Cutaneous lymphangiectasia, also called as acquired lymphangioma, is a benign cutaneous disorder involving the dermal and subcutaneous lymphatic channels. It can rarely occur on the vulva. We describe a 35-year-old woman who came with multiple raised lesions over the vulva and left upper thigh of 1 year duration. She gave history of getting treated for multiple swellings that developed over right side of the neck and inguinal regions on both sides three decades ago. On local genital examination, the patient had a large polypoidal growth involving both sides of the vulva, left upper thigh, and over pubic area. Multiple linear scars were present over the upper thighs and groin bilaterally. The patient underwent simple vulvectomy and left thigh growth excision. Histopathological examination of the vulvectomy specimen confirmed our diagnosis.

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Blistering over the vulval region can be due to multiple causes, each having nearly a similar presentation. Thus, a thorough understanding of the various etiologies is necessary to make a correct diagnosis. Clinically, there always remains some ambiguity as to the precise diagnosis, thus investigations, such as biopsy, play a very essential role in clinching the correct diagnosis. Most of these disorders are amenable to treatment and thus an early intervention is a must to prevent morbidity associated with these diseases.

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The importance of randomized controlled trials (RCTs) versus observational studies has been debated for several years. However, the question is not whether RCTs are better than observational study designs. RCTs certainly provide the most unbiased answers in scenarios where it is logistically and ethically feasible to conduct both RCTs and observational studies. That is, study design is not a choice but a function of matching the research question to provide the most unbiased answers. The basic concept that underpins every clinical research project is the requirement of a clearly defined research question domain. Broadly, the clinical research question domain relates to prognosis, diagnostic accuracy, treatment or adverse events. While RCTs provide the most unbiased answers on questions related to the efficacy of treatments, other designs are better suited to answer questions related to prognosis or diagnostic accuracy of tests. In this paper, we illustrate the significance of matching study design to the research question domain while using clinical scenarios as an example. Although there are several other question domains that also concern the practice of medicine, we are only focusing on study designs concerning the issue of prognosis and diagnostic accuracy in this paper.

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Objective: The anal sex among heterosexual couples is on the rise as reported in many scientific studies. Considering that unprotected anal sex has higher risk of human immunodeficiency virus (HIV) transmission than the vaginal sex, we undertook a study to understand the anal sex practices among Female Sex Workers (FSW). Materials and Methods: The study was conducted among FSW attending 11 randomly selected sexually transmitted infection (STI) clinics in Bill and Melinda Gates supported targeted interventions in Andhra Pradesh. A structured questionnaire was administered to the 555 FSW attending these clinics by project clinic counselors. Informed consent was obtained from all the study participants. Results: Engaging in anal sex was self reported by 22% of sex workers, though demand from clients was reported to be much higher (40%). The reasons for anal sex practices included more money (61%), clout/influence of the client (45%), risk of losing client (27%), and forced sex (1.2%). Factors associated with anal sex were higher number of clients, higher duration of sex work, higher income, and older age group. Associated risks perceived by FSW were bleeding and injury to anal canal (98%) while only 28% associated it with higher HIV transmission risk. Reported Condom and lubricant use was about 88% and 39% respectively. Conclusion: The study shows that there is frequent anal sex, inconsistent condom and infrequent lubricant usage, economic and physical coercion, and low awareness of STI/HIV transmission risk among FSW, which have serious implications for HIV prevention programmes. There is a need to focus on anal sex education and use of lubricants along with condoms during anal sex in FSW-targeted interventions in AP.

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Background: Men who have sex with men (MSMs) are a vulnerable population for spread of sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). Apart from being important for HIV transmission, they tend to have a different distribution patterns of STDs. Few Indian studies have looked into this aspect. Objective: We retrospectively analyzed the available data on MSM from Suraksha clinic of a tertiary care hospital in a metropolitan city from 2004 to 2010. Materials and Methods: A total of 75 MSM constituting 11.4% of the total 660 patients visited our Suraksha clinic in these 6 years. The clinical and behavioral profile of each patient along with the pattern of STDs was evaluated. Observations and Results: 75% of the MSMs were promiscuous; one-third of them indulging in only homosexual activities. Syphilis was the most common STD, followed by condyloma acuminata, herpes genitalis, and gonorrhea. On comparing the data on the STD profiles of the heterosexual males, predisposition toward bacterial STDs among MSMs was observed. Conclusion: Identification of MSMs is important as most of them are bisexual and promiscuous, thereby playing a role in spread of STDs in vast number of partners. The profile of STDs also differs in MSM, which makes it all the more important to identify them.

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Gonorrhoea is a sexually transmitted disease marked by urethritis in males; it may also be transmitted to other organs through contact with infected genital secretions or urine, although rare in this era of modern antibiotics and rapid diagnostic tools. It could pose a difficult situation when we encounter emerging resistant strains. This paper reports a male who presented initially with unilateral gonococcal conjunctivitis contracted via autoinoculation and was found out to be suffering from gonococcal urethritis.

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Objectives : To assess the impact of scaled-up sexually transmitted infection (STI) intervention under National AIDS Control Program (NACP) III and to examine the profile of STI/RTI clinic (now named Suraksha Clinic) attendees. Materials and Methods : A retrospective study by data analysis was done from April 2008 to March 2010. The scaled-up intervention comprised of (i) adopting enhanced syndromic approach, (ii) capacity building by appointing counselors and trainings of staff, (iii) strengthening STI/RTI clinics by provision of logistics and privacy by civil works, and (iv) supervisory support. The outcome which directly influenced service delivery was evaluated within this framework. Results : Sixteen "Suraksha Clinics" have been remodeled, equipped with supplies and laboratory set up. A total of 64,554 clinic visits were reported of which 27,317 [42%] attended the clinics for index STI/RTI complaint(s). Majority of the clients (44%) were young, 25-44 years old. Male to female ratio was 1:1.8. In females, the commonest complaint was lower abdominal pain (25%) and vaginal discharge (33%), the commonest syndrome. Amongst laboratory-confirmed STIs, 305 (1.4%) attendees were positive for trichomoniasis, while bacterial vaginosis was corroborated in 230 (1.07%) patients with clue cells. Amongst antenatal women, 251 were reactive for syphilis (≥1:8 dilutions). 10,579 partners of index STI/RTI patients were notified and partner management was attained to the level of 99%. Conclusion : Preliminary results show increased utilization of STI clinical services, though laboratory services need further strengthening. Continued supportive supervision and capacity building will enable skill development and quality monitoring.

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Introduction: Prevalence of sexually transmitted infection shows regional variations. Though a rising trend of prevalence of viral STI s has been observed, syphilis still continues to remain a commonly diagnosed STI. Aim: To study the current status of acquired syphilis in a tertiary care hospital. Materials and Methods: Retrospective analysis of all the cases of acquired syphilis registered in our hospital from 2005 to 2009 was done. Complete epidemiological, clinical, and investigational data were recorded and assessed. Observation: Total of 570 cases attended the STI clinic from year 2005 to 2009. 42 (7.36%) cases were diagnosed as syphilis. There were 32 (74%) males and 11 (26%) were females. 25 (60%) were married. Only two patients were less than 15 years of age. Primary syphilis was diagnosed in 21 (50%), secondary in 10 (24%), and latent in 11 (26%) cases. Two (9.5%) of primary syphilis showed multiple chancre. Concomitant primary chancre and lesions of secondary syphilis were seen in 2 (20%) patients. Secondary syphilis presented as condyloma lata (50%), maculo-papular rash (40%), and lues maligna in one patient who was HIV positive. Mixed infection was diagnosed in eight patients of which herpes genitalis was the commonest. Two patients were serologically positive for HIV. Conclusion: Incidence of syphilis had shown a constant trend over last 5 years. In lieu of change in trends of sexual practices, condyloma was the commonest presentation of secondary syphilis. Pustular syphilis was observed in association with HIV and could be a marker of the immune-deficient state.

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Introduction: Trichomoniasis is a relatively neglected area of research in Sri Lanka. Given the number of infections observed, an analysis of sociodemographic characteristics of patients would be valuable in prevention. Materials and Methods: Data were collected from 359 newly registered women at a tertiary level sexually transmitted diseases clinic over a period of 18 months. Trichomoniasis was diagnosed by culture of vaginal swabs collected from the posterior fornix. Results: The prevalence of trichomoniasis in the sample was 7.2%. Of those who tested positive for trichomoniasis, 76% were in the age group of 21-45 years, 68% were married and living with a spouse and 60% were unemployed. A diagnosis of Trichomoniasis was associated with being married (OR, 1.6; CI, 0.56-4.41), age over 33 years (OR=1.3, CI, 0.55-2.9), being employed (OR, 1.3; CI, 0.56 - 2.94), having an education of less than ten years at school (OR, 3.0; CI 1.28-7.26) and not using condoms during the last sexual act (OR 2.0, CI 0.84-4.86). The risk was less among commercial sex workers (OR, 0.3, CI: 0.14-0.85), those with multiple sexual partners (OR, 0.2; CI; 0.073-0.408) and women reporting extramarital sexual relationships (OR, 0.3; CI, 0.128-0.733). Conclusions: Education on safe sex and recognition of symptoms is currently targeted at high risk groups such as commercial sex workers. Extending these programmes to the rest of the community will further reduce the risk of transmission of trichomonas.

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Penicillium marneffei is a dimorphic fungus, which can cause fatal infection in HIV-infected patients. The aim of this article is to report a rare case of penicillinosis in an HIV-positive patient from a nonendemic area such as Paonta Sahib, Himachal Pradesh. The patient presented with nonhealing painful ulcer on tongue, chest pain, cough, and chronic diarrhea. Diagnosis was made possible through blood investigations and culture reports of saliva and blood samples.

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Congenital syphilis may present with unusual symptoms in early stages which needs to be identified for prompt treatment. Here, we present a case of 13-day-old female child with congenital syphilis presenting with cleft lip.

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We report a case of recurrent deep venous thrombosis in a 44-year-old woman, intravenous drug user and HIV-infected, who injected cocaine in the groins and veins of the dorsum of the feet. She suffered several episodes of deep venous thrombosis and soft-tissue infections in the lower limbs. Images of Doppler ultrasound scan revealed thrombosis in the right popliteal vein with partial recanalization and calcified thrombi in the territory of the right femoral vein. After use of heparin and oral anticoagulation, her clinical evolution was uneventful, and she was asymptomatic at the occasion of the hospital discharge. This report calls for better awareness about injections in the groins and superficial femoral veins, which are part of the deep venous system. Thrombosis related to HIV infection is highlighted.

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A 35-year-old male diagnosed as HIV with tuberculous lymphadenopathy, presented with acute increase in size of neck swelling and fever. The patient was on antiretroviral therapy and antitubercular treatment. Investigations revealed raised CD4 counts and the pus from swelling showed mycobacteria other than tuberculosis (MOTT) on bacteriological examination.The patient was started on steroids, azithromycin, and ciprofloxacin to which he responded well. We report this case to highlight the occurrence of immune reconstitution disease in HIV patients and also to bring out the fact that atypical infection like MOTT may confound the diagnosis even in regions like ours where MOTT is rarely reported.

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