Serological screening for syphilis in HIV-infected individuals: is a non-treponemal test adequate in the era of increasing of new syphilis infections?
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1 Abstract no. WEPE 494 Serological screening for syphilis in HIV-infected individuals: is a non-treponemal test adequate in the era of increasing of new syphilis infections? G.Chrysos 1, D.Karageorgopoulos 1,3, A.Lazaridou 2, C.Poulopoulou 2, K.Chrysou 1, P.Chatziastros 1, E.Friligou 1, P. Mistylis 1, A.Sotiropoulos 1, K.Digalaki 2, D.Paraskeva 1,3 1. Infectious Diseases Unit; 2. Department of Microbiology, Tzaneio General Hospital, Piraeus, 3. Hellenic Center for Disease Control and Prevention, Athens, Greece
2 Background Traditionally, serologic screening for syphilis involves performing a nontreponemal test (e.g. VDRL, RPR) first, which is confirmed, if positive, with a treponemal test. The diagnostic accuracy of non-treponemal tests for syphilis might be lower in patients with HIV-infection. False positive tests due to immune activation can be common. False negative tests can also be observed, particularly in seriously immunocompromised patients. The reversal of the traditional order of serologic testing for syphilis (i.e., performing a treponemal test first) is gaining interest with regard to HIV-infected patients. The advent of automated enzyme immunoassay tests facilitates the change in the screening algorithm. We aimed to assess serologic screening for syphilis with the use of the Fluorescent Treponemal Antibody Absorption test (FTA-Abs) in HIV-positive patients.
3 Patients and methods Because of a steep increase in the incidence of syphilis in high-risk patient groups in Greece, FTA-Abs testing has been included, along with Rapid Plasma Reagin (RPR) testing, in the routine (every 6-12 months) serologic screening protocol for syphilis, followed at the HIV Clinic (Infections Diseases Unit) of Tzaneio General Hospital, Piraeus, Greece, in January We retrospectively examined the records of the Microbiology Laboratory of our hospital to identify the patients followed in the HIV Clinic who had undergone serologic testing for syphilis between 1/1/2010 and 1/10/2011. We reviewed all of the available paper and electronic medical records of these patients and extracted relevant demographic, clinical and laboratory data.
4 Results (1) During the study period, 171 unique HIV-infected, sexually-active patients were screened at least once with FTA-Abs for syphilis, out of the 350 patients followed in our Clinic. 135/171 (78,9%) had a negative FTA-Abs test result. None of the above 135 patients had a positive non-treponemal RPR test.
5 Results (2) 23/171 (13,5%) had a positive FTA-Abs test result. Out of the 23 patients with positive FTA-Abs, 9 (39,1%) also had a positive RPR test. Five out of the 9 patients with both tests positive, were found to have early syphilis. The remaining 14/23 (60,9%) FTA-Abs positive patients had negative RPR. 3/14 patients underwent additional serologic testing at a reference laboratory and did not have a positive result for another treponemal test (Treponema pallidum particle agglutination assay (TP-PA) or Treponema pallidum enzyme immunoassay (TP-EIA)). Thus, the positive FTA-Abs test result was considered as false-positive. 4/14 patients had a positive clinical history for syphilis or a history of previously positive serologic tests for syphilis.
6 Results (3) 13/171 (7,6%) additional patients had an indeterminate or weekly positive FTA-Abs test result Out of the 13 patients with indeterminate/weekly positive FTA-Abs, 1 (7,7%) patient had positive RPR and early syphilis, 6 (50,0%) had negative RPR, For the remaining 6 patients, data for a recent RPR test were not available.
7 Results (4) FTA + FTA - FTA ± TOTAL RPR (5.8%) RPR (94.2) TOTAL 23 (13.5%) 135 (78.9%) 13 (7.6%) 171 (100%)
8 Main findings and discussion The use of FTA-Abs in the serologic screening for syphilis in HIV-infected patients resulted in the identification of all of the 10 patients who had a positive RPR. 20/171 (11,7%) patients had a positive or indeterminate FTA-Abs test with a negative RPR. These patients could have had false positive FTA-Abs, treated syphilis, or late latent syphilis (false negative RPR). Although the sensitivity of RPR in diagnosing syphilis is considered very high, case reports have described RPR-seronegative syphilis in HIV-positive patients. A negative non-treponemal test may not rule out syphilis in patients with advanced immunosuppression. Reinfection may be difficult to rule out in some patients, and reactivation or relapse of a previously treated infection is also possible for an HIV-positive person. The diagnostic value of FTA-ABS can be greater in HIV-infected patients with latent syphilis. FTA-ABS turns positive earlier and remains positive longer than RPR.
9 Conclusion The use of FTA-Abs in the serologic screening for syphilis in HIV-infected patients can lead to the identification of a greater number of patients with probable syphilis than with RPR alone. Clinicians should consider the sensitivity of FTA-ABS to be high in HIV-infected persons with untreated syphilis beyond the primary stage of infection. The patients with a positive FTA-Abs test and a negative RPR test need confirmatory testing with another treponemal test. If asymptomatic patients have a positive non-treponemal test and negative confirmatory treponemal test results, it is very unlikely that they have active syphilis.
10 Literature cited 1. Centers for Disease Control and Prevention (CDC). Syphilis testing algorithms using treponemal tests for initial screening-- four laboratories, New York City, MMWR Morb. Mortal. Wkly. Rep. 2008; 57: Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, MMWR Recomm Rep 2010; 59:1-110.
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