Term
| Causative Agent of Chancroid |
|
Definition
|
|
Term
| True or False: H. ducreyi infects only humans |
|
Definition
| True, there are no animal or environmental reservoirs for H. ducreyi. |
|
|
Term
| Morphology and staining characteristics of H. ducreyi |
|
Definition
| Gram negative coccobacillus |
|
|
Term
| Global prevalence of chancroid |
|
Definition
| 4-6 Million from a WHO estimate |
|
|
Term
| Most common diseases that cause genital ulcers |
|
Definition
| Chancroid, syphilis, genital herpes |
|
|
Term
| Epidemiologic correlates of chancroid transmission are: |
|
Definition
| IDU, other street drug use, high amount of sexual activity as in commercial sex workers, HIV and HSV co-infection are common |
|
|
Term
Diseases that cause genital ulcers tend to the risk of contracting or transmitting HIV
|
|
Definition
|
|
Term
| The true prevalence of chancroid is probably: |
|
Definition
| Under-estimated, because H. ducreyi is difficult to culture and clinical diagnoses are unreliable, no commercial PCR assay is available yet. |
|
|
Term
| The proposed mechanism of chancroid and increased HIV transmission is: |
|
Definition
| The cell-mediated immune response is chiefly CD4 Th1, the influx of CD4 cells facilitates transmisison of HIV |
|
|
Term
| The incubation period of H. ducreyi is: |
|
Definition
| From one day to several weeks, median period is about one week |
|
|
Term
| H. ducreyi replicates between these two stages of disease: |
|
Definition
| Papular and pustular, the first sign of infection is typically small papules in the genital area, which eventualy become non-indurated ulcers. Bacteria can be shed before ulcer formation. |
|
|
Term
| True or false, H. ducreyi can synthesize heme and thus does not use hemolysin to liberate heme from host erythrocytes |
|
Definition
| False, the sole source of iron and heme for H. ducreyi is human erythrocytes, which are lysed with hemolysin and then the heme is taken up into the bacterial cells via TonB-dependent receptors, a member of a family of outer membrane proteins. |
|
|
Term
| Initial presentation of genital lesions in chancroid |
|
Definition
| Papules with surrounding tender erythematous tissue |
|
|
Term
| True or false, like chancres in syphilis, ulcers in chancroid are non-tender |
|
Definition
| False, the ulcers in chancroid are tender and non-indurated, and bleed easily when palpated |
|
|
Term
| True or false, inguinal lymphadenopathy is present in two thirds of all cases of chancroid |
|
Definition
| False, inguinal lymphadenopathy is present in about half of all cases of chancroid, these can progress to bubos and rupture, leading to chronic draining sinuses |
|
|
Term
|
Definition
| Painful and swollen lymph node, can form in chancroid if left untreated |
|
|
Term
| True or false, azithromycin 1 mg PO once a day for a week is the preferred tx for chancroid |
|
Definition
| False, azithromycin 1 mg PO as a one time tx is the preferred initial treatment for chancroid, along with ceftriaxone 250 mg IM single dose and ciprofloxacin 500 mg PO bid for three days, or erythromycin 500 mg PO tid for three days. Resistance to ceftriaxone outside the US has been reported, especially in HIV + patients |
|
|
Term
| What are some prevention keys for chancroid? |
|
Definition
| Any sexual partners within preceding 10 days of symptom onset should be treated. |
|
|
Term
| True or False: C. trachomatis can synthesize peptidoglycan |
|
Definition
| True, all genes necessary for peptidoglycan synthesis are present in the chlamydia genome, however it lacks the FSTZ gene which initiates cell division. |
|
|
Term
| True or False: Chlamydia is the most common sexually transmitted infection in the United States |
|
Definition
| True, with black women and men disproportionately affected, and C. trachomatis is a major cause of PID and sterility in women and men. |
|
|
Term
| True or false, along with humans, pigs and birds are reservoirs of C. trachomatis |
|
Definition
| False, humans are the only reservoir |
|
|
Term
| True or false, chlamydia incidence tends to peak in the summer months |
|
Definition
| False, chlamydia exhibits no temporal pattern |
|
|
Term
| What is the co-infection proportion of men with gonococcal urethritis with C. trachomatis? |
|
Definition
| 20%, asymptomatic carriage is relatively uncommon (<1/3 of all men with positive swabs for chlamydia), however 40-50% of NGU is caused by C. trachomatis |
|
|
Term
| In homosexual men, which strain(s) of C. trachomatis produce the most severe symptoms of proctitis? |
|
Definition
| The lymphogranuloma venereum (LGV) strains, includes rectal pain and discharge |
|
|
Term
| True or false, chlamydia is the most common cause of epididymitis in heterosexual men and prostatitis in men <35 |
|
Definition
| True, it is rare to see epididymitis in homosexual men with chlamydia |
|
|
Term
| What syndrome, which includes symptoms of urethritis, also presents with polyarthritis and is probably of autoimmune origin? |
|
Definition
| Reiter's syndrome, it is associated with a gene in the HLA-B27 locus. |
|
|
Term
| True or false, men and women have about equal rates of asymptomatic carriage of chlamydia |
|
Definition
| False, 30-60% of women with chlamydia infections are asymptomatic, with the cervix being the most common site of infection. Chlamydia cannot infect squamous epithelial cells, instead favoring the cuboidal cells of the cervix. |
|
|
Term
| Along with PID, what other clinical diagnoses are common in chlamydia infection in women? |
|
Definition
| Cervicitis is most common, then endometritis, perihepatitis (Fitz-Hugh Curtis Syndrome), urethritis, and LGV |
|
|
Term
| Risk factors for chlamydial infection include: |
|
Definition
| Number of sexual partners, black race, young age, marital status and poverty |
|
|
Term
| The annual incidence of chlamydia infections in the US is: |
|
Definition
| 4 millions cases per year |
|
|
Term
| What are three complications of chlamydial infection related to pregnancy and childbirth? |
|
Definition
| Inclusion conjuctivitis of the neonate, onset 5-14 days after birth, can be self-limited by tx with erythromycin is recommended, Infant pneumonia can be a serious consequence, staccato cough and apnea, afebrile, tx with erythromycin, most common cause of infant pneumonia in US |
|
|
Term
| These three serovars of C. trachomatis cause LGV |
|
Definition
|
|
Term
| This stage of LGV is typically self limited, may cause proctitis with mucopurulent discharge and is the least severe of the three stages of LGV |
|
Definition
| Stage 1, usually resolves in a few weeks |
|
|
Term
| This stage of LGV can result in the formation of draining sinus tracts, fistulas, takes more than a month to resolve, can occur with fever, myalgia and unilateral lymphadenopathy and leaves permanent scars |
|
Definition
| Stage two, bubo formation can rupture leading to sinus tracts and fistulas |
|
|
Term
| This stage of chlamydia is rare, affecting only 5% of those infected, but can result in lymphedema and elephentiasis |
|
Definition
|
|
Term
| Given the unreliable nature of culture and clinical dx, these tests are the most sensitive for detecting chlamydia |
|
Definition
| Nucleic Acid Amplification tests, not commercially available for chlamydia yet in the US, other STD tests should be done as well |
|
|
Term
| Who should be screened for chlamydia? |
|
Definition
- Sexually active non-pregnant women <24 or older with other risk factors (poverty, race, single, past infection)
- All pregnant women <24 or older pregnant women wiht risk factors
- Do not screen low risk women >25
- Men should not be screened
|
|
|
Term
| These two STI's have often been confused throughout history, given similar symptoms of mucopurulent discharge from the urethra |
|
Definition
| Gonorrhea and syphilis, Paracelsus thought gonorrhea to be an early sx of syphilis, John Hunter thought he was incoulating himself with gonorrheal discharge and in fact gave himself syphilis |
|
|
Term
| This is the causative agent of gonorrhea |
|
Definition
| Neisseria gonorrheae, a gram negative diplococcus |
|
|
Term
| These outer membrane molecules, as opposed to most gram negative bacteria, are thought to be an example of molecular mimicry, protecting neisseriae from host defenses |
|
Definition
| Lipooligosaccharide, as opposed to lipopolysaccharide, are similar to human sugars in cells, so host immune systems are more tolerant |
|
|
Term
| What are some functions of pili on N. gonorrheae? |
|
Definition
| Adherence to mucosal epithelial cells and sperm, inhibition of phagocytosis by macrophages, along with protein II |
|
|
Term
| This structure, common to gram negative and positive bacteria, is toxic to fallopian cilliary cells |
|
Definition
| Peptidoglycan of the inner cell membrane |
|
|
Term
| What is the incidence rate of gonorrhea infection in the US? |
|
Definition
| 1.4 million cases annually, most are not reported, similar risk factors as chlamydia, syphilis |
|
|
Term
| True or false, men are affected by gonorrhea at twice the rate of women |
|
Definition
| False, women have slightly higher rates of infection than men |
|
|
Term
| This group has some of the highest rates of gonorrhea infection |
|
Definition
| MSM, men who have sex with men, an order of magnitude higher incidence on a yearly basis |
|
|
Term
| True or false, gonorrhea can be spread through any type of sexual contact, not just penetrative intercourse, and can be spread vertically as well |
|
Definition
| True, and ejaculation does not need to take place for transmission to occur |
|
|
Term
| True or false, gonorrhea is only communicable when symptoms are present (mucopurulent discharge, urethritis, proctitis in men) |
|
Definition
| False, most cases are asymptomatic and communicable |
|
|
Term
| True or false, gonorrhea gains entry to mucosal epithelial cells via receptor-mediated endocytosis (e.g. clathrin coated pits) |
|
Definition
| False, N. gonorrheae are endocytosed but not dependent on receptors, use LOS and pilus to gain entry to cells, then exocytose into the sub-endothelial space |
|
|
Term
| True or false, women have a higher risk of developing infection after exposure to gonorrhea than men |
|
Definition
| True, 60-90% opposed to 25-35%, sx include cervicitis, bartholinitis, PID, urethritis |
|
|
Term
| True or false, Disseminated gonorrhea can cause polyarthritis, purulent arthritis and tenosynovitis |
|
Definition
| True, this type is resistant to humoral immunity but sensitive to penicillin, lacks protein II |
|
|
Term
| True or false, gonorrhea has developed abx resistance via plasmid transfer and displays beta-lactamase activity |
|
Definition
| True, still susceptible to azithromycin and doxycycline |
|
|
Term
| When should tx for chlamydia and gonorrhea be combined in someone positive for gonorrhea |
|
Definition
| When NAAT is positive for chlamydial DNA, otherwise co-tx is not necessary, gram stain is sufficient for dx in symptomatic persons, otherwise EIA "gonozyme" or culture with anti-fungal and abx to isolate neisseria |
|
|
Term
| This third-generation cephalosporin is the recommended current tx for gonorrheal infection |
|
Definition
| 125 mg ceftriaxone one time tx |
|
|
Term
| This tx, required by law in many states, is effective in preventing neonatal opthalmia |
|
Definition
| Administration of silver nitrate drops perinatally to the eys if the mother has gonorrhea |
|
|
Term
| True or false, screening for gonorrhea is recommended for all women regardless of risk profile |
|
Definition
| False, only women with elevated risk profile should be screened, men should not be screened |
|
|
Term
| True or false: A late tester is a person who tests positive for HIV, and within a year progresses to AIDS |
|
Definition
| True, 35% of new diagnoses in the US are late testers |
|
|
Term
| True or false: AIDS-defining illnesses and opportunistic infections are terms that can be used interchangeably |
|
Definition
| False, AIDS-defining illness are a specific set of illnesses that occur in HIV+ individuals, marking the progression to AIDS. A clinical dx is still based on a CD4 count <200, but even this isn't necessary in all dx, ie TB in an HIV+ individual is diagnostic of AIDS with or without serologic confirmation |
|
|
Term
| Historically, this illness marked the first recorded evidence in the US of AIDS, it still is the most common presenting OI in HIV+ individuals |
|
Definition
| PCP, Pneumocystis jirovecii pneumonia, a yeast-like fungus that causes diffuse interstitial and lobar pneumonia, its total incidence has decreased as ART is an effective prophylaxis against infection |
|
|
Term
| True or false: All AIDS-defining illnesses are infectious in etiology |
|
Definition
| False, though some cancers do have infectious etiologies, AIDS-related wasting is of unclear etiology, perhaps due to the hypermetabolic state induced by prolonged immune response, and some neoplasms in the set of AIDS-defining illnesses are of unclear etiology |
|
|
Term
| A yellow-white exudate covering the tongue, oropharynx or esophagus that can be wiped off, with underlying erythema, is likely to be this organism |
|
Definition
|
|
Term
| True or false: HIV can infect monocytes and macrophages without inducing cytopathic effects, making them an effective reservoir for HIV infection |
|
Definition
| True, both monocytes and macrophages can carry high intracellular viral loads without being destroyed, dendritic cells in lymph nodes are also implicated as reservoirs of infection |
|
|
Term
| In spite of initial viremia, which causes the acute retroviral symptoms of fever, myalgia, cough/sore throat and possibly a rash, HIV primarily infects what tissues as opposed to the blood? |
|
Definition
| Lymphoid (spleen, thymus, lymph nodes) and neural tissue (glial cells, not neurons) |
|
|
Term
| True or false: HIV-2 is prevalent in the US, Europe and Latin America, while HIV-1 is prevalent in Western Africa and SE Asia |
|
Definition
| False, other way around, they are genetically distinct but similar enough to both be called HIV |
|
|
Term
| What are the five populations most at risk for HIV infection? |
|
Definition
| MSM, still the most prevalent but incidence rates have fallen behind those of IDU and female partners of male IDU, children of mothers infected with HIV, and hemophiliacs, though their risk is about 1/200k due to screening of the blood supply and of doners |
|
|
Term
| This viral antigen is readily detected prior to seroconversion and can be used to test for the presence of HIV infection |
|
Definition
|
|
Term
| Other than p24, what are the contents of the viral core? |
|
Definition
| p7/p9 nucleocapsid proteins, two strands of viral RNA and the three viral enzymes necessary for viral replication: integrase, protease and reverse transcriptase |
|
|
Term
| This viral protein makes up the matrix between the envelope and core |
|
Definition
|
|
Term
| What two envelope proteins are critical to ensuring HIV infectivity, and what are their functions? |
|
Definition
| gp120 and gp41, gp120 binds to CD4 receptors on T cells and monocytes/macrophages, while gp41 facilitates fusion of the viral envelope to the host cell membrane to inject the viral core |
|
|
Term
| Which viral proteins display the most antigenic variation, making vaccine production difficult? |
|
Definition
| The envelope proteins make good vaccine targets b/c they are necessary for infection, but they display the most antigenic variation |
|
|
Term
| In addition to the M (major), O (outlier) and N (neither) sub-groups of HIV-1, clades A-K can be used to sub-divide group M. Which clade is most prevalent in North America? |
|
Definition
|
|
Term
| M tropic HIV binds this chemokine receptor, while T-tropic binds this other chemokine receptor, which is not expressed on non-T cells |
|
Definition
| CCR5 and CRCX4, the latter being specific to CD4+ T cells, T tropic HIV predominates in advanced infection, contributing to a worse prognosis |
|
|
Term
| Following synthesis of viral cDNA, what two fates await the new DNA? |
|
Definition
| It can remain as a linear episome in the cell, or enter the nucleus and integrate with host DNA, this can occur even in non-dividing cells as viral DNA can access host DNA through nuclear pores facilitated by viral proteins |
|
|
Term
| In addition to integration of viral cDNA into the host DNA, what must occur for viral replication to take place? |
|
Definition
| Cytokine stimulation of infected T-cells activates transcription factors, like NF-kB, which is normally inhibited in CD4 cells, bind to promoter sites on host DNA and initiate transcription of host DNA, which includes viral DNA, examples of cytokines inlude IL1, IL2, IL6, GM-CSF and TNFa |
|
|
Term
| The body can generate 2 billion CD4 T-cells a day while HIV can replicate up to 100 million new virions a day, how come CD4 counts still drop so drastically in advanced disease? |
|
Definition
| HIV can reduce CD4 cells indirectly by destroying lymphoid tissue, soluble gp120 might bind to CD4 marking them for destruction by CD8+ CTLs, destroying naiive and thymic T cells, and inducing apoptosis in uninfected CD4 cells |
|
|
Term
| Describe the paradoxic involvement of B cells in the natural history of HIV? |
|
Definition
| B cells actually upregulate their production of antibodies leading to hypergammaglobulinemia, however they are not effective antibodies, as disseminated infections of encapsulated bacteria like mycobacteria occur in AIDS patients, where antibodies are important in controlling infection |
|
|
Term
| True or false: CD4 counts are still the most important clinical markers of disease progression |
|
Definition
| True, viremia is low in the progression to AIDS but CD4 counts provide information on immune functional status |
|
|
Term
| Without treatment how long does it take for an HIV infected person to progress to AIDS, on average? |
|
Definition
|
|
Term
True or false: HAART or Highly Active Antiretroviral Therapy is comprised of
a combination of 3‐4 antiretroviral agents and is the current
standard of care for HIV therapy. |
|
Definition
| True, susceptiblities differ but generally it is an effective tx for HIV infection |
|
|
Term
| What are the 6 classes of anti-retroviral drugs available to tx HIV? |
|
Definition
| nucleoside-analog reverse transcriptase inhibitors (NRTI), NNRTI, CCR5 antagonists (maraviroc), Integrase inhibitors, Protease inhibitors, gp41 fusion inhibitors (enfurtivide) |
|
|
Term
| The first antiretroviral rx approved, this drug is an NRTI, crosses the BBB, and distributes well in all other tissues |
|
Definition
| zidovudine (AZT), a pyrimidine analog, metabolized by CYP 2A6 so co-administration with acetaminophen or other drugs can potentiate toxicity, resistance is common |
|
|
Term
| Often used in combination with zidovudine, this drug is less toxic and has good synergistic effects with zidovudine |
|
Definition
| lamuvidine, a cytosine analog, also not affected by food ingestion as much as AZT |
|
|
Term
| True or false: It is advised to use lamuvidine with other cytosine analogs like zalcitabine to potentiate its effects |
|
Definition
| False, they can actually inhibit eachother |
|
|
Term
| These drugs are effective tx, but inhibit CP450 enzymes in the liver causing toxicity, don't distribute in the CNS and cause numerous side effects, including fat redistribution (buffalo hump effect) |
|
Definition
| Protease inhibitors, resistance is also common so using as a single agent is not recommended, lopinavir is a recommended protease inhibitor |
|
|
Term
| This drug, while not used alone, can potentiate other protease inhibitors |
|
Definition
|
|
Term
| True or false: Treponema pallidum pertenue is the causative agent of syphilis |
|
Definition
| False, Treponema pallidum pallidum causes syphilis, Treponema pallidum pertenue causes Yaws (skin disease in the tropics) and Treponema pallidum carateum causes Pinta, Treponema pallidum endemicum causes endemic syphilis, the three other than syphilis are non-STD |
|
|
Term
| This stage of syphilis, associated with a painless chancre and occurring 10-90 days from exposure, is infectious via sexual or MCT |
|
Definition
|
|
Term
| T or F: Only secondary syphilitic infection can invade the nervous system |
|
Definition
| False, Primary and secondary syphilis will invade the CNS in 25-60% of cases |
|
|
Term
| T or F: Early neurosyphilis is asymptomatic |
|
Definition
|
|
Term
| 5% of those infected with syphilis will develop (), characterized by meningitis, cranial neuritis, ocular involvment and meningovascular disease |
|
Definition
| Early symptomatic neurosyphilis |
|
|
Term
| This consequence of () syphilis is associated with delusions of grandeur, delirium and ultimately death |
|
Definition
| General paresis *of the insane*, late neurosyphilis |
|
|
Term
| T or F: Latent syphilis is asymptomatic and only infectious via MCT |
|
Definition
|
|
Term
| What period of time is required to distinguish early latent syphilis from late latent syphilis? |
|
Definition
|
|
Term
| T or F: Tertiary syphilis, including neurosyphilis, is non-infectious |
|
Definition
|
|
Term
| T or F: the onset of different types of tertiary syphilis can be from 2-45 years after infection |
|
Definition
| True, CV syphilis, gummatous disease and late neurosyphilis all can occur much later than the original infection |
|
|
Term
| T or F: Primary syphilis, in addition to a chancre, presents with inguinal lymphadenopathy |
|
Definition
|
|
Term
| T or F: Tertiary syphilis consists of a flu-like syndrome, rashes and can occur with hepatitis, meningitis or glomerulonephritis |
|
Definition
| False, secondary syphilis |
|
|
Term
| T or F: Secondary syphilis presents with a rash that can be anywhere but also shows up on the palms and heels. |
|
Definition
| True, maculopapular and pustular rashes can occur anywhere, including palms, soles, armpits and back |
|
|
Term
| T or F: Latent syphilis begins once the rash of secondary syphilis has healed |
|
Definition
|
|
Term
| What two ways can syphilis be transmitted during latent syphilis? |
|
Definition
| Blood-blood and congenitally |
|
|
Term
| The three hallmarks of tertiary syphilis are: |
|
Definition
| Degeneration of the CNS, CV system and formation of granulomatous lesions (gummas) |
|
|
Term
Match each description with the name of the syndrome/disease in symptomatic neurosyphilis
-
- Spirochetes attack the blood vessels of the brain and meninges causing cerebrovascular occlusion and subsequent infarction in the brain and spinal cord
- Spirochetes invade the brain leading to insidious but progressive loss of mental and physical functions with mood alteration, terminating in severe dementia
- Damage to sensory nerves in the DCML and dorsal spinal roots, leading to impaired joint position sense, loss of pain sensation and absent DTR
- Pupil accomodates but does not react to light, seen in general paresis or tabes dorsalis
|
|
Definition
| Meningovascular disease, general paresis, tabes dorsalis, Argyll-Robertson pupil |
|
|
Term
| What percent of patients in latent syphilis progress to tertiary syphilis? |
|
Definition
| 40% 6-40 years from infection |
|
|
Term
| In asymptomatic neurosyphilis, what CSF features would lead to a diagnosis? |
|
Definition
| Pleocytosis of WBC, elevated protein, decreased glucose and presence of antibodies |
|
|
Term
| What is the most serious consequence of cardiovascular syphilis? |
|
Definition
| Aortic aneurysm post aortitis, aortic insufficency can occur too, in 10% of cases and is not resolvable with treatment |
|
|
Term
| T or F: the granulomata that form in liver skin and bone as a result of tertiary syphilis will not resolve without treatment |
|
Definition
| False, they eventually necrose and become fibrotic on their own |
|
|
Term
| What are some consequences of congenital syphilis? |
|
Definition
| Abortion, stillbirth or secondary-tertiary syphilis in the newborn, as well as deafness |
|
|
Term
| T or F: T. pallidum infection is diagnosed with immunofluorescent or dark field microscopy |
|
Definition
| False, serologic tests are preferred |
|
|
Term
| T or F: Treponemal serologic tests like the VDRL and RPR use antibodies to cardiolipin and lecithin, lipids released by the body to fight the infection, to detect the presence of infection, and are used to assess the success of syphilis treatment |
|
Definition
| False, those are non-treponemal tests |
|
|
Term
| T or F: Non treponemal tests (FTA ABS) for syphilis use antitreponemal antibodies specific to treponemal surface proteins. Since these are directed at the spirochete, they are more specific than other tests but will stay positive after treatment is successful, and are used to confirm the treponemal tests |
|
Definition
| False, the above describes treponemal tests. |
|
|
Term
| T or F: early syphilis (primary and secondary) is treated with penicillin, while tertiary and congenital disease is treated exclusively with erythromycin |
|
Definition
| False, both penicillin as first choice, be benzathine penicillin in early disease, penicillin G in late disease, if there's an allergy can use erythromycin or tetracycline but they won't work on neurosyphilis |
|
|
Term
| T or F: Syphilis is the third most common STD in the US following chlamydia and gonorrhea |
|
Definition
|
|
Term
| T or F: Syphilis has a host in humans and pigs |
|
Definition
| False, we are the only naturally occurring host |
|
|
Term
| T or F: Syphilis can increase the likelihood of HIV transmission 2-5 fold, MSM should get tested for both annually |
|
Definition
|
|
Term
| T or F: the probability of syphilis infection following sexual contact with an infected individual is 50-70% |
|
Definition
|
|
Term
| These broad, elevated plaques occur in secondary syphilis, usually in the armpits or antecubitus. |
|
Definition
|
|
Term
| T or F: in general paresis, depression, mania and psychosis are more common than dementia and personality changes |
|
Definition
| False, dementia and personality changes are more common |
|
|
Term
| The triad of late congenital syphilis is: |
|
Definition
| interstitial keratitis, hutchinson teeth (small incisors shaped like a screwdriver) and deafness |
|
|
Term
| Match the sequence of VDRL/RPR tests and FTA tests to the interpretation: ++, +-, -+ |
|
Definition
| Active syphilis infection, false-positive on non-treponemal, successfully treated syphilis |
|
|
