A Study on Clinico Serological Prevalence of Syphilis in Patients with HIV/AIDS

“A STUDY ON CLINICO-SEROLOGICAL PREVALENCE OF

SYPHILIS IN PATIENTS WITH HIV/AIDS”

Dissertation submitted in partial fulfillment of the requirements for the degree of

M.D. (DERMATOLOGY, VENEREOLOGY AND LEPROSY)

BRANCH XX

MADRAS MEDICAL COLLEGE CHENNAI.

THE TAMILNADU Dr. MGR MEDICAL UNIVERSITY CHENNAI

CERTIFICATE

Certified that this dissertation titled “CLINICO-SEROLOGICAL

PREVALENCE OF SYPHILIS IN PATIENTS WITH HIV/AIDS” is a

bonafide work done by Dr.M.MUNIRAJ Post graduate student of the

Department of Dermatology, Venereology and Leprosy, Madras Medical

College, Chennai – 3, during the academic year 2016 – 2019. This work has

not previously formed the basis for the award of any degree.

Prof. Dr. S.KALAIVANI, M.D., D.V., Prof.Dr.U.R.DHANALAKSHMI, M.D., DD.,

Director and Professor, Professor and Head,

Institute of Venereology, Department of Dermatology &

Madras Medical College, Leprosy,

Chennai – 600 003. Madras Medical College,

Chennai – 600 003.

Prof. Dr. R. JAYANTHI, M.D., FRCP (Glas).,

DEAN

Madras Medical College,

DECLARATION

The dissertation entitled “CLINICO-SEROLOGICAL

PREVALENCE OF SYPHILIS IN PATIENTS WITH HIV/AIDS” is a

bonafide work done by Dr.M.MUNIRAJ at Department of Dermatology,

Venereology and Leprosy, Madras Medical College, Chennai – 3, during the

academic year 2016 – 2019 under the guidance of Prof. Dr. S. KALAIVANI

M.D.,D.V., Director and Professor, Institute of Venereology, Madras Medical

College, Chennai -3.

This dissertation is submitted to The Tamil Nadu Dr. M.G.R. Medical

University, Chennai towards partial fulfillment of the rules and regulations for

the award of M.D Degree in Dermatology, Venereology and Leprosy

(BRANCH – XX).

Prof. Dr. S. KALAIVANI, M.D., D.V.,

Director and Professor, Institute of Venereology, Madras Medical College, Chennai- 600 003.

DECLARATION

I, Dr.M.MUNIRAJ solemnly declare that this dissertation

titled “CLINICO - SEROLOGICAL PREVALENCE OF SYPHILIS IN

PATIENTS WITH HIV/AIDS” is a bonafide work done by me at Madras Medical College during 2016-2019 under the guidance and supervision of

Prof. Dr. S.KALAIVANI, M.D., D.V., Director and Professor, Institute of

Venereology, Madras Medical College, Chennai-600 003.

This dissertation is submitted to The Tamil Nadu Dr. M.G.R. Medical

University, Chennai towards partial fulfillment of the rules and regulations for

the award of M.D Degree in Dermatology, Venereology and Leprology

(BRANCH – XX).

(DR.M.MUNIRAJ)

PLACE:

SPECIAL ACKNOWLEDGEMENT

My sincere thanks to Prof. Dr. R. JAYANTHI M.D., FRCP (Glas).,

Dean, Madras Medical College, Chennai-3 for allowing me to do this

ACKNOWLEDGEMENT

I am grateful to Prof. Dr.S.KALAIVANI, M.D., D.V., Director and Professor, Institute of Venereology., for her advice, guidance and encouragement for my study. She has been a source of constant motivation and encouragement throughout the study. I am extremely grateful to her for guiding me throughout the study.

I would like to express my sincere and heartfelt gratitude to Professor and Head of the Department of Dermatology, Prof. Dr. U.R. DHANALAKSHMI, M.D., D.D., D.N.B for her kindness and support throughout the study.

I wish to thank Dr. C. VIJAYA BASKAR, M.D., D.C.H., Associate Professor, Institute of Venereology for his guidance.

I sincerely thank Prof. Dr. S. NIRMALA M.D., Professor and HOD, Occupational and Contact Dermatitis for her valuable support.

I sincerely thank Prof. Dr. R. PRIYAVATHANI ANNIE MALATHY, M.D., D.D., D.N.B., M.N.A.M.S., Professor of dermatology for her help and support.

I thank Prof. Dr. AFTAB JAMEELA WAHAB, M.D., D.D., Professor of Dermatology for her advice and encouragement.

I thank Prof. Dr. V. SAMPATH, M.D., D.D., Professor of Dermatology for his advice and encouragement.

I am grateful to Prof. Dr. J. MANJULA, M.D., D.N.B., Professor, Department of Dermatology for her invaluable guidance, help and encouragement.

I humbly thank my Co-Guide Dr.E.BALASUBRAMANIAN, M.D.D.V.L., Assistant Professor, Institute of Venereology for his valuable guidance throughout my work. I would like to express my sincere and heartfelt gratitude for the time which he devoted for my research project.

I also thank my Assistant Professors Dr. P. PRABAHAR, M.D.D.V.L., Dr.H.DHANASELVI, M.D.D.V.L., Dr.K.GAYATHRI, M.D.D.V.L., Dr.R.SNEKAVALLI, M.D.D.V.L., Dr. T. VANATHI, M.D.D.V.L., Dr.T.VASANTHI, M.D.D.V.L., and Dr .C. DURGVATHI, M.D.D.V.L., Institute of Venereology for their able guidance.

I thank Dr. M. SUBHA, M.D (Microbiology)., DGO ., Professor of Serology and Dr.S. HEMALATHA, M.D., for her help and support.

I extend my gratitude to Dr.R.MADHU, M.D.,(DERM)., D.C.H., Dr.V.N.S.AHAMED SHARIFF, M.D.D.V.L., Dr.B.VIJAYALAKHSMI, M.D.D.V.L., Dr.R.MANIPRIYA, M.D.D.V.L., D.C.H., Dr.C.L.CHITRA, M.D.D.V.L., Dr. K.DEEPA, M.D.D.V.L., Dr.S.VENKATESAN DNB.,DD and Dr.S.THAMZIHSELVI, M.D.D.V.L., Assistant professors, Department of Dermatology for their kind support and encouragement.

CONTENTS

Sl. No. Title Page No.

1. INTRODUCTION 1

2. REVIEW OF LITERATURE 2

3. AIMS AND OBJECTIVES 37

4. MATERIALS AND METHODS 38

5. RESULTS 40

6. DISCUSSION 76

7. CONCLUSION 81

ANNEXURES

BIBLIOGRAPHY

CLINICAL IMAGES

MASTER CHART

KEY TO MASTER CHART

INFORMATION SHEET

PATIENT CONSENT FORM

PROFORMA

PLAGIARISM DIGITAL CERTIFICATE

1

INTRODUCTION

Syphilis is a infectious disease caused by Spirochaete Treponema

pallidum. The disease is transmitted mainly by sexual contact. Treponema

pallidum may infect any organ causing an infinite number of clinical

presentations. Human Immunodeficiency Virus (HIV) is the causative agent of

AIDS. HIV can infect and progressively destroy helper ”T”cells, killer ‘T’

cells and macrophages, thus altering the host immune response to other

bacteria, virus and parasites. These two sexually transmitted diseases are of

major public health concern. In this study, we made an effort to analyse

various clinical presentations of syphilis and serological prevalence of syphilis

2

REVIEW OF LITERATURE

Sir William Osler

DEFINITION (1)

Syphilis was defined by Stokes, as an infectious disease; due to

Treponema pallidum; of great chronicity; systemic from the outset; capable

of involving practically every structure of the body in its course; distinguished

by florid manifestations on the one hand and years of complete asymptomatic

latency on the other hand; able to simulate many diseases in the field of

medicine and surgery; transmissible to off-spring in man; transmissible to

certain laboratory animals and treatable to the point of presumptive cure.(1)

HISTORY OF SYPHILIS (1)

There are two theories regarding the origin of syphilis. One, the

Unitarian theory, according to which the disease originated in the tropics as a

primitive Treponemal disease and later spread to more temperate climates

affecting more advanced communities where transmission by sexual contact

became the usual mode of spread of disease.

The other theory is the Columbian theory, according to which the

disease was brought to Europe with the return of Columbus in 1493 after his

3

From Europe the disease spread to India and Far East through Portuguese

sailors.

The disease acquired its name from a poem “Syphilis sive morbus

gallicus” written in 1530 by an Italian Pathologist Girolamo Fracastoro about

an infected mythical shepherd named Syphilis afflicted with the French

disease as punishment for cursing the gods.

Fritz Schaudinn and Erich Hoffmann in 1905 discovered the spiral

organism in serum from a lesion of secondary syphilis. They reported that

syphilis was caused by a spirochaete which they named “Spirochaeta pallids”.

This work was quickly confirmed when Karl Landsteiner introduced the dark

field method for the detection of organism in 1906.

In 1943, Penicillin which was discovered by Sir Alexander Fleming and

developed by Florey in Oxford, was successfully used by Mahoney and his

colleague to treat syphilis. With the emergence of AIDS epidemic a time has

come, to review the earlier said quotation as ,

4

EPIDEMIOLOGY

Every cases of infectious syphilis should be considered as a potential

source of infection. Syphilis occurs all over the world without any restriction

to any social class.

The factors that operate and interact in acquisition and spread of the

disease are complex in nature. Sexual promiscuity and prostitution are the twin

menaces around which resolve other factors. The population explosion,

migration of people from rural to urban areas, disproportionate male to female

ratio in urban and pilgrim centres, the mushrooming growth of slums in the

cities and towns leading to overcrowding with lower socioeconomic status,

decline in moral values, lack of personal and sexual hygiene, all account for

the spread of disease. The social stigma attached to a sexually transmitted

disease leads to its concealment and aids its spread. The cinema, magazines,

wall posters, exhibits, advertisements, etc. also encourage promiscuity.

In India, prostitution is still an important cause for the spread of STDs.

Economic factors play a considerable role in prostitution particularly among

the underprivileged.

A country’s socioeconomic structure and its functioning determines the

prevalence of syphilis in a community. In India, as well as in other developing

countries, poor reporting systems make it difficult to obtain the exact

incidence and prevalence of syphilis. The reported incidence of early syphilis

among STD patients in India varies from 7.1 to 99.9%. Syphilis is the

5

serological surveys its prevalence ranges from 2.66 to 26.6%. Syphilis is

more common in males than in females. It has been observed that majority of

males continue to be sexually active even after acquiring the infection.(2)

PATHOGENESIS(3)

The complex host microbe interactions that characterize the varied

clinical course of syphilis are poorly understood. The outer membrane of

Treponema pallidum is a phospholipid bilayer through which only a few

antigenic proteins protrude and the major membrane immunogens are

subsurface proteolipids. These structural features, along with a slow doubling

time of 30- 33 hours, result in a delay in host immune response since the

principal immunogens are largely inaccessible as long as the spirochetes

remain intact. This feature undoubtedly plays a role in the organism’s ability to

persist despite an apparently vigorous host immune response and the

development of cross reacting non specific non treponemal antibodies. The

immune response fails to clear the infection in many instances because an

effective Th1 (cellular) response is downregulated in difference to an

ineffective Th2 (humoral) response. In immunologically dysfunctional persons

(eg. those infected with HIV) aggressive and/or persistent chronic infections

are more likely. Spirochetemia can occur throughout the course of Treponema

pallidum infection including asymptomatic stages of incubation and latent

6

CLASSIFICATION

CONGENITAL ACQUIRED

1.Early EARLY SYPHILIS (Infectious)

2.Late 1. Primary

3.Stigmata 2. Secondary

3. Early latent

4. Relapse and Reinfection

LATE SYPHILIS (Non infectious) 1.Late latent

2.Tertiary syphilis

-BENIGN TERTIARY(16%)

-CARDIOVASCULAR(10.4%)

-NEUROSYPHILIS(6.4%).

PRIMARY SYPHILIS

It is characterized by chancre which develops after an incubation

period of 9-90 days (mean 21 days) following infection and is usually

accompanied by regional lymphadenitis.

The primary chancre presents as sharply defined, usually single,

painless genital ulcer with clean surface and indurated base which express

serous exudates on manipulation and is accompanied by bilateral

7

nodes. The primary lesions will heal within three to ten weeks and may go

unnoticed by the patient.(1,4)

SECONDARY SYPHILIS(5)

The lesions of secondary syphilis usually occur six to eight

weeks after the appearance of primary lesions. The lesions are generalized,

affecting the skin and mucous membranes.

Characteristically, these eruptions are non vesicular, non pruritic,

widespread and bilaterally symmetrically distributed.

TYPES OF CUTANEOUS LESIONS IN SECONDARY SYPHILIS (6)

¾ Macular Syphilide.

¾ Papular Syphilide.

¾ Papulo squamous Syphilide.

¾ Pustular Syphilide.

¾ Annular, Corymbose, Papulosquamous, Lichenoid and Lenticular.

MACULAR SYPHILIDE

Appearing at about 8 weeks, the eruption may be pinkish, coppery red,

round or oval in shape distributed chiefly over shoulders, chest, back,

abdomen and flexor surfaces of upper arms. It disappears in few days or

8

PAPULAR SYPHILIDE

Maculopapular rash is most characteristic which appears 3 months post

infection. They present as dull red, non scaly lesion distributed over trunk,

extremities, face and genitals. Lichenoid, nodular and acneiform lesions also

occur.

CORONA VENERIS – Linear arrangement of papules along the forehead

below hairline.

BUSCHKE OLLENDORF SIGN – Deep dermal tenderness can be elicited

over the rash present over bony prominence by pressing the papule directly

with a small blunt object like pin head.

CONDYLOMA LATA

Large fleshy, grayish white, moist, flat topped and broad based

papule and plaque distributed over intertriginous areas like perianal area,

between thigh and scrotum, vulva and perineal regions. It is loaded with

9

HAIR INVOLVEMENT IN SECONDARY LESIONS MAY PRESENT

AS

1. Follicular papular lesions

2. Diffuse alopecia

3. Irregular patches of non scarring hair loss on occipital and parietal

regions of scalp (moth eaten alopecia).

NAILS

Nail involvement may lead to britttle nails, pitting, onycholysis or

shedding.

Nail fold involvement will lead to paronychia.

PAPULO SQUAMOUS SYPHILIDE:

1. Papular eruption in which scaling is prominent and papules coalesce to

form plaque.

2. Presence of scaly plaque may resemble the clinical picture of psoriasis.

LUES MALIGNA (7)

1. Malignant syphilis is an explosive form more prevalent in

immunosuppresed individuals.

2. Characterised by prodrome of fever, headache, muscular pain

10

3. The eruption soon become necrotic resulting in sharply marginated ulcer

with thick rupioid crust.

4. Mucous membrane may be involved and hepatitis may occur.

MUCOSAL PATCH - Grayish white patch in which surface gets eroded

forming a sharply defined superficial erosion surrounded by a dull red

area. Confluence of the lesions form irregular serpiginous erosions

called as ‘SNAIL TRACK ULCERS’ seen in oral and genital

mucosa.

LATENT SYPHILIS (6,8)

The latent period of syphilis follows the secondary stage. By definition

latent syphilis is that stage of syphilis where there are no clinical signs or

symptoms of the disease; the spinal fluid has been examined and its negative,

but the serological tests for syphilis are reactive. This latent period is divided

into early and late. Early means that the disease has been present for less than

two years and late for more than two years.

LATE SYPHILIS(8)

In this stage of syphilis, the following clinical features are encountered.

1. Late latent syphilis.

2. Late benign (Gumma including visceral syphilis).

11

The optic neuritis and optic atrophy are considered as special late entity.

LATE BENIGN SYPHILIS The essential lesion of late benign syphilis is

gumma. Gummas are probably the result of hypersensitivity reactions of

treponemal infection. The most common site are skin, bone and liver, but

nearly any organ may be involved.

Skin lesions may be solitary or multiple, tend to form circles or

segments of circle. They are destructive and chronic. They tend to heal

centrally and extend peripherally. Skin lesions may present as nodular

lesions, psoriasiform lesions or subcutaneous gumma. They heal with tissue

paper scarring.

Bone lesions are usually marked by periosteitis with as sociated

new bone formation, or by gummatous osteitis with bone destruction. Deep

seated boring pain at the site is the commonest symptom. The most common

sites are cranial bones, the tibia and the clavicle.

CARDIOVASCULAR SYPHILIS(8)

Cardiovascular syphilis is usually caused by medial necrosis of

aorta, with aortic dilatation which may extend into valve commissures. The

clinical signs of cardiovascular syphilis are those of aortic insufficiency or

saccular aneurysm of the thoracic aorta. When fully developed, these

12

hypertension, arteriosclerosis and previous rheumatic heart disease is

essential.

Saccular aneurysm of the thoracic aorta is primafacie evidence

of cardiovascular syphilis. Aortic insufficiency with no other valvular lesions

in a person of middle age, with a reactive serological test should be

considered cardiovascular syphilis, until proven otherwise. VDRL titre are

usually low in cardiovascular syphilis.

CENTRAL NERVOUS SYSTEM SYPHILIS(1, 9, 10)

The treponemes usually invade CNS within 3-18months of inoculation

with the organism. Syphilitic invasion of the CNS may be asymptomatically

present throughout the entire course of infection and may present as clinical

neurosyphilis at any point in the natural history of infection beyond the

primary stage. The initial event in the neurosyhilitic infection is a meningitis,

which occurs in 25 percent of all cases of syphilis. Usually, the meningitis is

asymptomatic and can be discovered only by lumbar puncture. This meningitis

may persist in an asymptomatic stage or ultimately after a period of years

leads to either General paresis of insane due to parenchymal involvement of

brain or Tabes doralis due to parenchymatous involvement of spinal cord. In

some cases, however there may be a natural subsidence of the meningitis-

spontaneous regressions. Asymptomatic neurosyphilis can be recognized

13

Examination Of The Cerebrospinal Fluid In Neurosyphilis (11, 12)

The CSF is a sensitive indicator of presence of active neurosyphilitic

infection. The CSF abnormalities consists of

1. Cell count : More than 5 lymphocytes is abnormal.

2. Total proteins : A total protein of more than 40mgs% is usually

abnormal.

3. CSF VDRL : A reactive CSF VDRL is practically always an

indication of central nervous system syphilis, but

not necessarily of its activity. False positive

reactions in the spinal fluid are rare.

4. Increase in gammaglobulin(IgG) - Usually with oligoclonal banding.

The glucose content is usually normal. In general, the cell count may

be expected to return first to normal followed by the protein and finally the

serological test. Early forms of neurosyphilis (meningeal and meningo

vascular) and ocular syphilis (uveitis) were more common in patients who

were inadequately treated for early syphilis than in untreated patients. Partial

therapy cleared most treponemes from the peripheral sites of infection,

organisms remaining in the eye and the central nervous system after

inadequate therapy were then able to multiply unhampered by the immune

14

DIAGNOSIS:

BEDSIDE INVESTIGATIONS(13)

DARK FIELD MICROSCOPY

In a dark field microscope only light rays hitting the organism or

particles at an oblique angle, enter the microscope objective and so the

organism appears bright object which exhibits cork screw movement on a

dark background. The main component of a dark field microscope is the dark

field condenser.

SPECIMEN COLLECTION

ULCER

1. With gloved hands clean the ulcer using a gauze piece soaked in normal

saline. Let the ulcer dry. Hold the ulcer between thumb and index finger.

Allow serous fluid to come out from the ulcer. Transfer the serous fluid

to clean sterile glass slide. Put the cover slip and add drop of oil on the

condenser of dark field microscope and examine the slide immediately.

LYMPH NODE

Lymph nodes commonly affected are inguinal, axillary, cervical,

15

In cases without genital ulcer, lymph node is injected with 0.2

ml of sterile normal saline, then aspiration should be done and aspirated fluid is

examined under dark field microscope for motile treponemes.

GRAM STAIN - To look for gram negative organisms.

TZANCK SMEAR - To look for herpes virus.

TISSUE SMEAR - To look for donovanosis.

SEROLOGICAL TESTS FOR SYPHILIS(14)

NON TREPONEMAL TESTS TREPONEMAL TESTS

Complement fixation

tests(Wasserman reaction)

Flocculation test

-Rapid plasma regain(RPR)

-Venereal Disease Research

Laboratory(VDRL)

-Toluidine Red Unheated Serum

Test(TRUST)

Treponema pallidum immobilization

assay(TPI)

Fluorecent treponemal antibody

absorption(FTA-AbS) test.

Treponema pallidum haemagglutination

assay(TPHA)

Treponema pallidum passive particle

agglutination assay(TPPA)

Enzyme immune assay(EIA)

Western Blot(WB) and Pseudoblots

Automated Chemiluminescence platforms

Chromatographic point of care (POC)tests

16

RAPID PLASMA (15)

The rapid plasma reagin refers to a type of rapid diagnostic test

that looks for non specific antibodies in the blood of patients. The term reagin

means that the test does not look for antibodies against the actual bacterium

but for antibodies against substances released by cells when they are damaged

by Treponema pallidum.

VDRL

Slide Flocculation tests

REQUIREMENTS

1. VDRL antigen (Cardiolipin antigen is an alcoholic solution composed of

0.03% cardiolipin, 0.21% lecithin, 0.9% cholesterol), 0.9% normal

saline, VDRL slide, micropipette.

READING

No Clumps - Non reactive.

Small Clumps - Weakly Reactive.

Medium and large clumps - Strongly reactive.

17

TREPONEMA PALLIDUM HAEMAGGLUTINATION ASSAY (TPHA):

Patient’s Serum + Sheep erythrocytes*

(*Coated with sonically treated T.Pallidum)

Incubate

Agglutination No agglutination

(antibody in serum of patients with syphilis) (no antibody)

Irregular deposition of RBCs in the form of a smooth matt, Clear button type

covering the well. deposit of RBCs.

18

FLUORESCENT TREPONEMAL ANTIBODY ABSORPTION

(FTA-Abs) TEST:

Patient’s serum + sorbent (autoclaved culture of Reiter’s treponeme)

Group reactive antibodies removed

Slide with acetone fixed killed Treponema pallidum

Incubate fluorescein conjugated anti human globulin serum

Dark ground condenser with UV microscope

Antibody to T.pallidum present No antibody to T.pallidum

Fluorescent treponemes No Fluorescent treponemes

19

TREATMENT OF PRIMARY, SECONDARY AND EARLY LATENT

SYPHILIS (15, 16)

RECOMMENDED REGIMEN

- Inj. Benzathine penicillin G 2.4million units intramuscular single dose (1.2

million units deep IM in each buttock) given after testing intradermal

sensitivity for penicillin (or)

Inj.Procaine benzyl penicillin 1.2 million IU daily I.M for 10 days.

All the patients who have syphilis should be tested for HIV infection. If

it is negative, a repeat test should be done after 3 months, especially in areas

where the HIV prevalence is high. Patients with early syphilis who have

features suggestive of meningitis or uveitis should be evaluated for

neurosyphilis.

ALTERNATIVE REGIMEN FOR PENICILLIN ALLERGIC PATIENTS

- Cap. Doxycycline 100mg BD orally for 2weeks (or)

- Tab. Erythromycin 500mg QID orally for 2weeks.

The efficiency of these regimens is not well documented. Hence

frequent follow up of the patients receiving these therapies is essential. The

effectiveness of these therapies in HIV infected patients has not been studied.

Although limited clinical studies suggest that azithromycin and ceftriaxone are

effective in the treatment of syphilis, their use in the clinical practice is yet to

20

FOLLOW UP

EVERY MONTH - FIRST 3 MONTHS.

EVERY 3 MONTH - NEXT 9 MONTHS.

EVERY 6 MONTHS - NEXT 1 YEAR.

There should be fourfold decrease in the non treponemal (VDRL) titre

within 6 months. Patients who have persistent symptoms or recurrence, or who

have four fold increase in the VDRL titre or failure of titre to decline four

fold within 6 months should be re-evaluated for reinfection, treatment failure,

HIV infection or unrecognized CNS infection. All such patients should

undergo a thorough neurological evaluation including CSF analysis and HIV

testing. When they are retreated, they should preferably be given 3 weekly

doses of Inj. Benzathine penicillin G 2.4million units, unless CSF examination

indicates that neurosyphilis is present.

TREATMENT OF LATE LATENT SYPHILIS

All the patients who have latent syphilis should be evaluated for tertiary

syphilis. CSF analysis is clearly indicated if any one of the following criteria is

present.

- CNS or eye changes.

- Evidence of active tertiary syphilis.

- HIV infection.

-Treatment failure.

21

If the CSF analysis shows features of neurosyphilis then the patient

should be treated for the same.

Late latent syphilis should be treated with 3 weekly doses of Inj.

Benzathine Penicillin G 2.4 million units IM after test dose or Inj. Procaine

benzyl penicillin G 1.2 million units IM daily for 20 days.(16)

DOSES IN CHILDREN

Three weekly injection of Benzathine Penicillin G at a dose of 50,000

units per kg body weight upto an adult dose of 2.4million units IM.

FOLLOW-UP

EVERY MONTH - FIRST 3 MONTHS.

EVERY 3 MONTH - NEXT 9 MONTHS.

EVERY 6 MONTHS - NEXT 1 YEAR.

EVERY YEAR - NEXT 3 YEARS.

After treatment, the patient should be re-evaluated for neurosyphilis if

any of the following criteria is present.

- Fourfold increase in the titre of VDRL.

- An initially high VDRL titre(>1.32) failing to decline at least fourfold

within 12-24 months of therapy.

22

ALTERNATIVE REGIMENS FOR PENICILLIN ALLERGIC

PATIENTS

- Cap.Doxycycline 100mg orally BD for 30days or

- Tab. Erythromycin 500mg orally QID for 30days

TREATMENT OF TERTIARY SYPHILIS (GUMMA AND

CARDIOVASCULAR SYPHILIS)

Three weekly doses of Inj. Benzathine Penicillin G 2.4 million units

deep i.m after test dose.

TREATMENT OF NEUROSYPHILIS

Patients with neurosyphilis or syphilitic eye disease in the form of

neuroretinitis, optic neuritis, uveitis or any other cranial nerve palsies should

have CSF examination and be treated with Aqueous crystalline penicillin G

18-24 million units per day administered as 3-4million units IV every 4hours or

continuous infusion for 10to 14 days.

Benzathine penicillin G has no role in the treatment of neurosyphilis as

it does not cross the blood barrier in sufficient quantity.

FOLLOW UP

CSF should be re-examined every 6 months until it becomes normal.

CSF cell count should become normal by 6 months and CSF VDRL and

23

MANAGEMENT OF SEX PARTNERS

The sex partners should be evaluated clinically and serologically and

treated according to the following recommendations.

1. Persons who are exposed within the 90 days preceding the diagnosis of

primary, secondary or early latent syphilis in a sex partner might be

infected even if seronegative; therefore such persons should be treated

with epidose of Inj. Benzathine penicillin 2.4 million units deep i.m

after test dose (single dose).

2. Persons who were exposed >90 days before the diagnosis of primary,

secondary or early latent syphilis in a sex partner should be treated

presumptively if serologic test results are not available immediately and

the opportunity for follow up is uncertain.

3. For purpose of partner notification and presumptive treatment of

exposed sex partners, patients with syphilis of unknown duration who

have high non treponemal serological test titre(>1.32) can be assumed

to have early syphilis. However serologic titre should not be used to

differentiate early from late latent syphilis for the purpose of

determining treatment.

4. Long term sex partners of patients who have latent syphilis should be

evaluated clinically and serologically for syphilis and treated on the

24

ACQUIRED IMMUNE DEFICIENCY SYNDROME

Human immunodeficiency virus (HIV) the aetiological agent

of AIDS belongs to lentivirus, subgroup of the family retroviridae. AIDS was

first reported in the year 1981, a case report of rare disease, pneumocystis

carnii pneumonia and other unusual infections among young homosexual

men. In 1980 Robert Gallo and his colleagues reported the isolation of first

human retro virus which they named Human T cell lymphotropic virus(17)

In 2017, HIV prevalence in India was 0.2 % . Between 2010

and 2017 new infections declined by 27% and AIDS – related deaths more than

halved, falling by 56%. (17)

The three states with the highest HIV prevalence in India are

Manipur, Mizoram and Nagaland. High prevalence districts in Tamil nadu are

Madurai, Chennai, Thiruvallur, Trichy, Tirunelveli, Salem, Coimbatore and

Namakkal. (17)

In 1985, the first commercial ELISA test for the detection of

HIV was developed. In 1986, the first case was detected in Madras Medical

College, Chennai, South India. In 1987, the first drug active against HIV-

Zidovudine was introduced.

HIV 1 is related to virus found in chimpanzee. HIV 2 virus is

25

HIV 1 is divided into 3 groups.

M Group (major) - Most common worldwide.

Subtypes are A, B, C, D, F, G, H, J, K. Different subtypes can combine genetic

material to form a hybrid virus known as circulating recombinant

forms(CRF). Around 89 CRF exist.

N Group (non-M, non-O ) - 20 Group N infections have been recorded.

O Group (Outlier group) - Not usually seen outside of west central

Africa.

WHO CLINICAL DEFINITION

In Africa, AIDS cases reporting is largely based on the WHO clinical

BANGUI definition. Using this definition AIDS in an adult is defined by the

existence of atleast 2 of the major signs associated with atleast 1 minor sign, in

the absence of major causes of immune suppression such as cancer or severe

malnutrition or recognized aetiologies.

MAJOR SIGNS

a. Weight loss >10% of body weight.

b. Chronic diarrhoea >1 month.

26

MINOR SIGNS

a. Persistent cough for more than one month.

b. Generalized pruritic dermatitis.

c. Recurrent Herpes zoster.

d. Oropharyngeal candidiasis.

e. Chronic progressive and disseminated Herpes simplex infection.

f. Generalized lymphadenopathy.

WHO CLINICAL STAGING

PRIMARY HIV INFECTION

Asymptomatic

Acute retroviral syndrome

STAGE 1

Asymptomatic

Persistent generalized lymphadenopathy

STAGE 2

Unexplained weight loss( less than 10% presumed body weight).

Recurrent respiratory tract infection

27

Herpes zoster

Recurrent oral ulceration

Papular pruritic eruptions

Seborrheic dermatitis

STAGE 3

Unexplained weight loss( greater than 10%)

Chronic diarrhoea > 1 month

Unexplained fever > 1 month

Persistant oral candidiasis

Oral hairy leukoplakia

Pulmonray Tuberculosis( CURRENT)

Unexplained anaemia, neutropenia, thrombocytopenia

STAGE 4

HIV wasting syndrome

Pneumocystic Carinii Pneumonia

Severe bacterial pneumonia

Chronic herpes infection

Oesophageal candidiasis

Kaposi sarcoma

CMV infection

28

Disseminated mycosis

HIV encephalopathy.

DIAGNOSIS OF HIV

Direct predictors of HIV

1.Antibody detection.

2.Antigen detection :p24 antigen.

3. Detection of viral nucleic acid.

4.Virus isolation.

Indirect predictors of HIV

1.Total and differential leukocyte count

2. T- lymphocyte subset assays.

3. Platelet count.

4. IgG and IgA levels.

5.Skin test for CMI.

SCREENING TEST

ELISA AND RAPID TEST

ENZYME LINKED IMMUNOSORBENT ASSAY (ELISA) (18)

It detects IgG and uses indirect, sandwich, or competitive

methodologies. Serological test for the detection of HIV are classified as first

to fourth generation test based on the type of antigens used and the principle of

29

GENERATION ANTIGENS COMMENTS

FIRST Antigens from HIV lysates. Lack of sensitivity and

specificity.

SECOND Recombinant proteins and or

synthetic peptides.

Improved sensitivity.

THIRD Recombinant proteins and or

synthetic peptides in an antigen

sandwich configuration.

Very high

sensitivity;reduces window

period;detects HIV 1 and

HIV 2 separately.

FOURTH Detection of both HIV antigens

and antibodies .

Further reducing the

window periods.

FALSE POSITIVE

Autoimmune diseases

Alcoholic hepatitis

Primary biliary cirrhosis

Leprosy

30

FALSE NEGATIVE

Technical error.

Window period

RAPID TEST

NACO recommends the use of rapid test kits which detects >99.5% of

all HIV infected individuals and have false positive results < 2% of all

those who are tested.

TYPES

Immunoconcentration (Vertical flow).

Agglutination assay.

Immunochromatographic assay.

Dipstick comb assay on Enzyme immune assay.

Enzyme linked immunosorbent assay

MOLECULAR ANALYSIS (18)

Nucleic acid amplification test (NAAT) includes test for the

qualitative detection of HIV 1 DNA or RNA as well as quantitative detection

of HIV 1 RNA through various assays. Though positive NAAT result confirm

HIV diagnosis, the NAAT result may turn out negative if tested within 7 to 10

days of exposure. NACO does not recommend the use of NAAT during acute

31

QUALITATIVE PCR FOR HIV DNA

In infants the sensitivity for detection of HIV DNA is 100 % at

4 to 6 weeks of age.

QUALITATIVE TRANSCRIPTION MEDIATED AMPLIFICATION

FOR HIV-1 RNA

Sensitivity is 100% at 6 to 12 weeks of age.

p24 Antigen(16,18)

The HIV p24 antigen is present as either an immune complex,

with anti p24 antibodies or as free p24 antigen in the blood of infected

individuals. The positive p24 test confirms diagnosis of HIV infection. p24

antigen increases to detectable levels between 1 and 3 weeks after HIV

infection. However negative test does not rules out HIV infection. This test is

based on ELISA.

SYPHILIS AND HIV CO-INFECTION

The interaction between syphilis and HIV co infection is complex and

remained incompletely understood despite there being more than 2 decades of

clinical experience with co-infected patients. The increase in the rate of

syphilis and other sexually transmitted diseases among MSM represent a

32

PATHOGENESIS

Effect of syphilis over HIV(19)

1. Syphilitic genital ulcers are cofactors for the bidirectional transmission of

HIV.

2. Virulent Treponema pallidum and /or its abundant membrane lipoproteins

(NTP 47) induce HIV-1 gene expression and production in chronically

infected macrophages via NF-kB activation, leading to the progression of HIV

infection.

3. Syphilis causes transient increase in viral load and decrease in CD4 cell

count but that recedes after infection is treated. The transient increase in viral

load constitute to the increased rise of HIV transmission among patients with

concordant HIV infection and syphilis.

EFFECT OF HIV OVER SYPHILIS.(19)

1. HIV infection reduces the immunologic responses to treponemal infection,

both cell-mediated and humoral immunity, which impairs the host defence

against syphilis and facilitate its progression.

2.Transient immunosuppression during the early stage of syphilis has a

similar effect on host defences against HIV, leading to a synergistic

immunosuppressive state as manifested by a decrease invitro lymphocyte

33

CLINICAL PRESENTATIONS

1. Despite minor difference, syphilis presents similarly in HIV infected and

HIV uninfected patients.

2. In primary syphilis, HIV infected patients may present with multiple

chancre and with larger and deeper lesions.

3. Rapid progression from primary to secondary stage of syphilis.

Approximately one fourth of HIV infected patients presents with concomitant

lesions of both primary and secondary stage of syphilis at time of diagnosis.

4. In secondary stage papular or nodular eruptions, nodulo ulcerative lesions

with necrotic centre(LUES MALIGNA). These skin lesions have been

characterized as more aggressive forms of secondary syphilis in HIV infected

persons.

5. NEUROSYPHILIS IN HIV (20)

Approximately 35% of persons with secondary syphilis have

asymptomatic CNS involvement. Most cases of symptomatic neurosyphilis

reported among HIV infected persons are acute syphilitic meningitis and

meningovascular neurosyphilis.

A case report of medial medullary syndrome with neurovascular

34

reported in a HIV infected workers who had been exposed 7years earlier.

Other cases of syphilitic meningomyelitic with sporadic parapareisis,

syphilitic poyradiculopathy with progressive leg pain and weakness are also

reported.

Ocular and otolgic complications have been reported widely. The most

common ocular finding in patients with concurrent HIV infection is retinitis

followed by uveitis, chorioretinitis, retro bulbar neuritis, papillitis and optic

neuronitis.

Otolgic syphilis- sensorineural hearing loss, tinnitus, imbalance.

The diagnosis of syphilis may be more complicated in HIV infected

patients because of false positive and false negative serological results for

Treponema pallidum and atypical clinical presentation in HIV.

CSF WBC may be elevated due to opportunistic infection or unknown

cause. CSF WBC>20 is sensitive and specific criteria for neurosyphilis in such

situations. Currently CDC does not recommend CSF examination in early

syphilis who have no CNS symptoms.

TREATMENT OF SYPHILIS AND HIV CO- INFECTION

Primary, secondary, Early latent syphilis

35

FOLLOW UP

Clinical and serological follow up are done at 3, 6, 12, 24 months. CSF

examination and retreatment with 3 weekly doses of Inj. Benzathine penicillin

G are recommended in patients whose non treponemal titre do not fall

fourfold within 6-12 months of therapy.

LATE LATENT SYPHILIS

Patients with late latent syphilis or syphilis of unknown duration should

undergo CSF examination. If it is normal then 3 weekly doses of Inj.

Benzathine penicillin G 2.4 million units is given. If there are CSF

abnormalities then they are treated as neurosyphilis.(16)

FOLLOW UP

Clinical and serological examination are repeated at 6, 12, 18, 24

36

TREATMENT OF NEUROSYPHILIS (16)

Intravenous administration of Aqueous crystalline penicillin G at a

dose of 18 – 24 million units daily for 14 days. Alternatively procaine

penicillin G is given at a dose of 2.4 million units IM daily for 14 days along

with probenecid 500 mg QID for 14 days.(16)

FOLLOW UP

CSF examination should be done at 6 month interval until CSF is

normal and reassessment of CSF should be undertaken when neurosyphilis is

37

AIMS AND OBJECTIVES

1. To study the socio demographic patterns and the risk factors involved in

transmission of syphilis.

2. To analyse the clinical presentations of syphilis in presence of

HIV/AIDS .

3. To analyse the serological variations of syphilis in presence of

38

MATERIALS AND METHODS

STUDY DESIGN

Prospective study

STUDY PERIOD

One year ( June 2017 – May 2018).

SAMPLE

Patients attending for self screening and high risk groups in Out Patient

Department, Institute of Venereology, Madras Medical College/RGGGH,

Chennai – 600003.

INCLUSION CRITERIA.

1. Those who are willing to participate in the study.

2. Age >12 years and <60 years.

3. High Risk groups like Homosexuals, IV drug abuse, recepients of blood

and blood products.

EXCLUSION CRITERIA

1. Patients who refuse to participate in the study.

39

METHODOLOGY (MATERIALS AND METHODS)

Detailed clinical history including presenting complaints, sexual

history, past history of Ano-genital disease and any treatment taken would be

elicited. All the participants should undergo complete genital and physical

examination.

In both male and patients presenting with genital ulcer, microscopic

examination of smear from ulcers will be done with dark field microscopy,

gram staining and leishman stains, Tzanck and Tissue smear. In case of

genital discharge, in male patients – gram stain smear for gonococci, normal

saline and potassium hydroxide wet mount would done. In females,

endocervical swab for gonococcus culture and endocervical smear for gram

stain will be done. Smears from vagina for gram staining, normal saline and

potassium hydroxide wet mount will be taken.

Routine Laboratory tests and serological investigations will be done for

all participants. Screening test for syphilis will be done by VDRL and

confirmed by Treponema pallidum hemagglutination assay (TPHA). ELISA

for HIV-1 and 2 ANTIBODY ASSAY will be done after informed consent and

40

RESULTS

Table 1: PREVALENCE OF HIV POSITIVE AMONG STD

ATTENDEES DURING STUDY PERIOD

SEX

STD ATTENDEES

(NUMBERS)

HIV POSITIVE (NUMBERS)

PREVALENCE (%)

MALE 8870 138 1.6 %

FEMALE 5593 82 1.5 %

TOTAL 14463 220 1.5 %

Prevalence of HIV positive among STD attendees during study period was

estimated at 1.5 %.

8870 5593 138 82 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 Male Female Number   of   patients Sex

Prevalence

of

HIV

among

total

STD

attendees

41 14463 187 0 2000 4000 6000 8000 10000 12000 14000 16000 Prevalence Number   of   patients

Prevalence

of

syphilis

among

STD

attendees

STD attenders Syphilis postive

Table 2: PREVALENCE OF SYPHILIS AMONG GENERAL STD

ATTENDEES

STD ATTENDEES (NUMBERS)

SYPHILIS ALONE POSITIVE

PREVALENCE OF SYPHILIS (%)

14463 187 1.29%

The prevalence of syphilis among STD attendees during the study period was

42

Table 3: PREVALENCE OF SYPHILIS AMONG HIV POSITIVE

INDIVIDUALS

Total HIV POSITIVE HIV AND SYPHILIS

COINFECTION

PREVALENCE OF

SYPHILIS AMONG

HIV POSITIVE

INDIVIDUALS (%)

220 37 16.8%

The prevalence of syphilis among HIV infected individuals during the

43 220

37

0 50 100 150 200 250

Prevalence

Number

of

patients

Prevalence

of

HIV

and

syphilis

coinfection

among

STD

attendees

44

Table 4(a): AGE WISE DISTRIBUTION OF HIV POSITIVE

PATIENTS VS HIV AND SYPHILIS COINFECTED PATIENTS

(MALES INCLUDING TRANSGENDER).

AGE GROUP (IN YEARS)

HIV – POSITIVE

SYPHILIS NEGATIVE

(n-113)

HIV AND SYPHILIS

(n-25)

NUMBERS PERCENTAGE

(%) NUMBERS

PERCENTAGE (%)

11-20 3 3 1 4

21-30 32 28 10 40

31-40 40 35 8 32

41-50 20 17 5 20

>50 18 15 1 4

The prevalence of HIV infection and HIV and syphilis coinfection

45 3 32 40 20 18 1 10 8 5 1 0 5 10 15 20 25 30 35 40 45

11‐20 21‐30 31‐40 41‐50 >50

Number   of   male   patients

Age group

Age

distribution(Males)

46

Table 4(b): AGE WISE DISTRIBUTION OF HIV POSITIVE

PATIENTS VS HIV AND SYPHILIS COINFECTED PATIENTS

(FEMALES).

AGE GROUP (IN YEARS)

HIV – POSITIVE

SYPHILIS NEGATIVE

(n-70)

HIV AND SYPHILIS

(n-12)

NUMBERS PERCENTAGE

(%) NUMBERS

PERCENTAGE (%)

11-20 2 3 1 8

21-30 9 13 3 25

31-40 34 48 6 50

41-50 20 29 2 17

>50 5 7 0 0

The prevalence of HIV infection and HIV and syphilis coinfection

47 2 9 34 20 5 1 3 6 2 0 0 5 10 15 20 25 30 35 40

11‐20 21‐30 31‐40 41‐50 >50

Number   of   female   patients

Age group

Age

distribution(Females)

48

Table 5: PREVALENCE OF SYPHILIS AMONG HIV POSITIVE

INDIVIDUALS

Analysis of sex distribution revealed that males have higher prevalence

(18.11%) of HIV and syphilis coinfection.

138 82 25 12 0 20 40 60 80 100 120 140 160 Male Female Number   of   pa tien ts Sex

Sex

distribution

HIV positive HIV and syphilis coinfection

SEX TOTAL HIV POSITIVE (NUMBERS)

HIV AND SYPHILIS COINFECTION (NUMBERS) PREVALENCE OF SYPHILIS AND HIV COINFECTION (%)

MALE 138 25 18.11%

FEMALE 82 12 14.63%

49

Table 6(a): MARITAL STATUS OF HIV AND SYPHILIS

COINFECTED MALE PATIENTS

MARITAL STATUS HIV AND SYPHILIS COINFECTION _(N-25)

NUMBERS PERCENTAGE (%)

MARRIED 13 52 %

SINGLE 12 48 %

Majority of males with HIV and syphilis coinfection were

50 13

12

11.4 11.6 11.8 12 12.2 12.4 12.6 12.8 13 13.2

Married Single

Number

of

male

patients

Marital history

51

Table 6(b): MARITAL STATUS OF HIV AND SYPHILIS

COINFECTED FEMALE PATIENTS.

MARITAL STATUS

HIV AND SYPHILIS COINFECTED FEMALES

(N-12)

NUMBERS PERCENTAGE (%)

MARRIED 6 50 %

SINGLE 1 8 %

WIDOWED 1 8 %

SEPARATED 4 33 %

Majority of HIV positive females were married(50%), though a

significant number were either separated from their husband (33%) or

52 6

1 1

4

0 1 2 3 4 5 6 7

Married Single Widowed Separated

Number

of

female

patients

Marital history

53

Table 7(a): SEXUAL BEHAVIOUR OF HIV AND SYPHILIS

COINFECTED MALE PATIENTS

SEXUAL BEHAVIOR HIV AND SYPHILIS

COINFECTED MALE PATIENTS NUMBERS PERCENTAGE

(%)

HETEROSEXUAL 9 36

BISEXUAL 4 16

HOMOSEXUAL 12 48

Majority of males were promiscuous and failed to use condoms. Most

of them were homosexual (48%).

9

4

12

0 2 4 6 8 10 12 14

Heterosexual Bisexual Homosexual

Number

54

Table 7(b): SEXUAL BEHAVIOUR OF HIV AND SYPHILIS

COINFECTED FEMALE PATIENTS

SEXUAL BEHAVIOUR HIV AND SYPHILIS

COINFECTED FEMALE

PATIENTS

NUMBERS PERCENTAGE

(%)

55

Table 8(a): DOMICILE OF HIV POSITIVE VS HIV AND SYPHILIS

COINFECTED MALE PATIENTS

48 65 9 16 0 10 20 30 40 50 60 70 Rural Urban Number   of   male   patients Domicile

Domicile

vs

Infection

HIV positive HIV and syphilis coinfection

DOMICILE HIV-POSITIVE

(N-113)

HIV AND SYPHILIS

COINFECTION (N-25) NUMBERS PERCENTAGE (%) NUMBERS PERCENTAGE (%)

RURAL 48 42 9 36

56

Table 8(b): DOMICILE OF HIV POSITIVE VS HIV AND SYPHILIS

COINFECTED FEMALE PATIENTS.

65% of both HIV positive Vs HIV and syphilis coinfected males and

females hailed from urban areas.

25 45 4 8 0 5 10 15 20 25 30 35 40 45 50 Rural Urban Number   of   female   patients Domicile

Domicile

vs

Infection

HIV positive HIV and syphilis coinfection

DOMICILE HIV-POSITIVE

(N-70)

HIV AND SYPHILIS

COINFECTION (N-12) NUMBERS PERCENTAGE (%) NUMBERS PERCENTAGE (%)

RURAL 25 36 4 33

57

Table 9(a): OCCUPATION OF HIV AND SYPHILIS COINFECTED

MALE PATIENTS.

OCCUPATION HIV AND SYPHILIS

COINFECTED MALE

PATIENTS

(N-25)

NUMBERS PERCENTAGE

(%)

Agriculture 2 8

Coolie 5 20

Private company

(Graduates- B.A, B.Com, B.Sc)

9 36

Electrician 3 12

Barber 2 8

Driver 2 8

MSM sex worker 1 4

Painter 1 4

A significant number of HIV and syphilis coinfected males were

working in private company (36%), remaining patients (Agriculture, coolie,

58 2

5

9

3

2 2

1 1

0 1 2 3 4 5 6 7 8 9 10

Number

of

male

patients

Occupation

59

Table 9(b): OCCUPATION OF HIV AND SYPHILIS COINFECTED

FEMALE PATIENTS

OCCUPATION HIV AND SYPHILIS

COINFECTED FEMALE

PATIENTS

(N-12)

NUMBERS PERCENTAGE

(%)

Agriculture 2 17

Coolie 2 17

Private company

(Graduates -B.A, B.Com, B.Sc)

4 33

House wife 2 17

House keeping 1 8

Commercial Sex Worker(CSW) 1 8

A significant number of HIV and syphilis coinfected females were

working in private company(33%), remaining patients (Agriculture, coolie)

60 2 2 4 2 1 1 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Agriculture Coolie Private 

company

Housewife House 

keeping CSW Number   of   female   patients Occupation

61

Table 10(a): PRESENTING COMPLAINTS OF HIV AND SYPHILIS

COINFECTED MALE PATIENTS.

COMPLAINTS HIV AND SYPHILIS

COINFECTED MALE

PATIENTS

(N-25)

NUMBERS PERCENTAGE

(%)

Self screening 8 32

Urethral Discharge 1 4

Genital ulcer 4 16

Genital wart 2 8

Skin rash 5 20

Constitutional symptoms like Fever,Cough

Loss of weight and appetite –private

referral

4 16

Genital itching 1 4

A significant number of HIV and syphilis coinfected positive males

(32%) had come for self screening. Among symptomatic, significant number

62 8

1

4

2

1

5

4

0 1 2 3 4 5 6 7 8 9

Number

of

male

patients

Presenting complaints

63

Table 10(b): PRESENTING COMPLAINTS OF HIV AND SYPHILIS

COINFECTED FEMALE PATIENTS.

COMPLAINTS HIV AND SYPHILIS

COINFECTED FEMALE

PATIENTS

(N-12)

NUMBERS PERCENTAGE

(%)

Self screening 5 42

Genital Discharge 2 17

Genital ulcer 1 8

Skin rash 1 8

Constitutional symptoms like Fever,Cough

Loss of weight and appetite –private

referral

3 25

A significant number of HIV and syphilis coinfected positive females

(42%) had come for routine screening. Among symptomatic, significant

64 5

2

1 1

3

0 1 2 3 4 5 6

Self checkup Discharge Genital ulcer Skin rash Constitutional 

symptoms

Number

of

female

patients

Presenting complaints

65

Table 11(a): ASSOCIATED DISEASES OF HIV AND SYPHILIS

COINFECTED MALE PATIENTS.

DISEASE HIV AND SYPHILIS COINFECTED

MALE PATIENTS

(N-25)

NUMBERS PERCENTAGE (%)

Gonorrhoea 2 8

Genital Herpes 4 16

Genital wart 3 12

Genital scabies 1 4

Genital molluscum contagiosum 1 4

Oral candidiasis 3 12

Dermatophytosis 4 16

Tuberculosis 1 4

No other associated diseases 6 24

Genital herpes (16%) was the most common associated STD among

the HIV and syphilis coinfected male patients. Concomitant infection with

various STD’S like warts (12%), gonorrhoea(8%) and non venereal conditions

66 2

4

3

1 1

3

4

1

6

0 1 2 3 4 5 6 7

Number

of

male

patients

Associated diseases

67

Table 11(b): ASSOCIATED DISEASES OF HIV AND SYPHILIS

COINFECTED FEMALE PATIENTS.

DISEASE

HIV AND SYPHILIS COINFECTED FEMALE PATIENTS

(N-12)

NUMBERS PERCENTAGE (%)

Bacterial vaginosis 1 8

Vulvo vaginal candidiasis 3 25

Trichomonas vaginitis 1 8

Genital wart 1 8

Dermatophytosis 2 17

Tuberculosis 1 8

No other associated diseases 3 25

Vulvo vaginal candidiasis (25%) was the most common associated STD

among the HIV and syphilis coinfected female patients. Concomitant

infection with various STD’S like Genital warts(8%), Bacterial vaginosis(8%)

and non venereal conditions like dermatophytosis, Tuberculosis were

68

1

3

1 1

2

1

3

0 0.5 1 1.5 2 2.5 3 3.5

Number

of

female

patients

Associated diseases

69

Table 12(a): PREVALENCE - STAGE OF SYPHILIS AMONG HIV

POSITIVE MALE PATIENTS.

STAGE OF SYPHILIS

HIV AND SYPHILIS COINFECTED MALE PATIENTS

(N -25)

NUMBERS PERCENTAGE (%)

Primary syphilis 3 12

Secondary syphilis 8 32

Early latent syphilis 6 24

Late latent syphilis 7 28

Cardiovascular syphilis 1 4

Neuro syphilis 0 0

In our study, most of the HIV infected male syphilitic patients

presented with early syphilis manifestations (68%) [Primary syphilis (No 3,

12%), Secondary syphilis (No 8, 32%), Early Latent syphilis (No-6, 24%),

70

3

8

6

7

1

0 0

1 2 3 4 5 6 7 8 9

Number

of

patients

Stages of syphilis

71

Table 12(b) : PREVALENCE - STAGE OF SYPHILIS AMONG HIV

POSITIVE FEMALE PATIENTS.

STAGE OF SYPHILIS

HIV AND SYPHILIS COINFECTED FEMALE PATIENTS

(N -12)

NUMBERS PERCENTAGE (%)

Primary syphilis 0 0

Secondary syphilis 6 50

Early latent syphilis 4 33

Late latent syphilis 2 16

Cardiovascular syphilis 0 0

Neuro syphilis 0 0

In our study, most of the HIV infected female syphilitic patients

presented with early syphilis manifestations (83%) [Primary syphilis (No 0),

Secondary syphilis (No 6, 50%), Early Latent syphilis (No-4, 33%), Late

72 0

6

4

2

0 0

0 1 2 3 4 5 6 7

Number

of

patients

Stages of syphilis

73 420 246 512 633 589 0 100 200 300 400 500 600 700

Primary  Secondary Early latent 

syphilis

late latent 

syphilis Cardiovascular  syphilis Average   CD4   count

Stages of syphilis

CD4

count

Table 13 : AVERAGE CD4 COUNT IN HIV AND SYPHILIS

COINFECTION.

STAGE OF SYPHILIS AVERAGE CD4 COUNT

Primary syphilis 420

Secondary syphilis 246

Early latent syphilis 512

Late latent syphilis 633

Cardiovascular syphilis 589

Average CD4 count among study population was lowest

(246 cells/cumm) in patients presenting with secondary syphilis

74

Table 14: VDRL REACTIVITY IN HIV SEROPOSITIVE PATIENTS

STAGE VDRL TITRE AVERAGE

VDRL TITRE

<1:8 >1:8 to <1:64 >1:64

PRIMARY 2 1 - 9.33(N-3)

SECONDARY 1 6 7 74(N-14)

EARLY LATENT SYPHILIS

4 7 - 27.27(N-11)

LATE LATENT SYPHILIS

7 1 - 2.75(N-8)

CARDIOVASCULAR SYPHILIS

1 - - 1 (N-1)

Lowest VDRL titre =1:4

Highest VDRL titre =1:256

2 1 4 7 1 1 6 7 1 0 7 0 0 0 1 2 3 4 5 6 7 8

Primary  Secondary Early latent 

syphilis

late latent syphilis CardioVascular 

Syphilis Number   of   individuals

Stages of syphilis

VDRL

reactivity

75

DISCUSSION

In India there is a strong epidemiological association between HIV

infection and syphilis. Both diseases are predominantly sexually transmitted

and syphilis patients are at increased risk for HIV infection. This study is

designed to know the prevalence of syphilis, its clinical presentations,

serological variations, therapeutic response to standard therapy in presence of

HIV infection.

The prevalence of HIV among STD attendees in this study was 1.5%

comparitevely higher than that in a study conducted by Fabiola Mesqita

callegari, Lauro Ferreira, et al., in the year 2015 where HIV prevalence among

adults in general population was 0.6%. (21)

The prevalence of syphilis infection among STD attendees in our

study was 1.29% which was somewhat lower than that observed in a study

by Signorini DJ, Monteiromc, et al., in the year 2005 was 2.7%.( 22)

In our study prevalence of syphilis in HIV infected individuals was

16.8%, whereas in a study conducted by Adolf R, Bercht F, Aronis ML, et

al., in the year 2012 the similar result (2.7% -24.4%) was obtained. (23)

Majority of patients (70%) in our study were in sexually active age

group of 20 -40 years and Mean age for Syphilis and HIV coinfected males

76

obtained in a study conducted by Joseph Forbi, et al., where the mean age of

HIV and syphilis coinfected males was 41.3 years against 30.4 years for

females. (24)

Prevalence of HIV and syphilis coinfection were higher in males

(18.11%) than females (14.63%).

It was observed that 65% of both HIV positive Vs HIV and syphilis

coinfected males and females hailed from urban areas. This indicates that

the prevalence of HIV and syphilis was higher in cities with larger floating

populations and in more developed cities. Similar results were observed in a

previous study conducted by Pan X , Zhu Y, Wang Q, et al., where 75% of

cases reported from urban areas..(25)

35% of HIV and syphilis coinfected patients hailed from rural areas.

This indicates that HIV population has also infiltrated into the rural

population.

This study found that 48 % of HIV and syphilis coinfection occurs in

patients with sexual behavior of Men sex with Men(MSM). Similar results

(54%) were obtained in a study by Wenjie Dai, Zhenzhou Luo, et al. in the year

2017. (26)

Majority of males and females with HIV and syphilis coinfection

77

from their husband (33%) or widowed (8%). This implies that the spouses of

infected persons are susceptible to acquire infection from their partners.

Majority of males were promiscus and failed to use contraceptives.

A significant number of HIV and syphilis coinfected males and females

were working in private company (35%) and Commercial sex worker(CSW)

accounts for (8%) but in a study conducted by Mwumvaneza Mutagoma,

Laetia Nyirazinyoye, et al., showed that higher prevalence among lower

socioeconomic status. (27)

Our study revealed that higher prevalence concentrated among urban

population and educated persons due to increased chance of contacts, high

risk sexual behaviours and increased Men having sex with Men. Sex

education, contraceptive methods have to be reach both urban and rural areas.

Among symptomatic males, significant number of patients account for