This document provides an overview of syphilis of bones and joints, including its pathology, clinical manifestations, diagnosis, and management. Syphilis is caused by the bacterium Treponema pallidum, which can spread to bones via the bloodstream. In bones, it causes inflammatory responses that can destroy tissue. Congenital syphilis commonly involves the long bones and skull in infants. Clinical features may include pseudoparalysis or bone deformities. Radiographs show changes to the growth plates and periosteal reactions. Adult syphilis often causes painless periostitis of long bones and skull. Diagnosis involves serology tests and microscopy. Treatment is with penicillin, including high dose intravenous regim

1. INTRODUCTION, CLINICAL
MANIFESTATIONS, DIAGNOSIS,
MANAGEMENT OF SYPHILIS OF BONES
AND JOINTS
BY
DR HARI CHANDANA

2. INTRODUCTION
• Bone , bone marrow and the periosteum are favoured sites for involvement of
syphilis.
• Syphilis is caused by a spirochete- treponema pallium.
• Due to advent of penicillin syphilis has become rare these days.
• However occasional condition requires identification and differentiation from
other diseases.

3. PATHOLOGY
• The bacteria is blood borne and lodges within medulla particularly at
metaphysis.
• It calls for a low grade inflammatory response which causes outpouring of
lymphocytes and plasma cells.
• If the defenses are adequate the bacteria are destroyed and exudate is
resorped or the granulation tissue invades , trabeculae are destroyed and
healing takes place by fibrosis.
• If defenses are inadequate the virulence of the organism destroys the
tissues locally causing necrosis.
• The infective material extends through haversian system to periosteal
space, osteoblastic reaction becomes extensive leading to reactive new
bone formation.

4. Bone and joint changes in syphilis are seen mainly in
* congenital syphilis – early congenital and late
congenital
* Adult syphilis – late stages ie in tertiary syphilis

5. EARLY CONGENITAL SYPHILIS
• Medulla is always involved.
• Metaphysis is most commonly involved due to rich blood supply.
• The granulation tissue invades the zone of calcified cartilage and therefore
fails to resorp and accumulates in large amounts at the epihyseal plate.
• It also interferes with laying of osteoid tissue therefore the trabeculae formed
are sparse and irregular.
• These explains the radiographic features.

6. CLINICAL FEATURES
• Shortly after birth the limb displays a large tender swelling at the joint.
• Child becomes irritable, restless and cries often.
• The limb is held immobile as if paralysed – parrots pseudoparalysis
• Other features are snuffles, skin lesions, mucous patches.

7. LATE CONGENITAL SYPHILIS
• Late congenital syphilis is regarded as tertiary stage of congenital syphilis.
• It occurs after 2-3 yrs.
• Osteoblastic changes occurs at femur, tibia and skull.
• Periosteal bone formation is seen over anterior aspect of tibia causing bony
prominence – "sabre tibia" ( no actual bowing of tibia).
• Nodular thickenings of outer table of skull is seen – parrots nodes .
• Hot cross bun look of cranium is seen.
• Thickening of inner third of clavicle - HIGOUMENAKIS SIGN
• BULL DOG JAW – prominent mandible

8. • CLUTTONS JOINTS – large, bilateral, painless effusions occurring at knee
joints. Seen between 8 to 18 yrs age. It is symmetrical synovitis. Arises
intermittently and disappears mysteriously. No radiological features are seen.
• SYPHILITIC DACTYLITIS – phalanges and metacarpals are enlarged and
deformed by osteoblastic changes. Become spindle shaped with a painful
boggy swelling. Radiography shows marked increase in density with multiple
areas of gummatous destruction.
• Associated features are interstitial keratitis, eighth nerve deafness, deformed
incissor teeth: " HUTCHINSONS TRIAD"

10. RADIOGRAPHIC CHANGES
• Metaphysis is widened, irregular saw toothed appearance or moth eaten
appearances are seen.
• Increased zone of density of metaphysis with osteoporosis just beyond it is
seen.
• Epiphyseal separation is seen.
• Laminated periosteal ossifications are seen.
• Wimberger sign – localised b/l destruction of metaphysis of medial proximal
tibia. Pathognomic of congenital syphilis.

12. ADULT SYPHILIS
• Bone and joint lesions are seen in tertiary stage of syphilis.
• Atleast 50% have bone involvement but only a few manifest clinically and
radiologically.
• Periostitis is the most common lesion found in both skull and long bones.
• The periosteum becomes edematous and is infiltrated with round cells and
granulation tissue which further becomes fibrous tissue and is ossified by a
lace like deposition of new bone.
• In skull outer table is chiefly involved but the gummatous destruction may
erode the table causing leutic meningitis

13. CLINICAL FEATURES
• Bony lesions are seen as painless, fixed , non tender swellings of long bones
and skull.
• No signs of inflammation are seen.
• If neighbouring joint is involved effusion, irregular lumpy swelling and little
restriction of movement is seen.
• If extensive destruction is present a secondary infection may cause
suppurative arthritis.

14. RADIOGRAPHIC CHANGES
• Picture of early infection is negative.
• Prolonged infection causes – osteoblastic
densities, thickening of cortex, lace like
or laminated sub periosteal thickening .
• Gummatous destruction may manifest as
moth eaten appearance with
interspersed areas of sclerosis.

15. DIAGNOSIS
• Congenital syphilis:
• History of repeated spontaneous abortions of mother
• Physical examination
• Serological tests: fluroscent treponemal antibody absorped test, VDL, RPR.
• These are generally negative in first few months of life. Can be done in
mother
• Radiological features.

16. • Adult syphilis:
• History and clinical examination.
• Dark field microscopy: To demonstrate the spirochete
• Serological tests: TPHA, VDRL, RPR , FTA-ABS( highly sensitive and specific)
• Radiological features.

17. TREATMENT
• Congenital syphilis:
• Early syphilis Recommended Regimens
Aqueous crystalline penicillin G 100,000–150,000 units/kg/day, administered as
50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8
hours thereafter for a total of 10 days
• OR Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10
days

18. • Recommended Regimens for late syphilis in Infants and Children
Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million
units in a single dose
Or
Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million
units, administered as 3 doses at 1-week intervals (total 150,000 units/kg up to
the adult total dose of 7.2 million units)

19. • Recommended Regimens for Adults
• Early Latent Syphilis
Benzathine penicillin G 2.4 million units IM in a single dose
• Late Latent Syphilis or Latent Syphilis of Unknown Duration
Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4
million units IM each at 1-week intervals

20. THANK YOU