Infectious Disease Alert Updates
By Carol A. Kemper, MD, FACP
An old plague resurges in modern cities
Harper KN, et al. Syphilis: Then and now. The Scientist Feb 2014: http://bit.ly/1gMDlT6
Not a week goes by where I do not see at least one or two newly diagnosed cases of syphilis — and not just in my HIV+ MSM patients. Syphilis is beginning to appear in young heterosexuals as well. While most of these are identified based on screening serological studies, more patients than ever are presenting with signs and symptoms of secondary syphilis. And an HIV+ patient at our county clinic recently presented with osteomyelitis of the carpal bones secondary to syphilis, something I've not seen in 20 years of ID/HIV consultation.
Two important questions remain, where did syphilis come from? And how did treponemal infection evolve into a sexually transmitted disease, from what was essentially a skin and skeletal disease passed on through close contact? Was it an old disease from the "New World", brought home to Europe by Christopher Columbus in the 15th century? Or is it older still? The "unifying diagnosis" postulates that a pre-Columbus, syphilitic-like organism causing infection in humans and/or primates in Africa or the Mediterranean was brought to the New World, where it morphed into yet another syphilitic disease, called Yaws. And then worked its way back to the Continent, possibly sailing home with Columbus to infect the "Old World" with a new variant trepemal disease, syphilis. But none of this has been proven.
Paleontologists have labored to trace the path of treponemal infection through skeletal findings. Syphilis can cause classical bone lesions, which, while not pathogenomic for treponemal infection, are highly suggestive. These include what are called "caries sicca" or clusters of shallow depressions in the external calvarium, surrounded by star-like cracks; and tibial swelling and regrowth, with shallow pits and ulceration on the shin bone — under a classical periosteal reaction — another tell-tale skeletal finding. Such skeletal evidence can be readily found in in the Pre-Columbus New World, but the search for similar bone lesions in pre-Columbus Europe has not been as rewarding. Bone lesions can be found, but they're either suspected to be from other diseases, such as leprosy, or carbon dating fails to provide conclusive dates pre-Columbus's voyage.
In 2008, microbiologists attempted to prove what historians and paleontologists could not. The first strain of "modern" T. pallidum, isolated from a patient 86 years earlier, was sequenced in 2008. Other strains of T. pallidum, as well as other human treponemal strains causing bezel and yaws were compared, creating a phylogenetic tree. Non-human primate strains of treponemes — which cause a contagious skin infection with bubos under the axilla and muzzle in West African monkeys — were also used. Unfortunately existing treponemal strains are too limited to provide much depth to the tree — but the data suggested that modern syphilis strains are most closely related to strains causing Yaws in Guyana, South America. (In fact, Christopher Columbus sailed to Guyana on this third voyage in 1498, encountering two major indigenous tribes of peoples, the Arawaks and the Caribs). The Governor of the West Indies in 1537 wrote in the "Historia General y Natural de las Indias", that a pre-existing but fairly benign skin disease in the area, which the Spanish called Bubas, was transmitted to the sailors of Columbus by indigenous women.
But why then did treponemal Yaws evolve into a sexually transmitted disease? Theories abound but the commonly held belief is that the sheer numbers of people living on the Continent, mostly in crowded cities, close quarters and loose mores quickly allowed for the spread of syphilis thru sexual means. A seminal event may have triggered the explosion of syphilis throughout the "Old World". When King Charles VIII of France invaded Naples in 1494-1498 with 25,000 troops, a nasty new infection broke out amongst the troops and accompanying prostitutes, with large boils and open weeping sores, and terrible joint pains. Those troops eventually returned to their homes, and from there, the infection spread rapidly throughout Europe. It is estimated by the 20th century, syphilis infected 10% of London residents, 15% of Parisians, and 20% of U.S. military recruits.
Another sentinel event in San Francisco may have triggered the ongoing resurgence of syphilis in the United States. It's a great story and demonstrates the ingenuity of the SF Public Health Dept. By the 1990's, syphilis had largely been beaten back in the United States. In 1999, the County of San Francisco reported only 17 cases of syphilis (remarkable when you consider the number of HIV cases in the city at that time). But a cluster of primary syphilis cases occurred in 7 gay men that year, 5 of whom were HIV+. The group was known for their sexual activity, finding anonymous partners through the internet. One individual alone estimated recent sexual contact with at least 47 "partners" found on the net, known only by their internet handles. The SFPHD reached out to AOL to assist in identifying and contacting these individuals but AOL declined, asserting that sexually transmitted disease exposure did not comprise a sufficient threat. The SFPHD reached out to enlist the help of "Planet Out", a local gay men's activist group, who alerted the gay on-line community to the possible outbreak through "chat rooms", where people were looking for partners. At least 50 contacts came forward for testing and treatment — but it was estimated that another 50-100 contacts slipped through the net. By 2003, SF county reported 595 cases of syphilis. Syphilis was back.
Wash your hands before eating !
Kundrapu S, et al. A randomized trial of soap and water hand wash versus alcohol hand rub for removal of Clostridium difficile spores from hands of patients. Infect Control Hosp Epidemiol 2014, 35(2):204-205.
These authors examined the frequency of hand contamination with C. difficile organisms and spores in hospitalized patients. Swab specimens were obtained from patients with C. difficile infection (CDI) as well as patients identified as asymptomatic carriers of C. difficile identified through surveillance techniques, before and after either hand washing with soap and water or after alcohol hand rubs. The specimens were cultured and colonies counted; isolates were also tested for cytotoxin production.
Specimens were obtained before and after a total of 62 hand washes and 59 alcohol hand rubs in 44 patients (2-4 hand hygiene events per patient). Before hand hygiene, 9 of 28 (32%) of patients with symptomatic CDI and 6 of 16 (38%) of asymptomatic carriers had positive cultures. Half of the 121 hand cultures were positive, with an average of 12 colonies per hand swab (range, 1-100 colonies per hand). All of the C. difficile isolates cultured exhibited toxin production.
Swabs taken after the use of alcohol hand rub showed little effect on colony counts. However, hand washing not only significantly reduced colony counts, cultures were negative from 90% of the hands after washing with soap and water.
We've instituted a program for hand washing before meals with a nice warm soapy wash cloth — brought with the meal tray by the kitchen staff in a nice plastic bag — just like the airlines. It's a good practice — and this data suggests it could play an important role in reducing inoculation or re-infection with C. difficile organisms and spores. But I'd like to see more vigorous hand washing encouraged by patients throughout the day, especially before meals.
Wash your toys before sex!
Centers for Disease Control and Prevention. Likely female-to-female sexual transmission of HIV Texas, 2012. MMWR 2014; 63 (10): 209-212.
The CDC has reported a rare case of sexual transmission of HIV during a 6-month exclusive relationship between two HIV discordant women, one of whom was known to be HIV+ and the other negative (a routine plasma donor). Sequencing of the viruses determined they were virtually identical, and the newly infected woman had no other recognized risk factors and believes the couple was monogamous.
Transmission of HIV between women during sex is highly unusual but has been previously reported. In large surveys of women presented for HIV care, virtually none of them presented with a sole risk factor of sexual contact with another HIV+ woman. This couple routinely engaged in unprotected sexual contact, had sexual contact during menses, and employed the use of sex toys. Their sexual play was described as occasionally "rough".
Although rare, HIV transmission may occur between discordant HIV+/HIV- women. Avoiding sex during menses, and the use of female condoms, especially during rougher sex, and cleaning toys between partners, may be helpful in avoiding transmission.