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Internal Warts and Associated Anal Diseases Are Common in Patients Attending a County HIV Clinic

Edelstein, Howard MD; Ritter, J. Trees MD

JAIDS Journal of Acquired Immune Deficiency Syndromes: August 1st, 2004 - Volume 36 - Issue 4 - p 989-990
Letters to the Editor

Highland General Hospital, Oakland, California

Reprints: Howard Edelstein, Adult Immunology Clinic, Highland General Hospital, 1411 East 31st Street, Oakland, CA 94602 (e-mail:

To the Editor:

Due to the high frequency of infection caused by papillomavirus and its potential serious sequelae, routine anal examination including anoscopy and anal Pap smears has been suggested for all HIV-seropositive patients. 1 However, due to limited resources, small numbers of available examiners, and other factors, many institutions such as ours are unable to follow these recommendations. In this letter, we report the results of anoscopy performed serially on male patients attending a county HIV clinic.

All HIV-seropositive males seen by the principal investigator at the Adult Immunology Clinic, Highland General Hospital (Oakland, CA), were offered entry into the study over a 6-month period during 2003–2004. Examination included visual external anal inspection, digital examination, and anoscopy. Most patients were receiving highly active antiretroviral therapy, and CD4 cell counts varied markedly.

Fifty-three patients were offered entry into the study, of whom only 2 deferred evaluation. Of the 51 patients who were evaluated, 13 (25%) were found to have internal anal disease. Of these patients, 3 were heterosexual, and 10 were bisexual or homosexual. Previous surgical intervention for internal warts had been performed on 3 patients. Ten patients were judged to have new internal disease, of whom 8 had both internal and external warts, 1 had internal warts only, and 1 had an anal polyp (evaluation in progress). Some of these patients had active or previous warts at other sites (face, penis), implicating autoinfection as a possible source of contagion.

Most patients were referred for surgical treatment of the internal warts, but those with limited disease were treated in the office. In addition to warts, 1 patient was found to have a chronic rectal fistula, and 1 had a severely dysplastic verrucous lesion with areas of carcinoma in situ in the stalk.

The high incidence of anal warts among HIV-seropositive patients (range, 3%–25%) has been well described in the literature. 2 Up to 78% of these patients also have internal disease. 2 The high incidence (25%) of internal warts and other diseases in our study and the presence of a malignant polyp in 1 of our subjects underscore the need for routine anoscopy. Despite limited resources, the rudimentary skills of anoscopy can be taught to most clinicians, particularly when examination is directed primarily toward detection of rectal polyps and warts.

On the basis of our findings, we suggest anal examination for all HIV-seropositive patients. Patients with a history of internal warts or active external warts or those who have unprotected sex should probably undergo yearly anoscopy, while those at lower risk could probably be evaluated every 3 to 5 years.

Howard Edelstein, MD

J. Trees Ritter, MD

Highland General Hospital, Oakland, California

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1. Palefsky JM, Holly EA, Ralson ML, et al. Anal squamous intraepithelial lesions in HIV-positive and HIV-negative homosexual and bisexual men. Prevalence and risk factors. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;17:320–326.
2. Vukasin P. Anal condyloma and HIV-associated anal disease. Surg Clin North Am. 2002; 82:1199–1211.
© 2004 Lippincott Williams & Wilkins, Inc.