Etiology of genital ulcer disease in a sexually transmitted infection reference center in Manaus, Brazilian Amazon

Genital ulcer disease: Study of factors associated and utility of rapid diagnostic methods in current pandemic

Background

Genital ulcer disease (GUD) is regarded as the most difficult conundrum for clinicians, as valid and rapid methods to diagnose them are limited, especially in India. The sexual behavior of an individual plays a role in the causation of GUD, and it depends on psychological, behavioral, and social well-being, which was significantly affected during the COVID-19 pandemic. Hence, the present study was undertaken to determine the etiology of genital ulcers by using simple, rapid microbiological methods and to study various factors associated with them.

Materials and Methods

Various rapid tests like staining (Giemsa, Gram, and Diff Quick) and serology for antibody detection were used to diagnose agents causing genital ulcers among 71 suspected patients during the study period of 1 year. After due informed consent, sociodemographic and behavioral factors were recorded in proforma and analyzed.

Results

Rapid tests could aid in diagnosing 47.9% of cases of GUD. Turnaround time was less than 60 minutes for all tests carried out. Genital herpes was the most common GUD followed by syphilis. Male gender (74.6%), age group of more than 34 years old (62%), literate (71.8%), and earning (70.4%) constituted most of the population presenting with GUD. Behavioral factors like promiscuity with a known person (83.1%) had a significant association (P 0.04) with GUD.

Conclusion

Rapid diagnostic tests could assist in the early treatment of GUD cases. Factors like literacy, financial independence, and promiscuity with known individuals were associated with GUD in our study during the COVID-19 pandemic.

Molecular Characterization of Genital and Extragenital Lesions With the PlexPCR VHS Assay in Patients Diagnosed With Syphilis

Background

Syphilis diagnosis relies on immunologic markers and clinical protocols. However, syphilitic lesions can be confused with other genital ulcer diseases.

Methods

Using a PlexPCR VHS assay, we analyzed lesion DNA samples from 87 individuals who were clinically diagnosed with early syphilis infection and had at least 1 positive serologic test result. DNA was detected by the PlexPCR VHS multiplex assay and β-globin genes.

Results

Among the participants, 99% (86/87) had a positive rapid treponemal test result. DNA was successfully detected in 91% (79/87) of the lesion samples. PlexPCR VHS identified 5 herpes simplex virus (HSV)/Treponema pallidum coinfections (2 HSV-1 and 3 HSV-2), only T pallidum DNA in 62% (49/79), and only HSV-2 in 12.7% (10/79). While 19% (15/79) were negative for all pathogens, none were varicella zoster virus positive. The PlexPCR VHS had 68.4% agreement with the clinical diagnosis.

Conclusions

Since the PlexPCR VHS detects multiple organisms simultaneously, it can help to confirm actual syphilis and identify other pathogen coinfections or the pathogen causing the ulcer.

Epidemiological Survey of Human Alphaherpesvirus 2 (HSV-2) Infection in Indigenous People of Dourados Municipality, Central Brazil

Sexually transmitted Human alphaherpesvirus 2 (HSV-2) causes genital ulcers, especially among sexually active adolescents and adults. We estimated the exact prevalence of anti-HSV-2 antibodies and correlated it with the demographic and behavioral aspects of the Indigenous population of the Jaguapirú and Bororó villages (Dourados, Mato Grosso do Sul (MS), Brazil). In total, 1360 individuals (>18 years old) were administered serologic tests. The prevalence of anti-HSV-2 IgM was 12.9%, that of anti-HSV-2 IgG was 57.2%, and 8.5% cases tested positive for both HSV-2 IgM and IgG. The prevalence of anti-HSV-2 antibodies was higher in females (59.5%) compared to males (49%), with an OR of 0.64 (0.49-0.83). Anti-HSV-2 antibodies were found in 14.2%, 12.3%, 15.4%, and 14.5% of participants with urinary problems, genital wounds, genital warts, and urethral discharge, respectively. In summary, the seroprevalence of HSV-2 in the Indigenous population was five times higher than that reported in the general adult Brazilian population. Educational level, income level, smoking, condom use, incarceration, illicit drug abuse, the sharing of used needles and syringes without adequate disinfection, homosexual relationships, prostitution, the sexual practices among drug users, and avoidance of contraceptive methods could contribute to the facilitation of HSV-2 transmission in the Indigenous population. Our results may help develop culturally appropriate intervention programs that eliminate health-access barriers and improve the implementation of public health policies aimed at promoting information regarding and preventing, treating, and controlling HSV-2 infection in Brazilian Indigenous populations.

Chancroid Coexisting with Vaginal Candidiasis: A Case Report

BACKGROUND: Chancroid is a sexually transmitted disease caused by the Gram-negative bacteria, Haemophilus ducreyi. In endemic areas, the ratio of men to women is 3:1. Clinical symptoms of chancroid manifest as genital ulcers which are generally painful and tender with irregular edges. The base of the ulcer can be covered with yellow or gray necrotic purulent exudate, and often bleeds when rubbed. Vaginitis is an inflammation of the vagina and can be accompanied with symptoms such as vaginal discharge, complaints of itching, and pain. The most common cause is an imbalance of bacteria or normal flora in the vagina. CASE REPORT: We report a case of chancroid in a 20-year-old woman in conjunction with vaginal candidiasis that was later identified as Candida glabrata. The patient was then treated with a combination of oral antibiotics and antifungals, as well as normal saline dressing that then showed significant clinical improvements. CONCLUSION: Chancroid is a sexually transmitted disease that is still prevalent especially in developing countries. Diagnosis of the disease is often made clinically and should be promptly treated to prevent further complications. Coexistence of chancroid with vaginal candidiasis is rare, and combination of antibiotics and antifungals, as well as normal saline dressing proved to be effective in treating the condition.

Brazilian Protocol for Sexually Transmitted Infections, 2020: infections that cause genital ulcers

Infections that cause genital ulcers are one of the themes comprising the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. The Protocol and Guidelines have been developed based on scientific evidence and validated in discussions with specialists. This article addresses clinical genital ulcer syndrome caused by sexually transmitted infections and its most common etiological agents: Treponema pallidum (syphilis), herpes simplex virus-2 (genital herpes) and herpes simplex virus-1 (perioral herpes), Haemophilus ducreyi (chancroid), Chlamydia trachomatis serotypes L1, L2 and L3 (lymphogranuloma venereum), and Klebsiella granulomatis (donovanosis). Epidemiological and clinical aspects of these infections and guidelines for their diagnosis and treatment are presented, including strategies for surveillance, prevention, and control actions to support health managers and professionals in the qualification of care. Approximately 70% of the genital ulcers attended in specialized clinics are due to sexually transmitted infections, particularly in adolescents and young adults.

Use of a Multiplex PCR Assay To Assess the Presence of Treponema pallidum in Mucocutaneous Ulcerations in Patients with Suspected Syphilis

We evaluated the utility of the commercial Allplex genital ulcer real-time PCR multiplex assay for detecting Treponema pallidum, herpes simplex virus 1 (HSV-1) and 2 (HSV-2), and Chlamydia trachomatis serovar L (lymphogranuloma venereum [LGV]) DNA in mucosal and genital ulcers in the context of suspected syphilis. In total, 374 documented genital and mucosal ulcers from patients with and without syphilis presenting at several sexually transmitted infection (STI) centers in France from October 2010 to December 2016 were analyzed at the National Reference Center (CNR) for Bacterial STIs at Cochin Hospital in Paris. T. pallidum subsp. pallidum detection results were compared with the final diagnosis based on a combination of clinical examination, serological results, and in-house nested PCR (nPCR). Detections of HSV and LGV were validated against reference methods. We found that 44.6% of the 374 samples tested were positive for T. pallidum subsp. pallidum, 21% for HSV, and 0.8% for LGV. No positive results were obtained for 30.7% of samples, and 4.8% presented coinfections. For T. pallidum subsp. pallidum detection, the overall sensitivity was 80% (95% confidence interval [CI], 76.1 to 84.1%), specificity was 98.8% (95% CI, 97.7 to 99.9%), positive predictive value was 98.8% (95% CI, 97.7 to 99.9%) and negative predictive value was 80.2% (95% CI, 76.2 to 84.2%), with a rate of concordance with the reference method of 92.5% (k = 0.85). This PCR multiplex assay is suitable for T. pallidum subsp. pallidum detection in routine use and facilitates the simultaneous rapid detection of a broad panel of pathogens relevant in a context of suspected syphilis lesions.

A Young Patient with Painful Penile Lesions

Chancroid is a rare infection in the United States and many other developed countries. Infrequently identified as a cause of genital ulcer disease, chancroid’s atypical presentation has only been reported in approximately 20 cases annually in the United States since 2011. Infection with the causative organism, Haemophilus ducreyi, leads to an erythematous papule that rapidly evolves into a pustule. Infected individuals commonly have more than one ulcer about 2 cm in diameter that is typically noted as painful. The base of the ulcer is usually covered with a gray or yellow purulent exudate and bleeds when scraped.

Despite a heavy focus in preclinical medical education, the notably rare chance to see and diagnose chancroid in clinical practice adds to the complicated profile of this infection’s identification and subsequent treatment. Such lack of familiarity contributes to reports of accuracy of clinical diagnosis ranging from 30% to 80%.

Self-collected versus clinician-collected samples for HSV-2 and HSV-2/HPV screening in HIV-infected and -uninfected women in the Tapajós region, Amazon, Brazil

The aim of this study was to evaluate the prevalence of herpes simplex virus 2 (HSV-2) and HSV-2/human papillomavirus (HPV) co-infection by self-collected samples compared to clinician-collected samples in human immunodeficiency virus 1 (HIV-1)-infected and -uninfected women from the Tapajós region, Amazon, Brazil. A cross-sectional study was conducted with 439 anal and cervical scrapings and cervico-vaginal self-collected samples obtained from 153 eligible HIV-infected and -uninfected women. Real-time PCR for HSV-2 and nested PCR for HPV detection were performed. A multivariate analysis identified risk factors for HSV-2/HPV co-infection. The anogenital prevalence of HSV-2 was 9.2% (14/153), HPV was 67.3% (103/153) and HSV-2/HPV co-infection was 6.5% (10/153). There was a significant overall agreement (95.5%, 11/133, kappa 0.64, 95% CI 0.38–0.90, p < 0.0001) for HSV-2 detection by the self-collected and clinician-collected samples. HSV-2 genital infection was more prevalent than anal infection in all participants. HIV-infected women had a higher prevalence of HSV-2 and HSV-2/HPV. No woman with a cervical squamous intraepithelial lesion had HSV-2/HPV co-infection. Risk factors for HSV-2/HPV were age ≤25 years (aOR = 10.07) and being single (aOR = 3.79). In general, young and single women are at greater risk for HSV-2/HPV infection. Self-collection can be a useful strategy for the screening of HSV-2 and HPV in limited-resource settings.

Diagnosing sexually transmitted infections in resource-constrained settings: challenges and ways forward

INTRODUCTION

Sexually transmitted infections (STIs) remain prevalent and are increasing in several populations. Appropriate STI diagnosis is crucial to prevent the transmission and sequelae of untreated infection. We reviewed the diagnostic accuracy of syndromic case management and existing point-of-care tests (POCTs), including those in the pipeline, to diagnose STIs in resource-constrained settings.

METHODS

We prioritized updating the systematic review and meta-analysis of the diagnostic accuracy of vaginal discharge from 2001 to 2015 to include studies until 2018. We calculated the absolute effects of different vaginal flowcharts and the diagnostic performance of POCTs on important outcomes. We searched the peer-reviewed literature for previously conducted systematic reviews and articles from 1990 to 2018 on the diagnostic accuracy of syndromic management of vaginal and urethral discharge, genital ulcer and anorectal infections. We conducted literature reviews from 2000 to 2018 on the existing POCTs and those in the pipeline.

RESULTS AND DISCUSSIONS

The diagnostic accuracy of urethral discharge and genital ulcer disease syndromes is relatively adequate. Asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections limit the use of vaginal discharge and anorectal syndromes. The pooled diagnostic accuracy of vaginal syndromic case management for CT/NG is low, resulting in high numbers of overtreatment and missed treatment. The absolute effect of POCTs was reduced overtreatment and missed treatment. Findings of the reviews on syndromic case management underscored the need for low-cost and accurate POCTs for the identification, first, of CT/NG, and, second, of Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) and NG and MG resistance/susceptibility testing. Near-patient POCT molecular assays for CT/NG/TV are commercially available. The prices of these POCTs remain the barrier for uptake in resource-constrained settings. This is driving the development of lower cost solutions.

CONCLUSIONS

The WHO syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed to address asymptomatic STIs. POCTs that are accurate, rapid, simple and affordable are urgently needed in resource-constrained settings to support the uptake of aetiological diagnosis and treatment.

Herpes simplex virus type 1 epidemiology in Latin America and the Caribbean: Systematic review and meta-analytics

OBJECTIVES

To investigate the epidemiology of herpes simplex virus type 1 (HSV-1) in Latin America and the Caribbean.

METHODS

Systematic review and meta-analytics guided by the Cochrane Collaboration Handbook and reported following the PRISMA guidelines.

RESULTS

Thirty-three relevant reports were identified including 35 overall (and 95 stratified) seroprevalence measures, and five and nine proportions of virus isolation in genital ulcer disease (GUD) and in genital herpes, respectively. Pooled mean seroprevalence was 57.2% (95% CI: 49.7-64.6%) among children and 88.4% (95% CI: 85.2-91.2%) among adults. Pooled mean seroprevalence was lowest at 49.7% (95% CI: 42.8-56.6%) in those aged ≤10, followed by 77.8% (95% CI: 67.9-84.8%) in those aged 10-20, 82.8% (95% CI: 73.1-90.8%) in those aged 20-30, 92.5% (95% CI: 89.4-95.1%) in those aged 30-40, and 94.2% (95% CI: 92.7-95.5%) in those aged ≥40. Age was the strongest source of heterogeneity in seroprevalence, explaining 54% of variation. Evidence was found for seroprevalence decline over time. Pooled mean proportion of HSV-1 isolation was 0.9% (95% CI: 0.0-3.6%) in GUD and 10.9% (95% CI: 4.4-19.4%) in genital herpes.

CONCLUSIONS

HSV-1 is a widely prevalent infection in this region, but its epidemiology may be slowly transitioning, with still limited contribution for HSV-1 in genital herpes.

Herpes simplex virus type 2 and cytomegalovirus perigenital ulcer in an HIV infected woman

We report a case of mucocutaneous Herpes Simplex Virus (HSV)-2 and Cytomegalovirus (CMV) infection in a 39-year-old female with acquired immunodeficiency syndrome, who presented with a perigenital ulcer. The patient was receiving antiretroviral treatment (ART) for 3 months before presentation. Scraping from the perigenital ulcer was positive for HSV-2 and Treponema pallidum using polymerase chain reactions (PCR). The extent and duration of the lesions led us to consider the possibility of coinfection with CMV. The patient also tested positive for CMV by PCR. On subsequent follow-up after 8 weeks, the genital lesions had healed completely. This is possibly ascribable to the ART, which led to significant immune reconstitution.

Novel variants of human herpesvirus 2 from Brazilian HIV-1 coinfected subjects

BACKGROUND Human herpesvirus 2 (HHV-2) have DNA genome with a limited genetic variability and have been classified into two clades. OBJECTIVES To identify and characterise six HHV-2 isolates derived from Brazilian women. METHODS HHV-2 isolates were performed polymerase chain reaction (PCR) and sequencing of 2250 pb of the glycoprotein B (gB) coding regions. FINDINGS Four HHV-2 isolates were classified into clade B, while the remaining two, derived from HIV-1 co-infected women, showed a notable genetic divergence (> 1%). MAIN CONCLUSION The results reveal novel HHV-2 variants. The impact of these novel variants on HHV-2 pathogenesis and HIV/HHV-2 coinfection need to be investigated.

Etiology of Genital Ulcer Disease in Male Patients Attending a Sexually Transmitted Diseases Clinic: First Assessment in Cuba

BACKGROUND

Sexually transmitted diseases (STDs) and in particular genital ulcer disease (GUD) have a major impact on morbidity and mortality in developing countries. The World Health Organization recommends the use of syndromic guidelines for the treatment of sexually transmitted infections (STIs) in resource-constrained countries. Surveillance of autochthonous etiologies provides epidemiological information contributing to the prevention and treatment of STIs. We investigated the etiology and factors associated with GUD among male patients attending a STD clinic in Havana, Cuba.

METHODS

Swabs from genital ulcers of 113 male patients, collected from May 2012 to June 2015, were analyzed using PCR for herpes simplex virus types 1 and 2, Treponema pallidum, Haemophilus ducreyi, and Chlamydia trachomatis. We also investigated the clinical and epidemiological characteristics associated with the presence of these pathogens in GUD.

RESULTS

At least one of the pathogens was detected in 70% of patients. The occurrence of the pathogens was herpes simplex virus type 2 (HSV-2) (51.3%), T. pallidum (29.2%), and C. trachomatis (1.8%). Co-infections occurred as follows: T. pallidum-HSV-2 (10.6%), C. trachomatis-HSV-2 (0.9%) and C. trachomatis-T. pallidum (0.9%). Herpes simplex virus type 1 and H. ducreyi were not detected. Ages 15 to 40 years, HIV-positive serostatus, and no condom use were significant risk factors for the presence of HSV-2 in genital ulcers.

CONCLUSIONS

Our preliminary results highlight the predominance of HSV-2 and T. pallidum as the leading GUD etiologies in the study population and identified risk factors associated with HSV-2. This information should help to inform guidelines for better management of GUD in Havana, Cuba.

High prevalence of curable sexually transmitted infections among pregnant women in a rural county hospital in Kilifi, Kenya

BACKGROUND

Women attending antenatal care (ANC) in resource-limited countries are frequently screened for syphilis and HIV, but rarely for other sexually transmitted infections (STIs). We assessed the prevalence of curable STIs, defined as infection with either Chlamydia trachomatis or Neisseria gonorrhoeae or Trichomonas vaginalis, from July to September 2015.

METHODS

In a cross-sectional study, women attending ANC at the Kilifi County Hospital, Kenya, had a urine sample tested for C. trachomatis/N. gonorrhoeae by GeneXpert® and a vaginal swab for T. vaginalis by culture. Bacterial vaginosis (BV) was defined as a Nugent score of 7-10 of the Gram stain of a vaginal smear in combination with self-reported vaginal discharge. Genital ulcers were observed during collection of vaginal swabs. All women responded to questions on socio-demographics and sexual health and clinical symptoms of STIs. Predictors for curable STIs were assessed in multivariable logistic regression.

RESULTS

A total of 42/202 (20.8%, 95% confidence interval (CI):15.4-27.0) women had a curable STI. The prevalence was 14.9% for C. trachomatis (95% CI:10.2-20.5), 1.0% for N. gonorrhoeae (95% CI: 0.1-3.5), 7.4% for T. vaginalis (95% CI:4.2-12.0), 19.3% for BV (95% CI: 14.1-25.4) and 2.5% for genital ulcers (95% CI: 0.8-5.7). Predictors for infection with curable STIs included women with a genital ulcer (adjusted odds ratio (AOR) = 35.0, 95% CI: 2.7-461.6) compared to women without a genital ulcer, women who used water for cleaning after visiting the toilet compared to those who used toilet paper or other solid means (AOR = 4.1, 95% CI:1.5-11.3), women who reported having sexual debut ≤ 17 years compared to women having sexual debut ≥18 years (AOR = 2.7, 95% CI:1.1-6.6), and BV-positive women (AOR = 2.7, 95% CI:1.1-6.6) compared to BV-negative women.

CONCLUSION

One in five women attending ANC had a curable STI. These infections were associated with genital ulcers, hygiene practices, early sexual debut and bacterial vaginosis.

Comparison of Diagnostic Accuracy of PCR Targeting the 47-Kilodalton Protein Membrane Gene of Treponema pallidum and PCR Targeting the DNA Polymerase I Gene: Systematic Review and Meta-analysis

Treponema pallidum PCR (Tp-PCR) testing now is recommended as a valid tool for the diagnosis of primary or secondary syphilis. The objectives were to systematically review and determine the optimal specific target gene to be used for Tp-PCR. Comparisons of the performance of the two main targets are tpp47 and polA genes were done using meta-analysis. Three electronic bibliographic databases, representing abstract books from five conferences specialized in infectious diseases from January 1990 to March 2015, were searched. Search keywords included ("syphilis" OR "Treponema pallidum" OR "neurosyphilis") AND ("PCR" OR "PCR" OR "molecular amplification"). We included diagnostic studies assessing the performance of Tp-PCR targeting tpp47 (tpp47-Tp-PCR) or the polA gene (polA-Tp-PCR) in ulcers from early syphilis. All studies were assessed against quality criteria using the QUADAS-2 tool. Of 37 studies identified, 62.2% were judged at low risk of bias or applicability. Most used the U.S. Centers for Disease Control and Prevention (CDC) case definitions for primary or secondary (early) syphilis (89.2%; n = 33); 15 (40.5%) used darkfield microscopy (DFM). We did not find differences in sensitivity and specificity between the two Tp-PCR methods in the subgroup of studies using adequate reference tests. Among studies using DFM as the reference test, sensitivities were 79.8% (95% confidence intervals [CI], 72.7 to 85.4%) and 71.4% (46.0 to 88.0%) for tpp47-Tp-PCR and polA-Tp-PCR (P = 0.217), respectively; respective specificities were 95.3% (93.5 to 96.6%) and 93.7% (91.8 to 95.2%) (P = 0.304). Our findings suggest that the two Tp-PCR methods have similar accuracy and could be used interchangeably.