Syphilis

1. Caused by Treponemapallidum
2. Congenital syphilis, Acquired syphilis
3. Incubation period 10-90 days

Syphilis, Congenital

Acquired Syphilis

1. Divided into series of imprecise stages
   • Primary
   • Secondary
   • Early and Late Latent
   • Tertiary
2. Neurosyphilis may occur during any stage

Primary Syphilis

1. Chancre
   • Painless papule which quickly erodes leaving ulcer
   • Base smooth without exudate
   • Borders raised and firm
   • Heal within 3-6 weeks
   • Accompanied by painless, non-suppurativeregional lymphadenopathy

Secondary Syphilis

• Lesions appear 2-8 weeks after primary chancre
• Constitutional symptoms
  • fever, malaise, pharyngitis, anorexia, arthralgias, and generalized painless lymphadenopathy
  • Epitrochlearnodes suggests syphilis
• Discrete macular, pink-to-red lesions 3-10 mm in diameter
  • Most commonly on palms and soles
• Condylomalata
  • Broad grayish plaques in warm moist intertriginousareas
  • Teeming with spirochetes
• Mucous patches
  • Superficial, silvery gray erosions that occur on mucous membranes
  • Teeming with spirochetes
• Asymptomatic involvement of CNS common

Latent and Tertiary Syphilis

• Early latent syphilis (< 1 yr duration)
  • Time when recurrent lesions of secondary syphilis recure
• Late latent syphilis (> 1 yr duration)
  • Resistance to both reinfection and relapse
• Tertiary syphilis
  • Aortic dilatation from medial necrosis
  • Neurosyphiliswith focal ischemia as result of endarteritis
  • Demyelinizationof posterior columns with sensory ataxia, lightning pains and autonomic dysfunction (tabesdorsalis)
  • Uveitis, retinitsand optic neuritis
• Neurosyphilis can occur during any stage

Evaluation

1. Nontreponemal (VDRL and RPR)
2. Treponemal (fluorescent treponemal ab absorption test [FTA-ABS] and microhemagglutination test for T. pallidum [MHA-TP])

Therapy Expectations

• Re-evaluate clinically and serologically for syphilis 6 months and 12 months after treatment
• Quantitative non-treponemaltests gradually become non-reactive
  • Should be non-reactive one yearafter successful treatment of primary syphilis
  • Should be non-reactive two yearsafter successful treatment of secondary syphilis
  • Should be non-reactive five yearsafter successful treatment of late syphilis
• Reactive treponemaltests are positive for life despite treatment

Diagnosis

• Cross-reactivity/false-positive:
  • Treponemal: spirochetal diseases
  • Non-treponemal: viral infections, lymphoma, TB, malaria, endocarditis, connective tissue disease, pregnancy
• False-negative tests in non-treponemal tests in early primary syphilis, latent acquired syphilis of long duration, and late congenital syphilis

Treatment

• Adults/adolescents/children:
  • Benzathine PCN G x 1 for primary, secondary, and early latent
  • Benzathine PCN G weekly for three doses for late latent, unknown duration and tertiary syphilis
  • Alternative: doxycycline or tetracycline (inferior)

Key Points

• Congenital syphilis may be asymptomatic at birth & present up to 2 years old
• Non-treponemal tests (VDRL, RPR) are the initial screen
• Neurosyphiliscan occur at any stage
• Clinical & serological re-evaluation is imperative following treatment
• Penicillin!!!!

CHLA Board Review 2005