Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features

Hemophagocytosis: the cause of anemia and thrombocytopenia in congenital syphilis

Congenital syphilis is a rare, serious disease that continues to be a major health-care problem. The infected neonate may be asymptomatic or multiple-organ system involvement may occur. Anemia and thrombocytopenia are common hematological findings. Hemophagocytic lymphohistiocytosis (HLH) is a clinicopathological condition characterized by activation and uncontrolled nonmalignant proliferation of T lymphocytes and macrophages. The authors report an infant with congenital syphilis as a very rare cause of hemophagocytic syndrome. The reason for anemia and thrombocytopenia in congenital syphilis is not clear. The authors suggest that hemophagocytosis may play role in pathogenesis of cytopenia, particularly thrombocytopenia in patients with congenital syphilis.

A large ulcer and cutaneous small‐vessel vasculitis associated with syphilis infection

Cutaneous vasculitis (CV) is a condition with cutaneous manifestations and possible systemic involvement. The causative factors or associated diseases are usually drugs, infection, collagen vascular disease, or malignancy. Syphilis as a cause of cutaneous vasculitis is rare. We report the case of a large cutaneous ulcer and small-vessel vasculitis associated with syphilis infection. We suggest that in apparently idiopathic CV or a chronic ulcer refractory to treatment, screening should be performed to detect any underlying infection such as syphilis. It is important to have a rapid and accurate diagnosis because the lesions are very contagious, but may be rapidly and completely cured by early administration of antibiotic treatment.

Laboratory diagnosis of syphilis with automated immunoassays

The serological detection of specific antibodies to Treponema pallidum is of particular importance in the diagnosis of syphilis. The purpose of this study was to evaluate diagnostic performances of automated immunoassays in comparison with T. pallidum hemagglutination test (TPHA) and Western Blot (WB). The retrospective study was performed with different panels of sera: 244 clinical and serological characterized syphilitic sera and 203 potentially interfering samples. All the sera were tested by Enzygnost Syphilis, ARCHITECT Syphilis TP, TPHA, and homemade WB. The diagnostic performances of the two assays were very similar: both Enzygnost Syphilis and ARCHITECT Syphilis TP performed with a sensitivity of 99.2%, whereas the specificity was 98.5 and 98.4%, respectively. Considering the suitability for automation, both immunoassays may represent a good choice as a screening test. However, the use of a confirmatory test, such as TPHA or WB, remains a must in order to avoid false-positive results.

Profile of blood donors with serologic tests reactive for the presence of syphilis in São Paulo, Brazil

BACKGROUND

Syphilis screening of blood donors is a common practice worldwide, but very little is known about the meaning of a positive serologic test for syphilis in blood donors and the risk profile of these donors. The aim of this study was to determine the demographic characteristics and risk behaviors of blood donors with recent and past syphilis and their implications for blood bank testing and deferral strategies.

STUDY DESIGN AND METHODS

Demographic characteristics, category of donation, number of previous donations, sexual behavior, and history of sexually transmitted diseases were reviewed comparing blood donors with recent and past syphilis from January 1, 1999, to December 31, 2003.

RESULTS

A total of 2439 interviews were reviewed, including 2161 (88.6%) donors with past and 278 (11.4%) with recent syphilis infection. Factors associated with recent infection included younger age (< or = 20 years odds ratio [OR], 36.5; 95% confidence interval [CI], 15.8-84.1), two previous donations (OR, 2.7; 95% CI, 1.9-3.9), male-male sex (homosexual OR, 8.2; 95% CI, 3.2-20.8; and bisexual OR, 11.4; 95% CI, 3.6-36.3), two or more partners in the past 12 months (OR, 2.3; 95% CI, 1.3-4.0), symptoms for syphilis (OR, 4.5; 95% CI, 2.8-7.1), and human immunodeficiency virus (HIV) seropositivity (OR, 39.6; 95% CI, 4.6-339.8). Community donors were also associated with recent syphilis infection (OR, 1.5; 95% CI, 1.2-1.9) compared to replacement donors.

CONCLUSION

Sexual history, including male-male sex and multiple partners, were strongly associated with recent syphilis infection, which in turn was strongly associated with HIV. Continuous and vigilant surveillance that includes assessing sexual history and other factors associated with syphilis are needed to guide blood safety policies.

Syphilis and HIV co-infection

Syphilis is a complex disease, which is sexually transmitted. The incidence of syphilis is rising all over the world, partly due to the increased transmission in HIV patients and other high risk groups such as men who have sex with men. Interestingly syphilis itself facilitates HIV infection in several ways. Great importance exists in recognition of both diseases and their complex interactions. This article will review the manifestations of syphilis in the context of HIV infected patients, and the challenging diagnosis and management of these patients.

Cost effectiveness of enzyme immunoassay and immunoblot testing for the diagnosis of syphilis

The burden of disease and associated health-care costs of syphilis are significant despite widespread screening and treatment. Our objective was to conduct an economic evaluation using a simulation model when comparing enzyme immunoassay (EIA) initial testing and Inno-Lia (IL) confirmatory testing (EIA + IL) with rapid plasma reagin (RPR) initial testing and Treponema pallidum particle agglutination assay (TPPA) and fluorescent treponemal antibody absorption assay (FTA-ABS) confirmatory testing (RPR + TPPA/FTA). Estimates of prevalence, test costs and utilization of services for 2006 were derived from Alberta databases. Estimates of test characteristics were derived from the available literature. The incremental cost-effectiveness ratio was Canadian $461 per additional correct diagnosis (less costly and more effective). EIA + IL is cost-effective when compared with RPR + TPPA/FTA for screening and diagnosis of syphilis.

Specific and sensitive diagnosis of syphilis using a real-time PCR for Treponema pallidum

A real-time PCR assay with a Taqman probe was developed that targeted the polA gene of Treponema pallidum. The test was validated using an analytical panel (n = 140) and a clinical panel of genital samples (n = 112) from patients attending a sexually transmitted infections clinic. High sensitivities and specificities of 94-100% were achieved using two real-time PCR platforms, the Rotor-Gene and the iCycler. The assay can be completed within 2 h, enabling reporting in <8 h. This fast and robust assay is suitable for implementation in routine laboratories for diagnosing primary syphilis.

Formulas for estimating the costs averted by sexually transmitted infection (STI) prevention programs in the United States

Background

Sexually transmitted infection (STI) prevention programs can mitigate the health and economic burden of STIs. A tool to estimate the economic benefits of STI programs could prove useful to STI program personnel.

Methods

We developed formulas that can be applied to estimate the direct medical costs and indirect costs (lost productivity) averted by STI programs in the United States. Costs and probabilities for these formulas were based primarily on published studies.

Results

We present a series of formulas that can be used to estimate the economic benefits of STI prevention (in 2006 US dollars), using data routinely collected by STI programs. For example, the averted sequelae costs associated with treating women for chlamydia is given as (C_w)(0.16)(0.925)(0.70)($1,995), where C_w is the number of infected women treated for chlamydia, 0.16 is the absolute reduction in the probability of pelvic inflammatory disease (PID) as a result of treatment, 0.925 is an adjustment factor to prevent double-counting of PID averted in women with both chlamydia and gonorrhea, 0.70 is an adjustment factor to account for the possibility of re-infection, and $1,995 is the average cost per case of PID, based on published sources.

Conclusion

The formulas developed in this study can be a useful tool for STI program personnel to generate evidence-based estimates of the economic impact of their program and can facilitate the assessment of the cost-effectiveness of their activities.

Life-threatening bite injury of the lower lip after use of metamizole

INTRODUCTION

Bite wounds of the oral mucosa heal after eliminating the causative irritant, but there are serious exceptions from the rule. We present the case of a 37-year-old woman with an ulcer of the mucosa of the lower lip, which had been present for 10 days, and leucopenia.

DISCUSSION

Agranulocytosis after the use of metamizole is part from leukaemia and lues, a rare reason for non-healing ulcers of the mucosa of the oral cavity without fulminant signs for inflammation.

CONCLUSION

As this is a life-threatening disease, medical therapy must begin immediately.

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.

Diagnosis and management of fetal growth restriction: the role of fetal therapy

Fetal growth restriction remains a major cause of perinatal morbidity and mortality in modern obstetric practice. Placental insufficiency is the most common association, but is often a diagnosis of exclusion. Currently, no treatment can ameliorate or reverse established growth restriction: maximising gestational age and judicious timing of steroid administration and delivery are the primary tasks for the obstetrician. Although comprehensive surveillance of the preterm fetus now includes ductus venosus Doppler studies, its effectiveness in timing delivery has yet to be confirmed in randomised controlled trials. More basic research on the regulation of fetal growth is needed before specific therapies for established growth restriction can be developed.

Maternal syphilis and intimate partner violence in Bolivia: a gender-based analysis of implications for partner notification and universal screening

OBJECTIVES

Use a gender perspective to analyze a partner notification study conducted in antenatal clinics in Bolivia to assess the association between intimate partner violence (IPV) and partner notification.

GOAL

Guide the implementation of a safe, feasible, and culturally appropriate partner notification strategy in Bolivia in order to reduce the potential of IPV.

STUDY DESIGN

We conducted a cross-sectional survey with women (n = 209) and their notified partners (n = 137) and structured interviews with a subsample of participants.

RESULTS

Nearly 40% of women reported IPV in the past year and 28% mentioned fear of violence as a barrier to notifying their partners. Overall, 65% of women reported that they had notified their partners about their positive syphilis test results. Women who did not perceive violence as a barrier had greater odds of notifying their partner of their syphilis status (OR = 1.82; CI [0.93-3.60]; P <0.08). Women who could not protect themselves against partners' syphilis had a lower odds of notifying their partner (OR = 0.06; CI [0.049-0.656]; P <0.0001). Women who notified their partners said it was a favorable experience. Most men said they responded well to their partner's disclosure but could understand other men acting violently, especially when infidelity was involved.

CONCLUSIONS

The majority of women who participated were able to notify male partners of their positive syphilis diagnosis but also reported high levels of domestic violence. The data suggest that public health practitioners should concomitantly screen for IPV and syphilis during pregnancy and assist women in abusive relationships on how to communicate sensitive disclosure information to partners.

Scaling Up Antenatal Syphilis Screening in Mozambique: Transforming Policy to Action

OBJECTIVES

This paper examines the decade-long scale-up process of antenatal syphilis screening through Mozambique's National Health System.

GOAL

The primary goal is to provide lessons learned in the provision of integrated antenatal care resource-poor settings and identify key challenges to successful scale-up.

STUDY DESIGN

We documented health systems activities associated with improvements in the proportion of women tested, treated, and partners treated for syphilis.

RESULTS

The proportion of women in antenatal visit screened for syphilis in the two target provinces has risen from 5% in 1992 to between 60% and 95% consistently since 1999. This success required multiple levels of health system strengthening.

CONCLUSIONS

The Mozambique experience shows that key elements to effective antenatal syphilis screening include adequate workforce, facilities, coherent systems of care, community involvement, donor management, advocacy, and leadership.

Managing congenital syphilis again? The more things change …

PURPOSE OF REVIEW

Untreated syphilis may have profound adverse effects on pregnancy outcome, resulting in spontaneous abortion, stillbirth, premature delivery or perinatal death, or can result in significant morbidity during infancy, childhood or adolescence. In this article, we review current strategies for the management of maternal and congenital syphilis nationally and in resource-poor settings.

RECENT FINDINGS

Since 1998, a dramatic increase in syphilis diagnoses has been documented among women of child-bearing age in the UK and elsewhere. The low prevalence of congenital syphilis in many developed countries may have led to complacency, hindering modern-day management of this historically important condition. Follow-up studies indicate that present antenotal and postnatal interventions could be improved. This conclusion extends to resource-poor settings endemic for syphilis in which rapid diagnostic techniques are currently being validated.

SUMMARY

A stringent follow-up of pregnant women with syphilis before delivery and a proactive approach to identifying and treating exposed neonates born to such patients are needed.

Characterization of the Western blotting IgG reactivity patterns in the clinical phases of acquired syphilis

We standardized the Western blotting (WB) method for detecting Treponema pallidum IgG (Tp-IgG) antibodies in sera samples of patients with syphilis and correlated the reactivity profile of bands with the clinical phases of the disease. The WB Tp-IgG has 100% sensitivity and 99.5% specificity. The clinical phases of the disease were associated with the reactive bands from TpN15 to TpN47. Quantitative Venereal Disease Research Laboratories was used to assist the WB Tp-IgG analysis. In primary syphilis, the reaction intensity for the antigenic band TpN47 was usually more intense when compared with other clinical phase. In secondary and sometimes in early latent syphilis, antibodies reacted with high numbers of antigenic proteins of T. pallidum. In late latent syphilis, various bands became negative, but the TpN15 and TpN47 were reactive. In tertiary syphilis, we observed reactivity with the TpN15 band and low reactivity with the TpN47. We concluded that WB Tp-IgG could be used to confirm serologic tests and characterize clinical phases of syphilis.

Evaluation of the LIAISON chemiluminescence immunoassay for diagnosis of syphilis

We report the results of an evaluation of the LIAISON Treponema pallidum-specific assay, a one-step sandwich chemiluminescence immunoassay (CLIA), as a screening test and as a confirmatory test for the diagnosis of syphilis. The assay was compared with the CAPTIA Syphilis-G enzyme immunoassay (EIA) and with a testing algorithm that also included the rapid plasma reagin (RPR) and T. pallidum particle agglutination (PA) assays. As a screening test, the CLIA showed levels of agreement with the EIA and with the algorithm, respectively, of 94.1 and 100% for 51 samples from patients with primary or secondary syphilis, 93.2 and 98.7% for 999 samples sent to the laboratory for routine syphilis testing, 84.5 and 94.0% for 200 samples from human immunodeficiency virus-positive patients, 98.0 and 100% for 200 samples from pregnant patients, and 94.3 and 98.3% for 992 samples from apparently healthy adults. As a confirmatory test, the CLIA showed 99% agreement with the EIA for 204 RPR-positive samples. After resolution with further T. pallidum PA testing and the discarding of one sample of insufficient quantity, there was 100% agreement for the remaining 203 samples. For the total group of 2,645 samples, the overall relative sensitivity was 95.8% and the relative specificity was 99.1%. We conclude that the LIAISON CLIA demonstrated excellent sensitivity and specificity when evaluated as a confirmatory test and as a screening test for syphilis among various patient populations, including specific populations with reportedly increased rates of false-positive nontreponemal test results.

Why do we need quality-assured diagnostic tests for sexually transmitted infections?

The bacterial sexually transmitted infections (STIs) syphilis, gonorrhoea and chlamydia can all be cured with a single dose of antibiotic. Unfortunately, however, these infections often remain undiagnosed as many infected individuals have few if any symptoms. Diagnostic tests with high sensitivity and specificity are available for all three infections but, owing to their expense and the lack of laboratory capacity, most people in developing countries do not have access to these tests. There is a great need for simple, cheap diagnostic tests for STIs that can be performed at the point of care, enabling treatment to be given immediately. It is hoped that recent advances in our understanding of the pathogenesis of these infections, and the availability of the complete genome sequences for each causative organism, will lead to the development of improved point-of-care tests that will reduce the burden of these diseases in developing countries.

Why do we need quality-assured diagnostic tests for sexually transmitted infections?

The bacterial sexually transmitted infections (STIs) syphilis, gonorrhoea and chlamydia can all be cured with a single dose of antibiotic. Unfortunately, however, these infections often remain undiagnosed as many infected individuals have few if any symptoms. Diagnostic tests with high sensitivity and specificity are available for all three infections but, owing to their expense and the lack of laboratory capacity, most people in developing countries do not have access to these tests. There is a great need for simple, cheap diagnostic tests for STIs that can be performed at the point of care, enabling treatment to be given immediately. It is hoped that recent advances in our understanding of the pathogenesis of these infections, and the availability of the complete genome sequences for each causative organism, will lead to the development of improved point-of-care tests that will reduce the burden of these diseases in developing countries.

Inadequate syphilis screening among women with prenatal care in a community with a high syphilis incidence

OBJECTIVES AND GOAL

This study was designed to evaluate the extent to which pregnant women in a community with a high syphilis incidence were screened for syphilis according to standard recommendations of twice during prenatal care and at labor and delivery.

STUDY DESIGN

Labor and delivery records from 4 hospitals in Miami-Dade County, Florida, were abstracted to obtain maternal and prenatal care characteristics and syphilis screening practices.

RESULTS

Of the 1991 women, records indicated that 1655 (83%) were screened at least once during prenatal care, 220 (11%) were screened twice during prenatal care before delivery, and 184 (9%) were screened twice during prenatal care and at delivery. Attending a private clinic, having more than adequate prenatal care and having private insurance were associated with not being screened at least twice before delivery.

CONCLUSIONS

Few women were screened according to standard recommendations, and provider or institutional-related factors affected adequacy of screening.

Transmission of syphilis by solid organ transplantation

Two organ recipients developed serologic evidence of syphilis infection after renal transplantation from a common deceased donor with a history of treated syphilis. Testing of donor serum for syphilis, which occurred after transplantation, gave results interpreted as consistent with past infection. However, subsequent serologic results in the recipients suggested transmission of infection at transplantation due to active infection of the donor. This may be explained by recent donor re-infection in view of the current syphilis epidemic in the United Kingdom. An initial error in the treatment of recipients further served to highlight unfamiliarity in managing this resurgent infection in the context of organ transplantation.

Symptomatic Relapse of Neurologic Syphilis after Benzathine Penicillin G Therapy for Primary or Secondary Syphilis in HIV-Infected Patients

We describe 3 symptomatic cases of neurologic syphilis that occurred after the administration of the usual therapy for primary or secondary syphilis in human immunodeficiency virus (HIV)-infected patients. We discuss the difficulty of diagnosing neurosyphilis, the need for lumbar puncture, and risk factors of relapse. Because HIV infection may alter the natural history and response of neurologic syphilis to treatment, scrupulous follow-up and repeated cycles of therapy are warranted.

Secondary syphilis after liver transplantation: case report and review of the literature

Syphilitic disease is uncommon, but its incidence has increased worldwide in the last few years. An unusual manifestation of secondary syphilis after orthotopic liver transplantation is described which confirms that lues should be considered in patients with immune deficiency and abnormal liver function tests.

Persistent brain infection and disease reactivation in relapsing fever borreliosis

Relapsing fever, an infection caused by Borrelia spirochetes, is generally considered a transient, self-limiting disease in humans. The present study reveals that murine infection by Borrelia duttonii can be reactivated after an extended time as a silent infection in the brain, with no bacteria appearing in the blood and spirochete load comparable to the numbers in an infected tick. The host cerebral gene expression pattern is indistinguishable from that of uninfected animals, indicating that persistent bacteria are not recognized by the immune system nor cause noticeable tissue damage. Silent infection can be reactivated by immunosuppression, inducing spirochetemia comparable to that of initial densities. B. duttonii has never been found in any host except man and the tick vector. We therefore propose the brain to be a possible natural reservoir of the spirochete. The view of relapsing fever as an acute disease should be extended to include in some cases prolonged persistence, a feature characteristic of the related spirochetal infections Lyme disease and syphilis.

High rates of syphilis among STI patients are contributing to the spread of HIV-1 in India

BACKGROUND

Recent syphilis outbreaks have raised concern regarding the potential enhancement of HIV transmission. The incidence of syphilis and its association with HIV-1 infection rates among a cohort of sexually transmitted infection (STI) clinic attendees was investigated.

METHODS

2732 HIV-1 seronegative patients attending three STI and one gynaecology clinic, were enrolled from 1993-2000 in an ongoing prospective cohort study of acute HIV-1 infection in Pune, India. At screening and quarterly follow up visits, participants underwent HIV-1 risk reduction counselling, risk behaviour assessment and HIV/STI screening that included testing for serological evidence of syphilis by RPR with TPHA confirmation. Patients with genital ulcers were screened with dark field microscopy.

RESULTS

Among 2324 participants who were HIV-1 and RPR seronegative at baseline, 172 participants were found to have clinical or laboratory evidence of syphilis during follow up (5.4 per 100 person years, 95% CI 4.8 to 6.5 per 100 person years). Independent predictors of syphilis acquisition based on a Cox proportional hazards model included age less than 20 years, lack of formal education, earlier calendar year of follow up, and recent HIV-1 infection. Based on a median follow up time of 11 months, the incidence of HIV-1 was 5.8 per 100 person years (95% CI 5.0 to 6.6 per 100 person years). Using a Cox proportional hazards model to adjust for known HIV risk factors, the adjusted hazard ratio of HIV-1 infection associated with incident syphilis was 4.44 (95% CI 2.96 to 6.65; p<0.001).

CONCLUSIONS

A high incidence rate of syphilis was observed among STI clinic attendees. The elevated risk of HIV-1 infection that was observed among participants with incident syphilis supports the hypothesis that syphilis enhances the sexual transmission of HIV-1 and highlights the importance of early diagnosis and treatment of 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.

Ocular manifestations and treatment of syphilis

Syphilis is a sexually transmitted, chronic, systemic infection caused by the spirochete Treponema pallidum. If left untreated, the disease progresses through four stages, with the potential to cause significant morbidity to any major organ of the body. Frequent syphilitic ocular manifestations, which can occur at any stage of the disease, include interstitial keratitis, anterior, intermediate, and posterior uveitis, chorioretinitis, retinitis, retinal vasculitis and cranial nerve and optic neuropathies. Diagnosis is centered around a high level of clinical suspicion and includes treponemal specific and non-treponemal serologic tests. All patients with newly diagnosed syphilis should be tested for co-infection with human immunodeficiency virus, as the risk factors are similar for both diseases. Additionally, all patients with ocular syphilis should be tested for neurosyphilis. The preferred treatment for all stages of syphilis remains parenteral penicillin G. With proper diagnosis and prompt antibiotic treatment, the majority of cases of syphilis can result in a cure.

Syphilis: Uncommon presentations in adults

The clinical manifestations of syphilis are variable in appearance and have been described for centuries. The disease has been arbitrarily divided mainly into three stages. Uncommon presentations of syphilis in adults include (a) primary syphilis-atypical forms of chancre vary in size, shape, morphology, and color. Small ulcus durum is single or multiple, grouped, or herpetiform. Giant necrotic and phagedenic chancres are resolved with scar formation. In intratriginous areas, ulcus durum is rhagadiform, linear, "rocket type," or bilateral. (b) Secondary syphilids include macular (roseolas, leukomelanoderma), papular (small miliar or lichenoid, or with large size-lenticular or nummular), papulosquamous, syphilis cornee, psoriasiform, annular en cockade, nodular, condylomata lata, malignant syphilis, and others; there are also mucosal lesions, loss of the hairs, and alteration of the nails. (c) Tertiary syphilis occurs decades after infection in three main forms: gummatous, cardiovascular, and neurosyphilis (asymptomatic, meningeal, meningovascular, and parenchymatous-such as general paresis or tabes dorsalis). Early recognition of the clinical manifestations of syphilis is important for the start of treatment, recovery of patients, and the prevention of the spread of disease.

Syphilis treatment: old and new

Syphilis has challenged scientists and clinicians since its first appearance in the late 1400s and debate continues to surround the best practice in management. Difficulties in defining the goals of successful treatment have contributed to problems in determining recommendations for the ideal management. Treatment regimens currently in use were developed before randomised controlled trials became standard. This, combined with national differences in disease definition, staging and varying interpretations of the studies, as well as the emergence of complicating comorbid conditions, such as HIV, has resulted in a lack of consensus for treatment. This paper will discuss the history and current treatment of syphilis focusing on dilemmas faced by clinicians today, including the emergence of a resistant strain. Despite the difference between current national guidelines, penicillin G largely remains the treatment of choice. Close follow up, monitoring and ensuring adequate compliance remain the most important aspects in the treatment of syphilis.

Evaluation of LIAISON Treponema Screen, a novel recombinant antigen-based chemiluminescence immunoassay for laboratory diagnosis of syphilis

The purpose of this study was to evaluate the diagnostic performance of LIAISON Treponema Screen (DiaSorin, Saluggia, Italy), a new automated chemiluminescence immunoassay (CLIA), in comparison with that of rapid plasma reagin (RPR) and the following currently used treponemal tests: hemagglutination test (TPHA), immunoenzymatic assay (EIA), and Western blot (WB). First, a retrospective study was performed with a panel of 2,494 blood donor sera, a panel of 131 clinical and serologically characterized syphilitic sera, and 96 samples obtained from subjects with potentially interfering diseases or conditions. A prospective study was also performed by testing 1,800 unselected samples submitted to the Microbiology Laboratory of the St. Orsola Hospital in Bologna, Italy, for routine screening for syphilis. As expected, RPR was the least specific method, especially when potentially cross-reacting sera were tested. On the contrary, all of the treponemal tests proved to be very specific (99.9%) and they performed with the following sensitivities: 100% (WB), 99.2% (CLIA), 95.4% (EIA), and 94.7% (TPHA).

Avaliação de campanhas de saúde com ênfase na sífilis congênita: uma revisão sistemática

Campanhas têm sido instrumentos de políticas públicas de saúde, freqüentemente utilizadas no Brasil para esclarecer, motivar ou conseguir o apoio da população e/ou dos profissionais de saúde, em ações relevantes para a saúde pública. Esta revisão procurou levantar subsídios para a avaliação de campanhas de saúde, particularizando-se as metodologias utilizadas, tendo em vista a avaliação de campanhas dirigidas ao controle da sífilis congênita. Os conjuntos de palavras-chave utilizados foram "sífilis congênita + avaliação"; "campanhas de saúde + avaliação" e, "campanha + saúde + avaliação". As bases de dados pesquisadas foram a Medline (Medical Literature Analysis and Retrieval System Online) da National Library of Medicine (EUA), a LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde) e da PAHO (Pan-American Health Organization), no período de 1980 e 2003. Foram incluídos 37 artigos nessa revisão, sendo 15 referentes à sífilis congênita e avaliação e 22 à campanha de saúde e avaliação. A revisão realizada mostrou que existe um espaço a ser preenchido neste campo, principalmente no que se refere à construção metodológica. Apesar da palavra avaliação constar nesses vários artigos, a fundamentação teórica encontrada não foi totalmente condizente com as propostas apresentadas.

The pathogenesis of syphilis: the Great Mimicker, revisited

Syphilis is a chronic sexually transmitted infection caused by Treponema pallidum subspecies pallidum. Its protean clinical presentations earned it the name of the 'Great Mimicker'. Understanding of disease pathogenesis and how host-pathogen interactions influence the course of disease have been compromised by the facts that the organism cannot be grown in vitro and, as an exclusively human pathogen, inferences made from animal models are of limited applicability. Many questions remain about how T. pallidum biology contributes to distinctive features of syphilis, such as its ability to persist in the presence of a brisk host response or its propensity for neuro-invasion and congenital transmission. In 1998, the genome of T. pallidum was sequenced. The organism has a relatively small genome, suggesting that it utilizes host biosynthesis to fulfil some of its metabolic needs. While biological functions are suggested for only about 55% of T. pallidum's 1041 open reading frames, even these relatively early studies offer important insights into syphilis pathogenesis. A family of repeat genes, the Tp genes, encode proteins homologous to the major sheath proteins of T. denticola. Antibodies to the TprK variable regions are protective in a rabbit model. With successive passage, increasing diversity is observed in the TprK V region genes. Antigenic variation through gene conversion has been hypothesized to be one mechanism of escaping immune surveillance, allowing for prolonged infection and persistence in the presence of a robust host response. Human and animal studies suggest that a Th1 response is elicited in primary syphilis. Progression to the secondary stage is accompanied by a shift to a Th2 response, allowing for incomplete clearance of the pathogen. In pregnancy, intense inflammatory responses and prostaglandins induced by fetal infection may be responsible for fetal death or pre-term delivery and severe growth retardation or other manifestations of congenital syphilis. Understanding of the molecular targets of these immune responses may facilitate the development of vaccines for syphilis.

[Up to date in sexually transmitted infections: epidemiology, diagnostic approaches and treatments]

In the last years, there have been important advances in sexually transmitted infections such as genome sequencing of Treponema pallidum, Chlamydia trachomatis or Mycoplasma genitalium; the new taxonomic position of Calymmatobacterium granulomatis; commercial diagnostic systems based on nucleic acid amplification; the emergence of quinolone resistance in Neisseria gonorrhoeae; new therapeutic approaches in vulvovaginal candidiasis that include boric acid; the demonstration that valacyclovir reduces the risk of transmission of genital herpes or the availability of immune-response modifier in the treatment of genital warts, and that are questions in the goal of this review. Viral hepatitis and HIV were no reviewed by space reasons.

Otosyphilis: report on six cases

Syphilis is a multisystemic disease that may also affect the inner ear. The objective of this study was to investigate the frequency, clinical presentation and outcome of otosyphilis. A retrospective analysis of inpatients seen by a team of ENT specialists and dermatologists at a teaching hospital in Dresden, Germany, during 1986-2000. Six cases of otosyphilis had been diagnosed. None was related to risk factors such as HIV infection or drug abuse. We identified four female and two male patients, age range 25-58 years. Four patients suffered from syphilis stage II, one from syphilis stage and another from congenitial syphilis. ENT complaints included loss or impairment of hearing, tinnitus and nystagmus. All were treated with penicillin G. Adjuvant therapy included systemic corticosteroids oral pentoxifillin in two patients each. Improvement of ENT symptoms was achieved in all but one patient, who suffered from congenitial syphilis. This study confirms that otosyphilis is still a complication of syphilis in developed countries. The first line therapy is systemic penicillin G. There is a lack of controlled trials for adjuvant treatments such as corticosteroids and pentoxifillin. Clinical cooperation between dermatologists/venereologists and ENT specialists supports the best outcome.

Syphilis bei HIV-Koinfektion. Syphilis with HIV coinfection

In recent years a rising incidence of syphilis has been observed, especially in the population of homosexual men. Because of altered sexual behavior in terms of increased promiscuity paralleled by decreased use of condoms and the fact that a syphilis infection increases the susceptibility to HIV coinfection, the incidence of HIV is also rising once again in this population. In patients with HIV coinfection, the course of syphilis is often atypical or dramatic. Stage-specific features suggesting coinfection include prolonged primary ulcers persisting well into the secondary stage, numerous atypical cutaneous findings in the second stage and a rapid progression from stage to stage. The diagnosis of syphilis may be more difficult because of false positive or false negative serological findings in patients with HIV coinfection. Whether or not the CNS is more often involved is this patient group has not been established by prospective studies and remains controversial. However, WHO and CDC recommendations include evaluation of the CSF in HIV-infected patients with either late syphilis or when the time course is unknown period. There is worldwide agreement on the therapy of syphilis in patients with HIV coinfection. Patients with early syphilis should be treated with 2.4 benzathine penicillin i.m. once or twice; patients with late syphilis, twice or three times. Patients presenting with clinical or serological signs of neurosyphilis require 18-24 million IU penicillin i.v. daily for at least 2 weeks.

Syphilis in the HIV era

The incidence of syphilis has consistently increased from 2000 to 2002. We report a case of acquired syphilis with symptoms of Tullio phenomenon in a patient concurrently diagnosed with HIV infection. The resurgence of syphilis in HIV-positive groups at high risk has public health implications for prevention of both diseases.

Resurgence in infectious syphilis in Ireland: an epidemiological study

INTRODUCTION

In 2000, a syphilis outbreak was identified in Ireland.

MATERIALS AND METHODS

A prospective enhanced database was established in 2000. Crude incidence rates for the general population, men who have sex with men (MSM), and HIV-positive MSM were calculated.

RESULTS

Three hundred fifty-six cases of infectious syphilis were diagnosed at 1 center. Eighty-five percent of cases were identified as MSM. Crude incidence rates in MSM, ranging in age between 20 and 44 years, peaked in 2001 at 719 cases per 100000 of the MSM population. A total of 17.4% of cases occurred in HIV-infected individuals. Crude incidence rates of syphilis in HIV-positive MSM in the center increased to 7280 per 100000. Similar percentages of MSM with and without HIV infection had unprotected anal intercourse (37% and 41%, respectively).

CONCLUSION

High-risk sexual behavior continues among HIV-infected and -noninfected MSM. Crude incidence rates among MSM in Ireland are alarming when compared with other outbreaks.

Apport de l'imagerie au diagnostic de l'infection ostéoarticulaire

Radiographic diagnosis plays an important role in bone and joint infection management but the techniques used do not all present the same interest. Conventional radiography may not be informative during the first weeks and ultrasonography is especially useful to show accumulation of intra articular fluid or edematous soft-tissue. Computed tomography, magnetic resonance imaging, bone scintigraphy are the best exams for this diagnosis. According to the type of infection (septic arthritis, osteomyelitis, spondylodiskitis, diabetic foot, prosthetic joint infection), and to anatomical localization, the examination is chosen depending on its sensitivity and its specificity for bone and joint infection management.