|Year : 2022 | Volume
| Issue : 3 | Page : 169-173
A retrospective study on seroprevalence and clinical spectrum of syphilis from a tertiary care center in South India
Ananya B Reddy, Malcolm Pinto, Spandana Prakash Hegde, Amina Asfiya M. Iqbal, Vishal Bejai, M Manjunath Shenoy
Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College, Yenepoya (Deemed to be University), Mangalore, Karnataka, India
|Date of Submission||02-Jun-2021|
|Date of Decision||20-Dec-2021|
|Date of Acceptance||21-Dec-2021|
|Date of Web Publication||12-Jul-2022|
Dr. M Manjunath Shenoy
Department of Dermatology, Venereology and Leprosy, Yenepoya Medical College Hospital, Yenepoya (Deemed to be University), Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Objectives: Syphilis is a sexually transmitted disease (STD) and a great imitator with a varied range of clinical manifestations. Incidence of syphilis has been on the rise in the last decade. In this study, we have analyzed the seroprevalence and clinical staging of syphilis cases reported in our healthcare facility. Materials and Methods: We conducted a retrospective analysis of syphilis by reviewing data from hospital sources from January 2017 to December 2019. Out of 8827 screened patients, the clinical data from patients who were serologically positive for both rapid plasma reagin and Treponema pallidum hemagglutination tests were retrieved and statistically analyzed. Results: Of the 8827 samples screened, 35 were diagnosed as cases of syphilis. Among 35 cases, primary syphilis was diagnosed in 8, secondary syphilis in 10, and latent syphilis in 17 cases. There were 4 (11.4%) females and 31 (88.6%) males. Twenty-one (60%) were married. Of 31 males, 23 (74.2%) were men who have sex with men (MSM). Among the 35 patients, 33 (94.3%) had unprotected and 2 (5.7%) had protected sexual activity. Out of them, 3 patients were human immunodeficiency virus positive, which included 2 with secondary and 1 with latent syphilis. Conclusion: Identification and health education of MSM, especially with respect to using barrier methods of contraception, are necessary in the prevention of transmission of STDs. With epidemiological trends showing syphilis re-emerging as a major sexually transmitted infection, there is a need to conduct multicenter prospective studies with larger sample size for better understanding and effective assessment of control measures.
Keywords: Rapid plasma reagin, seroprevalence, syphilis, Treponema pallidum hemagglutination
|How to cite this article:|
Reddy AB, Pinto M, Hegde SP, Iqbal AA, Bejai V, Shenoy M M. A retrospective study on seroprevalence and clinical spectrum of syphilis from a tertiary care center in South India. APIK J Int Med 2022;10:169-73
|How to cite this URL:|
Reddy AB, Pinto M, Hegde SP, Iqbal AA, Bejai V, Shenoy M M. A retrospective study on seroprevalence and clinical spectrum of syphilis from a tertiary care center in South India. APIK J Int Med [serial online] 2022 [cited 2022 Aug 11];10:169-73. Available from: https://www.ajim.in/text.asp?2022/10/3/169/350746
| Introduction|| |
Syphilis is a sexually transmitted disease (STD) caused by the spirochete Treponema pallidum. It is often addressed to as the great mimicker in the specialty of medicine and surgery. The disease spectrum of syphilis ranges from the patient being asymptomatic to development of serious complications involving the cardiovascular and central nervous system. Appropriate estimate of the disease burden is severely challenged by sparse availability of data, which is attributable to the poor attendance at the STD clinic due to the stigma attached, lack of inter-department coordination, limited diagnostic facilities, and failure to detect asymptomatic cases. An increased incidence in cases of syphilis has been reported by studies in the last two decades,,,, with an increase in cases among men who have sex with men (MSM).
Information regarding the serological and clinical profile of patients of syphilis from coastal Karnataka has not been extensively studied. Hence, we conducted a retrospective, hospital-based study to evaluate the seroprevalence of syphilis and the associated clinical manifestations from January 2017 to December 2019.
| Materials and Methods|| |
This retrospective study was carried out in a tertiary care teaching hospital in coastal Karnataka from January 2017 to December 2019 after obtaining institutional ethical clearance (YEC2/470/24.08.2020). Data from 8827 patients were screened and those who tested positive for both rapid plasma reagin (RPR) and T. pallidum hemagglutination (TPHA) tests, which are regularly performed in our laboratory for the diagnosis of syphilis, were included for analysis. The various sources of data included those attending STD clinic, referred from integrated counseling and testing center, blood bank, antenatal clinic, and hospital information system records. Clinical records of each patient including epidemiology (age, sex, marital status, educational status, and sexual orientation), occupation, comorbidities, clinical examination (ulcers, lymphadenopathy, morphology of rash, and staging of syphilis), treatment data, and associated STD were retrieved. The patients mainly belonged to the regions of the coastal districts of Karnataka (Dakshina Kannada and Udupi); however, also included are some inhabitants from the other parts of Karnataka and Kerala states. The data were entered in excel sheet and analyzed using SPSS Software version 23 (IBM Corp., N.Y., USA), and the descriptive statistics such as frequency, mean, standard deviation, and other applicable statistical tests were utilized for analyzing the data.
| Results|| |
A total of 8827 cases were screened for syphilis in 3 years. Out of these, 35 patients who were positive for both RPR and TPHA test were included in the study. The RPR titers ranged from 1:2 to 1:128, the most common titer being 1:8 in 10 cases. Seroprevalence of syphilis in our hospital during the study period was 0.0039, and the year-wise distribution of the laboratory test positivity is depicted in [Table 1]. The sociodemographic profile of the patients is represented in [Table 2].
There were 31 (88.6%) males and 4 (11.4%) females, aged 18–71 years, with mean age being 32.8 years. Majority of the patients belonged to the age group between 20 and 29 years, with most of them being graduates. Twenty-one (60%) were married, of whom 17 (81%) had pre or extramarital unprotected contact with known people. MSM accounted for 23 (74.2%) patients with majority of them belonged to the age group of 20–29 years. All the patients who exhibited homosexual behavior gave a history of peno-anal contact, with 2 patients in addition to orogenital contact. Of the 35 patients, 33 (94.3%) had unprotected and 2 (5.7%) had protected sexual activity. The most common presentation of syphilis was latent syphilis in 17 (48.6%) patients, followed by secondary syphilis in 10 (28.6%) and primary syphilis in 8 (22.9%) patients. The year-wise distribution of stages of syphilis is shown in [Table 3].
|Table 3: Percentage of various stages of syphilis from January 2017 to December 2019|
Click here to view
The various clinical presentations of patients with syphilis are summarized in [Table 4].
All the 8 primary syphilis cases manifested with a solitary, painless, indurated ulcer [Figure 1], with 4 patients having bilateral inguinal lymphadenopathy. None of the patients had multiple chancres or co-infections.
Among the secondary syphilis cases, 8 had maculopapular rash and 3 had papulosquamous lesions [Figure 2]a and [Figure 2]b. Five patients manifested with palmoplantar syphilides [Figure 3]. Annular lesion on the face [Figure 4] and moth-eaten alopecia were seen in one patient each. Oral mucosal patch [Figure 5] and generalized lymphadenopathy were present in 4 and 3 patients, respectively. Concomitant presence of primary chancre was not noted in any of the secondary syphilis patients.
|Figure 2: (a) Papulosquamous syphilides on the neck. (b) Papulosquamous syphilides on the trunk|
Click here to view
Three (8.6%) cases were serologically positive for human immunodeficiency virus (HIV) infection. Of the 3 patients, 2 (66.7%) were diagnosed with secondary syphilis and 1 (3.2%) had latent syphilis.
All the patients had received standard care of treatment intramuscular benzathine penicillin as per the 2015 CDC STD treatment guidelines.
| Discussion|| |
The last few decades has witnessed a substantial change in the epidemiological patterns of STD. There has been a shift in the etiological profile of STDs from bacterial to viral infections. Dominance of STDs caused by viral infections may possibly be a result of change in sexual practice and increasing cases of HIV. Although the prevalence of syphilis has been fairly stable, few studies worldwide have reported resurgence of syphilis., Kulkarni et al. have reported a surge in the number of syphilis cases at their center during their study period between 2017 and 2018.
Serological profile of syphilis
Our study observed that the RPR titers ranged from 1:2 to 1:128, with the most common titer being 1:8. Jain et al. have reported 1:1024 as the maximum titer, with 1:16 being the most common titer in their study.
We utilize RPR in conjunction with TPHA test for the definitive diagnosis and case definition of syphilis, thus excluding biologic false-positive (BFP) cases from our study. Previous studies have documented varying rates of BFP reactions. This highlights the need for sequential usage of both nontreponemal and treponemal tests to prevent misdiagnosis, underdiagnosis, or overdiagnosis of syphilis., There are studies that have reported both increase and decrease, in the seroprevalence of syphilis during their study period. In contrast, constant seroprevalence was observed in our study.
Majority of the patients in our study were males and belonged to the age group between 20 and 29 years, which has been observed in few other studies.,,, The presence of high sexual activity in the age group of 20–29 years explains the age distribution. Sociocultural hindrances to visit a hospital and absence of alarming symptoms could explain lower representation of females during data collection.,
Most of our patients were graduates as opposed to a study by Kumarasamy et al. where they observed higher number of patients who completed had primary education. Majority of our patients were employed which is similar to other studies., All of our female patients were home makers which are in consistent with a study by Ray et al. where majority of the female patients were homemakers. In a study by Garg et al., 72% of patients were unmarried with promiscuity in 75% of patients, whereas in our study, 40% were unmarried. Further, majority of the patients exhibited promiscuous behavior. Of the total 35 patients, 33 (94.3%) unprotected and 2 (5.7%) protected sexual activity were reported.
Among 31 male patients, 23 (74.2%) were MSM in contrast to other studies, where they observed in lesser number., Majority of them belonged to the age group between 20 and 29 years, which was similar to a study done by Aggarwal et al. Twelve among these patients were married, and this can be explained by the fact that homosexuality is considered a taboo in our country. Eight (22.8%) of our patients reported of being bisexually oriented, as opposed to 7 and 33 patients in studies by Shah et al. and Aggarwal et al., respectively. In a study carried out in Delhi targeting MSM, anogenital warts (23.08%) was the most common disease reported, followed by syphilis (21.2%). MSM constitute a vulnerable group for transmission of STDs due to factors such as higher frequency of anal intercourse, reduced usage of barrier methods such as condoms, multiple sexual partners, and reluctance to go for regular health assessment due to associated stigma.
Clinical profile of syphilis
All 8 patients with primary syphilis presented with a solitary, indurated hard chancre. Primary syphilis presenting with multiple chancres has been observed in few studies.,, Mixed infections with herpes genitalis and condyloma acuminata in patients with primary syphilis were noted in few studies, which in contrary was absent in ours.,
We observed maculopapular rash to be the most common presentation among secondary syphilis cases which is similar to the studies by Kar and Nishal et al. Concomitant presence of primary chancre was not noted in any of our secondary syphilis patients, in contrast to a study done by Jain et al. where they observed presence of primary chancre in twp patients with secondary syphilis.
Hair involvement in syphilis has not been highlighted in most studies on syphilis, to the best of our knowledge, except for one conducted in Italy where moth-eaten alopecia was detected in 4 cases. One of our patients had moth-eaten alopecia.
The most common stage of presentation in our study was latent syphilis (48.6%). Few studies have shown a rise in the prevalence of syphilis with an increased presentation of latent stage. The presence of asymptomatic lesions, misdiagnosis, or inadequate treatment during the early clinical presentation, extensive use of antimicrobials, and implementation of syndromic approach for management of STDs are the factors responsible for this.,, Secondary (2) and latent (1) syphilis were the most common presentations among patients with HIV co-infection which is consistent with the findings of the study by Sethi et al.
Currently, Centers for Disease Control and Prevention has advocated using the term “syphilis, early nonprimary, nonsecondary” and “syphilis, unknown duration, or late” instead of “early latent syphilis” and “late latent syphilis,” respectively.
Majority of the patients were lost for follow-up, and RPR of the cerebral spinal fluid was not done in latent syphilis patients as a routine. This study may not represent community prevalence of the disease as data were collected from a single center and are not representative of any particular region of India. We have not discussed on the therapy of the cases and the follow-up of clinical and serology since our focus was on the seroprevalence of syphilis. These are also the limitations of the study.
| Conclusion|| |
Our 3-year retrospective hospital-based study observed an increased incidence of latent syphilis with a constant seroprevalence during the study period. It is of paramount importance that health-care providers are trained to improve their skills in diagnosing and treating syphilis. This can be achieved by routine screening of sexually active MSM for syphilis and other STDs. Identification and health education of MSM, especially with respect to using barrier methods of contraception, are necessary as they play a vital role in the transmission and maintenance of STDs in vast number of partners. With epidemiological trends of syphilis as a major sexually transmitted infection, there is a need to conduct multicenter prospective studies with larger sample size for better understanding and effective assessment of control measures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Peeling RW, Mabey D, Kamb ML, Chen XS, Radolf JD, Benzaken AS. Syphilis. Nat Rev Dis Primers 2017;3:17073.
Desai VK, Kosambiya JK, Thakor HG, Umrigar DD, Khandwala BR, Bhuyan KK. Prevalence of sexually transmitted infections and performance of STI syndromes against aetiological diagnosis, in female sex workers of red light area in Surat, India. Sex Transm Infect 2003;79:111-5.
Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S, et al.
Changing trends in sexually transmitted disease in a regional STD centre in North India. Indian J Med Res 2006;124:559-68.
] [Full text]
Schumacher CM, Ellen J, Rompalo AM. Changes in demographics and risk behaviors of persons with early syphilis depending on epidemic phase. Sex Transm Dis 2008;35:190-6.
Raju R, Rajaram M. Resurgence of syphilis in a tertiary care center in South India – A retrospective study. Int J Sci Stud 2018;6:120-3.
Kulkarni V, Parchure R, Darak S. Let's not let the guard down! – Early indications of syphilis resurgence? Indian J Dermatol Venereol Leprol 2019;85:246-7.
] [Full text]
Aggarwal P, Bhattar S, Sahani SK, Bhalla P, Garg VK. Sexually transmitted infections and HIV in self reporting men who have sex with men: A two-year study from India. J Infect Public Health 2016;9:564-70.
Jain A, Mendiratta V, Chander R. Current status of acquired syphilis: A hospital-based 5-year study. Indian J Sex Transm Dis 2012;33:32-4.
] [Full text]
CDC. Sexually Transmitted Disease Surveillance 2018. Atlanta: U.S. Department of Health and Human Services; 2019. Available from: https://www.cdc.gov/std/stats/
. [Last accessed on 2020 Aug 29].
Patwardhan VV, Bhattar S, Bhalla P, Rawat D. Seroprevalence of syphilis by VDRL test and biological false positive reactions in different patient populations: Is it alarming? Our experience from a tertiary care center in India. Indian J Sex Transm Dis 2020;41:43-6. [Full text]
Tankhiwale SS, Naikwade SR. Seroprevalence of syphilis and biologically false positive cases in a tertiary care center. Indian J Dermatol Venereol Leprol 2014;80:340-1.
] [Full text]
Sethi S, Mewara A, Hallur V, Prasad A, Sharma K, Raj A. Rising trends of syphilis in a tertiary care center in North India. Indian J Sex Transm Dis 2015;36:1403.
] [Full text]
Maity S, Bhunia SC, Biswas S, Saha MK. Syphilis seroprevalence among patients attending a sexually transmitted disease clinic in West Bengal, India. Jpn J Infect Dis 2011;64:506-8.
Khan S, Menezes GA, Dhodapkar R, Harish BN. Seroprevalence of syphilis in patients attending a tertiary care hospital in Southern India. Asian Pac J Trop Biomed 2014;4:995-7.
Devi SA, Vetrichevvel TP, Pise GA, Thappa DM. Pattern of sexually transmitted infections in a tertiary care centre at Puducherry. Indian J Dermatol 2009;54:347-9.
] [Full text]
Narayanan B. A retrospective study of the pattern of sexually transmitted diseases during a ten-year period. Indian J Dermatol Venereol Leprol 2005;71:333-7.
] [Full text]
Jain VK, Dayal S, Aggarwal K, Jain S. Changing trends of sexually transmitted diseases at Rohtak. Indian J Sex Transm Dis 2008;29:23-5. [Full text]
Kumarasamy N, Balakrishnan P, Venkatesh KK, Srikrishnan AK, Cecelia AJ, Thamburaj E, et al.
Prevalence and incidence of sexually transmitted infections among South Indians at increased risk of HIV infection. AIDS Patient Care STDS 2008;22:677-82.
Garg T, Chander R, Jain A, Barara M. Sexually transmitted diseases among men who have sex with men: A retrospective analysis from Suraksha clinic in a tertiary care hospital. Indian J Sex Transm Dis 2012;33:16-9.
] [Full text]
Shah BJ, Karia DR, Pawara CL. Syphilis: Is it making resurgence? Indian J Sex Transm Dis 2015;36:17881.
] [Full text]
Mayer KH. Sexually transmitted diseases in men who have sex with men. Clin Infect Dis 2011;53:S79-83.
Dourmishev LA, Dourmishev AL. Syphilis: Uncommon presentations in adults. Clin Dermatol 2005;23:555-64.
Kar HH. Incidence of secondary syphilis on a rise and need for a separate flow chart for its syndromic management. Indian J Sex Trans Dis 2004;25:22-5.
Nishal PK, Kapoor A, Jain VK, Dayal S, Aggarwal K. Changing trends in acquired syphilis at a Tertiary Care Center of North India. Indian. J Sex Transm Dis 2015;36:149-53.
Piraccini BM, Broccoli A, Starace M, Gaspari.V, D'Antuono A, Dika E, et al.
Hair and scalp manifestations in secondary syphilis: Epidemiology, clinical features and trichoscopy. Dermatology 2015;231:171-6.
Padhiyar JK, Patel NH, Buch J, Chhibber A. Is latent syphilis new normal among clinical presentations of syphilis? Study from a tertiary care institute. Nepal J Dermatol Venereol Leprol 2019;17:27-31.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]