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Outline
• Brain teaser
• Introduction
• History of syphilis
• Bacteriology
• Pathophysiology
• Diagnosis
• Treatment
• Syphilis + HIV
Brain teaser
% 15
12
0
2007 2008 2009 2010 2011 2012 2013 2014
6
Sources: Prepared by www.aidsdatahub.org based on HIV Sentinel Sero‐surveillance Survey Reports.
History of syphilis
• The name ‘Syphilis’ comes from the poem Syphilis sive morbus gallicus (Latin for
"Syphilis or The French Disease") written by Italian physician and poet, Girolamo
Fracastoro in 1530.
• It was called several names depending on the regions and political frictions
among the countries.
• French disease in Italy, Malta, Poland and Germany
• Italian disease in France
• Spanish disease by Dutch
• Polish disease in Russia
• Christian/Frank disease by Turks
6‐8 weeks
1‐20 years
Primary Syphilis
• Incubation period ‐ 3 weeks (range 10‐90 days)
• Genital lesion starts with a papule and then progress to an ulcer
which is
• Painless
• Indurated
• Well circumscribed
• Healed spontaneously within 1‐6 weeks
• Inguinal lymphadenopathy for genital lesions and cervical
lymphadenopathy for oral ones can be present.
• Syphilitic chancres are highly infectious.
Chancres!
Source: Public Health—Seattle & King County STD Clinic Centers for Disease Control and Prevention
Public Health Image Library (Robert E. Sumpter,
Secondary Syphilis
• This stage indicates haematogenous dissemination of the organism (Bacteremia)
and high infectiousness.
• Secondary stage starts 4 to 8 weeks after the onset of the primary chancre.
• Victims may present with constitutional symptoms such as fever, malaise, arthralgia
• Rash is present in 75‐100% of cases.
• Lymphadenopathy ‐ 50‐86% of cases
• Mucous patches ‐ 6‐30% of cases (oral cavity, pharynx, larynx or genitalia
• Condylomata lata ‐ 10‐20% of patients (wart‐like papules)
• Alopecia ‐ 5% of patients
• Visceral organs involvement
• Neurologic symptoms ‐ can present with neurosyphilis.
Latent Syphilis
• This stage represent the latency of the disease when few signs and symptoms
appear in spite of the persistent of the organisms.
• This stage can occur between primary and secondary and between secondary
relapses.
• The latent syphilis should be considered in the following situations:
• Seropositivity for T. Pallidum
• No past diagnosis of syphilis
• No evidence of active primary, secondary or tertiary syphilis
• It can be subclassified into:
• Early latent syphilis
• Late latent syphilis
• Latent syphilis of unknown duration
Early Latent Syphilis
• It represent the period of infection of < 1 year. (WHO: <2
years)
• No clinical/serological diagnosis of primary/secondary syphilis
with at least one of the following:
• No past signs and symptoms of primary or secondary syphilis
• A documented seroconversion or a sustained (>2 weeks) fourfold or
greater increase in titre in non‐treponemal test in 1 year
• A history of sexual exposure with a partner with documented
primary/secondary/early latent syphilis
• No other source of transmission in 1 year
Late Latent Syphilis
• It represents the infection with > 1 year in duration (WHO: > 2 years)
• No clinical/serological diagnosis of primary/secondary syphilis with at
least one of the following:
• Reactive nontreponemal tests and no past diagnosis of syphilis
• A past history of syphilis treatment and currently reactive nontreponemal test
with fourfold or greater increase from the previous one
Latent syphilis of unknown duration
• It’s the condition when the duration of infection cannot be known.
• It’s practically to manage this condition as late latent syphilis.
Tertiary syphilis
• Also called as late syphilis.
• It’s rare in antibiotic era.
• Without appropriate treatment, about 30% of patients progress to
tertiary stage within 1‐20 years.
• Gummatous lesions can appear in skeletal, spinal and mucosal areas,
eyes and viscera.
• the lesions can be confused with CA.
• About 20‐30 years after infection, it can present as ascending aortic
aneurysm, aortic insufficiency or coronary ostial stenosis.
Neurosyphilis
• The patient can present with neurological signs and symptoms when T. pallidum
invades CNS.
• It can occur in ANY stage of syphilis.
• Early neurosyphilis
• A few years after infection
• Can manifest as acute syphilitic meningitis, a basilar meningitis with cranial nerves III, VI, VII
and VIII involvement, meningovascular syphilis, an endarteritis with stroke‐like syndrome and
seizures.
• Late neurosyphilis
• Decades after infection
• Can manifest as general paresis and tabes dorsalis
• Can also present with wide variety of neurologic symptoms
• Ocular involvement can occur in both early and late.
Ocular syphilis
• T. pallidum can infect any part of eye.
• Signs and symptoms can vary and be broad.
• Anterior/posterior/pan‐ uveitis
• Lid involvement
• Episcleritis
• Vitritis
• Retinitis
• Papillitis
• Interstitial keratitis
• Acute retinal necrosis
• Retinal detachment
• Can present with acute or chronic.
• Ocular syphilis can be seen solely without other neurological manifestations.
Don’t Forget the Eyes!
Syphilitic ulcers increase HIV transmission risk. Syphilis can cause transient increase in HIV RNA and
decrease in CD4 count
Mobile apps from CDC
iOS Android
References
• National STD Curriculum https://www.std.uw.edu
• Sexually Transmitted Diseases Treatment Guidelines, 2015, CDC
• WHO guidelines for the treatment of Treponema pallidum (syphilis)
2016
• STI management guidelines, 2017 (Myanmar)
Thank you for your attention.