170: Syphilis Flashcards
1
Q
What are the four distinct clinical phases of syphilis?
A
- Primary Stage: Characterized by a chancre.
- Secondary Stage: Characterized by skin eruptions with or without lymphadenopathy and organ disease.
- Latent Period: Absence of signs or symptoms, with only reactive serologic tests as evidence of infection.
- Tertiary Stage: Involves cutaneous, neurologic, or cardiovascular manifestations.
2
Q
What is the recommended treatment for most types of syphilis?
A
The recommended treatment for most types of syphilis is benzathine penicillin G, with the dose and administration schedule determined by the disease stage.
3
Q
What factors have contributed to the increased incidence of syphilis among MSM?
A
- Decrease in safe sex practices resulting from successful HIV treatments.
- Use of the internet to meet sex partners.
- Serosorting to choose partners with the same HIV status.
- Increase in recreational drug use, including methamphetamine and erectile dysfunction medications.
4
Q
What are the three infectious lesions of syphilis in adults?
A
- Chancres
- Condyloma lata
- Mucous patches
These lesions can be present anywhere on the body but are typically located in or around the genital, anal, or oral areas.
5
Q
What is the incubation period for a chancre to develop after inoculation with syphilis?
A
The incubation period for a chancre to develop ranges from 10 to 90 days, with an average of 3 weeks.
6
Q
A 25-year-old MSM patient presents with a painless ulcer on the glans penis. What is the most likely diagnosis, and what is the next step in management?
A
The most likely diagnosis is primary syphilis characterized by a chancre. The next step is to confirm the diagnosis with serologic testing and initiate treatment with benzathine penicillin G.
7
Q
A pregnant woman is diagnosed with syphilis. What is the risk to the fetus, and at what stage of maternal infection is transmission most likely?
A
The fetus is at risk of congenital syphilis, which can occur at any stage of maternal infection but is most likely during the early stages.
8
Q
What are the typical features of a chancre in syphilis?
A
Typical features of a chancre include:
- Sharply demarcated
- Regular, raised borders that are indurated, giving the lesion a cartilaginous feel
- Clean base
- Painless
The absence of any of these features does not rule out syphilis.
9
Q
What is the significance of the ‘dory flop’ sign in syphilis?
A
The ‘dory flop’ sign indicates retraction of the foreskin when a chancre is present on the underside, causing the foreskin to flip suddenly. This sign helps distinguish chancres from other nonindurated causes of genital ulcer disease, such as HSV infection and chancroid, which do not present with the same induration.
10
Q
What is the typical healing time for a chancre with and without treatment?
A
A chancre typically heals in:
- 3 to 6 weeks without treatment
- 1 to 2 weeks with treatment
Scarring typically does not occur, although thin atrophic scars may be present.
11
Q
What are the characteristics of secondary syphilis?
A
Secondary syphilis is characterized by:
- Infectious vasculitis
- Localized or diffuse mucocutaneous lesions
- Generalized lymphadenopathy
- Laboratory evidence from tissues or sera consistent with syphilis
- Cutaneous and mucosal locations are most common
12
Q
What are the common cutaneous findings in secondary syphilis?
A
Common cutaneous findings in secondary syphilis include:
- Syphilids or syphiloderms typically erupt 3 to 12 weeks after the chancre appears.
- Erythematous macules or maculopapules present symmetrically on the trunk and extremities in 40% to 70% of cases.
- Copper-colored round papules or macules on palms and soles in nearly 75% of cases.
- Mucous patches on the tongue that efface lingual papillae.
- Annular papules and plaques around the mouth and nose, referred to as “nickels and dimes.”
13
Q
A 30-year-old patient presents with a rash on the palms and soles, described as erythematous macules with annular scales. What is the most likely diagnosis, and what other symptoms might you expect?
A
The most likely diagnosis is secondary syphilis. Other symptoms may include generalized lymphadenopathy, mucous patches, and systemic symptoms like fever and malaise.
14
Q
A patient presents with a painless, sharply demarcated ulcer with a clean base on the cervix. What is the most likely diagnosis, and what is the typical incubation period?
A
The most likely diagnosis is primary syphilis. The typical incubation period ranges from 10 to 90 days, with an average of 3 weeks.
15
Q
A patient presents with a unilateral labial swelling with a rubbery consistency. What is the diagnosis, and what is this finding called?
A
The diagnosis is primary syphilis, and this finding is called edema indurativum.
16
Q
A patient presents with a deep, bright-red necrotic ulcer with a soft base and exudate. What is this uncommon presentation of primary syphilis called?
A
This is called a phagedenic chancre.
17
Q
A patient presents with a painless, cartilaginous-feeling ulcer on the glans penis. What is the name of this lesion, and what is its significance?
A
This lesion is called a Hunterian chancre or ulcus durum, and it is characteristic of primary syphilis.
18
Q
A patient presents with a painless ulcer on the foreskin that causes the foreskin to flip suddenly when retracted. What is this sign called?
A
This sign is called the dory flop sign, and it helps distinguish chancres from other genital ulcer diseases.
19
Q
What are the characteristics of mucous patches and condyloma lata in secondary syphilis?
A
- Mucous patches: Teeming with spirochetes, highly infectious, appear as erosions in the mouth.
- Condyloma lata: Present as moist, flat, well-demarcated papules or plaques with macerated surfaces, commonly found in intertriginous areas such as the labial folds and perianal region. Reported in 8% and 17% of patients with secondary syphilis, respectively.
20
Q
What systemic symptoms may accompany secondary syphilis?
A
- Symptoms include:
- Sore throat
- Malaise
- Headache
- Weight loss
- Fever
- Musculoskeletal aches
- Pruritus
- Hoarseness
- Pharyngitis, tonsillitis, laryngitis, gastritis, hepatitis, and renal disease may also occur, along with hematologic abnormalities like lymphopenia and elevated ESR.
21
Q
What distinguishes early latent syphilis from late latent syphilis?
A
- Early latent syphilis: Acquired within the last year, may relapse into secondary syphilis, leading to possible sexual transmission.
- Late latent syphilis: Acquired more than 1 year ago, requires different management and has a longer therapeutic course.
22
Q
What are the manifestations of tertiary syphilis?
A
- Tertiary syphilis may include:
- Gummas: Granulomatous, erosive, nodular lesions affecting skin and bones.
- Cardiovascular syphilis: Late manifestations of neurosyphilis are also considered part of tertiary syphilis.
23
Q
What are the characteristics and healing process of gummas in tertiary syphilis?
A
- Gummas: Nontender pink to dusky-red nodules or plaques, vary in size, favor sites of previous trauma, and may develop geometric configurations.
- Healing process:
- Initially firm, develops a gummy consistency from necrotic tissue.
- Can form cylindrical, punched-out ulcers with clean granulomatous bases.
- Superficial gummas heal with atrophic scars; deeper lesions leave thickened, pitted scars.
24
Q
A patient with a history of untreated syphilis presents with a saddle-nose deformity. What stage of syphilis is this, and what is the underlying pathology?
A
This is tertiary syphilis, specifically late benign syphilis. The saddle-nose deformity results from gummas causing destruction of nasal cartilage and bone.
25
A patient presents with a painless, firm, dull-red nodule on the scalp that has a gummy consistency. What is the diagnosis, and what is the hallmark lesion of this stage?
The diagnosis is tertiary syphilis, and the hallmark lesion is a gumma.
26
A patient with secondary syphilis has patchy nonscarring alopecia described as 'moth-eaten.' What other cutaneous findings might you observe?
Other findings may include erythematous macules or papules on the trunk and extremities, mucous patches, and condyloma lata.
27
A patient presents with white-to-yellow erosions on the tongue that efface lingual papillae. What is the diagnosis, and are these lesions infectious?
The diagnosis is secondary syphilis, and these mucous patches are highly infectious.
28
A patient with secondary syphilis has moist, flat, well-demarcated plaques in the perianal region. What are these lesions called, and are they infectious?
These lesions are called condyloma lata, and they are highly infectious.
29
A patient with secondary syphilis has a rash that spares the face but forms a crown-like pattern around the hairline. What is this finding called?
This finding is called the Crown of Venus or corona veneris.
30
A patient with secondary syphilis has a rash on the palms and soles that crosses the palmar creases. What is the significance of this finding?
This is a classic finding in secondary syphilis, present in nearly 75% of cases.
31
A patient with untreated syphilis develops a perforation of the nasal septum. What stage of syphilis is this, and what is the underlying lesion?
This is tertiary syphilis, and the underlying lesion is a gumma.
32
A patient with secondary syphilis has a white scaly ring on the surface of papulosquamous lesions. What is this finding called?
This finding is called the Biett collarette.
33
A patient with secondary syphilis has crusted, scaly papules that ulcerate and have an oyster shell-like surface. What is this rare manifestation called?
This is called malignant lues.
34
A patient with secondary syphilis has annular papules and plaques around the mouth and nose. What is this presentation colloquially referred to as?
This presentation is referred to as 'nickels and dimes.'
35
A patient with tertiary syphilis has granulomatous nodular lesions on the scalp. What is the hallmark lesion of this stage, and how does it heal?
The hallmark lesion is a gumma, which heals with atrophic or thickened, pitted scars.
36
A patient with secondary syphilis has patchy alopecia and loss of the lateral third of the eyebrows. What is this finding called?
This finding is called moth-eaten alopecia.
37
A patient with secondary syphilis has moist plaques in the axillae and web spaces between the toes. What are these lesions, and are they infectious?
These lesions are condyloma lata, and they are highly infectious.
38
A patient with tertiary syphilis has a solitary gumma on the penis. What is this lesion called?
This lesion is called pseudochancre redux.
39
A patient with secondary syphilis has a rash that developed while the chancre was still present. What is the significance of this finding?
This overlap of primary and secondary syphilis is more common among HIV-infected individuals.
40
A patient with secondary syphilis has a rash that includes hyperkeratotic and pustular lesions. Are these lesions infectious?
With the exception of mucous patches and condyloma lata, these cutaneous manifestations are not typically infectious.
41
A patient with secondary syphilis has pigmentary changes on the neck. What is this finding called, and what causes it?
This finding is called the necklace of Venus or leukoderma colli syphiliticum, caused by inhibition of melanogenesis.
42
A patient with tertiary syphilis has granulomatous nodular lesions on the pretibial area. What is the hallmark lesion of this stage, and what is its consistency?
The hallmark lesion is a gumma, which has a gummy consistency due to necrotic tissue accumulation.
43
A patient with secondary syphilis has mucous patches on the corners of the mouth. What are these lesions called, and are they infectious?
These lesions are called split papules, and they are highly infectious.
44
A patient with secondary syphilis has systemic symptoms like sore throat and fever. What other systemic findings might you expect?
Other findings may include pharyngitis, hepatitis, renal disease, and hematologic abnormalities like anemia and elevated ESR.
45
A patient with secondary syphilis has a rash that includes lichenoid and nodular lesions. What is the significance of these findings?
These are less-common presentations of secondary syphilis and are not typically infectious.
46
A patient with tertiary syphilis has granulomatous nodular lesions on the forehead. What is the hallmark lesion of this stage, and how does it respond to treatment?
The hallmark lesion is a gumma, which responds briskly to appropriate antibiotic therapy but leaves scars.
47
A patient with secondary syphilis has a rash that includes papules on the penis and scrotum. What is the significance of these findings?
These papules are characteristic of secondary syphilis and may be annular or papulosquamous.
48
A patient with tertiary syphilis has granulomatous nodular lesions on the scalp that ulcerate. What is the hallmark lesion of this stage, and what is its appearance?
The hallmark lesion is a gumma, which appears as a nontender, pink to dusky-red nodule with central necrosis.
49
A patient with tertiary syphilis has granulomatous nodular lesions on the buttocks. What is the hallmark lesion of this stage, and what is its progression?
The hallmark lesion is a gumma, which may grow horizontally and vertically, forming scalloped borders.
50
What are the characteristics of granulomatous nodular and noduloulcerative lesions in late benign syphilis?
- Superficial, firm, painless, dull-red, shiny, flat nodules
- Range in size from several millimeters to 2 cm
- Can coalesce into large plaques or ulcerate
- May resemble granuloma annulare
51
What are the noncutaneous findings associated with gummas in tertiary syphilis?
- Gummas can affect any organ, especially the bones, liver, heart, brain, stomach, and upper respiratory tract.
- Serious complications can arise when critical organs like the brain are involved.
- Cardiovascular manifestations affect 10% to 40% of those infected, leading to significant morbidity and mortality.
52
What are the common genital locations affected by syphilis in men?
1. Glans penis
2. Shaft of the penis
3. Scrotum
53
What are the noncutaneous findings associated with gummas in tertiary syphilis?
Gummas can affect any organ, especially the bones, liver, heart, brain, stomach, and upper respiratory tract.
54
What are the serious complications when critical organs are involved in tertiary syphilis?
Serious complications can arise when critical organs like the brain are involved.
55
What percentage of those infected with syphilis experience cardiovascular manifestations?
Cardiovascular manifestations affect 10% to 40% of those infected, leading to significant morbidity and mortality.
56
What are the common genital locations affected by syphilis in women?
1. Vulva
2. Vagina
3. Cervix
4. Labia
5. Perineum
57
What are the areas where a chancre may not be visible?
1. Rectum
2. Throat
3. Urethra
4. Scrotum
5. Vaginal canal
58
What are the extracutaneous sites that gummas can affect?
1. Bones
2. Liver
3. Heart
4. Brain
5. Stomach
6. Upper respiratory tract
59
What are the unique syphilitic lesions and their corresponding stages?
| Lesion Description | Stage |
|-------------------|-------|
| Solitary gumma of the penis | Tertiary |
| Plantar lesion resembling callous | Secondary |
| Non-tender nodules on scalp or forehead | Secondary |
| Painless, sharply demarcated ulcer | Primary |
| Unilateral labial swelling | Secondary |
| Annular papules around mouth and nose | Secondary |
| Superficial, firm, painless nodules | Secondary |
| Confluent mucous patches on the tongue | Secondary |
| White-to-yellow erosions on the tongue | Secondary |
| Mucous patches on corners of the mouth | Secondary |
60
What stage of syphilis is a patient with untreated syphilis who develops aortic regurgitation in, and what is the underlying cause?
This is tertiary syphilis, specifically cardiovascular syphilis. The underlying cause is syphilitic aortitis.
61
What is the underlying pathology of aortic regurgitation in a patient with tertiary syphilis, and how is it diagnosed?
The underlying pathology is syphilitic aortitis, and it can be diagnosed with imaging and serologic tests.
62
What is asymptomatic neurosyphilis and how is it treated?
Asymptomatic neurosyphilis is defined by CSF abnormalities and is treated to prevent progression to symptomatic neurosyphilis, although the benefits of treatment are not well documented.
63
What are the common manifestations of early symptomatic neurosyphilis?
The common manifestations include ocular abnormalities, other cranial nerve involvement, acute meningitis, other syndromes (headache, altered mental status, or both), and cerebrovascular accidents.
64
What are the two syndromes associated with late neurosyphilis?
The two syndromes associated with late neurosyphilis are general paresis of the insane (dementia paralytica) and tabes dorsalis.
65
What are the ocular manifestations of syphilis?
Ocular syphilis can involve chancres or gummas of the conjunctiva, syphilitic interstitial keratitis, anterior, posterior, and pan uveitis, retinal detachment, cataracts, glaucoma, optic nerve involvement, pupillary abnormalities, and palsies of cranial nerves.
66
What is the probability of congenital syphilis transmission based on the stage of maternal infection?
The probability of congenital syphilis transmission is 70% to 100% for primary syphilis, 40% for early latent syphilis, and 10% for late latent syphilis.
67
What are the prominent manifestations of early congenital syphilis in a child under 2 years old?
The prominent manifestations include fever, rash, hepatosplenomegaly, persistent rhinitis, hydrops fetalis, lymphadenopathy, neurosyphilis, leukocytosis, thrombocytopenia, periostitis, osteochondritis, and pseudoparalysis of Parrot.
68
What is late congenital syphilis and how does it manifest?
Late congenital syphilis occurs in a child who is at least 2 years old and typically manifests over the first 2 decades of life, resulting from damage caused during early infection.
69
A patient presents with sensory ataxia, bowel and bladder dysfunction, and Argyll Robertson pupils. What is the likely diagnosis, and what stage of syphilis does it represent?
The likely diagnosis is tabes dorsalis, which represents late neurosyphilis.
70
A patient with syphilis reports eye pain, redness, and photophobia. What is the most likely diagnosis, and how should it be managed?
The most likely diagnosis is syphilitic uveitis, the most common ophthalmic manifestation of early neurosyphilis. It should be managed similarly to other neurologic manifestations of neurosyphilis.
71
A patient with untreated syphilis develops rapidly progressive dementia and personality changes. What is the diagnosis, and what stage of syphilis does it represent?
The diagnosis is general paresis of the insane (dementia paralytica), which represents late neurosyphilis.
72
A patient with syphilis develops a stroke affecting the middle cerebral artery. What is the likely diagnosis, and what stage of syphilis does it represent?
The likely diagnosis is meningovasculitis, a manifestation of early symptomatic neurosyphilis.
73
What should be done for a patient with syphilis who has a history of HIV infection and presents with neurologic symptoms?
A CSF examination should be performed to evaluate for neurosyphilis.
74
What should be done for a patient with syphilis who has a history of HIV infection and presents with ocular symptoms?
A CSF examination should be performed to evaluate for ocular syphilis, a subset of neurosyphilis.
75
What should be done for a patient with syphilis who has a history of HIV infection and presents with otologic symptoms?
A CSF examination should be performed to evaluate for otologic syphilis, a subset of neurosyphilis.
76
What should be done for a patient with syphilis who has a history of HIV infection and presents with signs of tertiary syphilis?
A CSF examination should be performed to evaluate for neurosyphilis, as tertiary syphilis can involve the CNS.
77
What is the most common ophthalmic manifestation of early neurosyphilis?
Uveitis is the most common ophthalmic manifestation of early neurosyphilis.
78
What is the significance of the Argyll Robertson pupil in neurosyphilis?
The Argyll Robertson pupil is associated with tabes dorsalis and indicates damage to the nervous system, as it accommodates but does not react to light.
79
What are the indications for CSF examination in persons with syphilis?
Indications include neurologic, ophthalmic, or otologic signs or symptoms, evidence of active tertiary syphilis, and treatment failure.
80
What is ocular syphilis and how can it manifest?
Ocular syphilis is a subset of neurosyphilis that can involve almost any portion of the eye and may manifest as conjunctivitis, uveitis, retinal detachment, and optic nerve involvement.
81
What are the key manifestations of Hutchinson triad in syphilis?
The Hutchinson triad includes interstitial keratitis, Hutchinson teeth, and eighth nerve deafness.
82
How does HIV infection influence the presentation of syphilis in patients?
HIV-infected persons are more likely to present with more than 1 chancre, larger and deeper chancres in primary syphilis, signs of secondary syphilis while at least 1 chancre is present, and atypical and aggressive presentations of syphilis.
83
What are the implications of syphilis on HIV viral load and CD4+ T-cell count during infection?
During syphilis infection, there is a transient increase in HIV viral load and a decrease in CD4+ T-cell count, which can facilitate HIV transmission among HIV-infected patients who are also coinfected with syphilis.
84
What are the recommended follow-up practices for HIV-infected persons with syphilis?
HIV-infected persons with primary or secondary syphilis should have more frequent follow-up, typically every 3 to 6 months depending on risk behaviors.
85
What are the biological mechanisms that account for the synergy between syphilis and HIV infections?
The synergy can be attributed to disruption of epidermal or mucosal barriers caused by syphilis ulcers and migration of inflammatory cells to these lesions, which are targets for HIV.
86
What is the significance of the T. pallidum subspecies pallidum in the context of syphilis?
T. pallidum subspecies pallidum is the causative agent of syphilis, a motile, spiral-shaped bacterium that invades the bloodstream rapidly and can cross barriers such as the blood-brain barrier and placental barrier.
87
How does HIV infection affect the risk of neurosyphilis?
HIV infection increases the risk of neurosyphilis, especially in patients with advanced HIV disease and lower CD4 cell counts.
88
What is the condition called when a patient with HIV infection has persistently reactive nontreponemal test results after treatment?
This condition is called a serofast reaction.
89
What is the condition called when a patient with HIV infection develops neurosyphilis after treatment?
This condition is called neurorelapse.
90
What should be considered for a patient with HIV infection who presents with atypical chancres?
Atypical and aggressive presentations of syphilis are more common in HIV-infected patients, and clinical suspicion should guide diagnosis and treatment.
91
What could explain a nonreactive nontreponemal test in a patient with HIV infection?
The nonreactive test could be due to the prozone phenomenon or seronegative syphilis, which are more common in HIV-infected patients.
92
What should be done to confirm the diagnosis in a patient with HIV infection who presents with a rash?
Skin biopsy, darkfield microscopy, or PCR should be performed if serology is nonreactive.
93
What is the most likely cause of a chancre in a patient with HIV infection?
The chancre is caused by T. pallidum infection and is more likely to be larger and deeper in HIV-infected patients.
94
What should be done for a patient with HIV infection who presents with signs of secondary syphilis?
Clinical suspicion should guide diagnosis and treatment, as HIV-infected patients are more likely to present with signs of secondary syphilis while a chancre is still present.
95
What is the most likely diagnosis for a patient with HIV infection who presents with neurologic symptoms?
The most likely diagnosis is neurosyphilis, which is more common in HIV-infected patients.
96
What are the potential complications of syphilis in HIV-infected individuals?
They may experience neurorelapse, developing neurosyphilis following treatment for primary, secondary, or early latent syphilis.
97
What is the importance of skin biopsy or darkfield microscopy in syphilis diagnosis?
These methods are used when syphilis is suspected clinically and serology is nonreactive.
98
What is the treatment recommendation for syphilis in HIV-infected persons?
CDC treatment recommendations do not depend on HIV infection status; outcomes are not improved with more intense or prolonged treatment.
99
What are the signs of secondary syphilis that may be more pronounced in HIV-infected individuals?
They are more likely to manifest signs of secondary syphilis while at least one chancre is present.
100
What is the significance of the T. pallidum genome size in relation to its characteristics?
The T. pallidum genome is relatively small (1.14 Mb), which reflects its limited metabolic capabilities and reliance on the host.
101
What are the implications of serofast reactions in syphilis treatment?
Serofast reactions indicate persistently reactive nontreponemal test results, even following appropriate treatment.
102
What are the potential eye abnormalities associated with syphilis?
Potential eye abnormalities include interstitial keratitis, glaucoma, or corneal scarring.
103
What is the role of inflammatory cells in the context of syphilis and HIV?
Inflammatory cells migrate to syphilis ulcers, which are targets for HIV, increasing the risk of HIV transmission.
104
What is the clinical significance of the Hutchinson teeth in syphilis?
Hutchinson teeth are associated with congenital syphilis and indicate dental abnormalities.
105
What do serofast reactions indicate in syphilis treatment?
Serofast reactions indicate persistently reactive nontreponemal test results, even following appropriate treatment.
106
What are the potential eye abnormalities associated with syphilis?
Interstitial keratitis, glaucoma, or corneal scarring.
107
What is the clinical significance of Hutchinson teeth in syphilis?
Hutchinson teeth are a manifestation of congenital syphilis, indicating potential developmental issues.
108
What is the relationship between syphilis and the risk of neurosyphilis in HIV-infected individuals?
HIV infection increases the risk of neurosyphilis, especially in those with lower CD4 cell counts.
109
What are the implications of the prozone phenomenon in syphilis testing?
It can lead to false-negative results in serologic testing for syphilis.
110
What are the characteristics of the T. pallidum bacterium?
It is motile, spiral-shaped, and surrounded by a cytoplasmic membrane, with a thin layer of peptidoglycan providing structural stability.
111
What is the significance of the 8th nerve deafness in syphilis?
It is one of the manifestations of the Hutchinson triad, indicating potential congenital syphilis effects.
112
What is the importance of serologic testing for syphilis in HIV-infected individuals entering care?
They should have a serologic test for syphilis upon entering care and repeated testing based on sexual activity and risk behaviors.
113
What are the potential complications of untreated syphilis in the context of HIV?
Untreated syphilis can lead to severe complications, including neurosyphilis and increased HIV transmission risk.
114
What is the role of the immune response in syphilis infection?
The immune response is mediated by lymphocytes, macrophages, and plasma cells, which infiltrate at all stages of infection.
115
What are the implications of the inability to culture T. pallidum in vitro?
It necessitates the use of animal models for studying the bacterium and its disease manifestations.
116
What is the clinical significance of the 'saddle-nose deformity' in syphilis?
It is a manifestation of destruction of nasal cartilage, indicating advanced disease.
117
What is the significance of the 'scaphoid scapula' in syphilis?
It is a physical manifestation associated with chronic periostitis in syphilis.
118
What are the implications of the 'saber shins' sign in syphilis?
It indicates anterior bowing of the midtibia, a physical manifestation of chronic periostitis.
119
What is the significance of 'mulberry molars' in the context of syphilis?
They indicate syphilis vasculitis in developing tooth buds, a manifestation of congenital syphilis.
120
What is the role of IgM and IgG in the humoral immune response to T. pallidum infection?
- **IgM** appears approximately 2 weeks after exposure.
- **IgG** follows 2 weeks thereafter.
- IgM, along with IgG, continues to be produced during infection and can lead to immune-complex formation.
- Antibody titers peak during bacterial dissemination in secondary syphilis.
121
What are the limitations of the immune response in preventing reinfection with T. pallidum?
- The immune response is **insufficient** to eradicate T. pallidum from the host.
- It is also **inadequate** to prevent reinfection after a person is cured of syphilis, although it might modify the course of reinfection.
- Reinfected persons may be more likely to be **asymptomatic**.
122
What are the steps involved in preparing darkfield specimens for the detection of T. pallidum?
1. Remove crusts from the surface of the lesion.
2. Clean the surface of the lesion with a sterile saline-soaked gauze.
3. Squeeze the base of the lesion with 2 gloved fingers to induce the presence of a serous exudate on the surface.
4. Collect exudate with a glass slide, cover slip, or bacteriologic loop.
5. Add a drop of nonbacteriostatic normal saline and cover with a cover slip only if the amount of exudate is insufficient to prevent the slide from drying out prior to microscopic examination.
6. Examine the slide within 5 to 20 minutes using a darkfield microscope for the presence of T. pallidum.
123
What is the sensitivity range of darkfield microscopy for detecting T. pallidum, and what factors can affect it?
- The sensitivity of darkfield microscopy ranges from **74% to 79%**, but it declines as time elapses.
- Dead treponemes cannot exhibit the motility required for diagnosis, leading to false-negative results.
- Prior application of a topical antibiotic can also result in a **false-negative** darkfield specimen.
124
What are the barriers to vaccine development for syphilis?
- **Variability** in outer membrane protein antigens.
- Limited number of antigens on T. pallidum to which immunoprotective antibodies could bind.
- Possibility that the formation of a host protein coat around T. pallidum might prevent antibody binding.
- Potential lack of **commercial incentive** to produce a vaccine.
125
A patient presents with a painless ulcerative lesion on their genitalia. What diagnostic test should be performed immediately, and why?
Darkfield microscopy should be performed immediately as it is the diagnostic test of choice for chancres and can detect T. pallidum organisms before serologic tests become reactive.
126
A patient with HIV presents with symptoms of secondary syphilis and a nonreactive nontreponemal test. What could explain this result, and what should be done?
The nonreactive test could be due to the prozone phenomenon or seronegative syphilis. The test should be repeated with diluted serum, and clinical suspicion should guide treatment.
127
A patient with syphilis has a chancre on their lip. Why is darkfield microscopy not recommended in this case?
Darkfield microscopy is not recommended for oral lesions because nonpathogenic treponemes are normally present in the oral cavity and can be mistaken for T. pallidum.
128
What is the role of Th-1 cytokines in secondary syphilis?
Th-1 cytokines (IL-2 & IFN-γ) are downregulated, coinciding with the peak of antibody titers, which may help the organism evade the host immune response.
129
What is the significance of IgM and IgG in the humoral immune response to syphilis?
IgM appears approximately 2 weeks after exposure, while IgG appears 2 weeks thereafter, indicating an immune response during infection.
130
How does the immune response affect reinfection in untreated syphilis patients?
The immune response is sufficient to prevent reinfection in persons with untreated syphilis, known as the Law of Colles or chancre immunity.
131
What are the barriers to developing a vaccine for syphilis?
Barriers include variability in outer membrane protein antigens, limited number of antigens on T. pallidum, and potential lack of commercial incentive to produce a vaccine.
132
What is the diagnostic test of choice for chancres and moist lesions of secondary syphilis?
Darkfield microscopy is the diagnostic test of choice for these lesions.
133
Why can't darkfield microscopy be used to test oral lesions for T. pallidum?
Oral lesions cannot be tested because nonpathogenic treponemes are normally present in the oral cavity and can be mistaken for T. pallidum.
134
What is the sensitivity range of darkfield microscopy for detecting T. pallidum?
The sensitivity of darkfield microscopy ranges from 74% to 79%, but declines as time elapses.
135
What is the purpose of direct fluorescence antibody tests in syphilis diagnosis?
Direct fluorescence antibody tests are used to stain lesional exudate to identify T. pallidum, with a sensitivity of 73% to 100%.
136
What is the role of PCR-based methods in syphilis diagnosis?
PCR-based methods are used to detect T. pallidum DNA from lesions.
137
What histopathological features are associated with primary syphilis?
Histopathological features include epidermis similar to secondary syphilis, papillary dermal edema, and infiltrates characterized by lymphocytes and plasma cells.
138
What is the significance of the immune response in tissue damage caused by syphilis?
The immune response is likely responsible for the tissue damage caused in syphilis, particularly in areas near the site of a chancre.
139
What precautions must be taken when handling darkfield specimens?
Universal precautions must be used when collecting and handling darkfield specimens, as they are very infectious.
140
What is the importance of clinical suspicion in diagnosing syphilis?
Diagnosis depends on clinical suspicion and laboratory testing to detect infection with T. pallidum; treatment should not be delayed for lab results if suspicion is high.
141
What is the potential outcome for reinfected persons after being cured of syphilis?
Reinfected persons may be more likely to be asymptomatic after being cured of syphilis, although it might modify the course of reinfection.
142
What is the role of antibody titers in secondary syphilis?
Antibody titers peak during bacterial dissemination in secondary syphilis, indicating an active immune response.
143
How can T. pallidum evade the host immune response?
T. pallidum can evade the immune response by residing in immune-privileged tissues and varying its surface proteins during infection.
144
What is the significance of the Warthin-Starry stain in syphilis diagnosis?
Warthin-Starry stains can visualize T. pallidum organisms along the dermal-epidermal junction and in blood vessels, aiding in diagnosis.
145
What is the recommended procedure for preparing darkfield specimens?
The procedure includes removing crusts, cleaning the lesion, squeezing to induce exudate, and collecting the exudate for examination.
146
What is the role of immune-complex formation in secondary syphilis?
Immune-complex formation can occur during infection, potentially affecting the immune response to T. pallidum.
147
What is the clinical implication of serologies being negative in primary syphilis?
Serologies can be negative in up to 30% of patients with primary syphilis, indicating that clinical suspicion is crucial for diagnosis.
148
What is the significance of the immune response in preventing syphilis reinfection?
The immune response is sufficient to prevent reinfection in untreated syphilis patients, but not to eradicate T. pallidum from the host.
149
What are the characteristics of the immune response in secondary syphilis?
The immune response is somewhat active against T. pallidum, helping block attachment to host cells and enhancing phagocytosis.
150
What is the importance of the timing of darkfield microscopy examination?
The examination should occur within 5 to 20 minutes to ensure the presence of motile organisms for accurate diagnosis.
151
What are the histopathological features of a chancre in primary syphilis?
The edge of a chancre shows epidermis similar to that of secondary syphilis, with characteristic inflammatory infiltrates.
152
What is the role of the immune response in the pathogenesis of syphilis?
The immune response contributes to tissue damage and the clinical manifestations of syphilis, particularly in untreated cases.
153
What is the significance of the Law of Colles in syphilis?
The Law of Colles states that persons with untreated syphilis will not experience another episode of primary syphilis as long as they remain untreated.
154
What is the role of direct fluorescence antibody tests compared to darkfield microscopy?
Direct fluorescence antibody tests allow for later evaluation of the smear, while darkfield microscopy requires immediate examination.
155
What is the clinical significance of the immune response in syphilis?
The immune response can help block the attachment of T. pallidum to host cells, but it is insufficient to eradicate the organism.
156
What is the potential impact of a host protein coat on T. pallidum?
The formation of a host protein coat around T. pallidum might prevent antibody binding, complicating immune response and vaccine development.
157
What is the importance of universal precautions in syphilis diagnosis?
Universal precautions are essential when handling specimens from syphilis lesions due to their infectious nature.
158
What is the significance of the sensitivity of direct fluorescence antibody tests?
The sensitivity of direct fluorescence antibody tests ranges from 73% to 100%, making them a reliable method for detecting T. pallidum.
159
What is the role of histopathologic examination in syphilis diagnosis?
Histopathologic examination is not essential for diagnosis but can be useful in unusual or questionable cases.
160
What are the histological features shared by primary and secondary syphilis?
- **Epidermis**:
- Psoriasiform hyperplasia
- Exocytosis of lymphocytes
- Spongiform postulation
- Parakeratosis
- **Dermis**:
- Marked papillary dermal edema
- Perivascular and/or periadnexal infiltrate of lymphocytes and/or histiocytes, sometimes granulomatous (most intense in the papillary dermis)
- Plasma cells present in 3/4 of cases.
161
What is the significance of the prozone phenomenon in nontreponemal tests for syphilis?
The **prozone phenomenon** occurs in a small percentage of secondary syphilis cases where very high antibody titers inhibit test reactivity, leading to a false-negative result. To exclude this phenomenon, the test must be repeated with diluted serum.
162
What is the treatment success criterion for nontreponemal serologic tests?
Treatment success is defined as a **fourfold (two-dilution) decline** in nontreponemal test titer, although many may revert to nonreactive results. Treated primary syphilis typically becomes nonreactive in 60% of cases by 4 months and nearly all patients by 12 months.
163
What are the characteristics of treponemal serologic tests compared to nontreponemal tests?
- **Sensitivity**: Greater sensitivity in the primary and late stages of syphilis.
- **Specificity**: Slightly higher specificity.
- **False positives**: Rare, but can be associated with narcotic addiction, infections, or autoimmune diseases.
- **Clinical use**: Reactive treponemal test results essentially rule out biologic false-positive reactions on nontreponemal tests and confirm a diagnosis of syphilis when followed by a reactive nontreponemal test result.
164
What is the reverse sequence algorithm in syphilis testing?
The **reverse sequence algorithm** involves:
1. Performing a treponemal EIA test first.
2. If the EIA result is reactive, a nontreponemal test is then performed.
3. Both reactive results confirm a diagnosis of syphilis.
This method is less expensive and is increasingly used in large-volume laboratories for the lab diagnosis of syphilis.
165
A patient with syphilis has a reactive nontreponemal test followed by a reactive treponemal test. What does this confirm?
This confirms a diagnosis of syphilis.
166
A patient with syphilis has a nonreactive nontreponemal test 12 months after treatment. What stage of syphilis were they likely treated for?
They were likely treated for primary syphilis, as most patients achieve nonreactive nontreponemal test results within 12 months.
167
A patient with syphilis has a persistently reactive treponemal test result years after treatment. What does this indicate?
This is expected, as persons who have had syphilis usually have reactive treponemal test results for life, even after successful treatment.
168
A patient with syphilis has a reactive nontreponemal test but a nonreactive treponemal test. What could explain this result?
This could indicate a false-positive nontreponemal test result or a very early stage of syphilis.
169
What were patients likely treated for?
They were likely treated for primary syphilis, as most patients achieve nonreactive nontreponemal test results within 12 months.
170
What does a persistently reactive treponemal test result indicate in a patient with a history of syphilis?
This is expected, as persons who have had syphilis usually have reactive treponemal test results for life, even after successful treatment.
171
What could explain a reactive nontreponemal test but a nonreactive treponemal test?
This could be a biologic false-positive result, which is usually associated with low titers (<1:8).
172
What histological features are shared between primary and secondary syphilis?
Primary and secondary syphilis share many histological features, including changes more marked in papular lesions and less so in macular lesions.
173
What is the significance of plasma cells in the dermis of secondary syphilis cases?
Plasma cells are present in 3/4 of cases and indicate an immune response in the dermis.
174
What are gummatous lesions associated with tertiary syphilis?
Gummatous lesions are granulomas with central zones of acellular necrosis.
175
When do nontreponemal serologic tests begin to become reactive after syphilis infection?
Nontreponemal serologic tests begin to become reactive 4 to 5 weeks after infection.
176
What percentage of cases may revert to nonreactive status during late latent syphilis?
25% to 30% of cases may revert to nonreactive during late latent syphilis.
177
What indicates treatment success for nontreponemal tests?
Treatment success is indicated by a fourfold (two-dilution) decline in nontreponemal test titer.
178
What is the prozone phenomenon in the context of secondary syphilis testing?
The prozone phenomenon occurs when very high antibody titers inhibit test reactivity, producing a false-negative result.
179
What is the traditional algorithm for diagnosing syphilis?
The traditional algorithm involves performing a nontreponemal test first, followed by a treponemal test for confirmation.
180
What does a reactive treponemal test result signify?
A reactive treponemal test result essentially rules out the possibility of a biologic false-positive reaction on a nontreponemal test.
181
What is the reverse sequence algorithm in syphilis testing?
The reverse sequence algorithm involves performing a treponemal EIA test first, followed by a nontreponemal test only if the EIA result is reactive.
182
What is the expected outcome for treated primary syphilis patients regarding nontreponemal test results?
Treated primary syphilis patients are nonreactive in 60% by 4 months and nearly all by 12 months.
183
What factors can lead to false-positive results in nontreponemal tests?
False-positive results can be associated with narcotic addiction, infections, and connective tissue or autoimmune diseases.
184
What is the expected serologic response for treated secondary syphilis patients?
Treated secondary syphilis patients are expected to be nonreactive 12 to 24 months after treatment.
185
What is the role of treponemal tests in the diagnosis of syphilis?
Treponemal tests detect antibodies to T. pallidum and confirm a diagnosis of syphilis when reactive nontreponemal tests are present.
186
What is the significance of serofast patients in syphilis testing?
Serofast patients fail to achieve a 4-fold decline in titer but have adequate serologic decline; their nontreponemal test titers do not become undetectable.
187
What is the expected sensitivity of treponemal tests weeks after infection?
Treponemal tests have decreased sensitivity weeks after infection but are nearly 100% sensitive by 12 weeks.
188
What is the importance of monitoring serologic titers in syphilis treatment?
Monitoring serologic titers is crucial to determine whether the person has responded to treatment appropriately.
189
What is the expected behavior of nontreponemal titers over time in untreated patients?
Nontreponemal titers may decline over time even in the absence of treatment, and untreated late latent syphilis may have nonreactive results.
190
What is the relationship between HIV infection and seronegative secondary syphilis?
Cases of seronegative secondary syphilis have been reported in HIV-infected persons, complicating diagnosis.
191
What is the significance of the 15% to 25% nonreactive rate in treponemal tests after treatment?
15% to 25% of patients may become nonreactive between 2-3 years after treatment of primary syphilis, indicating variability in immune response.
192
What is the role of the CDC guidelines regarding serofast patients?
CDC guidelines recommend additional follow-up and testing only for serofast patients who do not achieve a fourfold decline in titer.
193
What is the expected outcome for serologic tests in patients with a history of syphilis?
Persons who have had syphilis usually will have reactive treponemal test results for life, even after successful treatment.
194
What is the significance of the two-dilution decline in nontreponemal test titers?
A two-dilution decline in nontreponemal test titers is an indicator of treatment success in syphilis.
195
What is the expected behavior of nontreponemal tests in the absence of treatment?
Nontreponemal tests may remain reactive in low titers for up to 5 years or longer in untreated patients.
196
What is the clinical implication of a reactive treponemal test followed by a reactive nontreponemal test?
A reactive treponemal test followed by a reactive nontreponemal test confirms a diagnosis of syphilis.
197
What is the expected behavior of nontreponemal tests in treated secondary syphilis patients?
Treated secondary syphilis patients are expected to be nonreactive 12 to 24 months after treatment.
198
What is the significance of the prozone phenomenon in syphilis testing?
The prozone phenomenon can lead to false-negative results in secondary syphilis cases due to high antibody titers inhibiting test reactivity.
199
What is the recommended treatment for all stages of syphilis?
Penicillin is the recommended treatment for all stages of syphilis.
200
What is the significance of a 4-fold decline in serologic nontreponemal titer after treatment?
A 4-fold decline in serologic nontreponemal titer indicates treatment success, showing reversion to a nonreactive result in the absence of persistent signs or symptoms of syphilis.
201
What are the complications associated with treatment failure in syphilis?
Treatment failure may be associated with neurosyphilis and is assessed by clinical history and physical examination. If treatment failure cannot be ruled out, retreatment with 7.2 million units of benzathine penicillin G may be necessary.
202
What is the Jarisch-Herxheimer reaction and when does it occur?
The Jarisch-Herxheimer reaction is a self-limited clinical syndrome consisting of fever, headache, and other symptoms that occurs within the first 24 hours after initiating therapy for syphilis.
203
What is the follow-up recommendation for HIV-infected persons with primary or secondary syphilis?
HIV-infected persons with primary or secondary syphilis should have follow-up at 3, 6, 9, 12, and 24 months to monitor treatment response.
204
What is the recommended management for a pregnant woman with a penicillin allergy diagnosed with syphilis?
The pregnant woman must be desensitized to penicillin and treated with penicillin, as it is the only drug known to prevent maternal transmission and treat fetal infection.
205
What should be done if a patient treated for syphilis shows a fourfold increase in nontreponemal test titers during follow-up?
The increase could indicate reinfection or treatment failure. The patient should be treated with 7.2 million units of benzathine penicillin G (divided into 3 weekly doses) and undergo CSF examination to rule out neurosyphilis.
206
What steps should be taken to evaluate a neonate born to a mother with reactive nontreponemal and treponemal tests?
The neonate should undergo a quantitative nontreponemal serologic test on infant serum, as umbilical cord blood might yield false-positive results. Additional tests like darkfield microscopy or PCR of suspicious lesions should also be considered.
207
What is the condition called when a patient with a history of syphilis treatment has persistently reactive nontreponemal test results?
This condition is called a serofast reaction. Additional clinical follow-up and, in some cases, retreatment or CSF evaluation to rule out CNS infection are recommended.
208
What should be done if a patient with syphilis has a reactive treponemal EIA test but a nonreactive nontreponemal test?
A tie-breaker test (alternate treponemal test) should be performed, and clinical suspicion should guide diagnosis and treatment.
209
What does a fourfold decline in nontreponemal test titers after treatment indicate?
This indicates treatment success, as a fourfold decline in nontreponemal test titers is a marker of effective treatment.
210
What should be done for a patient with syphilis who has a history of treatment but presents with new symptoms?
A clinical history and physical examination should be performed, and if treatment failure cannot be ruled out, the patient should be treated with 7.2 million units of benzathine penicillin G and undergo CSF examination.
211
How should follow-up differ for HIV-infected patients with syphilis compared to non-HIV-infected patients?
HIV-infected patients with primary or secondary syphilis should have more frequent follow-up at 3, 6, 9, 12, and 24 months.
212
What should be done for an HIV-infected patient with signs of congenital syphilis?
The patient should be evaluated for congenital syphilis using quantitative nontreponemal serologic tests, darkfield microscopy, or PCR.
213
What should be done for an HIV-infected patient with signs of reinfection?
Clinical history and physical examination should be performed, and if reinfection is confirmed, the patient should be treated with 7.2 million units of benzathine penicillin G.
214
What should be done for an HIV-infected patient with signs of treatment failure?
A CSF examination should be performed to evaluate for neurosyphilis, and the patient should be treated with 7.2 million units of benzathine penicillin G if treatment failure is confirmed.
215
What should be done for pregnant women who are penicillin-allergic?
They must be desensitized to and treated with penicillin, as it is the only drug known to prevent maternal transmission and treat infection in the fetus.
216
What is the significance of a 4-fold decline in serologic nontreponemal titer after treatment?
It indicates treatment success, or reversion to a nonreactive result following appropriate treatment.
217
What is the follow-up recommendation for HIV-infected persons with primary or secondary syphilis?
They should be followed up at 3, 6, 9, 12, and 24 months.
218
What is the clinical significance of treatment failure in HIV-infected patients?
Treatment failures are more common in HIV-infected patients, indicating the need for careful monitoring and possible retreatment.
219
What is the role of darkfield microscopy or PCR in congenital syphilis diagnosis?
They are used to test suspicious lesions or body fluids for evidence of congenital syphilis.
220
What should be done for any neonate with proven congenital syphilis?
They should have CSF tested for VDRL reactivity, WBC count, and protein level, as well as other tests to rule out differential diagnoses.
221
What is the Jarisch-Herxheimer reaction?
It is a self-limited clinical syndrome consisting of fever, headache, and other symptoms that occurs within the first 24 hours after initiating therapy.
222
What is the recommended treatment for reinfection or treatment failure in syphilis?
Treat with 7.2 million units of benzathine penicillin G, divided into 3 weekly doses.
223
What is the importance of clinical and serologic follow-up after syphilis treatment?
It is important to monitor response to treatment and to identify any potential treatment failures or reinfections.
224
What are the potential complications of tertiary syphilis?
Tertiary syphilis can lead to irreversible damage to vital structures through gummas or cardiovascular or CNS involvement.
225
What is the recommended follow-up interval for congenital syphilis?
Follow-up should occur every 2 to 3 months.
226
What should be done if treatment failure cannot be ruled out in a syphilis patient?
Treat with 7.2 million units of benzathine penicillin G, divided into 3 weekly doses, and perform CSF examination.
227
What is the role of macrolides in syphilis treatment?
Macrolides, including Azithromycin, may be used but have reports of treatment failures and resistance, so caution is advised.
228
What is the clinical significance of serologic tests in congenital syphilis?
Serologic tests are crucial for diagnosing congenital syphilis and assessing the need for further evaluation and treatment.
229
What are the symptoms of the Jarisch-Herxheimer reaction?
Symptoms include fever, headache, flare of mucocutaneous lesions, and tender lymphadenopathy.
230
What is the recommended management for patients with neurosyphilis?
Patients should be treated for neurosyphilis if it is present, based on CSF examination results.
231
What is the significance of a negative nontreponemal test in the context of positive treponemal tests?
It may indicate serodiscordant patients, which can occur in various clinical settings such as prozone phenomenon or early primary syphilis.
232
What is the recommended treatment for penicillin-allergic persons with syphilis who are not pregnant?
Doxycycline is recommended for penicillin-allergic persons with syphilis who are not pregnant and do not have neurosyphilis.
233
What is the importance of testing CSF in suspected cases of congenital syphilis?
CSF testing is important to rule out other differential diagnoses and assess for potential complications.
234
What should be done for patients experiencing severe symptoms after syphilis treatment?
Patients should seek medical attention if symptoms are severe, especially if they experience a Jarisch-Herxheimer reaction.
235
What is the significance of the CDC's recommendation for a fourfold decline in titer?
A fourfold decline in titer is a key indicator of treatment success in syphilis management.
236
What are the potential outcomes for patients with primary and secondary syphilis after treatment?
The majority will have resolution of symptoms with no permanent sequelae, even without treatment.
237
What is the role of serologic tests in the management of syphilis?
Serologic tests are used to monitor treatment response and detect reinfection or treatment failure.
238
What is the recommended approach for patients with a history of treatment for syphilis?
Patients with a history of treatment will require no further management unless recent reexposure is suspected.
239
What is the significance of the 15% to 20% of primary and secondary syphilis cases that remain serofast?
These cases will not achieve the expected fourfold decline in titer.
240
What is the significance of the 15% to 20% of primary and secondary syphilis cases that remain serofast?
These cases will not achieve the expected fourfold decline in titer, indicating a need for ongoing monitoring and potential retreatment.
241
What is the recommended follow-up for patients treated for syphilis?
Follow-up is recommended at 6-month intervals until a fourfold decline is documented, with specific exceptions for certain populations.
242
What is the clinical implication of the prozone phenomenon in syphilis testing?
It can lead to false-negative results in serologic tests, complicating the diagnosis of syphilis.
243
What is the recommended management for patients with treatment failure?
Patients should be treated with 7.2 million units of benzathine penicillin G, divided into 3 weekly doses, and assessed for neurosyphilis.
244
What is the significance of the CDC's guidelines regarding treatment regimens for syphilis?
The guidelines ensure that treatment is effective and appropriate, regardless of a person's HIV infection status.
245
What is the importance of clinical history and physical examination in assessing reinfection?
They are crucial for determining whether a patient has been reinfected or is experiencing treatment failure.
246
What should be done for infants born to mothers with reactive nontreponemal and treponemal tests?
They should be evaluated with quantitative nontreponemal serologic tests on infant serum to assess for congenital syphilis.
247
What is the pathogenesis of syphilis thought to result from?
The pathogenesis is thought to result from cytokine release mediated by the release of lipoproteins from dying T. pallidum organisms.
248
What emergency condition can arise from the administration of penicillin injection?
Anaphylaxis can occur, which is a life-threatening emergency managed by epinephrine and other medications.
249
What should patients be educated about at the time of initial treatment for syphilis?
Patients should be educated to distinguish an allergic reaction from a Jarisch-Herxheimer reaction, which precludes further treatment with penicillin or related drugs.
250
What is the management protocol for at-risk sex partners exposed to syphilis within 90 days?
At-risk sex partners exposed during the 90 days preceding the diagnosis should be examined and tested for syphilis and treated presumptively due to the high efficacy of prophylactic treatment.
251
What is the recommended screening for pregnant women regarding syphilis?
Pregnant women should be screened during their first prenatal visit, with retesting early in the third trimester and at delivery if at high risk for syphilis.
252
Is late congenital syphilis reversible with treatment?
False. Late congenital syphilis is not reversible with treatment.
253
Do nontreponemal serologic tests begin to become reactive 3 to 4 weeks after infection?
True. Nontreponemal serologic tests begin to become reactive 3 to 4 weeks after infection.
254
Can T. pallidum cross the blood-brain barrier and placental barrier?
True. T. pallidum can cross many barriers such as the blood-brain barrier and placental barrier.
255
What is the Jarisch-Herxheimer reaction?
The Jarisch-Herxheimer reaction occurs within the first 24 hours after initiating therapy for syphilis.
256
A patient develops fever, headache, and a flare of mucocutaneous lesions within 24 hours of syphilis treatment. What is the likely cause, and how should it be managed?
The patient is likely experiencing a Jarisch-Herxheimer reaction, a self-limited clinical syndrome. They should be encouraged to rest, maintain fluid intake, and use acetaminophen for symptom relief.
257
A patient with syphilis develops a fever of 39°C within 6 hours of treatment. What is the likely cause, and how should the patient be counseled?
The likely cause is a Jarisch-Herxheimer reaction. The patient should be counseled that this reaction is self-limited and not an allergic reaction to penicillin.
258
What is the management protocol for patients experiencing anaphylaxis from penicillin injection?
Anaphylaxis is managed by administering epinephrine and other medications, such as antihistamines, along with emergent transfer to a monitored setting.
259
What is the risk period for primary syphilis?
The risk period for primary syphilis is 3 months plus the duration of symptoms.
260
What is the recommended management for sex partners exposed during the 90 days preceding the diagnosis of syphilis?
They should be examined and tested for syphilis and treated presumptively due to the high efficacy of prophylactic treatment.
261
What is the significance of screening in preventing syphilis transmission?
Screening is important in identifying asymptomatic patients who should be treated, especially in high-risk groups.
262
What is the recommended screening frequency for sexually active MSM?
Sexually active MSM should be screened at least annually, and every 3 to 6 months if at increased risk.
263
What is the most common ophthalmic manifestation of early neurosyphilis?
The most common ophthalmic manifestation is typically chorioretinitis.
264
What are the two syndromes commonly associated with late neurosyphilis?
The two syndromes typically include general paresis and tabes dorsalis.
265
What percentage of congenital syphilis occurs in patients with mothers who have primary syphilis?
The specific percentage is not provided in the text, but it is a significant concern in maternal health.
266
What is the pain associated with osteochondrotic lesions in infants called?
The pain is referred to as 'pain associated with osteochondrotic lesions' causing the infant to refuse to move the affected anatomical area.
267
What is Hutchinson Triad?
Hutchinson Triad typically includes notched teeth, interstitial keratitis, and eighth nerve deafness.
268
What is the diagnostic test of choice in chancres?
Typically, a dark field microscopy or serologic testing is used.
269
What is the treatment for penicillin-allergic persons with syphilis who do not have neurosyphilis?
Alternatives like doxycycline or tetracycline are commonly used.
270
What is the management if treatment failure cannot be ruled out?
Management should be based on clinical evaluation and further testing.
271
Is late congenital syphilis reversible with treatment?
False, late congenital syphilis is not reversible with treatment.
272
Does the diagnosis of syphilis in a child before the neonatal period raise the question of child abuse?
True, it should raise the question of child abuse.
273
Are HIV infected persons more likely to present with more than 2 chancres?
True, HIV infected persons are more likely to present with more than 2 chancres.
274
Can T. pallidum survive outside the host for more than a few hours?
False, T. pallidum cannot survive outside the host for more than a few hours.
275
Can T. pallidum cross the blood-brain barrier and placental barrier?
True, T. pallidum can cross many barriers such as the blood-brain barrier and placental barrier.
276
Is the immune response sufficient to prevent syphilis reinfection in untreated persons?
False, the immune response is insufficient to prevent syphilis reinfection in persons who have untreated syphilis.
277
When do nontreponemal serologic tests begin to become reactive after infection?
Nontreponemal serologic tests begin to become reactive 3 to 4 weeks after infection.
278
What are serodiscordant patients?
Serodiscordant patients are those with both initial and 'tie-breaker' treponemal tests negative, but the nontreponemal test is positive.
279
When does the Jarisch-Herxheimer reaction occur after initiating therapy?
The Jarisch-Herxheimer reaction occurs within the first 24 hours after initiating therapy.
280
Can both nontreponemal and treponemal serologic tests be used to monitor treatment response?
True, both nontreponemal and treponemal serologic tests can be used to monitor treatment response.
281
Are treponemal tests recommended for the diagnosis of congenital syphilis?
True, treponemal tests are recommended for the diagnosis of congenital syphilis.
282
What are the recommended treatments for adults with primary or secondary syphilis who are HIV-infected?
For HIV-infected individuals with primary or secondary syphilis, the recommended treatment is Benzathine penicillin G: 2.4 million units, administered IM in a single dose.
283
What is the follow-up schedule after treatment for early latent syphilis?
The follow-up schedule after treatment for early latent syphilis is 6, 12, and 24 months after treatment.
284
What is the sensitivity of the RPR test for primary syphilis?
The sensitivity of the RPR test for primary syphilis is 86% (77-99%).
285
What is the specificity of the TPPA test for secondary syphilis?
The specificity of the TPPA test for secondary syphilis is 96% (95-100%).
286
What are the recommended treatments for late latent syphilis in HIV-uninfected individuals?
For HIV-uninfected individuals with late latent syphilis, the recommended treatment is Benzathine penicillin G: 3 doses of 2.4 million units IM given at 1-week intervals.
287
What is the recommended treatment for primary or secondary syphilis in HIV-infected individuals?
Benzathine penicillin G, 2.4 million units, administered IM in a single dose.
288
What alternative treatment is recommended for penicillin-allergic nonpregnant women with primary or secondary syphilis?
Doxycycline 100 mg orally twice daily for 14 days.
289
What is the expected time frame for a fourfold decline in titer after treatment for late latent syphilis?
12 to 24 months after treatment.
290
What is the sensitivity of the FTA-ABS test for secondary syphilis?
100%.
291
What is the expected time frame for a fourfold decline in titer after treatment for primary syphilis?
6 and 12 months after treatment.
292
What are some common causes of biologic false-positive nontreponemal tests?
| Cause Type | Examples |
|------------|----------|
| Physiologic | Pregnancy, Advanced age |
| Infection | Lyme disease, Relapsing fever, Leptospirosis, Syphilis, Yaws |
| Viral Infection | Cytomegalovirus, HIV, Herpes simplex, Mumps, Mycoplasma pneumoniae |
| Bacterial Infection | Pneumonia, Tuberculosis |
| Protozoan Infection | Malaria, Kala azar, Trypanosomiasis |
| Autoimmune | Hemolytic syndrome, Systemic lupus erythematosus |
| Disease | Autoimmune diseases, Malignancy, Drug abuse, Malnutrition |
293
How do serologic reactivities in syphilis patients change over time?
| Time Postinfection (Weeks) | % of Patients Who Test Positive |
|----------------------------|-------------------------------|
| 2 | 50% |
| 4 | 80% |
| 6 | 90% |
| 10 | 95% |
| 20 | 100% |
294
What is the interpretation process for the reverse sequence algorithm in syphilis testing?
1. **Treponemal test positive (EIA/CIA+)**:
- Proceed to nontreponemal test (e.g., RPR).
- If nontreponemal test positive (RPR+):
- Syphilis is likely (untreated or treated infection).
- If nontreponemal test negative (RPR-):
- Syphilis is unlikely, but false negatives in very early syphilis are possible.
2. **Treponemal test negative (EIA/CIA−)**:
- Syphilis is unlikely, but if there is concern for incubating or very early primary syphilis, repeat in 2 to 4 weeks.
295
What are some common causes of biologic false-positive nontreponemal tests in acute conditions?
Pregnancy, spirochete infections like leptospirosis, and viral infections such as mononucleosis and HIV infection.
296
What is the significance of the serologic reactivity patterns in syphilis patients over time?
The patterns show the percentage of patients who test positive for different syphilis tests over time, indicating the progression of the disease and the effectiveness of treatment.
297
How does the reverse sequence algorithm interpret treponemal test results?
If the treponemal test is positive, a nontreponemal test is performed to assess the likelihood of syphilis; if negative, syphilis is unlikely but early infection cannot be ruled out.
298
What does a positive nontreponemal test indicate in the context of syphilis diagnosis?
It indicates that the patient may have untreated or treated syphilis.
299
What should be done if a treponemal test is negative but there is concern for early syphilis?
Repeat the test in 2 to 4 weeks to confirm the diagnosis.
300
What are the clinical stages of syphilis as indicated in the serologic reactivity graph?
The clinical stages include primary, secondary, latent (asymptomatic), and tertiary syphilis.
301
What does the presence of IgM antibodies indicate in the context of syphilis testing?
IgM antibodies indicate recent infection, typically seen in the early stages of syphilis.
302
What is the role of the VDRL/RPR tests in the management of syphilis?
These tests are used to screen for syphilis and monitor treatment response, showing a decrease in positive results after effective treatment.
303
What are the implications of a positive alternative treponemal test (TPPA) in the diagnosis of syphilis?
A positive TPPA indicates early primary syphilis, treated infection, or untreated infection, necessitating further evaluation.
304
What factors can lead to false-positive results in nontreponemal tests?
Factors include autoimmune diseases, viral infections, and other non-syphilis related conditions.
