Syphilis lecture PP

Definition
Causative organism
Mode of transmission
Incubation period
Clinical picture:
Acquired syphilis
Congenital syphilis
Diagnosis
Treatment
Prognosis

1. Dr. Walaa Mostafa Ahmed Medical commission Family physician specialist

2. We will discuss: Definition Causative organism Mode of transmission Incubation period Clinical picture: Acquired syphilis Congenital syphilis Diagnosis Treatment Prognosis

3. DEFINITION Syphilis is a sexually transmitted disease (STD) caused by the spirochete Treponema pallidum .

4. Treponema pallidum: is a fragile spiral bacterium 6-15 micrometers long by 0.25 micrometers in diameter. Its small size makes it invisible on light microscopy; therefore, it must be identified by its distinctive movements on darkfield microscopy. It can survive only briefly outside of the body; thus, transmission almost always requires direct contact with the infectious lesion. T pallidum is a labile organism that cannot survive drying or exposure to disinfectants; thus, fomite transmission (e.g., from toilet seats) is virtually impossible

5. MODE OF TRANSMISSION acquired syphilis : sexual contact with infectious lesions via blood product transfusion (if blood has been collected during early syphilis) occasionally through breaks in the skin that come into contact with infectious lesions. Congenital syphilis: from mother to fetus in utero

6. INCUBATION PERIOD Incubation time from exposure to Treponema pallidum to development of primary lesions, which occur at the primary site of inoculation T pallidum rapidly penetrates intact mucous membranes or microscopic dermal abrasions and, within a few hours, enters the lymphatics and blood to produce systemic infection In acquired syphilis, range from 10-90 days with averages 3 weeks

7. CLINICAL PICTURE acquired syphilis: there are 4 stages : Primary syphilis Secondary syphilis Latent syphilis: early, late Tertiary syphilis Congenital syphilis

8. Primary syphilis Primary syphilis occurs 10-90 days after contact with an infected individual. It manifests mainly on the glans penis in males and on the vulva or cervix in females. 10% of syphilitic lesions are found on the anus, fingers, oropharynx, tongue, nipples, or other extragenital sites. Regional nontender lymphadenopathy follows invasion. Lesions (chancres) usually begin as non painful solitary, raised, firm, red papules that can be several centimeters in diameter. The chancre erodes to create an ulcerative crater within the papule, with slightly elevated edges around the central ulcer. It usually heals within 4-8 weeks, with or without therapy.

9. Secondary syphilis Secondary syphilis manifests in various ways. Mild constitutional symptoms of malaise, headache, anorexia, nausea, aching pains in the bones, and fatigue often are present, as well as fever and neck stiffness It usually presents with a cutaneous eruption within 2-10 weeks after the primary chancre generally nonpruritic and bilaterally symmetrical and are distributed widely with frequent involvement of the palms and soles with generalized nontender lymphadenopathy is typical

10. Secondary syphilis:

11. Latent syphilis Latent syphilis is divided into early latent and late latent. The distinction is important because treatment for each is different. The early latent period is the first year after the resolution of primary or secondary syphilis. Late latency syphilis is not infectious; however, women in this stage can spread the disease in utero Latency may last from a few years to as many as 25 years before the destructive lesions of tertiary syphilis manifest. Affected patients asymptomatic during the latent phase, and the disease is detected only by serologic tests.

12. Tertiary syphilis The lesions of gummatous tertiary syphilis usually develop within 3-10 years of infection Tertiary (late) syphilis is slowly progressive and may affect any organ. The disease is generally not thought to be infectious at this stage. A gumma is a soft, non-cancerous growth and it is a form of granuloma . Gummas are most commonly found in the liver ( gumma hepatis ), but can also be found in brain, heart, skin, bone, testis, and other tissues, leading to a variety of potential problems Manifestations may include the following: Impaired balance, paresthesias, incontinence, and impotence Focal neurologic findings, including sensorineural hearing and vision loss Dementia Chest pain, back pain, stridor, or other symptoms related to aortic aneurysms

13. Tertiary syphilis

14. COMPLICATIONS Complications of syphilis may include the following: Cardiovascular disease - Aortic aneurysm CNS disease - Dementia, stroke Membranous glomerulonephritis Paroxysmal cold hemoglobinemia Irreversible end-organ damage Disfigurement by gummas

15. Congenital syphilis Trans placental from infected mother to fetus or at the birth Congenital syphilis is associated with several adverse outcomes as LBW, premature at birth, miscarriage, congenital anomalies or death of baby.

16. Congenital syphilis Early congenital syphilis Late congenital syphilis occurs within the first 2 years of life. Rhinitis (snuffles) which is highly infectious Skin lesion: maculopapular rash Lymphadenopathy Hepatosplenomegaly Failure to thrive Jaundice, anemia osteochondritis     emerges in children older than 2 years. Gummatous ulcers Bony prominence on for head Saddle nose Short maxilla Hutchinson's triad: interstitial keratitis, 8 nerve deafness and dental deformities

17. Congenital syphilis

18. DIAGNOSIS T pallidum cannot be cultivated in vitro and is too small to be seen under the light microscope. Serologic testing is considered the standard method of detection for all stages of syphilis

19. first perform nontreponemal serology screening using: the Venereal Disease Research Laboratory (VDRL) rapid plasma reagin (RPR)

20. treponemal test: Because of the possibility of false-positive results, confirmation for any positive or equivocal nontreponemal test result should follow with a treponemal test, such as: the fluorescent treponemal antibody-absorption (FTA-ABS) microhemagglutination assay T pallidum (MHA-TP) T pallidum hemagglutination (TPHA) T pallidum particle agglutination (TPPA) tests. Treponemal enzyme immunoassay (EIA) for immunoglobulin G (IgG) and immunoglobulin M (IgM) may be performed

21. Darkfield microscopy: is a possible mode of evaluating moist cutaneous lesions, such as the chancre of primary syphilis or the condyloma lata of secondary syphilis

22. Others: Imaging Studies: depending on the organ system involved. For example, granulomatous disease of the liver can be seen on computed tomography (CT) of the abdomen. Lumbar puncture: in individuals with late latent syphilis if treatment fails or if neurologic or ocular symptoms are present .It is also indicated if there are other changes indicative of tertiary syphilis (e.g., gumma, aortitis).

23. TREATMENT PENICILLIN IS THE DRUG OF CHOICE TO TREAT SYPHILIS .

24. The following regimens are recommended for penicillin treatment: Primary or secondary syphilis - Benzathine penicillin G 2.4 million units intramuscularly (IM) in a single dose Early latent syphilis - Benzathine penicillin G 2.4 million units IM in a single dose Late latent syphilis or latent syphilis of unknown duration - Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals Pregnancy - Treatment appropriate to the stage of syphilis is recommended.

25. patients allergic to penicillin: they currently are recommended only as alternative treatment regimens in patients allergic to penicillin. A 10- to 14-day trial of ceftriaxone is effective for treating early syphilis, although the optimal dose and duration have not been established. Doxycycline and tetracycline for 28 days have been used for many years and are the only acceptable alternatives to penicillin for the treatment of latent syphilis. Doxycycline is the preferred alternative to penicillin owing to its tolerability.

26. Surgical Care Surgical care is reserved for treating the complications of tertiary syphilis (e.g., aortic valve replacement).

27. PROGNOSIS For patients diagnosed with either primary or secondary syphilis (without auditory/neurologic/ocular involvement), the prognosis is good following appropriate treatment T pallidum remains highly responsive to the penicillins , and cure is likely. Overall prognosis for tertiary syphilis depends on the extent of scarring and tissue damage, as treatment arrests further damage and inflammation but cannot reverse previous tissue damage

28. REFERENCES Cox DL, Chang P, McDowall AW, Radolf JD. The outer membrane, not a coat of host proteins, limits antigenicity of virulent Treponema pallidum. Infect Immun . 1992 Mar. 60(3):1076-83. Fitzgerald TJ. The Th1/Th2-like switch in syphilitic infection: is it detrimental?. Infect Immun . 1992 Sep. 60(9):3475-9. Bowen V, Su J, Torrone E, Kidd S, Weinstock H. Increase in Incidence of Congenital Syphilis - United States, 2012-2014. MMWR Morb Mortal Wkly Rep . 2015 Nov 13. 64:1241-5. Patton ME, Su JR, Nelson R, Weinstock H, Centers for Disease Control and Prevention (CDC). Primary and secondary syphilis--United States, 2005-2013. MMWR Morb Mortal Wkly Rep . 2014 May 9. 63 (18):402-6. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2007 Supplement, Syphilis Surveillance Report. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/std/Syphilis2007/ . Accessed: April 14. CDC. Primary and secondary syphilis--United States, 2003-2004. MMWR Morb Mortal Wkly Rep . 2006 Mar 17. 55(10):269-73. World Health Organization. Global prevalence and incidence of selected curable sexually transmitted infections: Overview and estimates. Geneva: 2001. Akovbian VA, Gomberg MA, Prokhorenkov VI. Syphilitic vignettes from Russia. Dermatol Clin . 1998 Oct. 16(4):687-90, x. HIV prevention through early detection and treatment of other sexually transmitted diseases--United States. Recommendations of the Advisory Committee for HIV and STD prevention. MMWR Recomm Rep . 1998 Jul 31. RR-12:1-24.

29. REFERENCES Cooley LA1, Pearl ML, Flynn C, Ross C, Hart-Cooper G, Elmore K, et al. Low viral suppression and high HIV diagnosis rate among men who have sex with men with syphilis--Baltimore, Maryland. Sex Transm Dis . 2015 Apr. 42(4):226-31. Su JR, Weinstock H. Epidemiology of co-infection with HIV and syphilis in 34 states, United States—2009. Proceedings of the 2011 National HIV Prevention Conference, August 13-17, 2011 . HARRISON LW. The Oslo study of untreated syphilis, review and commentary. Br J Vener Dis . 1956 Jun. 32(2):70-8. ROCKWELL DH, YOBS AR, MOORE MB Jr. THE TUSKEGEE STUDY OF UNTREATED SYPHILIS; THE 30TH YEAR OF OBSERVATION. Arch Intern Med . 1964 Dec. 114:792-8. McClure EM, Goldenberg RL. Infection and stillbirth. Semin Fetal Neonatal Med . 2009 Aug. 14(4):182-9. Kupka R, Kassaye T, Saathoff E, Hertzmark E, Msamanga GI, Fawzi WW. Predictors of stillbirth among HIV-infected Tanzanian women. Acta Obstet Gynecol Scand . 2009. 88(5):584-92. Dismukes WE, Delgado DG, Mallernee SV, Myers TC. Destructive bone disease in early syphilis. JAMA . 1976 Dec 6. 236(23):2646-8. Sule RR, Deshpande SG, Dharmadhikari NJ, Joshi VR. Late cutaneous syphilis. Cutis . 1997 Mar. 59(3):135-7. [Guideline] U.S. Preventive Services Task Force. Screening for Syphilis Infection. Recommendation Statement. 2004. Workowski KA, Bolan GA. Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. MMWR . June 5, 2015. 64(RR3):1-137.

30. REFERENCES GP. Serologic screening for syphilis. Rationale, cost, and realpolitik. Sex Transm Dis . 1996 Jan-Feb. 23(1):45-50. Young H. Syphilis. Serology. Dermatol Clin . 1998 Oct. 16(4):691-8. Binnicker MJ, Jespersen DJ, Rollins LO. Direct comparison of the traditional and reverse syphilis screening algorithms in a population with a low prevalence of syphilis. J Clin Microbiol . 2012 Jan. 50(1):148-50. [Guideline] Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep . 2006 Aug 4. 55:1-94. U.S. Preventive Services Task Force. Screening for syphilis infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med . 2009 May 19. 150(10):705-9. Ghanem KG. Management of Adult Syphilis: Key Questions to Inform the 2015 Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. Clin Infect Dis . 2015 Dec 15. 61 Suppl 8:S818-36. [Guideline] Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep . 2010 Dec 17. 59:1-110. Ghanem KG, Workowski KA. Management of adult syphilis. Clin Infect Dis . 2011 Dec. 53 Suppl 3:S110-28.