Primary syphilis lesion characteristics, serological response and management in HIV-positive and HIV-negative men who have sex with men

Abstract

The characteristics and serological responses of primary syphilis are not completely understood. We aimed to describe the characteristics, the serological responses and presumptive treatment of primary syphilis in HIV-positive and -negative men who have sex with men (MSM). We conducted a retrospective review of microbiological and demographic information from MSM presenting with primary syphilis. There were 111 cases of primary syphilis in MSM, the median age was 46 (IQR = 37–53years) and 40 (36%) were living with HIV. Fifty percent of MSM presented with painful lesions and 14% with extra-genital lesions. Extra-genital lesions were significantly more likely to be painful than non-genital lesions (OR 4.72; 95%CI = 1.25–17.83, p = 0.02). Overall, a reactive serological response demonstrated a sensitivity of 80% (57/71) compared with Treponema pallidum PCR. Serology was more sensitive in MSM with no previous syphilis (OR = 3.38, 95%CI = 1.00–11.43, p < 0.05). MSM presenting with painless lesions were more likely to be treated presumptively (OR = 3.39, 95%CI = 1.38–8.33, p < 0.002). There were no differences in the characteristics, serological responses or management according to HIV status. Fifty percent of MSM with primary syphilis presented with painful lesions; extra-genital lesions are more likely to be painful than genital lesions, serology is positive in 80% and there were no differences between HIV-positive and -negative MSM. Understanding the characteristics of primary syphilis will underpin public health campaigns.

Syphilis Infections, Reinfections and Serological Response in a Large Italian Sexually Transmitted Disease Centre: A Monocentric Retrospective Study

“…In our study, an apparently overall better serological response was found in PLWH; the primary explanation for this is that PLWH are chronically evaluated in our centre with scheduled visits every 6 months. This increases the detection rate of syphilis infection at earlier stages, which is linked to a better serological response [38].…”

How would sexual health clinicians manage first attendance by men who have sex with men with anogenital ulcers?

“…It has been shown that MSM presenting with genital ulcers of primary syphilis are offered presumptive treatment on 52–71% of occasions, MSM wait up to 14 days for treatment and are more likely to be treated if they have painless genital lesions. 2,4,5 Benzathine penicillin is the first line treatment for syphilis in our centres, and there have been no restriction of access to benzathine. We aimed to find out what the current clinical practice is when experienced sexual health clinicians are faced with MSM presenting with anogenital ulcers.…”

“…2 The diagnosis of primary syphilis is by dark-field microscopy (DFM), Treponema pallidum polymerase chain reaction (PCR) or serology. 3–5 Dark-field microscopy requires skilled staff, and its use is diminishing. Sexual health clinicians need to make a complex clinical decision with MSM presenting with genital ulcers at their first attendance; firstly, the causes of genital ulcers are broad (syphilis, herpes and Lymphogranuloma Venereum), and presumptive treatment is based on factors including penicillin allergy and availability of benzathine penicillin.…”