Microbiology, Syphilis, Sexual transmitted Disease.

1. SYPHILIS
“THE GREAT PRETENDER”
By
Dhananjay A. Desai
Research Scholar
Department of Microbiology
N. A. C. & Sc. College, Ahmednagar
dhananjayashokdesai@gmail.com

3. Overview
• History of Syphilis.
• Transmission pathogenesis and stages of syphilis.
• Diagnostic tests.
• Treatment and partner management.
• Epidemiology.

4. The great pox
• Epidemic in 15 century Europe.
• Rapid spread and served symptoms in early stages.
• Epidemic coincide with Columbus return from america in
1493.
• Endemic but unrecognized.
• A gift from new world.

5. Syphilis Discovery of its causes
• 1903: Infection successfully transmitted to
monkeys.
• 1905: Identification of the bacterium Treponema
pallidum.
• 1906: Dark field microscopy.

6. Taxonomy
• Domain: Bacteria
• Phylum: Spirochaetes
• Order: Spirocheteles
• Family: Spirochetacae
• Genus: Treponema
• Species: pallidum

7. Characteristics
• Helical, tightly coil, Mobile.
• 5-10 µm in length and 0.1-0.4 µm diameter.
• Pathogenic Treponema associated with ten Diseases.
• Veneral syphilis- Pallidum
• Endemic- Endemicum
• YAWS- Pertenue
• Pinta- Carateum
• Obligatory parasite of human.

8. Epidemiology
and
Aspects of
Syphilis Prevention

9. Primary and secondary syphilis — Rates by state:
United States and
outlying areas, 2007

10. Distribution of Reported STD in
World, 2008

11. Method of Infection
• Viable bacteria from chancre enter through the fissure or
mucous membrane.
• Bacteria multiply locally and causes painless chancre.
• Spared via blood stream and lymphatic system.
• Can almost infect many organ and tissue.
• Continuous in vitro culture yet Not to be achieved.

13. Symptoms
(some have no symptoms for years)
• 3 Stages:
 Primary
 Secondary
 Late or latent
• Congenital (passed from a mother to her child)

14. Pathogenesis
• Multiple at the site of inoculation and form chancre.
• Spread to local lymph nodes and then to blood
stream.
• Can involve of many body organs.
• Infection and inflammation of blood vessels.

15. Primary Stage
• Appearance of a single sore or chancre (about 21 day
after infection).
• Chancre lasts 3-6 weeks and heal by treatments.
• If untreated disease progress to next stage.

16. Secondary stage
• Occur as chancre is healing or few weeks after.
• Skin rash developed on one or more areas.
• appear like other disease (usually doesn’t cause itching).
• Other symptoms: fever, swollen lymph gland, sore throat,
patchy hair loss, headaches, weight loss.
• Without treatment disease progress to next late stage.

17. Late stage
(Hidden stage)
• Person continues to have syphilis even through they
are no symptoms.
• Disease can damage eyes, brain, nervous system,
liver, bones, joints.
• Sign include: difficulty coordinating muscle
movement, paralysis, numbness, gradual blindness,
even death.

18. Diagnostic Tests
• Dark field
• PCR
• VDRL/RPR
• EIA

19. T. pallidum on Dark field

20. T. pallidum by DFA-TP

21. Syphilis Serology
• Non-Treponema tests
 VDRL (Venereal Disease
Research Laboratory)
 RPR (Rapid Plasma Reagin)
 TRUST (Toluidine Red
Unheated Serum Test)
 USR (Unheated Serum
Reagin)
• Treponema tests
 TP-PA (Treponema Pallidum
Particle Agglutination)
 FTA-abs (Fluorescent
Treponema Antibody -
Absorbed)
 EIA (Enzyme Immunoassay)

22. Treponemal Tests
• Specific for T. pallidum
• Measure antibody (IgM & IgG) directed against T.
pallidum antigens by particulate agglutination (TP-
PA) or immunofluorescence (FTA-abs)
• May remain positive after treatment
• More sensitive and specific than non-trep. tests
• More expensive and labour intensive
• Can not quantitate…not useful for following response
to treatment

23. FTA-ABS

24. Non-Treponemal Tests
• VDRL and RPR are most commonly used.
• Detect Abs against cardiolipin-lecithin-cholesterol
antigens; not specific for T. pallidum.

25. Uses of Non-Treponemal Tests
• Screening.
• Evaluation of patients with symptoms or possible re-
infection.
• Follow-up assessment after treatment.

26. RPR Test for Syphilis

27. Non-Treponemal Tests
Advantages
• Rapid & inexpensive compared to treponemal tests.
• Easy to perform.
• Quantitative (can be tittered)
• Used to follow response to therapy.
• Can evaluate possible reinfection.

28. Non-Treponemal Tests
Disadvantages
• Biological false positive reactions (BFPs).
• Viral illnesses including HIV, recent immunizations, IDU,
autoimmune and chronic diseases.
• False negative reactions.
• Prozone effect.
• Early primary and late latent stages.

29. Sensitivity of Serologic Tests
According to Stage
• Test 1 2 Latent Tertiary
• VDRL/RPR 74-87% 100% 88-100% 37-94%
• FTA-ABS 70-100% 100% 100% 96%
• MHA-TP* 69-90% 100% 97-100% 94%
• *MHA-TP and TP-PA probably perform equivalently.

30. Serologic Pitfalls
in the Diagnosis of Syphilis
• Negative nontreponemal test may occur early in primary
or late in tertiary - check FTA-ABS or TP-PA.
• Prozone phenomenon: false negative due to lack of
agglutination with high antibody levels.
• Serofast: persistent, low-level positive titre after adequate
treatment.

31. Treatment
and
Partner Management

32. Treatment of Penicillin G
• Intravenous or intramuscular injection of penicillin G
is the preferred drug for treatment of all stages of
syphilis
• Benzathine penicillin G, aqueous procaine penicillin
or aqueous crystalline penicillin can be used

33. Syphilis Resistant to
Azithromycin?
• In San Francisco, the frequency of azithromycin-resistant T. pallidum
isolates increased from 4% during 2000–2002 to 37% during 2003.
• San Francisco STD clinic discontinued use of azithromycin for treating
syphilis infection.
• Notified San Francisco medical providers of azithromycin treatment
failures.
• Recommendation to use Benzathine penicillin G.
• Doxycycline as alternative in PCN-intolerant.
• National notification via MMWR.

34. Syphilis: Treatment
in Pregnancy
• Penicillin is the only adequate form of treatment for
syphilis in pregnancy.
• Penicillin-allergic patients - Hospitalize, desensitize
& treat with penicillin.
• Erythromycin is not accepted as alternative drug in
penicillin-allergic patients.

35. Management of Contacts
• Contacts to primary, secondary or early latent syphilis.
• Persons exposed within 90 days preceding the diagnosis
in a sex partner might be infected even if seronegative:
Treat presumptively.
• Persons exposed >90 days before the diagnosis should be
treated presumptively if serologic tests are unavailable or
follow up is uncertain; if serologic tests are negative no
treatment is needed.

36. Chances Reduction
• Abstain from sex until treatment is finished and until
partners have been evaluated and treated.
• Use condoms consistently and correctly.
• Avoid having sex with partners with genital ulcers/lesions
or rashes.
• Get check-ups every 6 months if engaging in sex with
more than one sex partner.

38. NOW TOPIC OPEN FOR DIOSCUSSION