Clinical manifestations of early syphilis by HIV status and gender: results of the syphilis and HIV study

Syphilis in the AIDS era: diagnostic dilemma and therapeutic challenge

This review argues that syphilis has been underdiagnosed and undertreated, a problem that goes back to the beginning of the Wassermann era, and indeed long before. Non-treponemal tests do not detect the larger pool of persons with latent syphilis, the immunological consequences of which have not been systematically investigated in the context of HIV infection and progression to AIDS. Recent efforts to confirm the prevalence of syphilis in high-risk patients by reverse sequence screening, i.e. using a treponemal test first, as the screening test, have revealed untreated syphilis at higher rates than expected. Further testing using PCR discovered even more previously undetected cases. We suggest that latent syphilis is a chronic active immunological condition that drives the AIDS process and cannot be managed with the older Wassermann-based algorithm, and that non-treponemal tests have failed to associate syphilis with immune suppression since this screening concept was developed in 1906. In light of the overwhelming association between a past history of syphilis and HIV seroconversion, more sensitive tools, including recombinant antigen-based immunological tests and direct detection (PCR) technology, are needed to adequately assess the role of latent syphilis in persons with HIV/AIDS. Repeating older syphilis reinoculation studies may help establish a successful animal model for AIDS, and resolve many paradoxes in HIV science.

Patterns of syphilis testing in a large cohort of HIV patients in Ontario, Canada, 2000-2009

Background

Since 2000, reported syphilis cases increased ten-fold in Canada, particularly among men who have sex with men (MSM) co-infected with HIV. We characterized temporal patterns of of syphilis testing in a large cohort of HIV patients in Ontario, Canada.

Methods

We analyzed data from a multi-site cohort of people in HIV care from 2000 to 2009. Data were obtained from medical charts, interviews and record linkage with the syphilis test database at the Public Health Ontario Laboratories. We estimated the proportion that had syphilis testing at least once per year and the period and annual prevalence of reactive tests.

Results

Among 4232 participants, the annual proportion tested rose from 2.7% (95%CI 1.9, 3.5) in 2000 to 54.6% (95%CI 52.9, 56.3) in 2009. Testing was most common for participants who were men who have sex with men (MSM), aged <30, recently diagnosed with HIV, were antiretroviral treatment naive, had routine HIV lab testing at least twice in that year, or tested for syphilis in the preceding year. The proportion with at least one reactive test in 2000–09 was 21.0% (95%CI 19.4, 22.7) for MSM, 5.3% (95%CI 3.3, 7.4) for non-MSM males, and 2.6% (95%CI 1.2, 4.0) for women. Among MSM, the annual prevalence of reactive syphilis tests with high RPR titre (≥1:16) peaked at 3.8% in 2009.

Conclusions

The burden of syphilis co-infection rose considerably among HIV-positive MSM, such that by 2009, at least 1 in 5 men had laboratory evidence of current or past infection. Interventions may be needed to boost syphilis testing to achieve goals set by guidelines even in settings with universal health care.

Syphilis treatment response among HIV-discordant couples in Zambia and Rwanda

BACKGROUND

Syphilis continues to be a common sexually transmitted infection, despite the availability of inexpensive and effective treatment. Infection in human immunodeficiency virus (HIV)-discordant couples is important because syphilis increases the risk of HIV acquisition. Current US treatment guidelines recommend 1 dose of benzathine penicillin for early syphilis, irrespective of HIV status, but data from coinfected patients are limited.

METHODS

Retrospective analysis of 1321 individuals in 2 African HIV-discordant couple cohorts was performed. Cox proportional hazards analysis and multivariable modeling were used to assess predictors of serologic response to treatment at 180 days and 400 days. Modeling was performed for all episodes of positive rapid plasma reagin (RPR) test results and on a subset with higher RPR titers (≥1:4).

RESULTS

A total of 1810 episodes of syphilis among 1321 individuals were treated with penicillin between 2002 and 2008. Although a positive RPR was more common in the HIV-infected partners, HIV infection did not impact the likelihood of serologic response to therapy (odds ratio [OR], 1.001; P = .995). By 400 days, 67% had responded to therapy, 27% were serofast, and 6.5% had documented reinfection. Prevalent infections were more likely to remain serofast than incident infections (33% vs 20% at 400 days).

CONCLUSIONS

In 2 HIV-serodiscordant couple cohorts in Africa, incident syphilis had a very good likelihood of response to penicillin therapy, irrespective of HIV infection. This supports current Centers for Disease Control and Prevention treatment guidelines. A high proportion of prevalent RPR-positive infections remain serofast despite treatment.

Laboratory findings in neurosyphilis patients with epileptic seizures alone as the initial presenting symptom

A retrospective chart review was performed to characterize the clinical presentation, the characteristic combination of serologic and cerebrospinal fluid (CSF) abnormalities, and the neuroimaging findings of neurosyphilis (NS) patients who had epileptic seizures alone as an initial presenting symptom. In a 6.75-year period, 169 inpatients with NS were identified at Zhongshan Hospital (from June 2005 to February 2012). We demonstrated that 13 (7.7%) of the 169 NS patients had epileptic seizures alone as an initial presenting feature. Epileptic seizures occurred in NS patients with syphilitic meningitis (2 cases), meningovascular NS (5 cases), and general paresis (6 cases). The types of epileptic seizures included simple partial, complex partial with secondary generalization (including status epilepticus), and generalized seizures (no focal onset reported). Nine of NS patients with only epileptic seizures as primary symptom were misdiagnosed, and the original misdiagnosis was 69.23% (9/13). Ten (10/13, 76.9%) patients had an abnormal magnetic resonance imaging, and 7 (7/13 53.8%) patients had abnormal electroencephalogram recordings. In addition, the sera rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TPPA) from all 13 patients were positive. The overall positive rates of the CSF-RPR and CSF-TPPA were 61.5% and 69.2%, respectively. Three patients demonstrated CSF pleocytosis, and 9 patients exhibited elevated CSF protein levels. Therefore, NS with only epileptic seizures at the initial presentation exhibits a lack of specificity. It is recommended that every patient with clinically evident symptoms of epileptic seizures should have a blood test performed for syphilis. When the serology results are positive, all of the patients should undergo a CSF examination to diagnose NS.

Clinical aspects of adult syphilis

Syphilis has been resurgent in Australian cities for the last decade. The varied presentation of this infection requires the physician to consider syphilis in the differential diagnosis of a broad range of conditions. Most cases are in men who have sex with men, young people in remote Aboriginal communities, or travellers from high-prevalence countries. The diagnosis and staging of syphilis require a sexual history, physical examination and interpretation of serological and microbiological findings. Penicillin remains the mainstay of effective treatment and has been used successfully for over 65 years. Treatment failure is rare, whereas reinfection is common. The interaction of syphilis and human immunodeficiency virus is complex, but standard therapy remains curative, and lumbar puncture is rarely required. Regular testing of high-risk individuals, contact tracing with empirical treatment and serological follow up are important components of syphilis control.

Long-term neurological follow-up of HIV-positive patients diagnosed with syphilis

No cerebrospinal fluid (CSF) abnormalities are found in HIV-positive patients in long-term follow-up after standard syphilis treatment. Syphilis has been reported to have immunological effects on HIV infection and HIV is known to modulate both the manifestations of syphilis and the serological response to therapy. HIV-positive patients who had been diagnosed with and treated for syphilis prior to 2007 were identified. Patients were consented for lumbar puncture. Serum HIV viral load, CD4 count and CSF were recorded. Thirty-five patients with previously diagnosed and treated syphilis underwent lumbar puncture. Thirty-four patients had a normal neurological exam. Only one patient had an abnormal mean white cell count (10.7 cells per high-power field). The finding that those with previously diagnosed syphilis had normal CSF and clinical findings is reassuring and supports the practice of using standard syphilis therapy in HIV-positive patients.

Emergency department management of sexually transmitted infections

Patients seeking treatment for sexually transmitted infections (STIs) account for a large number of emergency department (ED) visits per year. Despite the large volume of patients, STIs are often missed or treated inappropriately. Due to the high prevalence and incidence of STIs in the United States, it is important that emergency practitioners recognize symptoms consistent with STIs, and treat presumptively. This practice leads to overtreatment of STIs; however, when weighed against the public health risk and complications of untreated disease, empiric treatment is recommended. This article provides an overview of STIs encountered in the ED and recommendations for their treatment.

Evaluation and Management of Syphilis in the HIV-Infected Patient

Rates of syphilis continue to increase in the United States and HIV-infected patients make up a large proportion of cases. The interaction between syphilis and HIV is complex and still incompletely understood. Although diagnosis and management of HIV-infected patients with syphilis is, in general, similar to HIV-uninfected patients, the former may be at increased risk for complications. Recent data suggest that HIV-induced immunosuppression may alter the course of syphilis and that highly active antiretroviral therapy may have a beneficial effect on syphilis outcomes. Prevention strategies consisting of sexual risk assessments, condom use, treatment of infected partners, yearly screening for syphilis of all HIV-infected patients, and enhanced clinical and serologic follow-up of treated HIV-infected patients are critical components of a comprehensive approach to care.

Neurosyphilis manifesting with unilateral visual loss and hyponatremia: a case report

Background

Syphilis is called the chameleon of the diseases due to its variety of its clinical presentations, potentially affecting every organ of the body. Incidence of this ancient disease is once again on the increase worldwide.

Case presentation

We here report an unusual case of neurosyphilis manifesting with unilateral visual loss and hyponatremia. The patient also had primary syphilitic lesions and was concomitantly diagnosed with Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) infection. Treatment with ceftriaxone and prednisolone, completely resolved the hyponatremia and visual acuity was partially restored.

Conclusion

Awareness of syphilis as a differential diagnosis is important as previously unreported presentations of neurosyphilis can arise, especially in HIV infected patients.

Management of syphilis in the HIV-infected patient: facts and controversies

After reaching an all time low at the turn of the millennium in several industrialized countries, the syphilis incidence is rising again, perhaps as a consequence of unsafe sexual behavior in response to improved antiretroviral therapeutic options for HIV. Since the beginning of the HIV pandemic, numerous reports on the various aspects of the interaction between syphilis and HIV have been published. Controversies persist on many issues of the management of coinfected patients. This contribution presents a critical appraisal of the available literature. Few large-scale, properly designed, controlled studies have compared syphilis baseline presentation and treatment response according to HIV status. Among the weakness are (1) high rates of patients lost to follow-up, (2) lack of long-term follow-up, (3) lack of gold standard criteria for treatment response, (4) small sample size, and (5) lack of stratification according to syphilis stage, ongoing antiretroviral treatment, CD4 cell count and HIV viral load. From the available data, and given the ever-possible publication bias, we conclude that if HIV has an effect on the course of syphilis, it is small and clinically manageable in most cases. The controversial issues discussed should furnish the rational for clinical research during the forthcoming decade.

Secondary syphilis: the classical triad of skin rash, mucosal ulceration and lymphadenopathy

After years of declining incidence in many developed countries, syphilis infection has re-emerged as a major public health problem in the past decade. The secondary stage of syphilis epitomizes the capacity of the infection to present in myriad ways. The skin, lymph glands and mucosal membranes are the most commonly affected tissues.

Drug-related behaviors independently associated with syphilis infection among female sex workers in two Mexico-US border cities

AIMS

To identify correlates of active syphilis infection among female sex workers (FSWs) in Tijuana and Ciudad Juarez.

DESIGN

Cross-sectional analyses of baseline interview data. Correlates of active syphilis (antibody titers >1 : 8) were identified by logistic regression. Setting Tijuana and Ciudad Juarez, two Mexican cities on the US border that are situated on major drug trafficking routes and where prostitution is quasi-legal.

PARTICIPANTS

A total of 914 FSWs aged > or =18 years without known human immunodeficiency virus (HIV) infection who had had recent unprotected sex with clients.

MEASUREMENTS

Baseline interviews and testing for syphilis antibody using Treponema pallidum particle agglutination (TPPA) and rapid plasma reagin (RPR) tests.

FINDINGS

Median age and duration in sex work were 32 and 4 years, respectively. Overall, 18.0% had ever injected drugs, 14.2% often or always used illegal drugs before or during sex in the past month, 31.4% had clients in the last 6 months who injected drugs, and 68.6% reported having clients from the United States. Prevalence of HIV and active syphilis were 5.9% and 10.3%, respectively. Factors independently associated with active syphilis included injecting drugs (AOR: 2.39; 95% CI: 1.40, 4.08), using illegal drugs before or during sex (AOR: 2.06; 95% CI: 1.16, 3.65) and having any US clients (AOR: 2.85; 95% CI: 1.43, 5.70).

CONCLUSIONS

Among female sex workers in Tijuana and Ciudad Juarez, drug-using behaviors were associated more closely with active syphilis than were sexual behaviors, suggesting the possibility of parenteral transmission of T. pallidum. Syphilis eradication programs should consider distributing sterile syringes to drug injectors and assisting FSWs with safer-sex negotiation in the context of drug use.

Occurrence, risk factors, diagnosis and treatment of syphilis in the prospective observational Swiss HIV Cohort Study

BACKGROUND

Annual syphilis testing was reintroduced in the Swiss HIV Cohort Study (SHCS) in 2004. We prospectively studied occurrence, risk factors, clinical manifestations, diagnostic approaches and treatment of syphilis.

METHODS

Over a period of 33 months, participants with positive test results for Treponema pallidum hemagglutination assay were studied using the SHCS database and an additional structured case report form.

RESULTS

Of 7244 cohort participants, 909 (12.5%) had positive syphilis serology. Among these, 633 had previously been treated and had no current signs or symptoms of syphilis at time of testing. Of 218 patients with newly detected untreated syphilis, 20% reported genitooral contacts as only risk behavior and 60% were asymptomatic. Newly detected syphilis was more frequent among men who have sex with men (MSM) [adjusted odds ratio (OR) 2.8, P < 0.001], in persons reporting casual sexual partners (adjusted OR 2.8, P < 0.001) and in MSM of younger age (P = 0.05). Only 35% of recommended cerebrospinal fluid (CFS) examinations were performed. Neurosyphilis was diagnosed in four neurologically asymptomatic patients; all of them had a Venereal Disease Research Laboratory (VDRL) titer of 1:>or=32. Ninety-one percent of the patients responded to treatment with at least a four-fold decline in VDRL titer.

CONCLUSION

Syphilis remains an important coinfection in the SHCS justifying reintroduction of routine screening. Genitooral contact is a significant way of transmission and young MSM are at high risk for syphilis. Current guidelines to rule out neurosyphilis by CSF analysis are inconsistently followed in clinical practice. Serologic treatment response is above 90% in the era of combination antiretroviral therapy.

Emerging issues in management of sexually transmitted diseases in HIV infection

Sexually transmitted diseases (STDs) occur often among sexually active persons with HIV infection. Incident STDs may complicate the course of HIV infection and potentiate HIV transmission in the coinfected individual by mucosal disruption and an increase in HIV concentration in ulcers and involved mucous membranes. Conducting ongoing periodic sexual risk assessments in HIV-positive patients in routine medical care is critical to identifying asymptomatic infections. HIV clinicians should be familiar with updated recommendations for screening, diagnosis, and treatment of bacterial and viral STDs, including those specific to HIV infection. This article addresses emerging issues in the management of STDs in HIV-infected persons and summarizes the latest evidence that can be applied to clinical decision-making in this population.

Renal and urologic emergencies in the HIV-infected patient

Antiretroviral therapy has revolutionized the care of individuals infected with the human immunodeficiency virus (HIV) and has fundamentally altered the scope of the disease. Acute renal failure and chronic kidney disease from medication toxicity and comorbid noninfectious illnesses are just as likely today as end-organ injury from the virus itself. Chronic immunosuppression renders HIV-infected patients vulnerable to any of several unique urological infections not frequently seen in immunocompetent patients. A deeper understanding of renal and urological emergencies in the context of the HIV-infected patient will better prepare the emergency physician to render optimal care to this rapidly expanding and aging patient population.

Etiology of genital ulcer disease. A prospective study of 278 cases seen in an STD clinic in Paris

OBJECTIVES

The goal of this study was to identify the causes and factors associated with genital ulcer disease (GUD) among patients attending a sexually transmitted disease (STD) clinic in Paris.

METHODS

This study was a prospective investigation of GUD cases. Data were collected from 1995 to 2005. In each case, a Dark Field Examination (DFE), Gram stain, inoculation onto Thayer Martin agar, Columbia agar and chocolate agar with 1% isovitalex and 20% fetal calf serum, PCR Chlamydia trachomatis (Amplicor Roche), culture for herpes simplex virus (HSV) on MRC 5 cells and PCR HSV (Argene Biosoft) were obtained from the ulceration. First Catch Urine (FCU) PCR for Chlamydia trachomatis and syphilis, HIV, HSV, and HBV serologies were also performed.

RESULTS

A total 278 cases of GUD were investigated, 244 (88%) in men and 34 (12%) in women. Primary syphilis accounted for 98 cases (35%), genital herpes for 74 (27%), chancroid for 8 (3%), other infections for 12 (5%). In 91 (32%) patients, no identifiable microorganism was documented. Primary syphilis was more prevalent in MSMs (P < 0.0001), while genital herpes and chancroid were significantly associated with heterosexuality (both P < 0.0001). A high level of HIV infection (27%) was found, particularly in patients with primary syphilis (33%). In the univariate analysis, no statistical difference was found between syphilis and herpes according to clinical presentation, pain being the only item slightly more frequent in herpes (P = 0.06). In the multivariable model syphilis was associated with being MSM (OR: 51.3 [95% CI: 14.7-178.7], P < 0.001) and with an ulceration diameter >10 mm (OR: 9.2 [95% CI: 2.9-30.7], P < 0.001). Genital herpes was associated with HIV infection in the subgroup of MSWs (OR: 24.4 [2.4-247.7], P = 0.007). We did not find significant differences in the clinical presentation of the ulcers according to HIV status.

CONCLUSION

The profound changes of the epidemiology of GUD during the decade, due to disappearance of chancroid and reemergence of infectious syphilis have led to a new distribution of pathogens, genital herpes, primary syphilis and GUD from unknown origin, accounting each for one third of cases. No clinical characteristic is predictive of the etiology, underlining the importance of performing a thorough microbiologic evaluation. Close association with HIV is still a major public health problem.

Syphilis epidemiology and clinical outcomes in HIV-infected and HIV-uninfected patients in Kaiser Permanente Northern California

BACKGROUND

Syphilis rates are rising in California, but the impact of HIV infection on syphilis infection remains uncertain. We describe differences between HIV-infected and HIV-uninfected patients diagnosed with syphilis within Kaiser Permanente Northern California.

METHODS

We performed retrospective analyses of patients diagnosed with incident syphilis from 1995 to 2005 (622 cases/9989 HIV-infected patients and 3584/4,442,780 HIV-uninfected). Among cases, we ascertained demographic, clinical characteristics, and laboratory (including baseline labs and repeated RPR titers) data. We performed Poisson regression (incidence) and Cox proportional hazard modeling (reduction in RPR and serologic failure after syphilis therapy) adjusting for age, gender, and HIV status and among HIV-infected cases only by use of antiretroviral therapy (ART).

RESULTS

HIV-infected patients had incident syphilis rates of 62.3/1000 person-years compared with 0.8/1000 HIV-uninfected patients, corresponding to an adjusted rate ratio of 86.0 (P <0.001); rate differences increased significantly over time. HIV-infected patients had a greater likelihood of reduction in RPR and serologic failure after syphilis therapy (HR = 2.5 and 2.6 respectively [P <0.001 both]). Among HIV-infected only, patients on ART had lower rates of infection but higher likelihood of reduction in RPR after syphilis therapy and serologic failure compared with patients not on ART.

CONCLUSIONS

HIV-infected patients had greater rate of incident syphilis compared with HIV-uninfected, a disparity which increased over time. HIV-infected patients had greater likelihood of decline in RPR and serologic failure. HIV-infected patients should be screened for syphilis regularly.

Multiple ulcers in primary syphilis with negative rapid plasma reagin and Venereal Disease Research Laboratory tests: an unusual presentation during the re-emergence of syphilis in Albania

Since 1995 infectious syphilis has re-emerged in Albania. As syphilis has become more common, more unusual presentations are being recognized. We present a case of an HIV-negative man with primary syphilis presenting with multiple penile ulcers and negative rapid plasma reagin and Venereal Disease Research Laboratory tests. The case illustrates the challenges of diagnosing early syphilis and the importance of not relying on non-treponemal tests.

Pathogen-pathogen interaction: a syndemic model of complex biosocial processes in disease

There is growing awareness of the health implications of fact that infectious agents often do not act independently; rather their disease potential is mediated in diverse and significant ways by their relationships with other pathogens. Pathogen-pathogen interaction (PPI), for example, impacts various virulence factors in human infection. Although still in its infancy, the study of PPI, a form of epidemiological synergism, is emerging as an important arena of new research and new understanding in health and clinical care. The aims of this paper are to: 1) draw attention to the role of PPI in human disease patterns; 2) present the syndemics model as a biosocial approach for examining the nature, pathways, contexts, and health implications of PPI; and 3) suggest the utility of this approach to PPI. Toward these ends, this paper (a) reviews three of case examples of alternative PPIs, (b) describes the development and key concepts and components of the syndemics model with specific reference to interacting infectious agents, (c) contextualizes this discussion with a brief review of broader syndemics disease processes (not necessarily involving infections disease), and (d) comments on the research, treatment and prevention implications of syndemic interaction among pathogens.

Clinical and serologic baseline and follow-up features of syphilis according to HIV status in the post-HAART era

There is a lack of large studies appraising the effect of the human immunodeficiency virus (HIV) on the course of syphilis since the advent of highly active antiretroviral therapy (HAART). We aimed to appraise the effect of HIV on clinical and serologic features of syphilis at baseline and during follow-up in the post-HAART era.We designed a retrospective cohort study of consecutive syphilis cases, diagnosed between 2000 and 2007, in an academic venereal disease center. Data were collected using standardized medical forms. Patients were treated according to the European guidelines. Serologic failure was defined as either a 4-fold rise in Venereal Disease Research Laboratory (VDRL) titers 30-400 days posttreatment or a lack of 4-fold drop in VDRL titers at 270-400 days posttreatment.Among 279 syphilis cases with informative baseline clinical and serologic data, HIV infection was significantly associated with men having sex with men, French origin, multiple partners, lesser usage of condom, history of sexually transmitted disease, early syphilis, anal primary chancre, and cutaneous eruption. Median baseline titer from the Treponema pallidum hemagglutination assay (TPHA) was higher in HIV-infected patients (p = 0.02).Among 144 informative syphilis cases, there was a nonsignificant trend for a lower rate of serologic response among HIV-positive patients (91.8% vs. 98.3%, p = 0.14). Serologic failure was significantly associated with a history of previous syphilis (p < 0.05). The median delay to serologic response was similar in HIV-positive (117 d) and in HIV-negative (123 d) patients (p = 0.44).We conclude that for patients under HAART treatment, the effect of HIV on serologic response to syphilis treatment is likely minimal or absent.

Qualitative and quantitative aspects of the serological diagnosis of early syphilis

Summary:

The aim of the present study was to evaluate the use of various serological tests in the diagnosis of early syphilis. The Murex enzyme immunoassay (EIA) test was used for screening; the Venereal Diseases Research Laboratory (VDRL) test, the Treponema pallidum particle agglutination assay (TPPA) and the Mercia antitreponemal IgM EIA were used in all the patients with a positive screening test and in those with suspected syphilis or in known contacts. In 89 cases of primary syphilis, the Murex EIA screening test was positive in 67 (75%) patients, the Mercia IgM EIA in 80 (90%) cases, the VDRL in 60 (67%) cases and the TPPA in 85 (96%) cases. All the tests were positive in 68 patients with secondary syphilis. In 72 cases of early latent syphilis, the Murex EIA screening test was positive in 68 (94%) patients, the Mercia IgM EIA in 50 (69%) cases, the VDRL in 61 (85%) cases and the TPPA in 68 (94%) cases. The Mercia IgM EIA was the only test positive in four (6%) of these cases; these four patients were known contacts. Antibody titres in the VDRL and TPPA increased as the infection progressed.

Syphilis and hepatitis B Co-infection among HIV-infected, sex-trafficked women and girls, Nepal

Sex trafficking may play a major role in spread of HIV across South Asia. We investigated co-infection with HIV and other sexually transmitted diseases among 246 sex-trafficked women and girls from Nepal. Those who were HIV positive were more likely than those who were HIV negative to be infected with syphilis and/or hepatitis B.

Primary syphilis

Cases of syphilis have been increasing in the UK and it remains an important public health problem. Here, we provide an overview of syphilis, its presentation, diagnosis and management.

Reexamining syphilis: an update on epidemiology, clinical manifestations, and management

OBJECTIVE

To review the epidemiology, clinical features, diagnosis, and treatment of syphilis.

DATA SOURCES

Studies and reviews were abstracted from MEDLINE (1950-April 2007) using the search term syphilis. All papers were cross-referenced to identify additional studies and reviews for inclusion.

STUDY SELECTION AND DATA EXTRACTION

Pertinent original research articles, review articles, and book chapters were evaluated.

DATA SYNTHESIS

Syphilis is a spirochetal disease that has plagued mankind for centuries. Following a low incidence of syphilis in the US for the last 2 decades, rates are now increasing both in the US and other parts of the world. Once acquired, syphilis can pass through 4 distinct stages of disease: primary syphilis, secondary syphilis, latent syphilis, and tertiary syphilis, with each stage being characterized by different symptoms and levels of infectivity. Diagnosis is made primarily by serologic assays with nontreponemal tests such as the Venereal Disease Research Laboratory and the Rapid Plasma Reagin assay used for screening. Treponemal tests including the Treponema pallidum particle agglutination and the fluorescent treponemal antibody absorption test are then used for confirmation. Recommended treatment regimens are based largely on uncontrolled trials and clinical experience. Penicillin is the treatment of choice, with the preparation and treatment duration varying for different stages. Benzathine penicillin is the treatment of choice for all stages of syphilis except neurosyphilis, for which aqueous crystalline penicillin or procaine penicillin is used due to the central nervous system penetration of these formulations. Coinfection with both syphilis and HIV occurs frequently due to common risk factors. These 2 diseases interact with each other, making both diagnosis and treatment more complicated.

CONCLUSIONS

Clinicians should be aware of the signs and symptoms of syphilis as well as current guidelines for the management and treatment of this disease.

Syphilis in the United States: an update for clinicians with an emphasis on HIV coinfection

Diagnosis and treatment of syphilis are challenging because of its variable clinical presentation and course and the lack of definitive tests of cure after treatment. This review of the most recent literature on the epidemiology, clinical manifestations, current diagnosis, and treatment of syphilis is focused toward clinicians who treat patients with this disease. Syphilis coinfection with human immunodeficiency virus is emphasized because it is increasingly common in the United States and affects the initial presentation, disease course, diagnosis, and treatment of syphilis. Of particular consequence is the effect of human immunodeficiency virus on the clinical diagnosis, prevalence, and course of neurosyphilis, one of the most serious consequences of syphilis infection.

The resurgence of syphilis among men who have sex with men

PURPOSE OF REVIEW

To identify recent progress and emerging problems in addressing syphilis among men who have sex with men.

RECENT FINDINGS

A resurgence of syphilis has occurred among men who have sex with men in many developed countries. Infection has been associated with HIV coinfection, multiple partners, and recreational drug use. Unlike HIV, oral sex appears to be a common route of syphilis transmission. Many prevention approaches have shown, at best, modest success. Variable clinical presentation and potentially inconclusive lab tests make diagnosis confusing.

SUMMARY

As the infection remains relatively rare, clinicians treating men who have sex with men should maintain a high index of suspicion for syphilis lesions, and should screen their sexually active patients for latent disease. Debates about syphilis control and treatment continue. The clinical manifestations, serologic responses, efficacy of treatment, and complications of syphilis have always been complicated. HIV coinfection adds to the confusion.

Current Controversies in the Management of Adult Syphilis

Clinical management of patients with syphilis is controversial. This article summarizes recent research on syphilis treatment efficacy and outcomes and is based on a comprehensive systematic review of published literature, relevant abstracts, conference proceedings, technical reports, and guidelines. Penicillin remains the drug of choice for the treatment of syphilis. Although several studies have suggested that azithromycin may have clinical efficacy, macrolide resistance has been widely documented among strains of Treponema pallidum, and treatment failures have been reported. Ceftriaxone is effective for the treatment of syphilis when used in multiple-dose regimens. Lumbar puncture should be performed for human immunodeficiency virus-infected patients with syphilis of >1 year's duration and a serum nontreponemal test titer > or =1 : 32, as well for other patients for whom the clinical suspicion of neurosyphilis is high. Newer laboratory tests for syphilis are undergoing extensive evaluation and may prove to be useful for future clinical care. American and European approaches to syphilis treatment are similar, but they vary across several parameters.

Evaluation of the Treponema pallidum particle agglutination technique (TP.PA) in the diagnosis of neurosyphilis

The Treponema pallidum particle agglutination technique (TP.PA) was evaluated, in comparison with the Venereal Disease Research Laboratory (VDRL) test, microhemagglutination assay for Treponema pallidum antibodies (MHA-TP), and fluorescent treponemal antibody-ABS (FTA-Abs) test for the diagnosis of neurosyphilis. We have studied 198 cerebrospinal fluid (CSF) samples from patients with syphilis, including neurosyphilis, treated syphilis, and with other neurological manifestations than neurosyphilis. All tests were nonreactive in these last group of patients. In the neurosyphilis patients, sensitivity of the TP.PA was 100%. The performance of this test in CSF from patients with primary syphilis was as good as that of the other tests. In secondary and latent syphilis, the TP.PA results (27 reactive samples/73) were similar to those of the MHA-TP (25 reactive samples/73). In the individuals treated for syphilis, the TP.PA, FTA-Abs, and MHA-TP tests were found to be reactive in eight, six, and eight samples, respectively. In conclusion, it seems that the TP.PA can be used in CSF to diagnose neurosyphilis, although as for other serological tests, interpretation of results should be done in conjunction with other neurosyphilis parameters.

Cutaneous manifestations of syphilis : recognition and management

After a marked decline in the number of syphilis cases in the context of AIDS prevention campaigns, a significant increase has been observed in states of the former Soviet Union since 1994. In recent years, outbreaks have also been reported in the US, Canada, and several European countries. The current epidemic in the US and in different parts of Europe has largely involved men who have sex with men, many of whom are infected with HIV. Since a misdiagnosis of syphilis can have serious consequences for the patient and also for pregnancies and newborns, clinicians should be aware of the many manifestations of syphilis and difficulties in the diagnosis and management of the disease. Younger clinicians in particular are no longer familiar with the diverse clinical symptoms and the complex diagnostics of syphilis. Patients co-infected with HIV may present with atypical clinical manifestations and laboratory test results. Furthermore, through its association with an increased risk of HIV infection, syphilis has acquired a new potential for morbidity and mortality, and the diagnosis of syphilis should be routinely considered in patients with uveitis, sudden deafness, aortic thoracic aneurysm, or pregnancy. Only a minority of syphilis infections are detected in the primary stage. This may be because of atypical locations and, occasionally, atypical morphology of the lesions; however, it may also be because of the difficulty of detecting the pathogen. In the secondary stage, which is clinically extremely diverse, the diagnosis is confirmed serologically. There is a need for increased awareness of the symptoms and signs of acute infections, together with a willingness to consider the diagnosis of syphilis in patients with vague symptoms. An increasing number of diagnostic tests (both specific and nonspecific) are now available. However, in the absence of clinical symptoms or in cases with a low titer or inconsistent test results, diagnosis of syphilis can be difficult or even impossible. Treatment and follow-up should follow current guidelines designed for the involved area. In this article, the cutaneous manifestations of syphilis and their diagnostic and therapeutic management are described in detail.

Syphilis and HIV Infection: an Update

Although once on decline in the United States and Europe, the incidence of syphilis has been on the rise since 2000. This increase is noteworthy because there is a high coinfection rate with HIV, especially among men who have sex with men. In light of high coinfection rates, all HIV-infected patients should be tested for syphilis and vice versa. HIV can alter the clinical manifestations of syphilis and, in turn, syphilis has the potential to change the course and transmission of HIV. This article addresses variations in clinical presentation, diagnosis, and management of individuals coinfected with HIV and syphilis.

Serological response to syphilis treatment in HIV-positive and HIV-negative patients attending sexually transmitted diseases clinics

BACKGROUND

HIV-positive patients treated for syphilis may be at increased risk for serological failure.

OBJECTIVE

To compare follow-up serologies and serological responses to treatment between HIV-positive and HIV-negative patients attending two sexually transmitted disease (STD) clinics.

STUDY DESIGN

Existing records were reviewed from HIV-positive patients who were diagnosed and treated for syphilis at the public STD clinics in Baltimore, Maryland, USA, between 1992 and 2000. Results of their serological follow-up were compared with those of HIV-negative clinic patients at the time of syphilis treatment. Failure was defined as lack of a fourfold drop in rapid plasma reagin (RPR) titre by 400 days after treatment or a fourfold increased titre between 30 and 400 days.

RESULTS

Of the 450 HIV-positive patients with syphilis, 288 (64%) did not have documented follow-up serologies and 129 (28.5%) met the inclusion criteria; 168 (17%) of 1000 known HIV-negative patients were similarly eligible. There were 22 failures in the HIV-positive group and 5 in the HIV-negative group (p<0.001). The median times to successful serological responses in both groups were 278 (95% confidence interval (CI) 209 to 350) and 126 (95% CI 108 to 157) days, respectively (p<0.001). A multivariate Cox's proportional hazards model showed an increased risk of serological failure among the HIV-positive patients (hazards ratio 6.0, 95% CI 1.5 to 23.9; p = 0.01).

CONCLUSION

HIV-positive patients treated for syphilis may be at higher risk of serological failure. Despite recommendations for more frequent serological follow-up, most patients did not have documentation of serological response after standard treatment for syphilis.

Biological basis for syphilis

Syphilis is a chronic sexually transmitted disease caused by Treponema pallidum subsp. pallidum. Clinical manifestations separate the disease into stages; late stages of disease are now uncommon compared to the preantibiotic era. T. pallidum has an unusually small genome and lacks genes that encode many metabolic functions and classical virulence factors. The organism is extremely sensitive to environmental conditions and has not been continuously cultivated in vitro. Nonetheless, T. pallidum is highly infectious and survives for decades in the untreated host. Early syphilis lesions result from the host's immune response to the treponemes. Bacterial clearance and resolution of early lesions results from a delayed hypersensitivity response, although some organisms escape to cause persistent infection. One factor contributing to T. pallidum's chronicity is the paucity of integral outer membrane proteins, rendering intact organisms virtually invisible to the immune system. Antigenic variation of TprK, a putative surface-exposed protein, is likely to contribute to immune evasion. T. pallidum remains exquisitely sensitive to penicillin, but macrolide resistance has recently been identified in a number of geographic regions. The development of a syphilis vaccine, thus far elusive, would have a significant positive impact on global health.

Sífilis: diagnóstico, tratamento e controle

A sífilis é doença infecto-contagiosa, transmitida pela via sexual e verticalmente durante a gestação. Caracteriza-se por períodos de atividade e latência; pelo acometimento sistêmico disseminado e pela evolução para complicações graves em parte dos pacientes que não trataram ou que foram tratados inadequadamente. É conhecida desde o século XV, e seu estudo ocupou todas as especialidades médicas e, de modo especial, a dermatologia. Seu agente etiológico, o Treponema pallidum, nunca foi cultivado e, apesar de descrito há mais de 100 anos e sendo tratado desde 1943 pela penicilina, sua droga mais eficaz, continua como um problema de saúde importante em países desenvolvidos ou subdesenvolvidos. Dadas as características da forma de transmissão, a doença acompanhou as mudanças comportamentais da sociedade e nos últimos anos tornou-se mais importante ainda devido à possibilidade de aumentar o risco de transmissão da síndrome de imunodeficiência adquirida. Novos testes laboratoriais e medidas de controle principalmente voltadas para o tratamento adequado do paciente e parceiro, uso de preservativo, informação à população fazem parte das medidas adotadas para controle da sífilis pelos responsáveis por programas de saúde.