Sexually transmitted rectal infections in a cohort of 'men having sex with men'

Antimicrobial resistance determinants in the oropharyngeal microbiome of 'men having sex with men' attending an sexually transmitted infection clinic

BACKGROUND

'Men having sex with men' (MSM) represent a key population with a significant prevalence of pharyngeal Neisseria gonorrhoeae (NG) infections and a high rate of antimicrobial resistance genes in the pharyngeal microbiome. As NG can acquire antibiotic resistance genes from other commensal oropharyngeal bacteria, monitoring the prevalence of these resistance determinants is critical to curtail the spread of NG-resistant strains.

PURPOSE AND RESEARCH DESIGN

Here, we assessed the distribution of five resistance genes (pen (A), mtr (R), gyr (A), par (C), msr (D)) in the oropharynx of 164 MSM, attending an Outpatient clinic for STI screening.

RESULTS

The most frequently detected resistance gene was msr (D) (88.4%), followed by gyr (A) (67.1%). The distribution of resistance genes was not influenced by pharyngeal gonorrhea nor by the HIV status, whereas a younger age was associated with mtr (R) presence (p = .008). Subjects using mouthwash exhibited significantly lower levels of mtr (R) (p = .0005). Smoking habit was associated with a higher prevalence of par (C) (p = .02). A noteworthy association was observed between the presence of msr (D) gene and the use of antibiotics (p = .014).

CONCLUSIONS

Our findings reveal an enrichment of antimicrobial resistance genes in the oropharynx of MSM. These insights could aid in the development of screening programs and antimicrobial stewardship initiatives targeting populations at heightened risk of pharyngeal gonorrhea.

Chlamydia trachomatis and Neisseria gonorrhoeae rectal infections: Interplay between rectal microbiome, HPV infection and Torquetenovirus

Men having sex with men (MSM) represent a key population, in which sexually transmitted rectal infections (STIs) caused by Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and high-risk HPV (HR-HPV) are very common and linked to significant morbidity. Investigating the anorectal microbiome associated with rectal STIs holds potential for deeper insights into the pathogenesis of these infections and the development of innovative control strategies. In this study, we explored the interplay at the rectal site between C. trachomatis, N. gonorrhoeae, HR-HPV infection, and the anorectal microbiome in a cohort of 92 MSM (47 infected by CT and/or NG vs 45 controls). Moreover, we assessed the presence of Torquetenovirus (TTV), a non-pathogenic endogenous virus, considered as a possible predictor of immune system activation. We found a high prevalence of HR-HPV rectal infections (61%), especially in subjects with a concurrent CT/NG rectal infection (70.2%) and in people living with HIV (84%). In addition, we observed that TTV was more prevalent in subjects with CT/NG rectal infections than in non-infected ones (70.2% vs 46.7%, respectively). The anorectal microbiome of patients infected by CT and/or NG exhibited a reduction in Escherichia, while the presence of TTV was significantly associated with higher levels of Bacteroides. We observed a positive correlation of HR-HPV types with Escherichia and Corynebacterium, and a negative correlation with the Firmicutes phylum, and with Prevotella, Oscillospira, Sutterella. Our findings shed light on some of the dynamics occurring within the rectal environment involving chlamydial/gonococcal infections, HPV, TTV, and the anorectal microbiome. These data could open new perspectives for the control and prevention of STIs in MSM.

Orogenital and anal infection by Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and other sexually transmitted infections in men who have sex with men in Lisbon

BACKGROUND

Men who have sex with men (MSM) are at risk for sexually transmitted infections (STIs), but more data on extragenital carriage are needed.

AIM

We assessed the genital and extragenital prevalence of bacterial and other STIs in MSM in a Lisbon sexual health clinic.

METHODS

We screened oral, anal, and urine samples of MSM visiting the GAT-CheckpointLX clinic June 2017-December 2021 for Chlamydia trachomatis (including lymphogranuloma venereum, LGV), Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis, Mycoplasma hominis, Ureaplasma urealyticum, and U. parvum. Ano-oro-genital lesions were tested for LGV, Treponema pallidum, and Herpes Simplex Virus. Blood was tested for HIV and T. pallidum antibodies.

RESULTS

N. gonorrhoeae was found in 16.6% of the MSM followed by C. trachomatis (13.2%), M. genitalium (10.3%) and T. vaginalis (0.2%). The most frequent occurrence was anorectal (C. trachomatis, M. genitalium) and oral (N. gonorrhoeae). We found high carriage of U. urealyticum (36.1%) and M. hominis (22.1%). LGV was detected in 21.8% of chlamydia-positive anorectal swabs. Syphilis was detected in 22.6% of tested MSM, while 13.8% had HIV. Gonorrhoea and chlamydia were significantly more prevalent in MSM with concomitant HIV or syphilis.

CONCLUSION

The substantial extragenital prevalence of bacterial STIs in MSM, and HIV and syphilis coinfections, suggest screening has value in identifying hidden carriage and in contributing for providing better care.

Clinic-based evaluation of the dual Xpert CT/NG assay on the GeneXpert System for screening for extragenital chlamydial and gonococcal infections amongst men who have sex with men

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections have increased globally. Asymptomatic infections represent a significant risk of long-term complications. Men who have sex with men (MSM) are disproportionally affected, underscoring the need to offer screening programmes to this population. CT/NG Point of Care Testing (POCT) constitutes a strategic tool to improve the continuum of STI care, however extensive real-life evaluations amongst at risk populations are lacking. The aim of this study is to estimate the GeneXpert CT/NG assay performance and usability for CT and NG at genital and extragenital sites for screening amongst MSM.

METHODS

This study was a multi-site sexual health clinic-based evaluation (Italy, Malta and Peru) with consecutive enrolment. A first void urine sample (divided in two aliquots), two oropharyngeal and two anorectal swabs were collected for each study participant. One specimen set (one for each anatomical site) was tested with the dual index test (Cepheid) at the clinics by the healthcare staff, the other set with FDA/CE approved Nucleic Acid Amplification Tests (NAATs) at the laboratory. Clinical sites and reference laboratories participated in an internal and external quality control programme. Sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values for each anatomical site were estimated using a meta-analytic approach.

RESULTS

One thousand seven hundred two MSM were recruited across all clinical sites for a total of 5049 biological specimens. NG and CT were respectively detected in 274 and 287 of samples. Overall, the NG POCT sensitivity and specificity was 91.43% and 99.75% in urine (LR + 372.80, LR- 0.09), 89.68% and 99.55% in rectal specimens (LR + 197.30, LR- 0.10) and 75.87% and 98.77% at the pharynx respectively (LR + 61.94, LR- 0.24). The CT component of the POCT sensitivity was 84.82% and specificity 99.63% in urine (LR + 228.68, LR- 0.15), 78.07% and 99.19% respectively on rectal site (LR + 96.23, LR-0.22), 67.79% and 99.88% respectively at pharyngeal site (LR + 554.89, LR- 0.32). 95.95% of MSM reported to be willing to wait for POCT results and no provider reported difficulties in terms of performance or interpretation of the results of the Xpert CT/NG.

CONCLUSION

Rapid turnaround time, ease of use and high acceptability make the Xpert CT/NG testing system a strategic tool for increasing testing frequency, reaching those not yet tested and offering the possibility of immediate treatment if needed. The assay showed good negative likelihood ratios and confirms its use to rule out CT/NG infections. Sensitivity varied across sites and pathogens. Periodic staff training at the testing sites should be mandatory.

British Association of Sexual Health and HIV (BASHH) United Kingdom national guideline for the management of sexually transmitted enteric infections 2023

This is the first British Association of Sexual Health and HIV (BASHH) national guideline for the management of sexually transmitted enteric infections (STEI). This guideline is primarily aimed for level 3 sexual health clinics; however, it may also be applicable to other settings such as primary care or other hospital departments where individuals with STEI may present. This guideline makes recommendations on testing, management, partner notification and public health control of STEI.

Risk Prediction Score for Screening Asymptomatic Sexually Transmitted Infections in HIV-positive French Men Who Have Sex with Men (ANRS 9520 DRIVER)

OBJECTIVES

Asymptomatic sexually transmitted infections (STI) are frequent among men who have sex with men (MSM). Identifying asymptomatic STIs is a crucial issue, not only for secondary but also for primary prevention, as early treatment can reduce transmission risk. We aimed to develop a self-reported predictive score for early identification of asymptomatic STIs.

METHODS

Participants provided clinical data and completed a self-administered questionnaire including sociodemographic variables and behaviors during the 6 previous months. We used multivariable logistic regression to identify factors associated with asymptomatic STIs. We calculated the accuracy of the model by the non-parametric area (AUC) under the receiver-operating-characteristic (ROC) curve to find the optimal discriminant threshold for screening.

RESULTS

A total of 781 HIV-positive MSM were included with a mean age of 46.8 years. Asymptomatic STI prevalence was 13.2%. Detectable plasma HIV RNA (adjusted odds ratio (aOR [95% CI): 2.54 [1.23;5.25]), inconsistent condom use during anal sex (2.20 [1.36;3.56]), group sex (2.00 [1.15;3.45]), during or-genital practices (1.83 [1.12;3.01]), not being in stable relationship (1.70 [1.01;2.66] and an item from a sensation-seeking behavioral scale "I don't like watching porn videos" (1.61 [1.01;2.59] were associated with asymptomatic STI. AUC was 0.7 and with optimal threshold of 0.1082 for this model; sensitivity was 80.4%. Self-reported asymptomatic STI predictive score was built with this threshold according to the 6 factors in the final model.

CONCLUSIONS

As this predictive score is not designed to be diagnostic, but to provide indications for diagnostic tests, its ease of administration and sensitivity remain the most important features. Its use in clinical practice for early detection of asymptomatic STIs potentially can reinforce STI primary and secondary prevention.

Weighing Potential Benefits and Harms of Mycoplasma genitalium Testing and Treatment Approaches

This systematic review demonstrates increasing antimicrobial resistance and incomplete understanding of the bacterium’s natural history.

Since Mycoplasma genitalium was identified 40 years ago, much of the epidemiology has been described, diagnostic tests have been developed and approved, and recommended treatment approaches have been identified. However, the natural history remains incompletely understood, and antimicrobial resistance has rapidly increased. This review summarizes evidence published since the US Centers for Disease Control and Prevention 2015 Sexually Transmitted Diseases Treatment Guidelines. Data on sequelae remain insufficient, macrolide resistance is common, and fluoroquinolone resistance is increasing. Potential benefits of testing and treatment include resolving symptoms, interrupting transmission, and preventing sequelae. Potential harms include cost, patient anxiety, and increasing antimicrobial resistance.

Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, and Ureaplasma spp. Coinfection in an HIV-Positive Homosexual Man

A 21-year-old human immunodeficiency virus-positive male patient presented with complaints of multiple hyperpigmented verrucous papules over his perianal area. He reported having unprotected anal and oral sex with multiple male partners. On examination, superficial ill-defined perianal erosions were present. A first void urine sample and clinician-collected rectal and oropharyngeal swabs were sent for the detection of Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis , and Ureaplasma spp. Rectal swab tested positive for all the four pathogens. Oropharyngeal swab and urine samples tested positive for C. trachomatis . The patient was treated with doxycycline and moxifloxacin. This case underscores the importance of screening of men who have sex with men for possible coinfections with multiple sexually transmitted pathogens.

Gonorrhoea: a systematic review of prevalence reporting globally

BACKGROUND

The World Health Organization (WHO) recommends periodic gonorrhoea prevalence assessments in the general population or proxies thereof (including pregnant women, women attending family planning clinics, military recruits, and men undergoing employment physicals for example) and in population groups at increased risk, including men-who-have-sex-with-men (MSM) and sex workers.

METHOD

We evaluated reported prevalence data, including estimates from proxy general population samples to reflect the WHO recommendations. We describe the outcomes from the general population country-by-country and extend previous reviews to include MSM, sex workers, and extragenital infections.

RESULT AND CONCLUSION

In our systematic search, 2015 titles were reviewed (January 2010-April 2019) and 174 full-text publications were included. National, population-based prevalence data were identified in only four countries (the United States of America, the United Kingdom, Peru, New Caledonia) and local population-based estimates were reported in areas within five countries (China, South Africa, Brazil, Benin, and Malawi). The remaining studies identified only reported test positivity from non-probability, proxy general population samples. Due to the diversity of the reviewed studies, detailed comparison across studies was not possible. In MSM, data were identified from 64 studies in 25 countries. Rectal infection rates were generally higher than urogenital or pharyngeal infection rates, where extragenital testing was conducted. Data on sex workers were identified from 41 studies in 23 countries; rates in female sex workers were high. Current prevalence monitoring was shown to be highly suboptimal worldwide. Serial prevalence monitoring of critical epidemiological variables, and guidelines to optimize prevalence study conduct and reporting beyond antenatal settings are recommended.

Vaginal and Anal Microbiome during Chlamydia trachomatis Infections

Background.Chlamydia trachomatis (CT) is the agent of the most common bacterial sexually transmitted infection worldwide, with a significant impact on women's health. Despite the increasing number of studies about the vaginal microbiome in women with CT infections, information about the composition of the anal microbiome is still lacking. Here, we assessed the bacterial community profiles of vaginal and anal ecosystems associated or not with CT infection in a cohort of Caucasian young women. Methods. A total of 26 women, including 10 with a contemporary vaginal and ano-rectal CT infection, were enrolled. Composition of vaginal and anal microbiome was studied by 16S rRNA gene profiling. Co-occurrence networks of bacterial communities and metagenome metabolic functions were determined. Results. In case of CT infection, both vaginal and anal environments were characterized by a degree of dysbiosis. Indeed, the vaginal microbiome of CT-positive women were depleted in lactobacilli, with a significant increase in dysbiosis-associated bacteria (e.g., Sneathia, Parvimonas, Megasphaera), whereas the anal microbiota of CT-infected women was characterized by higher levels of Parvimonas and Pseudomonas and lower levels of Escherichia. Interestingly, the microbiome of anus and vagina had numerous bacterial taxa in common, reflecting a significant microbial 'sharing' between the two sites. In the vaginal environment, CT positively correlated with Ezakiella spp. while Gardnerella vaginalis co-occurred with several dysbiosis-related microbes, regardless of CT vaginal infection. The vaginal microbiome of CT-positive females exhibited a higher involvement of chorismate and aromatic amino acid biosynthesis, as well as an increase in mixed acid fermentation. Conclusions. These data could be useful to set up new diagnostic/prognostic tools, offering new perspectives for the control of chlamydial infections.

Chlamydia trachomatis anorectal infections by LGV (L1, L2 and L2b) and non-LGV serotypes in symptomatic patients in Buenos Aires, Argentina

BACKGROUND

Chlamydia trachomatis (CT) can infect the anorectum producing various signs and symptoms. There is scarce literature regarding the differences between LGV and non-LGV CT anorectal manifestations. We compare the clinical spectrum of LGV and non-LGV infections.

METHODS

Patients over 18 years with presumptive infectious anorectal symptoms were examined in two healthcare centres in Buenos Aires. The patients were studied and treated according to current sexually transmitted infection guidelines. Anorectal swabs were collected to detect and genotype CT.

RESULTS

A three-year-long study on 317 patients with anorectal symptoms showed 45.11% CT infection (85% LGV strains). Of 140 samples, 92 were sequenced: 80/119 LGV (L2b 45%, L1 32.5% and L2 22.5%) and 12/21 non-LGV. Older age and HIV+ status were significantly higher in the LGV group. Anal discharge, bleeding, severe proctitis and anal ulcers were more common in the LGV group. Multivariate logistic regression analysis revealed that HIV infection, anorectal bleeding and oro-anal sex are independent predictors of LGV infection.

CONCLUSIONS

In patients with anorectal symptoms, LGV serovars predominate over non-LGV ones. Clinical manifestations are not pathognomonic of a specific biovar. If genotyping is not available, having clinical predictors may help to presume an LGV infection and define length of treatment.

Comprehensive Molecular Screening in a Cohort of Young Men Who Have Sex With Men and Transgender Women: Effect of Additive Rectal Specimen Source Collection and Analyte Testing

BACKGROUND

This study's purposes were to characterize detection rates of several sexually transmitted infection (STI) agents and describe the effect additional specimen source and analyte screening has on STI detection within a cohort of young men who have sex with men and transgender women.

METHODS

Within a 16-month interval, 1966 encounters involved dual urine and rectal swab submissions assessed by commercial transcription-mediated amplification-based assays for Chlamydia trachomatis and Neisseria gonorrhoeae and by off-label transcription-mediated amplification-based Trichomonas vaginalis and Mycoplasma genitalium testing. Identification of STI carriers used algorithms involving Food and Drug Administration-cleared screening methods, laboratory-modified testing for extraurogenital C. trachomatis and N. gonorrhoeae, and laboratory-developed tests for T. vaginalis and M. genitalium.

RESULTS

Food and Drug Administration-indicated urine C. trachomatis and N. gonorrhoeae screening revealed 39 encounters (2.0%) yielding one or both agents. Via C. trachomatis and N. gonorrhoeae screening that included rectal swab analysis, 264 encounters (13.4%) yielded evidence of either (140 C. trachomatis, 88 N. gonorrhoeae) or both (36 participants) infections. Detection rates for C. trachomatis and N. gonorrhoeae were 1.4% and 0.6% for urine screening and 8.2% and 6.2% for rectal screening, respectively. Off-label screening identified 413 additional encounters with STI (5 T. vaginalis, 396 M. genitalium, 12 with both). Of these identifications, 82.1% were generated from analysis of rectal swabs (4 participants with T. vaginalis, 323 participants with M. genitalium, 12 with both). Overall detection rates of T. vaginalis (0.2% urine, 1.3% rectal) and M. genitalium (9.1% urine, 21.5% rectal) were variable.

CONCLUSIONS

Additive analyte testing, including extraurogenital collections, contributes to comprehensive STI screening within a high-risk demographic.

Whole-Genome Enrichment and Sequencing of Chlamydia trachomatis Directly from Patient Clinical Vaginal and Rectal Swabs

Chlamydia trachomatis, an obligately intracellular bacterium, is the most prevalent cause of bacterial sexually transmitted infections (STIs) worldwide. Numbers of U.S. infections of the urogenital tract and rectum have increased annually. Because C. trachomatis is not easily cultured, comparative genomic studies are limited, restricting our understanding of strain diversity and emergence among populations globally. While Agilent SureSelect^XT target enrichment RNA bait libraries have been developed for whole-genome enrichment and sequencing of C. trachomatis directly from clinical urine, vaginal, conjunctival, and rectal samples, public access to these libraries is not available. We therefore designed an RNA bait library (34,795 120-mer probes based on 85 genomes, versus 33,619 probes using 74 genomes in a previous one) to augment organism sequencing from clinical samples that can be shared with the scientific community, enabling comparison studies. We describe the library and limit of detection for genome copy input, and we present results of 100% efficiency and high-resolution determination of recombination and identical genomes within vaginal-rectal specimen pairs in women. This workflow provides a robust approach for discerning genomic diversity and advancing our understanding of the molecular epidemiology of contemporary C. trachomatis STIs across sample types, geographic populations, sexual networks, and outbreaks associated with proctitis/proctocolitis among women and men who have sex with men.IMPORTANCE Chlamydia trachomatis is an obligate intracellular bacterium that is not easily cultured, which limits our understanding of urogenital and rectal C. trachomatis transmission and impact on morbidity. To provide a publicly available workflow for whole-genome target enrichment and sequencing of C. trachomatis directly from clinical urine, vaginal, conjunctival, and rectal specimens, we developed and report on an RNA bait library to enrich the organism from clinical samples for sequencing. We demonstrate an increased efficiency in the percentage of reads mapping to C. trachomatis and identified recombinant and identical C. trachomatis genomes in paired vaginal-rectal samples from women. Our workflow provides a robust genomic epidemiologic approach to advance our understanding of C. trachomatis strains causing ocular, urogenital, and rectal infections and to explore geo-sexual networks, outbreaks of colorectal infections among women and men who have sex with men, and the role of these strains in morbidity.

Prevalence and incidence of hepatitis C virus infection in men who have sex with men: a systematic review and meta-analysis

BACKGROUND

WHO has set targets for hepatitis C virus (HCV) elimination by 2030. We did a global systematic review of HCV prevalence and incidence in men who have sex with men (MSM) to provide updated estimates that can guide community education and public health policy.

METHODS

We did a systematic review and meta-analysis of studies published and listed on MEDLINE or Embase between Jan 1, 2000, and Oct 31, 2019, including conference proceedings. Studies were eligible if they reported measures of HCV prevalence or HCV incidence (or both) among MSM. Studies that relied on participants' self-reported HCV status with no laboratory confirmation were excluded. Pooled HCV estimates in MSM were stratified by HIV status and by injecting drug use, then by WHO region and by income level. Random-effects meta-analysis was done to account for between-study heterogeneity and examined using the I² statistic. Pooled HCV prevalence was also compared with HCV estimates in the general population and presented as prevalence ratios (PRs). In HIV-negative MSM, incidence estimates were stratified by use of HIV pre-exposure prophylaxis (PrEP). The systematic review was registered with PROSPERO, number CRD42020156262.

FINDINGS

Of 1221 publications identified, 194 were deemed to be eligible and included in the systematic review and meta-analysis. Overall, the pooled HCV prevalence in MSM was 3·4% (95% CI 2·8-4·0; I²=98·0%) and was highest in Africa (5·8%, 2·5-10·4) and South-East Asia (5·0%, 0·0-16·6). Globally, HCV prevalence was 1·5% (1·0-2·1) in HIV-negative MSM and 6·3% (5·3-7·5) in HIV-positive MSM. Compared with the general population, HCV prevalence was slightly higher in HIV-negative MSM (PR 1·58, 95% CI 1·14-2·01) and markedly higher (6·22, 5·14-7·29) in HIV-positive MSM. Pooled HCV prevalence was substantially higher in MSM who had ever injected drugs (30·2%, 22·0-39·0) or currently injected drugs (45·6%, 21·6-70·7) than in those who never injected drugs (2·7%, 2·0-3·6). In HIV-negative MSM, the pooled HCV incidence was 0·12 per 1000 person-years (95% CI 0·00-0·72) in individuals not on PrEP and 14·80 per 1000 person-years (9·65-20·95) in individuals on PrEP. HCV incidence in HIV-positive MSM was 8·46 per 1000 person-years (6·78-10·32).

INTERPRETATION

HIV-positive MSM are at substantially increased risk of HCV. Overall, HIV-negative MSM had a slightly higher prevalence of HCV than the general population but had a lower prevalence than HIV-positive MSM. High HCV incidence in more recent PrEP studies suggests that as PrEP use increases, greater HCV transmission might occur. HCV burden in MSM varies considerably by region, which is likely to be associated with variation in the prevalence of injecting drug use and HIV.

FUNDING

World Health Organization.

Lymphogranuloma venereum genovariants in men having sex with men in Italy

Objectives

Lymphogranuloma venereum (LGV) is an STI caused by Chlamydia trachomatis serovars L1-L3. In Europe, the current epidemic is caused mainly by L2b genovariant, although increasing cases associated with other L2 variants have been reported. Here, we assessed the distribution of rectal LGV genovariants among men having sex with men (MSM) in Italy.

Methods

From 2016 to 2020, all the anorectal swabs collected from MSM attending the STI Clinic of St. Orsola-Malpighi Hospital in Bologna and positive for C. trachomatis were stored. LGV infection was confirmed by a pmpH PCR, and, subsequently, a fragment of the ompA gene was amplified and sequenced. Sequences were aligned to reference strains representing different LGV variants.

Results

LGV cases accounted for one-third of all chlamydial rectal infections with a total prevalence of 4.1% (76/1852). Total number of LGV cases per year remained constant. LGV was mainly found in symptomatic patients (>65%), older than 30 years, with a high burden of other STIs (63.7% HIV-positive, 35.5% with concurrent rectal gonorrhoea, 19.7% with early syphilis). A decreasing trend in HIV-LGV co-infection was noticed over time. Three main LGV genovariants were detected (L2f, 46.1%; L2b, 23.0%; L2-L2b/D-Da, 16.9%), together with other known L2b variants (mainly L2bV2 and L2bV4). Two novel L2b ompA variants with non-synonymous single-nucleotide polymorphisms were found. Over time, the percentage of L2f cases dropped gradually, with a significant increase in L2-L2b/D-Da cases (p=0.04).

Conclusions

In our area, LGV is endemic among MSM with different circulating genovariants. Active surveillance and genotyping programmes are needed to reduce re-establishing of LGV infection.

Investigating the decline in Lymphogranuloma venereum diagnoses in men who have sex with men in the United Kingdom since 2016: an analysis of surveillance data

Background Following an upward trajectory in Lymphogranuloma venereum (LGV) diagnoses in the UK from 2004 to 2016, with annual diagnoses increasing from 28 to 904, diagnoses fell to 641 in 2017; this was inconsistent with the upward trend in other bacterial sexually transmissible infections (STIs) between 2016 and 2017. An analysis of surveillance data from multiple sources to investigate the possible factors contributing to this decline in LGV was performed.

METHODS

LGV tests and diagnoses in the UK from 2004 to 2018 were captured through laboratory data from the LGV Reference Laboratories and laboratories conducting in-house LGV testing. These data and clinical diagnoses data from England were analysed alongside the national management guidelines issued over the course of the epidemic.

RESULTS

LGV diagnoses increased between 2004 and 2015 and then decreased between 2016 and 2018. LGV testing increased from 2010 to 2018 (2690-10850). Test positivity halved between 2015 (14.8%, 929-6272) and 2018 (7.3%, 791-10850). Peaks in LGV testing and diagnoses appeared to coincide with the publication of national LGV management guidelines and changes to clinical practice. The proportion of LGV diagnoses among HIV-positive men who have sex with men (MSM) fell between 2013 and 2018 (74-48%).

CONCLUSIONS

The fall in diagnoses and positivity were likely due to increasing earlier clinical diagnosis and treatment. Changes to the national management guidelines, the clinical policy and practice of some larger clinics and potentially changes to the guidelines for the treatment of chlamydia broadened the scope of testing and increased testing in asymptomatic patients which, in combination, likely had a positive effect on the control of LGV infection.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) have a higher prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections compared to the rest of the population, often remaining undiagnosed. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence and incidence of CT/NG infection using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25.9% in 81 MSM at follow-up (CT 14.8%, NG 14.8%, dual infection 3.7%). CT/NG incidence was estimated at 53.0 (95% CI, 34.5-81.3) per 100 person-years. Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex [adjusted odds ratio (aOR)=6.2, 95% CI (1.7-22.9)] and being in formal employment [aOR=7.5, 95% CI (1.1-49.2)]. Six NG isolates were obtained at follow-up; all were susceptible to ceftriaxone and cefixime and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: There is a high prevalence and incidence of asymptomatic rectal CT and NG in MSM reporting RAI in coastal Kenya. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) have a higher prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections compared to the rest of the population, often remaining undiagnosed. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence and incidence of CT/NG infection using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25.9% in 81 MSM at follow-up (CT 14.8%, NG 14.8%, dual infection 3.7%). CT/NG incidence was estimated at 53.0 (95% CI, 34.5-81.3) per 100 person-years. Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex [adjusted odds ratio (aOR)=6.2, 95% CI (1.7-22.9)] and being in formal employment [aOR=7.5, 95% CI (1.1-49.2)]. Six NG isolates were obtained at follow-up; all were susceptible to ceftriaxone and cefixime and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: There is a high prevalence and incidence of asymptomatic rectal CT and NG in MSM reporting RAI in coastal Kenya. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

Insights into penicillin-induced Chlamydia trachomatis persistence

Chlamydia persistence is a viable, but non-cultivable, growth stage, resulting in a long-term relationship with the infected host cell. In vitro, this condition can be induced by different stressor agents, including beta-lactam antibiotics, as penicillin. The aim of this study was to get new insights into the interactions between Chlamydia trachomatis (serovars D and L2) and the epithelial host cells (HeLa) during persistence condition. In particular, we evaluated the following aspects, by comparing the normal chlamydial development cycle with penicillin-induced persistence: (i) cell survival/death, (ii) externalization of phosphatidylserine, (iii) caspase 1 and caspase 3/7 activation, and (iv) reactive oxygen species (ROS) production by the infected cells. At 72 h post-infection, the cytotoxic effect displayed by CT was completely abolished for both serovars and for all levels of multiplicity of infection only in the cells with aberrant CT inclusions. At the same time, CT was able to switch off the exposure of the lipid phosphatidylserine on the surface of epithelial cells and to strongly inhibit the activation of caspase 1 and caspase 3/7 only in penicillin-treated cells. Forty-eight hours post-infection, CT elicited a significant ROS expression both in case of a normal cycle and in case of persistence. However, serovar L and penicillin-free infection activated a higher ROS production compared to serovar D and to penicillin-induced persistence, respectively. In conclusion, we added knowledge to the cellular dynamics taking place during chlamydial persistence, demonstrating that CT creates a suitable niche to survive, switching off signals able to activate phagocytes/leukocytes recruitment. Nevertheless, persistent CT elicits ROS production by the infected cells, potentially contributing to the onset of chronic inflammation and tissue damages.

Mosaic structure of the penA gene in the oropharynx of men who have sex with men negative for gonorrhoea

The oropharynx represents a crucial site for the emergence of multi-drug resistance in Neisseria gonorrhoeae. The mosaic penA alleles, associated with decreased susceptibility to cephalosporins, have emerged by DNA recombination with partial penA genes, particularly those from commensal pharyngeal Neisseria species. Here, we investigated the prevalence of the mosaic structure of the penA gene in the oropharynx of men who have sex with men testing negative for pharyngeal gonorrhoea. From January 2016 to June 2018, 351 gonorrhoea-negative men who have sex with men attending a sexually transmitted infection clinic in Italy were enrolled. Pharyngeal swabs underwent a real-time polymerase chain reaction (PCR) for the detection of the mosaic penA gene. In case of positivity, PCR products were sequenced and searched against several sequences of Neisseria strains. Overall, 31 patients (8.8%) were found positive for the presence of the mosaic penA gene. The positivity was significantly associated with previous cases of pharyngeal gonorrhoea (relative risk [RR]: 3.56, 95% confidence interval 1.44–8.80) and with recent exposure to beta-lactams (RR: 4.29, 95% confidence interval 2.20–8.38). All penA-positive samples showed a high relatedness (90–99%) with mosaic-positive Neisseria strains. Our data underline that commensal Neisseria species of the oropharynx may be a significant reservoir for genetic material conferring antimicrobial resistance in N. gonorrhoeae.

Prevalence of rectal Mycoplasma genitalium and macrolide resistance in men who have sex with men attending Sydney Sexual Health Centre

Background Sexually transmissible infections (STIs) have been increasing in men who have sex with men (MSM) in recent years; however, few studies have investigated the prevalence or antimicrobial resistance in rectal Mycoplasma genitalium in this group. This study aimed to determine the prevalence and predictors of rectal M. genitalium in MSM attending an urban sexual health service in Sydney, Australia, namely the Sydney Sexual Health Centre (SSHC), as well as estimate the rate of macrolide resistance.

METHODS

A prospective cross-sectional analysis was conducted of rectally asymptomatic MSM having a rectal swab collected as part of their routine care. Participants self-collected a rectal swab to be tested for M. genitalium and completed a 14-item questionnaire that provided information on behavioural risk factors. The prevalence of rectal M. genitalium was determined and multivariate analysis was performed to assess the associations for this infection. Positive specimens then underwent testing for macrolide-resistant mutations (MRMs) using the ResistancePlus MG assay (SpeeDx, Eveleigh, NSW, Australia).

RESULTS

In all, 742 patients were consecutively enrolled in the study. The median age was 31 years (interquartile range 27-39 years), with 43.0% born in Australia. Overall, 19.0% of men were bisexual, 22.9% were taking pre-exposure prophylaxis (PrEP) and 4.3% were HIV positive. The prevalence of rectal M. genitalium was 7.0% (95% confidence interval (CI) 5.3-9.1) overall and 11.8% in those taking PrEP. On multivariate analysis, PrEP use was significantly associated with having rectal M. genitalium (odds ratio 2.01; 95% CI 1.09-3.73; P = 0.01). MRMs were detected in 75.0% (36/48; 95% CI 60.4-86.4%) of infections.

CONCLUSION

Rates of rectal M. genitalium infection were high among asymptomatic MSM attending SSHC and MRMs were detected in 75% of infections. PrEP use was found to be significantly associated with rectal M. genitalium infection. These data contribute to the evidence base for screening guidelines in MSM.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) have a higher prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections compared to the rest of the population, often remaining undiagnosed. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence and incidence of CT/NG infection using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25.9% in 81 MSM at follow-up (CT 14.8%, NG 14.8%, dual infection 3.7%). CT/NG incidence was estimated at 53.0 (95% CI, 34.5-81.3) per 100 person-years. Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex [adjusted odds ratio (aOR)=6.2, 95% CI (1.7-22.9)] and being in formal employment [aOR=7.5, 95% CI (1.1-49.2)]. Six NG isolates were obtained at follow-up; all were susceptible to ceftriaxone and cefixime and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: There is a high prevalence and incidence of asymptomatic rectal CT and NG in MSM reporting RAI in coastal Kenya. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

Rectal Microbiota Associated With Chlamydia trachomatis and Neisseria gonorrhoeae Infections in Men Having Sex With Other Men

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) represent the most common agents of sexually transmitted rectal infections among men having sex with other men (MSM). In this study, we assessed the bacterial composition of the rectal microbiota associated with CT and/or NG infections in a cohort of men reporting unsafe rectal intercourse. A total of 125 rectal swabs were collected and four groups were compared: non-infected subjects (n = 53), patients with CT (n = 37), or NG rectal infection (n = 17) and patients with contemporary positivity for CT/NG (n = 18). CT and NG infections were detected by a real-time commercial test and the rectal microbiota composition was analyzed from rectal swabs through sequencing of the hypervariable V3-V4 regions of the 16S rRNA gene. The rectal microbiota of all subgroups was dominated by Prevotellaceae, Enterobacteriaceae, and Ruminococcaceae families. Irrespective of the analyzed subgroup, we found that the rectal environment of all the enrolled MSM was rich in Prevotella and Escherichia genera. Moreover, a shift in the bacterial composition between patients with sexually transmitted rectal infections and controls was noticed: infected patients were characterized by a depletion of Escherichia species, associated with an increase of anaerobic genera, including Peptoniphilus, Peptostreptococcus, and Parvimonas. Overall, the presence of rectal symptoms did not significantly modify the rectal microbiota profiles among the four groups of analyzed patients. We confirmed that HIV-positive patients are characterized by a lower bacterial richness than HIV-negative subjects. However, we found that the presence of HIV has a different impact on bacterial rectal communities compared to CT and NG infections, modifying the relative abundance of several genera, including Gardnerella, Lactobacillus, Corynebacterium, and Sutterella. Information about the rectal microbiota composition in CT and NG infections could shed light on the pathogenesis of these conditions and could contribute to the onset of new strategies for their control.

Diversity of vaginal microbiome and metabolome during genital infections

We characterized the vaginal ecosystem during common infections of the female genital tract, as vulvovaginal candidiasis (VVC, n = 18) and Chlamydia trachomatis infection (CT, n = 20), recruiting healthy (HC, n = 21) and bacterial vaginosis-affected (BV, n = 20) women as references of eubiosis and dysbiosis. The profiles of the vaginal microbiome and metabolome were studied in 79 reproductive-aged women, by means of next generation sequencing and proton based-nuclear magnetic resonance spectroscopy. Lactobacillus genus was profoundly depleted in all the genital infections herein considered, and species-level analysis revealed that healthy vaginal microbiome was dominated by L. crispatus. In the shift from HC to CT, VVC, and BV, L. crispatus was progressively replaced by L. iners. CT infection and VVC, as well as BV condition, were mainly characterised by anaerobe genera, e.g. Gardnerella, Prevotella, Megasphaera, Roseburia and Atopobium. The changes in the bacterial communities occurring during the genital infections resulted in significant alterations in the vaginal metabolites composition, being the decrease of lactate a common marker of all the pathological conditions. In conclusion, according to the taxonomic and metabolomics analysis, we found that each of the four conditions is characterized by a peculiar vaginal microbiome/metabolome fingerprint.

Mycoplasma Genitalium and Mycoplasma Hominis are prevalent and correlated with HIV risk in MSM: a cross-sectional study in Shenyang, China

Background

A high proportion of men who have sex with men (MSM) use geosocial networking apps (Apps) to seek partners. However, the relationship of app use with HIV risk is unknown. Further, the risks of some sexually transmitted infection (STIs), including Mycoplasma genitalium, have seldom been studied among MSM.

Methods

MSM were enrolled at a community-based HIV testing site in Shenyang, China. After completing a questionnaire survey, we collected rectal swabs and venous blood specimens. We then simultaneously tested for ten STIs (Chlamydia trachomatis [CT], Neisseria gonorrhea [NG], Ureaplasma urealyticum [Uu], Ureaplasma parvum species [Up1, Up3, Up6, Up14), Mycoplasma hominis [Mh], Mycoplasma genitalium [Mg], and Herpes Simplex Virus Type 2 (HSV-2) using multiple PCR. We also performed blood tests for HIV, Syphilis, Hepatitis C antibody (HCV-Ab), Hepatitis B Surface Antigen (HBsAg), and Hepatitis A-IgM (HAV-IgM), etc.

Results

One hundred and eighty-three MSM participated in this study, of which 51.4% reported seeking partners through apps in the past year. The prevalence of HIV was 19.7%, Syphilis 12.0%, HAV 1.1%, rectal Mg 15.3% and Mh 7.1%. Multivariable logistic regression showed that HIV infection was independently correlated with app-using behavior (adjusted odds ratio[aOR] = 2.6), Mg infection (aOR = 3.2), Mh infection (aOR = 4.1) and Syphilis infection (aOR = 3.1) (each P < 0.05).

Conclusions

App use, Mg, Mh and Syphilis infection were correlated with higher HIV Risk in MSM. Geosocial networking apps should be utilized for HIV interventions targeting MSM. There is a need for more expansive STIs screening, particularly for Mg, Mh and Syphilis in MSM.

Misclassification of sexual health risks in a self-identified low risk cohort of men who have sex with men (MSM) enrolled in a community based PrEP program

The CDC recommends PrEP for MSM at substantial risk of HIV acquisition, leaving clinicians unsure whether to prescribe PrEP to MSM who do not disclose HIV risk factors. A longitudinal cohort of MSM requesting PrEP despite reporting during a clinical visit either 100% condom use or participation in oral sex only and no other risk factors was followed over 13 months at a community clinic in San Francisco to assess the accuracy of their HIV risk perception. Participants completed a sexual and substance use behavior questionnaire at baseline, outside of the clinical visit and were followed by quarterly HIV/STI testing and condom use change questionnaires. Condomless sex increased from 0% at baseline to 12% at month 1, peaked at 34% at month 7, and then decreased again to 8% at month 13. Rates of pharyngeal GC/CT varied from 7% at baseline to 12% at month 13, while rectal GC/CT decreased from 6% at baseline to 0% at month 13. The rate of syphilis was 1% both at baseline and at month 13, however, 11% and 15% of clients tested positive for syphilis at months 1 and 7 respectively.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) experience a high burden of Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) infections. These remain largely undiagnosed in the context of syndromic treatment. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence of CT/NG using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence was assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25% in 84 MSM at follow-up (CT 14.3%, NG 14.3%, dual infection 3.6%). Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex (aOR=6.2, 95%CI (1.7-22.9)) and being in formal employment (aOR=7.5, 95%CI (1.14-49.2)). Six NG isolates were obtained at follow-up; all isolates were susceptible to ceftriaxone and cefixime (1 st line treatment for NG) and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: The high prevalence of asymptomatic rectal CT and NG in MSM reporting RAI demonstrates the need for frequent screening or presumptive treatment. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG, suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

Pharyngeal Chlamydia and gonorrhea: a hidden problem

In this study we assessed the prevalence and predictors of pharyngeal infections due to Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in a cohort of patients attending an STI Clinic. From January 2016 to September 2018, 893 patients attending the STI Clinic of St Orsola-Malpighi Hospital (Bologna, Italy) and reporting unprotected oral sex were enrolled. A pharyngeal swab for the molecular detection of CT and NG was collected from each patient. Positive CT samples were further genotyped by an omp1 gene PCR. A total of 134 cases of gonorrhea (15%) and 34 chlamydial infections (3.8%) were detected in the pharyngeal site, with no significant differences between males (all men who have sex with men [MSM]) and females. More than 90% of the infections were completely asymptomatic, suggesting that symptoms were not predictors of a pharyngeal infection ( P = 0.7). On the contrary, a history of sexual contacts with a partner positive for CT and/or NG ( P < 0.0001), HIV positivity ( P = 0.01), and the presence of concurrent genital and/or rectal infections ( P < 0.0001) were significantly associated with CT/NG pharyngeal infections. Pharyngeal lymphogranuloma venereum cases were rare (prevalence: 0.4%), asymptomatic, and only found in MSM. Better knowledge about pharyngeal CT/NG infections could help to set up effective strategies for their prevention.

Survival and death of intestinal cells infected by Chlamydia trachomatis

The sexually transmitted pathogen Chlamydia trachomatis (CT) is able to replicate and survive in human intestinal epithelial cells, being the gastro-intestinal tract a suitable site of residence for this microorganism. In this context, no detailed information about the mechanisms of cell death in intestinal cell lines after a chlamydial infection is available. The aim of this study was to compare the effect of two different CT serovars (D and L2) on the survival/death of different intestinal cell lines (Caco-2 and COLO-205), using endocervical cells (HeLa) as a reference model of genital infection. Seventy two hours after chlamydial infection at different multiplicity of infection (MOI) levels, the viability of HeLa, Caco-2 and COLO 205 cells was evaluated through dose-response experiments by means of a MTS-based assay. To get deeper insights in the mechanisms of cell death induced by CT, cell viability was assessed in presence of different inhibitors (i.e. pan-caspase inhibitor Z-VAD, necroptosis inhibitor Necrostatin-1, hydrogen peroxide scavenger catalase, caspase-1 inhibitor Ac-YVAD-cmk). Moreover, the activation of effector caspases and the presence of cellular apoptotic/necrotic changes were evaluated at different time points after CT infection. Our results demonstrated that, for both chlamydial serovars, intestinal cell lines are more resistant to CT-induced cell death compared to HeLa, thus representing a suitable ‘niche’ for chlamydial residence and replication. In literature, apoptosis has been widely described to be the main cell death mechanism elicited by chlamydia infection. However, our data demonstrate that necroptosis plays a relevant role, proceeding in parallel with apoptosis. The protective effect of catalase suggests the involvement of oxidative stress in triggering both cell death pathways. Moreover, we demonstrated that caspase-1 is involved in CT-induced cell death, potentially contributing to host inflammatory response and tissue damage. Cells infected by L2 serovar displayed a higher activation of effector caspases compared to cells infected with serovar D, suggesting a serovar-specific activation of apoptotic pathways and potentially explaining the greater virulence of L serovars. Finally, we found that Chlamydia elicits the early externalization of phosphatidylserine on the external leaflet of plasma membrane independently of caspase activation.

A case report of proctitis associated with Mycoplasma genitalium in a man who has sex with men

Mycoplasma genitalium is an infection of increasing concern due to its potential to cause sequelae in the reproductive tract and the development of antimicrobial resistance. Its role as a cause of proctitis in people with high-risk sexual behaviour has not been properly defined yet but it seems to be less symptomatic than proctitis caused by Chlamydia trachomatis or Neisseria gonorrhoeae. We present a case of a man who has sex with men with proctitis associated with M. genitalium after excluding other infections known to cause STI proctitis.

Lymphogranuloma venereum presenting as an ulcer on the tongue

Oropharyngeal lymphogranuloma venereum (LGV) is an uncommon presentation and mainly consists of either asymptomatic infections or enlarged cervical lymphadenopathy. According to cross-sectional studies, the prevalence of pharyngeal LGV among men who have sex with men (MSM) seems to be very low. Tissue tropism could explain the difference between rectal and oral mucosa infection frequencies. This paper reports the singular case of an oral ulcer caused by LGV in an MSM who had also an asymptomatic rectal infection. Given the increasing number of cases of LGV, unusual presentations such as oral ulceration may be seen more frequently.