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BackgroundPrimary syphilis is characterised by the appearance of an ulcerated lesion (chancre) on the anogenital or oral mucosa from which Treponema pallidum DNA may be detectable by PCR. Serological tests for syphilis may be non-reactive in early infection, even after the appearance of a chancre. We reviewed the use of a multiplex-PCR (M-PCR) test to determine the added value of T. pallidum DNA detection in the management of individuals presenting with mucocutaneous ulceration at a sexual health service in central London.MethodsWe performed a cross-sectional analysis of all individuals with detectable T. pallidum DNA from September 2019 to April 2020. Electronic patient records were reviewed and concomitant results for treponemal serology and/or rapid plasma reagin (RPR) extracted, along with demographic data, history of syphilis and indices of sexual behaviour including number of sexual partners contacted. Any subsequent treponemal serology and RPR results were also reviewed.ResultsM-PCR swab specimens were performed in 450 individuals, of whom 63 (14%) had detectable T. pallidum DNA; 60 of 63 (95%) were gay or bisexual men and 11 of 63 (17%) were living with HIV. A history of treated syphilis was present in 17 of 63 (27%). Same-day treponemal serology/RPR testing was performed in 58 of 63 (92%) patients. Of the 58 who had same-day syphilis serology/RPR, 9 (16%) had their syphilis infection confirmed by treponemal DNA PCR alone. A total of 165 partners were traced as contacts of infection, of whom 25 (15%) were contacts of individuals diagnosed by M-PCR testing alone.ConclusionIn individuals with T. pallidum PCR-positive lesions, around one in six in our cohort were negative on standard diagnostic serological tests for syphilis. Treponemal DNA testing is an important addition to serological assays in individuals with mucocutaneous ulceration who are at risk of recent syphilis infection and facilitates early diagnosis and contact tracing.

Syphilis has re-emerged as a significant public health threat in recent years. While most cases of syphilis are currently diagnosed in low-income and middle-income countries, the incidence of syphilis has been increasing in Western industrialised countries since the 1990s, particularly among gay, bisexual and other men who have sex with men (MSM).1 Increased rates among heterosexuals in these countries have also been reported in more recent years, most often in marginalised populations.2 In England, there were 7982 diagnoses of syphilis during 2019, a 200% increase since 2010. Although three-quarters of cases were diagnosed in MSM, cases in heterosexual men and women have increased by 69% and 117%, respectively, between 2015 and 2019, and the number of cases of congenital syphilis (CS) has also increased.3 The underlying drivers of the increase in heterosexually acquired syphilis cases in England remain unclear. Syphilis is caused by Treponema pallidum subspecies pallidum and is typically transmitted by direct contact with an infectious lesion during sexual intercourse. The clinical presentation of syphilis is divided into three stages, primary, secondary and tertiary, and the first two are the most infectious stages. Typically, primary syphilis presents as a painless ulcer (chancre) which usually occurs in genital sites and resolves within 3 to 8 weeks. If left untreated, 25% of patients will develop secondary syphilis, a systemic disease characterised by fever, rash and lymphadenopathy. Secondary syphilis will resolve spontaneously in 3 to 12 weeks and all untreated cases will progress to latent (asymptomatic) infection, with one-third …

Background:Sir William Osler once wrote: “He, who knows syphilis, knows medicine”.Whilst the Tuskegee Syphilis trials live in infamy, the advent of succesful penicillin treatment and sexual health education resulted in the lowest recorded incidence ever in 20011.Unfortunately, cases of syphilis have nearly tripled in the past decade (from 2,847 in 2009 to 7,541 in 2018 in the UK)1. WHO now estimates the global median prevalence of Syphilis, among men who have sex with men, is 6%2The current cohort of clinicians will therefore have limited clinical experience of Syphilis, which can often mimic rheumatic conditions. We present the clinical experience of a tertiary teaching centre hospital.Objectives:To identify the scope of clinical cases, with a diagnosis of Syphilis, during 2018-2019 at St Georges University Hospital, London, UK.Methods:Clinical cases were identified by health professionals and a retrospective review of medical records was undertaken.Results:There were 4 cases identified during 2018-19.PatientAgeSexPast Medical HistorySymptomatologyRisk FactorsPresumed DiagnosisSerology169MaleHypertensionGCABilateral visual loss, rashMSMPrednisoloneTocilizumabGCA-related visual lossRPR 1:64TPPA 1: 10248246FemaleNilJoint pain and swelling, rashHepatitis B Core Antibody positiveUndifferentiatedInflammatory ArthritisRPR 1: 16340MaleNilJoint pain, alopecia, uveitis and rash, weight lossMSMPrimary SyphilisRPR 1: 16TPPA 1: 10248486FemalePulmonary Sarcoidosis, Squamous cell carcinoma of left maxillary sinusLower motor neuron facial nerve palsyPrednisoloneSarcoidosisRPR 1:4TPPA 1:80GCA: Giant cell arteritis, MSM: Men who have sex with men, RPR: rapid plasma regain, TPPA: Treponema pallidum particle agglutination assayCase 1:The patient was diagnosed with bilateral uveitis secondary to primary syphilis, and immunosuppression may have contributed to this.Case 2:The rash developed after the initial presentation and an extended infection screen was performed.Case 3:The patient had a 6 month duration of symptoms and had had a negative sexual health screen 1 year prior to presentation.Case 4:The patient had no features of extra pulmonary sarcoidosis and an infectious screen was undertaken.All 4 cases were referred to the Infectious Disease Unit for treatment. 3 patients received standard treatment with Penicillin, and 1 patient received an oral course of Doxycycline, due to a penicillin allergy.2 of the 4 cases had complete resolution of symptoms, and 2 of the cases had only partial resolution of symptoms at the time of publication.Conclusion:Syphilis can present with an inflammatory arthritis, PMR and GCA –type symptoms, ocular inflammation, neurological disturbance and rashes that can mimic autoimmune conditions.Our cases highlight the increasing incidence, as well as the risk of reactivation following immunosuppression. Current practice does not advise routine testing for syphilis prior to initiation of immunosuppressive therapy. However the rising incidence should prompt careful evaluation, and detailed sexual history, particularly in high risk groups. The diagnostic test interpretation and treatment requires close collaboration with Infectious Diseases Specialists.References:[1]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/805903/2018_Table_1_STI_diagnoses_and_rates_in_England_by_gender.ods[2]Report on global sexually transmitted infection surveillance 2018, WHO, ISBN: 978-92-4-156569-1Disclosure of Interests:None declared

There has been an increase in infectious syphilis in Australia.1 The diagnosis of primary syphilis is by dark field microscopy, PCR testing or serological testing; however, serology may be negative in early syphilis.2 3 With the loss of our ability to perform dark field microscopy, patients are either treated empirically or await the results of molecular and/or serological testing for confirmation of Treponema pallidum infection. We aimed to determine whether the proportion of patients with primary syphilis were treated empirically and, if treatment was delayed, how long patients had to wait for treatment and what proportion of patients with primary syphilis had negative serology at time of presentation. We reviewed clinical notes of patients who presented with anogenital lesions and had …

Syphilis recognition in HIV-positive patients has important implications. Initial data from this study, established in June 2012 to better understand the natural history of syphilis and treatment response, examine the characteristics of patients including sexual behaviour, rates of concurrent sexually transmitted infections (STI) and type of treatment given.Patients were recruited from Ireland, Poland and Germany. Data gathered included demographics, method of syphilis acquisition, stage of syphilis infection, HIV status, nadir and current CD4 counts and HIV viral suppression rates. Data were then subanalysed into HIV-positive and HIV-negative groups.Of 175 patients recruited, 68% were HIV-positive and 86.3% were men who have sex with men. Most HIV-positive patients presented with secondary syphilis (55.7% vs 13.2%) (p=0.0001) while the majority of HIV-negative patients had primary syphilis noted at the time of recruitment (47.2% vs18.9%, p=0.0002). Approximately half of all patients had a HIV RNA viral load40 copies/mL (55%). Previous syphilis infection occurred more frequently in HIV-positive than HIV-negative patients (p=0.0001). Concurrent STIs at the time of syphilis diagnosis were found in 26.8%, of whom 31 (25.4%) were HIV-positive (p=0.64). HIV-positive patients received doxycycline more frequently than their HIV-negative counterparts (33.6% vs 1.9%, p=0.0001) while HIV-negative patients were treated with long-acting penicillin in 88.7% of cases vs 58% of HIV-positive patients (p=0.0002).A 40% rate of unsuppressed viraemia, high levels of STIs and varying treatment regimens represent a public health risk for Europe, suggesting the model of sexual healthcare delivery in HIV-positive patients requires further evaluation.

To determine the aetiology of genital ulcer disease (GUD) and its association with HIV infection in the mining community of Carletonville, South Africa, from two cross sectional surveys of consecutive men presenting with genital lesions during October 1993 to January 1994 and July to November 1998.A multiplex polymerase chain reaction (M-PCR) assay combined with amplicon detection was used to identify DNA specific sequences of Treponema pallidum, herpes simplex virus (HSV), and Haemophilus ducreyi. A real time PCR assay was used to differentiate between HSV-1 and HSV-2.M-PCR detected T pallidum, HSV, and H ducreyi in 10.3%, 17.2%, and 69.4% of 232 GUD patients during 1993-4 and in 12.4%, 36.0%, and 50.5% of 186 GUD patients in 1998. The proportion of patients with more than one agent increased significantly from 7.3% (17/232) in 1993-4 to 16.7% (31/186) in 1998 (p0.01). HSV-2 was detected in a higher proportion of ulcer specimens from HIV infected patients than in specimens from HIV uninfected patients during both time periods (1993-4: 26.2% v 6.7%, p0.001; 1998: 42.1% v 29.6%, p0.09).Based on two cross sectional surveys, 4 years apart, chancroid remained the leading cause of GUD in men who presented at the STD clinic with genital ulcers in the mining community of Carletonville, South Africa. The relative prevalence of primary syphilis has remained low. However, HSV-2 has emerged as a more significant cause of GUD and the proportion of GUD patients infected with more than one agent also increased significantly. HSV-2 DNA was detected in a significantly higher proportion of ulcer specimens from HIV positive patients than from HIV negative patients. No association was found between HIV infection status and the relative prevalence of chancroid or syphilis.

A 57 year old man was referred urgently to the oral and maxillofacial surgery clinic. He described a three month history of fatigue, recurrent sore throats, and a persistent “cold sore.” An irregular and indurated ulcer was present on the right oral commissure (fig 1⇓), and an ipsilateral swelling was palpable in the submandibular triangle (fig 2⇓). He had no relevant medical history. He drank little alcohol and was a non-smoker. Fig 1 Irregular and indurated ulcer present on the right oral commissure Fig 2 Ipsilateral swelling palpable in the submandibular triangle ### 1. What are the most important differential diagnoses to consider? #### Short answer The most important differential diagnoses to consider include herpes labialis, primary syphilis, and squamous cell carcinoma. #### Discussion Primary syphilis should be considered alongside herpes simplex labialis if the symptoms do not resolve in 10-14 days.1 Association with other red flags such as induration, bleeding, and concurrent cervical lymphadenopathy should prompt fast track referral to the local head and neck oncology clinic. Malaise is a common feature of syphilis that would not normally be seen at an early stage of squamous cell carcinoma. Cases of syphilis have risen dramatically in recent years. In the UK, USA, and other Western countries, this rise has been most marked in men who have sex with men, so taking a targeted sexual history is essential.2 Syphilis is classified …

In 2010, we published an initial evaluation of a multiplex PCR for the detection of herpes simplex virus (HSV)-1, HSV-2 and Treponema pallidum in patients with genital ulcer disease.1 This study indicated that the assay would improve our ability to detect primary syphilis with little detrimental impact on overall service costs and turnaround time (TRT). We now present 5-year experience (14 March 2009 to …

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.

To investigate the accuracy of clinical diagnosis in genital ulcer disease (GUD); to devise management strategies for improving the control of GUD and thereby limit the spread of HIV-1 infection.Clinical and microbiological assessment of GUD in men and women. The index of suspicion, diagnostic accuracy, diagnostic efficiency and positive and negative predictive values of a clinical diagnosis were investigated.City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa.100 men and 100 women with genital ulcers.The accuracy of a clinical diagnosis was, in men: lymphogranuloma venereum (LGV) 66%, donovanosis 63%, chancroid 42%, genital herpes 39%, primary syphilis 32%, mixed infections 8%, and in women; secondary syphilis 94%, donovanosis 83%, genital herpes 60%, primary syphilis 58%, chancroid 57%, LGV 40%, mixed infections 14%. Overall, diagnostic efficiency was greater in women than in men. When compared with other causes of GUD, donovanosis ulcers bled to the touch and were larger and not usually associated with inguinal lymphadenopathy. In women, extensive vulval condylomata lata were readily differentiated from all other causes of GUD.A clinical diagnosis in genital ulceration was less accurate in men than in women. The diagnostic accuracies for donovanosis and secondary syphilis were relatively high but for most other conditions were low. Differences between clinical and laboratory diagnostic accuracies may reflect similarities between the clinical appearances of the various causes of GUD, the presence of mixed infections, atypical ulceration due to longstanding disease, and insensitive laboratory tests. In this community all large ulcers should be treated empirically for syphilis and donovanosis. Uncircumcised men with GUD are an important HIV core or "superspreader" group locally, and prevention strategies should include counselling and health education in the light of the inaccuracy of clinical diagnosis found in this study. The development of rapid accurate tests for GUD is urgently required.Clinical and microbiological assessments of genital ulcer disease (GUD) were taken in 100 men and 100 women with genital ulcers at the City Health Sexually Transmitted Diseases Clinic of King Edward VIII Hospital in Durban, South Africa. The study was conducted to investigate the accuracy of clinical diagnosis in GUD and to devise strategies for improving the control of GUD and the spread of HIV-1 infection. The authors found clinical diagnosis in genital ulceration to generally be less accurate in men than in women. Diagnostic accuracies for donovanosis and secondary syphilis were relatively high, but low for most other conditions. The observed differences between clinical and laboratory diagnostic accuracies may reflect similarities between the clinical appearances of the various causes of GUD, the presence of mixed infections, atypical ulceration due to longstanding disease, and insensitive laboratory tests. It is recommended that all large ulcers in this community be treated empirically for syphilis and donovanosis. Rapid accurate tests for GUD urgently need to be developed. The authors also stress that uncircumcised men with GUD are an important HIV core group locally and that prevention strategies should include counseling and health education given the inaccuracy of clinical diagnosis found in the study.

OBJECTIVE--To study the localisation of treponemes and to analyse the inflammatory infiltrate in biopsy specimens from patients with primary or secondary syphilis, or early infectious yaws. MATERIALS AND METHODS--Skin biopsies originating from human lesions of primary (29x) or secondary (15x) syphilis (Rotterdam), or early yaws (18x) (West Sumatra) were studied. Different histochemical and immunohistochemical detection methods were used in this study. RESULTS AND CONCLUSION--The histochemical silver staining method according to Steiner revealed the presence of T. pallidum in all cases of primary syphilis studied. In 10 out of 14 cases of secondary syphilis, treponemes were demonstrated. With an immunofluorescence staining technique (IF) using anti-T. pallidum antiserum raised in rabbits (a-Tp), T. pallidum was demonstrated in 28 out of 29 cases of primary syphilis, and in 14 out of 14 studied cases of secondary syphilis. The silver staining method and IF showed identical localisations of T. pallidum (mainly in the dermal-epidermal junction zone or throughout the dermis). Using a-Tp antiserum in the indirect immunofluorescence technique, T. pertenue could be demonstrated in the dermis more often than with Steiner silver staining. However, epidermotropism of T. pertenue in yaws specimens was remarkable, compared with more mesodermotropism of T. pallidum; numbers of T. pertenue in the dermis were limited in all specimens. The dermal inflammatory infiltrate in primary and secondary syphilis was composed mainly of lymphocytes and plasma cells. In most cases more T (CD3 positive) cells than B (CD22 positive) cells were present. Regarding T cell subpopulations, in primary syphilis, T helper/inducer (CD4 positive) cells predominated in 86% of cases. In secondary syphilitic lesions, numbers of T helper/inducer cells were less frequent than or equal to T-suppressor/cytotoxic (CD8 positive) cells in 60% of cases. Remarkably, in yaws specimens the inflammatory infiltrate consisted mainly of IgG, but also IgA and IgM producing plasma cells. T or B lymphocytes were scarce, which is in sharp contrast with findings in syphilitic lesions.

The reactivity of a non-specific reagin (RPR) test and a specific treponemal (FTA-ABS) test were determined in 21 patients with primary syphilis, 430 patients with proven non-treponemal genital ulcerations and 719 patients with acute urethritis presenting at a clinic for sexually transmitted diseases in southern Africa. Excluding those 21 cases of primary syphilis, 358 of 1149 tests performed (31%) were found to be reactive by at least one test. The rate of false positive RPR tests was very low (0.02%). Significantly higher rates of seropositivity were detected in patients with genital ulcerations than in patients with acute urethritis. The highest rates were detected among patients with proven lymphogranuloma venereum (34% RPR positive, FTA-ABS positive; 19% RPR negative, FTA-ABS positive). The geometric mean titres (GMT) of positive RPR tests in non-treponemal infections were found to be lower than in darkfield positive cases of genital ulcer disease.

Background Globally, syphilis remains a major and resurgent public health problem with high incidence rates in many settings, including among men who have sex with men (MSM). Left untreated, syphilis can lead to further transmission, morbidity and enhanced Human Immunodeficiency Virus (HIV) transmission. A primary chancre is classically described as an indurated single painless ulcer at the site of Treponema pallidum inoculation. However, recent clinical experience is that primary syphilis can present atypically, as multiple and/or painful ulcers with features suggestive of genital herpes. We aimed to describe serology and Treponema pallidum polymerase chain reaction (Tp PCR) positive lesions of primary syphilis in men, the rates of painful or multiple lesions, whether there was concurrent genital Herpes simplex virus (HSV) infection and whether concurrent HIV infection altered the presentation. Methods Tp PCR positive results with confirmatory syphilis serology and HSV PCR results reported by VIDRL were identified and compared to MSHC medical records over a five-year period from 2010 to 2014. Results 183 patients fulfilled the criteria of Tp PCR positive primary syphilis. Primary syphilis lesions were frequently painful (49.2%) or multiple (37.7%), and were infrequently associated with HSV (2.7%). Presentation was not significantly altered by HIV status. Anal lesions were more common in HIV positive men (34.2%) than in HIV negative men (11.6%). Syphilis reinfections were more common in HIV positive men (39.5%) than in HIV negative men (11.7%). Conclusion Tp PCR is a useful tool to confirm syphilis as a cause of genital lesions and positivity may precede serological markers. Early syphilis lesions may be clinically misidentified as HSV infection if syphilis is not considered. Awareness of the clinical variability of primary syphilis lesions should be included in health promotion messages to the public and health care providers. Disclosure statement There are no conflicts of interest.

Background In many countries, sexually transmitted infections (STI) are treated syndromically. Thus, patients diagnosed with genital ulcer disease (GUD) in Zimbabwe receive antimicrobials that cover infections with Treponema pallidum (TP: benzathine penicillin), Haemophilus ducreyi (HD: erythromycin) and herpes simplex virus (HSV: acyclovir). However, periodic surveys into the aetiology of GUD are necessary to inform treatment guidelines. Methods For this study, we recently completed enrollment of 200 patients with GUD at 6 clinics in Zimbabwe. To date, test procedures have been completed for patients enrolled at Harare clinics (N = 70). Ulcer specimens were obtained for testing using a validated multiplex polymerase chain reaction assay (M-PCR, National Institute of Communicable Diseases, Johannesburg) for TP (primary syphilis), HD (chancroid), HSV (genital herpes) and Chlamydia trachomatis strains associated with lymphogranuloma venereum (CT-LGV). Blood samples were collected for HIV testing by a standard rapid HIV test algorithm (First Response™ followed by Alere HIV 1/2™) and considered positive when reactive on both. Results To date, M-PCR testing is complete for all 70 patients with GUD recruited from the Harare clinics (38 men and 32 women). Of these, 17 (24.2%) were positive for HSV, 8 (11.4%) were positive for TP, and 1 was positive for CT-LGV. No cases of chancroid were detected. The overall HIV positivity rate was 43.1%. HIV rates were higher among patients with HSV (62.5%, p = 0.07, Chi Square Test) and TP (87.5%, p Conclusions Genital herpes was the most common cause of GUD in our survey, followed by primary syphilis. The association of HIV infection with HSV and TP suggests high risk for co-transmission; however some HSV ulcerations among HIV-infected patients may be the result of HSV reactivation among immunocompromised patients. Our study methods and data should be relevant for other countries using a syndromic management to STI control.

Background/introduction Diagnosis of primary syphilis is confirmed by serological tests suggestive of the stage of the disease. In most cases specific (IgM/IgG) and non-specific (RPR) antibodies develop in response to primary treponemal infection. Lack of development of such antibodies is known to occur amongst HIV positive patients but is unusual among HIV negative patients with no significant comorbidities. Aim(s)/objectives To present a cluster of four cases of primary syphilis from our clinic with unexpected serological results. Methods We describe four unusual cases of HIV-negative MSM, all of whom presented with penile lesions (three chancres and an atypical lesion). These cases were identified by clinicians between July 2014 and January 2015. Clinical and laboratory records were retrospectively interrogated. Clinical photographs will be used to illustrate these cases. Results In all cases, patients with no history of previous syphilis returned positive results on one or more specific treponemal serological tests with persistently negative RPR. Three cases had recent negative syphilis screening at our clinic. Darkfield microscopy also failed to demonstrate T. pallidum in those with chancres. In all cases, treatment of presumed syphilis led to the resolution of the lesions. Discussion/conclusion These cases demonstrate the ongoing difficulties with treponemal diagnostic test interpretation. There are reports in the literature that men over 35 may be more likely to return a false negative RPR result, but overall prevalence of false negative RPR in primary syphilis is uncertain. Over-reliance on serology may result in under diagnosis of syphilis even in HIV-negative MSM.

Background/introduction In Autumn 2014 a surprising number of patients were being diagnosed with early syphilis, in the sexual health clinic, Reading. From January 2014 to January 2015 twenty-one early syphilis cases arose. Whereas 2013 totalled 5 cases, which was an average year. Aims/objectives To identify if this constituted an outbreak. Determine why increasing numbers of early syphilis were arising and which patients groups were at risk. To prevent further cases. Methods January to September cases were reviewed retrospectively and then new cases prospectively. Public Health England was notified and an action meeting ensued. Patient behaviours and contact tracing data collected. Letters written to inform healthcare services. Clinic information boards and website updated. Social media and appropriate charity organisations approached to reach target groups. Results Eight presented with primary syphilis, ten with secondary and three with early latent. Eighteen cases were men who have sex with men (MSM), highlighting the main at risk group. Seven of the MSM were HIV positive with three being newly diagnosed. The average number of sexual contacts was twelve with one third using social networking apps to meet. Discussions/conclusions Syphilis outbreak confirmed. MSM patients are the main risk group with one third HIV co-infection, which is a concern. Common usage of social networking apps identified to meet sexual partners, which can involve serosorting. Collaboration between sexual and Public Health teams resulted in raising awareness. Hopefully these measures will reduce the number of cases but it will require close monitoring.

Background/introduction There has been little published regarding quantitative results of newer serological assays in infectious syphilis. Previous studies have shown an association between VDRL and TPPA titre and stage of syphilis; with higher titres in secondary syphilis. Aim(s)/objectives To examine quantitative relationships between serological results and stage of syphilis including newer assays. Methods Early syphilis cases diagnosed March 2011–August 2014 were identified from a sexual health clinic database. Cases classified as primary, secondary and early latent by clinical diagnosis. Serology results were recorded including TPPA, VDRL (used until 01/03/2012), RPR (used from 01/03/2012), IgG (Abbott Architect Total Antibody Test), and IgM (lab21 IgM EIA). Results 155 patients included. 149 male, 6 female. Average age 38. 92% men were MSM. 32% HIV positive. 33% classified as primary, 21% secondary, 46% early latent. 64% new diagnoses, 36% re-infected. Discussion/conclusion Results confirmed the quantitative relationship between syphilis stage and VDRL and TPPA titre identified previously. Additionally this study showed that IgM and IgG values, using Lab 21 IgM EIA and Abbott Architect Total Antibody Test assays, are also linked to stage of syphilis. Unsurprisingly, IgG titres were highest in secondary and lowest in primary syphilis. IgM values were lowest in early latent and highest in secondary syphilis.

Background Cohort and cross-sectional studies have shown syphilis is associated with risk for HIV infection. However, population-based estimates of the actual risk for HIV following syphilis infections are lacking. Methods In New York City, HIV and STD surveillance registries are separately maintained. Cases reported to these registries with diagnoses from 2000-June 2010 were matched using a deterministic algorithm. We measured HIV incidence among men following primary or secondary syphilis diagnoses. We calculated time at risk for HIV among men diagnosed with HIV ≥ 60 days after syphilis diagnosis; men without reported HIV were presumed uninfected and censored on 3/31/2011. Results Of 2,805 men with syphilis who contributed 11,714 person-years of follow-up, 423 (15.1%) subsequently acquired HIV; annual incidence was 3.61% (95% CI: 3.27%, 3.97%). Median time to HIV diagnosis was 582 days (range 60–3150). HIV incidence was highest among men who have sex with men (MSM) (5.56%, 95% CI: 5.02%–6.13%), relatively uniform across race/ethnicity and year of syphilis diagnosis, and decreased with increasing age at syphilis diagnosis. HIV incidence was higher among males with secondary compared with primary syphilis (4.10% vs. 2.64%, p Conclusions On a population level, one in 20 MSM with syphilis are diagnosed with HIV within a year; highly frequent HIV testing and HIV pre-exposure prophylaxis should be considered for HIV-negative syphilis cases. Secondary syphilis suggests untreated primary lesions; the higher HIV incidence among these cases underscores the importance of appropriate STD/HIV screening and early syphilis detection. Registry matching/integration permits identification of high-risk individuals, such as men repeatedly acquiring STD, for targeting prevention activities.

Background Serologic tests for syphilis remain the mainstay of diagnosis. However, diagnosis of congenital syphilis is complicated by the passive transfer of maternal antibodies to the infant. Non treponemal test (NTT) titres should decline by age 3 months and should be non reactive by age 6 months if the infant was not infected or was infected but adequately treated. Limited data exist on the serologic outcome of treponemal tests (TT) in cases with clinical or laboratory evidence of congenital syphilis at birth. Methods Cases meeting Canadian surveillance criteria for confirmed early congenital syphilis [within 2 years of birth] (http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/09vol35/35s2/Syphilis-eng.php) were reviewed from the Alberta Health Services Edmonton zone from 2005 to 2010. Under Alberta9s Public Health Act, maternal stage, treatment information and serologic follow-up and infant clinical, laboratory and treatment information are obtained and stored in a provincial STI database. Results 22 cases met surveillance criteria for confirmed congenital syphilis: six were either stillborn/deceased at birth, three are still under 18 month serologic follow-up, one had persistently reactive TT (21 months) and four had reactive TT at the end of their follow-up period (ages 11, 12, 13 and 15 months). 3/5 cases with persistently reactive TT were treated with 9–10 days of intravenous penicillin within 0–2 days of birth, 1 at 3 months of age and 1 at 8 months of age. In 4/5 of these cases, the RPR had reverted to non reactive at the end of the follow-up period while in the 5th case (treated at 8 months), the RPR declined from a titre of 1:4096 dilutions at birth to 1:64 dilutions at 11 months of age. The remaining eight cases had negative TTs, as summarised in the table. All were treated with 10 days of intravenous penicillin (except case #2 treated with 9 days) see Abstract P3-S6.03 table 1. Conclusions As with early treatment of primary syphilis cases, seroreversion of TT can occur in cases meeting clinical and laboratory criteria for congenital syphilis. Seroreversion was observed with older TT such as TPPA and FTA-ABS as well as the newer syphilis EIA.

Background Edmonton, Canada has been experiencing a rise in infectious syphilis cases since 2003, attributed to individuals engaging in transactional sex and substance use. As well, Aboriginal people had disproportionately higher rates of the infection. The results of a case study of primary syphilis cases were shared with community organisations serving vulnerable populations to ascertain their suggestions on strategies to increase testing for syphilis among this population. Agencies suggested that compensating clients for syphilis screening at a community organisation would increase testing rates. We sought to determine if more cases among the target population were diagnosed through outreach testing that provided financial compensation than by routine screening methods by other healthcare professionals. Methods A data extract containing demographics, ethnicity, and risk behaviours for infectious syphilis cases in Edmonton between April 2007 and November 2008 was obtained from the provincial STI database. An additional database, which held demographic and risk group information on participants in the project, was also analysed. Client demographics and risk behaviours were compared using χ2 or Fisher9s exact test for categorical variables and Mann–Whitney for continuous variables. Results A total of 931 testing visits were completed with 877 individuals. Three-quarters of individuals reported a history of substance use (77.1%; n=676) with more than one-quarter of individuals involved in transactional sex, either as a sex worker (n=204) or contact with a sex worker (n=110). Over half of the individuals (51.3%; n=450) were Aboriginal. Ten newly diagnosed infectious syphilis cases were found. The proportion of cases detected among female sex workers was 2.9% (6 cases out of 209 testing visits) and was 2.0% (2 cases out of 98 testing visits) among male sexual contacts of sex workers. Female cases were more likely to be a sex worker when tested through outreach (75%) than by routine testing sites (23.5%, p=0.006) see Abstract P5-S4.05 table 1. Conclusions By offering testing at community agencies with financial compensation to individuals, a higher rate of cases were found among sex workers than through routine testing methods. By treating cases among individuals linked to high transmission activity, we aim to reduce the transmission of infectious syphilis.

Background Syphilis rates among men who have sex with men (MSM) in the US are rising. In 2009, 62% of reported primary and secondary syphilis cases in the U.S. were among MSM. Self- and partner-examination for primary syphilis (painless chancre) might increase early detection and treatment and reduce transmission. As the first step in a study to increase syphilis lesion awareness, we collected baseline data on rates of self- and partner-examination. Methods Data were collected from five MSM STD or infectious disease clinics in the US before and after introduction of brochures with pictures and information about syphilis signs, transmission, and prevention. Surveys included questions about demographics, sexual behaviours, syphilis knowledge and self- and partner-examination. Data were analysed using SAS V.9.2. Results From September 2009 to January 2011, 586 sexually active men completed a survey; 124 (21%) from Arizona, 128 (22%) from the District of Columbia, 202 (34%) from Florida and 132 (22%) from Georgia; 542 (92.5%) reported having sex with men only and 44 (7.5%) reported having sex with men and women. Most participants (334, 57%) were aged 18–39 years, 240 (41%) were 40–59 years and 12 (2%) were older than 60 years; 222 (38%) reported one partner, 180 (31%) 2–3 partners, 133 (23%) 4–10 partners, and 51 (9%) >10 partners in the last 3 months or since their last clinic visit. Most participants correctly identified oral (510, 87%), anal (529, 90%) and oral-anal sex (487, 83%) as ways to transmit syphilis. Few recognised frottage that is, rubbing against someone (112, 19%) and kissing (196, 34%) as other modes of transmission. Over 50% reported self-examination of mouth, penis and skin at least once a week, whereas less than half reported partner-examination of these areas (Abstract O2-S5.05 table 1). Less than 50% reported self- or partner-examination of anus at least once a week. Rates of self-examination did not vary by number of partners or age; whereas, examining partner9s mouth, penis and skin was less frequent (p 3 partners. Conclusions The majority of MSM reported examining themselves at least once a week, but did not examine their partners as frequently. MSM with >3 partners were less likely to examine their partners9 bodies than those with fewer partners. Analysis of surveys from men after brochure introduction will determine whether education materials increase rates of self- and partner-examination.

Background Recently noteworthy aspect of the problem is associated with an increase in cases of syphilis as part of mixed infection including HIV. Mixed infection syphilis and HIV alters the clinical picture and prognosis of both diseases. Methods 316 patients with early forms of syphilis were treated in city hospital in St. Petersburg in 2006–2010. The study group included 153 patients with syphilis + HIV (10 - primary syphilis, 117 - secondary syphilis, 26 - early neurosyphilis). Control group - 163 patients with syphilis (14 - primary syphilis, 115 - secondary syphilis, 34 - early neurosyphilis). Ophthalmic and otolaryngological manifestations of syphilis were estimated. Results Ophthalmic and otolaryngological manifestations of syphilis were diagnosed in 18 (11.8%) patients of study group and 4 (2.5%) - control group (p In none of the groups ophthalmic and otolaryngological manifestations in patients with primary syphilis were not determined. Specific papillitis (5 (3.3%)) and specific panuveit (5 (3.3%) as well as specific laryngeal neuropathy (1 (0.6%)) and specific bilateral hypoacusis (1 (0.6%)) were identified only in study group. Specific anterior uveitis was detected in both groups (1 and 2 patients), specific angina (3 and 1 patients) and specific laryngitis (monochorditis) (2 and 1 patients) of study and control group respectively. Among 18 patients of study group with ophthalmic and otolaryngological manifestations were 12 cases of secondary syphilis and 6 - early neurosyphilis. 1 patient showed simultaneous ophthalmic, otolaryngological disorders and diffuse neurological symptoms. Conclusion Clinical manifestations of syphilis were more varied in patients with HIV. Ophthalmic and otolaryngological manifestations of syphilis were more common in patients with mixed infection syphilis + HIV, which may indicate a more severe course of syphilis in these patients.

Lymphogranuloma venereum (LGV) in Europe emerged in 2003 affecting mostly MSM. Rectal primary LGV causing proctitis has been by far de most common clinical manifestation. In Barcelona, with a cumulative number of around 200 cases up to 2012, some cases have appeared with extrarectal manifestations since 2008. We report two cases in MSM with genital primary LGV mimicking primary syphilis. Case 1. A 29-year-old HIV-positive man presented with a genital chancre and inguinal lymphadenopathy of 10 days’ duration. He reported 5 casual partners the last 3 months. Although dark-field exam was negative the patient was treated with benzathine penicillin G 2.4 million units. He was seen 4 days later without improvement, with buboes and genital edoema. A swab from the ulcer was positive for LGV and negative for syphilis and chancroid by PCR. A diagnosis of bubonulus was made, and the patient started doxycycline 100 mg/12 h for 21 days. He improved persisting a small residual soft mass on the shaft of the penis. Case 2. A 37-year-old HIV-negative man presented with a genital ulcer and lymphadenopathy of 2 days’ duration. He had multiple unprotected casual partners in sex parties 3 days before. Three consecutive dark-field exams were negative. Five days later the ulcer persisted like a chancre and inguinal buboes were more evident. LGV was detected from the ulcer while syphilis and herpes were negative by PCR. The clinical manifestations resolved quickly after completion of treatment with doxycycline as above. Cases with non-rectal lesions would be expected as LGV spreads. When present, the most common presentation of the primary lesion in the genitalia is a nonindurated herpetiform evanescent ulcer. Clinicians must be vigilant to the evolving faces of LGV, be prepared to recognise the full manifestations of this disease and consider LGV in the differential diagnosis of genital chancre.

The treatment of infected cases, active case finding and the follow-up are the tasks of the dermato-venereological network. Since data on treated syphilis cases were available from decades back, a retrospective analysis was done. Objective Syphilis patients treated between 1990–2011 in Szabolcs-Szatmar-Bereg county compared with national data, with the following criteria: Changes in morbidity in the county and in the country with sex distribution, Analysis by age group among women, especially during pregnancy, Distribution by diagnosis in women and in pregnant women including the trimester, Results between 1990–2011, the outpatient clinic in Szabolcs-Szatmar-Bereg county treated a total of 469 syphilis cases (women n = 243/52%/, male n = 226/48%/), out of 243 patients, 69 had applied the syphilis diagnosis during pregnancy, The diagnosis of syphilis among pregnant women was as follows: primary syphilis 1/1.5%/, secondary syphilis: 17/25%/, early latent: 48/69.5%/, late latent: 3/4%/. between 1990–2000 the syphilis occurred sporadically among pregnant women, the number of however the cases between 2003–2008 increased significantly (in 1990–2000 n = 6; in 2001–2011 years n = 63), According the age group distribution, syphilis infection in pregnant women were most common in the 20–34 age-group(20–24/30%/, 25–29/20%%,30–34/23%/) and the 15–19 age group was also affected (16%) In terms of ethnicity, 49% of pregnant women (n = 34) was roma, 22% of them was from Ukraine, (n = 15) and 29% of them was Hungarian (n = 20), Conclusions The following factors played a role in spreading of syphilis in Szabolcs-Szatmar-Bereg county The county’s geographic location. Significant illegal prostitution (cross-border, massage parlours, roadside, living prostitution), The lack of knowledge of the professions about syphilis Lack of knowledge of the population

In the years 1996–2012 all together 4966 pregnant women infected with syphilis were registered in Belarus (8.36% from the general number of the women with syphilis for this period - 59426 cases). Primary syphilis was diagnosed in 13.2% of patients, secondary syphilis - 30.5%, latent early syphilis - 55.9%, latent late syphilis - 0.4%. Disease has been revealed in I trimester of pregnancy in 56.7% of patients, II trimester - 23.2%, III trimester - 17.5%, after delivery - 2.6%. 45.1% of women have made abortion after disease revealing. There are 127 children with congenital syphilis (CS) registered in 1994–2012 in Belarus in total, but last two years cases of CS have not been registered. Among women which have given birth to children with CS primary syphilis was not diagnosed, secondary syphilis - 26.7%, latent early syphilis - 71.4%, seroresistant syphilis - 1.9%. Reinfection was registered in 8.5% of patients. Early CS with symptoms (Table) has been revealed in 24(18.9%) of children, early latent CS - in 81.1%. Cases of late CS have not been registered. Three children have died within the first month of a life.

Background The epidemiology of syphilis in Georgia has traditionally been determined by socio-economic factors such as low solvency of Georgian population, urban migration, level of financing of STI prevention programmes etc. This study reports on the epidemiology of syphilis in Georgia over the period of 2000–2011. Methods Analysis of 12 years data on syphilis incidence provided by the National Center for Diseases Control and Public Health, Tbilisi, Georgia. Results In 2000 morbidity due to syphilis was 20.3, while in 2002 it reached 31.2 per 100,000 inhabitants. However, in 2011 the incidence had decreased to 11.0 per 100,000 inhabitants. The most affected age group is persons aged between 20–29 years and the infection has been slightly more prevalent among men (67% of all registered cases) than among the women. Over the recent four years, though, syphilis has become more prevalent among the 30–39 years old men. The incidence is also higher in urban areas. Since 2000 latent syphilis prevails, comprising 83% of all syphilis cases and primary syphilis steadily decreases, e.g. in 2010–2011 constituting only 7–8% of all diagnosed cases. During these years, neurosyphilis constituted 0.5–1.2% of all syphilis cases. In 2000 12 cases of congenital syphilis were registered, compared to 16 cases in 2012. Conclusions The incidence of syphilis remains high in Georgia and epidemiological trends are well coinciding with those in many other countries of Eastern Europe. The high incidence of newly detected latent vs. primary syphilis may indicate a suboptimal surveillance, diagnostics and management of STI patients. A correlation between the availability of the financed STI programmes and increasing incidences of syphilis was also noted.

Background Concomitant syphilis and human immunodeficiency virus (HIV) infection is increasingly frequent in industrialised countries. We examined the effect of active syphilis on CD4 counts and plasma HIV-1 viral loads Methods All patients with syphilis-HIV coinfection treated at the Sheba medical centre between 2007 and 2012 were included in the study. Patients were divided to those with early or secondary syphilis and to those with latent syphilis (early and late). CD4 cell counts and plasma HIV-1 viral loads were measured before, during and following syphilis treatment. Results 17 patients were included: all were men having sex with men, 11 (65%) were treated with ART: 5 with primary syphilis, 4 patients with secondary syphilis, 2 patient with early latent and 6 patients with latent syphilis of unknown duration (rpr > 1:32), one of them with neurosyphilis. Median CD4 cell count significantly dropped during syphilis by 25%: from 575 (246–828) before syphilis diagnosis to 415 (195–630) cells/mm3 during syphilis (p = 0.0002). After penicillin treatment it rose back to 621 (250–1379) (p = 0.01). Plasma VL in 6 of the patients that did not receive ART increased during syphilis, although this rise was not statistically significant. Conclusions Syphilis was associated with a transient decrease in the CD4 cell count and with an increase in VL in HIV-infected men; This increase in VL, although statistically non sugnificant, may explain at least partially the increased risk of HIV transmission in HIV patients not treated by ART that are co infected with syphilis.

Background The usefulness of syphilis rapid tests in STI counselling services is under discussion in Germany. For this reason, we evaluated the performance of the Determine® Syphilis rapid test (TP-RT) in comparison to standard serological syphilis tests. Materials and Methods The TP-RT was carried out in 2,203 serum or plasma samples from the German syphilis consiliary laboratory (Labor Krone GbR, Bad Salzuflen) representing a broad spectrum of relevant samples from public health institutions, STI and HIV ambulances, hospitals and others, including samples from 532 MSM, 417 female sex workers and 260 pregnant women. The treponemal antibody status was determined using the Architect® Syphilis TP CMIA (Abbott) as a screening test. Results The TP-RT specificity was determined at 99.4% and the sensitivity at 97.0%. For 12.2% of the positive sera the TP-RT demonstrated only borderline findings. From a subset of 135 positive samples the TP-RT showed reactivity after 15 min in 121 (89.7%), 30 min in 129 (95.6%), 60 min in 131 (97.0%) and after 24 h in all of 135 (100%). More than 70% of the positive findings were related to past treponemal infections. In two cases of primary syphilis a borderline TP-RT result only occurred after 45 to 60 min. Discussion The TP-RT is not able to differentiate active from past treponemal infections. Any reactive TP-RT finding has to be further tested by conventional syphilis tests. Negative TP-RT results after a reading time from 15 to 30 minutes does not exclude the presence of highly infectious early stages of syphilis. A minimum reading time of 1–2 hours is recommended. The high number of borderline findings even in active syphilis cases poses the risk of incorrect assessment of the test results. The routine use of rapid tests is not recommended for syphilis diagnosis in Germany.

Background We conducted a retrospective study based on patients’ records of the Sexually Transmitted Infections Unit of “A. Sygros” Hospital in Athens, Greece. This is a tertiary referral centre for sexually transmitted infections from an area that has almost half the population of Greece. Methods We focused on Primary Syphilis (PS), having confirmed the diagnosis both clinically and serologically. We documented the total annual number of patients, the male/female ratio, and the patients’ ethnic origin and sexual orientation. Results We reviewed 1184 patients over the last eight years. The total number of patients with PS has risen from 111 in 2005 to 157 in 2012, an increase of 41.44%. The mean annual number is 144. The mean male/female ratio is 4.85, with a peak value of 8.50 in 2011. The majority of patients are of Greek origin, ranging from 67.4% to 87.2%. Within the male patients group, it seems that the percentage of homosexuals has risen steadily from 2005 (20.7%) up to 2011 (59.0%) with a decline in 2012 (46.0%). The mean value over eight years is 45.03%. Conclusion PS in Greece is on the rise. This is probably related to moving populations because of immigration and sex trade. Changes in sexual behaviour can also be a factor. However, the majority of patients are Greek, despite immigrant influx. Men are the most numerous subgroup among PS patients, representing more than 80% of the total number of patients. Furthermore, there seems to be a trend towards predominance of homosexual men as the core group among male patients.

Introduction Successful treatment response for early syphilis involves resolution of signs and a fourfold decrease in RPR/VDRL or sero-reversion between 3 and 6 months. However, in the HIV-positive population the serological response can be unusual. Aims To compare serological response after treatment of early syphilis between HIV-positive and negative cohorts. Methods Retrospective cohort study of 100 HIV positive (HP) and 92 negative (HN) patients with early syphilis at an inner city GUM clinic from 2002 to 2011. Data were collected on demographics, stage of syphilis, treatment and serological response. Results Both HP and HN cohorts were mainly MSM (72 HN, 96 HP) and Caucasian (HN 76, HP 78). Median age 33 (range 20–63 years) in the HN and 37 (range 19–59 years) in the HP. Stage of syphilis: HN group, 22/92 primary, 26 secondary and 44 early latent (EL). HP group: 26/100 primary, 34 secondary and 39 EL. The HN group were treated with the standard regimen for their stage of disease. 49/100 of the HP group received treatment for neurosyphilis. 25/92 HN and 14/100 HP were lost to follow-up following treatment. Excluding these patients, by 6 months, 18/20 (90%) of the HP group with primary syphilis sero-reverted or had a fourfold decrease in RPR/VDRL compared to 17/17 (100%) of the HN. By 6 months, 51/55 (93%) of the HP group with secondary/EL syphilis had sero-reverted or had a fourfold decrease in RPR/VDRL compared to 41/45 (91%) of the HN. Median CD4 count in the HP group was 380 cells/μl prior to treatment and 518 after treatment. There were 4 reinfections in the HN group and 10 in the HP. Conclusions There were high rates of serological treatment success for early syphilis in both groups. However, the HP group were less likely to have a successful response by 6 months in primary syphilis. This study also demonstrates the need for strategies to address the large number of patients lost to follow-up.

Background Follman balanitis as an initial presentation of primary syphilis is well described and syphilis is a known cause of lymphocoele. Inguinal buboes are commonly seen in chancroid and lymphogranuloma venereum but not in syphilis. We report an unusual case of syphilis presenting with balanitis, lymphocoele and bubo together. Case report A 24-year-old man presented with a painless lump in the right groin for 2 weeks and a swelling and red spot on the glans penis for 2 days. He had three casual male partners all within the UK in the preceding 3 months and had an episode of unprotected insertive anal intercourse 2 months before, with no episodes of vigorous intercourse or masturbation. There was a 2 cm fluctuant non-tender lymph node in the right groin, a non-tender cord-like swelling under the coronal sulcus on the same side and a well defined erythematous patch with an infiltrated base on the glans. No other local or systemic signs. A dark field microscopy preparation from the balanitis was negative; one from the lymph node aspirate showed characteristic motile spirochaetes typical of Treponema pallidum ; a positive Treponemal EIA-IgM and RPR (titre of 1:4) confirmed a diagnosis of syphilitic bubo with Follman balanitis and lymphocoele. The lymph node aspirate on gram staining showed pus cells. Chlamydia NAAT (SDA) was negative from the balanitis and lymph node aspirate. The rest of the STI screen including HIV serology was negative. He was treated with Benzathine penicillin 2.4 m IU IM weekly for 2 weeks with clinical resolution. All three contacts had been informed. Discussion (1) Balanitis is a common presentation in GUM clinics and this case highlights the importance of including syphilis in the differential diagnosis. (2) Early syphilis can cause lymphocoele and inguinal bubo. (3) Aspiration of lymph nodes for dark field microscopy examination enabled point of care diagnosis and facilitates early treatment and partner notification.

Objective High rates of syphilis have been reported among men who have sex with men (MSM) internationally. Guidelines recommend presumptive treatment of sexual contacts of individuals with syphilis at the point of care. The aim of this study was to determine the proportion who were infected with syphilis and the factors predictive of infection among men reporting contact with a man with syphilis. Design Contacts who were syphilis infected (cases) were compared with those who were uninfected (controls). Setting This study was conducted at the main public sexually transmitted diseases clinic in Victoria, Australia. Participants One hundred and seventy-two MSM presenting as sexual contacts of men with syphilis at a sexual health service in Melbourne, Australia, between July 2007 and October 2011 were assessed for syphilis. Outcome measures Proportion of MSM who are infected with syphilis and factors associated with infection. Results Of the 172 men who presented reporting contact with syphilis, 26 (15%, 95% CI 10 to 20%) had syphilis. One man had primary syphilis, 4 had secondary syphilis, while the remaining 21 had early latent syphilis. Infection was associated with unprotected anal sex over the prior 3 months (adjusted OR 6.1, 95% CI 1.4 to 26.8). Conclusions One in seven men presenting as contacts of syphilis had syphilis infection, most of whom were latently infected. Contacts reporting recent unprotected anal sex were more likely to have syphilis.

According to the statistical data in Belarus pregnant women made of 8—17% of all women with confirmed syphilitic infection. About 15% women have primary syphilis, 30%—secondary, and 55%—latent syphilis. Aim of study. Study the social structure and concurrent pathology in pregnant women with confirmed syphilitic infection in Belarus. Methods 95 case histories of pregnant women with confirmed diagnosis of syphilitic infection where analysed during 2003—2008. Middle age of women was 25.5±51 years. Results Middle gestational period when syphilitic infection was registered was 21.5±20.4 weeks (in 1—12 weeks—in 10,5% of women; in 13—24 weeks—in 56.8%, in 25—36 weeks—in 30.5%, and in 37—40 weeks—in 2.2%). Concurrent STI where registered in 66.3% of women: trichomoniasis in 11.1%, urogenital candidiasis—in 25,4%, urogenital chlamydiasis—in 12.7%, mixed infection (chlamydia and ureoplasma) in 4.8%. Anaemia was registered in 25.1% of cases, fetoplacental insufficiency—in 7.1% of cases. From all women 67.3% where not officially married and their partners where not checked up as far as they where working outside Belarus. Only 8 women (8.4%) mentioned occasional sexual contacts. Unemployed women made of 52.6% of studied patients. Majority of employed women (64%) worked as unskilled workers. Others where academics—6.67%, medical professions—8.89%, students—8.89%, others—6.67%. Conclusion Syphilitic infection in Belarus is detected quite late (usually 13—36 weeks). High percentage of pregnant women in Belarus are women with low social status and poor education.

Background Following a rise in cases of early syphilis in the UK, a programme of national enhanced surveillance (ES) was commenced in 2001 by the Health Protection Agency with the aims of establishing case distribution and trends in behaviour groups. Local analysis of data acquired via the ES has led to changes to our services in targeting specific high risk groups through increased outreach and community based screening and improvement in health promotion interventions. These include screening for syphilis in all patients attending STI/HIV clinics, dedicated MSM and CSW clinics and outreach work to gay saunas and CSW. The purpose of this study is to look at the epidemiology of infectious syphilis in East and Inner City London over the past decade to provide data on the burden of infection and to further inform local strategy as a measure of outbreak control. Methods Data were obtained from patients with infectious syphilis attending the Royal London and St Bartholomew9s Hospitals in the City and East London from 2001 to 2010. The data were collated and analysed from the ES form. Results Of 778 patients, 39% had primary syphilis, 37% secondary syphilis and 24% had early latent syphilis; 94% were male, 6% female, 51% white British and 12% were Afro-Caribbean. Of the male, 85% were MSM. Three cases were age 40 years of age. 257 (32%) were HIV positive. The main reasons for attendance at clinic were for routine screen (24%), symptom management (46%), consequent of partner notification (6%). 18% had one partner, 58 % had 2–9 partners, 19% had 10–99 partner, and 2% had ≥100 partners past 3 months. 82% acquired their syphilis in London, 4% acquired elsewhere in UK, and 8% in Europe. 4% were female sex workers and 6% acquired their infection through sex workers. 10% acquired their infection in gay saunas, 21% acquired through clubs and 14% via the internet. There were 21 cases in 2001, 115 in 2006 and 44 cases in 2010. Conclusions (1) The syphilis outbreak peaked in 2006 and has decreased by 62% in 2010 indicating that intervention strategy which is still in place, is having an effect. (2) More preventive work need to be done in clubs and on internet dating. (3) HIV coinfection is common and is a cause for concern as syphilitic ulcers enhanced transmission of HIV and HIV coinfection can lead to more severe syphilis manifestation. (4) 21% had 10 partners past 3 months, mainly untraceable, and sex abroad will continue to fuel the outbreak.

Background Algorithms for syphilis serologic testing traditionally have relied on screening with a non-treponemal test, such as the rapid plasma reagin (RPR) test or the toluidine red unheated serum test (TRUST) followed by confirmation using a treponemal test, such as Treponema pallidum particle agglutination (TP-PA). To reduce time, material and labour costs, many laboratories, including at the Comprehensive Health Centre in Kingston, Jamaica, have reversed the sequence testing first with a rapid treponemal test followed by non-treponemal testing of reactive sera. Methods In a survey of STIs among men who have sex with men (MSM) in Jamaica, syphilis serologic testing is currently conducted using an initial rapid treponemal SD Bioline Syphilis 3.0 test followed by TRUST for reactive sera. Discordant sera that are Bioline-positive and TRUST-negative, or sera with TRUST titres Results Among 135 sera evaluated using the reverse syphilis screening sequence, 13 (9.6%) had a positive rapid treponemal test. Among these 13 reactive sera, 6 (46.2%) were nonreactive with TRUST. All discordant sera were also reactive by TP-PA, indicating that initial rapid testing did not produce false-positives in this setting. The proportion of discordant syphilis test results was similar among HIV+ and HIV- men. The prevalence of primary syphilis detected by concordant positive treponemal and non-treponemal tests in this survey was 5.2%, compared to 5.3% in a previous survey conducted in this population during 2007–2008 using the traditional screening sequence. Conclusions The prevalence of primary syphilis among MSM in Kingston has not changed since the previous survey. In the current survey using the reverse screening sequence, nearly half of sera that were reactive with the treponemal test produced discordant results with the non-treponemal test. Such results are consistent with previous syphilis infection, treated or untreated, or early primary syphilis in which non-treponemal antibodies have yet to develop. Distinguishing these possibilities requires detailed history and clinical assessment in addition to serologic test results.

It is known that HIV co-infection with syphilis may accelerate the onset of gummata and neurosyphilis and increase their severity. However, this has only been reported for cardiovascular syphilis in two previous cases.1,2 This case-control study deals with a total of 14 HIV seropositive and 100 HIV 1 and 2 seronegative individuals with syphilis, who were seen in our clinic between June 2000 and May 2001. Of the 14 HIV seropositive individuals, 12 were reactive for VDRL (venereal diseases reference laboratory) and TPHA ( Treponema pallidum haemagglutination assay) and two had primary syphilis confirmed by dark field examination for T pallidum . Of the …

Although epidemiological studies suggest that the incidence of primary syphilis is rising,1 neurosyphilis remains an uncommon manifestation of Treponema pallidum infection. In addition, the MRI appearances of this treatable neurological condition are not well known. Many patients with neurosyphilis are asymptomatic, but manifestations include subacute basal meningitis, a meningovascular syndrome of small deep cerebral and cranial nerve infarctions, chronic gummatous inflammation with focal intracranial mass lesions, chronic comportmental dementia of general paresis, and chronic sensory-ataxic myelopathy of tabes dorsalis. We report a case in which a meningeal form of neurosyphilis presented with rapid evolution of a pupil-involving oculomotor nerve palsy to highlight the clinical, CSF, and MRI features and good response to treatment. The patient was a 54 year old right handed homosexual man with a history of syphilis of unknown stage, treated with penicillin 25 years previously. He was well until 6 weeks prior to evaluation when he sustained minor head trauma in an automobile accident, followed by intermittent headaches, fatigue, photophobia, and anorexia. Four days before …

EDITOR—The study by Catchpole et al looked at the seroprevalence of HIV-1 infection in homosexual and bisexual men presenting with an acute sexually transmitted infection.1 Sexually transmitted infections facilitate the transmission of HIV. Herpes simplex type 2 infection and primary syphilis increase the infectivity of HIV by compromising mucosal surfaces.2 Gonococcal and chlamydial urethritis increase shedding of HIV-1 in semen, therefore increasing the risk of HIV transmission risk.3 Further studies have shown the effectiveness of antimicrobial …

Enzyme linked immunosorbent assays with an ultrasonicate of Treponema pallidum (TP-ELISA) or axial filament of Treponema phagedenis biotype Reiter (AF-ELISA) were developed to detect treponemal antibody. TP-ELISA and AF-ELISA were compared with the T pallidum haemagglutination assay (TPHA), the fluorescent treponemal antibody-absorbed (FTA-ABS) test, and the Venereal Disease Research Laboratory (VDRL) test for sensitivity and specificity of serodiagnosis of syphilis. A total of 1423 serum samples, 253 from patients with various stages of syphilis, 500 from patients attending a sexually transmitted disease (STD) clinic, and 670 from people without syphilis, were investigated. At all stages of syphilis the sensitivity of the TP-ELISA, the AF-ELISA, the TPHA, and the FTA-ABS test did not differ significantly, except that the AF-ELISA was less sensitive than the TPHA (p less than 0.05) for treated syphilis. In primary syphilis, neurosyphilis, and treated syphilis the TP-ELISA and AF-ELISA were significantly more sensitive than the VDRL test (p less than 0.05). The specificity of all tests was comparable (p greater than 0.05). The TP-ELISA and AF-ELISA appear to be good alternatives to the TPHA as screening tests for syphilis. Because of the easy availability of a well defined antigen the AF-ELISA seems to be better suited for large scale testing.

The fluorescent treponemal antibody test for cerebrospinal fluid (FTA-CSF) using monospecific conjugates anti-IgG, IgM, and IgA was used to determine the presence of anti-treponemal antibodies in the spinal fluid of 335 patients with primary, secondary, and latent syphilis and symptomatic and asymptomatic neurosyphilis and of patients with certain neurological disorders. Of these, 230 (68·65%) patients had non-reactive results to this test. Of the remaining 105 patients, 78, 63, and 10 had reactive results with anti-IgG, IgM, and IgA conjugates respectively. Of the 129 cases of known syphilis, 11 were diagnosed as primary, 32 as secondary, and 50 as latent, and 36 patients had neurosyphilis. None of the specimens from the patients with primary syphilis gave reactive results to the test. Specimens from 21 (65·62%) of the 32 patients with secondary syphilis, 30 (60%) of the 50 patients with latent syphilis, and all (97·22%), except one, of the 36 patients with neurosyphilis gave reactive results to one at least of the IgG, IgM, or IgA FTA-CSF tests. Among the specimens from patients with secondary syphilis twice as many gave reactive results with anti-IgG conjugate than with anti-IgM conjugate. However, with specimens from patients with latent syphilis and neurosyphilis this ratio was diminished to 1·5:1. The Kolmer complement-fixation test, although superior in sensitivity and specificity to the Venereal Disease Research Laboratory (VDRL) test, in patients with secondary and latent syphilis and neurosyphilis, was greatly inferior to the FTA-CSF test. Data indicate that anti-treponemal antibodies can be detected in the spinal fluid even in patients with no neurological symptoms in cases of secondary syphilis and that the FTA-CSF test can be a valuable tool in the early detection of an immunological response to treponemal infection in the spinal fluid.

For the serodiagnosis of syphilis a quantitative passive agglutination (MCA-TP) test for antibodies to Treponema pallidum was performed with chemically stable microcapsules with no antigenic activity instead of with conventional sheep erythrocytes. The microcapsules were easily sensitised with the antigen of sonicated Treponema pallidum by treatment with glutaraldehyde. Compared with the Treponema pallidum haemagglutination test (TPHA) the MCA-TP test was superior for detecting cases of primary syphilis. Furthermore, the decrease in antibody titre during treatment was more evident in this test than in the FTA-ABS or the TPHA tests. The MCA-TP test performed on IgM and IgG gel-filtered fractions of sera from patients with syphilis proved that the sensitised microcapsule antigen reacted sharply with the IgM antibodies specific to syphilis.

The Treponema pallidum specific IgM haemagglutination (TP-IgM-HA) test uses erythrocytes sensitised with antiserum to human IgM to separate IgM from IgG in serum. Specific antitreponemal IgM captured in this way is detected by adding a second reagent comprising erythrocytes sensitised with T pallidum antigen. Eighty two serum samples from 82 patients with untreated syphilis, 521 samples from 73 patients with treated syphilis, and 1872 samples from people who did not have syphilis were examined by the 19S(IgM)-TPHA (T pallidum haemagglutination), IgM-FTA-ABS (fluorescent treponemal antibody absorbed), TP-IgM-ELISA (enzyme linked immunosorbent assay), and TP-IgM-HA tests for the presence of 19S(IgM) antibodies specific to treponemes. The sensitivity of the TP-IgM-HA test was 97.6% and the specificity was 99.7%. We also traced IgM specific to treponemes in untreated patients with primary syphilis by four different tests. The TP-IgM-HA test results clearly reflected the effect of the treatment.

Electron microscopical studies of primary syphilitic lesions showed intensive changes in the capillaries in the form of endothelial proliferation and extensive infilitration of different cells in the surrounding connective tissue. The degenerative changes in axon terminals could explain the painless course of primary induration.

The distribution of T-lymphocyte subpopulations was studied in 34 patients with primary or secondary syphilis before and after treatment. An absolute and relative T lymphopenia was found in all patients. In primary syphilis the concentration of helper cells--T cells with Fc receptors for IgM (T mu)--was low whereas in secondary syphilis the suppressor cell concentration--T cells with Fc receptors for IgG (T gamma)--was reduced. Using lymphocytes from healthy subjects this could be imitated in vitro by the addition of serum from patients with secondary syphilis. In many autoimmune diseases a low concentration of T gamma may be a primary factor in the production of autoantibodies. The occurrence of similar changes in patients with secondary syphilis, however, indicates that such fluctuations in the T-cell subpopulations may take place during a strong immune response.

Clean microscopic slides are dipped in a solution of mercuric chloride and sucrose in 30% alcohol and allowed to dry. A thin transparent film of cytological fixative is thus formed on both sides of the slide. Fixative slides, prepared in this manner, can be stored indefinitely provided that they are not exposed to a warm, humid atmosphere. When a drop of fluid containing bacteria, protozoa, or mammalian cells is spread over the surface of such a slide the formed elements are immediately fixed, the finer cytological details being well preserved. Staining and examination are carried out when the specimen arrives at the laboratory. This method is particularly suitable for a diagnostic laboratory service in which most of the specimens arrive by mail. The method has been successfully employed in the diagnosis of Trichomonas vaginalis infection of the female genital tract. This parasite was found by phase-contrast microscopy in 47% of 1,000 women examined at a police court clinic. Fixative slide preparations were also obtained from these women at the time of their medical examination. Of these specimens, 38·6% showed the presence of Tr. vaginalis , and 10% were also found to be infected with N. gonorrhoeae. The fixative slide technique may also prove of value in such widely separated fields as exfoliative cytology and the diagnosis of primary syphilis.

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.

The incidence of early infectious syphilis in Singapore rose from 8.7 per 100,000 in 1980 to 25 per 100,000 in 1984. In this epidemiological study of 100 patients with early syphilis, 70 were men, the mean age was 31.7 (range 17 to 68) years, 25 patients had primary syphilis, 47 secondary syphilis, and the remaining 28 had early latent syphilis. Female prostitutes were cited as sources of infection by 46 and homosexual contacts by 11. Reduced herd immunity, decreased use of penicillin, greater population movement, and decreased surveillance and awareness have contributed to this rise in infectious syphilis.

The natural killer cell activity was studied in 25 patients with primary, secondary, or latent syphilis before and after treatment. In primary syphilis natural killer cell activity was increased, especially in patients lacking circulating lipoidal antibodies. In patients who had become seroreactive in the lipoidal tests it was depressed in those with secondary and latent syphilis. The natural killer cell activity thus becomes activated by the syphilitic infection but is significantly reduced during progression of the disease. The importance of the natural killer cell activity in controlling syphilitic infection is questionable.