Indian J Sex Transm Dis Indian J Sex Transm Dis
Official Publication of the Indian Association for the Study of Sexually Transmitted Diseases
Indian J Sex Transm Dis
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   Table of Contents - Current issue
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July-December 2018
Volume 39 | Issue 2
Page Nos. 79-142

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ORIGINAL ARTICLES  

Prevalence of reproductive tract infection symptoms and treatment-seeking behavior among women: A community-based study p. 79
Deepak Sharma, Naveen Krishan Goel, Meenal Madhukar Thakare
DOI:10.4103/ijstd.IJSTD_97_16  
Introduction: Reproductive tract infection (RTI) is a public health problem affecting women's health, especially in developing country like India. The associated stigma with this reproductive morbidity is often a deterrent in seeking health care. Aims and Objectives: The aim was to study the prevalence of RTI symptoms and treatment-seeking behavior among married women of reproductive age group. Methodology: It was a community-based cross-sectional study. A total of 276 women were interviewed in the community by trained medical social workers. RTI symptoms were defined according to the syndromic case management guideline developed by the World Health Organization. Statistical analysis was performed using the Epi Info software for Windows (CDC Atlanta). Results: About one-third (98/276; 35.5%) of women reported symptoms suggestive of RTI. The most commonly experienced symptoms were foul-smelling vaginal discharge (68/98; 69.4%) followed by lower abdominal pain not associated with menstruation (51/98; 52.0%). Around half of those having RTI symptoms sought treatment for their problem (57.1%). Conclusion: Health-care professionals in India should focus on strengthening women knowledge of RTI symptoms and encouraging them to seek health care.
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A safety analysis of different drug regimens used in human immunodeficiency virus-positive patients p. 84
Nidhi S Chauhan, Samidh P Shah, Mira K Desai, Asha Shah
DOI:10.4103/ijstd.IJSTD_116_17  
Background: Long-term toxicity of antiretroviral agents is rarely addressed in initial clinical trials. Effective pharmacovigilance is essential for long-term safety of antiretroviral therapy (ART). Materials and Methods: All adverse drug reactions (ADRs) reported due to ART between January 2014 and September 2016 were analyzed as per different drug regimens used. ADRs were also analyzed for system organ classification, seriousness, time relationship of ADRs with drug therapy, causality (as per the World Health Organization-Uppsala Monitoring Centre scale and Naranjo algorithm), and severity (Hartwig and Siegel scale). Comparison was done between (tenofovir + lamivudine + efavirenz [TLE]) and (zidovudine + lamivudine + nevirapine [ZLN]) regimens. Results: During a study period, 2983 patients were on ART. The most common drug regimen prescribed was TLE (1805) followed by ZLN (326). A total of 325 (10.89%) ADRs were reported in which 150 ADRs were reported in TLE regimens (46%) and 130 in ZLN regimens (40%). The mean age of patients with ADRs was 40 ± 12.56 years and men (58.1%) were more affected than women (41.8%). The most common system organ involved in ZLN regimen was blood (50, 39%) and skin (35, 27%), while it was neurological (63, 42%) and renal disorder (27, 18%) in TLE regimen. Most of ADRs were observed after 1 month of therapy (79.5%) and showed possible causal relation with drug therapy (78.15%). Majority of ADRs were mild in nature (86.7%). The serious ADRs were reported more in ZLN (18%) regimen as compared to TLE (9%) (P < 0.05). Conclusion: Both ART regimens are associated with ADRs affecting all body system; however, the frequency and severity of ADR are high with ZLN regimen.
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Prevalence of nonadherence and its associated factors affecting on HIV adults follow-up at antiretroviral therapy clinic in Batu Hospital, Eastern Ethiopia p. 91
Fitala Jima, Ramanjireddy Tatiparthi
DOI:10.4103/ijstd.IJSTD_37_17  
Background: HIV/acquired immunodeficiency syndrome is a major public health problem and a development predicament that affects all sectors, drastically affecting the health, economic, and reducing social life expectancy, deepening poverty, and contributing to and exacerbating food shortages. Strict adherence to antiretroviral therapy (ART) regimen is essential to obtain the desired benefit and to avoid the emergence of drug resistance and clinical failure; therefore, this study is aimed to assess the antiretroviral (ARV) adherence among the HIV patients and suggesting them by possible ways for improving the adherence. Methods: A cross-sectional study was conducted in Batu Hospital, Batu town. The sample size was found to be 160, and systemic random sampling was used to collect data by providing a pretested structured questionnaire. The qualitative data were analyzed to identify the significance of the relationship between the dependent and independent variables. Results: A total of 160 patients was agreed to involve in our survey, 85.6% of patients were adherent by self-report. The main reason of nonadherence cited by the patients were; being away from home for some social reasons (33.4%), being too busy with other things (25.0%), simply forgot to take their ART (25.0%), developed toxicity or side effects (8.3%), having problems for fear of stigma and disclosure (8.3%), and (7.5%) of participants also shortage of ARV medications at hand because of some public holidays or weekends that coincide with date of appointments. Conclusion and Recommendations: The self-report adherence rate was higher than that seen in developing countries. Programs and clinical efforts to improve medication taking in the study setups should strive to provide the regular follow-up for patients, increase patients' awareness of the side effects of ARVs and possible remedies, integrate medications better into patients' daily routines, improve patients' confidence, trust, and satisfaction with their caregivers, and teach patients to use memory aids.
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Study of prevalence of dermatophytes among human immunodeficiency virus/AIDS patients in Shadan Institute of Medical Sciences and Teaching Hospital and Research Centre, Hyderabad, Telangana, India p. 98
Syed Yousuf Ali, Sukumar Reddy Gajjala, Akhilesh Raj
DOI:10.4103/ijstd.IJSTD_103_16  
Introduction: The objective of the study was to evaluate the prevalence of dermatophytoses in human immunodeficiency virus (HIV) patients as well as to analyze the influence of CD4+ T-cell level in the Dermatology and STD Outpatient Department of Shadan Institute of Medical Sciences Teaching Hospital and Research Centre, Himayat sagar road, Hyderabad (Telangana state). The patients were tested for dermatophytic infections, as well as for the CD4+ T-cell counts. A total of 120 HIV-seropositive patients were included in this study, among which 38 were diagnosed of dermatophytosis. A majority of patients were in the 21–30 years' age group. Tinea cruris was seen in majority of the cases, with Trichophyton rubrum being the most common culprit. Background: Cutaneous fungal infections have been reported worldwide as being one of the most common human infectious diseases in clinical practice. Dermatophytoses in individuals with HIV infection seem to manifest with atypical, multiple, or extensive lesions more frequently. Aims: The aim of this study was to determine the prevalence of dermatophytic infections among HIV-seropositive patients and their relation with CD4 count. Materials and Methods: This single-center prospective study was conducted in all HIV-seropositive patients (by double ELISA methods) who attended the Dermatology and STD Outpatient Department of Shadan Institute of Medical Sciences Teaching Hospital and Research Centre, Himayat sagar road, Hyderabad (Telangana state), from March 2015 to September 2016. They were screened for cutaneous fungal infections and those who tested positive were recruited for this study. Results: A total of 120 HIV-seropositive patients were included in this study, among which 38 were diagnosed of dermatophytosis. Most patients were in the 21–30 years' age group. Tinea cruris was the most common variant, and T. rubrum was the most common offending pathogen. It was also found that the CD4+ T-cell count does not influence the occurrence of dermatophytoses. Conclusion: Superficial fungal infections are a common yet significant problem in HIV infection. They are characterized by the diversity of clinical aspects; the lesions are mostly caused by T. rubrum. It is essential that optimum treatment should be administered.
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Genital molluscum contagiosum in females – therapeutic efficacy and comparative evaluation of topical 10% and 20% potassium hydroxide p. 102
Chetna Singla, Bharat Bhushan Mahajan, Tejinder Kaur, Suresh Kumar Malhotra, Nidhi Sharma
DOI:10.4103/ijstd.IJSTD_100_16  
Introduction: Molluscum contagiosum (MC) is a cutaneous viral infection caused by a poxvirus, manifested by discrete, papular, pearly lesions with central umbilication. Genital lesions are mainly transmitted sexually. Till date, several forms of medical and surgical therapies have been used with variable success. In the present study, an attempt was made to review all the female patients of genital MC attending the sexually transmitted infection (STI) clinic of the Department of Dermatology, Venereology, and Leprosy of Guru Nanak Dev Hospital, Amritsar. Aims and Objectives: In the present study, therapeutic efficacy and comparative evaluation of topical 10% and 20% of potassium hydroxide (KOH) were undertaken. Materials and Methods: A total of 30 female patients of age group 18–50 years with clinically diagnosed MC and more than ten lesions were enrolled in this study. The lesions in each patient were divided into two equal Groups A and B. Topical 10% KOH was applied over lesions of Group A and 20% over lesions of Group B with the help of 26G needle. First, two applications were done by the doctor, and subsequent applications were done twice a week at bedtime at home by the patient herself until crusting. These cases were followed up at 4th day, 1st, 2nd, 3rd, 4th, 6th, 8th, 10th, and 12th week. Results were analyzed objectively and photographically at each follow-up and at the end of the study statistically. Results: Mean duration of treatment ± standard deviation in normal patients, HIV-positive patients, patients with associated STIs, patients with associated non-STIs, and pregnant patients in Group A and Group B was 6.83 ± 2.692, 9.33 ± 1.633, 6.83 ± 2.887, 8.20 ± 3.347, and 8.75 ± 2.121 weeks and 5.2 ± 2.156, 7.33 ± 1.633, 5.25 ± 2.050, 6.20 ± 2.864, and 6.50 ± 1.414 weeks, respectively. Conclusion: Topical 20% KOH is better than 10% KOH in genital MC in females.
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Awareness of needle-stick injuries among health-care workers in a tertiary health-care center p. 107
Rituja V Sardesai, Sudarshan P Gaurkar, Vidyadhar R Sardesai, Vasudha V Sardesai
DOI:10.4103/ijstd.IJSTD_30_18  
Context: Needle-stick injuries (NSIs) pose a great occupational risk of blood-borne disease transmission in health-care workers (HCWs). Diseases of primary significance include hepatitis B, hepatitis C, and human immunodeficiency virus infection. Aims: This study aimed to check the awareness regarding the health hazards associated with NSIs and awareness regarding postexposure prophylaxis (PEP) and hepatitis B vaccination in HCWs. Settings and Design: This is a cross-sectional study conducted in a tertiary care government hospital. Subjects and Methods: A sample size of 100 HCWs, which consisted of 20 residents, 20 interns, 20 lab assistants, 20 nurses, and 20 Class IV workers, was taken. A predefined questionnaire was used and answers were documented. Statistical Analysis Used: Chi-square test was used for statistical analysis. Results: Out of the 100 HCWs enrolled in the study, 45% had a history of NSI during their career, the highest count was seen in Class IV workers i.e. 14 [70%]. Only 21% of the HCWs knew about the diseases transmitted by NSI. Only 30% of Class IV workers were aware of hepatitis B vaccination and none of them were vaccinated. Quite a good number of HCWs were aware regarding the first step to be undertaken in case of NSI. However, their knowledge regarding PEP was not up to the mark. Conclusions: NSIs were seen in all the categories of HCWs, but the awareness regarding health hazards due to NSI was inadequate. Except Class IV workers, rest of the HCWs were overall aware regarding hepatitis B vaccination. There is a need to give emphasis as regards to awareness of PEP in case of a NSI.
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Clinico-mycological analysis and antifungal resistance pattern in human immunodeficiency virus-associated candidiasis: An Indian perspective p. 111
Ravinder Kaur, Bhanu Mehra, Megh Singh Dhakad, Ritu Goyal, Preena Bhalla, Richa Dewan
DOI:10.4103/ijstd.IJSTD_89_17  
Objectives: Candidiasis is a common human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome-associated opportunistic mycoses. The present study ascertained the species spectrum of Candida strains recovered from different clinical samples from symptomatic HIV-positive individuals and determined the antifungal susceptibility profile of the isolates. Materials and Methods: A variety of specimens were collected from 234 symptomatic HIV seropositive individuals depending on their clinical manifestations and subjected to direct microscopic examination. Blood samples were inoculated in biphasic blood culture medium and all other specimens on Sabouraud dextrose agar with chloramphenicol and incubated at 35°C–37°C. Species identification of the recovered Candida isolates was attempted on the basis of germ tube production, micromorphology on corn meal agar, color and morphology on HiCrome Candida Differential agar, and carbohydrate fermentation and assimilation tests. Susceptibility testing of the isolates was performed employing the VITEK 2 system. Results: A total of 167 Candida isolates were obtained; Candida albicans (136), Candida tropicalis (13), Candida krusei (8), Candida parapsilosis (5), Candida glabrata (4), and Candida kefyr (1). Fluconazole resistance was more frequent among nonalbicans species, and significantly higher 5-fluorocytosine resistance compared to C. albicans was also observed. Eight Candida strains (six C. krusei, one C. kefyr, and one C. albicans) were multidrug resistant. Conclusion: Although C. albicans continues to be the leading etiological agent of candidiasis, the incidence of nonalbicans species among HIV-positive Indian individuals is rising. Antifungal resistance was higher among nonalbicans Candida species. Another issue of therapeutic concern is the possible emergence of multidrug-resistant Candida strains among these patients.
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Evaluation of interobserver reliability of Nugent score for diagnosis of bacterial vaginosis p. 120
Swapna Muthusamy, Jessy Varghese, Vinod Raveendran, Kavitha Ezilarasan, Joshy Maducolil Easow
DOI:10.4103/ijstd.IJSTD_98_16  
Background: Vaginal discharge is the commonly narrated compliant of the female attendees of sexually transmitted infection clinic, among which bacterial vaginosis (BV) is responsible for one-third of the visits. BV is often diagnosed clinically which warrants laboratory confirmation. Aims: The study aims to detect the reliability of the Nugent scoring system between observers for the diagnosis of BV. Materials and Methods: This is a prospective study including 177 high vaginal swabs. The gram-stained smears were examined by three independent microbiologists, and the Nugent scoring was performed. Statistical analysis was performed using IBM-SPSS version-22 statistical package for kappa value. Results: Concordant results were seen in 64.03% of smears, discordant results were given in 4.51% of smears, and partial agreement was observed in 31.63% of smears. Conclusion: Interobserver reliability is good for the Nugent score. The Nugent score is a simple and reliable method for the diagnosis of BV that can be adapted even in the resource poor settings.
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CASE REPORTS Top

Recurrent, nodular lesions over the vulva: A diagnostic challenge p. 124
Suvarna Samudrala, M Ramesh Bhat
DOI:10.4103/ijstd.IJSTD_101_16  
Angiokeratomas are benign tumors characterized by proliferation and dilatation of blood vessels in the upper dermis. They are divided into widespread and localized forms. The localized forms are further classified as angiokeratoma of Fordyce, angiokeratoma circumscriptum neviforme, circumscribed angiokeratoma, and angiokeratoma of Mibelli, of which angiokeratoma of Fordyce is the most common. A 38-year-old female, with no systemic comorbidities presented with recurrent, asymptomatic dark, raised lesions over the vulva for 15 years, progressively increasing in size and number. There were no similar complaints in the family or spouse. On examination, multiple pedunculated hyperpigmented papules and nodular lesions with a verrucous surface were present over the bilateral labia majora and pubic area. Per speculum examination revealed no abnormalities. The oral, conjunctival, and genital mucosae were normal. There were no similar lesions elsewhere over the body. Histopathological examination revealed marked dilatation of papillary dermal vessels forming large, blood-filled cavernous channels, suggestive of angiokeratoma. The lesions were removed using radiofrequency. We present this case due to the rarity of its occurrence and to emphasize the importance of ruling out nonvenereal causes of genital lesions.
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Haemophilus parainfluenzae urethritis through orogenital transmission Highly accessed article p. 127
Ajit Saxena, Reetika Dawar, Upasana Bora
DOI:10.4103/ijstd.IJSTD_45_17  
Urethritis, which is characterized by urethral inflammation, results from infectious, traumatic, and immune sources. Amongst the infectious causes, urethritis is usually acquired through sexual route and all show similar symptoms and signs. The present case is from India of a patient with urethritis caused by Haemophilus parainfluenzae transmitted through orogenital route.
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Syphilis cornee mimicking lichen planus clinically and histologically p. 130
Betsy Ambooken, Neelakandhan Asokan, KT Jisha, Lincy Ninan
DOI:10.4103/ijstd.IJSTD_15_18  
Palmoplantar lesions of secondary syphilis are often termed “syphilis cornee.” A 32-year-old male presented with itchy lichenoid papules on both soles and left palm associated with grayish white papules on the buccal mucosa and glans penis. Initial clinical diagnosis of palmoplantar lichen planus with mucosal involvement was supported by the histopathological finding of interface dermatitis. However, more detailed history, serological tests of syphilis, and review of histopathological findings led us to revise the diagnosis as syphilis cornee. This case highlights the uncommon presentation of syphilis cornee as pruritic palmoplantar lichenoid papules with histology showing interface dermatitis. A high index of clinical suspicion of secondary syphilis is needed as its manifestations are often deceptive.
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Measles, mumps, and rubella vaccine in genital warts: A case report of two patients Highly accessed article p. 133
Dilip Meena, Shilpi Sharma, Payal Chauhan
DOI:10.4103/ijstd.IJSTD_44_16  
Genital warts have a big psychological impact on the affected individuals, as the treatment requires time and multiple sessions at a time. They can also increase the chances of acquiring other sexually transmitted diseases. Various treatment options are available including the topical application of imiquimod, podophyllin, trichloroacetic acid application, cryotherapy, and radiofrequency cautery. However, all of these require multiple sessions, and chances of recurrences are high. Some of them also have multiple local side effects as burning, irritation, erythema, and swelling. Overall genital warts represent a frustrating challenge for both patients and physicians. Intralesional immunotherapy has shown promising efficacy in the treatment of warts including the following: Bacille Calmette–Guerin vaccine, candida antigen, Mw vaccine, and measles, mumps, and rubella (MMR) vaccine. We report the two cases of genital warts, who had an excellent response with intralesional MMR vaccine.
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Acquired angiokeratomas of the vulva p. 136
Kirti Deo, Kedar Nath Dash, Yugal Kishor Sharma, Meenakshi Wadhokar, Aayush Gupta
DOI:10.4103/ijstd.IJSTD_50_16  
Angiokeratomas are benign cutaneous lesions consisting of numerous ectatic blood vessels present in the superficial dermis and usually involving the scrotum. Although usually asymptomatic, they may be complicated by sporadic or profuse bleeding. We report the development of multiple vulvar angiokeratomas in a 40-year-old female after undergoing a perineoplasty successfully treated with electrocautery.
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Giant molluscum contagiosum unmasked probably during an immune reconstitution inflammatory syndrome p. 139
Aayush Gupta, Yugal Kishor Sharma, Manoj Ghogre, Shubhshree Misra, Shilpa Pawar
DOI:10.4103/ijstd.IJSTD_60_16  
Restoration of specific immune responses by combined antiretroviral therapy (cART) in patients infected with human immunodeficiency virus (HIV) may paradoxically cause an inflammatory reaction known as immune reconstitution inflammatory syndrome (IRIS). We report the emergence of giant nodules of molluscum contagiosum (MC) on the face and thighs 2 months after initiation of cART in a 45-year-old male patient with acquired immune deficiency syndrome. To the best of our knowledge, our report describes the first case of MC probably unmasked during IRIS from India.
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PHOTO QUIZ Top

Multiple pruritic plaques on scrotum-what is your diagnosis? p. 141
Ashma Surani, Yogesh Marfatia, Ravi Bavariya
DOI:10.4103/ijstd.IJSTD_82_18  
Differential diagnosis of genital lesions must include venereal and nonvenereal dermatosis. Atypical manifestations of common dermatosis exclusively over scrotum pose diagnostic challenge and histopathology plays a crucial role in such cases.
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