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The aim - to find the optimal attributing rules to distinguish groups of latent stages of syphilis and false positive serological tests of using multivariate discriminant analysis Material and methods. The objects of the study were serum samples from patients with late latent (N=34) syphilis and false positive serological tests (N=31). The samples were studied to determine IgG and IgM levels using indirect immunofluorescent reaction with immunochip containing recombinant antigens T. pallidum Results The mathematical model allows to differentiate with a high degree of confidence patients with late latent syphilis and with false-positive serological reactions to syphilis. Conclusions. . Multivariate discriminant analysis makes possible to create reliable mathematical models to classify patients with late latent syphilis and with false-positive serological reactions to syphilis.

ObjectivesIntramuscular benzathine penicillin G is not available in certain countries. In a previous report, 3 g/day amoxicillin with probenecid was shown to be effective in treating syphilis in patients with HIV; however, 7.3% of patients changed their therapy owing to adverse events. The objective of this study was to assess the clinical efficacy and tolerability of 1.5 g/day amoxicillin without probenecid for the treatment of syphilis.MethodsThe routine clinical records of patients diagnosed with syphilis and treated with 1.5 g/day amoxicillin at a tertiary care hospital between 2006 and 2018 were retrospectively analysed. Syphilis was diagnosed if serum rapid plasma reagin (RPR) titres were ≥8 RU and the Treponema pallidum latex-agglutination test was positive. Serological cure was defined as a ≥fourfold decrease in the RPR titre within 12 months in symptomatic early syphilis and within 24 months in latent syphilis.ResultsOverall, 138 patients (112 with HIV) were analysed. The percentages of primary, secondary, early latent, late latent and latent syphilis of unknown duration were 8.0%, 50.0%, 25.4%, 5.8% and 10.9%, respectively. The median treatment duration was 4.5 weeks (IQR 4–8 weeks), which was not related to the stage of syphilis. Two patients (1.5%) changed treatment due to skin rash. The rate of serological cure was 94.9% (131/138; 95% CI 89.8% to 97.9%) overall; 93.8% (105/112; 95% CI 87.5% to 97.5%) in patients with HIV and 100% (26/26; 95% CI 86.8% to 100%) in patients without HIV. Treatment duration was not related to the treatment efficacy.ConclusionThe regimen of 1.5 g/day amoxicillin without probenecid is highly effective with a low switch rate in patients with and without HIV.

Elevation of cerebrospinal fluid neurofilament light subunit and phosphorylated neurofilament heavy subunit level was found in symptomatic neurosyphilis, not in asymptomatic neurosyphilis, and the high levels of cerebrospinal fluid neurofilament light subunit and phosphorylated neurofilament heavy subunit could decrease after treatment of neurosyphilis., Background Although clinical manifestations of symptomatic and asymptomatic neurosyphilis are different, few laboratory tests could reflect the difference. Methods A total of 92 non–HIV-infected patients with syphilis were enrolled in this study, including 23 with symptomatic neurosyphilis, 51 with asymptomatic neurosyphilis, and 18 with latent syphilis, which were excluded neurosyphilis because they were found to have no symptom and normal cerebrospinal fluid (CSF) tests and served as the control group. The concentrations of neurofilament light subunit (NF-L) and phosphorylated neurofilament heavy subunit (pNF-H) in the CSF were measured and compared among these groups, as well as before and after treatment in the symptomatic and asymptomatic groups. Results The median concentrations of NF-L in the symptomatic neurosyphilis, asymptomatic neurosyphilis, and control groups were 5806, 218, and 266 pg/mL, respectively (P < 0.001), and the median concentrations of pNF-H were 986, 43, and 49 pg/mL, respectively (P < 0.001). A subgroup of 15 symptomatic neurosyphilis and 10 asymptomatic neurosyphilis patients were followed up and underwent CSF examination 6 months after the antineurosyphilis treatment. The median concentration of NF-L in the symptomatic neurosyphilis group decreased from baseline 6420 to 2914 pg/mL after the treatment (P = 0.03), and the median concentration of pNF-H in the symptomatic neurosyphilis group decreased from baseline 1399 to 246 pg/mL after the treatment (P = 0.03). Conclusions Neurofilament light subunit and pNF-H were significantly elevated in the symptomatic neurosyphilis patients, not in asymptomatic neurosyphilis, which was an implication of the different pathogeneses in neurosyphilis.

Syphilis is a multi-organ system bacterial infection caused by the bacterium Treponema pallidum. Syphilis can advance through four clinical stages: primary, secondary, latent, and tertiary. Once in the tertiary stage, mortality is seen in up to 58% of individuals. Here, we present a case of latent neurosyphilis manifesting after initiation of the immunosuppressive medication secukinumab, a monoclonal antibody that antagonizes interleukin-17A. A 66-year-old male with type II diabetes mellitus, hyperlipidemia, and rheumatoid arthritis presented to the emergency department for a right lower quadrant abdominal cellulitis at the site of his insulin pump. On examination, a non-blanching papular rash on the palms and soles with several scaling papules was discovered. No visible pustules, oral lesions, or perirectal lesions were seen. Neurological examination was noncontributory. His past medical history revealed initiation of secukinumab for the management of rheumatoid arthritis two months prior to presentation. The rash developed six weeks after starting secukinumab. Basic laboratory tests, including a complete blood count, thyroid panel, renal function panel, fasting blood glucose, electrolytes, and C-reactive protein, were within normal limits. A hepatic panel revealed mildly elevated alkaline phosphatase, alanine transaminase, and erythrocyte sedimentation rate Westergren level. Laboratory tests for hepatitis B, hepatitis C, HIV-1, Chlamydia trachomatis, and Neisseria gonorrhoeae all returned negative. A rapid plasma reagin (RPR) titer returned positive at 1:128, and a serum Treponema pallidum Ab returned reactive. Lumbar puncture serologies demonstrated a positive Venereal Disease Research Laboratory (VDRL) test. The patient was diagnosed with latent neurosyphilis and started on intravenous crystalline penicillin G for three weeks. A thorough history, comprehensive physical examination, and basic workup should be performed in any individual prior to immunosuppressive medication initiation. On initial presentation, our patient had an isolated rash on the palms and soles, which is classical for secondary syphilis. The specific manifestations seen in syphilis depend upon the timing, site, and immune status of the individual. Due to its ability to have a variety of presentations, syphilis should always remain on the differential for any physician caring for immunocompromised individuals. Again, initiation of immunosuppressive medications, such as the monoclonal antibody secukinumab, can result in the reactivation of previously dormant infections. As physicians, we must carefully screen our patients prior to initiating immunosuppressive agents to prevent disease reactivation.

A mentally ill antenatal mother of 34 weeks gestation was diagnosed as a case of latent syphilis of unknown duration and was treated adequately with benzathine penicillin. One month after last dose of penicillin she delivered a male baby without any clinical or radiological evidence of syphilis, but reactive RPR in 1:64 dilution. Baby was treated as per CDC guidelines. It is also the gestational age at which the mother was treated decides the outcome in child in addition to stage of syphilis. These reported congenital syphilis cases necessitates early screening and adequate treatment of syphilis mainly in pregnancy.

Syphilis, human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) share transmission routes. Syphilis infection can increase the risk of acquiring and transmitting HIV in key populations. The aims of this study were to investigate the risk factors and co-infection patterns for HIV, HBV and HCV in patients with syphilis. A retrospective study was conducted of 2,412 patients with syphilis (1,922 (79.68%) with latent syphilis, 336 (13.93%) with secondary syphilis, 78 (3.23%) with primary syphil-is, 72 (2.99%) with tertiary syphilis, and 4 (0.17%) with congenital syphilis). Positive results were odserved in 8.21% (134/1,620) of patients tested for HIV, 5.75% (82/1,427) for HBV, and 1.02% (14/1,374) for HCV, respectively. Multivariate logistic regression analysis found that male sex (adjusted odds ratio (AOR) 26.03; 95% confidence interval (CI) 10.37-65.36), age

Background Syphilis causes considerable morbidity not only in adults but also in children. Unfortunately, acquired syphilis in children has not received due attention and remains a relatively ignored field. Methods This was a retrospective study, in which epidemiologic, clinical, and investigational data were analyzed from medical records of all sexually transmitted infection (STI) cases attending the STI clinic of Pt. B. D. Sharma, PGIMS, Rohtak from January 1992 to November 2018. Children of age ≤14 years with acquired syphilis were studied. Results Of 9138 STD cases registered from January 1992 to November 2018, 39 were children with acquired syphilis, of whom 22 were males and 17 were females. The majority were in 12-14 years age group (22 cases; 56.41%). A history of sexual abuse could be elicited in 10 patients. Three gave a history of voluntary sexual activity. Examination revealed secondary syphilis in 32, latent syphilis in 6 and only one case of primary chancre. Analysis of incidence of pediatric acquired syphilis cases over three-year intervals during the last 27 years indicated an initial decreasing trend followed by recent slight rise in last 3 years. Conclusion Social inhibitions and reluctance to report child sexual abuse may have led to an underestimate of actual prevalence. The prevalence in the 12- to 14-year age group may indicate emerging trends of promiscuous sexual behavior. The recent rising trend in occurrence of childhood acquired syphilis may mirror the recent resurgence of adult syphilis.

Renal manifestations of syphilis are variable, with membranous nephropathy being the most commonly described lesion. Rapidly progressive glomerulonephritis (RPGN) is rare and there is only one case report in the literature describing syphilis-associated crescentic glomerulonephritis. We report a rare case of RPGN secondary to latent syphilis, which resolved with penicillin treatment in the absence of immunosuppressive therapy. A 28-year-old Black male with a history of HIV was evaluated for severe acute kidney injury, nephrotic-range proteinuria, and active urine sediment. Serologies for glomerulonephritis were negative. Rapid plasma reagin and treponema pallidum particle agglutination assay were reactive, confirming syphilis diagnosis. Kidney biopsy revealed focal and segmental necrotizing and crescentic lesion. Patient received weekly benzathine penicillin (PCN) for 3 weeks, and renal function improved to baseline. This dramatic improvement happened with PCN alone, a finding which has not been previously reported. We recommend that syphilis be considered in the differential diagnosis of all patients with proteinuria or suspected glomerulonephritis.

매독에 대한 환자들의 두려움과 불안감은 매우 크다. 잠복매독을 진단하고 치료하는 것은 매독의 진행과 전염을 막기위함이면서, 환자들의 두려움과 불안감을 치료하는 것이다. 이를 위해서는 매독이라는 병 자체에 대한 이해와 함께 매독혈청 검사의 종류와 특징, 제한점에 대한 깊은 이해가 필요하겠다....

Background Neurosyphilis is one of the most feared complications of syphilis. The question of how to identify patients at higher risk in order for timely intervention whilst avoiding unnecessary lumbar puncture remains. Methods Between August 2009 and March 2013, a total of 834 HIV-negative patients with primary, secondary or latent syphilis were recruited. Venous blood and cerebrospinal fluid specimens were collected for diagnoses of syphilis and/or neurosyphilis and information of socio-demographic and behavioral characteristics was collected by interviewing with a questionnaire. Results The prevalence of neurosyphilis differed among patients with primary (7.1%), secondary (23.8%) and latent (26.6%) syphilis. Neurosyphilis was more likely in male patients (1.52-fold). Compared with patients aged

Persistent non-treponemal titres after treatment are common among patients with latent syphilis. Although retreatment is often done in clinical practice, optimal management remains uncertain due to the paucity of data regarding serological response to retreatment and long-term outcomes. We compared the serological responses of serofast latent syphilis patients retreated with 7.2 million units of benzathine penicillin with the responses of patients who did not receive retreatment (control group). We retrospectively analysed the serological response to therapy following retreatment of 35 serofast latent syphilis patients at 12 months with benzathine penicillin 2.4 million units weekly for 3 weeks. In all, 74.3% (26/35) of the cases with latent syphilis who failed to achieve serological cure at 12 months after initial therapy achieved serological cure after retreatment and after an additional 12 months of follow-up. However, statistically similar serological cure rate was observed in 80.0% (28/35) of the control group ( p > .05). Our findings illustrate no improvement in serological response among serofast latent patients retreated with three doses of benzathine penicillin.

An unconfirmed positive treponemal enzyme immunoassay (enzyme immunoassay positive, Treponema pallidum particle agglutination negative and rapid plasma reagin negative) presents a clinical challenge to distinguish early syphilis infection from false-positive results. These cases are referred for syphilis line assay (INNO-LIA) and recalled for repeat syphilis serology. We performed a retrospective audit to establish the proportion of HIV-negative cases with unconfirmed positive enzyme immunoassay results, the proportion of these cases that received an INNO-LIA test and repeat syphilis serology testing and reviewed the clinical outcomes; 0.35% (80/22687) cases had an unconfirmed positive treponemal enzyme immunoassay result. Repeat syphilis serology was performed in 80% (64/80) cases, but no additional cases of syphilis were identified. Eighty-eight per cent (70/80) received an INNO-LIA test; 14% (5/37) unconfirmed enzyme immunoassay-positive cases with no prior history of syphilis were confirmed on INNO-LIA assay, supporting a diagnosis of latent syphilis. As a confirmatory treponemal test, the INNO-LIA assay may be more useful than repeat syphilis serological testing.

Clinical case We present the case of a 32 year-old man, HIV positive in treatment, that presented to our hospital. He had erythematous papules scattered through his trunk, limbs (including palms and soles) and genitalia. He denied previous genital, oral or anal ulcer. His previous serological tests for syphilis were negative. We suspected a secondary syphilis and prescribed Benzatin G Penicillin 2.4 M IU. The patient referred to the emergency room for a flu-like reaction and worsening of the skin lesions after the injection. We performed a biopsy that confirmed the clinical diagnosis of syphilis, and the serological test came out positive (RPR 64). After the second injection of penicillin, the patient experienced a second reaction, with fever and malaise. Before the third treatment we administered prednisone for three days, and he had no reaction. The Jarisch-Herxheimer Reaction (JHR) is well known since the Middle Ages, when it was associated with mercury ointments used for the treatment of syphilis. The first literary descriptions came from Jarisch in 1895 and Herxheimer seven years later. Since then it has been described during the antibiotic treatment of various spirochete infections. It begins 2 to 8 hours after the treatment, as a flu like reaction with high fever and is sometimes associated to an aggravation of the syphilis symptoms. It usually resolves in 24 hours without treatment, but the patients usually receive antipyretic treatment. This reaction appears in 50% of primary syphilis, and up to 75% of secondary syphilis. It’s very rare in latent syphilis, but can appear in 30% of neuro-syphilis. There has been only one description of a recurrent JHR, in a patient with a late latent syphilis that had 2 JHR after 2 consecutive penicillin injections. To our knowledge it has not been described in any other syphilis patient.

Background: Aim of this study was to determine the prevalence of HIV in syphilis in patients attending the STD clinic in a tertiary care center.Methods: Study was conducted in all new patients attending the STD clinic during the study period of 6 months from June 2012 to November 2012. Clinically suspected cases of syphilis were diagnosed serologically and all the patients were tested for HIV after proper counselling and consent.Results: In a total of 200 new patients attended the STD clinic 47 (23.5%) were diagnosed as syphilis. Majority of the cases (43) were latent syphilis in our study. A total of 77 (38.5%) cases were reactive to HIV. Among the 47 (23.5%) syphilis cases 24 (51%) were reactive to HIV. In the age group of 21-30 years most of the syphilis male (5/6) patients showed HIV reactivity.Conclusions: Seroprevalence of syphilis among other STI was found to be significant. Rising trend in latent syphilis was noted may be due to antenatal checkup, purpose of foreign job and strict blood screening protocols. The prevalence of HIV in syphilis individual was 51% and it was high in the age group of 31-50 when compared to other age group. In the age group of 21-30 most of the males, diagnosed as syphilis were serologically positive for HIV. Hence these sexually active groups were to be targeted for their safe sexual practice to prevent the transmission of HIV.

The goal of the present study was to determine the performance of two traditional non-treponemal tests for syphilis. Syphilis sera ( n = 209) included different stages of disease, and control sera ( n = 247) were from patients with tumours, leprosy, systemic lupus erythematosus, hepatitis, pregnant women and healthy individuals. Treponema pallidum ELISA, Treponema pallidum particle agglutination and rapid treponema-specific tests were used as gold standards. Rapid plasma reagin or toluidine red unheated serum test had a sensitivity and specificity of over 95%. False-negative reactions of rapid plasma reagin and toluidine red unheated serum test were observed mainly in primary and latent syphilis cases, and false-positive reactions were present in systemic lupus erythematosus, hepatitis-infected patients. Overall, both non-treponemal tests had high sensitivities and specificities making the assays attractive as screening tests for syphilis. When examined on WHO reference serum samples and based on lower limits of detection, non-treponemal tests were less sensitive than treponema-specific tests.

Over the past decade, the incidence of syphilis and widespread macrolide resistance in its etiological agent, Treponema pallidum subsp. pallidum, have become a major health concern across countries, including China. Regional trends in subtypes and antibiotic resistance can be monitored effectively by molecular surveillance programs. In this study, whole blood samples were used to assess circulating T. pallidum strains collected from various regions of Hunan, China, between 2013 and 2015.Traditional polymerase chain reaction, targeting polA, tpp47, bmp, and tp0319 genes, was used as preliminary screening assay. About 455 polymerase chain reaction-positive specimens were obtained from 2253 whole blood samples of patients with secondary or latent syphilis. Molecular subtyping was performed using a Centers for Disease Control and Prevention-based typing method combined with an analysis of the variable region of tp0548 gene. Resistance to macrolides was analyzed by examining point mutations in 23S rRNA, and the presence of the G1058C point mutation within 16S rRNA associated with decreased susceptibility to doxycycline was assessed.Circulating T. pallidum strains were resolved into 32 subtypes, among which subtype 14d/f was predominant. A2059G mutation in 23S rRNA, and the G1058C mutation in 16S rRNA was absent, but the prevalence of A2058G mutation in 23S rRNA was 97.5%.We found that it is possible to use whole blood to evaluate molecular subtypes and monitor antibiotic resistance in circulating T. pallidum strains, especially when chancres are absent. High frequency of macrolide-resistant T. pallidum indicates that macrolide antibiotics, such as azithromycin, should be avoided as a treatment option for syphilis in Hunan, China.

Background: Syphilis presents with a wide range of mucocutaneous and systemic manifestations, which can mimic many other diseases. The pattern of acquired syphilis is changing in recent years because of widespread use of antibiotics and HIV infection which leads to under diagnosis. Aim was to study the demographic factors and changing pattern of clinical features of acquired syphilis.Methods: Retrospective analysis of all cases of sexually transmitted infections registered in the Department of Venereology, Thanjavur Medical College from January 2013 to December 2017 was done. The data regarding epidemiological, clinical and investigational details were recorded and analyzed for changing trends in incidence, pattern and clinical presentation of syphilis.Results: Of the total 14,672 cases attended theSTI clinic, 140 patients were diagnosed as having syphilis. There were 101 (79.4%) males and 39 (27.8%) females. Primary Syphilis was diagnosed in 18 (12.25%), Secondary syphilis in 38 (27.14%) and latent in 84 (60%) cases. Palmoplantar syphilide was the most common skin manifestation seen in 20 (52.63%) cases of secondary syphilis. 11 (7.85%) patients was human immunodeficiency virus (HIV) reactive.Conclusions: Our study indicates an increasing trend in the prevalence of syphilis cases in last 5 years with a rise in early symptomatic syphilis demanding steps to increase awareness among the general population.

Treatment, contact investigation, and reporting decisions for syphilis cases are based on the stage of disease. Because of limitations of current staging protocols, the rapid plasma reagin (RPR) titer has been proposed as an alternative priority marker for contact investigation.We describe the RPR titers and stages for 10,021 syphilis cases reported between 1997 and 1999 in Columbia, South Carolina; Houston, Texas; and Jackson, Mississippi. We constructed receiver operating characteristic curves (ROC curves) to compare titer and stage. We calculated the number of infected contacts to evaluate the use of titer to prioritize contact investigation.RPR titers differed by stage, with 67% of primary, 95% of secondary, 78% of early latent, and 41% of late latent and unknown duration having titers1:8; however, there was considerable overlap in titer distributions. The ROC curve based on titer values demonstrated good agreement between titer and latent stage. Prioritization by titer (or =1:8) of latent cases would result in a similar number of cases interviewed and contacts located as stage prioritization, although different cases are prioritized.Titer distributions meaningfully but imperfectly distinguish populations with different stages. Recent analyses and anecdotal reports indicate the difficulty and inconsistency of staging latent syphilis. Over time, titer could provide a more objective and reliable historical record of syphilis trends. Titer may be a useful alternative or adjunct to stage in prioritizing latent syphilis cases for investigation.

Summary The aim of the study was to determine the characteristics of primary and late latent syphilis cases that were non-reactive on initial screening by rapid plasma reagin (RPR) but reactive by treponemal tests. RPR test results of all primary and late latent syphilis cases in the province of Alberta, Canada during 1980–2001 were compiled. The proportion of syphilis cases that were non-reactive by RPR testing was compared with reactive cases. Multiple logistic regression was used to identify factors associated with non-reactive RPR results. Among primary syphilis cases, 224 (26%) were non-reactive on initial RPR and were compared with 639 reactive primary cases. Independent factors associated with a non-reactive result were male gender (odds ratio, [OR] = 1.99 [1.22–3.26]), Caucasian ethnicity (OR = 1.77 [1.20–2.61]) and diagnosis during the 1980–1986 syphilis outbreak period in Alberta (OR = 3.13 [1.45–6.74]). Of the late latent cases, 512 (39%) were non-reactive by RPR and 791 were reactive. A non-reactive test for late latent cases was associated with male gender (OR = 2.91 [2.15–3.94]), Canadian Aboriginal (OR = 2.91 [1.59–5.32]), Caucasian (OR = 1.87 [1.35–2.58]), black ethnicity (OR = 1.76 [1.28–2.42]) and diagnosis during the 1980–1986 Alberta syphilis outbreak (OR = 1.67 [1.29–2.16]). RPR testing alone is insufficient to diagnose primary and late latent infections under certain conditions and patient characteristics. Case detection was lower for late latent syphilis when compared with primary syphilis based on the properties of the RPR. Further studies are needed to inform the optimal use of the RPR test in laboratory testing algorithms for the diagnosis of syphilis and to determine the cost effectiveness of better screening tests for syphilis.

Aim: To examine the clinical manifestations of syphilitic uveitis in a population and review trends in incidence at a tertiary referral centre. Methods: A retrospective, non-comparative interventional case series of 22 consecutive patients with syphilitic uveitis who were managed in the Ocular Inflammation and Immunology Services of the Singapore National Eye Centre between 1995 and 2006. Results: Twenty-two patients (mean age 52.7 years, range 18–78) with a positive serum fluorescent treponemal antibody absorption test (100%) and negative HIV serology were reviewed. Non-granulomatous anterior uveitis was the commonest presenting finding (18/29 eyes, 62.06%). Posterior uveitis was seen in four (13.7%), intermediate uveitis in three (10.3%) and panuveitis was seen in eight (27.5%) eyes at presentation. Vitritis (19 eyes, 65.4%) was the commonest posterior segment finding. The majority (86.4%) had latent syphilis at the time of ocular involvement. An increasing trend in the number of cases of ocular syphilis in the past decade was not observed. Conclusions: Despite resurgence in infectious syphilis, this centre did not see a dramatic rise in cases of syphilitic uveitis. Ocular syphilis presented most frequently as a non-granulomatous inflammation. Therefore, syphilis serology should be sought even for cases of anterior uveitis.

In this study, polymerase chain reaction (PCR) techniques were used to detect Treponema pallidum DNA in samples from patients with latent syphilis. Sixty-nine patients with latent syphilis and 18 with treated syphilis were included. Whole blood, plasma, sera and ear scrapings, totalling 235 samples from patients with latent syphilis, were obtained. Three PCR assays (47-PCR, polA-PCR and M-PCR assays) were performed. The 47-PCR yielded the highest number of positive samples –92/235 (39.1%), followed by M-PCR –90/235 (38.3%) and polA-PCR –73/235 (31.1%). Ear scrapings presented the highest number of positives (47/84 –56%), followed by plasma samples (36/84 –42.9%), whole blood (32/84 –38.1%) and sera (21/84 –25%). In conclusion, we have confirmed that T. pallidum can be found in blood of patients with latent syphilis. The 47-PCR technique was found to be the most sensitive, whereas ear lobe scrapings seem to be the best specimen for detection of T. pallidum DNA in latent syphilis.

The aim of the study was to compare the outcome of syphilis treatment in HIV-infected and -uninfected patients. An observational study on patients diagnosed with early syphilis in three genitourinary clinics in the UK between January 2003 and June 2005 was conducted. Failure of the initial Venereal Disease Research Laboratory (test) (VDRL) titre to decrease four-fold within 12 months in the absence of history of re-infection was considered as treatment failure. During the study period, 190 HIV-uninfected and 129 HIV-infected patients were diagnosed, and 161 (84%) HIV-uninfected and 100 (77.5%) HIV-positive patients with diagnosis of syphilis who had 24 months follow-up syphilis serology results were included in the study ( P = 0.10). There were 381 and 508 follow-up episodes for HIV-infected and -uninfected patients, respectively, within 24 months. One HIV-infected patient was diagnosed with neuro-syphilis. After 12 months, 102 (63%) HIV-uninfected and 76 (70%) HIV-infected patients were treated ( P = 0.04). On Cox proportional hazard model, successful treatment after 12 months was associated with having VDRL titre more than 1:6 (hazard ratio [HR] 1.011; 95% confidence interval [CI], 1.004–1.019; P = 0.002). Those with negative immunoglobulin M enzyme immunoassay were less likely to have been successfully treated after 12 months (HR 0.676 [95% CI 0.518–0.883]; P = 0.004). HIV sero-status, age, sex group and treatment regimen were not associated with success of treatment. In conclusion, HIV sero-status did not play a role in the outcome of syphilis treatment. Treatment failure in a proportion of HIV-infected patients is due to a slower decline in VDRL titre rather than lack of response to treatment.

Patients with latent syphilis or syphilis of unknown duration should be evaluated for tertiary disease and neurosyphilis. The aim of this retrospective study was to determine relevant serological parameters for the identification of those individuals with syphilis who are most likely to have neurosyphilis and who therefore require lumbar puncture. After excluding repeated estimates and patients whose blood syphilis serology had either been negative or not been determined within 3 months of lumbar puncture, 265 out of 710 cerebrospinal fluids from 1988 to 2004 were analysed. In each of those patients the earliest available pairs of serum and cerebrospinal fluid samples were evaluated. The diagnosis of neurosyphilis was based on criteria according to established guidelines. Forty-three of 265 patients (16.2%; 5 women, 38 men; mean age 47+/-16 years) had neurosyphilis. Seven of 72 (9.7%) of those testing HIV-positive, fulfilled the criteria of neurosyphilis. Not a single patient with neurosyphilis tested Venereal Disease Research Laboratory test (VDRL)-negative in peripheral blood, an effect which was highly significant (p < 0.01, chi2-test). The median blood-VDRL titre was significantly higher in patients with neurosyphilis than in those without (1:32 vs. 1:0; p < 0.01, t-test, two-sided). Hence, neurosyphilis is very unlikely in patients with a negative blood-VDRL. Therefore, lumbar puncture is not recommended in these patients.

The risk of hepatitis B among men having sex with men (MSM) is high, with core antibody rates ranging from 5% to 81%. We describe an outreach, hepatitis B vaccination programme aiming to raise awareness of hepatitis B and increase vaccination uptake. The 13-week programme used an ultra rapid vaccination schedule. Follow-up was defined as complete if the client was core antibody positive, had adequate surface antibody levels following prior vaccination or received three vaccine doses. One hundred and fifty clients were screened for hepatitis B and syphilis. Three cases of untreated syphilis (early latent) and one case of e-antigen-positive hepatitis B were detected. With the aid of text-message reminders, a vaccination completion rate of 76.6% was achieved, with 82.5% completing follow-up. In conclusion, this programme succeeded in reaching MSM not routinely accessing services. Text messaging was an acceptable and effective method of follow-up, resulting in high vaccination completion rates.

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.

Background/aim The Jarisch-Herxheimer reaction (JHR) is an acute systemic event that can occur during the treatment of spirochetal infections, especially Treponema pallidum in patients with syphilis. JHR has clinical characteristics of an inflammatory reaction to antibiotic treatment and can occur with many medications as long as the antitreponemal concentrations are sufficiently high. Methods The incidence of and risk factors for JHR were investigated retrospectively among 1125 patients with syphilis. A total of 357 patients (32%) had secondary syphilis, 129 (12%) primary, 178 (16%) early latent, 174 (15%) late latent and 285 (25%) latent unknown duration; two patients had tertiary syphilis. Results Sixteen patients (1.4%) developed JHR. All JHRs occurred in patients with secondary and latent syphilis treated with penicillin. Conclusions JHR occurred much less frequently than in previously reported studies. It is important that dermatologists recognize the clinical characteristics of JHR so that it is not misinterpreted as an allergic reaction to treatment.

Bone infection, particularly of the skull and the long bones of the legs and arms, despite being a common characteristic of tertiary stage syphilis and congenital syphilis in the past, is seldom encountered clinically due to effective antibiotic therapy. We report a case of a 62-year-old man who presented with one-month acute pain in the left leg. Treponema pallidum particle agglutination test was positive, and radiography showed a pathological fracture of the left tibiofibula. Surgical debridement and biopsy of the bone marrow were performed and a pathological diagnosis of syphilis osteomyelitis was entertained. The patient's symptoms resolved completely after a six-week course of penicillin. We identified 17 previously published cases of bone lesions of syphilis, eight of which had syphilitic osteomyelitis, seven were syphilitic osteitis and two had syphilitic periostitis. We suggest that bone lesions such as osteomyelitis caused by syphilis can be the only manifestation of late latent syphilis.

Late cutaneous syphilis has become a rarity as a result of the effective treatment of early and latent syphilis with antibiotics. We report a heterosexual male who presented with multiple large annular plaques of two years duration. Skin biopsy revealed endarteritis and non-caseating granulomas in the dermis along with plasma cells. VDRL and TPHA were reactive. ELISA for HIV-1 antibodies was reactive. This is the first report of nodular tertiary syphilis as the presenting manifestation of HIV.

The Jarisch–Herxheimer reaction (JHR) is a syndrome observed after antimicrobial treatment of some infectious diseases. The syndrome has clinical characteristics of an inflammatory reaction to antibiotic treatment. A prospective study of patients with a clinical and laboratory diagnosis of syphilis was conducted at a sexually transmitted diseases clinic in Rio de Janeiro, Brazil. Patients were treated with benzathine penicillin and observed for the JHR. A total of 115 patients were included in this study. Fifty-one patients (44%) had secondary syphilis; 37 (32%), primary; 26 (23%), latent; and one (1%), tertiary syphilis. Ten patients (9%) developed the JHR. All JHRs occurred in patients with secondary and latent syphilis. No patients experienced an allergic reaction to penicillin. The JHR occurred less frequently than in previous studies. It is important that health-care professionals recognize the clinical characteristics of the JHR so that it is not misinterpreted as an allergic reaction to penicillin.

Primary syphilis is a genital ulcer disease. The leading signs and symptoms are painless and indurated ulcers and regional lymph nodes. Secondary syphilis is marked by non-itching exanthema with involvement of the palms and the soles of the feet.

In 2005, syphilis screening in the Greater Toronto Area of Canada moved from the rapid plasma reagin (RPR) to a treponemal enzyme immunoassay (EIA). We sought to understand the consequences of this change on laboratory results and testing patterns with a population-based retrospective study of laboratory-based diagnoses of syphilis.Samples positive under RPR (1998-2005) and EIA (2005-2008) screening were confirmed with an alternate treponemal test, and during the latter period underwent RPR testing. We compared monthly rates and the forecasting relationship between positives and future submissions with time-series methods, and assessed risk factors for EIA(+)/RPR(-) results using Poisson regression.A total of 3,092,938 submissions were included. Following EIA implementation, confirmed positive rates increased by 10.3 per 100,000 population (P0.001). 0.59% of EIA(+)/RPR(-) individuals converted to RPR(+) within 2 months. EIA(+)/RPR(-) patients were more likely to be male (incidence rate ratio [IRR]: 2.3, 95% confidence interval [CI]: 1.6-2.5), asymptomatic (IRR: 1.8, 95% CI: 1.3-2.8), and aged50 years (IRR: 2.4, 95% CI: 1.6-3.5) than those with EIA(+)/RPR(+) results. We detected a significant positive feedback loop between positive tests and subsequent submissions. This relationship was only transiently evident for EIA(+)/RPR(-) results up to 1 year following the changeover.EIA screening facilitates identification of probable latent syphilis and earlier serological detection of infectious syphilis, but may transiently cause increases in testing and indirectly suggests that physicians' interpretation of RPR(-) serology may lead to partner testing. In the absence of a true gold standard, implementation of EIA screening warrants careful communication regarding serological interpretation.

OBJECTIVES: To investigate the contribution of a real-time PCR assay for the detection of Treponema pallidum in various biological specimens with the secondary objective of comparing its value according to HIV status. METHODS: Prospective cohort of incident syphilis cases from three Swiss hospitals (Geneva and Bern University Hospitals, Outpatient Clinic for Dermatology of Triemli, Zurich) diagnosed between January 2006 and September 2008. A case-control study was nested into the cohort. Biological specimens (blood, lesion swab or urine) were taken at diagnosis (as clinical information) and analysed by real-time PCR using the T pallidum 47 kDa gene. RESULTS: 126 specimens were collected from 74 patients with primary (n = 26), secondary (n = 40) and latent (n = 8) syphilis. Among primary syphilis, sensitivity was 80% in lesion swabs, 28% in whole blood, 55% in serum and 29% in urine, whereas among secondary syphilis, it was 20%, 36%, 47% and 44%, respectively. Among secondary syphilis, plasma and cerebrospinal fluid were also tested and provided a sensitivity of 100% and 50%, respectively. The global sensitivity of T pallidum by PCR (irrespective of the compartment tested) was 65% during primary, 53% during secondary and null during latent syphilis. No difference regarding serology or PCR results was observed among HIV-infected patients. Specificity was 100%. CONCLUSIONS: Syphilis PCR provides better sensitivity in lesion swabs from primary syphilis and displays only moderate sensitivity in blood from primary and secondary syphilis. HIV status did not modify the internal validity of PCR for the diagnosis of primary or secondary syphilis.

Objectives: To determine the sensitivity and specificity of the Architect Syphilis Chemiluminescence Assay (CLIA): a new highly automated screening test for syphilis. Methods: To establish the sensitivity of the Architect Syphilis assay we tested 129 stored sera from serologically characterised cases of untreated syphilis. The sera were selected to contain a disproportionately high number of primary infections. There were 79 primary infections, 29 secondary infections, 9 early latent infections and 12 latent syphilis of unknown duration. To establish the specificity of the assay we tested 1107 sera that had been submitted for routine syphilis serology. Results: The Architect CLIA and the Treponema pallidum particle agglutination test (TPPA) were in total agreement for all untreated infection with sensitivity of 98.4%. This was significantly higher than the sensitivity of the Murex immune capture enzyme (ICE) immunoassay (86%, p

Purpose: To describe an unusual case of latent syphilis that presented with postoperative inflammation. Methods: Case report. Results: A 62-year-old African American woman developed persistent postoperative inflammation following cataract surgery. Despite a regimen of topical corticosteroid, the inflammation did not settle. A uveitic workup indicated that the patient had latent syphilis. She was referred to Infectious Disease and the inflammation resolved with intravenous penicillin. Conclusions: Postoperative inflammation has not previously been reported as the first sign of latent syphilis. This report underscores the importance of considering syphilis in the differential diagnosis of chronic inflammation, including the postoperative period.

The objective of this study was to identify the demographic characteristics and sexual behaviour associated with primary, secondary and early latent syphilis in Birmingham and its epidemiologic and public health implications. All new patients diagnosed as having infectious syphilis in a genitourinary service in Birmingham in the period from January 2005 to December 2005 were studied retrospectively (history, physical examination, serology) to determine the stage of their disease. During the 12-month period, 69 new cases of primary, secondary and early latent syphilis were diagnosed. Patients were most commonly male (96%), aged between 20 and 44 years, symptomatic (84%) and were white men who had sex with men or Asian/Black Caribbean heterosexual men. Unemployment and having multiple partners were common in infected patients. Based on the results of this study, control measures are being undertaken, using enhanced surveillance, to focus on appropriate health promotion initiatives.

Since the late 1990s, there has been a resurgence of infectious syphilis, with notable outbreaks in Brighton, Manchester, London and Dublin, predominately among men who have sex with men (MSM). We report a similar outbreak in Northern Ireland. Genitourinary (GU) medicine clinic attendees were assessed from 1 July 2000 to 30 June 2005 to identify those who met the agreed criteria for primary, secondary or early latent syphilis. In total, 161 individuals were diagnosed with syphilis and 121 were MSM. Sixteen individuals indicated a contact in Dublin as the likely source of infection. Thirty were identified through contact tracing. Over half contracted the infection through oral intercourse. Most (106) had one or two partners in the previous three months. Twelve cases were HIV positive (nine were aware of their status at the time of presumed infection). In conclusion, initially, cases acquired their infection in Dublin and, as the outbreak gained momentum, syphilis was contracted within Northern Ireland. The cohort was not generally associated with a high number of sexual contacts, multiple anonymous partners or specific locations. The challenge is to educate both patients and health-care professionals to sexual health issues; specifically, the risk associated with casual oral sex by MSM.

Introduction The results of syphilis surveillance showed that there were some singnicant problems in syphilis stage diagnosis and case-reporting in China. In order to assess the data quality of syphilis case reported in the country, and identify the problems for improving the quality, we conducted this sampling survey. Methods According to the national protocol and syphilis diagnostic criteria, checking data with original reporting cards, clinical and laboratory logs of syphilis cases reported, assessment of diagnosis correctness were conducted by related experts at 43 medical hospitals/institutions sampled in 13 counties of 10 prefectures in 5 provinces based on geographic distribution to evaluate the data quality, and Excel 2003 and SPSS18.0 software were employed in data analysis. Results The proportions of the reporting cards timely reported, completely filled, correctly filled, correctly entered by web for syphilis cases were as high as with 99.82% (1691/1694), 97.05% (1644/1694), 96.22% (1630/1694) and 96.22% (1630/1694), respectively, and the one of the reporting cards repeatedly reported was very low with 1.42%(24/1694) in 5 provinces. The proportions of correct diagnosis for syphilis cases was high with 95.40% (2491/2611), however, the ones of correct stage for primary, secondary and latent syphilis were not high with 42.49% (167/393), 77.46% (275/355) and 85.89% (1497/1743), respectively. There was the severe bias of misclassification in primary and secondary syphilis, the reason of which was that some latent syphilis cases were falsely classified into primary and secondary ones by non dermatological/STD and in-patients department doctors. Conclusion The indicators of data quality related to reporting information and correct diagnosis of syphilis cases were high, however proportion of correct stage for primary and secondary syphilis cases was low, which directly affected on analysis of syphilis incidence. It is urged that the training on related doctors in syphilis diagnosis criteria should be strengthened to substantially improve the data quality. Disclosure of interest statement No potential conflicts of interest.

Background In Germany, the number of syphilis cases doubled 2001–04 to over 3,000/year and remained mainly stable until 2009. Between 2010 and 2013, the number increased between 11% and 22%. We analysed syphilis surveillance data to assess characteristics of this rise and whether it is continuing. Methods Since 2001, laboratories are required to notify syphilis diagnoses anonymously, physicians complement clinical information. Potential double notifications are identified. We described syphilis cases by year of diagnosis, age, sex, area of residence and transmission category. Results Overall, 5,722 cases were reported in 2014, corresponding to a 14% rise compared to 2013. The overall incidence was 7.1 per 100,000 inhabitants, with highest incidences in large cities such Berlin (31.0), Cologne (31.9) and Munich (27.2), especially in Berlin inner city areas (61.3–86.2/100,000 inhabitants). Notified cases increased in 13/16 federal states in 2014, and increase in Germany in a linear manner by 669 cases/year since 2010 (R 2 = 0.9994). Men accounted for 94% of cases in 2014. The likely mode of transmission was available for 74% of cases; of these, 84% were men who have sex with men (MSM), in 16% heterosexual transmission was reported. The proportion of MSM aged 40 years or above was stable since 2008 with 49%. Stage of infection was reported in 74% of cases in 2014. Of these, 35% were diagnosed as primary, 27% as secondary and 35% as latent syphilis, similar to previous years. Conclusion Syphilis cases continue to increase strongly since 2010, mainly attributable to MSM in large German cities, also in higher age groups. Berlin as a centre of sex tourism for MSM worldwide is heavily affected. Against the background of high proportions of cases diagnosed in later stages, early diagnosis and treatment, but also consistent condom use, are important to minimise the risk of syphilis and subsequently potential HIV-transmission. Disclosure of interest statement The authors have nothing to disclose.

Background Patient-initiated partner notification (PN) is a cornerstone of STD control in resource-limited public health systems. We conducted a randomised, controlled trial of two new tools to support PN among MSM: anonymous, internet-based notification systems and patient-delivered partner referral cards. Methods We screened 1,625 MSM for syphilis in Lima, Peru between 2012–2014. Enrollment was limited to MSM with symptomatic primary or secondary syphilis (n = 133) and/or latent syphilis diagnosed by RPR/TPPA (n = 406; Seroprevalence: 25.0%). After enumerating all recent partners and providing details of their three most recent partners, 370 participants were randomly assigned to four intervention arms: 1) Standard PN Counselling (Control) [n = 94]; 2) Counselling and Referral to Internet PN (www.inspot.org) [n = 95]; 3) Counselling and Provision of 5 Partner Referral Cards [n = 97]; or 4) Counselling with both Internet PN and Partner Referral Cards [n = 84]. Self-reported notification of recent sexual partners was assessed by CASI among the 354 participants who returned for 14-day follow-up. Results The median age of participants enrolled was 27 (IQR: 23–34), with a median of 3 partners (IQR: 1–5) in the past month and a baseline HIV seroprevalence of 64.1%. Participants referred to internet PN (Arms 2 and 4) or provided with printed partner referral cards (Arms 3 and 4) were more likely to have notified ≥1 partners at 14-day follow-up than participants who received only PN counselling (OR: 2.26 [95% CI: 1.33, 3.82] and 1.94 [95% CI: 1.15, 3.27], respectively). The fraction of all recent partners notified was significantly greater in the Internet PN (56.5%, p Conclusions Internet notification systems and printed partner referral cards provide inexpensive, effective tools to support patient-directed PN, significantly improving notification by Peruvian MSM with syphilis. Additional research is needed to optimise use of different PN technologies in specific partnership contexts.

Introduction: Prevalence and pattern of acquired syphilis are changing in India in recent years because of good laboratory diagnosis and treatment, but it still remains a major public health problem with significant regional variations. Aim: To study the changing trend of acquired syphilis in a Tertiary Care Center of North India. Subjects >and Methods: Retrospective analysis of all the cases of sexually transmitted infections (STIs) registered in the Skin and VD Department of PGIMS, Rohtak from January 2008 to December 2012 was done. Complete epidemiological, clinical, and investigational data were recorded and analyzed for changing trends in prevalence, pattern and clinical presentations of syphilis. Observation: Total of 1462 cases attended the STI clinic from January 2008 to December 2012. A total of 124 patients were venereal diseases research laboratory reactive, of which 33 (2.25%) were false positive cases, and Treponema pallidum hemagglutination was reactive in 91 cases (6.22%). Totally, 91 (6.22%) cases were diagnosed as syphilis. Of 91 cases, 78 (85.71%) were males and 13 (14.29%) were females. Primary syphilis was diagnosed in 21 (13.08%), secondary in 38 (41.76%), and latent in 32 (35.16%) patients. 4 (10.53%) of the secondary syphilis were having asymptomatic rash, 14 (36.84%) had condyloma lata and 17 (44.74%) had genital ulcer with cutaneous rash. Mixed infection was detected in 7 patients. 8 (8.79%) were human immunodeficiency virus positive. Conclusion: Although our study indicates a decreasing trend in the prevalence of syphilis in last 5 years, there is a rise in latent syphilis as compared to primary syphilis demanding steps to increase awareness among general population.

Syphilis cases were reviewed to see if reported stages met the Centers for Disease Control and Prevention case definition. Classification was excellent for primary and secondary and good for late latent, but half of early latent and unknown duration were misclassified. New surveillance definitions are suggested, comments requested. Background: Uncertainty when staging latent syphilis should lead clinicians to call it late latent (requires more treatment) and disease investigators to call it early latent (priority for partner investigation). Accurate surveillance requires consistent case definitions. Objective: Assess validity of reported syphilis stages. Methods: Record reviews in 6 jurisdictions to determine if reported cases met the Centers for Disease Control and Prevention case definitions. Results: Nine hundred seventy-three records from 6 jurisdictions in 2002 showed excellent agreement for reported primary (94.0%) and secondary (95.4%), good agreement for late latent (80.2%), and poor agreement for early latent (48.4%) and unknown duration (49.7%). Unknown duration (age ≤35 and nontreponemal test titer ≥32) was often misinterpreted to mean not known. Early latent (within the past year, documented: seroconversion, fourfold titer increase, symptoms, or contact with an independently documented early syphilis case) was often misinterpreted to include patients with risky behavior, young age, or high nontreponemal test titers. Conclusions: The unknown duration stage should be dropped. Surveillance of latent syphilis would be more consistent if cases were reported as having high or low titers on nontreponemal test. Alternative approaches are solicited from readers.

Clinical situations for which penicillin is indicated as the sole effective treatment are not infrequent, in these circumstances penicillin allergy complicates their medical management. No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, or syphilis in pregnant women, it is not possible choosing an alternative non betalactam antibiotic. The management of the patient who has a history of penicillin allergy include skin testing to determine if penicillin-specific IgE antibodies exist, and desensitization if penicillin is the choice treatment. We report a case of successful desensitization to penicillin in a 30 year-old pregnant woman with latent syphilis and penicillin allergy, where the first penicillin study was not positive, but the repetition of diagnosis test (reassessment) with the same betalactam reagents than in the first study two weeks later the initial evaluation was positive, detecting allergic sensitization not detected at the previous examination.

Background India is a large country with marked heterogeneity in prevalence of sexually transmitted infections (STIs) which has implications for STI control strategies. The study objective was to measure the prevalence and incidence of common bacterial STIs in a cohort of female sex workers (FSWs) in known high STI prevalence cities in response to a package of standardised interventions under Avahan, the India AIDS Initiative of the Bill & Melinda Gates Foundation. Methods FSWs attending clinics were followed up periodically over 6–9 months. At every visit, vaginal swabs were tested for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) by Gen-Probe APTIMA Combo II. During the baseline and final visits, vaginal swabs were tested for Trichomonas vaginalis (TV) by PCR and blood was tested for syphilis using Rapid Plasma Reagin (RPR) with confirmatory Treponema pallidum Haemagglutination Assay (TPHA). All participants received presumptive treatment for gonorrhoea and chlamydia at the baseline visit and syndromic STI management at all subsequent visits. Results A total of 417 FSWs were recruited, 360 returned for at least one follow-up visit, and 282 completed the final visit. The total follow-up period was 109.4 person years (median 0.18 years, maximum 1.07 years). Self-reported consistent condom use with commercial and regular partners was 70% and 17%, respectively. A substantial proportion of cervical and trichomonal infections were asymptomatic (see Abstract P5-S6.19 table 1). The incidence of GC/CT and TV was 1.0 and 2.0 per person year respectively. Three new cases of latent syphilis were detected at the final visit. Conclusions The incidence of GC, CT and TV and the considerable burden of asymptomatic infections indicate the need for periodic presumptive treatment at high STI prevalence sites in India. The current regime of bi-annual syphilis screening is justified. Consistent condom use and partner treatment, particularly for regular partners, need to be re-emphasised.

A retrospective study of 767 HIV positive patients from a large urban public hospital, 238 of whom were co-infected with syphilis, was performed to determine the prevalence of neurosyphilis. A prevalence of 3% of neurosyphilis in the co-infected cohort was demonstrated. The 7 cases of neurosyphilis ascertained were of the early stage variety, with cranial nerve involvement the predominant focal deficit. Of the 5 cases presenting after initial diagnosis and treatment of syphilis, 4 were felt to be inadequately treated. An overall prevalence of 1% (7/767) was determined for the entire HIV(+) cohort. The majority of the cases of syphilis (90%) were characterized as latent syphilis. Based on these findings, the authors recommend routine CSF examination in all patients who are HIV positive and who present with latent syphilis. Treatment regimens should be maximized in an effort to reduce the prevalence of neurosyphilis in such a co-infected cohort.

Objectives To evaluate the usefulness of routine lumbar puncture in non-HIV patients with untreated latent syphilis. Methods We conducted a prospective study in Seoul National University Bundang Hospital from May 2003 to December 2005. Participants in routine health check-ups of the healthcare system were screened for serological evidence of syphilis by the Treponema pallidum particle agglutination (TPPA) test. Lumbar puncture was performed, with consent, on untreated latent syphilitic patients. Neurosyphilis was defined as positivity for cerebrospinal fluid Venereal Disease Research Laboratory (CSF VDRL) or pleocytosis with positivity for CSF TPPA or elevation of CSF protein with IgG index exceeding 0.85. Results Of 21 507 participants, 282 (1.4%) had serological evidence of syphilis. 117 (41%) of these had a history of syphilis treatment and 2 were seropositive for HIV. Among the 163 non-HIV patients with untreated latent syphilis, 70 (43%) underwent lumbar puncture. All the patients had VDRL titres less than 1:16. Abnormal neurological signs or symptoms were present in eight (11%) patients. CSF abnormalities were seen in 57 (81%), but no patient (0%, 95% CI 0 to 6.2) was diagnosed with neurosyphilis. Conclusions The estimated prevalence of neurosyphilis among non-HIV patients with untreated latent syphilis and serum VDRL