[Classical sexually transmitted diseases in the anorectal region]. / Klassische sexuell übertragbare Infektionen im Analbereich.

BACKGROUND: Sexually transmitted infections (STIs) in the anorectal region are disproportionally detected in risk populations such as men who have sex with men (MSM). However, due to changes in sexual behaviour they are increasingly diagnosed in heterosexual individuals. Due to the recent implementation of oral HIV pre-exposure prophylaxis together with lack of condom use, a further rise in STIs is expected. OBJECTIVES: This review addresses epidemiology, clinical picture, diagnostic pitfalls and current therapy guidelines of "classical" bacterial STIs involving the anorectum. CONCLUSIONS: STI manifestations in the anal region are frequently nonspecific or asymptomatic so that the diagnosis may be missed. In an endoscopic examination of the rectum, they can even mimic inflammatory bowel disease or malignancy. Therefore, knowledge of possible symptoms of bacterial STIs in this area is helpful for early diagnosis. Coinfections with other STIs are common and should prompt a search of other pathogens including HIV and hepatitis B/C.

[Sexually transmitted infections and male fertility]. / Sexuell übertragbare Infektionen und männliche Fertilität.

BACKGROUND: Sexually transmitted infections (STI) are common worldwide and can cause impairment of fertility. In women pelvic inflammatory disease with subsequent tubal sterility is well-documented but the influence of STI on male fertility is still controversely discussed OBJECTIVE: The effects of various bacterial and viral STI on male fertility are discussed. MATERIAL AND METHODS: An evaluation of the international literature up to 30 April 2018 was carried out including studies on larger collectives from the Asiatic region. RESULTS: There is still an inconsistent picture of the influence of various bacterial and viral STI on male fertility. Direct or indirect evidence of the impact of a pathogen alone on the quality of ejaculates could not be clearly demonstrated; however, there are indications of a negative effect by Mycoplasma and Ureaplasma species in large Asiatic collectives. The transmission of viral pathogens, such as human papillomavirus (HPV), herpes simplex virus (HSV) and hepatitis B virus (HBV) possible impairs the success of assisted reproductive techniques. In contrast, manifest inflammatory processes of the male genital tract caused by STI (in particular Chlamydia and gonococci) or human immunodeficiency virus (HIV) infections often result in impairment of sperm qualtity. CONCLUSION: In cases of male fertility disorders a microbiological clarification is recommended. Further studies on the effect of STI on male fertility in larger collectives are necessary, particularly for Caucasian populations. The utilization of existing preventive measures, such as screening for Chlamydia in young women and HPV vaccination also for young males, should be intensively promoted.

PEPDar: A randomized prospective noninferiority study of ritonavir-boosted darunavir for HIV post-exposure prophylaxis.

OBJECTIVES: PEPDar compared the tolerability and safety of ritonavir-boosted darunavir (DRV/r)-based post-exposure prophylaxis (PEP) with the tolerability and safety of standard of care (SOC). The primary endpoint was the early discontinuation rate among the per-protocol population. METHODS: PEPDar was an open-label, randomized, multicentre, prospective, noninferiority safety study. Subjects were stratified by type of event (occupational vs. nonoccupational, i.e. sexual) and were randomized to receive DRV/r plus two nucleoside reverse transcriptase inhibitors (NRTIs) or SOC PEP. Twenty-two private or university HIV clinics in Germany participated. Subjects were ≥ 18 years old and had documented or potential HIV exposure and indication for HIV PEP. They initiated PEP not later than 72 h after the event and were HIV negative. RESULTS: A total of 324 subjects were screened, the per-protocol population was 305, and 273 subjects completed the study. One hundred and fifty-five subjects received DRV/r-based PEP and 150 subjects received ritonavir-boosted lopinavir (LPV/r)-based PEP for 28-30 days; 298 subjects also received tenofovir/emtricitabine. The early discontinuation rate in the DRV/r arm was 6.5% compared with 10.0% in the SOC arm (P = 0.243). Adverse drug reactions (ADRs) were reported in 68% of DRV/r subjects and 75% of SOC subjects (P = 0.169). Fewer DRV/r subjects (16.1%) had at least one grade 2 or 3 ADR compared with SOC subjects (29.3%) (P = 0.006). All grades of diarrhoea, nausea, and sleep disorders were significantly less frequent with DRV/r, while headache was significantly more frequent. No HIV seroconversion was reported during follow-up. CONCLUSIONS: Noninferiority of DRV/r to SOC was demonstrated. DRV/r should be included as a standard component of recommended regimens in PEP guidelines.

[Sexually transmitted infections of the anorectal region]. / Sexuell übertragbare Erkrankungen der Analregion.

BACKGROUND: Sexually transmitted infections (STIs) are increasingly observed in men who have sex with men (MSM), which is associated with the success in the antiretroviral treatment of HIV infection. Additionally, in heterosexuals, anal intercourse is more prevalent than previously assumed. Thus, anorectal manifestations of STIs are not a rare condition. OBJECTIVES: This review will focus on the clinical picture, diagnosis and therapy of frequent STIs involving the anorectal region. CONCLUSIONS: Due to localisation and frequent asymptomatic course, STIs in this region often pose diagnostic problems. Anorectal manifestations of STIs consist of tumorous masses, ulcers or proctitis and may be misdiagnosed as malignancy or inflammatory bowel disease. Herpes simplex and syphilis primarily show ulcerations and may involve the perianal region, whereas gonorrhoea and lymphogranuloma venereum mainly cause proctitic symptoms with exsudation. Because of commonly occurring coinfections a complete diagnostic workup concerning other STIs should be performed.

Analysis of risk factors for late presentation in a cohort of HIV-infected patients in Dresden: positive serology for syphilis in MSM is a determinant for earlier HIV diagnosis.

PURPOSE: Late HIV presentation is still a health concern, even in industrialised countries. Data concerning this problem in Eastern Germany are scarce. We investigated associated factors in a cohort of HIV-infected patients in Dresden, Germany, including syphilis serology as a proxy for sexual risk behaviour. METHODS: A retrospective cohort study on 348 patients presenting for the first time in our treatment centre from 1986 to 2010 was undertaken. Risk factors of late (CD4 cells <350/µl) and very late (CD4 cells <200/µl) presentation either to care or to diagnosis were identified by means of logistic regression analyses. RESULTS: Of 348 classifiable patients, 54 % were late and 33.9 % were very late presenters to care. In a subgroup of 260 patients with recent HIV diagnosis, 50.4 % were late and 31.2 % were very late presenters to diagnosis. Age >24 years was a significant independent factor associated with late or very late presentation, but not male gender, originating from high-prevalence countries (HPC) or years of presentation. Being MSM alone was not associated with early or late HIV presentation, but MSM with positive TPHA or TPPA showed a lower risk of late presentation, predominantly in those presenting late to diagnosis [odds ratio (OR) 0.42, p = 0.048]. CONCLUSIONS: A positive syphilis screening test seems to be a determinant for lower risk of late presentation to HIV care and diagnosis in MSM. The presence and awareness of sexually transmitted infections (STIs) such as syphilis may lead to earlier utilisation of HIV health care and, thus, promote earlier HIV diagnosis. HIV prevention strategies should focus more on STIs and not only on HIV.

Nurses' perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group.

BACKGROUND: Nurses have a high risk of developing hand eczema due to hand disinfection procedures. OBJECTIVES: To investigate the perception of nurses regarding the adverse effects of hand washing (HW) and alcoholic disinfection (ADI), and to obtain data on the prevalence of hand dermatitis and sensitization to alcohols and alcohol-based hand rubs (ABHRs). METHODS: A self-administered questionnaire survey, carried out as a pilot study (PS), followed by a modified multicentre study (MC) in five hospitals. Patch tests to ethanol (80%), 1-propanol (60%), 2-propanol (70%) and ABHRs were performed in a subsample. RESULTS: The majority (PS 60.1%; MC 69.5%) of nurses considered ADI to be more damaging than HW. Mostly, ADI and HW were suspected to have irritant effects (ADI 79.2%/52.1%; HW 65.5%/36.2%) compared with an allergenic potential (ADI 10.4%/5.8%; HW 7.8%/3.9%). The prevalence of hand dermatitis in the MC was 13.4% by self-diagnosis and 22.4% by symptom-based questions. In 50 tested individuals no sensitization and only two irritant reactions to alcohols and three single-positive reactions to ABHRs were observed, none of the latter related to alcohols. CONCLUSIONS: Although ADI is known to cause less skin irritation than HW, nurses perceive ADI as more damaging, resulting in: (i) a low compliance with ADI and (ii) a higher prevalence of hand dermatitis because the more deleterious HW is preferred. This may result in an increase in occupational disease and nosocomial infections. Educational programmes should promote ADI as a procedure with good efficiency and skin tolerability to reduce the prevalence of hand eczema in nurses and to enhance compliance with hand hygiene standards.

[Late secondary syphilis with ulceration of the tongue during HIV coinfection: case report]. / Spätsekundäre Syphilis mit Ulzeration der Zunge bei HIV-Koinfektion: Fallbericht.

With the continuing rise of syphilis incidence, late stages and atypical courses with HIV-coinfection can be expected. A 45 year old HIV infected male presented with an unusual manifestation of late secondary syphilis on the tongue, which was first diagnosed as a squamous cell carcinoma but cleared after therapy with penicillin. He also exhibited psoriasiform and annular lesions on the trunk and hyperkeratotic papules on the palms of the hand and soles of the feet. A TPHA test was negative due to a prozone phenomenon. With this case, we would like to emphasize the formerly well known relationship between the lesions of tertiary syphilis on the tongue and development of secondary carcinoma.

[Treatment of toxic epidermal necrolysis. Experience with 9 patients with consideration of intravenous immunoglobulin]. / Behandlung der toxischen epidermalen Nekrolyse. Erfahrungen bei 9 Patienten unter Berücksichtigung von intravenösen Immunglobulinen.

Toxic epidermal necrolysis (TEN) is the maximal variant of severe bullous drug reactions with a high mortality rate of 30-40%. Treatment should be interdisciplinary and is best provided in an intensive care setting. Since no specific therapy has been established, supportive intensive care and topical treatment are of crucial importance. Between 1995 and 2005, nine patients with TEN were treated in the anesthesiology intensive care unit in cooperation with dermatology in the University Hospital of Dresden. All patients initially received corticosteroids and five patients were additionally treated with intravenous immunoglobulins (IVIG). The overall mortality of 33% was underestimated by the SAPS II-Score, whereas it was overestimated by the TEN-specific SCORTEN. In more severely affected patients, other scoring systems in addition to SCORTEN should be used for prediction of prognosis and evaluation of therapy. The mortality rate of our IVIG treated patients was 20% vs. 50% compared to the non-IVIG-group. However, due to the small number of patients and contradictory results in the literature, IVIG cannot be generally recommended for the treatment of TEN, but should be considered in early stages of the disease.

[Lymphogranuloma venereum. Two cases from Dresden]. / Lymphogranuloma venereum : Zwei Fälle aus Dresden.

Lymphogranuloma venereum (LGV) caused by Chlamydia trachomatis serovar L1-3 was formerly a rare sexually transmitted disease in western countries. Recently, an outbreak of LGV and LGV proctitis among men who have sex with men (MSM) was reported from the Netherlands. We report two cases from Dresden, Germany, of white HIV1-infected MSM who presented in November 2004 with genital ulcers along with inguinal lymphadenitis (case 1) and ulcerative proctitis (case 2). The clinical picture and high titers of serum IgG and IgA antibodies pointed to infection with Chlamydia trachomatis. Appropriate specimens were positive for Chlamydia trachomatis with culture and PCR. Subsequent genotyping of the major outer membrane protein (MOMP) by restricted fragment length polymorphism confirmed serovar L2. Treatment with doxycycline for 3-4 weeks was effective. The incidence of LGV is increasing among MSM in Europe. Since most of the reported cases have been HIV1-infected and ulcerative STDs enhance HIV transmission, both health care providers and patients should be more aware of LGV.

[Haemophilus influenzae]. / Haemophilus influenzae: Relevanter Erreger für Harnwegsinfektionen?

A resurgence in the incidence of sexually transmitted diseases (STD) has occurred in Germany over the past ten years. Along with the classical STD such as syphilis and gonorrhea, new and as yet atypical organisms such as shigella or hepatitis A virus play a role in high-risk patients. We report a case of urethritis caused by H. influenzae Biotype II in an HIV-positive patient. The prevalence of H. influenzae as a relevant pathogen causing urinary tract infections is underestimated because of a lack of selective culture media and no requirements for notification.

Localized pulmonary infection associated with Mycobacterium tilburgii in an HIV-infected patient.

The case of an HIV-infected patient with low CD4+ cell count and localized pulmonary infection associated with Mycobacterium tilburgii, a recently recognized atypical mycobacterial species, is reported. Diagnosis was confirmed by repeated detection of mycobacterial DNA in lung biopsy specimens. After surgical removal of the pulmonary nodules, treatment with antimycobacterial combination therapy led to a complete and sustained recovery of the respiratory symptoms.M. tilburgii so far has only been described to cause disseminated infection in three patients, two of them suffering from acquired immunodeficiency syndrome. To our knowledge, this is the first report of localized pulmonary disease attributed to this mycobacterial species. As it responds to antimycobacterial combination therapy, efforts to establish the diagnosis using PCR methods in patients with suspected pulmonary disease due to mycobacteria other than tuberculosis should be undertaken.

[Increase in syphilis and STD coinfections in HIV-infected individuals in Dresden]. / Zunahme der Syphilis und STD-Koinfektionen bei HIV-Infizierten in Dresden.

BACKGROUND: In the past few years, increased diagnoses of syphilis and other sexually transmitted diseases (STD) have been reported in the cities of the United States and Europe, including Germany. The majority of cases identified were men who have sex with men (MSM). PATIENTS AND METHODS: A retrospective chart review of 144 HIV-infected patients from Dresden enrolled between 2000 and October 2003 was analyzed for the prevalence of syphilis and other STDs and compared with previous data of 104 patients collected between 1993 and 1999. RESULTS: The seroprevalence of syphilis increased from 13.5% to 17.5%, mainly due to a marked increase of active early syphilis from 0% to 7% of patients, all of whom were MSM. 63% of the patients had clinical or serological signs of other STDs. CONCLUSION: These data confirm previous reports on the increase of syphilis among MSM. The frequent occurrence of other STDs in HIV-infected patients outlines the need for special STD screening offers and adequate counseling.