Cutaneous tuberculosis in HIV-infected individuals: Lessons learnt from a case series

Introduction: Extrapulmonary tuberculosis (TB) causes a significant burden of disease worldwide, especially among HIV-infected individuals and those with other immunosuppressive conditions. Cutaneous TB is an important manifestation of extrapulmonary TB but is uncommonly reported in South Africa despite the high burden of HIV and TB co-infection. There is a paucity of published data on clinical presentation and outcome of cutaneous TB in this context. Raising awareness of this condition among clinicians is imperative to improve early diagnosis and optimise treatment outcomes. Patient presentation: In this series, we present three cases of cutaneous TB, two adults and one child, referred to a tertiary hospital from two primary healthcare centres and from a general practitioner. We demonstrate that the clinical presentation is diverse, ranging from papular lesions to abscesses, and that concordant pulmonary TB may be present. Management: In particular, we show the importance of performing diagnostic procedures (e.g. aspiration) in individuals presenting with an abscess that does not respond to broad spectrum antimicrobial treatment, particularly in those with advanced immunosuppression. Outcome and conclusion: The outcome of our three patients was poor, highlighting the need for earlier diagnosis in this WHO Stage 4 condition and intensive management of clinical cases. Keywords: HIV-medicine; Retro-Viral Disease; Mycobacteria; Tuberculosis; Multidrug Resistance; Cutaneous Tuberculosis; Cutaneous Disease; immunocompromised

Importance of Candida infection and fluconazole resistance in women with vaginal discharge syndrome in Namibia

BACKGROUND : Vaginal discharge syndrome (VDS) is a common condition. Clinical management targets sexually transmitted infections (STIs) and bacterial vaginosis (BV); there is limited focus on Candida infection as cause of VDS. Lack of Candida treatment coverage and, if present, antifungal resistance may result in VDS treatment failure. This study aimed to determine the prevalence of Candida infection, antifungal resistance, and coinfections in Namibian women with VDS. METHODS : A cross-sectional study was performed using 253 vaginal swabs from women with VDS in Namibia. Demographic data was collected, and phenotypic and molecular detection of Candida species was performed followed by fluconazole susceptibility testing of Candida isolates. BV was diagnosed using Nugent score microscopy; molecular detection of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis was performed. RESULTS : Candida species was detected in 110/253 women (43%). Ninety women (36%) had Candida albicans and 24 (9.5%) had non-albicans Candida species. The non-albicans species detected were 19 (17%) Candida glabrata, 4.0 (3.5%) Candida krusei, and 1.0 (0.9%) Candida parapsilosis. Candida albicans were more frequently isolated in younger (p = 0.004) and pregnant women (p = 0.04) compared to non-albicans Candida species. Almost all (98%) Candida albicans isolates were susceptible to fluconazole while all non-albicans Candida species were fluconazole resistant. STIs were diagnosed in 92 women (36%): 30 (12%) with C. trachomatis, 11 (4.3%) N. gonorrhoeae, and 70 (28%) T. vaginalis; 98 (39%) women had BV. Candida infection alone was diagnosed in 30 women (12%), combined with STIs in 42 women (17%) and was concurrent with BV in 38 women (15%). Candida infection was more often detected in swabs from women without C. trachomatis detected (6.4% vs. 16%; OR 0.30; 95% CI 0.10–0.77, p = 0.006). CONCLUSIONS : The high prevalence of Candida infection, especially those due to non-albicans Candida species that are resistant to fluconazole, is a great concern in our setting and may lead to poor treatment outcomes. Access to microbiological testing for Candida species in the context of syndromic management is warranted.The University of Pretoria Doctoral Commonwealth Scholarship.http://www.aricjournal.comam2023Medical Microbiolog

Early- and late-stage ocular complications of herpes zoster ophthalmicus in rural South Africa

OBJECTIVES : To describe the spectrum of ocular complications of herpes zoster ophthalmicus (HZO) in rural South Africa. METHODS : Patients presenting with visual complaints and active or healed HZO at the ophthalmology outpatient department of three hospitals in rural South Africa were included in this study. Demographic and clinical data were collected, and HIV status was determined for all participants. RESULTS : Forty-eight patients were included, and 81% were HIV infected. Poor vision was reported by 94% of patients, painful eye by 79% and photophobia by 63%. A diverse spectrum of ocular complications was observed with corneal inflammation and opacification in 77% followed by anterior uveitis in 65%. The majority (65%) presented with late-stage ocular complications associated with irreversible loss of vision whereas early-stage complications, such as punctate epithelial keratitis and anterior uveitis, were less common. Blindness of the affected eye was observed in 68% of patients with late-stage complications. There was a considerable delay between onset of symptoms and first presentation to the ophthalmology outpatient department (median time 35 days; range 1–2500 days), and longer delay was associated with late-stage ocular complications (P = 0.02). CONCLUSIONS : HZO patients present with relatively late-stage ocular complications, and blindness among these patients is common. The delayed presentation to the ophthalmology outpatient department of hospitals in our rural setting is of concern, and efforts to improve ocular outcomes of HZO are urgently needed.In part funded by the Rotterdamse Stichting Blindenbelangen and the Rotterdam Global Health Initiative. Anova Health Institute receives a grant from the US President’s Emergency Plan for AIDS Relief (PEPFAR) programme via the US Agency for International Development.http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-31562017-03-31hb2016Medical Microbiolog

Antimicrobial resistance in Neisseria gonorrhoeae and Mycoplasma genitalium isolates from the private healthcare sector in South Africa : a pilot study

BACKGROUND. Reports have emerged globally of antimicrobial resistance (AMR) in Neisseria gonorrhoeae and Mycoplasma genitalium infections. In South Africa (SA), there are substantial differences between private and public healthcare with regard to antimicrobial drug prescribing practice, which could affect AMR patterns of private and public healthcare patients. OBJECTIVES. To perform a pilot study to determine the frequency of AMR of N. gonorrhoeae and M. genitalium in patients accessing SA’s private healthcare sector. METHODS. In this cross-sectional study, N. gonorrhoeae-positive cultures and M. genitalium DNA samples were collected from a private healthcare reference laboratory from August 2018 to August 2019. In N. gonorrhoeae-positive cultures, antimicrobial susceptibility testing was performed, followed by N. gonorrhoeae multiantigen sequence typing (NG-MAST) to determine genetic relatedness of the isolates. To determine macrolide and fluoroquinolone resistance rates, M. genitalium-positive samples were analysed by sequencing the 23S rRNA, gyrA and parC genes. RESULTS. Twenty-one N. gonorrhoeae- and 27 M. genitalium-positive specimens were included in this analysis. High rates of resistance were detected among gonococcal isolates, with 90% resistance to tetracycline, 86% to penicillin and 62% to ciprofloxacin, but no resistance to azithromycin, cefixime and ceftriaxone. NG-MAST revealed genetically diverse isolates with 83% novel NG-MAST sequence types. Macrolide and fluoroquinolone resistance-associated mutations were detected in 18.5% (n=5/27) and 7.4% (n=2/27) of M. genitalium strains, respectively. CONCLUSIONS. We observed high frequencies of ciprofloxacin, penicillin and tetracycline resistance in N. gonorrhoeae and macrolide resistance-associated mutations in M. genitalium in private healthcare sector patients in SA. This finding highlights the need to use diagnostics for sexually transmitted infections and to include the private healthcare sector in antimicrobial surveillance and stewardship programmesNational Health Laboratory Service Research Trust.http://www.samj.org.zadm2022Medical Microbiolog

Evaluation of Presto(plus) assay and LightMix kit Trichomonas vaginalis assay for detection of Trichomonas vaginalis in dry vaginal swabs

This is an evaluation study of the Prestoplus Assay for T. vaginalis by comparing to the TIB MOLBIOL LightMix Kit Trichomonas vaginalis Assay using 615 dry collected vaginal and rectal swabs. Discordant samples were analyzed by the Qiagen® Microbial DNA qPCR for TV Assay. Both assays showed comparable performances (McNemar p > 0.05).http://www.elsevier.com/ locate/jmicmeth2017-08-31hb2016Microbiology and Plant Patholog

A 10-year cohort analysis of routine paediatric ART data in a rural South African setting

South Africa’s paediatric antiretroviral therapy (ART) programme is managed using a monitoring and evaluation tool known as TIER.Net. This electronic system has several advantages over paper-based systems, allowing profiling of the paediatric ART programme over time. We analysed anonymized TIER.Net data for HIV-infected children aged <15 years who had initiated ART in a rural district of South Africa between 2005 and 2014. We performed Kaplan–Meier survival analysis to assess outcomes over time. Records of 5461 children were available for analysis; 3593 (66%) children were retained in care. Losses from the programme were higher in children initiated on treatment in more recent years (P < 0·0001) and in children aged ≤1 year at treatment initiation (P < 0·0001). For children aged <3 years, abacavir was associated with a significantly higher rate of loss from the programme compared to stavudine (hazard ratio 1·9, P < 0·001). Viral load was suppressed in 48–52% of the cohort, with no significant change over the years (P = 0·398). Analysis of TIER.Net data over time provides enhanced insights into the performance of the paediatric ART programme and highlights interventions to improve programme performance.This study was funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) under Cooperative Agreement number 674-A-12-00015 to the Anova Health Institute.http://journals.cambridge.org/action/displayJournal?jid=HYGhb2016Microbiology and Plant Patholog

Gender identity and HIV risk among men who have sex with men in Cape Town, South Africa

Gender identity plays a potentially important role contributing to HIV risk among MSM in South Africa. Where studies have included a focus on gender identity, MSM reporting gender non-conformity have been found to have a higher risk of being HIV positive than other MSM. This article examines HIV risk among gender non-conforming MSM in a sample of 316 MSM in Cape Town, South Africa. Reporting gender non-conformity was associated with higher HIV prevalence and increased HIV risk behaviour. Gender non-conformity was also associated with a higher likelihood of being unemployed and reporting low household incomes. These findings highlight the importance of gender-identity as a factor affecting access to HIV treatment, care, and prevention in South Africa and this is an issue that needs to be addressed in interventions targeting MSM populations.U.S. President’s Emergency Plan for AIDS Relief [grant number 674-A-12-00015].http://www.tandfonline.com/loi/caic202019-04-18hj2018Medical Microbiolog

Genetic variation in the MBL2 gene is associated with Chlamydia trachomatis infection and host humoral response to Chlamydia trachomatis infection

This study aims to assess the potential association of MBL2 gene single nucleotide polymorphisms (SNPs) to Chlamydia trachomatis infection. We analysed a selected sample of 492 DNA and serum specimens from Dutch Caucasian women. Women were categorized into four groups of infection status based on the results of DNA and antibody tests for C. trachomatis: Ct-DNA+/IgG+, CtDNA+/IgG−, Ct-DNA−/IgG+, and Ct-DNA−/IgG−. We compared six MBL2 SNPs (−619G > C (H/L), −290G > C (Y/X), −66C > T (P/Q), +154C > T (A/D), +161A > G (A/B), and +170A > G (A/C)) and their respective haplotypes in relation to these different subgroups. The −619C (L) allele was less present within the Ct-DNA−/IgG+ group compared with the Ct-DNA−/IgG− group (OR = 0.49; 95% CI: 0.28–0.83), while the +170G (C) allele was observed more in the Ct-DNA+/IgG+ group as compared with the Ct-DNA−/IgG− group (OR = 2.4; 95% CI: 1.1–5.4). The HYA/HYA haplotype was more often present in the Ct-DNA−/IgG− group compared with the Ct-DNA+/IgG+ group (OR = 0.37; 95% CI: 0.16–0.87). The +170G (C) allele was associated with increased IgG production (p = 0.048) in C. trachomatis PCR-positive women. This study shows associations for MBL in immune reactions to C. trachomatis. We showed clear associations between MBL2 genotypes, haplotypes, and individuals’ stages of C. trachomatis DNA and IgG positivity.NGI Life Sciences Pre-Seed and a EuroTransBio grant.https://www.mdpi.com/journal/ijerphMedical Microbiolog

Doxycycline post-exposure prophylaxis for sexually transmitted infections in South Africa

Data availability This opinion paper does not contain original data for sharing. References are included for all the data mentioned in the manuscript.DATA AVAILABILITY : This opinion paper does not contain original data for sharing. References are included for all the data mentioned in the manuscript.South Africa has a large burden of bacterial sexually transmitted infections (STIs) with high rates among men who have sex with men (MSM). Randomised controlled trials have recently demonstrated high effectiveness of doxycycline post-exposure prophylaxis (PEP) for prevention of bacterial STIs in MSM, with 70% – 85% reductions in Chlamydia trachomatis infection and syphilis, and approximately 50% reduction in Neisseria gonorrhoeae infection. Doxycycline PEP was not demonstrated to be effective in reducing C. trachomatis and N. gonorrhoeae infection among Kenyan cisgender women. Although no worrisome trends in antimicrobial resistance (AMR) were observed in the trials, important concerns remain about doxycycline PEP and AMR development in STIs, other pathogens, commensals, and the microbiome. Tetracycline resistance in N. gonorrhoeae is already widespread in South Africa, but emergence of AMR in other STIs would be concerning. Larger sample sizes of doxycycline PEP users with longer follow-up time are needed to understand the impact that doxycycline PEP may have on AMR at individual and population level. In this opinion article, we weigh the benefits of doxycycline PEP for prevention of bacterial STIs against the existing AMR concerns and data gaps in the South African context. Based on the current evidence, we conclude that it would be reasonable to offer doxycycline PEP to high-risk MSM on a case-by-case basis, provided that it is offered by experienced sexual health clinicians in settings that have access to diagnostic STI testing and ongoing AMR surveillance.http://www.sajhivmed.org.zaam2024Medical MicrobiologySDG-03:Good heatlh and well-bein

Doxycycline post-exposure prophylaxis for sexually transmitted infections in South Africa

South Africa has a large burden of bacterial sexually transmitted infections (STIs) with high rates among men who have sex with men (MSM). Randomised controlled trials have recently demonstrated high effectiveness of doxycycline post-exposure prophylaxis (PEP) for prevention of bacterial STIs in MSM, with 70% – 85% reductions in Chlamydia trachomatis infection and syphilis, and approximately 50% reduction in Neisseria gonorrhoeae infection. Doxycycline PEP was not demonstrated to be effective in reducing C. trachomatis and N. gonorrhoeae infection among Kenyan cisgender women. Although no worrisome trends in antimicrobial resistance (AMR) were observed in the trials, important concerns remain about doxycycline PEP and AMR development in STIs, other pathogens, commensals, and the microbiome. Tetracycline resistance in N. gonorrhoeae is already widespread in South Africa, but emergence of AMR in other STIs would be concerning. Larger sample sizes of doxycycline PEP users with longer follow-up time are needed to understand the impact that doxycycline PEP may have on AMR at individual and population level. In this opinion article, we weigh the benefits of doxycycline PEP for prevention of bacterial STIs against the existing AMR concerns and data gaps in the South African context. Based on the current evidence, we conclude that it would be reasonable to offer doxycycline PEP to high-risk MSM on a case-by-case basis, provided that it is offered by experienced sexual health clinicians in settings that have access to diagnostic STI testing and ongoing AMR surveillance