Syphilis in Men Who Have Sex With Men: A Warning Sign for HIV Infection

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Gállego-Lezáun, M. Arrizabalaga Asenjo, J. González-Moreno, I. Ferullo, A. Teslev, V. Fernández-Vaca, A. Payeras Cifre" "autores" => array:7 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Gállego-Lezáun" "email" => array:1 [ 0 => "cgallego@hsll.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Arrizabalaga Asenjo" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "González-Moreno" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Ferullo" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Teslev" ] 5 => array:2 [ "nombre" => "V." "apellidos" => "Fernández-Vaca" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Payeras Cifre" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Medicina Interna, Hospital Son Llàtzer, Palma de Mallorca, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sífilis en hombres que tienen sexo con hombres: una alarma para la detección de infección por VIH" ] ] "textoCompleto" => "IntroductionSyphilis is a universally distributed disease caused by the spirochete Treponema pallidum subspecies pallidum that has important health, social, and economic repercussions. The number of syphilis cases has been increasing in various European and North American cities since the second half of the 20th century.<a class="elsevierStyleCrossRefs" href="#bib0120">1,2</a> Men who have sex with men (MSM) account for much of this increase.<a class="elsevierStyleCrossRefs" href="#bib0130">3–6</a> A worryingly high proportion of MSM with syphilis are also infected with the human immunodeficiency virus (HIV).<a class="elsevierStyleCrossRefs" href="#bib0130">3,5,7</a> The reasons for this change of trend appear to be complex<a class="elsevierStyleCrossRef" href="#bib0150">7</a> but include migratory movements, contacts between different population groups, changes in risky behaviors, the use of various drugs, and the decrease in safe sex practices in MSM that coincided with the introduction of antiretroviral (ARV) therapy.<a class="elsevierStyleCrossRef" href="#bib0155">8</a> In 2011, 3522 cases of syphilis were reported in Spain, and the incidence of the disease was 7.6 cases per 100 000 inhabitants. The annual incidence of syphilis grew considerably between 2005 and 2011.<a class="elsevierStyleCrossRef" href="#bib0125">2</a> The autonomous communities that reported the highest rates were Madrid (14.3 cases per 100 000 inhabitants), the Balearic Islands (11.6 cases per 100 000 inhabitants), and Asturias (10.9 cases per 100 000 inhabitants).<a class="elsevierStyleCrossRef" href="#bib0125">2</a> The aim of our study was to describe the clinical and epidemiological characteristics of syphilis in MSM within the area of influence of our hospital and to compare these characteristics with those of heterosexual men.Materials and MethodsDesignWe performed a retrospective analysis of the syphilis serologies carried out between January 2005 and June 2013 at Hospital Son Llàtzer, a 350-bed hospital in Palma de Mallorca that serves a population of 225 000 inhabitants. The study was approved by the hospital's research committee.PatientsAll cases of syphilis confirmed serologically in MSM during the study period were included regardless of the reason for which the serology was ordered (screening of asymptomatic patients or appearance of clinical symptoms).MethodsAt our hospital, the first step in syphilis screening is a treponemal test that detects antitreponemal antibodies by means of a chemiluminescence immunoassay (CLIA), a test described as having 100% sensitivity and 99.8% specificity.<a class="elsevierStyleCrossRef" href="#bib0160">9</a> In the event of a positive CLIA result, a rapid plasma reagin test (RPR) and a second treponemal test—Treponema pallidum hemaglutination assay (TPHA)—are then carried out to confirm the result of the first test or detect a false positive.Study VariablesThe following clinical and serologic data were retrospectively collected from the patients’ electronic medical records: age, sexual orientation, smoking and alcohol intake, HIV serology, CD4 cell count, use of ARV therapy, previous diagnosis of syphilis, other sexually transmitted infections (STIs), country of origin, syphilis status, and treatment received.Definitions<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a)Primary syphilis: Clinical picture (hard chancre accompanied or not by bilateral lymph node enlargement) consistent with positive results in treponemal tests (CLIA, TPHA), regardless of nontreponemal test results.</li><li class="elsevierStyleListItem" id="lsti0010">b)Secondary syphilis: Clinical picture consistent with positive results in treponemal (CLIA, TPHA) and nontreponemal (RPR) tests.</li><li class="elsevierStyleListItem" id="lsti0015">c)Early latent syphilis: Positive results in treponemal (CLIA, TPHA) and nontreponemal (RPR) tests without clinical symptoms, with evidence of a picture consistent with primary syphilis or seroconversion > 1 year before diagnosis.</li><li class="elsevierStyleListItem" id="lsti0020">d)Late latent syphilis or syphilis of unknown duration: Positive results in treponemal (CLIA, TPHA) tests, regardless of nontreponemal test results, without clinical symptoms or prior treatment, and with evidence of syphilis infection > 1 year earlier or unknown duration of infection.</li><li class="elsevierStyleListItem" id="lsti0025">e)Neurosyphilis: Clinical suspicion of syphilis affecting the central nervous system and positive serology in the cerebrospinal fluid in either nontreponemal (venereal disease research laboratory) or treponemal (fluorescent treponemal antibody absorption) tests.<a class="elsevierStyleCrossRef" href="#bib0155">8</a></li><li class="elsevierStyleListItem" id="lsti0030">f)Serologic cure: 2-dilution RDR titer decrease in patients with positive nontreponemal test results.</li><li class="elsevierStyleListItem" id="lsti0035">g)Reinfection: Serologic titer increase following a correct serologic response.</li><li class="elsevierStyleListItem" id="lsti0040">h)Treatment failure: Decrease of < 4titers at 6months.</li></ul>StatisticsIn the descriptive analysis, we determined medians and ranges for continuous variables and frequencies and percentages for categorical variables. Quantitative variables were compared using the t test. For qualitative variables, the χ2 test was used when the necessary applicability criteria were met. Statistical significance was set at a value of P<.05. For risk estimation, odds ratios were calculated with a 95% CI. The statistical analysis was carried out using the SPSS statistical package (version 18) and Epidat (version 3.1).ResultsDuring the study period, 323 cases of syphilis were diagnosed. In 161 cases (49.8%), the patient's sexual orientation was included in the clinical record: 55 patients (34.2%) were MSM and 106 (65.8%) were heterosexual. Of the heterosexual patients, 39 (36.8%) were men and 67 (63.2%) were women. Although there was some interannual variability, the number of syphilis cases diagnosed per year was relatively stable. The trend over time in the diagnosis of syphilis cases in MSM remained stable throughout the study period.Results in Men Who Have Sex With MenIn MSM patients, the median age was 37.5 years (range, 20-80y). Other epidemiologic variables are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Serologic status for HIV was known in all cases. Forty-one patients (74.5%) were HIV-positive. Of the HIV-positive patients, 12 (29.3%) were receiving ARV therapy. In the remaining 29 patients, HIV and syphilis were diagnosed simultaneously. In HIV-infected patients, the median CD4 count was 456cells/μl (range, 29-979cells/μl).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Syphilis was diagnosed clinically in 27 cases (49.1%) and by screening in 28 asymptomatic patients (50.9%). Evidence of previous syphilis infection was present in 13 cases (23.6%).The most frequent clinical form of the disease was late latent syphilis or syphilis of unknown duration, which was diagnosed in 23 cases (41.8%) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). A total of 50 patients underwent treatment, 48 (96.0%) with penicillin and 2 (4.0%) with doxycycline, although the reason for the use of the latter drug was not indicated in the clinical records. No treatment was carried out in 5 patients with late latent syphilis, and the reason was not indicated in the clinical records. Clinical and serologic cure was achieved in 30 patients (60.0%). Cure was not achieved in 1 case (2.0%) because the patient died for another reason, and the remaining 19 patients (34.5%) were lost to follow-up.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Results in Heterosexual MenIn heterosexual men, the median age was 47.3years (range, 18-85 y), significantly higher than in MSM (P<.0053). Other epidemiologic variables are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. As in MSM, serologic status was known for all patients in this subgroup. Twelve heterosexual patients (30.8%) were HIV-positive. In HIV-infected patients, the median CD4 count was 422cells/μl (range, 94-1030cells/μl). Syphilis was diagnosed clinically in 12 cases (30.8%) and by screening in 27 asymptomatic patients (69.2%). As in MSM, the most frequent clinical form of syphilis in heterosexual men was late latent syphilis or syphilis of unknown duration, which was diagnosed in 27 cases (69.2%) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Seven heterosexual men (17.9%) were lost to follow-up—fewer than in the MSM group, although the difference was not statistically significant.Comparative analysis revealed that HIV coinfection was more common in MSM than in heterosexual men, as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. Although there were no statistically significant differences between the clinical diagnoses and the screening diagnoses (even when each clinical form is analyzed separately), the symptomatic forms of the disease were more common in MSM. The median CD4 count was higher in MSM patients than in HIV-infected heterosexual patients—in whom it was 422cells/μl (range, 23-103cells/μl)—although the difference was not statistically significant.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Comparative analysis of HIV-infected men (either MSM or heterosexual) and non-HIV-infected men showed only that syphilis reinfection was more common in the former group (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Finally, we observed a trend toward a greater prevalence of symptomatic cases in HIV-infected patients, although no statistically significant differences were found, even when patients were analyzed by syphilis status.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionOur study allowed us to obtain an overview of the clinical and epidemiologic characteristics of syphilis infection in the MSM population in our area. The high percentage of patients coinfected with HIV in our case series was noteworthy, as was the number of reinfections. The clinical form diagnosed most frequently was late latent syphilis or syphilis of unknown duration, as would be expected in a population in which screening accounts for more than half of diagnoses. The high percentage of patients lost to follow-up was notable.In recent years, the incidence of syphilis has increased worldwide<a class="elsevierStyleCrossRefs" href="#bib0120">1,10</a> and also in Spain<a class="elsevierStyleCrossRef" href="#bib0125">2</a> and the Balearic Islands specifically. This increase in the incidence of syphilis has occurred mainly in HIV-infected people, particularly MSM.<a class="elsevierStyleCrossRef" href="#bib0150">7</a> Although our study found a stable trend in diagnoses of syphilis in MSM, it must be noted that the study period—from 2005, when the CLIA method of syphilis screening became available, until 2013—was very short.Most of the worldwide increase in the incidence of syphilis occurred in the late 1990s and the first years of the 21st century, with a linear increase continuing until the present day. This increase has coincided with the introduction of ARV therapy—which allows better control of HIV infection—and a consequent change in risky behaviors brought about by a false sense of protection against potential HIV-related clinical complications.<a class="elsevierStyleCrossRef" href="#bib0170">11</a> In a series of 26 patients in Spain, inconsistent condom use and a larger number of sexual partners were found to be risk factors for syphilis in MSM.<a class="elsevierStyleCrossRef" href="#bib0175">12</a>Because our study was conducted at a hospital—as opposed to a center dedicated exclusively to treating STIs—we have no specific data on risk behaviors. Approximately half of the MSM patients in our series were diagnosed clinically—a notable finding, as one would expect more cases to be diagnosed by screening in this high-risk group. This finding can probably be explained by the fact that the patients included in the analysis were evaluated in a hospital setting as opposed to a primary care center or a center dedicated exclusively to STIs, where screening would be the predominant diagnostic method.When the MSM population was compared with the population of heterosexual men, the symptomatic forms of syphilis—primary, secondary, and neurosyphilis—were found to be more frequent in MSM, although the differences were not statistically significant. HIV coinfection was also more common in MSM. This finding is consistent with the previous literature,<a class="elsevierStyleCrossRef" href="#bib0180">13</a> although, notably, the percentage of MSM coinfected with HIV was much larger than in other series,<a class="elsevierStyleCrossRefs" href="#bib0135">4,5,12</a> including a Spanish multicenter epidemiologic study of more than 500 MSM with syphilis.<a class="elsevierStyleCrossRef" href="#bib0180">13</a> The high percentage of HIV coinfection in our case series—even higher than that found in a Spanish epidemiologic study of hospitalizations for syphilis<a class="elsevierStyleCrossRef" href="#bib0130">3</a>—was not limited exclusively to MSM. Because syphilis and HIV share mechanisms of transmission, diagnosis of both infections is not uncommon, especially in groups like MSM that engage in risky sexual practices. In addition, syphilis can enhance transmission of HIV, mainly through mucosal abnormalities caused by genital ulcers.<a class="elsevierStyleCrossRef" href="#bib0185">14</a> The association between syphilis and HIV is therefore of great epidemiologic and clinical importance because both infections are associated with high morbidity and mortality and are therefore public health problems.<a class="elsevierStyleCrossRefs" href="#bib0150">7,8</a> HIV infection can also modify the natural course of syphilis infection, and symptomatic infections (secondary syphilis, neurosyphilis) are more common in HIV-infected patients.<a class="elsevierStyleCrossRef" href="#bib0190">15</a> This could explain the larger number of symptomatic syphilis diagnoses in MSM in our study (nearly three quarters of MSM with syphilis were also infected with HIV). This result contrasts with the findings of other international case series in which the percentage of coinfected patients was smaller,<a class="elsevierStyleCrossRefs" href="#bib0195">16–19</a> although most of those works were based on studies of population screening.Remarkably, nearly three quarters of the cases of HIV-syphilis coinfection were diagnosed simultaneously, a much higher percentage than that found in other case series.<a class="elsevierStyleCrossRefs" href="#bib0135">4,18,20</a> In these patients, HIV was diagnosed at a relatively early stage (with a median CD4 count of 456), as in previous studies.<a class="elsevierStyleCrossRef" href="#bib0135">4</a> This finding highlights the importance of proper screening for HIV infection in syphilis-infected MSM, which could allow the viral infection to be diagnosed at an earlier stage.The number of patients lost to follow-up in our study was high—approximately one third of the evaluated population—but lower than the percentage found in other case series.<a class="elsevierStyleCrossRef" href="#bib0210">19</a>The percentage of MSM patients was lower than that found in other Spanish studies, although the earlier works were based on studies carried out in large cities at centers specialized in STIs, where larger aggregations of this risk group can be found.<a class="elsevierStyleCrossRefs" href="#bib0135">4,5,12</a>Our study had several limitations. As a retrospective review based on data from clinical records, it was subject to information bias. Additionally, the number of MSM patients was low, probably because many cases with positive serologies for syphilis were excluded from the analysis (latent and treated syphilis were indistinguishable in the patient records). In light of the fact that different societies<a class="elsevierStyleCrossRefs" href="#bib0220">21–23</a> have different recommendations regarding screening methods, one possible explanation for this—in addition to the lack of patient follow-up—could be an erroneous interpretation of serologic profiles. Finally, because sexual orientation was recorded in less than half of the clinical histories, a large number of patients were excluded from the analysis.In conclusion, syphilis-HIV coinfection is very common, especially in the MSM population. The presence of syphilis or HIV should alert the physician to the possibility of the other infection. HIV screening in patients with syphilis, especially MSM, would probably lead to more, and earlier, diagnoses of HIV.Ethical DisclosuresProtection of persons and animalsThe authors declare that no experiments were performed on humans or animals for the purpose of this study.Confidentiality of dataThe authors declare that they followed their hospital's regulations regarding the publication of patient information.Right to privacy and informed consentThe authors have obtained the informed consent of the patients and/or subjects referred to in this article. This document is in the possession of the corresponding author.Conflicts of InterestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres576320" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec592974" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres576319" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec592973" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Patients" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Study Variables" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Definitions" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistics" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Results in Men Who Have Sex With Men" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Results in Heterosexual Men" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0065" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Protection of persons and animals" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflicts of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-03-09" "fechaAceptado" => "2015-05-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec592974" "palabras" => array:3 [ 0 => "Syphilis" 1 => "Men who have sex with men" 2 => "Human immunodeficiency virus" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec592973" "palabras" => array:3 [ 0 => "Sífilis" 1 => "Hombres que tienen sexo con hombres" 2 => "Virus de la inmunodeficiencia humana" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo describe the clinical and epidemiological characteristics of syphilis in men who have sex with men (MSM) in an area of Mallorca, Spain. MethodsWe performed a retrospective analysis of syphilis cases in MSM seen at a hospital in Mallorca between January 2005 and June 2013. ResultsFifty-five cases of syphilis were recorded in MSM during the study period (34.3% of all cases diagnosed), and 74.5% of these patients had human immunodeficiency virus (HIV) coinfection. The two diseases had been diagnosed simultaneously in 70.7% of this population. Patients with HIV coinfection had a median CD4 count of 456cells/μL (range, 29-979 cells/μL). Syphilis was diagnosed clinically in 49.1% of cases and by screening in the remaining 50.9%. The most common form of syphilis was late latent or indeterminate syphilis (41.9% of cases). In the group of men with syphilis, MSM had a higher risk of HIV infection. ConclusionsA majority of MSM with syphilis had HIV coinfection. HIV screening is therefore essential in this population and could even result in early diagnosis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosDescribir las características clinicoepidemiológicas de la sífilis en la población de hombres que tienen sexo con hombres en un área de Mallorca. MétodosRevisión retrospectiva de los casos de sífilis en pacientes hombres que tienen sexo con hombres (HSH) entre enero de 2005 y junio de 2013 en un hospital de Mallorca. ResultadosEncontramos 55 casos de sífilis en HSH, el 34,3% de los casos de sífilis del periodo de estudio. El 74,5% tenían coinfección por el virus de la inmunodeficiencia humana (VIH). El 70,7% de los diagnósticos de infección por VIH y sífilis fueron simultáneos. Los pacientes con infección por VIH tenían una mediana de CD4 de 456 (29-979). Se diagnosticaron por clínica el 49,1% y por cribado el 50,9% de los casos. La sífilis latente tardía o indeterminada fue la entidad más frecuente (41,9%). Los pacientes HSH tenían más riego de estar infectados por VIH que los varones no HSH. ConclusionesLa mayoría de pacientes HSH con sífilis presentan coinfección por el VIH, siendo por lo tanto fundamental el cribado de VIH en estos pacientes, lo que incluso puede permitir un diagnóstico temprano de la misma." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gállego-Lezáun C, Arrizabalaga Asenjo M, González-Moreno J, Ferullo I, Teslev A, Fernández-Vaca V, et al. Sífilis en hombres que tienen sexo con hombres: una alarma para la detección de infección por VIH. Actas Dermosifiliogr. 2015;106:740–745." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: ARV, antiretroviral; HIV, human immunodeficiency virus; MSM, men who have sex with men; STI, sexually transmitted infection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSM (n=55) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Heterosexual Men (n=39) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (50.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (46.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Alcoholism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (14.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">HIV infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (74.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (30.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">HIV infection with ARV therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (29.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (12.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other STIs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (14.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Genital warts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (5.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Herpes simplex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (5.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Nongonococcal urethritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Immigrants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (27.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (28.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Previous syphilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (23.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (20.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab940636.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical Characteristics of Male Patients (MSM and Heterosexual Men) With Syphilis." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviation: MSM, men who have sex with men." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical Form \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSM (n=55) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Heterosexual Men (n=39) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Primary syphilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (16.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (7.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Secondary syphilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (25.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (15.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Early latent syphilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Late latent syphilis or syphilis of unknown duration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (41.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (69.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Neurosyphilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (9.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab940639.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical Stage of Syphilis Cases in MSM and Heterosexual Men." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: HIV, human immunodeficiency virus; MSM, men who have sex with men; NS, not significant; OR, odds ratio; STI, sexually transmitted infection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSM(n=55) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Heterosexual Men(n=39) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diagnosis by screening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (50.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (69.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clinical diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (49.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (30.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reinfection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (23.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (20.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">HIV-infected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (74.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (30.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">< .0001; OR, 6.59 (95% CI, 2.67-16.26) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other STIs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (14.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.034; OR, 3.44 (95% CI, 1.07-11.07) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab940638.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparative Analysis of Syphilis Cases in MSM and Heterosexual Men." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: HIV, human immunodeficiency virus; NS, not significant; OR, odds ratio; STI, sexually transmitted infection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HIV-Infected(n=53) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Non-HIV-Infected(n=41) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diagnosis by screening \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (62.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (53.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clinical diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (37.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (46.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reinfection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (30.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (12.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.032; OR, 3.11 (95% CI, 1.06-9.03) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other STIs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (15.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab940637.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparative Analysis of Syphilis Cases in HIV-Infected Men and Non-HIV-Infected Men." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Centers for Disease Control and Prevention. 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Syphilis in Men Who Have Sex With Men: A Warning Sign for HIV Infection

Sífilis en hombres que tienen sexo con hombres: una alarma para la detección de infección por VIH

C. Gállego-Lezáun

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cgallego@hsll.es

Corresponding author.

, M. Arrizabalaga Asenjo, J. González-Moreno, I. Ferullo, A. Teslev, V. Fernández-Vaca, A. Payeras Cifre

Medicina Interna, Hospital Son Llàtzer, Palma de Mallorca, Spain

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    "titulo" => "Syphilis in Men Who Have Sex With Men&#58; A Warning Sign for HIV Infection"
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      "es" => array:1 [
        "titulo" => "S&#237;filis en hombres que tienen sexo con hombres&#58; una alarma para la detecci&#243;n de infecci&#243;n por VIH"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Syphilis is a universally distributed disease caused by the spirochete <span class="elsevierStyleItalic">Treponema pallidum</span> subspecies <span class="elsevierStyleItalic">pallidum</span> that has important health&#44; social&#44; and economic repercussions&#46; The number of syphilis cases has been increasing in various European and North American cities since the second half of the 20th century&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;2</span></a> Men who have sex with men &#40;MSM&#41; account for much of this increase&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#8211;6</span></a> A worryingly high proportion of MSM with syphilis are also infected with the human immunodeficiency virus &#40;HIV&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;5&#44;7</span></a> The reasons for this change of trend appear to be complex<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> but include migratory movements&#44; contacts between different population groups&#44; changes in risky behaviors&#44; the use of various drugs&#44; and the decrease in safe sex practices in MSM that coincided with the introduction of antiretroviral &#40;ARV&#41; therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> In 2011&#44; 3522 cases of syphilis were reported in Spain&#44; and the incidence of the disease was 7&#46;6 cases per 100&#160;000 inhabitants&#46; The annual incidence of syphilis grew considerably between 2005 and 2011&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> The autonomous communities that reported the highest rates were Madrid &#40;14&#46;3 cases per 100&#160;000 inhabitants&#41;&#44; the Balearic Islands &#40;11&#46;6 cases per 100&#160;000 inhabitants&#41;&#44; and Asturias &#40;10&#46;9 cases per 100&#160;000 inhabitants&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> The aim of our study was to describe the clinical and epidemiological characteristics of syphilis in MSM within the area of influence of our hospital and to compare these characteristics with those of heterosexual men&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0010" class="elsevierStylePara elsevierViewall">We performed a retrospective analysis of the syphilis serologies carried out between January 2005 and June 2013 at Hospital Son Ll&#224;tzer&#44; a 350-bed hospital in Palma de Mallorca that serves a population of 225&#160;000 inhabitants&#46; The study was approved by the hospital&#39;s research committee&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">All cases of syphilis confirmed serologically in MSM during the study period were included regardless of the reason for which the serology was ordered &#40;screening of asymptomatic patients or appearance of clinical symptoms&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">At our hospital&#44; the first step in syphilis screening is a treponemal test that detects antitreponemal antibodies by means of a chemiluminescence immunoassay &#40;CLIA&#41;&#44; a test described as having 100&#37; sensitivity and 99&#46;8&#37; specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> In the event of a positive CLIA result&#44; a rapid plasma reagin test &#40;RPR&#41; and a second treponemal test&#8212;<span class="elsevierStyleItalic">Treponema pallidum</span> hemaglutination assay &#40;TPHA&#41;&#8212;are then carried out to confirm the result of the first test or detect a false positive&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study Variables</span><p id="par0025" class="elsevierStylePara elsevierViewall">The following clinical and serologic data were retrospectively collected from the patients&#8217; electronic medical records&#58; age&#44; sexual orientation&#44; smoking and alcohol intake&#44; HIV serology&#44; CD4 cell count&#44; use of ARV therapy&#44; previous diagnosis of syphilis&#44; other sexually transmitted infections &#40;STIs&#41;&#44; country of origin&#44; syphilis status&#44; and treatment received&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Definitions</span><p id="par0030" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Primary syphilis</span>&#58; Clinical picture &#40;hard chancre accompanied or not by bilateral lymph node enlargement&#41; consistent with positive results in treponemal tests &#40;CLIA&#44; TPHA&#41;&#44; regardless of nontreponemal test results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Secondary syphilis</span>&#58; Clinical picture consistent with positive results in treponemal &#40;CLIA&#44; TPHA&#41; and nontreponemal &#40;RPR&#41; tests&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Early latent syphilis</span>&#58; Positive results in treponemal &#40;CLIA&#44; TPHA&#41; and nontreponemal &#40;RPR&#41; tests without clinical symptoms&#44; with evidence of a picture consistent with primary syphilis or seroconversion &#62;&#160;1 year before diagnosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Late latent syphilis or syphilis of unknown duration</span>&#58; Positive results in treponemal &#40;CLIA&#44; TPHA&#41; tests&#44; regardless of nontreponemal test results&#44; without clinical symptoms or prior treatment&#44; and with evidence of syphilis infection &#62;&#160;1 year earlier or unknown duration of infection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">e&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Neurosyphilis</span>&#58; Clinical suspicion of syphilis affecting the central nervous system and positive serology in the cerebrospinal fluid in either nontreponemal &#40;venereal disease research laboratory&#41; or treponemal &#40;fluorescent treponemal antibody absorption&#41; tests&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">f&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Serologic cure</span>&#58; 2-dilution RDR titer decrease in patients with positive nontreponemal test results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">g&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Reinfection</span>&#58; Serologic titer increase following a correct serologic response&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">h&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment failure</span>&#58; Decrease of &#60;&#160;4<span class="elsevierStyleHsp" style=""></span>titers at 6<span class="elsevierStyleHsp" style=""></span>months&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistics</span><p id="par0075" class="elsevierStylePara elsevierViewall">In the descriptive analysis&#44; we determined medians and ranges for continuous variables and frequencies and percentages for categorical variables&#46; Quantitative variables were compared using the <span class="elsevierStyleItalic">t</span> test&#46; For qualitative variables&#44; the &#967;<span class="elsevierStyleSup">2</span> test was used when the necessary applicability criteria were met&#46; Statistical significance was set at a value of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46; For risk estimation&#44; odds ratios were calculated with a 95&#37; CI&#46; The statistical analysis was carried out using the SPSS statistical package &#40;version 18&#41; and Epidat &#40;version 3&#46;1&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">During the study period&#44; 323 cases of syphilis were diagnosed&#46; In 161 cases &#40;49&#46;8&#37;&#41;&#44; the patient&#39;s sexual orientation was included in the clinical record&#58; 55 patients &#40;34&#46;2&#37;&#41; were MSM and 106 &#40;65&#46;8&#37;&#41; were heterosexual&#46; Of the heterosexual patients&#44; 39 &#40;36&#46;8&#37;&#41; were men and 67 &#40;63&#46;2&#37;&#41; were women&#46; Although there was some interannual variability&#44; the number of syphilis cases diagnosed per year was relatively stable&#46; The trend over time in the diagnosis of syphilis cases in MSM remained stable throughout the study period&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results in Men Who Have Sex With Men</span><p id="par0085" class="elsevierStylePara elsevierViewall">In MSM patients&#44; the median age was 37&#46;5 years &#40;range&#44; 20-80<span class="elsevierStyleHsp" style=""></span>y&#41;&#46; Other epidemiologic variables are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Serologic status for HIV was known in all cases&#46; Forty-one patients &#40;74&#46;5&#37;&#41; were HIV-positive&#46; Of the HIV-positive patients&#44; 12 &#40;29&#46;3&#37;&#41; were receiving ARV therapy&#46; In the remaining 29 patients&#44; HIV and syphilis were diagnosed simultaneously&#46; In HIV-infected patients&#44; the median CD4 count was 456<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;l &#40;range&#44; 29-979<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;l&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Syphilis was diagnosed clinically in 27 cases &#40;49&#46;1&#37;&#41; and by screening in 28 asymptomatic patients &#40;50&#46;9&#37;&#41;&#46; Evidence of previous syphilis infection was present in 13 cases &#40;23&#46;6&#37;&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The most frequent clinical form of the disease was late latent syphilis or syphilis of unknown duration&#44; which was diagnosed in 23 cases &#40;41&#46;8&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; A total of 50 patients underwent treatment&#44; 48 &#40;96&#46;0&#37;&#41; with penicillin and 2 &#40;4&#46;0&#37;&#41; with doxycycline&#44; although the reason for the use of the latter drug was not indicated in the clinical records&#46; No treatment was carried out in 5 patients with late latent syphilis&#44; and the reason was not indicated in the clinical records&#46; Clinical and serologic cure was achieved in 30 patients &#40;60&#46;0&#37;&#41;&#46; Cure was not achieved in 1 case &#40;2&#46;0&#37;&#41; because the patient died for another reason&#44; and the remaining 19 patients &#40;34&#46;5&#37;&#41; were lost to follow-up&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Results in Heterosexual Men</span><p id="par0100" class="elsevierStylePara elsevierViewall">In heterosexual men&#44; the median age was 47&#46;3<span class="elsevierStyleHsp" style=""></span>years &#40;range&#44; 18-85 y&#41;&#44; significantly higher than in MSM &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0053&#41;&#46; Other epidemiologic variables are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; As in MSM&#44; serologic status was known for all patients in this subgroup&#46; Twelve heterosexual patients &#40;30&#46;8&#37;&#41; were HIV-positive&#46; In HIV-infected patients&#44; the median CD4 count was 422<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;l &#40;range&#44; 94-1030<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;l&#41;&#46; Syphilis was diagnosed clinically in 12 cases &#40;30&#46;8&#37;&#41; and by screening in 27 asymptomatic patients &#40;69&#46;2&#37;&#41;&#46; As in MSM&#44; the most frequent clinical form of syphilis in heterosexual men was late latent syphilis or syphilis of unknown duration&#44; which was diagnosed in 27 cases &#40;69&#46;2&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Seven heterosexual men &#40;17&#46;9&#37;&#41; were lost to follow-up&#8212;fewer than in the MSM group&#44; although the difference was not statistically significant&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Comparative analysis revealed that HIV coinfection was more common in MSM than in heterosexual men&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Although there were no statistically significant differences between the clinical diagnoses and the screening diagnoses &#40;even when each clinical form is analyzed separately&#41;&#44; the symptomatic forms of the disease were more common in MSM&#46; The median CD4 count was higher in MSM patients than in HIV-infected heterosexual patients&#8212;in whom it was 422<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;l &#40;range&#44; 23-103<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;l&#41;&#8212;although the difference was not statistically significant&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Comparative analysis of HIV-infected men &#40;either MSM or heterosexual&#41; and non-HIV-infected men showed only that syphilis reinfection was more common in the former group &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Finally&#44; we observed a trend toward a greater prevalence of symptomatic cases in HIV-infected patients&#44; although no statistically significant differences were found&#44; even when patients were analyzed by syphilis status&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Our study allowed us to obtain an overview of the clinical and epidemiologic characteristics of syphilis infection in the MSM population in our area&#46; The high percentage of patients coinfected with HIV in our case series was noteworthy&#44; as was the number of reinfections&#46; The clinical form diagnosed most frequently was late latent syphilis or syphilis of unknown duration&#44; as would be expected in a population in which screening accounts for more than half of diagnoses&#46; The high percentage of patients lost to follow-up was notable&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In recent years&#44; the incidence of syphilis has increased worldwide<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;10</span></a> and also in Spain<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> and the Balearic Islands specifically&#46; This increase in the incidence of syphilis has occurred mainly in HIV-infected people&#44; particularly MSM&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> Although our study found a stable trend in diagnoses of syphilis in MSM&#44; it must be noted that the study period&#8212;from 2005&#44; when the CLIA method of syphilis screening became available&#44; until 2013&#8212;was very short&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Most of the worldwide increase in the incidence of syphilis occurred in the late 1990s and the first years of the 21st century&#44; with a linear increase continuing until the present day&#46; This increase has coincided with the introduction of ARV therapy&#8212;which allows better control of HIV infection&#8212;and a consequent change in risky behaviors brought about by a false sense of protection against potential HIV-related clinical complications&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> In a series of 26 patients in Spain&#44; inconsistent condom use and a larger number of sexual partners were found to be risk factors for syphilis in MSM&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Because our study was conducted at a hospital&#8212;as opposed to a center dedicated exclusively to treating STIs&#8212;we have no specific data on risk behaviors&#46; Approximately half of the MSM patients in our series were diagnosed clinically&#8212;a notable finding&#44; as one would expect more cases to be diagnosed by screening in this high-risk group&#46; This finding can probably be explained by the fact that the patients included in the analysis were evaluated in a hospital setting as opposed to a primary care center or a center dedicated exclusively to STIs&#44; where screening would be the predominant diagnostic method&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">When the MSM population was compared with the population of heterosexual men&#44; the symptomatic forms of syphilis&#8212;primary&#44; secondary&#44; and neurosyphilis&#8212;were found to be more frequent in MSM&#44; although the differences were not statistically significant&#46; HIV coinfection was also more common in MSM&#46; This finding is consistent with the previous literature&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> although&#44; notably&#44; the percentage of MSM coinfected with HIV was much larger than in other series&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4&#44;5&#44;12</span></a> including a Spanish multicenter epidemiologic study of more than 500 MSM with syphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> The high percentage of HIV coinfection in our case series&#8212;even higher than that found in a Spanish epidemiologic study of hospitalizations for syphilis<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a>&#8212;was not limited exclusively to MSM&#46; Because syphilis and HIV share mechanisms of transmission&#44; diagnosis of both infections is not uncommon&#44; especially in groups like MSM that engage in risky sexual practices&#46; In addition&#44; syphilis can enhance transmission of HIV&#44; mainly through mucosal abnormalities caused by genital ulcers&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> The association between syphilis and HIV is therefore of great epidemiologic and clinical importance because both infections are associated with high morbidity and mortality and are therefore public health problems&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7&#44;8</span></a> HIV infection can also modify the natural course of syphilis infection&#44; and symptomatic infections &#40;secondary syphilis&#44; neurosyphilis&#41; are more common in HIV-infected patients&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> This could explain the larger number of symptomatic syphilis diagnoses in MSM in our study &#40;nearly three quarters of MSM with syphilis were also infected with HIV&#41;&#46; This result contrasts with the findings of other international case series in which the percentage of coinfected patients was smaller&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">16&#8211;19</span></a> although most of those works were based on studies of population screening&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Remarkably&#44; nearly three quarters of the cases of HIV-syphilis coinfection were diagnosed simultaneously&#44; a much higher percentage than that found in other case series&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4&#44;18&#44;20</span></a> In these patients&#44; HIV was diagnosed at a relatively early stage &#40;with a median CD4 count of 456&#41;&#44; as in previous studies&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> This finding highlights the importance of proper screening for HIV infection in syphilis-infected MSM&#44; which could allow the viral infection to be diagnosed at an earlier stage&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The number of patients lost to follow-up in our study was high&#8212;approximately one third of the evaluated population&#8212;but lower than the percentage found in other case series&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The percentage of MSM patients was lower than that found in other Spanish studies&#44; although the earlier works were based on studies carried out in large cities at centers specialized in STIs&#44; where larger aggregations of this risk group can be found&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4&#44;5&#44;12</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Our study had several limitations&#46; As a retrospective review based on data from clinical records&#44; it was subject to information bias&#46; Additionally&#44; the number of MSM patients was low&#44; probably because many cases with positive serologies for syphilis were excluded from the analysis &#40;latent and treated syphilis were indistinguishable in the patient records&#41;&#46; In light of the fact that different societies<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">21&#8211;23</span></a> have different recommendations regarding screening methods&#44; one possible explanation for this&#8212;in addition to the lack of patient follow-up&#8212;could be an erroneous interpretation of serologic profiles&#46; Finally&#44; because sexual orientation was recorded in less than half of the clinical histories&#44; a large number of patients were excluded from the analysis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In conclusion&#44; syphilis-HIV coinfection is very common&#44; especially in the MSM population&#46; The presence of syphilis or HIV should alert the physician to the possibility of the other infection&#46; HIV screening in patients with syphilis&#44; especially MSM&#44; would probably lead to more&#44; and earlier&#44; diagnoses of HIV&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ethical Disclosures</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protection of persons and animals</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for the purpose of this study&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Confidentiality of data</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospital&#39;s regulations regarding the publication of patient information&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Right to privacy and informed consent</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in this article&#46; This document is in the possession of the corresponding author&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of Interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Materials and Methods"
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              "titulo" => "Results in Men Who Have Sex With Men"
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              "titulo" => "Results in Heterosexual Men"
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    "tienePdf" => true
    "fechaRecibido" => "2015-03-09"
    "fechaAceptado" => "2015-05-21"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:3 [
            0 => "Syphilis"
            1 => "Men who have sex with men"
            2 => "Human immunodeficiency virus"
          ]
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          "palabras" => array:3 [
            0 => "S&#237;filis"
            1 => "Hombres que tienen sexo con hombres"
            2 => "Virus de la inmunodeficiencia humana"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the clinical and epidemiological characteristics of syphilis in men who have sex with men &#40;MSM&#41; in an area of Mallorca&#44; Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective analysis of syphilis cases in MSM seen at a hospital in Mallorca between January 2005 and June 2013&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Fifty-five cases of syphilis were recorded in MSM during the study period &#40;34&#46;3&#37; of all cases diagnosed&#41;&#44; and 74&#46;5&#37; of these patients had human immunodeficiency virus &#40;HIV&#41; coinfection&#46; The two diseases had been diagnosed simultaneously in 70&#46;7&#37; of this population&#46; Patients with HIV coinfection had a median CD4 count of 456<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L &#40;range&#44; 29-979 cells&#47;&#956;L&#41;&#46; Syphilis was diagnosed clinically in 49&#46;1&#37; of cases and by screening in the remaining 50&#46;9&#37;&#46; The most common form of syphilis was late latent or indeterminate syphilis &#40;41&#46;9&#37; of cases&#41;&#46; In the group of men with syphilis&#44; MSM had a higher risk of HIV infection&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A majority of MSM with syphilis had HIV coinfection&#46; HIV screening is therefore essential in this population and could even result in early diagnosis&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir las caracter&#237;sticas clinicoepidemiol&#243;gicas de la s&#237;filis en la poblaci&#243;n de hombres que tienen sexo con hombres en un &#225;rea de Mallorca&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n retrospectiva de los casos de s&#237;filis en pacientes hombres que tienen sexo con hombres &#40;HSH&#41; entre enero de 2005 y junio de 2013 en un hospital de Mallorca&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Encontramos 55 casos de s&#237;filis en HSH&#44; el 34&#44;3&#37; de los casos de s&#237;filis del periodo de estudio&#46; El 74&#44;5&#37; ten&#237;an coinfecci&#243;n por el virus de la inmunodeficiencia humana &#40;VIH&#41;&#46; El 70&#44;7&#37; de los diagn&#243;sticos de infecci&#243;n por VIH y s&#237;filis fueron simult&#225;neos&#46; Los pacientes con infecci&#243;n por VIH ten&#237;an una mediana de CD4 de 456 &#40;29-979&#41;&#46; Se diagnosticaron por cl&#237;nica el 49&#44;1&#37; y por cribado el 50&#44;9&#37; de los casos&#46; La s&#237;filis latente tard&#237;a o indeterminada fue la entidad m&#225;s frecuente &#40;41&#44;9&#37;&#41;&#46; Los pacientes HSH ten&#237;an m&#225;s riego de estar infectados por VIH que los varones no HSH&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de pacientes HSH con s&#237;filis presentan coinfecci&#243;n por el VIH&#44; siendo por lo tanto fundamental el cribado de VIH en estos pacientes&#44; lo que incluso puede permitir un diagn&#243;stico temprano de la misma&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#225;llego-Lez&#225;un C&#44; Arrizabalaga Asenjo M&#44; Gonz&#225;lez-Moreno J&#44; Ferullo I&#44; Teslev A&#44; Fern&#225;ndez-Vaca V&#44; et al&#46; S&#237;filis en hombres que tienen sexo con hombres&#58; una alarma para la detecci&#243;n de infecci&#243;n por VIH&#46; Actas Dermosifiliogr&#46; 2015&#59;106&#58;740&#8211;745&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ARV&#44; antiretroviral&#59; HIV&#44; human immunodeficiency virus&#59; MSM&#44; men who have sex with men&#59; STI&#44; sexually transmitted infection&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSM &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Heterosexual Men &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Smoking</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;50&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;46&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Alcoholism</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;14&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">HIV infection</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;74&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;30&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">HIV infection with ARV therapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;29&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;12&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Other STIs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;14&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Genital warts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;5&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Herpes simplex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;5&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nongonococcal urethritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;3&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Immigrants</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;27&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;28&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Previous syphilis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;23&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;20&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Clinical Characteristics of Male Patients &#40;MSM and Heterosexual Men&#41; With Syphilis&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; MSM&#44; men who have sex with men&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical Form&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSM &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Heterosexual Men &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Primary syphilis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;16&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;7&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Secondary syphilis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;25&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;15&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Early latent syphilis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Late latent syphilis or syphilis of unknown duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;41&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;69&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Neurosyphilis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Clinical Stage of Syphilis Cases in MSM and Heterosexual Men&#46;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; HIV&#44; human immunodeficiency virus&#59; MSM&#44; men who have sex with men&#59; NS&#44; not significant&#59; OR&#44; odds ratio&#59; STI&#44; sexually transmitted infection&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MSM&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Heterosexual Men&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diagnosis by screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;50&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;69&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clinical diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;49&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;30&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Reinfection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;23&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;20&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">HIV-infected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;74&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;30&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;&#160;&#46;0001&#59; OR&#44; 6&#46;59 &#40;95&#37; CI&#44; 2&#46;67-16&#46;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Other STIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;14&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;034&#59; OR&#44; 3&#46;44 &#40;95&#37; CI&#44; 1&#46;07-11&#46;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparative Analysis of Syphilis Cases in MSM and Heterosexual Men&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; HIV&#44; human immunodeficiency virus&#59; NS&#44; not significant&#59; OR&#44; odds ratio&#59; STI&#44; sexually transmitted infection&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diagnosis by screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;62&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;53&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clinical diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;37&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;46&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Reinfection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;30&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;12&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;032&#59; OR&#44; 3&#46;11 &#40;95&#37; CI&#44; 1&#46;06-9&#46;03&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Other STIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;15&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparative Analysis of Syphilis Cases in HIV-Infected Men and Non-HIV-Infected Men&#46;</p>"
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    ]
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Article information

ISSN: 15782190
Original language: English

DOI:10.1016/j.adengl.2015.09.003

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Year/Month	Html	Pdf	Total

2024 November	11	9	20
2024 October	82	49	131
2024 September	88	38	126
2024 August	142	71	213
2024 July	111	52	163
2024 June	98	31	129
2024 May	80	31	111
2024 April	72	20	92
2024 March	85	23	108
2024 February	118	37	155
2024 January	65	40	105
2023 December	53	14	67
2023 November	71	28	99
2023 October	73	29	102
2023 September	95	34	129
2023 August	49	13	62
2023 July	47	31	78
2023 June	51	26	77
2023 May	57	33	90
2023 April	27	11	38
2023 March	59	32	91
2023 February	51	38	89
2023 January	31	39	70
2022 December	52	57	109
2022 November	45	50	95
2022 October	25	25	50
2022 September	16	51	67
2022 August	25	39	64
2022 July	26	47	73
2022 June	22	29	51
2022 May	46	62	108
2022 April	67	46	113
2022 March	66	66	132
2022 February	48	33	81
2022 January	47	45	92
2021 December	25	40	65
2021 November	41	53	94
2021 October	37	47	84
2021 September	26	37	63
2021 August	28	26	54
2021 July	33	30	63
2021 June	28	38	66
2021 May	53	24	77
2021 April	74	44	118
2021 March	68	28	96
2021 February	90	38	128
2021 January	57	28	85
2020 December	56	28	84
2020 November	53	20	73
2020 October	38	16	54
2020 September	52	21	73
2020 August	39	20	59
2020 July	32	22	54
2020 June	51	25	76
2020 May	45	24	69
2020 April	36	22	58
2020 March	53	29	82
2020 February	6	0	6
2019 December	4	3	7
2019 November	0	1	1
2019 October	0	2	2
2019 September	4	0	4
2019 August	0	1	1
2019 July	0	2	2
2019 June	2	1	3
2019 May	0	7	7
2019 April	0	7	7
2019 March	2	4	6
2019 February	0	1	1
2019 January	2	0	2
2018 December	2	2	4
2018 November	1	0	1
2018 October	2	2	4
2018 September	5	0	5
2018 June	0	1	1
2018 May	0	5	5
2018 April	0	2	2
2018 March	1	0	1
2018 February	22	3	25
2018 January	26	9	35
2017 December	23	10	33
2017 November	30	8	38
2017 October	23	8	31
2017 September	21	15	36
2017 August	25	12	37
2017 July	29	7	36
2017 June	28	20	48
2017 May	29	15	44
2017 April	20	11	31
2017 March	16	57	73
2017 February	20	8	28
2017 January	14	5	19
2016 December	25	15	40
2016 November	39	39	78
2016 October	24	23	47
2016 September	0	4	4
2016 August	0	1	1
2016 July	0	1	1
2016 June	1	1	2
2016 May	0	10	10
2016 March	0	5	5
2016 February	0	6	6
2016 January	0	4	4
2015 November	0	13	13

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