Manifestaciones coloproctológicas de las infecciones de transmisión sexual ocasionadas por Chlamydia Trachomatis, Neisseria Gonorrhoeae y Treponema Pallidum. Presentación casuística / Coloproctological manifestations of sexually transmitted infections caused by Chlamydia Trachomatis, Neisseria Gonorrhoeae and Treponema Pallidum. Case presentation

Introducción: Las infecciones transmisibles sexualmente (ITS) con afectación anorrectal constituyen un desafío pues las manifestaciones producidas por Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) y Treponema pallidum (TP) son similares. Objetivo: Evaluar si las manifestaciones anorrectales debidas a CT, NG y TP asociadas al examen proctológico permiten diagnóstico certero, sin estudios complementarios. Pacientes y método: Estudio retrospectivo. Revisión de registros de pacientes atendidos en consultorio coloproctológico. Periodo: 01/08/2015-01/07/2016. Se incluyeron pacientes con diagnóstico de ITS anorrectal, excepto aquellos con HPV únicamente. A todos se les pesquisaron ITS mediante hisopado anal para CT por inmunofluorescencia y para estudio directo y cultivo de NG, VDRL para TP y además HIV. Variables: sexo, edad, HIV, sexo anal, uso de preservativo, motivo de consulta y resultado de estudios efectuados. Resultados: Treinta y cuatro pacientes (32 hombres). Edad mediana 31,5 años (rango: 19-65). Veinticinco pacientes HIV + (73,5%). Veintinueve pacientes (28 hombres) mantenían sexo anal. 91% no usaba preservativo adecuadamente. 65% tuvo una única infección (ITS pura). Se diagnosticaron 14 sífilis (8 puras), 14 clamidiasis (7 puras) y 11 gonococcias (7 puras). Co-infección entre ellas: 9% y con HPV: 26%. La úlcera fue la manifestación en 7/8 casos de sífilis puras (todas dolorosas, excepto una). El resto presentó síntomas variados (condilomas virales atípicos, secreción purulenta y proctorragia). Más del 50% de las gonococias puras (4/7) se manifestó con úlcera, sin embargo, el dolor estuvo presente siempre (8/8) y en tres se asoció secreción purulenta. En cambio, la mitad de los pacientes con clamidiasis puras, se manifestó con proctorragia causada por un tumor rectal/sigmoideo inflamatorio, clínicamente indistinguible de neoplasia maligna. Todos las sífilis y gonococias tuvieron correlato con las pruebas diagnósticas, no así las clamidiasis cuyo diagnóstico no pudo confirmarse en tres casos (37,5%), que respondieron al tratamiento empírico. Conclusión: NG y TP anorrectal provocaron mayormente síntomas similares a los de etiología no venérea y se requirió del laboratorio para el diagnóstico etiológico. La presencia de tumor con biopsia negativa para neoplasia maligna en pacientes de riesgo para ITS obliga a descartar clamidiasis. (AU)

Introduction: Sexually transmitted infections (STIs) are a challenge in medical consultation. The clinical manifestations of infection by Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Treponema pallidum ( TP) share symptoms at anorectal level. This implies the need for a high index of suspicion for diagnosis, which is based on history, physical examination and laboratory tests that not always are accurate or available . Purpose: Assess whether clinical signs of anorectal infections by CT, NG and TP associated with proctologic exams, lead to an accurate etiologic diagnosis without the help of specific laboratory studies. Patients and methods: Observational, retrospective study, based on a review of records of patients treated at the outpatient clinic of the Hospital Fernandez (City of Buenos Aires) department of coloproctology, in the period between August 2015 and July 2016. Patients who underwent STI diagnosis were all considered, but to those whose only diagnosis was infection by human papilloma virus (HPV) were excluded from the analysis. All patients were tested after the three etiologies of STI (anal swab for CT study by immunofluorescence, swabbing for direct study, and cultivation of NG and TP VDRL) and HIV. Variables analyzed: sex, age, presence of HIV infection, practice of receptive anal sex, proper use of condoms, signs and symptoms that prompted the consultation, and results of diagnostic tests. Results: 34 patients (32 men) were included. Median age 31.5 years (range: 19-65, interquartile range: 26-37). Twenty-five patients (73.5%) were HIV+. Twenty-nine patients (28 men) remained receptive anal sex. 91% did not use condoms properly. 65% of infections were pure, without other STI asociada-. 14 cases of syphilis (8 pure), 14 Chlamydia (7 pure) and 11 gonococcias (7puras), including co-infection in 9% of cases, no evidence of a more frequent another co-infection diagnosed. Co-infection with HPV was detected in 9 (26%) cases. The ulcer was the sign in 7/8 cases of pure syphilis (all painful, except one). The rest is expressed by a variety of symptoms (atypical viral warts, purulent and bloody diarrhea). Similarly, just over 50% (4/7) of pure gonococcias demonstrated ulcer, but the pain was always present (8/8 of pure gonococcias) and three associated with purulent discharge. Instead of the ten patients with pure chlamydia, 50% manifested with bloody diarrhea caused by a rectal tumor / inflammatory sigmoid, clinically indistinguishable from malignancy. All cases of syphilis and gonococcal were correlated with diagnostic tests; not those whose diagnosis of chlamydial infection (confirmed in eight and was negative in three, 37.5%) who responded to empiric treatment indicated by the clinical suspicion. Conclusion: While this is a small series, it shows that the NG and TP in the anorectal location mostly caused symptoms similar to those of non-venereal ethology most of the times, and laboratory assistance for etiologic diagnosis was required. The presence of tumor with negative biopsy for malignancy in patients at risk for STIs, leads chlamydia to be ruled out. (AU)

Cribado de infecciones cervicales de transmisión sexual en mujeres embarazadas y su relación con la microbiota vaginal / Screening of cervical sexually transmitted infections in pregnant women and the relation with the vaginal microbiota

Resumen Introducción: La mujer embarazada está expuesta anumerosas infecciones de transmisión sexual (ITS), las que pueden producir aborto, enfermedad en el feto y/o en el recién nacido, además de alteraciones en el curso normal del embarazo. Objetivo: Realizar tamizaje de infección cervical asintomática en mujeres embarazadas y su relación con la microbiota. Pacientes y Métodos: Se enrolaron 85 mujeres embarazadas sin cervicitis clínica que consultaron en control de rutina de embarazo (47 pacientes) o que fueron derivadas a una unidad de ITS (38 pacientes). Se tomaron muestras de fondo de saco vaginal, que fueron analizadas por técnicas clásicas de microscopía y cultivo corriente y reacción de polimerasa en cadena para Neisseria gonorrhoeae, Trichomonas vaginalis y Chlamydia trachomatis. Resultados: Se encontró 12,9% de infección por C. trachomatis, 2,4% de T. vaginalis. En este estudio no se encontró N. gonorrhoeae. El 23,3% de pacientes con microbiota alterada (vaginosis bacteriana y microbiota intermedia) fue positiva para C. trachomatis. Conclusión: En este trabajo, encontramos una alta frecuencia de infección por C. trachomatis, que se relaciona en forma significativa con la presencia de microbiota alterada. Esta alta frecuencia debería promover estrategias preventivas en los controles de salud de la mujer embarazada.

Background: Pregnant woman is exposed to many sexual transmitted infections (STI). Many of these infections may produce diseases in the fetus and newborn, and also alteration in the normal course of the pregnancy. Aim: Screening of asymptomatic cervical infection in pregnant woman and its relationship with the vaginal microbiota. Patients and Methods: 85 pregnant women without clinical cervicitis who consult in the routine pregnant control (47 patients) and women derived from STI service (38 patients). The samples were obtained from the vaginal fund sac and were analyzed with optic microscopy, cultures and PCR of Neisseria gonorrhoeae, Trichomonas vaginalis and Chlamydia trachomatis. Results: 12,9% of the enrolled women were positive for C. trachomatis, 2,4% for T. vaginalis. In this study, we did not found N. gonorrhoeae. We observed 23,3% of patients with altered microbiota (bacterial vaginosis and intermediate microbiota) was positive for C. trachomatis. Conclusions: In this study, we found a high frequency of C. trachomatis infection, that correlates with the presence of altered microbiota. This high frequency would promote preventive strategies in the pregnant women routine controls.

Adolescentes encuentran fácil tomar sus propias muestras para estudio de infecciones de transmisión sexual / Adolescents find it easy to collect their own samples to study sexually transmitted infections

Background: As alternative for patients that fear genital examination, we assessed adolescent's comfort and ease with self-collected samples for nucleic acid amplification testing for sexually transmitted infections. Patients and Methods: Sexually active Chilean adolescents and youth under 25 years (174 males and 117 females) were enrolled. Females used self-collected vaginal swabs and males collected first-stream urine. A satisfaction survey evaluating self-sampling system was applied. Results: Self-collection was considered easy in 99.3% of the interviewees (CI 95% 0.88-0.98). In women, 79.3% preferred vaginal self-collected samples than pelvic exam (CI 95% 0.73-0.85). In men, 80.3% preferred self-collected first-stream urine to urethral swabs (CI 95% 0.73-0.87). Assuming that self-collected sampling were available, 89.6% of women (CI 95% 0.85-0.94) and 93.2% of men (CI 95% 0.89-0.98) would be prone to be tested more often. Ease of self-collected sampling is not associated with age, gender, educational level or poverty. Conclusions: Chile currently does not have sexually transmitted infections surveillance or screening programs for youth and adolescents. Given self-collected sampling's good acceptability, it could be successfully used when these programs are implemented.

Introducción: Como alternativa para pacientes que temen al examen genital o para aquellos asintomáticos, se evaluó la satisfacción de adolescentes con el sistema de autotoma -muestra tomada por el propio paciente- para amplificación de ácidos nucleicos y determinación de infecciones de transmisión sexual (ITS). Material y Método: Se enrolaron 174 mujeres y 117 hombres menores de 25 años sexualmente activos. Las mujeres se realizaron autotoma con tórula vaginal. Los hombres, autotoma de orina de primer chorro. Se aplicó encuesta de satisfacción. Resultados: A 99,3%, le resultó fácil obtener muestras mediante autotoma (IC 95% 0,88-0,98). En mujeres, 79,3% prefirió la autotoma vaginal por sobre el examen pélvico (IC 95% 0,73-0,85). En hombres, 80,3% prefirió la autotoma de orina por sobre el hisopado uretral (IC 95% 0,73-0,87). Si la autotoma estuviera disponible, 89,7% de las mujeres (IC 95% 0,85-0,94) y 93,2% de los hombres (IC 95% 0,89-0,98) estarían dispuestos a someterse a un examen de ITS en forma más seguida. Encontrar fácil la autotoma no se asoció con edad, género, escolaridad ni pobreza. Conclusiones: Chile aún no tiene programas de vigilancia o detección de ITS para jóvenes y adolescentes. Dada la buena aceptabilidad de la autotoma, se podría emplear exitosamente cuando estos programas se implementen.

Doenças sexualmente transmissíveis: infecção por Chlamydia trachomatis / Sexually transmitted diseases: Chlamydia trachomatis infection

Este trabalho reviu a infecção urogenital por Chlamydia trachomatis, considerada a doença bacteriana sexualmente transmissível mais comum no mundo, especialmente na população de adolescentes e jovens. Grande parte das infecções clamidiais é assintomática, principalmente nas mulheres, e se não tratadas podem causar complicações, como a doença inflamatória pélvica (DIP), com seqüelas como a infertilidade, gravidez ectópica e dor pélvica crônica. Por várias décadas, a cultura foi considerada como o padrão ouro no diagnóstico dessa infecção. Nos últimos anos foram introduzidos os testes de detecção ácidos nucléicos, como a reação em cadeia da polimerase (PCR) e a reação em cadeia da ligase (LCR). Apresentou-se o tratamento recomendado pelo Ministério da Saúde, bem como os princípios da prevenção que incluem a educação sexual, o diagnóstico e tratamento dos casos diagnosticados e de seus parceiros sexuais, abrangendo a proposta de rastreamento nas populações de risco.

Comparison of four nonculture diagnostic tests for Chlamydia trachomatis infection.

OBJECTIVE: Chlamydia trachomatis (CT) is one of the commonest sexually transmitted diseases leading to urethritis, epididymitis, prostatitis in men and urethritis, cervicitis, endometritis and pelvic inflammatory disease, sometimes complicated by infertility and ectopic gestation in women. Since culture of fastidious bacteria in a monocellular medium is not available in most laboratories we compared direct immunofluorescence antigen detecting test (DFA) with three other nonculture tests-antigen detecting enzyme immunoassay (EIA), Papanicolaou staining (Pap) and Geimsa stain for endocervical swabs from women in reproductive age group. METHODS: Three hundred and fifty seven women between 16 and 41 years of age and attending family welfare clinics of IRR were evaluated for the presence pap smears. In 100 cases DFA staining was compared with Geimsa staining. RESULTS: DFA test was positive in 60/357 (16.8%), EIA in 29 (8.1%) of cases and Pap smear in 37 (10%) cases. In the second group DFA was positive in 17 (17%) and Geimsa in 10 (10%) cases. CONCLUSION: Amongst the four tests DFA showed maximum sensitivity. ELISA is less expensive but has lower sensitivity. Pap stain also has less sensitivity and good specificity, the quality of smear is likely to affect the diagnosis. Though Geimsa stain is cheapest, for chlamydial cervicitis in our experience it was not as sensitive as DFA. Thus each laboratory must decide the method depending on its resources.

Donovanose / Granuloma inguinale

A donovanose é uma infecção causada pela Calymmatobacterium granulomatosis, que afeta principalmente a região genital. De caráter progressivo e destrutivo, vem aumentando sua incidência nos últimos anos, despertando grande interesse pela necessidade de diagnóstico precoce, com a finalidade de evitar estádios avançados que limitam a vida do indivíduo. Os autores, após algumas considerações sobre os antecedentes da enfermidade e seus aspectos clínico-patológicos, relatam o case de um paciente do sexo feminino, 33 anos, com donovanose de caráter insidioso, progressivo e evolução de 10 anos. No momento da admissão, a paciente apresentava lesões ulcerovegetantes nas regiões vulvar, crural e abdominal baixa, que após manejo terapêutico adequado, obteve melhora satisfatória do quadro clínico. Nos comentários fazemos breve referência às complicações e terapêutica atual realizada para cura da patologia e das infecções secundárias, dando melhoria de condições vitais dos pacientes

Sífilis adquirida na infåncia: estudo clínico, laboratorial e abuso sexual / Acquired syphilis in childhood: clinical study, diagnosis laboratory and sexually abuse

Apesar do arsenal terapêutico e dosrecursos diagnósticos, é inegável o aumento da incidência das DST, aí incluída a sífilis, também entre crianças. Este trabalho determina a ocorrência da sífilis adquirida entre as crianças atendidas no Setor de DST/UFF entre 1987 e 1996; descreve os achados clínicos e laboratoriais destas crianças, investiga a ocorrência de abuso sexual e procura divulgar a importåncia do reconhecimento precoce e tratamento desta patologia. Para atingir os objetivos, é feita a revisäo dos arquivos do DST/UFF, com descriçäo dos pacientes atendidos com esta patologia. Foi feita revisäo bibliográfica de 25 anos do Index Medicus, bem como através de bancos de dados da Internet. Somente 3 pacientes foram atendidos neste período, tendo como sintomas mais frequêntes o condiloma plano, seguindo-se as adenomegalias inguinais. A literatura relatou ainda o registro de cancro e os pacientes assintomáticos como frequentes. A sorologia positiva para sífilis e a suposiçäo de abuso sexual foram observados na totalidade dos pacientes

La microscopía electrónica en el diagnóstico de enfermedades infecciosas de transmisión sexual: experiencia institucional / Diagnosis by electronic micrography of sexually transmited diseases. An institutional experience

Se informa los resultados, de seis estudios de enfermedades de transmisión sexual (STD) que se han hecho en nuestra Institución. En infecciones por el citomegalovirus, el diagnóstico por microscopía electrónica se puede efectuar en menos de media hora a través de la tinción negativa (PTA). En casos de mujeres embarazadas y seropositivas para VIH, fue posible demostrar partículas semejantes a virus de VIH en diferentes niveles dentro del tejido placentario. En los núcleos de celulas del epitelio cervical se observaron partículas virales semejantes a papilomavirus. En este estudio se confirmó que los Mycoplasmas pueden adherirse o penetrar en los espermatozoides. También se muestra que la Chlamydia trachomatis puede llevar a cabo su ciclo vital en el interior de células espermáticas. Finalmente, material fotográfico es presentado para mostrar los mecanismos de invasión de la Gardnerella vaginalis en células epiteliales vaginales

Isolation of Chlamydia trachomatis among women with symptoms of lower genital tract infection.

Isolation of chlamydia trachomatis from the endocervix using cyclohexamide-treated McCoy cells were done in order to estimate the prevalence rate of its infection among gynecologic out patients who had symptoms and/or signs of lower genital tract infection. There were 498 patients from May 1989 to July 1990. Eighty-six per cent of these patients were 25 years old or older. Most of them (63%) were agricultural employees. Ninety-three per cent were married and 78 per cent had less than or equal to seven yrs of education. Of 476 specimens, isolation rate of C. trachomatis was 7.8 per cent. Other infectious agents isolated by culture were Niesseria gonorrhea 4.8 per cent (24/497), Candida albicans 15.5 per cent (77/498) and Gardnerella vaginalis 6.08 per cent (303/498). Direct microscopy identified 9.4 per cent (32/380) of Trichomonas vaginalis. Multiple logistic regression analysis was able to identify four significant risk factors independently associated with isolation of C. trachomatis. These factors were N. gonorrheal cervicitis (odds ratio = 5.7, 95%, CI = 1.9, 17.0); age less than 25 yrs (odds ratio = 3.3, 95%, CI = 1.5, 7.4); G. vaginalis vaginitis (odds ratio = 3.0, 95%, CI = 1.3, 7.1) and purulent vaginal discharge (odds ratio = 2.5, 95%, CI = 1.5, 5.5).

Infecciones vaginales: aspectos prácticos del diagnóstico y tratamiento / Vaginal infections: practice aspects of the diagnosis and treatment

El problema del flujo vaginal y los síntomas asociados de prurito vulvar y mal olor son consultas frecuentes, especialmente en mujeres jóvenes. Estos síntomas son por lo general causados por los síndromes de vaginosis bacteriana (VB), candidosis vaginal y tricomoniasis. La VB es la causa más común de estas infecciones vaginales. Las características de la secreción vaginal no son diagnósticas y no discriminan entre VB y tricomoniasis. En todo los casos, la cervicitis debida a clamidia o gonorrea debería ser excluída. El exámen microscópico, en el momento del examen, es la herramienta diagnóstica más importante. El examen al fresco de la secreción vaginal generalmente es útil asociado con la tinción de gram de muestra cervicales, vaginales o uretrales. Los cultivos vaginales son necesarios sólo para confirmación o en casos en que el diagnóstico no esté claro con el examen de microscopia. Las pautas de tratamiento deben ser específicas, tales como metranidazol para VB y tricomoniasis, y agentes antifúngicos, sistémicos o locales, para candidosis. Las recurrencias son comunes y requieren manejo e investigación cuidadosa. Las parejas sexuales necesitan también investigación y tratamiento