Syphilis

Syphilis is a sexual transmittent disease caused by infection, through abrassion in the skin or mucous membrane, with spirochates Triponema palidum.

In adults the infection is usually sexually acquired; however, transmission by kissing, blood transfusion and percutaneous injury has been reported.

In infants: The infection  may be transplacental

Morphology

ü  Long (4-30 mm), thin walled, flexible, spiral rods

ü  Motile with axial filaments. (other bacteria are motile with flagella)

ü  Pathogenic strains cannot be cultured in bacteriological media

ü  Do not take Gram’s stain.

Mode of transmission

ü  Sexually transmission(main)

ü  Kissing

ü  Blood transfusion

ü  Percutaneous injury

ü  Transplacental

15.6 Classification of syphilis

Stage	Acquired	Congenital
Early	1.      Primary 2.      Secondary 3.      Latent	Clinical and latent
Late	1.      Latent 2.      Benign tertiary 3.       Cardiovascular 4.      Neurosyphilis	Clinical and latent

Acquired syphilis:

Stage	Acquired	Features
Early:	Primary	1.       The incubation period is usually between 14 and 28 days(average-21 days), with a range of 9–90 days 2.       The primary lesion or chancre develops at the site of infection and its painless, usually in the genital area 3.       A dull red macule develops, becomes papular and then erodes to form an indurated ulcer (chancre) 4.       The draining inguinal lymph nodes may become moderately enlarged, mobile, discrete and rubbery. The chancre and the lymph nodes are both painless and non-tender, unless there is concurrent or secondary infection 5.   Without treatment, the chancre will resolve within 2–6 weeks to leave a thin atrophic scar 6.       Chancres may develop on the vaginal wall and on the cervix 7.       Extragenital chancres are found in about 10% of patients, affecting sites such as the finger, lip, tongue, tonsil, nipple, anus or rectum 8.   Anal chancres often resemble fissures and may be painful
	Secondary	1.       This occurs 6–8 weeks after the development of the chancre, when treponemes disseminate to produce a multisystem disease 2.       Constitutional features, such as mild fever, malaise and headache, are common. Over 75% of patients present with a rash on the trunk and limbs that may later involve the palms and soles; this is initially macular but evolves to maculopapular or papular forms, which are generalised, symmetrical and non-irritable 3.       Scales may form on the papules later 4.       The rash affects the trunk and proximal limbs, and characteristically involves the palms, soles and face. Lesions are red, changing to a ‘gun-metal’ grey as they resolve 5.       Without treatment, the rash may last for up to 12 weeks. Condylomata lata (papules coalescing to plaques) may develop in warm, moist sites such as the vulva or perianal area 6.       Generalised non-tender lymphadenopathy is present in over 50% of patients 7.       Mucosal lesions, known as mucous patches, may affect the genitalia, mouth, pharynx or larynx and are essentially modified papules, which become eroded 8.       Rarely, confluence produces characteristic ‘snail track ulcers’ in the mouth 9.       Other features, such as meningitis, cranial nerve palsies, anterior or posterior uveitis, hepatitis, gastritis, glomerulonephritis or periostitis, are sometimes seen 10.   Neurological involvement may be more common in HIV-positive patients 11.   The differential diagnosis of secondary syphilis can be extensive, but in the context of a suspected STI, primary HIV infection is the most important alternative condition to consider 12.   Non-STI conditions that mimic the rash include psoriasis, pityriasis rosea, scabies, allergic drug reaction, erythema multiforme and tinea versicolor 13.   The clinical manifestations of secondary syphilis will resolve without treatment but relapse may occur, usually within the first year of infection. Thereafter, the disease enters the phase of latency
	Latent	1.       This phase is characterised by the presence of positive syphilisserology or the diagnostic cerebrospinal fluid (CSF) abnormalities of neurosyphilis in an untreated patient with no evidence of clinical disease 2.       It is divided into early latency (within 2 years of infection), when syphilis may be transmitted sexually, and late latency, when the patient is no longer sexually infectious 3.       Transmission of syphilisfrom a pregnant woman to her fetus, and rarely by blood transfusion, is possible for several years following infection
Late	Latent	1.       This may persist for many years or for life 2.       Without treatment, over 60% of patients might be expected to suffer little or no ill health 3.       Coincidental prescription of antibiotics for other illnesses, such as respiratory tract or skin infections, may treat latent syphilisserendipitously
	Benign tertiary	1.       This may develop between 3 and 10 years after infection but is now rarely seen in the UK 2.       Skin, mucous membranes, bone, muscle or viscera can be involved 3.       The characteristic feature is a chronic granulomatous lesion called a gumma, which may be single or multiple. Healing with scar formation may impair the function of the structure affected 4.       Skin lesions may take the form of nodules or ulcers, whilst subcutaneous lesions may ulcerate with a gummy discharge 5.       Healing occurs slowly, with the formation of characteristic tissue paper scars 6.       Mucosal lesions may occur in the mouth, pharynx, larynx or nasal septum, appearing as punched-out ulcers. Of particular importance is gummatous involvement of the tongue, healing of which may lead to leucoplakia with the attendant risk of malignant change 7.       Gummas of the tibia, skull, clavicle and sternum have been described, as has involvement of the brain, spinal cord, liver, testis and, rarely, other organs 8.       Resolution of active disease should follow treatment, though some tissue damage may be permanent. Paroxysmal cold haemoglobinuria may be seen
	Cardiovascular	1.       This may present many years after initial infection 2.       Aortitis, which may involve the aortic valve and/or the coronary ostia, is the key feature. Clinical features include aortic incompetence, angina and aortic aneurysm 3.       The condition typically affects the ascending aorta and sometimes the aortic arch; aneurysm of the descending aorta is rare 4.       Treatment with penicillin will not correct anatomical damage and surgical intervention may be required
	Neurosyphilis	1.       This may also take years to develop 2.       Asymptomatic infection is associated with CSF abnormalities in the absence of clinical signs 3.       Meningovascular disease, tabes dorsalis and general paralysis of the insane constitute the symptomatic forms 4.       Neurosyphilisand cardiovascular syphilis may coexist and are sometimes referred to as quaternary syphilis

Pathological investigation of acquired syphilis

Stages	Diagnosis
Primary syphilis	ü  Detection of T.pallidum by dark ground illumaination from chancre ü  Serological tests: - Non-treponemal (nonspecific) tests - Venereal Disease Research Laboratory (VDRL) test - Rapid plasma regain (RPR) - Treponemal antigen-based on enzyme immunoassay (EIA) - Treponemal haemaggutination assay (TPHA) - T.pallidum  particle agglutination assay (TPPA) - Fluorescent Treponema antibody absorbtion test (FTA-ABS) ü  CSF study shows Pleocytosis(In medicine, pleocytosis is an increased cell count (from Greek pleion, "more"), particularly an increase in white blood cell count, in a bodily fluid, such as cerebrospinal fluid. It is often defined specifically as an increased white blood cell count in cerebrospinal fluid) in 10%-20% of cases.
Secondary syphilis	ü  As in primary ü  CSF study-abnormal in 40% of patients. Spirochaetes are found in CSF in 30% of cases
Latent syphilis	ü  In this stage, there is no clinical feature and no organism is detected. Only serological tests are positive ü  Sfter 1 year of infection late latent syphilis develops ü  This stage may persist ofr many years or for lofe with little or no ill health
Tertiary	ü  FTA-ABS ü  Low titre TPHA tests are positive and remain positive throughout life even after treatment ü  Typical lesion is formation of Gumma(A gumma is a soft, non-cancerous growth resulting from the tertiary stage of syphilis. It is a form of granuloma. Gummas are most commonly found in the liver (gumma hepatis), but can also be found in brain, heart, skin, bone, testis, and other tissues, leading to a variety of potential problems including neurological disorders or heart valve disease.)
Benign Tertiary Syphilis	Follow the feature to diagnosis
Neurosyphilis	ü   May be asymptomatic or symptomatic which may present as features of tabes dorsalis or general paresis of insane(GPI) ü  In eye, there is Argyll Robertson pupil
Meningeal or menigovuscular syphilis	ü  Follow the symptoms ü  Follow the past history ü  Characterized by headache, nausea, vomiting, neck-stiffness, cranial nerve palsy, seizure, change in mental status
Cardiovascular syphilis	ü  Results from endarteritis obliterans of vasa vasorum ü  Occurs in 10% of late untreated syphilis, 10-40 years after infection. ü  Aortitis, aortic regurgation, aortic aneurysm, coronaryostial stenosis may occur ü  Clinical findings confirmed by STS and lesional skin bipsy ü  DGI test is always negative

Treatment of acquired syphilis

Stage	Acquired	Homoeopathic treatment
Early	Primary	1.       For recent and hitherto untreated Chancre: Quicksilver 2X three grains in a day, may also give 4x-6x. 2.   All mercury symptoms are Worse at night, from warmth of bed, from damp, cold, rainy weather, Worse during perspiration 3.       hereditary syphilis manifestations, are within its range; bullae, abscesses, snuffles, marasmus, stomatitis or destructive inflammations 4.       Complaints increase with the sweat and rest; all associated with a great deal of weariness, prostration, and trembling 5.       Tendency to formation of pus, which is thin, greening, putrid; streaked with blood 6.       Nitric acid is recommended by all, in the first decimal dilution, by Yeldham, the first centesimal by Jhar, the third centesimal by Schneider. 7.       For phagedaenic( a rapidly spreading ulcer that destroys tissues as it increases in size) Chancre: Mercurius vivus is warmly commended by Jahr, Hartmann and Gerson. Jousset mentions Nitric acid, Silicea and Arsenicum Album in high dilution. Cauterisation (Cauterize is usually a medical term. In surgery, using an electrical tool to cauterizethe incision seals off blood vessels, resulting in a cleaner operation that heals more easily. Extreme cold, electricity, and chemicals are also used outside the bodycauterize, or "burn off," warts and vessels that cause nosebleeds) or the application of an oinment containing one part in a thousand of Arsenic.
	Secondary	1.       Secondary stage of syphilis when there is a febrile chloro-anaemia, rheumatoid pains behind sternum, around joints, etc.; ulceration of mouth and throat, etc. These are the special conditions and stages to which Mercur is homeopathic and where the 2X will do surprising work 2.       Bahr belives these to be purely Syphilitic only when superficial, and treats them with Quicksilver, but when they are Phagedaenic, deeply penetrating and threatening to affect the bones, he substitutes, for the mouth, Kali iodatum and bichromicum, for  the nose, Kali idodatum and Aurum Muriaticum and for the larynx, Heper sulphuris and perhaps, iodine and kali bichromicum. Ulcers of the throat by Quicksilver but the ulceration is simple, but if it’s phagedaenic then Mercurius corrosive-half a grain of the 2nd trituration morning and evening. 3.       Other medicines are Lachesis, Lycopodium, Thuja, Cinnabar, Sulphur in superfacial erosions of the mucous surfaces. 4.       Yeldham recommends that the throat be treated in the first instance for simple inflammation, as with Belladonna or Apis and then with the Iodides of Mercury or Nitric acid, also by Nitrate of Silver and attaches much importance to the administration of Cod-liver oil. 5.       For falling of hair: Hepar Sulphuris.
	Latent
Late	Tertiary	1.       Iodine of  potassium, Aurum for instansce, for Syphilitic lupus, for Caries of the facial bones, for suppurating tophi, and finally for sarcocele 2.       The other drugs are Mezereum, Phosphorus and phosphoric acid, Staphisagria, Silicea, Fluoric and nitric acids, Guaiacum and Sulphur. 3.       But Jahr places Aurum, of which he gives half a grain of the third trituration every four days 4.       The gammata is often cured by Silicea in the first instance and in the second by Arsenicum. 5.       For the melancholy and prostration of the syphilitico-mercurial cachexia Aurum can be given. 6.

Stage	Acquired	Alopathic treatment
Early	Primary	ü  Infection Benzathine penicillin 2.4 million units in single dose IM in each buttoc. If there is allergy to panicilin then: Tetracycline 500mg  4 times a day for 15 days. ü  If tetracyline is contraindicated as in pregnancy then Erythromycin 500 mg 4 times a day for 15 days or ü  Oral doxycycline 100 mg twice daily for 14 days
	Secondary	ü  As primary syphilis
	Latent	ü  Benzathine Penicillin may be given: total dose 7.2 million units of which 2.4 million units on the thigh and then weekly injection for 2 doses.
Late	Latent	ü  In this stage alternate therapy to penicillin is done by Doxycycline 100 mg twice daily or ü  Tetracyline 500 mg 4 times daily. Both drugs should be given for 4 weeks
	Benign tertiary	This stage can occur at any time after secondary syphilis, even, after many years. It may involve any organ. No organism is detected, so this stage is not infective (no drug is prescribed accept homoeopathic medicine). Typical lesion is formation of Gumma
	Cardiovascular
	Neurosyphilis

 

Congenital syphilis

Congenital syphilis is rare where antenatal serological screening is practised. Antisyphilitic treatment in pregnancy treats the fetus, if infected, as well as the mother.

Features develop after four months of gestation when the foetus becomes immune-competent.

Treponemal infection may give rise to a variety of outcomes after 4 months of gestation, when the fetus becomes immunocompetent:

1.       miscarriage or stillbirth, prematurely or at term

2.       birth of a syphilitic baby (a very sick baby with hepatosplenomegaly, bullous rash and perhaps pneumonia)

3.       birth of a baby who develops signs of early congenital syphilisduring the first few weeks of life

4. birth of a baby with latent infection who either remains well or develops congenital syphilis/stigmata later in life

1.                         15.7 Clinical features of congenital syphilis

Early congenital syphilis (neonatal period)

ü  Maculopapular rash

ü  Condylomata lata

ü  Mucous patches

ü  Fissures around mouth, nose and anus

ü  Rhinitis with nasal discharge (snuffles)

ü  Hepatosplenomegaly

ü  Osteochondritis/periostitis

ü  Generalised lymphadenopathy

ü  Choroiditis

ü  Meningitis

ü  Anaemia/thrombocytopenia

Late congenital syphilis

ü  Benign tertiary syphilis

ü  Periostitis

ü  Paroxysmal cold haemoglobinuria

ü  Neurosyphilis

ü  8th nerve deafness

ü  Interstitial keratitis

ü  Clutton’s joints (painless effusion into knee joints)

Stigmata

ü  Hutchinson’s incisors (anterior–posterior thickening with notch on narrowed cutting edge)

ü  Mulberry molars (imperfectly formed cusps/deficient dental enamel)

ü  High arched palate

ü  Maxillary hypoplasia

ü  Saddle nose (following snuffles)

ü  Rhagades (radiating scars around mouth, nose and anus following rash)

ü  Salt and pepper scars on retina (from choroiditis)

ü  Corneal scars (from interstitial keratitis)

ü  Sabre tibia (from periostitis)

ü  Bossing of frontal and parietal bones (healed periosteal nodes)

ü  Clutton’s joints (painless effusion into knee joints)

ü  8^th nerve damage.