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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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Secondary Syphilis with Eosinophilia Complicated by Severe Jarisch-Herxheimer Reaction. Case Rep Infect Dis 2020; 2020:2150314. [PMID: 32518698 PMCID: PMC7201786 DOI: 10.1155/2020/2150314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 11/06/2019] [Accepted: 11/30/2019] [Indexed: 11/18/2022] Open
Abstract
It has long been acknowledged that syphilis is a disease with a diverse range of presentations. We herein describe a case of a young man who presented with fever, rash, and eosinophilia following the commencement of allopurinol, only to be diagnosed with secondary syphilis on histopathology. His treatment was complicated by a severe exacerbation of his cutaneous eruption following the commencement of penicillin, likely secondary to a Jarisch-Herxheimer reaction, an entity often overlooked by clinicians managing syphilis.
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Arando M, Fernandez-Naval C, Mota-Foix M, Alvarez A, Armegol P, Barberá MJ, Esperalba J, Vall-Mayans M. The Jarisch-Herxheimer reaction in syphilis: could molecular typing help to understand it better? J Eur Acad Dermatol Venereol 2018; 32:1791-1795. [PMID: 29775498 DOI: 10.1111/jdv.15078] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/12/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The Jarisch-Herxheimer reaction (JHR) is a febrile inflammatory reaction that may occur in patients after treatment of syphilis. The overall rate is estimated to be 10-25% with broad variations over time. It appears to be related to factors like stage of the disease or reagin titres. In this study, we aimed to describe the incidence of and risk factors including strain typing for JHR among patients with syphilis. METHODS From January through October 2015, 224 consecutive patients (82 of them with HIV) who were diagnosed with early syphilis were enrolled in this prospective observational study in a referral STI clinic in Barcelona. An appointment was offered to them after 10-14 days of treatment to inquire about the reaction with the use of a standardized form. Treponema pallidum molecular typing was made to detect a possible strain related to reaction. RESULTS Overall, 28% of patients developed JHR. This varied from 56% in secondary, 37% in primary to 7% in early latent syphilis. The most frequent types of reaction were fever (57.5%) and worsening of the lesions (31%). The median time to development of JHR was 6 h [IQR 4-10 h] and lasted a median of 9 h [IQR 4-24 h]. The JHR was less probable in early latent compared to primary/secondary syphilis (P = 0.04) and in patients treated with doxycycline compared to those treated with penicillin (P = 0.01). No differences were seen regarding reagin titres or HIV status, and no association with a specific strain was found. CONCLUSIONS In this study, JHR occurred in a similar frequency as in other contemporary studies. Symptomatic syphilis and treatment with penicillin were associated with an increased risk of JHR, whereas the previous episode of syphilis was associated with a low risk of it. We could not find associations with specific strains of T. pallidum.
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Affiliation(s)
- M Arando
- STI Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Hospital Vall d'Hebron, Barcelona, Spain.,Medicine Department, Autonomous University of Barcelona, Barcelona, Spain
| | - C Fernandez-Naval
- Vall d'Hebron Institute of Research, Hospital Vall d'Hebron, Barcelona, Spain.,Genetics and Microbiology Department, Autonomous University of Barcelona, Barcelona, Spain
| | - M Mota-Foix
- Statistics and Bioinformatics Unit, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - A Alvarez
- STI Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - P Armegol
- STI Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - M J Barberá
- STI Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - J Esperalba
- Microbiology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - M Vall-Mayans
- STI Unit Vall d'Hebron-Drassanes, Infectious Diseases Department, Hospital Vall d'Hebron, Barcelona, Spain
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Acute pustular eruption following a Jarisch-Herxheimer reaction in the treatment of syphilis. JAAD Case Rep 2018; 4:259-261. [PMID: 29687066 PMCID: PMC5909471 DOI: 10.1016/j.jdcr.2017.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Wang C, He S, Yang H, Liu Y, Zhao Y, Pang L. Unique manifestations and risk factors of Jarisch-Herxheimer reaction during treatment of child congenital syphilis. Sex Transm Infect 2017; 94:562-564. [PMID: 28942420 DOI: 10.1136/sextrans-2016-053083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 07/23/2017] [Accepted: 08/26/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The objective of this retrospective study was to summarise the clinical manifestations of, and to analyse the incidence and risk factors of, Jarisch-Herxheimer reaction (JHR) during the treatment of children with symptomatic congenital syphilis. METHODS Clinical data of 60 children with clinically and laboratory diagnosed congenital syphilis, hospitalised in Beijing Ditan Hospital between January 2010 and November 2015, were collected and analysed. RESULTS A total of 11 patients with congenital syphilis (11/60, 18.3%) developed JHR. JHR occurred in 1-6 hour after the first dose of penicillin. Common clinical manifestations included fever (11/11, 100%), irritability (11/11, 100%), rapid pulse and breathing (11/11, 100%), exacerbation of existing rash (5/11, 45.6%) and chills (3/11, 27.3%). Of the 11 patients who developed JHR, 9 patients (9/11, 81.8%) had bone syphilis, 10 (10/11, 90.9%) had more than three organs affected by syphilis and 10 (10/11, 90.9%) had a high plasma concentration of rapid plasma reagin (RPR) (≥1:256); these percentages were significantly higher than in patients who had not developed JHR (p<0.05), suggesting that the occurrence of JHR was related to bone syphilis, having more than three organs affected by syphilis and a high plasma concentration of RPR. CONCLUSIONS Clinicians should be familiar with the risk factors for this reaction and its common clinical manifestations.
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Affiliation(s)
- Caiying Wang
- Department of Paediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shuxin He
- Department of Paediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hongling Yang
- Department of Paediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yuhuan Liu
- Department of Paediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yang Zhao
- Department of Paediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Lin Pang
- Department of Paediatrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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Butler T. The Jarisch-Herxheimer Reaction After Antibiotic Treatment of Spirochetal Infections: A Review of Recent Cases and Our Understanding of Pathogenesis. Am J Trop Med Hyg 2016; 96:46-52. [PMID: 28077740 DOI: 10.4269/ajtmh.16-0434] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/20/2016] [Indexed: 02/04/2023] Open
Abstract
Within 24 hours after antibiotic treatment of the spirochetal infections syphilis, Lyme disease, leptospirosis, and relapsing fever (RF), patients experience shaking chills, a rise in temperature, and intensification of skin rashes known as the Jarisch-Herxheimer reaction (JHR) with symptoms resolving a few hours later. Case reports indicate that the JHR can also include uterine contractions in pregnancy, worsening liver and renal function, acute respiratory distress syndrome, myocardial injury, hypotension, meningitis, alterations in consciousness, seizures, and strokes. Experimental evidence indicates it is caused by nonendotoxin pyrogen and spirochetal lipoproteins. Mediation of the JHR in RF by the pro-inflammatory cytokines tumor necrosis factor (TNF), interleukin (IL)-6, and IL-8 has been proposed, consistent with measurements in patients' blood and inhibition by anti-TNF antibodies. Accelerated phagocytosis of spirochetes by polymorphonuclear (PMN) leukocytes before rise in cytokines is responsible for removal of organisms from the blood, suggesting an early inflammatory signal from PMNs. Rarely fatal, except in neonates and in pregnancy for African women whose babies showed high perinatal mortality because of low birth weight, the JHR can be regarded as an adverse effect of antibiotics, necessary for achieving a cure of spirochetal infections.
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Affiliation(s)
- Thomas Butler
- Department of Microbiology and Immunology, Ross University School of Medicine, Portsmouth, Dominica, West Indies.
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Amelot F, Picot E, Meusy A, Rousseau C, Brun M, Guillot B. [Syphilis in Montpellier, France, from 2002 to 2011: Survey in a free hospital screening centre for venereal disease and in the dermatology unit of a regional public hospital]. Ann Dermatol Venereol 2015; 142:742-50. [PMID: 26362133 DOI: 10.1016/j.annder.2015.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 04/15/2015] [Accepted: 07/09/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND In a context of resurgent syphilis in France since 2000, we conducted a retrospective study in two different centres in Montpellier, France: the dermatology department of a public hospital and an anonymous and free centre for provision of information, diagnosis and treatment of venereal diseases (CDAG-CIDDIST). PATIENTS AND METHODS All patients with syphilis seen from January 2002 to December 2011 were included with the collaboration of the National Health Institute (InVS) and the Bacteriology Department of the public hospital. Epidemiology, clinical presentation, serological data, and treatment and monitoring data for up to 2 years were recorded. RESULTS One hundred and seventy-five cases of syphilis were diagnosed: 154 at the CDAG and 21 at the dermatology unit. Ninety-six percent of cases concerned men with a median age of 36 years. Eighty-two percent of these cases involved men having sex with men (MSM). Forty-nine percent of cases were diagnosed in the secondary stage, 22% in the primary stage and 28% in the latent stage. The treatment administered in the majority of cases (73%) was benzathine-penicillin G. The numbers of patients showing incomplete follow-up were equal at both centres, with 31 patients (17.7%) failing to attend the follow-up visit. A decrease of at least 2 dilutions in VDRL score occurred in the year following treatment for 93 of 103 patients (90%). Patients managed at the dermatology department were older than their counterparts managed at the CDAG and exhibited more frequent cutaneous eruptions (58% vs. 3%, P<0.0001) but were less frequently bisexual. However, no significant differences were seen concerning sex and associated infections (hepatitis, gonococcal infection, HPV or herpes). DISCUSSION Syphilis is on the rise, especially in the MSM population. The epidemiological characteristics of our cohort were consistent with those of other Western European countries. Although the reasons for consultation differed between CDAG/CIDDIST and the dermatology department, the two centres are complementary. Benzathine-penicillin G was the most commonly used treatment, in accordance with the recommendations. Measures must be introduced to improve patient monitoring without compromising anonymity.
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Affiliation(s)
- F Amelot
- Département de dermatologie, CHU, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34000 Montpellier, France.
| | - E Picot
- CDAG/CIDDIST de Montpellier, département de dermatologie, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - A Meusy
- Département de l'information médicale, hôpital La-Colombière, 39, avenue Charles-Flahault, 34295 Montpellier cedex 5, France
| | - C Rousseau
- Cellule de l'InVS en région languedoc-roussillon (CIRE), département coordination des alertes et des régions, institut de veille sanitaire, ARS LR - 28 Parc-Club du Millénaire, 1025, rue Henri-Becquerel, CS3000, 34067 Montpellier cedex 2, France
| | - M Brun
- Laboratoire de bactériologie, hôpital Arnaud-de-Villeneuve, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
| | - B Guillot
- Département de dermatologie, CHU, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34000 Montpellier, France
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Jarisch-Herxheimer reaction among HIV-positive patients with early syphilis: azithromycin versus benzathine penicillin G therapy. J Int AIDS Soc 2014; 17:18993. [PMID: 25174641 PMCID: PMC4150017 DOI: 10.7448/ias.17.1.18993] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 06/15/2014] [Accepted: 07/17/2014] [Indexed: 11/08/2022] Open
Abstract
Introduction The Jarisch-Herxheimer reaction, a febrile inflammatory reaction that often occurs after the first dose of chemotherapy in spirochetal diseases, may result in deleterious effects to patients with neurosyphilis and to pregnant women. A single 2-g oral dose of azithromycin is an alternative treatment to benzathine penicillin G for early syphilis in areas with low macrolide resistance. With its potential anti-inflammatory activity, the impact of azithromycin on the incidence of the Jarisch-Herxheimer reaction in HIV-positive patients with early syphilis has rarely been investigated. Methods In HIV-positive patients with early syphilis, the Jarisch-Herxheimer reaction was prospectively investigated using the same data collection form in 119 patients who received benzathine penicillin G between 2007 and 2009 and 198 who received azithromycin between 2012 and 2013, when shortage of benzathine penicillin G occurred in Taiwan. Between 2012 and 2013, polymerase chain reaction (PCR) assay was performed to detect Treponema pallidum DNA in clinical specimens, and PCR restriction fragment length polymorphism of the 23S ribosomal RNA was performed to detect point mutations (2058G or A2059G) that are associated with macrolide resistance. Results The overall incidence of the Jarisch-Herxheimer reaction was significantly lower in patients receiving azithromycin than those receiving benzathine penicillin G (14.1% vs. 56.3%, p<0.001). The risk increased with higher rapid plasma reagin (RPR) titres (adjusted odds ratio [AOR] per 1-log2 increase, 1.21; confidence interval [CI], 1.04–1.41), but decreased with prior penicillin therapy for syphilis (AOR, 0.37; 95% CI, 0.19–0.71) and azithromycin treatment (AOR, 0.15; 95% CI, 0.08–0.29). During the study period, 310 specimens were obtained from 198 patients with syphilis for PCR assays, from whom T. pallidum was identified in 76 patients, one of whom (1.3%) was found to be infected with T. pallidum harbouring the macrolide resistance mutation (A2058G). In subgroup analyses confined to the 75 patients infected with T. pallidum lacking resistance mutation, a statistically significantly lower risk for the Jarisch-Herxheimer reaction following azithromycin treatment was noted. Conclusions Treatment with azithromycin was associated with a lower risk for the Jarisch-Herxheimer reaction than that with benzathine penicillin G in HIV-positive patients with early syphilis. Previous benzathine penicillin G therapy for syphilis decreased the risk, whereas higher RPR titres increased the risk, for the reaction.
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Belum GR, Belum VR, Chaitanya Arudra SK, Reddy B. The Jarisch–Herxheimer reaction: Revisited. Travel Med Infect Dis 2013; 11:231-7. [DOI: 10.1016/j.tmaid.2013.04.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/31/2013] [Accepted: 04/03/2013] [Indexed: 10/26/2022]
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Li J, Wang LN, Zheng HY. Jarisch-Herxheimer reaction among syphilis patients in China. J Eur Acad Dermatol Venereol 2012; 27:1304-7. [PMID: 22607395 DOI: 10.1111/j.1468-3083.2012.04544.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/AIM The Jarisch-Herxheimer reaction (JHR) is an acute systemic event that can occur during the treatment of spirochetal infections, especially Treponema pallidum in patients with syphilis. JHR has clinical characteristics of an inflammatory reaction to antibiotic treatment and can occur with many medications as long as the antitreponemal concentrations are sufficiently high. METHODS The incidence of and risk factors for JHR were investigated retrospectively among 1125 patients with syphilis. A total of 357 patients (32%) had secondary syphilis, 129 (12%) primary, 178 (16%) early latent, 174 (15%) late latent and 285 (25%) latent unknown duration; two patients had tertiary syphilis. RESULTS Sixteen patients (1.4%) developed JHR. All JHRs occurred in patients with secondary and latent syphilis treated with penicillin. CONCLUSIONS JHR occurred much less frequently than in previously reported studies. It is important that dermatologists recognize the clinical characteristics of JHR so that it is not misinterpreted as an allergic reaction to treatment.
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Affiliation(s)
- J Li
- Department of Dermatology and Venereology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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