Diagnosis and treatment of syphilis

Benzathine penicillin G in the treatment of neurosyphilis

The definition, pathogenesis, incidence, diagnosis, and treatment of neurosyphilis are discussed. Controlled trials of benzathine penicillin in the treatment of neurosyphilis are reviewed, as are recent case reports of benzathine penicillin failures. Although few well-controlled studies exist to document conclusively the efficacy of benzathine penicillin in the treatment of neurosyphilis, its use is recommended in selected situations.

Tabes dorsalis progressing to general paresis after 20 years despite routine penicillin therapy

A man with a history of treatment for early syphilis presented with tabes dorsalis. Despite receiving a course of penicillin accepted as adequate by the World Health Organisation the illness progressed to tabo-paresis after 20 years. Reinfection cannot be excluded.

Laboratory investigation of syphilis

Without treatment, syphilis passes through primary, secondary, latent, and tertiary stages. The disease can be diagnosed directly by microscopic identification of the infective organism or serologically. Nontreponemal serologic tests are most suitable for screening and following response to therapy, while treponemal tests are used to confirm a positive nontreponemal test result. Biologic false positives are not uncommon. Because of the danger of infection to the fetus, serologic testing for syphilis is mandatory in all pregnant women. Nontreponemal tests can also be performed on CSF to document neurosyphilis.

Analysis of a large pedigree with elliptocytosis, multiple lipomatosis, and biological false-positive serological test for syphilis

Elliptocytosis, multiple lipomatosis, and biological false-postive serological test for syphilis (BFPSTS) were found in a single individual. One hundred eighty relatives were tested for the three diseases: 74 were typed for seven blood group antigens, and 58 were typed for four electrophoretic enzyme markers. Likelihood analysis of the pedigree data confirmed independent dominant inheritance for elliptocytosis and lipomatosis. BFPSTS appears dominant, but the analysis was inconclusive. No linkages were found between any disease gene and any marker gene. Two female pedigree members with BFPSTS developed systemic lupus erythematosus, a finding in agreement with the previously described association. The analysis did not lead to any conclusions about the causal relationship between the two traits.

The intraocular penetration of cefuroxime after parenteral administration

Cefuroxime (Zinacef) is a new second generation cephalosporin which is resistant to beta-lactamases produced by both Gram-negative and Gram-positive organisms, with an antibacterial spectrum that includes practically all likely ocular pathogens except pseudomonas. It is shown to penetrate into the eye after intravenous (1.5g) or intramuscular (1 g) injection and achieve therapeutic concentrations, with absence of side effects. Cefuroxime is therefore a useful antibiotic for ophthalimic infections and should have a role in combination with gentamicin in intraocular infections, particularly those of unknown aetiology.

Cochleovestibular involvement as the first sign of syphilis

Three cases of syphilis with cochleovestibular symptoms are reported. There was either cochlear or vestibular involvement in two cases and, in the trird, cochlear and vestibular involvement together. The disorder was unilateral in all three. In one case there was a concurrent lesion of the oculomotor nerve which was the motive for consultation. There was no other symptom suggesting the diagnosis of syphilis in any case. The important features of diagnosis are discussed.

Cerebrospinal fluid findings in asymptomatic patients with reactive serum fluorescent treponemal antibody absorption tests

It is common to examine the cerebrospinal fluid in untreated or inadequately treated asymptomatic patients with a reactive serum fluorescent treponemal antibody absorption (FTA-ABS) test before initiating antibiotic therapy for syphilis. This prospective study evaluated the usefulness of such examination. Four hundred thirty-two patients over 40 years old, reporting for annual physical examination, had a serum FTA-ABS test. Thirty-seven (8.6%) patients and 2 of 4 spouses were reactive repeatedly. Of the 39 patients with reactive tests, 7 had a history of penicillin therapy for syphilis, 5 had received heavy metal therapy, and 27 had no history of syphilis. These 39 patients had a neurological examination, serum VDRL, Treponema pallidum immobilization (TPI), and repeat FTA-ABS tests by two other laboratories. The TPI test was reactive in 30 (77%). Four had nonspecific neurological signs. Routine CSF examination (cells, total protein, VDRL, glucose, IgG%) on 30 patients with a history of inadequate treatment had a low diagnostic yield. Two patients had an unexplained total protein elevation (57 and 61 mg/dl) and 1 had a mildly increased IgG% (15%). All cell counts, VDRL tests, and glucose levels were normal. Agarose electrophoresis demonstrated one or more CSF immunoglobulin bands in 10 (36%) of 28 patients, possibly representing an immunological marker of past or latent central nervous system infection.

Influence of genital herpes on results of fluorescent treponemal antibody absorption test

Both the fluorescent treponemal antibody absorption (FTS-ABS) test and Venereal Disease Laboratory (VDRL) test for syphilis were performed routinely on 113 men with histories of genital ulcerations. The difference in negative VDRL and borderline FTS-ABS results between patients with and without herpes simplex virus in their genital ulcers and no evidence of previous or untreated syphilis was not statistically significant. Furthermore, use of the FTA-ABS test as a confirmatory rather than a screening test eliminates false-positive, borderline, or reactive results in patients with non-syphilitic ulcers.

Specificity of the FTA-ABS and TPHA tests during pregnancy

In order to determine whether pregnancy influences the specificity of the fluorescent treponemal antibody absorption (FTA-ABS) and Treponema palidum haemagglutination assay (TPHA) tests, these tests, together with the quantitative fluorescent treponemal antibody (FTA) and Venereal Disease Research Laboratory (VDRL) tests, were carried out simultaneously on 2000 pregnant women who attended for compulsory prenatal screening. In only one patient (0.05% of the total investigated) was a positive result to the TPHA test obtained, the specificity of which it was impossibile to confirm. The FTA-ABS test gave a weakly reactive result of the borderline type but this was found to be non-specific in only four (0.2%) patients. The results of our investigations showed that the specificity of the FTA-ABS and the TPHA tests performed on pregnant women did not differ from the specificity of these tests when carried out on other population groups.

Diagnosis and chronic mental illness

This paper describes the occurrence of chronicity in varying psychiatric illnesses. There is not an unequivocal definition of chronicity, but with the exception of the illnesses that will be described below and that lead directly or indirectly to death from CNS complications of the illness, chronicity will require a duration of a minimum of five years without a significant remission. Chronicity is further differentiated into four different kinds of chronicity: chronic--death, chronic--self-limited, chronic--remission, and chronic--recurrent. The illnesses that may be considered as possibly fulfilling the criteria for chronic will be noted and a method for deciding whether an illness qualifies will be outlined.

Demonstration by labeled treponemal antigen of specific antibodies in the tissue infiltrates of secondary syphilis

Specific antitreponemal antibodies have been demonstrated by immunofluorescence techniques in the lymphoplasmocytic infiltrates which characterize early symphilitic lesions. A purified suspension of Nichols strain Treponema pallidum was sonified and labeled with fluorescein isothiocyanate and applied to cryostat sections of 12 biopsy specimens from the cutaneous lesions of 11 patients with proven secondary syphilis, using a modified direct immunofluorescence procedure. Specimens from various inflammatory dermatoses processed similarly served as controls. Granular fluorescence was noted in the dermis in 9 of the 12 specimens corresponding to areas of heavy plasma cell infiltration and some fluorescence was found directly on plasma cells which were identified by subsequent hematoxylin and eosin staining. This fluorescence could be blocked by prior incubation of the sections with unlabeled sonified treponemal suspension. Control slides did not reveal any fluorescence. The use of labeled treponemal antigen may aid the tissue diagnosis of early syphilitic lesions which can mimic a variety of dermatological disorders.

Evaluation of reagin screen, a new serological test for syphilis

A total of 1,020 serum and plasma specimens were tested using the Venereal Disease Research Laboratory (VDRL), Rapid Plasma Reagin (RPR) card, Reagin Screen (RST) and Fluorescent Treponemal Antibody-Absorption (FTA-ABS) tests. In 257 normal patients, all screening tests were nonreactive; the FTA-ABS test was reactive for one patient. In 588 patients with treated and untreated syphilis, the RST results were 91.7% in agreement with the VDRL and RPR results. In 175 patients with diseases that cause biological false reactions, the RST was 94% in agreement with the other screening tests. The titer of the RST was within one dilution of the corresponding VDRL titer in 91.7% of the 360 speciments tested and within one dilution of the RPR titer in 96.9% of 358 specimens quantitated by both tests.

Sexually transmissible diseases

There is a widespread recrudescence of venereal disease. The possible reasons for this are discussed. Each disease is then considered from the viewpoints of clinical course, diagnosis, and treatment. Treatment failures are discussed in detail, immunity is covered, and recommendations for the future conclude the presentation.

Comparison of the counter-immunoelectrophoresis technique with the Reiter protein and three other serological tests as a first line test for syphilis

The counter-immunoelectrophoresis technique with the Reiter protein (RP-CIE) was compared with two complement fixation tests (Kolmer and RPCF) and a flocculation test (VDRL) in sensitivity and specificity. Of the 1,927 consecutive attendants of a venereal disease clinic whose serum samples were used, 250 were considered to be syphilitic. The number of true-positive and false-positive reactions were: 121 and 4 (VDRL), 124 and 2 (Kolmer), 179 and 41 (RPCF), 166 and 16 (RP-CIE). The VDRL and the RPCF combined were more sensitive and less specific than the VDRL combined with the Kolmer. If the RPCF was replaced by the RP-CIE the sensitivity remained the same but the specificity was higher. The RP-CIE scored more positives than the RPCF in untreated cases of primary syphilis. The results argue for substitution of the RP-CIE for the Kolmer in the combination with the VDRL in the serodiagnosis for syphilis. Moreover, the RP-CIE presents the technical advantages of simplicity, speed of performance, and of not being hampered by the anticomplementary nature of the serum sample.

The fluorescent treponemal antibody-absorption (FTA-ABS) test for syphilis

The FTA test was developed at a time when immunofluorescence procedures were not well-defined. Through technique control and research, a modification of the FTA test, the FTA-ABS, has attained a position as one of the leading treponemal tests to confirm the reagin tests for syphilis. In this review of the FTA-ABS test, attention has been focused on reagent development, with the anticipation that reagent standardization may soon become a reality. The T. pallidum antigen obtained by extracting infected rabbit testicular tissue has evolved from a preparation in which the treponemes remained in the initial extracting fluid to a reagent that can be free of rabbit tissue and globulin. These washed antigen preparations improve visibility of the treponemes on the microscope slide, reduce background fluorescence, and reduce or prevent from occurring nonspecific reactions that are a result of tissue and globulin components. Both washed and nonwashed antigens are available commercially, and, to date, little differentiation has appeared on the product label. The predominant immunoglobulin that reacts with T. pallidum in the indirect fluorescent antibody tests appears to be IgG. This is the major immunoglobulin detected in the FTA-ABS test. IgM, although increased in early syphilis, is also increased in other clinical conditions. Several reports suggest that adult IgM detection in the present FTA-ABS test would be nonspecific. Until specific IgM antibody in adult syphilis can be detected without a risk to test specificity, the conjugate for the FTA-ABS test should continue to be an anti-IgG reagent. Class-specific, anti-IgG reagents are more expensive than other reagents; however, their use may eliminate the problem of nonspecificity resulting from IgM detection. Additionally, micromethods can be used to reduce cost, and this possibility should be investigated. The sorbent that contains an antigen to the Reiter treponeme may or may not specifically absorb the reactivity that occurs in normal sera; certainly, there are questionable aspects about this reagent. Group antibodies not related to Reiter treponemes may be responsible for some nonspecific reactivity; additionally, antiglobulin factors have been reported to participate in the reaction. Antigens free of rabbit serum factors and class-specific, antiimmunoglobulin reagents are available, and may lead to a better understanding of nonspecific reactions. These reagents should allow resolution of the possible multiplicity of reactivity. In this interim period, the sorbent, with its possible nonspecific nature, appears to maintain a biological balance between natural or group and immune antibodies when used to detect IgG antibody.

Treponema pallidum haemagglutination test as a screening procedure for the diagnosis of syphilis

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