2020 European guideline on the management of syphilis

The serological dilemma: rethinking syphilis treatment evaluation

INTRODUCTION

Nontreponemal tests (NTT) constitute a significant method in syphilis detection, playing a crucial role in screening, diagnosing, and monitoring disease activity. However, recent discussions have cast doubt on the traditional belief that NTT are suitable for evaluating treatment efficacy, as inconsistencies between NTT results and syphilis treatment outcomes have been observed with some frequency.

AREAS COVERED

We have delineated the current status of serological methods for evaluating the therapeutic efficacy of syphilis treatment and summarized and discussed the exploration of biomarkers for syphilis therapy. A literature search was conducted in PubMed over all available dates for relevant published papers and conference abstracts with the search terms, 'Syphilis,' 'Treponema pallidum,' 'Serofast,' 'Treatment efficacy evaluation,' 'Nontreponemal,' 'RPR,' 'TRUST,' 'VDRL,' 'Neurosyphilis,' 'Pregnant syphilis,' 'Congenital syphilis,' 'Reinfection,' 'Cardiolipin,' 'Serology.'

EXPERT OPINION

Currently, the assessment of treatment efficacy through serological methods is limited to the use of the NTT. Therefore, it is imperative for clinicians to gain a deeper understanding of the significance and limitations of the NTT, as well as a focus on exploring more potential indicators for evaluating treatment efficacy.

Tabes dorsalis: a rare presentation of neurosyphilis in Western Europe

We present a case of tabes dorsalis with delayed diagnosis in a carpenter who presented with a VIth cranial nerve palsy, decreased deep tendon reflexes, reduced sense of vibration and an unsteady gait. After deterioration of symptoms with almost complete loss of vision due to bilateral optic atrophy, pronounced relative afferent pupillary defect and severe gait ataxia, and 4 years of extensive diagnostic testing and ineffective treatments, including several MRIs, genetic analysis and eye surgeries, serological testing was positive for syphilis. Elevated Treponema pallidum activity markers in the serum and cerebrospinal fluid confirmed the diagnosis. The patient then disclosed a history of syphilis 30 years ago, treated insufficiently with an oral antibiotic. While laboratory results improved, no clinical amelioration was achieved after treatment. This case demonstrates the need for thorough medical history and targeted diagnostic workup to achieve early recognition, diagnosis and treatment of neurosyphilis to prevent irreversible sequelae.

AEDV Expert Document on the Management of Ulcerative Venereal Infections

Currently, ulcerative sexually transmitted infections, including syphilis, herpes simplex virus (HSV), lymphogranuloma venereum (LGV), chancroid, donovanosis and, more recently, monkeypox (MPOX), represent a growing challenge for health care professionals. The incidence of syphilis and LGV has increased in recent years in Spain. Additionally, HSV, syphilis and chancroid can also increase the risk of HIV acquisition and transmission. The population groups most vulnerable to these infections are young people, men who have sex with men (MSM) and commercial sex workers. It is important to make a timely differential diagnosis since genital, anal, perianal, and oral ulcerative lesions may pose differential diagnosis with other infectious and non-infectious conditions such as candidiasis vulvovaginitis, traumatic lesions, carcinoma, aphthous ulcers, Behçet's disease, fixed drug eruption, or psoriasis. For this reason, the dermatologist plays a crucial role in the diagnosis and management of sexually transmitted infections. This chapter presents the main epidemiological, clinical and therapeutic features associated with these infections.

[Translated article] AEDV Expert Document on the Management of Ulcerative Venereal Infections

Currently, ulcerative sexually transmitted infections, including syphilis, herpes simplex virus (HSV), lymphogranuloma venereum (LGV), chancroid, donovanosis and, more recently, monkeypox (MPOX), represent a growing challenge for health care professionals. The incidence of syphilis and LGV has increased in recent years in Spain. Additionally, HSV, syphilis and chancroid can also increase the risk of HIV acquisition and transmission. The population groups most vulnerable to these infections are young people, men who have sex with men (MSM) and commercial sex workers. It is important to make a timely differential diagnosis since genital, anal, perianal, and oral ulcerative lesions may pose differential diagnosis with other infectious and non-infectious conditions such as candidiasis vulvovaginitis, traumatic lesions, carcinoma, aphthous ulcers, Behçet's disease, fixed drug eruption, or psoriasis. For this reason, the dermatologist plays a crucial role in the diagnosis and management of sexually transmitted infections. This chapter presents the main epidemiological, clinical and therapeutic features associated with these infections.

Secondary Syphilis Presenting With an Interstitial Granuloma Annulare-Like Histopathologic Pattern: A Report of 2 Cases

ABSTRACT

Syphilis, known as "the great mimicker," is caused by the spirochete Treponema pallidum and is characterized by a diverse array of clinical and histopathologic presentations. In secondary cutaneous syphilis, the most consistent morphological features include a superficial and deep perivascular infiltrate containing plasma cells, varying degrees of endothelial swelling, irregular acanthosis, elongation of rete ridges, a vacuolated pattern, and the presence of plasma cells. Although serologic tests are essential for definitive diagnosis, spirochetes can sometimes be directly identified in silver-stained tissue slides or through immunohistochemistry. Granuloma annulare is a relatively common, benign, self-limiting condition with 3 main variants: conventional, subcutaneous, and interstitial, each with distinct characteristics. In this study, we report 2 cases of cutaneous secondary syphilis with a striking granulomatous reaction pattern that closely mimics the interstitial variant of granuloma annulare. Owing to the severity of the tertiary stage of syphilis, distinguishing between these 2 entities is crucial.

Syphilis Infection During Pregnancy: The Possible Effect on the Course of Pregnancy and Fetal Outcomes-A Case Report and Literature Review

Background/Objectives: A wide range of syphilis-related pregnancy complications are encountered in clinical practice. Active surveillance of the epidemiological situation in different countries and a series of retrospective data analyses allow for a comprehensive assessment of the feasible consequences of syphilis infection during pregnancy. The negative effects of infection on reproductive health are also described. Risk-increasing factors (inadequate or late treatment, partner coinfection) and protective factors (timely diagnostics and treatment) are distinguished. The importance of adequate and timely management as well as the accessibility of healthcare and socioeconomic status, which influence health outcomes, are stressed. This article presents a rare case of untreated syphilis infection during pregnancy. The infection was diagnosed during the first antenatal visit; how-ever, treatment was not initiated. At the 33rd week of gestation, the patient was admitted to the hospital because of sparse bloody vaginal discharge. Following sudden fetal hypoxia, an urgent cesarean section was performed at 33 weeks of gestation. A preterm newborn was delivered in critical condition, and congenital syphilis was diagnosed. Methods: We searched the PubMed, Cochrane, and MeSH databases using the key search terms "treponema pallidum", "sexually transmitted infections", "pregnancy", "congenital infection", "syphilis", and "congenital syphilis", as well as their combinations. A total of 28 papers published over a ten-year period were included in the literature review. A clinical case was analyzed. Results: The impact of syphilis on pregnancy is quite evident. Our case showcased one of the most common impacts, i.e., premature birth, of congenital infections with associated bacterial meningitis, respiratory distress syndrome, multiple organ damage, and insufficient weight. Such associations with many adverse pregnancy outcomes as well as congenital syphilis and neonatal defects are often avoidable. Conclusions: Considering the potential consequences of infections, the issue of sexually transmitted diseases remains relevant, and improving diagnostic and treatment opportunities becomes of paramount importance as cases increase.

Modified TPPA combined with western blotting facilitates syphilis diagnosis in isolated reactive treponemal chemiluminescence immunoassay sera: a prospective cohort study

BACKGROUND

The challenge of dealing with isolated reactive treponemal chemiluminescence immunoassay (CIA) results in clinical practice has prompted the development of a more efficient algorithm for distinguishing true infection from false reactivity in isolated CIA sera.

METHODS

A prospective cohort study was conducted at Wuhan Tongji Hospital, involving 119,002 individuals screened for syphilis using CIA from January 1, 2015, to January 6, 2017. Samples with reactive CIA results underwent simultaneous testing with the T. pallidum passive particle agglutination assay (TPPA) and the rapid plasma reagin test (RPR). Additionally, a subgroup of 189 individuals with differing TPPA statuses was selected for further analysis using Western blotting (WB) and a modified TPPA assay (titer, 1:20). To identify the optimal serological approach for distinguishing true from false reactivity in sera with isolated reactive CIAs (CIA+TPPA-RPR-), two distinct algorithms were developed and evaluated. The first algorithm involved reflexively testing CIA+TPPA-RPR- sera with the modified TPPA, followed by WB if nonreactive. The second algorithm began with WB, followed by the modified TPPA if nonreactive or indeterminate.

RESULTS

WB demonstrated lower sensitivity compared to TPPA, but it identified six syphilis cases among the 89 CIA+TPPA- samples. Both WB and modified TPPA exhibited a specificity of 100%. The two supplementary confirmatory algorithms detected 12 additional syphilis cases, with the first algorithm being more cost-effective and labor-saving.

CONCLUSION

A combination of a modified TPPA (titer, 1:20) and WB can serve as a reliable algorithm for distinguishing true syphilis infection from false reactive signals in isolated reactive CIA sera.

CLINICAL TRIAL NUMBER

Not applicable.

[Translated article] AEDVAEDV Expert Recommendations on the Management of Suppurative Sexually Transmitted Infections

The incidence of sexually transmitted infections (STIs) is increasing in Spain. Suppurative STIs are one of the most frequent reasons for consultation in specialized centers. The reason for suppurative STIs is multiple and their empirical treatment varies with the currently growing problem of antimicrobial resistance. Dermatologists are trained and prepared to treat these diseases, but their correct management requires active knowledge of national and international guidelines. The present document updates, reviews and summarizes the main expert recommendations on the management and treatment of these STIs.

AEDV Expert Recommendations on the Management of Suppurative Sexually Transmitted Infections

The incidence of sexually transmitted infections (STIs) is increasing in Spain. Suppurative STIs are one of the most frequent reasons for consultation in specialized centers. The reason for suppurative STIs is multiple and their empirical treatment varies with the currently growing problem of antimicrobial resistance. Dermatologists are trained and prepared to treat these diseases, but their correct management requires active knowledge of national and international guidelines. The present document updates, reviews and summarizes the main expert recommendations on the management and treatment of these STIs.

The performance of a novel diagnostic criteria for neurosyphilis in HIV-negative patients

Diagnosing neurosyphilis in clinical settings poses significant challenges due to the absence of highly efficient diagnostic criteria. Our objective was to enhance the existing diagnostic criteria and assess their sensitivity and specificity for identifying neurosyphilis in HIV-negative patients. We conducted a retrospective review of patient records from a cross-sectional study carried out between December 2019 and May 2023. This study was designed to explore clinical practices in the diagnosis and treatment of neurosyphilis. We proposed and validated a new set of diagnostic criteria across 782 cases, comparing three different NS criteria for diagnostic efficiency. Among the 782 patients analyzed, 410 were diagnosed with neurosyphilis, while 372 were not. The newly developed NS criteria demonstrated a sensitivity of 99.5% and a specificity of 94.6%, with the added benefit of being user-friendly. In subgroups categorized by neurological symptoms and syphilis stages, the new NS criteria also exhibited high sensitivity and specificity. Statistical analyses confirmed that the novel NS criteria performed comparably well to the expanded NS criteria. The novel NS criteria for HIV-negative patients exhibited high sensitivity and specificity, proving to be both effective and convenient for physicians to implement.

Doxycycline post-exposure prophylaxis for preventing bacterial sexually transmitted infections (STIs): Are clinical providers supportive?

BACKGROUND

Bacterial sexually transmitted infections (STIs) continue to increase in the United States. Despite evidence of the effectiveness of doxycycline post-exposure prophylaxis (Doxy-PEP) to prevent STIs, little is known about providers' attitudes and willingness to implement Doxy-PEP.

METHODS

An online questionnaire was sent to 575 clinical providers in New York State in September 2022.

RESULTS

Ninety-one eligible individuals responded. Most providers served men who have sex with men (MSM) (84%); reported willingness to recommend Doxy-PEP (98%, 77%, and 67% for chlamydia, syphilis, and gonorrhea, respectively); preferred Doxy-PEP administration for MSM and transgender populations; believed recurring bacterial STIs (88%) and reported condomless sex (85%) were the most important characteristics to consider for recommending Doxy-PEP; and were concerned about antibiotic resistance (90%) (primarily for Neisseria gonorrhoeae). Insurance costs were the most perceived community-associated barriers (35%). There were no significant differences in providers' recommendations towards Doxy-PEP use when comparing clinicians' years of experience, regions, or professional titles.

CONCLUSIONS

Study results suggest high willingness and support for implementing Doxy-PEP. As this survey was administered prior to national guidelines on the use of Doxy-PEP, these data can be used as a baseline to compare to studies conducted after their release to formulate appropriate messages for providers to improve implementation.

Atypical Oral Mucosal Lesions in Syphilis: A Case Report Highlighting the Diagnostic and Therapeutic Aspects of the "Great Imitator"

The diagnostic process and discrimination of mucosal lesions present a formidable challenge for numerous clinicians, primarily attributable to the common overlap of clinical manifestations observed across various categories, including infectious, autoimmune, connective tissue, and systemic vascular inflammatory diseases. In cases of mucosal lesions, syphilis presents distinctive characteristics that can help clinicians differentiate it from other conditions. The most common manifestation of primary syphilis is mostly a painless, firm, indurated ulcer known as a chancre, which typically appears at the site of inoculation, with enlargement of regional lymph nodes. Sometimes, its painless course may be misleading. The objective of our study is to raise awareness of venereal diseases in cases of atypical oral mucosal lesions that do not respond to local treatment. A 32-year-old man was referred to the department of dermatology due to an enlarging, painful inflammatory lesion with central breakdown, covered with honey-yellow crusts on the lower lip. A positive history of herpes labialis was noted. The patient denied risky sexual behaviors or new partners in the last three months. Submandibular and left cervical lymph nodes were found enlarged in ultrasound examination, and laboratory tests showed elevated inflammatory parameters. Empirical antibiotic therapy with amoxicillin-clavulanate in conjunction with oral acyclovir did not lead to clinical improvement. The inadequate therapeutic response prompted the pursuit of further diagnostic investigations, including serological tests encompassing both treponemal and nontreponemal tests. Co-infections with human immunodeficiency virus (HIV) and hepatotropic viruses were excluded. The serological testing resulted positive, and after receiving the diagnosis, the patient admitted to engaging in high-risk sexual behaviors. The treatment with benzathine penicillin was successful. In the differential diagnosis of ulcers located on mucous membranes or vermilion border, the primary symptom should always be considered. Early serological testing remains the gold standard for diagnosis. Appropriate treatment with benzathine penicillin leads to satisfactory effects.

BASHH UK guidelines for the management of syphilis 2024

The 2024 UK guidelines for the management of syphilis are in line with current evidence and practice within the UK. Key updates are detailed at the start of the article. These guidelines are accompanied by the first UK guidelines for the management of syphilis in pregnant people and children, 2024.

Evaluating the clinical utility of semi-quantitative luciferase immunosorbent assay using Treponema pallidum antigens in syphilis diagnosis and treatment monitoring

To assess the clinical applicability of a semi-quantitative luciferase immunosorbent assay (LISA) for detecting antibodies against Treponema pallidum antigens TP0171 (TP15), TP0435 (TP17), and TP0574 (TP47) in diagnosing and monitoring syphilis. LISA for detection of anti-TP15, TP17, and TP47 antibodies were developed and evaluated for syphilis diagnosis using 261 serum samples (161 syphilis, 100 non-syphilis). Ninety serial serum samples from 6 syphilis rabbit models (3 treated, 3 untreated) and 110 paired serum samples from 55 syphilis patients were used to assess treatment effects by utilizing TRUST as a reference. Compared to TPPA, LISA-TP15, LISA-TP17, and LISA-TP47 showed a sensitivity of 91.9%, 96.9%, and 98.8%, specificity of 99%, 99%, and 98%, and AUC of 0.971, 0.992, and 0.995, respectively, in diagnosing syphilis. Strong correlations (rs = 0.89-0.93) with TPPA were observed. In serial serum samples from rabbit models, significant differences in the relative light unit (RLU) were observed between the treatment and control group for LISA-TP17 (days 31-51) and LISA-TP47 (day 41). In paired serum samples from syphilis patients, TRUST titres and the RLU of LISA-TP15, LISA-TP17, and LISA-TP47 decreased post-treatment (P < .001). When TRUST titres decreased by 0, 2, 4, or ≥8-folds, the RLU decreased by 17.53%, 31.34%, 48.62%, and 72.79% for LISA-TP15; 8.84%, 17.00%, 28.37%, and 50.57% for LISA-TP17; 22.25%, 29.79%, 51.75%, and 70.28% for LISA-TP47, respectively. Semi-quantitative LISA performs well for syphilis diagnosis while LISA-TP17 is more effective for monitoring syphilis treatment in rabbit models and clinical patients.

British Association of Sexual Health and HIV (BASHH) UK guidelines for the management of syphilis in pregnancy and children 2024

This new guideline details the specific management of syphilis in pregnancy and in children. It is to be used in clinical practice alongside the BASHH UK guidelines for the management of syphilis 2024.

Case report: Cerebral syphilitic gumma: a case retrospective report of eight cases

Background

Cerebral syphilitic gumma (CSG), a rare manifestation of neurosyphilis, presents characteristics akin to intracranial tumors, often leading to clinical misdiagnosis.

Objective

This study aimed to summarize the clinical experience in diagnosing and treating CSG.

Materials and methods

The present study conducted a retrospective analysis of clinical data, encompassing the baseline characteristics, clinical presentation, diagnosis, treatment, and prognosis of eight patients with CSG who were treated and diagnosed by our institution.

Results

The median age at the initial diagnosis was 57.5 years, comprising six males and two females. The predominant clinical manifestations included headaches in eight cases, motor and sensory disorders in four cases, epileptic seizures in one case, and dysarthria in one patient. The serum Treponema pallidum haemagglutination assay (TPHA) and toluidine red unheated serum test (TRUST) yielded positive in all eight patients. The contrast-enhanced magnetic resonance imaging (MRI) revealed irregular ring-shaped enhancement of lesions in three patients, while nodular enhancement of lesions was observed in five patients. In terms of treatment, seven patients underwent surgery. The postoperative pathological tissue showed granulomatous inflammation. Six patients exhibited an elevated protein concentration in their cerebrospinal fluid (CSF), while two patients demonstrated a reduced CSF glucose level. Additionally, positive results were obtained for both CSF TPHA and TRUST in all eight patients. The clinical diagnosis of CSG was confirmed in eight patients who exhibited notable clinical improvement following penicillin treatment. Subsequent reevaluation of the imaging findings demonstrated complete resolution of the enhanced lesions.

Conclusion

In clinical practice, CSG should be considered for patients with intracranial lesions and positive serum syphilis antibodies. Timely and accurate diagnosis enables patients with CSG to achieve a more favorable prognosis through active anti-syphilis treatment.

Serum homocysteine levels as a predictor of neurosyphilis among HIV-negative syphilis patients: A single-center retrospective study

This study investigates the differences in peripheral blood parameters between patients with non-neurosyphilis and neurosyphilis, aiming to identify potential serum biomarkers to predict the occurrence of neurosyphilis and avoid unnecessary lumbar punctures. A retrospective analysis was conducted on 110 HIV-negative syphilis patients in this study. We found that the serum homocysteine (Hcy) levels in the non-neurosyphilis group, asymptomatic neurosyphilis group, and symptomatic neurosyphilis group were 12.30 (10.45, 13.25), 17.50 (12.03, 26.28), and 15.70 (13.70, 20.20), respectively. The serum Hcy levels in the asymptomatic neurosyphilis group and symptomatic neurosyphilis group were significantly higher than those in the non-neurosyphilis group (P<0.05). The AUC for serum Hcy in diagnosing neurosyphilis was 0.861 (95% CI: 0.715-0.950), with a sensitivity and specificity of 98.47% and 71.43% respectively. The study indicated that serum Hcy levels serve as a potential biomarker to differentiate neurosyphilis from non-neurosyphilis.

Separating Infectious Proctitis from Inflammatory Bowel Disease-A Common Clinical Conundrum

Proctitis refers to inflammation in the rectum and may result in rectal bleeding, discharge, urgency, tenesmus, and lower abdominal pain. It is a common presentation, particularly in genitourinary medicine and gastroenterology, as the two most common causes are sexually transmitted infections and inflammatory bowel disease. The incidence of infective proctitis is rising, particularly amongst high-risk groups, including men who have sex with men, those with HIV seropositive status, and those participating in high-risk sexual behaviours. The most commonly isolated organisms are Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema palladium, herpes simplex virus, and Mycoplasma genitalium. Recently, proctitis was also identified as a common feature during the Mpox outbreak. Distinguishing infective proctitis from inflammatory bowel disease remains a significant clinical challenge as there is significant overlap in the clinical presentation and their endoscopic and histological features. This review compares and highlights the distinguishing hallmarks of both inflammatory and infective causes of proctitis. It provides a practical guide to describe the key features that clinicians should focus on in both clinical and key diagnostic investigations to avoid potential misdiagnosis.

Clinical spectrum of late symptomatic neurosyphilis in China: an 11-year retrospective study

OBJECTIVES

This study aimed to describe the clinical features of neurosyphilis in Chinese patients in an attempt to find clinical features that are helpful for the early identification of neurosyphilis.

METHODS

This retrospective study included people with syphilis who visited Shanghai Skin Disease Hospital between January 2010 and December 2020. Lumbar puncture was performed on those who met the inclusion and exclusion criteria. The diagnosis of neurosyphilis was based on clinical and laboratory findings. The parameters were analysed statistically.

RESULTS

Of the 3524 patients with neurosyphilis, 2111 (59.9%) and 1413 (40.1%) were asymptomatic and symptomatic neurosyphilis, respectively. General paresis was the most common type of symptomatic neurosyphilis (46.8%). The clinical manifestations of symptomatic neurosyphilis include psychiatric and neurotic symptoms, among which general paresis predominantly presented as psychiatric symptoms such as affective (66.7%) and memory disorder (72.9%). Tabes dorsalis is often presented as neurotic symptoms. One hundred fifty patients (10.6%) with symptomatic neurosyphilis presented candy signs, a rare and specific neurosyphilis symptom that is common in general paresis. Girdle sensation was presented in 13 patients, mainly with tabes dorsalis, which had not been reported in previous studies.

CONCLUSIONS

Notably, the candy sign is identified as a specific symptom of general paresis, while girdle sensations are highlighted as a particular symptom of tabes dorsalis. This is the largest study describing the clinical spectrum of neurosyphilis since the onset of the penicillin era and could help doctors learn more about the disease. A comprehensive description of the possible clinical manifestations of late symptomatic neurosyphilis, particularly highlighting rare symptoms, can identify suspicious patients and prevent diagnostic delays.

Nano-enhanced benzylpenicillin: Bridging antibacterial action with anti-inflammatory potential against antibiotic-resistant bacteria

This study investigates the enhancement of benzylpenicillin's antibacterial properties using nanomedicine, specifically by developing benzylpenicillin nanoemulsions. To address the escalating issue of bacterial resistance, we employed the advanced techniques Raman spectroscopy and atomic force microscopy to analyze the nanoemulsions' molecular structure and characteristics. We then evaluated the impact of these nanoemulsions on nitric oxide production by macrophages to deternine their potential to modulate inflammatory responses. We further assessed the antibacterial effectiveness of the nanoparticles against the pathogens Streptococcus pyogenes (Group A Streptococcus) and Streptococcus agalactiae (Group B Streptococcus). The results of antibiograms showed significant efficacy against Gram-positive bacteria, with minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) values, confirming their bactericidal potential. The investigation into the mechanism of action suggested substantial disruption to bacterial membrane integrity, underscoring a possible mode of antibacterial activity. Overall, the study provides valuable insights into the synergistic relationship between antibiotics and nanoparticles. In particular, it demonstrates the potential of benzylpenicillin nanoparticles to enhance the antimicrobial efficacy and influence inflammatory responses obtained by evaluating nitrite, IL-6 and TNF-α, offering promising avenues for future clinical applications and strategies to combat bacterial resistance.

Neurosyphilis-Induced Psychosis in Europe: A Systematic Review of Case Reports

The tertiary stage of syphilis appears to be the most diverse of the three recognized, with a number of cardiovascular, gummatous, neurological and psychiatric symptoms. This systematic review's aim is to analyze cases of organic psychoses secondary to tertiary syphilis, inspect the diagnostic procedures and assess the effectiveness of treatment. Case studies from Pubmed and MEDLINE Ultimate were sought out with the Boolean expression '((neurosyphilis) OR (syphilis) OR (treponema pallidum)) AND (case report) AND ((psychosis) OR (psychotic))' to later undergo screening for exclusion criteria (according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines). Each report was accepted independently by two authors. Case reports were later appraised using the JBI Critical Appraisal Checklist for Case Reports. Finally, 11 case reports were included in the study. The most frequently reported psychiatric symptoms were delusions (91%) and hallucinations (81%), disorientation (about 42%) and sleep disturbances and memory loss (36%). Several inconsistencies in diagnostic processes were found in some of the case reports, while treatment procedures were more in line with the guidelines. A disease as complex as neurosyphilis requires great awareness and cooperation between various medical specialties. Despite its mimicry and variability in presentation, the discussed case reports prove that it can be successfully dealt with.

Analysis of Neurosyphilis Imaging Methods and Treatment: A Focused Review

Neurosyphilis, a severe complication of syphilis caused by Treponema pallidum, progresses through multiple stages, including asymptomatic, meningeal, meningovascular, and late parenchymal forms such as syphilitic paresis and tabes dorsalis. Neurosyphilis spreads through sexual contact and from mother to child. Symptoms of neurosyphilis include nausea, cranial nerve deficiencies, and seizures. Diagnosing this condition is particularly challenging due to its varied symptoms, which frequently overlap with other neurological disorders. Current diagnostic approaches primarily rely on cerebrospinal fluid (CSF) analysis and neuroimaging techniques like magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT). The exploration of recent advances in neurosyphilis testing and the expanding role of imaging techniques in tracking treatment efficacy are seen. Penicillin G continues to be the primary treatment, with ceftriaxone serving as an alternative for patients with penicillin allergies. Even though ceftriaxone is less potent than penicillin G, it can still successfully eradicate neurosyphilis in patients. This review seeks to deepen the understanding of neurosyphilis pathophysiology, refine diagnostic accuracy, and inform evidence-based treatment approaches. This will ultimately contribute to improved patient outcomes.

Syphilis in pregnant women and congenital syphilis from 2012 to 2021 in Switzerland: a multicentre, retrospective study

BACKGROUND AND AIMS OF THE STUDY

Congenital syphilis is a rare complication of syphilis in pregnant women. Vertical transmission may occur at any time during pregnancy. The incidence of congenital syphilis has been increasing worldwide. Congenital syphilis has been a notifiable disease for many years in Switzerland but reporting does not include maternal features associated with syphilis in pregnancy or infant's subsequent development. We described syphilis cases among pregnant women screened over a 10-year period in Switzerland and subsequent cases of congenital syphilis, in order to identify maternal risk profiles and to optimise prevention. Second, we compared the characteristics of pregnant women screened early (1st trimester) vs late in pregnancy (2nd or 3rd trimester). Finally, we assessed the risk factors for premature birth among these women with syphilis.

METHODS

A multicentre retrospective study conducted in Swiss hospitals from 2012 to 2021, including pregnant women who screened positive for syphilis (Treponema pallidum haemagglutination assay [TPHA] / T. pallidum particle agglutination assay [TPPA ] ≥1:80) and newborns exposed to T. pallidum in utero and/or congenitally infected and with a positive syphilis serology at birth. Data were collected from medical records.

RESULTS

A total of 147 syphilis-positive pregnant women and 102 infants were included. A history of treated syphilis was known for 44% (65/147) of the mothers corresponding to a serological scar and the remaining 56% (82/147) were newly identified syphilis cases. Syphilis screening was done during the first trimester in 54%, second trimester in 29% and third trimester in 13% of cases. Two babies were diagnosed with congenital syphilis (1.96%). Several potential factors that could contribute to women's risk of syphilis during pregnancy were identified such as a foreign origin (93% of mothers), lack of healthcare insurance (25%), no employment status (37%), drug use (5%), co-infection with other sexually transmitted infections (24%) and a late first antenatal consultation (42%). The number of pregnant women without insurance was higher in women diagnosed in the second or third trimester than in those diagnosed in the first trimester (odds ratio 0.41; 95% CI 0.19-0.89; p = 0.024). Syphilis diagnosed in the second or third trimester was associated with a late first antenatal consultation (odds ratio 77.82; 95% CI 9.81-617.21; p <0.001). A high rate of intrauterine growth retardation and of preterm birth was observed in newborns (18% versus 6% in Switzerland in 2022).

CONCLUSION

Congenital syphilis remains rare in Switzerland. However, we found potential maternal factors associated with a positive syphilis serology during pregnancy, which can help to improve future prevention measures. The study protocol was registered on ClinicalTrials.gov (ID NCT05975502).

Epidemic of multiple Treponema pallidum strains in men who have sex with men in Japan: efficient multi-locus sequence typing scheme and indicator biomarkers

BACKGROUND

The challenges in culturing Treponema pallidum have hindered molecular-biological analysis. This study aims to establish a molecular epidemiological analysis of syphilis among Japanese men who have sex with men (MSM) and to investigate the relationship between bacteremia and associated pathophysiology.

METHODS

We used whole blood specimens from syphilis-diagnosed individuals in Tokyo, collected between February 2019 and June 2022. All individuals were MSM, and most were people with HIV (97.2%). We used a multi-locus sequence typing (MLST) scheme for epidemiological analysis. Sequences for MLST (TP0136, TP0548, and TP0705) were obtained.

RESULTS

Out of 71 whole blood samples, 26 samples (36.6%) were positive for TP0136, and we sequenced three loci for MLST in 22 samples (31.0%). The most frequently detected sequence type (ST) was ST3 (n = 9), followed by ST6 (n = 6). Phylogenetic analysis revealed that 12 samples belonged to the SS14-like group (60%), and 8 samples belonged to the Nichols-like group (40%). Treponema pallidum subsp. endemicum (TEN), the cause of bejel was detected in three samples (12%). There was a significant association between TP0136 detection rate and C- reactive protein (CRP) (77.0% at a cut-off:0.5 mg/dL).

CONCLUSION

Both SS14-like and Nichols-like strains were circulating concurrently, and TEN could have been sexually transmitted among MSM with HIV. Elevated CRP may indicate the presence of the pathogen in the blood.

High increase of Nichols-like clade circulating Treponema pallidum subsp. pallidum in Barcelona from 2021 to 2023

Worldwide, more than 90% of contemporary syphilis strains belong to SS14-like clade. This study aimed to describe the molecular profile of circulating Treponema pallidum subsp. pallidum (TPA) strains in Barcelona, Spain, from 2021 to 2023 building upon our report in 2015 which showed that 94.8% of typed strains belonged to the SS14 clade. Multilocus sequence typing (MLST) was conducted on TPA-positive samples obtained from swab samples by sequencing the tp0136, tp0548, and tp0705 loci. Strains were classified as Nichols-like or SS14-like clade. Macrolide and tetracycline resistance‑associated mutations were determined through analysis of 23S rDNA and 16S rRNA gene sequences. Of the 96 typeable samples, 47.9% belonged to SS14-like and 52.1% to the Nichols-like. Fourteen haplotypes were identified, with ST26 representing 43.8% of the samples, distributed across 11 haplotypes in the SS14-like and 3 haplotypes in the Nichols-like. All the samples showed macrolide resistance-associated mutations, while none exhibited tetracycline-associated mutations. Our findings revealed a substantial shift in the proportion of TPA clades within the Barcelona population from 2021 to 2023, characterized by a higher proportion of Nichols-like strains compared to 2015 and international trends. The varying temporal and geographical trends underscore the need for regular surveillance to understand regional variations in syphilis and strengthen control programs.

[Translated article] AEDV Expert Consensus for the Management of Syphilis

Syphilis -the "great simulator" for classical venereologists-is re-emerging in Western countries despite adequate treatment; several contributing factors have been identified, including changes in sexual behaviour, which won't be the topic of this article though. In 2021, a total of 6613 new cases of syphilis were reported in Spain, representing an incidence of 13.9×100 000 inhabitants (90.5%, men). Rates have increased progressively since 2000. The clinical presentation of syphilis is heterogeneous. Although chancroid, syphilitic roseola and syphilitic nails are typical lesions, other forms of the disease can be present such as non-ulcerative primary lesions like Follmann balanitis, chancres in the oral cavity, patchy secondary lingual lesions, or enanthema on the palate and uvula, among many others. Regarding diagnosis, molecular assays such as PCR have been replacing dark-field microscopy in ulcerative lesions while automated treponemal tests (EIA, CLIA) are being used in serological tests, along with classical tests (such as RPR and HAART) for confirmation and follow-up purposes. The interpretation of these tests should be assessed in the epidemiological and clinical context of the patient. HIV serology and STI screening should be requested for anyone with syphilis. Follow-up of patients under treatment is important to ensure healing and detect reinfection. Serological response to treatment should be assessed with the same non-treponemal test (RPR/VDRL); 3-, 6-, 12-, and 24-month follow-up is a common practice in people living with HIV (PLHIV). Sexual contacts should be assessed and treated as appropriate. Screening is advised for pregnant women within the first trimester of pregnancy. Pregnant women with an abortion after week 20 should all be tested for syphilis. The treatment of choice for all forms of syphilis, including pregnant women and PLHIV, is penicillin. Macrolides are ill-advised because of potential resistance.

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

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

Palmar Psoriasis or Missed Syphilis?

N/a.

Refining a non-invasive prediction model for neurosyphilis diagnosis by using immunoassay to detect serum anti-TP0435 (TP17) and TP0574 (TP47) IgG antibodies: two-centre cross-sectional retrospective study in China

OBJECTIVES

Invasive lumbar puncture is the conventional method for diagnosing neurosyphilis (NS). We investigated a non-invasive alternative method to detect serum Treponema pallidum-specific antibodies against highly immunogenic antigens TP0171 (TP15), TP0435 (TP17), and TP0574 (TP47) by using luciferase immunosorbent assay.

METHODS

A total of 816 HIV-negative patients suspected of NS from the Beijing and Guangzhou cohorts were retrospectively selected and tested for serum anti-TP15, TP17, and TP47 IgG antibodies. Two diagnostic prediction models were developed using stepwise logistic regression in the Beijing cohort, and evaluated in the Guangzhou cohort for external validation.

RESULTS

Serum antibodies against TP15, TP17, and TP47 showed moderate capability for NS diagnosis in the Beijing cohort and the corresponding area under the receiver operating characteristic curves (AUCs) were 0.722 [95% confidence interval (CI): 0.680-0.762)], 0.780 (95% CI: 0.741-0.817), and 0.774 (95% CI: 0.734-0.811), respectively. An expanded NS prediction model integrated with anti-TP17 and anti-TP47 antibodies showed better performance than the base NS diagnostic model without anti-TP17 and anti-TP47 antibodies with the AUC of 0.874 (95% CI: 0.841-0.906) vs. 0.845 (95% CI: 0.809-0.881) (p = 0.007) in the development cohort, and 0.934 (95% CI: 0.909-0.960) vs. 0.877 (95% CI: 0.840-0.914) (p < 0.001) in validation cohort, respectively. Decision curve analysis revealed that the net benefit of the expanded model exceeded that of the base model when the threshold probability was between 0.10 and 0.95 in both the development and external validation cohorts.

DISCUSSION

Serum antibodies against TP17 and TP47 exhibited promising diagnostic capability for NS and significantly enhanced the predictive accuracy of model for NS diagnosis. Our study highlights the potential of serum treponemal antibody detection as a non-invasive method for NS diagnosis to substitute invasive lumbar puncture in NS diagnosis.

Increase in congenital syphilis in a tertiary-care centre from Madrid, Spain: Back to the classics

Globally, an increase in sexually transmitted diseases worldwide has been reported, including acquired Treponema pallidum infection. Congenital syphilis is the mother-to-child transmission syphilis infection, experiencing an increase in cases returning to incidence rates of years ago. We report three cases of symptomatic congenital syphilis occurring in a tertiary-care hospital in Madrid (Spain). Cases were diagnosed by serology and molecular biology methods. The use of molecular techniques in specimens such as skin lesion, subplacental exudate swabs, bronchoalveolar aspirate, or cerebrospinal fluid could favour the diagnosis of this clinical entity, especially in symptomatic newborns with systemic involvement.

Endocarditis and ascending aortic aneurysm with aortic valve insufficiency secondary to late syphilis: Case report

Venereal syphilis, caused by Treponema pallidum, is a major global health problem. Untreated latent syphilis can progress to tertiary syphilis, often leading to severe complications such as cardiac involvement, particularly syphilitic aortitis, which may manifest decades after the initial infection. We present a case of a 46-year-old woman who developed an ascending aortic aneurysm and severe aortic valve insufficiency due to late-stage syphilis. She presented with bilateral lower limb edema, intermittent chest pain, decreased functional capacity, and dyspnea, ultimately requiring hospitalization for cardiogenic shock. Diagnostic imaging revealed significant aortic valve damage and aneurysmal dilation of the ascending aorta, while serological tests confirmed tertiary cardiovascular syphilis. Surgical intervention involved the reconstruction of the ascending aorta and replacement of the aortic valve with a bioprosthetic valve. Histopathological analysis indicated chronic endocarditis. Postoperative management included intensive care support and antibiotic treatment. The patient demonstrated satisfactory recovery, with no further complications reported at the 3-month follow-up.

AEDV Expert Consensus for the Management of Syphilis

Syphilis -the "great simulator" for classical venereologists-is re-emerging in Western countries despite adequate treatment; several contributing factors have been identified, including changes in sexual behaviour, which won't be the topic of this article though. In 2021, a total of 6613 new cases of syphilis were reported in Spain, representing an incidence of 13.9×100 000 inhabitants (90.5%, men). Rates have increased progressively since 2000. The clinical presentation of syphilis is heterogeneous. Although chancroid, syphilitic roseola and syphilitic nails are typical lesions, other forms of the disease can be present such as non-ulcerative primary lesions like Follmann balanitis, chancres in the oral cavity, patchy secondary lingual lesions, or enanthema on the palate and uvula, among many others. Regarding diagnosis, molecular assays such as PCR have been replacing dark-field microscopy in ulcerative lesions while automated treponemal tests (EIA, CLIA) are being used in serological tests, along with classical tests (such as RPR and HAART) for confirmation and follow-up purposes. The interpretation of these tests should be assessed in the epidemiological and clinical context of the patient. HIV serology and STI screening should be requested for anyone with syphilis. Follow-up of patients under treatment is important to ensure healing and detect reinfection. Serological response to treatment should be assessed with the same non-treponemal test (RPR/VDRL); 3-, 6-, 12-, and 24-month follow-up is a common practice in people living with HIV (PLHIV). Sexual contacts should be assessed and treated as appropriate. Screening is advised for pregnant women within the first trimester of pregnancy. Pregnant women with an abortion after week 20 should all be tested for syphilis. The treatment of choice for all forms of syphilis, including pregnant women and PLHIV, is penicillin. Macrolides are ill-advised because of potential resistance.

Neutrophil-Associated Proteins as Novel Biomarkers Elevated in Cerebrospinal Fluid of Patients With Neurosyphilis

BACKGROUND

The immunopathological mechanisms underlying neurosyphilis remain incompletely elucidated, and the diagnosis of neurosyphilis presents challenges.

METHODS

We used an antibody microarray to detect 640 proteins in cerebrospinal fluid (CSF) samples collected from 6 patients with non-neurosyphilis and 10 with neurosyphilis. The levels of CSF CXCL1, CXCL8, G-CSF, LCN2, MMP8, and MMP9 in 46 patients with non-neurosyphilis, 51 with untreated neurosyphilis, and 31 posttreatment for neurosyphilis were quantified using enzyme-linked immunosorbent assay. The associations between the levels of these proteins and clinical parameters in neurosyphilis were evaluated using Spearman analysis, and the diagnostic performance of these proteins in neurosyphilis was assessed using receiver operating characteristic curve.

RESULTS

A total of 102 differentially expressed proteins between neurosyphilis and non-neurosyphilis were identified. The levels of significantly elevated neutrophil-associated proteins (CXCL1, CXCL8, G-CSF, LCN2, MMP8, and MMP9) in neurosyphilis positively correlated with white blood cell counts, rapid plasma regain (RPR) titer, and protein concentration in CSF. The combination of CSF CXCL8, MMP9, and LCN2 yielded an area under the curve of 0.92 for diagnosing neurosyphilis, surpassing that of CSF RPR.

CONCLUSIONS

CXCL1, CXCL8, G-CSF, LCN2, MMP8, and MMP9 could be associated with central nervous system damage of neurosyphilis. The combination of CSF CXCL8, MMP9, and LCN2 is a promising biomarker for diagnosing neurosyphilis.

Uncovering the mechanisms of host mitochondrial cardiolipin release in syphilis: Insights from human microvascular endothelial cells

The release of host mitochondrial cardiolipin is believed to be the main factor that contributes to the production of anti-cardiolipin antibodies in syphilis. However, the precise mechanism by which mitochondria release cardiolipin in this context remains elusive. This study aimed to elucidate the mechanisms underlying mitochondrial cardiolipin release in syphilis. We conducted a cardiolipin quantitative assay and immunofluorescence analysis to detect mitochondrial cardiolipin release in human microvascular endothelial cells (HMEC-1), with and without Treponema pallidum (Tp) infection. Furthermore, we explored apoptosis, a key mechanism for mitochondrial cardiolipin release. The potential mediator molecules were then analyzed through RNA-sequence and subsequently validated using in vitro knockout techniques mediated by CRISPR-Cas9 and pathway-specific inhibitors. Our findings confirm that live-Tp is capable of initiating the release of mitochondrial cardiolipin, whereas inactivated-Tp does not exhibit this capability. Additionally, apoptosis detection further supports the notion that the release of mitochondrial cardiolipin occurs independently of apoptosis. The RNA-sequencing results indicated that microtubule-associated protein2 (MAP2), an axonogenesis and dendrite development gene, was up-regulated in HMEC-1 treated with Tp, which was further confirmed in syphilitic lesions by immunofluorescence. Notably, genetic knockout of MAP2 inhibited Tp-induced mitochondrial cardiolipin release in HMEC-1. Mechanically, Tp-infection regulated MAP2 expression via the MEK-ERK-HES1 pathway, and MEK/ERK phosphorylation inhibitors effectively block Tp-induced mitochondrial cardiolipin release. This study demonstrated that the infection of live-Tp enhanced the expression of MAP2 via the MEK-ERK-HES1 pathway, thereby contributing to our understanding of the role of anti-cardiolipin antibodies in the diagnosis of syphilis.

Early Congenital Syphilis Presenting With Severe Congenital Pneumonia and Cutaneous Manifestations in a Neonate at Birth: A Case Report

Transplacental transmission of Treponema pallidum spirochetes from an infected mother to the fetus during pregnancy results in the infectious condition known as congenital syphilis (CS). Once a forgotten disease, CS has now re-emerged. We report the clinical case of an early CS in a neonate girl presented with severe congenital pneumonia (pneumonia alba) requiring intubation, along with skin lesions that were visible from birth on the palms and soles of the feet. Neonate's treponemal and non-treponemal tests were positive, and the mother's rapid plasma reagin (RPR) test was also positive after birth, and the mother did not have prenatal screening or follow-ups due to socioeconomic reasons. Neonate's radiological investigations found a diffuse, uniform opacification of both lungs ("white lung") on chest X-ray, consistent with congenital pneumonia (pneumonia alba), in addition to increased radiolucency, widening, irregularity, and erosions in the lower limbs, with periventricular leukomalacia and possible petechial hemorrhages on cerebral magnetic resonance imaging. The neonate was given a 10-day course of intravenous penicillin G along with five days of concurrent inotrope support, IV hydrocortisone for seven days, IV vancomycin and meropenem for 10 days, along with respiratory support. The neonate stayed in the neonatal intensive care unit (NICU) for a period of 54 days in total and was discharged with a clinically favorable outcome.

Syphilis among Roma community: a single-center experience in Bulgaria (socio-demographic data collection, 2008-2022)

INTRODUCTION

With a population of roughly 11 million, the Roma (Gypsies) are the largest ethnic minority in Europe, particularly in the countries of Central and Eastern Europe. A number of serious socioeconomic issues, such as poor health, low levels of education, unemployment, discrimination, criminal activity, high-risk sexual behavior, and a high rate of illnesses, including STDs, are present in their society.

Selective attention function impairment in HIV-negative patients with early forms of neurosyphilis

BACKGROUND

The attentional network test (ANT) is widely used to evaluate the performance of three attentional networks: alerting, orienting and executive attention networks. This study aimed to investigate the characteristics of attention functions in HIV-negative patients with early forms of neurosyphilis (NS) and their correlation with abnormalities in brain magnetic resonance imaging (MRI).

METHODS

Thirty patients with early forms of NS, 31 patients with syphilis but without NS (Non-NS) and 35 healthy controls were recruited from an HIV-negative cohort between September 2020 and November 2022. The participants were evaluated with the ANT and the Mini-Mental State Examination (MMSE). Brain MRI was performed in NS and Non-NS patients.

RESULTS

No significant differences were observed in the MMSE scores among the three groups. However, patients with early forms of NS showed poorer performance in orienting and alerting functions than Non-NS group (F = 6.952, P = 0.011 and F = 8.794, P = 0.004, respectively); No significant difference was observed in executive function between the two groups (F = 0.001, P = 0.980). Multivariate analysis of variance using the Bonferroni post hoc test indicated that patients with NS exhibited less efficient orienting function (P = 0.023), and alerting function (P = 0.003) but not executive function (P = 0.99), compared to Non-NS patients. Additionally, a significant difference was found in orienting function between patients with NS and healthy controls (P < 0.001) compared to healthy controls. MRI scans revealed that the NS group had a higher prevalence of abnormalities in the frontal lobes and/or the temporoparietal junction compared to the Non-NS group (24/25 vs. 13/19, P = 0.032).

CONCLUSIONS

The orienting and alerting functions but not executive function were significantly less efficient in early forms of NS group than in the Non-NS group (P < 0.01). This indicates deficits in selective attention in patients with early forms of NS. Brain MRI scans revealed abnormalities in the frontal and/or parietal lobes, as well as the temporoparietal junction, suggesting potential neuropathological correlates of these attentional deficits.

Syphilis testing in blood donors, France, 2007 to 2022

BackgroundSyphilis in blood donors (BD) has increased in many countries.AimWe aimed to describe trends in syphilis seroposivity in BD in France, to identify risk factors and assess if a non-treponemic test (NTT) could define BD having recovered from syphilis for more than 1 year.MethodsThe analysis covered the period 2007 to 2022 and 45,875,939 donations. Of the 474 BD syphilis-positive in 2022, 429 underwent additional investigations with an NTT. History of syphilis was obtained at the post-donation interview or based on serology results for repeat donors.ResultsUntil 2021, positivity rates remained stable (mean: 1.18/10,000 donations, range: 1.01-1.38). An increased rate was observed in 2022 (1.74/10,000; p = 0.02). Over the whole study period, prevalence was 2.2 times higher in male than in female BD (4.1 times higher in 2022). The proportion of males with an identified risk factor who have sex with men increased from 16.7% in 2007 to 64.9% in 2022. Based on NTT, 79 (18%) of the donors who were seropositive in 2022 were classified as having been infected in the previous year. History of syphilis was available for 30 of them. All had an infection within the previous 3 years. Among seven donors with a syphilis < 12 months before testing, one had an NTT titre ≥ 8, three a titre between 1 and 4, three were negative.ConclusionSyphilis seropositivity increased considerably in BDs in 2022, mostly in males, notably MSM. Available data did not allow appropriate evaluation of the NTT to distinguish recent from past infection.

Characteristic Profiling of Soluble Factors in the Cerebrospinal Fluid of Patients With Neurosyphilis

BACKGROUND

Soluble inflammatory factors in the cerebrospinal fluid (CSF) of patients with neurosyphilis have been investigated with low-throughput technology. This study aimed to illustrate the characteristics of soluble factor profiles in CSF of patients with neurosyphilis.

METHODS

We measured the concentrations of 45 cytokines, chemokines, and growth factors in CSF from 112 untreated syphilis cases, including latent syphilis (LS), asymptomatic neurosyphilis (ANS), meningeal neurosyphilis (MNS), meningovascular neurosyphilis (MVNS), paralytic dementia (PD), and ocular syphilis (OS).

RESULTS

Thirty-three differentially expressed soluble factors (DeSFs) were categorized into 3 clusters. DeSF scores of clusters 1 and 2 (DeSFS1 and DeSFS2) were positively correlated with elevated neopterin and neurofilament light subunit (NF-L) concentration, respectively. DeSF scores of cluster 3 were positively correlated with white blood cells, protein, NF-L, and neopterin. Patients with LS, ANS, and OS exhibited an overall lower abundance of DeSFs. Patients with PD exhibited significantly increased levels of clusters 1 and 3, and the highest total DeSF score, whereas patients with MNS and MVNS showed enhanced levels of cluster 2. Receiver operating characteristic analysis revealed that DeSFS1 effectively discriminated PD, and DeSFS2 discriminated MNS/MVNS with high accuracy.

CONCLUSIONS

Patients with neurosyphilis at different stages have distinctive patterns of soluble factors in CSF, which are correlated with immune status and neuronal damage.

Lack of Serological Response by Delivery to Syphilis Treatment Does Not Impact Pregnancy Outcomes

Objectives: Maternal syphilis can lead to serious adverse pregnancy outcomes, including neonatal death. A 4-fold decline in blood non-treponemal titer at six months after the treatment of syphilis compared to the baseline is considered as an adequate serological response. However, the duration of normal human gestation does not allow the ascertainment of an adequate serological response. Aim: The aim of this study was to assess correlations between the lack of a 4-fold decrease in non-treponemal titer by delivery after syphilis treatment and fetal and newborns' condition and serological outcomes. Methods: Fourteen pregnant patients (gestational age 16-22 weeks) diagnosed with early syphilis (secondary or latent) were treated with intramuscular benzathine penicillin and subsequently monitored clinically, serologically, and ultrasonographically at monthly intervals. Based on the non-treponemal test results at delivery, patients were stratified into two groups: those with a 4-fold decline in titers and those without such a decline. All newborns were clinically and serologically assessed for congenital syphilis at birth and then monitored until serological tests became negative. Results: Fifty percent of the included women did not achieve a 4-fold decline in non-treponemal titer by delivery. Patients from the group showing a 4-fold decline in RPR titer at delivery and those without such a decline did not differ in basic demographic and clinical characteristics or in ultrasound parameters used for fetal assessment. Based on the clinical and laboratory assessments of newborns on the day of delivery and during a 6-month follow-up, none were diagnosed with congenital syphilis or required treatment for syphilis. Conclusions: The lack of an adequate serological response to syphilis therapy by delivery among patients treated between 16 and 22 weeks of pregnancy does not appear to be associated with adverse fetal and neonatal outcomes.

Neurosyphilis Presenting as Psychiatric Symptoms at Younger Age: A Case Report

Neurosyphilis is a central nervous system infection caused by Treponema pallidum that imitates various neurological and mental disorders. Therefore, patients with this disease are prone to misdiagnoses. Here, we report a case of neurosyphilis with a psychotic disorder as the main manifestation. A young girl exhibited mental and behavioural abnormalities after a heartbreak, which manifested as alternating low mood, emotional irritability, and a lack of interest in social relations, followed by memory loss. The cerebrospinal fluid protein - Treponema pallidum particle agglutination test was positive, the toluidine red unheated serum test titre was 1:4, the white blood cell count was 5 × 10^6/L, the cerebrospinal fluid protein level was 0.97 g/L, and the brain CT was abnormal. After admission, the possibility of neurosyphilis was considered and the patient received intravenous penicillin G treatment. The patient's clinical symptom ms improved. This case emphasises that doctors should maintain clinical suspicion of Treponema pallidum infection in adolescent patients with mental abnormalities.

Antimicrobial treatment and resistance in sexually transmitted bacterial infections

Sexually transmitted infections (STIs) have been part of human life since ancient times, and their symptoms affect quality of life, and sequelae are common. Socioeconomic and behavioural trends affect the prevalence of STIs, but the discovery of antimicrobials gave hope for treatment, control of the spread of infection and lower rates of sequelae. This has to some extent been achieved, but increasing antimicrobial resistance and increasing transmission in high-risk sexual networks threaten this progress. For Neisseria gonorrhoeae, the only remaining first-line treatment (with ceftriaxone) is at risk of becoming ineffective, and for Mycoplasma genitalium, for which fewer alternative antimicrobial classes are available, incurable infections have already been reported. For Chlamydia trachomatis, in vitro resistance to first-line tetracyclines and macrolides has never been confirmed despite decades of treatment of this highly prevalent STI. Similarly, Treponema pallidum, the cause of syphilis, has remained susceptible to first-line penicillin.

Persistence of Treponema pallidum IgM antibodies in serum: What is their meaning?

We studied the detection of Treponema pallidum (TP)-IgM antibodies in the serum of 69 patients treated for syphilis. The persistence of TP-IgM antibodies in serum for more than 3 years was the only clue to suspect an active infection and, therefore, to investigate a central nervous system involvement.

Prevalence and Treatment Outcomes of Syphilis among People with Human Immunodeficiency Virus (HIV) Engaging in High-Risk Sexual Behavior: Real World Data from Northern Greece, 2019-2022

In this study, we aimed to assess the prevalence of syphilis among people with human immunodeficiency virus (HIV; PWH) engaging in high-risk sexual behavior, determine the stage of syphilis, and evaluate treatment efficacy. A retrospective single-center cohort study was conducted at the AHEPA University General Hospital of Thessaloniki, focusing on PWH at high risk for sexually transmitted infections (STIs) attending outpatient care from January 2019 to December 2022. Sociodemographic and clinical data were collected, incident syphilis rates were identified, associations with HIV-related characteristics were explored, and the treatment response was assessed. Among 991 participants, 94 PWH were diagnosed with syphilis, representing 9.4% of the cohort. Incident syphilis cases experienced a decrease in the early COVID-19 era compared to 2019, followed by a gradual increase leading up to 2022. The majority of syphilis cases were asymptomatic latent syphilis (71.1%). Men who have sex with men (MSM) and younger individuals exhibited higher rates of co-infection during the study period. No significant association was found between incident syphilis and HIV-related factors. Most syphilis cases (86%) were treated with benzathine penicillin G (BPG). Treatment with BPG and doxycycline showed an increased success rate (96.7% vs. 92.9%), with no statistically significant difference observed between them (p = 0.438). This study highlights the alarming incidence of syphilis among PWH engaging in high-risk sexual behavior, particularly among younger MSM. BPG remains effective, and alternative regimens like doxycycline show promise, especially in settings with penicillin shortages or patient allergies.

Diagnosing Tabes Dorsalis in HIV-Negative Patients: Clinical Features, Neuroimaging, and Laboratory Insights in the Modern Antibiotic Era

Background

Tabes dorsalis is a late manifestation of neurosyphilis, characterized by progressive ataxia, lightning pains, loss of proprioception, and urinary incontinence. The absence of a definitive diagnostic standard and the non-specific clinical manifestations have led to a significant rate of misdiagnoses.

Methods

Hospitalized patients with tabes dorsalis at Peking Union Medical College Hospital between January 2010 and December 2023 were reviewed.

Results

A total of 13 patients were included, with 10 males and 3 females. The median age was 50 years (range, 34-64). The most frequent initial symptoms were limb numbness (30.8%) and lightning pains (30.8%). Eleven patients (84.6%) received misdiagnoses prior to the final diagnosis. The most frequently observed physical sign was positive Romberg's sign (84.6%). Notably, Argyll Robertson pupil was presented in 7 subjects (53.8%). Serological tests revealed positive rapid plasma regain (RPR) and Treponema pallidum particle agglutination (TPPA) for all patients. All CSF samples were TPPA-reactive. Intramedullary hyperintensity on T2-weighted imaging of spinal MRI was found in 5 patients (38.5%). All patients received anti-syphilitic treatment, with effective treatment recorded in five cases.

Conclusion

This study underscores the importance of neurological symptoms and signs in diagnosing tabes dorsalis. Individuals with progressive ataxia and positive Romberg's sign should be closely monitored for potential neurosyphilis. Integrating clinical features, laboratory tests, and neuroimaging could reduce misdiagnosis and expedite the initiation of anti-syphilitic therapy.

Congenital Syphilis: A Re-Emerging but Preventable Infection

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

Could ceftriaxone be a viable alternative to penicillin for the treatment of ocular syphilis?

This study was conducted to compare the effectiveness of ceftriaxone with that of aqueous crystalline penicillin G in treating ocular syphilis. We conducted a retrospective study from 2010 to 2021. Syphilis patients were administered either ceftriaxone (2 g intravenously daily for 14 days) or aqueous crystalline penicillin G [4 million units (MU) intravenously every 4 h for 14 days] as therapeutic interventions. Subsequently, we utilized these two groups to assess the serological results, cerebrospinal fluid analysis, and visual acuity at time intervals spanning 3 to 6 months post-treatment. A total of 205 patients were included, with 34 assigned to the ceftriaxone group and 171 to the penicillin group. The median age of patients was 56 years, with an interquartile range of 49-62 years, and 137 of them (66.8%) were male. Between 3 and 6 months after treatment, 13 patients (38.2%) in the ceftriaxone group and 82 patients (48.0%) in the penicillin group demonstrated effective treatment based on the clinical and laboratory parameters. The crude odds ratio (OR) was 0.672 (95% confidence interval [CI]: 0.316-1.428, P = 0.301), indicating no significant difference in effectiveness between the two groups. Thirty patients (17.5%) in the penicillin group and six patients (17.6%) in the ceftriaxone group did not experience successful outcomes. Notably, no serious adverse effects were reported in both the groups. There was no significant difference in the effectiveness of ceftriaxone and aqueous crystalline penicillin G in treating ocular syphilis. The administration of ceftriaxone without requiring hospitalization presents a convenient and safe alternative treatment option for ocular syphilis.