The document provides a comprehensive overview of the management of syphilis, detailing stages, investigation methods, and treatment options. It covers various diagnostic tests, including dark field microscopy, direct fluorescent antibody tests, and serological tests, along with their specificity and indications. Treatment is primarily with penicillin, with specific regimens tailored based on the stage of syphilis and patient factors.

1. Syphilis
(Management)
Jeetendra Bhandari

2. Stages of Syphilis

3. Management
• Investigation
• Treatment

4. Investigation
• Tests to demonstrate the spirochete
• Serology test

5. Tests to demonstrate the spirochete
 Dark field microscopy
 Direct Fluorescent Antibody T. pallidum (DFA-TP) Test
 Polymerase Chain Reaction

6. Collection of samples
 The lesion is cleansed with water and dried
 Grasped firmly between the thumb and index finger
 Abraded sufficiently to cause clear or faintly blood- stained plasma
to exude when squeezed
 Surface of a clean coverslip is touched to the surface of the lesion so
that plasma adheres
 Then dropped on a slide and pressed down
 The specimen is quickly examined

7. Dark field microscopy
 Quickest and most direct method
 Positive in primary and secondary syphilis
 Sample can be taken from the primary chancre or papular lesions of
secondary syphilis (mostly from condylomata lata)
 Unreliable in oral cavity as T. pallidum can not be distinguished from
oral saprophytic spirochetes
 May be negative in patients treated with systemic or local antibiotics
 Failure to identify do not exclude diagnosis of primary syphilis

8.  Motility can be appreciated:
 A projection in the direction of
long axis
 A rotation on its long axis
 A bending or twisting from
side to side
 The precise uniformity of the
spiral coils is not distorted during
this movements

9. Direct Fluorescent Antibody T.pallidum (DFA-
TP) test
 Permit the identification of organism when smares can’t be examined
immediately
 Fluorescent antibodies angainst T.pallidum used for identification
 Better than dark field microscopy as it is reliable in case of oral
lesions as well
 Air dry specimen of lymph nodes aspirate, genital mucosal lesion,
and chancres are used

10. Polymerase Chain Reaction
 The genetic sequence of T.pallidum has been traced
 PCR is therefore 100% sensetive and specific for detecting T.pallidum
 PCR can also diagnose other genital lesions at the same time
 However, at present, its use is limited to clinical research only

11. Serological tests
• 2 types
• Treponemal
• Non Treponemal

12. Treponemal
• Detect specific Anti treponemal antibodies
• Have high specificity and sensitivity exceeding 95%
• Examples include:
 Enzyme immunoassay (EIA) for IgG and IgM
 Fluorescent treponemal antiboy absorption (FTA-ABS)
 Microhemagglutination assay T.pallidum (MHA-TP)
 T.pallidum hemagglutination (TPHA)
 T.pallidum particle agglutination (TPPA)
 EIA IgM becomes +ve at 2-3 wks after infection (initial time of chancre
development)
 Except EIA IgM, other treponemal test remain positive for life in most of
the patients.

13. Non-treponemal test
 Serum of person with syphilis aggregate cardiolipin-cholesterol-lecithin antigen
 Can be viewed in slides, tubes or autoanlyser
 Become positive within 5-6 weeks of infection, shortly before the primary
chancre heals
 Negative in the early stage of primary syphilis
 Negative or decrease titers with treatment
 Examples include:
 Veneral disease research laboratory (VDRL)
 Rapid plasma reagin (RPR)

14. Important points
 Due to false-positive result, one positive result must be confirmed by
another
 Usually for screening a non-treponemal test (VDRL/RPR)
 If positive, for confirmationa treponemal test
 Non-treponemal test is important in monitoring the response to
treatment

15. Some important points
• NTT (+ve) TT (+ve) syphilis
• NTT (+ve) TT (-ve) Biological false positive(BFP) NTT
• NTT (– ve) TT (+ve) previous syphilis, late latent syphilis
• If two TT do not give same result, than should be confirmed by a
third TT

16. Some data:

17. Biological False Positive test(BFP) result
• Denotes a positive serological test for syphilis in persons with no
history or clinical evidence of syphilis
• Term applied to +vs non trepnemal test and a negative treponemal
tests
• Are of 2 types
• Acute(revert to negative within 6 months)
• Chronic(do not revert within 6 months)

18. Causes for acute and chronic BFP
Acute BFP
• Vaccination
• Infection( infective
mononucleosis, hepatitis,
measles, typhoid, varicella,
influenza, malaria)
• Pregnancy
Chronic BFP
• Connective tissue disease(SLE)
• Chronic liver disease
• Multiple blood transfusion
• Intravenous drug usage
• Advancing age

19. • False positive result to treponema test are less common
• Condition for false positive treponema are
• Lupus erythematous
• Drug induced Lupus
• Scheleroderma
• Rheumatoid arthritis
• Pregnancy
• Genital herpes simplex infection

20. CSF analysis in syphilis
 CSF evaluation are not routinely performed in asymptomatic patients
with syphilis
 CSF analysis is recommended when:
 Auditory, opthalmic or neurological symptoms
 HIV +ve with RPR >= 1:32
 Patient with latent syphilis and HIV +ve or failure of initial therapy

21. Other tests
 X-rays of the affected bone in osseous syphilis
 CT scan of the head for neurosyphilis
 Chest x-rays for aortic dilatation and syphilitic aortitis.
 Tests for other sexually transmitted infections like HIV, hepatitis B.

22. Treatment

23. Penicillin Therapy
• Penicillin G, administered parenterally, is the preferred drug for
treating all stages of syphilis
• The preparation used, dosage, and the length of treatment depend
on the stage and clinical manifestations
• The effectiveness of penicillin was well established through clinical
experience even before value of RCT was recognized
• Parenteral penicillin G is the only therapy with documented high
efficacy for syphilis during pregnancy
23

24. Primary, secondary or early latent(less than 1
year)
• Benzathine Penicillin G ,2.4 MU,
• Single dose
• Intramuscular injection
• If allergic to Penicilline(non pregnant, HIV negative)
• Tetracycline 500 mg, orally, 4 times a day
Or
• Doxycycline 100 mg, orally, twice daily
• If intolerable to above
• Ceftriaxone 1 gm IM or IV for 8-10 days
For 2 weeks

25. • Azithromycin and Erythromycine no longer used due to resistance
• Close follow up is recommended in patient treat with non-penicillin
based regimens
• Alternative regimens not recommended for patient with HIV and
syphilis

26. For late and late latent syphilis(>1 year) & HIV
negative
• Benzathine Penicillin G - 2.4 MU
• Intramuscular
• Once a week for 3 weeks
• Non-pregnant, penicillin allergic, HIV negative
• Tetracycline 500 mg, orally, 4 times a day
Or
• Doxycycline 100 mg, orally, 2 times a day
30 days

27. For neurosyphilis
• Penicillin G Crystalline (3-4 MU)
• Intravenous
• Every 4 hour for 10-14 days
Or
• Procaine Penicillin 2.4 MU/day, Intramuscular
+
• Probenecid 500 mg orally, 4 times a day
• If allergy conformed with penicillin, allergy should be desensitized,
and treatment should be continued
For 10-14 days

28. For Congenital Syphilis
• It is complex to treat in neonate
• For older children with congenital syphilis
• Aqueous crystalline penicillin G-200000 to 300000 IU/Kg/Day;
• Intravenous or Intramuscular(50,000 IV every 4-6 hours) for 10-14 days

29. For pregnant women
• Treated with penicillin in dose appropriate for the stage of syphilis
• 2nd dose of Benzathine Penicillin , 2.4 MU, IM, administered 1 week
after initial dose
• USG should be done to identify congenital infection
• Follow up quantitive serologic test should be performed monthly until
delivery
• Penicillin Allergy should be desensitized

30. HIV positive patient(with primary and secondary
syphilis), non allergic, no neurologic or psychiatric
problem
• Benzathine penicillin G
• 2.4 MU
• IM
• For 3 weeks
• If allergic to penicillin
• Desensitize to allergy
• Follow up non treponemal test at 3, 6, 9 and 12 months

31. The Jarisch-Herxheimer Reaction
• An acute febrile reaction due to a rapid release of treponemal antigen
with an associated allergic reaction in the patient
• Caused by antisyphilitic treatment, especially penicilline
• Accompanied by headache, myalgia, fever, exacerbation of
inflammatory reaction at sites of localized spirochetal infection
• Usually occur within 6-8 hours of treatment
• Occurs most frequently among patients with early syphilis
• Antipyretics can be used to manage symptoms- not prevent
• Might induce early labor or cause fetal distress in pregnant women,
but this should not prevent or delay therapy
31

32. Treatment of sex partner
• Partner at risk
• Exposed within 90 days of diagnosis of primary, secondary or early latent
syphilis, Seronegative should also be treated
• If serologic titer of patient is greater than 1:32
• Treatment
• Benthine penicillin, 2.4 MU, IM, Single dose

33. Serological testing after treatment
 VDRL or RPR testing performed routinely to ensure appropriate
response
 For primary and secondary syphilis, HIV-negative, non-pregnant
patient, testing is repeated every 3 months in the first year, every 6
months in the second year, and yearly thereafter
 Four-fold decrease in titer is expected at 6 months in primary and
secondary (12-24 months in case of latent syphilis)
 If response is inadequate, HIV testing and CSF analysis is done

34. Aim of treatment

35. References
• RICHARD WELLER, HAMISH HUNTER AND MARGARET MANN. Clinical
Dermatology, FIFTH EDITION.
• James, William D. (William Daniel), Andrews’ Diseases of the skin : clinical
dermatology. — 11th ed.
• Up to date ver. 21
• CDC. Sexually Transmitted Disease Treatment Guidelines, 2010. CDC. 2010
(Available at: http://www.cdc.gov/mmwr/ pdf/rr/rr5912.pdf
• NCASC. National Guidelines on Case Management of Sexually Transmitted
Infections. NCASC. 2009: 58-61,77-78 (Available at:
http://www.ncasc.gov.np/ncasc/Operational%20guidelines/National%20gu
idelines%20on%20STI%20case%20management.pdf

36. Thank you!!