Syphilis lecture PP

Dr. Walaa Mostafa Ahmed
Medical commission
Family physician specialist
Syphilis

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

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

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

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

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

CLINICAL PICTURE
• acquired syphilis: there are 4 stages :
1. Primary syphilis
2. Secondary syphilis
3. Latent syphilis: early, late
4. Tertiary syphilis
• Congenital syphilis

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.

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

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.

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

COMPLICATIONS
• Complications of syphilis may include the following:
1. Cardiovascular disease - Aortic aneurysm
2. CNS disease - Dementia, stroke
3. Membranous glomerulonephritis
4. Paroxysmal cold hemoglobinemia
5. Irreversible end-organ damage
6. Disfigurement by gummas

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.

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

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

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

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:
1. the fluorescent treponemal antibody-absorption (FTA-ABS)
2. microhemagglutination assay T pallidum (MHA-TP)
3. T pallidum hemagglutination (TPHA)
4. T pallidum particle agglutination (TPPA) tests.
5. Treponemal enzyme immunoassay (EIA) for immunoglobulin G (IgG) and
immunoglobulin M (IgM) may be performed

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

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).

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.

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.

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

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

REFERENCES
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and STD prevention. MMWR Recomm Rep. 1998 Jul 31. RR-12:1-24.

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.
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August 13-17, 2011.
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• ROCKWELL DH, YOBS AR, MOORE MB Jr. THE TUSKEGEE STUDY OF UNTREATED SYPHILIS; THE 30TH YEAR OF OBSERVATION. Arch Intern
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• McClure EM, Goldenberg RL. Infection and stillbirth. Semin Fetal Neonatal Med. 2009 Aug. 14(4):182-9.
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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.
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REFERENCES
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• Young H. Syphilis. Serology. Dermatol Clin. 1998 Oct. 16(4):691-8.
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recommendation statement. Ann Intern Med. 2009 May 19. 150(10):705-9.
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Transmitted Diseases Treatment Guidelines. Clin Infect Dis. 2015 Dec 15. 61 Suppl 8:S818-36.
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• Ghanem KG, Workowski KA. Management of adult syphilis. Clin Infect Dis. 2011 Dec. 53 Suppl 3:S110-28.

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