SYPHILLIS, HERPES,

HEPATITIS, and HPV

SYMPTOMS, DIAGNOSIS,
AND TREATMENT
 REFERENCES

Transcon Pocket Pharmacopoeia

Rapid Review of Pathology By Edward Goljan
USMLE Step 2 Mock Exam
Kaplan’s USMLE Master the Boards STEP 3
 CATEGORY: SYPHILLIS

GENERAL MALASISE, HEADACHE,

SWEATING, RIGORS, AND
TEMPORARY EXACERBATIONS OF
SYPHILITIC LESIONS OCCURRING 6-23
HRS AFTER INITIAL TREATMENT
WITH PENICILLIN IS CALLED THIS
REACTION
 WHAT IS THE JARISCH-
HERXHEIMER REACTION
 WHAT IS SYPHILLIS

Sexually Transmitted Disease caused by an

organism in the Spirochete family

Spirochetes do not gram stain and must be

visualized with dark field microscopy

Treponema Palladium is the Spirochete that

causes Syphilis
 How is Syphillis Classified?

CONGENITAL – Mother to
child

ACQUIRED – Primary,
Secondary, tertiary
 Transmission of Treponema Pallidium:
Causative agent of Syphillis

Treponema Pallidum is transmitted from

spirochete-containing lesions of skin or
mucous membranes (e.g., genitalia, mouth,
and rectum) of an infected person to
another persons by intimate contact.

T. Pallaidium can also be transmitted from

pregnant women to their fetuses across the
placenta

8
 Primary Syphillis

Chancres can appear within the third week, post-

exposure and disappear within 10-90 days
Chancres are solitary, painless, indurated local
ulcers
Locations of chancres: penis, labia, mouth
Regional lymphadenopathy is rubbery, discrete, and
non-tender on palpation
 Secondary Syphillis
10

Maculopapular rash of trunk, palms, and soles

Appears 6-12 weeks after infection
Generalized lymphadenopathy
Condyloma lata = papules that develop at the
mucocutaneous junctions and moist areas; flat lesions
located on penis, vulva, labia, and perianal area that
extremely infectious
Alopecia
Secondary syphilis may persist for life with one-third
of the patients progressing to tertiary syphilis
 Tertiary Syphillis
 Can occur 3-20 years after exposure
 Neurosyphillis – Argyll Robertson pupil is a small,
irregular pupil that reacts normally to accommodation but
not to light = “Prostitute’s Eye”
 Tabes Dorsalis – locomotor ataxia that results in pain,
sensory changes, and loss of tendon reflexes
 Syphilitic Aneurysm – T. Pallidum infects the vaso vasorum
of the ascending and transverse portions of aortic arch
leading to vasculitis causing vessel ischemia and leading to
dilation of the aortic valve ring
 Gummas – chronic, granulomatous reaction found in any
organ or tissue
 Congenital Syphillis

Transmission is transplacental
Occurs after 20 weeks of gestation
Associated with Hepatitis
Clinical Findings are Hutchinson’s teeth, saddle
nose, saber shins (bony abnormalities), blindness
NOTE: Hutchinson’s teeth: Infants’ incisors become
tapered like pegs and their molar teeth resemble
mulberries
 Diagnosis of Syphillis
13

Screening tests for Syphillis are the Venereal Disease

Research Laboratory (VDRL) and Rapid Plasmin
Reagin (RPR) tests
VDRL and RPR are non-treponemal antigen tests
that look for antibody reaction to cardiolipin

Specific serologic tests for Syphillis are the FTA-ABS

or the Microhemagglutin test for antibodies to
Treponema Pallidum (MHA-TP) are confirmatory
tests done if the screen tests are positive
 Diagnosis of Syphilis ctd.

VDRL and RPR gradually become normal after

treatment ensues

FTA-ABS MHA-TP remain positive for life

False positives VDRL with EBV, collagen vascular

disease, TB, Subacute Bacterial Endocarditis
 Treatment of Syphillis
Primary and Secondary Syphilis are treated with 2.4
million units of intramuscular Benzathine penicillin
given once a week
Tertiary syphilis is treated with penicillin 10-20
million units/day IV for 10 days
Penicillin-allergic patients receive doxycyline for
primary and secondary syphilis
Penicillin-allergic patients must be desensitized for
tertiary syphilis
Pregnant patients must undergo desensitization for
Syphillis treatment
WHAT STAGE OF
SYPHILLIS DOES THIS
IMAGE REPRESENT?
WHAT STAGE OF
SYPHILLIS DOES THIS
IMAGE REPRESENT?

Rash in syphillis
WHAT STAGE OF
SYPHILLIS DOES THIS
IMAGE REPRESENT

Rash on hands in Syphillis

19
  
Herpes simplex lesion of lower lip, second day after onset. CDC 20
Classical primary genital herpes affecting
the vulva.

21
Genital herpes on
22
penis area
Herpes Simplex Virus II (HSV II)
23

Causes 90% of Herpes

Simplex infections
Genital herpes
Neonatal herpes
 Symptoms of HSV-2

Dysuria

Tender skin

Red, erythematous skin

Blisters

Symptoms can occur from 2 to 20 days after

infection
 Lab Diagnosis of Herpes
25

A rapid diagnosis from skin lesions can be made by

using the Tzanck smear, in which cells from the
base of the vesicle are stained with Giemsa stain.

The presence of multinucleated giant cells

suggests herpes virus infection.

A rapid diagnosis of encephalitis can be made by

detecting HSV-l DNA in the spinal fluid using a
PCR assay (most sensitive test), but virus is
rarely recovered from the spinal fluid.
 Treatment
ZOVIRAX (Acyclovir) – inhibits DNA polymerase;
side effects include local skin irritation (if topical),
GI distress, renal disturbances, headache, tremor,
rash, and neurotoxicity

DOSING:
Apply ointment q 3 hours, 6 times a day, for 7 days

Apply cream 5 times per day for 4 days

 Types of Hepatitis

Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
 Hepatitis B
- Transmission: Sexual, transplacental, and
paraenteral (i.e. IV or IM) transmission
- Diagnostic test: HBsAg, anti-HBsAg, HBeAg, HBV
DNA, IgM Anti-HBcAg
- 10% of Adults have chronic infection
- 80% - 90% of infants have chronic infection
- Carrier state
- Associated with hepatocellular carcinoma
- Prophylaxis: Hepatitis B immune globulin, vaccine,
interferon, Lamivuidine
 A Little More about Hepatitis B

Symptoms include: fever, fatigue, loss of appetite,

nausea, vomiting, abdominal pain, dark urine, clay-
colored stools, joint pain, jaundice
Incubation period is 60-150 days with an average of
90 days
Mandatory Hepatitis B vaccinations are given to
newborns before they leave the hospital
Three doses of the Hepatitis B vaccines are given:
Day 1 of life, 1 month (2nd does) later, 6 months (3rd
dose)
 Treatment of Hepatitis B

EPIVIR (Lamivuidine, 3TC) – reverse transcriptase

inhibitor; causes GI distress, headache, insomnia,
fatigue

DOSING
Adults – 100 mg po daily
Children – 3 mg/kg (up to 100 mg) po daily
 Hepatitis C

Transmitted across the placental, paraenteral (i.e. IV

or IM), limited sexual transmission

Associated with Hepatocellular carcinoma

Treatment: Interferon, Ribavarin

 Work-up for Hepatitis B

 + HBsAg indicates risk for vertical transmission of

HBV

Next step in management for +HBsAg is is to order

HBVe antigen

+HBeAg siginifies highly infectious state

 Human Papilloma Virus
HPV is the causative agent of
Genital Warts

HPV can cause Cervical,

Vulvar, and Penile Cancers
 Transmission of HPV

 Transmission primarily occurs by skin-to-skin contact and

by mouth-to-genital or genital-to-genital contact

 Papillomaviruses infect squamous epithelial cells and

produce a characteristic cytoplasmic vacuole, a process
called koilocytosis.

 Koilocytes are a hallmark of infection by these viruses.

 DIAGNOSIS of HPV

No form of testing is routinely necessary

Biopsy, scraping, smears, and serology are of no

definite benefit

The purpose of a Pap smear is to screen for

abnormal cells
 Treatment of HPV

Mechanical removal: cryotherapy with liquid

nitrogen, laser removal, or trichloroacetic acid or
podophyllin (must be applied by physician in clinic
or hospital)

Podophyllin is potentially teratogenic and should be

avoided in pregnancy

Imiquinnod is local immunostimulant that takes

several weeks to result in sloughing off of the warts
 Papilloma Viruses Link To Cancer
37

 Most common are Types 6 and 11 which causes genital

warts.

 Most cervical, vulvar and penile cancers are associated

with Types 16 and 18 (70% of penile cancers)

 Papilloma viruses are found in 91% of women with

cervical cancer

 Vaccine for HPV - GARDASIL

 GARDISIL

HPV vaccine that protects against 4 types of HPV

In girls and young women ages 9 to 26, Gardasil
protects against two types of HPV that cause 75% of
cervical cancers
Gardasil helps protect girls and women ages 9 to 26
against 70% of vaginal cancers and 50% of vulvar
cancers
In boys and young men ages 9 to 26, Gardasil helps
protects against 90% cases of genital warts
 39

What is
the
scientific
name of
these
lesions?

Genital warts on the penis

Genital warts on vulvoperianeal
40
area
 Abnormal tissue development

41
 Practice Question #1

Which of the following accurately describes Syphilis?

A. The initial lesion is usually a painful genital ulcer
B. A maculopapular rash on the palms and soles is
nearly path gnomonic of primary syphilis
C. The causative agent is a gram-negative
coccobacillus
D.Tertiary syphilis may result in dementia
E. The FTA-ABS is the most commonly used testing
for Syphilis
 Practice Question #2

 A 65 year-old man presents with subacute onset of confusion and is

found to have a positive rapid plasmin reagin (RPR) syphilis test. The
man’s wife thinks he may have had a sexually transmitted disease while
in the army 40 years ago but does not know if he was ever treated for it.
The man has not been sexually active for 3 years according to his wife.
Which of the following is true?
 A. A more specific serologic test for syphilis is not needed in this setting
 B. Treatment for syphilis often causes RPR test to become negative
 C. A Venereal Disease Research laboratory (VDRL) test for syphilis can
be used to confirm the diagnosis of syphilis
 D. the man needs a urethral swab to check for spirochetes
 E. None of the above