PITFALLS OF AN OVERDEPENDENCE ON CLINICAL OBSERVATIONS IN VENEREOLOGY

By Major M. P. Vora

Maharashtra Medical Journal

Volume XXV: Number – 11 of February 1979.

Pages 413 to 417.

V enereal diseases are not a single entity but a melange of different diseases due to varied etiologies. They are characterised at times by an absence of discernible physical change, a wide spectrum of signs and symptoms and a lack of stereotyped clinical pattern. Thus so-called ‘classical case’ is the exception rather than the rule. They are not merely a just therapeutic or a social problem but also a continuing and varying problem with growing expansion. Their management has naturally assumed an increasing importance. It would be a serious mistake to ignore them. With high incidence, reaching epidemic proportions, one has to be constantly alert to think of them for differential diagnosis, in various complaints especially genital. No general practitioner can shirk off the responsibility for their early and precise diagnosis, proper treatment and control. For, there are and would be many venereal patients who prefer to be treated by their own private doctor, whose judgment and skills count immensely.

The hallmark of good medical services is not only the proper understanding of the problem but also a sound knowledge of the subject, proficiency in technical skills and procedures, a careful study of medico-social aspects, sympathetic attitude and human understanding. In spite of technical advances, one often comes across too often the physician, who is willing to diagnose or misdiagnose V.D. simply by relying on his clinical judgment. Such an over-dependence on clinical observations to the total neglect of proper technical procedures often leads to serious mistakes. It results in a waste of time, materials, unnecessary sufferings and irreparable disabilities, besides offering opportunities for spread of diseases. The proper approach to V.D. demands a careful attention to the history, detailed physical examination and tactful interrogation in strict privacy, appropriate laboratory tests, contact-tracing, proper and adequate therapy, followed by tests of cure. Some of these procedures are in fact extensions of the physical examination. However, all too often a therapy is ordered without the least attention to number of essential procedures such as laboratory tests to determine the exact etiology, contact-tracing and treating the source of infection and confirming the eradication if infection or ‘cure’. All too often he allows a negative laboratory report to be the decisive factor in his diagnosis. Obviously, the importance of establishing the precise diagnosis on which depends the appropriate treatment and applicability of inherent procedures is not realised.

Today, modern life in urban areas is a transient mass of migrant workers with changed attitudes and values, and sexual permissiveness; a fast world-wide travel, increasing tourism, call girls, good-time; young people with greater independence and freedom present increasing opportunities for sexual activities and rapid spread of V.D. The most important factor contributing to the present state of affairs has been a complete lack of awareness and better appreciation on the part of the doctor.

A few actual examples of an expensive dependence on clinical impressions and subsequent effects can be very convincing.

• A young man of 24 years had a small ulcer on the penis and was given an ointment, which gave him quick relief. After about a month, he developed an ulcer on the same spot. His doctor gave him an injection, some tablets and an ointment. The ulcer healed quickly. After a long interval of 6 to 7 years, one evening he felt weakness and numbness on the right side of his body. The next morning he woke up with a complete paralysis of his right side. Subsequent investigations confirmed syphilitic etiology of the cerebrovascular accident.

• A 35-year old man complained of growing difficulty in walking in darkness and increasing difficulty in seeing. He became totally blind in 4 months. He was diagnosed as a case of optic atrophy due to syphilis. On inquiry, he told that he had a small ulcer on the genital some 10 to 12 years ago after sex relation with a woman. He had then received an injection and a few pills from the doctor.

• After a month of her first delivery, a young woman complained of severe abdominal pain, and high fever. She was diagnosed as a case of an acute abdomen, requiring an immediate operation. On opening the abdomen, her ovaries and tubes were found to be acutely inflammed and were removed. The laboratory report confirmed gonococcal etiology. A conservative treatment with antibiotics could have given her complete relief, and the major operation and permanently imposed sterility could have been saved, had the doctor been more alert and screened her carefully.

Four other females aged 22 to 26, who had a similar complaint underwent an operation of laparotomy for peritonitis of gonococcal etiology. With a high index of suspicion, a careful history, clinical examination and proper screening, and a direct laparoscopy the correct diagnosis could have been arrived at and a major operation avoided.

• A young msn complained of itching and ulcers on the penis. He was diagnosed as a case of infected scabies and treated with tropical applications. After four weeks, he developed the skin rash obviously due to secondary syphilis. His blood showed a strong V.D.R.L. positivity.

• A 24-year male suffered from pain and purulent anal discharge. On clinical examination, an anal fistula and a fissure in ano were found. An operation of fistulectomy and fissurectomy was performed. Specimens showed Treponema pallidum and a positive blood serology for syphilis.

• A 35-year old man was given an operation for piles. Subsequent blood serology for syphilis was found to be positive.

• A 26-year old man had an ulcer on the right side of the anus and warty growths around the anus. The warty growths were treated surgically and a dressing was given for the ulcer and snipped areas around the anus. Blood serology for syphilis was found to be positive afterwards.

Actually, surgery has no place in the treatment of primary and secondary manifestations of syphilis at the ano-rectal site. In the above cases the correct diagnosis was either missed or not even considered and some of the cases underwent unnecessary surgery. Stories like these could be repeated number of times, anywhere and in all fields of medical practices for want of alertness and co-ordination in all branches of medicine. Such incidences happen often and at many places. All the patients could have been completely cured of their infections and permanent disabilities could have been prevented, if their real illness or exact etiology was properly judged and treated adequately before it was too late. This would have also minimised the spread of disease.

There are more than 60 million new cases yearly, who suffer from similar infections but most of these are being offered less than an adequate or incompetent medical care. This is the central and established fact in the modern era of medical technology and introduction of laboratory discipline.

A failure to make correct diagnosis may occur when the careful physical examination is entirely normal or when the primary sites of infection, modes of sexual practices, local and systemic complications and various manifestations of either syphilis or gonorrhoea are not taken into consideration. Since a classical book picture may not be always available, one has to be alert and think of these possibilities. With the history of exposure, any lesion either genital or extra-genital, typical or atypical, obvious or concealed should arouse a strong suspicion, make one think of the possibility of co-existence of a venereal disease, and prompt one to carry out appropriate laboratory tests either for the confirmation or the exclusion of V.D. Both syphilis and gonorrhoea can be asymptomatic or without a demonstrable physical findings and the precise diagnosis can only be established by the laboratory investigations. A failure to suspect a venereal disease and neglect to confirm or exclude it can have serious consequences. The anus and the rectum are common sites for V.D. So also are the mouth and the pharynx because of increasing orogenital sex contacts. Oralism (i.e. fellatio and cunnilingus) and ano-genitalism are not uncommon and in hetro- and homo-sexual practices.

In any ulcer in the genital area, one must consider first sexually transmitted diseases and rush for the immediate detection of the Treponema pallidum of syphilis. This being so, one must take into consideration the realities of human sexual behaviour including new tendencies in the present times and include them for a consideration within this group- ulcers found elsewhere particularly in the oral and anal region. Full history, careful clinical examination, laboratory investigations, tactful interrogation and the same type of investigations of the patients’ sexual contacts have to be carried out routinely with speed, consistency and thoroughness. If these basic and essential procedures cannot be possible, it would be wise for the doctor to refer the patient to a special clinic where adequate facilities for the necessary procedures and investigations are at hand and avoid prescribing drugs or topical application that may interfere with an early and precise diagnosis. In all cases of genital ulcers, the doctor’s first objective shall be to diagnose or exclude early syphilis- a sneak with far-reaching effects-and if it is found to be present, to stop its transmission by treating the disease safely and speedily. Steps must also be taken to trace sexual contacts and to induce them for a medical check-up and treatment. To these duties is added the responsibility to exclude other sexually transmitted diseases particularly gonorrhoea, chancroid, donovanosis and lymphogranuloma venerium.

It must be emphasised that the so-called typical appearance of the primary syphilitic chancre is illusory especially in the early stage and is likely to be modifies by inadequate treatment, secondary infection or co-existence of a dual disease. It is therefore risky to base diagnosis on the clinical expressions alone. A syphilitic chancre begins as a micropapule or ulcer and its precise diagnosis depends on the demonstration of a typical, living Treponema pallidum in the serum, taken from the lesion, after it is cleaned with isotonic saline. If the first dark-ground examination is unsuccessful, it should be repeated on three consecutive days; the blood serology for syphilis and physical examination should be carried out, at regular intervals, for a period of three months. If the ulcer is secondarily infected, and the regional lymph nodes are enlarged and painful, it is justifiable to prescribe sulphanilamide 2g initially, followed by 1g four times a day for 5 to 7 days, depending on the condition of the lymph nodes. This does not affect the recovery of germs of syphilis. The importance of withholding antiseptics or antibiotics for the genital ulcer until at least three dark-ground examinations are finished will be appreciated. When a chancre is encountered on the lip, in the mouth, at the anus or rectum, where non-pathogenic Treponemes are often present, the interpretation of the results of the dark-ground examination becomes rather difficult. In the homosexual male (passive agent) the primary sore may take the form of a slightly indurated fissure, leading to a mistaken diagnosis of a fissure in ano. At times, the primary sore may be situated on the inner surface prepuce or in the external meatus of the urethra in the male and on the cervix or the endocervix in the female and is likely to be missed on cursory or casual examination. A careful clinical examination of the lesion-whether hidden or obviously visible-is very important but is often neglected for want of privacy, time or unwillingness on the part of the patient.

In the secondary syphilis, a variety of skin rashes, generalised lymph node enlargement, moist lesions or papules in the mouth, on the genitalia and around the anus, pains in bones and seropositivity are noted. The large hypertrophic papules and condyloma latum tend to confine on the vulva in the female and in the anal region in both sexes. Maceration and secondary infection of the condyloma latum are common.

In the serologic tests for syphilis, V.D.R.L. a non-specific test, is highly sensitive but takes some time, usually 6 to 8 weeks after the infection and 2 to 4 weeks after the appearance of the primary sore, to develop positivity and becomes negative in about 4 to 5 months after the successful treatment of the early syphilis. In the case of a genital ulcer which is dark-ground negative for T. pallidum, repeated physical examination and V.D.R.L tests need to be performed over a period of three months as a routine before the exclusion of syphilis. The specific tests FTA-ABS, RPCF, FTA, and TPHA become positive earlier than the non-specific test, V.D.R.L. and remain so for a longer time than the V.D.R.L. Hence they are not of particular use in assessing the adequacy or efficacy of the treatment. They cannot be used for routine screening of large number of sera. None of these specific tests is affected by the treatment and persist positive for life-time.

Gonorrhoea

Burning while passing urine, urethral discharge and the vaginal discharge are symptoms of obscure origin. It is all easy to assume that they are due to gonorrhoea; however, the patient may mean something else. Unless the N. gonococcus is demonstrated in smear or cultures, they should not be classified as gonorrhoea. Hence the distinction gonorrhoea and other causes giving rise to similar signs and symptoms becomes of paramount importance. The primary sites of infection in the male can be the urethra, paraurethral ducts, Tyson’s ducts, anus or the pharynx. The primary sites of infection in the female can be Skene’s ducts, urethra, Bartholin’s duct, the cervix, the endocervix, anus or the pharynx. The samples of secretion and exudate from the sites are taken and smears and cultures on Thyer Martin or Stuart’s Transport medium are made and examined.

Gram-stained smear shows gram-negative intracellular diplococci. Oxidase reaction shows pale violet coloured colonies.

Sugar fermentation - Glucose is fermented but not maltose or saccharose.

Fluorescent test - Gonococci can be visualized in smears and cultures.

Blood test for syphilis is done over a period of three months to exclude syphilis.

Differential diagnosis - In the male, balanitis, Trichomonas vaginalis, candidosis, non-specific genital infection, Chlamydia, T-strain mycoplasma, Tric agent, chemical or traumatic urethritis, allergic urethritis, herpes virus hominis, bacterial other than gonococcus urethritis, cystitis, intraurethral chancre or venereal warts, etc. have to be considered. In the female, T-vaginalis, candidosis, non-specific genital infections, Chlamydia, foreign body, herpes virus hominis, venereal warts, condylomata lata, etc. needs consideration.

Chancroid

It is due to Ducrey Haemophilus bacillus; incubation period is 1 to 3 days. The ulcer is painful, bleeds easily, has irregular and undermined edges, autoinoculable, multiple lesions, soft base, painful and suppurative unilocular bubo. Good smear and culture in the first week are diagnostic.

Short intra and extracellular gram-negative bacilli.

Intra-dermal test:

Dark-ground examination for T. pallidum - persistently negative. Blood serology for syphilis - negative for 3 months.

Differential diagnosis:

Syphilitic chancre, secondary or tertiary syphilitic lesions, herpes genitalis, infected scabies and pediculosis, balanitis, infected warts, traumatic ulcer, chemical or infected dermatitis, Follicullitis, tubercular ulcer, insect bite, epithelioma, granuloma inguinale, primary lesion of lymphogranuloma venereum, Behcet’s syndrome, boil or furuncle cyst, lichen planus, lichen simplex, hydradenitis suppurativa, varicella, variola, molluscum contagiosa, erythema multiformi, psoriasis, scleroderma, lichen niditus, lichen sclerosis atrophicus, pemphigus, Bowen’s disease, Queyrat’s erythroplasia, Leucoplakia, Balanitis xerotica, acne agminata, epidermosis bullosa, Filariasis, amoebic ulcer, self-infected ulcer, etc.