Viral STI Lecture 1 2024 PDF

Viral Sexuality Transmitted Infections Dr Vongani Muthambi Clinical Virologist [email protected]  VIRAL SEXUALITY TRANSMITTED INFECTIONS Part 1 Objectives To list common viruses associated with sexually transmitted infections To briefly explain the pathogene...

Viral Sexuality Transmitted Infections Dr Vongani Muthambi Clinical Virologist [email protected]  VIRAL SEXUALITY TRANSMITTED INFECTIONS Part 1 Objectives To list common viruses associated with sexually transmitted infections To briefly explain the pathogenesis &/or clinical presentation of each viral STI To discuss the virology laboratory diagnosis & management of each viral STI To discuss the prevention and basic management of viral STIs 3  STIs with the greatest incidence are: Introduction Bacteria: Syphilis, Gonorrhoea, Chlamydia and Trichomoniasis There are >20 types of STIs Viruses : Herpes simplex virus, HIV, >1 million sexually transmitted infections human Papillomavirus, Hepatitis B & are acquired every day worldwide Moluscum contagiosum In some instances, a person may be having an STIs without knowing ~500 million people are estimated to have Majority of STIs are asymptomatic or of genital infection with herpes simplex virus mild symptoms – not recognized as an >290 million women have HPV infection STIs STIs increase the risk of HIV acquisition STIs may be caused by a number of different pathogens Viruses; Bacteria; & Parasites STIs can lead to reproductive health complications e.g. infertility or mother-to- child transmission http://www.who.int/mediacentre/factsheets/fs110/en/ 4  Viruses Associated with Common Viral STIs Herpes simplex virus (HSV-2 & HSV-1) Genital ulcer Other sexually transmitted viruses Human papilloma virus (HPV) Hepatitis B ( see GIT Cervical cancer block) Genital warts Hepatitis A Human Immunodeficiency syndrome virus (HIV) CMV EBV Acute retroviral syndrome Kaposi sarcoma Acquired Immunodeficiency syndrome (AIDS) HTLV-1 Moluscum contagiosum virus Ebola virus Zika virus Epidermal hypertrophic nodules 5  Herpes simplex viruses Genital herpes simplex infection The commonest sexually transmitted viral infection worldwide HSV establishes a latent persistent infection Both HSV type 2 and 1 can cause genital herpes HSV Type 2 leading cause of genital herpes HSV type is associated with most cases of recurrent genital herpes (Type 1 is often the causes mouth &/or lip sores (fever blisters/cold sores) and type 2 may be the cause) There is an increasing rate of anogenital herpetic infections Attributed to HSV-1 infection Prominent among young women, immunocompromised and MSM 7 MedicineNet.com HSV Genital infection… 9 HSV Genital infection Pathogenesis Entry Cracks / cut on the skin genital area Labia, Lining of the genital tract Primary / initial infection Virus attaches & penetrates local sensory nerves closest to point of entry & establish latent infection Genital HSV infection → Lumbosacral nerves innervating the genitalia Oro-facial HSV infection → Trigeminal nerve innervating the face The HSV may be harbour at other dorsal root ganglia including superior cervical, vagal & geniculate ganglia Recurrent HSV Genital infection Occur in 60% of patient who had primary HSV infection Features of recurrent genital HSV Limited number of lesions Often located unilaterally May occur anywhere in the anogenital area – the buttock or anal cleft Usually associated with itching rather significant pain  Severe recurrent HSV >6 HSV episodes per year For these pts: 6-12 months of lower dose Rx may be considered on individual bases 11  HSV Genital infection Transmission Clinical presentation Direct skin-to-skin contact with herpes HSV 1 or HSV 2 genital manifestation are infected person indistinguishable Direct contact with herpes infested ulcer; blister Symptoms occur in 4 – 7 days after sexual or asymptomatic shedding person contact The hallmark feature: painful, itchy lesions Many people have mild Symptoms or are (blisters) or ulcer in the genital region asymptomatic while shedding the virus intermittently in the anogenital area In women – the lesion are usually located bilaterally on the vulva; the vagina & cervix  In men – the lesions are observed on the penile glans or penile shaft In homosexual men – the lesions are located in the peri-anal & anal region Commonly associated Sx: Fever, dysuria associated with urethritis & cystitis, & localized inguinal lymphadenopathy 12 HSV Genital infection… Complications Aseptic meningitis (assosciated with HSV2 genital lesions) Sacral radiculomyelitis resulting in urinary retention Severe hepatitis Secondary bacterial infection – follows genital HSV infection In pregnancy Primary perinatal maternal genital HSV during birth → severe neonatal HSV infection Diagnosis Genital HSV is a clinical diagnosis Lab: HSV DNA PCR: Material from fresh lesions or blood (EDTA tube) Serology: Blood (Clotted tube) Primary infection – IgM result: positive or IgG result: 4-fold rise on paired sera 13 HSV Genital infection… Prevention Behavioural Modification Abstinence / avoiding sexual act Safer sex One sexual partner in a committed relationship Use of sexual barrior – condoms (female / male) Treatment Acyclovir (Zovirax) 400mg 3X/day Valaciclovir (Zelitrex) 500mg 2X/day Duration: 7-10 days unless lesions continue to appear NB: IV Rx is required for genital herpes accompanied by other systems complications! 14 Hepatitis B virus Mode of transmission Horizontal – commonest route in Sub-Saharan Africa Perinatal – high endemic areas (mothers who are HBeAg carrier) Sexual Blood Prevalence ~240 million people have chronic HBV infection globally Highest in sub-Saharan Africa and East Asia In SA: estimated at 10%  Viral Hepatitis B.. Clinical features: Incubation long (4-26weeks) Acute infection 70% subclinical, 30% icteric (jaundice) 90% of adults clear infection Chronic carrier (HBsAg > 6 months) 80-90% of infection at infancy ~10-15% among adult with HBV infection 40% of chronic carriers progress to cirrhosis & liver Ca  Primary infection Patients who clears the virus HBsAG is the marker of infection, if >6months =chronic infection Vaccinated patient http://microbialcell.com/wordpress/wp-content/uploads/2016/08/Table-3-Hepatitis-B-virus-and-its-sexually-transmitted-infection.jpg  Human deficiency virus Infection Facts: 2012 HIV prevalence in South Africa was 12,2% ~1,2 million more people compared to 2008 prevalence 139 000 new infections occurring in the youth aged 15-24 (HIV incidence of 1,5%) 300 000 new infections were estimated for the group age >25 years (HIV incidence was 1,4%) 396 000 new infections in the age group 15-49 years (HIV incidence was 1,7%) Highest infections ( 15-45 age group) Women are mostly infected  HIV Infection… Risk of transmission Varies widely depending on the type of sexual exposure HIV transmission is higher among MSM than among heterosexual relationships HIV transmission is higher in uncircumcised males than circumcised males [ circumcision reduces the risk of infection by 65%] STIs increases the risk of acquiring and transmitting HIV infection  Inflammation and ulcer lower the barrier to HIV infection  STIs can evoke an influx of receptive cells with expression of a greater number of CCR5 and CD4 receptors per cell  The risk of HIV acquisition for a woman with mucosal inflammation or a genital ulcer is greatly increased  Rectal mucosa is thin and friable and heavily defended against infection, thereby enriched with cells receptive to HIV 19 Mode of transmission Factors increasing the risk of HIV transmission Sexual intercourse Unprotected sex STI Other mode: High viral load Exposure to infected blood & Substance abuse bodily fluid Multiple sexual patners Mother-to-child transmission douching HIV and STI HIV is greatly affected by bacterial and viral STIs that cause genital ulcers and/or mucosal inflammation How ????? STIs increase infectiousness of people living with HIV by increasing the viral load in the genital tract  STI increasing susceptibility for HIV acquisition in those who are not infected with HIV  Some STIs can increase blood viral load and promote progression of disease  Acute / Primary HIV Infection The diagnosis is frequently missed by clinicians ~10-50% of individuals are asymptomatic Symptoms May be noted 2 – 4 weeks post HIV exposure Infectious Mononucleosis Fever Non-specific Sore throat May present as a infectious mononucleosis Lymphadenopathy Acute retroviral syndrome Fever, sore throat, lymphadenopathy, rash, ulcer,myalgia &/or arthralgia, diarrhea, weight loss and headache A wide range of other symptoms have been described i.e Mucocutaneous ulcers; CNS involvement High HIV viral load(VL),CD4 count decreased but>500 The symptoms are self-resolving 21 HIV Infection… Diagnosis (higher degree of suspicion! 4th Generation ELISA - done on 2 different assays Risk reduction interventions Behavioural intervention A, B & C – Abstain, Be faithful to 1 partner and Condom use strategies Promote male circumcision 23 Biomedical interventions Post-exposure prophylaxis(PEP) Pre-exposure prophylaxis(PrEP) Must be taken within 72hrs Tenofovir disoproxil fumarate( TDF) /Tenofovir alafenamide (TAF) ; Emtricitabine(FTC) or Lamivivudine ( 3TC) Plus Dolutegravir 1st September 2016 criteria to initiate[ highly active antiretroviral therapy] HAART was changed in SA in line with Eligibility Criteria for Universal test and treat (UTT): All HIV positive children, adolescents and adults regardless of CD4 The patient must be willing and ready to start ART Early Rx initiation for HIV infected pts → suppression of plasma viral load → ↓ risk of HIV transmission Identifying new infection – test & treat HIV @ Point of care Screen & Treat STIs Human T lymphotropic virus type-1 (HTLV-1) Retroviridae Family Worldwide distribution & estimated that at least 5–10 million people harbor the virus Risk of transmission via tissue transplantation, high prevalence has been defined as greater than 1% in the general population or greater than 1 in 10,000 first time blood donors The highest areas of prevalence are located in Japan, Africa, the Caribbean Islands, Melanesia, the Mashhad area of north-eastern Iran and South America. Brazil, which potentially harbors 800,000 people with HTLV-1 &represents the largest number of carriers on the American continent HTLV-1 is etiologically linked with a) adult T cell leukemia-lymphoma (ATLL) b) tropical spastic paraparesis/HTLV-1-associated myelopathy (TSP/HAM) c) Uveitis d) infective dermatitis  Molluscum Contagiosum It is a member of the Poxviridae family Viruses in this family include eradicated Small pox MC is considered to be a benign skin tumour Occurrence is worldwide & humans are regarded as the only host Transmission Direct contact Shared towels Mild trauma to the skin i.e contact sport Sexually transmitted 26  Molluscum Contagiosum… Diagnosis Clinical diagnosis – appearance of the lesion Lesion description: single or, more often, multiple, rounded, dome-shaped, pink, waxy papules / bumps that are 2-5 mm (rarely up to 1.5 cm) in diameter. The papules are umbilicated and the center. Limitation of serology – MC induces poor inflammatory response Management The infection is benign Spontaneous recovery Treatment is usually for cosmetic reasons Physical methods: curettage & cryotherapy – mild trauma / irritation may release the virus & induce the immune response Chemical Rx: phenolics, silver nitrates, trichloroacetic acid etc. 27  Monkeypox virus Poxviridae Clinical presentation Causes Mpox disease 1 to 4 days of prodromal symptoms: Mpox is a zoonotic disease  fever ( 38.5-40.5°C) Endemic in West and Central Africa headache, myalgia, fatigue with Democratic Republic of the Lymphadenopathy (within 2-3 days after the fever) Congo (DRC) having the highest (differentiating feature of monkeypox from burden smallpox and chickenpox ) Infected patients may be contagious at this time Fever often accompanied by chills, drenching sweats, severe headache, backache, myalgia, malaise, anorexia,pharyngitis, shortness of breath, and cough (with or without sputum)  Mode of transmission Infected animal bodily fluids, cutaneous or mucosal lesions Monkeypox does not spread easily between people. Human-to-human transmission occurs through close contact: With infectious material from skin lesions and respiratory secretions of an infected person Respiratory droplets in prolonged face-to-face contact(health workers, household members and other close contacts of active cases at greater risk) Through fomites SEXUAL transmission( associated with current world wide out break) Transmission via placenta from mother to fetus (which can lead to congenital monkeypox) or during close contact during and after birth Possible risk : Eating inadequately cooked meat and other animal products of infected animals  Monkeypox lesions Start in the oropharynx then appear on the skin Skin lesions on face and extremities including palms and soles Lesions typically begin to develop simultaneously and evolve together May or may not spread to the rest of the body The total number of lesions may vary from a small amount to thousands Serum antibodies are often detectable by the time lesions appear. In 2 to 4 weeks the lesions evolve in 1 to 2-day increments through macular, papular, vesicular, and pustular phases Other affected area :oral mucous membranes (in 70% of cases),genitalia (30%) and conjunctivae (20%) ,Cornea Condition resolves around 3 to 4 weeks after symptom onset in most cases. Patients are no longer considered infectious after all crusts fall Complications of Mpox Secondary bacterial infections Respiratory distress, bronchopneumonia, Gastrointestinal involvement ( severe nausea , vomitting, , diarrhoea with dehydration) Sepsis Encephalitis Corneal ulceration with ensuing loss of vision. Haemorrhagic disease Diagnosis Mpox World Health Organization (WHO) recommends that the optimal specimens for diagnosis include Direct sampling from lesions: Smears of exudate from vesicular lesions or scabs For PCR Management of MPox Usually self limiting disease. Patient managed symptomatically Antiviral drugs approved to treat smallpox including tecovirimat and brincidofovir, can be potentially deployed for its use on treating monkeypox Management of Viral STIs Prevention strategies Counselling and behavioural interventions Barrier methods Point of care diagnosis Still a challenge Follow up on results is required - this can impede on care or treatment Effective prevention & treatment Limited Vaccines Safe and highly effective vaccines but limited to HBV and HPV Antivirals Antiviral can modulate the course of the disease Available for HSV, HIV, HBV 33 References Cohen MS, Bartlett JG and Bloom A. HIV Infection: Risk factors and Prevention Strategies. UpToDate. 2016, April. Available online at: www.uptodate.com Sax PE, Bartlett JG and Bloom A. Acute and Early HIV Infection: Clinical manifestations and Diagnosis. UpToDate. 2016, May. Available online at: www.uptodate.com Albrecht MA, Hirsch MS and Mitty J. Treatment of genital Herpes simplex virus Infection. UpToDate. 2015, October. Available online at: www.uptodate.com Richter KL. Cervical cancer screening – a New viral Paradigm. CME. 2011;29(5):194-199 Zuckerman AJ, Banatvala JE, Schoub BD, Griffiths PD and Mortimer P. Principles & Practice of Clinical Virology. 6th Ed. 2009. Wiley-Blackwell, UK World Health Organisation. Sexually transmitted infections (STIs). Available online at: http://www.who.int/mediacentre/factsheets/fs110/en South African National HIV Prevalence, Incidence and Behaviour Survey, 2012. Available online at: http://www.hsrc.ac.za/uploads/pageContent/4565/SABSSM%20IV%20LEO%20final.pdf Veterans Health Administration. Women’s Health: A Guide to Preventing Infection. Available online at: http://www.publichealth.va.gov/docs/womens-health-guide/womens- health-preventing-infections.pdf 34