SEXUALLY TRANSMITTED INFECTIONS

Narlou M. Artiaga-Wenceslao, RMT, MD

CHLAMYDIA TRACHOMATIS
NEISSERIA GONORRHEA
TREPONEMA PALLIDUM
GARDNERELLA VAGINALIS
CHLAMYDIA TRACHOMATIS

Chlamydiae:
Chlamydia trachomatis
Chlamydia (Chlamydophila) pneumonia
Chlamydia (Chlamydophila) psittaci

The chlamydiae can be viewed as gram-negative bacteria, and obligate intracellular parasites .

• lack mechanisms for the production of metabolic energy

• cannot synthesize adenosine triphosphate (ATP)
DEVELOPMENTAL CYCLE

2 forms of Chlamydia
• Elementary body
• Reticulate body.

Elementary body (EB):

• small cell
• environmentally stable
• infectious particle
• high affinity for host epithelial cells and rapidly enter them
Heparan sulfate–like proteoglycans of C trachomatis: mediate
initial interaction between EBs and host cells
Reticulate body (RB)
• reorganized EB
• larger structure
• devoid of an electron-dense nucleoid
• Covered by a membrane-bound vacuole
Reading Assignment:
• divides by binary fission
Differentiate EB from RB by its
The membrane-bound vacuole becomes filled with EBs derived
DNA and RNA component
from the RBs to form a cytoplasmic inclusion .
Newly formed Ebs: liberated from the host cell to infect new cells.
24–48 hours: developmental cycle
 Elementary bodies stain purple with Giemsa stain—in
contrast to the blue of host cell cytoplasm. The larger,
noninfective Reticulate Bodies stain blue with Giemsa
stain.

If stained with dilute Lugol’s iodine solution, some of the

inclusions of C trachomatis appear brown because of the
glycogen matrix that surrounds the particles
ANTIGEN

Chlamydiae

Genus–specific antigens
• heat-stable lipopolysaccharides with 2-keto- 3-deoxyoctanoic acid as an immunodominant
component

• detected by complement fixation (CF) and immunofluorescence.

Species-specific or serovar-specific antigens

• outer membrane proteins
• detected by immunofluorescence
• at least 18 serovars : include A, B, Ba, C–K, and L1–L3
McCoy cells treated with cycloheximide: used to isolate chlamydiae

TREATMENT:
Cell wall inhibitors: penicillins and cephalosporins
• result in the production of morphologically defective forms but are not effective in clinical diseases.

Inhibitors of protein synthesis: tetracyclines, erythromycins

• effective in most clinical infections.

Susceptible to inhibition by sulfonamides.

Aminoglycosides are noninhibitory
Humans are the natural host for C trachomatis

Endemic trachoma: Serovars A, B, Ba, and C

Sexually transmitted disease: Serovars D–K
LGV: Serovars L1, L2, and L3
CHLAMYDIA TRACHOMATIS SEROVARS D–K: GENITAL INFECTIONS AND INCLUSION CONJUNCTIVITIS

Men:
• nongonococcal urethritis (50%)
• epididymitis
Women:
• Urethritis
• Cervicitis
• Frothy discharges
• pelvic inflammatory disease
• sterility and predispose to ectopic pregnancy

Proctitis and proctocolitis may occur in men and women.

50% urethritis : Dysuria, nonpurulent discharge, and frequency of urination
Infection symptomatic or asymptomatic but communicable to sex partners.

Genital secretions of infected adults can be self-inoculated into the conjunctiva,

resulting in inclusion conjunctivitis, an ocular infection that closely resembles
Acute Trachoma.
CHLAMYDIA TRACHOMATIS GENITAL INFECTIONS AND INCLUSION CONJUNCTIVITIS

Newborn infection:
• passage through an infected birth canal
• 20–60% of infants acquire the infection
• 15–20% of infected infants manifesting eye symptoms
• 10–40% manifesting respiratory tract involvement

Inclusion conjunctivitis of the newborn

• mucopurulent conjunctivitis
• 7–12 days after delivery
• subside with erythromycin or tetracycline treatment or spontaneously after weeks or months
• Usually not associated with bacterial conjunctivitis
• Chronic infection resembles trachoma
Laboratory Diagnosis
A. Specimen Collection

• specimens contain infected human cells

• Endocervical specimens
• collected after removal of discharge and secretions from the cervix.
• A swab or cytology brush is used to scrape epithelial cells from 1 to 2 cm deep into the endocervix.
• Dacron, cotton, rayon, or calcium alginate on a plastic shaft should be used to collect the specimen;
some wooden shafts are toxic to chlamydiae
• transport tubes

• For culture
• swab specimens placed in a chlamydiae transport medium
• kept at refrigerator temperature before transport to the laboratory
• Urine
• tested for presence of chlamydial nucleic acid
• Only the first 20 mL of the void should be collected
• larger volume of bladder urine would dilute the initial urine  result in a negative test
B. Nucleic Acid Detection

Nonamplified probe assays

• Nucleic Acid Hybridization Test
• DNA probe hybridizes to a specific sequence of chlamydiae 16S rRNA
• amount of hybrid formed is detected by chemiluminescence
• Another hybridization assay used RNA probes to detect chlamydiae DNA sequences.
• sensitivity and specificity : not as good as the nucleic acid amplification tests (NAATs)
• less expensive than the NAATs

Nucleic acid amplification tests

• tests of choice to diagnose genital C trachomatis infections.
• PCR, strand displacement, and transcription mediated amplification.
• highly sensitive and specific
• simultaneously detect Neisseria gonorrhoeae
C. Direct Cytologic examination (Direct Fluorescent Antibody) and enzyme-Linked immunoassay (EIA)

DFA: uses monoclonal antibodies directed against a species-specific antigen on the chlamydial MOMP.
EIA: detects the presence of genus-specific antigens extracted from EBs in the specimen.
• very low sensitivity
• EIAs are being phased out as acceptable methods for screening for both chlamydia and gonorrhea.

D. Culture
• costly and arduous
• delayed results
• Culture is generally much less sensitive than NAATs
• McCoy cells treated with cycloheximide
E. Serology

• Serum antibodies occur much more commonly in genital tract infections than in trachoma
• A titer rise occurs during and after acute chlamydial infection.
• Because of the high prevalence of chlamydial genital tract infections in some societies, there is a high
background of antichlamydial antibodies in the population; serologic tests to diagnose genital tract
chlamydial infections generally are not useful.
• In genital secretions (eg, cervical), antibody can be detected during active infection and is directed against
the infecting immunotype (serovar).
Treatment
• Tetracyclines (eg, doxycycline) are commonly used in nongonococcal urethritis and in nonpregnant infected women.
• Azithromycin is effective and can be given to pregnant women.
• Topical tetracycline or erythromycin is used for neonatal N gonorrhoeae infections but may not effectively prevent
neonatal C trachomatis infection.
• Systemic therapy should be used for inclusion conjunctivitis because topical therapy may not cure the eye infections or
prevent respiratory disease.
LYMPHOGRANULOMA VENEREUM
• sexually transmitted disease caused by C trachomatis
• characterized by suppurative inguinal adenitis
• most common in tropical climates.

Properties of the Agent

• Particles contain CF heat-stable chlamydial group antigens
• Contain one of three serovar antigens (L1–L3)
Clinical Findings

Days to weeks after exposure

• a small, evanescent papule or vesicle develops on external genitalia, anus, rectum, or elsewhere
• The lesion may ulcerate
• remains unnoticed and heals in a few days
• Later on: regional lymph nodes enlarge  tend to become matted and painful

• In men, inguinal nodes are most commonly involved both above and below Poupart’s ligament, and the overlying skin
often turns purplish as the nodes suppurate and eventually discharge pus through multiple sinus tracts.
 Clinical Findings

• In women and in homosexual men, the perirectal nodes

are prominently involved, with proctitis and a bloody
mucopurulent anal discharge. Lymphadenitis may be
most marked in the cervical chains.

• During the stage of active lymphadenitis

• fever, headaches, meningismus, conjunctivitis, skin
rashes, nausea and vomiting, and arthralgias

• Meningitis, arthritis, and pericarditis occur rarely.

• Antimicrobial drug treatment  chronic inflammatory

process progresses to fibrosis, lymphatic obstruction,
and rectal strictures.

• The lymphatic obstruction may lead to elephantiasis of

the penis, scrotum, or vulva.
Laboratory Diagnosis

A. Smears Pus, buboes, or biopsy material may be stained, but particles are rarely recognized.

B. Culture

Suspected material is inoculated into McCoy cell cultures. The inoculum can be treated with an aminoglycoside (but not
with penicillin) to lessen bacterial contamination. The agent is identified by morphology and serologic tests.

C. Serology

• Antibodies are commonly demonstrated by the CF reaction.

• positive 2–4 weeks after onset of illness
TREATMENT

• The sulfonamides and tetracyclines have been used with good results, especially in the early stages.
• Late stages require surgery.

EPIDEMIOLOGY AND CONTROL

• highest incidence of LGV has been reported from subtropical and tropical areas
• spread by sexual contact
• The portal of entry may sometimes be the eye (conjunctivitis with an oculoglandular syndrome).
• The genital tracts and rectums of chronically infected (but at times asymptomatic) persons serve as reservoirs of
infection.
• Laboratory personnel exposed to aerosols of C trachomatis serovars L1–L3 can develop a chlamydial pneumonitis with
mediastinal and hilar adenopathy. If the infection is recognized, treatment with tetracycline or erythromycin is
effective. The measures used for the control of other sexually transmitted diseases also apply to the control of LGV.
Case finding and early treatment and control of infected persons are essential.
 NEISSERIA GONORRHEA

Neisseria:
gram-negative,
nonmotile diplococcus,
~0.8 μm in diameter
kidney shaped;
when the organisms occur in pairs
 NEISSERIA GONORRHEA

NEISSERIA GONORRHOEAE
• Gonococci
• oxidize only glucose
• produce smaller colonies
• Gonococci that require arginine, hypoxanthine, and uracil tend to grow most slowly on primary culture
• Gonococci isolated from clinical specimens or maintained by selective subculture have typical small
colonies containing piliated bacteria.
• On nonselective subculture, larger colonies containing nonpiliated gonococci are also formed.
• Opaque and transparent variants of both the small and large colony types also occur; the opaque
colonies are associated with the presence of a surface-exposed protein, Opa.
 NEISSERIA GONORRHEA

Surface structures

A. Pili (Fimbriae)
• hairlike appendages
• enhance attachment to host cells and
resistance to phagocytosis
• Pili undergo phase variation (on/off switch
of pili production). Nonpiliation greatly
reduces virulence.

B. Por
• extends through the gonococcal cell
membrane
• occurs in trimers to form pores in the
surface through which some nutrients enter
the cell.
• preventing phagosome–lysosome fusion
 NEISSERIA GONORRHEA

C. Opa Proteins
• function in adhesion of gonococci within colonies and in attachment of gonococci to host cell receptors

D. Rmp (Protein III)

• reduction-modifiable protein (Rmp)
• associates with Por in the formation of pores in the cell surface.

E. Lipooligosaccharide
• Triggers tumor necrosis factor alpha and damage to the mucosa

F. Other Proteins
Lip (H8)
• surface exposed protein that is heat modifiable

• Gonococci can switch from one antigenic form (pilin, Opa, or LPS) to another antigenic form of the same molecule.
• The molecules’ rapid switching from one antigenic form to another helps the gonococci elude the host immune
system.
NEISSERIA GONORRHEA

Clinical Symptoms

• Gonorrhea is a mucos membrane infection

• Often asymptomatic in women
• Asymptomatic/symptomatic persons may transmit the disease
• Repeated infection may cause scarring with subsequent sterility/ectopic pregnancy.
• reflects various types of infections
CLINICAL MANIFESTATIONS

1. Urethritis in men is characterized by thick, yellow, purulent exudate containing bacteria and numerous neutrophils;
frequent, painful urination; and possibly an erythematous meatus. Complications include epididymitis and
prostatitis in males.
2. Endocervicitis or urethritis in women is characterized by a purulent vaginal discharge; frequent, painful urination;
and abdominal pain. Approximately 50% of cases go undiagnosed. Complications include arthritis, pelvic
inflammatory disease, and sterility.
3. Rectal infections (prevalent in homosexual males) are characterized by painful defecation, discharge, constipation,
and proctitis.
4. Pharyngitis is characterized by purulent exudate; the mild form mimics viral sore throat, whereas the severe form
mimics streptococcal sore throat.
5. Disseminated infection (blood stream invasion) is infection in which organisms initially localize in the skin, causing
dermatitis (a single maculopapular, erythematous lesion), then spread to the joints, causing overt, painful arthritis
of the hands, wrists, elbows, and ankles.
6. Infant eye infection (ophthalmia neonatorum), which is contracted during passage through the birth canal, is
characterized by severe, bilateral purulent conjunctivitis that may rapidly lead to blindness.
Laboratory Diagnosis
• Identification
• gram-negative, intracellular and extracellular diplococci.
• Numerous neutrophils appear in purulent exudate
• Culture should be immediately placed on warm Thayer-Martin chocolate agar in a candle jar.
• Oxidase test is positive.
• Organisms use glucose but not maltose.
• Newer techniques involve immunofluorescence, enzyme-linked immunosorbent assay (ELISA), or gene
probes on a clinical swab.

• Clinical specimens
• In women, both genital and rectal cultures should be obtained.
• Lubricant should not be used when using speculum because it kills many organisms
• disseminated gonorrhea: blood and synovial fluid should be cultured
Control
Treatment
• Ceftriaxone should be given, followed by a tetracycline to treat possible
chlamydial infection.
• 50% of cases, pelvic inflammatory disease is severe enough to warrant
hospitalization.

Prevention
• The patient's sexual partners should be treated and condom use should be
encouraged.
• Asymptomatic patients should be identified by culture and treated.
• To prevent neonatal gonococcal conjunctivitis, topical silver nitrate or
tetracycline should be used.
SEXUALLY TRANSMITTED INFECTIONS

Narlou M. Artiaga-Wenceslao, RMT, MD

CHLAMYDIA TRACHOMATIS
NEISSERIA GONORRHEA
TREPONEMA PALLIDUM
GARDNERELLA VAGINALIS
TREPONEMA PALLIDUM

Spirochete: Large, long, slender and motile bacteria

helically coiled, spiral or corkscrewshaped bacilli
Most common human pathogens: Borrelia ,Treponema and Leptospira

T. pallidum:
• Reproduce by transverse fission

• Glycosaminoglycan coating
• Outer membrane: contains peptidoglycan and maintains the structural integrity
• Endoflagella (axial filaments): encased by the outer membrane.
• begin at each end of the organism and wind around it, extending to and overlapping at the midpoint.
• propels the spirochete in a twisting motion
• Inner membrane (cytoplasmic membrane):
• provides osmotic stability and covers the protoplasmic cylinder.
 TREPONEMA PALLIDUM AND SYPHILIS

Morphology and identification

A. Typical Organisms
• 0.2 μm in width and 5–15 μm in length
• spiral coils spaced at 1 μm from one another
• Motile
• thin spirals seen with immunofluorescent stain or dark-field illumination
• Do not stain well with aniline dyes
• Seen in tissues when stained by a silver impregnation method

B. Culture
• Pathogenic T. pallidum: never been cultured continuously on artifi cial
media, in fertile eggs, or in tissue culture
• Nonpathogenic treponemes (eg, Reiter strain) can be cultured
anaerobically in vitro. (They are saprophytes antigenically related to T.
pallidum.)
TREPONEMA PALLIDUM

C. Growth Characteristics
• microaerophilic organism (3–5% 02)
• saprophytic Reiter strain grows on a defined medium of 11 amino acids, vitamins, salts, minerals, and serum
albumin.
• Can remain motile for 3–6 days at 25°C.
• In whole blood or plasma stored at 4°C, organisms remain viable for at least 24 hours
• slow multiplication rate, 30 hours division time

D. Reactions to Physical and Chemical Agents

Drying, temperature to 42°C: kill spirochete
trivalent arsenic, mercury, and bismuth: immobilized and kill spirochete
Penicillin: treponemicidal in minute concentrations

E. Genome
Circular chromosome: 1,138,000 base pairs, small for bacteria.
 TREPONEMA PALLIDUM

Antigenic Structure
• Protein antigen inaccessible to antibodies
• Endoflagella has three core proteins: homologous to other
bacterial flagellin proteins plus an unrelated sheath protein.
• Cardiolipin, (phospholipid) is an important component of the
treponemal antigens
• It has hyaluronidase that breaks down the hyaluronic acid in
the ground substance of tissue. This enhances the
invasiveness of the organism.
• The spirochetes cause the development of a distinct
antibody-like substance, REAGIN, which gives positive
complement fixation (CF) and flocculation test results with
aqueous suspensions of cardiolipin extracted from normal
mammalian tissues.
• Reagin and antitreponemal antibody can be used for the
serologic diagnosis of syphilis.
 TREPONEMA PALLIDUM

Pathogenesis, Pathology, and Clinical Findings

A. Acquired Syphilis

• Transmitted by sexual contact

• Infectious lesion: skin or mucous membranes of genitalia
• 4-8 spirochetes: cause infection

Spirochetes multiply locally at site of entry  some spread to nearby lymph nodes  reach the bloodstream
 TREPONEMA PALLIDUM

Pathogenesis, Pathology, and Clinical Findings

A. Acquired Syphilis

PRIMARY SYPHILIS
 2–10 weeks after infection  papule develops at the site of infection  breaks down to form painless ulcer
with a clean, hard base (“HARD CHANCRE”)  “Primary Lesion” which always heals spontaneously
• Inflammation: lymphocytes and plasma cells. This “primary lesion”
 TREPONEMA PALLIDUM

Pathogenesis, Pathology, and Clinical Findings

A. Acquired Syphilis

SECONDAR SYPHILIS
 2–10 weeks later  “Secondary” Lesions appear
• red maculopapular rash anywhere on the body, hands and feet
• moist, pale papules (condylomas) in anogenital region, axillae, and mouth
• syphilitic meningitis, chorioretinitis, hepatitis, nephritis (immune complex type), or periostitis
• subside spontaneously

• Primary and secondary lesions: rich in spirochetes and highly infectious

 TREPONEMA PALLIDUM

Pathogenesis, Pathology, and Clinical Findings

A. Acquired Syphilis

• Contagious lesions: recur within 3–5 years after infection, but NOT INFECTIOUS
• Syphilitic infection subclinical
• 30% of cases  COMPLETE CURE WITHOUT TREATMENT
• Another 30%, the untreated infection remains latent (principally evident by positive serologic test
results)
 TREPONEMA PALLIDUM

Pathogenesis, Pathology, and Clinical Findings

A. Acquired Syphilis

TERTIARY SYPHILIS
~ 40%  “Tertiary Stage”  development of granulomatous lesions (GUMMAS) in the skin, bones, and liver;
degenerative changes in the CNS (meningovascular syphilis, paresis, tabes); or cardiovascular lesions (aortitis,
aortic aneurysm, aortic valve insufficiency).
• treponemes are very rare
• exaggerated tissue response , hypersensitivity to the organisms
 TREPONEMA PALLIDUM
B. Congenital Syphilis

Pregnant woman  syphilis  blood  placenta  fetus at 10th–15th weeks of gestation.

Some fetuses die  miscarriages/stillborn
Others are born live  develop the congenital syphilis in childhood
• interstitial keratitis
• Hutchinson’s teeth
• saddle nose
• Periostitis
• CNS anomalies
• treatment of mother during pregnancy prevents congenital syphilis.
• The reagin titer in the blood of the child rises with active infection but falls with time if
antibody was passively transmitted from the mother.
• In congenital infection, the child makes immunoglobulin M (IgM) antitreponemal antibody.
 TREPONEMA PALLIDUM

Diagnostic Laboratory Tests

A. Specimens
• Tissue fluid expressed from early surface lesions for direct visualization
• Blood can be obtained for serologic tests
• Cerebrospinal fluid (CSF) is useful for Venereal Disease Research Laboratory (VDRL) testing

B. Dark-Field examination
A drop of tissue fluid/exudate  placed on a slide  coverslip is pressed over it
Examined under oil immersion within 20 minutes of collection
NOT be performed on lesions within the oral cavity because it is not possible to differentiate pathogenic from commensal
spirochetes.

Treponemes disappear from lesions within a few hours after the beginning of antibiotic treatment.

C. Immunofluorescence
Tissue fluid /exudate  spread on a glass slide, air dried, and sent to the laboratory fixed, stained with a fluorescein
labeled antitreponeme antibody  examined by means of immunofluorescence microscopy
 TREPONEMA PALLIDUM

D. Nucleic Acid Amplification Tests

polymerase chain reaction (PCR)

E. Serologic
Tests for Syphilis
These tests use either nontreponemal or treponemal antigens.
 TREPONEMA PALLIDUM

1. Nontreponemal tests
• universally used as screening tests for syphilis
• widely available
• low cost
• used to follow the efficacy of therapy
• quantitative results using serial twofold dilutions, amount of reagin present in serum at the highest dilution
giving a positive result

• Drawbacks
• Not very sensitive in early syphilis, positive 2–3 weeks of untreated syphilis and secondary syphilis
• False-positive results can occur with many other diseases
• Prozone phenomenon, particularly in secondary syphilis (antibody excess produces a negative result at
low serum dilutions but positive results at higher dilutions)
 TREPONEMA PALLIDUM

1. Nontreponemal tests

• Antigens: cardiolipin, cholesterol, and purified lecithin reacts with syphilitic “reagin” antibodies
flocculation=positive

• Reagin is a mixture of IgM and IgG antibodies reactive with the cardiolipin–cholesterol–lecithin complex

• The VDRL and unheated serum reagin (USR) tests require microscopic examination to detect flocculation.
• The rapid plasma reagin (RPR) test and toluidine red unheated serum test (TRUST) have colored particles
that become caught in the mesh of the antigen–antibody complex, allowing the tests to be read without
microscopic magnification.
• Results develop within a few minutes, particularly if the suspension is agitated.

• A positive nontreponemal test result late after treatment for syphilis suggests ineffective treatment or
reinfection.

• The VDRL test becomes positive in patients with neurosyphilis.

• Reagin antibodies do not reach the CSF from the bloodstream; formed in the CNS in response to syphilitic
infection.
 TREPONEMA PALLIDUM

2. Treponemal antibody tests

• measure antibodies against T pallidum antigens

• used to CONFIRM a positive result from a nontreponemal test is truly positive or falsely positive
• Positive result: strong indication of T pallidum infection
• tests remain positive for life independent of therapy for syphilis
• reported as reactive or nonreactive (or occasionally inconclusive)
• costly than the nontreponemal test
 TREPONEMA PALLIDUM

2. Treponemal antibody tests

T pallidum–Particle Agglutination (TP-PA) test

• most widely used treponemal test
• Gelatin particles sensitized with T pallidum antigens
• Anti-T pallidum antibodies (IgG, IgM, or both) react with the sensitized particles  agglutinated particles forms in the
well of the microdilution tray.

T pallidum Hemagglutination (TPHA) and the microhemagglutination T pallidum (MHA-TP)

• same principles as the TP-PA
• sheep erythrocytes rather than gelatin particles
• more prone to nonspecific agglutination

Fluorescent Treponemal Antibody Absorbed (FTAABS) test

• difficult to perform, the test is used only in selected circumstances
• uses indirect immunofluorescence to detect reactive antibodies, including killed T pallidum and the patient’s serum
absorbed with sonicated saprophytic Reiter spirochetes plus antihuman γ-globulin labeled with a fluorescent compound.
• presence of IgM FTA in the blood of newborns  evidence of in utero infection (ie, congenital syphilis).
• negative FTA-ABS result on CSF tends to exclude neurosyphilis
• positive FTAABS result on CSF can occur by transfer of antibodies from serum and is not helpful in the diagnosis of
neurosyphilis.
 TREPONEMA PALLIDUM

2. Treponemal antibody tests

Multiple relatively similar treponemal antibody tests using enzyme immunoassay (EIA) or chemiluminescence (CIA) formats
for T pallidum are available. These tests use antigens obtained by sonication of T pallidum or recombinant antigens. An
aliquot of serum at a standard dilution is added to a sensitized well of a microdilution plate. After washing,
addition of an enzyme-labeled conjugate, and further washing, a precursor substrate is added. A color change or CIA
indicates a reactive serum. Because some of these assays are available as high-throughput automated tests, many
laboratories have now reversed the traditional algorithm for screening. Instead of screening with the nontreponemal test and
verifying with a treponemal assay, the high throughput allows screening with a more sensitive treponemal test. The
advantage to this approach is that patients with early disease or untreated latent disease are more likely to be detected (see
earlier discussion).

There are some concerns about variability in assay performance among these tests that result in more false positives when
testing low prevalence populations. Because of this, the Centers for Disease Control and Prevention (CDC) has recommended
an algorithm for confirming a positive EIA or CIA test result with a quantitative RPR or other nontreponemal test. If the RPR
result is positive, a current or past infection with syphilis is likely. If the RPR result is negative, then additional testing with a
traditional treponemal test such as the TP-PA is recommended. If the TP-PA result is positive, syphilis is likely; if it is negative,
syphilis is unlikely.
 TREPONEMA PALLIDUM

Immunity
• active or latent syphilis : resistant to superinfection with T pallidum
• eradicated infection : susceptible to infection

Treatment
Penicillin:
• concentrations of 0.003 U/mL  treponemicidal activity
• treatment of choice
• < 1 year’s duration is treated by a single injection of Benzathine Penicillin G 2.4 Million Units
Intramuscularly
• older or latent syphilis, benzathine penicillin G intramuscularly , three times at weekly intervals
• Neurosyphilis: larger amounts of intravenous
• tetracyclines or erythromycin: be substituted
• Jarisch-Herxheimer reaction may occur within hours after treatment is begun. It is caused by the release
of toxic products from dying or killed spirochetes.
 TREPONEMA PALLIDUM

Epidemiology, Prevention, and Control

With the exceptions of congenital syphilis and the rare occupational exposure of medical personnel, syphilis is acquired
through sexual exposure. Reinfection in treated persons is common. An infected person may remain contagious for
3–5 years during “early” syphilis. “Late” syphilis, of more than 5 years’ duration, is usually not contagious. Consequently,
control measures depend on (1) prompt and adequate treatment of all discovered cases, (2) follow-up on sources of
infection and contacts so they can be treated, and (3) safe sex with condoms. Several sexually transmitted diseases can be
transmitted simultaneously. Therefore, it is important to consider the possibility of syphilis when any one sexually
transmitted disease has been found.
 TREPONEMA PALLIDUM
Concept Checks
• The genus Treponema includes T pallidum subspecies pallidum, which causes syphilis; T pallidum subspecies
pertenue, which causes yaws; T pallidum subspecies endemicum, which causes endemic syphilis (also called bejel); and
Treponema carateum, which causes pinta.
• T pallidum cannot be cultivated on artificial media; therefore, they are detected directly in tissues or exudates
using dark-field microscopy, immunofluorescence, or molecular tests.
• Infections with T pallidum subspecies pallidum are limited to humans and are acquired by direct sexual contact
and less commonly transplacentally (congenital disease) or through occupational exposure.
• The primary lesion at the site of inoculation is the painless “hard chancre,” a type of genital ulcer.
• Untreated primary infection can lead to secondary disease with spread of the spirochetes systemically; latent
disease is characterized by the absence of symptoms but with a positive serologic test result. The tertiary stage involves
serious disease with central nervous system or cardiac manifestations.
• In addition to direct detection in clinical specimens, most often the diagnosis is made by serologic testing. The
traditional testing algorithm involves screening using a nontreponemal test followed by confirmation with a treponemal
test such as the TP-PA.
• The availability of high-throughput EIA or CIA tests has resulted in the reversal of this sequence of testing with
many laboratories offering screening with one of these treponemal tests followed by confirmation with the nontreponemal
test. Concern for false-positive test results has prompted the CDC to recommend an algorithm that confirms a negative
nontreponemal test result with one of the traditional treponemal tests.
• Penicillin is the drug of choice for treatment of all stages of syphilis.
 GARDNERELLA VAGINALIS

BACTERIA THAT CAUSE VAGINOSIS

Bacterial vaginosis I
• common vaginal condition of women of reproductive age
• associated with premature rupture of membranes and preterm labor and birth
• Gardnerella vaginalis and Mobiluncus species

Gardnerella vaGinalis
• serologically distinct organism
• isolated from the normal female genitourinary tract
• associated with vaginosis, inflammatory cells are not present
• In wet smears  yields “clue cells,” which are vaginal epithelial cells covered with many gram-variable
bacilli
• “fishy” odor
• pH of the vaginal secretions : greater than 4.5 (normal pH is <4.5)
• suppressed by metronidazole, suggesting an association with anaerobes. Oral metronidazole is generally
curative.
 GARDNERELLA VAGINALIS

Mobiluncus SpECIES
• motile, curved, gram-variable or gram negative, anaerobic rods
• isolated from “bacterial vaginosis,”
• clinical variant of the vaginosis
• may be part of the normal vaginal anaerobic microbiota
• detected in Gram-stained smears of vaginal secretions
• grow with difficulty in anaerobic cultures.
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