Syphilis

Question 1

Definition

Answer 1

STI caused by spirochete (meaning ‘spiral-shaped’) bacterium Treponema pallidum

Question 2

Clinical stages of syphilis

Answer 2

• Incubation and primary syphilis
• Secondary syphilis
• Latent syphilis
• Tertiary syphilis

Question 3

Incubation and primary syphilis

Answer 3

Aquired by:
= direct contact with active syphilitic lesion.
= Vertically across placenta causing foetal/congenital infection
Intubation:
- Once acquired, T. pallidum penetrates skin and enters subcutaneous tissues, where it incubates 9 - 90 days, before producing the symptoms of primary pyphilis

Question 4

Secondary syphilis

Answer 4

Initial infection cleared by host immune responses and the chancre disappears
However, within 6 months homogeneous dissemination of the bacteria causes a syndrome of systemic features = 2’ syphilis
- Widespread rash
- Wart-like lesions
- Constitutional symptoms

Question 5

Latent syphilis

Answer 5

Resolution of syphilis over a period of weeks
Two stages of latent syphilis:
- Early latent syphilis: ASx and +ve serology within 2 years of infection
- Late latent syphilis: ASx and +ve serology and beyond 2 years of infection
Px infective in ELS but not in LLS
1/3 of Px go into tertiary
1/4 may relapse and develop Sx of secondary syphilis

Question 6

Tertiary syphilis

Answer 6

End-organ damage as a result of syphilis infection. This occurs as three main clinical entities:
- Neurosyphilis
- Cardiovascular syphilis
- Gummatous syphilis

Question 7

Epidemiology

Answer 7

Men who have sex with men
IV drug users
Sex workers
Multiple sexual partners and the presence of other STI’s

Question 8

Primary syphilis Signs

Answer 8

Femoral lympadenopathy

Question 9

Primary Syphilis Symptoms

Answer 9

• A single chancre (painless ulcer), usually on the genital
• Occasionally the chancre appears on the pharynx, anus or intravaginally
• Multiple chancres: rare, more likely if HIV positive

Question 10

Secondary syphilis signs

Answer 10

• Diffuse maculopapular rash affecting palms and soles, this is the classic presenting feature
• Patchy oral ulceration (‘snail track ulcers’)
• Condylomata lata: wart-like lesions at site of skin friction e.g. perianal, vulval, submammary, axillary
• Patchy alopecia: ‘moth-eaten’ appearance
• Generalised lymphadenopathy (non-tender)

Question 11

Secondary syphilis symptoms

Answer 11

Fever
Headaches

Question 12

Neurosyphilis S+S

Answer 12

• Meningovascular syphilis: stroke due to arteritis
• Argyll-Robertson pupil: constricts to accommodation, but not to light
• General paralysis of the insane: loss of intellect, insight and memory, with spastic paresis and delusions changes in personality
• Tabes dorsalis: inflammation and degeneration of spinal dorsal columns

Question 13

Cardiovascular syphilis S+S

Answer 13

• Aortic aneurysm
• Aortic regurg
• Coronary ostia stenosis -> angina and heart failure
• Conduction defects

Question 14

Gummatous syphilis

Answer 14

• Gumma: a nodule or nodulo-ulcer that heals with central scarring (but remains active in the periphery
• Gummata: Commonly occur on skin but can occur on any organ
• Bony gummata: cause bone destruction
• Gummata in other organs

Question 15

Diagnosis

Answer 15

ASx Px:
- FIRST LINE: Treponemal-specific antibody test:(usually EIA)
- If +ve = cofirmatory treponemal test (TPPA/TPHA) and non-treponemal test (RPR/VDLR) should be performed.
Sx Px:
- Full syphilis serology screen (EIA, TPPA, RPR)
- Swabs of active ulceration lesions for PCR and microscopy
‘ DARK-GROUND MICRSCOPY’ = Spiral-shaped rods

Question 16

Investigations to consider

Answer 16

HIV test
Screening test for other STIs
MRI/CT + LP = if neurophilis suspected
ECG and echo = of cardiovascular syphilis suspected

Question 17

Treatment

Answer 17

FIRST LINE:
- Early syphilis (primary, secondary, early latent): single dose IM BENZATHINE BENZYLPENICILLIN
- Late latent and gummatous syphilis : 3 doses of IM BENZATHINE BENZYLPENICILLIN once weekly for 3 weeks
- Cardiovascular syphilis : 3 days of oral PREDNISOLON and 3 once-weekly doses of BENZATHINE BENZYLPENICILLIN
Neurosyphilis syphilis : 14 days of IM PROCAINE PENICILLIN and oral PROBENECID

Question 18

Second line if Px allergic to penicillin

Answer 18

Oral doxycyline

Question 19

Partner notification

Answer 19

Primary syphilis : all partners in the last 3 months
Secondary/early latent syphilis : all partners in the last 2 years
Late latent or tertiary syphilis : case-by-case basis as determined by staging of the disease

Question 20

Congenital syphilis

Answer 20

IV benzylpenicillin ( not benzathine penicillin) for 10 days

Question 21

Complications

Answer 21

Tertiary syphilis
HIV
Jarisch-Herxheimer reaction:
Reaction to toxins released from bacteria when they are killed by antibiotics
Occurs 1-3 hours after the initial dose
Usually causes constitutional symptoms (fever, headache, myalgia)
There is no wheeze or hypotension, unlike in anaphylaxis
Manage with oral fluids and analgesia