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 2022
Volume 43 | Issue 2
Page Nos. 115-249

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EDITORIAL  

Parting remarks from the outgoing editor Highly accessed article p. 115
Yogesh S Marfatia
DOI:10.4103/ijstd.ijstd_108_22  
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REVIEW ARTICLES Top

A systematic review of eHealth modes in preventing sexually transmitted infections p. 117
Firoozeh Nourimand, Afsaneh Keramat, Masoumeh Sayahi, Leila Bozorgian, Zahra Hashempour
DOI:10.4103/ijstd.ijstd_55_22  
Prevention of sexually transmitted diseases (STDs) is critical. Despite developing treatment and prevention programs, sexually transmitted infections (STIs) are essential in developing acute and chronic diseases. Because “eHealth” (electronic-Health) has excellent potential for disseminating health information to the public regarding STDs, we aimed to identify and review all published articles focusing on preventing STIs. After constructing the design and answering population, intervention, comparison, and outcome questions, two authors conducted a systematic literature search in four online databases in January 2022. The screening process and data extraction were conducted by two authors independently, and then, a quality assessment was performed. After removing duplicates, and two rounds of shortlisting, 16 articles were included for data extraction out of 5113 entries. Included studies were of different designs and assessed six preventive outcomes categories, with condom use being the most frequent result among studies. We also extracted implementation outcomes and reviewed them. Included studies with 13,137 participants have provided reasonable evidence of the effectiveness of different types of eHealth in improving STI prevention interventions. Although this systematic review was not without limitations, it can no longer be ignored that eHealth modes offer many opportunities to prevent STDs, especially among the young population.
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Female sexual dysfunction: A potential minefield Highly accessed article p. 128
Smitha S Prabhu, Snigdha Hegde, Suhani Sareen
DOI:10.4103/ijstd.IJSTD_82_20  
Female sexual dysfunction (FSD) is a much-neglected aspect of feminine health, especially in patriarchal cultures. We collated data from pertinent published literature on FSD to explore the types, associations, and best possible approach to FSD in the Indian context. We fed search words “female sexual dysfunction,” “sexual health,” “India,” into medical search engines such as PubMed, Google Scholar, Clinical Key, ProQuest, SciVal for locating pertinent articles from which data was synthesized and extracted. Female sexual response is complex and is influenced by physiological, behavioral, social, and cultural factors. The latest Diagnostic and Statistical Manual of Mental Disorders-5 criteria classified FSD into female sexual interest/arousal disorder, female orgasmic disorder and genito-pelvic pain/penetration disorder, along with categories common to both genders like substance/drug induced and other unspecified subsets. Diagnosis requires detailed and specific history taking and clinical evaluation to rule out comorbidities. Treatment is multifaceted and prolonged, involving pharmacological, psychological, and behavioral therapy in both partners. Almost all Indian studies in this field have small sample sizes and none of the studies focused on FSD as the primary complaint. FSD is still an unexplored field of Indian medicine. Although newer treatment options and techniques are being explored, there is much to achieve. We need to develop culturally suitable questionnaires taking into account the Indian female psyche. Management should be holistic and involve focused liaison clinics, including dermatology, gynecology, psychiatry, clinical psychology, and urology specialties.
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ORIGINAL ARTICLES Top

Prevalence of nonviral reproductive tract infections/sexually transmitted infections in female patients with cervicovaginal discharge: Excerpts from a regional reference center in North India Highly accessed article p. 135
Sunil Sethi, Nandita Sharma, Megha Sharma, Rajneesh Dadwal, Charu Singh, Hemant Chaudhary, Sakshi Malhotra, Rakesh Yadav, Vanita Gupta
DOI:10.4103/ijstd.ijstd_48_21  
Background: To study the prevalence of common nonviral reproductive tract infections/sexually transmitted infections (RTI/STI) prevailing among females who presented to our regional STI reference center and to ascertain the association of various symptoms with different RTI/STIs. Materials and Methods: A retrospective analysis of female patients presenting to our STI Regional center located in the Department of Medical Microbiology in PGIMER, Chandigarh, was done between April 2018 and December 2019 for patients presenting with cervico-vaginal discharge. Two to three swabs were collected from each patient. The first swab was subjected to wet mount, gram stain, Potassium hydroxide (KOH) test, and culture on blood agar, the colonies obtained were identified by matrix-assisted laser desorption time of flight mass spectrometer (MALDI TOF-MS). Second swab was used for DNA extraction and detection of Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), and Chlamydia trachomatis (CT) by polymerase chain reaction. The third swab, when available, was inoculated onto pleuropneumonia-like organisms (PPLO) broth. Results: One thousand and thirteenth of 1472 (69%) female patients were symptomatic and the most common presenting symptoms were vaginal discharge (707/1013 [69.8%]), infertility (266/1013 [26.2%]), genital itching (60/1013 [5.9%]), lower abdomen pain (47/1013 [4.6%]) and burning micturition (16/1013 [1.6%]). The most prevalent RTI/STI was bacterial vaginosis (BV) 18.2% (269/1472), followed by vulvovaginal candidiasis (VVC) 6.8% (100/1472) and trichomoniasis (TV) 1.9% (28/1472). Five cases each of Mycoplasma genitalium and Ureaplasma urealyticum, three of NG and one of CT were also identified. Coinfections were seen in 40 (2.7%) cases. The most common causative agent responsible for VVC in our study was Candida albicans (65%). Conclusion: RTI/STIs were common among women and 69% were symptomatic. BV was the most common STI present in 18.2%, followed by VVC (6.8%) and trichomoniasis (1.9%).
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Vulval dermatoses (venereal and nonvenereal) among female patients presenting to a tertiary care hospital in North India p. 141
Karamjot Kaur, Manjit Kaur Mohi, Dimple Chopra, Rishu Sarangal, Jatinder Raj Singh Saini, Preeyati Chopra
DOI:10.4103/ijstd.ijstd_18_22  
Background: The skin and mucosa of the vulva are different from the rest of the human body, as it is derived from all three embryological layers. It is more prone to dermatological diseases, both infectious and noninfectious. Aims and Objectives: Our study was a prospective descriptive study on female patients attending the skin outpatient department with complaints of vulval dermatoses. Our aim was to determine the prevalence of venereal and nonvenereal dermatoses (infectious and non-infectious) along with age-wise distribution of these in our area. Materials and Methods: All female patients presenting with visible skin lesions on the vulva from January 2019 to December 2019 were included in this study. Various diagnostic tests such as Gram staining, Tzanck smear, KOH mount, herpes simplex virus serology, and skin biopsy were performed wherever necessary. Observations and Results: The study included 520 patients in whom 525 lesions were identified. These were grouped under venereal and non-venereal dermatoses. Nonvenereal dermatoses were further grouped under infectious and non-infectious conditions. Maximum patients were in the age group of 21–40 years (50.19%). The most common dermatoses were non-venereal infections, seen in 220 (42.30%) patients followed by non-venereal, non-infectious dermatoses seen in 177 (34.04%) patients whereas venereal dermatoses were seen in 128 (24.61%) patients. Conclusion: Most of the patients were in the reproductive age group, and the prevalence of infectious dermatoses both venereal and non-venereal was much more than that of non-infectious conditions affecting the vulval skin as per our study.
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Does performance and operational superiority of point-of-care test make it the investigation of choice in confirming syphilis? p. 146
Aradhana Bhargava, Sonal Nagia, Prashant Verma, Shikha Bansal, Niti Khnuger, Ashok Saxena
DOI:10.4103/ijstd.ijstd_30_22  
Background: According to the World Health Organization, 6 million cases of syphilis occur every year. Serological tests for syphilis form the mainstay of diagnosis for syphilis. We evaluated the performance of point-of-care test (POCT) against other specific treponemal test for confirming the diagnosis of syphilis. Materials and Methods: Does performance and operational superiority of POCT make it the investigation of choice in confirming syphilis? Retrospectively, data were analyzed of 599 serum samples from Apex Regional sexually transmitted disease centre, Safdarjung Hospital, New Delhi, received for testing by syphilis treponemal assays (both nontreponemal reactive and nonreactive). These samples underwent treponemal testing for syphilis by the Treponema pallidum hemagglutination (TPHA), fluorescent treponemal antibody absorption test (FTA-ABS), and POCT. Performance characteristics (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], and diagnostic accuracy), and operational characteristics of POCT and TPHA were evaluated against the gold standard FTA-ABS. Results: A total of 599 samples were evaluated, of which 61.76% were positive by FTA-ABS. On analysis, the sensitivity was 91.08% and 91.89%, specificity was 89.08% and 87.34%, PPV was 93.09% and 92.14%, NPV was 86.08% and 86.96%, and diagnostic accuracy was 90.32% and 90.15% for POCT and TPHA, respectively. The lower cost, shorter turnaround time, lesser infrastructure and workforce need, and easy availability make the POCT operationally superior to TPHA. Conclusion: Owing to its operational superiority and higher specificity POCT can replace TPHA for confirming the diagnosis of Syphilis. POCT are affordable, equipment free, have room temperature storage, and yield result within 15 minutes, enabling same day testing and treatment. It can be used in a resource limited setting, for community setup or even self-testing.
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Understanding drug resistance patterns across different classes of antiretrovirals used in HIV-1-infected treatment-Naïve and experienced patients in Mumbai, India p. 150
Raj Gurubuxrai Harjani, Asha Krishnaraj Iyer, Ankita Chaurasia
DOI:10.4103/ijstd.ijstd_101_20  
Background: The aim of this study is to find out the proportion of treatment-naïve (Tn) and treatment-experienced (Te) patients experiencing HIV drug resistance (DR) to different classes of antiretrovirals (ARVs) being used for HIV treatment and their in class DR correlation. Methods: A cross-sectional study was done on 109 HIV patients enrolled at a private hospital in Thane, India, from 2014 to 2019. All patients were tested for CD4 count, viral load, and resistance to ARVs. Results: Sixty-six patients were Tn and 43 patients were Te. Among Tn and Te patients, the percentage of high-level resistance (HLR) for nonnucleoside reverse transcriptase inhibitors (NNRTI) was 4.55% and 37.8%, respectively, for nucleoside reverse transcriptase inhibitors (NRTI) was 0.43% and 36.4%, respectively. No HLR was observed for protease inhibitors (PIs) among Tn patients, while Te patients showed 2.62% HLR. Tn and Te patients showed high susceptibility for Darunavir (98.48% and 95.34%, respectively) followed by Atazanavir and Lopinavir (96.96%, each and 90.69%, each). Tn patients showed HLR for Lamivudine and Emtricitabine (1.52%, each). Integrase Strand Transfer Inhibitors were susceptible (100%) in both Tn and Te patients. A positive correlation was observed for within class across ARVs. Conclusion: An increased incidence of HLR was observed for NNRTI as compared to NRTI while PIs and integrase strand transfer inhibitors (INSTIs) demonstrated no HLR in either group of patients. When selecting a regimen for Tn patients consisting of NRTIs + NNRTIs genotypic DR test is essential. While with PIs or INSTIs its optional. Among Te patients, DR testing is recommended for all classes of drugs.
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Study of clinical profile and outcomes in progressive multifocal leukoencephalopathy in acquired immunodeficiency syndrome patients in the highly active antiretroviral therapy era – An observational study p. 156
Sumit Arora, Faiz M H. Ahmad, Rajesh Deshwal, Pradeep Behal
DOI:10.4103/ijstd.IJSTD_29_18  
Background and Objectives: Progressive multifocal leukoencephalopathy (PML) is a viral infection affecting the central nervous system (CNS) seen mostly in advanced human immunodeficiency virus (HIV) infection. There is limited data on the epidemiology and disease course of these patients from India. This study was aimed to determine the frequency of PML in patients with HIV/acquired immunodeficiency syndrome (AIDS) and the clinical presentation and prognosis of these patients. Materials and Methods: The study was conducted at a tertiary care HIV center in New Delhi. Data of 765 patients from our anti-retroviral therapy (ART) clinic during a span of 4 years were retrospectively analyzed and reviewed. The diagnosis was based on the clinical and radiological picture and exclusion of other differential diagnosis by cerebrospinal fluid and serological studies. Results: Of 765 patients with HIV/AIDS, 12 (1.56%) were diagnosed with PML on the basis of consistent clinical and radiological features after ruling out other differential diagnosis. PML was the initial presentation of HIV infection in 8 (55.5%) patients. 11 (89%) patients had CD4 count <200/μl. Insidious onset focal limb weakness (50%) and dysarthria (50%) were common symptoms. Magnetic resonance imaging of the brain revealed characteristic white matter lesions in all the patients. The estimated median survival was 40 months (95% confidence interval, 23.88–53.19 months). Interpretation and Conclusions: Our results show that PML is associated with high morbidity despite the institution of highly active ART (HAART), but mortality has significantly declined if ART is started early. Key to good response is early diagnosis and HAART.
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Emerging trends in sexually transmitted diseases in a tertiary care center in Davangere, Karnataka: A five year study p. 161
M Anirudh, Sugareddy , Aishwarya Sivuni, Nadiga Rajashekhar, HC Mangala
DOI:10.4103/ijstd.ijstd_109_20  
Background: Sexually transmitted diseases (STDs) are a public health challenge, and the epidemiological profile is variable by geographical region and distinct from that of other diseases. Accurate knowledge of emerging disease trends is crucial for formulating effective control strategies. Aims and Objectives: The aim and objective of this study were to identify the changing scenario and emerging trends of STDs in Davangere, Karnataka, by evaluating patients attending a tertiary care center. Materials and Methods: A tertiary care-based retrospective study was conducted by analyzing the clinical records of the attendees presenting to the STD clinic at Chigateri General Hospital affiliated to JJM Medical College in Davangere, Karnataka, for a period of 5 years from January 2015 to December 2019. The collected data were analyzed and statistically compared with other studies. Results: Out of the 614 patients studied, the male-to-female ratio was 2:1, with 30–39 age groups being most affected. Eighty-eight percent of patients were married, with 36.64% giving a history of extramarital contact. Homosexual and bisexual contacts were observed to be 5.21% and 0.65%, respectively. Viral STDs affected nearly half of the patients (49.51%), followed by fungal (28.88%), bacterial (22.63%), and others (3.1%). The most common STD observed was herpes genitalis as seen in 101 (24.48%) patients, followed by candidal balanoposthitis (17.1%). Thirty-three (5.7%) patients were diagnosed with more than one STD. Of these patients, 13 were seropositive for HIV, resulting in a prevalence of 2.12%. Conclusion: The epidemiological profile of STDs is ever changing, and this study found an increase in viral and fungal STDs and downward trend of bacterial STDs comparable to that of studies from other regions.
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Syphilis in the era of re-emergence: A 6-year retrospective study from a tertiary care center in South India Highly accessed article p. 165
Palanisamy Jeevanandham, Betsy Ambooken, Neelakandhan Asokan, Sarin Abdul Salam, Renu Venugopal
DOI:10.4103/ijstd.ijstd_109_21  
Background: During the last several years, we have observed a rise in the number of patients with syphilis in our center. Aims: To find out the trends in the presentation of syphilis to our clinic over a 6-year period and to analyze the clinicoepidemiological features of those patients. Settings and Design: A retrospective chart review. Subjects and Methods: We analyzed the case records of all cases of syphilis registered in our sexually transmitted infection (STI) clinic from October 1, 2012, to September 30, 2018. Syphilis was diagnosed based on clinical or serological evidence. We also evaluated these patients for any concomitant STI, including hepatitis B, hepatitis C, and HIV. Statistical Analysis Used: The data were analyzed using SPSS software (version 20). Chi-square test was done for comparing categorical data, and P < 0.05 was considered statistically significant. Results: During the study period, 215 patients with STI attended our clinic. Of these, 66 (31%) patients had acquired syphilis. Among them, 3 (4.5%) had primary syphilis, 23 (34.8%) had secondary syphilis, and 40 (60.6%) had latent syphilis. Fifteen (22.7%) patients had concomitant HIV infection. A statistically significant rise in the number of cases of syphilis compared with other STIs was noted in the latter half of the study period (P = 0.001). Among the 50 males with acquired syphilis, 29 (58%) were men having sex with men (MSM), including 19 bisexual persons. Among the five antenatal cases, two were detected very late in pregnancy. Conclusions: We observed a marked increase in the number of cases of syphilis during the latter half of the study period. Primary and secondary syphilis were more frequent among MSM, suggesting a need to strengthen targeted intervention programs among them. More rigorous antenatal screening is necessary to prevent congenital syphilis.
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A retrospective analysis of sexually transmitted infections among males presenting to a tertiary care hospital of India p. 170
Sunil Sethi, Nandita Sharma, Charu Singh, Hemant Chaudhry, Rajneesh Dadwal, Sakshi Malhotra, Vanita Gupta
DOI:10.4103/ijstd.ijstd_86_21  
Context: Sexually transmitted infections (STIs) are one of the most neglected diseases, leading to a high percentage of morbidity and mortality in India. The World Health Organization estimated that 20% of persons living with human immunodeficiency virus/acquired immunodeficiency syndrome are in their 20s and one out of twenty adolescents contract an STI each year. Aims: The present study was conducted to study the characteristics of the pattern of STI in adult males and study the prevalence of various STIs among them. Settings and Design: This retrospective study was conducted by retrieving records of males presenting to STI laboratory of our tertiary care hospital between (April 2018 and December 2019). Subjects and Methods: The patients comprised high-risk group males, approached through nongovernmental organizations (NGOs) and slum population visiting the dispensary attached to our institute. The age group of the patient included was between 0 and 85 years. Results: A total of 1023 males presented to our STI laboratory out of which 124 (12.12%) were symptomatic. The most common complaint was urethral irritation seen in 22.5%, followed by discharge in 9.6%. The most common sexually transmitted disease among symptomatic (34/124) as well as asymptomatic (172/899) men was syphilis showing a combined prevalence of 20% (206/1023). Out of 124 symptomatic patients, 29 (23.38%) complained of urethritis due to gonococcal infection. The association between the two was found to be significant (i.e., P < 0.05). Conclusion: STIs are a serious health problem in our country. Approximately 6% of the adult population have one or the other STI amounting to 30–35 million cases per year. An intensive study is the need of the hour which could help clinicians as well as microbiologists to control the spread of these infections.
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Etiology of cervicitis: Are there new agents in play? p. 174
Shikha Bansal, Aradhana Bhargava, Prashant Verma, Niti Khunger, Paveen Panchal, Naveen Joshi
DOI:10.4103/ijstd.ijstd_75_21  
Background: Considering the changing causative and resistance pattern of agents implicated in sexually transmitted infections (STIs), etiological diagnosis is imperative, especially in countries practicing syndromic management. This study was designed to identify etiological agents associated with cervicitis and to analyze their association with clinical and behavioral profile. Materials and Methods: Female STI clinic attendees presenting with cervico-vaginal discharge were examined for the presence of cervicitis. Endocervical swabs were collected for gram staining and real-time polymerase chain reaction was performed for various bacterial and viral STI agents in patients presenting with cervical discharge. A vaginal swab was also evaluated for bacterial vaginosis by Nugent's criteria. Results: Of 64 patients with vaginal discharge, 26.6% and 12.5% patients complained of genital itching and lower abdominal pain, respectively. Mean of 36.6 pus cells/hpf were observed, appreciably greater number in patients with Neisseria gonorrhoeae and Chlamydia trachomatis infections (P = 0.0063 and 0.0032, respectively). Pus cells were high (mean 68 pus cells/hpf) in patients with Ureaplasma urealyticum, though this may be attributed to coexisting N. gonorrhoeae. Agents isolated from endocervix were N. gonorrhoeae, 17 (26.6%), Trichomonas vaginalis, 4 (6.3%), HSV1 and C. trachomatis, 1 each (1.6%), HSV2, 9 (14.1%), U. urealyticum 5 (7.8%), Ureaplasma parvum 26 (40.6%), Mycoplasma genitalium (0%), and Mycoplasma hominis 11 (17.2%). Bacterial vaginosis was diagnosed in 14 (21.9%) patients. Multiple agents were isolated in 10 (two), 6 (three), 6 (four), and 1 (five) patients. Isolation of M. hominis and U. parvum was significantly associated with bacterial vaginosis (P = 0.04 and 0.003, respectively). Nonusage of condoms and mental stress predisposed to cervicitis. Conclusion: We concluded that there are changing etiological patterns of cervicitis. There is need to use tests that detect wider array of organisms, and can replace standard culture methods with molecular assays ,to increase the ability to diagnose more number of organisms implicated in cervicitis.
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CASE REPORTS Top

Kaposi's sarcoma: An interesting case report in a human immunodeficiency virus-positive heterosexual male p. 179
Harshitha K Reddy, Belliappa P Raju, Vishal Methre, Akshay Samagani
DOI:10.4103/ijstd.ijstd_11_21  
Kaposi's sarcoma (KS) is an angioproliferative neoplasm that affects skin and other organs. It is one of the acquired immune deficiency syndrome (AIDS)-defining conditions, which tends to occur at low CD4 count. It is the most common neoplasm among patients with AIDS in the Western population. It is rarely reported from India. We report the case of a 38-year-old human immunodeficiency virus-positive heterosexual male, with an unusual presentation of KS.
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Serum galactomannan in histoplasmosis in HIV p. 181
Ankita Baidya, Charu Goel Sachdeva, Priyanka Bhatia, Ankur Pruthi, Sangeeta Joshi
DOI:10.4103/ijstd.ijstd_92_21  
Histoplasmosis is an opportunistic infection (OI) in HIV infected patients. The Diagnosis is challenging due to lack of testing facilities. Hereby we report a young male who presented with fever & rash, was diagnosed with HIV and disseminated histoplasmosis. The timely management with antifungals was started after the of positive serum galactomannan report in the background of appropriate clinical setting.
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Prozone phenomenon in secondary syphilis with HIV co-infection: Two cases p. 183
Praneet Awake, Kalpana Angadi, Sourav Sen, Prasad Bhadange
DOI:10.4103/ijstd.ijstd_43_22  
Prozone phenomenon is defined as a false-negative response resulting from higher antibody titer which interferes with formation of antigen–antibody lattice, necessary to visualize a positive flocculation test. The prozone effect can be observed in syphilis testing with cases of very high antibody titers, such as secondary syphilis, or with human immunodeficiency virus (HIV) co-infection. We report two cases of prozone phenomenon in secondary syphilis with HIV co-infection who initially tested nonreactive for rapid plasma reagin test but tested positive with further higher dilution.
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Cutaneous manifestations leading to a diagnosis of a case of severe disseminated histoplasmosis in a human immunodeficiency virus-positive child p. 185
Aradhana Sood, Deep Kumar Raman, Asmita Sinha, Biju Vasudevan
DOI:10.4103/ijstd.ijstd_59_22  
This 9-year-old boy who was human immunodeficiency virus positive since birth presented with raised skin lesions, breathlessness, and cough and was treated as a case of disseminated tuberculosis. When no improvement was seen, he was referred to the dermatologist whose examination revealed papulonodular lesions with crusting over the face and extremities. Based on clinical suspicion of histoplasmosis, investigations done revealed a CD4 count of 3 cells/μL and histopathological features of histoplasmosis along with the disseminated disease. Cutaneous manifestations thus led to an early diagnosis of the case and a good prognostic outcome.
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Bowen's disease on two different unrelated anatomical sites (genitals and nail) in succession in an immunocompromised patient p. 189
Saba Mohammed Musaddique Ansari, Ankit Gupta, Chitra Shivanand Nayak
DOI:10.4103/ijstd.ijstd_2_22  
Bowen's disease (BD) is a premalignant condition. Its exact etiology is unknown but chronic arsenic and sun exposure, and human papillomavirus infection is known predisposing factors. Pigmented lesions of BD represent 1.7%–5.5% of all BD cases. BD in the nail unit is challenging due to its varied clinical presentations such as fissure, ulceration, warty lesion, paronychia, onychocryptosis, and nail dystrophy. We present the case of a 43-year-old married, immunocompromised male (HIV), with a CD 4 count of 478, on tenofovir, atazanavir boosted with ritonavir regimen, known diabetic presented with multiple asymptomatic discrete, rounded, hyperpigmented verrucous papules on both surfaces of shaft of penis and scrotum and a single, 4 cm × 3 cm, irregular, smooth surfaced, hyperpigmented plaque, on the base of the penis extending to the upper part of the scrotum of 1-year duration with history of multiple unprotected sexual exposures with unknown female partners. Regional lymphadenopathy and systemic complaints were absent. Biopsy from hyperpigmented verrucous papule and hyperpigmented plaque was consistent with verruca vulgaris and pigmented Bowen's disease, respectively. The patient was lost to follow-up. Ten months later, he presented with longitudinal melanonychia with a subungual hyperpigmented mass protruding beyond the distal nail margin near the lateral nail fold of the right middle finger nail with an absent Hutchinson's sign. Longitudinal excisional biopsy of nail lesion was consistent with BD. He was started on 5-fluorouracil 5% for BD of genitals and podophyllin application for verruca vulgaris with remarkable improvement in both the lesions and there is no recurrence of nail lesion after 9 months of excision.
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An inscrutable entity: A case report of late congenital syphilis p. 192
Pratiksha Kanubhai Rathwa, Jatin Chauhan, Nidhi Pravinkumar Patel, Hiral Shah, Nipul V Vara
DOI:10.4103/ijstd.ijstd_1_22  
Congenital syphilis is an outcome of maternal syphilis that occurs due to the transmission of Treponema pallidum via the placenta of untreated or inadequately treated pregnant women to their newborns. It is now a very rare cause of neurological, developmental, and musculoskeletal disability and death in infants after the advent of penicillin. Here, we report a case of late congenital syphilis presented with classic stigmata of syphilis at the age of 10 years. Reactive serological titer of rapid plasma reagin test and venereal disease research laboratory test confirmed the diagnosis.
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Erythema nodosum leprosum with genital ulceration - A rare and interesting case report p. 194
A Rupan, Seeniammal Sivanu, Palanivel Nirmaladevi
DOI:10.4103/ijstd.ijstd_31_21  
Erythema nodosum leprosum (ENL) is a type III hypersensitivity phenomenon seen in the lepromatous spectrum of leprosy. Involvement of external genitalia is very rare, and genital mucosal involvement is still rare. We report a 39-year-old man with episodic fever, red raised skin lesions predominantly in the lower extremities, and painful genital ulcers for 1-month duration. Genital examination revealed two irregularly shaped, mildly indurated, punched-out tender ulcers with yellowish slough on an erythematous base. Bilateral ulnar and common peroneal nerves were moderately thickened, more on the left side with bilateral stocking type of anesthesia associated with the left side fixed ulnar claw hand and left foot drop. By appropriate investigations and therapeutic elimination, the patient was diagnosed as borderline lepromatous Hansen's disease with type 2 reaction and grade 2 deformity. This case is reported for the rare occurrence of ENL lesions involving the genital mucosa in the form of ulceration.
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Congenital syphilis presenting as fulminant early-onset sepsis p. 196
Mayur Sureshbhai Shah, Apexa Prakash Jain, Ashutoshsingh N Rathod, Harshita P Jain, Dhrumika N Sheth, Shruchi Bhargava
DOI:10.4103/ijstd.ijstd_5_22  
Congenital syphilis (CS) is a rare entity and one of the most well-known congenital infections. A case of early CS presenting with fulminant sepsis is reported. A high index of suspicion is needed by the clinician to diagnose and treat this potentially life-threatening disease.
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Cytomegalovirus induced genital ulcer in human immunodeficiency virus positive patient p. 198
Kavya K Shree, Sachin Somashekar, Eswari Loganathan
DOI:10.4103/ijstd.ijstd_127_20  
Cytomegalovirus (CMV) can cause life-threatening disease in immunocompromised patients, such as those with human immunodeficiency virus. It is a rare but important cause of ulceration in the female genital tract. Although cutaneous manifestations are rare, there are growing reports of CMV infections in genital and perigenital ulcers in immunocompromised individuals. CMV disease of the female genital tract may result in significant morbidity, with fever, pain, bleeding, and superinfection, and it may be associated with the development of pelvic inflammatory disease and cervical intraepithelial neoplasia. There are several options for diagnosis and for safe treatment.
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Jarisch–Herxheimer reaction in syphilis p. 201
B Radhakrishnan Nair, S Murugan
DOI:10.4103/ijstd.ijstd_3_22  
Jarisch–Herxheimer reaction (JHR) is a focal, local, or systemic reaction, which follows the first dose of antisyphilitic remedy. JHR is a self-limiting reaction. The appearance of secondary syphilitic rashes following injection of benzathine penicillin was not so common nowadays to meet with JHR. Rashes were resolved completely a week after the injection. This case was reported to alert the physicians about the appearance of secondary syphilitic rashes following the antisyphilitic treatment which could be confused with hypersensitive reactions of penicillin.
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Disseminated histoplasmosis as a presenting manifestation in an HIV patient – A case report from South India p. 203
G Anu Kiruba Devi, Remya Raj Rajamohanan, Vinupriya Sakkaravarthi, Pampa Ch Toi, Malathi Munisamy
DOI:10.4103/ijstd.ijstd_45_21  
Histoplasmosis has heterogenous clinical presentation ranging from mild and self-limiting respiratory disease to disseminated forms with high mortality. In progressive disseminated histoplasmosis (PDH), patient presents with fever, lymphadenopathy, hepatosplenomegaly, adrenal enlargement, hemophagocytic lymphohistiocytosis and non-specific mucocutaneous lesions, usually in late stage of HIV. Cutaneous involvement is upto 25% in PDH which are papules, plaques, nodules and ulcers. Forty-two year old male, recently diagnosed as HIV positive presented with complaints of multiple painful ulcerated lesions over face, neck, tongue, arms, trunk & genitalia. Skin Biopsy was suggestive of histoplasmosis. Patient showed excellent response with amphotericin B and itraconazole. Since histoplasmosis is relatively uncommon, there should be a high-index of suspicion when an HIV patient presents with disseminated skin lesions.
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Case report of co-existing keratotic balanitis and squamous cell carcinoma in a 42-year-old male p. 206
Neerja Puri, Onkar Singh, Balvinder Kaur Brar
DOI:10.4103/ijstd.ijstd_50_21  
Although a number of premalignant and malignant lesions affect the genitalia of men, such as condyloma acuminata, erythroplasia of queyrat, squamous cell carcinoma, hyperkeratotic balanitis is rare and a patient showing both hyperkeratotic and well-differentaited squamous cell carcinoma is rarer. We report the case of a 42-year-old male, who had a hyperkeratotic plaque like lesions over the glans, with accompanied atrophic areas.
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Female sexual dysfunction: A clinical case series p. 208
Shrutakirthi Damodar Shenoi, Smitha S Prabhu
DOI:10.4103/ijstd.IJSTD_67_20  
Introduction: Female sexual dysfunction (FSD) is a much-neglected area of medicine possibly due to the stigma attached to sexual functioning in most religions and cultures. Materials and Methods: Here, we report a case series of 12 females with FSD from the data collated from the sexual dysfunction clinic of a tertiary care hospital in South India. Results: Of the 370 patients who were seen in the sexual dysfunction clinic, only 12 (3.24%) were women aged from 22 to 58 years with a duration of marriage 3 months to 25 years. The commonly encountered problems were dyspareunia and hypoactive sexual disorder. Three had nonconsummated marriages. After evaluation, two patients were treated with antipsychotics and all were offered psychosexual counseling. Conclusion: Female sexual dysfunction remains unrecognized and under reported, especially in patriarchal cultural societies of the Indian subcontinent.
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Case series of rare nonvenereal vulvar dermatoses p. 210
Swagata Tambe, Priyanka Patil
DOI:10.4103/ijstd.ijstd_40_21  
Nonvenereal vulvar diseases such as syringoma and vestibular papillomatosis can be difficult to differentiate from genital warts. Misdiagnosis of these conditions can lead to improper treatment without significant improvement and prolonged suffering. Histopathology may differentiate these conditions from sexually transmitted diseases and help in appropriate treatment. Here, we present case series of four rare vulvar diseases.
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LETTERS TO EDITOR Top

Correspondence - “Bone health, HIV-infected children, antiretroviral therapy, and hemoglobinopathy” p. 214
Rujittika Mungmunpuntipantip, Viroj Wiwanitkit
DOI:10.4103/ijstd.ijstd_104_21  
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Severe beginning of the end (BOTE) sign in molluscum contagiosum after initiation of antiretroviral therapy in an AIDS patient: A possible immune reconstitution inflammatory syndrome manifestation! p. 214
Ritu Mittal, Jasleen K Sandhu, Brijdeep Singh
DOI:10.4103/ijstd.ijstd_36_21  
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A study on HIV-infected individuals who reported CD4+ cell count below 100 cells/μl multiple times after more than 6 months of antiretroviral therapy at the apex tertiary referral hospital of India p. 216
Shesh Prakash Maurya, Ravinder Singh, Sanjeev Sinha, Hitender Gautam, Bimal Kumar Das
DOI:10.4103/ijstd.ijstd_103_21  
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Venereal disease research laboratory serology after COVID-19 vaccination: The first report p. 218
Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/ijstd.ijstd_113_21  
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AIDS and monkeypox: Cooccurrence and clinical concern on immunodeficiency p. 219
Pathum Sookaromdee, Viroj Wiwanitkit
DOI:10.4103/ijstd.ijstd_60_22  
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A rare case of genital porokeratosis associated with epididymo-orchitis p. 220
Monika Kulhari, Hania Qamar Khan, Syed Suhail Amin, Ruquiya Afrose
DOI:10.4103/ijstd.ijstd_56_22  
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Buschke–Lowenstein tumor: An intermediate between condyloma acuminata and verrucous carcinoma p. 222
Yogindher Singh, Sheela Kuruvila, Manjiri Phansalkar
DOI:10.4103/ijstd.ijstd_72_22  
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High-risk behavioral tendencies in human immunodeficiency virus-positive patients on antiretroviral therapy: A 5-year retrospective study from a tertiary care center p. 223
S Pradeep Nair
DOI:10.4103/ijstd.ijstd_63_22  
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Letter in response to “A case of primary and secondary syphilis presenting together as immune reconstitution inflammatory syndrome” p. 224
Bhushan Kumar, Akash P Mustari, Sunil Dogra
DOI:10.4103/ijstd.ijstd_40_22  
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Efficacy of potassium hydroxide in patient of giant molluscum contagiosum: Use of common agent with a novel technique p. 226
Neha Chetan Jangid, Kirankumar Solanki Madhusudan, Vinita U Brahmbhatt, Bela Shah Jashwantlal
DOI:10.4103/ijstd.ijstd_87_22  
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Isolated plantar keratoderma with uveitis: A rare presentation of secondary syphilis in an HIV-negative male p. 227
Krupeksha Krishnanath Naik, Prachi C Bhandare, Varadraj V Pai
DOI:10.4103/ijstd.ijstd_39_21  
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Tuberculosis and human immunodeficiency virus coinfection complicated by immune reconstitution inflammatory syndrome p. 229
Bhupen Barman, Md Jamil, Biswajit Dey, Pranav Ish
DOI:10.4103/ijstd.ijstd_99_21  
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CD4+ count change after COVID-19 vaccination: Observation on HIV-infected vaccine recipient p. 231
Rujittika Mungmunpuntipantip, Sim Sai Tin, Viroj Wiwanitkit
DOI:10.4103/ijstd.ijstd_90_21  
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Hyperpigmented papules over labium majus: A venereal cause or something else p. 232
Neel Prabha, Soumil Khare, Hitesh Yadav, Nighat Hussain
DOI:10.4103/ijstd.ijstd_16_21  
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Conventional versus reverse testing algorithm for syphilis in high-risk population: A diagnostic dilemma p. 233
Bineeta Kashyap, Rituparna Saha, Vikas Saini, Narendra Pal Singh
DOI:10.4103/ijstd.ijstd_23_21  
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Successful management of Zoons balanitis with the combination of pimecrolimus and excimer laser p. 235
Satish Udare, Priyanka Deelip Patil, Punam Chilgar
DOI:10.4103/ijstd.ijstd_59_21  
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Lichen planus hypertrophicus of the vulva – An isolated presentation p. 236
Kavita Poonia, Kanika Dogar, Mala Bhalla
DOI:10.4103/ijstd.ijstd_78_21  
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Accuracy of Gram-stained smears as screening tests for Neisseria gonorrhoeae: Brief communication p. 238
Mohamed Abdalla Khalid
DOI:10.4103/ijstd.ijstd_132_20  
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RESIDENTS PAGE Top

Eponymous Signs in STIs p. 241
Navnee Jain, Disha Baxi, Yogesh Marfatia, Rashmi Mahajan
DOI:10.4103/ijstd.ijstd_101_22  
Eponymous medical signs are those that are named after a person or persons, usually the physicians who first described them, as a tribute to the pioneers in the field who have significantly contributed toward the present understanding of the subject. They also help in providing an easy milieu for remembering the particulars of disease with their diagnostic significance including signs, tests, criteria, laws, or reflexes. Besides paying tributes to stalwarts in the field, who dedicated their lives for this cause, they also facilitate our current understanding of the great masquerade.
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PHOTOFEATURE Top

Crusted scabies in AIDS patient, a clinical challenge to be sorted out with a simple bedside test p. 246
Bonthu Indira, S Darsan
DOI:10.4103/ijstd.ijstd_31_22  
Norwegian or crusted scabies is a highly contagious severe variant of scabies described first among leprosy patients in Norway in 1848 by Boeck and Danielsen. Herein, we report a case of crusted scabies in an AIDS patient with large hyperpigmented macules covered with thick crusts present over the axilla, inguinal region, and gluteal region. Treatment started immediately with ivermectin, permethrin, and keratolytics after doing KOH microscopy. Mite population may exceed 1 million/person. Hence, it is highly infectious and can set off epidemics of scabies in home or institutions.
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PHOTO QUIZ Top

Suspicious perianal nodule p. 248
Ruben Linares Navarro, Gorka Ruiz-Carrillo Ramírez, Luis Miguel Valladares Narganes, Manuel Ángel Rodríguez Prieto
DOI:10.4103/ijstd.ijstd_115_21  
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