syphilis

CAI TAO
 Requirements
Supposed to Master:
The etiology and pathogenesis,
The transmission,
The classification and stages,
The clinical manifestations,
The Laboratory examination
the diagnosis, treatment of syphilis
 Definition of sexually
transmitted diseases (STDs)

STDs are a group of infectious diseases

transmitted through human sexual behavior
(WHO)
 Classification of STDs
The common STDs includes:
Nongonococcal urethritis
Gonorrhea
Condylomata acuminata
Syphilis
Genital herpes
 Origins of Syphilis
Syphilis was a shepherd boy`s name of
ancient Greece.
Debate about the origins of syphilis has
continued for nearly 500 years, ever since
early sixteenth-century Europeans blamed
each other, referring to it variously as the
Venetian, Naples, or French disease. One
hypothesis assumes a New World origin, and
holds that sailors who accompanied
Columbus and other explorers brought the
disease back to Europe.
Etiology and pathogenesis of syphilis

The organism: spirochete Treponema

pallidum.
the spirochete enters through the skin or
mucous membrans, on which the primary
manifestations are seen.
In congenital syphilis the treponeme crosses
the placenta and infects the fetus.
 Transmission
Direct infection
Sexual intercourse(95%)>Moist
kissing>Sexual touching.
Indirect infection eating-utensils, drinking
vessels, pipes or moist towels, etc.
Blood infection
 puncture with needle, syphilitic patients-health
people.
 transplacental , mother-fetus
 Classification and stages
Acquired syphilis
Early stage:
 Primary stage
 Secondary stage
 Early latent syphilis

Late stage:
 Tertiary stage
 Late latent syphilis

Congenital syphilis
 Clinical manifestation
Primary syphilis----
chancre
 incubation period: 2~4w.
 occurs on the penis or
scrotum of 70% of men
with syphilis and on the
vulva, cervix, or
perineum of more than
50% of women with
syphilis.
 Clinical manifestation

 Extragenital chancres
occur most commonly
above the neck, typically
affecting the lips or oral
cavity.
 The primary lesion
usually is a single
ulcerated lesion with a
surrounding red areola.
The edge and base of
the ulcer have a
cartilaginous (buttonlike)
consistency on palpation.
 Clinical manifestation

 The lesion is highly infectious; when

abraded, it exudes a clear serum
containing numerous T pallidum
organisms.
 Chancres are usually painless.

 The regional lymph nodes usually enlarge

painlessly and are firm, discrete, and
nontender
 Chancre will heals slowly over 2 to 8
weeks if untreated.
 Clinical manifestation

Secondary syphilis
The manifestations of
the secondary stage
are extremely variable
and usually include
localized or diffuse
s y m m e t r i c
mucocutaneous
lesions.
 Clinical manifestation

 The rashes aire generally widespread, frequent

involvement of the palms and soles.
 Clinical manifestation
The cutaneous eruption may consist of macular,
papular papulosquamous, or follicular lesion.
 Clinical manifestation

Tiny papular follicular

syphilids involving hair
follicles may result in
patchy alopecia. In
addition to the classic
moth-eaten alopecia.
 Clinical manifestation

Condyloma latum :
In 10% of patients,
highly infectious
papules develop at
the mucocutaneous
junctions and, in
moist intertriginous
skin, become
hypertrophic and
dull pink or gray.
 Less common findings include
periostitis, arthralgias, meningitis,
nephritis, hepatitis, and ulcerative
colitis
 Clinical manifestation

Tertiary syphilis
 Gummatous syphilis
 Cardiovascular syphilis

 Neurosyphilis
 Clinical manifestation

Congenital syphilis
Early manifestations
 Early signs and symptoms include development of
a diffuse rash, characterized by extensive
sloughing of the epithelium, particularly on the
palms, soles, and skin around the mouth and anus.
 A compilation of early clinical presentations of
congenital syphilis included abnormal bone
radiographs, hepatomegaly, splenomegaly,
petechiae, other skin rashes, anemia,
lymphadenopathy, jaundice, pseudoparalysis, and
snuffles.
 A classic mucocutaneous sign is depressed linear
scars radiating from the orifice of the mouth and
termed rhagades (Parrot lines).
 Clinical manifestation
Late manifestations
 Late signs and symptoms are rare and, if
encountered, usually involve complications
including interstitial keratitis, cranial nerve
VIII deafness, corneal opacities, and/or
recurrent arthropathy.
 Dental abnormalities may be evident, such
as centrally notched and widely spaced,
p e g - shaped, upper central in cis o rs
(Hutchinson teeth) and sixth-year molars
with multiple poorly developed cusps
(mulberry molars).
 Clinical manifestation

Latent syphilis
 In latent syphilis, there are no clinical
signs or symptioms of the disease, and it
presence is detectable only by serologic
testing.
 Laboratory examination
Darkfield examination
Da rkfield microscopy is ess e n tia l in
evaluating moist cutaneous lesions, such as
the chancre of primary syphilis or the
condyloma lata of secondary syphilis.
When dark-field microscopy is not available,
direct immunofluorescence staining of fixed
smears (direct fluorescent antibody
Treponema pallidum [DFA-TP]) is an option.
Both procedures detect the causative
organism at a rate of approximately 85-92%.
Serologic tests
Nontreponemal tests
 Measure nonspecific antibodies (reagins)
 Employ cardiolipin antigen
 Screening and diagnostic tests
 Response to therapy
 RPR, VDRL, TRUST
Treponemal tests
 Specific antibodies
 confirmatory tests
 FTA-ABS, TPHA,MHA-TP, TPI
 Diagnosis
Genital Ulcer Evaluation
Diagnosis based on medical history and
physical examination often inaccurate
Serologic test for syphilis
Culture/antigen test for herpes simplex
Haemophilus ducreyi culture in settings
where chancroid is prevalent
Biopsy may be useful
 Diagnosis
Disease history
Clinical manifestation
Laboratory data
 Primary syphilis: chancre + darkfield
examination
 Secondary syphilis: skin lesions +
serological tests
 treatment
Penicillin remains the mainstay of treatment.
Penicillin use is the only therapy used
widely for neurosyphilis, congenital syphilis,
or syphilis during pregnancy. Rarely, T
pallidum has been found to persist following
adequate penicillin therapy; at the same
time, there is no indication that the
organism has acquired resistance to
p e n i c i l l i n .
 treatment

In patients with allergy to penicillin, skin

testing and desensitization are
recommended. Make every effort to
document penicillin aller gy before
c h oo s i n g a n a l t e r na t i v e tr e a tm en t
because the efficacy of alternative
regimens is questionable in all stages of
syphilis. Many treatment failures have
been reported.
 treatment

Tetracycline, doxycycline and ceftriaxone

have shown antitreponemal activity in
clinical trials; however, they currently are
recommended only as alternative
treatment regimens in patients allergic
to penicillin.
 treatment

Primary and Secondary Syphilis Treatment

Recommended Regimen for Adults(CDC)
Benzathine penicillin G 2.4 million units IM in a single
dose.
Recommended Regimen for Children(CDC)
Benzathine penicillin G 50,000 units/kg IM, up to the
adult dose of 2.4 million units in a single dose.
Penicillin Allergy
Doxycycline 100 mg orally twice daily for 14 days.
Tetracycline 500 mg four times daily for 14 days.
Ceftriaxone 1 gram daily either IM or IV for 8--10 days.
Azithromycin a single oral dose of 2 grams.
 treatment
Treatment in Pregnancy
Screen for syphilis at first prenatal visit; repeat RPR third
trimester/delivery for those at high risk or high prevalence
areas
Treat for the appropriate stage of syphilis
Some experts recommend additional benzathine penicillin
2.4 mu IM after the initial dose for primary, secondary, or
early latent syphilis
Management and counseling may be facilitated by
sonographic fetal evaluation for congenital syphilis in the
second half of pregnancy
Pregnant patients who are allergic to penicillin should be
desensitized and treated with penicillin or receive the
recommended total dose of erythromycin; tetracycline
should not be used
 treatment
Latent Syphilis

Recommended regimen
Benzathine penicillin G 2.4 million units IM
at one week intervals x 3 doses
Penicillin allergy
Doxycycline 100 mg orally twice daily
or
Tetracycline 500 mg orally four times daily
Duration of therapy 28 days; close clinical and
serologic follow-up; data to support alternatives
to pcn are limited
 Follow-Up
Treatment failure can occur with any regimen.
However, assessing response to treatment
often is difficult, and definitive criteria for cure
or failure have not been established.
Nontreponemal test titers may decline more
slowly for patients who previously had
syphilis. Patients should be reexamined
clinically and serologically at 3 month
intervals in the first year and then at 6 month
intervals tor 2 to 3 years after treatment.
Patients who have signs or symptoms
that persist or recur or who have a
sustained fourfold increase in
nontreponemal test titer (i.e., compared
with the maximum or baseline titer at
the time of treatment) probably failed
treatment or were reinfected. These
patients should be re-treated.
 Reivew
What is the cause of syphilis?
How do syphilis occur?
How do syphilis transmit?
What is chancre?
What is condyloma lata?
What laboratory examinations are there
of syphilis?
How should primary syphilis be treated?
 Case 1

A male, 45 years old,

complained of nontender
genital erosion. Physical
examination revealed
inguinal adenophthy. His
serologic test for syphilis
(RPR) was positive at a
titer of 1:64. Three months
after Benzathine penicillin G
2.4 million units IM in a
single dose the RPR titer 2 cm round eroded red plaque
in glans penis
dropped to 1:1.
 Case 2
A 30-year-old man was evaluated for a rash of 2 weeks
duration on his hands and feet ,rapidly spreading to invove
his trunk and face. He also had a chancre on his penis with
painless regional lymph adenopathy which he developed a
 Case 2

few weeks prior to the eruption. Other than the skin rash
his physical examination was normal. Screening for
sexually transmitted diseases revealed positive .Venereal
Disease Research Laboratory (VDRL)and rapid plasma
reagin(RPR) tests.