Register      Login
Sexual Health Sexual Health Society
Publishing on sexual health from the widest perspective
REVIEW

Impact of HIV-1 infection on the clinical presentation of syphilis in men who have sex with men

Craig Tipple
+ Author Affiliations
- Author Affiliations

A Department of Medicine, Imperial College London, St Mary’s Hospital, Norfolk Place, London, W2 1PG, UK. Email: c.tipple@imperial.ac.uk

B Jefferiss Wing Centre for Sexual Health, St Mary’s Hospital, Praed Street, London, W2 1NY, UK.

Sexual Health 12(2) 110-118 https://doi.org/10.1071/SH14157
Submitted: 16 August 2014  Accepted: 13 October 2014   Published: 17 December 2014

Abstract

Men who have sex with men (MSM), especially those with HIV-1 infection, are disproportionately affected by syphilis in higher income countries. The course, and some of the clinical features of the disease, especially the development of neurosyphilis, can be affected by HIV-1 co-infection. This review documents potential differences in the clinical features of syphilis in HIV-1 infected and uninfected MSM and highlights the importance of a thorough examination and high index of suspicion when seeing and treating MSM at risk of sexually transmissible infections.


References

[1]  LaFond RE, Lukehart SA. Biological basis for syphilis. Clin Microbiol Rev 2006; 19 29–49.
Biological basis for syphilis.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD28XhsFGjtLY%3D&md5=9798cac4c51ddaae0ef566f4fa714f0cCAS | 16418521PubMed |

[2]  World Health Organization (WHO). Prevalence and incidence of selected sexually transmitted infections. Geneva: WHO Press; 2011.

[3]  Simms I, Fenton KA, Ashton M, Turner KM, Crawley-Boevey EE, Gorton R, et al The re-emergence of syphilis in the United Kingdom: the new epidemic phases. Sex Transm Dis 2005; 32 220–6.
The re-emergence of syphilis in the United Kingdom: the new epidemic phases.Crossref | GoogleScholarGoogle Scholar | 15788919PubMed |

[4]  Diaz A, Junquera ML, Esteban V, Martínez B, Pueyo I, Suarez J, et al HIV/STI co-infection among men who have sex with men in Spain. Euro Surveill 2009; 14
| 1:CAS:528:DC%2BD1MXltFejs7o%3D&md5=89cb283762c595a91b8b7bd926c27193CAS | 20003899PubMed |

[5]  Griemberg G, Bautista CT, Pizzimenti MC, Orfus G, Alonso B, Fernández T, et al High prevalence of syphilis-HIV co-infection at four hospitals of the city of Buenos Aires, Argentina. Rev Argent Microbiol 2006; 38 134–6.
| 1:STN:280:DC%2BD28jhsFGqsQ%3D%3D&md5=2b7392687bbed24450ba3cf993aefa7fCAS | 17152210PubMed |

[6]  Chow EP, Wilson DP, Zhang L. HIV and syphilis co-infection increasing among men who have sex with men in China: a systematic review and meta-analysis. PLoS ONE 2011; 6 e22768
HIV and syphilis co-infection increasing among men who have sex with men in China: a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3MXhtFGhtLjO&md5=00869cce73fe347fa8a4ac214c6e0620CAS | 21857952PubMed |

[7]  Ciesielski CA. Sexually transmitted diseases in men who have sex with men: an epidemiologic review. Curr Infect Dis Rep 2003; 5 145–52.
Sexually transmitted diseases in men who have sex with men: an epidemiologic review.Crossref | GoogleScholarGoogle Scholar | 12642001PubMed |

[8]  Public Health England. The epidemiology of sexually transmitted infections in London, 2012 data; 2014. Available online at: http://webarchive.nationalarchives.gov.uk/20140714084352/; http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317141171280 [verified 17 November 2014].

[9]  Shockman S, Buescher LS, Stone SP. Syphilis in the United States. Clin Dermatol 2014; 32 213–8.
Syphilis in the United States.Crossref | GoogleScholarGoogle Scholar | 24559556PubMed |

[10]  Blocker ME, Levine WC, St Louis ME. HIV prevalence in patients with syphilis, United States. Sex Transm Dis 2000; 27 53–9.
HIV prevalence in patients with syphilis, United States.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c7hvFSgsw%3D%3D&md5=28dfe2bf53b069a51e59ae76fcc80932CAS | 10654870PubMed |

[11]  Hourihan M, Wheeler H, Houghton R, Goh BT. Lessons from the syphilis outbreak in homosexual men in east London. Sex Transm Infect 2004; 80 509–11.
Lessons from the syphilis outbreak in homosexual men in east London.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2crpvFGrsA%3D%3D&md5=f5494b838306ce00cfc5f3b58e063108CAS | 15572625PubMed |

[12]  Tucker SC, Yates VM, Thambar IV. Unusual skin ulceration in an HIV-positive patient who had cutaneous syphilis and neurosyphilis. Br J Dermatol 1997; 136 946–8.
Unusual skin ulceration in an HIV-positive patient who had cutaneous syphilis and neurosyphilis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2szmtVyksg%3D%3D&md5=da5fc24a2a0b6cbfe7b673405f0d93cdCAS | 9217833PubMed |

[13]  Musher DM, Hamill RJ, Baughn RE. Effect of human immunodeficiency virus (HIV) infection on the course of syphilis and on the response to treatment. Ann Intern Med 1990; 113 872–81.
Effect of human immunodeficiency virus (HIV) infection on the course of syphilis and on the response to treatment.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK3M%2Flt1OqsQ%3D%3D&md5=9faf57093672cc0f6f7c63cef4fbecfeCAS | 2240901PubMed |

[14]  Glover RA, Piaquadio DJ, Kern S, Cockerell CJ. An unusual presentation of secondary syphilis in a patient with human immunodeficiency virus infection. A case report and review of the literature. Arch Dermatol 1992; 128 530–4.
An unusual presentation of secondary syphilis in a patient with human immunodeficiency virus infection. A case report and review of the literature.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK383lsFekuw%3D%3D&md5=eac66ed694eedcc039d7e145341fc84eCAS | 1580662PubMed |

[15]  Katz DA, Berger JR, Duncan RC. Neurosyphilis. A comparative study of the effects of infection with human immunodeficiency virus. Arch Neurol 1993; 50 243–9.
Neurosyphilis. A comparative study of the effects of infection with human immunodeficiency virus.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK3s7otlSqsQ%3D%3D&md5=87df5402764f69b30aa9108558858a34CAS | 8442701PubMed |

[16]  Garnett GP, Aral SO, Hoyle DV, Cates W, Anderson RM. The natural history of syphilis. Implications for the transmission dynamics and control of infection. Sex Transm Dis 1997; 24 185–200.
The natural history of syphilis. Implications for the transmission dynamics and control of infection.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s3ls1aqug%3D%3D&md5=e7651a11e95fc557a651d1e675c941d2CAS | 9101629PubMed |

[17]  Radolf J, Lukehart S. Pathogenic Treponema: molecular and cellular biology. Wyndmondham, UK: Caister Academic Press; 2006.

[18]  Baughn RE, Musher DM. Secondary syphilitic lesions. Clin Microbiol Rev 2005; 18 205–16.
Secondary syphilitic lesions.Crossref | GoogleScholarGoogle Scholar | 15653827PubMed |

[19]  Gjestland T. The Oslo study of untreated syphilis; an epidemiologic investigation of the natural course of the syphilitic infection based upon a re-study of the Boeck–Bruusgaard material. Acta Derm Venereol Suppl (Stockh) 1955; 35 3–368.
| 1:STN:280:DyaG28%2FltlKmtA%3D%3D&md5=a0fd265c002d9e7fa9b436712a547b4cCAS | 13301322PubMed |

[20]  Kampmeier RH. The Tuskegee study of untreated syphilis. South Med J 1972; 65 1247–51.
The Tuskegee study of untreated syphilis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaE3s%2FhtVGjtA%3D%3D&md5=d0271ab83dc948ddcde07eafc3fe5fd8CAS | 5074095PubMed |

[21]  Roberts WC, Ko JM, Vowels TJ. Natural history of syphilitic aortitis. Am J Cardiol 2009; 104 1578–87.
Natural history of syphilitic aortitis.Crossref | GoogleScholarGoogle Scholar | 19932796PubMed |

[22]  O’Donnell JA, Emery CL. Neurosyphilis: a current review. Curr Infect Dis Rep 2005; 7 277–84.
Neurosyphilis: a current review.Crossref | GoogleScholarGoogle Scholar | 15963329PubMed |

[23]  Lynn WA, Lightman S. Syphilis and HIV: a dangerous combination. Lancet Infect Dis 2004; 4 456–66.
Syphilis and HIV: a dangerous combination.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2czhvFGhtg%3D%3D&md5=5cf36c88ad35ce618251657b6d858197CAS | 15219556PubMed |

[24]  Burgoyne M, Agudelo C, Pisko E. Chronic syphilitic polyarthritis mimicking systemic lupus erythematosus/rheumatoid arthritis as the initial presentation of human immunodeficiency virus infection. J Rheumatol 1992; 19 313–5.
| 1:STN:280:DyaK38zjtlCrsg%3D%3D&md5=e076c9eb109024069f572f1ecdb14578CAS | 1629836PubMed |

[25]  Reginato AJ. Syphilitic arthritis and osteitis. Rheum Dis Clin North Am 1993; 19 379–98.
| 1:STN:280:DyaK3s3ns1SisQ%3D%3D&md5=f5bd3c0ff195229023fd1403949e6b80CAS | 8502778PubMed |

[26]  Kastner RJ, Malone JL, Decker CF. Syphilitic osteitis in a patient with secondary syphilis and concurrent human immunodeficiency virus infection. Clin Infect Dis 1994; 18 250–2.
Syphilitic osteitis in a patient with secondary syphilis and concurrent human immunodeficiency virus infection.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2c3htl2lsA%3D%3D&md5=f59af12b72368691e25164797ad424a3CAS | 8161637PubMed |

[27]  Kusner DJ, Ellner JJ. Syphilis: a reversible cause of nephrotic syndrome in HIV infection. N Engl J Med 1991; 324 341–2.
Syphilis: a reversible cause of nephrotic syndrome in HIV infection.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK3M%2FpsV2rsw%3D%3D&md5=d6e40059d96de917cae36fa607f8733eCAS | 1986297PubMed |

[28]  Zaharopoulos P, Wong J. Cytologic diagnosis of syphilitic pleuritis: a case report. Diagn Cytopathol 1997; 16 35–8.
Cytologic diagnosis of syphilitic pleuritis: a case report.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s7oslarsw%3D%3D&md5=132e5cb6b3bc3a71d6a05b4e4364602eCAS | 9034734PubMed |

[29]  Olmos JM, Fernández-Ayala M, Gutierrez JA, Val JF, González-Marcías J. Superior vena cava syndrome secondary to syphilitic aneurysm of the ascending aorta in a human immunodeficiency virus-infected patient. Clin Infect Dis 1998; 27 1331–2.
| 1:STN:280:DyaK1M%2FksVGnuw%3D%3D&md5=0545ef729af49e156ea04d7c186eb73aCAS | 9827300PubMed |

[30]  Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH, Chiu M, et al A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group. N Engl J Med 1997; 337 307–14.
A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2szmsFSnsg%3D%3D&md5=c376d0f715f0ff042365b2a793fac2a1CAS | 9235493PubMed |

[31]  Rompalo AM, Lawlor J, Seaman P, Quinn TC, Zenilman JM, Hook EW. Modification of syphilitic genital ulcer manifestations by coexistent HIV infection. Sex Transm Dis 2001; 28 448–54.
Modification of syphilitic genital ulcer manifestations by coexistent HIV infection.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD3MXmsV2ktro%3D&md5=2719727ff55efd6182697c127d03cf04CAS | 11473216PubMed |

[32]  Hope-Rapp E, Anyfantakis V, Fouéré S, Bonhomme P, Louison JB, de Marsac TT, et al Etiology of genital ulcer disease. A prospective study of 278 cases seen in an STD clinic in Paris. Sex Transm Dis 2010; 37 153–8.
Etiology of genital ulcer disease. A prospective study of 278 cases seen in an STD clinic in Paris.Crossref | GoogleScholarGoogle Scholar | 19910862PubMed |

[33]  Tipple C, Hanna MO, Hill S, Daniel J, Goldmeier D, McClure MO, et al Getting the measure of syphilis: qPCR to better understand early infection. Sex Transm Infect 2011; 87 479–85.
Getting the measure of syphilis: qPCR to better understand early infection.Crossref | GoogleScholarGoogle Scholar | 21752804PubMed |

[34]  Hutchinson CM, Hook EW, Shepherd M, Verley J, Rompalo AM. Altered clinical presentation of early syphilis in patients with human immunodeficiency virus infection. Ann Intern Med 1994; 121 94–100.
Altered clinical presentation of early syphilis in patients with human immunodeficiency virus infection.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2c3ovVeqtw%3D%3D&md5=43c6872e3fa8a905ee3000a93b507bfeCAS | 7912483PubMed |

[35]  Schöfer H, Imhof M, Thoma-Greber E, Brockmeyer N, Hartmann M, Gerken G, et al Active syphilis in HIV infection: a multicentre retrospective survey. The German AIDS Study Group (GASG). Genitourin Med 1996; 72 176–81.
| 8707318PubMed |

[36]  Centres for Disease Control and Prevention Primary and secondary syphilis – Jefferson county, Alabama, 2002–2007. MMWR Morb Mortal Wkly Rep 2009; 58 463–7.
| 19444149PubMed |

[37]  Gunn RA. Expedited intervention services for possible occult primary syphilis among MSM with asymptomatic incident syphilis. Sex Transm Dis 2009; 36 594–5.
Expedited intervention services for possible occult primary syphilis among MSM with asymptomatic incident syphilis.Crossref | GoogleScholarGoogle Scholar | 19661841PubMed |

[38]  Wong W, Chaw JK, Kent CK, Klausner JD. Risk factors for early syphilis among gay and bisexual men seen in an STD clinic: San Francisco, 2002–2003. Sex Transm Dis 2005; 32 458–63.
Risk factors for early syphilis among gay and bisexual men seen in an STD clinic: San Francisco, 2002–2003.Crossref | GoogleScholarGoogle Scholar | 15976605PubMed |

[39]  Farhi D, Benhaddou N, Grange P, Zizi N, Deleuze J, Morini JP, et al Clinical and serologic baseline and follow-up features of syphilis according to HIV status in the post-HAART era. Medicine 2009; 88 331–40.
Clinical and serologic baseline and follow-up features of syphilis according to HIV status in the post-HAART era.Crossref | GoogleScholarGoogle Scholar | 19910747PubMed |

[40]  Sands M, Markus A. Lues maligna, or ulceronodular syphilis, in a man infected with human immunodeficiency virus: case report and review. Clin Infect Dis 1995; 20 387–90.
Lues maligna, or ulceronodular syphilis, in a man infected with human immunodeficiency virus: case report and review.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2M3mtV2ntg%3D%3D&md5=88dc2fb92195caefe60bb90abbec9080CAS | 7742445PubMed |

[41]  Wappner D, Carbia S, Gioseffi L, Schroh R, Losso MH. Diagnosis: malignant syphilis. Clin Infect Dis 1997; 25 1343–7.
| 1:STN:280:DyaK1c%2FptlCjsA%3D%3D&md5=ed450c4f73fa7b51f4fcaee3fa3103f7CAS | 9431374PubMed |

[42]  Hira SK, Patel JS, Bhat SG, Chilikima K, Mooney N. Clinical manifestations of secondary syphilis. Int J Dermatol 1987; 26 103–7.
Clinical manifestations of secondary syphilis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL2s7ptlCjtg%3D%3D&md5=a67463d6bc2a328e173973f01bdd326bCAS | 3570579PubMed |

[43]  Castro JG, Alcaide ML, Rosa-Cunha I. Clinical and epidemiological characteristics of individuals with very high rapid plasma reagin. Int J STD AIDS 2013; 25 593–5.
Clinical and epidemiological characteristics of individuals with very high rapid plasma reagin.Crossref | GoogleScholarGoogle Scholar | 24352133PubMed |

[44]  Heyman A, Sheldon WH, Evans LD. Pathogenesis of the Jarisch-Herxheimer reaction; a review of clinical and experimental observations. Br J Vener Dis 1952; 28 50–60.
| 1:STN:280:DyaG38%2FmsFehsw%3D%3D&md5=d417e6cba2a703ee59b8f9aeadf22259CAS | 14935211PubMed |

[45]  Bryceson AD. Clinical pathology of the Jarisch-Herxheimer reaction. J Infect Dis 1976; 133 696–704.
Clinical pathology of the Jarisch-Herxheimer reaction.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaE283hs1WhtA%3D%3D&md5=e537c56532747775abb12b4fb45a59cfCAS | 932495PubMed |

[46]  Pound MW, May DB. Proposed mechanisms and preventative options of Jarisch-Herxheimer reactions. J Clin Pharm Ther 2005; 30 291–5.
Proposed mechanisms and preventative options of Jarisch-Herxheimer reactions.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD2MXlslKmtbs%3D&md5=9daf90eace29f14978b1961ef9dbda74CAS | 15896248PubMed |

[47]  Johns DR, Tierney M, Felsenstein D. Alteration in the natural history of neurosyphilis by concurrent infection with the human immunodeficiency virus. N Engl J Med 1987; 316 1569–72.
Alteration in the natural history of neurosyphilis by concurrent infection with the human immunodeficiency virus.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL2s3ivVykug%3D%3D&md5=81181a2a84d8b3df357504206fce87a0CAS | 3587290PubMed |

[48]  Flood JM, Weinstock HS, Guroy ME, Bayne L, Simon RP, Bolan G. Neurosyphilis during the AIDS epidemic, San Francisco, 1985–1992. J Infect Dis 1998; 177 931–40.
Neurosyphilis during the AIDS epidemic, San Francisco, 1985–1992.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1c7psVGrug%3D%3D&md5=27b146799625cea64aaf58c573579bdeCAS | 9534965PubMed |

[49]  Marra CM. Update on neurosyphilis. Curr Infect Dis Rep 2009; 11 127–34.
Update on neurosyphilis.Crossref | GoogleScholarGoogle Scholar | 19239803PubMed |

[50]  Dumaresq J, Langevin S, Gagnon S, Serhir B, Deligne B, Tremblay C, et al Clinical prediction and diagnosis of neurosyphilis in HIV-infected patients with early syphilis. J Clin Microbiol 2013; 51 4060–6.
Clinical prediction and diagnosis of neurosyphilis in HIV-infected patients with early syphilis.Crossref | GoogleScholarGoogle Scholar | 24088852PubMed |

[51]  Marra CM, Maxwell CL, Smith SL, Lukehart SA, Rompalo AM, Eaton M, et al Cerebrospinal fluid abnormalities in patients with syphilis: association with clinical and laboratory features. J Infect Dis 2004; 189 369–76.
Cerebrospinal fluid abnormalities in patients with syphilis: association with clinical and laboratory features.Crossref | GoogleScholarGoogle Scholar | 14745693PubMed |

[52]  Marra CM, Maxwell CL, Tantalo L, Eaton M, Rompalo AM, Raines C, et al Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter? Clin Infect Dis 2004; 38 1001–6.
Normalization of cerebrospinal fluid abnormalities after neurosyphilis therapy: does HIV status matter?Crossref | GoogleScholarGoogle Scholar | 15034833PubMed |

[53]  Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA. Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients. Clin Infect Dis 2008; 47 258–65.
Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients.Crossref | GoogleScholarGoogle Scholar | 18532887PubMed |

[54]  Centers for Disease Control and Prevention (CDC) Symptomatic early neurosyphilis among HIV-positive men who have sex with men–four cities, United States, January 2002-June 2004. MMWR Morb Mortal Wkly Rep 2007; 56 625–8.
| 17597693PubMed |

[55]  Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA. Neurosyphilis in a clinical cohort of HIV-1-infected patients. AIDS 2008; 22 1145–51.
Neurosyphilis in a clinical cohort of HIV-1-infected patients.Crossref | GoogleScholarGoogle Scholar | 18525260PubMed |

[56]  Taylor MM, Aynalem G, Olea LM, He P, Smith LV, Kerndt PR. A consequence of the syphilis epidemic among men who have sex with men (MSM): neurosyphilis in Los Angeles, 2001–2004. Sex Transm Dis 2008; 35 430–4.
A consequence of the syphilis epidemic among men who have sex with men (MSM): neurosyphilis in Los Angeles, 2001–2004.Crossref | GoogleScholarGoogle Scholar | 18446083PubMed |

[57]  Chang CC, Leslie DE, Spelman D, Chua K, Fairley CK, Street A, et al Symptomatic and asymptomatic early neurosyphilis in HIV-infected men who have sex with men: a retrospective case series from 2000 to 2007. Sex Health 2011; 8 207–13.
Symptomatic and asymptomatic early neurosyphilis in HIV-infected men who have sex with men: a retrospective case series from 2000 to 2007.Crossref | GoogleScholarGoogle Scholar | 21592435PubMed |

[58]  Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC) Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59 1–110.
| 21160459PubMed |

[59]  Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA. Lumbar puncture in HIV-infected patients with syphilis and no neurologic symptoms. Clin Infect Dis 2009; 48 816–21.
Lumbar puncture in HIV-infected patients with syphilis and no neurologic symptoms.Crossref | GoogleScholarGoogle Scholar | 19187028PubMed |

[60]  Chan DJ. Syphilis and HIV co-infection: when is lumbar puncture indicated? Curr HIV Res 2005; 3 95–8.
Syphilis and HIV co-infection: when is lumbar puncture indicated?Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD2MXhslChtw%3D%3D&md5=c6cc4c5feb5bcb79a3de7a98f315c878CAS | 15638727PubMed |

[61]  Kiss S, Damico FM, Young LH. Ocular manifestations and treatment of syphilis. Semin Ophthalmol 2005; 20 161–7.
Ocular manifestations and treatment of syphilis.Crossref | GoogleScholarGoogle Scholar | 16282150PubMed |

[62]  Aldave AJ, King JA, Cunningham ET. Ocular syphilis. Curr Opin Ophthalmol 2001; 12 433–41.
Ocular syphilis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3MnovVWktg%3D%3D&md5=c85e033f05986f51d0da796c8e09aff6CAS | 11734683PubMed |

[63]  Gaudio PA. Update on ocular syphilis. Curr Opin Ophthalmol 2006; 17 562–6.
Update on ocular syphilis.Crossref | GoogleScholarGoogle Scholar | 17065926PubMed |

[64]  Balba GP, Kumar PN, James AN, Malani A, Palestine AG, Welch JN, et al Ocular syphilis in HIV-positive patients receiving highly active antiretroviral therapy. Am J Med 2006; 119 e21
Ocular syphilis in HIV-positive patients receiving highly active antiretroviral therapy. Crossref | GoogleScholarGoogle Scholar | 16651059PubMed |

[65]  Shalaby IA, Dunn JP, Semba RD, Jabs DA. Syphilitic uveitis in human immunodeficiency virus-infected patients. Arch Ophthalmol 1997; 115 469–73.
Syphilitic uveitis in human immunodeficiency virus-infected patients.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s3mtlyrsA%3D%3D&md5=5ad70734fdb0a3957a5f58c42ce5211bCAS | 9109754PubMed |

[66]  Pónyai K, Ostorházi E, Mihalik N, Rozgonyi F, Kárpáti S, Marschalkó M. Syphilis and HIV coinfection – Hungarian Sexually Transmitted Infection Centre Experience between 2005 and 2013. Acta Microbiol Immunol Hung 2013; 60 247–49.
Syphilis and HIV coinfection – Hungarian Sexually Transmitted Infection Centre Experience between 2005 and 2013.Crossref | GoogleScholarGoogle Scholar | 24060550PubMed |

[67]  Anderson J, Mindel A, Tovey SJ, Williams P. Primary and secondary syphilis, 20 years’ experience. 3: Diagnosis, treatment, and follow up. Genitourin Med 1989; 65 239–43.
| 1:STN:280:DyaK3c%2FjsVyktA%3D%3D&md5=c439e0624546a6e5cec2ac0977080c4fCAS | 2807281PubMed |

[68]  Chapel TA. The signs and symptoms of secondary syphilis. Sex Transm Dis 1980; 7 161–4.
The signs and symptoms of secondary syphilis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaL3M7gtlGgug%3D%3D&md5=9822e0b1ae02f076645c530ceadca840CAS | 7455863PubMed |

[69]  Yimtae K, Srirompotong S, Lertsukprasert K. Otosyphilis: a review of 85 cases. Otolaryngol Head Neck Surg 2007; 136 67–71.
Otosyphilis: a review of 85 cases.Crossref | GoogleScholarGoogle Scholar | 17210336PubMed |