Syphilis - Clinicals, Diagnosis, and Management

Infectious diseases

Clinicals - History

Fact Explanation
History of contact with infected person Treponema pallidum is a gram negative spiral-shaped bacterium with a flagella belongs to the family Spirochaetaceae. Dermal micro abrasions or intact mucous membranes are the routes of entry into the body. Direct contact with a syphilis lesion in the form of anal, vaginal, or oral sex is the main mode of transmission of syphilis. Therefore an unprotected anal, vaginal, or oral sex or direct contact with the lesions increase the risk of getting the disease. Usually they develop lesions 3 weeks after exposure. Primary ,secondary and early latent periods are the most infectious periods. History of contact with infected person
Treponema pallidum is a gram negative spiral-shaped bacterium with a flagella belongs to the family Spirochaetaceae. Dermal micro abrasions or intact mucous membranes are the routes of entry into the body. Direct contact with a syphilis lesion in the form of anal, vaginal, or oral sex is the main mode of transmission of syphilis. Therefore an unprotected anal, vaginal, or oral sex or direct contact with the lesions increase the risk of getting the disease. Usually they develop lesions 3 weeks after exposure. Primary ,secondary and early latent periods are the most infectious periods.
Painless ulcers on the penis, vagina, anus, the rectum Syphilis has main 3 stages: primary, secondary and latent. Firm, round, and painless sore(chancre) is the first symptom to occur, at the first site of T. pallidum invasion, which may be healed by few weeks. There can be more than one chancres. This is painless when compared to chancroid. During the secondary stage there can be involvement of mucous membrane manifesting as sores in the labia or cervix., vagina, anus, rectum and mouth. Painless ulcers on the penis, vagina, anus, the rectum
Syphilis has main 3 stages: primary, secondary and latent. Firm, round, and painless sore(chancre) is the first symptom to occur, at the first site of T. pallidum invasion, which may be healed by few weeks. There can be more than one chancres. This is painless when compared to chancroid. During the secondary stage there can be involvement of mucous membrane manifesting as sores in the labia or cervix., vagina, anus, rectum and mouth.
Mouth and lip ulcers Due to the mucous membrane involvement. Mouth and lip ulcers
Due to the mucous membrane involvement.
Rash There can be a red or brown rash associated with syphilis occurring on the palms, soles, trunk or other parts of body which it is not itchy. Usually occurs 2-8 weeks after acquiring the infection. This occurs if the primary infection progressed to the secondary stage. Rash
There can be a red or brown rash associated with syphilis occurring on the palms, soles, trunk or other parts of body which it is not itchy. Usually occurs 2-8 weeks after acquiring the infection. This occurs if the primary infection progressed to the secondary stage.
Fever, muscle aches, headaches and fatigue, sore throat, weight loss During the second stage, as the systemic features of syphilis. Second stage features usually occur within 3 months of initial infection. Fever, muscle aches, headaches and fatigue, sore throat, weight loss
During the second stage, as the systemic features of syphilis. Second stage features usually occur within 3 months of initial infection.
Numbness, paralysis, loss of consciousness and seizures These are symptoms of the late stage of syphilis. There are 2 stages according to the epidemiological aspect. Early latency stage (one-year period without symptoms of primary or secondary syphilis ) is known to be an infectious period, late latency period (period more than one year) is noninfectious. Numbness, paralysis, loss of consciousness and seizures
These are symptoms of the late stage of syphilis. There are 2 stages according to the epidemiological aspect. Early latency stage (one-year period without symptoms of primary or secondary syphilis ) is known to be an infectious period, late latency period (period more than one year) is noninfectious.
Blindness, focal weakness, pain on neck retraction, nausea, vomiting Due to the neurosyphilis. Neurosyphilis is where organism pass through the blood brain barrier and causes neurological symptoms. Cerebrovascular accident , meningitis, visual problems may occur. Blindness, focal weakness, pain on neck retraction, nausea, vomiting
Due to the neurosyphilis. Neurosyphilis is where organism pass through the blood brain barrier and causes neurological symptoms. Cerebrovascular accident , meningitis, visual problems may occur.
Risk factors: Having multiple sexual partners, having sex with a partner who has many sex partners, commercial sex workers These increase the risk of contracting syphilis. Risk factors: Having multiple sexual partners, having sex with a partner who has many sex partners, commercial sex workers
These increase the risk of contracting syphilis.
History HIV or other sexually transmitted diseases Having one sexually transmitted disease increases the risk of another sexually transmitted disease. History HIV or other sexually transmitted diseases
Having one sexually transmitted disease increases the risk of another sexually transmitted disease.
Congenital syphilis: spontaneous abortion, stillbirth, and premature delivery Infected woman can transmit the disease to the developing fetus, and this risk of fetal infection is higher during the first year of infection. Congenital syphilis: spontaneous abortion, stillbirth, and premature delivery
Infected woman can transmit the disease to the developing fetus, and this risk of fetal infection is higher during the first year of infection.

Clinicals - Examination

Fact Explanation
Painless ulcer Chancre is situated at anus, vagina, cervix. The important feature is this ulcer is painless and nontender. Lues maligna is where lesions may become necrotic. Painless ulcer
Chancre is situated at anus, vagina, cervix. The important feature is this ulcer is painless and nontender. Lues maligna is where lesions may become necrotic.
Rash This may be a mucocutaneous rash. Maculopapular, papular, macular, and annular papular lesions are seen trunk and proximal extremities. Rash
This may be a mucocutaneous rash. Maculopapular, papular, macular, and annular papular lesions are seen trunk and proximal extremities.
Generalized nontender lymphadenopathy This occurs in the majority during the second stage of the infection. Generalized nontender lymphadenopathy
This occurs in the majority during the second stage of the infection.
Syphilitic alopecia (loss of hair) Hair loss in syphilis has a characteristic appearance, described as “moth-eaten” appearance. Syphilitic alopecia (loss of hair)
Hair loss in syphilis has a characteristic appearance, described as “moth-eaten” appearance.
Condylomata lata These are enlarged, intertriginous mucosal papules that are macerated and form flat, moist, lesions which are highly infectious. Condylomata lata
These are enlarged, intertriginous mucosal papules that are macerated and form flat, moist, lesions which are highly infectious.
Vision abnormalities Neurosyphilis, will be manifesting as ocular disease. Vision abnormalities
Neurosyphilis, will be manifesting as ocular disease.
Neck stiffness Due to meningitis as a complication. Neck stiffness
Due to meningitis as a complication.

Investigations - Diagnosis

Fact Explanation
Darkfield microscopy Treponema pallidum can not be identified with light microscopy. It is therefore visualized by dark ground microscopy on a sample taken from an open sore. These are motile spiral organisms that may appear loosely coiled, thick, and coarse. Darkfield microscopy
Treponema pallidum can not be identified with light microscopy. It is therefore visualized by dark ground microscopy on a sample taken from an open sore. These are motile spiral organisms that may appear loosely coiled, thick, and coarse.
Serology nontreponemal tests: Venereal Disease Research Laboratory and rapid plasma reagin and tests Detects antibodies to lipoidal antigens present in either the host or T. pallidum and not specific to syphilis. VDRL can give false negative results during the early course of disease and false positive results in infectious mononucleosis, lupus erythematosus, antiphospholipid antibody syndrome, hepatitis A, leprosy, and malaria. Serology nontreponemal tests: Venereal Disease Research Laboratory and rapid plasma reagin and tests
Detects antibodies to lipoidal antigens present in either the host or T. pallidum and not specific to syphilis. VDRL can give false negative results during the early course of disease and false positive results in infectious mononucleosis, lupus erythematosus, antiphospholipid antibody syndrome, hepatitis A, leprosy, and malaria.
Treponema pallidum particle agglutination assay (TPPA), Treponema pallidum haemagglutination assay (TPHA) and an enzyme immunoassay (EIA) If the VDRL is positive, it should be confirmed with a more specific investigation like Treponema pallidum particle agglutination assay (TPPA), Treponema pallidum haemagglutination assay (TPHA) and an enzyme immunoassay (EIA). These tests are specific to treponemal antigens and need for the disease conformation. Treponema pallidum particle agglutination assay (TPPA), Treponema pallidum haemagglutination assay (TPHA) and an enzyme immunoassay (EIA)
If the VDRL is positive, it should be confirmed with a more specific investigation like Treponema pallidum particle agglutination assay (TPPA), Treponema pallidum haemagglutination assay (TPHA) and an enzyme immunoassay (EIA). These tests are specific to treponemal antigens and need for the disease conformation.

Investigations - Management

Fact Explanation
Serology Patients with early and congenital syphilis usually need serologic testing (nontreponemal and treponemal tests) 1, 3, 6, 12, and 24 months after treatment and those after late disease need the testing at 12 and 24 months after treatment. Serology
Patients with early and congenital syphilis usually need serologic testing (nontreponemal and treponemal tests) 1, 3, 6, 12, and 24 months after treatment and those after late disease need the testing at 12 and 24 months after treatment.
Cerebro spinal fluid analysis Cerebro spinal fluid examinations 6-monthly for the first 2 years or until the CSF becomes normal are needed in neurosyphilis. Pleocytosis will be seen over initial 6 months.HIV infected persons need frequent reviews at annual intervals. Cerebro spinal fluid analysis
Cerebro spinal fluid examinations 6-monthly for the first 2 years or until the CSF becomes normal are needed in neurosyphilis. Pleocytosis will be seen over initial 6 months.HIV infected persons need frequent reviews at annual intervals.
Congenital syphilis Asymptomatic infants of affected mothers are followed monthly until their nontreponemal antibody disappears. Congenital syphilis
Asymptomatic infants of affected mothers are followed monthly until their nontreponemal antibody disappears.
Screening for other sexually transmitted diseases As the person is vulnerable for contracting other diseases especially HIV, it is important to screen for them. Blood should be checked for hepatitis: hepatitis B surface antigen test, hepatitis C antibody testing and Human Immunodeficiency Virus (HIV) with Enzyme immunoassay (EIA) tests and rapid antibody testing. Screening for other sexually transmitted diseases
As the person is vulnerable for contracting other diseases especially HIV, it is important to screen for them. Blood should be checked for hepatitis: hepatitis B surface antigen test, hepatitis C antibody testing and Human Immunodeficiency Virus (HIV) with Enzyme immunoassay (EIA) tests and rapid antibody testing.
Cerebro spinal fluid analysis There is increased protein and leukocyte levels in the cerebrospinal fluid in neurosyphilis. Cerebro spinal fluid analysis
There is increased protein and leukocyte levels in the cerebrospinal fluid in neurosyphilis.
Cerebro spinal fluid -VDRL (Venereal Disease Research Laboratory) test This will be reactive in the presence of neurosyphilis. Cerebro spinal fluid -VDRL (Venereal Disease Research Laboratory) test
This will be reactive in the presence of neurosyphilis.

Management - Supportive

Fact Explanation
Management of pain and fever Acetaminophen or nonsteroidal anti-inflammatory medications (ibuprofen, naproxen, ketoprofen) can be used for the management of fever and pain. Management of pain and fever
Acetaminophen or nonsteroidal anti-inflammatory medications (ibuprofen, naproxen, ketoprofen) can be used for the management of fever and pain.
Steroid therapy Steroid therapy reduces the incidence of febrile reactions associated with the "Jarisch-Herxheimer reaction" reaction, Steroid therapy
Steroid therapy reduces the incidence of febrile reactions associated with the "Jarisch-Herxheimer reaction" reaction,
Prevention ABC approach is a key strategy for the prevention of sexually transmitted diseases where it focuses on behavioural changes in individuals and programmes to implement such changes in the individual. Abstinence, Be faithful, use Condoms are the key elements of this approach. Avoiding unsafe sexual relationships or restricting the sexual relationships to a faithful one partner is the best way to achieve the prevention. In cases where the person does not adhere this, using condoms is advised. Condoms have to be used in the correct way at each time person involved in the the sexual activities.
It helps to prevent transmission of syphilis by preventing contact with the syphilitic ulcers. Antenatal testing using VDRL better provision of antenatal services, and appropriate treatment of pregnant women are important in preventing congenital syphilis.
Prevention
ABC approach is a key strategy for the prevention of sexually transmitted diseases where it focuses on behavioural changes in individuals and programmes to implement such changes in the individual. Abstinence, Be faithful, use Condoms are the key elements of this approach. Avoiding unsafe sexual relationships or restricting the sexual relationships to a faithful one partner is the best way to achieve the prevention. In cases where the person does not adhere this, using condoms is advised. Condoms have to be used in the correct way at each time person involved in the the sexual activities.
It helps to prevent transmission of syphilis by preventing contact with the syphilitic ulcers. Antenatal testing using VDRL better provision of antenatal services, and appropriate treatment of pregnant women are important in preventing congenital syphilis.

Management - Specific

Fact Explanation
Penicillin Penicillin is the treatment of choice for treatment of syphilis. Primary and secondary stage is treated with a single dose of benzathine penicillin G (2.4 million units IM), whereas late stage requires more several doses. Penicillin kills susceptible bacteria by interfering with production of cell walls. Dying treponemes can release some inflammatory substances causing induction of inflammation, manifesting as muscle aches, fever, headache with worsening of the lesions within 24 hours of antibiotics. This is called, "Jarisch-Herxheimer reaction" and it occurs often with the treatment with penicillin than with erythromycin or tetracycline . Penicillin
Penicillin is the treatment of choice for treatment of syphilis. Primary and secondary stage is treated with a single dose of benzathine penicillin G (2.4 million units IM), whereas late stage requires more several doses. Penicillin kills susceptible bacteria by interfering with production of cell walls. Dying treponemes can release some inflammatory substances causing induction of inflammation, manifesting as muscle aches, fever, headache with worsening of the lesions within 24 hours of antibiotics. This is called, "Jarisch-Herxheimer reaction" and it occurs often with the treatment with penicillin than with erythromycin or tetracycline .
Other antibiotics Doxycycline, tetracycline, probenecid, erythromycin are the alternatives. The newer cephalosporins, i.e., cefmetazole, ceftizoxime, and cefetamet are the newer agents under the experimentation. Other antibiotics
Doxycycline, tetracycline, probenecid, erythromycin are the alternatives. The newer cephalosporins, i.e., cefmetazole, ceftizoxime, and cefetamet are the newer agents under the experimentation.
Management of complications Treatment should be given to the infants, depending on the maternal serological status and clinical signs of syphilis in the infant. Meningitis, visual problems need special attention. Management of complications
Treatment should be given to the infants, depending on the maternal serological status and clinical signs of syphilis in the infant. Meningitis, visual problems need special attention.
Management of congenital syphilis Congenital syphilis can cause dangerous effects like cerebral palsy, hydrocephalus, sensorineural hearing loss and musculoskeletal deformity. In situations where diagnosis of congenital syphilis is suspected before delivery, examination of the placenta and cord should be done for typical pathological changes and spirochetes, desquamation or ulcerative skin lesions or nasal discharge (‘snuffles’), for spirochetes. If the baby is exposed to syphilis antenatally, serological testing for syphilis, should be done. Aqueous crystalline penicillin G, 50,000 units/kg/dose intravenously every 12 h in the first seven days of life,then increased up to every 8 h till 10 to 14 days. Management of congenital syphilis
Congenital syphilis can cause dangerous effects like cerebral palsy, hydrocephalus, sensorineural hearing loss and musculoskeletal deformity. In situations where diagnosis of congenital syphilis is suspected before delivery, examination of the placenta and cord should be done for typical pathological changes and spirochetes, desquamation or ulcerative skin lesions or nasal discharge (‘snuffles’), for spirochetes. If the baby is exposed to syphilis antenatally, serological testing for syphilis, should be done. Aqueous crystalline penicillin G, 50,000 units/kg/dose intravenously every 12 h in the first seven days of life,then increased up to every 8 h till 10 to 14 days.
The treatment for syphilis in pregnancy The treatment for syphilis in pregnancy is same as that of non pregnant individuals. However the only agent that is appropriate in pregnancy is penicillin. Tetracyclines are contraindicated in pregnancy due to the adverse effects on fetal bone and tooth development. Erythromycin also contraindicated due to the placental transfer. Penicillin is given as 2.4 million units of benzathine penicillin G (BPG) intramuscularly in one dose. Same dose weekly for three weeks is recommended for the late latent syphilis. The treatment for syphilis in pregnancy
The treatment for syphilis in pregnancy is same as that of non pregnant individuals. However the only agent that is appropriate in pregnancy is penicillin. Tetracyclines are contraindicated in pregnancy due to the adverse effects on fetal bone and tooth development. Erythromycin also contraindicated due to the placental transfer. Penicillin is given as 2.4 million units of benzathine penicillin G (BPG) intramuscularly in one dose. Same dose weekly for three weeks is recommended for the late latent syphilis.
Vaccine Passive transfer of antibodies against T. pallidum can be done and experiments are done on a multivalent vaccine as an effective vaccine for syphilis. Vaccine
Passive transfer of antibodies against T. pallidum can be done and experiments are done on a multivalent vaccine as an effective vaccine for syphilis.

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