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Why Is Syphilis Important?

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Presentation on theme: "Why Is Syphilis Important?"— Presentation transcript:

1 Why Is Syphilis Important?
Tammy Foskey, MA Manager, STD/HIV Public Health Follow-Up Team (512)

2 Syphilis Is: A Bacterial Infection that can be chronic and systemic
Infectious During Specific Time Frames related to Stage Sexually Transmitted (oral, vaginal, anal) Curable

3 Many persons (including physicians) are unaware that we are currently seeing an increase in the number of syphilis infections Syphilis can increase the risk for transmission of HIV (if co-infected) by 3-5x Having HIV can make someone more susceptible to an infection with syphilis, if exposed Syphilis increases HIV viral load and decreases CD4 cell counts in HIV-infected persons with new syphilis infections

4 This is a schematic diagram which shows how spirochetes enter regional lymph nodes from a skin chancre, and then enter the bloodstream. Also shown are the organ systems that might be impacted: CSF, brain, eye, ear, endolymph, liver, intestines, kidneys and skin.

5 Syphilis Syphilis is sometimes called: “bad blood”, pox, or
a “zipper cut”

6 Epidemiology of Syphilis
In the 1940s: Syphilis was distributed widely throughout the U.S. : 85% increase in the incidence of primary and secondary syphilis –Why? After 1990, reported cases of syphilis decreased approximately 15% per year to an all-time low in 2000 : crack cocaine had an impact on the increased rates due to the exchange of sex for money/drugs

7 Epidemiology of Syphilis (continued)
Late 1990s: syphilis elimination a feasible goal Rates remain high in: Some urban areas throughout the U.S.; Rural areas in the South; Some minority populations who suffer from poverty, lack of access to health care, and breakdown of stable community and personal relationships. Recent outbreaks have been associated in men who have sex with men (MSM) The Syphilis Elimination Project began in the late 1990s with the support of the CDC and other partners. Houston has been “highlighted” as one of the top 10 cities in the US with early syphilis cases (new infections under a year) and the majority of the infections in Houston are among the MSM population.

8 Syphilis – Treponema pallidum

9 Syphilis – Treponema pallidum on darkfield examination

10 How is Syphilis Transmitted?
Sexual contact with infectious lesion In utero and intrapartum Sharing needles (extremely rare) The organism can be transmitted during sexual activities, in utero and accidental direct inoculation (needle sharing). Sharing needles is less efficient and when doing partner elicitation, sex partners as well as needle-sharing partners should be sought. Rarely is syphilis transmitted by non-sexual means and fomites (inanimate objects that might harbor an organism) because the organism does not survive outside the body. With sexual contact, the spirochetes will pass through intact mucous membrane or abraded skin. This agent has never been successfully cultured in artificial media nor will it retain a gram stain. The rate of acquisition of syphilis from an infected sexual partner has been estimated at about 30%.

11 So what Does Syphilis Look Like?
Syphilis is the chronic systemic infection that is transmitted through direct contact with the infectious organism, a corkscrew bacterium called Treponema Pallidum, also known as a spirochete. T. Pallidum was identified in 1905 by Schaudinn and Hoffman. Syphilis was epidemic in late 15th century Europe. The disease received its present name from the poem by Facastoro in 1530 about the afflicted shepherd, Syphilis.

12 Syphilis has Several Stages with different signs/symptoms
Incubation Stage Days Average 21 Days Not infectious to others during this stage No signs/symptoms are present Blood tests are negative Once the treponeme has entered the body, an incubation period begins. The date the organism enters the body is the inoculation date and the period of time till the onset of symptoms is the incubation period. Symptoms could occur in as little as 10 days after inoculation and can take as long as 90 days. The average length of time from inoculation to the onset of primary symptoms is 3 weeks (21 days). During this period, blood tests for syphilis will be negative.

13 Common Symptoms of Syphilis Primary Stage
Occurs in males and females A painless sore called a chancre develops where the spirochete entered the body The sore may be located on the genitals, lips, anus, or other area of direct contact The chancre will last 1-5 weeks (on average 3 weeks) and heal without treatment The person can transmit the infection very easily during this stage The primary stage is associated with one sore, called a chancre. Spirochetes are living in the chancre and are easily passed during this stage. 90% of all infections are passed during this stage of the infection.

14 Clinical Manifestations- Primary Syphilis
Chancre Clean based, painless, indurated ulcer with smooth firm borders Unnoticed in 15-30% of patients often because of the location and because it is painless Resolves in 1-5 weeks HIGHLY INFECTIOUS Blood tests may not show infection for up to 7 days after the chancre develops Because the chancre is painless, it may not be noticed especially if is located on the cervix or in the rectal area. It will resolve on its own without treatment.

15 Primary syphilis-chancre

16 Primary Syphilis- chancre
After the incubation period, the person would develop the first clinical sign of syphilis-a chancre- at the point where the spirochete first entered the body (inoculation point). The chancre will vary in size but usually is greater than .5cm. The chancre generally is painless, although it looks like it would hurt. Source: Florida STD/HIV Prevention Training Center

17 Primary syphilis - chancre

18 Primary syphilis - chancre

19 Primary syphilis – chancre of anus

20 The chancre could be located in the anal canal or on the anus making it difficult to see. And, because it is painless, unrecognized. Early syphilis in MSM is diagnosed in the secondary or early latent stage much more often than in the primary stage. When the primary lesion is found in the anorectal area, it is commonly misdiagnosed as traumatic lesion, fissure or hemorrhoiditis.

21 Primary syphilis - chancre

22 Here we see an example of a lesion at the urethral meatus (opening of the urethra).

23 Darkfield testing is not useful for diagnosis in the mouth due to saprophytic spirochetes found in the mouth. However, direct fluorescent antibody testing is useful in these situations.

24 Here we see a chancre on the arm pit area
Here we see a chancre on the arm pit area. Remember syphilis does not require an exchange of body fluids for transmission. This patient was practicing frottage (rubbing, touching skin)

25 A chancre on the nipple. This nipple came in contact with an infectious lesion somehow. MOST chancres occur on the genitals.

26 Syphilis Early Latency Stage
Lasts weeks (average 4 weeks) No symptoms are present, not infectious Happens between primary and secondary stages 2/3 of persons will have some period of latency between primary and secondary stages Blood tests are positive VDRL or RPR TPPA or FTA-ABS After the primary stage approximately 2/3 of the infected individuals will enter a period of latency where no visible symptoms are present but a blood test for syphilis is positive. The latency period between primary and secondary can be between 0 and 10 weeks, with an average latency period being 4 weeks. Latency can occur any time during untreated syphilis. Early latency occurs in the first 12 months and late latency occurs after 12 months.

27 Common Symptoms of Syphilis Secondary Stage
May include skin rashes, fever, swollen lymph glands, headache, hair loss, and muscle ache The skin rash may be on the palms of hands, bottoms of the feet, or any part of the body The rash may last 2-6 weeks (average of 4 weeks); it will heal without treatment The person may be infectious (C. Lata and/or Mucous Patches) 10% of syphilis infections are passed during the secondary stage. Many of the symptoms are not infectious so it makes it more difficult to transmit the infection. The secondary symptoms will resolve without treatment within 6 weeks, on average a month for most persons.

28 Secondary Syphilis Diagnosed by Symptoms RPR or VDRL FTA-ABS or TPPA
Darkfield examination (of C. lata) Frequently secondary syphilis is diagnosed based on a combination of symptoms and blood tests. The RPR or VDRL are the initial tests that are done because most labs have the capability of doing a “stat RPR”. Confirmatory testing in the form of the TPPA (formerly the MHA-TP) or an FTA-ABS are done also. However, these results may take 1-2 days. If a person has one of the infectious symptoms (condylomata lata), a darkfield may be able to be done to detect the presence of spirochetes.

29 Secondary Syphilis: Papulosquamous Body Rash
Almost 100% of persons with secondary syphilis will experience some sort of rash. The rash does not tend to itch, unlike rashes related to allergic reactions. Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides

30 Secondary Syphilis: Generalized Body Rash
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

31 Secondary syphilis

32 Secondary Syphilis: Rash
Less common. May be mis-diagnosed as a bad case of acne. Because it will resolve without treatment, sometimes medication for acne or an allergic reaction is prescribed and appears “to cure” the problem, when in fact the problem would have resolved on its own and the medication only gave the “appearance” of helping. Source: Cincinnati STD/HIV Prevention Training Center

33 Secondary syphilis

34 Secondary Syphilis: Palmar Rash
Usually a tell-tale symptom of secondary syphilis. Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides

35 Secondary Syphilis: Plantar Rash
Often if there is a rash on the hands, there is also one of the bottom of the feet. This is referred to as a “palmar-plantar” rash. Source: Florida STD/HIV Prevention Training Center

36 As the eruptions progress, some of the rashes may become thickened and red and elevated.
Palmer and Plantar papulosquamous secondary syphilis Annular syphilids (a raised circular ring that is scaly and layered and is a deep red color) some with a deeper color in the center and becoming less pigmented as it moves away from the center. Papulosquamous syphilids are typically flat papules, which are red, indurated, and slightly scaly. Lesions may be limited to the genital region.

37 Secondary Syphilis Source: Florida STD/HIV Prevention Training Center
Additional rashes…in case you haven’t seen enough Source: Florida STD/HIV Prevention Training Center

38 Secondary Syphilis: Condylomata Lata
This is one of the infectious symptoms of secondary syphilis. It is the rapid growth of moist warts, giving the appearance of genital warts related to HPV. However, these growths are teeming with spirochetes and are highly infectious. Those health care providers who do not see a great deal of syphilis and/or genital warts may mistakenly treat these with medication or freeze them. Again, they will resolve over 2-6 weeks on their own without treatment and the medication didn’t really help but it gave the appearance of helping. Source: Florida STD/HIV Prevention Training Center

39 Typically they are a moist wart-like growths that may be larger than most genital warts but are not larger due to being a tumor They usually occur in the folds of the skin in areas such as the genitals C Lata are usually covered with a grayish film/exudate containing spirochetes making them much more infectious than other secondary symptoms. These will return to normal with treatment (for syphilis) or will go away if not treated. Darkfield can be done without needing to abrade the tissue. Highly infectious. There may also be C. lata of the toe webs. It is an uncommon manifestation but in some cases this phenomenon may be the only physical sign of syphilis; therefore, it is important that a high index of suspicion is maintained when evaluating toe web lesions in patients at risk for syphilis.

40 Here we see C Lata on the shaft of the penis, scrotum and inner thigh.

41 Secondary Syphilis: Mucous Patches
Mucous patches can appear on oral, rectal, and vaginal mucous membranes. They are another infectious secondary syphilis symptom.

42 Mucous patches on the inside of the upper lip.

43 Secondary syphilis: alopecia

44 Alopecia (hair loss) Alopecia may occur during secondary syphilis as a patchy thinning or as a diffuse loss of hair, eyebrows, beard hair, or any other hairy body area may be involved. The hair loss is frequently located in the back of the head and another common loss of hair is the outer third of the eyebrows. The lost hair re-grows in both treated and untreated patients.

45 Secondary syphilis: papulo-pustular rash

46 Primary and Secondary Syphilis Disease Process
Date of inoculation Incubation 10-90 days Avg: 21 days Primary Syphilis Lasts 1 – 5 weeks Average: 3 weeks Early Latency 0 – 10 weeks Avg: 4 weeks Secondary Syphilis: Lasts 2-6 weeks Average: 4 weeks A review of the stages of syphilis and the time periods. Most will have a period of latency between primary and secondary. If not, overlap could be 2-3 days

47 Neuro-Syphilis Can occur any time after initial infection
May occur more commonly early in the course of infection (secondary or latent) when someone is co-infected with HIV Associated with neurologic symptoms including: Vision changes or eye pain Hearing loss Headaches/dizziness Generalized weakness Seizures Confusion Changes in personality or affect

48 Neurosyphilis: spirochetes in neural tissue

49 Congenital Syphilis Syphilis that is transmitted during pregnancy (or at time of delivery) Often the mother has received no or inadequate prenatal care

50 Syphilis in Pregnancy can Cause:
Preterm delivery Stillbirth Congenital infections Neonatal death Syphilis in pregnancy may cause pre-term delivery, stillbirth, congenital infections or infant death depending on the stage of maternal infection prior to delivery. Adequate therapy of maternal syphilis prior to the 16th week of gestation usually prevents fetal damage. Untreated primary and secondary syphilis during pregnancy affects virtually 100% of fetuses, with 50% of such pregnancies resulting in premature delivery or perinatal death. Untreated early latent syphilis during pregnancy results in a 40% rate of prematurity or perinatal death.

51 Kassowitz Law The longer the duration of untreated syphilis, prior to pregnancy, the less likely the fetus will be infected or stillborn. Untreated syphilis can be passed to the fetus from the infected mother at any time during the pregnancy, but the longer the duration of untreated syphilis, prior to pregnancy, the less likely the fetus will be infected or stillborn (Kassowitz’s Law). Therefore, the prognosis is better for a fetus whose mother contracted syphilis before she became pregnant. In other words, a women with primary or secondary syphilis usually will deliver an infant either with syphilis, that is premature, or is stillborn; while a woman in a later stage is more likely to give birth to a healthy child. Syphilis is a systemic disease shortly after its inception, and women may transmit the infection to their fetus in utero shortly after onset of infection. Transmission to the fetus in utero has been documented as early as the 9th week of pregnancy. The risk of infecting a fetus declines gradually during the course of untreated illness; after about 8 years there is little risk in even the untreated mother.

52 Maternal Transmission of Syphilis
26% remain free of disease or revert to sero-negative Infants born to untreated syphilis mothers 25% remain sero-positive but not clinically affected 49% display symptoms of syphilis In pregnant women with untreated syphilis, there is a 40% risk of infant death. However, in the Oslo study of untreated syphilis, 26% of the babies born to syphlitic mothers remained free of disease or converted to seronegative, 25% were seropositive but remained clinically unaffected, and 49% displayed syphilis symptoms. 40% risk for infant death

53 A routine blood test for syphilis protects the pregnant mother and her baby.
Syphilis can go undetected for several reasons. Foremost, is the fact that approx. 25% of women in Texas do not receive prenatal care or any blood test before delivery. Also, the first sign of syphilis, as discussed, is a painless chancre at the point of inoculation. In many women, the chancre is usually hidden in the vagina, rectum or mouth where it goes unnoticed. Other signs of syphilis such as alopecia, malaise, rashes, and low grade fever could be attributed by women as physiologic changes of pregnancy. Exact figures for the rate of primary and secondary syphilis among pregnant women are not available and vary depending on the population studied. 80% of women with infectious syphilis are within the 15 to 34 year age group and the group who are most likely to be pregnant.

54 Texas Congenital Syphilis Cases by Year, 2000-2008

55 Texas Congenital Syphilis Cases by Year of Report and County, 2002-2008
Tarrant – 10 Bexar – 11 Jefferson - 9

56 Texas Congenital Syphilis Cases by Year of Report and Race, 2002-2008

57 Syphilis Treatment in Pregnancy
Screen for syphilis at first prenatal visit; repeat RPR at 28 and 32 weeks’ gestation and at time of delivery for those at high risk or high prevalence areas Treat for the appropriate stage of syphilis Some experts recommend additional Benzathine penicillin G 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

58 State Statistics

59 Primary and Secondary Syphilis Cases by Year of Report - Texas, 1971-2008

60 Primary and Secondary Syphilis Cases by Year of Report - Texas, 1998-2008

61 P&S Syphilis Case Rates by Year of Report and Race/Ethnicity - Texas, 1998-2008

62 Primary and Secondary Syphilis Case Rates by Age Group - Texas, 2008

63 P&S Syphilis Case Rates by Year of Report and Sex - Texas, 1998-2007
Male Female

64 MSM P&S Syphilis by Year of Report - Texas, 2000-2008

65 HIV-Positive P&S Syphilis by Year of Report - Texas, 2000-2007

66 P&S Syphilis Cases by Surveillance Site, 2000, 2007, 2008

67 P&S Syphilis Cases by Surveillance Site, 2000, 2007, 2008

68 P&S Syphilis Case Rates by County - Texas, 2008

69 2009 Year-to-Date Syphilis
P&S Cases  2008 2009 # Increase % Increase TEXAS TOTAL 374 401 27 7% DALLAS 52 78 26 50% TARRANT 21 41 20 95% BEXAR 66 14 27% JEFFERSON 34 42 8 24% FORT BEND 4 10 6 150% Early Latent Cases 480 694 214 45% 94 163 69 73% 49 76 55% HARRIS 143 169 18% 17 32 15 88% MONTGOMERY 1 13 12 1200% TRAVIS 31 43 39%

70 National Statistics

71 Primary and secondary syphilis — Rates: Total and by sex United States, 1988–2007 and the Healthy People 2010 target Note: The Healthy People 2010 target for P&S syphilis is 0.2 case per 100,000 population.

72 Primary and secondary syphilis — Rates by state: United States and outlying areas, 2007
Note: The total rate of P&S syphilis for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was 3.8 per 100,000 population. The Healthy People 2010 target is 0.2 case per 100,000 population.

73 Primary and secondary syphilis — Reported cases by reporting source: United States, 1984–2004
Note: Prior to 1996, the STD clinic source of report corresponded to public (clinic) source of report, and the non-STD clinic category corresponded to private source of report. After 1996, as states began reporting morbidity data electronically, the specific source of report (i.e., STD clinic) began to be reported from an increasing number of states.

74 Primary and secondary syphilis — Cases by reporting source and sex: United States, 1997–2006

75 Testing and Treatment

76 Syphilis Testing Non-Treponemal RPR VDRL Results quantitative Highly sensitive Treponemal Darkfield TPPA FTA-ABS Results qualitative Highly specific Once reactive, remains reactive for life Other than a positive darkfield that can be the sole test for diagnosis in the primary stage (before blood tests would be reactive)…. A presumptive diagnosis of syphilis is possible with the use of two types of serological tests for syphilis: BOTH ARE ANTIBODY TESTS Nontreponemal (RPR and VDRL) used for screening and follow-up Treponemal (TPPA, FTA-ABS) used for confirmation A darkfield test is also considered a treponemal test but is not used for confirmation The use of one type of test alone is not sufficient for diagnosis. Nontreponemal antibody titers usually correlate with disease activity, and results should be reported quantitatively. (1:1-1:512) A four-fold change in titer, or two dilutions, (e.g. 1:4 to 1:16 or 1:32 to 1:8), is necessary to demonstrate a substantial difference between two nontreponemal test results that were obtained using the same serological test. 15-25% of patients treated during the primary stage may revert to being serologically nonreactive after 2-3 years on non-treponemal tests. One test alone is not sufficient for the diagnosis of syphilis except for the Darkfield!

77 RPR Card Range from 1:1 to 1:512 1:2 1:1 1:4 1:8 1:16 1:32 1:64 1:128
This is an example of an RPR card that would be used in the lab to determine the titer level. The first 1 indicates the amount of serum they would use from the client. The second number reflects the amount of reagent they would use. When the lab personnel stop seeing a reaction in one of the circles, the circle where they last saw any reaction is where they would “call it”. There may be differences between lab personnel who read them but there should not be a difference of more than one “well”. Meaning one lab tech would not read it as a 1:4 and another read it as 1:64. But, one might read it as 1:4 and another as 1:2 or 1:8. The RPR becomes important when interpreting response to treatment and possible re-infection or treatment failure. 1:32 1:64 1:128 1:256 1:512

78 Penicillin The drug of choice since 1943
Benzathine Penicillin G-LA 2.4mu given as 1.2mu/dose intramuscularly Infection with syphilis under 1 year, 1x Infection with syphilis (unknown duration or longer than 1 year), 3x (1x/week for three weeks) In 1943, penicillin became available for use and has remained the drug of choice. The G is very important since it is the long-acting form of penicillin. It is thick and painful. No resistance has developed. After treatment for primary or secondary syphilis, about 33-66% of patients have a febrile reaction with chills, fever, arthralgias, headache, and transiently increased prominence of lesions. This is called the Jarisch-Herxheimer reaction and the onset is generally within 4-6 hours after treatment and subsides within 24 hours. Most reactions can be managed by reassurance of the patient and aspirin or ibuprofen. Pregnant women who develop a Jarisch-Herxheimer reaction may have premature onset of labor. This is more common among those being treated for early syphilis (primary, secondary and early latent) rather than late latent syphilis. Hospitalization may be recommended for women beyond 20 weeks gestation who have early syphilis for close observation and fetal monitoring. The Jarisch-Herxheimer reaction is not limited to syphilis treatment, and can result during treatment of other conditions, notably leptospirosis, brucellosis, Lyme disease.

79 Clinical and Serologic Follow-Up
All HIV-infected patients treated for syphilis should be evaluated clinically and serologically at 3, 6, 9, 12, and 24 months to rule out treatment failure Treatment success is determined by a four-fold decrease in titer by 6-12 months (early) or months (late) after treatment Lumbar puncture/CSF testing may be necessary if treatment failure is suspected

80 The only way to ensure freedom from an STD is total abstinence.
Mutual monogamy with a disease-free partner is the next best thing. Reduce or limit the number of sexual partners. Refrain from sex with those known to be at increased risk (e.g. symptomatic, sex workers, et al) Use condoms. When used correctly and consistently, condoms can and do prevent the spread of most STDs. Condom effectiveness to prevent syphilis is limited to the amount of skin it covers; a condom may not prevent direct contact with infectious symptoms located at sites other than the distal penis or inside the vagina, anus or mouth.

81 Syphilis Management of Sex Partners
All sex partners should be treated. For identification of at-risk partners, the time periods are: 3 months plus duration of symptoms –primary 6 months plus duration of symptoms –secondary 1 year for early latent syphilis Treat if testing is unavailable All sex partners of persons with syphilis a year or less should be tested and treated. Many will receive treatment to prevent an incubating infection from developing. This is called “primary prevention”. DIS are very involved with active syphilis cases and do their best to get to people who may still be “incubating” and not yet infectious to anyone else to assure they receive treatment before being able to pass on the infection to anyone else. “Secondary prevention” is when a person with “active disease” is located. Treatment then prevents further complications from developing but he/she may have already transmitted the infection.

82 So What Can You Do? Talk with all clients about the risk for STDs if they are having sex Talk with clients about use of recreational drugs (meth and cocaine especially) Encourage clients to be tested for STDs regularly (every 3-6 months) Develop a relationship with your local Disease Intervention Specialist (DIS) to assist you and your client with confidential notification of partner(s)

83 So What Can You Do? (cont’d)
Ask about new partners often, so it becomes “normal” and comfortable for you and your clients Refer to local/regional health department if new partners could be at risk for HIV and/or syphilis or other STDs

84 So What Can You Do? (cont’d)
If you have clients that are female and are pregnant or planning to become pregnant: Be sure she is receiving regular pre-natal care She should be tested at her first prenatal visit Strongly recommend re-testing during 3rd trimester (especially in areas of the state where there are high rates of syphilis) She will also be tested at time of delivery

85 So What Can You Do? (cont’d)
Make referrals when appropriate to other community interventions and/or services including: Comprehensive Risk Counseling Services (CRCS) Group and Community Level Interventions, i.e. WiLLOW Mpowerment SISTA Healthy Relationships Mental Health Referral Substance Abuse Treatment

86 References www.cdc.gov/std/syphilis
HIV and Syphilis Co-infection: Trends and Interactions Syphilis Increases HIV Viral Load and Decreases CD4 Cell Counts Syphilis and HIV


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