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Letters to the Editor H u m a n immunodeficiency virus infection acquired in Thailand
Accepted for publication 8 December I989 Sir, T h e transmission of the human immunodeficiency virus in certain developing countries has been the subject of much debate. Where H I V infection is endemic amongst heterosexuals, such as in central Africa, it is known that a previous history of sexually transmitted disease, and in particular genital ulcer disease, is often associated with H I V infection. 1 We have recently seen such a case which highlights this problem. A 34-year-old British heterosexual male caucasian lived and worked in Thailand for 5 years. During this period he had frequent penetrative vaginal intercourse with female prostitutes predominantly from Bangkok. H e rarely used a condom. In I986 he was treated for urethral gonorrhoea and approximately 6 months later developed an episode of acute painful genital ulceration which was treated with oral erythromycin, following which the ulcers have not recurred. On his recent return to England he requested a full check-up for sexually transmitted diseases. H e gave no history of having received blood products or of intravenous drug misuse, and although he had visited Zambia in I975 there was no history of sexual contact there. Physical examination at the time revealed a wellnourished man with folliculitis of the chest and upper arms, seborrhoeic dermatitis and angular stomatitis. Serological tests for Syphilis were negative, as were urethral cultures for Neisseria gonorrhoea. Hepatitis B core antibody was detected indicating previous exposure to the virus, but Hepatitis B surface antigen was not found. H I V T y p e I antibody was detected by three different tests; competitive (Wellcome) and direct binding (Abbott) E L I S A s using recombinant antigen, and a particle agglutination test (Serodia) using cell-grown antigen. Serum H I V p24 antigen was also detected by E L I S A (Abbott), and confirmed by neutralisation. His T 4 L y m p h o c y t e count was 0"4 × (IO9/1). After follow-up for I2 months he remains reasonably well despite refusing antiretroviral chemotherapy. His cutaneous manifestations are under control with topical anti-fungal agents and no opportunistic infections have developed. We believe this man acquired his H I V Infection from a Thai prostitute and that the presence of genital ulcer disease at the time, which was presumed to be chancroid, may have facilitated transmission of the virus. Chancroid is a particularly common sexually transmitted disease in Thailand and a major cause of genital ulceration. It is particularly common amongst prostitutesfl and its impact on the spread of H I V infection has already been recognised. 2 A proposed mechanism for retroviral transmission is that an increased pool of macrophages and lymphocytes associated with genital ulcers act as target cells for H I V thus enhancing its transmission during sexual intercourse. 4 We feel that Thailand, like central Africa and the Americas, should be regarded as a 'high risk area' which poses a serious risk to sexually active overseas visitors there.
Department of Genito-Urinary Medicine, Hope Hospital, Salford, M6 8HD, U.K. Public Health Laboratory Service, Withington Hospital, Manchester, M2o 8LR, U.K.
B.P. Goorney
J. Craske .4. J. L. Turner
Letters to the Editor
26 5
References I. Simonsen JN, Cameron DW, Gakinya MN et al. HIV infection among men with sexually transmitted diseases. NEJM; 319 (5): 274-278. 2. Waugh MA. Chancroid and HIV. Br MedJ 1989; 298: 321. 3. Mindel A. Chancroid. Br MedJ 1989; 298: 64-65. 4- Piot P, Laga M. Genital ulcers, other sexually transmitted diseases, and the sexual transmission of HIV. Br Med J 1989; 298: 623-624.
An u n u s u a l p r e s e n t a t i o n o f s a l m o n e l l a i n f e c t i o n Accepted for publication 18 December 1989 Sir, Although salmonella bone infection is known to occur in patients with sickle cell disease it is very rare in individuals who are otherwise healthy. We describe such a case. A 55-year-old Caucasian male first presented to his doctor with anterior chest pain in 1987. At that time all investigations were negative. H e presented again in October of the same year with a swelling over the manubriosternal junction which he thought had developed during the previous 2 to 3 months. Although there was a small area of erythema and scaling of the skin, there had never been any discharge, nor was there significant pain or tenderness to suggest an acute infection. His doctor prescribed flucloxaciUin for 28 days but the condition did not improve. W h e n first seen by a Consultant Orthopaedic Surgeon in January 1988 there was a firm diffuse swelling, tender but not fluctuant, over the u p p e r part of the sternum. T h e r e was no tenderness over the spine and no pain on compression of the body of the sternum or rib cage. Review of previous X-rays suggested periosteal reaction at the manubriosternal junction with a suggestion of substernal soft tissue thickening. A further X - r a y of the sternum and chest now showed the same sort of localised reaction in the manubriosternal join region as before. T h e r e was no increase in the shadowing within the chest substernally and no expansion or destruction of the sternum or m a n u b r i u m . H e was advised to continue with flucloxacillin. H e was seen again z weeks later because he felt ill and the swelling was more inflamed. On examination there was a large area of inflammation with a suggestion of fluctuation. A minute amount of pus was aspirated which was sent for microscopy, culture, including AFB, and antibiotic susceptibility tests. Salmonella brandenburg sensitive to amoxycillin, co-trimoxazole, chloramphenicol and ciprofloxacin was isolated. T h e patient was treated with amoxycillin 5o0 mg t.d.s, for 3 weeks after which, on examination, there was less swelling, erythema and tenderness. T h e dose was reduced to 25o m g t.d.s, for a further 6 weeks, at the end of which time he had completely recovered. Although the patient did not give any history of diarrhoea or of travel abroad, it is possible that he carried this salmonella in his gut before haematogenous spread occurred. A stool culture sent after salmonella had been isolated from the abscess was however negative. Salmonella bone infection in patients with sickle cell disease is well known. 1 M o r e o v e r Salmonella paratyphi A has been isolated from bone m a r r o w alone when the organisms were sequestrated there following inappropriate antibiotic therapy in a patient returning f r o m abroad with pyrexia of unknown originfl Infection of the
Letters to the Editor H u m a n immunodeficiency virus infection acquired in Thailand
Accepted for publication 8 December I989 Sir, T h e transmission of the human immunodeficiency virus in certain developing countries has been the subject of much debate. Where H I V infection is endemic amongst heterosexuals, such as in central Africa, it is known that a previous history of sexually transmitted disease, and in particular genital ulcer disease, is often associated with H I V infection. 1 We have recently seen such a case which highlights this problem. A 34-year-old British heterosexual male caucasian lived and worked in Thailand for 5 years. During this period he had frequent penetrative vaginal intercourse with female prostitutes predominantly from Bangkok. H e rarely used a condom. In I986 he was treated for urethral gonorrhoea and approximately 6 months later developed an episode of acute painful genital ulceration which was treated with oral erythromycin, following which the ulcers have not recurred. On his recent return to England he requested a full check-up for sexually transmitted diseases. H e gave no history of having received blood products or of intravenous drug misuse, and although he had visited Zambia in I975 there was no history of sexual contact there. Physical examination at the time revealed a wellnourished man with folliculitis of the chest and upper arms, seborrhoeic dermatitis and angular stomatitis. Serological tests for Syphilis were negative, as were urethral cultures for Neisseria gonorrhoea. Hepatitis B core antibody was detected indicating previous exposure to the virus, but Hepatitis B surface antigen was not found. H I V T y p e I antibody was detected by three different tests; competitive (Wellcome) and direct binding (Abbott) E L I S A s using recombinant antigen, and a particle agglutination test (Serodia) using cell-grown antigen. Serum H I V p24 antigen was also detected by E L I S A (Abbott), and confirmed by neutralisation. His T 4 L y m p h o c y t e count was 0"4 × (IO9/1). After follow-up for I2 months he remains reasonably well despite refusing antiretroviral chemotherapy. His cutaneous manifestations are under control with topical anti-fungal agents and no opportunistic infections have developed. We believe this man acquired his H I V Infection from a Thai prostitute and that the presence of genital ulcer disease at the time, which was presumed to be chancroid, may have facilitated transmission of the virus. Chancroid is a particularly common sexually transmitted disease in Thailand and a major cause of genital ulceration. It is particularly common amongst prostitutesfl and its impact on the spread of H I V infection has already been recognised. 2 A proposed mechanism for retroviral transmission is that an increased pool of macrophages and lymphocytes associated with genital ulcers act as target cells for H I V thus enhancing its transmission during sexual intercourse. 4 We feel that Thailand, like central Africa and the Americas, should be regarded as a 'high risk area' which poses a serious risk to sexually active overseas visitors there.
Department of Genito-Urinary Medicine, Hope Hospital, Salford, M6 8HD, U.K. Public Health Laboratory Service, Withington Hospital, Manchester, M2o 8LR, U.K.
B.P. Goorney
J. Craske .4. J. L. Turner
Letters to the Editor
26 5
References I. Simonsen JN, Cameron DW, Gakinya MN et al. HIV infection among men with sexually transmitted diseases. NEJM; 319 (5): 274-278. 2. Waugh MA. Chancroid and HIV. Br MedJ 1989; 298: 321. 3. Mindel A. Chancroid. Br MedJ 1989; 298: 64-65. 4- Piot P, Laga M. Genital ulcers, other sexually transmitted diseases, and the sexual transmission of HIV. Br Med J 1989; 298: 623-624.
An u n u s u a l p r e s e n t a t i o n o f s a l m o n e l l a i n f e c t i o n Accepted for publication 18 December 1989 Sir, Although salmonella bone infection is known to occur in patients with sickle cell disease it is very rare in individuals who are otherwise healthy. We describe such a case. A 55-year-old Caucasian male first presented to his doctor with anterior chest pain in 1987. At that time all investigations were negative. H e presented again in October of the same year with a swelling over the manubriosternal junction which he thought had developed during the previous 2 to 3 months. Although there was a small area of erythema and scaling of the skin, there had never been any discharge, nor was there significant pain or tenderness to suggest an acute infection. His doctor prescribed flucloxaciUin for 28 days but the condition did not improve. W h e n first seen by a Consultant Orthopaedic Surgeon in January 1988 there was a firm diffuse swelling, tender but not fluctuant, over the u p p e r part of the sternum. T h e r e was no tenderness over the spine and no pain on compression of the body of the sternum or rib cage. Review of previous X-rays suggested periosteal reaction at the manubriosternal junction with a suggestion of substernal soft tissue thickening. A further X - r a y of the sternum and chest now showed the same sort of localised reaction in the manubriosternal join region as before. T h e r e was no increase in the shadowing within the chest substernally and no expansion or destruction of the sternum or m a n u b r i u m . H e was advised to continue with flucloxacillin. H e was seen again z weeks later because he felt ill and the swelling was more inflamed. On examination there was a large area of inflammation with a suggestion of fluctuation. A minute amount of pus was aspirated which was sent for microscopy, culture, including AFB, and antibiotic susceptibility tests. Salmonella brandenburg sensitive to amoxycillin, co-trimoxazole, chloramphenicol and ciprofloxacin was isolated. T h e patient was treated with amoxycillin 5o0 mg t.d.s, for 3 weeks after which, on examination, there was less swelling, erythema and tenderness. T h e dose was reduced to 25o m g t.d.s, for a further 6 weeks, at the end of which time he had completely recovered. Although the patient did not give any history of diarrhoea or of travel abroad, it is possible that he carried this salmonella in his gut before haematogenous spread occurred. A stool culture sent after salmonella had been isolated from the abscess was however negative. Salmonella bone infection in patients with sickle cell disease is well known. 1 M o r e o v e r Salmonella paratyphi A has been isolated from bone m a r r o w alone when the organisms were sequestrated there following inappropriate antibiotic therapy in a patient returning f r o m abroad with pyrexia of unknown originfl Infection of the
