POSTGRAD. MED. J., (1965), 41, 613 Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from IMMIGRANTS TO THE UNITED KINGDOM AND VENEREAL INFECTIONS N. ROSEDALE, M.R.C.P. (Ed.) Consultant Venereologist, West Middlesex Hospital, Hillingdon Hospital and Lewisham Group of Hospitals.
THE problem of venereal infections in the Gonorrhoea in the Male immigrant population of this country may be The amount of gonorrhoea actually brought summed up as 'very much the same as any into this country by immigrants is insignificant; other inhabitant-but much more often'. Some in almost every case the disease is acquired sexually transmitted infections (lymphogranu- here. It must be accepted that, in general, our loma venereum, chancroid and granuloma immigrants are not of high intelligence and inguinale) are more common in the home bring the social and sexual customs of their countries of some of our immigrants. These native lands with them. It would also appear have always been seen here in small numbers, that some, West Indians and Mediterraneans usually in the region of our seaports, usually in particular, have a highly developed sexual in sailors and travellers of all nationalities, and instinct and the women available to them it is surprising that during the years of mass (cheap prostitute or casual pick up) are likely immigration from tropical and sub-tropical to be infected. Protected by copyright. countries that there has been no appreciable increase in their reported incidence. For Clinical Picture example, the number of cases of lympho- The clinical picture in the vast majority is granuloma venereum diagnosed in the venereal very straightforward. A heavy purulent urethral disease clinics of England and Wales was 86 discharge is noticed a few days after intercourse, in 1955, 103 in 1963 and 78 in 1964. most often in the region of 5 days but incubation It must be made clear that all figures for periods of 2 to 14 days are acceptalble. The the incidence of the various infections dealt patient has, of course, been infectious through- with are derived from the annual returns made out this period and it is in these days that by the venereal disease clinics of England and wives and other regular sexual contacts may Wales to the Ministry of Health. Any infections be infected. Dysuria may also be noticed but dealt with by general practitioners or any other in most cases this is a minor complaint and it hospital department are not recorded. It has is the actual discharge that makes the patient http://pmj.bmj.com/ been estimated that these unrecorded cases seek medical aid. may be in the region of 25% of the reported It is essential at this stage that the urethral cases. pus is examined bacteriologically by a Gram Gonorrhoea is the venereal disease of this stained smear and, possibly, by culture. country at present, with a reported incidence Gonococci are usually seen as the only organism of 36,049 cases in 1963 (the last full year for present in the urethral pus and appear as gram which figures have been published). 27,895 of negative diplococci. these cases were males. An analysis of 25,942 If the patient has passed urine immediately on September 23, 2021 by guest. of these men (by the Co-operative Clinical before examination, pus may be scanty and it Group) has shown that of these only 46.3% is advisable to repeat the examination when were United Kingdom born. No less than more pus has collected before a diagnosis is 53.70/, of these male cases occurred in foreign made and any treatment offered. born patients (25.2% were West Indians, 28.5% When no gonococci can be demonstrated (if from other countries). (British Co-operative necessary, after repeated examination) and when Clinical Group Gonorrhoea Study 1963). no other obvious cause for the presence of Figures 1 and 2 show the marked increase urethral pus can be found e.g. trichomonas in the reported cases of gonorrhoea over the vaginalis, the diagnosis, by exclusion, is that past few years and the high proportion of of non-gonococcal urethritis. Before any treat- foreign born males who contribute to this ment is offered it is advisable to take a sample figure. of blood for Wassermann test, etc. This test at 614 POSTGRADUATE MEDICAL JOURNAL October, 1965Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from
U.K. BORN 38 ---- OTHERS 36 34 0 32
0 70 60
24AY 50- u1X828 5 40 E22 ' 20 o 30 u 18 20 16 10 14 1952 53 54 55 56 57 58 59 60 61 62 1951 52 53 54 55 56 57 58 59 60 61 62 63 64 YEAR FIG. 2.-Estimated relative numbers of male patients with gonorrhoea 1952-62 i(after Willcox, 1965). FIG. 1.-Reported incidence of cases of gonorrhoea treated for the first time in clinics of England and Wales 1951-1964. 1952 1955 1958 1960 1961 1962 U.K. Born Males 69.7 67.3 51.5 49.5 47.2 44.0Protected by copyright. Other Males 30.3 32.7 48.5 50.5 52.8 56.0 (From annual reports of Chief Medical Officer of the Ministry of Health) Percentages of U.K. born and other males with Year Males Females Total gonorrhoea in co-operative group studies. 1951 14,975 3,089 18,064 1952 15,510 3,585 19,095 alternative is in a 1953 15,242 4,021 19,263 efficient, chloramphenicol 1954 13,962 3,574 17,536 similar dose. 1955 14,079 3,766 17,845 True penicillin resistance of gonococci is 1956 16,377 4,011 20,388 extremely rare but the coincidence of a strain of 1957 19,620 4,761 24,381 with a of resistance to the 1958 22,398 5,489 27,887 gonococci degree 1959 24,964 6,380 31,344 drug and a poorly absorbed penicillin injection 1960 26,618 7,152 33,770 may result in a treatment failure. Frequently, 1961 29,519 7,588 37,107 a second injection of a similar dose of 1962 28,329 7,109 35,438 penicillin
will result in cure. It be tohttp://pmj.bmj.com/ 1963 27,895 8,154 36,049 may necessary *1964 29,067 8,749 37,816 increase the dose of penicillin (e.g. procaine (From the 4 penicillin 1,200,000 u. daily for 3 days). quarterly re- Obviously, there will be some exceptions to turns of * 1964) this very simple account of signs and symptoms, Estimated diagnosis and treatment of acute gonorrhoea in the male. It is possible for a gonococcal this time, of course, is of no value in detecting urethritis to exist with only the most minimal a syphilitic infection acquired at the same time urethral discharge. A scraping of the terminal on September 23, 2021 by guest. as the gonorrhoea but is necessary as a 'base urethra with a platinum loop when the patient line'. has not passed urine for some hours (preferably When gonococci have been found and overnight) should demonstrate the infection. examination has not revealed any sign of any It is also possible (but very unusual) for other infection, treatment may be started at gonorrhoea to be entirely asymptomatic and be once. The drug of choice is penicillin and a demonstrable only in the prostatic secretion. single injection of procaine penicillin in the order of 900,000 to 1,200,000 units will cure the Complications great majority (in the region of 90 to 95%). Under present conditions, complications of In cases of penicillin sensitivity, a short course acute gonorrhoea in the male are uncommon. of tetracycline (0.25 g. q.d.s. for 4 days) gives Direct spread of the infection into periurethral almost as good results. A third, and very tissues may (with secondary organisms) form October, 1965 ROSEDALE: Immigrants and Venereal Infections 615 Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from an abscess. Spread via the posterior urethra In the majority of cases, however, the patient to the vas deferens and infection of an will have had a number of other sexual epididymis is the most common early comp- exposures in the meantime and following the lication, usually when the patient has neglected one 'risk' that results in an infection of his urethral discharge for some days or weeks. gonorrhoea and ignoring all the others cannot Late complications should not occur under be considered practical medicine. Encourage- present conditions when the infection can be ment for regular attendance at a clinic for diagnosed and adequately treated within a very routine serological testing by all promiscuous short space of time. However, some of the patients is reasonable. older immigrants may have had one or more It must be accepted that a fair proportion infections in their own countries that were of the more irresponsible patients (with many inadequately treated or not treated at all. Such West Indians among them) will not return to patients may have a urethral stricture. This the clinic after receiving one injection of may be entirely asymptomatic or cause some penicillin whatever advice or instructions they loss of power in the urinary stream that the may be given. Another group will default after patient has got used to over the years. Some their first follow up visit a few days after may present as retention of urine when the treatment (or any visit to the clinic when they oedema of a fresh urethral infection blocks a are not actually given treatment in one form distorted, scarred urethra. or another). Such patients usually return to The possibility of a stricture is often the clinic at once if any further signs or suggested by the presence of a slight urethral symptoms develop and it is difficult to say discharge containing some pus cells and large that any real harm commonly results from such numbers of secondary organisms even when carefree behaviour.
the specimen is taken with special care from Protected by copyright. as far within the urethra as the platinum loop Gonorrhoea in the Female (and the patient! ) will allow. The gentle passage The reported number of cases of gonococcal of a gum elastic bougie or urethroscopy would infection in females in 1963 was 8,154. Details then be indicated, although such mechanical of country of origin of 7,459 of these cases interference may be postponed until secondary show that of these women 77.9% were born infection is under control. in the United Kingdom, 10.5% were West Indians and 11.6% were other immigrants. Follow Up (British Co-operative Clinical Group Gonor- Follow up of these cases serves two purposes. rhoea Study 1963). When the female immigrant Firstly, one establishes that the original in- is involved in a venereal infection she is fre- fection has been cured by demonstrating the quently a secondary contact i.e. the infection is disappearance of urethral pus. When no passed on to her by her husband or other regular sexual partner after he has acquired the in- discharge is obvious, the urine is inspected as http://pmj.bmj.com/ a low grade urethral infection will produce fection from an 'extra marital' sexual contact. pus 'threads' easily seen in a freshly passed specimen. Clinical Aspects The other function of the follow up of the The most important point about a gonococcal treated patient is the exclusion of syphilis (or infection in the female is that a very high any other venereal infection) that may have proportion of cases (in the region of 50%) been acquired at the same time as the are entirely asymptomatic. In others, the gonorrhoea. It is usually considered desirable symptoms and signs may be very slight and, on September 23, 2021 by guest. to examine the patient clinically and serolo- in themselves, do not encourage an early visit gically at monthly intervals for three months to a doctor or a clinic. Most females with after the original infection. There is reason gonococcal infections attend for medical advice to believe that the treatment of acute gonorrhoea only when their male partners have announced with a large injection of penicillin (e.g. 1,200,000 their own infections. units of procaine penicillin) will cure an early A definite history of gonorrhoea in a sexual infection of syphilis that may have been acquired contact of a female should infer a similar at the same time. It is obviously impossible to diagnosis in her until it can be confirmed or diagnose early syphilis in the first few days excluded by repeated bacteriological examina- of its incubation period and, under present tion. It is not generally realised that a number conditions, it is still advisable to attempt the of repeated examinations by smear and culture full 'trad itional' follow up. from urethra and cervix (and sometimes, 616 POSTGRADUATE MEDICAL JOURNAL October, 1965Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from rectum) may be necessary to demonstrate the (900,000 units or 1,200,000 units) being all that gonococcus in an infected and infectious is necessary for the majority. Larger doses woman. The number of negative tests necessary are, of course, necessary if there are any to exclude an infection cannot be laid down complications. Other antibiotics, tetracycline but must depend on the venereologist's clinical etc. may be necessary. impression and the patient's history including, of course, all possible information on possible Follow Up infection in her consort or consorts. It is not The difficulty of demonstrating the gono- rare for' the gonococcus to escape detection coccus before treatment in some females has until six or more serial smears and cultures been stressed. It follows that tests of cure are have been taken. equally unreliable when performed on only one This is another field of venereology where or two occasions after treatment. Here again, the writer suggests a practical approach to a some happy compromise between what is practical subject. The gonococcus may be clinically ideal and what is acceptable to the found in an infected female on her first patient is necessary. In most cases, if three examination; on the other hand it has been serial smears and cultures at weekly intervals stressed that an accurate diagnosis may be after treatment are negative, the patient is delayed for some time. Many female patients probably cured. It is unfortunately true that will not return to the clinic for repeated the best way to diagnose gonorrhoea in a examinations whatever is said to them. Many female is to have intercourse with her! The West Indian and Mediterranean males will majority of female immigrants will have insist on resuming sexual activity with their resumed an active sex life long before this is women within a day or two without any regard sanctioned by their medical advisers. Infection to any medical advice, diagnosis, tests or is, of course, not always transmitted by a singleProtected by copyright. treatment. act of coitus but, in time, a healthy male Obviously, a firm diagnosis before any partner (or partners) confirms a cured female. treatment is offered is highly desirable for both doctor and patient, but this ideal requires some measure of co-operation from the patient. In Complications of Gonorrhoea in the Female dealing with a fair proportion of immigrant The most important complication of gonor- females (or English women who have an rhoea in the female is salpingitis, acute, immigrant male as their sexual partner) it is subacute or chronic but is not necessarily more an unfortunate fact that any delay in diagnosis common in immigrant women than in any other or treatment will result in re-infection of the socially comparable group. male or a defaulting female until re-infection Diagnosis is best made by demonstrating the of the male has gonococcus in specimens from the usual sites occurred. Such delays and (urethra, cervix and possibly rectum) in the defaults also increase the chances of important presence of salpingitis. complications e.g. salpingitis, in the females. http://pmj.bmj.com/ Many immigrant females and female consorts The Gonococcal Complement Fixation Test of immigrant males have no interest whatever may be of some limited value in this type of in a diagnosis but simply wish to get rid of case. On the whole, it is an unreliable test any 'germ' that they may have. with a high incidence of false positive reactions One cannot lay down any firm rule of in a low titre. However, the repeated finding management but offering treatment to a pro- of a strongly positive G.C.F.T. in a female bably infected female is reasonable even when with salpingitis suggests that the original cause first tests are negative if this is all that the of her condition may have been gonococcal. on September 23, 2021 by guest. patient wants. It should, of course, be explained It does not necessarily follow that the present to the patient that the giving of treatment episode of salpingitis is gonococcal. It may be implies a diagnosis of gonococcal infection and that the original specific infection occurred that routine follow up examinations are some time in the past and that secondary necessary. infection of a damaged tu'be accounts for the present flare up of acute or subacute salpingitis. Treatment Treatment When a diagnosis has been made or the Bed rest is indicated and the usual nursing decision made to treat as a contact of gonor- care of a patient with pelvic inflammation. In rhoea, treatment is given as for the male patient, the very acute case, where differential diagnosis a single injection of procaine penicillin from acute appendicitis may be difficult, Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from October, 1965 ROSEDALE: Immigrants and Venereal Infections 617 penicillin (500,000 units of crystalline penicillin ground microscopy of serum from any genital 6 hourly for a few days) is often dramatically ulcer for Treponema pallidum and by serial effective. In the more commonly seen subacute blood tests are necessary to exclude the and chronic cases, bed rest is always indicated infection: the former continuing as long as an too but broad spectrum antibiotics may be open ulcer is present, the latter until at least more effective than penicillin. When possible, three months has elapsed after the last possible antibiotic therapy should be related to culture date of infection. and sensitivity of organisms in a cervical swab. Latent Syphilis is a diagnosis of exclusion. Obviously, more direct bacteriological examina- Standard serological tests (the Wassermann tion of the infected Fallopian tube is impossible. Reaction, Kahn test, V.D.R.I., Price's Pre- Flare up of a subacute-on-chronic salpingitis cipitation Reaction, etc.) are confirmed as is, unfortunately, not uncommon and in some positive on repeated testing: it is usual to cases removal of the damaged tube (tulbes) is confirm these results with one or more of the indicated as the only alternative to frequent more specific tests (Reiter Protein Complement episodes of ill health, dyspareunia, etc. Fixation Test, Fluorescent Treponemal Anti- Other complications, abscess of the duct of 'body Test or Treponemal Immobilisation Test). Bartholin's gland, Skene's abscess and the very Primary and secondary syphilis are excluded rare gonococcal arthritis are dealt with by by negative clinical examination. Late syphilis, removing the focus of gonococcal infection with particularly lesions of the cardio-vascular and adequate doses of penicillin. Otherwise, basic nervous systems are excluded, again by general surgical principles apply and pus, once formed, physical examination, chest X-ray and screening must be drained. Bartholin's abscesses require for cardiac and aortic contours and adequate incision and drainage when they do by examination of the cerebro-spinal fluid by Protected by copyright. not often reoccur. Frequent recurrence may lumbar puncture. The important CSF investi- be an indication for surgical removal of the gations are cell count, protein content, globulin gland and its duct. estimation, Lange curve and Wassermann reaction. Syphilis A diagnosis of latent syphilis is, of course, The incidence of early infectious syphilis an indication for treatment. When any mani- (primary, secondary and latent in the first year festation of late syphilis is discovered other of infection) treated in the venereal disease general medical care and treatment may be clinics of England and Wales in 1963 was necessary in addition to a course of anti- 1,390 (Males 1,135, Females 255). An analysis syphilitic treatment. of the racial groups making up this figure A practical point in the management of a suggest that the male numbers were made up patient with early infectious syphilis is the of 62.6% U.K. born, 6.6% West Indians and matter of defaulting by the more irresponsible 30.7% other immigrants. The figures for women (not necessarily an immigrant). It is often http://pmj.bmj.com/ were 59.4%/. U.K. born, 29.1% West Indians advisable to give a large initial dose of long and 11.5% other immigrants. (Annual Report acting penicillin (e.g. 2,400,000 units of of Chief Medical Officer of Ministry of Health benzathine penicillin, given in two injections, 1963.) This distribution is markedly different one into each buttock) on diagnosis of primary from the distribution of gonorrhoea. or secondary syphilis. Many of these cases will The longer incu'bation period of syphilis be cured by this dose even if they never return makes it a disease more likely to be brought for further treatment. The course of
treatment on September 23, 2021 by guest. into the country by immigrants. for the vast majority who attend as requested An attempt is made by Health Officers to involves a course of procaine penicillin amount- diagnose early infection by examination on ing to a total dose in the region of 10 mega arrival at Ports of entry, and, when a diagnosis units. A suggested routine course, using pro- of early infectious syphilis is confirmed, the caine penicillin with 2% aluminium monos- immigrant is refused admission to the country. tearate, is an injection of 1,200,000 units three The numbers dealt with in this way must be times weekly to a total of 10 injections. minute. It should also be remembered that a diagnosis The clinical details of the various stages of of syphilis at any stage implies the responsibility syphilis are beyond the scope of this paper. of arranging examination of sexual contacts Basic principles apply and any genital ulceration and, when indicated, children of patients. should suggest at least the possibility of an The matter of the diagnosis, treatment and early syphilitic infection. Investigation by dark general management of syphilis has not been Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from 61,8 POSTGRADUATIE MEDICAL JOURNAL October, 1965 dealt with in detail as the incidence of syphilis a history of yaws diagnosed and treated in in immigrants is not so high as that of childhood; many others have been exposed gonorrhoea. to the infection but have never been so diagnosed. Non-Syphilitic Positive Serological Tests So far as we are concerned, when early lesions In the majority of Europeans, a series of have healed there is no clinical or serological repeated strongly positive serological tests for differentiation between the two conditions. An syphilis suggests past or present infection with adult patient may have been treated for yaws Treponema pallid'um. This may have been in childhood and then acquired syphilis later treated, inadequately treated or untreated. in life. Biological false positive reactions may occur A suggested procedure to follow when and have been attributed to a variety of acute serological tests of an immigrant from a yaws and chronic infections. In many cases, no area (West Indies, Africa, etc.) are found to be obvious reason can be found for the false repeatedly positive and when a biological false positive reaction once syphilis has been excluded positive has been excluded is: as the cause mainly by the more specific tests previously mentioned (R.P.C.F.T., F.T.A., (1) A careful history of possible yaws T.P.I.). infection in childhood, treated or un- All this applies equally to the immigrant treated. The possibility of yaws lesions patient but, in this group, in brothers and sisters or playmates, the non venereal describing the typical lesions on the legs, treponematoses have also to be considered. is worth enquiring after. A history of venereal contacts, infections, blood tests, Treponematoses penicillin or other antibiotic therapy forProtected by copyright. There are various diseases found in different any reason should be noted. parts of the world that are due to organisms similar to the Treponema pallidum of syphilis. (2) Complete clinical examination to exclude Whether these are closely related infections or the lesions of primary or secondary the same infection modified by time, social syphilis and the late lesions of cardio- customs, etc. is not certain. There are various vascular and neuro-syphilis (as previously theories including the suggestion (again under detailed). At the same time a search change of environment, etc.) that venereal is made for any scars on the legs that syphilis can change to the non-venereal have the typical appearance of old yaws treponematosis and vice-versa. One of the lesions. Differentiation of the roughly treponematoses, yaws, wuhich 'is endemic in circular 'tissue paper' scar of the yaws the tropical and sub-tropical home countries lesion from scars of old trauma and of so many of our immigrants is our main sepsis may however be difficult or concern in this country. impossible. The scarring and thickeninghttp://pmj.bmj.com/ The causative organism of yaws is the of the skin of the soles of the feet of Treponema pertenue, and is indistinguishable crab yaws is another suggestive sign. from the Treponema pallidum. The relationship It must be emphasised again that a between the two diseases has been mentioned definite history of a yaws infection with but will not be gone into further. The undoubted signs of old lesions may important fact is that yaws is a transmissible coincide with a superinfection with infection but most often as venereal syphilis. a result of contact on September 23, 2021 by guest. among children and not sexual contact among (3) The examination of all available sexual adults. The primary lesion of yaws may be contacts and, where indicated, children, found anywhere on the surface of the body in an attempt to find evidence of syphilis. and the disease may be seen in its early in- In practice, this procedure is not of fectious stage in recently arrived child very great value. There have probably immigrants. The clinical course is roughly been many other sexual contacts besides comparable to that of syphilis and soon reaches the one(s) immediately availa-ble and a latent stage or results in cure but possibly the contacts may also have had yaws. leaving the serological tests positive. In the (4) The titre of the positive serological tests vast majority of cases of immigrants with may be an additional indicator, very suspected yaws (treated or untreated) the weak positives in young patients sug- problem will be one of interpretation of gesting yaws. Strong positive reactions serological tests. Many immigrant patients give in older patients suggest syphilis but October, 1965 ROSEDALE: Immigrants and Venereal Infections 619 Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from unfortunately are of very little real require careful consideration and a decision diagnostic value. for each individual case. As in all treated (5) Treatment. As there is no means of syphilitic women the child is observed at absolute differentiation between the regular intervals after birth. If it remains well venereal and non-venereal trepone- in all respects, a clinical examination and blood matoses, the only practical step is to tests at the age of about 6 weeks (when the offer a course of treatment sufficient to 'carry over' of maternal reagin to the infant's cure syphilis if it is present. The course serum has probably disappeared) are desirable may be as previously suggested or may to confirm a healthy child. be modified (to suit the patient) to injections of benzathine penicillin in The 'Tropical' Venereal Diseases larger doses at greater intervals (e.g. These are placed last because, although the Penidural L.A. 2,400,000 units x 3 doses most specific venereal diseases of the immigrant at intervals of 10 days to two weeks). population, they are numerically almost insigni- (6) Serological and clinical follow up of the ficant when compared to the immigrants' share patient as in a case of treated syphilis. of the standard venereal diseases of this country-gonorrhoea and syphilis. Pregnant Women The one group in which this problem is seen Lymphogranuloma Venereum particularly frequently is the pregnant immigrant In the case of this infection it is quite likely female. Their fertility rate appears to be high that the reported incidence as shown in Table and the routine blood test performed in the does not represent the true figure. The later
course of each pregnancy yields a high pro- manifestations in older patients are more likely Protected by copyright. portion of positive reactions. The routine to be dealt with in other hospital departments procedures enumerated above must be gone and never referred to the Venereal Disease through on each occasion. In the new case, Clinic. a history of one or many previous healthy Lymphogranuloma venereum is a virus pregnancies in their home country suggests infection and is usually transmitted by sexual that the cause may not be syphilitic but there contact. The primary lesion appears on the is no alternative to offering a standard course genitalia within a few days of contact and of treatment. usually takes the form of a small papule or Even in the case of a woman previously herpetiform vesicle. It is frequently unnoticed examined and treated during one or many by the patient. The usual presenting signs and pregnancies in this country, the presence of symptoms develop later (usually 3 to 5 weeks persistently positive serological tests is usually later) and takes the form of pain and swelling an indication for a further course of penicillin in one or both groups of inguinal glands. as one can never be absolutely certain that Clinically, this is recognised as an adenitis and http://pmj.bmj.com/ syphilis has not been acquired between periadenitis. The infection is, as a rule, sub- pregnancies. Examination of sexual contacts acute and (in a white-skinned patient) the each time is of value; if the consort remains inflamed area has a bluish tinge very charac- the same and he is sero-negative on each teristic of this condition. Suppuration usually occasion, recent syphilis in the female is that develops and, if neglected, may discharge much more unlikely. through the skin. Some cases may present The generally accepted practice in most of as acute relapses of a subacute infection: in the clinics of this country is-that such pregnant these, chronic induration of the inguinal area on September 23, 2021 by guest. immigrant women are offered a further course and signs of partly healed or healed sinuses of penicillin during each pregnancy while their may be found. The lesions are not usually so serological tests remain positive to avoid (how- tender that bending the leg is impossible and ever rarely it might happen) the possibility of the swelling in the groin may show the skin a syphilitic foetus. fold of movement of the hip (this is a point Penicillin sensitivity is a possible danger. in the differential diagnosis from the buboe of When it exists or develops during treatment, chancroid or other more acute septic adenitis). drugs of the tetracycline group may be sub- Diagnosis. The Frei Test is of some value stituted. There is evidence that these drugs in confirming the diagnosis of L.G.V. This is can damage the foetus if given in the last three an intradermal injection of killed virus, usually months of pregnancy. In such a case, the into the skin of the forearm with a control question of whether or not to treat would injection of the suspending fluid into the skin 620 POSTGRADUATE MEDICAL JOURNAL October, 1965Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from TABLE 1 REPORTED INCIDENCE OF CHANCROID, LYMPHOGRANULOMA VENEREUM AND GRANULOMA INGUINALE IN THE VENEREAL DISEASE CLINICS OF ENGLAND AND WALES (1957-1964). Year Chancroid Lymphogranuloma Granuloma Inguinale Male Female Venereum 1957 254 6 76 20 1958 247 12 77 19 1959 265 2 80 12 1960 226 5 102 14 1961 227 1 98 14 1962 154 3 96 16 1963 153 6 103 10 *1964 136 4 78 7 *1964 figures estimated from the four quarterly returns of 1964 of the other arm. A papular reaction with an drug in doses of the order of 2 g. daily over area of indurated erythema at the site of in- a period of about 21 days. Alternating this jection (usually read at 48 hours) is recorded course with sulphonamides in doses of 4 g. as a positive reaction. The disadvantages of this daily is another suggested regime. test are that it is sometimes delayed even in The Ano-Rectal Syndrome of Lympho- the presence of definite lesions of Venereum is not but early L.G.V. granuloma uncommon, Protected by copyright. is (Erskine, 1958) and that a proportion of im- seen more frequently in hospital departments migrants produce positive Frei reactions without other than the venereological dept. It is seen clinical evidence of the infection. King, Barwell more often in females and it has been suggested and Catterall (1956) confirmed the diagnosis (Grace, 1943) that most cases of proctitis and in only 2% of a total group of 1,119 patients rectal stricture in males result from homo- (991 white, 118 coloured) when the total of sexual contact. In the majority of his cases, positive tests was 18.4%. This study was per- (73.8% of 145 cases) the clinical picture was of formed in the earlier days of mass coloured stricture with proctitis. In the older immigrant immigration and their findings in the two female, stricture without proctitis may be the groups was: White positive reactors, male late result of genital infection with spread 16%, female 11%, Coloured positive reactors, (with suppuration, scarring etc.) to the para- male 50%, female 36%. rectal lymph glands. The Complement Fixation Test is a little Treatment is along the lines described for the more sensitive as a test. It is or diagnostic gener- inguinal genital form. Mechanical dilatationhttp://pmj.bmj.com/ ally accepted that a titre of 1.32 or more is of rectal strictures may be necessary. Some- necessary to establish the diagnosis. In early times, more drastic surgery with temporary or cases, it is of value to demonstrate a rising permanent colostomy may be indicated. Lym- titre of the L.G.V. Complement Fixation Test phogranuloma venereum should certainly be in specimens examined at intervals of (say) considered in the diagnosis of proctitis and two weeks. Both the intradermal test and com- rectal stricture in an immigrant plement fixation test will, of course, produce patient. positive reactions in the presence of infection Chancroid. on September 23, 2021 by guest. with other viruses in the psittacosis-lympho- This is a specific genital infection granuloma group. caused by Haemophilus ducreyi. It is seen Treatment. Local. Once pus has formed in commonly in tropical and sub-tropical regions a buboe, it should be aspirated using a wide of the world and is associated with lack of bore needle. Allowing spontaneous rupture or hygiene. The incidence in this country is not incision frequently results in the development high (Table 1). of a chronic sinus. The incubation period is usually only a General. The present position and opinions matter of 2 to 4 days. The disease presents on the value of antibiotic therapy in the acute as one or more superficial, painful ulcers condition has been summarised in Recent with ragged undermined edges. These lesions Advances in Venereology (King, 1964). Oxy- may soon be associated with involvement of the tetracycline seems to be the most satisfactory inguinal lymph glands resulting in very pain- October, 1965 ROSEDALE: Immigrants and Venereal Infections 621 Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from
sa::*:!::i·:.l':·,:·: To summarise: the diagnosis of chancroid .. :.· .:i"" .:;:·.·.··. as the cause of genital ulceration is most often .';"'':'':":a':siiji: ':.·:.:·rii:i%i..i..iii'i'''(:i.i'ii:l;lii;i.iiii.fi"'l':' ::;:.' i· :::::::ii.9. Efil(iEiliplii made on clinical incubation .·.':zisai-·l::·:·::;: ···: ....::····.::·:·.:::;:::::, grounds (short idb:':·····l:l::i:':..i. ·i,ii:ii. period followed by the development of multiple CI:ll:l·.·:·l::.. ·.· ":·:'i:ii· .·:· ····l·:::i::: painful ragged ulcers and associated inguinal ·':·:;::i:.i:::.i··::·· :. ·:l.iiiiif buboe(s)). Isolation of the causative organism .:::::·::::. by smear and culture is best attempted in '::'i·:.::::::'·'· ::.ii·.·· .:.:.. ·:::I··:;:::::i:: material removed from an unruptured buboe Bi.'i::ii:ii"i' ··· il!iD:i· i·"l'. :·'·j::i:·.: by aspiration. Perhaps a more important duty Zi8iJlii:-::'':··'· ·······: is :·;ii::··. the exclusion of a syphilitic infection (by the usual procedures of dark ground examination illiili.bifi.itiirii:n·::"p::.'('I :::::j.··· ;I.:::·PBiB::l··:··: of material from the ulceration and serial Ill:i:$;i;;i.izi::I::. ':"':· ':·····.:.·.·'''::·:··'· ·: ·I·:::··· ·····:: ::::·: blood tests). Fortunately, chancroidal infections j.i..ilifidii..i....il(i···ij will respond to drugs which are not treponem- leci''::i:::::i·:i·:i::· I:·l;.:.:i.·i:;·::.:::;:· icidal so that treatment of chancroid and ex- Ri:":: ':'":::::: i:·:l··l:ia:. ·:··: clusion of syphilis can proceed together. Treatment. Sulphonamides are effective. 1 g. four times for 10 to 14 is often all ;:a;r·:·:I daily days -.l.-;:.:·'·:i::.; :·:·:· .:·:.·i I:i that is li··s:s:·E·:n::;:·g: required. tiBii181 :airiiiii-:Ea:n: Streptomycin, 1 g. daily for five days has iFilL. I.F.B.F;i..dl.C.:.$I.P" -.e.Rgi.Lfi produced good results (Asin, 1952). A com- .·.la:ir:i·i:r::iPi::::: L8aaar.snrii.ri.:.i.?.:iPiB:ii:::PiCi'lj -····:r:·::·;:·::· ':'·· bined course of streptomycin and sulphona- ::,:: :n::a. mides is perhaps the most effective of all. -I . -s.ls%a.%83sR.s;;..:i.i.j.i.i.5:::;.:(j Other antibiotics, the tetracyclines and Protected by copyright. ·I·-·r;:,:·;:· :F:i: a:P: :r:::r::-:· chloramphenicol are also effective but are best avoided LiSiF:iiil(:i·:· '·.··.·:.';:'.a.a. "Il.sBIIBP.PBB%B.S(.i.l..i8ili;ii.iOii as they will interfere with routine
fi:l::::':: to eliminate this :···::.·...r testing syphilis (in country, :: I;iil .s.aaaas.s.gii very much more common as a cause of genital iCi.E:i.il(.:. ···. '.::··:·:·. ···:·.:91i!i ulceration than :·::.·:·:: chancroid).
-;:*·.··:;·:;:·; FIG. 3.--Bilateral inguinal buboes of lympho- Granuloma Inguinale aranulonma venereum. This must be considered in the differential ful adenitis and periadenitis. This, as a rule, diagnosis of genital ulceration in an immigrant is much more acute than the buboe of lympho- patient. As Table 1 shows, the reported granuloma venereum. Spontaneous rupture may incidence in this country is still minute, only occur shortly after the appearance of suppura- 10 cases in 1963 and the figure for 1964 is tion. likely to be even smaller (7 cases reported so http://pmj.bmj.com/ Diagnosis may be made by demonstrating far, in the four quarterly returns for 1964). the causative organism but this is not easy. Granuloma inguinale is caused by the Ducrey's bacillus does not grow well in the Donovan body (Donovania Granulomatis) and presence of other organisms and specimens may be demonstrated by smear or biopsy of from open, secondarily infected, ulcers are not the lesion. satisfactory. The best material is obtained by This condition is generally considered with of an buboe. the transmitted aspiration unruptured sexually conditions but, since on September 23, 2021 by guest. Intradermal Test. The Ito-Reenstierna test, the condition is rarely seen in both sexual the intradermal injection of a killed suspension partners, its classification as a venereal disease of Ducrey's bacillus is of limited use. A high is in doubt. Greenblatt (1958) (quoted by incidence of positive reactions has been reported Barrow, 1958), in a series of several hundred in apparently normal individuals (Willcox, patients with granuloma inguinale in Georgia, 1952) and although these may be true reactions U.S.A., found only about 6 cases of conjugal indicating contact with the organism at some infection. time, the test is not of great value in the im- Clinical Appearance. Single or multiple mediate diagnosis of a genital ulcer. granulomatous ulcers on or close to the Diagnosis by biopsy is one suggested pro- genitalia with a smooth velvet-like appearance cedure (Heyman, Beeson and Sheldon, 1945) is generally described. Differential diagnosis but is often not a practicable procedure, mainly from a malignant ulcer is usually suggested by from ,the patients' point of view! the naked eye appearance and, in fact, car- 622 POSTGRADUATE MEDICAL JOURNAL October, 1965Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from It is worth repeating that non-gonococcal urethritis in males is a diagnosis of exclusion- mainly from a gonococcal infection. In the 9P.":: :·V:' other causes deserve a little .i. O' ...:W immigrant patient, ,:·· V. more consideration: Urethritis due to Tricho- ?.'?L ;; ·. monas is in various series .*· Vaginalis reported ··· ··;..r:t·.;2.Lj.j... .* ;· ·.· from 1% to 15% of all cases of non-gonococcal '1 ::· urethritis. There is no doubt that the more it is looked for, the more it will 'be found and ....- .·· ,··.:. that the incidence will be markedly higher in .t.i....··qlhll...l·l.*'.I*.,.e.F. the .··c:.i.i;; .....: male sexual partners of women found to T··T.:.it:· harbour the parasite in the (to the extent a vagina i.a.a ·:*·:.Y**Yi.*i.**i.u.4.1r. of 40% to 60% of those examined.) ·;·.,.k. One other cause of urethral pus (often as- .;···. :?ii ::· sociated with a variety of secondary organisms) ··· i;:Z:· x··- :i:··..r has been previously mentioned: a urethral :i. stricture resulting from one or many previous episodes of urethral infection, untreated or in- adequately treated. Non-Gonococcal Infection in the Female. No comparable condition to N.G.U. in the male has been discovered in the female. In our present state of ignorance, the best that one can do is to examine the female partner whenProtected by copyright. possible and attempt to treat any abnormality that may be found. It has been suggested that mere empirical treatment of the female partner serves no useful purpose (Rosedale, 1959). FIG. 4.-Penile lesions of granuloma inguinale Also, in the author's experience, many male patients return to the same female partner after cinomatous change has been reported occasion- treatment of an episode of N.G.U. when that ally. female has not been examined or treated for Treatment anything and never suffer a recurrence of their Streptomycin is the drug of choice. 4 g. daily urethral inflammation. for five days has been suggested (Greenblatt, Barfield, Dienst, West and Zises, 1952). Summary and the have Chloramphenicol tetracyclines Gonorrhoea and syphilis are the only com-http://pmj.bmj.com/ also been reported as producing good results, monly seen venereal diseases of this country. but, again, these are best avoided until syphilis These and other sexually transmitted conditions has been excluded as a cause or as a co- e.g. non-gonococoal urethritis in the male, are incidental infection. seen very much more frequently than the other venereal diseases of the countries of origin of Other Sexually Transmitted Conditions many of our immigrants (chancroid, lympho- Non-gonococcal urethritis in males is a con- granuloma venereum, granuloma inguinale). dition that has shown an increased incidence Immigrants, particularly the males, account on September 23, 2021 by guest. over recent years, comparable to the increased for a very large proportion of the reported incidence of gonorrhoea. No large scale surveys venereal disease of this country (over 50% of of the country of origin of patients has been all new cases of gonorrhoea in males occurring undertaken but it would appear that the male in foreign-born men). immigrant to this country is contributing his The one specific problem in venereology disproportionate share of this infection also. peculiar to the immigrant alone is the interpreta- Willcox (1965) reporting on 800 consecutive tion of positive serological tests for syphilis. males with non-gonococcal urethritis treated most often found on routine ante-natal blood at St. IMary's Hospital, Paddington, during testing. The differentiation between venereal 1961 found that only 40% were United King- syphilis and a non-venereal treponematosis as dom born. Of the 60% foreign born, 30% were the cause is usually impossible and the usual West Indians, 30% other immigrants. practical solution is to treat as for syphilis. October, 1965 ROSEDALE: Immigrants and Venereal Infections 623 Postgrad Med J: first published as 10.1136/pgmj.41.480.613 on 1 October 1965. Downloaded from The 'tropical' venereal diseases must always Study of Antibiotics in the Treatment of Granu- be considered in the of immi- loma Inguinale, Amer. J. Syph., 36, 186. investigation GREENBLATr, R. B., (1958) quoted by BARROW, J. grants with genital and other lesions, particular- (1958): Granuloma Inguinale in a Jamaican and ly those newly arrived in this country, but the his Wife, Brit. J. vener. Dis., 34, 34. vast majority share and spread the diseases HEYMAN, A., BEESON, P. B., and SHELDON, W. H. that have always been endemic in the normal (1945). Diagnosis of Chancroid. The Relative of this Efficiency of Biopsies, Cultures, Smears, Auto- population country. innoculations and Skin Tests, J. Amer. med. Ass., 129, 935. KING, A. J., BARWELL, C. F., and CATtERALL, R. D. REFERENCES (1956): Intradermal Tests in the Diagnosis of Lymphogranuloma Venereum, Brit. J. vener. Dis., ANNUAL REPORT OF THE CHIEF MEDICAL OFFICER OF 32, 209. HEALTH FOR THE YEAR 1963, 65, London: H.M.S.O. KING, A. J. (1964): Recent Advances in Venereology. ASIN, J. (1952): Chancroid. A report of 1,402 cases, p. 320-331, London: J. & A. Churchill. Amer. J. Syph., 36, 483. ROSEDALE, N. (1959): Female Consorts of Men with BRITISH CO-OPERATIVE CLINICAL GROUP GONORRHOEA Non-Gonococcal Urethritis, Brit. J. vener. 35, STUDY 1963 (1965): Brit. J. vener. Dis., 41, 24. 245. Dis., ERKSKINE, D. (1958): Lymphogranuloma Venereum. WILLCOX, R. R. (1952): The Ito Skin Test for A Review of 61 cases, Brit. J. vener. Dis., 34, 163. Chancroid in the Adult and Juvenile African, GRACE, A. W. (1943): Anorectal Lymphogranuloma Amer. J. Syph., 36, 284. Venereum, J. Amer. med. Ass., 122, 74. WILLCOX, R. R. (1965): Immigration and Venereal GREENBLATr, R. B., BARFIELD, W. E., DIENST, R. B., Disease in Great Britain, Brit. J. clin. Pract. In WEST, R. M., and ZISES, M. (1952): A Five Year Press. Protected by copyright. http://pmj.bmj.com/ on September 23, 2021 by guest.