The document discusses syphilis, a chronic bacterial infection caused by Treponema pallidum, detailing its clinical aspects, stages, and transmission modes, including sexual contact and mother-to-fetus transmission. It outlines the clinical presentation during various stages, diagnostic methods, treatment options, and management of contacts and congenital cases. Treatment primarily involves penicillin, with specific regimens based on the stage of the disease.

1. Syphilis: Clinical Aspects,
Epidemiology, and Control

2. Taxonomy
 Domain: Bacteria
 Phylum: Spirochaetes
 Order: Spirochetales
 Family: Spirochaetaceae
 Genus: Treponema
 Species: pallidum
 A Bacterial Infection
that can be chronic and
systemic
 Infectious During
Specific Time Frames
related to Stage
 Sexually Transmitted
(oral, vaginal, anal)
 Curable
Syphilis is:

3. The mode of transmission can be:
 Sexual, which is the most important mode of
infection.
 Sexual perversion ( homosexual and orogenital
contacts ).
 Accidental inoculation.
 Through contaminated blood.
 Transplacental infection, from an infected mother
to the fetus.
 During delivery as the baby passes through an
infected canal.

4. Clinical stages of syphilis
2 years
Acquisition
(~30%)
1o
2o
2o
Early syphilis
(infectious)
Late syphilis
(non-infectious)
3o
Incubation period
10-90 days
(average 21 days)
Weeks to few months Episodes may recur
(occurs in 25%)
1 to 30 years:
If untreated
occurs in
40%, 25%
clinically
recognisable

5. WHO clinical classification of syphilis

6. Primary Syphilis
Chancre:
Appears 10-90 days after
infection
Typically single, painless,
clean-based lesion with
rolled edges

7. Primary Syphilis
Chancre, Tongue

8. Secondary Syphilis
Signs and Symptoms
 Usually occurs 3-6 weeks after primary
chancre
• Rash (75-90%)
• Generalized lymph node swelling (70-90%)
• Constitutional symptoms (50-80%)
• Mucous patches (5-30%)
• Condyloma lata (5-25%)
• Patchy alopecia or hair loss (10-15%)
• Symptoms of neurosyphilis (1-2%)
• Less common: meningitis, hepatitis,
arthritis, nephritis

9. Macular
Rashes of Secondary
Syphilis
Palmar
Papular

10. Secondary Syphilis Macular
Eruptions
 Exanthematic erythema 6-8 weeks after
chancre, extends rapidly, may last hours to
months
 Round indistinct, slightly scaling ham-colored
macules
 Pain, burning absent, pruritus may be present
 Generalized shotty adenopathy

11. Rash of Secondary Syphilis

12. Macular


13. Rash of Secondary Syphilis

14. Secondary Syphilis
Papular Eruptions
 Arise later than macular, raw-ham, round, 2-
5mm or more in diameter, slightly raised,
smooth or thick scale
 Face and flexures of arms and legs, trunk
 Palmar and plantar yellowish-red spots
 Ollendorf’s sign; papule tender to touch of a
blunt probe

15. Palmer/Plantar Rash of Secondary Syphilis

16. Maculo-papular

17. Papulo-squamous

18. Pustular

19. Condyloma lata
wart-like lesions in moist
intertriginous areas.
• Sessile
• don’t bleed easily.
• D.D.: Condyloma
accuminata:
 Pedunculated
 Bleed easily.
 All of these lesions teem
with treponemes and are
highly contagious.

20. Secondary Syphilis
Mucous Membrane
 Present in 1/3 of secondary syphilis
 Most common is “syphilitic sore throat”
 Diffuse pharyngitis, hoarseness
 Tongue; patches of desquamation of papillae
 Ulcerations of tongue and lips in late stages

21. SECONDARY SYPHILIS
 Mucous patches are oral lesions found on the lips, cheeks,
tongue, palate, tonsils these are oval or circular, slightly
raised patches, covered by a grayish sodden membrane .
Superficial ulcers in the form of “ snail-track” are occasionally
seen.

22. Mouth

23. Mucocutaneous Lesions of Secondary Syphilis

24. Generalized lymphadenopathy
 Discrete.
 Rubbery.
 Not tender.

25. Secondary Syphilis
Moth-Eaten Alopecia (Hair Loss)

26. Less Common
Retinitis

27. Systemic Manifestations:
 Malaise
 Anorexia
 Headache
 Sore throat
 Arthralgia
 Low grade fever
 Nephrotic syndrome.

28. Secondary Syphilis
Diagnosis
 Nontreponemal serologic tests for syphilis are
strongly reactive (seronegativity rarely in
AIDS)
 Spirochetes on darkfield exam

29. Secondary Syphilis
Ddx “Great Imitator”
 Pityriasis rosea
 Drug eruptions
(pruitic)
 Lichen planus;
Wickham’s striae,
Koebner’s, pruitic
 Psoriasis; no
adenopathy
 Sarcoidosis; need
serology and silver
staining of biopsy
 Infectious
mononucleosis, false
pos RPR
 Geographic tongue
 Aphthous stomatitis

30. TERTIARY SYPHILS
is a no contagious but highly destructive phase
of syphilis which may take many years to
develop; it may manifest itself in several
forms:
 Gummas
 Neuro-syphilis
 Cardiovascular Syphilis

31. Gummas
 It develops in 15% of
untreated cases within 1-10
years after infection.
 highly destructive tertiary
syphilitic lesions that usually
occur in skin and bones but
may also occur in other
tissues.
 Slowly progressive, painless,
dull red nodule or plaque.
 Breakdown into ulcer with
wash-leather floor.
 Regional Ln are not enlarged.
 Not infectious.

32. Gummas in tertiary
syphilis

33. Neurosyphils
 in which there are no
symptoms of CNS
involvement but the CSF is
abnormal:
• Elevated lymphocytes
• Elevated protein.
• Positive CSF VDRL tests
• Approximately 20% of these
patients progress to
symptomatic neurosyphilis
 Symptoms of neurosyphilis:
• 8% of untreated
cases.
• 5-35 years after
infection.
 Invasion of the CNS occurs
early when generalized
dissemination occurs (2°
syphilis).
Asymptomatic Symptomatic

34. Diagnostic Tests

35. Diagnostic Tests for Syphilis
 Darkfield / DFA-TP
 PCR
 VDRL/RPR
 FTA-abs / TP-PA (MHA-TP)
 EIA

36. T. pallidum on Darkfield

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

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

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

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

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

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

43. 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
titer after adequate treatment

44. CONGENITAL SYPHILIS
Early congenital syphilis:
 occur before the age of 1 year;
 occur in children from 1 to 4 year.
• a) late syphilitic ophtalmopathy (involvement of
the eyes);
Late congenital syphilis:
 b) other forms of the late congenital syphilis
(involvement of the skin, mucous membrane,
nervous system, latent syphilis).

45. Diagnosis of congenital syphilis
 Mothers anamnesis
 Examination of placenta and umbilical cord
 Assessment of typical characteristics of congenital
syphilis in different growing group
 Treponema pallidum can be demonstrated in a smear
from skin lesions with moist surface.
 Assessment of eye ground
 An X-ray examination of the long bones
 Clinical assessment of parents.

46. Possible results of pregnancy, according to
the time of affection of pregnant:
 Abortion ( pregnant affected by syphilis before pregnancy or
during first month of pregnancy)
 Stillbirth ( pregnant affected by syphilis during 4 -5 month of
pregnancy)
 Birth of child with congenital syphilis ( pregnant affected by
syphilis during 6 -7 month of pregnancy)
 If pregnant affected by syphilis during last 1,5-2 month of
pregnancy, fetus can affected from mother in delivery
during passing through an infected canal

47. Congenital syphilis:
of children before the age of 1 year
 Syphilitic pemphigus
 Diffuse infiltration
 Syphilitic rhinitis
 Osteochondritis
 Syphilitic chorioretinitis

48. Syphilis of placenta
 Placenta is edematous,
pale, greasy and bulky.
 Weight of placenta is 800-
900 g (500g in normal).
 Placenta is more than one-
fourth of fetal body weight
( more than one- fifth in
normal).
 Treponema pallidum can
be demonstrated in a
smear from placenta
( that’s why it is very
contagious).

49. Syphilis of fetus
 Maceration of fetus.
 Sometimes dead.
 Little weight.
 Enlargement of liver and spleen.
 Lungs are enlarged, thick, grey-yellow in their color
(“Pneumonia Alba”).

50. Syphilitic pemphigus
 Present after burning or
appeared within the first days
ore weeks of life.
 Consists of bullas
0,5-1 sm. in dm.
 Vesicles and erosions distributed
bilaterally and symmetrically on
the front of the palms and soles.
 Treponema pallidum can be
demonstrated in a smear from
bulla.

51. Diffuse infiltration
 Appeared within the first
weeks or month of birth
around angles of mouth,
lips, buttocks, palms,
soles and anus.
 Zones of affection are flat
,thick ,yellow-brawn in
color with shinny surface.
 Later fissuring of lips,
deep fissures at the
angles of the mouth may
be seen, after recovering
of which we can see
specific fusiform radial
atrophic scars.

52. Syphilitic rhinitis
 Nasal breathing is
difficult.
 Highly infectious
purulent-serous and
hemorrhagic nasal
discharges ( snuffles).
 Breathing is hoarse and by
mouth.
 Nasal septum is dislocated
or destroyed with the
future deformation of the
nose.

53. Syphilitic chorioretinitis
Assessment of eye
ground show points of
pigment and zones of
depigmentations -
symptom of
“salt- and-pepper”

54. Osteochondritis
 The main specific and
characteristic changes of the
bones in patient with congenital
syphilis in children before the age
of 1 year
 Appeared in intrauterine period
and cant be diagnose till the end
of 1 year of birth
 During X-ray examination we can
see light strips 0,5-1,5 mm
( breach of ossification cartilage)
between metaphysic and
epiphysis
 On josses places bones fractures
can appear

55. Congenital syphilis:
of children from1 to 4 year
 Condiloma lata can also appeared on genital organs, inguinal folds, perianal zones with
moister surface and large amount of Treponema pallidum .
 Pustules, nodules, erosions of mucous membranes of oral cavity.
 Affection of bones, inner organs and nerves system can be present.
 Certain amount of papules in extremities, buttocks, genital organs, on the inguinal folds. They
can be moister. Erosions with a large amount of Treponema pallidum on their surface.

56. Late congenital syphilis
Can appear in 5-20 years old and later is
characterized by many specific changes in the:
 Skin
 Bones
 Mucous membranes
 Inner organs
 Nerve system
 Sensitive organs

57. International classification of
late congenital syphilis
 Late syphilitic
ophtalmopathic
(involvement of the eyes).
 Late congenital
neurosyphilis.
 Others form of late
congenital syphilis
1. Affection of bones
2. Affection of teeth
(Hutchinson’s teeth)
3. Hutchinson’s triad
( interstitial keratitis,
Hutchinson’s teeth, eight
nerve deafness).

58. Syphilis: Treatment
Penicillin G
u Intravenous or intramuscular
injection of penicillin G is the
preferred drug for treatment of all
stages of syphilis
u Benzathine penicillin G, aqueous
procaine penicillin or aqueous
crystalline penicillin can be used
u Bicillin-LA (not CR)

59. Syphilis: Treatment
Primary, Secondary & Early Latent
 Recommended regimen:
 Benzathine penicillin G 2.4 million units
IM once
 Non-pregnant penicillin-allergic adults *
Data to support the use of alternatives to
penicillin are limited and if used, close follow-
up is essential
Ceftriaxone1 g IM daily x 8-10 d or
(Azithromycin 2 g po)…not recommended
in CA
* Efficacy in HIV + persons not studied so use with
caution

60. Syphilis: Treatment
Late Latent and Unknown Duration
 Recommended regimen:
Benzathine Penicillin G 7.2 million units
total, given as 3 doses of 2.4 million units
each at 1 week intervals
 Non-pregnant penicillin-allergic adults *
• Doxycycline* 100mg orally two times a
day for 4 weeks or
• Tetracycline* 500mg orally four times a
day for 4 weeks
*Close follow-up essential and efficacy in HIV+ not studied so use with
extreme caution

61. Syphilis: Treatment
Neurosyphilis
 Recommended regimen:
 Aqueous Crystalline Penicillin G 18-24 million
units IV daily administered as 3-4 million IV
every 4 hrs for 10 -14 days
 Alternative regimen:
• Procaine Penicillin G 2.4 million units IM daily
plus Probenecid 500 mg PO daily, both for
10-14 days

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

63. Partner Evaluation for Syphilis
Exposure Periods
 All partners within the following
time periods require evaluation:
• 1o
: 90 days + duration of symptoms
• 2o
: 6 months + duration of symptoms
• Early latent: 1 year
 Partners of patients with syphilis of
unknown duration and titers >
1:32 should also be evaluated

64. Management of Contacts
u Contacts to primary, secondary or
early latent syphilis
u Persons exposed within 90 days
preceding the diagnosis in a sex
partner might be infected even if
seronegative: Treat presumptively
u 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

65. Jarisch-Herxheimer
reaction
 Manifestations: general malaise, fever, headache, sweating,
rigors, or a temporary exacerbation of the syphilitic lesions.
 Usually seen w early syphilis, especially secondary syphilis.
 Seen within 6 to 12 h of initial treatment.
 Usually subsides within 24 h and poses no danger but may
produce anxiety.
 However, patients with general paresis or a high CSF cell
count are likely to develop serious disorders, such as seizures
or strokes.
 It may be confused with allergy to antibiotics.
 May indicate coexistent syphilis in patients treated for other
conditions with antibiotics active against syphilis
 This reaction should be explained to the patient before
treatment.

66. THE END