SYPHILIS

 

Etiology :

  1. Due to Treponema Pallidum. Transmitted  sexually, congenitally and by blood transfusion (serologically negative donor in early primary stage).

S & S:

  1. Stage I (primary) - Chancre, painless, ulcerated lesion/s with raised border to genitalia, anus, vulva etc.  Contagious. Regional adenopathy  is present. Incubation 3-4 wks. If not treated resolves in 4 wk. and is followed by:
     
  2. Stage II  (secondary) - Disseminated rash (various clinical presentations including erythematous macules  copper colored macules and papules, mucous patches and alopecia (consult Dermatology Atlas for  typical  lesions)  to trunk, extremities, palms and soles. Lymphadenopathy and constitutional S & S, including arthralgia may accompany the findings.  Appears 2-10 wks. after primary. Candilomata lata  is a specific type of secondary syphilis that is present in moist areas of  body (groin, web spaces). Moist to inspection and is very contagious as compared to dry skin lesions of second stage. All lesions resolve spontaneously after wk. and  may enter latent phase i.e. asymptomatic with  occasional skin rash flare.
     
  3. Stage III ( tertiary = late phase) present with neurological , CV  and skin (gumma, rush) changes. May appear years later. Only 1/3 of untreated pts will develop this late phase. This stage is rarely communicable, unless fetomaternal passage is present. This stage is not contagious since the skin lesions are consequence of  chronic inflammation (granuloma) and are not due to the presence of  T. Pallidum.  This is also why the dark-field exam in this stage is negative.

DX:

  1. Darkfield exam is the only definitive test and visualizes treponema on microscope exam. Obtained from wet lesion.  Squeeze lesion (don't forget gloves) and collect serum on glass slide.
     
  2. Serology test available are: 1) FTA-ABS  and 2) the nontreponemal test e.g. VDRL and RPR.  The FTA  (usually reported as positive or negative) are positive for life and are not used for F/U.
     
  3. The VDRL must be reported as titer and compared to previous result. If newly positive or fourfold  rise from previous level is present, presumptive diagnosis of syphilis is made. VDRL has many false positives. With proper treatment the titer level should decrease by fourfold within 3-6 mo. VDRL testing is done also on CSF if neurosyphilis is suspected. While in primary syphilis VDRL takes 3-4 wks. to become positive from day of infection, in secondary and tertiary syphilis VDRL is always positive.
     
  4. Skin biopsy is used in dx of tertiary syphilis.
     
  5. Primary syphilis should be distinguished from Chancroid, herpes, fixed drug eruption,  lymphogranuloma venereum and granuloma inguinale.
     
  6. Secondary syphilis should be distinguished from  pityriasis rosea,  tinea, psoriasis, lichen planus and drug eruptions.  Condyloma lata should be differentiated from condyloma accuminata.

Treatment:

  1. Primary, secondary and early latent (< 1 year) phase are treated with Benzathine penicillin G 2.4 million U IM.IM weekly for 2 weeks. If penicillin allergic: Doxycycline 100 mg PO bid or tetracycline 500 mg PO qid for 14 days.
     
  2. More than 1 year latent and late phase are treated with Benzathin PCN 2.4 million U IM qwk x 3 wk. If penicillin allergic: Doxycycline 100 mg PO bid or tetracycline 500 mg PO qid  for 28 days.
     
  3. Neurosyphilis is treated with Aqueous PCN 2-4 million U IM qd +  probenicide 500 mg PO qid both for 2 wks.
     
  4. All pts must be re-tested for VDRL in 3 mo and if pt is HIV (+) q month re-testing is advised since these patients are at increased risk of treatment failure and CNS relapse.
     
  5. At any time during treatment of syphilis  JARISCH-HERXHAIMER reaction can occur. C/O flu like symptoms and arthralgia and lasts 24 hrs. Treatment is symptomatic.
     
  6. All patients with syphilis should be tested for HIV disease.

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