Nontreponemal Tests Research Articles

Development of a novel magnetic particle-based agglutination immunoassay for anticardiolipin antibody detection in syphilis

ObjectivesSerological tests of non-treponemal and treponemal types are the most frequently used for syphilis diagnosis. Treponemal tests are available in wide variety of assay formats; however, limited advances have been...

Syphilis Laboratory Guidelines: Performance Characteristics of Nontreponemal Antibody Tests.

We reviewed the relevant syphilis diagnostic literature to address the following question: what are the performance characteristics, stratified by the stage of syphilis, for nontreponemal serologic tests? The database search included key terms related to syphilis and nontreponemal tests from 1960–2017, and for data related to the venereal disease research laboratory test from 1940–1960. Based on this review, we report the sensitivity and specificity for each stage of syphilis (primary, secondary, early latent, late latent, or unknown duration; tertiary as well as neurosyphilis, ocular syphilis, and otic syphilis). We also report on reactive nontreponemal tests in conditions other than syphilis, false negatives, and automated nontreponemal tests. Overall, many studies were limited by their sample size, lack of clearly documented clinical staging, and lack of well-defined gold standards. There is a need to better define the performance characteristics of nontreponemal tests, particularly in the late stages of syphilis, with clinically well-characterized samples. Published data are needed on automated nontreponemal tests. Evidence-based guidelines are needed for optimal prozone titrations. Finally, improved criteria and diagnostics for neurosyphilis (as well as ocular and otic syphilis) are needed.

Evidence Review for Centers for Disease Control and Prevention Guidance Development on Laboratory Testing to Detect Treponema pallidum Infection (Syphilis).

The articles in this supplement address key questions on syphilis diagnostics, provide reference tables of test performances, and discuss optimal specimens and knowledge gaps. Laboratory-developed genetic direct detection tests could be most useful at the point of care and add to the currently available serologic methods of nontreponemal and treponemal tests.

The Traditional or Reverse Algorithm for Diagnosis of Syphilis: Pros and Cons.

We reviewed relevant syphilis diagnostic literature to address the question “What diagnostic considerations should be taken into account when screening for syphilis using the traditional or reverse algorithm?” Improved laboratory diagnosis of syphilis is an important element of the effort to reduce syphilis rates. Screening for syphilis is performed using either a nontreponemal or treponemal test (part of the traditional or reverse algorithm, respectively). Both syphilis algorithms are used by laboratories. However, there are limited data on the performance and cost-effectiveness of the algorithms. An expert panel generated “key questions” in the laboratory diagnosis of syphilis. This paper pertains to the key factors that should be considered when deciding whether to screen for syphilis using either the traditional or the reverse algorithm. A systematic literature review was performed, and tables of evidence were created to address this question.

Clinical Test Performance of a Rapid Point-of-Care Syphilis Treponemal Antibody Test: A Systematic Review and Meta-analysis.

We reviewed relevant syphilis diagnostic literature and conducted a meta-analysis to address the question, “What is the sensitivity and specificity of the Syphilis Health Check, a rapid qualitative test for the detection of human antibodies to Treponema pallidum.” The Syphilis Health Check is the only rapid syphilis test currently cleared by the Food and Drug Administration (FDA). We conducted a systematic review and a meta-analysis using Bayesian bivariate random-effects and fixed-effect models to create pooled estimates of sensitivity and specificity of the Syphilis Health Check. We identified 5 test evaluations published in the literature and 10 studies submitted to the FDA and for a Clinical Laboratory Improvement Amendments waiver application. The pooled sensitivity (95% CI) from the laboratory evaluations (n = 5) was 98.5% (92.1–100%), while pooled specificity was 95.9% (81.5–100.0%). The pooled sensitivity for prospective studies (n = 10) was 87.7% ( 71.8–97.2%), while pooled specificity was 96.7% (91.9–99.2%). Using nontreponemal supplemental testing, the sensitivity improved to a pooled sensitivity of 97.0% (94.8–98.6%). The Syphilis Health Check may provide accurate detection of treponemal antibody.

Phase II trial evaluating the clinical efficacy of cefixime for treatment of active syphilis in non-pregnant women in Brazil (CeBra)

BackgroundSyphilis is a sexually and vertically transmitted infection caused by the bacteria Treponema pallidum for which there are few proven alternatives to penicillin for treatment. For pregnant women infected with syphilis, penicillin is the only WHO-recommended treatment that will treat the mother and cross the placenta to treat the unborn infant and prevent congenital syphilis. Recent shortages, national level stockouts as well as other barriers to penicillin use call for the urgent identification of alternative therapies to treat pregnant women infected with syphilis.MethodsThis prospective, randomized, non-comparative trial will enroll non-pregnant women aged 18 years and older with active syphilis, defined as a positive rapid treponemal and a positive non-treponemal RPR test with titer ≥1:16. Women will be randomized in a 2:1 ratio to receive the oral third generation cephalosporin cefixime at a dose of 400 mg two times per day for 10 days (n = 140) or benzathine penicillin G 2.4 million units intramuscularly based on the stage of syphilis infection (n = 70). RPR titers will be collected at enrolment, and at three, six, and nine months following treatment. Participants experiencing a 4-fold (2 titer) decline by six months will be considered as having an adequate or curative treatment response.DiscussionDemonstration of efficacy of cefixime in the treatment of active syphilis in this Phase 2 trial among non-pregnant women will inform a proposed randomized controlled trial to evaluate cefixime as an alternative treatment for pregnant women with active syphilis to evaluate prevention of congenital syphilis.Trial registrationTrial identifier: www.Clinicaltrials.gov, NCT03752112. Registration Date: November 22, 2018.

Retrospective comparison between non-treponemal and treponemal tests for screening of blood donors for syphilis and their correlation with donor history in a tertiary care teaching hospital

Background and objectivesTreponemal tests provide advantage of better detection during early, late and latent stages of syphilis with equal or higher sensitivity & specificity in comparison to non-treponemal tests. The objective of the present study was to analyse the level of concordance between treponemal and non-treponemal tests for donor screening and to correlate them with donor history. Materials and methodsRetrospective analysis of syphilis screening by treponemal (Chemiluminescence & TPHA) and non-treponemal tests (RPR) was done and donor history for high-risk behaviour and factors associated with false positivity were collected from post-donation counselling and collected data was coded and analysed. ResultsAmongst the 12,000 donors screened, reactivity rate by RPR, TPHA and Chemiluminescence was 0.45%, 0.8% and 1.17% respectively. There was discordance of 62% and 32% for reactive results by RPR and TPHA respectively when compared with Chemiluminescence. History of high-risk behaviour was present in ∼ 50% and 15% of donors with discordant results by RPR and TPHA respectively. Of 34 donors who were reactive only by Chemiluminescence and were followed up, 15% had history of high-risk behaviour and 56% had factors associated with false reactivity. ConclusionTreponemal tests showed high syphilis reactivity amongst blood donors as compared to non-treponemal tests most likely due to their ability to detect early, late and latent syphilis cases. This may confer added transfusion safety in centres dependent on replacement donors without NAT testing by identifying donors with high-risk history with negligible increase in discard rate due to false reactivity.

Syphilis in Pregnancy

AbstractSyphilis is a sexually transmitted bacterial disease relevant to pregnancy because it has the potential to cause congenital syphilis if it occurs at any time during pregnancy. An upsurge in cases of syphilis in women and hence congenital syphilis has been reported worldwide recently. 40% of cases can result in spontaneous miscarriages, stillbirth, non-immune hydrops, fetal growth restriction and perinatal death, as well as serious sequelae in liveborn infected children. Pregnancy complications can be avoided by early detection and treatment in the antenatal period. All antenatal women should be screened for syphilis at the first antenatal visit. There is no gold standard for diagnostic test of syphilis. A combination of serological tests consisting of treponemal and a non treponemal test are used for diagnosis. Screening with non-treponemal tests such as rapid plasma reagin or venereal disease research laboratory test combined with confirmation of reactive individuals with treponemal tests such as the fluorescent treponemal antibody absorption assay is the usual cost effective approach. Those at risk should be retested in the third trimester. Treatment during pregnancy should be with penicillin depending upon the stage of the maternal infection. All neonates born to mothers who have reactive nontreponemal and treponemal test results should be evaluated.

Cerebrospinal fluid treponemal antibody titres: a breakthrough in the diagnosis of neurosyphilis

Neurosyphilis, like other infections of the central nervous system, results in intrathecal antibody production.1 2 Both treponemal and non-treponemal (lipoidal) antibodies are produced and will continue to be produced even...

Usefulness of New Automated Treponemal Tests in the Diagnosis of Early Syphilis: A Series of 15 Cases

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

Syphilis testing among spouses of patients with syphilis in Japan: an epidemiological study using an administrative claims database.

The number of syphilis cases reported in Japan, transmitted mainly by heterosexual contact, has been increasing since 2014. However, Japan has not introduced partner services programmes, and it remains unclear whether contacts of patients with syphilis undergo testing. This study aimed to estimate the proportion of spouses of patients with syphilis who underwent syphilis testing. We retrospectively identified patients who had recently started syphilis treatment as well as their spouses from a Japanese claims database for employee health insurance plans, collected between 2010 and 2017. Spousal syphilis testing was defined as either a nontreponemal or treponemal test within three months after the index patient started treatment. We determined the proportion of spousal syphilis testing and analysed its associations with patient and spouse characteristics, and year of syphilis treatment. Of the 217 patients who were identified to have started syphilis treatment, 29 (13.3%) spouses underwent syphilis testing: 23/182 (12.6%) among wives, and 6/35 (17.1%) among husbands, of male and female index patients, respectively. Among wives aged <45 years, the proportion tested declined over time. Despite the rise in syphilis incidence, the proportion of spouses tested, including women of reproductive age, declined. In Japan, partner services programmes need to be implemented to control sexually transmitted infections.

Une syphilis « précoce »

Syphilis mainly affects men who have sex with men (MSM) between the ages of 20 and 49. Herein we report a case in a teenager illustrating extension of the epidemic to other populations. A 15-year-old boy consulted in May 2018 for an anal fissure and painful oral erosions. He reported having had unprotected anal sex with another male teenager of the same age three months earlier. Syphilis serology was positive, with a positive treponemal test (TT) and non-treponemal test (VDRL) at 1/128. A treponemal bacterial DNA PCR assay was also positive for swabs obtained from the oral erosions and anal fissure. Due to a history of allergy to penicillin the patient was treated with doxycycline 200mg daily for 14 days. One month later, the mucosal lesions had subsided, and 3 months later the VDRL titer had decreased by 2 dilutions. This case of "early" syphilis illustrates a change in the French epidemiology of sexually transmitted diseases (STIs). STIs currently affect very young and previously unexposed metropolitan French populations. These infections are increasing in teenagers due to an increase in high-risk sexual behavior associated with a lack of knowledge of STIs. This case is a reminder of the current decline in the level of knowledge about STIs among teenagers as compared to young people of the same age in the 1990s.

Study of reliability and concordance between two VDRL tests for syphilis investigation in patients with HIV followed-up at a university hospital in Rio de Janeiro in 2017–2019

Introduction: The laboratory diagnosis of syphilis is given by a positive treponemal test and a non-treponemal test, with VDRL (Veneral Disease Research Laboratory) being the “gold standard”. Objective: To compare two tests commercially validated for biological fluids and analyzed by different operators, in order to assess their performance in detecting high (≥:8) and low (≤1:2) titrations, as well as to determine the agreement between results in paired serum samples from patients with syphilis and living with HIV. Methods: Cross-sectional study, approved by the Research Ethics Committee of the teaching hospital Gaffrée e Guinle (HUGG), under CAAE 66558117.0.0000.5258. The study population was composed by patients diagnosed with syphilis and confirmed by the positivity of one or more treponemal tests. All samples were analyzed simultaneously by two different operators, each using a kit: VDRL WAMA Diagnóstica®, São Carlos, SP, Brazil; VDRL Brás, Laborclin®, Pinhais, PR, Brazil. The SPSS statistical program was used. Results: 110 serum samples from patients diagnosed with syphilis treated at HUGG were analyzed. The frequency of high VDRL titrations among patients, following the VDRL criterion ≥1:8, was practically the same in both tests, with 68% in VDRL Laborclin and 69% in VDRL WAMA (p = 0.87) and VDRL ≤1:2, 80% for WAMA and 83% for Laborclin (p = 0.72). The results of VDRL were tabulated in pairs; then the Cohen’s Kappa coefficient of agreement was calculated (Κ) 0.32 (95%CI 0.21–0.41; p<0.00001), as well as the weighted Kappa (Kw) and the intraclass correlation coefficient (ICC) 0.89 (95%CI 0.84–0.92; p<0.00001). The Bland-Altman diagram was also used. We found poor agreement between the VDRL tests when results were nominally concordant, that is, with the same titles in both tests. However, if partial agreement is considered, the interpretation of the magnitude of agreement estimators was almost complete (≥0.80). Conclusion: Reliability and agreement were high between the VDRL tests of both manufacturers when considering the close titrations (up to two dilutions). Further reliability and agreement studies are essential between the non-treponemal tests available and used in Brazil.

Neurosyphilis in Brazilian newborns: a health problem that could be avoided.

ABSTRACTSyphilis is a public health problem, especially in pregnant women, due to the risk of transmission to the fetus and the involvement of the central nervous system, causing neurosyphilis. A case-control study was carried out to analyze the variables associated with neurosyphilis in Brazilian newborns of pregnant women with syphilis admitted for childbirth. Newborns were submitted to treponemal and non-treponemal tests, cerebrospinal fluid analysis, and long bone radiography. Newborns diagnosed with neurosyphilis and congenital syphilis were defined as cases and controls, respectively. The length of hospitalization and mean cost of neurosyphilis treatment were also evaluated. Twenty-one cases of newborns with neurosyphilis and 42 controls with congenital syphilis were included in the study. Out of 63 pregnant women with syphilis, 95.2% (60/63) received prenatal care, 74.6% (47/63) were diagnosed with syphilis during this period, 31.9% (15/47) underwent treponemic tests, 80.8% (38/47) were treated with penicillin and only 46.8% (22/47) of the partners received the treatment. Clinical complications such as low birth weight were observed in 12.7% (8/63) of the newborns. About 50.8% (32/63) of the newborns were hospitalized due to syphilis complications and each case of neurosyphilis spent at least US$ 881.48 on treatment and hospitalization. The results showed that the prenatal coverage is not sufficient to prevent neurosyphilis. The late diagnosis of syphilis in pregnant women and inadequate follow-up of sexual partners may favor the vertical transmission of T. pallidum in pregnant Brazilian women. Thus, improving the quality of health services is important for a more effective control of neurosyphilis.

Clinical manifestations and outcomes of ocular syphilis in Asian Indian population: Analysis of cases presenting to a tertiary referral center.

Purpose:To describe disease manifestations and outcomes of ocular syphilis in Asian Indian population.Methods:Retrospective analysis of patients diagnosed with ocular syphilis at a tertiary referral center in India. Demographics, history, extraocular and ocular manifestations, ocular and systemic investigations, treatment and visual acuity outcomes were noted. All patients were diagnosed after necessary laboratory investigations including HIV ELISA (Human immunodeficiency virus, enzyme-linked immunosorbent assay), VDRL (venereal disease research laboratory), and TPHA (treponema pallidum hemagglutination).Results:Totally, 20 patients with mean age at presentation 38.25 ± 9.76 were analyzed. 9/20 patients had bilateral involvement. 8/20 had concurrent HIV at presentation with an average CD4 counts of 592.25 ± 411.34 cells/microliter. The mean duration of symptoms at time of presentation was 15.45 ± 35.15 weeks. VDRL test was reactive in 45% (9/20) patients whereas, all patients had a reactive TPHA test. Clinical manifestations included outer retinal placoid chorioretinitis lesions (8/20, 40%), followed by retinitis mimicking acute retinal necrosis as the second most common phenotype (4/20, 20%). Other presenting manifestations noted were panuveitis, miliary retinitis lesions, retinal vasculitis, intermediate uveitis, and anterior uveitis. The clinical phenotypes in immunocompromised included panuveitis, acute retinal necrosis and isolated anterior uveitis. Mean follow up duration was 6.32 ± 6.15 months. An improvement in mean best corrected visual acuity (BCVA) of (0.63 LogMAR, approximately 6 Snellen lines, P < 0.02) was noted at last follow-up.Conclusion:Phenotypic manifestations of ocular syphilis are varied. Non-treponemal tests like VDRL may be unreliable when compared with treponemal tests in diagnosing ocular syphilis. Syphilitic uveitis is considered equivalent to neurosyphilis and is treated similar to neurosyphilis.

Syphilis among HIV serodiscordant partners associated with Human Papillomavirus Infection in a bisexual man

Introduction: Syphilis and HIV infections are sexually transmitted infections whose diagnosis and treatment contribute toward preventing congenital transmission. Objective: To report a case of three sexually transmitted infections detected in a male partner during Couple Consultation and syphilis in the female partner during prenatal care. Case report: A 34-year-old black female G2P1 pregnant woman was referred to an outpatient clinic of sexually transmitted infections in Vitória, Brazil, reporting a 30-day evolution of painless papular lesions in the external genitalia, suggestive of condylomata lata. Nontreponemal tests were positive for syphilis and negative for HIV. The husband reported unprotected receptive anal intercourse and possessed anal condylomatous lesions and perianal condylomata lata. He was positive for both HIV and syphilis. Histopathological findings showed low-grade HPV lesions and the PCR test found 16, 39, and 53 HPV subtypes. Treatment with benzathine penicillin G was successful for both partners. Conclusion: This study emphasizes the need for Couple Consultation during pregnancy to identify and treat possible sexually transmitted infections.

Ocular syphilis in an immunocompetent man.

A healthy 47-year-old immunocompetent man from Northern Canada presented for ophthalmologic assessment after experiencing one month of right-sided photopsias, floaters, and a right lower nasal quadrant visual field defect. Optic disc swelling, vitritis, chorioretinitis, peripheral retinal infiltrates and hemorrhages were noted in the right eye. A broad right inferior arcuate and nasal visual field defect were also present. Fluorescein angiography of the right retina showed dilated disc vessels and staining of the optic disc.Treponemal antibody testing, using chemiluminescent microparticle immunoassay, was highly positive; this was followed by a Venereal Disease Research Laboratory (VDRL) test with a titre of 1:32 and confirmed by Treponema pallidum particle agglutination (TP-PA) test. Testing did not demonstrate any co-infections.Cerebrospinal fluid (CSF) analysis revealed strong reactivity (4+) to the Treponemal antibody by immunofluorescence antibody absorbed (FTA-ABS) test and non-reactivity by CSF VDRL test. Syphilis PCR of CSF was negative. A diagnosis of neurosyphilis was made. He was treated with ceftriaxone 2 grams IV q24h for 14 days. The vitritis gradually improved.Familiarity with syphilis diagnostics is becoming increasingly important, especially given its recent resurgence amongst several at risk groups. This patient’s case highlights that non-reactive CSF VDRL is not a reliable test in the context of positive serum results and a compatible clinical picture. CSF Treponemal tests such as TP-PA and FTA-ABS offer higher sensitivity than non-treponemal tests such as VDRL in the context of CNS involvement and ocular syphilis.

Epidemiological Characterization of the Infection by Treponema Pallidum in Pregnant Women in Beira City, Sofala, Mozambique

Introduction: Syphilis is one of several diseases that can be transmitted during pregnancy and childbirth, which can lead to complications during pregnancy and in the newborn. This is especially so when the pregnant woman is not diagnosed or treated properly and in a timely manner. Methodology: Data from 262 pregnant women prospectively included, aged 18-41years, attended at the Ponta Gêa Health Centre for antenatal clinics has been analyzed from January to September of 2016. In the prospective study, a rapid treponemal and a non-treponemal test were performed. A structured questionnaire was used to collect socio demographic and clinical variables, which was developed from the literature review. Results: The prevalence of active syphilis was 11.8%; the majority of reactive pregnant women were aged 18-25years (55.4%), (61.3%) of pregnant women were treated with doses below those recommended; only a small number of the partners were treated successfully. The highest seroprevalence of syphilis was found in housewives (77%), in those who attended primary education (71.6%) in those who had a monthly income of 1000- 3000 MZN (70.3%), in those with two or more pregnancies (55.7%) and living with someone has husband and wife (63.5%). The syphilis/HIV co-infection rate was high. Conclusion: According to the results obtained in this study, urgent measures are needed to assess the problems encountered and to improve the screening approach, treatment and monitoring of syphilis during pregnancy in order to prevent the cases of congenital syphilis.

Epidemiological profile of 39 cases of microcephaly caused by congenital infections diagnosed in the state of Rio Grande do Sul between 2015-2017

Introduction: Microcephaly is a clinical finding that can arise from congenital anomalies or emerge after childbirth. Maternal infections acquired during pregnancy can result in characteristic brain damage in the newborn (NB), which may be visible even in the fetal stage. Objective: To describe the epidemiological profile of newborns with reported microcephaly and diagnosed with congenital infections in the state of Rio Grande do Sul between 2015 and 2017. Method: A cross-sectional study was carried out on data collected from the Public Health Event Registry as well as from medical records. The investigation included serologies for toxoplasmosis and rubella; polymerase chain reaction (PCR) for Zika virus (ZIKV) in the blood and cytomegalovirus in the urine; non-treponemal tests for syphilis; and brain imaging tests. Results: Of the 257 reported cases of microcephaly, 39 were diagnosed with congenital infections. Severe microcephaly was identified in 13 patients (33.3%) and 51.3% of the cases showed alterations in brain imaging tests. In relation to the diagnosis of congenital infections, three patients (7.7%) were diagnosed with ZIKV, nine (23.1%) with cytomegalovirus, nine (23.1%) with toxoplasmosis, and 18 (46.1%) with congenital syphilis. The three cases of ZIKV showed calcification in brain imaging tests, signs of arthrogryposis, excess occipital skin and irritability, characterizing the typical phenotype of ZIKV infection. Conclusion: Most cases of congenital infection had severe neurological lesions, particularly the cases of ZIKV, which can cause neurodevelopmental delays and sequelae in these infants throughout early childhood. Keywords: Microcephaly; Congenital Infection; Zika Virus

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

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