26 - 170 - SYPHILIS Flashcards
incubation period of syphilis
10-90 days (Ave: 3 weeks)
chancre develops after an incubation period that ranges from 10 to 90 days (average: 3 weeks)
syphilis infection is considered sexually transmissible solely in these stages
primary or secondary syphilis
- lesions are only present during these stages
what are the Infectious lesions of syphilis
- chancres,
- condyloma lata,
- mucous patches
- “snuffles” and bullous lesions (congenital syphilis)
typical chancre is also called
Hunterian chancre or ulcus durum (hard ulcer)
what is dory flop sign
Retraction of the foreskin when a chancre is present on the underside causes the foreskin to flip suddenly, a sign known as the dory flop, after the movement of a dory, a small wooden fishing boat, which flips suddenly when overturned.
The dory flop sign can help distinguish chancres from other nonindurated causes of genital ulcer disease, such as herpes simplex virus infection and chancroid, that present without the induration that leads to the sudden flip of the foreskin.
unilateral labial swelling with rubbery consistency and intact surface, indicative of a deep-seated chancre
Edema indurativum
Extragenital chancres occur where there may be exposure, and are most frequent in what location?
oropharyngeal cavity
Relapses of primary syphilis is called
monorecidive syphilis or chancre redux
deep, bright-red, necrotic ulcer with a soft base and exudate, resulting from secondary bacterial infection associated with immunosuppression
phagedenic chancre
Lesions of secondary syphilis are called..
syphilids or, when affecting the skin, syphiloderms
Erythematous macules or maculopapules seen in secondary syphilis are called..
roseola syphilitica
what do you call the white scaly ring on the surface of papulosquamous lesions of secondary syphilis?
Biett collarette
- characteristic of, but not pathognomonic for, syphilis
seborrheic dermatitis–like lesions around the hairline
Crown of Venus or corona veneris
Plantar lesions can be variously mistaken for calluses
clavi syphilitici
Annular papules and plaques can be present around the mouth and nose, in a presentation colloquially referred to as
“nickels and dimes”
rare manifestation that presents as crusted or scaly papules and plaques that can ulcerate or become necrotic, with an oyster shell-like surface
Malignant lues
These lesions, described as rupioid, are often seen in association with high nontreponemal titers and systemic symptoms.
what do you call confluence of mucous patches on the tongue in patients with secondary syphilis ?
Mucous patches can be present elsewhere in the oral cavity, on other mucous membranes (such as on the genitalia), or at the corners of the mouth, where they appear as “split papules,” with an erosion traversing the center
plaques fauchée en prairie
What do you call the moist, flat, well-demarcated **papules or plaques with macerated or eroded surfaces **in intertriginous areas, commonly in the labial folds in females or in the perianal region in all patients
condyloma lata
These lesions, described as rupioid, are often seen in association with high nontreponemal titers and systemic symptoms.
Malignant lues
The secondary stage is followed by an asymptomatic stage with no clinical findings, with seroreactivity by definition the only evidence of infection
latent syphilis
Asymptomatic patients who have acquired syphilis within the last year are classified as having what type of latent syphilis ?
“early latent” infection
why is distinction between early latent and asymptomatic syphilis acquired more than 1 year ago (often termed late latent syphilis) important?
- First, up to 25% of patients with early latent syphilis may relapse into secondary syphilis, leading to possible sexual transmission.
- Second, clinical management of patients with early latent syphilis differs from management of patients with late latent syphilis
The treatment of early latent syphilis is the same as that of primary and secondary (collectively termed early syphilis), whereas late syphilis requires an extended therapeutic course
criteria for early latent syphilis
A patient can be classified as having early latent syphilis if, within the year preceding discovery of the reactive serologic test, the patient had 1 of the following:
- Documented seroconversion or a sustained (longer than 2 weeks) fourfold or greater increase in nontreponemal test titers;
- Unequivocal symptoms of primary or secondary syphilis;
- A sex partner documented to have primary, secondary, or early latent syphilis; or
- Reactive nontreponemal and treponemal tests if the patient’s only possible exposure occurred within the previous 12 months
fraction of patients with latent syphilis which may progress to tertiary syphilis
- 1/3 - tertiary
- 2/3 - remain in latency
approximately one-third of patients with untreated latent syphilis progress to tertiary syphilis, typically after 15 to 40 years, while the other two-thirds remain in latency
granulomatous, erosive, nodular lesions which most commonly affect the skin and bones
gummas
The signs and symptoms of syphilis that occur after secondary syphilis that do not involve the cardiovascular or nervous systems have historically been referred to as
late benign syphilis
Lesions of late benign syphilis are caused by **delayed-type hypersensitivity responses **to the small number of treponemes present in the involved tissue or organ
hallmark of late benign syphilis
gumma
- granulomatous nodular lesion with variable central necrosis, which most commonly affect the skin or mucous membranes (80% of gummas)
- Gummas are nontender pink to dusky-red nodules or plaques that vary in size from millimeters to many centimeters in diameter
- They favor sites of **previous trauma **and may arise anywhere on the body, but are more common on the scalp, forehead (Fig. 170-27), buttocks, and presternal, supraclavicular, or pretibial areas
refers to a solitary gumma of the penis
Pseudochancre redux
what stage of syphilis does neurosyphilis occur?
any stage
most common ophthalmic manifestation of early neurosyphilis
Uveitis
presenting as eye pain, redness, and photophobia
most common manifestation of otologic syphilis
sensorineural hearing loss
The 2 syndromes commonly associated with late neurosyphilis
- dementia paralytica AKA general paresis of the insane
- tabes dorsalis
- General paresis presents as a rapidly progressive dementia, accompanied by personality changes
- Tabes dorsalis presents with sensory ataxia and bowel and bladder dysfunction, resulting from damage to the posterior columns of the spinal cord
- Tabes dorsalis can be accompanied by an Argyll Robertson pupil (which accommodates, but does not react to, light) and optic atrophy.
syphilis in a child younger than 2 years of age, include fever, rash, hepatosplenomegaly, and persistent rhinitis (“snuffles”)
early congenital syphilis
what do you call the manifestation of early congenital syphilis presenting with **pain associated with osteochondrotic lesions **causing the infant to refuse to move the affected anatomic area
“pseudoparalysis of Parrot”
If present at delivery, the rash of early congenital syphilis is usually bullous and very infectious. What do you call this manifestation?
“syphilitic pemphigus”
defined as disease occurring in a child who is at least 2 years old that typically manifests over the first 2 decades of life
Late congenital syphilis
frontal bossing of late congenital syphilis
Olympian brow
thickening of the sternoclavicular portion of the clavicle
Higoumenakia sign
anterior bowing of the midtibia
saber shins
peg-shaped notched central incisors
Hutchinson teeth
Hutchinson triad of late congenital syphilis
- Hutchinson teeth
- Interstitial keratitis
- Eighth nerve deafness
organelles that are responsible for T. pallidum’s characteristic corkscrew motility
endoflagella
what T cells predominate in chancres
CD4+ T cells
what T cells predominate in lesions of secondary syphilis.
CD8+ T cells
serologies can be negative in up to how many % of patients with primary syphilis?
30%
diagnostic test of choice in chancres, moist lesions of secondary syphilis (condylomata lata and mucous patches), and the discharge from rhinitis in congenital syphilis
darkfield microscopic examination
- Darkfield examination will often be positive before serologic tests become reactive
- Importantly, because nonpathogenic treponemes are normally present in the oral cavity and can be mistaken for T. pallidum, darkfield microscopy cannot be used to test oral lesions
- lesions of syphilis suitable for darkfield examination are very infectious
How do you collect specimen for darkfield examination?
What lesions can be tested?
- Darkfield specimens are prepared by removing crusts from the surface of the lesion, cleaning the surface of the lesion with a sterile saline-soaked gauze, squeezing the base of the lesion with 2 gloved fingers to induce the presence of a serous exudate on the surface, and collecting the exudate with a glass slide, cover slip, or bacteriologic loop
- Only if the amount of exudate is insufficient to prevent the slide from drying out prior to microscopic examination should a drop of nonbacteriostatic normal saline be added before covering the slide with a cover slip.
- The slide is examined within 5 to 20 minutes by a trained microscopist, using a darkfield microscope
Specimen: chancres, moist lesions of secondary syphilis (condylomata lata and mucous patches), and the discharge from rhinitis in congenital syphilis
stains for T. pallidum organisms
Livaditis or Warthin-Starry stains
differentiate nontreponemal from treponemal tests
* nontreponemal tests - detect IgG and IgM antibodies to l**ipoidal material **released from damaged host cells and possibly from T. pallidum
*** treponemal tests **- detect antibodies to T. pallidum itself
- Persons who have had syphilis usually will have reactive treponemal test results for life, even after successful treatment, making a reactive treponemal test in a person with a history of syphilis generally not useful clinically.
The 2 most widely used nontreponemal tests
VDRL and rapid plasma reagin (RPR) tests
examples of treponemal tests
- TPPA, T. pallidum particle agglutination;
- MHA-TP, microhemagglutination assay for Treponema pallidum
- FTA-ABS, fluorescent treponemal antibody absorption assay
- TPHA, T. pallidum hemagglutination
- EIA, enzyme immunoassay
tests used both to diagnose syphilis, and to monitor response to treatment
VDRL and RPR
The VDRL and RPR begin to become reactive how many after infection?
4 to 5 weeks
with 100% sensitivity by approximately 12 weeks, and revert to nonreactive in 25% to 30% of cases during late latent syphilis
definition of treatment success serologically
Treatment success is defined serologically as a fourfold (two-dilution) decline in nontreponemal test titer
- Treatment success is generally defined as a fourfold decline in serologic nontreponemal titer (or reversion to nonreactive result) following appropriate treatment, in the absence of persistent signs or symptoms of syphilis, and within a specified time frame depending on stage of infection and HIV infection status of the infected person.
- An example of a fourfold decline in titer is a 1:64 titer declining to 1:16, or a 1:16 titer declining to 1:4
In persons treated for secondary syphilis, the tests usually become nonreactive how many months after treatment?
12 to 24 months
Both patients who fail to achieve a fourfold decline in titer, as well as those who have adequate serologic decline but whose nontreponemal test titers do not become undetectable, have been referred to as?
serofast
In a small percent of secondary syphilis cases, very high antibody titers inhibit test reactivity, producing a false-negative result.
What do you call this phenomenon?
prozone phenomenon
Sensitivity of treponemal tests is low in the weeks after infection, but is nearly 100% by what week?
12 weeks
Causes of Biologic False-Positive Nontreponemal Tests
recommended preparation of penicillin for most stages of syphilis
Benzathine penicillin G
- has a long half-life - critical therapeutically because of the slow dividing time of T. pallidum
Penicillin-allergic persons with syphilis who are not pregnant and do not have neurosyphilis may be treated with what drug?
doxycycline
what should be done to pregnant women with syphilis who are penicillin-allergic?
must be desensitized to and treated with penicillin, which is the only drug that is known to prevent maternal transmission and to treat infection in the fetus
The CDC recommends followup at how many month intervals until a fourfold decline is documented?
6-month interval
If treatment failure cannot be ruled out, the patient should be treated with how many units of benzathine penicillin G?
If treatment failure cannot be ruled out, the patient should be treated with** 7.2 million units of benzathine penicillin G (divided into 3 weekly doses);** CSF examination should be performed to determine whether neurosyphilis is present, and, if it is, the patient also should be treated for neurosyphilis
self-limited clinical syndrome consisting of fever, headache, flare of mucocutaneous lesions, tender lymphadenopathy, pharyngitis, malaise, myalgia, and leukocytosis occurring within the** first 24 hours** after initiating therapy.
Jarisch-Herxheimer reaction
- The fever peaks 6 to 8 hours after the onset, usually around 39°C (102.2°F), but it can be as high as 42°C (107.6°F).
- Patients should be warned about the possibility of developing this reaction before receiving treatment
- thought to result from cytokine release mediated by the release of lipoproteins from dying T. pallidum organisms.
risk period of partners of patients with syphilis
- identifying which sex partners are at risk of infection depends both on the elapsed time since last exposure and stage of infection in the source patient.
- This risk period is 3 months plus duration of symptoms for primary syphilis, 6 months plus duration of symptoms for secondary syphilis, and **1 year **for early latent syphilis and latent syphilis of unknown duration.
at-risk sex partners of persons diagnosed with syphilis
Sex partners exposed during the **90 days preceding the diagnosis of primary, secondary, or early latent syphilis **should be examined and tested for syphilis.
However, regardless of results of the physical examination and laboratory tests, those partners should be treated presumptively because of the high efficacy of prophylactic treatment and the likelihood (up to 63%) that they been infected but have yet to show clinical or laboratory evidence of disease.
How frequent should a sexually active MSM be screened for syphilis ?
at least annually, and every 3 to 6 months if at increased risk (eg, patient or sexual partner has multiple partners)
