Etiology of genital ulcer disease and association with human immunodeficiency virus infection in two tanzanian cities

BACKGROUND: The etiological agent is usually not established in cases of genital ulcer disease (GUD) in Tanzania, since diagnosis and treatment of this disease are based mainly on clinical rather than microbiologic parameters. GUD increases the risk of infection with HIV. However, the association between specific GUD infections and HIV infection has not been fully investigated. GOAL: The goal was to determine the etiology of GUD and the prevalence of HIV infection in patients with GUD in urban areas of Tanzania. STUDY DESIGN: A total of 102 clinical specimens were collected from 52 and 50 patients with GUD in Dar es Salaam and Mbeya, respectively, and from 93 patients with genital discharge in a cross-sectional study. Two polymerase chain reaction (PCR) assays were used to identify either a single target DNA or all three DNAs of the major causes of GUD: Haemophilus ducreyi, Treponema palladum and herpes simplex virus type 2 (HSV-2). The sera from all patients were tested for antibodies to HIV and T palladum. RESULTS: In Dar es Salaam, DNA from HSV-2, and was detected in 63%, 13%, and 2%, respectively, of the 52 genital ulcer specimens. The corresponding figures in Mbeya were 34%, 10%, and 0% of 50 specimens. Overall, 9% of the 102 patients with GUD were infected with both HSV-2 and, and 39/102 genital ulcer specimens (38%) were negative for the DNA of all three pathogens. The HIV infection rates among GUD patients were 46% and 52% in Dar es Salaam and Mbeya, respectively; among the non-GUD patients, the corresponding rates were 35% and 45%, respectively. The HIV infection rate in Dar es Salaam was significantly higher among women (11/14; 78%) than among men (13/38; 34%) (P = 0.004). Among the HIV-seropositive GUD patients, 71% and 46% (P < 0.003) were coinfected with HSV-2 in Dar es Salaam and Mbeya, respectively. Furthermore, women with HSV-2 in Dar es Salaam were significantly more likely to be HIV-infected than men (60% versus 39%; P相似文献   

An indolent penile herpetic ulcer in a patient with previously undiagnosed human immunodeficiency virus infection

We report a case of an atypical penile herpetic ulcer in a man with previously undiagnosed human immunodeficiency virus (HIV) infection. Swabs of the lesion were negative for herpes simplex virus (HSV) by culture and electron microscopy. However, histopathology of biopsy material showed characteristic herpetic multinucleate giant cells. Immunochemistry using polyclonal antibodies was positive for HSV1 and HSV2. The lesion completely resolved after treatment with aciclovir and the patient subsequently tested positively for HIV antibodies.     

HIV infection and genital ulcer disease

Between December 1990 and July 1991, 17 male HIV patients between the ages of 21 and 47 years in an Indian hospital were identified and information was obtained on their history, age, source of infection, hospitalization, places and sources of sexual contact, and extramarital sexual contacts. Each patient with a sexually transmitted disease (STD) underwent HIV testing too using ELISA whose results were subsequently confirmed by Western Blot. 15 of the 17 patients also had an associated genital ulcer disease (GUD), which was a significant relationship. 12 had asymptomatic generalized lymphadenopathy and 5 were afflicted with persistent generalized lymphadenopathy. Of the 17 patients, 9 had chancroid, 2 had an early phase of syphilis, 3 had lymphogranuloma venereum, 1 each had candidal balanitis, condylomata acuminata, and acute gonorrhea. Eight patients contracted the HIV infection in Bombay. 14 patients had contracted the disease from prostitutes. Homosexual contacts were denied by all. 13 patients admitted a single instance of extramarital sexual contact. In a study of 123 HIV seronegative prostitutes monitored regularly, HIV seroconversion was significantly associated with GUD. There is convincing evidence that GUD increases the risk of acquiring HIV infection because the breach of mucosal integrity of the genitalia provides a more efficient route for viral entry. Other risk factors documented for sexual transmission of HIV in addition to STDs are: lack of male circumcision, receptive anorectal sexual intercourse, lack of condom use, and advanced HIV-related immunosuppression in the index case. Since GUD predisposes to HIV infection, it is imperative to treat genital ulcer and to increase sex education regarding HIV.     

Human immunodeficiency virus infection

Knowledge of the ever increasing spectrum in cutaneous pathology caused by infection with the human immunodeficiency virus (HIV) is essential for the clinician examining high-risk individuals as well as patients presenting with recent suspicious cutaneous/mucocutaneous lesions. Timely diagnosis of the unique lesions associated with developing immunodeficiency (such as Kaposi's sarcoma and oral hairy leukoplakia)--as well as the often atypical and overlapping infections and neoplastic and allergic manifestations--is critical in order to initiate the appropriate treatment that may prove life saving and help extend the lives of individuals struck by infection with HIV.     

Coexistence of urethritis with genital ulcer disease in South Africa: influence on provision of syndromic management

OBJECTIVE: To assess whether syndromic management of genital ulcer disease was sound, if based on the premise that men with genital ulcers rarely have a concomitant urethral infection. METHODS: Specimens were taken in 1998 from 186 mine workers in Carletonville, South Africa, who were seen consecutively with genital ulcers. The specimens comprised a swab from the ulcer, a urethral swab for a Gram stained smear, and 10-15 ml of a first catch urine sample. The latter was tested by ligase chain reaction assays for Neisseria gonorrhoeae and Chlamydia trachomatis specific DNA sequences and by a polymerase chain reaction (PCR) assay for Mycoplasma genitalium. Ulcer inducing micro-organisms were detected either by a multiplex PCR assay, or in the case of lymphogranuloma venereum (LGV) serologically, and human immunodeficiency virus (HIV) infection was detected by an enzyme linked immunosorbent assay (ELISA) test. RESULTS: Most (54%) of the ulcers were chancroidal, 18% were herpetic (HSV type 2), 6.5% primary syphilitic, and 3.2% due to LGV. More than one micro-organism was detected in 9.1% of the ulcers and less than 10% were undiagnosed. Microscopic examination of the urethral smears showed that 99 (53%) of the men had urethritis, of whom 45 (45%) were infected with N gonorrhoeae. Of the 54 men (55%) who had non-gonococcal urethritis (NGU), 11 (19.6%) harboured C trachomatis or M genitalium. Almost two thirds (64.5%) of the men had HIV infection, but this did not seem to have influenced the aetiology of the ulcers. Nor was a particular ulcer associated with one type of urethritis more than the other. Neither C trachomatis nor M genitalium was associated significantly with non-gonococcal urethritis (NGU) in either HIV positive or HIV negative men. CONCLUSION: The combination of antibiotics used for the management of genital ulcer disease in men in this South African mining population needs to be widened to encompass frequently occurring concomitant gonococcal urethritis and NGU infections. This means treatment with long acting penicillin, combined with ciprofloxacin and azithromycin or erythromycin. A similar situation may exist in other geographical locations with a need to provide appropriate antimicrobial combinations depending on the patterns of infection detected.     

Human immunodeficiency virus infection and pregnancy

Human immunodeficiency virus infection profoundly affects the medical community and is spreading rapidly in women of childbearing age worldwide. Transmission of HIV from mother to child can occur in utero, during labor, or after delivery through breast-feeding. Most of the infants are infected during delivery.

We focus on the factors affecting the transmission of HIV, diagnostic and resistance tests, strategies to prevent mother-to-child transmission with special reference to mode of delivery, infant feeding, and use of antiretroviral therapy. The risk of infection for the infant can be decreased by reducing maternal viral load, by elective cesarean delivery, and by avoidance of breast-feeding. The efficacy of antiretroviral treatment should be balanced against the possibility of embryonic or fetal toxicity. The choice of therapy should be based on the woman's treatment history, the clinical status, and the available prognostic markers, which are related to the progression of disease in the mother and the risk of mother-to-child transmission HIV transmission.     

Soap and water prophylaxis for limiting genital ulcer disease and HIV-1 infection in men in sub-Saharan Africa.

In general, East, Central and Southern Africa appear to be worse affected by HIV-1 infection than West Africa. So far there is little evidence to suggest that differences in either sexual behaviour or numbers of sexual partners could account for this disparity. Two risk factors in men for acquiring HIV-1, that tend to vary along this geographical divide, are lack of circumcision and genital ulcer disease (GUD) which are much less common in West Africa. Although uncircumcised men with GUD are an important high frequency HIV-1 transmitter core group, few interventions have targeted such individuals. Given the recent expansion in AIDS-related technologies, is it possible that methods effective in limiting GUD in the preantibiotic era have been overlooked? During the first and second world wars, chancroid, the commonest cause of GUD in Africa today, was controlled successfully with various prophylactics including soap and water. Many parts of Africa are undergoing social upheaval against a background of violence, and in this environment soap and water prophylaxis would now seem to merit re-evaluation as an intervention for preventing both GUD and HIV-1 in uncircumcised men. By facilitating healing of traumatic, inflammatory and infected penile lesions, pre- and post-exposure prophylaxis with soap and water could be a cheap and effective method for decreasing the risks of acquiring GUD and HIV in this vulnerable group of uncircumcised men.     

Herpes simplex virus and cytomegalovirus co‐infection presenting as exuberant genital ulcer in a woman infected with human immunodeficiency virus

In patients infected with human immunodeficiency virus (HIV), genital herpes can result in severe and atypical clinical presentations, and can become resistant to aciclovir treatment. Rarely, these manifestations may represent concurrent herpes simplex virus (HSV) with other agents. We report a 41‐year‐old black woman with HIV who presented with extensive and painful ulceration of the genitalia. Histological examination of a biopsy sample was suggestive of herpetic infection, and intravenous aciclovir was started, but produced only partial improvement. PCR was performed on the biopsy sample, and both HSV and cytomegalovirus (CMV) DNA was detected. Oral valganciclovir was started with therapeutic success. CMV infection is common in patients infected with HIV, but its presence in mucocutaneous lesions is rarely reported. This case exemplifies the difficulties of diagnosis of genital ulcers in patients infected with HIV. The presence of exuberant and persistent HSV genital ulcers in patients with HIV should also raise suspicions of the presence of co‐infection with other organisms such as CMV.     

Human immunodeficiency virus infection and porphyria cutanea tarda

A recent report documents three homosexual men with porphyria cutanea tarda associated with acquired immune deficiency syndrome (AIDS). We report two brothers with hemophilia and human immunodeficiency virus (HIV) exposure who developed porphyria cutanea tarda. These brothers are heterosexual, have familial porphyria cutanea tarda, and developed overt familial porphyria cutanea tarda in their early twenties. One brother's symptoms were provoked by attending an ultraviolet A suntanning parlor. Our two patients, unlike the previously reported three patients, have not developed AIDS, though one patient has evidence of defective cell-mediated immunity. Three of the five cases of porphyria cutanea tarda associated with HIV infection involved familial porphyria cutanea tarda. It now may be advisable to order HIV serology tests in patients who have porphyria cutanea tarda. We recommend that HIV-positive individuals avoid ultraviolet A radiation because of its immunosuppressive effects in persons already at risk of immunosuppression. Such exposure is further contraindicated in those individuals with porphyria cutanea tarda.     

Genital ulcer disease in women in Durban, South Africa.

OBJECTIVE--To study the microbial aetiology of genital ulcer disease (GUD) in women. DESIGN--Microbial and clinical assessment of genital ulcers in women. SETTING--City Health sexually transmitted diseases clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS--100 Zulu women with genital ulceration who had not received antibiotics in the previous two weeks. RESULTS--Syphilis was diagnosed in 40%, genital herpes in 18%, donovanosis (granuloma inguinale) in 16%, chancroid in 14%, lymphogranuloma venereum in 7% and scabies in 2%. No recognised cause was detected in 18%. Secondary syphilis was diagnosed in 21%, primary syphilis in 16% and mixed primary and secondary syphilis in 3%. Multiple infections were detected in 13 women, of whom 12 had syphilis. Bleeding was observed from the ulcers of 59 during swab collection. Three women had HIV-1 antibodies. Neisseria gonorrhoeae was isolated from the ulcers and endocervix of two women and from the endocervix alone in nine. Generalised scabies was diagnosed in 14. CONCLUSIONS--All the major causes of GUD are prevalent in Zulu women in Durban: secondary syphilis was the commonest diagnosis. Donovanosis, which often presents late with large ulcers, and genital herpes are now significant problems. Mixed infections with coexisting syphilis are common. All women in this population with GUD should be treated for syphilis and receive oral antibiotics effective for chancroid and donovanosis.     

Genital ulcer disease in men in Durban, South Africa.

OBJECTIVE--To study the microbial aetiology of genital ulcer disease (GUD) in men. DESIGN--Microbiological and clinical assessment of genital ulcers in men. SETTING--City Health sexually transmitted diseases clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS--100 Zulu men with genital ulcers who had not received antibiotics in the previous four weeks. RESULTS--Syphilis was diagnosed in 42%, chancroid in 22%, donovanosis (granuloma inguinale) in 11%, genital herpes in 10% and lymphogranuloma venereum (LGV) in 6%. No pathogens were identified in 24%. Mixed infections were detected in 14 men, in whom 13 had syphilis. Five men had HIV-1 antibodies. Neisseria gonorrhoeae was isolated from the ulcers and urethra in seven men and from the urethra alone in five. Scabies was diagnosed clinically in eight. CONCLUSIONS--All the major causes of GUD are prevalent in Zulu men in Durban. Primary syphilis was the commonest and was invariably present in mixed infections. Donovanosis was under-reported and was associated with a long delay before presentation. In this population, genital ulcers other than superficial lesions should be treated with anti-syphilitic therapy and oral antibiotics effective against chancroid and donovanosis.     

Herpes simplex virus infection and genital ulcer disease among patients with sexually transmitted infections in Dar es Salaam, Tanzania

The relative importance of Haemophilus ducreyi and Treponema pallidum in genital ulcer disease in Africa has decreased recently, whereas that of herpes simplex virus (HSV) type 2 has increased. We analysed 301 lesional specimens from Tanzanian patients with genital ulcer disease for the presence of H. ducreyi, T. pallidum and HSV-1/HSV-2 by performing a separate PCR for each pathogen. Infectious agents were detected in 211 (70%) of the cases. A single pathogen was found in 191 samples and two or more pathogens in the remaining 20. HSV-2 represented 83% of all identified pathogens, HSV-1 8%, T. pallidum 4% and H. ducreyi 5%. HSV-1 was identified as a single pathogen in four samples, in combination with others in an additional 14 samples. Thus, HSV-1 can also be the cause of genital ulcer disease in Africa. Regular surveillance of genital ulcer disease aetiology is important in programs for management of genital ulcer disease and HIV in Africa.     

Human papillomaviruses and genital disease

Human papillomavirus (HPV) infection is causally related to several benign and malignant diseases of the anogenital tract. In this article the authors detail the epidemiology, methods of transmission and risk factors, pathogenesis, and oncogenesis of HPV, and describe clinical manifestations and current treatments. Special attention is given to condyloma acuminatum and non-cervical anogenital intraepithelial neoplasia. The authors conclude with the latest information on prophylactic vaccine development and prospects for future control of HPV-related disease.     

Epidermodysplasia verruciformis-associated papillomavirus infection complicating human immunodeficiency virus disease

Three males infected with the human immunodeficiency virus (HIV) were noted to have extensive flat warts of the face and/or body. In two there were also pityriasis versicolor-like lesions. Biopsies showed foamy, basophilic, distended cytoplasm in granular layer keratinocytes, characteristic of the human papillomavirus types seen in epidermodysplasia verruciformis. DNA hybridization techniques demonstrated the presence of HPV-type 8 in one patient and HPV 5 and 8 in another. Patients with immune suppression due to HIV infection may demonstrate the clinical features of epidermodysplasia verruciformis with the same potentially oncogenic HPV types.     

Human immunodeficiency virus and leprosy: an update

Coinfection with human immunodeficiency virus (HIV) has a major effect on the natural history of many infectious diseases, particularly mycobacterial diseases. Early in the HIV epidemic, it was predicted that HIV infection would worsen leprosy outcomes, with more patients developing lepromatous disease, an impaired response to multidrug therapy and fewer reactions. However, studies on the epidemiologic and clinical aspects of leprosy suggest that the course of leprosy in coinfected patients has not been greatly altered by HIV. In contrast, initiation of antiretroviral treatment has been reported to be associated with activation of subclinical Mycobacterium leprae infection and exacerbation of existing leprosy lesions. With regular new discoveries about the interaction of leprosy and HIV, the need to maintain research in this field is of considerable importance.