Makindo Medical Notes.com

Related Subjects: |Treponema |Bejel (Endemic syphilis) |Pinta |Yaws (Frambesia) |Syphilis

Syphilis appears to have arrived in Barcelona in 1493 from South America. Reached Naples in 1494. At some point in time seems to have become a venereal disease. Similar spirochetal infections exist in South America. Famous victims include Popes, Cardinals of the church of England, Henry VIII and Ivan the Terrible. Led to the use of handshakes instead of the customary public kissing and due to hair loss the fashion of wearing wigs. A story about a shepherd called Syphilis was written in 1530 who had been struck down by the disease and this name was used to refer to the disease. Also called Luetic disease. The Germans, Poles and Italians called it the "French disease", the French called it the "Neapolitan disease" and the Neapolitans called it the "Spanish disease". The Portuguese called it the "Castilian disease". The Turks called it the "Christian disease" etc...(Reference: Europe - A history 1997 by Norman Davies )

About

• To know syphilis is to know medicine - William Osler
• Infectious sexually transmitted disease caused by Treponema pallidum
• A spirochaete: Spiral corkscrew-like bacilli unable to be grown on culture
• Possibly originated in South America
• Vertical transmission from mother to baby
• recent increase in cases in the UK possibly related to the sex industry and prostitution
• Always screen for HIV and other STDs

Clinical

• Primary disease - primary chancre: gains entry via abraded skin to form a painless papule and then ulcer on genitals, lips, anus at the initial point of inoculation which heals over a few weeks.
• Secondary syphilis: 2-6 weeks later with a widespread maculopapular rash and systemic symptoms such as malaise, sore throat, lymphadenopathy, arthralgia, condylomata lata (anal warty lesions) and nail track ulcers

Tertiary syphilis after 10 years

• CNS
  • Syphilitic meningitis: Seen with secondary stage rash. Headache, malaise, neck stiff and elevated CSF WCC and +ve RPR
  • Meningovascular syphilis : After 20 years of disease. Chronic disorder with brain and cord infarcts, seizures, cranial nerve lesions and Argyll Robertson pupils.
  • Tabes dorsalis: After 10-20 years. Affects the posterior nerve root and ganglia. Lightening pains. Argyll Robertson pupils. Impaired vibration and proprioception and positive Romberg's. RPR and VDRL +ve
  • General paresis: Usually after 20 years of exposure. Generalised atrophy. Headaches, frontal lobe involved. Progressive dementia. Delusions, personality change. Argyll Robertson pupils. Subdural haematomas.
  • Gummatous lesions of the brain and cord are rare
• Cardiovascular:
  • Aorta: endarteritis of vasa vasorum in ascending aorta causes aortitis, aortic regurgitation and aortic arch dilatation and aneurysm formation
• Gummas also seen in bone, liver, testes and skin

Congenital syphilis

• Increased risk of Late abortion or stillbirth as Treponema pallidum crosses the placenta.
• Rarely seen unless mum has syphilis for over 5 years.
• Seen after 2 to 6 weeks after birth with "Snuffles" and nasal discharge
• Moon's molars and Hutchinson's incisors (notched)
• Bone lesions - sabre tibia, Osteochondritis and periostitis
• Saddle nose, Hepatomegaly,
• Interstitial keratitis
• Deafness due to VIII th nerve involvement

Investigations

• Dark ground illumination of fluid from lesions shows the organisms
• The T. pallidum enzyme immunoassay (EIA) is the screening test of choice and if positive can be confirmed by the TPHA and VDRL
• The T. pallidum EIA and haemagglutinin assay (TPHA) and fluorescent treponemal antibody (FTA) all remain positive despite treatment and are also positive with Yaws
• The Venereal disease research laboratory (VDRL) test is positive after 3 weeks and then becomes negative after treatment or in late neurosyphilis.
• Neurological - CSF elevated WCC and elevated protein
• Screen for other STDs especially HIV.

Management

• Primary/secondary disease - Daily IM Procaine Benzylpenicillin 2.4 MU for 10 days or Doxycycline 100 mg BD for 14 days
• Tertiary disease - Daily IM Procaine Benzylpenicillin for 1 month
• Beware the Jarisch - Herxheimer reaction in secondary syphilis mediated by the release of TNF-alpha, IL-6 and IL-8
• Doxycycline or Ceftriaxone for the Penicillin allergic