VIRAL PARTIALITY

Dr.Pradeep Johnson

Mentor : Dr.Senthilnathan

Chief Complaints

A 39 year old male presented with complaint of

Genital ulcers 4 months duration.

H/O Presenting Illness

After sexual intercourse with a CSW in Nov 2008.

Mild burning sensation – prepucesal area . On the next day vesicles appeared over the

dorsal and the ventral aspect of penis visible on retraction of the prepuce.

After 14 days patient noticed the area of the vesicles ulcerated.

Not associated with systemic symptoms.

H/O Past Illness

Diagnosed case of PLHA since 18/12/08 with base line CD4 count 35.

No H/o ATT. On CTZ prophylaxis since Dec 2008. No H/o Diabetes, Hypertension, Jaundice. No H/o other OI’S. No previous history of genital ulcers.

Personal History

Milk vendor does not maintain personal hygiene.

Patient does not have the habit of using soap. Mixed diet. Non smoker, Alcoholic. Widower with 2 male children. 8 and 6 years old not tested for HIV. Wife died on June 2008 (? Cause).

Sexual Behavior History

Denies Premarital and Extramarital contact. Indulged in risky sexual behavior with CSW’s

after death of spouse (June 2008).

Treatment History

On CTZ Prophylaxis since Dec 2008. ART since 23/02/2009 with AZT/3TC/NVP at

GHTM. Took treatment for genital ulcer in a private

clinic – details not available.

General Examination

Patient conscious, stable, afebrile, thin built. No Pallor

Cyanosis

Clubbing

Icterus

Koilonychia

Lymphadenopathy

Pedal Edema

Neurological deficit, Higher mental functions normal Oral cavity - NAD

Systemic Examinations

CVS : Apex beat normal in position

S1 S2 audible, No added sounds

RS : Trachea mid line

NVBS

No raised JVP

P/A : Soft, No organomegaly

CNS : NAD

Vital Signs

BP : 110/70 mm Hg

Pulse : 80/min

Temperature : Normal

Height : 175 cm

Weight : 65 kg

BMI : 21

Examination of External Genitalia

Ulcers with erythematous base visible over the retracted

prepuce on the dorsal and ventral aspect of size 2 x 1.5

cm and 1 x1 cm, well demarcated, non indurated, non weeping.

No visible discharge from the urethra

No visible discharge on milking of the urethra

No inguinal lymphadenopathy

Scrotum and cord structures are normal,

Anal region - NAD

Primary diagnosis?.

Differential Diagnoses?

Differential Diagnosis

Herpes genitalis

Primary syphilis Chancroid Lymphogranuloma venereum Allergic contact dermatitis Trauma Candidiasis

Differential Diagnosis Cont…..

• Behcet's syndrome • Fixed drug eruption • Folliculitis • Ulcerative balanitis • Neoplasia

What does Herpes Mean?

Summary

A 39 year old Sero positive male since Dec 2008

Ulcers over the penis 4 month duration . Ulcer developed from vesicles after sexual encounter with CSW.

Base line CD4 count 35 (Dec 2008)

Started on ART on 23/02/2009 with AZT/3TC/NVP regimen.

Investigations

CBC

RBS

LFT

RFT

Sputum AFB

Mantoux Test

X-ray chest PA view

TEST RESULTS

HB 11.2 gm/dl

RBC 3.84 x 10 cu mm

WBC 6.2 x 10 cu mm

Platelet 182 x 10 cu mm

RBS 83 mg/dl

Sr.Amylase 99 u/l

Test Results

Urea 12mg/dl Creatinine 1.1mg/dl Mantoux Neg Sputum AFB Neg

(3 smear)

Test ResultsBilirubin 0.9 mg/dl

SGOT 46 u/l

SGPT 40 u/l

SAP 101 u/l

Protein 8.2 g/dl

Albumin 3.6

Globulin 4.6 g/dl

Laboratory Investigation

VDRL - Non reactive Tzanck smear - Multinucleated giant cells KOH - Negative D.F for TP - Negative Chlamydia serology – Negative Gonorrhea smear - Negative HSV serology - Positive

Discussion

When the suppressive therapy to be given? How long and what’s the dosage?.

What is the drug of choice for Acyclovir resistant?.

What is the drug for suppressive therapy in Acyclovir resistant patients?.

Final Diagnosis

PLHA/Chronic genital herpetic ulcer/ WHO Staging IV

TREATMENT Treat all initial episodes: - Acyclovir 200 mg orally 5 times (or 400 mg 3 times) daily

for 7 to 10 days, - Famciclovir 250 mg orally 3 times a day for 7-10 days, - Valacyclovir 1.0 g orally twice a day for 7-10 days.

Pregnant women with initial episodes: - Acyclovir 200 mg orally 5 times (or 400 mg 3 times) daily

for 7 to 10 days.

Primary herpes proctitis: - Acyclovir 400 mg 5 times daily for 7 to 10 days.

courtesy : http://www.cdc.gov/std/treatment/.

Recurrent episodes Any of the following: Acyclovir 400 mg orally 3 times a day for 5 days, Acyclovir 800 mg orally twice a day for 5 days, Famciclovir 125 mg orally twice a day for 5 days, Famciclovir 1000 mg orally twice a day for 1 day, Valacyclovir 500 mg orally twice a day for 3 days, Valacyclovir 1.0 gram orally once a day for 5 days.

Suppressive (prophylactic) therapy

Acyclovir 400 mg orally twice a day, Famciclovir 250 mg orally twice a day, Valacyclovir 500 mg orally once a day, Valacyclovir 1.0 gram orally once a day.

courtesy : http://www.cdc.gov/std/treatment/.

Recommended regimens for episodic infection in persons infected with HIV

Acyclovir 400 mg orally 3 times a day for 5-10 days,

Acyclovir 200 mg 5 times a day for 5-10 days, Famciclovir 500 mg orally twice a day for 5-10

days, Valacyclovir 1.0 gram orally twice a day for 5-

10 days.

courtesy : http://www.cdc.gov/std/treatment/.

Recommended regimens for daily suppressive therapy in persons infected with HIV

Acyclovir 400-800 mg orally twice to three times a day,

Famciclovir 500 mg orally twice a day, Valacyclovir 500 mg orally twice a day.

courtesy : http://www.cdc.gov/std/treatment/.

Management

T.Acyclovir 400 mg tid for 21 days

AZT/3TC/NVP

T.CTZ 2 od

T.MVT/BCT/FST 1 od

Advised maintain personal hygiene.

Review after 1 month.

PARTIALITY

Discussion

Does circumcision play a role in preventing HIV and Herpes Genitalis?

What is the simplest documented method to prevent Herpes Genitalis (apart from total abstinence from sex) ?

Male circumcision significantly reduced the incidence of HIV and herpes simplex virus type 2 (HSV-2) infection and the prevalence of human papillomavirus (HPV) infection, suggesting potential public health benefits, according to the results of a randomized controlled trial reported in the March 26 issue of the New England Journal of Medicine.

Male Circumcision for the Prevention

of HSV-2 and HPV Infections and Syphilis

Aaron A.R. Tobian,et al., N Engl J Med 2009;360:1298-309.

Inactivation of Herpes Simplex Viruses by NonionicSurfactantsSAMUEL S. ASCULAI,t* MARGARET T. WEIS, MARTHA W. RANCOURT,AND A. B. KUPFERBERGtt ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Apr. 1978, p. 686-690

ACKNOWLEDGEMENTS

The Superintendent , GHTM

Medical Director, I TECH

RMO, GHTM

All Mentors, GHTM

Chief fellow

I TECH Faculty

Fellows

Thank YOU !