Misclassification of the stages of syphilis: implications for surveillance

Primary syphilis without chancre – A case report of rare syphilitic balanitis of Follmann

Introduction

Syphilitic balanitis of Follmann (SBF) is a rare condition of primary syphilis which is characterized by any kind of balanitis with or without chancre on the penis combined with the presence of swollen inguinal lymph nodes confirmed by the finding of Treponema pallidum in the lesions or by the positive serological syphilitic testing. Timely identification of the SBF is very important in properly treating the disease stopping the spread of syphilis.

Case presentation

A 42year-old heterosexual male patient came to our clinic and complained of a painless, hard erythema nodule with a whitish scale in his coronal sulcus of the penis for about a week. The dermatologic examination revealed an infiltrative, hard erythematous lesion surrounding the coronal sulcus of the patient’s penis, with mild erosion and a small amount of exudation. There was a whitish pseudomembrane-like covering on the surface of the erythematous lesion in the coronal sulcus, which is mimicked as candidal balanitis. The result of the fungus microscopic examination was negative, while the laboratory findings showed positive results in serologic syphilitic testing. The patient was diagnosed with primary syphilis and intramuscularly treated with a dose of benzylpenicillin of 2.4 million units. The patient’s skin lesions disappeared completely 60 days after penicillin treatment.

Conclusion

To our knowledge, this is the first SBF case reported in China. Syphilitic balanitis of Follmann may have variable clinical appearances. We emphasize that when balanitis with risky sexual activities or with sexually transmitted diseases, the diagnosis of SBF should be kept in mind.

Enhancing the Control of Syphilis Among Men Who Have Sex With Men by Focusing on Acute Infectious Primary Syphilis and Core Transmission Groups

The syphilis epidemic among men who have sex with men (MSM) has been increasing steadily. Many syphilis control programs focus on assuring treatment of all persons diagnosed with early syphilis without prioritizing acute primary syphilis or specific subgroups. Acute primary syphilis is highly infectious and contributes to a high proportion of new cases. Surveillance data show that among MSM with incident syphilis (primary or secondary) only about 35% are identified in the primary stage, indicating that most primary cases are missed and untreated. Patients with primary syphilis and large numbers of sex partners may play a major role in maintaining syphilis transmission. Considering those issues, sexually transmitted disease (STD) programs should consider increasing their focus on primary syphilis by assigning primary cases the highest priority, expanding client and clinician health education, and increasing the detection of primary syphilis through increased serologic screening frequency among high-risk MSM. Furthermore, syphilis control programs should implement steps to identify asymptomatic high-probable occult primary cases based on low titer (≤1:8) and recent seroconversion. Finally, to address core transmission groups, programs should implement periodic risk assessment to identify persons with a high number of sex partners and offer these individuals risk-reduction counseling, case management, and selective syphilis preexposure or postexposure doxycycline chemoprophylaxis. Although reprioritizing prevention efforts might be challenging, the Centers for Disease Control and Prevention, community advocacy groups, university STD research centers, and national STD prevention training centers can assist by providing support for consensus discussions and direction in developing operational guidance, some of which may be best delivered through STD and human immunodeficiency virus program partnerships.

Reported Primary and Secondary Syphilis Cases in the United States: Implications for HIV Infection

BACKGROUND

Recent increases in syphilis among men who have sex with men (MSM) are especially concerning, given the biologic and epidemiologic associations between syphilis and HIV infection. We sought to better describe the current epidemiology of primary and secondary (P&S) syphilis and the prevalence of HIV infection among reported P&S syphilis cases by demographic group, including sex of sex partner, in the United States in 2016.

METHODS

We reviewed national P&S syphilis case report data from 2016, including available risk factor information such as sex of sex partner and HIV status. Data were extracted from the National Electronic Telecommunications System for Surveillance, the system through which Centers for Disease Control and Prevention receives notifiable sexually transmitted disease data from all 50 states and the District of Columbia. The proportion of cases with HIV coinfection was calculated using cases with known HIV status as the denominator.

RESULTS

Of 27,814 P&S syphilis cases reported in 2016, 58.1% were among MSM, 13.9% were among men who have sex with women only, 11.0% were among women, and 16.9% were among men without data on sex of sex partners. Similar patterns were observed across geographic regions, race/ethnicity groups, and most age groups. Overall, 38.5% of reported P&S syphilis cases with known HIV status were coinfected with HIV. The prevalence of HIV coinfection was highest among MSM (47.0%) compared with men who have sex with women only (10.7%) or women (4.1%). Among MSM with P&S syphilis, the prevalence of HIV coinfection was highest among black MSM, ranging from 33.8% among black MSM aged 15 to 19 years to 77.8% among black MSM aged 45 to 49 years.

CONCLUSIONS

These data underscore the epidemiologic linkages between syphilis and HIV, particularly among MSM. Primary and secondary syphilis may represent an opportunity to prevent HIV infection among persons who are HIV negative and identify and link to care persons living with HIV infection but not currently engaged in care.

Sexually transmitted diseases

Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases, remain a growing worldwide problem and public health issue. This article covers the epidemiology of STIs, the history and physical findings, screening guidelines, and the general plan to combat STIs. Prevention is discussed using the latest information from the Centers for Disease Control and Prevention and other references. Infections discussed from the standpoint of cause, epidemiology, risk factors, clinical disease, diagnosis, and treatment include gonorrhea, Chlamydia trachomatis, Trichomonas vaginalis, syphilis, chancroid, Herpes simplex, lymphogranuloma venereum, granuloma inguinale, Herpes papilloma virus, Molluscum contagiosum, and pubic lice.

Estimating the population size of men who have sex with men in the United States to obtain HIV and syphilis rates

BACKGROUND

CDC has not previously calculated disease rates for men who have sex with men (MSM) because there is no single comprehensive source of data on population size. To inform prevention planning, CDC developed a national population size estimate for MSM to calculate disease metrics for HIV and syphilis.

METHODS

We conducted a systematic literature search and identified seven surveys that provided data on same-sex behavior in nationally representative samples. Data were pooled by three recall periods and combined using meta-analytic procedures. We applied the proportion of men reporting same-sex behavior in the past 5 years to U.S. census data to produce a population size estimate. We then calculated three disease metrics using CDC HIV and STD surveillance data and rate ratios comparing MSM to other men and to women.

RESULTS

Estimates of the proportion of men who engaged in same-sex behavior differed by recall period: past year = 2.9% (95%CI, 2.6-3.2); past five years = 3.9% (3.5-4.4); ever = 6.9% (5.1-8.6). Rates on all 3 disease metrics were much higher among MSM than among either other men or women (38 to 109 times as high).

CONCLUSIONS

Estimating the population size for MSM allowed us to calculate rates for disease metrics and to develop rate ratios showing dramatically higher rates among MSM than among other men or women. These data greatly improve our understanding of the disproportionate impact of these diseases among MSM in the U.S. and help with prevention planning.

Comparison of sexual mixing patterns for syphilis in endemic and outbreak settings

BACKGROUND

In a largely rural region of North Carolina during 1998-2002, outbreaks of heterosexually transmitted syphilis occurred, tied to crack cocaine use and exchange of sex for drugs and money. Sexual partnership mixing patterns are an important characteristic of sexual networks that relate to transmission dynamics of sexually transmitted infections (STIs).

METHODS

Using contact tracing data collected by disease intervention specialists, we estimated Newman assortativity coefficients and compared values in counties experiencing syphilis outbreaks to nonoutbreak counties, with respect to race/ethnicity, race/ethnicity and age, and the cases' number of social/sexual contacts, infected contacts, sex partners, and infected sex partners, and syphilis disease stage (primary, secondary, early latent).

RESULTS

Individuals in the outbreak counties had more contacts and mixing by the number of sex partners was disassortative in outbreak counties and assortative nonoutbreak counties. Although mixing by syphilis disease stage was minimally assortative in outbreak counties, it was disassortative in nonoutbreak areas. Partnerships were relatively discordant by age, especially among older white men, who often chose considerably younger female partners.

CONCLUSIONS

Whether assortative mixing exacerbates or attenuates the reach of STIs into different populations depends on the characteristic/attribute and epidemiologic phase. Examination of sexual partnership characteristics and mixing patterns offers insights into the growth of STI outbreaks that complement other research methods.

Repeat syphilis among men who have sex with men in California, 2002-2006: implications for syphilis elimination efforts

OBJECTIVES

We examined rates of and risk factors for repeat syphilis infection among men who have sex with men (MSM) in California.

METHODS

We analyzed 2002 to 2006 California syphilis surveillance system data.

RESULTS

During the study period, a mean of 5.9% (range: 4.9%-7.1% per year) of MSM had a repeat primary or secondary (PS) syphilis infection within 2 years of an initial infection. There was no significant increase in the annual proportion of MSM with a repeat syphilis infection (P = .42). In a multivariable model, factors associated with repeat syphilis infection were HIV infection (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.14, 2.37), Black race (OR = 1.84; 95% CI = 1.12, 3.04), and 10 or more recent sex partners (OR = 1.99; 95% CI = 1.12, 3.50).

CONCLUSIONS

Approximately 6% of MSM in California have a repeat PS syphilis infection within 2 years of an initial infection. HIV infection, Black race, and having multiple sex partners are associated with increased odds of repeat infection. Syphilis elimination efforts should include messages about the risk for repeat infection and the importance of follow-up testing. Public health attention to individuals repeatedly infected with syphilis may help reduce local disease burdens.

Endemic early syphilis among young newly diagnosed HIV-positive men in a southeastern U.S. state

An epidemic of HIV infections among college students who are primarily men who have sex with men (MSM) have been reported from North Carolina, a state with one of the highest syphilis rates in the southeastern United States. We assessed the proportion of early syphilis coinfections among young HIV-infected individuals statewide and associated risk factors. From January 2002 to July 2006, chart abstractions were performed from North Carolina surveillance records for newly diagnosed HIV-positive men 18-30 years of age reported between 2000-2005, and a subset of women in the same age group. Bivariable and multivariable analyses were conducted to assess early syphilis risk factors among HIV-infected persons. During the 6-year period, there were 1460 HIV-positive men aged 18-30 years reported in North Carolina; 90 (6.2%) were coinfected with early syphilis without a significant change over time. Data were available for 551 HIV-positive women diagnosed from 2002-2005; only 6 (1.1%) were coinfected. Fifty-five percent of coinfected men were diagnosed with both infections on the same date of evaluation. Young HIV-infected men who are black (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI], 1.3, 4.1), MSM (aOR 3.8; 95% CI, 1.8, 7.8), or reported sex with both genders (aOR 5.1; 95% CI, 2.2, 11.5), or anonymous sex (aOR 2.1; 95% CI, 1.3, 3.3) were more likely to have early syphilis. Although male coinfections have not increased over time, early syphilis has become endemic among young HIV-positive men statewide, emphasizing the need to provide screening for both infections among high-risk individuals.