Centers for Disease Control and Prevention Syphilis Summit: Difficult Clinical and Patient Management Issues.

Despite over a century of clinical experience in diagnosing and managing patients with syphilis, many thorny clinical questions remain unanswered. We focus on several areas of uncertainty for the clinician: the role of serologic tests in diagnosing syphilis and assessing syphilis treatment responses, and the risk of neurosyphilis and ocular syphilis in patients with syphilis. We also address whether clinical approaches should differ in patients who are, and are not, infected with HIV. The current increases in syphilis rates in the United States and elsewhere underscore our urgent need to definitively address these issues.

Sífilis y embarazo: ¿pensamos en la neurosífilis? / Syphilis and pregnancy: Do we think in neurosyphilis?

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Respuesta: Sífilis y embarazo: ¿pensamos en la neurosífilis? / Reply: Syphilis and pregnancy: Do we think in neurosyphilis?

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[Syphilis and pregnancy: study of 94 cases]. / Sífilis y embarazo: estudio de 94 casos.

BACKGROUND AND OBJECTIVE: To study the epidemiology, diagnosis, treatment strategies and perinatal outcomes of gestational syphilis. PATIENTS AND METHOD: We performed a retrospective study of 94 pregnant women with syphilis whose gestation and delivery were monitored in a Department of Obstetrics from 2002 to 2010 among a total of 85,806 births of women without syphilis in the same period. RESULTS: The prevalence of gestational syphilis was 0.11%. Most of the women were foreign and the most prevalent type was late latent syphilis. Only 57 patients underwent right treatment despite adequate prescription. Maternal complications were confirmed in 31 pregnant women and 16 cases had fetal complications. We diagnosed 4 cases of neonatal syphilis, 3 of them with syphilitic meningitis, whose mothers had not completed the treatment correctly. CONCLUSIONS: The implementation of a mandatory syphilis serology in the pregnancy has enabled us to diagnose many cases of late latent syphilis. The successful completion of treatment must be ensured to prevent vertical transmission.

[Epidemiological and clinical aspects of neurosyphilis in Morocco]. / Aspects épidémiologiques et cliniques de la neurosyphilis au Maroc.

Neurosyphilis accounts for 56%-70% of all visceral syphilis and is a complication in 5%-10% of cases of untreated syphilis. The aim of this study was to evaluate the epidemiological aspects and clinical presentations of neurosyphilis in Morocco through a series of 201 patients attending the Centre for Neurological Services at the university hospital in Rabat between 1986 and 1997. The mean age of the patients was 41.26 (SD 9.23) years (range: 17-70 years); the majority (91%) were male. The incidence of neurosyphilis in Morocco is high. From 31 cases per year in 1985, it has fallen since 1990 to reach 10 cases in 1997. Among the different clinical presentations recorded, chronic meningoencepahalitis was the commonest, followed by meningovasculitis, tabes dorsalis and optic atrophy.

Syphilis, neurosyphilis, penicillin, and AIDS.

Early neurosyphilis, characterized by meningitis, cranial nerve abnormalities, and cerebrospinal accidents, was first described in patients with syphilis who received inadequate courses of arsphenamine. Although more effective, penicillin at conventional doses does not yield treponemacidal levels in the central nervous system and probably does not eradicate the infecting organisms, suggesting that it works synergistically with the host's immune response in preventing neurosyphilis. Neurosyphilis after penicillin therapy was almost unheard of in the United States until it began to appear in human immunodeficiency virus (HIV)-infected patients. Numerous cases of syphilitic meningitis, cranial nerve abnormalities, and strokes have been reported in the past decade; about one-half of reported patients had received penicillin therapy, often within the previous 6 months. Thus, more intensive diagnostic evaluation, perhaps including routine cerebrospinal fluid analysis, more intensive therapy, for example with at least three doses of benzathine penicillin, and far more rigorous follow-up are indicated in HIV-infected subjects with syphilis. Since the efficacy of conventional therapy is now uncertain, novel approaches to treatment deserve systematic evaluation.

[Economic aspects of serologic syphilis tests in routine screening in Viennese hospital facilities]. / Okonomische Aspekte der serologischen Syphilisteste im Routinebetrieb der Wiener Krankenanstalten.

971, 786 patients in Viennese municipal hospitals were routinely screened by serological testing for syphilis between January 1980 and December 1984, leading to the detection of 28,090 cases of untreated latent infection. The annual incidence varied between 7463 and 4623 cases. Roughly one third of patients with untreated syphilis develop severe late manifestations: 10.4% show cardiovascular involvement, 6.5% get neurosyphilis and 15.8% have a gumma. The mortality rate is 85% in cardiovascular disease and 64% in neurosyphilis, whilst irreversible incapacity is the fate of the remaining 15% and 36% of these patients, respectively. Calculations on the basis of the current costs for treatment of the acute diseased and for nursing of incapacitated patients reveal that routine screening of all in- and out-patients of the Viennese municipal hospitals is completely justified from the medical and the economic point of view and should, therefore, be reinforced.

Mielitis sifilitica aguda / Acute syphilitic myelitis

The case of a 45-year old man who presented with a few-hour history of interscapular pain and progressive dificulty walking, in whom a final diagnosis of syphilitic myelitis was made, is reported. This is a rare complication of syphilitic involvement of the Central Nervous System. Its pathological and clinical characteristics are due to vascular impairment, which explains the acute onset and poor prognosis of the disease. The condition should be suspected in cases of acute myelopathy of uncertain etiology.

The significance of cerebrospinal fluid routine screening for neurosyphilis.

From 1980 to 1985 the cerebrospinal fluid microhaemagglutination assay for Treponema pallidum antibodies (MHA:TP-CSF) was routinely examined from 10 386 consecutive CSF samples of more than 10,000 patients admitted to a large neurological unit in Helsinki. Twenty one patients were considered to have neurosyphilis on the basis of clinical, serological and CSF findings. The MHA:TP-CSF test was positive in 14 patients, in 4 patients the result was undefined, and in 3 patients negative. No false-positive results were obtained. Ten of the patients had no previous history of syphilis demonstrating the value of this type of routine screening, and in only 2 of these patients the diagnosis was suspected by clinicians before the CSF examination. The serum MHA:TP was positive in all examined 18 neurosyphilis patients indicating its value for the routine screening method instead of the CSF examination.

[Neurosyphilis mortality in a psychiatric hospital over a 50-year period]. / Mortalidade for neurossífilis em hospital psiquiátrico durante 50 anos.

Through information gathered at the statistical and medical register service it was done a descriptive study of some epidemiologic aspects of neurosyphilis at the Juliano Moreira Hospital (Bahia) in a period of 50 years (1930 - 1979). Coeficients of specific mortality were stablished . The distribution of the disease was analyzed according to sex, diagnosis in relation to the year, decades and periods before and after penicilinotherapy . Based on the results it is possible to conclude that: neurosyphilis has a cyclic character in epidemiologic level; women are more resistant or less exposed to the disease; males are more often affected; with the penicilinotherapy it was observed a progressive decrease of mortality; the last death caused by neurosyphilis at the Juliano Moreira Hospital occurred in 1971.