Syndromic management of sexually transmitted diseases.

Abstract

urethral discharge was noted. Microscopy of a Gram stained urethral specimen revealed Gram negative, intracellular diplococci for which he was treated immediately with a dose of 400 mg of ofloxacin. A provisional diagnosis of first episode of herpes simplex virus infection of the oropharyngeal cavity was made, and he was advised to take aciclovir 200 mg x 5 for 5 days. The patient reported to have always practised homosexual orogenital sex and had never practised anal sex. The sexual history of the recent casual partner was not known. He admitted to having had a similar sexual contact with another male partner 10 weeks earlier. This was his previous regular partner for 5 years who had no known history of genital herpes. He retumed after 10 days when he was reported to be well and asymptomatic. On examination the oropharyngeal ulcers were noted to be almost healed. A test of cure for N gonorrhoeae from a urethral specimen was reported negative on microscopy. A blood sample was sent for a repeat estimation of HSV antibody. Herpes simplex virus type 1 (HSV-1) was isolated from the specimen from oropharyngeal ulcers in cell culture. The serum HSV-1 antibody level showed a significant rise from less than 1 in 10 during the first visit to more than 1 in 40 on the tenth day during the follow up visit. This rise in HSV-1 antibody level was consistent with seroconversion for HSV-1. Microscopy result of N gonorrhoeae from the urethra on his first visit was confirmed on culture. A pharyngeal specimen did not grow N gonorrhoeae. Isolation of a high proportion of HSV-1 among women with first episode of genital HSV infection was first reported from Sheffield.3 Since then an annually increasing prevalence of HSV-1 in female anogenital herpes has been reported by others.4 The practice of cunnilingus has been proposed as one of the possible causes of such a trend.5 It seems reasonable to assume that such sexual activity could similarly lead to a transmission ofHSV from the genital area to the oropharyngeal cavity. In the present case, the occurrence of herpetic lesions in the oropharyngeal cavity within 1 week of unprotected orogenital contact suggests possible transmission of HSV-1 from the genital area to the oropharynx. A first episode of genital HSV-1 infection almost always indicates a true primary infection with HSV.6 Thus, seroconversion for HSV-1 in the present case suggests primary infection with this virus and also substantiates the possibility of transmission of HSV from recent orogenital contact. The incidence of sexually acquired oropharyngeal herpes due to HSV may increase as a result of increased prevalence of orogenital sexual activity. Because of the risk of transmission of HSV from asymptomatic viral shedding, the prevalence of HSV carriage and shedding from the oropharynx of sexually active adults needs to be investigated. During counselling, the possibility of acquisition of HSV infection of the oropharyngeal cavity from the anogenital region, and vice versa, should be discussed. RANJANA RANI JARVIS B P GOORNEY Hope Hospital and Bolton Centre for Sexual Health