Atypical Manifestations of Syphilis: A 10-Year Retrospective Study

Syphilitic pneumonia: case report and systematic review

Syphilitic pneumonia is a rare secondary form of Treponema pallidum infection. In this article, we present a case of syphilitic pneumonia in a patient living with Human Immunodeficiency Virus (HIV) with good immune-virological status. We also performed a systematic review of literature and we found 43 cases of syphilitic pneumonia described since 1886. We added our case report and performed a statistical analysis. Our analysis showed that 40/44 (91%) were males, with a median age of 46 years old (IQR 37-56), 9/28 (32%) were people living with HIV (data not available for 16/44 patients), 17/27 (63%) had syphilitic-related hepatitis during the clinical presentation (data not available for 17/44 patients), and 28/42 (66.6%) of patients had maculopapular rash compatible with secondary forms (data not available for 2/42 patients). Furthermore, 74.4% of patients had nodular lesions on chest X-ray or pulmonary Computed Tomography scan. Given the high rate of nodular pneumonia among patients, clinicians should consider it as a common presentation in syphilitic pneumonia.

Herald Patch as the Only Evidence of Pityriasis Rosea: Clinical, Laboratory and Pathogenetic Features

Pityriasis rosea (PR) is a self-limited exanthem associated with the endogenous systemic reactivation of human herpesvirus (HHV)-6 and HHV-7. The disease typically begins with a single erythematous patch on the trunk (herald patch), followed by a secondary eruption of smaller papulosquamous lesions. Rarely, the herald patch may be the only cutaneous manifestation of PR. The present work aimed to examine the clinical and laboratory features of the PR cases characterized by the herald patch as the sole cutaneous manifestation and to compare them with the classic form of PR. An observational, retrospective study was conducted on patients presenting with herald patch as the only sign of PR (cases) and on a series of age- and sex-matched patients who presented with a typical PR pattern (controls). The records of the patients were extracted from a PR registry, which collected data on patients with PR diagnosed from 2003 to 2023 by at least two dermatologists from the same study team. Nineteen patients (eleven males, eight females) with a mean age of 27.1 years presented the herald patch as the only cutaneous manifestation of PR. Nineteen age- and sex-matched patients were considered controls. In the cases, the exanthem duration was shorter than in controls, and the mean HHV-6 and HHV-7 DNA plasma load was lower than in controls. This rare variant of PR might be considered an abortive form of the exanthem that occurs when the HHV-6/7 reactivation from latency is contrasted by a more robust immunological response than in classic PR.

Annular Eroded Plaque With Honey-Colored Crusting On Scrotum

A man in his 40s presented with a dry erythematous, annular plaque with focal erosion and a collarette of desquamative, honey-colored crusting on the scrotum. What is your diagnosis?

Interesting case of syphilis with atypical vegetative lesions

Syphilis is a re-emerging disease, and suspicion of syphilis infection should be considered in all cases with atypical skin manifestations, mainly when there is a history of unprotected sexual intercourse. Here, we describe a case of secondary syphilis in a woman aged 42 years, who presented with an atypical, painful and itchy skin rash with vegetative cerebriform lesions, which resolved after the administration of penicillin. Multiplex PCR targeting Treponema pallidum on vaginal and lesion swabs, along with syphilis serology, confirmed the diagnosis.

Atypical Oral Mucosal Lesions in Syphilis: A Case Report Highlighting the Diagnostic and Therapeutic Aspects of the "Great Imitator"

The diagnostic process and discrimination of mucosal lesions present a formidable challenge for numerous clinicians, primarily attributable to the common overlap of clinical manifestations observed across various categories, including infectious, autoimmune, connective tissue, and systemic vascular inflammatory diseases. In cases of mucosal lesions, syphilis presents distinctive characteristics that can help clinicians differentiate it from other conditions. The most common manifestation of primary syphilis is mostly a painless, firm, indurated ulcer known as a chancre, which typically appears at the site of inoculation, with enlargement of regional lymph nodes. Sometimes, its painless course may be misleading. The objective of our study is to raise awareness of venereal diseases in cases of atypical oral mucosal lesions that do not respond to local treatment. A 32-year-old man was referred to the department of dermatology due to an enlarging, painful inflammatory lesion with central breakdown, covered with honey-yellow crusts on the lower lip. A positive history of herpes labialis was noted. The patient denied risky sexual behaviors or new partners in the last three months. Submandibular and left cervical lymph nodes were found enlarged in ultrasound examination, and laboratory tests showed elevated inflammatory parameters. Empirical antibiotic therapy with amoxicillin-clavulanate in conjunction with oral acyclovir did not lead to clinical improvement. The inadequate therapeutic response prompted the pursuit of further diagnostic investigations, including serological tests encompassing both treponemal and nontreponemal tests. Co-infections with human immunodeficiency virus (HIV) and hepatotropic viruses were excluded. The serological testing resulted positive, and after receiving the diagnosis, the patient admitted to engaging in high-risk sexual behaviors. The treatment with benzathine penicillin was successful. In the differential diagnosis of ulcers located on mucous membranes or vermilion border, the primary symptom should always be considered. Early serological testing remains the gold standard for diagnosis. Appropriate treatment with benzathine penicillin leads to satisfactory effects.

Corymbiform syphilis: A rare dermatological presentation

Syphilis is often referred to as the 'great imitator' due to its diverse clinical manifestations throughout its clinical stages and polymorphic nature. We report a case of a 24-year-old man-who-has-sex-with-men presenting with an atypical syphilitic rash on the trunk, with a corymbiform appearance. This case highlights the necessity for clinicians to maintain a high index of suspicion for sexually transmitted infections, especially when there are skin manifestations of an uncertain nature.

Parkinsonism plus syndrome in neurosyphilis: Clinical insights and brain imaging

BACKGROUND

While Parkinsonism plus syndrome (PPS) is one of several atypical manifestations in neurosyphilis patients, its clinical features and brain-related manifestations are inadequately documented. In this cross-sectional study, we endeavored to indicate some key clinical and imaging features of neurosyphilis patients, particularly those specific to PPS.

METHODS

We retrospectively included all syphilis patients enrolled in the study from January 2021 to February 2024. All in all, 54 neurosyphilis patients with PPS were recruited. Their socio-demographical features, clinical status, presentations, laboratory manifestations and neuroimaging were analyzed retrospectively.

RESULTS

The predominant phenotype was general paresis (GP). Median age at onset was 50 years, and 87.0 % of the patients were male. Bradykinesia (53.7 %) was the most common manifestation of PPS in neurosyphilis patients. The most frequent physical sign was orofacial dyskinesia (the Candy sign), which accounted for 51.9 % of cases. In nearly three quarters (71.1 %), magnetic resonance imagery revealed temporal, hippocampal lobe, or whole brain atrophy, while 13.3 % exhibited basal ganglia lacunar infarction, and 22.2 % cases had focal demyelination in the cerebral peduncle, cerebellum, frontal lobe, parietal lobe, hippocampus and/or lateral vertical.

CONCLUSIONS

Neurosyphilis patients exhibited PPS in involving bradykinesia, tremor rigidity and, in most cases, GP. Brain atrophy and basal ganglia lesion were the most common imaging findings in neurosyphilis patients with PPS. Our results should help to elucidate PPS characteristics PPS and neuroimaging mechanisms in neurosyphilis patients with PPS.

A Loop-Mediated Isothermal Amplification Assay Utilizing Hydroxy Naphthol Blue (LAMP-HNB) for the Detection of Treponema pallidum Subspp. pallidum

Treponema pallidum subspp. pallidum is a spirochaete bacterium that causes syphilis, one of the most common sexually transmitted diseases. Syphilis progresses through four distinct stages, each characterized by specific symptoms, namely primary, secondary, latent, and late (tertiary) syphilis. Serology has been considered the primary diagnostic approach. However, it is plagued by problems such as the limited specificity of nontreponemal tests and the inadequate correlation of treponemal tests with disease activity. In this study, we focused on the development of a loop-mediated isothermal amplification assay utilizing hydroxy naphthol blue (LAMP-HNB) for the diagnosis of T. pallidum subspp. pallidum. Specifically, this study seeks to determine the analytical sensitivity (limit of detection; LOD) and analytical specificity. Four hundred clinical serum samples were analyzed for diagnostic sensitivity, specificity, and predictive value, and each technique's 95% confidence intervals (95% CI, p < 0.05) were evaluated. The limit of detection for polymerase chain reaction with agarose gel electrophoresis (PCR-AGE), the loop-mediated isothermal amplification assay combined with agarose gel electrophoresis (LAMP-AGE), and LAMP-HNB were 116 pg/µL, 11.6 pg/µL, and 11.6 pg/ µL, respectively. Analytical specificity examinations indicated the absence of cross-reactivity with Leptospira interrogans, Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, human immunodeficiency virus (HIV), and healthy human serum in PCR-AGE, LAMP-AGE, and LAMP-HNB. The diagnostic sensitivity, diagnostic specificity, positive predictive value (PPV), and negative predictive value (NPV) for PCR-AGE were 100.00 (100.00)%, 94.50 (94.40-94.60)%, 94.79 (94.69-94.88)%, and 100.00 (100.00)%, respectively. While, for LAMP-AGE and LAMP-HNB, they were 100.00 (100.00)%, 91.00 (90.87-91.13)%, 91.74 (91.63-91.86)%, and 100.00 (100.00)%, respectively. The LAMP-HNB test is simple, rapid, highly sensitive, and highly specific, without requiring expensive equipment. In the future, the LAMP-HNB assay may develop into a single-step diagnostic process, enabling the use as point-of-care testing for the diagnosis, prevention, and management of syphilis infection.

Clinical and Laboratory Characteristics, Diagnosis, and Treatment of Patients with Neurosyphilis in Emergency Department: A Retrospective Study of 12 Patients

Purpose

Syphilis, caused by Treponema pallidum, presents a diagnostic challenge due to its diverse clinical manifestations. Neurosyphilis has seen a resurgence in recent years, particularly among men who have sex with men and those living with HIV. Diagnosis of neurosyphilis in emergency settings is challenging due to its varied neurological presentations. This study aims to serve as a reference for dermatologists and neurologists in diagnosing and treating neurosyphilis.

Patients and Methods

This retrospective study analyzed patients who presented with neuropsychiatric symptoms and were ultimately diagnosed with neurosyphilis. These patients were collected from the emergency department in Peking Union Medical College Hospital between January 2018 and November 2023. The medical history, clinical symptoms, laboratory examinations, cranial MRI characteristics, and treatment regimens of these patients were investigated.

Results

Among the included 12 neurosyphilis patients, memory deterioration was observed in 8 out of the 12 neurosyphilis patients. Diagnosis often resulted in delays, with misdiagnoses mainly including Alzheimer's disease, stroke, and epilepsy. Neuroimaging revealed various abnormalities, predominantly affecting ventricular and temporal regions. Treatment with penicillin-based regimens varied in compliance, with only a minority of patients adhering to guidelines. Treatment outcomes were inconsistent, with some patients experiencing irreversible neurological damage and fluctuating serum rapid plasma reagin (RPR) titers.

Conclusion

Diagnosis of neurosyphilis in the emergency department remains challenging, necessitating awareness of its varied neurological presentations. Enhanced diagnostic strategies are imperative to accelerate treatment initiation and improve outcomes for affected individuals.

Loop-Mediated Isothermal Amplification Assay Using Gold Nanoparticles for Detecting Treponema pallidum subspp. pallidum

BACKGROUND

Venereal syphilis in humans is caused by Trepenoma pallidum subspp. pallidum. A study has shown that 30,302 individuals in Thailand had syphilis in 2020, with a male-to-female ratio of 1:0.8 and the highest incidence rate at ages between fifteen and twenty-four.

METHODS

This research aimed to develop a loop-mediated isothermal amplification assay using gold nanoparticles (LAMP-AuNPs). Analytical sensitivity, diagnostic specificity, accuracy, and predictive values for each technique are provided.

RESULTS

The diagnosis sensitivities of polymerase chain reaction using agarose gel electrophoresis (PCR-AGE), loop-mediated isothermal amplification assay using agarose gel electrophoresis (LAMP-AGE), and LAMP-AuNPs were 116 ng/µL, 11.6 ng/µL, and 11.6 ng/µL, respectively. We evaluated the analytical specificity using PCR and a LAMP-based assay, and there was no cross-reactivity to Leptospira interrogans, Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, human immunodeficiency virus (HIV), and healthy humans. After analyzing 400 serum samples of patients suspected of syphilis, the LAMP-AGE and LAMP-AuNPs assays displayed 100% diagnostic sensitivity scores, 91% diagnostic specificity scores, 95.5% accuracy rates, 100% positive predictive values (PPVs), and 91% negative predictive values (NPVs), the positive likelihood ratio (LR+) was 11.11, while the negative likelihood ratio (LR-) was 0. Conversely, for PCR assays displayed 100% diagnostic sensitivity scores, 94.5% diagnostic specificity scores, 97.25% accuracy rates, 100% PPVs, and 94.5% NPVs, LR+ was 18.18, and LR- was 0.

CONCLUSIONS

The LAMP-AuNPs technique demonstrates rapidity, affordability, and convenience, rendering it well-suited for point-of-care applications in the diagnosis, prevention, and management of pathogenic infections.

Global, regional, and national burden of syphilis, 1990-2021 and predictions by Bayesian age-period-cohort analysis: a systematic analysis for the global burden of disease study 2021

Objective

To comprehensively assess the global burden of syphilis and related risk factors over 1990-2021, forecast future disease trends, and understand the impact of syphilis on global health.

Methods

Global Burden of Disease Study 2021 (GBD 2021) data were used for age-, sex-, and region-stratified analysis of the numbers and age-standardized rates (per 100,000 population) of syphilis incidence, prevalence, deaths, and disability-adjusted life years (DALYs). Next, a differential analysis of syphilis risk factors was performed. Finally, trends for years after 2021 were predicted using Bayesian age-period-cohort (BAPC) prediction models.

Results

In 2021, the total number of syphilis prevalence globally was 70,541,482.80 (95% uncertainty interval: 54,910,897.66-88,207,651.97), with the highest numbers noted in Central Sub-Saharan Africa [4,622.60 (95% uncertainty interval: 3,591.97-5,753.45)]. Over 1990-2021, the global age-standardized prevalence and incidence rates increased, whereas the age-standardized death and DALY rates decreased. Among all groups, infants aged <5 years demonstrated the highest age-standardized DALY rates. Moreover, the lower the sociodemographic index (SDI), the higher was the age-standardized rate. The primary factor contributing to syphilis disease burden was identified to be unsafe sex. BAPC analysis revealed an overall increase in age-standardized prevalence rate in the <5-year age group over 1990-2035, and the highest age-standardized prevalence rate occurred in the 25-34-year age group.

Conclusion

Between 1990 and 2021, syphilis occurrence and prevalence increased consistently. Projections indicated a continual increase in syphilis incidence in children aged <5 years, and age-standardized prevalence rates were the highest in adults aged 25-34 years. Our results regarding the epidemiological trends of syphilis and its variations across regions, age groups, and sexes may aid policymakers in addressing the global impact of the disease effectively.

Syphilis Clinical Complexity: A Dual-Case Study Illustrating Diagnostic Dilemmas and Management Strategies

Syphilis, a bacterial sexually transmitted infection, poses diagnostic challenges due to its diverse clinical manifestations. This report presents two distinctive cases illustrating the diagnostic dilemmas and management strategies associated with syphilis. The first case describes a male in his early 30s presenting with secondary syphilis and condyloma lata, illustrating the atypical genital lesions that can arise. The second case involves a male in his late 40s with late latent syphilis exhibiting unusual cutaneous manifestations, underscoring the diagnostic complexities of the disease. These cases underscore the importance of healthcare providers remaining vigilant in identifying unusual presentations of syphilis to ensure timely intervention and prevent transmission and complications.

A Case of Perianal Annular Rash: Atypical Presentation of Recurrent Secondary Syphilis

Syphilis is a complex, systemic infectious disease caused by Treponema pallidum subspecies pallidum. Secondary syphilitic lesions typically manifest within 3 months following initial exposure to T. pallidum. The predominant cutaneous manifestations of secondary syphilis are macula and papule. Certain individuals with syphilis may present with an atypical rash during the secondary stage owing to immunosuppression and other factors. Herein, we report a rare case of atypical recurrent secondary syphilis around the anus in a 65-year-old woman. Based on cerebrospinal fluid findings and skin biopsy results, the patient was ultimately diagnosed as neurosyphilis and recurrent secondary syphilis. Following intravenous antibiotic therapy, the patient's rash improved significantly. This case underscores the importance for physicians to remain vigilant regarding the possibility of syphilis when encountering cases exhibiting unusual clinical manifestations, as a definitive diagnosis necessitates a comprehensive evaluation.