Rapid Plasma Reagin Titer Research Articles

Effect of adverse storage conditions of antigen reagent on performance of the rapid plasma reagin test.

The aim of this study was to evaluate the performance of rapid plasma reagin (RPR) testing using expired and adversely stored antigen reagent. The sensitivity of RPR using antigen stored at 36 degrees C was compared at 3-monthly intervals with RPR using fresh antigen on 116 sera reactive by RPR and by Treponema pallidum particle agglutination (TPPA). After multiple phases of freezing and thawing, 8.3% of initial RPR reactive sera seroreverted. After storage at 36 degrees C for one year and 24 weeks after expiration the overall sensitivity of the adversely stored antigen was 93.8% compared with fresh antigen; the sensitivity was 100% for sera with RPR titres > or = 1:4 and 85.4% for sera with RPR titres of 1:1 and 1:2. The high stability of the reagent may increase the feasibility of the RPR test for use in poorly-equipped healthcare centres in developing countries.

Posterior uveitis in patients with positive serology for syphilis.

The clinical features and ophthalmologic findings of 20 patients with syphilitic posterior uveitis seen at the Detroit Medical Center from November 1993 through February 1996 were reviewed. The mean age was 58 years; 8 patients were male and 12 were female; and all patients were black. Three of 9 patients tested were HIV positive. Patients were divided into 2 groups: those with acute (8) and those with chronic (12) syphilitic posterior uveitis. Chorioretinitis was the predominant uveitic pattern (15/20). Eighteen patients presented with blurred vision. All patients had reactive serum fluorescent treponemal antibody, absorbed (FTA-ABS); 3 had nonreactive rapid plasma reagin (RPR). Mean RPR titer in the chronic uveitis group and in the acute uveitis group was 1:27.3 and 1:209.8, respectively. Seven patients had abnormal cerebrospinal fluid (CSF); CSF VDRL was reactive in 2 patients. All patients were treated with intravenous penicillin G. Eight of 14 patients seen at follow-up showed improvement of ophthalmologic findings. Syphilis should be considered in the differential diagnosis of posterior uveitis.

Syphilitic lymphadenopathy. Histology and human immunodeficiency virus status.

Few reports on syphilitic lymphadenopathy have appeared in 20 years, and none have compared findings in patients with and without human immunodeficiency virus (HIV) infection, despite the recent epidemic spread of syphilis and HIV. Twelve cases of syphilitic lymphadenopathy were studied and grouped according to HIV status. Patients were 21 to 62 years old (median, 29 years); 7 were men, 5 were women. Biopsy sites were cervical (7 cases), inguinal (4), and axillary (1) lymph nodes. All patients had evidence of syphilis. Rapid plasma reagin titers ranged from 1:32 to 1:512. Treponemal hemagglutination was positive in all cases tested. Spirochetes were found with Steiner staining in 2 cases. HIV testing was positive in 4, negative in 2, and unknown in 6 cases. Lymph nodes were enlarged and often fragmented due to capsular fibrosis and chronic inflammation, with focal obliteration of the subcapsular sinus. Follicular and interfollicular hyperplasia was seen in all cases and was usually marked, with prominent vascular proliferation, plasma cells, immuno-blasts, histiocytes, and occasional neutrophils. Follicle lysis and granulomas suggestive of unconfirmed toxoplasmosis were each seen in 1 case, and Kaposi sarcoma in 2, all in HIV-positive patients. Lymphoplasmacytic infiltration was marked, especially in interfollicular areas, with peri-vascular plasma cell cuffing in all cases and obliterative endarteritis in about half (7 of 12, 56%). Immunostaining for CD45RO (UCHL-1), CD20 (L26), kappa, lambda, and CD68 (Kp-1) revealed a mixed population of T cells, polyclonal B cells, and interfollicular histiocytes. Distribution of T and B cells (immunoarchitecture) was essentially normal and similar in all cases, regardless of HIV status. Syphilis produces essentially identical findings in lymph nodes in both HIV-positive and HIV-negative patients. The morphologic findings described should prompt evaluation for infection with Treponema pallidum and, in light of the current epidemic, HIV.

Prenatal Syphilis Screening: Identification of Population Risks

Syphilis remains a leading cause of maternal and neonatal morbidity worldwide. Screening of pregnant women is an important preventative health measure, as maternal and neonatal effects are preventable if identified early. All patients receiving prenatal care at National Naval Medical Center have a rapid plasma reagin (RPR) test performed at their initial obstetric visit, in accordance with the Centers for Disease Control (CDC) guidelines and the Public Health Service Expert Panel on the Content of Prenatal Care. At the 28 week visit, this test is repeated. To better direct screening of our patient population, which is similar to other military and civilian institutions, the following study examines syphilis screening of all patients who delivered at National Naval Medical Center from February 1996 until July 1996. No patient had a positive RPR titer during this period. This study supports the CDC recommendation that RPR titers do not need to be repeated at the week 28 visit in a low-risk population. This study is pertinent to military and civilian hospitals changing to a TRI care or other HMO-based system, where observation of population risk will better direct the effectiveness of screening programs.

Syphilis serology in human immunodeficiency virus infection: evidence for false-negative fluorescent treponemal testing.

Injection drug users were assessed serologically for human immunodeficiency virus infection and syphilis every 6 months. Treatment histories were reviewed for any high-titer biologic false-positive (BFP) reactors, that is, persons with rapid plasma reagin (RPR) titers > or = 1:4 and negative results for fluorescent treponemal antibody absorption (FTA-ABS) tests. Selected sera were analyzed further by immunoblotting for the presence of antibodies reactive with specific Treponema pallidum antigens. Of 112 BFP reactors, 35 (31%) had at least one RPR test reactive at a dilution >1:8 while the FTA-ABS test remained nonreactive. Five reactors (4.5%) converted from nonreactive to reactive by FTA-ABS test; 4 (3.6%) were reactive by FTA-ABS tests but later became nonreactive. Antibodies to T. pallidum membrane antigens were detected in some samples that were persistently nonreactive by FTA-ABS test. Serologic patterns over time, along with very high-titer BFP reactions and reactivity with T. pallidum-specific antigens, suggest that some BFP reactions may represent FTA-negative syphilis.

First year serologic response to treatment for syphilis: a model for prediction of seroreversion.

There is no straightforward test available, within weeks of treatment for syphilis, to assess adequacy of serologic response. We propose a method to predict non-treponemal seroreversion based on short term response. To develop and illustrate this method, we used data from 370 individuals with infectious syphilis. Individual serologic response appears to be a linear function of (log) time, suggesting the possibility of using rapid plasma reagin titres recorded in the first few months after treatment to determine the slope of the linear treatment response line. The slope of the response line, during the first year after treatment, is an important predictor of seroreversion but must be considered in conjunction with pre-treatment titre. We recommend development of an action line be developed based on these variables. Such a line would indicate the necessity for retreatment if the line plotted from the patient's first year response failed to fall below the action line.

Syphilitic uveitis in human immunodeficiency virus-infected patients.

To document the incidence and clinical features of syphilitic uveitis in patients coinfected with human immunodeficiency virus (HIV). Retrospective chart review. Single tertiary uveitis referral center. The charts of HIV-infected patients with uveitis and a reactive fluorescent treponemal antibody absorption test seen between November 1983 and June 1995 were reviewed. Syphilis was the most common bacterial cause of uveitis in this group. Thirteen patients (0.6% of the 2085 HIV-positive patients seen in the clinic during the study period) were dually infected. Twelve patients were male. Six patients (46%) had previously been treated for syphilis, 4 with intramuscular penicillin G benzathine only. Four patients (31%) had isolated anterior uveitis, 3 patients (23%) had anterior and intermediate uveitis, and 5 patients (38%) had panuveitis. One patient (8%) presented with optic nerve and retinal atrophy. Eight patients were treated with intravenous penicillin, 3 with intravenous and intramuscular penicillin, and 1 with intravenous ceftriaxone sodium. Of the 12 patients for whom follow-up examinations were available after treatment, ocular inflammation decreased in 11 (92%) and visual acuity improved in 8 (67%). Rapid plasma reagin titers decreased a median of 64-fold compared with pretreatment levels, and all patients with reactive cerebrospinal fluid who underwent pretreatment and posttreatment lumbar punctures normalized following therapy with intravenous antibiotics. Syphilis is an uncommon cause of uveitis in HIV-infected patients. Anterior uveitis is the most common ocular manifestation, but panuveitis is more common than isolated anterior uveitis. Intravenous penicillin is effective therapy.

Apparent failure of one injection of benzathine penicillin G for syphilis during pregnancy in human immunodeficiency virus-seronegative African women.

Syphilis remains a major cause of premature birth, fetal and perinatal death, and congenital syphilis in South Africa, despite systematic antenatal screening by rapid plasma reagin and treatment with 2.4 million U of benzathine penicillin G. To determine whether one injection of 2.4 million of U of benzathine penicillin G, as recommended by the 1993 Centers for Disease Control and Prevention guidelines, is sufficient treatment for early syphilis during pregnancy. Outcome of pregnancy was prospectively analyzed after zero to three weekly intramuscular injections of benzathine penicillin G in 180 of 212 human immunodeficiency virus-seronegative black urban women with syphilis in Pretoria, South Africa. One hundred eight women receiving two or three weekly intra-gluteal injections of benzathine penicillin G had a favorable pregnancy outcome. However, after only one injection, lower birth weight, increased immaturity, prematurity, and total preterm birth rate resulted. Total pregnancy loss and perinatal mortality were also increased. After exclusion of patients treated with oral penicillin derivatives and adjustment for the estimated duration of treponemicidal levels at 3 weeks after injection, the perinatal outcome was reanalyzed. Treponemicidal coverage of 3 weeks or less resulted in decreased birth weight (2,748 vs. 3,130 g, P = 0.004) compared with treponemicidal coverage lasting longer than 3 weeks. In addition, the relative risks for prematurity (relative risk [RR], 8.5; 95% confidence interval [CI95], 2.5-28), perinatal mortality (RR, 20.5; CI95, 2.3-184), and congenital syphilis (RR 2.0; CI95-0.6-6.8) were increased when coverage was less then 3 weeks. These results were comparable to those obtained when no treatment was given. Most of the incompletely treated women delivered at less than 4 weeks after they received their injection. These also had the worst neonatal outcome. Impaired outcome due to short treatment clustered in early attenders of prenatal care (before the 28th week of gestation) and when the initial rapid plasma reagin titer was higher than 16. Although numbers were small for a firm conclusion, incompletely treated and untreated women who had taken intercurrent oral ampicillin had an improved birth weight, lower prematurity rate, and lower fetal rate. One intramuscular injection of 2.4 million U benzathine penicillin G or treponemicidal concentrations lasting 3 weeks or less is not sufficient therapy for pregnant women with syphilis. Although fetal outcome is clearly improved at birth with more than one injection, without follow-up of the neonates, complete cure cannot be predicted from these data. To obtain treponemicidal activity for longer than 3 weeks, the authors recommend administration of two injections of 2.4 million U benzathine penicillin at least 1 week apart, if possible at 4 weeks or more before delivery. This therapy is especially important for patients who attend prenatal care before 28 weeks of pregnancy or when the rapid plasma reagin titer is higher than 16.

Retrospective Analysis of the Serologic Response to the Treatment of Syphilis During Pregnancy

Objective: The purpose of this study was to assess the effect of several maternal variables on the serologic response following the treatment of syphilis in pregnancy. Methods: A 5-year chart review identified 95 patients coded with syphilis at Hermann Hospital. Inclusion criteria were 1) serologically confirmed syphilis infection during the index pregnancy, 2) complete treatment during the index pregnancy, and 3) minimum of one follow-up rapid plasma reagin (RPR) titer. Forty-nine of 95 patients met the inclusion criteria. Treatment response was evaluated by comparing each post-treatment titer of a patient to her pretreatment titer. Each comparison was considered an “observation.” Each observation was classified as either a positive response (≥4-fold titer decline) or a negative response (<4-fold titer decline). Maternal variables assessed included 1) prior history of syphilis untreated or incompletely treated prior to the index pregnancy, 2) gestational age, 3) titer level, 4) unknown duration, 5) positive response at 1 month, 6) positive response at 2 months, 7) positive response at >3 months, and 8) race. Results: A positive response following treatment was significantly more likely if there was no prior history of syphilis or if there was a high initial RPR titer (>32). Only 33/54 (61%) observations at or greater than 3 months had a positive response. Conclusions: Our study suggests that an absence of a history of syphilis and an initial high RPR titer are predictive of a positive response following appropriate treatment. Given the low percentage of observations with a positive response at 3 months, we speculate that we may be undertreating our pregnant patients with syphilis infection.

Retrospective analysis of the serologic response to the treatment of syphilis during pregnancy

Objective The purpose of this study was to assess the effect of several maternal variables on the serologic response following the treatment of syphilis in pregnancy. Methods A 5-year chart review identified 95 patients coded with syphilis at Hermann Hospital. Inclusion criteria were 1) serologically confirmed syphilis infection during the index pregnancy, 2) complete treatment during the index pregnancy, and 3) minimum of one follow-up rapid plasma reagin (RPR) titer. Forty-nine of 95 patients met the inclusion criteria. Treatment response was evaluated by comparing each post-treatment titer of a patient to her pretreatment titer. Each comparison was considered an “observation.” Each observation was classified as either a positive response (≥4-fold titer decline) or a negative response (<4-fold titer decline). Maternal variables assessed included 1) prior history of syphilis untreated or incompletely treated prior to the index pregnancy, 2) gestational age, 3) titer level, 4) unknown duration, 5) positive response at 1 month, 6) positive response at 2 months, 7) positive response at >3 months, and 8) race. Results A positive response following treatment was significantly more likely if there was no prior history of syphilis or if there was a high initial RPR titer (>32). Only 33/54 (61%) observations at or greater than 3 months had a positive response. Conclusions Our study suggests that an absence of a history of syphilis and an initial high RPR titer are predictive of a positive response following appropriate treatment. Given the low percentage of observations with a positive response at 3 months, we speculate that we may be undertreating our pregnant patients with syphilis infection. Infect. Dis. Obstet. Gynecol. 5:23–28, 1997. © 1997 Wiley-Liss, Inc

Maternal syphilis: the next pregnancy.

We sought to determine: (1) the perinatal outcomes in the subsequent pregnancy; (2) the natural history of serologic titers over the course of the two pregnancies; and (3) the incidence and risk factors for delivering an infant with congenital syphilis in the subsequent pregnancy. Over a five-year period, we reviewed the charts of 46 women with maternal syphilis during pregnancy who had a subsequent pregnancy and delivered in our institution. The initial and subsequent pregnancy outcomes were contrasted. To characterize the subsequent pregnancy risk of congenital syphilis, those women with recurrent congenital syphilis were contrasted to women who delivered infants without congenital syphilis. Rapid plasma reagin (RPR) titers in the initial and subsequent pregnancy were analyzed by neonatal outcome. Forty percent of the women who delivered an infant with congenital syphilis in their first pregnancy delivered yet another infant with congenital syphilis in the subsequent pregnancy. Continued cocaine use was the single most important risk factor for delivering another infant with congenital syphilis (p < 0.0001). Forty-two percent of the women who delivered an infant without congenital syphilis in the initial pregnancy delivered an infant with congenital syphilis in the subsequent pregnancy. Birthweight, the number of neonatal hospital days, and the incidence of respiratory distress syndrome (RDS), neonatal pneumonia, abruption, and positive meconium drug screens were not significantly different between the initial and subsequent pregnancies. As with the initial pregnancy, women continued to experience poor pregnancy outcomes in the subsequent pregnancy.

Syphilitic Gummas in a Patient with Human Immunodeficiency Virus Infection

Figure 1. A 26-year-old woman who was positive for the human immunodeficiency virus presented with focal motor seizures, a CD4 cell count of 238 per cubic millimeter, a rapid plasma reagin titer of 1:32, and a positive test for serum treponemal IgG antibody. One year earlier, she had received a single dose of intramuscular penicillin (dose and rapid plasma reagin titer not known). On admission, gadolinium-enhanced T1-weighted magnetic resonance imaging showed multiple syphilitic cerebral gummas (Panels A and B). Studies of cerebrospinal fluid revealed a white-cell count of 20 per cubic millimeter (92 percent lymphocytes and 8 percent . . .

Serologic Response to Treatment of Syphilis in Patients With HIV Infection

Much controversy exists concerning the manifestations, therapy, and response to treatment of syphilis in patients coinfected with the human immunodeficiency virus (HIV). To assess the effect of HIV infection on the serologic response to treatment of patients with syphilis. Sixty-four HIV-seropositive patients with syphilis were matched with 64 patients with syphilis who were HIV negative. Matching criteria included age (+/- 5 years), sex, race, initial rapid plasma reagin (RPR) titer (+/- 1 dilution), and stage of syphilis at entry. There were 26 matched patients with early syphilis, 26 matched patients with late syphilis, and 12 matched patients with biological false-positive RPR. The HIV-positive patients with early syphilis received three doses of penicillin G benzathine. All other patients received treatment as recommended by the Centers for Disease Control and Prevention, Atlanta, Ga. Our study's major end points were clinical and serologic response to treatment. All 16 patients with symptomatic syphilis were cured. No patient developed clinical signs of neurosyphilis during the 12-month follow-up period. Twenty-nine (56%) of 52 HIV-positive patients with early or late syphilis did not have a fourfold decrease in RPR titer 6 months after treatment compared with 20 (38%) of 52 matched controls (P = .06). No unique characteristics identifying patients who did not respond serologically could be established. The HIV-positive patients with initial RPR less than 1:32 experienced a significantly slower decrease in RPR at 12 months than did the controls (P < .001). Patients with syphilis who are HIV positive are less likely to experience serologic improvement after recommended therapy than are patients with syphilis who are HIV negative. Patients with HIV infection who contract syphilis should receive intensive and prolonged follow-up, and consideration should be given to designing alternative regimens.

Neurosyphilis in HIV-infected patients.

To determine the prevalence and the clinical and serological findings of neurosyphilis in HIV-infected patients, Treponema pallidum hemagglutination (TPHA) tests, CD4+ lymphocyte counts and determination of rapid plasma reagin (RPR) titers were performed in 972 HIV-infected patients over a period of 3.5 years. Patients were scored according to the Centers for Disease Control's classification for HIV infection. Reactive serum syphilis tests and positive cerebrospinal fluid (CSF)-Venereal Disease Research Laboratory (VDRL) tests, with or without clinical symptoms, were used as the criteria for diagnosis of neurosyphilis. The TPHA test was positive in 31 patients, representing 3.1% of all HIV-infected patients included in the study. Of these, 13 were intravenous drug addicts, 14 were homosexuals and 4 were heterosexuals. Diagnosis of syphilis was concurrent with HIV infection in 19 patients, prior to HIV infection in 6 patients and after HIV infection in 6 patients. CSF examinations were performed in 28 of the 31 (90.3%) patients with serologically evident syphilis. Four patients had positive CSF-VDRL tests with pleocytosis (23.5% of untreated syphilis patients in whom CSF was examined), three of whom reported mild headache, which was considered a doubtful manifestation of neurosyphilis. Patients with syphilis diagnosed and treated prior to diagnosis of HIV infection did not have evidence of neurosyphilis. Seven patients had pleocytosis with a negative CSF-VDRL test, without any clinical manifestations of neurosyphilis. There was no significant difference in the mean CD4+ lymphocyte count between patients with and without neurosyphilis (p = 0.5). RPR titers in neurosyphilis patients were greater than those in patients previously treated for syphilis and in those with pleocytosis only (p = 0.046 and 0.036, respectively). All neurosyphilis patients had an RPR titer > 1:8. After therapy, neurosyphilis patients had negative CSF-VDRL tests with a lower level of pleocytosis. The prevalence of neurosyphilis was 0.4% in HIV-infected patients and 23.5% in HIV-infected patients with untreated syphilis. This high prevalence of neurosyphilis warrants CSF examination in HIV-infected patients with syphilis, regardless of the stage of syphilis.

Lumbar Puncture for Evaluation of Latent Syphilis in Hospitalized Patients

To determine the prevalence of abnormal neurologic findings and cerebrospinal fluid abnormalities in hospitalized patients with serologic evidence of latent syphilis. Cross-sectional survey. Consecutively admitted hospital inpatients from an inner-city population were screened for serologic evidence of syphilis with reactive plasma reagin and confirmatory fluorescent treponemal antibody absorption assays. In those with reactive tests, such clinical findings as a history of treatment for syphilis, neurologic abnormalities, presence of human immunodeficiency virus infection, and rapid plasma reagin titer were correlated with cerebrospinal fluid white blood cell count, protein level, and VDRL result. Of 490 consecutive patients, 52 (11%) had serologic evidence of syphilis. Forty-three (83%) of these underwent lumbar puncture. Of the 43, 31 (72%) were seronegative for human immunodeficiency virus and 12 (28%) were seropositive. No patient had a reactive cerebrospinal fluid VDRL test. Cerebrospinal fluid abnormalities were seen in 32% of human immunodeficiency virus-seronegative patients and in 67% of human immunodeficiency virus-seropositive patients. Cerebrospinal fluid abnormalities were not predicted by history of treatment for syphilis, abnormal neurologic findings, or an elevated rapid plasma reagin titer. Cerebrospinal fluid IgG indexes in patients with elevated cerebrospinal fluid protein levels suggested that the protein abnormalities were not caused by local antibody production. Nonreactive cerebrospinal fluid fluorescent treponemal antibody absorption tests suggest that the cerebrospinal fluid abnormalities were not the result of neurosyphilis. There was a high prevalence of cerebrospinal fluid abnormalities in hospitalized patients with latent syphilis detected by routine screening. Because of the nonspecificity of the cerebrospinal fluid findings, routine lumbar puncture for such patients appears to contribute little to the treatment of latent syphilis.

SPECT in Neurosyphilis

A 41-year-old woman had a mild confusional state after an assault. She reported a history of sexual promiscuity, and subsequent testing revealed a serum rapid plasma reagin titer of 1:64, a cerebral spinal fluid venereal disease research laboratory titer of 1:8, and fluorescent treponemal antibody absorption reactive in both serum and CSF. Neurobehavioral testing revealed only subtle deficits in attention. MRI (T1 and T2 weighted of the brain), and EEG were normal. SPECT showed areas of hypoperfusion in a patchy distribution involving the parietal lobes bilaterally. This pattern is suggestive of meningovasculitis

Treatment of asymptomatic congenital syphilis: Benzathine versus procaine penicillin G therapy

We compared the efficacy of two treatment regimens for asymptomatic congenital syphilis. Between June 1989 and July 1991, we prospectively and randomly assigned 169 patients to receive either one dose of benzathine penicillin G or procaine penicillin G for 10 days. There were no significant differences between the treatment groups in regard to birth weight, sex, race, gestational age, Apgar scores, infant or maternal rapid plasma reagin (RPR) titers, fluorescent treponemal IgM antibody, or maternal treatment. Patients were examined at 2 to 3, 6, and 12 months after treatment; treatment failure was defined as clinical signs or persistent laboratory evidence of congenital syphilis. Nine patients were removed from the study during the neonatal period, eight were lost to follow-up, and 152 patients were examined 2 to 3 months or more after treatment. Among these 152 patients, none had clinical evidence of congenital syphilis at follow-up, and all the patients tested at 2 to 3 months after treatment (68 in the benzathine penicillin G group and 61 in the procaine penicillin G group) had at least a fourfold decrease in RPR titers. The RPR became nonreactive in all but three of the infants (two in the procaine penicillin G group and one in the benzathine penicillin G group; all three were 2 to 3 months of age when last tested). We conclude that treatment failure did not occur with either regimen and that there was no significant difference in outcome between the two groups.

The Prozone Phenomenon in Syphilis Associated With HIV Infection-Reply

The letter by Haslett and Laverty describes a new clinical setting for the occurrence of the prozone phenomenon. The authors mention that the unexpected rapid decline of the original titer should have aroused some suspicion. We recently saw a very similar case. Our patient was human immunodeficiency virus positive, with a CD4 lymphocyte count of 0.02×10 9 /L and an original rapid plasma reagin titer of 1:2048 in March 1993. For his neurosyphilis (cerebrospinal VDRL was positive at a titer of 1:64) and coexistent bacterial endocarditis (group G Streptococcus), he received a 4-week treatment with penicillin, 3×10 3 U intravenously every 4 hours. On follow-up 3 months later, his rapid plasma reagin titer was reported as nonreactive. On routine follow-up 6 months later, his rapid plasma reagin titer was again positive, with a titer of 1:2048. Unfortunately, the second specimen was not available for testing. The importance of the prozone

Altered clinical presentation of early syphilis in patients with human immunodeficiency virus infection.

To compare clinical presentations of patients with early syphilis who did or did not have human immunodeficiency virus (HIV) infection. Case-control study. The sexually transmitted diseases clinics of the Baltimore City Health Department. Patients with newly diagnosed primary, secondary, or early latent syphilis who had voluntary HIV testing from January 1990 to November 1991. Data on sexual history, risk behaviors, and physical findings (before knowledge of HIV or syphilis serologic test results) were extracted from clinical records. Diagnoses of syphilis were confirmed by reactive syphilis serologic tests. Rapid plasma reagin titers reported to the disease registry of the Baltimore City Health Department were abstracted to determine therapeutic response. Patients positive for HIV who returned for follow-up had further counseling, staging, and CD4 lymphocyte testing. Data were available on 309 of 527 patients with early syphilis: 108 patients with primary syphilis, 116 with secondary syphilis, and 85 with early latent syphilis. Seventy (23%) patients had concurrent HIV infection. Patients with HIV infection presented more often with secondary syphilis than did patients with syphilis who were HIV seronegative (53% [37 of 70] compared with 33% [79 of 239]; P = 0.01). The same was true for heterosexual men with HIV infection (46% [16 of 35]) compared with heterosexual men without infection (25% [35 of 142]; P < 0.03). Among those who denied intravenous drug use, 59% (22 of 37) of patients with HIV infection presented with secondary syphilis compared with 33% (65 of 198) of patients without infection (P < 0.01). Among patients with first episodes of syphilis, patients positive for HIV who had secondary syphilis were more likely to present with persistent chancres (43% [9 of 21] compared with 15% [11 of 72]; P = 0.01). The rate of decline in the rapid plasma reagin titers during a 12-month period after treatment did not differ between patients with and without HIV infection (P = 0.15). The clinical presentation of syphilis in patients with HIV infection differs from that of patients without HIV infection in that patients with HIV infection present more often in the secondary stage and those with secondary syphilis are more likely to have chancres.

Maternal/congenital syphilis in a large tertiary-care urban hospital.

Among the women delivering a total of 9,591 infants in 1990 at Hutzel Hospital in Detroit, 148 had positive results in the rapid plasma reagin (RPR) and fluorescent treponemal antibody-absorption tests for syphilis. This group included primarily young, black, multigravid women with a history of crack cocaine use. RPR titers ranged from 1:1 to 1:256 among the 103 mothers not treated or inadequately treated for syphilis. Two mothers with very low RPR titers (1:2) delivered a stillborn infant and an infant with a reaction in the cerebrospinal fluid Venereal Disease Research Laboratory (CSF-VDRL) test, respectively. Seventy-five percent of the infants born to untreated or inadequately treated women had asymptomatic congenital syphilis. The remaining 25% were stillborn (6 infants) or had clinical features of congenital syphilis (3 infants), a reactive CSF-VDRL test (11 infants), or radiological evidence of periostitis or metaphysitis (6 infants). Abnormalities were documented in the placentas from 11 live births and one stillbirth. The resurgence of congenital syphilis highlights the need for better diagnostic tests and for studies that will determine optimal therapy for mother and infant.