Ulcerative disease of the anorectum in the HIV+ patient

Project Gel a Randomized Rectal Microbicide Safety and Acceptability Study in Young Men and Transgender Women

OBJECTIVES

The purpose of Project Gel was to determine the safety and acceptability of rectal microbicides in young men who have sex with men (MSM) and transgender women (TGW) at risk of HIV infection.

METHODS

MSM and TGW aged 18-30 years were enrolled at three sites; Pittsburgh, PA; Boston, MA; and San Juan, PR. Stage 1A was a cross-sectional assessment of sexual health and behavior in MSM and TGW. A subset of participants from Stage 1A were then enrolled in Stage 1B, a 12-week evaluation of the safety and acceptability of a placebo rectal gel. This was followed by the final phase of the study (Stage 2) in which a subset of participants from Stage 1B were enrolled into a Phase 1 rectal safety and acceptability evaluation of tenofovir (TFV) 1% gel.

RESULTS

248 participants were enrolled into Stage 1A. Participants' average age was 23.3 years. The most common sexually transmitted infection (STIs) at baseline were Herpes simplex (HSV)-2 (16.1% by serology) and rectal Chlamydia trachomatis (CT) (10.1% by NAAT). 134 participants were enrolled into Stage 1B. During the 12 week period of follow-up 2 HIV, 5 rectal CT, and 5 rectal Neisseria gonorrhea infections were detected. The majority of adverse events (AEs) were infections (N = 56) or gastrointestinal (N = 46) and were mild (69.6%) or moderate (28.0%). Of the participants who completed Stage 1B, 24 were enrolled into Stage 2 and randomized (1:1) to receive TFV or placebo gel. All participants completed Stage 2. The majority of AEs were gastrointestinal (N = 10) and of mild (87.2%) or moderate (10.3%) severity.

CONCLUSIONS

In this study we were able to enroll a sexually active population of young MSM and TGW who were willing to use rectal microbicides. TFV gel was safe and acceptable and should be further developed as an alternative HIV prevention intervention for this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01283360.

Anal Fissure

Anal fissure (fissure-in-ano) is a very common anorectal condition. The exact etiology of this condition is debated; however, there is a clear association with elevated internal anal sphincter pressures. Though hard bowel movements are implicated in fissure etiology, they are not universally present in patients with anal fissures. Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents. When nonoperative management fails, surgical treatment with lateral internal sphincterotomy has a high success rate. In this chapter, we will review the symptoms, pathophysiology, and management of anal fissures.

Anal fissure

Anal fissure is one of the most common anorectal problems. Anal fissure is largely associated with high anal sphincter pressures and most treatment options are based on reducing anal pressures. Conservative management, using increased fiber and warm baths, results in healing of approximately half of all anal fissures. In fissures that fail conservative care, various pharmacologic and surgical options offer satisfactory cure rates. Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure. This review outlines the key points in the presentation, pathophysiology, and management of anal fissure.

Anal fissure

Anal fissure is a common disorder that is effectively treated and prevented with conservative measures in its acute form, whereas chronic fissures may require medical or surgical therapy. This article discusses the nonoperative and operative management strategies, reviews the current literature on expected outcomes, and provides guidance on dealing with fissures in special situations, such as patients with inflammatory bowel disease or hypotonic sphincters.

Hypertrophic herpes simplex simulating anal neoplasia in AIDS patients: report of five cases

Five patients (4 males; mean age, 46.4 years) with painful verrucous perianal lesions caused by herpes simplex virus are described. All patients had had AIDS for a long time and were using highly active antiretroviral therapy. CD4+ counts ranged from 73 to 370/mm3. All lesions were submitted to resection under subdural anesthesia. Histologic examinations revealed epithelial hyperplasia and dense inflammatory process, composed mainly of lymphocytes and plasma cells, extended just to the hypodermis. Immunohistochemistry was positive for herpes simplex virus Type 2 in four patients and for herpes simplex virus Type 1 in one patient, and did not detect human papillomavirus antigens. Three patients had recurrences after 3, 10, and 12 months. Resection was performed on two patients; one had a new recurrence after three months. Oral acyclovir eliminated the lesion in the third patient. The analysis of our patients suggests that herpes simplex virus, Types 1 and 2, may cause verrucous lesions simulating neoplasia in patients with AIDS using antiretroviral therapy.

Anal condyloma and HIV-associated anal disease

Although there are a large variety of anal diagnoses associated with the HIV population, anal condyloma and anal ulcerations make up the vast majority. A large percentage of individuals having multiple concurrent pathologies should also be noted. Thus, this article concentrates on anal condyloma, anal ulceration and HIV, making note of other significant issues.

Fissurectomy with posterior midline sphincterotomy and anoplasty (FPSA) in the management of chronic anal fissures

Although lateral internal sphincterotomy is widely accepted as the treatment of choice for anal fissures, we report our experience of successfully treating 195 consecutive patients with posterior chronic anal fissures by performing fissurectomy with midline sphincterotomy and anoplasty (FPSA). The surgical technique is described and its indications and results are briefly discussed.

Management of idiopathic ulcer of the anal canal by excision in HIV-positive patients

PURPOSE

The aim of this article is to show our results from the surgical treatment of idiopathic anal ulcers.

METHODS

We present 33 patients with acquired immunodeficiency syndrome and idiopathic perianal ulcers. They presented with anal pain that failed to improve with medical treatment. Evaluation under anesthesia typically showed an irregular ulcer in the anal canal and an intersphincteric abscess. Surgical treatment consisted of an incision around the ulcer, its excision including margins but not its base, and abscess drainage.

RESULTS

All patients experienced significant immediate postoperative pain relief. Biopsies of the ulcer showed chronic inflammation, and no specific agents appeared in cultures.

CONCLUSIONS

These lesions seem to have the same cryptogenic origin as perianal abscesses, and we recommend surgical treatment to provide symptom relief.

Perianal diseases in HIV-positive patients compared with a seronegative population

PURPOSE

The aim of this report was to present our cases showing the prevalence and cause of perianal diseases in human immunodeficiency virus-positive patients.

METHODS

We compared 1,860 human immunodeficiency virus-positive patients to 1,350 human immunodeficiency virus-negative outpatients with perianal diseases, examined from January 1989 to December 1996, and the results obtained with the treatment methods for seropositive patients. Among them, 88.7 percent were males, mostly in the age range from 30 to 50 years old.

RESULTS

Condylomas, ulcers, hemorrhoids, fistulas, fissures, abscesses, and tumors were the most frequently diagnosed diseases. Two or more anal diseases occurred in 16.7 percent of patients. Among the human immunodeficiency virus-negative patients we noticed the same incidence of gender, and most were in the age range of 40 to 60 years old. Hemorrhoids, fistulas, skin tags, and fissures were diagnosed.

CONCLUSIONS

From statistical analysis we may conclude that human immunodeficiency virus-positive patients have more condylomas, ulcers, tumors, fistulas, and abscesses than human immunodeficiency virus-negative patients, who have more hemorrhoids. Incidence of fissures was similar in the two groups.

Anal warts, sexually transmitted diseases, and anorectal conditions associated with human immunodeficiency virus

Sexually transmitted diseases (STDs) are the cause of many different anorectal symptoms and complaints. Patients often present concerned that they have hemorrhoids. It is very important for primary care providers to be aware of the prevalance of anorectal STDs, common presentations, and management options. This article specifically addresses anal warts, gonorrhea, chlamydia, syphilis, herpes, and anorectal manifestations associated with HIV.

Gastrointestinal pathology in HIV-infected patients

Specific pathologic processes, particularly oral, esophageal, and intestinal infections, are common in the alimentary tract of AIDS patients. Many of these diseases are adequately assessed only by biopsy with histologic examination. Most are rare or unreported in immunocompetent hosts and are easily missed by those not familiar with them. This article describes the gross or endoscopic and histologic appearances and the diagnostic criteria for enteric pathologic processes seen in HIV-infected individuals.

Anorectal diseases

A proper understanding of the disease of the anorectum in the HIV-positive population mandates a familiarity with the ongoing advances in antiviral chemotherapy, mechanisms of oncogenesis, and effect of HIV infection on wound dynamics. As the prognosis for HIV-infected patients improves, therapies must reflect the expected increased survival of these patients.

Surgery for anal lesions in HIV-infected patients

Anorectal manifestations are commonplace in patients with HIV infection. However, standardized or rational treatment of these conditions has not been proposed and many patients are denied adequate treatment based on fear of complications. This review looks critically at the available literature to draw conclusions about treatment, results and complications of surgery for anorectal problems in these patients.

The diagnosis of anal ulcers in AIDS patients

Recent reports have suggested that routine microscopic evaluation of anal ulcer tissue from AIDS patients is not the most accurate way to diagnose viral infection. This study was undertaken to determine if either viral culture (VC) or immunohistochemistry (IHC) can improve the diagnostic accuracy as compared with routine hematoxylin and eosin (H&E) staining. Specifically, we sought to identify inclusion bodies of cytomegalovirus (CMV) or herpes simplex virus (HSV) to assist in the diagnosis of CMV or HSV. All patients had clinical evidence of an anal ulcer or a nonhealing anal fissure. Duration of symptoms ranged from 1 week to 3 months with a mean of 6 weeks. All specimens were submitted for viral culture in addition to routine H&E staining; immunohistochemistry was also performed. Twenty-five paraffin-embedded anal ulcer biopsies from 23 male patients (age range 27-73; mean 37.4 years) with the diagnosis of AIDS or AIDS-related complex (ARC) were reviewed over a 4 year period (1988-1992). Routine H&E staining revealed 6 (22%) specimens with CMV inclusions. Four of these 6 reacted positively with IHC (67%) and one was positive on viral culture (17%). In the remaining 19 specimens that did not reveal infection with CMV (78%), IHC was positive in 2 patients (10%) and viral culture was positive in 1 patient (5%). Although HSV was not seen in any of the specimens on H&E staining, IHC was positive in one patient (3.5%) and viral culture reacted positively in 8 (29%) specimens. Thus IHC is a good confirmatory test for CMV inclusions and can be used to achieve a definitive diagnosis in equivocal cases.(ABSTRACT TRUNCATED AT 250 WORDS)