SEXUALLY TRANSMITTED DISEASES ()

SYPHILIS

Syphilis
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Description History Stage Skin Findings Laboratory Differential diagnosis Treatment

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Description

Description

Description A sexually transmitted infectious disease caused by the spirochete treponema pallidum. It can affect virtually every organ in the body and mimic various other disease. Untreated, syphilis passes through three stage: primary infectious, secondary, and latent, or progression to a rare tertiary. Syphilis is also called lues.

Description

Treponema pallidum is the organism responsible for syphilis, been here photographed through a dark-field microscope.

History

History

History

Syphilis is of great historical importance. It was named after an afflicted sheep herder named Syphilus in 1530. It is believed the disease was introduced to Europe by Columbus after returning from the West Indies, and its spread within Europe was blamed on frequent wars within the region at that time. Incidence declined after World War because of penicillin treatment.

History
The Tuskegee study is a dark part of syphilis history. In 1932, penicillin therapy for black men who were infected with syphilis was withheld in order to study the short-time and long-time effects of the disease.

Syphilis has become more common with the introduction of the acquired immune deficiency syndrome (AIDS) and is more common in homosexual men, bisexual men, and prostitutes.

Stage

Stage

Primary Syphilis

Stage

A cutaneous ulcer (chancre) is acquired by direct contact with an infectious lesion. The chancre appears 10-90 days (average 21 days) after exposure. It develops at the site of initial contact. Chancres are usually solitary, but multiple lesion can occur. Untreated primary chancres resolve in 75% of cases, but the spirochete remains within the host.

Secondary Syphilis

Stage

Secondary syphilis results from hematogenous and lymphatic spread of the spirochete. The secondary stage begins approximately 6 weeks after the chancre appears and it lasts for 2-10 weeks. An influenza-like syndrome occurs with mucocutaneous lesion, hepatosplenomegaly, and generalized adenopathy. The distribution and morphologic characteristics of individual lesion vary. Syphilis in this stage is easily confused with numerous other cutaneous and systemic disease, and therefore it has been termed the great imitator.

Latent Syphilis

Stage

The results of serologic test are positive (not false positive) without evidence of active disease. The early latent period begins 1 year or less from the onset of primary disease; late latent syphilis may last more than 4years. About 25% of untreated cases in the secondary stage relapse during the first year; a small percentage relapse in the second year.

Tertiary Syphilis

Stage

Tertiary Syphilis is characterized by a small number of organisms eliciting a large or brisk cellular immune response. Systemic disease develops in about 25% of untreated or inadequately treated cases. Cardiovascular and central nervous system involvement, with systemic granulomas or gummas may occur.

Congenital Syphilis

Stage

Treponema pallidum can be transmitted from an infected mother to her fetus. In untreated cases, 25% of neonates are stillborn, 25% die shortly after birth, 10% have no symptoms, and 40% will have late symptomatic congenital syphilis. In early congenital syphilis, rash, hepatosplenomegaly, bone and joint changes occur before age 2 years. In late congenital syphilis, bone and joint changes, neural deafness and interstitial kertitis occur after age 5 years. Therapy before the 16th week of gestation usually prevents infection of the fetus. A fetus is at greatest risk when the mother has syphilis for less than 2 years.

Skin Findings

Skin Findings

Primary Syphilis

Skin Findings

The chancre begins as a papule, undergoes ischemic necrosis, and erodes. A painless (sometimes tender), hard and indurated chancre of 0.3-2.0cm forms. The borders are raised, smooth, and sharply defined. These lesions may be asymptomatic and undetected on the cervix of women, allowing transmission to the unsuspecting. Painless, hard, discrete, non-suppurative regional lymphadenopathy develops in 1-2 weeks. The chancre heals with scarring, typically in 3-6weeks.

Primary Syphilis

Skin Findings

The lesion begins as a papule that under ischemic necrosis and erodes, forming a 0.3-2.0cm, painless to tender, hard, indurated ulcer. The base is clean, with a scant yellow serous discharge

The border of the ulcer are raised, smooth, and sharply defned.

Secondary Syphilis 1

Skin Findings

This stage of syphilis is characterized by systemic, cutaneous and mucosal signs and symptoms. Fever, malaise, pharyngitis, adenopathy and weight loss and meningeal signs (headache) are common. The most common sign is a non-pruritic generalized, pink, scaly papular eruption(80%). The lesions develop sloely, appear in a variety of shapes, including round, ellipsoid, and annular and persist for weeks or months. Symmetric hyperpigmented oval papules with a collarette of scale appear on the palms or the soles in most patient.

Secondary Syphilis 2

Skin Findings

Irregular alopecia of the beard, scalp, and eyelashes occurs which is sometimes referred to as moth-eaten alopecia. Whitish, moist, anal condyloma lata lesions are highly infectious wart-like papules that are characteristic of syphilis. Classic split papules appear at the angle or commissures of the mouth. All secondary lesions are infectious with direct contact or palpation. Without treatment, lesions of this stage relapse in about 20% of patients within a year.

Secondary Syphilis

Skin Findings

The lesion of secondary syphilis have marked tendency to polymorphism, with various types of lesions presenting simultaneously. They have a coppery tint and assume a variety of shapes. Eruptions may limited and discrete, or profuse and generalized.

Secondary Syphilis

Skin Findings

Lesion on the palms and soles occurs in the majority of patients with secondary syphilis. A coppery color resembling that of clean-cut ham is characteristic of secondary syphilis.

Latent Syphilis

Skin Findings

The results of serologic test are positive (not false positive) without evidence of active disease. The early latent period begins 1 year or less from the onset of primary disease; late latent syphilis may last more than 4years. About 25% of untreated cases in the secondary stage relapse during the first year; a small percentage relapse in the second year.

Tertiary Syphilis

Skin Findings

Very few if any clinical signs of syphilis in this stage.

Congenital Syphilis

Skin Findings

Gummer or granulomatous lesions develop subcutaneously, expand and ulcerate in the skin. These lesions also occur in the liver, bones and other organs.

Laboratory

Laboratory

Laboratory
Direct detection of treponemes is diagnostic. Detection of the treponemes from skin lesions can be achieved under dark-field microscopy, which shows corkscrew rotation motility of the small, spiral syphilis spirochete. There are two serologic screening tests: the rapid plasma reagin test and the Venereal Disease Research Laboratory, or VDRL,test. These screening tests are reactive by day 7 of the chancre and are easy to perform. Latent syphilis can be diagnosed by a reactive screening test. Positive results from the screening tests should be confirmed with a florescent treponemal antibody absorption test.

Laboratory
One-third of latent syphilis-infected people have a negative or non-reactive result in the RPR test. They show no signs of disease and only have a positive result on the microhemagglutination-treponema pallidum antibody test. Another third have a positive RPR test and microhemagglutination-treponema pallidum test, and the remaining third have clinical symptoms of tertiary disease. Tertiary syphilis is diagnosed by elevated cerebrospinal fluid pressure, protein concentration and specific antitreponemal antibodies. False-positive results are possible with all serologic tests.

Differential Diagnosis

Differential Diagnosis

Primary Syphilis
Herpes simplex Chancroid Behcet syndrome Fixed drug eruption Traumatic ulcers

Differential Diagnosis

Secondary Syphilis

Differential Diagnosis

Pityriasis rosea Guttate psoriasis Lichen planus Tinea versicolor Exanthematous drug eruption Viral eruptions

Treatment

Treatment

Treatment
In early disease (primary, secondary, latent less than 1 year) the drug of choice is benzathine penicilin G 2.4 million units intramuscularly, given once. In late disease (lasting more than 1 year) the drug of choice is benzathine penicilin G 2.4 million units intramuscularly once a week for 3 weeks consecutively. People who are allergic to penicilin can be given doxycycline 100mg twice a day for 2 weeks, or tetracycline, 500mg four times a day for 2 weeks. Successful therapy is indicated by a falling RPR titer.

Treatment

RPR testing should be repeated 3, 6, and 12 months after treatment is complete. Treatment is repeated when there is a sustained fourfold increase in the RPR titer. Therapy is repeated when a high titer does not show a fourfold decrease with 1 year. In most patients infected with the human immunodeficiency virus, syphilis responds to standard treatment regimens.

The End
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