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CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, Canada22nd IUSTI-EUROPE CONFERENCE ON SEXUALLY TRANSMITTED INFECTIONS Oral communication Thursday 10/19/2006 14:00 Auditorium Richelieu Session 1: Syphilis and GUD Abstract N°O.001CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, CanadaObjectives: To ascertain if syphilis screening reliably detects latent disease, including in

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CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, Canada

22nd IUSTI-EUROPE CONFERENCE ON SEXUALLY TRANSMITTED INFECTIONS Oral communication Thursday 10/19/2006 14:00 Auditorium Richelieu Session 1: Syphilis and GUD Abstract NO.001

CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, Canada

Objectives: To ascertain if syphilis screening reliably detects latent disease, including in the HIV context, by comparing standard syphilis testing with newlydeveloped techniques, using either recombinant antigen based treponemal serology or direct detection by DNA amplification.

CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, Canada

Methods: (1) 500 patients at a downtown Toronto HIV clinic were screened from 1988-1992 with both RPR and quantified treponemal tests, including MHA-Tp (TPHA).

SYPHILIS - A ROLE IN SEXUALLY ACQUIRED AIDS? D.K. MacFadden, R.H. Notenboom, J. Scythes Dept. of Medicine, University of Toronto, Laboratory Services Branch, Ministry of Health, Community Initiative for AIDS Research, Toronto, Ontario, Canada Biology and Pathogenicity of Treponemes Conference University of Birmingham, England, 11-13 April 1989Numerous inconsistencies have been noted in HIV epidemiology between the various risk groups. Clinical signs of HIV infection seem to appear much later in previously healthy heterosexuals. Marked differences in both expression and progression of HIV disease between the sexually and non-sexually acquired forms have been reported. These differences might well be explained by a hypothetical interrelationship between STDs and AIDS thereby explaining the predisposition to HIV infection both in North American homosexuals and the heterosexual population of sub-Saharan Africa. Extensive historical data supports the role of an STD as a co-factor allowing significant viral expression. Certain aspects of HIV epidemiology may therefore be explained by concomitant infection by treponemes and HIV. Although the natural history of HIV infection in North American homosexuals is well documented, it appears that infection by non-sexual means results in less serious disease or prolongation of a clinically latent period. This is supported by evidence that infectivity rates of immunologically intact individuals, e.g. needle-stick exposures, hemophiliacs and transfusion recipients are less than that of immunologically impaired transfusion recipients, e.g. hypogammaglobulinemia, leukemia, etc. Seroconversions in the immunologically intact groups may carry a less serious prognosis re: progression to AIDS. The reported differences between sexually and non-sexually acquired AIDS may result from failure to diagnose treponemal disease either due to the inadequacies of treponemal testing or due to secondary effects of HIV infection. a) Of 43 patients in a gay primary practice, 13 reported a history of treatment for syphilis; 6 of these were negative in all syphilis tests (VDRL, MHA-TP, FTA and TPI). b) Furthermore, 83 HIV antibody positive {and not end-stage} homosexual patients, in order of presentation, at an HIV clinic were all VDRL negative; 12 were negative in treponemal tests despite a history of treated syphilis. 24 reported a history, i.e. 50% lost antibody. c) To investigate the concommitance of HIV antibody and treponemal antibody status, we tested 100 homosexuals blinded. Only one out of the 10 patients with AIDS was treponemal antibody positive.

SYPHILIS AND HIV: SEROPREVALENCE AND CLINICAL OBSERVATIONS IN HIV CLINIC, TORONTO Fralick RA, Scythes JB, Notenboom RH, MacFadden DK The Toronto Hospital, Western Division, Community Initiative for AIDS Research, Laboratory Services Branch, Ontario Ministry of Health, Toronto, Canada 10th International Meeting of the International Society for STD Research Helsinki, Finland, August 27 - September 1, 1993 Objective: To determine the reliability of syphilis testing in HIV positive patients attending the Toronto Hospital's Immunology Clinic. Methods: Chart review and analyses of history of syphilis and current CD4+ counts. Results: Out of 500 active patients, 398 with no history of syphilis and CD4+ counts over 200 excluded. Among the remaining 102 patients no primary or secondary syphilis was diagnosed; 53% had reactive treponemal tests (CD4+ count: range 6-1015, mean 272). No patient had documented clinical or serological relapse despite 11 patients (20.4% of reactive treponemal tests) who had reactive treponemal tests without a history of syphilis. Follow up of these patients showed no clinical signs or serological evidence of active syphilis. Six patients with a history of syphilis had nonreactive treponemal tests (CD4+ count: range 27-170, mean 78). Reactive non-treponemal tests and the late sequelae of syphilis infection in HIV positive population are much lower than expected. Reinfection and super-infection are difficult to detect, and potentially atypical in the immunosuppressed or in those with previous syphilis. Significantly 11 patients had reactive treponemal tests yet no history of syphilis. Conceivably there are many HIV patients like this. The immune response to syphilis is cell-mediated. The 6 patients with a history of syphilis, nonreactive treponemal tests and lower CD4+ T-lymphocyte counts represent an important sub group who have lost their treponemal antibodies. Conclusion: Further clinical study is needed to determine their susceptibility to active tertiary syphilis.

CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, Canada

Results: (1) None of 500 patients were RPR(+), while 60/500 were TPHA (+), 11 of whom had no syphilis history. Six with a syphilis history were TPHA (-) with CD4 < 80/ul.

CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, Canada

Methods: (2) Serum aliquots from a further 250 patients from the University of Toronto's AIDS Epi-Study were similarly tested in 1992.

RELIABILITY OF SYPHILIS TESTS IN PATIENTS WITH HIV Notenboom R; MacFadden DK Laboratory Services Branch, Ministry of Health, Toronto, Canada VIII International Conference on AIDS/III STD World Congress, Amsterdam, the Netherlands, 19-24 July 1992

OBJECTIVE: To assess the extent of treponemal antibody decrease in persons at risk for HIV and to determine whether such loss is a specific one. METHODS: Paired sera collected at a 3-4 year interval from patients attending primary care facilities and/or an HIV clinic were tested for syphilis by Microhemagglutination for Treponema pallidum (MHA-TP). Paired sera of which at least the first specimen was reactive in the MHA-TP were also tested blinded for HIV, Toxoplasma gondii (Tg) and mumps. Additional tests for syphilis were carried out as well: Fluorescent Treponemal Antibody-Absorbed Test (FTAAbs), Captia IgG for T. pallidum and quantitative MHA-TP. RESULTS: A) HIV ab+ patients showed a significantly larger proportion with decreasing MHA-TP titers than HIV abpatients (24/40 vs. 1/15). In the HIV ab+ group, we found 6 seroreversions to non-reactive by MHA-TP, none in HIV ab- group. B) Among HIV ab- patients no changes in anti Tg, anti mumps or anti Tp were found, while among HIV ab+ patients we found 2 instances in which all four serological markers were decreased. In 6 cases, (HIV ab+) changes in anti mumps titers were not parallel by changes in Tp tests. CONCLUSION: Serological tests may underestimate the incidence of (past) syphilis in HIV ab+ patients. The decrease in treponemal antibodies in these patients is not due to a generalized loss of antibody.

CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, Canada

Results: (2) Of 125/250 Epi-Study patients with HIV, 24 had dropping treponemal titres during B-cell polyclonal activation, while only one HIV(-) case lost treponemal antibody selectively in this way.

CAN WE RELIABLY DIAGNOSE SYPHILIS?J. Scythes, C. M. Jones Community Initiative for AIDS Research Toronto, Canada

Methods: (3) 557 patients from another downtown HIV/STD clinic were screened in 2000 as above, and also monitored with the Trep-Chek, a more sensitive, FDA-approved, recombinant ag-based EIA test.

TREPONEMAL BASED SCREENING FOR SYPHILISDETECTING LATENT CASES N. denHollander, R. Berry, M. Fearon Ontario Public Health Laboratory, Toronto, Canada 2000 General Meeting of the American Society for Microbiology Los Angeles, California, May 21-25, 2000 Background: With the advent of national plans to eliminate syphilis from the United States and Canada it becomes vital that all cases (new and old) be identified and where necessary treated. Most laboratories in North America use nontreponemal based screening tests for syphilis. We asked how many cases of "unknown" syphilis infection were being missed using this, the oldest of all syphilis assays. Methods: We selected 557 "high risk" (from STD Clinics) specimens from our routine syphilis submissions which were non-reactive in our standard non-treponemal test [Rapid Plasma Reagin (RPR)] and re-tested them using a new automatable EIA. The EIA (Trep-Chek Phoenix Bio-Tech Corp) utilizes recombinant antigens from Treponema pallidum. All specimens were also tested using a microhemagglutination assay for T. pallidum (MHA-Tp) and EIA positives were confirmed using a T. pallidum specific Western blot (WB). Sensitivity of the new assay was checked against 15 patients with proven early primary syphilis (direct fluorescence confirmed, dark-field positive smears from primary lesions) and a panel of 16 treated, confirmed syphilis patients. A panel of 119 "biological false positive" specimens (RPR reactive but MHA-Tp non-r