Mycoplasma genitalium (MG) is an emerging sexually transmitted pathogen. It is an important cause of nongonococcal urethritis in men and is associated with cervicitis and pelvic inflammatory disease in women, putting them at risk of infertility. Multiple factors that aid pathogenesis of MG include its ability of adhesion, gliding motility, and intracellular invasion by means of the tip organelle. Through intracellular localization and antigenic variation, MG could result in treatment-resistant chronic infection. There are limited data on the prevalence of MG in Indian patients with urogenital syndromes. Recently, a high prevalence of extra genital infection with MG has been reported. Molecular assays are the major diagnostic techniques of MG infection. Antimicrobial agents such as macrolides, along with fluoroquinolones, are the treatment of choice for MG infections. The issue of drug resistance to azithromycin and fluoroquinolones in MG is rising globally. As molecular tests are becoming available for MG, both for the diagnosis and the detection of antimicrobial resistance, any patient with MG infection should then be tested for antimicrobial resistance. Consideration of MG as a cause of sexually transmitted disease in the Indian population is crucial in diagnostic algorithms and treatment strategies. The purpose of this review is to understand the prevalence of MG in different clinical scenarios, molecular mechanisms of pathogenesis, current status of antimicrobial resistance, and its impact on MG treatment.

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Vaginal discharge in children can be due to many causes. Foreign body in vagina is an unusual cause. Foul-smelling, blood-stained vaginal discharge should raise the suspicion of foreign body in vagina. Magnetic resonance imaging (MRI), vaginal examination under general anesthesia may detect foreign bodies in vagina. We found a cotton fiber ball in vagina, probably caused by the child's teddy bear as a cause of vaginal discharge in a 5-year-old child. A repeat MRI suggested foreign body in the vagina and vaginal exploration under general anesthesia helped for the removal of cotton fiber ball, which led to complete clearance of the vaginal discharge in the child.

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Genital warts caused by human papillomavirus are one of the most common sexually transmitted diseases seen in the outpatient department. Treatment modalities of genital warts vary depending on the size, site, extent of the lesions, and patient compliance. Here, we report a case of extensive genital warts managed with oral retinoids which resulted in complete clearance.

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Substantial increase in the outbreaks of sexually transmitted infections (STIs) and associated mortalities have raised international concerns. Concurrent with the escalation of established STIs, developing epidemics and outbreaks of newly emerging sexually transmissible pathogens pose serious problems for people and added burden and challenges for public health practitioners and researchers. Importantly, most of the emerging STIs are frequently found among vulnerable groups, such as men having sex with men and human immunodeficiency virus patients, which may result in large outbreaks in the near future. Furthermore, enhanced spread of antimicrobial resistance among these pathogens ever more limits treatment options for STIs. Thus, it is the optimal time to consider whether an infectious agent is sexually transmissible and develop treatment protocol for handling new STIs with pandemic potential. In this review, we explore emerging STIs, their current epidemiological status, and future perspective.

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The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic still exists as a major global public health burden, especially in the middle- and low-income countries. Antiretroviral therapy (ART) remains a sole option to reduce the mortality and morbidity associated with this disease as no approved vaccine candidates are available. About 67% of the people living with HIV (PLHIV) have received the ART in 2019 worldwide. As a consequence of increased ART regimes, the prevalence of drug resistance mutations (DRM) also has been escalating and it would become a significant barrier in achieving the United Nations Programme on HIV/AIDS goal of eliminating HIV by 2030. So far, nucleoside reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), and protease inhibitor-(PI) associated DRM have been reported across the globe with a considerable escalation in the annual prevalence rate of pretreatment NNRTI DRM. Conversely, NRTI-associated DRM is still under 5%, with a few scattered reports of significant increase from few countries such as southern and eastern Africa. Likewise, in India, the propositions of NRTI and NNRTI-associated DRM have increased since the commencement of the nationwide ART program in 2004. In agreement to the global trend, M1841/V, a type of NNRTI, remains as a dominant DRM among PLHIV. In this review, we tried to collate various mechanisms of DRM in PLHIV. In addition, patterns of HIV DRM in India and their future challenges on drug-related mutations have been discussed.

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Context: Lichen planus (LP) is known to be associated with viral infections such as hepatitis B and C, but its association with HIV is rarely reported. Lichenoid drug eruptions have been implicated as the side effects of anti-retroviral therapy. Aims and Objectives: The aim of this study is to study demographics, clinical, histological, and immunological profile of the HIV patients presenting with lichenoid dermatitis. Subjects and Methods: HIV patients presenting with LP such as lesions were evaluated with complete history and physical examination. Demographic profile of patients was studied with features such as age, sex, duration of disease, distribution of the lesions, CD4 count, concomitant medications, associated comorbidities, and response to the treatment. Results: Twenty-one HIV patients presenting with LP such as lesions were studied. Of these, 20 patients had LP and one patient had lichenoid drug reaction. The age of the patient ranged from 40 to 60 years with no sex predilection. The duration of lesions ranged from 15 days to 7 years. Eleven patients had simultaneous cutaneous and oral involvement, five patients had only oral involvement and four patients of LP and one patient of lichenoid drug reaction had only cutaneous lesions. All the patients were on antiretroviral therapy, mainly on lamivudine, zidovudine, and nevirapine. Almost all the patients had CD4 count of more than 250 at the time of presentation. One patient was diagnosed to have lupus erythematosus and LP overlap. Patients were treated with oral medications such as corticosteroids, methotrexate, and dapsone and topical medications such as corticosteroids and calcineurin inhibitors. Conclusions: The appearance of LP such as lesions in HIV patients is a rare occurrence with 11 cases of LP reported till date. Our case series of 20 patients will throw light on possible etiology and difficulties in the management of LP such as lesions in HIV patients.

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Background: HIV-infected individuals can live with the virus for decades, and the physicians have to review the long-term health implications of weight gain as they would for any other patient. Although the integrase strand transfer inhibitors (INSTIs) class of drugs are one of the most popular regimens used for rapid reduction and maintenance in HIV cases, the weight gain resulting from their use is concerning. The use of dolutegravir (DTG) an INSTI is observed to have a weight gain in people living with HIV. Since bictegravir is also an INSTI, it is expected to show a similar weight gain. Objective: This retrospective analyses the change in the weight in 22 patients, who showed a trend of increase in weight when on DTG and later when switched to bictegravir therapy showed reduction in the increased weight. Methods: This is a retrospective analysis from our clinic (Dr. Saple's Clinic) in Mumbai from the duration of March 2018 to March 2021. Excessive weight gain was observed when the patients were on DTG therapy. The therapy was then switched to an equally potent integrase strand inhibitor bictegravir to get the benefit of efficacy of antiretroviral therapy and avoid the weight gain effect seen with DTG. Results: In our case review, we found results contrary to this. After 22 patients were treated on DTG for 9 to 24 months (mean 20.68 months), the baseline weight of 74.04 kg increased significantly to 84.26 kg (P < 0.05). After switching over to bictegravir for a mean period of 8 – 12 months (mean 11.72 months), this weight reduced to mean of 77.08 kg, a drop was clinically observed but was not statistically significant. Conclusion: Our finding could be the first instance were weight loss has been reported post switching the patients from DTG therapy to Bictegravir. Considering smaller patient population this outcome may need further confirmed through large group study.

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Background: The overall prevalence of vulvar diseases in the literature is low because of underreporting and is often neglected; thus, its impact on a female's life is often underestimated. Objectives: This study is aimed to determine the prevalence of vulvar diseases and their associated risk factors in patients attending a tertiary care hospital. Materials and Methods: This is a descriptive, cross-sectional, and case–controlled study wherein all female patients attending the dermatology outpatient department (OPD) were screened for the signs and symptoms of vulvar dermatoses and were enrolled after obtaining informed consent and institutional ethics committee approval for 21 months. Out of them, 200 patients who consented and had signs and symptoms of vulvar diseases were selected as cases, and the same number of age-matched females were enrolled as controls with no signs and symptoms of vulvar dermatoses. Results: During the study period, 9431 females attended the dermatology OPD, of which the prevalence was 2.12% (200 patients). The most common infection was genital infection without sexually transmitted infection (57%) (tinea cruris [33.5%]), followed by inflammatory dermatoses (21%) (lichen sclerosus et atrophicus [6%]). The most common risk factor found statistically significant (P ≤ 0.005) were homemakers (49%) and the use of undergarments of mixed fabric (70.68%), followed by nonmenopausal females (63.15%). Conclusion: Our study findings indicated that the prevalence was low, which reflects the tip of an iceberg. Further clinical and population-based studies, a multidisciplinary approach including gynecological consult for diagnostic and therapeutic approach is needed for the optimal management of vulvar diseases.

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Background: Bacterial vaginosis (BV) is the most common cause of vaginal discharge (VD) in women of reproductive age group. It is marked by displacement of beneficial Lactobacillus sp. by polymicrobial flora. BV is becoming a major public health concern as it is associated with adverse birth outcomes and increased susceptibility to sexually transmitted infections (STIs). Diagnosis of BV is currently done using clinical criteria (Amsel's) and the microbiological criteria (Nugent's scoring), the latter being the gold standard. Many out patient settings lack in microscopy facility and also skilled microbiologists, so reliance is placed on findings of clinical examination. Aims and Objectives: The aim of the study was to correlate Amsel's criteria with low (7–8) versus high (9–10) positive Nugent's scores for better understanding on utility of clinical criteria. Material and Methods: Patients with self-reported symptoms of vaginal discharge, genital itching were included and their pelvic examination was performed. Two swab samples were collected from lateral wall of vagina and posterior fornix and tested for BV infection using both Amsel's criteria and Nugent's score. Results: Of the total 125 women, 29 (23.2%) were positive for BV by Amsel's criteria, whereas 34 (27.2%) were positive by Nugent's scoring. Amsel's criteria showed a sensitivity of 100% with high Nugent's scores and 81% with low scores, thereby implying very few cases of diseased individuals being missed. Conclusion: This study demonstrates the continued utility of the Clinical criteria in outpatient setting as a screening test.

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Abnormal vaginal discharge is common among the females of the reproductive age group. Vulvovaginitis caused by azole-resistant Candida albicans is rare. Recurrent vulvovaginal candidiasis (RVVC) causes significant patient distress and morbidity. The vaginal microflora is a complex micro-ecological environment comprising different microbiological species in variable quantities and relative proportions. Any disturbance in the aforesaid causes vaginitis, for instance, aerobic vaginitis (AV) results from the displacement of healthy vaginal Lactobacillus species with aerobic pathogens. We report AV with RVVC caused by C. albicans resistant to even second generation azoles which has not been previously reported to the best of our knowledge.

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Background: Stevens-Johnson syndrome/Toxic Epidermal Necrolysis (SJS/TEN) are severe mucocutaneous reactions, considered as variants of same pathologic process. It is characterized by epidermal blisters, necrosis and sloughing predominantly of drug induced etiology. Due to severe cutaneous reactions, the genital manifestations associated with SJS/TEN are less studied. The chronic sequelae of genital manifestations results in severe gynecological, urological and sexual related complications, and have a great impact on the quality of life of patients. Aims And Objectives: To study the genital manifestations associated with SJS/TEN. Materials and Methods: Patients of SJS/TEN attending the Out-patient and In-patient Department of Skin and VD in a tertiary care hospital, having genital manifestations were included in the study. Genital examination of all patients were observed and recorded with a follow up for 6 months. Results: A total of 30 patients, twelve males (40%) and eighteen females (60%), were included. Genital manifestations were observed in 18 (60%) patients, with a male:female ratio of 1:2, i.e. males 6 (36.66%) and females 12 (63.33). All patients presented in the acute stage of the disease. Four female patients (33.3%) developed chronic manifestations in the form of labial synechiae in 2 (16.66%), vaginal synechiae in 1 (8.33%), vaginal strictures in 1 (8.33%) patient. None of the male patients developed chronic sequelae. Conclusion: SJS/TEN are rare diseases, but the mucocutaneous involvement, especially of genitourinary system and their long-term sequelae have a major impact on the quality of life of affected patients. The genital manifestations are largely preventable by means of proper awareness and early intervention.

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Introduction: Lichen sclerosus (LS) is a chronic dermatosis frequently located over labial, perineal, and perianal areas. The etiology is multifactorial and includes genetic, autoimmune, hormonal, and infectious aspects. Materials and Methods: A series of twenty genital LS patients was carried out to evaluate the signs, symptoms, complications, and affliction of quality of life. Results: Eighteen out of twenty patients were female between 30 and 73 years and showed smooth, glistening, and whitish plaques. The mean duration was 8.4 years. Itching and burning was the most common symptom (75%) corresponding to excoriation and fissuring of genitalia (75%). Malignancy was seen in two cases (10%). The mean Vulvar Quality of Life Index was 9.2, higher in younger patients. Discussion: LS is a disorder of older age group with female preponderance. It is a source of significant morbidity, and long-standing cases predispose to vulvar malignancy. Conclusion: To conclude, early diagnosis with proper counselling of the patient and his/her partner regarding various aspects of disease are essential for a wholesome approach.

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Autoimmune cytopenias may be the initial presentation in patients with HIV infection or can develop while on treatment with antiretroviral therapy (ART). These cytopenias usually resolve after initiation of ART. We report a rare case of HIV who presented with Evans syndrome on ART, being refractory to steroids and rituximab but with response to splenectomy.

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Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis affecting various sites, isolated genital PG being an uncommon presentation. We report a case of a 50-year-old diabetic male who presented with 2 penile ulcers. Extensive evaluation was done for sexually and nonsexually transmitted infections, malignancy, drug-induced vasculitis, and immunobullous etiology. A diagnosis of PG was made based on the clinical findings and histopathological exclusion of other causes. The patient showed a rapid response to prednisolone, dapsone, and colchicine. This report highlights the importance of keeping PG as a differential diagnosis in cases of genital ulcers which may mimic other sexually transmitted infections.

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Context: The AIDS dementia complex is one of the most common and clinically important complications of HIV infection. Subclinical dementia not presenting with features of frank disease may be missed. The use of screening tools provides a good alternative to a psychiatrist's diagnosis in resource-limited settings like the site of this study. Aims: The study aimed to analyze various parameters such as age, gender, duration of the disease, duration since treatment, clinical staging, CD4 count, mode of transmission, and comorbidities like tuberculosis with the prevalence of AIDS dementia complex in the participants. Settings and Design: A cross-sectional study involving 180 participants was conducted over a duration of 18 months. Materials and Methods: The assessment of dementia was done using the International HIV Dementia Scale. Statistical Analysis Used: Backward binomial logistics regression. Results: Both duration of treatment and duration since diagnosis of HIV were found to be significantly associated with the presence of AIDS dementia. Patients having stage 4 disease and CD4 counts <200 were likelier to have dementia as compared to other participants. People with an unknown mode of transmission had higher odds of having AIDS dementia than persons having a mode of transmission as via blood/blood products/invasive procedures/mother-to-child transmission/IV drug abuse. Binomial logistic regression revealed mode of transmission or rather its awareness to be the strongest contributor. Conclusions: These findings highlight the need for early screening and diagnosis of HIV-associated dementia in patients living with HIV and that of early assessment and initiation of treatment.

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Epstein-Barr virus (EBV) infection can rarely present as encephalitis in HIV patients. We report a case of a 22-year-old female patient, diagnosed to have HIV infection 8 years back. She presented with headache and altered behavior for a week and focal fits for 2 days. Neurological examination was unremarkable. Cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis with raised protein. EBV was detected in CSF using polymerase chain reaction test. Magnetic resonance imaging of the brain revealed T2/fluid-attenuated inversion recovery hyperintensities involving the left frontal cortex, left thalamus, and right medial temporal cortex. The patient was started on antiviral therapy considering the diagnosis of EBV encephalitis. The patient completely recovered over the next few weeks.

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Primary central nervous system (CNS) lymphoma is an aggressive malignancy which constitutes one of the acquired immunodeficiency syndrome -defining illnesses. Early diagnosis and timely management can increase the chances of cure. Although many times the diagnosis is straightforward, we present a case of primary CNS lymphoma in a human immunodeficiency virus--positive individual which posed as a major diagnostic dilemma with initially normal imaging findings. A 42-year-old male presented with unremitting fever and a perianal ulcer for 3 months. A battery of diagnostic tests were negative, including a positron emission tomography-computed tomography scan and a magnetic resonance imaging brain. With unresolving symptoms and a high index of suspicion as he developed dizziness and loss of balance, the same were repeated which confirmed a space-occupying lesion in the cerebellum. Although treatment was instituted, the patient did not recover and died in the 4^th month of treatment.

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Syringomas commonly occur in women over the face, neck, and chest. They are usually asymptomatic and mainly of cosmetic concern. The vulva is an uncommon site for syringomas. A 45-year-old woman had asymptomatic lesions over the face, of 28 years duration and presented with vulvar papules, associated with severe pruritus for the past 2 months. Clinical and histopathological examination confirmed them to be syringomas. Coexistent facial and vulvar syringomas are rare. Further, vulvar syringomas presenting as pruritus vulvae is still rarer. We report a case with severe pruritus vulvae causing sufficient distress to seek medical care, which is remarkably unusual.

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Introduction: Chronic HIV infection and antiretroviral therapy (ART) are the major causes of cardiovascular diseases (CVDs) and mortality in HIV patients. This study was conducted to look upon the effect of ART on CVD risk markers in patients on different ART regimens and ART-naïve patients. Methods: It was a cross-sectional, observational study done on 120 HIV-infected patients. CV risk markers were assessed and correlated with disease-specific factors within individual subgroups differentiated as Group A (ART naïve), Group B (first-line ART), and Group C (second-line ART). Carotid intimal medial thickness (CIMT) and high-sensitivity C reactive protein (hsCRP) were done to classify cases as having CVD. Results: CVD risk parameters were found to be significantly higher in cases on ART, as compared to ART-naïve cases. The mean CIMT among cases in Group C, Group B, and Group A was 0.072 ± 0.01 cm, 0.063 ± 0.01 cm, and 0.055 ± 0.01 cm, respectively (P < 0.01). 95%, 65% and 25% cases in Group C, Group B, and Group A, respectively, had high CIMT (>0.06 cm) and were seen to be directly correlated with disease-related factors, i.e., duration of disease and ART, type of ART, and low CD4 cell counts. hsCRP was significantly increased in 65 out of total 120 cases. The mean hsCRP in Group A, Group B, and Group C was 3.69 ± 3.37, 4.21 ± 3.4, and 5.72 ± 3.54 mg/L, respectively (P < 0.01), which corresponds to the high risk of CVD. Conclusion: CVD risk parameters of CIMT and hsCRP are seen to be higher in patients on ART than ART-naive subjects.

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Background: Most research on adolescent focuses on the risk associated with the illness. Very little research has been carried out on adolescents who have been diagnosed with HIV since birth. With recent advances with ART treatment, life span of these children has increased, and there are lots of protective factors in the environment influencing the resilience. The present study has focused on the resilience among the adolescence with respect to the living arrangement, i.e., in institutionalized care and extended family. Methodology: The current study follows an exploratory research design with the aim of comparing resilience among adolescents living in the institutional setup and those living with their families–parents and extended families. Adolescents receiving ART treatment from a tertiary care hospital constitute universe and were selected purposively for the study. Resilience was measured using Child and Youth Resilience Measure. Results: The results indicated that 70% of the female and majority of them belong to Hindu religion. For majority, the mode of transmission is mother to child. There is no statistically significant difference between the resilience with respect to the living arrangement. However, respondents are resilient. Conclusion: This study has given a space for resilience for different groups of adolescents with respect to the living arrangement.

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Pseudoepitheliomatous keratotic and micaceous balanitis (PKMB) is a rare nonvenereal penile condition with a risk of malignant transformation. We report a case of PKMB in a 45-year-old male who presented with multiple keratotic growths over his glans penis after circumcision for long-standing phimosis. Histopathology revealed pseudoepitheliomatous hyperplasia and atypical cells. He was successfully treated with wide local excision.

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