HIV and STDs: October 2018

Colorectal STDs may be occasionally misdiagnosed as inflammatory bowel disease. That’s the conclusion of this small case series (n=16). The patients were all men who have sex with men, most were HIV positive, and both their clinical presentation and findings on endoscopy suggested IBD. After an initial misdiagnosis of IBD, 14/16 patients were diagnosed with rectal chlamydia (four with LGV serotypes), 5/14 with gonorrhea, and 4/14 with syphilis. Delays in establishing the correct diagnoses ranged from one month to three years. So, before you send your sexually active MSM patient off to GI for an IBD evaluation, make sure you’ve done your due diligence in screening rectally for sexually transmitted diseases. 30125691

Speaking of extragenital STDs, this review of records of 526 transgender patients from 26 public STD clinics (506 women, 120 men) demonstrated that when chlamydial and gonococcal infections were present, solely extragenital disease was common in both transgender women (86% and 81%, respectively) and transgender women (29% each). One might conclude from this that it’s important to screen for STDs based on the types of sex that patients report having. However, studies in cisgender heterosexual patients at STD clinics have shown that people who claim not to have oral and anal sex still have quite a bit of pharyngeal and rectal chlamydia and gonorrhea, some of which might be missed by genital screening along, so arguably the most effective approach is to screen all three mucosa in everyone regardless of gender or what kind of sex they tell you they have. 30278030

Seven days of metronidazole is more effective than a single dose for trichomoniasis. The authors conducted an open-label RTC involving three US sexual health clinics. Women with Trichimonas vaginalis infection were randomized to receive either a single 2g dose of metronidazole or 500mg twice a day for seven days. The primary outcome was T. vaginalis infection at a test of cure visit 4 weeks after completing treatment. A total 623 women were randomized to the two treatment groups; a larger sample size was planned but the study was stopped early due toinadequate funding. Patients in the 7-day group were less likely to be persistently positive for T. vaginalis at the test of cure visit than patients in the single-dose group (11% vs 19%; RR 0.55, p<0.0001). Self-reported adherence rates were over 95% in both groups, and side effects of the regimens were similar (nausea in 23%, headache in 7%, and vomiting in 4%). 30278030

Double vision portends a poor outcome in patients with neurosyphilis. The authors reviewed the cases of 144 patients from 22 referral centers across the world (but mostly in Turkey) who had definite neurosyphilis, defined as both a positive CSF VDRL and a positive serum serological treponemal or nontreponemal test. Thirty percent of the cohort had HIV infection. The most common presenting symptoms were headache, fatigue, and altered mentation, each present in just over a third of patients; a fifth had some sort of neuropsychiatric manifestation. A quarter of patients who had an eye exam had evidence of ocular involvement and a third of patients who had an audiologic exam had evidence of otic involvement.

Headache was more common in patients who ultimately did well (47% vs 29%; p=0.03; OR 0.3 for a poor outcome in multivariate analysis, 95% CI 0.1-0.7), whereas double vision was more common in those who did poorly (20% vs 7%; p=0.02; OR 5.9 for a poor outcome in multivariate analysis, 95% CI 1.7-20.9). CSF glucose was significantly lower in patients who ultimately did well (53 versus 62; p=0.001) – I don’t know what to make of that. As for treatment, 77% of patients received IV penicillin and 22% ceftriaxone and they both did about as well, though interestingly steroid administration was more frequent in the patients with an ultimately good outcome (18% vs 3%; p=0.004). 30368740