title: Etiology of genital ulcer disease. A prospective study of 278 cases seen in an STD clinic in Paris.
abstract: OBJECTIVE
  The goal of this study was to identify the causes and factors associated with genital ulcer disease (GUD) among patients attending a sexually transmitted disease (STD) clinic in Paris.
  
  
  METHODS
  This study was a prospective investigation of GUD cases. Data were collected from 1995 to 2005. In each case, a Dark Field Examination (DFE), Gram stain, inoculation onto Thayer Martin agar, Columbia agar and chocolate agar with 1% isovitalex and 20% fetal calf serum, PCR Chlamydia trachomatis (Amplicor Roche), culture for herpes simplex virus (HSV) on MRC 5 cells and PCR HSV (Argene Biosoft) were obtained from the ulceration. First Catch Urine (FCU) PCR for Chlamydia trachomatis and syphilis, HIV, HSV, and HBV serologies were also performed.
  
  
  RESULTS
  A total 278 cases of GUD were investigated, 244 (88%) in men and 34 (12%) in women. Primary syphilis accounted for 98 cases (35%), genital herpes for 74 (27%), chancroid for 8 (3%), other infections for 12 (5%). In 91 (32%) patients, no identifiable microorganism was documented. Primary syphilis was more prevalent in MSMs (P < 0.0001), while genital herpes and chancroid were significantly associated with heterosexuality (both P < 0.0001). A high level of HIV infection (27%) was found, particularly in patients with primary syphilis (33%). In the univariate analysis, no statistical difference was found between syphilis and herpes according to clinical presentation, pain being the only item slightly more frequent in herpes (P = 0.06). In the multivariable model syphilis was associated with being MSM (OR: 51.3 [95% CI: 14.7-178.7], P < 0.001) and with an ulceration diameter >10 mm (OR: 9.2 [95% CI: 2.9-30.7], P < 0.001). Genital herpes was associated with HIV infection in the subgroup of MSWs (OR: 24.4 [2.4-247.7], P = 0.007). We did not find significant differences in the clinical presentation of the ulcers according to HIV status.
  
  
  CONCLUSIONS
  The profound changes of the epidemiology of GUD during the decade, due to disappearance of chancroid and reemergence of infectious syphilis have led to a new distribution of pathogens, genital herpes, primary syphilis and GUD from unknown origin, accounting each for one third of cases. No clinical characteristic is predictive of the etiology, underlining the importance of performing a thorough microbiologic evaluation. Close association with HIV is still a major public health problem.
authors.affiliation: Centre clinique et biologique des MST, Hôpital Saint-Louis AP-HP, 42 Rue Bichat, Paris, France.
authors.forename: Emilie
authors.initials: E
authors.lastname: Hope-Rapp
authors.forename: Vassili
authors.initials: V
authors.lastname: Anyfantakis
authors.forename: Sebastien
authors.initials: S
authors.lastname: Fouéré
authors.forename: Philippe
authors.initials: P
authors.lastname: Bonhomme
authors.forename: Jean B
authors.initials: JB
authors.lastname: Louison
authors.forename: Thibault Tandeau
authors.initials: TT
authors.lastname: de Marsac
authors.forename: Benedicte
authors.initials: B
authors.lastname: Chaine
authors.forename: Pascale
authors.initials: P
authors.lastname: Vallee
authors.forename: Isabelle
authors.initials: I
authors.lastname: Casin
authors.forename: Catherine
authors.initials: C
authors.lastname: Scieux
authors.forename: François
authors.initials: F
authors.lastname: Lassau
authors.forename: Michel
authors.initials: M
authors.lastname: Janier
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities; D002602:Chancroid / Q000453:epidemiology / Q000382:microbiology; D005260:Female; D005831:Genital Diseases, Female / Q000453:epidemiology / Q000209:etiology*; D005832:Genital Diseases, Male / Q000453:epidemiology / Q000209:etiology*; D006558:Herpes Genitalis / Q000453:epidemiology / Q000821:virology; D006801:Humans; D008219:Lymphogranuloma Venereum / Q000453:epidemiology / Q000382:microbiology; D008297:Male; D008875:Middle Aged; D010297:Paris / Q000453:epidemiology; D012749:Sexually Transmitted Diseases / Q000453:epidemiology / Q000209:etiology*; D013587:Syphilis / Q000453:epidemiology / Q000382:microbiology; D014456:Ulcer / Q000453:epidemiology / Q000209:etiology*; D055815:Young Adult