感染期末整理

HIV
1.The CD4 cell surface molecule was identi ed as the main receptor for HIV.
2.The main co-receptors 可入侵細胞受體 of HIV: CXCR4 and CCR5
3.RNA, 反轉錄病毒 destroys all the T-cell lymphocytes
4.世界多流⾏HIV-1, 0.7%
5.套膜蛋⽩：gp120 最外層 gp41穿膜; core protein:p24
6.傳播：性⾏為、⾎液、⺟體垂直感染
7.繁殖：RNA進入host cell 反轉錄成DNA integrate into宿主DNA做出HIV proteins
8.Acute Retroviral syndrome ：40% to 90% patients with acute HIV infection
have acute retroviral syndrome.Often not recognized. Symptoms like fever,
lymphadenopathy淋巴結腫⼤, pharyngitis, thrush.
9.CD4量對免疫缺乏者可決定不同疾病
10.AIDS:CD4<200, 空窗期具有傳染⼒！！測試時P24會最先驗出來後p160
Screen Test: ELISA/Con rm Test : Western blot/PCR
Screen rest evolution
1st Antihuman IgG

2nd Bind HIV ab 提⾼HIV-1 O組的敏感性

3rd Bind HIV ab 測IgM

4th Detect both IgG and IgM and P24 , do not distinguish antigen reactivity and antibody reactivity
Distinguish between HIV-1 and HIV-2

說明
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11.Treatment
(1)When to start ART?
2013:CD4 cell count ≤500 or Active TB disease/HIV懷孕
Today: everyone who has HIV, reduces the risk of HIV transmission
(2)What to Start?
INSTI plus 2 NRTIs (for most patients)
DTG/ABC/3TC ( if HLA-B*5701 negative）
(3)PEP: A regimen containing 3 (or more) antiretroviral drugs for 4 weeks
most e ective when begun as soon as possible
less e ective when started more than 72 hours after exposure
持續追蹤0.1.3.6個⽉
(4)PrEP: negative HIV , B肝且有打疫苗
regimen-the xed-dose TDF+emtricitabine (truvada)
-the xed-dose TAF+emtricitabine(Descovy) ; 不適⽤陰道性交
12.PJP
(1)空氣傳播
(2)肺囊蟲肺炎是常⾒的後天免疫不全症候群的定義感染症(AIDS-de ning illness)，
⼤部份發⽣在HIV感染後CD4<200的病⼈
(3)胸部X光檢查典型上會呈現瀰漫性浸潤，向肺⾨周圍延伸，幾乎完全存在於肺泡內
(4)症狀多為漸進性的呼吸短促
(5)正常的X光片可以看⾒空洞、氣胸、胸腔積液、ground glass
(6)斷層掃描 (HRCT) 具有對 PCP 具有⾼靈敏度
(7)診斷：主要⽤Tissue biopsy因PCR-cannot distinguish between colonization
and disease
(8)treatment:primary-TMP-SMX for 21 days
secondary預防-單效⼝服片SMX

13.TB
(1)Those with higher CD4 cell counts (>400 cells/mm3) present similarly to
those without HIV
(2)TB in advanced immunosuppression: Sputum acid-fast smears are less
likely to be positive than in those with cavitary disease
(3)treatment:isoniazid, rifampin, pyrazinamide , and ethambutol
(4) patients with both HIV and active TB who are not on ART should be started
on ART as：
CD4 counts <50 cells/mm3 盡快開始抗逆轉錄病毒治療，但應在開始抗結核治療後 2 週內

CD4 counts ≥50 cells/mm3 Initiate ART within 8 weeks of starting TB treatment

all pregnant women with HIV Initiate ART as early as feasible預防垂直感染

tuberculous meningitis Caution

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 14.Mycobacterium avium complex (MAC)
(1)Usually occurs when in HIV people with CD4<50
(2)Primary prophylaxis: Azithromycin – 1250 mg po Q week Start when CD4
count ≤ 50

15.Cytome galovirus (CMV)infection

(1)HIV Patient CD4 <50
(2)視網膜炎、肺炎和結腸炎
(3)Diagnosis: biopsy (de nite) ,culture ,PCR 有owl’s eyes
(4) Treatment: antiviral agent (usually ganciclovir)

16.Cryptococcosis
(1)CD4 counts <100.
(2)CNS:癲癇發作和局灶性神經功能缺損。
(3)Diagnosis:CSF + India ink

17.Toxoplasmosis
(1)Usually in AIDS patients with CD 4 count < 100/mm3
(2)CNS infection:
Ring-enhancing cerebral lesions Meningitis Chorioretinitis
(3)de nitive diagnosis requires biopsy
(4)Brain imaging: demonstrates a typical radiographic
appearance (eg, multiple ring-enhancing lesions)
(5) Treatment: Initial regimen:containing sulfadiazine and pyrimethamine
For patients without a sulfa allergy TMP-SMX may also be an
e ective alternative treatment regimen

18.Malignancy
Kaposi’s Sarcoma(KSV): HHV-8, Most common malignancy in HIV in pre ART
area.Skin: Deep purple/red lesions; Can appear anywhere on skin

19.Candidiasis:thrush
(1)Invasion of esophageal mucosa:Most commonly seen in HIV-
infected patients with advanced immunosuppression (CD4<200 cells/microL)
症狀：吞嚥痛，吞嚥困難，疼痛
(2)oral:painless

20.Herpes Zoster帶狀皰疹Caused by varicella zoster virus

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 21.IRIS: exaggerated immune response to underlying opportunistic
pathogens ,develop symptoms one week to a few months of the initiation of
antiretrovirals.可考慮Administer steroids

Leptospirosis
1. Key words:silver staining、潮濕跟⽔環境、rats、尿⾎傳播、 conjunctival
su usion眼睛發紅但無分泌物、後期Weil’s syndrome(出⾎、黃疸、腎衰竭）、
⾎⼩板減少
2. Pathogenic: L.interrogans
3. 很多不同種⾎清型⽤rrs gene分類
4. 可活動、有鞭⽑、可活很久
5. 致病
Leptospiremic phase 菌⾎期 可從⾎中分離 Blood

Immune phase 組織內⾏走 Urine

6. 診斷：check expose history, CSF會有無菌腦膜炎,⾎⼩板減少、MAT⾎清檢測

可以直接con rm
7. Treatment:Doxycycline

Rickettsial
1. Key words: tick, mite, ea, or louse, ⼤疹⼦, eschar,肺炎,⼭區,突發⾼燒
2. 傳播常為tick類但只有C. burnetii ⽤空氣！！且導致Q fever(zoonosis)易慢性like
⼼內膜炎
3. 確切診斷需⾎清加上地區性強
4. R. prowazekii，常導致疾病復發
5. 通⽤：先攻擊⾎管內⽪細胞導致凝⾎異常、WBC可能下降、肝指數偏⾼、
intracellular
6. 診斷：⾎清要做到兩週後⼀開始可能陰性(斑疹群可能cross reaction)
7. Treatment:Tetracycline,Doxycycline
8. 不同種
種類 致病 傳播 特徵 Treatment

Rocky mountain spotted R. rickettsii Tick Delayed diagnosis Doxycycline

fever 淋巴⾎⾏擴散到全⾝
並感染許多相鄰的內⽪細胞
⼿腳疹⼦
cross reaction

Mediterranean spotted R. conorii

fever
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 African tick-bite fever R. africae multiple eschars

Rickettsialpox R. akari Mite Infects mice

中間有⼤⽔泡

Flea-borne spotted fever R. felis Cat ea

Epidemic (Louse-borne) R. prowazekii 冷、戰爭 Doxycycline

typhus

Endemic murine typhus R. typhi 鼠蚤 暖！

Or called ea-borne
typhus
地⽅斑疹傷寒

Scrub typhus O. tsutsugamushi chiggers 傷⼝中間有eschar

Ehrlichioses and 攻擊WBC! Leukopenia

anaplasmosis dogs
埃立克體病和無形體病
*Human granulocytotropic
anaplasmosis (HGA):Lyme
disease區域相同

9. Q Fever
• Worldwide distributed except New Zealand and Antarctica
• 會導致動物流產
• Coxiella burnetii 空氣傳播、胞內
• 躲在巨噬細胞吞噬溶酶體造成很難治療變慢性感染
• 接⽣新動物的⼈易感染
• 症狀會跟地區有不同ex.肺炎：Nova Scotia、⾁芽腫肝炎：台灣
Acute 多無特別症狀 phase II ab 台灣肝炎其他肺炎 懷孕嚴重
Chronic phase I ab Endocarditis (culture-negative
endocarditis)
⼼內膜炎（培養多成陰性）

Norcardiosis
1. Key word: soil, opportunistic infection, 分⽀陽性桿菌,acid fast stains
(mycolic acid),熱帶,空氣傳播,肺炎（Single or multiple nodule ）,Brain
abscess, 分段潰爛,⽩黃橘⾊,
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2. GPB gram positive bacillus
1. NBA: Nocardia, Bacillus, Actinomycete
2. CCL: Clostridium, Corynebacterium, Listeria
3. 細胞免疫低的⼈易受感染
4. weight loss, Co-infection with Nocardia and TB ,
5. Brain abscess：找潛在感染源
6. ⾎型擴散局部nodule 眼疾
7. 要有症狀才有意義
8. 免疫⼒低的⼈要多注意
9. 質譜儀分析
10. Treatment治療期要拉長:SMX-TMP, Amikacin, amoxicillin,
11. 病⼈治療後狀況跟本⾝免疫很有關

Actinomycosis
1. Key words:長得慢！Sulfur granules, 像腫塊不好治療,⼦宮內避孕器, frozen
pelvis
2. Colonize the mouth, colon, and vagina ,骨盆腔
3. 頭頸部 disease： Often mistaken for a neoplasm
4. 胸disease:fever, chest pain,定點膿胸
5. 常轉移⾄肺跟肝
6. Treatment:penicillin

Herpesviridae
1. 有套膜
HHV1 表⽪細胞 唇皰疹 HSV

HHV2 表⽪細胞 ⽣殖器皰疹,腦膜炎

HHV3 表⽪細胞 VZV

HHV4 B cells Kissing disease

HHV5 Monocytes lymphocytes 單核球上升

HHV6 T cells 玫瑰疹 ⾎球下降

HHV7 T cells 玫瑰疹 ⾎球下降

HHV8 B cells Kaposi;s sarcoma ⾎球下降

2. 48⼩時內給抗病毒藥物最有效
CMV:
EBV:⼤顆紅⾎球
DNA virus
1. Serotype: B-3,7 F-40,41

1. 注意傳播⽅式、病媒蚊
Dengue Aedes aegypti

Aedes albopictus

2. 登⾰熱warning sign*8
腹痛、持續嘔吐、肋膜積⽔、粘膜出⾎、疲憊、肝腫⼤了2公
分、HCT increase but platelet count decrease
3. 登⾰出⾎熱的pathogenesis, 相關症狀-
4. Zika virus常⾒症狀及相關併發症