Update on syphilis and pregnancy

Congenital Syphilis: A Re-Emerging but Preventable Infection

Congenital syphilis presents a significant global burden, contributing to fetal loss, stillbirth, neonatal mortality, and congenital infection. Despite the target established in 2007 by the World Health Organization (WHO) of fewer than 50 cases per 100,000 live births, the global incidence is on the rise, particularly in low- and middle-income regions. Recent data indicate a rate of 473 cases per 100,000 live births, resulting in 661,000 total cases of congenital syphilis, including 355,000 adverse birth outcomes such as early fetal deaths, stillbirths, neonatal deaths, preterm or low-birth-weight births, and infants with clinical congenital syphilis. Alarmingly, only 6% of these adverse outcomes occurred in mothers who were enrolled, screened, and treated. Unlike many neonatal infections, congenital syphilis is preventable through effective antenatal screening and treatment of infected pregnant women. However, despite available screening tools, affordable treatment options, and the integration of prevention programs into antenatal care in various countries, congenital syphilis remains a pressing public health concern worldwide. This review aims to summarize the current epidemiology, transmission, and treatment of syphilis in pregnancy, as well as to explore global efforts to reduce vertical transmission and address the reasons for falling short of the WHO elimination target.

Syphilis Treatment Among People Who Are Pregnant in Six U.S. States, 2018-2021

OBJECTIVE

To describe syphilis treatment status and prenatal care among people with syphilis during pregnancy to identify missed opportunities for preventing congenital syphilis.

METHODS

Six jurisdictions that participated in SET-NET (Surveillance for Emerging Threats to Pregnant People and Infants Network) conducted enhanced surveillance among people with syphilis during pregnancy based on case investigations, medical records, and linkage of laboratory data with vital records. Unadjusted risk ratios (RRs) were used to compare demographic and clinical characteristics by syphilis stage (primary, secondary, or early latent vs late latent or unknown) and treatment status during pregnancy (adequate per the Centers for Disease Control and Prevention's "Sexually Transmitted Infections Treatment Guidelines, 2021" vs inadequate or not treated) and by prenatal care (timely: at least 30 days before pregnancy outcome; nontimely: less than 30 days before pregnancy outcome; and no prenatal care).

RESULTS

As of September 15, 2023, of 1,476 people with syphilis during pregnancy, 855 (57.9%) were adequately treated and 621 (42.1%) were inadequately treated or not treated. Eighty-two percent of the cohort received timely prenatal care. Although those with nontimely or no prenatal care were more likely to receive inadequate or no treatment (RR 2.50, 95% CI, 2.17-2.88 and RR 2.73, 95% CI, 2.47-3.02, respectively), 32.1% of those with timely prenatal care were inadequately or not treated. Those with reported substance use or a history of homelessness were nearly twice as likely to receive inadequate or no treatment (RR 2.04, 95% CI, 1.82-2.28 and RR 1.83, 95% CI, 1.58-2.13, respectively).

CONCLUSION

In this surveillance cohort, people without timely prenatal care had the highest risk for syphilis treatment inadequacy; however, almost a third of people who received timely prenatal care were not adequately treated. These findings underscore gaps in syphilis screening and treatment for pregnant people, especially those experiencing substance use and homelessness, and the need for systems-based interventions, such as treatment outside of traditional prenatal care settings.

Pharmacokinetics and Safety of Intramuscular Injectable Benzathine Penicillin G in Japanese Healthy Participants

An intramuscular (IM) suspension of benzathine penicillin G (BPG) has been used as first-line therapy for the treatment of syphilis worldwide since its approval in the 1950s. However, there are limited reports about the pharmacokinetics of BPG. A Phase 1 study was conducted on eight Japanese healthy participants to investigate the pharmacokinetics (samples collected predose to 648 h post-dose) and safety of 2.4 million units of BPG after a single IM injection. Following administration, penicillin G, the active moiety of BPG, was absorbed slowly from the injection site with a median time to Cmax (tmax) of 48 h post-dose. After the achievement of Cmax, concentrations of penicillin G declined slowly in a monophasic fashion with a mean apparent terminal half-life of 189 h. Geometric mean AUCinf and Cmax were 50770 ng•h/mL and 259 ng/mL, respectively. Median time (range) above the well-accepted therapeutic concentration (18 ng/mL) for syphilis treatment was 561 h (439-608 h [18-25 days]), which reached and exceeded the necessary duration of 7-10 days for syphilis treatment. Two participants were underdosed with residual drug left in the syringe due to the high viscosity of the drug product. Only one (12.5%) participant reported a mild adverse event of nasopharyngitis, which was considered not related to the study treatment. The study results supported BPG approval in Japan as an option for syphilis treatment.

Syphilis seroprevalence and associated factors: A cross-sectional study in formal female sex workers in a province of Peru

Syphilis is a sexually transmitted infection (STI) considered a public health problem that affects vulnerable and at-risk populations, such as sex workers. We designed a retrospective cross-sectional study based on the review of health evaluation records of sex workers who attended consultations to obtain comprehensive health cards at a Health Center in the Province of San Vicente de Cañete in Peru during the year 2020. We obtained sociodemographic and employment information and the RPR (rapid plasma reagin) test results to diagnose syphilis. We evaluated 220 records of sex workers with a mean age of 27.9 ± 6.9 years and the initiation of sexual relations of 16.0 ± 1.6 years, while the accumulated time they had as sex workers was 2.9 ± 2.4 years. 85.9% of those evaluated reported being heterosexual. The prevalence of syphilis was 7.3% (CI95: 4.2%-11.5%). Being a homosexual sex worker was significantly associated with syphilis (OR: 19.6; 95% CI: 4.8-80.0) compared to heterosexuals. The prevalence of syphilis presented a value similar to that reported in other Latin American and national studies, and it is evident that it is a health problem among sex workers.

Treponema pallidum recombinant protein Tp47 activates NOD-like receptor family protein 3 inflammasomes in macrophages via glycolysis

Glycolysis is a key pathway in cellular glucose metabolism for energy supply and regulates immune cell activation. Whether glycolysis is involved in the activation of NOD-like receptor family protein 3 (NLRP3) inflammasomes during Treponema pallidum (T. pallidum) infection is unclear. In this study, the effect of T. pallidum membrane protein Tp47 on NLRP3 inflammasome activation in rabbit peritoneal macrophages was analysed and the role of glycolysis in NLRP3 inflammasome activation was explored. The results showed that Tp47 promoted NLRP3, caspase-1, and IL-1β mRNA expression in macrophages, enhanced glycolysis and glycolytic capacity of macrophage, and promoted the production of macrophage glycolytic metabolites citrate, phosphoenolpyruvate, and lactate. The M2 pyruvate kinase (PKM2) inhibitor shikonin down-regulated the Tp47-promoted NLRP3, caspase-1, and IL-1β mRNA expression in macrophages, and suppressed the Tp47-enhanced glycolysis and glycolytic capacity. Similarly, si-PKM2 significantly inhibited Tp47-promoted NLRP3, caspase-1, and IL-1β mRNA expression and the Tp47-enhanced glycolysis and glycolytic capacity in macrophages. In conclusion, Tp47 activated NLRP3 inflammasomes via PKM2-dependent glycolysis and provided a new perspective on the effect of T. pallidum infection on host macrophages, which would contribute to the understanding of the infection mechanism and host immune mechanism of T. pallidum.

Determinants of congenital syphilis in Fortaleza, Brazil: A retrospective case-control study

Congenital syphilis (CS) is a significant public health problem in Brazil. Despite efforts to increase syphilis testing and treatment among pregnant women, rates of CS in the country remain high. We conducted a retrospective case-control study to identify potential associations between the mothers' sociodemographic characteristics, clinical factors related to the current and previous pregnancies, and the occurrence of CS among newborns in Fortaleza, a populous city with one of the highest incidences of CS in Brazil. Data from newborns diagnosed with CS between 2017 and 2020 were extracted from SINAN, the national database for notifiable diseases. Data from women who had delivered an infant with CS were extracted from SINASC, the national database for registration of live births, and linked with their infant's data. CS cases and non-CS controls were matched by year of birth at a ratio of 1:3 respectively. Potential associations were estimated using a multivariate regression model accounting for sociodemographic, obstetric, and antenatal care-related factors. Epidemiological data from 8,744 live births were included in the analysis, including 2,186 cases and 6,588 controls. The final multivariate regression model identified increased odds of delivering an infant with CS among pregnant women and girls aged below 20 years (OR 1.29), single women (OR 1.48), women who had less than 8 years of formal education (OR 2.42), women who delivered in a public hospital (OR 6.92), women who had more than 4 previous pregnancies (OR 1.60), and women who had one or more prior fetal loss (OR 1.19). The odds of delivering an infant with CS also increased as the number of antenatal visits decreased. Women who did not attend any antenatal visits had 3.94 times the odds of delivering an infant with CS compared to women who attended 7 or more visits. Our study found that increased odds of delivering an infant with CS were highly associated with factors related to socioeconomic vulnerability. These determinants not only affect the access to essential antenatal care services, but also the continuity and quality of such preventive measures. Future policies aimed at reducing the incidence of CS should not only target those pregnant women and adolescents with identifiable risk factors for testing, but also assure high quality care, treatment and follow-up for this group.

Placental Syphilis: A Comprehensive Review of Routine Histomorphology, HIV Co-infection, Penicillin Treatment, Immunohistochemistry, and Polymerase Chain Reaction

Introduction: Placental examination is valuable for diagnosing congenital syphilis, but the classic histological triad is not always observed. This study aimed to identify additional morphological clues, evaluate the sensitivity of IHC and qPCR, and investigate the impact of HIV co-infection and penicillin treatment on placental morphology. Materials and methods: Two hundred and fifteen placental specimens with treponemal infection were reviewed. Morphological findings, IHC, and qPCR results were analyzed. Results: Chronic villitis (94%), acute chorioamnionitis (91.6%), and villous immaturity (65.6%) were the most common abnormalities. HIV co-infection and penicillin treatment were associated with reduced frequencies of inflammatory lesions. IHC and qPCR exhibited sensitivities of 74.4 and 25.8%, respectively, confirming the diagnosis in 42 cases with negative or unknown serology. Conclusion: Villitis, chorioamnionitis, and villous immaturity were identified as the predominant placental abnormalities. HIV co-infection and penicillin treatment can impact morphology and hamper the diagnosis. IHC and q-PCR are valuable adjuncts when serology is negative.

Treponema pallidum recombinant protein Tp47 enhanced interleukin-6 secretion in human dermal fibroblasts through the toll-like receptor 2 via the p38, PI3K/Akt, and NF-κB signalling pathways

Interleukin-6 (IL-6) is a multi-effective cytokine involved in multiple immune responses. Whether fibroblasts also turn out to be a cytokine IL-6 factory during interaction with Treponema pallidum is not yet understood. To explore whether fibroblasts participate in inflammation due to syphilis, a series of experiments were performed to explore the role of T. pallidum lipoprotein Tp47 in IL-6 production in human dermal fibroblasts. The Toll-like receptor 2 (TLR2) and participating signalling pathways in this process were also evaluated. The results showed that the expressions of IL-6 and the protein levels of TLR2 in fibroblasts were upregulated after stimulation with Tp47, and this effect was impeded by the TLR2 inhibitor C29. In addition, Tp47 promoted the phosphorylation of p38, PI3K/Akt, and nuclear factor-kappaB (NF-κB), and the translocation of NF-κB in fibroblasts. Moreover, p38, PI3K, and NF-κB inhibitors significantly reduced IL-6 production in fibroblasts stimulated with Tp47. Furthermore, the TLR2 inhibitor C29 inhibited the phosphorylation of p38, Akt, and NF-κB, and the translocation of NF-κB in fibroblasts. In conclusion, our results showed that Tp47 enhanced IL-6 secretion in human dermal fibroblasts through TLR2 via p38, PI3K/Akt, and NF-κB signalling pathways. These findings contribute to our understanding of syphilis inflammation.

Epidemiology of syphilis infections among pregnant women in Tanzania: Analysis of the 2020 national representative sentinel surveillance

BACKGROUND

Syphilis has detrimental effects on the health of the mother and that of both fetuses and newborns exposed in utero or at delivery. Understanding its local epidemiology is essential for policies, planning, and implementation of targeted preventive interventions. Using data from the 2020 National Sentinel Surveillance of pregnant women attending antenatal clinics (ANCs) in Tanzania we determined the prevalence and determinants of syphilis among pregnant women in Tanzania mainland.

METHODOLOGY

The ANC surveillance was conducted in 159 ANC sites from all 26 regions of Tanzania's mainland from September to December 2020. It included all pregnant women 15 years and above on their first ANC visit in the current pregnancy during the survey period. Counseling for syphilis was done using standard guidelines at the ANC and testing was done using rapid SD Bioline HIV/Syphilis Duo test kits. Analysis was done using both descriptive statistics to determine the prevalence and characteristics of syphilis, whereas, logistic regressions were used to examine the independent association between syphilis and dependent variables.

RESULTS

A total of 38,783 women [median age (Interquartile range (IQR)) = 25 (21-30) years] participated in the surveillance. Of them, 582 (1.4%) tested positive for syphilis. A wide regional variation was observed with the highest burden in Kagera (4.5%) to the lowest burden in Kigoma (0.3%). The odds of syphilis infections were higher among older women and those with no formal education. Compared with primigravids, women with 1-2, those with 3-4 and those with more than four previous pregnancies had 1.8 (aOR = 1.8, 95% CI: 1.2-2.5), 2.1 (aOR = 2.1, 95% CI: 1.4-3.1) and 2.6 (aOR = 2.6, 95% CI: 1.7-3.9) higher odds of syphilis infection respectively.

CONCLUSION

Syphilis is still prevalent among pregnant women in Tanzania with a wide regional disparity. Efforts to prevent new infections, screen pregnant women, and treat those infected should be strategized to include all regions and renewed emphasis on regions with high burden, and importantly among women who are multipara, with a low level of education, and advanced age.

Sexually Transmitted Infections & the Heart

Sexually transmitted infections (STIs) have substantial morbidity and mortality worldwide, with over 1 million new infections occurring daily. Similarly, cardiovascular (CV) disease is the leading global cause of death and has tremendous impact on disability as well as quality of life. Several STIs have potential CV consequences and may precipitate reoccurrence of underlying CV comorbidity. Notably, untreated STIs and associated CV complications have an increased impact on marginalized individuals and those with limited access to health resources and care. Syphilis, human immunodeficiency virus, human papillomavirus, herpes simplex virus, hepatitis B, hepatitis C, cytomegalovirus, chlamydia, gonorrhea, and trichomoniasis have been identified as having CV implications. Yet, the data linking compromised CV health and STIs have not previously been summarized. The present review encapsulates the current knowledge surrounding the impacts of STIs on CV health as well as diagnostic and treatment strategies.

Congenital syphilis in the twenty-first century: an area-based study

The resurgence of syphilis and subsequent risk for newborns has been described worldwide; however, European data on this congenital infection is lacking. We report the activity of a multidisciplinary specialized unit assisting a large area in the Southern Italy. A retrospective cohort study has been conducted at the Perinatal and Pediatric Infectious Diseases Units of the Federico II University of Naples, enrolling all newborns and children referred from January 2010 to June 2022 exposed to Treponema pallidum in utero and/or congenitally infected. A total of 323 patients were included in the analysis. Twenty (6.2%) received a diagnosis of confirmed congenital syphilis (CS) and one died. Fifteen CS cases had typical clinical features. Since 2017, the number of referred neonates tripled while the rate of late maternal diagnoses did not significantly differ. When compared with mothers of exposed infants, mothers of CS cases were younger (25 ± 7.2 vs 29.9 ± 6 years, p = 0.041), had less previous pregnancies (0.64 vs 1.11, p = 0.044), and received a diagnosis of syphilis at a later stage of pregnancy (86% vs 20%, from third trimester or later on; p < 0.001). Appropriate maternal therapy was protective against vertical transmission (- 1.2; - 1.4, - 1 95% CI; p < 0.001). Paternal syphilis status was known in 36% of cases.

CONCLUSION

CS has still a significant impact. Prevention should be implemented towards specific maternal risk profiles. A specialized unit is the preferable model to improve surveillance and healthcare for this neglected population.

WHAT IS KNOWN

• The resurgence of syphilis and subsequent risk for newborns has been described worldwide. • European data on this congenital infection is lacking.

WHAT IS NEW

• Congenital syphilis has a significant impact still in Europe and prevention should be implemented towards specific maternal risk profiles.  • A specialized unit is the preferable model to improve surveillance and healthcare for this neglected population.

Syndromic Treatment of STIs in Low-income Countries is Inadequate: Current Threats and Future Directions

Sexually transmitted infections (STIs) pose a serious public health threat with more than 1 million curable infections diagnosed every day. While these infections are prevalent globally, the approach to evaluation and treatment varies greatly based on the capacity to make an accurate diagnosis. In low-resource settings, a syndromic approach is often used over an etiologic-based evaluation and management. Syndromic treatment of STIs recognizes groups of symptoms and recommends a multidrug empiric treatment that will cover the most likely causative organisms. By definition, syndromic treatment cannot be used as a screening tool, leaving a large portion of asymptomatic infections untreated. This will lead to the persistence of infection and associated sequelae including pelvic inflammatory disease and infertility. Syndromic treatment also leads to the overtreatment of many infections, which contributes to antimicrobial resistance. The rising threat of Neisseria gonorrhoeae resistance to last-line antibiotics is of global concern. Rapid, accurate, affordable, and easy-to-use point-of-care testing needs to be made readily available to all corners of the world to provide better care to patients and address the growing threat of multidrug resistant organisms. An urgent and collaborative global effort is needed to address the looming threat of a dangerous STI that is resistant to last-line antibiotics.

Spatial Heterogeneity and Its Influencing Factors of Syphilis in Ningxia, Northwest China, from 2004 to 2017: A Spatial Analysis

Syphilis remains a growing and resurging infectious disease in China. However, exploring the influence of environmental factors on the spatiotemporal distribution of syphilis remains under explore. This study aims to analyze the spatiotemporal distribution characteristics of syphilis in Ningxia, Northwest China, and its potential environmental influencing factors. Based on the standardized incidence ratio of syphilis for 22 administrative areas in Ningxia from 2004 to 2017, spatiotemporal autocorrelation and scan analyses were employed to analyze the spatial and temporal distribution characteristics of syphilis incidence, while a fixed-effect spatial panel regression model identified the potential factors affecting syphilis incidence. Syphilis incidence increased from 3.78/100,000 in 2004 to 54.69/100,000 in 2017 with significant spatial clustering in 2007 and 2009-2013. The "high-high" and "low-low" clusters were mainly distributed in northern and southern Ningxia, respectively. The spatial error panel model demonstrated that the syphilis incidence may be positively correlated with the per capita GDP and tertiary industry GDP and negatively correlated with the number of health facilities and healthcare personnel. Sex ratio and meteorological factors were not significantly associated with syphilis incidence. These results show that the syphilis incidence in Ningxia is still increasing and has significant spatial distribution differences and clustering. Socio-economic and health-resource factors could affect the incidence; therefore, strengthening syphilis surveillance of migrants in the economically developed region and allocating health resources to economically underdeveloped areas may effectively help prevent and control syphilis outbreaks in high-risk cluster areas of Ningxia.

Congenital syphilis. New questions about a neglected but re-emerging condition

In this issue of Case Reports, Cifuentes-Cifuentes et al. (1) describe a case of congenital syphilis (CS) in a newborn resulting from the first pregnancy of a woman who, despite having been diagnosed with syphilis through serological tests four years earlier, had not received treatment.

Fetal and neonatal abnormalities due to congenital syphilis: a literature review

OBJECTIVE

The recent recrudescence of syphilis among women of childbearing age is associated with an increasing number of cases of congenital syphilis. We aimed to summarize the fetal and neonatal abnormalities due to congenital syphilis infection, particularly signs amenable to prenatal diagnosis.

METHODS

Eligible studies were retrieved from the PubMed collection database. Articles focusing on postnatal and antenatal abnormalities covered the periods from 1969 to 2019 and 1975 to 2019, respectively. This review included cohort studies, case series and case reports reporting findings regarding congenital syphilis infections described before and/or after birth. Articles were reviewed by three experts in prenatal diagnosis, and all findings were classified as amenable or not amenable to prenatal diagnosis.

RESULTS

A total of 432 cases of congenital syphilis infection were reported. Abnormalities were described antenatally in 161 cases, postnatally in 319 cases, and in both the antenatal and postnatal periods in 57 cases. The most frequently reported signs amenable to prenatal diagnosis were abdominal abnormalities (hepatomegaly, splenomegaly, and bowel abnormalities), fetal growth restriction, and elevated middle cerebral artery peak systolic velocity in the context of ascites or atypical hydrops. Brain abnormalities were rare and never isolated. In the neonatal period, the most common abnormalities were hepatosplenomegaly, bone damage and skin lesions.

CONCLUSION

We found that no individual sonographic sign or pattern of signs is pathognomonic for fetal syphilis. In fetuses with ultrasound abnormalities suggestive of congenital infection, syphilis must be considered as part of the work-up. This article is protected by copyright. All rights reserved.

The negative impact of most relevant infections on fertility and assisted reproduction technology

Infections may act with variable impact on the physiopathology of the reproductive organs, determining infertility or reducing the outcomes of assisted reproduction technology. The aim of this narrative review is to describe the existing evidence regarding the pathogens with a supposed or recognized role in reproductive medicine. Viral hepatitis, as well as HIV, can reduce sperm quality. Syphilis carries a risk of erectile dysfunction and increased endometrial thickness. Chlamydia is the main cause of pelvic inflammatory disease. In relation to Mycoplasma and Ureaplasma spp., only few species seem to show a correlation with infertility and poor in-vitro fertilization outcomes. There is evidence of a role for bacterial vaginosis in early pregnancy loss. HPV infection in males seems to determine infertility. Herpesviruses are more a risk for fetuses than for fertility itself. Zika virus is responsible for altered early embryo development and waiting to conceive is recommended in suspected or confirmed cases. The impact of SARS-CoV-2 is yet to be elucidated. Rubella and toxoplasmosis can provoke important congenital defects and therefore screening is mandatory before conception; a vaccine for Rubella is recommended. Further and well-designed studies are still needed to better elucidate the role of some infectious agents, to improve fertility and its treatments.

Características sociodemográficas y clínicas de la sífilis gestacional en Cali, 2018

Introducción.

La sífilis gestacional se considera de interés en salud pública por las repercusiones que tiene en la madre y el hijo. Pese a tener protocolos para su notificación, diagnóstico y manejo, en Colombia se siguen evidenciando limitaciones en su control.

Objetivo.

Describir las características sociodemográficas, clínicas y de distribución espacial de las pacientes con sífilis gestacional en Cali, Colombia, en el 2018.

Materiales y métodos.

Se hizo un estudio transversal con 427 casos de sífilis gestacional reportados al Sistema de Vigilancia en Salud Pública (Sivigila). Para el procesamiento estadístico, se utilizó el programa R, versión 3.5.3. Las variables cualitativas se presentan como proporciones y, las cuantitativas, mediante medidas de tendencia central y dispersión, Para la distribución espacial, se usó el programa Qgis 3.0.

Resultados.

La razón de sífilis gestacional fue de 17 casos por 1.000 vivos (incluidos los mortinatos). El 57,1 % de las pacientes pertenecía al régimen subsidiado de salud y el 16,6 % no estaba asegurado. El 90,4 % de los casos se diagnosticó durante el embarazo; el 47,2% recibió tres dosis de penicilina y el 57,6 % de los contactos recibió tratamiento.

Conclusiones.

La tasa de sífilis gestacional en Cali en el 2018 fue superior a la nacional y la enfermedad se presentó con mayor frecuencia en mujeres gestantes en condición de vulnerabilidad socioeconómica, lo que coincidió con la distribución espacial en general. Se evidenció la falta de oportunidad en la detección temprana y el manejo de la infección tanto en las pacientes como en sus contactos, lo cual dificulta el control de la enfermedad y refleja la inadecuada aplicación de la ruta integral de atención en salud materno-perinatal.

Lessons learnt from syphilis-infected blood donors: a timely reminder of missed opportunities

OBJECTIVE

Due to the increased number of syphilis infections diagnosed in the UK and beyond, we reviewed our data on blood donors infected with syphilis in the UK and Ireland between 2016 and 2019.

METHODS

Data were extracted from the surveillance database for all blood donors confirmed positive for syphilis in the UK and Ireland between 2016 and 2019, together with the total number of donations tested during that period. Data on positive cases included gender, age group, reported treatment, symptoms and confirmatory results. All cases were divided into recently acquired within 24 months and past syphilis infection. We also reviewed the information on symptoms characteristic of syphilis reported by blood donors with an untreated syphilis infection during the postdonation discussions.

RESULTS

Screening of 8 246 600 blood donations for treponemal antibodies identified 316 blood donors with confirmed syphilis infection in the UK and Ireland between 2016 and 2019 (1.6 per 100 000 donations). 42% of them (133 of 316) were classed as a recent infection based on their donation testing results, previous donation date and clinical history provided, and they were hence considered potentially infectious. Most of these blood donors (202 of 316, 64%) had not been previously diagnosed or treated for syphilis, although 50 of them reported symptoms consistent with syphilis infection and 19 had been misdiagnosed despite seeking medical help.

CONCLUSIONS

This observational study shows that syphilis infection remains undiagnosed, especially among heterosexual men, and that infectious syphilis is often missed as a differential diagnosis even when donors have presented with genital or oral ulceration, rashes in the genital area and lymphadenopathy. Considering the recent resurgence of syphilis infections in the UK and beyond and our generally expanding sexual networks, it is important to consider syphilis in differential diagnosis even if specific risk factors have not been identified.

Risk Factors for Stillbirth among Pregnant Women Infected with Syphilis in the Zhejiang Province of China, 2010-2016

BACKGROUND

The World Health Organization estimated that about 1.36 million pregnant women suffered from syphilis in 2008, and nearly 66% of adverse effects occurred in those who were not tested or treated. Syphilis infection is one of the most common maternal factors associated with stillbirth.

OBJECTIVE

This study aimed to determine the risk factors for stillbirth among pregnant women infected with syphilis.

METHODS

In this retrospective study, data on stillbirth and gestational syphilis from 2010 to 2016 were extracted from the prevention of mother-to-child transmission (PMTCT) program database in the Zhejiang province. A total of 8,724 pregnant women infected with syphilis were included. Multiple logistic regression analysis was performed to determine the degree of association between gestational syphilis and stillbirth.

RESULTS

We found that the stillbirth percentage among pregnant women infected with syphilis was 1.7% (152/8,724). Compared with live births, stillbirth was significantly associated with lower maternal age, not being married, lower gravidity, the history of syphilis, nonlatent syphilis stage, higher maternal serum titer for syphilis, inadequate treatment for syphilis, and later first antenatal care visit. In multiple logistic analysis, nonlatent syphilis (adjusted odds ratio (AOR) = 2.03; 95% CI = 1.17, 3.53) and maternal titers over 1 : 4 (AOR = 1.78; 95% CI = 1.25, 2.53) were risk factors for stillbirth, and adequate treatment was the only protective factor for stillbirth (AOR = 0.16; 95% CI = 0.10, 0.25).

CONCLUSIONS

Nonlatent syphilis and maternal titers over 1 : 4 were risk factors for stillbirth, and adequate treatment was the only protective factor for stillbirth.

Syphilis in pregnancy: The impact of "the Great Imitator"

Syphilis remains a common congenital infection over the globe. There has been a tremendous rise in the number of congenital syphilis cases worldwide in the last 20 years. It affects large numbers of pregnant mothers in high burden regions causing a significantly high perinatal mortality and morbidity, which can be easily prevented by early antenatal screening and treatment. Diagnosis of maternal syphilis in pregnancy mainly based on clinical symptoms, serological tests and direct identification of treponemes in clinical samples. However, the diagnosis can be challenging due to the relapsing-remitting nature of the disease. The early stage of the infection is usually symptomatic which is commonly followed by an asymptomatic latent phase but infectious and as a result serological tests will be positive. The risk of transplacental transmission is high during the second and third trimester. Obstetric complications of syphilis include spontaneous miscarriage, non-immune hydrops, stillbirth, preterm labour, low birth weight, increased neonatal mortality and congenital syphilis among neonates. Penicillin is the drug of choice for treatment and should be commenced immediately. Babies born to mothers with syphilis should also be treated with penicillin. Early detection and prompt intervention are the key to the prevention and successful control of congenital syphilis. The aim of this review is to highlight the impact of syphilis infection on pregnancy and discuss the current trends in diagnosis and management of maternal and congenital syphilis.

Syphilis-associated septic cardiomyopathy: case report and review of the literature

Background

Septic cardiomyopathy has been observed in association with influenza, indicating that not only bacteria but also other infective agents can cause this condition. There has been no systematic study as to whether Treponema pallidum infection induces septic cardiomyopathy, and we are the first to report this possibility.

Case presentation

We report two cases of a 48-year-old man and a 57-year-old man who were diagnosed with syphilis-related septic cardiomyopathy. The diagnosis of cardiomyopathy was made based on elevation of cardiogenic markers and decrease in ejection fraction evaluated by echocardiography. Screen for infective pathogens was negative except for syphilis, which supported our diagnosis. The two patients recovered following effective anti-syphilis treatment and advanced life support technology. Syphilis serology became negative after treatment.

Conclusion

Syphilis has the potential to cause septic cardiomyopathy. Clinicians should consider Treponema pallidum in cases of septic cardiomyopathy with unknown pathogens. However, the specific pathophysiological mechanism of syphilis-associated septic cardiomyopathy has not been elucidated, and more specific studies are needed.

Sexually Transmitted Infections in Pregnancy: An Update for Primary Care Providers

This article provides an overview of the incidence and prevalence of sexually transmitted infections in pregnant women in the United States. It discusses screening guidelines and best practices related to treatments. Safety, pharmacology, and monitoring of both the woman and her fetus are detailed.

Perinatal HIV as an infectious cause of developmental regression

Although many pathogens affect neurodevelopment, most do so by stalling or arresting developmental progress with damage to central nervous system (CNS) cells and circuits during fetal life, leaving lifelong sequelae after early neuronal infection. In utero infections with CNS repercussions generally result from direct infection of fetal neural cells, with varying degrees of CNS involvement depending on the stage of fetal development. Human Immunodeficiency Virus (HIV) is distinct from other conditions as it does not cause immediate repercussions to the CNS unless HIV perinatal infection is accompanied by other co-infections. Nevertheless, distinct from the other congenital infections which generally induce failure to attain developmental milestones, perinatal HIV infection causes developmental regression, with often indolent but progressive neurodevelopmental consequences. Loss of developmental milestones has long been recognized as an Acquired Immune Deficiency Syndrome defining condition, often with growth failure. HIV encephalopathy presents as developmental delay/loss of developmental milestones, with manifestations in motor, mental and expressive language functions. Perinatal HIV disease is herein reviewed, with focus on developmental outcomes, diagnosis and treatment.

Recombinant Treponema pallidum protein Tp0136 promotes fibroblast migration by modulating MCP-1/CCR2 through TLR4

BACKGROUND

Chancre self-healing is an important clinical feature in the early stages of syphilis infection. Wound healing may involve an important mechanism by the migration of fibroblasts filling the injured lesion. However, the specific mechanism underlying this process is still unknown.

OBJECTIVES

We aimed to analyse the role of Tp0136 in the migration of fibroblasts and the related mechanism.

METHODS

The migration ability of fibroblasts was detected by a wound-healing assay. RT-PCR and ELISA detected the expression of MCP-1, IL-6 and MMP-9. TLR4 expression was detected by RT-PCR. The protein levels of CCR2 and relevant signalling pathway molecules were measured by Western blotting.

RESULTS

Tp0136 significantly promoted fibroblast migration. Subsequently, the levels of MCP-1 and its receptor CCR2 were increased in this process. The migration of fibroblasts was significantly inhibited by an anti-MCP-1 neutralizing antibody or CCR2 inhibitors. Furthermore, studies demonstrated that Tp0136 could activate the ERK/JNK/PI3K/NF-κB signalling pathways through TLR4 activity and that signalling pathways inhibitors could weaken MCP-1 secretion and fibroblast migration.

CONCLUSIONS

These findings demonstrate that Tp0136 promotes the migration of fibroblasts by inducing MCP-1/CCR2 expression through signalling involving the TLR4, ERK, JNK, PI3K and NF-κB signalling pathways, which could contribute to the mechanism of chancre self-healing in syphilis.

Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management

For millions of years, microbiota residing within us, including those in the oral cavity, coexisted in a harmonious symbiotic fashion that provided a quintessential foundation for human health. It is now clear that disruption of such a healthy relationship leading to microbial dysbiosis causes a wide array of infections, ranging from localized, mild, superficial infections to deep, disseminated life-threatening diseases. With recent advances in research, diagnostics, and improved surveillance we are witnessing an array of emerging and re-emerging oral infections and orofacial manifestations of systemic infections. Orofacial infections may cause significant discomfort to the patients and unnecessary economic burden. Thus, the early recognition of such infections is paramount for holistic patient management, and oral clinicians have a critical role in recognizing, diagnosing, managing, and preventing either new or old orofacial infections. This paper aims to provide an update on current understanding of well-established and emerging viral, bacterial, and fungal infections manifesting in the human oral cavity.

Case report of eight pregnant women with syphilis

Congenital syphilis may lead to severe sequelae in affected infants. The prevalence of syphilis in women of childbearing age has increased worldwide. From 2015 to 2018, we encountered eight pregnant women with syphilis including six with late latent and two with early latent syphilis. Seven pregnant women with syphilis received antibiotic therapies of oral amoxicillin, intravenous penicillin G, or the both. The syphilotherapies in four cases were considered effective, because rapid plasma reagin titers decreased. None of the seven pregnant women who received syphilotherapies had congenital syphilis. The remaining one woman who did not undergo a maternity checkup or syphilotherapy delivered a stillbirth with congenital syphilis at 29 gestational weeks.

Congenital Syphilis: A Challenging Case for NICU Clinicians

Congenital syphilis (CS) has been consistently on the rise in the United States since 2012, despite long-standing recommendations for routine testing and treatment of pregnant women. CS is associated with miscarriage, stillbirth, early infant death, and organ dysfunction in the newborn. Prevention is the optimal goal; however, early identification of infected infants is imperative to reduce the risk of serious, long-term complications. Clinicians must possess adequate knowledge of CS and the potentially life-threatening conditions that can arise to provide immediate and effective care. This case study portrays the clinical presentation of an infant with CS and the management of the multisystem effects of the disease.

Evaluation of the Abbott ARCHITECT™ cytomegalovirus IgM/IgG, rubella IgM/IgG, and syphilis treponemal antibodies enzyme immunoassays in a mother and child health center population

This study evaluated the concordance of Architect™ chemiluminescent microparticle immunoassays with Captia™ ELISA for cytomegalovirus (CMV) IgM and IgG, with Enzygnost™ and Captia™ ELISA for rubella IgM and IgG and with Trep-Sure™ ELISA for syphilis treponemal antibodies in a mixed pediatric and obstetrical population. Total agreement between assays and Kappa statistic value were 82.5% (95% CI: 75.6-87.7) and 0.65 (95% CI: 0.54-0.77) for CMV IgM, 82.8% (95% CI: 76.7-87.6) and 0.65 (95% CI: 0.55-0.75) for CMV IgG, 89.2% (95% CI: 82.9-93.4) and 0.56 (95% CI: 0.36-0.75) for rubella IgM, 88.6% (95% CI: 82.9-92.6) and 0.74 (95% CI: 0.63-0.84) for rubella IgG, and 97.9% (95% CI: 94.5-99.4) and 0.89 (95% CI: 0.79-1.00) for syphilis treponemal antibodies. This study demonstrates that the Architect™ chemiluminescent microparticle immunoassays correlate well with other FDA-approved ELISA assays in this specific population.

Congenital and perinatal infections

Congenital and perinatal infections represent major causes of permanent disability among children worldwide. Linked together by the acronym TORCH, denoting Toxoplasma gondii, rubella virus, cytomegalovirus, and herpes virus, congenital infections can result from only a modest number of human pathogens that cross the placenta and infect the fetus. Although congenital rubella syndrome has been eliminated in the Americas by immunization, several pathogens discussed in this chapter cannot currently be prevented by vaccines or effectively treated with the available antimicrobial drugs. Due to the immaturity of the immune system, newborn infants are at risk for postnatally acquired infections with certain viruses and several bacteria. This chapter summarizes the epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment, and prevention of selected pathogens that can damage the developing nervous system. As emphasized by the persisting challenges of preventing congenital cytomegalovirus infection and the emergence of severe brain damage associated with congenital Zika syndrome, these pathogens remain important causes of cerebral palsy, epilepsy, and intellectual disability.

LATE DIAGNOSIS OF CONGENITAL SYPHILIS: A RECURRING REALITY IN WOMEN AND CHILDREN HEALTH CARE IN BRAZIL

OBJECTIVE

To describe a case of congenital syphilis with a late diagnosis and identify missed opportunities at diverse phases/levels of healthcare, which led to late diagnosis.

CASE DESCRIPTION

Boy, 34 days of life, referred from a basic healthcare unit to a tertiary hospital due to enlarged abdominal volume and progressive jaundice for 2 weeks, fecal hypocholia, hepatosplenomegaly, anemia, low platelet count and elevated liver enzymes. At physical examination, the infant presented with erythematous-exfoliative lesions on the palms and soles, macular rash in the inguinal region, ascitis, palpable liver 5 cm below the right costal margin and a palpable spleen 3 cm from the left costal margin. Infant serology: reactive CMIA (chemiluminescent microparticle immunoassay), VDRL (Venereal Diseases Research Laboratory) 1:1024 and reactive TPHA (Treponema pallidum Hemagglutination). Maternal serology: reactive CMIA and TPHA, VDRL 1:256. Radiography of the long bones showed symmetric periostitis, periosteal thickening, and lucent bands in the femur, humerus, ulna and tibia. After treatment with crystalline penicillin, the infant showed clinical and laboratory improvement, receiving hospital discharge at the 18th hospitalization day.

COMMENTS

This case shows that congenital syphilis is occasionally diagnosed late as a result of failed strategies to prevent this disease, both in the basic and secondary/tertiary levels of care. The application of interventions recommended by the Ministry of Health and identification of the situation in which there is ineffective implementation of these measures are important to assess routine care in all levels of healthcare and diverse units responsible for newborn and infant health care.