health

Syphilis is caused by infection, through abrasions in the skin or
mucous membranes, with the spirochaete Treponema pallidum.
In adults the infection is usually sexually acquired; however,
transmission by kissing, blood transfusion and percutaneous injury
has been reported. Transplacental infection of the fetus can occur

The natural history of untreated syphilis is variable. Infection may remain latentthroughout, or clinical features may develop at any time. All infected patientsshould be treated. Penicillin remains the drug of choice for all stages of infection. CLASSIFICATION OF SYPHILIS Stage 1- Acquired Early Primary Secondary Latent Late Latent Benign tertiary Cardiovascular Neurosyphilis 2- congenital Early Clinical and latent Late Clinical and latent ACQUIRED SYPHILIS Early syphilis Primary syphilis The incubation period is usually between 14 and 28 days with a range of 9-90 days.The primary lesion or chancre develops at the site of infection, usually in the genital area. A dull red macule develops, becomes papular and then erodes to form an induratedulcer (chancre). The draining inguinal lymph nodes may become moderately enlarged,mobile, discrete and rubbery. The chancre and the lymph nodes are both painless andnon-tender, unless there is concurrent or secondary infection. Without treatment, thechancre will resolve within 2-6 weeks to leave a thin atrophic scar. Chancres may develop on the vaginal wall and on the cervix. Extragenital chancres arefound in about 10% of patients, affecting sites such as the finger, lip, tongue, tonsil, nipple,anus or rectum. Anal chancres often resemble fissures and may be painful. Secondary syphilis This occurs 6-8 weeks after the development of the chancre when treponemes disseminateto produce a multisystem disease. Constitutional features such as mild fever, malaise andheadache are common. Over 75% of patients present with a rash on the trunk and limbsthat may later involve the palms and soles; this is initially macular but evolves to maculo-papular or papular forms, which are generalised, symmetrical and non-irritable. Scales may form on the papules later. 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. Generalised non-tender lymphadenopathy is present inover 50% of patients. Mucosal lesions, known as mucous patches, may affect the genitalia,mouth, pharynx or larynx and are essentially modified papules, which become eroded.Rarely, confluence produces characteristic 'snail track ulcers' in the mouth. Other features such as meningitis, cranial nerve palsies, anterior or posterior uveitis, hepatitis, gastritis, glomerulonephritis or periostitis are sometimes seen. 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 Latent syphilis This phase is characterised by the presence of positive syphilis serology or the diagnostic cerebrospinal fluid (CSF) abnormalities of neurosyphilis in an untreated patient with no evidence of clinical disease. 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. Transmission of syphilis from a pregnant woman to her fetus, and rarely by blood transfusion, is possible for several years following infection. Late syphilis Late latent syphilis This may persist for many years or for life. Without treatment over 60% of patients might be expected to suffer little or no ill health. Coincidental prescription of antibiotics for other illnesses such as respiratory tract or skin infections may treat latent syphilis serendipitously. Benign tertiary syphilis This may develop between 3 and 10 years after infection but is now rarely seen in the UK. Skin, mucous membranes, bone, muscle or viscera can be involved. 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. Skin lesions may take the form of nodules or ulcers whilst subcutaneous lesions may ulcerate with a gummy discharge. Healing occurs slowly with the formation of characteristic tissue paper scars. 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. 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. Resolution of active disease should follow treatment, though some tissue damage may be permanent. Paroxysmal cold haemoglobinuria . birth of a baby with latent infection who either remains well or develops congenital syphilis/stigmata later in life . Investigations in adult cases SEROLOGICAL TESTS FOR SYPHILIS Non-treponemal (non-specific) tests Venereal Diseases Research Laboratory (VDRL) test Rapid plasma reagin (RPR) test Treponemal (specific) antibody tests Treponemal antigen-based enzyme immunoassay (EIA) for IgG and IgM T. pallidum haemagglutination assay (TPHA) T. pallidum particle agglutination assay (TPPA) Fluorescent treponemal antibody-absorbed (FTA-ABS) Test Investigations in suspected congenital syphilis Passively transferred maternal antibodies from an adequately treated mother may give rise to positive serological tests in her baby. In this situation, non-treponemal tests should become negative within 3-6 months of birth. A positive EIA test for antitreponemal IgM suggests early congenital syphilis. A diagnosis of congenital syphilis mandates investigation of the mother, her partner and any siblings. Management Penicillin is the drug of choice. Specific regimens depend on the stage of infection. Longer courses are required in late syphilis and in HIV co-infection. Doxycycline is indicated for patients allergic to penicillin, except in pregnancy (see below). Azithromycin has also been advocated, but recent outbreaks in UK cities have been associated with strains of T. pallidum such as Street 14 that are resistant to macrolides. All patients must be followed up to ensure cure, and partner notification is of particular importance. Resolution of clinical signs in early syphilis with declining titres for non-treponemal tests, usually to undetectable levels within 6 months for primary syphilis and 12-18 months for secondary syphilis, are indicators of successful treatment. Specific treponemal antibody tests may remain positive for life. In patients who have had syphilis for many years there may be little serological response following treatment. Pregnancy Penicillin is the treatment of choice in pregnancy. Erythromycin stearate can be given if there is penicillin hypersensitivity, but crosses the placenta poorly; the newborn baby must therefore be treated with a course of penicillin and consideration given to retreating the mother. Some specialists recommend penicillin desensitisation for pregnant mothers so that penicillin can be given during temporary tolerance. The author has successfully prescribed ceftriaxone 250 mg i.m. for 10 days in this situation. Babies should be treated in hospital with the help of a pediatrician. .