Co-infection of syphilis and gonorrhea: Double Venus's curse on a homosexual male.

Sir,

Sexually transmitted co-infections are common among female sex workers, men having sex with men (MSM) and injectable drug users owing to their high-risk sexual behavior. Such multiple coexisting sexually transmitted infections (STIs), particularly ulcerative STIs increase the risk of acquiring HIV infection by manifold.[1]

A 21-year-old male presented to our outpatient department with a painless genital ulcer of 10 days duration and copious urethral discharge associated with dysuria for 5 days. Patient gave a history of oro-insertive and ano-insertive sex with many male partners in the previous 1-month. Examination of genitalia revealed a single well defined nontender indurated ulcer of size 2 cm over corona glandis. Urethral meatus was found to be inflamed along with copious nonfoul smelling purulent discharge [Figure 1]. Right sided firm nontender inguinal lymphadenopathy was present. Examination of skin, oral cavity and other systems were normal.

Figure 1

Primary chancre indicated by white arrow and urethral discharge indicated by red arrow

The venereal disease research laboratory test was reactive in 1:4 dilutions at the time of presentation. Subsequently, the diagnosis was confirmed with a positive Syphicheck. Gram stained smear of urethral discharge showed multiple intracellular Gram-negative diplococci and pus cultured showed gonococcal growth. Chlamydial polymerase chain reaction done from the urethral discharge was also negative. Serological tests for HIV, HSV-2, and hepatitis B surface antigen were negative. Patient was given syndromic treatment according to NACO guidelines. Urethral discharge completely resolved in 3 days and the ulcer resolved in a week, after treatment.

John Hunter's claim that syphilis and gonorrhea were one disease caused by a common pathogen was based on his erroneous and controversial, supposedly self-inoculation experiment (1767). Unfortunately, the inoculated pus material was obtained from a patient who probably had a co-infection of syphilis and gonorrhea. His claim remained unchallenged for many years because of his authority and reputation in the field of medicine, before Philippe Ricord could successfully disprove it (1838).[2] Such a combination of sexually transmitted co-infections is rarely reported these days.

In this case the patient reported to have had multiple sexual contacts with many unknown males in the previous month and had indulged in ano-insertive and oro-insertive acts each time. Considering the incubation period of syphilis and gonorrhoea, and the order of appearance of symptoms, it is likely that he had acquired these infections from different sources.

The exact prevalence of various STIs among MSM in India is not known.[3] MSM have high rates of HIV and sexually transmitted diseases compared with demographically matched controls.[4] STI rates among MSM are on the increase. Individual high-risk behaviors such as higher number of lifetime sex partners, high rates of partner change, unprotected sex and anal intercourse are contributory factors. Prevalence of various STIs was significantly higher among HIV-positive MSM than HIV-negative MSM. Various coexisting STIs are thus a strong risk factor for acquiring HIV among MSM.[5]

All these facts reiterate the importance of routine screening of all possible STIs using appropriate tests in high-risk individuals. Such a rare combination of STIs coexisting in this case is an evidence for very high prevalence of STIs among MSM and the role of high-risk sexual practices in transmitting STIs among them.

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