There was an interesting case called “Stolen Slippers” from the Song Dynasty in ancient China concerning the legendary judge Bao Zheng. Dealing with HIV infections, HIV PEP (post exposure prophylaxis), and sexually transmitted diseases (STD) on a daily basis in Singapore, even cases from the files of Justice Bao from China may sometimes be relevant. In the following case study, the “Stolen Slippers” from Song Dynasty furnished us with a lesson learnt: when it comes to spousal relationships, one should be careful but not overly pedantic and suspicious.
A bespectacled, fortyish receptionist saw me one bright and sunny morning for chronic, intermittent episodes of increased vaginal discharge without abnormal, foul odor. She was faithfully married to her husband for about 15 years. She had no extramarital affairs, or any prior history of STDs. All previous tests for STDs were negative.
Over the years, she had consulted several doctors for a similar complaint of intermittent, unexplained vaginal discharge accompanied by occasional post-coital bloody spotting (tiny bleeds). There were several PAP smears performed which revealed inflammatory changes. These changes were unresponsive to previous courses of antibiotics given by her gynecologist, and cervical cryotherapy proved futile.
She was convinced that her symptoms were due to her husband’s unfaithfulness. In her own words, she had never stolen anything in her life. But this one thing she had unwittingly stolen: her husband’s STD.
I told her about Justice Bao Zheng and the story of the “Stolen Slippers.” A lustful monk, eyeing on a man’s wife schemed to prove that the wife was unfaithful to her husband. The monk eventually convinced the man by presenting him with a pair of his wife’s slippers – a pair that the monk had stealthily stolen from her.
“Do not be too quick to make a judgment. Your “stolen infection” might turn out to be something insignificant after all!” I quipped. Just as the monk stole the pair of slippers to prove the woman’s alleged unfaithfulness, the receptionist thought that she had inadvertently “stolen” an STD from her husband, which proved his infidelity.
After a long conversation along with much tears and words from the lady, I proceeded with the physical examination. Examination revealed a normal external genitalia. The cervix had a mucopurulent exudate in the external os, and swabs for cervical samples induced brisk endocervical bleeding.
My initial impression was a diagnosis of mucopurulent cervicitis. I sent the swab samples for an STD screen to rule out gonorrhea, Chlamydia, trichomoniasis and herpes. On top of that, blood was drawn for other STD and HIV testing.
Given the patient’s age and history, I felt that gonorrhea and Chlamydia was quite unlikely. I sent her home after a detailed discussion of her symptoms and presentation. No treatment was given on this first visit. Although I did not ask for her comprehension of ancient Chinese history or the story of the “Stolen Slippers,” I did tell her to ensure her husband came to see me.
He did. Again it was a bright, sunny day.
In truth, I often joked that Singapore has indeed four seasons: hot, hotter, hottest and hazy (when our neighboring country decided it was fine to perform slash-and-burn agriculture on a regular basis).
Her husband vehemently denied any unfaithfulness on his part, and his earnest declaration earned my partial confidence in his fidelity. My confidence in him was further enhanced when his tests returned negative for all STDs. Science, not Justice Bao, had proven him clear of all sexually transmitted infections (STI). I bade him adieu after handling him a thick copy of his tests results.
The receptionist returned to see me roughly a week later. She had persistent symptoms and physical examination was similar to her previous visit. Her PAP smear revealed many polymorphonuclear leukocytes and inflammatory changes. HPV DNA was negative. No organisms were seen on wet mount. Nucleic acid amplification test (NAAT) for Chlamydia and gonorrhea, plus cultures for Trichomonas vaginalis and HSV were all negative. VDRL and HIV serology were likewise negative.
The diagnosis was clearly idiopathic mucopurulent cervicitis (idiopathic MPC). The cause was really unknown. It is still not known if idiopathic MPC has any negative effects on the patient or the partner, and the current consensus suggests that treatment was unnecessary in the absence of Chlamydia, gonorrhea, and Mycoplasma genitalium.
As NAAT test for M. genitalium is currently difficult to obtain, both the receptionist and her husband were given empirical therapy with Avelox. As a side note, Avelox was chosen because azithromycin-resistance in Mycoplasma genitalium is an emerging problem in several continents, and Avelox (Moxifloxacin) seems to be the only drug that consistently eradicates this organism.
Despite treatment with Avelox, her symptoms unfortunately never quite abated. But she was extremely elated to learn that her husband did not have any STDs.
Hers was not a case of “stolen infection” after all! But being a doctor by profession, my training could not quite exclude “stolen affection” though.
Patients are advised not to refer to ancient Chinese history for the diagnosis of STDs and HIV infection. Please consult your doctor for HIV PEP (HIV post exposure prophylaxis), and HIV or STD screening and testing.
