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
July-December 2017
Volume 38 | Issue 2
Page Nos. 113-202

Online since Monday, October 23, 2017

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Inflammatory dermatoses in human immunodeficiency virus Highly accessed article p. 113
Taru Garg, Sarita Sanke
DOI:10.4103/ijstd.IJSTD_22_17  
Various inflammatory dermatoses have been described in association with human immunodeficiency virus (HIV) infection. These either present in the usual way or in varied atypical presentations. This article gives a brief review about the etiopathogenesis and clinical presentation of the common inflammatory dermatoses associated with HIV such as psoriasis, reactive arthritis, seborrheic dermatitis, eosinophilic folliculitis, pruritic papular eruption, photosensitivity disorders prurigo nodularis, atopic dermatitis, and ichthyosis.
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ORIGINAL ARTICLES Top

Determinants of HIV positivity among injecting drug users in Delhi and Punjab p. 121
Pushpanjali Swain, Jayanta K Das, Sonoo Jha, Ganesh Kumar Sharnngadharan
DOI:10.4103/2589-0557.216990  
Context: In India, the HIV positivity among injecting drug users (IDUs) stands at a staggering 7.71%. Among the states, HIV positivity among IDUs is highest in Punjab and Delhi, 21.2% and 18.3%, respectively. Interestingly, these two states are near to the “Golden Crescent.” Aims: The aim of this study was to examine the similarities and differences between the IDUs in Punjab and Delhi, in the context of vulnerability to HIV. Settings and Design: This study uses data from the HIV Sentinel Surveillance-2010–2011 (HSS). The HSS is a cross-sectional data collection process for HIV surveillance in India. HSS, apart from collecting the blood samples from the respondents, also collects basic sociodemographic as well as some information on the drug use patterns of the IDUs. Data and Methods: The raw data from HSS 2010–2011 were used for this study. Bivariate and multivariate analyses performed to obtain the results. Results: Descriptive analyses revealed that the IDUs of Punjab and Delhi are very different from each other. In Delhi, 62.4% of IDUs inject drugs for more than 5 years; whereas in Punjab, it was only 32.4%. Majority of the Delhi IDUs (86.5%) inject more than three times a week whereas the corresponding percentage in Punjab was only 29.5%. The profiles of the HIV positives also differ between these two states. Conclusions: It would be prudent to adopt state-specific strategies to prevent the spread of HIV among the IDUs.
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Correlating CD4 count with mucocutaneous manifestations in HIV-positive patients: A prospective study p. 128
C Chandrakala, K Parimalam, Afthab Jameela Wahab, N Anand
DOI:10.4103/ijstd.IJSTD_130_15  
Background: Mucocutaneous findings may be the presenting symptoms in HIV-afflicted individuals. A multitude of mucocutaneous diseases also occurs during the course of the ailment, with some conditions being classed as disease defining. They include infectious diseases and noninfective inflammatory and neoplastic dermatoses. With progressive fall in CD4 count, there is a change in the types of mucocutaneous lesions encountered. Aim: This study aims to statistically correlate the CD4 counts with the mucocutaneous manifestations in 100 HIV-positive patients. Materials and Methods: A total of 100 cases of HIV-positive patients with skin and mucous membrane manifestations were selected serially. A complete history was taken, clinical examination was done, and the CD4 count was noted. Patients were divided into four groups (Groups I, II, III, IV) with different ranges of CD4 values, namely, <50, 50–200, 201–500, >500, respectively. Results: The distribution of study population in CD4 ranges showed that majority (47%) of the study population had CD4 count between 201 and 500, and 29% of the study group had CD4 count between 50 and 200 cells. Almost 21% of the patients had the count > 500 cells and 3% had cell count < 50. Majority of the infectious and non-infectious dermatoses were common in the CD4 count between 201–500 (Group III) and 50–200 (Group II). In the study groups, 52 cases (52%) were on antiretroviral therapy (ART), and the remaining 48 cases (48%) were not on ART at the time of diagnosis of mucocutaneous manifestations. Out of 48 ART-naïve cases, 23 patients were screened and newly diagnosed at the outpatient department (OPD) based on the mucocutaneous manifestations. Most of the patients with multiple mucocutaneous conditions were in the CD4 count <200, whereas single manifestation was seen predominantly in CD4 count >200. Conclusion: Statistically significant association with the CD4 count was seen in herpes zoster ophthalmicus, genital wart, genital herpes, vaginal discharge syndrome, scabies, pyoderma, dermatophytosis, Hansen's disease, herpetic gingivostomatitis, seborrhoeic dermatitis, lichen planus, and drug reactions. These dermatoses may indicate the worsening of immune status and the need for regular monitoring with periodical CD4 counting. Occurrence of dermatoses such as photosensitive eczema, drug reaction, lichen planus, Type I lepra reaction, and herpes zoster ophthalmicus in patients on ART may be due to IRIS. To avoid the more frequent occurrence of infectious dermatoses and to reduce the development of IRIS with ART, all HIV-positive cases may be started on ART at higher CD4 count. Screening for HIV infection is suggested whenever the following conditions are seen: persistent oral candidiasis, atypical manifestations of zoster, herpes zoster ophthalmicus, herpetic gingivostomatitis and MC in adults, exaggerated IBA, and extensive seborrhoeic dermatitis.
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A clinico-etiological study of urethritis in men attending sexually transmitted disease clinic at a tertiary hospital p. 136
A Kashinath Nayak, TV Anoop, S Sacchidanand
DOI:10.4103/ijstd.IJSTD_98_15  
Introduction: Urethritis is an important sexually transmitted infection in the present day. Causative agents are many for urethritis, ranging from bacteria, virus, to protozoa. Aim: The aim was to study the various etiological agents and clinical presentation of men with urethritis. Materials and Methods: This was a cross-sectional study conducted at a tertiary care center in Bengaluru. After taking written informed consent, 100 men with symptoms of urethritis were enrolled in the study. Their demographic details, presenting symptoms, and examination findings were documented using a questionnaire and a pro forma. Results were tabulated and analyzed using mean. Results: Nearly 68% had urethral discharge with dysuria as the presenting symptom. Nearly 27% had only dysuria without discharge as the main complaint. Almost 15% had coexistent genital ulcer disease. Human immunodeficiency virus infection was present in 10% in the population studied. The most prevalent organism isolated was Neisseria gonorrhoeae (45%). Chlamydia trachomatis was isolated in 13%. Trichomonas vaginalis was isolated in two patients. Conclusion: Our study highlights the high prevalence of gonorrhea in India when nongonococcal urethritis is the forerunner in the Western world. In addition, T. vaginalis as a cause of urethritis has to be considered in our setup.
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Current trends in opportunistic infections in children living with HIV/AIDS in a tertiary care hospital in Northern India p. 142
Gaurav Dhaka, BL Sherwal, Sonal Saxena, Yogita Rai, Jagdish Chandra
DOI:10.4103/2589-0557.216992  
Introduction: A prospective cohort study was undertaken from November 2010 to March 2012 at Kalawati Saran Children's Hospital (KSCH), Lady Hardinge Medical College (LHMC), New Delhi. The study included all HIV positive children aged between 0-15 years that were registered in the anti-retroviral therapy (ART) centre during the study period. HIV +ve children enrolled at the ART centre were started on ART on the basis of CD4counts (National/NACO guidelines). Materials and Methods: Various samples were collected from the patients depending on their presenting complaints as per the standard protocols. These included stool, sputum, gastric aspirate, urine, blood, pus and CSF. All the samples were processed in the microbiology laboratory as per the standard techniques. Majority of children presented to the hospital with respiratory system involvement. Fever with cough was the presenting symptom in around half of all the children suggesting involvement of upper and/or lower respiratory tract. Diarrhea and protein energy malnutrition (PEM) were the next most common findings. Clinical presentations more suggestive of HIV (e.g. generalized lymphadenopathy, mucocutaneous lesions, oral thrush etc.) were less commonly the presenting complaints. Results: OIs are still a major health hazard in children living with HIV/AIDS. The pattern of OIs encountered in a developing country like ours is different from the pattern observed in western countries. Tuberculosis is still a major problem as well as other bacterial infections. Fungal and parasitic infections are also a common health hazard. ART is a major pillar for combat against this dreadful disease. As suggested by our study, timely initiation of ART leads to an increase in CD4+ counts which is imperative in protection against OIs in HIV infected patients. Hence, routine monitoring of CD4+ counts and timely initiation and continuation of ART should be a major event in the life of a child infected with HIV.
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A retrospective study of the pattern of sexually transmitted infections from a tertiary care hospital of Rajasthan p. 147
Asha Nyati, Savera Gupta, Suresh Kumar Jain, Devender Yadav, BL Patidar, Mukul Sharma
DOI:10.4103/ijstd.IJSTD_82_16  
Background: Knowledge about the current patterns of sexually transmitted infections (STIs) is essential as they pose a major health problem worldwide and even more so in the developing countries like ours. Owing to the lack of advanced laboratory facilities at most of the centers, the cases are evaluated and managed as per the syndromic approach proposed by the National AIDS Control Organization. Aims: We aim to study the patterns of STIs seen over the past 4 years based on the syndromic approach. Materials and Methods: A retrospective analysis of the data of STI clinic over 4 years (April 2012–March 2016) was carried out. Showing all cases attending STI clinic are subjected to clinical examinations and investigated. Tests for HIV and venereal disease research laboratory were performed in all patients. STIs were categorized as per the syndromic approach. The proportions were calculated and data collected were analyzed. Results: A total of 4847 cases (1845 males and 3002 females) were studied. The most common STI overall was cervicovaginal discharge followed by genital herpes, warts, molluscum contagiosum, genital ulcerative disease-nonherpetic, lower abdominal pain, and urethral discharge in decreasing order of frequency. Genital herpes was the most common STI in males. Collectively, the proportion of viral STI was more as compared to nonviral STI. The number of newly diagnosed HIV cases was 19 (0.4%). Conclusion: The contemporary trend of STIs is relative rise in the proportion of viral STIs including genital herpes, warts, and molluscum contagiosum. Since STIs and HIV perpetuate each other, prompt diagnosis and adequate treatment of all cases of STIs is necessary to prevent HIV transmission.
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Assessment of metabolic syndrome in HIV-infected individuals p. 152
Diki Palmu Theengh, Pushpa Yadav, Amit Kumar Jain, Parvati Nandy
DOI:10.4103/ijstd.IJSTD_55_16  
Background: Metabolic syndrome (MS) is a cluster of risk factors for cardiovascular disease and Type 2 diabetes mellitus. Objectives: The aim is to assess the prevalence of MS in HIV patients receiving highly active antiretroviral therapy (HAART) and to compare it with treatment naïve HIV patients. Methods: Cross-sectional study carried out in a teaching hospital in North India. A total of 116 HIV positive patients who were on HAART and those who were treatment naïve were included in the study. Adult Treatment Panel III (ATP III) and International Diabetes Foundation (IDF) definitions were used to define MS. Clinical and laboratory investigations were performed as per requirement and then analyzed using SPSS software. Results: A high prevalence of MS was observed in HIV positive patients (ATP III – 19.8% and IDF – 25.9%). The prevalence of MS was higher in the anti-retroviral therapy (ART) group (ATP III – 33.3% and IDF – 36.4%) than ART-naïve group (ATP III – 2% and IDF – 12%). Conclusions: A sincere effort should always be made to detect MS in patients on HAART, especially in Indian subcontinent where there is a genetic predisposition to cardiovascular risk.
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Number of HIV-infected cases in Iran: True or just an iceberg p. 157
Hassan Joulaei, Kamran Begheri Lankarani, Parvin Afsar Kazerooni, Maryam Marzban
DOI:10.4103/2589-0557.216984  
Background: The number of HIV cases in Iran is increasing. Knowledge of the changing epidemiology of HIV is fundamental for service planning and prevention activities. This study aims to estimate the number of HIV-infected cases by the capture and recapture method for size estimation. Materials and Methods: From 2002 to 2009, we used three different centers – hospitals, the Voluntary Counseling and Testing (VCT) center, and a central prison in Fars Province for data retrieval. The overlaps between these centers were investigated to determine the true estimate of HIV cases. Finally, interactions were analyzed by a linear logarithm model with STATA version 9 software. Results: We observed 5167 HIV cases. The number of males was ten times more than that of females. The most frequent age range was between 15 and 44 years. The majority of cases (n = 3347) were retrieved from the VCT center. The least number of infected persons were located in the prison and hospitals. The estimated number of cases in Fars Province was 14,925 from 2002 to 2009. The best model consisted of three sources. Conclusion: Covering the system of medicine deputy for registering the number of infected cases with HIV is poor in Iran. Improvements in making arrangements for enhancing the quality of data related to HIV-infected cases are essential for solving this problem and must be on the agenda for medical policymaking.
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Drug reaction with eosinophilia and systemic symptoms related to antiretroviral treatment in human immunodeficiency virus patients p. 163
David Brandariz, Alex Smithson, Vanesa Anton-Vazquez
DOI:10.4103/ijstd.IJSTD_70_17  
Background: The drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a life-threatening condition caused by different medications. The objective of this study was to analyze DRESS cases related to antiretroviral therapy in human immunodeficiency virus (HIV) patients. Materials and Methods: Systematic review of DRESS suspected cases in HIV patients associated to antiretrovirals published between January 1998 and April 2017. The registry of the severe cutaneous adverse reactions score was used to classify each report as a “definitive,” “probable,” “possible,” or “no” DRESS case. Clinical characteristics, management, and outcomes were evaluated. Results: Thirty-five case reports were analyzed involving 5 antiretrovirals: Abacavir in 10 (28.6%) cases, efavirenz in 6 (17.1%), nevirapine in 12 (34.3%), raltegravir in 6 (17.1%), and tenofovir in 1 (2.9%). Mean age of the patients was 40 ± 13 years, 65% of which were male. A total of 57.1% reports were classified as having a “definitive-probable” DRESS case. Management was based on withdrawal of the causal antiretroviral and corticosteroids in 68.6% of the cases. None of the patients died. Treatment with nevirapine or raltegravir, the longer onset of symptoms and the presence of lymphadenopathy, eosinophilia, liver involvement, and a longer time for clinical resolution were more frequent among “definitive-probable” DRESS cases. Conclusions: A DRESS syndrome has to be suspected in HIV patients with lymphadenopathy, eosinophilia, and liver involvement developing weeks after the initiation of nevirapine or raltegravir. Suspension of the causal antiretroviral and in most cases treatment with corticosteroids allowed adequate clinical control.
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Pattern of sexual behavior in adolescents and young adults attending STD clinic in a tertiary care center in South India p. 171
Surendran Uma Maheswari, S Kalaivani
DOI:10.4103/ijstd.IJSTD_9_16  
Background and Objectives: There is an alarming increase in the prevalence of sexually transmitted infections (STIs) among adolescents and young adults of our country. The aim of our study is to depict the current pattern of sexual behavior in this vulnerable sector of population. Materials and Methods: The study was performed by reviewing the medical records of 1140 adolescents and young adults from January 2015 to June 2015. Demographic and sexual behavior data were collected in a predesigned format. The outcome variables such as age of coital debut, sexual promiscuity, and knowledge about condom usage were statistically analyzed among the study population. Results: The male: female ratio was 1.6:1. Nearly 78.2% were unmarried and 60% have completed their high school level education. Mean age of coital debut was 21.1 years in males and 18.6 years in females and 201 (17.6%) were practicing risky sexual behavior. Homosexuality was observed in 109 (33.4%) men. Furthermore, 149 (13.1%) had exposure to commercial sex workers. Prevalence of STIs was 99 (8.7%). The overall condom usage at least once was reported only by eighty (23.5%) adolescents. Complete knowledge about condom usage was found to be very low (8%). Conclusion: Our study reports a high incidence of risky sexual behavior as well as a lack of complete knowledge about safe sex practices in the study population. The need of the hour is to implement sex education program at high school level to prevent STIs in this vulnerable population.
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CASE REPORTS Top

Giant seborrheic keratosis of the genitalia with an unusual histopathological finding p. 176
Ganga Vellaisamy Seethalakshmi, Swetha Venugopal, Govindarajan Nanjappachetty, Gopalan Kannan
DOI:10.4103/ijstd.IJSTD_95_16  
Seborrheic keratosis (SK) of the external genitalia is a rare entity which can be easily misinterpreted as genital warts. Histopathology is a useful tool to make a diagnosis in such cases. We report a 62-year-old male who presented with multiple polypoidal lesions exclusively on the external genitalia. Histopathology was suggestive of hyperkeratotic type of SK which showed some unusual features.
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Hypersexuality – a cause of concern: A case report highlighting the need for psychodermatology liaison p. 180
Era Dutta, Nilesh M Naphade
DOI:10.4103/ijstd.IJSTD_27_16  
Sexual addictions are behavioral addictions. Hypersexuality is used to describe non-paraphilic “excesses” of sexual behavior. Hypersexual disorder (HSD) can be accompanied by clinically significant social, personal distress, and medical morbidity. Common medical comorbidities seen with HSD are the sexually transmitted diseases (STDs). We present one such case with management. A psychodermatology liaison clinic would be the ideal one-stop for screening patients with STDs for HSD.
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Case series of genital tuberculosis p. 183
Aditi Chhonkar, Swagata Tambe, Yashant Aswani, Chitra S Nayak
DOI:10.4103/ijstd.IJSTD_3_17  
Genital tuberculosis (TB) is a rare, comprising <0.5% cases of extrapulmonary TB. Among cases of genitourinary TB, glandular TB is even rarer. Its a diagnosis of exclusion. Most patients present later in the course of disease due to the associated stigma in view of site of involvement and the hesitancy on the patients's part. We saw two such cases of nonhealing genital ulcers in immunocompetent males.
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LETTERS TO EDITOR Top

Sexual abuse in males: An underreported issue p. 187
Deepak Juyal, Deepika Yadav, G Sethuraman, Adarsh Kumar, Trupti Shende, Somesh Gupta, Benu Dhawan
DOI:10.4103/ijstd.IJSTD_80_16  
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Author Reply p. 188
Bhushan Kumar
DOI:10.4103/ijstd.IJSTD_97_17  
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Clinical approach to nonvenereal genital ulcer p. 189
Avani Modi, Yogesh S Marfatia
DOI:10.4103/ijstd.IJSTD_91_17  
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PHOTOFEATURE Top

Alopecia syphilitica p. 192
Hsiu-Hui Chiu, Chieh-Shan Wu
DOI:10.4103/ijstd.IJSTD_92_16  
Alopecia syphilitica is a less common manifestation of secondary syphilis. It could present with other mucocutaneous symptoms of secondary syphilis or rarely present as the only symptom of secondary syphilis, the so-called “essential syphilitic alopecia.” Herein, we present a case of essential syphilitic alopecia to remind physicians, especially for sexually active patients.
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PHOTO QUIZ Top

Perigenital warty lesions-what is your diagnosis? p. 194
Devi Sathianadha Menon, Yogesh S Marfatia
DOI:10.4103/ijstd.IJSTD_84_17  
Perigenital warty lesions can be of diverse origin. An attempt should be made to rule out sexually transmitted disease (STD). If the diagnosis is not settled, biopsy may clinch the diagnosis.
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QUIZ Top

PG quiz: STD and pregnancy! p. 197
Reema Rajesh Baxi, Yogesh S Marfatia
DOI:10.4103/ijstd.IJSTD_82_17  
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ABSTRACTS Top

Abstracts from the current global literature: Finasteride and sexual dysfunction p. 200
Avani M Modi, Devi Sathianadha Menon, Yogesh S Marfatia
DOI:10.4103/ijstd.IJSTD_25_17  
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