8/11/2019 Nej m Cpc 1400839

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case records of themassachusetts general hospital

T he n e w e n g l a n d j o u r n a l o f medicine

n engl j med 370;21 nejm.org may 22, 20142032

Founded byRichard C. CabotEric S. Rosenberg, m.d.,Editor Nancy Lee Harris, m.d., Editor

Jo-Anne O. Shepard, m.d.,Associate Editor Alice M. Cort, m.d.,Associate EditorSally H. Ebeling,Assistant Editor Emily K. McDonald,Assistant Editor

Rajesh T. Gandhi, m.d.,Guest Editor

From the BotswanaUPenn Partnership,Philadelphia and Gaborone, Botswana(D.R.-M.); the Department of Obstetricsand Gynecology, University of Pennsylvania,Philadelphia (D.R.-M.); the Departments ofRadiation Oncology (A.H.R., J.A.E.) andPathology (D.C.W.), Massachusetts Gen-eral Hospital, the Department of Medicine,Brigham and Womens Hospital (S.D.-P.),and the Departments of Radiation Oncol-

ogy (A.H.R., J.A.E.), Medicine (S.D.-P.),and Pathology (D.C.W.), Harvard MedicalSchool all in Boston; and the Depart-ment of Anatomical Pathology, NationalHealth Laboratory, and the Departmentof Pathology, University of Botswana both in Gaborone, Botswana (M.K.A.K.).

N Engl J Med 2014;370:2032-41.

DOI: 10.1056/NEJMcpc1400839

Copyright 2014 Massachusetts Medical Society.

Presentation of Case

Dr. Rajesh T. Gandhi(Medicine, MGH): A 46-year-old woman with human immuno-deficiency virus (HIV) infection was seen by a clinician in Botswana (working incollaboration with members of a Massachusetts General Hospital [MGH] outreachprogram) because of postcoital bleeding.

The patient had been generally well until 6 years before presentation, whenweight loss and pelvic pain developed and she requested HIV testing at a govern-ment clinic. HIV-antibody testing was positive.

Four years 3 months before presentation, the CD4+ T-cell count was 193 cells percubic millimeter (Table 1), indicating that the patient was eligible for antiretroviraltreatment (ART) in Botswana. The white-cell count was 3400 cells per cubic milli-meter (reference range, 3900 to 8600), and the blood level of creatinine was 0.41 mgper deciliter (36 mol per liter; reference range, 0.45 to 0.81 mg per deciliter [40 to72 mol per liter]). Two months later, treatment with a combination of tenofovir,emtricitabine, and efavirenz was begun. At a follow-up appointment 1 month later,a gynecologic examination was performed to evaluate vaginal discharge, urinary fre-quency, and dysuria. Abnormalities were reported, and administration of a 10-daycourse of amoxicillin was begun. Pathological examination of the specimen obtainedduring a screening Papanicolaou (Pap) test revealed a low-grade squamous intra-epithelial lesion; however, the patient never received this result. Four months after

the initiation of ART, the CD4+ T-cell count had improved (Table 1).One month later (5 months after the initiation of ART), the patient again reporteddysuria; a course of nalidixic acid was administered. During the next 18 months, shecontinued to have recurrent pelvic pain, dysuria, and vaginal discharge. She soughtcare from traditional healers for these symptoms and postponed reporting thesymptoms to her medical caregivers and undergoing a repeat Pap test, since shebelieved that the traditional therapies would help; the symptoms did not improve.Approximately 13 months before this presentation, the patient reported vaginalpruritus. Speculum examination revealed white patches on the cervix, and a repeatPap test revealed a high-grade squamous intraepithelial lesion. One month later,

Case 16-2014: A 46-Year-Old Womanin Botswana with Postcoital Bleeding

Doreen Ramogola-Masire, M.D., Anthony H. Russell, M.D.,Scott Dryden-Peterson, M.D., Jason A. Efstathiou, M.D., D.Phil.,

Mukendi K.A. Kayembe, M.D., and David C. Wilbur, M.D.

The New England Journal of Medicine

Downloaded from nejm.org on September 16, 2014. For personal use only. No other uses without permission.

Copyright 2014 Massachusetts Medical Society. All rights reserved.

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case records of the massachusetts general hospital

n engl j med 370;21 nejm.org may 22, 2014 2033

on review of the test results, colposcopic exami-nation with biopsy was scheduled for the nextavailable appointment, which was 14 monthslater.

Approximately 10 months before this presen-tation, a small amount of vaginal bleeding re-portedly occurred each time the patient had

sexual intercourse; the patient was referred forgynecologic evaluation. One month before thispresentation, the complete blood count, the cre-atinine level, and tests of liver function werenormal; other results are shown in Table 1. Shereturned to the HIV clinic for evaluation.

The patient reported no dyspareunia. She hadundergone menarche at 15 years of age and f irsthad sexual intercourse after the age of 17 years,and she was gravida 7, para 5. Medications in-cluded tenofovir, emtricitabine, and efavirenz; shehad no known allergies. She lived in an urban

area in Botswana with her five children andtheir father (who was also receiving ART for HIVinfection). She did not smoke, drink alcohol, or useillicit drugs. She was employed periodically in asmall shop. There was no family history of cancer.

On examination, the abdomen was soft,without distention, rebound, or palpable masses.On pelvic examination, there were ulcers at theintroitus; a malodorous, fungating lesion, 6 cm by2 cm, on the right lateral vaginal wall, extendingfrom the fornix to the introitus, with minimalbleeding on contact; and a nodular cervix. The re-mainder of the general examination was normal.

Diagnostic procedures were performed.

Differential Diagnosis

Dr. Doreen Ramogola-Masire:This 46-year-old HIV-infected woman presented after 10 months ofrecurrent postcoital bleeding. Other symptomsincluded intermittent urinary frequency, dysuria,pelvic pain, vaginal discharge, and pruritus. Shehad had two Pap tests, 3 years apart, with the

results showing low-grade and high-grade squa-mous intraepithelial lesions. She had been receiv-ing treatment for HIV for approximately 4 years,with virologic suppression and good CD4+ T-cellrecovery.

Postcoital bleeding is defined as bleedingthat occurs during or after sexual intercoursenot related to menses, and the differential diag-nosis varies with age and menstrual status.Postcoital bleeding typically results from a sur-

Table1.

LaboratoryData.

Variable

Reference

Range*

4Yr3Mo

before

Presen-

tation

3Yr

9Mo

before

Presen-

tat

ion

3Yr3Mo

before

Presen-

tation

2Yr8Mo

before

Presen-

tation

1Yr8Mo

before

Presen-

tation

13Mo

before

Presen-

tation

6M

o

before

Pres

en-

tation

1Mo

before

Presen-

tation

CD4+T-cellcount(cells/mm

3)

4671603

193

281

249

308

373

330

352

483

HIVRNA(copies/ml)