eLetters

30 e-Letters

published between 2017 and 2020

  • Authors response to Loebers eLetter

    We apologise for the delay in responding to your letter. We were only recently notified of this by email. Thank you for taking the time to construct your letter in response to our published short report, to which you raise several points which require addressing.

    Firstly we feel it is important to highlight that although this service evaluation focussed specifically on HIV, we acknowledged that the HIV sampling kit was part of a more comprehensive STI kit (syphilis, chlamydia, and gonorrhoea tests). We were upfront with this fact in our report, and therefore refute the claim by the responder that our paper failed to consider the wider test portfolio required by sexual health screening services.

    Of greater concern to us, we note a major error in the calculations from the data provided by the responders for their “RRR” and “HIV result obtained/ STI kit requested” values. This is important, as the foundation of their concluding statement is based on this error. The responder's have incorrectly used the number of returned kits (256,717) instead of the number of requested kits (319,485) in calculating the RRR (request-to-return ratio) and the “HIV result obtained/STI kit requested” proportion. Applying the correct calculation, the RRR value using the responder's data is not 1.36 (256,717/188,187) but 1.70 (319,485/188,187). The “HIV result obtained/STI kit requested” proportion using the correct calculation is 58.9% (188,187/319,485) and not 73.3%...

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  • Management of asymptomatic Mycoplasma genitalium to mitigate the threat of drug resistance

    Peter J White, MRC Centre for Outbreak Analysis & Modelling and NIHR Health Protection Research Unit in Modelling and Health Economics, Imperial College London.
    Other Contributors:
    Joanna Lewis, MRC Centre for Outbreak Analysis & Modelling, Imperial College London.
    Paddy J Horner, Population Health Sciences, and NIHR Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol.

    Pitt et al. commented “asymptomatic patients are not recommended for M. genitalium testing except sexual contacts... The current approach might need rethinking if asymptomatic infections are found to be an important reservoir for AMR and/or a source of infection and disease”.[1]
    Recent analysis of the POPI cohort found 4.9% (95%CrI 0.4%–14.1%) of M. genitalium infections in women progressed to pelvic inflammatory disease, compared with 14.4% (5.9%–24.6%) of Chlamydia trachomatis infections.[2] Combined with its lower prevalence this means that M. genitalium is a much less important cause of disease in women than C. trachomatis.[2]
    There is considerable uncertainty in the natural history and epidemiology of M. genitalium,[3] and we don’t know the importance of asymptomatic infection in transmission. Low bacterial load might limit infectivity but a long duration of infection[2,3] means there may be many potentially-infectious sex-acts. In fact, the BASHH guidelines are motivated by concern about transmission from asymptomatic...

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  • Testing for STIs in Brazil using molecular methods

    The Research Letter by Marinho FL and Zauli D (1) is interesting, but it raises several contentious issues. Understanding the prevalence of genital-tract micro-organisms that constitute the genital microbiome (2) is important (3) and the authors were concerned with this in respect of six micro-organisms that were detected by a molecular method (PCR). Whether they give them equal weight so far as pathogenicity is concerned is unclear because they did not relate them to any specific clinical disease. We appreciate that any micro-organism mentioned, including U. urealyticum, might have pathogenic potential under certain circumstances (4), but finding U. urealyticum as the most prevalent (62.47%) followed by M. hominis (9.31%) does not elevate their status as pathogens and raises clinically important questions of whether these micro-organisms, including U. parvum, should be tested for at all in a diagnostic procedure, unless part of a research programme, and, if tested, whether such positive results justify treatment. Admittedl the authors do not expressly state that, on the basis of a positive test result, patients would be treated automatically with antibiotics. Nevertheless, we must emphasize that the use of antibiotics in many such cases would seem inappropriate, not least because it might promote antibiotic resistance, sometimes in microbes of undoubted importance, such as N. gonorrhoeae and M. genitalium (6). Modern molecular technology is a boon, but it must not be al...

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  • Syphilis proctitis in Men who have sex with men: response to Mwasakifwa GE et al

    We read with interesting the recent report by Mwasakifwa and colleagues demonstrating that presence of mucopurulent ano-rectal discharge on clinical examination was associated with identification of a sexually transmitted organism by NAAT testing in men who have sex with men (MSM) with symptomatic proctitis.1 We also showed that sexually transmitted proctitis in MSM is often associated with more than one organism and that even with sensitive NAAT testing, there are a significant proportion of cases of MSM with proctitis with negative microbiology tests.2 We were however surprised that Mwasakifwa and colleagues did not identify any cases of syphilis in their analysis. This may have been because syphilis PCR testing was only conducted in a small proportion of cases? Ano-rectal syphilis was first described between 1945-1966 although most of these cases had anal ulceration with pain on defecation. Syphilis ‘proctitis’ was first described in 1975 from the USA in a man with rectal pain and discharge.3 In our series of MSM with proctitis, we reported 6/78(8%) cases of syphilis based upon PCR testing from the rectal mucosa during proctoscopy.2 The recent increase in infectious syphilis particularly in MSM is likely to increase the number of cases of ano-rectal syphilis. The clinical features of syphilis as the epidemic evolves may be changing and more MSM are presenting with painful lesions than was previously believed. We do agree that clinical examination of the ano-rectal area...

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  • Cross-sectional study of patients tested for STIs using molecular methods in Brazil

    Dear David Taylor-Robinson,

    We are very grateful with your contribution.

    It was a study that we evaluated the incidence of these pathogens on population that had done the molecular test to IST in a big laboratory in Brazil, this is only an epidemiological study. The microorganism have been chosen according availability of tests offered, so it was not evaluated the pathogenicity of each microorganism. Besides that our objective is only describe the profile of brazilian population, and did not correltated any data with clinical treatment. The molecular technology in Brazil is used as confirmatory of clinical diagnostic. The microorganism incidence in Brazil could be different from others countries due to characteristics of our population.

    Best regards.

    Danielle Alves Gomes Zauli

  • Syphilis proctitis in Men who have sex with men: Response to Richardson et al

    We thank Richardson et al., for their response to our recent publication titled “Proctitis in gay and bisexual men. Are microscopy and proctoscopy worthwhile?”[1]. The authors have previously reported findings of men who have sex with men (MSM) with proctitis, highlighting the polymicrobial nature of proctitis and symptomatic presentations with negative nucleic acid amplification testing (NAAT). However, they observed 8% (6/78) of MSM had syphilis proctitis based on NAAT from rectal mucosa[2] in contrast; we did not identify any.

    Our study and the Richardson study have three main differences. Firstly, in our study, only a small proportion of MSM were tested for rectal syphilis (10.5% (16/154), and all patients were syphilis NAAT negative. Data on syphilis serology was not collected. As per our local guidelines, NAAT for rectal syphilis is based on clinical signs. None of our remaining patients had an appropriate history or clinical signs (ulcers) which would have triggered targeted NAAT for anorectal syphilis.

    Secondly, 43% of GBM in our study were using pre-exposure prophylaxis (PrEP)and undergoing three monthly serological screening for Human Immunodeficiency Virus (HIV) and syphilis delivered as part of comprehensive sexually transmissible infections (STIs) and PrEP package. We postulate that this may have had a “protective” benefit against ‘symptomatic rectal syphilis”, through frequent STI testing or treatment of sexual contacts and engagement with heal...

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  • ATTENTION EDITOR and EDITORIAL TEAM: PLAGERISM

    Please note that this article is almost identical to one written by Daniel Richardson and colleagues in 2017? Did you not use anti plagiarism software? I am an editor of another journal but have keen interest in sexual health and the journal. I am shocked that this has been allowed to go to publication an print. I do not know Daniel Richardson, but they should be informed and action should be taken by you or the BMJ group.

  • ?? Similar article published a few years ago

    Dear Editor, I am a contraception doctor working in the UK who reads STI. I have an interest in education. I read Dewsnap et al's publication in this months journal and am shocked as it is almost identical to one from a few years ago. Surely this is blatant Plagiarism although one of the authors is the same. Does the BMJ group know this? is this allowed in the BASHH column. Does BASHH know? does the previous author who wrote the original know (? David Richardson?)

    This should be addressed with COPE?

    Yours Marie

  • TPPA test accuracy matters

    Although we agree with Ghanem et al. that CSF TPPA titer is a valuable test for the diagnosis of neurosyphilis[1], we would like to emphasize that a cut-off TPPA titer should be recommended with caution as proposed by others [2]. Such semi-quantitative laboratory tests may vary depending on the operator or reagent. Our IQC from a single patient during a 2 years period showed that TPPA inaccuracy is about 2 titers (Table). Moreover, a 2 log2 variation is accepted by organisms providing samples for external quality assessment for syphilis serology [3]. Similarly to what occurs with neuroborreliosis, quantifying anti-treponema pallidum IgG (antiTp- IgG) in CSF, immunoassays in serum and intrathecal antibodies index could be a reliable approach for the diagnosis of neurosyphilis. We found some positive antiTp-IgG index in CSF with TPPA titers below 320, suggesting an intrathecal synthesis of anti-treponema pallidum IgG. The diagnosis of neurosyphilis still lacks a gold standard test and further research is warranted. 1. Ghanem, K.G., Cerebrospinal fluid treponemal antibody titres: a breakthrough in the diagnosis of neurosyphilis. Sex Transm Infect, 2020.
    2. Marra, C.M., et al., Cerebrospinal Fluid Treponema pallidum Particle Agglutination Assay for Neurosyphilis Diagnosis. J Clin Microbiol, 2017. 55(6): p. 1865-1870.
    3. Muller, I., et al., Is serological testing a reliable tool in laboratory diagnosis of syphilis? Meta-analysis of eight external quality control sur...

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  • Mixed and mono-infections in non-gonococcal infections

    The paper by Jordan SJ et al (1) is thought stimulating. The CDC guideline to regard 2-4 PMN/HPF as depicting NGU is possibly not widely observed, despite having been said 5 years ago (2). This and the inference that 1 or <1 PMN/HPF means no NGU must put a strain on those counting and poses the question of what variation might exist between observers.
    When 5 different micro-organisms were sought but not found in urethritis, the invitation was there to consider the role of oral and anal bacteria and those occurring in BV. An association between this and NGU has been noted in the past (3). Unfortunately it was not taken into account here. It is also curious that when looking at the role of Ureaplasma species, the authors did not consider U.parvum. Admittedly, others have considered it to be less important than U.urealyticum (4) but not banished it to the graveyard completely.
    Finally, the issue of bacterial load is important in considering pathogenicity. The authors state that they used quantitative PCRs but they did not provide ANY quantitative results. Why is that? These and longitudinal studies are required.
    I believe the conclusion of the authors is not fully founded. Remember, Koch's postulates have been fulfilled for U.urealyticum (5).
    REFERENCES
    1. Jordan SJ, Toh E, Williams AJ, et al. Aetiology and prevalence of mixed-infections and mono-infections in non-gonococcal urethritis in men: a case-control study. Sex Transm Inf 2020;...

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