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
Coverpage
January-June 2017
Volume 38 | Issue 1
Page Nos. 1-106

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REVIEW ARTICLE  

Pre- and post-sexual exposure prophylaxis of HIV: An update Highly accessed article p. 1
Yogesh S Marfatia, Sheethal K Jose, Reema R Baxi, Ruchi J Shah
DOI:10.4103/ijstd.IJSTD_26_17  
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.
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ORIGINAL ARTICLES Top

Knowledge and attitude about sexually transmitted infections other than HIV among college students p. 10
Nagesh Tumkur Subbarao, A Akhilesh
DOI:10.4103/0253-7184.196888  
Background: Sexually transmitted infections (STIs) are the infections which are mainly transmitted through sexual intercourse.Young individuals in the age group of 16 to 24 years are considered to be at more risk for STIs compared to older adults. Young individuals are more likely to practice unprotected sex and have multiple sexual partners. If the STIs are not treated adequately, it can lead to various complications.Most of the people may be aware about HIV/AIDs because of the awareness created by media and the government programs, however knowledge about STIs other than HIV/AIDS is low in the developing countries. Materials and Methods: This study was a descriptive cross sectional study to assess the knowledge, awareness and attitude of college students about STIs other than HIV. A total of 350 engineering students from various semesters were included in the study. They were asked to fill up an anonymous questionnaire. Results: Two hundred and fifty six (73%) males and 94 (27%) females participated in the study. 313 (90%) students had heard about sexually transmitted infections (STIs) and 223 (64%) students had heard about STIs other than HIV. 99% of students knew about HIV where as less than 50% of students knew about other STIs. Teachers, internet and media were the source of information for most of the participants. Almost 75% of the students knew about the modes of transmission of STIs. Less than 50% of the participants knew about the symptoms of STIs and complications. Also attitude of the students towards sexual health and prevention of STIs was variable. Conclusion: The findings of our study shows that it is important to orient the students about sexual health and safe sexual practices as it will go a long way in prevention and control of STIs. Also the morbidities and complications associated with STIs can be prevented.
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Study of pruritus vulvae in geriatric age group in tertiary hospital p. 15
Jasleen Kaur, Jyotika Kalsy
DOI:10.4103/0253-7184.192632  
Background: According to the World Health Organization criteria, geriatric population is people above 60 years of age. In this phase of life, a woman has already gone through menopause and its associated emotional, physical, and hormonal changes. These changes are due to gradual loss of estrogen that comes with menopause which results in dramatic changes in the appearance of vulva and vagina. With age, skin of vulva becomes thin, loses elasticity, and moisture so that the patient starts feeling burning and itchy sensation. The normal acidic pH changes to basic which alters the flora and makes the person prone to other bacterial infections. Apart from infections, there are many other dermatological and nondermatological causes of vulvar itching in this age group such as eczema, contact dermatitis, lichen planus (LP), lichen sclerosus atrophicans, lichen simplex chronicus (LSC), prolapse, incontinence, and carcinoma. The aim is to diagnose the causes of pruritus vulvae in the geriatric age group to decrease the misery of these patients. Methods: We selected 40 consecutive females of age group ranging from 60 to 75 years coming to skin OPD with the complaint of pruritus of vulvar region over a period of 1 year. Clinical examination, complete blood count, fasting blood sugar, wet mount, pap smear, and skin biopsy were done in every case. Results: Out of the forty patients who were included in this study, 17 (42.5%) were diagnosed as a case of LSC and 11 (27.5%) patients had atrophic vaginitis. Three (7.5%) patients presented with tinea. Three (7.5%) cases were clinically diagnosed as scabies. Another 2 (5%) cases were diagnosed as LP and Candida was seen in other 2 (5%) cases. 1 (2.5%) case was diagnosed as bacillary vaginosis and 1 (2.5%) patient was of lichen sclerosus. Conclusion: Pruritus vulvae of geriatric age group are of diverse etiology, therefore, treatment based on precise diagnosis is of prime importance.
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What puts them at risk? A cross-sectional case–control survey of demographic profile and sexual behavior of patients with sexually transmitted infections at a tertiary care center in North India p. 22
Rama Raj, Vishal Gupta, Mona Pathak, Vishnubhatla Sreenivas, Seema Sood, Sarman Singh, Kaushal K Verma, Neena Khanna, Bimal K Das, Somesh Gupta
DOI:10.4103/0253-7184.196885  
Background: Sexually transmitted infections (STIs) are a major public health problem in developing nations. Identification of risk factors can help in formulating effective strategies against them. The present study was conducted in a tertiary care hospital in North India over 1 year to identify the risk factors associated with STIs. Materials and Methods: A questionnaire-based cross-sectional case–control survey was conducted where participants answered questions on demographic details, sexual behavior, and awareness of STIs. Cases were patients with STIs whereas controls were randomly selected from healthy individuals accompanying patients with nonvenereal complaints attending our hospital. Results: There were 106 cases and 64 controls. STI patients had sexual debut 2 years before controls. A higher proportion of STI cases had lower education, multiple sexual partners, lived separately from their partner, had nonregular partners, had protected sex in the last month, had sex under influence of alcohol/illicit drugs, sex in unstructured settings, and engaged in transactional sex, in comparison to controls (P < 0.05). More cases were aware of the symptoms/preventive measures of STIs (P < 0.001). On multivariate analysis, multiple sexual partners, sex under influence of alcohol/illicit drugs with nonregular partner, protected sex in the last month, and knowledge of preventive measures were found to be statistically associated with STIs (P < 0.05). Conclusions: Our study identifies risk-behavior patterns in patients with STIs, which should be modified to reduce the burden of these diseases. Increasing the knowledge about STIs in these patients can translate into more common condom usage that lends support for strengthening sexual health programs at grass-root levels. Limitations: The small size of the study population could have led to decreased power of the study to detect differences between cases and controls. The external validity of our results needs to be tested in different population groups involving larger sample sizes.
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Treatment outcomes and loss to follow-up rate of male patients with gonococcal and nongonococcal urethritis who attended the sexually transmitted disease clinic: An 8-year retrospective study p. 37
Charussri Leeyaphan, Sukhum Jiamton, Pattriya Chanyachailert, Theetat Surawan, Viboon Omcharoen
DOI:10.4103/0253-7184.196884  
Background: Poor follow-up compliance of patients with infectious urethritis is a recognized and serious public health problem in Thailand. Aim: The aim of this study was to determine treatment outcomes and loss to follow-up rate of male patients with gonococcal urethritis (GU) and non-GU (NGU) at a sexually transmitted disease (STD) clinic at Thailand's tertiary hospital. Methods: This retrospective chart review of male patients who sought treatment at STDs Clinic, Siriraj Hospital, and who were diagnosed with GU and/or NGU was conducted during January 2007 to December 2014 study period. Results: Two hundred and twenty-seven male urethritis patients were included in this study with a mean age was 29.5 years. GU and NGU were found in 120 (52.9%) and 107 (47.1%) of patients, respectively. Overall prevalence of GU and NGU during the 8-year study period at STD Clinic, Siriraj Hospital, was 8.6% and 7.8%, respectively. Ninety-six patients (42.3%) were lost to follow-up. Recurrent urethritis was found in 23.8% of patients, and HIV infection was identified in 11.6%. Mean age of patients lost to follow-up was 29 years. Compared with patients who attended every scheduled follow-up visit, men who have sex with men had a significantly lower rate of loss to follow-up (P = 0.012). Conclusion: Almost half of patients with GU or NGU were lost to follow-up, and one-quarter had recurrent urethritis. Fast and easy access to services that provide accurate diagnostic testing and effective treatment should be a public health priority to prevent complications and reduce rates of disease transmission.
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Study of prevalence of sexually transmitted infections/human immunodeficiency virus and condom use among male-to-female transgender: A retrospective analysis from a tertiary care hospital in Chennai p. 43
Subhash Dasarathan, S Kalaivani
DOI:10.4103/0253-7184.196889  
Context: A “Transgender” person is one who dresses as, desires to be, has undergone surgery to become or identifies with opposite sex. They have a higher risk of sexually transmitted infection (STI) due to a combination of biological and social reasons. They have risky sexual behaviors but low-risk perception. Aims: The aim of this study is to determine the prevalence of STI/human immunodeficiency virus (HIV) in transgender (TG) and association with condom use. Settings and Design: A retrospective study of 82 male-to-female TGs attending our sexually transmitted disease (STD) clinic from 2011 to 2014 was undertaken. Subjects and Methods: Detailed history including sexual exposure, high-risk practices, and condom usage was obtained, and clinical examination for any evidence of STI was done. They were screened for the presence of STI/HIV and other appropriate investigations were done whenever required. Statistical Analysis Used: Retrospective analysis was used. Results: In our study, the total prevalence of STI/HIV in the studied population was 48.8% which was considerably higher than the prevalence in the general population which was 5.4%. Promiscuity rate of TGs studied was 45%, 33% of them were male sex workers. Syphilis was the most common STD, followed by HIV, genital warts, and gonorrhea. The prevalence of condom use was 45.1%, and the prevalence of STI/HIV in the condom used TGs was 14.6%. Conclusion: Based on the above findings, the TG group is found to have a higher prevalence of HIV/STI despite the higher use of condoms which is mostly attributable to the lack of correct and consistent use of condoms. This stresses upon the importance of promoting the condom usage and knowledge, and also this group should be the focus of intensive intervention programs aimed at STI screening and treatment, reduction of risky sexual behavior, and promotion of HIV counseling and testing.
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Effects of fitness training on physical fitness parameters and quality of life in human immunodeficiency virus-positive Indian females p. 47
Renuka Patil, Apurv Shimpi, Savita Rairikar, Ashok Shyam, Parag Sancheti
DOI:10.4103/0253-7184.196886  
Purpose: Highly active antiretroviral therapy has significantly extended survival of human immunodeficiency virus (HIV) infected patients. These drugs suppress replication of HIV but at the same time, have many physical and mental side effects which may affect daily activities of the patients. The present study assessed if moderate intensity exercise program helped in enhancing the physical fitness and quality of life (QoL) in HIV positive females which may reduce the comorbidities associated with the disease and medications. Aim and Objectives: The aim of this study is to study the effects of moderate intensity physical training on physical fitness parameters and QoL in HIV positive females. Methodology: Post IEC approval, a randomized control, single-blinded, parallel group trial was conducted on 55 females (20 experimental HIV, 20 control HIV, 15 control normal) matching the selection criteria. Post informed consent, their muscular endurance, flexibility, aerobic capacity, and QoL was assessed. Moderate intensity physical exercises were given to experimental HIV and control normal 5 days/week for 8 weeks and subjects were reassessed for above parameters. Intragroup analysis was performed using paired t-test while inter-group was by one-way ANOVA with alpha set at ≤0.05. Results: Moderate-intensity exercises improved muscular endurance ( P < 0.05), flexibility (P < 0.05), and aerobic capacity ( P < 0.05)in experimental HIV and control normal group as compared to control HIV group. QoL in experimental HIV showed improvement in all the domains. Conclusion: Moderate-intensity exercises help improve the physical fitness as well as enhance the QoL in HIV positive females.
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Clinico-epidemiological profile of patients attending Suraksha Clinic of tertiary care hospital of North India p. 54
HS Banger, Anisha Sethi, Sita Malhotra, Suresh Kumar Malhotra, Tejinder Kaur
DOI:10.4103/0253-7184.203436  
Background: Sexually transmitted infections (STIs) are a global health problem. Trends of STIs vary from place to place depending on various epidemiological factors prevailing in that respective geographic area. Aims and Objectives: The present study was conducted to find the pattern and prevalence of different STIs out of total STI clinic attendees, to identify any change in the trend of STIs, various epidemiological factors, and behavior of individual diseases. Materials and Methods: Case records of the patients, attending the STI clinic (Suraksha Clinic) attached with Department of Dermatology, Venereology, and Leprosy of a tertiary care medical college and hospital of North India from April 2007 to March 2014, were analyzed. All the patients were thoroughly examined and investigated. Results: This study included a total of 5468 STI clinic attendees out of which 3908 were diagnosed to have STIs. Most of the patients were male, married, and in the third decade of their lives. In our study, the highest number of patients had herpes genitalis, i.e., 850 patients (21.75%) followed by 415 patients (10.61%) having genital warts. Molluscum contagiosum was present in 239 patients (6.11%), 106 patients (2.71%) had urethral discharge whereas 81 patients (2.07%) diagnosed to have syphilis. Viral infections accounted for 38.48% of cases. Human immunodeficiency virus (HIV) positivity was seen in 414 patients (10.59%) of total STI cases. Conclusion: The trend of STIs is changing from bacterial to viral diseases. This is because of the widespread use of antibacterial, self-medication, and treatment through national program. STIs enhance the susceptibility of an individual to acquire or transmit HIV through sexual contact.
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Proton pump inhibitors are associated with a reduced likelihood for sexually transmitted diseases in women in the emergency department p. 60
Johnathan Michael Sheele, Nathan Morris, Donald Byars, Frank Counselman
DOI:10.4103/0253-7184.203438  
Background: Proton pump inhibitors (PPIs) have been shown in cell culture to kill Trichomonas vaginalis (TV) at lower half maximal inhibitory concentration values than metronidazole (Flagyl), the most common medication used to treat the infection. However, there have been no previous clinical investigations to determine if PPIs are associated with reduced risk for TV. Materials and Methods: We examined the records of female patients who received testing in the emergency department for TV, Neisseria gonorrhoea (GC), and Chlamydia trachomatis (CT) between 2010 and 2014 at two academic medical centers to determine if PPI and histamine type 2 receptor antagonist (H2RA) drugs were associated with TV and GC/CT infections. Results: We found that H2RAs were associated with an increased likelihood for TV (odds ratio [OR]: 2.0, P< 0.0001) and GC and/or CT infections (OR: 1.49, P< 0.0001). PPIs were associated with a reduced likelihood for TV (OR: 0.75, P< 0.0001) and GC and/or CT infections (OR: 0.57, P< 0.0001). In patients infected with GC and/or CT, the likelihood of coinfection with TV was reduced in those taking a PPI (OR: 0.64, P = 0.054) and increased in those taking an H2RA (OR: 1.62, P = 0.003). Conclusions: PPIs are associated with a reduced risk for TV and GC/CT infection.
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Study of clinical profile of herpes zoster in human immunodeficiency virus positive and negative patients at a rural-based tertiary care center, Gujarat p. 65
Rita V Vora, Gopikrishnan Anjaneyan, Rahul Krishna S Kota, Abhishek P Pilani, Nilofar G Diwan, Nidhi N Patel
DOI:10.4103/0253-7184.203440  
Background: Herpes zoster usually presents with typically grouped vesicles on erythematous base involving single dermatome with self-limiting nature in immunocompetent individuals while it may present in extensive form involving multiple dermatomes involvement or disseminated form in immunocompromised, especially in human immunodeficiency virus (HIV). Aims and Objectives: The aim of this study was to study the prevalence of HIV in patients of herpes zoster, to compare the clinical presentation of herpes zoster in HIV-infected and noninfected patient. Materials and Methods: The study was carried out in the Department of Dermatology in a Teaching Institute of Gujarat, from June 2008 to May 2014 after ethical clearance. The study population included all the patients with a clinical diagnosis of herpes zoster. All the patients were investigated for HIV infection after written consent. Results: Out of total 688 patients of herpes zoster, 35 (5.1%) were HIV-positive, 26 (74.3%) were males and 9 (25.7%) were females. Among HIV-positive patients, 29 (82.85%) patients had localized dermatomal involvement, 4 (11.42%) patients had multiple dermatomal involvement, and only 2 (5.71%) had disseminated zoster while among HIV-negative, 636 (97.40%) had localized dermatomal involvement, 14 (2.14%) patients had multiple dermatomal involvement, and 3 (0.45%) had disseminated zoster. Cervical dermatome was most commonly involved dermatome in patients of HIV. Conclusion: Disseminated and multiple dermatomal involvement was more commonly involved among HIV-positive patients when compared to HIV-negative patients.
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Epidemiology and clinico-investigative study of organisms causing vaginal discharge p. 69
Swetha Venugopal, Kannan Gopalan, Asha Devi, A Kavitha
DOI:10.4103/0253-7184.203433  
Background: Abnormal vaginal discharge is a common clinical problem in reproductive age group. It is the second most common problem after abnormal uterine bleeding. It is a neglected health problem, most commonly caused due to vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis (BV). Objectives: The present study was conducted to determine the prevalence of common organisms causing vaginal discharge and also to know the variety of clinical presentation. Materials and Methods: A cross-sectional descriptive study was conducted in the Skin and STD Outpatient Department of Vinayaka Mission Kirupananda Variyar Medical College Hospital, Salem, who presented with abnormal vaginal discharge between September 2012 and September 2014. A total of 100 women in the reproductive age group who had symptoms of vaginitis were examined. Data were coded and analyzed. Results: Out of the 100 patients examined, 77 (77%) cases were organism positive. Among the positive cases, BV (27%) was the most common microbiological cause of abnormal vaginal discharge, followed by trichomoniasis (25%), vaginal candidiasis (22%), combined infection (Candida and BV) (3%), and nonspecific cases (23%). Conclusion: Out of 100 cases, few cases showed discordance between clinical and laboratory diagnosis. This discordance can be due to pitfalls in identifying the causative agent clinically or obscuring of the findings due to improper treatment received for other ailments. Thus, clinico-investigative correlation is more important than other clinical findings alone.
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CASE REPORTS Top

Extramammary Paget's disease of vulva: A rare entity p. 76
Sandhya Yadav, Pratik Gahalaut, Hardev Singh Soodan, Nitin Mishra, Madhur Kant Rastogi
DOI:10.4103/0253-7184.196891  
Extramammary Paget's disease is a rare cutaneous, intraepithelial adenocarcinoma involving primarily the epidermis but occasionally extending into the underlying dermis. The condition typically presents as a red, velvety, pruritic skin rash of the vulva region which closely mimics a multitude of other, more common conditions. As a result, vulvar Paget's disease is frequently misdiagnosed, leading to an often lengthy lag time (an average of about 2–3 years) between the onset of symptoms and diagnosis.
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Co-infection of syphilis and hepatitis B with carcinoma penis in a human immunodeficiency virus male p. 78
Balaji Govindan, Kalaivani Subramanian, Maduravasagam Karunakaran
DOI:10.4103/0253-7184.194321  
Human immunodeficiency virus (HIV) infections have a high probability of co-infections with Syphilis and hepatitis B virus since they share the common routes of transmission. We report a 41-year-old HIV male (on antiretroviral therapy for the past 6 years) admitted for a complaint of penile ulcer for 2 months. Serology for syphilis and hepatitis B were positive. Skin biopsy of the penile ulcer confirmed squamous cell carcinoma. Henceforth, the patient was referred to oncology department for further management. We present this rare combination of syphilis and hepatitis B with carcinoma penis in an HIV patient.
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Fiessinger-Leroy's disease: A rare case report p. 81
Yash Hemendra Dhamecha, Rikeeta Deshmukh, Bharti Patel, Neela Bhuptani
DOI:10.4103/0253-7184.203435  
Fiessinger-Leroy's disease (Reiter's disease) is rare and not commonly reported in India. This paper reports a case of a 35-year-old male with Fiessinger-Leroy's disease, occurring after balanitis. The patient presented with symmetrical polyarthritis, pruritic scaly plaques, keratoderma blenorrhagicum, and hematuria with histopathology of skin suggestive of Fiessinger-Leroy's disease. The case is presented with a view to document the occurrence of the same in India.
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Vulvo-vaginal ano-gingival syndrome: Another variant of mucosal lichen planus p. 86
Nidhi Sharma, SK Malhotra, Madhu Kuthial, KS Chahal
DOI:10.4103/0253-7184.203432  
Vulvo-vagino-gingival syndrome was described as a distinctive pattern of erosive plurimucosal lichen planus (LP), and it is a clinical triad of vulval, vaginal, and gingival LP. It can lead to sequelae such as vaginal and urethral stenosis which can have severe implications on the quality of life. We report a case of a 40-year-old female who developed urethral, vaginal, as well as anal stenosis as a result of long-term exclusive mucosal LP involving vulvo-vaginal and anal mucosa along with oral LP without any other cutaneous involvement. This case is being reported because of the rare association of anal LP with vulvo-vagino-gingival syndrome and its gross similarity to lichen sclerosus.
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Ramsay Hunt syndrome in a patient with human immunodeficiency virus infection p. 89
Mrinal Gupta
DOI:10.4103/0253-7184.203439  
Ramsay Hunt syndrome (RHS) is a rare, severe complication of varicella-zoster virus reactivation in the geniculate ganglion, characterized by hearing loss, pain, and vesicles in the ear or mouth along with ipsilateral facial palsy. Although it is rare, it is more commonly found with immunodeficiency conditions. We report a case of a 35-year-old human immunodeficiency virus positive male, having CD4+ count of 336/μl, who presented with RHS and had vertigo, painful vesicular eruptions on the right ear and unilateral sensorineural hearing loss. He was treated immediately with valacyclovir and prednisolone, and the complete recovery was achieved at 6 months after the onset.
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Acral pebbles: A novel manifestation of partially treated syphilis p. 92
Vijay Zawar, Tarang Goyal
DOI:10.4103/0253-7184.203431  
Atypical manifestations in syphilis are known and pose a diagnostic dilemma. Early suspicion, timely investigations, diagnosis, and treatment, is the key to successful management. We report a patient of secondary syphilis, who presented as genital ulcer and small pebbles like eruptions on the palmar aspect of his fingers.
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LETTERS TO EDITOR Top

Syphilis incognito: Resurgence of the covert devil – keeping the eyes open p. 95
Ankita Srivastava
DOI:10.4103/0253-7184.194319  
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Solitary plaque in the perianal region p. 96
Rizwana Barkat, Anupam Das, Piyush Kumar, Sushil S Savant
DOI:10.4103/0253-7184.196890  
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Secondary syphilis: An unusual presentation p. 98
Piyush Kumar, Anupam Das, Avijit Mondal
DOI:10.4103/0253-7184.194318  
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Exploring the scope of enhanced gonococcal antimicrobial surveillance programme p. 100
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava, Jegadeesh Ramasamy
DOI:10.4103/0253-7184.203434  
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Seroprevalence of transfusion-transmissible infections among replacement and voluntary blood donors in a tertiary care hospital p. 101
Disha Arora, Ketan Garg, DS Rawat
DOI:10.4103/0253-7184.203442  
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RESIDENTS PAGE Top

An approach to venerophobia in males p. 103
BB Mahajan, Mansak Shishak
DOI:10.4103/0253-7184.203441  
Venerophobia is a lesser recognized entity in clinical practice though the prevalence is on the rise. Our observations of current trends in the Sexually Transmitted Diseases (STI) clinic indicate that venerophobia is not an uncommon presentation among youngsters following an isolated or multiple episodes of sexual contact. This has a major bearing on the mental as well as sexual health. So far, there is no published data available in literature on the prevalence and extent of the problem. In this paper, we have made an attempt to cover the various modes of presentation, laboratory investigations and have outlined an approach towards the management of venerophobia in males.
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