CC BY
26
Comparison ofdinical, morphological and radiographic data enables to see a complete "picture" ofpathological process, whereas development and prediction of outcome can be assessed based on dynamical X-Ray and CT examinations, which accurately reflects morphological stages of pathological process and following clinical manifestations. (Fig. 7, 8).
Conclusions:
1. X-ray picture in the initial phase of interstitial pulmonary edema was identical in patients of both groups. With the progression of the pathological process of X-ray and CT picture in ARDS was characterized by diffuse consolidation of lung tissue more in dependent zones, posterior and basal segments, while in patients with cardiogenic edema changes were found mostly in central zone, with the presence of pleural effusion and dilation of heart (borders). Reticular changes were observed in the resolution phase ofARDS edema, whereas cardiogenic pulmonary edema was characterized by increase of venous type pulmonary pattern with peribronchovasal infiltration.
2. Dependence of obtained X-ray/radiographic and CT data from the dynamics of clinical manifestations and a particular disease which led to the development of the pathological process were identified. Patients of the first group were generally admitted with acute,
first time occuring pathology (sepsis, pancreatitis, interstitial pneumonia, massive bleeding), dynamics of clinical symptoms depended on the disease severity and the rate of development of processes in the body. Patients of the second group, as a rule, had a history of chronic diseases (coronary heart disease, hypertension, valvular heart disease), with a long history, hemodynamic changes, heart muscle restructuring, congestion in the pulmonary circulation.
3. Morphological process in membranogenic and cardiogenic pulmonary edemas had different mechanisms. ARDS was characterized by damage of interalveolar septum capillaries. Morphologically three stages were identified: the first stage- exudative (6-24 hours after causative agent's affect) stage was characterized by congestion in capillaries, exudation of high protein level hemorrhagic fluid into alveoli, and formation of hyaline membranes, the second stage- proliferative stage was characterized by regeneration of alveolar epithelium and organization offibrous exudates, the third stage — fibrous stage was characterized by scarring of pulmonary tissue. All above-mentioned signs were not present in cardiogenic pulmonary edema and fluid leakage into alveoli was related to damage of contractile function of cardiac muscle.
References:
1. Amosov V.I, Zolotnitskaya V. P. Experimental simulation of thromboembolism of pulmonary artery//Regional blood circulation and microcirculation, 2003; 3 (7): 54-57.
2. Ashbaugh D. G., Bigelow D. B., Petty T. L., Levine B. E. Acute respiratory distress syndrome in adults//Lancet. - 1967. - Vol. 2 - P. 319323.
3. Gritsan A. I., Kolesnichenko A. P. The importance of adult respiratory distress syndrome in the structure of acute surgical and somatic pathology//Actual problems of intensive care unit (Irkutsk). - 2001, 1-2 (8-9): 12-16.
4. Kassil V. L., Zolotokrylina E. S. Acute respiratory distress syndrome. - M.: Medicine, 2003. - 224 p.
5. Mistafin D. G. Respiratory distress-syndrome in patients with sepsis.//Clinical medicine. - M., 2000; 50-53.
6. Moroz V. V., Golubev A. M. Principles of diagnosis of acute lung damage's early manifestations//General reanimatology, 2006; 5-7.
7. Murray J. P., Matthay M. A., Luce J. M. et al. An expanded definition of adult respiratory distress syndrome//Amer. Rev. Respir. Dis. -1988. - Vol. 138, N3. - P. 720-733.
8. Prokop M., Galanski M. Spiral and Multislice computed tomography: 2-volume study guide/Transl. from English; Editors: Zuba-reva A. V., Shotemor S.Sh. - M.: MED-press-inform, 2006-2007.
9. Timofeev I. V. Pathology of treatment. - Saint-Petersburg, 1999.-655.
10. Vlasov P. V. X-ray aspects of acute respiratory lung failure syndromes: Scientific publications//Medical visualization. - M, 2006; 50-61.
Irsalieva Fatima Khusnutdinovn, National Specialized Scientific Center of Allergology, Tashkent Kamalov Zaynitdin Sayfutdinovich, Institute of Immunology Academy of Sciences of the Republic of Uzbekistan E-mail: [email protected]
Immune status parameters and prognosis of the efficiency of allergen-specific immunotherapy in patients with persistent allergic rhinitis
Absrtact: The dynamics of the immunologic status parameters in 62 patients with persistent allergic rhinitis (PAR), who received the complete course of allergen specific immunotherapy (ASIT) was studied. Monitoring of the level of immunologic parameters was carried out before immunocorrecting therapy and upon completing ASIT course. ASIT efficiency in patients with PAR is characterized by high initial level of immunological parameters CD3+; CD4+; CD8+ and IgG and change in concentration of IL-4, IL-6, IL-8 in blood at the early stages of treatment.
Keywords: lymphocytes, immunocompetent cells, allergen specific immunotherapy, persistent allergic rhinitis, cytokines, interleykins.
Principal method of allergic diseases treatment, based upon gen-specific immunotherapy (ASIT) [8; 9]. This is the most bio-1st type allergic reaction, including grass pollen allergy, is aller- logically justified method of allergy treatment, aimed at switch
of IgE — response to a "symptom-free" method of the allergen recognition and inactivation by way of artificial increase in antigenic load [3; 5].
Allergen-specific immunotherapy (ASIT) is the only method of treatment of IgE-mediated diseases, which is able to change natural development of atopic process. At the same time information about early changes in immunological reactivity in course ofASIT in addition to contribution to understanding mechanisms of its efficiency can promote prognosticating therapy results, choice of its most optimal variant, or, vice versa, to be a predictor of inexpediency of the method of treatment of a particular patient.
The aim of this research was determined by the peculiarities of change of immunological indicators in blood serum in patients with persistent allergic rhinitis (PAR) during ASIT.
Therapy efficiency has been evaluated according to the Duch-aine five-grade scale (1955) upon completion of complete ASIT course as "excellent" in case of complete disappearance of symptoms or insignificant nasal events and nasal discomfort during contact with allergen; result of treatment was evaluated as "good" in case of preservation of episodic AR symptoms; "satisfactory" effect — preservation of persistent AR symptoms, though less expressed as before treatment: "unsatisfactory" — the result of the treatment, when patient's condition remained unchanged or became worse.
Monitoring of the immunologic parameters level was performed before starting immunocorrecting therapy and upon ASIT completion. It included detection of membrane antigens of lymphocytes in peripheral blood by way of immunophenotyping (CD3+, CD4+, CD8+, CD16+, CD20+, CD23+, CD95+) with application of monoclonal antibodies (PJSC "Sorbent", Russia). For quantification of the total IgE content "IgE- ELISA-Best-strip" (CJSC "Vector-Best", Russia) was used. Cytokines concentration (IL-4, IL-6, IL-8) was determined by the method of enzyme-linked immunoelectro-diffusion assays (LLC "Cytokin" St. Petersburg, Russia). Dynamics of the level of immunological parameters in serum was evaluated differentially in groups with good/excellent and satisfactory/unsatisfactory effect of the complete ASIT course.
Material was statistically processed with the help of "STATIS-TICA6.0" software, quantitative characteristic of the indicator in case of normal distribution was performed with the help of arithmetic mean (M) and standard deviation (s); in case of distribution, different from the normal, median value with interquartile range (Me (Q2-Q3)) was used; Mann-Whitney test criteria (for related groups) and Wilcoxon test criteria (for unrelated groups) have been employed for evaluation of reliability of differences between groups.
Results and discussion. ASIT is the only method of treatment of IgE-dependent diseases, allowing changing the natural development of atopic process. ASIT mechanisms are multiple and dynamical and theoretically lead to such rearrangement of immunologic reactivity of the patient, in case of which tolerance to challenging
Materials and methods. The research was carried out in the design of prospective cohort study in 62 patients in the age of 1840 years, suffering from moderate PAR in course ofASIT.
Inclusion criteria: presence of confirmed PAR diagnosis according to international standards ARIA [1] with duration of acute stage of not less than 120 days a year; age 18-40 years (30,5±2,8 years); clinical (including pharmacological remission of the disease at the time ofinclusion to the study); confirmed sensibilization to pollen and/or domestic allergens; presence of informed consent of the parents.
Exclusion criteria: presence of contraindications for ASIT; previously performed ASIT; immunomodulating therapy during last 6 months; presence of non-allergic pathology of ENT organs.
The patients, included to the study, received out-patient variant of ASIT according to the scheme, provided in Table 1 [2].
dose of the allergen is induced. Clinically successful ASIT is associated with induction of Th1-profile of CD4+-lymphocytes (level A); induction of immunological tolerance, determined by relative decrease of allergen specific reactivity and suppression of CD4+, CD25+- regulatory T-lymphocytes (level A). ASIT efficiency does not depend on the level of decrease of allergen-specific IgE (level A), and the increase of allergen-specific IgG titre is not a predictor of ASIT duration and the level of its efficiency (level A). At the same time the vast majority of researchers describe only final changes in immune status values, induced by prolonged administration of allergen dose, which sufficiently exceeds the same in case of natural exposure. Despite the fact it should be taken into account that the character of immunological reactivity of the patient against the background of ASIT depends on the number of factors, including allergen dose administered and changes in course of treatment [10; 15]. The possibility ofvarious sensitivity of patients to low doses of allergen and other factors, which can determine the character of immunological reactivity to ASIT and further influence its efficiency, are also to be taken into account.
Prognosis of allergen-specific immunotherapy prognosis is an important factor to guarantee the quality of treatment of patient with grass pollen allergy and elaboration of criteria, possible methods and courses of allergen-specific immunotherapy continuation.
Analysis of PAR clinical symptoms upon completion of the complete ASIT course showed that "good" or "excellent" effect of treatment was achieved in 62,9% (in 39 out of 62) patients, and in 37,1% (in 23 out of 62) it was qualified as "satisfactory".
Clinical and allergological examination of patients with effective and ineffective ASIT revealed a number of factors, providing negative influence upon treatment results. The information on comparative characteristics of efficiency and inefficiency of ASIT are given in table 2, from which it can be seen that patients with ineffective ASIT were older (p<0,05) and had severe course of the disease (p<0,05), greater intensity of clinical manifestations (p<0,05), frequency and duration (p<0,05) of acute phases, greater frequency
Table 1. — Scheme of ASIT performance
Allergen dilution Allergen dose, ml (in 1 ml-10000 PNU) Frequency of administration
1:10 000 0000 0,1-0,3-0,5 Every day
1:1 000 000 0,1-0,3-0,5 Every day
1:100 000 0,1-0,3-0,5 Every day
1:10 000 0,1-0,3-0,5 Every day
1:1 000 0,1-0,2-0,3-0,4-0,5 Twice a week
1:100 0,1-0,2-0,3-0,4-0,5 Once a week
1:10 0,1-0,2-0,3-0,4-0,5 Once in two weeks
1:10 0,1-0,2-0,3-0,4-0,5 Once in two weeks
of cause-significant allergens and sensibilization level, less total dose with ineffective ASIT also had initially lower values of CD3+, CD4+, (in PNU) and lower initial immunological parameters. The patients CD8+, CD95+ and IgG (p<0,01).
Table 2. - Clinical and immunological characteristics of patients with grass pollen allergies with effective and ineffective allergen-specific immunotherapy
Factors Efficient ASIT, n=39 Inefficient ASIT, n=23 P
Age, years 29, 3±1,9 33,9±1,1 <0,01
Percentage of clinical manifestations 66,7±2,1 76,8±4,0 <0,01
Intensity of clinical manifestations, grades 2,63±0,05 2,94±0,03 <0,01
Amount of relapses, times 4,4±0,4 6,9±0,7 <0,01
Duration of relapses, days 91,8±9,9 120,0±10,7 <0,05
Amount of cause-significant allergens, 5,2±0,4 8,0±0,5 <0,01
Allergen total dose (in PNU) 5935,1±316,8 4548,6±387,3 <0,01
CD3+ 50,6±1,2 42,5±1,4 <0,01
CD4+ 35,9±1,4 29,4±0,8 <0,01
CD8+ 20,6±0,5 17,5±1,1 <0,01
CD20+ 10,7±0,6 6,9±0,4 <0,01
CD16+ 11,8±0,4 8,1±0,7 >0,05
CD23+ 2,6±0,7 4,1±0,8 >0,05
CD95+ 1,9±0,6 1,07±0,4 <0,01
HPH 1,24±0,04 0,83±0,01 <0,01
Ig A 1,81±0,05 1,47±0,13 <0,01
Ig M 1,2±0,02 1,1±0,01 >0,05
Ig G 12,2±0,4 10,1±0, 2 <0,01
Total Ig E 412,9±21,4 402,9±18,9 >0,05
According to the data of analysis, performed by us, significant predictors for ASIT inefficiency for examined patients are male sex, raising the risk of ASIT inefficiency formation by 1,42 times; age over 30 years — by 1,16 times, seasons of relapses: spring-summer-autumn -by 1,69 times, spring-autumn — by 1,4 times, spring — by 1,3 times; the number of cause-significant allergens over 5 — by 2,01 times; allergy-specific therapy total dose less than 4000 PNU — by 2,48 times; CD3+ less than 45% — by 2,0 times; CD4+ less than 25% — by 2,67 times; CD8+ less than 20% — by 4,0 times and IgG less than 10, g/l — by 4,4 times.
Under the influence of the first ASIT course, which is called ineffective, reliable decrease of sensitivity of nasal and respiratory tract to specific allergen can be pointed out. Thus, decrease of intensity of nasal congestion by 50,8% (from 2,91 to 1,43 grades); decrease in sneezing — by 62,2% (from 2,91 to 1,1 grades); decrease in conjunctival manifestations — by 71,2% (2,83 to 0,82 grades) and respiratory manifestations — by 62,0% (from 3 to 1,14 grades) was observed in patients.
Information about clinical manifestations was correlated with the intensity of skin sensitivity and are represented on the Figure 1.
Figure 1. Percentage of patients with the absence of skin sensitivity to specific allergens after the first ASIT course and its efficiency
According to results received in all the patients in comparative aspect the dynamics of cytokine status values was studied (Table 3). Table 3. - Cytokine status values in patients with various ASIT efficiency
Value [25-75%] Before ASIT ASIT day 30 ASIT day 90
I (n=39) II (n=23) I (n=39) II (n=23) I (n=39) II (n=23)
IL-4R, pg/ml 4,5 [0-15] 0,0 [0-0,5] not studied not studied 2,0 [0-6,1]* 0,0 [0-3,4]
IL-6R, pg/ml 1,6 [0,75-3,15] 2,0 [1,45-2,85] 0,6 [0,22-1] 1# [0,85-1,2] 0,35 [0,1-1,54] 0,54*# [0,410,61]
IL-8R, pg/ml 1,48 [0-3,11] 1,05 [0,7-4,2] 3,9*# [3,1-6,9] 2,85* [0-3,5] 3,8* [0-8,1] 5,0*# [3,6-7]
IL-5R, pg/ml 0,0 [0-5] 0,0 [0-14] not studied not studied 20,0 [0-31] 12,5 [5-24]
*p<0,05 on the average with source data I - excellent/good ASIT
#p<0,05 on the average with previous study II - satisfactory/unsatisfactory ASIT result
First of all, the attention was given to different dynamics ofval-ues, reflecting progress ofinflammatory process. Dynamics ofIL-6. level reflects intensification of its expression during first few days of treatment with significant decrease in group with good/excellent effect by day 30 (p=0,01). Less effective ASIT was characterized by slow decrease in cytokine level during whole observation period with achievement of minimal values only by day 90 of the therapy (p<0,05).
One more cytokine with expressed anti-inflammatory properties is IL-8. Its role in case of topical pathology lies, first of all, in regulation of the late stage of allergic reaction but its role in ASIT efficiency mechanisms is little characterized. According to Jacobi et al. it is known that administration of etiologically significant allergen to patients with seasonal allergic rhinitis out ofpollen dispersion period does not lead to change in IL-8 synthesis during the day and night [12]. Though other authors showed that complete ASIT course was accompanied by expressed (3-4-fold) cytokine synthesis effort [6], that allowed concluding of participation of IL-8 in regulation of additional ASIT mechanisms.
The results of our examination demonstrated increase of cytokines level during ASIT. In the group with good results of therapy it was observed by the day 30 of the therapy with preservation of achieved level within further two months. Low treatment efficiency was associated with a slower and more durable (up to day 90) increase of content of this cytokine in serum. This conforms to the above supposition that low sensitivity to high allergen dilution may be the reason for insufficient activation of immune system at early stages, what further leads to decrease in its efficiency, as well as to described dynamics of other cytokines, regulating inflammatory process at early ASIT stages (IL-6) [11; 16].
Unexpected results were obtained for proallergic cytokines — IL-4 and IL-5. Despite the fact, that for effective ASIT decrease in cytokines production by the end of complete course of treatment was described [9]. It is known, that various doses of allergen influence formation of Th-phenotype of immune response in a various way. In particular, it is known that low allergen doses promote Th2 — variant, whereas high doses are characteristic of late ASIT stages, promote synthesis of Th1 — cytokines range [7]. In course of our study good/excellent effect of the therapy was accompanied by a reliable decrease in IL-4 level in course of treatment by the day 90 (p=0,017), what corresponds to existing ideas ofASIT mechanisms and remained unchanged in the second group. Significantly greater frequency of cases with undetermined IL-4 level is observed in the group of patients with insufficient therapeutic effect (64,6% versus 20,4%). It is possible that lower activation abilities of immune sys-
tem may be a reason for insufficient ASIT efficiency. Despite the fact that IL-13 by structural and functional characteristics is close to IL-4, its dynamics had an opposite character (its increase by day 90 of observation in the both groups (p=0.04)), what requires further study. The data concerning dynamics of IL-5 change in course ofASIT are of ambiguous character [4; 13; 14]. In our study the initial level of IL-5 in most patients was undetermined. By the moment of achieving maximal therapeutic dose of allergens in the group with good effect a reliable intensification in cytokine production (p=0.02) is achieved. In spite of the fact that insufficient treatment efficiency was associated with the absence of reliable changes in the value, by this moment definable cytokines levels were in 73,9% (17 out of 23) patients. It is possible that in this case synthesis of IL-5 does not reflect activation of allergic inflammation and may be interpreted as non-specific reaction of the body to increased (maximal) allergen load by this term. This corresponds to the data ofMoverare R. about the fact that in patients with sensibilization to the pollen ASIT during pollination period of etiologically significant plants leads to intensification of IL-4 and IL-5 expression [14].
Thus, the data received witness of the fact that in patients with pollen disease as a result showed immune deficiency of T-cell link, which is characterized by the decrease of both absolute and relative content of CD3-lymphocytes, as well as reduction in subpopulation of expressing CD4, CD8-, CD16-antigens on the cells membrane. Changes in effector link of immune system functioning are the result of persistent imbalance of proliferation and apoptosis processes: against the background oflow readiness of immunocompetent cells to apoptosis high allergen-specific proliferation of lymphocytes took place.
ASIT efficiency in patients with respiratory allergic diseases depends on initial ability of immune system to activation with low doses of allergen, rather quick suppression of proinflammatory cytokines induced thereby, as well as active functioning of the antiinflammatory cytokines system.
Conclusion
1. It has been found that in patients with pollen disease immune deficiency of T-cell link, which is characterized by decrease both in absolute and relative content of CD3-lymphocytes, as well as by decrease in the amount of lymphocytes, expressing CD4, CD8-, CD16-antigens on the cells membrane.
2. It has been found that changes in effector link of immune system functioning are the consequence of persistent imbalance of processes of proliferation and apoptosis: against the background of low readiness of immunocompetent cells to apoptosis high allergen-specific proliferation of lymphocytes took place.
3. It has been determined that ASIT efficiency in patients with respiratory allergic diseases depends on initial ability of immune system to activation with low doses of allergen, rather
quick suppression of pro-inflammatory cytokines, induced thereby, as well as active functioning of the anti-inflammatory cytokines system.
References:
1. Аллергический ринит и его влияние на астму (ARIA): Руководство для врачей и мед. сестер. М., 2001, 24 с.
2. Гущин И. С. Аллергенспецифическая иммунотерапия атопических заболеваний: пособие для врачей. М., 2002, 32 с.
3. Гущин И. С. Физиология иммунитета и аллергия//Физиология и патология иммунной системы. 2004. - № 9. - C. 17-20.
4. Park H. S. Clinical and immunologic changes after allergen immunotherapy with Hop Japanese pollen. Ann Allergy, Asthma Immunol. 2001, v.86, No. 4. P. 444-448.
5. Akdis M., Akdis C. A. Mechanisms of allergen-specific immunotherapy. J. Allergology Clin. Immunol. 2007, v.119 (issue 4). P. 780-789.
6. Andersson T. N., Ekman G. J., Gronlund H. et al. A noveladjuvant-allergen complex, CBP — r Fel d 1, induces up-regulation of CD86 expression and enhances cytokine release by human dendritic cells in vitro. Immunology. 2004. v. 113 (2). P. 253-259.
7. Arshad S. H. Primary prevention of asthma and allergy. J. Allergy Clin. Immunol. 2005. v. 116. P. 3-144.
8. Canonica W., Baena-Cagna C. E., Bousquet J. et ак Recommendations for standardization of clinical trials with Allergen Specific Immunotherapy for respiratory allergy. Allergy 2007, v. 62. P. 317-324.
9. Ciprandi G., Marseglia G. L., Tosca M. A. Allergen-specific immunotherapy: an update on immunological mechanisms of action. Monaldi Arch. Chest. Dis. 2006, v.65 (1). P. 34-37.
10. Fujisawa T., Nagao M., Hosoki Yu. Et al. Biomarkers for allergen immunotherapy in cedar pollinosis. Allergology Int. 2009, v.58, No. 2. P. 163-170.
11. Grzela K., Grzela T., Lazarczyk M. et al. Influence of allergen-specific immunotherapy on IL-4-dependent IL-12 production by monocytes. Int. J. Mol.Med. 2002, v.10, №. P. 481-484.
12. Jacobi H., Poulsen L. K., Reimert C. M. etc. IL-8 and the activation of eosinophils and neutrophils following nasal allergen challenge. Int. Arch. Allergy Immunol. 1998, v. 116. P. 53-59.
13. Jutel M., Akdis M., Blaser K., Akdis C. A. Mechanisms of allergen specific immunotherapy — T- cell tolerance and more. Allergy. 2006, v. 61 (7). P. 796-807.
14. Moverare R. Allergen-specific increase in IL — and IL-5 secreation from peripheral blood mononuclear cells during brichpollen immunotherapy. Allergy. 2007, v. 53, Issue 3. P. 275-281.
15. Silny W. Effectiveness of specific immunotherapy in the treatment of children and youngsters suffering from atopic dermatitis. Part III. Serum concentrations of selected immunologic parameters. Wiadomosci lekarskie 2005, v.58 (5-6), P. 287-294.
16. Toshiyuki Tazaki, Kenji Minoguchi, Takuya Yokoe et al. Allergen rush immunotherapy increases interleukin (IL)-12 production and IL-12 receptor p2 chain expression in patients with allergic asthma. Cell Immunol. 2004, v.228 (1). P. 20-26.
Israilov Xikmatjon Tuygunovich, Republican Specialized Scientific-practical Medical Center of Dermatology and Venereology, Uzbekistan, Tashkent city
E-mail: [email protected]
The study of clinical manifestations and status of immune-interferon system in patients with recurrent genital Herpes
Abstract: The achieved results in the patients with recurrent genital Herpes indicate misbalance of cytokine and interferon systems of lymphocytes with disorders of differentiation of T-helpers and the way if signaling response.
Keywords: recurrent genital Herpes, immunological status.
Genital infection called Herpes Simplex virus (HSV) continues to stay constantly growing problem ofhealth care, spreading among people in the whole world and seriously affecting health status, es-
pecially young sexually active people [3; 6; 11]. It is mostly conditioned by wide spread of these viruses, long intra cellular persistence of the agents, their effect on the processes of immune genesis, often relapses, difficult diagnostics and therapy [7; 9; 10]. In the modern time in spite of remarkable success achieved in diagnostics and therapy of urogenital infections, morbidity rate stay high both in our country and abroad [1; 4]. Special importance in the structure of urogenital infections is occupied by the affect of HSV 1 and 2 types [5; 8]. The problems of epidemiology, causes of infection growth, often relapses, polymorphism of clinical manifest, the role of organism protection systems in the pathogenesis and clinical progress of
recurrent forms of herpetic infection require profound study of and condition the necessity of the improvement of therapy methods for patients with often recurrent genital Herpes which served the objective of our work.
Materials and methods. During 2008-2011 we observed 97 patients with often recurrent (from 4 to 10 and more relapses per year) genital Herpes (GH) who applied to anonymous testing and clinical departments of RSSPMC of DV of the MHC of the RUz. Among them there were 74 men and 23 women. Sick children were in the age from 18 to 58 years old. Term of the disease was from 1 to 5 years. At the moment of application all patients had stage of active manifestations of genital Herpes. In 12 (12.4%) patients the disease proceeded in combination with ITSW, including 4 patients with urogenital Chlamydia, 3 with ureo-mycoplasma in-
