Syphilis in adults

Secondary syphilis presenting with alopecia and leukoderma in a stable HIV-positive patient in a resource-limited setting: a case report

BACKGROUND

Syphilis is an infection caused by the bacteria Treponema pallidum. It is mainly transmitted through oral, vaginal and anal sex, in pregnancy and through blood transfusion. Syphilis develops in primary, secondary, latent and tertiary stages and presents with different clinical features at each stage. Infected patients can remain asymptomatic for several years and, without treatment, can, in extreme cases, manifest as damage in several organs and tissues, including the brain, nervous tissue, eyes, ear and soft tissues. In countries with a high human immunodeficiency virus (HIV) burden, syphilis increases the risk of HIV infections. We report the case of a young HIV-positive black woman who presented with alopecia and hypopigmentation as features of secondary syphilis.

CASE PRESENTATION

A virologically suppressed 29-year-old woman on Anti-retroviral Therapy (ART) presented with a short history of generalized hair loss associated with a non-itchy maculopapular rash and skin depigmentation on the feet. Limited laboratory testing confirmed a diagnosis of secondary syphilis. She was treated with Benzathine Penicillin 2.4MU. After receiving three doses of the recommended treatment, the presenting features cleared, and the patient recovered fully.

CONCLUSION

This case demonstrates the importance of a high index of clinical suspicion and testing for syphilis in patients presenting with atypical clinical features of secondary syphilis, such as hair loss and hypopigmentation. It also highlights the challenges in diagnosing and clinically managing syphilis in a resource-limited setting.

Ignored and undervalued in public health: a systematic review of health state utility values associated with syphilis infection

BACKGROUND

Syphilis is a sexually transmitted infection causing significant global morbidity and mortality. To inform policymaking and economic evaluation studies for syphilis, we summarised utility and disability weights for health states associated with syphilis.

METHODS

We conducted a systematic review, searching six databases for economic evaluations and primary valuation studies related to syphilis from January 2000 to February 2022. We extracted health state utility values or disability weights, including identification of how these were derived. The study was registered in the international prospective register of systematic reviews (PROSPERO, CRD42021230035).

FINDINGS

Of 3401 studies screened, 22 economic evaluations, two primary studies providing condition-specific measures, and 13 burden of disease studies were included. Fifteen economic evaluations reported outcomes as disability-adjusted life years (DALYs) and seven reported quality-adjusted life years (QALYs). Fourteen of 15 economic evaluations that used DALYS based their values on the original Global Burden of Disease (GBD) study from 1990 (published in 1996). For the seven QALY-related economic evaluations, the methodology varied between studies, with some studies using assumptions and others creating utility weights or converting them from disability weights.

INTERPRETATION

We found a limited evidence base for the valuation of health states for syphilis, a lack of transparency for the development of existing health state utility values, and inconsistencies in the application of these values to estimate DALYs and QALYs. Further research is required to expand the evidence base so that policymakers can access accurate and well-informed economic evaluations to allocate resources to address syphilis and implement syphilis programs that are cost-effective.

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.

Case report: Successive ipsilateral and contralateral laryngeal nerve palsy as probable manifestation of neuroborreliosis

Neuroborreliosis is part of advanced stage of Lyme disease and often characterized by damage to the cranial and/or peripheral nerves. Involvement of one or both recurrent nerves is rare. Diagnosis is often difficult and based on a set of clinical manifestations, biological arguments, and cerebrospinal fluid (CSF) analysis. A 70-year-old man was referred to our Voice Clinic with a 3-month history of dysphonia caused by right vocal fold paralysis (VFP) without any cutaneous symptoms of tick bite or erythema migrans in the previous weeks and normal initial radiological examination (neck and thorax CT). Methylprednisolone had already been prescribed but without any clinical improvement. Late biological investigation 3 months after initial symptoms of VFP showed high IgG (93 U/mL; reference <10 U/mL) against Borrelia burgdorferi (BB), which was confirmed by two immunoblot markers (VIsE, p39 antigens). Therefore, a possible manifestation of Lyme disease with involvement of the right inferior laryngeal nerve was suspected, namely Lyme neuroborreliosis. However, given the spontaneous recovery of the patient after 7 months without any adapted antimicrobial regimen treatment, the diagnosis of neuroborreliosis was not confirmed by a lumbar puncture. Nineteen months later, the patient presented again for the same symptomatology but as left VFP. High IgG (68 U/mL) and IgM (>6, reference <0.90) levels against BB were confirmed by immunoblot. Subsequently, lumbar puncture was performed and revealed IgG against BB at 46.1 UA/mL (reference<5.5 UA/mL) in the CSF, with an extremely high IgG intrathecal synthesis antibody index (281.33, positive if > 1.5). Intrathecal antibody synthesis is the gold standard for Lyme neuroborreliosis demonstrating a specific immune response to BB in the central nervous system, but with the limitation of persistence for years after eradication. Our patient did not exhibit pleocytosis in the CSF. Therefore, two criteria of the European Federation of Neurological Societies (EFNS) guidelines are fulfilled for possible neuroborreliosis. Doxycycline treatment led to rapid recovery in less than 8 weeks and normal mobility of the left vocal fold. Because of this very uncommon clinical presentation with two successive episodes of VFP for no other obvious reason and serological evidence from the serum and CSF during the second episode, we consider it possible that the first episode of VFP could also have been a manifestation of neuroborreliosis. This case is the first report of possible relapse of laryngeal palsy successively on the right, and then the left side as a manifestation of Lyme neuroborreliosis.

Neurosyphilis-Induced Psychosis: A Unique Presentation of Syphilis With a Primary Psychiatric Manifestation

Syphilis is a predominantly sexually transmitted infection caused by the spirochete Treponema pallidum. The infection presents with four different stages and although rare, can lead to behavioral symptoms if not treated in its earliest form. It can cause psychosis, mania, depression, anxiety, and personality changes. Screening and early treatment of syphilis are essential in preventing neurosyphilis and its neuropsychiatric symptoms. Neurosyphilis is rarely the initial presentation of syphilis. This is a case report of a 30-year-old female with neurosyphilis who presented with psychosis as the primary presentation.

Clinical Conundrums: Differentiating Monkeypox From Similarly Presenting Infections

Post the coronavirus disease 2019 (COVID-19) pandemic, there arises the concern of a new epidemic as cases of monkeypox are being confirmed, globally. With the initial clinical manifestation of monkeypox resembling that of the common cold or seasonal flu, recognizing alternative differential diagnoses is imperative as a medical health practitioner. The characteristic monkeypox maculopapular rash with the progression to vesicles and pustules before scabbing can be described in several other infections. Understanding the disease progression and distinct clinical presentation of monkeypox in its various stages may allow for a more expedient diagnosis among healthcare providers. Though eradicated, the clinical presentation of smallpox is the most similar to that of monkeypox; however, smallpox is no longer a concern for the general population. Other conditions such as molluscum contagiosum, syphilis, varicella zoster, measles, rickettsialpox, and scabies can present with rashes that may resemble singular or multiple states of the monkeypox rash progression. The ability to correctly diagnose an individual's condition promptly may allow healthcare providers to provide correct supportive therapies or treatments.

Quality of life, depressive symptoms, anxiety, and sexual function in mothers of neonates with congenital syphilis in the Northeast Brazil: A cohort study

Background

Congenital syphilis is an important public health problem in low- and middle-income countries. Poor neonatal health outcomes associated with the disease may lead to maternal psychological distress and feelings of helplessness. This study aimed to evaluate the quality of life, anxiety levels, depressive symptoms, and sexual function in mothers of neonates with congenital syphilis in the Northeast of Brazil.

Methods

This cohort study compared patient-centered outcomes between mothers of neonates with congenital syphilis and mothers of healthy neonates during the first three months of the postpartum period. The study was conducted in Sergipe state, Northeast Brazil, a region with one of the highest rates of congenital syphilis (14·1 cases per 1000 live births). Quality of life, depressive symptoms, anxiety levels, and sexual function were evaluated by using the World Health Organization Quality of Live - shortened version (WHOQoL-BREF) instrument, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory, and Female Sexual Function Index, respectively. Unadjusted differences between groups were anayzed by using the Mann-Whitney test. Glass's delta with 95% confidence interval (CI) was used to measure the effect size.

Findings

Sixty-three women were included in each group. During the in-hospital stay, mothers of neonates with congenital syphilis had lower scores for overall quality of life (p < 0·001; large effect size: -0·559 [95% CI -0·683 to -0·405]) and higher levels of anxiety (p < 0·001; large effect size: 0·558 [95% CI 0·403 to 0·681]) and depressive symptoms (p < 0·001; large effect size: 0·561 [95% CI 0·407 to 0·684]) than mothers of healthy neonates. Three months after childbirth, we found persistent depressive symptoms (p = 0·021; small effect size: 0·239 [95% CI 0·041 to 0·419]) and low overall sexual function (p = 0·041; small effect size: -0·211 [95% CI -0·394 to -0·012]) among mothers of neonates with congenital syphilis compared to the control group.

Interpretation

Mothers of neonates with congenital syphilis present poorer quality of life, mental health, and sexual function compared to mothers of healthy neonates.

Funding

Brazilian Federal Agency for Coordination of Improvement of Higher Education Personnel (CAPES).

Sífilis adquirida na população de 50 anos ou mais

Objetivo: avaliar a prevalência de sífilis adquirida na população ≥50 anos residente em Santa Catarina, sua distribuição geográfica e tendência no período 2013-2018.Métodos: estudo ecológico exploratório, analisando dados na plataforma virtual da Diretoria de Vigilância Epidemiológica, relativos às notificações de sífilis na população catarinense com ≥50 anos, sendo a faixa etária dividida em quatro grupos: 50-59 anos, 60-69 anos, 70-79 anos e ≥80 anos.Resultados: a taxa de ocorrência de sífilis na população estudada aumentou de 18,2 para 110,7 casos /100.000 habitantes no período. O incremento foi observado em todas as faixas etárias a partir dos 50 anos e sexos, destacando-se a população de 50-59 anos. As maiores incidências foram verificadas nas macrorregiões Grande Florianópolis e Planalto Norte/Nordeste.Conclusão: houve crescimento exponencial do agravo no período 2013-2018, na população referida, para ambos os sexos, ocorrendo de forma diferenciada segundo macrorregião de saúde. Os resultados obtidos preocupam e merecem atenção da gestão pública.

Membranous Glomerulonephritis as an Uncommon Presentation of Secondary Syphilis: A Reminder on Therapeutic Decision-Making in Clinical Practice

Membranous glomerulonephritis is one of the common causes of nephrotic syndrome in the adult population. It is idiopathic in the majority of patients, but the secondary forms can be seen in the setting of autoimmune disease, cancer, infection, and following exposure to certain medications. However, subclinical syphilis-related membranous nephropathy remains a particularly rare clinicopathologic entity in modern times. In this article, we chronicle an interesting case of latent syphilis masquerading as membranous glomerulonephritis, which resolved with benzathine penicillin without requiring immunosuppressive treatment. We further supplement this paper with a concise review of the relevant literature that delineates the utility of appropriate antibiotic therapy in the management of luetic membranous nephropathy. Clinicians should remain cognizant of secondary syphilis while evaluating patients for possible glomerulonephritis or those presenting with proteinuria. Additionally, patients with hepatitis B, hepatitis C, and human immunodeficiency virus infections are not infrequently coinfected with Treponema pallidum. Therefore, a high index of suspicion for systemic manifestations of syphilis such as nephrotic syndrome is warranted in the setting of a coinfection. Prompt diagnosis and treatment of syphilis may result in resolution of proteinuria, without the need for standard immunosuppressive therapy commonly used in clinical practice.

Neurosyphilis: a series of 178 cases at the 3rd-level hospital of Marrakesh (Morocco)

Neurosyphilis (NS) is an infection of the central nervous system (CNS), caused by Treponema pallidum. Up to 4-10% of patients with untreated syphilis may develop NS which still constitutes a health challenge. The aim of this study is to analyze epidemiological, clinical, paraclinical, therapeutic, and progression profiles of NS in the south of Morocco. Authors analyzed retrospectively 178 files of patients with neurosyphilis, collected in the Neurology Department of Marrakesh over 25 years from January 1994 to March 2019. In our study, the mean age was 46 years (17-75 years). The number of males was dominant (87.6%). The most common presentation was meningoencephalitis. Four cases were atypical (late congenital syphilis, amyotrophic lateral sclerosis, neurosyphilis associated with neuro-Behcet's disease, and acute polyradiculoneuropathy). All patients had positive TPHA and VDRL serologies in blood; CSF-TPHA was positive in all patients, and CSF-VDRL was positive in 64.0% of patients. CT scan and brain MRI showed cortical atrophy in the majority of cases. One hundred seventy-seven patients were treated with intravenous injection of aqueous penicillin G. Neurosyphilis is still a significant medical problem in developing countries, and its occurrence in HIV infection is the reason for a growing number of new cases in developed countries. Given the frequent atypical manifestations of the disease, screening for neurosyphilis should be considered in all patients with neurological or psychiatric symptoms.

Prevalence of sexually transmitted infections among cervical cancer suspected women at University of Gondar Comprehensive Specialized Hospital, North-west Ethiopia

Background

Sexually transmitted infections (STIs) such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Syphilis have continued a significant public health problem, especially in areas with substandard infection prevention and control programs. It is known that STIs are largely associated with the increased occurrence of cervical cancer. To date, little is known about the burden of STIs among cervical cancer suspected women in Ethiopia.

Objectives

To assess the seroprevalence of STIs and associated risk factors among cervical cancer suspected women with special emphasis on HIV, HBV, HCV, and Syphilis.

Methods

A hospital-based cross-sectional study was conducted among cervical cancer suspected women at the University of Gondar Comprehensive Specialized Hospital from February to April 2017. A pre-tested and structured questionnaire was used to collect data on patients’ characteristics. The patient’s serum or plasma samples were tested for HIV, HBV, HCV, and syphilis using enzyme-linked immunosorbent assay. In all aspects, the standard operational procedure was strictly followed. Data were analyzed using SPSS version 20 software and presented using tables. Statistical associations were measured using bivariate and multivariable logistic regression. A p-value of below 0.05 was considered statistically significant.

Result

A total of 403 cervical cancer suspected women with the mean age of 42.54 (SD + 11. 24) years were enrolled in the study. The overall prevalence of STIs was 16.6% (67/403) and the prevalence of HIV, HBV, HCV, and syphilis was 36/403 (8.9%), 10/403 (2.5%), 4/403 (1%), and 29/403 (7.2%) respectively. History of multiple sexual partners (Adjusted OR = 3.02, 95%CI 1.57–5.79, P = 0.001), alcohol addiction (Adjusted OR = 2.2, 95%CI 1.07–4.5, P = 0.031), history of STI (Adjusted OR = 3.38; 95% CI: 1.76–6.47, P = 0.00) and not use of condom (Adjusted OR = 4.99; 95% CI: 1.5–16.16, P = 0.007) were significantly associated with STIs.

Conclusion

The prevalence of STIs was generally higher among cervical cancer suspected patients. Health education is encouraged to promote awareness about the prevention of STIs.

Predictors of serological cure after penicillin therapy in HIV-negative patients with early syphilis in Shenzhen, China

BACKGROUND

Syphilis is a common infectious disease worldwide. Serological monitoring is important for syphilis management. We currently know little about the characteristics of this seronegative response. The aim of this study was to explore the factors associated with serological cure after treatment of early syphilis.

METHODS

A retrospective cohort study was conducted and the data of patients with early syphilis in a clinic in Shenzhen from 2011 to 2019 were retrieved. Univariable and multiple Cox proportional hazard regression models were utilized to identify factors associated with a serological cure state among syphilis patients with early syphilis two years after treatment.

RESULTS

A total of 346 (85.9%) syphilis patients achieved serological cure. The multivariate analysis results revealed that having a baseline TRUST titer >1:8 was associated with an increased probability of serological cure, compared with having a baseline TRUST titer ≤1:8 (HR = 1.43, 95% CI = 1.10-1.85, P<0.01); primary syphilis was positively associated with serological cure, compared with participants with latent early syphilis (HR = 1.72, 95% CI = 1.27-2.33, P<0.001).

CONCLUSIONS

Two years after treatment, a higher percentage of early syphilis patients achieved serological cure. The study indicated that the syphilis stage and baseline serum titer were crucial factors associated with serological cure.

Detection and analysis of blood donors seropositive for syphilis

BACKGROUND

The increasing incidence of syphilis worldwide has called attention to the risk of transmission by transfusion.

AIMS

To determine the prevalence of active syphilis in blood donors and characterise the serological profile of syphilis-positive donors.

METHODS

Samples positive for Treponema pallidum using the chemiluminescent microparticle immunoassay (CMIA) during blood donor screening from 2017 to 2018 were tested by the Venereal Disease Research Laboratory (VDRL) non-treponemal test and for anti-T. pallidum IgM by ELISA (Immunoassay Enzyme test for detection of IgM antibodies). The INNO-LIA Syphilis test (Line Immuno Assay solid test for confirmation antibodies to Treponema pallidum) was performed as a confirmatory test on samples that were positive on ELISA-IgM but negative on VDRL. ELISA-IgM (+) samples were also tested for T. pallidum DNA in sera by real-time polymerase chain reaction (PCR).

RESULTS

Of 248 542 samples screened, 1679 (0.67%) were positive for syphilis by CMIA. Further analysis was performed on 1144 (68.1%) of these samples. Of those tested, 16% were ELISA IgM(+)/VDRL(+), 16.5% were ELISA IgM(-)/VDRL(+), 4.1% were ELISA IgM(+)/VDRL(-), and 63.4% were ELISA IgM (-)/VDRL(-). The INNO-LIA Syphilis test results were 33 (3%) positive, 2 (0.2%) undetermined and 12 (1%) negative. Of the 230 EIA-IgM(+) samples (20.1%), 5 (2.2%) were PCR positive. The prevalence of active syphilis in 2017 and 2018 was 0.1% and 0.07%, respectively, and overall prevalence of serologic markers for syphilis was highest among male, unmarried, 25-34-year-olds with a high school education and who were first-time donors.

CONCLUSION

There is a risk of transfusion-transmitted syphilis in blood banks that exclusively use the VDRL test for donor screening, as is currently the situation in some Brazilian blood centres, as well as in other blood centres around the world.

Dermatoscopic findings of syphilitic alopecia

Syphilis is an infectious disease that has afflicted mankind for centuries, but a recent increase in worldwide incidence has been evidenced. The authors describe a patient with typical lesions of secondary syphilis and moth-eaten alopecia, whose dermoscopic examination demonstrated empty hair follicles, vellus hair, follicular hyperkeratosis, peripheral black dots, dilated and tortuous vessels, reddish brown background, and hypopigmentation of the hair shafts. Furthermore, this case presented an erythematous background more evident than previously described cases.

Development of a novel magnetic particle-based agglutination immunoassay for anticardiolipin antibody detection in syphilis

Objectives

Serological tests of non-treponemal and treponemal types are the most frequently used for syphilis diagnosis. Treponemal tests are available in wide variety of assay formats; however, limited advances have been made for the improvement of conventional non-treponemal tests. The objective of this work was to develop a novel non-treponemal magnetic particle-based agglutination assay (NT-MAA) and evaluate its feasibility for syphilis testing.

Methods

Cardiolipin was modified and coupled to magnetic microbeads. Serum diluted in phosphate-buffered saline was mixed with cardiolipin-coupled beads and incubated in a round bottom microplate for 90–120 min followed by visual inspection. A panel of reported syphilis (n=127) and non-reactive (n=244) specimens was prepared to evaluate the NT-MAA performance in comparison to conventional rapid plasma reagin (RPR). Treponema pallidum particle agglutination (TP-PA) assay and enzyme immunoassay (EIA) were included. Analytical sensitivity and reproducibility of NT-MAA were also determined.

Results

The non-treponemal NT-MAA and RPR showed sensitivity of 90.6% and 88.2% and specificity of 96.7% and 100%, respectively. The treponemal TP-PA and EIA yielded sensitivity of 100% and 99.2%, respectively, and 100% specificity by both assays. The per cent agreement between NT-MAA and RPR was 97% (kappa=0.931, 95% CI 0.891 to 0.971). Analytical sensitivity determined with IgM anticardiolipin antibody (ACA) was 2.6 µg/mL for both NT-MAA and RPR, while IgG ACA yielded 0.9 µg/mL and 1.7 µg/mL for NT-MAA and RPR, respectively. Qualitative results of intra-assay and interassay reproducibility revealed 100% consistency for NT-MAA.

Conclusion

Preliminary evaluation of the novel NT-MAA validated proof of concept using laboratory-characterised syphilis sera and demonstrated performance comparable to RPR. Further validation of NT-MAA using additional specimens with better clinical staging may broaden the scope of developed test for syphilis diagnosis.

Development of a syphilis serum bank to support research, development, and evaluation of syphilis diagnostic tests in the United States

The Centers for Disease Control and Prevention’s (CDC) Division of STD Prevention, in collaboration with the Association of Public Health Laboratories (APHL), is developing a nationally available syphilis serum repository for research of Food and Drug Administration (FDA)-cleared or investigational syphilis diagnostic assays in the United States. State and local public health laboratories (PHL) submitted de-identified residual sera with information on collection date, volume, storage conditions, freeze-thaw cycles, PHL serology results, reported syphilis stage and demographic details if available. Previous test results were blinded and sera (N=152 reported syphilis stage, N = 131 unknown status) were tested at CDC using five FDA-cleared and one investigational syphilis tests. Treponemal and nontreponemal test sensitivity ranged from 76.3–100% and 63.2–100%, respectively, among staged specimens. The conventional treponemal assays showed high concordance of 95.4%. By providing syphilis stage and comprehensive serological test data, developed repository may serve as a valuable resource for diagnostic test validation studies.

Screening for Sexually Transmitted Diseases

This article discusses sexually transmitted infections (STI) screening and focuses on reportable STIs. This includes gonorrhea, chlamydia, syphilis, and human immunodeficiency virus. Hepatitis B and C, trichomonas, and herpes are covered as well. Recommendations are summarized from the various organizations that produce screening recommendations. These screening recommendations only apply to asymptomatic individuals. Once an individual has symptoms, testing becomes diagnostic. It is important to know the prevalence of STIs within your population. If you work in a population with a high prevalence of a specific disease, you may want to screen regardless of the recommendations.

Laboratory Evaluation of a Commercially Available Rapid Syphilis Test

Serological diagnosis of syphilis depends on assays that detect treponemal and nontreponemal antibodies. Laboratory certification and trained personnel are needed to perform most of these tests, while high costs and long turnaround time can hinder treatment initiation or linkage to care. A rapid treponemal syphilis test (RST) that is simple to perform, accessible, and inexpensive would be ideal. The Syphilis Health Check (SHC) assay is the only Food and Drug Administration (FDA)-cleared and Clinical Laboratory Improvement Amendments (CLIA)-waived RST in the United States. In this study, 1,406 archived human serum samples were tested using SHC and traditional treponemal and nontreponemal assays. Rapid test results were compared with treponemal data alone and with a laboratory test panel consensus defined as being reactive by both treponemal and nontreponemal assays for a given specimen, or nonreactive by both types of assays. The sensitivity and specificity of the SHC assay compared with treponemal tests alone were 88.7% (95% confidence interval [CI], 86.2 to 90.0%) and 93.1% (95% CI, 90.0 to 94.9%), respectively, while comparison with the laboratory test panel consensus showed 95.7% (95% CI, 93.6 to 97.2%) sensitivity and 93.2% (95% CI, 91.0 to 95.1%) specificity. The data were further stratified based on age, sex, pregnancy, and HIV status. The sensitivity and specificity of the SHC assay ranged from 66.7% (95% CI, 46.0 to 83.5%) to 91.7% (95% CI, 87.7 to 94.7%) and 88% (95% CI, 68.8 to 97.5%) to 100% (95% CI, 47.8 to 100%), respectively, across groups compared to traditional treponemal assays, generally increasing for all groups except the HIV-positive (HIV+) population when factoring in the laboratory test panel consensus. These data contribute to current knowledge of the SHC assay performance for distinct populations and may guide use in various settings.

A 30-Year-Old Man with HIV, Fever, and a Rash

Patients who present with papular rashes have a wide differential diagnosis particularly in the setting of immune compromise. A 30-year-old male diagnosed with HIV since 2009, never on antiretroviral therapy, with a nadir CD4 count of 333 cells/mm³ and a current viral load of 44,300 copies/mL, presented with a diffuse monomorphic papular eruption that began on his trunk and extremities and subsequently spread to the penis and scrotum, sparing the distal acral sites. A thorough infectious workup revealed a positive rapid plasma reagin (RPR) and varicella IgM and IgG antibodies. Interestingly, the patient had been diagnosed and treated for syphilis in the past with a recent downtrending RPR drawn prior to hospitalization. Repeat RPR was elevated and a preliminary histopathology report demonstrated folliculocentric inflammation with lymphocytes, plasma cells, and polymorphonuclear leukocyte predominance supported the diagnosis of syphilis. After receiving intramuscular penicillin G benzathine, he developed intermittent fevers and new papules. Intravenous (IV) acyclovir was initiated for presumed disseminated varicella given his positive varicella-zoster virus IgM and IgG. However, final pathology results revealed a large spirochete burden. The fevers and rash progression were attributed to the development of a Jarisch-Herxheimer reaction. IV acyclovir was discontinued and he completed a course of intramuscular penicillin G benzathine. He was also given a course of doxycycline for rectal chlamydia which was diagnosed during hospitalization.

Immunology and Medical Microbiology

We are continuously exposed to many pathogens through inhalation, ingestion, and touch. The immune system protects us from the majority of these pathogens as flatworms, bacteria, fungi, and viruses. We have also witnessed tremendous progress in the prevention and treatment of infectious diseases; still, they remain a major challenge and are responsible for major cause of death and disability worldwide. The immune system’s memory response and vaccination have resulted in complete eradication of many diseases. Our immune system is very adaptive and consists of a variety of cells and molecules, which play an active role in protecting us. It not only protects us from the outside pathogenic agents but also is also capable of recognizing the body’s own components. It recognizes them as self and does not induce response against them. It is known as self-/non-self-discrimination. Sometimes due to certain defects or other reasons when the immune system is not able to differentiate self, then it mounts an attack on self-components leading to autoimmunity. The importance of the immune system was recognized by early work of Dr. Edward Jenner and Louis Pasteur; they recognized the abilities of the immune system, and since then the system was gradually being explored and it laid the foundation of immunology.

However, day-by-day microbes are also posing health risks as new strains are continuously being evolved. Many chemotherapeutic agents have been developed to control the spread and infections. However, microbes are also continuously developing the ability of their survival with emergence of new strains and properties. Antibiotic resistance is occurring with all classes of microbes posing a serious clinical problem in managing infections. The diseases like tuberculosis, cholera, and rheumatic fever, which were believed to be eradicated, have ferociously reemerged. The reemergence and new pathogenic agents might be the result of mutations in their genome and changes occurring in the environment. In this chapter, basic concept of the immune system and some of the diseases of the skin, gastrointestinal tract, nervous system, and respiratory system caused by microorganisms are discussed along with sexually transmitted diseases and characterization of pathogens.

Concomitant Immunity Induced by Persistent Leishmania major Does Not Preclude Secondary Re-Infection: Implications for Genetic Exchange, Diversity and Vaccination

BACKGROUND

Many microbes have evolved the ability to co-exist for long periods of time within other species in the absence of overt pathology. Evolutionary biologists have proposed benefits to the microbe from 'asymptomatic persistent infections', most commonly invoking increased likelihood of transmission by longer-lived hosts. Typically asymptomatic persistent infections arise from strong containment by the immune system, accompanied by protective immunity; such 'vaccination' from overt disease in the presence of a non-sterilizing immune response is termed premunition or concomitant immunity. Here we consider another potential benefit of persistence and concomitant immunity to the parasite: the 'exclusion' of competing super-infecting strains, which would favor transmission of the original infecting organism.

METHODOLOGY / PRINCIPLE FINDINGS

To investigate this in the protozoan parasite Leishmania major, a superb model for the study of asymptomatic persistence, we used isogenic lines of comparable virulence bearing independent selectable markers. One was then used to infect genetically resistant mice, yielding infections which healed and progressed to asymptomatic persistent infection; these mice were then super-infected with the second marked line. As anticipated, super-infection yielded minimal pathology, showing that protective immunity against disease pathology had been established. The relative abundance of the primary and super-infecting secondary parasites was then assessed by plating on selective media. The data show clearly that super-infecting parasites were able to colonize the immune host effectively, achieving numbers comparable to and sometimes greater than that of the primary parasite.

CONCLUSIONS / SIGNIFICANCE

We conclude that induction of protective immunity does not guarantee the Leishmania parasite exclusive occupation of the infected host. This finding has important consequences to the maintenance and generation of parasite diversity in the natural Leishmania infectious cycle alternating between mammalian and sand fly hosts.

The Great Pretender: Rectal Syphilis Mimic a Cancer

Rectal syphilis is a rare expression of the widely recognised sexual transmitted disease, also known as the great imitator for its peculiarity of being confused with mild anorectal diseases because of its vague symptoms or believed rectal malignancy, with the concrete risk of overtreatment. We present the case of a male patient with primary rectal syphilis, firstly diagnosed as rectal cancer; the medical, radiological, and endoscopic features are discussed below.

Primary syphilis of the oropharynx: an unusual location of a chancre

A 33-year-old man presented with a two-week history of an asymptomatic ulcer of the oropharynx and submandibular lymph nodes swelling. Laboratory examinations were normal, but serological tests revealed positivity for rapid plasma reagin, Treponema pallidum haemagglutination assay and anti- T. pallidum IgM antibodies. Since the patient denied any homosexual relationship, a biopsy of the lesion was performed, which confirmed primary syphilis. The patient received an intramuscular injection of Benzathine Penicillin G (2.4 MU) with complete resolution of the lesion. Extragenital chancres occur in at least 5% of patients with primary syphilis, and the oral mucosa is the most frequent location as a consequence of orogenital/oroanal contact with an infectious lesion. Because of their transient nature, these oral ulcerations are often underestimated by the patient or by any unsuspecting clinician. Health professionals should consider the recent sexual history of their patients and should be prepared to recognise oral and systemic manifestations of sexually transmitted infections.

A case of secondary syphilis demonstrating nephrotic syndrome and a solitary intrahepatic mass in a human immunodeficiency virus-1-infected patient

A 37-year-old, human immunodeficiency virus-1-infected Japanese man was referred because of nephrotic syndrome following emergence of generalized skin rash. Serological tests for syphilis turned out to be positive within ten months of the referral. Abdominal echography incidentally revealed a solitary intrahepatic mass without a detectable blood flow in segment 7. The patient's signs and symptoms, as well as the intrahepatic mass, resolved promptly after administration of amoxicillin. We consider that, in the present case, secondary syphilis caused the nephrotic syndrome and the intrahepatic mass, both of which have rarely been reported to date.

Evaluation of syndromic management of sexually transmitted infections within the Kisumu Incidence Cohort Study

While laboratory aetiological diagnosis is considered the gold standard for diagnosis and management of sexually transmitted infections (STIs), syndromic management has been presented as a simplified and affordable approach for STI management in limited resource settings. STI signs and symptoms were collected using staff-administered computer-assisted personal interview and audio computer-assisted self-interview. Participants underwent a medical examination and laboratory testing for common STIs. The performance of syndromic management was assessed on the agreement between interviewing methods as well as accurate diagnosis. We screened 846 participants, of whom 88 (10.4%) received syndromic STI diagnosis while 272 (32.2%) received an aetiological diagnosis. Agreement between syndromic and aetiological diagnoses was very poor (overall kappa = 0.09). The most prevalent STI was herpes simplex virus type 2 and the percentage of persons with any STI was higher among women (48.6%) than men (15.6%, p < 0.0001). Agreement between audio computer-assisted self-interview and computer-assisted personal interview interviewing methods for syndromic diagnosis of STIs ranged from poor to good. Our findings suggest that syndromic management of STIs is not a sufficient tool for STI diagnosis in this setting; development and improvement of STI diagnostic capabilities through laboratory confirmation is needed in resource-limited settings.

Determination of class M and G antibodies to T.pallidum antigens in patients with primary syphilis

The authors present the results of a study of blood serum samples obtained from patients with clinically diagnosed primary syphilis by the linear immunoblotting method to determine IgM and IgG antibodies to T. pallidum antigens, which enabled the authors to study the intensity of the humoral immune response to individual T. pallidum antigens at early stages of the infection. The humoral response by means of the synthesis of specific class M antibodies in case of primary syphilis was accompanied by the formation of Class G antibodies in most cases; the frequency of revealing Class M and G antibodies was as follows: TmpA antigen 100 and 98.68%; TpN47 90.79 and 97.37%; TpN17 90.79 and 89.47%; TpN 15 72.37 and 73.69% of all cases, respectively; the content of class G antibodies to each of the four T. pallidum antigens exceeded the levels of Class M antibodies by more than twice. Different profiles of the humoral immune response with the involvement of IgM and IgG antibodies distinguished by a more expressed synthesis of antibodies to any or several of T. pallidum antigens were discovered and characterized for the first time. The clinical sensitivity of the IgM immunoblotting method for diagnosing primary syphilis amounted to 85.53%, IgG immunoblotting 92.11%, which means that the method can be used to diagnose early forms of syphilis.

Pityriasis lichenoides-like secondary syphilis and neurosyphilis in a HIV-infected patient

Papulo- and vesiculo-necrotic lesions are rare manifestations of secondary syphilis. Until now it has been described only in HIV-infected patients with advanced stages of immunosuppression. This case report describes an unusual case of PLEVA-like syphilis in a 33-year-old man with newly diagnosed HIV infection. Despite that the CD4 cells level and viral load did not indicate the advance stage of immunosuppression, the unusual manifestation of syphilis and neurosyphilis occurred. The presented case indicates the need for HIV screening in every patient with syphilis especially when the clinical manifestation is unusual. Importance of syphilis testing in every case with atypical rashes should be also highlighted.

A case of secondary syphilis presenting as multiple pulmonary nodules

Syphilis is a sexually transmitted disease caused by Treponema pallidum. The prevalence of this disease has recently increased worldwide. However, pulmonary involvement in secondary syphilis is extremely rare. A 51-year-old heterosexual male patient presented with multiple pulmonary nodules with reactive serology from the Venereal Disease Research Laboratory test and positive fluorescent treponemal antibody absorption testing. A hematogenous metastatic malignancy was suspected and an excisional lung biopsy was performed. Histopathological examination showed only central necrosis with abscess and plasma cell infiltration, but no malignant cells. The patient reported sexual contact with a prostitute 8 weeks previously and a penile lesion 6 weeks earlier. Physical examination revealed an erythematous papular rash on the trunk. Secondary syphilis with pulmonary nodules was suspected, and benzathine penicillin G, 2.4 million units, was administered. Subsequently, the clinical signs of syphilis improved and the pulmonary nodules resolved. The final diagnosis was secondary syphilis with pulmonary nodular involvement.

Methods for the determination of M class anti-T. pallidum antibodies for early diagnostics of syphilis

The review covers issues related to the present-day administration of laboratory blood test methods for the determination of specific Class M immunoglobulins against antigens of the syphilis pathogen, T. pallidum (immune-enzyme assay, immunofluorescence reaction, linear immunoblotting). Indications and diagnostic features of the aforesaid medical methods for early diagnostics of acquired or congenital syphilis were determined; cases of reinfection were verified and the intensity of the infection was assessed in the patients who had previously received specific treatment. The article provides recommendations for using specific IgM determination methods described in present-day Russian and foreign guides and standards of syphilis diagnostics.

Oral Syphilis: a retrospective analysis of 12 cases and a review of the literature

OBJECTIVE

To present a retrospective analysis of multicentre case series of oral syphilis and a review of relevant literature.

SUBJECTS AND METHODS

A PUBMED search was carried out from 1950 to 2011. Clinical records of patients with exclusive/prevalent oral manifestations of syphilis were collected and examined in three independent hospitals.

RESULTS

Of 23 reports describing 34 patients were detected through the review (35% primary, 56% secondary, and 9% tertiary disease), describing unspecific ulcers (59%), mucosal patches (23%), keratosis (6%), pseudomembranes (3%), and gumma (9%). Multicentre case series revealed 12 patients with oral syphilis, of which 17%, 58%, and 25% with, respectively, primary, secondary, and tertiary lesions. Clinically, patients showed white patches (17%), blistering mucositis (8%), chronic unspecific ulcers with/without skin lesions (50%), gumma (17%), and necrosis of the dorsum of the tongue (8%). Oral bullae and tongue necrosis are never described in the current review.

CONCLUSIONS

Diagnosis of syphilis remains a challenge because of the multiform and polymorphous clinical pattern at onset and its ability to imitate different diseases. It is mandatory to include syphilis in the differential diagnosis of unusual oral lesions. Diagnosis of oral lesions of syphilis is often difficult, and biopsy is required in controversial cases.

HIV and STI prevalence and determinants among male migrant workers in India

BACKGROUND

Our objective was to estimate for the first time the prevalence and determinants of human immunodeficiency virus type 1 (HIV-1) and sexually transmitted infections (STIs) among male migrants in India.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a multi-stage stratified probability sample survey of migrant (defined as not born in Surat city) men aged 18 to 49 years working in the diamond and textile industries in Surat city. Behavioural and biological data were collected. Biological data included laboratory diagnosed herpes simplex virus type 2 (HSV-2), syphilis, chlamydia, gonorrhoea, Trichomonas vaginalis (together defined as 'any STI') and HIV-1. Likely recently acquired STIs included chlamydia, gonorrhoea, T. vaginalis and syphilis with rapid plasma reagin ≥1:8. The response rate was 77% (845/1099). Among 841 participants, HIV-1 prevalence was 1.0%, 'any STI' prevalence was 9.5% and 38.9% of these STIs were likely to have been recently acquired. Being a diamond worker, Surat resident for 10+ years and recent antibiotic use were each associated with higher odds of 'any STI' (aORs 1.83 (95% CI 1.09-3.09), 1.98 (95% CI 1.22-3.22) and 2.57 (95% CI 1 .17-5.64), respectively) after adjusting for the other two factors and age. The main study limitation was social desirability bias for self-reported sexual behaviour; STIs were diagnosed in some self-reported virgins.

CONCLUSIONS/SIGNIFICANCE

HIV and STI prevalence were lower than expected, but prevention interventions remain necessary in Surat since almost 40% of STIs among participants were probably recently acquired and sentinel surveillance HIV prevalence remains high. The participants had a similar HIV prevalence to Surat antenatal clinic attendees, a proxy for the general population. This suggests migrants are not always at higher risk of HIV compared to the general population in their migration destination. Our findings highlight the need to contextualise research findings from a specific setting with other local information to guide HIV/STI prevention interventions.

Asymptomatic transmission of Treponema pallidum (syphilis) through deceased donor liver transplantation

A 55-year-old woman underwent liver transplantation (LT) with a graft from a deceased donor. Mandatory pre-donation investigations showed positive syphilis serology that was available only after the transplant, with high Treponema pallidum particle agglutination assay titer compatible with donor syphilis infection. Despite the institution of appropriate post-exposure prophylaxis, the recipient demonstrated latent seroconversion; however, liver graft function improved without evidence of syphilitic hepatitis or other manifestations of the disease. Through this first reported case of asymptomatic transmission of syphilis following LT, we highlight the investigations and treatment strategies for donor-derived syphilis in liver transplant recipients. This report supplements the existing limited evidence on safe use of infected grafts from syphilitic donors through appropriate post-exposure prophylaxis.

Management of syphilis in the HIV-infected patient: facts and controversies

After reaching an all time low at the turn of the millennium in several industrialized countries, the syphilis incidence is rising again, perhaps as a consequence of unsafe sexual behavior in response to improved antiretroviral therapeutic options for HIV. Since the beginning of the HIV pandemic, numerous reports on the various aspects of the interaction between syphilis and HIV have been published. Controversies persist on many issues of the management of coinfected patients. This contribution presents a critical appraisal of the available literature. Few large-scale, properly designed, controlled studies have compared syphilis baseline presentation and treatment response according to HIV status. Among the weakness are (1) high rates of patients lost to follow-up, (2) lack of long-term follow-up, (3) lack of gold standard criteria for treatment response, (4) small sample size, and (5) lack of stratification according to syphilis stage, ongoing antiretroviral treatment, CD4 cell count and HIV viral load. From the available data, and given the ever-possible publication bias, we conclude that if HIV has an effect on the course of syphilis, it is small and clinically manageable in most cases. The controversial issues discussed should furnish the rational for clinical research during the forthcoming decade.

Routine antenatal syphilis screening in South west Nigeria- a questionable practice

BACKGROUND

Untreated maternal syphilis is strongly associated with adverse birth outcomes, especially in women with high titre syphilis. The WHO recommends routine serological screening in pregnancy. Some workers have advised a reappraisal of this practice, having demonstrated low sero-prevalence in their antenatal population. In view of this, the aim of this study was to determine the seroprevalence of syphilis in the antenatal population presenting at a major hospital in south-west Nigeria.

METHODS

This was a cross sectional study of healthy pregnant Nigerian women attending Adeoyo Maternity Hospital in the capital of Oyo State. The case record of every pregnant woman presenting for their first antenatal clinic visit over a 4-month period (September 1st to December 31st 2006) was reviewed.

RESULTS

During the study period, two thousand six hundred and seventy-eight women sought antenatal care. Three hundred and sixty-nine women (369; 13.4%) had incomplete records and were excluded from analysis. The records of the 2,318(86.6%) women with adequate records were subsequently reviewed. The mean age of the women was 27.4 years (± 5.34) and the mean gestational age 26.4 weeks (±6.36). The modal parity was 0. Only three patients were found to be reactive for syphilis giving a prevalence of 0.13%.

CONCLUSION

The sero- prevalence value in this study is quite low and may justify the call to discontinue routine antenatal syphilis screening. However, a more rigorous screening program using diagnostic tests with higher sensitivity maybe necessary before jettisoning this traditional aspect of antenatal care.

Syphilis epidemiology and clinical outcomes in HIV-infected and HIV-uninfected patients in Kaiser Permanente Northern California

BACKGROUND

Syphilis rates are rising in California, but the impact of HIV infection on syphilis infection remains uncertain. We describe differences between HIV-infected and HIV-uninfected patients diagnosed with syphilis within Kaiser Permanente Northern California.

METHODS

We performed retrospective analyses of patients diagnosed with incident syphilis from 1995 to 2005 (622 cases/9989 HIV-infected patients and 3584/4,442,780 HIV-uninfected). Among cases, we ascertained demographic, clinical characteristics, and laboratory (including baseline labs and repeated RPR titers) data. We performed Poisson regression (incidence) and Cox proportional hazard modeling (reduction in RPR and serologic failure after syphilis therapy) adjusting for age, gender, and HIV status and among HIV-infected cases only by use of antiretroviral therapy (ART).

RESULTS

HIV-infected patients had incident syphilis rates of 62.3/1000 person-years compared with 0.8/1000 HIV-uninfected patients, corresponding to an adjusted rate ratio of 86.0 (P <0.001); rate differences increased significantly over time. HIV-infected patients had a greater likelihood of reduction in RPR and serologic failure after syphilis therapy (HR = 2.5 and 2.6 respectively [P <0.001 both]). Among HIV-infected only, patients on ART had lower rates of infection but higher likelihood of reduction in RPR after syphilis therapy and serologic failure compared with patients not on ART.

CONCLUSIONS

HIV-infected patients had greater rate of incident syphilis compared with HIV-uninfected, a disparity which increased over time. HIV-infected patients had greater likelihood of decline in RPR and serologic failure. HIV-infected patients should be screened for syphilis regularly.

Magnetic resonance imaging features of osseous manifestations of early acquired syphilis

We report the case of a 64-year-old man who initially presented with a maculopapular rash followed several weeks later by bilateral shin pain and infiltrative cutaneous lesions over the lower legs. The plain radiographs were not contributory, and the patient was referred for a whole-body bone scan, which demonstrated multifocal osseous lesions, including such lesions in the lower legs, skull and facial bones. Magnetic resonance imaging (MRI) demonstrated numerous small tibial and fibular nodular lesions involving the medullary cavity and the cortex. A diagnosis of acquired syphilis was made, based on skin biopsy. Results of serological testing were consistent with recent infection. The patient was treated with intramuscular injection of penicillin, and follow-up MRI demonstrated gradual resolution of the osseous lesions. Bone involvement is a relatively rare manifestation of early acquired syphilis. Although the plain radiographic features of the bony changes in acquired syphilis are well documented, there have been no reports of the magnetic resonance imaging findings in the appendicular skeleton.

Rectal syphilis mimicking rectal cancer

Rectal syphilis, known as a great masquerader, can be difficult to diagnose because of its variable symptoms. Gastroenterologists should be aware of the possibility of rectal syphilis when confronted with anorectal ulcers, and should gather a detailed history about sexual preferences and practices, including homosexuality. We report a case of primary rectal syphilis mimicking rectal cancer on radiologic imaging. In this report, we described the clinical, endoscopic, and radiologic features of this rare case.