STI (Syphilis& Chancroid)

By: Dr.Hawine Bekele

July 4,2017

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 Outline
Overview of STD
Introduction
Epidemiology
Ethiology
Pathogenesis
Mode of transmission
Clinical presentation
Diagnosis
Management
Prevention

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 Objectives
At the end of the lecture students should be able to:
Understand about STD
Know the epidemiology, aetiology, transmission and
clinical presentation of the infection
Get acquainted with the management and preventive
methods of the infection

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 Overview of STIs
 STIs are infectious diseases transmitted by
intimate contact:-
sexual activity; Sexual intercourse,
 blood transfusion
 from mother to child:
– during pregnancy (e.g. HIV and syphilis);
– at delivery (e.g. gonorrhea, Chlamydia
and HIV);
– after birth through breast milk (e.g. HIV);
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 MYTHS OF STDs
True or False
1. Most people with an STD experience painful
symptoms.
2. Birth control pills prevent the spread of STDs.
3. Douching will cure and STD.
4. Abstinence is the best way to prevent STDs.
5. If you get an STD once, and are treated, you
can’t get it again.
6. A person does not need to see a doctor if she/he
notices scores on his/her genitals once, but then
they go away.
7. Condoms help prevent the spread of STDs

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 Introduction
 A sexually transmitted disease (STD), also known as
sexually transmitted infection (STI) or venereal
disease (VD), is an illness that has a significant
probability of transmission between humans or animals
by means of sexual contact, including vaginal
intercourse, oral sex, and anal sex.

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  While in the past, these illnesses have mostly been
referred to as STDs or VD, in recent years the term
sexually transmitted infection (STI) has been
preferred, as it has a broader range of meaning; a
person may be infected, and may potentially infect
others, without showing signs of disease.

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 Some STIs can also be transmitted via use of an IV
drug needle after its use by an infected person, as well
as through childbirth or breastfeeding.
 Most STIs affect both men and women, but in many
cases the health problems they cause can be more
severe for women. If a pregnant woman has an STI, it
can cause serious health problems for the baby.

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 METHODS OF TRANSMISSION:
Low Risk or No Risk
 Abstaining  Sharing lip balm
 Hugging  Mutual monogamy
 Kissing  Massage
 Holding hands  Sharing forks,
 Dancing knives, etc.
 Sitting on toilets

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 METHODS OF TRANSMISSION:
High Risk
 Sexual Intercourse
 vaginal
 anal
 oral
 Blood-to-blood contact
 Sharing needles or other drug-use equipment
 Tattoo or body piercing
 Infected mother to her baby

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 Epidemiology
 Globally 340 million new cases of curable STIs occur
every year (69 million are in sub-Saharan Africa)( 2001;
WHO)
 Prevalence higher in urban than rural
 Higher in unmarried & young adults
 More frequent among females than males between
the ages of 14-19
 After the age of 19, there is slight male
preponderance
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 STI incidence rates remain high in most of the world,
despite diagnostic and therapeutic advances that can
rapidly render patients with many STIs noninfectious and
cure most.
Sexually active adolescent girls both with and without
lower genital tract symptoms (Worldwide in 2006) include
chlamydia trachomatis (10 to 25%), Neisseria
gonorrhoeae (3 to 18%), syphilis (0 to 3%), Trichomonas
vaginalis (8 to 16%), and herpes simplex virus (2 to 12%).

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 Among adolescent boys (Worldwide, 2006) with no
symptoms of urethritis, isolation rates include C.
trachomatis (9 to 11%) and N. gonorrhoeae (2 to 3%).
 In 2006, WHO estimated that more than 1 million people
were being infected daily.
About 60% of these infections occur in young people <25
years of age, and of these 30% are <20 years.
 Between the ages of 14 and 19, STIs occur more frequently
in girls than boys by a ratio of nearly 2:1; this equalizes by
age 20.

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 B. STIs in Ethiopia
 There is little information of STIs in Ethiopia
 There is no uniformity in reporting of STIs in Ethiopia
 Total of 451,686 cases reported between June 1988 &
June 2002 in Ethiopia
 2% prevalence (DHS 2005)
 2.5% to 3.3% (cross-sectional community based study
1994/95)

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STI statistics

Symptomatic

Asymptomatic

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 Factors Affecting Transmission
 Behavioral Factors
 Personal factors
 Socio-economic
 Cultural
 Biological & clinical

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Medical Complications of STIs some Examples

CAUSE COMPLICATIONS
Gonococcal & Infertility, Ectopic pregnancy, chronic pelvic
Chlamydial infections pain, urethral stricture, peritonitis

Gonorrhea Blindness in infants,

Disseminated gonococcal infection

Chlamydia pneumonitus in infants

Acquired syphilis Permanent brain, Heart disease
Congenital syphilis Extensive organ & tissue damage
Human papilloma virus Genital cancer, obstructed labor
 Bacterial vs. Viral STI’s
 Bacterial STI’s include  Viral STI’s include HPV,
Chlamydia, LGV, HIV, Herpes, & Hepatitis
gonorrhea & syphilis B
 Can be treated and cured  There is NO cure
with antibiotics  Medication available to
 Untreated infection can treat symptoms only
cause PID, infertility, &  Can pass onto others for
epididymitis the rest of your life

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 Pathology
 Many STIs are (more easily) transmitted through the mucous
membranes of the penis, vulva, rectum, urinary tract and (less
often - depending on type of infection) the mouth, throat,
respiratory tract and eyes.
 The visible membrane covering the head of the penis is a
mucous membrane, though it produces no mucus (similar to
the lips of the mouth).
 Mucous membranes differ from skin in that they allow certain
pathogens into the body. Pathogens are also able to pass
through breaks or abrasions of the skin, even minute ones.

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  The shaft of the penis is particularly susceptible due to the
friction caused during penetrative sex.
 The primary sources of infection in ascending order are
venereal fluids, saliva, mucosal or skin (particularly the
penis), infections may also be transmitted from feces, urine
and sweat.
 The amount required to cause infection varies with each
pathogen but is always less than you can see with the naked
eye.
 Some infections labeled as STIs can be transmitted by direct
skin contact. Herpes simplex, pubic lice and HPV are both
examples.
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 The link between STI & HIV

Both share same behavior & mode of transmission

STIs facilitate the transmission of HIV
 A person with open sores in the genital area is much
more likely both to contract and to transmit HIV.
 Chancroid and syphilis are the main bacterial causes
of sores:
 Genital herpes also facilitates HIV transmission.

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 The link between STI & HIV
Cont’d
 Chlamydia, gonorrhea and trichomoniasis can also
facilitate the transmission of HIV.
 This may be for one or both of two reasons:

I. increase the number of white blood cells

II. Genital inflammation

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 The link between STI & HIV
Cont’d
 The presence of HIV can make people more
susceptible to the acquisition of STIs

 The presence of HIV increases the

severity of STIs and
their resistance to standard treatment

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Clinical presentations of HIV and STI co-infection

 Atypical presentation of Syphilis, rapid progression to

neurosyphilis
 Atypical lesions of chancroid
 Recurrent or persistent genital ulcers from HSV2
 Severe genital herpes may require suppression of
recurrence with acyclovir

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Clinical presentations of HIV and STI co-infection
cont’d

 Human papilloma virus with exophytic genital warts

 Risk of treatment failure with single injection of

Benzathine Penicillin in primary syphilis

 Topical anti-fungals are less effective

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 Contact Notification and Treatment
We define the STI client as index case and his/her sexual
partners who could be the source of infection or who could
have been infected by the index case as contacts.
The concept of contact notification and treatment is based on
the following facts:
 Each STI client must have been infected by a sexual partner
who should also be treated.
 Each STI client is a potential source of infection to sexual
partner(s) until treatment is completed.

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 Contact Notification & Treatment cont…
 A treated STI client is cured but not immune. This means
that s/he can be re-infected if the sexual partners still have
the STI, a reason why these partners should be treated
according to equivalent syndrome of the index patient to
break the chain of STI transmission and to reduce the
chance of the client being re- infected.

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 STI Prevention
Abstain from sexual intercourse (only method that
is 100% effective)
Don’t share needles or other drug-use equipment
Have only 1 mutually faithful, uninfected sexual
partner
Get tested for STI’s before having sex
Use a latex condom & spermicide
Avoid alcohol & other drugs

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  Syphillis..........

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 Introduction
Syphillis is an infectious veneral disease caused by the
spirochete T.pallidum.
It is transmissible by sexual contact with infectious
lesions, from mother to featus in utero, via blood
product transfussion and occasionally through breaks
in the skin that comes into contact with the infectious
lesion.
If untreated it will progress through 4 stages: primary,
second, latent and tertiary.

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 Syphilis has a myriad of presentations and can mimic
many other infections and immune mediated processes
in advanced stages. Hence it has earned the name ”the
greater imposter ”
The complex and variable manifestations of the
disease prompted sir William Osler to remark “the
physician who knows syphilis knows medicine ”

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 Historical background
Epidemic in late 15th century Europe
Rapid spread and severe symptoms in early stages
Epidemic coincided with Columbus’ return from
America in 1493
? endemic but unrecognized
? A gift from the new world

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 Syphilis…Discovery of its Cause

1903: Infection successfully transmitted

to monkeys

1905: Identification of the bacterium

Treponema pallidum (“Spirochaeta
pallida”)

1906: Darkfield microscopy

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 Epidemiology
Disease Trends in the U.S :
 Distributed widely throughout the U.S. in the 1940s
 After the 1940s, declined rapidly with the introduction of
penicillin therapy and broad-based public health programs
 1986–90: 83% increase in the incidence of primary and
secondary syphilis
 1990s: reported cases of syphilis declined 89.7% to an all-
time low in 2000
 Remains a public health problem in the U.S.
 MSM an important risk population

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 International statistics:
Internationally, the prevalence of syphilis varies by
region.
Syphilis remains prevalent in many developing
countries and in some areas of North America, Asia,
and Europe, especially in eastern Europe.
The highest rates are in south and south east Asia
followed closely by sub-saharan Africa.
The third highest rates are in the regions of Latin
America and the caribbean.

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 Age distribution:
Syphilis is most common during the years of peak
sexual activity.
Most new cases occur in men and women aged 20-29
years.
In 2013, the rate of primary and secondary syphilis was
highest in people aged 25-29 years(27 per 100,000)
The incidence of congenital syphilis has increased to
11.6 cases per 100,000 live births in 2014, the highest
congenital syphilis reported since 2001.

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 Sex distribution:
Men are affected more frequently with primary or
secondary syphilis than women.
This difference has varied over time. 1.6:1- 10:1

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 Worldwide
WHO estimates 12 million new cases per year
90% of those cases in developing countries
In Russia and Eastern Europe, its contributing to hiv
infections
North America and Western Europe rates have shifted to
MSM, and illicit drug users
In Africa more females are infected than males
USA
During the 90’s rates steadily decreased
2001-2002 syphilis rates began to increase
Increase primarily in males, suggesting MSM

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 Taxonomy

Domain: Bacteria
Phylum: Spirochaetes
Order: Spirochetales
Family: Spirochaetaceae
Genus: Treponema
Species: pallidum
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 Pathogenesis

Microbiology
Etiologic agent: Treponema pallidum, subspecies

pallidum
Corkscrew-shaped, motile microaerophilic bacterium

Cannot be cultured in vitro

Cannot be viewed by normal light microscopy

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 Pathogenesis

Treponema pallidum

42 Electron photomicrograph, 36,000 x.

Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
 Pathogenesis

Treponema pallidum on Darkfield

Microscopy

43
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
 Characteristics
Helical, tightly coiled, mobile
5-20 um in length, 0.1-0.4 um in diameter
Pathogenic treponemes associated with 4 diseases
Venereal syphilis (pallidum)
Yaws (perfenue)
Endemic (endemicum)
Pinta (carateum)
Obligate parasites of humans

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 Pathogenesis

Pathology
Penetration:
T. pallidum enters the body via skin and mucous
membranes through abrasions during sexual contact
Transmitted transplacentally from mother to fetus during
pregnancy
Dissemination:
Travels via the circulatory system (including the
lymphatic system and regional lymph nodes) throughout
the body
Invasion of the central nervous system (CNS) can occur
during any stage of syphilis.

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 Pathophysiology
Acquired syphilis
In acquired syphilis T.pallidum rapidly penetrates
intact mucous membrane or microscopic dermal
abrasions and within a few hours enter the lymphatic
and blood to produce systemic infection.
Incubation time from exposure to development of
primary lesions, which occurs at primary sites of
inoculation averages 3 weeks but can range from 10-
90 days.

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 Regardless of the stage of disease and location of
lesion, histopathology hallmarks of syphilis include
endarteritis and a plasma cell rich infiltrate.
The syphilitic infiltrate reflects a delayed type
hypersensitivity response to T.pallidum, and in certain
individuals with tertiary syphillis, this response by
sensitized T-lymphocytes and macrophages results in
gummatous ulcerations and necrosis.

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 Method of infection
Viable bacteria from a chancre enters through a fissure
or mucus membrane
Bacteria multiply locally and causes a painless chancre
Spreads via blood stream or lymphatic system
Can infect almost any organ or tissue
Continuous in vitro culture has yet to be achieved

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 Clinical presentation
Physicians must keep a high index of suspicion for the
diagnosis of syphillis, as the manifestations of syphilis
are non specific.
Rigorous attention to the time course of symptoms is
required for proper staging of the diseases.

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 Obtain a thorough sexual and social history including
the number of sexual partners, condom use, hx of STD
in the patient and their partners, IV drug use, and
exposure to blood products.
In children and infants seek a maternal history, history
of exposure to individual with syphilis or blood
products and a hx of sexual abuse.

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 Primary syphilis occurs 10-90 days after contact with
an infected individual.
It manifest mainly on the glans penis in males and on
the vulva and or cervix in females.
Ten percent of syphilitic lesions are found on the anus,
fingers, oropharynx, tongue, nipples, or other extra
genital sites.
Regional non tender lymphadenopathy follows
invasion.

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 Lesions usually begin as solitary, raised, firm, red
papules that can be several cm in diameter.
The chancer erodes to create an ulcerative crater
within the papule, with slightly elevated edges around
the central ulcer.
It usually heals 4-8 weeks with or without therapy.

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 Primary Syphilis
 Primary lesion or "chancre" develops at the site of
inoculation.
 Chancre
 Progresses from macule to papule to ulcer;
 Typically painless, indurated, and has a clean base;
 Highly infectious;
 Heals spontaneously within 3 to 6 weeks; and
 Multiple lesions can occur.

 Regional lymphadenopathy: classically rubbery, painless,

bilateral
 Serologic tests for syphilis may not be positive during early
primary syphilis.
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 Clinical Manifestations

Primary Syphilis—Penile Chancre

54
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Primary Syphilis—Labial Chancre

55
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Primary Syphilis—Perianal Chancre

56
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Primary Syphilis—Chancre of the Tongue

57
Source: CDC/ NCHSTP/ Division of STD Prevention /STD Clinical Slides
 Clinical Manifestations

Secondary Syphilis
 Secondary lesions occur several weeks after the primary
chancre appears; and may persist for weeks to months.
 Primary and secondary stages may overlap
 Mucocutaneous lesions most common
 Clinical Manifestations:
 Rash (75%–100%)
 Lymphadenopathy (50%–86%)
 Malaise
 Mucous patches (6%–30%)
 Condylomata lata (10%–20%)
 Alopecia (5%)
 Liver and kidney involvement can occur
 Splenomegaly is occasionally present
 Serologic tests are usually highest in titer during this stage.

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 lasts 3-6 weeks.
After the chancre comes a copper-colored skin rash
which may appear on the palms of the hands, soles of
the feet, or in more severe cases covers the entire body.

The rash may be accompanied by fever, headaches,

indigestion, loss of appetite, or loss of hair in spots
over the scalp.

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 A localized or diffuse mucocutaneous rash(generally
non pruritic and bilaterally symmetrical ) with
generalized non tender lymphadenopathy is typical.
Mild constitutional symptoms of malaise, headache,
anorexia, nausea and fatigue may be present.

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 Clinical Manifestations

Secondary
Syphilis—
Papulosquamous
Rash

61
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Secondary Syphilis—
Palmar/Plantar Rash

Source: Seattle STD/HIV Prevention Source: CDC/NCHSTP/Division of STD

Training Center at the University of Prevention, STD Clinical Slides
62 Washington, UW HSCER Slide Bank
 Clinical Manifestations

Secondary Syphilis— Generalized Body

Rash

Source: Cincinnati STD/HIV Prevention

Training Center
Source: CDC/NCHSTP/Division of STD Prevention, STD
Clinical Slides

63
 Clinical Manifestations

Secondary Syphilis—
Papulo-pustular Rash

64
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Secondary Syphilis— Condylomata lata

65
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Secondary Syphilis— Nickel/Dime Lesions

66
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Secondary Syphilis— Alopecia

67
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Latent Period
All symptoms disappear so that the victim thinks he/she is
cured.
If not received treatment the bacterium remains in the
body and begins to damage the internal organs including
the brain, nerves, eyes, heart, blood vessels, liver,
bones, and joints.

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 Clinical Manifestations

Host suppresses infection, but no lesions are

clinically apparent
Only evidence is a positive serologic test
May occur between primary and secondary stages,
between secondary relapses, and after secondary
stage
Categories:
Early latent: <1 year duration
Late latent: 1 year duration

69
 Clinical Manifestations

Neurosyphilis
 Occurs when T. pallidum invades the central nervous system
(CNS)
 May occur at any stage of syphilis

 Can be asymptomatic

 Early neurosyphilis occurs a few months to a few years after

infection
 Clinical manifestations can include acute syphilitic meningitis,
meningovascular syphilis, and ocular involvement
 Neurologic involvement can occur decades after infection and
is rarely seen
 Clinical manifestations can include general paresis, tabes dorsalis, and
ocular involvement
70  Ocular involvement can occur in early or late neurosyphilis.
 Clinical Manifestations

Neurosyphilis—Spirochetes in Neural Tissue

Silver stain, 950x

71
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Tertiary (Late) Syphilis

It is slowly progressive and may affect any organ. The
disease is not thought to be infectious at this stage.
Approximately 30% of untreated patients progress to
the tertiary stage within 1 to 20 years.
Rare because of the widespread availability and use of
antibiotics
Manifestations
Gummatous lesions
Cardiovascular syphilis

72
 The lesions of guammatous tertiary syphilis usually
develop within 3-10 yrs of infection.
The patient complaints are usually secondary to bone
pain, which is described as a deep boring pain
characteristically worse at night.

73
 Clinical Manifestations

Late Syphilis—Serpiginous Gummata of

Forearm

74
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Late Syphilis - Ulcerating Gumma

75
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Late Syphilis—Cardiovascular

76
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Congenital Syphilis
 Occurs when T. pallidum is transmitted from a pregnant
woman to her fetus
 May lead to stillbirth, neonatal death, and infant disorders
such as deafness, neurologic impairment, and bone
deformities
 Transmission can occur during any stage of syphilis; risk is
much higher during primary and secondary syphilis
 Fetal infection can occur during any trimester of pregnancy
 Wide spectrum of severity exists; only severe cases are
clinically apparent at birth
 Early lesions (most common): Infants <2 years old; usually
inflammatory
 Late lesions: Children >2 years old; tend to be immunologic and
destructive

77
 Clinical Manifestations

Congenital Syphilis—Mucous Patches

78
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Congenital Syphilis— Hutchinson’s Teeth

79
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Clinical Manifestations

Congenital Syphilis— Perforation of Palate

80
Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides
 Primary: (3 days – 3 months) starts as a small,
painless sore called a chancre; goes away on it’s own
Secondary: (2 – 24 weeks) rash on the body, palms of
hands & soles of feet, hair loss, feeling sick
Latent: lesions or rashes can recur

81
 Transmission
Contact with infectious, moist lesion(s), most
commonly during oral, anal or vaginal sex

Less common through casual skin-to-skin contact

Mother-to-child transmission

Cannot be spread by use of toilet seats, swimming

pools, hot tubs, shared clothing or eating utensils

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 Transmission
 During early (primary and secondary) syphilis, efficiency of
transmission ~ 30%.

 Perinatal transmission can occur:

- at any time during pregnancy
- at any stage of the disease

 Syphilis can infect infants of untreated mothers. Chance of vertical

transmission by stage of infection:
-primary syphilis = 50%
-early latent syphilis = 40%
-late latent syphilis = 10%
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-tertiary syphilis = 10%
 Lesson IV: Syphilis Diagnosis

84
 Diagnosis

Aspects of Syphilis Diagnosis

1. Clinical history

2. Physical examination

3. Laboratory diagnosis

85
 Diagnosis

Clinical History
Assess
History of syphilis
Known contact to an early case of syphilis
Typical signs or symptoms of syphilis in the past 12
months
Most recent serologic test for syphilis

86
 Diagnosis

Physical Examination

Oral cavity
Lymph nodes
Skin of torso
Palms and soles
Genitalia and perianal area
Neurologic examination
Abdomen

87
 Diagnosis

Laboratory Diagnosis
Identification of Treponema pallidum in lesion exudate
or tissue
Darkfield microscopy
Tests to detect T. pallidum
Serologic tests to allow a presumptive diagnosis
Nontreponemal tests
Treponemal tests

88
 Diagnosis

Darkfield Microscopy
What to look for
T. pallidum morphology and motility

Advantage
Definitive immediate diagnosis
Rapid results

Disadvantages
Requires specialized equipment and an experienced
microscopist
Possible confusion with other pathogenic and
nonpathogenic spirochetes
Must be performed immediately
Generally not recommended on oral lesions
Possibility of false-negatives
89
 Diagnosis

Serologic Tests for Syphilis

Two types
Treponemal (qualitative)
Nontreponemal (qualitative and quantitative)
The use of only one type of serologic test is
insufficient for diagnosis

90
 Diagnosis

Nontreponemal Serologic Tests

Principles
Measure antibody directed against a cardiolipin-lecithin-
cholesterol antigen
Not specific for T. pallidum

Titers usually correlate with disease activity and results are

reported quantitatively
May be reactive for life, referred to as “serofast”

Nontreponemal tests include VDRL, RPR, TRUST,

USR
91
 Diagnosis

Nontreponemal Serologic Tests (continued)

Advantages
 Rapid and inexpensive
 Easy to perform and can be
done in clinic or office
 Quantitative
 Used to follow response to
therapy
 Can be used to evaluate
possible reinfection
Disadvantages
 May be insensitive in
certain stages
 False-positive reactions
may occur
 Prozone effect may cause
a false-negative reaction
(rare)

92
 Diagnosis

Treponemal Serologic Tests

Principles
Measure antibody directed against T. pallidum antigens
Qualitative
Usually reactive for life
Titers should not be used to assess treatment response
Treponemal tests include TP-PA, FTA-ABS, EIA, and CIA

93
 Diagnosis

Sensitivity of Serological Tests in Untreated

Syphilis
Stage of Disease (Percent Positive [Range])

Test Primary Secondary Latent Tertiary

VDRL 78 (74–87) 100 95 (88–100) 71 (37–94)

RPR 86 (77–99) 100 98 (95–100) 73
FTA-ABS* 84 (70–100) 100 100 96
Treponemal
76 (69–90) 100 97 (97–100) 94
Agglutination*
EIA 93 100 100

*FTA-ABS and TP-PA are generally considered equally sensitive in the primary stage of disease.

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 Diagnosis

Causes of False-Positive Reactions in

Serologic Tests for Syphilis
Disease RPR/VDRL FTA-ABS TP-PA
Age Yes
Autoimmune Diseases Yes Yes
Cardiovascular Disease Yes Yes
Dermatologic Diseases Yes Yes --
Drug Abuse Yes Yes
Febrile Illness Yes
Glucosamine/chondroitin sulfate Possibly
Leprosy Yes No --
Lyme disease Yes
Malaria Yes No
Pinta, Yaws Yes Yes Yes
Recent Immunizations Yes -- --
STD other than Syphilis Yes

95 Source: Syphilis Reference Guide, CDC/National Center for Infectious

Diseases, 2002
 Diagnosis

Diagnosis of Latent Syphilis

Criteria for early latent syphilis, if within the year
preceding the evaluation
Documented seroconversion or 4-fold increase in
comparison with a serologic titer
Unequivocal symptoms of primary or secondary syphilis
reported by patient
Contact to an infectious case of syphilis
Only possible exposure occurred within past 12 months
Patients with latent syphilis of unknown duration
should be managed clinically as if they have late
latent syphilis.
Public health laws require that all cases of syphilis be
reported to the state/local health department.
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 Diagnosis

CNS Disease Diagnostic Issues

 CNS disease can occur during any stage of syphilis.
 Conventional therapy is effective for the vast majority of
immuno-competent patients with asymptomatic CNS
involvement in primary and secondary syphilis.

97
 Diagnosis

Indications for CSF Examination

Patients with syphilis who demonstrate any of the
following criteria should have a prompt CSF evaluation:
Neurologic or ophthalmic signs or symptoms
Evidence of active tertiary syphilis (e.g., gummatous lesions)
Treatment failure
HIV infection with a CD4 count ≤350 and/or a nontreponemal
serologic test titer of ≥1:32 

98
 Diagnosis

Diagnosis of CNS Disease

 No test can be used alone to diagnose neurosyphilis.

 VDRL-CSF: highly specific, but insensitive

 Diagnosis usually depends on the following factors:

 Reactive serologic test results
 Abnormalities of CSF cell count or protein
 A reactive VDRL-CSF with or without clinical manifestations

 CSF leukocyte count usually is elevated (>5 WBCs/mm3) in

patients with neurosyphilis.
 The VDRL-CSF is the standard serologic test for CSF, and when
reactive in the absence of contamination of the CSF with blood, it
is considered diagnostic of neurosyphilis. However, in early
syphilis it can be of unknown prognostics significance.
99
 Diagnosis

Effect of HIV Infection on Syphilis

Syphilis and HIV infections commonly coexist.

Clinical course is similar to non-HIV-infected
patients.
Although uncommon, unusual serologic responses
can occur.
 If clinical suspicion of syphilis is high and the
serologic tests are negative, then use of other tests
(e.g., biopsy of the lesion or rash) should be
considered.
Conventional therapy is effective.
100
 Patient Management

101
 Management

Therapy for Primary, Secondary, and Early

Latent Syphilis

Benzathine penicillin G 2.4 million units

intramuscularly in a single dose (Bicillin L-A®)

If penicillin allergic

Doxycycline 100 mg orally twice daily for 14 days, or
Tetracycline 500 mg orally 4 times daily for 14 days

Source:
102 Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2010. MMWR 2010;59 (No. RR-12).
 Management

Therapy for Late Latent Syphilis

Benzathine penicillin G 7.2 million units total,
administered as 3 doses of 2.4 million units
intramuscularly each at 1-week intervals
If penicillin allergic
Doxycycline 100 mg orally twice daily for 28 days or
Tetracycline 500 mg orally 4 times daily for 28 days

Source:
103 Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2010. MMWR 2010;59 (No. RR-12).
 Management

Therapy for Tertiary Syphilis

Benzathine penicillin G 7.2 million units total,

administered as 3 doses of 2.4 million units
intramuscularly each at 1-week intervals
If penicillin allergic
Doxycycline 100 mg orally twice daily for 28 days or
Tetracycline 500 mg orally 4 times daily for 28 days

Source:
104 Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2010. MMWR 2010;59 (No. RR-12).
 Management

Therapy for Neurosyphilis

Aqueous crystalline penicillin G 18–24 million units per
day, administered as 3–4 million units intravenously
every 4 hours or continuous infusion for 10 to14 days
intravenously
Alternative regimen (if compliance can be ensured)
Procaine penicillin 2.4 million units intramuscularly once daily
PLUS Probenecid 500 mg orally 4 times a day, both for 10 to14
days

Source:
105 Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2010. MMWR 2010;59 (No. RR-12).
 Management

Therapy for Syphilis in Pregnancy

Treat with penicillin according to stage of infection.
Erythromycin is no longer an acceptable alternative drug
in penicillin-allergic patients.
Patients who are skin-test-reactive to penicillin should be
desensitized in the hospital and treated with penicillin.
Some evidence suggests that additional therapy can be
beneficial for pregnant women in some settings.

Source:
106 Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2010. MMWR 2010;59 (No. RR-12).
 Management

Jarisch-Herxheimer Reaction
 Self-limited reaction to antitreponemal therapy
 Fever, malaise, nausea/vomiting; may be associated with chills and
exacerbation of secondary rash

 Occurs within 24 hours after therapy

 Not an allergic reaction to penicillin

 More frequent after treatment with penicillin and treatment of early

syphilis
 Antipyretics can be used to manage symptoms, but they have not
been proven to prevent this reaction.
 Pregnant women should be informed of this possible reaction, that it
may precipitate early labor, and to call obstetrician if problems
107
 Management

Syphilis and HIV/Other STDs

HIV infected persons with primary, secondary, and
early latent syphilis should receive a single
intramuscular dose of 2.4 MU of benzathine penicillin.
Penicillin-allergic patients with syphilis and HIV
whose compliance cannot be ensured should be
desensitized and treated with penicillin.
All patients who have syphilis should be tested for
HIV infection.
Consider screening persons with syphilis for other
STDs, based on risk.
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 Management

Follow-Up
Primary or secondary syphilis
Reexamine at 6 and 12 months.
Follow-up titers should be compared to the maximum or
baseline nontreponemal titer obtained on day of treatment.
Latent syphilis
Reexamine at 6, 12, and 24 months.
HIV-infected patients
3, 6, 9, 12 and 24 months for primary or secondary syphilis
6, 12, 18, and 24 months for latent syphilis
Neurosyphilis
Serologic testing as above
Repeat CSF examination at 6-month intervals until normal

109
 Management

Treatment Failure

Indications of probable treatment failure or

reinfection include
Persistent or recurring clinical signs or symptoms
Sustained 4-fold increase in titer
Titer fails to show a 4-fold decrease within 6–12 months
Retreat and re-evaluate for HIV infection.
CSF examination can be considered.

110
 Prevention

111
 Prevention

Patient Counseling and Education

Nature of the disease
Transmission
Treatment and follow-up
Risk reduction

112
 Prevention

Management of Sex Partners

For sex partners of patients with syphilis in any stage
Draw syphilis serology
Perform physical exam

For sex partners of patients with primary, secondary,

or early latent syphilis
Treat presumptively as for early syphilis at the time of
examination, unless
 The nontreponemal test result is known and negative and
 The last sexual contact with the patient is > 90 days prior to
examination.

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 Prevention

Screening Recommendations
Screen pregnant women at least at first prenatal
visit.
In high prevalence communities, or patients at risk
 Test twice during the third trimester, at 28 weeks, and at delivery,
in addition to routine early screening.
Any woman who delivers a stillborn infant after 20
weeks gestation should be tested for syphilis.
Screen other populations based on local prevalence
and the patient’s risk behaviors.

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 Thank you!!!!!

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