The changing epidemiology of genital ulcer disease in South Africa: has donovanosis been eliminated?

OBJECTIVES: We used an in-house molecular assay for the detection of Klebsiella granulomatis in ulcer specimens collected over a 12-year surveillance period in order to determine whether a diagnosis of donovanosis could be ascribed to genital ulcer disease (GUD) of unknown aetiology in our setting. METHODS: Between 2007 and 2018, a total of 974 genital ulcer specimens with no previously identified sexually transmitted (STI) pathogens were selected from STI aetiological surveys conducted in all nine provinces of South Africa. Giemsa-stained ulcer smears from the same participants had previously been routinely analysed for the presence of typical Donovan bodies within large mononuclear cells. A Klebsiella screening assay targeting the phoE (phosphate porin) gene was used in combination with restriction digest analysis and sequencing to confirm the presence of K. granulomatis. RESULTS: The Klebsiella screening assay tested positive in 19/974 (2.0%) genital ulcer specimens. Restriction digest analysis and nucleotide sequencing of the phoE gene confirmed that none of these specimens was positive for K. granulomatis DNA. Similarly, Donovan bodies were not identified in the Giemsa stained ulcer smears of these specimens. CONCLUSIONS: This is the first study to assess K. granulomatis as a cause of genital ulceration in South Africa over a 12-year surveillance period using molecular methods. The results demonstrate that K. granulomatis is no longer a prevalent cause of GUD in our population.

Novel tp0548 Sequence-Type of Treponema pallidum Identified in Barcelona, Spain.

A novel tp0548 sequence-type of Treponema pallidum has been identified in a genital ulcer sample collected from a patient diagnosed with primary syphilis at the Hospital Universitari Vall d'Hebron in Barcelona. Following the nomenclature used in the Enhanced Centers for Disease Control and Prevention Typing methodology, letter "z" has been assigned to the new sequence type.

Highlighting a Potential Pitfall: Positive Treponema pallidum Immunohistochemical Stain in a Patient Without Syphilis.

The Treponema pallidum antibody immunohistochemical (IHC) stain has improved our ability to detect the organism histologically. We present a case of a man with genital condyloma acuminatum with a positive T. pallidum IHC stain but negative T. pallidum serologies and no syphilitic symptoms. It has been shown that the T. pallidum antibody IHC can cross-react, staining other spirochetes, including Borrelia burgdorferi and the Brachyspira family of intestinal spirochetes. Because of the proximity of our patient's lesions to the anus, and the persistently negative T. pallidum serologies, we believe nontreponemal spirochetes colonized the condyloma, giving a false-positive T. pallidum IHC. This cross-reactivity is a potential diagnostic pitfall and is important for the dermatopathologist to recognize, thereby avoiding false diagnosis of syphilis.

Trichophyton mentagrophytes - a new genotype of zoophilic dermatophyte causes sexually transmitted infections.

BACKGROUND: A new genotype of the zoophilic fungal species Trichophyton (T.) mentagrophytes was recently described in two studies. It was isolated from three patients who had visited Southeast Asia and one patient who had visited Egypt. In contrast to these studies, we have observed a number of cases with the dimensions of an epidemic outbreak. PATIENTS AND METHODS: At the University Hospital Charité Berlin, 43 patients, mostly suffering from highly inflammatory, painful and persistent infections of the pubogenital region were observed between January 2016 and July 2017. Mycological examination was performed with fungal culture and sequencing of the ITS (internal transcribed spacer) region of the ribosomal DNA. Three additional genomic regions were spot-checked. RESULTS: In 37 of the cases, a new genotype of T. mentagrophytes (referred to here as T. mentagrophytes VII) was isolated as the etiological agent, and sequencing revealed identical sequences for all isolates. Most of the infected patients had no history of travel, and only two patients reported contact with animals. CONCLUSIONS: The new genotype clustered phylogenetically among the strains of the zoophilic species T. mentagrophytes with four different DNA markers. While human-to-human transmission of zoophilic dermatophytes is rare, transmission via sexual contact seemed to be quite effective here.

The Etiology of Genital Ulcer Disease and Coinfections With Chlamydia trachomatis and Neisseria gonorrhoeae in Zimbabwe: Results From the Zimbabwe STI Etiology Study.

BACKGROUND: In many countries, sexually transmitted infections (STIs) are treated syndromically. Thus, patients diagnosed as having genital ulcer disease (GUD) in Zimbabwe receive a combination of antimicrobials to treat syphilis, chancroid, lymphogranuloma venereum (LGV), and genital herpes. Periodic studies are necessary to assess the current etiology of GUD and assure the appropriateness of current treatment guidelines. MATERIALS AND METHODS: We selected 6 geographically diverse clinics in Zimbabwe serving high numbers of STI cases to enroll men and women with STI syndromes, including GUD. Sexually transmitted infection history and risk behavioral data were collected by questionnaire and uploaded to a Web-based database. Ulcer specimens were obtained for testing using a validated multiplex polymerase chain reaction (M-PCR) assay for Treponema pallidum (TP; primary syphilis), Haemophilus ducreyi (chancroid), LGV-associated strains of Chlamydia trachomatis, and herpes simplex virus (HSV) types 1 and 2. Blood samples were collected for testing with HIV, treponemal, and nontreponemal serologic assays. RESULTS: Among 200 GUD patients, 77 (38.5%) were positive for HSV, 32 (16%) were positive for TP, and 2 (1%) were positive for LGV-associated strains of C trachomatis. No H ducreyi infections were detected. No organism was found in 98 (49.5%) of participants. The overall HIV positivity rate was 52.2% for all GUD patients, with higher rates among women compared with men (59.8% vs 45.2%, P < 0.05) and among patients with HSV (68.6% vs 41.8%, P < 0.0001). Among patients with GUD, 54 (27.3%) had gonorrhea and/or chlamydia infection. However, in this latter group, 66.7% of women and 70.0% of men did not have abnormal vaginal or urethral discharge on examination. CONCLUSIONS: Herpes simplex virus is the most common cause of GUD in our survey, followed by T. pallidum. No cases of chancroid were detected. The association of HIV infections with HSV suggests high risk for cotransmission; however, some HSV ulcerations may be due to HSV reactivation among immunocompromised patients. The overall prevalence of gonorrhea and chlamydia was high among patients with GUD and most of them did not meet the criteria for concomitant syndromic management covering these infections.

Association between male accesory gland infections and prostate cancer in Turkish men: A case-control study.

It is well known that chronic inflammation contributes to several forms of human cancer. Although several studies have investigated the association between prostatitis and prostate cancer, there is a lack of specifically designed study about male accessory gland infections (MAGI) and prostate cancer co-occurrence. We aimed to investigate this association with a case-control study in Turkish men. A total of 155 patients were enrolled to the study. After the pathological examination of the transrectal ultrasound-guided prostate biopsy specimens, patients were divided the two groups as control and prostate cancer and the presence of MAGI was determined. Of 155 patients, 145 met inclusion criteria. In the prostate cancer group, MAGI diagnose was determined in 18 of 31 patients (58.06%), while it was determined in 25 of 114 (21.93%) patients in the control group (p = .001). A significant correlation between MAGI and pathological Gleason score also revealed (p = .0001). We demonstrated that men with MAGI have increased risk for the development of prostate cancer. Moreover, in this population, most of the prostate cancers tend to be clinically significant or high grade.

Prevalence and antimicrobial resistance of genital Mollicutes in Italy over a two-year period.

Knowledge of the prevalence and antimicrobial susceptibility of genital Mollicutes is crucial to offer guidelines for empirical treatments. The aim of this study was to investigate the prevalence and the resistance profile of Mycoplasma hominis (MH) and Ureaplasma urealyticum/Ureaplasma parvum (UU/UP) in genital samples over a two-year period in Bologna, Italy. From January 2015 to December 2016, data on all the subjects providing uro-genital specimens for Mollicutes detection by culture were analyzed. A total of 4660 subjects (84.4% females) were enrolled and an overall Mollicutes prevalence of 30.9% was found. Women turned positive for Mollicutes infection twice as often as men (33.3% vs 17.8%) and the detection rate progressively decreased with increasing age. Ureaplasmas represented the commonest species isolated (overall prevalence: 24.2%), whereas mixed infections (6.5%) and MH single infections (3.9%) were far less common. Ureaplasma species showed significant levels of quinolone resistance, especially to ciprofloxacin (77%), whereas MH strains were non-susceptible to azithromycin and roxithromycin in about 90% of cases. Mollicutes co-infections showed a more severe resistance pattern than single infections. Over time, the resistance rate for azithromycin and roxithromycin increased significantly. Globally, our results revealed that minocycline and doxycycline can still be first-line drugs for Mollicutes treatment.

Genotype-Specific Concordance of Chlamydia trachomatis Genital Infection Within Heterosexual Partnerships.

BACKGROUND: Sexual transmission rates of Chlamydia trachomatis (Ct) cannot be measured directly; however, the study of concordance of Ct infection in sexual partnerships (dyads) can help to illuminate factors influencing Ct transmission. METHODS: Heterosexual men and women with Ct infection and their sex partners were enrolled and partner-specific coital and behavioral data collected for the prior 30 days. Microbiological data included Ct culture, and nucleic acid amplification testing (NAAT), quantitative Ct polymerase chain reaction, and ompA genotyping. We measured Ct concordance in dyads and factors (correlates) associated with concordance. RESULTS: One hundred twenty-one women and 125 men formed 128 dyads. Overall, 72.9% of male partners of NAAT-positive women and 68.6% of female partners of NAAT-positive men were Ct-infected. Concordance was more common in dyads with culture-positive members (78.6% of male partners, 77% of female partners). Partners of women and men who were NAAT-positive only had lower concordance (33.3%, 46.4%, respectively). Women in concordant dyads had significantly higher median endocervical quantitative Ct polymerase chain reaction values (3,032) compared with CT-infected women in discordant dyads (1013 inclusion forming units DNA equivalents per mL; P < 0.01). Among 54 Ct-concordant dyads with ompA genotype data for both members, 96.2% had identical genotypes. CONCLUSIONS: Higher organism load appears associated with concordance among women. Same-genotype chlamydial concordance was high in sexual partnerships. No behavioral factors were sufficiently discriminating to guide partner services activities. Findings may help model coitus-specific transmission probabilities.

Genitourinary infections in diabetic patients in the new era of diabetes therapy with sodium-glucose cotransporter-2 inhibitors.

AIMS: To review prevalence and significance of urinary tract (UTI) and genital infections (GI) in diabetes and the effects of sodium glucose cotransporter 2 (SGLT-2) inhibitors on these complications. DATA SYNTHESIS: The prevalence of asymptomatic bacteriuria (ASB) is 2-3 times higher in diabetic than in non-diabetic women. The treatment of ASB has no impact on the development of UTIs and/or a decline in renal function. Therefore, there is no indication for screening for and/or treatment of ASB. The incidence of UTI is higher and frequently complicated in diabetic patients, particularly in those with longer duration of disease and of older age. There is no consistent evidence of an association between A1c levels, glycosuria and the risk of ASB and/or UTIs. Diabetes is a known risk factor for Candida colonization and GI, and a poor glycemic control is associated with a higher risk. While patients treated with SGLT-2 inhibitors may have a non-significant increased risk of UTI, they have a clearly increased risk of GI; most of these infections are mild, easy to treat, and the rate of recurrence is low. CONCLUSION: Diabetic patients are at high risk of UTIs and of GI. Only GI are associated with poor glycemic control. Although patients treated with SGLT-2 inhibitors have an increased 3-5 fold risk of GI, proper medical education can reduce this risk.

Male genital dermatophytosis - clinical features and the effects of the misuse of topical steroids and steroid combinations - an alarming problem in India.

Genital dermatophytosis has been considered rare by most Western authorities. However, to the contrary, Indian reports have shown a higher prevalence of genital dermatophytosis due to warm and humid climate, overcrowding and lack of hygiene. A review is presented for 24 cases of male genital dermatophytosis occurring in patients suffering from tinea cruris in India who have been randomly applying various broad-spectrum steroid antifungal and antibacterial creams containing one or more antifungal and antibiotic in addition to potent corticosteroids, mainly clobetasol propionate. This is such a common phenomenon that Indian dermatologists are witnessing an epidemic of sorts of steroid-modified dermatophytosis and we hereby share various clinical presentations of dermatophytosis of penis and/or scrotum in patients with tinea cruris who have been applying the above-mentioned creams. The review also discusses the bleak scenario that prevails in India regarding the drug regulatory affairs that allow such dangerous and irrational combinations that are sold over the counter because of misinterpretation of the law and lax implementation of existing laws.

[Tinea in the genital area : A diagnostic and therapeutic challenge]. / Tinea im Genitalbereich : Eine diagnostische und therapeutische Herausforderung.

Pubogenital tinea or tinea genitalis represents a rare type of dermatophytosis which, however, is increasingly being diagnosed. The mons pubis is affected, but also the outer regions to the penis shaft and the labia together with the groins. Pubogenital tinea is a more superficial erythrosquamous type, but strong inflammatory dermatomycoses of the genital area as tinea genitalis profunda ranging to kerion celsi are observed. A total of 30 patients (14-63 years of age, 11 men and 19 women) with pubogenital tinea are described. Most patients originated from Graz, Austria, while 2 patients were from Germany (Saxony and Isle of Sylt). Causative agents were mainly zoophilic dermatophytes: Microsporum (M.) canis (11), Trichophyton (T.) interdigitale (9), T. anamorph of Arthroderma benhamiae (2), and T. verrucosum (1). Anthropophilic fungi were T. rubrum (6) and T. tonsurans (1). Anamnestic questions should include contact with pets, physical activities, and travel. Genital shaving and concurrent tinea pedis and onychomycosis are disposing factors. Treatment consisted of oral antifungals except in the three women who were pregnant. Preferably, itraconazole or terbinafine was used, while in a single case, fluconazole was administered. Griseofulvin was not used, because this classic systemic antifungal agent is not allowed any more in Austria. In one patient, oral antifungal therapy was changed from itraconazole to terbinafine due to inefficacy.

Brucellosis, genital campylobacteriosis and other factors affecting calving rate of cattle in three states of Northern Nigeria.

BACKGROUND: Reproductive diseases limit the productivity of cattle worldwide and represent an important obstacle to profitable cattle enterprise. In this study, herd brucellosis and bovine genital campylobacteriosis (BGC) status, and demographic and management variables were determined and related to predicted calving rate (PrCR) of cattle herds in Adamawa, Kaduna and Kano states, Nigeria. Serum samples, preputial scrapings, questionnaire data, trans-rectal palpation and farm records were used from 271 herds. The Rose-Bengal plate test and competitive enzyme-linked immunosorbent assay were used for Brucella serology and culture and identification from preputial samples for BGC. A herd was classified as positive if one or more animals tested positive. The PrCR was determined as the number of calvings expected during the previous 6 and next 6 months as a percentage of the number of postpubertal heifers and cows in the herd. A multilevel linear regression model was used to estimate the herd-level effect of Brucella abortus seropositivity, Campylobacter fetus infection and other factors on calculated PrCR. RESULTS: The reproductive performance of the cattle herds was generally poor: Only 6.5% of the nursing cows were pregnant and 51.1% were non-pregnant and acyclic; the mean annual PrCR was 51.4%. Brucella abortus and C. fetus infection of herds were independently associated with absolute reduction in PrCR of 14.9% and 8.4%, respectively. There was also a strong negative association between within-herd Brucella seroprevalence and PrCR. Presence of small ruminants, animal introduction without quarantine and the presence of handling facilities were associated with lower PrCR, whereas larger herd size, supplementary feeding, routine mineral supplementation and care during parturition were associated with higher PrCR. CONCLUSIONS: Brucellosis and BGC may be largely responsible for the poor reproductive performance of indigenous Nigerian cattle. Farmer education and measures to improve the fertility of cattle herds are suggested.

Neonatal necrotizing fasciitis of the scrotum caused by Streptococcus agalactiae.

We herein describe the case of a 27-day-old male infant who was brought to the emergency room for intermittent crying, and swelling of the left scrotum. Based on the clinical findings, necrotizing fasciitis was suspected, and surgical intervention was successfully completed within a few hours of admission. Streptococcus agalactiae type Ia was cultured from the drained abscess, and was considered the causative pathogen. To our knowledge, this is the first report of neonatal necrotizing fasciitis caused by S. agalactiae. Prompt diagnosis and immediate surgical debridement are crucial in the initial management of this disease.

Denominators count: supplementing surveillance data for genital Chlamydia trachomatis infection with testing data, Norway, 2007 to 2013.

As genital Chlamydia trachomatis (chlamydia) infection is often asymptomatic, surveillance of diagnosed cases is heavily influenced by the rate and distribution of testing. In 2007, we started supplementing case-based surveillance data from the Norwegian Surveillance System for Communicable Diseases (MSIS) with aggregated data on age group and sex of individuals tested. In this report, annual testing rates, diagnosis rates and proportion positive for chlamydia in Norway between 1990 and 2013 are presented. From 2007, rates are also stratified by age group and sex. The annual testing rate for chlamydia culminated in the early 1990s, with 8,035 tested per 100,000 population in 1991. It then declined to 5,312 per 100,000 in 2000 after which it remained relatively stable. Between 1990 and 2013 the annual rate of diagnosed cases increased 1.5 times from ca 300 to ca 450 per 100,000 population. The proportion of positive among the tested rose twofold from ca 4% in the 1990s to 8% in 2013. Data from 2007 to 2013 indicate that more women than men were tested (ratio: 2.56; 95% confidence interval (CI): 2.56-2.58) and diagnosed (1.54; 95% CI: 1.52-1.56). Among tested individuals above 14 years-old, the proportion positive was higher in men than women for all age groups. Too many tests are performed in women aged 30 years and older, where 49 of 50 tests are negative. Testing coverage is low (15%) among 15 to 24 year-old males. Information on sex and age-distribution among the tested helps to interpret surveillance data and provides indications on how to improve targeting of testing for chlamydia. Regular prevalence surveys may address remaining limitations of surveillance.

[Efficiency of bacteriological culture and the immunofluorescent assay to detect Campylobacter fetus in bovine genital fluids]. / Eficiencia del cultivo bacteriológico y de la inmunofluorescencia en la detección de Campylobacter fetus en fluidos genitales bovinos.

Bovine genital campylobacteriosis is a reproductive disease that affects cattle production. It is caused by Campylobacter fetus subspecies, C. fetus fetus (Cff) and C. fetus venerealis (Cfv). The aim of this study was to identify the presence of C. fetus in genital fluids by bacteriological culture and direct immunofluorescence (DIF) and to compare the results. Two groups of 6 heifers and 5 bulls, one infected with Cff (Cff group) and the other with Cfv (Cfv group) were formed. Two heifers and 2 bulls, all of them uninfected, made up the control group. Samples of cervicovaginal mucus and preputial fluid were processed by culture and DIF. In the Cff group, 100% of the heifers and 80% of the bulls were infected, while in the Cfv group, 50% of the heifers and 60% of the bulls were infected. The degree of agreement (Kappa values) from benchmarking diagnostic techniques were 0.57 for heifers in the Cff group and 0.52 for heifers in the Cfv group, whereas the values for bulls were 0.17 and 0.27, respectively. Heifers yielded more positive results in the DIF assay than in the culture, exhibiting 5.6% increase in the Cff group and 7.4% in the Cfv group. The lowest percentage of positive results for DIF in bulls, 40% less for the Cff group and 5.2% for the Cfv group, could be due to improper sampling. Kappa values showed moderate agreement for the heifers and low for the bulls.

[Improved sample collection methods and bacteriologic localization patterns for male genital tract infection].

OBJECTIVE: To improve the sample collection methods and bacteriologic localization patterns in male genital tract infection, and to investigate the influence of specimen collection and pathogen isolation on the diagnosis and treatment of prostatitis. METHODS: We collected the samples of the initial urinary stream, the third portion of the urinary stream, expressed prostatic secretion (ESP), and semen from 200 adult males with chronic prostatitis-like symptoms, inoculated them quantitatively in culture media for isolation of microorganisms, and evaluated their laboratory diagnostic significance according to the count of colonies and distribution of the isolates. RESULTS: A total of 468 strains of microorganisms were isolated from the samples, including 414 strains of bacteria spp (88.5%), 12 strains of fungi spp (2.6%), 40 strains of mycoplasma spp (8.5%), and 2 strains of chlamydia spp (0.4%). Pathogens were isolated from the ESP in 66 cases (33.0%), from the semen in 34 cases (17.0%), and from both the ESP and semen in 100 cases (50.0%). Only 1 species of pathogen was found in the ESP samples of 36 cases (18.0%), in the semen samples of 20 cases (10%), and in both the ESP and semen samples of 39 cases (19.5%); 2 species in the ESP samples of 30 cases (15.0%), in the semen samples of 14 cases (7.0%), and in both the ESP and semen samples of 60 cases (30.0%); and 3 species in both the ESP and semen samples of 1 case (0.5%). CONCLUSION: Multiple microbial infection (MMI), multi-organ infection (MOI) and drug-resistance strains infection are common in patients with prostatitis-like symptoms, frequently leading to missed diagnosis and misdiagnosis in clinic and laboratory, and affecting the effect of antimicrobial therapy. MMI and MOI can be diagnosed and differentially diagnosed with the improved sample collection methods and bacteriologic localization patterns.

Genitourinary skin and soft tissue infections: a prospective contemporary evaluation of causative pathogens.

PURPOSE: Prior literature identified anaerobes as the predominant causative organisms in genitourinary skin and soft tissue infections. However, the increasing prevalence of community acquired, methicillin resistant Staphylococcus aureus infection has brought about the growing need to reevaluate these infections and their causative organisms. We examined the causative organisms and risk factors in suppurative superficial genitourinary infections, and evaluated the growing role of community acquired, methicillin resistant S. aureus. MATERIALS AND METHODS: We performed a single institution, prospective assessment of 60 adults who presented between August 2008 and July 2010 with genitourinary skin and soft tissue infections requiring incision and drainage. Patients completed a standardized, nonvalidated questionnaire before undergoing débridement of the site. RESULTS: A total of 60 patient specimens were obtained and 92 bacterial pathogens were isolated. Of these pathogens 55% were aerobes. S. aureus was the most predominant cultured organism, representing 25% of all cultured organisms, and 65% of these isolates were community acquired, methicillin resistant S. aureus. The most commonly associated comorbidities included diabetes mellitus, tobacco smoking and heavy alcohol use. HIV/AIDS showed a statistically significant association with community acquired, methicillin resistant S. aureus infection (OR 11.00, 95% CI 1.05-115.51, p = 0.0456), as did the cumulative number of community acquired, methicillin resistant S. aureus risk factors (OR 2.64, 95% CI 1.31-5.33, p = 0.007). CONCLUSIONS: Aerobic organisms now account for most of these infections and community acquired, methicillin resistant S. aureus has emerged as a significant causative organism. Populations that may be at increased risk for these infections include patients with diabetes mellitus, heavy alcohol users and tobacco smokers. In patients with HIV/AIDS or multiple community acquired, methicillin resistant S. aureus risk factors the latter organism is more likely to be the causative organism.