Duration of syphilis symptoms at presentations in men who have sex with men in Australia: are current public health campaigns effective?

The rapid rise in syphilis cases has prompted a number of public health campaigns to assist men who have sex with men (MSM) recognize and present early with symptoms. This study aimed to investigate the temporal trend of the duration of self-report symptoms and titre of rapid plasma reagin (RPR) in MSM with infectious syphilis. Seven hundred and sixty-one syphilis cases in MSM diagnosed at the Melbourne Sexual Health Centre (MSHC) from 2007-2013 were reviewed. Median duration of symptoms and RPR titres in each year were calculated. The median durations of symptoms with primary and secondary syphilis were 9 [interquartile range (IQR) 6-14] days and 14 (IQR 7-30) days, respectively. The overall median titre of RPR in secondary syphilis (median 128, IQR 64-256) was higher than in primary syphilis (median 4, IQR 1-32) and in early latent syphilis (median 32, IQR 4-64). The median duration of symptoms for primary syphilis, secondary syphilis and titre of RPR level did not change over time. Public health campaigns were not associated with a significant shorter time from onset of symptoms to treatment. Alternative strategies such as more frequent testing of MSM should be promoted to control the syphilis epidemic in Australia.

An open-label phase II pilot study investigating the optimal duration of imiquimod 5% cream for the treatment of external genital warts in women.

Our objective was to determine the optimal duration of treatment with imiquimod for external genital warts over 4, 8, 12 or 16 weeks. A total of 120 women with a history of genital warts for a median of 3-6 months and prior alternative treatments in 73% were evaluated for total clearance rates. There was no statistically significant difference in complete clearance rates after 16-week follow-up across treatment groups: four weeks (40.0%), eight weeks (48.4%), 12 weeks (39.3%) and 16 weeks (51.6%). Imiquimod was well tolerated, and in those treated for four weeks there was a lower incidence of local skin reactions such as erythema and erosion, and no incidences of pain. These preliminary results suggest that a four-week treatment course of imiquimod applied thrice weekly for women with external genital warts may provide a reasonable approach with comparable efficacy and compliance, and minimal adverse events, drug costs and clinic visits.

Psychosocial impact of type-specific herpes simplex serological testing on asymptomatic sexual health clinic attendees.

The usefulness of type-specific testing for herpes simplex virus type 2 (HSV-2) is much debated with proponents arguing for likely change in the sexual behaviour of asymptomatic carriers and opponents suggesting that testing may have significant adverse psychological impact while not promoting behaviour change. In the present study we examine the impact of HSV-2 serological testing on psychological well-being, self-esteem, anxiety, sexual self-perceptions and sexual practices among a sample of 180 clients of a sexual health clinic. Of the participants, 21 (11.7%) were HSV-2 positive at entry to the study. No adverse psychological consequences of a positive test were observed among those participants followed for 3 months (n=124) or for 6 months (n=97). There was little significant change observed in sexual behaviour although a general but not significant pattern of decreased sexual behaviour with casual partners was observed among participants who tested HSV-2 negative. While supportive of the value of HSV-2 testing, these findings require replication in larger samples and different populations.

Detection of herpes simplex virus in genital specimens by type-specific polymerase chain reaction.

Viral isolation is the standard method for the detection of herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) in clinical specimens. This study describes the development of a type-specific polymerase chain reaction (PCR) assay for detection and typing of HSV-1 and HSV-2, and a comparison of its sensitivity with that of isolation in a clinical setting. Specimens from patients presenting with genital ulcers were tested for the presence of HSV by both methods. Oligonucleotide primers were selected to enable type-specific amplification of HSV-1 and HSV-2 DNA. Conditions were optimized to allow detection and typing from a single reaction tube using a multi-primer PCR method. When compared with PCR, the sensitivity of isolation was 67% and the specificity 97%. This protocol allowed rapid, sensitive and accurate detection and typing of HSV with a single PCR assay.

Sexually transmitted infections.

It should be remembered that sexually transmitted infections may present with symptoms and signs not immediately referable to the genital tract. All practitioners should be aware of the changes in incidence and prevalence of these important infections.

Topical imiquimod 5% as a treatment for localized genital Kaposi's sarcoma in an HIV-negative man: a case report.

We report a case of Kaposi's sarcoma (KS) in an HIV-negative man who has sex with men (MSM) that was successfully treated by topical application of imiquimod 5% cream (Aldara). Our case highlights a potentially effective and non-invasive method of treatment of Kaposi's sarcoma in the shortest timeframe yet recorded. The location of the lesions on the patient's penis also highlights the need for a non-invasive treatment.

Use of computerized medical records to determine the feasibility of testing for chlamydia without patients seeing a practitioner.

The proportion of clinically important diagnoses in a low-risk, asymptomatic population who use a computer-assisted self-interview (CASI) to assess risk was needed to determine optimal health service delivery. Medical records were retrospectively analysed between July 2008 and June 2009 for risk characteristics and diagnoses. A total of 7733 new patients completed a CASI, of whom 1060 were asymptomatic heterosexuals. From this low-risk group, 26 diagnoses were made on the day of presentation, including 22 cases of genital warts (2.08% [95% confidence interval (CI) 1.22-2.93]), three cases of genital herpes (0.28% [95% CI 0.055-0.82]) and one case of unintended pregnancy (0.094% [95% CI 0.0061-0.52]). Additionally, there were 54 cases of chlamydia detected (5.09% [95% CI 3.77-6.42]). As chlamydia is effectively diagnosed and managed from self-collected samples, patient review is not always required. This study provides evidence for an express testing service for chlamydia to streamline the screening of low-risk, asymptomatic heterosexual patients as identified by CASI without the need to for a traditional face-to-face consultation.

Symptoms of non-gonococcal urethritis in heterosexual men: a case control study.

OBJECTIVE: To determine microbial and behavioural factors contributing to non-gonococcal urethral symptoms in men. METHODS: Case-control study of heterosexual men with non-gonococcal urethral symptoms (cases) and without urethral symptoms (controls) attending Melbourne Sexual Health Centre, Australia. Sexual behaviour and condom use were measured by questionnaire. First stream urine was tested for potential pathogens: Chlamydia trachomatis (ligase chain reaction), Mycoplasma genitalium (polymerase chain reaction, PCR), Ureaplasma urealyticum (culture and PCR), and Streptococcus spp, Gardnerella vaginalis, and Haemophilus species (culture). Urethral smears from cases were examined for polymorphonuclear leucocytes. RESULTS: 80 cases and 79 controls were recruited over 4 months in 2002-3. 49 cases (61%) had urethritis by microscopic criteria, 17 (21%) had Chlamydia trachomatis (adjusted odds ratio (OR) 27 (95% confidence interval (CI): 3.4 to 222)), five (6%) had Mycoplasma genitalium (OR 6.1 (95% CI: 0.6 to 61)), and 11 (14%) had Gardnerella vaginalis (OR 9.0 (95% CI: 1.6 to 52)). Other organisms were not significantly associated with urethral symptoms. The presence of urethritis on urethral smear did not predict the presence of Chlamydia trachomatis (OR 1.7 (95% CI: 0.5 to 5.4)). Urethral symptoms were significantly associated with unprotected vaginal sex with more than one casual partner (OR 9.3 (95% CI: 1.3 to 65)) and unprotected anal sex with a regular partner in the past month (OR 3.5 (95% CI: 1.0 to 13)). CONCLUSION: Gardnerella vaginalis and unprotected anal sex may cause symptoms of non-gonococcal urethritis. Microscopy of the urethral smear to diagnose urethritis in this population does not help to identify which men with urethral symptoms require treatment for chlamydia.

Characteristics of adenovirus associated urethritis.

OBJECTIVES: To describe the characteristics of adenovirus urethritis in men. METHOD: Cases occurred over a 30 month period among men presenting with urethritis to Melbourne Sexual Health Clinic. All cases had a urethral Gram stain and underwent testing for chlamydia, gonorrhoea, herpes, and adenovirus. Cases were empirically treated with a macrolide or doxycycline. RESULTS: Eight cases of adenovirus associated urethritis were identified in whom no other causative organism was isolated. Cases were clustered in autumn and winter of each year and all reported recent insertive oral sex and seven reported recent insertive vaginal sex. All patients complained of dysuria, seven had meatitis and mucoid discharge, six had conjunctivitis, and four constitutional symptoms. Three sexual contacts were known to be symptomatic. CONCLUSION: Adenovirus is an uncommon cause of urethritis in men but it should be considered in all males presenting with dysuria, meatitis, and associated conjunctivitis or constitutional symptoms.

Ticrynafen and hydrochlorothiazide. A comparison in hypertensive patients with renal impairment.

The efficacy of ticrynafen in the treatment of hypertension in patients with moderate renal impairment was compared with that of hydrochlorothiazide in a randomised, double-blind crossover trial in eleven subjects with renal insufficiency. Significant reductions in blood pressure occurred with both treatments, with the maximum responses occurring at different time intervals and to different degrees in individual patients. Thus, although ticrynafen caused a significant reduction in blood pressure in this group of hypertensive patients with renal insufficiency, it was not consistently different from that which could be achieved with hydrochlorothiazide. Ticrynafen also significantly reduced the serum uric acid concentration, compared with a significant rise with hydrochlorothiazide. No major biochemical abnormalities or side-effects were encountered in any subject. Thus, in these patients with renal insufficiency, ticrynafen still demonstrated a uricosuric effect as well as a useful anti-hypertensive action.

Pulmonary paragonimiasis in an immigrant from Laos.

A chest X-ray film, taken in a refugee camp in Thailand six months before a 25-year-old Laotian farmer arrived in Australia, demonstrated lesions which were assumed to be tubercular. Despite antituberculous chemotherapy, the lesions continued to grow. On the man's arrival in Australia, cytological examination of bronchial washings showed the presence of numerous Paragonimus ova, and the patient received treatment with praziquantel. Paragonimiasis should be suspected in a Southeast-Asian refugee who presents with a pulmonary lesion which is similar to that of tuberculosis.