1. Syphilis
Definition: Syphilis is a systemic infection caused by the spirochete Treponema pallidium,
which is transmitted mainly by direct sexual intercourse (venereal syphilis) and less commonly via placenta (congenital syphilis) or by accidental inoculation from the infectious Materials
T. Pallidum spirochetes cannot be cultured but are detected by silver stains, dark field examination and immunofluorescence technique

3. Pathogenesis:
􀂾 The organism is delicate and susceptible to drying and does not survive long outside the
body.
􀂾 The organism invades mucosa directly possibly aided by surface abrasions following
intercourse with an infected person, a primary lesion, an ulcer known as the chancre,
develops at the site of infection usually on the external genetalia but also lips and anorectal
region. Within hours, the T. pallidum pass to regional lymph nodes and gain access to
systemic circulations. Thereafter, the disease is unpredictable. Its incubation period is
about 3 weeks.

4. Whatever the stage of the disease and location of the lesions the histologic hallmarks of
syphilis are
A. Obliterative endarteritis
B. Plasma cell rich mononuclear cell infiltrates.
􀂾 The endarteritis is secondary to the binding of spirochetes to endothelial cells mediated
by fibronectin molecules bound to the surface of the spirochetes. The mononuclear
infiltrates are immunologic response.
􀂾 Host humeral and cellular immune responses may prevent the formation of chancre on
subsequent infections with T. pallidum but are insufficient to clear the spirochetes.

5. STAGES OF SYPHILIS Primary Secondary Latent Late or tertiary
Early latent
Late latent
Late or tertiary
May involve any organ, but main parts are:
Neurosyphilis
Cardiovascular syphilis
Late benign (gumma)

6. PRIMARY SYPHILIS (The Chancre)
Incubation period 9-90 days, usually ~21 days.
Develops at site of contact/inoculation.
Classically: single, painless, clean-based, indurated ulcer, with firm, raised borders. Atypical presentations may occur.
Mostly anogenital, but may occur at any site (tongue, pharynx, lips, fingers, nipples, etc...)
Non-tender regional adenopathy
Very infectious.
May be darkfield positive but serologically negative.
Untreated, heals in several weeks, leaving a faint scar.

7. SECONDARY SYPHILIS Seen 6 wks to 6 mos after primary chancre
Usually w diffuse non-pruritic, indurated rash, including palms & soles.
May also cause:
Fever, malaise, headache, sore throat, myalgia, arthralgia, generalized lymphadenopathy
Hepatitis (10%)
Renal: an immune complex type of nephropathy with transient nephrotic syndrome
Iritis or an anterior uveitis
Bone: periostitis
CSF pleocytosis in % (but, symptomatic meningitis is seen in <1%)

8. SECONDARY SYPHILIS (Cont.)
The skin rash:
Diffuse,
often with a superficial scale (papulosquamous).
May leave residual pigmentation or depigmentation.
Condylomata Lata:
Formed by coalescence of large, pale, flat-topped papules.
Occur in warm, moist areas such as the perineum.
Highly infectious.
Mucosal lesions:
~ 30% of secondary syphilis patients develop mucous patch (slightly raised, oval area covered by a grayish white membrane, with a pink base that does not bleed).
Highly infectious

10. Lesions of syphilis resolve without treatment although person remains infected

11. LATENT SYPHILIS
Positive syphilis serology without clinical signs of syphilis (& has normal CSF).
It begins with the end of secondary syphilis and may last for a lifetime.
Pt may or may not have a h/o primary or secondary syphilis.
Is divided into early and late latency.

12. LATENT SYPHILIS (cont.)
Early latent:
The first year after the resolution of primary or secondary lesions, or
A reactive serologic test for syphilis in an asymptomatic individual who has had a negative serologic test within the preceding year.
Infectious.
Late latent:
Usually not infectious, except for the pregnant woman, who may transmit infection to her fetus.

13. LATE SYPHILIS ‘Tertiary Syphilis’
Is the destructive stage of the disease.
Lesions develop in skin, bone, & visceral organs (any organ).
The main types are:
Late benign (gummatous)
Cardiovascular &
Neurosyphilis
Can be crippling and life threatening
Blindness, deafness, deformity, lack of coordination, paralysis, dementia may occur
It is usually very slowly progressive, barring certain neurologic syndromes which may develop suddenly due to endarteritis and thrombosis in the CNS
Late syphilis is noninfectious.

14. NEUROSYPHILIS Divided into 5 groups, which may overlap:
Asymptomatic neurosyphilis
Syphilitic meningitis
Meningovascular syphilis
General paresis
Tabes dorsalis

15. TABES DORSALIS Occurs 20-30 years after the initial infection.
It is uncommon.
More common in whites and in men.
It’s a slowly progressive, degenerative disease involving the posterior columns and posterior roots of the spinal cord.
Results in progressive loss of peripheral reflexes, impairment of vibration and position sense, and progressive ataxia.
Bladder incontinence & impotence are common.
Chronic destructive changes of the large joints of the affected limbs may be seen in advanced cases (i.e., Charcot's joints).

16. CARDIOVASCULAR SYPHILIS
May not manifest clinically until years after infection, but usually begins within 5-10 years after initial infection.
Primarily aortic insufficiency and aortic aneurysm of the ascending aorta. Other large arteries may sometimes be involved, and rarely the coronary ostia may be involved.
Caused by obliterative endarteritis of the vasa vasorum with resultant damage to the intima & media of the great vessels, causing dilatation of the ascending aorta and eventually results in stretching of the ring of the aortic valve, producing aortic insufficiency. The valve cusps remain normal.
Asymptomatic aortitis is best diagnosed by visualizing linear calcifications in the wall of the ascending aorta.
More common in men than in women and possibly in blacks than in whites.

17. :
Syphilitic gummas - there are grey white rubbery masses of variable sizes. They occur
in most organs but in skin, subcutaneous tissue, bone, Joints and testis. In the liver,
scarring as a result of gummas may cause a distinctive hepatic lesion known as hepar
lobatum.
- Collapse of the bridge of the nose and palate can occur with perforation
- Osteitis and periosteitis may lead to thickening and deformity of long bones such as the
sabre tibia
- Histologically, gummas look like a central coagulative necrosis characterized by
peripheral granumatous responses. TheTrepanosomas are scanty in these gummas
and difficult to demonstrate

18. Late syphilis - ulcerating gumma

19. Congenital syphilis
􀂾 This infection is most severe when the mother's infection is recent. Treponemas do
not invade the placental tissue or the fetus until the fifth month of gestation (since
immunologic competence only commences then) syphilis causes late abortion, still
birth or death soon after delivery or It may persist in latent forms to become apparent
only during childhood or adult life.
􀂾 The out come of congenital syphilis depends on stage of maternal infection (i.e. the
degree of maternal spirochataemia). In primary and secondary stages, the fetus is
heavily infected and may die of hydrops in utero or shortly after birth. Liver and
pancrease show diffuse fibrosis. The placenta is heavy, and pale with plasmacytic
villitis. After maternal second stage, the effects of congenital syphilis are progressively
less severe.
􀂾 Less dramatic visceral disease, papular lesions on skin and mucosae such as the
nose snuffles, may be seen with Huchinson's teeth, and interstial keratitis.
􀂾 Children infected in utero who are sero -positive show no lesions until two or more
years after birth are classified as having late congenital syphilis. The late congenital
syphilis is distinctive for the triads: Interstial keratitis; Hutchinson teeth and Eight
nerve deafness

20. TESTS FOR SYPHILIS Dark field Microscopy VDRL, RPR FTA-ABS, MHA-TP
Direct Fluorescent Antibody (DFA)