Abnormalities of Liver Function during HIV Seroconversion Illness

In 6 patients with a severe human immunodeficiency virus (HIV) seroconversion illness distinct abnormalities of liver transaminases were observed; in addition there was marked hepatomegaly in 5 patients.

Successful treatment of four patients with recalcitrant vaginal trichomoniasis with a combination of zinc sulfate douche and metronidazole therapy

BACKGROUND AND OBJECTIVES

There is no certain cure available for patients suffering from recalcitrant trichomoniasis. Zinc sulfate is reported to have antitrichomonal properties. We report our experience in treating four patients empirically with a combination of zinc sulfate douche and metronidazole.

STUDY DESIGN

A retrospective case analysis. Patients who presented to the tertiary referral clinic with chronic recurrent trichomoniasis without evidence of reinfection were treated empirically with a combination of zinc sulfate douching (1%) followed by a metronidazole 500 mg suppository per vaginale twice daily and 200 to 400 mg three times a day orally. The douching and suppository were used prophylactically for 3 nights after menstruation for some months.

RESULTS

Four patients who had a history of 4 months to 4 years of culture-positive symptomatic trichomoniasis and received a variety of therapies before referral were treated successfully. At the review of 2 to 5 months after therapy, all had remained asymptomatic and the results of clinical and laboratory examinations were normal.

CONCLUSIONS

The exact role of zinc sulfate douching in the successful outcome is not certain, but the combination therapy requires only a moderate dose of metronidazole (1.6-2.2 g/day), avoiding the side effects of larger doses. The combination therapy therefore merits further evaluation.

To test or not to test, could you repeat the question?

We aimed to investigate clinical practice in the offering of HIV tests and subsequent uptake in a central London genitourinary medicine (GUM) clinic. A random sample (n = 330) of attenders at 3 inner-London GUM departments was surveyed. Reasons for and rates of offering of HIV tests were recorded and analysed in relation to demographic, risk group information and uptake. The results were integrated with the latest unlinked, anonymous seroprevalence data for the clinic. After exclusion of patients known to be HIV-positive or to have recently undergone HIV testing, HIV tests were offered to 96% of homo/bisexual men, 55% of heterosexual men and 60% of heterosexual women. Comparison with anonymous HIV seroprevalence data showed an inverse relationship between seroprevalence rates for heterosexual men/women (2.5% vs 1%) and rates of HIV test offering. A lack of research into the policy of offering HIV tests may have resulted in inconsistencies in practice. An evidence based policy should offer HIV tests in line with seroprevalence.

Hepatitis A seroprevalence in homosexual and heterosexual men

OBJECTIVE

To determine the seroprevalence of hepatitis A antibodies in homosexual and heterosexual males attending a genitourinary medicine (GUM) clinic.

DESIGN

Prospective study of male patients recruited from a GUM clinic during a 10 week period in 1993.

SETTING

Central London outpatient GUM department at Chelsea and Westminster Hospital.

SUBJECTS

255 patients were recruited, comprising 185 homosexual and 70 heterosexual males. Ninety two men were known to be HIV-positive, of whom 89 were homosexual.

MAIN OUTCOME MEASURES

Serum samples were screened for both IgM and IgG antibodies to hepatitis A by enzyme linked immunoassay. Results were matched to an anonymously completed questionnaire.

RESULTS

81 of the 255 subjects (31.8%) had been exposed to hepatitis A, two of whom were IgM positive. There were similar hepatitis A seroprevalence rates in homosexual (32.4%) and heterosexual men (30.0%). Although 48.1% of the homosexual men were known to be HIV-positive, compared with 4.3% of the heterosexuals. Hepatitis A seroprevalence remained comparable in both groups after patients with known HIV infection were excluded from the analysis. 11.4% of the heterosexual men admitted to oral-anal sexual contact compared with 62.2% of the homosexual men. This sexual practice was not associated with antibodies or a past history of hepatitis A exposure.

CONCLUSIONS

There was no detectable difference in hepatitis A seroprevalence between male homosexual and heterosexual GUM clinic attenders, despite a much higher level of oral-anal sexual activity among the homosexual population.

Comparison of vaginal flora after treatment with a clotrimazole 500 mg vaginal pessary or a fluconazole 150 mg capsule for vaginal candidosis

The effect of antifungal therapy on the vaginal microbial flora was studied in 23 patients suffering from culture-positive, symptomatic vaginal candidosis. They were randomly allocated to receive either a 500 mg clotrimazole vaginal pessary or a 150 mg fluconazole capsule. Quantitative microbiological examination was carried out on samples of vaginal secretions obtained prior, and at intervals up to 10 days after, treatment. No significant difference was found in the vaginal flora before or after therapy in individual patients or between the treatment groups. In patients with C glabrata or C krusei, the yeasts persisted longer in the vagina with poorer response to either of the medications.

Sexually transmitted diseases in HIV-1 seropositive women at presentation

Ninety women who were HIV antibody positive attended the genitourinary medicine clinics of East Riverside up to May 1990. Seventy-five of these women (83%) were examined for co-existent sexually transmitted disease (STD) at presentation. The prevalence of STD in these women was compared to the incidence of STD in all females attending in 1989. Syphilis and chlamydia were found to be significantly more common in women with HIV infection. We feel that a full examination for STD is an important aspect in the management of these women.

Self-medication by women attending a genitourinary medicine clinic

A questionnaire was completed by 103 symptomatic women attending a busy, walk-in genitourinary medicine clinic in London before seeing a doctor. This questionnaire asked about the patients' own diagnosis of symptoms, previous remedies and their source. The answers were compared to their past history and current diagnosis. Of symptomatic women 56% had used a self-administered remedy prior to attending the clinic. This was significantly associated with a history of a previous episode of genital infection which had produced similar symptoms to the current problem. Forty-three percent of those who used self-medication reported some improvement in symptoms and more than 50% tolerated longer than 10 days of symptoms before attending the clinic.

Gonococcal arthritis caused by auxotype P in a man with HIV infection

The development of gonococcal arthritis is reported in a man with HIV infection and CDC Stage IVC2 disease. The diagnosis of disseminated Neisseria gonorrhoeae was facilitated by microbiological examination of a joint aspirate. The auxotype identified by culture was moderately resistant to penicillin, a characteristic which is highly unusual for an organism causing disseminated gonococcal infection. This case serves as an example of the role of HIV infection in the modification of host response to common pathogens and the need for clinicians to modify their management of disseminated gonococcal infection especially in immunosuppressed persons.

Single dose therapy of vaginal candidiasis: a comparative trial of fenticonazole vaginal ovules versus clotrimazole vaginal tablets

An open, randomized comparative clinical trial was performed in 153 patients suffering from symptomatic vaginal candidiasis confirmed by mycological tests. Patients were allocated at random into two groups: the first group (consisting of 75 subjects) was treated with a single vaginal ovule of fenticonazole (600 mg) and the second group (consisting of 78 subjects) was treated with a single vaginal tablet of clotrimazole (500 mg). Therapeutic efficacy was assessed by microbiological and clinical criteria 7 days and 1 month (when possible) after the single dose treatment. At the first follow-up visit, complete disappearance of the signs and symptoms or a highly significant reduction of their intensity was observed in both treatment groups. No significant difference was evident between the two drugs. At 7 days, the mycological tests gave negative results in 92% of the patients in the fenticonazole group and in 88.5% of the patients in the clotrimazole group. The difference between the two treatment groups was again not statistically significant. The second follow-up visit was performed in 55 (73.3%) patients of the fenticonazole group and in 52 (66.7%) patients of the clotrimazole group. The results indicate that 83.6% of patients in the fenticonazole group and 69.2% of patients in the clotrimazole group were still disease free at the time of this visit. Both drugs were well tolerated. Mild, local and short lasting side-effects were reported in only 5 cases of the group treated with fenticonazole.(ABSTRACT TRUNCATED AT 250 WORDS)

Rheumatological lesions in individuals with human immunodeficiency virus infection

One hundred and twenty-three patients with human immunodeficiency virus infection have been referred to rheumatologists at our hospitals between October 1985 and April 1989 because of musculoskeletal symptoms. Thirty-four homosexual men presented with acute, peripheral, non-erosive arthritis (mean number of four joints affected) with the knees being involved in 23. Other features developing concurrently with arthritis included psoriasis, keratoderma blenorrhagica, plantar fasciitis, urethritis, conjunctivitis and anterior uveitis. Four of five patients investigated were HLA-B27-positive; none of 15 patients tested had raised titres of rheumatoid or antinuclear factors. Various infections were associated with the onset of arthritis and two patients with a recent history of diarrhoea had serological evidence of yersinia infection. No micro-organisms were identified within the joint except for HIV itself. At the time of onset of arthritis four of these individuals had the acquired immunodeficiency syndrome (AIDS); 11 were not known to be HIV-positive before testing which was performed following referral for arthritis. Six patients have since developed AIDS and four have died. In 15 individuals, including those who progressed to AIDS, joint symptoms have been severe, persistent and poorly responsive to non-steroidal anti-inflammatory drugs. In only five patients has the arthritis been known to resolve. Synovitis has also been seen in two women: in one of these HIV infection was thought to have been acquired through intravenous drug abuse. Other rheumatic lesions included myalgia/myositis, non-inflammatory peripheral arthritis, spinal pain, soft tissue lesions, arthralgia or myalgia of unknown cause and infective lesions including septic arthritis and bony infection due to histoplasmosis and atypical mycobacterial infection. It appears likely that HIV infection is a risk factor for the development of seronegative arthritis and other rheumatic lesions.

Effects of protein malnutrition on the mouse submandibular gland

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Benign tertiary syphilis and HIV infection

Benign tertiary (gummatous) syphilis has virtually disappeared [1]. Two homosexual men with gummata have presented to genitourinary medicine clinics in west London in recent months. They both had antibodies to HIV. It is possible that otherwise adequately treated syphilis has progressed to the tertiary stage as a consequence of HIV infection and modification of the immune response.

Clinical investigations of lymphadenopathy, including lymph node biopsies, in 24 homosexual men with antibodies to the human T-cell lymphotropic virus type III (HTLV-III)

The findings of 27 lymph node biopsies performed on 24 homosexual patients with lymphadenopathy are presented. Six had acquired immune deficiency syndrome (AIDS) and 18 lymphadenopathy only, of whom one subsequently developed AIDS. All these patients had antibodies to the human T-cell lymphotropic virus type III (HTLV-III) suggesting that HTLV-III is currently the commonest cause of lymphadenopathy in homosexual men. The histopathological findings of six of seven nodes from AIDS patients showed either follicular depletion alone or follicular and paracortical lymphocyte depletion. Nodes from four patients showed Kaposi's sarcoma, three of which also showed follicular hyperplasia. In two of these patients there were no cutaneous manifestations of this condition. One lymph node from a patient with persistent generalized lymphadenopathy (PGL) showed Mycobacterium tuberculosis. Six nodes from six other patients have had features of toxoplasmosis although there was no serological or clinical evidence of recent toxoplasma infection. The remaining 11 lymph nodes from patients with PGL and one node from a patient with transient lymphadenopathy, showed reactive follicular hyperplasia only. We conclude that homosexuals with lymphadenopathy who are HTLV-III antibody positive do not need a routine node biopsy unless an alternative diagnosis is strongly suspected.

Systemic absorption and persistence of tioconazole in vaginal fluid after insertion of a single 300-mg tioconazole ovule

After vaginal insertion of a 300-mg ovule of tioconazole in 10 patients with vaginal candidiasis, the mean concentration in plasma was 21.2 ng/ml (range, 10.6 to 35.8 ng/ml) at 8 h and was not measurable at 24 h in 9 of 10 patients. The mean vaginal concentration at 24 h was 21.4 mg/liter (range, 2.4 to 50 mg/liter) and remained detectable in 7 of 9 and 2 of 9 patients after 48 and 72 h, respectively.

Single dose oral amoxycillin 3 g with either 125 mg or 250 mg clavulanic acid to treat uncomplicated anogenital gonorrhoea

A single supervised oral dose of amoxycillin 3 g combined with clavulanic acid 125 mg as a suspension (Augmentin 3.125G) plus probenecid 1 g, cured 97 of 100 assessable patients who had uncomplicated anogenital gonorrhoea. Thirteen of the 100 patients were infected with penicillinase producing strains of Neisseria gonorrhoeae (PPNG) and 11 (85%) of these patients were cured, including one infected with a PPNG strain that was also resistant to spectinomycin. Another group of 93 assessable patients was treated with ampicillin 3 g plus probenecid 1 g, and only 85 (91%) patients were cured. Of the eight treatment failures in this group, five were found to be infected with PPNG strains. In a second study 144 assessable patients were treated with amoxycillin 3 g combined with clavulanic acid 250 mg, (Augmentin 3.250G) plus probenecid 1 g, and a 97% cure rate was again obtained. Five of seven (71%) patients infected with PPNG strains were cured. Although both Augmentin regimens were effective for treating gonorrhoea caused by PPNG and non-PPNG strains, side effects were noted in more patients treated with 250 mg clavulanic acid (24%) than with 125 mg clavulanic acid (5%). In addition, a similar cure rate was obtained in the three primary sites of infection, the urethra, cervix, and rectum.

Clinical findings and serological evidence of HTLV-III infection in homosexual contacts of patients with AIDS and persistent generalised lymphadenopathy in London

Between 1980 and 1984 28 homosexual men who had had ano-genital intercourse with patients with either acquired immunodeficiency syndrome (AIDS) or persistent generalised lymphadenopathy (PGL) were followed up. The pattern of the sexual links indicated that within this group there were two clusters, one consisting of 7 men and the other of 13.17 of the 28 contacts became ill with either AIDS or PGL; among those in the clusters, 4 died of AIDS and 11 had PGL, and of the rest 2 had PGL. 16 of the 19 men in the clusters who were tested for HTLV-III antibodies were seropositive, as were 7 of those not in the clusters. 111 men attending a genitourinary medicine clinic who had not had known contact with either AIDS or PGL patients and who were being screened for syphilis served as controls. Of these, 19/86 who were homosexual and 0/25 who were heterosexual were positive for HTLV-III antibodies. None of the 4 who died of AIDS had had contact with each other. The 2 in the first cluster seemed to have been linked by a symptomless HTLV-III-negative man, who was also probably the link between the two clusters, while in the second cluster the chief "carrier" seemed to be a seropositive man in whom PGL developed. These findings are consistent with the hypothesis that HTLV-III is the sexually transmitted causative agent of AIDS and PGL.

Treatment failure with penicillin in early syphilis

A patient with primary syphilis had a recurrence of his penile chancre after generally acceptable penicillin treatment. Retreatment with a similar but extended penicillin regimen was successful. This is the first report of such a treatment failure.

Total pancreatectomy for carcinoma of the pancreas

Survival after partial pancreaticoduodenectomy (Whipple procedure) for carcinoma of the pancreas is uniformly poor. In the absence of nodal metastasis this may be due to extension of tumor beyond the line of resection of the pancreas or to a multicentric origin of the tumor. The material reviewed contained an illustration of the latter circumstance and provides a logical reason for recommending total pancreatectomy as the procedure of choice in resectable pancreatic carcinoma.

Acute toxic nephropathies: clinical pathologic correlations

Man's ever increasing exposure to numerous drugs and chemicals, which are the results of medical and industrial progress, produces a by-product of acute toxic nephropathies. These include acute toxic renal failure, drug-induced acute oliguric renal failure, acute hemorrhagic glomerulonephritis, nephrotic syndrome, tubular disturbances and potassium deficiency. In depth information is provided for the previously mentioned disorders.

Chronic toxic nephropathies--diagnosis and management

As a result of industrial and medical progress, man is exposed to an ever changing array of chemicals, drugs and biological products. The kidneys are extremely vulnerable to chronic toxic effects of these substances. Although acute renal failure, nephrotic syndrome and renal tubular disorders result from acute nephrotoxicity, chronic renal failure with renal failure and hypertension result from chronic nephrotoxicity. Heavy metals, analgesic agents and antimicrobials are the common nephrotoxic substance producing chronic renal disease. Medical management consists of preventive exposure measures and early detection of nephrotoxicity by modern industrial medicine. In addition, early clinical diagnosis with appropriate management may prevent the need for chronic hemodialysis and renal transplantation.