Is aggressive management of perianal ulcers in homosexual HIV-seropositive men justified?
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S L Schmitt1, S D Wexner, J J Nogueras
1Department of Colorectal Surgery, Cleveland Clinic Florida, Ft. Lauderdale 33309.
Insights
This study found that aggressive diagnosis and treatment, including medical and surgical options, successfully healed most perianal ulcers in men with HIV. Culture-based diagnostics were more effective for identifying ulcer causes.
Area of Science:
- Infectious Diseases
- Gastroenterology
- Immunology
Background:
- Perianal ulcers are a significant complication in individuals with Human Immunodeficiency Virus (HIV).
- Understanding the causes and effective treatments for these ulcers is crucial for patient management.
Purpose of the Study:
- To investigate the causes (etiology) of perianal ulcers in HIV-seropositive men.
- To determine the most effective diagnostic methods for these ulcers.
- To assess the healing rates and outcomes of various treatments.
Main Methods:
- A cohort of 26 HIV-seropositive homosexual or bisexual males with perianal ulcerations was studied.
- Diagnostic procedures included biopsies for microscopy and cultures.
- Patients received medical treatments (antivirals, antibiotics) and/or surgical interventions.
Main Results:
- Biopsies identified an immunoblastic lymphoma in one patient.
- Microbial cultures proved more effective than microscopy in identifying ulcer etiology.
- Overall healing occurred in 68% of patients, with 100% healing in those receiving surgical treatment.
Conclusions:
- Aggressive diagnostic approaches are essential for effective perianal ulcer management in HIV-positive individuals.
- A combination of medical and conservative surgical treatments can successfully heal the majority of these ulcers.
- Culture-based diagnostics offer superior etiological insights compared to microscopy.
Abstract:
A study was undertaken to assess the etiology, optimal diagnostic method, and incidence of healing of perianal ulcers in HIV-seropositive men. Between March 1990 and December 1991, 26 HIV-seropositive homosexual or bisexual males were referred with perianal ulcerations. According to CDC criteria, three (12 percent) were Class II, six (23 percent) were Class III, and 17 (65 percent) were Class IV. Eighteen patients had one ulcer, five had two ulcers, and two had three ulcers. In one patient the ulcer was circumanal. Patients with superficial erosions were not included. Biopsies were obtained in 23 patients for routine microscopy, HIV, cytomegalovirus, herpes simplex virus, and acid-fast bacilli. Biopsy revealed an immunoblastic lymphoma in one patient. A comparison of microscopy and culture results revealed culture to be more helpful in determining the etiology of these ulcers. Medical treatment included reverse transcriptase inhibitors (zidovudine, dideoxyinosine, and dideoxycytosine), oral and topical Zovirax (Burroughs Wellcome, Research Triangle Park, NC), ganciclovir, and oral broad-spectrum antibiotics. Surgical treatment included lateral internal sphincterotomy in three patients and seton placement in one patient. Follow-up for at least four weeks was obtained in 22 patients. Overall, healing occurred in 15 patients (68 percent): three (20 percent) were Class II, four (27 percent) were Class III, and eight (53 percent) were Class IV. Healing occurred in all four patients who underwent surgical treatment. In conclusion, aggressive diagnostic maneuvers allow the use of both medical and conservative surgical measures to successfully treat the majority of perianal ulcers in this patient population.