AEDV Expert Consensus for the Management of Syphilis

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

Optic neuritis secondary to syphilis

Optic neuritis is a rare manifestation of syphilis, and the involvement of the central nervous system should be considered synonymous with neurosyphilis. This infectious disease, well known as the great imitator, can affect any structure and produce multiple clinical symptoms. Here, we report a case of a 62- year-old male patient who presented to our service with decreased vision and myodesopsias in right eye. The posterior segment showed a hyperemic nerve with peripapillary hemorrhages and retinal pigment epithellium hyperplasia. The patient was recently diagnosed with HIV. Serology for syphilis was positive with posterior decreased levels of nontreponemal test following treatment with ceftriaxone. Optic neuritis can occur at any stage of syphilis and must always be considered a differential diagnosis.

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.

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: an Age-old Problem that is Still Relevant Today]

Neurosyphilis is the clinical manifestation of syphilis that can arise during either the early or late stages of infection. Even though dedicated treatment for all clinical forms of syphilis has been available for many years, the advanced stages of the disease are still prevalent, with irreversible sequelae. This article reviews the current evidence, diagnostic methods and specific treatment for tertiary syphilis.

Syphilitic posterior placoid chorioretinitis as initial presentation of early neurosyphilis

CASE REPORT

A 36 year-old male with a recent HIV diagnosis, presented with loss of vision of his left eye. Ophthalmoscopy revealed a unilateral yellowish placoid lesion in the macula. After fluorescein angiography, optical coherence tomography, optical coherence tomography angiography, syphilis serology, and cerebrospinal fluid results, he was diagnosed with neurosyphilis and syphilitic posterior placoid chorioretinitis.

DISCUSSION

Acute syphilitic posterior placoid chorioretinitis is a rare ocular manifestation of syphilis. All patients with characteristic clinical and angiographic findings of acute syphilitic posterior placoid chorioretinitis should be tested for a neurosyphilis and human immunodeficiency virus co-infection. Early treatment with intravenous penicillin is usually effective with good visual results.

[Webino syndrome caused by meningovascular syphilis. A rare entity with an unexpected cause]

CASE REPORT

The patient is a 57-year-old obese and hypertensive male. His chief complaints were double vision and dizziness, with mild exodeviation in both eyes in primary gaze position in the ocular motility examination, but more predominant in the left eye. The exotropia was noticeably more evident on the attempted upgaze. On horizontal gaze, the abducting eye deviated fully, but the adducting eye did not cross the midline. Nystagmus in the abducting eye and convergence impairment were found. Pupil size and testing were normal. Ataxia and areflexia were also present. Bilateral internuclear ophthalmoplegia was suspected and imaging and laboratory tests were performed. The CAT scan showed a right occipital hypo-attenuated lesion. In the MRI scan, a mesencephalic subacute ischemic lesion was found, involving the medial rectus sub-nuclei. Blood and cerebrospinal fluid test for syphilis were positive.

DISCUSSION

Bilateral internuclear ophthalmoplegia is a very uncommon -and difficult to diagnose- condition. In the reported case the lesion involved the medial rectus sub-nuclei. This fact could explain the exotropia in the primary gaze position, and supports that is not possible to exclude the involvement of the medial rectus sub-nuclei in the webino syndrome. The rapid identification of the pathology contributed to the better prognosis of the patient.