Syphilis is a sexually transmitted disease caused by the bacterium Treponema pallidum. It has four stages: primary, secondary, latent, and tertiary. The primary stage involves a chancre at the infection site. Secondary syphilis causes a rash and mucous patches. Latent syphilis has no symptoms. Tertiary syphilis can cause gummas, neurological issues, and cardiovascular complications if left untreated. Syphilis is diagnosed through fluid microscopy, serological tests like RPR and FTA-ABS, and clinical history. It is treated with penicillin, doxycycline, or ceftriaxone depending on the stage. Prevention involves abstinence, condoms,

1. SYPHILIS

2. INTRODUCTION
 Is a sexually transmitted disease caused by the spirochetal bacterium
Treponema pallidum.
 Route of transmission : Sexual contact;
Congenital syphilis (mother to child in utero).
 Earlier name – ‘King of VD’; replaced now by AIDS.

3. SYPHILIS INFECTION
 4 stages
1] Primary syphilis
 via direct sexual contact (exposure to the infectious lesions of a person
with syphilis).
 Primary chancre of syphilis is seen at the site of infection 10-90 days
post-initial exposure (average 21 days)
 Chancre:
 1° skin lesion at site of contact (usually genitalia, but can be anywhere on
the body).
 firm, painless skin ulceration localized at the point of initial exposure to the
spirochete (often on penis / vagina / rectum).
 Multiple lesions (rarely); typically only one lesion is seen.
 Persists for 4 - 6 weeks, then heals; local lymph node swelling can
occur.
 Asymptomatic during initial incubation period (many patients do not seek
medical care immediately).
 Cannot be contracted through toilet seats, daily activities, hot tubs, or
sharing eating utensils or clothing

4. PRIMARY CHANCRE ( AT INFECTION SITE)

5. 2] Secondary syphilis
 Approximately 1-6 months post-primary infection (commonly 6 - 8
weeks).
 Many different manifestations.
 Patient is most contagious in this stage.
 Symmetrical reddish-pink non-itchy rash on trunk and extremities.
 Rash – usually on palms of the hands and the soles of the feet.
 Moist areas of body - the rash becomes flat, broad, whitish lesions
known as ‘Condylomata lata’.
 ‘Serpentine Ulcers’ – in mouth.
 Mucous patches on the genitals or in the mouth.
 Genital warts, ulcers and chancres.
 All of these lesions are infectious and contain active treponema
organisms.
 Fever, sore throat, malaise, wt. loss, headache, meningismus.
 Enlarged lymph nodes
 Rare manifestations :
• acute meningitis, hepatitis, renal disease, hypertrophic gastritis, patchy
proctitis, ulcerative colitis, rectosigmoid mass, arthritis, periostitis, optic
neuritis, intersitial keratitis, iritis, and uveitis.

6. Syphilitic Lesions on patient’s back (left);
chest (right)

7. SECONDARY SYPHILIS (RASH ON PALMS OF
HAND)

8. ‘Serpentine’ Ulcers

9. 3] Latent syphilis
 Defined as having ‘serologic proof of infection without signs or
symptoms of disease.’
 Can be either early or late.
 Early latent syphilis: having syphilis for two years or less from the
time of initial infection without signs or symptoms of disease.
 Late latent syphilis: infection for more than two years but without
clinical evidence of disease.
 Distinction is important for both therapy and risk for transmission.
* Early latent syphilis : single I.M. injection of long-acting penicillin;
* Late latent syphilis : three injections each week.
 50% of latent syphilis cases progress into late stage syphilis;
25% stay in the latent stage, and rest 25% make a full recovery.

10. 4] Tertiary syphilis
 Occurs 1-10 years after initial infection, (can take up
to 50 years also).
 ‘Gummas’ or granulomas…
 soft, tumor-like balls of inflammation;
 are chronic; immune system is unable to completely clear
the organism.
 appear almost anywhere in the body (including the
skeleton).
 Gummas: indicate chronic inflammatory state in body;
mass-effects upon the local anatomy.

11. Tertiary Syphilis (contd’.)
 Diverse Neurological complications at this stage.
 Neuropathic joint disease - joint surfaces
degenerate due to loss of sensation and fine position
sense (proprioception).
 Severe manifestations - Neurosyphilis and CV
syphilis.
 ‘Generalized paresis of the insane’ - changes in
personality and emotions, hyperactive reflexes.
 Argyll-Robertson pupil (diagnostic sign in which the
small and irregular pupils constrict in response to
focusing the eyes, but not to light).
 ‘Tabes dorsalis’ (locomotor ataxia) - spinal cord
disorder, results in characteristic shuffling gait.

12. Tertiary Syphilis (contd.)
 CV complications :
• syphilitic aortitis, aortic aneurysm; aortic regurgitation;
• aneurysm of sinus of Valsalva.
• Infects the ascending aorta→ Dilation and aortic
regurgitation; (heard as a heart murmur).
• Insiduous course ( HF - presenting sign is observed after
years of disease).
• Coronary arteries - vessels narrowing.
• ‘de Musset's sign’ - Syphilitic aortitis causes bobbing of
the head (head nodding in time with the heart beat).

13. Syphilitic ‘Gumma’ on the nose

14. MODEL OF HEAD OF A PATIENT WITH
TERTIARY SYPHILIS

16. Neurosyphilis (contd.)
General Paresis / General Paresis of the Insane (GPI)
• Severe manifestation of neurosyphilis.
• Chronic dementia, ultimately results in death within 2-3 years.
• Patients - progressive personality changes, memory loss, poor
judgment. (Rarely - psychosis, depression or mania).
• Brain imaging usually shows atrophy.

17. EARLY DIAGNOSTIC TESTS
 Wasserman test (1906) – some false positive results, but
helped in preventing transmission to others.
 Hinton test (1930) – by William Augustus Hinton; fewer false
positive results
Both tests have been replaced by newer analytical tests.

18. DIAGNOSIS
 Fluid Microscopy
• from the 1° or 2° lesion using darkfield illumination;
• high accuracy.
 Rapid Plasma Reagin Test (RPR)
• Looks for non-specific Abs in patient’s blood (indicative of
syphilis);
• Does not look for Abs against the actual bacterium, but for Abs
against substances released by cells when damaged by T.
pallidum.
• Visualize the ‘Flocculation reactions’.
• Effective screening test only; ‘False Positives’ (sometimes).

19.  Venereal Disease Research Laboratory tests (VDRL test)
• Developed in 1946 by Harris, Rosenberg and Reidel.
• Non-treponemal serological screening for syphilis;
• To assess response to therapy; detects CNS involvement;
Used as a diagnostic aid (congenital syphilis).
• Detects ‘Anti-cardiolipin Abs’
• False positives: hepatitis, drugs, pregnancy, RA,
rheumatic fever, lupus and leprosy.
Cardiolipin
• is an important component of the inner mitochondrial membranes; (IgG, IgM or IgA).
• is seen in many diseases like syphilis, malaria, TB etc.

20. VDRL test (contd).
 Fluorescent Treponemal Ab - Absorption test (FTA-ABS)
• More specific; uses Treponemal species- specific Abs.
• Disadvantage – once a patient is positive, the test always shows
positive (even when patient has recovered); can’t establish
therapy efficacy.
 Treponema Pallidum Haemagglutination test (TPHA)
• Classic, indirect hemagglutination test.
• For the detection of Abs against Treponema pallidum.
• RBCs are sensitized with T. pallidum antigens → RBCs aggregate
together to form distinctive patterns on the surface of a microplate
wells.
• False Positives are common (due to Abs directed against other
non-pathogenic or non target treponemas, such as T. pallidum
subsp endemicum, T. pallidum subsp. pertenue, and T. carateum).

21. Dx tests (contd.)
 ELISA test
 Sexual history of patient
 CSF analysis (Leucocytsis in Neurosyphilis)

22. PREVENTION
 Abstinence; protective devices.
 T. pallidum readily crosses intact mucosa and cut skin,
including areas not covered by a condom.
 Individuals sexually exposed to a person with primary,
secondary, or early latent syphilis within 90 days preceding the
diagnosis should be assumed to be infected and treated for
syphilis, even if they are currently seronegative.
 Long-term sex partners of patients with late syphilis should be
evaluated clinically and serologically and treated appropriately.
 All patients with syphilis should be tested for HIV.
 Patient education is important.

23. TREATMENT
1] Penicillin G
• First choice of treatment.
• For Early syphilis – one dose is sufficient.
• For Latent Syphilis – weekly dose for 3 weeks.
• Parenteral penicillin G can be used during pregnancy.
2] Oral Tetracycline and Doxycycline
• For penicillin-sensitive patients.
3] Ceftriaxone, Azithromycin

24.  Neurosyphilis
• NO oral antibiotics
• Penicillin G i.v. Q4H continuously for 10 – 14 days.
• Procaine penicillin + Probenecid – if I.V. administration isn’t
possible.
• Procaine injections are very painful;
• Benzathine penicillin G - 3 weekly doses after completing 14-
day course of aq.crystalline / aq.procaine penicillin G.
• Ceftriaxone I.M. daily for 14 days

25. THE END