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A sexually transmitted disease is seldom considered in the differential diagnosis of patients with clinical gastritis. A patient with gastric syphilis is reported to alert emergency department physicians to this entity. History and physical findings of syphilis should be sought and rapid plasma reagin tests should be obtained in the patient with severe or refractory gastritis.
Sensitivity and specificity of IgG detection by Western blotting performed with a lysate of Treponema pallidum whole cells were compared with those of the most common assays used in the laboratory diagnosis of syphilis, i.e. fluorescent treponemal antibody absorption test (FTA-ABS) and treponemal haemagglutination assay (TPHA). Thirty-five serum samples obtained from twenty-one patients with a clinical diagnosis of early syphilis, based on the presence of typical chancre or skin or mucous membrane lesions, were studied. In addition, thirty blood samples from donors, ten sera positive for Borrelia burgdorferi and five positive for Leptospira interrogans were tested as controls. The clinical diagnosis was the reference method used to compare the performance of the serological tests. Western blotting performed with a sensitivity and specificity of 100%, whereas the corresponding sensitivity and specificity for FTA-ABS were 88.5% and 98%, respectively. The performance of TPHA showed a sensitivity of 86% and a specificity of 100%.
We describe three homosexual men presenting to the ear, nose and throat clinic with severe tonsillitis. All were subsequently diagnosed with secondary syphilis of the tonsil. Syphilis should be considered as a diagnosis in high risk patients presenting with tonsillar lesions, even in the absence of other classical features of the disease.
A 36 year old male developed bilateral sensorineural deafness as the chief manifestation of secondary syphilis. Cerebrospinal fluid showed pleocytosis. Treatment with penicillin and prednisone resulted in good recovery of hearing. Initial recovery seemed dependent on corticosteroids. Deafness can complicate acquired syphilis in both early and late stages of the disease and may be its sole manifestation. Early acquired syphilitic deafness is usually the result of a meningitis affecting the eighth nerve and responds well to treatment. These features are contrasted with those of late acquired syphilitic deafness.
HISTORY AND CLINICAL FINDINGS: A 44-year-old heterosexual man reported having been jaundiced for 4 days. He drank little alcohol. There was no history of venereal disease. INVESTIGATIONS: Laboratory tests indicated marked cholestasis (alkaline phosphatase 1589 U/I, gamma-GT 449 U/I), but only moderately raised transaminases (GOT 66 U/I, GPT 230 U/I), with a bilirubin level of 4.8 mg/dl. Ultrasonography revealed diffuse parenchymal damage in the liver, while endoscopic retrograde cholangiopancreatography showed no abnormalities. Viral hepatitis was excluded by serological tests. Histology of a liver biopsy showed inflammatory infiltration of the portal areas and of the liver parenchyma. Routine syphilis serology indicated fresh infection with Treponema pallidum. There was a healing painless ulcer in the area of the sulcus coronarius of the genitals. TREATMENT AND COURSE: 2.4 mill. I.U. benzathine benzylpenicillin were administered intramuscularly. This rapidly improved his condition and liver function tests became normal. CONCLUSION: In case of hepatitis of uncertain genesis syphilis should be considered as a possible cause, even in the absence of other signs of the disease.
Recognizing congenital syphilis in pediatric patients is of utmost importance with regard to therapy. The case of a 5-year-old girl with salt and pepper fundus demonstrates the importance of a thorough family history which led towards the diagnosis of congenital syphilis. This paper stresses the importance of family history in pigmented lesions of the fundus.
Serum and CNS fluid from 45 patients was tested to provide serum/CNS fluid ratios for IgG, albumin and TPHA titre, as well as protein ratios after Delpech and Lichtblau. Local production of specific antibody in the CNS was demonstrated in 10 of 11 patients with a clinical diagnosis of active neurosyphilis. In 16 patients with questionably active neurosyphilis there were only seven with findings supporting the diagnosis of neursyphilis. Local formation of syphilis antibodies was not demonstrated in any of 18 patients without evidence of CNS syphilis. These findings indicate that demonstration of CNS production of immunoglobulins and confirmation of their treponema specificity provide a further means of serodiagnosis of neurosyphilis.
BACKGROUND: Identification of infants with Treponema pallidum infection of the central nervous system remains challenging. METHODS: We used rabbit-infectivity testing of the cerebrospinal fluid to detect T. pallidum infection of the central nervous system in infants born to mothers with syphilis. The results were compared with those of clinical, radiographic, and conventional laboratory evaluations; IgM immunoblotting of serum and cerebrospinal fluid; polymerase-chain-reaction (PCR) assay testing of serum or blood and cerebrospinal fluid; and rabbit-infectivity testing of serum or blood. RESULTS: Spirochetes were detected in the cerebrospinal fluid of 19 of 148 infants by rabbit-infectivity testing. Exposure of the infant to antibiotics before cerebrospinal fluid was obtained for rabbit-infectivity testing was associated with a negative test result (P=0.001). Spirochetes were detected in the cerebrospinal fluid in 17 of 76 infants (22 percent) who had no prior antibiotic exposure. These 17 infants included 41 percent (16 of 39) of those with some abnormality on clinical, laboratory, or radiographic evaluation; 60 percent (15 of 25) of those with abnormal findings on physical examination that were consistent with congenital syphilis; and 41 percent (17 of 41) of those with a positive result on IgM immunoblotting or PCR testing of serum, blood, or cerebrospinal fluid, or a positive result on rabbit-infectivity testing of serum or blood. Only one infant who had normal findings on clinical evaluation had a positive cerebrospinal fluid rabbit-infectivity test. Overall, central nervous system infection was best predicted by IgM immunoblotting of serum or PCR assay of serum or blood. CONCLUSIONS: Most infants with T. pallidum infection of the central nervous system can be identified by physical examination, conventional laboratory tests, and radiographic studies. However, the identification of all such infants requires the use of additional tests, including IgM immunoblotting and PCR assay.
Traditional tests for detection of syphilis are labour intensive and costly. Enzyme immunoassays (EIAs) are readily automated and cost effective if large numbers of tests are performed. Four experiments were devised to evaluate a syphilis EIA test kit where resources are limited: (1) testing antenatal patients; (2) testing refugees; (3) testing a high prevalence population; and (4) testing "problem sera" (containing autoantibodies or antibodies to other infective agents). Forty-one available syphilitic sera from antenatal patients were tested to evaluate sensitivity. Specificity was determined through testing sera determined to be nonreactive with rapid plasma reagin and Treponema pallidum hemagglutination tests, calculating the sample size (456) on the confidence interval (CI) required. Two runs were performed on antenatal sera, giving sensitivities of 32% (95% CI: 20%, 47%) and 37% (95% CI: 24%, 52%) and specificities of 92% (95% CI: 89%, 94%) and 90% (95% CI 87%, 92%), respectively. We present a method to evaluate a serological test where resources are limited. Unexpectedly, the test kit performed poorly as a screening test. New serological tests need to be evaluated in-house prior to adoption.
Without treatment, syphilis passes through primary, secondary, latent, and tertiary stages. The disease can be diagnosed directly by microscopic identification of the infective organism or serologically. Nontreponemal serologic tests are most suitable for screening and following response to therapy, while treponemal tests are used to confirm a positive nontreponemal test result. Biologic false positives are not uncommon. Because of the danger of infection to the fetus, serologic testing for syphilis is mandatory in all pregnant women. Nontreponemal tests can also be performed on CSF to document neurosyphilis.
Not since the early 1950s has the number of new cases of syphilis been as high as it is now. The infectious agent, Treponema pallidum, is extremely difficult to culture in vitro and almost impossible to see by conventional light microscopy. A nonspecific antibody test is used for screening and a specific treponemal antibody test for confirmation. Because of the complexity of the disease, the sensitivity and specificity of a given test can vary according to disease stage. The physician must understand the limits imposed on testing by the disease process and the special circumstances that prevail in testing patients for prenatal and congenital syphilis as well as neurosyphilis. With early detection and treatment, cure can be achieved and long-term complications avoided.
Although congenital syphilis has been recognized for several centuries and an efficient treatment with penicillin became available more than a half-century ago, the disease is still with us. Inability to culture in vitro the causative agent, Treponema pallidum, and the lack of an adequate animal model have prevented exploration of the various immunopathological events affecting the natural course of congenital infection. The purpose of this review is to analyze the disease in the context of recent knowledge acquired from human and experimental animals, particularly from the guinea pig model of congenital and neonatal syphilis, and to describe how the infection interacts with the maternal-fetal unit and how it is further modulated by the conceptus' ontogenic development. We also attempt to elucidate several old immunologic concepts and misconceptions that have remained unchallenged for too long.
Regardless of the nontreponemal test used for the screening and diagnosis of syphilis, biological false-positive results (BFPs) are documented in 1%-2% of all cases. An association between BFPs and human immunodeficiency virus (HIV) infection in men has been suggested. We conducted a cohort study to determine whether a similar association between HIV seropositivity and BFPs exists for women. Among 156 HIV-seropositive women, 9 (5.8%) had a BFP for syphilis. Among 633 HIV-seronegative women, only 1 (0.2%) had a BFP. When the 25 HIV-seropositive patients and 55 HIV-seronegative patients with reactive rapid plasma reagin tests and microhemagglutination assays for antibodies to Treponema pallidum were excluded from the calculations, 6.9% and 0.2% of HIV-seropositive and HIV-seronegative women, respectively, had BFPs (P < .001; odds ratio, 39.45; 95% confidence interval, 6.4-879.0). An association was found between injection drug use and BFPs for the population of HIV-infected women but did not entirely account for the differences between this group and the HIV-seronegative group.
Paraffin-embedded tissue from all 17 autopsies performed following 56 stillbirths associated with maternal syphilis during a 3-year period (1987-1989) was reexamined to compare immunofluorescent antigen (IFA) testing with silver staining for the detection of Treponema pallidum. Congenital syphilis (CS) originally was diagnosed in 9 of the 17 cases of stillbirth, on the basis of positive silver stains (7 cases) or morphological findings alone (2). Upon review, silver staining revealed T. pallidum in 10 of 17 cases and IFA testing revealed the pathogen in 15 of 17 cases, enabling diagnosis of CS in 16 of 17 cases of stillbirth associated with a reactive maternal rapid plasma reagin (RPR) card test. Most stillbirths associated with a reactive maternal RPR test during this time period involved CS, and IFA testing for T. pallidum is superior to silver staining for the identification of treponemes.
Application of an epidemiologic strategy, involving repeated annual screening, public relations activities and treatment to selected groups, for syphilis control in four communities is described. The predictive value of the VDRL screening test was influenced by the titre of the test and the age and location of individuals on whom it was performed. The predictive value of 1:8 VDRL titres (for active syphilis) varied from zero in individuals over 50 years of age, in one community to 0.96 in individuals 10-29 years old in another. Reduction in transmission of infection was closely related to the degree of screening coverage of the community and adjacent communities with which intercourse occurred.
Antibodies to herpes simplex virus type 2 (HSV-2), antibodies to hepatitis B virus (HBV) core antigen (anti-HBc), and VDRL antibodies (serologic evidence of syphilis) were evaluated in women known to be infected with human immunodeficiency virus type 1 (HIV-1) (n = 95) or human T lymphotropic virus type I (HTLV-I) (n = 45) and controls (n = 89). HIV-1-seropositive women were more likely than controls to have antibodies to HSV-2 (88% vs. 54%; P less than .001), anti-HBc (67% vs. 43%; P = .008), and VDRL antibodies (21% vs. 8%; P = .02). Similarly, HTLV-I-seropositive women were more likely than controls to have antibodies to HSV-2 (82% vs. 54%; P = .003) and anti-HBc (67% vs. 43%; P = .008). There was no evidence that HIV-1 or HTLV-I predisposed to chronic hepatitis B virus infection. The stronger associations between HIV-1 and HTLV-I with HSV-2 than the associations with syphilis or HBV are consistent with the hypothesis that recurrent disruptions of mucous membranes caused by HSV-2 infections predispose to sexual transmission of HIV-1 and HTLV-I.
Twenty-eight cases of congenital syphilis (CS) were diagnosed shortly after birth at the Mount Hope Women's Hospital, Trinidad, during the period January 1985 to December 1988. The average annual incidence of CS was 115 per 100,000 live births, and the absolute number of cases and annual incidence doubled in the latter 2 years of the study. Diagnostic criteria used were a positive VDRL test in the 23 liveborn infants (100 per cent), signs suggestive of CS and confirmatory post-mortem findings. All mothers attended antenatal clinic at least once and 18 (64 per cent) were 25 years or younger. Only 17 (68 per cent) of the 25 gravidae with a positive VDRL test received treatment. Of 11 untreated gravidae, two did not have a VDRL test done, one had a negative VDRL test, three delivered before test results became known, one went into labour before going for treatment, and four (two of whom were substance abusers) did not comply with instructions to obtain treatment. There were five stillbirths and five neonatal deaths. There was no perinatal mortality when treatment was given earlier than 5 weeks before delivery, but mortality increased steeply if treatment was delayed or not given at all during pregnancy. Factors which contributed to this rise in the incidence of CS were an increased incidence of syphilis in females and failure to treat infected pregnant women.
Benefit-cost analysis was applied to a model of first-trimester screening for syphilis where approximately ten new cases of early infections are identified and treated per 50,000 pregnancies. The cost of the screening is estimated to be +4.60 (U. S.) per participating woman, while the benefit-cost ratio was 3.8; thus the economic benefits are nearly four times the cost of the program. Furthermore, there are many other beneficial factors that cannot be evaluated in terms of money. The validity of the results varies with discount rates, frequencies of syphilitic infection, and rates of transmission to the fetus. If the incidence of maternal syphilis is 0.005%, the benefits equal the costs of the prevention program. In Norway, prenatal screening has been obligatory for 30 years. This represents a net benefit, or a total savings, of +8.6 million (U. S.; 1979). From an economic point of view, the first-trimester serologic screening should continue unabridged, whereas an extended preventive program, including premarital screening or additional third-trimester serologic tests, may not be advisable in Norway.