Natural history, dynamics, and ecology of human papillomaviruses in genital infections of young women: protocol of the PAPCLEAR cohort study

INTRODUCTION

Human papillomaviruses (HPVs) are responsible for one-third of all cancers caused by infections. Most HPV studies focus on chronic infections and cancers, and we know little about the early stages of the infection. Our main objective is to better understand the course and natural history of cervical HPV infections in healthy, unvaccinated and vaccinated, young women, by characterising the dynamics of various infection-related populations (virus, epithelial cells, vaginal microbiota and immune effectors). Another objective is to analyse HPV diversity within hosts, and in the study population, in relation to co-factors (lifestyle characteristics, vaccination status, vaginal microbiota, human genetics).

METHODS AND ANALYSIS

The PAPCLEAR study is a single center longitudinal study following 150 women, aged 18-25 years, for up to 2 years. Visits occur every 2 or 4 months (depending on HPV status) during which several variables are measured, such as behaviours (via questionnaires), vaginal pH, HPV presence and viral load (via qPCR), local concentrations of cytokines (via MesoScale Discovery technology) and immune cells (via flow cytometry). Additional analyses are outsourced, such as titration of circulating anti-HPV antibodies, vaginal microbiota sequencing (16S and ITS1 loci) and human genotyping. To increase the statistical power of the epidemiological arm of the study, an additional 150 women are screened cross-sectionally. Finally, to maximise the resolution of the time series, participants are asked to perform weekly self-samples at home. Statistical analyses will involve classical tools in epidemiology, genomics and virus kinetics, and will be performed or coordinated by the Centre National de la Recherche Scientifique (CNRS) in Montpellier.

ETHICS AND DISSEMINATION

This study has been approved by the Comité de Protection des Personnes Sud Méditerranée I (reference number 2016-A00712-49); by the Comité Consultatif sur le Traitement de l'Information en matière de Recherche dans le domaine de la Santé (reference number 16.504); by the Commission Nationale Informatique et Libertés (reference number MMS/ABD/AR1612278, decision number DR-2016-488) and by the Agence Nationale de Sécurité du Médicament et des Produits de Santé (reference 20160072000007). Results will be published in preprint servers, peer-reviewed journals and disseminated through conferences.

TRIAL REGISTRATION NUMBER

NCT02946346; Pre-results.

Placental and pulmonary cryptococcosis associated with fungemia in patient with acquired immunodeficiency syndrome

Cryptococcosis is a systemic mycosis with a chronic or subacute progression caused by the inhalation of dehydrated yeasts or basidiospores. The causative agents are C. gattii and C. neoformans. The latter is more commonly associated with cellular immunodeficiency and is not rare in patients with Acquired Immunodeficiency Syndrome (AIDS). Cryptococcosis is common in pregnant women with AIDS; however, it is uncommon for the placenta to be affected, with few reported cases in the literature. We present the case of a pregnant woman with AIDS who had placental and pulmonary cryptococcosis associated with fungemia, with a satisfactory clinical outcome obtained after therapy.

Viral metagenomics updated the prevalence of human papillomavirus types in anogenital warts

To investigate the composition of human papillomavirus (HPV) types in anogenital warts (AGWs), viral nucleic acid in 110 AGWs, pooled into 11 specimen pools, were subjected to viral metagenomic analysis. After finding HPV7 in AGWs, conventional PCR screening was performed for HPV7 in other 190 individual AGW specimens. Viral metagenomic results indicated that 29 different types of HPV were recovered, with HPV11 and HPV6 showing the highest proportion of sequence reads. HPV7 was detected in 7 of 11 pools, 5 of which contained abundant HPV7 sequence reads. 24 complete genomes of HPV were acquired in viral metagenomic analysis, including 5 HPV7 genomes, based on which phylogenetic analysis and pairwise sequence comparison were conducted. PCR screening for HPV7 in other 190 individual AGW specimens revealed 25 positive cases (13.16%), of which the amplified fragments were sequenced and confirmed to be HPV7 sequences. Although HPV7 was generally found in hand warts and recently also in warts in toe webs, our data suggested that the role of HPV7 in AGW should be considered in the future clinical test and vaccine development for AGWs.

[HPV infection of the external genitalia in men whose female partners have cervical HPV infection]

OBJECTIVE

Human papilloma virus (HPV) is a necessary cause of cervical cancer and is also closely related to penile cancer, oropharyngeal cancer, and anal cancer in males. However, few studies are reported on male HPV. This study aimed to investigate HPV infection of the external genitalia in men whose female partners have cervical HPV infection.

METHODS

We collected the relevant data on the male outpatients whose partners had cervical HPV infection in our Department of Urology and Andrology from August to December 2016. We obtained samples with nylon swabs from the glans penis, corona, inner layer of the prepuce and penile body and detected different types of HPV infection using the Hybribio HPV typing kit, PCR and membrane hybridization.

RESULTS

Valid data were collected from 140 males, which showed 83.5% of HPV infection of the external genitalia, including 60 cases of HPV6 (43.2%), 27 cases of HPV16 (19.4%), 14 cases of HPV39 (10.1%), 13 cases of HPV18 (9.4%), 13 cases of HPV58 (9.4%), and 13 cases of HPV52 (9.4%). Redundant prepuce was found in 75.5% of the males, but there was no statistically significant difference in the incidence rate of HPV infection between the normal and redundant prepuce groups (P > 0.05).

CONCLUSIONS

Men who have the female partners with positive cervical HPV are at high risk of HPV infection and therefore need to be screened and treated so as to reduce HPV infection in both sexes.

Genital Aphthous Ulcers and a Case of Suspected Chikungunya: A Short Clinical Case

Genital aphthous ulcers can result from multiple conditions including febrile syndromes. Chikungunya infection manifests mainly as fever accompanied by polyarthralgia and pruritic rash. Nevertheless, healthcare providers should be alert to additional presentations. This is the case of a young woman presenting with painful genital ulcers after a three day prodome of fever and polyarthralgia. As a suspected case of Chikungunya infection and a clinical diagnosis of aphthae, treatment with oral prednisone for two weeks produced complete resolution of ulcers with no scarring. It is important to recognize that genital aphthous ulcers can develop in a febrile presentation such as that with Chikungunya. Although sexually transmitted diseases should be ruled out as a more common diagnosis in cases of genital lesions, knowledge about this unusual dermatological presentation would represent not only adequate prompt treatment but will minimize equivocal diagnosis as a sexually transmitted disease.

Comparison of the analytical and clinical performance of five tests for the detection of human papillomavirus genital infection

HPV-based screening provides greater protection against cervical cancer (CC) than cytology-based strategies. Currently, several molecular diagnostic assays for the detection of human papillomavirus (HPV) are available. In this study, we analyzed 5 different HPV testing and genotyping techniques (Hybrid Capture 2 [HC2; Qiagen, Hilden, Germany], AnyplexTMII HPV28 [Anyplex; Seegene, Seoul, Korea], Linear Array [Roche, Branchburg, NJ, USA], GP5+/6+ PCR-EIA-RH [Labo Bio-medical Products, Rijswijk, The Netherlands] and CLART2 [Genomica, Madrid, Spain]) in 295 women referred to the hospital Colposcopy Clinic from 2007 to 2008 due to positive HPV test results or an abnormal Pap test. DNA extraction for HPV genotyping was performed in cervical sample specimens after Pap test and HPV detection by HC2. The inclusion criteria were: (1) adequate cervical sampling with sufficient material for the Pap test and HPV detection and genotyping, and (2) colposcopically-directed biopsy and/or endocervical curettage. HC2 showed the highest sensitivity for high-grade squamous intraepithelial lesion and CC (HSIL+) detection (96.1%), but all the HPV genotyping tests showed a higher specificity. (Anyplex 86.8%; Linear Array 86.0%; GP5+/6+ 78.8%; CLART2 76.5%). The agreement between HC2 results and the other techniques was similar: 82.4%, kappa=0.650 for Anyplex; 83.4%, kappa=0.670 for Linear Array, 79.93%, kappa=0.609 for GP5+/6+ and 82.4%, kappa=0.654 for CLART2. HPV 16 and/or 18 infection was a risk factor for underlying HSIL+ in the univariate analysis. Anyplex showed the highest risk of underlying HSIL+ after positive HPV 16 and/or 18 tests (OR 31.1; 95% CI 12.1-80.0).

An atypical herpetic vulval ulcer in an African woman: an important lesson

A 43-year-old woman from Southern Africa presented with an eight-month history of a painless vulval ulcer. She did not have any relevant past medical or drug history. She had never had, or ever been offered an HIV antibody test despite being from an endemic region. On examination, there was an ulcer on her right labia and a painless right inguinal lymph node. Herpes simplex virus (HSV) type 2 culture was positive. The HIV antibody test was also positive. Other cultures and serology including syphilis were negative. A biopsy was suggestive of herpes simplex. The vulval ulcer resolved on oral aciclovir only.

Atypical genital herpes has been described in HIV disease, although it is often painful. This case emphasises the importance of offering an HIV antibody test to patients presenting with atypical genital ulcers. Moreover, it reinforces the paradigm that 'any anogenital ulcer (painful or not) can be herpetic in origin'.

Imiquimod for anogenital warts in non-immunocompromised adults

BACKGROUND

30% of people with anogenital warts (AGW) have spontaneous regression of lesions but there is no way to determine whether a specific lesion will remain. There are a wide range of options available for treating people with AGW and selection is based on clinician's experience, patient preferences and adverse effects. The imiquimod could offer the advantages of patient-applied therapies without incurring the limitations of provider-administered treatments.

OBJECTIVES

To assess the effectiveness and safety of imiquimod for the treatment of AGW in non-immunocompromised adults.

SEARCH METHODS

We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (15 April 2014), CENTRAL (1991 to 15 April 2014), MEDLINE (1946 to 15 April 2014), EMBASE (1947 to 15 April 2014), LILACS (1982 to 15 April 2014), World Health Organization International Clinical Trials Registry (ICTRP) (15 April 2014), ClinicalTrials.gov (15 April 2014), Web of Science (2001 to 15 April 2014) and OpenGrey (15 April 2014). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the use of imiquimod with placebo, any other patient-applied or any other provider-administered treatment (excluding interferon and 5-fluorouracil which are assessed in other Cochrane Reviews) for the treatment of AGW in non-immunocompromised adults.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We resolved any disagreements through consensus. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Ten RCTs (1734 participants) met our inclusion criteria of which six were funded by industry. We judged the risk of bias of the included trials as high. Six trials (1294 participants) compared the use of imiquimod versus placebo. There was very low quality evidence that imiquimod was superior to placebo in achieving complete and partial regression (RR 4.03, 95% CI 2.03 to 7.99; RR 2.56, 95% CI 2.05 to 3.20, respectively). When compared with placebo, the effects of imiquimod on recurrence (RR 2.76, 95% CI 0.70 to 10.91), appearance of new warts (RR 0.76, 95% CI 0.58 to 1.00) and frequency of systemic adverse reactions (RR 0.91, 95% CI 0.63 to 1.32) were imprecise. We downgraded the quality of evidence to low or very low. There was low quality evidence that imiquimod led to more local adverse reactions (RR 1.73, 95% CI 1.18 to 2.53) and pain (RR 11.84, 95% CI 3.36 to 41.63).Two trials (105 participants) compared the use of imiquimod versus any other patient-applied treatment (podophyllotoxin and podophyllin). The estimated effects of imiquimod on complete regression (RR 1.09, 95% CI 0.80 to 1.48), partial regression (RR 0.77, 95% CI 0.40 to 1.47), recurrence (RR 0.49, 95% CI 0.21 to 1.11) or the presence of local adverse reactions (RR 1.24, 95% CI 1.00 to 1.54) were imprecise (very low quality evidence). There was low quality evidence that systemic adverse reactions were less frequent with imiquimod (RR 0.30, 95% CI 0.09 to 0.98).Finally, two trials (335 participants) compared imiquimod with any other provider-administered treatment (ablative methods and cryotherapy). There was very low quality of evidence that imiquimod did not have a lower frequency of complete regression (RR 0.84, 95% CI 0.56 to 1.28). There was very low quality evidence that imiquimod led to a lower rate of recurrence during six-month follow-up (RR 0.24, 95% CI 0.10 to 0.56) but this did not translate in to a lower recurrence from six to 12 months (RR 0.71, 95% CI 0.40 to 1.25; very low quality evidence). There was very low quality evidence that imiquimod was associated with less pain (RR 0.30, 95% CI 0.17 to 0.54) and fewer local reactions (RR 0.55, 95% CI 0.40 to 0.74).

AUTHORS' CONCLUSIONS

The benefits and harms of imiquimod compared with placebo should be regarded with caution due to the risk of bias, imprecision and inconsistency for many of the outcomes we assessed in this Cochrane Review. The evidence for many of the outcomes that show imiquimod and patient-applied treatment (podophyllotoxin or podophyllin) confer similar benefits but fewer systematic reactions with the Imiquimod, is of low or very low quality. The quality of evidence for the outcomes assessing imiquimod and other provider-administered treatment were of very low quality.

Human papillomavirus-related diseases of the female lower genital tract: oncogenic aspects and molecular interaction

The causal role of human papillomavirus (HPV) in all cancers of the uterine cervix has been firmly established biologically and epidemiologically. Most cancers of both the vulva and the vagina are also induced by HPV. Papillomaviruses are perfectly adapted to their natural host tissue, the differentiating epithelial cell of skin or mucosae, and exploit the cellular machinery for their own purposes. The infectious cycle is initiated once the infectious particles reach the basal layer of the epithelium, where they bind to and enter the cells. The critical molecules in the process of virus replication are the viral proteins E6 and E7, which interact with a number of cellular proteins. In experimental system these interactions have been shown to induce proliferation and eventually immortalization and malignant transformation of cells. Binding of E7 to pRb activates the E2F transcription factor, which then triggers the expression of proteins necessary for DNA replication. Unscheduled S-phase would normally lead to apoptosis by the action of p53. However, in HPV-infected cells, this process is counteracted by the viral E6 protein, which targets p53 for proteolytic degradation. Besides blocking p53 function in regulation of apoptosis, high-risk HPV proteins interact with both extrinsic and intrinsic apoptotic pathways. As an aberration of virus infection, constant activity of the viral proteins E6 and E7 leads to increasing genomic instability, accumulation of oncogene mutations, further loss of cell-growth control and ultimately cancer. The immune system uses innate and adaptive immunity to recognize and combat foreign agents that invade the body, but these methods are sometimes ineffective against human papillomavirus. HPV has several mechanisms for avoiding the immune system. Furthermore, HPV infections disrupt cytokine expression with the E6 and E7 oncoproteins, particularly targeting the expression of interferon genes. Approximately 10% of individuals develop a persistent infection, and it is this cohort who is at risk of cancer progression, with the development of high-grade precursor lesions and eventually invasive carcinoma.

Human papillomavirus infections in nonsexually active perinatally HIV infected children

Although human papillomavirus (HPV) infections are common in HIV-infected adults, little is known about children. Our objective was to examine the prevalence of and risks for HPV of the oral mucosal and external genital areas in nonsexually active (NSA) perinatally (P) HIV+ children and compare with HIV-exposed but uninfected (HEU) children. A convenience sample attending a pediatric clinic were enrolled. Samples for HPV were obtained from the oral and anogenital areas and tested for one of 37 HPV types. The mean age of the 48 PHIV+ children was 14.3±3.9 years vs. 6.2±4.8 for the 52 HEU (p<0.001). Of the 23 PHIV+ girls, 30.4% had anogenital and 17% had oral HPV, and of the 27 HEU girls, 2 (7.4%) anogenital and 0 had oral HPV. Of the boys, 4/23 (17.4%) and 1/25 (4%) PHIV+ had anogenital and oral HPV, respectively, and 3/24 (12.5%) and 1/25 (4%) HEU had anogenital and oral HPV, respectively. Rates of HPV did not differ by age among the PHIV+, whereas older HEU were more likely to have HPV than younger HEU (p=0.07). This large age gap precluded statistical comparison by HIV status. The presence of HPV in NSA PHIV+ children may have implications regarding HPV vaccination efficacy.

The Lower Anogenital Squamous Terminology Project and its implications for clinical care

Based on a growing need for unified terminology to describe the pathologic and clinical spectrum of lesions, the American Society for Colposcopy and Cervical Pathology and the College of American Pathologists Pathology and Laboratory Quality Center convened the Lower Anogenital Squamous Terminology (LAST) Project to reassess and harmonize the terminology used to describe human papillomavirus-associated squamous lesions of the lower anogenital tract as manifested in a variety of end organs. The distinction between cancer precursors and those without malignant potential leads to consistency in the interpretation of management guidelines and the therapeutic options.

Clinical protection of goats against CpHV-1 induced genital disease with a BoHV-4-based vector expressing CpHV-1 gD

Caprine herpesvirus type 1 (CpHV-1) is an alphaherpesvirus causing genital disease leading to abortion in adult pregnant goats and a systemic disease with high morbility and mortality in kids. Further, Caprine herpesvirus 1 infection represents a valuable large animal model for human herpesvirus induced genital disease, exploitable for pathogenic studies, new vaccines and antiviral molecules testing. Here, the bovine herpesvirus 4 (BoHV-4) based vector derived from an apathogenic isolate of BoHV-4 and expressing the immunodominant CpHV-1 glycoprotein D (BoHV-4-A-gD(cp)gD(106)ΔTK) was constructed and its ability to protect goats against CpHV-1 induced genital disease evaluated. The subcutaneous route of recombinant BoHV-4 administration was first tested in vivo/ex vivo by in vivo image analysis and in vitro by goat skin primary cultures preparation and transduction. Next, an exploratory immunization and safety study in goats was performed with two recombinant BoHV4, BoHV-4-A-gD(cp)gD(106)ΔTK or BoHV-4-CMV-IgK-gE2gD-TM. In both cases no clinical signs were evident but a good titer of serum neutralizing antibodies was produced in all inoculated animals. When a challenge experiment was performed in a new group of animals using a highly pathogenic dose of CpHV-1, all the vaccinated goats with BoHV-4-A-gD(cp)gD(106)ΔTK were protected toward CpHV-1 induced genital disease respect to the unvaccinated control which showed typical vaginal lesions with a high grade of clinical score as well as a long lasting viral shedding. In summary, the data acquired in the present study validate BoHV-4-based vector as a safe and effective viral vector for goat vaccination against CpHV-1 induced genital disease and pave the way for further applications.

Genetic diversity of HPV-6 in concurrent multiple anogenital warts

INTRODUCTION

Anogenital warts (AGW) are the most common benign tumors in the anogenital area. They are etiologically associated with alpha human papillomaviruses (HPV), in more than 90% of cases with HPV-6 and HPV-11. AGW frequently displays a multifocal and multicentric appearance. However, it is not clear whether the occurrence of multiple AGW in a particular patient is a consequence of infection with single or multiple HPV genomic variants of a given HPV genotype.

METHODS

Forty-five HPV-6 isolates from fresh-frozen AGW tissue specimens, obtained from 18 patients with concurrent multiple AGW, were included. The entire HPV-6 L1, E5a, E5b ORFs, and LCR genomic region was sequenced.

RESULTS

Fourteen different HPV-6 L1-LCR-E5a-E5b genomic variants were identified among 18 patients with concurrent multiple AGW. In 17 out of 18 patients, a single identical HPV-6 L1-E5a-E5b-LCR genomic variant was identified in all concurrent multiple AGW collected in an individual patient. Co-infection with two different HPV-6 genomic variants was identified in one patient.

DISCUSSION

The presence of an identical HPV genomic variant in all concurrently present multiple AGW within an individual patient supports the hypothesis that the occurrence of multiple concurrent AGW is a consequence of infection with a single HPV-6 genomic variant, rather than infection with multiple genomic variants of HPV-6.

Predictors and clinical implications of HPV reservoire districts for genital tract disease

Persistence of human papillomavirus infection (HPV) of the cervix after treatment for cervical intraepithelial neoplasia predisposes to lesion recurrence. Given the weakness of natural immunity against HPV it has been suggested that certain anatomical sites could act as viral reservoirs though which the infection could be retransmitted to the cervix even if the initial HPV tests after treatment are negative. This review examined the possible role of various reservoirs such as the oral cavity, the anus, the fingers and the partner's penis. The available data are insufficient to confirm a significant risk of cervical re-infection from any site other than the penis. It seems that the risk of transmission by the male partner can be reduced by consistent condom use; therefore this should be included in the patient's counselling. Further studies are required to elucidate the role of the other sites especially the anus where some reports imply a possibility for transmission to the cervix. In this context expanding the indications for HPV vaccination to include women who have been treated for CIN should be considered.

HIV-1 pathogenesis: the virus

Transmission of HIV-1 results in the establishment of a new infection, typically starting from a single virus particle. That virion replicates to generate viremia and persistent infection in all of the lymphoid tissue in the body. HIV-1 preferentially infects T cells with high levels of CD4 and those subsets of T cells that express CCR5, particularly memory T cells. Most of the replicating virus is in the lymphoid tissue, yet most of samples studied are from blood. For the most part the tissue and blood viruses represent a well-mixed population. With the onset of immunodeficiency, the virus evolves to infect new cell types. The tropism switch involves switching from using CCR5 to CXCR4 and corresponds to an expansion of infected cells to include naïve CD4(+) T cells. Similarly, the virus evolves the ability to enter cells with low levels of CD4 on the surface and this potentiates the ability to infect macrophages, although the scope of sites where infection of macrophages occurs and the link to pathogenesis is only partly known and is clear only for infection of the central nervous system. A model linking viral evolution to these two pathways has been proposed. Finally, other disease states related to immunodeficiency may be the result of viral infection of additional tissues, although the evidence for a direct role for the virus is less strong. Advancing immunodeficiency creates an environment in which viral evolution results in viral variants that can target new cell types to generate yet another class of opportunistic infections (i.e., HIV-1 with altered tropism).

[Modern ways of treating female genital infections]

In article various ways of increase of efficiency of treatment of is mixed the bacterial-virus infection of the bottom department of sexual ways at women by means of application in complex therapy of homologous bacteriophages, pectovit, antiviral -immunomodulation therapies and sated with oxygen (oxygenic) water solutions of antiseptic tanks are considered. The scientifically-practical urgency of this problem is represented and actual for the decision of an important social and economic problem of improvement of quality of life, decrease in number of infectious complications and perfection of the medical help to sick women with frequent recidives an infection of the bottom department of sexual ways.

Factors associated with the seroprevalence of 26 cutaneous and two genital human papillomavirus types in organ transplant patients

Viral skin infections are commonly present in organ transplant recipients (OTR). In this study, we aimed to identify factors associated with human papillomavirus (HPV) infections in OTR. Patients with solid-organ transplants were recruited from the outpatient nephrology and dermatology clinics in five European countries. Only patients with no current or past skin cancer were included in this analysis. Serum samples were analysed for antibodies to the L1 proteins of 26 cutaneous and two genital HPV types from five phylogenetic genera (α, β, γ, μ and ν). The most consistent association was found between recreational sun exposure and the seroprevalence of all tested genera, except α. The antibody presence of any β type was higher among people who had been transplanted at least 23 years prior to participation than in those who had been transplanted for less than 7 years. The prevalence of two γ-HPV types (60 and 65) and three β-HPV types (15, 38 and 49) was associated with time since transplantation. The presence of a high number of warts was associated with the presence of any μ-PV or ν-PV types, and having greater than 50 keratotic skin lesions was almost significantly associated with the presence of antibodies to two or more γ-PV. Discrepancies in the results of the present study, as well as in previous reports, may depend on different methodologies and on geographical variations. Our results also indicate that further research with more standardized methods is needed to clarify the role of cutaneous HPV in OTR.

Imiquimod 3.75% cream applied daily to treat anogenital warts: combined results from women in two randomized, placebo-controlled studies

OBJECTIVE

To evaluate if new imiquimod formulations using a shorter treatment duration are safe and efficacious to treat anogenital warts.

METHODS

In two studies 534 women ≥12 years of age (mean 33.4) with 2-30 warts (mean 7.9) and total wart area ≥10 mm(2) (mean 166.3) were randomized (1:2:2) to placebo (106), imiquimod 2.5% (212) or 3.75% (216) creams applied once daily until complete clearance or a maximum of 8 weeks.

RESULTS

For placebo, imiquimod 2.5% and 3.75%, respectively, complete clearance of all warts was achieved in 14.2%, 28.3%, and 36.6% of women (intent-to-treat, P = 0.008 imiquimod 2.5%, and P < 0.001 3.75% versus placebo). Mean changes in wart counts were -10.7%, -50.9%, and -63.5% (per-protocol, P < 0.001 each active versus placebo) and safety-related discontinuation rates 0.9%, 1.4%, and 2.3%.

CONCLUSIONS

Imiquimod 3.75% applied daily for up to 8 weeks was well tolerated and superior to placebo in treating women with external anogenital warts.

TA-CIN, a vaccine incorporating a recombinant HPV fusion protein (HPV16 L2E6E7) for the potential treatment of HPV16-associated genital diseases

Commercially available prophylactic HPV vaccines for cervical cancer prevention have limited use in women with previous viral exposure. Therefore, a therapeutic HPV vaccine would benefit patients with HPV-associated genital diseases. Being developed by Cancer Research Technology Ltd, under license from Xenova Group plc, TA-CIN (Tissue Antigen - Cervical Intraepithelial Neoplasia) is a fusion protein vaccine comprising the HPV16 viral proteins L2, E6 and E7 for the treatment of HPV16-associated genital diseases. In mouse models, TA-CIN induced dose-dependent HPV16-specific CD4 and CD8 T-cell responses, which were enhanced when boosted with the vaccinia-based vector vaccine TA-HPV (Therapeutic Antigen - HPV). A phase I clinical trial of TA-CIN in healthy volunteers reported no serious adverse events and HPV16-specific cellular immune responses. Phase II trials in patients with anogenital and vulval intraepithelial neoplasia investigated heterologous prime/boost strategies with TA-CIN/TA-HPV and TA-HPV/TA-CIN, but neither of the regimens offered advantages over single-agent TA-HPV. A recent phase II trial investigating imiquimod/TA-CIN in patients with vulval intraepithelial neoplasia demonstrated significant infiltration of CD4 and CD8 T-cells in lesion responders and complete lesion regression in 63% of patients. More comprehensive case-controlled trials are needed to define responders to immunotherapy with TA-CIN and verify its prophylactic and therapeutic properties.

Chlamydia trachomatis, Mycoplasma genitalium, Neisseria gonorrhoeae, human papillomavirus, and polyomavirus are not detectable in human tissue with epithelial ovarian cancer, borderline tumor, or benign conditions

OBJECTIVE

We sought to analyze the presence of the microorganisms Chlamydia trachomatis, Mycoplasma genitalium, Neisseria gonorrhoeae, human papillomavirus (HPV), and the polyomaviruses BK virus (BKV) and JC virus (JCV) in ovarian tissues of women with ovarian carcinomas, borderline tumors, and benign conditions.

STUDY DESIGN

Ovarian tissue, snap-frozen and stored at -80 degrees C, from 186 women with benign conditions, borderline tumors, and epithelial ovarian cancer, as well as tissue from the contralateral ovary of 126 of these women, were analyzed regarding presence of C trachomatis and N gonorrhoeae (transcription mediated amplification), M genitalium (real-time polymerase chain reaction [PCR]), HPV (PCR), and BKV and JCV (PCR).

RESULTS

All the tissue samples studied were found negative for the microorganisms analyzed.

CONCLUSION

C trachomatis, M genitalium, N gonorrhoeae, HPV, and the polyomaviruses BKV and JCV are not detectable in ovarian tissues either from women with benign conditions and borderline tumors or from women with ovarian cancer.

Gynecologic infections seen in cervical smears in Kuwait

OBJECTIVE

To study the different gynecologic infections seen in cervical smears in Kuwait.

STUDY DESIGN

Over a 6-year period (2002-2007), a total of 42,294 cervical smears were studied in Mubarak Al-Kabeer Hospital, Kuwait. Conventional and ThinPrep (Cytyc Corp. Boxborough, Massachusetts) smears were first screened by cytotechnicians and finally reported by cytopathologists, Smears showing inflammation were analyzed with reference to Kuwaiti women.

RESULTS

Of the 41,748 (98.7%) patients with satisfactory smears, inflammatory changes were observed in 17, 593 (42.1%). Specific infection was identified in 2,679 (15.2%) cases, of which 60.8% were Kuwaitis. The infections seen were Candida sp (73.8%), Trichomonsa vaginalis (11.9%), human papillomavirus (HPV99) (8.2%), Actinomyces-like organisms (3.4%), Chlamydia trachomatis (2.2%) and herpes simplex virus (0.5%). No significant difference was found in the proportion of infectious agents among Kuwaiti and non-Kuwaiti women except marginally higher T vaginalis (10.9% vs 13.4%, p = 0.05) among non-Kuwaitis. Candida sp was the most detectable infectious agent in both Kuwaiti (74.6%) and non-Kuwaiti women (72.4%). Chi2 for trend revealed an increasing proportion of smears from Kuwaiti women found with specific infections (p = 0.049) as compared to those of non-Kuwaitis over the years.

CONCLUSION

The prevalence of infections identified on cervical smears was found to be almost similar in Kuwaiti and non-Kuwaiti women except for T vaginalis, which was higher among non-Kuwaitis as compared to Kuwaitis (10.9% vs. 13.4%, p = 0.051). The Candida sp was the most detectable infectious agent, 74.6% in Kuwaiti and 72.4% in non-Kuwaiti women, followed by T vaginalis, the second and HPV being the third.

HPV detection in the oral and genital mucosa of women with positive histopathological exam for genital HPV, by means of the PCR

Infection by the Human Papilloma Virus (HPV) is one of the most frequent sexually transmitted diseases all over the world. The relationship between oral and genital HPV remains uncertain, as it is with its role on oral carcinogenesis. The goal of the present investigation was to check for the presence of HPV DNA in the oral and genital mucosas of women with HPV genital infection, using the polymerase chain reaction (PCR).

Study method

Cross-sectional cohort.

Materials and Methods

this is a pilot and prospective study involving 30 women, aged between 14 and 51 years, with HPV genital infection, confirmed by histopathology. All the patients were submitted to the exam and sample collection by swabbing the oral and genital mucosas in order to test for HPV DNA through the PCR technique.

Results

none of the oral cavity samples were positive for HPV, while in the genital tract, HPV was detected in 17 (57%) of the 30 patients, especially HPVs 6b and 16.

Conclusion

Results show a higher percentage of genital HPV in comparison to the oral cavity, and suggest that genital HPV does not seem to be a predisposing factor for the oral infection in the same patient.

[Anogenital warts: a clinical, pathological and virological study]

The objective of this study was to investigate the possible relationship between the presence of anogenital warts (AGW) in children and the sexual abuse as mode of transmission. Our series includes 8 patients with AGW who were treated in our hospital during the year 2007. A complete physical examination was carried out, including colposcopy or anoscopy, and samples were taken for histopathological examination and human papiloma virus (HPV) subtyping. We considered perinatal transmission as a possible route in two cases. Although sexual abuse was definitively confirmed in only one case, we observed some findings in four cases that led us to consider the possibility of sexual abuse. We did not consider the possibility of heteroinoculation or autoinoculation from common warts in any case. Our results have demonstrated the difficulty in assessing with certainty the source of HPV contamination in children with AGW.

[HPV caused pathological changes in genital system of mice]

The recombined adenovirus DNA was transfected into 293 cells for packing and amplification of replication-deficient Ad-CMV-E6/E7, Ad-K14 -E6/E7 virus was purified by CsCl density gradient centrifugation , recombined adenovirus Ad-CMV-E6/E7, Ad-K14 -E6/E7 were used as experimental group, while pAd-CMV and pAdtrack-K14 were used as control group. Four of them were injected through one main vein of nude mice tail respectively. These mice were then treated with 0.05 mg 17beta-estradiol over 12 weeks. Mice were anaesthesiaed with 2.5% Avertint and the vagina, mammary gland, ovaries and uterus were dissected and fixed in 3.75% paraformaldehyde overnight at 4 degrees C. Paraffin-embedded sections, HE staining and identification of P53 and Bcl-2 protein via immunohistochemistry were performed. The expression of E6/E7 was verified by RT-PCR in different tissue of nude mice. HE staining showed evident hyperplasy in cervix-uterus transformation zone of experimental group 2. The expression of mutant P53 and Bcl-2 were higher than control group via immunohistochemical S-P method in uterus stroma-cell. Western blotting also showed that E6 protein was expressed. The expression of E6/E7 was higher than control group by human cytokeratin promoter 14 and hyperlasy changes were detected in epithelial tissue of cervix-uterus transformation zone.

Cancer registries and monitoring the impact of prophylactic human papillomavirus vaccines: the potential role

The recent US Food and Drug Administration licensure of a prophylactic vaccine against oncogenic human papillomavirus (HPV) types 16 and 18, the first of its kind, poses unique challenges in postmarketing vaccine surveillance, especially in measuring vaccine effectiveness against biologic endpoints of HPV infection. Historically, the national system of population-based cancer registries in the US has provided high-quality data on cancer incidence and mortality for the most important biologic endpoints, namely, anogenital cancers and some oral cavity/oropharyngeal cancers. There also has been some data collection on cancer precursors; however, this activity has been inconsistent and of lower priority. Because effectiveness against HPV-associated cancers will not be measurable for several decades, strengthening and possibly expanding the capacity of registries to collect precancer data, which are earlier manifestations of infection, must be considered. Collecting type-specific data on HPV-associated precancers and cancers. While keeping in mind the current limitations of registry operations, they discuss resources that may be needed to implement and sustain these types of activities.

Human papilloma virus associated with genital infection

Genital human papillomavirus (HPV) infections are among the most common sexually transmitted diseases. HPV is associated with a spectrum of diseases ranging from benign vulgar verrucae and condylomata accuminata to malignant cancers of the cervix, vulva, anus and penis. Genital HPV is in most cases transmitted sexually, but non-sexual routes of transmission, such as perinatal and autoinoculation, are possible. Men can be a reservoir of the virus that lives in latent or subclinical form on genital mucosa. Such an asymptomatic infection may be an oncogenic factor in the development of cervical cancer Colposcopic examination of the genitalia after the application of 3-5% acetic acid is a reliable method for the identification of subclinical HPV infection. Successful therapy of anogenital warts is characterized by their complete clearance, as well as by the lack of recurrence. Current treatments do not reliably eradicate HPV infections. The diagnosis and therapy of HPV infection in men is potentially beneficial because the eradication of penile HPV infection may decrease the reservoir of the virus.

Normal establishment of virus-specific memory CD8 T cell pool following primary infection during pregnancy

Suppression of cell-mediated immunity has been proposed as a mechanism that promotes maternal tolerance of the fetus but also contributes to increased occurrence and severity of certain infections during pregnancy. Despite decades of research examining the effect of pregnancy on Ag-specific T cell responses, many questions remain. In particular, quantitative examination of memory CD8 T cell generation following infection during pregnancy remains largely unknown. To examine this issue, we evaluated the generation of protective immunity following infection during pregnancy with a nonpersistent strain of lymphocytic choriomeningitis virus (LCMV) in mice. The CD8 T cell response to LCMV occurred normally in pregnant mice compared with the nonpregnant cohort with rapid viral clearance in all tissues tested except for the placenta. Despite significant infiltration of CD8 T cells to the maternal-fetal interface, virus persisted in the placenta until delivery. Live pups were not infected and generated normal primary immune responses when challenged as adults. Memory CD8 T cell development in mice that were pregnant during primary infection was normal with regards to the proliferative capacity, number of Ag-specific cells, cytokine production upon re-stimulation, and the ability to protect from re-infection. These data suggest that virus-specific adaptive memory is normally generated in mice during pregnancy.

Herpes simplex virus infection and genital ulcer disease among patients with sexually transmitted infections in Dar es Salaam, Tanzania

The relative importance of Haemophilus ducreyi and Treponema pallidum in genital ulcer disease in Africa has decreased recently, whereas that of herpes simplex virus (HSV) type 2 has increased. We analysed 301 lesional specimens from Tanzanian patients with genital ulcer disease for the presence of H. ducreyi, T. pallidum and HSV-1/HSV-2 by performing a separate PCR for each pathogen. Infectious agents were detected in 211 (70%) of the cases. A single pathogen was found in 191 samples and two or more pathogens in the remaining 20. HSV-2 represented 83% of all identified pathogens, HSV-1 8%, T. pallidum 4% and H. ducreyi 5%. HSV-1 was identified as a single pathogen in four samples, in combination with others in an additional 14 samples. Thus, HSV-1 can also be the cause of genital ulcer disease in Africa. Regular surveillance of genital ulcer disease aetiology is important in programs for management of genital ulcer disease and HIV in Africa.

College blues and hues

BACKGROUND

Vulvar ulcerations are an entity that practicing gynecologists frequently encounter in daily practice.

CASE

A 21-year-old nulliparous college student presented with a 3-day history of itching to the genital area with associated tenderness and sore bumps. She was initially treated for vulvovaginal candidiasis and instructed to return several days later for follow-up. Repeat examination revealed multiple coalescent and necrotic-appearing ulcerations confined to the labia minora, vagina, and posterior fourchette. All of the lesions eventually resolved.

CONCLUSION

This case reminds us to broaden our differential diagnosis when considering causes of genital tract ulcerations in reproductive-aged females.

Cervical cancer prevention: high hopes

(1) Most cases of high-grade anogenital dysplasia and malignancy are caused by human papillomavirus (HPV) genotypes 16 and 18. Anogenital papilloma and condyloma acuminata are mainly caused by HPV6 and HPV11. (2) A recombinant vaccine covering these four genotypes is now marketed in the European Union for the prevention of condyloma, precancerous lesions, and cancers of the female lower genital tract. (3) A three-dose vaccination schedule (0, 2 and 6 months) elicits an immune response in almost all women, but the minimum antibody titre required for clinical protection is not known. Immune protection lasts at least 5 years, but no one knows what happens after that time. (4) Three double-blind randomised placebo-controlled trials involving a total of about 18 000 women aged 16 to 23 had sufficiently similar designs to pool results for analysis. Nearly all (around 98%) of women not yet infected with papillomavirus of a genotype covered by the vaccine were protected from dysplasia caused by one of these genotypes. The vaccine did not affect dysplasia caused by other genotypes, nor was it effective in women who were already infected. In total, among women not yet infected with a papillomavirus genotype covered by the vaccine, the vaccine prevented about 38% of high-grade dysplasias of all types (0.5 versus 0.8 cases per 100 woman-years). (5) The vaccine also markedly reduced the incidence of genital warts and high-grade vulvar and vaginal dysplasia. There are no data on efficacy beyond 4.5 years. (6) These results are somewhat undermined by methodological problems, such as follow-up lasting only a maximum of 4.5 years whereas cervical cancer takes much longer to develop. In addition, there were very few cases of dysplasia in each trial, and results were largely based on post hoc subgroup analyses. (7) Apart from local reactions, which occurred in more than 80% of vaccinated women, the only adverse effect of papillomavirus vaccination was fever (12.9% of those on the vaccine versus 11% on placebo). (8) There is no evidence thus far that prenatal exposure due to HPV vaccination during the month preceding conception is harmful. (9) The clinical results are promising but further follow-up is needed to answer ongoing questions, such as the incidence of cervical cancer after vaccination and the duration of protection. Cervical cancer screening remains necessary, even for vaccinated women, and a continued need exists for measures designed to prevent all sexually transmitted diseases.

Infectious correlates of HIV-1 shedding in the female upper and lower genital tracts

OBJECTIVES

To determine the effects of vaginal, cervical, and endometrial infections on shedding of HIV-1 RNA in the female genital tract.

DESIGN

Cross-sectional.

METHODS

Antiretroviral-naive women from Nairobi, Kenya with CD4 cell counts >or= 350 cells/mul had plasma and endocervical wick samples collected for HIV quantification by real-time RNA reverse transcriptase-polymerase chain reaction. Vaginal and cervical Gram stains and endometrial biopsies were obtained. Vaginal Gram stain was used to diagnose bacterial vaginosis and to quantify Lactobacillus levels.

RESULTS

Twenty-six of 50 (52%) women had detectable endocervical HIV-1 RNA with a median endocervical viral load of 1760 copies/ml (range: undetectable to 1 1,030,000 copies/ml). Women with decreased Lactobacillus had 15.8-fold [95% confidence interval (CI), 2.0-123] greater endocervical HIV-1 RNA than women with normal Lactobacillus levels. Women with plasma cell (PC) endometritis [>or= 1 PC/high-power field (hpf)] had a 15.8-fold (95% CI, 2.0-120) higher endocervical HIV RNA level than women without PC endometritis. Both these associations remained after controlling for plasma viral load. Cervicitis (>or= 30 polymorphonuclear leukocytes/hpf), however, was not associated with endocervical HIV-1 RNA shedding (P = 0.81).

CONCLUSIONS

In HIV-1-infected, antiretroviral-naive women without symptoms of pelvic inflammatory disease infection, abnormal vaginal flora and inflammatory cells in the endometrium affected HIV-1 shedding from the lower genital tract. These data suggest that both the upper and lower genital tracts contribute to female HIV-1 genital shedding.

Impact of microbicides and sexually transmitted infections on mucosal immunity in the female genital tract

Human immunodeficiency virus, genital herpes, and other sexually transmitted infections are a critical national and global health priority requiring the rapid development of safe and effective control methods. Topical microbicides, self-administered agents designed for vaginal use, that block transmission at the mucosal surface may provide a realistic method of intervention that could be distributed worldwide. An optimal microbicide should protect against infection but must also be safe, without adversely affecting the mucosal environment, including mediators of host defense. Thus, a critical component in microbicides development is to identify optimal assays that could serve as surrogate markers to predict safety of microbicides prior to embarking on large-scale clinical trials. This will require a greater understanding of the mediators of mucosal immunity in the female genital tract.