Presentation on theme: "PENCEGAHAN SIFILIS DARI IBU KE ANAK"— Presentation transcript:
1 PENCEGAHAN SIFILIS DARI IBU KE ANAK Dr. Nor Azah bt Mohamad NawiPakar Perubatan Keluarga UD54Klinik Kesihatan Bakar Arang
2 VDRL dan RPR Venereal Diseases Research Laboratory Juga dikenali sebagai non-treponemal test.RPR: Rapid Plasma ReaginUjian saringan untuk sifilis.False positive: kehamilan, yaws, malaria, Connective tissue disease, HIV, leprosy etc.Untuk diagnos sebagai sifilis, perlu sahkan dgn ujian pengesahan:TPHA, TPPA, dark-ground microscopy, FTA-Abs, ELISA, EIA, atau PCR.
4 TPHA/TPPA? TPHA: Treponema pallidum haemagglutination assay Bound to erthrocytesTPPA: Treponema pallidum particle agglutinationBound to gelatinBaru dan lebih mudah dari TPHAKedua-duanya mengesan antibodiDilakukan bila RPR/VDRL reactive
5 SENSITIVITY OF SEROLOGICAL TESTS FOR SYPHILIS LatentFTA-Abs85%100%97%TPHA60-70%VDRL75%70%
6 Interpretasi Ujian Darah CategoryVDRLTPPACommentNegativeNRTiada bukti sifilis. Ulang ujian 1 & 3 blnReactiveCross reaction? Rpt testWeakly positiveWRPositiveCurrent or past infectionSEJARAH PENDEDAHAN PENYAKIT PENTING
7 Syphilis Cause: Treponema pallidum A sphirochaette 50% pesakit ada tanda-2 klasikalScreening : at booking and 28/52 POA.Cara Jangkitan:Diperolehi/AcquiredEarlyLateKongenitalEarly, < 2 yearsLate, > 2 years7
8 Natural history of syphilis (Course of untreated syphilis) days6 wks - 6mthsFirst 2 years2 years to a lifetimeSpontaneouscure (30%)ExposurePrimarysyphilisSecondarysyphilisEarlylatentLate latent syphilis(30%)Neuro-syphilis(12%)Cardiovascular(14%)Gumma(14%)
9 Acquired Syphilis Late Syphilis: Early Syphilis: After 2 years 1st 2 yearsPrimaryIP 9 – 90 daysChancre (ulcer) and lympadenopathy2. Secondary: stage bacteraemiaIP: 6 wk – 6/12Generalised non-irritating skin lesion, condylomata lata , mucucutaneous lesion and patchy alopecia3. Early latent: Positive serology without Sn n SxLate Latent- Tiada gejalaTertiary Benign1 – 45 (15) years laterBenign gumma of skin, bones3. Cardiovascular15 – 30 years laterAortic aneurysm4. Neurosyphilis- Bila-bila masaBerlaku lebih awal di kalangan RVD positive
11 Early : Primary syphilis IP: 1-3 weeksUsually Painless single papule then became ulcer, round/ovalWell circumscribed, clean floor, no exudateUsually no vesicleRegional lymphadenopathyAny anogenital ulcer should be considered to be due to syphilis unless proven otherwise.90% genital ulcer, 10% extragenital
13 Early: Secondary syphilis 6 weeks to 6 monthsStage of bacteremiaMay cause uveitis, cranial nerve palsies, hepatitis and splenomegalyThe most common featuresfever,lymphadenopathy,diffuse non irritatingrashcondyloma lata
14 Patchy alopecia of secondary syphilis Patchy alopecia of secondary syphilis. Hair loss also occurs commonly from the lateral third of the eyebrows.
15 Early: Secondary syphilis Malignant syphilis – widespread necrotic papulopustules and ulcers with severe systemic symptoms
17 Diagnosis of Secondary Syphilis All serological tests for syphilis are expected to be positive in secondary syphilisRPR/ VDRL titres in untreated cases are often > 1:8 (VDRL) and > 1: 16 (RPR)If a specific treponemal test is used for diagnosis and is found to be positive, use the VDRL/ RPR test to determine disease activity, and to monitor response to therapy
18 Early Latent SyphilisDiagnosed by a POSITIVE SEROLOGY without symptoms and signs in a person known to be sero-negative in the previous 2 years
19 LATE SYPHILIS: > 2 years Late latent: AsxBenign Tertiary Syphilis (Gumma)1 – 45 (average 15) years after infection,destructive granulomatous lesions on skin, bonesCardiovascular Syphilis15 – 30 yrsNeurosyphilis: at any stage of syphilis, earlier in HIV patient
20 Tertiary syphilis (3 – 12 years later) Necrotic nodulesor plaquesGummas on lower limb
21 Late: Benign Tertiary syphilis Gummatous SyphilisNodules on skin, bones,Can also involve the kidney, heart, brain and respiratory
23 Late: 4. Neurosyphilis Involves Central Nervous System Meningovascular (MV) or parenchymatous syphilisSx of MV syphilis: Headache, vertigo and CN palsyParenchymatous: General paresis of insane
24 Parenchymatous syphilis GPI: gradual personality change, ataxia, stroke, opthalmic involvement and tabes dorsalis (lightning pain, sensory impairment and mobility problem)Rx: Admit for Ix (LP) and IM/IV antibiotic.
25 Serology interpretation 34 years old female G3P2 at 12 weeks came for booking. Below the serology findingInterpretasi?VDRLReactive1:2 titreTPHAnegativeFTABs
26 Serology interpretation 42 years old Malay male, asymptomatic came for VDRL screening as his pregnant partner was treated for syphilis. Below his serology result.VDRLNRTPHApositiveFTAabs
27 Serology Interpretation 23 years old Male history of painless penis ulcer for 5 days. History of visit to Thai border recentlyBelow the serology resultNext step?VDRLnegativeTPHAFTA abs
28 Treatment Early Syphilis - IM Benzathine Penicillin 2.4 mega units single dose or- IM Procaine Penicillin G 600,000 daily x 10/7
29 Early Syphilis: For patients allergic to penicillin: T. Doxycycline 100 mg bd x 14/7: (contraindicated in pregnancy)T. Erythromycin 500 mg qid x 14/7T. Erythromycin ES 800 mg qid x 14/7IM Ceftriaxone 250 mg daily x 10/7T. Azithromycin 2 G single doseErythromycin should not be used because of the high risk of failure to cure the foetus.If erythromycin is used, paediatricians must be alerted and babies have to be treated prophylactically with penicillin and monitored.
30 Penicillin allergy in Pregnant Women Should be meticulously interviewed regarding the validity of the history.Currently, no proven alternative therapies to penicillin are available for treating neurosyphilis, congenital syphilis or syphilis in pregnancy.Therefore, skin testing, with desensitisation, if indicated, should be done for these patients.
31 MANAGEMENT OF PATIENTS WITH HISTORY OF PENICILLIN ALLERGY Desensitisation should be done in a hospital setting because serious IgE-mediated allergic reactions may occur.A protocol is recommended (refer STI guideline).Oral penicillin in increasing concentration is administered every 15 minutes. Sensitisation is completed within 4 hours with a cumulative dose of 1.3 million units of penicillin V.
32 Jarisch-Herxheimer reaction An acute febrile illness with headache, myalgia, chills and rigors and resolving within 24 hours.This is common in early syphilis but is usually not important unlessneurological or ophthalmic involvement orin pregnancy when it may cause fetal distress and premature labour (second half of pregnancy)
33 Jarisch-Herxheimer reaction It is uncommon in late syphilis but can potentially be life threatening if there is involvement of strategic sites (coronary ostia, larynx, nervous system).Prednisolone can reduce the reaction.RecommendationIn early syphilis : Treat with ParacetamolIn Neurosyphilis, Cardiovascular, certain cases of benign tertiary and late latent syphilis:Treat with Prednisolone 40-60mg daily for 3 days: begin 24 hours before treatment and for 2 days after starting treatment.
34 ADVICEAbstain from sex until 1 week after they and their partner(s) have completed treatment.CONTACT TRACING Examine and investigate all sex partners and treat epidemiologically.Primary syphilis, notify sexual partners within the past 3/12.Secondary syphilis with clinical relapse or in early latent syphilis: 2 years All patients should be offered patient and provider referral as a method of contacting any sexual partner. The method agreed upon with the patient should be clearly documented.Epidemiological treatment for asymptomatic contacts of early syphilis is recommended.
35 Incubating/ Epidemiological Rx: Partner IM B. Penicillin 2.4 mega units single dose orT. Doxycycline 100 mg bd x 14/7 orT. Azithromycin 1 G single dose
36 F/UP for TPHA Positive in Pregnancy Repeat VDRL/RPR titre1/12 after last dosethen monthly until delivered and then3/12ly – 6/12ly as non-pregnant women until seronegative or at low titre.
37 Treatment 2. Late Latent Syphilis Inj. Benzathine Penicillin 2.4 millionunit i.m once a week for 3/52i.e. 3 dosesGap between doses: < 14/7.If missed< repeat whole cycle of Rx.Or IM Procaine penicillin G 600,000 units for 17 days
38 For patients allergic to penicillin: T. Doxycycline 100 mg oral bd x 28/7 (c/i in pregnancy) orErythromycin 500mg q.i.d P.O for 28 daysErythromycin ES 800mg q.i.d P.O for 28 days
39 Follow-up of Late Syphilis Examine and 6 monthly VDRL x 2 years then yearly until seronegative or low titre (1:4 or less)
40 Syphilis: Rx Failure and Re-Rx Clinical Sx persistInitial High titre VDRL failed to decreased fourfold by 1 yearSustained four fold increase of VDRL titre
41 Syphilis: Persistent Reactor Titre VDRL persistently > 1:4 despite retreatment with B. Penicillin and trial of treatment with Doxycycline for 28 days when she was not pregnant.
42 REMINDERFor all pregnant lady and partner with TPHA positive, don’t forget to screen for other STIs i.e:HIV Ab, HCV, HBsAgGC smearTV wet smear
43 Pengendalian Bayi dari Ibu TPPA Positif Dr Nor Azah Mohamad NawiPakar Perubatan Keluarga UD54Klinik Kesihatan Bakar Arang
45 Congenital SyphilisCaused by transplacental transmission of spirochetes; the transmission rate approaches 90% if the mother has untreated primary or secondary syphilis.The child is at greatest risk of contracting syphilis when the mother is in the early stages of infectionA woman in the secondary stage of syphilis decreases her child's risk of developing congenital syphilis by 98% if she receives treatment before the last month of pregnancy
46 Untreated Syphilis in Pregnancy Fetal infection can develop at any time during gestation.Because inflammatory changes do not occur in the fetus until after the first trimester of pregnancy, organogenesis is unaffected.All organ systems may be involved.Can cause:Miscarriages,Premature birthStillbirthsDeath of newborn babies: pulmonary haemorrhage.
47 Congenital Syphilis Manifestations are defined as Early-onset disease, Early if they appear in the first 2 years of lifeLate: develop after age 2 years.Early-onset disease,result from transplacental spirochetemia and are analogous to the secondary stage of acquired syphilis. (Congenital syphilis does not have a primary stage)Late-onset disease (>2 years) is considered contagious.
48 Early-onset congenital syphilis (before or at age 2 y) 60% are asymptomatic at birth.Sx develop within the first 2/12 of life. Almost 100% has hepatomegaly; biochemical evidence of liver dysfunction is usually observed.Common Sn: skeletal abnormalities, rash, and generalized lymphadenopathy.Radiographic abnormalities, periostitis or osteitis, involve multiple bones. Sometimes, the lesion is painful and an infant will favor an extremity (pseudopalsy)
49 Early-onset congenital syphilis (before or at age 2 y) Maculopapular rash, may involve palms and soles.In contrast to acquired syphilis, a vesicular rash and bullae (pemphigus syphiliticus) may develop - highly contagious.Mucosal involvement may present as rhinitis ("snuffles") – poor feeding.Nasal secretions are highly contagious.
50 Early-onset congenital syphilis (before or at age 2 y) Hematological abnormalities include anemia and thrombocytopenia. Some have leukocytosis.Abnormal CSF examinationSeen in a half of symptomatic infants,10% of asymptomatic baby.
51 Late Onset Manifestations Neurosyphilis and involvement of the teeth, bones, eyes, and the eighth cranial nerve, as follows:Bone involvement - Saber shins, saddle nose, short maxillae, protruding mandible, swollen kneesHigoumenakis sign, enlargement of the sternal end of clavicle in late congenital syphilis.Teeth involvement - Notched, peg-shaped incisors (Hutchinson teeth)Pigmentary involvement - Linear scars (rhagades) at the corners of the mouth and nose result from bacterial infection of skin lesions.Interstitial keratitis - Presents in the 1st or 2nd decade of lifeSensory-neural hearing loss (eighth cranial nerve deafness) - Presents between age 10 and 40 years.
53 Infants should be evaluated if they were born to sero +ve women who: Have untreated syphilisWere treated for syphilis less than 1 month before deliveryWere treated for syphilis during pregnancy with a non - penicillin regimenDid not have the expected decrease in RPR titre after treatmentWere treated but had insufficient serologic follow-up during pregnancy to assess disease activity
54 EVALUATION OF INFANT A thorough physical examination RPR (compare with mother’s titre) / EIAFTA-AbsCSF analysis for cells, protein and CSF-VDRL testLong bones X-rayChest X-ray
55 Treat if they have: Any evidence of active disease A reactive CSF-VDRL / FTA-AbsAn abnormal CSF finding ( WBC > 5/ mm3 or protein > 50 mg / dl ) regardless of CSF serologySerum RPR titre that are at least 4 times higher than their mother's.Positive EIA-IgM antibody* Treatment (with penicillin) before the development of late symptoms is essential
56 RxAqueous Cystalline Penicillin G: 50,000 units/kg/dose 12 hourly for first 7 days then 8 hourly for the following 3-7 days ORProcaine Penicillin, 50,000 units/kg daily IM for days OR*IV/IM Ceftriaxone 75 mg/kg (< 30 days old) or 100 mg/kg (>30 days old)*If more than a day of treatment is missed, the whole course should be restartedInfants who should be evaluated but whose follow-up cannot be assured should be treated with a single dose of Benzathine Penicillin, 50,000 units/kg IM.
57 F/up and MonitoringSero-positive untreated infants must be closely monitored at 1, 2, 3, 6, and 12 months of age.RPR should decrease by 3/12 of age and usually disappear by 6/12 of age. Treat (with the same regimen as above) if:Symptoms and signs persist or recurRPR titre increase fourfold or more by 3/12 of ageRPR still positive by 6/12 of ageTPHA still positive by 1 year of age
58 Treated InfantsMonitored clinically and serologically at 1, 3, 6, 12, 18, and 24 months. Lumbar puncture should be repeated 6 monthly till normal.
59 THERAPY OF OLDER INFANTS AND CHILDREN After the newborn period, children discovered to have syphilis should have a CSF analysis to rule out congenital syphilis.Any child with congenital syphilis or with neurologic involvement should be treated withAqueous Cystalline Penicillin, 200, ,000 units/kg/day administered as 50,000 units/kg/dose 4-6 hourly for 10 to 14 days (B, III)