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Craft M, Ohene-Nyako P, Yung-Ping Chong D. Congenital Syphilis and the Orthopaedic Perspective: A Case Report. JBJS Case Connect 2024; 14:01709767-202406000-00023. [PMID: 38704646 DOI: 10.2106/jbjs.cc.24.00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
CASE We report a case of an otherwise healthy 4-month-old male infant presenting with unexplained metaphyseal lucent bands and diaphyseal periosteal reactions in bilateral extremities upon radiograph, who was ultimately diagnosed with congenital syphilis. After subsequent workup and treatment, the patient had appropriate range of motion of all extremities within 2 weeks after discharge. CONCLUSION The purpose of this report was to increase the awareness of the rising incidence of congenital syphilis in the United States and educate fellow orthopaedic surgeons on ways to differentiate the skeletal manifestations of congenital syphilis from other pathologies with significant bone involvement.
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Affiliation(s)
- Madison Craft
- Department of Orthopedic Surgery & Rehabilitation, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Prince Ohene-Nyako
- University of Oklahoma Health Sciences Center, College of Medicine, Oklahoma City, Oklahoma
| | - David Yung-Ping Chong
- Department of Orthopedic Surgery & Rehabilitation, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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2
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Song YJ, Choi H. Seasonality of syphilis in males through the 2011 to 2019 mandatory surveillance period: A cross-sectional study in South Korea. Medicine (Baltimore) 2023; 102:e36723. [PMID: 38115249 PMCID: PMC10727654 DOI: 10.1097/md.0000000000036723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/21/2023] Open
Abstract
Although the effects of seasonality on syphilis have been discussed previously, no previous study has evaluated the seasonality of syphilis incidence by sex and age group. We examined the seasonality of syphilis incidence by sex and age group in Korea from 2011 to 2019. The incidence of syphilis was calculated on the basis of Korea Diseases Control and Prevention Agency data, and an autoregressive integrated moving average (ARIMA) model and seasonal and trend decomposition using Loess were used to analyze the seasonality of the incidence in relation to epidemiological factors. The annual age-standardized incidence rates of primary, secondary, and congenital syphilis were 21.1, 8.8, and 64.0 cases/million persons, respectively, from 2011 to 2019. The highest incidence rates for primary and secondary syphilis were observed among those aged 20 to 29, 13 to 19, and 30 to 49 years, but not among the lower age groups. In analyses based on the ARIMA model, all univariate time series showed the highest goodness-of-fit results with ARIMA for primary syphilis (1,1,2), secondary syphilis (1,1,1), and congenital syphilis (0,1,2) (2,0,0) models. This study suggests that the incidence of secondary syphilis shows a summer seasonality for males and the highest incidence rate in the 20 to 29-year age group for both males and females in Korea. Public health action is needed to prevent an increase in syphilis incidence associated with sex, age group, and seasonal patterns.
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Affiliation(s)
- Yeong-Jun Song
- Division of HIV/AIDS Prevention and Control, Bureau of Infectious Disease Policy, Korea Disease Control and Prevention Agency, Cheongju-si, South Korea
| | - Hoyong Choi
- Division of HIV/AIDS Prevention and Control, Bureau of Infectious Disease Policy, Korea Disease Control and Prevention Agency, Cheongju-si, South Korea
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3
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Fukama E, Nomura T, Hatanaka D, Kusakari M, Takahashi H, Nakamura T, Takahashi N. Cytokine profiles in an extremely preterm infant with congenital syphilis. Fukushima J Med Sci 2023; 69:185-189. [PMID: 37766559 PMCID: PMC10694514 DOI: 10.5387/fms.2023-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/07/2023] [Indexed: 09/29/2023] Open
Abstract
We report the cytokine profiles of an infant with congenital syphilis as a first case. This female infant was born by vaginal delivery at a gestational age of 27 weeks during her mother's treatment for syphilis. Elevation of T helper (Th)-1 cytokines (interleukin (IL)-2, IL-12) and IL-17, which supports immunological mechanisms of Th-1, was similar to that in cases of syphilis in adults. IL-6 and granulocyte colony-stimulating factor (G-CSF), the synergistic effects of which cause the leukemoid reaction, were also elevated. The levels of interferon-γ and IL-17 in cerebral spinal fluid, which are elevated in neurosyphilis in adults, were slightly elevated.
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Affiliation(s)
- Eisuke Fukama
- Department of Neonatology, Japanese Red Cross Musashino Hospital
| | - Tomoaki Nomura
- Department of Neonatology, Japanese Red Cross Musashino Hospital
| | - Daisuke Hatanaka
- Department of Neonatology, Japanese Red Cross Musashino Hospital
| | - Michiko Kusakari
- Department of Neonatology, Japanese Red Cross Musashino Hospital
| | | | | | - Naoto Takahashi
- Department of Pediatrics, Tokyo University School of Medicine
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4
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Lazzarin S, Giacomelli A, Moschese D, Antinori S, Gervasoni C. Drug Shortages Highlight the Need for Expanded Treatment Options for Syphilis. Clin Infect Dis 2023; 77:1356. [PMID: 37390811 DOI: 10.1093/cid/ciad396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/02/2023] [Accepted: 06/26/2023] [Indexed: 07/02/2023] Open
Affiliation(s)
- Samuel Lazzarin
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Andrea Giacomelli
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Davide Moschese
- I Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
| | - Spinello Antinori
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
- Dipartimento di Scienze Biomediche e Cliniche Luigi Sacco, Università degli Studi di Milano, Milan, Italia
| | - Cristina Gervasoni
- III Division of Infectious Diseases, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli-Sacco University Hospital, Milan, Italy
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Wu H, Xue M, Wu C, Lu Q, Ding Z, Wang X, Fu T, Yang K, Lin J. Scaling law characteristics and spatiotemporal multicomponent analysis of syphilis from 2016 to 2022 in Zhejiang Province, China. Front Public Health 2023; 11:1275551. [PMID: 37965512 PMCID: PMC10642232 DOI: 10.3389/fpubh.2023.1275551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/10/2023] [Indexed: 11/16/2023] Open
Abstract
Background Syphilis has caused epidemics for hundreds of years, and the global syphilis situation remains serious. The reported incidence rate of syphilis in Zhejiang Province has ranked first in the province in terms of notifiable infectious diseases for many years and is the highest in China. This study attempts to use the scaling law theory to study the relationship between population size and different types of syphilis epidemics, while also exploring the main driving factors affecting the incidence of syphilis in different regions. Methods Data on syphilis cases and affected populations at the county level were obtained from the China Disease Control and Prevention Information System. The scaling relationship between different stages of syphilis and population size was explained by scaling law. The trend of the incidence from 2016 to 2022 was tested by the joinpoint regression. The index of distance between indices of simulation and observation (DISO) was applied to evaluate the overall performance of joinpoint regression model. Furthermore, a multivariate time series model was employed to identify the main driving components that affected the occurrence of syphilis at the county level. The p value less than 0.05 or confidence interval (CI) does not include 0 represented statistical significance for all the tests. Results From 2016 to 2022, a total of 204,719 cases of syphilis were reported in Zhejiang Province, including 2 deaths, all of which were congenital syphilis. Latent syphilis accounted for 79.47% of total syphilis cases. The annual percent change (APCs) of all types of syphilis, including primary syphilis, secondary syphilis, tertiary syphilis, congenital syphilis and latent syphilis, were - 21.70% (p < 0.001, 95% CI: -26.70 to -16.30), -16.80% (p < 0.001, 95% CI: -20.30 to -13.30), -8.70% (p < 0.001, 95% CI: -11.30 to -6.00), -39.00% (p = 0.001, 95% CI: -49.30 to -26.60) and - 7.10% (p = 0.008, 95% CI: -11.20 to -2.80), respectively. The combined scaling exponents of primary syphilis, secondary syphilis, tertiary syphilis, congenital syphilis and latent syphilis based on the random effects model were 0.95 (95% CI: 0.88 to 1.01), 1.14 (95% CI: 1.12 to 1.16), 0.43 (95% CI: 0.37 to 0.49), 0.0264 (95% CI: -0.0047 to 0.0575) and 0.88 (95% CI: 0.82 to 0.93), respectively. The overall average effect values of the endemic component, spatiotemporal component and autoregressive component for all counties were 0.24, 0.035 and 0.72, respectively. The values of the autoregressive component for most counties were greater than 0.7. The endemic component of the top 10 counties with the highest values was greater than 0.34. Two counties with value of the spatiotemporal component higher than 0.1 were Xihu landscape county and Shengsi county. From 2016 to 2022, the endemic and autoregressive components of each county showed obvious seasonal changes. Conclusion The scaling exponent had both temporal trend characteristics and significant heterogeneity in the association between each type of syphilis and population size. Primary syphilis and latent syphilis exhibited a linear pattern, secondary syphilis presented a superlinear pattern, and tertiary syphilis exhibited a sublinear pattern. This suggested that further prevention of infection and transmission among high-risk populations and improvement of diagnostic accuracy in underdeveloped areas is needed. The autoregressive components and the endemic components were the main driving factors that affected the occurrence of syphilis. Targeted prevention and control strategies must be developed based on the main driving modes of the epidemic in each county.
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Affiliation(s)
- Haocheng Wu
- Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China
- Key Laboratory for Vaccines and Prevention and Control of Infectious Disease of Zhejiang Province, Hangzhou, China
| | - Ming Xue
- Hangzhou Centre for Disease Control and Prevention, Hangzhou, China
| | - Chen Wu
- Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China
| | - Qinbao Lu
- Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China
| | - Zheyuan Ding
- Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China
| | - Xinyi Wang
- Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China
| | - Tianyin Fu
- Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China
| | - Ke Yang
- Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China
| | - Junfen Lin
- Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China
- Key Laboratory for Vaccines and Prevention and Control of Infectious Disease of Zhejiang Province, Hangzhou, China
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Castro-Fonseca E, Rosa B, Silva VR, Andrade CV, Praxedes I, Guastavino AB, Esteves CG, Chalfun G, Prata-Barbosa A, Chimelli L, Garcez PP, Lent R. Pronounced decline of absolute cell numbers in the brain of a newborn with congenital syphilis. J Neuropathol Exp Neurol 2023; 82:887-890. [PMID: 37550256 DOI: 10.1093/jnen/nlad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Affiliation(s)
- Emily Castro-Fonseca
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Barbara Rosa
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Viviane R Silva
- Fernandes Figueira Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Cecilia V Andrade
- Fernandes Figueira Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Inês Praxedes
- Department of Pathology, Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andréa B Guastavino
- Department of Neonatology, Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Claudia G Esteves
- Department of Neonatology, Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Georgia Chalfun
- Department of Neonatology, Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Arnaldo Prata-Barbosa
- Department of Neonatology, Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Pediatrics, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Leila Chimelli
- Laboratory of Neuropathology, Rio de Janeiro State Brain Institute, Rio de Janeiro, Brazil
| | - Patricia P Garcez
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Roberto Lent
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
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Warzywoda S, Fowler JA, Nourse C, Wu M, Britton S, Rowling D, Griffin P, Lazarou M, Hamilton Z, Dean JA. Syphilis in pregnancy: a qualitative investigation of healthcare provider perspectives on barriers to syphilis screening during pregnancy in south-east Queensland. Sex Health 2023; 20:330-338. [PMID: 37245957 DOI: 10.1071/sh22193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/08/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Increasing rates of syphilis in pregnancy (SiP) in Australia and other high-income countries, has led to the resurgence of congenital syphilis. Suboptimal syphilis screening during pregnancy has been identified as a key contributing factor. METHODS This study aimed to explore, from the perspective of multidisciplinary healthcare providers (HCPs), the barriers to optimal screening during the antenatal care (ANC) pathway. Semi-structured interviews conducted with 34 HCPs across multiple disciplines practising in south-east Queensland (SEQ) were analysed through a process of reflexive thematic analysis. RESULTS Barriers were found to occur at the system level of ANC, through difficulties in patient engagement in care, limitations in the current model of health care delivery and limitations in the communication pathways across health care disciplines; and at the individual HCP level, through HCP knowledge and awareness of epidemiological changes in syphilis in SEQ, and adequately assessing patient risk. CONCLUSION It is imperative that the healthcare systems and HCPs involved in ANC address these barriers to improve screening in order to optimise management of women and prevent congenital syphilis cases in SEQ.
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Affiliation(s)
- Sarah Warzywoda
- The University of Queensland, Faculty of Medicine, School of Public Health, 288 Herston Road, Herston, Qld 4006, Australia
| | - James A Fowler
- The University of Queensland, Faculty of Medicine, School of Public Health, 288 Herston Road, Herston, Qld 4006, Australia
| | - Clare Nourse
- The University of Queensland, Faculty of Medicine, School of Medicine, 288 Herston Road, Herston, Qld 4006, Australia; and Infection Management and Prevention Service, Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, 501 Stanley Street, South Brisbane, Qld 4101, Australia
| | - Mandy Wu
- The University of Queensland, Faculty of Medicine, School of Medicine, 288 Herston Road, Herston, Qld 4006, Australia; and Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, 501 Stanley Street, South Brisbane, Qld 4101, Australia
| | - Sumudu Britton
- The University of Queensland, Faculty of Medicine, School of Medicine, 288 Herston Road, Herston, Qld 4006, Australia; and Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, 7 Butterfield Street, Herston, Qld 4029, Australia
| | - Diane Rowling
- Metro North Public Health Unit, Metro North Hospital and Health Service, Bryden Street, Windsor, Qld 4030, Australia
| | - Paul Griffin
- The University of Queensland, Faculty of Medicine, School of Medicine, 288 Herston Road, Herston, Qld 4006, Australia; and Mater Health Brisbane, Raymond Terrace, South Brisbane, Qld 4101, Australia
| | - Mattea Lazarou
- The University of Queensland, Faculty of Medicine, School of Public Health, 288 Herston Road, Herston, Qld 4006, Australia; and Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, 501 Stanley Street, South Brisbane, Qld 4101, Australia
| | - Zoe Hamilton
- The University of Queensland, Faculty of Medicine, School of Public Health, 288 Herston Road, Herston, Qld 4006, Australia
| | - Judith A Dean
- The University of Queensland, Faculty of Medicine, School of Public Health, 288 Herston Road, Herston, Qld 4006, Australia
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Maldonado-Barrueco A, Grasa CD, Grandioso-Vas D, Del Rosal T, Sánchez-Holgado M, Sánchez-García L, López-Ortego P, Falces-Romero I, García-Rodríguez J, Quiles-Melero I. Treponema pallidum causing congenital syphilis with severe multisystem involvement. J Travel Med 2023; 30:6967000. [PMID: 36591923 DOI: 10.1093/jtm/taac152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Alfredo Maldonado-Barrueco
- Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
| | - Carlos Daniel Grasa
- Pediatric Infectious Disease Unit, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
- CIBERINFEC ISCIII, Instituto de Salud Carlos III, Madrid, Spain
| | - David Grandioso-Vas
- Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
| | - Teresa Del Rosal
- Pediatric Infectious Disease Unit, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
- Neonatology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
| | - María Sánchez-Holgado
- Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Madrid, Spain
| | - Laura Sánchez-García
- Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Madrid, Spain
| | - Paloma López-Ortego
- Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Madrid, Spain
| | - Iker Falces-Romero
- Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
- CIBERINFEC ISCIII, Instituto de Salud Carlos III, Madrid, Spain
| | - Julio García-Rodríguez
- Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
- CIBERINFEC ISCIII, Instituto de Salud Carlos III, Madrid, Spain
| | - Inmaculada Quiles-Melero
- Clinical Microbiology and Parasitology Department, Hospital Universitario La Paz-Carlos III-Cantoblanco, Madrid, Spain
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Smith-Guzmán NE. A paleoepidemiological approach to the challenging differential diagnosis of an isolated 1500-year-old anomalous molar from Panamá. Int J Paleopathol 2022; 39:1-13. [PMID: 36029689 DOI: 10.1016/j.ijpp.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/02/2022] [Accepted: 07/03/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study seeks to quantify the presence and prevalence of specific genetic and infectious diseases in the pre-Colombian Panamanian population and uses these data to consider the plausibility of these diseases as causative factors in the development of an abnormal supernumerary cusp morphology in a 1500-year-old isolated molar recovered from Cerro Juan Díaz (Los Santos, Panama). MATERIALS 267 individuals from pre-Columbian sites throughout Panama. METHODS The anomalous tooth was analyzed through macroscopic, odontometric, and radiographic means. Tentative differential diagnosis was performed using inferences from paleopathological features of the broader regional population. RESULTS The regional sample showed evidence of treponemal infection and developmental anomalies in 10.1% and 10.9% of individuals, respectively. CONCLUSIONS While not able to rule out three potential genetic conditions, more evidence was found to support the differential diagnosis of congenital syphilis as the causative agent leading to the development of abnormal supernumerary cusps in the isolated molar. SIGNIFICANCE This study demonstrates how characterizing disease experience in the population can assist in differential diagnoses at the individual level and cautions against the assumption that any one lesion in isolation is unique to only one specific pathological condition. LIMITATIONS The timing discrepancy between clinical descriptions of congenital syphilis and genetic disorders, lack of knowledge on pathophysiological mechanisms of the former, poor preservation of Treponema pathogen ancient DNA, and deficiencies in modern public health data from Panama limit the differential diagnosis. SUGGESTIONS FOR FURTHER RESEARCH Inclusion and serious contemplation of genetic diseases in paleopathological differential diagnoses is necessary.
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Bin S. Congenital pemphigus syphiliticus: a characteristic feature of a forgotten disease. BMJ Case Rep 2021; 14:e246310. [PMID: 34620640 PMCID: PMC8499253 DOI: 10.1136/bcr-2021-246310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sakviseth Bin
- Neonatal Intensive Care Unit, Calmette Hospital, Phnom Penh, Cambodia
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Shah S, Garg S, Heath K, Ofili O, Bansal Y, Seghers F, Storey A, Taylor M. Estimation of benzathine penicillin G demand for congenital syphilis elimination with adoption of dual HIV/syphilis rapid diagnostic tests in eleven high burden countries. PLoS One 2021; 16:e0256400. [PMID: 34411167 PMCID: PMC8376004 DOI: 10.1371/journal.pone.0256400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background WHO recommends use of rapid dual HIV/syphilis tests for screening pregnant women (PW) during antenatal care to prevent mother-to-child transmission. Scale-up of testing implies a need to accurately forecast and procure benzathine penicillin (BPG) to treat the additionally identified PW with syphilis. Methods Country-reported ANC coverage, PW syphilis screening and treatment coverage values in 2019 were scaled linearly to EMTCT targets by 2030 (constant increasing slope from 2019 figures to 95% in 2030) for 11 focus countries. Antenatal syphilis screening coverage was substituted with HIV screening coverage to estimate potential contribution of rapid dual HIV/syphilis tests in identifying additional PW with syphilis. BPG demand was calculated for 2019–2030 accordingly. Results The estimated demand for BPG (in 2.4 million unit vials) using current maternal syphilis prevalence and treatment coverage will increase from a baseline of 414,459 doses in 2019 to 683,067 doses (+65%) in 2021 assuming immediate replacement of single HIV test kits with rapid dual HIV/syphilis tests for these 11 countries. Continued scale up of syphilis screening and treatment coverage to reach elimination coverage of 95% will result in an estimated demand increase of 160%, (663,969 doses) from 2019 baseline for a total demand of 1,078,428 BPG doses by 2030. Conclusions Demand for BPG will increase following adoption of rapid dual HIV/syphilis test kits due to increases in maternal diagnoses of syphilis. To eliminate congenital syphilis, MNCH clinical programs will need to synergize with disease surveillance programs to accurately forecast BPG demand with scale up of antenatal syphilis screening to ensure adequate treatment is available for pregnant women diagnosed with syphilis.
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Affiliation(s)
- Sapan Shah
- Clinton Health Access Initiative (CHAI) India, New Delhi, Delhi, India
- * E-mail:
| | - Surbhi Garg
- Clinton Health Access Initiative (CHAI) India, New Delhi, Delhi, India
| | - Katherine Heath
- Department of Global Programmes of HIV, Hepatitis, STI, World Health Organization (WHO), Geneva, Switzerland
- Macfarlane Burnet Institute, Melbourne, Australia
| | - Obiageli Ofili
- Clinton Health Access Initiative (CHAI), Boston, Massachusetts, United States of America
| | - Yashika Bansal
- Clinton Health Access Initiative (CHAI) India, New Delhi, Delhi, India
| | - Frederic Seghers
- Clinton Health Access Initiative (CHAI), Boston, Massachusetts, United States of America
| | - Andrew Storey
- Clinton Health Access Initiative (CHAI), Boston, Massachusetts, United States of America
| | - Melanie Taylor
- Department of Global Programmes of HIV, Hepatitis, STI, World Health Organization (WHO), Geneva, Switzerland
- United States Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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12
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Domingues CSB, de Lannoy LH, Saraceni V, da Cunha ARC, Pereira GFM. Brazilian Protocol for Sexually Transmitted Infections 2020: epidemiological surveillance. Rev Soc Bras Med Trop 2021; 54:e2020549. [PMID: 34008715 PMCID: PMC8210489 DOI: 10.1590/0037-8682-549-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 11/22/2022] Open
Abstract
This article summarizes the chapter on epidemiological surveillance of sexually transmitted infections (STI) that comprises the 2020 Clinical Protocol and Therapeutic Guidelines (PCDT) for Comprehensive Care for People with STI, published by the Health Surveillance Department of the Brazilian Ministry of Health. It presents some reflections on the new case definitions for surveillance of acquired syphilis, syphilis in pregnant women, and congenital syphilis. The 2020 PCDT-IST was elaborated grounded on scientific evidence and validated in discussions with specialists. Epidemiological and clinical aspects are addressed, and health service managers' guidelines regarding programmatic and operational management of these diseases are presented. Guidelines for health professionals on screening, diagnosing, and treating people with STI and their sex partners, in addition to strategies for surveillance, prevention, and control actions, are also published. sexually transmitted infections are among the most common diseases in the world. They affect people's health and life, impact reproductive and child health, contribute to infertility and complications during pregnancy and birth.
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Affiliation(s)
- Carmen Silvia Bruniera Domingues
- Secretaria de Estado da Saúde de São Paulo, Centro de Referência e Treinamento de Doenças Sexualmente Transmissíveis e Aids, São Paulo, SP, Brazil
| | | | - Valeria Saraceni
- Secretaria Municipal de Saúde do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Gerson Fernando Mendes Pereira
- Secretaria de Estado da Saúde de São Paulo, Centro de Referência e Treinamento de Doenças Sexualmente Transmissíveis e Aids, São Paulo, SP, Brazil
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Freitas FLS, Benzaken AS, de Passos MRL, Coelho ICB, Miranda AE. Brazilian Protocol for Sexually Transmitted Infections 2020: acquired syphilis. Rev Soc Bras Med Trop 2021; 54:e2020616. [PMID: 34008726 PMCID: PMC8210480 DOI: 10.1590/0037-8682-616-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 11/22/2022] Open
Abstract
The Clinical Protocol and Therapeutic Guidelines for Comprehensive Care of People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020, includes updates concerning acquired syphilis. The document comprises rapid test use, safety and efficacy of benzathine benzylpenicillin, case follow-up, neurosyphilis clinical and laboratory management, approaching sex partners, assistance and monitoring of diagnosed pregnant women, and syphilis and HIV co-infection specificities, as well as a case notification summary. Health managers and professionals must be continuously trained so as to integrate care and surveillance, to strengthen actions for efficient control of syphilis, to broaden the search for sex partners, and to expand access of most vulnerable populations to health services. Most people with syphilis are asymptomatic; this contributes to the maintenance of the transmission chain. Without adequate treatment of pregnant women with syphilis, severe consequences can occur, such as miscarriage, prematurity, low birth weight, natimortality, and congenital syphilis.
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Affiliation(s)
- Francisca Lidiane Sampaio Freitas
- Ministério da Saúde, Secretaria de Vigilância em Saúde, Brasilia, DF, Brasil
- Universidade de Brasília, Programa de Pós-Graduação em Saúde Coletiva, Brasília, DF, Brasil
| | - Adele Schwartz Benzaken
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brasil
- AIDS Healthcare Foundation, Los Angeles, Califórnia, USA
| | | | | | - Angélica Espinosa Miranda
- Ministério da Saúde, Secretaria de Vigilância em Saúde, Brasilia, DF, Brasil
- Universidade Federal do Espírito Santo, Vitória, Brasil
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Pietrobelli A, Mariotti V, Fusari S, Gasparini A, Bettuzzi M, Morigi MP, Belcastro MG. Syphilis in an Italian medieval jewish community: A bioarchaeological and cultural perspective. Int J Paleopathol 2020; 30:85-97. [PMID: 32570054 DOI: 10.1016/j.ijpp.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES We aim to discuss the presence of treponemal infections in three individuals belonging to a large (∼400 individuals) Late Medieval cemetery (14th -16th century) that archaeological and documentary sources place within a Jewish context, and to discuss the role of these diseases in a biocultural perspective. MATERIALS AND METHODS An anthropological and paleopathological study was conducted on skeletal remains of three individuals, though macroscopic and tomographic examination. RESULTS Cranial lesions in which simultaneous destructive and proliferative processes (caries sicca) are noted. Long bones also present osseous alterations with increased bone density and non-uniform thickening. CONCLUSIONS Skeletal lesions are consistent with treponemal infections (possibly either endemic or acquired syphilis). Historical documentation could help the interpretation of our cases, recording a syphilis outbreak in Bologna in 1496, possibly coeval to the Late Medieval Jewish cemetery. SIGNIFICANCE These cases of treponematosis are unique, documenting the presence of the disease within the Jewish Medieval community in Italy, as they frame the effects and consequence of the infection in shaping social and cultural contexts of the medieval Italian and European communities. They offer material evidence to elaborate on the historical documents on the hostility Jewish community suffered. LIMITATIONS Radiocarbon dating have not been performed directly on skeletal remains of the three pathological individuals. δ13C and δ15N isotope ratios should also be acquired to estimate the marine diet component, to account for possible marine reservoir effect on radiocarbon age calibration.
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Affiliation(s)
- Annalisa Pietrobelli
- Dept. of Biological, Geological and Environmental Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy.
| | - Valentina Mariotti
- Dept. of Biological, Geological and Environmental Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Samantha Fusari
- Dept. of Biological, Geological and Environmental Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Anthony Gasparini
- Dept. of Biological, Geological and Environmental Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Matteo Bettuzzi
- Dept. of Physics and Astronomy, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Maria Pia Morigi
- Dept. of Physics and Astronomy, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Maria Giovanna Belcastro
- Dept. of Biological, Geological and Environmental Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
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Sriwijitalai W, Wiwanitkit V. Late-onset congenital syphilis: is it another disease? Arq Neuropsiquiatr 2018; 76:640. [PMID: 30365630 DOI: 10.1590/0004-282x20180086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 06/03/2018] [Indexed: 06/08/2023]
Affiliation(s)
| | - Viroj Wiwanitkit
- Hainan Medical University, China; honorary professor, dr DY Patil University, India
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Abstract
We present the clinical and light microscopic ophthalmological findings in a 60-year-old woman with bilateral, symmetrical, paracentral anterior synechia formation and healed, old, inactive interstitial keratitis, probably secondary to congenital syphilis. The patient underwent ECCE and IOL implantation in the left eye and a triple procedure (corneal transplantation, ECCE and IOL) in the right eye. Gonioscopy, fluorescein angiography and light microscopy of a specimen from the triple procedure revealed a fibrovascular connection between the iris and cornea. The etiology of the funnel-shaped bilateral iridocorneal synechiae is discussed.
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Affiliation(s)
- P Ruusuvaara
- Department of Ophthalmology, University of Helsinki, Finland
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Arellano-Estrada JL, López-Lara CS, Barreras-Valenzuela E. [[Response to "Congenital syphilis in the state of Baja California"]]. Salud Publica Mex 2018; 60:99-100. [PMID: 29689664 DOI: 10.21149/9105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Affiliation(s)
- Jorge Luis Arellano-Estrada
- Jurisdicción Tijuana, Instituto de Servicios de Salud de Baja California, Coordinación de Vigilancia Epidemiológica. México
| | - Cinthia Selene López-Lara
- Jurisdicción Tijuana, Instituto de Servicios de Salud de Baja California, Coordinación de Vigilancia Epidemiológica. México
| | - Erendida Barreras-Valenzuela
- Jurisdicción Tijuana, Instituto de Servicios de Salud de Baja California, Coordinación de Vigilancia Epidemiológica. México
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ROTTMANN A. [The problem of focal syphilis, syphilis congenital tarda and endemic syphilis with reference to syphilis-test revaccination as diagnosticum]. Arztl Monatshefte Berufl Fortbild 2014; 5:687-702. [PMID: 24542034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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WILKINSON EE, SAUNDERS WH, HANSEN E. Penicillin in the treatment of congenital syphilis. Tex State J Med 2010; 41:401-404. [PMID: 21006369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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ARON HCS, BARTON RL, BAUER TJ. Prenatal syphilis: its prevention by use of penicillin in treatment of pregnant women with early infectious syphilis. ACTA ACUST UNITED AC 2010; 56:349-56. [PMID: 20262873 DOI: 10.1001/archderm.1947.01520090069008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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DE LAS OBRAS Y LOSCERTALES JM. [Treatment of congenital syphilis with penicillin]. Actas Dermosifiliogr 2008; 39:82. [PMID: 18903790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
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Jerrold L. Litigation, legislation, and ethics. A study in proximate causation. Am J Orthod Dentofacial Orthop 2002; 122:228-9. [PMID: 12165780 DOI: 10.1067/mod.2002.127042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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31
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Muto R, Ohashi H. [Fetal syphilis syndrome]. Ryoikibetsu Shokogun Shirizu 2001:698-9. [PMID: 11462640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Affiliation(s)
- R Muto
- Department of Pediatrics, Tokyo Women's Medical University
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32
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Abstract
Although congenital syphilis has been recognized for several centuries and an efficient treatment with penicillin became available more than a half-century ago, the disease is still with us. Inability to culture in vitro the causative agent, Treponema pallidum, and the lack of an adequate animal model have prevented exploration of the various immunopathological events affecting the natural course of congenital infection. The purpose of this review is to analyze the disease in the context of recent knowledge acquired from human and experimental animals, particularly from the guinea pig model of congenital and neonatal syphilis, and to describe how the infection interacts with the maternal-fetal unit and how it is further modulated by the conceptus' ontogenic development. We also attempt to elucidate several old immunologic concepts and misconceptions that have remained unchallenged for too long.
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Affiliation(s)
- V Wicher
- Wadsworth Center for Laboratories and Research, New York State Department of Health, Empire State Plaza, Albany, NY 12201-0509, USA
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34
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Abstract
A case of congenital syphilis which presented with paroxysmal cold haemoglobinuria is described. The patient had aortic incompetence, and the significance of this finding is discussed. The Coombs test was studied, and positive results appear to be due to interaction between antiglobulin serum and complement adsorbed on to the test cells, this adsorption being promoted by the cold antibodies.
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Abstract
A collection of 44 cases of malignancy in scars, chronic ulcers, and sinuses, included the following predisposing lesions: a 20-year-old sinus from ischial bursitis, a 23-year-old bed sore, a congenital gumma about 50 years old, three burn scars (average age of scar 56 years), 11 sinuses from chronic osteomyelitis, and 27 chronic ulcers of the leg. The osteomyelitis cases included two rapidly fatal sarcomas, one in a sinus present for 16 years, the other in a 20-year-old sinus. The remaining tumours in this group were squamous carcinomas that developed in sinuses with an average duration of 37 years. In the cases of varicose ulcer, the ulcer had been present on the average for 21 years before the onset of malignancy. One patient in this group, with an ulcer not known to be more than five years old, developed a sarcoma that was fatal in six months. The biopsy diagnosis was difficult in 17 cases, including one of the cases of sarcoma. The difficulty was greatest in cases of osteomyelitis. The conditions discussed are now known as ;Marjolin's ulcer'. In the present series, the degree of malignancy in tumours arising in scars may be low but the malignancy of tumours arising in chronic ulcers and sinuses may be high.
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Lyon DJ. Congenital syphilis: when the medium fails to transmit the message. Med J Aust 1994; 160:94-5. [PMID: 8309379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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40
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Chandra R, Bhat BV, Bhatia BD. Neonatal syphilis with glaucoma and periosteitis. Indian Pediatr 1992; 29:1584-5. [PMID: 1291513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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41
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Ben-Ari J, Danzuger Y, Mimouni M. [Congenital syphilis]. Harefuah 1987; 113:253-5. [PMID: 3322986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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42
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Southby R. Long-term follow-up records. Aust Paediatr J 1983; 19:36-9. [PMID: 6870699 DOI: 10.1111/j.1440-1754.1983.tb02049.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Having accumulated a very large series of patients' records over a period of 60 years, some involving three generations of a family, the author has selected cases that illustrate the opportunities to observe the progress of patients from infancy for more than half a century. This unique opportunity has included a variety of clinical conditions such as congenital syphilis, cretinism, acute osteomyelitis, and pink disease and represents a long term follow-up of conditions which reflect both the paediatrics of the past and the changes in the pattern of disease which have occurred in the course of 60 years.
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Abstract
This study is an analysis of the electronystagmogram (ENG) changes in 17 patients with luetic vestibular disease with early and late acquired syphilis and congenital syphilis. Vestibular disturbances occurred in 80% of patients with luetic otitis. Among these patients the ENG gives signs of peripheral rather than central vestibular injury, and reduced vestibular response to caloric stimulation is the most common finding. Congenital syphilis patients have the greatest dysfunction, both in degree of ENG changes and incidence of bilaterality. We found no correlation between FTA-ABS levels and the amount of hearing impairment or vestibular injury. Treatment with penicillin and steroids had a beneficial subjective effect upon the symptoms of vertigo in over half the patients.
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44
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Fournier Y. [The case of Paul and Virginia and André also... 2. Syphilis]. Infirm Can 1979; 21:26-30. [PMID: 252492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Arthritis, Infectious
- Bacterial Infections/diagnosis
- Bacterial Infections/drug therapy
- Conjunctivitis
- Enteritis
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/etiology
- Meningitis
- Osteomyelitis
- Pneumonia, Pneumococcal
- Prognosis
- Sepsis
- Skin Diseases, Infectious
- Syphilis, Congenital
- Umbilical Cord
- Urinary Tract Infections
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46
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Barbero S, Ponte PL. [Infectious diseases in the fetus and newborn infant]. Arch Sci Med (Torino) 1977; 134:413-35. [PMID: 610692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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47
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Rossant L. [Congenital syphilis]. Infirm Fr 1977:17-9. [PMID: 584703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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48
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Marett WC. The treatment of syphilis. J S C Med Assoc 1976; 72:460-2. [PMID: 1071770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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49
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Abstract
This review comprises brief discussions of the epidemiology, clinical manifestations, laboratory features, and treatment of the oculogenital diseases as they appear typically in the newborn infant, the child, and the adult. Inclusion conjunctivitis is the most frequently occurring oculogenital infection in all three categories of patient. Oculogenital diseases are becoming increasingly important in both frequency and severity. They can be extremely serious and may thus require the immediate attention of the physician.
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50
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Brown MS. Syphilis and gonorrhea: an update for nurses in ambulatory settings. Nursing 1976; 6:71-4. [PMID: 1042561 DOI: 10.1097/00152193-197601000-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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