Decentralization brought no significant change to the health sector. Active panchayat support to PHCs existed in only a few places, but wherever it was present, the result was positive. Kerala should find an alternative strategy to channel panchayats towards health before health loses its battle for resources.

We are reporting a rare case of primary mucocutaneous histoplasmosis. A 47-year-old male with a part-time job of rearing pigeons presented with a non-healing oral ulcer with no associated systemic symptoms. Differential diagnosis of oral ulcerative lichen planus, squamous cell carcinoma and mucocutaneous leishmaniasis was considered. Histopathology showed multiple organisms with a peripheral halo, stained strongly with Gomori methenamine silver stain.

Background:Hirsutism is the presence of terminal hair in females in males pattern. It occurs in 5%–15% of women. Modified Ferriman–Gallwey (mFG) score of ≥ 8 is considered hirsutism, but there are populations with a low mFG score. In clinical practice, hirsutism is subjective. Although hirsutism is considered as a purely esthetic problem, it is associated with many underlying disorders, especially androgen excess disorders. Polycystic ovarian syndrome (PCOS) disease is the most common cause of androgen excess in females, and there are reports of its association with metabolic syndrome. Metabolic syndrome occurs alone in hirsutism.Aims:To assess mFG score in patients who consider themselves as hirsute. To study the association between metabolic syndrome and hirsutism.Methods:Hospital-based cross-sectional study design was adopted. A structured questionnaire was used to collect sociodemographic and clinical data. The severity of hirsutism was assessed using mFG score and metabolic syndrome was diagnosed by the American Heart Association criteria. mFG score was expressed as mean and Student's t-test and Chi-square statistic were used as the tests of significance. Logistic regression analysis was performed.Results:The mean mFG score was 5.5. Metabolic syndrome was present in 44%. About 65.2% of patients with score ≥8 had metabolic syndrome, whereas only 37.7% of patients with score <8 had metabolic syndrome (P = 0.019). Metabolic syndrome (P = 0.018) and PCOS (P = 0.003) were the significant variables in logistic regression analysis. Triglyceride levels ≥150 mg/dl and waist circumference ≥88 cm were the components of metabolic syndrome that were significantly associated with hirsutism (P = 0.006 in both).Conclusions:To find the ideal cutoff of mFG score to define hirsutism in our population, a population study among females in the reproductive age group has to be conducted. As there is a definite association of hirsutism and metabolic syndrome, and metabolic syndrome can result in cardiovascular complications, any women presenting with terminal hair in a male pattern should be evaluated for metabolic syndrome irrespective of the mFG score.

c l i n i c a l e p i d e m i o l o g y a n d g l o b a l h e a l t h 3 ( 2 0 1 5

A 39-year-old man presented with a chronic nonhealing toe ulcer and multiple skin-colored papules on the back, arms, and knees. From an initial small erosion, the toe lesion ulcerated over a 1.5-year period, while the papules progressed over a 6-month period, first appearing on the back and then spreading to the arms and knees. The past medical and family history were non-contributory. Pertinent findings included the aforementioned well-defined, asymmetric, shiny papules (Fig. 1). There were multiple, discrete, erythematous, pedunculated, tumor-like masses of various sizes over the right thigh (Fig. 2) and a well-defined 4 cm x 3 cm ulcer on the second toe of the left foot, the floor of which was covered by necrotic slough. There was distal loss of sensation to temperature, touch, and pain. The greater auricular, ulnar, radial cutaneous and common peroneal nerves were thickened bilaterally, but non-tender. A clinical diagnosis of histoid leprosy was made. The differential diagnosis for the tumor-like thigh masses included dermatofibroma, neurofibroma, and Kaposi's sarcoma. The hemogram, liver/renal function tests, chest X-ray, and abdominal ultrasound were normal. Human immunodeficiency virus enzyme-linked immunosorbent assay (HIV ELISA) was negative. The ear lobe smear (ELS) for acid-fast bacilli showed a bacterial index (BI) of 6+[> 1000 organisms/oil immersion field (oif)] and a morphological index (MI) of 50%. The skin-colored papules on the back and the pedunculated masses showed a BI of 5+ (100-1,000 organisms/oif) and an MI of 50%. The normal skin showed a BI of 4+ (10-100 organisms/oif) and an MI of 5%. Biopsy of the papules and pedunculated tumors showed a well-circumscribed area of the dermis packed with many acid-fast organisms and foamy macrophages, consistent with histoid leprosy (Fig. 3). Fite-Faraco stain demonstrated cells packed with lepra bacilli. A final diagnosis of lepromatous leprosy, histoid variant, was made. Dapsone, clofazimine, rifampicin, and, later, ofloxacin were started.

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A 36-year-old young male with multiple heterosexual contacts presented with bilateral inguinal bubo and the classical "sign of groove". A diagnosis of lymphogranuloma venereum (LGV) was made and a three-week course of doxycycline was given. Lack of response prompted us to investigate further. A biopsy of the bubo was consistent with non-Hodgkin's lymphoma (NHL). Immunohistochemistry of the lymph node done at the Regional Cancer Center (RCC), Trivandrum, confirmed the diagnosis as NHL of diffuse large B-cell type. The second patient, a 32-year-old male with two unprotected heterosexual contacts presented with a left-sided inguinal bubo of six weeks duration. An empirical course of doxycycline was given even though investigations did not reveal any STI. Lack of response prompted us to do a lymph node biopsy, which was consistent with NHL, which later with immunohistochemistry was confirmed as NHL, diffuse large cell type. We are reporting here that the "sign of groove" is not specific for LGV as thought earlier, but can occur in NHL also.

Background: Sexually transmitted infections (STIs) are a major public health problem in developing countries, and treatment with the right medicine at the right time is necessary to reduce transmission and improve sexual and reproductive health. Laboratory diagnosis has undergone changes in the recent years. The new generation tests are not cost-effective in resource-poor settings. Papanicolaou smear (Pap smear) of the cervix is a simple, quick, and inexpensive screening procedure for cervical cancer that can also give a clue to the presence of STIs. Methods: A hospital-based cross-sectional design with fifty patients was conducted studied. The initial diagnosis based on clinical findings and routine laboratory results was compared with the final diagnosis incorporating Pap smear results. Results: The Pap smear was abnormal in 96%, and the abnormalities were koilocytosis (30%), endocervicitis (24%), Trichomonas vaginalis (16%), multinucleated giant cells (10%), low-grade squamous intraepithelial lesion (10%), and clue cells (8%). Pap smear could diagnose an infection in 64%, of which 38% were asymptomatic. Clinical and Pap smear correlation was found only in 26% of the patients. Conclusion: Along with the conventional methods, Pap smear can be a valuable tool in diagnosing STIs. This can detect asymptomatic infections, not detected by conventional methods, thus preventing complications and further spread in the community. Asymptomatic human papillomavirus (HPV) infection and trichomoniasis are the two STIs that can be easily detected by Pap smear. By detecting asymptomatic cervical HPV infection, the patients at risk for carcinoma of the cervix can be identified and referred to gynecology department for further management.