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Moursi MO, Hamam W, Hajjar A, Es‐Salim M, Aboukhalaf S, Jamil O, Zahid M. Ischemic stroke as an initial presentation of neurosyphilis in a newly diagnosed HIV patient: A case report and literature review. Clin Case Rep 2024; 12:e8794. [PMID: 38736579 PMCID: PMC11087217 DOI: 10.1002/ccr3.8794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/02/2024] [Accepted: 04/02/2024] [Indexed: 05/14/2024] Open
Abstract
With syphilis resurgence, physicians should be more vigilant to infection-induced cerebral vasculitis in high-risk patients presenting with neurological symptoms. In this case, neurosyphilis should not be missed. Thorough serologic screening and lumbar puncture are crucial for diagnosis, and further research is needed for safe and effective treatments in these populations.
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Affiliation(s)
- Moaz O. Moursi
- Department of Internal MedicineHamad General HospitalDohaQatar
- College of Medicine, QU HealthQatar UniversityDohaQatar
| | - Wael Hamam
- Department of Internal MedicineHamad General HospitalDohaQatar
| | - Adnan Hajjar
- Department of Internal MedicineHamad General HospitalDohaQatar
| | | | - Soha Aboukhalaf
- Department of Internal MedicineHamad General HospitalDohaQatar
- College of Medicine, QU HealthQatar UniversityDohaQatar
| | - Omar Jamil
- College of Medicine, QU HealthQatar UniversityDohaQatar
- Department of RadiologyHamad General HospitalDohaQatar
| | - Muhammad Zahid
- Department of Internal MedicineHamad General HospitalDohaQatar
- College of Medicine, QU HealthQatar UniversityDohaQatar
- Weill Cornell Medical CollegeDohaQatar
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Abstract
Dermatologists are familiar with the classic aspects of syphilis. Our objective in this update is to display novel features of sexually acquired syphilis, its pathophysiology, natural history, atypical clinical variants, skin of color, clinical pearls, and prospects. Textbook knowledge, congenital syphilis, epidemiology, and historical data are excluded.
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Affiliation(s)
- Jorge Navarrete
- Department of Dermatology, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile; Department of Dermatology and Sexually Transmitted Infections Clinic, Hospital Padre Hurtado, Santiago, Chile.
| | - Stephanie Saavedra-Portales
- Department of Dermatology and Sexually Transmitted Infections Clinic, Hospital San Juan de Dios, Santiago, Chile
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Ikeuchi K, Fukushima K, Tanaka M, Yajima K, Saito M, Imamura A. Changes in rapid plasma reagin titers in patients with syphilis before and after treatment: A retrospective cohort study in an HIV/AIDS referral hospital in Tokyo. PLoS One 2023; 18:e0292044. [PMID: 37768989 PMCID: PMC10538775 DOI: 10.1371/journal.pone.0292044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Although the rapid plasma reagin (RPR) test is used to determine treatment efficacy for syphilis, animal studies show that it decreases gradually after an initial increase even without treatment. Pre-treatment changes in RPR titer in humans and its relationship with post-treatment changes in RPR titer are not well known. METHODS We retrospectively analyzed the clinical records of syphilitic patients who underwent automated RPR (Mediace) testing twice before treatment (i.e., at diagnosis and treatment initiation) within 1-3 months at an HIV/AIDS referral hospital in Japan between 2006 and 2018. The RPR values were expressed as the ratio to the value at treatment initiation. The mean monthly relative change in the RPR after treatment was calculated on the log2 scale for each patient and analyzed by multivariable linear regression. RESULTS Sixty-eight patients were identified. The median age was 45 (interquartile range [IQR], 38-50), 98.5% (67/68) were men, and 97.1% (66/68) had HIV. The median RPR titer ratio at treatment initiation/diagnosis was 0.87 (IQR, 0.48-1.30). The RPR titer decreased more than twofold in 26.5% (18/68) and more than fourfold in 10.3% (7/68) before treatment. In the multivariable analysis, higher age (predicted monthly RPR relative change on the log2 scale 0.23/10 years [95% confidence interval [CI], 0.090-0.37]), history of syphilis (0.36 [95% CI, 0.07-0.65]), and a lower ratio of RPR at treatment initiation/diagnosis (-0.52/every 10-fold increase [95% CI, -0.81 to -0.22]) were associated with a slower RPR decrease after treatment. CONCLUSIONS In a mostly HIV patient population, RPR titer can show more than four-fold spontaneous increase or decrease within 1-3 months. Pre-treatment spontaneous decrease of RPR titer was associated with a slower decrease in post-treatment RPR titer.
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Affiliation(s)
- Kazuhiko Ikeuchi
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
- Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, The University of Tokyo, Minato-ku, Tokyo, Japan
| | - Kazuaki Fukushima
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Masaru Tanaka
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Keishiro Yajima
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Makoto Saito
- Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, The University of Tokyo, Minato-ku, Tokyo, Japan
| | - Akifumi Imamura
- Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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Henriques BL, Vidal JE, Gamba C, Avelino-Silva VI. Lumbar puncture for neurosyphilis investigation in asymptomatic patients with HIV-syphilis coinfection: a cross-sectional study among infectious disease specialists. SAO PAULO MED J 2023; 141:20-29. [PMID: 36043668 PMCID: PMC9808987 DOI: 10.1590/1516-3180.2021.0744.r1.03032022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 03/03/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Syphilis is a major public health issue worldwide. In people living with human immunodeficiency virus (PLHIV), there are higher incidences of both syphilis and neurosyphilis. The criteria for referring PLHIV with syphilis for lumbar puncture is controversial, and the diagnosis of neurosyphilis is challenging. OBJECTIVE To describe the knowledge, attitudes, and practices of infectious disease specialists and residents in the context of care for asymptomatic HIV-syphilis coinfection using close-ended questions and case vignettes. DESIGN AND SETTING Cross-sectional study conducted in three public health institutions in São Paulo (SP), Brazil. METHODS In this cross-sectional study, we invited infectious disease specialists and residents at three academic healthcare institutions to answer a self-completion questionnaire available online or in paper form. RESULTS Of 98 participants, only 23.5% provided answers that were in line with the current Brazilian recommendation. Most participants believed that the criteria for lumbar puncture should be extended for people living with HIV with low CD4+ cell counts (52.0%); in addition, participants also believed that late latent syphilis (29.6%) and Venereal Disease Research Laboratory (VDRL) titers ≥ 1:32 (22.4%) should be conditions for lumbar puncture in PLHIV with no neurologic symptoms. CONCLUSION This study highlights heterogeneities in the clinical management of HIV-syphilis coinfection. Most infectious disease specialists still consider syphilis stage, VDRL titers and CD4+ cell counts as important parameters when deciding which patients need lumbar puncture for investigating neurosyphilis.
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Affiliation(s)
- Bárbara Labella Henriques
- MD. Doctoral Student, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - José Ernesto Vidal
- MD. PhD. Infectious Disease Specialist, Department of Neurology, Instituto de Infectologia Emilio Ribas, São Paulo (SP), Brazil; Infectious Disease Specialist, Department of Infectious Diseases, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Cristiano Gamba
- MD. Infectious Disease Specialist, Centro de Referência e Treinamento DST AIDS (CRT), São Paulo (SP), Brazil
| | - Vivian Iida Avelino-Silva
- MD, PhD. Infectious Disease Specialist, Department of Infectious Disease, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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5
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Yan J, Luo L, Han J, Yan D, Zhang B, Zhang Z, Shi J, Zhu M, Yu J, Liu S, Qi J, Yang Z. Comparing Noninvasive Predictors of Neurosyphilis Among Syphilis Patients With and Without HIV Co-Infection Based on the Real-World Diagnostic Criteria: A Single-Center, Retrospective Cohort Study in China. AIDS Res Hum Retroviruses 2022; 38:406-414. [PMID: 34314231 DOI: 10.1089/aid.2021.0085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Diagnosis of neurosyphilis is currently based on the cerebrospinal fluid (CSF) assessments and CSF-Venereal Disease Research Laboratory (CSF-VDRL) is the traditional "gold standard." In the real world, CSF assessments and CSF-VDRL are not always available. This study aimed to identify noninvasive predictors of neurosyphilis based on real-world clinical parameters and diagnostic criteria in populations with different HIV status. In this retrospective cohort study, syphilis patients with different HIV statuses hospitalized for neurosyphilis screening were retrospectively recruited at an infectious disease hospital. Neurosyphilis was defined by real-world diagnostic criteria. Logistic regression and receiver operating characteristic curve analysis were used to investigate and evaluate predictors of neurosyphilis. In total, 528 patients were enrolled, including 143 syphilis patients without HIV infection and 385 HIV/syphilis-co-infected patients. One hundred twelve and 304 neurosyphilis patients were identified in the HIV-negative and HIV-positive groups, respectively. A high serum toluidine red unheated serum test (TRUST) titer was a robust predictor of neurosyphilis in all participants. An age ≥50 years old [adjusted odds ratio (aOR) = 5.062, 95% confidence interval (CI), 1.449-17.680] in the HIV-negative group and CD4+ T cell count <330/μL (<300 as reference, aOR = 0.552, 95% CI, 0.315-0.966) in the HIV-positive group were predictors of asymptomatic neurosyphilis. In real-world situations, for asymptomatic syphilis patients, relatively old age and a high serum TRUST titer in HIV-negative populations, and CD4+ T cells <330/μL and/or serum TRUST titer >1:64 in HIV-positive populations might predict neurosyphilis.
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Affiliation(s)
- Jun Yan
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Lian Luo
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Jie Han
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Dingyan Yan
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Binhai Zhang
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Zhongdong Zhang
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Jinchuan Shi
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Mingli Zhu
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Jianhua Yu
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Shourong Liu
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Jianjiang Qi
- Hangzhou Seventh People's Hospital, Affiliated Mental Center, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Zongxing Yang
- Xixi Hospital of Hangzhou, Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
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Martínez-Ayala P, Quiñonez-Flores A, González-Hernández LA, Ruíz-Herrera VV, Zúñiga-Quiñones S, Alanis-Sánchez GA, Cabrera-Silva RI, Amador-Lara F, Sánchez-Reyes K, Álvarez-Zavala M, Vázquez-Limón JC, Sánchez-Navarro JP, Andrade-Villanueva JF. Clinical features associated with neurosyphilis in people living with HIV and late latent syphilis. Int J STD AIDS 2022; 33:330-336. [PMID: 34978502 PMCID: PMC8958567 DOI: 10.1177/09564624211063091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background The diagnosis of neurosyphilis is a challenge, and the criteria for deciding when to perform a lumbar puncture are still controversial, especially in people living with HIV with a late latent syphilis diagnosis. Methods Retrospective analysis of demographic, clinical, and laboratory data of people with HIV and documented late latent syphilis or syphilis of unknown duration with a cerebrospinal fluid VDRL test. Results 122 patients were evaluated, of whom 52 had the diagnosis of neurosyphilis. Patients with and without neurosyphilis presented a similar viral load and lymphocyte CD4+ T-cell count. Neurological symptoms (OR 6.4, 95% CI 2.1–22.4; p < 0.01), serum VDRL titers of 1:32 (p<0.01), 1:64 (p = 0.055), and ≥1:128 (p < 0.001) were associated with neurosyphilis. Furthermore, serum VDRL ≥1:32 were associated with (OR 24.9, 95% CI 5.45–154.9; p < 0.001) or without (OR 6.5, 95% CI 2.0–29.2; p = 0.004) neurological symptoms with neurosyphilis; however, VDRL ≤1:16 with neurological symptoms can be associated with neurosyphilis (OR 7.6, 95% CI 1.03–64.3; p = 0.046). Conclusion Neurological symptoms, particularly headache, were predictors of neurosyphilis in people with HIV irrespective of their viral load and lymphocyte CD4+ T-cell count in late latent syphilis. A serum VDRL ≥1:32 increased the risk of neurosyphilis in patients with or without any symptoms.
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Affiliation(s)
- Pedro Martínez-Ayala
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico
| | | | - Luz Alicia González-Hernández
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico.,HIV and Immunodeficiencies Research Institute, 42571University of Guadalajara, Guadalajara, Mexico
| | | | - Sergio Zúñiga-Quiñones
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico
| | | | | | - Fernando Amador-Lara
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico
| | - Karina Sánchez-Reyes
- HIV and Immunodeficiencies Research Institute, 42571University of Guadalajara, Guadalajara, Mexico
| | - Monserrat Álvarez-Zavala
- HIV and Immunodeficiencies Research Institute, 42571University of Guadalajara, Guadalajara, Mexico
| | | | | | - Jaime Federico Andrade-Villanueva
- HIV Unit, 103531Hospital Civil of Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico.,HIV and Immunodeficiencies Research Institute, 42571University of Guadalajara, Guadalajara, Mexico
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Quilter LAS, de Voux A, Amiya RM, Davies E, Hennessy RR, Kerani RP, Madera R, Matthias J, Pearson VM, Walters JK, Wilson C, Kidd S, Torrone E. Prevalence of Self-reported Neurologic and Ocular Symptoms in Early Syphilis Cases. Clin Infect Dis 2021; 72:961-967. [PMID: 32103243 DOI: 10.1093/cid/ciaa180] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Neurosyphilis, a complication of syphilis, can occur at any stage of infection. Measuring the prevalence of neurosyphilis is challenging, and there are limited data on the prevalence of neurologic or ocular symptoms among patients with syphilis. We sought to describe the prevalence of neurologic and/or ocular symptoms among early syphilis (ES) cases and the clinical management of symptomatic cases enrolled in the STD Surveillance Network (SSuN) Neuro/Ocular Syphilis Surveillance project. METHODS Persons diagnosed with ES were selected for interviews based on current health department protocols in 5 participating SSuN jurisdictions from November 2016 through October 2017. All interviewed ES cases were screened for self-reported neurologic and/or ocular symptoms. Additional clinical information on diagnostic testing and treatment for cases concerning for neurosyphilis/ocular syphilis was obtained from providers. RESULTS Among 9123 patients with ES who were interviewed, 151 (1.7%; 95% confidence interval [CI], 1.4%-1.9%) reported ≥ 1 neurologic or ocular symptom. Of the 53 (35%) who underwent lumbar puncture, 22 (42%) had documented abnormal cerebrospinal fluid, of which 21 (95%) were treated for neurosyphilis/ocular syphilis. Among the remaining 98 symptomatic patients with no documented lumbar puncture (65%), 12 (12%) were treated for and/or clinically diagnosed with neurosyphilis/ocular syphilis. CONCLUSIONS We observed a low prevalence of self-reported neurologic and/or ocular symptoms in interviewed ES cases. Approximately one-third of ES cases who self-reported symptoms underwent further recommended diagnostic evaluation. Understanding barriers to appropriate clinical evaluation is important to ensuring appropriate management of patients with possible neurologic and/or ocular manifestations of syphilis.
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Affiliation(s)
- Laura A S Quilter
- Epidemic Intelligence Service, Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alex de Voux
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rachel M Amiya
- Washington State Department of Health, Shoreline, Washington, USA
| | - Erin Davies
- Washington State Department of Health, Shoreline, Washington, USA
| | - Robin R Hennessy
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,New York City Department of Health and Mental Hygiene, New York, New York, USA
| | - Roxanne P Kerani
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Robbie Madera
- Philadelphia Department of Public Health, Philadelphia, Pennsylvania, USA
| | - James Matthias
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Florida Department of Health, Tallahassee, Florida, USA
| | | | | | - Craig Wilson
- Florida Department of Health, Tallahassee, Florida, USA
| | - Sarah Kidd
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Elizabeth Torrone
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Tuddenham S, Katz SS, Ghanem KG. Syphilis Laboratory Guidelines: Performance Characteristics of Nontreponemal Antibody Tests. Clin Infect Dis 2021; 71:S21-S42. [PMID: 32578862 PMCID: PMC7312285 DOI: 10.1093/cid/ciaa306] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We reviewed the relevant syphilis diagnostic literature to address the following question: what are the performance characteristics, stratified by the stage of syphilis, for nontreponemal serologic tests? The database search included key terms related to syphilis and nontreponemal tests from 1960–2017, and for data related to the venereal disease research laboratory test from 1940–1960. Based on this review, we report the sensitivity and specificity for each stage of syphilis (primary, secondary, early latent, late latent, or unknown duration; tertiary as well as neurosyphilis, ocular syphilis, and otic syphilis). We also report on reactive nontreponemal tests in conditions other than syphilis, false negatives, and automated nontreponemal tests. Overall, many studies were limited by their sample size, lack of clearly documented clinical staging, and lack of well-defined gold standards. There is a need to better define the performance characteristics of nontreponemal tests, particularly in the late stages of syphilis, with clinically well-characterized samples. Published data are needed on automated nontreponemal tests. Evidence-based guidelines are needed for optimal prozone titrations. Finally, improved criteria and diagnostics for neurosyphilis (as well as ocular and otic syphilis) are needed.
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Affiliation(s)
- Susan Tuddenham
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samantha S Katz
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Khalil G Ghanem
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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9
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Abstract
PURPOSE OF REVIEW In the context of a resurgence of syphilis worldwide, it can be anticipated that a rise in cases of ocular, otic, and neurosyphilis will also be seen. This article reviews the current epidemiology, manifestations, and approach to management and treatment. RECENT FINDINGS Although studies continue investigating alternate approaches and new diagnostic tests for ocular and neurosyphilis, few data exist to change current diagnostic algorithms and approaches to diagnosis, management, or follow up. SUMMARY The diagnosis of neurologic and eye/ear involvement with syphilis may be delayed because of a lack of specificity of findings, low suspicion for syphilis, fluctuation in symptoms, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis and re-education about the protean manifestations of syphilis by all clinicians is required provide timely diagnosis and management of ocular, otic, and neurosyphilis.
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Dunaway SB, Maxwell CL, Tantalo LC, Sahi SK, Marra CM. Neurosyphilis Treatment Outcomes After Intravenous Penicillin G Versus Intramuscular Procaine Penicillin Plus Oral Probenecid. Clin Infect Dis 2021; 71:267-273. [PMID: 31504293 DOI: 10.1093/cid/ciz795] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Data comparing neurosyphilis treatment regimens are limited. METHODS Participants were enrolled in a study of cerebrospinal fluid (CSF) abnormalities in syphilis that was conducted at the University of Washington between April 2003 to May 2014. They were diagnosed with syphilis and referred by their providers due to concerns for neurosyphilis. We evaluated 150 people with CSF abnormalities who were treated with either intravenous aqueous penicillin G (PenG) or intramuscular aqueous procaine penicillin G plus oral probenecid (APPG-P). An abnormal CSF diagnosis was defined as a white blood cell (WBC) count >20/µL, a CSF protein reading >50 mg/dL, or a reactive CSF-Venereal Disease Research Laboratory test (VDRL). Hazard ratios for normalization of CSF or serum measures were determined using Cox regression. RESULTS In individuals treated with either PenG or APPG-P, CSF WBCs and CSF-VDRL reactivity normalized within 12 months after treatment, while protein normalized more slowly and less completely. There was no relationship between treatment regimen or human immunodeficiency virus (HIV) status and likelihood of normalization of any measure. Among those living with HIV, CSF WBC counts and CSF-VDRL reactivity were more likely to normalize in those treated with antiretrovirals. Unexpectedly, CSF WBCs were more likely to normalize in those with low CD4+ T cell counts. When neurosyphilis was more stringently defined as a reactive CSF-VDRL, the relationship with the CD4+ T cell count remained unchanged. CONCLUSIONS In the current antiretroviral treatment era, neurosyphilis treatment outcomes are not different for PenG and APPG-P, regardless of HIV status. The relationship between the normalization of CSF WBC counts and CD4+ T cell counts may indicate continued imprecision in neurosyphilis diagnostic criteria, due to HIV-related CSF pleocytosis.
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Affiliation(s)
- Shelia B Dunaway
- Department of Medicine, Division of Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Clare L Maxwell
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Lauren C Tantalo
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Sharon K Sahi
- Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Christina M Marra
- Department of Neurology, University of Washington, Seattle, Washington, USA
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Abstract
PURPOSE OF REVIEW Neurosyphilis (NS) and Lyme neuroborreliosis (LNB) are spirochetal diseases with distinct clinical manifestations. The diagnosis of NS remains challenging due to imperfect diagnostic criteria and testing modalities. With LNB, misconceptions about diagnosis and treatment lead to considerable morbidity and drug related adverse effects. RECENT FINDINGS Although studies continue investigating alternate approaches and new diagnostic tests for NS, few data exist to change current approaches to diagnosis, management or follow up. In the diagnosis of LNB, the chemokine CXCL13 shows promising diagnostic accuracy. A systematic review discourages the use of cell-based assays when investigating Lyme disease. Clinical studies show no benefit from extended antibiotic treatment for patients with unspecific symptoms labelled as having Lyme disease. SUMMARY The diagnosis of NS may be delayed due to a lack of specificity of findings, low suspicion for syphilis, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis is required provide timely diagnosis and management of NS. Fortunately, penicillin remains the treatment of choice. Overdiagnosis and overtreatment in patients labelled as having Lyme disease can be avoided by an evidence-based approach towards diagnosis and treatment.
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12
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Janier M, Unemo M, Dupin N, Tiplica GS, Potočnik M, Patel R. 2020 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol 2020; 35:574-588. [PMID: 33094521 DOI: 10.1111/jdv.16946] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/04/2020] [Indexed: 12/22/2022]
Abstract
The 2020 edition of the European guideline on the management of syphilis is an update of the 2014 edition. Main modifications and updates include: -The ongoing epidemics of early syphilis in Europe, particularly in men who have sex with men (MSM) -The development of dual treponemal and non-treponemal point-of-care (POC) tests -The progress in non-treponemal test (NTT) automatization -The regular episodic shortage of benzathine penicillin G (BPG) in some European countries -The exclusion of azithromycin as an alternative treatment at any stage of syphilis -The pre-exposure or immediate post-exposure prophylaxis with doxycycline in populations at high risk of acquiring syphilis.
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Affiliation(s)
- M Janier
- STD Clinic, Hôpital Saint-Louis AP-HP and Hôpital Saint-Joseph, Paris, France
| | - M Unemo
- WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, Department of Laboratory Medicine, Microbiology, Örebro University Hospital and Örebro University, Örebro, Sweden
| | - N Dupin
- Syphilis National Reference Center, Hôpital Tarnier-Cochin, AP-HP, Paris, France
| | - G S Tiplica
- 2nd Dermatological Clinic, Carol Davila University, Colentina Clinical Hospital, Bucharest, Romania
| | - M Potočnik
- Department of Dermatovenereology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - R Patel
- Department of Genitourinary Medicine, the Royal South Hants Hospital, Southampton, UK
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13
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Singh S, Puranik P, Lin E, Marti M, Liu A. Neurosyphilis in AIDS patient presenting as isolated cranial nerve 6 palsy. Clin Case Rep 2020; 8:1877-1879. [PMID: 33088510 PMCID: PMC7562863 DOI: 10.1002/ccr3.3018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/14/2020] [Accepted: 05/15/2020] [Indexed: 12/23/2022] Open
Abstract
Early neurosyphilis can occur in an immunocompromised host. It has a widely varied presentation. Isolated CN6 as presenting symptom has not been described.
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Affiliation(s)
| | | | - Ethan Lin
- Department of Family Practice California Hospital Medical Center Los Angeles California USA
| | - Miriam Marti
- Department of Neurology Adventist Health White Memorial Los Angeles California USA
| | - Antonio Liu
- Department of Neurology Adventist Health White Memorial Los Angeles California USA
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Akalp FD, Yılmaz S, Erol MK, Avcı E, Avcı R. Ocular Syphilis Unmasked Following Bilateral Intravitreal Dexamethasone Implant (Ozurdex) Injection. Ophthalmic Surg Lasers Imaging Retina 2019; 50:e77-e80. [PMID: 30893461 DOI: 10.3928/23258160-20190301-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/03/2018] [Indexed: 11/20/2022]
Abstract
Intraocular corticosteroids are used in ophthalmologic conditions such as macular edema secondary to vascular occlusions, diabetes, and uveitis. Infectious ocular diseases must be ruled out before intravitreal corticosteroid implantation. Here, the authors report a case that has been referred to their clinic for surgical treatment due to dense vitreous hemorrhage in the right eye after bilateral intravitreal dexamethasone implantation. As an intraoperative finding, diffuse changes in the color-like paleness of the retina as well as intraretinal white-colored deposits were observed. Serology tests were performed, and syphilis serology was positive. Intravenous penicillin provides resolution of inflammation. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e77-e80.].
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Bazewicz M, Lhoir S, Makhoul D, Libois A, Van den Wijngaert S, Caspers L, Willermain F. Neurosyphilis cerebrospinal fluid findings in patients with ocular syphilis. Ocul Immunol Inflamm 2019; 29:95-101. [PMID: 31647700 DOI: 10.1080/09273948.2019.1672193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: To evaluate neurosyphilis cerebrospinal fluid (CSF) findings and initial ophthalmic manifestations in patients with syphilitic uveitis.Methods: We retrospectively reviewed the records of CSF analysis of 14 patients with syphilitic uveitis with treponemal analysis - chemiluminescent immunoassay and TPHA- and non-treponemal analysis - Rapid Plasma Reagin test - RPR.Results: 86% were males and 43% HIV+. Ocular signs of syphilis lead to the diagnosis of syphilis in 78% of patients. Typical syphilitic uveitis presentations included: acute syphilitic posterior placoid chorioretinitis (50% of patients), retinitis (21% of patients) and punctate inner retinitis (7% of patients). 57% of patients had definite neurosyphilis by the CDC criteria, while 71% had CSF abnormalities suggestive of central nervous system involvement.Conclusion: Based on international guidelines, the frequent CSF abnormalities found in syphilitic uveitis patient supports the diagnosis of neurosyphilis in a majority of patients.
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Affiliation(s)
- M Bazewicz
- Ophthalmology, CHU Saint-Pierre and Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - S Lhoir
- Ophthalmology, CHU Saint-Pierre and Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - D Makhoul
- Ophthalmology, CHU Saint-Pierre and Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - A Libois
- Infectious Diseases, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - S Van den Wijngaert
- Microbiologie, Laboratoire Hospitalier Universitaire Bruxelles - Universitaire Laboratorium Brussels, Brussels, Belgium
| | - L Caspers
- Ophthalmology, CHU St Pierre, Brussels, Belgium
| | - F Willermain
- Ophthalmology, CHU Saint-Pierre and Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Centers for Disease Control and Prevention Syphilis Summit: Difficult Clinical and Patient Management Issues. Sex Transm Dis 2019; 45:S10-S12. [PMID: 30102680 DOI: 10.1097/olq.0000000000000851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite over a century of clinical experience in diagnosing and managing patients with syphilis, many thorny clinical questions remain unanswered. We focus on several areas of uncertainty for the clinician: the role of serologic tests in diagnosing syphilis and assessing syphilis treatment responses, and the risk of neurosyphilis and ocular syphilis in patients with syphilis. We also address whether clinical approaches should differ in patients who are, and are not, infected with HIV. The current increases in syphilis rates in the United States and elsewhere underscore our urgent need to definitively address these issues.
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Zhu L, Shi M, Peng RR, Gu X, Guan Z, Xu H, Zhou P. Neurosyphilis is more common in malignant syphilis: A case series and review of the literature. Int J STD AIDS 2019; 30:779-785. [PMID: 31142223 DOI: 10.1177/0956462419826710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Malignant syphilis is a rare skin manifestation of secondary syphilis, which has been reported primarily in the HIV-infected population. This study aimed to investigate the relationship between HIV infection, malignant syphilis, and neurosyphilis through a systematic chart review of 26 malignant syphilis patients seen at our hospital. We also performed a literature review of 83 reported malignant syphilis cases since 1987, when the first case of malignant syphilis co-infected with HIV was reported. We found there was no direct association between HIV infection and malignant syphilis or neurosyphilis. In contrast, we found that much higher proportion (30%) of malignant syphilis patients develop concurrent neurosyphilis compared to those with the common type of secondary syphilis (13.1%). Physicians should be aware of the fact that neurosyphilis is more common among patients with malignant syphilis and the importance of investigating for neurosyphilis in such patients.
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Affiliation(s)
- Lin Zhu
- Department of Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, China
| | - Mei Shi
- Department of Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, China
| | - Rui-Rui Peng
- Department of Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, China
| | - Xin Gu
- Department of Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, China
| | - Zhifang Guan
- Department of Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, China
| | - Huanbin Xu
- Department of Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, China
| | - Pingyu Zhou
- Department of Sexually Transmitted Disease Institute, Shanghai Skin Disease Hospital, Shanghai, China
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Workup for Optic Atrophy. Neuroophthalmology 2019. [DOI: 10.1007/978-3-319-98455-1_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Consider Syphilis in Case of Lymphopenia in HIV-Infected Men Who Have Sex with Men (MSM): A Single-center, Retrospective Study. Infect Dis Ther 2018; 7:485-494. [PMID: 30377976 PMCID: PMC6249181 DOI: 10.1007/s40121-018-0219-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction The way syphilis affects the immunologic and virologic parameters of a human immunodeficiency virus (HIV) infection remains controversial. The aim of this study was to investigate the impact of syphilis infection on lymphocyte and lymphocyte subset counts as well as viral load in HIV-infected patients. Methods All HIV-infected patients attending the outpatient clinic for infectious diseases of Hannover Medical University Hospital diagnosed with syphilis between 2009 and 2016 were retrospectively evaluated for changes in total lymphocyte, B cell, CD3+ T cell, CD4+ and CD8+ T cell counts as well as in HIV viral load. These parameters were assessed at three different time points, i.e., 3–6 months before, at diagnosis and 3–6 months after treatment of syphilis. Results Eighty-four HIV-infected patients, all with early syphilis, were identified. The vast majority were men who have sex with men (MSM), and 80% were receiving antiretroviral therapy (ART). Syphilis was associated with a significant reduction in the total lymphocyte count and counts of all studied lymphocyte subsets, including CD4+ T cells, whose percentage among lymphocytes did not change. No significant changes in HIV viral load were observed at any of the studied time points. Further, antibiotic treatment of syphilis restored lymphocyte counts back to pretreatment levels. Conclusion Syphilis induces a relative non-CD4+ T cell-specific lymphopenia in HIV-infected patients. Our data suggest that serologic testing for syphilis should be considered in HIV-infected MSM in case of an otherwise unexplained drop in total lymphocyte count. Electronic supplementary material The online version of this article (10.1007/s40121-018-0219-9) contains supplementary material, which is available to authorized users.
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Abstract
The epidemiology of spinal cord disease in human immunodeficiency virus (HIV) infection is largely unknown due to a paucity of data since combination antiretroviral therapy (cART). HIV mediates spinal cord injury indirectly, by immune modulation, degeneration, or associated infections and neoplasms. The pathologies vary and range from cytotoxic necrosis to demyelination and vasculitis. Control of HIV determines the differential for all neurologic presentations in infected individuals. Primary HIV-associated acute transverse myelitis, an acute inflammatory condition with pathologic similarities to HIV encephalitis, arises in early infection and at seroconversion. In contrast, HIV vacuolar myelopathy and opportunistic infections predominate in uncontrolled disease. There is systemic immune dysregulation as early as primary infection due to initial depletion of gut-associated lymphoid tissue CD4 cells and allowance of microbial translocation across the gut that never fully recovers throughout the course of HIV infection, regardless of how well controlled. The subsequent proinflammatory state may contribute to spinal cord diseases observed even after cART initiation. This chapter will highlight an array of spinal cord pathologies classified by stage of HIV infection and immune status.
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Affiliation(s)
- Seth N Levin
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jennifer L Lyons
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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Abstract
The body of evidence for mania as a secondary syndrome due to organic diseases is small. The clinical diagnosis and management of these patients are mainly based on clinical experience and on some case reports. Treatment should be focused on both the underlying medical illness and the control of acute symptoms. Mania due to a medical condition is relevant in the clinical setting, and thus more research is needed to add evidence-based recommendations to the currently available clinical knowledge. In this review, we summarize the latest information on the etiology, epidemiology, diagnostic aspects, and management of secondary mania.
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Lang R, Read R, Krentz HB, Peng M, Ramazani S, Vu Q, Gill MJ. A retrospective study of the clinical features of new syphilis infections in an HIV-positive cohort in Alberta, Canada. BMJ Open 2018; 8:e021544. [PMID: 29991630 PMCID: PMC6082489 DOI: 10.1136/bmjopen-2018-021544] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/25/2018] [Accepted: 04/27/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Syphilis is a global health concern with an estimated 12 million infections occurring annually. Due to the increasing rates of new syphilis infections being reported in patients infected with HIV, and their higher risk for atypical and severe presentations, periodic screening has been recommended as a routine component of HIV care. We aimed to characterise incident syphilis presentation, serological features and treatment response in a well-defined, HIV-infected population over 11 years. METHODS Since 2006, as routine practice of both the Southern Alberta Clinic and Calgary STI programmes, syphilis screening has accompanied HIV viral load measures every 4 months. All records of patients who, while in HIV care, either converted from being syphilis seronegative to a confirmed seropositive or were reinfected as evidenced by a fourfold increase in rapid plasma reagin (RPR) after past successful treatment, were reviewed. RESULTS We identified 249 incident syphilis infections in 194 different individuals infected with HIV; 72% were initial infections whereas 28% were reinfections. Half (50.8%) of the infections were asymptomatic and identified only by routine screening. Symptomatic syphilis was more common when RPR titres were higher (p=0.03). In patients with recurrent syphilis infection, a trend was noted favouring symptomatic presentation (62%, p=0.07). All 10 patients with central nervous system (CNS) syphilis involvement presented with an RPR titre ≥1:32. Following syphilis infection, a decline of 42 cells/mm3 in CD4 (p=0.004) was found, but no significant changes in viral load occurred. No association was found with the stage of syphilis or symptoms at presentation and antiretroviral therapy use, CD4 count or virological suppression. CONCLUSION Routine screening of our HIV-infected population identified many asymptomatic syphilis infections. The interaction of HIV and syphilis infection appears to be bidirectional with effects noted on both HIV and syphilis clinical and serological markers.
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Affiliation(s)
- Raynell Lang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ron Read
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hartmut B Krentz
- S Alberta HIV Clinic, Alberta Health Services, Calgary, Alberta, Canada
| | - Mingkai Peng
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Soheil Ramazani
- S Alberta HIV Clinic, Alberta Health Services, Calgary, Alberta, Canada
| | - Quang Vu
- S Alberta HIV Clinic, Alberta Health Services, Calgary, Alberta, Canada
| | - M John Gill
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- S Alberta HIV Clinic, Alberta Health Services, Calgary, Alberta, Canada
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Jiang Y, Weng R, Zhang Y, Fan R, Liu Y, Chen Z, Peng F, Chen Y, Chen X. The performance of rapid plasma reagin (RPR) titer in HIV-negative general paresis after neurosyphilis therapy. BMC Infect Dis 2018; 18:144. [PMID: 29606102 PMCID: PMC5879544 DOI: 10.1186/s12879-018-3062-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 03/25/2018] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Repeated nontreponemal serologic test for syphilis titers is recommended to evaluate treatment response. However, it is unknown whether serum rapid plasma reagin (RPR) titer can serve as a surrogate for determining the efficacy of treatment in general paresis (GP) remains unknown. METHODS We retrospectively reviewed data from 105 GP patients, who were divided into two groups (62 CSF RPR+ patients and 43 CSF RPR- patients) according to reactive RPR test status in CSF. Clinical assessment included the Mini-Mental State Examination (MMSE) scores, CSF examinations (WBC count, protein concentration and RPR titer), and serum tests (RPR titer and TPPA). Among the 105 GP patients, 13 CSF RPR+ patients and 6 CSF RPR- patients had a 12 months follow-up of CSF, serum measures and MMSE. RESULTS The median serum RPR titer was significantly higher in CSF RPR+ patients than that in CSF RPR- GP patients, 1:8 [IQR 1:4-1:32] vs. 1:4 [IQR 1:4-1:8] (P < 0.001). The number of CSF RPR+ patients with serum RPR titer≥1:32 was significantly higher when compared with CSF RPR- patients (P = 0.001). For CSF RPR+ patients, the MMSE scores improved or remained constantly after penicillin treatment. For CSF RPR+ patients, the CSF RPR titer declined four-fold in 85% (11/13) of the patients, whereas the serum RPR titer declined four-fold in only 46% (6/13) of the patients, the odds ratio is 6.4 (95% confidence interval 1.0-41.2). CONCLUSIONS A four-fold decline in CSF RPR titer is a good predictor for treatment efficacy in CSF RPR+ GP patients within 12 months after the completion of therapy.
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Affiliation(s)
- Ying Jiang
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China.
| | - Ruihui Weng
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Yuefeng Zhang
- Department of Neurology, Guangzhou Brain Hospital, Affiliated Brain Hospital of Guangzhou Medical University, 36 Mingxin Road, Guangzhou, Guangdong, 510370, People's Republic of China
| | - Rong Fan
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Yulun Liu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Zhigang Chen
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Xiaohong Chen
- Department of Neurology, The Third Affiliated Hospital, Sun Yat-sen University, 600 Tianhe Road, Guangzhou, Guangdong, 510630, People's Republic of China.
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Wang Z, Liu L, Shen YZ, Zhang RF, Qi TK, Tang Y, Song W, Chen J, Lu H. The clinical and laboratory features of neurosyphilis in HIV-infected patients: A retrospective study in 92 patients. Medicine (Baltimore) 2018; 97:e0078. [PMID: 29489672 PMCID: PMC5851754 DOI: 10.1097/md.0000000000010078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 02/03/2018] [Accepted: 02/13/2018] [Indexed: 11/17/2022] Open
Abstract
Neurosyphilis (NS) is an important component of central nervous system diseases among HIV-infected patients. However, its characteristics are not very clear. A retrospective analysis of clinical and laboratory findings was performed in 92 NS patients with HIV infection from a tertiary hospital in Shanghai, China. The patients had a median age of 38 years and a median CD4 count of 198 cells/μL. In all, 44.6% (41/92) were diagnosed as asymptomatic NS (ANS), 23.9% (22/92) as syphilitic meningitis, 17.4% (16/92) as cerebrovascular NS, and 14.1% (13/92) as parenchymal syphilis. A quarter of patients (23/92) complicated with ocular syphilis (OS), 60.9% (14/23) of which were ANS. The serum tolulized red unheated serum test (TRUST) titers were ≤1:8 in 15 patients (16.3%), 1:16-1:128 in 51 patients (55.4%), and ≥1:256 in 26 patients (28.3%). Sixty-nine patients (75.0%) had both cerebrospinal fluid (CSF) TRUST and Treponema pallidum particle assay reactive. CSF pleocytosis and protein elevation were found in 58.7% and 53.3% of patients, respectively. Syphilitic meningitis was more likely to present with CSF pleocytosis than ANS (P = .001), cerebrovascular NS (P < .001), and parenchymal NS (P < .001). The proportion of patients with CSF elevated protein was lower in ANS group than that in syphilitic meningitis (P = .003), cerebrovascular NS (P = .001), and parenchymal NS groups (P = .025), and was higher in sero-TRUST titers ≤1:8 group than that in 1:16-1:128 (P = .01) and 1:256-1:1024 groups (P = .005).This study revealed that ANS was the most common clinical type of NS in HIV-infected patients, which should be considered in HIV and syphilis co-infection patients without neurologic symptoms, especially in those with OS. Different patterns of NS might have different CSF features which may also vary with sero-TRUST titers.
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Affiliation(s)
- Zhenyan Wang
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
| | - Li Liu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
| | - Yin-Zhong Shen
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
| | - Ren-Fang Zhang
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
| | - Tang-Kai Qi
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
| | - Yang Tang
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
| | - Wei Song
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
| | - Jun Chen
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
| | - Hongzhou Lu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Fudan University
- Huashan Hospital affiliated to Fudan University, Shanghai
- Medical College of Fudan University, Shanghai, China
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Ho EL, Maxwell CL, Dunaway SB, Sahi SK, Tantalo LC, Lukehart SA, Marra CM. Neurosyphilis Increases Human Immunodeficiency Virus (HIV)-associated Central Nervous System Inflammation but Does Not Explain Cognitive Impairment in HIV-infected Individuals With Syphilis. Clin Infect Dis 2018; 65:943-948. [PMID: 28525592 DOI: 10.1093/cid/cix473] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/16/2017] [Indexed: 11/13/2022] Open
Abstract
Background Individuals infected with human immunodeficiency virus (HIV) who have previously had syphilis may have cognitive impairment. We tested the hypothesis that neurosyphilis causes cognitive impairment in HIV by amplifying HIV-related central nervous system (CNS) inflammation. Methods HIV-infected participants enrolled in a study of cerebrospinal fluid (CSF) abnormalities in syphilis underwent the mental alternation test (MAT), venipuncture, and lumbar puncture. CSF concentrations of chemokine (C-X-C motif) ligand 10 (CXCL10), chemokine (C-C motif) ligand 2 (CCL2), and neurofilament light (NFL) were determined by commercial assays. The proportion of peripheral blood mononuclear cells (PBMCs) and of CSF white blood cells (WBCs) that were activated monocytes (CD14+CD16+) was determined by flow cytometry. Neurosyphilis was defined as detection of Treponema pallidum 16S RNA in CSF or CSF white blood cells (WBCs) >20/uL or a reactive CSF-Venereal Disease Research Laboratory (VDRL) test; uncomplicated syphilis was defined as undetectable CSF T. pallidum, CSF WBCs ≤5/uL and nonreactive CSF-VDRL. MAT <18 was considered low. Results Median proportion of PBMCs that were activated monocytes (16.6 vs. 5.3), and median CSF CXCL10 (10658 vs. 2530 units), CCL2 (519 vs. 337 units) and HIV RNA (727 vs. 50 c/mL) were higher in neurosyphilis than in uncomplicated syphilis (P ≤ .001 for all comparisons). Neurosyphilis was not related to low MAT scores. Participants with low MAT scores had higher median CSF CXCL10 (10299 vs. 3650 units, P = .008) and CCL2 (519 vs. 365 units, P = .04) concentrations than those with high MAT scores. Conclusions Neurosyphilis may augment HIV-associated CNS inflammation, but it does not explain cognitive impairment in HIV-infected individuals with syphilis.
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Affiliation(s)
- Emily L Ho
- Department of Neurology, Swedish Neuroscience Institute, Seattle
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Marra CM. Other central nervous system infections: cytomegalovirus, Mycobacterium tuberculosis, and Treponema pallidum. HANDBOOK OF CLINICAL NEUROLOGY 2018; 152:151-166. [PMID: 29604973 DOI: 10.1016/b978-0-444-63849-6.00012-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Human immunodeficiency virus (HIV)-infected individuals are particularly susceptible to several central nervous system infections: human cytomegalovirus, which may cause encephalitis, ventriculitis, polyradiculitis, or polyradiculomyelitis; Mycobacterium tuberculosis, which can cause meningitis or space-occupying lesions; and Treponema pallidum subspecies pallidum (T. pallidum), which affects the meninges, cerebrospinal fluid, cranial nerves, and vasculature in early neurosyphilis, and additionally the brain and spinal cord parenchyma in late neurosyphilis. Central nervous system cytomegalovirus infection is seen in HIV-infected individuals with very advanced immunosuppression. Its prognosis is poor and optimal therapy has not been determined. Tuberculous meningitis has a high mortality in those also infected with HIV, especially in the developing world, and better therapies are urgently needed. As the rates of syphilis increase in the developed world, neurosyphilis and in particular ocular syphilis are increasingly reported. The likelihood of all three of these central nervous system infections is decreased in individuals who receive potent antiretroviral therapy.
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Affiliation(s)
- Christina M Marra
- Departments of Neurology and Medicine, University of Washington School of Medicine, Seattle, WA, United States.
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Galindo J, Mier JF, Miranda CA, Rivas JC. [Neurosyphilis: an Age-old Problem that is Still Relevant Today]. ACTA ACUST UNITED AC 2017; 46 Suppl 1:69-76. [PMID: 29037341 DOI: 10.1016/j.rcp.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/06/2017] [Indexed: 01/28/2023]
Abstract
Neurosyphilis is the clinical manifestation of syphilis that can arise during either the early or late stages of infection. Even though dedicated treatment for all clinical forms of syphilis has been available for many years, the advanced stages of the disease are still prevalent, with irreversible sequelae. This article reviews the current evidence, diagnostic methods and specific treatment for tertiary syphilis.
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Affiliation(s)
- Juliana Galindo
- Hospital Psiquiátrico Universitario del Valle, Cali, Colombia
| | - Juan Felipe Mier
- Escuela de Medicina, Facultad de Salud, Universidad del Valle, Cali, Colombia
| | - Carlos Alberto Miranda
- Hospital Psiquiátrico Universitario del Valle, Cali, Colombia; Escuela de Medicina, Facultad de Salud, Departamento de Psiquiatría, Universidad del Valle, Cali, Colombia
| | - Juan Carlos Rivas
- Hospital Psiquiátrico Universitario del Valle, Cali, Colombia; Escuela de Medicina, Facultad de Salud, Departamento de Psiquiatría, Universidad del Valle, Cali, Colombia; Fundación Valle del Lili, Cali, Colombia.
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Marra CM, Maxwell CL, Dunaway SB, Sahi SK, Tantalo LC. Cerebrospinal Fluid Treponema pallidum Particle Agglutination Assay for Neurosyphilis Diagnosis. J Clin Microbiol 2017; 55:1865-1870. [PMID: 28381602 PMCID: PMC5442543 DOI: 10.1128/jcm.00310-17] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/27/2017] [Indexed: 11/20/2022] Open
Abstract
Limited data suggest that the cerebrospinal fluid Treponema pallidum particle agglutination assay (CSF-TPPA) is sensitive and a CSF Treponema pallidum hemagglutination assay (CSF-TPHA) titer of ≥1:640 is specific for neurosyphilis diagnosis. CSF-TPPA reactivity and titer were determined for a convenience sample of 191 CSF samples from individuals enrolled in a study of CSF abnormalities in syphilis (training data set). The sensitivity of a reactive test and the specificity for reactivity at serial higher CSF dilutions were determined. Subsequently, CSF-TPPA reactivity at a 1:640 dilution was determined for all available samples from study participants enrolled after the last training sample was collected (validation data set, n = 380). Neurosyphilis was defined as (i) a reactive CSF Venereal Disease Research Laboratory test (CSF-VDRL), (ii) detection of T. pallidum in CSF by reverse transcriptase PCR, or (iii) new vision loss or hearing loss. In the training data set, the diagnostic sensitivities of a reactive CSF fluorescent treponemal antibody absorption test (CSF-FTA-ABS) and a reactive CSF-TPPA did not differ significantly (67 to 98% versus 76 to 95%). The specificity of a CSF-TPPA titer of ≥1:640 was significantly higher than that of lower dilutions and was not significantly different from that of CSF-VDRL. In the validation data set, the diagnostic specificity of a CSF-TPPA titer of ≥1:640 was high and did not differ significantly from that of CSF-VDRL (93 to 94% versus 90 to 91%). Ten CSF samples with a nonreactive CSF-VDRL had a CSF-TPPA titer of ≥1:640. If a CSF-TPPA titer of ≥1:640 was used in addition to a reactive CSF-VDRL, the number of neurosyphilis diagnoses would have increased from 47 to 57 (21.3%). A CSF-TPPA titer cutoff of ≥1:640 may be useful in identifying patients with neurosyphilis when CSF-VDRL is nonreactive.
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Affiliation(s)
- Christina M Marra
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Clare L Maxwell
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Shelia B Dunaway
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Sharon K Sahi
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Lauren C Tantalo
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Njiru E, Abdulkadir J, Kamuren Z, Kigen G. Early neurosyphilis presenting with facial palsy and an oral ulcer in a patient who is human immunodeficiency virus positive: a case report. J Med Case Rep 2017; 11:134. [PMID: 28499407 PMCID: PMC5429523 DOI: 10.1186/s13256-017-1297-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 04/18/2017] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Neurosyphilis is the tertiary stage of Treponema pallidum infection that involves the central nervous system, which occurs within days or weeks after an initial syphilis infection, especially in immunocompromised patients. The diagnosis of neurosyphilis is quite challenging as it is uncommon and often presents with obscure symptoms since any organ system may be involved. CASE PRESENTATION We describe a case of a 40-year-old African man who is human immunodeficiency virus positive with early neurosyphilis who presented with a stiff neck, headache, confusion, restlessness, and a left-sided chest pain; he did not respond to an empiric treatment of ceftriaxone and fluconazole for meningitis, and tramadol for headache. Ten days after admission, he developed generalized tonic-clonic convulsions; on examination he had ipsilateral facial nerve palsy and an oral ulcer, and responded well to benzathine penicillin treatment. CONCLUSIONS Laboratory diagnosis of neurosyphilis is challenging because to date there is no single laboratory test which is considered sensitive enough for diagnosis of the disease, especially in resource-limited settings. Clinical judgment is still an important part of diagnosis; and neurosyphilis should be considered a diagnostic differential in patients with Human Immunodeficiency Virus presenting with central nervous system involvement and in other high-risk patients.
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Affiliation(s)
- Evangeline Njiru
- Department of Internal Medicine, Moi University School of Medicine, P.O. Box 4606, 30100, Eldoret, Kenya
| | - Jamil Abdulkadir
- Department of Internal Medicine, Moi University School of Medicine, P.O. Box 4606, 30100, Eldoret, Kenya
| | - Zipporah Kamuren
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, 30100, Eldoret, Kenya
| | - Gabriel Kigen
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, 30100, Eldoret, Kenya.
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Xiao Y, Tong ML, Liu LL, Lin LR, Chen MJ, Zhang HL, Zheng WH, Li SL, Lin HL, Lin ZF, Xing HQ, Niu JJ, Yang TC. Novel predictors of neurosyphilis among HIV-negative syphilis patients with neurological symptoms: an observational study. BMC Infect Dis 2017; 17:310. [PMID: 28446129 PMCID: PMC5406894 DOI: 10.1186/s12879-017-2339-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/24/2017] [Indexed: 11/24/2022] Open
Abstract
Background Known predictors of neurosyphilis were mainly drawn from human immunodeficiency virus (HIV)-infected syphilis patients, which may not be applicable to HIV-negative populations as they have different characteristics, particularly those with neurological symptoms. This study aimed to identify novel predictors of HIV-negative symptomatic neurosyphilis (S-NS). Methods From June 2005 to June 2015, 370 HIV-negative syphilis patients with neurological symptoms were recruited, consisting of 191 S-NS patients (including 123 confirmed neurosyphilis and 68 probable neurosyphilis patients) and 179 syphilis/non-neurosyphilis (N-NS) patients. Clinical and laboratory characteristics of S-NS were compared with N-NS to identify factors predictive of S-NS. Serum rapid plasma reagin (RPR), Treponema pallidum particle agglutination (TPPA), and their parallel testing format for screening S-NS were evaluated. Results The likelihood of S-NS was positively associated with the serum RPR and TPPA titers. The serum TPPA titers performed better than the serum RPR titers in screening S-NS. The optimal cut-off points to recognize S-NS were serum RPR titer ≥1:4 and serum TPPA titer ≥1:2560 respectively. A parallel testing format of a serum RPR titer ≥1:2 and serum TPPA titer ≥1:1280 screened out 95.8% of S-NS and all confirmed cases of neurosyphilis. S-NS was independently associated with male sex, serum RPR titer ≥1:4, serum TPPA titer ≥1:2560, and elevated serum creatine kinase. Concurrence of these factors increased the likelihood of S-NS. Conclusions Quantitation of serum TPPA is worthwhile and performs better than serum RPR in screening S-NS. Serum RPR, serum TPPA, male sex, and serum creatine kinase can predict S-NS. Moreover, patients with both a serum RPR titer <1:2 and a serum TPPA titer <1:1280 have a low probability of S-NS, suggesting that it is reasonable to reduce lumbar punctures in such individuals.
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Affiliation(s)
- Yao Xiao
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China.,Xiamen Hospital of Traditional Chinese Medicine, Xiamen, 361009, China.,Xiamen Zhongshan Hospital, Fujian Medical University, Xiamen, 361004, China
| | - Man-Li Tong
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China
| | - Li-Li Liu
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China
| | - Li-Rong Lin
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China
| | - Mei-Jun Chen
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China
| | - Hui-Lin Zhang
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China
| | - Wei-Hong Zheng
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China
| | - Shu-Lian Li
- Xiamen Huli District Maternity and Child Care Hospital, Xiamen, 361009, China
| | - Hui-Ling Lin
- Xiamen Huli District Maternity and Child Care Hospital, Xiamen, 361009, China
| | - Zhi-Feng Lin
- Xiamen Huli District Maternity and Child Care Hospital, Xiamen, 361009, China
| | - Hui-Qin Xing
- Institute of Neuroscience, Medical College of Xiamen University, Xiamen, 361005, China
| | - Jian-Jun Niu
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China. .,Xiamen Zhongshan Hospital, Fujian Medical University, Xiamen, 361004, China.
| | - Tian-Ci Yang
- Zhongshan Hospital, Medical College of Xiamen University, Xiamen, 361004, China.
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The Great Impostor: Transaminitis Masking the Coinfection of Syphilis and Human Immunodeficiency Virus. Case Rep Med 2017; 2017:2481961. [PMID: 28400821 PMCID: PMC5376408 DOI: 10.1155/2017/2481961] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/05/2017] [Accepted: 02/28/2017] [Indexed: 11/20/2022] Open
Abstract
Introduction. The incidence of syphilis continues to rise in the United States over the past 15 years. This disease process is classified into stages and may present with a coinfection of Human Immunodeficiency Virus (HIV). Case Report. We present a case of a 32-year-old African American male who presented with cutaneous manifestations of secondary syphilis and transaminitis. A workup revealed that the transaminitis was secondary to underlying syphilitic hepatitis in the presence of HIV coinfection. The patient had a reactive rapid plasma reagin (RPR) of 1 : 64 TU and reactive Treponema pallidum particle agglutination assay (TPPA). Lab findings showed alkaline phosphate (ALP) of 648 unit/L, aspartate aminotransferase (AST) of 251 unit/L, and alanine aminotransferase (ALT) of 409 unit/L. Conclusion. Syphilitic hepatitis is a recognized entity in the medical literature. It is a manifestation of secondary syphilis and it is more commonly seen in coinfected patients with both syphilis and HIV. Therefore, primary care physicians should keep infectious etiologies (e.g., syphilis and HIV) in the differential diagnosis of patients who present with unexplained liver dysfunction in a cholestatic pattern.
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Salamano R, Ballesté R, Perna A, Rodriguez N, Lombardo D, García N, López P, Cappuccio P. Cerebrospinal fluid examination may be useful in diagnosing neurosyphilis in asymptomatic HIV+ patients with syphilis. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:128-32. [PMID: 26982990 DOI: 10.1590/0004-282x20160016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 11/03/2015] [Indexed: 11/21/2022]
Abstract
Lumbar puncture in neurologically asymptomatic HIV+ patients is still under debate. There are different criteria for detecting neurosyphilis through cerebrospinal fluid (CSF), especially in cases that are negative through the Venereal Disease Research Laboratory (VDRL), regarding cellularity and protein content. However, a diagnosis of neurosyphilis can still exist despite negative VDRL. Treponema pallidum hemagglutination assay (TPHA) titers and application of the TPHA index in albumin and IgG improve the sensitivity, with a high degree of specificity. Thirty-two patients were selected for this study. VDRL was positive in five of them. The number of diagnoses reached 14 when the other techniques were added. It was not determined whether cellularity and increased protein levels were auxiliary tools in the diagnosis. According to our investigation, CSF analysis using the abovementioned techniques may be useful in diagnosing neurosyphilis in these patients.
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Affiliation(s)
- Ronald Salamano
- Sección Neuroinfectología, Instituto de Neurología, Hospital de Clínicas, Montevideo, Uruguay
| | - Raquel Ballesté
- Sección Inmunología, Departamento de Laboratorio Clínico, Hospital de Clínicas, Montevideo, Uruguay
| | - Abayubá Perna
- Sección Neuroinfectología, Instituto de Neurología, Hospital de Clínicas, Montevideo, Uruguay
| | - Natalia Rodriguez
- Sección Inmunología, Departamento de Laboratorio Clínico, Hospital de Clínicas, Montevideo, Uruguay
| | - Diego Lombardo
- Sección Neuroinfectología, Instituto de Neurología, Hospital de Clínicas, Montevideo, Uruguay
| | - Natalia García
- Sección Inmunología, Departamento de Laboratorio Clínico, Hospital de Clínicas, Montevideo, Uruguay
| | - Pablo López
- Sección Inmunología, Departamento de Laboratorio Clínico, Hospital de Clínicas, Montevideo, Uruguay
| | - Pablo Cappuccio
- Servicio de Enfermedades Infecto-Contagiosas, Hospital Pasteur, Montevideo, Uruguay
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Tipirneni A, Koch S, Romano JG, Malik AM. A 27-Year-Old Man With Right-Sided Hemiparesis and Dysarthria. Neurohospitalist 2016; 6:174-180. [PMID: 27695601 DOI: 10.1177/1941874416648197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Anita Tipirneni
- Cerebrovascular Division, Department of Neurology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Sebastian Koch
- Cerebrovascular Division, Department of Neurology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Jose G Romano
- Cerebrovascular Division, Department of Neurology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Amer M Malik
- Cerebrovascular Division, Department of Neurology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
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35
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Roberts CP, Klausner JD. Global challenges in human immunodeficiency virus and syphilis coinfection among men who have sex with men. Expert Rev Anti Infect Ther 2016; 14:1037-1046. [PMID: 27626361 DOI: 10.1080/14787210.2016.1236683] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Syphilis and human immunodeficiency virus (HIV) coinfection disproportionately affects men who have sex with men (MSM), and the rate of coinfection has been increasing over the last decade. HIV and syphilis coinfection is particularly challenging because the infections interact synergistically thereby increasing the risk of acquisition and transmission as well as accelerating disease progression. Areas covered: This paper reviews and summarizes the epidemiology, pathogenesis, diagnosis, clinical management and prevention of HIV and syphilis coinfection among MSM. Expert commentary: Research does not support a different syphilis treatment for coinfected individuals; however, coinfection may warrant a recommendation for antiretroviral therapy. In order to reverse the epidemic of syphilis and HIV coinfection, there needs to be greater awareness, improved cultural sensitivity among health care providers, improved access to preventative services and increased screening for syphilis and HIV.
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Affiliation(s)
- Chelsea P Roberts
- a David Geffen School of Medicine , University of California Los Angeles , Los Angeles , CA , USA
| | - Jeffrey D Klausner
- a David Geffen School of Medicine , University of California Los Angeles , Los Angeles , CA , USA.,b Division of Infectious Diseases, Department of Medicine , University of California, Los Angeles , Los Angeles , CA , USA
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Abstract
Syphilis has long been known as the great imitator. Its heterogeneity can manifest in the form of meningitis, space occupying gummas, vasculitis, strokes, cranial neuropathies, myelopathy, dementia, and seizures. The incidence has been rising with each year, mainly in men who have sex with men accounting for 83% of cases. With the coexistence of immunocompromised states, especially HIV (human immunodeficiency virus), the usually chronic and insidious course of tertiary neurosyphilis can be accelerated. Stroke can occur as a result of neurosyphilis in its meningovascular form, and the likelihood of this increases with HIV co-infection, especially in high-risk groups such as intravenous drug users and men who have sex with men. Here, we discuss a case of a young man who presented with an ischemic stroke found to have neurosyphilis and HIV and consider the management of these co-morbid conditions.
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Affiliation(s)
- Riddhi Patira
- 1 Department of Neurology, Temple University Hospital, Philadelphia, PA, USA
| | | | - Jijo J Wang
- 2 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Neurosyphilis and ophthalmic syphilis in persons with negative rapid plasma reagin and positive treponemal antibody test results. Sex Transm Dis 2016; 42:347-9. [PMID: 25970316 DOI: 10.1097/olq.0000000000000282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The detection of serodiscordant syphilis test results raises several important clinical and public health questions. Based on our retrospective review, the probability of neurosyphilis in persons with serodiscordant serologies is low. The probability of ophthalmic syphilis may be higher, but we lack objective measures for that diagnosis.
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Kingston M, French P, Higgins S, McQuillan O, Sukthankar A, Stott C, McBrien B, Tipple C, Turner A, Sullivan AK, Radcliffe K, Cousins D, FitzGerald M, Fisher M, Grover D, Higgins S, Kingston M, Rayment M, Sullivan A. UK national guidelines on the management of syphilis 2015. Int J STD AIDS 2015; 27:421-46. [PMID: 26721608 DOI: 10.1177/0956462415624059] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/02/2015] [Indexed: 12/12/2022]
Abstract
These guidelines are an update for 2015 of the 2008 UK guidelines for the management of syphilis. The writing group have piloted the new BASHH guideline methodology, notably using the GRADE system for assessing evidence and making recommendations. We have made significant changes to the recommendations for screening infants born to mothers with positive syphilis serology and to facilitate accurate and timely communication between the teams caring for mother and baby we have developed a birth plan. Procaine penicillin is now an alternative, not preferred treatment, for all stages of syphilis except neurosyphilis, but the length of treatment for this is shortened. Other changes are summarised at the start of the guideline.
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Affiliation(s)
- M Kingston
- Manchester Centre for Sexual Health, Manchester, UK
| | - P French
- Mortimer Market Centre, London, UK
| | - S Higgins
- North Manchester General Hospital, Manchester, UK
| | - O McQuillan
- Manchester Centre for Sexual Health, Manchester, UK
| | - A Sukthankar
- Manchester Centre for Sexual Health, Manchester, UK
| | - C Stott
- Manchester Centre for Sexual Health, Manchester, UK
| | - B McBrien
- Manchester Centre for Sexual Health, Manchester, UK
| | - C Tipple
- Jefferiss Wing Centre for Sexual Health, Imperial College Health Care NHS Trust, London, UK
| | - A Turner
- The Public Health England/Clinical Virology Laboratory, Manchester Royal Infirmary, Manchester, UK
| | | | | | - Keith Radcliffe
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Darren Cousins
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Mark FitzGerald
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Martin Fisher
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Deepa Grover
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Stephen Higgins
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Margaret Kingston
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Michael Rayment
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
| | - Ann Sullivan
- Clinical Effectiveness Group, British Association for Sexual Health and HIV, Macclesfield, UK
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Shi M, Peng RR, Gao Z, Zhang S, Lu H, Guan Z, Gao Y, Wang C, Zhou P. Risk profiles of neurosyphilis in HIV-negative patients with primary, secondary and latent syphilis: implications for clinical intervention. J Eur Acad Dermatol Venereol 2015; 30:659-66. [PMID: 26660338 DOI: 10.1111/jdv.13514] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 10/01/2015] [Indexed: 11/26/2022]
Affiliation(s)
- M. Shi
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
| | - R.-R. Peng
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
| | - Z. Gao
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
- Clinical School of Anhui Medical University; Anhui Medical University; Hefei Anhui China
| | - S. Zhang
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
- Clinical School of Anhui Medical University; Anhui Medical University; Hefei Anhui China
| | - H. Lu
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
| | - Z. Guan
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
| | - Y. Gao
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
| | - C. Wang
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
| | - P. Zhou
- Department of Sexually Transmitted Disease Institute; Shanghai Skin Disease Hospital; Shanghai China
- Clinical School of Anhui Medical University; Anhui Medical University; Hefei Anhui China
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Marra CM, Tantalo LC, Sahi SK, Dunaway SB, Lukehart SA. Reduced Treponema pallidum-Specific Opsonic Antibody Activity in HIV-Infected Patients With Syphilis. J Infect Dis 2015; 213:1348-54. [PMID: 26655298 DOI: 10.1093/infdis/jiv591] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/30/2015] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected individuals may have poorer serological responses to syphilis treatment and may be more likely to experience neurosyphilis. Treponema pallidum is cleared from sites of infection by opsonization, ingestion, and killing by macrophages. METHODS Serum samples from 235 individuals with syphilis were tested for T. pallidum-specific opsonic activity. Blood T. pallidum concentrations were determined by real-time polymerase chain reaction amplification of the tp0574 gene, and T. pallidum was detected in cerebrospinal fluid (CSF) by reverse-transcriptase polymerase chain reaction of 16S ribosomal RNA. RESULTS Opsonic activity was higher with higher serum rapid plasma reagin titers (P < .001), and in those treated for uncomplicated syphilis before serum collection (P < .001). Opsonic activity was lower in HIV-infected than in HIV-uninfected individuals even after the above factors were taken into account (P = .006). In participants in whom blood T. pallidum was detectable, those with the highest opsonic activity had lower blood T. pallidum concentrations. In multivariable analyses, there was not a significant relationship between opsonic activity and detection of T. pallidum in CSF or CSF-VDRL reactivity. CONCLUSIONS Serum T. pallidum-specific opsonic activity is significantly lower in HIV-infected individuals. Impaired T. pallidum-specific immune responses could contribute to differences in the course of disease or treatment response.
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Affiliation(s)
| | | | | | | | - Sheila A Lukehart
- Department Medicine (Infectious Diseases) Department Global Health, Harborview Medical Center, University of Washington, Seattle
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Sun JJ, Wang ZY, Shen JY, Shen YZ, Liu L, Wang JR, Zhang RF, Lu HZ. Serum TRSUT Titer ≥1: 16 Is a Predictor for Neurosyphilis Among HIV-Infected Patients With Concurrent Syphilis and No Neurological Symptoms. Medicine (Baltimore) 2015; 94:e2023. [PMID: 26559304 PMCID: PMC4912298 DOI: 10.1097/md.0000000000002023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Investigating the predictors for lumbar puncture to diagnose the asymptomatic neurosyphilis among HIV and syphilis co-infected patients in Shanghai, China. Respectively, screening the medical records from August 1, 2009 to June 30, 2015. Those HIV-infected patients with concurrent syphilis who had received lumbar puncture were selected and their clinical and demographic data were recorded. Participants comprised symptomatic and asymptomatic patients. The latter ones could be further divided into 3 groups: late syphilis, early syphilis with anti-syphilis treatment failure, and early syphilis with serum toludine red unheated serum test (TRUST) ≥1:32. Both syphilis stage and anti-syphilis treatment effect were defined by common criteria, and syphilis of unknown duration was considered as late syphilis. Asymptomatic neurosyphilis was defined as neurosyphilis without neurological symptoms such as headache, cognitive dysfunction, motor deficits, auditory or ophthalmic abnormalities, and stroke. Neurosyphilis was defined as reactive cerebrospinal fluid (CSF) TRUST and/or CSF white blood cell >20 cells/μL without other reasons. Mann-Whitney test and Fisher's exact test were used for analyzing the difference between neurosyphilis and non-neurosyphilis group. Logistic regression test was performed to analyze the risk factors for neurosyphilis. In total, 170 participants were collected, and the rate of neurosyphilis was 32.35%. Among all the 105 participants without neurological symptoms, 80 patients were with late syphilis and 25 were with early syphilis. Among the early syphilis patients, 23 had a TRUST ≥1:32 and the other 2 experienced an anti-syphilis treatment failure. The differences of clinical and demographic variables between neurosyphilis and non-neurosyphilis group were not statistically significant except the serum TRUST titer (P < 0.01). From HIV/syphilis co-infected patients with or without neurological symptom, those who had neurological symptoms, CD4 <350 per μL and serological TRUST titer ≥1:16 were 4.9-fold (95% confidence interval [CI]: 2.37-10.31), 4.3-fold (95% CI: 1.17-15.78), and 4.1-fold (95% CI: 1.58-10.76), respectively, more likely to be diagnosed with neurosyphilis. Asymptomatic patients whose serum TRUST titer ≥1:16 were 8.48-fold (95% CI: 1.08-66.63) more likely to have asymptomatic neurosyphilis. Among asymptomatic HIV-infected patients with late syphilis or early syphilis experienced an anti-syphilis treatment failure, those who have a serum TRUST titer ≥1:16 are suggested to perform lumbar puncture in order to avoid delayed diagnosis and the occurrence of severe sequelae of syphilis.
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Affiliation(s)
- Jian-Jun Sun
- From the Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University (J-JS, Z-YW, J-YS, Y-ZS, LL, J-RW, R-FZ, H-ZL); Department of Infectious Disease, Huashan Hospital Affiliated to Fudan University (H-ZL); and Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, China (H-ZL)
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Merins V, Hahn K. Syphilis and neurosyphilis: HIV-coinfection and value of diagnostic parameters in cerebrospinal fluid. Eur J Med Res 2015; 20:81. [PMID: 26445822 PMCID: PMC4596308 DOI: 10.1186/s40001-015-0175-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/17/2015] [Indexed: 11/20/2022] Open
Abstract
Background Neurosyphilis might be difficult to diagnose particularly in asymptomatic patients and patients with HIV-coinfection. The objective of this study was to evaluate current diagnostic standards for neurosyphilis in HIV-positive and -negative patients. Methods We studied retrospectively patients with an active syphilis infection who had additionally undergone lumbar puncture. Patients where the criteria for the diagnosis of a definite or probable neurosyphilis were applicable were further analyzed for clinical symptoms, CSF, HIV-status as well as Treponema pallidum testing in serum and CSF. Correlation analysis of categorical variables was done by using the Chi-square test or in cases of small sample sizes the exact test of Fisher. p values ≤0.05 were considered significant. Results Eighty-nine patients were diagnosed with syphilis. All necessary criteria for the diagnosis of a neurosyphilis were available in 67 of them including 35 HIV-positive and 32 HIV-negative patients. A definite neurosyphilis could be retrospectively diagnosed in 13 and a probable in another 25 cases. Normal CSF results were more likely in HIV-negatives (p = 0.016). A neurosyphilis was correlated to a CSF pleocytosis > 5 cells/µl and to an albumin quotient >7.8 mg/dl regardless of a parallel HIV infection. HIV-positives had more frequently a CSF-RPR titre >1:4 than HIV-negatives (p = 0.031). However, the RPR test in CSF in definite or probable neurosyphilis had a sensitivity of only 21 %. Discussion Our data show that a pleocytosis and an elevated albumin quotient correlate with neurosyphilis. However, the CSF-RPR test as gold standard in neurosyphilis diagnostics has a very low sensitivity.
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Affiliation(s)
- V Merins
- Group Practice Family Physicians, Alt-Buckow 9-11, 12349, Berlin, Germany.
| | - K Hahn
- Department of Neurology, Universitätsmedizin Charité, Charitéplatz 1, 10117, Berlin, Germany.
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Tsai HC, Ye SY, Lee SSJ, Wann SR, Chen YS. Expression of CXCL2 in the serum and cerebrospinal fluid of patients with HIV and syphilis or neurosyphilis. Inflammation 2015; 37:950-5. [PMID: 24419746 DOI: 10.1007/s10753-014-9815-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The potential mechanisms for blood-brain barrier damage and the diagnosis of neurosyphilis in HIV patients co-infected with syphilis (HIV-S) are unclear. The aim of the study was to determine the expression of CXCL2 in the serum and cerebrospinal fluid (CSF) of HIV-S patients. A total of 34 HIV patients and 7 controls were enrolled in a HIV clinical cohort for diagnosis of neurosyphilis in Taiwan. Serum and CSF concentrations of CXCL2 were determined by ELISA. Neurosyphilis was defined as a CSF white blood cell count of ≧20 cells/μl or a reactive CSF Venereal Disease Research Laboratory (VDRL). Demographics and medical histories were collected. All the patients with HIV-S were males. Most (80%) had sex with men (MSM) and serum rapid plasma reagin (RPR) titers of ≧1:32. The medium age was 37 (range 21-68) years. The medium CD4 T cell counts at the time of the diagnosis of syphilis were 299 (range 92-434) cells/μl. Eight patients (24%) had neurosyphilis based on a reactive CSF VDRL test (n = 5) or increased CSF white blood cell counts of ≧20 cells/μl (n = 3). The concentrations of CSF CXCL2 were significantly higher in patients with HIV and neurosyphilis as compared to HIV with syphilis, HIV, and controls (p = 0.012). There were no significant differences in serum concentrations between the four groups. There was a correlation between CSF CXCL2 concentrations with neurosyphilis (p = 0.017), CSF white blood cell count (p = 0.001), and CSF protein levels (p = 0.005). The CSF level of CXCL2 can be used to distinguish those with or without neurosyphilis in HIV infected patients.
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Affiliation(s)
- Hung-Chin Tsai
- Section of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, #386 Ta-Chung 1st Road, Kaohsiung, 813, Taiwan, Republic of China,
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Benson CE, Soliman MK, Knezevic A, Xu DD, Nguyen QD, Do DV. Bilateral papillitis and unilateral focal chorioretinitis as the presenting features of syphilis. J Ophthalmic Inflamm Infect 2015; 5:16. [PMID: 26069511 PMCID: PMC4456579 DOI: 10.1186/s12348-015-0045-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 03/30/2015] [Indexed: 11/23/2022] Open
Abstract
Background Syphilis is a multisystem bacterial infection caused by Treponema pallidum. The incidence of infection in the United States has risen by more than 75% since the year 2000, when it was at a low of 2.1 per 100,000 people. Ocular involvement may occur in any stage of infection and may present in a variety of ways, with posterior uveitis being the most common manifestation. We report a case of ocular syphilis infection with an unusual presentation of bilateral non-granulomatous panuveitis with papillitis and unilateral focal chorioretinitis. Findings This is a retrospective case report with literature review. A 39-year-old Caucasian female presented with a 2-week history of bilateral ocular flashes and left eye pain. Dilated fundus examination revealed mild optic disc edema in both eyes, the right eye more than the left. In the left eye, there was an area of retinal elevation and whitening involving the peripheral retina. Fluorescein angiography, B-scan ultrasonography, and ocular coherence tomography were performed, and laboratory tests were ordered based on the clinical presentation. After rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-Abs) were positive, syphilitic uveitis was confirmed, and the patient was admitted for a 14-day course of high-dose intravenous penicillin G. Conclusions The first signs and symptoms of syphilis may be ocular, which can lead to a diagnostic challenge. A high index of suspicion is the key for early diagnosis of ocular syphilis. Prompt treatment with intravenous penicillin G is highly effective in resolving the infection.
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Affiliation(s)
- Christy Elizabeth Benson
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA
| | - Mohamed Kamel Soliman
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA ; Department of Ophthalmology, Assiut University Hospital, Al Gamaa St, Assiut, 71516 Egypt
| | - Alexander Knezevic
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA
| | - Daisy Ding Xu
- Tenth People's Hospital, 301 Yanchang Road, Shanghai District, Shanghai, 200072 China
| | - Quan Dong Nguyen
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA
| | - Diana V Do
- Stanley M Truhlsen Eye Institute, University of Nebraska Medical Center, 3902 Leavenworth Street, Omaha, NE 68105 USA
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Abstract
A review article is addressed the issue of the diagnosis and treatment of neurosyphilis that is developing against the background of HIV-infection. HIV-infected patients are at higher risk of neurologic, ocular and auricular manifestation of syphilis as well as treatment failures and relapses. Diagnosis of neurosyphilis in HIV-positive patients is complicated because both infections cause similar changes in the cerebrospinal fluid (CSF). The effectiveness of neurosyphilis treatment in patients with HIV co-infection is difficult to estimate, since the normalization of their CSF goes slower comparing to HIV-negatives. The increase in incidence of syphilis and HIV co-infection is anticipated in the coming years. This necessitates a comprehensive study of the problem and requires the development of new approaches to neurosyphilis diagnosis and treatment in co-infected patients.
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Morshed MG, Singh AE. Recent trends in the serologic diagnosis of syphilis. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2015; 22:137-47. [PMID: 25428245 PMCID: PMC4308867 DOI: 10.1128/cvi.00681-14] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complexities in the diagnosis of syphilis continue to challenge clinicians. While direct tests (e.g., microscopy or PCR) are helpful in early syphilis, the mainstay of diagnosis remains serologic tests. The traditional algorithm using a nontreponemal test (NTT) followed by a treponemal test (TT) remains the standard in many parts of the world. More recently, the ability to automate the TT has led to the increasingly widespread use of reverse algorithms using treponemal enzyme immunoassays (EIAs). Rapid, point-of-care TTs are in widespread use in developing countries because of low cost, ease of use, and reasonable performance. However, none of the current diagnostic algorithms are able to distinguish current from previously treated infections. In addition, the reversal of traditional syphilis algorithms has led to uncertainty in the clinical management of patients. The interpretation of syphilis tests is further complicated by the lack of a reliable gold standard for syphilis diagnostics, and the newer tests can result in false-positive reactions similar to those seen with older tests. Little progress has been made in the area of serologic diagnostics for congenital syphilis, which requires assessment of maternal treatment and serologic response as well as clinical and laboratory investigation of the neonate for appropriate management. The diagnosis of neurosyphilis continues to require the collection of cerebrospinal fluid for a combination of NTT and TT, and, while newer treponemal EIAs look promising, more studies are needed to confirm their utility. This article reviews current tests and discusses current controversies in syphilis diagnosis, with a focus on serologic tests.
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Affiliation(s)
- Muhammad G Morshed
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, and BC Public Health Microbiology and Reference Laboratory, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Ameeta E Singh
- Department of Medicine/Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
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Ho EL, Spudich SS. Neurosyphilis and the impact of HIV infection. Sex Health 2015; 12:148-54. [DOI: 10.1071/sh14195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 01/18/2015] [Indexed: 11/23/2022]
Abstract
Neurosyphilis is a complication of systemic syphilis. This review of the clinical presentation, diagnostic laboratory findings, treatment and management of neurosyphilis discusses the impact of HIV and the specific challenges it brings, focusing on areas of controversy, and highlighting important questions that remain to be answered.
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Janier M, Hegyi V, Dupin N, Unemo M, Tiplica G, Potočnik M, French P, Patel R. 2014 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol 2014; 28:1581-93. [PMID: 25348878 DOI: 10.1111/jdv.12734] [Citation(s) in RCA: 254] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 08/04/2014] [Indexed: 12/30/2022]
Affiliation(s)
- M. Janier
- STD Clinic; Hôpital Saint-Louis AP-HP and Hôpital Saint-Joseph; Paris France
| | - V. Hegyi
- Department of Pediatric Dermatovenereology; Comenius University; Bratislava Slovak Republic
| | - N. Dupin
- Syphilis National Reference Center; Hôpital Tarnier-Cochin; AP-HP; Paris France
| | - M. Unemo
- WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections; Department of Laboratory Medicine; Microbiology; Örebro University Hospital; Örebro Sweden
| | - G.S. Tiplica
- 2nd Dermatological Clinic; Carol Davila University; Colentina Clinical Hospital; Bucharest Romania
| | - M. Potočnik
- Department of Dermatovenereology; University Medical Centre; Ljubljana Slovenia
| | - P. French
- Central and North West London NHS Trust and University College; London UK
| | - R. Patel
- Department of Genitourinary Medicine; the Royal South Hants Hospital; Southampton UK
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Marra CM, Sahi SK, Tantalo LC, Ho EL, Dunaway SB, Jones T, Hawn TR. Toll-like receptor polymorphisms are associated with increased neurosyphilis risk. Sex Transm Dis 2014; 41:440-6. [PMID: 24922103 PMCID: PMC4414322 DOI: 10.1097/olq.0000000000000149] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Single-nucleotide polymorphisms (SNPs) in toll-like receptors (TLR) 1, 2, and 6 impair cell signaling in response to spirochetal lipoproteins. We investigated whether common SNPs in TLR1, TLR2, or TLR6 were associated with laboratory- or clinically-defined neurosyphilis. METHODS Polymorphisms in the genes for TLR1 (a T→G mutation at position 1805), TLR2 (a G→A mutation at position 2258), and TLR6 (a C→T mutation at position 745) were sought in 456 white patients with syphilis. Laboratory-defined neurosyphilis included a reactive cerebrospinal fluid (CSF)-Venereal Disease Research Laboratory (VDRL) test. Clinically-defined neurosyphilis included new vision or hearing loss. Controls had CSF white blood cells of 5/μL or less, nonreactive CSF-Venereal Disease Research Laboratory, and no vision or hearing loss. RESULTS Overall, 26.2% of patients had laboratory-defined and 36.2% had clinically-defined neurosyphilis. Compared with controls, patients with any of the 3 SNPs were more likely to have laboratory-defined neurosyphilis. Those with TLR2 or TLR6 SNPs were more likely to have clinically-defined neurosyphilis. These associations were independent of serum rapid plasma reagin titer. CONCLUSIONS A common TLR1 polymorphism is associated with an increased risk of laboratory-defined neurosyphilis, and common TLR2 and TLR6 polymorphisms are associated with an increased risk of both laboratory- and clinically-defined neurosyphilis. These data suggest that host factors impact the natural history of syphilis.
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Affiliation(s)
| | - Sharon K. Sahi
- Department of Neurology, University of Washington, Seattle, WA, USA
| | | | - Emily L. Ho
- Department of Neurology, University of Washington, Seattle, WA, USA
| | | | - Trudy Jones
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Thomas R. Hawn
- Department of Medicine, University of Washington, Seattle, WA, USA
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Velasco Montes J, González Díez S. [Syphilis and pregnancy: do we think of neurosyphilis?]. Med Clin (Barc) 2014; 142:516-7. [PMID: 24315747 DOI: 10.1016/j.medcli.2013.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 09/05/2013] [Indexed: 10/25/2022]
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