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青少年性病與愛滋病之 診斷與治療

青少年性病與愛滋病之 診斷與治療. 衛生署 疾病管制局 中區傳染病防治醫療網 王任賢 指揮官. HIV/AIDS. Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome. What Is HIV/AIDS?. Acquired immunodeficiency syndrome (AIDS) is caused by the human immunodeficiency virus (HIV).

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青少年性病與愛滋病之 診斷與治療

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  1. 青少年性病與愛滋病之診斷與治療 衛生署 疾病管制局 中區傳染病防治醫療網 王任賢 指揮官

  2. HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

  3. What Is HIV/AIDS? • Acquired immunodeficiency syndrome (AIDS) is caused by the human immunodeficiency virus (HIV). • HIV attacks and destroys white blood cells, causing a defect in the body’s immune system. • The immune system of an HIV-infected person becomes so weakened that it cannot protect itself from serious infections. When this happens, the person clinically has AIDS. • AIDS may manifest as early as 2 years or as late as 10 years after infection with HIV.

  4. Clinical Spectrum of AIDS • Group 1: Acute infection 0-3 weeks • Window period: Seroconversion 3-12 weeks • Group 2: Asymptomatic infection 0-10 years • Group 3: Persistent generalized LAP • Group 4: Other HIV-related diseases • Constitutional diseases • Neurological disorders • Opportunistic infections • Secondary neoplasms • Other conditions

  5. 107 106 105 104 103 102 Natural History of HIV Infection Without the Use of Antiretroviral Tx Primary Infection Death + Acute HIV syndrome Wide dissemination of virus Seeding of lymphoid organs 1200 1100 1000 900 800 700 600 500 400 300 200 100 0 OpportunisticDiseases Clinical latency HIV/RNA Copies per ml Plasma Constitutional Symptoms CD4 + T Lymphocyte Count (cells/mmm3) 0 3 6 9 12 1 2 3 4 5 6 7 8 9 10 11 Years Weeks Source: Fauci, A., Pantaleo, D., Stanley S., Weismann, D. Annals of Internal Medicine 124: 6754-3, 1996

  6. Signs and Symptoms of AIDS • Fever of unknown origin • Enlarged lymph glands • Skin rashes and cough • Persistent diarrhea • Severe weight loss • Skin lesions • Loss of appetite and fatigue

  7. Signs and Symptoms in HIV Disease * n=314 J Palliative Care, 1994: 10(2): 95.

  8. Diagnosis of HIV Mainly serological • Through antibody testing with ELISA; if positive, confirmation by Western Blot • Culture of blood and tissues • RT-PCR：mainly for follow up

  9. HIV test and counseling

  10. Treatment of HIV Infected Patients • At present, no drug or therapy can cure AIDS • Availability of anti-AIDS vaccines appears unlikely in the near future • A combination of three antiretrovirals (ARVs) is the gold standard for treatment • ARVs are not universally available, are very expensive and must be administered correctly

  11. 性病之診斷分類及治療

  12. 性病之分類 尿道炎及子宮頸炎 陰部潰瘍 鼠蹊淋巴腫 陰部新生物 全身性感染

  13. 男性尿道炎 症狀 分泌物、小便疼痛、尿道口癢 病原菌 Neisseria gonorrhoeae Chlamydia trachomatis Ureaplasma urealyticum ? Herpes simplex virus Trichomonas vaginalis 鑑別診斷 臨床症狀、潛伏期、 實驗室診斷

  14. 確認男性尿道炎 Urethral Gram-stained smear> 5 PMNs/1,000X Subjective urethritis symptoms+ objective urethral discharge Only subjective urethritis symptomsavoid urination 4-8 hr & reexamine in 7 days First 5-10 CC of voided urine + centrifugeGram-stained sediment > 15 PMNs/500X

  15. 尿道炎病患檢查 Gram’s stain Culture for N. gonorrhoeae Culture for C. trachomatis

  16. Culture for N. gonorrhoeae Specimen for culture male: urethral discharge female: cervical discharge Sampling and transportation cotton in plastic swab & candle jar Media for growth chocolate agar modified Thayer-Martin agar

  17. Culture for C. trachomatis Specimen for culture male: urethral swab female: swab of cervical cannel Sampling and transportation cotton in plastic swab SPG or 2SP in iced water Technique for culture shell vial technique

  18. 淋病 治療方式： Routine treatment ceftriaxone 125 mg IM cefixime 400 mg PO Disseminated gonococcal infection (DGI) ceftriaxone 1 gm IV qd until S/S improve + cefixime 400 mg PO bid for 10-14 days

  19. 淋病 • 通報定義 • 由醫師臨床診斷感染淋病，且符合實驗室診斷定義者。 • 實驗室診斷定義：由染色鏡檢或培養分離出淋菌雙球菌，或使用PCR或其他檢驗方式偵測出淋菌抗原或基因。 • 需1週內通報。

  20. 披衣菌尿道炎及子宮頸炎 治療方式： Routine treatment azithromycin 1 gm PO, single dose tetracycline 500 mg q6h for 7 days ofloxacin 300 mg PO bid for 7 days Pregnant women azithromycin 1 gm PO, single dose

  21. 尿道炎治療後症狀 若治療後，尿道炎症狀持續，該怎麼辦： 追出性伴侶，並給予治療 重新確認尿道炎的存在 若無尿道炎存在，只需加強病人信心即可 若仍有尿道炎存在，可給予metronidazole2 gm PO stat 慢性攝護腺炎 (不可能)

  22. 陰道分泌物之鑑別診斷 白帶 (bacterial vaginosis) high pH, Lactobacilli (-), Whiff test (+),fish odor, clue cell 念珠菌陰道炎 (Candida vaginitis) 糖尿病、懷孕、避孕藥、長期使用類固醇 陰道滴蟲症 (Trichomonas vaginitis) 淺綠色泡沫狀分泌物，奇癢無比 子宮頸炎

  23. 陰道分泌物之治療 白帶 metronidazole 500 mg PO bid for 7 days 念珠菌陰道炎 fluconazole 150 mg PO once 陰道滴蟲症 metronidazole 2 gm PO once 子宮頸炎 治療同男性尿道炎

  24. 陰部潰瘍 原因： Primary syphilis (chancer) Chancroid (Hemophilus ducreyi) Genital herpes Trauma

  25. 陰部潰瘍的鑑別診斷 鑑別診斷 外型，是否疼痛 病史 潛伏期 鼠蹊部淋巴腫 實驗室診斷

  26. Specimen preparation in darkfield examination Clean up lesion with saline Scrape lesion gently until exudation,avoid bleeding Squeeze out exudate & wipe off with slide Add a drop of saline Observe in darkfield microscope

  27. 梅毒之血清學診斷(1/2) 當血中VDRL(+)時： 若TPHA>1:80,代表現在或以前曾有梅毒 若TPHA<1:80,代表VDRL(+)非由梅毒造成 何種情況下表示梅毒仍有活性? 有明顯早期梅毒症狀，而血清反應呈陽性者 二次血清STS有四倍上升者 經BPN治療6個月後STS有四倍下降者 未經治療者，單次血清VDRL(+),TPHA>1:1280

  28. 梅毒之血清學診斷(2/2) 何種情況下表示梅毒已沒有活性? 經完整BPN治療，且沒再接觸梅毒病患者 經完整BPN治療，6月後STS並沒有4倍變動者 無症狀病患,STS維持低而穩定的效價時 若您對梅毒的活性有任何疑問時： 可給予病患BPN治療以觀測STS的變化，但在您尚未診斷出有活性梅毒前，請勿輕易向病患下診斷。

  29. 梅毒 治療方式： 感染梅毒一年以內 benzathine penicillin 2.4 MU IM once 感染梅毒一年以上，無侵犯中樞神經者 benzathine penicillin 2.4 MU IM qwk X 3 感染梅毒一年以上，有侵犯中樞神經者 aqu PCG 3 MU q4h IV for 10 days+ benzathine penicillin 2.4 MU IM qwk X 3

  30. 梅毒 • 通報範圍 • 活性梅毒通報定義：同時符合通報條件1+2或僅符合通報條件3者。 • 非活性梅毒通報定義：僅符合通報條件2者。

  31. 梅毒 • 通報條件 • 臨床症狀出現硬下疳或全身性梅毒紅疹等臨床症狀。 • 未曾接受梅毒治療或病史不清楚者，RPR（+）或VDRL（+），且TPHA=1：320以上(包括320)。 • 曾經接受梅毒治療者，VDRL價數上升四倍。 • 需1週內通報。

  32. 軟下疳 (chancroid) 潰瘍很痛，而且很髒 病原菌 Hemophilus ducreyi，極難培養 診斷 school of fish appearance in smear 病患多接觸過妓女 治療 azithromycin 1 gm PO once ceftriaxone 250 mg IM once

  33. Genital Herpes 會再發且不會好的病 藥物治療可縮短病變及疼痛時間 藥物沒法治癒此病

  34. 傳統陰部疱疹 治療方式： 初次發作 acyclovir 400 mg PO tid for 7-10 days 初次發作並侵犯到直腸或膀胱 acyclovir 400 mg PO 5/D for 7-10 days 嚴重的再發 acyclovir 400 mg PO tid for 5 days 預防性療法 acyclovir 400 mg PO bid for 1 year

  35. 鼠蹊肉芽腫 (lymphogranuloma venerum) 病原菌 Chlamydia trachomatis 單獨淋巴腫而沒有潰瘍，groove sign (+) 男：女=10：1 女性多以陰部水腫或瘺管表現 診斷 淋巴結抽取液培養，血清學檢查 治療 tetracycline 500 mg q6h for 3 weeks

  36. 菜花(anogenital warts) Condylomata acuminata Human papilloma virus Cauterization 30-50% bi- or trichloroacetic acidliquid nitrogen10% podophyllin resin1% podophyllotoxin (condylox)carbon dioxide laser

  37. Pelvic inflammatory disease Clinical diagnosis by exclusion of ectopic pregnancy and appendicitis Endogenous β-lactam/b-lactamase inhibitor Exogenous ceftriaxone + azithromycin Remove IUD

  38. 懇 請 賜 教

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