1. SYPHILIS and HIV-infection
VSMU
Department of dermatovenereology
Zykova O.S.
2017

2. Syphilis is a common infections, sexually transmitted disease caused by the bacterium Treponema pallidum.

3. Treponema pallidum
The bacterium, T. pallidum, was first identified by Schaudinn and Hoffmann in 1905;
A year later, August von Wassermann devised the first serum reaction test for syphilis.
With this test, a diagnosis for syphilis could be made, but unfortunately there was no effective treatment until the discovery of sulfonamides and penicillin in the late 1930’s

4. Treponema pallidum: form
spiral
cyst-form
L - form

5. Treponema pallidum: Drying Boiling UV-Radiation
has a slender, coiled morphology
hen examined by dark field microscopy it moves with a drifting rotary motion (corkscrew). 
can not survive outside its only known natural host (humans) because it has limited metabolic capacities in order to synthesize its own bionutrients.
Can not be cultivated in vitro
Sensitivity
Drying
Boiling
UV-Radiation
Spiritus aethylicus 70º

6. The primary mode of syphilis transmission
Sexual contact
Nonsexual contact
Blood transfusion, transplantation
From the pregnant woman to the fetus
If the newborn comes in contact with a contagious lesion.

7. Syphilis: periods (current stage)
1. Incubation time
Duration - 3 weeks since trunsmission
(directly proportional to the size of the inoculum and may vary from 3 to 90 days).
absence of clinical manifestations
2. Primary syphilis
Duration weeks after incubation time
3. Secondary syphilis
Duration years after primary syphilis
4. Tertiary syphilis
Duration – years after secondary syphilis
Latent syphilis
Absence of of clinical manifestations
Positive serological tests

8. Syphilis: pathologic changes
Obliterative endarteritis that is found in all stages of the disease.
In the primary chancre an inflammatory infiltrate formed by polymorphonuclear leucocytes and macrophages and rich of treponemes is the typical feature.
Gummas are agranulomatous lesions formed by a necrotic coagulated center and associated with small-vessels obliterative endarteritis. 

9. Primary syphilis : clinical manifestations- chancre, regional lymphadenitis
The chancre of lips
erosive
papular
hypertrophic
dwarf
cortical
in the form of painful cracks
The chancre of tongue
ulcerative
slit-shaped
sclerotic
The chancre of tonsils (specific amigdalitis)^
Unilaterans, painful, difficulty swallowing
Typical:
Atypical: diffuse hyperemia, induration without defect of mucosa
diphtheroidous
Gangrenous (with common symptoms)
The chancre of gums
Ulcerative
Atypical: complicated with co-infections
Differential diagnosis:
Herpes, aphthous stomatitis, tuberculosis, squamous cell carcinoma, periodontal abscess and language abscess, botryomycoma, ect.

10. Zaboltvaniya, peredavaemyie polovym puyiom. / Gl. red. Borisenko K. K
Zaboltvaniya, peredavaemyie polovym puyiom./ Gl.red. Borisenko K.K.. – M.:GEOTAR MEDICINA, 1998.

12. Secondary syphilis of the oral mucoses: Localisation
Throat (Erythematous-infiltrative angina, papular rash)
Tongue
Mucous membrane of the cheeks
Lips

13. Secondary syphilis of the oral mucoses: papular rash
Fresh papules (up to 1 day) - round, bluish-red, up to 1 cm, with not acting thin infiltration
"Opal plaque" (5-7 days) - white papule with necrosis of the epithelium. After grattage it turns into a bright - red thick elevating erosive papule.
Papules in the period from days – red thick elevating erosive papule.

14. Papuls of the tongue: Atrophic, Hypertrophic
Zaboltvaniya, peredavaemyie polovym puyiom./ Gl.red. Borisenko K.K.. – M.:GEOTAR MEDICINA, 1998.

15. Secondary syphilis of the tongue : Clinical variants
Cracks
Erosions,
Ulcers
Abrasions,
Narrow keratosis with umbilicated in the center

16. Secondary syphilis : Differential diagnosis
oral squamous carcinoma,
Leukoplakia: Idiopathic leukoplakia, tobacoco-induced leukoplakia, candidal leukoplakia (chronic hyperplastic leukoplakia)
candidosis,
plaque lichen planus,
frictional keratosis,
lichenoid reaction to drug or amalgam,
granulomatous diseases,
oral hairy leukoplakia.

17. Tertiary syphilis of the oral mucoses: common symptoms
dense infiltration
painlessness
absence of regional lymphadenitis
invasive growth
primary elements - tuberculum and nodus
Zaboltvaniya, peredavaemyie polovym puyiom./ Gl.red. Borisenko K.K.. – M.:GEOTAR MEDICINA, 1998.

18. Laboratory Confirmation
Dark-Field Microscopy
Direct Fluorescence
PCR
Serology:
nontreponemal tests for screening,
treponemal tests for confirmation of diagnosis.

19. Treponema pallidum: Drying Boiling UV-Radiation
has a slender, coiled morphology
hen examined by dark field microscopy it moves with a drifting rotary motion (corkscrew). 
can not survive outside its only known natural host (humans) because it has limited metabolic capacities in order to synthesize its own bionutrients.
Can not be cultivated in vitro
Sensitivity
Drying
Boiling
UV-Radiation
Spiritus aethylicus 70º

20. Nontreponemal tests
The nontreponemal tests measure both IgG and IgM antiphospholipid antibodies formed by the host in response to lipoidal material released by damaged host cells early in infection and lipid from the cell surfaces of the treponeme itself.
RPR (Rapid Plasma Reagins) – тест быстрых плазменных антигенов (количественная и качественная модификации)
TRUST (Toluidin Red Unheated Serum Test) – тест с толуидиновым красным и непрогретой сывороткой
VDRL (Venerial Disease Research Laboratory) – тест c инактивированной сывороткой в количественной модификации (для исследования ликвора)
USR (Unheated Serum Reagins) – тест определения активных реагинов плазмы

21. Treponemal tests
The former is able to reveal syphilis antibodies in the patient’s serum in the early stage, while the last two become positive somewhat later during the course of infection.
Fluorescent treponemal antibody (FTA-ABS)
T. Pallidum hemagglutination (TPHA)
MHA-TP which is a modified version of TPHA.
The MHA-TP test is highly specific (>98%) and sensitive in patients with secondary syphilis.
ELISA, Western blot

22. Congenital Syphilis
Transmission to the fetus is usually via the placenta, but may occur during delivery in the presence of maternal genital lesions.
The risk of vertical transmission ranges from 70 to 100% for primary syphilis to 40% for early latent disease to 10% for late latent disease.

23. Congenital Syphilis
Infection of the fetus may result in abortion, stillbirth, neonatal death or disease.
Congenital syphilis can be early or late with the early features that are similar to the manifestations of secondary syphilis in adults.
These include generalized lymphadenopathy, maculopapular rash, hepatosplenomegaly, glomerulonephritis and bone alterations of tibia, hands, feet, clavicles, and skull.
Late features of congenital syphilis include bone, teeth and nervous system alterations.

24. Late features of congenital syphilis
Labyrinth deafness
Ocular interstitial keratitis
Hutchinson´s teeth
Bone deformations
Scars Rodinson -Furne
The bumps and gumma
Manifestations of late neurosyphilis
Late visceral manifestations of syphilis
Serological tests
Banchenko G.V., 2002.

25. Possible signs of late congenital syphilis
Dental erosion (coronal, apical)
Anomalies of tooth volume
Anomalies of tooth shape (amorphism)
The absence of some teeth
Malformations of the jaw
Poor dentition

26. HIV-infection
Chronic, heavy, life-threatening disease that is associated with the pathogenic action of the human immunodeficiency virus mainly on cells of immunity system.

27. Oral ulcers in HIV-infected patients
Nonspecific aphthous-like ulcers,
Ulcers caused by herpes group viruses
Non-Hodgkin's lymphoma;
Lues maligna.
Mycotic granulomatous foci (cryptococcosis, histoplasmosis)
others
large,
persistent,
painful.

28. Kaposi's sarcoma
Zaboltvaniya, peredavaemyie polovym puyiom./ Gl.red. Borisenko K.K.. – M.:GEOTAR MEDICINA, 1998.

29. Kaposi's sarcoma:
erythematous plaque of oral mucous

30. Kaposi's sarcoma: oral hairy leukoplakia

31. Questions 1. Syphilis: duration
Incubation time, Primary , Secondary, Tertiary syphilis
2. Primary syphilis:main features
Chancre, regional lymphadenitis
2. Latent syphilis:
Absence of of clinical manifestations
Positive serological tests
3. Secondary syphilis of the oral mucoses: Localisation
Throat
Tongue
Mucous membrane of the cheeks
Lips
4. Secondary syphilis of the oral mucoses: differential diagnosis
oral squamous carcinoma, leukoplakia, candidosis, plaque lichen planus, frictional keratosis, lichenoid reaction to drug or amalgam, granulomatous diseases,oral hairy leukoplakia.
5. Oral ulcers in HIV-infected patients: diseases
Nonspecific aphthous-like ulcers, ulcers caused by herpes group viruses, non-Hodgkin's lymphoma; lues maligna, mycotic granulomatous foci (cryptococcosis, histoplasmosis), others