Great Pox ( smallpox) Great Pox [1,2] [2] [3] Philippe Ricord (syphilitic chancres) 1983 (Traite des maladies veneriennes) (primary) (s

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1 222 (reverse algorithm) 1, penicillin RPR/VDRL (reverse algorithm) 2017:27: syphilis Girolamo Fracastoro 1530 Syphilis sive morbus Gallicus (Syphilis or the French Disease) (syphilis) [1] (04) DOI: /ICJ

2 Great Pox ( smallpox) Great Pox [1,2] [2] [3] Philippe Ricord (syphilitic chancres) 1983 (Traite des maladies veneriennes) (primary) (secondary) (tertiary) [1] 1905 Fritz Schaudinn Erich Hoffmann Gram (-) Spirochaeta palida [1] 1906 von Wassermann (Nontreponemal Tests PRP: rapid plasma reagin Venereal Disease Research Laboratory VDRL) 1912 Henry J. Nichols William H. Hough salvarsan ( Nichols strain) [4] ( ) 1910 Paul Ehrlich Salvarsan ( arphenamine 606) salvarsan (magic bullet) [1] 1928 (penicillin) [5] 1943 John Mahoney penicillin [6] (doxycycline tetracycline) (azithromycin) (ceftriaxone) [7] ( Benzathine penicillin G)

3 µm 6~20 µm DNA 1.14 Mb ( E. coli DNA 4.6 Mb Bacillus subtilis DNA 4.2 Mb) (tricarboxylic cycle) ( 7 ) 30~33 [8] [8] 20 ( ) 1960 [9] ~ ~ ~ ,715 60% [10] [11] (syphilis serology test, STS) (nontreponemal test) (treponemal test) () [12,13] (rapid plasm reagin, RPR) (Veneral Disease Research Laboratory test, VDRL) VDRL 56 30

4 % %-60% 80% 5% (Gumma) 10% 15% 10 5 (General paresis) (Tabes dorsalis) 2-5% 2-9% [11] RPR RPR VDRL (Treponema pallidum haemagglutination, TPHA) (Treponema pallidum particle agglutination, TPPA) (fluorescent treponemal antibody absorption test, FTA-ABS) (Treponema pallidum latex agglutination, TPLA) (Enzyme immunoassay, EIA) (Chemiluminescence Immunoassays, CIA)

5 226 [12] VDRL RPR (biologic false-positive) 1~2% (HIV ) [11] RPR VDRL RPR/ VDRL 86/87% 100/100% 98/96% 73/71% TPHA/FTA-ABS 86/84% 100/100% 100/100% 99/96% [14] (darkfield microscopy) 15% [15] PCR DNA [12] (reverse algorithm) (immunoassay) (IgG IgG & IgM) RPR/VDRL (reverse algorithm) () [13,16,17] ( ) ( RPR) [16] RPR/ VDRL TPHA ( IgG-ELISA CLIA) 100%/98% 100%/100% 100%/100% 100%/99% ( RPR) [14] CDC % (n = 4834)

6 227 ( RPR VDRL) ( ) ( TPPA FTA-ABS ) ( RPR ) ( ) [13] ( ) 56.7% (n = 2743) ( RPR) ( TPPA FTA-ABS) 31.6% (n = 866) [17] reverse algorithm [17] EIA RPR [16] 2016 (1) (non-treponemal test) (treponemal test) (2) (

7 228 ( ) ( ) ( RPR VDRL) ( TPPA ) ( ) ( 2-4 ) ( ) (reverse algorithm) [13]

8 [13] 229 ( ) ( TPPA) ( RPR) Non-reactive Reactive Non-reactive Non-reactive Reactive Non-reactive Reactive Reactive Reactive

9 230 ) (3) (CSF-VDRL) (non-treponemal test) 4 (treponemal test) (TPHA) (TPPA) (FTA-ABS) (TPLA) (EIA) (CIA) Penicillin penicillin penicillin penicillin [18] penicillin ( Aqueous crystalline penicillin G Benzathine penicillin G) () 6-12 [19] primary syphilis secondary RPR nonreactive RPR [20] (reverse algorithm) RPR References 1. Franzen C: Syphilis in composers and musicians- -Mozart, Beethoven, Paganini, Schubert, Schumann, Smetana. Eur J Clin Microbiol Infect Dis 2008;27: Rothschild BM: History of syphilis. Clin Infect Dis 2005;40: Harper KN, Fyumagwa RD, Hoare R, et al:

10 231 Treponema pallidum infection in the wild baboons of East Africa: distribution and genetic characterization of the strains responsible. PLoS One, 2012;7: doi: /journal.pone Nichols HJ, Hough WH: Demonstration of Spirochaeta Pallida in the Cerebrospinal Fluid. JAMA 1913;60: Fleming A: On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B. influenzae. Bull World Health Organ 2001;79: Mahoney JF, Arnold RC, Sterner BL, et al: Penicillin Treatment of Early Syphilis: II. JAMA 1984;251: Tramont EC: Syphilis in adults: from Christopher Columbus to Sir Alexander Fleming to AIDS. Clin Infect Dis 1995;21: Lafond RE, Lukehart SA: Biological basis for syphilis. Clin Microbiol Rev 2006;19: Hook EW 3rd, Marra CM: Acquired syphilis in adults. N Engl J Med 1992;326: Garnett GP, Aral SO, Hoyle DV, et al: The natural history of syphilis. Implications for the transmission dynamics and control of infection. Sex Transm Dis 1997;24: Golden MR, Marra CM, Holmes KK: Update on syphilis: resurgence of an old problem. JAMA 2003;290: Larsen SA, Steiner BM, Rudolph AH: Laboratory diagnosis and interpretation of tests for syphilis. Clin Microbiol Rev 1995;8: Association of Public Health Laboratories (2015). Suggested Reporting Language for Syphilis Serology Testing. Available org/aboutaphl/publications/documents/id_ Suggested_Syphilis_Reporting_Lang_ pdf 14. Sena AC, White BL, Sparling PF: Novel Treponema pallidum serologic tests: a paradigm shift in syphilis screening for the 21st century. Clin Infect Dis 2010;51: Creegan L, Bauer HM, Samuel MC, et al: An evaluation of the relative sensitivities of the venereal disease research laboratory test and the Treponema pallidum particle agglutination test among patients diagnosed with primary syphilis. Sex Transm Dis 2007;34: Loeffelholz MJ, Binnicker MJ: It is time to use treponema-specific antibody screening tests for diagnosis of syphilis. J Clin Microbiol 2012;50: Centers for Disease Control and Prevention (CDC): Discordant results from reverse sequence syphilis screening-five laboratories, United States, MMWR 2011;60: Katz KA, Klausner JD: Azithromycin resistance in treponema pallidum. Curr Opin Infect Dis 2008;21: Workowski KA, Bolan GA: Sexually transmitted diseases treatment guidelines, MMWR Recomm Rep 2015;64: Fiumara NJ: Serologic responses to treatment of 128 patients with late latent syphilis. Sex Transm Dis 1979;6:

11 232 The Differences in Syphilis Diagnosis between Traditional and Reverse Testing Algorithm and Its Impact on Clinical Interpretation Cheng-Mao Ho 1,2, Mao-Wang Ho 3 1 Department of Clinical Pathology and 2 Infectious Disease, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation 3 Deapartments of Infectious Disease, China Medical University Hospital, Taichung, Taiwan Syphilis is a historic disease. Its prevalence rate remained high despite treatment with penicillin. With the advent of automatic systems used in clinical laboratories, the reverse algorithm has been suggested, which involves the replacement of the traditional syphilis screening test (RPR/VDRL) with the immunoassay. To date, the reverse algorithm is approved by the Centers for Disease Control as an alternative method for syphilis diagnosis. As more automatic systems are available in the clinical laboratories in Taiwan, the reverse algorithm for syphilis diagnosis is mostly commonly used. Understanding the differences between the traditional and reverse algorithms for syphilis diagnosis would be essential for all medical staffs. Key words: Syphilis, reverse algorithm, diagnosis, immunoassay

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72-04.indd 愛滋病毒感染者之梅毒感染的治療與追蹤楊家瑞亞東醫院內科部感染科愛滋病毒感染者之梅毒治療由於愛滋病毒與梅毒之共同感染會促成愛滋病毒易於傳播, 亦同時會讓梅毒感染症狀變化更為多樣化, 且較快進展至 [1,2] 因此, 如何