Syhilis Ch 153
I. Definition: \u2018 a chrnic systemic infection caused by Trponema pallidum subspecies pallidum, is usually sexually transmitted and is characterized by episodes of active disease interrupted by periods of latency. Latency 2-6 weeks primary lesion w/ regional lymphadenopathy. 2ndary bacteremic stage w/ gen. Mucocut. Lesions and gen. Lymphadenopathy latent period of subclinical infection for years. 3tiary stage or progressive destructive mucocut., musculo, or parenchymal lesions, aortitis or CNS disease. II. Etiology T. pallidum subspecies pallidum: cytoplasm has trilaminar cytoplasmic memb w peptidoglycan layer for structural rigidity. Lipid outer memb. Has structural proteins. \u2022Endoflagella wind around cell body in periplasmic space Responsible for motility \u2022Genomic family TprK w/ variable (V) regions target humoral immune response and is a mechanism for immune invasion. \u2022The only known natural host for T. pallidum is the human! III. Epidemiology \u2022Usually acquired by sexual contact w/ infections lesions. Also by non sexual contact, infection in utero and blood transfusion.. \u2022Populations at risk have varied from homosexual men to african populations to homosexual men again with HIV. \u2022Congenital syphilis include all live or stillborn infants delivered to women with untreated women with untreated or inadequately treated syphilis at delivery. IV. Natural course and pathogenesis or untreated syphilis \u2022Repidly penetrates intact mucous membranes or microscopic abrasions \u2022Enters lymphatics and blood to prod systemic infection and metastatic foci b4 appearance of 1ary lesion. \u2022Incubation period of syphlis is inversely proportional to the number of organisms inoculated \u2022107 treponemes/g tissue before appearance of clinical lesion.
1ary lision appears @ site of inoculation persists 4-6 wks heals spontaneously \u2022histopath :1ary lesons have perivascular infiltration \u20222dary syphilis appear 6-8wks after healing of chancre. (some appear months after or enter the next latent phase w.out even noticing 2dary lesions) \u2022histopath: - hyperkeratosis or epidermis \u2022
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capillary proliferation
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dermal papillae
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perivascular infiltration
Treponemes are found in many tissue, invasion of CNS during 1st wks or months \u2022Gen. Nontenderlymphadenopathy is noted in 85% pxns w/ 2ndary syphilis \u20222dary leions subside w/in 2-6wks latent stage detectable only by serologic testing. \u2022Thanks to antibiotics, tertiary disease such as gumma and CV syphils are now rare. \u2022
V. Manifestations a. Primary syphilis \u2022Typical 1ary chancre: single painless papule that rapidly becomes eroded and indurated w/ cartilaginous onsistency on edge and base of ulcer. \u2022Multiple 1ary lesions more common in men w/ concurrent HIV. \u2022Differentials: Primary Tender nodes & multiple painful vesucles- later genital ulcerate- w/ systemic herpes symptoms inc fever Begins w unilateral cluster of Recurrent painful vesicles w/out genital adenopathy herpes Chancroid Painful, superficial, exudative, nonindurated ulcers, multiple Donovanosi Granulomatous ulcer that s although painless, is friable. Regional lymphadenopathy may persist for months while anal and ext. genital chancres heal w/in 4-6 wks. b. Secondary syphilis \u2022Localized or diffuse symmetric mucocutaneous lesions and generalized nontender lymphadenopathy \u2022
\u2022Tabes dorsalis is a late manifestation of Initial lesions are bilat. Symmetric, pale red.pink, nonpruritic, discrete, round syphilis that presents as symptoms and signs of demyelination of the posterior macules 5-10mm in diameter. columns, dorsal roots and dorsal root After several days or wks, red papular lesions appear progress to necrotic lesions ass\u2019td w ganglia. increasing endarteritis and perivascular e. Other manifestations of Late Syphilis mononuclear infiltration, distrib. Widely and freq. i. Cardiovascular syphilis \u2022Attributable to endarteritis obliterans of the Involve the palms and soles. \u2022In warm, intetriginous body areas, papules vasa vasorum enlarge to become eroded and prod. Broad, Late benign syphilis (gumma) ii. \u2022Gummas are multiple or diffuse but usually moist, pink or gray-white highly infections lesions called condylomata lata. solitary lesions that range from microscopic \u2022Superficial mucosal erosions called mucous in size to several cm in diameter. \u2013a granulomatous inflammation w/ central area patches also occur \u2022Hepatic invovlement is commmon although of necrosis. \u2022 Tx w/ penicillin results in rapid healing of asymptomatic \u2022Renal invovlement prod. Proteinuria active gummatous lesions Congenital syphilis iii. associated w/ acute nephrotic syndrome. \u2022 From transmission from a syphilitic woman c. Latent syphilis to her fetus across the placenta. Lesions \u2022(+) serologic tests for syphilis, w/ normal generally have their onset after the 4 th month CSF exam and absence of clin. of gestation, when fetal immunologic Manifestations of syphilis, indicate diagnosis competence begins to develop. 3 types: (1) of latent syphilis. st early manifestations w/in 1st 2 yrs of life are \u2022Early latent syphilis: 1 year after infection infectious and resemble the manifestations \u2022Late latent syphilis: > 1yr after infection in of severe 2dary syphilis in adults (2) late entreated pxn, associated w/ relative manifestations w/ch appear after 2 yrs & re immunity to infectious relapse. 3 outcomes: noninfectious (3)residual stigmata. 1)lifetime persistence in infected individ \u2022Earliest sign of congenital syphilis is rhinitis 2)dev\u2019t of late syphilis 3) spontaneous cure \u2022The most common early manifestations are of enfection bone changes. d. Involvement of the CNS \u2022 60% of last cases (untreated after 2yrs of Asymptomatic neurosyphilis i. \u2022In pxns who lack neuro. Ss/s but have CSF age) remain subclinical \u2022characteristic stigmata:- Hutchinsons\u2019s agnormalities inc. mononuclear pleocytosis, inc. protein concentrations, or reactive teeth : centrally notched, widely spaced, Veneral Disease Research Laboratory peg-shaped upper central incisor- and mulberry molars (6th year molars with (VDRL) slide test. multiple, poorly dev. Cusps. Symptomatic neurosyphilis ii. \u2022Major clinical categories of symptomatic frontal bossing, saddle nose and poorly neurosyphilis inc: meningeal , dev\u2019d maxillae meningovascular, parenchymatous syphilis. \u2022Meningeal syphilis prsents w/ headache, VI. Laboratory examinations \u2022Cannot be demonstrated by culture nausea, vomiting, neck stiffness, CN invovlement, seizures and changes in \u2022Dark-field microscopic exam mental status. \u2022Direct fluorescent antibody T. pallidum test. \u2022Meningovascular syphilis reflects diffuse inflammation of the pia and arachnoid w/ a. Serologic tests for syphilis evidence of focal or widespread arterial \u2022Nontreponemal tests measure IgG and IgM involvement of small, med or large vessels. directed against a cardiolipin-lecithin\u2022PARESIS: Personality, Affect, Reflexes cholesterol antigen complex (hyperactive), Eye, Sensorium, Intellect and \u20222 standard streponemal tests are used: the Speech are affected in widespread late fluorescent treponemal antibody-absorbed parenchymal damage. test (FTA-ABS test) and the agglutination assays for antibodies to T. pallidum \u2022
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b. Evaluation for Neurosyphilis • Detected by examination of CSF for pleocytosis (>5 WBC/mm3), inc. protein concentration (>45mg/dl) or VDRL reactivity. c. Evaluation for Syphilis in pxns infected w HIV • Syphilis and other genital ulcer diseases may be important risk factors for the acquisition and transmission of HIV infection. VII. •
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Treatment Pen G is the drug of choice for all stages of syphilis. Refer table 153-3 An infant should be treated at birth if the seropositive mother has received penicillin therapy in the 3rd trimester, inadequate penicillin treatment or therapy w a drug other than penicillin, of her tx status is unknown or if the infant may be diff to follow. Jarisch-Herxheimer Reaction consists of fever, chills, myalgia, headache, tachycardia, inc RR, inc circulating neutrophil count and vasodilation w. mild hypotension amd may follow the initiation of tx for syphilis. Follow up response of syphilis to tx should be determined by monitoring quantitative VDRL or RPR titer Cellular immunity is considered impt in immunity and healing of early lesions
Marian USTMedB2007
