3. Overview
ā¢ History of Syphilis.
ā¢ Transmission pathogenesis and stages of syphilis.
ā¢ Diagnostic tests.
ā¢ Treatment and partner management.
ā¢ Epidemiology.
4. The great pox
ā¢ Epidemic in 15 century Europe.
ā¢ Rapid spread and served symptoms in early stages.
ā¢ Epidemic coincide with Columbus return from america in
1493.
ā¢ Endemic but unrecognized.
ā¢ A gift from new world.
5. Syphilis Discovery of its causes
ā¢ 1903: Infection successfully transmitted to
monkeys.
ā¢ 1905: Identification of the bacterium Treponema
pallidum.
ā¢ 1906: Dark field microscopy.
11. Method of Infection
ā¢ Viable bacteria from chancre enter through the fissure or
mucous membrane.
ā¢ Bacteria multiply locally and causes painless chancre.
ā¢ Spared via blood stream and lymphatic system.
ā¢ Can almost infect many organ and tissue.
ā¢ Continuous in vitro culture yet Not to be achieved.
12.
13. Symptoms
(some have no symptoms for years)
ā¢ 3 Stages:
ļ¼ Primary
ļ¼ Secondary
ļ¼ Late or latent
ā¢ Congenital (passed from a mother to her child)
14. Pathogenesis
ā¢ Multiple at the site of inoculation and form chancre.
ā¢ Spread to local lymph nodes and then to blood
stream.
ā¢ Can involve of many body organs.
ā¢ Infection and inflammation of blood vessels.
15. Primary Stage
ā¢ Appearance of a single sore or chancre (about 21 day
after infection).
ā¢ Chancre lasts 3-6 weeks and heal by treatments.
ā¢ If untreated disease progress to next stage.
16. Secondary stage
ā¢ Occur as chancre is healing or few weeks after.
ā¢ Skin rash developed on one or more areas.
ā¢ appear like other disease (usually doesnāt cause itching).
ā¢ Other symptoms: fever, swollen lymph gland, sore throat,
patchy hair loss, headaches, weight loss.
ā¢ Without treatment disease progress to next late stage.
17. Late stage
(Hidden stage)
ā¢ Person continues to have syphilis even through they
are no symptoms.
ā¢ Disease can damage eyes, brain, nervous system,
liver, bones, joints.
ā¢ Sign include: difficulty coordinating muscle
movement, paralysis, numbness, gradual blindness,
even death.
22. Treponemal Tests
ā¢ Specific for T. pallidum
ā¢ Measure antibody (IgM & IgG) directed against T.
pallidum antigens by particulate agglutination (TP-
PA) or immunofluorescence (FTA-abs)
ā¢ May remain positive after treatment
ā¢ More sensitive and specific than non-trep. tests
ā¢ More expensive and labour intensive
ā¢ Can not quantitateā¦not useful for following response
to treatment
24. Non-Treponemal Tests
ā¢ VDRL and RPR are most commonly used.
ā¢ Detect Abs against cardiolipin-lecithin-cholesterol
antigens; not specific for T. pallidum.
25. Uses of Non-Treponemal Tests
ā¢ Screening.
ā¢ Evaluation of patients with symptoms or possible re-
infection.
ā¢ Follow-up assessment after treatment.
27. Non-Treponemal Tests
Advantages
ā¢ Rapid & inexpensive compared to treponemal tests.
ā¢ Easy to perform.
ā¢ Quantitative (can be tittered)
ā¢ Used to follow response to therapy.
ā¢ Can evaluate possible reinfection.
28. Non-Treponemal Tests
Disadvantages
ā¢ Biological false positive reactions (BFPs).
ā¢ Viral illnesses including HIV, recent immunizations, IDU,
autoimmune and chronic diseases.
ā¢ False negative reactions.
ā¢ Prozone effect.
ā¢ Early primary and late latent stages.
29. Sensitivity of Serologic Tests
According to Stage
ā¢ Test 1 2 Latent Tertiary
ā¢ VDRL/RPR 74-87% 100% 88-100% 37-94%
ā¢ FTA-ABS 70-100% 100% 100% 96%
ā¢ MHA-TP* 69-90% 100% 97-100% 94%
ā¢ *MHA-TP and TP-PA probably perform equivalently.
30. Serologic Pitfalls
in the Diagnosis of Syphilis
ā¢ Negative nontreponemal test may occur early in primary
or late in tertiary - check FTA-ABS or TP-PA.
ā¢ Prozone phenomenon: false negative due to lack of
agglutination with high antibody levels.
ā¢ Serofast: persistent, low-level positive titre after adequate
treatment.
32. Treatment of Penicillin G
ā¢ Intravenous or intramuscular injection of penicillin G
is the preferred drug for treatment of all stages of
syphilis
ā¢ Benzathine penicillin G, aqueous procaine penicillin
or aqueous crystalline penicillin can be used
33. Syphilis Resistant to
Azithromycin?
ā¢ In San Francisco, the frequency of azithromycin-resistant T. pallidum
isolates increased from 4% during 2000ā2002 to 37% during 2003.
ā¢ San Francisco STD clinic discontinued use of azithromycin for treating
syphilis infection.
ā¢ Notified San Francisco medical providers of azithromycin treatment
failures.
ā¢ Recommendation to use Benzathine penicillin G.
ā¢ Doxycycline as alternative in PCN-intolerant.
ā¢ National notification via MMWR.
34. Syphilis: Treatment
in Pregnancy
ā¢ Penicillin is the only adequate form of treatment for
syphilis in pregnancy.
ā¢ Penicillin-allergic patients - Hospitalize, desensitize
& treat with penicillin.
ā¢ Erythromycin is not accepted as alternative drug in
penicillin-allergic patients.
35. Management of Contacts
ā¢ Contacts to primary, secondary or early latent syphilis.
ā¢ Persons exposed within 90 days preceding the diagnosis
in a sex partner might be infected even if seronegative:
Treat presumptively.
ā¢ Persons exposed >90 days before the diagnosis should be
treated presumptively if serologic tests are unavailable or
follow up is uncertain; if serologic tests are negative no
treatment is needed.
36. Chances Reduction
ā¢ Abstain from sex until treatment is finished and until
partners have been evaluated and treated.
ā¢ Use condoms consistently and correctly.
ā¢ Avoid having sex with partners with genital ulcers/lesions
or rashes.
ā¢ Get check-ups every 6 months if engaging in sex with
more than one sex partner.