Syphilis in the United States: an update for clinicians with an emphasis on HIV coinfection

Workplace factors associated with willingness to undergo human immunodeficiency virus testing during workplace health checkups

BACKGROUND

To examine workplace factors associated with willingness to undergo human immunodeficiency virus (HIV) testing during workplace health checkups.

METHODS

This cross-sectional study used an Internet-based self-administered questionnaire to obtain data from a pool of 24,287 Japanese workers. Binary and multiple logistic regression analyses evaluated the association between workplace factors and HIV testing. Data were adjusted for sex, age, marital status, education, and history of HIV testing.

RESULTS

We gathered information from 4,143 (17.1%) respondents, of whom 1,129 (27.3%) were willing to be tested for HIV as part of a workplace health checkup. The participants were 20-59 years old. Approximately half of the participants were male (49.9%), half were married (48.9%), and half had completed higher education (47.6%). Workplace hepatitis testing was offered to 15.6% of the respondents, and most participants underwent health checkups without their colleagues (52.1%) at a medical facility (60.2%). Willingness to undergo HIV testing was positively correlated with having an increased risk of occupational blood exposure (vs. not at risk, adjusted odds ratio [OR]: 1.74, 95% confidence interval [CI]: 1.41-2.15) or working in medical and welfare roles (vs. manufacturing, OR: 1.40, 95% CI: 1.07-1.84). The presence of occupational health staff at the workplace (vs. their absence, adjusted OR: 1.35, 95% CI: 1.16-1.59) and hepatitis testing (vs. not testing, adjusted OR: 2.02, 95% CI: 1.66-2.44) increased willingness to undergo HIV testing.

CONCLUSIONS

A pilot HIV-testing program involving individuals at an increased risk of occupational blood exposure and undergoing hepatitis tests in workplaces providing occupational health staff support is recommended.

Otosyphilis

Otosyphilis can be challenging to diagnose, but, if left unrecognized, it may cause irreversible damage. An immunologic interplay between syphilis and human immunodeficiency virus (HIV) makes coinfection likely and may predispose people with HIV to neurosyphilis. In this study, we present a case of a man in his 50s with hearing loss and vertigo diagnosed with otosyphilis as well as a new diagnosis of HIV. This case and corresponding discussion serve to inform the noninfectious disease-trained clinician of the symptoms, diagnostics, and treatment options for otosyphilis as well as to discuss the relationship between HIV and syphilis and demonstrate the importance of disease recognition.

[Trends of HIV and syphilis prevalence among pregnant women in antenatal clinics in Togo: Analysis of sentinel serosurveillance results between 2008 and 2016]

INTRODUCTION

The aim of our work was to analyse the trends of HIV infection and syphilis among pregnant women in prenatal consultation (PNC) in healthcare facilities in Togo.

METHODS

This was an analytical retrospective study, covering the period from 2008 to 2016 and focusing on pregnant women aged 15 to 49 seen in PNC for the first time in maternal and child health services in Togo.

RESULTS

During the study period, 41,536 pregnant women were registered in 2008, 2009, 2010, 2014 and 2016, respectively 8079, 8572, 8430, 7920 and 8535.The mean age of the patients was 26 ± 6 year in 2008, 2009 and 2010. The overall HIV prevalence decreased from 3.4% in 2008 to 2.9% in 2016 (p = 0.0145). It fell from 1% in 2008 to 0.5% in 2016 and from 3.6% in 2008 to 1.4% in 2016 (p < 0.0001) among 15-19 year-old and 20-24 year-old respectively. HIV prevalence in rural areas is two times lower than in urban areas between 2008 and 2016 with a statistically significant difference. The prevalence of syphilis decreased significantly from 2008 (1.3%) to 2016 (0.6%), (p < 0.0001). It is low and not associated with age in 2008; 0.2% and 0.4% in 2016 respectively in the 15 to 19 and 20 to 24 age groups. This prevalence is significantly low between 2008 and 2016 in both urban and rural areas.

CONCLUSION

Our study documents a relatively low prevalence of syphilis and HIV among pregnant women in Togo, with a significant decrease among adolescents and young women, attesting to the effectiveness of the increased screening and comprehensive prevention of sexually transmitted infections (STIs) and HIV, including the antiretroviral treatment as prevention (TASP) approach, and the neonatal syphilis elimination programme in the country.

Rash, red eyes, lip erosions and genital ulcer - What is the diagnosis?

Maculopapular eruptions are frequently described as large areas of rash characterised by red, small, confluent bumps. They are frequently puzzling for the attending clinician due to the multiple possible aetiologies. Accurate diagnosis is important because treatment varies depending on the aetiology, and some rashes can be life-threatening if not treated promptly. Common aetiologies implicated include drug allergies, infection-related (for example: viral exanthems, scarlet fever) and autoimmune conditions (for example: Still's disease). We report a case of maculopapular eruption associated with mucocutaneous involvement and systemic symptoms. The possible differential diagnoses and approach to the management of this patient are discussed.

High Baseline C-Reactive Protein Level Can Predict the Occurrence of the Jarisch-Herxheimer Reaction in Patients with Active Syphilis

Background

The Jarisch–Herxheimer reaction (JHR) is an inflammatory reaction that can occur after treatment for syphilis. The mechanism of JHR is unknown. The level of C-reactive protein (CRP) increases during infection and inflammation. We hypothesized that CRP may be involved in the JHR in syphilitic patients at initial syphilis infection and also through interactions with benzathine penicillin-induced phagocytosis.

Methods

This prospective cohort study enrolled syphilitic adult patients with/without JHR between July 2018 and October 2020. Serum samples before and after the administration of the first dose of benzathine penicillin were obtained. The serum level of CRP was determined by ELISA. The Kruskal–Wallis test was used to compare the levels of CRP in different groups, and the Wilcoxon signed-rank test was used to compare changes in CRP before and after benzathine penicillin treatment.

Results

Twenty-nine syphilitic patients and three control groups (10 men who have sex with men (MSM) taking pre-exposure prophylaxis, 10 HIV-infected patients without syphilis, and 12 HIV-infected patients with previous syphilis) were enrolled. All 29 syphilitic patients were MSM, and 21 patients (72%) were infected with HIV. Overall, 41% (12/29) of the patients developed the JHR. The active syphilis groups had significantly higher serum levels of CRP (median 11,761 ng/mL, IQR 2986–19,061 ng/mL). There were no significant differences in the serum levels of CRP before or after benzathine penicillin treatment. The 12 patients with the JHR had significantly higher CRP levels before benzathine penicillin treatment (16,262 ng/mL [IQR 12,033–26,150 ng/mL] vs 3489 ng/mL [IQR 924–160,640] ng/mL, p = 0.0059, 95% CI 4002–17,098 ng/mL, area under the curve 0.799, 95% CI 0.632–0.966, sensitivity 1, specificity 0.647, with a CRP cut-off value of 4569.32 ng/mL).

Conclusion

A high baseline CRP level can predict the occurrence of the JHR in syphilitic patients treated with benzathine penicillin.

Effectiveness and Tolerability of Oral Amoxicillin in Pregnant Women with Active Syphilis, Japan, 2010-2018

We conducted a nationwide retrospective study in Japan to evaluate the effectiveness of oral amoxicillin or ampicillin as alternatives to injectable benzathine penicillin G for treating pregnant women with syphilis and preventing congenital syphilis (CS). We investigated 80 pregnant women with active syphilis treated with amoxicillin or ampicillin during 2010–2018. Overall, 21% (15/71) had pregnancies resulting in CS cases, and 3.8% (3/80) changed therapies because of side effects. Among 26 patients with early syphilis, no CS cases occurred, but among 45 with late syphilis, 15 (33%) CS cases occurred. Among 57 patients who started treatment >60 days before delivery, 8 (14%) had CS pregnancy outcomes. We found oral amoxicillin potentially ineffective for preventing CS cases among pregnant women with late syphilis but potentially effective in those with early syphilis. Prospective studies are needed to definitively evaluate the efficacy of amoxicillin for the treatment of pregnant women with syphilis to prevent CS.

A case series with literature review on adjunctive usage of intravitreal ceftazidime in ocular syphilis with human immunodeficiency virus infection

BACKGROUND

Penicillin is the conventional treatment for all stages of syphilis, including ocular and neurosyphilis, according to the recommendations by the Centre for Disease Control and Prevention Sexually Transmitted Disease. This case series highlighted three cases of ocular syphilis which showed prompt treatment response as early as 24 h after the adjunctive intravitreal ceftazidime injection.

METHODS

Case Series.

RESULTS

In case 1, there was significant improvement in the vision and vitritis after 24 h of a single intravitreal ceftazidime injection. In case 2, the patient achieved his best vision after a total of three intravitreal injections in his left eye and one in his right eye. In case 3, there was a further resolution of perivascular sheathing and retinal haemorrhages seen 1 week after a single intravitreal ceftazidime injection.

CONCLUSION

The efficacy of intravitreal ceftazidime injection as a local adjunctive therapy in ocular syphilis treatment is noteworthy. It can be considered in cases which show suboptimal or slower treatment response despite early commencement of systemic penicillin to prevent devastating ocular sequelae.

Azithromycin vs penicillin G benzathine for early syphilis: A meta-analysis of randomized controlled trials

Syphilis is a very serious infection that causes acute cutaneous manifestations. Penicillin is the gold standard for treating syphilis. This meta-analysis was conducted based on self-published randomized controlled trials (RCTs) data to compare the efficacy of azithromycin with penicillin for treating syphilis. RCTs on azithromycin vs penicillin for the treatment of syphilis were retrieved from the Cochrane Library, MEDLINE, EBSCO, Embase, Ovid, and other databases, and the estimated risk ratio (RR) and 95% confidence interval (CI) were used to study the following outcome indicators: 3-month response rate, 6-month response rate, 12-month response rate, recurrence rate, serum fixation rate, and failure rate. This meta-analysis included seven RCTs involving 639 subjects (of whom 335 were treated with azithromycin and 304 were treated with penicillin). There was no significant difference in the 3-month response rate (RR = 0.97, 95% CI: 0.79-1.19), 6-month response rate (RR = 1.01, 95% CI: 0.85-1.20), 12-month response rate (RR = 1.02, 95% CI: 0.97-1.09), serum fixation rate (RR = 0.71, 95% CI: 0.24-2.12), and failure rate (RR = 0.62, 95% CI: 0.33-1.16). In summary, there is no evidence in the literature that azithromycin is less effective than penicillin for treating syphilis.

Neurocognitive disorder due to neurosyphilis: a case report

INTRODUCTION

Neurosyphilis is a chronic infectious disease caused by Treponema pallidum that can cause a great variety of neuropsychiatric signs and symptoms, which complicates its diagnosis.

CASE DESCRIPTION

This case occurred in a 40-year-old man who consulted the Emergency Department because of a convulsion (de novo) which was related to a chronic condition of cognitive impairment and psychosis. The appropriate studies were performed for the diagnosis of neurosyphilis and the recommended treatment was initiated. The patient presented clinical improvement and was discharged.

DISCUSSION

Positive VDRL serology results and imaging findings of marked cortical atrophy conducted to consider a late-stage parenchymatous neurosyphilis with serious cognitive impairment and associated psychosis. Treatment with crystalline penicillin was formulated, which reduced the intensity of the patient's symptoms; however, the patient's lack of interest to attend the check-ups significantly reduces his chances of an adequate recovery.

CONCLUSIONS

Neurosyphilis must be suspected in patients with clinically evident neurological or psychiatric symptoms. Analysis of VDRL serology and neuroimaging studies are important as an initial evaluation of the patient and must be complemented with cognitive tests or mental examination to determine the state of cognitive impairment.

Investigation of syphilis immunology and Treponema pallidum subsp. pallidum biology to improve clinical management and design a broadly protective vaccine: study protocol

BACKGROUND

The syphilis epidemic continues to cause substantial morbidity and mortality worldwide, particularly in low- and middle-income countries, despite several recent disease control initiatives. Though our understanding of the pathogenesis of this disease and the biology of the syphilis agent, Treponema pallidum subsp. pallidum has improved over the last two decades, further research is necessary to improve clinical diagnosis and disease management protocols. Additionally, such research efforts could contribute to the identification of possible targets for the development of an effective vaccine to stem syphilis spread.

METHODS

This study will recruit two cohorts of participants with active syphilis infection, one with de novo infection, one with repeat infection. Whole blood specimens will be collected from each study participant at baseline, 4, 12, 24, 36, and 48 weeks, to track specific markers of their immunological response, as well as to compare humoral reactivity to Treponema pallidum antigens between the two groups. Additionally, we will use serum specimens to look for unique cytokine patterns in participants with early syphilis. Oral and blood samples, as well as samples from any syphilitic lesions present, will also be collected to sequence any Treponema pallidum DNA found.

DISCUSSION

By furthering our understanding of syphilis pathogenesis and human host immune response to Treponema pallidum, we will provide important data that will help in development of new point-of-care tests that could better identify active infection, leading to improved syphilis diagnosis and management. Findings could also contribute to vaccine development efforts.

Syphilis and HIV Co-infection in Mississippi: Implications for Control and Prevention

Syphilis and HIV are important public health issues in the United States, especially in the southeastern region. This study aimed to determine and describe the co-infection pattern in Mississippi by using a case-controlled design to analyze cases diagnosed with syphilis or HIV from 2007 to 2016. Direct matching was employed to identify cases that were co-infected during the same calendar year, and binary logistic regression analysis was used to determine predictors of co-infection. Results showed that 1736 (34.0%) of syphilis and HIV cases were co-infected during the same calendar year. Binary logistic regression results demonstrated that race, gender, age group, and exposure category were independently associated with co-infection status. These analyses highlighted the progressive increase of co-infection rates in Mississippi. Collaboration between STI/HIV surveillance teams may identify high-risk individuals and reduce transmission of both diseases.

The prevalence and associated factors of Treponema pallidum among HIV-positive and HIV-negative individuals who attended voluntary counseling and testing center of St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia: A cross-sectional study design

Background:

Treponema pallidum and HIV are among the most common public health problems in Ethiopia. These infections are interrelated. Treponema pallidum causes genital ulcer which enhances HIV transmission and complicates HIV by causing severe ulcer among HIV-positive individuals. Although Treponema pallidum and HIV have a similar route of transmission, screening services for Treponema pallidum are not available in most of the voluntary counseling and testing centers.

Objectives:

This study aimed to assess the seroprevalence of Treponema pallidum and sociodemographic factors among HIV-positive and HIV-negative individuals from the voluntary counseling and testing center of St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia.

Methods:

In this research, a cross-sectional study was conducted and a total of 292 consecutive samples were collected from the voluntary counseling and testing center of St. Paul’s Hospital Millennium Medical College. Data were collected using an interviewer-administered questionnaire. A blood specimen was tested for the presence of Treponema pallidum using rapid plasma reagin and a rapid test kit for HIV. The data were entered and analyzed using SPSS version 20.

Results:

The overall prevalence of Treponema pallidum was 5/292 (1.7%). All HIV-positive clients were negative for Treponema pallidum. None of the risk factors were significantly associated with Treponema pallidum.

Conclusion:

In this study, the prevalence of Treponema pallidum was 5/292 (1.7%). None of the study participants were co-infected with Treponema pallidum and HIV.

Recommendation:

There was a lack of association between syphilis and HIV in this study, but still the prevalence of Treponema pallidum among voluntary counseling and testing center clients is a public health problem. Therefore, Treponema pallidum infection control strategies should be designed in parallel with HIV control strategy and actions should be taken to avert the problem, including the provision of better health education and screening services at voluntary counseling and testing centers parallel with HIV.

Utility of rapid plasmin reagin titres in assessing treatment response and re-infection for infectious syphilis

Background The rapid plasma reagin (RPR) assay is commonly used as a surrogate marker of infectious syphilis, but is non-specific, slow to change and variable in its rate of decline post treatment.

METHODS

Within an urban sexual health service testing predominantly men who have sex with men, a file review of RPR changes was undertaken in all subjects who had a dilution level of ≥1:4, between January 2015 to the end of December 2018.

RESULTS

Overall, 248 cases of infectious syphilis were identified in 215 subjects (165 HIV seropositive, 50 HIV seronegative). Among unique-subject cases with follow-up RPR recorded, seroreversion to a non-reactive titre was achieved in only 42.3% (71/168) cases at a median of 235 days (interquartile range: 138-348 days) and was significantly less likely if patients had HIV infection (P = 0.02), late latent syphilis (P = 0.003) or a subsequent syphilis infection (P < 0.0001). Having HIV infection (P = 0.03) or a subsequent episode of syphilis (P = 0.01) were associated with a lower likelihood of documented cure.

CONCLUSIONS

The slow decay in RPR titres post therapy and the inability of a significant number of subjects to achieve a non-reactive result over time makes RPR a poor test for assessing the adequacy of treatment or in diagnosing re-infection, especially in populations having repeated and frequent risk exposures. As the number of syphilis cases continue to climb, better tests that accurately assess pathogen presence are urgently needed.

Syphilis among adult males with a history of male-to-male sexual contact living with diagnosed HIV in New York State (excluding New York City): The challenge of intersecting epidemics

Since 2009, syphilis has been increasing in New York State (NYS) excluding New York City (NYC) among men with a history of male-to-male sexual contact (MSM). Because MSM make up a disproportionate number of new HIV infections, this study aims to: 1) establish yearly rates of early syphilis diagnosis, 2) assess factors associated with early syphilis diagnosis, and 3) describe missed opportunities for earlier diagnosis of syphilis among MSM living with diagnosed HIV(MSMLWDH) in NYS, excluding NYC. A cohort of adult MSMLWDH alive in 2013 were followed through 2016 to identify individuals with at least one early syphilis diagnosis between July 2014 and December 2016. Early syphilis diagnosis rates were calculated for 2015 and 2016. Crude relative risks and 95% confidence intervals were calculated to determine associations between available covariates and both syphilis diagnosis and missed opportunities. Missed opportunities were defined as reports of an HIV-related laboratory test within a given window corresponding to syphilis staging where syphilis testing was not performed at the same time. Of 7,512 MSMLWDH, 50.0% were non-Hispanic white, 85.4% aged ≥35, and 320(4.3%) had an early syphilis diagnosis. Yearly rates were: 1,838/100,000, and 1,681/100,000 in 2015 and 2016, respectively. Persons who were non-Hispanic black, living with diagnosed HIV for less than three years, aged <45, and were always virally suppressed or always in HIV care were significantly more likely to have a syphilis diagnosis. Over half of individuals had evidence of a missed opportunity for earlier syphilis diagnosis. Syphilis stage at diagnosis, older age, and syphilis diagnosis not concurrent with an HIV-related laboratory test were associated with a higher likelihood of having a missed opportunity. This study supports high interrelatedness of the syphilis and HIV epidemics among MSM. Since syphilis can impact HIV viral load suppression status, efforts to end the HIV epidemic need to be coupled with syphilis elimination efforts.

Clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging

BACKGROUND

Syphilitic myelitis caused by Treponema pallidum is an extremely rare disease. However, symptomatic neurosyphilis, especially syphilitic myelitis, and its clinical features have been infrequently reported. Only a few cases of syphilitic myelitis have been documented. To the best of our knowledge, there are only 19 reported cases of syphilitic myelitis. However, the clinical features of syphilitic myelitis with longitudinally extensive myelopathy have been still not clear.

AIM

To explore the clinical features of syphilitic myelitis with longitudinally extensive myelopathy on spinal magnetic resonance imaging (MRI).

METHODS

First, we report a patient who suffered from syphilitic myelitis with symptoms of sensory disturbance, with longitudinally extensive myelopathy with "flip-flop sign" on spinal MRI. Second, we performed a literature search to identify other reports (reviews, case reports, or case series) from January 1987 to December 2018, using the PubMed and Web of Science databases with the terms including "syphilis", "neurosyphilis", "syphilitic myelitis", "meningomyelitis", "central nervous system", and "spine". We also summarized the clinical features of syphilitic myelitis with longitudinally extensive myelopathy.

RESULTS

A total of 16 articles of 20 cases were identified. Sixteen patients presented with the onset of sensory disturbance (80%), 15 with paraparesis (75%), and 9 with urinary retention (45%). Eleven patients had a high risk behavior (55%). Five patients had concomitant human immunodeficiency virus infection (25%). Serological data showed that 15 patients had positive venereal disease research laboratory test (VDRL)/treponema pallidum particle agglutination (TPHA), and 17 had positive VDRL/TPHA in cerebrospinal fluid (CSF). Seventeen patients were found to have elevated leukocytosis and protein in CSF. On MRI, 16 patients showed abnormal hyperintensities involved the thoracic spine, 6 involved the cervical spine, and 3 involved both the cervical and thoracic spine. There were 3 patients with the "flip-flop sign". All the patients were treated with penicillin, and 15 patients had a good prognosis.

CONCLUSION

Our case further raises awareness of syphilitic myelitis as an important complication of neurosyphilis due to homosexuality, especially in developing countries such as China.

Syphilis

Syphilis is an infectious disease caused by the spirochaete Treponema pallidum subsp. pallidum which is transmitted by sexual contact or vertical transmission during pregnancy. The incidence of syphilis has increased in the last years, mainly among men who have sex with men. Without treatment, the disease develops into different clinical stages, being able to present cardiovascular or irreversible neurological complications after a number of years. The disease is classified as early syphilis - primary, secondary and early latent syphilis (less than 12 months) - which is contagious, and as late syphilis - late latent and tertiary syphilis- which is rarely contagious. Diagnosis and management are often a challenge because of its diversity of manifestations and the difficulty of interpretation of serological tests. The treatment of syphilis is based on penicillin or doxycycline in allergic patients. Treatment failure because of resistance has been described with azithromycin. The follow up with a serological test is recommended in all patients with syphilis in order to ascertain cure after the treatment and to diagnose possible reinfections.

Neurosyphilis Presenting with Anxiety: A Case Report

The number of cases of late and late latent syphilis in the United States is on the rise. This diagnosis is often forgotten when an elderly patient is being worked up for altered mental status. Rarely does a 70-year-old male with neurosyphilis present simply with anxiety. Due to the decreased severity of the presentation, this patient was sent home from the emergency department multiple times until the anxiety progressed to psychosis. He was finally admitted with delirium, suicidal ideation, and paranoia. A routine Treponema pallidum antibody test returned positive and a further workup of confirmatory lab work, a thorough neurological exam, and magnetic resonance imaging (MRI) revealed a chronic syphilis infection. This case study explores signs in the history and physical examination that should quickly prompt a provider to consider neurosyphilis in their differential. This patient presented with Argyll-Robertson pupils and significant risk factors. The goal of this discussion is to bring awareness to this infrequent presentation and share simple examination techniques that could have been used to diagnose and treat this patient's symptoms more promptly. In doing so, the hope is to raise awareness for the diagnosis of neurosyphilis, especially in the elderly patient presenting with psychiatric symptoms.

The unfaithful neuritis

A 55-year-old man with a history of mantle cell lymphoma reported acute blurred vision in the right eye. Although initially diagnosed with acute retrobulbar optic neuritis, 3 weeks later retinal infiltrates and vitritis developed, but vitrectomy resulted negative for vitreoretinal lymphoma. Further investigation revealed a serology positive for syphilis. This case highlights the role of the ophthalmologist in the diagnosis of syphilis, which is able to mimick multiple eye disorders, optic neuritis, and vitreoretinal lymphoma among others.

LncRNA Expression in CD4+ T Cells in Neurosyphilis Patients

Recent studies have shown that several long noncoding RNAs (lncRNAs) are involved in regulating the immune response to cope with pathogenic invasion. To date, the roles of lncRNAs in the CD4+ T cell response to Treponema pallidum (T. pallidum) infection in neurosyphilis patients remain unknown. The mRNA and lncRNA expression profiles of CD4+ T cells that were isolated from neurosyphilis patients and healthy controls were analyzed by microarray. A total of 2258 lncRNAs and 1728 mRNAs were identified as over-expressed or under-expressed, respectively (fold change > 1.5) in the CD4+ T cells of neurosyphilis patients compared to the healthy controls. The lncRNA-mRNA co-expression network showed that 59 lncRNAs showed significant differences along with significantly different mRNAs. Among the 59 gene pairs, the LOC79999 mRNA was positively correlated with the RP11-160E2.16, RP11-160E2.11, and RP11-160E2.19 lncRNAs, and the NKX1-1 mRNA was positively correlated with the RP11-1398P2.1, RP11-160E2.19, and XLOC_003422 lncRNAs. The following five mRNAs were correlated with two differential lncRNAs: DUSP16, AP000349.1, FAM115C, TIMM8A, and SMCHD1. Gene Ontology (GO) analysis revealed that the differentially expressed coding genes were mainly involved in biological processes and the top 4 terms that associated with above-mentioned differentially expressed coding genes were as follows: defense response to fungus, defense response to bacterium, killing of cells of other organism and disruption of cells of another organism. A subsequent pathway analysis was also conducted, and several pathways, including the T cell receptor, MAPK, and TGF-beta signaling pathways, were associated with the differentially expressed mRNAs. This study reveals the differential expression profiles of lncRNAs in the CD4+ T cell response to the T. pallidum infection in neurosyphilis patients. LncRNAs are involved in key biological processes that comprise the CD4+ T cell response to the T. pallidum infection.

Comparison of efficacy of treatments for early syphilis: A systematic review and network meta-analysis of randomized controlled trials and observational studies

BACKGROUND

Parenteral penicillin is the first-line regimen for treating syphilis, but unsuitable for some patients due to penicillin allergy and lacking health resources. Unfortunately, the efficacy of penicillin alternatives remains poorly understood. This study aimed to assess the efficacy of ceftriaxone and doxycycline/tetracycline in treating early syphilis relative to that of penicillin, and thereby to determine which antibiotic is a better replacement for penicillin.

METHOD

By searching literature from PubMed, Cochrane Central Register of Controlled Trials, Embase, the Web of Science, and ClinicalTrials.gov and systematically screening relevant studies, eligible randomized controlled trials (RCTs) and observational studies on treatments with penicillin, doxycycline/tetracycline, and ceftriaxone for early syphilis were identified and combined in this systematic review. Estimated risk ratios (RRs) and 95% confidence intervals (CIs) were utilized to compare their serological response and treatment failure rates. At 12-month follow up, serological response rates were compared by a direct meta-analysis and network meta-analysis (NMA), while treatment failure rates were compared with a direct meta-analysis.

RESULT

Three RCTs and seven cohort studies were included in this research. The results of NMA demonstrated that no significant differences existed in serological response rate at 12-month follow-up between any two of the three treatments (doxycycline/tetracycline vs. penicillin RR = 1.01, 95%CI 0.89-1.14; ceftriaxone vs. penicillin RR = 1.00, 95%CI 0.89-1.13; ceftriaxone vs. doxycycline/tetracycline RR = 0.99, 95%CI 0.96-1.03), which was consistent with the outcomes of the direct meta-analysis. In addition, the direct meta-analysis indicated that, at 12-month follow-up, penicillin and ceftriaxone treatment groups had similar treatment failure rates (RR = 0.92, 95%CI 0.12-6.93), while treatment failure rate was significantly lower among penicillin recipients than among doxycycline/tetracycline recipients (RR = 0.58, 95%CI 0.38-0.89).

CONCLUSION

Ceftriaxone is as effective as penicillin in treating early syphilis with regard to serological response and treatment failure rate. Compared with doxycycline/tetracycline, ceftriaxone appears to be a better choice as the substitution of penicillin.

Prevalence of and Associated Risk Factors for High Risk Human Papillomavirus among Sexually Active Women, Swaziland

BACKGROUND

High risk human papillomavirus (hr-HPV) infection and the dual burden of HIV remains a huge challenge in some low-income countries (LICs) such as Swaziland with limited or no data. We estimated the prevalence and investigated determinants of hr-HPV, including HIV infection among sexually active women in Swaziland.

METHODS

A total of 655 women aged between 15 and 49 years from five health facilities were randomly enrolled using a cross-sectional study design. Cervical cells were tested for hr-HPV types using GeneXpert HPV Assays.

RESULTS

The overall weighted hr-HPV prevalence was 46.2% (95%CI: 42.8-49.5). Of hr-HPV infected women, 12.4% (95%CI: 8.6-17.5) were HPV16-positive, 13.8% (95%CI:12.0-15.8) were positive for HPV18/45, 26.7% (95%CI: 24.2-29.3) for HPV31/33/35/52/58, 7.6% (95%CI: 7.6-11.9) for HPV51/59 and 11.0%, (95%CI: 7.9-15.3) for HPV39/56/66/68. Prevalence of hr-HPV decreased with increasing age. Overall HIV prevalence remained high (42.7%; 95%CI: 35.7-46.2). HIV infection was associated with hr-HPV infection (Adjusted OR = 4.9, 95%CI: 3.043-7.8, p<0.001). Overall hr-HPV/HIV co-infection was 24.4% (95%CI: 20.3-29.1) which was significantly higher among younger age groups (p<0.001). Prevalence of multiple group hr-HPV infection was significantly higher in HIV-positive versus -negative women (27.7% and 12.7% respectively, p<0.001). The presence, absence or unknown of history of STI with HIV did not appear to modify the relationship with hr-HPV (OR = 4.2, 95%CI: 2.6-7.1, OR = 4.6, 95%CI: 2.8-7.7, p<0.001, p<0.001 and OR = 4.1, 95%CI: 1.3-13.4, p<0.021 respectively).

CONCLUSION

The prevalence of hr-HPV infection was high and significantly associated with HIV among sexually active women. Furthermore, the study has provided essential information about the HIV link with hr-HPV infections which may explain the high prevalence among HIV infected women. This can contribute to policy development and planning of prevention strategies incorporating HPV infection prevention especially among youth and HIV infected people.

Longitudinally Extensive Transverse Myelitis and Optic Neuropathy Associated with Syphilitic Meningomyelitis and Human Immunodeficiency Virus Infection: A Case Report and Review of the Literature

The incidence of co-infection with Treponema pallidum and human immunodeficiency virus (HIV) is increasing in developing and developed countries. The neurological complications of both infections occasionally occur simultaneously during a clinical course. We herein report the case of an HIV carrier with syphilitic meningomyelitis and subclinical optic neuropathy. The patient presumably had latent syphilis and slowly developed longitudinally extensive transverse myelitis (LETM). A cerebrospinal fluid examination confirmed the diagnosis of active neurosyphilis based on an elevated T. pallidum hemagglutination assay index. A change in the patient's immune status, possibly due to HIV, might have converted the syphilis from latent to active, leading to LETM of the spinal cord.

Syphilis and HIV/Syphilis Co-infection Among Men Who Have Sex With Men (MSM) in Ecuador

There is a reemergence of syphilis in the Latin American and Caribbean region. There is also very little information about HIV/Syphilis co-infection and its determinants. The aim of this study is to investigate knowledge, attitudes, and practices regarding sexually transmitted infections (STIs), in particular syphilis infection and HIV/Syphilis co-infection, as well as to estimate the prevalence of syphilis among men who have sex with men (MSM) in a city with one of the highest HIV prevalence rates in Ecuador. In this study, questionnaires were administered to 291 adult MSM. Questions included knowledge about STIs and their sexual practices. Blood samples were taken from participants to estimate the prevalence of syphilis and HIV/syphilis co-infection. In this population, the prevalence of HIV/syphilis co-infection was 4.8%, while the prevalence of syphilis as mono-infection was 6.5%. Participants who had syphilis mono-infection and HIV/syphilis co-infection were older. Men who had multiple partners and those who were forced to have sex had increased odds of syphilis and HIV/syphilis co-infection. A high prevalence of syphilis and self-reported STI was observed, which warrants targeted behavioral interventions. Co-infections are a cause for concern when treating a secondary infection in a person who is immunocompromised. These data suggest that specific knowledge, attitudes, and behaviors among MSM are associated with increased odds of STIs (including HIV/syphilis co-infections) in this region of Ecuador.

The Prevalence of Syphilis Infection and Its Associated Factors in the General Population of Rwanda: A National Household-Based Survey

Background. The prevalence of syphilis among HIV-infected people is a public health concern, but there is limited literature to describe the true burden of syphilis in resource-limited settings. We conducted this survey in 2013 to estimate the prevalence of syphilis. Methods. A cross-sectional survey. Participants were tested for syphilis and HIV. Factors associated with syphilis infection were identified. Results. The prevalence of syphilis was 0.9% (95% CI: 0.7-1.1). This prevalence was higher in the 25-49-year-old age (1.1% [95% CI: 0.8-1.3]) than in the 15-24-year-old age (0.6% (95% CI: 0.4-0.9)). Women with lower education had a higher prevalence of syphilis (1.2% (95% CI: 0.9-1.5)) compared to others (0.4% (95% CI: 0.2-0.8)). This prevalence among HIV-infected people was six times higher: 4.8% (95% CI: 2.9-7.9) compared to HIV-negative people (0.8% (95% CI: 0.6-1.0)). The prevalence of syphilis among HIV-infected females was 5.9% (95% CI: 3.4-10.0). HIV-infected or concurrent sexual partners was associated with increased syphilis prevalence with aOR = 4.2 (95% CI: 2.5-7.2) and aOR = 4.2 (95% CI: 2.8-6.5), respectively. Conclusions. The prevalence of syphilis was significantly higher among HIV-infected patients. HIV infection and concurrent sexual partners are associated with an increased prevalence of syphilis. Preventing HIV might help in preventing syphilis.

Sexually Transmitted Infections

Sexually transmitted infections (STIs) remain a significant burden on public health in the United States. Primary prevention counseling with early diagnosis and treatment remain the best methods to decrease the incidence of STIs. Through significant public heath interventions, the incidence of gonorrhea, Chlamydia, and trichomoniasis is decreasing; however, the incidence of primary and secondary syphilis is increasing. Human papilloma virus remains the most common STI, but new vaccinations have the possibility of having a significant impact on this virus's disease potential. This review discusses the most common STIs in the United States, focusing on clinical presentation, diagnosis, and treatment.

Risk Factors of HIV and Other Sexually Transmitted Infections in China: A Systematic Review of Reviews

BACKGROUND

Sexually Transmitted Infections (STIs) are a global challenge. China, once said to have eradicated STIs, is now facing a rapid rise in the prevalence of HIV/STIs. This review of reviews aims to map HIV/STI risk factors among the Chinese population, with the objective of identifying risk factors to inform the formulation of effective prevention strategies.

METHODS

A systematic search using key terms related to HIV/STIs, risk factors and the Chinese population in both English and Chinese databases (PubMed, PsycINFO, the Cochrane Library; Wanfang data, CNKI, VIP and SINOMED) was conducted, and peer-reviewed systematic reviews on the topic from 1991 to 2014 were selected. Identified risk factors were grouped into different level determinants based on the HIV Social Epidemiology Model, and then evaluated and reported based on the PRISMA checklist.

FINDINGS

Of the twenty-eight reviews included, the majority were focused on well-established, individual level risk factors within key populations, with some highlighting the complexity of interacting factors (e.g., alcohol use and higher income in male migrants). While twenty-two reviews covered individual factors, only ten mentioned social factors and five had contents on structural factors. There are gaps in the evidence on social and structural level impacts of HIV/STIs, such as on stigma, discrimination, health policy, access to care, and illicit drug control policies. Migration and social expectation appear to pose a significant threat in aggravating the HIV/STI situation in China; for example, incarceration patterns indicated a significant risk of HIV/STIs for female sex workers.

CONCLUSIONS

Since international guidelines recommend an integrated and multi-level approach to HIV/STI prevention, a comprehensive approach targeting interventions at all levels along the continuum of care is needed to effectively curtail HIV/STI transmission in China. More research is needed to better understand the impact of socio-political interventions within a Chinese context.

Human immunodeficiency virus-positive secondary syphilis mimicking cutaneous T-cell lymphoma

Malignant syphilis or lues maligna is a severe form of secondary syphilis that was commonly reported in the pre-antibiotic era, and has now reemerged with the advent of the human immunodeficiency virus (HIV) epidemic. However, the characteristic histopathological findings of malignant syphilis remain controversial. The aim of this case report was to clarify the clinical and histopathological findings of HIV-positive malignant secondary syphilis. A Japanese man in his forties complained of fever, skin lesions, headache, and myalgia without lymphadenopathy during the previous 4 weeks. The skin lesions manifested as erythematous, nonhealing, ulcerated papules scattered on his trunk, extremities, palm, and face. Although the skin lesions were suspected to be cutaneous T-cell lymphomas on histological analyses, they lacked T-cell receptor Jγ rearrangement; moreover, immunohistochemical analyses confirmed the presence of spirochetes. The patient was administered antibiotics and anti-retroviral therapy, which dramatically improved the symptoms. On the basis of these observations of the skin lesions, we finally diagnosed the patient with HIV-associated secondary syphilis that mimicked cutaneous T-cell lymphoma. The patient’s systemic CD4+ lymphocyte count was very low, and the infiltrate was almost exclusively composed of CD8+ atypical lymphocytes; therefore, the condition was easily misdiagnosed as cutaneous lymphoma. Although the abundance of plasma cells is a good indicator of malignant syphilis on skin histological analyses, in some cases, the plasma cell count may be very low. Therefore, a diagnosis of malignant secondary syphilis should be considered before making a diagnosis of primary cutaneous peripheral T-cell lymphoma or lymphoma associated with HIV infection.

High frequency of neurosyphilis in HIV-positive patients diagnosed with early syphilis

BACKGROUND

Syphilis is an infection frequently seen with HIV, and European guidelines on the management of syphilis suggest that HIV-infected patients may have an increased risk of early neurological involvement, sometimes asymptomatic. Recent study shows a relationship between neurosyphilis and cerebrospinal fluid (CSF) HIV viral load (VL), which in turn may be associated with subsequent neurocognitive decline.

OBJECTIVES AND METHODS

The aim of the study was estimation of the frequency of neurosyphilis among HIV-positive patients with early syphilis. The study included all patients diagnosed with early syphilis who had lumbar puncture performed in the years 2008-2012. Analysis included CSF parameters (serology, mononuclear cells, protein, glucose, chloride and lactate levels), CD4 count, serum VL and highly active antiretroviral therapy (HAART). Diagnosis of neurosyphilis was confirmed by CSF serology [positive fluorescent treponemal antibody and/or Venereal Disease Research Laboratory (VDRL) test(s)] and increased number of mononuclear cells. Statistical analysis included χ(2) tests with an accepted significance level of P < 0.05.

RESULTS

Lumbar puncture was performed in 72 patients, all men, with median age 33 (interquartile range 11) years. Neurosyphilis was confirmed in 65 (90.28%) of the patients. No statistically significant association between CSF parameters and CD4 count was found. However, statistically significant associations were found only between pleocytosis and serum VL > 1000 HIV-1 RNA copies/mL (P = 0.0451), as well as HAART treatment (P = 0.0328). The proportion of confirmed neurosyphilis cases, also in patients with low serum VDRL titres, was very high.

CONCLUSIONS

Considering the high proportion of patients who objected to having LP performed in the absence of neurological symptoms and the risk associated with this procedure, it may be preferable to use treatments with good CNS penetration in all HIV-positive patients with early syphilis.

History of syphilis in women living with AIDS and associated risk factors in São Paulo, Brazil

OBJECTIVE

to describe the epidemiological profile, risk behaviors, frequency of prior history of syphilis in women living with AIDS and to investigate associated factors.

METHODS

a cross-sectional study conducted with women living with HIV attending at Reference Center for AIDS in São Paulo. Demographic, behavioral, and clinical data were analyzed based on medical records.

RESULTS

a total of 598 women were included in the study and the prevalence of previous syphilis was 6.2% (95% CI 4,3-8,1). Seventy-three percent of women were less than 40 years of age when diagnosed with AIDS and 49.6% had more than eight years of formal education. 67.2% were white and 65.9% were not married or living with a partner, 53.2% reported that their first sexual intercourse aged more than 15 years, 56.5% reported having only one partner in the last year and 13% reported drug use. Regarding laboratory data, 83.8% had CD4+ <500 cells/ mm3 upon diagnosis of AIDS. Previous syphilis was associated with the use of crack cocaine [AOR = 6.8 (95% CI 1.7 - 27.5)], >1 sexual partner in the last year [AOR = 6.6 (95% CI 1.2 - 37.1)], CD4 + <500 cells/mm3 [AOR = 3.8 (women 1.1 - 13.6)], HIV diagnosis > 8 years [AOR = 2.4 (95% CI 1.0 - 5.8)].

CONCLUSION

a high prevalence of previous syphilis was found in the population studied, and crack use was identified among the main associated risk factors. Interventions to reduce the risk of sexual transmission of HIV and syphilis must be strengthened, with the implementation of control actions, screening strategies, early diagnosis and treatment, preventing complications, reducing morbidity and improving sexual and reproductive health.

High-dose oral amoxicillin plus probenecid is highly effective for syphilis in patients with HIV infection

BACKGROUND

Intramuscular benzathine penicillin G (BPG) is widely used for the treatment of syphilis. However, BPG is not available in some countries. This study examined the effectiveness and safety of high-dose oral amoxicillin plus probenecid for the treatment of syphilis in patients with human immunodeficiency virus type 1 (HIV-1).

METHODS

This retrospective observational study included 286 HIV-infected male patients with syphilis (median age, 36 years; median CD4 count, 389 cells/µL) who were treated with oral amoxicillin 3 g plus probenecid. Syphilis was diagnosed by both serum rapid plasma reagin (RPR) titers ≥8 and positive Treponema pallidum hemagglutination test. Patients with neurosyphilis diagnosed by cerebrospinal fluid examination were excluded. Successful treatment was defined as a at least 4-fold decrement in RPR titer.

RESULTS

The overall treatment efficacy was 95.5% (95% confidence interval [CI], 92.4%-97.7%; 273/286 patients), and efficacy for primary, secondary, early latent, late latent, and unknown duration syphilis was 93.8% (95% CI, 68.1%-99.8%; 15/16), 97.3% (95% CI, 92.9%-99.2%; 142/146), 100% (95% CI, 90.5%-100%; 37/37), 85.7% (95% CI, 58.6%-96.4%; 18/21), and 92.4% (95% CI, 81.9%-97.3%; 61/66), respectively. Treatment duration was mostly 14-16 days (49.7%) or 28-30 days (34.3%), with efficacy of 94.4% (134/142) and 95.9% (94/98), respectively; 96.3% of successfully treated patients achieved a ≥4-fold decrement in RPR titer within 12 months. Adverse events were noted in 28 (9.8%) patients, and 25 of these (89.3%) were successfully treated. Only 6% of patients underwent lumbar puncture.

CONCLUSIONS

The combination of oral amoxicillin 3 g plus probenecid was highly effective and tolerable for the treatment of syphilis in patients with HIV-1 infection.

A single dose of benzathine penicillin G is as effective as multiple doses of benzathine penicillin G for the treatment of HIV-infected persons with early syphilis

BACKGROUND

Treatment guidelines recommend the use of a single dose of benzathine penicillin G (BPG) for treating early syphilis in human immunodeficiency virus (HIV)-infected persons. However, data supporting this recommendation are limited. We examined the efficacy of single-dose BPG in the US Military HIV Natural History Study.

METHODS

Subjects were included if they met serologic criteria for syphilis (ie, a positive nontreponemal test [NTr] confirmed by treponemal testing). Response to treatment was assessed at 13 months and was defined by a ≥4-fold decline in NTr titer. Multivariate Cox proportional hazard regression models were utilized to examine factors associated with treatment response.

RESULTS

Three hundred fifty subjects (99% male) contributed 478 cases. Three hundred ninety-three cases were treated exclusively with BPG (141 with 1 dose of BPG). Treatment response was the same among those receiving 1 or >1 dose of BPG (92%). In a multivariate analysis, older age (hazard ratio [HR], 0.82 per 10-year increase; 95% confidence interval [CI], .73-.93) was associated with delayed response to treatment. Higher pretreatment titers (reference NTr titer <1:64; HR, 1.94 [95% CI, 1.58-2.39]) and CD4 counts (HR, 1.07 for every 100-cell increase [95% CI, 1.01-1.12]) were associated with a faster response to treatment. Response was not affected by the number of BPG doses received (reference, 1 dose of BPG; HR, 1.11 [95% CI, .89-1.4]).

CONCLUSIONS

In this cohort, additional BPG doses did not affect treatment response. Our data support the current recommendations for the use of a single dose of BPG to treat HIV-infected persons with early syphilis.

Neurosyphilis: epidemiology, pathogenesis, clinical course and laboratory diagnostics

The article describes the key achievements and problems related to studying neurosyphilis. It also shows the dynamics of neurosyphilis incidence in Russia and abroad from the early twentieth century and up to present. The article also describes issues related to the pathogenesis, clinical course and pathomorphism of the disease. The authors present current approaches to the laboratory diagnostics of neurosyphilis.

Scaling up epidemics of acute hepatitis C and syphilis in HIV-infected men who have sex with men in Spain

BACKGROUND

Outbreaks of acute hepatitis C in HIV-positive men who have sex with men (MSM) are being reported in large cities in western countries along with increasing rates of sexually transmitted diseases.

METHODS

All HIV individuals attended at a large outclinic in Madrid within the last 5 years were examined. Incident syphilis was diagnosed based on rapid plasma reagin (RPR) reactivity, being negative previously or showing >4-fold increase. Acute hepatitis C was diagnosed based on HCV antibody seroconversion and/or positive serum HCV-RNA after being negative within the last year.

RESULTS

A total of 859 episodes of syphilis and 19 of acute hepatitis C were diagnosed during the study period. Syphilis was recognized in 65/2,094 (3.1%) individuals attended in 2008 and rose up to 261/2,512 (10.4%) in 2012 (P < 0.001). Acute hepatitis C was diagnosed in only one subject in 2008 but rose up to 7 in 2012 (P = 0.12). All 19 HIV patients with acute hepatitis C were MSM. Syphilis was diagnosed concomitantly in seven. All eight individuals who were treated with peginterferon/ribavirin were cured, whereas only one untreated experienced spontaneous clearance (P = 0.004). Two clusters of infections by HCV genotypes 4 and 1a were identified by phylogenetic analyses.

CONCLUSIONS

The incidence of acute hepatitis C is low but steadily increasing in HIV-positive MSM in Madrid (<1% yearly), despite the very high rates of syphilis (currently 20% yearly in HIV-positive MSM). Preventive measures for sexually transmitted infections and periodic HCV screening are warranted in this population as treatment of acute hepatitis C is very effective.

Syphilis and HIV coinfection - Hungarian Sexually Transmitted Infection Centre Experience between 2005 and 2013

BACKGROUND

STIs like HIV and syphilis are acquired as comorbidities by high risk populations and may influence their original course and prognosis.

METHODS

Between January of 2005 and 2013 data of syphilis and HIV patients were collected at the Department of Dermatology of Semmelweis University, Budapest. Diagnostic procedures included clinical analysis and screening of serum samples for Treponema pallidum and HIV antibodies.

RESULTS

A total of 1,401 new syphilitic and 338 new HIV infections were diagnosed. In syphilis patients 86.58% had monoinfection,7.92% already had an HIV infection and 5.5% had acquired syphilis and HIV infection simultaneously, so 22.78% of the new HIV patients acquired the infection with syphilis together. Male gender, MSM (men who had sex with men) orientation and positive past venerological history were dominant in all groups. Most patients were diagnosed in a latent infectious stage based on the result of a serological check-up. Secondary stage and neurosyphilis were more common in coinfections.

CONCLUSION

(i) male gender, MSM orientation, and positive venerological history are risk factors for acquiring new STIs, (ii) clinical course were different in HIV infected patients, (iii) but their timely and regular check-ups resulted in earlier diagnosis of syphilis, suggesting the necessity for frequent screening.

Opt-out and opt-in testing increases syphilis screening of HIV-positive men who have sex with men in Australia

Background

Since 2005, Australian clinicians were advised to undertake quarterly syphilis testing for all sexually active HIV-positive men who have sex with men (MSM). We describe differences in syphilis testing frequency among HIV-positive MSM by clinic testing policies since this recommendation.

Methods

Three general practices, two sexual health clinics and two hospital HIV outpatient clinics provided data on HIV viral load and syphilis testing from 2006–2010. Men having ≥1 viral load test per year were included; >95% were MSM. We used Chi-2 tests to assess changes in syphilis testing frequency over time, and differences by clinic testing policy (opt-out, opt-in and risk-based).

Results

The proportion of men having HIV viral loads with same-day syphilis tests increased from 37% in 2006 to 63% in 2007 (p<0.01) and 68–69% thereafter. In 2010, same-day syphilis testing was highest in four clinics with opt-out strategies (87%, range:84–91%) compared with one clinic with opt-in (74%, p = 0.121) and two clinics with risk-based strategies (22%, range:20–24%, p<0.01). The proportion of men having ≥3 syphilis tests per year increased from 15% in 2006 to 36% in 2007 (p<0.01) and 36–38% thereafter. In 2010, the proportion of men having ≥3 syphilis tests in a year was highest in clinics with opt-out strategies (48%, range:35–59%), compared with opt-in (39%, p = 0.121) and risk-based strategies (8.4%, range:5.4–12%, p<0.01).

Conclusion

Over five years the proportion of HIV-positive men undergoing syphilis testing at recommended frequencies more than doubled, and was 5–6 times higher in clinics with opt-out and opt-in strategies compared with risk-based policies.

Clinical Spectrum of Oral Secondary Syphilis in HIV-Infected Patients

Background. Oral lesions may constitute the first clinical manifestation in secondary syphilis, but detailed descriptions in HIV-infected individuals are scarce. Objective. To describe the clinical characteristics of oral secondary syphilis in HIV-infected patients and its relevance in the early diagnosis of syphilis. Methods. Twenty HIV/AIDS adult subjects with oral secondary syphilis lesions presenting at two HIV/AIDS referral centers in Mexico City (2003–2011) are described. An oral examination was performed by specialists in oral pathology and medicine; when possible, a punch biopsy was done, and Warthin-Starry stain and immunohistochemistry were completed. Intraoral herpes virus infection and erythematous candidosis were ruled out by cytological analysis. Diagnosis of oral syphilis was confirmed with positive nontreponemal test (VDRL), and, if possible, fluorescent treponemal antibody test. Results. Twenty male patients (median age 31.5, 21–59 years) with oral secondary syphilis lesions were included. Oral lesions were the first clinical sign of syphilis in 16 (80%) cases. Mucous patch was the most common oral manifestation (17, 85.5%), followed by shallow ulcers (2, 10%) and macular lesions (1, 5%). Conclusions. Due to the recent rise in HIV-syphilis coinfection, dental and medical practitioners should consider secondary syphilis in the differential diagnosis of oral lesions, particularly in HIV-infected patients.

A longitudinal evaluation of Treponema pallidum PCR testing in early syphilis

Background

Syphilis is a growing public health problem among men who have sex with men (MSM) globally. Rapid and accurate detection of syphilis is vital to ensure patients and their contacts receive timely treatment and reduce ongoing transmission.

Methods

We evaluated a PCR assay for the diagnosis of Treponema pallidum using swabs of suspected early syphilis lesions in longitudinally assessed MSM.

Results

We tested 260 MSM for T pallidum by PCR on 288 occasions: 77 (26.7%) had early syphilis that was serologically confirmed at baseline or within six weeks, and 211 (73.3%) remained seronegative for syphilis. Of 55 men with primary syphilis, 49 were PCR positive, giving a sensitivity of 89.1% (95% CI: 77.8%-95.9%) and a specificity of 99.1% (95% CI: 96.5%-99.9%). Of 22 men with secondary syphilis, 11 were PCR positive, giving a sensitivity of 50% (95% CI: 28.2%-71.8%) and a specificity of 100% (95% CI: 66.4%-71.8%). Of the 77 syphilis cases, 43 (56%) were HIV positive and the sensitivity and specificity of the PCR test did not vary by HIV status. The PCR test was able to detect up to five (10%) primary infections that were initially seronegative, including one HIV positive man with delayed seroconversion to syphilis (72 to 140 days) and one HIV positive man who did not seroconvert to syphilis over 14 months follow-up. Both men had been treated for syphilis within a week of the PCR test.

Conclusions

T pallidum PCR is a potentially powerful tool for the early diagnosis of primary syphilis, particularly where a serological response has yet to develop.

HIV infection and stroke: current perspectives and future directions

HIV infection can result in stroke via several mechanisms, including opportunistic infection, vasculopathy, cardioembolism, and coagulopathy. However, the occurrence of stroke and HIV infection might often be coincidental. HIV-associated vasculopathy describes various cerebrovascular changes, including stenosis and aneurysm formation, vasculitis, and accelerated atherosclerosis, and might be caused directly or indirectly by HIV infection, although the mechanisms are controversial. HIV and associated infections contribute to chronic inflammation. Combination antiretroviral therapies (cART) are clearly beneficial, but can be atherogenic and could increase stroke risk. cART can prolong life, increasing the size of the ageing population at risk of stroke. Stroke management and prevention should include identification and treatment of the specific cause of stroke and stroke risk factors, and judicious adjustment of the cART regimen. Epidemiological, clinical, biological, and autopsy studies of risk, the pathogenesis of HIV-associated vasculopathy (particularly of arterial endothelial damage), the long-term effects of cART, and ideal stroke treatment in patients with HIV are needed, as are antiretrovirals that are without vascular risk.