Genital Ulcers Research Articles

Genital ulcers caused by sexually transmitted agents

Genital ulcers (GUs) represent a diagnostic challenge and can be secondary to neoplastic and inflammatory processes of different causes. Among those of infectious etiology, there are sexually transmitted infections (STIs), a very frequent reason for seeking the health service. The most common agents are herpes simplex virus and Treponema pallidum and, more rarely, Haemophilus ducreyi, Klebsiella granulomatis and Chlamydia trachomatis. A careful dermatological examination offers important diagnostic elements; however, atypical manifestations are very common. Distinctive characteristics of ulcers to look out for include their margin, edge, bottom, and base. Regional lymph node chain alterations should be evaluated regarding their number, size, mobility, consistency, inflammation, and pain on palpation. Diagnostic tests have variable sensitivity and specificity, and molecular tests are currently considered the reference exams. The rapid immunochromatographic tests represented a significant advance, as they can be performed with blood obtained from the digital pulp, offer results in up to 30 minutes, and do not require a laboratory structure. The treatment of persons affected by GU/STIs must be immediate, as it aims to prevent complications, as well as reduce transmission. It is not always considered that people with GUs/STIs have varying degrees of depression, anxiety, and self-reproach, with an impact on relationships. Establishing a bond and trusting the professional is essential for adherence to treatment and preventive measures that must be discussed individually.

Acute genital ulcers in a young girl: a clinical challenge: Lipschütz ulcer

Acute genital ulcers in a young girl: a clinical challenge: Lipschütz ulcer

Indigenous traditional knowledge of medicinal plants used for the management of HIV / AIDS opportunistic infections in Katsina State, Nigeria

Background: Medicinal plants are widely used for the management of many diseases including HIV / AIDS opportunistic infections in Katsina State, North-western part of Nigeria. The usage of those plants is, however, poorly documented. Method: An ethnobotanical study was conducted to document medicinal plants used for the management of HIV / AIDS opportunistic infections in three Local Government Areas (one from each Senatorial Zone) of Katsina State, Nigeria. Information was obtained through a semi-structured questionnaire administered to 150 respondents comprising traditional healers, herbalists, farmers and HIV / AIDS patients. Results: The survey revealed 48 plant species distributed among 44 genera and 28 families. The highest Relative Frequency of Citation was observed in Anogeissus leiocarpa (DC.) Guill. and Perr (0.75). Fabaceae represented by 11 species appeared to be the most utilised family. Highest Informant Consensus factor was observed in abnormal vaginal discharge and genital ulcer. Most of the cited species are trees that are sourced from the wild and majority of medications are prepared in the form of decoction which is taken orally. The most used plant parts were leaves (40%). Conclusion: The study revealed substantial numbers and knowledge of medicinal plants used for the treatment of HIV / AIDS related infections in Katsina State, Nigeria. Further investigations to establish the pharmacological potentials of the cited species with regard to the treatment of HIV / AIDS are highly recommended. Keywords: Ethnobotanical survey; HIV / AIDS; Opportunistic infections; Medicinal plants; Katsina state

Behcet’s disease with oral manifestations during pregnancy

Behçet’s disease is a multisystemic inflammatory chronic vasculitis of unknown etiology characterized by recurrent oral ulcers, genital ulcers, eye lesions, and dermatological manifestations that is usually diagnosed during the reproductive years. There is limited information about the effects of Behçet’s disease on pregnancy and vice versa, but in most women, it appears to improve during this period. However, cases of activation or exacerbation of the disease in pregnancy are not uncommon and they are mainly manifested by oral ulcers, genital ulcers, and skin lesions. Corticosteroids and topical sucralfate are safe to use in pregnancy and while breastfeeding to treat oral ulcerations. The purpose of this study is to synthesize available information about Behçet’s disease oral manifestations in pregnancy, diagnosis, and treatment.

Vulvar Biopsy as a Key for the Diagnosis of Langerhans Cell Histiocytosis with Multifocal Involvement: Case Report and Review of Literature

Langerhans cell histiocytosis is a rare disease and due to its heterogeneous presentation represents a diagnostic and therapeutic challenge. We present the case of a patient with diabetes insipid us and panhypopituitarism, with the appearance of painful vulvar ulcers.

Efficacy and safety of apremilast and its impact on serum cytokine levels in patients with Behçet's disease.

To evaluate the long-term clinical efficacy of apremilast in Behçet's disease (BD) and its effect on serum cytokine levels. This study included 15 BD patients who were treated with apremilast. The rates of change in oral and genital ulcers, skin lesions, arthritis, and arthralgia were evaluated every 3months for 12 months. The efficacy of apremilast was compared between patients with and without oral ulcer remission. Changes in the serum levels of interferon-gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), interleukin (IL)-10, IL-17A, IL-6, IL-8, and IL-23 between baseline and 3months after apremilast initiation were compared. After 3months, oral and genital ulcers disappeared in most cases. The skin and joint lesions tended to improve for up to 6months; however, recurrence was observed after 9months. The improvement of genital ulcers was earlier in the oral ulcer remission group than the oral ulcer non-remission group, with the genital ulcers disappearing within the first 3months. The baseline levels of serum cytokines, analyzed in seven patients, did not exhibit significant associations with specific organ lesions. After administration of apremilast, the TNF-α and IL-23 levels significantly decreased; however, the IFN-γ, IL-6, IL-8, and IL-10 levels did not show significant changes. The rates of decrease in the serum IL-6, IFN-γ, and IL-10 levels were greater in patients with improved oral ulcers. Modulation of serum cytokine levels with apremilast might underlie the efficacy of apremilast in oral ulcers in BD patients.

Isolated neuro-Behçet’s disease in a child, from headache to diagnosis: A case report

Behçet's disease (BD) is an immuno-inflammatory multi-systemic disease characterized by ophthalmological and skin involvement, also oral and genital ulcers. Its etiology and pathogenesis are not clearly known. Neuro-Behçet's disease can occur as an isolated form or a rare complication of BD. Besides, diagnosis of neuro-Behçet's disease is difficult. Since Neuro-Behçet can result in morbidity and mortality, early diagnosis and treatment are important. The most important genetic factor in the pathogenesis of BD is Human Leucocyte Antigen (HLA-B 51) allele positivity. A 9-year-old girl was brought to our outpatient clinic for 6 months with a migraine-like headache. The headache of the patient has a partial response to analgesics and rarely awakes from sleep at night accompanied by vomiting. The patient was diagnosed with an isolated neuro-Behçet's disease by HLA-B 51 allele positivity and brain magnetic resonance imaging (MRI) findings. In the current study, the roles of HLA-B 51 allele positivity and brain MRI findings were discussed in the diagnosis of neuro-Behçet's disease.

Penile Ulcer as the Unusual Initial Presentation of Nasal NK/T Cell Lymphoma

AbstractExtranodal natural killer (NK)/T cell lymphoma is a highly aggressive non-Hodgkin lymphoma that predominantly affects the upper aerodigestive tract. The nasal type accounts for ∼80% of cases of NK/T cell lymphomas. In advanced stages, the disease can disseminate to various sites such as skin, testis, eyes, gastrointestinal tract, and soft tissue. NK/T cell lymphoma presenting as lesion in penis is extremely rare. While reviewing the published literature, we found only three reported cases of NK/T cell lymphoma involving the penis. Among them, none was primary NK/T cell lymphoma of penis. We report a 60-year-old NK/T cell lymphoma patient who presented with destructive penile ulcer as the initial presenting symptom, who subsequently was found to have a nasal mass also with features of NK/T cell lymphoma. He underwent partial penectomy elsewhere and chemotherapy with steroid, methotrexate, ifosfamide, L-asparaginase, and etoposide protocol was given.

Clinical characteristics and predictors for cardiovascular system involvement in patients with Behçet's disease.

The purpose of this study is to analyse the clinical characteristics of Behçet's disease (BD) patients in China with or without cardiovascular system involvement, and to develop a risk model to identify factors related to cardiovascular involvement in BD. This retrospective cohort study, using the information on BD in Shenzhen People's Hospital from January 2000 to December 2021, included 95 patients; BD patients without cardiovascular system involvement (n=63) and with cardiovascular system involvement (n=32). Patients with BD who were males and had a combination of hypertension and a longer duration of disease were more likely to have cardiovascular involvement (p < 0.05). Compared to patients without cardiovascular involvement, manifestations of genital ulcers are rarely observed in those with cardiovascular involvement (60.32% vs. 37.50%, p=0.035). The binary logistic regression analysis found that ascending aortic widening and a history of hypertension were independent risk factors for BD with cardiovascular system involvement (OR=1.277, 95% CI 1.09, 1.495, p=0.002; OR=11.578, 95% CI 1.308, 102.639, p=0.028). The established prediction model indicated that can help to predict the likelihood of cardiovascular involvement in a patient with BD. Cardiovascular involvement in BD is not rare at all, however, it is often underreported due to a lack of specificity. BD patients who are male, have a history of combined hypertension, and have a long duration of disease should be focused on the presence of combined cardiovascular system involvement, with particular attention to the patient's ascending aortic internal diameter.

100 Lipschütz ulcer in teenagers – Case report

Objective: Raise awareness about this rare situation, that gynecologists, pediatricians and dermatologists can face. Introduction: The sharp vulvar ulcer or Lipschütz’s ulcer was described for the first time in 1913 as vulvar ulceration, lymphadenopathy and fever in a teenager. The Lipschütz’s ulcer is a rare condition, that features the fast appearance of painful necrotic ulcerations on the vulva. It usually occurs in girls with no sexual activity and is preceded by symptoms similar to the influenza, such as malaise, fever and others.

A caval donato... guarda anche in bocca!

A 15-year-old girl with vulvar ulcers previously attributed to recurrent herpetic infection is presented. Aphthous oral ulcers were also present and the diagnosis of Behçet disease was eventually made.

TREATMENT OF BEHÇET’ S DISEASE AND CURRENT APPROACHES

Objective: Behçet's Disease (BD) is a multisystemic inflammatory disease which courses with relapses and characterized by four major symptoms of oral aphthous ulcers, genital ulcers, skin lesions and ocular lesions; and five minor symptoms including joint involvement, gastrointestinal ulcers, epididymitis, vascular lesions and neurological involvement. Treatment in BD varies according to the clinical course of age at which the disease begins, gender, the organs involved and the clinical course of the disease; therefore, it should be performed according to the person and the symptoms. While empirical treatment of BD is still continuing; recently, effective protocols have been implemented due to the pathogenesis of the underlying disease that is better defined and many broad-spectrum therapeutic agents have been presented for the treatment. This review is presented to bring together the specific treatment procedures applied during the progression of the disease. Result and Discussion: Although there is no specific treatment strategy for BD, which is an inflammatory disease characterized by local and systemic involvements, treatment procedures range from local corticosteroids to monoclonal antibodies, determined by the type and severity of symptoms. Studies are still continuing on diseases affecting the vascular and gastrointestinal system in BD. Conventional immunosuppressive agents, including corticosteroids, colchicine and azathioprine, and cyclosporine are used in the treatment of BD. Recently, tumor necrosis factor (TNF) inhibitors have become available for a variety of rheumatic diseases, and published data indicate that TNF inhibitors represent a significant therapeutic advance for patients with severe and resistant disease as well as those with contraindications or intolerance to these therapies.

AB0639 Common Femoral Vein Thickness Measurement as a diagnostic test in Incomplete Behçet’s Disease

BackgroundBehçet's disease (BD) is characterized by recurrent oral and/or genital aphthous ulcers accompanied by cutaneous, ocular, articular, gastrointestinal and central nervous system lesions. Diagnosing BD can be a clinical challenge in patients presenting with a limited number of organ manifestations, especially with single major organ involvement. We reported the first controlled doppler ultrasound study showing increased common femoral vein (CFV) thickness in BD (1). We recently also showed that increased CFV thickness is a distinctive feature of BD, rarely present in other inflammatory or vascular diseases such as ankylosing spondylitis, systemic vasculitides, venous insufficiency, and non-inflammatory DVT with a specificity higher than 80% for the cut-off value of ≥ 0.5 mm. We suggest that CFV thickness measurement is an easy, non-invasive diagnostic test for BD (2).ObjectivesIn this study, we aimed to assess the diagnostic performance of CFV thickness measurement in patients with ‘Incomplete’ Behçet’s Disease diagnosed by expert opinion.MethodsWe included 28 patients with incomplete BD (15 male, 12 female) diagnosed with expert opinion and followed in the Marmara University Behcet’s Clinic. Demographic, clinical characteristics and treatment data were recorded during routine visits. Common femoral vein wall thickness was measured by an experienced radiologist at the same day.ResultsMedian age was 34.3 years and median disease duration 2 years (0-16). Four patients were newly diagnosed. At follow-up onset, oral ulcers were present in 22 (78.6%), genital ulcers in 6 (21.6%), papulopustular lesions in 4 (14.3%) and pathergy positivity in 5 (17.9%) patients. Ten (35.7%) patients had familial BD. While 24 (85.7%) patients had major organ involvement, 4 (14.3%) patients had mucocutaneous disease. Distrubution of major organ involvements were given in Figure 1.Figure 1.Distribution of major organ involvements (n) in study groupAll patients except 1, had CFV thickness value above the cut-off value of ≥0.5 mm. Right CFV thickness was 0.71 (0.3-1.3) mm and left CFV thickness 0.72 (0.4-1.2) mm. Bilateral femoral vein thicknesses were similar in patients with and without an history of familial BD.ConclusionDiagnosing BD can be challenging in patients presenting with one major organ involvement such as oral ulcers and posterior uveitis, brain-stem disease or arterial aneurysms, especially in countries with a low prevalence. These patients are generally diagnosed as ‘incomplete’ BD by ‘expert opinion’. Early diagnosis is of utmost importance in some of these cases, especially with venous thrombosis as their management differs from non-inflammatory venous thrombosis, necessitating immunosuppressive use rather than anticoagulant therapy. Our results show that CFV thickness measurement with Doppler US, a non-invasive, fast and cost-effective radiological modality, is a valuable diagnostic test in incomplete BD, especially with major organ involvement.

AB1300 AA AMYLOIDOSIS IN A PATIENT WITH MUTATIONS IN BOTH ADA2 AND A20 GENES

BackgroundAdenosine Deaminase 2 Deficiency (DADA2) and Haploinsufficiency of A20 (HA20) are two recently described monogenic autoinflammatory diseases (AID). The uncontrolled inflammatory response has been associated with an increased risk of AA amyloidosis in other AID, but there are only two reported patients with DADA2-related amyloidosis so far.1,2ObjectivesWe herein report a patient with AA amyloidosis and AID associated with both DADA2 and HA20.MethodsWe used the Ion Torrent platform for deep sequencing.ResultsCase: A 20-year-old male patient born to consanguineous parents (Figure 1), was admitted to our hospital with fever and abdominal pain in June 2014. Peritonitis, hepatomegaly, and a palpable non-tender mass in the right axillary cavity were detected in physical examination, and his laboratory investigations revealed neutrophilic leukocytosis, high acute phase reactants (APR), and nephrotic range proteinuria. CT angiography showed multiple thrombotic microaneurysms in celiac, splenic, superior, and inferior mesenteric and bilateral renal arteries; and MRI documented an additional aneurysm in anterior communicating artery. No finding was detected in hepatitis serology. He had been diagnosed with polyarteritis nodosa, and prednisolone and azathioprine were started. Renal histopathology confirmed the AA amyloidosis. Genetic analysis revealed no pathogenic MEFV variant. Colchicine and anakinra 100 mg/day were added to his treatment. He experienced 1-2 abdominal episodes annually between 2014-2019, and APR were normal between attacks. In March 2019, he was admitted to the hospital because of abdominal pain, high APR, and iron deficiency anemia. No gross pathology was observed in endoscopic examination of gastrointestinal tract, but histopathological investigation of the gastric mucosa and terminal ileum showed AA amyloidosis. Multiple aneurysms were detected in renal arteries with angiography. Deep sequencing of the targeted genes revealed homozygous p.Pro251Leu in ADA2 gene and heterozygous p.Thr647Pro in TNFAIP3 gene encoding A20, confirming the molecular diagnosis of DADA2 and HA20. The patient described oral recurrent aphthous ulcers starting from his childhood, but he had no uveitis or genital ulcers. His mother and brother also had recurrent oral aphthous ulcers. Genetic analyses showed heterozygous p.Pro251Leu variant in ADA2 gene in his mother, and heterozygous p.Gln703Lys variant in NLRP3 gene as well as heterozygous p.Thr647Pro TNFAIP3 variant and heterozygous p.Pro251Leu ADA2 in his brother. An improvement in his findings was observed within 2 weeks after switching his anakinra to adalimumab 40 mg every other week. At his last visit in February 2021, the patient had no complaints with normal APR, and urinalysis analysis showed 200 mg/day proteinuria, which was regressed from 3 g/day.ConclusionThis is the first case of AA amyloidosis associated with ADA2 and TNFAIP3 (A20) variants. ADA2 p.Pro251Leu variant has previously been validated as likely pathogenic, and our patient’s clinical findings were mainly compatible with DADA2. On the other hand, TNFAIP3 gene p.Thr647Pro mutation has been reported as variant of unknown significance, but it may have contributed to the DADA2 associated increased risk of amyloidosis. A better response of proteinuria to adalimumab treatment indicates superiority of anti-TNFs in DADA2 patients compared to anti-IL-1 drugs.

Etiological Surveillance of Genital Ulcer Syndrome in South Africa: 2019 to 2020.

Herpes simplex virus (HSV) has been the leading cause of genital ulcer syndrome (GUS) in South Africa for more than a decade, and acyclovir therapy is incorporated into syndromic management guidelines. We conducted surveillance at 3 sentinel sites to define the common sexually transmitted etiologies of GUS and to determine whether current syndromic management is appropriate. Secondary objectives of surveillance were to determine the seroprevalence of coinfections (HIV, syphilis, HSV-2) in persons presenting with GUS. Consecutive, consenting adult men and women presenting with visible genital ulceration were enrolled between January 1, 2019, and December 31, 2020. Genital ulcer swab and blood specimens were collected and transported to a central sexually transmitted infection reference laboratory in Johannesburg. Among 190 participants with GUS, HSV-2 was the most frequently detected ulcer pathogen (49.0%; 95% confidence interval [CI], 41.9%-56.1%). The relative prevalence of the second most common ulcer-derived pathogen, Treponema pallidum, was 26.3% (95% CI, 20.5%-33.1%), with 90% of primary syphilis cases having a positive rapid plasma reagin (RPR) titer. Male sex was independently associated with primary syphilis compared with herpetic ulcers, after adjusting for the effect of casual sex partners and other exposures (adjusted odds ratio, 3.53; 95% CI, 1.35-9.21; P = 0.010). The overall HIV prevalence among participants was 41.3% (78 of 189; 95% CI, 34.2%-48.6%). Herpes simplex virus 2 remains the predominant cause of GUS, justifying the continued use of acyclovir in syndromic guidelines. Adequate supplies of benzathine penicillin G for syphilis treatment are essential at primary health care level, in addition to the provision of syphilis and HIV risk reduction services.

Regulation of NLRP3 inflammasome by zinc supplementation in Behçet's disease patients: A double-blind, randomized placebo-controlled clinical trial

BackgroundOverproduction of NLRP3 inflammasome complex is one of the causes of Behcet's disease's (BD) auto-inflammatory nature. The aim of current study was to examine the effect of zinc supplementation on NLRP3 inflammasome expression; as well as clinical manifestations of BD. MethodsIn this double-blind parallel placebo-controlled randomized clinical trial, 50 BD patients were randomly allocated into either zinc gluconate (30 mg/day elemental zinc) or placebo groups for 12 weeks. The mRNA expression of NLRP3 and caspase-1 in the leukocytes, serum level of zinc and IL-1β, anthropometric measures, and clinical manifestations of patients were collected at pre- and post-intervention phase. The Iranian Behçet's disease dynamic activity measure (IBDDAM) was scored to measure the treatment effect using the calculation of number needed to treat (NNT). Analysis of covariance was performed to obtain the corresponding effect sizes. ResultsZinc gluconate led to a significant improvement in genital ulcer (P = 0.019). Zinc supplementation decreased NLRP3 and caspase-1 genes expression compared with placebo group (baseline-adjusted P-value = 0.046 for NLRP3 and P-value = 0.003 for caspase-1), even after adjustment for the effect of confounding factors (baseline- and confounders-adjusted P-value = 0.032 for NLRP3 and P-value = 0.004 for caspase-1). Baseline and confounders adjusted effect size demonstrated that zinc was effective in reducing the serum level of IL-1β (P = 0.046). The NNT [95 %CI] for the rate of IBDDAM improvement was 3 [1.7–8.5]. ConclusionsZinc gluconate supplementation (30 mg/day) for a 3-month period can be considered as an adjuvant therapy in alleviating inflammation and genital ulcer among BD patients.

Perianal ulcers without genital ulcers: a rare presentation of Behçet's disease.

Perianal ulcers without genital ulcers: a rare presentation of Behçet's disease.

A giant coronary artery aneurysm in a patient with Behçet's syndrome.

A 34-year-old male was admitted to our clinic for investigating chest pain and high CRP (92 mg/l) with suspicion of Behçet’s syndrome (BS). He had a history of partially recanalized deep vein thromboses (DVT) that occurred 3 years ago in the left femoral vein and 1 year ago in the right femoral vein; recurrent oral ulceration and positive HLA-B51 testing. He did not report genital ulcers, nodular skin lesions, uveitis or other BS-associated symptoms. Pulmonary chest CT angiography did not reveal pulmonary artery involvement. Skin pathergy test and uveal examination could not be performed due to urgent coronary angiography (CA) for increasing angina pectoris. CA revealed a giant aneurysm in the left anterior descending artery (Fig. 1). A coronary artery bypass graft operation was performed after a 3-day course of methylprednisolone (1 g/day) and CYC (1000 mg i.v.) with a BS diagnosis with coronary arteritis, although he was not fulfilling BS diagnostic criteria [1].

Pattern and Visual Prognostic Factors of Behcet's Uveitis in Northwest Iran.

PurposeTo investigate the pattern of ocular involvement in Behcet's disease (BD) with predictors of patients' final state of vision.MethodsThis historical cohort encompassed the clinical records of 200 patients diagnosed according to the International Criteria for BD (ICBD), over a period of 17 years between 2004 and 2021.ResultsThe prevalence of Behcet's uveitis (BU) was more common in females and patients in the fourth decade of life. Ninety-five patients (47.5%) had evidence of ocular involvement in the initial ophthalmologic evaluation, and 171 patients (85.5%) manifested evidence of BU during the follow-up visits of which bilateral non-granulomatous panuveitis was the most common anatomical pattern of involvement (32.9%) followed by posterior (27.6%), anterior (26.5%), and intermediate (13.8%) uveitis. The prevalent accompanying signs were oral aphthous (67%), skin lesions (29%), and genital ulcers (19.5%). Cystoid macular edema (CME) was the most frequent ocular complication (62%), followed by cataract (57.5%) and epiretinal membranes (ERM) (36.5%). Univariate analysis showed the following determinants: male gender, younger age at onset, panuveitis, posterior uveitis, retinal vasculitis, and longer duration of uveitis as poorer visual prognostic factors of the disease. Multivariate analysis demonstrated a higher chance of poor visual prognosis of BD in patients with panuveitis, posterior uveitis, retinal vasculitis, and longer duration of uveitis.ConclusionThis cohort study demonstrated an overview on epidemiological patterns of BU along with the visual prognostic factors in Iranian patients.

The dark art of syphilis serology - an analysis of testing algorithms at a UK reference laboratory.

Introduction. Due to the complex nature of treponemal serology interpretation, testing algorithms vary across the UK.Gap statement. There is currently no gold standard method for interpretation of discordant serology results.Aim. To analyse serological response in early infection and to determine the best approach for discordant total antibody EIA and TPPA samples.Methodology. National reference laboratory serology and PCR (genital ulcer swabs) results from 2010 to 2017 were extracted from an electronic laboratory database.Results. A total of 24149 sera underwent analysis. Of syphilis PCR positive cases with contemporaneous sera, 33% (17/52) were IgM positive/equivocal, whilst all were EIA and TPPA positive. No sera with isolated IgM positivity (0/90) demonstrated seroconversion consistent with early treponemal infection, in contrast to 17% (2/12) of sera with isolated TPPA positivity. Isolated EIA positivity was observed in 6.2% (1499/24149) samples with the same result on repeat testing in 73% (154/211). In 100 samples with discordant EIA/TPPA results, IgG Immunoblot was more commonly positive (12/41, 29%) or equivocal (24/41, 59%), in those with a higher EIA antibody index, compared to those with a low antibody index, of which none tested positive and 2/3 (67 %) were equivocal.Conclusion. Isolated IgM positivity was not helpful in identifying early infection; isolated total antibody EIA positivity is unlikely to be a significant finding. IgG immunoblot testing was unable to determine clear treponemal antibody status in nearly half of all EIA/TPPA discordant samples.