We were interested in the case report, "Perianal Crohns Disease
masquerading as perianal warts"[1] (August)
In which the authors highlight the diagnostic difficulty with other
anogenital conditions such as perianal warts.
Plus the initial lack of obvious bowel symptoms considered to be the
hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged
43 wh...
We were interested in the case report, "Perianal Crohns Disease
masquerading as perianal warts"[1] (August)
In which the authors highlight the diagnostic difficulty with other
anogenital conditions such as perianal warts.
Plus the initial lack of obvious bowel symptoms considered to be the
hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged
43 who presented with a vulvitis of several months duration, the main
symptoms being pruritis vulvae and superficial dyspareunia. There was
absolutely no gastrointestinal symptoms or systemic upset and past general
health was good.
Initial clinical examination revealed diffuse erythema and swelling
of the Labia Majora, and some perineal fissuring was also noted.
All routine STI screening tests were negative, and a provisional diagnosis
of Vulval Dermatitis was made.
With agreement of the patient a therapeutic trial of Hydrocortisone 1 % was
tried but with no effect.
A vulval biopsy was therefore carried out which revealed histological
features consistent with Crohns disease,i.e. non-caseating granuloma,giant
cells and chronic inflammatory infiltrate.
A colonoscopy was reported as normal and the patient remains asymptomatic.
This case, in common with the reported case[1], reminds us that Crohns
disease can present initially as a common clinical condition to GU
Clinics, such as warts or vulvitis.
The diagnosis rests primarily on biopsy of the lesion,this is especially
so in cases of "metastatic disease"[2] either preceeding bowel involvement
by years,[3] or exclusive involvement of genital tract only.[2]
Is it possible that Crohns disease of the genital tract is an
underdiagnosed condition?
Benjamin Goorney
References
(1) Garg M, Kawsar M, Forster GE, and Medows NJ. Perianal Crohn’s disease masquerading as perianal warts. Sex Transm Infect 2002;78:302-303.
(2) Urbanek M, Neill SM, Mckee PH. Vulval Crohns disease: difficulties in diagnosis. Clinical and Experimental Dermatology 1996;21:211-214.
(3) Bruce L, Donaldson, MD. Crohns disease: its gynecologic aspect. Am J Obstet Gynecol 1978;131:196-202
Bailis does not support his claim that male circumcision provides significant protection against disease with recent data. He uses antique data that are highly suspect.1
The Diseker study uses data from inner city STD clinics.2 This introduces significant population bias due to the significantly uneven distribut...
Bailis does not support his claim that male circumcision provides significant protection against disease with recent data. He uses antique data that are highly suspect.1
The Diseker study uses data from inner city STD clinics.2 This introduces significant population bias due to the significantly uneven distribution of ethnic groups within the United States between urban and suburban areas. Moreover, Diseker et al. later reports a 15.6% clinician error in determination of circumcision status.3 Therefore, such data cannot be considered to be reliable. Van Howe's survey of the literature found only a slight reduction in genital ulcer disease (GUD) in circumcised men that was counterbalanced by an increase in urethritis.4 Van Howe reports that the rate of STDs in the United States has increased as the rate of circumcision has increased.4
Laumann et al. report that the United States adult male population is 77% circumcised.5 If circumcision reduced STIs, then one would expect to find the United States to be nearly free of STIs. Such is not the case. Tanne reports an epidemic of STDs in the United States.6
Circumcision is an injurious surgical procedure. There is a high rate of complications.7 Circumcision amputates significant amount of erogenous tissue and leaves a lifetime irreversible injury.8 Adverse sexual and psychological effects are documented.9 The current state of medical science contraindicates the prophylactic use of male circumcision.
George Hill
Executive Secretary
Doctors Opposing Circumcision
2442 NW Market Street, Suite 42
Seattle, Washington 98107
USA
Web: http://faculty.washington.edu/gcd/DOC/
References:
Bailis SA. Letter. Sex Transm Infect 2001;77(6):462-3.
Although our study population was homogeneous and Baltimore is known
to have high sexually transmitted disease (STD) rates, we believe
sufficient evidence exists to support our recommendation of twice yearly
chlamydia screening of sexually active females less than 25 years of age.
Chlamydia screening in most adolescent female populations yields
prevalence rates greater than 10%, except in areas wit...
Although our study population was homogeneous and Baltimore is known
to have high sexually transmitted disease (STD) rates, we believe
sufficient evidence exists to support our recommendation of twice yearly
chlamydia screening of sexually active females less than 25 years of age.
Chlamydia screening in most adolescent female populations yields
prevalence rates greater than 10%, except in areas with long-standing
chlamydia control programs, such as in the United States Pacific
Northwest.[1-5] In a large private sector managed care organization serving
a diverse adolescent population, including members residing in wealthy
suburban communities, we found chlamydia prevalence rates well above 10%
in adolescents chlamydia tested and a median time to reinfection of six
months among those with repeat tests.[1]
Drs. Pittrof and Kegg claim that our recommendation of twice yearly
chlamydia screening “apply only to … self selected women who attend sexual
health clinics.” In our study, the females with the highest rates of
infection were screened at school-based health centers providing
comprehensive primary care health services.[6]
Drs. Pittrof and Kegg advocate for screening practices to be dictated
by disease prevalence in specific populations. We agree in concept.
However, the chlamydia burden in private sector populations has not been
well described, and most health services do not have the resources or
technology to generate population-based incidence or prevalence data. In
addition, many chlamydia prevalence rates are determined with less
sensitive tests than were used in our study and may underestimate the true
disease burden.[2]
Chlamydia is mostly an asymptomatic infection with serious
consequences. We were unable to predict risk of infection among adolescent
females based on prior STDs, clinical presentation, or risk behaviors.
Since the risk of pelvic inflammatory disease and its sequelae increase
with the duration of untreated infection, we feel it is cavalier to assume
without supporting evidence that chlamydia is not a hidden problem in any
given adolescent population. Therefore, we recommend screening all
sexually active adolescent females for chlamydia infection twice yearly
until evidence to the contrary is generated.
Gale R Burstein, MD, MPH
Jonathan M Zenilman, MD
Johns Hopkins University
Baltimore, MD
Thomas C Quinn, MD
Johns Hopkins University
Baltimore
National Institute of Health
Bethesda, MD
(1) Burstein GR, Snyder MH, Conley D, Boekeloo B, Quinn TC, Zenilman
JM. Sexually transmitted disease screening practices and diagnosed
infections in a large managed care organization. Sex Transm Dis In Press
(2) Schacter J. Chlamydia trachomatis: the more you look, the more you
find – how much is there? Sex Transm Dis 1998;25:229-231.
(3) Winter L, Goldy AS, Baer C. Prevalence and epidemiologic
correlates of Chlamydia trachomatis in rural and urban populations. Sex
Transm Dis 1990;17:30-36.
(4) Fisher M, Swenson PD, Risucci D, Kaplan MH. Chlamydia trachomatis
in suburban adolescents. J Pediatr 1987;111:617-20.
(5) Cohen DA. Nsuami M. Etame RB. Tropez-Sims S. Abdalian S. Farley
TA. Martin DH. A school-based Chlamydia control program using DNA
amplification technology. Pediatr 1998 101:E1
(6) Burstein GR, Zenilman JM, Gaydos CA, Diener-West M, Howell MR,
Brathwaite W, Quinn TC. Risks of incident Chlamydia trachomatis infections
diagnosed by DNA amplification testing among inner city females with
repeat clinic visits. Sex Transm Infect 2001;77:26-32.
Burstein and colleagues present interesting data concerning repeat
diagnosis of Chlamydia trachomatis in inner city women. Their data may
however not support all their conclusions. In their methods section they
state that “the frequency of diagnosis of first incident infection was
estimated by calculating the median time interval in months between first
test and first positive test during the study period a...
Burstein and colleagues present interesting data concerning repeat
diagnosis of Chlamydia trachomatis in inner city women. Their data may
however not support all their conclusions. In their methods section they
state that “the frequency of diagnosis of first incident infection was
estimated by calculating the median time interval in months between first
test and first positive test during the study period among all females
with negative results at first test and at least one subsequent positive
test.”
Using this approach they calculated an incidence of 20.3/1000 person
months for women aged <25 years and recommended to “screen ALL females
<_25 years="years" for="for" chlamydia="chlamydia" twice="twice" yearly="yearly" regardless="regardless" of="of" symptoms="symptoms" previous="previous" infections="infections" condom="condom" use="use" or="or" multiple="multiple" partner="partner" risk.="risk." however="however" their="their" population="population" studied="studied" was="was" not="not" representative="representative" the="the" total="total" women="women" aged="aged" _25="_25" years.="years." calculated="calculated" incidence="incidence" and="and" final="final" recommendation="recommendation" apply="apply" only="only" to="to" a="a" particular="particular" sub="sub" _-="_-" self="self" selected="selected" who="who" attend="attend" sexual="sexual" health="health" clinics="clinics" later="later" develop="develop" c="c" trachomatis="trachomatis" infection.="infection." we="we" suggest="suggest" that="that" members="members" this="this" should="should" be="be" screened="screened" even="even" more="more" frequently="frequently" they="they" clinics.="clinics." p="p"/>The data presented by Burnstein and colleagues does however not allow the
calculation of the ideal screening interval for members of other
populations (ie most women under the age of 25 years).
Low and colleagues present a very important paper. They should be given
the opportunity to remove my doubts about the validity of their findings:
They used a cross sectional design to determine incidence; however,
unless the average duration of conditions is known longitudinal studies
are required to determine this. The presented study assessed
disease status of self-selected participants over a period of...
Low and colleagues present a very important paper. They should be given
the opportunity to remove my doubts about the validity of their findings:
They used a cross sectional design to determine incidence; however,
unless the average duration of conditions is known longitudinal studies
are required to determine this. The presented study assessed
disease status of self-selected participants over a period of 2 years. For
most of the participants the disease status at the beginning of the 2-year
study period was unknown. This allows the calculation of the period
prevalence, “which represents the proportion of cases that exist within a
population at any point during a specified period of time. The numerator
thus includes cases tat were present at the start of the period plus new
cases that developed during this time”.[1]
For conditions with a long duration (such as asymptomatic infection in
women) the incidence may be considerably lower than the period prevalence.
The key message of the paper is that rates of gonorrhoea and chlamydia diagnosis differ between different black ethnic groups. As the
authors mention in their discussion “differential sexual heath service use
by the ethnic groups may account for some of the observed disparity”.
Knowledge, attitudes, individual and group norms, resources and ease of
access determine care seeking. Ease of access should be similar for
members of different ethnic groups living is the same ward. Maybe Low and
colleagues would like to present the data controlling for confounding by
ward of residence.
References
(1) Hennekens CH, Burning JE. Measures of disease frequency in Epidemiology
in Medicine. Ed, Mayrent SL. Boston 1987:54-100.
Mr McElborough considers it unfortunate that reference labs may have
developed their algorithms in the case of conventional syphilis diagnosis
and these do little to help with HIV coinfected patients. Guidelines for
serological diagnosis in coexisting HIV infection, neurosyphilis and
congenital infection are currently under preparation by the (Public Health Laboratory Service) PHLS Syphilis
Forum and will...
Mr McElborough considers it unfortunate that reference labs may have
developed their algorithms in the case of conventional syphilis diagnosis
and these do little to help with HIV coinfected patients. Guidelines for
serological diagnosis in coexisting HIV infection, neurosyphilis and
congenital infection are currently under preparation by the (Public Health Laboratory Service) PHLS Syphilis
Forum and will be available later this year.
In Edinburgh, the syphilis/HIV co-infected population may be much
smaller than in Brighton, but we have not experienced the serological
problems that Mr McElborough refers to. It would be most helpful if Mr
McElborough published details of the atypical serology that he has
encountered in coinfected patients.
Hugh Young
Medical Microbiology
Edinburgh University Medical School
Teviot Place, Edinburgh EH8 9AG, UK
Whilst it is comforting that some research is finally being carried
out in depth on the risk of STIs amongst women who have sex with women
(WSW), any conclusions drawn from this study for WSW in general need to be
handled with a great deal of caution when one looks at the make-up of the
subjects and controls.
For example, over twice as many of the WSW as the control group were
current sex workers;...
Whilst it is comforting that some research is finally being carried
out in depth on the risk of STIs amongst women who have sex with women
(WSW), any conclusions drawn from this study for WSW in general need to be
handled with a great deal of caution when one looks at the make-up of the
subjects and controls.
For example, over twice as many of the WSW as the control group were
current sex workers; 38% of the WSW had had a previous termination of
pregnancy; nearly six times as many of the WSW had a history of injecting
drug use.
The researchers themselves say their "clinic population... may not be representative of the WSW in the general community". This is an understatement - and any reporting of this study must make very clear statements about the dangers of inappropriate conclusions about STIs
amongst women who have sex with women generally.
In our area the high HIV prevalence has made the interpretation of
syphilis tests paticularly problematic. Coinfected patients do appear to
reactivate their treponemal infection or possibly reinfection with a
different "strain" in the presence of profound immunosuppression. As with
some other agents IgM can persist for several years with peaks and
troughs! Non-treponemal tests are uniformly negative whilst...
In our area the high HIV prevalence has made the interpretation of
syphilis tests paticularly problematic. Coinfected patients do appear to
reactivate their treponemal infection or possibly reinfection with a
different "strain" in the presence of profound immunosuppression. As with
some other agents IgM can persist for several years with peaks and
troughs! Non-treponemal tests are uniformly negative whilst TPHA levels
can fluctuate widely! It is perhaps unfortunate that reference labs may
have developed their algorithms in the face of conventional syphilis
diagnosis - these do little to help with HIV coinfected patients.
Denis McElborough
Public Health Laboratory
Royal Sussex County Hospital
Eastern Road, Brighton, UK
Fether at al present a very interesting case control study on
STIs in women who have sex with women (WSW). This was not a community
based sample and thus prone to selection bias. In order to appreciate the
results in full it would help to know how cases and controls were identified
and how controls were selected.
As bisexual or homosexual orientation may
be difficult to disclose even in a sympat...
Fether at al present a very interesting case control study on
STIs in women who have sex with women (WSW). This was not a community
based sample and thus prone to selection bias. In order to appreciate the
results in full it would help to know how cases and controls were identified
and how controls were selected.
As bisexual or homosexual orientation may
be difficult to disclose even in a sympathetic and non-judgemental
setting, studies using self-reported sexual orientation to determine
case or control status will always have a degree of differential
misclassification.
It is likely that WSW who volunteer this information
differ not only from women who do not have sex with women but also from
WSW who do not volunteer the information but admit it when prompted, and
from those who do not admit it even when prompted.
Without this information it is difficult to determine the importance of
various prevalence quoted in the paper. All I learn from this paper at
present is that women who have sex with women also take other risks.
I commend Shamanesh et al for their searching and informed
account of the impact of globalisation on the world AIDS problem.
Revisiting Alma Ata 1978: the existence of gross inequalities between
advantaged and disadvantaged peoples is "politically, socially and
economically" unacceptable.
22 years on, are we closer to the ideal of "health for all" or further
away. When will we learn?
Dear Editor
We were interested in the case report, "Perianal Crohns Disease masquerading as perianal warts"[1] (August) In which the authors highlight the diagnostic difficulty with other anogenital conditions such as perianal warts. Plus the initial lack of obvious bowel symptoms considered to be the hallmark of Crohns disease.
We too have recently seen a similar case, but in an older women aged 43 wh...
Dear Editor,
Although our study population was homogeneous and Baltimore is known to have high sexually transmitted disease (STD) rates, we believe sufficient evidence exists to support our recommendation of twice yearly chlamydia screening of sexually active females less than 25 years of age. Chlamydia screening in most adolescent female populations yields prevalence rates greater than 10%, except in areas wit...
Burstein and colleagues present interesting data concerning repeat diagnosis of Chlamydia trachomatis in inner city women. Their data may however not support all their conclusions. In their methods section they state that “the frequency of diagnosis of first incident infection was estimated by calculating the median time interval in months between first test and first positive test during the study period a...
Low and colleagues present a very important paper. They should be given the opportunity to remove my doubts about the validity of their findings: They used a cross sectional design to determine incidence; however, unless the average duration of conditions is known longitudinal studies are required to determine this. The presented study assessed disease status of self-selected participants over a period of...
Mr McElborough considers it unfortunate that reference labs may have developed their algorithms in the case of conventional syphilis diagnosis and these do little to help with HIV coinfected patients. Guidelines for serological diagnosis in coexisting HIV infection, neurosyphilis and congenital infection are currently under preparation by the (Public Health Laboratory Service) PHLS Syphilis Forum and will...
Whilst it is comforting that some research is finally being carried out in depth on the risk of STIs amongst women who have sex with women (WSW), any conclusions drawn from this study for WSW in general need to be handled with a great deal of caution when one looks at the make-up of the subjects and controls.
For example, over twice as many of the WSW as the control group were current sex workers;...
In our area the high HIV prevalence has made the interpretation of syphilis tests paticularly problematic. Coinfected patients do appear to reactivate their treponemal infection or possibly reinfection with a different "strain" in the presence of profound immunosuppression. As with some other agents IgM can persist for several years with peaks and troughs! Non-treponemal tests are uniformly negative whilst...
Dear Editor
Fether at al present a very interesting case control study on STIs in women who have sex with women (WSW). This was not a community based sample and thus prone to selection bias. In order to appreciate the results in full it would help to know how cases and controls were identified and how controls were selected.
As bisexual or homosexual orientation may be difficult to disclose even in a sympat...
I commend Shamanesh et al for their searching and informed account of the impact of globalisation on the world AIDS problem. Revisiting Alma Ata 1978: the existence of gross inequalities between advantaged and disadvantaged peoples is "politically, socially and economically" unacceptable. 22 years on, are we closer to the ideal of "health for all" or further away. When will we learn?