衛生署 疾病管制局 中區傳染病防治醫療網 王任賢 指揮官 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

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

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.

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

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 107 106 105 104 103 102 1200 1100 1000 900 800 700 600 500 400 300 200 100 Opportunistic Diseases Clinical latency Constitutional Symptoms HIV/RNA Copies per ml Plasma CD4 + T Lymphocyte Count (cells/mmm3) 0 3 6 9 12 1 2 3 4 5 6 7 8 9 10 11 Weeks Years Source: Fauci, A., Pantaleo, D., Stanley S., Weismann, D. Annals of Internal Medicine 124: 6754-3, 1996

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

Signs and Symptoms in HIV Disease Prevalence* Pain 52% Tiredness 50% Anxiety 40% Sleep disturbance 37% Mouth sore 33% Sadness 32% Weight loss 31% Nausea 28% Symptom Prevalence Fever 27% Cough Depression 24% Diarrhea Skin Problem Pruritus 23% Respiratory problem 22% Vomiting 20% * n=314 J Palliative Care, 1994: 10(2): 95.

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

HIV test and counseling

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

性病之診斷分類及治療

性病之分類 尿道炎及子宮頸炎 陰部潰瘍 鼠蹊淋巴腫 陰部新生物 全身性感染

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

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

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

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

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

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

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

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

尿道炎治療後症狀 若治療後，尿道炎症狀持續，該怎麼辦： 追出性伴侶，並給予治療 重新確認尿道炎的存在 若無尿道炎存在，只需加強病人信心即可 若仍有尿道炎存在，可給予metronidazole 2 gm PO stat 慢性攝護腺炎 (不可能)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

菜花(anogenital warts) Condylomata acuminata Human papilloma virus Cauterization 30-50% bi- or trichloroacetic acid liquid nitrogen 10% podophyllin resin 1% podophyllotoxin (condylox) carbon dioxide laser

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

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