Syphilis

Syphilis: Transmission

Transmission The major routes of transmission are sexual and vertical (in utero from an infected pregnant woman via hematogenous spread to her fetus). An infected individual is primarily contagious to sex partners during the primary and secondary stages of infection when infectious lesions or rash are present.

Which of the following is (are) true regarding the progression of syphilis? a. The most common clinical manifestation of primary syphilis is a chancre at the site of inoculation. b. The primary syphilis chancre is highly infectious and it resolves without treatment. c. Latent syphilis may occur between the primary and secondary stages or after the secondary stage. d. Tertiary syphilis is rare. e. All of the above are correct.

All of the above are correct.

Syphilis: At-risk sex partners

At-risk sex partners are determined based on the patient's diagnosed stage of disease. Partners exposed during the following time periods, before the patient receives treatment, should be considered at-risk: Primary: three months plus duration of symptoms Secondary: six months plus duration of symptoms Early latent: one year

Clinical Manifestations and Sequelae Primary Syphilis

Clinical Manifestations and Sequelae Primary Syphilis • The chancre is a major indicator of primary syphilis. Chancres progress from papule to ulcer. The chancre is typically painless, indurated, and has a clean base. It is highly infectious and heals spontaneously within 1 to 6 weeks. Multiple chancres occur in 25% of cases.

Congenital syphilis: manifestations

Congenital syphilis is traditionally classified as either early or late disease. Early manifestations occur within the first two years of life, and late manifestations occur after two years of age. Early manifestations are the most common. Early lesions (in infants <2 years old) • Are usually inflammatory; • May involve skin (can be bullous or exudative) or mucous membranes; • Can result in alopecia, generalized lymphadenopathy, meningitis, osteitis or osteochondritis, and hepatosplenomegaly; and • May include hematologic abnormalities such as thrombocytopenia and anemia.

What confirms the diagnosis of primary syphilis?

Darkfield examination of penile lesion. Identification of T. pallidum on darkfield examination confirms the diagnosis of primary syphilis.

Syphilis: definitive methods for diagnosing early syphilis

Darkfield examinations and direct fluorescent antibody tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis. Serologic tests for syphilis allow for a presumptive diagnosis of syphilis and for following response to therapy. A nontreponemal serologic test must be confirmed by a treponemal serologic test.

Syphilis: Dissemination

Dissemination Before clinical signs or symptoms appear (e.g., during the first hours to days after infection), T. pallidum accesses the circulatory system, including the lymphatic system and regional lymph nodes. Invasion of the central nervous system can occur during any stage of syphilis.

Syphilis:manifestations

Early clinical manifestations (primary and secondary stages) primarily involve the skin and mucosal surfaces, although secondary syphilis is a systemic illness. Latent disease has no clinical signs or symptoms. Late manifestations may affect virtually any organ system, and neurosyphilis can occur at any stage of syphilis.

A patient with no clinical signs or symptoms, a history of a palmar rash six months ago, and a positive serologic test for syphilis (positive nontreponemal test with a positive confirmatory treponemal test) fits the criteria for: Secondary syphilis Early latent syphilis None of the above

Early latent syphilis is correct. The patient fits the criteria for early latent syphilis because of the positive serologic test for syphilis, lack of current clinical manifestations, and history of secondary syphilis symptoms within the past twelve months.

Syphilis: Follow-up titers

Follow-up titers should be compared to the nontreponemal titer obtained on day of treatment. Primary, secondary, and early latent syphilis require quantitative VDRL or RPR at six and 12 months.

For adults with primary, secondary, and early latent syphilis without neurologic involvement, prescribe?

For adults with primary, secondary, and early latent syphilis without neurologic involvement, prescribe Benzathine penicillin G, intramuscularly, 2.4 million units in a single dose.

Syphilis: Nature of the Disease

Nature of the Disease • Syphilis may be symptomatic or asymptomatic. • Because syphilis is a systemic infection, extra-genital symptoms (such as rashes and alopecia) may occur. • Untreated syphilis in pregnancy can lead to death or severe disability in the fetus. • Sequelae of untreated syphilis include neurologic and cardiovascular disorders.

Syphilis: Follow-Up

Patients treated for primary or secondary syphilis should be reexamined clinically and serologically six months and 12 months following treatment. Patients with latent syphilis should be followed up clinically and serologically at six, 12, and 24 months. HIV-infected patients should be evaluated more frequently (i.e., at 3, 6, 9, 12, and 24 months with primary or secondary syphilis; at 6, 12, 18, and 24 months for HIV-infected persons with latent syphilis.

Syphilis: Screening in Pregnant women

Pregnant women should be screened and counseled at least at the first prenatal visit. For communities and populations in which the prevalence of syphilis is high, or for patients at risk, serologic testing should be performed twice during the third trimester, at 28 weeks, and at delivery, in addition to routine early screening. Any woman who gives birth to a stillborn infant after 20 weeks gestation should be tested for syphilis. No infant should leave the hospital without the maternal serologic status having been determined at least once during pregnancy and preferably again at delivery.

Syphilis: Presumptive treatment

Presumptive treatment should be given to those persons who were exposed within the 90 days preceding a sex partner's diagnosis of primary, secondary, or early latent syphilis, because they might be infected, even if seronegative. Persons who were exposed >90 days before a sex partner's diagnosis of primary, secondary, or early latent syphilis should also be treated presumptively if serologic test results are not available immediately and the opportunity for follow-up is uncertain.

Syphilis and HIV

Syphilis and HIV Syphilis and HIV infections commonly coexist. In general, the clinical course of syphilis in HIV-infected patients is similar to that in nonHIV-infected patients.

Syphilis: summary

Syphilis is a systemic, sexually-acquired infection whose etiologic agent is Treponema pallidum (a thin, corkscrew-shaped, motile bacterium). Major routes of transmission are sexual and vertical, and the incubation period is approximately 10 to 90 days. Syphilis was distributed widely throughout the U.S., but declined rapidly with the introduction of penicillin therapy and broad-based public health programs after the 1940s. While the national rate of syphilis declined to a historic low in 2000, rates have since risen, and syphilis remains a public health problem in the U.S..

Syphilis: summary- assessment

The clinician should assess whether the patient has a history of syphilis, known contact to an early case of syphilis, or typical signs or symptoms of syphilis in the past 12 months. This will provide clues as to how long the patient has had the disease and whether or not this is a new infection. A thorough exam includes checking the oral cavity, lymph nodes, skin of torso, palms, and soles, and the genitalia and perianal area for signs of infection. A neurological exam should be completed that concentrates on cranial nerves, including II, VI, VII, and VIII. An abdominal exam for liver tenderness.

The definitive method for diagnosing early syphilis is ?

The definitive method for diagnosing early syphilis is darkfield microscopy tests of lesion exudate or tissue. Darkfield microscopy T. pallidum cannot be viewed by normal light microscopy. Darkfield microscopy can identify T. pallidum with its spiral shape, 10-14 coils, corkscrew motion, and a total length of 6-20 micrometers. Advantages of darkfield microscopy: • Definitive immediate diagnosis (useful in primary and secondary disease) • Rapid results Disadvantages of microscopy: • An experienced microscopist and specialized equipment (often not available outside of a specialized clinic) are required. • Confusion with other pathogenic or nonpathogenic spirochetes may occur. Generally not recommended on oral lesions because of specificity problem with nonpathogenic spirochetes in the oral cavity. • It must be performed immediately because motility is important to identification. The sensitivity of darkfield microscopy decreases as the lesion heals. • Possibility of false-negatives increases with use of topical substances such as soap and water, antibiotic ointments, etc.

Syphilis: Transmission

Transmission • Syphilis is transmitted sexually or vertically (from pregnant mother to fetus). • Syphilis is most infectious during the primary and secondary stages (when lesions or rashes are present). However, lesions may be inapparent. All at-risk sex partners need to be evaluated and possibly treated. • Syphilis is associated with increased susceptibility to HIV acquisition.

Syphilis: Treatment and Follow-Up

Treatment and Follow-Up • If treated with penicillin, the Jarisch-Herxheimer reaction may occur. • Return for follow-up serology at six and 12 months for primary and secondary syphilis for 24 months (every three months, if HIV- positive). • The patient may be "serofast" or have positive treponemal and nontreponemal serologic tests for life.

Tertiary (late) Syphilis (other than neurosyphilis)

Without treatment, approximately 30% of patients progress to the tertiary stage within 1 to 20 years of infection. Yet, tertiary syphilis is rare because of widespread availability and use of antibiotics. • Gummatous lesions may occur in skeletal, spinal, and mucosal areas, eyes, and viscera (lung, stomach, liver, genitals, breast, brain, and heart). The destructive lesions can clinically mimic carcinoma. The average onset is 10-15 years after infection. • Cardiovascular syphilis is indicated by pathologic lesions of the aortic vasovasorum. It clinically presents as ascending aortic aneurysm, aortic insufficiency, or coronary ostial stenosis. The average appearance is about 20-30 years after infection.

The risk of transmission to the fetus is highest during which stage(s) of syphilis? a. Primary and secondary b. Late c. latent d. Early latent e. The risk is the same regardless of the stage of disease.

a. Primary and secondary

What is the appropriate treatment for diagnosis of primary syphilis? a) Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units intramuscularly each at one-week intervals b) Benzathine penicillin G 2.4 million units intramuscularly in a single dose c) If penicillin allergic, use vancomycin 250 mg orally four times a day for ten days plus rifampin 600 mg orally twice a day d) b or c

b) Benzathine penicillin G 2.4 million units intramuscularly in a single dose

Which of the following are true about syphilis in the U.S.? a. Recent syphilis outbreaks have occurred in MSM subpopulations. b. P&S syphilis rates reached an all-time low in 2000. c. P&S syphilis is widespread throughout the United States. d. Syphilis disproportionately affects African Americans. e. All of the above are true.

e. All of the above are true.

Adults therapy: Neurosyphilis

Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units intravenously every four hours or continuous infusion for 10-14 days intravenously Alternative regimen (if compliance can be ensured): Procaine penicillin 2.4 million units intramuscularly once daily plus Probenecid 500 mg orally four times a day, both for 10-14 days

Syphilis: Partner Management

Partner Management and Public Health Measures Sexual transmission of T. pallidum occurs only when mucocutaneous syphilitic lesions are present; such manifestations are uncommon after the first year of infection. However, these lesions may be clinically inapparent. Persons sexually exposed to a person with syphilis in any stage should be evaluated clinically and serologically.

Syphilis: partner management

Partners within 90 days prior to the onset of primary symptoms should be evaluated for syphilis. Even if results are negative, they should be treated prophylactically for syphilis.

Syphilis: Pathogenesis and Microbiology

Pathogenesis and Microbiology The etiologic agent of syphilis is Treponema pallidum, subspecies pallidum. It is a corkscrew-shaped, motile microaerophilic bacterium that cannot be cultured in vitro.

Syphilis: Penetration

Penetration T. pallidum enters the body via skin and mucous membranes through macroscopic and microscopic abrasions during sexual contact. It may also be transmitted transplacentally from mother to fetus during pregnancy.

Physical Examination

Physical Examination A thorough exam includes checking the oral cavity, lymph nodes, skin of torso, palms and soles, and the genitalia and perianal area for signs of infection. A pelvic examination should be conducted on female patients. A neurologic exam should be completed that concentrates on cranial nerves including II (optic), III (oculomotor), VI, VII (facial), and VIII (auditory). An abdominal exam should be performed for liver tenderness.

Which of the following is not a sign of secondary syphilis? Alopecia Chancre at the site of inoculation Condyloma lata Palmar/plantar rash Papulosquamous rash

Chancre at the site of inoculation. A chancre at the site of inoculation is an indication of primary syphilis.

Adults therapy: Late latent or latent syphilis

Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units intramuscularly each at one-week intervals If penicillin allergic (one of the following): Doxycycline 100 mg orally twice daily for 28 days Tetracycline 500 mg orally four times daily for 28 days

Adults therapy: Tertiary syphilis without neurologic involvement:

Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units intramuscularly each at one-week intervals If penicillin allergic: Treat according to treatment for late latent syphilis.

Adults therapy: Primary, secondary, and early latent syphilis without neurologic involvement:

Benzathine penicillin G, intramuscularly, 2.4 million units in a single dose If penicillin allergic (one of the following): Doxycycline 100 mg orally twice daily for two weeks Tetracycline 500 mg orally four times daily for two weeks

Congenital Syphilis

Congenital syphilis occurs when T. pallidum is transmitted from a pregnant woman with syphilis to her fetus. Untreated syphilis during pregnancy may lead to stillbirth, neonatal death, and infant disorders such as deafness, neurologic impairment, and bone deformities. Transmission to the fetus in pregnancy can occur during any stage of syphilis, but the risk is much higher when a pregnant woman is in the primary or secondary stage of syphilis. Fetal infection can occur during any trimester of pregnancy. A wide spectrum of severity exists, and only severe cases are clinically apparent at birth.

Syphilis: summary

In primary syphilis, a chancre occurs at the site of inoculation. The chancre is typically painless, indurated, has a clean base and resolves without treatment. A rash occurs in 75%-90% of secondary syphilis cases. Any new onset macular, papular, or squamous rash should be evaluated to rule out secondary syphilis. Generalized lymphadenopathy and malaise are usually present. Tertiary (late) syphilis is rare, but may include gummatous lesions or endarteritis of the aortic vasovasorum. Neurosyphilis can be with or without symptoms, and can occur at any stage.

Latent Syphilis: A positive serologic test

Latent Syphilis- Patients who have latent syphilis of unknown duration should be managed clinically as if they have late latent syphilis. A positive serologic test for syphilis is the only evidence of infection during latent syphilis!! Latent syphilis occurs in two categories: • Early latent (syphilis infection of <1 year duration) and • Late latent (syphilis infection of ≥1 year duration).

Tertiary (late) Syphilis: Neurosyphilis

Neurosyphilis occurs when T. pallidum invades the central nervous system. This may occur at any stage of syphilis, and neurosyphilis can be asymptomatic. Early forms of neurosyphilis usually occur a few months to a few years after infection. Clinical manifestations include acute syphilitic meningitis, a basilar meningitis that typically involves cranial nerves III, VI, VII and VIII; or meningovascular syphilis, an endarteritis that presents as a stroke-like syndrome with seizures. Late forms of neurosyphilis usually occur decades after infection, and they are rarely seen. Clinical manifestations include general paresis and tabes dorsalis. Serologic treponemal tests are usually reactive. Ocular involvement can occur in early or late neurosyphilis.

Syphilis in Pregnancy

When syphilis is diagnosed in a pregnant woman, treat with penicillin according to stage of infection. Patients who are skin-test-reactive to penicillin should be desensitized in the hospital and treated with penicillin. NOTE: Erythromycin is no longer an acceptable alternative drug for penicillin- allergic patients!!! Some experts recommend that a second dose of Benzathine penicillin G 2.4 million units intramuscularly be administered one week after the initial dose for pregnant women who have primary, secondary, or early latent infection. Treatment of the mother during the last month of pregnancy or with a drug other than penicillin cannot be considered adequate treatment for the fetus.

What is the appropriate treatment for late latent syphilis or latent syphilis of unknown duration? a) Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units intramuscularly each at one-week intervals b) Benzathine penicillin G 2.4 million units intramuscularly in a single dose c) If penicillin allergic, use vancomycin 250 mg orally four times a day for ten days plus rifampin 600 mg orally twice a day d) b or c

a) Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units intramuscularly each at one-week intervals This regimen is recommended for late latent syphilis or latent syphilis of unknown duration.

The recommended therapy for a pregnant woman with early latent syphilis: a. Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units intramuscularly each at one- week intervals b. Benzathine penicillin G, intramuscularly, 2.4 million units in a single dose c. Erythromycin 500 mg orally four times a day for 14 days d. Doxycycline 100 mg orally twice a day for 14 days

b. Benzathine penicillin G, intramuscularly, 2.4 million units in a single dose

Which of the following is true of Treponema pallidum? a. It can be cultured in vitro. b. It has a distinctive corkscrew shape. c. It measures approximately 0.3 micrometer in diameter. d. All of the above are true.

b. It has a distinctive corkscrew shape.

Stan's partner, Tracy, is found to be infected and is diagnosed with primary syphilis. She is also in her second trimester of pregnancy and is allergic to penicillin. Which of the following is true? a. Tracy should be treated with doxycycline 100 mg orally twice a day for 14 days. b. Tracy should be desensitized in the hospital and treated with penicillin. c. Tracy cannot become reinfected if she receives adequate treatment.

b. Tracy should be desensitized in the hospital and treated with penicillin. Correct. Pregnant women with syphilis who are skin test reactive to penicillin should be desensitized and treated with penicillin.

Joey was diagnosed with primary syphilis and treated on April 15. At that time, he had a penile lesion that had been present for two weeks. Which of the following at-risk sex partners should be treated presumptively? a. Frances (last exposure March 15) b. Casey (last exposure February 14) c. All of the above should be treated presumptively.

c. All of the above should be treated presumptively. Correct. Sex partners of a person diagnosed with primary syphilis should be evaluated and treated presumptively if their exposure was within 90 days prior to the onset of the primary syphilis symptoms. In this case, that would be any sex partner of Joey's from January 1 (90 days prior to the onset of his primary lesion) and April 15 (date of treatment). It may take up to 90 days for a serologic test to show positive in someone exposed to T. pallidum.

Which of the following changes in titer should prompt concern about possible treatment failure or reinfection? a. Treatment date: RPR 1:128 Six-month follow-up: RPR 1:32 b. Treatment date: VDRL: 1:128 Six-month follow-up: VDRL 1:16 c. Treatment date: RPR: 1:128 Six-month follow-up: RPR 1:64 d. All of the above reflect adequate response to therapy.

c. Treatment date: RPR: 1:128 Six-month follow-up: RPR 1:64 Correct. A change from 1:128 to 1:64 is only a twofold or one dilution decrease. Anything less than a fourfold or two dilution decrease should prompt concern about possible treatment failure or reinfection.

Stan returned to the clinic for a follow-up exam one week later. One-week follow-up visit Stan's penile lesion was almost completely healed. He had not experienced a Jarisch-Herxheimer reaction. The RPR (repeated at the follow up visit because the initial one was negative) was 1:2. What type of follow-up evaluation(s) will Stan need? a) Repeat the HIV antibody test at three months b) Reexamine clinically and serologically six months after therapy c) Reexamine clinically and serologically 12 months after therapy d) Repeat the HIV antibody test in one month e) All of the above except d f) All of the above

e) All of the above except d

A patient is referred to you by the plasma center because she has a "positive RPR." Which of the following are appropriate next steps? a. Order a quantitative serologic nontreponemal test (e.g. RPR) and a confirmatory serologic treponemal test (e.g., FTA- ABS). b. Obtain a detailed history and assess whether she has had syphilis before. c. Contact your local health department STD program to see if they have additional information about the patient. d. Perform a complete physical examination. e. All of the above may be appropriate.

e. All of the above may be appropriate.