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
2
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.
3
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
4
Natural History of HIV Infection
Without the Use of Antiretroviral Tx
1200
Primary
Infection
1100
Death
Opportunistic
Diseases
1000
106
Clinical latency
900
CD4 + T Lymphocyte Count (cells/mmm3)
107
800
Constitutional
Symptoms
700
105
600
104
500
400
300
103
200
100
102
0
0• 3•
6• 9• 12
Weeks
1• 2•
3• 4
5•
6•
7•
8
9• 10• 11
Years
Source: Fauci, A., Pantaleo, D., Stanley S., Weismann, D. Annals of Internal Medicine 124: 6754-3, 1996
HIV/RNA Copies per ml Plasma
+ Acute HIV syndrome
Wide dissemination of virus
Seeding of lymphoid organs
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
6
Signs and Symptoms in HIV Disease
Symptom
Prevalence*
Symptom
Prevalence
Pain
52%
Fever
27%
Tiredness
50%
Cough
27%
Anxiety
40%
Depression
24%
Sleep
disturbance
37%
Diarrhea
24%
Skin Problem
24%
Mouth sore
33%
Pruritus
23%
Sadness
32%
22%
Weight loss
31%
Respiratory
problem
Nausea
28%
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
9
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
13
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
– 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
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
• 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
• 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
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)
– 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
– 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
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：
– 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?
– 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
• 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
– 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
– 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
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
• 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
懇請賜教