Lymphogranuloma venereum presenting as genital ulceration and inguinal syndrome in men who have sex with men in London, UK.

OBJECTIVES: To describe a series of lymphogranuloma venereum (LGV) cases presenting as inguinal syndrome and/or genital ulceration seen among men who have sex with men (MSM) in London, UK. METHODS: Collaborative retrospective case note review. Clinicians from three London genitourinary medicine (GUM) clinics accessed by large populations of MSM within the current LGV outbreak collected clinical data from confirmed cases of LGV inguinal syndrome or genital ulcer. LGV was confirmed by the detection of LGV-specific DNA from specimens such as bubo aspirates, ulcer swabs, urethral swabs, first void urine and rectal biopsy material. RESULTS: There were 13 cases detected overall: 5 cases of urethral LGV infection with inguinal adenopathy, 3 cases of genital ulcer with LGV inguinal adenopathy, 3 cases of isolated LGV-associated inguinal buboes, 1 case of a solitary LGV penile ulcer and 1 case with a penile ulcer and bubonulus. Only 6 of the 13 were HIV positive and all tested negative for hepatitis C. The majority of cases reported few sexual contacts in the 3 months preceding their diagnosis. CONCLUSIONS: Clinical manifestations of LGV in MSM have not been confined to proctitis in the current outbreak in the UK and a small but significant number of inguinogenital cases of LGV have been observed. Epidemiologically, many of the cases described seem to have occurred at the periphery of the current MSM LGV epidemic. Clinicians need to be vigilant for these less common presentations of LGV among MSM and specific diagnostic tests should be done from the relevant lesions.

Evaluation of a home-delivery service for HIV-infected patients attending an inner London HIV treatment centre.

Home delivery (HD) of medication is a goal of the Department of Health's Pharmacy in the Future; Implementing the NHS Plan. We evaluated the safety and effectiveness of an HD service for antiretroviral therapy (ART). Patients on ART with stable viral load (VL) <50 were identified. Comparison was made between patients using HD and those using the clinic-based pharmacy (CP). The primary endpoint was HIV virological failure (VF) (HIV VL >400 copies/mL on two consecutive occasions). Secondary endpoints included frequency of outpatient attendances (OPA) and an incidence of adverse events. Cumulative incidences (CulmIn) for each outcome event were calculated. Incidence-rate ratios (IRR) were obtained using Poisson regression. Of 1663 patients identified; 450 received HD and 1213 used CP. CuImIn of VF was =4% in those using HD and =7% in those using CP (IRR [95% confidence intervals, CI] =0.53, 0.32-0.90). HD patients had fewer OPA, less frequent blood test monitoring and less frequent abnormal liver function results (IRR [95% CI]= 0.63 [0.59-0.67] and 0.59 [0.53-0.67], 0.68 [0.65-0.71] and 0.64 [0.53-0.78], respectively). Patients deemed stable enough on social, psychological and medical grounds to receive HD of ART had a lower risk of VF, fewer OPA and no increase in adverse events when compared with patients using CP.

Ethnic differences in women with HIV infection in Britain and Ireland. The study group for the mrc collaborative study of HIV infection in women.

OBJECTIVE: To examine ethnic differences in the socio-epidemiological and clinical characteristics of a cohort of women with HIV infection in Britain and Ireland. DESIGN AND METHODS: Analysis of baseline data (ethnic group, sexual history, likely route of HIV infection, reasons for HIV testing and first AIDS-defining disease) from 400 women with HIV infection recruited into a cohort study from 15 genitourinary medicine/HIV clinics in Britain and Ireland. RESULTS: Sixty-five per cent of women were white and 29% black African. Their median number of lifetime sexual partners was seven and three, respectively (P < 0.001). Ninety-three per cent of black African and 43% of white women were probably infected through sexual intercourse. Injecting drug use was the most likely route of infection in 55% of white women, but none of the black African women. Perceived risk (33%) or investigation of symptoms (26%) were the most common reasons for HIV testing. Seven per cent of white women and 16% of black African women (P < 0.001) had AIDS when HIV infection was diagnosed. The distribution of first AIDS-defining diagnoses differed (P = 0.001) by ethnic group. For white women, the most common disease was Pneumocystis carinii pneumonia; for black African women it was pulmonary tuberculosis. CONCLUSION: There are important differences between black African and white women in sexual history and route of transmission, disease stage at diagnosis and pattern of AIDS-defining diseases.

Chlamydial urethritis in heterosexual men attending a genitourinary medicine clinic: prevalence, symptoms, condom usage and partner change.

A prospective study of 356 consecutive heterosexual male patients attending the Department of Genitourinary Medicine at University College Hospital was carried out to determine the prevalence of Chlamydia trachomatis. Patients were asked about their symptoms, use of condoms and change of sexual partner. The prevalence of non-gonococcal urethritis (NGU--chlamydia positive and negative urethritis) was 37% (131 of 356). C. trachomatis was shown to be the causative organism in 24% (31 of 131) of patients with NGU. The prevalence of other STDs in men with C. trachomatis and with non-chlamydial urethritis was 15% and 10% respectively. Men with C. trachomatis were significantly more likely than men with non-chlamydial urethritis to be asymptomatic (56% vs 35%). The prevalence of C. trachomatis was highest in men who had changed partner in the previous 3 months (20 of 32 men). A third of men never used condoms in the first 3 months of a new relationship and over half failed to use them after 3 months. There was no evidence that the reported use of condoms reduced the rate of infection with C. trachomatis.

Symptomatic management of HIV associated gastrointestinal disease.

This chapter describes the differential diagnosis and management of gastrointestinal symptoms associated with HIV infection. There is no clear point when management moves from intervention to palliation, and as with other manifestations of HIV disease, clinical decisions have to be guided by the wishes of the patient. In general, early diagnosis and treatment of HIV associated opportunistic infection are likely to keep patients symptom free, but when specific therapy is unavailable, unsuccessful or unwanted, then there is a clear indication to strive for symptom control using conventional palliative care.

Comparison of an enzyme immuno assay (Antigenz Chlamydia) with cell culture for the detection of genital chlamydial infection in high and low risk populations.

OBJECTIVE: To evaluate a new enzyme immuno assay, Antigenz Chlamydia, for the detection of chlamydial antigen in urogenital samples using cell culture as the gold standard for comparison and direct immuno fluorescence to aid resolving the discrepancies. SUBJECTS: 212 men and 303 women attending an STD clinic and 404 women of child bearing age attending gynaecological clinics. RESULTS: Sensitivity, specificity, predictive value of positive result and predictive value of negative result of the new test were 77.6%, 99.0%, 94.3%, and 95.7% respectively in the high risk population with a prevalence of 16.5%. In the low risk population the figures were 84.2%, 94.5%, 43.2% and 99.2% respectively with a prevalence of 4.7%. CONCLUSION: Antigenz Chlamydia is an easy and quick test to perform. The test is suitable for use in high risk and low risk populations provided all positive samples are confirmed.

Comparison of ofloxacin and metronidazole for the treatment of bacterial vaginosis.

The efficacy and safety of ofloxacin, 200 mg twice daily for 7 days, was compared with metronidazole, 400 mg twice daily for 7 days, for the treatment of bacterial vaginosis (BV). Diagnosis of BV was confirmed by at least 3 of the following 4 criteria: the presence of an abnormal vaginal discharge on examination, clue cells on microscopy of vaginal specimens, vaginal pH greater than 5.0 and a positive amine test. Vaginal specimens were examined for Mobiluncus spp, analysed for the succinate/lactate (S/L) ratio and cultured for Trichomonas vaginalis, Gardnerella vaginalis, Bacteroides spp. and Mycoplasma hominis. Patients were reviewed on completion of treatment (visit 2) and 14 days later (visit 3). The diagnosis of BV was accepted in 119 of 149 patients recruited, 60 of whom received treatment with ofloxacin and 59 received metronidazole. Sixty-two patients, 31 in each treatment group, completed the study. Diagnostic cure at visit 2 was significantly better in the metronidazole group with cure rates of 56% (metronidazole) vs 23% (ofloxacin) (P = 0.001); this was associated with higher eradication rates for G. vaginalis (100% vs 56%) and Bacteroides spp. (97% vs 49%). There were no significant differences between the two groups in clinical cure at either visit 2 or 3 or in diagnostic cure at visit 3. Both treatments were well tolerated. We conclude that metronidazole is likely to remain the first choice of treatment for BV but ofloxacin offers a safe and effective alternative.

Evaluation of an enzyme immunoassay (Chlamydiazyme) with confirmatory test for the detection of chlamydial antigen in urine from men.

First catch urine specimens from 312 male patients were examined for the presence of chlamydial antigen by an enzyme immunoassay (Chlamydiazyme). Positive results were repeated and confirmed using a blocking assay. In addition, urethral swabs were examined by cell culture for Chlamydia trachomatis. Discrepant results were further analysed by direct immunofluorescence (IF) of the spun urine deposit. Paired specimens were positive from 26 subjects, and negative from 276 subjects. Eight paired specimens were urethral culture positive, and urine EIA negative. Two specimens, urine EIA positive but urethral culture negative, were positive on direct IF. The sensitivity, specificity, predictive value of a positive result, and predictive value of a negative result for urine EIA against cell culture and/or direct IF were 77.8%, 100%, 100% and 97.2% respectively.

Outcome of untreated infection with Entamoeba histolytica in homosexual men with and without HIV antibody.

Among homosexual men the prevalence of infection with Entamoeba histolytica is high. To determine the clinical importance of this infection 55 homosexual men carrying the parasite were investigated in detail. No clinical, serological, or histological evidence of invasive amoebiasis was found in any of them. The patients were not treated and were followed up for 12 to 29 months (mean 21.6 months), during which period none developed symptoms that could be attributed to E histolytica. Spontaneous loss of the parasite occurred in 17 patients, some of whom later became reinfected. Sixteen patients had antibody to human immunodeficiency virus, and infection with E histolytica showed the same benign course in them as in the patients who did not have antibody. Throughout the study classification of the isolates of E histolytica consistently showed that they belonged only to non-pathogenic zymodemes. The findings provide further evidence that E histolytica in homosexual men is a commensal organism.

Treatment of first-attack genital herpes--acyclovir versus inosine pranobex.

77 patients with a first attack of genital herpes were entered into a double-blind trial to compare the efficacy of acyclovir with that of inosine pranobex. 24 patients received acyclovir with that of inosine pranobex, and 28 both drugs. Patients treated with acyclovir or both drugs healed more quickly and had a shorter duration of viral shedding than those treated with inosine pranobex. The time to first recurrence and frequency of subsequent recurrences were similar in the three treatment groups. Acyclovir is the treatment of choice for patients with a first attack of genital herpes.

Sex and the bowel.

Patients with gastrointestinal symptoms may not associate their problems with sexual activities or be unwilling to admit to homosexuality. The diagnosis may be delayed or missed and sexual partners are unlikely to be investigated. To complicate matters further the clinical manifestations of some infections may be markedly altered in a patient whose immune system has been compromised by infection with Human Immunodeficiency Virus.