HIV Urinary Tract Infection

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HIV Urinary Tract Infection Powered By Docstoc
					HIV
                        Retroviridae
+ RNA reverse transcribed to DNA, integrates into host cell,
transcribed by host then under viral control; replicates when
full-length RNA transcript made                 Other genes
                                    LTR                             LTR

Oncoviriniae                              gag   pol             env      AAAAAA
                                                      Complex retrovirus
Study of cancer genes
HTLV-1, HTLV-2—only human oncoviruses known; Tax and Rex proteins;
sexual/parenteral transmission; adult T-cell leukemia

Lentivirinae
HIV-1, HIV-2 cause AIDS by slowly destroying CD4+ T cells
Gag (p24), Pol, Env (gp120, gp41), Tat, Rev, Nef, Vif, Vpu
Development of opportunistic infections heralds onset of AIDS
(Mycobacterium, Cryptosporidium, Pneumocystis, Cryptococcus, CMV)
Follow CD4+ cell count, viral load to determine progress, effective therapy
Treat: RT inhibitors and protease inhibitors in combination—HAART
                                                                                                      Diploid Genome



           Envelope
           proteins



                                                   p24
Rectangular
nucleocapsid




Synthesizes dsDNA from RNA
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eibowitz 9/20
                    Reverse Transcriptase
                     Synthesizes dsDNA
                    from RNA



                    dsDNA
                    integrates into host
                    genome

www.hivafrica.org
www.hivafrica.org
HIV Diagnosis

Screen-ELISA (false +’s)
Confirm-Western Blot (false –’s)

Monitor-HIV PCR
HIV Immunity

             Mutations
• CCR5
   • Homozygous=immunity
   • Heterozygous=Slower course
• CXCR1
   Rapid progression to AIDS
Leibowitz 9/20
HIV Time Course

              Months
• 1-2 p24 Ag ↑ . CD4 lymphs ↓
• 3-6  Ab gp120,p24 ↑
               Years
• 3-10 p24 Ag↑ ↑. CD4 lymphs ↓ ↓ .
        Abs gp120,p24 ↓ ↓
Leibowitz 9/20
Opportunistic Infections
in Aids
• BacterialTB, M. avium

• ViralHSV, VZV, CMV, PML (JC virus)

• FungalCandida albicans, Crytptococcal
  meningititis, Histoplasmosis, Pneumocystis
  pneumonia

• ProtozoanToxoplasmosis, cryptosporidiosis
         Opportunistic Infection—
            Candida species
Infection arises from endogenous colonization of oral cavity,
Vagina, GI tract, rectum (80% individuals are colonized)
Upset of normal flora by antibiotics can result in infections;
Immunosuppression of any type
Cutaneous, mucocutaneous, chronic, systemic infections
Diagnosis: demonstration in 10% KOH prep, culture; germ
tube test for C. albicans
Cutaneous,mucocutaneous—topical
Systemic—amphotericin B, 5-fluoro-
cytosine, ketoconazole, fluconazole
         Systemic Infection—
       Histoplasma capsulatum
Acquired by inhalation; 500,000 in US annually
Endemic in Ohio, Mississippi, and lower Missouri
River valleys; found in birds (chickens, starlings) and bats
95% asymptomatic; 5% symptomatic (95%
nonspecific symptoms; 5% pneumonia [1% of these
develop systemic infection])
Diagnosis: tissue exam (small yeast in MF) and culture;
serology by CF or immunodiffusion for antibody response

                              Treat with amphotericin B
  Toxoplasma gondii—A Relative
         of Plasmodium
Incidence—Ubiquitous                  Spread
                                      Oocysts from cats to humans
Target organs                         Transplacentally
Lung, heart, lymphoid organs, CNS
Fetus—CNS, eyes                         Treatment
Immunosuppressed—CNS reactivation       Resolves in normal hosts
                                        Pyrimethamine-sulfadiazine
Diagnosis
Serology—Toxo IgG/IgM            Distinguishing characteristics
Tissue biopsy, fluids to
demonstrate trophs and cysts   Cyst packed
                               with
Tissue cell with
                               bradyzoites
trophozoites
(tachyzoites)
Prions
                   Prions
•   CJD-rapid progressive dementia
•   KURU
•   Scrapie –sheep
•   Mad cow Disease

• NO RNA/DNA---PROTEINS only
• Associated with spongiform encephalopathy
• N=α-helix Prions-β-pleated sheets
 HPV

• Types 16 & 18 

Cervical, penile, and anal cancers
Normal Flora
               Normal Flora
Skin   Staphylococcus epidermidis, Corynebacterium sp.

Nose   Staphylococcus aureus

Oropharynx      viridans streptococci, Neisseria sp.

Dental plaque Streptococcus mutans

Colon Bacteroides, Clostridium, Enterobacteriaceae (E. coli)

Vagina Lactobacillus, anaerobes of many types; E. coli, GBS

    Keeps out harmful bacteria by preventing colonization

         Helps maintain pH needed for barrier at site
Common Causes of
Pneumonia
      Lower Respiratory Infections
                  Community Acquired Pneumonia
   6 wk – 18 yr              18 yr – 40 yr                40 yr – 65yr
 Viruses, RSV              M. pneumoniae               S. pneumoniae
 M. pneumoniae             C. pneumoniae               H. influenzae
 C. pneumoniae             S. pneumoniae               Anaerobes
 S. pneumoniae                                         Viruses
                                                       M. pneumoniae
                        Special Problems
     >65 yr             Nosocomial—S. aureus, GNB, P. aeruginosa
S. pneumoniae           Immunocompromised—S. aureus, GNB, fungi,
Viruses, influenza      viruses, P. carinii w/ HIV
Anaerobes               Aspiration—anaerobes
H. influenzae           Alcoholic—S. pneumoniae, K. pneumoniae, S.
Gram-negative bacilli   aureus, L. pneumophila
                        Post viral— S. aureus, H. influenzae
                        Neonatal—Group B strep, E. coli, C. trachomatis
                        Atypcial– Mycoplasma, Legionella, Chlamydia
           Opportunistic Infection—
            Pneumocystis carinii
Infection of age and immunosuppression
Transmitted by droplet inhalation, close
contact
Pneumonitis, spreading from hilar areas
                                                Gomori’s methanamine
                                                silver stain
                                                Lung biopsy, 400X;
                                                courtesy TMSodeman

                           Treat with trimethoprim-sulfamethoxazole
                           or pentamidine (aerosol)
Immunofluorescent stain (MAb)
BAL,1000X; courtesy ASM
Causes of Meningitis
& CSF findings
                           Meningitis
0–6m       6m–6y                 6 y – 60 y         > 60 y
GBS        S. pneumoniae         N. meningitidis   S. pneumoniae
E. coli    N. meningitidis       Enteroviruses     Gram negative bacilli
Listeria   H. influenzae (B)     S. pneumoniae        Listeria
           Enteroviruses         HSV1

In AIDS: Cryptococcus neoformans, CMV, Toxoplasma gondii, JC virus

                          CSF Examination
     Organism       Pressure      Cells       Protein    Sugar
     Bacterial          ↑         ↑↑PMN          ↑         ↓
     Fungal/Tb          ↑          ↑lymphs       ↑         ↓
     Viral          Normal/↑       ↑lymphs    Normal     Normal
Osteomyelitis
           Osteomyelitis
         Assume S. aureus
• Most pplS. aureus
• Most in children
Sexually activeSeptic Arthritis,         N. gonorrhoeae (rare)

IV druge usersPseudomonas aeruginosa

Sickle CellSalmonella

Prosthetic replacementS. aureus, S epi

VertebralMycobacterium tb.
UTI’s
            Urinary Tract Infection
Cystitis / Lower urinary tract infection
  Dysuria, frequency, urgency, suprapubic pain, hematuria
  Ambulatory       E. coli                      50-80%
                   Staphylococcus saprophyticus 10-30% ♀sexually active
                   Klebsiella                    8-10%
                   Epidemiology ♀> ♂ 10:1

  Hospitalized (catheter-associated )
  E. coli, Proteus (associated w/stones), Klebsiella, P. aeruginosa, Serratia
  Long term care      P. aeruginosa, Proteus, Providencia, Serratia
Pyelonephritis / most ascending—same organisms
  Fever, chills, flank pain               Gynecologic abnormality
  Flow obstruction, kidney surgery        Diabetes, pregnancy, congenital,
  Catheterization                         Enlarged prostate in elderly ♂
UTI bugs
                  SSEEK PP
• Serratia marcescensred, nosocomial, drug resistant

• S. sapro2nd leading community-acquired UTI (sexually
  active women)

• E. coli#1 UTI, metallic green on EMB

• Enterobacter cloacaenosocomial, drug resistant

• Proteus mirabilisswarming, urease/struvite stones

• Pseudomonas aeruginosaBlue-green, fruity odor,
  nosocomial, drug resistant
Proteus-swarming
STD’s
     Sexually Transmitted Diseases
 ***Chlamydia trachomatis—urethritis, cervicitis, PID (subacute;
 salpingitis, endometritis; infertility; ectopic pregnancy) conjunctivitis
 Neisseria gonorrhoeae—urethritis, cervicitis, PID (acute; as for
 chlamydial PID), arthritis
 Treponema pallidum—syphilis
AIDS
HBV                 Vaginitis                    Chancroid-painful
                    Trichomonas vaginalis        Haemophilus ducreyi
   Vaginosis
   Greenish discharge
   Fishy odor           Genital herpes—HSV2/HSV1
   Nonpainful
   Clue cells present      Condyloma accuminata—HPV 6, 11
   Gardnerella vaginalis   Cervical dysplasia—HPV 16, 18
   Mobiluncus              Molluscum contagiosum--molluscipox
   Metronidazole
                      Spirochetes




Treponema pallidum—syphilis
1° painless chancre—diagnose with darkfield microscopy, FTA-Abs +(-)
2° disseminated lesions—maculopapular rash, condyloma, etc.—VDRL+,
        RPR +, FTA-Abs +; darkfield +
3° Gummas, aortitis, neurosyhilis--VDRL±, RPR ±, FTA-Abs +(-)
Teponema
                   Chlamydiaceae
Erythromycin;                            Biphasic life cycle
tetracyclines                            Elementary body infective
                                         Reticulate body replicative
FA, iodine, Giemsa stains

Chlamydia trachomatis
 ABC serotypes infect conjunctiva       Trachoma, blindness

 D-K             infect genitourinary   Urethritis, cervicitis
                                        Pelvic inflammatory disease
                                        Neonatal disease (eye/lung)

 L1, L2, L3      infect lymph nodes     Lymphogranuloma venereum
Chlamydophila pneumoniae—aerosol transmitted atypical pneumonia
                         in humans only
    Chlamydophila psittaci—aerosol transmitted atypical pneumonia
                           in birds AND humans
       Trichomonas vaginalis—A
           Urogenital Parasite
Incidence in US        Spread—Trophs
5-20% ♀, 2-10% ♂       Sexual intercourse,fomites

Target organs              Diagnosis
Vagina, urethra,prostate   Microscopic exam of vaginal or
                           urethral discharge; culture;
Treatment                  serologic detection of antigen,
Metronidazole              nucleic acid probe
Treat both partners

Distinguishing characteristics
 Sexually Transmitted Viruses
Virus                     Disease

Human papilloma viruses Genital warts (6, 11)
                        Cancers (16,18)
HSV2 (HSV1)               Genital herpes

HIV                       AIDS

HTLV-1                    T-cell leukemia; tropical
                          spastic paraperesis
CMV, HBV, HCV, HDV        No genital disease;
                          systemic instead
PID
    PID-C. trachomatis / N. gonorrhoeae

***Chlamydia trachomatis—urethritis, cervicitis, PID (subacute) conjunctivitis

  Neisseria gonorrhoeae—urethritis, cervicitis, PID (acute), arthritis


Chandelier Sign-Cervical Motion Tenderness
Purulent cervical discharge
salpingitis, endometritis, hydrosalpinx, tubo-ovarian abscess; infertility; ectopic
pregnancy, chronic pelvic pain, and adhesions


Other STDsGardnerella, Trichomonas
              References
• Medical Microbiology, 4th Ed., Murray et al.,
  Eds. Mosby; 2002.
• Cases in Medical Microbiology and Infectious
  Diseases, 2nd Ed., Gilligan, et al. Eds. ASM
  Press; 1997
• Underground Clinical Vignettes, Microbiology,
  Vol. I. Bhushan et al. S2S; 1999
• Underground Clinical Vignettes, Microbiology,
  Vol. II. Bhushan et al. SDS; 1999
• USMLE Review, TTHUS, 2004
     Peanut Butter and Jelly
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