Circinate balanitis, although a common manifestation of reactive arthritis, is usually an associated finding present along with the triad of arthritis, conjunctivitis, and urethritis. It is rarely seen as the only preceding manifestation of reactive arthritis. We hereby report a case of circinate balanitis as alone preceding presentation of reactive arthritis that was successfully treated with topical pimecrolimus 1% cream.

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Sexually transmitted infections (STIs) are a public health problem, and their prevalence is rising even in developed nations, in the era of HIV/AIDS. While the consequences of STIs can be serious, the good news is that many of these complications are preventable if appropriate screening is done in high-risk individuals, when infection is strongly suspected. The diagnostic tests for STIs serve many purposes. Apart from aiding in the diagnosis of typical cases, they help diagnose atypical cases, asymptomatic infections and also multiple infections. But, the test methods used must fulfill the criteria of accuracy, affordability, accessibility, efficiency, sensitivity, specificity and ease of handling. The results must be rapid, cost-effective and reliable. Most importantly, they have to be less dependent on collection techniques. The existing diagnostic methods for STIs are fraught with several challenges, including delay in results, lack of sensitivity and specificity. With the rise of the machines in diagnostic microbiology, molecular methods offer increased sensitivity, specificity and speed. They are especially useful for microorganisms that cannot be, or are difficult to cultivate. With the newer diagnostic technologies, we are on the verge of a major change in the approach to STI control. When diagnostic methods are faster and results more accurate, they are bound to improve patient care. As automation and standardization increase and human error decreases, more laboratories will adopt molecular testing methods. An overview of these methods is given here, including a note on the point-of-care tests and their usefulness in the era of rapid diagnostic tests.

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The emergence of multi-drug resistant sexually transmitted infections (STIs) is causing a treatment crisis across the globe. While cephalosporin-resistant gonorrhea is one of the most pressing issues, extensively antibiotic resistant Chlamydia trachomatis and Mycoplasma hominis are also becoming commonplace. Experts have suggested that the failure of current treatment regimens are "largely inevitable" and have called for entirely new classes of antimicrobial agents. With the exception of several new classes of drugs primarily targeting nosocomial infections, progress has been slow. While pharmaceutical companies continue to introduce new drugs, they are based on decade-old discoveries. While there is disagreement about what constitutes new classes of antibiotics, many experts suggest that the last truly new family of antimicrobials was discovered in 1987. This review summarizes the existing literature on antibiotic resistance in common bacterial and protozoal STIs. It also briefly discusses several of the most promising alternatives to current therapies, and further examines how advances in drug delivery, formulation, concentration, and timing are improving the efficacy of existing treatments. Finally, the paper discusses the current state of pharmaceutical development for multidrug-resistant STI.

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Several studies have reported prevalence rate of reproductive tract infections (RTIs) but very few studies have described health seeking behavior of patients. This paper critically looks at and summarizes the available evidence, systematically. A structured search strategy was used to identify relevant articles, published during years 2000-2012. Forty-one full-text papers discussing prevalence and treatment utilization pattern were included as per PRISMA guidelines. Papers examining prevalence of sexually transmitted diseases used biochemical methods and standard protocol for diagnosis while studies on RTIs used different methods for diagnosis. The prevalence of RTIs has not changed much over the years and found to vary from 11% to 72% in the community-based studies. Stigma, embarrassment, illiteracy, lack of privacy, cost of care found to limit the use of services, but discussion on pathways of nonutilization remains unclear. Lack of methodological rigor, statistical power, specificity in case definitions as well as too little discussion on the limitation of selected method of diagnosis and reliance on observational evidence hampered the quality of studies on RTIs. Raising awareness among women regarding symptoms of RTIs and sexually transmitted infections and also about appropriate treatment has remained largely a neglected area and, therefore, we observed absence of health system studies in this area.

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Seborrheic keratosis (SK) is a common benign condition of the skin. It does not usually appear before middle age. Upper trunk and face are the sites most commonly involved. Lesions are also frequently seen on the extremities. SK of the genitalia is a rare entity. It has been frequently mistaken as genital warts and differentiation is made only on histopathology. We report a case of SK with polypoidal lesions restricted to the skin on and around the genitalia since 10 years. SK should be considered in the differential diagnosis of pedunculated lesions of the penis. The histopathology after shave excision is diagnostic.

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Background: In the past few years, the interest in STDs and their management has increased tremendously because of their proven role in facilitation of HIV infection, which, in turn, also increases the risk of acquiring STIs. Sexually transmitted diseases (STDs) are a major health problem affecting mostly young people, not only in developing, but also in developed countries Male circumcision is being considered as strategy to reduce the burden of HIV/AIDS. Aims: (i) To screen the new patients attending the STI clinic for bacterial causes of STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and Gardnerella vaginalis) and (ii) to evaluate the role of various risk factors in the prevalence of STIs. Materials and Methods: The present study was conducted on 200 patients attending the STI clinic. They were evaluated for the prevalence of HIV and bacterial STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and Gardnerella vaginalis) along with the role of risk factors particularly circumcision. Results: The prevalence of HIV was 7% and prevalence of other STI was 20%. The causative agents were Chlamydia 8%, Gonorrhea 7.5%, Bacterial Vaginosis 2.7% and Syphilis 2%. Conclusion: The factors found to be significantly associated with the prevalence of STI were circumcision, positive HIV status, education, religion, multiple sexual partners, contact with Commercial sex workers (CSW), non use of contraception, profession involving long stay away from home, and past history of STI. The present study suggests that circumcision is a protective factor for acquisition of STIs but other factors like sexual behavior, use of barrier contraceptives, drug abuse etc., also play a role.

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Inguinal and femoral buboes are defined as localized enlargement of lymph nodes in the groin that are painful, and may or may not be fluctuant. We report a case of 42-year-old female who presented with bilateral inguinal swelling of 6 months duration. After a complete evaluation, she was found to be a case of isolated inguinal tuberculous lymphadenitis. There was complete resolution with standard antituberculous therapy. Isolated inguinal tuberculous lymphadenitis though a rare entity in developed countries is not uncommon in developing nations. In this era of syndromic management of sexually transmitted diseases, which carries its own pros and cons, this case report emphasizes the need to look beyond the venereal causes and calls for thorough evaluation and management.

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Molluscum contagiosum is known to occur in the advanced stages of immunodeficiency in HIV infected patients and may present as atypical variants including giant molluscum. Here we describe the rare occurrence of giant molluscum contagiosum in an HIV seropositive child, which warranted surgical excision followed by skin grafting due to its unusually large size. We also highlight in this case report, a rare granulomatous inflammatory reaction pattern to molluscum with panniculitis.

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Background: Changing trends of sexually transmitted infections (STI) and HIV/AIDS has been noted in the literature over years, depending to some extent on the geographical and cultural factors of the region. In Kashmir Valley also, the pattern of STI may be different from the rest of the country. Aims of the Study: The aim was to present the experience with patterns of STI in Kashmir. Materials and Methods: Retrospective hospital-based study carried out by detailed analysis of case records of 5-year period. Results: A total of 184 patients, 100 males and 84 females, had specific STI. Genital ulcer disease was the presentation in 54 patients (29.35%), out of which herpes genitalis was found in 27 patients (50%), followed by chancroid in 13 (24.07%) and syphilis in 10 (18.52%) patients. 42 female patients (22.83%) presented with vaginal discharge, out of which, 24 (57.14%) had vaginal candidiasis. 24 males (13.04%) presented with urethral discharge, out of which, 15 (62.5%) had nongonococcal and 9 (37.5%) gonococcal urethritis. Genital molluscum contagiosum (MC) was found in 19 patients (10.33%), and warts in 15 (8.15%). HIV positive serology was detected in 3 patients (1.63%). Conclusion: The most common STI encountered in our study was genital ulcer, followed by vaginal discharge, urethritis, genital MC, and genital warts. Herpes genitalis was the commonest genital ulcer; candidiasis was the most common cause of vaginal discharge and nongonococcal urethritis the most common cause of urethritis. These findings are by and large similar to those noted in other parts of our country.

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Background: Human immunodeficiency virus (HIV) infection remains a global health problem, although the development of highly active antiretroviral therapy (HAART) has significantly modified the course of HIV disease into a manageable disease with improved quality-of-life mainly in the developed countries. Very few studies are available regarding effect of HAART on oral lesions in developing countries like India. Aims and Objectives: The aim was to document and compare oral lesions in HIV-seropositive patients before and after HAART. Materials and Methods: Oral manifestations were recorded in 320 HIV seropositive patients attending to the Voluntary Counseling and Confidential Testing Centre at the Government General Hospital, Guntur, before and after treating with HAART and the results were statistically analyzed using Student's t-test and Chi-square test. Results: Oral Candidiasis was significantly reduced in patients under HAART after 3 months. Furthermore, there was decreased incidence of periodontal diseases, but increased hyperpigmentation in patients undergoing HAART. Conclusion: The oral manifestations of HIV infection have changed due to the advent of HAART. Many opportunistic infections have resolved as a result of an improved immune system. Though the risk of hyperpigmentation in those with HAART has increased the prevalence of oral candidiasis and periodontal diseases were less in patients who had access to HAART.

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Cutaneous horn refers to unusually cohesive keratinized material and not a true pathologic diagnosis. Though cutaneous horn has been described at various sites, horn over the penis is very rare and represents the most unusual site. The role of chronic irritation, phimosis, surgical trauma and radiotherapy have been implicated in penile horn formation. Penile horns present as elongated, keratinous, white or yellowish projections that range from a few millimeters to centimeters in size arising from the glans penis. Histopathology of the keratotic mass reveals nothing but keratin. The underlying mass may vary from verruca vulgaris to squamous cell carcinoma. The treatment is based on the pathology.

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Introduction: One of the major medical concerns in people living with HIV/AIDS (PLHA) is management of diarrhea that can lead to severe morbidity and mortality. Such clinical scenario warrants an analysis of intestinal parasites, which are important opportunistic pathogens in PLHA. Owing to the scarcity of recent pattern of intestinal opportunistic infections from this region, the study was designed to determine the opportunistic parasites causing diarrhea in PLHA; and to find out whether there is any significant difference in the enteric parasitic pathogens in patients with different immunological status and in those on highly active anti retro-viral therapy (HAART). Materials and Methods: Analysis of the spectrum of intestinal parasites was carried out with 192 subjects in two groups (142 HIV sero-positive patients having diarrhea and 50 HIV sero-negative patients having diarrhea). The routine light microscopic examination was carried out to determine the infection and CD4+ T-Lymphocyte count was estimated using flow cytometry. Results: Enteric parasites were detected in 35.9% of HIV sero-positive patients having diarrhea and 18% of HIV sero-negative patients having diarrhea. Most common opportunistic enteric parasite was Isospora belli (11.5%); others were Entamoeba histolytica (4.7%), Cryptosporidium sp. (3.6%), Strongyloides stercoralis (3.1%), Giardia intestinalis (3.1%) and Cyclospora cayatanenesis (1.6%). Opportunistic enteric parasites were detected in significantly low numbers in patients with CD4+ T-Lymphocyte counts >500 cells/ml; and in those taking HAART.

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The presentation and course of Sexually transmitted diseases(STI) may be altered by presence of coexisting HIV status. Aim of the study was to study the prevalence of STI in 50 females with HIV infection and 50 females without HIV infection and to study the pap smear of patients to look for any cellular changes (dysplasia) due to sexually transmitted infections. Material and methods: The present study was an observational study, which was undertaken on 100 females with STIs (50 females with coexistent HIV infection and 50 females without HIV infection), in the age group 15-49 years attending Skin and VD OPD of Rajindra hospital, Patiala. Results: In our study, the commonest presenting complaint in case of both HIV positive (66%) and HIV negative (80%) women was vaginal discharge. PAP smear abnormalities were present in 28 (56%) HIV positive women and 11 (22%) HIV negative women. In case of HIV positive women, the inflammation was trichomonal in 4 (8%), bacterial in 2 (4%), fungal in 2 (4%) and non-specific in 20 (40%) patients. In HIV negative women, the inflammation was trichomonal in 2 (4%) patients, bacterial in 2 (4%) patients and non-specific in 7 (14%) patients. The difference in abnormality seen in PAP smear between HIV positive and HIV negative women is statistically significant only in case of non-specific inflammation which is more common in case of HIV positive women. Conclusion: From the present study, it was concluded vaginal discharge was the commonest presenting complaint in both HIV positive and HIV negative women, though the commonest cause of vaginal discharge was candidiasis in HIV positive females and bacterial vaginosis in HIV negative females. Also, PAP smear abnormalities were significantly higher in HIV positive women than HIV negative women. So it is important that HIV positive women should have complete gynecological evaluation including a PAP smear with aggressive screening of STIs.

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Gumma is a characteristic lesion of tertiary syphilis that is rare nowadays, but still rarer is squamous cell carcinoma (SCC) arising from it. A 74-year-old male presented with throat pain and nasal twang with a past history of genital ulcer. Examination revealed a well-defined ulcer with a perforation of 1.5 cm over the hard palate with induration and nodularity at the margins. This patient also had leukoplakia over the ventral aspect of the tongue. His treponema pallidum hemagglutination assay was positive, and biopsy revealed well-differentiated SCC from the lesion over the palate and leukoplakia with dysplasia from the lesion over the tongue. Patient is on treatment from radiotherapy. To conclude, this is a unique presentation of syphilitic gumma with palatal perforation with SCC and syphilitic leukoplakia with Ca in situ over tongue. Thus, serology for syphilis should be done in all patients with SCC of the oral cavity.

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Human immunodeficiency virus (HIV)-related lymphomas are predominantly aggressive B-cells lymphomas. The most prevalent of the HIV-related lymphomas are diffuse large B-cell non-Hodgkin's lymphoma (NHL), which includes primary central nervous system lymphoma, and Burkitt lymphoma, whereas primary effusion lymphoma, plasmablastic lymphoma (PBL), and classic Hodgkin lymphoma are far less frequent. Of these, PBL is relatively uncommon and displays a distinct predilection for presentation in the oral cavity. In this manuscript, we report a primary testicular form of PBL in 44 year-old Border Security HIV positive patient who presented with bilateral testicular swelling of 1-year duration. On cytopathological and subsequent histopathological examination, the diagnosis of bilateral plasmablastic NHL was made. Extensive systemic work-up failed to reveal any disease outside the testes. Immune suppression rather than HIV itself is implicated in the pathogenesis of lymphomas. Herein, we report a case of PBL as AIDS-related malignancy presenting in testes and its correlation with CD4+ count.

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Trichoadenoma of Nikolowski is a rare, benign, well differentiated, slowly growing tumor of the hair follicle which was first described in 1958 by Nikolowski. It usually occurs as a solitary nodular lesion between 3 and 15 mm in diameter. It commonly occurs on the face or the buttocks. Herein we report a case of a slowly growing nodular plaque over the vulva of a 60-year-old female, histopathologically proven to be a trichoadenoma. The lesion was completely removed by ablative carbon dioxide laser (CO2).

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Background: Yeasts are important opportunistic pathogens, in individuals infected with human immunodeficiency virus (HIV). Yeast species inhabiting the oral mucosa of HIV-infected persons can act as source of oral lesions, especially as the individual progresses towards immunocompromised state. Present study was conducted to evaluate the diversity of yeasts in oral cavities of asymptomatic HIV-infected persons and their association with CD4 ⁺ cell counts. Materials and Methods: 100 HIV seropositive subjects and 100 healthy controls were screened for oral yeast carriage using standard procedures. Results: Of the 100 HIV-seropositive persons screened, 48 were colonized by different yeasts, either alone or in association with another species. Candida albicans was the most common species (56.90%) while non C. albicans Candida (NCAC) accounted for 39.65%. Among NCAC, Candida tropicalis and Candida krusei were most common. One isolate each of rare opportunistic pathogenic yeasts, Geotrichum candidum and Saccharomyces cereviseae, was recovered. The control group had an oral candidal carriage rate of 23%; C. albicans was the predominant species, followed by Candida glabrata, C. tropicalis and Candida parapsilosis. Antifungal susceptibility testing revealed no resistance in C. albicans, to the commonly used antifungal agents, whereas resistance or dose dependent susceptibility to fluconazole was observed in some of the NCAC species. Conclusion: Oral carriage of opportunistic pathogenic yeasts was greater in HIV-seropositive persons heading towards immunocompromised state, as evidenced by their CD4 ⁺ cell count. The predominant yeast isolated in this study (C. albicans), was found to be susceptible to commonly used antifungals.

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Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic disorder of the skin. Atypical variants of PG such as vegetative PG, bullous PG, and pustular forms are described in literature. Occasionally, granulomatous reaction in dermis may be seen on histology when PG is associated with Crohn's disease or in the vegetative variant of PG. We report a case of granulomatous PG involving the genitalia in a 43-year-old female without associated inflammatory bowel disease.

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Introduction: Heterosexual route is the most common mode of human immunodeficiency virus (HIV) transmission among married couples in India. The aim of the study was to determine HIV seroconcordance and serodiscordance among couples when one of the partners is HIV positive. Materials and Methods: A retrospective study which included HIV positive married cohabiting cases was carried out at the Department of Skin-VD, Medical College, Baroda. Detailed history of high-risk sexual behavior, blood transfusion (BT) and sexually transmitted infections (STIs) was taken. All the cases were examined for the presence of STIs and all males were examined for circumcision. The spouses of these cases were tested for HIV to know the seroconcordance/serodiscordance. Results: A total of 66 HIV positive cases were studied which included 34 males and 32 females. Forty-five cases had seropositive spouses that consisted of 20 out of 34 HIV positive males and 25 out of 32 HIV positive females. History of STI was present in 13 cases. History of BT in one of the spouses was present in 15 of 45 seroconcordant couples while in 6 out of 21 serodiscordant couples. Among 34 HIV positive males, circumcision was present in 8 cases out of which 6 were serodiscordant. Discussion: About 68% concordance suggests continued intramarital transmission probably due to lack of spousal communication and late testing. In cases having transfusion transmitted HIV, seroconcordance rate was found to be high. Such cases are usually asymptomatic and hence tested late but continue to transmit HIV by unprotected sexual activity.

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The human immunodeficiency virus (HIV) is known to cause altered disease presentations. We present here, the case of a 14-year-old boy who came to us with a chronic, painful, nonhealing ulcer of 4 months duration over the dorsum of right hand. Before our observation, he was variably diagnosed and treated as atypical mycobacterial infection, deep fungal infection, squamous cell carcinoma, and pyoderma gangrenosum. On administration of systemic corticosteroids his condition worsened, after which he was tested for, and found to be HIV positive. He was put onto valacyclovir, responded slowly, with healing after 2 months of antiviral therapy. The case report highlights unusual presentation in an under-considered age group and a slow response to otherwise effective therapy.

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A 14 year old boy, said to have had multiple transfusions during infancy, was brought to the hospital for complaints of pain over right thigh for one week duration. MRI reveals multiple osteolytic lesions with enhancing hyperintense bone marrow lesions over iliac bones, right acetabulum and lumbar vertebral bodies and enlarged para-aortic, iliac and inguinal lymph nodes. CT of the whole body revealed osteolytic lesions on skull, mandible, right scapula, head of both humeri, L1 and L4 vertebrae, 5 ^th and 10 ^th ribs, both acetabulum and ala of sacrum along with enlargement of cervical, axillary and mesenteric, iliac and inguinal nodes. HIV ELISA was positive. Viral load was 141,700 copies/ml. CD4 count was 226 cells/mm ³ . Multiple biopsy from the lesions and bone marrow revealed no evidence of tuberculosis and malignancy. Now the boy is on ART (ZDV + 3TC + EFV) since August 2013. His CD4 count improved and viral load became undetectable and he gained weight within 5 months of ART. Due to the rarity of its presentation, this case report is being reported.

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