The document discusses Treponema, the bacteria that causes syphilis and other treponematoses. It begins by introducing the genus Treponema and the four diseases it can cause: syphilis, yaws, endemic syphilis, and pinta. It then describes the clinical manifestations of syphilis, including primary, secondary, latent, and tertiary stages. Finally, it covers diagnosis, treatment, prevention strategies, and the links between syphilis and HIV.

1. Treponema
The Great Imitator
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2. Introduction
• Genus Treponema contains both pathogenic and nonpathogenic species. spirochaete bacterium
• Human pathogens cause four treponematoses:
• Nonpathogenic treponemes may be part of the normal flora of the intestinal tract, the oral cavity, or the
genital tract
• Some of the oral treponemes have been associated with gingivitis and periodontal disease
1. Syphilis (T. pallidum subspecies pallidum)
2. Yaws (T. pallidum subspecies pertenue)
3. Endemic syphilis (T. pallidum subspecies endemicum)
4. Pinta (T. carateum)

3. Clinical Manifestation
• Because syphilis exhibits diverse clinical manifestations that mimic many other infectious and noninfectious
disorders
• it has earned a reputation as “the great imitator”
• Treponema pallidum subspecies pallidum is the most invasive of the pathogenic treponemes
• It produces highly destructive lesions in almost any tissue of the body, including the central nervous system
• Treponema carateum is the least invasive and causes only cutaneous disease
• Treponema pallidum subspecies pertenue and endemicum are intermediate in invasiveness and cause
destructive lesions in bones and soft tissues

4. Clinical Manifestation
Primary syphilis
• Primary (or hard) chancre which usually begins as a single painless papule that rapidly becomes ulcerated,
hard, and indurated, covered by thick exudates. The most common sites are penis (in males), cervix or labia
(in females), and anal canal, rectum or mouth (in homosexual)
• Regional (usually inguinal) lymphadenopathy which appears within 1 week of onset of skin lesions
• Lymph nodes are painless firm, non-suppurative, and often bilateral
• The chancre generally heals within 4-6 weeks (range 2- 12 weeks), but lymphadenopathy may persist for
months

5. Clinical Manifestation
Secondary syphilis
• Secondary syphilis results from the systemic spread of the infection when treponemes replicate in the lymph
nodes, the liver, joints, muscles, skin, and mucous membranes distant from the site of the primary chancre.
• Skin and mucous membranes are commonly affected and characterized by:
• Skin rashes (palms and soles )
• Condylomata lata (mucocutaneous papules which coalesce to form large pink to grey lesions in warm moist
intertriginous areas (such as perianal region, vulva, and scrotum).
• Mucous patches (superficial mucosal erosions)
• Generalized lymphadenopathy is seen.
• The patient may also have syphilitic meningitis, hepatitis, nephritis (immune complex type), or periostitis.

6. Clinical Manifestation
Latent syphilis
• It is characterized with no clinical manifestations but serological evidence of infection persists.
• Latent syphilis is classified as early (high likelihood of relapse) or late (recurrence unlikely).
• Individuals with late latent syphilis are not generally considered infectious, but may still transmit infection to
the fetus during pregnancy and their blood may remain infectious.
• Latent syphilis may have one of the following fates: Persistent lifelong infection (common), Development of
late syphilis (rare), Spontaneous cure.

7. Clinical Manifestation
Tertiary syphilis
• Tertiary syphilis is responsible for a majority of the morbidity and mortality associated with the disease.
• The hallmark of tertiary syphilis is the destruction of tissue caused by a response to the presence of
treponemal antigens.
• The three most common forms are neurosyphilis, cardiovascular syphilis and gummatous syphilis.
• Gummatous syphilis: Granulomatous lesions in the skin, bones, and liver

8. Clinical Manifestation
Tertiary syphilis
Neurosyphilis
• Degenerative changes in the central nervous system
• Common manifestations include: Meningeal syphilis (meningitis), Meningovascular syphilis (vasculitis of
arteries leading to embolic stroke), paralytic dementia, Tabes dorsalis (demyelination of the posterior
columns)
Cardiovascular syphilis
• Characterized by aneurysm of ascending aorta ( dilation of aorta) and aortic regurgitation (leaking of aortic
valve)

9. Clinical Manifestation
Multiplication of the
organisms at the initial site
of entry produces the
primary stage
The dissemination of
treponemes to other tissues
results in the secondary stage
After a relatively prolonged period,
in some cases 20 to 30 years, the
tertiary or late stage evolves

10. Symptoms
About 2 to 10 weeks after the first sore appears, you may develop the following:
• A skin rash that causes small, reddish-brown sores
• Sores in your mouth, vagina, or anus
• Fever
• Swollen glands
• Weight loss
• Hair loss
• Headache
• Extreme tiredness (fatigue)
• Muscle aches

11. Symptoms

12. Structure
• Treponemes are helically coiled, corkscrew-shaped organisms 6 to 15 μm long and 0.1 to 0.2 μm wide
• The organisms stain poorly with aniline dyes. Treponemes in tissues can be visualized by silver
impregnation methods
• this organism has been considered a strict anaerobe, but it is now known to be microaerophilic.
Treponemes multiply by binary transverse fission
• It is rapidly inactivated by mild heat, cold, desiccation, and most disinfectants
• It has not been successfully cultured in vitro
• treponemes possess both outer and cytoplasmic membranes (not gram negative)
• three flagella originate from each end of the bacterium

13. Structure

14. Pathogenesis
• Humans are the only natural host for T pallidum subsp pallidum, and infection occurs through sexual
contact
• The organisms penetrate mucous membranes or enter minuscule breaks in the skin
• In women the initial lesion is usually on the labia, the walls of the vagina, or the cervix; in men it is on the
shaft or glans of the penis
• A chancre also may occur on lips, tongue, tonsils, anus, or other skin areas
• perivascular inflammation: This typically consists of proliferation of adventitial cells; perivascular cuffing
with lymphocytes, monocytes and plasma cells; and swelling and proliferation of endothelial cell

15. Congenital Syphilis
• A pregnant woman with syphilis can transmit T pallidum
to the fetus through the placenta beginning in the 10th –
15th weeks of gestation.
• Some of the infected fetuses die, and miscarriages result;
others are stillborn at term.
• Congenital anomalies include premature birth,
intrauterine growth retardation, and multiple organ
failure.

16. Congenital Syphilis
Manifestations of congenital syphilis include:
• Earliest manifestations occur within 2 years of age and affected children are infectious and they suffer
from mucocutaneous lesions, bone changes, hepatospleenomegaly and lymphadenopathy.
• Late congenital syphilis occurs after 2 years and is noninfectious.
• It is characterized by interstitial keratitis, eighth-nerve deafness, bilateral knee effusions (Clutton’s joints).
• Residual stigmata may remain for long time such as:
• Hutchinson’s teeth (notched central incisors)
• Mulberry molars
• Saddle nose (height of nose decreases), and saber shins (convexity of the tibia)
• In the congenital infection, the child makes IgM antitreponemal antibody.

17. Diagnosis
• Definitive diagnosis of syphilis is complicated by the inability to cultivate T pallidum subsp pallidum in
vitro
• Serologic tests are a mainstay of syphilis diagnosis
Diagnosis
Nontreponemal tests Treponemal Test
measure antibodies directed against lipid antigens,
principally cardiolipin, thought to be derived from
host tissues
detect antibodies directed against protein
constituents of T pallidum subsp pallidum.
Venereal Disease Research Laboratory (VDRL) test,
Rapid Plasma Reagin (RPR) tests
Antibody-Absorption (FTA-ABS) and
Microhemagglutination for T pallidum
(MHA-Tp) tests

18. Diagnosis
• Congenital syphilis is difficult to diagnose in asymptomatically infected neonates because
maternal antibodies (IgG) which pass through the placenta and enter the fetal circulation cause
reactivity in both nontreponemal and treponemal tests
• In uninfected infants, such maternal antibodies disappear by 3 months
• Because of the presence of maternal antibodies in the newborn, quantitative VDRL or RPR tests
should be performed monthly over the first 6 months
• If the titer increases or stabilizes and does not decrease, congenital syphilis is indicated and the
baby should be treated accordingly.

19. Control
• the condom remains the method of choice for prevention of sexual transmission
• Topical application of antibiotics, chemicals, creams, or lotions and thorough washing with soap
and water after sexual contact are highly ineffective
• race contacts of syphilitic patients; these contacts are then treated prophylactically before onset
of clinical manifestations
• Penicillin remains the drug of choice for treating syphilis
• Penicillin G
• Tetracycline in penicillin allergic patients

20. Link between STI’s and HIV
• A person who has an STI (urethral discharge or genital ulcer) runs as much as four times the risk of
contracting HIV from a sexual partner, than a person who is not infected with STI
• An ulcerative STI poses a significantly greater risk of HIV transmission; because the HIV virus can be
enter the body more easily through the genital ulcer
• HIV virus is present in large numbers in the semen and vaginal fluids of infected persons. Unsafe
sexual contact with an infected person enables easy entry of HIV virus especially in the presence of
ulcerative lesions on the genitalia
• Therefore, because of the strong link between HIV and STI, it is very important to treat all STI’s
completely and curatively as early as possible. Correct and consistent use of condoms can protect
against HIV and STI, by preventing contact with infected semen and vaginal fluids.

21. STI Clinics in Kerala - PULARI
'Pulari' or STI clinics are centres for the treatment of
Sexually Transmitted Infections free of cost to anyone
who walks into the clinics
Where?
Currently, there are 21 Pulari centres functioning in
Kerala. Out of this, 14 are in district hospitals and the
rest are in Govt. Medical Colleges / Co-op. Medical
Colleges (Pariyaram and Kochi)
General Hospital, STI Clinic,
Department of Dermatology & STD,
Medical College Hospital, Kozhikode

22. Anti retroviral treatment centers - USHUS
'Ushus' are the Anti Retroviral Treatment (ART) centres set up
in all the Government Medical Colleges in Kerala, functioning
under the department of medicine. ARV treatment, drugs for
opportunistic infections and the CD4 testing are all provided
free of cost to HIV positives. Kerala is the first state in India to
start ART for HIV positive people in 2004, by meeting funds
from its exchequer. Since 2006, the ART centres are
supported by National AIDS Control Organization
General Hospital, ART centre,
Department of Dermatology & STD,
Medical College Hospital, Kozhikode

23. ICTC- JYOTHIS
Jyothis or Integrated Counselling and Testing Centres
(ICTC) Centres provide HIV counseling and testing and
treatment referrals free of cost. There are 163 centres
across the state located at all Medical Colleges, District
Hospitals, General Hospitals, Taluk Hospitals as well as
at some ESI hospitals and Private hospitals. In addition,
there are centres in some railway stations and major
prisons.
General Hospita, Medical College
Hospital, Kozhikode