Proctitis: An Approach to the Symptomatic Patient

Proctitis is an inflammatory condition of the distal rectum that can be associated with common sexually transmitted infections (STIs), such as gonorrhea, chlamydia, and syphilis. For persons presenting with ulcerative findings on examination, in addition to syphilis, Mpox, lymphogranuloma venereum, and herpes simplex virus should be in the differential. Providers should also be aware that there are evolving data to support a role for Mycoplasma genitalium in proctitis. Performing a comprehensive history, clinical evaluation including anoscopy, and rectal nucleic amplification STI testing may be useful in identifying the cause of proctitis and targeting treatment.

Painful proctitis associated with anorectal mpox, syphilis, HSV, LGV, gonorrhoea and Mycoplasma genitalium in a person living with virologically suppressed HIV and vaccinated against mpox

A gay man with well-controlled HIV and vaccinated against mpox presented with severe proctitis. Testing revealed anorectal mpox, herpes simplex virus, lymphogranuloma venereum, Neisseria gonorrhoeae and Mycoplasma genitalium Serology was indicative of infectious syphilis. This case highlights the need to consider a wide range of concurrent sexually transmitted infections in patients with proctitis, including those vaccinated against mpox.

Single case of lymphogranuloma venereum on the tongue

Traditionally, lymphogranuloma venereum (LGV) has been associated with disease of the genital area. However, atypical presentations and proctitis are increasingly observed. We report a case of LGV affecting the dorsum of the tongue, which presented as a very painful ulcer. The response to doxycycline (100 mg two times per day for 21 days) was satisfactory. This case may represent a paradigm shift in the differential diagnosis of lingual ulcers.

Sexually transmitted infections in Spain: Current status

Sexually Transmitted Infections (STI) are a major public health problem. The problems inherent to their diagnosis, treatment and prevention have to do not only with their nature, but also with organizational issues and overlapping competencies of the different health authorities in Spain. The real situation of STI in Spain, at present, is poorly known. For this reason, the Scientific Committee on COVID and Emerging Pathogens of the Illustrious Official College of Physicians of Madrid (ICOMEM) has formulated a series of questions on this subject which were distributed, not only among the members of the Committee, but also among experts outside it. The central health authorities provide very high and increasing figures for gonococcal infection, syphilis, Chlamydia trachomatis infection and lymphogranuloma venereum (LGV). Both HIV infection and Monkeypox are two important STI caused by viruses in our environment, to which it should be added, mainly, Herpes simplex virus (HSV) and Human papillomavirus (HPV) infections. Emerging microorganisms such as Mycoplasma genitalium pose not only pathogenic challenges but also therapeutic problems, as in the case of N. gonohrroeae. The pathways that patients with suspected STI follow until they are adequately diagnosed and treated are not well known in Spain. Experts understand that this problem is fundamentally managed in public health institutions, and that Primary Care and Hospital Emergency Services, together with some institutions that deal monographically with this problem, are the recipients of most of these patients. One of the most serious difficulties of STI lies in the availability of the microbiological tests necessary for their diagnosis, particularly in this era of outsourcing of microbiology services. Added to this is the increased cost of implementing the latest generation of molecular techniques and the difficulties of transporting samples. It is clear that STI are not diseases to which the entire population is equally exposed and it is necessary to have a better knowledge of the risk groups where to focus the necessary interventions adapted to their characteristics. It should not be forgotten that STI are also a problem in the pediatric age group and that their presence can be a marker of sexual abuse with all that this implies in terms of health care and medicolegal activity. Finally, STI are infections that are associated with a high cost of care for which we have very little information. The possibility of expanding the automatic performance of laboratory tests for STI surveillance through laboratory routines is encountering ethical and legal problems that are not always easy to solve. Spain has created a ministerial area of specific attention to STI and there are plans to improve the diagnosis, treatment and prevention of these problems, but we still lack the necessary evidence on their impact. We cannot forget that these are diseases that transcend the individual and constitute a Public Health problem.

[Penile nodules, a rare clinical manifestation of lymphogranuloma venereum]

Lymphogranuloma venereum is a sexually transmitted disease caused by L1, L2 and L3 serovars of Chlamydia trachomatis. A rare clinical presentation of the primary stage is lymphangitis of the penis, with the appearance of one or more tense lymph nodes classically called "buboes". We report the case of an HIV-positive patient with sexually transmitted disease risk behaviors with penile nodules as a manifestation of lymphogranuloma venereum.

[Haemorrhagic proctocolitis as primary manifestation of lymphogranuloma venereum in an HIV-positive male]

This is a case report of lymphogranuloma venereum (LGV) manifesting as haemorrhagic proctocolitis in a homosexual HIV-positive male. The primary symptom was a rectal abscess, which was initially surgically treated and subsequently insufficiently treated with single-dose tablet azithromycin. The patient's symptoms were successfully treated after a 21-day doxycycline regime. LGV is a se xually transmitted infection with a rising incidence among persons with risk behaviour. This case report underlines the importance, that all positive rectal screenings for Chlamydia trachomatis should be routinely serotyped.

Unusual case of a rectal tumour

A 48-year-old man presented as an emergency with a 3-week history of rectal bleeding. Examination of his rectum revealed a circumferential tumour, 2 cm from the anal verge. An MRI scan reported a locally infiltrative mid-lower rectal tumour staged as T3d/T4 N2 MX. A colonoscopy revealed appearances of severe proctitis and biopsies did not show any evidence of dysplasia or malignancy. The patient was discussed at the regional colorectal cancer multidisciplinary team meeting with a management plan for neoadjuvant chemoradiotherapy following repeat biopsies, which were again negative for malignancy. He tested positive for the HIV and was referred to genitourinary medicine. A positive Chlamydia trachomatis nucleic acid test from a rectal swab was serovar L2 consistent with a diagnosis of lymphogranuloma venereum. He was treated with doxycycline and subsequent MRI scans showed reduction in tumour size with eventual resolution. This case report highlights the importance of HIV testing in patients with newly diagnosed colorectal tumours.

Chlamydia trachomatis and the risk of spontaneous preterm birth, babies who are born small for gestational age, and stillbirth: a population-based cohort study

BACKGROUND

Chlamydia trachomatis is one of the most commonly diagnosed sexually transmitted infections worldwide, but reports in the medical literature of an association between genital chlamydia infection and adverse obstetric outcomes are inconsistent.

METHODS

The Western Australia Data Linkage Branch created a cohort of women of reproductive age by linking records of birth registrations with the electoral roll for women in Western Australia who were born from 1974 to 1995. The cohort was then linked to both chlamydia testing records and the state perinatal registry for data on preterm births and other adverse obstetric outcomes. We determined associations between chlamydia testing, test positivity, and adverse obstetric outcomes using multivariate logistic regression analyses.

FINDINGS

From 2001 to 2012, 101 558 women aged 15 to 38 years had a singleton birth. Of these women, 3921 (3·9%) had a spontaneous preterm birth, 9762 (9·6% of 101 371 women with available data) had a baby who was small for gestational age, and 682 (0·7%) had a stillbirth. During their pregnancy, 21 267 (20·9%) of these women had at least one chlamydia test record, and 1365 (6·4%) of those tested were positive. Before pregnancy, 19 157 (18·9%) of these women were tested for chlamydia, of whom 1595 (8·3%) tested positive for chlamydia. Among all women with a test record, after adjusting for age, ethnicity, maternal smoking, and history of other infections, we found no significant association between a positive test for chlamydia and spontaneous preterm birth (adjusted odds ratio 1·08 [95% CI 0·91-1·28]; p=0·37), a baby who was small for gestational age (0·95 [0·85-1·07]; p=0·39), or stillbirth (0·93 [0·61-1·42]; p=0·74).

INTERPRETATION

A genital chlamydia infection that is diagnosed and, presumably, treated either during or before pregnancy does not substantially increase a woman's risk of having a spontaneous preterm birth, having a baby who is small for gestational age, or having a stillbirth.

FUNDING

Australian National Health and Medical Research Council.

Lymphogranuloma venereum genovar L2b concomitantly with syphilis and hepatitis C in a male patient in Poland – case report

We describe the first case of lymphogranuloma venereum (LGV) in Poland, with inguino-femoral lymphadenopathy, diagnosed and successfully treated according to the 2013 European LGV guideline. Chlamydia trachomatis genovar L2b, mainly responsible for the ongoing LGV epidemics among men who have sex with men (MSM) in Western European countries, was confirmed. The case also verified that co-infections with other sexually transmitted infections (syphilis and hepatitis C virus) are frequent in MSM LGV patients, as well as the very large difficulties with contact tracing for these patients. LGV needs to be considered in the diagnosis of inguinal lymph nodes inflammation or proctitis, especially in MSM. It is also crucial to have access to appropriate laboratory diagnostic methods in order to screen for and confirm all LGV cases by typing C. trachomatis genovars.

[Lymphogranuloma venereum]

Lymphogranuloma venereum belongs to the sexually transmitted diseases. The disease is caused by Chlamydia trachomatis serotypes L1, L2 and L3. In the beginning of the 21st century there has been observed a large increase in the incidence of this disease in the world. There is a frequent co-occurrence with other sexually transmitted diseases (HIV, syphilis, gonorrhea, hepatitis C). Predominantly this disease affects homosexuals, in which case the first manifestation of the disease may be proctitis or proctocolitis.

Lymphogranuloma venereum: an emerging cause of proctitis in men who have sex with men

Before 2003, lymphogranuloma venereum (LGV) was rare in developed nations. Several large clusters of LGV in men who have sex with men have been reported across Europe and in the United States of America (USA) since 2003. LGV is caused by L1, L2 and L3 serovars of Chlamydia trachomatis and is a sexually transmitted infection. LGV causes genital ulcers, infected inguinal lymph nodes (buboes) and proctitis/proctocolitis. Treatment with a three-week course of doxycycline prevents rectal strictures, bowel obstruction, bowel perforation and possibly death. Clinicians seeing men who have sex with men with inguinal lymphadenopathy and bowel symptoms should be aware of this current epidemic.

Saxophone penis revisited

Saxophone deformity of the penis is commonly secondary to diseases causing chronic lymphatic obstruction. Lymphogranuloma venereum (LGV) is an important cause for this deformity. A case of LGV in genito-anorectal syndrome with a saxophone penis is reported along with the contrast-enhanced computed tomography (CECT) findings of anorectal involvement, and a probable hypothesis for this typical appearance of the penis.

Sexually Transmitted Infections

Sexually transmitted infections (STIs) remain a significant burden on public health in the United States. Primary prevention counseling with early diagnosis and treatment remain the best methods to decrease the incidence of STIs. Through significant public heath interventions, the incidence of gonorrhea, Chlamydia, and trichomoniasis is decreasing; however, the incidence of primary and secondary syphilis is increasing. Human papilloma virus remains the most common STI, but new vaccinations have the possibility of having a significant impact on this virus's disease potential. This review discusses the most common STIs in the United States, focusing on clinical presentation, diagnosis, and treatment.

First detection of Chlamydia trachomatis LGV biovar in the Czech Republic, 2010-2011

We present four cases of proctitis in HIV-infected men having sex with men (MSM) living in the Czech Republic. The causative agent in all cases was the lymphogranuloma venereum (LGV) biovar of Chlamydia trachomatis. The spread of proctitis caused by C. trachomatis serovars L1–3 among MSM has been observed in several European countries, the United States and Canada since 2003. To our knowledge, no LGV cases in eastern Europe have been published to date.

Hepatitis C-seroconversion within three to six months after having contracted clinical syphilis and/or lymphogranuloma venereum rectitis in five homosexually active, HIV seropositive men

Five Human Immunodeficiency Virus (HIV) seropositive homosexually active men experienced hepatitis C-seroconversion in the period between September 2004 and January 2007 at a single HIV Reference Center (University Hospital Ghent, Belgium). There was no history of intravenous drug use. All had unprotected anal sex with multiple other HIV seropositive men in the recent past. All of them had clinical syphilis and/or lymphogranuloma venereum rectitis within three to six months before the hepatitis C-seroconversion was detected. This confirms the observations in other case reports and studies originating from the Netherlands, France, the United Kingdom and Germany, illustrating sexual transmission of hepatitis C virus (HCV) infection in this high-risk group. Physicians should be aware of the persistent high-risk behaviour in a subgroup of HIV seropositive homosexually active men and perform intensive sexual counselling and screening for other sexually transmitted diseases, including HCV, during medical follow-up.

Ano-rectal lymphogranuloma venereum: the first case in Italy

Lymphogranuloma venereum (LGV) is a sexually transmitted infection endemic in Central Africa, South-East Asia and in some countries of Central and South America. In Italy LGV has been sporadically reported in patients coming from abroad. The etiological agent of LGV is Chlamydia trachomatis serovars L1, L2, L3, differentiating by pathogenetic action. The clinical course of LGV can be divided into three stages with a initial small papule, which may ulcerate, at the site of inoculation, followed by massive lymphadenopathy, which is usually unilateral, and eventually by lymphatic obstruction, causing elephantiasis. During 2004 a LGV ano-rectal clinical variant has been described as an erosive proctitis among homosexual HIV-positive men in some countries of Western Europe, not coming from endemic areas. Until now this syndrome has been often explained as chronic intestinal inflammatory disease. This report describes a case of proctitis caused by CT serovar L2; to Authors' knowledge this is the first case reported in Italy.

The use of serological titres of IgA and IgG in (early) discrimination between rectal infection with non-lymphogranuloma venereum and lymphogranuloma venereum serovars of Chlamydia trachomatis

OBJECTIVES

To investigate whether serological titres of species-specific IgA and IgG antibodies in patients with rectal chlamydial infection could discriminate between infection with serovar L2 lymphogranuloma venereum (LGV) and infection with non-LGV serovars.

METHODS

A total of 39 male patients with chlamydial infection of the rectum were tested for titres of IgA and IgG antibodies within 14 days after detection of the infection and 6 and 12 months after adequate treatment. Data were collected regarding demographics, sexual orientation, HIV serostatus, history of chlamydial infection, concomitant sexually transmitted infection (STI) or HIV infection, hepatitis C virus antibodies and new STIs during follow-up.

RESULTS

Between May 2003 and November 2005, 24 men with confirmed L2 proctitis and 15 men with non-LGV rectal chlamydial infection were recruited. In multivariable analyses, both high titre of IgA within 14 days after detection of the infection and older age of the individual were found significantly associated with L2 proctitis (p<0.001 and p = 0.001, respectively). A total sum score of seven times IgA titre and individual's age >or=50 years resulted in an overall sensitivity of 92% and specificity of 100%. This total sum score was highly accurate for detection of LGV proctitis, with an area under the curve in a receiver operating characteristic curve of 0.989.

CONCLUSIONS

An increased IgA antibody response and the age of the infected individual are of possible diagnostic value for (early) detection of LGV proctitis.

Update on lymphogranuloma venereum in the United Kingdom

OBJECTIVES

This report updates the UK epidemiology of lymphogranuloma venereum (LGV) to the end of April 2007.

METHODS

The Health Protection Agency's Centre for Infections undertakes laboratory testing for LGV and subsequent epidemiological investigation of cases after laboratory confirmation of the LGV serovars (L1-3). Data analysis of enhanced surveillance and laboratory reports was undertaken.

RESULTS

From October 2004 to end April 2007, 492 cases of LGV have been diagnosed and enhanced surveillance forms have been returned for 423. Cases peaked in the third quarter of 2005 with an average of 32 cases per month, while in 2006 this fell to 12 cases per month. Nationally, the outbreak is focused in London, Brighton and the North West. All cases are in men, 99% of whom are MSM, with a median age of 40 and predominantly white ethnicity (91%). Co-infection remains considerable: HIV (74%); hepatitis C (14%); syphilis (5%); and other STIs including gonorrhoea, genital herpes and hepatitis B. The number of men reporting greater than 10 sexual contacts in the previous 3 months has reduced from 23% (47) to 13% (15) from 2005-2006.

DISCUSSION

The epidemic continues in the mostly white MSM population of the UK. The demographics of LGV remain similar to those previously described and high levels of HIV co-infection continue. Reduced numbers of sexual contacts might be contributing to the reduced numbers of LGV seen in 2006 but could simply mean that LGV is moving out of the highest risk groups.

[Genital ulcers caused by sexually transmitted diseases: current therapies, diagnosis and their relevance in HIV pandemy]

The sexual transmitted pathogens associated with genital ulcers are Treponema pallidum, Haemophilus ducreyi, Calymmatobacterium granulomatis, Chlamydia trachomatis and Herpes simplex virus type 1 or 2. Although geographic differences still exist, herpetic infections prevalence is growing worldwide as the most frequent ulcerative sexual transmitted disease. The failure of the many different used guidelines in achieving a sustained reduction in the number of new cases, in particular the WHO syndromic management, leads into an over treatment of bacterial agents and missing of viral agents. This situation is also associated with poor efficacy and wasting of economical resources. Ulcerative and non-ulcerative sexual transmitted diseases are important in the world HIV pandemy because they promote HIV transmission and are also associated with the disease evolution. Portugal had until recently the highest incidence of HIV infection in Europe and that points out to importance of treating and control of both ulcerative and non-ulcerative sexual transmitted diseases in order.

A cluster of acute hepatitis C virus infection among men who have sex with men--results from contact tracing and public health implications

OBJECTIVE

An acute hepatitis C virus (HCV) infection in an HIV-positive man who had sex with men (MSM) was notified. In the period of his seroconversion he was also diagnosed with a rectal lymphogranuloma venereum (LGV) infection, and was part of a cluster of 15 LGV cases in 2003. Our aim was to investigate HCV transmission and to search for potential spread among sexual contacts and known LGV patients.

METHODS

Our case series included the index, two recent contacts, and 14 LGV cases. They were interviewed about parenteral exposure for HCV, history of sexually transmitted diseases(STDs), sexual behaviour and drug use. Laboratory investigations included anti-HCV antibodies, HCV-polymerase chain reaction, and HCV genotyping.

RESULTS

Seven out of 17 MSM recently seroconverted for HCV (41%). Three genotypes were found. Parenteral risk factors were excluded. Six out of seven had LGV proctitis coinciding with HCV seroconversion, six (86%) were HIV infected. Unprotected anal contact was practised by both HCV uninfected and infected cases. Unprotected active and passive fisting was reported by all seven HCV infected men, compared with two of nine uninfected men (P = 0.003). Non-intravenous drug use during sexual activities was common among all MSM. Numerous, often anonymous, sexual contacts in various European countries were reported.

CONCLUSIONS

A cluster of acute HCV infection is reported among mostly HIV-positive MSM, with multiple partners throughout Europe. Sexual techniques potentially leading to mucosal damage (fisting), concomitant STDs such as LGV and drug use seem facilitating factors for spread. Extensive case finding and partner tracing is advocated as well as targeted prevention messages.

Giant scrotal elephantiasis

How much can a man carry? Penoscrotal elephantiasis is a debilitating syndrome. This is a case report of a patient with giant genital elephantiasis secondary to long-standing lymphogranuloma venereum infection in Ethiopia. Complete surgical resection of the pathologic tissue and penile reconstruction was undertaken with good cosmetic and functional results.

[Lymphogranuloma venereum and HIV infection. A case report]

We present a case of a young man with lymphogranuloma venereum in whom HIV infection was diagnosed.

Mri findings in primary non-Hodgkin's lymphoma of the liver

Primary lymphoma of the liver is a very rare malignancy. Most often, these lesions consist of diffuse large B-cell non-Hodgkin's lymphoma that occurs mostly in immunodeficient patients. To prove the primary nature of a hepatic lesion, a systemic lymphoproliferative disease should be ruled out. Secondary liver involvement during Hodgkin's and non-Hodgkin's lymphoma is frequent. In advanced cases the incidence varies from 25% to 50%. The present case describes the MRI features of a primary lymphoma of the liver presenting as a solitary nodule. The primary lymphoma presents as a T2-hyperintense homogeneous nodule, with a signal intensity comparable with the signal intensity of the spleen. Signal intensity is comparable on in and out of phase imaging. The nodule is slightly T1-hypointense and doesn't show any arterial contrast uptake. In the late venous phase a slight increase in signal intensity is noted. Two and a half minutes after the administration of contrast agent, the lesion is iso-attenuating with the liver parenchyma. This case is rare because of the concomitant presence of heterozygous sickle cell anaemia and the presence of Gamna-Gandy bodies in the splenic parenchyma. It remains uncertain whether the presence of the Gamna-Gandy bodies is associated with the liver lymphoma or with the underlying sickle cell anaemia, or with a combination of both.

[Two HIV-positive men with anorectal lymphogranuloma venereum and hepatitis C: emerging sexually transmitted diseases]

Two men, aged 41 and 28 years, both known to be HIV-positive, contracted multiple sexually-transmitted diseases (STDs) through unprotected anal sexual contact. These included lymphogranuloma venereum (LGV) proctitis and hepatitis C. Recently in The Netherlands and Belgium there has been an outbreak of LGV proctitis in HIV-positive men who have sex with men, caused by Chlamydia trachomatis serovar L2, an STD which up to now has been rare in Europe. Due to information about the epidemic received a few days previously, the LGV proctitis in the second patient could be diagnosed and treated rapidly. The incidence of STDs in men having sex with men is increasing, also in HIV-positive men. STDs with ulcerative lesions, such as LGV, facilitate transmission of other pathogenic micro-organisms, including HIV. This, in combination with high-risk sexual behaviour such as unprotected anal sexual intercourse, will increase the chance of blood-blood contact and hence the chance of contracting multiple STDs concurrently. Hepatitis C is not normally considered as an STD, but ulcerative lesions in one of the partners combined with high-risk sexual behaviour enables the hepatitis C virus to be sexually transmitted.

[Sexual transmission of hepatitis C in homosexual men]

An acute hepatitis C infection was diagnosed in three HIV-positive gay men, aged 43, 48 and 30 years, respectively. In all three, unprotected sexual intercourse and fisting was a universal risk factor for the infection. They all denied having used drugs intravenously, which is the most common risk factor. The third man had a documented proctitis (lymphogranuloma venereum) at the time when the HCV transmission must have taken place. No serious complications occurred during the acute HCV infection. Because the infection did not resolve spontaneously after a few months, all three men were treated with pegylated interferon and ribavirin. Recently, the number of cases of acute HCV infection has been seen to increase in The Netherlands. This may be due primarily to an increase in unprotected sexual intercourse and fisting. This hypothesis is supported by a documented increased prevalence of sexually transmissible diseases among gay men in The Netherlands. As acute infections may turn into chronic infections, treatment of an acute infection should be considered in order to prevent the chronic disease.

Unusual presentation of early lymphogranuloma venereum in an HIV-1 infected patient: effective treatment with 1 g azithromycin

The incidence of lymphogranuloma venereum (LGV) is low in the western world. Early LGV is characterised by bubonic disease following a painless papule or small ulcer. We report a white bisexual male who presented with a painful perianal ulcer, inguinal lymphadenitis, and concomitant infection with human immunodeficiency virus 1 (HIV-1). Chlamydia trachomatis serovar L2 was identified as the cause after polymerase chain reaction and genotyping the major outer membrane protein by restricted fragment length polymorphism. Treatment with a single dose of 1 g azithromycin was effective. This case illustrates that early LGV may mimic other genital ulcer diseases, such as genital herpes or chancroid, especially in HIV infected patients. In the western world, LGV must still be included in the differential diagnosis of bubonic disease with or without sexually acquired ulcers.

[New clinical forms and diagnosis of ophthalmic chlamydiosis]

The paper deals with new clinical forms of ophthalmoclamidiosis involving lesions to the choroids, retina, optic nerve and cornea. Uveitis and scleritis were found in 73.5% and 26.5%, respectively. Iridocyclitis and paneveitis prevailed in cases of uveitis. Forty-two patients, aged 3 to 53, were followed up. Bilateral ocular lesions were registered in 67% of them. The progression, clinical course and outcomes of the disease were investigated by using the up-to-date laboratory-and-immunologic methods. Direct immunofluorescence and polymerase chain reaction, when used alongside with serological examinations, were found to be most informative. A combination of ophthalmoclamidiosis with urogenital pathologies was registered in 76% of patients.

Bilateral groove sign with penoscrotal elephantiasis

Lymphogranuloma venereum (LGV) is a sexually transmitted disease of the lymph channels caused by Chlamydia trachomatis. Esthiomene, a rare late manifestation of LGV, is a primary infection affecting the lymphatics of scrotum, penis, or vulva. The male genitalia are affected less commonly by esthiomene, but we report a male patient who presented with inguinal syndrome, penoscrotal elephantiasis, along with enlargement of femoral lymph nodes.

[The Fitz-Hugh-Curtis syndrome in laparoscopic surgery]

The Fitz-Hugh-Curtis syndrome was diagnosed intraoperatory at 7.1% of the laparoscopic cholecystectomies in our clinic. The attitude in all cases was to perform a complete adhesiolysis. The reasons we consider that support this are: 1. the adhesions that fix the liver to the diaphragma do not allow the surgeon a comfortable access to perform cholecystectomy; 2. if these adhesions are torn accidentally during operation it could end up to the glissonian sheath rupture and uncontrollable bleeding; 3. adhesiolysis might be imposed in order to introduce the ports under visual control; 4. the traction determined by the perihepatitis process against the parietal peritoneum could be responsible for postoperative right quadrant pain; 5. the hepatodiaphragma adhesions make impossible the suction of the intraoperative secretions. A complete adhesiolysis allow a correct lavage of the suprahepatic area preventing the possible retention of clots, bile or even calculi. We didn't notice neither a longer duration of the intervention due to adesiolysis nor intra/or postoperative complications.

Coexistence of urethritis with genital ulcer disease in South Africa: influence on provision of syndromic management

OBJECTIVE

To assess whether syndromic management of genital ulcer disease was sound, if based on the premise that men with genital ulcers rarely have a concomitant urethral infection.

METHODS

Specimens were taken in 1998 from 186 mine workers in Carletonville, South Africa, who were seen consecutively with genital ulcers. The specimens comprised a swab from the ulcer, a urethral swab for a Gram stained smear, and 10-15 ml of a first catch urine sample. The latter was tested by ligase chain reaction assays for Neisseria gonorrhoeae and Chlamydia trachomatis specific DNA sequences and by a polymerase chain reaction (PCR) assay for Mycoplasma genitalium. Ulcer inducing micro-organisms were detected either by a multiplex PCR assay, or in the case of lymphogranuloma venereum (LGV) serologically, and human immunodeficiency virus (HIV) infection was detected by an enzyme linked immunosorbent assay (ELISA) test.

RESULTS

Most (54%) of the ulcers were chancroidal, 18% were herpetic (HSV type 2), 6.5% primary syphilitic, and 3.2% due to LGV. More than one micro-organism was detected in 9.1% of the ulcers and less than 10% were undiagnosed. Microscopic examination of the urethral smears showed that 99 (53%) of the men had urethritis, of whom 45 (45%) were infected with N gonorrhoeae. Of the 54 men (55%) who had non-gonococcal urethritis (NGU), 11 (19.6%) harboured C trachomatis or M genitalium. Almost two thirds (64.5%) of the men had HIV infection, but this did not seem to have influenced the aetiology of the ulcers. Nor was a particular ulcer associated with one type of urethritis more than the other. Neither C trachomatis nor M genitalium was associated significantly with non-gonococcal urethritis (NGU) in either HIV positive or HIV negative men.

CONCLUSION

The combination of antibiotics used for the management of genital ulcer disease in men in this South African mining population needs to be widened to encompass frequently occurring concomitant gonococcal urethritis and NGU infections. This means treatment with long acting penicillin, combined with ciprofloxacin and azithromycin or erythromycin. A similar situation may exist in other geographical locations with a need to provide appropriate antimicrobial combinations depending on the patterns of infection detected.

Epidemic Lymphogranuloma venereum during epidemics of crack cocaine use and HIV infection in the Bahamas

BACKGROUND

Since the early 1980s, the Bahamas has experienced sequential epidemics of freebase/crack cocaine use, genital ulcer-inguinal adenopathy disease (GUD), and heterosexual HIV infection.

GOAL

To prospectively define the etiology of GUD in patients at the Princess Margaret Hospital during outbreaks of crack cocaine use, GUD, and HIV infection in the Bahamas.

STUDY DESIGN

In Nassau, 47 consecutive patients with GUD underwent serologic testing for syphilis and for infections with HIV, herpes simplex virus type 2 (HSV-2), and Chlamydia trachomatis. Genital ulcer specimens were tested by culture and/or polymerase chain reaction (PCR) assay for Haemophilus ducreyi; by PCR and/or antigen assay for HSV; and by PCR for C trachomatis. Lymph node aspirates were tested by PCR for C trachomatis and H ducreyi.

RESULTS

Twenty patients (43%) had HIV infection; eight had lymphogranuloma venereum (LGV), confirmed by PCR detection of C trachomatis sequences consistent with the L2 serovar; and nine others had possible LGV, on the basis of serum microimmunofluorescent C trachomatis antibody titers > or =256. Inguinal lymphadenopathy or bubo was present in 15 of 17 patients, who thus met the laboratory criteria for definite or possible LGV, and in 7 of 30 who did not meet such laboratory criteria (P < 0.001). Thirteen patients had confirmed genital herpes, seven had confirmed chancroid, and four had probable or possible primary syphilis.

CONCLUSIONS

The epidemics in the Bahamas of crack use, heterosexual HIV infection, and GUD apparently included epidemic transmission of LGV.

Prevention and management of sexually transmitted diseases in adolescents

This review focuses on the diagnosis and treatment of common sexually transmitted diseases (STDs) encountered among adolescents in the U.S. and other developed countries. Included are new recommendations for the treatment of primary and recurrent genital herpes, management of pelvic inflammatory disease, and a revised approach to the care of adolescent victims of sexual assault. Diagnosis begins with a classification based on major clinical findings: genital ulcers with lymphadenitis, urethritis, vaginal discharge, pelvic inflammatory disease, and male STD syndromes. Appropriate laboratory evaluation for each of these clinical presentations is detailed and treatment options are summarized. Preventive interventions along with suggestions for an approach to the preadolescent well care visit, generally scheduled at age 11ñ12 years, are offered. Routine preventive therapy after a sexual assault takes into account difficulty in follow-up and the need to reassure adolescents and their families that all prophylaxis for possible infection has been provided.

Genital ulcers disease among sexually transmitted disease clinic attendees in Ibadan, Nigeria

Genital ulcer disease (GUD) is a risk factor in the transmission of human immuno deficiency virus (HIV). The goal of this study is to estimate proportion, identify risk factors, and improve prevention and control of GUD. This is a retrospective study of 211 cases of GUD seen between 1993 and 1997 in an urban public sexually transmitted disease (STD) clinic. Genital ulcers form 7.6% of all STDs seen. Overall, genital herpes was commonest (89 or 42.25%). It was the predominant infection (84 or 44.7%) in the males, while lymphogranuloma venereum (52 or 24.7%) was in females. The peak incidence in both sexes occurred in the 20-29 age group. Males out numbered females by a ratio of 8:1. Most of the patients were single 114 (68.3%) and most 70 or 33.3% were students. Risk markers identified were: casual sex (103 or 53.5%) and multiple sexual partners (77 or 36.5%). Both were significantly higher (P < 0.05) in single patients. Self-treatment, use of multiple drugs and incomplete course of antibiotics were also common. The need to intensify STDS education programmes to all occupational groups and to students in particular is highlighted. Commercial sex workers require periodic education, screening and treatment.