Etiology, pathogenesis, general motion of syphilis. Immunity Etiology, pathogenesis, general motion of syphilis. Immunity. Early syphilis. Secondary syphilis. Treatment of syphilis. Lector: Shkilna M.

CONTENT Clinical presentation of syphilis. Characteristics of Treponema pallidum. The mode of transmission. Pathogenesis of T. pallidum. Classification of syphilis. Chard chancre and lymphadehopathy. Atypical forms of chancre. Diagnosis and differential diagnosis of syphilis. Secondary syphilis. Diagnostic tests for syphilis. Sensitivity & specificity of serologic tests for syphilis. Therapy of syphilis.

SYPHILIS Treponema pallidum may infect any organ ( skin, mucous membrane, lymphatic nodes, inner organs), causing an infinite number of clinical presentations; thus the old adage,’’ he who knows syphilis knows medicine.’’ Infectious agent- Treponema pallidum.

SYPHILIS Caused by Treponema Pallidum

Treponema Pallidum

TREPONEMA PALLIDUM

Treponema pallidum corkscrew shaped, 0,25 micron in diameter; can be observed only by dark-field microscopy as a shining, silver corkscrew, against a dark background, with characteristic movements of propulsion, rotation on its own axis and angulations; reproductive time is estimated to be 30 to33hours (in contest to most bacteria, which replicate every 30 minutes); the Gram stain cannot be used, and growing the bacteria is difficult; is not stable in outside; it is very sensitive to dehumidification; it is very sensitive to boiling; it is very sensitive to disinfectants; usually enter the body through minute abrasions in the body, either on the skin or mucous membrane.

The mode of transmission can be: Sexual, which is the most important mode of infection. Kissing the genitalia can produce extra- genital chancres on the lips, fingers and nipples. Sexual perversion( homosexual and orogenital contacts ). Accidental inoculation. Through contaminated blood. Transplacental infection, from an infected mother to the fetus. During delivery as the baby passes through an infected canal.

Early syphilis A-Primary syphilis: Primary syphilis of genital organs. Primary syphilis of anal zone ( zone of rectum). Primary syphilis of other localization. B-Secondary syphilis: Secondary syphilis of the skin and the mucous membranes. Other forms of Secondary syphilis. C-Early latent syphilis:

LATE SYPHILIS 2. Neuro- syphilis. 3. Late latent syphilis. 1. Cardio-vascular syphilis. 2. Neuro- syphilis. 3. Late latent syphilis. 4. Late muco -cutaneous damage.

CONGENITAL SYPHILIS Early congenital syphilis: occur before the age of 1 year; occur in children from 1 to 4 year. Late congenital syphilis: a) late syphilitic ophtalmopathy (involvement of the eyes); b) other forms of the late congenital syphilis (involvement of the skin, mucous membrane, nervous system, latent syphilis).

PRIMARY SYPHILIS THE MAIN SYMPTOMS ARE: HARD CHANCRE LYMPHADENOPATHY

HARD CHANCRE Begins as a single, painless, well defined, regular or indurate (button-like) red brown papule plaque, from 0.3-to 2.0 cm, which may ulcerate. The ulcer has a clean floor which oozes clear serum on pressing, with a firm indurate border. The base is clean, with a scant, yellow, serous discharge and pink areola. Painful ulcers, multiple ulcers, secondarily infected ulcers, and non-indurated ulcers are variations of the classic chancre.

HARD CHANCRE Usually occurs on the genitalia (about 95%): the coronal sulcus, prepuce, frenulum, meatus (in the male). the cervix, labia major and minor, urethra, clitoris (in the female). Extragenital chancre occur in 5% of all cases of primary syphilis. the lip, which is associated with oral sex and anus, which is associated with anal intercourse. Other reported sites include: the tongue, tonsil, finger, eyelid, chin, nipple, umbilicus, axilla, and even the lower limb.

Primary Syphilis Chancre

PRIMARY SYPHILIS CHANCRE

PRIMARY SYPHILIS CHANCRE

“Kissing” Chancres Another example of “kissing” lesions in a female, this time in the frontal rather than the sagittal plane.

Chancre of the Tongue Chancres may occur anywhere within the oropharynx. They may be misdiagnosed as neoplastic, or as other inflammatory lesions unless syphilis is included in the differential diagnosis.

Oral Chancre - Lip Example of an primary oral chancre of syphilis in a 61 year old man (click the picture to link to the paper in the British Dental Journal).

Chancre of Hard Palate Clicking the picture links to the paper in the British Dental Journal with the case history of this patient – a young homosexual male who acquired this lesion after unprotected oral sex.

Chancre of the Lip

Facial Chancre

Facial Chancre Facial chancres may easily become secondarily infected, obscuring the underlying problem.

LYMPHADENOPATHY Spotty (small and rubbery firm, like lead shots). It is develops in 50-85% of patients approximately 1 week after the appearance of the primary ulcer.

Atypical forms of chancre Panarhicium Amygdalate Indurate edema

Complications of hard chancre ( in cases of non-rational therapy) 1. Balanitis. 2. Vulvitis and vulvovaginitis. 3. Phimosis. 4. Paraphimosis. 5. Gangrene.

Course of primary syphilis Sero-negative, when V.D.R.L is negative (3-4 weeks). Sero-positive, when V.D.R.L is positive (next 3-4 weeks).

Diagnosis is based upon : Clinical features : Incubation period of 9-90 days , following high-risk sexual behavior. Single, indurate (button-like ),painless clean-looking ulcer. Regional lymphadenopathy with discrete, rubbery nodes. Investigations: Demonstration of T. Pallidum on DGI. The fluorescent antibody test( F.T.A) Positive V.D.R.L. after 2-4 weeks after the onset of primary chancre.

SECONDARY SYPHILIS 1) muco-cutaneus lesions; 2) flu like syndrome: Headache(9-46%). Loss of appetite(25%) Pruritis (42%). Malaise (23-46%). Fever (5-39%). Less common symptoms include (painful eyes, joint or bone pain, sore throat). generalized adenopathy.

SECONDARY SYPHILIS Roseolar syphilide: macular erythematous rash, sometimes barely perceptible.it is generalized,faint rash occurring on the trunk, extremities, palms of the hands and soles of the feet. It fades on pressure.The macules vary in size from about 1\2 to 1 cm. This rash, when viewed from an oblique angle, is very apparent.

SECONDARY SYPHILIS RASH

SECONDARY SYPHILIS: GENERALIZED BODY RASH

SECONDARY SYPHILIS There are such types of Papular syphilide: Condiloma lata, Hypertrophic, papule syphilide with a moist, grayish plaque. The ulcerative type of lesions are not common, and are known as ecthymatous rupioid syphilides, On the palms and the soles, they may assume a pigmentary appearance, or present themselves as maculo - papulosquamous patches with infiltrated edges. Scaly lesions (Psoriasiform syphilides) resemble psoriasis ,except that there is indurations, the scales are less silvery, the surface not smooth; other stigmata of syphilis are present, and the V.D.R.L. is positive.

SECONDARY SYPHILIS – CONDYLOMATA LATA

SECONDARY SYPHILIS RASH

SECONDARY SYPHILIS Syphilitic leuco-melanoderma is a combination of hyper pigmentation and depigmentation. It is a rare condition occurring on the sides of the neck (Venera necklace), on the upper part of the chest and on the palms of the hands and the soles of the feet. Mucous patches are oral lesions found on the lips, cheeks, tongue, palate, tonsils these are oval or circular, slightly raised patches, covered by a grayish sodden membrane .superficial ulcers in the form of “ snail-track” are occasionally seen.

SECONDARY SYPHILIS

SECONDARY SYPHILIS RASH

Diagnostic Tests for Syphilis (Original Wasserman Test) NOTE: Treponemal antigen tests indicate experience with a treponemal infection, but cross-react with antigens other than T. pallidum ssp. pallidum.

Dark field Microscopy of Treponema pallidum

Syphilis Serology Non-treponemal tests Treponemal tests VDRL (Venereal Disease Research Laboratory) RPR (Rapid Plasma Reagin) TRUST (Toluidine Red Unheated Serum Test) USR (Unheated Serum Reagin) Treponemal tests TP-PA (Treponema Pallidum Particle Agglutination) FTA-abs (Fluorescent Treponemal Antibody -Absorbed) EIA (Enzyme Immunoassay)

Sensitivity & Specificity of Serologic Tests for Syphilis

Therapy of syphilis Penicillin is the drug of choice. Benzathine penicillin G but cannot pass the blood brain barrier. Procaine penicillin can pass the blood brain barrier, so protect CNS. 44

Early Syphilis Procaine penicillin 600,000 units daily IM for 10 days or, Benzathine penicillin G 2.4 million units IM in a single dose. 45

Late Syphilis Procaine penicillin 600,000 units daily IM for 20 days or, Benzathine penicillin G 2.4 million units IM every week for 5 weeks (12 million units). 46

Treatment Syphilis >1year; 2.4M PCN G weekly for 3 weeks Pcn-allergic; Tetra 500mg QID for 30 days Neurosyphilis; IV Infant 100,000 to 150,000 units/kg/day Procaine PCN BID for first seven days of life

Patients allergic to penicillin Tetracycline 500 mg /6hrs for 15 days in early and 30 days in late syphilis. Erythromycin 500 mg /6hrs for 15 days in early and 30 days in late syphilis. 48

REACTIONS TO THE TREATMENT 1- Reactions to penicillin: Anaphylactic shock or urticaria. 2- Therapuetic paradox: Healing of syphilitic lesions by fibrosis, so the condition becomes more worse (healing of syphilitic aortitis by fibrosis leads to coronary stenosis). 49

Jarisch-Herxheimer Reaction Intensification of existing syphilitic lesions and/or exacerbation of old ones following administration of penicillin due to immunological reaction to killed trponemes. The reaction subsides in 24 hours and you should simply warn the patient to expect it. 50

Prevention 51

Thank you 52