The inadequacy of standard treatment of dysplasias in a woman with acquired immune deficiency syndrome

International Journal of Gynecology & Obstetrics 47 (1994) 273-274

Case report

The inadequacy of standard treatment of dysplasias in a woman with acquired immune deficiency syndrome G. Del Priore*a, ‘Department

M.J. Leea, M. Barnesb, P. Garciab, M. Till’

of Obstetrics and Gynecology,

bDeparrment

The University of Rochester Rochester, NY.

of Obstetrics and Gynecology. Northwestern

‘Departmen

of Medicine.

Northwestern

Received 14 April 1994; revision received

University,

University.

Chicago, IL.

Chicago, IL.

USA

USA

USA

I August 1994: accepted I2 August 1994

Abstract

The current state of knowledge regarding the gynecologic care of HIV-infected women is in its infancy. Standard algorithms are not valid. We present an example of the inadequacy of routine surveillance and treatment methods in these patients. Practitioners should maintain a high index of suspicion for multifocal genital dysplasias and in-

dividualize patient follow-up and therapy. Keywords: HIV; Vulva; Vagina; Cervix; Dysplasia

1. Introduction

Women with HIV are thought to have unique manifestations of genital dysplasias. Despite the availability of information on other dermatologic manifestations of HIV disease, an on-line literature search on vulvar disorders in HIV(+) women did not identify any information on this specific topic [ 1,2]. Due to the paucity of objective guidance, gynecologists have no choice but to Corresponding author, The University of Rochester, Division of Gynecologic Oncology, 601 Elmwood Avenue, Box 668, l

Rochester, N.Y. 14642, USA. Tel.: +I 716 2753186; Fax: +I 716 2731051.

apply standard algorithms developed for immune competent women to the HIV(+) patient. This report discusses the management of a woman with AIDS at the Prentice Women’s Hospital Infectious Disease clinic who demonstrated an unusually rapid clinical course. It highlights the inadequacy of current surveillance and treatment regimens based on standard clinical guidelines. 2. Case report The

patient

is a 42-year-old

asthmatic

with

heterosexually acquired AIDS and a CD4 count of 108 cells/mm’. Her medications included zidovudine and oral prednisone. She reported normal

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J. Gynecol. Obster. 47 (1994)

yearly Pap smears including one 3 weeks before presentation. As part of her initial visit at our clinic, another Pap smear was obtained. This was interpreted as ‘low grade squamous intraepithelial lesion, mild dysplasia.’ Five weeks later, a standard and satisfactory colposcopic examination was consistent with flat condyloma and mild dysplasia of the cervix and no gross cervical, vaginal or vulvar lesions were present. Two biopsies of the cervix were obtained and read as ‘HPV and mild dysplasia.’ One month later an electrosurgical loop excision procedure was performed along with a repeat colposcopy. Again, no cervical, vaginal, or vulvar lesions were noted. The excised cone tissue was read as ‘moderate dysplasia, CIN II with free margins.’ The patient was seen for follow-up 4 months later. At that time, two obvious vulvar lesions, each approximately 2 cm in diameter, at 1 and 6 o’clock were seen and both were biopsied. There were no other gross lesions on the cervix, in the vagina, or on the perineum at this time. The pathologic diagnosis was ‘severe vulvar intra-epithelial dysplasia, VIN III,’ and the repeat Pap smear returned as ‘LGSIL, mild dysplasia’. The patient was scheduled for laser treatment of her vulvar lesions 3 weeks later, at which time new and easily visible vaginal and cervical condyloma were noted and biopsied. In addition, a new perirectal lesion, approximately 6 cm in diameter, was identified and biopsied. Frozen and permanent sections from the perirectal lesion revealed ‘mild and severe dysplasia.’ The colposcopic impression of the cervix at this time was consistent with mild dysplasia and the vagina with HPV. Biopsies of the vaginal and cervical lesions were interpreted as ‘HPV’ and ‘mild dysplasia,’ respectively. The patient had a protracted recovery with delayed healing of the laser sites. These areas required intensive daily local care for recurrent in-

273-274

fections. Subsequent biopsies of the formerly treated areas of the vulva and perineum have again revealed carcinoma in situ. The patient is currently being treated with topical trichloroacetic acid to these areas. 3. Comment The use of standard treatment and follow-up algorithms documented the rapid recurrence of this patient’s cervical dysplasia as well as the emergence of multi-focal genital dysplasia in a relatively short interval. However the rapid progression of the patient’s lesions suggests that standard therapeutic algorithms may be inadequate for the gynecologic problems faced by women with AIDS. Such patients may require more frequent gynecologic assessments and individualized management until experience with the spectrum of their problems becomes available. Although specific surveillance regimens have yet to be established for HIV-infected women, colposcopy, vaginoscopy and vulvoscopy should be considered for these high risk patients. Of perhaps greater importance, practitioners should be cautious when recommending therapies that although considered standard, may not help immunosuppressed patients. Well designed trials must be conducted to determine the most appropriate diagnostic and therapeutic protocols for all gynecologic manifestations of HIV disease.

References Zalla

MJ,

Su

manifestations

WPD,

Fransway

AF.

tion. Mayo Clin Proc 1992; 67: 1089-l Covino JM, McCormack etiology

in a human

WM.

virus infec-

108.

Vulvar ulcer of unknown

immunodeficiency

women: Response to treatment Obstet Gynecol

Dermatologic

of human immunodeficiency

1990; 163: 116-I

virus-infected

with zidovudine. 18.

Am J