26 - 170 - SYPHILIS

Question 1

incubation period of syphilis

Answer 1

10-90 days (Ave: 3 weeks)

chancre develops after an incubation period that ranges from 10 to 90 days (average: 3 weeks)

Question 2

syphilis infection is considered sexually transmissible solely in these stages

Answer 2

primary or secondary syphilis

• lesions are only present during these stages

Question 3

what are the Infectious lesions of syphilis

Answer 3

• chancres,
• condyloma lata,
• mucous patches
• “snuffles” and bullous lesions (congenital syphilis)

Question 4

typical chancre is also called

Answer 4

Hunterian chancre or ulcus durum (hard ulcer)

Question 5

what is dory flop sign

Answer 5

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.

Question 6

unilateral labial swelling with rubbery consistency and intact surface, indicative of a deep-seated chancre

Answer 6

Edema indurativum

Question 6

Extragenital chancres occur where there may be exposure, and are most frequent in what location?

Answer 6

oropharyngeal cavity

Question 7

Relapses of primary syphilis is called

Answer 7

monorecidive syphilis or chancre redux

Question 8

deep, bright-red, necrotic ulcer with a soft base and exudate, resulting from secondary bacterial infection associated with immunosuppression

Answer 8

phagedenic chancre

Question 9

Lesions of secondary syphilis are called..

Answer 9

syphilids or, when affecting the skin, syphiloderms

Question 10

Erythematous macules or maculopapules seen in secondary syphilis are called..

Answer 10

roseola syphilitica

Question 11

what do you call the white scaly ring on the surface of papulosquamous lesions of secondary syphilis?

Answer 11

Biett collarette

• characteristic of, but not pathognomonic for, syphilis

Question 12

seborrheic dermatitis–like lesions around the hairline

Answer 12

Crown of Venus or corona veneris

Question 13

Plantar lesions can be variously mistaken for calluses

Answer 13

clavi syphilitici

Question 14

Annular papules and plaques can be present around the mouth and nose, in a presentation colloquially referred to as

Answer 14

“nickels and dimes”

Question 15

rare manifestation that presents as crusted or scaly papules and plaques that can ulcerate or become necrotic, with an oyster shell-like surface

Answer 15

Malignant lues

These lesions, described as rupioid, are often seen in association with high nontreponemal titers and systemic symptoms.

Question 16

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

Answer 16

plaques fauchée en prairie

Question 17

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

Answer 17

condyloma lata

Question 18

These lesions, described as rupioid, are often seen in association with high nontreponemal titers and systemic symptoms.

Answer 18

Malignant lues

Question 19

The secondary stage is followed by an asymptomatic stage with no clinical findings, with seroreactivity by definition the only evidence of infection

Answer 19

latent syphilis

Question 20

Asymptomatic patients who have acquired syphilis within the last year are classified as having what type of latent syphilis ?

Answer 20

“early latent” infection

Question 21

why is distinction between early latent and asymptomatic syphilis acquired more than 1 year ago (often termed late latent syphilis) important?

Answer 21

• 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

Question 22

criteria for early latent syphilis

Answer 22

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:

1. Documented seroconversion or a sustained (longer than 2 weeks) fourfold or greater increase in nontreponemal test titers;
2. Unequivocal symptoms of primary or secondary syphilis;
3. A sex partner documented to have primary, secondary, or early latent syphilis; or
4. Reactive nontreponemal and treponemal tests if the patient’s only possible exposure occurred within the previous 12 months

Question 23

fraction of patients with latent syphilis which may progress to tertiary syphilis

Answer 23

• 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

Question 24

granulomatous, erosive, nodular lesions which most commonly affect the skin and bones

Answer 24

gummas

Question 25

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

Answer 25

late benign syphilis ## Footnote 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

Question 26

hallmark of late benign syphilis

Answer 26

gumma ## Footnote * **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

Question 27

refers to a solitary gumma of the penis

Answer 27

Pseudochancre redux

Question 28

what stage of syphilis does neurosyphilis occur?

Answer 28

any stage

Question 29

most common ophthalmic manifestation of early neurosyphilis

Answer 29

Uveitis ## Footnote presenting as eye pain, redness, and photophobia

Question 30

most common manifestation of otologic syphilis

Answer 30

sensorineural hearing loss

Question 31

The 2 syndromes commonly associated with late neurosyphilis

Answer 31

1. dementia paralytica AKA general paresis of the insane 2. tabes dorsalis ## Footnote * 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.

Question 32

syphilis in a child younger than 2 years of age, include fever, rash, hepatosplenomegaly, and persistent rhinitis (“snuffles”)

Answer 32

early congenital syphilis

Question 32

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**

Answer 32

“pseudoparalysis of Parrot”

Question 33

If present at delivery, the rash of early congenital syphilis is usually bullous and very infectious. What do you call this manifestation?

Answer 33

“syphilitic pemphigus”

Question 34

defined as disease occurring in a child who is at least 2 years old that typically manifests over the first 2 decades of life

Answer 34

Late congenital syphilis

Question 35

frontal bossing of late congenital syphilis

Answer 35

Olympian brow

Question 35

thickening of the sternoclavicular portion of the clavicle

Answer 35

Higoumenakia sign (fitz spelling) Other sources’ spelling: Higoumenaki’s or Higoumenakis’ sign

Question 36

anterior bowing of the midtibia

Answer 36

saber shins

Question 37

peg-shaped notched central incisors

Answer 37

Hutchinson teeth

Question 38

Hutchinson triad of late congenital syphilis

Answer 38

1. Hutchinson teeth 2. Interstitial keratitis 3. Eighth nerve deafness

Question 39

organelles that are responsible for T. pallidum’s characteristic corkscrew motility

Answer 39

endoflagella

Question 40

Question 41

what T cells predominate in chancres

Answer 41

CD4+ T cells

Question 42

what T cells predominate in lesions of secondary syphilis.

Answer 42

CD8+ T cells

Question 43

serologies can be negative in up to how many % of patients with primary syphilis?

Answer 43

30%

Question 44

diagnostic test of choice in chancres, moist lesions of secondary syphilis (condylomata lata and mucous patches), and the discharge from rhinitis in congenital syphilis

Answer 44

darkfield microscopic examination ## Footnote * 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

Question 45

How do you collect specimen for darkfield examination? What lesions can be tested?

Answer 45

* 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

Question 45

stains for T. pallidum organisms

Answer 45

Livaditis or Warthin-Starry stains

Question 45

differentiate nontreponemal from treponemal tests

Answer 45

*** 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** ## Footnote * 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.

Question 46

The 2 most widely used nontreponemal tests

Answer 46

VDRL and rapid plasma reagin (RPR) tests

Question 47

examples of treponemal tests

Answer 47

* 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

Question 48

tests used both to **diagnose** syphilis, and to **monitor response to treatment**

Answer 48

VDRL and RPR

Question 49

The VDRL and RPR begin to become reactive how many weeks after infection?

Answer 49

4 to 5 weeks ## Footnote with 100% sensitivity by approximately 12 weeks, and revert to nonreactive in 25% to 30% of cases during late latent syphilis

Question 50

definition of treatment success serologically

Answer 50

Treatment success is defined serologically as a **fourfold (two-dilution) decline** in nontreponemal test titer ## Footnote * 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

Question 51

In persons treated for secondary syphilis, the tests usually become nonreactive how many months after treatment?

Answer 51

12 to 24 months

Question 52

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?

Answer 52

serofast

Question 53

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?

Answer 53

prozone phenomenon

Question 54

Sensitivity of treponemal tests is low in the weeks after infection, but is nearly 100% by what week?

Answer 54

12 weeks

Question 55

Causes of Biologic False-Positive Nontreponemal Tests

Answer 55

Question 56

recommended preparation of penicillin for most stages of syphilis

Answer 56

Benzathine penicillin G ## Footnote * has a long half-life - critical therapeutically because of the slow dividing time of T. pallidum

Question 57

Penicillin-allergic persons with syphilis who are not pregnant and do not have neurosyphilis may be treated with what drug?

Answer 57

doxycycline

Question 58

what should be done to pregnant women with syphilis who are penicillin-allergic?

Answer 58

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**

Question 59

The CDC recommends followup at how many month intervals until a fourfold decline is documented?

Answer 59

6-month interval

Question 60

If treatment failure cannot be ruled out, the patient should be treated with how many units of benzathine penicillin G?

Answer 60

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

Question 61

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.

Answer 61

Jarisch-Herxheimer reaction ## Footnote * 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.

Question 62

risk period of partners of patients with syphilis

Answer 62

* 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.

Question 63

at-risk sex partners of persons diagnosed with syphilis

Answer 63

Sex partners exposed during the **90 days preceding the diagnosis of primary, secondary, or early latent syphilis **should be examined and tested for syphilis. ## Footnote 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.

Question 64

How frequent should a sexually active MSM be screened for syphilis ?

Answer 64

at least annually, and every 3 to 6 months if at increased risk (eg, patient or sexual partner has multiple partners)