Secondary syphilis in HIV infected patients with no condom use
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Prestileo T.S., Di Lorenzo F., Di Bella
HIV;AIDS;,syphilis;,condom,SecondarysyphilisinHIVinfectedpatientswithnocondomuse,INTRODUCTION,CLINICALPRESENTATION,DISCUSSION,REFERENCES
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Secondary syphilis in HIV infected patients with no condom use(pdf)
Correspondence to Tullio Prestileo, MD,Largo Giuliana 2, 90124 Palermo, Italy
Tel:+39 091 6302541 (home),+39 091 7033217 (hospital),Fax:+39 091 7033297,Mobile:+39 333 3207437
E-mail:tullioprestileo@virgilio.it
[Abstract] Objective Syphilis is a chronic infectious disease caused by the spirochete Treponema pallidum. It is transmitted during sexual intercourse and vertically, from the mother to the child during the pregnancy or the birth. Syphilis became a predominant Sexually Transmitted Disease (STD) disease among homo and heterosexual men and commercial sex workers. Syphilis has been and continues to be a disease often accompanying HIV. Methods Authors describe characteristic clinical courses of 14 patients with HIV infection diagnosed from, at least, 3 months. All patients were consecutively observed during the last 18 months. Results Patients presented maculopapular eruptions (duration 3~12 days) on extremities, trunk, face, palms and soles. They had no history of fever, chills, malaise, headache or previous rectal or genital ulcer. The diagnosis was established in all ten patients with the combination of two non-treponemal reaginic tests: Venereal Disease Research Laboratory (VDRL) test with a titre of 1：32 or more and qualitative Rapid Plasma Reagin (RPR). In addition one specific treponemal test was performed: Fluorescent Treponema Antibody (FTA-abs). Nine patients were treated with 2.4 million units of intramuscular benzathine penicillin the first time; then we continued with 1.2 million units every week for 4 weeks. These patients' maculopapular eruption vanished 10~20 days after initiation of therapy. The last five patients preferred to be treated with ceftriaxone, 1 gr intramuscular every day for 1 week, because they feared pain in the injection site. During the next follow-up, we observed no signs of significant HIV disease progression. Conclusions The authors believe that health policies should be formulated and designed to promote STD prevention strategies in the general population and in HIV infected patients. Condoms provide a very safe and cheap solution to the transmission of these diseases.
[Key words] HIV;AIDS; syphilis; condom
INTRODUCTION
Syphilis is a chronic infectious disease caused by the spirochete Treponema pallidum. It is transmitted during sexual intercourse and vertically, from the mother to the child during the pregnancy or the birth.
In North America and in the European Union, during the 1970s, syphilis became a predominant disease among homosexual men and commercial sex workers[1].
More recently the World Health Organization (WHO) estimated that the annual global incidence of syphilis is about 12 million cases, most of which occur in the underdeveloped nations, where the disease has remained a prominent cause of genital ulcer disease in women and hetero/homosexual men[2].
Syphilis has been and continues to be a disease often accompanying HIV[3].
In most recently diagnosed patients with HIV infection the clinical features, serological test results and responses to therapy are similar to those in the general population[4]. But numerous case reports suggest that in people with HIV infection syphilis might be a more aggressive illness, and serologic response to infection might be modified[5,6].
CLINICAL PRESENTATION
The authors describe characteristic clinical courses of HIV infected patients with secondary syphilis. These patients were observed from April 2004 to December 2005 in an outpatient infectious diseases clinic in Palermo, Italy.
In this period we observed 14 clinical pictures of secondary syphilis (12 Italian men, one British man and one Nigerian man, with mean age 33 years) 8 were homosexuals, two bisexuals and four heterosexuals.
All patients presented with maculopapular eruptions (duration 3~12 days) on extremities, trunk, face, palms and soles. They had no history of fever, chills, malaise, headache or previous rectal or genital ulcer.
In the recent past history, they had occasional sexual intercourse, often without condom use.
Physical examination revealed stable vital signs. Neither fever nor lymphadenopathies were found. A maculopapular eruption was present in the skin (see Figures 1, 2 and 3). Palms and soles were also affected. No genital and/or rectal ulcers were observed.
Figure 1 Patient No.4 Figure 2 Patient No.6 Figure 3 The UK patient (No.7)
HIV diagnosis had been made between 3 months and 7 years earlier.
Seven of the 14 patients were treated with Highly Active Antiretroviral Therapy (HAART); the remaining seven patients were treatment-naive; they had no indication for antiretroviral treatments[7,8].
All patients had a CD4+ count > 400/mmc (range between 401 and 702/mmc). In the treated patients, the HIV-RNA was undetectable. The treatment-naive patients were asymptomatic and they have a mean HIV-RNA level of 24.280 copies/ml (range from 8.000 to 39.000 copies/ml).
Published data shows that the diagnosis of secondary syphilis can also be established with common serologic tests[9,10] (Table 1).
Table 1 Sensibility of Commonly Used Serologic Tests for Diagnosis of Syphilis (%)
Note:from Larsen S.A. et al.: Clin. Microbiol. Rev. 1985 (adapted)
In our experience, the diagnosis was established in all 14 patients with the combination of two non-treponemal reaginic tests: Venereal Disease Research Laboratory (VDRL) test with a titre of 1：32 or more and qualitative Rapid Plasma Reagin (RPR). Inaddition one specific treponemal test was performed: Fluorescent Treponema Antibody (FTA-abs).
Nine patients were treated with 2.4 million units of intramuscular benzathine penicillin the first time; then we continued with 1.2 million units every week for 4 weeks. These patients' maculopapular eruption vanished 10~20 days after initiation of therapy. The last five patients preferred to be treated with ceftriaxone, 1 gr im qd for 1 week, because they feared pain in the injection site.
During the next follow-up, we observed no signs of significant HIV disease progression. The seven patients on HAART continued their therapy without change in clinical presentation, CD4+ cell counts and HIV-RNA level. The seven remaining patients showed no clinical progression in the 6 months follow-up; CD4+ cell count and HIV-RNA level were stable (mean CD4+ cell count: 459/mmc; mean HIV-RNA level: 21.000 copies/ml).
DISCUSSION
Our experience shows that secondary syphilis is more frequent in white adults, especially men. Epidemiological data from the United States and the European Union show that increase in sexual activity among adolescents and young adults and a lack of clinical services in settings convenient to this segment of society could have contributed to the increasing rates of syphilis and other sexually transmitted diseases (STD) among these patient groups[11].
A recently published study of Nigerian commercial sex workers living in Sicily, conducted by some authors of this paper, showed no evidence of Treponema pallidum infection[12].
The authors believe that these epidemiological and clinical observations show that health policies should be formulated and designed to promote STD prevention strategies in the general population and in HIV infected patients.
Among these groups, the estimated rate of syphilis is considerably higher than among the general population[3,13]. These findings highlight the importance of providing STD prevention and control services above all to HIV-infected persons.
At this point, the problem is unsolved. Condoms provide a very safe and cheap solution to the transmission of these diseases. Yet widespread condom use appears to be far from reality.
REFERENCES
1. Kilmarx PH, St Louis ME. The evolvong epidemiology of syphilis.Am J Public Health, 1995, 85: 1053-1054.
2. Division of STD Prevention. Sexually Transmitted Disease Surveillance.Atlanta, Center for Disease Control and Prevention，1999.
3. Centers for Diseases Control and Prevention. Primary and secondary Syphilis-US. Morb Mortal Weekly Rep, 2001, 50: 113.
4. Yinnon AM,Coury-Doniger P, Polite R,et al.Serologic response to treatment of syphilis in patients with HIV infection.Arch. Intern. Med, 1996, 156: 321-325.
5. Division of STD Prevention. Sexually Transmitted Disease Surveillance. Atlanta, Center for Disease Control and Prevention，1997.
6. Hutchinson CM, Hook EW,Shepherd M,et al.Altered clinical presentation of early syphilis in patients with human immunodeficiency virus infection. Ann Intern Med,1994, 121: 94-100.
7. Department of Health and Human Services (DHHS): Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. Oct, 29, 2004.
8. Ministero Italiano della Salute: Aggiornamento sulle conoscenze in tema di terapia antiretrovirale. 18 dicembre，2003.
9. Tremont EC. Treponema pallidum-Syphilis. In Mandell, Douglas and Bennett's “Principles and Practice of Infectious Diseases” 4th ed. Churchill Livingstone London-New York,1995, 2117-2133.
10. Larsen SA, Steiner BM, Rudolph AH.Laboratory diagnosis and interpretation of tests for syphilis. Clin Microbiol Rev, 1995, 8 (1): 1-21.
11. Webster LA, Berman SM, Greenspan JR. Surveillance for gonorrhea and primary and secondary syphilis among adolescents, U. S. 1981-1991.Morb Mort Weekly Rep. CDC Surveill Summ. 1993, 13,42(3):1-11.
12. Prestileo T, Dalle Nogare E, Di Lorenzo F,et al.Infectious diseases and sexual transmitted diseases in two different cohort of extra communitarian people in Palermo(Sicily,Italy)from 2000 to 2004.Rec Progr Med, 2005, 96(4): 180-182.
13. Chesson HW, Heffelfinger JD, Voigt RF, Collins D.: Estimates of primary and secondary syphilis rates in persons with HIV in the United States, 2002.Sex Transm Dis,2005, 32(5): 265-269.
Infectious Disease & AIDS Unit, Ospedale Casa del Sole-Pisani ASL 6 Palermo, Italy
(Editor HOU)
Secondary syphilis in HIV infected patients with no condom use(pdf)
Correspondence to Tullio Prestileo, MD,Largo Giuliana 2, 90124 Palermo, Italy
Tel:+39 091 6302541 (home),+39 091 7033217 (hospital),Fax:+39 091 7033297,Mobile:+39 333 3207437
E-mail:tullioprestileo@virgilio.it
[Abstract] Objective Syphilis is a chronic infectious disease caused by the spirochete Treponema pallidum. It is transmitted during sexual intercourse and vertically, from the mother to the child during the pregnancy or the birth. Syphilis became a predominant Sexually Transmitted Disease (STD) disease among homo and heterosexual men and commercial sex workers. Syphilis has been and continues to be a disease often accompanying HIV. Methods Authors describe characteristic clinical courses of 14 patients with HIV infection diagnosed from, at least, 3 months. All patients were consecutively observed during the last 18 months. Results Patients presented maculopapular eruptions (duration 3~12 days) on extremities, trunk, face, palms and soles. They had no history of fever, chills, malaise, headache or previous rectal or genital ulcer. The diagnosis was established in all ten patients with the combination of two non-treponemal reaginic tests: Venereal Disease Research Laboratory (VDRL) test with a titre of 1：32 or more and qualitative Rapid Plasma Reagin (RPR). In addition one specific treponemal test was performed: Fluorescent Treponema Antibody (FTA-abs). Nine patients were treated with 2.4 million units of intramuscular benzathine penicillin the first time; then we continued with 1.2 million units every week for 4 weeks. These patients' maculopapular eruption vanished 10~20 days after initiation of therapy. The last five patients preferred to be treated with ceftriaxone, 1 gr intramuscular every day for 1 week, because they feared pain in the injection site. During the next follow-up, we observed no signs of significant HIV disease progression. Conclusions The authors believe that health policies should be formulated and designed to promote STD prevention strategies in the general population and in HIV infected patients. Condoms provide a very safe and cheap solution to the transmission of these diseases.
[Key words] HIV;AIDS; syphilis; condom
INTRODUCTION
Syphilis is a chronic infectious disease caused by the spirochete Treponema pallidum. It is transmitted during sexual intercourse and vertically, from the mother to the child during the pregnancy or the birth.
In North America and in the European Union, during the 1970s, syphilis became a predominant disease among homosexual men and commercial sex workers[1].
More recently the World Health Organization (WHO) estimated that the annual global incidence of syphilis is about 12 million cases, most of which occur in the underdeveloped nations, where the disease has remained a prominent cause of genital ulcer disease in women and hetero/homosexual men[2].
Syphilis has been and continues to be a disease often accompanying HIV[3].
In most recently diagnosed patients with HIV infection the clinical features, serological test results and responses to therapy are similar to those in the general population[4]. But numerous case reports suggest that in people with HIV infection syphilis might be a more aggressive illness, and serologic response to infection might be modified[5,6].
CLINICAL PRESENTATION
The authors describe characteristic clinical courses of HIV infected patients with secondary syphilis. These patients were observed from April 2004 to December 2005 in an outpatient infectious diseases clinic in Palermo, Italy.
In this period we observed 14 clinical pictures of secondary syphilis (12 Italian men, one British man and one Nigerian man, with mean age 33 years) 8 were homosexuals, two bisexuals and four heterosexuals.
All patients presented with maculopapular eruptions (duration 3~12 days) on extremities, trunk, face, palms and soles. They had no history of fever, chills, malaise, headache or previous rectal or genital ulcer.
In the recent past history, they had occasional sexual intercourse, often without condom use.
Physical examination revealed stable vital signs. Neither fever nor lymphadenopathies were found. A maculopapular eruption was present in the skin (see Figures 1, 2 and 3). Palms and soles were also affected. No genital and/or rectal ulcers were observed.
Figure 1 Patient No.4 Figure 2 Patient No.6 Figure 3 The UK patient (No.7)
HIV diagnosis had been made between 3 months and 7 years earlier.
Seven of the 14 patients were treated with Highly Active Antiretroviral Therapy (HAART); the remaining seven patients were treatment-naive; they had no indication for antiretroviral treatments[7,8].
All patients had a CD4+ count > 400/mmc (range between 401 and 702/mmc). In the treated patients, the HIV-RNA was undetectable. The treatment-naive patients were asymptomatic and they have a mean HIV-RNA level of 24.280 copies/ml (range from 8.000 to 39.000 copies/ml).
Published data shows that the diagnosis of secondary syphilis can also be established with common serologic tests[9,10] (Table 1).
Table 1 Sensibility of Commonly Used Serologic Tests for Diagnosis of Syphilis (%)
Note:from Larsen S.A. et al.: Clin. Microbiol. Rev. 1985 (adapted)
In our experience, the diagnosis was established in all 14 patients with the combination of two non-treponemal reaginic tests: Venereal Disease Research Laboratory (VDRL) test with a titre of 1：32 or more and qualitative Rapid Plasma Reagin (RPR). Inaddition one specific treponemal test was performed: Fluorescent Treponema Antibody (FTA-abs).
Nine patients were treated with 2.4 million units of intramuscular benzathine penicillin the first time; then we continued with 1.2 million units every week for 4 weeks. These patients' maculopapular eruption vanished 10~20 days after initiation of therapy. The last five patients preferred to be treated with ceftriaxone, 1 gr im qd for 1 week, because they feared pain in the injection site.
During the next follow-up, we observed no signs of significant HIV disease progression. The seven patients on HAART continued their therapy without change in clinical presentation, CD4+ cell counts and HIV-RNA level. The seven remaining patients showed no clinical progression in the 6 months follow-up; CD4+ cell count and HIV-RNA level were stable (mean CD4+ cell count: 459/mmc; mean HIV-RNA level: 21.000 copies/ml).
DISCUSSION
Our experience shows that secondary syphilis is more frequent in white adults, especially men. Epidemiological data from the United States and the European Union show that increase in sexual activity among adolescents and young adults and a lack of clinical services in settings convenient to this segment of society could have contributed to the increasing rates of syphilis and other sexually transmitted diseases (STD) among these patient groups[11].
A recently published study of Nigerian commercial sex workers living in Sicily, conducted by some authors of this paper, showed no evidence of Treponema pallidum infection[12].
The authors believe that these epidemiological and clinical observations show that health policies should be formulated and designed to promote STD prevention strategies in the general population and in HIV infected patients.
Among these groups, the estimated rate of syphilis is considerably higher than among the general population[3,13]. These findings highlight the importance of providing STD prevention and control services above all to HIV-infected persons.
At this point, the problem is unsolved. Condoms provide a very safe and cheap solution to the transmission of these diseases. Yet widespread condom use appears to be far from reality.
REFERENCES
1. Kilmarx PH, St Louis ME. The evolvong epidemiology of syphilis.Am J Public Health, 1995, 85: 1053-1054.
2. Division of STD Prevention. Sexually Transmitted Disease Surveillance.Atlanta, Center for Disease Control and Prevention，1999.
3. Centers for Diseases Control and Prevention. Primary and secondary Syphilis-US. Morb Mortal Weekly Rep, 2001, 50: 113.
4. Yinnon AM,Coury-Doniger P, Polite R,et al.Serologic response to treatment of syphilis in patients with HIV infection.Arch. Intern. Med, 1996, 156: 321-325.
5. Division of STD Prevention. Sexually Transmitted Disease Surveillance. Atlanta, Center for Disease Control and Prevention，1997.
6. Hutchinson CM, Hook EW,Shepherd M,et al.Altered clinical presentation of early syphilis in patients with human immunodeficiency virus infection. Ann Intern Med,1994, 121: 94-100.
7. Department of Health and Human Services (DHHS): Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. Oct, 29, 2004.
8. Ministero Italiano della Salute: Aggiornamento sulle conoscenze in tema di terapia antiretrovirale. 18 dicembre，2003.
9. Tremont EC. Treponema pallidum-Syphilis. In Mandell, Douglas and Bennett's “Principles and Practice of Infectious Diseases” 4th ed. Churchill Livingstone London-New York,1995, 2117-2133.
10. Larsen SA, Steiner BM, Rudolph AH.Laboratory diagnosis and interpretation of tests for syphilis. Clin Microbiol Rev, 1995, 8 (1): 1-21.
11. Webster LA, Berman SM, Greenspan JR. Surveillance for gonorrhea and primary and secondary syphilis among adolescents, U. S. 1981-1991.Morb Mort Weekly Rep. CDC Surveill Summ. 1993, 13,42(3):1-11.
12. Prestileo T, Dalle Nogare E, Di Lorenzo F,et al.Infectious diseases and sexual transmitted diseases in two different cohort of extra communitarian people in Palermo(Sicily,Italy)from 2000 to 2004.Rec Progr Med, 2005, 96(4): 180-182.
13. Chesson HW, Heffelfinger JD, Voigt RF, Collins D.: Estimates of primary and secondary syphilis rates in persons with HIV in the United States, 2002.Sex Transm Dis,2005, 32(5): 265-269.
Infectious Disease & AIDS Unit, Ospedale Casa del Sole-Pisani ASL 6 Palermo, Italy
(Editor HOU)
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