Annals of African Medicine Annals of African Medicine Society ISSN: 1596-3519 Vol. 10, Num. 2, 2011, pp. 192-193

Annals of African Medicine, Vol. 10, No. 2, April-June, 2011, pp. 192-193

Letter to the Editor

Peculiarities of genital ulcer diseases in HIV-infected patients: Report of four cases from Zaria, Nigeria

Dimie Ogoina¹, Haruna M Muktar², Reginald O Obiako¹

¹ Department of Medicine, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna state, Nigeria
² Department of Haematology, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna state, Nigeria

Correspondence Address: Dimie Ogoina Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria Nigeria dimostic@yahoo.co.uk

Code Number: am11039

PMID: 21691031

DOI: 10.4103/1596-3519.82058

Dear Sir,

Studies in the literature on the clinical presentation and course of genital ulcer diseases (GUDs) in HIV-infected patients, described as atypical, chronic, aggressive and unresponsive to therapy, are scarce from northern Nigeria. We highlight our experiences in four heterosexual HIV-1 infected adults seen in Zaria, Northwest Nigeria, who were managed using the WHO syndromic management guidelines. ^[1]

Case 1: A 51-year-old antiretroviral therapy (ART) naive male having a CD4 cell count of 144 cells/μl presented with 6 months history of recurrent painful penile vesicles which evolved into multiple deep ulcers that were unresponsive to tablets acyclovir 400 mg tds. A syndromic diagnosis of genital herpes was made. He received highly active antiretroviral therapy (HAART) and acyclovir was increased to 800 mg tds for an extended period of 2 weeks, since active lesions persisted by the 7 ^th day of follow-up. His ulcers healed in 3 weeks [Figure - 1] with no recurrence after 3 months of follow-up.

Case 2: A 27-year-old ART naive spinster having a CD4 cell count of 168 cells/μl presented with 3 weeks persistent painful multiple vulvo-vagina vesicles which subsequently evolved into variable shallow and deep ulcers. A syndromic diagnosis of genital herpes was made. She received HAART and her ulcers healed with tablets acyclovir 800 mg tds for 2 weeks without recurrence after 2 months of follow-up.

Case 3: A 26-year-old ART naive spinster having a CD4 cell count of 84 cells//μl presented with 2 months left inguinal adenopathy, multiple necrotic foul-smelling ragged vulvo-vagina ulcers and vulva edema. The inguinal node suppurated and evolved into a deep necrotic ulcer with surrounding edema [Figure - 2]. A syndromic diagnosis of inguinal bubo, possibly chancroid, was made. She received HAART and tablets Doxcycline 100 mg bd for 21 days and Levofloxacin 500 mg daily for 7 days. Unfortunately, on the 10 ^th day of therapy, she presented with features of sepsis and died before further diagnostic investigations could be conducted.

Case 4: A 37-year-old ART experienced male truck driver presented with 6 weeks painful left inguinal adenopathy with subsequent suppuration, ulceration and purulent discharge from multiple sinuses [Figure - 3]. There was no genital ulcer. On HAART, his CD4 cell count had improved from 242 to 318 cells/μl, and his viral load was undetectable. A syndromic diagnosis of inguinal bubo, possibly lymphogranuloma venereum (LGV), was made. Inguinal bubo was aspirated from normal skin and he received tablets Doxcycline 100 mg bd for 21 days and Levofloxacin 500 mg daily for 7 days and the bubo healed in 4 weeks [Figure - 4].

The four cases presented are in agreement with other studies where GUDs in HIV-infected patients were found to be recurrent, chronic, aggressive and sometimes associated with systemic symptoms, ^[2],[3] as was seen in case 3. In view of the principal role of high HIV viral load and immunosuppression in the pathogenesis of these manifestations, ^[4],[5] HAART improves the recovery of GUD and prevents its recurrence, as demonstrated in our cases with genital herpes. In developing countries where sophisticated GUD diagnostic facilities are unavailable, the syndromic approach is simple, rapid and effective in the management of GUD, especially in HIV-infected patients who present atypically. ^[1]

References

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