Rising rates of syphilis in the era of syphilis elimination

OBJECTIVE: The objective of this study was to assess the impact of syphilis control activities in King County, Washington. STUDY DESIGN: We calculated rates of early syphilis and trends in numbers of persons tested and diagnosed through screening and partner notification from 1998 to 2005. RESULTS: Early syphilis cases increased from 38 in 1998 to 188 in 2005 with 92% occurring among men who have sex with men (MSM). Our health department conducted public awareness campaigns, increased publicly financed syphilis screening among MSM by 179%, and intensified partner notification efforts. Despite these efforts, the prevalence of syphilis among screened populations was only 1.1%, and 71% syphilis cases were diagnosed after seeking care for symptoms. The proportion of cases diagnosed through screening and partner notification did not significantly change during the evaluation period. Early syphilis incidence among MSM more than doubled between 2003 and 2005. CONCLUSIONS: New, innovative approaches to syphilis control are needed.     

新生儿期先天梅毒36例临床分析

目的：探讨新生儿期先天梅毒的临床表现特点。方法：总结分析36例新生儿期先天梅毒，观察患儿临床及实验室检查的改变。结果：无症状新生儿期先天梅毒占61％；新生儿期先天梅毒症状和体征主要有皮疹、肝脾肿大、肺部感染，36例患儿中，早产儿13例（36％），新生儿死亡5例（14％），血清学USR、TPPA、19SIgM—TPPA检测结果均为阳性，肝功能异常23例（64％），肾功能异常22例（61％）。结论：新生儿先天梅毒的诊断须结合临床体征、实验室诊断结果以及母亲的病史进行综合分析；妊娠梅毒患者应及时发现、诊断并给予规范治疗，才能有效地阻断先天梅毒的发生。     

早期梅毒465例临床及病理分析

目的：了解早期梅毒临床表现及误诊原因，探讨组织病理学在梅毒诊断中的意义。方法：对465例早期梅毒进行了临床分析，所有患者均作梅毒血清学检测，其中28例做了病理学检查。结果：一期梅毒81例，RPR(快速血浆反应素试验)及TPPA(梅毒螺旋体抗体凝集试验)阳性79例；二期梅毒361例，RPR及TPPA均呈阳性；隐性梅毒20例，RPR及TPPA均呈阳性。一期梅毒易误诊为软下疳、生殖器疱疹、疥疮结节、女阴溃疡等；二期梅毒斑疹及斑丘疹易误诊为玫瑰糠疹、过敏性皮炎等；鳞屑性丘疹易误诊为银屑病；扁平湿疣易误诊为尖锐湿疣等。结论：梅毒血清学检测对早期梅毒的诊断具有重要意义，病理检查对硬下疳、扁平湿疣、鳞屑性丘疹皮疹诊断有一定意义，而斑疹呈非特异性炎症改变，不具诊断意义。     

Routine screening for syphilis is justified in patients admitted to psychiatric, alcohol, and drug rehabilitation wards of the Veterans Administration Medical Center

Of 1515 patients admitted to psychiatric, alcohol, and drug rehabilitation services in the Veterans Administration Medical Center, Buffalo, NY, during the year 1987, who were screened by serologic tests for syphilis, 16 (1.05%) had positive rapid plasma reagin and fluorescent treponemal antibody-absorption tests for syphilis. A positive serologic test result was not suspected on clinical grounds in any of these patients. All were detected by routine screening. Of the 16 patients, 15 had charts available for review. Seven patients were treated for primary or late syphilis; four patients had received previous treatment; and four patients had no evaluation of test results and received no treatment. Routine screening of hospitalized patients who are alcohol or drug abusers is justified, but close follow-up is necessary to make screening meaningful.     

81例神经梅毒患者临床特征分析

目的:分析神经梅毒患者临床特征,以期为临床神经梅毒早诊断、早治疗提供科学依据。方法:回顾性分析了81例神经梅毒患者的临床特征、影像学表现、梅毒血清学和脑脊液检测结果。结果:81例神经梅毒患者中,非三期梅毒38例,三期梅毒43例,男性患者居多;55例(67.9%)有神经梅毒临床症状和体征,26例(32.1%)无神经梅毒症状和体征。81例梅毒血液检查结果显示,TRUST阳性80例,TPPA阳性81例;74例脑脊液检查结果显示,16例(21.6%)VDRL阳性,31例(41.9%)白细胞计数>10×10~6/L,52例(70.3%)蛋白量>500 mg/L。结论:神经梅毒患者多发于男性,临床特征及影像学表现复杂多样化。临床医生应全面认识该病的临床特点,给予患者规范治疗并进行健康教育及心理护理。     

Utilidad de las nuevas pruebas treponémicas automatizadas en el diagnóstico de la sífilis precoz. A propósito de 15 casos

BackgroundSyphilis is a sexually transmitted infection caused by Treponema pallidum, subspecies pallidum. As these bacteria are difficult to culture, syphilis must be diagnosed by serologic testing. The introduction of automated treponemal tests has led to changes in the traditional diagnostic algorithm for syphilis, which began with a nontreponemal test. We present 15 cases of primary syphilis detected using these new tools and review the microbiologic techniques used for the diagnosis of early syphilis.Material and methodsWe examined all cases of syphilis diagnosed in our department between January 2013 and September 2018 and selected patients with negative nontreponemal (rapid plasma reagin [RPR]) tests.ResultsOf the 158 patients diagnosed with syphilis during the study period, 15 had a negative RPR test, and 14 of them had a positive treponemal test. Fourteen of the patients were men and ages ranged from 22 to 60 years. Polymerase chain reaction was used to detect T pallidum in the lesion exudate from 8 patients and was positive in all cases. The 15 patients were treated with a single injection of 2.4 million units of benzathine penicillin G.ConclusionChemiluminescence immunoassays and T pallidum automated enzyme-linked immunoassays are useful in the diagnosis of early syphilis, and we believe that they should be adopted as screening tools given their diagnostic sensitivity, speed, and low cost.     

胎传梅毒152例临床流行病学调查分析

目的调查胎传梅毒患儿的临床流行病学资料,分析发病现状和发展趋势,为相关部门制定防控策略提供依据。方法采用回顾性分析方法,对本院2007-2011年收治的152例胎传梅毒患儿及其母亲临床资料进行统计分析。结果 5年共收治胎传梅毒152例;2011年较2007年增长11.70倍;月龄以0～1个月为主;85.53%的患儿母亲为流动人口;97.37%孕前未进行梅毒血清学筛查;88.82%未予正规青霉素治疗。结论胎传梅毒多发于农村流动人口,孕妇缺乏梅毒血清学筛查和正规青霉素治疗是导致胎传梅毒发生的重要原因。加强梅毒筛查、治疗及预防知识的宣传,对降低胎传梅毒意义重大。     

19S-IgM-TPPA试验诊断先天梅毒评价

目的:评价血清19S-IgM-梅毒螺旋体明胶颗粒凝集试验(19S-IgM-TPPA)诊断早期先天梅毒的应用价值,以指导临床实践。方法:以2003年3月-2006年2月期间符合纳入标准的156例婴儿为研究对象,对他们进行血清19S-IgM-TPPA试验,并随访至明确诊断。以回顾诊断为标准。结果:156例婴儿中,141例婴儿完成随访,其中123例排除先天梅毒,18例婴儿被确诊为早期先天梅毒(有症状14例,无症状4例)。19S-IgM-TPPA试验阳性结果16例,假阳性2例,假阴性4例,敏感性77.78%(有症状78.57%,无症状75%),特异性98.37%,诊断指数176.15%;阳性预测值87.5%,阴性预测值96.8%,调整预测值无改变;阳性似然比47.83,阴性似然比0.226。结论:19S-IgM-TP-PA诊断先天梅毒敏感性较好,特异性很高,对有症状早期先天梅毒,在常规标准血清试验确定前即可证实感染的存在,用于先天梅毒的诊断是良好的预测工具,在已经有TPPA的实验室中,19S-IgM-TP-PA不失为一种诊断先天梅毒的可供选择的方法。     

佛山市顺德区妊娠期孕妇梅毒筛查调查及不同干预效果的临床比较

目的:调查佛山顺德区孕妇妊娠期梅毒感染情况,分析其治疗结果,为该区域孕妇妊娠期梅毒的防治提供参照。方法:对2008年1月至2014年12月于佛山顺德区第四人民医院、广州医科大学附属乐从医院产科作产检的12704例孕妇作梅毒筛查,进行甲苯胺红不加热血清(TRUST)检查,对阳性病例作梅毒螺旋体血清颗粒凝聚(TPPA)试验,对确诊者作治疗干预,分析其妊娠结局。结果:12704例孕妇,筛查确诊为梅毒者58例,妊娠期梅毒发生率为0.46%。妊娠期梅毒患者中流动人口55例,占94.83%;2009年妊娠期梅毒发生率最高,达0.76%,随后逐渐下降,2013年最低,为0.29%,2014年略有上升,占0.37%;47例作全程规范化治疗的妊娠期梅毒患者,共8例出现不良妊娠结局,占17.02%,不同妊娠时间开始治疗的梅毒孕妇,不良妊娠结局发生率对比无统计学差异(P0.05);妊娠早期开始治疗的梅毒孕妇其新生儿RPR阳性率低于中晚期开始的治疗梅毒孕妇,以晚期治疗新生儿RPR阳性率最高(P0.05);不同RPR滴度梅毒孕妇不良结局发生率对比差异无统计学意义(P0.05);PR滴度≤1∶2孕妇,新生儿RPR阳性率50.00%,明显低于RPR滴度≥1∶4梅毒孕妇的91.67%(P0.05)。结论:重视产前、孕前梅毒筛查,强调在妊娠早期对梅毒孕妇作干预治疗,可预防先天性梅毒,降低不良妊娠结局发生率。     

Characteristics of the course of latent forms of syphilis

Seven patients with latent syphilis are described, in whom the routine serologic tests (RST) were negative during the first examination and over the course of therapy, and the specific tests (T. pallidum immobilization and immunofluorescence) were repeatedly positive before therapy. Early latent seropositive recurrent forms of syphilis were detected in the majority of these patients' sexual partners. The patients were not administered antisyphilis therapy before. The diagnosis of latent seronegative early syphilis negative in the RST is epidemiologically significant, for it helps timely carry out the necessary treatment and prophylaxis measures to prevent the disease dissemination.     

Is increased surveillance for asymptomatic syphilis in an HIV outpatient department worthwhile?

OBJECTIVES: Syphilis outbreaks have recently been reported in the United Kingdom, some of which have included cohorts of HIV positive individuals. As a result we commenced 3 monthly screening of syphilis serology (STS) for HIV positive patients having routine follow up blood tests. We assessed if there was an increased number of individuals being screened and also whether the screening programme was diagnosing early cases of syphilis. METHODS: Data from a 1 year period following introduction of screening (May 2001) were analysed and compared with data from the same period last year. The case notes of patients with a positive VDRL were reviewed to establish, firstly, whether these represented new diagnoses and, secondly, whether patients were asymptomatic at the time of screening. RESULTS: 2670 patients had at least one CD4 count measured in the period (surrogate for patients having routine bloods). Of these, 2266 patients had STS performed (85%). 38 patients had a positive VDRL. Of these, 20 were confirmed as having early syphilis which was asymptomatic at the time of screening. Six asymptomatic cases were also confirmed with newly positive TPPAs and a negative VDRL. These 26 asymptomatic cases represent 29% of all cases of early syphilis diagnosed in our department and 50% of cases in the HIV positive cohort. CONCLUSION: With intensive surveillance significant numbers of cases of asymptomatic early syphilis are being identified in a group of HIV individuals under routine follow up, at an earlier stage than would otherwise have been the case. This presents an opportunity to intervene not only to prevent clinical illness but also to institute infection control measures.     

妊娠梅毒的抗梅治疗及转归

近年来妊娠梅毒发病率有逐年增加趋势,临床主要表现为潜伏梅毒,未经有效治疗的妊娠梅毒对胎儿有严重的影响,抗梅治疗可显著改善妊娠结局。因此婚前、孕前、孕期梅毒血清学筛查相当重要,早发现、早治疗,可以大大降低先天梅毒的发生率。     

Screening for syphilis in arrestees: usefulness for community-wide syphilis surveillance and control

BACKGROUND: Syphilis screening of jail arrestees has been promoted as an effective method for both disease control and surveillance. GOALS: To evaluate the yield of the East Baton Rouge Parish Jail screening program in detecting previously undiagnosed syphilis, to evaluate the program as a means for monitoring community syphilis rates, and to characterize arrestees at greatest risk for syphilis infection. STUDY DESIGN: From July 1994 to December 1998, arrestees brought to the East Baton Rouge Parish Jail were screened for syphilis. Annual early syphilis prevalence in screened arrestees was calculated and compared with the annual period prevalence of early syphilis in the general population of East Baton Rouge Parish, as reported by laboratories and health providers. A case-control study of cases detected at the jail from 1995 to 1997 and contemporary controls was conducted. RESULTS: A total of 50,941 arrestees were booked into the East Baton Rouge Parish Jail, of whom 38,573 (76%) were screened for syphilis. Of the 38,573 arrestees screened, 494 (1.3%) were diagnosed with untreated syphilis. Of these, 299 (61%) were treated for syphilis before release. The estimated prevalence of early syphilis in arrestees decreased by 68% during the study period, from 0.79% in 1994 to 0.25% in 1998. During this time, the East Baton Rouge Parish community rates decreased by 79%, from 150 cases per 100,000 to 31 cases per 100,000. In female arrestees, a booking charge of prostitution was associated with syphilis (odds ratio [OR] 7.0; 95% CI, 1.5, 39.3). In male arrestees, a booking charge of felony theft was associated with syphilis (OR 4.8; 95% CI, 1.8, 13.8). However, only 15 (12%) of the early syphilis cases would have been detected if screening had been based on the booking charges found to be associated with syphilis in this study. CONCLUSIONS: Routine syphilis screening and treatment in jail settings is feasible and identifies many persons with syphilis. Monitoring of syphilis prevalence among arrestees is a useful method for monitoring community prevalence of syphilis. Analysis of booking charges may be useful for determining factors associated with syphilis infection, but not for developing screening criteria.     

19SIgM-TPPA对新生儿先天潜伏梅毒诊断的意义

目的探讨特异性19SIgM-TPPA抗体检测方法在诊断新生儿先天潜伏梅毒中的价值,同时观察妊娠梅毒患者垂直传播发生情况,并探讨其意义。方法应用特异性19SIgM-TPPA抗体检测方法对177例孕妇梅毒所生的新生儿进行检测。结果177例受检新生儿中,TRUST阳性112例(63.3%),TPPA阳性156例(88.13%),19SIgM阳性27例(15.25%)。早期先天梅毒患儿TRUST≥母亲TRUST2个滴度以上9例、>母亲TRUST2个滴度以内7例、<母亲TRUST滴度5例;因母亲血清标本缺或血清量不足,无法作比较的6例。27例先天梅毒有临床表现的6例,无临床表现21例。结论特异性19SIgM-TPPA抗体检测方法可作为先天梅毒特别是无症状新生儿先天梅毒诊断的试验。产前梅毒筛查和治疗对预防梅毒垂直传播有重要意义。     

Clinical manifestations of early syphilis by HIV status and gender: results of the syphilis and HIV study

BACKGROUND: Despite reports of unusual clinical presentations and therapeutic responses among HIV-infected patients with syphilis, syphilis has not been regarded as a serious opportunistic infection that predictably progresses among most HIV-coinfected patients. GOAL: To define and describe differences in the presentation and response to treatment of early syphilis among HIV-infected and HIV-uninfected patients, to describe any differences by gender, and to determine if clinical presentation of central nervous system involvement predicted serologic failure. DESIGN: A prospective, multicenter, randomized, controlled trial of enhanced versus standard therapy to compare the benefit of enhanced therapy, the clinical importance of central nervous system involvement, and the clinical manifestations of early syphilis infection among HIV-infected and HIV-uninfected patients. RESULTS: The median number of ulcers was significantly greater among HIV-infected and HIV-uninfected patients, as was the percent of HIV-infected patients with multiple ulcers. Among patients diagnosed with secondary syphilis, a higher percentage of HIV-infected patients presented with genital ulcers [13/53 (25%)] than did HIV-uninfected patients [27/200 (14%)]. No differences between HIV-infected and HIV-uninfected patients were detected for other secondary syphilis manifestations. Although women presented more frequently with secondary syphilis than did men, no other gender differences in clinical manifestations were noted. Neurologic complaints were reported most frequently among patients with secondary syphilis [103/248 patients (42%)] compared with patients with primary syphilis [32/136 (24%)] and early latent syphilis [48/ 142, (34%)] (P < 0.05), but no differences in neurologic complaints were apparent by HIV status or CSF abnormalities. No neurologic complaints were significantly associated with serologic treatment failures at 6 months. CONCLUSIONS: Overall, HIV infection had a small effect on the clinical manifestations of primary and secondary syphilis. Compared with HIV-uninfected patients, HIV-infected patients with primary syphilis tended to present more frequently with multiple ulcers, and HIV-infected patients with secondary syphilis presented with concomitant genitals ulcers more frequently.     

Strategies for syphilis prevention: findings from surveys in a high-incidence area

BACKGROUND: The persistence of syphilis in the United States suggests that a better understanding is needed of the potential for various public health approaches to prevent the spread of the disease. STUDY DESIGN: The authors conducted surveys of 92 persons with early syphilis, 56 uninfected sexual contacts, and 143 neighborhood controls in the Baton Rouge, Louisiana area. The surveys collected information regarding sexual behavior, access to and use of healthcare services, encounters at sites at which serologic screening for syphilis could be done, and exposure to interventions designed to prevent HIV infection. RESULTS: All groups reported high-risk sexual behavior. Cases and contacts were more likely than controls to report two or more sex partners in the previous year, but the three groups were similar in the percentage reporting five or more sex partners. Cases had poor access to health care and by some measures this access was less than that of controls. The potential screening site visited most frequently by cases was the public hospital emergency room (40%). Cases were less likely to have been exposed to programs designed to prevent HIV infection than uninfected contacts and controls combined (odds ratios, 0.51-0.66). CONCLUSIONS: Persons with syphilis were not unlike others in their neighborhoods, suggesting that syphilis is a sentinel event that indicates an entire neighborhood is at risk. Improvements in access to health care for sexually transmitted disease-related symptoms, screening in sites such as public hospital emergency rooms, and emphasizing sexual risk-reduction interventions may limit the spread of syphilis in these neighborhoods. To prevent syphilis in the long term, public health programs should also try to better understand and change other community-level socioeconomic factors that influence sexual behavior.     

IgM抗体诊断早期先天梅毒

我们用梅毒特异性19（s)IgM-TPPA抗体检测方法，对5例常规梅毒血清学方法RPR和TPPA两个试验均阳性的新生儿（其母亲已在怀孕时被确诊为不同病期梅毒）进行了检测。患儿中有3例19（s)IgM-TPPA阳性，另2例阴性。最终确诊3例新生儿为先天梅毒。特异性IgM检测应该作为新生儿和早期无症状先天梅毒确诊的实验诊断方法。加强婚前、孕前及早孕期的梅毒筛查和治疗，对控制先天梅毒的发生有重要意义。     

Las características epidemiológicas y clínicas de la epidemia de sífilis en Barcelona

BackgroundSince 2000, substantial increases in syphilis have been reported in metropolitan areas of Western countries, with increases noted among men who have sex with men (MSM). Clinical manifestations of syphilis might be influenced by concomitant VIH infection and previous episodes of syphilis. The objectives of this study were to describe the epidemiological and clinical characteristics of the cases of syphilis diagnosed in Barcelona.MethodsRetrospective study of cases with early syphilis diagnosed in the referral STI Unit of Barcelona from January 2003 to December 2013. Revision of medical records with structured collection of epidemiological and clinical data. Univariate and multivariate statistical analyses comparing the characteristics of MSM cases with and without VIH infection and with and without previous syphilis.ResultsA total of 1702 cases of syphilis (37% primary, 48% secondary and 14% early latent) were diagnosed, 93% of them in MSM. Among MSM 40% were coinfected with VIH, VIH-positive cases were associated with a previous syphilis (aOR, 5.2 [95% CI, 3.32-8.24]) and with unprotected anal intercourse (aOR, 1.75 [95%CI, 1.17-2.63]). Cases with a history of syphilis presented less often with primary syphilis compared to those without it (27.5% vs. 40%) (aOR, 0.58 [95% CI, 0.44-0.77]). One year after treatment, the clinical and serological evolution were similar between VIH-positive and VIH-negative cases.ConclusionThe epidemic of syphilis in Barcelona disproportionately affects MSM and is closelly linked to VIH infection. The presentation of syphilis is influenced by VIH infection and by previous history of syphilis, without significant differences in their evolution after one year of treatment.     

妊娠合并梅毒临床病例分析

目的：总结妊娠合并梅毒病例的临床特点及产前梅毒筛查情况，研究梅毒治疗时间对妊娠结果的影响。方法：对我院1998年4月—2002年4月间妊娠合并梅毒的病例进行回顾性分析。结果：妊娠合并梅毒病例30例，占住院分娩病例总数的0．49％。潜伏梅毒病25例，占83．3％；Ⅰ期梅毒、Ⅱ期梅毒及妊娠前驱梅治疗后血清固定的病例各占3．3％、6．7％、6．7％。晚期妊娠发现梅毒病例中，死胎或畸胎6例，先天性梅毒婴儿3例，远多于妊娠早期及中期发现梅毒的病例。结论：妊娠合并梅毒病例的临床表现以潜伏梅毒为主。治疗梅毒的时间对妊娠结局有一定影响。     

A consequence of the syphilis epidemic among men who have sex with men (MSM): neurosyphilis in Los Angeles, 2001-2004

OBJECTIVES: To describe the epidemiology and clinical findings of neurosyphilis (NS) cases diagnosed during the current syphilis epidemic occurring predominantly among men who have sex with men. METHODS: Syphilis cases reported to the health department were reviewed for diagnosis of NS, cerebrospinal fluid venereal disease research laboratory results, and/or treatment for NS. RESULTS: During 2001-2004, 7083 cases of syphilis were diagnosed in Los Angeles. One hundred nine cases of confirmed or probable NS occurring among persons aged 19 to 65 years were identified during this period (1.5%). Symptomatic NS was present in 1.2% of reported syphilis cases (86 of 7083). NS cases were inclusive of 71 (65%) men who have sex with men. Forty-two (49%) of the symptomatic NS cases occurred during secondary (N = 28) or early latent (N = 14) syphilis. Sixty-eight percent (N = 74) of the NS cases were human immunodeficiency virus (HIV)-positive. The estimated incidence of symptomatic NS among HIV-infected persons with early syphilis was 2.1% as compared with 0.6% among HIV-negative persons. CONCLUSION: Providers should maintain a high index of suspicion for NS among patients with syphilis, particularly those with HIV infection.