Condoms: Past, present, and future.

Though many methods of prevention of STI/HIV are available, condoms remain of utmost importance. They have gone a long way from the oiled silk paper used by the Chinese and the hard sheaths made of tortoise- shell used by the Japanese to the latex condoms of today. The breakthrough came when the rubber vulcanization process was invented by Charles Goodyear and eventually the first rubber condom was made. The condom offers maximum protection( more than 90%) against HIV, Hepatitis B virus and N.Gonorrhoea. They also offer protection in scenarios when alternate sexual practices are adapted. The female condom in the only female driven contraceptive method available today. Graphene and Nano lubricated condoms are new in the market and others in futuristic approach may include wearable technology/Technology driven condom and invisible Condoms. Both Correct and Consistent use of condoms needs to be promoted for HIV/STI prevention.

Study of 35 Cases of Hansen's Disease, which Required Treatment beyond Fixed Duration--Multi Drug Therapy.

Multi Drug Therapy (MDT) is the main weapon against leprosy since its inception in 1981. India achieved the level of elimination (< 1 case/10,000) on 31st December 2005. It has been proved in few studies that despite 2 years of regular therapy 10% of the patients continue to harbour viable persisters. There are many problems related with FD-MDT. Many cases have residual disease activity after completion of treatment. Aims of the present study was to study the profile of RFT cases in leprosy treated with FD-MDT, who required extended MDT, duration between completion of FD -MDT and clinical presentation, Acid Fast Bacilli (AFB) status, histopathology and type of leprosy at the time of presentation. A prospective study of 35 RFT (Released FromTreatment) cases with signs of activity were recruited in period betveen May 2007 to November 2001. All cases were diagnosed clinically and investigations were done for AFB smear, histopathological examination and Fite Faraco staining. We found that all the 35 cases, which required extended MDT, age group ranged from 10 to 65 years. Majority (71.4%) had taken previous Multi-Bacillary (MB) treatment for 1 year duration. Eleven (31.42%) of cases came within one year, 17 (48.57%) between one to two years and 7 (20%) cases after two years of stopping FD-MDT. AFB smear was positive in 36.84% of cases in which done. Majority of previously diagnosed MB cases presented as BT/TT in histopathology. Thus there is need to search for reliable prognostic markers for therapeutic purposes.

An update on oral human papillomavirus infection.

Human papillomavirus (HPV) constitutes the majority of newly acquired sexually transmitted infections (STIs) in United States as per the centers for disease control factsheet 2013. Genital HPV is the most common STI with incidence of about 5.5 million world-wide, nearly 75% of sexually active men and women have been exposed to HPV at some point in their lives. Oral Sexual behavior is an important contributor to infection of HPV in the oral mucosa especially in cases known to practice high risk behavior and initiating the same at an early age. HPV infection of the oral mucosa currents is believed to affect 1-50% of the general population, depending on the method used for diagnosis. The immune system clears most HPV naturally within 2 years (about 90%), but the ones that persist can cause serious diseases. HPV is an essential carcinogen being implicated increasingly in association with cancers occurring at numerous sites in the body. Though there does not occur any specific treatment for the HPV infection, the diseases it causes are treatable such as genital warts, cervical and other cancers.

Association of NLRP1 genetic variants and mRNA overexpression with generalized vitiligo and disease activity in a Gujarat population.

BACKGROUND: It has been suggested that NLRP1 is involved in susceptibility to a wide range of autoimmune diseases including generalized vitiligo (GV). Genetic polymorphisms in the gene encoding NLRP1 (previously known as NALP1) have previously been shown to be associated with GV and there is speculation about their involvement in the regulation of NLRP1 expression. OBJECTIVES: To explore NLRP1 polymorphisms and investigate their association with NLRP1 mRNA expression and disease activity in patients with GV. METHODS: Polymerase chain reaction (PCR)-restriction fragment length polymorphism and TaqMan single nucleotide polymorphism (SNP) genotyping techniques were used to genotype NLRP1 A/G (rs2670660), T/C (rs6502867) and A/T (rs12150220) polymorphisms in 537 patients with GV and 645 controls in Gujarat. NLRP1 mRNA levels were measured in the whole blood of 122 patients with GV and 175 controls using real-time PCR. RESULTS: The NLRP1 rs2670660 and rs6502867 polymorphisms were found to be in significant association with GV, minor alleles of these SNPs being prevalent in active cases of GV. The rs12150220 polymorphism was found have a marginal association with GV. The frequency of susceptible haplotype 'GCT' was significantly higher in patients with GV and increased the risk of vitiligo twofold. A significant increase in NLRP1 mRNA expression was observed in patients with GV and patients with active GV. NLRP1 mRNA expression was increased in patients with GV with the susceptible GG (rs2670660) and CC (rs6502867) genotypes. Patients with the susceptible GG (rs2670660) and CC (rs6502867) genotypes had early age of onset of GV. Moreover, patients in the age at onset group of 1-20 years showed increased expression of NLRP1 mRNA compared with the older age groups. Female patients showed a significant increase in NLRP1 mRNA and early age at onset of GV compared with male patients. CONCLUSIONS: Our results suggest that NLRP1 rs2670660 and rs6502867 polymorphisms may be genetic risk factors for susceptibility to and progression of GV. The upregulation of NLRP1 mRNA in patients with susceptible genotypes advocates the crucial role of NLRP1 in GV.

Microbicides and HIV: A Review and an update.

HIV is a pandemic which has continually posed challenges to the scientific society in large and to medical fraternity in particular in terms of treatment as well as prevention. The treatment is lifelong suppressive than curative; hence the importance has always been to prevention strategies. The strategies like abstinence, monogamy and consistent condom use have various societal and behavioural issues and HIV vaccine is still not at the horizon. In such a scenario, pre-exposure prophylaxis (PrEP) and microbicides have emerged as newer options of prevention. Microbicides are referred to as topical PrEP. They are compounds that can be applied inside the vagina or rectum to protect against sexually transmitted infections (STIs) including HIV. Microbicides can be vaginal and rectal and can be formulated as gels, foams, rings, hydrogels, silicone elastomer gels, diaphragm, quick-dissolve polyvinyl alcohol based films, and bioadhesive vaginal tablets. The microbicides have been divided into various categories based on where they disrupt the pathway of sexual transmission of HIV. The article highlights the classes of microbicides and various trials conducted on them. It also enumerates various approaches in pipeline like antimicrobial peptides, aptamers, flavonoids, small interfering RNAs and DNAs, and bioengineered lactic acid bacilli.

Interleukin-4 genetic variants correlate with its transcript and protein levels in patients with vitiligo.

BACKGROUND: Vitiligo is an acquired pigmentary disorder resulting from loss of melanocytes. Interleukin (IL)-4 has been shown to stimulate B-cell proliferation, to regulate immunoglobulin class switching (IgG1 and IgE) and to promote T-cell development. Polymorphisms in the IL4 gene are known to increase its expression, thereby implicating its role in vitiligo susceptibility. OBJECTIVES: To explore intron 3 VNTR (IVS3) and -590 C/T (rs2243250) promoter polymorphisms in the IL4 gene and to correlate them with the IL4 transcript, serum IL-4 and IgE levels to achieve genotype-phenotype correlation in patients with vitiligo from Gujarat. A replication study was done in a North Indian population. METHODS: The case-control study was performed to investigate these polymorphisms in 505 patients and 744 controls in Gujarat, and 596 patients and 397 controls in North India by polymerase chain reaction (PCR) and PCR-restriction fragment length polymorphism analysis. IL4 transcript levels were monitored by real-time PCR. Serum IL-4 and IgE levels were measured by enzyme-linked immunosorbent assay and electrochemiluminescence immunoassay, respectively. RESULTS: The genotype frequencies differed significantly between patients with generalized vitiligo and controls for both the polymorphisms in both populations. Allele frequencies significantly differed between patients with generalized vitiligo and controls for both the polymorphisms in the population from Gujarat. Interestingly, genotype and allele frequencies for -590 C/T single nucleotide polymorphism were significantly different between patients with localized vitiligo and controls in both the populations. The study revealed significantly increased IL4 mRNA, serum IL-4 and IgE levels in patients from Gujarat. Age of onset analysis of disease in patients suggested that the TTR2R2, TTR1R2 and CTR2R2 haplotypes had a profound effect in the early onset of the disease. CONCLUSIONS: Our results suggest that these polymorphisms of the IL4 gene may be genetic risk factors for susceptibility towards vitiligo and the upregulation of the IL4 transcript, protein and IgE levels in individuals with susceptible haplotypes reveal the crucial role of IL-4 in the pathogenesis of vitiligo.

Pruritic papular eruptions as presenting illness of HIV.

Mucocutaneous manifestations can be the first markers of HIV. We are reporting the case of an adolescent girl who presented with chronic, recurrent, intensely pruritic papular lichenified eruptions over extremities, face and trunk, which were exudative and crusted at places. She had delayed milestones with growth failure and no pubertal features. She did not have any risk factors to be suspected for HIV. The lesions were refractory to treatment, so she was tested for HIV and she came out to be HIV positive. This case reports pruritic papular eruptions as presenting illness of HIV.

Pre-exposure prophylaxis of HIV.

Pre-exposure prophylaxis (PrEP) is an experimental approach to HIV prevention and consists of antiretroviral drugs to be taken before potential HIV exposure in order to reduce the risk of HIV infection and continued during periods of risk. An effective PrEP could provide an additional safety net to sexually active persons at risk, when combined with other prevention strategies. Women represent nearly 60% of adults infected with HIV and PrEP can be a female-controlled prevention method for women who are unable to negotiate condom use. Two antiretroviral nucleoside analog HIV-1 reverse transcriptase inhibitor drugs are currently under trial as PrEP drugs, namely tenofovirdisoproxilfumarate (TDF) alone and TDF in combination with emricitabine (FTC), to be taken as daily single dose oral drugs. There are 11 ongoing trials of ARV-based prevention in different at risk populations across the world. The iPrex trial showed that daily use of oral TDF/FTC by MSM resulted in 44% reduction in the incidence of HIV. This led to publication of interim guidance by CDC to use of PrEP by health providers for MSM. Few other trials are Bangkok Tenofovir Study, Partners PrEP Study, FEM-PrEP study, and VOICE (MTN-003) study. Future trials are being formulated for intermittent PrEP (iPrEP) where drugs are taken before and after sex, "stand-in dose" iPrEP, vaginal or rectal PrEP, etc. There are various issues/concerns with PrEP such as ADRs and resistance to TDF/FTC, adherence to drugs, acceptability, sexual disinhibition, use of PrEP as first line of defense for HIV without other prevention strategies, and cost. The PrEP has a potential to address unmet need in public health if delivered as a part of comprehensive toolkit of prevention services, including risk-reduction, correct and consistent use of condoms, and diagnosis and treatment of sexually transmitted infections.

A case of congenital syphilis with Hutchinson's triad.

Late congenital syphilis is a rare entity and its early diagnosis and treatment is essential to prevent significant morbidity. We are reporting a case of late congenital syphilis presenting with Hutchinson's triad at an age of 14 years.

Lupus panniculitis as an initial manifestation of systemic lupus erythematosus.

In May, 2003, a 28-year-old female presented with large non-healing ulcers on face, trunk and limbs covered with black hemorrhagic crust. There were no other systemic manifestations. Diagnosis of lupus panniculitis was considered on clinical and histopathological grounds. The lesions healed completely, with scarring, with systemic corticosteroid, hydroxychloroquine and topical 2% mupirocin. She came again in November, 2005, with malar rash, joint pain, scarring alopecia of the scalp and albuminuria. Her ANA, AntidsDNA came positive and diagnosed as having systemic lupus erythematosus (SLE). She responded well to systemic corticosteroid, antimalarial and topical antibacterial. The evolution of lupus panniculitis is slow and characterized by regression of the inflammatory lesions when treated with antimalarial drugs. The lupus panniculitis generally has a favorable course.

Adolescent HIV/AIDS: Issues and challenges.

Adolescence (10-19 years) is a phase of physical growth and development accompanied by sexual maturation, often leading to intimate relationships. Adolescent HIV/AIDS is a separate epidemic and needs to be handled and managed separately from adult HIV. The adolescents can be subdivided into student, slum and street youth; street adolescents being most vulnerable to HIV/AIDS. Among various risk factors and situations for adolescents contracting HIV virus are adolescent sex workers, child trafficking, child labor, migrant population, childhood sexual abuse, coercive sex with an older person and biologic (immature reproductive tract) as well as psychological vulnerability. The most common mode of transmission is heterosexual, yet increasing number of perinatally infected children are entering adolescence. This is due to "bimodal progression" (rapid and slow progressors) among the vertically infected children. Clinically, the HIV infected adolescents present as physically stunted individuals, with delayed puberty and adrenarche. Mental illness and substance abuse are important co-morbidities. The disclosure and declaration of HIV status to self and family is challenging and guilt in sexually infected adolescents and tendency to blame parents if vertically affected need special consideration and proper counseling. Serodiscordance of the twins and difference in disease progression of seroconcordant twins are added causes of emotional trauma. Treatment related issues revolve around the when and what of initiation of ART; the choice of antiretrovirals and their dosages; issues related to long term ADRs; sense of disinhibition following ART commencement; adherence and resistance.

Hidradenitis suppurativa in AIDS.

Hidradenitis suppurativa (HS) is a disorder of the terminal follicular epithelium in the apocrine gland-bearing skin, characterized by comedo-like follicular occlusion, chronic relapsing inflammation, mucopurulent discharge, and progressive scarring. In this study, we report a case of 35-year-old HIV-positive man with recurrent nodular skin lesions with foul smelling discharge over face, gluteal region, thighs, and axilla. This case is unique because of its association with HIV leading to atypical manifestations and therapeutic challenges.

Reproductive tract infections in HIV positive women: A case control study.

BACKGROUND: Human immunodeficiency virus (HIV) infection primarily affects women during their reproductive years, and the coexistence of reproductive tract infections (RTIs) is not surprising given the fact that HIV is mainly acquired via heterosexual contact. AIM: The aim of the study was to compare the occurrence of RTIs among infected and noninfected women. MATERIALS AND METHODS: A case control study of 83 HIV positive women, tested by two enzyme linked immunosorbent assay (ELISA) and a matched control of 87 HIV negative women were screened for RTIs. They were submitted to gynecological examination and cervical cytology. RESULTS: The mean age for HIV positive women was 30 years and that for HIV negative women was 27 years. 18% HIV positive women had menstrual irregularities compared to 6% in seronegative group (P= 0.024). Vaginal infections including sexually transmitted infections (STIs) were found in 47 (57%) HIV positive women and 30 (34%) HIV negative women (P= 0.0037). Vaginal candidiasis was the most common infection (34%) in HIV positive women, followed by trichomoniasis (12%). Human papilloma virus (HPV) infection was seen in nine HIV positive women versus none in HIV negative women. Cervical cytology showed inflammation in 53 (64%) HIV positive women compared to 27 (31%) HIV negative women (P= 0.000023). Genital neoplasia, including carcinoma in situ was observed in 2 (2.5%) HIV positive women and in none of the HIV negative women. CONCLUSION: It is seen that reproductive tract morbidities are common in HIV positive women. So it is imperative that HIV positive women have a complete gynecological evaluation including a Papanicolaou (PAP) smear with aggressive screening of STIs.

Genital elephantiasis as a complication of chromoblastomycosis: A diagnosis overlooked.

Over the decades, causes of genital elephantiasis have changed only to become elusive to etiological diagnosis. This is a case of 20 year old male who presented with genital elephantiasis occurring due to lymphatic obstruction caused by chromoblastomycosis and super added erysipelas. The diagnosis of chromoblastomycosis was clenched by biopsy. We describe this case for the rarity of its occurrence.

Pregnancy and sexually transmitted viral infections.

Viral infections in pregnancy are a major cause of morbidity and mortality for both mother and fetus. Viral STIs occur as surface infection and then gradually infect immunologically protected sites. Therefore, these are asymptomatic, hidden and hence underdiagnosed, persistent and difficult to treat. HSV, HPV, HBV, HIV and CMV (cytomegalovirus) are the common ones. Most of these are transmitted during intrapartum period. Proper screening, identification and treatment offered during prenatal period may help in preventing their complications. Twenty five percent of women with a history of genital herpes have an outbreak at some point during the last month of pregnancy. Acyclovir is the accepted efficacious and safe therapy for HSV in pregnancy. Globally, HPV infection is the most common sexually transmitted infection. Neonatal transmission can occur in the absence of clinically evident lesions. HPV 6 or 11 may lead to Juvenile Onset Recurrent Respiratory Papillomatosis (JORRP). TCA, liquid nitrogen, laser ablation or electrocautery can be used to treat external genital HPV lesions at any time during pregnancy. Cesarean section is recommended only if the lesions are obstructing the birth canal. Mother to child transmission (MTCT) in HIV accounts for 15-30% during pregnancy and delivery, and a further 5-20% of transmission occurs through breastfeeding. HBV infection during pregnancy does not alter the natural course of the disease. In women who are seropositive for both HBsAg and HBeAg, vertical transmission is approximately 90%. Pregnancy is not a contraindication for HBV vaccination. Cytomegalovirus (CMV) is the most common intrauterine infection. Cytomegalic inclusion disease (CID) is the most severe form of congenital CMV infection. Treatment is supportive.