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Scythes JB, Jones CM. Syphilis in the AIDS era: diagnostic dilemma and therapeutic challenge. Acta Microbiol Immunol Hung 2013; 60:93-116. [PMID: 23827743 DOI: 10.1556/amicr.60.2013.2.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- John B Scythes
- Community Initiative for AIDS Research, Toronto, Canada.
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Iwamoto K, Aoyagi J, Kiyozuka T, Iwasaki Y, Fujioka T. Neurosyphilis With Unilateral Optic Tract Lesion Causing Homonymous Hemianopia. Neurologist 2009; 15:345-6. [DOI: 10.1097/nrl.0b013e3181921b0a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Müller M, Ewert I, Hansmann F, Tiemann C, Hagedorn HJ, Solbach W, Roider J, Nölle B, Laqua H, Hoerauf H. Detection of Treponema pallidum in the vitreous by PCR. Br J Ophthalmol 2006; 91:592-5. [PMID: 17108014 PMCID: PMC1954749 DOI: 10.1136/bjo.2006.110288] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Ocular involvement of syphilis still poses a clinical challenge due to the chameleonic behaviour of the disease. As the serodiagnosis has significant limitations, the direct detection of Treponema pallidum (TP) in the vitreous represents a desirable diagnostic tool. METHODS Real-time polymerase chain reaction (PCR) for the detection of TP was applied in diagnostic vitrectomies of two patients with acute chorioretinitis. Qualitative verification of TP by real-time PCR and melting point analysis according to a modified protocol was ruled out. Patients underwent complete ophthalmological examination with fundus photographs, fluorescein angiography, serological examination, antibiotic treatment and follow-up. RESULTS In two cases of acute chorioretinitis of unknown origin, real-time PCR of vitreous specimens of both patients provided evidence of TP and was 100% specific. Initial diagnosis of presumed viral retinitis was ruled out by PCR of vitreous specimen. Patients were treated with systemic antibiotics and showed prompt improvement in visual function and resolution of fundus lesions. CONCLUSIONS With real-time PCR, detection of TP in the vitreous was possible and delivered a sensitive, quick and inexpensive answer to a disease rather difficult to assess. In cases of acute chorioretinitis, the use of PCR-based assays of vitreous specimens in the diagnostic evaluation of patients is advisable. Although syphilitic chorioretinitis is a rare disease, PCR should include search for TP, as diagnostic dilemmas prolong definitive treatment in a sight-threatening disease.
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Affiliation(s)
- M Müller
- Eye Clinic, University of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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Abstract
Unexpectedly we have found large numbers of chronically ill Borrelia burgdorferi PCR- and seropositive patients in Houston, Texas, a zoonotically 'non-endemic' area. In order to understand this finding prior to sufficient data availability, we chose to examine critically currently accepted but troublesome 'Lyme disease' concepts. Our method was to analyze each foundation 'Lyme disease' premise within the context of available medical and veterinary literature, then to reconstruct the disease model consistent with the preponderance of that data. We find the present conceptualization of the illness seriously truncated, with a high likelihood of two distinct but connected forms of human B. burgdorferi infection. The yet-unrecognized form appears to have a broader clinical presentation, wider geographic distribution, and vastly greater prevalence. We conclude that 'Lyme disease' currently acknowledges only its zoonosis arm and is a limited conceptualization of a far more pervasive and unrecognized infection state that must be considered a global epidemic.
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Affiliation(s)
- W T Harvey
- Diversified Medical Practices, Texas, Houston, USA.
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Venkatesh P, Verma L, Tandon R, Verma K, Menon V, Tewari HK. Syphilitic neuroretinitis, a report of three cases and review of literature. Neuroophthalmology 2001. [DOI: 10.1076/noph.26.1.1.8050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Larsen SA, Steiner BM, Rudolph AH. Laboratory diagnosis and interpretation of tests for syphilis. Clin Microbiol Rev 1995; 8:1-21. [PMID: 7704889 PMCID: PMC172846 DOI: 10.1128/cmr.8.1.1] [Citation(s) in RCA: 455] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The lack of a method for demonstrating the presence of Treponema pallidum by growth necessitates the use of alternative methods. Traditionally, these methods are divided into direct detection methods (animal inoculation, dark-field microscopy, etc.) and serologic tests for the presence of patient antibody against T. pallidum. Serologic methods are further divided into two classes. One class, the nontreponemal tests, detects antibodies to lipoidal antigens present in either the host or T. pallidum; examples are the Venereal Disease Research Laboratory and rapid plasma reagin and tests. Reactivity in these tests generally indicates host tissue damage that may not be specific for syphilis. Because these tests are easy and inexpensive to perform, they are commonly used for screening, and with proper clinical signs they are suggestive of syphilis. The other class of test, the treponemal tests, uses specific treponemal antigens. Confirmation of infection requires a reactive treponemal test. Examples of the treponemal tests are the microhemagglutination assay for antibodies to T. pallidum and the fluorescent treponemal antibody absorption test. These tests are more expensive and complicated to perform than the nontreponemal tests. On the horizon are a number of direct antigen, enzyme-linked immunosorbent assay, and PCR techniques. Several of these techniques have shown promise in clinical trials for the diagnosis of congenital syphilis and neurosyphilis that are presently difficult to diagnose.
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Affiliation(s)
- S A Larsen
- Division of Sexually Transmitted Diseases Laboratory Research, Centers for Disease Control and Prevention, Atlanta, Georgia 30333
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Abstract
We report a case of noduloulcerative tertiary syphilis that had gone misdiagnosed as discoid lupus erythematosus for many years. This case is noteworthy for (1) a Jarisch-Herxheimer-like reaction, (2) a dramatic response to penicillin therapy despite the presence of long-standing disease, and (3) posttreatment granulomas of possible hypersensitivity origin.
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Affiliation(s)
- G Chung
- Hahnemann University School of Medicine, Philadelphia, PA
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Abstract
A 30-year-old man with bilateral neuroretinitis and uveitis associated with secondary syphilis is described. Characteristic lesions on the palms of the hands and the soles of the feet gave us the clue to the diagnosis. Treatment with penicillin resulted in a rapid cure. Syphilic neuroretinitis is often associated with secondary meningitis. Early diagnosis and adequate therapy are important in this serious but treatable condition.
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Abstract
Syphilitic disease of the retina and/or the optic nerve head, without choroidal involvement, occurred in our 4 cases and in another 19 cases. The condition almost always takes place in the secondary stage, frequently associated with meningitis, and rarely in tertiary meningovascular syphilis. Fluctuating visual loss and floating spots without ocular pain are the presenting symptoms. Retinitis, papillitis, and neuroretinitis are accompanied by an inflammatory reaction in the vitreous and, sometimes, in the aqueous. Paracentral scotomas and blind spot enlargement, related with posterior pole and papillary edema, are the most usual visual field defects. Almost complete visual recovery is the rule in the treated cases, although in some instances cystoid macular edema and retinal ischemia due to endarteritis cause permanent visual loss. Treatment with crystalline penicillin is mandatory in patients with concomitant neurosyphilis, whereas procaine penicillin is seemingly sufficient in those with a normal cerebral spinal fluid examination.
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Abstract
A 34-year-old white man developed iridocyclitis and an iris mass. The iridocyclitis was preceded by a nodular rash which spared the palms and soles. An anterior segment fluorescein angiogram was performed which showed numerous permeable vessels. An ultrasound examination of the mass showed that it extended to the ciliary body. He had both a positive RPRCT and FTA-Abs. A skin biopsy was done which disclosed the nodules to be a rare form of secondary syphilis. The patient was treated with topical steroids and a cycloplegic agent, and later prednisone and intravenous penicillin, with eventual resolution of iris mass, iridocyclitis and skin nodules.
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Abstract
A patient with secondary syphilis had positive serum and cerebrospinal fluid findings. Fluorescent-antibody darkfield testing demonstrated spirochetes (Treponema pallidum) in the aqueous. There were clinical signs of secondary syphilis, including palmar skin lesions and frontal balding, and bilateral nasal altitudinal visual field loss. The discrete, waxy, yellow-white retinal lesions became increasingly pigmented and later migrated anteriorly into the vitreous chamber. The patient was treated with large amounts of penicillin (total dosage, 440 million units) and probenecid. Visual acuity improved to R.E. : 6/9 (20/30) and L.E.: 6/12 (20/40) and the inflammatory reaction disappeared. A second aqueous tap eight weeks after therapy ended showed no spirochetes by fluorescent-antibody testing.
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Krieglstein GK, Waller WK. Goldmann applanation versus hand-applanation and .schiötz indentation tonometry. ALBRECHT VON GRAEFES ARCHIV FUR KLINISCHE UND EXPERIMENTELLE OPHTHALMOLOGIE. ALBRECHT VON GRAEFE'S ARCHIVE FOR CLINICAL AND EXPERIMENTAL OPHTHALMOLOGY 1975; 194:11-6. [PMID: 1079117 DOI: 10.1007/bf00408271] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For evaluation of hand-applanation tonometry comparative measurements of intraocular pressure have been carried out using the Goldmann applanation tonometer, the Draeger and Perkins hand-applanation tonometers and the Schiötz indentation tonometer. A series of 52 eyes has been tested. The statistical analysis was based on the Goldmann tonometry as a reference system. The hand-applanation tonometers were found to be in satisfactory agreement with the Goldmann tonometer, whereas the Schiötz tonometer gave significantly low values in the pressure range considered.
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Collart P, Franceschini P, Poitevin M, Dunoyer F, Dunoyer M. Modified method of filtering cerebrospinal fluid and aqueous humour for the detection of treponemes. Proof of the persistence of their vitality in rabbits. Br J Vener Dis 1974; 50:251-6. [PMID: 4608150 PMCID: PMC1045035 DOI: 10.1136/sti.50.4.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Ovcinnikov NM, Korbut SE, Bednova VN, Timcenko GF, Milonova TI. Long-term results of penicillin treatment of early and late forms of syphilis in the rabbit. Br J Vener Dis 1973; 49:413-9. [PMID: 4583970 PMCID: PMC1044947 DOI: 10.1136/sti.49.5.413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Rice NS, Dunlop EM, Jones BR, Hare MJ, King AJ, Rodin P, Mushin A, Wilkinson AE. Demonstration of treponeme-like forms in cases of treated and untreated late syphilis and of treated early syphilis. Br J Vener Dis 1970; 46:1-9. [PMID: 4907520 PMCID: PMC1048013 DOI: 10.1136/sti.46.1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Chandler FW. A technique for detecting Treponema pallidum through the use of membrane filters and immunofluorescence staining. Br J Vener Dis 1969; 45:305-7. [PMID: 4902286 PMCID: PMC1047998 DOI: 10.1136/sti.45.4.305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Chandler FW, Norins LC. Studies on the quantitation of intraocular Treponema pallidum. An in vitro model. Br J Vener Dis 1969; 45:117-20. [PMID: 4892121 PMCID: PMC1048449 DOI: 10.1136/sti.45.2.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Chandler FW, Cannefax GR. Evaluation of darkfield and immunofluorescent techniques for demonstrating Treponema pallidum in fluids with small numbers of organisms. Br J Vener Dis 1969; 45:1-5. [PMID: 4887466 PMCID: PMC1048431 DOI: 10.1136/sti.45.1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Mothershed SM, Bullard JC. Preparation of fluorescein-labelled immune globulin for the identification of Treponema pallidum. Br J Vener Dis 1968; 44:201-7. [PMID: 4176782 PMCID: PMC1047949 DOI: 10.1136/sti.44.3.201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Norins LC. Selected aspects of syphilis and gonorrhea research in the United States, 1967. Br J Vener Dis 1968; 44:103-8. [PMID: 4949757 PMCID: PMC1047928 DOI: 10.1136/sti.44.2.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Lawton Smith J, Israel CW. Recovery of spirochagetes in the monkey by passive transfer from human late sero-negative syphilis. Br J Vener Dis 1968; 44:109-15. [PMID: 5005576 PMCID: PMC1047929 DOI: 10.1136/sti.44.2.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Smith JL, Israel CW, McCrary JA, Harner RE. Recovery of Treponema pallidum from aqueous humor removed at cataract surgery in man by passive transfer to rabbit testis. Am J Ophthalmol 1968; 65:242-7. [PMID: 4865728 DOI: 10.1016/0002-9394(68)93595-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Tarkkanen A, Horsmanheimo A. [Statistics of tonometry]. ALBRECHT VON GRAEFES ARCHIV FUR KLINISCHE UND EXPERIMENTELLE OPHTHALMOLOGIE. ALBRECHT VON GRAEFE'S ARCHIVE FOR CLINICAL AND EXPERIMENTAL OPHTHALMOLOGY 1968; 176:245-51. [PMID: 5304393 DOI: 10.1007/bf00414135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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