Serologic Evidence Of Syphilis Research Articles

S3170 Syphilitic Hepatitis With Cholestatic Liver Injury

Introduction: The incidence of syphilis in the United States has increased, predominantly among men who have sex with men. Very few patients with early syphilis meet the criteria for syphilitic hepatitis, but many are HIV+ and engage in high-risk sexual behavior. Case Description/Methods: A 30-year-old man who identified as a MSM presented with yellowing of his eyes and hyperbilirubinemia, preceded by one month with a rash and photosensitivity and redness of his right eye. He denied any penile lesions, history of liver disease or alcohol use. A physical examination revealed multiple hyperpigmented macular lesions over his torso, arms, palms, and the soles of his feet and scleral icterus. A slit lamp examination indicated anterior uveitis in both eyes and chorioretinitis/placoid retinitis in the right eye. CBC and iron studies showed mild anemia of chronic disease (Hb 11.7 g/dL). BMP was within normal limits. LFTs were as mentioned in Table 1. Blood tests showed positive HBsAb and T. pallidum antibody with RPR 1:128. Serum markers for viral hepatitis and HIV were negative. CSF from a lumbar puncture had an elevated WBC count (9/mm3). No biliary obstruction or masses were noted during on US and MRCP. Liver biopsy showed bland perivenular cholestasis (zone 3) (Fig. 1A) without necroinflammatory changes, mild to minimal portal inflammation (Fig. 1B), bile duct damage, and ductular reaction. The patient was treated with penicillin G for neurosyphilis, prednisolone and cyclopentolate for ocular syphilis, and ursodiol for cholestasis. Total bilirubin levels decreased to 1.7 mg/dL after 8 weeks of follow-up, and liver enzymes normalized. Discussion: This patient met the criteria for syphilitic hepatitis (elevated liver enzymes, serologic evidence of syphilis, exclusion of other etiology, and improvement following appropriate therapy). He also had bilateral anterior uveitis and placoid retinitis of the right eye, suggesting ocular syphilis. Serum chemistries, testing for T. pallidum and other serologies (including positive anti-smooth muscle antibody) supported hepatic involvement, and CSF studies were consistent with neurosyphilis. Liver biopsy showed a bland cholestatic pattern without evidence of other causes of liver disease. The biopsy results are compatible with syphilitic hepatitis, though histologic features can vary and direct staining for spirochetes has limited sensitivity. These findings, together with his rapid improvement with penicillin therapy, confirmed a diagnosis of syphilitic hepatitis.Figure 1.: (A) Liver specimen (x40 magnification, hematoxylin and eosin stain) showing bland perivenular cholestasis (zone 3 with rare apoptotic hepatocytes. No necroinflammatory activity is present. (B) Liver specimen (x40 magnification, hematoxylin and eosin stain) showing periportal inflammation and bile duct damage with mild bile ductular reaction. Table 1. - Liver function test results AST 41 IU/L ↑ (ULN < 38 IU/L) ALT 53 IU/L ↑ (ULN < 42 IU/L) ALP 210 IU/L ↑↑ (ULN < 129 IU/L) Total bilirubin 11.6 mg/dL ↑↑ (ULN < 1.3 mg/dL) Direct bilirubin 8.8 mg/dL ↑↑ (ULN < 0.4 mg/dL) GGT 53 (ULN < 61 IU/L) Albumin 3.8 g/dL INR 1.0 AST, aspartate transaminase; ALT, alanine transaminase; ALP, alkaline phosphatase; GGT, gamma-glutamyl transferase; INR, international normalized ratio; UNL, upper limits of normal.

S3020 Hepatitis From a Sexually Transmitted Bacterial Infection

Introduction: Syphilis is a multisystemic, sexually transmitted infection (STI) that is caused by the spirochete Treponema pallidum. Hepatic involvement is rare. We present a patient who was diagnosed with syphilitic hepatitis (SH). Case Description/Methods: A 54-year-old male presented to the hospital with one week of sharp upper abdominal pain, jaundice, poor appetite, and a 25-lb. weight loss. He also reported multiple sexual partners and a rash that developed 2 months ago. Vital signs were within normal range. Physical examination revealed scleral icterus, a soft, non-tender abdomen, a plaque-like penile lesion and small, circular lesions on his palms and soles of feet. Laboratory studies revealed aspartate aminotransferase (AST) 164 U/L, alanine aminotransferase (ALT) 207 U/L, alkaline phosphatase (ALP) 1395 U/L, total bilirubin 5.6 mg/dL, gamma-glutamyl transferase 782 U/L. Hepatitis panel, acetaminophen and alcohol levels were negative. Chronic liver disease work-up was unremarkable. Treponemal antibody and rapid plasma reagin test were both positive. HIV test and cerebrospinal fluid venereal disease research laboratory (VDRL) test were negative. Abdominal ultrasound and CT scan of the abdomen were unremarkable. Magnetic resonance cholangiopancreatography was notable for hepatomegaly and hepatitis. Patient received 1 dose of penicillin G 2.4 million units intramuscularly with remarkable improvement in his symptoms and liver function tests. He was discharged home with close follow-up with gastroenterology and infectious disease. Discussion: SH occurs in 0.2-9.7% of patients with syphilis and is most commonly seen in the primary and secondary disease stages. Clinical manifestations include a maculopapular rash (involving the trunk, palms and/or soles of feet), fatigue, poor appetite, hepatomegaly and icterus. Liver function tests (LFTs) may reveal a marked increase in ALP and GGT in comparison to ALT and AST. SH is diagnosed with abnormal LFTs, serological evidence of syphilis, exclusion of other liver diseases and LFTs returning to normal after antibiotic therapy as in our patient. The histological features of SH include inflammatory infiltration of the bile duct and hepatic granulomas. Spirochetes are often difficult to identify in liver tissue. Penicillin is the mainstay of treatment. Clinicians should consider syphilitic hepatitis in a patient with abnormal LFTs (especially ALP) and a rash involving the palms and soles of feet in the appropriate clinical context.

270. New Onset Seizure Presented as Neurosyphilis

BackgroundThe term “neurosyphilis” refers to infection of the central nervous system (CNS) by Treponema pallidum. It can occur at any time after initial infection. Early in the course of syphilis, the most common forms of neurosyphilis involve the cerebrospinal fluid (CSF), meninges, and vasculature (asymptomatic meningitis, symptomatic meningitis, and meningovascular disease). Late in disease, the most common forms involve the brain and spinal cord parenchyma (general paralysis of the insane and tabes dorsalis).MethodsA 31-year-old man who suddenly developed a new onset generalized tonic clonic seizure, was admitted to the emergency department. He had no history of epilepsy and denied any vision or gait problems. The brain MRI showed no abnormalities. He had a history of rapid plasma reagent (RPR) titer 1:32 and a positive fluorescent treponemal antibody absorption (FTA-ABS) test in 2017. However, the RPR result was non-reactive when he retested a week later and therefore was not diagnosed with syphilis and did not get treated at that time. His most recent RPR titer was 1:16. HIV serology and other STD tests were all negative. His wife and his 3 kids were negative for syphilis. Due to serological evidence of syphilis and neurological symptoms, we arranged him to get a lumbar puncture to rule out neurosyphilis. ResultsHis CSF study showed positive venereal disease research laboratory (VDRL), WBC cell count 44 cells/ul (lymphocytes 80%, Neutrophil 20%), Glucose 50 mg/dl, Protein 75 mg/dl. Based on the CSF study, he was diagnosed with neurosyphilis and was treated with intravenous Penicillin G 3-4 million units every 4 hours for 14 days, followed by Benzathine Penicillin 2.4million units intramuscularly on day 21. ConclusionThis is an unusual case because his false negative RPR result has hindered the prompt diagnosis and management of syphilis. RPR is a nontreponemal test and therefore it is not always reliable as a diagnostic criteria. False negatives in RPR may occur in certain conditions such as in early primary or in late stage syphilis and prozone phenomenon. This case illustrates the importance of using a reverse sequence algorithm in diagnosing syphilis. Thorough history taking is also crucial in conjunction with serological tests to determine the diagnosis and to ensure appropriate treatment.Disclosures All Authors: No reported disclosures

Syphilis in HIV-infected mothers and infants: results from the NICHD/HPTN 040 study.

Untreated syphilis during pregnancy is associated with spontaneous abortion, stillbirth, prematurity and infant mortality. Syphilis may facilitate HIV transmission, which is especially concerning in low- and middle-income countries where both diseases are common. We performed an analysis of data available from NICHD/HPTN 040 (P1043), a study focused on the prevention of intrapartum HIV transmission to 1684 infants born to 1664 untreated HIV-infected women. This analysis evaluates risk factors and outcomes associated with a syphilis diagnosis in this cohort of HIV-infected women and their infants. Approximately, 10% of women (n=171) enrolled had serological evidence of syphilis without adequate treatment documented and 1.4% infants (n=24) were dually HIV and syphilis infected. Multivariate logistic analysis showed that compared with HIV-infected women, co-infected women were significantly more likely to self-identify as non-white (adjusted odds ratio [AOR] 2.5, 95% CI: 1.5-4.2), to consume alcohol during pregnancy (AOR 1.5, 95% CI: 1.1-2.1) and to transmit HIV to their infants (AOR 2.1, 95% CI: 1.3-3.4), with 88% of HIV infections being acquired in utero. As compared with HIV-infected or HIV-exposed infants, co-infected infants were significantly more likely to be born to mothers with venereal disease research laboratory titers≥1:16 (AOR 3, 95% CI: 1.1-8.2) and higher viral loads (AOR 1.5, 95% CI: 1.1-1.9). Of 6 newborns with symptomatic syphilis, 2 expired shortly after birth, and 2 were HIV-infected. Syphilis continues to be a common co-infection in HIV-infected women and can facilitate in utero transmission of HIV to infants. Most infants are asymptomatic at birth, but those with symptoms have high mortality rates.

Neurosyphilis Presenting Unilateral Oculomotor Nerve Palsy and Bilateral Pupil Involvement

Of the symptomatic disorders associated with neurosyphilis, the earliest manifestation is syphilitic meningitis. Approximately 5% of patients with secondary syphilis develop associated meningitis. Headaches, meningismus, cranial nerve palsies (chiefly, in descending order of frequency, VII, VIII, VI, and II. Here, we report a case of neurosyphilis presenting as unilateral oculomotor nerve palsy with bilateral pupil involvement (Argyll-Robertson pupil). A 43-year-old male presented with diplopia in both eyes at a neurology clinic 2 weeks before. He had right paralytic blepharoptosis, and both pupils were fixed and both pupils were not observed direct and indirect reflex and anisocoric. We observed Argyll Robertson pupil. He had 35 prisms of right exotropia, 2 prisms of right hypertropia at near and distance in the state of primary deviation and 60-prism right exotropia and 4- prism hypertropia in the state of secondary deviation. He had extraocular movement disorder in all gazes except abduction. We considered oculomotor nerve palsy associated with neurosyphilis based on the Argyll Robertson pupil. His orbit MRI suggested right oculomotor neuritis due to the presence of diffuse thickening of the right oculomotor nerve with enhancement. Finally, he was diagnosed with syphilis as a result of CSF protein 96.0, VDRL 7.5, and FTA-ABS (+) and was administered penicillin (4,000,000 units) and oral steroid (50 mg). One week after, his intraocular pressure was in the normal range. Extraocular movement examination findings were favorable as a result of 20-prism right exotropia at near and distance in the state of primary deviation and 35-prism right exotropia in the state of secondary deviation. He had extraocular movement disorder only in upper gaze. A diagnosis of neurosyphilis should be considered in patients with serologic evidence of syphilis and one or more of the following cerebrospinal fluid abnormalities; mononuclear pleocytosis, elevated protein, increased immunoglobulin G, or the presence of oligoclonal bands.

Associated factors with syphilis among human immunodeficiency virus-infected men who have sex with men in Taiwan in the era of combination antiretroviral therapy

Little is known about the factors associated with syphilis among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) with access to combination antiretroviral therapy (cART) in Taiwan, where MSM has re-emerged as the leading risk group for HIV transmission. From March to October 2011, MSM who regularly attended HIV clinics at a university hospital were invited to participate in the study. A structured questionnaire interview was conducted to collect information on sociodemographic characteristics, immunologic and virologic status, sexual partners and patterns of sexual behavior, and use of recreational drugs. During the study period, 310 HIV-infected MSM with a mean age of 35.5 years were enrolled, of which 82.3% (n = 255) were sexually active and 37.4% (n = 116) used recreational drugs in the past 6 months. Syphilis was self-reported in 46.5% (n = 144) of the participants after HIV infection was diagnosed and 37.5% (112/299) had serologic evidence of syphilis within 1 year before enrollment. Multivariate logistic regression analysis limited to those who were receiving cART showed that higher CD4 counts [adjusted odds ratio (AOR): 1.17; 95% confidence interval (CI): 1.02-1.34], lower educational achievement (AOR: 1.95; 95% CI: 1.05-3.63), serosorting (AOR: 3.32; 95% CI: 1.04-10.63), and use of recreational drugs (AOR: 2.55; 95% CI: 1.26-5.13) were associated with syphilis. Improved immune status, lower educational achievement, serosorting, and use of recreational drugs were associated with syphilis among HIV-infected MSM who were receiving cART. These findings suggest that strengthening client-specific counseling is needed to reduce risks for syphilis among HIV-infected MSM in Taiwan.

Criteria for the Diagnosis of Neurosyphilis in Cerebrospinal Fluid

The origin of cerebrospinal fluid (CSF) syphilis antibodies (intrathecal or blood-derived) is in doubt. Little is known about CSF test behavior under the condition of physiological or disturbed functioning of blood-CSF barrier (BCB) and intrathecal immunoglobulin (Ig) production. We collected 126 serum/CSF pairs from patients with serological evidence of syphilis. We explored the relationships between the established facts of intrathecal Ig synthesis and/or BCB dysfunction and the results of CSF diagnostic tests: the Treponema pallidum hemagglutination (TPHA) test, the fluorescent treponemal antibody absorption (FTA-Abs) test, the Venereal Disease Research Laboratory (VDRL) test, and white blood cell counts. We checked the criteria used either to support or refute the diagnosis of neurosyphilis. Reactive CSF-VDRL tests, elevated CSF-white blood cell counts, and elevated CSF-TPHA titers/indices were associated with the signs of intrathecal Ig synthesis, whereas nonreactive CSF-fluorescent treponemal antibody absorption, nonreactive CSF-TPHA tests, and CSF-TPHA titers from 1:4 to 1:160 were associated with cases where the intrathecal synthesis was not detected. There were some peculiarities of the tests toward BCB dysfunction.Most of reactive CSF-VDRL test samples and CSF samples with pleocytosis were also meeting at least 1 of the CSF-TPHA titer/indices-based criteria. T. pallidum hemagglutination indices were in no better conformity with the facts of intrathecal immune response than CSF-TPHA titers. Our findings have shown that all the examined criteria for the diagnosis of neurosyphilis in CSF are different assessment tools of intrathecal humoral immune activity and support the hypothesis that high CSF treponemal-specific antibody titers are a consequence of inflammatory pathology of the central nervous system.

Answer to June 2013 Photo Quiz

Answer: Cholestatic hepatitis secondary to secondary syphilis and neurosyphilis Skin rash is the most common characteristic of secondary syphilis and can take any form except vesicular lesions. Our patient had the classical distribution of symmetric, macular, or papular eruptions involving the trunk and extremities, including the palms and soles. Although the patient denied having had sexual activity for the prior 2 years, these lesions typically present weeks to months postexposure. Uveitis is the most common ocular manifestation of secondary and tertiary syphilis in both HIV-positive and HIV-negative patients, occurring in 2.5 to 5% of the untreated patients that progress to this stage. The diagnosis should prompt an analysis of the cerebrospinal fluid to exclude neurosyphilis, which was diagnosed in our patient. The diagnostic criteria for syphilitic hepatitis are abnormal liver enzymes indicating hepatic involvement, serologic evidence of syphilis in conjunction with acute clinical presentation consistent with primary or secondary syphilis, and exclusion of alternative causes of hepatic damage with prompt liver function recovery after antimicrobial therapy (1, 2). This case met all the aforementioned criteria. In addition, the histological features of inflammation with polymorphonuclear cells, hepatocellular necrosis, mild hepatocellular cholestasis, and cholangitis were also consistent with the diagnosis. The clinical manifestations of syphilitic hepatitis are likely to be subsequent to the dissemination of the treponema to the liver (2–4). However, demonstration of spirochetes in liver biopsy specimens has been inconsistent. The failure to demonstrate spirochetes in liver biopsy samples may be due to technical factors during storage and staining specimens or may be the result of effective phagocytosis by Kupfer cells (2). In this case, the Warthin-Starry stain did not demonstrate spirochetes, but spirochetes were visibly stained by a specific immunohistochemical stain highly specific for Treponema pallidum (Biocare Medical, LLC, Concord, CA). (See page 1657 in this issue [doi:10.1128/JCM.00702-12] for photo quiz case presentation.)

Etiology and STI/HIV Coinfections Among Patients With Urethral and Vaginal Discharge Syndromes in South Africa

This study was undertaken to establish the etiology of the male urethral discharge (MUDS) and vaginal discharge (VDS) syndromes, to determine the prevalence of other sexually transmitted infections (STI) and human immunodeficiency virus (HIV) coinfections, and to examine associations between STIs and HIV serostatus among STI patients in South Africa. A total of 507 MUDS and 300 VDS patients were recruited in Cape Town (CPT) and Johannesburg (JHB). A multiplex polymerase chain reaction assay detected Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium infections. Bacterial vaginosis and candidiasis were detected by microscopy. Sera were screened for syphilis, HSV-2, and HIV antibodies. Etiological diagnoses were made for 92% of MUDS patients and 85% of VDS patients. Gonorrhoea accounted for 85% (CPT) and 71% (JHB) of MUDS presentations. Chlamydia was the second most frequently detected MUDS pathogen (CPT, 13%; JHB, 24%). Among VDS patients, bacterial vaginosis was the most common cause (CPT, 46%; JHB, 36%) and trichomoniasis the most frequently detected STI pathogen (CPT, 19%; JHB, 34%). Few patients (4%) had serological evidence of syphilis. The HSV-2 and HIV seroprevalence were higher in Johannesburg compared to Cape Town and among women compared to men. HIV infection was statistically significantly associated with HSV-2 seropositivity at both sites and with the presence of N. gonorrhoeae and absence of C. trachomatis in Cape Town MUDS patients. Gonorrhoea and bacterial vaginosis were confirmed as the most frequent causes of MUDS and VDS. The high HIV seroprevalence in STI patients emphasizes the need to address HIV testing among this population.

Psychiatric manifestations during the course of late (tertiary) syphilis: Diagnostic dilemmas and therapeutic considerations a propos of a case report

Introduction:Neurosyphilis results from infection of the brain, meninges or spinal cord by the spirochete Treponema pallidum and comprises a wide spectrum of clinical and pathological features including psychiatric symptoms. We report the case of a patient who presented with psychotic symptoms and was diagnosed with late syphilis.Case report:A 45-year-old male with anxiety, insomnia, auditory hallucinations, delusions of persecution and mild cognitive impairment of relative recent onset was admitted to the Department of Skin and Venereal Diseases because of serological evidence of syphilis (TPHA 1:320). Upon admission treatment with olanzapine (15 mg/d) was started. Further evaluation yielded positive syphilis serology (TPHA, RPR and FTA-abs) in serum, slight cerebral atrophy in CT and discrete aneurysmatous dilatation of the aortic arch by heart ultrasonography. CSF findings did not satisfy laboratory criteria for the confirmation of diagnosis of active neurosyphilis. Late (tertiary) syphilis with beginning cardiovascular involvement was diagnosed and treatment with benzathin penicillin was administered. Six months later he was readmitted for a follow-up examination. Psychiatric symptoms were improved.Conclusion:Although quite rare today, neurosyphilis should be considered in the differential diagnosis of patients with psychotic symptoms and positive syphilis serology, as the appropriate treatment depends on early and accurate diagnosis. Moreover, given the wide use of antibiotics, abortive cases of neurosyphilis with atypical presentation forms must also be considered. Finally, this case suggests that in addition to the appropriate antibiosis, treatment with antipsychotics seems to be effective in controlling psychiatric symptoms emerging in the course of late syphilis.

Inguinal phlegmon and positive serology for syphilis after penile bite laceration: true, true and unrelated

Among many causes of penile injury, sexual activity is infrequently reported. The present case involved delay in recognition, which led to development of a phlegmon near major vascular structures. Positive serologic evidence of syphilis was an incidental finding.

Inflammatory ocular hypertension syndrome (IOHS) in patients with syphilitic uveitis

Aim:To determine the prevalence and clinical characteristics of the inflammatory ocular hypertension syndrome (IOHS) in patients with uveitis and serological evidence of syphilis.Methods:A retrospective, observational case review of 39 consecutive...

Adult-Onset Syphilitic Stromal Keratitis

To characterize the clinical features and therapeutic outcome of stromal keratitis associated with syphilis in adults. Observational case series. We examined the clinical and laboratory records at a single center of individuals with active stromal keratitis who had serological evidence of syphilis by a treponemal specific test. Five patients, 36 to 81 years of age, developed stromal keratitis during late syphilis. One patient with developmental signs of congenital syphilis had bilateral stromal keratitis. The others were otherwise healthy when they presented with unilateral, nonulcerative, infiltrative keratitis with stromal edema of the peripheral or paracentral cornea and mild to moderate corneal vascularization. All had an appropriate response to topical corticosteroid therapy, and two recovered good vision. Stromal keratitis recurred in two patients months to years later. Nonulcerative stromal keratitis presents in adults with syphilis as marginal, central, or multifocal stromal inflammation with neovascularization that responds to corticosteroid therapy but occasionally recurs.

Sexually transmitted infections among married women in Dhaka, Bangladesh: unexpected high prevalence of herpes simplex type 2 infection

Objectives: To document the prevalence of reproductive tract infections (RTI) and sexually transmitted infections (STI) among women attending a basic healthcare clinic in Dhaka, Bangladesh, to identify risk factors associated...

Breastfeeding, genetic, obstetric and other risk factors associated with mother-to-child transmission of HIV-1 in Sao Paulo State, Brazil. Sao Paulo Collaborative Study for Vertical Transmission of HIV-1.

To evaluate the effect of maternal, obstetric, neonatal and post-natal factors on the risk of vertical transmission of HIV-1. Multicentre retrospective cohort study. Obstetric and paediatric clinics in four cities in Sao Paulo State, Brazil. Child's HIV-1 infection status. Data were collected by standardized record abstraction and interview on 553 children born to women identified as HIV-1-infected before or at delivery. Paediatric infection was determined by immunoglobulin G anti-HIV-1 tests at age 18 months or by AIDS diagnosis at any age. Multivariate logistic regression was used to assess the effect of potential risk factors on vertical transmission of HIV-1. HIV-1 infection status was determined for 434 children (follow-up rate of 78%); 69 were classified as HIV-1-infected [transmission risk, 16%; 95% confidence interval (CI), 13-20%]. In multivariate analysis, advanced maternal HIV-1 disease [odds ratio (OR), 4.5; 95% CI, 2.1-9.5], ever breastfed (OR, 2.2; 95% CI, 1.2-4.2), child's negative Rhesus blood group (OR, 2.5; 95% CI, 1.2-5.5), third trimester amniocentesis (OR, 4.1; 95% CI, 1.2-13.5) and black racial group (OR, 0.3; 95% CI, 0.1-0.9) were independently and significantly associated with mother-to-child transmission of HIV-1. Transmission was increased marginally with prematurity, more than 10 lifetime sexual partners and prolonged duration of membrane rupture. No association was found between child's HIV-1 infection and mode of delivery or serological evidence of syphilis during pregnancy. These findings support the importance of severity of maternal HIV-1 disease in the risk of vertical transmission of HIV-1, indicate measures to reduce transmission by avoiding amniocentesis and breastfeeding and suggest that race and Rhesus blood type may be markers for genetic susceptibility to infection.

Definitions of genital ulcer disease and variation in risk for prevalent human immunodeficiency virus infection.

Although genital ulcer disease (GUD) has been associated with human immunodeficiency virus (HIV) infection in a number of studies, definitions of genital ulceration have varied. The authors hypothesized that the association of GUD with prevalent HIV infection may vary according to the definition of GUD that is used. As part of a prospective cohort study, 863 patients were interviewed and examined who presented to a sexually transmitted disease (STD) clinic for new symptom evaluation and who agreed to HIV testing to determine demographic and behavioral risk associated with prevalent HIV infection. To determine the association between GUD and prevalent HIV, the following definitions of GUD were used: observed ulcers, history of syphilis, serologic evidence of syphilis, observed culture-proven genital herpes, and serologic evidence of herpes simplex virus type II (HSV-2) infection. Of 481 men and 382 women enrolled, prevalent HIV infection was detected in 12.5% and 5.2%, respectively. In multivariate analyses controlling for known HIV risk behaviors, prevalent HIV infection was associated with observed GUD (odds ratio [OR] = 2.0, 95% confidence intervals (CI) = 1.0-3.9), a history of syphilis (OR = 6.0, CI = 2.8-12.7), and serologic evidence of syphilis (OR = 3.7, CI = 1.9-7.0), but not with serologic evidence of HSV-2 (OR = 1.2, CI = 0.7-2.1), nor with observed HSV-2 culture-positive genital ulcerations (OR = 1.0, CI = 0.4-4.2). Factors contributing to different strengths of association between HIV infection and a history of syphilis or serologic evidence of syphilis included the presence of underdiagnosed syphilis infection in people with reactive serologic tests and the absence of serologic reactivity in people with a positive history. Although GUD is strongly associated with prevalent HIV, the strength of the association depends on the definition of GUD used. For accurate evaluation of people at risk for HIV, clinicians and researchers should use multiple definitions of GUD.

Meningococcal antibody titres in infants of women immunised with meningococcal polysaccharide vaccine during pregnancy.

Seventy five Gambian women were immunised with a single dose of a group A+group C meningococcal polysaccharide vaccine during the last trimester of pregnancy. IgG antibody titres were measured in mothers and in their infants by an enzyme-linked immunosorbent assay (ELISA). All women had a good response to vaccination and maternal antibodies were high at the time of delivery (23.2 micrograms/ml for group A antibodies and 14.3 micrograms/ml for group C antibodies). However, only a proportion of this antibody crossed the placenta; cord blood:maternal antibody ratios were 30% for group A antibody and 44% for group C antibody, respectively. Considerable variability in cord blood:maternal blood ratios was seen between individuals. This could not be related to age, parity, or ethnic group. Mean group A and group C cord blood:maternal blood ratios were lower in women with serological evidence of syphilis than in seronegative women, and diminished transfer of group A antibody was noted in women with active malarial infection of the placenta. Antibody titres declined rapidly in infants and by the age of 3-4 months these had reached control values. Maternal immunisation may give infants some protection against group A and group C meningococcal disease but only during the first few months of life.

Asymptomatic congenital syphilis and auditory brainstem response

Untreated congenital syphilis is a known cause of hearing loss. In order to ascertain if infants are at risk of hearing loss at birth, 75 neonates with serologic evidence of syphilis and APGAR scores greater than 9 at 5 min were examined by auditory brainstem response (ABR) audiometry. All of the infants had normal ABRs. Ophthalmologic examination revealed no evidence of interstitial keratitis. Lumbar puncture was attempted on all the neonates. Cerebrospinal fluid (CSF) was successfully obtained from 41 infants and revealed no abnormalities. This study demonstrates that asymptomatic infants with serologic evidence of syphilis do not require audiologic evaluation in the neonatal period.

Human Immunodeficiency Virus Infection in Long-Distance Truck Drivers in East Africa

A cross-sectional survey was performed to determine the seroprevalence and correlates of human immunodeficiency virus (HIV) infection among long-distance truck drivers in Kenya. Truck drivers along the Mombasa-Nairobi highway were enrolled at a roadside research clinic. A standardized interview and serologic evaluation for HIV and syphilis were conducted. We enrolled 970 truck drivers and their assistants of whom 257 (27%) had HIV antibodies. In univariate analysis, HIV infection was correlated with older age, non-Kenyan nationality, Christian religion, longer duration of truck driving, travel outside of Kenya, less frequent visits to wives, and more frequent visits to prostitutes. Uncircumcised status, history of genital ulcer disease or urethritis during the previous 5 years, and a positive Treponema pallidum hemagglutination assay for syphilis were each associated with positive HIV serostatus. Univariate correlates of uncircumcised status included younger age, non-Kenyan nationality, Christian religion, travel outside of Kenya, and less frequent visits to prostitutes. There was a significant association between uncircumcised status and 5-year history of genital ulcer disease or serologic evidence of syphilis, but not with 5-year history of urethritis. In multivariate analysis, HIV infection was independently associated with uncircumcised status (adjusted odds ratio [OR], 4.9; 95% confidence interval [CI], 2.8 to 8.4), history of genital ulcer disease (adjusted OR, 2.4; 95% CI, 1.5 to 4.1), history of urethritis (adjusted OR, 1.8; 95% CI, 1.1 to 2.9), more frequent sex with prostitutes (more than once per month; adjusted OR, 1.7; 95% CI, 1.1 to 2.8), and positive T pallidum hemagglutination assay (adjusted OR, 1.2; 95% CI, 1.0 to 1.4). The attributable risk percentage for the association between HIV and uncircumcised status was 70%, and the population attributable risk was 25%. Truck drivers in east Africa are at high risk of HIV infection. The strongest correlates of HIV seropositivity were uncircumcised status and history of both ulcerative and nonulcerative sexually transmitted diseases.

Routine serologic screening for syphilis in hospitalized patients: high prevalence of unsuspected infection in the elderly.

To evaluate the potential yield of routine serologic testing for syphilis in hospitalized patients. Sera from consecutive patients admitted to an inpatient general medical service of a Baltimore hospital were tested using the RPR and FTA-ABS tests for syphilis. Two hundred ninety-one (149 males and 142 females) of 344 patients (85%) hospitalized during the study period participated, with ages ranging from 17 to 98 years. Seventy-seven percent of participants were African-American. Results of serologic tests for syphilis and human immunodeficiency virus were correlated with questionnaire responses. Associations were sought between results of serologic testing and demographic characteristics, medical problems, and a history of syphilis. No patient had an admitting diagnosis of syphilis. Thirty-seven patients (13%) had both reactive RPR and FTA-ABS tests. Although serologic evidence of syphilis was significantly associated with age older than 50 years and with a history of syphilis, 59% of patients with both reactive RPR and FTA-ABS tests did not give a history of syphilis. Ten percent of patients were HIV seropositive; however HIV seropositivity was not significantly associated with serologic evidence of syphilis. Unsuspected latent syphilis was common in this population. Routine serologic screening for syphilis should be considered in some hospitals.