The Great Pretender: early syphilis mimicking acute sclerosing cholangitis.

A 36-year old man with known HIV infection presented to an outpatient genitourinary service with jaundice, rash and sore throat. Investigations revealed marked biochemical abnormalities, including alkaline phosphatase and alanine transaminase >10 times the upper limit of normal. Liver ultrasound was normal, but stricturing and beading of the intrahepatic biliary tree was seen on magnetic resonance cholangiopancreatography (MRCP), similar to changes associated with sclerosing cholangitis. Serological syphilis antibodies were detected with a positive immunoglobulin M (IgM) and rapid plasma reagin of 1:128, in keeping with early infection. Liver biopsy showed large bile duct obstruction with portal oedema, bilirubinostasis and neutrophil polymorph infiltration around proliferating ductules; specific stains for spirochaetes were negative. Symptoms and biochemical markers improved rapidly after treatment for secondary syphilis with oral steroids and intramuscular benzathine penicillin. A repeat MRCP 18 months post syphilis treatment showed resolution. This case illustrates syphilis presenting as acute sclerosing cholangitis.

Chronic genital ulceration: a 'topical' issue.

We report a case of a chronic non-healing penile ulcer due to repeated topical application of crushed paracetamol tablets. To our knowledge, there are no such reports in the literature.

British HIV Association (BHIVA) national cohort outcomes audit of patients commencing antiretrovirals from naïve.

OBJECTIVES: The aim of this work was to audit the extent to which routine HIV care in the UK conforms with British HIV Association (BHIVA) guidelines and specifically the proportion of patients starting highly active antiretroviral therapy (HAART) who achieve the outcome of virological suppression below 50 HIV-1 RNA copies/mL within 6 months. METHODS: A prospective cohort review of adults with HIV infection who started antiretroviral therapy (ART) for the first time between April and September 2006 was carried out using structured questionnaire forms. RESULTS: A total of 1170 adults from 122 clinical sites participated in the review. Of these patients, 699 (59.7%) started ART at CD4 counts <200 cells/microL and 193 (16.5%) had not been tested for HIV drug resistance. Excluding patients with valid reasons for stopping short-term ART, 795 (73.5%) of 1081 patients had an undetectable viral load (VL) at follow-up. Detectable VL was strongly associated with pretreatment CD4 count below 50 cells/microL and pretreatment VL above 100 000 copies/mL, and was not associated with clinic location or case load. About a quarter of patients did not have a VL measurement during the first 6 weeks after starting ART. CONCLUSIONS: The majority of patients who initiated ART at sites participating in this UK national audit were managed within the BHIVA guidelines and achieved virological suppression below 50 copies/mL around 6 months after commencing treatment. Poor VL outcomes were associated with very low CD4 cell count and/or high VL at baseline but not with clinic case load or location. There is an urgent need to diagnose patients at an earlier stage of their HIV disease.

An audit of baseline HIV-1 genotypic resistance testing in a UK provincial city.

Baseline HIV-1 resistance testing is recommended in the 2005 BHIVA treatment guidelines. We compared the practice in our clinic with these guidelines. The aim of this study was to assess the prevalence of transmitted resistance in all antiretroviral therapy-naïve patients identified from our virology resistance test database. In 2006, 93% of all newly diagnosed patients had a baseline HIV-1 genotypic resistance test performed. The estimated prevalence of transmitted resistance was 8% in newly diagnosed patients and 7% overall with the majority in subtype B. These findings are in keeping with nationally reported data. It was of concern that we also identified a number of patients who had tested negative in the previous year.

Montelukast in the treatment of HIV associated immune reconstitution disease.

The pathogenesis of immune reconstitution disease (IRD) is not well understood and it can be difficult to manage. Leukotrienes exert proinflammatory effects, have an important role in the innate immune response, and are relatively deficient in HIV infection. Montelukast is a leukotriene receptor antagonist (LTRA) currently licensed for the treatment of asthma. We report a series of three patients with severe HIV associated IRD (cases 1 and 2 associated with starting HAART and unresponsive to steroids), who obtained clinically dramatic responses to treatment with montelukast. The first case is of IRD to secondary syphilis and the second and third to tuberculosis. Cases 1 and 3 both relapsed after a temporary break from montelukast and resolved on restarting. Montelukast should be considered in HIV associated IRD as an alternative to steroids and where these are not effective. Leukotriene overactivity may be implicated in IRD.

The interrelation of demographic and geospatial risk factors between four common sexually transmitted diseases.

OBJECTIVES: To examine the interrelation between demographic and geospatial risk factors for gonorrhoea, chlamydia, genital warts, and genital herpes. DESIGN: We analysed age, sex, ethnicity, socioeconomic status, and area of residence for Leeds residents aged 15-54 with Neisseria gonorrhoeae, genital Chlamydia trachomatis, first episode genital herpes, and first episode genital warts during 1994-5. The 1991 UK census provided denominator population information. RESULTS: Regression analysis showed that young age (15-24 years), ethnicity (with a gradient of risk black >white >Asian), and residence in inner city areas of deprivation were independent risk factors for all STDs. There were highly significant correlations in the geospatial distribution of incidence rates between the four infections. However, there was variation in the degree of central urban clustering, with gonorrhoea having the most restricted, and genital warts and chlamydia the widest distribution. 31% of all disease occurred in the four inner city census wards, representing 15% of the population. CONCLUSION: These results are in keeping with core group theory applying in a unified manner to the four most common UK sexually transmitted diseases in this urban area. Population based studies are needed to clarify whether ethnicity is associated with differing sexual behavioural or mixing patterns. Our data suggest that chlamydia screening in women <25 years of age could detect 70% of cases in the community, that such programmes should give particular emphasis to implementation in core group areas, and that they could function as unifying strategies for the control of most common STDs within urban areas.

An audit of baseline assessment of patients with HIV infection.

A multicentre retrospective medical audit was conducted on the baseline investigations of new patients with HIV infection. A total of 20 investigations were audited for men and 21 for women. Data were received on 49 newly diagnosed patients infected with HIV from 8 centres in the Yorkshire region. The audit demonstrated that half of the patients were not screened for sexually transmitted infections. However, the majority of baseline assessment considered as standard of care, had been performed.

Re-audit of antiretroviral prescribing in HIV patients.

We have found an overall improvement in the prescribing of antiretroviral therapy (ART) in the Yorkshire region between 1997 and 1999 but have identified a clinic where a significant number of patients continue on suboptimal treatment. It has been shown that the substantial reduction in the HIV-associated morbidity and mortality was related to the introduction of protease inhibitors (PIs), which became part of triple ART regimens in mid 1990s. There is evidence that treatment with 2 agents will eventually fail and such prescribing needs to be addressed. Further investigation has shown that patient choice has been an important issue in this locality. Treatment options need to be negotiated between patient and physician and prescribing contrary to patients' wishes may adversely affect adherence. The British HIV Association (BHIVA) guidelines were updated earlier this year to reflect recent advances in management. In view of the importance of optimal prescribing, ART is kept as a standing item on the agenda at our regional audit meetings. These are held every 4 months. We will continue to audit this topic at regular intervals.

Phase IIa safety and immunogenicity of a therapeutic vaccine, TA-GW, in persons with genital warts.

A fusion protein vaccine consisting of human papillomavirus 6 L2E7 with Alhydrogel was developed for the treatment of genital warts. Twenty-seven subjects with genital warts received 3 immunizations over 4 weeks in an open-label study. The vaccine was well-tolerated, and all subjects made serum IgG antibodies, predominantly IgG1, against L2E7. Nineteen of 25 tested persons made antigen-specific T cell proliferative responses to L2E7, and peripheral blood mononuclear cells when cultured with L2E7 in vitro produced both interferon-gamma and interleukin (IL)-5, although IL-5 predominated after the final vaccination. Five subjects completely cleared warts within 8 weeks. Subjects whose warts were not cleared by 8 weeks were offered conventional therapy. Recurrence of warts was not seen in any of the 13 persons whose warts cleared by vaccine alone or with conventional therapy. While these preliminary results of the use of this therapeutic immunogen are encouraging, proof of efficacy will require randomized double-blind trials.

Patient attitudes to type specific serological tests in the diagnosis of genital herpes.

OBJECTIVE: To assess patient attitudes to HSV-2 serotesting and the effect of providing detailed information regarding genital herpes, the blood test, and its implications. METHODS: Consecutive genitourinary medicine clinic attenders were asked to complete an anonymous self administered questionnaire. Half received minimal additional information while the other half received a detailed information sheet. RESULTS: Overall, 200 clinic attenders with a median age of 27 years (range 15-57) completed the questionnaire, 92.4% wanted to know if they, and 90.8% if their partners, had been infected with genital herpes; 65% expected testing as part of screening without further discussion. Overall, on a scale of 1-10, 2% scored 1 (equivalent to definitely not wanting a test), while 45.5% scored 10 (equivalent to definitely wanting a test). The overall median score was 9 (95% confidence interval 8-10) suggesting a strong opinion in favour of testing. The desire to test in each of five described hypothetical situations increased significantly (p < 0.001) when compared with the general desire. CONCLUSIONS: Clinic attenders expressed a strong preference to be serotested for HSV-2 which was unaltered by the provision of information highlighting implications, although influenced significantly by the context in which they were asked. Should reliable tests become available the level of demand could have important implications on laboratory and counselling resources.

A multidistrict audit on the management of Chlamydia trachomatis in genitourinary medicine clinics in Yorkshire.

Nine genitourinary clinics (one teaching hospital and 8 district general hospitals) within the Yorkshire Deanery audited the management of uncomplicated genital chlamydial infections in male and female patients attending between January and December 1995. Standards set included: 100% of chlamydia-positive patients to be treated within 2 weeks of diagnosis; 100% of patients to return for test of cure within one month of treatment; 100% of patients to be referred for contact tracing. Four hundred and thirty-six of a total 1356 cases were audited. Eighty-nine per cent received treatment within 2 weeks; 64% returned for a test of cure within one month; 93% were referred for contact tracing. Changes in practice and a region-wide multidisciplinary audit initiative resulted from the study.

Antioxidant-micronutrients and HIV infection.

We measured plasma levels of all the antioxidant-micronutrients in subjects with HIV infection and controls. Plasma levels of all the carotenoids, including lutein, cryptoxanthin, lycopene, alpha-carotene and beta-carotene as well as vitamins A, C and E and cholesterol were assayed in 35 subjects with HIV infection and 38 controls. We found a significant depletion of all the carotenoids (P < 0.001) and vitamin C (P < 0.01) and cholesterol (P < 0.001) but not vitamins A or E in HIV-infected subjects. Further analysis of the HIV-infected subjects revealed that plasma levels of 4 of the groups of carotenoids and cholesterol were correlated with CD4 count but that beta-carotene and vitamins A, C and E were not. These results are reviewed in the light of the published literature and we conclude that these abnormalities of antioxidant-micronutrients are likely to reflect a metabolic phenomenon associated with HIV infection. However, an additional contribution to these deficiencies from malabsorption later in HIV disease cannot be ruled out.

The sexual behaviour and knowledge about AIDS in a group of young adolescent girls in Leeds.

A questionnaire was given to 56 sexually active girls 12-16 years old, in a juvenile assessment centre or attending a genitourinary medicine clinic. Sexual behaviour, drug use, contraceptive practice and knowledge and attitudes about AIDS were evaluated. The girls were similar in demographic characteristics from both centres and were regarded as one group. Sexual experience ranged from 1 partner ever to 70 clients/week; 19 girls had contracted a sexually transmitted disease at some time. Half had never used a contraceptive. Twenty eight had used illicit drugs, with two girls experimenting with intravenous misuse. Misconceptions about modes of transmission of HIV were common, but most girls knew some basic facts about the virus. Most girls realised they were at risk, were anxious about contracting HIV infection in the future, but had not modified their behaviour in terms of condom usage. This study indicates that high risk adolescents need to be targeted for effective health education in order to modify behaviour patterns which put them at risk of acquiring HIV in the future.

Screening donors for sexually transmitted disease in donor insemination clinics in the UK. A survey.

A survey conducted amongst the 40 donor insemination centres in the UK registered by the Royal College of Obstetricians and Gynaecologists (RCOG) showed that most of the clinics had no structured policy for control of common (non-HIV) sexually transmitted diseases within their programmes.

Patterns of carriage of group B streptococci in genitourinary medicine clinic patients.

Anogenital carriage of group B streptococci was found in 46% (57/125) of men and 38% (68/179) of women attending a genitourinary medicine clinic. Colonisation with group B streptococci was more common in patients who had a history of more than one sexual partner in the preceding three months, but was not related to any previous sexually transmitted infection. Group B streptococci were isolated from either one or both partners of 28 couples, in 12 of which both partners yielded isolates that were indistinguishable by serotyping and phage typing. Colonisation with matching isolates of group B streptococci was more common in couples who had relatively stable relationships.