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
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July-December 2021
Volume 42 | Issue 2
Page Nos. 95-185

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ORIGINAL ARTICLES  

Identification of vaccine candidate proteins in Ureaplasma urealyticum causing infertility Highly accessed article p. 95
Shilpa Jeevappa Shiragannavar, Shivakumar B Madagi
DOI:10.4103/ijstd.IJSTD_7_19  
Background: Ureaplasma urealyticum has gained resistance to number of antibiotics and has been of the greatest concerns nowadays. The treatment options remain extremely low due to the increased levels of intrinsic resistance gained by the pathogen. Aim: The present study focuses on designing a peptide-based vaccine as there is no vaccine available for the pathogen. Materials and Methods: All the protein sequences of pathogen were collected and examined using various in silico methods to identify the most immunogenic proteins. The study identifies the proteins which are antigenic in nature which induce the immune response, which lends to quick response of immune system on reinfection. The study describes peptide-based vaccine against U. urealyticum using molecular docking and molecular dynamics simulation approach. Results: The study identifies novel putative vaccine candidate proteins that are antigenic, membrane bound and non-allergenic. Conclusion: The results of the study imply that the vaccine candidate proteins identified may bring about vigorous enduring defensive immunity against U. urealyticum.
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High carriage rate of intestinal parasites among asymptomatic HIV-seropositive individuals on antiretroviral therapy attending the tertiary care hospital in Varanasi, India p. 101
Manish Kumar Purbey, Aradhana Singh, Simmi Kumari, Tuhina Banerjee
DOI:10.4103/ijstd.IJSTD_39_18  
Introduction: Infections by intestinal parasites (IPs) are prevalent among human immunodeficiency virus (HIV)-seropositive individuals. Although diarrhea is the usual manifestation, asymptomatic presentations are common. In such situations, the problem of parasitosis is often underestimated. This study was performed to assess the presence of IPs among asymptomatic HIV-seropositive patients. Materials and Methods: A case–control study was designed, including stool samples from 75 asymptomatic HIV-seropositive patients and 75 seronegative patients with gastrointestinal discomfort. IPs was identified by microscopy and polymerase chain reaction (PCR) for Entamoeba spp, Cryptosporidium and Microsporidium spp. The data were statistically analyzed using the Chi-square test. Results: The prevalence of IPs in HIV-seropositive cases (25.33%) was statistically significantly more (P < 0.05) than that of controls (4%). Helminths predominated in both the groups. PCR detected IPs in 5 (6.6%) additional microscopy-negative cases. The presence of IPs was associated with CD4 count <200 cells/μl. Conclusion: The asymptomatic carriage of IPs in HIV patients poses an important reservoir in the community. To prevent transmission, frequent screening is needed.
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A cross-sectional descriptive study of clinical and serological prevalence of syphilis infection in people living with HIV and its effect on CD4+ T cells p. 106
Suresh Kumar Behara, Surya Amrutha Bindu Satti
DOI:10.4103/ijstd.IJSTD_68_19  
Context: The natural history of syphilis could be altered in the presence of HIV. It has been documented that syphilis infection increases the risk of HIV transmission by at least 3-fold. Aims: The aim of the study was (1) to study clinical presentation of syphilis in HIV individuals, (2) to estimate seroprevalence of syphilis in HIV individuals, and (3) to study the effect of syphilis infection on CD4+ T cells. Subjects and Methods: HIV-positive patients attending sexually transmitted infection clinic for a period of 1 year from June 2017 to May 2018 in the age group of 15–70 years were included in the study. A detailed history was taken; genital and dermatological examination was done. All patients were tested with VDRL and treponema pallidum hemagglutination assay (TPHA). Pearson's Chi-square test was used to compare categorical variables and Student's t-test was used to compare continuous variables. Results: Out of ninety study population, nine (10%) had clinical manifestations of syphilis. VDRL was positive with significant titers in all cases of syphilis. TPHA was positive in 88.9% of cases with clinical syphilis and 17.3% of cases without clinical manifestations of syphilis. Mean CD4 count was low among patients having syphilis infection compared to study population. Conclusion: This study shows high prevalence of syphilis in HIV and highlights the importance of preventing and promptly treating syphilis in people living with HIV, as the active infection is associated with fall in CD4 count, which leads to opportunistic infections.
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Evaluation of role of interferon gamma release assays in the diagnosis of latent tuberculosis in human immunodeficiency virus-infected patients p. 111
Rajender Singh, Nazish Fatima, Indu Shukla, Mohammed Shameem
DOI:10.4103/ijstd.IJSTD_16_20  
Introduction: Tuberculosis (TB) is the most common opportunistic infection in human immunodeficiency virus (HIV)-infected individuals. The risk of eventually developing active TB from latent TB infection (LTBI) is about 10% per year in HIV-positive patients in contrast to 10% lifetime risk in HIV-negative patients. Until recently, the tuberculin skin test (TST) was the only tool available for diagnosing LTBI. Interferon-gamma release assays (IGRAs) were recently developed and address many of the limitations of TST test, especially in immunocompromised state. Aims and Objectives: (1) To determine the prevalence of latent, active pulmonary, and multidrug-resistant (MDR)-TB among HIV-positive patients in and around Aligarh region; (2) sensitivity and specificity of TST and IGRAs for diagnosis of LTBI in HIV positive patients; and (3) to assess drug resistance and mutational patterns of the clinical isolates of MDR-TB in HIV-TB co-infection. Materials and Methods: A cross-sectional study was done on all the patients attended the ICTC centre, JNMC, AMU Aligarh, seropositive for HIV, i.e. 469 (sample size) for the study period of 2 years from October 2015 to October 2017. All 469 HIV-positive patients were screened for latent and active pulmonary TB. Diagnosis of TB (active and latent) was made using clinical, radiological, and microbiological tests. TST and IGRA testing along with CD4 cell counts were also determined. Line probe assay was also done to assess drug resistance and mutational patterns of MDR-TB in HIV patients. Results: In our study, prevalence of HIV infection was 5.04%. Sixty-seven (14.28%) patients were as active TB (HIV-TB co-infection), out of which only one patient (1.49%) was confirmed as MDR-TB, 117 (24.94%) were diagnosed as LTBI. It was also evaluated that IGRA has more sensitivity (75%) and specificity (76%) than TST with sensitivity of 71.7% and specificity 66%. Conclusion: As there is no gold standard test for latent TB, longitudinal follow-up is needed to interpret discordant test results. There is a need to interpret negative QFT results with caution and to test for latent TB at higher CD4 counts, if possible. Interferon gamma assays can become better tool for diagnosis of especially for latent TB. However, more research study required for establish their relevance, especially in immunocompromised states.
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Spectrum of malignancies among human immunodeficiency virus-infected patients at a tertiary level human immunodeficiency virus-anti-retroviral therapy center in a North Indian hospital p. 118
Sumit Arora, Ashwin Mahesh, Nalin Kumar Mahesh, Niket Verma
DOI:10.4103/ijstd.IJSTD_28_19  
Introduction: Human immunodeficiency virus (HIV)-infected individuals have a higher risk of some types of cancer. A chronic immunodeficiency state, increased survival in the highly active antiretroviral therapy (HAART) era and predisposition to certain oncogenic viral infections have been postulated as the main reasons. While, the incidence of acquired immunodeficiency syndrome (AIDS) defining cancers (ADCs) is declining in the post-HAART era, non-AIDS-defining cancers (NADCs) are becoming an important cause of mortality in these patients. Materials and Methods: Analysis of the data of HIV-infected patients registered at an apex centre was done for 7 years. All patients were subjected to routine investigations on presentation (baseline) and during follow-up for the occurrence of any malignant disease. CD4 cell counts before starting anti-retroviral therapy and before the diagnosis of malignancy were noted. The date of the last review and the current status/outcome were recorded. Results: Out of 1258, 17 patients were diagnosed with various malignancies. Seven patients (41.2%) had ADCs and the remaining 10 (58.8%) had NADCs. The mean duration between diagnosis of HIV infection and diagnosis of malignancy was 59.53 months. The mean survival duration from the diagnosis of malignancy for all cases was 21 months. The mean survival duration was 29 months and 15 months for ADC and NADC group respectively. Conclusions: NADCs are on the rise in the era of effective use of HAART and increasing life span of HIV patients. The index of suspicion for cancer should be higher in such patients, especially compared to opportunistic infections in view of good immunovirologic status.
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Psychological health and well-being in patients with sexually transmitted infections: A prospective cross-sectional study p. 125
Swati Singh, Satyendra Kumar Singh
DOI:10.4103/ijstd.IJSTD_77_19  
Background: Patients with sexually transmitted infections (STIs) suffer not only with the physical problems but also with various psychological problems. Majority of bacterial STIs are treatable in a short period, while viral STIs may persist for longer duration or have frequent recurrences. Aims and Objectives: The aim of the study was To study different aspects of psychological health and well-being in patients with STIs. Materials and Methods: Study design was a prospective cross-sectional hospital-based study. Data were collected during July 2016–April 2018. STIs were divided into four groups (genital herpes, genital warts, and genital discharge and syphilis). One way analysis of variance and Scheffe Test were used for analysis of the data. Results: A total of 410 patients were included in the study. Majority of patients were suffering with genital herpes (139), followed by warts (104), discharge (92), and syphilis (75). Genital herpes and genital warts indicated significantly more cognitive affective (CA) depression as compared to the patients suffering with syphilis. Satisfaction with life was more with genital discharge and syphilis in comparison to the patients with genital warts and genital herpes. Genital herpes showed more perceived stress in comparison to genital discharge. Genital warts indicated more somatic depression as compared to syphilis and genital discharge patients while genital herpes showed more somatic depression than in patients suffering with genital discharge. Genital warts and genital herpes indicated significantly more overall depression as compared to the patients suffering with syphilis. Conclusion: Overall depression was more in patients with genital herpes and warts. The findings provide empirical bases for extended studies on behavioral intervention programs.
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Clinical patterns of sexually transmitted diseases in human immunodeficiency virus-infected individuals in a tertiary care center in South India p. 132
D Dinesh Kumar, Anoop Thyvalappil, Kashinath Nayak
DOI:10.4103/ijstd.IJSTD_23_17  
Background: Human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) synergize to aggravate the associated morbidity of each other in the human body. Aims: The aim was to study the pattern of presentations of STDs in patients with HIV. Materials and Methods: This study was conducted by selecting 100 consecutive cases of HIV infection with symptoms suggestive of co-existing STD attending the outpatient department in a tertiary care center in south India. Results: Most of the patients belonged to the age group of 26–30 years, with a slight male preponderance. Genital ulcer was the predominant presenting complaint (60%), followed by dysuria (32%) and genital growth (29%). Genital ulcer was the most common lesion (56%), followed by other genital lesions (37%) and extragenital lesions (18%). Among the investigations, Tzanck smear was most commonly seen positive (62.3% of 61 patients), followed by positive potassium hydroxide mount and Venereal Disease Research Laboratory. About 35.5% of the male patients and 60.53% of the female patients had multiple diagnoses. In males, herpes genitalis (29.76%) was the most common STD, followed by condyloma accuminata (23.08%). In females, candidal vulvovaginitis (28.12%) was the most common STD, followed by herpes genitalis (23.43%). Conclusion: Our study found genital ulcer as the most common symptom and sign of STD in HIV-infected patients. Herpes genitalis was the most common STD among males and candidal vulvovaginitis was the most common STD among females.
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Bone health in HIV-infected children on antiretroviral therapy: An Indian study p. 138
Shruti Bhise, Ashish Jain, Lalita Savardekar, Naman S Shetty, Ira Shah
DOI:10.4103/ijstd.IJSTD_35_19  
Aim: The aim of this study is to determine the bone health in HIV-infected children on antiretroviral therapy (ART). Materials and Methods: This cross-sectional study was carried out in 31 HIV-infected children aged 5–18 years. Each patient underwent testing for serum calcium, phosphorous, alkaline phosphatase, and 25(OH) Vitamin D. Bone mineral density (BMD) was done using a DXA scanner. Patients' z scores for BMD of the lumbar spine and left femoral neck were noted. The factors associated with low BMD were analyzed. Results: Seven (22.6%) children had a low spinal BMD and 6 (19.4%) had low femoral neck BMD. Low serum calcium was seen in 6 (19.4%) patients and high alkaline phosphatase was seen in 15 (48.4%) patients. Low serum 25 (OH) Vitamin D levels were present in 30 (96.8%) patients, whereas all the patients had normal serum phosphorous. Duration of ART in those with low spinal BMD was 4.6 ± 3.4 years as compared to 6.4 ± 3.2 years in those with normal spinal BMD (P = 0.235) and for low left femoral neck BMD was 3.9 ± 2 years as compared to 6.5 ± 3.4 years for those with normal femoral neck BMD (P = 0.031). Mean 25(OH) Vitamin D levels were 8.4 ± 2.8 ng/ml in those with low femoral neck BMD as compared to 13.6 ± 8.3 ng/ml in those with normal femoral neck BMD (P = 0.015). Type of ART did not have any association with low BMD. Conclusion: Over 95% of HIV-infected children have low 25(OH) Vitamin D levels which affect the appendicular BMD. BMD is affected more in children who have been on ART for a shorter time. No particular ART regimen is associated with low BMD.
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Sexually transmitted infections in the elderly: A 6-year retrospective study in a tertiary care hospital in New Delhi p. 144
Vineet Relhan, Anuva Bansal, Pallavi Hegde, Bijaylaxmi Sahoo
DOI:10.4103/ijstd.IJSTD_60_20  
Background: Worldwide, a steady rise in the incidence of sexually transmitted infections (STIs) in the elderly has been reported and is attributed to aging, unsafe sexual practices, and delayed health-care seeking behavior, leading to a delayed diagnosis and persistence of infection in the community. The aim of this study was to assess the demographic profile, risk factors, and clinical pattern of geriatric STIs. Aims: The aim of the study was to assess the demographic profile, risk factors, and clinical pattern of STIs among patients aged ≥60 years presenting to the STI clinic in the dermatology outpatient department at a large tertiary care hospital in New Delhi, over a period of 6 years. Materials and Methods: This was a retrospective observational study. Data collection was done for all patients of 60 years and above age group who visited the STI clinic in the dermatology outpatient department, over a period of past 6 years, with symptoms/signs suggestive of an STI, irrespective of whether the final evaluation demonstrated an STI. Results: A total number of 123 patients above 60 years of age presented to the STI clinic between 2013 and 2018. The cases presenting annually demonstrated a rising trend and increased from 17 cases in 2013 to 33 in 2018. The most common complaints were ulcers over the genitalia and genital discharge noted in 28.4% of cases each. The most common syndromic diagnosis was vaginal discharge in 25% of cases. Other STDs diagnosed were candidial balanoposthitis in 19.5%, herpes genitalis and genital warts in 16.2% each, and genital scabies in 6.5% cases. Limitations: The limitations included a small sample size, retrospective analysis, and categorization of the STDs as syndromes, following standard guidelines developed by the National Aids Control Organization (NACO) and the WHO. Conclusion: It is necessary to destigmatize STDs among the elderly, encourage inclusion in screening programs, and offer prompt diagnosis and treatment.
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CASE REPORTS Top

Onycho-mucocutaneous syndrome secondary to human immunodeficiency virus disease p. 150
B Madhuri, Spandana P Hegde, Manjunath M Shenoy
DOI:10.4103/ijstd.IJSTD_94_18  
Cutaneous, mucosal, and nail examination is the key to unveiling a plethora of systemic diseases. Mucocutaneous lesions directly related to human immunodeficiency virus (HIV) infection usually present as initial manifestations of immune deficiency, of which few lesions act as predictors of an immunocompromised state. Here, we report two cases who presented with onycho-mucocutaneous symptoms which raised the suspicion of and invariably led to the diagnosis of an underlying immunosuppression secondary to HIV infection.
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Mucous patch of secondary syphilis masquerading as leukokeratosis: An atypical presentation p. 153
Arushi Jain, Kriti Maheshwari, Kalpana Gupta, Sanjay Meena
DOI:10.4103/ijstd.IJSTD_85_19  
Syphilis is known to inflict human being since long. It has varied clinical presentations. Atypical presentations are not uncommon and may jeopardize the clinical acumen of experienced clinician. Here, we are reporting a case of syphilis presenting as a sole manifestation in oral cavity.
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A case of primary and secondary syphilis presenting together as immune reconstitution inflammatory syndrome p. 156
Debdeep Mitra, Gautam Kumar Singh, Barnali Mitra, Krishna Talukdar, Amen Dhillon, Tegveer Singh
DOI:10.4103/ijstd.IJSTD_58_20  
Immune reconstitution inflammatory syndrome (IRIS) is a condition during the clinical course of HIV infection in which there is paradoxical worsening and/or new onset of opportunistic infections in a HIV-positive patient who has recently been started on anti-retroviral therapy (ART). We present a case of AIDS with CD4 count of 20 cells/μl who presented within 6 weeks of starting ART with a CD4 count of 160 cells/μl and a painless solitary genital ulcer along with annular dark-colored plaques over soles. His screening test for syphilis was negative both during baseline evaluation, prior to initiation of ART, and during his clinical presentation. His disease was confirmed based on a positive treponema pallidum hemagglutination test report and a suggestive skin biopsy. He responded well to three doses of Benzathine Penicillin and continuation of ART. There are very few case reports of syphilis presenting as IRIS and this case is all the more unique as he had features of both primary and secondary syphilis occurring together within 6 weeks of starting ART. This report would reiterate the fact that syphilis and HIV co-infection can alter the natural course of both the diseases and a high index of suspicion is required for treating them.
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Perineal warty plaques: A case of verrucous porokeratosis p. 159
Prakriti Shukla, Swastika Suvirya, Parul Verma, Meenakshi Batrani, Sucheta Pathania, Kiran Preet Malhotra
DOI:10.4103/ijstd.IJSTD_74_19  
Nonvenereal genital dermatoses form an important category of disorders, and verrucous porokeratosis is a rare and less recognized entity among the same. We present the case of a young adult male with warty growths over scrotum and buttocks for a year. Characteristic cornoid lamellae with typical differentiating features were seen in the histopathology, establishing the diagnosis. This case emphasizes the rare nonvenereal cause for a condition clinically mimicking condyloma acuminata.
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Lepromatous leprosy as a presenting feature of HIV p. 162
Vasudha A Belgaumkar, Ravindranath B Chavan, Nitika S Deshmukh, Abhishek P Ponathil
DOI:10.4103/ijstd.IJSTD_44_19  
Various bacterial, mycobacterial and fungal opportunistic infections occur frequently in immunocompromised individuals, however, leprosy in retroviral disease is a relatively rare association. Hereby, we report a case of lepromatous leprosy that presented with clinical features mimicking other opportunistic infections and subsequently led to the diagnosis of HIV. The myriad challenges associated with the diagnosis and management of HIV–leprosy coinfection are also discussed. Thus, although uncommon, atypical cutaneous lesions in HIV-seropositive patients warrant investigation for leprosy.
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Generalized anetoderma: An unusual manifestation of secondary syphilis treated with injection penicillin p. 166
Anu Y Patel, Krina B Patel, Hinal J Prajapati, Poojaben P Desai
DOI:10.4103/ijstd.IJSTD_81_19  
Anetoderma also called macular atrophy is a rare, benign disorder characterized microscopically by the pan-dermal loss of elastic fibers in the dermis and presenting clinically as circumscribed, skin-colored or gray-white atrophic macules and/or patches on the trunk and/or extremities. Lesions are described as having a “sac-like” appearance, since they bulge or herniate upon palpation. It is a rare benign condition of diverse etiology; whose characteristic is the diminution or absence of the dermal elastic fibers. Anetoderma is divided into primary (idiopathic) and secondary anetoderma, with the former occurring in areas of previously normal skin and the latter developing in areas of prior skin pathology. Both may occur in association with underlying systemic conditions and warrant evaluation for associated disorders. There are no effective treatment options for anetoderma at present. We report here an unusual case of generalized anetoderma occurring in association with secondary syphilis treated with injection benzathine penicillin.
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Gonococcal tonsillar infection in a female sex worker p. 169
Pathum Sookaromdee, Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/ijstd.IJSTD_30_17  
Gonorrhea is a common sexually transmitted disease that can be seen worldwide. Gonorrhea usually presents with the genital disorder. Nevertheless, rare clinical manifestation can also be seen. Here, the authors would like to present the case of a female prostitute presenting with repeated tonsillitis and finally diagnosed for gonococcal tonsillar infection. In the present day, there are a variety of sexual preferences and sexual intercourse that might result in unexpected clinical problems. Asking for the unusual oral sex history should be included in the history taking of the patients with recurrent pharyngitis and tonsillitis.
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Clinicodemographic profile of syphilis with rising trends at a tertiary care hospital: The tip of the iceberg p. 171
AP Gosavi, Ravindranath B Chavan, Akanksha Bandhade, Drashana R Kundale
DOI:10.4103/ijstd.IJSTD_12_18  
Syphilis, a genito-ulcerative disease caused by the organism Treponema pallidum subspecies pallidum, is renowned for its invasiveness and immune - evasiveness if untreated.Historical reports from the 15th century indicate that syphilis was perceived as a dangerous infection, and a source of public alarm via fear of contagion and dread of its manifestations. It has varied and subtle features that makes clinical diagnosis difficult and leads to many infections being unrecognised. The total number of reported cases of syphilis (all stages) increased 13.3% during 2017-2018. WHO estimates that each year 11 million new cases of syphilis occur globally among adults of 15-49 years of age. In our retrospective study, we analysed trends of syphilis in different groups of patients attending our tertiary care centre and reviewed the increase in disease pattern with varied clinical presentations. It is important for the medical practioners to be vigilant to look out for usual as well as unusual presentation of the great imitator.
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Portal system thrombosis in an HIV-infected child p. 175
Pawan Daga, Ira Shah
DOI:10.4103/ijstd.IJSTD_27_19  
HIV infection can lead to venous thrombosis due to protein C deficiency, protein S deficiency, or antiphospholipid syndrome. Most patients present with deep vein thrombosis or pulmonary embolism. We report a 10-years-old HIV-infected girl who presented with life-threatening hematemesis. Computed tomography scan of the abdomen and angiography showed thrombosis of the portal vein, superior mesenteric vein, and splenic vein. She was advised antiretroviral therapy and prothrombotic workup, however, she took discharge against medical advice.
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LETTERS TO EDITOR Top

Cutaneous horn on the penile shaft p. 177
Ramesh Kumar Kushwaha, Alpana Mohta, Umesh Gautam, Suresh Kumar Jain
DOI:10.4103/ijstd.IJSTD_75_19  
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Oral condyloma lata: A rare case report p. 178
Pritee Sharma, Ramesh Kumar Kushwaha, Asha Nyati, Alpana Mohta, Suresh Kumar Jain
DOI:10.4103/ijstd.IJSTD_88_19  
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Sexualized drug use (“chemsex”) and sexually transmitted infections p. 180
Deepak Juyal, Benu Dhawan, Vijay Thawani, Shweta Thaledi
DOI:10.4103/ijstd.IJSTD_91_18  
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A case of paracoccidioidomycosis in a HIV-positive patient p. 182
Debdeep Mitra, Krishna Talukdar, Gautam Kumar Singh, Barnali Mitra
DOI:10.4103/ijstd.IJSTD_80_20  
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Pattern of sexually transmitted infections at a tertiary care center of Western India: A 12-years retrospective study p. 184
Pooja Agarwal, Siddhartha Saikia, Ashish Jagati, Krishana Gajjar, Priyanka Vadher, Shefali Patel
DOI:10.4103/ijstd.IJSTD_96_19  
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