Indian J Sex Transm Dis Indian J Sex Transm Dis
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  Table of Contents  
LETTER TO EDITOR
Year : 2012  |  Volume : 33  |  Issue : 1  |  Page : 68-69
 

Authors' reply


1 Department of Microbiology, UCMS and GTB Hospital, Dilshad Garden, Delhi - 110 095, India
2 Dermatology and STD, UCMS and GTB Hospital, Dilshad Garden, Delhi - 110 095, India

Date of Web Publication14-Mar-2012

Correspondence Address:
Shilpee Choudhry
Department of Microbiology, UCMS and GTB Hospital, Dilshad Garden, Delhi - 110 095
India
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PMID: 22529465

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How to cite this article:
Choudhry S, Ramachandran V G, Das S, Bhattacharya S N, Mogha NS. Authors' reply. Indian J Sex Transm Dis 2012;33:68-9

How to cite this URL:
Choudhry S, Ramachandran V G, Das S, Bhattacharya S N, Mogha NS. Authors' reply. Indian J Sex Transm Dis [serial online] 2012 [cited 2014 Sep 15];33:68-9. Available from: http://www.ijstd.org/text.asp?2012/33/1/68/93838


Sir,

We are extremely grateful for receiving the valuable comments from Dr. Bhushan Kumar in reference to the article "Pattern of sexually transmitted infections and performance of syndromic management against etiological diagnosis in patients attending STI clinic of a tertiary care hospital" published in Indian Journal of Sexually Transmitted Diseases and AIDS, Year 2010, Volume 31, Issue 2 (p. 104-108). We have made an earnest attempt to answer all possible queries listed.


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  • The diagnosis of herpes simplex infection was made on the basis of smear with giant cells, positive serology for HSV-2/HSV-1 or on clinical examination or all of them together or in some other combinations?

   Reply Top


  • The diagnosis of herpes simplex infection was made when any of these were seen

    1. Smear made from genital ulcer showing multi-nucleated giant cells.
    2. Patient's serum positive for IgM HSV-1/HSV-2.

   Comment Top


  • VDRL test is a nontreponemal test and does not indicate the presence of T. pallidum in a given patient. T. pallidum has to be demonstrated only by dark ground illumination, immunofluorescence, or staining procedure in a smear or biopsy specimen - so the translation of VDRL positivity to presence of T. pallidum is not correct. Same is true for TPHA test supposed to reflect presence of T. pallidum. Both tests can be positive due to past infection and may not relate to the present ulcer.

   Reply Top


  • VDRL test is indeed nontreponemal test/nonspecific test. Hence, all the patients who tested positive for VDRL were confirmed by specific test TPHA.
  • If there is four-fold rise of VDRL titre, it is suggestive of acute infection. In our study, it was further confirmed by specific treponemal test, i.e., TPHA.
  • Nontreponemal tests used for screening have the advantage of being widely available, inexpensive, convenient to perform on large numbers of specimens, and necessary for determining the efficacy of treatment (two-fold decrease in titre in successful treatment and becomes negative in treated patients).
  • VDRL test becomes negative after successful treatment, while TPHA can remain positive. Hence VDRL was used as screening test which was further confirmed by TPHA.
  • Dark ground illumination can diagnose treponemal infection most quickly and effectively by the demonstration of motile treponemes in wet preparation of serous exudates. But there are certain limitations:-

    1. These tests require examination of potentially infectious specimen that may also contain HIV (unfixed material must be examined within 10-30 minutes to maintain treponemal motility).
    2. T. pallidum must be carefully distinguished from other treponemes that may occur in genital ulcer. Accurate interpretation of dark ground microscopy demands much experience.
    3. If the initial test is negative, the procedure should be repeated daily for at least 3 days; antibiotic should be withheld during this period.
    4. Organisms are not easily found in skin lesions of secondary syphilis except those in moist skin areas.
    5. A negative dark-field finding does not exclude the diagnosis of syphilis. Too few organisms may be present to be observed, because the lesion may be in the healing stage, or the spirochete may have been altered by systemic or topical treatment.
    6. The sample for dark-field microscopy may be reported as unsatisfactory as a result of the presence of too many blood cells, air bubbles, or tissue fragments for an accurate reading.
  • Immunofluorescent staining

    1. The direct fluorescent-antibody staining for T. pallidum (DFA-Tp) test whereby a smear of exudates is made on a slide, fixed in acetone overcome the problem of examining potentially infectious material but do not solve the problem of specificity.
    2. A negative test result does not exclude the diagnosis of syphilis since the ability to demonstrate pathogenic Treponema spp. can be affected by the condition of the lesion or sample, plus various technical factors.

   Comment Top


  • To attach significance to the VDRL/TPHA positivity in a particular, titre is important which is not given in the text. So the basic question - how was the ulcer diagnosed to be syphilitic: On the basis of appearance or the positivity of either serological test or a combination of all?

   Reply Top


  • As mentioned above either the four fold rise in VDRL titre or titre >8 is considered as serologically positive and having acute infection. Such samples were further subjected to TPHA for confirmation.
  • All patients included in the study were screened for syphilis by VDRL and confirmed by TPHA irrespective of their sign and symptoms.
  • Those who presented with genital ulcer and serologically positive for syphilis were diagnosed as primary syphilis.
  • Those patients who presented with generalized maculopapular rash and not genital ulcer, and were serologically positive for syphilis, diagnosed as secondary syphilis.

   Comment Top


  • [Table 1] gives total number of patients with genital ulcers to be (61 + 30 = 91) - but in [Table 2] the number of patients with HSV-2 (37 + 49 = 86) and with T. pallidum is (45 + 26 = 71), so the total is 157 - where is the catch? But to me it means (even if we exclude patients with more than one infection) that patients with positive laboratory reports - even without ulcers have been included in the category of GUD. Given results also prove my contention. Genital herpes (86/300), syphilis (71/300), total ulcers in only 91, obviously so many cannot be with mixed infection ulcers so there is an overlap in the laboratory positives.

   Reply Top


  • [Table 1] showed incidence of syndrome/symptoms presented by patients to STI clinic. As shown, 91 patients presented with genital ulcer syndrome and three patients presented with genital ulcer as well as genital discharge syndrome.
  • [Table 2] showed incidence of sexually transmitted pathogens as detected by laboratory tests. Here, HSV-2 was detected in 86 patients while T. pallidum in 71 patients. The total (157) is much higher than the patients presented with GUS. This is because

    1. There were 17 patients (especially females) who were serologically positive for HSV-2 but presented with genital discharge and not genital ulcer. [Table 3].
    2. There were 30 patients who were serologically positive for T. pallidum but presented with generalized maculo-papular rash and not GUS. They were diagnosed as secondary syphilis and not primary syphilis.
    3. Sixteen patients had mixed infections.

   Comment Top


  • [Table 3] gives the number of patients given syndromic treatment to be (60 + 15) but originally there were 91 patients with genital ulcers?

   Reply Top


  • [Table 3] compared the syndromic management vs. laboratory diagnosis.
  • It showed that in 69 patients, HSV-2 was the pathogen causing GUS, but by syndromic management 60 patients were managed for HSV-2 infection.
  • It also showed that in 14 patients, T. pallidum was the pathogen causing GUS but by syndromic management treatment was given in 15 patients.
  • In 16 patients with GUS, the syndromic management was given for LGV or chancroid but laboratory diagnosis could not be established. Hence, the statistical values regarding these diseases could not be calculated.





 

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