Multiple sexually transmitted infections as a presenting feature of human immunodeficiency virus/AIDS.

A 45-year-old married male presented with nonhealing, painless ulcers with purulent discharge over genitals for 3 months. He had molluscum contagiosum over genitalia and forehead. A tissue smear suggested a diagnosis of donovanosis. Biopsy suggested diagnosis of molluscum contagiosum and serology was positive for human immunodeficiency virus 1 and herpes simplex 2. The patient was started on acyclovir and doxycycline. Antiretroviral therapy was initiated. The patient responded slowly over a period of 8 weeks. Immunocompromised patients having nonhealing genital ulcers must be subjected to tissue smear to pick up the diagnosis of granuloma inguinale.

Oral Mucosal Lesions - A Study of 369 Cases.

Background: Diagnosing and treating oral cavity lesions is a challenging task for most of the clinicians due to similar symptoms and clinical appearances. Frequently, histopathology and immunohistochemistry aid in making the diagnosis. Objectives: The objectives were to describe the clinical features, and histopathological features and systemic association in patients with oral mucosal lesions (OML). Materials and Methods: A cross-sectional descriptive study was undertaken at a tertiary care centre in patients with OML. A total of 369 cases with OML were included in the study. Results: Males constituted 61.78% of the cases. History of habits such as tobacco, gutka chewing, smoking, and alcohol was given by 32.25%, 29.81%, 26.56%, and 11.38% of cases, respectively. Common symptoms were soreness, burning sensation, oral pain and ulcers. Both oral and cutaneous involvement was seen in 17.89% of cases. Oral lichen planus (oral LP) constituted largest group of patients (21.96%) wherein reticulate type was the most frequent type and buccal mucosa was the commonest site. Oral carcinomas constituted 20.33% of cases followed by infective etiology (11.92%), vesiculobullous group of diseases (10.30%), aphthous stomatitis (8.94%), premalignant lesions (7.05%) such as leukoplakia (3.80%) and submucous fibrosis (2.44%). Histopathology was done in 209 cases. Clinico-histopathological correlation was seen in oral LP (90.27%), oral pemphigus (82.35%), and malignancies (98.66%). Conclusion: Oral LP formed the largest group of cases followed by Oral squamous cell carcinoma (SCC). Several rare conditions, such as Melkersson-Rosenthal syndrome and blue rubber bleb nevus syndrome were also a part of the study. Thorough clinical and histopathological examination in this diverse group of diseases clinches the diagnosis.

Male circumcision and Sexually transmitted Infections - An update.

Role of male circumcision (MC) as a tool to prevent sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) was assessed. An attempt was made to search articles related to association between MC and STIs/HIV. A thorough search was carried out to find out quality articles published in indexed specialty journals. Centers for Disease Control and Prevention and World Health Organization (WHO) sites were also referred. Warm and moist environment of area under foreskin facilitates some pathogens to persist and replicate. Further, the thinness of foreskin predisposes it to minor trauma and abrasions that facilitate the entry of pathogens. MC reduces HIV infection risk by 50%-60% over time and reduces the risk of men acquiring herpes simplex virus-2 and human papillomavirus (HPV) that can cause penile and other anogenital cancers, by 30%. There is no significant reduction in risk of acquiring syphilis, but reduced risk of acquisition of Haemophilus ducreyi is reported. MC is reported to be beneficial in conditions such as traumatic injury, Balanitis Xerotica Obliterans, refractory balanoposthitis, and chronic, recurrent urinary tract infections. MC also reduces the chances of penile carcinoma by facilitating improved penile hygiene, lowering HPV/HIV transmission rates, and reducing chronic inflammatory conditions such as phimosis and balanitis. MC has been recommended by the WHO and UNAIDS in 2007 as an additional HIV prevention intervention in settings of high HIV prevalence. MC is an important adjunct to safe sex education, condom use, and vaccination (HPV) in reducing the global burden of HIV/STIs-related morbidity and mortality.

A Comparative Study of Intralesional Vitamin D3, Measles Mumps Rubella Vaccine, and Tuberculin Purified Protein Derivative in the Treatment of Recalcitrant Warts: An Approach to Solve a Therapeutic Conundrum.

BACKGROUND: Human papilloma virus infects and proliferates in skin or mucosal cells to cause warts. Most of the current therapeutic modalities are ablative, act only on treated lesions, and lack a well-defined treatment endpoint. These being blind procedures, recurrence rates are high, owing to the remnant virus. Intralesional immunotherapy plays a significant role, as it potentially acts on treated and distant lesions. OBJECTIVES: We sought to study and compare the efficacy, safety profile, and recurrence rates of intralesional immunotherapy modalities (vitamin D3; measles, mumps, and rubella [MMR] vaccine; and tuberculin purified protein derivative [PPD]) in treating viral warts. METHODS: An open-label interventional study of 60 cases of cutaneous viral warts was performed in a tertiary care center attached to a medical college after obtaining approval from the institutional ethics committee. Each patient was consecutively assigned into Group 1 (vitamin D3: 0.2mL of 15mg/mL), Group 2 (MMR: 0.5mL), or Group 3 (tuberculin PPD: 0.1mL of 10TU). One or two warts were injected per session every two weeks. Response was assessed. Adverse effects were noted. Cases were followed up monthly for three months. RESULTS: The MMR group had the maximum patients with complete response (15 of 20, 75%) followed by tuberculin PPD group (13 of 20, 65%) and vitamin D3 group (12 of 20, 60%). No major adverse drug reactions were reported in any of the groups. CONCLUSION: Immunotherapy offers a safe and promising approach in patients with extensive cutaneous viral warts in difficult to treat sites.

Hypertrophic lichen planus of the vulva - A missed diagnosis.

Lichen planus (LP) is an inflammatory dermatosis which can affect the skin, nails, and all mucous membranes, including the genitalia. Lichen planus on vulvar keratinized skin can manifest with diverse clinical features, probably due to higher temperature, PH, humidity, and bacterial flora which may modify typical cutaneous features. While lichen planus (LP) may affect the vulva in isolation, it may also be part of generalized outbreak in up to 20% cases. Herein, a case of a 53 year-old female who presented with a severely pruritic plaque over labia majora Since 6 -7 months, with no response to potent topical corticosteroids is reported. Provisional diagnosis of lichen simplex chronicus was considered however, histopathology was suggestive of hypertrophic lichen planus.

Behcet disease - A nonvenereal cause of genital ulceration.

Behcet's disease (BD) is a chronic, relapsing, inflammatory vascular disease with no diagnostic or pathognomonic test. Here, we present a case of 26-year-old male with a complaint of recurrent oral, genital, and cutaneous lesions. The diagnosis of BD was confirmed on the basis of revised the International Criteria for BD. The case was treated satisfactorily with systemic corticosteroid in the tapering dose and oral Dapsone.

Genital lichen planus: An underrecognized entity.

Genital lichen planus (LP) is an underrecogonized dermatosis. The appearance is often unlike classical LP elsewhere, and hence, the condition goes undiagnosed in many. Vulvo-vaginal LP in particular, can be a distressing condition often leading to scarring and a poor quality of life. Treatment for most of the genital LP variants is similar to managing LP elsewhere; however, the erosive variant requires special attention as treatment outcomes are often disappointing and the disease runs a protracted course. Potential for development of malignancy also exists, as in oral LP, and hence close follow up is essential.

Verrucous lesions over external genitalia as a presenting feature of pemphigus vegetans.

Pemhigus vegetans is a rare variant of pemphigus vulgaris which primarily occurs in the flexures of the body. We report a case of pemphigus vegetans in an 85-year-old female presenting with hypertrophic verrucous lesions over external genitalia and perianal region. There was no history of preceding oral lesions. The diagnosis of pemphigus vegetans was considered on the clinical ground and confirmed by histopathological examination.

Epidemiological, clinical, and immunological profile of cases at the time of HIV testing (a clinic-based observational cross-sectional study).

INTRODUCTION: With the availability of free antiretroviral therapy (ART), HIV/AIDS has become a chronic manageable disease, but its transmission still continues. Early testing, though desirable, is still a far-fetched goal. MATERIALS AND METHODS: Forty-six newly detected HIV cases attending skin and sexually transmitted disease (STD) outpatient department (OPD) were studied. Careful inquiry was made to know the reason for HIV testing, marital status, concordance rate in married couples, and CD4 count at the time of presentation. RESULTS: Of the 46 cases, 27 (59%) cases were in the age range of 20-40 years with 41% females and 59% males. Forty-one cases were married and cohabiting, out of which 19 were seroconcordant. Condom was used by 5/19 cases in seroconcordant group and 3/22 cases in serodiscordant group. Fourteen (30.4%) cases were tested for an epidemiologic reason (the most common being spouse positivity and antenatal care testing). Of the remaining 32 cases, the reason for testing was mucocutaneous manifestations in 16 cases, STD in 10 cases, and systemic illnesses (fever of unknown origin and weight loss) in 6 cases. Mean CD4 count was 336/cumm, with 17 cases having CD4 count <250/cumm. CONCLUSION: Except one, all cases were tested either because they were symptomatic or were referred by health-care provider for epidemiologic reasons. The presence of mucocutaneous manifestations including STD and systemic illnesses as the reason for testing as well as low CD4 count at the time of testing suggest less and late testing. Low condom use and high STD rate in married couple imply continued intramarital transmission. Although HIV seropositivity offers an entry point into continuum of comprehensive care package which includes free ART, it appears that HIV testing is still less and late.

Association of interleukin 1 receptor antagonist intron 2 variable number of tandem repeats polymorphism with vitiligo susceptibility in Gujarat population.

BACKGROUND: Vitiligo is a multifactorial, polygenic, autoimmune skin disorder caused by selective destruction of melanocytes. Interleukin 1 receptor antagonist intron 2 polymorphism was found to be associated with various autoimmune disorders. AIMS: We aimed to investigate the association of interleukin 1 receptor antagonist intron 2 variable number of tandem repeats polymorphism (rs2234663) with vitiligo to assess interleukin 1 receptor antagonist transcript levels and to perform possible genotype-phenotype correlation. METHODS: Three hundred and seven vitiligo patients and 316 controls were enrolled in the study, genotyping of interleukin 1 receptor antagonist rs2234663 was performed by polymerase chain reaction, and relative gene expression of interleukin 1 receptor antagonist was carried out in peripheral blood mononuclear cells from patients (n = 36) and controls (n = 36) by real-time-PCR. RESULTS: A significant difference was observed in the frequency of interleukin 1 receptor antagonist *A (1/2) genotype among patients with active and stable vitiligo (P = 0.0172). Interleukin 1 receptor antagonist*A (2/2) genotype and allele frequencies were significantly different between SV patients and controls (P = 0.0246 and P = 0.0046, respectively). Significant difference was also observed for interleukin 1 receptor antagonist*A2 (allele) in active and stable vitiligo patients (P = 0.0060). However, other comparisons did not show any significant difference in genotype and allele frequencies. Moreover, interleukin 1 receptor antagonist*A (3/2) genotype was observed only in patients whereas interleukin 1 receptor antagonist*A (5/2) was observed only in controls. Gene expression analysis showed no significant difference in interleukin 1 receptor antagonist transcript levels in patients compared to controls (P = 0.5962). Interestingly, genotype-phenotype correlation analysis revealed that individuals with IL1RN*A (2/2) exhibited higher interleukin 1 receptor antagonist expression compared to other major genotypes interleukin 1 receptor antagonist*A (1/2) (P = 0.01) and interleukin 1 receptor antagonist*A (1/1) (P = 0.03). LIMITATIONS: More case-control studies on interleukin 1 receptor antagonist rs2234663 polymorphism and gene expression from different ethnic populations are required to explore the impact of interleukin 1 receptor antagonist in vitiligo susceptibility. CONCLUSION: Interleukin 1 receptor antagonist*A2 might be a risk factor for progressive vitiligo.

Association of elevated homocysteine levels and Methylenetetrahydrofolate reductase (MTHFR) 1298 A > C polymorphism with Vitiligo susceptibility in Gujarat.

BACKGROUND: Several studies have reported hyperhomocysteinemia in vitiligo patients, suggesting the potential role of elevated homocysteine levels in precipitating vitiligo. OBJECTIVES: We aimed to estimate homocysteine and vitamin B12 levels, and to investigate the role of MTHFR 677 C > T and 1298 A > C polymorphisms in vitiligo susceptibility in Gujarat population. METHODS: Homocysteine and vitamin B12 levels were estimated in plasma of 55 vitiligo patients and 60 controls by Electrochemiluminescence immunoassay (ECLIA). Polymerase chain reaction- restriction fragment length polymorphism (PCR-RFLP) and amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) techniques were used to genotype MTHFR 677 C > T and 1298 A > C polymorphisms in 520 vitiligo patients and 558 controls. RESULTS: Our results showed significantly elevated homocysteine levels (p = 0.0003) as well as significant decrease in vitamin B12 levels (p = 0.0102) in vitiligo patients, as compared to controls. No significant difference in genotype and allele frequencies of MTHFR 677 C > T polymorphism was observed among patients and controls, however, the frequency of 'CC' genotype of MTHFR 1298 A > Cpolymorphism was significantly increased in patients as compared to controls (p = 0.0151). Analysis based on the type of vitiligo revealed a significant increase in 'C' allele of MTHFR 1298 A > C polymorphism in patients with generalized (p = 0.003) and active (p = 0.007) vitiligo as compared to controls. Both the polymorphisms of MTHFR were in low linkage disequilibrium (LD) and susceptible 'TC' haplotype was more frequently observed (p = 0.008) in vitiligo patients. Interestingly, elevated homocysteine levels were also positively correlated with MTHFR 1298 A > C polymorphism in vitiligo patients. Structure based in silico prediction revealed structural perturbations in MTHFR protein due to Ala222Val and Glu429Ala amino acid substitution. CONCLUSIONS: The present findings suggest that MTHFR 1298 A > C polymorphism and, altered homocysteine and vitamin B12 levels might play a vital role in the precipitation of vitiligo.

Pre- and post-sexual exposure prophylaxis of HIV: An update.

Pitfalls in current HIV prevention strategies include late HIV testing, vulnerability among youth and females; lack of emphasis on treatment, low acceptance of circumcision, and nonavailability of protective vaccines. Continuing high-risk sexual behavior, forceful sex, coercive and nonconsensual sex, rape, and unprotected sexual activities make women the most vulnerable to acquisition of sexually transmitted infection/HIV and necessitates a more radical approach of prevention in high-risk individuals who do not have HIV. Preexposure prophylaxis is defined as the administration of antiretroviral drugs to an uninfected person before potential HIV exposure to reduce the risk of infection and continued during risk. The rationale of this approach is to administer preventive dose of drug(s) before exposure to HIV so the moment virus enters the body, HIV replication is inhibited and HIV is not able to establish permanent infection. Postexposure prophylaxis (PEP) following potential sexual exposure is an important form of nonoccupational PEP which is an emergency intervention to abort HIV acquisition arising from exposure to HIV-infected blood or potentially infectious bodily fluids following sexual exposure.