Screening for 'window-period' acute HIV infection among pregnant women in rural South Africa.

OBJECTIVES: The aim of this study was to evaluate the HIV-1 RNA pooled nucleic acid amplification testing (NAAT) strategy to screen pregnant women in the 'window period' of acute HIV infection (AHI) in rural South Africa. METHODS: In 2007 and 2008, 750 consecutive pregnant women on their first antenatal care visit to a primary health care clinic were tested anonymously for HIV infection. HIV-1 RNA pooled NAAT was performed on HIV antibody-negative samples. All positive pools were tested individually and positive samples were classified as incident cases to calculate HIV incidence. RESULTS: The overall HIV prevalence was 37.3% [95% confidence interval (CI) 34.3­41.3]. Of the 467 HIV antibody-negative samples, four (0.9%) were HIV-1 RNA-positive. The mean viral load in the four samples was 386 260 HIV-1 RNA copies/mL (range 64 200­1 228130). The HIV incidence was 11.2%per year (95% CI 0.3­22.1) and all women with AHI were 21 years of age. CONCLUSIONS: Identifying AHI in pregnancy is important for health interventions to reduce perinatal and heterosexual transmission of HIV, and to estimate HIV incidence for epidemiological surveillance.

TB treatment outcomes following directly-observed treatment at an urban outpatient specialist TB facility in South Africa.

The treatment of 450 consecutive new patients with pulmonary TB was evaluated to determine outcome following directly-observed treatment. In all, 176 (39.1%) patients were cured, 23 (5.1%) completed treatment, 80 (17.8%) defaulted treatment, 24 (5.3%) died, 54 (12.0%) were lost to follow-up and 93 (20.7%) were transferred out. Increasing age was significant for death. Males were more likely to default and those with negative pretreatment sputum smears and those who were unemployed were more likely to be lost to follow-up. The overall treatment success rate remains low. Our data suggests that greater emphasis is needed to improve TB treatment success.

A randomized controlled trial of azithromycin versus doxycycline/ciprofloxacin for the syndromic management of sexually transmitted infections in a resource-poor setting.

A randomized controlled trial was carried out to assess the effectiveness of azithromycin versus a standard regimen with doxycycline/ciprofloxacin in the treatment of sexually transmitted infections in a resource-poor environment. Infection with Chlamydia trachomatis was cured in 23/24 (95.8%) of women in the azithromycin arm versus 19/21 (90.5%) in the doxycycline arm (P = 0.6), resulting in three treatment failures. Gonorrhoea was cured in 55/56 (98.2%) women, with one treatment failure in a patient with concomitant C. trachomatis infection. These results indicate that a single oral dose of azithromycin may prove to be a more effective and convenient treatment for sexually transmitted infections in women in a resource-poor environment

Evolution in the trends of antimicrobial resistance in Neisseria gonorrhoeae isolated in Durban over a 5 year period: impact of the introduction of syndromic management.

Antimicrobial susceptibility testing was performed on isolates of Neisseria gonorrhoeae obtained from patients attending the City Health STD clinic in Durban, KwaZuluNatal, using the following drugs: penicillin, tetracycline, ciprofloxacin, ofloxacin, ceftriaxone, spectinomycin, erythromycin and azithromycin. These isolates were collected over a 6 year period from 1995 to 2000. Four hundred and fifteen strains were tested: 61 in 1995, 198 in 1997, 98 in 1998/99 and 58 in 1999/2000. A shift to the right is observed in the susceptibilities of N. gonorrhoeae to the currently recommended drugs in the syndromic management guidelines viz. penicillin, tetracycline, ceftriaxone, ciprofloxacin, spectinomycin and erythromycin. The prevalence of penicillinase-producing N. gonorrhoeae is currently c. 30%, whereas that of plasmid-mediated tetracycline-resistant N. gonorrhoeae is c. 50%. There is a definite association between the MICs of strains falling within the penicillin and tetracycline chromosomally resistant group, and strains exhibiting a decreased susceptibility to ciprofloxacin and ceftriaxone. The MICs of azithromycin showed a similar distribution when compared with erythromycin for 1999/2000 isolates. We postulate that the presence of efflux pumps might play a role in the increasing MICs that we observe among structurally unrelated groups of drugs. Furthermore, widespread use of these antimicrobials in the community may offer a selective advantage to the development of resistance. The implications of this are far reaching and the local susceptibility trends of N. gonorrhoeae need to be monitored constantly to direct therapy.

Transepithelial elimination of cutaneous vulval granuloma inguinale.

BACKGROUND: Transepithelial elimination (TEE), a distinct and well-known entity, is a process during which the skin eradicates undesirable or irritative dermal substances through intact epidermis or follicular epithelium by passive or active means. Although TEE is being described in an increasing number and range of pathological processes, to date, TEE of granuloma inguinale (GI) remains unrecorded in the English-language literature. The aims of this study were: 1) To appraise the light microscopic and ultrastructural morphological epidermal changes that are associated with TEE of cutaneous vulval GI; and 2) To determine the role of intra-epidermal leucocytes and histiocytes in the pathogenesis of TEE of vulval GI. METHODS: This is a retrospective 9-year histopathological review of all cases diagnosed and coded as vulval granuloma inguinale in the Department of Anatomical Pathology, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa. Ultrastructural evaluation was performed on selected cases using a Jeol transmission electron microscope. RESULTS: Of 53 skin biopsies from 47 patients with vulval GI, 43 were suitable for the study. The age range of patients was 15-40 years (mean age=22 years). There were eleven papular, twelve nodular, seven verrucous and thirteen ulcerative lesions. Donovan bodies within macrophages, free-lying Donovan bodies and dense aggregates of neutrophils and plasma cells were seen in the dermis of all biopsies. There was consistent overlying pseudoepitheliomatous hyperplasia. The dermal inflammatory infiltrate hugged the dermo-epidermal junction and appeared entrapped between elongated and acanthotic epidermal rete ridges and pegs. Transepidermal neutrophil microabscesses, histiocytes containing Donovan bodies and neutrophilic and histiocytic fragmentation were present. A variable number of free-lying and intra-histiocytic Donovan bodies and neutrophils were present on the surface of the epidermis. On ultrastructural investigation epidermal spongiosis, intracellular oedema, free-lying, intra-neutrophilic and intra-histiocytic Donovan bodies, and intact and degenerating neutrophils and histiocytes were evident between keratinocytes. The degenerative histiocytes demonstrated marked vacuolation, mitochondrial swelling and bacilli within phagolysosomal vacuoles, bound by intact or disrupted limiting membranes. CONCLUSION: The inflammatory infiltrate at the epitheliomesenchymal interface, pseudoepitheliomatous hyperplasia, intra-epidermal accumulation and disintegration of neutrophils and histiocytes, and the associated release of lytic enzymes, play important contributory roles in TEE of GI. TEE of infectious agents is a poorly recognised mechanism of spread of infectious diseases and represents a public health hazard. In cutaneous vulval GI, TEE is highlighted as a hitherto unrecognised, potential method of spread of Calymmatobacterium granulomatis.

Sudden death caused by myocardial tuberculosis: case report and review of the literature.

A 25-year-old fit man died suddenly while playing social soccer. Autopsy revealed an infiltrative lesion involving the left ventricle with overlying pericarditis. No other significant pathologic changes were observed. Histologic examination showed necrotizing granulomatous inflammation. No acid-fast bacilli were demonstrated in the pericardial fluid or on histologic examination. The presence of Mycobacterium tuberculosis DNA complex was confirmed by use of the ligase chain reaction technique. The differential diagnosis of myocardial tuberculosis includes sarcoidosis, rheumatic fever, rheumatoid arthritis, giant-cell-containing tumors, idiopathic (giant-cell) myocarditis, and bacterial infections such as tularemia and brucellosis. This case illustrates the protean manifestations of tuberculosis and highlights the use of molecular biologic techniques in arriving at a definitive diagnosis in cases of suspected tuberculosis.

Phylogenetic analysis of Calymmatobacterium granulomatis based on 16S rRNA gene sequences.

Calymmatobacterium granulomatis is the aetiological agent of granuloma inguinale - a chronic granulomatous genital infection - and is morphologically similar to members of the genus Klebsiella. This study determined the 16S rRNA gene sequence of C. granulomatis and the taxonomic position of the organism in relation to the genus Klebsiella. Genomic DNA was extracted from C. granulomatis-infected monocytes and from frozen and formalin-fixed paraffin wax-embedded tissue biopsy specimens from patients with histologically proven granuloma inguinale. The 16S rDNA was amplified by PCR with broad range oligonucleotide primers. The amplified DNA fragments were cloned into pMOS vector, digested with Bam HI and Pst1 restriction endonucleases, hybridised with a gram-negative bacterial probe (DL04), sequenced in both directions by the automated ALF DNA sequencer, verified on an ABI Prism 377 automated sequencer and analysed with DNASIS and MEGA software packages. Sequence analysis revealed DNA homology of 99% in C. granulomatis from the different sources, supporting the belief that the bacteria in the culture and the biopsy specimens belonged to the same species, although there was some diversity within the species. Phylogenetically, the strains were closely related to the genera Klebsiella and Enterobacter with similarities of 95% and 94% respectively. C. granulomatis is a unique species, distinct from other related organisms belonging to the gamma subclass of Proteobacteria.

Ultrastructure of Calymmatobacterium granulomatis: comparison of culture with tissue biopsy specimens.

The ultrastructural features of cells of Calymmatobacterium granulomatis from monocyte co-cultures and tissue biopsy specimens were compared. In cultures the bacteria were mainly extracellular, i.e., not within membrane-bound vacuoles. The bacterial body was surrounded by a uniformly extensive homogeneous layer with a relatively high electron density. This layer varied considerably in tissue biopsy specimens, having either homogeneously electron-dense or delicate web-like structures with varying density and thickness. In tissue specimens the bacteria were located predominantly within vacuoles of varying sizes in the cytoplasm of the macrophages and, occasionally, extracellularly within the intercellular spaces of the stroma. The bacterial cytoplasm contained ribosomes scattered throughout with electron-dense granules located peripherally. The trilaminar cell-wall structure was typical of a gram-negative organism, comprising an outer membrane, a middle electron-opaque layer and an inner plasma membrane. Surface structures such as fimbriae, flagella and bacteriophages were not identified in specimens from either source.

Growth and cultural characteristics of Calymmatobacterium granulomatis--the aetiological agent of granuloma inguinale (Donovanosis).

Granuloma inguinale is a chronic destructive granulomatous disease of the genitalia. The clinical diagnosis is often unreliable and the definitive diagnosis is based on the visualisation of 'Donovan bodies' in tissue smears or biopsy specimens. The organism implicated in its aetiology, Calymmatobacterium granulomatis, was reported to have been cultured > 30 years ago, but little is known about the organism because of its fastidious nature and the difficulty in culturing it. Twenty-two biopsy specimens from female patients with clinical and laboratory-confirmed granuloma inguinale were treated with amikacin 10 mg/L and inoculated in a monocyte co-culture system with peripheral blood mononuclear cells (PBMC) from a single donor and autologous sera. The method was subsequently modified by pretreatment of specimens with vancomycin 5 mg/L and metronidazole 10 mg/L in addition to amikacin 10 mg/L for the purpose of decontamination, pooled blood donor PBMC and by the use of heat-inactivated fetal calf serum instead of autologous serum for culture. This modified method was used to culture additional biopsy specimens and genital ulcer scrapings from female and male patients, respectively. All monocyte co-cultures were examined by a rapid Giemsa (RapiDiff) stain and by an indirect immunofluorescence test with immune sera. Representative cultures were examined by transmission electron microscopy. C. granulomatis was successfully isolated in pure culture by the monocyte co-culture system from four biopsy specimens and 14 genital ulcer scrapings. The cultured organisms were visible both intra- and extra-cellularly and were extremely pleomorphic, with characteristic single and biopolar condensation. The numbers of the organisms increased after each passage. All positive cultures showed bright fluorescence when tested with immune sera. Transmission electron microscopy of the cultured bacteria demonstrated a typical gram-negative cell wall consisting of an outer membrane, middle electron opaque layer and an inner plasma membrane. The capsule was thick and electron dense. Numerous electron dense granules were present within the cytoplasm.

Bacterial vaginosis and lower genital tract infections in women attending out-patient clinics at a tertiary institution serving a developing community.

The prevalence of bacterial vaginosis and other lower genital tract infections were determined in women from a developing community. Patients were recruited from four out-patient clinics of a large urban tertiary referral hospital serving the indigent Black population of KwaZulu/Natal, South Africa. A total of 208 women attending the sexually transmitted diseases (STD) (n = 51), colposcopy (n =50), family planning (n = 52) and antenatal (n = 55) clinics were investigated. Endocervical and vaginal specimens were collected for microbiological investigation of recognised sexually transmitted pathogens. Estimation of vaginal pH, amine test and wet smear microscopy were performed at the bedside. Peripheral venous blood was obtained for serological tests for syphilis, hepatitis B surface antigen and antibody to the human immunodeficiency virus (HIV). Vaginal infections were detected in a total of 50% (104) of women, endocervical infections alone in 9% (18) and concurrent vagino-endocervical infections in 20% (41). Bacterial vaginosis (BV) was diagnosed in 35% (73) and its prevalence amongst different clinic populations ranged from 25% to 41% with no significant differences between any groups. Trichomoniasis was detected significantly more often in women attending the STD and antenatal clinics. Endocervical infections were found mainly in women attending the STD clinic, though the prevalence of Chlamydia trachomatis amongst the other clinic attenders ranged from 13% to 20%. Micro-organisms such as Gardnerella vaginalis, Mycoplasma hominis, anaerobes and curved Gram-negative rods were found in significantly higher number of women with BV. This study confirms the high prevalence of vaginal, endocervical and mixed vagino-endocervical infections in women from developing communities. The high prevalence of bacterial vaginosis as a single infection and its association with other recognised sexually transmitted pathogens in a large proportion of women, is of significance since such infections not only predispose to ascending upper genital tract infections but are also associated with complications in pregnancy such as premature rupture of membranes, preterm labour and endometritis.

Granuloma inguinale in association with pregnancy and HIV infection.

OBJECTIVES: A retrospective study to confirm the clinical impression of an increasing prevalence of granuloma inguinale (GI) in women, and to evaluate its association with pregnancy and HIV infection. METHODS: Clinical records of all patients with a definitive diagnosis of GI attending the gynecology and antenatal clinics at King Edward VIII Hospital, Durban, South Africa, over a period of 36 months (January 1991-December 1993). RESULTS: A total of 123 women were diagnosed with GI. The diagnosis was made by tissue smear alone in 21% (n = 26), histology 43% (n = 53) and by a combination of smear and histology in the rest. Forty-two percent (n = 52) were pregnant. The only difference between pregnant and non-pregnant women were the presence of rectal and pelvic lesions in the latter. Sixty-nine percent (n = 36) delivered vaginally while the remaining (n = 16) were delivered by cesarean section. The indications for cesarean section were obstetric except for a patient in labor with extensive untreated vulval granuloma. In the majority (85%) GI had no influence on pregnancy outcome. There was no evidence of congenital GI in the neonates. Twenty-seven percent (30/113) had positive syphilis serology and 16% (18/110) had antibody to HIV. There were no differences in the clinical features and outcome of HIV positive and negative women. CONCLUSION: This study shows that GI is increasing in pregnancy in Durban, South Africa. Despite the concern that pregnancy promotes dissemination of GI, such an effect could not be established as the clinical response to treatment and outcome were similar in both pregnant and non-pregnant women. Infection with HIV also did not alter the clinical presentation and outcome of the disease in the patients studied.

Prominence of penicillinase-producing strains of Neisseria gonorrhoeae in gonococcal arthritis--experience in Durban, South Africa.

Penicillin resistance amongst gonococcal strains causing disseminated gonococcal infection (DGI) has been infrequently reported worldwide. The clinical records of 34 patients with gonococcal arthritis seen over a 53-month period were reviewed. The study population consisted of 32 blacks and two Indians with a mean age of 23.5 yr (range 14-46 yr) and a female to male ratio of 2.8:1. The diagnosis of gonococcal arthritis was made on the basis of isolation of Neisseria gonorrhoeae from the SF alone in 20 patients, SF and genital site in nine genital site alone in two and genital site and synovial tissue in one patient and synovial tissue alone in two patients. Eighteen of the 32 (56%) synovial isolates were penicillinase-producing strains of N. gonorrhoeae (PPNG). Monoarthritis was the commonest mode of presentation and seen in 73% of patients. The joints most frequently involved were the wrist (44%), knee (41%), ankle (15%) and shoulder (12%). None of the patients had cutaneous lesions. The occurrence of DGI is usually associated with protein 1-A serotype and arginine, hypoxanthine and uracil requiring auxotype, but all isolates available for auxotyping in this study were prototrophic. This study shows a very high prevalence of PPNG strains causing DGI, an observation which has important therapeutic implications.

Antimicrobial susceptibilities of Gardnerella vaginalis.

The in vitro susceptibilities of 93 clinical isolates of Gardnerella vaginalis to 25 antimicrobial agents were determined by the agar dilution method. All isolates were susceptible to penicillin, ampicillin, erythromycin, clindamycin, chloramphenicol, and trimethoprim. Activity was poor for vancomycin, LY146032, the cephalosporins, ciprofloxacin, and imipenem. Some resistance was observed with tetracycline and minocycline. The MICs of metronidazole paralleled those of tinidazole, with the hydroxymetabolite of metronidazole being the most active. One strain was resistant to all three agents. Marked resistance to aztreonam, amikacin, and sulfamethoxazole was observed.

The association between sexually transmitted pathogens and cervical intra-epithelial neoplasia in a developing community.

OBJECTIVE--To determine the association of sexually transmitted pathogens in women with cervical intra-epithelial neoplasia (CIN). SETTING--An urban tertiary referral hospital serving a large indigent developing community. PARTICIPANTS--48 women attending a colposcopy clinic and 49 women attending a family planning clinic. METHODS--Vaginal, endocervical, rectal swab specimens and sera were collected for the detection of sexually transmitted pathogens. Cervical cytology was performed on all patients. Women attending the colposcopy clinic had confirmation of abnormal cervical cytology by colposcopic directed biopsy. RESULTS--The mean age of women with CIN (33 years) was significantly greater than that of the women without CIN (28 years) and that of the family planning group (26 years). There was a high prevalence of sexually transmitted pathogens in all women. A significantly higher prevalence of bacterial vaginosis was found in women with CIN compared to those without (50% vs 20%; p = 0.034). The human papilloma virus (HPV) was detected in 46% of women with CIN and 65% of those without CIN. Chlamydia trachomatis (21%) and Trichomonas vaginalis (39%) were detected frequently in women with CIN. C. trachomatis (14%-21%) was detected more frequently than Neisseria gonorrhoeae (3-5%) in all asymptomatic women studied. CONCLUSION--This study demonstrates a high prevalence of sexually transmitted pathogens in women with and without CIN as well as family planning clinic attenders. Bacterial vaginosis was a significant finding in women with CIN. C. trachomatis was detected in a high proportion of all women studied and found more commonly than N. gonorrhoeae. We therefore recommend that all women attending gynaecological services in a developing community be investigated and treated for sexually transmitted diseases.

Sexually transmitted pathogens and colposcopic findings in asymptomatic HIV-1 antibody-positive blood donors.

Sixteen asymptomatic human immunodeficiency virus (HIV-1) antibody-positive female blood donors were examined for sexually transmitted diseases by lower genital tract microbiological tests and colposcopy. Two donors had generalised lymphadenopathy, and in 13 (81.2%) human papillomavirus was detected on histological examination. In 5 (31.2%) Neisseria gonorrhoeae was cultured. Sexually transmitted pathogens were found in all but 3 subjects and multiple agents were detected in 9. The high prevalence of sexually transmitted diseases coupled with the generally poor response to counselling has a frightening potential for spread of HIV locally.

Sexually transmitted pathogens in acute pelvic inflammatory disease.

The prevalence of sexually transmitted pathogens in two groups of women was studied: 50 women with clinical diagnoses of acute pelvic inflammatory disease (PID) and 50 asymptomatic women attending a family planning clinic (FPC). Genital specimens, collected by non-invasive procedures, were examined. Endocervical Neisseria gonorrhoeae was present in 62% of the PID group and 10% of the FPC group (P less than 0.0001). One-third of N. gonorrhoeae isolates were penicillinase-producing strains. Chlamydia trachomatis was isolated from the endocervix in 30% of the PID group and 26% of the FPC group (P = 0.8240 NS). Mycoplasma hominis was more prevalent in the vaginas and endocervices of the PID group than the FPC group (84% and 72% v. 50% and 42%; P = 0.0006 and 0.0047 respectively). Trichomonas vaginalis was present in 56% of the PID group and 20% of the FPC group (P = 0.0004). Syphilis serology was positive in 34% of the PID group and 10% of the FPC group (P = 0.0026). In the PID group of patients, 8% were positive for HBsAg. Antibody to the human immunodeficiency virus was not detected in any of the 100 women. The high prevalence of recognised sexually transmitted pathogens underlines the need for appropriate antimicrobial agent(s) active against N. gonorrhoeae, C. trachomatis and M. hominis in patients with PID. In view of the high prevalence of penicillinase-producing strains of N. gonorrhoeae, routine use of an antibiotic active against such strains is desirable.

Sexually transmitted pathogens in pregnant women in a rural South African community.

One hundred and ninety three consecutive pregnant women attending peripheral antenatal clinics attached to Ngwelezana Hospital, Empangeni, Kwa-Zulu, were examined for evidence of sexually transmitted pathogens. The following incidences were found: Trichomonas vaginalis 49.2% (95), Candida spp 38.3% (74), Chlamydia trachomatis 11.4% (22), Gardnerella vaginalis 6.2% (12), Neisseria gonorrhoeae 5.7% (11), positive syphilis serology results 11.9% (23), hepatitis B surface antigen 4.1% (eight). No woman had antibody to human immunodeficiency virus (HIV). Dyskaryotic smears were found in 20 (10.4%). Human papillomavirus (HPV) was detected cytologically in 11 (5.7%). The range of sexually transmitted pathogens found in this rural community was similar to that found in urban groups studied in South Africa.

Antibiotic-resistant pneumococci in hospitalized children.

A search for nasopharyngeal carriers of Streptococcus pneumoniae was conducted in 573 children hospitalized in Durban, South Africa. Study subjects were divided into two groups, comprising 305 new admissions and 268 patients who had been hospitalized for more than 24 h. Of the 573 children 178 (31%) yielded pneumococci on nasopharyngeal culture; 99 (32%) and 79 (29%) children in the new admission and in-patient categories respectively. Twenty-one (12%) pneumococci were resistant to penicillin, including 11 strains that were resistant to more than one antibiotic. Resistant pneumococci belonged exclusively to serotypes 6 and 19 (Danish nomenclature), which were also the commonest serotypes among penicillin-sensitive strains. Factors that correlated with carriage of penicillin-resistant pneumococci were hospitalization for more than 24 h, young age and recent exposure to beta-lactam antibiotics.