Acute syphilitic posterior placoid chorioretinitis

Six patients with evidence of secondary syphilis presented with visual loss in both eyes caused by large, placoid, yellowish lesions with faded centers at the level of the pigment epithelium in the macula and juxtapapillary areas. All eyes had vitreitis. All of the lesions showed a similar fluorescein angiographic pattern of early hypofluorescence and late staining. Five patients had mucocutaneous lesions typical of secondary syphilis. All five patients treated with antibiotics had prompt improvement in visual function and resolution of the fundus lesions. The ophthalmoscopic and angiographic appearance of these posterior fundus lesions was sufficiently characteristic to suggest a diagnosis of secondary syphilis. Modification of the host response to syphilis by human immune deficiency virus (HIV) infection may be partly responsible for this peculiar fundus picture. Three of the four patients tested positive for HIV.

Secondary syphilitic lesions

An important theme that emerges from all early historical accounts is that in addition to the decreased virulence of Treponema pallidum, the incidence of secondary syphilis has decreased drastically over the past three centuries. Even in the early 20th century, most syphilologists were of the opinion that the disease had undergone changes in its manifestations and that they were dealing with an attenuated form of the spirochete. Such opinions were based primarily on the observations that violent cutaneous reactions and fatalities associated with the secondary stage had become extremely rare. The rate of primary and secondary syphilis in the United States increased in 2002 for the second consecutive year. After a decade-long decline that led to an all-time low in 2000, the recent trend is attributable, to a large extent, by a increase in reported syphilis cases among men, particularly homosexual and bisexual men having sex with men. The present review addresses the clinical and diagnostic criteria for the recognition of secondary syphilis, the clinical course and manifestations of the disease if allowed to proceed past the primary stage of disease in untreated individuals, and the treatment for this stage of the disease.

The signs and symptoms of secondary syphilis

The signs and symptoms of 105 patients with secondary syphilis were evaluated in a clinic for treatment of sexually transmissible diseases. The symptoms were, in order of decreasing frequency, pruritus, 44 patients; sore throat, 16; headache, nine; muscle aches, nine; fever, five; meningismus, three; loss of scalp hair, three; loss of appetite, two; loss of weight, two; and visual disturbances, one. The dominant morphologic characteristics of the lesions, in order of decreasing frequency, were maculopapular, 73 patients; papular, 13; macular, 10; annular papular, six; papulopustular, two; and psoriasiform papular, one. Almost a fourth of the patients were not aware that they had mucocutaneous lesions, and > 20% of patients had inconspicuous lesions. The distributions and morphologic features of the lesions of eight patients (7.6%) suggested other dermatoses.

Secondary syphilis: a clinico-pathological review

The histological appearances found in biopsies from fifty-seven patients with secondary syphilis have been correlated with the clinical morphology of the eruptions. Considerable variation of histological pattern was encountered, and the frequency with which some of the classically described changes were found to be absent or inconspicuous is stressed. Of particular interest were the findings that, in nearly one-quarter of the biopsies, plasma cell infiltration was either absent or very sparse, and that vascular damage was seen in less than half. Where present, the vessel changes were almost entirely confined to swelling of the endothelial cells. Proliferation of the endothelial cells was most uncommon. The epidermis was very frequently involved in the inflammatory process. Exocytosis, spongiosis, parakeratosis, and acanthosis were the most frequent changes. No consistent histological difference between papular and papulo-squamous lesions could be found but macular lesions demonstrated more superficial and less intense dermal infiltration as well as less severe epidermal involvement. In late secondary lesions, the infiltrate became granulomatous, but in other respects the duration of the exanthem could not be correlated with the pathology. The differential diagnosis from pityriasis lichenoides and other inflammatory dermatoses is discussed and the value of histopathology in the diagnosis of secondary syphilis is emphasized.

Ocular syphilis in patients with human immunodeficiency virus infection

We diagnosed ocular syphilis in three homosexual men infected with human immunodeficiency virus (HIV). Ocular inflammation included uveitis, optic neuritis, and retinitis. Dermatologic and central nervous system manifestations of secondary syphilis were also present. The history of homosexuality was difficult to obtain. Concomitant infection with HIV may alter the course of syphilis, obscure the diagnosis, and impair the response to therapy.

Secondary syphilis in cali, Colombia: new concepts in disease pathogenesis

Venereal syphilis is a multi-stage, sexually transmitted disease caused by the spirochetal bacterium Treponema pallidum (Tp). Herein we describe a cohort of 57 patients (age 18-68 years) with secondary syphilis (SS) identified through a network of public sector primary health care providers in Cali, Colombia. To be eligible for participation, study subjects were required to have cutaneous lesions consistent with SS, a reactive Rapid Plasma Reagin test (RPR-titer > or = 1 : 4), and a confirmatory treponemal test (Fluorescent Treponemal Antibody Absorption test- FTA-ABS). Most subjects enrolled were women (64.9%), predominantly Afro-Colombian (38.6%) or mestizo (56.1%), and all were of low socio-economic status. Three (5.3%) subjects were newly diagnosed with HIV infection at study entry. The duration of signs and symptoms in most patients (53.6%) was less than 30 days; however, some patients reported being symptomatic for several months (range 5-240 days). The typical palmar and plantar exanthem of SS was the most common dermal manifestation (63%), followed by diffuse hypo- or hyperpigmented macules and papules on the trunk, abdomen and extremities. Three patients had patchy alopecia. Whole blood (WB) samples and punch biopsy material from a subset of SS patients were assayed for the presence of Tp DNA polymerase I gene (polA) target by real-time qualitative and quantitative PCR methods. Twelve (46%) of the 26 WB samples studied had quantifiable Tp DNA (ranging between 194.9 and 1954.2 Tp polA copies/ml blood) and seven (64%) were positive when WB DNA was extracted within 24 hours of collection. Tp DNA was also present in 8/12 (66%) skin biopsies available for testing. Strain typing analysis was attempted in all skin and WB samples with detectable Tp DNA. Using arp repeat size analysis and tpr RFLP patterns four different strain types were identified (14d, 16d, 13d and 22a). None of the WB samples had sufficient DNA for typing. The clinical and microbiologic observations presented herein, together with recent Cali syphilis seroprevalence data, provide additional evidence that venereal syphilis is highly endemic in this region of Colombia, thus underscoring the need for health care providers in the region to be acutely aware of the clinical manifestations of SS. This study also provides, for the first time, quantitative evidence that a significant proportion of untreated SS patients have substantial numbers of circulating spirochetes. How Tp is able to persist in the blood and skin of SS patients, despite the known presence of circulating treponemal opsonizing antibodies and the robust pro-inflammatory cellular immune responses characteristic of this stage of the disease, is not fully understood and requires further study.

Subfamily I Treponema pallidum repeat protein family: sequence variation and immunity

A 12-membered Treponema pallidum repeat (Tpr) protein family has been identified in T. pallidum subsp. pallidum, the causative agent of syphilis. The subfamily I Tpr proteins (C, D, F, and I) possess conserved sequence at the N- and C-termini and central regions that differentiate the members. These proteins may be important in the immune response during syphilis infection and in protective immunity. Strong antibody responses have been observed toward some of the subfamily I Tpr proteins during infection with different syphilis isolates. Some sequence variation has also been identified in one subfamily I Tpr member, TprD, among T. pallidum subsp. pallidum isolates. In this study, we examined sequences in the remaining subfamily I Tpr proteins among strains. Both TprF and TprI were conserved among T. pallidum subsp. pallidum isolates. While some heterogeneity was identified in TprC. We further examined the immune response and protective capacity of TprF protein in this paper. We demonstrate that the N-terminal conserved region of the subfamily I Tpr proteins elicits strong antibody and T-cell responses during infection, and immunization with this region attenuates syphilitic lesion development upon infectious challenge.

Malignant syphilis (lues maligna) and concurrent infection with HIV

BACKGROUND

During the past 2 1/2 years we observed six patients who had a reactive serology for syphilis, of which four developed widespread noduloulcerative and two vesiculonecrotic lesions. The purpose was to report the occurrence of lues maligna, a rare form of secondary syphilis, in five patients infected with the human immunodeficiency virus (HIV) and in one patient with risk factors for infection.

METHODS

Tzanck preparations, viral cultures, and skin biopsies were performed to evaluate the etiology of the lesions.

RESULTS

Syphilis serology titers ranged from 1:32 to 1:128 and in one instance was as low as 1:8. Such titers can also be found in patients with the latent form of syphilis. Therefore, confirmation of the clinical diagnosis of lues maligna was dependent on skin biopsies that were compatible with secondary syphilis and negative viral studies that excluded varicella, disseminated varicella-zoster or herpes simplex. Lues maligna takes an aggressive course in HIV-infected patients since four of the patients required hospitalization and the two patients who refused to complete treatment, subsequently developed more severe skin and constitutional symptoms.

CONCLUSIONS

HIV-infected patients are at risk for developing lues maligna. Despite its malignant presentation, lues maligna lesions respond rapidly to treatment with penicillin. Secondary syphilis should be added to the list of diseases known to be more aggressive in HIV-infected patients.

Primary and secondary syphilis, 20 years' experience. 2. Clinical features

The notes of 946 patients with primary and 854 with secondary syphilis were retrospectively reviewed. Of the 184 heterosexual men with primary syphilis, 182 (99%) had chancres affecting the penis, compared with 467 (64%) of the 728 homosexual men (p less than 0.0001). Anorectal chancres occurred in 249 (34%) of homosexual men. The commonest features of secondary syphilis included a rash, lymphadenopathy, and mucous patches of the mouth or genital area. Hepatitis, meningitis, other neurological problems, iridocyclitis, and periostitis were all exceptionally rare. The clinical features of primary and secondary syphilis do not appear to have changed in recent years.

Histologic features of secondary syphilis: A multicenter retrospective review

BACKGROUND

Secondary syphilis has a wide spectrum of clinical and histologic manifestations.

OBJECTIVE

We sought to determine the frequency of histopathological features characterizing secondary syphilis, and which are most common in specimens displaying few diagnostic findings.

METHODS

In a multicenter, retrospective analysis of biopsy-proven secondary syphilis, cases were subcategorized by the number of histologic characteristics present.

RESULTS

The 106 cases mostly had 5 to 7 of the features studied. Many features were scarcer in cases with 5 or fewer features, including endothelial swelling (87.7% overall vs 72.4% ≤5 features), plasma cells (69.8% vs 48.3%), and elongated rete ridges (75.5% vs 27.6%). Specimens with 5 or fewer features were more likely to be truncal (61.1% vs 34.4% overall), demonstrate rete ridge effacement (44.8% vs 19.8%), and have pityriasis rosea (33.3% vs 17.2%) or drug eruption (33.3% vs 10.9%) in the clinical differential. An interstitial inflammatory pattern was the most common characteristic of specimens with 5 or fewer features (75.9%).

LIMITATIONS

This was a retrospective review.

CONCLUSION

The independent value of many histologic features of syphilis may be overestimated. Combinations of endothelial swelling, interstitial inflammation, irregular acanthosis, and elongated rete ridges should raise the possibility of syphilis, along with the presence of vacuolar interface dermatitis with a lymphocyte in nearly every vacuole and lymphocytes with visible cytoplasm.

Secondary syphilis in persons infected with and not infected with HIV-1: a comparative immunohistologic study

To better understand the cutaneous immune response to Treponema pallidum, we performed an immunohistologic study of skin biopsies from a total of 11 patients with secondary syphilis; biopsies from five persons infected with HIV-1 were included in the analysis to assess at the tissue level the impact of concomitant HIV-1 infection on disease expression. In all of the biopsies, staining for HLA-DR, a marker for cellular activation, was observed among infiltrating leukocytes, dermal vascular endothelial cells, and keratinocytes. Infiltrating mononuclear cells stained positively for CD4 or CD8, with CD4+ cells always being in the majority. Surprisingly, most of the CD4+ cells had histiocytic, rather than lymphocytic, morphologic characteristics. Immunostaining for CD14 confirmed that these cells were monocytic in origin, whereas immunostaining for CD3 revealed that the lymphocytes were predominantly CD8+ cytotoxic T cells. B cells were not detected despite the presence of variable numbers of plasma cells in all specimens. By immunofluorescence, all of the specimens demonstrated perivascular deposition of immunoglobulins, complement, or fibrinogen; linear staining at the dermal-epidermal junction also was observed in most of the specimens. No differences in immunocytochemical or immunofluorescence staining patterns were observed between the specimens from patients who were HIV positive and patients who were HIV negative. In addition to providing a more precise definition of the infiltrating cells in syphilitic lesions, our results, taken as a whole, indicate that cellular immune processes are largely responsible for the development of cutaneous manifestations during syphilitic infection and that coinfection with HIV-1 has little discernible effect on the cutaneous response to T. pallidum.

Clinical manifestations of secondary syphilis

The results of a prospective study, aimed at having a fresh look at the clinical features of secondary syphilis in 89 patients, are presented. Eighty-one (91.0%) had syphilides, and of these, 24 (29.6%) had atypical morphology. Two or more groups of lymph nodes were enlarged in 60, and hepatosplenomegaly was seen in 20 (22.5%) patients. Condylomata data in atypical sites occurred in six patients. A total of 10 patients had alopecia on the scalp, and anterior uveitis was seen in 7 (7.9%). The clear CSF showed minimal elevation of lymphocytes in one of the 21 patients on whom lumbar puncture was performed and may, therefore, be considered unnecessary as a routine procedure. An awareness of the varied clinical presentations would assist in early diagnosis of the disease and help reduce its complications.

Primary and secondary syphilis: a histopathological study

We present a study of biopsies taken from skin lesions of 44 patients presenting with primary or secondary syphilis. In most primary lesions erosion or, more often, ulceration was present, with a dense inflammatory infiltrate. In secondary syphilis a wide variety of histological changes was present. Blood vessels were frequently involved, with marked endothelial swelling and often proliferation. Treponemes were demonstrated with the Steiner staining method in all investigated cases of primary syphilis and in 71% of secondary syphilis cases. Treponemes were present throughout the dermis, particularly perivascularly, and in the dermal-epidermal junction zone. In two specimens of secondary syphilis treponemes were located predominantly in the epidermis, but there were always some microorganisms demonstrable in the dermis. The inflammatory infiltrate was often located in a perivascular coat-sleeve-like arrangement. In this study plasma cells and lymphocytes were present in all specimens of primary and secondary syphilis. Syphilitic lesions differed from yaws lesions mostly in the location of treponemes and the affection of blood vessels. In this histopathological study of early syphilis, treponemes did not show the epidermiotropic character of yaws, and blood vessel changes were more pronounced than in yaws. Unfortunately, due to the protean histopathological manifestations described in venereal syphilis and in yaws, these two treponemal diseases cannot always be differentiated on histological grounds alone.

Histological aspects of sexually transmitted genital lesions

Occasional biopsies of genital lesions due to chancroid, secondary syphilis (the condyloma latum) and granuloma inguinale are encountered in routine histopathological practice. These lesions have specific microscopical appearances enabling a confident, or at least a presumptive, diagnosis to be made in most cases, yet the value of biopsy in the diagnosis of these diseases is not generally appreciated. The ulcer of chancroid shows three zones--a narrow superficial zone of degenerate leucocytes and fibrin, a broader middle zone with characteristic vascular changes, and a deep zone in which there is a plasma cell and lymphocyte infiltrate. The condyloma latum shows hyperplasia of the epidermis which is infiltrated with polymorphonuclear leucocytes in addition to the mononuclear infiltration of the dermis. Large numbers of spirochaetes are found in the area of the polymorph exocytosis of the epidermis. The inflammatory infiltrate of granuloma inguinale consists of a neutrophil and plasma cell infiltrate with moderate numbers of large mononuclear cells in which there are one or more vacuoles containing Donovan bodies.

Nodular secondary syphilis

Nodular secondary syphilis in a 23-year-old Indian man was characterized by numerous papular, nodular and plaque skin lesions, without involvement of the mucous membranes. The histopathology showed sarcoid-like granulomata with lymphocytes, histiocytes, eosinophils, plasma cells and multinucleated giant cells. The differential diagnosis included deep mycoses, leprosy, tuberculosis, sarcoidosis and lymphoma. The results of serological tests and the rapid response to penicillin indicated a correct diagnosis.

Secondary syphilis: a clinicopathologic study

BACKGROUND

With the resurgence of syphilis in the HIV era, a greater awareness of the clinicopathologic features of the disease is desirable. This report describes and correlates the clinical and histopathologic features of secondary syphilis seen at a teaching hospital in Delhi, India.

METHODS

Forty biopsies of mucocutaneous lesions from 31 consecutive patients with secondary syphilis, seen between September 1987 and January 1991, were studied and the histopathologic findings correlated with the clinical findings.

RESULTS

A spectrum of histopathologic changes ranging from a minimal infiltrate to granulomatous inflammation throughout the dermis was seen. The pattern of inflammation correlated well with the type of skin lesion, with macules showing the least and nodules the most prominent changes. The predominant cell type in the infiltrate was the mononuclear cell/lymphocyte. Plasma cells were seen infrequently except in condylomata lata. Endothelial proliferation, the "classical" feature of the histopathology of syphilis was noted infrequently.

CONCLUSIONS

The histologic manifestations of secondary syphilis appear to be as varied as the clinical ones. This calls for close interaction between the clinician and the pathologist to correlate the clinical, serologic, and histologic findings to establish the diagnosis of syphilis.

Immunoperoxidase technique for detecting spirochetes in tissue sections: comparison with other methods

BACKGROUND

With the increasing incidence of human immunodeficiency virus (HIV) infection and immunosuppressive therapy, the incidence of syphilis has been increasing. Given the fact that the above conditions may mask or obscure the usual clinical signs and symptoms of syphilis, a means of enhanced detection is essential. AIMS METHODS: The purpose of this study was to determine whether an immunoperoxidase method using an antibody against treponemes would increase the sensitivity and specificity of diagnosis in biopsies of patients with secondary syphilis. This was compared to serology and silver stain in cases of known syphilis.

RESULTS

Immunoperoxidase for treponemes was at least as sensitive (9/10) as pathology (9/10), and more sensitive than conventional silver stain (6/10) or serology (7/10).

CONCLUSIONS

In those equivocal cases of secondary syphilis, where confirmation is essential, immunoperoxidase for treponemes may be a useful adjunct.

Nodular secondary syphilis mimicking cutaneous lymphoreticular process

We hereby report a case presenting a rare form of secondary syphilis with an unusual nodular eruption accompanied by pruritus and generalized lymphadenopathy, bearing a striking resemblance to lymphoma. The histologic picture was also misleading and was compatible with lymphocytoma cutis. The diagnosis was eventually made after results of serologic tests for syphilis were found to be positive, with an extremely high titer of VDRL, and dark-field microscopy had demonstrated spirochetes in a nodular lesion. Secondary syphilis should thus be considered in the differential diagnosis of nodular lesions resembling lymphoreticular disease. It is also suggested that syphilis be added to the list of diagnoses belonging to the category of pseudolymphoma.

Detection of Treponema pallidum in skin lesions of secondary syphilis and characterization of the inflammatory infiltrate

BACKGROUND

Syphilis is an ancient sexually transmitted disease. However, the pathogenesis of mucocutaneous lesions of secondary syphilis is not completely understood.

METHODS

We analyzed the presence of Treponema pallidum in formalin-fixed, paraffin-embedded biopsy specimens from mucocutaneous lesions of secondary syphilis using highly sensitive nested polymerase chain reaction (PCR). The inflammatory infiltrates from the same specimens are also characterized using immunohistochemical methods.

RESULTS AND CONCLUSIONS

Ten out of 24 (41.7%) specimens are T. pallidum positive using nested PCR, whereas none of them is T. pallidum positive using traditional silver staining. The presence of T. pallidum in the mucocutaneous lesions indicates that mucocutaneous lesions of secondary syphilis might be caused by direct T. pallidum invasion rather than by an allergic reaction. Furthermore, the majority of inflammatory infiltrating cells are CD45RO-positive T cells and CD68-positive macrophages, suggesting that cellular immunity plays an important role in the host reaction against T. pallidum infection in secondary syphilis.

Nodular tertiary syphilis mimicking granuloma annulare

We describe a 47-year-old man with annular plaques on the arms and torso that were treated as granuloma annulare, based on clinical and histopathologic findings. Exacerbation of the lesions during treatment with topical corticosteroids prompted a search for an infectious cause, which proved to be syphilis in the tertiary stage. The clinician should maintain a high index of suspicion for syphilis in the differential diagnosis of unusual annular skin lesions in a patient with noncaseating granulomas seen on skin biopsy.