Cause Of Genital Ulceration Research Articles

Acute leukaemia presenting as vulvar ulcers in an adolescent girl

The common causes of genital ulcers in young women are sexually transmitted infections. We report an unusual case of leukaemia in an adolescent who primarily presented with fever and genital ulcers. A 16-year-old unmarried girl presented with a 2-month history of painless ulcerative lesions over her external genitalia intermittent high-grade fever and swelling of the left knee joint. She had been investigated at other hospitals for rheumatic fever systemic lupus erythematosus typhoid fever and malaria since these are relatively common causes of prolonged fever in young patients in India. This work-up was negative after which she was referred to our hospital for review. Examination revealed a young girl in good general condition. She had a temperature of 101°F mild pallor and petechiae over her lower limbs but no lymphadenopathy. Respiratory cardiac and abdominal examinations were normal. Genital examination revealed a 3 × 2 cm superficial non-tender ulcer with a necrotic base and well-defined margins over the right labia majus. There were similar but smaller ulcerative lesions over the left labium majus and both groins. (excerpt)

Tropical STIs

<h2>Abstract</h2> Chancroid, lymphogranloma venereum (LGV) and donovanosis (granuloma inguinale) are causes of genital ulceration found predominantly in tropical areas. Following recognition of the association between genital ulcers and HIV transmission, these conditions have been the subject of renewed interest. Although the incidence of all three conditions appears to be decreasing, a high index of suspicion should be maintained for new outbreaks of disease. Chancroid, (causative organism Haemophilus ducreyi) usually presents with painful sores similar to genital herpes. Polymerase chain reaction (PCR) tests are the most sensitive method of diagnosis. Treatment is with ciprofloxacin or erythromycin. LGV (causative agent Chlamydia trachomatis serovars L1-L3) usually presents with a single, small ulcer, followed by inguinal lymphadenopathy in the secondary stage. The tertiary or anogenital-rectal stage is associated with lymphatic vessel obstruction and complications including rectal stricture, fistula and adhesions. PCR tests are now available. Treatment is with doxycyline, 100 mg b.d. for 14 days. Donovanosis (causative organism Klebsiella granulomatis comb nov or Calymmatobacterium granulomatis) classically causes beefy, red ulcers. Four variants are reported – ulcerogranulomatous, hypertrophic, necrotic and sclerotic. Extragenital lesions are increasingly recognized. The diagnosis is usually confirmed by identifying Donovan bodies on tissue smears by direct microscopy. Treatment is with azithromycin. The WHO has recommended that these and other STIs in developing countries be managed by the syndromic approach that involves treatment for the most likely causes of a syndrome. Health education, condom promotion, contact tracing, compliance with treatment and voluntary testing and counselling for HIV should also be promoted.

Topical microbicides for the prevention of genital herpes infection

Genital herpes is one of the most prevalent sexually transmitted infections worldwide and is the most common cause of genital ulcers. Despite increased public awareness and the initiation of efforts to prevent transmission, the prevalence of herpes simplex virus (HSV) type 2 continues to increase. What makes HSV so difficult to control is that most sexual and perinatal transmission occurs during unrecognized or asymptomatic shedding. The impact of genital herpes as a public health threat is amplified because of its epidemiological synergy with HIV/AIDS. Thus, there is an urgent need for novel prophylactic methods, such as topical microbicides designed for genital application, to prevent both HSV and HIV transmission. Several candidate microbicides are being advanced to clinical trials based on in vitro activity and animal studies. These include compounds that inactivate virus directly, those that enhance innate immunity, and drugs that block viral binding and entry. A more vigorous evaluation of the safety of these and other candidate topical microbicides in development should include assessment of the impact of repeated application on innate host defences in the genital tract.

Potential Effect of HIV Type 1 Antiretroviral and Herpes Simplex Virus Type 2 Antiviral Therapy on Transmission and Acquisition of HIV Type 1 Infection

Biological strategies for interrupting transmission of human immunodeficiency virus (HIV) type 1 should be directed at reducing infectiousness of and susceptibility to HIV-1. Potential antiretroviral interventions include reducing the likelihood of transmission of HIV-1 by reducing HIV-1 load in the blood and genital tract of HIV-1--infected person, prophylaxis after high-risk exposure, and pre-exposure prophylaxis for very high risk populations. Antiviral treatment of herpes simplex virus (HSV) type 2, the most common cause of genital ulcers, should be evaluated as a strategy for HIV-1 infection prevention by reducing infectiousness of and susceptibility to HIV-1, on the basis of biological and epidemiological data indicating that HSV-2 facilitates transmission and acquisition of HIV-1. The rationale for antiretroviral and HSV-2-specific interventions and studies to test these strategies are described.

The role of dendritic cells in immune responses against vaginal infection by herpes simplex virus type 2

Herpes simplex virus type 2 is a leading cause of genital ulcers that affects more women than men worldwide. Recent evidence indicates that protective immunity can be generated by specialized dendritic cells in the female genital mucosa. This article aims to provide an overview of the effector immunity required for protection from genital herpes, and to discuss the mechanism by which specific subsets of dendritic cells mediate induction of adaptive immunity following genital infection with herpes simplex virus type 2 in vivo.

Seroprevalence and correlates of herpes simplex virus type 2 among urban Tanzanian women.

Data on herpes simplex virus type 2 (HSV-2) among women in the general population of developing countries are limited. The goal of the study was to determine the seroprevalence of HSV-2 and to identify clinical, demographic, and behavioral correlates among women attending primary health care clinics. This was a cross-sectional survey of 382 randomly chosen women aged 15 to 49 years. The seroprevalence of HSV-2 was 39%. Only 2% had a history of genital herpes. HSV-2 was associated with antibody to HIV-1 (OR=2.3 [CI, 1.1-4.7]), syphilis (OR=4.7 [CI, 1.4-4.7]), and genital ulcers (OR=9.7 [CI 2.5-36.9]). Age, sexual debut, number of sex partners, and history of spontaneous abortion were found to be significantly associated with HSV-2. Eighty-two percent of the women with genital ulcers were HSV-2-seropositive, while syphilis accounted for 6% of cases. HSV-2 may thus be the most common cause of genital ulcers in this population. In view of the high HSV-2 seroprevalence and its association with HIV-1 and genital ulcers, integration of HSV-2 therapeutic management in STD syndromic algorithms is recommended. Counseling on symptom recognition, asymptomatic shedding, and preventive measures is needed.

Prevalence of herpes simplex virus type 2 antibody in Cameroon.

Genital herpes is one of the most common sexually transmitted diseases. As a leading cause of genital ulceration, herpes genitalis plays a role in facilitating the transmission of HIV. Although HIV infection is most prevalent in Cameroon, information is lacking about prevalence of herpes simplex virus (HSV) type 2 infection in this country. The goal was to determine the prevalence of HSV-2-specific antibody in blood specimens from individuals in Cameroon. Blood specimens were randomly collected from 410 clinic attendees (215 males, 195 females) in Douala, the most populous city in Cameroon. One hundred fifteen of the individuals (28.0%) were HIV-infected. Samples were tested by a type-common HSV IgG enzyme immunoassay not discriminating between HSV-1 and HSV-2 antibodies and by two glycoprotein G-2-based enzyme immunoassays for detection of HSV-2-specific antibody. All but three blood samples were positive for type-common HSV IgG antibodies. Sixty-seven specimens (16.3%) were concordantly negative for HSV-2 antibody by both assays, and 287 (70.0%) specimens were concordantly positive. Fifty-six specimens (13.7%) yielded discrepant results between the two assays. On the basis of specimens with concordantly positive results, the overall HSV-2 seroprevalence was 70.0%. HSV-2 seroprevalence was significantly higher among HIV-infected individuals than among HIV-negative ones. Because of the serious morbidity and mortality caused by HSV-2, effective programs are needed to halt the spread of HSV-2 infection in Cameroon.

Common skin disorders of the penis

Diseases of the male genitalia range from infectious lesions to inflammatory and neoplastic conditions, including many genital manifestations of more general skin diseases. This review highlights the clinical features, diagnosis and treatment of the most common dermatoses of the male genitalia. Herpes genitalis and infections caused by human papillomavirus (HPV) are increasing, particularly in young sexually active people. Herpes simplex virus infection is the commonest infectious cause of genital ulceration, with evidence that many infections are asymptomatic. HPV infection may be latent, subclinical and clinical. The most common causal agents for condyloma acuminatum are low-risk HPV 6 and 11; high-risk HPV types 16 and 18 are associated with premalignant and malignant lesions. Treatment for genital warts remains unsatisfactory; recurrences are common. Imiquimod, a new topical immunotherapeutic agent, which induces interferon and other cytokines, has the potential to be a first-line therapy for genital warts. Scabies and pediculosis are transmitted by skin-to-skin contact and sexual transmission is common, with the penis and scrotum favourite locations for scabious lesions. Oral ivermectin, a highly active antiparasitic drug, is likely to be the treatment of choice, but until approval is granted it should be reserved for special forms of scabies. Common skin diseases, e.g. psoriasis and lichen planus, may have an atypical appearance in the genital area. The typical psoriatic scale is usually not apparent because of moisture and maceration. Allergic contact dermatitis of the genital area may result from condoms, lubricants, feminine hygiene deodorant spray and spermicides. More often, contact dermatitis is irritant, resulting from persistent moisture and maceration. Lichen sclerosus is a chronic inflammatory disease that occurs as atrophic white patches on the glans penis and foreskin. The penile form is a common cause of phimosis in uncircumcised men; involvement of the urethral meatus may lead to progressive meatal stenosis. Plasma cell balanitis is a benign, idiopathic condition presenting as a solitary, smooth, shiny, red-orange plaque of the glans and prepuce of a middle-aged to older man. Squamous cell carcinoma (SCC) in situ, e.g. erythroplasia of Queyrat and Bowen's disease, cannot be excluded clinically; their apparent clinical benignity may lead to lengthy periods of misdiagnosis and biopsy is required to confirm the diagnosis. SCC is the most common malignancy of the penis and the role of oncogenic HPV-types has been also established in SCC of the penis. Prevention of SCC of the penis presupposes an identification of risk factors, early detection of all pre-cancerous lesions and treatment of phimosis.

Genital ulcer disease in Ilorin, Nigeria

This is a review of 32 consecutive cases of patients with genital ulcers or who were repeatedly reactive to serological tests for syphilis (STS) at the Venereology Clinic of the University Teaching Hospital, Ilorin, Nigeria, between January 1993 and April 1995. The criteria for diagnosis of the various conditions included the history, clinical presentation and the results of laboratory investigations. The commonest cause of genital ulcers was chancroid, accounting for 6(18.7%) of the 32 cases. Other common causes were lymphogranuloma venereum (LGV), gential herpes and primary syphilis, each acounting for 12.5 percent of the cases. An unusual presentation of oro-genital aphthosis, with hyperkeratosis and paraesthesia of a localized area on the palm, in addition to the usual genital and oral lesions was reported. Also reported were cases of perigenital cutaneous onchocerciasis and a case of leprosy presenting as chronic biological false positive (BFP) to STS. Patients with chancroid responded favourably to treatment with ceftriaxone (Rocephin) and so was the hyperkeratosis of oro-gential aphthosis to topical treatment with flumethasone pivalate/salicylic acid ointment (Locasalen). The importance of histological technique for making the diagnosis of some tropical conditions affecting the genitals was highlighted, and the exercise of caution in interpreting the results of STS was advocated. (Af. J. of Clinical and Experimental Microbiology: 2002 3(1): 21-23)

Chancroid infections in women

Chancroid is a sexually transmitted disease that is caused by Haemophilus ducreyi. It is one of the main causes of genital ulcers in developing countries as well as the United States. It is seen as a co-infection with other diseases such as herpes simplex virus and human immunodeficiency virus. Haemophilus ducreyi is a gram-negative, facultative anaerobic bacillus. The organism is highly contagious. In women, the ulcer is seen most commonly on the vulva. The lesion usually presents within 3 days to 2 weeks after exposure. If left untreated, a painful inguinal adenitis (bubo) will occur. Diagnosis is often difficult, and a high clinical suspicion is important. H. ducreyi may be grown in a culture medium, identified by Gram stain, or isolated by polymerase chain reaction. The infection can be treated with azithromycin, ceftriaxone, ciprofloxin, or erythromycin. Affected patients should be screened for other sexually transmitted infections, and their partners should be treated with similar antibiotic regimens.

Chancroid: from clinical practice to basic science.

Chancroid is a sexually transmitted disease caused by the bacterium Haemophilus ducreyi. It usually presents as a genital ulcer and may be associated with regional lymphadenopathy and bubo formation. H. ducreyi infection is predominantly seen in tropical resource-poor regions of the world where it is frequently the most common etiological cause of genital ulceration. Genital ulcer disease has been shown to be an extremely important co-factor in HIV transmission. With the advent of the AIDS epidemic, there has been increased research effort to elucidate those factors involved in the pathogenesis of chancroid. Several putative virulence factors have now been identified and isogenic H. ducreyi mutants constructed by mutagenesis of their encoding genes. This approach has facilitated investigations into the role each of these putative virulence factors may play in H. ducreyi pathogenesis through the use of in vitro and in vivo model systems. One major goal of current chancroid research is to identify antigens which are immunogenic and could form the basis of a vaccine against H. ducreyi infection. Such a vaccine, if shown to be effective in decreasing the prevalence of chancroid, could have the added benefit of slowing down the HIV incidence rates in those populations where chancroid is a major co-factor for HIV transmission.

Increasing prevalence of genital herpes in developing countries: implications for heterosexual HIV transmission and STI control programmes.

The recognition that sexually transmitted infections (STI) facilitate HIV transmission among heterosexuals has led to a rejuvenated focus on improving STI control as a component of HIV prevention programmes in developing countries. While efforts so far have focused mainly on all STI, there is increasing evidence that genital ulcers facilitate a considerable proportion of HIV transmission among heterosexuals and that this effect has been underestimated. This paper focuses on the epidemiology of genital herpes in developing countries past and present. To review the scientific literature about the epidemiology of genital herpes in developing countries and discuss the implications of the findings for STI control and HIV prevention programmes. SEARCH METHODOLOGY: A Medline search for June 1966 to August 1999 using the keywords, genital herpes, STD and developing countries, and genital ulcers in MeSH and free text. Abstract books from recent international AIDS conferences and other international STD conferences were reviewed. The annual reports of the medical officers of heath for Harare 1982-1998 and Durban 1989-1997 were reviewed to detect trends in genital herpes diagnoses. Genital herpes, formerly regarded as a minor STI in most developing countries, has now emerged as a leading cause of genital ulceration in many countries where syphilis and chancroid were more prevalent previously. This increased recognition of genital herpes reflects both a change in the pattern of STI epidemiology through a decline in syphilis and chancroid as a response to HIV control programmes and improved techniques for diagnosing herpetic infection. Countries with significant heterosexual HIV epidemics also appear to have rapidly increasing numbers of genital herpes cases. The emergence of this herpes epidemic must be addressed through innovative strategies that will be viable, sustainable, acceptable, and effective in developing countries. In countries where genital herpes is a significant problem, local adaptation of WHO treatment algorithms should be made. STI service providers should be trained about issues around the transmission of herpes and how best to advise clients about dealing with, and recognising, recurrences. The effectiveness of antiviral treatment for genital herpes should be investigated in core groups at high risk of HIV.

Frequent Recovery of HIV-1 From Genital Herpes Simplex Virus Lesions in HIV-1–Infected Men

Genital ulcer disease has been epidemiologically linked as a risk factor in the transmission of the human immunodeficiency virus 1 (HIV-1). While herpes simplex virus 2 (HSV-2) is the most common cause of genital ulcers, no study has systematically evaluated the frequency or titer of HIV-1 virus in HSV-2 lesions. To compare lesional HIV-1 RNA levels during and after genital HSV-2 reactivation and to evaluate the frequency, titer, and duration of HIV-1 RNA shedding in lesions due to HSV-2. Convenience sample. Sexually transmitted disease research clinic at the University of Washington, Seattle. Twelve HIV-infected men with a history of symptomatic HSV-2 infection who underwent daily sampling of genital lesions for HIV-1 RNA by polymerase chain reaction assay and HSV-2 by culture. Detection of lesional HIV RNA and HSV-2. HIV-1 RNA was detected from lesional swabs in 25 of 26 consecutively studied HSV-2 episodes and on 67% of days in which genital lesions were noted. The HIV-1 RNA titers in lesional swabs exceeded 10000 copies/mL of swab sample in 75% of samples (range, 2.2-3.2 x 10(5) copies/mL of swab sample). HIV-1 RNA in genital lesion swabs was seen in persons with high and low titers of plasma HIV-1 RNA and was not associated with plasma HIV-1 RNA levels. HIV-1 virions can consistently be detected in genital ulcers caused by HSV-2, which suggests that genital herpes infection likely increases the efficiency of the sexual transmission of HIV-1.

Chancroid, lymphogranuloma venereum and granuloma inguinale

Genital ulcers are common presentations in sexually transmitted disease clinic settings and, in some developing countries, account for as many as 1 % of primary care visits. Clinical differentiation as to etiology is fraught with error. As a result, syndromic therapy is absolutely necessary and can effectively treat most patients who present with genital ulcer disease. The interactions of genital ulcer disease with HIV continue to be problematic. In many societies, Hemophilus ducreyi is the most important cause of genital ulcers. The biology of this organism is now under intensive investigation and it has proven to be a most intriguing, complex pathogen. Much less progress is occurring with either Calymmatobacterium granulomatis or Chlamydia trachomatis types associated with LGV. Prevention has to be the primary objective and some studies, particularly those from Thailand, suggest that this can be achieved within resource-limited societies.

A morphological study of penile chancroid lesions in human immunodeficiency virus (HIV)-positive and -negative african men with a hypothesis concerning the role of chancroid in HIV transmission

Chancroid, the most common cause of genital ulceration in Africa, is known to be associated epidemiologically with heterosexual transmission of human immunodeficiency virus (HIV). The pathophysiological mechanisms by which chancroid might facilitate the spread of HIV are obscure. To investigate the role of chancroid in HIV transmission, the authors studied the histological features of biopsies from 11 men with penile chancroid lesions including five who were serologically positive for HIV. The histomorphologic and immunophenotypic nature of the inflammatory infiltrates suggests that there is a significant role for cell-mediated immunity in the host response to Hemophilus ducreyi infection. This response may be critical to the role of chancroid in HIV transmission.

Adenovirus types 2, 8, and 37 associated with genital infections in patients attending a sexually transmitted disease clinic

Adenoviruses (Ads) are an important cause of respiratory illness, conjunctivitis, and gastroenteritis, but they are seldom recognized as a potential cause of sexually transmitted disease. We performed virus cultures on approximately 7,000 patients attending a sexually transmitted disease clinic or other health department clinics for the evaluation of genital ulcers, urethritis, or conjunctivitis. Ads were isolated from genital or conjunctival specimens obtained from 23 (0.33%) patients. Among the 20 Ad-positive men, 15 (75%) had urethritis, 12 (60%) had conjunctivitis, and 10 (50%) had both. All three Ad-positive women had vaginal discharge and genital ulcers or fissures. Ad isolates from 17 patients were available for serotyping. Ad type 37 was isolated from 14 patients, Ad type 8 was isolated from 2 patients, and Ad type 2 was isolated from 1 patient. In three of the Ad type 37 cases, Ad was recovered from both urethral and conjunctival specimens. One of the Ad type 8 cases had conjunctivitis, but the Ad type 2 case did not. Ads, particularly type 37, may be a sexually transmissible cause of genital ulcers, urethritis, and conjunctivitis.

Genital Ulcer Disease

There are five major sexually transmitted diseases producing genital ulcerations. Their prevalence varies among geographic regions. Whereas genital herpes is the most frequent cause of genital ulcer in western Europe and North America, the most common cause of genital ulcer disease in developing countries appears to be chancroid. Owing to frequently atypical presentation and mixed infections, an accurate clinical diagnosis is very difficult. Successful management of genital ulcer disease depends on accurate diagnosis corroborated by performance of appropriate laboratory tests when possible.

Chronic giant ulceration of the vulva in an HIV seropositive woman

AbstractHerpes simplex virus (HSV) infection is a common cause of genital ulceration. Primary presentation is usually with multiple, small, discrete, tender ulcers. We report an unusual case of chronic, giant ulceration of the vulva in a woman immunosuppressed by the human immunodeficiency virus (HIV). This was the first presentation of symptomatic disease. The diagnosis of HSV infection was made initially on histological examination of a punch biopsy from the ulcer and subsequently confirmed by viral isolation. The response to antiviral therapy with acyclovir was rapid. Other causes of genital ulceration are discussed and we highlight the diagnostic benefit of histological examination of a punch biopsy.

The diagnosis and treatment of donovanosis (granuloma inguinale).

Donovanosis is a predominantly tropical cause of genital ulcer occurring chiefly in small endemic foci in all continents except Europe. Diagnosis requires the careful collection, staining and examination of smears or biopsies of characteristic genital and, occasionally, extragenital lesions for demonstration of the pathognomonic Donovan bodies (Calymmatobacterium granulomatis) within histiocytes. Successful isolation of C. granulomatis has rarely proved feasible, the last report being in 1962. Donovanosis has a characteristic histopathological picture which occasionally simulates epithelioma. The antibiotics reported as showing good activity in donovanosis are those with good activity against gram negative bacilli and whose lipid solubility ensures good intracellular penetration. They include streptomycin, chloramphenicol, erythromycin, lincomycin, cotrimoxazole and the tetracyclines. More recently, good results have been reported with norfloxacin and thiamphenicol. The treatment of donovanosis in pregnant women and patients with AIDS poses special problems. Complications of donovanosis such as elephantiasis, stricture and pelvic abscess may require surgery. Contacts should be traced for examination but only treated if lesions are found.

The Association Between Genital Ulcer Disease and Acquisition of HIV Infection in Homosexual Men

We analyzed the association of herpes simplex virus (HSV) infection and syphilis, the two most common causes of genital ulceration in homosexual men, with human immunodeficiency virus (HIV) infection in 200 men enrolled between 1983 and 1986 into a study evaluating the microbial causes of acute proctitis. Infection with HIV was independently associated with a history of syphilis, serologic evidence of syphilis, a history of HSV infection, and antibody to HSV-2. Antibody to HIV was not associated with a history of other genital infections or with antibody to Chlamydia trachomatis or HSV-1. Similar associations were observed in 111 asymptomatic homosexuals seen for HIV screening. Men who presented with primary HSV proctitis had a lower prevalence of HIV antibody than those with preexisting HSV-2 antibody (44% vs 68%); this suggests that HSV-2 infection antedated HIV infection. These data suggest that genital ulcerative diseases are an important risk factor for the acquisition of HIV infection in homosexual men; measures directed at control of these diseases may reduce the transmission of HIV in this population. ( JAMA 1988;260:1429-1433)