Primary Syphilis Research Articles

C1 (Clinical Case) Case Presentation: Acute Genital Ulceration in a 15-Year-Old Girl

Abstract Introduction/Background Genital ulceration may occur in various conditions, and requires a systematic approach to its diagnosis. This should include consideration of both infectious and non-infectious etiologies. The most common causes of genital ulceration are herpes simplex virus (HSV) types 1 and 2 and syphilis (Treponema pallidum). Genital HSV may be asymptomatic or painful, and may present with inguinal lymphadenopathy, and fever. Primary syphilis may escape recognition as it presents with a single, painless, well-demarcated “chancre” that heals spontaneously in 3-6 weeks. Non-infectious etiologies of genital ulceration can include cutaneous drug reactions, and mechanical or chemical trauma. Granulomatous genital inflammation can be an extra-intestinal manifestation of Crohn’s disease characterized by pathognomonic “knife-cut” vulvar ulcers. This report presents a case of Lipschütz’s ulceration, or reactive non-sexually-acquired genital ulceration, as an under-recognized cause of genital ulcers in children. Case Description A previously healthy 15-year-old female presented to the emergency department with six days of daily fevers, and 72 hours of non-bloody diarrhea that had self-resolved. In addition, she complained of nausea and a headache. Notably, in the last day, she had developed labial swelling, perianal pruritus, and vaginal burning. On history, her last menstrual period was one week ago, and she was not sexually active. It was noted that she had consumed Kinder-SurpriseTM eggs in the last week, which had been recently recalled for Salmonella contamination. Pelvic exam initially showed multiple hemorrhagic vesicles involving the labia minora (Fig. 1A). On day one of admission, she developed two symmetric, well-delimited ulcers at the 5 o’clock and 7 o’clock positions on the labia minora, each 12 mm x 5 mm in size (Fig. 1B). By the second day of admission, she had dysuria requiring catheterizing. HSV, chlamydia and gonorrhea were not detected on vaginal swabs, and serologic testing for syphilis was negative. Salmonella montevideo was detected on her blood cultures and she was started on intravenous antibiotics. Her vulvar ulcers improved with a conservative regimen of local hygiene, wound care, and pain control. The final diagnosis was of Lipschütz’s ulceration (LU). Discussion LU is characterized by the sudden onset of necrotic and painful genital ulcers, and typically occurs in young (< 20 years old), sexually inactive females who have no history of genital ulcers, and were not previously affected by a chronic inflammatory condition. In LU, there are usually 1-3 lesions that are large (>10 mm), shallow and well-delimited. These tend to occur on the medial aspects of the labia minora and vestibule and have a symmetric “kissing” distribution on opposing surfaces. Voiding disorders, aphthous ulcers and enlarged inguinal lymph nodes have also been reported in LU. The pathophysiology of LU is not well understood. It often occurs concomitantly with an infectious disease and develops before its resolution. LU is most associated with Epstein-Barr virus, but has also been described with cytomegalovirus, mycoplasma species, Toxoplasma gondii, and influenza A and B. LU is self-limited and generally resolves without recurrence or long-term sequelae within 3 weeks. For analgesia, topical lidocaine is recommended, especially 5-10 minutes before micturition. Sitz baths, application of a bland barrier cream prior to and after voiding, avoidance of pads and underwear, and maintenance of good hydration to minimize irritation by concentrated urine also constitute important components of supportive care for LU. Conclusion Lipschütz’s ulcers are poorly understood and therefore under-diagnosed, or mis-diagnosed as herpes simplex infection, in which case they are treated with acyclovir without benefit. Identification of an etiologic trigger, such as a viral or bacterial infection, can aid in their appropriate detection. To date, there is one other reported case of LU associated with salmonella. This case report aims to describe LU as an uncommon but important entity in the paediatric population. Images

Ischemic strokes revealing neurosyphilis: Study of six (6) observations at the neurology Department of the University Hospital of Conakry.

In sub-Saharan Africa (SSA), stroke is a major public health problem and the etiological aspects are poorly studied and documented because of under-medicalization; the syphilitic etiology is rarely mentioned. We performed a retrospective study of 472 patients hospitalized for ischemic stroke between 2016 and 2021 in the Neurology Department of the University Hospital of Conakry, confirmed by neuroradiological explorations (brain CT, MRI-Angio) and a biological workup including VDRL-TPHA serological reactions in blood and CSF. Syphilitic etiology was retained for six (6) patients (4 men and 2 women) with a mean age of 43years (extremes 36 and 49years). The clinical picture was dominated by carotid syndromes: superficial and deep sylvian syndrome, anterior cerebral artery syndrome and vertebro-basilar syndromes and one case of lacunar syndrome.The diagnosis was based on the positivity of serological reactions (VDRL-TPHA) in blood and cerebrospinal fluid (CSF) and the presence of a predominantly lymphocytic hypercellularity and a hyperproteinorachy in the CSF in the absence of any other etiology. These neurological vascular syndromes consecutive to a cerebral treponematous attack are often the result of a still poorly conducted management of primary and secondary syphilis in our country.

Primary syphilis, an extremely uncommon cause of acute-onset phimosis.

We present a case of phimosis in the context of primary syphilis with a preputial chancre. An accurate diagnosis after an appropriate examination and patient history allowed conservative treatment with antibiotics and the avoidance of circumcision in this patient.

Anti-Treponema pallidum IgA response as a potential diagnostic marker of syphilis

ObjectivesSerological tests for syphilis detect mainly total Ig, IgM or IgG antibodies. We aimed to evaluate the specific IgA response in syphilis patients according to disease stage. MethodsA serum IgA-enzyme immunoassay was developed using commercially available microplates coated with recombinant treponemal antigens and an anti-IgA-conjugate. To define a cut-off, we used 91 syphilis positive and 136 negative sera previously defined by the rapid plasma reagin and the Treponema pallidum particle agglutination results. Then we determined the intra- and inter-assay precisions, diagnostic sensitivity according to the clinical stage (in 66, 55 and 42 sera from primary, secondary and latent syphilis patients, respectively) and specificity (in 211 sera from people with conditions different to syphilis). IgA values were further measured in 71 sera from patients with previously treated syphilis. ResultsThe newly developed IgA-enzyme immunoassay showed a good discrimination between negative and positive samples with intra- and inter-assay variation coefficients <20%. The sensitivity was 80.3% (95% CI, 70.0–90.6), 100.0% (95% CI, 99.1–100.0) and 95.2% (95% CI, 87.6–100.0) in primary, secondary and latent syphilis, respectively, and the specificity was 98.1% (95% CI, 96.0–100.0). Further, IgA values were negative in 61.3% (38/62) of patients with previously treated syphilis. DiscussionOur findings suggest serum IgA as a sensitive and specific marker of syphilis and its detection could be used as a screening assay for active infection. Further evaluation is needed in prospective longitudinal field studies.

Timely Diagnosis of Incubating Syphilis Infections Using Treponema pallidum Transcription-Mediated Amplification Assay.

Syphilis is a complex, multistage, sexually transmitted infection (STI) caused by the bacterium Treponema pallidum subspecies pallidum (TP). New diagnostic tools are needed to minimize transmission. In this study, we aimed to assess the additional value of an investigational transcription-mediated amplification test for TP (TP-TMA) for routine diagnostics. Between September 2021 and August 2022, visits by all participants of the national preexposure prophylaxis (PrEP) program at the sexual health center (SHC) in Amsterdam were included. Anal, pharyngeal, vaginal, and urine samples collected for Chlamydia trachomatis and Neisseria gonorrhoeae screening were additionally tested with the TP-TMA assay based on detection of 23S rRNA of TP. In total, 9974 SHC visits by 3283 participants were included. There were 191 infectious syphilis cases diagnosed: 26 (14%) primary syphilis, 54 (29%) secondary syphilis, and 111 (58%) early latent syphilis. In 79 of the 191 (41%) syphilis cases, at least 1 sample was TP-TMA-positive. For 16 participants, the positive TP-TMA result was not concordant with routine diagnostics. Of those, 2 participants were treated for syphilis within a week before the visit. Eight participants were treated for a syphilis notification at the visit or for another STI. Five participants were diagnosed with syphilis at the following visit, and 1 participant was lost to follow-up. By adding the TP-TMA assay to routine diagnostics, we identified 14 of 191 (7%) additional syphilis infections among participants of the national PrEP program. The TP-TMA assay is a useful diagnostic tool to increase syphilis case finding and thus limit the transmission of syphilis.

Simultaneous primary and secondary syphilis: a case report in an immunocompetent patient

Simultaneous primary and secondary syphilis: a case report in an immunocompetent patient

Mpox and primary syphilis co-infection in a newly arrived traveller from South America.

Mpox and primary syphilis co-infection in a newly arrived traveller from South America.

Syphilis and COVID-19: Changing trends.

There is a change in the pattern and prevalence of acquired syphilis due to better awareness, surveillance, laboratory diagnosis, and treatment in India in recent years. However, restrictive measures for COVID-19 may produce different effects on incidence. We aimed to study the changing trend of acquired syphilis in relation to COVID-19 outbreak in a tertiary care hospital in North India. A retrospective analysis of all the cases of sexually transmitted infections (STIs) was done from January 2016 to June 2022. Demographic, clinical, and laboratory data of acquired syphilis were recorded and analyzed for changing trends in prevalence, clinical presentations, association with HIV and other sexually transmitted diseases (STDs), and its relation to COVID-19. Statistical analysis was done using SPSS software. A total of 1105 patients attended STD clinic from January 2016 to June 2022, of which 216 patients were venereal disease research laboratory and Treponema pallidum hemagglutination assay positive (19.5%). Before COVID-19, there was an increasing trend of acquired syphilis (late latent). Patients diagnosed with syphilis pre- and postlockdown did not differ significantly in their mean age, median age, male/female ratio, and HIV status. However, there is an increase in number of cases of primary and secondary syphilis postlockdown which was statistically significant. Restrictive measures for COVID-19 during the lockdown produced a declining trend of syphilis. It is unclear whether the observed decrease in number of STI cases was due to true decline, inadequate testing, underreporting, or avoidance of high-risk sexual activities. The upsurge in the number of cases of acquired syphilis after lockdown suggests the possibility that lockdowns did not completely disrupt STI transmission.

CPC04 A rare rupioid rash

Abstract A 59-year-old man was referred to an urgent skin cancer dermatology clinic with a 4-month history of multiple skin lesions on his trunk, arms and face. The lesions were painful, increasing in size, bleeding and oozing serous fluid. The patient reported being otherwise systemically well, with a history of mild eczema and a background of high alcohol intake. On examination, he had a striking rash with numerous large rupioid plaques with thick crusting and surrounding erythema on the trunk and limbs. Smaller plaques were seen on the face and neck. An infective aetiology was favoured with an initial differential diagnosis of ecthyma or atypical mycobacterial infection. A biopsy was taken, as well as screening blood tests. Treponemal antibodies were detected; rapid plasma reagin was reactive (1 : 32), as was Serodia Treponema pallidum particle agglutination test (1 : 1280), suggesting active syphilis infection. His biopsy demonstrated granulomatous inflammation, associated with neutrophils, plasma cells and increased mucin deposition. Immunohistochemical staining for T. pallidum confirmed corkscrew-like organisms within the basal epidermis and upper dermis, consistent with secondary syphilis; screening for concurrent HIV infection was negative. The patient was referred to a local genitourinary clinic for treatment with benzylpenicillin and for full sexual health screening. The word ‘rupioid’ describes oyster or limpet shell-shaped thick keratotic lesions and is derived from the Greek word rhupos, meaning ‘filth’. Differential causes for rupioid lesions include cutaneous T-cell lymphoma, psoriasis, scabies and syphilis. Rupioid syphilis is also termed ‘malignant syphilis’ or ‘Lues maligna’, describing well-demarcated plaques with thick, lamellate and adherent crusts. It is most frequently encountered in HIV-positive patients; in HIV-negative patients, the associated comorbidities are diabetes, alcoholism, drug abuse, psoriasis and hepatitis. Typically, there is rapid clinical improvement once antibiotic treatment is administered, but episodes of Jarisch Herxheimer reaction are reported. Syphilis diagnoses have tripled over the last 10 years, with cases in the heterosexual population rising most rapidly. Dermatologists have a pivotal role to play in diagnosing primary and secondary syphilis, thereby preventing the long-term sequelae of tertiary syphilis and controlling the rising prevalence of the disease in the general population. This case highlights a striking and rare manifestation of secondary syphilis which, once seen, will not be forgotten.

Case Report: Concomitant presence of two STIs in a male patient

Background: The spirochaete Treponema pallidum subsp. pallidum, which causes the infectious disease syphilis, can be spread through sexual contact or perinatal transmission. In recent years, cases of syphilis have increased, especially among individuals engaging in behaviour that makes them more vulnerable (condomless sex and multiple sexual partners) and in men who have sex with men. Condylomata acuminata (external genital warts) is one of the most common viral sexually transmitted infections (STIs). Individuals who are behaviourally vulnerable are also highly prone to be exposed to one or more STIs. Our case exemplifies the occurrence of two STIs in a young man who was behaviourally vulnerable to acquiring STIs. Case: We report a case of a 21-year-old year old heterosexual man presenting with concomitant primary syphilis and genital warts. He presented with a painless genital ulcer and warty growths on his glans penis. Examination showed a painless indurated ulcer and multiple genital warts. Serology was positive for quantitative serological disease research laboratory test (1:16 titre). The patient was diagnosed with two concomitant STIs. He was treated as per the latest Centers for Disease Control and Prevention (CDC) guidelines for primary syphilis and podophyllin resin for genital warts. After four weeks, the genital ulcer showed complete healing and there was a significant reduction of genital warts. Conclusions: Individuals with multiple sexual partners engaging in sexual activity without the use of prevention tools are at a greater chance of acquiring two or more STIs. To reduce concomitant transmission, preventive measures against genital ulcer diseases caused by human papilloma virus, syphilis, herpes, and chancroid, such as early identification and treatment, and condom distribution, must be strengthened as part of national STI prevention. Patients with two or more STIs should be followed regularly to assess the progress of infection and should be offered timely medical treatment.

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.

Refining Timely Diagnosis of Early Syphilis by Using Treponema pallidum PCR or IgM Immunoblotting Next to Conventional Serology for Syphilis.

Treponema pallidum subsp. pallidum is a fastidious spirochete and the etiologic agent of syphilis, a sexually transmitted infection (STI). Syphilis diagnoses and disease staging are based on clinical findings and serologic testing. Moreover, according to most international guidelines, PCR analysis of swab samples from genital ulcers is included in the screening algorithm where possible. It has been suggested that PCR might be omitted from the screening algorithm due to low added value. As an alternative to PCR, IgM serology might be used. In this study, we wanted to establish the added value of PCR and IgM serology for diagnosing primary syphilis. Added value was defined as finding more cases of syphilis, preventing overtreatment, or limiting the extent of partner notification to more recent partners. We found that both PCR and IgM immunoblotting could aid the timely diagnosis of early syphilis in ~24% to 27% of patients. PCR has the greatest sensitivity and can be applied to cases with an ulcer with suspected reinfection or primary infection. In the absence of lesions, the IgM immunoblot could be used. However, the IgM immunoblot has better performance in cases with suspected primary infection than in reinfections. The target population, testing algorithm, time pressures, and costs should determine whether either test provides sufficient value to be implemented in clinical practice.

Effectiveness of JYNNEOS Vaccine Against Diagnosed Mpox Infection - New York, 2022.

In 2022, an international Monkeypox virus outbreak, characterized by transmission primarily through sexual contact among gay, bisexual, and other men who have sex with men (MSM), resulted in 375 monkeypox (mpox) cases in the state of New York outside of New York City (NYC).*,† The JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic), licensed by the U.S. Food and Drug Administration (FDA) against mpox as a 2-dose series, with doses administered 4 weeks apart,§ was deployed in a national vaccination campaign.¶ Before this outbreak, evidence to support vaccine effectiveness (VE) against mpox was based on human immunologic and animal challenge studies (1-3). New York State Department of Health (NYSDOH) conducted a case-control study to estimate JYNNEOS VE against diagnosed mpox in New York residents outside of NYC, using data from systematic surveillance reporting. A case-patient was defined as a man aged ≥18 years who received a diagnosis of mpox during July 24-October 31, 2022. Contemporaneous control patients were men aged ≥18 years with diagnosed rectal gonorrhea or primary syphilis and a history of male-to-male sexual contact, without mpox. Case-patients and control patients were matched to records in state immunization systems. JYNNEOS VE was estimated as 1 - odds ratio (OR) x 100, and JYNNEOS vaccination status (vaccinated versus unvaccinated) at the time of diagnosis was compared, using conditional logistic regression models that adjusted for week of diagnosis, region, patient age, and patient race and ethnicity. Among 252 eligible mpox case-patients and 255 control patients, the adjusted VE of 1 dose (received ≥14 days earlier) or 2 doses combined was 75.7% (95% CI = 48.5%-88.5%); the VE for 1 dose was 68.1% (95% CI = 24.9%-86.5%) and for 2 doses was 88.5% (95% CI = 44.1%-97.6%). These findings support recommended 2-dose JYNNEOS vaccination consistent with CDC and NYSDOH guidance.

The Mucosal Manifestations of Syphilis in the Head and Neck.

Objectives: Syphilis is a resurging disease which can present itself in many ways, including lesions within the head and neck mucosa. Some of these lesions may clinically mimic oral malignancies. This literature review aims to better characterize the mucosal presentations of syphilis. Methods: PubMed, EMBASE, and clinicaltrials.gov were searched for full-text, English articles published from 1950 to 2022 that reported patients with head and neck mucosal manifestations of syphilis. Articles were screened according to PRISMA guidelines. Results: One hundred forty-three manuscripts documenting 236 individual patients were included in the review. Patients with secondary syphilis accounted for 62% of patients presenting with head and neck mucosal lesions. The most common lesions found in primary and secondary syphilis were ulcerations, primarily found on the tongue, lips, and palate. While serologic studies are the gold standard for diagnosing syphilis, biopsy of these lesions have characteristic syphilitic changes. Conclusions: Syphilis' nickname of "The great imitator" remains to be true, and the head and neck mucosal manifestations of this disease can resemble commonly seen malignancies. Awareness of this disease and its lesions is prudent given the rising incidence of syphilis within the United States.

The Ongoing Impact of COVID-19 on Testing for and Diagnoses of HIV and Bacterial Sexually Transmitted Infections in Oregon.

The COVID-19 pandemic has disrupted HIV and sexually transmitted infection (STI) testing accessibility. We sought to assess the longer-term impacts of COVID-19 on HIV and STI testing and diagnosis in Oregon. First, we examined HIV, Neisseria gonorrhoeae / Chlamydia trachomatis (CT), and syphilis tests conducted at the Oregon State Public Health Laboratory (public sector) and a large commercial laboratory (private sector) and HIV, N. gonorrhoeae , CT, and primary and secondary (P&S) syphilis diagnoses in Oregon from January 1, 2019, to December 31, 2021. We compared monthly testing and diagnosis rates in 5 prespecified periods: pre-COVID-19 (January 2019-February 2020), stay-at-home order (March 2020-May 2020), reopening (June 2020-December 2020), vaccine availability (January 2021-June 2021), and Delta/early Omicron spread (July 2021-December 2021). Second, we calculated the number of HIV and STI diagnoses per test in the public and private sectors. Finally, we used seasonal autoregressive integrated moving average models to predict expected HIV and STI diagnoses for comparison to those observed. Both public and private sector HIV and bacterial STI testing fell to nadirs in April 2020 with incomplete recovery to 2019 levels by the close of 2021. Compared with pre-COVID-19, public sector and private sector testing was significantly lower in all subsequent periods. Compared with pre-COVID-19, P&S syphilis cases were 52%, 75%, and 124% greater in the reopening, vaccine availability, and Delta/early Omicron periods, respectively. From March 2020 to December 2021, we observed an excess of P&S syphilis cases (+37.1%; 95% confidence interval, 22.2% to 52.1%) and a deficit in CT cases (-10.7%; 95% confidence interval, -15.4% to -6.0%). By December 2021, HIV/STI testing had not recovered to pre-COVID-19 levels, and HIV/STI continues to be underdiagnosed. Despite decreased testing, P&S syphilis cases have increased substantially.

Genetic Profiling of the Full-Length tprK Gene in Patients with Primary and Secondary Syphilis.

TprK antigenic variation is acknowledged as an important strategy developed by Treponema pallidum to achieve immune evasion. Previous studies applied short-read sequencing to explore tprK gene sequence diversity in clinical samples; however, due to the limitations of short-read sequencing, it was difficult to determine the linkage between the seven V regions, and crucial information about full-length tprK variants was lost. Although two recent studies explored complete tprK gene profiles in natural human syphilis infection, there are still too few profiled full-length tprK variants among clinical T. pallidum isolates to fully understand the characteristics of TprK coding diversity. Here, Pacific Biosciences (PacBio) long-read sequencing was applied to examine the diversity of full-length tprK variants in 21 clinical T. pallidum isolates from 11 patients with primary syphilis and 10 patients with secondary syphilis. A total of 398 high-confidence full-length sequences, which presented remarkable sequence heterogeneity, were found. However, these full-length tprK variants exhibited limited variation in length and GC content, showing 24 length types and average GC content of 51.5 ± 0.42% and 51.6 ± 0.26% for primary and secondary syphilis samples, respectively. Additionally, the combined patterns of mutated V regions generating new tprK variants were obviously different in primary and secondary syphilis samples. The diversity of tprK gene sequences in primary syphilis samples may represent the underlying variability of the bacterium; conversely, the variability of the tprK gene in secondary syphilis samples may more accurately reflect how T. pallidum escapes host immune clearance. These data highlight the tprK gene as an important coding gene that shows conflicting genetic characteristics but underlies the persistence of spirochete infection. IMPORTANCE The resurgence of syphilis in both low- and high-income countries has attracted attention, and persistent infection by the pathogen has long been a research focus. The tprK gene, encoding the hypervariable outer membrane protein, is thought to be responsible for pathogen immune evasion and persistent infection. Here, PacBio long-read sequencing was applied to examine the diversity of full-length tprK variants in 21 clinical T. pallidum isolates from 11 patients with primary syphilis and 10 patients with secondary syphilis. The results showed that the sequences of the tprK gene were remarkably heterogeneous; however, the sequences presented limited variation in length and GC content. The investigation of the combined patterns of the V regions allowed us to gain insight into the features of the tprK gene generating new variants at different clinical stages. The findings of this study will be helpful for further exploration of the pathogenesis of syphilis.

51 Syphilis Incidence Following an STI Diagnosis Among Cisgender Women in Baltimore, MD, from 2009-2021

OBJECTIVES/GOALS: The primary objective of this study is to evaluate the risk of an early syphilis diagnosis following a chlamydia, gonorrhea, or HIV diagnosis, and to determine differences by race, repeat infection, diagnosing provider and STI/HIV risk behavior among cisgender women in Baltimore, MD. METHODS/STUDY POPULATION: Public health surveillance data from 2009-2021 was used to examine the overall incidence of syphilis infections among cisgender women ages 13-50 diagnosed with a reportable STI (chlamydia, gonorrhea, or HIV) and the percentage of total infections that were early infections (primary, secondary, or early latent syphilis) in Baltimore City. Data were collected on age, race, diagnosing location (i.e., STI clinic, private provider, etc.), preceding STI diagnoses, and sexual risk behaviors. STI-specific cumulative incidence and incidence rate ratios were used to compare syphilis diagnoses among Black vs. white women, women with repeat STI diagnoses vs. one STI diagnosis, women diagnosed at a public vs. private clinic, and commercial sex workers and substance users vs. those not reporting these risk behaviors. RESULTS/ANTICIPATED RESULTS: Based on recent surveillance data, we expect approximately 79,000 chlamydia, gonorrhea, and HIV diagnoses among cisgender women between 2009-2021. We hypothesize that 3% of chlamydia, gonorrhea, and HIV diagnoses among cisgender women will be followed by a syphilis diagnosis within the study period. Extrapolating from previous studies of early syphilis in men who have sex with men in Baltimore, we expect the rate of syphilis diagnosis following STI diagnosis will be higher in Black vs. white women, women with a prior gonorrhea or HIV diagnosis vs. chlamydia diagnosis, women with repeat STI diagnoses vs. one STI diagnosis, women diagnosed at public STI clinics vs. those diagnosed by private providers, and women reporting commercial sex work and/or substance use vs. those not reporting these risk behaviors. DISCUSSION/SIGNIFICANCE: Local healthcare providers should offer syphilis screening to any woman diagnosed with a chlamydia, gonorrhea, or HIV infection. The higher rates of early syphilis diagnosis among women with repeat STI diagnoses or a prior gonorrhea or HIV diagnosis suggests regular screening is critical in these populations.

Primary syphilis of the oropharynx mimicking a neoplasm.

Syphilis is surging in Japan and worldwide among both homosexual and heterosexual individuals. Diagnosis can be challenging because syphilis is "the great imitator" and clinical manifestations are highly variable. Oral manifestations of syphilis are usually seen in the second stage and the primary syphilis in the oral cavity is rare. We describe a heterosexual man with isolated tonsillar lesions initially misdiagnosed as pharyngeal lymphoma and subsequently diagnosed as primary syphilis. Clinicians should be aware that isolated oropharyngeal involvement can occur in the primary syphilis and can mimic a neoplasm.

Reduced Risk of Syphilis Reinfection in Men Interviewed by Disease Intervention Specialists: A Pilot Study

Syphilis is a highly transmissible sexually transmitted infection. Rising rates of infection and reinfection are of great concern to public health officials. In local health departments across the U.S., disease intervention specialists attempt to interview all people diagnosed with early syphilis, to elicit sexual partner information, and to trace and treat the partners. This method of interviewing and contact tracing is an evidence-based practice that reduces the spread of the disease in the community, but few studies address the relationship between the disease intervention specialists' interviews and index patient reinfections. We hypothesized that patients who were interviewed, patients who provided partner information, and patients with more treated partners would have a reduced risk of reinfection. Our sample consisted of 82 men listed in the Suffolk County Department of Health Services syphilis log who were diagnosed with primary, secondary, or early latent syphilis. We determined whether and when the patients were reinfected during a set time period, from 2016 to 2020. Kaplan-Meier analyses with log-rank statistics and Cox hazard proportional models were used to calculate time to reinfection and hazard ratios. Although none of the models produced p<0.05, notable trends were observed. In subset analyses of interviewed patients, 23.8% of patients who named partners were reinfected during the study period, whereas 50% of those who did not name partners were reinfected during that time. In addition, the hazard ratio for index patients who named partners was 0.51 (95% CI=0.225, 1.170, p=0.113). When some or all the patients' partners were treated, 20% were reinfected by the end of the study, whereas 33.3% of cases with no partners treated were reinfected by the end of the study. The hazard ratio for patients with some or all partners treated was 0.48 (95% CI=0.136, 1.711, p=0.258). Although none of the results was statistically significant, trends suggest that partner elicitation and partner treatment status could be associated with reduced risk of syphilis reinfection. Because this pilot study utilized a small convenience sample that was not tested for statistical power, we could not adequately address these trends. Future studies, with larger sample sizes, should address these relationships.

Bilateral chancre of the tongue: An unusual presentation of primary syphilis.

Syphilis is a sexually transmitted infectious disease caused by the spirochete bacterium Treponema pallidum. A characteristic lesion of primary syphilis is chancre. It can develop over genital or extra genital sites, depending on the site of contact with the infectious agent. Cases of oral syphilis have been on the rise in the previous two decades, probably because of the involvement of the oral cavity in sexual practices. We here report an unusual case of primary syphilis who presented with a painless indurated oral ulcer over the lateral borders of the tongue.