Genital Cultures Research Articles

Childhood Factitious Disorders—A “Hot” Case of Menstruation

Background: Factitious disorders are rarely reported in the pediatric gynecologic literature. We present a case of factitious menstruation in a ten year old prepubertal child. Case: A ten year old girl presented to her pediatrician’s office with an episode of vaginal bleeding. She reports bright red vaginal bleeding that over 4 days changed to an orange colored odorous discharge. The bleeding occured at regular intervals throughout the day. In the pediatrician’s office she was found to have a normal exam. A White Blood Cell count was 5.9 K/uL, Hemoglobin 13.3mg/dl, Hematocrit 38.8%, and the platelet count 276k. Sedimentation rate was 6 mm/hr, Thyroid Stimulating Hormone was 0.777 uIU/ml, Lutenizing Hormone 0.3 mIU/ml, Follicle Stimulating Hormone 9 mIU/ ml, Estradiol 7 pg/ml, and Free Thyroxine 1.15 ng/d. A computerized tomography (CT) scan of the abdomen and pelvis with nonionic contrast was within normal limits. There was no comment on the uterus, ovaries, or vagina. A non-contrast CT scan of the head is normal but with limited evaluation of pituitary gland. The patient was referred to an adolescent medicine specialist for further evaluation. Physical exam revealed a thin, pale prepubescent child. Breasts are prepubescent, SMR 1. Her abdomen was soft but tender to palpation in the left lower quadrant. Pubic Hair was SMR 1. Her external genitalia were normal. The hymen was annular and no discharge or erythema was present. The rectal exam was normal. A pelvic ultrasound demonstrated a prepubescent, anteverted uterus with an endometrial stripe 0.1 cm. There was no evidence of echogenic foreign body. The ovaries are normal. Gonorrhea/Chlamydia Nucleic Acid Amplification testing was negative. A genital culture grows 3+ normal flora. The patient was seen again in conjunction with a pediatric gynecologist. The vagina is irrigated with 20cc of saline. The effluent was clear. Heme testing from pad was negative. A few days later the mother found a vial of hot sauce in the child’s book bag. When confronted, the child confesses to placing the foreign liquid on the pad. A planned exam under anesthesia is thus avoided. Comments: A high index of suspicion is required in diagnosing factitious disorders. Psychosomatic illnesses have a wide spectrum of presentation and are likely more common than realized. There are three distinct mental health disorders in which a patient intentionally produces physical symptoms or illness: Malingering, Factitious Disorder, and Factitious Disorder by proxy. In Factitious Disorder the patient produces symptoms or signs to assume the sick role. Examples include induced infections and factitious fever. Malingering differs from Factitious Disorder in that in Malingering, the individual is consciously motivated by an external incentive, such as missing school or work. In Factitious Disorder the individual is usually not aware of the motivation behind the factitious behavior and external incentives are absent. Recognizing the possibility of factitious illness in patients who present with atypical clinical manifestations is imperative to reduce unnecessary risk to the patient through continued medical evaluations and to avoid long term psychopathology.

A trial of the validity of genital smears and cultures with gonococcal vaccine provocation in diagnosing genital gonorrhoea in women

In Russia the diagnosis of gonorrhoea in women relied on microscopy, justified by the hypothesis that sensitivity increases using 'provocation' techniques. The aim was to test the value of Gonovaccine as provocation in women who would have received it normally. Cervical specimens from 204 women were tested by culture and a ligase chain reaction (LCR) assay before the women were randomized to receive provocation or not. Further cervical specimens were obtained 24, 48 and 72 hours later for microscopy, culture and LCR tests. In both provocation and non-provocation arms, 24 women were positive for gonorrhoea by the LCR assay. Test-by-test, sensitivity of microscopy was 30% in the provocation arm and 13% in the control arm (P = 0.0407, Fisher's exact test). Patient-by-patient, sensitivity of microscopy was 50% in the provocation arm, but only 25% in the control arm (P = 0.0675, Fisher's exact test). The cost per case was greater ($214) using provocation with microscopy than culture and microscopy at the first visit ($150). Thus, although Gonovaccine provocation doubled the sensitivity of microscopy in detecting gonococci, the internationally recommended protocol of microscopy and culture at first visit should be adopted as routine practice in Russia. The findings raise questions about the pathogenesis and natural history of gonorrhoea.

Establishment of testis-specific SOX9 activation requires high-glucose metabolism in mouse sex differentiation

In mouse sex differentiation, SRY promotes Sertoli cell differentiation via SOX9 action, resulting in testis formation. SRY/SOX9 also initiates various testis-specific morphogenic events including glycogenesis in pre-Sertoli cells, suggesting the importance of glucose storage for certain SRY/SOX9-downstream events in gonadal sex determination. However, it remains unclear which cell types and what molecular/cellular events require sex-dimorphic high-energy metabolic rate. Here we show that the establishment of SOX9 activation itself is a metabolically active process with sex-dimorphic high-energy requirements in gonadal sex differentiation. The glucose-deprivation and metabolic rescue experiments using genital ridge cultures of the XY/XX-wildtype and XX/ Sry transgenic embryos demonstrated that, among the various somatic cell types, pre-Sertoli cells are the most sensitive to glucose starvation despite the differences between XX/ Sry and XY genotypes. Moreover, our data showed that, in developing pre-Sertoli cells, the high-glucose metabolic state is required for the establishment of SOX9 expression through an ECM (extracellular matrix)-mediated feed-forward pathway. In contrast, the expression of SRY, SF1/Ad4Bp, GATA4 and WT1, as well as initiation of early SOX9 expression, is properly maintained in the glucose-deprived condition. Therefore, our results imply the metabolic importance of the high-glucose condition for the establishment of SOX9 activation in testis differentiation.

Identifying the causes of stillbirth: a comparison of four classification systems

To identify the classification protocol for stillbirth that minimizes the rate of unexplained causes. All stillbirths at > 22 weeks from 1995-2007 underwent a workup inclusive of fetal ultrasonography, amniocentesis for karyotype and cultures, placental histology, fetal autopsy, skin biopsy, total body X-ray, maternal testing for thrombophilias, TORCH, Parvovirus spp, thyroid function, indirect Coombs, Kleiheuer-Betke test, and genital cultures. To such a cohort, we applied the 4 most commonly used classification protocols. The stillbirth rate during the study period was 0.4% (154/37,958). The RoDeCo classification provided the lowest rate of unexplained stillbirth (14.3%) compared with Wigglesworth (47.4%), de Galan-Roosen (18.2%), and Tulip (16.2%) classifications. Mean gestational age at stillbirth in unexplained vs explained stillbirth was similar in the 4 protocols. Adoption of a consistent and appropriate workup protocol can reduce the rate of unexplained stillbirth to 14%.

Duration of Antimicrobial Prophylaxis for Group B Streptococcus in Patients With Preterm Premature Rupture of Membranes Who Are Not in Labor

Group B streptococcus (GBS), which colonizes as many as 30% of pregnant women, remains a major cause of serious neonatal infection. GBS may be transmitted by ascending infection after rupture of the fetal membranes or may be acquired during vaginal delivery. Disease may develop within or after the first week of life. The investigators conducted a retrospective cohort study of pregnant women with preterm premature rupture of membranes (PPROM) before 37 weeks' gestation—a condition accounting for nearly 40% of all preterm births. Cultures from the lower third of the vagina and rectum were obtained on admission and each day thereafter, and intravenous antibiotics were given until cultures were negative for 3 consecutive days. The authors hypothesized that GBS can be cleared from the genital tract with fewer than 3 days of antimicrobial therapy. All patients received an antepartum course of betamethasone or dexamethasone. Penicillin G was the primary prophylactic antibiotic; a loading IV dose of 5 million units was followed by 2.5 million units every 4 hours. Patients allergic to penicillin received clindamycin instead. Of 169 patients taking part in the study, 33 (19.5%) were GBS-positive when admitted. Counting multifetal pregnancies, there were 140 neonates in the GBS-negative group and 35 in the GBS-positive group. Neonatal sepsis developed in 19 newborn infants (11.2%), 3 of whose mothers were GBS-positive at admission. In no instance was neonatal sepsis a result of GBS infection. Genital tract cultures for GBS were negative by day 2 in all but one patient, and by day 3 in all instances. All but 2 of the GBS-positive patients received penicillin G. None of the GBS-negative group became GBS-positive after 2 consecutive days of negative cultures. The overall incidence of positive blood cultures in neonates whose mothers had PPROM was 10.9%. In pregnant women presenting with PPROM, 3 days of prophylaxis with IV antibiotic, penicillin G in the present study, reliably eradicates GBS from the genital tract. Further studies are needed to learn whether even shorter courses of antimicrobial therapy are effective.

Genital examination, microscopy and high vaginal swabs: are these valuable components of a sexually transmitted infection screen in asymptomatic women?

Improving access to genitourinary (GU) medicine services in the face of increasing demand and escalating rates of sexually transmitted infections (STIs) necessitates a review of current practice and modernization of service provision. At a time when GU medicine resources are limited and technology is available to perform non-invasive screening tests for chlamydia and gonorrhoea, we question the cost-effectiveness of routine genital examination, microscopy and culture of a high vaginal swab (HVS) in the management of asymptomatic women attending a GU medicine clinic. We conducted a case-note review of 206 consecutive asymptomatic female GU medicine clinic attendees who requested 'a check up'. We conclude that routine on-site microscopy of samples from the cervix, urethra and vagina, and laboratory culture of a HVS did not influence the outcome of patient care. No clinically significant genital tract pathology was identified on examination, with the possible exception of one woman in whom HSV1 was diagnosed opportunistically. The results of this study have significant implications for service provision and patient management.

Duration of antimicrobial prophylaxis for group B streptococcus in patients with

Duration of antimicrobial prophylaxis for group B streptococcus in patients with

Isolation of Herpes Simplex Virus From the Genital Tract During Symptomatic Recurrence on the Buttocks

To estimate the frequency of isolation of herpes simplex virus (HSV) from the genital tract when recurrent herpes lesions were present on the buttocks. Data were extracted from a prospectively observed cohort attending a research clinic for genital herpes infections between 1975 and 2001. All patients with a documented herpes lesion on the buttocks, upper thigh or gluteal cleft ("buttock recurrence") and concomitant viral cultures from genital sites including the perianal region were eligible. We reviewed records of 237 subjects, 151 women and 86 men, with a total of 572 buttock recurrences. Of the 1,592 days with genital culture information during a buttock recurrence, participants had concurrent genital lesions on 311 (20%, 95% confidence interval [CI] 14-27%) of these days. Overall, HSV was isolated from the genital region on 12% (95% CI 8-17%) of days during a buttock recurrence. In the absence of genital lesions, HSV was isolated from the genital area on 7% (95% CI 4%-11%) of days during a buttock recurrence and, among women, from the vulvar or cervical sites on 1% of days. Viral shedding of herpes simplex virus from the genital area is a relatively common occurrence during a buttock recurrence of genital herpes, even without concurrent genital lesions, reflecting perhaps reactivation from concomitant regions of the sacral neural ganglia. Patients with buttock herpes recurrences should be instructed about the risk of genital shedding during such recurrences. II-2.

Do Ureaplasma urealyticum infections in the genital tract affect semen quality?

To investigate the relationship between Ureaplasma urealyticum (UU) infection and semen quality. From 2001 to 2003, 346 eligible patients aged 20-45 years were invited from two hospitals in Shanghai, China, to participate in an investigation which included questionnaires about general and reproductive health, an external genital tract examination, UU culture and semen analysis. Multiple linear regression models were used to examine whether UU had a significant effect on semen quality after adjustment for confounding factors. Findings suggested that UU infection was associated with higher semen viscosity and lower semen pH value. Sperm concentration was lower in UU positive subjects than that in UU negative subjects (54.04 X 10(6)/mL vs.70.58 X 10(6)/mL). However, UU did not significantly affect other semen quality indexes. UU infection of the male genital tract could negatively influence semen quality.

1141180267 Mechanism of HIV transmission across female primary genital epithelial cells

Our lab is utilizing human primary genital epithelial cultures to investigate the mechanism of HIV transmission across the female genital mucosa. Primary endometrial epithelial cells (ECs) grown on matrigel‐ coated cell inserts were used for HIV infection studies. EC's were infected with cell‐ free or cell‐ associated R5 and X4 virus strains. Infections were performed in the presence or absence of the appropriate macrophage (U937) or T‐cell (Jurkat) target cell‐ line in basolateral compartments of cultures. Virus was quantified from supernatants using p24 ELISA. U373‐CXCR4 and CCR5 magi cell lines were utilized to measure infectious virus and tropism. Sybrgreen real time PCR was used to detect viral RNA in cell lysates. Infectious HIV particles were found only in basolateral supernatants of EC's infected with X4 strains of HIV in the presence of appropriate target cells. This indicated that EC's may not be productively infected, but were only able to transmit HIV in the presence of target cells. These results were supported by the detection of higher levels of gag gene (CT‐15) in X4 target cells compared to EC's (CT‐25) using real‐time PCR. No infectious virus was present in primary EC's infected with cell‐free R5 strain, although gag gene product was detected by real time PCR in both R5 target cells as well as EC's. P24 levels in supernatants were not indicative of infectious virus. Our data indicates that R5 and X4 virus strains have differential abilities to cross the female genital mucosa to infect target cells. The presence of target cells appears to be critical for the production of infectious HIV particles under these culture conditions. These studies are providing important information regarding the ability of HIV‐1 to cross the female genital mucosa.

Quality assurances: Decreasing clinically irrelevant testing from clinical microbiology laboratories, part I

Forget the “garbage in, garbage out” adage! In an effort to be proactive and make the driving force of the diagnostic clinical microbiologist be “quality in, quality out,” this article addresses ways to improve the pre-analytical and post-analytical components of samples sent to the microbiology laboratory for testing. It focuses on producing clinically relevant information and defines opportunities to avoid reporting of clinically irrelevant information. Part I of this article addresses blood cultures, respiratory specimens, genital cultures, wound and CSF specimens.

Nitric Oxide Stimulates a Large-Conductance Ca2+-Activated K+ Channel in Human Skin Fibroblasts through Protein Kinase G Pathway

In order to investigate the large-conductance Ca²⁺-activated K⁺ (BK_Ca) channel and determine the effects of nitric oxide (NO) on the channel in human skin fibroblasts, we performed electrophysiological patch clamp recordings on 5th-passage cells of human genital skin cultures. The whole-cell outward K⁺ current was increased with depolarization, and proved to be sensitive to NS1619 (a selective BK_Ca channel activator) and iberiotoxin (a specific BK_Cachannel inhibitor). The single-channel currents showed 226 pS of mean conductance in symmetrical K⁺. Sodium nitroprusside (SNP; an NO donor) significantly increased the K⁺ current amplitude in the whole-cell mode, and open probability of the channel (NPo) in the cell-attached mode, but not in the inside-out mode. S-nitroso-N-acetylpenicillamine (an NO donor) and 8-Br-cGMP (a membrane-permeant cGMP analogue) also increased the BK_Cachannel activity. The stimulatory effect of SNP on BK_Ca channels was inhibited by pretreatment with 1H-[1,2,4]-oxadiazolo[4,3-a]quinoxalin-1-one (a soluble guanylyl cyclase inhibitor), or KT5823 [a specific protein kinase G (PKG) inhibitor]. Cytoplasmic PKG also increased the channel activity in inside-out patches. In conclusion, the present data indicate that BK_Ca channels constitute a significant fraction of K⁺ current in human skin fibroblasts, and that NO increases NPo of BK_Ca channels, which are mediated via the cGMP/PKG pathway, without direct effects on the channel.

High vaginal swab cultures in normal and preterm labor

Previous studies have shown that ascending intrauterine infection is one of the major causes of preterm birth and fetal infection. Which microorganism is associated with preterm labor is still a matter of conflicting reports. Reports about the prediction of intrauterine and fetal infection from lower genital tract cultures are also not consistent. The aim of this study is to find out whether any specific microorganism is associated with preterm birth and whether high vaginal swab (H.V.S) cultures can be used to predict fetal infection. The study took place at Abha Maternity Hospital between September 1999 and June 2000 after approval by the hospital ethics committee. High vaginal swabs were taken from 132 women in preterm labor or preterm premature rupture of the membranes (24–36 weeks gestation) and from a control of 136 women in term labor (=37 weeks). The swabs were cultured aerobically and anaerobically and bacteria identified using conventional methods. After delivery newborns who were admitted to the neonatal intensive care unit were also bacteriologically investigated by blood culture and surface bacteriology. (excerpt)

Herpes simplex virus type 1 is the prevailing cause of genital herpes in the Tel Aviv area, Israel.

The changing epidemiology of genital herpes with the increasing importance of herpes simplex virus (HSV) type 1 prompted a study on the relative prevalence of HSV-1 and HSV-2 among cases of genital herpes in the Tel Aviv area, Israel. A retrospective laboratory-based study of positive genital and nongenital herpes cultures performed at the Beilinson Medical Center between 1993 and 2002. Data regarding the number of isolates of each type and the age and sex of patients with genital lesions were retrieved from the database. Cultures were performed using Vero cells, and positive results were confirmed and typed by immunofluorescence. A total of 285 positive genital cultures and 659 positive nongenital cultures were recorded. HSV-1 was identified in 189 (66.3%) of the positive genital specimens and in 656 (99.55%) of the nongenital specimens. HSV-1 was isolated in 174 of 262 (66.4%) female subjects and 15 of 23 (65.2%) male subjects. The proportion of HSV-1 genital isolates was 72.7% in patients 15 to 24 years of age, 62% in those 25 to 44 years, and 46% in those aged 45 years or older. Overall, the annual isolation rate of genital HSV-1 has not changed markedly over the years. Herpes simplex virus type 1 has clearly been the predominant HSV type isolated from genital specimens in the Tel Aviv area over the last decade.

Salmonella sepsis and miscarriage

We present a case of a miscarriage at 16 weeks of gestation due to infection and transplacental passage of Salmonella group C. This was identified as being Salmonella Virchow from genital tract swab culture, and placental Gram-staining revealed numerous colonies of Gram-negative bacilli within the fibrin between the placental villi, confirming a true villitis associated with a hematogenous infection. Based on the patient's history, it was suggested that she had contracted the salmonella infection from eating undercooked eggs. Treatment of salmonella infection in pregnancy is controversial, and antibiotic therapy should be reserved for cases of invasive disease, using amoxicillin or a cephalosporin.

A Review of the Physiology and Pharmacology of Peripheral (Vaginal and Clitoral) Female Genital Arousal in the Animal Model

We review contemporary scientific data concerning the physiology and pharmacology of peripheral female genital arousal responses in the animal (rabbit and rat) model. We reviewed the contemporary literature and our research studies concerning physiology and pharmacology of peripheral genital arousal from 3 experimental animal models, including genital smooth muscle cell culture, genital strip organ bath and in vivo animal model studies. Nitric oxide (NO) appears to be a key pathway mediating clitoral smooth muscle relaxation. In the vagina NO appeared to have a more controversial role in mediating vaginal muscularis smooth muscle relaxation. Vasoactive intestinal polypeptide induced vaginal smooth muscle relaxation. Functional alpha-adrenergic receptors were expressed in the clitoris and vagina, and mediated norepinephrine induced genital smooth muscle contraction. Androgens and estrogens modulated distinct physiological responses in vagina, and androgens facilitated vaginal smooth muscle relaxation. Papaverine hydrochloride, a smooth muscle relaxant, and phentolamine mesylate, an alpha-blocker, administered into the vaginal spongy muscularis layer increased vaginal wall pressure and vaginal blood flow. Sildenafil caused significant increases in genital (clitoral and vaginal) blood flow and vaginal lubrication in intact and ovariectomized animals. This response was more pronounced in animals treated with estradiol, suggesting that the NO cyclic guanosine monophosphate pathway is involved in the physiological mechanism of female genital arousal and that sildenafil facilitates this response in an in vivo animal model. To achieve improved understanding of the biological aspects of female sexual function, further research is needed in the physiology and pharmacology of peripheral (clitoral and vaginal) genital arousal in the animal model.

Predeominace of Herpes Simplex Virus Type 1 from Patients with Genital Herpes in Nova Scotia

The epidemiology of genital herpes is changing with evidence to suggest an increasing incidence of herpes simplex virus type 1 (HSV-1) infections. The results of 6529 HSV genital cultures taken between April 1998 and December 2001 were reviewed. overall, HSV-1 was recovered more often than HSV-2; 1213 versus 1045. This trend was particularly striking in young women 30 years of age or less, in whom 70.8% of isolates were HSV-1. In men of the same age range, 45% of isolates were HSV-1. The proportion of women with HSV-1 declined from 73.7% in those younger than 31 years of age to 4.5% in those older than 60 years of age.These observations have important implications. The decline in the relative proportion of HSV-1 isolates from young adults may be the result of changing sexual practices, changing susceptibility or increased exposure to HSV-1 during vaginal intercourse. In this setting HSV-2 vaccines may be less likely to produce the desired reduction in the overall prevalence of genital herpes infections.

Intrapartum antibiotic prophylaxis 1: relative effects of recommended antibiotics on gram-negative pathogens

OBJECTIVE: To assess whether the antibiotic chosen for intrapartum antibiotic prophylaxis affects the subsequent exposure of the neonate to ampicillin-resistant gram-negative bacteria. METHODS: We performed a randomized clinical trial of ampicillin versus penicillin for intrapartum antibiotic prophylaxis. Genital tract cultures for Enterobacteriaceae were obtained at study entry and 8–36 hours postpartum. Organisms were isolated, identified, and tested for ampicillin susceptibility. RESULTS: The ampicillin ( n = 175) and penicillin ( n = 177) groups, respectively, did not differ in rates of ampicillin-resistant Escherichia coli at entry (25% versus 22%, P = .57) or postpartum (36% versus 38%, P = .64). Similarly, groups did not differ in rates of ampicillin-resistant Enterobacteriaceae at entry (38% versus 32%, P = .23) or postpartum (51% versus 55%, P = .46). However, postpartum culture rates of resistant Escherichia coli were higher than entry culture rates for both the ampicillin (36% versus 25%, P = .026) and penicillin (38% versus 22%, P < .001) groups. Postpartum culture rates of resistant Enterobacteriaceae were also higher than entry culture rates for both the ampicillin (51% versus 38%, P < .001) and penicillin (55% versus 32%, P < .001) groups. Results were similar when considering only women who received two or more doses and no additional antibiotics. CONCLUSION: Intrapartum antibiotic prophylaxis with either ampicillin or penicillin increases exposure of neonates to ampicillin-resistant Enterobacteriaceae.

Involvement of a matrix metalloproteinase in MIS-induced cell death during urogenital development

Programmed cell death of the Müllerian duct eliminates the primitive female reproductive tract during normal male sexual differentiation. Müllerian inhibiting substance (MIS or AMH) triggers regression by propagating a BMP-like signaling pathway in the Müllerian mesenchyme that culminates in apoptosis of the Müllerian duct epithelium. Presently, the paracrine signal(s) used in this developmental event are undefined. We have identified a member of the matrix metalloproteinase gene family, Mmp2, as one of the first candidate target genes downstream of the MIS cascade to function as a paracrine death factor in Müllerian duct regression. Consistent with a role in regression, Mmp2 expression was significantly elevated in male but not female Müllerian duct mesenchyme. Furthermore, this sexually dimorphic expression of Mmp2 was extinguished in mice lacking the MIS ligand, suggesting strongly that Mmp2 expression is regulated by MIS signaling. Using rat organ genital ridge organ cultures, we found that inhibition of MMP2 activity prevented MIS-induced regression, whereas activation of MMP2 promoted ligand-independent Müllerian duct regression. Finally, MMP2 antisense experiments resulted in partial blockage of Müllerian duct regression. Based on our findings, we propose that similar to other developmental programs where selective elimination or remodeling of tissues occurs, localized induction of extracellular proteinases is critical for normal male urogenital development.

Six-year study of the incidence of herpes in genital and nongenital cultures in a central Kentucky medical center patient population.

Herpes infections are among the most common sexually transmitted diseases and are the most common cause of genital ulcer disease in the United States. This study addresses the changing distribution of herpes simplex virus type 1 (HSV-1) and HSV-2 in patients presenting for evaluation of herpetic infections. Viral culture results from the University of Kentucky Clinical Microbiology Laboratory were reviewed for a 6-year period (1994 through 1999). Data were collected on patient sex, site of culture, and culture result. These data were analyzed statistically to identify yearly trends. Of the 4,498 cultures analyzed, nearly equal proportions of HSV-1 (13.3%) and HSV-2 (12.0%) were detected for an overall culture positivity rate of 25.3%. Approximately two-thirds of all positive cultures were from women. Although HSV-2 remained the predominant type of genital herpes, over the 6-year span of this study, there was a trend toward increasing proportions of HSV-1 genitalis, with 31.8% of male patients and 44.8% of female patients demonstrating HSV-1 genitalis by 1999. The majority of patients with HSV in nongenital sites grew HSV-1. Although there was significant yearly variation, HSV-2 was isolated from only 9.4% of patients with nongenital HSV for the entire 6-year period. This study therefore concludes that HSV-2 remains primarily a genital pathogen, while HSV-1 is taking on an increasingly important role in causing genital ulcer disease in addition to being the primary nongenital HSV.