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Papp JR, Park IU, Fakile Y, Pereira L, Pillay A, Bolan GA. CDC Laboratory Recommendations for Syphilis Testing, United States, 2024. MMWR Recomm Rep 2024; 73:1-32. [PMID: 38319847 PMCID: PMC10849099 DOI: 10.15585/mmwr.rr7301a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Abstract
This report provides new CDC recommendations for tests that can support a diagnosis of syphilis, including serologic testing and methods for the identification of the causative agent Treponema pallidum. These comprehensive recommendations are the first published by CDC on laboratory testing for syphilis, which has traditionally been based on serologic algorithms to detect a humoral immune response to T. pallidum. These tests can be divided into nontreponemal and treponemal tests depending on whether they detect antibodies that are broadly reactive to lipoidal antigens shared by both host and T. pallidum or antibodies specific to T. pallidum, respectively. Both types of tests must be used in conjunction to help distinguish between an untreated infection or a past infection that has been successfully treated. Newer serologic tests allow for laboratory automation but must be used in an algorithm, which also can involve older manual serologic tests. Direct detection of T. pallidum continues to evolve from microscopic examination of material from lesions for visualization of T. pallidum to molecular detection of the organism. Limited point-of-care tests for syphilis are available in the United States; increased availability of point-of-care tests that are sensitive and specific could facilitate expansion of screening programs and reduce the time from test result to treatment. These recommendations are intended for use by clinical laboratory directors, laboratory staff, clinicians, and disease control personnel who must choose among the multiple available testing methods, establish standard operating procedures for collecting and processing specimens, interpret test results for laboratory reporting, and counsel and treat patients. Future revisions to these recommendations will be based on new research or technologic advancements for syphilis clinical laboratory science.
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Ramchandani MS, Cannon CA, Marra CM. Syphilis. Infect Dis Clin North Am 2023; 37:195-222. [PMID: 37005164 DOI: 10.1016/j.idc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Syphilis is an important public health problem in the U.S. and many high-income nations. The rates of syphilis continue to increase and there is an urgent need for medical providers of a variety of backgrounds to recognize this disease. In this review, we cover the key clinical findings of syphilis and provide an overview of the diagnosis and management of this disease in adults.
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Gao ZX, Gou Y, Liu XQ, Peng LW. Advances in laboratory diagnostic methods for cerebrospinal fluid testing for neurosyphilis. Front Public Health 2022; 10:1030480. [PMID: 36452956 PMCID: PMC9703065 DOI: 10.3389/fpubh.2022.1030480] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
Neurosyphilis is a chronic infectious disease caused by the invasion of Treponema pallidum into the central nervous system. In recent years, with the increase in the latent syphilis infection rate, the incidence of neurosyphilis has gradually increased, the typical symptoms of neurosyphilis have decreased, atypical manifestations have increased, and the clinical manifestations have become increasingly diverse. Cerebrospinal fluid testing plays an important role in the diagnosis of neurosyphilis. In recent years, there have been many advances in cerebrospinal fluid testing. This review focuses on the current and potential laboratory indicators of neurosyphilis in cerebrospinal fluid, aiming to provide a reference for clinical application and ideas for future experimental research of neurosyphilis.
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Affiliation(s)
- Zheng-Xiang Gao
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yu Gou
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Xiao-Qin Liu
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Lei-Wen Peng
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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Currens L, Sivakumar S, Jun-O'Connell AH, Ionete C, Ghasemi M. Neurosyphilis presenting with focal middle cerebral artery stenosis and acute ischemic stroke: A case report. Radiol Case Rep 2022; 17:1620-1625. [PMID: 35321268 PMCID: PMC8935340 DOI: 10.1016/j.radcr.2022.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 10/28/2022] Open
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Freitas FLS, Benzaken AS, de Passos MRL, Coelho ICB, Miranda AE. Brazilian Protocol for Sexually Transmitted Infections 2020: acquired syphilis. Rev Soc Bras Med Trop 2021; 54:e2020616. [PMID: 34008726 PMCID: PMC8210480 DOI: 10.1590/0037-8682-616-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 11/22/2022] Open
Abstract
The Clinical Protocol and Therapeutic Guidelines for Comprehensive Care of People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020, includes updates concerning acquired syphilis. The document comprises rapid test use, safety and efficacy of benzathine benzylpenicillin, case follow-up, neurosyphilis clinical and laboratory management, approaching sex partners, assistance and monitoring of diagnosed pregnant women, and syphilis and HIV co-infection specificities, as well as a case notification summary. Health managers and professionals must be continuously trained so as to integrate care and surveillance, to strengthen actions for efficient control of syphilis, to broaden the search for sex partners, and to expand access of most vulnerable populations to health services. Most people with syphilis are asymptomatic; this contributes to the maintenance of the transmission chain. Without adequate treatment of pregnant women with syphilis, severe consequences can occur, such as miscarriage, prematurity, low birth weight, natimortality, and congenital syphilis.
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Affiliation(s)
- Francisca Lidiane Sampaio Freitas
- Ministério da Saúde, Secretaria de Vigilância em Saúde, Brasilia, DF, Brasil
- Universidade de Brasília, Programa de Pós-Graduação em Saúde Coletiva, Brasília, DF, Brasil
| | - Adele Schwartz Benzaken
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, AM, Brasil
- AIDS Healthcare Foundation, Los Angeles, Califórnia, USA
| | | | | | - Angélica Espinosa Miranda
- Ministério da Saúde, Secretaria de Vigilância em Saúde, Brasilia, DF, Brasil
- Universidade Federal do Espírito Santo, Vitória, Brasil
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6
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Gaspar PC, Bigolin Á, Alonso Neto JB, Pereira EDDS, Bazzo ML. Brazilian Protocol for Sexually Transmitted Infections 2020: syphilis diagnostic tests. Rev Soc Bras Med Trop 2021; 54:e2020630. [PMID: 34008728 PMCID: PMC8210484 DOI: 10.1590/0037-8682-630-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 11/22/2022] Open
Abstract
The recommendations for diagnostic tests for investigating syphilis are part of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections and the Technical Manual for Syphilis Diagnosis, published by the Brazilian Ministry of Health. These recommendations were developed based on scientific evidence and discussions with a panel of experts. This article presents direct tests to detect Treponema pallidum in lesions and algorithms that combine treponemal and non-treponemal antibody tests to assist in syphilis diagnosis, with the aim of contributing to the efforts of health service managers and health professionals in qualifying health care. The article also covers the use of non-treponemal tests to investigate neurosyphilis and guidelines for interpreting non-treponemal antibody titers in monitoring the treatment and diagnosis of congenital syphilis, as well as prospects for innovations in diagnosis. The critical role of rapid immunochromatographic treponemal tests for public health and for addressing syphilis is also highlighted. Highlighted excerpt: During the natural evolution of syphilis, activity periods with distinct clinical, immunological, and histopathological characteristics are interspersed with latent periods when there are no signs or symptoms, making access to tests critical for early diagnosis.
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Affiliation(s)
- Pâmela Cristina Gaspar
- Ministério da Saúde do Brasil, Secretaria de Vigilância em Saúde, Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis, Brasília, DF, Brasil.,Universidade de Brasília, Programa de Pós-Graduação em Saúde Coletiva, Brasília, DF, Brasil
| | - Álisson Bigolin
- Ministério da Saúde do Brasil, Secretaria de Vigilância em Saúde, Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis, Brasília, DF, Brasil.,Universidade Federal de Santa Catarina, Laboratório de Biologia Molecular, Microbiologia e Sorologia, Florianópolis, SC, Brasil
| | - José Boullosa Alonso Neto
- Ministério da Saúde do Brasil, Secretaria de Vigilância em Saúde, Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis, Brasília, DF, Brasil
| | - Esdras Daniel Dos Santos Pereira
- Ministério da Saúde do Brasil, Secretaria de Vigilância em Saúde, Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis, Brasília, DF, Brasil
| | - Maria Luiza Bazzo
- Universidade Federal de Santa Catarina, Laboratório de Biologia Molecular, Microbiologia e Sorologia, Florianópolis, SC, Brasil
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Park IU, Tran A, Pereira L, Fakile Y. Sensitivity and Specificity of Treponemal-specific Tests for the Diagnosis of Syphilis. Clin Infect Dis 2021; 71:S13-S20. [PMID: 32578866 PMCID: PMC7312216 DOI: 10.1093/cid/ciaa349] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We conducted a systematic review of relevant syphilis diagnostic literature to address the question, “What is the sensitivity and specificity of the treponemal tests currently approved by the Food and Drug Administration (FDA) for the diagnosis of syphilis (by stage)?” There were 16 treponemal assays evaluated: 13 immunoassays and 3 manual assays (fluorescent treponemal antibody absorbed test [FTA-ABS], microhemagglutination assay for Treponema pallidum antibodies [MHA-TP], Treponema pallidum particle agglutination assay [TP-PA]). MHA-TP and FTA-ABS were less sensitive in primary and secondary syphilis than TP-PA; TP-PA is the most specific manual treponemal assay. There is insufficient evidence to recommend one particular treponemal immunoassay (eg, enzyme immunoassays, chemiluminescence immunoassays, microbead immunoassays) over another based on published performance data. For diagnosis of neurosyphilis, cerebrospinal fluid (CSF) TP-PA has similar performance to CSF FTA-ABS in studies with patients with definitive or presumptive neurosyphilis. However, CSF treponemal testing has limitations in its sensitivity and specificity and should be interpreted within the context of the clinical scenario, additional CSF test results and syphilis prevalence.
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Affiliation(s)
- Ina U Park
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Department of Family and Community Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
- Correspondence: I. U. Park, Department of Family and Community Medicine, University of California San Francisco School of Medicine, Medical Consultant, Division of STD Prevention, Centers for Disease Control and Prevention, STD Control Branch, 850 Marina Bay Parkway, Building P, 2nd Floor, Richmond, CA 94804 ()
| | - Anthony Tran
- Public Health Laboratory, Department of Forensic Sciences, Washington, DC, USA
| | - Lara Pereira
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yetunde Fakile
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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8
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Gaspar PC, Bigolin Á, Alonso Neto JB, Pereira EDDS, Bazzo ML. [Brazilian Protocol for Sexually Transmitted Infections 2020: syphilis diagnostic tests]. ACTA ACUST UNITED AC 2021; 30:e2020630. [PMID: 33729411 DOI: 10.1590/s1679-4974202100006.esp1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/15/2020] [Indexed: 11/22/2022]
Abstract
The recommendations for diagnostic tests for investigating syphilis are part of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections and the Technical Manual for Syphilis Diagnosis, published by the Brazilian Ministry of Health. These recommendations were developed based on scientific evidence and discussions with a panel of experts. Aiming to contribute to the efforts of health service managers and health professionals in qualifying health care, this article presents the use of direct tests to detect Treponema pallidum in lesions, as well as algorithms that combine treponemal and non-treponemal antibody tests to assist in the diagnosis of syphilis. The article also covers use of non-treponemal tests to investigate neurosyphilis and guidelines for interpreting non-treponemal antibody titers in monitoring treatment and diagnosis of congenital syphilis, as well as prospects for innovations in diagnosis. The important role of rapid immunochromatographic treponemal tests for public health and for addressing syphilis is also highlighted.
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Affiliation(s)
| | - Álisson Bigolin
- Ministério da Saúde, Secretaria de Vigilância em Saúde, Brasília, DF, Brasil
| | | | | | - Maria Luiza Bazzo
- Universidade Federal de Santa Catarina, Programa de Pós-Graduação em Farmácia, Florianópolis, SC, Brasil
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Freitas FLS, Benzaken AS, Passos MRLD, Coelho ICB, Miranda AE. [Brazilian Protocol for Sexually Transmitted Infections 2020: acquired syphilis]. ACTA ACUST UNITED AC 2021; 30:e2020616. [PMID: 33729409 DOI: 10.1590/s1679-4974202100004.esp1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/23/2020] [Indexed: 11/22/2022]
Abstract
The Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Ministry of Health of Brazil in 2020, includes the update on acquired syphilis. The document comprises rapid tests use, safety and efficacy of the administration of benzathine benzylpenicillin, follow-up of cases, clinical and laboratory management of neurosyphilis, approach to sexual partnerships, assistance and monitoring of diagnosed pregnant women, and specificities of syphilis and HIV co-infection, as well as a summary of the notification of cases. It is necessary to train health managers and professionals on a continuous basis, with a view to integrating care and surveillance, strengthening effective syphilis control actions, increasing the search for sexual partnerships, and expanding the access of the most vulnerable populations to health services.
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Haynes AM, Giacani L, Mayans MV, Ubals M, Nieto C, Pérez-Mañá C, Quintó L, Romeis E, Mitjà O. Efficacy of linezolid on Treponema pallidum, the syphilis agent: A preclinical study. EBioMedicine 2021; 65:103281. [PMID: 33721817 PMCID: PMC7973135 DOI: 10.1016/j.ebiom.2021.103281] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/10/2021] [Accepted: 02/26/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Penicillin G, the current standard treatment for syphilis, has important drawbacks, but virtually no preclinical or clinical studies have been performed to identify viable alternatives. We tested, both in vitro and in vivo, three marketed antibiotics with adequate pharmacological properties to treat syphilis. METHODS We used an in vitro culturing system of T. pallidum to perform drug susceptibility testing and applied quantitative PCR targeting the tp0574 gene to measure bacterial growth. To confirm in vivo efficacy, fifteen rabbits were infected intradermally with T. pallidum at eight sites each and randomly allocated to an experimental treatment (linezolid, moxifloxacin, clofazimine) or a control arm (benzathine penicillin G [BPG], untreated). The primary outcome was treatment efficacy defined as the time to lesion healing measured from the date of treatment start. Secondary outcomes were absence of treponemes or treponemal mRNA in injection sites, absence of seroconversion, and cerebrospinal fluid (CSF) abnormalities and negative rabbit infectivity tests (RIT). FINDINGS Linezolid showed in vitro bactericidal activity at concentrations of 0.5 µg/mL or higher. When administered orally to experimentally infected rabbits, it induced healing of early lesions at a time similar to BPG (hazard ratio 3.84; 95% CI 2.05-7.17; p < 0.0001 compared to untreated controls). In linezolid-treated animals, dark-field microscopy and qPCR assessment showed no presence of treponemes after day 3 post-treatment start, serologic test did not convert to positive, CSF had no abnormalities, and RIT was negative. Moxifloxacin and clofazimine failed to inhibit bacterial growth in vitro and could not cure the infection in the rabbit model. INTERPRETATION Linezolid, a low-cost oxazolidinone, has in vitro and in vivo activity against T. pallidum, with efficacy similar to BPG in treating treponemal lesions in the animal model. Our findings warrant further research to assess the efficacy of linezolid as an alternative to penicillin G to treat syphilis in human clinical trials. FUNDING European Research Council (ERC) under the European Union's Horizon 2020 research and innovation program (Grant agreement No. 850450).
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Affiliation(s)
- Austin M Haynes
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Lorenzo Giacani
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Marti Vall Mayans
- Fight Aids and Infectious Diseases Foundation, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Maria Ubals
- Fight Aids and Infectious Diseases Foundation, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain; Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | | | - Clara Pérez-Mañá
- Clinical Pharmacology Unit, Hospital, Universitari Germans Trias i Pujol, Institut de Recerca Germans Trias i Pujol (HUGTiP-IGTP), Badalona, Spain; Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Llorenç Quintó
- Barcelona Institute for Global Health, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Manhiça Health Research Institute (CISM), Maputo, Mozambique
| | - Emily Romeis
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Oriol Mitjà
- Fight Aids and Infectious Diseases Foundation, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain; Lihir Medical Centre-International SOS, Lihir Island, Papua New Guinea.
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Chi S, Weintrob A. More than meets the eye: Papilledema from syphilis posing as idiopathic intracranial hypertension. Int J STD AIDS 2020; 31:1117-1119. [PMID: 32753004 DOI: 10.1177/0956462420943017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Idiopathic intracranial hypertension (IIH), or pseudotumor cerebri, is a diagnosis of exclusion. Elevated intracranial pressure (ICP) can result from a variety of inflammatory and structural causes affecting cerebrospinal fluid production and absorption. First described in 1935, syphilis is a well-established cause of elevated ICP, referred to as syphilitic hydrocephalus. We report a case of a 49-year-old man presenting with vision changes and headache who was treated for IIH without resolution of symptoms, and eventually diagnosed with syphilitic hydrocephalus. Syphilis should be considered as a cause of elevated ICP prior to a diagnosis of IIH.
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Affiliation(s)
- Sharon Chi
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Amy Weintrob
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
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Krishnan D, Zaini SSM, Latif KA, Joseph JP. Neurosyphilis presenting as acute ischemic stroke. Clin Med (Lond) 2020; 20:95-97. [DOI: 10.7861/clinmed.2019-0368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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De Simone L, Pellegrini F, Cirone D, Cimino L, Falardeau J. The unfaithful neuritis. Surv Ophthalmol 2018; 63:875-879. [PMID: 29859200 DOI: 10.1016/j.survophthal.2018.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/04/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
A 55-year-old man with a history of mantle cell lymphoma reported acute blurred vision in the right eye. Although initially diagnosed with acute retrobulbar optic neuritis, 3 weeks later retinal infiltrates and vitritis developed, but vitrectomy resulted negative for vitreoretinal lymphoma. Further investigation revealed a serology positive for syphilis. This case highlights the role of the ophthalmologist in the diagnosis of syphilis, which is able to mimick multiple eye disorders, optic neuritis, and vitreoretinal lymphoma among others.
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Affiliation(s)
- Luca De Simone
- Department of Ophthalmology, University Campus Bio-Medico of Rome, Rome, Rome, Italy; Immunology Eye Unit, Azienda USL IRCCS, Reggio Emilia, Reggio Emilia, Italy
| | - Francesco Pellegrini
- Neuro-Ophthalmology Service, Department of Ophthalmology, "De Gironcoli" Hospital, Conegliano, Treviso, Italy
| | - Daniele Cirone
- Uveitis Service, Department of Ophthalmology, Villa Anna Hospital, San Benedetto del Tronto, Ascoli Piceno, Italy
| | - Luca Cimino
- Immunology Eye Unit, Azienda USL IRCCS, Reggio Emilia, Reggio Emilia, Italy.
| | - Julie Falardeau
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA
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Castro R, Águas MJ, Batista T, Araújo C, Mansinho K, Pereira FDLM. Detection of Treponema pallidum Sp. Pallidum DNA in Cerebrospinal Fluid (CSF) by Two PCR Techniques. J Clin Lab Anal 2016; 30:628-32. [PMID: 26892231 DOI: 10.1002/jcla.21913] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 10/15/2015] [Accepted: 11/05/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Laboratory diagnosis of neurosyphilis is complicated especially when it is asymptomatic, no single laboratory test result being appropriate to diagnose central nervous system infectivity caused by Treponema pallidum. Our objective was to evaluate two polymerase chain reaction (PCR) techniques for the detection of T. pallidum DNA in the cerebrospinal fluid (CSF) of patients with syphilis. METHODS One hundred twenty-four CSF samples from patients with reactive blood tests for syphilis were obtained. Two PCR techniques (47-PCR, polA-PCR) were used to detect T. pallidum DNA. The laboratory criteria used for the diagnosis of neurosyphilis to which the PCR techniques were compared were those recommended by the IUSTI: 2008 European guidelines on the management of syphilis. RESULTS Treponema pallidum DNA was detected amplified in 37 of 124 (29.8%) and 30 of 124 (24.2%) samples with the 47-PCR and polA-PCR, respectively. Sensitivities were 75.8% and 69.7% and specificities 86.8% and 92.3%, respectively, for 47-PCR and polA-PCR techniques, respectively. The three CSF samples of patients with primary syphilis did not fulfill the criteria of neurosyphilis and DNA was only detected in one by the 47-PCR. In samples from secondary syphilis and neurosyphilis, three of nine and nine of nine respectively, results were coincident for the two PCR techniques and neurosyphilis criteria. Major discrepancies between the two PCR techniques and neurosyphilis diagnostic criteria were observed in latent syphilis. CONCLUSION Beyond some limitations of the study, which are discussed here, both PCR techniques seem to be useful for the diagnosis of neurosyphilis, although 47-PCR presents a higher sensitivity and polA-PCR a higher specificity.
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Affiliation(s)
- Rita Castro
- Instituto de Higiene e Medicina Tropical, Unidade de Microbiologia Médica, Lisboa, Portugal.
| | - Maria João Águas
- Serviço de Infecciologia, Hospital Garcia de Orta, Lisboa, Portugal
| | - Teresa Batista
- Serviço de Infecciologia e Medicina Tropical, Hospital de Egas Moniz (Centro Hospitalar de Lisboa Ocidental), Lisboa, Portugal
| | - Carlos Araújo
- Serviço de Infecciologia e Medicina Tropical, Hospital de Egas Moniz (Centro Hospitalar de Lisboa Ocidental), Lisboa, Portugal
| | - Kamal Mansinho
- Serviço de Infecciologia e Medicina Tropical, Hospital de Egas Moniz (Centro Hospitalar de Lisboa Ocidental), Lisboa, Portugal
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15
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Merins V, Hahn K. Syphilis and neurosyphilis: HIV-coinfection and value of diagnostic parameters in cerebrospinal fluid. Eur J Med Res 2015; 20:81. [PMID: 26445822 PMCID: PMC4596308 DOI: 10.1186/s40001-015-0175-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/17/2015] [Indexed: 11/20/2022] Open
Abstract
Background Neurosyphilis might be difficult to diagnose particularly in asymptomatic patients and patients with HIV-coinfection. The objective of this study was to evaluate current diagnostic standards for neurosyphilis in HIV-positive and -negative patients. Methods We studied retrospectively patients with an active syphilis infection who had additionally undergone lumbar puncture. Patients where the criteria for the diagnosis of a definite or probable neurosyphilis were applicable were further analyzed for clinical symptoms, CSF, HIV-status as well as Treponema pallidum testing in serum and CSF. Correlation analysis of categorical variables was done by using the Chi-square test or in cases of small sample sizes the exact test of Fisher. p values ≤0.05 were considered significant. Results Eighty-nine patients were diagnosed with syphilis. All necessary criteria for the diagnosis of a neurosyphilis were available in 67 of them including 35 HIV-positive and 32 HIV-negative patients. A definite neurosyphilis could be retrospectively diagnosed in 13 and a probable in another 25 cases. Normal CSF results were more likely in HIV-negatives (p = 0.016). A neurosyphilis was correlated to a CSF pleocytosis > 5 cells/µl and to an albumin quotient >7.8 mg/dl regardless of a parallel HIV infection. HIV-positives had more frequently a CSF-RPR titre >1:4 than HIV-negatives (p = 0.031). However, the RPR test in CSF in definite or probable neurosyphilis had a sensitivity of only 21 %. Discussion Our data show that a pleocytosis and an elevated albumin quotient correlate with neurosyphilis. However, the CSF-RPR test as gold standard in neurosyphilis diagnostics has a very low sensitivity.
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Affiliation(s)
- V Merins
- Group Practice Family Physicians, Alt-Buckow 9-11, 12349, Berlin, Germany.
| | - K Hahn
- Department of Neurology, Universitätsmedizin Charité, Charitéplatz 1, 10117, Berlin, Germany.
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Guarner J, Jost H, Pillay A, Sun Y, Cox D, Notenboom R, Workowski K. Evaluation of treponemal serum tests performed on cerebrospinal fluid for diagnosis of neurosyphilis. Am J Clin Pathol 2015; 143:479-84. [PMID: 25779998 DOI: 10.1309/ajcpwsl3g8rxmcqr] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES We evaluated the use of treponemal serum tests in cerebrospinal fluid (CSF) to diagnose neurosyphilis since CSF-Venereal Disease Research Laboratory (VDRL) is specific but lacks sensitivity. METHODS We tested CSF specimens using the following treponemal serum tests: INNO-LIA, Treponema pallidum particle agglutination (TP-PA), Trep-Sure, and Maxi-Syph. The reference standard to calculate sensitivity and specificity was having two or more reactive/positive tests on CSF. RESULTS The reference standard group included 11 cases that fulfilled the definition of neurosyphilis (reactive CSF-VDRL plus symptoms) and three cases that did not fulfill the definition: two cases had neurologic symptoms but a nonreactive CSF-VDRL, and one had several positive CSF syphilis tests (reactive VDRL and positive treponemal and syphilis polymerase chain reaction) but no history (referred sample). Controls included 18 patients in whom a CSF-VDRL was performed the same week as patients in the reference group. The sensitivity was 85.7% (12/14) for CSF-VDRL, 92.9% (13/14) for Trep-Sure, 100% (10/10) for Maxi-Syph, 92.3% (12/13) for INNO-LIA, and 83.3% (10/12) for TP-PA. Specificity was 100% for all tests. CONCLUSIONS Treponemal serum tests performed on CSF were useful in identifying two patients with nonreactive CSF-VDRL.
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Affiliation(s)
- Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Heather Jost
- Syphilis Laboratory Reference and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Allan Pillay
- Syphilis Laboratory Reference and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - Yongcheng Sun
- Syphilis Laboratory Reference and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | - David Cox
- Syphilis Laboratory Reference and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Kimberly Workowski
- Program Development and Quality Improvement Branch, Centers for Disease Control and Prevention, Atlanta, GA
- Department of Medicine, Emory University, Atlanta, GA
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Canadian Public Health Laboratory Network laboratory guidelines for the diagnosis of neurosyphilis in Canada. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2015; 26 Suppl A:18A-22A. [PMID: 25798161 PMCID: PMC4353983 DOI: 10.1155/2015/167484] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neurosyphilis refers to infection of the central nervous system by Treponema pallidum, which may occur at any stage. Neurosyphilis has been categorized in many ways including early and late, asymptomatic versus symptomatic and infectious versus non-infectious. Late neurosyphilis primarily affects the central nervous system parenchyma, and occurs beyond early latent syphilis, years to decades after the initial infection. Associated clinical syndromes include general paresis, tabes dorsalis, vision loss, hearing loss and psychiatric manifestations. Unique algorithms are recommended for HIV-infected and HIV-uninfected patients, as immunocompromised patients may present with serologic and cerebrospinal fluid findings that are different from immunocompetent hosts. Antibody assays include a VDRL assay and the FTA-Abs, while polymerase chain reaction for T. pallidum can be used as direct detection assays for some specimens. This chapter reviews guidelines for specimen types and sample collection, and identifies two possible algorithms for use with immunocompromised and immunocompetent hosts using currently available tests in Canada, along with a review of treatment response and laboratory testing follow-up.
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Morshed MG, Singh AE. Recent trends in the serologic diagnosis of syphilis. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2015; 22:137-47. [PMID: 25428245 PMCID: PMC4308867 DOI: 10.1128/cvi.00681-14] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complexities in the diagnosis of syphilis continue to challenge clinicians. While direct tests (e.g., microscopy or PCR) are helpful in early syphilis, the mainstay of diagnosis remains serologic tests. The traditional algorithm using a nontreponemal test (NTT) followed by a treponemal test (TT) remains the standard in many parts of the world. More recently, the ability to automate the TT has led to the increasingly widespread use of reverse algorithms using treponemal enzyme immunoassays (EIAs). Rapid, point-of-care TTs are in widespread use in developing countries because of low cost, ease of use, and reasonable performance. However, none of the current diagnostic algorithms are able to distinguish current from previously treated infections. In addition, the reversal of traditional syphilis algorithms has led to uncertainty in the clinical management of patients. The interpretation of syphilis tests is further complicated by the lack of a reliable gold standard for syphilis diagnostics, and the newer tests can result in false-positive reactions similar to those seen with older tests. Little progress has been made in the area of serologic diagnostics for congenital syphilis, which requires assessment of maternal treatment and serologic response as well as clinical and laboratory investigation of the neonate for appropriate management. The diagnosis of neurosyphilis continues to require the collection of cerebrospinal fluid for a combination of NTT and TT, and, while newer treponemal EIAs look promising, more studies are needed to confirm their utility. This article reviews current tests and discusses current controversies in syphilis diagnosis, with a focus on serologic tests.
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Affiliation(s)
- Muhammad G Morshed
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, and BC Public Health Microbiology and Reference Laboratory, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Ameeta E Singh
- Department of Medicine/Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
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Singh AE, Levett PN, Fonseca K, Jayaraman GC, Lee BE. Canadian Public Health Laboratory Network laboratory guidelines for congenital syphilis and syphilis screening in pregnant women in Canada. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2015; 26 Suppl A:23A-8A. [PMID: 25798162 PMCID: PMC4353984 DOI: 10.1155/2015/589085] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Despite universal access to screening for syphilis in all pregnant women in Canada, cases of congenital syphilis have been reported in recent years in areas experiencing a resurgence of infectious syphilis in heterosexual partnerships. Antenatal screening in the first trimester continues to be important and should be repeated at 28 to 32 weeks and again at delivery in women at high risk of acquiring syphilis. The diagnosis of congenital syphilis is complex and is based on a combination of maternal history and clinical and laboratory criteria in both mother and infant. Serologic tests for syphilis remain important in the diagnosis of congenital syphilis and are complicated by the passive transfer of maternal antibodies which can affect the interpretation of reactive serologic tests in the infant. All infants born to mothers with reactive syphilis tests should have nontreponemal tests (NTT) and treponemal tests (TT) performed in parallel with the mother's tests. A fourfold or higher titre in the NTT in the infant at delivery is strongly suggestive of congenital infection but the absence of a fourfold or greater NTT titre does not exclude congenital infection. IgM tests for syphilis are not currently available in Canada and are not recommended due to poor performance. Other evaluation in the newborn infant may include long bone radiographs and cerebrospinal fluid tests but all suspect cases should be managed in conjunction with sexually transmitted infection and/or pediatric experts.
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Affiliation(s)
- Ameeta E Singh
- Division of Infectious Diseases, University of Alberta, Edmonton, Alberta
| | - Paul N Levett
- Saskatchewan Disease Control Laboratory, Regina, Saskatchewan
| | - Kevin Fonseca
- Alberta Provincial Laboratory for Public Health, Calgary, Alberta
| | - Gayatri C Jayaraman
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Ontario
| | - Bonita E Lee
- Division of Pediatric Infectious Diseases, University of Alberta, Edmonton, Alberta
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Cho YW, Kim CR, Han YS, Chung IY, Park JM. Clinical Manifestations of Ocular Syphilis Combined with Neurosyphilis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2014. [DOI: 10.3341/jkos.2014.55.4.602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Yong Wun Cho
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Che Ron Kim
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Yong Seop Han
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - In Young Chung
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - Jong Moon Park
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Science, Gyeongsang National University, Jinju, Korea
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Dumaresq J, Langevin S, Gagnon S, Serhir B, Deligne B, Tremblay C, Tsang RSW, Fortin C, Coutlée F, Roger M. Clinical prediction and diagnosis of neurosyphilis in HIV-infected patients with early Syphilis. J Clin Microbiol 2013; 51:4060-6. [PMID: 24088852 PMCID: PMC3838065 DOI: 10.1128/jcm.01989-13] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 09/24/2013] [Indexed: 11/20/2022] Open
Abstract
The diagnosis of neurosyphilis (NS) is a challenge, especially in HIV-infected patients, and the criteria for deciding when to perform a lumbar puncture (LP) in HIV-infected patients with syphilis are controversial. We retrospectively reviewed demographic, clinical, and laboratory data from 122 cases of HIV-infected patients with documented early syphilis who underwent an LP to rule out NS, and we evaluated 3 laboratory-developed validated real-time PCR assays, the Treponema pallidum particle agglutination (TPPA) assay, the fluorescent treponemal antibody absorption (FTA-ABS) assay, and the line immunoassay INNO-LIA Syphilis, for the diagnosis of NS from cerebrospinal fluid (CSF) samples of these patients. NS was defined by a reactive CSF-VDRL test result and/or a CSF white blood cell (WBC) count of >20 cells/μl. Thirty of the 122 patients (24.6%) had early NS. Headache, visual symptoms, a CD4 cell count of <500 cells/μl, and viremia, as defined by an HIV-1 RNA count of ≥50 copies/ml, were associated with NS in multivariate analysis (P = <0.001 for each factor). Blood serum rapid plasma reagin (RPR) titers were not associated with early NS (P = 0.575). For the diagnosis of NS, the PCR, FTA-ABS, TPPA, and INNO-LIA assays had sensitivities of 58%, 100%, 68%, and 100%, specificities of 67%, 12%, 49%, and 13%, and negative predictive values of 85%, 100%, 84%, and 100%, respectively. Visual disturbances, headache, uncontrolled HIV-1 viremia, and a CD4 cell count of <500 cells/μl were predictors of NS in HIV-infected patients with early syphilis, while blood serum RPR titers were not; therefore, RPR titers should not be used as the sole criterion for deciding whether to perform an LP in early syphilis. When applied to CSF samples, the INNO-LIA Syphilis assay easily helped rule out NS.
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Affiliation(s)
- Jeannot Dumaresq
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier Affilié Universitaire Hôtel-Dieu de Lévis, Lévis, Québec, Canada
| | - Stéphanie Langevin
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Simon Gagnon
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bouchra Serhir
- Laboratoire de Santé Publique du Québec, Sainte-Anne-de-Bellevue, Québec, Canada
| | - Benoît Deligne
- Département de Médecine Interne et Vasculaire, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Cécile Tremblay
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Laboratoire de Santé Publique du Québec, Sainte-Anne-de-Bellevue, Québec, Canada
| | - Raymond S. W. Tsang
- Division of Syphilis Diagnostics and Vaccine Preventable Bacterial Diseases, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Claude Fortin
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Département de Microbiologie et d'Immunologie de l'Université de Montréal, Montréal, Québec, Canada
| | - François Coutlée
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Département de Microbiologie et d'Immunologie de l'Université de Montréal, Montréal, Québec, Canada
| | - Michel Roger
- Département de Microbiologie et d'Infectiologie, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Département de Microbiologie et d'Immunologie de l'Université de Montréal, Montréal, Québec, Canada
- Laboratoire d'Immunogénétique, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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23
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The Performance of Cerebrospinal Fluid Treponemal-Specific Antibody Tests in Neurosyphilis. Sex Transm Dis 2012; 39:291-7. [DOI: 10.1097/olq.0b013e31824c0e62] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shah BB, Lang AE. Acquired neurosyphilis presenting as movement disorders. Mov Disord 2012; 27:690-5. [PMID: 22410849 DOI: 10.1002/mds.24950] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/05/2012] [Accepted: 01/19/2012] [Indexed: 11/10/2022] Open
Abstract
After a significant decline in the second half of the 20th century, rates of infection with syphilis are again on the rise. Long known as the "great mimicker," syphilitic infection can be difficult to recognize clinically and this particularly holds true for neurologic manifestations of the disease. Gait dysfunction and sensory ataxia have been historically well described in neurosyphilis literature; however, other movement disorders have been reported to a lesser extent. Here we review reports of movement disorders in acquired neurosyphilis. Given its increasing incidence, it is important to be cognizant of its diverse presentation and retain a high index of suspicion for syphilis, particularly as it is completely curable in the early stages.
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Affiliation(s)
- Binit B Shah
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada
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25
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Shapshak P, Kangueane P, Fujimura RK, Commins D, Chiappelli F, Singer E, Levine AJ, Minagar A, Novembre FJ, Somboonwit C, Nath A, Sinnott JT. Editorial neuroAIDS review. AIDS 2011; 25:123-41. [PMID: 21076277 PMCID: PMC4464840 DOI: 10.1097/qad.0b013e328340fd42] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Paul Shapshak
- Division of Infectious Disease, Department of Internal Medicine, Tampa General Hospital, Tampa, Florida, USA
- Department of Psychiatry and Behavioral Medicine, University of South Florida, College of Medicine, Tampa, Florida, USA
| | - Pandjassarame Kangueane
- Biomedical Informatics, 17A lrulan Sundai Annex, Pondicherry, India
- AIMST University, Kedha, Malaysia
| | - Robert K. Fujimura
- Geriatric Research Education and Clinical Centers, Veterans Administration, Puget Sound Healthcare System, Seattle, Washington
| | - Deborah Commins
- Department of Pathology, University of Southern California Keck School of Medicine, Los Angeles
| | | | - Elyse Singer
- Department of Neurology and National Neurological AIDS Bank, UCLA School of Medicine, Westwood, California
| | - Andrew J. Levine
- Department of Neurology and National Neurological AIDS Bank, UCLA School of Medicine, Westwood, California
| | - Alireza Minagar
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | | | - Charurut Somboonwit
- Division of Infectious Disease, Department of Internal Medicine, Tampa General Hospital, Tampa, Florida, USA
- Clinical Research Unit, Hillsborough Health Department, Tampa, Florida
| | - Avindra Nath
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - John T. Sinnott
- Division of Infectious Disease, Department of Internal Medicine, Tampa General Hospital, Tampa, Florida, USA
- Clinical Research Unit, Hillsborough Health Department, Tampa, Florida
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Abstract
Neurosyphilis literally means syphilitic infection of the central nervous system, but it is often referred to incorrectly as "tertiary syphilis." Neurosyphilis can occur at any time in the course of syphilis, even in the earliest, primary, stage. Early forms of neurosyphilis primarily affect the meninges, cerebrospinal fluid, and cerebral or spinal cord vasculature. Late forms of neurosyphilis primarily affect the brain and spinal cord parenchyma. Uveitis and hearing loss related to syphilis are most common in early syphilis and may be accompanied by early neurosyphilis. The treatment for syphilis-related eye disease and hearing loss is the same as the treatment for neurosyphilis. Neurosyphilis is more commonly seen in patients infected with HIV, and much of the recent literature pertains to this risk group. This article provides a critical review of recent literature on the diagnosis, clinical findings, risk factors, and management of neurosyphilis.
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Affiliation(s)
- Christina M Marra
- University of Washington School of Medicine, Harborview Medical Center, Box 359775, 325 Ninth Avenue, Seattle, WA 98104, USA.
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29
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Affiliation(s)
- Diego Cadavid
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Charlestown, 02129, USA.
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Lee JP, Koo SH, Jin SY, Kim TH. Experience of meningovascular syphilis in human immunodeficiency virus infected patient. J Korean Neurosurg Soc 2009; 46:413-6. [PMID: 19893736 DOI: 10.3340/jkns.2009.46.4.413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 09/25/2009] [Accepted: 10/04/2009] [Indexed: 11/27/2022] Open
Abstract
Since the start of the antibiotic era, syphilis has become rare. However, in recent times, it has tended to be prevalent concomitantly with human immunodeficiency virus (HIV) infection and coinfection in North America and Europe. Now, such cases are expected to increase in elsewhere including Korea. A 40-year-old male patient visited hospital complaining of a headache for about one month. Brain computed tomography and magnetic resonance imaging, showed leptomeninged enhancing mass with edema an right porisylvian region, which was suspected to be glioma. Patient underwent a blood test and was diagnosed with syphilis and acquired immune deficiency syndrome. Partial cortical and subcortical resection were performed after small craniotomy. The dura was thick, adhered to the brain cortex, and was accompanied by hyperemic change of the cortex. The pathologic diagnosis was meningovascular syphilis (MS) in HIV infection. After the operation, the patient was treated with aqueous penicillin G. Thereafter, he had no neurological deficit except intermittent headache. At first, this case was suspected to be glioma, but it was eventually diagnosed as MS in HIV coinfection. At this point the case was judged to be worth reporting.
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Affiliation(s)
- Jung-Pyo Lee
- Department of Neurosurgery, College of Medicine, Soonchunhyang University, Seoul, Korea
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Castro R, Prieto ES, da Luz Martins Pereira F. Nontreponemal tests in the diagnosis of neurosyphilis: an evaluation of the Venereal Disease Research Laboratory (VDRL) and the Rapid Plasma Reagin (RPR) tests. J Clin Lab Anal 2008; 22:257-61. [PMID: 18623120 DOI: 10.1002/jcla.20254] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The Venereal Disease Research Laboratory (VDRL) test has long been considered the best serological test for the diagnosis of neurosyphilis. The goal of this study was to find out if the Rapid Plasma Reagin (RPR) could be an alternative to the VDRL. Cerebrospinal fluid (CSF) and sera samples from patients in the following stages of syphilis were tested: 8 had symptomatic and 16 asymptomatic neurosyphilis, 4 were in the primary stage, 6 had secondary syphilis, and 92 were in the latent stage. We have also studied 61 samples from individuals with treated syphilis and 126 with other neurological diseases than neurosyphilis. All the CSF samples were studied with both RPR and VDRL tests. RPR and VDRL test results were mostly concordant. The specificity of these tests for current neurosyphilis was 99% for the VDRL and 99.3% for the RPR, whereas the sensitivity was 70.8 and 75%, respectively, for the VDRL and RPR. In view of these results it seems to us that the RPR could be an alternative to the VDRL in the diagnosis of neurosyphilis.
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Affiliation(s)
- Rita Castro
- Instituto de Higiene e Medicina Tropical, Unidade de Doenças Sexualmente Transmitidas, Lisboa, Portugal.
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Manifestations extra-cutanéomuqueuses de la syphilis secondaire. Ann Dermatol Venereol 2008; 135:451-8. [DOI: 10.1016/j.annder.2008.03.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 03/28/2008] [Indexed: 11/22/2022]
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Kent ME, Romanelli F. Reexamining syphilis: an update on epidemiology, clinical manifestations, and management. Ann Pharmacother 2008; 42:226-36. [PMID: 18212261 DOI: 10.1345/aph.1k086] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the epidemiology, clinical features, diagnosis, and treatment of syphilis. DATA SOURCES Studies and reviews were abstracted from MEDLINE (1950-April 2007) using the search term syphilis. All papers were cross-referenced to identify additional studies and reviews for inclusion. STUDY SELECTION AND DATA EXTRACTION Pertinent original research articles, review articles, and book chapters were evaluated. DATA SYNTHESIS Syphilis is a spirochetal disease that has plagued mankind for centuries. Following a low incidence of syphilis in the US for the last 2 decades, rates are now increasing both in the US and other parts of the world. Once acquired, syphilis can pass through 4 distinct stages of disease: primary syphilis, secondary syphilis, latent syphilis, and tertiary syphilis, with each stage being characterized by different symptoms and levels of infectivity. Diagnosis is made primarily by serologic assays with nontreponemal tests such as the Venereal Disease Research Laboratory and the Rapid Plasma Reagin assay used for screening. Treponemal tests including the Treponema pallidum particle agglutination and the fluorescent treponemal antibody absorption test are then used for confirmation. Recommended treatment regimens are based largely on uncontrolled trials and clinical experience. Penicillin is the treatment of choice, with the preparation and treatment duration varying for different stages. Benzathine penicillin is the treatment of choice for all stages of syphilis except neurosyphilis, for which aqueous crystalline penicillin or procaine penicillin is used due to the central nervous system penetration of these formulations. Coinfection with both syphilis and HIV occurs frequently due to common risk factors. These 2 diseases interact with each other, making both diagnosis and treatment more complicated. CONCLUSIONS Clinicians should be aware of the signs and symptoms of syphilis as well as current guidelines for the management and treatment of this disease.
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Affiliation(s)
- Molly E Kent
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
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Castro R, Prieto ES, Aguas MJ, Manata MJ, Botas J, Araújo C, Borges F, Aldir I, Exposto FDL. Evaluation of the Treponema pallidum particle agglutination technique (TP.PA) in the diagnosis of neurosyphilis. J Clin Lab Anal 2007; 20:233-8. [PMID: 17115423 PMCID: PMC6807610 DOI: 10.1002/jcla.20147] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The Treponema pallidum particle agglutination technique (TP.PA) was evaluated, in comparison with the Venereal Disease Research Laboratory (VDRL) test, microhemagglutination assay for Treponema pallidum antibodies (MHA-TP), and fluorescent treponemal antibody-ABS (FTA-Abs) test for the diagnosis of neurosyphilis. We have studied 198 cerebrospinal fluid (CSF) samples from patients with syphilis, including neurosyphilis, treated syphilis, and with other neurological manifestations than neurosyphilis. All tests were nonreactive in these last group of patients. In the neurosyphilis patients, sensitivity of the TP.PA was 100%. The performance of this test in CSF from patients with primary syphilis was as good as that of the other tests. In secondary and latent syphilis, the TP.PA results (27 reactive samples/73) were similar to those of the MHA-TP (25 reactive samples/73). In the individuals treated for syphilis, the TP.PA, FTA-Abs, and MHA-TP tests were found to be reactive in eight, six, and eight samples, respectively. In conclusion, it seems that the TP.PA can be used in CSF to diagnose neurosyphilis, although as for other serological tests, interpretation of results should be done in conjunction with other neurosyphilis parameters.
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Affiliation(s)
- Rita Castro
- Unidade de Doenças Sexualmente Transmitidas/Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal.
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Abstract
Neurosyphilis continues to be a difficult diagnosis for clinicians. The decision to perform a lumbar puncture, interpretation of cerebrospinal fluid findings, clear diagnostic guidelines, establishment of definitive therapy (including alternatives to penicillins), and approach to the follow-up of patients with neurosyphilis are all areas that pose ongoing challenges to clinicians. Coinfection with HIV has also further complicated the already challenging arena of neurosyphilis presentation, diagnosis, and management. Clinicians must recognize the recent changes in the epidemiology of syphilis and know when to initiate appropriate screening. This article highlights the limitations and controversies related to neurosyphilis diagnosis and treatment, and current recommendations on management of patients with neurosyphilis, including those coinfected with HIV.
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Affiliation(s)
- Judith A O'donnell
- Division of Infectious Diseases, Room 6303, NCB Mailstop 461, Hahnemann University Hospital, Broad and Vine Streets, Philadelphia, PA 19102, USA.
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Affiliation(s)
- P Adam
- Laboratory of Reference for CSF and Neuroimmunology, Homolka Hospital Prague, Czech Republic
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Murialdo A, Marchese R, Abbruzzese G, Tabaton M, Michelozzi G, Schiavoni S. Neurosyphilis presenting as progressive supranuclear palsy. Mov Disord 2000; 15:730-1. [PMID: 10928586 DOI: 10.1002/1531-8257(200007)15:4<730::aid-mds1020>3.0.co;2-o] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- A Murialdo
- Department of Neurosciences and Vision, University of Genoa, Italy
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Abstract
The central nervous system (CNS) is susceptible to bacterial, viral, and fungal infections, and prion diseases. Examination of the cerebrospinal fluid (CSF) is crucial in diagnosing these infections. Cerebrospinal tests may directly identify an organism and its nucleic acid and surface constituents by culture, polymerase chain reaction (PCR), or antigen detection. Alternatively, antibody to an organism may be identified in CSF by enzyme-linked immunosorbent assay (ELISA), Western blot, or complement fixation assay. This article discusses how these CSF tests are performed and addresses the sensitivity and specificity of such tests for the diagnosis of selected CNS infections.
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Affiliation(s)
- J R Zunt
- Acting Assistant Professor, Department of Neurology, University of Washington School of Medicine, Seattle, Washington 98104, USA.
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39
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Singh AE, Romanowski B. Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features. Clin Microbiol Rev 1999; 12:187-209. [PMID: 10194456 PMCID: PMC88914 DOI: 10.1128/cmr.12.2.187] [Citation(s) in RCA: 317] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Syphilis is a chronic disease with a waxing and waning course, the manifestations of which have been described for centuries. It occurs worldwide, and the incidence varies significantly with geographic location. Transmission is mainly by sexual contact. The causative organism, Treponema pallidum, was first described in 1905, but because of the inability to culture the organism and the limitations of direct microscopy, serologic testing is the mainstay of laboratory diagnosis. The disease has been arbitrarily divided into several stages. The primary stage is defined by a chancre at the site of inoculation. The secondary stage is characterized by a polymorphic rash, lymphadenopathy, and other systemic manifestations. A variable asymptomatic latent period follows, which for epidemiologic purposes is divided into early (<1 year) and late (>1 year) stages. The early stages (primary, secondary, and early latent) are potentially infectious. The tertiary stage is the most destructive and is marked by cardiovascular and neurologic sequelae and gummatous involvement of any organ system. Congenital infection may result in protean early or late manifestations. Unlike many other bacteria causing infectious diseases, the organism remains sensitive to penicillin, and this remains the mainstay of therapy.
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Affiliation(s)
- A E Singh
- Alberta Health STD Services, University of Alberta, Edmonton, Alberta, Canada
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Abstract
Syphilis poses a serious health problem in many developing countries and in some areas of North America and Europe, especially Eastern Europe. This article initially addresses the state of the art regarding the interaction between syphilis and HIV infection and its consequences for management and treatment. Further attention is given to laboratory diagnosis of syphilis and false-positive and false-negative serologic reactions. The diagnosis and management of neurosyphilis, ocular, cardiovascular, and congenital syphilis are addressed, as well as management of syphilis patients allergic to penicillin and the Jarisch-Herxheimer reaction. Finally, the role of partner(s) and contact tracing is discussed.
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Abstract
BACKGROUND The cerebrospinal fluid (CSF)-Venereal Disease Research Laboratory (VDRL) test is only 27% sensitive for diagnosing neurosyphilis. Discriminant analysis, used on 124 patients, shows that other commonly used laboratory tests can, in combination, identify 87% of patients with neurosyphilis with 94% specificity. STUDY DESIGN The insensitivity of the CSF-VDRL (27% in persons with neurosyphilis) and the foreseen greater need to identify and treat neurosyphilis in the era of human immunodeficiency virus caused us to analyze the serum and cerebrospinal fluid results of 73 patients with syphilis and of 51 patients with clinically diagnosed neurosyphilis. Discriminant analysis was applied to different sets of laboratory tests to find the combination of test results best able to predict retrospectively the clinical diagnosis of syphilis or neurosyphilis, without reference to the CSF-VDRL. RESULTS The predicting function averages 94% specificity and 87% sensitivity. Test result variables considered together are: CSF-FTA-ABS, serum FTA-ABS, CSF-TPHA, serum TPHA, and CSF cells. CONCLUSIONS The authors conclude that clinicians or laboratories can, independently of the CSF-VDRL, compute a score showing whether the results of a set of commonly used tests suggest neurosyphilis in a patient.
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Affiliation(s)
- S MacLean
- Ludwig Boltzmann Institute of Dermato-Venerological Serodiagnosis, Vienna-Lainz Hospital, Austria
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Rodriquez-Baño J, Izquierdo G, Muniain MA. Neurosyphilis in patients with human immunodeficiency virus infection. N Engl J Med 1995; 332:1169; author reply 1170-1. [PMID: 7700294 DOI: 10.1056/nejm199504273321712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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