Matters arising 417

Polypoidal and giant molluscum conta- lesions as in Petersen's study.3 This suggests but agreed to infective after coun- giosum that genital MCV occurs in HIV infected selling. The rest attended for a check-up. patients, as a sexually acquired infection Other STDs identified in the women The letter by Kumar and Dawn' on a case of early and once established may present in (sometimes in combination) were Neisseria solitary, giant penile molluscum contagio- an opportunist form; however, the clinical gonorrhoeae in 4-6% (2), Chlamydia tra- Genitourin Med: first published as 10.1136/sti.71.6.417 on 1 December 1995. Downloaded from sum (MCV) merits further comment and site manifesting is determined by the degree chomatis 18-6% (8), Candida albicans 18&6% clarification. We have observed a cardiac of immunosuppression. (8), genital warts 16-2% (7), Gardnerella transplant recipient who was therapeutically A J REA vaginalis 6-9% (3), Herpes simplex Type 1 in B T GOH immunosuppressed, with recalcitrant facial Department of Genitourinary Medicine, 2-3% (1). An incidental finding of septate MCV, some of which are "giant MCV". Ambrose King Centre, was noted in a 15 year old seen This clinical entity does exist in non-HIV Royal London Hospital, because of genital warts. patients contrary to Kumar and Dawn's London El JBB, UK In this -study, saline wet-mount phase statement. We have just completed a clinical contrast microscopy identified 88-3% (38) survey that showed a positive correlation 1 Kumar B, Dawn G. Polypoidal and giant mol- of the women and 50% (1) of the men at the between CDC categories B and C HIV dis- luscum contagiosum in an AIDS patient. first attendance, allowing prompt treatment. ease and facial MCV, compared with genital Genitourin Med 1995;71:57. Subsequent culture identified 95.3% (41) of 2 Thompson CH, de Zwart-Steffe RT, lesions in stage CDC A and non-HIV clinic Donovan B. Clinical and molecular aspects the women and 50% (1) of the men. attenders (p < 0-001 Fisher's exact test) of molluscum contagiosum infection in Opportunistic cervical cytology was done in (table). The clinical and molecular study by HIV-1 positive patients. Int J STD AIDS 14 of the women and trichomoniasis was 2 1992;3: 101-6. Thompson et al also demonstrates the facial 3 Petersen CS, GerstoffJ. Molluscum contagio- identified only in 75.3% (11) confirmed by predilection of MCV in advanced HIV dis- sum in HIV infected patients. Dermatology culture. ease, but not to the exclusion of genital 1992;184:19-21. Various hypotheses for the decline in inci- dence of trichomoniasis had been made,3 but we believe that routine phase contrast Anatomical sites ofMCV infection in patients at HIV and GUM clinics microscopic examination of saline wet- Site presentation mount vaginal material from the posterior Total no. patients fornix and urethral discharge should remain HIVstatus with MCV Face Genitalltrunkllimb as an essential screening modality for tri- HIVCDC C 12 12 (100%) 0 (0%) chomoniasis in STD clinics, recognising the HIV CDC B 4 3 (75%) 1 (25%) failure rate of various culture medium.4 HIV CDC A 3 0 (0%) 3 (100%) However, direct immunofluorescence with Presumptive HIV neg 70 1 (1-43%)* 69 (98.57%) monoclonal antibodies holds promise as a GUM patients sensitive and specific alternative of cultures *Cardiac transplant recipient. for the rapid detection of Trichomonas vaginalis in clinical specimens.5 T C HARRY S RASHID Ignored trichomonal infestation diag- according to the National Health Service K M SARAVANAMUTTU nosed by Papanicolaou smear Cervical Screening Programme guidelines. Department of Genito-Urinary Medicine We modified the guidelines by screening T L SHRESTHA opportunistically sexually active teenagers- Department ofMedical Microbiology, The retrospective study of Petersen et all on Sunderland District General Hospital, ignored trichomonal infestation diagnosed those aged under 20 years, in particular sex- Kayll Road, Sunderland by Papanicolaou smear reiterates the value ual contact(s) of men infected with genital SR4 7TP, UK of routine saline wet-mount phase contrast warts. Address correspondence to: Dr Tubonye C Harry. microscopy as part of the diagnostic screen- In the period 1992-1994, 45 cases of ing in the evaluation of women (and men trichomoniasis were identified (43 women 1 Petersen CS, Carl L, Alnor D, Thomsen U, and two men). Of the men; one was a single Thomsen HK. Ignored trichomonal infesta- with urethral discharge) who attend an http://sti.bmj.com/ 24 year old who attended as an asympto- tion diagnosed by Papanicolaou smear. STD clinic.2 Genitourin Med 1995;71:257-8. A recent audit in our unit evaluating the matic contact. Phase contrast microscopy of 2 Thin RN, Barlow D, Bingham JS, Bradbeer C. efficacy of saline wet-mount phase contrast saline wet-mount urethral scrape showed Investigation and management guide for sex- microscopy in the diagnosis of trichomonia- motile trichomonads confirmed by culture. ually transmitted diseases (excluding HIV). The was a married 34 old who IntJ STD AIDS 1995;6:130-6. sis in the period 1992-1994 confirms its other year 3 Harry TC, Rashid S, Saravanamuttu KM, continued usefulness as part of the diag- attended with a urethral discharge. Clinical Shrestha TL. Trichomoniasis: prespectives nostic tool in screening attenders at a geni- examination and microscopic review of in declining prevalence in a GUM clinic. Sex

Gram-stained urethal smear and two glass Transm Dis 1994;21:357-9. on September 26, 2021 by guest. Protected copyright. tourinary medicine (GUM) clinic. Our unit 4 Clay JC, Veeravahu M, Smyth RW. Practical in the north east England region serves a urine test provided an initial diagnosis of problems of diagnosing trichomoniasis in catchment population of about 320,000 non-gonococcal urethritis. He was com- women. Genitourin Med 1988;64: 115-7. residing in the coastal city of Sunderland menced on a dose of 500 mg oxytetracycline 5 Krieger JN, Tam MR, Stevens CE, Nielson IO, Hale J, Kiviat NB, Holmes KK. and its suburbs. As a routine, after obtain- twice a day for two weeks while awaiting his Diagnosis of trichomoniasis. Comparison of ing relevant medical, sexual, contraceptive cultural diagnosis. Phase contrast micro- conventional wet-mount examination with histories and a genital examination, a saline scopy was not done. Trichomoniasis was cytologic studies, cultures and monoclonal wet-mount smear from the confirmed from culture. His contact seen antibody staining of direct specimens. JAAMA posterior vaginal 1988;259: 1223-7. fornix in women and a urethral scrape from elsewhere had confirmed trichomoniasis. men with urethral discharge were examined The mean age of the 43 women was 22-5 by phase contrast microscopy. They were years, range 14-43. Of these women 44-2% The value of in genito- initially scanned at x 100 looking for (19) were aged under 20 years; 95.3% (41) urinary medicine motile trichomonads and then at x 400 to declared themselves single, separated or confirm motility and morphology of tri- divorced. Contraceptive use reported In view of Griffiths' further comments on chomonads. Samples from the posterior were; oral contraceptive pill 30.2% (13), colposcopy in genitourinary medicine,' it vaginal fomix and urethral discharge were depo-provera 4-6% (2), intra-uterine coil seems that a brief final observation may be inoculated into commercially available device 2-3% (1). No form of contraceptive justified. Oxoid Trichomonas Medium (Basingstoke, use was reported by 53-4% (23) and 9.3% The original paper2 was a retrospective UK Ltd), incubated at 37°C and examined (4) were pregnant. report which looke back historically to 1986. after two days and seven days for motile tri- The source of referral was: 41-8% (18) The paper clearly identified that the colpo- chomads. Gram-stained smears were done were self referred, 30-2% (13) were referred scopy approach that was being explored on vaginal, urethral and cervical sites by their GP, 16-7% (7) attended following was exactly that of the very wide use of including cultures for Neisseria gonorrhoeae, a provider referral and 11-6% (5) were the colposcope as practised throughout Gardnerella vaginalis, Candida albicans and referred from the Antenatal Clinic or Germany, Spain, Italy and much of France Chlamydia trachomatis (ELISA). Serological Gynaecology Department. and South America. Quite simply magnifica- tests were done for syphilis and hepatitis B The reported reason for attendance was; tion of the is considered to be a better surface antigen routinely and for HIV (I vaginal discharge in 53-4% (23), genital wart way to detect a range of cervical diseases. and II) antibodies on request after appropri- infection 16-2% (7) and 9.3% (4) attended This includes infectious and inflammatory ate counselling. Cervical cytology was done requesting only testing for HIV antibodies conditions. Clearly this broad approach can