Dr. Meg-angela Christi Amores Syphilis Dr. Meg-angela Christi Amores

Etiology chronic systemic infection caused by Treponema pallidum usually sexually transmitted characterized by episodes of active disease interrupted by periods of latency Incubation period: 2-6 weeks average

Transmission Nearly all cases of syphilis are acquired by sexual contact with infectious lesions nonsexual personal contact infection in utero blood transfusion organ transplantation

Stages Primary stage Secondary Stage Tertiary Stage Lesion with regional lymphadenopathy Secondary Stage generalized mucocutaneous lesions and generalized lymphadenopathy Tertiary Stage characterized by progressive destructive mucocutaneous, musculoskeletal, or parenchymal lesions; aortitis; or symptomatic central nervous system (CNS) disease

Natural Course T. pallidum rapidly penetrates intact mucous membranes or microscopic abrasions in skin within a few hours enters the lymphatics and blood primary lesion appears at the site of inoculation, usually persists for 4–6 weeks, and then heals spontaneously

generalized parenchymal, constitutional, and mucocutaneous manifestations of secondary syphilis usually appear ~6–8 weeks after the chancre heals some patients may enter the latent stage without ever recognizing secondary lesions

Secondary Syphilis Invasion of the CNS by T. pallidum occurs during the first weeks CSF abnormalities are detected in as many as 40% of patients during the secondary stage Generalized nontender lymphadenopathy is noted in 85% of patients with secondary syphilis lesions subside within 2–6 weeks, then latency

Tertiary Syphilis 30% in pre-antibiotic era most common types of tertiary disease were the gumma , cardiovascular syphilis , symptomatic neurosyphilis (tabes dorsalis)

Clinical Manifestations Primary Syphilis Chancre – painless papule that becomes eroded Becomes indurated Characteristic cartilaginous consistency at base/edge Heterosexual men: Penis Homosexual men: anus or rectum Women: cervix and labia

Clinical manifestations Lymphadenopathy The nodes are firm, nonsuppurative, and painless. Inguinal lymphadenopathy is bilateral and may occur with anal as well as with external genital chancres. The chancre generally heals within 4–6 weeks (range, 2–12 weeks), but lymphadenopathy may persist for months

Other diseases that must be differentiated: Herpes Simplex inguinal adenopathy, but the nodes are tender and the lesions consist of multiple painful vesicles, which later ulcerate and are often accompanied by systemic symptoms Chancroid painful, superficial, exudative, nonindurated ulcers, more often multiple than in syphilis Tender adenopathy

Secondary Syphilis localized or diffuse mucocutaneous lesions and generalized nontender lymphadenopathy healing primary chancre is still present in 15% of cases macular, papular, papulosquamous, and occasionally pustular syphilides pale red or pink, nonpruritic, discrete macules distributed on the trunk and proximal extremities; these macules progress to papular lesions, frequently involve the palms and soles

Secondary Syphilis Condylomata lata Mucous patches broad, moist, pink or gray-white, highly infectious lesions in warm, moist, intertriginous areas : perianal region, vulva, scrotum Mucous patches superficial mucosal erosions that occur in 10–15% of patients and commonly involve the oral or genital mucosa

Secondary Syphilis Constitutional symptoms that may accompany or precede secondary syphilis: sore throat (15–30%) fever (5–8%) weight loss (2–20%) malaise (25%) anorexia (2–10%) headache (10%) meningismus (5%)

Latent Syphilis Positive serologic tests for syphilis normal CSF examination absence of clinical manifestations of syphilis

CNS Involvement Asymptomatic Neurosyphilis lack neurologic symptoms and signs but who have CSF abnormalities reactive Venereal Disease Research Laboratory (VDRL) slide test T. pallidum can be isolated from CSF of 30% of patients even in the absence of other CSF abnormalities

CNS Involvement Symptomatic Neurosyphilis onset of symptoms usually comes <1 year after infection for meningeal syphilis 5–10 years for meningovascular syphilis 20 years for general paresis, 25–30 years for tabes dorsalis ataxic wide-based gait and footslap; paresthesia; bladder disturbances; impotence; areflexia; and loss of position, deep pain, and temperature sensations

Management Diagnosis T. pallidum cannot be detected by culture Serologic tests: Treponemal (FTA-ABS) Non-treponemal (RPR, VDRL) False positive tests: autoimmune, drug use, leprosy

Management Treatment Penicillin G : 2.4 mU IM single dose Neurosyphilis: Aqueous penicillin G (18–24 mU/d IV, given as 3–4 mU q4h or continuous infusion) for 10–14 days

Jarisch-Herxheimer Reaction After initiation of treatment mild reaction consisting of fever, chills, myalgias, headache, tachycardia, increased respiratory rate, increased circulating neutrophil count, and vasodilation with mild hypotension a response to lipoproteins released by dying T. pallidum organisms