Syphilis Disease

DESCRIPTION

A sexually transmitted infection, characterized by sequential stages (acute, subacute or chronic), with the spirochete, Treponema pallidum

Infectious (primary or early syphilis) consists of a primary stage and a secondary stage. It may include neurosyphilis (central nervous system involvement). If the patient is untreated, the infectious stage may be followed by a latent stage.
Latent syphilis is an asymptomatic phase in an untreated patient, characterized by positive specific treponema Ab test with normal CSF. Early latent is less than 1 year and late latent is more than 1 year after onset of infection.
Neurosyphilis may occur at any stage in syphilis. Primary, secondary stages usually asymptomatic; tertiary stage is symptomatic.
Tertiary (or late syphilis) stage is late generalized syphilis
Congenital is syphilis acquired in utero
System(s) affected: Reproductive, Skin/Exocrine, Nervous, Cardiovascular
Genetics: N/A
Incidence/Prevalence in USA:
- 1989 – 18.4/100,000 new cases
- 1997 – 3.2/100,000 new cases (50% occurred in just 31 counties of 3,115 U.S. counties)
- 1998 – 2.6/100,000
Predominant age: Sexually active years
Predominant sex: Male > Female

SIGNS AND SYMPTOMS

Infectious syphilis – primary
- Chancre begins as a papule which erodes to a 0.3 to 2 cm non-tender ulcer with a hard edge and clean, yellow base (unless secondarily infected) 9 to 90 days after exposure (median 3 weeks)
- Usually found on genitalia, frequently solitary, may be multiple, may have regional lymphadenopathy
- Heals with scarring in 3 to 6 weeks with 75% of patients having no further symptoms
Infectious syphilis – secondary
- 25% of patients enter this stage 2–6 weeks after exposure, may overlap with chancre
- Resolves spontaneously in 2–6 weeks in most patients
- May wax and wane between secondary and latent stages
- Rash is bilaterally symmetric, generalized polymorphic, palpable lesions with “fresh cut ham” color, non-pruritic, usually not bullous or vesicular, frequently on palms and soles
- Patchy alopecia of scalp, eyebrows and beard common
- Mucous patches – thin gray smears – and condyloma lata – moist, flat, pink, peripheral warty lesions – may be present on glans, perianal, vulva areas
- Generalized lymphadenopathy and flu-like symptoms occur early with rash
- Rarely may be accompanied by nephritis, meningitis, uveitis, hepatitis
- Mild hepatosplenomegaly often noticeable
Latent syphilis
- Characterized by positive serology but no signs or symptoms
- Patient is not infectious after one year, but may relapse to infectious secondary stage if untreated (25% in first year, small percent second year, none after that)
Tertiary syphilis
- Marked by cardiovascular (aortic valve disease or aneurysms)
- Deep cutaneous (gummas which are destructive granulomatous pockets)
- Orthopedic (Charcot's joints, osteomyelitis) complications (rare with antibiotics)
- Serologies often negative
Neurosyphilis
- Can be any stage with CNS involvement, eye, ear symptoms
- Meningitis, tabes dorsalis
- General paresis
Congenital syphilis (children are asymptomatic until age 2)
- Failure to thrive
- Rhinitis
- Lymphadenopathy
- Jaundice
- Anemia
- Hepatosplenomegaly
- Nephrosis
- Meningitis
- Rash (the hallmark) similar to secondary syphilis in adults, but may be bullous or vesicular

CAUSES

Treponema pallidum

RISK FACTORS

Multiple sexual partners
Exposure to infected body fluids
IV drug use
Infants may be exposed transplacentally

LABORATORY

Requires either demonstration of organisms on microscopy or positive serology on blood or cerebrospinal fluid (CSF)
Organism may not be cultured, but diagnosis is never made on clinical signs and symptoms alone
Nonspecific treponemal tests: Venereal Disease Research Laboratory (VDRL) or rapid plasma reagin (RPR) are characterized as follows:
- Relatively inexpensive, primary screening test
- Positive within 7 days of exposure
- Titer decreases with time or treatment
- Used to monitor therapy: fourfold rise in titer indicates new infection while failure to decrease fourfold within one year is treatment failure; always use the same test (VDRL or RPR). Since some patients stay serofast, follow-up can be difficult.
- False-positive common but positives are highly suggestive even without clinical signs and symptoms (confirm with fluorescent treponemal antibody absorption [FTA-ABS])
- Titer ≥ 1:64 even without confirming test is probably diagnostic of acute syphilis or other treponematoses
- Labs need to titer tests to final end point (not report as ">1:512" for example) to make best use of results in monitoring therapy response
- Beware of prozone phenomenon – negative results due to very high titers of antibody. Test diluted serum sample, as well, to declare a given specimen as negative.
Specific treponemal tests: Fluorescent treponemal antibody absorption (FTA-ABS), microhemagglutination Treponema pallidum (MHA-TP)
- More expensive, used to confirm diagnosis
- Usually positive for life after treatment
- Due to unusual nonspecific test results in HIV-infected patients, these tests may be needed to absolutely rule out syphilis
Lumbar puncture for CSF serologies (plus WBC, protein, glucose) should be done:
- In cases of latent syphilis where duration is unknown or non-penicillin therapy is planned
- Whenever neurological symptoms are present
- VDRL, not RPR, is used on CSF; may be negative in neurosyphilis
- Negative FTA-ABS or MHA-TP on CSF excludes neurosyphilis
- Positive FTA-ABS or MHA-TP on CSF is not diagnostic

Drugs that may alter lab results: Many drugs reported to cause false-positive, but this is relatively uncommon with a good history
Disorders that may alter lab results:

Rheumatic (SLE: false-positive)
Acute febrile illness
HIV infection
Pregnancy

PATHOLOGICAL FINDINGS

Aneurysm, osteomyelitis, gummas in late cases

SPECIAL TESTS

Dark field microscopy
Immunofluorescence
Skin biopsy

IMAGING

Only in late cases as indicated

DIAGNOSTIC PROCEDURES

Specialized test available from Center for Disease Control (CDC) to confirm false-positive if necessary

APPROPRIATE HEALTH CARE

Outpatient, except for initiating IV penicillin or desensitization

GENERAL MEASURES

Baseline serologies prior to treatment to monitor its success
Prompt institution of antibiotics
Symptomatic treatment of the chancres and rash of secondary syphilis (for patient's comfort only) includes baths, antihistamines, etc. Chancres require only routine cleansing with water and mild soap.

SURGICAL MEASURES

N/A

ACTIVITY

Full activity, but no sexual contacts until declared cured

DIET

No special diet

PATIENT EDUCATION

Need to trace and treat all sexual contacts of the patient
Keep follow-up appointments to monitor success of therapy
Advise patient to avoid intercourse until treatment is complete
Local health department can provide literature and contact tracing

PREVENTION/AVOIDANCE

Discuss safe sex
Use of condoms

POSSIBLE COMPLICATIONS

Cardiovascular disease
Central nervous system disease
Membranous glomerulonephritis
Paroxysmal cold hemoglobinemia
Organ damage that cannot be reversed
Jarisch-Herxheimer reaction, marked by fever, chills, headache, myalgias, new rash is common on starting treatment (of primary or secondary disease; less common with tertiary) due to the lysis of treponemes and should not be confused with a reaction to antibiotics. It is managed with antihistamines and antipyretics.

EXPECTED COURSE AND PROGNOSIS

Excellent in all cases except late syphilis complications and a few HIV-infected patients
Syphilis in HIV patient: HIV should be considered in any patient with syphilis. There are more frequent false-negative treponemal and non-treponemal tests, and the serologic response to therapy is less predictable. Patients with early syphilis have more treatment failures and a higher incidence of neurosyphilis. Follow-up is important.

ASSOCIATED CONDITIONS

Other sexually transmitted diseases
HIV infection and hepatitis B (strongly urge patients treated for syphilis to obtain screenings for both)

AGE-RELATED FACTORS

Pediatric: In non-congenital cases, must consider possible child abuse
Geriatric: N/A
Others: N/A

PREGNANCY

Early detection is imperative, all expectant mothers should have serologies as part of routine prenatal care in the first trimester. If high exposure risk, repeat in second trimester and at delivery.

OTHER NOTES

Many experts urge more aggressive treatment than standard regimens in all patients and strongly advocate the use of penicillin rather than any alternative antibiotic

ABBREVIATIONS

CSF = cerebrospinal fluid
FTA-ABS = fluorescent treponemal antibody absorption
MHA-TP = microhemagglutination Treponema pallidum
VDRL = Venereal Disease Research Laboratory
RPR = rapid plasma reagin

Clinical Investigations

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