Maria Hadjivassiliou

Imiquimod-induced vitiligo in a patient with genital warts.

Editor A 32-year-old man presented to our clinic with a 5-year history of genital warts. He was on remission after multiple cryotherapy sessions but his problem had relapsed 3 months before presentation. Apart from transient erythema, oedema and erosions, he never had any other problems with cryotherapy. The patient had 15 genital warts on the shaft of the penis and scrotum with a total wart area 2 cm and was advised to use imiquimod 5% cream every other night for 6–8 h. After a month on imiquimod, he noticed some irritation of the genital area, consisting mostly of erythema and desquamation without any erosions, and some depigmentation first starting from the penis and gradually spreading. Despite those problems he persisted on the treatment for another 2 months. At the end of 3 months on imiquimod the dorsal surface of the penis and part of the pubic area and scrotum were totally depigmented without total resolution of his warts. Upon examination, one could detect two genital warts on the shaft of the penis and vitiligo involving the dorsal surface of the penis, scrotum and pubic area. Imiquimod was discontinued. Slight repigmentation (2%) and no further depigmentation were noted in a 3-month followup period (fig. 1). The patient was circumcised and he was perfectly fit and well. It is noteworthy that his father suffered from vitiligo and diabetes mellitus.

Prevalence of different HPV types and estimation of prognostic risk factors based on the linear array HPV genotyping test.

The aim of the study was to evaluate the prevalence and risk factors of HPV in a gynecologic population attending outpatient clinics using two new molecular tests. The Amplicor HPV test and the Linear Array (LA) HPV Genotyping test were used for the detection of HPV DNA in 320 women. Multiple logistic regression was used to identify independent prognostic factors of HPV positivity. The agreement between the two methods in terms of their qualitative results was 89.3% (kappa: 0.63). Based on the LA results, the overall prevalence of HPV DNA was 49.1%, 95% confidence interval (95% CI: 43.5%, 54.7%). The prevalence of high‐risk HPV types was 30.3%. The predominant types were HPV‐6 (24.8%) and HPV‐16 (20.4%). Among women with normal cytology, the prevalence of HPV was much higher in those presenting other findings, such as inflammation, than those without other abnormal findings (49.5% vs. 31.5%). On the basis of multivariate analysis, the risk of HPV infection was higher among women with multiple sexual partners [>3 vs. 1: OR = 3.1, 95% CI: (1.5, 7.2)], Pap smear findings [low/high‐grade lesions vs. negative: OR = 2.8, 95% CI: (1.2, 6.5)], the presence of warts [yes vs. no: OR = 3.0, 95% CI: (1.5, 6.3)] and no history of child birth [no vs. yes: OR = 2.6, 95% CI: (1.0, 6.7)]. Younger age was an additional risk factor for HPV infection with carcinogenic genotypes [OR for 1 year increase = 0.93, 95% CI: (0.89, 0.98)]. J. Med. Virol. 81:2059–2065, 2009.

HIV-1 infection-associated risk factors among sexually transmitted disease patients in Athens, Greece: 1990 to 1996.

Objective: To determine trends in HIV seroprevalence and related risk factors among patients with sexually transmitted diseases (STDs) and to report the respective epidemiologic history characteristics. Methods: A cross‐sectional seroepidemiologic study conducted from 1990 to 1996 among 5,669 symptomatic STD cases was carried out. Results: The overall HIV test acceptance was 98.9%, and 1.2% patients (n = 66) were seropositive. Highest rates were detected among those who were born or resided in Sub‐Saharan Africa. Seropositivity fluctuates significantly by age, and is excessive in persons 45 years and older (2.6%). A significant decreasing trend in STD incidence and HIV seroprevalence among patients younger than 25 years was detected. Male homosexuals and bisexuals (MSM) exhibited the highest overall rate of infection (5.8%) followed by intravenous drug users (2%). Highly promiscuous STD patients (ie, those who had more than 10 partners during the past 6 months) presented a significantly increased HIV seroprevalence when compared with patients of the same sexual orientation. STD patients infected with HIV mostly belonged to notable risk categories of AIDS (men who have sex with men, 72.7%). Awareness of serostatus was low (13.6%). In male patients, the HIV seropositivity rate was significantly higher among early syphilis and proctitis cases, whereas in females this higher rate occurred with herpes genitalis. Conclusions: Promiscuity and sexual orientation significantly influence the seroprevalence rate. Exposure to HIV remained stable despite the above declining time trends, which implies the need for additional preventive interventions targeted to the real health and illness behavior of the partner.

Incidence determinants of gonorrhea, chlamydial genital infection, syphilis and chancroid in attendees at a sexually transmitted disease clinic in Athens, Greece

Objective  To determine the specific impact on the incidence rate of some demographic and behavioral characteristics in outpatients with four bacterial sexually transmitted diseases (STDs).

Determinants of genital wart case detection rates among STD clinic attendees in Athens, Greece

Background and objective  To report significant sociodemographic and behavioral outpatient characteristics associated with the diagnosis of genital warts.

Human papillomavirus assay in genital warts – correlation with symptoms

Our purpose was to investigate the human papillomavirus (HPV) type distribution using the Hybrid Capture 2 (HC2) Microplate assay in males. We tested a urethral swab from 550 HIV-negative males with genital warts and 64 HIV-negative males clinically free of genital warts, partners of HPV-infected females, using the HC2 Microplate assay. A perianal swab was also obtained from patients with perianal warts. In the first group, HPV DNA of any type was detected in 280 (50.9%) patients. Relatively few patients with urethral or perianal warts demonstrated a negative test (both P < 0.0001). Low-risk types were commoner, accounting for 60.0% of the HPV cases, high/intermediate-risk types accounted for 23.6%, while 46 men (16.4%) were infected with both types. Of 13 subjects (20.3%) of the second group who tested positive for HPV DNA, 61.5% were infected by low-risk types, 23.1% by high/intermediate-risk types and 15.4% had a dual infection. In conclusion, male partners of infected females and males with genital warts are predominantly infected by low-risk HPV types, but a substantial proportion is also or only affected by high-risk types.

Prognostic factors for the response to treatment in males with genital warts

Background  Factors predicting an unfavourable course of genital warts to treatment have not been determined.

Buschke–Löwenstein tumour:

teenage girls without the knowledge and resources to help themselves? Only 37% of consultants were aware that Gardasil is licensed for prescription. In fact, the Department of Health states that Gardasil can be prescribed if clinically indicated (on an FP10 prescription). Some general practitioners are unaware of this, and many have expressed disappointment at the lack of national advice on the vaccines. One consultant pointed out ‘GPs will not prescribe on the whole unless a health practitioner requests it for their own family use, i.e. we got it but three neighbours were refused in our practice’. In conclusion, a vaccine that may not provide the full range of potential social, health and economic advantages is currently being used in our national programme. However, public awareness, even among well-educated medical professionals, is sorely lacking. The vaccination contract is due for renewal: the UK needs to join most of Europe, Canada, Australia and the USA who have chosen to protect their young women with the quadrivalent vaccine. Better education of the general population is also needed so that the majority can add their voices to the debate.

Atopic patients with genital warts have a more protracted clinical course and a greater probability of recurrences.

The factors predicting an unfavourable response of genital warts to treatment have not been determined. The disease characteristics were recorded for 390 patients with genital warts and treated by cryotherapy. The time to achieve clearance was recorded. A personal and family history of asthma, hay fever or eczema, as well as a personal history of common warts and number of recurrences was obtained by telephone four to five years after the clinical visits. In multiple regression analysis, the number of lesions (P < 0.001), extent of the disease (P = 0.003) and personal history of atopy (P = 0.001) were found to influence the time until response to treatment. Similar results were obtained for family history of atopy. The number of sexual partners (P = 0.007), extent of the disease (P = 0.009) and personal history of atopy (P < 0.001) were the main factors influencing the probability of recurrence in multiple logistic regression. The results for family history of atopy were again similar. The study concludes that atopy is a major factor influencing the time frame of the therapeutic response and the probability of recurrence in patients with genital warts.

Human papillomavirus detection in men with sexually transmitted disease and in healthy controls.

Sir: In this study, we included 105 male patients attending our sexually transmitted disease (STD) clinic for symptoms other than genital warts, who agreed to participate in the study. Patients reporting ever having genital warts or ever having a sexual partner with human papillomavirus (HPV) infection were excluded from the study. We also included 102 healthy male volunteers attending the dermatology outpatients clinics of Andreas Sygros Hospital for symptoms not related to STD. Similarly, men with a present or past history of genital warts or ever having a partner with HPV infection were excluded. The study was approved by the ethical committee of our institution. Participants of both groups underwent a routine clinical examination by two experienced physicians to exclude the presence of genital warts. Patients of the first group were routinely tested according to their signs and symptoms for Treponema pallidum (dark-field microscopy), Neisseria gonorrhoeae (Gram stain and culture), Chlamydia trachomatis (direct immunofluorescence or polymerase chain reaction (PCR)) and herpes simplex virus 1 (HSV1) and HSV2 (direct immunofluorescence or enzyme immunosorbent assay (EIA)). All patients of the first group, irrespective of their clinical symptoms, underwent a blood test for syphilis (Venereal Disease Research Laboratory (VDRL) and T. pallidum EIA immunoglobulin G (IgG) tests) and HIV infection (anti-HIV1, 2 EIA). Participants of both groups were subsequently tested for the presence of HPV at the genital area (Hybrid Capture Microplate II assay – Digene Corporation). Sampling was performed by a sterile cytobrush, which was rotated at an angle of 3601 into the urethra. Another cytobrush was scraped along the coronal sulcus, the glans penis and the inner surface of the prepuce. Both cytobrushes were then placed in a storage bottle of a Digene Swab Specimen collection kit containing buffer solution provided by the manufacturer and the bottles were kept at 201C until the detection test. The method identifies high–intermediate oncogenic risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) and low oncogenic risk HPV types (6, 11, 42, 43, 44). Viral DNA detection was done according to the instructions of the manufacturer. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS Inc.) for Windows 11.0. Associations between categorical variables were examined by w–test, along with calculating Cramer’s V and l-correlation coefficients and Fisher’s exact probability test. The probability measures for all calculations were also provided and values of Po0.05 were considered significant. The mean age of the first group of patients was 33.56 (712.5) and of the healthy volunteers was 41.11 (718.9). Twelve patients of the first group suffered from early syphilis (primary and secondary), two from latent syphilis, 27 from gonococcal urethritis, 12 from chlamydial urethritis, two from both gonococcal and chlamydial urethritis, 23 suffered from genital herpes, 19 from nonspecific urethritis, seven from a genital ulcer with no identifiable infective cause and one from trichomonas urethritis. HPV DNA was detected in 5.3% (11/105) of the first group and in 2.9% (6/102) of the healthy volunteers. No statistically significant difference was observed regarding HPV DNA detection between the two groups (P1⁄4 0.312). The type of HPV positivity (low, high/intermediate, low and high/intermediate) did not show any statistically significant difference between the two groups. Patients of the first group demonstrated 2.9% (6/105) positivity for low-risk types, 1.9% (4/105) positivity for high–intermediate–risk types and 0.5% (1/105) positivity for both lowand high–intermediate-risk HPV types. Of the six HPV DNA-positive healthy volunteers, one (0.5%) tested positive for low-risk types, two (1.0%) tested positive for high–intermediate-risk types and three (1.4%) tested positive for both types. Currently, the detection of HPV infection is being done by using signal amplification methods such as the Hybrid Capture II system (HC2, Digene Corporation, Gaithersburg, MD, USA) or target amplification such as PCR. Although HC2 does not permit the identification of specific HPV types, it does not necessarily lack clinical sensitivity. In our study, we found that men presenting with an STD other than genital warts are not at increased risk for HPV infection in comparison to healthy volunteers. The percentage of HPV-positive men (5.3%) suffering from STDs did not differ significantly from that observed in healthy men (2.9%). Takahashi et al., using the HC2, detected HPV DNA more frequently (18.5%) in patients with urethritis than in healthy controls (1.2%). Probably the homogenous population, where all suffered from urethritis, played a role in the higher detection rate observed by Takahashi et al. The association between history of STD and HPV infection has been controversial as other investigators have reported a positive association between a history of STD and HPV infection, while others have not. Baldwin et al. concluded that genital warts is the only STD to be associated with penile HPV infection. Certain STD pathogens such as HSV2 have been implicated as co-factors for the HPV-mediated pathogenesis, which enhances HPV replication and integration in women but not in men. Similarly, tissue destruction and inflammation associated with other STDs could facilitate HPV infection and could explain the association of several STDs with seroprevalence. Interestingly, in our study, no specific pathogen (T. pallidum, chlamydia, N. gonorrhoeae, HSV2, trichomonas) increased the detection rate of HPV. In conclusion, men suffering from STDs other than genital warts, although considered a high-risk population for any other STD, were not found in our study to be at