The colposcopic atlas of schistosomiasis in the lower female genital tract based on studies in Malawi, Zimbabwe, Madagascar and South Africa.

BACKGROUND: Schistosoma (S.) haematobium is a neglected tropical disease which may affect any part of the genital tract in women. Female genital schistosomiasis (FGS) may cause abnormal vaginal discharge, contact bleeding, genital tumours, ectopic pregnancies and increased susceptibility to HIV. Symptoms may mimic those typical of sexually transmitted infections (STIs) and women with genital schistosomiasis may be incorrectly diagnosed. An expert consensus meeting suggested that the following findings by visual inspection should serve as proxy indicators for the diagnosis of schistosomiasis of the lower genital tract in women from S. haematobium endemic areas: sandy patches appearing as (1) single or clustered grains or (2) sandy patches appearing as homogenous, yellow areas, or (3) rubbery papules. In this atlas we aim to provide an overview of the genital mucosal manifestations of schistosomiasis in women. METHODOLOGY/PRINCIPAL FINDINGS: Photocolposcopic images were captured from women, between 1994 and 2012 in four different study sites endemic for S. haematobium in Malawi, Zimbabwe, South Africa and Madagascar. Images and specimens were sampled from sexually active women between 15 and 49 years of age. Colposcopic images of other diseases are included for differential diagnostic purposes. SIGNIFICANCE: This is the first atlas to present the clinical manifestations of schistosomiasis in the lower female genital tract. It will be freely available for online use, downloadable as a presentation and for print. It could be used for training purposes, further research, and in clinical practice.

Anaemia in pregnancy is associated with advanced HIV disease.

BACKGROUND: Anaemia is a common clinical finding in HIV infected women and has been associated with advanced disease. The use of antiretroviral drugs such as Zidovudine (ZDV) either for prevention of mother to child transmission (MTCT) of HIV or used in combination with other antiretrovirals have been implicated in the development or increased severity of anaemia. We report the prevalence, type, severity and incidence of anaemia in a cohort of HIV infected women who initiated antiretroviral prophylaxis or treatment during pregnancy. METHODS AND MATERIALS: This is a retrospective cohort data analysis of 408 HIV infected pregnant women who participated in a breastfeeding intervention study (HPTN 046 Study, ClinicalTrials.gov NCT 00074412) in South Africa. Women initiated zidovudine prophylaxis for PMTCT or triple antiretroviral treatment in pregnancy according to the standard of care. Laboratory and clinical data in pregnancy, <72 hours and 2 weeks postdelivery were extracted from the main database and analysed. RESULTS: The mean Hb concentration was 10.6 g/dL at baseline and 262/408 (64.2%) women were diagnosed with anaemia (Hb<11 g/dL) in pregnancy, 48/146 (32.9%) subsequently developed anaemia intrapartum or postpartum and 89/310 (28.7%) of all cases of anaemia remained unresolved by 2 weeks postdelivery. In a univariate analysis, CD4 count and gravidity were significant risk factors for anaemia in pregnancy, RR 1.41; 1.23-1.61 (p<0.001) and 1.10; 1.01-1.18 (p = 0.02) respectively. After adjusting for antiretroviral regimen, age and gravidity in a multivariable analysis, only the CD4 count remains a significant risk factor for anaemia in pregnancy and postdelivery. CONCLUSION: In conclusion, anaemia was most common among women in the advanced stage of HIV infection (CD4<200 cells/mm3). There was no evidence of an association between ZDV or triple ARVs and anaemia.

Use of the myocardial performance index as a prognostic indicator of adverse fetal outcome in poorly controlled gestational diabetic pregnancies.

OBJECTIVE: The aim of this study was to determine whether there are any changes in cardiac function in fetuses of poorly controlled gestational diabetics and whether these changes influence perinatal outcome. METHODS: Twenty-nine pregnant women with severe gestational diabetes on insulin therapy in the third trimester of pregnancy were recruited and matched with 29 women with normal pregnancies (control group). Using Doppler echocardiography, the modified myocardial performance index (Mod-MPI) and E wave/A wave peak velocities (E/A) ratios were determined. Placental resistance Doppler markers were also determined in both groups. Adverse perinatal outcome was defined as perinatal death, admission to the neonatal intensive care unit, cord pH <7.15, 5-min Apgar score <7 and presence of cardiomyopathy. RESULTS: The median Mod-MPI was increased (0.59 vs 0.38; p < 0.0001) and the E/A ratio was decreased (0.65 vs 0.76; p < 0.0001) in fetuses of diabetic mothers compared with controls. An MPI >0.52 had a sensitivity of 100% [95% confidence interval (CI) 85-100%] and specificity of 92% (95% CI 70-92%) for prediction of adverse perinatal outcome, including one stillbirth and one neonatal death. No abnormal outcomes occurred in the control group. CONCLUSIONS: There is significant impairment of cardiac function in fetuses of poorly controlled gestational diabetics. Mod-MPI and E/A ratio have the potential to improve fetal surveillance in diabetic pregnancies.

Gestational age-adjusted trends and reference intervals of the Modified Myocardial Performance Index (Mod-MPI) and its components, with its interpretation in the context of established cardiac physiological principles.

OBJECTIVE: The objective of this study is to establish gestational age-adjusted reference intervals and trends of the modified myocardial performance index (Mod-MPI), isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), and ejection time (ET) in pregnancy METHODS: A cross-sectional study using Doppler echocardiography to determine the Mod-MPI was performed on 419 fetuses from 20 to 38 weeks of gestation. Doppler signals of the opening and closing of the mitral and aortic valves were used as landmarks to determine the ICT, IRT, and ET. The Mod-MPI was modeled using fractional polynomials and the exponential-normal model. RESULTS: The Mod-MPI was relatively constant from 20 to 26 weeks and thereafter steadily decreased with advancing gestational age. ICT and ET remained constant, whereas IRT decreased with advancing gestation similar to the Mod-MPI. CONCLUSION: Reference intervals of the Mod-MPI evaluating fetal cardiac function have been established. Maturational and developmental alterations in the myocardial performance in utero resulting in better ventricular compliance is most likely responsible for the decreasing trend of the Mod-MPI noted with advancing gestation.

Infantile donovanosis presenting as external auditory canal polyps: a diagnostic trap.

Two infants, 6 months and 4 months of age, presented with bilateral or unilateral external auditory canal polyps and otorrhea, respectively. Additional findings on examination included otitis media and mastoiditis. Tympanic membrane perforation was noted in one patient and a postauricular abscess in the other. Incisional biopsies of the polyps and abscess were reported as nonspecific mixed inflammation and abscess wall, respectively. There was a limited response to an empirical 5-day course of trimethoprim sulfamethoxazole. The children were referred to the academic hospital, and excision of the polyps and biopsies of the middle ear, mastoid, and postauricular abscess was undertaken. All the biopsies demonstrated donovanosis. Reappraisal of the initial incisional biopsies also confirmed donovanosis. Trimethoprim sulfamethoxazole was administered to both patients for 3 weeks, with resolution of the lesions. Subsequent investigations confirmed genital tract donovanosis, human immunodeficiency virus seropositivity, acquired immunodeficiency syndrome, and pulmonary tuberculosis in both mothers. Heightened awareness of the occurrence of donovanosis at unusual sites and improved recognition of the histomorphological features of the disease, especially in small and superficial biopsies, are pivotal not only for its correct diagnosis in extragenital cutaneous and extracutaneous locations but also for timely and adequate therapy and an improved infant and maternal outcome.

Bartonella quintana-induced vulval bacillary angiomatosis.

Bacillary angiomatosis (BA) is an increasingly reported infection, mainly in patients with acquired immunodeficiency syndrome. Different epidemiological risk factors are associated with the transmission of the causative agents, Bartonella henselae and B. quintana. Vulval BA is described rarely. Two patients presented with a vulval mass (Patient 1) and a verrucous vulval growth (Patient 2), which were diagnosed clinically as tuberculosis and carcinoma, respectively. Patient 1 also had pulmonary tuberculosis and Kaposi sarcoma. Biopsy of the vulval lesions confirmed BA, characterized by a multilobular proliferation of blood vessels that were lined by epithelioid endothelial cells. There were prominent intervascular neutrophils, karyorrhectic debris, and clumps of paravascular argyrophilic organisms. The biopsy from Patient 1 was deep dermal/subcutaneous in location and displayed foci of confluent suppuration. There was florid pseudoepitheliomatous hyperplasia in the biopsy from Patient 2. Molecular investigations confirmed intralesional B. quintana, hitherto unreported in vulval BA, as the causative agent in both biopsies. On follow-up, Patient 2 had developed additional lesions in the vulva and thigh, but all her lesions and the vulval mass (Patient 1) responded to erythromycin treatment. Patient 1 succumbed to tuberculosis. Heightened recognition of BA underpins rapid and optimal clinicopathological diagnosis, even in uncommon locations. Identification of the causative Bartonella species is important for appropriate, interventive social management.

Concomitant malacoplakia and granuloma inguinale of the cervix in acquired immune deficiency syndrome.

We describe concomitant granuloma inguinale (GI) and malacoplakia of the cervix in 2 acquired immune deficiency syndrome (AIDS) patients aged 27 and 36 years. Both patients presented with a bloody foul-smelling vaginal discharge. Speculum examination confirmed cervical ulceration, prompting the diagnosis of cervical carcinoma in both patients. Cervical punch biopsies confirmed the characteristic features of GI; granulation tissue containing a dense plasma cell infiltrate, aggregates of neutrophils, and vacuolated enlarged histiocytes containing Donovan bodies were noted. Many of these histiocytes and sheets of von Hansemann cells contained intracytoplasmic Michaelis-Gutmann bodies, confirming concomitant malacoplakia. Michaelis-Gutmann bodies were also present in extracellular locations. Ultrastructural examination confirmed these histopathologic findings. One patient died of disseminated tuberculosis before treatment was initiated. The other patient did not return for a follow-up visit of her cervical lesion. Concomitant GI and malacoplakia is unreported in genital and extragenital sites; Klebsiella granulomatis must therefore be added to the list of bacteria associated with malacoplakia. Malacoplakia of the female genital tract is documented rarely and remains unreported, to date, in AIDS patients. Similar to the pathogenetic mechanisms described for AIDS-associated malacoplakia in extragenital sites, it is hypothesized that, in addition to abnormal macrophage functioning and an inability to degrade bacteria, special constituents of K. granulomatis are undigestable by lysosomal enzymes in human immunodeficiency virus-infected patients.

Amebiasis cutis revisited.

BACKGROUND: Amebiasis cutis (AC) is reported infrequently. This study assesses the clinicopathological spectrum, co-existent visceral involvement and impact of human immunodeficiency virus (HIV) co-infection on AC. METHODS: An 8-year prospective clinicopathological evaluation of patients with AC. RESULTS: Thirty-one biopsies of ulcers, fistulae, fissures, abscesses, polypoid and warty lesions in perianal, penile, scrotal, vulval, buttock, chest and abdominal wall sites were evaluated. Of these, 11 had a 'superficial' (superficial AC) and 20 a 'deep' (deep AC), histopathological pattern. Superficial AC showed predominant epidermal spongiosis, liquefactive necrosis, ulceration and fissures with hematophagous amebic trophozoites (HATs). Deep AC had confluent deep dermal and subcutaneous liquefactive, coagulative or suppurative necrosis and HATs. Seven biopsies showed vasculitis or thrombosis with luminal HATs. OUTCOME: Fourteen patients died; 9 had concomitant visceral amebiasis, 5 had other co-infections. Six who died were HIV seropositive, three were seronegative; all had deep AC. Of the 17 survivors, 11 (8 HIV positive) had superficial AC that healed with metronidazole treatment; the remaining 6 (one HIV seropositive) required additional surgical intervention. CONCLUSION: Deep AC is predictive of co-existent, contiguous visceral disease. The effective management, histopathological mimickers and diagnostic pitfalls of superficial and deep AC differ. The outcome in HIV-infected patients is dependent on co-existent systemic diseases.