Syphilis in adults

Case report-Depression with psychotic features as an atypical presentation of neurosyphilis

Recurrent depression with psychotic features is an atypical presentation of neurosyphilis. This case emphasizes the polymorphic clinical presentation of neurosyphilis and how it mimics affective disorders with psychotic symptoms.

Prevalence and associated factors of Treponema pallidum infection in a rural area of southwestern China

Background

Epidemiological data on Treponema pallidum infection are scarce from the southwestern region of China. The purpose of this study was to determine the distribution and determinants of T. pallidum infection in the region.

Methods

A community-based cross-sectional study of 2608 participants aged ≥14 years was conducted in a rural area of southwestern China in 2014–15. A pretested questionnaire was used to collect sociodemographic characteristics and other factors associated with T. pallidum infection. The diagnoses of T. pallidum, human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) infections were determined by commercial test kits. Logistic regression analysis was used to determine the correlates for T. pallidum infection, and adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

Results

The prevalence of T. pallidum infection was 1.2% (95% CI 0.8 to 1.7%). Risk factors varied by gender. In the male group, T. pallidum infection was significantly associated with ever injection drug use (aOR = 9.42, 95% CI 2.47 to 35.87) and HCV infection (aOR = 13.28, 95% CI 3.20 to 51.70). In the female group, correlates for T. pallidum infection included spouse having syphilis (aOR = 126.66, 95% CI 7.58 to 2122.94), ever having blood transfusion (aOR = 10.51, 95% CI 1.58 to 41.21) and HBV infection (aOR = 4.19, 95% CI 1.35 to 10.93).

Conclusions

The prevalence of T. pallidum infection was high in the rural area of southwestern China. Correlates for T. pallidum infection varied with sex specific. Intervention should be developed for the prevention and control of T. pallidum infection.

Changes in neurosyphilis presentation: a survey on 286 patients

Although neurosyphilis (NS) keeps plaguing worldwide, often with oligosymptomatic and atypical manifestations, the most recent reports fail to provide useful information, like details of the clinical history and even of the previous early therapy. We conducted a survey of the literature of the last 5 years on the clinical presentation of NS, recording the aforementioned inaccuracies. One hundred and thirty-seven articles were collected, reporting on 286 patients. General paresis was the commonest form (49%), often manifesting with cognitive impairment and psychiatric symptoms. Syphilitic meningitis was found in 63 patients (22%), mainly with ocular or auditory involvement. Meningovascular and tabetic form were both found in 12% of cases. Gummatous and epileptic manifestations were rare. Perusal of the literature confirms that NS prevalence is increasing, often with manifestations that are atypical for timing and type of lesions. Unfortunately, many articles are lacking of critical information, like an accurate clinical history and timing of the therapy making difficult to assess the effectiveness of penicillin in preventing NS.

Nodular syphilitic scleritis masquerading as an ocular tumor

Background

Scleritis may be the initial or only presenting feature of systemic, autoimmune, or infectious disorders. Corticosteroids are the mainstay of treatment for immune-mediated scleritis. However, steroids could prove detrimental when used to treat infectious scleritis. Hence, infectious causes of scleritis should be ruled out.

Findings

A 47-year-old male from central India presented with swelling, pain, and redness in the left eye since 2 months. The patient was diagnosed elsewhere as having an extraocular extension of intraocular tumor and advised radiation brachytherapy for the same. Clinical examination revealed nodular scleritis in the left eye. The patient did not have any systemic illness or complaints suggestive of connective tissue disease. Laboratory investigations ruled out the same. However, Venereal Disease Research Laboratory (VDRL) test was positive. Rapid plasma reagin (RPR) test and Treponema pallidum hemagglutination assay (TPHA) were also positive, confirming the diagnosis of syphilis. Ultrabiomicroscopy (UBM) and ultrasound scan of the eye ruled out intraocular tumor. Treatment was initiated with benzathine penicillin 2.4 million units per week for 3 weeks to which the patient responded remarkably well.

Conclusions

Although rare, syphilis can present as nodular scleritis masquerading as ocular tumor. Syphilis must be considered in the list of etiological diagnoses in patients presenting with nodular scleritis, and testing for this disease should be a part of routine investigation in patients with scleritis.

Azithromycin versus penicillin G benzathine for early syphilis

BACKGROUND

Syphilis is a complex systemic disease caused by a spirochete, Treponema pallidum. The World Health Organization estimates that at least 12 million people worldwide are currently infected with syphilis. In this review we compared two current standards of treatment for early syphilis, benzathine benzylpenicillin (penicillin G) and azithromycin.

OBJECTIVES

To evaluate the efficacy and safety of azithromycin versus benzathine penicillin (penicillin G) for early syphilis.

SEARCH METHODS

We searched the following databases using the search terms detailed in Appendix 1: the Cochrane Sexually Transmitted Diseases Group Specialized Register (July 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) published in The Cochrane Library (Issue 7 2011), MEDLINE (1948 to July 2011), EMBASE (1980 to July 2011), PsycINFO (1806 to July 2011) and the Chinese Biological Medicine Literature Database (CBM) (1978 to 2011). The search was not limited by language.

SELECTION CRITERIA

Randomized controlled trials comparing azithromycin with benzathine penicillin G at any dose for the treatment of early syphilis.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria to potential studies, with any disagreements resolved by discussion. The risk of bias of each study was assessed by the same two review authors. We pooled data using an odds ratio (OR).

MAIN RESULTS

Three studies (generating four eligible study comparisons) were included. One study is ongoing. There was no statistically significant difference between azithromycin and benzathine penicillin treatment in the odds of cure (OR 1.04, 95% CI 0.69 to 1.56); nor any difference at three months (OR 0.97, 95% CI 0.62 to 1.50), six months (OR 1.09, 95% CI 0.76 to 1.54) or nine months (OR 1.45, 95% CI 0.46 to 6.42). Subgroup analysis by primary and latent syphilis and by dose of azithromycin (2 g and 4 g) did not explain the variation between the study results. The reporting of computed mild to tolerated adverse events, from two included trials, indicated no statistically significant difference between azithromycin and benzathine penicillin (OR 1.43, 95% CI 0.42 to 4.95), although with a high level of heterogeneity (P = 0.05, I(2) = 74%).

AUTHORS' CONCLUSIONS

Differences in the odds of cure did not reach statistical significance when azithromycin was compared with benzathine penicillin for the treatment of early syphilis. No definitive conclusion can be made regarding the relative safety of benzathine penicillin G and azithromycin for early syphilis. Further studies on the utility of benzathine penicillin G for early syphilis are warranted.

Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease

The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.

Clinical and magnetic resonance imaging findings of HIV-negative patients with neurosyphilis

There have been no serial studies about neuroradiological findings of neurosyphilis in the literature. There have been only case reports concerning HIV negative patients with neurosyphilis. We present 8 HIV negative neurosyphilis patients two of whom are women. The mean age of the patients was 48 years+/-12.37. Five of the 8 patients had general paresis, two optic atrophy and one multiple cranial neuropathies. The CSF findings were quite similar in 6 of 8 patients. In half of the patients cranial MRI showed mild cerebral atrophy. Nonspecific hyperintense small foci in 3 patients are thought to be related to syphilis. Hyperintensity involving bilateral medial and anterior temporal regions more prominent on the left side was seen in one of the patients with general paresis. This finding may be due to cytotoxic edema associated with status epilepticus and may mimic herpes simplex and other limbic encephalitides. Though not typical, certain MRI findings guides for the diagnosis of neurosyphilis.

Cutaneous manifestations of syphilis : recognition and management

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

Sexually Transmitted Infections in Switzerland: Return of the Classics

Recent trends in western Europe show an increase in sexually transmitted infections (STIs). Available surveillance data in Switzerland confirm this rising trend. Gonorrhoea rates more than doubled between 1996 and 2003, and for Chlamydia there was a 64% increase from 1999 to 2003. Notifications of syphilis cases almost doubled in the year 2002 and rose to 174% compared to the period of 1998-2001. The resurgence of syphilis in 2002 and 2003 was most important in Zurich and Geneva with 54 and 24% of all cases, respectively. Eighty-four percent occurred in males, 40% affecting males who had sex with males, and at least 17% were HIV co-infected. For 2004, further increases in these bacterial STIs are expected. Increased awareness of the symptoms and signs of acute infections is needed as well as considering the diagnosis of STIs in patients with vague symptoms. In addition, laboratory reporting or mandatory disease notifications are needed to monitor syphilis trends in Switzerland.

The syphilis reactor grid: help or hindrance for syphilis surveillance?

BACKGROUND

Health departments use reactor grids (sex, age, and serologic test for syphilis [STS] titer criteria) to determine which persons to evaluate for untreated syphilis.

GOAL

The goal of the study was to assess reactor grid performance in Chicago and reactor grid use nationally in 1999 to 2000.

STUDY DESIGN

We reviewed Chicago health department records to identify characteristics of persons with a reactive STS excluded from evaluation by reactor grid criteria and syphilis cases not meeting evaluation criteria. We surveyed health departments regarding reactor grid use.

RESULTS

Of persons with a reactive STS, 46% did not meet criteria for health department evaluation, including 62% of men, 29% of women, and 21% with titers > or =1:8. The reactor grid would have excluded 17% of primary syphilis cases. Overall, 82% of health departments use reactor grids.

CONCLUSIONS

Reactor grids are widely used and may exclude persons with infectious syphilis from health department evaluation, especially men. The impact of reactor grid use on syphilis control and surveillance in the United States should be evaluated.

Forgotten but not gone: the continuing scourge of congenital syphilis

Much attention is being given to the prevention of HIV infection in babies through transmission from the mother. By contrast, regrettably little concern is raised about the increasing numbers of babies born with congenital syphilis. In affluent countries congenital syphilis is very rare, but in many poor countries, including the newly independent countries of eastern Europe and the former Soviet Union, the numbers are high and increasing. In much of sub-Saharan Africa, around 10% of pregnant women are affected by syphilis. The prevention of congenital syphilis is more cost-effective than the prevention of mother-to-child transmission of HIV. The control of congenital syphilis could indirectly have a beneficial effect on the HIV epidemic by reducing susceptibility to infection. Although the procedure to prevent congenital syphilis through antenatal screening and treatment is well established, implementation of effective programmes in resource-poor settings has proved very difficult. A new and focused approach to tackling congenital syphilis is needed. It should combine different mixes of interventions, such as mass treatment, focused screening, and universal screening, according to the local epidemiology and available resources. A task-force approach to defining the most appropriate interventions together with support for some research should be a priority for support under the Global Health Fund.

Antibiotics for syphilis diagnosed during pregnancy

BACKGROUND

Congenital syphilis is an increasing problem in many developing countries and in the transitional economies of Eastern Europe and the former Soviet Union. In several countries this increase has been aggravated by HIV/AIDS. While the effectiveness of penicillin in the treatment of syphilis in pregnant women and the prevention of congenital syphilis was established shortly after the introduction of penicillin in the 1940s, there is uncertainty about the optimal treatment regimens.

OBJECTIVES

To identify the most effective antibiotic treatment regimen (in terms of dose, length of course and mode of administration) of syphilis with and without concomitant infection with HIV for pregnant women infected with syphilis.

SEARCH STRATEGY

MEDLINE 1966 to March 2000; EMBASE 1974 to March 2000, the Cochrane Controlled Trials Register (last searched March 2001), the Cochrane Pregnancy and Childbirth group trials register (last searched March 2001) and the references of traditional reviews were searched. Experts in specialist units were contacted.

SELECTION CRITERIA

It was planned that any trial in which an attempt is made to allocate treatment for syphilis during pregnancy by a random or quasi-random method would be included in this review.

DATA COLLECTION AND ANALYSIS

Information was extracted using a data extraction sheet and this included entry criteria, the source of controls, and whether the authors stratified by the stage of pregnancy when the diagnosis of syphilis was made.

MAIN RESULTS

Twenty six studies met the criteria for detailed scrutiny. However, none of these met the pre-determined criteria for comparative groups and none included comparisons between randomly allocated groups of pregnant women.

REVIEWER'S CONCLUSIONS

While there is no doubt that penicillin is effective in the treatment of syphilis in pregnancy and the prevention of congenital syphilis, uncertainty remains about what are the optimal treatment regimens. Further studies are needed to evaluate treatment failure cases with currently recommended regimens and this should include an assessment of the role of HIV infection in cases of prenatal syphilis treatment failure. The effectiveness of various antibiotic regimens for the treatment of primary and secondary syphilis in pregnant women need to be assessed using randomised controlled trials which compare them with existing recommendations.

Syphilis testing

The organism that causes syphilis, Treponema pallidum, is impossible to culture in the clinical laboratory. Direct visualization of the pathogen is one laboratory technique used in the diagnosis of syphilis. Currently, serologic testing is the most widely used laboratory technique in diagnosing syphilis and monitoring its course after treatment. Serologic tests are divided into two categories, the nontreponemal and treponemal antibody tests. Newer techniques such as enzyme immunoassays have shown excellent results.

Syphilis

Syphilis was first recognized as a distinct syndrome in Europe in the fifteenth century. Despite knowledge of congenital infection for more than 450 years and the existence of adequate therapy for 55 years, congenital infection remains a problem for the practicing clinician. Syphilis is caused by Treponema pallidum. Infection may be transmitted horizontally by sexual contact and vertically as a result of hematogenous dissemination across the placenta. Syphilis is classified as primary, secondary, latent, and tertiary. The diagnosis may be established by darkfield examination of clinical lesions and by serological assays. The drug of choice for syphilis is penicillin. This agent is the only antibiotic of proven value for the treatment of congenital syphilis. Accordingly, infected pregnant women who are allergic to beta-lactam antibiotics must be desensitized and then treated with penicillin.

Syphilis exposure in patients with uveitis

PURPOSE

The purpose of the study is to determine the frequency of syphilis exposure in patients with uveitis, identify patient characteristics associated with serologic fluorescent treponemal antibody assays (FTA-ABS) reactivity, and examine the clinical implications of syphilis exposure in patients with uveitis.

METHODS

A retrospective review of the records of 552 consecutive patients examined in the referral uveitis clinic of an urban eye hospital between January 1989 and January 1994 was performed.

RESULTS

Forty-four (8%) of 552 consecutive patients with uveitis had serologic evidence of syphilis exposure on the basis of a strongly reactive serum FTA-ABS. Syphilis was presumed to be the sole cause of uveitis in 24 patients (4.3%) over the 5-year period. The racial demographic profile of those patients with serologic evidence of syphilis was consistent with the reported distribution of syphilis cases, but there were relatively few identifiable risk factors for sexually transmitted disease (including only three patients who were positive with human immunodeficiency virus). The choice of antibiotic treatment of these patients was variable and sometimes suboptimal.

CONCLUSIONS

This study implicates syphilis exposure as a more common etiology of uveitis than did previous reports, advocates routine serum FTA-ABS testing of patients with uveitis, and indicates a need for a more aggressive role of the ophthalmologist in antibiotic treatment of patients with uveitis and syphilis exposure.

Diagnosis and treatment of infectious diseases in HIV-infected hosts

Treatment of infectious diseases in patients with HIV infection is of primary importance in patient care. Viral, bacterial, parasitic, and fungal pathogens all may affect these patients. It is essential that accurate diagnoses be made and appropriate therapy be administered as early as possible.

Sexually transmitted diseases update

STDs have worldwide distribution and result in immense social and economic cost. Knowledge of the clinical signs, symptoms, current clinical tests, and treatment recommendations is important for all health care professionals.

Lues-lues: maternal and fetal considerations of syphilis

Although syphilis occurs infrequently among Canadian and American women, global antenatal screening is still warranted. The reason is that congenitally acquired syphilis is serious, yet largely preventable. Those women at highest risk for the disease seem to be crack and cocaine users, as well as those without antenatal care. These women should be screened for syphilis during the first and early-third trimesters, whenever possible, or at the time of delivery. HIV testing should be routinely recommended. Syphilis is diagnosed using microscopy and/or serologic testing. Although nontreponemal serology (VDRL and RPR) is acceptable as the initial screening test, sensitivity and specificity for syphilis vary between 60 and 75 percent and 84 and 99 percent, respectively. These are also many causes of false-positive test results. Treponemal serology (FTA-ABS and MHA-TP) are used to confirm nontreponemal tests. The only acceptable treatment of syphilis during pregnancy is penicillin. For those with disease of less than 1 year's duration, it is suggested that two doses of benzathine penicillin G (2.4 million units I.M.) be administered 1 week apart. Disease of greater or unknown duration requires a longer, modified regimen. Serious adverse reactions to therapy are rare, and penicillin-allergic mothers can be skin tested, followed by desensitization if required. Exactly how HIV infection modifies the detection and treatment of syphilis in pregnancy is unclear. Treatment of HIV-infected women with syphilis is presently no different than non-HIV patients, unless invasion of the central nervous system is suspected.

Essential syphilitic alopecia revisited

There has been a resurgence of syphilis in the past decade. Uncommonly, diffuse hair loss, termed essential alopecia, is the only sign of syphilitic infection. We describe two patients with syphilis in whom the first sign of disease was alopecia and discuss the clinical and histopathologic findings of essential syphilitic alopecia.

Prevalence of neurosyphilis at Government Rajaji Hospital, Madurai, India

Forty patients (34 males and 6 females) with neurological complaints/manifestations and with a past history of multiple sexual partners attending the Government Rajaji Hospital, Madurai, India between April 1992 and October 1992 were investigated for neurosyphilis. Metabolic disorders, hypertension, ischaemic heart disease, arrhythmias and trauma were excluded. Seven males (17.5%) were found to have neurosyphilis. The youngest was 26 years old and the oldest was 47. All were married and of low socioeconomic background. Meningovascular syphilis was the predominant presentation (6:1). Associated cardiovascular involvement was noticed in one of the cases. There was no associated HIV infection in these cases. The incidence is higher than previous reports from this centre.

A patient with neurosyphilis presenting as chorea

Despite the marked decline in frequency of neurosyphilis over the past three decades in the United Kingdom, new cases continue to appear both sporadically and as a complication of HIV infection. There is clinical evidence that neurosyphilis is becoming less typical. We describe a case of neurosyphilis presenting predominantly with choreoathetosis and associated hemiparesis in an otherwise healthy, immunocompetent patient. Only six cases of neurosyphilis presenting with features of basal ganglia damage have been reported in the recent literature, five of whom had HIV infection.

Ocular syphilis

There has been a steady increase in the number of cases of syphilis in the United States since the middle 1980s, with a dramatic rise in incidence among heterosexual men and women and of congenital syphilis. There also have been changes in geographic distribution of cases and an association with cocaine use. The ophthalmologic manifestations of syphilis are broad. There is anecdotal evidence that the natural history of syphilitic infection is altered by coinfection with human immunodeficiency virus. The potential of coinfection with HIV makes the clinical evaluation, treatment, and assessment of therapeutic outcome of syphilitic infection more confounding and controversial. This article provides a review of the changing demographics and ophthalmic manifestations of syphilis, the current status of laboratory testing techniques, and management approaches to various types of ocular syphilis.