Vol. 17, No. 42
THE JOHNS HOPKINS MICROBIOLOGY NEWSLETTER
Monday, November 16, 1998
Outbreaks reported to DHMH by local health depts. for 11/9/98-11/13/98:
6 foodborne gastroenteritis associated with commercial food service facilities, 1 gastroenteritis in an assisted living facility, 1 pneumonia/acute respiratory infection in an assisted living facility, 1 foodborne gastroenteritis in a food service facility, 1 influenza-like illness in an assisted living facility
Clinical History: A 52 year old African-American male came into the clinic complaining of a four day history of "blurry" vision in his left eye. He denied fevers, chills, nausea, vomiting, and diarrhea. He also denied having a stiff neck, low pain or photophobia. He had no recent trauma and no previous history of eye problems. Past medical history was significant for diabetes mellitus controlled by diet. He was on no medications, had no allergies, and denied drug and alcohol use. Ophthalmologic examination showed left conjunctival injection, trace macular edema, and "cells" in the anterior chamber. Visual acuity was 20/100 in the left eye and 20/20 in the right eye.
Laboratory Diagnosis: Serologic testing was positive for Human Immunodeficiency Virus (HIV), Venereal Disease Research Laboratory (VDRL) reagin test and Rapid plasma reagin (RPR) card test. Both the VDRL and RPR are nonspecific treponemal tests which are inexpensive, rapid, and convenient for screening large number of patients for syphilis. Because false-positive VDRL and RPR's commonly occur whenever there is a strong immunologic stimulus such as HIV infection, a specific treponemal test, the Fluorescent antibody adsorbed test (FTA-abs), was performed which confirmed the diagnosis of syphilitic uveitis.
Discussion: Syphilis is a complex systemic illness caused by the spirochete Treponema pallidum spp. pallidum. The organism is slender, tightly coiled, and moves with a drifting rotary motion causing the characteristic undulating movement seen on direct examination with darkfield microscopy. The organism is usually spread through sexual contact after penetrating intact mucous membranes or abraded skin. It then enters the blood stream and disseminates throughout the body where it can invade virtually any organ in the body including the central nervous system (CNS). Clinically, syphilis is divided into primary, secondary, latent and late stages. The primary stage refers to the development of the primary lesion known as a chancre which become evident 2 to 12 weeks after contact, include a skin rash, mucocutaneous lesions, condyloma lata, generalized lymphadenopathy, and constitutional or flu-like symptoms.
Late syphilis, often referred to as neurosyphilis or cardiovascular syphilis, is a slowly progressive inflammatory disease than can affect any organ and can produce clinical illness several years after the initial infection. Patients with concomitant HIV and syphilis infections often present with a more protracted and malignant course with greater constitutional symptoms, atypical rashes, and have a significant predisposition to develop neurosyphilis, especially uveitis. Treatment with Benzathine penicillin G intramuscularly for 2 or 3 doses is highly efficacious for patients with early primary or secondary syphilis. However, in HIV patients a more vigorous or prolonged course of therapy often in conjunction with oral antibiotics is recommended in addition to aggressive serologic follow-up detect persistent infections.
Epidemiology: Historically the number of new cases of syphilis reached its peak in the United States during World War II then declined rapidly after the introduction of penicillin therapy and broad-based public health programs, to its nadir in the 1950's. In 1960 the syphilis rates began to increase and have remained relatively stable up until 1986. During 1986-1990 there was a dramatic increase in the number of syphilis cases occurring primarily among heterosexuals. The epidemic was thought to be due to the exchange of sex for drugs, especially crack cocaine. Since 1991, however, syphilis rates have begun to decline again and there was an 83% reduction in cases from the peak of 20.3 per 100,000 people in 1990 and 3.2 per 100,000 in 1997. Maryland's syphilis rate, however, is more than five times the national average according to the Center for Disease Control (CDC). According to the CDC the rate of new cases in the state of Maryland during 1997 was 17.6 per 100,000 blacks contracting the disease compared to 0.5 of every 100,000 whites and 1.6 per 100,000 Hispanics. Maryland's population is about 25% black, according to the 1990 U.S. Census. In January of 1998 Baltimore officials announced that city, state and federal funds will be appropriated to help hire more doctors, nurses, and assistants in order to fight the city's syphilis problem. Dr. Peter Beilenson, the head of Baltimore's health department, stated recently in an article in The Baltimore Sun that are numbers of those infected with syphilis has been dropping for the past three quarters suggesting that efforts for disease prevention and treatment have been working.
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