grant number
1ND/B762U/1B/1999/0379 provided to the HIV/STI Prevention and Care Research
Programme of the Population Council India.
IB
jt-
MODULE 8
1
MODULE 8
OVERVIEW
Sexually transmitted infections (STIs) remain a major public health problem in most
parts of the world. Failure to diagnose and treat STIs in early stages may result in
serious complications including infertility, foetal wastage, ectopic pregnancy,
anogenital cancer, premature death, neonatal and infant infections.
The HIV epidemic has focused greater attention on the control of STI as it is known
that STIs enhance the sexual transmission of HIV infection. Both ulcerative and non
ulcerative STIs have been shown to increase the risk of acquiring HIV infection. STIs
also increase the infectiousness of HIV-positive persons. Patients with HIV infection
have increased morbidity associated with STIs and these STIs may be more difficult
to treat.
9
V
Effective management of STIs is one of the corner stones of STLcontrol as it prevents
development of complications and offers opportunity for targeted education
regarding HIV prevention. Therefore appropriate and effective treatment at the first
encounter of a patient with STIs is an important public health measure.
STI case management includes correct anti-microbial therapy to reduce infectivity
and obtain cure and comprehensive care of the patient's needs for reproductive
health. Etiological diagnosis of STIs is problematic in many settings. So syndrome
based STI management has been developed and advocated in large number of
countries in the developing world.
National demographic characteristics in India reflect an environment that is
vulnerable to transmission of sexually transmitted infections (STI): a young
population; more men than women, rapid rate of urbanization and severe socio
economic inequality.
STIs are highly prevalent in some areas, but rare in others and differ widely between
groups of differing risk of acquiring STIs. In high risk groups overall STI prevalence
may be very high, eg. 40% in sex workers and 20 % in truck drivers.
Studies of HIV sero-prevalence have shown increasing rates among sex workers, STI
clinic attenders, IV drugs users and in the ante-natal clinic in different parts of India.
It is estimated that there are about 4 million HIV positive persons in India. The
predominant route of spread is heterosexual transmission. The risk factors for
acquiring HIV infection are multiple sexual partners, sex with commercial sex
workers, unprotected sexual intercourse, ulcerative and non-ulcerative genital
disease, current or past history of STIs, intravenous drug use and lack of
circumcision.
This module would help you to improve your skills in management of STI and
develop your STI clinical services. Individual risk assessment of acquiring STI and
STI oriented examination technique will be dealt with in contact course II.
2
MODULE 8
OBJECTIVES
After completion of this module the student should be able to:
1. Recognise the magnitude of STI problem in India.
2. Recognize the role of STIs in the transmission of HIV infection.
3. Understand the principles of syndromic case management.
4. Recognize different STI syndromes and use flow charts in their
management.
5. Describe the importance of treatment of partners, risk behaviour reduction
and condom promotion in STI management.
3
MODULE 8
CONTENTS
Title
Approach to STI
STI agents and symptoms
STI & RTI Case management
Activity8.2
HIV/STI Co-factor effect
Reading
Public Health Importance of
STI and HIV/STI co-factor effect
Activity 8.3 Genital Ulcer-Part I
Reading
Genital Ulcer Syndrome
Quality STD care training
Activity 8.4 Genital Ulcer- Part II
Activity 8.5 Condom promotion
Reading
Quality STD care training
Activity 8.6 Behaviour Communication
Reading
Quality STD care training
Activity 8.7 Inguinal Bubo
Reading
Quality STD care training
Inguinal Bubo
Activity 8.8 Vaginal discharge
Reading
Quality STD care training
Vaginal discharge
Activity 8.9 Urethral discharge
Reading
Quality STD care training
Urethral discharge
Activity 8.10 Scrotal swelling
Reading
Quality STD care training
Scrotal swelling
Activity 8.11 Lower abdominal pain
Reading
Quality STD care training
Lower abdominal pain
Activity 8.12 Secondary syphilis
Reading
Secondary syphilis
Activity 8.13 Positive VDRL
ActivityS.I
Reading
Reading
Tests ^treatment of syphilis
Time (minutes)
10
10
15
10
Page
4
41
37-40
6
15
5
42-43
10
10
10
10
20
10
20
10
10
5
10
15
44-45
50
10
12
61-68
14
69-75
16
53
46
18
10
46
20
51
48
10
10
10
10
10
10
10
10
10
10
10
5
10
Activity 8.14 Other STIs
Reading
Other STIs
Activity 8.15 Other STIs -treatment
5
5
5
TMA
Total estimated study time
40
395
8
52
22
55
49
24
54
50
26
51
28
51-52
30
53
32
35-36
4
MODULE 8
The following activity will enable you to
.
different
approaches to
to STI
STI management and the causative
----- c approaches
agents of different STfs syndCee. feed, ■■ST!
STIs syndromes.
Ca„ a.n.rrm.„t, lpg
.37.40) and
„d "STI
”d
(pg-37-40)
•nd .Wt0TO. (pg.41)l„ the reader. Jfter 9
1 *■’
you can sndertate the follo^pg aotlyity
ACTIVITY 8.1
APPROACH TO STI (TIME: 10 MIN.)
1. List the advantages and <disadvantages
”
of syndromic
approach to management of STIs.
I*
OtA/c/k
2. -
....
3.
4. — /]_
5
t
~
DISADVANTAGES
Vvfaj
"
[j-v.
ADVANTAGES
1.
'I'oY
z>/
2-^
7
iWrlyC
>
ClAJU X
’r>vC- FC^AA W.. O
< *<*.•*
,
1^0^^
C.
CrW. -a/ tv^UM
3.
4.
5.
2. What are the common causative agents
of the different
STIs syndromes?
STIs SYNDROME
1. Genital ulcer
DISEASES
-
2. Urethral discharge
3.Inguinal bubo
, I L JP
Ct
£> T) ,
4. Vaginal discharge
7
5. Scrotal swelling
7
)
6. Lower abdominal pain
P']
.
? X Gi 1/,
5
MODULE 8
^^FEEDBACK 8.1
1. List the advantages and disadvantages
of syndromic
approach to management of STIs
ADVANTAGES
DISADVANTAGES
1. Treatment at the first visit.
L Over-treatment
2. Cost saving.
2. False positive diagnosis.
3. No loss to follow up.
3. Social problems related to STI
4. Effective in mixed infection.
misdiagnosis.
5. Applicable in settings without laboratory
facilities.
4. Over-treatment of sex partner based on
syndromic diagnosis.
6. Reduces risk of STI and HIV
transmission.
7. Can be applied by paramedical workers.
2. What are the ccommon
-diseases which produce the
different STIs syndromes?
STI SYNDROME
DISEASES
1. Genital ulcer
Syphilis, Chancroid, Genital herpes, Donovanosis (Granuloma
inguinale), Lymphgranuloma venereum
2. Urethral discharge
Gonococcal and non-gonococcal urethritis
3.Inguinal bubo
Lymphgranuloma venereum, Chancroid
4. Vaginal discharge
Cervical
discharg<
appearing as vaginal
discharge
Vulvovaginal candidiasis, Trichomoniasis, Bacterial vaginosis
Gonococcal and Chlamydial cervicitis
5. Scrotal swelling
Lymphgranuloma venereum and Gonorrhoea
6. Lower
pain
Pelvic inflammatory
chalmydia.
abdominal
disease
caused
by
gonorrhoe
or
6
MODULE 8
This activity aims to help you learn about the STI/HIV
co-factor effect, jPlease read, "Public health importance
of STIs and STI/HIV co-factor effect" (pg. 42-43) of the
reader. After completing the reading you can proceed to
the next activity._____
ACTIVITY 8.2
HIV/STI CO-FACTOR EFFECT (TIME: 10 MIN.)
1.
Which are the STIs that increase the susceptibility
of HIV-negative individuals to HIV infection?
:
What are
the
mechanisms
underlying
the
increased
HIV
susceptibility?
Cwt jvu
— /
O'/'-r <
\
,5^
y1
—
V
C fTd •
—---------------
2.Why do STIs increase the infectiousness of HIV positive
individua1s?
3. In which stage
of an HIV epidemic
is
the
control
of
STIs an effective strategy for reducing HIV transmission?
L Vi ^A.
iv-j if
M.
^7^wv ^/i
4. What are important strategies for reducing STIs in the
community?
C
I
-a (__
7
MODULE 8
^FEEDBACK 8.2
1.Which are the STIs that increase the susceptibility of
of HIV-negative individuals to HIV infection? What are
the
mechanisms
underlying
the
increased
HIV
susceptibility?______________
Genital ulcers caused by syphilis, chancroid and genital herpes and gonorrhoea,
chlamydia and trichomoniasis increase susceptibility to HIV infection. The basis of
the increased succeptibility is:
a. STIs interrupt the integrity of the genital epithelium
b. STIs attract inflammatory cells which increase access of I II V virus to CD4
receptors.
2. Why do STIs increase the infectiousness of HIV positive
individuals?______________
The concentration of HIV virus in semen is increased in patients with urethritis. HIV
virus can be detected in genital ulcers. HIV shedding is increased in HIV infected women
with gonococcal cervicitis. STIs are hypothesised to upregulate the viral load which
increases concentration of virus in genital fluids.
3. In
which
stage
of
an
HIV
epidemic
is
the
control
of
STIs an effective strategy for reducing HIV transmission?
STIs treatment is an effective strategy for HIV control in the early and moderately
advanced stages of an HIV epidemic when the prevalence is rising. Once the epidemic
becomes generalised then the contribution of STIs to the epidemic seems to steadily
decrease.
4. What are important strategies for reducing STIs in the
community?
Training of GPs in syndromic case management of STIs.
Training of health workers to screen and detect STIs in the community.
Education of the community regarding symptoms of STIs and to improve health seeking
behavior regarding STIs.
Sexual behaviour change and condom promotion.
8
MODULE 8
This activity aims to help you learn about the management
5 patient with genital ulcer.
ulcer. Please
Please read
read ,, ^Genital
Ulcer Syndrome" (pg. 44-45) of the reader and Quality STD
Care Training
Training Module
Module page
page 50 Genital Ulcer - treatment
flow chart, f
"
After completing the reading you can proceed
to the next activity.____
ACTIVITY 8.3
GENITAL ULCER - PART I (TIME: 5 MIN.)
30 year old Mr. Venkatappa, comes with complaints of of painless ulcer of the
penis of 2 weeks duration. On examination there were three mild tender 0.5 cm
sized non-indurated ulcers on the coronal sulcus. There was no past history of
genital ulcer.
l.List the STIs which can cause genital ulcers.
1. s.
2.
(J
5.
2.
3
4.
i.
A
)
How would you manage this patient?
Sx/'vt.
r/r/
5
y-
3.What
serological
transmitted diseases
patient?
tests
would
to
you
screen
for
like to do
4 . How would you follow-up this patient?
What would you do if the patient failed to
treatment?
How should the patient's partner be screened?
sexually
on this
respond
to
9
MODULE 8
^^FEEDBACK 8.3
l.List the STIs
patient:
1. Herpes Simplex
2. Syphilis
3. Chancroid
4. Donovanosis
5. LGV
which can cause
genital ulcers
in this
2. How would you manage this patient?
Inj. Benzathine Penicillin 24 million units in 2 injections (give one injection in each
buttock).
+ Erythromycin 500 mg QID for 7 days
or Ciprofloxacin 500 mg as a single dose.
3.What
serological
transmitted
diseases
tests
would
to
screen
you
like
for
to
do
sexually
on
this
patient?
VDRL/RPR, HIV- ELISA, HBsAg after pre-test counselling (as in all cases of patients
with STIs).
4.
How would you follow-up this patient? What would you
do if the patient failed to respond to treatment?
What should the patient's partner be screened for?
Review after 7 days. If the ulcer has not healed then you should assess compliance with
medications. If the patient has been compliant then he should be referred to a higher
centre for further evaluation.
Follow up RPR/VDRL results and other serological tests HIV ELISA and HBsAg.
'The partner should be screened according to syndromic case management.
________________________
_______________
10
MODULE 8
GENITAL ULCER - PART II (TIME: 10 MIN.)
Twenty-five year old Mr.
Kuppan comes to your clinic.
has been iworking as a
He
lorry driver for the last
During his trips he has
4 years.
been in the habit of
commercial sex workers
visiting
and does not use condoms.
complains of a sore c
He
on the penis since 9 days.
On questioning, he gives
a history of
of paxnful lesions starting
recurrent episodes
as
tiny vesicles on the
prepuce and glans penis, which
then ulcerate.
The
lesions heal in 4 to 5 days,
These
lesions
occur
at a
frequency of about once a month.
Examine Fig. 8-A (in cover)
What is the most lively diagnosis
in this patient?
~ //<
__________
you manage this pat,ient
Acx.
2)
'
7^
/d
-
of
treatment
that
we
4
4. What treatment can
be given to prevent
recurrence of
the disease?
5. The patient's HIV ELISA test
was positive. What do you
think are factors that led to this
patient acquiring HIV
infection?
)
<77
MODULE 8
11
■-^FEEDBACK 8.4
l.What is the most likely diagnosis in this patient?
- Herpes Genitalis
Genital HSV infection is mostly diagnosed on clinical grounds.
2. How would you manage this patient?
_
__________
Herpetic genital ulcers are usually self- limiting. They require symptomatic treatment with
dilute potassium permanganate soaks. However since this patient’s lesions are lasting for
a longer duration, it would be advisable to start on Acyclovir 400 mg tid for 5-7 days.
3. what are the other components
should institute in this case?
of
treatment
that we
prevent
recurrence
of
Risk reduction counseling
Condom promotion
4.
What
treatment
can
be
the
disease?
Suppressive treatment with Tab. Acyclovir 400 mg twice a day is indicated as the patient
has > 6 episodes per year.
5. The patient's HIV ELISA test was positive. What do you
think are factors that led to this patient acquiring HIV
infection?_______________________ ______________ __________ —
—-—r—7The patient has history of unprotected sex, sexual partners were CSW s and has had
multiple partners all of which will increase the risk of acquiring HIV infection.
Any genital ulcerative disease will increase the risk of acquiring HIV. The risk of
acquiring HIV infection is in the order of 20-100 fold per sexual act.
The patient was not circumcised. The absence of circumcision also increases the risk of
acquiring HIV infection.------------------- - --------------------------------------------------------------
12
MODULE 8
This activity will help you learn about how to educate
patients regarding condom use. Read Quality STD Care
Module, page 61-68 Session 6 Condom Promotion and then
proceed to the activity.
ACTIVITY 8.5
CONDOM PROMOTION (TIME: 10 MIN.)
1. What are common misconceptions regarding condom use?
2.What are common errors in the use of condoms?
I
*
3.
In what ways can a doctor promote condoms in his/her
clinic?
4. How will a person know if a condom is of good quality?
13
MODULE 8
^FEEDBACK 8.5
1. What are common misconceptions regarding condom use?
Condoms reduce sexual pleasure
Women do not like using condoms
Condoms tear during sexual intercourse
2.What are common errors in the use of condoms?
1. Condom packet opened and applied before penis is erect.
2. Condom unrolled before application.
3. Tip of condom not squeezed while applying it.
4.
Penis not withdrawn immediately after ejacultation.
5. Reservoir tip not facing downward while slipping off condom.
6. Condom not disposed properly.
3.
In what ways can a doctor promote
clinic?_____________________
Distribute condoms.
Display condom information in the clinic.
Explain and demonstrate condom use.
condoms
in their
4. How will a person know if a condom is of good quality?
Check expiry date on packet.
If condom dried or sticky or changed in colour or uneven in texture, it may be damaged.
14
MODULE 8
This activity will help you learn about counselling and
behaviour change communication in the context of STIs
management.
Read Quality STD Care Module,
page 69-75
Session
7
"Counselling
and.
Behavioural
Change
Connnunication" and then proceed to the activity.
ACTIVITY 8.6
BEHAVIOR CHANGE COMMUNICATION
(TIME: 10 MIN.)
1. What are important tips in interviewing
facilitate behaviour change?
A
2.
Who
are
the
patients
who
__ of ---
C
need
special
technique to
attention
to
to
in
initiate behaviour change communication?
c
3.
What are the most important messages
behaviour change communication?
convey
15
MODULE 8
^FEEDBACK 8.6
1. What are important tips in
facilitate behaviour change?
interviewing
technique
to
A Ustcning and understanding approach may build the confidence of the patient
Give appropriate information.
Clarify doubts.
Encourage and support patients to change risky behaviour.
2. Who are the patients who need spacial
initiate behaviour change communication?
Patients who come for treatment for STIs the first time.
n l- L on I ion
I Q
Patients who come for treatment for STIs the second time.
Persons whose lifestyle and job may promote risky behaviour.
Women whose husbands may have risky behaviour.
3. What are the most important messages to convey in
behaviour change communication?
Basic information on STDs and HIV infection.
Emphasise need for compliance to drug regimen.
Importance of safe sexual behaviour:
Abstaining from sex till cure, not having penetrating sex, using condom correctly and
consistently.
Need for concurrent partner treatment.
Emphasise the need for follow-up.
16
MODULE 8
This activity aims to help you learn about the management
of a patient with inguinal bubo. Please read z "Inguinal
Bubo" (pg. 46) of the reader and Quality STD Care Training
Module page 53 Inguinal Bubo - treatment flow chart.
After completing the reading you can proceed to the next
activity.
ACTIVITY 8.7
INGUINAL BUBO (TIME: 10 MIN.)
Thirty-five year old Mr. Ramachandran, a labourer, comes
with history of swelling in the left inguinal area of 20
days' duration.
He has been diagnosed to have HIV
infection since 2 years.
On examination, 1there were no lesions on the external
genitalia.
However,
there was
left-sided
inguinal
swelling with overlying erythema.
Examine Fig. 8-B (in cover).
1.
List the sexually transmitted diseases
present as inguinal lymph node swelling.
1.
2.
3.
4.
2.What is the clinical sign in the picture?
3. How would you manage this patient?
which
can
17
MODULE 8
'^FEEDBACK 8.7
1.
List the sexually transmitted diseases
present as inguinal LN swelling.
1. Lymphogranuloma venereum
2. Chancroid
which
3. Syphilis
4. HIV infection
2.What is the clinical sign in the picture?
Groove sign. This sign is seen only in about 20% of cases with LGV.
3. How would you manage this patient?
Doxycycline 100 mg twice a day for 14 days.
Bubo may have to be aspirated. Incision and drainage is not recommended.
Since the patient is HIV positive, the treatment may have to be prolonged.
can
18
MODULE 8
This activity aims to help you learn about the management
of a patient
with vacrinal
vaginal
cf
discharge.
Please read,
^Vaginal Discharge" (pg. 46-47) of the reader and Quality
STD Care Training Module, page 52 Vaginal Discharge treatment flow chart. After completing the reading you
can proceed to the next activity.
ACTIVITY 8.8
APPROACH TO VAGINAL DISCHARGE
(TIME: 10 MIN.)
Twenty five year old Mrs. Vijaya, who is a housewife from
a nearby town, has history of vaginal discharge since 4
weeks.
On
speculum
examination
there
was
profuse
yellowish vaginal discharge. The risk assessment was
negative.
1. List the RTI's that can cause vaginal discharge in this
patient.
' CX^—,\7
2. What laboratory
discharge?
tests
could
be
done
on
I
I J)
t. ho
vagina 1
3. How would you manage this patient?
- ATh>/-.z
-
— ^-<^A^X4rf
( '1A-O
T
)
4. What serological test to screen for STIs would you do
in this patient?
hH?
19
MODULE 8
^FEEDBACK 8.8
1. List the RTI's that can cause vaginal discharge in this
patient.
1. Trichomoniasis
2. Vulvo vaginal candidiasis
3. Bacterial vaginosis
One should keep in mind that infections that cause such as gonorrhoea and Chlamydia
infection, whilst usually asymptomatic, may cause cervical discharge which presents as
vaginal discharge
2. What laboratory tests could be done at the time of the
vaginal examination?
KOH, saline mount, Gram staining
1
3. How would you manage this patient?
T. Metronidazole 400 mg TID for 7 days
Examine partner and institute treatment with Metronidazole.
4. What serological test to screen for STIs would you do
in this patient?
VDRL/RPR, HIV ELISA, HBsAg
20
MODULE 8
This activity aims to help
you learn about the management
of a patient with
urethral discharae.
Please read,
discharge.
"Urethral discharge" (pg. 48)
of the reader and Quality
STD Care Training Module
page 51 Urethral Discharge trea tment flow chart.
After completing the reading you
can proceed to the next activity.
ACTIVITY 8.9
URETHRAL DISCHARGE (TIME: 10 MIN.)
Twenty-nine year old Sadaaivam is unmarried, and comes
with history of discharge per urethra since 2 days.
On
questioning, he admits to having had1 multiple partners in
the past 3 years. On examination
discharge per urethra
was confirmed.
1. Please list the likely pathogens that
cause discharge
per urethra in this patient.
)
2. What test would you do for presumptive diagnosis?
1
■
3. The gram stain showed
gram-negative intra-cellular
diplococci. How would you manage the patient?
0)
4'
4. On follow up, his HIV ELISA was positive,
to change his treatment regime?
Do you have
5. However, his symptoms of dysuria were
-hft are the Possibilities to be considered?
persisting.
)
—-s
-
*7
21
MODULE 8
"FEEDBACK 8.9
1. Please list the likely pathogens that cause discharge
per urethra in this patient.
Neisseria gonorrhoea
Chlamydia trachomatis
2. What test would you do for presumptive diagnosis?
Gram stain of discharge.
3. The gram stain showed gram-negative intra-cellular
diplococci. How would you manage the patient?
Cap. Doxycycline 100 mg bd x 7 days.
T. Ciprofloxacin 500 mg stat or Inj. Ceftriaxone 250 mg IM stat.
To abstain from sexual intercourse until 7 days after therapy is initiated.
To-come back for evaluation after 1 week.
To bring partner for examination and treatment.
Condom usage whenever he has sexual relationships.
This patient is being treated for both gonorrhoea and chlamydial infection because of
possibility of co-infection and difficulty of excluding diagnosis of NGU. The same
treatment could be administered if gram stain was not available.
4. On follow up, his HIV ELISA was positive,
to change his treatment regime?
Do you have
No
5. However, his symptoms of dysuria were
What are the possibilities to be considered?
persisting.
Lack of treatment compliance
Treatment failure
Other etiologies such as Trichomoniasis
Re-infection
Re-treat with initial regime, if he did not comply with the initial treatment regime
or was re-exposed to untreated sex partner(s).
Treat with Metronidazole to treat for possible trichomonas urethritis.
Dose- Metronidazole 400 mg TIP for 7 days.
22
MODULE 8
This activity aims to help you learn about the management
of a patient with scrotal swelling. Please read, "Scrotal
Swelling" (pg. 49) of the reader and Quality STD Care
Training Module page 55 Scrotal Swelling- treatment flow
chart. After completing the reading you can proceed to
the next activity.
ACTIVITY 8.10
SCROTAL SWELLING (TIME: 10 MIN.)
A 25 year old man presents to the clinic with symptoms of
pain in the scrotum for 3 days . On examination he has a
tender
and
warm
unilateral
scrotal
swelling .
The
epididymes was tender and thickened. There is no inguinal
adenopthy.
On
milking
the
urethra
there
is
minimal
discharge per urethra.
1. What additional history and examination will you
evaluate for?
2. What is the likely diagnosis? What differential
diagnosis do you need to take into account?
r\j-
/I
1
3. What treatment will you initiate?
> ___
c
_
iitr
>
■
kfk L
23
MODULE 8
^FEEDBACK 8.10
1. What additional history and examination will you
evaluate for?
History of trauma, onset of pain (acute onset may suggest torsion), loin to groin pain
(may suggest torsion testis), previous similar episodes (may suggest filarial epididymoorchitis), recent urethral discharge and history of high risk behaviour, past history of
tuberculosis.
1
Examination- Inspection (scrotal oedema), palpation (enlarged tender testis which is
elevated and has transverse lie and pain not relieved on elevation of the scrotum is
suggestive of torsion testis), epididymal thickening and warmth.
2. What is the likely diagnosis? What differential
diagnosis do you need to take into account?
Epididymo-orchitis eg. due to Chlamydia trachomatis or Neisseria gonorrhoea (since the
onset is not acute, there is urethral discharge and the scrotum is warmth).
The differential diagnosis includes epididyo-orchitis of other causes, bacterial,
tuberculous, and filarial, trauma, torsion testis and testicular tumour.
3. What treatment will you initiate?
Cap. Doxycycline 100 mg bd x 7 days
1. Ciprofloxacin 500 mg stat or Inj. Ceftriaxone 250 mg IM stat
Elevation of the scrotum with scrotal support.
Analgesics
To abstain from sexual intercourse until 7 days after therapy is initiated.
To come back for evaluation after 1 week.
To bring partner for examination and treatment.
Condom usage whenever he has sexual relationships
24
MODULE 8
This activity aims to help
- -you learn about
--- the
-- management
of a lady presenting with abdominal pain. Please read,
"Lower abdominal pain" (pg. 50) of the reader and Quality
STD Care Training Module page 54 Lower abdominal pain treatment flow chart. After completing the reading you
can proceed to the next activity.
ACTIVITY 8.11
LOWER ABDOMINAL PAIN (TIME: 10 MIN.)
A
22
year
old young
lady presented to the outpatient
clinic with complaints of lower abdominal pain and fever
for 4 days. On examination: Temperature - 101° F, Iliac
fossa
motion
tenderness
present.
tenderness.
Pelvic
Speculum
examination-
examination
examination-
cervival
Copper-T
in
Scanty mucopurulent discharge from the cervix.
adnexal masses felt on bimanual examination.
No
situ.
1. What additional history will you ask for?
2 . What additional findings will you look for on
abdominal examination?
3. What treatment will you initiate?
25
MODULE 8
'^FEEDBACK 8.11
1. what additional history will yOU ask for?
l-lislory ofmlssc(j
history of sexual behaviour of patient and partner.
2. What findings will
you look for on abdominal
examination?
3. What treatment will
you initiate?
Remove copper-i~aftcr 2-4 days.
Ciprofloxacin 500 mg stat
Doxycycline 100 mg BD for 14 days
Metronidazole 400 mg BD for 14 days
2G
MODULE 8
This activity aims to help you learn about the management
of a patient with features of secondary syphilis. Please
read, "Secondary Syphillis" (pg. 51) of the reader. After
completing the reading you can proceed to the next
activity.
ACTIVITY 8.12
SECONDARY SYPHILIS (TIME: 10 MIN.)
Forty-year old Mr. Dhanasekar, who is a clerk in a bank, comes
with a history of a non-pruritic rash on the trunk and palms
since 1 week. Examine Fig. 8-D (in cover).
"1 . What is the differential diagnosis of this symptom?
.A
-
2. What additional history would you ask for to help you
diagnose this patient's disease?
7
3. What diagnostic test will you order?
<V~*
f c.c
27
MODULE 8
^FEEDBACK 8.12
1. What is the differential diagnosis of this symptoms?
Drug rash
Exanthematous fever
Secondary syphillis
Primary skin disease
2. What additional history would you ask for to help you
diagnose this patient's disease?
1. Fever
2. Malaise
3.
Headache
4. Drug intake prior to the onset of the rash.
5. Prior history of skin rash and genital ulcer.
6. History of mucosal lesions.
7. Assess risk of acquiring STIs.
Genital examination is also essential to look for a healing uLccr and inguinal adenopathy.
3. What diagnostic test will you order?
VDRL or RPR
28
MODULE 8
This activity aims to help you learn about the management
3 patient with a positive VDRL report. Please read,
^Serological
tests
for
syphilis
and
Treatment
of
Syphillis" (pg.51-52) of the reader. After completing the
reading you can proceed to the next activity.
ACTIVITY 8.13
POSITIVE VDRL TEST (TIME: 5 MIN.)
In
the past history of Mr.
Dhanasekar
(the patient in
Activity 8.12),
there was a positive history of a single
painless genital ulcer 6
months ago which healed with
topical
ointments.
His
VDRL
was
reactive
in
1:64
dilutions, and his HIV ELISA was positive.
1. What is your diagnosis?
--C4
2. What treatment would you institute in this case?
it differ since patient is HIV positive?
(2*
Does
A
3. When should the serological test be repeated and how
would you follow up the patient?
I
H } I
l
29
MODULE 8
^FEEDBACK 8.13
1. What is your diagnosis?
Secondary syphilis.
2. What treatment would you institute in this
Does it differ since patient is HIV positive?
case?
Benzathine penicillin G 2.4 million units IM in a single dose
The treatment does not differ and is the same in HIV infected individuals. However
patient needs to be on close follow up.
3. When should the serological test be repeated and how
would you follow up the patient?
Patient should be re examined clinically and serologically 3, 6, 9 and 12 months following
treatment
30
MODULE 8
This activity aims to help you learn about the clinical
recognition of patients with other STIs. Please read
Other STIs" (pg.53) of the reader. After completing the
reading you can proceed to the next activity
ACTIVITY 8.14
OTHER STI (TIME: 5 MIN.)
Study the photographs 8-E and 8-F in attached cover.
N
o
Photo
1
Fig. 8- E
2
Fig.
Diagnosis
8-F
31
MODULE 8
^FEEDBACK 8.14
N
o
Photo
Diagnosis
1
Fig. 8-E
Genital wart
2
Fig. 8-F
Molluscum contagiosum
32
MODULE 8
This activity aims to help you learn about the treatment
of a patients with other STIs.
ACTIVITY 8.15
OTHER STI - TREATMENT (TIME: 5 MIN.)
How would you treat the respective patients in photographs Fig. 8-E and 8-F?
N Diagnosis
Treatment
o
1
2
33
MODULE 8
^FEEDBACK 8.15
N
o
1
Diagnosis
Treatment
Genital warts
Treatment options:
1.Podophyllin
applications
2 . Cryotherapy
3. Cautery
4. Excision
2
Molluscum contagiosum
Treatment options:
1. Needling
2. Cryotherapy
3. TCA/MCA
application
4 . Cautery
34
NOTES
MODULE 8
37
MODULE 8
IREADINGS
STI and RTI Case Management
(Excerpt from: The management and control of sexually transmitted infection,
and their implications for AIDS control in South-east Asia Heiner Grosskurth
, Gurumurthy Rangaiyan to be published in Journal of Health Management)
Appropriate case management for STIs and RTIs comprise the following
steps: a brief history, physical examination, correct diagnosis, early and
effective treatment, health education to achieve good treatment comphance
and sustainable risk reduction, and effective partner notification (Adler et al
1998, WHO 2001).
Approaches to STI/RTI diagnosis
There are three distinct approaches to arrive at an STI diagnosis: clinical.
laboratory based and syndromic diagnosis.
(i) The clinical approach attempts to arrive at a specific diagnosis based on
clinical examination, and to treat the assumed aetiology. I’his traditional
approach has been widely used by care providers without access to
laboratory services. However, many studies have demonstrated that the
sensitivity and specificity of this strategy is low even in the hands of
experienced providers (Holmes and Ryan 1999). For example in a study from
South Africa, clinicians diagnosed correctly only about one third of men with
chancroid and ten percent of patients with mixed aetiologies (Dangor 1990).
In a similar observation from China, 12 of 106 cases of syphilis were
incorrectly classified as herpes genitalis, and did not receive the correct
treatment (Wang et al 2002). The clinical approach should therefore be
abandoned.
(ii) The laboratory based aetiological approach tries to identify the organism
responsible for the symptoms with which a patient presents. A number of
obstacles make this approach largely inappropriate for many areas in
Southeast Asia: Sufficiently equipped laboratories do not exist in rural
communities and many smaller towns, and even in urban areas where they
exist, quality control systems are often insufficient (WHO 2001). For some
STIs, such as Chlamydia trachomatis infection, available tests are expensive,
sophisticated or too insensitive.
(iii) The syndromic approach is based on the diagnosis of the syndrome, and
deliberately does not attempt to identify the underlying aetiology. A
syndrome is defined as a combination of symptoms and easily recognisable
signs. Important STI/RTI syndromes are the genital ulcer syndrome in men
and women, the urethral discharge syndrome in men, the syndrome of
38
MODULE 8
painful testicular swelling in men, the vaginal discharge syndrome in women,
the lower abdominal pain syndrome in women, and the inguinal adenopathy
syndrome (buboe) in men and women. Each STI/RTI syndrome can be
caused by a variety of aetiological agents. The occurrence of these aetiologies,
and their proportional distribution may differ between regions and countries.
Not all aetiological agents are sexually transmitted. For example, vaginal
discharge may be caused by STIs (due to trichomoniasis and occasionally to
gonococcal or chlamydial cervicitis) as well as by endogenous RTIs (bacterial
vaginosis and candidiasis).
The syndromic approach to case management implies that all major likely
aetiological causes of the presenting syndrome are treated simultaneously at
the place and time of first contact of the patient with the health sector. This
approach has been promoted by the World Health Organization for more
than a decade (WHO 1991).
Advantages of syndromic STI/RTI case management
Delays in the initiation of treatment are avoided, as patients do not need to
wait for laboratory results. Secondly, because all major possible causes of
STI/RTI syndromes are covered, cure is usually achieved early on. These
advantages are important from a public health perspective: onward
transmission is reduced, complications are prevented, chents are satisfied and
their confidence in the health system strengthened.
The increased costs due to overtreatment of aetiological agents (that arc not
present in a particular patient) are outweighed by savings on laboratory costs.
In a study of 1500 hypothetical STI patients with different syndromes using
decision-theory analysis, it has been demonstrated that both clinical and
laboratory based case management would cost two to three times as much as
the syndromic based approach (WHO 1993).
The treatment of STIs can be standardised with the help of algorithms, thus
enabling paramedical staff to treat STIs effectively in areas where physicians
are not available. WHO has published a complete set of syndromic
management algorithms and recommendations for the selection of drugs
(WHO 2001). Syndromic case management thus allows STI treatment services
to be integrated within the existing primary care system. The validity and the
operational feasibility of this approach and its cost-effectiveness in reducing
new HIV infection has been demonstrated in studies in Asia and elsewhere
(Djajakusumah et al 1998, Hong et al 2002, Chilongozi et al 1996, Grosskurth
et al 2000ii).
The effectiveness of specific algorithms depends on the correct choice of
drugs to be included in the algorithms. WHO has emphasised that the
39
MODULE 8
recommended algorithms should not be applied blindly but have to be
adapted to the specific local epidemiological and antimicrobial sensitivity
pattern (WHO 2001). It is therefore essential that countries monitor these
patterns and that algorithms are constructed that are based on sound
surveillance data. Each country should therefore have at least one reference
clinic and laboratory that have access to primary care STI/RTI patients, and
large countries require more than one such sentinel site. Unfortunately this
essential requisite is often lacking.
A study conducted at rural child health/family planning Hinicq in
Bangladesh has recently demonstrated the importance of this principle.
Women who presented with vaginal discharge were examined to identify the
causative agents of their complaints. Only about 30% of the 320 participating
women had detectable infections, most of which were caused by bacterial
vaginosis and candidiasis. Cervical infections due to Neisseria gonorrhoeae
and Chlamydia trachomatis were found in only 3 women. The application of
the unadapted WHO algorithm that is presently in use in Bangladesh would
lead to a high rate of overtreatment, and almost 90% of programme costs
would be spent on uninfected women. In addition, women diagnosed as
having an STI' are potentially exposed to matrimonial conflicts or even
violence (Hawkes et al 1999). Clearly, local adaptation of tire algorithm is
required, and in this particular case should take other causes for abnormal
vaginal discharge such as potential side-effects of contraceptive use into
consideration.
Disadvantages of the syndromic approach
Patients are frequently treated for infections which they do not have, thus
exposing them to possible side effects unnecessarily.
Not rarely, physicians who are familiar with the classical diagnostic principle
whereby treatment should always be based on a precise diagnosis, have
difficulties in accepting a method which they perceive as 'unscientific'
(Kumar et al 1995) or third world medicine'. However, few procedures
recommended in the context of disease management in developing countries
are based on so much careful research as the syndromic management of STIs
(Chilongoti et al 1996, Dallabetta et al 1998, Harrison et al 2000, Mayaud et al
1997, Grosskurlh el al 2000ii).
The syndromic management of vaginal infections has generally worked very
well. The approach has occasionally been criticised because vaginal discharge
often reappears within some months following initial improvement.
However, this problem does usually not originate from the kind of diagnostic
approach used, but from the high recurrence rate of bacterial vaginosis.
40
MODULE 8
Between 50% and 70% of patients with proven and appropriately treated
actenal vaginosis experience recurrence of symptoms (Boris et al 1997).
The main problem, however, lies in the management of cervical infections due
to Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). Because NG
ial
m°St1danSerous
agents of the female reproductive
.
.
bCfaUSe *ey occasionally present as vaginal discharge, their
treatment is often mcluded in algorithms for the management of the vaginal
discharge syndrome.
Unfortunately, these infections are usmally
asymptomatic, and seem to cause clinical symptoms in less than 15%
( orenromp et al 2002). Such algorithms have a high sensitivity because all
genume cervical infections will be treated, but a very6 low specificity, as many
omen will be treated unnecessarily; for example 97% in a study from
Bangladesh (Bogaerts et al 1999). On the other hand, the sensitivity wCuld be
zero if the treatment of NG and CT were not included in the algorithm.
An attempt to overcome this problem has been made through the
introduction of a risk assessment step into algorithms for the management of
the vaginal discharge syndrome, hoping that this would increase the
algorithms specificity for NG and CT infection without losing much
sensitivity (Mayaud et al 1998, WHO 2001). The risk assessment refers to
parameters known to be associated with an increased risk of cervical
in echon. Queshons are for example asked about the age of the patient (e g
less than 21 years), about the marital status (unmarried; new partner in the
previous three months), about the number of partners during the recent past
recent use of condoms, and whether the partner has himself a discharge or
u cer The validity of this approach has been evaluated in a variety of settings
ut the results are not at all encouraging, unfortunately. Whilst its specificity
of this approach is often higher than 90%, its sensitivity in detecting cervical
infections ranged only from 5% to 46% in studies from India, Myanmar and
anzama (Mayaud et al 1998; Vishwanath et al 2000; Department of Health
Myanmar and I opulation Council, Thailand, 2002). As can be imagined the
s ategy is particularly ineffective and leads to much overtrea^tment in
populations with low prevalences of cervical infections such as that in the
study from Bangladesh mentioned above (Hawkes et al 1999).
During a recent technical meeting at WHO it has therefore been decided to
revise the existing recommendations for the case management of vamnal
^charge, risk assessment to identify women with cervical infections as part
of the management of vaginal discharge should in future only be used in
populations with a proven high prevalence of NG and CT infections. The
algorithms for vaginal discharge should focus on vaginal infections.
41
MODULE 8
STIs- agents and symptoms
_____ Etiological agent_____ Common symptom
Herpes simplex virus Vesicles, genital ulcer
Type 2__________________
Genital ulcer, bubo,
Treponema pallidum
Syphilis
condylomata and skin
rash.. .................................
Genital ulcer, bubo
Haemophilus
ducreyii
Chancroid__________
Chlamydia trachomatis Genital ulcer, bubo
^ymphogranuloma
/LI-3 serovars)_________
venereum___________
Genital ulcer
Calymmatobacterium
Donovanosis
granulomatis__________
granuloma inguinale
In men: discharge per
Neisseria gonorrhoeae
Gonorrhoea
urethra, dysuria, scrotal
swelling.
In women: often
asymptomatic,
sometimes cervical
mucopus presenting as
vaginal discharge.
Vaginal discharge
Gardnerella vaginalis
Bacterial vaginosis
Bacteriodes sp.________
Chlamydial genital tract Chlamydia trachomatis* In men: discharge per
urethra, dysuria, scrotal
infection
swelling
In women: often
asymptomatic,
sometimes cervical
mucopus presenting as
vaginal discharge
In women: vaginal
Trichomonas vaginalis
Trichomoniasis
discharge
In men: urethral
discharge, dysuria______
In women: Vaginal
Candida albicans
Vulvovaginal
discharge
candidiasis
In men: Candidal
balanitis'
Lower abdominal pain
Neisseria gonorrheae
Pelvic inflammatory
or
tenderness
Chlamydia trachomatis
disease
Vaginal anaerobes
*Other less common agents of NGU are Ureaplasma urealyticum,
Mycoplasma genitahum
_________ STI
Genital herpes
42
MODULE 8
Public health importance of STIs and the STI/IITV co-factor effect
Heiner Grosskurth, Gurumurthy Rangaiyan
Sexually transmitted infections (STIs) represent a major public
health problem in developing countries. Nearly 150 million sexually
transmitted infections occur annually in Southeast Asian countries.
According to the World Development Report 1993, the burden of
disease in women of child bearing age caused by STIs (without HIV
infection) and RTIs is the second highest of all groups of diseases,
surpassed only by maternity related disorders. It is their
complications and long term consequences rather than the acute
infections that make STIs such an important public health problem
for women and their offspring: acute and chronic pelvic
inflammatory disease, infertility, puerperal sepsis, ectopic
pregnancy, miscarriage, stillbirth, preterm delivery, low
birthweight and severe congenital infections.
However, the public health importance of STIs has risen even more
since it is known that STIs enhance the sexual transmission of HIV
infection.
At the individual level, STIs increase the susceptibility of HIV
negative individuals for HIV infection because they interrupt the
integrity of the genital epithelium and because they attract
inflammatory cells that in turn increase access of HIV to CD4
receptors. Genital ulcers caused by syphilis, chancroid and genital
herpes, but also gonorrhoea, chlamydial infection and
trichomoniasis are all known to increase HIV susceptibility. There is
some evidence that this may also be the case for bacterial vaginosis.
STIs also increase the infectiousness of HIV-positive persons. The
concentration of HIV in semen has been found to be six times
higher among HIV-positive men who have urethritis compared to
those who have not. Similarly, HIV shedding is increased in HIV
infected women who suffer from gonococcal infection of the cervix,
for example due to gonorrhoea. HIV can also be detected in genital
ulcers. It has been hypothesised that STIs upregulate the viral load
of HIV in the blood, which in turn enhances the concentration of
HIV in genital fluids.
Most epidemiological studies that investigated the cofactor effect of
STIs on HIV transmission reported relative risks in the order of 2 to
8, suggesting an up to 8-fold increased risk of HIV acquisition in the
presence of STIs (Fleming and Wasserheit 1999). However, such
43
MODULE 8
studies underestimate the per exposure risk of HIV transmission in
the presence of STIs. For example for genital ulcers, data are
consistent with a 10 - 50 fold increase in the probability for male to
female HIV transmission per sexual act, and a 50 - 300 fold increase
for female to male transmission.
At the population level, STIs seem to be one of the key factors that
drive the HIV pandemic in developing countries. The proportion of
new HIV infections in a population due to bacterial STIs is
particularly high in early and moderately advanced HIV epidemics
when HIV prevalences are still rising. There is evidence from
computer based simulation studies that the HIV epidemic could not
have taken off in some countries without the facilitation by other
STIs. However, once the epidemic approaches a generalised stage,
the contribution of STIs to the epidemic seems to steadily decrease.
Thereafter, most transmissions occur within stable partnerships
even in the absence of STIs, and viral load becomes the main
determinant of HIV transmission.
The effective control of STIs in early HIV epidemics, particularly
among high risk behaviour groups and bridging populations where
STI prevalences are high, has the potential to prevent the
generalisation of these epidemics, and is therefore of paramount
importance. This is precisely the epidemiological situation that
currently still prevails in most parts of Asia, including India.
44
MODULE 8
Genital Ulcer Syndrome
[Adapted from _(WHO) Guidelines for Management of Sexually
Transmitted
Infection. WHO/HIV_AIDS/2001.01WHO/RHR/01.10.]
I he relative prevalence of causative organisms for Genital ulcer syndrome
varies in different parts of the world and may change over time. Clinical
differential diagnosis of genital ulcers is inaccurate, particularly in settings
where several aetiologies are common. Clinical manifestations and patterns of
Genital ulcer syndrome may be further altered in the presence of HIV
infection. After examination to confirm the presence of genital ulceration,
treatment appropriate to local aetiologies and antibiotic sensitivity patterns
should be given. For example, in areas where both syphilis and chancroid are
prevalent, patients with genital ulcers should be treated for both conditions.
In many parts of the world, genital herpes is the most frequent cause of
Genital ulcer syndrome. Where HIV infection is prevalent, an increasing
proportion of cases of Genital ulcer syndrome is likely to harbour herpes
simplex virus. Laboratory-assisted differential diagnosis is rarely helpful at
the initial visit, as mixed infections are common. In addition, in areas of high
syphilis prevalence, a reactive serological test may reflect a previous infection
and give a misleading picture of the patient's present condition. Not all,
genital ulcers are caused by sexually transmitted infections and oilier causes
include traumatic ulcer, tuberculosis, amoebiasis, aphthous ulcer, erythema
multiforme and rarely malignancy.
HIV testing should be performed in the management of patients who have
genital ulcers. Since hepatitis B can also bej also sexually acquired, a screening
HBsAg should also be done.
lhe clinical picture of ulcer disease may be severe and prolonged with I 1IV
infection requiring longer course of therapy. Recurrence rates after treatment
may be higher. The presence of ulcerative genital disease increases both nsk
of acquiring and transmitting HIV infection. Careful clinical follow up is
required to ensure cure of the ulcer disease and prevention of recurrence.
45
MODULE »
GENITAL ULCER SYNDROME
Disease
Agent
Clinical
features
Treatment
Chancroid
Haemophilus
ducreyi
Ulcers multiple,
painful,
irregular with
undermined
edges, and not
indurated (soft
chancre).
Unilateral
painful bubo
(Suppuration
may occur).
Erythromycin
500 mg Q1D for
7 days.
OR
Ciprofloxacin
500 mg stat.
OR
Ceftriaxone 250
mg
intramuscularly
(IM) in a single
dose.
Granuloma
Inguinale
(Donovanosis)
Calymmatobacterium
granulomatis
Genital herpes
lymphgranuloma
venereum (LGV)
Syphilis
Herpes
simplex
type 2 and 1
(1 ISV-2 and HSV1)
Multiple painful
grouped vesicles;
vesicles ulcerate
and coalesce
Chlamydia
trachomatis
serovars LI, L2
and L3
Transient ulcer
Treponema
pallidum
No regional
lymphadenopathy
Bilateral
adenopathy in
primary infection
Recurrent herpes
genitalis common
Unilateral tender
inguinal
adenopathy
(Groove sign seen
in 20% of patients)
Firm
bilateral
adenopathy
Doxycycline 100 mg
orally twice a day for
at least 21 days.
OR
Trimethoprim
sulfamethoxazole one
double-strength
(800mg/160mg)
tablet orally twice a
day for at least
3 weeks.
OR
Azithromycin 1 g
orally in a single
dose.
Primary:
Acyclovir 400 mg
orally three times
a day for 7-10
Aspiration of
bubo*.
Doxycycline 100
mg orally twice a
day for 14 days.
Alternative
Regimen:
Fry thromycin
base 500 mg orally
four times a day
for 14 days.
Benzathine
penicillin G,
2.4 million
units IM.
Penicillin
allergy:**
Tetracycline,
500 mg RO,
four times
daily, for 15
days.
(OR)
Doxycycline,
100 mg PO,
twice daily
for 15 days.
Painless, progressive
ulcer ("beefy red
appearance")
days.
OR
Acyclovir 200 mg
orally five limes a
day for 7-10 days.
Recurrent Herpes:
Initiate treatment
< 48 hours of
onset for 5 days
Suppressive
therapy:
(>6 recurrences
per year)
Acyclovir 400 mg
orally twice a day
------------ -—------------tor
for a tew
few years.
*lf in doubt about the underlying cause, buboes must not be incised and drained but should
be aspirated with the needle inserted through healthy tissue.
** In pregnant women allergic to penicillin desensitise to Penicillin.
Painless
single ulcer
indurated
with clean
base.
16
MODULE 8
Inguinal bubo
[Adapted from —(WHO) Guidelines for Management of Sexually Transmitted
Infection. WHO/HIV_AIDS/2001.01WHO/RHR/01.10.]
Inguinal and femoral buboes arc localised enlargements of the lymph nodes
in the groin area, which are painful and may be fluctuant. They are frequently
associated with lymphogranuloma venereum and chancroid. In many cases of
chancroid an associated genital ulcer is visible, but occasionally may not be.
Non-sexually transmitted local and systemic infections (e.g. infections of the
lower limb) can also cause swelling of inguinal lymph nodes.
See Lymphgranuloma venereum and Chancroid (page 45).
Vaginal discharge
[Adapted from __(WHO) Guidelines for Management of Sexually Transmitted
Infection. WHO/HIV_AIDS/2001.01WHO/RHR/01.10.]
A spontaneous complaint of abnormal vaginal discharge (abnormal in terms
of quantity colour or odour) is most commonly due to a vaginal infection.
Rarely, it may be the result of muco-purulent STI-related cervicitis. T.
vaginalis, C. albicans and bacterial vaginosis are the commonest causes of
vaginal infection and N. gonorrhoeae and C .trachomatis cause cervical infection.
The clinical detection of cervical infection is difficult because a large
proportion of women with gonococcal or chlamydial cervical infection are
asymptomatic. The symptom of abnormal vaginal discharge is highly
indicative of vaginal infection, but poorly predictive for cervical infection.
Thus, all women presenting with vaginal discharge should receive treatment
for trichomoniasis and bacterial vaginosis. Among women presenting with
discharge, one can attempt to identify those with an increased likelihood of
being infected with N. gonorrhoeae and/or C. trachomatis. Microscopy adds
little to the diagnosis of cervical infection and is not recommended. To
identify women at greater risk of cervical infection, an assessment of a
woman's risk status is useful, especially when risk factors are adapted to the
local situation. Women who are positive on risk assessment, have a higher
likelihood of cervical infection than those who are risk negative. Women with
vaginal discharge and a positive risk assessment could therefore be offered
treatment for gonococcal and chlamydia cervicitis. Where resources permit,
one could consider the use of laboratory tests to screen women with vaginal
discharge including saline mount. Gram stain and KOH preparation. Such
screening could be applied to all women with discharge or selectively to those
with discharge and a positive risk assessment Most patients with Chlamydia
and Gonococcal infection are asymptomatic and require screening and
treatment. Treatment of both these agents does not differ in HIV positive
individuals.
47
MODULE 8
________ VAGINAL DISCHARGE
Candidial vaginitis
Trichomonas
vaginitis
Etiology
Bacterial
vaginosis
Candida albicans and
other Candida sp.
Trichomonas
Vaginalis
Gardnerella
vaginalis,
anaerobic
bacteria.
Mycoplasma
genitalium
Vaginal discharge,
vulval itching, burning
Vaginal
discharge
Malodorous,
Discharge
Discharge
Curdy white discharge
Profuse
Yellow frothy
Discharge
White or grey
Homogenous
discharge
Genital
examination
Erythema of introitus
and vaginal wall,
vulvar dermatitis
Erythema of
vagina
Strawberry
cervix
None
Microscopy.
KOH - hyphae seen
Motile
Trichomonas
vaginalis on wet
mount
Treatment
Miconazole or
Clotrimazole pessaries
daily for 3 days.
Or
Fluconazole 150 mg
stat.
Clue cells
(squamous cells
covered by
bacterial rods) on
wet mount______
Metronidazole*
400 mg tid for 7
days or
Metronidazole 2
G stat.**
Clinical
Features
Symptoms
Metronidazole* 2
gm stat.
Tinidazole 2 G
stat or
Metronidazole
400 mg tid for 7
days.___________
* Patients taking the imidazoles should be cautioned against taking alcohol for upto 24 hours
after taking the last dose.
** Treatment of sex partner in bacteria! vaginosis is not indicated.
Patients with vaginal discharge need to be treated for Gonorrhoea and Chlamydia infection if
risk assessment is positive or if there is mucopurulent cervicitis.
Gonorrhoea - T. Ciprofloxacin 500 mg stat
Chlamydial infection - Doxycycline 100 mg BD for 7 days.
48
MODULE 8
Urethral Discharge
[Adapted from __(WH0) Guidelines for Management of Sexually Transmitted
Infection. WHO/HIV_AIDS/2001.01WHO/RHR/01.10.]
Male patients complaining of urethral discharge and/or dysuria should be
examined for evidence of discharge. If none is seen, the urethra should be
gently massaged from the ventral part of the penis towards the meatus. If
microscopy is available, examination of the urethral smear may show an
increased number of polymorphonuclear leukocytes and a gram stain may
demonstrate the presence of gonococci. In the male, more than 5
polymorphonuclear leukocytes per high power field (x 1000) are indicative of
urethritis. If the patient complains of dysuria and there is no discharge on
examination, a positive leucocyte esterase test or > 10 PMNs/HPF of first
voided urine or after holding urine for 4 hours also confirms the diagnosis of
urethritis. The major pathogens causing urethral discharge are N. gonorrhoeae
and Chlamydia trachomatis (C. trachomatis). In the syndromic management,
treatment of a patient with urethral discharge should adequately cover these
two organisms.
Persistent or recurrent symptoms of urethritis may be due to drug resistance,
poor compliance or re-infection. In some cases there may be infection with
Trichomonas vaginalis (TV). There is new evidence suggesting high prevalence
of TV in men with urethral discharge in some geographical settings. Where
symptoms persist or recur after adequate treatment for gonorrhoea and
chlamydia in index patient and partner(s), the patient should be treated for
TV. If the symptoms still persist at follow up the patient must be referred.
Patients who have urethritis and also are infected with HIV should receive the
same treatment regimen as those who are HIV-negative.______
Non-gonococcal urethritis
Gonorrhoea
Chlamydia trachomatis
Neisseria gonorrhea
Gradual
Mild
Abrupt
Severe
Mucoid
Less
Purulent
More
Microscopy.
Gram negative intra-cellular diplococci
Urethral smear
> 5 PMNs/HPF
Treatment
Azithromycin 1 g orally in a single
dose
OR
Doxycycline 100 mg orally twice a day
for 7 days.
Alternative Regimens
Erythromycin base 500 mg orally four
times a day for 7 days
Ciprofloxacin 500 mg stat
Or
Azithromycin 2 G stat
Or Ceftriaxone 250 mg IM
stat
Etiology
Clinical Features
Onset
Dysuria
Discharge
Quality
Quantity
49
MODULE 8
Scrotal swelling
[Adapted from _(WHO) Guidelines for Management of Sexually
Transmitted
Infection. WHO/HIV_AIDS/2001.01WHO/RHR/01.10.]
Inflammation of the epididymis (epididymitis) usually manifests itself by
acute onset of unilateral testicular pain and swelling, often with tenderness of
the epididymis and vas deferens and occasionally with erythema and oedema
of the overlying skin. In men under 35 years of age, this is more frequently
due to sexually transmitted organisms than in those over 35 years of age.
When the epididymitis is accompanied by urethral discharge, it should be
presumed to be of sexually transmitted origin, commonly gonococcal and/or
chlamydial in nature. The adjacent testis is often also inflamed (orchitis),
giving rise to epididymo-orchitis. In older men, where there may have been
no risk of a sexually transmitted infection, other general infections may be
responsible, for example, Escherichia coli, Klebsiella sp. or Pseudomonas
aeruginosa. A tuberculous orchitis, generally accompanied by an epididymitis,
is always secondary to lesions elsewhere, especially in the lungs or bones. It is
important to consider other non-infectious causes of scrotal swelling, such as
trauma, testicular torsion and tumour. Filarial lymphadenitis is another
prevalent cause of scrotal swelling. Testicular torsion, which should be
suspected when onset of scrotal pain is sudden, is a surgical emergency that
needs urgent referral. If not effectively treated, STI-related epididymitis may
lead to infertility.
J
Treatment
Treatment of Gonorrhoea- T. Ciprofloxacin 500 mg stat or Inj. Ceftriaxone 250
mg IM stat
Treatment of Chlamydia- T. Doxycycline 100 mg bd for 10 days.
50
MODULE 8
Lower abdominal pain
[Adapted from _frVHO) Guidelines for Management of Sexually Transmitted
Infection. ^HO/HIV_AIDS/2001.01WHO/RHR/01.10.]
AH sexually active women presenting with lower abdominal pain should be
refully evaluated for the presence of salpingitis and/or endometritis pelvrc inflammatory disease (PID). In addition, routine bimanual and
abdommal exammations should be carried out on all women with a suspected
I smce some women with PID or endometritis will not complain of lower
abdominal pain. Women with endometritis may present with complaints of
vaginal discharge and/or bleeding and/or uterine tenderness on pelvic
exammation. Symptoms suggestive of PID include abdominal pain
dyspareuma, vaginal discharge, menometrorrhagia, dysuria, pain associated
with menses, fever, and sometimes nausea and vomiting.
PID is difficult to diagnose because clinical manifestations are varied PID
becomes highly probable when one or more of the above symptoms are seen
m a woman with adnexal tenderness, evidence of lower genital tract infection,
and cervical motion tenderness. Enlargement or induration of one or both
fallopian tubes, a tender pelvic mass, and direct or rebound tenderness may
also be present. The patient's temperature may be elevated but is normal in
many cases. In general, clinicians should err on the side of over-diagnosing
and treating suspected cases. Hospitalisation of patients with acute pelvic
inflammatory disease should be seriiously
’ considered
- when: the diagnosis is
uncertain; surgical emergencies suchi as appendicitis and ectopic pregnancy
can not be excluded; a pelvic abscess is suspected; severe illness precludes
management on an outpatient basis; the patient is pregnant; the patient is
unable to follow or tolerate an outpatient regimen; or the patient has failed to
respond to outpatient therapy. Many experts recommend that all patients
with acute PID should be admitted to hospital for treatment. Etiological
agents include N. gonorrhoeae, C. trachomatis, anaerobic bacteria (Bacteroides
spp. And Gram-positive cocci). Facultative Gram-negative rods and
Mycoplasma genitalium have also been implicated. As it is impossible to
differentiate between these clinically, and a precise microbiological diagnosis
is
icu t, e treatment regimens must be effective against this broad range
of pathogens. The regimens recommended in the syndromic case
management for abdominal pain are based on this principle.
51
MODULE 8
Secondary syphilis
Clinical findings:
Rash: macular, papular, pustular, combination; usually nonpruritic; may
involve palms and soles in 60%. Generalized lymphadenopathy: 86%. Mucous
patches (5-30%): flat patches involving mouth, pharynx, larynx, genitals.
Condylomata lata (5-25%): heaped, wart-like, papules that enlarge in warm
intertriginous areas (gluteal folds, nasolabial folds, axillae, between toes,
under breasts, perineum and peri-anal etc.); teaming with treponemes and are
highly infectious. Constitutional symptoms: malaise, headache, pharyngitis,
slight fever, myalgia; liver and kidney involvement, patchy alopecia.
Serologic Tests for Syphillis
Adapted from: (CDC) Sexually Transmitted Diseases Treatment Guidelines 2002
MMWR 2002; 51:1-80.
a)
VDRL and RPR
Titers usually correlate with disease activity; resj llts-should be reported
quantitatively. A fourfold change in titer, (e.g., frorisr 1:16 to 1:4 or from 1:8 to
1:32) is necessary to demonstrate clinical response to treatment using the
same testing method and by the same laboratory. Results from the two tests
cannot be compared because RPR titers are slightly higher than VDRL titers.
Titers usually become nonreactive with time after treatment; antibodies can
persist at a low titer for a long period of time, sometimes for the life of the
patient. This response is referred to as the "serofast reaction/' VDRL and RPR
are non-specific tests that may sometimes give false-positive results and
ideally should be confirmed using a treponemal test.
b) Treponemal tests
Fluorescent treponemal antibody absorbed[FTA-ABS], T pallidum
haemagglutination [TPHA] will have reactive tests for the remainder of their
lives, regardless of treatment or disease activity. Antibody titers correlate
poorly with disease activity and should not be used to assess treatment
response.
c) HIV infection
Some HIV-infected patients can have atypical serolggic ,test .results (unusually
high, unusually low, or fluctuating titers). When serologic tests and clinical
syndromes suggestive of early syphilis do not correspond with one another,
use of other tests (e.g., biopsy and direct microscopy) should be considered.
However, for most HIV-infected patients, serologic tests are accurate and
reliable for the diagnosis of syphilis and for following the response to
treatment.
52
MODULE 8
Treatment of Syhillis
Secondary syphilis:
Benzathine penicillin G, 2.4 million units IM.
Penicillin allergic: Tetracycline, 500 mg PO, for 4 weeks. (OR)
Doxycycline, 100 mg PO, twice daily for 4 weeks.
Pregnant women sensitive to penicillin should be treated with:
Erythromycin 500 mg QID for 15 days.
Follow-Up:
1. Early syphilis: quantitative VDRL or RPR at 6,12 months.
2. Late latent, tertiary: quantitative VDRL or RPR at 3, 6, 12, 18, 24 months.
3. Neurosyphilis: serological testing as above, with repeat CSF examination at
six-month intervals for 3 years or until normal.
4. HIV-infected patients: 3, 6, 9,12 months for early syphilis, adding 18 and 24
months for syphilis of >1 year duration.
53
MODULE 8
OTHER STIs
1. Genital Warts
Etiology: Human Papilloma virus
Clinical findings: Warty excresences in the following areas:
Men- penis, scrotum, urethral meatus, perianal region
Women- Introitus, vulva, perineum, cervix and vagina
HIV infection:
The warts tend to become very large and there is risk of malignant
transformation into squamous cell carcinoma
TreatmentPodophyllin application
80% TCA or MCA
Curretage, cryosurgery, electrocautery and excision
If complete clearance of warts is not achieved in a period of 6 weeks, it is
advised to use a different treatment modality or referral to a specialist is
recommended.
2. Molluscum conatgiosum
Etiology: Pox virus family.
Clinical findings: Flesh coloured smooth, firm and dome shaped papules with
central umbilication.
In HIV infection they develop widespread lesions over trunk and the face and
giant lesions tend to occur.
Treatment:
Needling, cryotherapy, cautery, TCA, Silver nitrate application
54
MODULE 8
REFERENCES
1 . (APAC) Prevention and Control Quality STD Care IModule
' ’ ’ for
' private
practitioners. AIDS Prevention and Control Project, Voluntary Health
Services 1998.
2. (CDC) Sexually Transmitted Diseases Treatment Guidehnes 2002
A4A4WR 2002; 51:1-80.
3. (WHO) Guidelines for Management of Sexually Transmitted Infection.
WHO/HIV_AIDS/2001.01WHO/RHR/01.10.
4. (NACO) Practical considerations in diagnosis and treatment of STDs.
5. (Grosskurth H, Rangaiyan G) The management and control of sexually
transmitted infection, and their implications for AIDS control in South
east Asia (to be published in Journal of Health Management).
FURTHER READING
1. Hawkes S, Santhya K.G. Diverse realities: sexually transmitted
infections and HIV in India. Sex. Transm. Infect. 2002; 78 (Suppl I): 13139.
2. Rodrigues JJ, Mehendale S.M et al. Risk factors for HIV infection in
people attending clinics for sexually transmitted diseases in India. BMJ
1995; 311:283-286.
3. Pedhambkar R.B, Pedhambkar B.S, Kura M.M. Study of risk factors
associated with HIV seropositivity in STIs patients at Mumbai, India.
Sexually Transmitted Infections 2001; 77:388-389.
4. Thomas K, Thyagarajan S.P et al. Community based prevalence of
sexually transmitted diseases and human immunodeficiency virus
infection in Tamil Nadu: a probability proportional to size cluster
survey. National Medical Journal of India 2002; 15:135-40.
5. Grosskurth H, Gray R et al. Control of sexually transmitted diseases for
HIV-1 prevention: understanding the implications of the Mwanza and
Rakai trials. Lancet 2000; 355:1981-7.
We would like to acknowledge the contributions of Drs. Heiner Grosskurth and
Gurumurthy Rangaiyan who helped in reviewing the module.
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