Syphilis and HIV co-infection

Sexual Abuse as a Cause of Sexually Transmitted Infections (STI) and Human Immunodeficiency Virus (HIV) in a Bisexual Adolescent Indonesian: A Case Report

Sexual abuse is any non-consensual sexual act or behavior using force, with significant concern in "men who have sex with men" (MSM), and younger individuals. The incidence of sexually transmitted infections (STI) is also prevalent in the cases of sexual abuse in this population, showing the need for comprehensive medical and psychological intervention. This study presents a case of a 15-year-old Indonesian MSM adolescent who experienced three forced sexual intercourse with a mid-thirties male friend 6 months before the consultation. Psychological evaluation showed signs of moderate depression, then the patient reported erythematous macules and collarettes on the palms and soles. These symptoms appeared 1 month before consultation, without associated pain or pruritus. Additionally, moist, skin-colored verrucous papules and plaques were observed in the perianal area, along with a history of unintentional weight loss. The Kinsey score was calculated as three, showing bisexuality. Testing confirmed positive results for both HIV and syphilis, leading to the secondary diagnosis. The patient tested negative for additional STI and was treated with benzathine benzylpenicillin G 2.4 million international unit (IU) and antiretroviral therapy. After one month, the skin lesions improved and the patient was referred to the psychiatric department for psychological treatment. Syphilis and HIV are the predominant infections, showing the critical necessity of administering appropriate medical treatment, such as antiretroviral therapy and comprehensive STI management, with psychological assessment and management to enhance the psychological well-being of sexually abused individuals.

The Effects of Syphilis Infection on Total Knee Arthroplasty Outcomes: A Retrospective Cohort Study

Objective: This study investigated the impact of recent syphilis infection on postoperative outcomes following total knee arthroplasty (TKA). We hypothesized that patients with a documented history of syphilis infection would experience a higher rate of postoperative complications compared to those without such a history. Methods: We conducted a retrospective cohort analysis using a national insurance claims database. Our study population included 237,360 patients who underwent primary TKA between 2005 and 2024. Patients were classified into two groups based on the presence (+Syph) or absence (-Syph) of a syphilis diagnosis within one year prior to the TKA. We evaluated the rates of several postoperative complications at 30 days postsurgery, including infection, hematologic issues, and cardiac events. Statistical analyses between groups was performed using chi-squared tests and Fisher's exact tests. Routine demographic data such as age, sex, race, and comorbidities were also analyzed. Results: Among the 237,360 TKA patients, we identified 71 with a history of syphilis within one year of their surgery. The +Syph group exhibited significantly higher rates of periprosthetic infection (4.23% vs. 0.81%, p = 0.001), need for manipulation under anesthesia (MUA) at four months (7.04% vs. 2.82%, p = 0.032), deep venous thrombosis (4.23% vs. 1.27%, p = 0.026), periprosthetic fracture (2.82% vs. 0.23%, p < 0.001), and pneumonia (2.82% vs. 0.62%, p = 0.019) within 30 days postTKA. No significant differences were observed in 30-day mortality, deep or superficial surgical site infections, wound dehiscence, blood loss anemia, or transfusion requirements. Additionally, rates of acute renal failure, pulmonary embolism, and cardiac events did not differ significantly between groups. Demographically, patients in the syphilis cohort had a higher prevalence of smoking and diabetes preoperatively within one year of their surgical date. Conclusions: A documented syphilis diagnosis within one year of TKA significantly affects postoperative outcomes, increasing the rates of prosthetic joint infection, MUA, deep venous thrombosis, periprosthetic fracture, and pneumonia. These findings underscore the need for heightened vigilance in the pre- and postoperative management of patients with a history of syphilis infection undergoing TKA. Further research is warranted to explore the relationship between prior syphilis infection and TKA outcomes, as well as to develop strategies to mitigate this increased risk.

Urgent focus on enhanced recovery after surgery of AIDS patients with limb fractures

Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.

Methods

A total of 120 PLWH with limb fractures, between January 2015 and December 2023, were included in this study. We established a multidisciplinary team to design and implement a standardized ERAS protocol. The demographic, surgical, clinical, and follow-up information of the patients were collected and analyzed retrospectively.

Results

Compared with the control group, the ERAS group had a shorter operating time, hospital stay, preoperative waiting time, postoperative discharge time, less intraoperative blood loss, and higher albumin and haemoglobin on the first postoperative day. The time to removal of the urinary catheter/drainage tube was shortened, and the drainage volume was also significantly reduced in the ERAS group. There was no significant difference in the visual analogue scale (VAS) scores on postoperative return to the ward, but the ERAS group had lower scores on the first, second, and third postoperative days. There were no significant differences in the incidence of complications, other than 10% more nausea and vomiting in the control group. The limb function scores at one-year follow-up were similar between the two groups, but time to radiological fracture union and time to return to physical work and sports were significantly reduced in the ERAS group.

Conclusion

The implementation of a series of perioperative nursing measures based on the concept of ERAS in PLWH with limb fracture can significantly reduce the operating time and intraoperative blood loss, reduce the occurrence of postoperative pain and complications, and accelerate the improvement of the functional status of the affected limb in the early stage, which is worthy of applying in more medical institutions.

Increasing incidence of syphilis: A case report of non-resolving papulosquamous rash and role of a biopsy in the prevention of delayed diagnosis

Syphilis is a sexually transmitted infection that is undergoing a resurgence in Canada and around the world. If not diagnosed correctly, syphilis can progress to its secondary and tertiary stages, affecting numerous organ systems. We present a case of a 41-year-old female who developed a papulosquamous rash, initially diagnosed as varicella with progression to a widespread and painful rash over 3 months. Based on clinical, histological, and serological findings, she was later diagnosed with secondary syphilis and successfully treated with intramuscular penicillin. This case underscores the importance of accurate diagnosis and treatment of syphilis to prevent systemic complications. We advocate for increased awareness among frontline providers with a proactive approach to diagnosis and management, including thorough history and physical examination, low threshold for performing serological testing, biopsy for lesions that do not resolve as expected with management, and multidisciplinary involvement for complex presentations of syphilis.

Multimodal Imaging Features of the Posterior Segment in Ocular Syphilis and HIV Co-Infection: A Single Center Case Series

OBJECTIVE

To analyze the frequent multimodal imaging features in posterior syphilitic uveitis.

PURPOSE

Syphilis infection has re-emerged as a global health problem. Multimodal imaging approach has been proposed for diagnosis and follow-up; there are not previous reports dedicated to the anatomic and visual outcomes in patients diagnosed with ocular syphilis and concomitant HIV infection.

METHODS

All demographic information was recovered; a complete ophthalmological examination and multimodal imaging evaluation (retinal fluorescein angiography (FA), autofluorescence (AF), optical coherence tomography (OCT)) were performed on initial visit and 1 month after antibiotic therapy.

RESULTS

   18 eyes of 9 patients were included. The most frequent features observed were: Hyperfluorescence on optic disk on FA, Hyperautofluorescence punctate pattern on AF, Vitritis on SD-OCT. After treatment, there was a functional and anatomical improvement.

CONCLUSION

Ocular syphilis represents a diagnostic challenge. Multimodal imaging approach allows identification of structural changes, follow-up and early detection of complications.

Prevalence and Treatment Outcomes of Syphilis among People with Human Immunodeficiency Virus (HIV) Engaging in High-Risk Sexual Behavior: Real World Data from Northern Greece, 2019-2022

In this study, we aimed to assess the prevalence of syphilis among people with human immunodeficiency virus (HIV; PWH) engaging in high-risk sexual behavior, determine the stage of syphilis, and evaluate treatment efficacy. A retrospective single-center cohort study was conducted at the AHEPA University General Hospital of Thessaloniki, focusing on PWH at high risk for sexually transmitted infections (STIs) attending outpatient care from January 2019 to December 2022. Sociodemographic and clinical data were collected, incident syphilis rates were identified, associations with HIV-related characteristics were explored, and the treatment response was assessed. Among 991 participants, 94 PWH were diagnosed with syphilis, representing 9.4% of the cohort. Incident syphilis cases experienced a decrease in the early COVID-19 era compared to 2019, followed by a gradual increase leading up to 2022. The majority of syphilis cases were asymptomatic latent syphilis (71.1%). Men who have sex with men (MSM) and younger individuals exhibited higher rates of co-infection during the study period. No significant association was found between incident syphilis and HIV-related factors. Most syphilis cases (86%) were treated with benzathine penicillin G (BPG). Treatment with BPG and doxycycline showed an increased success rate (96.7% vs. 92.9%), with no statistically significant difference observed between them (p = 0.438). This study highlights the alarming incidence of syphilis among PWH engaging in high-risk sexual behavior, particularly among younger MSM. BPG remains effective, and alternative regimens like doxycycline show promise, especially in settings with penicillin shortages or patient allergies.

Generalized Asymptomatic Nodulo-Ulcerative Lesions Without Systemic Symptoms in a Secondary Syphilis Patient Co-Infected with HIV

Syphilis is a sexually-transmitted disease with various clinical stages. Secondary syphilis manifestations may mimic other skin lesions. Patient co-infected with Human Immunodeficiency Virus (HIV), with CD4 cell counts of 200-499 cells/mm3, often manifests an atypical cutaneous lesion, which may also occur as nodular or ulcerative lesions. Generalized nodulo-ulcerative lesions without systemic symptoms in secondary syphilis patients with HIV co-infection are rarely reported. A 22-year-old man presented with generalized asymptomatic multiple erythematous papules and plaques with scales, as well as nodular and nodulo-ulcerative lesions on the trunk, both arms, and both legs. His lesions spread progressively without the presence of any prodromal symptoms or adenopathy. He was previously diagnosed with HIV and is currently on antiretroviral medications, with a CD4 cell count of 388 cells/μL. His venereal disease research laboratories (VDRL) result was reactive (titer of 1:256). His Treponema pallidum hemagglutination assay (TPHA) result was also reactive (titer of 1:10,240). A skin biopsy was performed from the nodulo-ulcerative lesion on his back. Hematoxylin-eosin staining revealed a hyperplastic epidermis, a massive influx of plasma cells, and lymphocyte infiltration into the deep dermis, especially in the peri-adnexal, peri-vascular, and peri-muscular regions. The patient was diagnosed with secondary syphilis with HIV co-infection. He had no previous history of drug allergy. A single dose of 2.4 million units of benzathine penicillin G was administered. Almost all the lesions became hyperpigmented macules after two weeks and resolved completely after one month. His VDRL titer declined to 1:32 after three months. The various atypical lesions of secondary syphilis may lead to misdiagnosis and delayed treatment. The presence of multiple asymptomatic nodulo-ulcerative lesion without prodromal symptoms may indicate the presence of secondary syphilis, notably in patients co-infected with HIV. Therefore, knowledge of atypical cutaneous manifestations of secondary syphilis is warranted in order to treat patients accordingly.

Neurological manifestations of syphilis-HIV coinfection in South Africa

OBJECTIVE

Syphilis and HIV coinfection is highly prevalent in South Africa, and both can cause neurological complications. We describe the clinical presentation and outcome of neurosyphilis in patients with and without HIV coinfection diagnosed at a tertiary facility, Groote Schuur Hospital (GSH), in South Africa.

METHODS

We retrospectively analyzed folders of adults with positive cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption test in 2018 and 2019, with follow-up data collected until 2022.

RESULTS

HIV-coinfection was identified in 35% of the 69 included patients. Patients with HIV-coinfection were more likely to be female (58% vs 25% female, p < 0.01), and present earlier (median age = 31 years vs. 40 years, p < 0.001). Neuropsychiatric manifestations (confusion, dementia, psychosis), and strokes were the commonest clinical presentations in both groups. Those with HIV-coinfection were significantly less likely to be diagnosed with neurosyphilis by the treating clinician (71% vs. 91%, p < 0.05), as were those with a negative CSF Venereal Disease Research Laboratory (74% vs. 94%, p < 0.05). Accurate diagnosis of neurosyphilis was associated with an increased 12-month survival (alive: N = 36 [63%]) relative to those who did not receive an accurate diagnosis (alive: N = 2 [17%], p < 0.05). Those who were optimally treated with antibiotics had significantly higher 12-month survival (alive: N = 33, 63%) compared to those with suboptimal treatment (alive: N = 5, 29%), p < 0.01.

CONCLUSION

Neurosyphilis presented similarly in those with and without HIV-coinfection. Accurate identification and optimal antibiotic treatment of neurosyphilis, particularly in CSF VDRL negative patients and those with HIV-coinfection, is necessary to improve patient survival.

A patient with secondary syphilis following incomplete treatment of primary infection

Syphilis is a bacterial infection caused by Treponema pallidum and is primarily transmitted via skin-to-skin or mucosal contact during sexual encounters, or through vertical transmission during pregnancy. Cases continue to rise globally across various demographic groups despite effective treatment and prevention interventions. We discuss the case of a 28-year-old cisgender man who presented with secondary syphilis 1 month after being inadequately treated for primary syphilis. Individuals can present with symptoms and signs of syphilis to clinicians of various subspecialties due to diverse clinical presentation. All health-care providers should be able to identify the common and less common manifestations of this infection, and adequate treatment and follow-up are crucial to preventing serious sequelae. Novel biomedical prevention interventions, such as doxycycline post-exposure prophylaxis, are on the horizon.

Syphilis and the host: multi-omic analysis of host cellular responses to Treponema pallidum provides novel insight into syphilis pathogenesis

Introduction

Syphilis is a chronic, multi-stage infection caused by the extracellular bacterium Treponema pallidum ssp. pallidum. Treponema pallidum widely disseminates through the vasculature, crosses endothelial, blood-brain and placental barriers, and establishes systemic infection. Although the capacity of T. pallidum to traverse the endothelium is well-described, the response of endothelial cells to T. pallidum exposure, and the contribution of this response to treponemal traversal, is poorly understood.

Methods

To address this knowledge gap, we used quantitative proteomics and cytokine profiling to characterize endothelial responses to T. pallidum.

Results

Proteomic analyses detected altered host pathways controlling extracellular matrix organization, necroptosis and cell death, and innate immune signaling. Cytokine analyses of endothelial cells exposed to T. pallidum revealed increased secretion of interleukin (IL)-6, IL-8, and vascular endothelial growth factor (VEGF), and decreased secretion of monocyte chemoattractant protein-1 (MCP-1).

Discussion

This study provides insight into the molecular basis of syphilis disease symptoms and the enhanced susceptibility of individuals infected with syphilis to HIV co-infection. These investigations also enhance understanding of the host response to T. pallidum exposure and the pathogenic strategies used by T. pallidum to disseminate and persist within the host. Furthermore, our findings highlight the critical need for inclusion of appropriate controls when conducting T. pallidum-host cell interactions using in vitro- and in vivo-grown T. pallidum.

Beaded Pearls Appearance in Syphilitic Chorioretinitis

PURPOSE

To report an atypical case of bilateral syphilitic chorioretinitis.

METHODS

A case report.

RESULTS

A young male presented with bilateral pigmentary retinal changes along with multifocal chorioretinal lesions along the blood vessels giving a "beaded pearl" appearance. He was a hitherto undiagnosed case of human immunodeficiency virus infection and was diagnosed to have syphilis. He had a favourable visual and anatomical outcome following treatment.

CONCLUSION

Multifocal chorioretinal lesions along blood vessels forming a "beaded pearls" appearance can be a rare and unique presentation of syphilis.

An Atypical Presentation of Acute Syphilitic Posterior Placoid Chorioretinitis With Concurrent Psoriasis Vulgaris Flare in an African American Male Infected With HIV

The diagnosis of secondary syphilis can be challenging due to its various clinical and histopathological presentations. A late or incorrect diagnosis can result in disease progression with consequent morbidity or mortality. Due to the importance of a correct diagnosis and specific treatment, it is of the utmost importance for healthcare providers to consider the various manifestations of syphilis. We describe an atypical presentation of secondary syphilis in an African American man infected with HIV and chronic psoriasis, who presented with two months of diffuse maculopapular rash and new visual changes, found to have acute syphilitic placoid chorioretinitis (ASPCC) and a psoriasis vulgaris flare.

A case of syphilis associated with immune reconstitution inflammatory syndrome and review of the literature

BACKGROUND

Immune reconstitution inflammatory syndrome (IRIS) associated with syphilis has rarely been described in HIV-infected patients. Diagnosis can be challenging because it is not always possible to discern it from a recent infection or a worsening of an undiagnosed one.

CASE PRESENTATION

An HIV-positive 42-year-old man with a poor compliance history of antiretroviral therapy presented at our unit and complained of ocular symptoms. Ocular syphilis diagnosis was posed after initial misdiagnosing with cytomegalovirus infection, and antiretroviral therapy compliance improved after switching to a bictegravir-based regimen. Despite intravenous (IV) penicillin, we observed an initial worsening with the appearance of new skin lesions, and IRIS syphilis was suspected. In the literature, 14 cases of IRIS syphilis are described, all regarding male patients. Seven were HIV naïve to therapy, and 7 HIV-experienced with poor therapy compliance. Basal syphilis serology was negative in ten, with subsequent seroconversion after the development of IRIS. IRIS-syphilis development was observed after a median time of 28 days from ART initiation; 10 cases were considered "unmasking-IRIS" and 4 "paradoxical-IRIS". Skin and ocular involvement were the most often reported. In most cases, it was not necessary to use a systemic steroid. A good outcome was reported in 12.

CONCLUSIONS

Syphilis should be considered in differential diagnosis with other diseases associated with IRIS. A negative syphilis serology before beginning antiretroviral therapy could convey the impression that syphilis has been ruled out. Whereas a high index of suspicion should be maintained when symptoms suggestive of syphilis, such as ocular and skin manifestations, are noticed after therapy has begun.

High Prevalence of Syphilis and Syphilis/HIV Coinfection among Men Who Have Sex with Men Who Attend Meeting Places in Mexico

Men who have sex with men (MSM) are disproportionately affected by syphilis, HIV, and syphilis/HIV coinfection. Antiretroviral therapy (ART) prevents HIV transmission but does not impede the spread or acquisition of syphilis. Information about syphilis/HIV coinfection among MSM is scarce. We aimed to determine the prevalence of syphilis/HIV coinfection in a national sample of MSM who attend meeting places (such as movies, clubs, gay bars, saunas, shopping malls, and others referred to by the same MSM participants of the study) in Mexico to evaluate factors associated with syphilis, and to compare the prevalence rates of syphilis between the current survey and DGE data. We performed a laboratory diagnosis to determine the rates of syphilis and HIV among the included MSM. The national and regional prevalence of syphilis was calculated. HIV and coinfection prevalence were determined only for the survey. All prevalence rates included 95%CIs. Descriptive, bivariate, and multivariate analyses were performed. The national prevalence rates of syphilis, HIV, and coinfection were 15.2%, 10.2%, and 5.7%, respectively. The region with the highest prevalence rate was Mexico City (39.4%). The center region, minimal “goods” (i.e., a minimal number of material possessions such as a car or dryer, etc., which served as a proxy for low economic income level), use of “inhalant drugs”, “HIV infection”, “sexual intercourse” only with men, “rewarded sex”, and “youngest age at first sexual encounter or debut” were risk factors for syphilis. In general, regional prevalence of syphilis was higher in the survey (2013) and DGE data from 2019 than in the DGE data from 2013. Similar to other countries, Mexico needs to assess elements around not only syphilis and HIV infections but also syphilis/HIV coinfection, and preventive measures focusing on MSM are needed.

Efficacy and Safety of Treatments for Different Stages of Syphilis: a Systematic Review and Network Meta-Analysis of Randomized Controlled Trials and Observational Studies

Parenteral penicillin is the first-line regimen for treating syphilis. However, allergic reactions and poor drug tolerance still present challenging problems with respect to use of this antibiotic. This study aimed to evaluate the efficacy and safety of ceftriaxone, erythromycin, minocycline, tetracycline, and doxycycline for syphilis treatment, compared with penicillin, to determine which antibiotic could be a better substitute for penicillin. This study included 17 articles, comprising 3 randomized controlled trials (RCTs) and 14 observational studies and involving 4,485 syphilis patients. Estimated risk ratios (RRs) and 95% confidence interval (CIs) were used to compare the serological response rates. At the 6- and 12-month follow-ups, the serological response rates were compared by direct meta-analysis and network meta-analysis (NMA). Based on direct meta-analysis, the serological response rates at the 3- and 24-month follow-ups were compared. Our NMA showed a higher serological response rate for ceftriaxone than for penicillin at the 6-month follow-up (RR of 1.12, 95% CI of 1.02 to 1.23). Ceftriaxone was equally effective as penicillin for syphilis in terms of serological response rates, and it was a better substitute for penicillin than ceftriaxone, erythromycin, minocycline, tetracycline, or doxycycline. However, more large-scale, high-quality, double-blind trials are still needed to determine whether ceftriaxone can safely replace penicillin for the treatment of syphilis when necessary. IMPORTANCE Parenteral penicillin is the first-line regimen for syphilis treatment. However, allergic reactions and poor drug tolerance still present emerging threatening problems with respect to use of this antibiotic. Our results showed a higher serological response rate for ceftriaxone than for penicillin at the 6-month follow-up. Sufficient data are not available for demonstrating significant differences in the efficacy of the other four antibiotics (erythromycin, minocycline, tetracycline, and doxycycline) for treating syphilis. In the clinical treatment of syphilis in patients who are allergic to penicillin or for whom penicillin is not available, ceftriaxone appears to be a better alternative treatment. This meta-analysis provides a reference for clinical treatment of syphilis. Currently, a lack of sufficient evidence to guide antibiotic treatment of syphilis exists, and a need for more high-quality RCTs is still present. This network meta-analysis can lay a foundation for further research.

Predicting the risk of HIV infection among internal migrant MSM in China: An optimal model based on three variable selection methods

Introduction

Internal migrant Men who have sex with men (IMMSM), which has the dual identity of MSM and floating population, should be more concerned among the vulnerable groups for HIV in society. Establishing appropriate prediction models to assess the risk of HIV infection among IMMSM is of great significance to against HIV infection and transmission.

Methods

HIV and syphilis infection were detected using rapid test kits, and other 30 variables were collected among IMMSM through questionnaire. Taking HIV infection status as the dependent variable, three methods were used to screen predictors and three prediction models were developed respectively. The Hosmer-Lemeshow test was performed to verify the fit of the models, and the net classification improvement and integrated discrimination improvement were used to compare these models to determine the optimal model. Based on the optimal model, a prediction nomogram was developed as an instrument to assess the risk of HIV infection among IMMSM. To quantify the predictive ability of the nomogram, the C-index measurement was performed, and internal validation was performed using bootstrap method. The receiver operating characteristic (ROC) curve, calibration plot and dynamic component analysis (DCA) were respectively performed to assess the efficacy, accuracy and clinical utility of the prediction nomogram.

Results

In this study, 12.52% IMMSMs were tested HIV-positive and 8.0% IMMSMs were tested syphilis-positive. Model A, model B, and model C fitted well, and model B was the optimal model. A nomogram was developed based on the model B. The C-index of the nomogram was 0.757 (95% CI: 0.701-0.812), and the C-index of internal verification was 0.705.

Conclusions

The model established by stepwise selection methods incorporating 11 risk factors (age, education, marriage, monthly income, verbal violence, syphilis, score of CUSS, score of RSES, score of ULS, score of ES and score of DS) was the optimal model that achieved the best predictive power. The risk nomogram based on the optimal model had relatively good efficacy, accuracy and clinical utility in identifying internal migrant MSM at high-risk for HIV infection, which is helpful for developing targeted intervention for them.

A peculiar case of syphilis infection: The great imitator is on the rise

The incidence of syphilis is on the rise worldwide and can pose many diagnostic and therapeutic difficulties for doctors. Given the wide variety of presenting symptoms, syphilis is also known as the great imitator, which in turn frequently leads to a pronounced diagnostic- and therapeutic delay for patients. Here we present a case report of syphilitic uveitis and papillitis accompanied by acute vision loss, a rare presentation of a tertiary syphilis infection that clinically mimicked a giant cell arteritis (GCA) or arteritic anterior ischemic optic neuropathy (AAION). The patient was treated with high-dose intravenous benzyl penicillin after which full vision was restored. By presenting this case, we hope to raise awareness for the increasing incidence of syphilis infections and stress the importance of syphilis testing in patients with otherwise unexplained uveitis.

Factors associated with active syphilis among men and women aged 15 years and older in the Zimbabwe Population-based HIV Impact Assessment (2015–2016)

Introduction

Ulcerative STIs, including syphilis, increase the risk for HIV acquisition and transmission due to the presence of ulcers/chancres that serve as a point-of-entry and exit for HIV. In Zimbabwe, diagnosis of syphilis often occurs in pregnant women who seek ANC services where syphilis testing is offered, and among men and women who seek health care for STIs. Zimbabwe’s national syphilis estimates are based on these diagnosed cases, with little information available about the prevalence of untreated syphilis among the general population. This analysis uses data from ZIMPHIA (2015–2016) to describe factors associated with active syphilis among men and women ages 15 years and older.

Methods

ZIMPHIA collected blood specimens for HIV and syphilis testing from 22,501 consenting individuals (ages 15 years and older). Household HIV testing used the national HIV rapid-testing algorithm with HIV-positive results confirmed at satellite laboratories using Geenius HIV-1/2 rapid test (Bio-rad, Hercules, California, USA). Point-of-care non-Treponemal and Treponemal syphilis testing was performed using Chembio’s Dual-Path Platform Syphilis Screen & Confirm Assay. Factors associated with active syphilis were explored using multiple variable, weighted logistic regression and were stratified by gender.

Results

The likelihood of active syphilis in HIV-positive females was 3.7 times greater in HIV-positive females than HIV-negative females (aOR: 3.7, 95% CI 2.3–5.9). Among males odds of having active syphilis was 5 times higher among those that engaged in transactional sex than those who did not have sex or transactional sex (aOR: 5.3, 95% CI 1.9–14.7), and 6 times higher if HIV positive versus negative (aOR: 5.9, 95% CI 3.0–12.0). Urban residence, province, education (highest attended), marital status, number of sex partners, consistency of condom use, pregnancy status (females), and circumcision status (males) were not significant in the adjusted model for either females or males.

Conculsion

HIV status was found to be the only factor associated with active syphilis in both females and males. Given the persistent link between HIV and active syphilis, it is prudent to link individuals’ diagnoses and treatments, as recommended by the WHO. Enhanced integration of STI and HIV services in health delivery points such as ANC, reproductive services, or male circumcision clinics, combined with consistent, targeted outreach to high-risk populations and their partners, may assist the MOHCC to eliminate active syphilis in Zimbabwe.

Resurgence of syphilis, the great imitator

Syphilis, one of the earliest diseases to be discovered in humans, still remains an enigma when it comes to its myriad manifestations and changing epidemiological profiles. There has been a surge in cases in the last few decades due to various factors. The human immunodeficiency virus (HIV) epidemics, global travel, increased incidence of male to male sexually transmitted diseases, online relationships culminating in casual sex are few of the important factors. Increased awareness could also be a factor for increased diagnosis. The multitude of clinical features especially when it comes to secondary syphilis and the rare tertiary manifestations, which can mimic various systemic disorders still pose a diagnostic challenge to the best of venereologists and physicians. This review aims to discuss the causes of resurgence in syphilis and few recent developments in pathogenesis, which could have led to this resurgence.

High Burden of Active Syphilis and Human Immunodeficiency Virus/Syphilis Coinfection Among Men Who Have Sex With Men, Transwomen, and Genderqueer Individuals in Zimbabwe

BACKGROUND

Syphilis increases human immunodeficiency virus (HIV) acquisition risk and impacts the immunologic and virologic response among people living with HIV (PLHIV). We assessed the prevalence of active or current syphilis and HIV/syphilis and their correlates among men who have sex with men (MSM), transwomen, and genderqueer (TGW/GQ) individuals in Zimbabwe.

METHODS

Among a respondent-driven sample of MSM and TGW/GQ who were tested for HIV and syphilis in Harare and Bulawayo, Zimbabwe in 2019 (n = 1511), multiple logistic regression was used to assess correlates of active syphilis. Unadjusted logistic regression was used among PLHIV (n = 340) due to small sample size. All analyses were unweighted as data did not reach convergence for HIV.

RESULTS

Prevalence of active syphilis overall and among PLHIV was 5.5% and 10.1%, respectively, in Harare, and 5.6% and 11.0%, respectively, in Bulawayo. Participants were more likely to have active syphilis if they were PLHIV (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.4-3.6), aged 25-34 years (aOR, 2.2 years; 95% CI, 1.3-3.8 years; reference, 18-24 years), or self-report sexually transmitted infection symptoms (aOR, 1.8; 95% CI, 1.1-3.0). Compared with Bulawayo TGW/GQ, MSM in Harare (aOR, 0.2; 95% CI, 0.1-0.5) and Bulawayo (aOR, 0.2; 95% CI, 0.1-0.4), and TGW/GQ in Harare (aOR, 0.2; 95% CI, 0.1-0.6) were less likely to have active syphilis. Among PLHIV, coinfection was 13.0% among TGW/GQ and 9.7% among MSM. Odds of coinfection were higher for those aged 25 to 34 years (OR, 3.7 years; 95% CI, 1.2-11.1 years) and lower among Harare MSM (OR, 0.2; 95% CI, 0.1-0.7), Bulawayo MSM (OR, 0.1; 95% CI, 0.0-0.4), and Harare TGW/GQ (OR, 0.1; 95% CI, 0.0-0.4) compared with Bulawayo TGW/GQ.

CONCLUSIONS

Findings highlight a high burden of syphilis among MSM and TGW/GQ and underscore the importance of HIV/syphilis detection and improved service delivery for these groups.

The Epidemiological Analysis of HIV/AIDS Patients: Sexually Transmitted Diseases Department VS. Other Departments in A General Hospital of Shanghai, China

BACKGROUND

Hospital is an important place for HIV/AIDS screening, and a general hospital is composed of multiple departments. Different departments have different levels of understanding of HIV/AIDS, especially the sexually transmitted diseases (STD) department is the main place for HIV/AIDS screening.

OBJECTIVE

The study aims to validate the common knowledge that the STD department is an important place for HIV/AIDS screening by comparing the epidemiological characteristics of HIV/AIDS patients in the STD department and other departments in Tongji Hospital, which can provide a theoretical basis for the precise and differentiated control of HIV/AIDS.

METHODS

A total of 283,525 HIV screening cases were analyzed from January 1st 2006 to December 31st 2018 in the STD department and other departments. The epidemiological data of 226 HIV/AIDS cases were retrospectively analyzed.

RESULTS

Firstly, the incidence of HIV/AIDS in the population served by Tongji Hospital was higher than that in Shanghai and China. Secondly, the positive rate of HIV screening test in the STD department was ten times higher than that of other departments. Thirdly, the social-demographic characteristics of HIV/AIDS patients in the STD department were different from those in other departments. Fourthly, there were differences in age, education, marital status and number of sex partners between men who have sex with men (MSM) and men who have sex with women (MSW). Fifthly, there was no difference except age in social-demographic characteristics of MSM between the STD department and other departments. Sixthly, compared with other departments, the majority of HIV/AIDS patients in the STD department were MSM. Seventhly, syphilis and HIV co-infection were not statistically significant in HIV/AIDS patients between the STD department and other departments.

CONCLUSION

Firstly, the significantly higher positive rate of an HIV screening test in the STD department emphasizes its importance as a place for screening HIV/AIDS patients. Secondly, HIV/AIDS patients diagnosed in the general hospital were mainly transmitted by sexual contact, and MSM accounted for the most part of these patients. More attention should be paid to screen outpatients, especially in the STD department and young men.

Syphilis Testing as a Proxy Marker for a Subgroup of Men Who Have Sex With Men With a Central Role in HIV-1 Transmission in Guangzhou, China

Objectives: The objectives of this study were to distinguish the role of men who have sex with men (MSM) with or without syphilis testing in HIV-1 transmission and to provide molecular evidence of syphilis testing as a proxy marker for identifying the subgroup of MSM.

Methods: HIV-1 transmission clusters were constructed by HIV-TRACE and Cluster Picker using HIV-1 pol sequences from 729 newly diagnosed HIV-infected MSM from 2008 to 2012 in Guangzhou, China. The role of MSM in HIV-1 transmission networks was determined by a node influence measurement and centrality analysis. The association between syphilis testing and factors related to HIV-1 transmission and antiretroviral treatment (ART) were analyzed by the Cox regression model.

Results: Among HIV-infected MSM, 56.7% did not test for syphilis at the time of HIV-1 diagnosis. MSM without syphilis testing was a specific subgroup of MSM with a larger closeness centrality and clustering coefficient than the recipients of syphilis testing (P < 0.001), indicating their central position in the HIV-1 transmission networks. The median degree and radiality within HIV-1 transmission networks as well as the median K-shell scores were also greater for MSM without syphilis testing (P < 0.001), suggesting their relatively greater contribution in transmitting HIV-1 than the receipts of syphilis testing. MSM with syphilis testing usually did not disclose their occupation or were more likely to be unemployed or to take non-skilled jobs, to have a history of sexually transmitted infections (STIs), and to be AIDS patients when diagnosed with HIV-1 infection (P < 0.05). Multivariable Cox regression analysis indicated that syphilis testing per se did not promote the engagement of ART (P = 0.233) or affect the speed of CD4⁺ T cell count recovery after treatment (P = 0.256).

Conclusions: Our study identifies syphilis testing as a proxy marker of a specific subgroup of HIV-infected MSM who refuse syphilis testing during HIV-1 diagnosis with an important role in HIV-1 transmission. Specific prevention and intervention targeting MSM without syphilis testing during HIV-1 care are urgently needed.

Long-term study of Borrelia and Babesia prevalence and co-infection in Ixodes ricinus and Dermacentor recticulatus ticks removed from humans in Poland, 2016-2019

Background

Lyme borreliosis (LB) is the most common vector-borne disease in Europe. Monitoring changes in the prevalence of different Borrelia species in ticks may be an important indicator of risk assessment and of differences in pathogenicity in humans. The objective of our study was to assess the prevalence, co-infection and distribution of Borrelia and Babesia species in ticks removed from humans in a large sample collected during a study period of 4 years.

Methods

The ticks were collected throughout Poland from March to November over 4-year period from 2016 to 2019. All ticks (n = 1953) were morphologically identified in terms of species and developmental stage. Molecular screening for Borrelia and Babesia by amplification of the flagellin gene (flaB) or 18S rRNA marker was performed. Pathogen identity was confirmed by Sanger sequencing or PCR–restriction fragment length polymorphism analysis.

Results

The ticks removed from humans in Poland during this study belonged to two species: Ixodes ricinus (97%) and Dermacentor reticulatus (3%). High Borrelia prevalence (25.3%), including B. miyamotoi (8.4%), was confirmed in Ixodes ricinus ticks removed from humans, as was the change in frequency of occurrence of Borrelia species during the 4-year study. Despite Babesia prevalence being relatively low (1.3%), the majority of tested isolates are considered to be pathogenic to humans. Babesia infection was observed more frequently among Borrelia-positive ticks (2.7%) than among ticks uninfected with Borrelia (0.8%). The most frequent dual co-infections were between Borrelia afzelii and Babesia microti. The presence of Borrelia was also confirmed in D. reticulatus (12.7%); however the role of these ticks in spirochete transmission to susceptible hosts is still unclear.

Conclusions

Although the overall risk of developing LB after a tick bite is low in Europe, knowledge of the prevalence and distribution of Borrelia and Babesia species in ticks might be an important indicator of the risk of both these tick-borne diseases.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04849-5.

Unusual clinical manifestation and challenging serological interpretation of syphilis: insights from a case report

Background

The clinical manifestations of recent syphilis can be variable, with typical and atypical patterns. Several conditions may cause atypical clinical aspects, including human immunodeficiency virus (HIV) co-infection. Besides the clinical features, co-infections may completely alter syphilis serological tests, causing interpretative difficulties and diagnostic delays. Aim of the work is to describe the difficulties encountered during the diagnostic evaluation of atypical skin manifestations and of the serology for syphilis of an HIV-infected patient who had contracted it several times.

Case presentation

In 2020, a 52-year old HIV-positive bisexual male patient was admitted to our department with a 4-month history of moderately itchy cutaneous lesions localized at his neck, trunk and arms. In 2013, the patient presented with a classic syphilitic roseola of the trunk and a secondary syphilis was diagnosed, with increased levels of rapid plasma reagin (RPR), Treponema pallidum hemagglutination assay (TPHA), anti-Treponema pallidum IgM and IgG Index. A second episode occurred in 2018, as a primary syphilis with multiple ulcerative lesions of the penis, and increased levels of RPR, IgG and IgM. In 2019, a further episode of secondary syphilis was treated with Doxycycline. In 2020, erythematous and papular lesions with vesicular components and urticarial erythema multiforme (EM)-like lesions were present at the neck, trunk and arms. Serological tests and Nucleic Acid Amplification Test (NAAT) for Treponema Pallidum were performed, as well as a cutaneous biopsy with histological and immunohistochemical evaluation of one lesion. NAAT was negative for T. pallidum. Serological test results were discordant with a new syphilis infection, showing only increased levels of RPR and anti-Treponema IgG. The cutaneous biopsy revealed a non specific histological pattern, while the immunohistochemical evaluation with anti-spirochetal antibodies was mandatory for the diagnosis of recent syphilis, showing clusters of rod-shaped elements, some of which with spiral form, focally present at the epidermis and adnexal structures.

Conclusions

Nowadays, syphilis may present with atypical clinical and serological features. Physicians should be aware of these possible alterations and consider syphilis even in case of uncommon clinical aspect and unclear serological tests. Cutaneous biopsy and immunohistochemical exam may be mandatory for the diagnosis.

Clinical Features of Ocular Pathology in Patients with Acquired Immunodeficiency Syndrome and Syphilis

INTRODUCTION

The present study aimed to analyze the clinical features of ocular pathology in patients with acquired immunodeficiency syndrome (AIDS) combined with syphilis.

METHODS

A total of 129 patients with AIDS and syphilis who first visited the Department of Ophthalmology in Beijing YouAn Hospital between 2012 and 2019 were included in the study. All patients underwent ophthalmologic examinations, such as best-corrected visual acuity (BCVA), slit lamp, intraocular pressure, dilated fundus examination, and color fundus photography as well as systemic examinations related to AIDS and syphilis. The patients were divided into four groups according to fundus disease: a normal fundi group, an HIV-related microvascular retinopathy (MVR) group, a cytomegalovirus retinitis (CMVR) group, and a syphilis-related retinopathy group.

RESULTS

The incidence of fundus disease was 70.7%. There were 36 patients with normal fundi (29.3%), 40 with HIV-related MVR (31.0%), 25 with CMVR (19.4%) (including 11 cases of CMVR with syphilis-related retinopathy), 26 (20.2%) with syphilis-related retinopathy, 1 (0.78%) case with acute retinal necrosis, and 1 (0.78%) case with PORN. The median blood CD4 + T-cell count in the syphilis-associated retinopathy group was 357.5 cells/μl, which was significantly higher than in the other groups; this difference was statistically significant. In the CMVR group, 11 cases with concomitant syphilis-associated retinopathy had lower BCVA and 10 (90.9%) had active inflammatory manifestations in the anterior segment.

CONCLUSION

The incidence of ocular pathology was high in patients co-infected with AIDS and syphilis, which might manifest in a variety of ocular manifestations; some patients may also have multiple ocular changes, which should be given great clinical attention.

Evolution of syphilis incidence in Sibiu county (Romania) over a period of 10 years (2009-2018)

Syphilis is the most common sexually transmitted disease that mainly affects socially active people, with a fluctuating worldwide incidence over the years. A retrospective study was conducted over a period of 10 years (2009-2018) that included 396 patients with syphilis diagnosed and monitored by Sibiu County Emergency Clinical Hospital, Romania. During this period (2009-2018), we observed a decrease in the new cases of syphilis by 35.90%, and the average syphilis incidence was 9.90 new cases per 100,000 inhabitants. Syphilis was diagnosed more frequently in men with an average age of 35.39 years, from urban areas, with and educational level of grades 9-12, unmarried, workers, or without occupation. Out of the 396 patients with syphilis, about 6% were HIV coinfected. Over half of the HIV coinfected cases were declared MSM (men who have sex with men), and 40% of these cases were registered in 2018. The most common clinical stage of syphilis was the latent form (67.93%). Regarding the syphilis treatment regimen, we noted the transition from the classic regimen with benzathine-penicillin G (100% in 2009) to alternative therapies (mainly with cephalosporins) in 2018 (56.86%). Our findings showed that in the last 10 years in our county, the incidence of syphilis had a downward trend, but with an increase in syphilis-HIV co-infection and neurosyphilis cases.

Trends of HIV/Syphilis/HSV-2 seropositive rate and factors associated with HSV-2 infection in men who have sex with men in Shenzhen, China: A retrospective study

Objectives

To analyze the trends of HIV/syphilis/HSV-2 seropositive rate and explore the related factors with HSV-2 infection to provide the basis for adjusting STD intervention strategies and formulating prevention and control measures among MSM in Shenzhen.

Methods

Time-location sampling was conducted among MSM in Shenzhen in 2012, 2014, 2016, and 2018. Data on demographics, sexual behaviors and the laboratory test results of HIV, syphilis, HSV-2 were collected. The χ² trend test was used to analyze the trends of HIV/syphilis/HSV-2 seropositive rate. The binary logistic regression model was used to explore the factors associated with HSV-2 infection.

Results

The seropositive rate of HIV fell significantly from 15.9% in 2012 to 8.7% in 2018 (P_trend = 0.003), syphilis seropositive rate was significantly decreased from 20.4% in 2012 to 14.8% in 2018 (P_trend = 0.025), HSV-2 seropositive rate had no significant change (16.7% in 2012 to 14.0% in 2018; P_trend = 0.617). In principal component logistic regression analysis showed that FAC1_1 (X₁ = Ever had sex with female, X₂ = Gender of first sexual partner, X₃ = Marital status, X₄ = Age group), FAC2_1 (X₅ = Education, X₆ = Monthly income (RMB), X₇ = Frequency of condom use in anal sex with men in the past 6 months), and FAC4_1 (X₉ = History of STDs) were significantly associated with HSV-2 infection.

Conclusions

The seropositive rates of HIV and syphilis have dropped significantly but are still high. HSV-2 seropositive rate had no significant change and maintained a high level. It is necessary to continue strengthening HIV and syphilis interventions among MSM in Shenzhen. HSV-2 detection and intervention are urgently required for MSM, which might be another effective biological strategy further to control the HIV epidemic among MSM in Shenzhen.

Clinical presentation of congenital syphilis in a rotavirus vaccine cohort study in Lusaka: a case series

BACKGROUND

Despite an otherwise robust national antenatal clinic program, maternal and congenital syphilis remains an important public health issue in Zambia. This case series reports the clinical presentation of seven infants diagnosed with congenital syphilis in Lusaka, Zambia.

CASE PRESENTATIONS

The cases in this series were incidental findings from a cohort of infants enrolled in a rotavirus vaccine immunogenicity study recruiting infants at 6 weeks of age. As part of clinical care for enrolled participants, we screened mothers of children who presented with adverse events of (i) repeated upper respiratory tract infections/coryza, (ii) skin lesions, and (iii) poor weight gain, for syphilis using rapid plasma reagin test. From a cohort of 214 mother-infant pairs enrolled between September and December 2018, a total of 115 (44.4%) of the mothers reported to have not been screened during antenatal care. Of these, four (3.5%) reported to have tested positive; and only two received treatment. Seven out of 57 (26.6%) children meeting the screening criteria had a positive rapid plasma reagin test result. The mean age at diagnosis was 4.5 months (1.3 months standard deviation), and the common presenting features included coryza (6/7), skin lesions (4/7), conjunctivitis (3/7), pallor/anemia (5/7), wasting (2/7), and underweight (5/7). Three of the seven infants were exposed to human immunodeficiency virus. Following diagnosis, all seven cases received standard treatment according to national treatment guidelines. That is, 6/7 cases received inpatient care with benzylpenicillin for 10 days, while 1/7 was treated as an outpatient and received daily procaine penicillin for 10 days.

CONCLUSION

These findings suggest that, though screening for syphilis is part of the standard antenatal care in Zambia, it is not offered optimally. There is urgent need to address programmatic shortcomings in syphilis screening and treatment to avoid long-term sequelae. Additionally, clinicians need to raise their index of suspicion and rule out syphilis when confronted with these clinical symptoms, regardless of the mother's human immunodeficiency virus status.

The clinical and demographic profile of women living with HIV admitted to the acute unit at Stikland Psychiatric Hospital

BACKGROUND

There is a paucity of research on the clinical profile of women living with human immunodeficiency virus (HIV) (WLWH) admitted with acute mental health illness. Existing studies are small and did not look at factors that could have an impact on medication adherence. As a first step to inform service delivery for this vulnerable population, a thorough understanding of the composition and needs of these patients should be identified.

OBJECTIVES

To describe the socio-demographic and clinical profile that could have an influence on the antiretroviral therapy (ART) adherence of WLWH at an inpatient psychiatric unit.

METHODS

In this retrospective audit, the medical records of all WLWH (18-59 years of age), discharged from the acute unit at Stikland Psychiatric Hospital, were reviewed over a 12-month period.

RESULTS

Of the 347 female patients discharged, 55 patients were positive for HIV (15.9%). The majority of them were unmarried (78.2%), unemployed (92.7%), had a secondary level of education (Grade 8-10) (58.2%), lived with a family member (83.6%) and had children (61.8%). The most common psychiatric diagnosis on discharge was substance use disorder with 78.2% of patients being categorised as substance users. Interpersonal violence was only reported by 5.5% of patients. Although most patients performed poorly on the Montreal Cognitive Assessment (MoCA) and International HIV Dementia Scale (IHDS), only 12% of patients received a diagnosis of HIV-associated neurocognitive disorder (HAND) upon discharge. Antiretroviral therapy (ART) was initiated in 21.8% of patients. Only eight patients had a viral load of < 200 copies/mL, indicating viral suppression.

CONCLUSION

Our findings may inform service planning and emphasise the need for targeted intervention strategies to improve treatment outcomes in this vulnerable group.

Lost and found: applying network analysis to public health contact tracing for HIV

Infectious disease surveillance is often case-based, focused on people diagnosed and their contacts in a predefined time window, and treated as independent across infections. Network analysis of partners and contacts joining multiple investigations and infections can reveal social or temporal trends, providing opportunities for epidemic control within broader networks. We constructed a sociosexual network of all HIV and early syphilis cases and contacts investigated among residents of 11 contiguous counties in North Carolina over a two-year period (2012-2013). We anchored the analysis on new HIV diagnoses ("indexes"), but also included nodes and edges from syphilis investigations that were within the same network component as any new HIV index. After adding syphilis investigations and deduplicating people included in multiple investigations (entity resolution), the final network comprised 1470 people: 569 HIV indexes, 700 contacts to HIV indexes who were not also new cases themselves, and 201 people who were either indexes or contacts in eligible syphilis investigations. Among HIV indexes, nearly half (48%; n = 273) had no located contacts during single-investigation contact tracing, though 25 (9%) of these were identified by other network members and thus not isolated in the final multiple investigation network. Constructing a sociosexual network from cases and contacts across multiple investigations mitigated some effects of unobserved partnerships underlying the HIV epidemic and demonstrated the HIV and syphilis overlap in these networks.

Infectious disorders of the vulva

The vulva can be affected by a variety of sexually transmitted infections as well as other common infections that are not typically related to sexual transmission. Vulvar infections may adversely affect the quality of life of the patients by causing discomfort and pain. Some of these infections, especially the ulcerative ones, may also increase the risk of transmission of other infectious diseases, including HIV. Due to the recently increasing number of sexually transmitted infections and atypical presentations of these infections in immunocompromised patients, it is important for pathologists to be familiar with histopathologic features of the infectious diseases of the vulva, so that accurate diagnoses can be rendered as promptly as possible. This review discusses the clinicopathologic presentations of the non-HPV related infections of the vulva.

Cutaneous Secondary Syphilis Resembling Non-Melanoma Skin Cancer

The cutaneous manifestations of secondary syphilis can vary significantly between patients, leading to a more difficult or delayed diagnosis. Here we present an instructive case of secondary syphilis in a 45-year-old, HIV-positive male patient. He presented with a solitary, crusted anterior neck nodule without concomitant systemic symptoms. Together, history and physical exam were concerning for non-melanoma skin cancer. Histopathologic evaluation of the lesion revealed an extensive infiltrate of plasma cells at the dermoepidermal junction, and immunohistochemical staining revealed numerous Treponema pallidum microorganisms. Physicians must keep syphilis in the differential diagnosis when evaluating atypical nodular lesions resembling non-melanoma skin cancer for the purpose of initiating appropriate antibiotic treatment and preventing future infectious complications.

The challenging diagnosis of overlapping oral primary/secondary syphilis with nonreactive serology

The prevalence of oral syphilis, known as "the great imitator" because of its diagnostic complexity and varied clinical manifestations, is increasing worldwide, particularly in people living with HIV (PLWH), who could present false-negative serological results. Although some studies have described the variable presentation of oral syphilis in the context of HIV infection, the difficulty in distinguishing between the primary and secondary stages, clinically and histopathologically, underscores the need to describe atypical cases. We report the case of a 28-year-old HIV-positive man presenting with a 3-month history of painless white/red ulcerated lesion on the soft palate. Physical examination revealed an ulcerated lesion with local signs of inflammation. Initial biopsy revealed a nonspecific inflammatory process and immunohistochemistry (IHC) using anti-Treponema pallidum antibodies showed negative results. The results of serological tests for syphilis (Venereal Disease Research Laboratory and fluorescent treponemal antibody-absorption test) were negative on repeated occasions. Nonetheless, polymerase chain reaction (PCR) assay and subsequent IHC for T. pallidum showed positive results, confirming the diagnosis of oral syphilis. This case illustrates that the diagnosis of oral syphilis is challenging in the absence of serological evidence, and specific tests such as PCR and IHC are useful complementary diagnostic tools.

Azithromycin vs penicillin G benzathine for early syphilis: A meta-analysis of randomized controlled trials

Syphilis is a very serious infection that causes acute cutaneous manifestations. Penicillin is the gold standard for treating syphilis. This meta-analysis was conducted based on self-published randomized controlled trials (RCTs) data to compare the efficacy of azithromycin with penicillin for treating syphilis. RCTs on azithromycin vs penicillin for the treatment of syphilis were retrieved from the Cochrane Library, MEDLINE, EBSCO, Embase, Ovid, and other databases, and the estimated risk ratio (RR) and 95% confidence interval (CI) were used to study the following outcome indicators: 3-month response rate, 6-month response rate, 12-month response rate, recurrence rate, serum fixation rate, and failure rate. This meta-analysis included seven RCTs involving 639 subjects (of whom 335 were treated with azithromycin and 304 were treated with penicillin). There was no significant difference in the 3-month response rate (RR = 0.97, 95% CI: 0.79-1.19), 6-month response rate (RR = 1.01, 95% CI: 0.85-1.20), 12-month response rate (RR = 1.02, 95% CI: 0.97-1.09), serum fixation rate (RR = 0.71, 95% CI: 0.24-2.12), and failure rate (RR = 0.62, 95% CI: 0.33-1.16). In summary, there is no evidence in the literature that azithromycin is less effective than penicillin for treating syphilis.

Neurosyphilis in AIDS patient presenting as isolated cranial nerve 6 palsy

Early neurosyphilis can occur in an immunocompromised host. It has a widely varied presentation. Isolated CN6 as presenting symptom has not been described.

Disabling complications of primary syphilis in a 34-year-old woman living with HIV

A 34-year-old woman managed at the department of skin and venereal diseases was diagnosised with primary syphilis (with gangrenisation and phagedenisation of the hard chancre) and HIV co-infection. In the nasolabial triangle area there was a large ulcerated defect of an irregular configuration and with dense crusts of brown-black colour, transiting to the nasal septum. The complete scarring of the chancre was observed on the 17th day. Complications of syphilis can have physical, psychological and social consequences and even lead to disability.

Arthropod Bite-Like Eruption as Rare Presentation of Secondary Syphilis in an HIV-Infected Patient

Secondary syphilis represents a diagnostic challenge due to its varied clinical manifestations. Co-infection with human immunodeficiency virus (HIV) adds to the diversity of the clinical presentation of syphilis. We herein report a case of secondary syphilis as an arthropod bite-like eruption in a previously undiagnosed HIV-coinfected patient. A 24-year-old homosexual male presented with multiple corticosteroid-resistant insect bite-like nodules on his trunk and bilateral arms. Skin biopsy disclosed plasma cell infiltration and positive Treponema pallidum staining. His symptoms got dramatic remission after benzathine penicillin G therapy. The presented case extends the clinical spectrum of secondary syphilis in HIV patient.

Atypical secondary syphilis presentation in a patient with human immunodeficiency virus infection: a case report

Introduction

Untreated syphilis may lead to severe complications. This infection has recently re-emerged in developed countries with a high number of cases coinfected with human immunodeficiency virus. In these patients, the skin lesions of secondary syphilis can be very atypical.

Case presentation

We report the case of a 38-year-old Bulgarian homosexual man who was coinfected with human immunodeficiency virus and syphilis. His skin contained multiple extensive necrotic lesions with abundant purulent secretion that covered his face, lips, scalp, and torso. Initial clinical diagnoses included varicella pustulosa and staphylococcal dermatitis. Human immunodeficiency virus infection in our patient had been established 2 years earlier in prophylactic studies, but had not been treated. Due to lack of penicillin, he was successfully treated with ceftriaxone, and the skin lesions underwent complete reversal. He also began antiretroviral therapy, which resulted in a significant effect on his immune status. Three months after the onset of antiretroviral therapy, he also achieved optimal viral suppression.

Conclusion

This case emphasizes the importance of considering cutaneous secondary syphilis in the differential diagnosis of any inflammatory cutaneous disorder in individuals infected with human immunodeficiency virus.

The epidemiology of syphilis in Ethiopia: a protocol for systematic review and meta-analysis covering the last three decades

BACKGROUND

Several individual epidemiological studies in Ethiopia suggest that syphilis is a public health problem. However, to the best of our knowledge, there is no synthesized and meta-analysis data on the epidemiology of syphilis in Ethiopia. This systematic review and meta-analysis aimed to summarize and synthesize existing data on the prevalence of syphilis in Ethiopia.

METHOD

Studies reporting the prevalence of syphilis will be identified from major databases and gray literature. The major databases (MEDLINE/PubMed, EMBASE, Web of Science, CINAHL, The Cochrane Library, Lilacs, and African journal online) and gray literature (Google Scholar search engine, official WHO and CDC websites, the online library of academic and governmental institutions in Ethiopia) will be searched. Studies published/reported from 1 January 1990 to 1 January 2019 will be included to have a contemporary estimation. A random-effect meta-analysis of prevalence will be used after stabilizing the variance of included studies using a single arc transformation. The quality of the included studies will be assessed using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instruments. Heterogeneity and publication bias will be assessed. If significant heterogeneity is detected, subgroup analysis will be done using study region, study population, diagnostic assay/syphilis screening tool, median sample size, year of data collection, study sites, sampling method, and methodological quality as grouping variables.

DISCUSSION

This systematic review and meta-analysis intend to contribute an improved knowledge on the epidemiology of syphilis in Ethiopia. Knowledge about the epidemiology of syphilis may help policymakers and other stakeholders to allocate resources and target interventions for the prevention and elimination of syphilis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018116231.

The prevalence of syphilis in HIV-seropositive patients: a retrospective study at the regional hospital in Agadir, Morocco

Introduction

HIV and syphilis are major public health problems in Morocco. The region of Souss-Massa, south-west of the country, hold more than 24% of HIV seropositive cases registered in Morocco during 2009. The aim of this study is to evaluate the seroprevalence of syphilis among HIV seropositive patients in the region of Souss-Massa, south-west of Morocco.

Methods

To evaluate the seroprevalence of syphilis and neurosyphilis among HIV seropositive patients, we retrospectively investigated the medical records of HIV-infected patients attending the regional hospital located in the city of Agadir, during the period comprised between 2011 and 2016.

Results

The population studied involved 1381 males (49.18%) and 1427 females (50.82%) HIV seropositive patients. Among them, 481 patients were seropositive for syphilis and three cases were diagnosed with neurosyphilis. The sex ratio distribution was 243 male (52.71%) and 218 female (47.29%). The prevalence of syphilis among the studied population was estimated to 16.42% with a slight dominance in male (17.63%) compared to female (15.28%). By contrast, neurosyphilis was only detected in male patients, with a prevalence estimated to 0.11%.

Conclusion

Even if the prevalence of HIV and syphilis is stable in the region of Souss-Massa, the prevalence of syphilis among HIV seropositive patients remained high and correlated positively with that of HIV infection. We did not find a significant difference between the genders, in relation to the prevalence of HIV and syphilis. We concluded that it was essential to continue monitoring the population, in order to improve the prevention and the access to the medical care in the south-west of Morocco.

A Nonhuman Primate Model for Rectally Transmitted Syphilis

Among men who have sex with men (MSM), those with a diagnosis of syphilis or other rectal sexually transmitted infections (STIs) are at a higher risk for human immunodeficiency virus acquisition, which is concerning given the large increase in recently reported syphilis cases in the United States. We have developed the first nonhuman primate model for rectally transmitted syphilis by exposing simian/human immunodeficiency virus-infected and naive rhesus macaques to Treponema pallidum in the rectum. All animals showed mucosal lesions, systemic dissemination, and seroconversion (treponemal antibodies). This model would be valuable for studying the manifestations of and interventions for T. pallidum infection, with and without human immunodeficiency virus coinfection.

Neurological disorders in HIV in Africa: a review

BACKGROUND

Neurological disorders in HIV infection are a common cause of morbidity and mortality. The aim of this paper is to provide a narrative overview of up to date information concerning neurological disorders affecting HIV infected persons in Africa.

METHODS

Seminal research concerning neurological disorders among HIV-infected adults in sub-Saharan Africa from prior to 2000 was combined with an in-depth search of PubMed to identify literature published from 2000 to 2017. The following Mesh terms were used. "Nervous System Diseases" "HIV Infections" and "Africa South of the Sahara" and "Seizures" or "Spinal Cord Diseases" or "Peripheral Nervous System Diseases" or "AIDS Dementia Complex" or "Opportunistic Infections" or "Immune Reconstitution Inflammatory Syndrome" or "Stroke". Only those articles written in English were used. A total of 352 articles were identified, selected and reviewed and 180 were included in the study. These included case series, observational studies, interventional studies, guidelines and reviews with metanalyses. The author also included 15 publications on the subject covering the earlier phase of the HIV epidemic in Africa from 1987 to 1999 making a total of 195 references in the study. This was combined with extensive personal experience diagnosing and treating these neurological disorders.

RESULTS

Neurological disorders were common, typically occurring in WHO stages III/IV. These were in three main categories: those arising from opportunistic processes mostly infections, direct HIV infection and autoimmunity. The most common were those arising from direct HIV infection occurring in >50%. These included HIV-associated neurocognitive dysfunction (HAND), neuropathy and myelopathy. Opportunistic infections occurred in >20% and frequently had a 6-9-month mortality rate of 60-70%. The main causes were cryptococcus, tuberculosis, toxoplasmosis and acute bacterial meningitis. Concurrent systemic tuberculosis occurred in almost 50%.

CONCLUSION

Neurological disorders are common in HIV in Africa and the main CNS opportunistic infections result in high mortality rates. Strategies aimed at reducing their high burden, morbidity and mortality include early HIV diagnosis and anti-retroviral therapy (ART), screening and chemoprophylaxis of main opportunistic infections, improved clinical diagnosis and management and programme strengthening.

Descriptive analysis of syphilis cases reported in Mato Grosso do Sul, Brazil identifies failure in treatment

INTRODUCTION

Syphilis infection remains an alarming public health problem worldwide.

METHODS

This study analyzed syphilis cases listed in the Information System on Diseases of Compulsory Declaration (SINAN) of Mato Grosso do Sul state in Brazil between January 2013 and December 2014.

RESULTS

Most of the evaluated syphilis cases would have been preventable through public education, particularly congenital syphilis in children of previously diagnosed mothers and infection by untreated sexual partners.

CONCLUSIONS

The incidence rate of syphilis could be reduced by improving prevention through counselling on the risk of infection, improving access to condoms, and increasing the frequency of diagnostic tests.

Doxycycline in the management of sexually transmitted infections

Doxycycline is a second-generation tetracycline, available worldwide for half a century. It is an inexpensive broad-spectrum antimicrobial agent largely used in the management of several bacterial infections, particularly involving intracellular pathogens, as well as in the treatment of acne or for the prophylaxis of malaria. Physicochemical characteristics of doxycycline (liposolubility) allow a high diffusion in the tissues and organs. It has high bioavailability and a long elimination half-life allowing oral administration of one or two daily doses. Over the last decade, the prevalence of bacterial sexually transmitted infections (STIs) (syphilis, chlamydiosis, gonorrhoea and Mycoplasma genitalium infections) has increased in most countries, mainly in MSM, many of whom are infected with HIV. In light of increasing prevalence of resistance towards first-line regimens of some STI agents and recently updated recommendations for STI management, doxycycline appears to be an attractive option compared with other available antibiotics for the treatment of some STIs due to its efficacy, good tolerability and oral administration. More recently, indications for doxycycline in STI prophylaxis have been evaluated. Considering the renewed interest of doxycycline in STI management, this review aims to update the pharmacology of, efficacy of, safety of and resistance to doxycycline in this context of use.