Fluid Venereal Disease Research Laboratory Research Articles

Posterior Segment Manifestations of Syphilis and Correlation With Serologic Markers of Infection.

Retrospective analysis correlating serologic titers of ocular syphilis with posterior segment manifestations. This study consisted of 40 patients (80 eyes imaged, 68 affected) with positive rapid plasma reagin (RPR) and Treponema Pallidum immunoglobulin G. We collected demographic and presentation data including HIV status, absolute CD4 count, RPR, cerebrospinal fluid-venereal disease research laboratory (CSF-VDRL) test, and retinal zone. We categorized imaging into syphilitic outer retinopathy (SOR), acute syphilitic posterior placoid chorioretinopathy, retinitis/chorioretinitis (RC), and papillitis. Multivariate analysis correlated HIV status, RPR, and VDRL titers with posterior segment findings and zone. Mean age of 42.8 ± 10.7 years, with 70% male patients. Presenting visual acuity (logMAR) 0.66 ± 0.74 did not correlate with RPR, nor was it associated with papillitis, RC, or acute syphilitic posterior placoid chorioretinopathy. Higher RPR (≥ 1:128) positively associated with SOR (P = 0.031) and zone 1 (odds ratio [OR], 1.62; P = 0.02), but negatively associated with zone 2 (OR 0.35; P = 0.005). HIV positivity increased RC odds (OR, 4.45; P = 0.047). Higher RPR correlated with SOR and zone 1, whereas HIV positivity correlated with RC. [Ophthalmic Surg Lasers Imaging Retina 2024;55:511-516.].

The optimum condition of the toluidine red unheated serum test for the replacement of the venereal disease research laboratory test in cerebrospinal fluid for neurosyphilis diagnosis

BackgroundThe cerebrospinal fluid (CSF) venereal disease research laboratory (VDRL) test remains the standard for the laboratory diagnosis of neurosyphilis. The toluidine red unheated serum test (TRUST) is an alternative to the VDRL test as a serological test for syphilis, but it lacks guidelines for its use in CSF for neurosyphilis diagnosis. MethodsA total of 210 suspected neurosyphilis patients were included, consisting of 124 neurosyphilis patients and 86 syphilis/non-neurosyphilis patients. The TRUST was modified into the CSF-TRUST-10 test with 10 μL of antigen by referring to the CSF-VDRL test, and the CSF-TRUST-17 test with 17 μL of antigen by referring to its procedures in serum. The diagnostic performance of the CSF-TRUST-10 and CSF-TRUST-17 tests and the concordance between them and the CSF-VDRL test were evaluated. ResultsThe diagnostic performance of the CSF-TRUST-10 and CSF-TRUST-17 tests for diagnosing neurosyphilis were comparable to the CSF-VDRL test, as well as the positive rate. The agreement rate was 98.7% between the qualitative CSF-TRUST-10 and CSF-VDRL tests. A total of 91.4% of the quantitative CSF-TRUST-10 results were consistent with the CSF-VDRL test, and the discordant results were no more than two titres. The agreement rate was 98.1% between the qualitative CSF-TRUST-17 and CSF-VDRL tests and 87.6% between the quantitative CSF-TRUST-17 and CSF-VDRL tests. ConclusionsThe CSF-TRUST with 10 μL of antigen could be an alternative for the CSF-VDRL test for neurosyphilis diagnosis. Our results provide a basis for using the TRUST to guide the diagnosis of neurosyphilis.

Clinical, Imaging, and Prognostic Differences of Neurosyphilis in HIV and Non-HIV Individuals

Background Neurosyphilis remains an important health issue, particularly in populations at risk like men who have sex with men. Our aim was determining differences in the clinical presentation and neuroimaging findings in HIV-positive and non-HIV neurosyphilis patients. Methods This is a retrospective study that included 30 patients who were classified either as non-HIV (n = 16) or HIV positive (n = 14) during the period 1997–2017 at the Instituto Nacional de Neurología y Neurocirugía. Results The main clinical signs in non-HIV patients were dementia (56%, P = 0.02), dementia plus neuro-ophthalmic alterations (50%, P = 0.01), delirious ideas (62.5%, P = 0.03), and judgment errors (44%, P = 0.02). In contrast, neuro-ophthalmic alterations were predominant in HIV-positive patients (85.7%, P = 0.02) along with pachymeningitis (57.1%, P = 0.021) and optic neuritis (57.1%, P = 0.023), as determined by neuroimaging. No significant differences in the cytochemical characteristics of cerebrospinal fluid were observed. Conclusions Dementia was predominant in non-HIV subjects, whereas neuro-ophthalmic lesions were observed earlier and more frequently in HIV-positive patients. Our results highlight the importance of visual signs in HIV-positive patients as an early manifestation of neurosyphilis, and the relevant role of the cerebrospinal fluid Venereal Disease Research Laboratory test in the evaluation of patients with dementia.

S3020 Hepatitis From a Sexually Transmitted Bacterial Infection

Introduction: Syphilis is a multisystemic, sexually transmitted infection (STI) that is caused by the spirochete Treponema pallidum. Hepatic involvement is rare. We present a patient who was diagnosed with syphilitic hepatitis (SH). Case Description/Methods: A 54-year-old male presented to the hospital with one week of sharp upper abdominal pain, jaundice, poor appetite, and a 25-lb. weight loss. He also reported multiple sexual partners and a rash that developed 2 months ago. Vital signs were within normal range. Physical examination revealed scleral icterus, a soft, non-tender abdomen, a plaque-like penile lesion and small, circular lesions on his palms and soles of feet. Laboratory studies revealed aspartate aminotransferase (AST) 164 U/L, alanine aminotransferase (ALT) 207 U/L, alkaline phosphatase (ALP) 1395 U/L, total bilirubin 5.6 mg/dL, gamma-glutamyl transferase 782 U/L. Hepatitis panel, acetaminophen and alcohol levels were negative. Chronic liver disease work-up was unremarkable. Treponemal antibody and rapid plasma reagin test were both positive. HIV test and cerebrospinal fluid venereal disease research laboratory (VDRL) test were negative. Abdominal ultrasound and CT scan of the abdomen were unremarkable. Magnetic resonance cholangiopancreatography was notable for hepatomegaly and hepatitis. Patient received 1 dose of penicillin G 2.4 million units intramuscularly with remarkable improvement in his symptoms and liver function tests. He was discharged home with close follow-up with gastroenterology and infectious disease. Discussion: SH occurs in 0.2-9.7% of patients with syphilis and is most commonly seen in the primary and secondary disease stages. Clinical manifestations include a maculopapular rash (involving the trunk, palms and/or soles of feet), fatigue, poor appetite, hepatomegaly and icterus. Liver function tests (LFTs) may reveal a marked increase in ALP and GGT in comparison to ALT and AST. SH is diagnosed with abnormal LFTs, serological evidence of syphilis, exclusion of other liver diseases and LFTs returning to normal after antibiotic therapy as in our patient. The histological features of SH include inflammatory infiltration of the bile duct and hepatic granulomas. Spirochetes are often difficult to identify in liver tissue. Penicillin is the mainstay of treatment. Clinicians should consider syphilitic hepatitis in a patient with abnormal LFTs (especially ALP) and a rash involving the palms and soles of feet in the appropriate clinical context.

A Comparison of Treponema pallidum Subspecies pallidum Molecular Typing Systems: Multilocus Sequence Typing vs. Enhanced Centers for Disease Control and Prevention Typing.

At least 3 syphilis typing systems are proposed. Recent work suggests that multilocus sequence typing (MLST) may be superior to enhanced Centers for Disease Control and Prevention typing (ECDCT) by yielding a higher discriminatory power. The goal of this study was to compare the 2 systems and identify associations between neurosyphilis and strain types. Multilocus sequence typing for tp0136, tp0548, and tp0705 was determined for DNA from 78 Treponema pallidum subspecies pallidum isolates propagated in rabbits, 10 oral and 10 genital or non-genital lesion swabs, and 10 blood samples from patients with syphilis. These samples were chosen because they were completely typeable by ECDCT. Using both systems, association between strain types and neurosyphilis, defined as a reactive cerebrospinal fluid Venereal Disease Research Laboratory test, was determined. Partial and complete ECDCT types were also determined for samples from different anatomical sites in 35 patients, and from blood and blood isolates (rabbit propagated) from 13 patients. The MLST type could be fully determined for 100 (92.6%) of 108 samples. Although MLST subdivided 3 common ECDCT types, it failed to distinguish among others. Neurosyphilis was more common in individuals infected with type 1.1.2 and tp0705 type 2 using MLST, and tp0548 type f using ECDCT. Enhanced Centers for Disease Control and Prevention typing was stable among anatomical sites and between patient-derived and rabbit propagated organisms. Compared with ECDCT, MLST was not uniformly more discriminating. Both typing systems demonstrate that specific types may be more neurotropic than others.

2020 STD Prevention Conference: Disrupting Epidemics and Dismantling Disparities in the Time of COVID-19.

2020 STD Prevention Conference: Disrupting Epidemics and Dismantling Disparities in the Time of COVID-19.

Alternatives to the Cerebrospinal Fluid Venereal Disease Research Laboratory Test for Neurosyphilis Diagnosis.

The diagnosis of neurosyphilis relies in large part on the cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) test, which is diagnostically specific but not sensitive. We determined the sensitivity and specificity of 3 CSF tests in addition to the CSF-VDRL in participants with syphilis enrolled in a research study: detection of Treponema pallidum ribosomal RNA, T. pallidum particle agglutination titer, and chemokine (C-X-C motif) ligand 13 (CXCL13) concentration. Neurosyphilis was defined as asymptomatic or symptomatic meningitis: CSF white blood cells >10/μL without or with neurological symptoms, including new vision or hearing loss. Cerebrospinal fluid-VDRL, CSF T. pallidum ribosomal RNA detection, and CSF T. pallidum particle agglutination titer ≥1:640 were specific (89%-96%) but not sensitive (12%-48%). In contrast, diagnostic sensitivity of CSF-CXCL13 thresholds established from receiver operating characteristic curves using the Youden index was 78% to 83% and specificity was 76% to 81%. In individuals with nonreactive CSF-VDRL, neurosyphilis diagnosis could be confirmed by CSF-CXCL13 concentration in 69% to 75%. Further studies of CSF-CXCL13 should include CSF samples from multiple cohorts and countries and should use standard neurosyphilis definitions to establish uniform thresholds for diagnosis.

Ocular syphilis: case series (2000–2015) from 2 tertiary care centres in Montreal, Canada

ObjectiveTo describe the demographics, clinical presentation, proportion of co-infection with human immunodeficiency virus (HIV), and treatment of patients with ocular syphilis seen at the ophthalmology department of 2 tertiary centres in Montreal, Canada. DesignRetrospective case series. Participants and MethodsA total of 169 eyes of 115 patients, seen between 2000 and 2015, with a positive syphilis treponemal serology and a likely syphilis-related ophthalmologic diagnosis. Subgroup analysis was performed between HIV-infected and HIV-uninfected patients. ResultsMean age of onset was 55 years, and 79% were male. Mean presenting logMAR visual acuity was 0.7. HIV status was available for 66%, of whom 49% were HIV-infected. The anatomical ocular diagnoses included isolated anterior uveitis (18%) and posterior segment involvement (42%). Both eyes were affected in 47%. Lumbar puncture (LP) was performed in 55%, of whom 22% had a positive cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) test. Antibiotherapy, consisting of intravenous penicillin alone or in addition to intramuscular benzathine penicillin, was administered in 65 patients (69%). Treatment allowed a visual improvement of –0.23 logMAR. HIV-infected patients were younger men (p < 0.01) and had more abnormal CSF analysis (p = 0.02), but there were no statistically significant differences in the anatomical location of ocular inflammation or visual function improvement. ConclusionsGiven its varied presentations, syphilis must always be part of the differential diagnosis of intraocular inflammation. HIV testing and an LP are required in the evaluation of ocular syphilis, which should be treated as neurosyphilis with the appropriate regimen.

Predictors of unfavorable outcome in neurosyphilis: Multicenter ID-IRI Study.

Neurosyphilis (NS) has different clinical manifestations and can appear during any stage of syphilis. We aimed to identify the factors affecting poor outcome in NS patients. Patients with positive cerebrospinal fluid Venereal Disease Research Laboratory test, and positive serological serum treponemal or nontreponemal tests were classified as definite NS. The data of 141 patients with definite NS were submitted from 22 referral centers. Asymptomatic NS, syphilitic meningitis, meningovascular syphilis, tabes dorsalis, general paresis, and taboparesis were detected in 22 (15.6%), 67 (47.5%), 13 (9.2%), 10 (7%), 13 (9.2%), and 16 patients (11.3%), respectively. The number of HIV-positive patients was 43 (30.4%). The most common symptoms were headache (n= 55, 39%), fatigue (n= 52, 36.8%), and altered consciousness (50, 35.4%). Tabetic symptoms were detected in 28 (19.8%), paretic symptoms in 32 (22.6%), and vascular symptoms in 39 patients (27.6%). Eye involvement was detected in 19 of 80 patients (23.7%) who underwent eye examination and ear involvement was detected in eight of 25 patients (32%) who underwent ear examination. Crystallized penicillin was used in 109 (77.3%), procaine penicillin in seven (4.9%), ceftriaxone in 31 (21.9%), and doxycycline in five patients (3.5%). According to multivariate regression analysis, while headache was a protective factor in NS patients, double vision was significantly associated to poor outcome. We concluded that double vision indicated unfavorable outcome among NS patients. A high clinical suspicion is needed for the diagnosis NS. As determined in our study, the presence of headache in syphilitic patients can help in early diagnosis of central nervous system disease.

Neurosyphilis as a Cause of Transverse Myelitis in a Teenage Girl

BackgroundSyphilis is a sexually transmitted infection that was nearly eradicated in 2001 but is now making a resurgence. It has a wide range of clinical manifestations depending on disease stage. Neurosyphilis is an infrequently seen infectious disease with central nervous system involvement that can occur in either early- or late-stage syphilis. The diagnosis of neurosyphilis is challenging, primarily because Treponema pallidum, the infecting organism, cannot be cultured in vitro. This article describes a patient with neurosyphilis and reviews the epidemiology and clinical manifestations, diagnostics, and treatment of neurosyphilis. Case ReportIn compliance with the request of the Privacy Board of our institution, the numerical age of this patient has been omitted. A sexually active teenage girl who was treated for primary syphilis 2 years earlier presented to a tertiary children's hospital with paresthesia and weakness of her right leg, left arm, and neck. Magnetic resonance imaging revealed cervical intramedullary cord edema consistent with transverse myelitis. Serum studies showed positive syphilis enzyme immunoassay, T. pallidum particle agglutination assay, and fluorescent treponemal antibody absorption. A serum rapid plasma reagin test was negative. A lumbar puncture was performed with normal cell count and protein. A cerebrospinal fluid Venereal Disease Research Laboratory test was negative. She was diagnosed with neurosyphilis and treated with intravenous steroids and penicillin G, with near complete resolution of symptoms. Why should an Emergency Physician Be Aware of This?The Centers for Disease Control and prevention has noted a steady rise of the incidence of syphilis since 2002. Emergency physicians should be familiar with the spectrum of the clinical manifestations of syphilis, challenges in diagnostics, and appropriate treatment course.

Watch Out! Syphilis Is Back – Case Series of Four Cases of Ocular syphilis

Background Syphilis is an ulcerative sexually transmitted genital infection caused by Treponema pallidum, which is a member of the order Spirochaetales, family Spirochaetaceae, and genus Treponema. The incidence rate of Syphilis has been steadily rising since 2000; from 2.1 cases per 100,000 population to up to 7.5 cases per 100,000 population in 2014–2015 (the highest rate since 1994). In the state of West Virginia, we have witnessed an increase in the number of cases from 0.5 cases per 100,000 population in 2011, to 5.9 cases per 100,000 population in 2015. Systemic symptoms can include cardiovascular and neurological manifestations. We report to your attention four cases of syphilis mainly with neurological and ocular manifestations.Methods We report a series of four cases of neurosyphilis we encountered between 2013 and 2016. Main presentation of all four cases was ocular; primarily redness and photophobia. Diagnosis was confirmed by standard ophthalmological examination with positive initial rapid plasma regain titers (RPR) and fluorescent treponemal antibody absorption testing (FTA-ABS). The cerebrospinal fluid venereal disease research laboratory test (CSF-VDRL) was positive in two of the four cases (in which lumbar puncture was performed). Two of the four cases suffered from an overt immunodeficiency (HIV and laryngeal cancer on chemotherapy) and subjects of all four cases confessed to high-risk sexual behaviors. All four cases were managed with continuous infusions of Penicillin G potassium 24 million International Units for 14 days with variable response.ResultsResponse to treatment was variable in that initial complete resolution was achieved in one patient (Case #3), another (Case #1) was retreated in 6 months due to rising RPR titers on follow-up with subsequent improvement. Two patients were lost to follow-up (Cases #2 and #4).Conclusion Sir William Osler reportedly said: “He who knows syphilis knows medicine”. The steady rise in the incidence of Syphilis warrants that health care providers consider such a diagnosis in the evaluation of suggestive neurological and ocular manifestations in predisposed patients. We also stress on the importance of follow-up to detect failure of initial treatment.Disclosures All authors: No reported disclosures.

Recent change in congenital syphilis in Korea: Retrospective 10 year study.

This study was conducted to evaluate recent clinical and anthropologic features of neonates with reactive serology for syphilis and their mothers from three institutions in Korea over an 11-year-period. The medical records of 20 neonates with reactive serology for syphilis and their mothers at three centers (Kyung Hee University Hospital, Kyung Hee University Hospital at Gangdong, and Korea Electric Power Corporation Hospital) seen between January 2000 and December 2010 were reviewed retrospectively. Among 20 mothers, 16 (80%) were native Korean and four (20%) were foreign-born immigrants. Two mothers (10%) were unmarried. The annual distribution of cases was three (15%) in 2000, one each (5%) in 2005 and 2006, respectively, two each (10%) in 2007 and 2008, respectively, six (30%) in 2009, and five (25%) in 2010. Just over half (55%) occurred across 2009 and 2010. All neonates, by definition, were diagnosed with presumptive congenital syphilis (CS). Among the neonates, four had positive cerebrospinal fluid venereal disease research laboratory test, and three exhibited symptoms and signs. In three centers in Seoul, Korea, the observed number of CS cases was higher in 2009 and 2010 than in previous years. This finding is consistent with a trend toward increasing prevalence of international marriage and suggests that more meticulous screening of CS is needed.

Point-of-care treponemal tests for neurosyphilis diagnosis.

The laboratory diagnosis of neurosyphilis rests upon identifying cerebrospinal fluid (CSF) abnormalities, including CSF-Venereal Disease Research Laboratory (VDRL) reactivity. The CSF-VDRL may not be available in the parts of the world where neurosyphilis is most common. Treponemal immunochromatographic strip tests (ICSTs) have been developed as point-of-care tests on blood for syphilis diagnosis in resource-limited settings. We optimized 3 commercial ICSTs for performance on CSF and tested CSF samples from 217 patients with syphilis. The Syphicheck-WB test (Qualpro Diagnostics, Goa, India; "Syphicheck") was chosen for further study based on agreement with CSF-VDRL test results. We determined CSF-Syphicheck titers for 152 samples. We modified the CSF-Syphicheck for point-of-care testing in a US sexually transmitted diseases clinic and compared results on 102 paired centrifuged and uncentrifuged CSF samples obtained in the laboratory to the results obtained at point of care; results of samples diluted 1:4 were compared in a subset. The diagnostic sensitivity of a reactive CSF-Syphicheck (62%-64%) and the diagnostic specificity of a CSF-Syphicheck titer at or above 1:4 (79%-81%) were equivalent to the CSF-VDRL (54%-69% sensitivity, 73%-75% specificity) for laboratory and clinical neurosyphilis diagnoses. The CSF-Syphicheck normalized after neurosyphilis therapy similarly to the CSF-VDRL. The modified CSF-Syphicheck performed well at the point of care, albeit with better performance on cell-free compared with uncentrifuged CSF. Cerebrospinal fluid treponemal ICSTs hold promise for point-of-care neurosyphilis diagnosis in regions where the CSF-VDRL is not available. Further study should address the performance of CSF ICSTs in resource-limited settings.

A Patient With Progressive Cognitive Decline and Periodic Abnormal Waves in EEG

We report one Chinese patient with neurosyphilis exhibiting periodic lateralized epileptiform discharges (PLEDs) in the electroencephalogram (EEG). The patient (male, 59 years old) manifested with progressive cognitive decline and abnormal behavior. After several days, he gradually lost contact with others, and fell into a coma. EEG revealed periodic abnormal waves, predominantly located in the right anterior frontal region. The serum and cerebrospinal fluid Venereal Disease Research Laboratory test and Treponema pallidum hemagglutination assay were positive. Magnetic resonance imaging (MRI) of brain showed focal atrophy in the right frontal and temporal region. Diffusion-weighted MRI showed "lace sign" in cortex, which could be seen as an early and special feature in Creutzfeldt-Jakob disease (CJD). To differentiate "PLEDs of neurosyphilis on EEG" from "periodic synchronous discharges (PSD) of CJD on EEG," we treated this patient with diazepam 20 mg intravenously. After 10 minutes, periodic abnormal waves on EEG disappeared, with improved mental status, which confirmed the diagnosis of PLEDs of neurosyphilis. Then, after the treatment with penicillin, the patient improved and returned to work.

Unilateral mydriasis as the primary sign of neurosyphilis

Syphilis can mimic most ocular disorders, and there is no characteristic to distinguish ocular syphilis from other eye diseases. We report a rare case of a 41-year-old man who presented with an Adie's-like pupil as the only feature of neurosyphilis. The patient met the criteria for the diagnosis of neurosyphilis by the finding of positive cerebrospinal fluid-Venereal Disease Research Laboratory (CSF-VDRL) and CSF-Treponema pallidum particle agglutination tests. The patient was then treated with 2 g intravenous ceftriaxone per day for 15 days because of penicillin allergy. Nine months after anti-syphilitic treatment alone, the diameter of the patient's left pupil reduced from 10 to 5 mm. The CSF-VDRL test was negative. It is highly recommended that any patients with ocular disease that does not respond to the routine treatment should undergo syphilis evaluation to avoid misdiagnosis.

Missed Opportunities for Preventing Congenital Syphilis Infection

To the Editor: Louisiana has experienced high and increasing rates of congenital syphilis (CS) since 2005.1 Using data from Louisiana’s Office of Public Health Sexually Transmitted Disease/HIV Program’s electronic investigation and reporting system, we reviewed data for all patients with CS born from January 1, 2010 to October 6, 2011. Similar to other recent US reports, we found women with documented prenatal care who did not receive recommended testing or treatment for syphilis.2 Fifty-five women gave birth to 57 infants identified as CS cases by the Louisiana Sexually Transmitted Disease/HIV Program; cases can be identified based on a mother’s history of untreated syphilis or findings in the infant.1 This corresponds to 51.9 cases per 100,000 births.3 Thirty-six women (65%) had documented prenatal care before 30 weeks of gestation. Of those 36, 4 (11%) had documented adequate treatment for syphilis before pregnancy, and 19 (53%) had adequate maternal treatment during pregnancy. Among those 23, 3 women had infants with abnormal evaluations. The remaining 20 women had infants who were classified as CS cases due to maternal serology or reasons that are unclear. Five (14%) of the 36 received penicillin-based treatment less than 30 days before delivery, and 8 (22%) had no treatment documented. No woman received non–penicillin-based treatment. Of the 8 women with no treatment documented, 1 had a positive syphilis test result 5 months before delivery, and 6 had their first positive test result at delivery or within 1 month of delivery, without documentation of prior negative test results. Only 1 untreated woman who tested positive at delivery had a documented negative syphilis test result at her first prenatal visit. The 5 women who received late treatment, together with the 7 women with no treatment who were tested late in pregnancy, represent 12 missed opportunities to prevent CS in Louisiana in less than 2 years. Documented infant evaluation was often incomplete, and some infants did not receive treatment. Twenty-three infants (40.3%) had a documented cerebrospinal fluid Venereal Disease Research Laboratory test, and 3 (13%) were positive. Seventeen infants (29.8%) had a documented cerebrospinal cell count/protein, and 12 (70.6%) had abnormal results. Twenty-three infants (40.3%) had documented bone radiographs, and 1 (4.3%) had an abnormal result. Three infants (5.3%) had unspecified clinical manifestations of CS documented on physical examination. Six infants (10%) were documented to have no treatment for CS during their hospitalization. Our analysis was limited to data in Louisiana’s electronic investigation and reporting system, and it is possible that clinical care occurred that was not documented by the public health workers. Congenital syphilis is preventable with quality, timely prenatal care. Although screening and treating women who do not present for prenatal care is a major challenge, providing appropriate care to those who do present is imperative. The Centers for Disease Control and Prevention, the American College of Obstetrics and Gynecologists, and the American Academy of Pediatrics recommend universal syphilis screening of pregnant women at the first prenatal visit and repeat screening in the third trimester and at delivery in high-morbidity areas.4 By working together, health departments and providers can ensure that these guidelines are followed and that pregnant women are treated for syphilis rapidly and appropriately to prevent CS infections. Camille E. Introcaso, MD Heather Bradley, PhD Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA [email protected] DeAnn Gruber, PhD Louisiana Office of Public Health STD/ HIV Program, New Orleans, LA Lauri E. Markowitz, MD Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA

Progressive Visual and Hearing Loss Secondary to Neurosyphilis

There is a rising incidence of syphilis in economically advanced countries. Early diagnosis can spare the patient devastating vision and hearing loss, as well as other significant morbidity. Ocular presentations of neurosyphilis are varied and numerous, requiring syphilis to be considered in many clinical situations, even if a negative medical history is reported. Features of Argyll Robertson pupils, however, are virtually pathognomonic of syphilis; therefore, careful pupil testing can be the key to making a correct and timely diagnosis. A 51-year-old woman with a history of unexplained hearing loss presented for a third opinion for progressive vision loss OU, which was previously labeled as functional loss. A review of records indicated significant worsening of visual acuity and visual fields over 6 months, with minimal remaining visual function. She exhibited features of optic neuropathy as well as 2 mm miotic pupils, with evident light-near dissociation bilaterally. Evaluation showed a reactive fluorescent treponemal antibody absorption and rapid plasma reagin (1:8 titer) and positive cerebral spinal fluid venereal disease research laboratory test. A diagnosis of neurosyphilis was made, and a 2-week course of intravenous penicillin treatment was completed. Despite treatment, her vision decreased to no light perception OU owing to the advanced course of the disease at the time of treatment. Neurosyphilis can occur at any stage of infection and needs to be considered in the differential diagnosis for many visual and ocular problems, especially in the setting of other systemic signs and symptoms. In this case, the combination of light-near dissociation and optic neuropathy with hearing loss was instrumental in dismissing the past diagnosis of functional vision loss and in pursuing the diagnosis of neurosyphilis. A timely diagnosis of neurosyphilis needs to be made to prevent devastating vision loss as seen in this case.

The Rapid Plasma Reagin Test Cannot Replace the Venereal Disease Research Laboratory Test for Neurosyphilis Diagnosis

The cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) test is a mainstay for neurosyphilis diagnosis, but it lacks diagnostic sensitivity and is logistically complicated. The rapid plasma reagin (RPR) test is easier to perform, but its appropriateness for use on CSF is controversial. RPR reactivity was determined for CSF from 149 individuals with syphilis using 2 methods. The CSF-RPR was performed according to the method for serum. The CSF-RPR-V was performed using the method recommended for the CSF-VDRL. Laboratory-defined neurosyphilis included reactive CSF-fluorescent treponemal antibody absorption test and CSF white blood cells >20/uL. Symptomatic neurosyphilis was defined as vision loss or hearing loss. CSF-VDRL was reactive in 45 (30.2%) patients. Of these, 29 (64.4%) were CSF-RPR reactive and 37 (82.2%) were CSF-RPR-V reactive. There were no instances where the CSF-VDRL was nonreactive but the CSF-RPR or CSF-RPR-V was reactive. Among the 28 samples that were reactive in all 3 tests, CSF-VDRL titers (median [IQR], 1:4 [1:4-1:16]) were significantly higher than CSF-RPR (1:2 [1:1-1:4], P = 0.0002) and CSF-RPR-V titers (1:4 [1:2-1:8], P = 0.01). The CSF RPR and the CSF-RPR-V tests had lower sensitivities than the CSF-VDRL: 56.4% and 59.0% versus 71.8% for laboratory-diagnosed neurosyphilis and 51.5% and 57.6% versus 66.7% for symptomatic neurosyphilis. Compared with the CSF-VDRL, the CSF-RPR has a high false-negative rate, thus not improving upon this known limitation of the CSF-VDRL for neurosyphilis diagnosis. Adapting the RPR procedure to mimic the CSF-VDRL decreased, but did not eliminate, the number of false negatives and did not avoid all the logistical complications of the CSF-VDRL.

Neurosyphilis With Unilateral Optic Tract Lesion Causing Homonymous Hemianopia

Homonymous hemianopia is not a rare symptom. Many causative lesions and pathologies are known, although a unilateral optic tract lesion caused by syphilis is rare. A 56-year-old woman developed a congruous right homonymous hemianopia and bilateral tonic pupils with irregular shape. Brain T2-weighted and fluid attenuated inversion recovery magnetic resonance imaging (MRI) revealed a spindle-like high-intensity lesion in her left postchiasmal optic tract. The rim of this lesion enhanced with gadolinium without meningeal enhancement. Serum and cerebrospinal fluid venereal disease research laboratory tests were positive. Cerebrospinal fluid contained 71 white blood cells/microL (mononuclear cells = 97%) and 48 mg/dL of protein. The hemianopia disappeared after administration of benzylpenicillin. Neurosyphilis should be added to the list of differential diagnoses for an isolated optic tract lesion.

Antenatal syphilis serology in pregnant women and follow-up of their infants in northern Italy

Positive syphilis serology was noted in 119 (0.49%) of the 24 053 pregnant women delivering at St Orsola Hospital in Bologna, Italy, from November 2000 through July 2007. Six presumptive cases of congenital syphilis with IgM western blot positive results were found. Two infants had a positive cerebrospinal fluid (CSF) Venereal Disease Research Laboratory test result (one also had a positive CSF PCR result), another presented long-bone lesions, and the remaining three were preterm. These observations confirmed that antenatal syphilis screening facilitates treatment during pregnancy and offsets vertical transmission; moreover, the use of IgM western blot and careful CSF examination allowed the identification and treatment of high-risk newborns.