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

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.

Increasing incidence of syphilis: A case report of non-resolving papulosquamous rash and role of a biopsy in the prevention of delayed diagnosis

Syphilis is a sexually transmitted infection that is undergoing a resurgence in Canada and around the world. If not diagnosed correctly, syphilis can progress to its secondary and tertiary stages, affecting numerous organ systems. We present a case of a 41-year-old female who developed a papulosquamous rash, initially diagnosed as varicella with progression to a widespread and painful rash over 3 months. Based on clinical, histological, and serological findings, she was later diagnosed with secondary syphilis and successfully treated with intramuscular penicillin. This case underscores the importance of accurate diagnosis and treatment of syphilis to prevent systemic complications. We advocate for increased awareness among frontline providers with a proactive approach to diagnosis and management, including thorough history and physical examination, low threshold for performing serological testing, biopsy for lesions that do not resolve as expected with management, and multidisciplinary involvement for complex presentations of syphilis.

Endothelial dysfunction of syphilis: Pathogenesis

Treponema pallidum is the causative factor of syphilis, a sexually transmitted disease (STD) characterized by perivascular infiltration of inflammatory cells, vascular leakage, swelling and proliferation of endothelial cells (ECs). The endothelium lining blood and lymphatic vessels is a key barrier separating body fluids from host tissues and is a major target of T. pallidum. In this review, we focus on how T. pallidum establish intimate interactions with ECs, triggering endothelial dysfunction such as endothelial inflammation, abnormal repairment and damage of ECs. In addition, we summarize that migration and invasion of T. pallidum across vascular ECs may occur through two pathways. These two mechanisms of transendothelial migration are paracellular and cholesterol-dependent, respectively. Herein, clarifying the relationship between T. pallidum and endothelial dysfunction is of great significance to provide novel strategies for diagnosis and prevention of syphilis, and has a great potential prospect of clinical application.

Metagenomic and paleopathological analyses of a historic documented collection explore ancient dental calculus as a diagnostic tool

Dental calculus is a microbial biofilm that contains biomolecules from oral commensals and pathogens, including those potentially related to cause of death (CoD). To assess the utility of calculus as a diagnostically informative substrate, in conjunction with paleopathological analysis, calculus samples from 39 individuals in the Smithsonian Institution's Robert J. Terry Collection with CoDs of either syphilis or tuberculosis were assessed via shotgun metagenomic sequencing for the presence of Treponema pallidum subsp. pallidum and Mycobacterium tuberculosis complex (MTBC) DNA. Paleopathological analysis revealed that frequencies of skeletal lesions associated with these diseases were partially inconsistent with diagnostic criteria. Although recovery of T. p. pallidum DNA from individuals with a syphilis CoD was elusive, MTBC DNA was identified in at least one individual with a tuberculosis CoD. The authenticity of MTBC DNA was confirmed using targeted quantitative PCR assays, MTBC genome enrichment, and in silico bioinformatic analyses; however, the lineage of the MTBC strain present could not be determined. Overall, our study highlights the utility of dental calculus for molecular detection of tuberculosis in the archaeological record and underscores the effect of museum preparation techniques and extensive handling on pathogen DNA preservation in skeletal collections.

Performance Assessment of Treponemal and Nontreponemal Tests for the Diagnosis of Acquired Syphilis

There are a variety of nontreponemal test (NTT) and treponemal test (TT) kits for the serologic diagnosis of syphilis. Because of the complexity of the infection (multiple clinical stages) and the different antigens used in these kits, a systematic evaluation of the accuracy of the currently available commercial tests is warranted. Our objective was to evaluate the performance of commercially available tests for the diagnosis of syphilis infection. In this study, we analyzed one NTT (Venereal Disease Research Laboratory [VDRL] test, Wiener Laboratories, Rosario, Argentina) and two TTs (fluorescent treponemal antibody absorption [FTA-ABS] test, Euroimmun, Lübeck, Germany, and syphilis recombinant ELISA v. 4.0 test [ELISA], Wiener Laboratories, Rosario, Argentina) using a panel of 187 samples, including serum samples from 31 individuals with primary syphilis, 77 with secondary syphilis, and 79 with latent syphilis. An additional 192 samples from uninfected individuals and 323 serum samples from individuals with other diseases were included. The sensitivities of the VDRL, ELISA, and FTA-ABS tests were 97.9%, 100%, and 96.3%, respectively. The VDRL and ELISA tests showed a specificity of 100%, and the FTA-ABS test showed a specificity of 99.5%. Accuracy was 98.9% for the VDRL test, 100% for the ELISA, and 97.9% for the FTA-ABS test. For primary, secondary, and latent syphilis, the ELISA achieved a diagnostic performance of 100%, whereas the sensitivity for the VDRL and FTA-ABS tests ranged from 96.8% to 98.7% and 93.7% to 98.7%, respectively. No difference was observed when the tests were used as traditional or reverse algorithms. In general, all three tests are able to discriminate positive and negative samples for syphilis, regardless of the diagnostic algorithm.

Ischemic stroke as an initial presentation of neurosyphilis in a newly diagnosed HIV patient: A case report and literature review

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.

Gaps in the prevention of mother-to-child transmission of syphilis: a review of reported cases, South Africa, January 2020-June 2022

INTRODUCTION

Congenital syphilis (CS) is preventable through timely antenatal care (ANC), syphilis screening and treatment among pregnant women. Robust CS surveillance can identify gaps in this prevention cascade. We reviewed CS cases reported to the South African notifiable medical conditions surveillance system (NMCSS) from January 2020 to June 2022.

METHODS

CS cases are reported using a case notification form (CNF) containing limited infant demographic and clinical characteristics. During January 2020-June 2022, healthcare workers supplemented CNFs with a case investigation form (CIF) containing maternal and infant testing and treatment information. We describe CS cases with/without a matching CIF and gaps in the CS prevention cascade among those with clinical information.

FINDINGS

During January 2020-June 2022, 938 CS cases were reported to the NMCSS with a median age of 1 day (interquartile range: 0-5). Nine percent were diagnosed based on clinical signs and symptoms only. During January 2020-June 2022, 667 CIFs were reported with 51% (343) successfully matched to a CNF. Only 57% of mothers of infants with a matching CIF had an ANC booking visit (entry into ANC). Overall, 87% of mothers were tested for syphilis increasing to 98% among mothers with an ANC booking visit. Median time between first syphilis test and delivery was 16 days overall increasing to 82 days among mothers with an ANC booking visit.

DISCUSSION

Only 37% of CS cases had accompanying clinical information to support evaluation of the prevention cascade. Mothers with an ANC booking visit had increased syphilis screening and time before delivery to allow for adequate treatment.

Ocular syphilis masquerading as CMV retinitis in a transplanted patient

BACKGROUND

Syphilis has historically been referred to as "the great imitator", for the extent of disease manifestations secondary to infection. Ocular manifestations include a wide range of intra-ocular inflammation.

METHODS

In this study, we report the case of a 52 years-old male patient with syphilitic hemorrhagic necrotizing retinitis.

RESULTS

The patient presented to the emergency room for rapid and progressive vision loss and ocular redness lasting three weeks and was under immunosuppressive treatment. The diagnosis was syphilitic hemorrhagic necrotizing retinitis mimicking the typical clinical picture of retinitis caused by Cytomegalovirus infection in immunocompromised patients.

CONCLUSIONS

The presented case highlights the need to consider ocular syphilis as a great masquerader even in the presence of atypical presentations such as hemorrhagic retinitis. Syphilis should be tested for treponemal and non-treponemal tests, and it should be ruled out as an etiological agent in every case of new-onset intra-ocular inflammation.

Evaluating the diagnostic accuracy of TpN17 and TmpA recombinant proteins in syphilis detection: a phase II study

Syphilis is a sexually transmitted infection (STI) caused by the spiral bacterium Treponema pallidum. Diagnosis is based on epidemiology, clinical and serology, but serodiagnosis is challenging because distinct clinical forms of the infection may influence serological performance. Several recombinant Treponema pallidum-proteins have already been tested for syphilis diagnosis and they are critical to achieve high accuracy in serological testing. A total of 647 samples were included in the study: 180 T. pallidum-positive samples, 191 T. pallidum-negative samples and 276 sera from individuals infected with unrelated diseases. The diagnostic potential was validated by analysis of ROC curves. For the indirect ELISA, TpN17 (100%) and TmpA (99%) showed excellent AUC values. Sensitivity values were 97.2% for TpN17 and 90.6% for TmpA, while specificity was 100% for both molecules. According to the clinical phase, TmpA ranged from 84% to 97%, with the highest value for secondary syphilis. TpN17 was 100% sensitive for the primary and secondary stages and 93.2% for recent latent syphilis. All clinical phases achieved 100% specificity. Accuracy values showed that TmpA (> 95%) and TpN17 (> 98%) presented high diagnostic accuracy for all clinical stages of syphilis. Cross-reactivity was only observed in one sample positive for Chagas disease (1.5%), when TpN17 was evaluated. On the other hand, TmpA showed reactivity for two samples positive for Chagas disease (3.1%), one sample positive for HBV (1.25%), two samples positive for HIV (9.5%) and one sample positive for HTLV (1.6%). The TmpA antigen's performance was evaluated in multiple studies for syphilis diagnosis, corroborating our findings. However, TpN17 sensitivity values have ranged in other studies. According to clinical stages of the infection, our findings obtained close performance values.

Cerebral syphilitic gumma misdiagnosed as brain abscess: A case report

BACKGROUND

Cerebral syphilitic gumma is a relatively rare clinical disease. Its clinical manifestations are non-specific, and the imaging manifestations are similar to other intracranial occupying lesions, often misdiagnosed as tumors or abscesses. There are few reports on this disease in the relevant literature. To our knowledge, we have reported the first case of cerebral syphilitic gumma misdiagnosed as a brain abscess.We report this case and provide useful information for clinical doctors on neurosyphilis diseases.

CASE SUMMARY

We report the case to explore the diagnostic essentials of cerebral syphilitic gumma and attempt to mitigate the rates of misdiagnosis and missed diagnosis by equipping physicians with knowledge of neurosyphilis characteristics. The clinical diagnosis and treatment of a patient with cerebral syphilitic gumma were reported. Clinical manifestations, classifications, and diagnostic points were retrospectively analyzed. The patient was admitted to the hospital with fever and limb weakness. Brain magnetic resonance imaging showed multiple space-occupying lesions and a positive serum Treponema pallidum gelatin agglutination test. The patient was misdiagnosed as having a brain abscess and underwent a craniotomy. A postoperative pathological diagnosis of syphilis gumma was made. The patient improved and was discharged after penicillin anti-syphilis treatment. Follow-up recovery was satisfactory.

CONCLUSION

Cerebral syphilitic gumma is rare in clinical practice, and it is often misdiagnosed and missed. Clinical diagnosis should be considered in combination with multiple examinations.

Updating an Overview of Teratology

In this chapter, the authors aim to update an overview of the principles of teratology, beginning with the definition of teratology, the critical point at which this process occurs, and some of the most common etiological agents that improve our understanding of teratology.Modern teratology has greatly improved in recent years with advances in new methods in molecular biology, toxicology, animal laboratory science, and genetics, increasing our knowledge of ambient influences. Nevertheless, there is a lot to do to reduce the influence of hazardous intervening agents, whether they target our genetics or not, that can negatively affect pregnancy and induce congenital development disorders, including morphological, biochemical, or behavioral defects.Certain agents might indeed be related to certain defects, but we have not been able to identify the cause of most congenital defects, which highlights the importance of finding and testing out new genetics techniques and conducting laboratory animal science to unravel the etiology and pathogenicity of each congenital defect.

Dendritic Cell-Derived Exosomes Stimulated by Treponema pallidum Induce Endothelial Cell Inflammatory Response through the TLR4/MyD88/NF-κB Signaling Pathway

Exosomes have been implicated in vascular damage in recent research. The influence of dendritic cell-derived exosomes generated by Treponema pallidum (T. pallidum) on the inflammatory process of vascular cells was examined in this study. Human umbilical vein endothelial cells (HUVECs) were cocultured with exosomes isolated from dendritic cells induced by T. pallidum. Western blot and reverse transcription-quantitative real-time polymerase chain reaction were used to assess toll-like receptor 4 (TLR4) expression and the quantity of proinflammatory cytokines. The findings showed that the expression of TLR4 was considerably upregulated, and TLR4 knockdown dramatically reduced interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) production in exosome-treated HUVECs. Furthermore, TLR4 silencing reduced myeloid differentiation primary response protein 88 (MyD88) and nuclear factor kappa light chain enhancer of activated B cells (NF-κB) levels in exosome-treated HUVECs. Additionally, suppression of the activity of NF-κB with BAY11-7082, an NF-κB inhibitor, also reduced the exosome-treated inflammatory response. Our results suggested that dendritic cell-derived exosomes stimulated by T. pallidum induced endothelial cell inflammation, and the TLR4/MyD88/NF-κB signal axis was activated, significantly increasing IL-1β, IL-6, and TNF-α expression. This may have a significant role in the vascular inflammatory response in syphilis, which would contribute to the understanding of the pathogenesis of syphilis and the host immunological response to T. pallidum.

Oral Secondary Syphilis in an HIV-Positive Transgender Patient: A Case Report and Review of the Literature

BACKGROUND

Syphilis is a worldwide sexually transmitted infection caused by Treponema pallidum. In most cases, the oral manifestations of syphilis infection are associated with cutaneous involvement. However, the present case report is noteworthy since the oral lesions are the sole clinical sign in an HIV-positive transgender patient.

CASE PRESENTATIONS

We reported an uncommon case of secondary syphilis in a 37-year-old seropositive transgender male, whose diagnostic suspect was based only on oral mucosal lesions. The patient was referred to the Oral Medicine Unit for the presence of multiple undiagnosed painful oral lesions. The intraoral examination revealed the presence of white and red plaques on the right and the left buccal mucosa and several painful lesions localized on the upper and lower labial mucosa. No cutaneous lesions were observed. Considering the sexual history of the patient and clinical findings, secondary syphilis infection was suspected. The serologic analysis was conducted, and the diagnosis of syphilis was confirmed. Moreover, to exclude the presence of oral epithelial dysplasia or malignant disease, an incisional biopsy was performed.

DISCUSSION

Compared to the literature data, oral lesions as lone signs of secondary syphilis infection are uncommon, especially in HIV-positive patients. Syphilis and HIV coinfection create a concerning situation as they interact synergistically, leading to an increased risk of transmission and faster disease progression.

CONCLUSIONS

This case report emphasizes the importance of considering syphilis as a diagnostic possibility, even when oral lesions are the only clinical manifestations, especially in HIV-positive patients. Comprehensive evaluation, including a detailed sexual history and careful oral examination, is essential for accurate diagnosis and appropriate management in such cases.

Tertiary Cardiovascular Syphilis Presenting as Aortic Regurgitation, Aortitis, Thrombus, and Coronary Artery Occlusion, Requiring Percutaneous Coronary Intervention

BACKGROUND Heart failure is caused by coronary artery disease, valvular disease, and arrhythmias and is highly treatable with recent technology. However, the incidence of syphilis is increasing worldwide. This case report describes tertiary cardiovascular syphilis, accompanied by aortic regurgitation, syphilitic aortitis complicated by thrombus of the ascending aorta, and coronary artery occlusion, requiring percutaneous coronary artery intervention. CASE REPORT A 51-year-old Japanese man with no significant medical history was admitted to the hospital for worsening shortness of breath on exertion. On physical examination, there was no edema in either lower leg. Chest X-rays showed an enlarged heart and pulmonary congestion, and echocardiography showed a left ventricular ejection fraction of 18%, with full circumferential wall motion impairment. Heart failure was diagnosed, and the patient was found to have severe coronary artery disease and aortic regurgitation. He underwent percutaneous coronary intervention (PCI) for his coronary artery occlusion and was treated with medications for heart failure. Two months later, his condition improved, and PCI was performed for the revascularization of the remaining coronary artery. After PCI was completed, the patient was evaluated for vasculitis. The aortic wall lesion was likely a result of non-active syphilitic aortitis, and the results of serological tests of syphilis were positive. Therefore, we concluded that the diagnosis was cardiovascular syphilis. CONCLUSIONS This case report has highlighted the need for clinicians to be aware of the cardiovascular findings in syphilis, including syphilitic aortitis, particularly at this time, when the global incidence of syphilis is increasing.

[Changes in vessel wall magnetic resonance contrast-enhancement in a patient with multiple cerebral infarction due to meningovascular neurosyphilis]

A 46-year-old man with a history of generalized skin rash following physical contact with possible syphilis infection developed right upper and lower extremity ataxia and right lower extremity paresis. Brain magnetic resonance (MR) imaging revealed multiple areas of acute cerebral infarction mainly within the territories of the right superior cerebellar artery (SCA) and left anterior cerebral artery. The patient was diagnosed with meningovascular neurosyphilis based on positive results on syphilis testing of the serum and cerebrospinal fluid. MR angiography revealed decreased signal intensity in the proximal segment of the right SCA, and gadolinium-enhanced three-dimensional T1-weighted MR images showed an enhancement of the vessel wall in this segment of the artery. Signal intensity in the right SCA showed partial improvement following the completion of intravenous penicillin treatment, and contrast enhancement of the vessel wall disappeared simultaneously with clinical improvement. Alterations in cerebral vessel walls on contrast-enhanced MR imaging in cases of meningovascular neurosyphilis may reflect vascular inflammatory activity.

Demystifying Ocular Syphilis - A Major Review

Syphilis, caused by the spirochaete, Treponema pallidum, continues to be a public health challenge globally with its rates steadily increasing in the past few years. The disease is transmitted through small breaks in the skin during sexual contact, or via congenital transmission in utero, either across the placenta or by contact with an active genital lesion during delivery. Estimated 5.7-6 million new cases are detected every year worldwide in the 15-49 years age group. An increased incidence has been reported in most populations with particular clusters in special groups like men who have sex with men, female sex workers, and their male clients. Ocular syphilis has a varied presentation and is considered a great mimicker in all cases of uveitis. The laboratory diagnosis of syphilis is predominantly based on serological tests including TPHA and VDRL. Parenteral penicillin is the cornerstone of treatment for all stages of ocular syphilis.

Psychosis Caused by a Somatic Condition: How to Make the Diagnosis? A Systematic Literature Review

BACKGROUND

First episode of psychosis (FEP) is a clinical condition that usually occurs during adolescence or early adulthood and is often a sign of a future psychiatric disease. However, these symptoms are not specific, and psychosis can be caused by a physical disease in at least 5% of cases. Timely detection of these diseases, the first signs of which may appear in childhood, is of particular importance, as a curable treatment exists in most cases. However, there is no consensus in academic societies to offer recommendations for a comprehensive medical assessment to eliminate somatic causes.

METHODS

We conducted a systematic literature search using a two-fold research strategy to: (1) identify physical diseases that can be differentially diagnosed for psychosis; and (2) determine the paraclinical exams allowing us to exclude these pathologies.

RESULTS

We identified 85 articles describing the autoimmune, metabolic, neurologic, infectious, and genetic differential diagnoses of psychosis. Clinical presentations are described, and a complete list of laboratory and imaging features required to identify and confirm these diseases is provided.

CONCLUSION

This systematic review shows that most differential diagnoses of psychosis should be considered in the case of a FEP and could be identified by providing a systematic checkup with a laboratory test that includes ammonemia, antinuclear and anti-NMDA antibodies, and HIV testing; brain magnetic resonance imaging and lumbar puncture should be considered according to the clinical presentation. Genetic research could be of interest to patients presenting with physical or developmental symptoms associated with psychiatric manifestations.

A case report of interstitial keratitis and secondary glaucoma after cataract surgery that may be related to late congenital syphilis

BACKGROUND

The destruction of blood eye barrier and the administration of corticosteroid eyedrops after phacoemulsification surgery can lead to the replication of the local potential pathogens. With the rapid increase and popularization of cataract surgery, all kinds of rare postoperative complications have appeared. Here, we report a case of interstitial keratitis and secondary glaucoma after cataract surgery, which may be related to late congenital syphilis, which eventually led to blindness in the right eye. We hope that the timely report of this case will enable doctors to pay more attention to the possibility of potential pathogen replication after cataract surgery, and enable more patients to receive reasonable and effective treatment.

CASE PRESENTATION

A 63-year-old female was referred to our clinic for investigation with a 1-week history of moderate pain in the right eye and ipsilateral headache in January 2020. She had cataract surgery on her right eye two years ago and on her left eye one year ago. The intraocular pressure (IOP) in the right eye was 43.2 mmHg and that in the left eye was 28.5 mmHg. Her right eye underwent medication, trabeculectomy and finally was subjected to ciliary body photocoagulation to control the IOP. The IOP of the left eye was well controlled by regular use of eye drops. In addition to the elevated IOP, the inflammation of the anterior segment and corneal stroma was found. Before cataract surgery, bilateral corneal opacities was revealed, but after cataract surgery, interstitial keratitis in both eyes was gradually aggravated, during the follow-up period from 2019 to 2021. She informed us that she had suffered from decreased vision in both eyes and was diagnosed with bilateral keratitis and congenital syphilis at the age of 20. In 2018, the serologic test for syphilis was positive in blood (Chemiluminescence analysis (CLIA): + ; Toluidine red unheated serum test (TRUST): + , titer was 1:1). However, four tests for TRUST were negative in 2019 and 2020, so she was not treated for syphilis.

CONCLUSION

This case of glaucoma and interstitial keratitis might be secondary to ocular inflammation caused by late congenital syphilis. The ocular inflammation and the activation of syphilis may be related to cataract surgery.

Syphilis vaccine: challenges, controversies and opportunities

Syphilis is a sexually or vertically (mother to fetus) transmitted disease caused by the infection of Treponema pallidum subspecie pallidum (TPA). The incidence of syphilis has increased over the past years despite the fact that this bacterium is an obligate human pathogen, the infection route is well known, and the disease can be successfully treated with penicillin. As complementary measures to preventive campaigns and early treatment of infected individuals, development of a syphilis vaccine may be crucial for controlling disease spread and/or severity, particularly in countries where the effectiveness of the aforementioned measures is limited. In the last century, several vaccine prototypes have been tested in preclinical studies, mainly in rabbits. While none of them provided protection against infection, some prototypes prevented bacteria from disseminating to distal organs, attenuated lesion development, and accelerated their healing. In spite of these promising results, there is still some controversy regarding the identification of vaccine candidates and the characteristics of a syphilis-protective immune response. In this review, we describe what is known about TPA immune response, and the main mechanisms used by this pathogen to evade it. Moreover, we emphasize the importance of integrating this knowledge, in conjunction with the characterization of outer membrane proteins (OMPs), to expedite the development of a syphilis vaccine that can protect against TPA infection.

Secondary Syphilis Presentation and Urticarial Eruption After Moderna COVID-19 Vaccination

The diversity of the cutaneous manifestations of syphilis and the ability of the spirochete to evade diagnosis have been well documented by medical literature. However, what triggers the onset of secondary syphilis is not yet clear because of difficulties studying the bacterium. Our case describes the onset of a heterogeneous rash (or coexisting rashes) that presented the day after vaccination with the Moderna mRNA-1273 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. The potential etiologies of the patient's rash: A vaccine reaction, reactivation of chronic spontaneous urticaria, or a physical sign of syphilis itself are then reviewed. The potential for the Moderna coronavirus disease 2019 (COVID-19) vaccine to be the catalyst of this patient's cutaneous manifestations of his immune system responses is also hypothesized.

Diagnostic utility of fine-needle aspiration cytology in syphilitic lymphadenitis: A case report

Syphilis is a sexually transmitted infection that causes serious health problems without treatment. Detection of syphilis is necessary to stop the spread of the infection. Cytological screeners and pathologists may experience fine-needle aspiration cytology (FNAC) for syphilitic lymphadenitis; however, its characteristic cytological features are rarely reported. We present FNAC cytological features of syphilitic lymphadenitis in a case of a 21-year-old man. He presented with a sore throat and painful neck lymphadenopathy. His swollen and painful neck persisted even with antibiotic treatment. Necrotizing lymphadenitis and lymphoma were clinically suspected. FNAC was taken from the swollen lymph node. Cytologic findings of the specimen showed various inflammatory cells with small-sized vessels arranged in a branching/arborizing fashion. The vessels were surrounded by inflammatory cells, including plasma cells, neutrophils, and macrophages. Perivascular plasma cell cuffing was focally seen along with inconspicuous granulomas. Neutrophils appeared to involve the vascular wall. The cytological findings suggested syphilitic lymphadenitis, and clinical findings and serological tests confirmed primary syphilis with concomitant human immunodeficiency virus infection. Branching/arborizing vessels associated with many plasma cells, vascular involvement of neutrophils, and granulomas may suggest syphilitic infection if the specimen is obtained via FNAC. (189 words).

Sensitivity and Specificity of two Investigational Point of care Tests for Syphilis and HIV (PoSH Study) for the diagnosis and treatment of infectious syphilis in Canada: a cross sectional study

OBJECTIVES

Single visit testing and treatment for syphilis can reduce follow-up visits. The objectives of this study were to evaluate the performance and treatment outcomes of two dual syphilis/HIV point-of care tests (POCT).

METHODS

Participants aged 16 years and older were offered concurrent syphilis/HIV POCT from fingerstick blood using two extremely rapid (<5 minutes) devices [MedMira Multiplo Rapid TP/HIV Test and INSTI Multiplex HIV1/2 Syphilis Ab test]. Those with positive POCT results were offered same day syphilis treatment and linkage to HIV care. Nurses performed testing at two emergency departments, First Nations community, correctional facility and STI clinic. POCT results were compared to standard serological testing. Sensitivity and specificity were calculated.

RESULTS

Between August 2020 and February 2022, 1526 visits were completed. Both POCT accurately identified participants with HIV (sensitivity=100·0% [24/24], 95% CI=86·2-100·0%, specificity=99·6% [1319/1324], 95% CI=99·1-99·8%), linking 24 HIV cases to care. Both tests were most sensitive with an RPR > 8 dilutions (Multiplo: sensitivity=98·3% [231/235], 95% CI=95·7-99·3%, specificity=99·5% [871/875], 95% CI=98·8-99·8%, INSTI Multiplex: sensitivity=97·9% [230/235], 95% CI=95·1-99·1%, specificity=99·8% [873/875], 95% CI=99·2-99·9%) and least sensitive with non-reactive RPR (Multiplo: sensitivity=54·1% [59/109], 95% CI=44·8-63·2%, specificity=99·5% [871/875], 95% CI=98·8-99·8%, INSTI Multiplex: sensitivity=28·4% [31/109], 95% CI=20·8-37·5%, specificity=99·8% [873/875], 95% CI=99·2-99·9%). 87·0% with a positive POCT were treated the same day.

CONCLUSIONS

Two extremely rapid (<5 minutes) dual syphilis/HIV POCT showed excellent sensitivity and specificity for the diagnosis of active syphilis (RPR > 1:8 dilutions) and HIV and confirmed the ability to offer single visit testing and treatment for syphilis and linkage to HIV care in diverse clinical settings.

Cerebral infarction as initial manifestation of meningovascular neurosyphilis in an immunocompetent patient - A case report with long term follow-up

To present a 29-year-old immunocompetent patient with neurosyphilitic changes characterized by multiple acute ischemic brain strokes along with significant narrowing of several large intracranial arteries. Ceftriaxone treatment for 14 days followed by benzathine benzylpenicillin weekly for additional 3 weeks, showed improvement in meningovascular changes.

Syphilis and dentists: The data about knowledge and awareness of clinicians in Turkey

Background: Syphilis may give pathognomonic signs in oral cavity. In order to emerge an awareness about dentists' role in syphilis management, it was aimed to obtain the data from them about their knowledge.Methods: This survey-based, cross-sectional study was conducted with 709 dentists practicing in Turkey. Participants answered 16 statements about syphilis "Transmission Routes," "Extra-oral Clinical Features," "Oral Findings," and "Diagnosis & Treatment" with options yes/no/I do not know. Moreover, they responded to two 5-point Likert type questions about their comfort level and frequency of taking sexual anamnesis. The statistical significance was set at p ≤ .05.Results: The mean age (years) and female/male ratio of the participants were 35.7 ± 10.2 and 449/260, respectively. The average of the correct answers in the survey was 10.38 ± 3.3. "Transmission Routes" had the highest ratio (50.6%) in terms of all questions in a single category that were answered correctly among groups. Dentists practicing at faculties had the highest number of correct answers (p = .003). The total number of correct answers and the number of correct answers in each category were positively related to both the level of comfort and the frequency of taking patient's sexual anamnesis (Oral Findings p = .002; others p ≤ .001).Conclusions: The results of this study indicate that dentists practicing in Turkey lack a significant level of knowledge about syphilis. This highlights the need for further training and education programs for dentists in Turkey.

Syphilis, the Great Imitator-Clinical and Dermoscopic Features of a Rare Presentation of Secondary Syphilis

Syphilis is characterized by a wide range of variable clinical symptoms; therefore, it is often referred to as "The Great Imitator". Here, we report the case of a 69-year-old hepatitis-C-positive MSM patient, who was admitted to our clinic due to a solitary firm painless erythematous maculopapular lesion with a central crater-like crust on the upper right thigh that occurred two months prior. The dermoscopy showed an erythematous, copper-colored, oval lesion with diffuse monomorphic dotted and glomerular vessels, central crust, and circular scaling (Biett's sign). The histological findings ruled out neoplasia and described a plasma cell infiltrate and endothelial swelling. Finally, the combination of the dermoscopic image, histological findings and the additionally acquired knowledge about the sexual history of the patient at the second visit led to the diagnosis, which was then confirmed with serological tests. Dermoscopy may become a supportive tool to facilitate the recognition of secondary syphilis; however, the reporting of these atypical cases is crucial to highlight the many faces of the disease so that clinicians consider syphilis as part of the differential diagnosis of non-specific lesions.

Syphilis in Dermatology: Recognition and Management

The incidence of syphilis has been increasing in the USA since 2000. Notably, the coronavirus disease 2019 pandemic negatively impacted the public health efforts to contain the spread of sexually transmitted diseases including syphilis and congenital syphilis. Clinical manifestations of syphilis are predominantly mucocutaneous lesions, thus dermatologists are primed to recognize the myriad presentations of this disease. Primary syphilis is classically characterized by a painless transient chancre most often located in the genital area. Secondary syphilis typically manifests clinically as systemic symptoms in addition to a mucocutaneous eruption of which a variety of forms exist. Although less common in the era of effective penicillin treatment, late clinical manifestations of syphilis are described as well. In addition to recognition of syphilis on physical examination, several diagnostic tools may be used to confirm infection. Treponema pallidum spirochetes may be detected directly using histopathologic staining, darkfield microscopy, direct fluorescent antibody, and polymerase chain reaction assays. A table detailing the histopathologic features of syphilis is included in this article. Serologic testing, non-treponemal and treponemal tests, is the preferred method for screening and diagnosing syphilis infections. Two serologic testing algorithms exist to aid clinicians in diagnosing positive syphilis infection. Determining the correct stage of syphilis infection combines results of serologic tests, patient history, and physical examination findings. Using the current Centers for Disease Control and Prevention case definitions and treatment guidelines, a management algorithm is proposed here. Penicillin remains the pharmacological treatment of choice although specific clinical situations allow for alternative therapies. Syphilis is a reportable disease in every state and should be reported by stage according to individual state requirements. Screening recommendations are largely based upon risks encountered through sexual exposures. Likewise, sexual partner management includes evaluating and treating persons exposed to someone diagnosed with an infective stage of syphilis. Close clinical follow-up and repeat testing are recommended to ensure appropriate response to treatment. This guide will discuss the current epidemiology of syphilis and focus on practice aspects of diagnosis and management, including public health reporting.

Primary syphilis presenting as a painful unilateral inguinal lymphadenopathy, without cutaneous manifestations, in a 71-year-old Japanese man: A case report

Syphilitic infection is usually observed in young patients, and the first stage of the disease (primary syphilis) is characterized by painless cutaneous and lymph node lesions. Herein, we describe a 71-year-old Japanese man with primary syphilis that presented as unilateral inguinal lymphadenopathy without skin lesions. Originally, an incarcerated hernia was clinically suspected. The lymph node pathologically showed suppurative lymphadenitis with vague granulomas; immunohistochemistry was highly suggestive of a syphilitic infection. Primary syphilis was confirmed by positive serological tests. Syphilitic infection should be included in the clinicopathological differential diagnoses for patients with inguinal lymphadenopathy, even in elderly patients without skin lesions.

Prevalence of Syphilis Infections Among Volunteer Blood Donors in Jinan Blood Center, China: A 15-Year Retrospective Study

BACKGROUND

Syphilis infections among volunteer blood donors increased rapidly in recent years. It is important to analyze the demographics of seropositive donor groups and help to recruit donors from low-risk population.

OBJECTIVE

The aim of this study was to analyze the syphilis prevalence among volunteer blood donors in Jinan Blood Center and give direction to blood recruitment.

METHODS AND MATERIALS

A cross-sectional study was conducted among blood donors in Jinan, China. Socio-demographic data and blood donation testing data from January 2007 to December 2021 were extracted from the database of blood management software of Jinan Blood Center for analysis. All blood samples were screened by ELISA, and those anti-TP-positive samples were counted and analyzed by sex, age, educational background, occupation and blood donation times. Logistic regression was used to explore risk factors associated with syphilis infection.

RESULTS

Totally 700,757 blood samples were collected in the study during 2007 to 2021, 2290 cases were detected anti-TP positive with a positive rate of 0.33%. Female, 35-44 years old, with a lower education degree, farmers and first-time donors were the high-risk subgroups.

CONCLUSION

Consultation and identification of high-risk population groups should be improved. Measures should be taken to make the donor recruitment more professional and detailed.

Clinical and laboratory features in patients with positive syphilis serology presenting with acute ischemic stroke or transient ischemic attack: a prospective cohort study

Background

Neurosyphilis (NS) can lead to acute ischemic stroke (AIS) or transient ischemic attack (TIA). We compared the clinical characteristics and laboratory features among AIS and TIA patients who were syphilis-seronegative (control group) or had latent syphilis (LS) or NS to evaluate their stroke outcome.

Methods

This prospective cohort study was conducted on patients who had recently suffered AIS or TIA. After serological syphilis screening, clinical and laboratory data were collected, and brain imaging and spinal tap (serologically syphilis-positive patients only) were performed. Stroke outcome was re-evaluated approximately three months later.

Results

The 344 enrolled patients were divided into three groups: control group (83.7%), LS (13.1%), and NS (3.2%). A multivariate analysis revealed: 1) age of ≥ 70 years, generalized brain atrophy via imaging, and alopecia (adjusted odds ratio [AOR] = 2.635, 2.415, and 13.264, respectively) were significantly associated with LS vs controls; 2) age of ≥ 70 years (AOR = 14.633) was significantly associated with NS vs controls; and 3) the proportion of patients with dysarthria was significantly lower (AOR = 0.154) in the NS group than in the LS group. Regarding the NS patient cerebrospinal fluid (CSF) profile, only 2/11 cases had positive CSF-Venereal Disease Research Laboratory (VDRL) test results; the other nine cases were diagnosed from elevated white blood cell counts or protein levels combined with positive CSF fluorescent treponemal antibody absorption (FTA-ABS) test results. Regarding disability, the initial modified Rankin scale (mRS) score was lower in the control group than in the NS group (p = 0.022). At 3 months post-stroke, the mRS score had significantly decreased in the control (p < 0.001) and LS (p = 0.001) groups. Regarding activities of daily living, the 3-month Barthel Index (BI) score was significantly higher in control patients than in LS (p = 0.030) or NS (p = 0.002) patients. Additionally, the 3-month BI score was significantly increased in the control (p < 0.001) and LS (p = 0.001) groups.

Conclusions

Because syphilis was detected in many AIS and TIA patients, especially those aged ≥ 70 years, routine serological syphilis screening may be warranted in this population. Patients with syphilitic infection had worse stroke outcomes compared with NS patients.

Clinical Protocols and Treatment Guidelines for the Management of Maternal and Congenital Syphilis in Brazil and Portugal: Analysis and Comparisons: A Narrative Review

(1) Background: Maternal syphilis (MS) and congenital syphilis (CS) are serious public health problems worldwide due to their high morbidity and mortality rates. (2) Objective: Evaluating the applicability of Clinical Protocols and Treatment Guidelines on case incidence trends in Brazil and Portugal. (3) Methods: The review was done through bibliographic research in two public databases and government websites from both countries, published between 2007 and 2022. All guidelines that contained CS and MS were selected. (4) Results and discussion: After evaluation, we found that Brazil and Portugal have adequate protocols for screening and treating congenital and maternal syphilis. (5) Conclusion: The results suggest that CS and MS incidence are notably higher in Brazil than in Portugal due to economic, cultural, and social disparities and the differences in territory size. Therefore, these demographic and socioeconomic factors could strongly influence efforts to fight against syphilis and thus control the infection.

A Rare Presentation of Undiagnosed Systemic Syphilis: A Case Report and Review of Literature

Within the specialties of infectious diseases and dermatology, few rashes involve the palms and soles. The syphilitic rash has a pathognomonic association with these body surfaces and signals physicians to investigate this disease. However, the distinct presentations and symptoms associated with syphilis and the various stages of the disease make it diagnostically challenging. We herein report a rather intricate and unusual case of a patient who presented with a new-onset headache and blurred vision and a two-month history of diffuse pruritic maculopapular rash sparing the palms and soles. Several physicians had not established a diagnosis in the outpatient setting. Inpatient workup eventually revealed that the patient was suffering from secondary syphilis with neurological and ocular involvement. Management included a prolonged course of intravenous penicillin G leading to a complete recovery. We share images of the skin findings and the details of the intricate workup and hospital course, as well as a review of the literature.

The Mydriatic Red Eye as the Initial Presentation of Syphilis

BACKGROUND

Syphilis is a sexually transmitted infection that has been increasing in prevalence since the early 2000s. Ocular involvement occurs in a minority of patients and must be in the differential diagnosis for patients who present with red eye and uveitis.

CASE REPORT

A 29-year-old woman presented to the emergency department with a painful, mydriatic red eye. Review of systems revealed a rash as well as a recent genital lesion and, on further questioning, she admitted to a history of intravenous drug use and high-risk sexual activity. Ophthalmology was consulted and the patient was diagnosed with bilateral uveitis. Serologic testing was positive for syphilis, and she was admitted and treated with intravenous penicillin, with resolution of her uveitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Red eye is a common ocular symptom in patients presenting to the emergency department. The differential diagnosis of the red eye is broad and can range from benign etiologies, such as conjunctivitis, to life- and sight-threatening conditions, such as endogenous endophthalmitis. Systemic diseases such as syphilis may present with primarily ocular symptoms, and ocular syphilis must be identified and managed appropriately to prevent devastating sequelae.

Identifying treponemal disease in early East Asia

Objectives

Historic records suggest that a virulent form of treponematosis, sexually transmitted syphilis was introduced to Asia from Europe by the da Gama crew, who landed in India in 1498. Our objective is to assess the gross pathology of human skeletal remains from the Tang dynasty of China to test the presence of treponemal infection in East Asia before 1498. We interpret this paleopathological evidence in the context of site ecology and sociocultural changes during the Tang dynasty.

Materials and methods

We examined the gross pathology of 1598 human skeletons from Xingfulindai (AD 618 to AD 1279) archeological site located on the Central Plain of China. Using the modified diagnostic criteria defined by Hackett's classical work, we classify the pathology as consistent, strongly suggestive, or pathognomonic for treponemal infection.

Results

Twelve adult individuals from Xingfulindai had bone lesions suggestive of systemic pathology. Two of these individuals displayed a combination of lesion patterns pathognomonic of treponemal disease and one had lesions consistent with treponematosis. The radiocarbon dates for the bone samples from these skeletons place them before AD 1200.

Conclusions

The location of Xingfulindai in a continental climatic zone is not typical for yaws and bejel ecology, because these strains occur in the tropics, or in hot, dry environments, respectively. The urban setting, where there is documented evidence for increased interaction between multiple ethnic groups and a developed institution of courtesans during the Tang dynasty, favors sexually transmitted syphilis as the more likely diagnosis. This study supports an earlier spread of syphilis to China than 1498.

Changes in mortality in a non-industrialized Portugal: Coimbra Municipal Cemetery records (1861-1914) and identified osteological collections

OBJECTIVE

To investigate if there were changes in mortality knowing that industrialization was a slow and late process in Portugal.

MATERIALS

The biographic information (1) of the individuals buried at the Coimbra Municipal Cemetery, considering three quinquennia: 1861-1865 (n = 1111, 18.3%), 1870-1974 (n = 2602, 42.7%), 1910-1914 (n = 2374, 39.0%), related to the periods before, during and at the end of the second industrialization and (2) of the Coimbra identified osteological collections (CIOC, N = 1796) composed of individuals who were born and died in the city.

METHODS

Excel databases with the biographic information were analyzed with SPSS.

RESULTS

Data from the cemetery show statistically significant differences between sexes and age-at-death mortalities. Non-adult mortality (higher in the age range from 1 to 7 years) has decreased over time which has increased mean age-at-death. The main adult occupations are domestic work (females) and craft activities (males). Child labor is common after the age of 14. The main causes of death (in both cemetery and CIOC records) were infections, respiratory diseases, heart disease, and malignant neoplasm. Among the communicable diseases, tuberculosis accounted for the highest number of deaths. The identified individuals have lesions compatible with tuberculosis and sinusitis while malignant neoplasms are more difficult to identify. The high prevalence of heart disease can overshadow other causes of death.

CONCLUSIONS

In the absence of industrialization, tuberculosis, heart disease, and malignant neoplasms increased over time, while respiratory diseases decreased.

SIGNIFICANCE

Mortality profile changed between 1861-1864 and 1910-1914 in Coimbra.

LIMITATIONS

The causes of death were studied, but not all diseases.

SUGGESTIONS FOR FURTHER RESEARCH

Study of other cemetery records for further comparison.

Neurosyphilis mimicking giant cell arteritis both clinically and microscopically

Temporal arteritis is usually caused by giant cell arteritis (GCA). However, inflammation of the temporal artery can also occur secondary to autoimmune diseases or infections.We present a remarkable case of a man in his 70s with biopsy proven temporal arteritis, who was later diagnosed with meningovascular neurosyphilis. The presentation of an acute onset monocular vision loss with inflammation of the temporal artery on biopsy appeared a GCA, misleading the physicians, as it turned out to be a manifestation of neurosyphilis.

[Syphilis infection in the ENT area]

The number of reported cases of syphilis has been increasing for years. The sexually transmitted disease is caused by the spirochete Treponema pallidum subspecies pallidum and progresses in different stages. Symptoms in the ENT area can occur in all stages. This means that a syphilis infection should always be considered by the ENT doctor as a differential diagnosis if the symptoms are suitable. Thus, with increasing oral sexual intercourse, the primary effect/hard chancre is more often observed in the oral cavity. In addition, symptoms can occur not only in the oral cavity, but also in the ear, nose, larynx, cervical and facial regions. The diagnosis is confirmed by direct pathogen detection or by serological detection. The spirochete cannot be cultivated. The therapeutic gold standard is the administration of benzathine penicillin G or procaine penicillin G. Doxycycline, macrolides or ceftriaxone are available as alternatives. In case of inner ear or cranial nerve involvement, the additional administration of a glucocorticoid is recommended. Before antibiotic therapy is administered, the patient must be informed about the possibility of a Jarisch-Herxheimer reaction. In cases of a syphilis infection, a collegial cooperation with the venereologists is always recommended so that an effective and comprehensive diagnosis and therapy can be carried out.

Possible effects of Treponema pallidum infection on human vascular endothelial cells

Pathogens can affect host cells in various ways, and the same effect can be found in the Treponema pallidum acting on the endothelium of host vessels, and the mechanism is often complex and multiple. Based on the existing T. pallidum of a cognitive framework, the first concerns involving T. pallidum or the bacteria protein directly acted on vascular endothelial cells of the host, the second concerns mainly involved in the process of T. pallidum infection in vivo blood lipid change, secretion of cytokines and the interactions between immune cells indirectly. Through both direct and indirect influence, this study explores the role of host by T. pallidum infect in the process of the vascular endothelium.

Ocular Syphilis as a Cause of Chronic Postoperative Uveitis Followed by a Localized Ocular Jarisch-Herxheimer-like Reaction

OBJECTIVE

The case draws attention to syphilis as a cause of chronic postoperative uveitis following cataract surgery and is the first to document transient worsening of ocular inflammation without systemic symptoms after initiation of treatment, suggesting a localized Jarisch-Herxheimer-like reaction.

DESIGN

Case report.

RESULTS

The average thickness of the retinal nerve fiber layer was used as an objective measure of intraocular inflammation. The patient's nerve edema worsened during a standard neurosyphilis treatment course and returned to normal several weeks after completion of therapy.

CONCLUSION

Syphilis serologic testing should be strongly considered in the work-up for chronic postoperative uveitis. A localized ocular Jarisch-Herxheimer-like reaction may occur and should not detract from completion of neurosyphilis treatment.

Multiple Spinal Syphilitic Gummas Diagnosed by Postoperative Histopathology and Antibiotic Responsiveness: A Case Report

Neurosyphilis is an infection of the central nervous system by Treponema pallidum. Gummatous neurosyphilis, especially spinal syphilitic gumma, is an exceedingly rare manifestation and may be misdiagnosed as other tumors due to its rarity. A 42-year-old man with a medical history of treatment for syphilis presented with rapidly progressive leg paralysis, leg sensory disturbance, and bladder and rectal disturbance. Spinal MRI demonstrated an intradural extramedullary lesion strongly compressing the spinal cord at the T6/7 level, which was accompanied with dural tail sign and perilesional meningeal thickening at the T6–T8 levels. Small intradural extramedullary lesions were also detected at the T1 and T8 levels. Serological and cerebrospinal fluid examinations for syphilis were both positive. In the treatment of spinal syphilitic gumma, the decompression of the spinal cord by lesionectomy followed by postoperative antibiotic treatment is considered to be an optimal procedure in patients with rapid progression of neurological deterioration. In the present case, the symptomatic main lesion that was compressing the thoracic cord was excised by surgery and analyzed by histopathological examination, and another small asymptomatic lesion was resolved by postoperative antibiotic treatment. Spinal syphilitic gumma was diagnosed using both histopathological findings of the surgically resected lesion and another residual lesion that was resolved by postoperative antibiotic treatment.

Mycotic abdominal aortic aneurysm caused by Borrelia afzelii: a case report

Background

Inflammatory aneurysms and mycotic aneurysms make up a minority of abdominal aortic aneurysms. Mainly autoimmune mechanisms are proposed in the pathogenesis of inflammatory aneurysms, and it is not routine to check for infectious agents as disease culprits.

Case presentation

A 58-year-old European male with complaints of abdominal and back pain for 8 weeks was admitted after a semi-urgent computed tomography scan revealed an 85 mm inflammatory abdominal aortic aneurysm. The patient had normal vital signs, slightly elevated inflammatory markers, and mild anemia on admission. Clinical examination revealed a tender pulsating mass in his abdomen. His clinical condition was interpreted as impending rupture and urgent repair of the aneurysm was deemed necessary. Due to the patient’s relatively young age and aneurysm neck morphology, open aortic repair was preferred. Preoperatively, the aneurysm appeared inflamed, with fibrous wall thickening and perianeurysmal adhesions. Aneurysm wall biopsies were sent to histopathological and microbiological diagnostics. Routine cultures were negative, but 16S rRNA gene real-time polymerase chain reaction was positive and Borrelia afzelii was identified by DNA sequencing of the polymerase chain reaction product. B. afzelii was also identified by sequencing the polymerase chain reaction product of a Borrelia-specific groEL target. Immunoglobulin G and M anti-Borrelia antibodies were present on serological analysis. Histopathological analysis displayed loss of normal aortic wall structure and diffuse infiltration of lymphocytes and plasma cells. The patient had an uneventful recovery and was discharged after 1 week to a regional rehabilitation facility. Though the patient fares clinically well and inflammatory markers had normalized, antimicrobial treatment with doxycycline continues at 3 months follow-up due to remaining radiologic signs of inflammation.

Conclusions

Borrelia infection in the setting of acute aortic pathology is a rare entity. To our knowledge, this is the first case report to demonstrate a mycotic abdominal aortic aneurysm as a rare manifestation of Lyme disease. Aortic wall biopsies and real-time polymerase chain reaction analysis of the specimen were essential for accurate diagnosis. This finding may contribute to the understanding of the etiology of inflammatory aneurysmal disease and abdominal aneurysms in general.

Evolutionary processes in the emergence and recent spread of the syphilis agent, Treponema pallidum

The incidence of syphilis has risen worldwide in the last decade in spite of being an easily treated infection. The causative agent of this sexually transmitted disease is the bacterium Treponema pallidum subspecies pallidum (TPA), very closely related to subsp. pertenue (TPE) and endemicum (TEN), responsible for the human treponematoses yaws and bejel, respectively. Although much focus has been placed on the question of the spatial and temporary origins of TPA, the processes driving the evolution and epidemiological spread of TPA since its divergence from TPE and TEN are not well understood. Here, we investigate the effects of recombination and selection as forces of genetic diversity and differentiation acting during the evolution of T. pallidum subspecies. Using a custom-tailored procedure, named phylogenetic incongruence method, with 75 complete genome sequences, we found strong evidence for recombination among the T. pallidum subspecies, involving 12 genes and 21 events. In most cases, only one recombination event per gene was detected and all but one event corresponded to intersubspecies transfers, from TPE/TEN to TPA. We found a clear signal of natural selection acting on the recombinant genes, which is more intense in their recombinant regions. The phylogenetic location of the recombination events detected and the functional role of the genes with signals of positive selection suggest that these evolutionary processes had a key role in the evolution and recent expansion of the syphilis bacteria and significant implications for the selection of vaccine candidates and the design of a broadly protective syphilis vaccine.

Direct fluorescence antibody testing augments syphilis diagnosis, compared to serology alone

In Ottawa, Canada, we initiated protocols to include non-serologic syphilis testing, as direct fluorescence antibody (DFA) for patients with syphilis symptoms. The purpose was to assess the ability of DFA to detect syphilis during acute infection and to determine if non-serologic testing could yield an increased number of syphilis diagnoses. We reviewed charts of patients of our local sexual health clinic for whom syphilis was suspected. A total of 69 clinical encounters were recorded for 67 unique patients, most of whom were male. The most common symptom was a painless genital lesion. Of the 67 patients, 29 were found to have a new syphilis diagnosis, among whom, 52% had positive syphilis serology and positive DFA, 34% had a positive syphilis serology and negative DFA, and 14% had negative syphilis serology and positive DFA. While DFA testing did not yield an abundance of new cases, it was useful to support findings from syphilis serology or confirm diagnosis where serology was negative. Where available, alternate non-serologic tests, such as nucleic acid amplification tests, should be considered above DFA due to its higher sensitivity for detecting syphilis in primary lesions; however, in clinical situations, when new syphilis infection is suspected, empiric treatment should not be delayed.