Syhilis Ch 153 • 1ary lision appears @ site of inoculation

persists 4-6 wks heals

I. Definition: ‘ a chrnic systemic infection spontaneously
caused by Trponema pallidum subspecies • histopath :1ary lesons have perivascular
pallidum, is usually sexually transmitted and is infiltration
characterized by episodes of active disease • 2dary syphilis appear 6-8wks after healing of
interrupted by periods of latency. chancre. (some appear months after or
Latency 2-6 weeks primary lesion w/ regional enter the next latent phase w.out even
lymphadenopathy. 2ndary bacteremic noticing 2dary lesions)
stage w/ gen. Mucocut. Lesions and gen.
• histopath: - hyperkeratosis or epidermis
Lymphadenopathy latent period of
subclinical infection for years. 3tiary stage or ­ capillary proliferation
progressive destructive mucocut., musculo, or ­ dermal papillae
parenchymal lesions, aortitis or CNS disease. ­ perivascular infiltration
II. Etiology
• Treponemes are found in many tissue,
T. pallidum subspecies pallidum:
cytoplasm has trilaminar cytoplasmic memb w invasion of CNS during 1st wks or months
peptidoglycan layer for structural rigidity. Lipid • Gen. Nontenderlymphadenopathy is noted
outer memb. Has structural proteins. in 85% pxns w/ 2ndary syphilis
• Endoflagella wind around • 2dary leions subside w/in 2-6wks latent
cell body in periplasmic space stage detectable only by serologic testing.
Responsible for motility • Thanks to antibiotics, tertiary disease such
• Genomic family TprK w/ variable (V) regions as gumma and CV syphils are now rare.
target humoral immune response and is a
mechanism for immune invasion. V. Manifestations
• The only known natural host for T. a. Primary syphilis
pallidum is the human! • Typical 1ary chancre: single painless
papule that rapidly becomes eroded and
III. Epidemiology indurated w/ cartilaginous onsistency on
• Usually acquired by sexual contact w/ edge and base of ulcer.
infections lesions. Also by non sexual • Multiple 1ary lesions more common in men
contact, infection in utero and blood w/ concurrent HIV.
transfusion.. • Differentials:
• Populations at risk have varied from Primary Tender nodes & multiple
homosexual men to african populations to genital painful vesucles- later
homosexual men again with HIV. herpes ulcerate- w/ systemic
• Congenital syphilis include all live or stillborn symptoms inc fever
infants delivered to women with untreated Recurrent Begins w unilateral cluster of
women with untreated or inadequately genital painful vesicles w/out
treated syphilis at delivery. herpes adenopathy
Chancroid Painful, superficial, exudative,
IV. Natural course and pathogenesis or nonindurated ulcers, multiple
untreated syphilis Donovanosi Granulomatous ulcer that
• Repidly penetrates intact mucous s although painless, is friable.
membranes or microscopic abrasions
• Enters lymphatics and blood to prod • Regional lymphadenopathy may persist for
systemic infection and metastatic foci b4 months while anal and ext. genital chancres
appearance of 1ary lesion. heal w/in 4-6 wks.
• Incubation period of syphlis is inversely b. Secondary syphilis
proportional to the number of organisms • Localized or diffuse symmetric
inoculated mucocutaneous lesions and generalized
• 107 treponemes/g tissue before appearance nontender lymphadenopathy
of clinical lesion.
• Initial lesions are bilat. Symmetric, pale
red.pink, nonpruritic, discrete, round
macules 5-10mm in diameter.
After several days or wks, red papular lesions
appear progress to necrotic lesions ass’td w
increasing endarteritis and perivascular
mononuclear infiltration, distrib. Widely and freq.
Involve the palms and soles.
• In warm, intetriginous body areas, papules
enlarge to become eroded and prod. Broad,
moist, pink or gray-white highly infections
lesions called condylomata lata.
• Superficial mucosal erosions called mucous
patches also occur
• Hepatic invovlement is commmon although
asymptomatic
• Renal invovlement prod. Proteinuria
associated w/ acute nephrotic syndrome.
c. Latent syphilis
• (+) serologic tests for syphilis, w/ normal
CSF exam and absence of clin.
Manifestations of syphilis, indicate diagnosis
of latent syphilis.
• Early latent syphilis: 1st year after infection
• Late latent syphilis: > 1yr after infection in
entreated pxn, associated w/ relative
immunity to infectious relapse. 3 outcomes:
1)lifetime persistence in infected individ
2)dev’t of late syphilis 3) spontaneous cure
of enfection
d. Involvement of the CNS
i. Asymptomatic neurosyphilis
• In pxns who lack neuro. Ss/s but have CSF
agnormalities inc. mononuclear pleocytosis,
inc. protein concentrations, or reactive
Veneral Disease Research Laboratory
(VDRL) slide test.
ii. Symptomatic neurosyphilis
• Major clinical categories of symptomatic
neurosyphilis inc: meningeal ,
meningovascular, parenchymatous syphilis.
• Meningeal syphilis prsents w/ headache,
nausea, vomiting, neck stiffness, CN
invovlement, seizures and changes in
mental status.
• Meningovascular syphilis reflects diffuse
inflammation of the pia and arachnoid w/
evidence of focal or widespread arterial
involvement of small, med or large vessels.
• PARESIS: Personality, Affect, Reflexes
(hyperactive), Eye, Sensorium, Intellect and
Speech are affected in widespread late
parenchymal damage.
• Tabes dorsalis is a late manifestation of
syphilis that presents as symptoms and
signs of demyelination of the posterior
columns, dorsal roots and dorsal root
ganglia.
e. Other manifestations of Late Syphilis
i. Cardiovascular syphilis
• Attributable to endarteritis obliterans of the
vasa vasorum
ii. Late benign syphilis (gumma)
• Gummas are multiple or diffuse but usually
solitary lesions that range from microscopic
in size to several cm in diameter. –a
granulomatous inflammation w/ central area
of necrosis.
• Tx w/ penicillin results in rapid healing of
active gummatous lesions
iii. Congenital syphilis
• From transmission from a syphilitic woman
to her fetus across the placenta. Lesions
generally have their onset after the 4th month
of gestation, when fetal immunologic
competence begins to develop. 3 types: (1)
early manifestations w/in 1st 2 yrs of life are
infectious and resemble the manifestations
of severe 2dary syphilis in adults (2) late
manifestations w/ch appear after 2 yrs & re
noninfectious (3)residual stigmata.
• Earliest sign of congenital syphilis is rhinitis
• The most common early manifestations are
bone changes.
• 60% of last cases (untreated after 2yrs of
age) remain subclinical
• characteristic stigmata:- Hutchinsons’s
teeth : centrally notched, widely spaced,
peg-shaped upper central incisor- and
mulberry molars (6th year molars with
multiple, poorly dev. Cusps.
­ frontal bossing, saddle nose and poorly
dev’d maxillae
VI. Laboratory examinations
• Cannot be demonstrated by culture
• Dark-field microscopic exam
• Direct fluorescent antibody T. pallidum test.
a. Serologic tests for syphilis
• Nontreponemal tests measure IgG and IgM
directed against a cardiolipin-lecithin-
cholesterol antigen complex
• 2 standard streponemal tests are used: the
fluorescent treponemal antibody-absorbed
test (FTA-ABS test) and the agglutination
assays for antibodies to T. pallidum
b. Evaluation for Neurosyphilis
• Detected by examination of CSF for
pleocytosis (>5 WBC/mm3), inc. protein
concentration (>45mg/dl) or VDRL reactivity.
c. Evaluation for Syphilis in pxns infected
w HIV
• Syphilis and other genital ulcer diseases
may be important risk factors for the
acquisition and transmission of HIV
infection.

VII. Treatment
• Pen G is the drug of choice for all stages of
syphilis. Refer table 153-3
• An infant should be treated at birth if the
seropositive mother has received penicillin
therapy in the 3rd trimester, inadequate
penicillin treatment or therapy w a drug
other than penicillin, of her tx status is
unknown or if the infant may be diff to follow.
• Jarisch-Herxheimer Reaction consists of
fever, chills, myalgia, headache,
tachycardia, inc RR, inc circulating
neutrophil count and vasodilation w. mild
hypotension amd may follow the initiation of
tx for syphilis.
• Follow up response of syphilis to tx should
be determined by monitoring quantitative
VDRL or RPR titer
• Cellular immunity is considered impt in
immunity and healing of early lesions

Marian USTMedB2007 