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In spite of its immutable susceptibility to penicillin, Treponema pallidum ( T . pallidum ) subsp. pallidum continues to cause millions of cases of syphilis each year worldwide, resulting in significant morbidity and mortality and underscoring the urgency of developing an effective vaccine to curtail the spread of the infection. Several technical challenges, including absence of an in vitro culture system until very recently, have hampered efforts to catalog the diversity of strains collected worldwide. Here, we provide near-complete genomes from 196 T . pallidum strains–including 191 T . pallidum subsp. pallidum –sequenced directly from patient samples collected from 8 countries and 6 continents. Maximum likelihood phylogeny revealed that samples from most sites were predominantly SS14 clade. However, 99% (84/85) of the samples from Madagascar formed two of the five distinct Nichols subclades. Although recombination was uncommon in the evolution of modern circulating strains, we found multiple putative recombination events between T . pallidum subsp. pallidum and subsp. endemicum , shaping the genomes of several subclades. Temporal analysis dated the most recent common ancestor of Nichols and SS14 clades to 1717 (95% HPD: 1543–1869), in agreement with other recent studies. Rates of SNP accumulation varied significantly among subclades, particularly among different Nichols subclades, and was associated in the Nichols A subclade with a C394F substitution in TP0380, a ERCC3-like DNA repair helicase. Our data highlight the role played by variation in genes encoding putative surface-exposed outer membrane proteins in defining separate lineages, and provide a critical resource for the design of broadly protective syphilis vaccines targeting surface antigens.

Abstract Loiasis is an infestation of the skin and eyes caused by the nematode Loa loa. We report a case of loiasis in a woman who contracted the infestation in Cameroon. The clinical picture was characterized by Calabar swellings on the upper limbs and axillary lymphadenopathy. Laboratory tests revealed persistent leucocytosis with neutropenia, lymphopenia, and eosinophilia. The search for microfilariae was always negative. The patient was successfully treated with ivermectin and albendazole. Follow-up (5 years) was negative for both clinical manifestations and laboratory tests.

Only some cases of pityriasis rosea (PR)/pityriasis rosea-like eruption (PRLE) after anti-SARS-CoV-2 vaccination have been reported. In the period May 2021 - February 2022 we observed five cases of clinically typical PR that appeared 2 to 3 weeks after anti-SARS-CoV-2 vaccination with BNT162b2 (3 patients) or mRNA-1273 (2 patients). In four patients PR appeared after the first vaccination; in one patient after the second one. In three patients a biopsy for histopathological examinations was carried out. Results were typical for PR. In all patients laboratory examinations were within normal ranges. All patients were treated with cetirizine. Complete remission was observed within 14-30 days. Four patients were subjected to the second vaccination, but no skin lesions appeared. All patients are currently in good general health. It is possible that a relationship anti-Sars-CoV-2 vaccination−PR/PRLE exists; however, it is very rare, in consideration of millions of vaccinated subjects and the low number of reported cases of PR/PRLE. The pathogenesis of this relationship is unknown. However, some hypotheses may be advanced: PR/PRLE following anti-Sars-CoV-2 vaccination may be just a coincidence; anti-Sars-CoV-2 vaccines cause a reactivation of HHV-6 and/or HHV-7; vaccines can induce a delayed hypersensitivity response clinically similar to drug-induced PRLE.

Introduction Anogenital warts (AGW) are a relevant clinical issue in the field of sexually transmitted disease, and to date no treatment provides a satisfactory clearance rate. Treatment can be both medical and surgical, and be provided by a healthcare provider or by the patient. Cryotherapy (CRYO) is among the most common treatments for AGW. Nitrizinc® Complex solution (NZCS) is a solution containing organic acids, nitric acid and zinc and copper salts that is applied topically to warts, producing mummification of the damaged tissue. It is considered to be an effective and well-tolerated treatment for genital and common warts. The aim of our study was to compare NZCS to CRYO in the treatment of AGW. Methods We performed a prospective, multicentre, single-blind, randomised, superiority clinical study involving 120 patients, aged 18–55 years, diagnosed with a first episode of AGW, with each patient having from three to ten AGW. The patients were treated either with NZCS or CRYO for a maximum of four treatments. Primary endpoints were: (1) comparison of the clinical efficacy of CRYO and NZCS, based on response to treatment (clearance of AGW) within four treatment sessions; and (2) tolerability, assessed via a short questionnaire at the end of each treatment session. Secondary endpoints were: (1) number of treatments needed for clearance; and (2) recurrence at 1 and 3e months after confirmed clearance. The results were analysed on an intention-to-treat basis. Results A complete response was achieved in 89.7% of the NZCS group and in 75.4% of the CRYO group ( p  = 0.0443). NZCS was found to be better tolerated. There was no difference between the NZCS and CRYO treatment arms in the number of sessions needed to clear the lesions. Recurrence occurred after 1 month in 18.4% of the NZCS group and 38.1% of the CRYO group ( p  = 0.0356), and after 3 months in 25 and 40.6% of these groups, respectively ( p  = 0.1479). Conclusions Nitrizinc® Complex solution can be considered to be as effective as CRYO for the treatment of small (< 5 mm) external AGW, with a better tolerability profile and lower rate of recurrence. Trial Registration ISRCTN identifier, ISRCTN36102369.

Neisseria gonorrhoeae (NG) antimicrobial susceptibility trends to azithromycin, cefixime and ceftriaxone were analyzed, from 2009 to 2016, to monitor changing antimicrobial susceptibility concomitant with the change in prescribing practice in 2012 from cefixime, or ceftriaxone, to ceftriaxone plus azithromycin. Patient characteristics predictive to be infected by antibiotic resistant N. gonorrhoeae were estimated. Finally, the protocol for the treatment of gonorrhoea, in comparison with the international guidelines, was also evaluated. Data on NG antimicrobial resistance were obtained from a network of sexually transmitted diseases clinics and other laboratories in 12 cities in Italy. We tested the 1,433 gonococci for antimicrobial susceptibility to azithromycin, cefixime and ceftriaxone using a gradient diffusion method. Logistic-regression methods with cluster robust standard errors were used to investigate the association of resistance categories with demographic and clinical patient characteristics and to assess changes in prescribing practices. To minimize bias due to missing data, all statistical models were fitted to data with forty rounds of multiple imputation, using chained equations. The percentage of isolates resistant to cefixime was 17.10% in 2009 and declined up to 1.39% in 2016; at the same time, those resistant to azithromycin was 23.68% in 2009 and 3.00% in 2012. Starting from 2013, azithromycin resistant gonococci tended to increase up to 7.44% in 2016. No ceftriaxone resistant isolates were observed. By multivariate analysis, the men who have sex with women (MSW) and women had a proportional adjusted OR of resistance of 1.25 (95%CI: 0.90; 1.73) and 1.67 (95%CI: 1.16; 2.40), respectively, in comparison with men who have sex with men (MSM). An aOR of resistance of 0.48 (95%CI: 0.21; 1.12) among NG isolated in the pharynx, compared with those isolated in genital sites, was calculated. The proportional aOR of resistance was 0.58 (95%CI: 0.38; 0.89) for presence vs absence of co-infection and 2.00 (95%CI: 1.36; 2.96) for past history vs no history of gonorrhoea.Finally, at least for the period 2013-2016, the older, subjects with anorectal or pharyngeal gonorrhoea infection, subjects with a co-infection, subjects with a previous gonorrhoea infection were not always correctly treated. Overall, our findings suggest the shifts in N. gonorrhoeae susceptibility to cefixime and azithromycin in the time frame period. First of all, the increasing rate of azithromycin resistance in 2015-2016 in NG isolated in the country need to be monitor in the future. Finally, extensive information on treatment regimens may be useful to asses treatment adherence particularly for the older subjects, subjects with an anorectal or pharyngeal infection, subjects with a co-infection and subjects with a previous history of gonorrhoea. Gonorrhoea treatment strategy should be based on the evidence obtained by the local antimicrobial surveillance system and data about treatment failures.

First of all, we thank the authors for their observations, which mainly reflect the difficulties in planning studies on the treatment of anogenital warts. [...]a longer evaluation period of 6–12 months would be interesting; however, in our experience, the number of patients not coming back after 6–12 months following treatment could be very high, preventing the collection of strong enough data for accurate interpretation. [...]we want to thank again Dr. Bertolotti and colleague for their observations, and we completely agree with their final statement.

Dear Editor,

BackgroundSyphilis incidence has exponentially increased in recent decades, particularly among men who have sex with men (MSM). Primary syphilis is characterised by a chancre appearing at the site of Treponema pallidum (TP) inoculation. Atypical morphological variants of syphilitic chancre are frequent. Clinical suspicion must be confirmed either by the demonstration of TP within the lesion through direct tests, such as dark field microscopy (DFM) or T. pallidum nucleic acid amplification technique (TP-NAAT), or by serological tests.ObjectivesTo analyse the clinical features, the sexual behaviour and the role of diagnostic tests in a cohort of men with primary syphilis in Milan.MethodsEpidemiological, clinical and laboratory data of male patients with primary syphilis seen at the STI Center of the University of Milan between 2015 and 2019 were retrospectively evaluated. Diagnosis was confirmed by at least one positive diagnostic test of either DFM, TP-NAAT or serology.ResultsAmong a total of 244 patients, 160 (65.6%) were MSM and 32 (13.1%) were living with HIV. One hundred twenty-four (50.8%) patients had a clinically atypical chancre. Chancres were exclusively extragenital in 30 (12.3%) patients, with MSM being more commonly affected (MSM vs heterosexuals: 16.3% vs 4.8%, respectively; p=0.012), and anal region the most frequently involved site. Chancres were multiple in 68/242 (28.1%) patients and morphologically atypical in 76/244 (31.1%). Diagnosis was obtained by (1) both serology and direct methods in 158/244 patients (64.7%), (2) serology solely in 47/244 (19.3%) and (3) direct methods solely in 39/244 (16%). DFM yielded positive results in 83/139 (59.7%) patients, while TP-NAAT gave positive results in 114/121 (94.2%) patients.ConclusionsPatients with primary syphilis frequently present with morphologically atypical chancres. Furthermore, MSM commonly exhibit extragenital involvement. A combined diagnostic approach including both direct and indirect tests is needed.

Vesico-pustular swabs tested negative for Herpes simplex virus (HSV), Chlamydia trachomatis (CT) and Treponema pallidum (TP), but positive for MPX on real-time polymerase chain reaction (PCR) in both patients. According to a large multicenter study [ 3], unilesional presentation accounts for about 10% of all MPX cases. Patient Age Sex/Sexual behaviour HIV status Travels abroad Unprotected sexual intercourses in the previous month Vaccination for smallpox Previuos STIs Number of lesions Localization Systemic symptoms MPX DNA Skin lesions MPX DNA pharynx 1 35 MSM + Greece Spain Yes No Syphilis 1 Foreskin No + – 2 29 MSM – No Yes No Syphilis, Gonorrhea 1 Penis trunk No + – Table 1 Epidemiological, clinical and laboratory data of two cases of unilesional MPX.