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Case of the Month - September 2014

Frans Radebe. National Institute of Communicable Diseases

A 29-year ago man presented at a dedicated sexually transmitted infections (STI) clinic in Johannesburg complaining of genital sores that started as small blisters on the penis that started spontaneously three weeks previously. He had the same sores in the past, which healed without treatment. He was seen by a private GP and treated with fluconazole, doxycycline and ceftriaxone but the symptoms persisted. On clinical examination he had septic ulceration of the glans penis with tenderness on palpitation without any discharge.

The patient was HIV positive with CD4 T cell count of 306 cells/mm3. He was ART-naive. He was treated syndromically according to genital ulcer treatment algorithms with benzathine penicillin IM, 2.4 MU, oral erythromycin 500mg 6 hourly for 7 days, and oral acyclovir 400mg 8 hourly for 7 days.

Samples were collected from the patient following the collection of brief demographic data and consent. These included a genital swab from the ulcer for multiplex PCR, and a blood sample for syphilis serology (RPR and TPPA).

The M-PCR for genital ulceration picks up HSV-1 and -2, Treponema pallidum, Haemophilus ducreyi, and Chlamydia trachomatis serovars L1-3. The patient was positive for HSV-2, TPPA was positive at a titre of 1:80, and RPR negative.

Question 1: What is the natural history, pathogenesis and clinical features of herpes virus infections?

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