Fluorescent Treponemal Antibody Absorption Research Articles

Performance Assessment of Treponemal and Nontreponemal Tests for the Diagnosis of Acquired Syphilis.

There are a variety of nontreponemal test (NTT) and treponemal test (TT) kits for the serologic diagnosis of syphilis. Because of the complexity of the infection (multiple clinical stages) and the different antigens used in these kits, a systematic evaluation of the accuracy of the currently available commercial tests is warranted. Our objective was to evaluate the performance of commercially available tests for the diagnosis of syphilis infection. In this study, we analyzed one NTT (Venereal Disease Research Laboratory [VDRL] test, Wiener Laboratories, Rosario, Argentina) and two TTs (fluorescent treponemal antibody absorption [FTA-ABS] test, Euroimmun, Lübeck, Germany, and syphilis recombinant ELISA v. 4.0 test [ELISA], Wiener Laboratories, Rosario, Argentina) using a panel of 187 samples, including serum samples from 31 individuals with primary syphilis, 77 with secondary syphilis, and 79 with latent syphilis. An additional 192 samples from uninfected individuals and 323 serum samples from individuals with other diseases were included. The sensitivities of the VDRL, ELISA, and FTA-ABS tests were 97.9%, 100%, and 96.3%, respectively. The VDRL and ELISA tests showed a specificity of 100%, and the FTA-ABS test showed a specificity of 99.5%. Accuracy was 98.9% for the VDRL test, 100% for the ELISA, and 97.9% for the FTA-ABS test. For primary, secondary, and latent syphilis, the ELISA achieved a diagnostic performance of 100%, whereas the sensitivity for the VDRL and FTA-ABS tests ranged from 96.8% to 98.7% and 93.7% to 98.7%, respectively. No difference was observed when the tests were used as traditional or reverse algorithms. In general, all three tests are able to discriminate positive and negative samples for syphilis, regardless of the diagnostic algorithm.

Üçüncü Basamak Bir Hastanenin Transfüzyon Merkezine Başvuran Donörlerde Sifiliz Tarama Sonuçlarının Değerlendirilmesi

Amaç: Kan bankacılığında Treponema pallidum'un neden olduğu sifiliz tanısı halk sağlığı açısından önemlidir. Donörler arasındaki olası vakaların yakalanması ve böylece donör kaybının en aza indirilmesi için en uygun algoritmanın benimsenmesi gerekmektedir. 2003 yılında Dünya Sağlık Örgütü ve 2010 yılında Avrupa Hastalık Önleme ve Kontrol Merkezi, sifiliz taramalarına Treponemal testlerle başlanmasını tavsiye etti. Bu çalışmada, kan bağışçısı adaylarında sifiliz taramasında reaktif Enzime Bağlı İmmünosorbent Test (ELISA) sonuçları ile yapılan doğrulayıcı testlerin sonuçlarının araştırılması amaçlandı.
 Gereç ve Yöntemler: Retrospektif olarak yapılan bu çalışmada, 2014-2021 yılları arasında Ankara Gülhane Eğitim ve Araştırma Hastanesinin kan bankasına kan bağışçısı olarak başvuran 69.127 bağışçı incelendi. Sifiliz tarama testinde reaktif çıkan donör adaylarından alınan örnekler, doğrulama testleri için Türkiye Halk Sağlığı Kurumu Mikrobiyoloji Referans Laboratuvarı'na gönderildi. Doğrulama testleri olarak Floresan Treponemal Antikor Emilimi (FTA-ABS) veya Treponema Pallidum Hemaglütinasyon Testi (TPHA) testleri kullanıldı.
 Bulgular: 128 donörde (%0,18) tekrar tekrar reaktif test sonuçları elde edildi. Doğrulayıcı bir test olarak 32 donöre TPHA uygulandı ve 11 pozitif sonuç (%34,3) elde edildi (Yanlış pozitiflik oranı = %65,7). FTA-ABS, doğrulama testi olarak 96 donörde yapıldı ve 59'unun (%61,4) testi pozitif çıktı (Yanlış pozitiflik oranı = %38,6). ELISA sinyal-kesme oranı beşin üzerinde olan 48 donörden 42'sinde FTA-ABS testi yapıldı ve 41 pozitif ve bir negatif sonuç elde edildi.
 Sonuçlar: Kan transfüzyonu ile ilişkili Treponema pallidum bulaşması önemli bir istenmeyen olay olduğundan, kan donörlerinin taranması için en uygun testlerin kullanılması gerekmektedir. Bu çalışma, FTA-ABS'nin ELISA-reaktif donörler için doğrulayıcı bir test olarak kullanılmasının, sifiliz tespit doğrulanmasını arttırdığını göstermektedir.

Syphilitic Chorioretinitis – two case Reports and Literature Analysis

IntroductionSyphilis, a systemic, sexually transmitted inflammatory disease caused by Treponema pallidum, presents challenges in diagnosis due to its varied manifestations. Ocular syphilis often presents with non-specific symptoms. This study aims to elucidate the diagnostic process through the analysis of two patient cases, including one with HIV co-infection.Material and MethodsThe study evaluated two ocular syphilis cases, diagnosed using comprehensive treponemal (fluorescent treponemal antibody absorption test, Treponema pallidum hemagglutination assay, enzyme immunoassay) and nontreponemal (venereal disease research laboratory test, rapid plasma reagin test) testing. Factors such asuveitis symptoms, sexual behavior, drug use, previous treatments, and available medical history were considered.ResultsThe results highlight the complexity of ocular syphilis diagnosis. Both cases underscored the need to include ocular syphilis in differential diagnoses for eye infections or inflammations, especially in patients with high-risk behaviors, drug use, or a history of syphilis. The non-specific nature of symptoms necessitates comprehensive testing for accurate diagnosis.ConclusionsThis study reinforces the importance of considering ocular syphilis in the differential diagnosis of inflammatory eye diseases. A meticulous approach combining both treponemal and nontreponemal tests is crucial for accurate diagnosis. These findings emphasize the need for thorough clinical evaluation and history-taking in patients presenting with ocular symptoms.

Neurological manifestations of syphilis-HIV coinfection in South Africa

ObjectiveSyphilis and HIV coinfection is highly prevalent in South Africa, and both can cause neurological complications. We describe the clinical presentation and outcome of neurosyphilis in patients with and without HIV coinfection diagnosed at a tertiary facility, Groote Schuur Hospital (GSH), in South Africa. MethodsWe retrospectively analyzed folders of adults with positive cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption test in 2018 and 2019, with follow-up data collected until 2022. ResultsHIV-coinfection was identified in 35% of the 69 included patients. Patients with HIV-coinfection were more likely to be female (58% vs 25% female, p < 0.01), and present earlier (median age = 31 years vs. 40 years, p < 0.001). Neuropsychiatric manifestations (confusion, dementia, psychosis), and strokes were the commonest clinical presentations in both groups. Those with HIV-coinfection were significantly less likely to be diagnosed with neurosyphilis by the treating clinician (71% vs. 91%, p < 0.05), as were those with a negative CSF Venereal Disease Research Laboratory (74% vs. 94%, p < 0.05). Accurate diagnosis of neurosyphilis was associated with an increased 12-month survival (alive: N = 36 [63%]) relative to those who did not receive an accurate diagnosis (alive: N = 2 [17%], p < 0.05). Those who were optimally treated with antibiotics had significantly higher 12-month survival (alive: N = 33, 63%) compared to those with suboptimal treatment (alive: N = 5, 29%), p < 0.01. ConclusionNeurosyphilis presented similarly in those with and without HIV-coinfection. Accurate identification and optimal antibiotic treatment of neurosyphilis, particularly in CSF VDRL negative patients and those with HIV-coinfection, is necessary to improve patient survival.

Acute Retinal Necrosis: Experience in a Reference Center in Santander – Colombia

ABSTRACT Introduction Acute retinal necrosis (ARN) is a severe eye disease demanding swift treatment to prevent blindness. Early action involving antiviral medications and corticosteroids is crucial for optimal visual outcomes. Objective We present an ARN case series showcasing treatment experience and results. Methodology Patients diagnosed with ARN based on SUN Working Group 2021 criteria were included; all underwent comprehensive eye exams, PCR analysis, and imaging. Results Eight patients were studied; PCR confirmed ARN in six. Induction treatment, either oral valacyclovir (5/8) or intravenous acyclovir (3/8), lasted 10-14 days. Maintenance included oral valacyclovir (6/8), oral valganciclovir (2/8) for six months, along with intravitreal ganciclovir. Visual outcomes were similar for oral and intravenous therapies; poor baseline acuity and macular involvement tend to result in a worse final acuity. Conclusions Swift treatment is vital to ARN management. Our findings emphasize effective treatment strategies' role in visual prognosis. Abbreviations ACV: Acyclovir; BCVA: Best Corrected Visual Acuity; CMV: Cytomegalovirus; EBV: Epstein Barr Virus; FTA-ABS: Fluorescent treponemal antibody absorption test; HSV 1-2: Herpes simplex virus 1-2; HIV: Human Immunodeficiency Virus; IV-ACV: Intravenous- Acyclovir; PCR: Polymerase Chain Reaction;Tg: Toxoplasma gondii; VZV: Varicella Zoster Virus; VCV: Valacyclovir; VDRL: Venereal disease research laboratory test.

ORAL MANIFESTATIONS OF SECONDARY SYPHILIS: A CASE REPORT

Syphilis is a sexually transmitted disease caused by Treponema pallidum infection. Oral manifestations of secondary syphilis can be more extensive and variable than those of primary syphilis. A 57-year-old female presented a one-month history of mouth and throat ulcers. Extraoral examination revealed cervical lymphadenopathy and erythematous spots on her wrists and side of left foot. Intraorally, there were multiple erosive plaques on palatine tonsils, border of the tongue, and lower labial mucosa. Diagnostic hypotheses included erythema multiforme, pemphigus vulgaris, and syphilis. Incisional biopsy was performed and histopathological analysis revealed chronic inflammatory infiltrate rich in lymphocytes and plasma cells. Therefore, infection was suspected and serological tests were performed. VDRL, TPPA, and FTA-ABS tests yielded positive results, indicating a diagnosis of syphilis. Antibiotic therapy was begun, and oral and skin lesions disappeared within one month. Clinicians must be familiarized with the oral manifestations of syphilis, an emerging disease with varied clinical aspects. Syphilis is a sexually transmitted disease caused by Treponema pallidum infection. Oral manifestations of secondary syphilis can be more extensive and variable than those of primary syphilis. A 57-year-old female presented a one-month history of mouth and throat ulcers. Extraoral examination revealed cervical lymphadenopathy and erythematous spots on her wrists and side of left foot. Intraorally, there were multiple erosive plaques on palatine tonsils, border of the tongue, and lower labial mucosa. Diagnostic hypotheses included erythema multiforme, pemphigus vulgaris, and syphilis. Incisional biopsy was performed and histopathological analysis revealed chronic inflammatory infiltrate rich in lymphocytes and plasma cells. Therefore, infection was suspected and serological tests were performed. VDRL, TPPA, and FTA-ABS tests yielded positive results, indicating a diagnosis of syphilis. Antibiotic therapy was begun, and oral and skin lesions disappeared within one month. Clinicians must be familiarized with the oral manifestations of syphilis, an emerging disease with varied clinical aspects.

The great masquerader: recurrent ischemic strokes secondary to meningo-vascular syphilis in a 62-year-old patient with stroke risk factors (P12-5.019)

<h3>Objective:</h3> N/A <h3>Background:</h3> Syphilis is a debilitating multisystem disease resulting from infection with the spirochete Treponema pallidum. Even though it is uncommon, it is a great mimic of stroke and is misdiagnosed almost 80% of the time. It commonly involves the middle cerebral artery and basilar or anterior spinal artery territories. 4% of patients with recurrent strokes can have syphilis. We present a patient with a recurrent stroke due to meningo-vascular syphilis (MVS). <h3>Design/Methods:</h3> A 62-year-old male with hypertension, hyperlipidemia, diabetes, and coronary artery disease presented with confusion and word-finding difficulty, and was found to have an acute ischemic stroke in the right basal ganglia (BG). The patient was discharged on dual anti-platelet therapy and statin for secondary stroke prevention. As a part of the stroke workup, he was found to be highly reactive for rapid plasma regain, and the subsequent fluorescent treponemal antibody absorption test was reactive with the diagnosis of syphilis. He presented again 3 weeks later with transient facial paralysis. The cerebrospinal fluid was positive for a Venereal Disease Research Laboratory test, indicative of MVS. He received 4 million units of penicillin every 4 hours intravenously for 14 days with improvement in symptoms and no further recurrence of strokes. <h3>Results:</h3> N/A <h3>Conclusions:</h3> Our patient presented with acute ischemic infarct in BG, etiology thought to be small vessel disease in the setting of multiple stroke risk factors. Meningo-vascular syphilis, a subtype of neurosyphilis, can cause recurrent ischemic strokes. While uncommon, neurosyphilis remains prevalent in the United States and is often misdiagnosed because of its heterogenous clinical features. Syphilis screening is usually considered in young patients with a prior documented history of sexually transmitted disease however it is prudent that patients with recurrent strokes might benefit from routine screening tests for syphilis, regardless of age group or the presence of stroke risk factors. <b>Disclosure:</b> Dr. Waheed has nothing to disclose. Dr. Carranza-Renteria has nothing to disclose. Dr. Yousuf has nothing to disclose.

Secondary Syphilis: Pathophysiology, Clinical Manifestations, and Diagnostic Testing

The subspecies T. pallidum pallidum is the cause of the most infamous sexually and congenitally transmitted disease, syphilis. This disease has an estimated incidence of six million infections every year. Multiple studies have noted that the prevalence of syphilis has been steadily increasing worldwide in recent decades, especially among MSMs and HIV-positive patients. Clinically, syphilis presents in four stages with multiple different clinical manifestations. In this paper, we examine the current literature to determine the history and progression, pathogenesis, clinical features, and testing of secondary syphilis. Secondary syphilis is a stage of the disease with the most exuberant local and systemic clinical manifestations. The basis of the pathogenesis of SS underscores the unique mechanisms by which Treponema pallidum utilizes to escape immune recognition while simultaneously induces inflammation. SS can affect multiple organ systems and become more than just an STD. The most common presentation of secondary syphilis is rash, which manifests as a copper-colored maculopapular lesion on the trunk, palms, and soles. Although the RPR, VDRL, and FTA-ABS tests are perhaps the most commonly used diagnostic tools for syphilis and make up the traditional and reverse algorithms, there are other methods, including morphology and immunohistochemistry.

The role of VDRL in phirang rog

A perfect scientific medical science by the name of Ayurveda is a gift given by our ancestors which deals with our daily activities to annual activities which help us to maintain our physical and mental health. Many diseases and their treatment have been described by them, some of which are not present today and some still exist. As new diseases arrived in the Indian subcontinent during the period, they came to India through invaders or traders, they were described by our ancestors with their pathogenesis, signs and symptoms, complication, prognosis and treatment. One of them is Phirang rog, which came from Europe, was not found in our scriptures before 16th century. Presently its compatibility with the Syphilis disease can be seen. Timely diagnosis and treatment is necessary to prevent the spreading of disease and the development of irreversible tissue damage. In Syphilis RPR (Rapid Plasma Reagin), VDRL (Venereal Disease Reasearch Laboratory Test), FTA-ABS (Fluorescent Treponemal Antibody Absorption), TP-PA (Treponema Pallidum Particle Agglutination assay), Darkfield microscopy are advised for diagnosis. This study has been done to prove the usefulness of VDRL in the diagnosis of Phirang rog.

Understanding Utilization and Seroprevalence of Syphilis Tests in Local Clinics and Hospitals in Korea

Diagnosis of syphilis, a sexually transmitted infection, can be based on clinical information and various combinations of results of both non-treponemal and treponemal assays. Because understanding a patient population is helpful for test utilization in the clinical laboratory, we aimed to investigate the results of syphilis serology tests requested from local clinics in Korea. We retrospectively evaluated the syphilis serology test results of serum Rapid Plasma Reagin (RPR), Treponema pallidum latex agglutination (TPLA), RPR titer, and fluorescent treponemal antibody absorption (FTA-ABS) IgG, and IgM tests performed in Korean adults in the laboratory information system of Green Cross Laboratories. We investigated the patterns of syphilis serology test results and possible interpretation according to combinations of syphilis serology based on a traditional testing algorithm. During the one-year study period, 33,746 RPR tests were performed in Korean adults (7,622 men and 26,124 women) with a median age of 35.1 years (interquartile range 30.8 - 43.4 years). Among these RPR tests, 317 (0.9%) showed RPR+ results and were performed simultaneous with TPLA tests. Among these 317 patients, 187 (59.0%) had RPR+/TPLA+ results. Among 130 patients with RPR+/TPLA- results, FTA-ABS IgG and IgM were only tested in 15 (11.5%): 14 were IgG-/IgM-, and one who underwent only the IgM test showed a negative result (probably a biological false positive of RPR). Among 187 RPR+/TPLA+ patients, 60 (2.1%) had RPR titer ≥ 1:8, and 10 were FTA-ABS IgM+ (including weak reactive results probably due to current infection or rare biological false-positive). Among 121 patients with RPR+/TPLA+/RPR titer ≤ 1:4, 30 were tested for FTA-ABS IgG and/or IgM: the two FTA-ABS IgM+ (including weak reactive) patients had an RPR titer of 1:4. This study will help to understand patient populations and test utilization for syphilis serology test interpretation in clinical laboratories in Korea. Further studies are needed to investigate the clinical impact of test utilization of syphilis serology in Korea.

Bilateral Extensive Syphilitic Punctate Inner Retinitis Triggering Macular Ischemia after Intravitreal Triamcinolone Injections

Purpose: To report a case of extensive syphilitic punctate inner retinitis (SPIR) triggering bilateral macular ischemia after intravitreal triamcinolone injections, and the multimodal retinal imaging findings.Case summary: A 69-year-old male patient with nonproliferative diabetic retinopathy was transferred to our hospital because of bilateral visual deterioration (to counting fingers) after the first intravitreal triamcinolone injection. Fundus examination revealed numerous yellow punctate precipitates in the superficial retinae, retinal arteriolitis, and vitritis. The punctate lesions and surrounding retinal regions showed decreased vascular density on optical coherence tomography angiography, and focal hypofluorescence on fluorescein angiography. The patient was positive for all of the Venereal Disease Research Laboratory test, the fluorescent treponemal antibody-absorption test, and &lt;i&gt;Treponema pallidum&lt;/i&gt; hemagglutination; we diagnosed bilateral SPIR. After treatment with aqueous crystalline penicillin solutions (24 million units per day for 14 days), the punctate lesions reduced but arteriolitis progressed to obliterative vasculitis. After 6 months, the bilateral SPIR and vitritis resolved, and the bilateral visual acuity improved to 20/100. However, inner retinal and macular ischemia persisted because of capillary nonperfusion attributable to obliterative vasculitis.Conclusions: Extensive SPIR can develop after an initial intravitreal steroid injection; the inner retinal ischemia and visual loss may persist after treatment because obliterative vasculitis develops. Therefore, patients scheduled for intravitreal steroid injections should be screened for syphilis infection.

Secondary syphilis in oral cavity: Case report and literature review

Introduction: Syphilis is the most common sexually transmitted infection and may have heterogeneous clinical features. There are several studies that report the incidence and clinical features of secondary syphilis, but little emphasis is placed on unusual clinical patterns. Here, we report a case of secondary intraoral syphilis with the appearance of whitish plaques. Case Report: A 30-year-old woman complained of multiple plaques in the oral cavity that had not healed for 15 days. An incisional biopsy was performed and revealed histological features consistent with syphilis. Serological test of venereal disease research laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-ABS) were reactive. Diagnosis of secondary syphilis was closed. The patient underwent penicillin therapy. Conclusion: In conclusion, secondary syphilis can become a potential diagnostic challenge due to the distinct clinical spectrum.

Comparison of 17 serological treponemal and nontreponemal assays for syphilis: A retrospective cohort study

ObjectivesRapid plasma reagin (RPR) and Treponema pallidum (TP) antibody test kits are often used to diagnose syphilis, although the relationship between their measured values is unclear. We aimed to reveal the relevance of these kits’ results. Design and methodsIn all, 143 sera from 110 patients were tested using 12 TP kits and 5 RPR kits and the results compared. ResultsThe specificity and sensitivity of RPR kits were 81–96% and 95–100%, respectively. The correlation coefficients (0.849–0.934) considerably differed between the manual RPR card test and latex agglutination (LA) assay kits. The following sensitivities were obtained: 82–91% for TP fluorescent treponemal antibody absorption assay (FTA-ABS), TP hemagglutination assay (HA), and TP particle agglutination assay (PA); 94–95% for TP LAs; and 92–100% for chemiluminescent immunoassay (CLIA), chemiluminescent enzyme immunoassay (CLEIA), and immunochromatography assay (IC). Correlation coefficients between TP kits were 0.753–0.974, and the measured values varied. Changes in RPR and quantifiable TP kits were the same for patients with reinfected syphilis and with syphilis under treatment. ConclusionsRPR tests had lower specificity than TP antibody tests. RPR card test and RPR LAs had similar specificity and sensitivity, but their measured values were different. RPR should be measured using automatic RPR LA without setting the upper limit of the reported value. RPR LA should also be standardized. The sensitivity of TP antibody was better in CLIA, CLEIA, and IC than in FTA-ABS, HA, PA, and LA. Therefore, TP antibody kits should be standardized and quantified.

Clinical and laboratory features in patients with positive syphilis serology presenting with acute ischemic stroke or transient ischemic attack: a prospective cohort study

BackgroundNeurosyphilis (NS) can lead to acute ischemic stroke (AIS) or transient ischemic attack (TIA). We compared the clinical characteristics and laboratory features among AIS and TIA patients who were syphilis-seronegative (control group) or had latent syphilis (LS) or NS to evaluate their stroke outcome.MethodsThis prospective cohort study was conducted on patients who had recently suffered AIS or TIA. After serological syphilis screening, clinical and laboratory data were collected, and brain imaging and spinal tap (serologically syphilis-positive patients only) were performed. Stroke outcome was re-evaluated approximately three months later.ResultsThe 344 enrolled patients were divided into three groups: control group (83.7%), LS (13.1%), and NS (3.2%). A multivariate analysis revealed: 1) age of ≥ 70 years, generalized brain atrophy via imaging, and alopecia (adjusted odds ratio [AOR] = 2.635, 2.415, and 13.264, respectively) were significantly associated with LS vs controls; 2) age of ≥ 70 years (AOR = 14.633) was significantly associated with NS vs controls; and 3) the proportion of patients with dysarthria was significantly lower (AOR = 0.154) in the NS group than in the LS group. Regarding the NS patient cerebrospinal fluid (CSF) profile, only 2/11 cases had positive CSF-Venereal Disease Research Laboratory (VDRL) test results; the other nine cases were diagnosed from elevated white blood cell counts or protein levels combined with positive CSF fluorescent treponemal antibody absorption (FTA-ABS) test results. Regarding disability, the initial modified Rankin scale (mRS) score was lower in the control group than in the NS group (p = 0.022). At 3 months post-stroke, the mRS score had significantly decreased in the control (p < 0.001) and LS (p = 0.001) groups. Regarding activities of daily living, the 3-month Barthel Index (BI) score was significantly higher in control patients than in LS (p = 0.030) or NS (p = 0.002) patients. Additionally, the 3-month BI score was significantly increased in the control (p < 0.001) and LS (p = 0.001) groups.ConclusionsBecause syphilis was detected in many AIS and TIA patients, especially those aged ≥ 70 years, routine serological syphilis screening may be warranted in this population. Patients with syphilitic infection had worse stroke outcomes compared with NS patients.

RECURRENT ORAL ERYTHEMA MULTIFORME: AN UNUSUAL SUBTYPE OF ERYTHEMA MULTIFORME

Recurrent oral erythema multiforme (ROEM) is an unusual subtype of erythema multiforme, which is characterized by multiple, recurrent, self-limiting, and painful oral ulcers, evidence of herpes simplex virus (HSV) infection, and absence of cutaneous lesions. The diagnosis of ROEM is difficult and challenging, because other similar diseases should be carefully excluded. Acyclovir and/or corticoids are employed but with variable results. A 52-year-old woman presented with recurrent and painful oral ulcers in the buccal mucosa, soft palate, and gingiva in the last 12 months, with 6 to 8 recurrences during this period. The histopathologic analysis revealed an unspecified chronic lymphoplasmacytic infiltrate. Serologic tests were negative, among others, for Veneral Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-ABS) but positive for HSV 1/2 IgG and IgM. This report emphasizes the importance of identifying the subtypes of erythema multiforme, aiming to deal with its therapeutic and prognostic implications. Recurrent oral erythema multiforme (ROEM) is an unusual subtype of erythema multiforme, which is characterized by multiple, recurrent, self-limiting, and painful oral ulcers, evidence of herpes simplex virus (HSV) infection, and absence of cutaneous lesions. The diagnosis of ROEM is difficult and challenging, because other similar diseases should be carefully excluded. Acyclovir and/or corticoids are employed but with variable results. A 52-year-old woman presented with recurrent and painful oral ulcers in the buccal mucosa, soft palate, and gingiva in the last 12 months, with 6 to 8 recurrences during this period. The histopathologic analysis revealed an unspecified chronic lymphoplasmacytic infiltrate. Serologic tests were negative, among others, for Veneral Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-ABS) but positive for HSV 1/2 IgG and IgM. This report emphasizes the importance of identifying the subtypes of erythema multiforme, aiming to deal with its therapeutic and prognostic implications.

MULTIPLE STOMATITIS IN A PATIENT WITH GANGLIONIC TUBERCULOSIS

An 18-year-old young man was referred for diagnosis of extensive lesions on the lips and oral mucosa. He reported a smoking habit and the recurrence of ganglionic tuberculosis during the interview, with significant weight loss. Medications in use included isoniazid (300 mg), ethambutol (1000 mg), pyraziamide (1000 g), and rifampicin (600 mg). Intraoral examination presented multiple painful ulcerated stomatitis, covered by a pseudomembrane, affecting the labial and buccal mucosa, tongue, and soft palate. The laboratory exams included herpes virus anti-(HV), cytomegalovirus anti-(CMV), fluorescent treponemal antibody absorption (FTA-ABS) negative; high IgE values, reagent for infectious mononucleosis (anti-virus capsid antigen (VCA)-IgM >160 U/mL). Screening for herpes virus in saliva presented positivity for HHV-7. With the diagnostic hypothesis of stomatitis associated with opportunistic infections, treatment consisted of antimicrobial photodynamic therapy, with substantial improvement in pain and reduction of lesions seen in the following 24 hours and full resolution of lesions 5 days after the first appointment.

RAPID TEST FOR SYPHILIS: IS IT RELIABLE?

Syphilis is a sexually transmitted infection caused by a bacterium (<i>Treponema pallidum</i>) that may present oral manifestations. A 26-year-old male patient presented with a 2-month history of a painful ulcer on the tongue. Medical history revealed low levels of hemoglobin and hematocrit. Intraoral examination showed an ulcer with well-defined borders on the tip of the tongue, measuring 1 cm in diameter. Moreover, erosive lesions with typical characteristics of benign migratory glossitis were seen in the tongue dorsum. The hypotheses for the ulcerated lesion were primary syphilis or ulceration related to anemia. Rapid tests for human immunodeficiency virus and syphilis were negative. A teleconsultation was required, and the oral medicine teleconsultant recommended Venereal Disease Research Laboratory and fluorescent treponemal antibody absorption exams, which confirmed the diagnosis of primary syphilis. The treatment included penicillin G benzathine (2,400,000 UI once a week for 3 weeks). Cases showing features suggesting syphilis require serological tests when rapid tests are negative.

Correlation of Treponemal Chemiluminescent Microparticle Immunoassay Screening Test Signal Strength Values With Reactivity of Confirmatory Testing.

Automated chemiluminescent microparticle immunoassays (CMIAs) are the most common first step at high-volume laboratories for syphilis screening. If the initial screening test is reactive, 1 more treponemal test is required, resulting in increased cost. In this multicenter study, we aimed to determine the correlation between the CMIA signal-to-cutoff ratio (S/Co) and the confirmatory tests to reduce unnecessary confirmatory testing. Eight hospitals from 5 provinces participated in this study. All laboratories used Architect Syphilis TP CMIA (Abbott Diagnostics, Abbott Park, IL) for initial screening. Treponema pallidum hemagglutination (TPHA), rapid plasma reagin (RPR), and fluorescent treponemal antibody absorption (FTA-ABS) were used as confirmatory tests according to the reverse or European Centre for Disease Prevention and Control algorithms. A receiver operating characteristic analysis was used to determine the optimal S/Co ratio to predict the confirmation results. We evaluated 129,346 serum samples screened by CMIA between January 2018 and December 2020. A total of 2468 samples were reactive; 2247 (91%) of them were confirmed to be positive and 221 (9%) were negative. Of the 2468 reactive specimens, 1747 (70.8%) had an S/Co ratio ≥10.4. When the S/Co ratios were ≥7.2 and ≥10.4, the specificity values were determined to be 95% and 100%, respectively. In a subgroup of 75 CMIA-positive patients, FTA-ABS was performed and 62 were positive. Among these FTA-ABS-positive patients, 24 had an S/Co ratio <10.4, and negative TPHA and RPR. We propose a potentially cost-effective reverse screening algorithm with a treponemal CMIA S/Co ratio ≥10.4, obviating the need for secondary treponemal testing in about 71% of the screening-reactive samples. This would substantially reduce the confirmatory testing volume and laboratory expenses. However, in high-risk group patients with CMIA positive results, S/Co ratio <10.4, and negative TPHA and RPR, FTA-ABS may be used for confirmation.

Does performance and operational superiority of point-of-care test make it the investigation of choice in confirming syphilis?

According to the World Health Organization, 6 million cases of syphilis occur every year. Serological tests for syphilis form the mainstay of diagnosis for syphilis. We evaluated the performance of point-of-care test (POCT) against other specific treponemal test for confirming the diagnosis of syphilis. Does performance and operational superiority of POCT make it the investigation of choice in confirming syphilis? Retrospectively, data were analyzed of 599 serum samples from Apex Regional sexually transmitted disease centre, Safdarjung Hospital, New Delhi, received for testing by syphilis treponemal assays (both nontreponemal reactive and nonreactive). These samples underwent treponemal testing for syphilis by the Treponema pallidum hemagglutination (TPHA), fluorescent treponemal antibody absorption test (FTA-ABS), and POCT. Performance characteristics (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], and diagnostic accuracy), and operational characteristics of POCT and TPHA were evaluated against the gold standard FTA-ABS. A total of 599 samples were evaluated, of which 61.76% were positive by FTA-ABS. On analysis, the sensitivity was 91.08% and 91.89%, specificity was 89.08% and 87.34%, PPV was 93.09% and 92.14%, NPV was 86.08% and 86.96%, and diagnostic accuracy was 90.32% and 90.15% for POCT and TPHA, respectively. The lower cost, shorter turnaround time, lesser infrastructure and workforce need, and easy availability make the POCT operationally superior to TPHA. Owing to its operational superiority and higher specificity POCT can replace TPHA for confirming the diagnosis of Syphilis. POCT are affordable, equipment free, have room temperature storage, and yield result within 15 minutes, enabling same day testing and treatment. It can be used in a resource limited setting, for community setup or even self-testing.

Melanoacanthoma, Plasma Cell Cheilitis and Langerhans Cell Hyperplasia on the Lower Lip: An Unusual Association and Immunohistochemical Analysis.

Oral melanoacanthoma is an uncommon reactive lesion, characterized by basal and prickle cell keratinocyte proliferation surrounded by pigment-laden dendritic melanocytes. Plasma cell cheilitis (PCC) is an inflammatory disorder of unknown aetiology, microscopically presenting a dense plasma cell infiltrate. Most PCC cases affect the lower lip. Langerhans cell hyperplasia (LCHyp), a non-neoplastic counterpart of the LC proliferations, has been reported in association with chronic inflammatory skin diseases. Here, we present an unusual association of melanoacanthoma, PCC and LCHyp on the lower lip in a 59-old-year male, expanding the clinicopathological spectrum of these uncommon lesions. The dendritic melanocytes were highlighted by Fontana-Masson stain and HMB-45, whereas S100, CD1a and CD207 evidenced numerous LCs. MUM1/IRF4, EMA, and CD138 highlighted sheets of polyclonal plasma cells, with an IgG4+/IgG+ ratio of 24%. FTA-ABS test for syphilis was negative.