Background: Sexually transmitted infections (STIs) are the most often reported infectious disorders in the world. Sexual intercourse with an infected partner is the most significant risk factor for STIs.1Sexually transmitted infections (STIs) are a major global health concern, with serious co-morbidities and mortality rates.
Objectives:
Material & Methods: Study Design: Hospital-based, cross-sectional study. Study area: The study was conducted in the Department of OBG & Microbiology of a Medical College, in Kolkata. Study period: 1st July 2023 to 30th June 2024. Study tools and Data collection procedure: The project was evaluated and approved by the ethics committee, of the institution. Written, informed consent was obtained from each participant at the time of enrolment in the study, and socio-demographic characteristics were recorded. Detailed sexual exposure history was taken of each individual including sexual partners, sexual behavior, and sexual practices. Only strongly suspected cases of ulcers of STD origin were studied after thorough clinical examination. Results: Out of 51 cases who used condoms, in 22 cases (18.3%) aetiology was identified. Whereas out of 69 cases who did not use condoms, in 62 cases (51.6%) aetiology was diagnosed. So, in condom used cases, the incidence of GUD was 43% whereas in condom not used cases, the incidence of GUD was 89.8%. This shows the impact of condom use in preventing genital ulcers. The present study included 4 cases from the high-risk group, Men having sex with men (MSM) 3 cases and female sex workers (FSW) 1 cases. These patients presented with genital ulcers and were diagnosed. Conclusion: This study concluded that eliminating bacterial GUDs caused an increase in cases of Viral GUDs (Genital Herpes). The presence of GUD increases HIV susceptibility, hence proper and regular use of latex condoms is required to avoid the transfer of STIs. Laboratory tests detected GUDs with numerous etiologies that had previously gone undetected clinically. This aids in the identification of cases and allows patients to obtain proper and appropriate care.
Sexually transmitted infections (STIs) are the most often reported infectious disorders in the world. Sexual intercourse with an infected partner is the most significant risk factor for STIs.1Sexually transmitted infections (STIs) are a major global health concern, with serious co-morbidities and mortality rates.
Between 2016 and 2017, the national aids Control Society recorded approximately 3.993 cases of STIs.2 Sexually transmitted diseases (STDs) include infections resulting in clinical diseases that may be symptomatic with clinical signs and involve genitalia and other parts of the body participating in sexual intercourse, e.g., syphilis, gonorrhoea, chancroid, donovanosis, non-gonococcal urethritis, genital warts, herpes genitalis, etc. In contrast, STIs include STDs and infections that may not.
Other known risk factors include being younger at the time of the first intercourse, having several sex partners, abusing illicit drugs or intravenous drugs, being an alcoholic, smoking, or being married. The results from the third release of the US National Longitudinal Mortality Research revealed that divorced/separated people are more likely than married people to contract HIV.3
Dermatologists frequently encounter sexually transmitted infections (STIs) in their practice and study. High-risk categories for STIs include sexually active youngsters and those engaging in promiscuous behaviour. Although HIV remains the primary focus, there has been a noticeable increase in the prevalence of other sexually transmitted infections worldwide. STIs are a global health issue due to their potentially devastating impact on the quality of life, especially for women. The link between STIs and HIV is substantial, as both illnesses affect the same population and share biochemical interactions. Infection with some STIs can raise the risk of HIV acquisition and transmission, altering the disease's progression.4
OBJECTIVES:
Study Design: Hospital-based, cross-sectional study.
Study area: The study was conducted in the Department of OBG & Microbiology of a Medical College, in Kolkata.
Study period: 1st July 2023 to 30th June 2024.
Sample size: A total of 2267 STI cases attended the hospital. Out of which 120 cases presented with genital ulcers, as evidenced by disruption of genital mucous membrane or epithelium, and they constituted the study group6. In females, genital ulcers on the mons pubis, labia major and minus, introitus, posterior commissure, and perianal and in the males the glans, urethral meatus, corona, coronal sulcus, shaft, penoscrotal junction, scrotum and perianal sites were involved in our study. Provision was made for enrolling patients referred from targeted intervention clinics run by nongovernmental organizations (NGOs).
Sampling Technique: Simple Random technique.
Inclusion Criteria:
Exclusion criteria:
Study tools and Data collection procedure:
The project was evaluated and approved by the ethics committee, of the institution. A written, informed consent was taken from each participant at the time of enrolment in the study and socio-demographic characteristics were recorded. Detailed sexual exposure history was taken of each individual including sexual partners, sexual behavior, and sexual practices. Only strongly suspected cases of ulcers of STD origin were studied after thorough clinical examination.
METHOD OF SAMPLE COLLECTION:
Swabs, discharge from ulcers and tissue specimens were collected for microscopy
Blood samples were collected from all the genital ulcer disease patients for serological tests
1.1. DARK-FIELD MICROSCOPY:
1.2. GRAM STAIN METHOD:
1.3. GIEMSA STAIN:
1.4. TZANCK SMEAR:
2.1. SEROLOGY FOR HSV- 2 IgM- ELISA
2.2. SEROLOGY FOR HSV 2 IgG- ELISA
2.3. SEROLOGY FOR VENEREAL DISEASE RESEARCH LABORATORY TEST (VDRL)
2.4. SEROLOGY FOR TREPONEMA PALLIDUM HAEMAGGLUTINATION ASSAY (TPHA):
Statistical analysis:
Data was analysed using SPSS 21.0 software. Descriptive parameters were represented as mean with SD or median. Continuous variables were compared using unpaired t-test/Mann Whitney u test. Chi-square or t-test will be used to determine significant outcome differences. Categorical data was represented as frequency with percentage. For all tests, a p-value of <0.05 was considered statistically significant.
During the study period, a total of 2267 STI cases attended the STD outpatient department. 150 patients with GUD were recruited for this study. Of these, 24 patients who were already on treatment were excluded from the study. 6 patients refused to participate in the study. Thus, 120 patients presenting with genital ulcers were included in the study, investigated for etiologies of genital ulcers and analyzed.
Table 1: Age and sex-wise distribution of Genital ulcer disease
AGE |
MALES |
FEMALES |
TOTAL |
<= 19YRS |
(3) 2.5% |
(1) 0.8% |
(4) 3.3% |
<= 24 YRS |
(13) 10.8% |
(6) 6% |
(19) 15.8% |
<= 44YRS |
(47) 39.1% |
(26) 21.6% |
(73) 60.8% |
>= 45YRS |
(6) 4.9% |
(8) 6.6% |
(14) 20% |
TOTAL |
(79) 65.8% |
(41) 34.1% |
(120) 100% |
The majority of the GUD patients (60.8%) were between 25 and 44 years of age, with (79 cases) 65.8% males and (41 cases) 34.1% females. There were no trans genders. The mean age in males was 32.79yrs and in females it is 34.146yrs. The total mean age was 33.468 years.
A total of (79 cases) 65.8% of males and (41cases) 34.1% of females participated in the study.
The majority of the participants were married 66.7% while 25.1% were unmarried and 7.6% were widowed.
The use of condoms with a regular partner was 12 %, while with a non-regular partner, it was 30 %. No condom was used in 58% of cases. In most of the subjects, 58.3% reported having sex with a regular partner, while 32% had sex with non-regular partners and 9.7% reported having sex with a sex worker. Among the participants 40%gave a history suggestive of previous STI episodes, ranging from ulcers, and redness/ itching to vaginal discharges.
Table 2: Literacy rate of the GUD cases and Partners
LITERACY RATE |
PERCENTAGE OF CASES |
PERCENTAGE OF PARTNERS |
Illiterate |
28.3% |
33.3% |
<=5th class |
10.8% |
19.1% |
<=12th class |
43.3% |
39.1% |
Graduate & above |
17.5% |
8.3% |
Among the female patients in the study group, most of them were homemakers by occupation, while among the male patients, there were office-goers, labourers, and students. Out of 39 cases of Cat 1, 28 were homemakers, 6 were students and 5 were unemployed. Out of 69 cases of Cat 2, 33 were labourers, 22 were drivers, 10 were farmers and 4 were from other professions.
Table 3: Etiological Diagnosis Of Genital Ulcers
|
DFM |
Gram staining- GNCB |
Giemsa Staining- MNGC |
VDRL |
TPHA |
HSV 2 IgM |
HSV 2 IgG |
Total |
HSV - 2 |
0 |
0 |
22 |
0 |
0 |
50 |
50 |
50 |
Chancroid |
0 |
14 |
0 |
0 |
0 |
0 |
0 |
14 |
Syphilis |
0 |
0 |
0 |
10 |
9 |
0 |
0 |
10 |
Chancroid+ HSV-2 |
0 |
4 |
0 |
0 |
0 |
0 |
4 |
4 |
Syphilis+ HSV-2 |
0 |
0 |
0 |
3 |
3 |
0 |
3 |
3 |
Syphilis + Chancroid |
0 |
3 |
0 |
3 |
2 |
0 |
0 |
3 |
A total of 120 cases of GUD were enrolled among 2267 STD clinic attendees over the study period, giving a prevalence of GUD of 5.29%. 40 cases (33%) reported similar history in their contacts and partners showing a prevalence of 1.76%. The commonest GUD encountered in the samples from the study population was Herpes simplex virus 2— 41.6%. Darkfield microscopy was performed on 27 cases of GUD presenting with clean ulcers, in which Treponema pallidum could not be visualized. Gram stain and Giemsa stain were done for 105 samples except for a few. Samples in which there was insufficient discharge due to crust formation were excluded. Gram stain was performed on 105 samples of which 21(17.5%)showed gram-negative coccobacilli suggestive of H. ducreyi. Giemsa stain was performed on 105 patients out of these, 22 (18.3%) showed multinucleated giant cells suggestive of Herpes simplex infection 2.
Serological tests (HSV-2 IgM ELISA, HSV-2 IgG ELISA, VDRL and TPHA) were performed on all 120 samples. Out of which 50 samples were positive for IgM ELISA, 57 samples were positive for HSV 2 IgG ELISA, 16 samples were positive for VDRL and 14 samples were positive for TPHA. There were 36 cases (30%) (13 females and 23 males) of clinically diagnosed GUD in which aetiological diagnosis could not be made even after complete processing. Multiple GUD. There were 10 cases where more than one GUD was diagnosed clinically (8.3%).
Table 4: Sex-wise distribution of etiological diagnosis of GUD
|
TOTAL |
MALE |
FEMALE |
HSV - 2 |
41.6% |
25.8% |
15.8% |
Chancroid |
11.6% |
6.6% |
5% |
Syphilis |
8.3% |
7.5% |
0.8% |
HSV 2 + Chancroid |
3.3% |
1.6% |
1.6% |
HSV 2 + Syphilis |
2.5% |
2.5% |
0 |
Syphilis + Chancroid |
2.5% |
2.5% |
0 |
Undiagnosed |
30.2% |
19.1% |
10.8% |
Of the 120 cases with GUD, 36 cases (30%) were HIV seropositive and 95% of them were on antiretroviral treatment with an average CD4 count of 600 cells/mm3.
Table 5: GUD among HIV-positive patients
|
CASES |
GRAMS |
GIEMSA |
VDRL |
TPHA |
HSV 2 IgM |
HSV 2 IgG |
PERCENTAGE |
HSV-2 |
21 |
0 |
6 |
0 |
0 |
10 |
21 |
58.3% |
Chancroid |
3 |
2 |
0 |
0 |
0 |
0 |
0 |
8.3% |
HSV 2+Chancroid |
1 |
1 |
0 |
0 |
0 |
0 |
1 |
2.7% |
Syphilis+HSV2 |
3 |
0 |
0 |
3 |
3 |
0 |
3 |
8.3% |
No GUD |
8 |
0 |
0 |
0 |
0 |
0 |
0 |
2.2% |
HSV-2 infection was a more common (58%) cause of GUD among patients with HIV.
Table 6: Prevalence of GUD in Condom users
|
Condom used |
No Condom |
HSV-2 |
10 (8%) |
40 (33.3%) |
Chancroid |
3 (2.5%) |
11 (9.1%) |
Syphilis |
5 (4.2%) |
5 (4.1%) |
Multiple GUD |
4 (3.3%) |
6 (5%) |
No GUD |
29 (24%) |
7 (3.8%) |
TOTAL CASES |
51 (42.5%) |
69 (57.5%) |
Out of 51 cases who used condoms, in 22 cases (18.3%) aetiology was identified. Whereas out of 69 cases who did not use condoms, in 62 cases (51.6%) aetiology was diagnosed. So, in condom used cases, the incidence of GUD was 43% whereas in condom not used cases, the incidence of GUD was 89.8%. This shows the impact of condom use in preventing genital ulcers. The present study included 4 cases from the high-risk group, Men having sex with men(MSM) 3 cases and female sex worker(FSW) 1 cases. These patients presented with genital ulcers and were diagnosed.
Table 7: Prevalence of GUD in High-risk group
High-risk group |
Etiological diagnosis |
MSM |
1 case of TP +HD |
MSM |
1 case of HSV 2 |
MSM |
1 case of HIV |
FSW |
1case of HD |
Prevalence of GUD has been very high in STD patients in India5. In this study, out of 2267 patients presenting with complaints of STDs, 120 patients had genital ulcers. The treatment differs according to the aetiology of GUD, the etiologic agent must be correctly identified. Due to the paucity of clinical STD laboratories in developing countries, diagnosis of STDs is limited and usually based solely on clinical criteria. Atypical presentation, HIV infection and the presence of multiple infections can markedly affect the accuracy of clinical diagnosis. In addition, routine laboratory tests for the detection of agents causing GUD are relatively insensitive6,7.
The present study revealed that GUDs are a common occurrence in STD clinic attendees with a prevalence of 5.29%. This correlates with other studies from India, Parimi Prabhakar et al.8(6.7%) and SumathiMuralidhar et al.9(7.45%)and also from France Emilie Hope-Rapp et al.10 had a GUD prevalence of 5%.
In the present study, we enrolled a total of 120 cases of GUD of STD origin. Among them, (in 79 cases) 65.8 % were males and (in 41 cases) 34.1 % were females (Table 2) which is close to the other study done by Sumathi Muralidhar et al9 (66.7%), Chaudhary et al.11(59.3%), Behets et al.12(70.9%) and BH Anand Kumar et al.13 (75%). They also reported the percentage of male predominance in our study. These figures confirm the predominance of males with genital ulceration seeking medical attention and attending general STD clinics. Considering the conservative nature of many Indian societies, it is understandable that GUDs are commoner among males because they have easy access and opportunity to seek multiple sexual partners and practice high-risk behaviour, in comparison to females9. The low percentage of females is probably due to ignorance, social inhibitions, asymptomatic carriers, and importantly prostitutes who suffer from genital STDs and do not seek medical attention11. Thus, most of the females suffering from STDs are not getting proper treatment and are prone to complications. Also, they act as carriers and may easily contract HIV as their mucosal barrier is compromised due to the presence of STD14.
The majority of males (47 cases) 39.1% and females (26 cases) 21.6% in the present study belonged to the 25 - 44 years of age group and the mean age group is 33.4 yrs. This is similar to the studies reported previously by Christiane Maria Moreira Gomes et al.15(32.7yrs), Parimi Prabhakar et al.8 (31.7yrs) and Gabriela Paz – Bailey et al.16 (29yrs). 21-40 years sexually active age group predominantly having STIs as reported by Vora et al.17. This may be a significant finding that this age group is economically productive and hence may have serious repercussions in loss of man-hours at work9.
In the present study, we found that Hindus were more commonly affected than Muslims this may be because of the practice of circumcision in the Muslim community. Similar reports were found in studies done by Chaudhary et al.11 R Chawla et al.18 and Emilie Hope-Rapp et al.7.
We found a high number of GUDs in married males and females both. In the present study, married women showed a higher number of GUDs than unmarried women because of the indirect risk of STDs. In many studies, Sumathi Muralidhar et al.9(67.8%) Christiane Maria Moreira Gomes et al.15 (60%) and Risbud et al.20 (54%) reported a higher percentage of GUDs in married patients. This signifies that multiple partner activity and casual sex go on irrespective of the marital status. Further, the risk of transmission of the disease is not restricted to their spouses but also to future generations as well, through vertical transmission14. This may be the reason for the increasing prevalence of GUD among partners (33%) of cases in the present study. Prompt identification of sexual partners through traditional contact tracing has been reportedly inefficient21.
We found 57.5% of GUD in unprotected sexual exposure in the present study. Even Emilie Hope-Rappet al.19 ( 54%), Christiane Maria Moreira Gomes et al.15 (60.4%), Parimi Prabhakar et al.8 (63.1%), and Gabriela Paz Bailey et al.22 (48%)reported lower condom use rate during sex with a regular or non-regular partner at the last sex act. The correct and consistent use of latex condoms is very effective in preventing transmission of STDs including HIV23. In the present study the incidence of GUD in condom-used cases was whereas in cases who did not use condoms, it was 89.8% showing the protective effect of condom usage in GUDs.
In our study, (48 cases) 40% of the patients had a history of GUD. The same finding was reported by Zainah S et al.24 (42%), Emilie Hope-Rapp et al.19 (46%) and Sumathi Muralidhar et al.9 (34.4%). Recurrences are more common with HSV as it can be shed for years and can be reactivated9. The present study showed VDRL reactive in 13.3% of cases which is similar to other studies by Sumathi Muralidhar et al.9 ( 10%) and Chawla R et al.18 (6.91%).In Emilie Hope-Rapp et al.19 71% of VDRL positives were homosexuals.
Dark field microscopy and serology have been important methods used in the diagnosis of Primary Syphilis. In the present study, no cases were positive for DFM. As per Stephen Morse et al.25 Darkfield microscopy provided no added advantage in the diagnosis of Primary Syphilis. Darkfield detection for T. pallidum was 39% sensitive and 82% specific, in contrast to rapid plasma reagin and fluorescent treponemal antibody absorption test, which was 66% sensitive and 90% specific. VDRL test results had the same sensitivity and specificity as the RPR test. VDRL is simple, economical and rapid and is easily available. Confirmation of VDRL results can be done by simple and less expensive tests such as TPHA.20 A positive RPR is considered indicative of an active infection. A patient was considered positive for T. pallidum if positive TPHA & FTA-abs results were obtained in combination in an RPR titre of >1:8 and no recent treatment for syphilis was documented.26
HSV-2 infections are at the greatest risk for HIV-1 acquisition, compared with individuals who are not infected with HSV-2 or who have prevalent HSV-2 infection. HSV-2 infection may increase the risk of HIV-1 acquisition through the influx of CD4 lymphocytes that have been observed in the context of recurrent HSV-2 infection and through the ability of HSV-2 to up-regulate HIV-1 replication. The elevated risk of HIV-1 acquisition among individuals exposed to recent incident HSV-2 infections may reflect a more vigorous immune response in individuals who are immunologically naive to HSV-2.27.
There is an increased risk of HIV via minor abrasions either through local traumas during sexual intercourse or secondary infection as a consequence of poor hygiene. Uncircumcised men in high-risk groups appear to be substantially more susceptible than circumcised men to acquiring HIV. Among these infected patients, the proportions with a genital ulcer increased as the CD4 count decreased, suggesting that genital ulcers were opportunistic infection28. However, likely, macro and micro disruptions of the epithelium and the presence of CD4+ lymphocytes in genital ulcers are important factors in viral transmission. 23 HSV recurrences, however, are expected to be more common among HIV-infected individuals as their CD4 levels decline by 200 cells/mm3.29 In the present study, the mean CD4 count was found to be 600 cells/mm3. Correlating with the study done by Anne M Rompalo et alwith the mean CD4 cell count among HIV infection and GUD was 664 cells/m3.30
The rate of mixed infections demonstrates the challenges in clinically differentiating herpetic and nonherpetic infections.8 Owing to atypical presentation and mixed infections clinical diagnosis has to be corroborated by appropriate laboratory tests. As laboratory facilities are not available in most of the centres, syndromic approach and syndrome-based treatment are practicable in developing countries to prevent the spread of sexually transmitted diseases13.
This study concluded that eliminating bacterial GUDs caused an increase in cases of Viral GUDs (Genital Herpes). The presence of GUD increases HIV susceptibility, hence proper and regular use of latex condoms is required to avoid the transfer of STIs. Laboratory tests detected GUDs with numerous etiologies that had previously gone undetected clinically. This aids in the identification of cases and allows patients to obtain proper and appropriate care.