1. SEXUALLY TRANSMITED DISEASES SYPHILIS ( LUES ) Dr D. Tenea Department of Dermatology University of Pretoria

2. History INTRODUCTION Venereal disease = old term STD – infections transmitted by sexual contact Sexually transmissible infections – caused by pathogens for which non-sexual routes of transmission predominate

3. History Bacteria : Neisseria gonorrhoea– Gonorrhoea Treponema Pallidum– Syphilis Haemophilus Ducreyi– Chancroid Chlamidia Trachomatis– LGV Mycoplasma Hominis / Ureaplasma urealyticum Viruses : HIV, HSV, CMV, HPV, MC, HTLV-1, -2, HAV, HBV, HCV Protozoa : Trichomonas vaginalis, Giardia Lamblia, E. Histolytica Fungi : Candida Albicans Ectoparasites : Phthirus pubis, Sarcoptes scabies SEXUALLY TRANSMITTED AND TRANSMISSIBLE PATHOGENS

4. History Sexually acquired chronic, systemic infection / congenital infection Progresses through active and latent stages Caused by genus Treponema pallidum – order Spirochaetales Leading cause of genital ulcer Worldwide distribution Higher incidence : men ( Blacks, Hispanics ) homosexuals, prostitutes SYPHILIS ( Lues )

5. History Laboratory Dx. of Syphilis Direct detection of Treponemes by darkfield microscopy Serologic tests for Ab. response ( treponemal tests : TPHA and non- treponemal tests : VDRL, RPR ) T. pallidum cannot be routinely cultured in vitro PCR—molecular biological detection of treponemal DNA – not as a routine test ( used in dx. of Neurosyphilis ) Histology : H&E + special stains ( Warthin-Starry stain for identification of Spirochetes in the tissues )

6. History Inoculation + penetration – mucosa and abraded skin Incubation : 14 – 21 days Primary Syphilis : painless chancre + regional lymphadenopathy VDRL / RPR / TPHA +ve in 80% cases Haematogeneous and lymphatic dissemination 3-8 wks. later Secondary Syphilis : - constitutional symptoms ( systemic manifestations ) - generalised lymphadenopathy - mucocutaneous manifestations - positive syphilis serology ( 100% ) - lesions disappear spontaneously ( 25% relapse in the first year ) NATURAL HISTORY OF UNTREATED SYPHILIS

7. History Latent Syphilis : Early latent stage ( < 1 year ) Late latent stage ( > 2 years ) – may last 2-20 years Absence of any clinical signs and positive serology 1/3 patients – clinical symptoms of tertiary syphilis Tertiary Syphilis : - superficial nodular syphilides ( confined to the skin ) - gummatous syphilides of the skin, bones, liver - cardiovascular syphilis - neurosyphilis - syphilitic hepatic cirrhosis - reactive blood + presence of anti-treponema Ab. in CSF NATURAL HISTORY – Ctd.

8. History Mother-to-child transmission risk : - Infection of the mother from contraception to 7 th. month of pregnancy transmission 100% - abortion, stillbirth, IUD, severe Cong. Syphilis - Infection 2 years before pregnancy or earlier : 50% risk - Infection after 7 th month of pregnancy : reduced risk of transmission - Infection 3-6 weeks before labor : no placental transmission ; risk of perinatal transmission CONGENITAL SYPHILIS

9. History Symptoms apparent during perinatal period –first 3months after birth Symptoms similar to acquired secondary Syphilis : - annular skin lesions / bullous disease with erosions - periorificial fissures ( perioral + perianal ) - snuffles ( bloody or purulent mucinous nasal discharge ) - lymphadenopathy - osteochondritis – painful (Parrot pseudoparalysis ) Skin manifestations are accompanied by constitutional symptoms ( fever, malaise, myalgia, arthralgia ) ; underweight, senile features EARLY CONGENITAL SYPHILIS

10. History Child / adolescent Corresponds to tertiary Syphilis in the adult Is not infectious Stigmata : - keratitis - Hutchinson`s teeth - neural deafness - Hutchinson`s triad LATE CONGENITAL SYPHILIS

11. History SYPHILIS AND HIV Syphilis / any other genital ulcers add to an increased risk for acquisition of HIV Syphilis manifestations are altered in HIV+ve patients Neurological manifestations are observed more often ( neurosyphilis is common in HIV ) Higher incidence of ulcerative lesions of secondary Syphilis in HIV + ve patients

12. History Treatment recommendations for Syphilis Penicillin G is still the treatment of choice for all stages of Syphilis No tendency toward Penicillin resistance found in T. Pallidum Tetracyclines are used as a 2 nd line therapy ( allergy / intolerance) Follow-up examinations ( VDRL, TPHA ) – every 3-6 months for 2 years for Early Syphilis and 3 years for Late Syphilis Evaluation of sexual partners + reporting are mandatory in many countries Primary, Secondary, Early latent Syphilis – a single dose 2.4 MU Benzanthine Penicillin Latent Syphilis > 1 year duration + Late Syphilis : 3 weekly IM. Inj. of 2.4 MU Penicillin

13. History TREATMENT – Ctd. Neurosyphilis ( persistent high titres of VDRL /TPHA ) – 24 million units IV. Pen. G in 6 divided doses for 14 days Pregnancy : Benzanthine Penicillin 2.4 MU given IM. Weekly X 3 Procaine Penicillin 50 000 units IM daily for 14-21 days Congenital : Benzanthine Penicillin 2.4 MU given IM. Weekly X 3 or Procaine Penicillin 50 000 u / kg IM daily for 14 days HIV infection : Benzanthine Penicillin 2.4 MU given IM weekly X 3 or Pen. G 2.4 MU adm. IV every 4 h. ( 12-14 mil. Dly for 14/7) Alternative regimens for Penicillin allergies : Doxycycline 200mg/d -14/7 Tetracycline 500mg 6hr. -14/7 Erythromycin 2g/dly – 14/7