We read the article of P. Zhou and collaborators1 with great
interest. We agree that clinicians should be aware that appropriate
therapy in early syphilis may be not sufficient for avoiding late-stage
disease, neuro-syphilis in particular. To support such an important issue,
we would like to deliver the data we obtained by a retrospective study we
conducted some years ago.
We read the article of P. Zhou and collaborators1 with great
interest. We agree that clinicians should be aware that appropriate
therapy in early syphilis may be not sufficient for avoiding late-stage
disease, neuro-syphilis in particular. To support such an important issue,
we would like to deliver the data we obtained by a retrospective study we
conducted some years ago.
The data were collected in our Section of Dermatology by examining
the clinical records of 62 patients diagnosed as having syphilis. Thirty
of them had early syphilis (either primary/secondary or latent since no
more than 2 years) and 32 had latent syphilis for more than 2 years. All
had been treated for at least 2 consecutive years with a total of at least
60 million units of benzathine penicillin. All patients were clinically
examined at the end of the treatment for neurological lesions and
compared with 62 serologically-negative subjects. The control group was of
the same gender and age (+3 years). Data have been analysed by the x2
test.
Neurological changes were observed in 22 patients (35%) vs 10 (16%)
controls. The difference was statistically significant. (x2 = 5.096; p =
0.024). Patients with early syphilis (36%) did not differ from patients
with latent syphilis (35%) (x2= 0.029; p=0.865).
Our study, which was conducted at a time in which long penicillin
treatments were usual in Italy, shows that penicillin, though extremely
effective in clearing the early cutaneous lesions, is grossly inefficient
to prevent late complications, neurological in particular. Worst than
that, it seems that it may even favour them. In fact, the prevalence of
neurological signs in our series is even higher than that found in Oslo
study2. This fact may simply depend on the incapacity of penicillin to
pass effectively through the hemato-encephalic barrier and achieve
treponemicidal concentrations in the central nervous system3, but other
factors, either autoimmune or atherosclerotic, should be taken into
consideration in the pathogenesis of neuro-syphilis. We believe that a
change of the supposedly "adequate" treatment for early syphilis should be
endeavoured.
This is retrospective study in which subjects were regular patients
with syphilis who have been treated with penicillin many years ago.
References
1. Zhou P, Gu X, Lu H, Guan Z, Qian Y.Re-evaluation of serological
criteria for early syphilis treatment efficacy: progression to
neurosyphilis despite therapy. Sex Transm Infect. 2012 Feb 23.
2. Gjestland T. The Oslo study of untreated syphilis; an
epidemiologic investigation of the natural course of the syphilitic
infection based upon a re-study of the Boeck-Bruusgaard material. Acta
Derm Venereol Suppl (Stockh). 1955;35(Suppl 34):3-368
3. Tramont EC. Persistence of Treponema pallidum following penicillin
G therapy. JAMA 1976; 236:2206-2207.
Over several years we have been interested in urethritis and its possible causes. We are aware that a few subjects whose urethral smears are Gram stain negative are, nevertheless,
infected with pathogenic micro-organisms. In view of this, we were interested in the paper by Orellano et al. 1 in which they indicate that this may be a bigger problem than otherwise thought...
Over several years we have been interested in urethritis and its possible causes. We are aware that a few subjects whose urethral smears are Gram stain negative are, nevertheless,
infected with pathogenic micro-organisms. In view of this, we were interested in the paper by Orellano et al. 1 in which they indicate that this may be a bigger problem than otherwise thought. However, we feel that there are aspects of their findings that deserve comment or questioning, as follows: i) The
men examined were more than fifteen years of age, but the range of ages and mean age are not mentioned. The fact that only 70 (14%) of 491 symptomatic men had 5 or more PMNLs suggests an
unusual population 2-4 ; ii) Samples of urethral exudate were taken from all men with urethral symptoms, which are not described. Was no man asymptomatic and referred as a contact for
a "check-up" ? ; iii) The duration of symptoms and any antibiotic use before examination are not mentioned; iv) Of the four urethral swabs, was the first always used for making a smear for staining? ; v) The Gram stain results are recorded as the number of PMNLs per high-power field , but is this a single field or 5 fields, which is standard practice? 5,6 ; vi) Gram staining was performed for all men with or without a discharge, yet no mention is made of whether more PMNLs were found in men with a discharge than in those without 2-4,7; vii) In the first six months of the study the test for detecting Chlamydia trachomatis was less sensitive than the test used in the second six months. What impact did this have on the relationship between C. trachomatis and the Gram stain results ?viii) The sensitivity of the Gram stain as a means of determining the existence of urethritis was assessed (Table 2) ; this was done by comparing the Gram stain results with a reference method, the latter being detection of the various micro-organisms. The rationale of this approach needs explanation since urethritis is not defined by micro-organisms that might cause it but by the presence of urethral inflammation. It is well recognized that Chlamydia trachomatis and ureaplasmas do not always elicit urethral inflammation in men 2,3,5,6,8.
REFERENCES
(1) Orellana MA, Gomez-Lus, Lora D. Sensitivity of Gram stain in the diagnosis of urethritis in men. Sex Transm Infect 2012; 88: 284-7.
(2) Falk L, Fredlund H, Jensen JS. Symptomatic urethritis is more prevalent in men infected with Mycoplasma genitalium than with Chlamydia trachomatis. Sex
Transm Infect 2004; 80 :289-93.
(3) Horner PJ, Thomas B, Gilroy CB et al. Do all men attending departments of genitourinary medicine need to be screened for non-gonococcal urethritis? Int J STD AIDS 2002; 13: 667-73.
(4) Janier M, Lassau F, Casin I et al. Male urethritis with and without discharge: a clinical and microbiological study. Sex Transm Dis 1995; 22: 244-52.
(5) Shahmanesh M. 2007 UK National Guideline on the Management of Nongonococcal Urethritis: updated December 2008. http://www bashh org/guidelines 2008 Available from: URL:http://www.bashh.org/guidelines
(6) Shahmanesh M, Moi H, Lassau F, Janier M. 2009 European Guideline on the Management of Male Non-gonococcal Urethritis. Int J STD AIDS 2009; 20 :458-64.
(7) Horner P. Asymptomatic men: should they be tested for urethritis? Sex Transm Infect 2007; 83 :81-4.
(8) Haddow LJ, Bunn A, Copas AJ et al. Polymorph count for predicting non-gonococcal urethral infection: a model using Chlamydia trachomatis diagnosed by ligase chain reaction. Sex Transm Infect 2004; 80 :198-200.
Jacques Pepin addresses the important
question of parenteral transmission of HIV-1 in Leopoldville, and criticises
aspects of our article (Sousa_et_al,2010,PLoS_ONE
5(4):e9936, http://www.plosone.org/article/info:doi/10.1371/journal.pone.0009936), in which we modelled the initial heterosexual
spread of HIV-1 in that city.1 Here, we respond directly to his
criticisms.
He writes that we used a genital ulcer
disease(GUD)-related risk ratio of HIV-1 transmission of up to 430. He derives
the latter from the measured and published 43% risk incurred by an
uncircumcised man exposed to a HIV-1-infected index woman with a genital ulcer,
which is 430 times the 0.1% baseline.2,3 However, it is misleading
to represent this parameter as equivalent to a GUD risk ratio of 430, as Pepin
does, because the measured 43% risk derived from two concomitant cofactors,
GUD and lack of circumcision, the latter increasing the risk from 4% to 43%.3
In addition, for most other situations involving GUD, the cofactor effect was
much lower in our simulations, consistent with the studies that estimated them
on a per act basis.3,4
The GUD-related risk ratios of around 3-5 cited by Pepin
are based on studies that asked participants whether they had GUD at any time within a long period (e.g.,
the last 12 months), a procedure that strongly underestimates the per act GUD effect.2
Pepin questions our postulated 10 weeks average ulcer
duration. Chancroid's ulcer lasts 10 weeks on average.5 On average,
syphilis' chancre lasts 12 days, and the secondary stage lasts 3.6 months, often
relapsing.6 A modelling study postulated 4 weeks of high sexual
infectiousness during syphilis secondary stage.7 We feel it is reasonable
to assume 4-6 weeks high HIV-1 infectiousness due to primary syphilis or
mucosal lesions associated with secondary syphilis. Lymphogranulomavenereum (LGV)
causes short initial genital ulcers but, in some women, it causes
genitoanorectal syndrome, involving years-lasting genital ulceration.8,9
Given that syphilis, chancroid, and LGV were the most common GUDs in early 20th
century Leopoldville, we consider our choice of ulcers averaging 10 weeks
appropriate.
As Pepin acknowledges, we previously reported low GUD prevalence
in 1950s Leopoldville/Kinshasa.1 We agree with him that substantial parenteral
transmission of HIV-1 may have occurred in Leopoldville/Kinshasa.
The International AIDS Society (IAS) nowadays expresses its deep
concern about continuing inflammatory and homophobic statements by
political leaders from different countries, and urges national and
international leaders to reject homophobia and to take affirmative steps
to reduce its impact on HIV.
One of the many lessons learned in the IAS more than 20 years of
leadership in HIV/AIDS, is that well-designed and appropr...
The International AIDS Society (IAS) nowadays expresses its deep
concern about continuing inflammatory and homophobic statements by
political leaders from different countries, and urges national and
international leaders to reject homophobia and to take affirmative steps
to reduce its impact on HIV.
One of the many lessons learned in the IAS more than 20 years of
leadership in HIV/AIDS, is that well-designed and appropriately targeted
programs, implemented with the support of public health and political
leadership, can effectively reduce HIV transmission in communities most at
risk for HIV, including gay men and other men who have sex with men (MSM).
A report issued at the end of 2011, led by some researchers in Cuba
provides solid evidence that HIV among MSM continues to be widespread, and
in many cases, is exacerbated by stigma, criminalization and the lack of
appropriate services. The study indicates that even in countries with low
HIV prevalence in the general population, the epidemic among MSM is
raging.
According to UNAIDS, fewer than one in 20 MSM around the world has access
to HIV prevention, treatment, and care and even fewer in low-
income settings. Compared to the HIV teuntries, reducing the social
exclusion of gay and MSM communities through the promotion and protection
of their human rights (including sexual rights and the right to health) is
not only consistent with, but a prerequisite to, good public health. Once
discriminatory policies are abolished and stigma and discrimination are
confronted, country-based programs can be put in place to encourage gay
men and MSM to stay free of HIV-infection, thus supporting national goals
of reducing HIV burden.
However, efforts to replicate these successful strategies in more
countries are hampered by recent homophobic statements made by political
leaders from some countries. Comments from these leaders, and other
politicians who call for the arrest, detention, and even killing of
homosexuals, are reprehensible.
Despite its much heralded success in promoting a public health response to
HIV, Uganda continues to cling to a colonial-era sodomy law that punishes
homosexual conduct with life imprisonment. And, Uganda is by no means the
exception. Worldwide, more than 85 countries criminalize consensual
homosexual conduct. Such laws give governments a pretext to invade
people's private lives and deny them essential hosting rates of 63-
85 percent seen among MSM in Australia, Europe, and North America, rates
among MSM in much of Africa, Asia, and Eastern Europe are often under 20
percent.
As it has been demonstrated in many different human rights: to live in
peace and in health.
Homophobia, whether propagated by government leaders, enforced by
outdated laws, or perpetuated through stigma and discrimination,
continues to fuel this epidemic, and should therefore be the number one
enemy of those who are serious about ending this global tragedy.
In our country, Cuba, the leaders are fighting against this, but we have
to do more to help these persons.
The recently published article, Chacko L, Ford N, Sbaiti M, Siddiqui
R. Adherence to HIV post-exposure prophylaxis in victims of sexual
assault: a systematic review and meta-analysis, Sex Transm Infect
doi:10.1136/sextrans-2011-050371, contributes greatly to our understanding
of the extent of poor adherence to post-exposure prophylaxis in victims
of sexual assault. It also clarifies the percentage of such patients
defau...
The recently published article, Chacko L, Ford N, Sbaiti M, Siddiqui
R. Adherence to HIV post-exposure prophylaxis in victims of sexual
assault: a systematic review and meta-analysis, Sex Transm Infect
doi:10.1136/sextrans-2011-050371, contributes greatly to our understanding
of the extent of poor adherence to post-exposure prophylaxis in victims
of sexual assault. It also clarifies the percentage of such patients
defaulting from care. The article illustrates how victims of sexual
assault fail to adhere to guidelines for prevention of HIV infection1.
Sadler AG, Mengeling MA, Syrop CH, Torner JC, Booth BM. Lifetime
Sexual Assault and Cervical Cytological Abnormalities Among Military
Women. Journal of Women's Health;20(11):1693-1701, revealed that female
victims of military sexual trauma have increased risk of cervical
cytological abnormalities. This increased gynecological health risk factor
requires vigilance in long-term screening to prevent poor future
outcomes. The adherence of women Veterans for cervical cancer screening is
imperative for their future welfare2,3.
The recent publication, Chacko L, Ford N, Sbaiti M, Siddiqui R.
Adherence to HIV post-exposure prophylaxis in victims of sexual assault: a
systematic review and meta-analysis, Sex Transm Infect
doi:10.1136/sextrans-2011-050371,thus reflects the poor adherence of
victims of sexual assault in the prevention of HIV infection1.
Up to 40% of female Veterans may have experienced military sexual
trauma, putting them at risk for cervical cytological abnormalities. It is
therefore clear that female Veterans, many of whom have experienced sexual
assault while in the military,would benefit from preventive care2-4.
Chacko L, et al. reinforce that victims of sexual assault need
support and encouragement to seek the medical care they require.
VA applauds such authors in clarifying the needs of those who have
experienced sexual assault and make it evident that these victims require
much support and help. VA hopes to provide the required support to victims
of sexual assault.1,3.
1. Chacko L, Ford N, Sbaiti M, Siddiqui R. Adherence to HIV post
-exposure prophylaxis in victims of sexual assault: a systematic review
and meta-analysis, Sex Transm Infect doi:10.1136/sextrans-2011-050371.
2. Sadler AG, Mengeling MA, Syrop CH, Torner JC, Booth BM. Lifetime
Sexual Assault and Cervical Cytological Abnormalities Among Military
Women. Journal of Women's Health;20(11):1693-1701.
3. Lutwak N. The Need for Gynecological Follow-Up Among Women
Veterans: The Association of Sexual Assault and Abnormal Cervical
Cytology. Journal of Women's Health; 2012;21(3).
4. Kelly UA, Skelton K, Patel M, Bradley B. More Than Military Sexual
Trauma: Interpersonal Violence, PTSD, and Mental Health in Women Veterans.
Research in Nursing and Health.2011;34(6):457-467.
Bender and colleagues found that relationships between levels of
chlamydia infection and complication rates of pelvic inflammatory disease
and ectopic pregnancy between and within countries over time were not
straightforward1. Many women diagnosed with a chlamydial infection are
anxious about future fertility. Fertiloscopy is a novel procedure to
assess fallopian tube function and may be a suitable alternative to the
go...
Bender and colleagues found that relationships between levels of
chlamydia infection and complication rates of pelvic inflammatory disease
and ectopic pregnancy between and within countries over time were not
straightforward1. Many women diagnosed with a chlamydial infection are
anxious about future fertility. Fertiloscopy is a novel procedure to
assess fallopian tube function and may be a suitable alternative to the
gold standard diagnostic of laparoscopy2. It is done under local
anaesthetic and may involve transvaginal hydrolaparoscopy, methylene blue
dye test, salpingoscopy, microsalpingoscopy and hysteroscopy. The main
feature of fertiloscopy is the ability of an optical device to be
introduced into the tubal ostium to bilaterally explore the tubal mucosa.
Optical magnification allows the assessment of the functional capability
of the fallopian tubes to be made. This may guide decisions about referral
for other treatments such as in vitro fertilisation2. Little is known
about women's attitudes towards fertiloscopy compared with other methods
of assessing tubal patency: hysterosalpingogram (HSG), hysterosalpingo
contrast-sonography (HyCoSy) or laparoscopy.
In December 2010 for a medical student research project we conducted
a community-based questionnaire survey of female patients' opinions
regarding these four methods of imaging to determine uterine tubal
patency. Following ethical review by the St. George's course organiser, an
information sheet and a questionnaire were given to consecutive female
patients aged between 15- 45 all attending a General Practice in
Cricklewood, North London. Patients who agreed to complete the
questionnaire were also given four information cards which described each
method of assessing tubal patency, including possible advantages and
disadvantages. An accompanying simple diagram of the female reproductive
tract was given as an aid. For the 20% of patients who could not read or
write English the investigator (AJ) explained the questions and the four
methods to them. The completed questionnaires were returned to the
investigator and the data were entered and analysed using SPSS.
The response rate was 94% (64/68) and the average age of responders
was 30 years old (range 16 to 45). Out of 64 respondents, 45% described
themselves as Asian, 37.7% White, 10% Black, 4.7% mixed, and 2.6% other
ethnic groups. Six participants (9%) reported that they had had a
chlamydia infection in the past.
The most preferred method to test tubal patency was fertiloscopy
(32%, n=20). The main reasons given were that the procedure was relatively
quick, no post surgery scars, and this method was the only one which
enabled visualisation of the interior of the fallopian tubes. The least
preferred method was laparoscopy (53%, n=34) as this caused post operative
scars, and required general anaesthetic. Although most women had heard
about chlamydia and knew it could be asymptomatic and prevented by using
condoms, nearly a quarter (23%, n=15) of this group of mainly Asian women
had never heard of chlamydia.
We agree with Bender et al.1 that development and validation of
indicators of chlamydia -related complications should be pursued.
Fertiloscopy appeared to be acceptable to women in this study and might be
more widely used to assess fertility, but more research should be done on
the opinions of women who have undergone the procedure. These findings
could also be useful in the design of a pilot study for a trial of
chlamydia screening using tubal patency as an outcome measure.
Acknowledgements
We thank the Chichele road GP surgery in Cricklewood, North West London
for allowing us to conduct the study.
Anushree Jagadambe, Dr. Pippa Oakeshott, Dr. Phillip Hay and Dr.
Kamal Ojha
Population Health Sciences and Education, St George's University of
London, London, SW17 ORE, UK
Correspondence to: A Jagadambe
Email: m0701746@sgul.ac.uk
References
1. Bender N, Herrmann B, Andersen B.et al. Chlamydia infection,
pelvic inflammatory disease, ectopic pregnancy and infertility: cross-
national study. Sex Transm Infect 2011;87: 601-608
2. Fertiloscopy in the management of female infertility [web page
online]. [cited 2011 Nov 16]; Available from:
URL:http://hcp.obgyn.net/laparoscopy/content/article/1760982/1891840
Sinka and colleagues found that using self-taken vaginal swabs for HPV testing was acceptable to young women who had defaulted from their initial HPV screening appointment at age 211. However, the rate of return of postal samples was low (13%, 725/5500). In October 2011 we conducted a feasibility study to evaluate response rates of 16-24yo female GUM clinic attenders to providing two self-taken vaginal swabs for Chlamydia tra...
Sinka and colleagues found that using self-taken vaginal swabs for HPV testing was acceptable to young women who had defaulted from their initial HPV screening appointment at age 211. However, the rate of return of postal samples was low (13%, 725/5500). In October 2011 we conducted a feasibility study to evaluate response rates of 16-24yo female GUM clinic attenders to providing two self-taken vaginal swabs for Chlamydia trachomatis and Mycoplasma genitalium testing and allowing access to NHS numbers and medical records for follow up. Women sitting in the female-only waiting area in the Courtyard Clinic at St George’s Hospital were approached by female Foundation Year 2 research doctors or medical students and given a flier about the study. This explained that women aged under 25 were being asked to help in research by providing self-taken samples and completing a questionnaire and that they would be given a lollipop. Those expressing interest were taken to a side room where they were given the full patient information leaflet and taken through the written consent process. They were shown how to take the swabs and asked to provide them in the nearest toilet in addition to any samples taken during their clinic consultation.
Of 154 women approached, 104 (68%) consented to take part. Non responders were similar mean age to responders (19.5 SD 2.5 versus 19.9 SD 2.9 years) but more likely to come from ethnic minority groups: 68% (32/47) versus 50% (50/101) p<_0.05. _="_" p="p"/>
Among responders, mean age of sexual debut was 15.9 (range 12-21 n=103); 48% (49/102) reported two or more sexual partners in the preceding 12 months; 33% (34/104) said they used condoms; and 51% (53/104) were smokers. There was a high prevalence of reported history of sexually transmitted infections. Of 101 responders, 26% said they had had chlamydia infection, 5% gonorrhoea and 5% pelvic inflammatory disease. Tests showed that 11.5% (12/104) were positive for Chlamydia trachomatis and 1% (1/104) for Neisseria gonorrhoeae.
All but one of the 104 participants gave consent for their NHS number to be obtained and used to access their hospital, general practice and GUM clinic records. This is important for future UK studies investigating long-term sequelae of sexually transmitted infections. All participants agreed their samples could be stored for future research. However, although all but one (103/104) agreed to provide follow up postal samples after three months, the current rate of return is 33% (17/52). As in the study by Sinka and colleagues1 and a postal survey of female students2, it is likely that the rate of return of follow up samples will be less than predicted.
References
1. Sinka K, Lacey M, Robertson C, Kavanagh K, Cushieri K, Nicholson D, Donaghy M, Acceptability and response to a postal survey using self-taken samples for HPV vaccine impact monitoring. STI Online First, published on October 11, 2011 as 10.1136/sextrans-2011-050211
2. Oakeshott P, Aghaizu A, Hay P, Reid F, et al. Is Mycoplasma genitalium in women the ‘new Chlamydia?’ A community-based prospective cohort study. Clinical Infectious Diseases 2010; 51: 1160-6
Lymphogranuloma venereum was described first by Wallace in 1833 and
again for Durand, Nicolas, and Favre in 1913. Climatic bubo is an
infection of sexual transmission caused by the bacterium Chlamydia
trachomatis. The first symptoms begin to appear from 3 to 12 days after
the contagion and they appear like a painless blister, that becomes an
ulcer, that can happen inadvertent and they can be confused with syphilis.
The l...
Lymphogranuloma venereum was described first by Wallace in 1833 and
again for Durand, Nicolas, and Favre in 1913. Climatic bubo is an
infection of sexual transmission caused by the bacterium Chlamydia
trachomatis. The first symptoms begin to appear from 3 to 12 days after
the contagion and they appear like a painless blister, that becomes an
ulcer, that can happen inadvertent and they can be confused with syphilis.
The lymph nodes of the groin increase in size and they is sensitized by
touch. Ulcers are coming along to destroy the internal and external
tissue, with loss of pus and blood. The destructive nature of the
lymphogranuloma also increments the risk of secondary infection for other
pathogenic microbes. Our society knows a lot about the HIV, but many times
we neglected other diseases than although they are not so dangerous like
the HIV, they cause damage and affect our young people. If we know our
enemies we will be able to combat them better.
Ocular syphilis is very rare, equivalent to 1-2% of uveitis, however,
is a simulator disease that can be confused, especially in
immunocompetent individuals, as HIV-positive patients are more likely to
acquire it. HIV co-infection with syphilis increases the risk of central
nervous system disease, patients with AIDS who do not receive
antiretroviral therapy, have bilateral disease and the posterior segment.
There are ma...
Ocular syphilis is very rare, equivalent to 1-2% of uveitis, however,
is a simulator disease that can be confused, especially in
immunocompetent individuals, as HIV-positive patients are more likely to
acquire it. HIV co-infection with syphilis increases the risk of central
nervous system disease, patients with AIDS who do not receive
antiretroviral therapy, have bilateral disease and the posterior segment.
There are many ways to manifest eye level, most of the publications
mentioned isolated cases of secondary syphilis in stage chronic phase, and
the majority in the neurosyphilis. In the cornea is suspected when there
is a bilateral stromal keratitis, which may be associated with closed-
angle glaucoma. In the iris can be expressed as granulomatous uveitis.
In a series of cases of Barile was shown 9% of posterior uveitis and 27 %
of panuveitis. Chao JR and colleagues reported four patients with
neurosyphilis by positive VDRL and increasing of leukocytes in the
cerebrospinal fluid. Two patients had placoid chorioretinitis, a
homosexual patient presented bilateral papilledema and a heterosexual man
presented anterior uveitis and bilateral papilledema. The condition of the
posterior pole can vary as much as vasculitis, macular edema,
neuroretinitis and even retinal necrosis.
Neuro-ophthalmological manifestations of syphilis include Argyll-Robertson
pupil, oculomotor nerve palsy and optic neuritis.
Treatment of ocular syphilis should be as neurosyphilis, recommended 12 MU
of penicillin G intravenously daily for 10-14 days or 2.4 MU procaine
penicillin intramuscularly daily with oral probenecid for two weeks.
Penicillin G benzathine can be applied after the treatment of penicillin G
or procaine, It should not be applied as a first option, since it does not
reach sufficient levels in the cerebrospinal fluid. In case of resistance,
can be applied ceftriaxone, 1 g 2 times a day for seven days.
We present two cases treated in our services in Cuba.
Case 1. This 31 years old male patient referred to the Service of
Infectious Diseases for being HIV positive and probable neurosyphilis by
bilateral papilledema, was under medical treatment with penicillin G
procaine. The reason for the consultation is low vision in Right eye (RE)
since two weeks ago. Physical examination: AV 20/80 in RE and 20/25 in LE
(Left Eye). IOP of 10 mm Hg in both eyes. RE with fine keratic
precipitates, cells in CA 1 +, there are no changes in anterior segment of
the LE. In the fundus papilledema is observed in RE and peripheral
posterior vitreous detachment in LE. The retinal fluorangiography (FAG)
shows active lesions of peripheral vasculitis and bilateral papilledema.
Report is sent to the Service of Infectious Diseases where a
antiretroviral therapy is indicated, in addition to completing his
studies, resulting positive FTA-abs test. Returns three months later his
vision improved to 20/25 in both eyes, in the fund of the eye is not
observed the edema of the optic nerve previously affected.
Case 2. Male patient, 32 years old, referred to the Service of Infectious
Diseases for diagnosis of neurosyphilis in HIV-positive FTA-abs test
positive. During his hospital stay was diagnosed with bilateral
papilledema and paralysis of the fourth right nerve. Admitted by the
presence of headache and diplopia of two months before to the first
review. Visual acuity is 20/30 right eye and 20/25 left eye.
His refraction is -0.75 sphere RE and -0.25 to - 0.75X 0 ° LE, improved
to 20/20 RE and 20/15 LE.
On examination of ocular motility is observed hiperhipotropia with
limitation to the depression of RE and Bielchowski test positive.
Conjunctive, cornea and lens of the normal characteristics. Fundus in both
eyes and optic disc with excavation 1 / 10, hyperemia and Raised edges,
tortuous vessels since the emergency. FAG requested and quoted with
results, the patient does not return.
The importance of health officials from a country to insist on control of
sexually transmitted diseases stems from the increased incidence of these
kind of
diseases such as syphilis, considered as a "great imitator" of many other
infectious diseases and some autoimmune diseases.
Dermatological tests are insensitive in the primary or secondary syphilis,
because it has reduced levels of normal lymphocyte blastogenesis. In the
case of HIV, it can cause a polyclonal expansion of inmunoglobuline IgG,
resulting in activation of B cells with a side effect of CD8, complicating
HIV infection. Opposite can also happen: there is a decrease of B cells,
giving false positive serological tests. T. pallidum increases HIV
replication and may also damage the mucosa by increasing the number of
cells receptive to HIV. Patients with genital ulcers have an increased
excretion of HIV RNA in seminal fluid.
In conclusion, ocular syphilis remains a cause of diverse and complex eye
conditions.
We should suspect this diagnosis in patients without other infectious
cause or autoimmune feature. Do not forget the background of sexual
transmission risk that patients often deny.
Conflict of Interest:
None declared
Patient Consent - There is no identifiable information presented so patient consent is not needed.
We read the article of P. Zhou and collaborators1 with great interest. We agree that clinicians should be aware that appropriate therapy in early syphilis may be not sufficient for avoiding late-stage disease, neuro-syphilis in particular. To support such an important issue, we would like to deliver the data we obtained by a retrospective study we conducted some years ago.
The data were collected in our Sectio...
Over several years we have been interested in urethritis and its possible causes. We are aware that a few subjects whose urethral smears are Gram stain negative are, nevertheless, infected with pathogenic micro-organisms. In view of this, we were interested in the paper by Orellano et al. 1 in which they indicate that this may be a bigger problem than otherwise thought...
This article contains invaluable information to learn more about Syphilis and it's control strategy. Thanks to the author.
Conflict of Interest:
None declared
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The International AIDS Society (IAS) nowadays expresses its deep concern about continuing inflammatory and homophobic statements by political leaders from different countries, and urges national and international leaders to reject homophobia and to take affirmative steps to reduce its impact on HIV. One of the many lessons learned in the IAS more than 20 years of leadership in HIV/AIDS, is that well-designed and appropr...
The recently published article, Chacko L, Ford N, Sbaiti M, Siddiqui R. Adherence to HIV post-exposure prophylaxis in victims of sexual assault: a systematic review and meta-analysis, Sex Transm Infect doi:10.1136/sextrans-2011-050371, contributes greatly to our understanding of the extent of poor adherence to post-exposure prophylaxis in victims of sexual assault. It also clarifies the percentage of such patients defau...
Bender and colleagues found that relationships between levels of chlamydia infection and complication rates of pelvic inflammatory disease and ectopic pregnancy between and within countries over time were not straightforward1. Many women diagnosed with a chlamydial infection are anxious about future fertility. Fertiloscopy is a novel procedure to assess fallopian tube function and may be a suitable alternative to the go...
Sinka and colleagues found that using self-taken vaginal swabs for HPV testing was acceptable to young women who had defaulted from their initial HPV screening appointment at age 211. However, the rate of return of postal samples was low (13%, 725/5500). In October 2011 we conducted a feasibility study to evaluate response rates of 16-24yo female GUM clinic attenders to providing two self-taken vaginal swabs for Chlamydia tra...
Lymphogranuloma venereum was described first by Wallace in 1833 and again for Durand, Nicolas, and Favre in 1913. Climatic bubo is an infection of sexual transmission caused by the bacterium Chlamydia trachomatis. The first symptoms begin to appear from 3 to 12 days after the contagion and they appear like a painless blister, that becomes an ulcer, that can happen inadvertent and they can be confused with syphilis. The l...
Ocular syphilis is very rare, equivalent to 1-2% of uveitis, however, is a simulator disease that can be confused, especially in immunocompetent individuals, as HIV-positive patients are more likely to acquire it. HIV co-infection with syphilis increases the risk of central nervous system disease, patients with AIDS who do not receive antiretroviral therapy, have bilateral disease and the posterior segment. There are ma...
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