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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   2016| July-December  | Volume 37 | Issue 2  
    Online since October 13, 2016

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Zoon balanitis: A comprehensive review
Surabhi Dayal, Priyadarshini Sahu
July-December 2016, 37(2):129-138
DOI:10.4103/0253-7184.192128  PMID:27890945
The diagnosis and management of nonvenereal diseases are always a tough challenge for the dermatologist due to lack of studies on its diagnostic criteria and standard treatment guidelines. Zoon balanitis (ZB) is one of the benign nonvenereal dermatoses, which presents as a solitary, persistent erythematous plaque usually on the glans penis primarily in the uncircumcised, middle-aged to old-aged men. Although it was described by Zoon in 1952, its etiopathogenesis still remains hypothetical. This article provides an overview of the epidemiology, clinical presentation, histopathological features, and diagnostic criteria and diagnostic methods of ZB. In addition to this, it is rather very important to differentiate this lesion from its clinical equivocal lesions such as erythroplasia of Queyrat, infective and other inflammatory penile dermatoses, which has been discussed in this review. The treatment modalities have also been reviewed in details, and the importance of circumcision as the treatment of choice has been emphasized.
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Prevalence of asymptomatic infections in sexually transmitted diseases attendees diagnosed with bacterial vaginosis, vaginal candidiasis, and trichomoniasis
R Rajalakshmi, S Kalaivani
July-December 2016, 37(2):139-142
DOI:10.4103/0253-7184.192121  PMID:27890946
Background: Sexually transmitted diseases (STD) are a major health problem affecting mostly young people in both developing and developed countries. STD in women causes both acute morbidity and complications such as infertility, ectopic pregnancy, low-birth weight, and prematurity. Aims: The aim of the study is to assess the prevalence of bacterial vaginosis, vaginal candidiasis, and trichomoniasis among asymptomatic females attending STD outpatient department in a tertiary care hospital in South India. Materials and Methods: A retrospective analysis of data collected from clinical records of 3000 female patients of age 18 to 49 over a period of 12 months (July 2014 to June 2015) was carried out at the Institute of Venereology, Madras Medical College. Complete epidemiological, clinical, and investigational data were recorded and analyzed for the prevalence of bacterial vaginosis, vaginal candidiasis, and trichomoniasis among asymptomatic patients. Results: About 48.37% (228/470) of bacterial vaginosis patients were asymptomatic. Nearly 45.38% (116/235) of vaginal candidiasis patients were asymptomatic and 30.35% (26/87) of trichomoniasis patients were asymptomatic. The above infections were common in the age group 25–35. Conclusion: Holistic screening protocol was incorporated for all female patients attending STD clinic even if asymptomatic and should be treated accordingly to prevent the acquisition of other serious sexually transmitted infections.
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Circumcision: Viable treatment option for resistant genital warts
Shekhar Neema, Disha Dabbas, Manas Chatterjee, Shantanu Banerjee
July-December 2016, 37(2):207-208
DOI:10.4103/0253-7184.188484  PMID:27890961
  1,319 38 -
Recapitulation of acquired immuno deficiency syndrome associated Kaposi's sarcoma
Balaji Govindan
July-December 2016, 37(2):115-122
DOI:10.4103/0253-7184.192120  PMID:27890943
Acquired immuno deficiency syndrome (AIDS) associated Kaposi's sarcoma (KS) is one of the clinical forms of KS. KS is caused by human herpes viruses 8 or KS associated herpes virus (KSHV). In India, till now, only 16 cases of AIDS associated KS was reported. Of all the clinical forms of KS, AIDS associated KS is distinct in many ways viz.; cutaneous manifestations commonly affects face and trunk rather than lower limbs, more mucosal lesions, rapidly progressive, and early systemic involvement. When human immunodeficiency virus (HIV) is co-infected with KSHV, in addition to the other pathogenic factors for the development of KS, HIV Tat protein promotes the proliferation of cytokine-activated endothelial cells and stimulates KS. Moreover, actions of HIV Tat lead to the aggressive course of KS in patients with AIDS, compared with the more confined behavior of KS in HIV-negative persons. Similarly, latency-associated nuclear antigen of KSHV would enhance HIV replication by activating the long terminal repeats of HIV-1 through its association with Tat. Effective antiretroviral treatment in AIDS associated KS results in reduction of the incidence of AIDS-related KS and regression of the existing lesions. Early diagnosis and treatment of AIDS associated KS would definitely increase the life span and quality of the patients.
  1,168 107 -
Role of high-sensitivity C-reactive protein measurements in HIV patients
Arun Vishwanath, Saif Quaiser, Ruhi Khan
July-December 2016, 37(2):123-128
DOI:10.4103/0253-7184.192127  PMID:27890944
As we herald into the 21st century, the quality of life and the repertoire of highly active antiretroviral therapy (HAART) have considerably improved. However, considerable work is still needed to educate the population about primary and secondary prevention modalities. Moreover, regular monitoring of immune response with patients on HAART with conventional biomarkers is still a problem in low resource settings which needs to be addressed. We aim to review high-sensitivity C-reactive protein as a potential biomarker in this regard.
  1,023 154 -
Successful management of recalcitrant perianal warts with two sessions of intralesional 5-fluorouracil
Aditya Kumar Bubna
July-December 2016, 37(2):210-212
DOI:10.4103/0253-7184.185499  PMID:27890963
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Knowledge, attitude, and perception of disease among persons living with human immunodeficiency virus/acquired immuno deficiency syndrome: A study from a tertiary care center in North India
Mrinal Gupta, Vikram K Mahajan, Pushpinder S Chauahn, Karainder S Mehta, Ritu Rawat, TN Shiny
July-December 2016, 37(2):173-177
DOI:10.4103/0253-7184.185500  PMID:27890953
Background: Although modification of behavioral practices among human immunodeficiency virus (HIV)-affected patients is important in decreasing HIV disease transmission, the knowledge, attitude, and perception studies about HIV infection rarely include persons living with HIV/acquired immuno deficiency syndrome (AIDS). Aims: To assess knowledge, attitude, and perceptions of persons living with HIV/AIDS for the disease and other epidemiological aspects. Materials and Methods: One-hundred and fifty consecutive persons living with HIV/AIDS were enrolled for this questionnaire-based cross-sectional, descriptive study. Results: These 150 patients comprised 93 men and 57 women, aged between 14 and 78 (mean 37.13) years. The majority, 112 (74.67%) patients were between 20 and 50 years of age and 116 (77.3%) patients were either illiterate or high-school dropouts. Drivers, laborers, and self-employed comprised 69 (74.2%) patients among affected males. Only 129 (86%) respondents had heard about HIV/AIDS and knew about its heterosexual transmission. Ninety-eight (65.3%) respondents were aware of disease transmission from infected blood or needle pricks. Interestingly, 106 (70.7%) respondents were aware of the importance of using condom in preventing disease transmission. Television/radio was the most common sources of information for 135 (90%) patients. Nearly, 69% respondents disfavored disclosing their disease to friends/colleagues fearing stigmatization. Conclusions: Information, education, and communication activities are imperative to educate persons living with HIV/AIDS about life-long nature of the disease, modes of its transmission, and significance of preventive measures to bridge the gaps in their knowledge. While improvement in individual economic status, education, and health services remains highly desirable, mass media can play a pivotal role in creating awareness among masses.
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Profile of pneumocystis infection in a tertiary care institute in North India
Ravinder Kaur, Pragyan Swagatika Panda, Richa Dewan
July-December 2016, 37(2):143-146
DOI:10.4103/0253-7184.185501  PMID:27890947
Context: Pneumocystis jirovecii pneumonia (PcP) is still remains a common opportunistic disease in human immunodeficiency virus (HIV) infected individuals. Study on PcP in developing countries are scarce. Aims: To study the occurrence of P. jirovecii infection in clinically suspected individuals in a tertiary care institute. Settings and Design: Retrospective study conducted in a tertiary care hospital. Materials and Methods: Two years data regarding respiratory sample analysis, HIV status, and cluster of differentiation 4 (CD4) cell count of clinically suspected pneumocystis infection patients with known/unknown HIV status were analyzed. Results: Data of 45 eligible patients were analyzed. The majority of the patients were male (between 21 and 50 years of age). Total 26 (57.7%) patients were HIV reactive, of which 14 had CD4 count of <200 cells/mm3. 20 patients (9 HIV reactive and 11 unknown HIV status) were confirmed with pneumocystosis by direct fluorescent antibody (DFA) staining. Four of 14 HIV reactive individuals who had CD4 count of <200 cells/mm3 and 5 of 12 HIV reactive individuals who had CD4 count of >200 cells/mm3 were positive for pneumocystosis. Conclusions: Pneumocystis pneumonia is still prevalent in North India and is mainly affecting patients in economically productive and sexually active age group. To diagnose pneumocystosis, DFA is an easily available method in resource-limited settings. Appreciating the actual HIV or immunodeficiency status and the CD4 profile of an individual with symptoms of pneumocystis infection will help the clinicians in early diagnosis and initiation appropriate therapy in individuals living with the disease.
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Prevalence of Vitamin B12 and folic acid deficiency in HIV-positive patients and its association with neuropsychiatric symptoms and immunological response
Prabha M. R. Adhikari, Mukta N Chowta, John T Ramapuram, Satish Rao, Karthik Udupa, Sahana Devdas Acharya
July-December 2016, 37(2):178-184
DOI:10.4103/0253-7184.192117  PMID:27890954
Background: Deficiency of micronutrients is prevalent even before the development of symptoms of HIV disease and is associated with accelerated HIV disease progression. Aims: This study evaluates the prevalence of folate and Vitamin B12deficiency in HIV-positive patients with or without tuberculosis (TB) and its association with neuropsychiatric symptoms and immunological response. Settings and Design: Cross-sectional, observational study in an outpatient setting. Patients and Methods: Four groups of HIV-positive patients with TB (Group I), HIV-positive patients with neuropsychiatric symptoms (Group II), HIV-positive patients without neuropsychiatric symptoms or TB (Group III), and HIV-negative controls with neuropsychiatric symptoms (Group IV). Vitamin B12and folate estimation was done using carbonyl metallo-immunoassay method. Statistical Analysis Used: ANOVA, Kruskal–Wallis and Mann–Whitney, Pearson's correlation. Results: The prevalence of folic acid deficiency was 27.1% in the Group I, 31.9% in the Group II, 23.4% in the Group III, and 32% in the Group IV being higher in patients with neuropsychiatric symptoms in both HIV and non-HIV patients. The prevalence of Vitamin B12deficiency was 18.8% in Group I, 9.1% in Group II, 4.8% in Group III, and 16.7% in Group IV. The patients with folate deficiency had more severe depression and anxiety. Conclusion: Nearly, 30% of the HIV patients had a folic acid deficiency, and about 10% of the HIV patients had Vitamin B12deficiency. The folate deficiency was highest among neuropsychiatric patients with or without HIV infection and Vitamin B12deficiency was higher among HIV patients with TB.
  686 56 -
A study of antiretroviral resistance patterns in treatment experienced and naive human immunodeficiency virus infected-patients
Raj Harjani, Ram Malkani
July-December 2016, 37(2):167-172
DOI:10.4103/0253-7184.192124  PMID:27890952
Background: About 10% of the patients had surveillance drug-related mutations for nonnucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) in an Indian study. It was also reported that resistance was maximum for nucleoside reverse transcriptase inhibitors (NRTIs) and minimum for PIs. Methods: The present study was a cross-sectional assessment of 21 human immunodeficiency virus (HIV)-infected individuals attending a HIV care center in a tertiary care center in Mumbai, Maharashtra, India. All HIV-infected individuals included in the present analysis were tested for CD4 count, viral load, and resistance to antiretrovirals (ARVs). Results: A total of 13 male and 8 female were included in the present analysis. Of these, 18 were treatment naive and three were treatment experienced patients. In treatment-naive patients, the proportion of high-level resistance (HLR) was 2% for NRTIs, 5% for PIs, and 11% for NNRTIs. In treatment-naive patients, high susceptibility was observed for darunavir (89%) followed by lopinavir (72%) and fosamprenavir (67%) among PIs. Similarly, susceptibility was high for NRTIs lamivudine (94%), emtricitabine (94%), and tenofovir (89%). However, we found HLR for nevirapine (39%) even in treatment-naive patients. Conclusions: The proportion of HLR was relatively low for PIs and NRTIs, compared with NNRTIs in treatment-naive patients. We also reported a high correlation in resistance patterns among drugs belonging to the same group. Thus, it may be useful to conduct ARV resistance even in newly infected HIV patients and those receiving medications for the first time.
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Aspergillus meningoencephalitis in a patient with human immunodeficiency virus infection: Normal cerebrospinal fluid does not mean absence of meningitis
Soaham Dilip Desai, Sanket Seth, Aniketh Shah, Bhalendu Vaishnav
July-December 2016, 37(2):185-189
DOI:10.4103/0253-7184.188482  PMID:27890955
A male with human immunodeficiency virus infection presented with febrile encephalopathy followed by seizures and left hemiparesis. Initial imaging with contrast computerized tomography (CT) scan brain and cerebrospinal fluid (CSF) examination were normal. Subsequent magnetic resonance imaging brain revealed bilateral parieto-occipital infarcts with bleed. He did not improve on treatment with broad-spectrum antibiotics, anti-tubercular drugs, and antifungals. He finally succumbed to the disease. His CSF culture grew Aspergillus after 2 weeks. Central nervous system (CNS) aspergillosis can present with variable presentations, and initial CT scan and CSF examination can be normal, especially in the immunosuppressed. High index of suspicion is required for the diagnosis of invasive CNS Aspergillus in the immunosuppressed.
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A situational analysis of sexual and reproductive health issues in physically challenged people, attending a tertiary care hospital in New Delhi
Utkarsha Agarwal, Sumathi Muralidhar
July-December 2016, 37(2):162-166
DOI:10.4103/0253-7184.188481  PMID:27890951
Background and Objectives: Physically challenged people constitute the most stigmatized sections of society, and are excluded from outreach programs, besides being considered sexually inactive. They have unaddressed sexual and reproductive healthcare (SRH) issues, predisposing them to sexual abuse and sexually transmitted infections (STIs). The huge paucity of data in this field prompted us to undertake this study. Materials and Methods: A cross-sectional survey was conducted on 100 people with more than 40% of permanent disability, attending various out/inpatient facilities of a tertiary care hospital in New Delhi, India. A structured, pretested questionnaire was used to assess SRH issues. Samples were collected from consenting individuals for diagnosis of various STIs, wherever relevant. Statistical analysis was done using Pearson's Chi-square test, considering significant at P <0.05. Results: Most people were in the age group of 15–30 years. Limbs were most commonly affected, and the use of assistive devices was statistically related to income levels (P = 0.045), 43% was married and 41% had children. Contraceptive usage was 33%, with a significant association (P = 0.03) with education levels. Issues related to sexual health included conditions ranging from nerve sensation loss in genitalia to fertility and gynecological issues, only 10% had received sexual counseling during rehabilitation. There were several misconceptions prevalent regarding HIV and STIs; 35% of the samples tested positive for chlamydia IgG. Interpretation and Conclusions: This is a pioneer study on a grossly neglected issue in India. There is a dire need to overcome hurdles and address the SRH issues of physically challenged people to achieve the universal WHO goal of “Health for All.”
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Nonhealing genital ulcer in AIDS: A diagnostic dilemma!
Yogesh S Marfatia, Devi Sathianadha Menon, Sheethal Jose, Brijesh Kumar Patel
July-December 2016, 37(2):197-200
DOI:10.4103/0253-7184.192130  PMID:27890958
HIV/AIDS-related immune alteration poses many diagnostic and therapeutic challenges. HIV-positive 44-year-old male, on second-line antiretroviral therapy (ART) presented with asymptomatic non healing, well-defined, erythematous ulcer over penis since 8 months with serosanguinous discharge. Inguinal lymph nodes were not palpable. Tzanck smear was negative. Biopsy was not done as the patient was not willing for the same. Acyclovir was given considering herpes infection to which there was no response, and hence azithromycin and metronidazole were given, without improvement. Minocycline was given to take care of possible atypical mycobacterial infection. Due to lack of response, corticosteroid was given for 2 weeks keeping in mind possibility of vasculitis, but there was no improvement. Although investigations to rule out tuberculous etiology were negative, empirical anti-Koch's therapy Category 2 was given without response even after 3 months. Finally, a biopsy was taken from lesion which was suggestive of donovanosis. Trimethoprim Sulfamethoxazole in higher dose was started to which he responded after 2 weeks, and therapy was continued till complete response. Patient is on second-line ART for last 7 years. He is clinically stable, but his CD4 count is hovering at around 250–300 suggestive of ART failure. Virological evaluation was not feasible. Diagnostic challenges posed include possibility of resistant bacterial, viral infection, vasculitis, or drug reaction in a setting of probable ART failure.
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Healthcare-seeking preferences of patients with sexually transmitted infection attending a tertiary care center in South Kerala
Sabeena Jayapalan
July-December 2016, 37(2):157-161
DOI:10.4103/0253-7184.188483  PMID:27890950
Background: Sexually transmitted infections (STIs) are a major public health problem in developing countries. These diseases are associated with increased risk of transmission of human immunodeficiency virus as well as adverse outcomes on pregnancy and reproductive health. Sexual behavior and healthcare-seeking behavior are identified as the true risk factors of STIs. Methods: Hospital-based cross-sectional study design was adopted. Eighty-five STI patients were studied regarding the inappropriate treatment-seeking behavior, the nature of the first point of contact with the health care, the appropriateness of treatment and the concerns of the patient regarding the services rendered by government health-care facilities. Results: Among the 85 patients studied, 55.3% were males and 44.7% were females. Inappropriate treatment-seeking behavior was seen in 29.8% of males and 36.8% of females. About 59.6% of males and 81.6% of females sought appropriate treatment from modern medicine practitioners before attending our institution. Only 7.1% of males and 3.2% of females received appropriate treatment. The government sector was the choice of treatment for 46.4% males and 93.5% females and this difference was statistically significant (P = 0.00081). Lack of free medicines, issues of confidentiality, and privacy were the major service-related issues in the public sector. Conclusion: Appropriate treatment at the first point of contact with the health system is an important measure to prevent further transmission and development of complications. Health providers from both private and public sector should be given frequent periodic training regarding syndromic management of STIs and the training should stress on the need for risk reduction and condom promotion messages along with medical management. Program planners should take necessary steps to ensure adequate and continuous supply of free drugs and tackle issues of confidentiality and privacy.
  594 47 -
p16 immunostaining as a predictor of anal and cervical dysplasia in women attending a sexually transmitted infection clinic
Deepika Pandhi, Kavita Bisherwal, Archana Singal, Kiran Guleria, Kiran Mishra
July-December 2016, 37(2):151-156
DOI:10.4103/0253-7184.192125  PMID:27890949
Background: Carcinogenesis caused by human papillomavirus (HPV) leads to over-expression of p16 protein. p16 may act as a marker of HPV integration with host genome and serve as a surrogate marker of HPV oncogenesis. Materials and Methods: A single center study of 75 women (35 HIV-positive and 40 HIV-negative women) was conducted. Anal and cervical specimens were obtained for cytology and p16 immunostaining. Results: The sensitivity of p16 to diagnose anal and cervical dysplasia was 50% and 58.8%, respectively, whereas specificity was 98.6% and 100%, respectively. Positive predictive value for anal and cervical was 75% and 100%, whereas negative predictive value was 95.8% and 89.2%, respectively. A strong relationship between the grade of dysplasia and intensity of p16 immunoscore was observed (Pearson correlation r = 0.666, P< 0.0001 and r = 0.496, P< 0.0001 for anal and cervical, respectively). Conclusion: p16 immunostaining with greater specificity for high-grade lesions may improve the diagnostic accuracy, especially for high-grade lesions which have a high risk of progression to malignancy and thereby necessitate treatment.
  593 37 -
Study of infections among human immunodeficiency virus/acquired immunodeficiency syndrome patients in Shadan Hospital, Telangana, India
Sukumar Gajjala Reddy, Syed Yousuf Ali, Azheel Khalidi
July-December 2016, 37(2):147-150
DOI:10.4103/0253-7184.192122  PMID:27890948
Background: Human immunodeficiency virus (HIV) pandemicity is a major concern today as it causes greater loss of productivity than any other disease. HIV infection leads to profound immune deficiency and patients become highly susceptible to opportunistic infections (OIs). HIV epidemic in India is heterogeneous in nature, both in terms of routes of transmission as well as geographical spread. Aims: (1) Determine prevalence of OIs among HIV-seropositive patients and their relation to CD4 count and to focus on the routes of transmission. (2) Analyze the route of transmission. Methods: This is a single-center prospective study including all the patients attending acquired immunodeficiency syndrome (AIDS) care center during the period of January 2014 to December 2014. Results: Among 71 patients included in this study, mean age was 30 years, 57.7% (41 patients) were male, 42.3% (30 patients) were female. Mean CD4 cell count of the study group was 260.11 and of patients on antiretroviral therapy increased subsequently to 553.37 cells/ml. Among the infections, the prevalence of candidiasis, tuberculosis (TB), tinea infections, seborrheic dermatitis, giardiasis, cryptosporidiosis, and Entamoeba histolytica were 36.6%, 29.58%, 4.22%, 2.82%, 4.22%, 1.4%, and 1.4%. Most predominant routes were heterosexual transmission at 94.3%. It was followed by vertical transmission seen in 2.8%. Homosexual transmission is 1.4% and intravenous drug abuse 1.4%. Conclusion: The frequency of infections among HIV/AIDS patients has got a similar linear relation with CD4 cell count. This study reports data will serve as a matrix for future evaluation. It is concluded that candidiasis, TB are the most common infections in the HIV-seropositive patients in the present study group.
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Neurokinin-1 receptor antagonists: A new revolution in antiretroviral treatment?
Udhayvir Singh Grewal
July-December 2016, 37(2):208-209
DOI:10.4103/0253-7184.192126  PMID:27890962
  512 43 -
Unusual presentation of mucocutaneous leishmaniasis in HIV-infected patient
Anupama Bains, Deepak Vedant, Priyanka Gupta, GR Tegta
July-December 2016, 37(2):193-196
DOI:10.4103/0253-7184.192118  PMID:27890957
Leishmaniasis is caused by protozoan parasite of genus leishmania. Visceral leishmaniasis, diffuse cutaneous leishmaniasis, and atypical forms of cutaneous leishmaniasis are common in HIV-infected patients. Our patient presented with an obstructive mass in nasal cavity and was diagnosed as a case of mucocutaneous leishmaniasis. Spontaneous healing of lesions in HIV-infected patients is rare rather they are unresponsive to treatment and have frequent relapses, especially in patients with low CD4 count. However, in our patient, the lesion improved significantly after 2 months of highly active antiretroviral therapy and co-trimoxazole prophylaxis.
  503 40 -
Anti-retroviral therapy's miracle in the treatment of Bowen's disease in a human immunodeficiency virus-positive patient: A rare case report
Kannan Gopalan, Seethalakshmi Ganga Vellaisamy, Navakumar Manickam, Razil Ahamed
July-December 2016, 37(2):201-204
DOI:10.4103/0253-7184.192123  PMID:27890959
Bowen's disease (BD) is a form of squamous cell carcinoma in situ often associated with human papillomavirus. Co-infection with human immunodeficiency virus (HIV) is associated with a greater risk of malignancy. We describe a case of BD in a 52-year-old unmarried HIV-positive male who presented with extensive skin lesions of 1-year duration. Histopathology was suggestive of BD. He had been tried with topical imiquimod cream and cryo-therapy for 6 months. We observed no response for these above therapies. He was started on with anti-retroviral therapy (ART) as his CD4 count was 253 cells/mm3. The entire cutaneous lesions completely disappeared within 6 months of ART, which was an interesting incidence.
  463 28 -
Protein S and protein C deficiency with multiple infarcts in a human immunodeficiency virus-infected female child
Ira Shah
July-December 2016, 37(2):190-192
DOI:10.4103/0253-7184.192119  PMID:27890956
Thrombotic episodes have occurred in patients with human immunodeficiency virus (HIV) infection, and various abnormalities leading to hypercoagulable state have been reported. However, multiple cerebral infarctions in an HIV-infected child along with protein S and protein C deficiency are rare. We report such a case in an antiretroviral therapy-naive HIV-infected female child.
  416 30 -
Cryptococcal lymphadenitis in a human immunodeficiency virus-infected patient: A diagnostic role of fine needle aspiration cytology and special stains
Jitendra G Nasit, Gauravi Dhruva
July-December 2016, 37(2):205-206
DOI:10.4103/0253-7184.192129  PMID:27890960
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