CORRESPONDENCE
HIV TESTING IN WOMEN WITH VAGINAL CANDIDIASIS To the Editor: Sadly, the specter of human immunodeficiency virus (HIV) infection looms over ever more clinical situations, and the article by Imam et al [1] is most helpful in drawing our attention to the special concerns of female patients. In making r e c o m m e n d a t i o n s a b o u t H I V testing of women, however, they imply that a first episode of candidal vaginosis ought tb p r o m p t routine HIV testing. I do not believe their data can be construed to support this, and the costs nationwide, both financially and emotionally, would be enormous. Testing in women with new-onset recurrent disease, as they suggest, may be more appropriate.
more careful analysis by the patient of possible risk factors during the past decade. Probably most N o r t h American women will not find it appropriate to have HIV testing after a single episode of non-antibiotic-associated vaginal candidiasis. Those women, however, who choose testing after such an episode will presumably be a self-selected group at greater than average risk for HIV infection; some members of this group may benefit greatly from early diagnosis and management of asymptomatic HIV infection. We believe that the cost of offering HIV testing routinely under these circumstances will be small relative to the benefits gained by individuals in whom HIV infection is recognized at an early stage.
DEL J. DEHART, M.D.
NAIYER IMAM, M.D. KENNETH H. MAYER, M.D. AL VAN FISHER, M.D. CHARLES C.J. CARPENTER, M.D. MICHAEL STEIN, M.D. STEPHANIE B. DANFORTH, R.N.
Bowman-Gray School of Medicine Winston-Salem, North Carolina 1. Imam N, Carpenter CCJ, Mayer KH, Fisher h, Stein M, Danforth SB. Hierarchical pattern of mucosal candida infections in HIV-seropositive women. Am J Med 1990; 89: 142-6.
Brown University Providence, Rhode Island
Submitted August 28, 1990, and accepted November 19, 1990
The Reply: We appreciate the thoughtful comments by Dr. DeHart in regard to our recent article on mucosal infections in HIV-positive women. We did not intend to imply that a first episode of vaginal candidiasis should prompt routine HIV testing, but rather that it prompt candid discussion with the patient of the possibility of underlying HIV infection. The article states that, in this setting, HIV testing with pre- and posttest counseling should be offered routinely and carried out when appropriate. We have found that offering HIV testing under, these circumstances often leads to a 536
EXTRACEPHALIC MANIFESTATIONS OF GIANT CELL ARTERITIS To the Editor: Reich et al [1] described extraocular and extracephalic complications of giant cell arteritis (GCA). They have performed a great service by bringing together most neurologic m a n i f e s t a t i o n s of GCA. I would like to add other extracephalic and extraocular manifestations of GCA not mentioned in their review article. Extracephalic GCA occurs in about 10% to 15% of patients with temporal arteritis, with the aorta and its branches being most often involved [2]. GCA in the aorta and its branches is encountered in 1.4% to 1.7% of unselected sub-
April1991 The AmericanJournalof Medicine Volume90
jects at autopsy [3]. Granulomatous giant cell aortitis may give rise to progressive aortic aneurysmat dilatation, aortic valve ring dilatation, and aortic regurgitation [2,4,5]. Occlusion of the coronary arteries by granulomatous GCA may lead to ischemic heart disease and myocardial infarction [2,3,6,7]. All these extracephalic c o m p l i c a t i o n s of GCA have a bearing on cerebral circulation and may result in cerebral ischemia and stroke. ALBERT C. CUETTER, M.D.
Texas Tech University Health Sciences Center El Paso, Texas 1. Reich KA, Giansiracusa DF, Strongwater SL. Neurologic manifestations of giant cell arteritis. Am J Med 1990: 89: 67-72. 2. Lie JT, Failoni DD, Davis DC. Temporal arteritis with giant cell aortitis, coronary arteritis, and myocardial infarction. Arch Pathol Lab Med 1986:110: 857-60. 3. Paulley JW. Coronary ischaemia and occlusion in giant cell (temporal) arteritis. Acta Med Scand 1980; 208: 257-63. 4. Klinkhoff AV, Reid GD, Moscovich M. Aortic regurgitation in giant cell arteritis. Arthritis Rheum 1985; 28: 582-5. 5. Bowles C, Hunder GG. Aortic valve involvement in temporal arteritis. Arthritis Rheum 1984; 27 (Suppl): S86. 6. Lie JT. Coronary vasculitis: a review in the current scheme of classification of vasculitis. Arch Pathol Lab Med 1987; 111: 224--33. 7.81och T, Waller BF, Vakili ST. Giant cell arteritis of the coronary arteries. Indiana Med 1987; 80: 2624. Submitted September 4, 1990, and accepted October 1, 1990
FLEXIBLE SIGMOIDOSCOPY FOR COLORECTAL NEOPLASIA To the Editor: The article by Gupta et al [1] on screening for colorectal carcinoma was of great interest to us. We have recently reviewed our experience in a university-based staff model health maintenance organization using 35-cm flexible sigmoidoscopy (35FS) [2]. We do believe effective screening can be
HIV TESTING IN WOMEN WITH VAGINAL CANDIDIASIS To the Editor: Sadly, the specter of human immunodeficiency virus (HIV) infection looms over ever more clinical situations, and the article by Imam et al [1] is most helpful in drawing our attention to the special concerns of female patients. In making r e c o m m e n d a t i o n s a b o u t H I V testing of women, however, they imply that a first episode of candidal vaginosis ought tb p r o m p t routine HIV testing. I do not believe their data can be construed to support this, and the costs nationwide, both financially and emotionally, would be enormous. Testing in women with new-onset recurrent disease, as they suggest, may be more appropriate.
more careful analysis by the patient of possible risk factors during the past decade. Probably most N o r t h American women will not find it appropriate to have HIV testing after a single episode of non-antibiotic-associated vaginal candidiasis. Those women, however, who choose testing after such an episode will presumably be a self-selected group at greater than average risk for HIV infection; some members of this group may benefit greatly from early diagnosis and management of asymptomatic HIV infection. We believe that the cost of offering HIV testing routinely under these circumstances will be small relative to the benefits gained by individuals in whom HIV infection is recognized at an early stage.
DEL J. DEHART, M.D.
NAIYER IMAM, M.D. KENNETH H. MAYER, M.D. AL VAN FISHER, M.D. CHARLES C.J. CARPENTER, M.D. MICHAEL STEIN, M.D. STEPHANIE B. DANFORTH, R.N.
Bowman-Gray School of Medicine Winston-Salem, North Carolina 1. Imam N, Carpenter CCJ, Mayer KH, Fisher h, Stein M, Danforth SB. Hierarchical pattern of mucosal candida infections in HIV-seropositive women. Am J Med 1990; 89: 142-6.
Brown University Providence, Rhode Island
Submitted August 28, 1990, and accepted November 19, 1990
The Reply: We appreciate the thoughtful comments by Dr. DeHart in regard to our recent article on mucosal infections in HIV-positive women. We did not intend to imply that a first episode of vaginal candidiasis should prompt routine HIV testing, but rather that it prompt candid discussion with the patient of the possibility of underlying HIV infection. The article states that, in this setting, HIV testing with pre- and posttest counseling should be offered routinely and carried out when appropriate. We have found that offering HIV testing under, these circumstances often leads to a 536
EXTRACEPHALIC MANIFESTATIONS OF GIANT CELL ARTERITIS To the Editor: Reich et al [1] described extraocular and extracephalic complications of giant cell arteritis (GCA). They have performed a great service by bringing together most neurologic m a n i f e s t a t i o n s of GCA. I would like to add other extracephalic and extraocular manifestations of GCA not mentioned in their review article. Extracephalic GCA occurs in about 10% to 15% of patients with temporal arteritis, with the aorta and its branches being most often involved [2]. GCA in the aorta and its branches is encountered in 1.4% to 1.7% of unselected sub-
April1991 The AmericanJournalof Medicine Volume90
jects at autopsy [3]. Granulomatous giant cell aortitis may give rise to progressive aortic aneurysmat dilatation, aortic valve ring dilatation, and aortic regurgitation [2,4,5]. Occlusion of the coronary arteries by granulomatous GCA may lead to ischemic heart disease and myocardial infarction [2,3,6,7]. All these extracephalic c o m p l i c a t i o n s of GCA have a bearing on cerebral circulation and may result in cerebral ischemia and stroke. ALBERT C. CUETTER, M.D.
Texas Tech University Health Sciences Center El Paso, Texas 1. Reich KA, Giansiracusa DF, Strongwater SL. Neurologic manifestations of giant cell arteritis. Am J Med 1990: 89: 67-72. 2. Lie JT, Failoni DD, Davis DC. Temporal arteritis with giant cell aortitis, coronary arteritis, and myocardial infarction. Arch Pathol Lab Med 1986:110: 857-60. 3. Paulley JW. Coronary ischaemia and occlusion in giant cell (temporal) arteritis. Acta Med Scand 1980; 208: 257-63. 4. Klinkhoff AV, Reid GD, Moscovich M. Aortic regurgitation in giant cell arteritis. Arthritis Rheum 1985; 28: 582-5. 5. Bowles C, Hunder GG. Aortic valve involvement in temporal arteritis. Arthritis Rheum 1984; 27 (Suppl): S86. 6. Lie JT. Coronary vasculitis: a review in the current scheme of classification of vasculitis. Arch Pathol Lab Med 1987; 111: 224--33. 7.81och T, Waller BF, Vakili ST. Giant cell arteritis of the coronary arteries. Indiana Med 1987; 80: 2624. Submitted September 4, 1990, and accepted October 1, 1990
FLEXIBLE SIGMOIDOSCOPY FOR COLORECTAL NEOPLASIA To the Editor: The article by Gupta et al [1] on screening for colorectal carcinoma was of great interest to us. We have recently reviewed our experience in a university-based staff model health maintenance organization using 35-cm flexible sigmoidoscopy (35FS) [2]. We do believe effective screening can be
