The document outlines the learning outcomes related to syphilis, including its classification into congenital and acquired forms, modes of transmission, and the identification of its primary, secondary, and tertiary stages. It details the clinical presentations and diagnostic methods for syphilis while highlighting its complications and the associated sexually transmitted infections. Key topics include the pathogenesis of the disease, symptoms in infants, and the features of tertiary syphilis.

1. Syphilis

2. Learning Outcomes
1. List the sexually transmitted diseases
2. Know the aetiology of syphilis and its mode of transmission
3. Give classification of syphilis into congenital and acquired type
4. Understand congenital syphilis, its way of transmission, age affected, sub classification
and its important features.
5. Identify Primary, secondary and tertiary stages of acquired syphilis
6. Study sites, morphology and fate of each stage
7. Clinical presentation and the diagnosis of syphilis
8. Have a global idea about the acquired syphilis, its common sites, morphology,
infectivity, and complications of each stage.

3. Sexually Transmitted Diseases(STDs)
Infectious diseases transmitted by close sexual
contact include;
Bacterial: Gonorrhea and Lymphogranuloma
venereum
Spirochete: Syphilis
Viral: HBV, Genital Herpes, HPV and HIV
infection
Protozoal: E. histolytica and Trichomonas

4. Syphilis
A chronic venereal endemic infection in all parts of the world caused by;
Treponema pallidum
Routes of Transmission
Close sexual contact: from an active cutaneous or mucosal lesion in a
sexual partner in the early stage of (primary or secondary) syphilis to
uninfected partner
Transplacental: across the placenta from mother to fetus (congenital
Syphilis)
Blood products: risk is low
*Syphilis is common in HIV-infected patients and promotes transmission of HIV
*Syphilis cannot be contracted through toilet seats, daily activities, hot tubs, or
sharing eating utensils or clothing)

5. Pathogenesis
• Once inside the body, organisms rapidly spread to distant sites
by lymphatic's and blood stream
• After initial infection, a primary lesion (chancre) appears at the
point of entry
• Incubation period: 9 and 90 days (average 21)
• Systemic dissemination continues during this period
• Host immune response produce two types of antibodies; non-
treponemal and specific treponemal antibodies to treponemal
antigens

6. Syphilis
Syphilis is classified into:
A- Congenital syphilis
1. Infantile syphilis(with stillborn/live born infants)
2. Late congenital syphilis
B- Acquired syphilis
1. Primary
2. Secondary
3. Latent
4. Tertiary

7. Congenital Syphilis
• Maternal transmission from infected mother, during primary and
secondary stages of syphilis
• Placenta is enlarged, pale, edematous and reveals;
- Proliferative endarteritis of fetal vessels
- Villitis with mononuclear inflammatory infiltrate
- Villous immaturity
• Clinically congenital syphilis may be;
1. Infantile syphilis
2. Late congenital syphilis

8. Infantile Syphilis
Stillborn Infants; The most common manifestations are:
• Hepatomegaly, due to extramedullary hematopoiesis
• Bone abnormalities, inflammation and disruption of
osteochondral junction in long bones and bone resorption
of flat bones of skull
• Pneumonitis
• Spirochetes are readily demonstrable in tissue sections
Live born infants; manifest at birth or within first few
months with;
• Chronic rhinitis
• Mucocutaneous lesions
• Visceral and skeletal changes as seen in stillborn infants

9. Late Congenital Syphilis
Untreated cong. syphilis of more than 2 years duration; classic manifestations
include;
Hutchinson’s teeth small widely spaced peg shaped permanent teeth
Hutchinson triad: notched central incisors, interstitial keratitis with blindness, and
deafness from eighth cranial nerve injury
Saber shin deformity caused by chronic inflammation of the periosteum of the
tibia
Deformed molar teeth ("mulberry molars")
Chronic meningitis
Chorioretinitis
Saddle shaped nose deformity Gummas destroying nasal bone and cartilage,
results in depressed bridge of nose

10. Hutchinson’s teeth Saddle Nose
2/13/2018

11. Chorioretinitis

12. Acquired Syphilis
Primary stage syphilis
• After initial exposure macule to papule appear on the skin at site of
contact which finally progress to ulcer called chancre
• Chancre a single, firm, painless, non-itchy skin ulceration with a clean
base and sharp borders measuring 0.3 to 3.0 cm in size, the lesion may be
genital or extra genital
• Chancre resolves spontaneously over a period of 4 to 6 weeks and is
followed in approx. 25% of untreated patients by the development of
secondary syphilis
• Localized Lymphadenopathy frequent, occurs 7 to 10 days after chancre
formation

13. Primary Chancre of Syphilis
2/13/2018

14. Secondary Syphilis
Occurs approximately 4 to 10 weeks after the primary infection
and clinically presents with;
• Generalized lymphadenopathy
• Mucocutaneous lesions as maculopapular or condyloma lata
(flat raised lesions)
• Symmetrical, reddish-pink, non-itchy rash on the trunk and
extremities, including the palms and soles which may become
maculopapular or pustular
Mucocutaneous lesions of both primary and secondary syphilis contains
spirochetes and are highly infectious

15. Secondary Syphilis
Rash on chest, palms, foot Papules on back
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16. Condyloma lata
• Reddish-brown papular
lesions on the penis or
anogenital area can
coalesce into large elevated
plaques up to 2-3 cm in
diameter, known as
condylomata lata, a highly
infectious lesion
• Lesions usually progress
from red, painful, and
vesicular to “gun metal grey”
as the rash resolves
2/13/2018

17. Latent Syphilis
• The latent (hidden) stage of syphilis begins when primary and
secondary symptoms disappear
• Without treatment, the infected person will continue to
have syphilis infection in their body even though there are no
signs or symptoms and are contagieous

18. Tertiary Syphilis
About one-third untreated syphilis enter into tertiary phase and shows
symptomatic lesions over the next 5 to 20 years, which includes;
Benign tertiary syphilis; gummas in various sites like; bone, skin, mucus
membrane and viscera, in liver gumma and scarring of hepatic parenchyma
divides liver into large nodules called hepar lobatum
Neurosyphilis; Tabes dorsalis and General paresis (involving spinal cord &
brain)
Cardiovascular syphilis; Syphilitic aortitis
*Patients with late latent or tertiary syphilis are much less likely to be infectious
because spirochetes are rare in these gummas

19. Tertiary Syphilis
Gumma of Nose Liver; hepar lobatum
2/13/2018

20. Microscopy Features
• Proliferative endarteritis and
perivascular inflammatory
infiltrate rich in plasma cells,
endothelial hypertrophy and
proliferation, followed by intimal
fibrosis and narrowing of vessel
lumen with local ischemia and
necrosis
• Gumma shows a central zone of
coagulation necrosis surrounded
by a mixed inflammatory infiltrate
composed of lymphocytes,
plasma cells, epithelioid cells,
occasional giant cells, and a
peripheral zone of dense fibrous
tissue

21. Spirochetes, demonstrable in
histologic sections with
Warthin-Starry stains
2/13/2018

22. 22

23. Diagnosis of Syphilis
Blood tests:
A. Non-treponemal tests
Like, Venereal Disease Research Laboratory (VDRL) test; Usually positive in early disease,
but may be negative in advanced disease, occasionally false positive, confirmation required
with Treponemal test
B. Treponemal tests
First tests to become positive and are useful for screening
Treponemal antibody tests usually become positive 2 to 5 weeks after the initial infection
and remain positive indefinitely
Cerebrospinal Fluid Examination:
Neurosyphilis is diagnosed by finding high numbers of lymphocytes and high protein levels
in the CSF
Direct testing of serous fluid from a chancre by:
Dark ground microscopy or Direct fluorescent antibody testing

24. Dark Field Microscopy

25. Immunofluorescence Syphilis

26. Chlamydia trachomatis
• A gram negative bacteria which can cause trachoma and
sexually transmitted diseases like Lymphogranuloma
venereum, urethritis, cervicitis, salpingitis
• Short incubation period of 2-5 days, about 50% of infected
males develops a primary genital lesion, a painless papule on
the penis which may ulcerate but usually heals within a few
days
• 1 and 4 weeks later patient develops an inguinal
lymphadenitis showing acute suppurative inflammation with
necrosis
• Chlamydial inclusions seen in the infected cell

27. Home Assignment
Q. How you will differentiate gumma of syphilis
from granuloma of tuberculosis.
2/13/2018

28. Learning Outcomes
1. The aetiology of syphilis and its way of transmission
will be discussed.
2. The classification of syphilis will be classified to
congenital and acquired.
3. The stages of acquired syphilis will be explained as
primary, secondary and tertiary syphilis.
4. The sites, morphology and fate of each stage will be
discussed.
5. The clinical presentation and the diagnosis of
syphilis will be given.

29. References
• Reading : Robbins Basic Pathology, 9th Edition
(2013), By: Kumar, Abbas, Aster
• Web Path
• WWW.fleshandbone.com
• WWW.studentconsult.com