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PubMed1996

Active syphilis in HIV infection: a multicentre retrospective survey. The German AIDS Study Group (GASG).

OBJECTIVE: To study syphilis in HIV infection focusing on immunocompromised patients with an atypical or aggressive clinical course of syphilis, inappropriate serological reactions or an unreliable response to therapy. STUDY DESIGN: A multicentre retrospective chart review using a standardised questionnaire for all patients with active syphilis. SETTINGS: Thirteen dermatological and medical centres throughout Germany, all members of the German AIDS Study Group (GASG). PATIENTS: Clinical data of 11,368 HIV infected patients have been analysed for cases of active syphilis requiring treatment. Asymptotic patients with reactive serological parameters indicating latent syphilis without a need for treatment were excluded. RESULTS: Active syphilis was reported in 151 of 11,368 HIV infected patients (1.33%, range per centre 0.3%-5.1%). Most of the 151 syphilis patients were male (93%) and belonged to the homosexual or bisexual exposure category for HIV infection (79%); another 6% were iv drug users. Among the 151 syphilis patients primary syphilis was diagnosed in 17.2%, maculopapular secondary syphilis in 29.1%, ulcerating secondary syphilis in 7.3%, neurosyphilis in 16.6% and latent seropositive syphilis without clinical symptoms but serological abnormalities indicating active syphilis in 25.2%. A history of prior treatments for syphilis was reported in 50%. At the time of syphilis diagnosis 26.5% of the patients were in CDC stage II, 33.8% in stage III and 24.5% in stage IV of HIV disease (CDC classification 1987). CD4 cell count was lowest in those with ulcerating secondary syphilis (mean 307, SD 140/microliters) and neurosyphilis (351, SD 235/ microliters). The highest CD4 count was found in patients with early primary and early secondary syphilis (444, SD 163/microliters and 470, SD 355/microliters). Inappropriate serological response to syphilis infection was found in 81 of 151 patients (54%). Remarkable findings were false negative VDRL titres (11 patients with non primary syphilis), false negative TPHA (1) or 19S-IgM-FTA-ABS-tests (16), and strongly reactive VDRL (> or = 512, 8) or TPHA titres (> or = 10 240, 47). Treatment failures were reported in at least 6 of 151 cases (4%). CONCLUSIONS: Atypical clinical and serological courses of syphilis were observed in HIV infected patients. Ulcerating secondary syphilis with general symptoms ("malignant syphilis") was 60 times more frequent than in historic syphilis series. Neurosyphilis was found in one sixth of those with active syphilis. Therefore lumbar puncture should be considered a routine in coinfections with HIV and syphilis. Treatment efficacy should be monitored carefully.

Adult↗
PubMed2005

Prenatal and congenital syphilis in British Columbia.

OBJECTIVE: To describe the incidence of maternal syphilis and the corresponding rate of infection in exposed neonates in British Columbia before and after a serious outbreak of infectious syphilis in the heterosexual population. METHODS: We conducted a retrospective chart review of pregnant women with positive syphilis serology and reported cases of congenital syphilis in British Columbia from 1994 to 2003. Clinical charts were reviewed for demographic information, staging of maternal syphilis, and stage of pregnancy when treatment was received. The primary outcome measure was the number of cases of congenital syphilis. We conducted a 2-sided z-test and Fisher's exact test to determine differences in the proportion of infectious syphilis in mothers and the number of cases of congenital syphilis before and during the major outbreak. RESULTS: In 389 478 live births in British Columbia between 1994 and 2003, 77% of mothers had prenatal syphilis serology. A diagnosis of syphilis was made in 183 mothers, resulting in 5 cases of congenital syphilis. Four of these were in infants whose mothers did not undergo prenatal syphilis testing. The proportion of pregnant women with infectious syphilis was significantly higher after the onset of a major outbreak of syphilis in the community than it was before (P = 0.001), but there was no significant difference in the number of cases of congenital syphilis (3 before and 2 after the outbreak, P = 0.36). CONCLUSION: Although syphilis rates in British Columbia during the study period rose steadily, the prevalence of congenital syphilis remained low. Our findings suggest that, in the context of a major outbreak, universal screening and prenatal syphilis testing may contribute to controlling rates of congenital syphilis.

Adult↗
PubMed1999

Efficacy of treatment for syphilis in pregnancy.

OBJECTIVE: To evaluate prospectively the Centers for Disease Control and Prevention (CDC) recommended regimens for the treatment of antepartum syphilis and prevention of congenital syphilis. METHODS: This was a prospective evaluation of recommended syphilis treatment regimens from September 1, 1987, to August 31, 1989, at Parkland Memorial Hospital, Dallas, Texas. Women with syphilis were staged and treated according to CDC recommendations. Treatment included 2.4 million units of intramuscular (IM) benzathine penicillin G for primary, secondary, or early latent (less than 1 year) syphilis. Women with late latent (uncertain or longer than 1 year) syphilis were treated with 7.2 million units of benzathine penicillin G IM over 3 weeks. RESULTS: During the study period, 448 of 28,552 women (1.6%) delivered were diagnosed with syphilis. One hundred eight were diagnosed at delivery and treated postpartum. The remaining 340 (75.9%) gravidas with untreated syphilis attending prenatal clinic comprised the study group. The success of therapy in preventing congenital syphilis was as follows: primary syphilis, 27 of 27; secondary syphilis, 71 of 75; early latent syphilis, 100 of 102; and late latent syphilis, 136 of 136. The success rate for all stages of syphilis was 334 of 340 (98.2%). The success rate of therapy in secondary syphilis was significantly different from that of the other groups (P = .03). Two of the six fetal treatment failures produced preterm stillborns. Only one maternal treatment failure occurred, in a human immunodeficiency virus-infected woman. CONCLUSION: The CDC-recommended regimens for the prevention of congenital syphilis and treatment of maternal infection are effective, but the highest risk of fetal treatment failure exists with maternal secondary syphilis.

Adult↗
PubMed2001

An epidemiological study of syphilis incognito, an emerging public health problem in Greece.

BACKGROUND: Syphilis incognito is a subtype of latent syphilis (early or late) characterized by no signs or symptoms of primary or secondary syphilis and diagnosed by positive serologic results for syphilis during routine screening. OBJECTIVE: To study the epidemiological characteristics, causes, and implications of syphilis incognito in Greece. PATIENTS AND METHODS: All new adult patients diagnosed as having syphilis in Andreas Sygros Hospital for Skin and Venereal Diseases, Athens, Greece, from 1989 through 1996 were studied prospectively and retrospectively (history, physical examination, serologic tests, cerebrospinal fluid examination, and imaging) to determine the stage of their disease. The epidemiological, clinical, and serologic characteristics of patients with syphilis incognito were recorded and analyzed. RESULTS: During the 8-year period, 711 new syphilis cases were detected; of these, 480 cases (67.5%) fulfilled the definition criteria of syphilis incognito. The male-female ratio was 1.8:1. Patients with syphilis incognito were most commonly heterosexual, had a median socioeconomic status, and were aged 20 to 39 years, and their conditions were diagnosed during routine screening for syphilis (prenatal care, hospital admission, or blood donation). However, the number of syphilis incognito cases appeared to decline during the period studied. CONCLUSIONS: The incidence of syphilis in Greece has decreased dramatically, following the trends in western Europe. The most common form of syphilis is syphilis incognito, affecting adults who are older and have a higher socioeconomic status than those in the past. Improved hygiene and wide use of antibiotics that minimize or abolish symptoms of early disease may have contributed to the frequency of syphilis incognito in recent years. Screening of asymptomatic persons, especially those at high risk, should continue and be reenforced to prevent the devastating consequences of unrecognized and untreated syphilis.

Adolescent↗
PubMed2001

Congenital syphilis surveillance and newborn evaluation in a low-incidence state.

OBJECTIVES: To evaluate congenital syphilis surveillance in Minnesota, to assess the evaluation and management of newborns at risk for congenital syphilis, and to assess prenatal syphilis screening. DESIGN: Case ascertainment and medical record review. SETTING: The 7-county Minneapolis-St Paul metropolitan area. PATIENTS: Newborns at risk for congenital syphilis during a 3-year period (1992-1994). MAIN OUTCOME MEASURES: The completeness of congenital syphilis case ascertainment, maternal demographic data, maternal syphilis management, newborn evaluation for and management of congenital syphilis, and hospital syphilis screening practices at delivery. RESULTS: Eighty mother-infant pairs who were at risk for congenital syphilis were identified from 3 sources. Using the Centers for Disease Control and Prevention's congenital syphilis case definition, 36 infants (45%) were classified as probable cases, 42 (53%) were classified as noncases, and 2 (3%) were syphilitic stillbirths. Forty-seven women (59%) had syphilis serologic tests performed in the third trimester; only 37 (46%) had syphilis screening at delivery. Conditions of the mothers of 8 probable cases (22%) were diagnosed at delivery. Most probable cases (86%) were evaluated; only 56% were evaluated adequately. Twenty-five probable cases (69%) were treated. Most hospitals did not have formal policies for syphilis screening at delivery. The Minnesota Department of Health's congenital syphilis registry lacked sensitivity (39%) as a case ascertainment method. CONCLUSIONS: Clinicians should adhere to standardized protocols in the evaluation and management of at-risk newborns. Vigilant screening prenatally and at delivery and adequate follow-up are critical to reduce congenital syphilis. Improved surveillance data and resources are needed for the identification and follow-up of newborns at risk for congenital syphilis.

Adolescent↗
PubMed2003

Congenital syphilis in the Russian Federation: magnitude, determinants, and consequences.

OBJECTIVES: Reported cases of congenital syphilis in the Russian Federation increased 26-fold from 1991-9. Our objectives were to describe the frequency, risk factors, and consequences of delivering an infant with congenital syphilis among pregnant women with active syphilis. METHODS: In a retrospective record review using consecutive sampling of logs at maternity hospitals in five geographic areas, data were abstracted for 850 women with active syphilis during pregnancy who had completed >/=20 weeks' gestation. Further information was abstracted from records in antenatal clinics, dermatovenereology clinics, and paediatric hospitals. We assessed the frequency of confirmed or probable congenital syphilis, used logistic modelling to identify independent predictors for delivering a baby with congenital syphilis, and calculated the proportion of infants with congenital syphilis who experienced late fetal death (20-27 weeks), stillbirth (>/=28 weeks), or infant death. RESULTS: A total of 64% (n=544) of 850 pregnant syphilis infected women delivered an infant with confirmed or probable congenital syphilis; 40% of the sample had no prenatal care. Among women with no prenatal care, 77% received either no treatment or inadequate treatment and 86% delivered an infant with congenital syphilis. Important independent and modifiable risk factors for delivery of an infant with congenital syphilis included receiving no prenatal care (adjusted OR 2.8, 95% CI 1.7 to 4.7) and having the first test for syphilis at >/=28 weeks' gestation (adjusted OR 4.0, 95% CI 2.6 to 6.0). Fatal outcomes were observed in 26% of infants with congenital syphilis, including late fetal death (7%), stillbirth (16%), or neonatal death (3%). CONCLUSIONS: In the Russian Federation, the frequency of congenital syphilis is high, risk factors for congenital syphilis are modifiable, and the consequences of congenital syphilis are severe.

Adolescent↗
PubMed1994

Altered clinical presentation of early syphilis in patients with human immunodeficiency virus infection.

OBJECTIVES: To compare clinical presentations of patients with early syphilis who did or did not have human immunodeficiency virus (HIV) infection. DESIGN: Case-control study. SETTING: The sexually transmitted diseases clinics of the Baltimore City Health Department. PATIENTS: Patients with newly diagnosed primary, secondary, or early latent syphilis who had voluntary HIV testing from January 1990 to November 1991. MEASUREMENTS: Data on sexual history, risk behaviors, and physical findings (before knowledge of HIV or syphilis serologic test results) were extracted from clinical records. Diagnoses of syphilis were confirmed by reactive syphilis serologic tests. Rapid plasma reagin titers reported to the disease registry of the Baltimore City Health Department were abstracted to determine therapeutic response. Patients positive for HIV who returned for follow-up had further counseling, staging, and CD4 lymphocyte testing. RESULTS: Data were available on 309 of 527 patients with early syphilis: 108 patients with primary syphilis, 116 with secondary syphilis, and 85 with early latent syphilis. Seventy (23%) patients had concurrent HIV infection. Patients with HIV infection presented more often with secondary syphilis than did patients with syphilis who were HIV seronegative (53% [37 of 70] compared with 33% [79 of 239]; P = 0.01). The same was true for heterosexual men with HIV infection (46% [16 of 35]) compared with heterosexual men without infection (25% [35 of 142]; P < 0.03). Among those who denied intravenous drug use, 59% (22 of 37) of patients with HIV infection presented with secondary syphilis compared with 33% (65 of 198) of patients without infection (P < 0.01). Among patients with first episodes of syphilis, patients positive for HIV who had secondary syphilis were more likely to present with persistent chancres (43% [9 of 21] compared with 15% [11 of 72]; P = 0.01). The rate of decline in the rapid plasma reagin titers during a 12-month period after treatment did not differ between patients with and without HIV infection (P = 0.15). CONCLUSIONS: The clinical presentation of syphilis in patients with HIV infection differs from that of patients without HIV infection in that patients with HIV infection present more often in the secondary stage and those with secondary syphilis are more likely to have chancres.

Adult↗
PubMed2005

Epidemic syphilis among homosexually active men in Sydney.

OBJECTIVES: To describe trends in the notification of infectious syphilis in New South Wales, the characteristics of homosexually active men recently notified with early syphilis, and the seroprevalence and incidence of syphilis, as well as associated risk factors, in a Sydney cohort of HIV-negative homosexually active men. DESIGN, SETTING AND PARTICIPANTS: Secondary analysis of New South Wales infectious syphilis surveillance data from 1998 to 2003; a case series of 57 homosexually active men diagnosed with early syphilis in inner Sydney from December 2002 to January 2004; and a prospective cohort study of syphilis among 1333 HIV-negative homosexually active men in Sydney recruited from June 2001 to December 2003. MAIN OUTCOME MEASURES: Rates of notification of infectious syphilis in New South Wales and in areas of inner Sydney; behavioural and clinical features of men with syphilis in the case series; and incidence of syphilis and hazard ratios (HRs) associated with sexual behaviours in the cohort study. RESULTS: Infectious syphilis notifications in inner Sydney rose more than 10-fold (from 6 in 1999 to 162 in 2003), and the increase was confined to men. Of 57 men with early syphilis in the case series, 54% were HIV-positive and 32% reported no symptoms of syphilis. These 57 men were highly sexually active and likely to report recreational drug use. In the cohort study, 1292 men (97% of participants) consented to syphilis testing; the incidence of syphilis was 0.78 per 100 person-years, and risk factors included reporting unprotected anal intercourse with HIV-positive partners (HR, 5.31; 95% CI, 2.00-184.93) and insertive oral sex (HR, 4.55; 95% CI, 1.14-18.18). CONCLUSION: Syphilis has been re-established among homosexually active men in Sydney, and HIV-positive men are over-represented. Frequent screening is needed in this population to curb the transmission of both syphilis and HIV.

Adolescent↗
PubMed2004

Universal antenatal screening for syphilis: is it still justified economically? A 10-year retrospective analysis.

OBJECTIVE: Because universal prenatal screening for syphilis has recently been called into question, we documented the development of syphilis in Austria and analysed the effectiveness of current antenatal syphilis screening practices. METHODS: The development of syphilis in Austria and Vienna was determined based on the data published by the Austrian Bureau of National Statistics (Statistik Austria) and the Vienna Health Authority (Gesundheitsamt Wien, MA15), respectively. The data obtained for Vienna were then compared with those for the remaining eight federal provinces. Also, we retrospectively analysed a total of 34,312 sera obtained between 1988 and 1999 from women screened for syphilis at delivery at the laboratory of the Department of Dermatology, University of Vienna. Serological screening was done with both the Venereal Disease Research Laboratory (VDRL) and the Treponema pallidum haemagglutination (TPHA) assays. Finally, we determined the number of cases of congenital syphilis diagnosed in Vienna between 1988 and 1999. RESULTS: In the past 10 years, the annual number of reported syphilis cases has remained fairly constant. In 1999 and 2000, there were 8.1 and 11.0 notifications of syphilis per 100,000 inhabitants in the capital Vienna, compared with 0.7 and 0.9 in the remaining provinces with a mainly rural character. At delivery, there were 96 cases of maternal syphilis that were both TPHA- and fluorescent treponemal absorption (FTA-ABS)-reactive, corresponding to a seroprevalence of 2.8 per 1000 births. Only 24 of the TPHA-reactive sera were VDRL-reactive. In Vienna, there were three stillbirth deliveries due to congenital syphilis and six cases of confirmed congenitally syphilis between 1988 and 1999. CONCLUSION: Universal syphilis screening may no longer be justified economically. The usefulness of VDRL-based syphilis screening should be reassessed. The screening focus should shift to regions with a high seroprevalence of syphilis. Universal syphilis screening does not appear warranted.

Adult↗