SYPHILIS

Syphilis

 Syphilis is a sexually transmitted infection caused by the

bacterium Treponema pallidum subspecies pallidum. The signs
and symptoms of syphilis vary depending in which of the four
stages it presents (primary, secondary, latent, and tertiary).
 Syphilis has been known as "the great imitator" as it may
cause symptoms similar to many other diseases.
 Etiology

 Causative agent – Treponema pallidum.

• Phylum: Spirochaetes
• Order: Spirochaetales
• Family: Spirochaetaceae
• Genus: Treponema
• Species: T. pallidum
Syphilis is caused by a spirochete organism,
Treponema Pallidum, which has a thin, slow-
moving, corkscrew-like body.
• Motile with characteristic movements, like
angulation, bending, rotatory motion, and, back
and forth squiggle.
The treponemes have a cytoplasmic and an outer
membrane. Using light microscopy, treponemes are
only visible using dark field illumination. They are
Gram negative, but some regard them too thin to be
Gram stained.
 TRANSMISSION

 Transmission of syphilis can be:

 Acquired:
• Sexual: through unprotected sexual contact, this being the
predominant method of transmission.
• Blood: through contaminated blood and blood products.
• Accidental: in health care workers, e.g., through needle prick injury.
 Congenital: Vertical transmission occurs in utero (transplacentally)
or at the time of delivery. Infectivity of mother is higher if she has
early stage of syphilis; before the fifth month of gestation, the fetus
even if infected escapes severe damage due to its inability to mount
an inflammatory response.
 Epidemiology
 In 2013 syphilis infected about 315,000 people. During 2010 it
caused about 113,000 deaths, down from 202,000 in 1990.
After decreasing dramatically with the availability of penicillin
in the 1940s, rates of infection have increased since the turn of
the millennium in many countries, often in combination with
human immunodeficiency virus (HIV). This is believed to be
partly due to increased promiscuity, prostitution, decreasing
use of condoms, and unsafe sexual practices among men who
have sex with men.
 In 2015, Cuba became the first country in the world to
eliminate mother-to-child transmission of syphilis.
Вставка рисунка

Deaths from Syphilis in 2012 per

million persons. Statistics from WHO,
grouped by deciles
0-0
1-1
2-3
4-10
11-19
20-28
29-57
58-138
 Classification

Early syphilis:
Infection <24 months old.
Lesions teeming with T. pallidum and so highly infectious.

Late syphilis:
Infection >24 months old.
T. pallidum sparse and so not infectious.
 International Classification of Diseases,
Revision 10 (1990)
A51 Early syphilis
A50 Congenital syphilis A51.0 Primary genital syphilis
A50.0 Early congenital syphilis, A51.1 Primary anal syphilis
symptomatic A51.2 Primary syphilis of other sites
A50.1 Early congenital syphilis, latent A51.3 Secondary syphilis of skin and mucous membranes
A50.2 Early congenital syphilis, A51.4 Other secondary syphilis
unspecified A51.5 Early syphilis, latent
A50.3 Late congenital syphilitic A51.9 Early syphilis, unspecified
oculopathy
A52 Late syphilis
A50.4 Late congenital neurosyphilis
A52.0 Cardiovascular syphilis
[juvenile neurosyphilis]
A52.1 Symptomatic neurosyphilis
A50.5 Other late congenital syphilis,
symptomatic A52.2 Asymptomatic neurosyphilis
A50.6 Late congenital syphilis, latent A52.3 Neurosyphilis, unspecified
A50.7 Late congenital syphilis, A52.7 Other symptomatic late syphilis
unspecified A52.8 Late syphilis, latent
A50.9 Congenital syphilis, unspecified A52.9 Late syphilis, unspecified
A53 Other and unspecified syphilis
A53.0 Latent syphilis, unspecified as early or late
A53. Syphilis, unspecified
 Clinical Features.

 Syphilis can present in one of four different stages:

primary, secondary, latent, and tertiary, and may also
occur congenitally. It was referred to as "the great
imitator" by Sir William Osler due to its varied
presentations
 Incubation period - 9–90 days (average 21 days).
 Clinical course
 
Stages of Syphilis
 
Contact (¹⁄₃ become infected)
↓ (10–90 days)
Primary (chancre)
↓ (3–12 weeks)
Secondary (mucocutaneous lesions, organ involvement)
↓ (4–12 weeks)

Early latent → Relapsing (1/4) (2 year from contact)

Late latent (more than 2 year)

Remission (²⁄₃) Tertiary (¹⁄₃)

Late benign
Cardiovascular
Neurosyphilis
Other symptomatic late syphilis
 Primary syphilis

 CHANCRE
 LYMPHANGITIS
 LYMPHADENOPATHY
 CHANCRE
 appears at the point of contact
 single
 firm
 painless
 non-itchy skin ulceration
 clean base and sharp borders
 between 0.3 and 3.0 cm in size.
 it evolves from a macule to a papule and finally to an erosion or ulcer
 multiple lesions may be present
 Rarely lesions may be painful or tender, and they may occur outside
of the genitals.
 Location of ulcers

 Males:
Coronals ulcus, glans, prepuce, and shaft of penis. Perianal area
in homosexual males.
 Females:
Labia minora, labia majora, and mons pubis. Sometimes in cervix
or vagina, when disease is asymptomatic.
Extragenital lesions:
Also seen on mouth, lips, tonsils, nipples, anus and finger.
CHANCRE
CHANCRE
Extragenital lesions:
 Uncommon presentations

 include giant necrotic chancre,

 phagedenic chancre (a deep, bright-red, necrotic ulcer with a soft base and
exudate, resulting from secondary bacterial infection associated with
immunosuppression),
 phimosis resulting from adherence of a chancre on the foreskin to the glans,
 paraphimosis is a condition in which the foreskin of an uncircumcised penis
becomes trapped behind the glans penis, and cannot be reduced (pulled back
to its normal flaccid position covering the glans).
 and balanitis.
 Chancres in women can be more edematous than indurated. Edema
indurativum is a unilateral labial swelling with rubbery consistency and intact
surface, indicative of a deep-seated chancre.
PHIMOSIS AND PARAPHIMOSIS
GIANT NECROTIC CHANCRE
EDEMA INDURATIVUM
 Lymphangitis

 inflammation of the regional lymph vessels which

connects the chancre to the regional lymph nodes. It
is mostly visible on the lymph vessels connecting the
chancre on the glans penis to the base of the penis in
male patients
 Lymphadenopathy

 Inguinal lymph node

enlargement frequently
(80%) occurs around the
area of infection,
occurring seven to 10
days after chancre
formation.
 Lymph nodes are
multiple, small, shotty,
firm (like lead shots)
 Primary syphilis

 The lesion may persist for three to six weeks

without treatment. Heals spontaneously (4–6
weeks) or on treatment, usually with a slightly
atrophic scar.
 Secondary syphilis

 is a systemic disease with cutaneous as well as

extracutaneous manifestations.
 Secondary syphilis occurs approximately four to ten
weeks after the primary infection.
 While secondary disease is known for the many
different ways it can manifest, symptoms most
commonly involve the skin, mucous membranes, and
lymph nodes.
 Skin lesions of SS
 may be few or numerous.
 Lesions are symmetrical initially, becoming asymmetrical later.
 There may be a reddish-pink, non-itchy rash on the trunk and
extremities, including the palms and soles.
 The rash may become maculopapular or pustular.
 It may form flat, broad, whitish, wart-like lesions known as
condyloma latum on mucous membranes.
 All of these lesions harbor bacteria and are infectious.
 Other symptoms may include fever, sore throat, malaise, weight
loss, hair loss, and headache.
 Rare manifestations include liver inflammation, kidney disease,
joint inflammation, periostitis, inflammation of the optic nerve,
uveitis, and interstitial keratitis.
 Secondary syphilis

 The acute symptoms usually resolve after three to six

weeks; however, about 25% of people may present
with a recurrence of secondary symptoms.
 Many people who present with secondary syphilis
(40–85% of women, 20–65% of men) do not report
previously having had the classic chancre of primary
syphilis
The different morphological forms of
cutaneous lesions seen are:

 Roseolar syphilide
 Papular syphilide
• Psoriasiform lesions
• Palm and sole lesions
• Condyloma lata
• Mucous patches
• Pustular
 Nonscarring alopecia
 Pigmentary changes
Roseolar syphilide: symmetrical erythematous
macular rash, often just perceptible.
Papular syphilide: most common rash
of SS.
Psoriasiform lesions: when scaling is predominant,
the lesions appear psoriasiform.
Palm and sole lesions: Hyperpigmented,
coppery red, scaly lesions. Or hyperkeratotic
papules.
 Condyloma lata
In intertriginous area, the papules may
erode superficially. Sometimes at
commissures, the papules split (split
papules). Also highly infectious are
condyloma lata, which present as moist,
flat, well-demarcated papules or plaques
with macerated or eroded surfaces in
intertriginous areas, commonly in the
labial folds in females or in the perianal
region in all. However, any moist
intertriginous area of the body can harbor
condyloma lata, including the axillae, web
spaces between toes, and the folds under
breasts or an abdominal panniculus.
Condyloma lata
Condyloma lata
 Mucous patches
Dull erythematous plaques with
grayish slough. Mucous patches are
white-to yellow erosions on the
tongue that efface lingual papillae.
Confluence of mucous patches on
the tongue has been termed
plaques fauches en prairie. Mucous
patches can be present elsewhere in
the oral cavity, on other mucous
membranes, or at the corners of the
mouth, where they appear as “split
papules,” with an erosion traversing
the center. Mucous patches are
teeming with spirochetes and,
hence, highly infectious.
Mucous patches
Mucous patches
Mucous patches
Malignant syphilide: pustular, necrotic, and rupioid
lesions may be seen in immunocompromised patients.
 NONSCARRING ALOPECIA

 described as “moth-
eaten” or, less
commonly, a diffuse
alopecia of the scalp.
Loss of lateral third of
the eyebrows can occur.
 Pigmentary changes

 (leukoderma colli
syphiliticum or, if on the
neck, “necklace of
Venus”) can result from
inhibition of
melanogenesis.
 SECONDARY SYPHILIS
 Patients with secondary syphilis can experience systemic
symptoms that include (in roughly descending order of
prevalence) sore throat, malaise, headache, weight loss, fever,
musculoskeletal aches, visual disturbances, and hoarseness.
Pharyngitis and tonsillitis, laryngitis, uveitis, gastritis, hepatitis,
renal disease (membranous glomerulopathy), and periostitis
have all been reported in secondary syphilis, as have
hematologicabnormalities including lymphopenia, anemia, and
elevated erythrocyte sedimentation rate.
 Without treatment, the secondary stage typically recedes in 4–
12 weeks. Scarring typically does not occur.
 LYMPHADENOPATHY

 Generalized, symmetrical, and rubbery lymphadenopathy.

Axillary, cervical, and inguinal groups invariably enlarged.
Lymph node groups like suboccipital, posterior cervical, and
epitrochlear which are normally not enlarged in other
diseases may also be enlarged, so a diagnostic clue.
 SYSTEMIC INVOLVEMENT SS

 Musculoskeletal system: Periostitis and arthritis

 Ocular: Iridocyclitis, uveitis, and choroidoretinitis.
 Renal: Nephrotic syndrome due to an immune complex
glomerulonephritis.
 Central nervous system: Cerebrospinal fluid abnormalities.
 TERTIARY SYPHILIS

 may occur approximately 3 to 15 years after the initial

infection, and may be divided into three different
forms: gummatous syphilis, late neurosyphilis, and
cardiovascular syphilis.
 Without treatment, a third of infected people develop
tertiary disease.
 People with tertiary syphilis are not infectious.
 GUMMATOUS SYPHILIS

 or late benign syphilis usually occurs 2 to 46 years after the initial

infection, with an average of 15 years. This stage is characterized
by the formation of chronic gummas, which are soft, tumor-like
balls of inflammation which may vary considerably in size. They
typically affect the skin, bone, and liver, but can occur anywhere,
may diffusely infiltrate an organ or tissue; they grow and heal
slowly and leave scars. 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 including neurological
disorders or heart valve disease.
GUMMATOUS SYPHILIS
GUMMATOUS SYPHILIS
 NEUROSYPHILIS
 refers to an infection involving the central nervous system. It
may occur early, being either asymptomatic or in the form of
syphilitic meningitis, or late as meningovascular syphilis,
general paresis, or tabes dorsalis, which is associated with
poor balance and lightning pains in the lower extremities.
Late neurosyphilis typically occurs 4 to 25 years after the
initial infection. Meningovascular syphilis typically presents
with apathy and seizure, and general paresis with dementia
and tabes dorsalis.
 CARDIOVASCULAR SYPHILIS

usually manifests 10 to 25 years after the initial infection as

aneurysmal dilation of the ascending aorta, insufficiency of the
aortic valve, or narrowing of the coronary arteries. Pulsations of
the dilated aorta may cause symptoms by compressing or
eroding adjacent structures in the chest. Symptoms include
brassy cough, and obstruction of breathing due to pressure on
the trachea, hoarseness due to vocal cord paralysis resulting
from compression of the left laryngeal nerve, and painful erosion
of the sternum and ribs or spine.
insufficiency of the aortic valve
ANEURYSMAL DILATION OF THE
ASCENDING AORTA
ANEURYSMAL DILATION OF THE
ASCENDING AORTA
 LATENT SYPHILIS

 is the stage of syphilis where there is persistent seroreactivity

in the absence of any clinical evidence of syphilis. It is further
described as either early (less than 2 year after secondary
syphilis) or late (more than 2 year after secondary syphilis) and
latent syphilis of unknown duration. Early latent syphilis may
have a relapse of symptoms. Late latent syphilis is
asymptomatic, and not as contagious as early latent syphilis.
 Clinical management of patients with late latent syphilis and
latent syphilis of unknown duration is identical and differs from
clinical management of patients with early latent syphilis.
 LATENT SYPHILIS
Early latent syphilis can be diagnosed if, within the year preceding
discovery of the reactive serologic test, a person had one of the
following:
 1. Documented seroconversion or fourfold or greater increase in
titer of a nontreponemal test;
 2. Unequivocal symptoms of primary or secondary syphilis;
 3. A sex partner documented to have primary, secondary, or
early latent syphilis;
 4. Reactive nontreponemal and treponemal tests from a person
whose only possible exposure occurred within the previous 12
months.
 CONGENITAL SYPHILIS

 syphilis is syphilis present in utero and at birth, and occurs

when a child is born to a mother with syphilis. Some infants
with congenital syphilis have symptoms at birth, but many
develop symptoms later. Newborns will typically not develop a
primary syphilitic chancre, but may present with signs of
secondary syphilis (i.e. generalized body rash).
 Rarely, the symptoms of syphilis go unseen in infants so that
they develop the symptoms of latent syphilis, including damage
to their bones, teeth, eyes, ears, and brain.
 CLASSIFICATION OF CONGENITAL
SYPHILIS

 Early congenital syphilis . By

definition, early congenital
syphilis occurs in children
between 0 and 2 years old.
 Late congenital syphilis is a
subset of cases of congenital
syphilis. By definition, it occurs
in children at or greater than 2
years of age who acquired the
infection trans-placentally.
 EARLY CONGENITAL SYPHILIS
 Failure to gain weight or failure to thrive, fever, irritability
 Rinitis, snuffles, aka "syphilitic rhinitis", which appears similar to the
rhinitis of the common cold, except it is more severe, lasts longer,
often involves bloody rhinorrhea, and is often associated with
laryngitis.
 Rash and infiltration of the mouth, genitals, and anus
 Rash -- starting as small blisters on the palms and soles, and later
changing to copper-colored, flat or bumpy rash on the face, palms,
and soles
 Skeletal lesions: Osteochondritis, osteomyelitis (diaphyseal),
periostitis. Osteochondritis occurs at metaphysis, widens the zone of
provisional calcification until there is epiphyseal separation (usually
before age 3 moths). X-ray shows lucent metaphyseal band. It heals
after 6 months of age.
EARLY CONGENITAL SYPHILIS

blisters on the palms and soles

RINITIS
 LATE CONGENITAL SYPHILIS

 Frequently-found group
of symptoms is
Hutchinson's triad, which
consists of Hutchinson's
teeth (notched incisors),
keratitis and deafness and
occurs in 63% of cases.
 Hutchinson's teeth

 Blunted upper incisor teeth known

as Hutchinson's teeth. Patients
with this have teeth that are
smaller and more widely spaced
than normal and which have
notches on their biting surfaces.
 It is named after Sir Jonathan
Hutchinson, an English surgeon
and pathologist, who first
described them. Hutchinson's
teeth form part of Hutchinson's
triad.
 HUTCHINSON'S TRIAD

 Inflammation of the cornea known as interstitial

keratitis. Keratitis is a condition in which the eye's
cornea, the front part of the eye, becomes inflamed.
The condition is often marked by moderate to intense
pain and usually involves any of the following
symptoms: pain, impaired eyesight, photophobia, red
eye and a 'gritty' sensation
 Deafness from auditory nerve disease.
 LATE CONGENITAL SYPHILIS
 Less the symptoms can be:
 Frontal bossing (prominence of the brow ridge)
 Saddle nose (collapse of the bony part of nose). It is characterized by
a loss of height of the nose, because of the collapse of the bridge.
The depressed nasal dorsum may involve bony, cartilaginous or both
bony and cartilaginous components of nasal dorsum.
 Hard palate defect
 Swollen knees
 Saber shins. Saber shin is a malformation of the tibia. It presents as a
sharp anterior bowing of the tibia. The Saber shin is a sharp-edged
anteriorly convex tibia.
 Short maxillae
 Protruding mandible
SABER SHINS
FRONTAL BOSSING
SADDLE NOSE
 DIAGNOSIS
 Blood tests are divided into nontreponemal and treponemal
tests.
 Neurosyphilis is diagnosed by finding high numbers of
leukocytes (predominately lymphocytes) and high protein
levels in the cerebrospinal fluid in the setting of a known
syphilis infection.
 Darkfield microscopy directs light obliquely through a slide of
exudate from a chancre or lymph node aspirate to directly
visualize spirochetes. Although the skills and equipment
required are not usually available, darkfield microscopy is a
specific test for early primary syphilis.
 Nontreponemal tests

 are used initially, and include venereal disease research

laboratory (VDRL) and rapid plasma reagin tests. However, as
these tests are occasionally false positives, confirmation is
required with a treponemal test, such as treponemal pallidum
particle agglutination (TPHA) or fluorescent treponemal
antibody absorption test (FTA-Abs), chemoluminescence
immunoassays (CLIA). False positives on the nontreponemal
tests can occur with some viral infections such as varicella and
measles, as well as with lymphoma, tuberculosis, malaria,
endocarditis, connective tissue disease, and pregnancy.
 TREPONEMAL TESTS

 detect antitreponemal antibodies qualitatively and are very

specific for syphilis. Neither reaginic nor treponemal tests
become positive until 3 to 6 wks. after the initial infection.
Thus, a negative result is common in early primary syphilis
and does not exclude syphilis until after 6 wk. Reaginic
titers decline after effective treatment, becoming negative
by 1 yr in primary and by 2 yr in secondary syphilis.
Treponemal tests usually remain positive for many decades,
despite effective treatment and thus cannot be used to
assess effectiveness.
 TREATMENT

 The first-choice treatment for uncomplicated syphilis remains a single dose of

intramuscular benzathine penicillin G.
 Doxycycline and tetracycline are alternative choices for those allergic to penicillin;
however, due to the risk of birth defects these are not recommended for pregnant
women. Resistance to macrolides, rifampin, and clindamycin is often present. Ceftriaxone,
a third-generation cephalosporin antibiotic, may be as effective as penicillin-based
treatment. It is recommended that a treated person avoid sex until the sores are healed.
 Late infections. For neurosyphilis, due to the poor penetration of penicillin G into the
central nervous system, those affected are recommended to be given large doses of
intravenous penicillin.
 If a person is allergic, ceftriaxone may be used or penicillin desensitization attempted.
Other late presentations may be treated with once-weekly intramuscular penicillin G for
three weeks. If allergic, as in the case of early disease, doxycycline or tetracycline may be
used, albeit for a longer duration. Treatment at this stage limits further progression, but
has only slight effect on damage which has already occurred.
POSTTREATMENT SURVEILLANCE

 After treatment, patients should have examinations

and reaginic tests at 3, 6, and 12 mo and annually
thereafter until the test is nonreactive. For
neurosyphilis, CSF testing every 6 mo until CSF cell
count is normal.