An overview of sexually transmitted diseases. Part III ... - Dermatology

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414 Czelusta, Yen-Moore, and Tyring J AM ACAD DERMATOL SEPTEMBER 2000 Table I. Recommended management for syphilis in HIV-infected patients 1 Stage Treatment Follow-up Primary, secondary, or early latent 2.4 × 10 6 U intramuscular benzathine Clinical and serologic exams at 3, 6, 9, 12, syphilis penicillin G once and 24 mo Late latent syphilis or syphilis of 2.4 × 10 6 U of intramuscular Clinical and serologic exams at 6, 12, 18, unknown duration benzathine penicillin G weekly for and 24 mo 3 wk Neurosyphilis or ocular syphilis* 3-4 × 10 6 U of intravenous aqueous If CSF pleocytosis was initially present, crystalline penicillin G every 4 h for CSF exams every 6 mo (for up to 2 yr) 10-14 days (or) intramuscular until this parameter returns to normal procaine penicillin 2.4 × 10 6 U daily and oral probenicid 500 mg 4 times per day for 10-14 days *Some experts recommend the addition of a single intramuscular dose of 2.4 × 10 6 U of benzathine penicillin G to the conclusion of therapy in cases of neurosyphilis. treatment 75,95,96 and a delayed serologic titer response after syphilis treatment. 79,97-99 Finally, other reports describe cases of seronegative syphilis, accelerated loss of antibody reactivity after treatment, antibody production to decreased numbers of treponemal antigens, and the return of titers to nonreactive as immunosuppression advances (Fig 3). 100-105 When serologic tests are inconsistent with clinical suspicion, other tests are indicated, such as lesional biopsy (Fig 4), dark-field microscopy, or direct fluorescent antibody staining of lesion material. 1 Still, the histologic features of a biopsied lesion may be altered in HIV-infected patients. 106 Progression to neurosyphilis despite appropriate therapy 71-73,80-85 has prompted some experts to recommend regular cerebrospinal fluid (CSF) examinations in HIV-infected patients when they are first diagnosed with either primary or secondary syphilis 1 in addition to current recommendations for CSF examinations in HIV-infected patients with late latent syphilis. * These experts recommend modification of treatment based on the CSF laboratory results. However, the CSF results in this population may be difficult to interpret, given the fact that HIV-positive patients have high rates of CSF abnormalities without syphilis infection. 1 General treatment guidelines as recommended by the CDC are outlined in Table I. In the management of patients with primary, secondary, or early latent syphilis, some specialists recommend supple- *Early latent syphilis is defined as those asymptomatic patients with titers suggestive of a current syphilis infection who, within the past year, acquired syphilis as reflected either by a documented seroconversion, indisputable symptoms of primary or secondary syphilis, or a sex partner who had primary, secondary, or early latent syphilis in the past year. Almost all other patients have either late latent syphilis or syphilis of unknown duration. mental antibiotic therapy in addition to that listed, and some experts recommend a CSF examination at 6 months after therapy in this group. 1 Those patients in this group who do not respond to treatment but whose CSF findings remain normal are treated with intramuscular benzathine penicillin G 2.4 × 10 6 U weekly for 3 weeks. 1 If during the follow-up of any patient with late latent syphilis or syphilis of unknown duration, he or she develops symptoms or a rise in antibody titers, then CSF should be examined and retreatment administered appropriately. 1 In any HIV-infected patient with syphilis of any stage, penicillin desensitization is recommended if the patient is allergic to penicillin. 1 The management of syphilis in the HIVinfected host is a complex issue in which further study is clearly necessary. Chancroid. Chancroid is the most common cause of genital ulceration in Africa, 107 and outbreaks have been reported in Europe, Canada, and the United States. 108,109 Men are most commonly affected, and the typical clinical presentation is single or multiple soft-edged ulcers that are accompanied by inguinal adenopathy in 40% to 70% of cases. 110 Although relatively few studies have evaluated chancroid in HIVpositive patients, the clinical presentation appears to have only minor differences from HIV-negative patients, and the rate of treatment failures may be slightly increased in HIV-positive patients. 111-115 Ulcer size was consistently unaffected by HIV serostatus in all studies surveyed. 111-114 The only differences reported include a longer ulcer duration 113,114 and a greater number of ulcers at initial presentation 113 in HIV-positive patients. Nonetheless, atypical presentations can occur as evidenced by an HIV-positive patient from New York who had chancroid that presented as a chronic penile ulcer
J AM ACAD DERMATOL VOLUME 43, NUMBER 3 Fig 5. HIV-positive patient. Chancroid with typical “kissing” ulcers. accompanied by the development of ulcers on his legs and digits 115 (Fig 5). Two studies that evaluated histologic features of punch biopsy specimens from chancroid ulcers found that specimens from HIV-negative and -positive patients had no notable differences. 114,116 As in the immunocompetent host, diagnosis of chancroid in the HIV-positive patient is ideally made by culture of the causative organism, Haemophilus ducreyi, or, if this is not possible, by the presence of a clinical presentation typical of chancroid (ie, genital ulcers, usually painful, often multiple, with ragged edges and a base covered by a necrotic, yellow-gray exudate), and negative laboratory evaluations for both Treponema pallidum and HSV. 1 Several clinical trials report the efficacy of antibiotic therapy for chancroid on the basis of their subjects’ HIV serostatus. 112-114,117-120 Studies of a single quinolone (fleroxacin) dose demonstrated that HIVpositive patients are cured of chancroid less frequently with these treatments than are HIV-negative patients. 117,118 However, despite the apparent consistent difference in response rates, none of these studies achieved statistical significance in this comparison. One study actually extended the quinolone therapy of HIV-negative patients to 5 days and compared it with single-dose therapy in HIV-positive patients. 112 Again, while the HIV-positive patients were cured at a lower rate than the HIV-negative patients, the difference was not statistically significant. Single-dose ceftriaxone and single-dose azithromycin demonstrate statistically sig- Czelusta, Yen-Moore, and Tyring 415 nificant failure rates in treating HIV-positive patients with chancroid when compared with HIV-negative patients. 119,120 Similarly, 7-day erythromycin therapy has shown significantly lower rates of curing chancroid infections in HIV-infected patients at 1 and 2 weeks after starting therapy, 113,114,120 but when these patients are observed to 3 weeks, the cure rates are not significantly different between HIV-positive and -negative patients. 114 Current CDC recommendations for treatment of chancroid in immunocompetent and HIV-infected patients are the same: oral azithromycin 1 g in a single dose, intramuscular ceftriaxone 250 mg in a single dose, oral ciprofloxacin 500 mg twice daily for 3 days, or oral erythromycin base 500 mg 4 times daily for 7 days. 1 In addition, the CDC notes that HIVpositive patients may require longer courses of therapy than those listed and that any of the regimens may fail. For this reason, close follow-up of HIV-positive chancroid patients with chancroid is essential. Granuloma inguinale. Granuloma inguinale, caused by Calymmatobacterium granulomatis, is endemic to the Caribbean, South America, South Africa, Southeast India, Papua New Guinea, and among the Aborigines in central Australia, 121 but it is extremely rare in North America. 122 It typically involves the genitalia with a chronic, destructive, beefy red, nontender granulomatous ulcer, and diagnosis is made in both HIV-positive and HIV-negative patients by visualizing characteristic intracytoplasmic Donovan bodies on microscopic evaluation of either tissue smears or biopsy specimens. 123 Few data are
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