Bacterial sexually transmitted diseases

Epidemiological analysis of blood donors from college students in Hefei city

RATIONALE

College students represent a unique demographic group as they are adults no longer under direct parental care, yet often lack the institutional health support available to more established members of society, which can lead to their health needs being neglected, despite their substantial contributions to blood donation. The objective of this study is to shed light on the health status of college students in Hefei, with a specific focus on transfusion-transmitted diseases. Based on the detailed data analysis, the implementation of some constructive strategies will play a good warning role in improving clinical blood safety and promoting better health monitoring of this population in the future.

AIMS & OBJECTIVES

The study aims to achieve two main objectives: On the one hand, to deepen our understanding of college students' participation in blood donation activities. On the other hand, to propose effective strategies for increasing youth involvement. Additionally, such research aims to afford recommendations for ensuring the safety of clinical blood supplies. Although the strategies and suggestions presented are speculative, they are grounded in the logical analysis of data and relevant theoretical frameworks. Therefore, these recommendations serve as a basis for potential future testing and implementation.

METHOD

The evaluation process for blood samples at the Hefei Blood Bank involves thorough serological testing for hepatitis B and C, HIV, and Treponema pallidum using both Enzyme-Linked Immunosorbent Assay (ELISA) and Nucleic Acid Testing (NAT). HIV reactive samples were further confirmed using Western Blot techniques at an external specialized laboratory. To ensure accuracy, each sample was tested with reagents from two different manufacturers. Moreover, any initially reactive sample was retested with the same reagent to eliminate potential false positives. In cases of conflicting results, alternative reagent kits are utilized for further confirmatory tests. Only samples that consistently show reactive results in consecutive tests are considered positive confirmation samples.

RESULTS & CONCLUSION

Upon analysis of the data set, it was found that out of the total 663,105 donors, 177,089 (26.7%) were identified as college students, with the remaining 486,016 categorized as noncollege students. Our study demonstrated a notably lower prevalence of blood-transmitted infections among college students (0.48%) in contrast to the wider donor population (1.23%), underscoring their potential as safe blood donors. To uphold this level of safety and protect public health, it is crucial to increase disease prevention awareness and advocate for responsible donation practices within this specific demographic. Strengthening confidentiality protocols and expanding education on safe sexual behaviors in university settings are vital actions to cultivate an environment that promotes informed and secure blood donation.

IN TERMS OF SPECIFIC INFECTIONS

The overall group had prevalence rates of 0.44% for hepatitis B, 0.15% for hepatitis C, 0.02% for HIV, and 0.42% for Treponema pallidum. When focusing on the student cohort, the prevalence rates were 0.17% for hepatitis B, 0.04% for hepatitis C, 0.02% for HIV, and 0.23% for Treponema pallidum. Transmissibility through blood transfusion All donors (%) Students (%) Non-students (%) Any infection 1.23 0.48 1.51 HbsAg 0.44 0.17 0.54 Anti-HCV 0.15 0.04 0.19 HIV Ag/Ab 0.02 0.02 0.02 Anti-TP 0.42 0.23 0.49 Individuals with two or more infectious agents occur more than once in all categories. While it leads to numerical over-representation, such overlap is minimal and statistically insignificant.

Deep Learning-based structure modelling illuminates structure and function in uncharted regions of β-solenoid fold space

Repeat proteins are common in all domains of life and exhibit a wide range of functions. One class of repeat protein contains solenoid folds where the repeating unit consists of β-strands separated by tight turns. β-solenoids have distinguishing structural features such as handedness, twist, oligomerisation state, coil shape and size which give rise to their diversity. Characterised β-solenoid repeat proteins are known to form regions in bacterial and viral virulence factors, antifreeze proteins and functional amyloids. For many of these proteins, the experimental structure has not been solved, as they are difficult to crystallise or model. Here we use various deep learning-based structure-modelling methods to discover novel predicted β-solenoids, perform structural database searches to mine further structural neighbours and relate their predicted structure to possible functions. We find both eukaryotic and prokaryotic adhesins, confirming a known functional linkage between adhesin function and the β-solenoid fold. We further identify exceptionally long, flat β-solenoid folds as possible structures of mucin tandem repeat regions and unprecedentedly small β-solenoid structures. Additionally, we characterise a novel β-solenoid coil shape, the FapC Greek key β-solenoid as well as plausible complexes between it and other proteins involved in Pseudomonas functional amyloid fibres.

Mating-Induced Common and Sex-Specific Behavioral, Transcriptional Changes in the Moth Fall Armyworm (Spodoptera frugiperda, Noctuidae, Lepidoptera) in Laboratory

The intermediate process between mating and postmating behavioral changes in insects is still poorly known. Here, we studied mating-induced common and sex-specific behavioral and transcriptional changes in both sexes of Spodoptera frugiperda and tested whether the transcriptional changes are linked to postmating behavioral changes in each sex. A behavioral study showed that mating caused a temporary suppression of female calling and male courting behavior, and females did not lay eggs until the next day after the first mating. The significant differences on daily fecundity under the presence of males or not, and the same or novel males, suggest that females may intentionally retain eggs to be fertilized by novel males or to be fertilized competitively by different males. RNA sequencing in females revealed that there are more reproduction related GO (gene ontology) terms and KEGG (Kyoto encyclopedia of genes and genomes) pathways (mainly related to egg and zygote development) enriched to upregulated DEGs (differentially expressed genes) than to downregulated DEGs at 0 and 24 h postmating. In males, however, mating induced DEGs did not enrich any reproduction related terms/pathways, which may be because male reproductive bioinformatics is relatively limited in moths. Mating also induced upregulation on soma maintenance (such as immune activity and stress reaction) related processes in females at 0, 6 and 24 h postmating. In males, mating also induced upregulation on soma maintenance related processes at 0 h postmating, but induced downregulation on these processes at 6 and 24 h postmating. In conclusion, this study demonstrated that mating induced sex-specific postmating behavioral and transcriptional changes in both sexes of S. frugiperda and suggested that the transcriptional changes are correlated with postmating physiological and behavioral changes in each sex.

Lactobacillus spp. in the reproductive system of female moths and mating induced changes and possible transmission

BACKGROUND

The microbiome in the insect reproductive tract is poorly understood. Our previous study demonstrated the presence of Lactobacillus spp. in female moths, but their distribution and function remain unclear. Lactobacillus spp. are known as the 'healthy' vaginal microbiome in humans.

RESULTS

Here, we studied the microbiome in the reproductive system (RS) and gut of Spodoptera frugiperda using 16S rDNA sequences. The obtained 4315 bacterial OTUs were classified into 61 phyla and 642 genera, with Proteobacteria, Firmicutes and Bacteroidota being the top three dominant phyla and Enterococcus and Asaia being dominant genera in most samples. Mating dramatically increased the abundance of pathogens or pathogenic functions in the gut, while in the RS, the change range was trivial. Taxonomy assignment identified thirteen Lactobacillus spp. in S. frugiperda, with Lactobacillus crustorum and Lactobacillus murinus showing high abundance. Three species found in S. frugiperda, namely L. reuteri, L. plantarum and L. brevis, have also been identified as human 'healthy' vaginal bacterial species. Lactobacillus spp. showed higher abundance in the RS of virgin females and lower abundance in the RS of virgin males and the gut of virgin females. Mating reduced their abundance in the RS of females but increased their abundance in the RS of males, especially in males mated with multiple females. The RS of virgin females and of multiple mated males were very similar in terms of composition and abundance of Lactobacillus species, with Lactobacillus crustorum showing much higher abundance in both tissues, potentially due to sexual transmission.

CONCLUSIONS

Lactobacillus spp. showed high abundance and diversity in the RS of female moths. The higher abundance of Lactobacillus spp. in the RS of female moths and the similarity of Lactobacillus species in female moths with human 'healthy' vaginal Lactobacillus spp. suggest that these bacterial strains are also an important microbiome in the RS of female moths.

Prevalence of Syphilis Infections among the Iranian Population: A Systematic Review and Meta-Analysis

Background

Syphilis is one of the most important sexually transmitted infections (STI) and a public health problem, but the literature describing the true burden of syphilis is limited. In Iran, there are no accurate results on the prevalence of syphilis. This study aimed to conduct a systematic review and meta-analysis of syphilis in Iran.

Methods

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of studies published on the prevalence of Syphilis in Iran. We systematically reviewed the literature to identify eligible studies as of Sep 13, 2020, in international and national databases. The results are presented in the form of forest plots and tables. Pooled prevalence and 95% confidence intervals were calculated using Der Simonian and Laird method. Perform subgroup analysis through population, gender, city, and diagnostic tests to assess the source of heterogeneity.

Results

We reviewed 1,229 papers and reports, and extracted data from 15 eligible records. The prevalence of combined syphilis in Iran is 0.1% (95% confidence interval [95% CI] 0.1-0.1%). The prevalence of syphilis was 0.4% in men (95% confidence interval [95% CI] -0.3, 1%) and 0.6% in women (95% confidence interval [95% CI] (0.1, 1%)). The cumulative meta-analysis showed a decline in the prevalence of syphilis between the years 1999 and 2015.

Conclusion

The prevalence of syphilis in Iran is low. In the past few decades, the prevalence of syphilis across the country has declined. Syphilis infection is a small burden that needs to be revised in the implementation of high-cost screening programs.

Mating Leads to a Decline in the Diversity of Symbiotic Microbiomes and Promiscuity Increased Pathogen Abundance in a Moth

Mating may promote microbial diversity through sexual transmission, while mating-induced immune responses may decrease it. Therefore, the study of mating-induced microbiomes changes under different mating systems is informative to unravel its biological relevance and evolutionary significance. Here, we studied the microbiomes in a community context within the abdomen of Spodoptera frugiperda females using 16S rDNA sequences by setting virgin females, and females mated once, twice, or thrice with the same or different males. Alpha and beta diversities revealed that mating significantly affected the composition of microbiomes in S. frugiperda females, wherein virgin females have the highest diversity, followed by one-time mated females and females mated with multiple males, while females mated repeatedly with the same male showed the lowest diversity. The low diversity in females mated repeatedly with the same male may be due to lower sexual transmission as only mated with one mate and higher immune response from repeated matings. Functional prediction by FAPROTAX and literature searching found 17 possible pathogens and 12 beneficial microbiomes. Multiple mating turned over the abundance of pathogens and beneficial microbes, for example, Enterococcus and Lactobacillus spp. (beneficial) showed higher abundance in virgin females while Morganella and Serratia spp. (pathogens) showed higher abundance in females mated with multiple males. These results suggest that mating causes a decline in the diversity of symbiotic microbiomes and promiscuity incurs a higher pathogen abundance in S. frugiperda females, which may be the result of sexual transmission of bacterial strains and immune responses targeting members of the microbiomes. To our knowledge, we demonstrate microbiomes changes in female insects under virgin and different mating regimes for the first time.

Ocular Syphilis Mimicking Giant Cell Arteritis

Syphilis is a rare cause of vision loss that mostly occurs after an infection of the meninges, brain tissue, and parenchyma. Syphilis can mimic auto-immune disease like giant cell arteritis which also manifest as sudden vision loss. Spirochete Treponema pallidum can spread through sexual contact and cause painless ulcers. Spirochetes can disseminate systemically and lead to secondary syphilis. Ocular syphilis can affect all parts of the eye in secondary and tertiary stages. It can present as scleritis, inflammation of the optic nerve, and uveitis.

We present the case of a 59- year-old male suffering from severe vision loss in the left eye and headache initially misdiagnosed with giant cell arteritis. He was correctly diagnosed with ocular syphilis after seeing a red macular rash on palms and soles, and was given penicillin G and probenecid. His visual acuity and field of vision improved soon.

Ocular syphilis is usually diagnosed late or misdiagnosed and leads to irreversible vision loss. Physicians should keep in mind the possibility of ocular syphilis in patients presenting with a sudden loss of vision and severe headaches.

Simultaneous identification of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis ‒ multicenter evaluation of the Alinity m STI assay

Objectives

Accurate and rapid diagnosis of sexually transmitted infections (STIs) is essential for timely administration of appropriate treatment and reducing the spread of the disease. We examined the performance of the new Alinity m STI assay, a qualitative real-time multiplex PCR test for simultaneous identification of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma genitalium (MG), and Trichomonas vaginalis (TV) run on the fully automated Alinity m platform.

Methods

This international, multicenter study evaluated the accuracy, reproducibility, and clinical performance of the Alinity m STI assay compared to commonly used STI assays in a large series of patient samples encountered in clinical practice.

Results

The Alinity m STI assay identified accurately and precisely single and mixed pathogens from an analytical panel of specimens. The Alinity m STI assay demonstrated high overall agreement rates with comparator STI assays (99.6% for CT [n=2,127], 99.2% for NG [n=2,160], 97.1% for MG [n=491], and 99.4% for TV [n=313]).

Conclusions

The newly developed Alinity m STI assay accurately detects the 4 sexually transmitted target pathogens in various collection devices across clinically relevant specimen types, regardless of single or mixed infection status.

Inorganic and Polymeric Nanoparticles for Human Viral and Bacterial Infections Prevention and Treatment

Infectious diseases hold third place in the top 10 causes of death worldwide and were responsible for more than 6.7 million deaths in 2016. Nanomedicine is a multidisciplinary field which is based on the application of nanotechnology for medical purposes and can be defined as the use of nanomaterials for diagnosis, monitoring, control, prevention, and treatment of diseases, including infectious diseases. One of the most used nanomaterials in nanomedicine are nanoparticles, particles with a nano-scale size that show highly tunable physical and optical properties, and the capacity to a wide library of compounds. This manuscript is intended to be a comprehensive review of the available recent literature on nanoparticles used for the prevention and treatment of human infectious diseases caused by different viruses, and bacteria from a clinical point of view by basing on original articles which talk about what has been made to date and excluding commercial products, but also by highlighting what has not been still made and some clinical concepts that must be considered for futures nanoparticles-based technologies applications.

Proctitis: a glance beyond inflammatory bowel diseases

Proctitis is an inflammation involving the anus and the distal part of the rectum, frequently diagnosed in the context of inflammatory bowel diseases (IBD). Nevertheless, when the standard therapy for IBD is ineffective, it becomes necessary for the clinician to review alternative etiologies, beginning from the broad chapter of infectious causes up to rare causes such as radiation, ischemia, diversion and traumatisms. While it is possible to find infectious proctitides caused by pathogens generally inducing extensive colitis, the growing incidence of both sexually transmitted infections and isolated proctitis reported in the recent years require a lot of attention. The risk appears to be higher in individuals participating in anal intercourse, especially men having sex with men (MSM) or subjects who use sex toys and participate to sex parties, dark rooms and so on. The commonest implicated pathogens are Neysseria gonorrhoeae, Chlamydia trachomatis, Herpes Simplex virus and Treponema pallidum. Herpes and Chlamydia infections mainly occur in HIV-positive MSM patients. Since symptoms and signs are common independently from etiology, performing a differential diagnosis based on clinical manifestations is complicated. Therefore, the diagnosis is supported by the combination of clinical history and physical examination and, secondly, by endoscopic, serologic and microbiologic findings. Particular emphasis should be given to simultaneous infections by multiple organisms. The involvement of experts in infectious diseases and in sexual health is crucial for the diagnostic and therapeutic management. The available therapies, empirically initiated or specific, in many cases are able to guarantee a good prognosis and to prevent relapses.

Mating-Induced Differential Expression in Genes Related to Reproduction and Immunity in Spodoptera litura (Lepidoptera: Noctuidae) Female Moths

Mating promotes reproductive activity, which may impact immune performance. Paradoxically, mating frequently challenges females' immunity (e.g., infections). Therefore, studies of postmating resource allocation between reproduction and survival are likely to shed new light on life-history trade-off and sexual selection. Here, we used RNAseq to test whether and how mating affected mRNA expression in genes related to reproduction and immunity in Spodoptera litura female moths. Results show a divergent change in the differentially expressed genes (DEGs) between reproduction and immunity: the immune response was largely downregulated shortly after mating (~6 h postmating), which has some recovery at 24 h postmating; reproductive response is trivial shortly after mating (~6 h postmating), but it largely upregulated at 24 h postmating (e.g., egg maturation related genes were highly upregulated). Considering the fact that most of the total DEGs downregulated from 0 to 6 h postmating (from 51/68 to 214/260) but most of the total DEGs upregulated at 24 h postmating (816/928), it is possible that trade-offs between reproduction and immunity occurred in mated females. For example, they may shut down immunity to favor sperm storage and save limited resources to support the increased energy required in reproduction (e.g., egg maturation and oviposition). Mating-induced infections should be trivial due to low polyandry in S. litura. A reduced immune defense may have no threat to S. litura survival but may benefit reproduction significantly. Furthermore, obvious expression changes were detected in genes related to hormone production, suggesting that endocrine changes could play important roles in postmating responses.

Gonorrhea and syphilis co-infection and related risk factors in HIV patients from Shiraz, South of Iran

Background:

Neisseria gonorrhea and Treponema pallidum as an obligate human pathogen are two common causes of sexually transmitted diseases (STDs). The present study aimed to determine the prevalence of N. gonorrhoeae and T. pallidum among human immunodeficiency virus (HIV) patients in the southwest Iran.

Methods:

This retrospective study was performed from 2004 to 2013, on HIV patients who were tested for detection of gonorrhea and syphilis infection at Shiraz HIV/AIDS Research Center. ELISA technique was used for preliminary detection of HIV and confirmed by a Western Blotting test. Gonorrhea was routinely diagnosed using direct Gram-staining and culturing on selective agar. Syphilis was routinely diagnosed by RPR test.

Results:

Of the 806 HIV patients, 39 (2.6%) cases had co-infection with gonorrhea. Compared with mono-HIV infected patients, gonorrhea was significantly more likely among the males (69.4% vs. 92.3%, P=0.002). History of addiction and prison seems to be a significant risk factor for gonorrhea infection (P<0.05). Also, the mean of CD4+lymphocyte was higher among gonorrhea infected patients (368±238 vs. 415±328). Logistic regression analysis showed that sexual contact increased risk of gonococcal infection about 4 fold (OR: 4, CI: 1.7-9.39, P=0.001). None of the HIV patients had syphilis co-infection.

Conclusions:

As a preliminary survey, our findings provided unique information on the prevalence of gonorrhea and syphilis co-infections among HIV patients. Moreover, we introduced the main risk factors associated with gonorrhea co-infection in HIV patients in our region including gender, history of addiction and prison, CD4+lymphocyte count, and transmission routes for effective management of STDs.

Prevalence and Risk Factors for Rectal and Urethral Sexually Transmitted Infections From Self-Collected Samples Among Young Men Who Have Sex With Men Participating in the Keep It Up! 2.0 Randomized Controlled Trial

BACKGROUND

Despite recommendations that sexually active men who have sex with men be regularly tested for sexually transmitted infections (STIs) and that testing reflect anatomical sites of potential exposure, regular testing is not widely performed, especially for rectal STIs. As such, little is known about the prevalence of rectal and urethral STIs among young men who have sex with men (YMSM).

METHODS

The current study examined the prevalence and risk factors for rectal and urethral chlamydia and gonorrhea in a sample of 1113 YMSM ages 18 to 29 years (mean, 24.07 years). Before participating in a randomized controlled trial for an online human immunodeficiency virus prevention program (Keep It Up! 2.0), participants completed self-report measures and self-collected urine and rectal samples. Participants mailed samples to a laboratory for nucleic acid amplification testing. Viability of self-collected samples was examined as a potential method to increase STI screening for MSM without access to STI testing clinics.

RESULTS

Results indicated that 15.1% of participants tested positive for an STI, 13.0% for a rectal STI, 3.4% for a urethral STI, and 1.2% for both rectal and urethral STIs. Rectal chlamydia was significantly more common (8.8%) than rectal gonorrhea (5.0%). Rectal STIs were higher among black YMSM compared with white YMSM. Additionally, rectal STIs were positively associated with condomless receptive anal sex with casual partners.

CONCLUSIONS

Findings call attention to the need for health care providers to test YMSM for rectal STIs. This study also demonstrates the viability of including self-collected samples for STI testing in an eHealth program.

Characteristics Associated With Urethral and Rectal Gonorrhea and Chlamydia Diagnoses in a US National Sample of Gay and Bisexual Men: Results From the One Thousand Strong Panel

BACKGROUND

Gay and bisexual men are at elevated risk for Neisseria gonorrhoeae and Chlamydia trachomatis (GC/CT). Rectal GC/CT symptoms may be less obvious than urethral, increasing opportunities for undiagnosed rectal GC/CT.

METHODS

A US national sample of 1071 gay and bisexual men completed urethral and rectal GC/CT testing and an online survey.

RESULTS

In total, 6.2% were GC/CT positive (5.3% rectal, 1.7% urethral). We calculated adjusted (for education, race, age, relationship status, having health insurance, and income) odds ratios for factors associated with rectal and urethral GC/CT diagnoses. Age was inversely associated with urethral and rectal GC/CT. Compared with white men, Latinos had significantly greater odds of rectal GC/CT. Among men who reported anal sex, those reporting only insertive sex had lower odds of rectal GC/CT than did men who reported both insertive and receptive. There was a positive association between rectal GC/CT and number of male partners (<12 months), the number of anal receptive acts, receptive condomless anal sex (CAS) acts, and insertive CAS acts. Compared with those who had engaged in both insertive and receptive anal sex, those who engaged in only receptive anal sex had lower odds of urethral GC/CT. The number of male partners (<12 months) was associated with increased odds of urethral GC/CT.

CONCLUSIONS

Rectal GC/CT was more common than urethral and associated with some demographic and behavioral characteristics. Our finding that insertive CAS acts was associated with rectal GC/CT highlights that providers should screen patients for GC/CT via a full range of transmission routes, lest GC/CT go undiagnosed.

Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis

Chronic proctitis refers to persistent or relapsing inflammation of the rectum, which results from a wide range of etiologies with various pathogenic mechanisms. The patients may share similar clinical presentations. Ulcerative proctitis, chronic radiation proctitis or proctopathy, and diversion proctitis are the 3 most common forms of chronic proctitis. Although the diagnosis of these disease entities may be straightforward in the most instances based on the clinical history, endoscopic, and histologic features, differential diagnosis may sometimes become problematic, especially when their etiologies and the disease processes overlap. The treatment for the 3 forms of chronic proctitis is different, which may shed some lights on their pathogenetic pathway. This article provides an overview of the latest data on the clinical features, etiologies, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.

Gonorrhoea of the sigmoid neovagina in a male-to-female transgender

A 33-year-old male-to-female transgender consulted our outpatient clinic with perneovaginal bleeding during and following coitus. Four years before, she underwent a total laparoscopic sigmoid neovaginoplasty. Physical, histological and endoscopic examination revealed neither focus of active bleeding nor signs of active inflammation. A polymerase chain reaction test performed on a neovaginal swab showed gonococcal infection. Treatment consisted of 500 mg intramuscular ceftriaxone. Three weeks later, our patient reported resolution of symptoms, consistent with eradication of the infection demonstrated by a follow-up neovaginal swab polymerase chain reaction. To our knowledge, this is the first case report of gonococcal infection of the sigmoid neovagina.

Sex, lies, and gastrointestinal tract biopsies: a review of selected sexually transmitted proctocolitides

There are many insults that result in gastrointestinal tract inflammation. Infections can be particularly challenging because (1) only a limited number of organisms provoke a specific endoscopic and/or histologic appearance; and (2) although some organisms may be present on biopsies, the findings may be so subtle or organisms so few that they are easily missed if the reviewer is not performing a specific search for the offender. Sexually transmitted infections (STI) are rarely a consideration at the time of GI biopsy examination and clinicians rarely inquire about sexual behavior at the time of initial patient interview. Although establishing a definitive STI diagnosis is not possible on histology alone, these infections are associated with inflammatory patterns that may help raise this diagnostic possibility. Becoming familiar with these patterns is necessary as worldwide outbreaks of these infections are being reported. This review aims to provide the pathologist with histologic clues associated with the most frequently encountered bacterial pathogens in the setting of STI proctitis, namely, Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum.

Pruritus ani: diagnosis and treatment

Pruritus ani is a common condition with multiple causes. Primary causes are thought to be fecal soiling or food irritants. Secondary causes include malignancy, infections including sexually transmitted diseases, benign anorectal diseases, systemic diseases, and inflammatory conditions. A broad differential diagnosis must be considered. A reassessment of the diagnosis is required if symptoms or findings are not responsive to therapy. The pathophysiology of itching, an overview of primary and secondary causes, and various treatment options are reviewed.