Aetiology of male urethritis in patients recruited from a population with a high HIV prevalence

The aetiology of urethritis, the significance of potential pathogens and the relation of urethritis to HIV infection were determined in 335 men (cases) with and 100 men (controls) without urethral symptoms. Urethral swab specimens were tested for different organisms by PCR or by culture for Neisseria gonorrhoeae. The prevalence of N. gonorrhoeae and Chlamydia trachomatis was 52 and 16%, respectively. The potential pathogens: Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis and herpes simplex virus (HSV), were present in 5, 36, 6 and 6% of the cases respectively. M. genitalium was the only potential pathogen associated with microscopic urethritis. After excluding gonococcal infections, U. urealyticum was more frequent in symptomatic patients, while the prevalence of T. vaginalis was similar among cases and controls. These results strongly suggest an a etiological role for M. genitalium in male urethritis, a possible role for U. urealyticum, but not for T. vaginalis. The control group, with 97% genital ulcer disease patients, was not suitable for the investigation of the role of HSV. The sero-prevalence of HIV was 45%. Current infections were not associated with HIV. However, a history of previous urethral discharge was associated with HIV in a multivariate analysis and supported the hypothesis that non-ulcerative sexually transmitted diseases facilitate HIV transmission.

Effectiveness of cotrimoxazole prophylaxis on mortality in adults with tuberculosis in rural South Africa

BACKGROUND

Adults with dual tuberculosis (TB) and HIV infection have a poor outcome. Studies in West Africa suggest that cotrimoxazole prophylaxis may reduce this mortality.

OBJECTIVE

To evaluate the effectiveness of cotrimoxazole in reducing mortality in adults with active TB, irrespective of HIV status, in a high prevalence setting.

DESIGN

Cohort study using historical controls.

METHODS

Adults treated for TB between 1998 and 2000 were traced and vital status at 6 months ascertained (2004: control group). All adults starting treatment for TB between June 2001 and June 2002 were offered cotrimoxazole prophylaxis 960 mg once daily for 6 months during TB treatment irrespective of HIV status (1321: intervention group). Mortality, adverse reactions and adherence were compared between intervention and control groups.

RESULTS

HIV seroprevalence in patients with TB at the start of the intervention was estimated to be 78%. Mortality at 6 months was 29% lower in the group given cotrimoxazole than in the control group. The number needed to treat to prevent one death during the period of TB treatment was 24. The benefit was seen across all types of TB but was only evident in new patients; patients being retreated had similar outcomes in both groups. Adverse events were infrequent and minor, with only two participants having treatment stopped for this reason.

CONCLUSION

Cotrimoxazole prophylaxis for all adults with TB, irrespective of HIV status, in an area of high HIV seroprevalence may be a feasible, safe and effective way to reduce mortality for the duration of treatment.

Vaginal tampons as specimen collection device for the molecular diagnosis of non-ulcerative sexually transmitted infections in antenatal clinic attendees

Self-inserted vaginal tampons for the molecular diagnosis of non-ulcerative STIs were evaluated. Cervical and vaginal swabs, tampons and urines were collected from 185 first-time antenatal clinic attendees. Cultures and nucleic acid amplification assays (NAA) were performed. The sensitivity of PCR on tampons for Trichomonas vaginalis was with 94% (CI 85-98%) significantly higher (P<0.001) than culture (50%, CI 38-62%) or urine (53%, CI 41-65%). Neisseria gonorrhoeae culture had a sensitivity of 64% (CI 36-86%), strand displacement assay (SDA) had a sensitivity of 79% (CI 49-94%) using tampon specimens, 57% (CI 30-81%) using endocervical swabs and 43% (CI 19-70%) using urines. There was no difference in sensitivity of SDA for Chlamydia trachomatis using tampon specimens, urine or endocervical swabs. The specificity approached 100% for all assays on all specimens. NAA on tampons for the detection of T. vaginalis, N. gonorrhoeae and C. trachomatis identified more infections than assays on swabs or urines. This reached statistical significance for T. vaginalis only.

Disseminated nocardiosis masquerading as abdominal tuberculosis

A 32-year-old patient was admitted with a community-acquired pneumonia. She had clinical evidence of AIDS and chest X-ray features consistent with pulmonary tuberculosis. While in the ward she developed an acute abdomen necessitating laparotomy, at which a diagnosis of abdominal tuberculosis was made. Sputum and intraoperative pus specimens grew a multiresistant Nocardia brasiliensis. Microbiological investigations for tuberculosis were negative. The patient died after a short ICU admission from multiple organ dysfunction syndrome.

Vertical transmission of Mycobacterium tuberculosis in KwaZulu Natal: impact of HIV-1 co-infection

BACKGROUND

Increases in perinatal TB have paralleled the exacerbation of the TB epidemic in KwaZulu Natal. The exact risks for vertical transfer of Mycobacterium tuberculosis (VTRTB) to the baby are unknown, as is the impact of HIV-1 co-infection, which frequently accompanies maternal TB disease in the region.

DESIGN

Prospective case series study of 82 HIV-1-infected and 25 non-infected pregnant mothers, King Edward VIII Hospital, KwaZulu Natal, South Africa.

RESULTS

Perinatal mortality in HIV-1/TB diseased mothers was 85/1000 and associated with maternal anaemia (P = 0.02); 46% of newborns were premature, 66% low birth weight and 49% intrauterine growth restricted. These were significantly higher than overall hospital rates (P < 0.01, OR 4.8, 95%CI 3.2-7.0). Sites of detection of maternal TB, distribution of bacteriologically-proven TB, obstetric comorbidity and perinatal morbidity were similar in HIV-1-infected and non-infected mothers. VTRTB was detected in 16 newborns (16%), occurring similarly in bacteriologically-proven and suspected maternal TB disease, with no difference between HIV-1-infected and non-infected mothers. Eleven newborns with VTRTB were HIV-1 exposed; 64% acquired HIV-1 and died from rapidly progressive disease by 10 months of age. HIV-1-infected mothers and their exposed newborns had significantly lower CD4 counts. No association between perinatal maternal viral load, CD4 count or VTRTB was detected.

CONCLUSION

Mothers with TB disease in pregnancy are at risk for significant perinatal morbidity, mortality and VTRTB.

Identification of women at high STD risk among STD clinic attendees: implications for STD programmes

We showed an association between current infection with a recognized sexually transmitted infection (STI) pathogen and HIV infection in women but not in men with non-ulcerative genital disease. While the accuracy of recognition of male urethritis and genital ulcer syndromes is high, this is significantly less for non-ulcerative STIs in women. The symptoms associated with the latter have a broad differential diagnosis including conditions of a non-STI nature. Local sexually transmitted disease (STD) clinic attendees often comprise patients with and without STIs. We hypothesized that this may be responsible for the association of current STI pathogens and HIV in women. To identify a group of women that would be representative of a true STD clinic population we looked at those with a past history of treated genital ulcers. When we analysed in this subset the association of current STI pathogen and HIV infection, a pattern emerged that was comparable with that in men.

Association between HIV-1 infection, the etiology of genital ulcer disease, and response to syndromic management

BACKGROUND

Reports on the effect of HIV-1 infection on healing rates of ulcers are conflicting.

GOAL

The goal was to determine the etiology and response to treatment of genital ulcer disease (GUD) in relation to HIV-1 infection.

STUDY DESIGN

This was a cohort study of patients with GUD treated with local syndromic management protocols.

RESULTS

Among the 587 recruited, the prevalences of infections due to HSV, Treponema pallidum, Chlamydia trachomatis (lymphogranuloma venereum [LGV]), Haemophilus ducreyi, Calymmatobacterium granulomatis, and HIV-1 were 48%, 14%, 11%, 10%, 1%, and 75%, respectively. The prevalence T. pallidum of was higher among men (P = 0.03), and an association was seen among HIV-1-seronegatives on univariate and multivariate analyses (P < 0.001; = 0.01). The prevalence of C trachomatis (LGV) was higher among females (P = 0.004), and an association was seen among HIV-1-seropositives on univariate analysis (P = 0.04). At follow-up, 40/407 (10%) showed a decreased healing tendency, not associated with ulcer etiology or HIV-1 seropositivity.

CONCLUSION

Response to syndromic management of GUD was acceptable and not associated with HIV-1 coinfection.

Influence of HIV-1 coinfection on effective management of abnormal vaginal discharge

BACKGROUND

Reports on microbiologic cure rates following syndromic management (SM) of women with nonulcerative sexually transmitted infections (STIs) are limited.

GOAL

The goal of the study was to determine the effectiveness of the drugs used in SM of nonulcerative STIs and bacterial vaginosis in women and to compare the response among those with and without HIV-1 coinfection.

STUDY DESIGN

This was a cohort study of women with nonulcerative STIs who were treated according to local SM protocols.

RESULTS

Of 692 women recruited, 415 (80%) returned 8 to 10 days later, and 290 (70%) consented to a second examination, in which specimens were obtained. Clinical cure was reported by 67%, and microbiologic cure ranged from 80% to 89% for the three discharge-causing STIs and was independent of HIV-1 status. Only 38% of those with bacterial vaginosis were cured, and HIV-1-infected women were less likely to be cured (28% versus 52%; P < 0.001).

CONCLUSIONS

Clinical and microbiologic response to SM of the nonulcerative STIs was not affected by HIV-1 coinfection, but cure rates for bacterial vaginosis were reduced.

Typing of Neisseria gonorrhoeae reveals rapid reinfection in rural South Africa

A recent study afforded us the opportunity to collect pre- and post-treatment isolates of Neisseria gonorrhoeae from women who supposedly failed to eradicate the organism when tested 8 to 10 days following treatment with a single, directly observed 250-mg dose of ciprofloxacin. In an attempt to differentiate true treatment failure from reinfection, we determined the ciprofloxacin MICs and performed auxotyping, serotyping, and opa typing of the pre- and post-treatment isolates. Paired isolates of N. gonorrhoeae were obtained from seven different women, despite susceptibility of the initial isolates to ciprofloxacin. Six of seven patients were infected with gonococcal isolates that differed significantly from their primary isolate. These most probably represent reinfection with a different strain, which could originate from the same partner infected with multiple strains or reinfected with a new strain or from a different partner. The susceptibility to ciprofloxacin of all isolates makes the possibility of multiple strains in the patient unlikely. The diversity of the isolates within the pairs therefore suggests rapid reinfection within the partnerships.

Lower dose of ciprofloxacin is adequate for the treatment of Neisseria gonorrhoeae in KwaZulu Natal, South Africa

The response of male gonococcal urethritis to a single 250 mg dose of ciprofloxacin versus 500 mg was studied. Both regimens were given in combination with doxycycline in the context of the local syndromic management protocol. There was no significant difference in response between the regimens, inclusive/exclusive of tetracycline susceptible isolates. One patient in the 250 mg arm failed to respond clinically but was microbiologically cured and four patients in the 500 mg arm failed microbiologically but responded clinically. All four isolates had ciprofloxacin MICs </=0.007 mg/l.

Diagnosis of bacterial vaginosis on self-collected vaginal tampon specimens

A vaginal tampon specimen was previously shown to be suitable for the molecular diagnosis of non-ulcerative sexually transmitted infections (STIs). Different tampon fluid preparations were evaluated for the diagnosis of bacterial vaginosis (BV). Women with pregnancy related problems were enrolled. Two observers evaluated the different tampon fluid preparations and vaginal smears collected during speculum examination using the Nugent score. Using the Amsel criteria, 21% of the 84 women enrolled were diagnosed with BV. Results of the tampon fluid preparations and vaginal smears showed excellent agreement for both observers (Spearman >0.80). The overall sensitivity and specificity was 91.7% (95% CI: 81.6-96.5) and 79.3% (95% CI: 67.2-87.8), respectively, using the Amsel criteria as reference standard. The tampon provides a specimen for the combined diagnosis of non-ulcerative STIs and BV. This non-invasively collected specimen may facilitate self-initiated testing and population-based studies as well as longitudinal studies that are necessary to gain insight in the epidemiology of BV related to STIs and HIV.

Trichomonas vaginalis is associated with pelvic inflammatory disease in women infected with human immunodeficiency virus

We assessed the association between the causative agents of vaginal discharge and pelvic inflammatory disease (PID) among women attending a rural sexually transmitted disease clinic in South Africa; the role played by coinfection with human immunodeficiency virus type 1 (HIV-1) was studied. Vaginal and cervical specimens were obtained to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and bacterial vaginosis. HIV-1 infection was established by use of serum antibody tests. A total of 696 women with vaginal discharge were recruited, 119 of whom had clinical PID. Patients with trichomoniasis had a significantly higher risk of PID than did women without trichomoniasis (P=.03). PID was not associated with any of the other pathogens. When the patients were stratified according to HIV-1 status, the risk of PID in HIV-1-infected patients with T. vaginalis increased significantly (P=.002); no association was found in patients without HIV-1. T. vaginalis infection of the lower genital tract is associated with a clinical diagnosis of PID in HIV-1-infected women.

Interrelationships among human immunodeficiency virus type 1 infection, bacterial vaginosis, trichomoniasis, and the presence of yeasts

Vaginal discharge of mixed etiology occurs frequently, with abnormal vaginal flora being the most common condition. The interrelationships among the disturbance of the vaginal ecology, the presence of yeasts, and infection with Trichomonas vaginalis and human immunodeficiency virus type 1 (HIV-1) were investigated among women presenting to a sexually transmitted diseases service. Analysis was done for 598 women. Although the prevalence of HIV-1 infection increased linearly with increasing Nugent's score (bacterial vaginosis score of Gram stain), the prevalence of T. vaginalis increased suddenly, from 12% in patients with a Nugent's score of < or =3 to 33% in patients with a score of 4, and remained at this level at higher scores. Yeast colonization and vulvovaginal candidiasis were inversely related to Nugent's scores. T. vaginalis might be responsible for the change in normal vaginal flora and may, therefore, be one of the causes of bacterial vaginosis. This could lead to more effective HIV-1 acquisition.

Molecular typing of Treponema pallidum in South Africa: cross-sectional studies

We evaluated a molecular subtyping system for Treponema pallidum for its ability to differentiate between strains obtained from male patients with primary syphilis in South Africa. Of 201 T. pallidum-positive specimens, 161 were typeable, revealing 35 subtypes. The unique subtypes identified in Durban, Cape Town, and Carletonville and the total number of subtypes suggested that the strain population was very diverse and varied geographically.

Evolution in the trends of antimicrobial resistance in Neisseria gonorrhoeae isolated in Durban over a 5 year period: impact of the introduction of syndromic management

Antimicrobial susceptibility testing was performed on isolates of Neisseria gonorrhoeae obtained from patients attending the City Health STD clinic in Durban, KwaZuluNatal, using the following drugs: penicillin, tetracycline, ciprofloxacin, ofloxacin, ceftriaxone, spectinomycin, erythromycin and azithromycin. These isolates were collected over a 6 year period from 1995 to 2000. Four hundred and fifteen strains were tested: 61 in 1995, 198 in 1997, 98 in 1998/99 and 58 in 1999/2000. A shift to the right is observed in the susceptibilities of N. gonorrhoeae to the currently recommended drugs in the syndromic management guidelines viz. penicillin, tetracycline, ceftriaxone, ciprofloxacin, spectinomycin and erythromycin. The prevalence of penicillinase-producing N. gonorrhoeae is currently c. 30%, whereas that of plasmid-mediated tetracycline-resistant N. gonorrhoeae is c. 50%. There is a definite association between the MICs of strains falling within the penicillin and tetracycline chromosomally resistant group, and strains exhibiting a decreased susceptibility to ciprofloxacin and ceftriaxone. The MICs of azithromycin showed a similar distribution when compared with erythromycin for 1999/2000 isolates. We postulate that the presence of efflux pumps might play a role in the increasing MICs that we observe among structurally unrelated groups of drugs. Furthermore, widespread use of these antimicrobials in the community may offer a selective advantage to the development of resistance. The implications of this are far reaching and the local susceptibility trends of N. gonorrhoeae need to be monitored constantly to direct therapy.

The effect of temperature on the interaction of Haemophilus ducreyi with human epithelial cells

To investigate if temperature affects the interaction of Haemophilus ducreyi with human epithelial cells, nine strains were used to evaluate the adhesion kinetics of the organism at 33 degrees C and 37 degrees C. The effect of the free toxin on the epithelial cells at those temperatures was also assessed. The cyto-adherence kinetics of H. ducreyi to the epithelial cells was significantly greater at 33 degrees C (10 times more) than at 37 degrees C in all seven clinical isolates tested. There was a significant difference in cell-associated H. ducreyi at 33 degrees C as compared with 37 degrees C. Control strains showed similar adhesion properties at both temperatures. However, the virulent strain CIP542 adhered in larger amounts than the avirulent strain A77. Electron microscopy revealed that there was more tissue necrosis at the lower than the higher temperature. The effect of the free toxin was the same at each temperature. However, strain A77 had significantly lower toxicity than strain CIP542 and the clinical isolates. These results suggest that H. ducreyi displays a temperature-dependent interaction with human epithelial cells, and this feature may play a role in the virulence of the organism in vivo. While the overall toxic effect of viable bacteria depends on the metabolic activity of the bacteria and is, therefore, higher at 33 degrees C than at 37 degrees C withthe same initial inoculum, the effect of the extracted toxin at molecular level with fixed concentrations is a temperature-independent event.

Sudden death caused by myocardial tuberculosis: case report and review of the literature

A 25-year-old fit man died suddenly while playing social soccer. Autopsy revealed an infiltrative lesion involving the left ventricle with overlying pericarditis. No other significant pathologic changes were observed. Histologic examination showed necrotizing granulomatous inflammation. No acid-fast bacilli were demonstrated in the pericardial fluid or on histologic examination. The presence of Mycobacterium tuberculosis DNA complex was confirmed by use of the ligase chain reaction technique. The differential diagnosis of myocardial tuberculosis includes sarcoidosis, rheumatic fever, rheumatoid arthritis, giant-cell-containing tumors, idiopathic (giant-cell) myocarditis, and bacterial infections such as tularemia and brucellosis. This case illustrates the protean manifestations of tuberculosis and highlights the use of molecular biologic techniques in arriving at a definitive diagnosis in cases of suspected tuberculosis.

Risk factors predicting complications in blood culture-proven typhoid fever in adults

To create a prognostic model for complications of blood culture-proven typhoid fever in adults (> or = 15 y old), a retrospective cohort was assembled though review of the medical records of the hospitalized patients treated for typhoid fever over a 3-y period ending January 1995. Of the 59 patients included, 21 (35.6%) developed various complications of typhoid fever. No patient included died. Four baseline variables (abdominal pain, systolic blood pressure < 100 mmHg, hypoalbuminaemia < 32 g/l and laboratory evidence of disseminated intravascular coagulation) were independently associated with complications and were used to create a prognostic model. The prediction accuracy of the model was determined using the concordance index (c-index). The results (c-index, 0.915 [95%, CI, 89.0-93.0]) showed that the model predicted complications significantly better than chance. The model stratified patients into 3 prognostic stages: low risk for complications (0%; stage I), intermediate risk (42.9%; stage II) and high risk (92.3%; stage III) (p = 0.001). If validated in other settings, it will help clinicians in predicting complications in patients with blood culture-proven typhoid fever on admission.

Sexually transmitted infections, adverse pregnancy outcome and neonatal infection

Prevention and treatment of sexually transmitted infections (STIs) in the sexually active population are the main steps to prevent perinatal infection. However, the spread of STIs continues at an astronomical pace despite various attempts at controlling the epidemic. An important reason for this lack of STI control is that a large percentage of infected people go untreated because they have asymptomatic or unrecognized infections. The microbial differential diagnosis of STIs implicated in adverse pregnancy outcome is broad and includes viral, bacterial and protozoal infections. Infertility, ectopic pregnancy, pelvic inflammatory disease, chorioamnionitis, premature rupture of membranes, preterm birth and puerperal sepsis are some of complications seen in women as a result of infection with sexually transmitted pathogens. In addition, STIs may facilitate the acquisition and transmission of HIV. In the fetus or neonate, complications include abnormalities of the major organ systems. Infections in the form of pneumonia or conjunctivitis may also occur. Due to the lack of simple, inexpensive and sensitive point-of-care tests, screening for STIs in pregnancy is not performed routinely.

Trial-of-antibiotic algorithm for the diagnosis of tuberculosis in a district hospital in a developing country with high HIV prevalence

OBJECTIVE

To evaluate a diagnostic algorithm for pulmonary tuberculosis based on smear microscopy and objective response to trial of antibiotics.

SETTING

Adult medical wards, Hlabisa Hospital, South Africa, 1996-1997.

METHODS

Adults with chronic chest symptoms and abnormal chest X-ray had sputum examined for Ziehl-Neelsen stained acid-fast bacilli by light microscopy. Those with negative smears were treated with amoxycillin for 5 days and assessed. Those who had not improved were treated with erythromycin for 5 days and reassessed. Response was compared with mycobacterial culture.

RESULTS

Of 280 suspects who completed the diagnostic pathway, 160 (57%) had a positive smear, 46 (17%) responded to amoxycillin, 34 (12%) responded to erythromycin and 40 (14%) were treated as smear-negative tuberculosis. The sensitivity (89%) and specificity (84%) of the full algorithm for culture-positive tuberculosis were high. However, 11 patients (positive predictive value [PPV] 95%) were incorrectly diagnosed with tuberculosis, and 24 cases of tuberculosis (negative predictive value [NPV] 70%) were not identified. NPV improved to 75% when anaemia was included as a predictor. Algorithm performance was independent of human immunodeficiency virus status.

CONCLUSION

Sputum smear microscopy plus trial of antibiotic algorithm among a selected group of tuberculosis suspects may increase diagnostic accuracy in district hospitals in developing countries.