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A man had widespread, noduloulcerative syphilitic lesions that appeared, chronologically, during the "secondary" stage of syphilis. There were no systemic manifestations of the disease, except for possible periostitis. The darkfield examination and spinal fluid examinations were negative for syphilis. It is suggested that the term "malignant" syphilis should be discarded in favor of nonduloulcerative cutaneous syphilis.
The characteristics and the working modalities of ELISA (Enzyme Linked Immunosorbent Assay) are outlined at the onset. Subsequently, the Authors refer the data relevant to the use of ELISA in the syphilis serodiagnosis, by describing the operative phases for the working out of the test with the enzyme peroxidase, and reporting the results of the clinical investigation performed on primary and secondary syphilis in progress, on treated primary and secondary syphilis (examinations performed 1 to 10 years after the end of therapy), on healthy blood donors, and on samples of false biological positivities. On the basis of the analysis of the results, the Authors feel that ELISA for its characteristics of sensitivity, easiness in carrying out, rapidity and reproducibility, might find a rational indication in the modern serodiagnosis of the syphilis.
An immunoelectrophoretic study of serum from patients with non-treated recently acquired syphilis (RAS) is made for the first time in our country. Increases in IgM and IgG fractions were detected; the increase of the former exceeded to the latter in patients with cutaneous symptomatic recently acquired syphilis (CSRAS) in comparison with those having mucous cutaneous symptomatic recently acquired syphilis (MCSRAS). IgG were increased in 100% of patients with this latter disease, although both fractions were increased in patients with latent recently acquired syphilis (LRAS).
A 21-month old infant with endemic syphilis who presented with nephrotic syndrome is described. Clinically, the features correlated well with those of renal disease associated with secondary syphilis. The onset of renal disease in association with syphilis after early infancy may be a valuable aid in drawing attention to the possibility of endemic syphilis. Morphologically the features were those of an immune complex-mediated glomerulonephritis. We regard the presence of a large number of immature-looking glomeruli as a retrogressive phenomenon.
We describe a patient with a painful lytic lesion of the clavicle and a granuloma of the liver in late secondary syphilis. The classic "moth-eaten" alopecia of the scalp as well as eyebrows and eyelashes suggested syphilis, although an initial false-negative VDRL test for syphilis (prozone phenomenon) caused a delay in diagnosis. Bone as well as liver involvement in early syphilis may be more common than previously recognized.
A retrospective questionnaire survey of a sample of 173 of the 360 cases of early congenital syphilis reported in 1972 revealed serious problems with diagnostic certainty, prevention, and treatment of congenital syphilis. Only 24 (13.9%) of the reported cases could be categorized as probably or definite cases based on criteria developed from a literature review. Forty percent of the mothers received no prenatal care and an additional 19% received no prenatal care until the third trimester. Initial and followup serologic testing was inadequate in those who received care. Eighty-three different penicillin treatment schedules were used in the treatment of 128 infants. Carefully reasoned diagnostic and therapeutic decision making about the management of congenital syphilis appears to be lacking.
A steady decline in the incidence of positive results to the Kahn test is reported in Malawian patients during the period 1968-75. Other studies have shown that the incidence of early and late syphilis in sub-Saharan Africa has dropped considerably over the past few decades. The number of reported cases of early syphilis in certain urban areas, however, appears to be high. It is suggested that the downward trend in the incidence of syphilis in Africa is related to the increased and often indiscriminate use of penicillin.
Reactions related to treatment of syphilis may be due to treponemal infection, therapy, or to the interaction of these. In this review I discuss the Jarisch-Herxheimer (J-H) reaction and the therapeutic paradox. Antibiotic side effects are not unique among patients treated for syphilis; therefore, readers are referred elsewhere for reviews of major antibiotic side effects. J-H reactions are acute, transient episodes with manifestations occurring both systemically and at local sites of treponemal concentration. These reactions are related to the rapid destruction of treponemes by various therapeutic agents. In this review, I suggest that J-H reactions may be significant only in syphilitic paresis, pregnancy complicated by syphilis, and when local inflammation can cause serious functional compromise, as with second or eighth cranial nerve involvement. Many workers use prednisone in conjunction with penicillin in some or all of these situations. However, the efficacy of corticosteroids has not been evaluated for such problems in clinical trials. Therefore, the use of prednisone can be supported only in very selected situations and for short duration (ie, 2 days). Therapeutic paradox, which is clinical worsening despite cure of infection, is said to result from scar formation after rapid treponemal destruction by therapeutic agents. The therapeutic paradox does not appear of great significance. Futhermore, no methods to prevent such reactions are generally advocated.
Of 5,954 adult inpatients consecutively discharged from a university hospital during a three-month period, only 8.4% had serologic tests for syphilis performed during hospitalization. The testing rate was 20.1% on patients admitted to a medical teaching service and 1.4% on a surgical teaching service. In patients tested, a positive rapid plasma reagin test result was obtained in 6.2% and the diagnosis was confirmed by further testing, but effective therapy was not always given. On 9 of 30 patient records listed syphilis as a diagnosis on discharge. We conclude that serologic testing for syphilis is routinely omitted in the evaluation of hospitalized patients; even when tests are positive, the results are often ignored.
Although Bell's palsy is usually idiopathic, occasional cases may have an identifiable infectious cause. When facial paralysis results from syphilis, it usually develops during the tertiary meningovascular stage. We report a 30-year-old man with secondary syphilis who developed facial paralysis associated with acute syphilitic meningitis. Spirochetes were identified in the cerebrospinal fluid by immunofluorescence using standard reagents from the fluorescent treponemal antibody absorption (FTA-ABS) test. Patients with Bell's palsy should be screened for syphilis with a blood FTA-ABS test, and treatment with corticosteroids should be considered only after an infectious cause has been excluded.
Observations made on fluorescent treponemal antibody absorption (FTA-ABS) immunoglobulin M (IgM) titres in patients with untreated early syphilis showed non-reactive or weakly reactive results in patients with primary (one of five cases) and secondary (two of 16 cases) lesions. In patients with primary (19.5%) and secondary (15%) syphilis sera remained reactive with increased titres for more than one year after treatment. The respective figures in the results of the Venereal Disease Research Laboratory (VDRL) test were zero in primary and 20% in secondary syphilis. The non-reactive FTA-ABS IgM results may possibly be explained by competitive inhibition of IgM by immunoglobulin G (IgG). The persistence of reactivity in a comparable percentage has been observed by other investigators (Grin et al., 1974; Wilkinson and Rodin, 1976). The current results therefore suggest that FTA-ABS IgM titres are less reliable for assessing the effect of treatment than the course of the VDRL titres. The phenomenon of a decrease in FTA-ABS IgM titres soon after treatment with a later rise before final non-reactivity is a matter for further investigation.
The case history of a man with primary syphilis of the right hand is described. This type of luetic condition nowadays is rare. The incidence of genital, anorectal, and extragenital primary syphilis in both men and women and in sailors presenting at the Venereological Outpatient Clinic of the Department of Dermatology of the University Hospital Rotterdam-Dijkzigt during a period of seven years was studied. In sailors and women only genital primary lesions were found, whereas in male civilians 6.3% of cases of primary syphilis had anorectal lesions. The primary lesions in this study were different from those reported in earlier literature.
In 19 of 20 patients in whom the correct diagnosis of primary or secondary syphilis was not obvious initially, a positive routine admission VDRL test result was the first indication of the correct diagnosis. A retrospective study during a one-month period to correlate hospital admissions by clinical service with required routine admission serologic tests for syphilis disclosed an overall compliance rate of only 37.1% (range, 94.6% to 8.0%). Of the 38 patients who did have a positive admission VDRL test result, 55.3% were falsely positive. The false-positive rate was slightly higher for weakly reactive titers than it was for higher titers. The routine serologic testing program uncovered 129 and 116 new cases of syphilis during 1976 and 1977, respectively. The decision to continue the routine admission VDRL screening program was made because the consequences of an incorrect diagnosis could be very great for an individual patient.
Recent discoveries in paleogenomics have revolutionized our understanding of syphilis and other human treponematoses. Far from being a pathogen that suddenly appeared in Europe in the late Middle Ages, we now know that Treponema pallidum has been circulated among human populations for millennia. Ancient genomes recovered from pre-Columbian contexts in the Americas show that major treponemal lineages had already diversified well before the modern era, often in the absence of recognizable skeletal lesions. Genomic analyses further indicate that treponemal diversity is not the result of extensive genetic acquisition, but rather of small-scale modulation of a highly conserved genome, notably via antigenic variation involving the tpr gene family. Combined with data on endemic treponematoses, congenital syphilis, and historical pathology collections, these findings support a model in which syphilis, yaws, and bejel represent context-dependent expressions of an ancient treponemal continuum, with implications for diagnosis, epidemiology, and vaccine design.
The incidence of infectious syphilis is much different from the number of reported cases in any given year; therefore, an estimate of the incidence is needed to formulate effective control programs for the future. A time series aggregation model that predicts the incidence of syphilis was developed. The model accounts for the number of treated but unreported cases, and it provides estimates of incidence for different age and racial groups. As an illustration the model was applied for estimation of the incidence of syphilis in the city of Chicago, Illinois. A sensitivity analysis revealed that a 10% variation in input parameters would cause an error of smaller than or equal to 4.1% in the estimates of incidence.
It was shown that T. pallidum immobilized in vitro by normal serum had lost its infectivity in rabbits. This finding suggested that the immobilizing activity of normal serum might play a role in the natural resistance of man against infections with T. pallidum. However, the results of serological studies of acquired early syphilis in man and of experimental syphilis in cynomolgus monkeys did not present evidence that the immobilizing activity of normal serum protected against syphilis infection.
Suppression of cellular immunity during primary and secondary infection may explain, in part, the unusual clinical evolution of syphilis. We have previously shown that lymphocytes from normal subjects undergo blastic transformation when exposed in vitro to Treponema refringens. This response was suppressed in patients with syphilis. the suppression being unrelated to serum factors. In the present paper we studied lymphocyte response in vitro to T. refringens, T. reiter, and T. pallidum as well as to monilia and trychophytins. The response to these antigens was suppressed in patients with syphilis although the response to phytohemagglutinin. pokeweed mitogen, and streptolysin was normal. These data support the hypothesis that human infection with T. pallidum is followed by a complex interaction between cellular and humoral immunity, the former being suppressed in primary and secondary stages.
Purified axial filaments from the cultivable Reiter treponeme, previously shown to share an antigenic component with pathogenic Treponemia pallidum, were evaluated as antigen in a diagnostic test for syphilis. Antibody to the filaments was revealed by counterimmunoelectrophoresis. Conditions that produced optimal results in the test were established. A total of 343 sera from normal individuals, biological false-positive reactors, and from patients in the different stages of syphilis were subjected to the test. The results indicate the test to be sensitive and highly specific for detecting treponemal antibodies in human syphilis.