An overview of sexually transmitted diseases. Part I

Sexually transmitted diseases are a persistent problem in the United States and throughout the world. Many of these infections involve the skin and may be encountered in the field of dermatology. This 3-part review highlights the cutaneous features, diagnosis, and treatment of 11 of the most commonly encountered sexually transmitted diseases, other than AIDS. However, this review does not cover sexually transmitted diseases such as chlamydia, which do not regularly have cutaneous manifestations. Part 1 focuses on syphilis, disseminated gonococcal infection, chancroid, lymphogranuloma venereum, granuloma inguinale, and genital herpes. Additional features, such as epidemiology and transmission of the organism, are discussed when applicable.

Granuloma inguinale (donovanosis) presenting as a neck mass in an infant

A case of granuloma inguinale (GI) presenting as a lateral neck mass in a 4-month-old, HIV-positive infant is described. The histological features of the mass were typical of GI, with numerous macrophages containing intracellular organisms with a "closed-safety-pin" appearance. This is a rare occurrence, and the mode of transmission of infection is discussed. An awareness of GI in infants by both clinicians and pathologists is important to prevent morbidity and allow for prompt institution of appropriate treatment.

Granuloma inguinale (donovanosis): an unusual cause of otitis media and mastoiditis in children

Granuloma inguinale (donovanosis) is seen predominantly in adults (it rarely occurs in children) and mainly affects genital skin and mucosa. Infection occurs at other skin and mucosal sites, and hematogenous dissemination to bone also has been described. The infection responds dramatically to appropriate antibiotic treatment. We present two cases of granuloma inguinale occurring in children (8 months and 5 months of age) causing mastoiditis and external ear discharges. A temporal lobe abscess also developed in the 8-month-old child. Subsequent computed tomography scans showed marked improvement in the brain lesion after treatment. The second child had a polypoid mass in the middle ear that on biopsy showed the features of granuloma inguinale. The mother of this child had biopsy-proven granuloma inguinale of the uterine cervix. These cases indicate that granuloma inguinale can be transmitted during vaginal delivery, and careful cleansing of neonates born to infected mothers is recommended.

Knowledge about AIDS and follow-up compliance in patients attending a sexually transmitted disease clinic in the highlands of Papua New Guinea

In a survey of 300 consecutive new attenders at the Porgera Health Centre Sexually Transmitted Disease Clinic information was obtained regarding knowledge about AIDS from male and female attenders. The differences between the sexes regarding a variety of socioeconomic variables, knowledge about AIDS and their compliance to follow-up appointments were studied as well as possible relationships between these social variables and the degrees of AIDS knowledge and compliance. Males tended to originate from further afield, be more educated, be either in salaried employment or not working at all, and be single as compared to females. They also admitted to more extramarital sexual contacts and received more adequate treatment. Knowledge about AIDS was also significantly higher amongst male attenders and in this group was correlated strongly with overall educational attainment and employment status but did not show any relationship with the number of extramarital contacts admitted to. Only 9% of the patients knew about condoms and their role in prevention. Follow-up compliance was generally poor, and not significantly higher in those with higher scores of knowledge about AIDS, but showed a relationship with the type of disease being treated and with the ultimate adequacy of treatment received.

Dermatologic manifestations of sexually transmitted diseases other than HIV

This article focuses on the common skin manifestations of sexually transmitted diseases. A number of unusual skin lesions associated with these diseases are shown, and pathogenesis and treatment are briefly presented. This article will be most useful as a reference for the formulation of the differential diagnosis of genital area skin lesions.

Mucocutaneous manifestations of chancroid, lymphogranuloma venereum and granuloma inguinale

The sexually transmitted diseases chancroid, lymphogranuloma venereum and granuloma inguinale should be familiar to physicians who care for patients at risk. The mucocutaneous manifestations of these three diseases must be distinguished from the lesions of other venereal diseases, such as primary syphilis and genital herpes simplex. Human immunodeficiency virus (HIV) infection should always be considered in patients with any venereal disease, since sexually transmitted diseases often occur together. Furthermore, the genital erosions that occur in patients with these three disorders may predispose them to HIV infection.

Genital ulcer disease: accuracy of clinical diagnosis and strategies to improve control in Durban, South Africa

OBJECTIVE

To investigate the accuracy of clinical diagnosis in genital ulcer disease (GUD); to devise management strategies for improving the control of GUD and thereby limit the spread of HIV-1 infection.

DESIGN

Clinical and microbiological assessment of GUD in men and women. The index of suspicion, diagnostic accuracy, diagnostic efficiency and positive and negative predictive values of a clinical diagnosis were investigated.

SETTING

City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa.

PARTICIPANTS

100 men and 100 women with genital ulcers.

RESULTS

The accuracy of a clinical diagnosis was, in men: lymphogranuloma venereum (LGV) 66%, donovanosis 63%, chancroid 42%, genital herpes 39%, primary syphilis 32%, mixed infections 8%, and in women; secondary syphilis 94%, donovanosis 83%, genital herpes 60%, primary syphilis 58%, chancroid 57%, LGV 40%, mixed infections 14%. Overall, diagnostic efficiency was greater in women than in men. When compared with other causes of GUD, donovanosis ulcers bled to the touch and were larger and not usually associated with inguinal lymphadenopathy. In women, extensive vulval condylomata lata were readily differentiated from all other causes of GUD.

CONCLUSION

A clinical diagnosis in genital ulceration was less accurate in men than in women. The diagnostic accuracies for donovanosis and secondary syphilis were relatively high but for most other conditions were low. Differences between clinical and laboratory diagnostic accuracies may reflect similarities between the clinical appearances of the various causes of GUD, the presence of mixed infections, atypical ulceration due to longstanding disease, and insensitive laboratory tests. In this community all large ulcers should be treated empirically for syphilis and donovanosis. Uncircumcised men with GUD are an important HIV core or "superspreader" group locally, and prevention strategies should include counselling and health education in the light of the inaccuracy of clinical diagnosis found in this study. The development of rapid accurate tests for GUD is urgently required.

Laboratory techniques used in the diagnosis of chancroid, granuloma inguinale, and lymphogranuloma venereum

The preceding discussion summarized the historical, modern, and evolving laboratory techniques for the diagnosis of chancroid, GI, and LGV. The correct diagnosis of these sexually transmitted diseases, which are uncommon in the United States and Europe but often endemic in Africa, Asia, and South American, can usually be made if appropriately selected laboratory techniques are used to confirm the presumptive clinical impression.

Clinico-epidemiological study of donovanosis in Durban, South Africa

OBJECTIVE

To describe the epidemiological and clinical features of donovanosis and their relevance to the possible coincident risk of HIV-1 transmission in patients attending an STD clinic.

DESIGN

Assessment of patients with donovanosis diagnosed by the detection of Donovan bodies on tissue smears stained by the RapiDiff technique.

SETTING

City Health STD Clinic, King Edward VIII Hospital, Durban, South Africa.

PARTICIPANTS

One hundred and seventy one patients with donovanosis.

RESULTS

Donovan bodies were detected in 171 (130 men, 41 women). Ulcers were present for longer than 28 days in 72 (55.4%) men and 19 (46.3%) women. Ninety five (55.6%) came from rural areas. Lesions were ulcero-granulomatous in 162, hypertrophic in eight and necrotic in one. Anal lesions were detected in one woman. Only one of 21 regular sexual partners examined was infected with donovanosis. Complete healing was observed in 41 (24%) who attended for follow up. Extensive lesions were sometimes observed in pregnant women. Serological tests for syphilis were positive in 40 (23.4%). HIV-1 antibodies were detected in 4/48 men and 0/15 women who underwent HIV testing. Donovanosis ulcers in three HIV-1 seropositive men were cured by standard antibiotic therapy.

CONCLUSIONS

Delay in presentation, extensive areas of genital ulceration and lack of co-existent infection with donovanosis among sexual partners were notable features. Primary health care facilities in rural areas do not appear to be providing an adequate service for patients with donovanosis. HIV control programmes should consider specific measures aimed at eradicating donovanosis in areas where the condition is prevalent.

A serological test for granuloma inguinale

OBJECTIVES

An indirect immunofluorescence technique applied to paraffin embedded tissue sections of lesions containing Donovan bodies was evaluated as a serological test for the diagnosis of granuloma inguinale.

METHODS

Sera from patients with proven granuloma inguinale, other sexually acquired genital ulcerations and blood donors from areas where granuloma inguinale is rarely encountered as well as from disease-endemic regions were tested. Sera were tested either unabsorbed or following absorption with whole Klebsiella pneumoniae bacteria.

RESULTS

Using unabsorbed sera at a dilution of 1:160 the test was found to have a sensitivity of 100%, specificity of 98%, positive predictive value (PPV) of 89% and negative predictive value (NPV) of 100%. There proved to be no advantage in preabsorbing sera with K. pneumoniae antigen.

CONCLUSIONS

In the absence of culture methods for Calymmatobacterium granulomatis, an indirect immunofluorescence technique may prove valuable for the diagnosis of individual cases of granuloma inguinale and as an epidemiological tool in studies of the disease.