management of syphilis

1. Syphilis
By Getahun K

2. Contents
• Historical background
• Introduction
• Features & maof syphilis
-primary
-Secondary
-Tertiary syphilis
• Congenital syphilis
• Syphilis in pregnancy
• Tests for detecting syphilis

3. "syphilos" ---meaning crippled/heart victim.

7. • T. pallidum
• IP 21 days ….but 10-90days
• Mode of Transmission
-Sexual
direct contact with an infectious moist lesion.
treponemes pass through intact mucous
membranes or abraded skin
– Vertical

8. Primary Syphilis
• Painless genital sore (chancre) on labia, vulva,
vagina, cervix, anus, lips, or nipples.
• Painless, rubbery, regional lymphadenopathy
followed by generalized lymphadenopathy in
the third to sixth weeks.
• Dark-field microscopic findings.
• Positive serologic test in 70% of cases

12. Syphilis - Treponema pallidum

13. Primary syphilis-chancre

14. Secondary Syphilis
• Bilaterally symmetric extragenital
papulosquamous eruption(6 weeks after
primary lesion).
• Condyloma latum, mucous patches.
• Dark-field findings positive in moist lesions.
• Positive serologic test for syphilis.
• Lymphadenopathy

15. Secondary syphilis - papulosquamous
rash

17. Secondary syphilis

18. Secondary syphilis - condyloma lata

19. Secondary syphilis - alopecia

20. Secondary syphilis
Rash and ulcerations
of secondary syphilis
3.2. Stages of syphilis

21. Latent syphilis
• no clinical signs but syphilis serology is
reactive……….?VDRL
• without a history of therapy, a patient passes
into latency
• History or serologic evidence of previous
infection
1. Early latent = infection less than one year
2. Late latent= infection occur for over one year

23. Lumbar puncture should be done in latent
syphilis of more than 1 year duration if:
• There are neurological symptoms
• Treatment fails
• Serological titer is 1:320 and higher
• Non penicillin therapy is planned
• There is concomitant HIV infection

24. Tertiary syphilis
- Gumma
- aortitis leading to valve incompetence and
aneurysm
- Neuro-syphilis

25.  Neurologic complications or neurosyphilis may
occur earlier or progress more rapidly in HIV-
positive patients
Meningitis, meningovascular, or parenchymatous
disease similar in HIV-uninfected patients
Concomitant uveitis and meningitis more common in
HIV-positive patients
 Asymptomatic neurosyphilis (CSF with elevated
protein, lymphocytosis, or positive serologic test, in
absence of symptoms): not a late complication or
manifestation
Neurosyphilis

26. • All patients require CSF sampling with
laboratory testing for cell count, protein,
VDRL, and FTA-ABS.
• FTA-ABS is less specific but very sensitive
when diagnosing neurosyphilis.

28. Management of ulcer
Benzathine penicillin 2.4 million units IM stat
Or (in penicillin allergy)
Doxycycline 100 mg bid for 14 days
Plus
Ciprofloxacin 500mg bid orally for 3 days.
Or
Erythromycin tablets 500 mg qid for 7 days

29. neurosyphilis
• Aqueous bezylpenicillin 10-12 million IU IV,
administered daily in doses of 2-4 million IU,
every 4 hours for 14 days.
• Alternative regimen:
– Procain benzylpenicillin, 1.2 million IU IM, once
daily, and probenecid, 500 mg orally, 4 times daily,
both for 10-14 days.

30. 3.2. Stages of syphilis
Primary Syphilis
Secondary Syphilis
Latent Syphilis
Tertiary Syphilis Persistent Asymptomatic
Relapse Trans placental
Transmission
Congenital Syphilis
40%
60%
Primary Chancre
Secondary lesions
Infection with T. pallidium
Gumma
(5 Yrs)
Cardiovascular
Syphilis
(10-15Yrs)
Tabes Dorsalis
(20 Yrs)

31. CONGENITAL SYPHILIS

32. • analogous to adult secondary disease, as the
disease is systemic from onset due to
transplacental hematogenous inoculation
• immunoglobulin (Ig)G (a reactive serologic
test if the mother's test was reactive)
• may appear healthy at birth--A rising titer
indicates congenital syphilis

33. Signs and symptoms of early congenital syphilis
• Rhinitis and serosanguinous discharge from
nostrils
• Bullous skin lesions
• Periostitis with pseudo paralysis
• Hepatosplenomegaly
• Nephrotic syndrome
• Chorioretinitis

40. • Confirmed diagnosis
– spirochete on dark field microscopy from placenta or
lesions from infant
• Presumptive
– Any infant whose mother had untreated syphilis
– Reactive specific treponemal tests with or without
manifestation of congenital syphilis.

41. Treatment of early congenital syphilis
• Aqueous crystalline penicillin G 50,000 units/kg IV tid for 10
days
Or
• Procaine Penicillin G 50,000 units/kg IM daily for 10 days.
• Note: CSF should be examined with RPR to exclude
involvement of the CNS

42. The late manifestations of congenital syphilis
• Deformity of long bones or nasal bridge
• Hutchinson’s triad consisting of deafness,
keratitis and peg shaped incisor teeth.
• Hydrocephalus with evidence of mental
retardation.

43. Treatment of late congenital syphilis
• Aqueous crystalline penicillin G 50,000
units/kg IV or IM QID for 10 days
• Alternative regimen for penicillin-allergic
patients, after the first month of life
– Erythromycin 7.5-12.5 mg/kg orally, QID for 30
days

45. SYPHILIS IN PREGNANCY

47. Syphilis in Pregnancy
• 2.7%
• RPR positivity rate of > 5% indicates high prevalence
• course of syphilis is unaltered by pregnancy
• Treponemes may cross the placenta at all stages of
pregnancy, but fetal involvement is rare before 18
weeks because of fetal immunoincompetence
• Grossly, the placenta looks hydropic --pale yellow, waxy,
and enlarged.

48. • Adverse outcomes
– miscarriage or stillbirth
– congenital syphilis in the newborn
– progression of latent syphilis in the mother
• RPR test should be routinely done on pregnant
mothers in their first trimester and treatment if
shows strong reactivity
• Weak reactivity--specific serologic tests before
treatment .

49. Management
• If primary syphilis, secondary syphilis, or/&
history of non-reactive RPR test within the
past 2 years:
– Benzathine penicillin G 2.4 million units IM
OR
– If allergic to penicillin, ceftriaxone 1 gm IM daily x
8 – 10 days

50. reactive RPR test in pregnancy
• If infected more than two years OR no prior
history of non-reactive RPR test:
– Benzathine penicillin G 2.4 million units IM x weekly
for 3 weeks
OR
– If allergic to penicillin, erythromycin 500 mg PO QID
x 30 days
– Repeat RPR in the 3rd trimester or delivery

51. In all aspects of syphilis
• H/E-safer sexual practice, partner notification
& tracing…..
• Condom promotion & use
• Screening for HIV,PREGNANCY
• Looking for complications is needed

57. Nontreponemal Tests
• measure reaginic antibody
• rapidly, relatively easily, and inexpensively
• syphilis screening
• false-positive reactions
• VDRL slide test(more specific-measure the
degree of reactivity), rapid reagin test, and
automated reagin

58. The VDRL test
• positive 3–6 weeks after infection, or 2–3
weeks after the appearance of the primary
lesion;
• positive in the secondary stage
• titer is usually lower or even nil in late forms
of syphilis

63. • a falling or stable titer in latent or late syphilis

65. False-positive serologic reactions
• collagen diseases
• infectious mononucleosis
• Malaria
• many febrile diseases
• leprosy, vaccination
• drug addiction
• old age
• possibly pregnancy

69. Treponemal Antibody Tests
• FTA-ABS test and MHA-TP
• detect antibody against Treponema spirochetes.
• Both tests are more sensitive and specific than
nontreponemal tests
• except the MHA-TP test with primary disease
• remain positive despite therapy (so they are not
given in titers or used to follow serologic
response to treatment).