Evaluation of syphilis in patients with HIV infection in Nigeria

Abstract

Summary Objective To document the manifestations of syphilis among patients with concurrent HIV infection over a 12‐month period. Method Descriptive, cross‐sectional, hospital‐based study of all adult patients with syphilis and HIV infection who attended the skin clinic of the University of Nigeria, Teaching Hospital, Enugu, between July 2000 and June 2001. A standardized questionnaire was used to record age, sex, marital status, occupation and risk factor for HIV infection; initial site of onset of rash/ulcers, duration of the illness, any concomitant affection of mucosa, hair and nails as well as treatments received by each patient prior to presentation. Morphological distribution of lesions, mucosal surface (conjuctival, vulval and rectal) examinations and documentation of concomitant disorders with HIV were noted by the examining dermatologist. Lesional biopsy and dark‐field microscopy were undertaken to confirm diagnosis where serologic (non‐treponemal and treponemal specific) tests for syphilis were inconsistent with clinical suspicion. Each patient had a routine chest x‐ray, mantoux and purified protein derivative (PPD) status taken. Results Thirty‐one patients (21 males) with concurrent syphilis and HIV were seen during the study period. Primary syphilis was diagnosed in nine (29%), secondary syphilis in 20 (64.5%) and latent syphilis in two (6.5%). Neurosyphilis was not observed. Prevalence of syphilis for these patients with concurrent HIV was 2.1%. Mean duration of syphilis was 3.9 months ± 1.4 and lesions of greatest concern occurred mainly on the genitalia. The glans penis was affected in 10 (32.3%) cases, the penile shaft in seven (22.6%), the oral cavity in five (16.1%), the rectum in six (19.4%) and the vulva in three (0.9%) cases. Nine (29.1%) patients had a history of primary syphilitic chancre, 19 (61.3%) had a past history of sexually transmitted disease (STD) – particularly genital ulcers – while three (9.7%) could not recall any past history of STD. Eighteen (59.3%) had a history of unprotected sex, 16 (51.7%) had multiple sexual partners, four (13.3%) had had oral sex, and one anal sex (3.3%); none admitted to being bisexual. Other relevant risk factors for HIV transmission were blood transfusion within 5 years for three (9.7%) and intravenous drug use in two (6.5%). Some patients had more than one condition as a potential source of exposure. Serological tests were weakly reactive in 17 (48.4%), strongly reactive in nine (29%) and non‐reactive in five (16.1%) patients. Three patients exhibited prozone phenomenon. Treatment comprised the syndromic approach, which currently is advocated for use in primary healthcare centres without facilities for aetiological diagnosis of sexually transmitted infections. Conclusion Our cases with concurrent syphilis and HIV/AIDS had unusual manifestations, responded to treatment more slowly and died sooner than cases described in Western literature due to generally lower levels of health.

Clinico-Pathologic Conference: Case 3

“…The potential for accelerated disease progression in this population underscores the need for early diagnosis; a goal which may be hindered by the atypical clinical presentation of syphilis in patients co-infected with HIV [6]. For instance, up to nearly onethird of patients with primary syphilis do not present with a classic indurated, clean-based, painless ulcer [6]; atypical chancres may be characterized by an irregular border [7] and pain [6]. In addition, multiple chancres, chancres which persist during secondary disease [7,8], and oral involvement are more commonplace in the HIV-infected population [7].…”

“…For instance, up to nearly onethird of patients with primary syphilis do not present with a classic indurated, clean-based, painless ulcer [6]; atypical chancres may be characterized by an irregular border [7] and pain [6]. In addition, multiple chancres, chancres which persist during secondary disease [7,8], and oral involvement are more commonplace in the HIV-infected population [7]. While the depth and induration of the dorsal tongue ulcers in this case were suggestive of chancres, the presence of multiple irregular, painful lesions was unusual, requiring confirmation with serologic studies.…”

“…Primary syphilitic chancres are classically solitary, clean-based, painless ulcers which most often affect the genitalia and anus. In the context of coinfection with HIV, atypical presentations consisting of multiple painful chancres [6] with an irregular border [7] and oral involvement [7] are more commonplace. In this clinical setting, the oral ulcerations could represent an atypical manifestation of primary disease.…”

“…This patient lacks these typical systemic manifestations expected for secondary syphilis. However, in the HIV-infected population, overlap of syphilitic phases has been documented [7,8] such that the lesion of the lateral tongue may represent a mucous patch of syphilis occurring concomitantly with persistent primary disease. Though recent RPR titers were negative, a detailed history of recent sexual activity, and repeated serologic testing would be helpful to exclude this possibility.…”

Prevalence of Syphilis among People living with HIV (PLHIV) attending a tertiary care hospital in coastal south India

“…9 The prevalence of HIV-syphilis co infection was 2.1% in Nigeria. 10 According to Chow et al prevalence of HIV-syphilis co-infection was 2.7% among men who have sex with men (MSM). 11 In a Spanish study of 1161 HIV-positive patients the baseline syphilis seroprevalence was 13%.…”