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PubMed1982

Humoral immune response in human syphilis to polypeptides of Treponema pallidum.

A molecular characterization of the polypeptide antigens of Treponema pallidum reactive with sera from patients with different stages of syphilis is described. Polypeptides of motile, virulent T. pallidum, purified from rabbit testes, were separated on SDS polyacrylamide gels and electrophoretically transferred to nitrocellulose for antigenic analysis ("Western blotting"). Serum IgG from uninfected individuals reacts weakly with three polypeptides of 45,000, 33,000, and 30,000 m.w. In this study patients with primary syphilis have IgM antibody, and all patients with syphilis have IgG antibody to at least four polypeptides of 45,000, 33,000, 30,000, and 15,500 m.w. Antibody to polypeptides of 42,000 and 16,500 m.w. appear to be markers for nonprimary syphilis. These six polypeptides have been termed the major antigenic proteins (MAP) of T. pallidum. Those patients studied with secondary and early latent syphilis acquire antibody to a set of 16 additional polypeptide antigens. Those patients studied with late latent or late syphilis have antibody to a much smaller set of five or four antigens, respectively, in addition to MAP. The results suggest that a correlation exists between acquisition of antibody and the development of "chancre immunity." Additionally, the loss of antibody that characterizes late latent and late syphilis may be associated with the potential development of destructive late syphilis.

Animals↗

PubMed1993

Surveillance for gonorrhea and primary and secondary syphilis among adolescents, United States--1981-1991.

PROBLEM/CONDITION: During the 1980s, an increasing proportion of adolescent women reported having had premarital sexual intercourse, thus potentially placing an increasing number of young persons at higher risk of acquiring a sexually transmitted infection. REPORTING PERIOD COVERED: To determine rates and examine trends of sexually transmitted infections among adolescents, we analyzed data for reported cases of gonorrhea and primary and secondary syphilis among 10- to 19-year-olds for 1981 through 1991. DESCRIPTION OF SYSTEM: Summary data for cases of gonorrhea and primary and secondary syphilis that were identified and reported to state health departments were sent annually to CDC. These data included total number of cases by disease (gonorrhea, primary and secondary syphilis), sex, racial/ethnic group (white, not of Hispanic origin; black, not of Hispanic origin; Hispanic; Asian/Pacific Islander; or American Indian/Alaskan Native), 5-year age group, and source of report (public, private). RESULTS: From 1981 through 1991, 24%-30% of the reported morbidity from gonorrhea and 10%-12% of the reported morbidity from primary and secondary syphilis in the United States affected the adolescent age groups. Some of the highest rates of gonorrhea during that time period were among 15- to 19-year-olds. Gonorrhea rates among adolescents increased or remained unchanged from 1981 through 1991, while the rates among older age groups decreased. Although primary and secondary syphilis rates were lower among adolescents than older age groups, adolescents contributed to the epidemic of syphilis that occurred from 1987 through 1990. Differences in reported rates of both syphilis and gonorrhea among white, black, and Hispanic adolescents increased during the latter half of the 1980s. INTERPRETATION: Reporting biases could account for some the differences among rates for white, black, and Hispanic adolescents. However, if gonorrhea has been underreported for any racial group, the high rates of gonorrhea among 15- to 19-year-olds represented an underestimate of the true infection rate. Increases in sexual activity among adolescents and a lack of clinical services in settings convenient to adolescents could have contributed to the increasing rates of gonorrhea and syphilis among these young persons during this time period. ACTIONS TAKEN: If gonorrhea and other sexually transmitted infections are cofactors for facilitating the transmission of human immunodeficiency virus (HIV), the high incidence of gonorrhea in some locales among some populations of adolescents could result in dramatic increases in HIV acquisition, a situation that demands attention from public health organizations.

Adolescent↗

PubMed1995

Syphilis. A tale of twisted treponemes.

Despite the widespread availability of effective treatment, the incidence of primary and secondary syphilis in the United States is on the rise. In addition, syphilis is occurring in a substantial number of patients infected with the human immunodeficiency virus (HIV), thus adding to the complexities of diagnosis and treatment. Primary syphilis represents a disseminated infection, often accompanied by abnormalities of the cerebrospinal fluid, that may pass unrecognized and progress to the myriad manifestations of secondary syphilis. The diagnosis of syphilis in patients with mucosal or skin lesions may be made by darkfield examination; once lesions have resolved, serologic tests are required. Patients with latent syphilis may have asymptomatic neurosyphilis and risk progression to tertiary disease. The diagnosis of asymptomatic neurosyphilis is necessary to determine the optimal treatment of patients with latent disease. The diagnosis of active neurosyphilis generally requires an inflammatory cerebrospinal fluid profile and a reactive cerebrospinal fluid VDRL test. Syphilis is common in HIV-infected patients, who may have an altered antibody response to infection and an apparent increased incidence of neurologic complications. The preferred treatment at all stages is penicillin, which is also the only recommended therapy for neurosyphilis. The optimal treatment of syphilis in HIV-infected patients is unknown.

Humans↗

PubMed1998

Reference laboratory surveillance of syphilis in England and Wales, 1994 to 1996.

Routine surveillance of syphilis of public health importance (infectious, congenital, and neurosyphilis) began in England and Wales in 1994, using reports from six PHLS laboratories that undertook serological and other reference work. One hundred and thirty-one cases were reported in the first two years, including 100 cases of infectious syphilis, with all regions reporting some infectious syphilis. Reports from PHLS laboratories represented one sixth of the number of cases seen in genitourinary clinics (KC60 data), but both systems produced comparable results. Laboratory reports provided more data on risk factors, which were not available elsewhere. This study documents the risk in England and Wales from infections originating in eastern Europe, where sexually transmitted infections including syphilis have reached epidemic proportions. Forty-five per cent of cases of infectious syphilis were reported to have been acquired in the United Kingdom (UK) and 59% of people with infectious syphilis were reported to have been born in the UK. Twenty per cent of the infectious cases were associated directly or indirectly with transmission in Russia or elsewhere in eastern Europe. The majority of infectious cases were from the white ethnic group. Eighty-five per cent of cases of infectious syphilis were reported to have been acquired heterosexually; 26% of male cases were reported to have been acquired homosexually. The PHLS laboratory reporting system is now well established, and could usefully be expanded to include other, non PHLS, laboratories that undertake reference work. It has the capacity to detect changes in the national epidemiology of syphilis, including imported infections.

Adult↗

PubMedDate not supplied

Syphilis: uncommon presentations in adults.

The clinical manifestations of syphilis are variable in appearance and have been described for centuries. The disease has been arbitrarily divided mainly into three stages. Uncommon presentations of syphilis in adults include (a) primary syphilis-atypical forms of chancre vary in size, shape, morphology, and color. Small ulcus durum is single or multiple, grouped, or herpetiform. Giant necrotic and phagedenic chancres are resolved with scar formation. In intratriginous areas, ulcus durum is rhagadiform, linear, "rocket type," or bilateral. (b) Secondary syphilids include macular (roseolas, leukomelanoderma), papular (small miliar or lichenoid, or with large size-lenticular or nummular), papulosquamous, syphilis cornee, psoriasiform, annular en cockade, nodular, condylomata lata, malignant syphilis, and others; there are also mucosal lesions, loss of the hairs, and alteration of the nails. (c) Tertiary syphilis occurs decades after infection in three main forms: gummatous, cardiovascular, and neurosyphilis (asymptomatic, meningeal, meningovascular, and parenchymatous-such as general paresis or tabes dorsalis). Early recognition of the clinical manifestations of syphilis is important for the start of treatment, recovery of patients, and the prevention of the spread of disease.

AIDS-Related Opportunistic Infections↗

PubMed2007

On-site rapid antenatal syphilis screening with an immunochromatographic strip improves case detection and treatment in rural South African clinics.

OBJECTIVES: Congenital syphilis is a significant cause of adverse pregnancy outcomes. In South Africa, rural clinics perform antenatal screening offsite, but unreliable transport and poor client follow up impede effective treatment. We compared 3 syphilis screening strategies at rural clinics: on-site rapid plasma reagin (RPR), on-site treponemal immunochromatographic strip (ICS) test, and the standard practice offsite RPR with Treponema pallidum hemagglutination assay (RPR/TPHA). METHODS: Eight rural clinics performed the on-site RPR and ICS tests and provided immediate treatment. Results were compared with RPR/TPHA at a reference laboratory. Chart reviews at 8 standard practice clinics established diagnosis and treatment rates for offsite RPR/TPHA. FINDINGS: Seventy-nine (6.3%) of 1,250 women screened on-site had active syphilis according to the reference laboratory. The on-site ICS resulted in the highest percentage of pregnant women correctly diagnosed and treated for syphilis (89.4% ICS, 63.9% on-site RPR, 60.8% offsite RPR/TPHA). The on-site RPR had low sensitivity (71.4% for high-titer syphilis). The offsite approach suffered from poor client return rates. One percent of women screened with the ICS may have received penicillin unnecessarily. There were no adverse treatment outcomes. CONCLUSIONS: The on-site ICS test can reduce syphilis-related adverse outcomes of pregnancy through accurate diagnosis and immediate treatment of pregnant women with syphilis.

Adolescent↗

PubMed2006

Prenatal syphilis infection is a possible cause of preterm delivery among immigrant women from eastern Europe.

OBJECTIVE: to evaluate the prevalence of maternal syphilis at delivery and neonatal syphilis infection in an Italian urban area, in connection with the increased flow of immigration. STUDY DESIGN: A prospective surveillance study was carried out in Bologna, Italy, from November 2000 to March 2006. All pregnant women were screened for syphilis at delivery. Infants born to seropositive mothers were enrolled in a prospective follow-up. RESULTS: During the study period 19,205 women gave birth to 19,548 infants. A total of 85 women were seropositive for syphilis at delivery. The overall syphilis seroprevalence in pregnant women was 0.44%, but it was 4.3% in women from eastern Europe and 5.8% in women from Central-South America. Ten women were first found positive at delivery, as they did not receive any prenatal care. Nine of these were from eastern Europe. All their infants were asymptomatic, but six had both reactive immunoglobulin (Ig)M western blot and rapid plasma reagin tests and were considered prenatally infected. Three of six were preterm (gestational age <37 weeks). CONCLUSIONS: In Italy, congenital syphilis infection is strictly related to immigration from eastern Europe. Although it is asymptomatic, it could cause premature delivery. Therefore, it is necessary to perform serological tests during the third trimester in mothers coming from endemic areas to adequately treat syphilis in pregnancy and prevent congenital infection. If the mother's test results are not available at delivery, it is necessary to investigate the newborn, especially if it is born prematurely.

Adolescent↗

PubMed1992

VDRL titres in early syphilis before and after treatment.

OBJECTIVE: To observe the pretreatment VDRL titres in different stages of early syphilis and evaluate the changes in VDRL titre following treatment using different treatment schedules. DESIGN: Retrospective study was carried out by analysing the records of cases of early syphilis treated between 1976 to 1981. SETTING: Armed Forces personnel treated at different service hospitals in India. SUBJECTS: Of 3183 cases of early syphilis treated with different regimens during this period, 1532 were fully followed-up for a period of 30 months. Records of these 1532 cases were analysed. MAIN OUTCOME MEASURES: Assessment of VDRL titres before treatment and during post treatment surveillance period of 30 months. Attainment of non-reactivity of VDRL test in various stages of early syphilis using different treatment schedules was evaluated. RESULTS: Relatively higher titres were observed in secondary syphilis. Following treatment it was observed that VDRL test was still reactive at the end of 6 months in 16.47% of primary, 27.56% of secondary and 18.95% of early latent cases; at the end of 12 months in 11.38% of primary, 17.25% of secondary and 15.79% of early latent cases while at 30 months reactivity was still observed in 6.60% of primary, 8.39% of secondary and 11.58% of early latent cases. CSF was examined in 1173 cases at 6 months, of which one case revealed VDRL reactivity while two cases showed reactivity amongst 1188 CSF examined at 30 months. There has been no significant difference with broad spectrum antibiotics and 2.4 MU benzathine penicillin. Results were better with 4.8 MU benzathine penicillin and procaine penicillin. CONCLUSION: VDRL test appears to be a reliable test for the follow-up of treated patients in early syphilis. Early treatment prevents development of seropositivity in seronegative syphilis while majority of seropositive cases attain seronegativity by 6 months. Higher doses of benzathine penicillin and procaine penicillin accelerate the speed of seroconversion.

Antigens, Bacterial↗

PubMed1999

[Positive results from serologic screening for syphilis in pregnancy in the Amsterdam region, 1991-1995].

OBJECTIVE: To evaluate the results of screening of pregnant women for syphilis in the region of Amsterdam, the Netherlands. DESIGN: Descriptive study and cost-benefit analysis. METHODS: In the period 1991-1995, physicians and midwives from the Amsterdam region sent serum samples of pregnant women to the Regional Public Health Laboratory of the Municipal Health Service (GG & GD) to be screened for syphilis. All physicians who had sent in specimens with a positive result of the Treponema pallidum haemagglutination assay (TPHA) and a confirming test result were asked, in the year of the screening, by telephone or in writing, what diagnosis they had made in the woman in question. Collection of these data was handled by the social nursing staffs of the outpatient clinics for sexually transmitted diseases in Amsterdam. The costs of laboratory tests and follow-up of the children were compared with the positive effects of special treatment and education avoided by antibiotic treatment. RESULTS: 54,344 serum samples were sent in. In the city of Amsterdam the coverage was 87.4%. In 81 women (0.15%) all the serological tests for syphilis were positive. From this group, 37 women had already been treated and 24 women were treated as a result of this screening programme (most of them had a foreign nationality), 10 for early syphilis and 14 for syphilis of unknown duration, preventing the birth of an estimated five to six children with congenital syphilis. The cost-benefit ratio was 1:15. CONCLUSION: Continuation of screening for syphilis during pregnancy in the Amsterdam region remains useful.

Cost of Illness↗

PubMedDate not supplied

[Congenital syphilis: an emerging emergency also in Brazil]

OBJECTIVE: To highlight to the fact that some newborns are not identified as having congenital syphilis, and will present to an emergency room within a few months with a severe disease. METHOD: Review of the charts concerning 3 patients with congenital syphilis, as well as review of the literature using Medline and Lilacs databases, covering the period from 1988 to 1999. RESULTS: We describe the case of 3 infants whose diagnosis of congenital syphilis was only established after the neonatal period, when they presented to the emergency room and were admitted to the pediatric intensive care unit. The first patient had neurosyphilis and nephrotic syndrome, the second had neurosyphilis, and the third had hepatitis. We discuss the clinical aspects of the cases, and comment on other clinical manifestations of congenital syphilis that should be within the purview of pediatric emergency medicine. We analyze the reasons for the failure to diagnose syphilis at birth, and describe some risk factors for gestational syphilis. CONCLUSIONS: Considering the rising incidence of syphilis in Brazil, and the possibility that the congenital infections are not recognized at birth, emergency physicians must keep a high degree of suspicion and an awareness of maternal risk factors, prenatal serology pitfalls, as well as of the several clinical presentations of congenital syphilis that can develop in the first months of life.

Journal Article↗

PubMed2007

Syphilis in China: results of a national surveillance programme.

BACKGROUND: After a massive syphilis epidemic in the first half of the 20th century, China was able to eliminate this infection for 20 years (1960-80). However, substantial changes in Chinese society have been followed by a resurgent epidemic of sexually transmitted diseases. Sporadic reports have provided clues to the magnitude of the spread of syphilis, but a national surveillance effort is needed to provide data for planning and intervention. METHODS: We collected and assessed case report data from China's national sexually transmitted disease surveillance system and sentinel site network. FINDINGS: In 1993, the reported total rate of cases of syphilis in China was 0.2 cases per 100,000, whereas primary and secondary syphilis alone represented 5.7 cases per 100,000 persons in 2005. The rate of congenital syphilis increased greatly with an average yearly rise of 71.9%, from 0.01 cases per 100,000 livebirths in 1991 to 19.68 cases per 100 000 livebirths in 2005. INTERPRETATION: The results suggest that a range of unique biological and social forces are driving the spread of syphilis in China. A national campaign for detection and treatment of syphilis, and a credible prevention strategy, are urgently needed.

Adult↗

PubMed2002

Forgotten but not gone: the continuing scourge of congenital syphilis.

Much attention is being given to the prevention of HIV infection in babies through transmission from the mother. By contrast, regrettably little concern is raised about the increasing numbers of babies born with congenital syphilis. In affluent countries congenital syphilis is very rare, but in many poor countries, including the newly independent countries of eastern Europe and the former Soviet Union, the numbers are high and increasing. In much of sub-Saharan Africa, around 10% of pregnant women are affected by syphilis. The prevention of congenital syphilis is more cost-effective than the prevention of mother-to-child transmission of HIV. The control of congenital syphilis could indirectly have a beneficial effect on the HIV epidemic by reducing susceptibility to infection. Although the procedure to prevent congenital syphilis through antenatal screening and treatment is well established, implementation of effective programmes in resource-poor settings has proved very difficult. A new and focused approach to tackling congenital syphilis is needed. It should combine different mixes of interventions, such as mass treatment, focused screening, and universal screening, according to the local epidemiology and available resources. A task-force approach to defining the most appropriate interventions together with support for some research should be a priority for support under the Global Health Fund.

Africa South of the Sahara↗

PubMed1989

The prevalence of positive serological tests for syphilis among elderly hospital patients.

Serological tests for syphilis were performed on 659 elderly patients admitted to hospital medical and psychiatric departments. Positive tests were found in 23 patients (3.5% of the sample), 17 women and 6 men. Six were subsequently discovered to have been treated previously for syphilis, and one other had radiological evidence to suggest that she had been treated with bismuth in the pre-penicillin era. Difficulties were encountered in classifying the stage of infection in some patients, particularly those with significant intellectual impairment. Eleven were diagnosed as late latent syphilis, seven as probable late latent syphilis, one as tabes dorsalis, one as possible cardiovascular syphilis, one as possible meningovascular syphilis, and one as late congenital syphilis.

Aged↗

PubMed1999

Enzyme-linked immunospot assay for the diagnosis of active Treponema pallidum infection during the various stages of syphilis.

BACKGROUND: Specific serologic assays for syphilis cannot differentiate current infections from past infections and are inefficient to monitor efficacy of antibiotic therapy. GOAL: To develop a new immunologic assay for the identification of active Treponema pallidum infection during the various stages of syphilis. STUDY DESIGN: Peripheral blood mononuclear cells obtained from patients with syphilis in an STD clinic were tested for T. pallidum-specific circulating antibody-secreting cells (ASC) by an enzyme-linked immunospot assay (ELISPOT). RESULTS: Specific ASC were demonstrated in all six patients with primary syphilis and in 14 of 16 patients diagnosed with secondary syphilis. ASCs were undetectable in five patients 8 to 16 days after appropriate therapy, but persisted in one case that was considered treatment failure. Among the 13 patients diagnosed with latent syphilis, six (46%) demonstrated ASC, reflecting antigenic stimulation. CONCLUSION: The ELISPOT assay is effective for the diagnosis of primary and secondary syphilis. The presence of circulating ASC suggests persistent active infection in some patients during the latent disease stage.

Adolescent↗

PubMed2000

Primary and secondary syphilis in the metropolitan area of Nashville and Davidson County, Tennessee: 1996 to 1998 epidemic described.

BACKGROUND: Metropolitan Nashville, Tennessee experienced a syphilis epidemic from 1996 to 1998. GOAL: This study describes the syphilis epidemic during this period. DESIGN: Descriptive analyses of syphilis surveillance data (1988-1998) were performed, with emphasis on the current epidemic (1996-1998), and were stratified by age, gender, race, and census tracts. RESULTS: Five features were observed regarding the 1996 to 1998 syphilis epidemic: (1) males and females were almost equally affected, with a delay in diagnosis in female patients; (2) the 30-39-year age group was most affected; (3) the 15-19-year age group had the highest percentage increase in incidence; (4) African Americans were the most affected population subgroup; and (5) downtown Nashville and the surrounding areas were most affected. CONCLUSION: Although talk of eradicating syphilis has surfaced nationally, Nashville has continually faced syphilis as a public health problem. During each of the past 3 years (1996-1998), the incidence of syphilis in this community has reached epidemic proportions.

Adolescent↗

PubMed1989

Sensitivity and specificity of an enzyme-linked immunosorbent assay using the recombinant DNA-derived Treponema pallidum protein TmpA for serodiagnosis of syphilis and the potential use of TmpA for assessing the effect of antibiotic therapy.

The recombinant DNA-derived Treponema pallidum membrane protein TmpA, purified from Escherichia coli K-12, was used in an enzyme-linked immunosorbent assay (ELISA) to evaluate its suitability in a screening test for syphilis and to monitor the effect of antibiotic treatment. The sensitivity of the TmpA ELISA was 76% for primary syphilis, 100% for secondary syphilis, and 98% for early latent syphilis. All except 1 of 15 serum samples positive for yaws were positive in this test. A specificity of 99.6% was found by testing more than 938 donor samples. The sensitivity and specificity of the TmpA ELISA are comparable to that of the T. pallidum hemagglutination assay, and therefore the test may be useful for the diagnosis of untreated syphilis. After antibiotic treatment, the level of anti-TmpA antibodies in sera of syphilis patients dropped sharply within 1 year. Thus, TmpA might be a useful antigen for monitoring successful treatment of syphilis.

Acute Disease↗

PubMed2004

Performance of routine syphilis serology in the Ethiopian cohort on HIV/AIDS.

OBJECTIVES: To assess the performance of routine syphilis screening during 5 year follow up of Ethiopian factory workers, participating in a cohort study on HIV/AIDS. METHODS: Syphilis serology test results of factory workers, who each donated at least six blood samples were evaluated. Screening in 1997-8 had been performed by the Treponema pallidum particle agglutination (TPPA) assay and in 1999-2001 by the rapid plasma reagin (RPR) test. TPPA had been followed by RPR or RPR by TPPA, in case of a positive screening result. Samples of study subjects showing inconsistent sequential TPPA and/or RPR results were retested independently by three laboratory technicians. RESULTS: A total of 540 cohort participants (8.3% HIV positive at enrollment) donated 4,376 blood samples (mean 8.3 per subject). From 93 of the 176 participants with at least one positive TPPA result during follow up, 152 samples were retested by RPR and/or TPPA. Based on the revised syphilis test results, the 540 cohort participants were classified as having no (70.5%), past (20.6%), prevalent (6.9%), or incident (2.0%) syphilis. The RPR screening test was difficult to interpret and yielded 8.2% biological false positive (BFP) RPR results, or 3.2% if weak positive results were excluded. There was no correlation between HIV infection and BFP RPR reactions. Sample mix-ups were detected in 1.2%. CONCLUSION: Evaluation of routine syphilis screening as performed in a long term cohort study on HIV/AIDS in Ethiopia showed difficulties encountered in syphilis screening programmes such as a high percentage of BFP RPR, inconsistencies in interpretation of the RPR test, and sample mix ups. The findings stress the need to develop a syphilis screening assay that is easy to perform and interpret and to implement quality assurance programmes.

AIDS-Related Opportunistic Infections↗

PubMed2005

Increasing detection of asymptomatic syphilis in HIV patients.

BACKGROUND/OBJECTIVES: The burden of new syphilis diagnoses in London has mainly been in men who have sex with men (MSM), many of whom are co-infected with HIV. Our HIV unit introduced regular serological screening for syphilis during routine follow up care to detect patients who may be at risk of asymptomatic infection. We assessed if this remained an effective and necessary strategy in the second year since introduction. METHODS: All HIV outpatients with newly positive syphilis serology between 1 May 2002 and 30 April 2003 were identified using a prospectively collected database. Only patients who were asymptomatic at the time of screening were included (cohort B). They were compared to patients in the exact preceding year (cohort A). RESULTS: 2655 patients had at least one CD4 count measured in the period (surrogate marker for patients having routine follow up bloods), of whom 2389 (90%) had syphilis serology performed. 40 individuals were found to have early asymptomatic infection (two were re-infections), compared to 26 patients in cohort A. These 40 patients represented 36% of all patients with infectious syphilis treated within our department and 56% of those who were HIV positive. The event rate in cohort B was 7.3 per 1000 patient years (CI 5.2 to 9.9) compared to 2.8 (CI 1.8 to 4.0) in cohort A. CONCLUSION: Routine screening is effective and has detected increasing numbers of HIV outpatients with early asymptomatic syphilis. Our department will continue this strategy for all HIV patients during their follow up care. We recommend that other units adopt similar initiatives that assist with regional control of the UK syphilis epidemic.

Adult↗