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

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416 Czelusta, Yen-Moore, and Tyring J AM ACAD DERMATOL SEPTEMBER 2000 Table II. Recommended therapy for granuloma inguinale and lymphogranuloma venereum 1 Infection Recommended therapy Alternative therapy Granuloma inguinale* Oral trimethoprim-sulfamethoxazole Oral ciprofloxacin 750 mg twice daily (or) double-strength tablet twice daily oral erythromycin base 500 mg 4 times (or) oral doxycycline 100 mg twice daily until lesions heal or for at least 3 wk daily until lesions heal or for at least 3 wk Lymphogranuloma venereum Aspiration or incision and drainage of Aspiration or incision and drainage of buboes if necessary and oral buboes if necessary and oral erythromycin doxycycline 100 mg twice daily for 3 wk base 500 mg 4 times daily for 3 wk *Gentamicin (1 mg/kg intravenously every 8 h) should be strongly considered in HIV-positive patients. available about the effects of HIV infection on this disease, but it appears that HIV-positive patients have ulcers that persist for a longer duration and may require more intensive antibiotic therapy as compared with HIV-negative patients. 124 A prospective case-control study of 50 patients (21 HIV-positive and 29 HIV-negative) in India demonstrated that, while the ulcer size and clinical presentations of HIV-positive and HIV-negative patients with granuloma inguinale were not significantly different, the mean duration to complete ulcer healing was significantly longer in HIV-positive patients (25.7 vs 16.8 days) and associated with greater tissue destruction. 124 A retrospective study of pregnant women with granuloma inguinale demonstrated no difference in pregnancy outcome between HIV-negative and HIV-positive patients. 125 Although extragenital dissemination of granuloma inguinale has been reported in association with HIV infection, 126 most case reports note the failure of traditional antibiotic treatments. 127-129 In one case, a patient who did not respond to therapy or relapsed after treatment with doxycycline, tetracycline, erythromycin, cephalexin, ceftriaxone, and trimethoprim-sulfamethoxazole finally responded to a combination of trimethoprimsulfamethoxazole and ofloxacin. 129 Currently the CDC recommends the same treatments for granuloma inguinale in HIV-negative and HIV-positive patients (Table II) with the note that gentamicin (1 mg/kg administered intravenously every 8 hours) should be strongly considered in HIVpositive patients. 1 Although granuloma inguinale is a relatively rare infection, O’Farell, Windsor, and Becker 28 have recommended a unified public health effort for its eradication based on its ease of treatment and strong association with HIV transmission. LYMPHOGRANULOMA VENEREUM Lymphogranuloma venereum, caused by the L 1 , L 2 , and L 3 immunotypes of Chlamydia trachomatis, may present clinically as primary (papule), secondary (inguinal), and tertiary (rectal) lesions. 130,131 Lymphogranuloma venereum occurs most frequently in tropical countries and is rare in the United States. 132 In both HIV-positive and HIV-negative patients, diagnosis is made by a combination of clinical presentation and high chlamydial complement fixation antibody titers (≥ 1:64). No studies have been performed on patients with concomitant HIV infection and lymphogranuloma venereum, and remarkably little anecdotal evidence regarding clinical features and treatment has been published. Retrospective analysis of 27 cases of lymphogranuloma venereum seen in a Paris hospital found 6 cases of concomitant HIV and lymphogranuloma venereum infection. HIV appeared to have no effect on the clinical presentation in each of these 6 cases. 133 Similarly, Heaton et al 134 reported a case in which an HIV-positive pregnant woman had uncomplicated lymphogranuloma venereum. Nonetheless, an atypical presentation of Parinaud’s oculoglandular syndrome (unilateral follicular conjunctivitis followed by enlargement of preauricular lymph nodes) with associated inguinal lymphadenopathy due to Chlamydia trachomatis immunotype L 2 has been reported. This patient responded well to surgical management, topical (ocular) cefazolin and gentamicin, and oral tetracycline. 135 The CDC recommends the same treatments for lymphogranuloma venereum in HIV-negative and HIV-positive patients (see Table II), with the note that disease duration may be prolonged in HIV-positive patients. 1 HUMAN PAPILLOMAVIRUS Subclinical genital human papillomavirus infections Subclinical genital human papillomavirus (HPV) can affect the cervix, vagina, vulva, penis, anus, or any other genital skin. 136 The same types can also
J AM ACAD DERMATOL VOLUME 43, NUMBER 3 Fig 6. HIV-positive patient. Oral condyloma acuminatum (ie, HPV type 6). infect the oral epithelium (Fig 6). The association between certain HPV types (eg, HPV types 16, 18, 31, and 45) and the development of dysplastic lesions in the cervix is well known. 137 The dysplastic lesion, termed a cervical squamous intraepithelial lesion (CSIL), occurs in the transformation zone along the squamocolumnar junction near the cervical os. CSIL is a precursor to cervical cancer. Similarly, the anal canal has a squamocolumnar junction and transformation zone that is affected by HPV infections. Specifically, the anal squamous intraepithelial lesion (ASIL) and invasive anal cancer appear to be associated with HPV infections, most notably HPV type 16 infections. 138-141 Genital HPV infections occur more commonly in HIV-infected men and women when compared with age-matched healthy control populations. 140,142-145 The lesions are more frequently diffuse, dysplastic, and subclinical in HIV patients, whereas control populations more commonly have condylomatous lesions and less commonly have subclinical and dysplastic lesions. 146 In addition, HIV-positive patients tend to be infected with more HPV types than control populations. 144,147-149 As CD4 cell count decreases, shedding of HPV and extent of disease appear to increase. 150,151 Given these clinical features, HPV replication and disease progression appear to be potentiated by HIV infections. 150,151 The mechanism behind this phenomena is unclear. HIV appears to influence gene transcription in HPV. 152,153 This may lead to a defect in the host’s local immune defenses and, when Czelusta, Yen-Moore, and Tyring 417 accompanied by the systemic immunosuppression of HIV infection, may explain the increased severity of HPV infections observed in this setting. Regardless of the exact mechanism, it is clear that HIV-infected persons have higher rates of cervical, anal, and other genital cancers (Figs 7 and 8). Those persons most at risk are women with a history of abnormal Papanicolaou (pap) smears and men or women who participate in receptive anal intercourse or have a history of anal condyloma. Not surprisingly, anal cancer is currently the fourth most common reportable cancer among HIV-positive men 154 and is about 7 times more common in homosexual men with HIV than those who are HIV seronegative. Likewise, cervical cancer in an HIV patient is an AIDS-defining illness. 38 Clinically, full genital examinations in HIV-positive patients are extremely important. In women, the CDC recommends two pap smears and pelvic examinations during the first year after a diagnosis of HIV. 1 If the results are normal, yearly pap smears and pelvic examinations are indicated thereafter. 1 Abnormal results should be managed in consultation with a gynecologist, and current CDC recommendations regarding this issue are listed in the “Interim Guidelines for Management of Abnormal Cervical Cytology.” 155 Some research suggests that pap smears are an insensitive method to screen for cervical cancer in AIDS patients. 156 Subsequently, some experts support colposcopy as a regular screening tool in patients when they are initially diagnosed with HIV. 156 Nonetheless, a more recent study con-
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