Rapid diagnostic testing for syphilis in Arctic communities (the STAR study): a multisite prospective field diagnostic accuracy study in an intended-use setting.

OBJECTIVES: We evaluated the field diagnostic accuracy of a syphilis rapid test (RDT), using serum and whole blood by non-laboratorians in two Canadian Arctic communities. METHODS: We implemented a multisite prospective field evaluation wherein patients were screened by an RDT containing treponemal and non-treponemal components (Chembio DPP® Syphilis Screen & Confirm) between January 2020 and December 2021. Venous whole blood and serum were collected for rapid testing and compared with laboratory-based serology reference testing using a reverse sequence algorithm of treponemal and rapid plasma reagin (RPR) testing. RESULTS: Overall, 135 whole blood and 139 serum specimens were collected from 161 participants during clinical encounters. Treponemal-RDT sensitivity against a treponemal-reference standard (38/161 confirmed cases) was similar for serum (78% [95% CI: 61-90%]) and whole blood (81% [95% CI: 63-93%]). In those with RPR titres ≥1:8 (i.e. suggestive of recent/active infection), sensitivity increased to 93% (95% CI: 77-99%) for serum and 92% (95% CI: 73-99%) for whole blood. Treponemal-RDT specificity was excellent (99% [95% CI: 95-100%]) for both specimen types. Non-treponemal-RDT sensitivity against RPR was 94% (95% CI: 80-99%) for serum and 79% (95% CI: 60-92%) for whole blood. Sensitivity increased to 100% (95% CI: 88-100%) for serum and 92% (95% CI: 73-99%) for whole blood when RPR titres ≥1:8. RDT performance with whole blood was similar to that with serum. DISCUSSION: Non-laboratorians using the RDT accurately identified individuals with infectious syphilis under real-world conditions in an intended-use setting at the point of care. Implementing the RDT can eliminate treatment delays and may enhance disease control.

Retrospective testing for the presence of monkeypox virus in a high-risk population from February-June 2022 in Alberta, Canada.

Background: A multi-country outbreak of monkeypox virus (MPXV) infections was identified by the World Health Organization in May 2022. The western Canadian province of Alberta identified its first case of MPXV in a returning traveller on June 2, 2022. We undertook a retrospective testing exercise to evaluate whether MPXV may have been circulating in the province earlier. Methods: Skin (genital and non-genital) and mucosal lesion swabs submitted for herpes simplex virus (HSV)/varicella zoster virus (VZV)/syphilis testing from male patients attending sexually-transmitted infection clinics across the province of Alberta from January 28 to May 30, 2022 were retrieved from storage. The population tested was selected based on the epidemiology of the current 2022 multi-country MPXV outbreak. Samples underwent viral nucleic acid extraction and testing for the presence of Orthopoxvirus DNA using a commercial real-time polymerase chain reaction (PCR) kit. Results: A total of 392 samples (representing 341 unique individuals of median age 31 years) were retrieved. Of them, 349 (89.0%) samples were submitted for HSV/VZV/syphilis testing, 13 (3.3%) for HSV/VZV only, and 30 (7.7%) for syphilis PCR only. None of the 392 samples tested were found to be positive for Orthopoxvirus DNA. Conclusions: The results of this study indicate that circulation of MPXV in a higher-risk population in Alberta, prior to the first case, was less likely. We recommend that other provinces/territories review their local epidemiology, context and resources prior to conducting similar studies.

Historique: En mai 2022, l'Organisation mondiale de la Santé a déclaré une flambée multinationale d'infection par le virus de la variole simienne (MPXV). Le 2 juin 2022, la province de l'Alberta, dans l'Ouest canadien, a recensé son premier cas de MPXV chez un voyageur de retour de l'étranger. Les chercheurs ont entrepris un exercice de dépistage rétrospectif pour évaluer la possibilité que le MPXV ait circulé auparavant dans la province. Méthodologie: Les chercheurs ont extrait de l'entreposage les écouvillons des lésions cutanées (génitales et non génitales) et muqueuses soumis en vue de dépister le virus herpès simplex (VHS), le virus varicelle-zona (VZV) et le virus de la syphilis des patients de sexe masculin qui avaient fréquenté les cliniques d'infections transmises sexuellement de la province de l'Alberta entre le 28 janvier et le 30 mai 2022. Ils ont sélectionné la population soumise au dépistage en fonction de l'épidémiologie de la flambée multinationale de MPXV en 2022. Les écouvillons ont été soumis à l'extraction et au test des acides nucléiques viraux pour dépister la présence d'ADN de l'Orthopoxvirus au moyen d'un test commercial d'amplification en chaîne par polymérase (PCR). RÉsultats: Les chercheurs ont extrait un total de 392 échantillons (représentant 341 personnes uniques d'un âge médian de 31 ans). De ce nombre, 349 (89,0 %) avaient été soumis au test PCR du VHS, du VZV et de la syphilis, 13 (3,3 %), du VHS et du VZV seulement et 30 (7,7 %), de la syphilis seulement. Aucun des 392 échantillons n'a donné de résultat positif à l'ADN de l'Orthopoxvirus. Conclusions: D'après les résultats de la présente étude, il est peu probable que le MPXV ait circulé dans la population plus vulnérable de l'Alberta avant la détection du premier cas. Les chercheurs recommandent que les autres provinces et territoires examinent leur épidémiologie locale, le contexte et les ressources avant de procéder à des études de ce type.

Sensitivity and specificity of two investigational Point of care tests for Syphilis and HIV (PoSH Study) for the diagnosis and treatment of infectious syphilis in Canada: a cross-sectional study.

OBJECTIVES: Single-visit testing and treatment for syphilis can reduce follow-up visits. The objectives of this study were to evaluate the performance and treatment outcomes of two dual syphilis/HIV point-of-care tests (POCTs). METHODS: Participants aged 16 years and older were offered concurrent syphilis/HIV POCTs with fingerstick blood sampling using two extremely rapid (<5 minutes) devices (MedMira Multiplo Rapid TP/HIV test and INSTI Multiplex HIV-1/HIV-2/Syphilis Antibody Test). Those with positive POCT results were offered same-day syphilis treatment and linkage to HIV care. Nurses performed testing at two emergency departments, a First Nations community, a correctional facility, and a sexually transmitted infection clinic. POCT results were compared with those of standard serological testing. Sensitivity and specificity were calculated. RESULTS: Between August 2020 and February 2022, 1526 visits were completed. Both POCTs accurately identified participants with HIV (sensitivity, 100% [24 of 24]; 95% CI, 86.2-100%; specificity, 99.6% [1319 of 1324]; 95% CI, 99.1-99.8%), linking 24 HIV cases to care. Both tests were most sensitive with a rapid plasma reagin (RPR) of ≥1:8 dilutions (Multiplo: sensitivity, 98.3% [231 of 235]; 95% CI, 95.7-99.3%; specificity, 99.5% [871 of 875]; 95% CI, 98.8-99.8%; INSTI Multiplex: sensitivity, 97.9% [230 of 235]; 95% CI, 95.1-99.1%; specificity, 99.8% [873 of 875]; 95% CI, 99.2-99.9%) and least sensitive with non-reactive RPR (Multiplo: sensitivity, 54.1% [59 of 109]; 95% CI, 44.8-63.2%; specificity, 99.5% [871 of 875]; 95% CI, 98.8-99.8%; INSTI Multiplex: sensitivity, 28.4% [31 of 109]; 95% CI, 20.8-37.5%; specificity, 99.8% [873 of 875]; 95% CI, 99.2-99.9%). Eighty-five percent of participants with infectious syphilis were treated on the same day as the positive POCT result. DISCUSSION: Two extremely rapid (<5 minutes) dual syphilis/HIV POCTs showed excellent sensitivity and specificity for the diagnosis of active syphilis (RPR, ≥1:8 dilutions) and HIV and confirmed the ability to offer single-visit testing and treatment for syphilis and linkage to HIV care in diverse clinical settings.

Serologic follow-up of solid organ transplant recipients who received organs from donors with reactive syphilis tests: A retrospective cohort study.

The increased procurement of organs from donors with risk factors for blood-borne diseases and the expanding syphilis epidemic have resulted in a growing number of organs transplanted from donors with reactive syphilis serology in our center. Based on guidelines, recipients typically receive therapy shortly after the transplant, but data on outcomes are limited. The primary objective of this study was to determine syphilis seroconversion rates at three months post-transplant in recipients of solid organs procured from donors with reactive syphilis serology. Organ donors and recipients were tested for syphilis antibody; positive results were confirmed with Treponema pallidum Particle Agglutination (TPPA). Eleven donors with reactive syphilis antibody donated organs to 25 syphilis negative recipients. Three recipients seroconverted at post-transplant month 3. All of them had received therapy shortly after transplant. TPPA was negative in all 3. Despite post-transplant treatment, 3 of 25 (12%) syphilis negative recipients of organs from syphilis positive donors seroconverted at 3 months. All remained TPPA negative possibly reflecting passive antibody transfer or differing test sensitivity to low level treponemal antibodies. Further studies are needed to assess optimal syphilis transmission prevention strategies and follow up recipient testing in organ transplantation.

Stopping syphilis transmission in Arctic communities through rapid diagnostic testing: The STAR study protocol.

BACKGROUND: Intense transmission of syphilis has emerged in some Canadian Arctic communities despite screening and prevention efforts. The remoteness of most communities and limited diagnostic infrastructure yield long delays (≥14 days) between screening and treatment of cases. These hamper syphilis control efforts and may contribute to sustained transmission. Syphilis rapid diagnostic tests (RDTs) have been developed to make screening more accessible and to inform clinical decision-making within the same clinical encounter. These RDTs have been successfully deployed in several countries, but not yet in Canada. METHODS AND DESIGN: We describe the methodology of the "Stopping Syphilis Transmission in Arctic Communities Through Rapid Diagnostic Testing" (STAR) study, wherein the clinical and epidemiological impact of deploying a dual syphilis RDT in the context of ongoing transmission in Nunavut and Nunavik will be evaluated. In this prospective multisite field evaluation, sexually active individuals aged ≥14 years at risk for syphilis will be offered screening by an RDT at the point-of-care by non-laboratory trained registered nurses. Whole blood and serum specimens will be concurrently collected, when feasible, for rapid testing with an RDT containing both treponemal and non-treponemal components (Chembio DPP® Syphilis Screen & Confirm) and compared to laboratory-based reference testing according to a reverse sequence algorithm. The diagnostic accuracy of the RDT, using both whole blood and centrifuged serum specimens, will be validated under real-world conditions in remote Northern settings, outside of specialized laboratories. Additionally, screening-to-treatment time, case detection rates, and the number of infectious contacts averted by using the RDT relative to reference testing will be estimated. The impact of both diagnostic approaches on syphilis transmission dynamics will also be modeled. DISCUSSION: This study will provide much needed evidence for strengthening rapid responses to emerging syphilis outbreaks in remote Arctic regions, by supplementing traditional diagnostic strategies with an RDT to rapidly triage patients likely in need of treatment. These results will also inform the development and tailoring of future diagnostic strategies and public health responses to emerging outbreaks in the North.

Retrospective Cohort Study Examining the Correlates of Reported Lifetime Stimulant Use in Persons Diagnosed With Infectious Syphilis in Alberta, Canada, 2018 to 2019.

BACKGROUND: We sought to examine the correlates for stimulant use in persons diagnosed with infectious syphilis during an outbreak in Alberta to help guide public health interventions. METHODS: Infectious syphilis data were extracted from the Communicable Disease and Outbreak Management database from January 1, 2018, to December 31, 2019. Behavioral, demographic, and lifetime reported stimulant use data were obtained. Descriptive analyses and logistic regression were performed for 3 subpopulations (gay, bisexual, and other men who have sex with men; men who have sex with women; and women). RESULTS: Of 3627 individuals diagnosed with infectious syphilis, 23.9% (n = 867) cases were not interviewed for substance use and were removed from further analysis. Of the remaining 2759 people, 41.8% (n = 1153) self-reported lifetime stimulant use. Gay, bisexual, and other men who have sex with men reported stimulant use less often than women (24.6% vs. 44.1%; P < 0.0001) and men who have sex with women (24.6% vs. 46.2%; P < 0.0001). Multivariable analyses demonstrated that stimulant use was associated with persons who injected drugs, had correctional involvement, or reported multiple sex partners. Men who have sex with women were more likely to self-report First Nations ethnicity (adjusted odds ratio, 1.76 [95% confidence interval, 1.25-2.49]), and women were more likely to have a concurrent gonorrhea infection (adjusted odds ratio, 1.62 [95% confidence interval, 1.15-2.28]). CONCLUSIONS: Nearly half of infectious syphilis cases in Alberta reported lifetime nonprescription stimulant use. Infectious syphilis cases with stimulant use were associated with injection drug use, multiple sex partners, and correctional involvement. Our observations highlight the need for integration of sexual health services into programs for people who use substances and those in corrections custody.

Lessons from management of syphilis in Nunavut, Canada, 2012-2020.

Background: Nunavut, part of Inuit Nunangat, is a geographically vast territory in northern Canada, with a population of over 38,000 people. Most (85%) of the population identify as Inuit. Nunavut has experienced a significant rise in heterosexual infectious syphilis cases since 2012. Management of communicable diseases, including syphilis, is challenging due to high staff turnover and long delays in specimen transport times. Social determinants of health are also an important contributor. The aim of this study is to describe the epidemiology and program elements for infectious syphilis from 2012-2020 and to highlight beneficial interventions. Methods: Syphilis is a notifiable disease in Nunavut with all cases reported to the Territorial Department of Health. Cases were staged by a medical consultant. Data were analyzed and released in public reports as part of the public health program. Results: From 2012 to 2020, 655 infectious syphilis cases were reported, with 53% of reported cases among females. Infection rates were highest in 20 to 39-year-olds. There was significant variability in reported cases over this time period by geographic region, with the majority of infectious cases reported from the Kivalliq region. Despite 48 reported cases in pregnancy, no confirmed congenital syphilis cases were identified. Program staff identified strengths of the response as well as ongoing needs, such as plain language resources available in multiple languages. Conclusion: Despite the logistical challenges with syphilis management in the territory, the overall outcomes have been positive, with no confirmed congenital cases identified. We attribute this to a coordinated effort by multiple partners including key actions by public health nurses and community health representatives.

Incentive-Based Sexually Transmitted and Blood-Borne Infections Screening in High-Income Countries: A Systematic Review.

BACKGROUND: Despite increasing access to treatment and screening, rates of sexually transmitted and blood-borne infections (STBBI) continue to rise in high-income countries. The high cost of undiagnosed and untreated STBBI negatively affects individuals, health care systems, and societies. The use of monetary and nonmonetary incentives may increase STBBI screening uptake in high-income countries. Incentivized screening programs are most effective when developed specific to context and target population. METHODS: Our review was performed according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. Inclusion criteria were as follows: English language, high-income countries, primary research studies, and older than 16 years. Study quality was assessed using Joanna Briggs Institute quality assessment tools. RESULTS: The search yielded 6219 abstracts. Thirteen articles met the inclusion criteria. Studies took place in the United States, the United Kingdom, and Australia. Populations screened included: postsecondary and tertiary students, parolees or probationers, youth, and inner-city emergency department patients. Incentivized STBBI screened were human immunodeficiency virus (n = 5), chlamydia (n = 7), and multiple infections (n = 1). Incentives offered were monetary (cash/gift cards/not specified) (n = 10), nonmonetary (n = 1), and mixed (n = 2). Both monetary and nonmonetary incentives enhance STBBI screening in high-income countries. CONCLUSION: Incentivized screening programs are most effective when developed specific to context and target population. Further research is needed to analyze incentivized screening across similar study designs and to evaluate long-term effectiveness.

Retrospective Cohort Study of the Incidence and Outcomes of Jarisch-Herxheimer Reactions After Treatment of Infectious Syphilis in Late Pregnancy.

ABSTRACT: Of 39 pregnant women at ≥20 weeks' gestation treated with benzathine penicillin G for infectious syphilis, we identified only 2 mild Jarisch-Herxheimer reactions. There were no immediate fetal sequelae. Data from our study do not support the recommendation for routine admission for the treatment of infectious syphilis in late pregnancy.

Retrospective audit of a convenience cohort of individuals on HIV pre-exposure prophylaxis in Alberta, Canada.

BACKGROUND: We undertook an audit of a province-wide HIV pre-exposure prophylaxis (PrEP) program in Alberta (Canada). METHODS: A retrospective record review of individuals accessing PrEP in Alberta included demographics, PrEP indication(s), and reported non-prescription drug and alcohol use from March 2016 to June 2019. Hepatitis A, B, C, HIV and syphilis serology, serum creatinine, and nucleic acid amplification tests testing for chlamydia and gonorrhea were collected. Descriptive statistics, incidence, and prevalence were calculated. RESULTS: A total of 511 participants were seen at STI, sexual, and reproductive health clinics and private family practitioner (FP) offices; 98.4% (503) were men, median age was 34 years (IQR 28-43 years), and 89.8% (459) were gay or bisexual men who have sex with men. Non-prescription drug use was reported by 39.3% (201) and alcohol use by 55.4% (283). 94.3% (482) reported condomless anal sex in the past 6 months. Testing rates were high (>95%) for all tests except for chlamydia and gonorrhea at the first follow-up visit 89.6%; (3-4 months). There was one HIV seroconversion. The incidence of new bacterial STIs was high: chlamydia 17 cases per 100 person-years (95% CI 13.5% to 21.4%), gonorrhea 11.14 cases per 100 person-years (95% CI 8.3% to 15.0%), and syphilis 1.94 cases per 100 person-years (95% CI 0.73% to 5.12%). CONCLUSIONS: Following implementation of a provincial program for PrEP in Alberta, PrEP initiation and continuation was feasible in a range of settings and by both specialists and FPs.

HISTORIQUE: Les chercheurs ont entrepris une vérification du programme provincial de prophylaxie pré-exposition (PrEP) du VIH en Alberta, au Canada. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers des personnes qui ont eu accès à la PrEP en Alberta, y compris les données démographiques, les indications d'administrer une PrEP et la consommation déclarée de médicaments sans ordonnance et d'alcool entre mars 2016 et juin 2019. Ils ont recueilli la sérologie de l'hépatite A, B et C, du VIH et de la syphilis, la créatinine sérique et les tests d'amplification des acides nucléiques de la Chlamydia et de la gonorrhée. Ils ont également calculé les statistiques descriptives, l'incidence et la prévalence de ces maladies. RÉSULTATS: Au total, 511 participants ont été vus dans des cliniques d'ITS, de santé sexuelle et de santé reproductive ainsi qu'au cabinet de médecins de famille privés, soit 98,4 % d'hommes (503), d'un âge médian de 34 ans (ÉIQ : 28 à 43 ans) et 89,8 % (459) d'hommes gay ou bisexuels qui avaient des relations sexuelles avec d'autres hommes. Ainsi, 39,3 % (201) ont déclaré consommer des médicaments sans ordonnance et 55,4 % (283), de l'alcool. De plus, 94,3 % (482) ont indiqué avoir eu des relations sexuelles anales sans préservatif au cours des six mois précédents. Les taux de dépistage étaient élevés (>95 %) à l'égard de tous les tests au premier rendez-vous de suivi (au bout de trois à quatre mois), sauf ceux de la Chlamydia et de la gonorrhée, qui s'élevaient à 89,6 %. Un cas de séroconversion du VIH a été constaté. L'incidence de nouvelles ITS bactérienne était élevée : 17 cas de Chlamydia par 100 années-personnes (IC à 95 %, 13,5 % à 21,4 %), 11,14 cas de gonorrhée par 100 années-personnes (IC à 95 %, 8,3 % à 15,0 %) et 1,94 cas de syphilis par 100 années-personnes (IC à 95 %, 0,73 % à 5,12 %). CONCLUSIONS: Après la mise en œuvre d'un programme provincial de PrEP en Alberta, il a été établi qu'il était possible d'entreprendre et de poursuivre la PrEP dans divers milieux, à l'instigation de spécialistes tout autant que de médecins de famille.

Incentive-Based Human Immunodeficiency Virus Screening in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: The majority of new human immunodeficiency virus (HIV) infections that occur worldwide are in sub-Saharan Africa. While recent gains have been made in many low- and middle-income countries (LMICs), substantial disparities in sexually transmitted and blood-borne infections (STBBI) screening and treatment still exist between LMIC and high-income countries. In addition to increasing STBBI screening uptake, providing incentives for STBBI screening may decrease perceived stigma associated with STBBI screening. METHODS: Our review was conducted as part of a larger systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and guidance from the Cochrane Handbook for Systematic Reviews of Interventions. This review focuses on incentivized STBBI screening in LMIC; high-income countries were excluded. Articles were excluded if their primary focus was on children and youth (younger than 16 years), results retrieval, treatment, behavioral change only, behavior intention, treatment adherence, or provider incentive. RESULTS: The search yielded 6219 abstracts. The search and selection criteria included all STBBI; however, only articles examining incentivized HIV screening met our inclusion criteria. Five articles representing 4 distinct studies from South Africa, Uganda, and Zimbabwe were included, all of which focused on incentivized HIV screening. Populations screened included the following: men, first-time testers, population-based surveillance program families, and insurance health plan members. Incentive structures varied widely and incentives were mainly food vouchers, lottery prizes, or household items. CONCLUSIONS: Our review was conducted to determine if patient incentives increase STBBI test uptake in LMIC. Overall, incentives were associated with an increase in HIV screening uptake. Most studies included focused solely on men. There is a significant void in understanding STBBI incentive-based screening outside of this context and in complex populations who should be targeted in incentivized HIV screening. Incentives appear most effective when developed specific to context and target population. Further research is needed to analyze incentivized screening across similar study designs, to evaluate long-term effectiveness, and to explore the ethical implications of incentivized care.

Molecular Characterization and Antimicrobial Resistance in Neisseria gonorrhoeae, Nunavut Region of Inuit Nunangat, Canada, 2018-2019.

We assessed antimicrobial resistance (AMR) in Neisseria gonorrhoeae in Nunavut, Canada, using remnant gonorrhea nucleic acid amplification test-positive urine specimens. This study confirms the feasibility of conducting N. gonorrhoeae AMR surveillance and highlights the diversity of gonococcal sequence types and geographic variation of AMR patterns in the territory.

Neurosyphilis and Lyme neuroborreliosis.

PURPOSE OF REVIEW: Neurosyphilis (NS) and Lyme neuroborreliosis (LNB) are spirochetal diseases with distinct clinical manifestations. The diagnosis of NS remains challenging due to imperfect diagnostic criteria and testing modalities. With LNB, misconceptions about diagnosis and treatment lead to considerable morbidity and drug related adverse effects. RECENT FINDINGS: Although studies continue investigating alternate approaches and new diagnostic tests for NS, few data exist to change current approaches to diagnosis, management or follow up. In the diagnosis of LNB, the chemokine CXCL13 shows promising diagnostic accuracy. A systematic review discourages the use of cell-based assays when investigating Lyme disease. Clinical studies show no benefit from extended antibiotic treatment for patients with unspecific symptoms labelled as having Lyme disease. SUMMARY: The diagnosis of NS may be delayed due to a lack of specificity of findings, low suspicion for syphilis, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis is required provide timely diagnosis and management of NS. Fortunately, penicillin remains the treatment of choice. Overdiagnosis and overtreatment in patients labelled as having Lyme disease can be avoided by an evidence-based approach towards diagnosis and treatment.

Ocular and neurosyphilis: epidemiology and approach to management.

PURPOSE OF REVIEW: In the context of a resurgence of syphilis worldwide, it can be anticipated that a rise in cases of ocular, otic, and neurosyphilis will also be seen. This article reviews the current epidemiology, manifestations, and approach to management and treatment. RECENT FINDINGS: Although studies continue investigating alternate approaches and new diagnostic tests for ocular and neurosyphilis, few data exist to change current diagnostic algorithms and approaches to diagnosis, management, or follow up. SUMMARY: The diagnosis of neurologic and eye/ear involvement with syphilis may be delayed because of a lack of specificity of findings, low suspicion for syphilis, fluctuation in symptoms, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis and re-education about the protean manifestations of syphilis by all clinicians is required provide timely diagnosis and management of ocular, otic, and neurosyphilis.

Retrospective review of tertiary and neurosyphilis cases in Alberta, 1973-2017.

OBJECTIVES: To review the notification rate and characteristics of tertiary and neurosyphilis cases in Alberta, Canada in the postantibiotic era. METHODS: A retrospective review of all neurosyphilis and tertiary syphilis cases reported in Alberta from 1973 to March 2017 was undertaken and cases classified into early neurosyphilis, late neurosyphilis and cardiovascular (CV) syphilis. Variables collected included demographics, sexual partners, HIV status, clinical parameters, symptoms and treatment and distributions were compared between early versus late neurosyphilis and asymptomatic versus symptomatic cases (stratified by early versus late stage). Data were analysed using IBM SPSS Statistics V.19.0. RESULTS: 254 cases were identified; 251 were neurosyphilis and 3 were CV. No cases of gummatous syphilis were reported. Early neurosyphilis accounted for 52.4% (n=133) and 46.1% (n=117) were late neurosyphilis cases; one (0.4%) case with unknown duration. Three outbreaks of infectious syphilis were identified during the study period and a concurrent rise in both early and late neurosyphilis was observed during the outbreak periods. The most common manifestation of symptomatic neurosyphilis was ocular involvement which was more likely in early neurosyphilis. Relative to late neurosyphilis cases, early neurosyphilis cases were more likely to be younger, Caucasian, born in Canada, HIV positive and reporting same sex partners. CONCLUSIONS: Our review of tertiary and neurosyphilis cases found that early and late neurosyphilis cases continue to occur in the context of cycling syphilis outbreaks. CV syphilis cases were extremely rare. Ongoing identification of new cases of syphilis and clinical evaluation of cases for complications continues to be important in the context of global resurgence of syphilis.

An unusual case of Erysipelothrix rhusiopathiae prosthetic joint infection from the Canadian Arctic: whole genome sequencing unable to identify a zoonotic source.

BACKGROUND: Erysipelothrix rhusiopathiae is a zoonotic pathogen that causes erysipeloid and is most frequently associated with exposure to domestic swine. Infection of native and prosthetic joints is a rarely reported manifestation. CASE PRESENTATION: We describe a case of E. rhusiopathiae prosthetic joint infection in a woman with a history of exposure to wild animals in the Canadian Arctic. Patient management involved a 1-stage surgical revision exchange with an antibiotic impregnated cement spacer and 6 weeks of intravenous penicillin G followed by 6 weeks of oral amoxicillin. Ten previously reported cases of E. rhusiopathiae joint infection are reviewed. Recent increases in mortality due to infection with this organism among host animal populations in the Canadian Arctic have generated concern regarding a potential increase in human infections. However, whole genome sequencing (WGS) of the organism was unable to identify a zoonotic origin for this case. CONCLUSIONS: Consideration should be given to E. rhusiopathiae as a cause of joint infections if the appropriate epidemiologic and host risk factors exist. Expanded use of WGS in other potential animal hosts and environmental sources may provide important epidemiologic information in determining the source of human infections.