Unit 7.1 SYPHILIS
What Nontreponemal tests are available on the market today?
-*Veneral Disease Research Laboratory (VDRL)* -*Rapid plasma reagin (RPR)* -Unheated serum reagin (USR) -Toluidine red unheated serum test (TRUST)
What are some factors that can lead to a false positive nontreponomal serologic test?
-Advanced age -Immunizations -Rheumatoid arthritis -Chickenpox -Hepatitis -Pregnancy -Systemic Lupus
What is the primary treatment and followup for neurosyphilis and ocular syphilis?
-Aqueous PCN G 18-24 million units IM for 10-14 days -May be administered as CI or every 4hrs -Follow-up with CSF exam until cell counts are normal
What is the primary treatment and followup for primary, secondary, and early latent syphilis?
-Benzathine PCN 2.4million units IM x 1 dose -Follow up serology at 6 and 11 months for primary and secondary syphilis) -Follow up serology at 6, 12, and 24 months for early latent syphilis
What is the primary treatment and followup for late latent, tertiary syphilis?
-Benzathine PCN G 2.4million units IM x 3 doses at 1 week intervals -Follow-up with serology at 6, 12, and 24months
What are the clinical manifestations of Tertiary (late) syphilis?
-Cardiovascular syphilis (endocarditis) -Gummatous lesions (Nonspecific granulomatous lesions that infiltrates skin, bone, and soft tissue) -Can be found in any organ
What is the purpose of Microscopy in the diagnosis of Syphilis?
-Darkfield microscopy tests sample directly from lesion exudate or tissue and looks for T. Pallidum morphology and motility
What are the advantages of Microscopy in the diagnosis of syphilis?
-Definitive immediate diagnosis -Rapid results -May be useful in early disease
What is the primary treatment and followup for pregnant patients with syphilis?
-Desensitize patient and use penicillin G.
What is the primary treatment and followup for primary, secondary, and early latent syphilis with allergy to penicillin?
-Doxycycline 100mg PO BID x 14 days OR -Ceftriazone 2g IM/OV daily for 10-14days -Follow up serology performed at 6, 12, and 24 months
What is the primary treatment and followup for late latent, tertiary syphilis with a penicillin allergy?
-Doxycycline 100mg PO BID x 28 days -Follow up serology performed at 6, 12, and 24 months
What are the two categories of the latent stage of syphilis?
-Early latent: <1 year duration -Late latent: >= 1 year duration
What are some disadvantages of nontreponemal serologic tests?
-False positive reactions do occur (therefore a confirmatory test is extremely important. The confirmatory test at a point is the treponemal serologic test)
What are some treponemal serologic tests available?
-Fluorescent treponemal antibody absorption (FTA-ABS) -T.Pallidum agglutination assay (TPPA - lookds at when serum is added to the reagent, does it clump? if it clumps then it's a positive test) -T.Pallidum hemagglutination assay (TPHA)
Lat onset neurosyphilis manifests as?
-General paresis -Tabes Dorsalis (process of progressive muscle weakness, gait abnormalities, complaints of all of a sudden lightning shooting pain, or you can get loss of coordination reflex) -Ocular involvement
What is the primary way to monitor a clinical response to syphilis treatment?
-Ideally a 4-fold reduction in RPR(Rapid plasma reagin- nontreponemal serologic test) titer suggests a clinical response
Early onset neurosyphilis manifests as?
-Meningitis -Ophthalmic involvement (conjunctivitis to retinitis) -Stroke -Cranial nerve dysfunction -Altered mental status
What are the two types of serology tests used when diagnosing syphilis?
-Nontreponemal (qualitative and quantitative report) -Treponemal (qualitative report)
How soon after initation of syphilis treatment does the Jarisch-Herxheimer reaction occur?
-Occurs within 24hours after initiation of syphilis therapy (especially in patients with primary and secondary disease where there's a high bacterial burden of the organism)
When is a patient infected with syphilis indicated for a CSF examination?
-Patients with syphilis (reactive serologic test) who demonstrate any of the following: (Neurologic or ophthalmic signs/symptoms, evidence of tertiary disease, i.e. gummatous lesions, treatment failure, i.e rise in titer) those patients will be indicated for a CSF examination
What physical characteristics define the first stage of syphilis?
-Primary syphilis a.k.a stage 1 is characterized by the appearance of a single chancre, but there may be multiple sores. The Chancre is usually but not always, firm, round, and painless. It appears at the location where syphilis first entered the body. These painless Chancres can occur in locations that make them difficult to notice (e.g. the vagina or anus).
What are the most common clinical manifestations of the secondary stage of syphilis?
-Rash (Most common 75-100%) -Lymphadenpathy (50-86%) -Malaise -Condylomata lata (10-20%) -Alopecia (5%) -Might see liver and kidney involvement (rare)
What are the disadvantages of Microscopy in the diagnosis of syphilis?
-Requires specialized equipment -Must be performed immediately -Not recommended for all lesions
When do secondary lesions associated with secondary syphilis occur?
-Secondary lesions occur several weeks after the primary chancre. Mucocutaneous lesions are the most common due to the hematogenous spread of the infection
What test is the mainstay in diagnosing syphilis?
-Serology tests
What are some important characteristics of Treponema pallidum, the causative organism of Syphilis?
-Spirochete - corkscrew shape -Obligate parasite (needs to be within the human host in order to survive -Microaerophilic and difficult to grow -It can only be viewed by a dark field microscope
What are the different stages of Syphilis and when do they occur?
-Stage 1 (occurs 3-90 days after exposure) -Stage 2 (occurs 4-10 weeks after initial infection) -Stage 3 (occurs 3-15 years after initial infection)
What are the main characteristics of neurosyphilis?
-Syphilis can invade the nervous system at any stage of infection and cause a wide range of symptoms, including headache, altered behavior, difficulty coordinating muscle movements, paralysis, sensory deficits, and dementia. -Approximately 40% of patients with primary or secondary syphilis will have CSF abnormalities -Persistence of these abnormalities is associated with greater risk of progression
Syphillis development is divided into stages (primary, secondary, latent, and tertiary), during which stages is Syphilis the most contagious?
-Syphilis is most contagious to sex partners during primary and secondary stages
How is syphilis acquired?
-Syphilis is sexually transmitted (can be vaginal, anal, or oral transmission)
What are the primary characteristics of Tertiary (late) syphilis?
-Tertiary syphilis is rare and develops in a subset of untreated syphilis infections; it can appear 10-30 years after infection was first acquired and it can be fatal. -*30% of untreated patients can progress to tertiary stage* -It's uncommon today because of access to antimicrobial therapy -Tertiary syphilis can affect multiple organ systems, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Symptoms of tertiary syphilis vary depending on the organ system affected
What is the primary characteristic of latent syphilis?
-The Latent(Hidden) stage of syphilis is a period of time when the host suppresses the infection, but no lesions are clinically apparent. In other words, during this period there are no visible signs or symptoms of syphilis. *Despite immune response, the organism is able to evade clearance*
In what way can we confirm that a person has a latent syphilis infection?
-The only evidence of infection during this stage is a positive serologic (blood) test
What is the purpose of nontreponemal serologic tests?
-These tests measure antibodies directed against a cardiolipin-lecithin-cholesterol antigen. The host infected with syphilis produces IgM and IgG antibodies against lipoidal material released from damaged host cells and possibly cardiolipin released from treponemes
What are some advantages to using nontreponemal serologic tests?
-They are inexpensive and easy to perform -They may detect any stage of syphilis
What is the primary causative organism of syphilis?
-Treponema pallidum
What is the purpose of treponemal serologic tests for diagnosing syphilis?
-Treponemal serologic tests measures antibody directed against T. Palidum antigens and it's *qualitative only* (meaning it's either positive or nah) -Treponemal serologic test can serve as a confirmatory test
What are some indications of failure of therapy in patients being treated for syphilis?
Early or secondary failure -Persistence of symptoms -4-fold increase in titers Latent failure -4-fold increase in RPR titer -High titer (>=1:32) fails to decline 4-fold within 1-2years -Signs/symptoms of syphilis
True or false? It's important to use only one type of serologic test when diagnosing syphilis?
False The use of only one type of serologic test is insufficient for diagnosis. Both need to be used to confirm that disease is there. Typically, a non-treponemal test will be ordered and if it's reactive, then a reflex to a treponemal is automatic
True or false? The rashes associated with the secondary stage of syphilis always cause an immense amount of itching?
False. The rash doesn't usually cause any itching
True or false? Once the Chancre from the primary stage of Syphilis spontaneously heals, the individual is clear of the infection?
False. If the infected person doesn't receive adequate treatment, the infection will progress to the secondary stage
True or false? The nontreponemal serologic tests are highly specific for T. Pallidum>
False. Nontreponemal tests are not specific for T. Pallidum
True or false? The result of the nontreponemal serologic tests are always qualitative only?
False. Results can be reported qualitatively (reactive or nah) or quantitatively (eg: 1:16)
True or false? The skin rashes associated with the secondary stage of syphilis only appear when the primary chancre is finished healing?
False. Skin rashes and/or mucous membrane lesions (sores in the mouth, vagina, or anus_ mark the second stage of symptoms. And these rashes associated with secondary syphilis can appear when the primary chancre is healing or several weeks after the chancre has healed
True or false? During the latent stage, since no further symptoms are present, patients don't need to seek further medical treatment?
False. Without treatment, the infected person will continue to have syphilis in their body even though there are no signs or symptoms. Approximately 30% progress to neurosyphilis or tertiary syphilis (if the infection remains untreated)
In addition to rashes, what other symptoms may be associated with the secondary stage of syphilis?
In addition to rashes, symptoms of secondary syphilis may include fever, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.
What is one common reaction patients on treatment for syphilis will experience?
Jarisch-Herxheimer reaction characterized by: -Headache -Myalgia -Fever
How does T. Pallidum enter the human body?
T.Pallidum enters the body via skin and mucous membrane abrasions that occur during sexual contact. Approximately 1/3 of patients exposed develop disease. -T. Pallidum then invades intracellular junction of the endothelium, resulting in hematogenous (through the blood) spread and seeding in multiple organs (including the CNS)
True or false? The symptoms of secondary syphilis will go away with or without treatment, and at this stage, patients don't need to seek further medical treatment?
TFalse. Deflee false. The lesions will disappear in 4-10 weeks, but without treatment, the infection will continue to progress to latent and possibly tertiary stage of disease (u tryna die?)
True or false? Jarisch-Hersheimer reaction to syphilis treatment is self-limiting, but symptoms may be treated with antipyretics?
True
True or false? Neurosyphilis can occur during any stage of syphilis and can be asymptomatic?
True
True or false? Syphilis can be passed on from a mother to her newborn?
True
True or false? The Chancre that develops during the primary stage of Syphilis lasts about 3-6weeks and heals spontaneously regardless of whether a person is treated or not?
True
True or false? VDRL is the only test for detecting CNS syphilis disease?
True
True or false? Patients are usually reactive for life to the treponemal serologic assays?
True Patients are reactive for life regardless of treatment