syphilis spirochaete

1. Spirochaete

2. Spirochaete
• Gram negative
• presence of varying number of endoflagella
• Pathogenic spirochetes belong to genera :
• 1. Treponema
• 2. Borrelia
• 3. Leptospira

3. Treponeme
• Veneral treponemes
• Treponema pallidum  syphilis
• Non veneral treponemes include :
• – T. endemicum(causative agent of endemic)
• – T. partenue (causative agent of yaws)
• – T. carateum (causative agent of pinta)

4. Staining
• Does not take ordinary stains
• Morphology & motility can be studied by dark ground or phase contrast
microscopy
• Silver impregnation method

5. Silver impregnation method
Fontana stain for staining film Levaditis method for tissue sections

6. Culture
• Pathogenic strain Cannot be cultured in artificical media
• Does not follow kochs postulate
• Reieter
• Non pathogenic strain
• cultivable
• Nichols strain
• Pathogenic hence non cultivable
• Serial testicular passage in rabbits

7. Syphilis
• Painless (non – bleeding) ulcer +painless lymphadenopathy

8. SYPHILIS
• Treponema Pallidum
• Spirochete
• 6 endoflagella

9. Treponema pallidum
• Spirochete
• Morphology / motility can be studied under
dark ground microscope
• Staining
• Silver impregnation method
• Light rose red with geimsa stain
• Fontanas method for Films
• Levaditis for tissue sections

10. Syphilis /veneral trepanomatosis
• IP 9- 90 days (avrg 21 days)
• Route of transmission
• Sexual
• Late d/s  minimum transmission
• transplacental

13. Late syphilis
Organism may no longer be seen but
both type of Ab test may remain +ve

14. Primary syphilis
• Hunterian or Hard chancre
• Single painless
• Indurated ulcer
• Highly infective
• At the site of inoculation
• b/l lymph node enlarged
• Firm /non tender/non suppurative (shotty enlargement of LN)
• After 1 wk of chancre
• heals with in 4- 8 weeks
FTA- ABS VDRL TPHA
First test to become positive After 1-2 weeks

15. Secondary syphilis
• Non-pruritic skin papules  macular roseola
(palms and soles are involved ) c.f lichen plnus
• 2-10 weeks after primary chancre
• Generalised non-tender lymphadenopathy +
• Perianal condyloma lata (infectious)
• Constitutional features like sore throat, malaise,
fever and joint pain may accompany the lesions
• All sero test +ve
• most contagious

16. Snail tract ulcer in secondary syphilis
Snail tract ulcer in secondary syphilis

17. • 1. Chancre redux is a recurrence of the primary sore at its original site
• In 1* syphilis
• 2. Any lesion at the site of a healed primary has been labelled
pseudochancre redux in 3* syphilis

18. Secondary syphilis
• Moth eaten alopecia +
• Buschke – ollendorff sign +
• Organ involvement
• HSM
• ↑↑ ALP
• Nephrotic syndrome
• GI involvement
• Hypertrophic gastritis/patchy proctitis
• Arthritis /periostitis

19. 2* syphilis
Arthritis

21. Framboesiform syphilis  large papules
crusted with dry serum/2*syph

22. Corymbose syphilide large papule
surrounded by small papule

23. Latent syphilis
• b/w secondary & tertiary
• Asymptomatic
• Reactive serology
• Normal CSF
• Early latent
• Occurs during first 2 yrs
• 25 % pts develop chancre redux
• Late latent
• > 2 yrs
• No relapse

24. Tertiary syphilis
• Gumma
• Cardiovascular syphilis  3A
• Aorta aneurysm ascending aorta ***
• Aortic incompetence
• Angina pectoris d/t coronal osteal stenosis
• Neurosyphilis
• Asymptomatic
• Meningeovascular syphilis
• Generalised paralysis of insane
• Tabes dorsalis
• Ocular syphilis

26. Neurosyphilis  CSF Ab tests are positive
• Asymptomatic
• No clinical abnormality
• Abnormal CSF
• Meningovascular syphilis
• After 10 yrs of infection
• Diffuse inflammation of meninges
• Stroke is the most common presentation
• General paresis of insane
• 20 yrs after infn
• Personality changes dementia, memory loss,loss on insight, euphoria,paraparesis
• Hyperactive reflexes
• AR pupil,charcoats joint
• Tabes dorsalis
• Demyelination of posterior column
• ataxic gait , rombergs sign
• Loss of temperature/deep pain /position

27. Gumma / late benign syphilis in tertiary stage
• Painless deep granulomatous ulcers
• Noninfecctious
• Spirochetes cannot be demonstrated
• In face scalp
• Punched out ulcers
• With wash leather slough
• Typically scar with retractile scarring  atrophic tissue paper scar

30. Heals by non tissue paper scar

31. Cardiovascular syphilis
TREE BARK APPEARANCE OF
ASCENDING AORTA
LEFT VENTRICULAR HYPERTROPHY
(COR BOVINUM)

32. • Occular syphilis
• Salt and pepper appearance of fundus
• Optic atrophy,neuritis

34. Generalised paralysis of insane
• PARESIS
• Personality
• Affect
• Reflexes  hyperactive
• Eye  AR pupil
• Sensorium  illusion ,delucions ,hallucinations
• Intellect  ↓recent memory /calculation/orientation/judgement/insight
• Speech

35. Tabes dorsalis

36. Congenital syphilis
• Transmitted in utero
• Transmission of Treponema pallidum from an infected woman to her
fetus across the placenta may occur at any stage of pregnancy,
• but the lesions of congenital syphilis usually develop after-the 4th month of
gestation, when "fetal immunologic" competence begins to develop
• Can be
• early or
• late congenital syphilis

37. Early congenital syphilis
• Similar to 2* syphilis highly infectious
• 2-8 weeks after
• FTT
• Mucocutaneous lesion (vesiculo bullous lesions)
• Generalised lymphadenopathy
• nasal snufflesn(rhinitis) early symptom
• Skin rash

38. • Earliest sign of congenital syphillis is rhinitis or snuffles.
• MC early manifestation are bone changes, hepatosplenomegaly,
lymphadenopathy.
• Clutton’s joint (Bilateral knee effusion), interstitial keratitis are late
manifestation

39. Late congenital syphilis
• Hutchinson’s triad
• Interstitial keratitis
• Deafness
• Hutchisons teeth (peg shaped/mulberry
molars

40. Late congenital
• Rhagades (linear fissure at mouth ,nares,peri anal area)
• Clutton’s joint
• b/l effusions of knee joint
• Osteitis & chondritis
• Saddle nose
• Sabre tibia
• Frontal bossing
• Perforated palate

41. Shaber shin
• Anterior tibial bowing

43. Charcots joint/neuropathic joint
• a. progressive destructive arthritis associated with loss of pain sensation,
proprioception, or both.
• b. Normal muscular reflexes
• c. modulate joint movement are decreased.
• d. Without these protective mechanisms, joints are subjected to repeated
trauma, resulting in progressive cartilage and bone damage.
• Disorders Associated with Neuropathic Joint Disease
• 1. Diabetes mellitus***
• 2. Tabes dorsalis (2nd MC)
• 3. Meningomyelocele
• 4. Syringomyelia
• 5. Amyloidosis
• 6. Leprosy
• 7. Peroneal muscular atrophy

44. • Presence of IgM in a neonate  confirms the diagnosis

45. Treponemal test
• For confirmation
• TPI
• FTA – Abs
• Ig M FTA Abs
Non-treponemal test
• Screening
• Monitoring response to Rx
• Cardiolipin Ag based
• VDRL (slide flocculation test)
• Wasserman (compliment fixation
test)
• Kahn’s test (tube flocculation test)
• RPR (rapid plasma regain)

46. Diagnostic tests
• Dark ground examination
• On 3 consecutive days
• Transudate from lesion
• Identfication of single motile organism  sufficient for diagnosis
• Serological test
• VDRL test
• Non specific test
• Biological false positives can occur
• Determine response to Rx
• FTA – Abs
• Flurescent treponemal Ab
• It becomes positive earlier than VDRL test
• Most sensitive test

47. • TPI test
• Most specific test
• Costly
• Once +ve always +ve

48. Serological tests
• a. Nontreponemal tests
• Nonspecifc (reagin antibody) tests using the cardiolipin antigen
(standard
• tests for syphilis or STS).
• 1. Wassermann complement fxation test
• 2.Kahn flocculation test
• 3. Venereal Disease Research Laboratory (VDRL) test
• 4. Rapid Plasma Reagin (RPR) test
• 5. Toluidine red unheated serum test (TRUST)

49. Non treponemal test
• Fall of 2 dilutions (4 fold) adequate treatment
• False positive non treponemal test
• Pregnancy
• Connective tissue ds
• RA
• SLE
• Malaria
• leprosy
• Non veneral trepanomatosis
• Relapsing fever
• IMN
• old age
• Intravenous drug use
• HCV
• HIV

50. RPR or VDRL
• It becomes positive 3-5 weeks of infection (7-10 days of appearance
of chancre)
• Used for follow up
• For monitoring response to therapy
• Testing of large number for screening purpose

51. Treponemal tests
• a. Group specifc test using cultivable treponemal (Reiter strain) antigen
• Reiter Protein CF (RPCF) test
• b. Specifc tests using pathogenic treponemes (T. palidum)
• I. Test using live T. pallidum
• Treponema pallidum Immobilization (TPI) test
• II. Tests using killed T. pallidum
• a. Treponema pallidum agglutination (TPA) test
• b. Treponema pallidum immune adherence (TPIA) test
• c. Fluorescent Treponemal Antibody Absorption (FTA-ABS) test
• III. Tests using T. pallidum extract
• a. Treponema pallidum Hemagglutination Assay (TPHA) Microhemagglutination test for
Treponema pallidum (MHA-TP)
• b. Treponema pallidum Enzyme Immunoassays (TP-EIA)

52. • FTA ABS
• First test to become positive
• Most sensitive
• TPI
• Most specific

53. Non Treponemal test Treponemal test Interpretation
+ + Active ongoing syphilis
+ - False +ve non treponemal test
- + Past treated infection

54. • For monitoring treatment- Ideal test is VDRL>RPR
• Primary syphilis- Most Sensitive : Western blot & EIA >TPPA> RP
• Secondary syphilis- –All equally sensitive (100%)
• Latent syphilis- Most Sensitive : All treponemal test >TPHA
• Late syphilis–Most Sensitive : FTA-ABS >TPHA
• Overall most specifc- TPHA, EIA,USR,TRUST (All 99% )>TPPA
• First test to be positive–FTA-ABS
• Rapid and mass screening-VDRL

57. Rx
• 1*,2* and early latent syphilis
• Benzathine penicillin G single IM dose of 2.4 million U
• Late latent
• Benzathine penicillin G single IM dose of 2.4 million U weekly * 3 weeks
• CNS syphilis & congenital syphilis
• Aqueous crystalline penicillin/ procaine penicillin G

61. Non veneral / endemic trepanomatosis
Ds Caused by Affects Rx
Bejel (endemic syphilis ) T.Endemicum Skin bones mucus
membranes
BPG
0.6 mega U (<10 year)
1.2 mega U(>10 year)
Yaws T.Pertenue Skin and bone (periostitis) BPG
Pinta T.Carateum Skin alone (non
destructive)
BPG
There are two types of serologic test for syphilis:
nontreponemal and treponemal. Both types of test are reactive
in persons with any treponemal infection, including yaws,
pinta, and endemic syphilis.

64. Jarisch herscheimer reaction
• Intensifiction of symptoms
because of the release of
antigenic protein (when
spirochaete is killed by
penicillin )
• With in 12 hours after 1st dose
• MC in secondary syphilis
• Most dangerous in tertiary 
given under steroid cover
• Brucellosis
• Borrelia
• Lyme ds
• Tick borne relapsing fever
• Cat scratch ds
• Q fever
• Syphilis (2*>1*>early latent)
• Typhoid fever

65. Borrelia

66. • Large, refractile spirochetes which can be stained by ordinary method
and are Gram (–) ve.
• Cork screw motility
• • Pathogenic species are :
• B.burgodorferi - Causes Lyme’s disease
• B.recurrentis - Causes Relapsing fever
• B.vincenti - Causes Vincent angina

67. Lyme disease
• Causative agent B.burgodorferi.

70. Bulls eye rash or target lesion of erthma
migrans

71. • Diagnosis
• – ELISA followed by western blot is best investigation.
• – Culture in BSK medium gives definitive diagnosis but not useful
clinically.
• – PCR particularly in persistant infection

72. • Treatment
• – For nervous manifestation and 30 heart block – Ceftriaxone is DOC.
• – For skin manifestation, arthritis 10 and 20 AV block – Doxycycline is DOC.

73. Relapsing fever
• Causative agent B.recurrentis.
• Relpases occur d/t antigenic variation of borrelia in vivo
• It is of 2 types :
• – Louse borne
• – Louse borne relapsing fever occur as epidemic
• Transmitted by body lice by crushing & rubbing in to abraded skin
• – Tick borne occur as sporadic / endemic cases
• Transmitted by bite of tick
• Treatment : Erythromycin is DOC

74. Relapsing fever

75. Vincent angina
• Causative agent B.vincenti
• Normal mouth commensal, but when associated with fusiform bacilli
(Fusobacterium fusiform) causes ulcerative gingivostomatitis or
oropharyngitis called vincent angina.
• Treatment : Penicillin and Metronidazole

76. Leptospirosis

77. Leptospirosis
• Zoonotic disease
• Leptospira are having characteristic
hooked ends

78. • Leptospirosis (sewer workers disease, Weil’s disease,
icterohemorrhagic fever) is zoonotic infection manifesting as fever,
jaundice and haemorrhage.
• Rats are the important hosts

79. • Leptospirosis is a zoonosis with rodents being most important
reservoir.
• Transmission results from ingestion or contact with urine, blood or
tissue from infected animal but not from bite.
• Since leptospires are excreted in urine of infected rat, water is
important vehicle.
• Human to human transmission don’t occur

81. • Incubation period averages 5–14 days
• Anicteric (90%) stage
• Present with fever & conjunctival congestion
• - Biphasic-
• – Septicemic or acute stage(1st week)
• – Immune stage (meningitis, uveitis, rash)- after 2nd week, excreted in urine
• Icteric
• Elevated bilirubin BUN & PT
• Icteric-(10%)- (Weil’s/hepatorenal hemorrhagic syndrome)-
• – Hepatomegaly & jaundice
• – Acute tubular injury(oliguric, with serum electrolyte abnormalities)
• – Hemorrhages (MC –pulmonary)
• – Hypotension

82. • Vaculitis is responsible for clinical features

83. • 1. Isolation of organism
• – From blood or CSF during 1st 10 days
• – From urine after 1 week
• – For isolation
• EMJH medium is useful
• Korthof medium
• 2.microscopy
• Dark ground microscopy
• 3. Serology
• – Microscopic agglutination test [MAT]
• Gold standard
• – ELISA

84. Rx
• Mild cases
• Doxycycline ampicillin or amoxicillin
• Moderate or severe
• Penicillin G
• DOC
• Doxycyline