Diagnosis and treatment of syphilis

Evaluation of a minimal array of Treponema pallidum antigens as biomarkers for syphilis diagnosis, infection staging, and response to treatment

IMPORTANCE

This manuscript explores the host humoral response to selected antigens of the syphilis agent during infection to evaluate their potential use as diagnostic tests and markers for treatment.

A Case Report of Secondary Syphilis Co-Infected with Measles: A Diagnostic Dilemma with Fever and Rash

Fever and rash as manifestations of infection by microorganisms are collectively known as febrile exanthem. Since viruses are more frequently associated with fever and rash, these symptoms are thus impetuously termed viral exanthem. However, bacteria represent a frequently overlooked infectious etiology causing rash in humans. In addition, certain microbes may exhibit pathognomonic features that erupt during illness and facilitate clinical diagnosis. Conversely, coinfections often obscure the clinical characteristics of the primary disease and further challenge clinicians attempting to reach a diagnosis. We retrospectively looked at de-identified clinical data of a patient who presented to the Hospital for Tropical Diseases in Bangkok in July 2019 with complaints of fever and rash. The case involved a 35-year-old who presented with a 3-day history of fever, respiratory symptoms, myalgia, conjunctivitis, diarrhea, and a generalized maculopapular rash. On examination, the patient was febrile, tachycardic, and tachypneic, with a mean arterial pressure of 95 mmHg. A differential white blood cell count showed: leukocytes, 5800/µL; neutrophils, 4408/µL; lymphocytes, 406/µL; and platelets, 155,000/µL. Striking findings involving the integumentary system included Koplik’s spots and generalized maculopapular rash. Further serology revealed positive immunoglobulin (Ig)M and IgG for both measles and rubella virus, including reactive serology for Treponema pallidum. Here we describe the clinical course and management of this patient.

Clinical presentation and serological diagnosis of syphilis reinfection in men living with HIV: a retrospective cohort study

OBJECTIVES

Studies on the characteristics of syphilis reinfection are scarce despite increasing numbers and proportions of cases. We aimed to gain insights into the clinical and serological presentation of reinfected men living with HIV and to evaluate diagnostic criteria for syphilis reinfection.

METHODS

We conducted a retrospective cohort study of 259 HIV-positive men diagnosed with syphilis between January 1999 and September 2015 at the University Hospital Zurich. We compared patients with a single syphilis infection (n=109) to patients with reinfections (n=150).

RESULTS

The two groups matched in age, sexual orientation and numbers of other STIs. Reinfected patients more often presented with latent syphilis than patients with a single syphilis episode (41.9% vs 8.9%; p<0.001). Although generally high venereal diseases research laboratory (VDRL) or rapid plasma reagin (RPR) titres (median 1:32) were seen in reinfected patients, 19.4% had titres ≤1:8. Treponema pallidum passive particle agglutination (TPPA) titres were significantly higher (1:81 840 vs 1:10 240; p<0.001), while IgM values were significantly lower (1.27 vs 3.5; p<0.001) in syphilis reinfections than in first infections. The TPPA increased ≥fourfold in >92.3% of reinfected patients.

CONCLUSIONS

Our data highlight the paramount importance of regularly screening patients at risk as syphilis reinfections in men living with HIV are more likely to be latent infections, that is, without symptoms. As non-treponemal tests might be biologically false-positive (up to a titre of 1:8) due to various conditions, a ≥fourfold increase of the TPPA might be considered as optional criterion for the diagnosis of syphilis reinfections. This could be especially valuable for diagnosing reinfected latent stage patients.

Clinical characteristics of patients with systemic lupus erythematosus showing a false-positive result of syphilis screening

A false-positive result of syphilis screening test (FPST) is a characteristic finding in patients with systemic lupus erythematosus (SLE). We evaluated the clinical characteristics of SLE patients with FPST at SLE diagnosis. We reviewed the medical records of patients with SLE who underwent the Venereal Disease Research Laboratory or Rapid Plasma Reagin tests at SLE diagnosis at Severance Hospital between 2006 and 2016. The baseline characteristics and clinical outcomes were compared between patients with FPST and those with a negative result of syphilis screening test. Of 145 patients with SLE, 20 patients showed FPST and 125 patients showed a negative syphilis screening result. At SLE diagnosis, patients with a negative result had higher SLE disease activity index (5.0 vs. 8.0, P < 0.001) and were more commonly complicated with nephritis (15.0% vs. 41.6%, P = 0.026). High level of serum total protein (> 8 g/dL) and the presence of anti-cardiolipin antibodies were independently associated with FPST (P = 0.010 and 0.037, respectively). During the follow-up (median 61 months), 5 patients with FPST (20.0%) and 12 patients without FPST (9.6%) were finally diagnosed with APS. The long-term risk of de novo thrombosis was higher in the FPST group (n = 4/20, 20% vs n = 6/125, 4.8%, P = 0.041). However, all-cause mortality showed no difference between the FPST group and the negative group. Patients with SLE showing FPST showed lower disease activity at SLE diagnosis but higher thrombotic risk and similar overall survival compared to those without FPST.

A Web Application to Facilitate Syphilis Reactor Grid Evaluations

BACKGROUND

Many health departments use a "reactor grid" to determine which laboratory-reported syphilis serologic test results require investigation. We developed a Web-based tool, the Syphilis Reactor Grid Evaluator (SRGE), to facilitate health department reactor grid evaluations and test the tool using data from Seattle & King County, Washington.

METHODS

We developed SRGE using the R Shiny Web application framework. When populated with a data set including titer results and final disposition codes, SRGE displays the percent of verified early syphilis cases by serologic titer result and patient age in each cell of the grid. The results can be optionally stratified by sex, test type, and previous rapid plasma reagin titer. The impact of closing laboratory results without investigation in cells selected by the user is dynamically computed. The SRGE calculates the percent of all laboratory reports closed ("efficiency gained"), the proportion of all early syphilis cases closed without investigation ("case finding loss"), and the ratio of percent of cases identified for investigation to percent of all laboratory reports investigated ("efficiency ratio"). After defining algorithms, users can compare them side-by-side, combine subgroup-specific algorithms, and export results. We used SRGE to compare the current Public Health-Seattle & King County (PHSKC) reactor grid to 5 alternate algorithms.

RESULTS

Of 13,504 rapid plasma reagin results reported to PHSKC from January 1, 2006, to December 31, 2015, 1565 were linked to verified early syphilis cases. Updating PHSKC's current reactor grid could result in an efficiency gain of 4.8% to 25.2% (653-3403 laboratory reports) and case finding loss of 1% to 8.4% (10-99 fewer cases investigated).

CONCLUSIONS

The Syphilis Reactor Grid Evaluator can be used to rapidly evaluate alternative approaches to optimizing the reactor grid. Changing the reactor grid in King County to close more laboratory results without investigation could improve efficiency with minimal impact on syphilis case finding.

Syphilis

Treponema pallidum subspecies pallidum (T. pallidum) causes syphilis via sexual exposure or via vertical transmission during pregnancy. T. pallidum is renowned for its invasiveness and immune-evasiveness; its clinical manifestations result from local inflammatory responses to replicating spirochaetes and often imitate those of other diseases. The spirochaete has a long latent period during which individuals have no signs or symptoms but can remain infectious. Despite the availability of simple diagnostic tests and the effectiveness of treatment with a single dose of long-acting penicillin, syphilis is re-emerging as a global public health problem, particularly among men who have sex with men (MSM) in high-income and middle-income countries. Syphilis also causes several hundred thousand stillbirths and neonatal deaths every year in developing nations. Although several low-income countries have achieved WHO targets for the elimination of congenital syphilis, an alarming increase in the prevalence of syphilis in HIV-infected MSM serves as a strong reminder of the tenacity of T. pallidum as a pathogen. Strong advocacy and community involvement are needed to ensure that syphilis is given a high priority on the global health agenda. More investment is needed in research on the interaction between HIV and syphilis in MSM as well as into improved diagnostics, a better test of cure, intensified public health measures and, ultimately, a vaccine.

Stillbirths: The Hidden Birth Asphyxia - US and Global Perspectives

Stillbirths are among the most common pregnancy-related adverse outcomes but are more common in low-income and middle-income countries than in high-income countries. In high-income countries, most stillbirths occur early in the preterm period, whereas in low-income and middle-income countries, most occur in term or in late preterm births. In low-income and middle-income countries, conditions, such as prolonged or obstructed labor, placental abruption, preeclampsia/eclampsia, fetal growth restriction, fetal distress, breech and other abnormal presentations, and multiple births, are associated with stillbirth. In high-income countries, placental abnormalities are the most common associations. Globally, fetal asphyxia is likely the most common final pathway to stillbirth.

Reducing stillbirths in low-income countries

Worldwide, 98% of stillbirths occur in low-income countries (LIC), where stillbirth rates are ten-fold higher than in high-income countries (HIC). Although most HIC stillbirths occur prenatally, in LIC most stillbirths occur at term and during labor/delivery. Conditions causing stillbirths include those of maternal origin (obstructed labor, trauma, antepartum hemorrhage, preeclampsia/eclampsia, infection, diabetes, other maternal diseases), and fetal origin (fetal growth restriction, fetal distress, cord prolapse, multiples, malpresentations, congenital anomalies). In LIC, aside from infectious origins, most stillbirths are caused by fetal asphyxia. Stillbirth prevention requires recognition of maternal conditions, and care in a facility where fetal monitoring and expeditious delivery are possible, usually by cesarean section (CS). Of major causes, only syphilis and malaria can be managed prenatally. Targeting single conditions or interventions is unlikely to substantially reduce stillbirth. To reduce stillbirth rates, LIC must implement effective modern antepartum and intrapartum care, including fetal monitoring and CS.

Syphilis in the AIDS era: diagnostic dilemma and therapeutic challenge

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

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.

Nontreponemal tests in the diagnosis of neurosyphilis: an evaluation of the Venereal Disease Research Laboratory (VDRL) and the Rapid Plasma Reagin (RPR) tests

The Venereal Disease Research Laboratory (VDRL) test has long been considered the best serological test for the diagnosis of neurosyphilis. The goal of this study was to find out if the Rapid Plasma Reagin (RPR) could be an alternative to the VDRL. Cerebrospinal fluid (CSF) and sera samples from patients in the following stages of syphilis were tested: 8 had symptomatic and 16 asymptomatic neurosyphilis, 4 were in the primary stage, 6 had secondary syphilis, and 92 were in the latent stage. We have also studied 61 samples from individuals with treated syphilis and 126 with other neurological diseases than neurosyphilis. All the CSF samples were studied with both RPR and VDRL tests. RPR and VDRL test results were mostly concordant. The specificity of these tests for current neurosyphilis was 99% for the VDRL and 99.3% for the RPR, whereas the sensitivity was 70.8 and 75%, respectively, for the VDRL and RPR. In view of these results it seems to us that the RPR could be an alternative to the VDRL in the diagnosis of neurosyphilis.

Assessment of the rapid test based on an immunochromatography technique for detecting anti-Treponema pallidum antibodies

A rapid test based on an immunochromatography assay - Determine™ Syphilis TP (Abbott Lab.) for detecting specific antibodies to Treponema pallidum was evaluated against serum samples from patients with clinical, epidemiological and serological diagnosis of syphilis, patients with sexually transmitted disease other than syphilis, and individuals with negative serology for syphilis. The Determine™ test presented the sensitivity of 93.6%, specificity of 92.5%, and positive predictive value and negative predictive value of 95.2% and 93.7%, respectively. One serum sample from patient with recent latent syphilis showed a prozone reaction. Determine™ is a rapid assay, highly specific and easy to perform. This technique obviates the need of equipment and its diagnostic features demonstrate that it may be applicable as an alternative assay for syphilis screening under some emergency conditions or for patients living in remote localities.

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.

Passively acquired treponemal antibody from intravenous immunoglobulin therapy in a pregnant patient

Intravenous immunoglobulin is purified, concentrated immunoglobulin G antibodies pooled from human blood donors. The passive transmission of various antibodies from intravenous immunoglobulin has been reported. However, to the best of our knowledge, there are no reports of acquisition of treponemal antibody from immunoglobulin therapy. A woman with a pregnancy complicated by neonatal alloimmune thrombocytopenia was treated with intravenous immunoglobulin to manage her fetal thrombocytopenia. The patient had no history of a syphilis infection. The patient's blood was screened for syphilis antibodies regularly and routinely because she donated platelets for transfusion to her fetus. During her intravenous immunoglobulin treatments, a positive result on a fluorescence antibody absorption test was confirmed, but the result on a rapid plasma reagin test was negative. Eleven weeks after her final dose, results of the fluorescence antibody absorption test were negative, with a negative rapid plasma reagin test result, suggesting passive acquisition of the treponemal antibody. Clinicians and pathologists must be aware of the possible acquisition of this antibody during the treatment and counseling of patients receiving intravenous immunoglobulin.

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

Syphilis is a chronic disease with a waxing and waning course, the manifestations of which have been described for centuries. It occurs worldwide, and the incidence varies significantly with geographic location. Transmission is mainly by sexual contact. The causative organism, Treponema pallidum, was first described in 1905, but because of the inability to culture the organism and the limitations of direct microscopy, serologic testing is the mainstay of laboratory diagnosis. The disease has been arbitrarily divided into several stages. The primary stage is defined by a chancre at the site of inoculation. The secondary stage is characterized by a polymorphic rash, lymphadenopathy, and other systemic manifestations. A variable asymptomatic latent period follows, which for epidemiologic purposes is divided into early (<1 year) and late (>1 year) stages. The early stages (primary, secondary, and early latent) are potentially infectious. The tertiary stage is the most destructive and is marked by cardiovascular and neurologic sequelae and gummatous involvement of any organ system. Congenital infection may result in protean early or late manifestations. Unlike many other bacteria causing infectious diseases, the organism remains sensitive to penicillin, and this remains the mainstay of therapy.

The association of false-positive rapid plasma reagin results and HIV infection

BACKGROUND AND OBJECTIVES

To study the relationship between a false positive rapid plasma reagin (RPR) result (FP), syphilis, and HIV infection in our patients.

METHODS

A prospective study of the incidence of FP tests and syphilis in the general population and its relationship to HIV infection over a period of 6 months.

RESULTS

8.76% of the population were HIV positive. False positives were found in 15% and 1.2% of the HIV infected and noninfected patients, respectively; the attributable risk for HIV was 14.97. Syphilis was found in 5% and 0.9% of the positive and negative HIV patients, respectively; the attributable risk for HIV was 5.4.

CONCLUSIONS

The incidence of false positive RPR results in the HIV-infected population is significantly higher than that of the non-HIV-infected patients.

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.

Laboratory diagnosis and interpretation of tests for syphilis

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.

Comparison of molecular and microscopic techniques for detection of Treponema pallidum in genital ulcers

We compared the ability of direct immunofluorescent staining (DFA) and the PCR to detect Treponema pallidum in specimens from patients with genital ulcer disease. Touch preparations from 156 patients with genital lesions were fixed in acetone and stained with a fluorescein-labeled monoclonal antibody specific for the 37-kDa antigen of T. pallidum. After microscopic examination, the smear was removed from the slide with a swab. DNA was extracted with phenol-chloroform and precipitated with isopropanol. Ten microliters of the extracted DNA was amplified by PCR using primers for the gene encoding the 47-kDa protein of T. pallidum and hybridized to an internal probe. Twenty-two of 156 specimens were positive for T. pallidum by DFA and PCR, while 127 were negative by both methods, yielding a concordance of 95.5% (kappa = 0.84). Four specimens were positive by PCR and negative by DFA, while three specimens were negative by PCR and positive by DFA. The DFA-negative, PCR-positive specimens may have resulted from the presence of large numbers of leukocytes on the slides, obscuring visualization of treponemes. The DFA-positive, PCR-negative results were not due to inhibition of the PCR since purified T. pallidum DNA was amplified when added to aliquots of these specimens. Negative results in these specimens were most likely due to inefficient recovery of their DNA. These data suggest that DFA and PCR are equivalent methods for detection of T. pallidum on touch preparations of genital lesions. Further refinements of the PCR assay are necessary for it to significantly improve the detection of T. pallidum in genital lesions.

Timely diagnosis of congenital infections

The acronym TORCH has served to increase awareness of congenital infections; however, this collective term suggests that the clinical manifestations of congenital infections are not distinguishable by pathogen. Although some clinical features may be common to several of these infections, a congenital infection caused by one pathogen generally can be distinguished from infection caused by another pathogen on a clinical basis. Pediatricians need to be aware of the prominent features of each congenital infection rather than to consider them collectively. This article focuses on the prominent features of the more common congenital infections, suggests a specific diagnostic approach, and reviews the available therapeutic strategies.

Syphilis as AIDS?--A call for research

Based upon a literature survey, this paper outlines the argument that Treponema pallidum may be the etiologic agent of AIDS. AIDS and syphilis have similar epidemiology, immunology and pathologies. In addition, the current methods of detecting and treating syphilis are inadequate. The similarities between syphilis and AIDS support the need for further research into their relationships, including the role Treponema pallidum may play in AIDS etiology.

[Outbreak of malaria induced among users of injectable drugs]

Five cases of malaria were detected among cocaine users by the local health service in Bauru, a city with a population of 260,000, located 324 km from S. Paulo, Brazil, during the first three weeks of July 1990. Autochthonous malaria had not occurred in Bauru since 1978, and all the five cases denied having recently traveled to endemic areas. An extensive epidemiologic survey conducted from July 19 to September 13 revealed that the 5 cases were in fact part of a malaria outbreak among endovenous drug users. Moreover, at least 114 other people, who had in the last three months shared syringes and needles with one or more proved cases, were also involved in the outbreak. One hundred and two people were identified and interviewed orally. The examination of thick smears made from samples collected from 99 of them confirmed 21 cases of vivax malaria. Three people with negative blood smears had an indirect immunofluorescent assay positive to P. vivax antigen. Although the index case could not be discovered, the investigation suggested that one or more people who had recently traveled to the Amazon region might have introduced the disease. The control of the outbreak was achieved after offering treatment with chloroquine (10 tablets) to confirmed cases and contacts, followed by weekly suppressive chloroquine (2 tablets) until the last contact was detected. Malaria examination of 91 blood samples also revealed a high prevalence of hepatitis B virus infection (40%) and HIV infection (58%) among those involved in the outbreak. The strategy used to identify the cases and the contacts and the difficulties overcome in carrying it through are described.(ABSTRACT TRUNCATED AT 250 WORDS)

The spectrum of syphilis in patients with human immunodeficiency virus infection

Five patients infected with the human immunodeficiency virus (HIV) with unusual manifestations of syphilis are reported. The high prevalence of HIV seropositivity among our patients with syphilis, the rapid progression to tertiary disease, the increased severity of the clinical manifestations, inappropriate antibody responses to infection, relapse without reexposure despite "adequate" treatment, and lack of response to penicillin therapy have been observed in these and in other patients. Data are presented to explain these unusual observations.

Luetic hearing loss: clinical presentation, diagnosis, and treatment

Luetic hearing loss, a relatively rare disorder, is significant because it is one of the few forms of progressive sensorineural hearing loss that may be reversed if diagnosed early and accurately and treated aggressively. With the increased incidence of systemic syphilis over the past few decades, the otolaryngologist can expect otosyphilis to appear more frequently. This report reviews the clinical presentation, histopathology, diagnostic workup, and current therapy for this disorder.

Tabes dorsalis: electrodiagnostic features

Electrodiagnostic data have not been previously reported in tabes dorsalis. A patient with tabes dorsalis is described whose nerve conduction studies and median nerve somatosensory evoked responses (SEPs) were normal. H-reflexes were absent. SEPs of the tibial nerve suggested posterior column dysfunction. These electrodiagnostic findings correlate precisely with the known pathology of tabes dorsalis.

Voiding dysfunction in tertiary syphilis

After years of decline to near disappearance, there recently has been an increasing incidence of syphilis in America. New cases of tertiary neurosyphilis are being reported which often have associated significant urologic sequelae. For the first time in the English literature, the uro-dynamic findings of a patient with tabes dorsalis are presented. Our findings indicate that treatment of urinary retention associated with tabes dorsalis is better managed by intermittent catheterization than by prostate surgery because of the impaired detrusor activity. A review of neurosyphilis and its urologic implications and urodynamic findings are presented. Prompt recognition of this entity should encourage a full urodynamic evaluation prior to a commitment to prostatic surgery.

Uveitis: a strategy for diagnosis

Uveitis may be the first presentation of a wide variety of underlying ocular and systemic diseases. It is important for the ophthalmologist to make a specific diagnosis in order to instigate specific therapy and give an accurate prognosis. The ability to recognise the clinical patterns of uveitis and to initiate appropriate investigations should form the basis of the ophthalmologist's management of the condition. To this end, we have considered uveitis under four major patterns of presentation--anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis--with subclasses within each of these four groups. We have outlined both the investigations which facilitate diagnosis of the possible underlying causes of inflammation and the interpretation of the results of such investigations.

Cerebral gumma

A patient presented with symptoms from a tumour in the frontal region. Syphilis had been treated 15 years earlier but the serological tests were inconclusive on this admission. The CT-scan showed oedema surrounding a contrast enhancing tumour. Angiography showed displaced but otherwise normal vessels. Histologically the lesion proved to be a gumma.

Decision tables and logic in decision analysis

Unmanageable bushy decision trees result when a decision analysis involves several investigations. They can be simplified for riskless tests by deriving the maximum expected utility decision table for the problem as an intermediate step. This table can be logically summarized as Boolean expressions involving the tests. A minimum-cost testing sequence may then be found by manipulation of the Boolean formulas. The relationship between the resulting decision criteria and the receiver operating characteristic is shown.

Detection of Treponema pallidum in lesion exudate with a pathogen-specific monoclonal antibody

The diagnosis of early syphilis currently requires dark-field microscopic or serologic demonstration of Treponema pallidum infection. Dark-field microscopy is not widely available and is complicated by the numerous saprophytic spirochetes which are present at oral and rectal mucosal surfaces. Serologic tests are positive in only 70 to 90% of patients with primary syphilis, and several days may be required for results to become available. We used a pathogen-specific, fluorescein-conjugated monoclonal antibody to examine lesion exudates from 61 patients for the presence of T. pallidum and compared the data with results of dark-field microscopy and serologic testing. The direct fluorescent-antibody technique revealed the presence of T. pallidum in 30 of 30 patients with early syphilis, and dark-field microscopy was positive for 29. Serologic tests were reactive for 27 of 30 patients with syphilis; in the 3 patients with nonreactive serologic tests, chancres had been present for 4, 6, and 21 days. Although 7 of 31 patients without syphilis had spiral organisms seen on dark-field microscopy, the direct fluorescent-antibody test was negative for all 31. The presence of nonpathogenic spirochetes was subsequently verified in 5 of 7 patients by using a second monoclonal antibody which reacts with nonpathogenic, as well as pathogenic, treponemes and related spirochetes. The demonstration of T. pallidum by using fluorescein-conjugated monoclonal antibodies is intrinsically specific and is as sensitive as dark-field microscopy for the diagnosis of early syphilis. This method provides a convenient, accurate means for the diagnosis of syphilis by health care providers, many of whom lack access to dark-field microscopy.

The role of lumbar puncture in the evaluation of dementia: the Durham Veterans Administration/Duke University Study

The use of lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis in the routine, initial evaluation of patients with dementia continues to be questioned. This is especially true in the investigation of infectious causes of dementia. To explore this question further, the authors performed a retrospective analysis of 672 hospitalized patients specifically evaluated for dementia. LP and CSF analysis were performed on 402 patients (60 per cent); routine bacteriologic, acid-fast, and fungal cultures were also obtained for 333 of these patients. Most patients were white (64 per cent) and male (63 per cent), their mean age being 66 +/- 11 years. Four patients were diagnosed as having meningitis--two with Cryptococcus neoformans, one with apparent Mycobacterium tuberculosis, and one with coagulase-positive Staphylococcus aureus. These patients were characterized by a subacute change in mental status, fever or meningismus, and CSF pleocytosis with abnormal CSF chemistries. None of the patients were found to have newly diagnosed neurosyphilis. The authors conclude that LP and CSF analysis should not be part of the routine evaluation of patients with dementia and should be performed only in the presence of such indications as a subacute duration of dementia, fever, and signs of meningeal irritation.

Clinical course and treatment of venereal spirochaetosis in New Zealand white rabbits

Ten sporadic cases of venereal spirochaetosis, caused by Treponema paraluis-cuniculi, were seen in New Zealand white rabbits in two years. An equal number of males and females were affected. Females tended to have milder clinical signs than males. Lesions were usually found on the prepuce in males and the vulva in females, although the anus and skin of the perineum were also affected. Facial lesions were rare. Lesions healed in seven to 28 days in rabbits treated with penicillin. Eight rabbits had antibodies reactive in the Venereal Disease Research Laboratory (VDRL), rapid plasma reagin (RPR), and fluorescent treponemal antibody absorbed (FTA-ABS) tests when the disease was first diagnosed. In several rabbits followed longitudinally, RPR test results became negative two to four months after antimicrobial treatment, VDRL antibody titres diminished but usually persisted at low levels, while FTA-ABS antibodies declined slowly and were still evident 12 months after treatment.

Essential mixed cryoglobulinaemia with false-positive serological tests for syphilis

Analysis of serum from a patient with cutaneous leukocytoclastic vasculitis showed a mixed cryoglobulin with a monoclonal IgM kappa-antiglobulin component (6.5 mg/ml), strong rheumatoid factor activity (latex titre 1/5000), and positive serological tests for syphilis (fluorescent treponemal antibody-absorbed and Treponema pallidum haemagglutination assay). After removal of antiglobulin activity by immunoabsorption with heat-aggregated gammaglobulin all serological test results for treponemal infection became negative. Serological tests for syphilis and rheumatoid factor on the supernatant from whole serum (minus cryoglobulin) remained positive though at a lower titre (latex 1/1250). Cryoglobulin isolated from whole serum retained rheumatoid and TPHA reactivity but was negative in the FTA-ABS test. The IgM and IgG cryoglobulin components purified by gel filtration on Sepharose showed no antitreponemal reactivity even when tested individually. Reducing the concentration of cryoglobulin to 1.5 mg/ml by plasma exchange converted the test results for syphilis to doubtful-positive or negative. These results indicated that high concentrations of antiglobulin activity may be associated with falsely positive specific antitreponemal test results and that this phenomenon depends on the concentration of cryoglobulin in the test sample.