Bacterial Lesions of the Oral Mucosa.

Nonodontogenic bacterial infections of the oral cavity are not a common finding in the United States. Nevertheless, there has been an increase in prevalence of certain bacterial sexually transmitted diseases, such as syphilis and gonorrhea, and conditions such as tuberculosis still pose a serious threat to certain segments of the population. Finally, given the uncommon nature and pathophysiology of these diseases, diagnosis is often delayed, resulting in more clinically significant disease and potential contamination of individuals. Thus, it is prudent that clinicians be familiar with these uncommon but potentially serious infectious diseases, so treatment can be instituted promptly.

Linear trends over 20 years in sexually transmitted infections among patients attending a tertiary care centre in north Kerala, India.

BACKGROUND: Worldwide, a declining trend is observed in sexually transmitted infections of bacterial origin which is reflected as a rise in the proportion of viral sexually transmitted infections. AIMS: To find out the clinical referral patterns of sexually transmitted infections among patients who attended the sexually transmitted infection clinic attached to Dermatology and Venereology Department of Government Medical College, Kozhikode from 1.1.1998 to 31.12.2017 and to study the linear trends in the pattern of sexually transmitted infections over 20 years. METHODS: After clearance from the institutional ethics committee, a retrospective study was conducted among patients who attended the sexually transmitted infection clinic of Government Medical College, Kozhikode from 1.1.1998 to 31.12.2017 and were diagnosed to have sexually transmitted infections. RESULTS: During the 20 year study period 5227 patients, attended the sexually transmitted infection clinic of our institution. Diagnosis of sexually transmitted infection was made in 2470 (47.3%) cases. Predominant sexually transmitted infections were herpes genitalis (964, 39%), condyloma acuminata (921, 37.9%) and syphilis (418, 17.2%). Viral sexually transmitted infections (1885, 76.3%) outnumbered bacterial sexually transmitted infections (575, 23.3%). A declining trend was noted for both bacterial and viral sexually transmitted infections over the 20 year period, which was more marked for the former. But the latter years of the study documented a rising trend in total sexually transmitted infections including bacterial sexually transmitted infections. LIMITATIONS: The study does not reflect the status of sexually transmitted infections in the general population since it was conducted in a tertiary referral center. CONCLUSION: The disturbing ascending trend recorded in sexually transmitted infections including syphilis during the final years of the 20-year period needs to be watched closely, to plan future strategies.

On Shakespeare and cutaneous diseases.

Disorders with dermatologic features are intractable and rife in Shakespeare's world. For this reason, they occupy an unusual position in culture. "The plague" and "leprosy" are popular insults and epithets-indictments of not external pathogens but of moral failure. It may be no surprise to identify, as a present-day reader, syphilis and the plague in early modern England, but what about other dermatologic conditions at the time? "The plague," "leprosy," "the pox," and "measles" are commonly used terms, although ultimately interchangeable in Shakespeare's plays. Rosacea and scurvy, however, are described by Shakespeare before they become named entities. Bardolph's skin characterizes his alcohol addiction and thievery, and Caliban's "monstrous" form mirrors his state as an untouchable in society. Shakespeare also documents the "royal touch" in Macbeth, which links the ability of a monarch to heal the skin lesions of extrapulmonary tuberculosisto political legitimacy. Shakespeare does little more than document this historic ritual around the skin, but he does catalogue the ways these acquired diseases of the skin are used in daily speech and character writing. At the end of Macbeth, the "royal touch" gives Prince Malcolm the backstory and political precedent to march on Dunsinane Hill to reclaim the Scottish throne.

Ancient and modern pathologies and therapies: St. Gallicanus Hospital in Rome between the 18th and 20th centuries.

St. Gallicanus Hospital in Rome, Italy, created by the will of Pope Benedict XIII (1649-1730) in 1725, was the first dermatologic hospital in the world. The strong bond between science and faith, humanitarian spirit and scientific research, and the profoundness and legacy of its entire history have all contributed to its legacy. We have traced its development by examining archival documents to understand the life of the institute and the diseases that were diagnosed and treated from the 18th century to the first half of the 20th century. Some of the main diseases were leprosy, mange, scabies, ringworm, and syphilis, which were widespread in Rome during the 18th and 19th centuries and were creating a mortal threat for much of the population. St. Gallicanus Hospital was dedicated to the diagnosis, treatment, and prevention of these diseases where possible. Special attention has been directed to syphilis and the use of penicillin therapy after its introduction in 1943, especially for curbing the extensive problems created by prostitution.

Epilepsy and syphilis: A systematic review and meta-analysis.

BACKGROUND: Epileptic seizures were noted as one of the most overlooked manifestations in syphilis; therefore a few clinicians are concerned about the relationship between epilepsy and syphilis. Our study sought to clarify the prevalence and clinical features of epileptic seizures in patients with syphilis. METHODS: We retrieved relevant articles from different databases, using the keywords "syphilis and epilepsy" and then performed statistical analysis to characterize the relationship between these diseases. RESULTS: Forty one articles were included in this study: eight described the prevalence of syphilis and epilepsy and the remaining 33 were case reports on syphilis with epileptic seizures. The meta-analysis included 1252 patients with syphilis. The pooled estimate of proportion of prevalence (95% confidence interval) was 0.1384 (0.0955-0.2005), and the proportion and heterogeneity showed different degrees of change among three subgroups. The systematic review included 46 cases of syphilis with epileptic seizures. Thirty two (80%) patients had motor seizures, among whom 20 (62.5%) had tonic-clonic seizures. In addition, 30 (75%) patients had impaired awareness and 18 (45%) had status seizures. Twenty five (62.5%) patients were 35-55 years of age, and 77.5% of the included patients were men. Thirty seven (97.4%) patients were seizure-free after anti-syphilis treatment. LIMITATIONS: Research in this field has been conducted for a relatively short period and publication bias may exist. Furthermore, some patients with syphilis and epileptic seizures may not have received a clear diagnosis. CONCLUSION: The proportion of prevalence was 0.1384. Most of the included patients were 35-55 years of age and had impaired awareness and motor seizures. Many patients with syphilis and epileptic seizure showed full recovery or the development of minor neurological sequelae, and nearly all patients were seizure-free after timely anti-syphilis treatment.

PCR detection for syphilis diagnosis: Status and prospects.

Syphilis, a re-emerging public health problem worldwide caused by Treponema pallidum subsp pallidum (T. pallidum), usually induces systemic and chronic inflammation in hosts who do not receive timely therapy after exposing to high-risk factors such as leprous sexual contact. Before the treatment, rapid and accurate detection of syphilis is essential. However, the existing detection methods, which focus on the treponemal or non-treponemal antibody test, both have inherent limitations. For instance, both of them cannot distinguish the stage and severity of syphilis. Non-treponemal test such as RPR, which is generally deemed to be used for assessing treatment response, is influenced by biological false positives. Therefore, it is imperative to seek out a new and effective diagnostic test. With recent advancements in molecular biology and whole-genome sequencing, the molecular diagnosis has increased in popularity, especially the use of polymerase chain reaction (PCR). Here, we firstly present a mini-review on the research of PCR detection methods used for syphilis diagnosis over the past decade, and we then compare these methodologies to assess their potential and the challenges faced. This information can provide a fresh perspective to help researchers address the current challenges.

Predictors of serological cure after treatment in patients with early syphilis: A retrospective observational study in Thailand.

BACKGROUND: Some patients with early syphilis who receive appropriate treatment do not reach a serological cure and have a persistent titer which does not meet the criteria for treatment failure (serofast state). AIMS: This retrospective study aimed to determine the prevalence of serological cure and the serofast state as well as the factors associated with serological cure after treatment of patients with early syphilis. METHODS: A serological cure was defined as occurring when there was a ≥4-fold decrease in nontreponemal titer, whereas patients with a ≥4-fold increase were considered as having either a treatment failure or reinfection. Nontreponemal titers that neither increased nor decreased ≥4-fold after treatment were considered to be in a serofast state. Seroreversion was defined as occurring when there was a negative test within 12 months of treatment. RESULTS: There were 179 patients with a mean age of 31.9 years; 174 (97.2%) were men, and 125 (70%) were HIV patients. Of the total, 174 (98%; 95% confidence interval 94.82-99.42%) patients achieved a serological cure, whereas five were in a serofast state 12 months after treatment. Those five serofast patients were all HIV-positive men, of which 4 (80%) had secondary-stage syphilis, a CD4 count ≤200 cells/µl and a titer <1:8. In a bivariate analysis, a serological cure was associated with a baseline Venereal Disease Research Laboratory >1:16 titers (P = 0.018), and a CD4 cell count >200 cells/µl in 6 months preceding treatment (P = 0.016). The median time to a serological cure was 96 days. Only 22 (12.3%) of the patients achieved seroreversion at 12 months after treatment. LIMITATIONS: A retrospective medical record review is likely to have a selection bias, and in our study, 196 (52%) patients were excluded due to missing information. CONCLUSIONS: Most patients with early syphilis who achieved a serological cure at 12 months after treatment had high baseline Venereal Disease Research Laboratory titers and CD4 cell counts. However, only 22 (12.3%) had a negative Venereal Disease Research Laboratory titer after 1 year of treatment.

Unusual Manifestations of Secondary Syphilis: Case Presentations.

Dear Editor, Syphilis is an infection caused by Treponema pallidum. Without treatment, it goes through the following stages: primary, secondary, latent, and tertiary (1). The clinical picture of secondary syphilis is very variable (2,3). We present two rare cases of secondary syphilis, one with nodular lesions initially considered to be lymphoma and second with periostitis, which was initially interpreted as an osteoma. To date, only 15 cases with nodular lesions and 10 cases with periostitis in secondary syphilis have been reported in the literature. The first patient was a 59 year old man who presented in a private practice with nodular lesions on the face and axillary and inguinal folds (Figure 1, a, b). The initial diagnostic consideration was lymphoma. A biopsy specimen was taken, and the histopathological features revealed epidermal hyperplasia with papillomatosis, minimal spongiosis with many neutrophils and with a marked inflammatory infiltrate in dermis, consisting of lymphocytes, plasma cells, and neutrophils; the diagnosis of interfaced dermatitis was established (Figure 1, d, e). After one month, the patient presented to our clinic with numerous nodular lesions, some of them painful, located on the trunk and intertriginous folds, including the intergluteal cleft - the lesions in this area being suggestive of condylomata lata (Figure 1, c). The diagnosis of secondary syphilis was taken into consideration, and screening serum tests were performed and found reactive: a Venereal Diseases Research Laboratory (VDRL) titer of 1:64 and Treponema pallidum Hemaglutination Assay (TPHA) titer of 1:80. Hepatitis and anti-human immunodeficiency virus (HIV) antibodies serology was negative. The biopsy was repeated and showed the same histopathological changes. In addition, Warthin-Starry staining was performed, revealing the presence of some spiral micro-organisms in the dermis corresponding to Treponema pallidum (Figure 1, f). A diagnosis of secondary syphilis was established, and the patient was treated with benzathine penicillin G 2.4 million units by intramuscular injection once a week for 2 consecutive weeks. The skin lesions regressed within 1 month, and serological tests showed a VDRL titer of 1:8 3 months after treatment. The second patient was a homosexual male, 35 years old, diagnosed with HIV infection, stage B2. He presented with bone pain in the calves and forearms, with insidious onset. He also presented with an associated erythematous maculo-papular rash on the trunk and limbs and generalized lymphadenopathy (Figure 2, a, b). The tibial crest and radius were sensitive to palpation. A right leg radiography was performed, raising suspicion of osteoid osteoma. The CT scan excluded the diagnosis of osteoma; taking into account the epidemiological context, the diagnosis of syphilis was suspected. The diagnosis was confirmed by leg ultrasound examination (2D US) which showed thickening of the compact tibial bone associated with subperiosteal destructive and proliferative changes (Figure 2, c, d) and by serology for syphilis: the VDRL titer was 1:32 and the TPHA titer was 1:80. The patient was treated with benzathine penicillin 2.4 million units, once a week, for 2 consecutive weeks, with clinical improvement. Syphilis continues to be a serious public health problem worldwide, even if it is a controllable disease due to diagnostic tests and effective and accessible treatment. According to the World Health Organization in 2008, the estimated number of new cases of sexually transmitted diseases in adults with syphilis is 10.6 million cases (4). The cases presented in this paper were characterized by unusual manifestations, requiring good collaboration between the dermatologist and other specialties. In the first case, the diagnosis of secondary syphilis was confirmed by positive serological, clinical, and histopathological findings. The main differential diagnosis of nodular syphilis includes lymphoma, sarcoidosis, Kaposi's sarcoma, atypical mycobacteriosis, deep fungal infections, leprosy, tuberculosis, leishmaniasis, and lymphomatoid papulosis (5). Another important differential diagnosis is between secondary and tertiary syphilis, especially when ulcerating nodules are present. Tertiary syphilis is characterized by unilateral, deep ulcerating nodules with necrotizing granulomas (6). Bone involvement during syphilis is mainly represented by polyarthritis, synovitis, osteitis, and periostitis (7,8). Syphilitic periostitis is characterized by localized or diffuse pain, particularly during the night, which is relieved by movement. The skull, the shoulder girdle, and the long bones are the most common sites of involvement (9). In conclusion, we presented two different cases of secondary syphilis that contribute to the clinical experience of rare cases presented in the literature, raising the awareness of dermatologists and other specialists about less specific clinical aspects of syphilis.