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Serologic diagnosis of syphilis: an update.

Tests used in the serologic diagnosis of syphilis can be divided into two main groups: nontreponemal (reagin) tests and treponemal tests. The most widely used nontreponemal test is the Venereal Disease Research Laboratory (VDRL) slide test, and the standard treponemal test is the manual fluorescent treponemal antibody-absorption (FTA-ABS) test. These tests and other newer tests available for the serologic diagnosis of syphilis are reviewed, with emphasis placed on their current clinical usefulness.

Complement Fixation Tests↗

Untargeted metabolomics in a prospective cross-sectional observational study reveals differences in plasma and cerebrospinal fluid between asymptomatic neurosyphilis and serofast syphilis.

Asymptomatic neurosyphilis (ANS), a diagnostically elusive complication of Treponema pallidum infection, necessitates invasive cerebrospinal fluid (CSF) analysis for detection. This study investigated metabolic differences between patients with ANS and those with serofast syphilis. Using untargeted metabolomics, we analyzed plasma and CSF from 15 patients with ANS, 15 patients with serofast syphilis, and 16 healthy controls via liquid chromatography-mass spectrometry. Univariate statistical analyses identified differential metabolites, followed by pathway enrichment through Kyoto encyclopedia of genes and genomes enrichment analysis and biomarker evaluation. Plasma analysis identified dysregulated tryptophan metabolism as a central feature in ANS, with key alterations in 4-(2-aminophenyl)-2,4-dioxobutanoic acid and 2-formylaminobezaldehyde. Comparative analysis further distinguished ANS through perturbations in inositol phosphate metabolism in both plasma and CSF. Spearman correlation analysis identified positive associations of the plasma biomarkers 1D-myo-inositol-1,3,4,6-tetrakisphosphate, inositol-1,3-bisphosphate, 4-(2-aminophenyl)-2,4-dioxobutanoic acid, and 2-formylaminobezaldehyde with CSF total protein. Our findings suggest that dysregulation in tryptophan and inositol phosphate metabolism may play an important role in ANS pathogenesis, warranting further confirmatory studies.

Humans↗

Laboratory evidence for impaired cellular immunity in different stages of syphilis.

Abundant evidence suggests that Treponema pallidum (T.p.) escapes humoral immune defence despite the host produces antibodies early in the infection. Since the serologic responses in syphilis have been studied in detail this paper focuses on the cellular immune mechanisms. For this purpose the leukocyte migration inhibition was investigated in 17 patients in different stages of syphilis. Leukocyte migration inhibition assay was performed before, and 7 days, 3 weeks, 2 mo. and 1 yr after start of treatment. Ultrasonicated T.p. were used as antigen corresponding to 5 X 10(6) to 2 X 10(7) Treponema pallida per ml. Controls without antigen, with addition of Concanavalin. A instead of T.p. and using cells of normal volunteers were run. There was no leukocyte migration inhibition before treatment, suggesting nonexistent or depressed cellular immunity in the untreated syphilitic patient. Significant leukocyte migration inhibition, however, was observed as early as 2 days after start of treatment, being most pronounced after 1 week. Hypothetical circulating blocking factors for cellular immune reactions might be present in the untreated syphilitic patient, which become abolished after therapy. Since stimulation with Con A of syphilitic leukocytes gave normal results even before treatment in the syphilitic patient, there might be a specific block of leukocyte migration inhibition against T.p.

Cell Migration Inhibition↗

Seronegative secondary syphilis in an HIV-infected patient.

Recently, increased rates of syphilis among gay men have been observed in American and European cities. It is important to establish the diagnosis because syphilis facilitates HIV transmission during the primary and secondary stages when sores are open on the skin. However the diagnosis can present a dilemma as negative reactions to serological tests may be observed in AIDS patients. We report here such a case in which the diagnosis was established on dark field examination.

Adult↗

The many faces of secondary syphilis: a re-emergence of an old disease.

There has been a recent dramatic re-emergence of syphilis in the UK. This article describes the varied clinical manifestations of secondary syphilis and describes the diagnosis and current guidelines for treatment, especially in association with human immunodeficiency virus infection.

AIDS-Related Opportunistic Infections↗

Rabbit model of disseminated syphilis: immunoblot and immunohistologic evidence for a role of specific immune complexes in lesion pathogenesis.

Circulating immune complexes (CIC) containing Treponema pallidum proteins have been preliminarily implicated as inducers of a neutrophilic vascular reaction in early human cutaneous lesions of secondary syphilis. To clarify the role of specific CIC in producing cutaneous and renal lesions, 12 rabbits were studied at the following intervals after induction of disseminated syphilis: 20 days (4 rabbits: biopsies of normal and lesional skin for direct immunofluorescence (IMF) for (IgG, IgM, IgA, Clq, C3, C4), fibrin, and T. pallidum proteins; routine histology; and immunoblots of serum for CIC containing T. pallidum proteins); 21 days (4 rabbits: as at 20 days without IMF for T. pallidum protein); 23 days (4 rabbits: as at 20 days without IMF); 30 days (same 12 rabbits restudied with routine histology of normal and lesional skin; kidneys from 4 rabbits removed for routine, IMF, and electron microscopy (EM). Treponemal polypeptide antigen (MW-87 kd) was demonstrated in CIC from rabbits. Routine cutaneous histology showed evolution of lesions from an early neutrophilic vascular reaction to the typical lymphoplasmacytic reaction. IMF showed vessel-based immunoreactants in 3 of the 4 rabbits tested at 20 days and 1 of 4 at 21 days, and T. pallidum proteins in 3 of 4 rabbits at 20 days. Routine histology, IMF, and EM studies of glomeruli showed glomerular abnormalities, but no evidence of immune deposits containing specific T. pallidum protein. Skin and kidney studies of 4 controls were all negative. These data indicate a role for specific immune complexes in the pathogenesis of cutaneous lesions in this rabbit model.

Animals↗

Roxithromycin (RU 965): effective therapy for experimental syphilis infection in rabbits.

Roxithromycin (RU 965), a new macrolide antibiotic, was shown to be effective for therapy of active syphilis in rabbits. Dark-field-positive lesions were produced in adult male rabbits by intradermal inoculation of approximately 10(6) Treponema pallidum organisms at each of 11 sites. Beginning 7 days after infection, six animals per group were treated with benzathine penicillin G (200,000 U, intramuscularly, weekly for 2 weeks) or roxithromycin (15 mg/kg of body weight, orally, twice daily for 15 days); six animals were not treated. Chancres in untreated animals were dark-field positive throughout the 16-day observation period; all benzathine penicillin-treated rabbits were dark-field negative 1 day after the initiation of therapy. Five of six animals treated with roxithromycin were dark-field negative on day 3 following the initiation of therapy; the sixth animal was dark-field negative by day 6. Lesions in untreated animals reached a mean (+/- standard deviation) maximum diameter of 14.7 +/- 1.91 mm compared with 8.4 +/- 3.6 mm for benzathine penicillin-treated (P less than 0.005) and 10.4 +/- 1.2 mm for roxithromycin-treated (P less than 0.001) animals. Ulceration occurred at 62 of 66 lesions in untreated animals compared with 0 of 66 lesions in each treated group. At 3, 6, and 12 weeks postinfection, Venereal Disease Research Laboratory antibody titers were significantly higher (P less than 0.05) in untreated than in treated animals. Titers in penicillin-treated versus roxithromycin-treated animals were significantly different at 6 weeks postinfection but not at 3 and 12 weeks postinfection. Transfer of tissue from treated rabbits to seronegative recipient animals did not reveal any evidence of persistent infection in the benzathine penicillin- or roxithromycin-treated animals. These findings indicate that benzathine penicillin and roxithromycin, at the doses indicated above, are effective in treating active syphilis in rabbit model.

Animals↗

Use of synthetic cardiolipin and lecithin in the antigen used by the venereal disease research laboratory test for serodiagnosis of syphilis.

The Venereal Disease Research Laboratory (VDRL) test is a microflocculation test for syphilis that uses an antigen containing cardiolipin, lecithin, and cholesterol. For more than 50 years, the preparation of natural cardiolipin and lecithin for this test has been based on the Pangborn method which involves isolating and purifying these components from beef hearts. This process is tedious and time-consuming and results in a variable purity range. In our studies, we found that a VDRL antigen using synthetic tetramyristoyl cardiolipin and synthetic 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine (lecithin) was as specific in detecting syphilis as a VDRL antigen made with natural components. In 85% of the cases, we obtained an endpoint titer of 1/2 or 1 dilution more than a titer obtained with a VDRL antigen made with natural components. The use of these pure synthetic compounds, with a purity of 99%, would offer advantages in the standardization and stability of the VDRL antigen. Because this antigen is the basic ingredient in the preparation of nontreponemal reagents such as the rapid plasma reagin, toluidine red unheated serum test, and the unheated serum reagin, the use of this synthetic VDRL antigen should also increase the reactivity of these reagents.

Cardiolipins↗

Experimental syphilis and serological examination for treponematosis in hares.

Of 202 captive hares studied, many of which had lesions on their external genital organs or testicular atrophy or both, 27% had positive serological tests for syphilis although dark-field examination of extracts of atrophic testes was negative. A total of 12 hares that were nonreactive for the serological test for syphilis was inoculated with Treponema pallidum, 9 intratesticularly and 3 intradermally. Six of the animals inoculated intratesticularly exhibited orchitis after 7 days with an associated accumulation of treponemes. No chancres developed in the intracutaneously inoculated animals during a 27-day period of observation. These results provide additional evidence to support the contention that endemic treponematosis occurs in wild hares and suggest that hares are moderately resistant to experimental infection with T. pallidum.

Animals↗

Target organs of infection in guinea pigs with acquired congenital syphilis.

The target organs of infection in guinea pigs with asymptomatic acquired or congenital syphilis were identified by PCR and in some cases by rabbit infectivity test (RIT). The prevalence of Treponema pallidum DNA was examined in the following seven organs: the inguinal and mesenteric lymph nodes, spleen, liver, kidney, heart, and brain. Test samples consisted of 95 organs from two genetically different strains of female guinea pigs (C4-deficient and Albany) with different susceptibilities to cutaneous infection by T. pallidum and 195 organs from their asymptomatic offspring. Twenty organs from dams of both strains injected with heat-killed T. pallidum and 19 organs from their progeny served as negative controls. The infections of mothers and neonates were documented by PCR, RIT, and serology. Though any of the organs tested could be infected, there was a spirochetal predilection for some anatomical locations, such as the lymph nodes, heart, and brain, regardless of the strain, route of maternal infection, and age. None of the 49 organs collected from control animals were positive by PCR. In infected C4-deficient dams, one to four organs were positive by PCR, whereas the organs of 7 of their 27 (25%) asymptomatic offspring were treponemal DNA negative, despite evidence of immunoglobulin M treponemal antibodies. Comparative analysis done by both PCR and RIT on a limited number of samples showed 90% agreement between results. An examination of multiple samples obtained from single organs demonstrated that even within 24 h of spirochetemia, when most organs appeared to be infected, not all samples from an individual organ were positive by PCR. A specific immunological response in guinea pigs with congenital syphilis was a more consistent parameter of vertical transmission than was an analysis of T. pallidum DNA.

Animals↗

Comparison of serum and plasma specimens for syphilis serology using the reagin screen test.

One serum and three plasma samples were obtained from each of 125 normal individuals and from 140 patients with treated or untreated syphilis. Serum samples were tested by the Venereal Disease Research Laboratory (VDRL) test and by the Reagin Screen Test (RST). Plasma specimens were tested only with the RST. When tested within 24 h after collection, all specimens from normal individuals were nonreactive. Plasma specimens from normal individuals stored for up to 72 h after collection continued to yield a clearly nonreactive result in 423 of the 426 samples tested by the RST. Serum and plasma samples from syphilis patients tested within 72 h after collection by the RST yielded qualitative and quantitative results almost identical to results of serum tested by the VDRL test.

Evaluation Studies as Topic↗

Blood spot screening and confirmatory tests for syphilis antibody.

We developed a blood spot test for syphilis antibody using enzyme-linked immunosorbent assay (ELISA) technology. Dried blood was eluted by buffered saline or, for a supplementary confirmatory test, by treponemal-antibody test diluent. Eluates were diluted in an absorption buffer (Calypte Biomedical, Berkeley, Calif.) and added to plate wells coated with cardiolipin antigen (ADI Diagnostics, Toronto, Ontario, Canada). The wells were washed and treated sequentially with an immunoglobulin G conjugate, buffer washes, and enzyme substrate. Substrate conversion was measured photometrically, and specimen reactivity was determined by reference to nonreactive controls. The optimum test protocol was established by tests of serum and plasma. The serum ELISA specificity with normal specimens was 98.9%. The sensitivity with sera from patients with undefined syphilis was 97.4%, that with sera from patients with documented primary and secondary disease was 100%, and that with sera from patients with early and late latent disease was 95.7%. The specificity of the spot test with donor blood was 94.2%, and its specificity with newborn blood was 94.9%. The sensitivity with 25 spots spiked with reactive sera was 96%. The seroprevalence rates for parturient women in one hospital were 6.01% according to spot tests of sera from 599 newborns and 6.81% according to Rapid Plasma Reagin tests of 499 maternal serum specimens. Seventy percent of infants born to 50 seropositive women were reactive by either the newborn spot or the Rapid Plasma Reagin serum test. The results show that blood spots may be used in seroprevalence or serodiagnostic studies, especially to identify women who are infected or to identify possible cases of congenital infection. The test provides for studies of children and adults when routine venipuncture and serum handling and storage are problematic.

Antibodies, Bacterial↗

Nephrotic syndrome and hepatitis in early syphilis.

A 54 year old man presented with features of acute hepatitis and the nephrotic syndrome. A diagnosis of active syphilis was only made by chance after extensive investigation. Syphilis should be considered in the differential diagnosis of both acute hepatitis and the nephrotic syndrome occurring separately as well as together.

Hepatitis↗

Dark ground microscopy and treponemal serological tests in the diagnosis of early syphilis.

OBJECTIVES: To evaluate the use of dark ground microscopy (DGM) and treponemal serological tests in the diagnosis of primary (PS) and secondary (SS) syphilis. METHODS: A retrospective case note review of patients with early syphilis who attended our department between January 2001 and December 2002. Data were collected on demographics, results of treponemal serology and DGM. RESULTS: 50 individuals had PS and 36 individuals had SS. DGM was performed in 31/50 (62%) of PS cases and this was positive in 97%. In 17 (34%) cases of PS, treponemal EIA was negative initially. DGM was performed on 13 of these, all of which were positive. Therefore, EIA had a sensitivity of 57% when compared to DGM. In 27 patients where EIA-IgM was performed, this was positive in 22 (81%), of which 12 were EIA negative on initial screening. All SS cases had positive EIA. DGM was performed in 19/36 (52%) of SS cases and was positive in 16/19--that is, a sensitivity of 84% when compared to EIA. The major reason why DGM was not performed in the cases of PS was that herpes was the presumed diagnosis and in SS the rash was attributed to other causes. CONCLUSIONS: DGM is a rapid and sensitive test while EIA takes time for results and is less sensitive in PS. EIA-IgM is a useful adjunct in PS. DGM allows immediate diagnosis, treatment, and partner notification preventing further transmission. Genitourinary medicine clinics should have trained staff to perform DGM on all anogenital ulcers and suspected syphilitic lesions.

Cohort Studies↗

A multi-centre evaluation of nine rapid, point-of-care syphilis tests using archived sera.

OBJECTIVES: To evaluate nine rapid syphilis tests at eight geographically diverse laboratory sites for their performance and operational characteristics. METHODS: Tests were compared "head to head" using locally assembled panels of 100 archived (50 positive and 50 negative) sera at each site using as reference standards the Treponema pallidum haemagglutination or the T pallidum particle agglutination test. In addition inter-site variation, result stability, test reproducibility and test operational characteristics were assessed. RESULTS: All nine tests gave good performance relative to the reference standard with sensitivities ranging from 84.5-97.7% and specificities from 84.5-98%. Result stability was variable if result reading was delayed past the recommended period. All the tests were found to be easy to use, especially the lateral flow tests. CONCLUSIONS: All the tests evaluated have acceptable performance characteristics and could make an impact on the control of syphilis. Tests that can use whole blood and do not require refrigeration were selected for further evaluation in field settings.

Humans↗

Bony symptoms in secondary syphilis.

Aching bony pains were prominent in six of 144 cases of secondary syphilis. These pains included headache, backache, aching pains in the limbs, and chest pains. The cause of some of these pains is not clear, but it is important to recognize that secondary syphilis may present with a variety of pains.

Adult↗

Treponema pallidum immune adherence test for serodiagnosis of syphilis. 3: Clinical significance and evaluation of treatment.

Antibody titres were measured in patients with clinical syphilis, and the effect of treatment on the results of the Treponema pallidum immune adherence (TPIA) test is reported. In the Treponema pallidum haemagglutination (TPHA) test little change in antibody titre occurred after treatment while in the fluorescent treponemal antibody-absorbed (FTA-ABS) test only a slight decrease occurred. The decrease in the antibody titre in the TPIA test was similar to that in the glass plate test, but the findings were different. From the results of gel filtration of sera obtained from patients with syphilis at different intervals after treatment it was apparent that the decrease in antibody titre after treatment mainly concerned the IgM antibody; thus, because of the high sensitivity of the TPIA test to IgM antibody the test is useful in evaluating the effect of treatment.

Antibodies, Bacterial↗