Syphilis

Question 1

Mc outcome of syphilis in pregnancy

Answer 1

Mid-trimester spontaneous abortion

Question 2

Stages of syphilis

Answer 2

●Primary:
1. Chancre (ulcer) @area of contact
2. Local lymphadenopathy (painless)
3. Heals spontaneously in 3-6wks

●Secondary: 3-8wks until 1yr post primary syphilis if untreated
1. Rash - no itch, on trunk, palms, soles
2. Condyloma lata (greyish-white moist plaques)
3. Mucous surfaces - red, raw
4. Resolves spontaneously in 2-6wks

●Latent: secondary stage left untreated
1. Sero-positive, no symptoms
2. Early latent: If infected <2yrs
3. Late latent: infected >2yrs, only vertical transmission or blood

●Tertiary: Upto 20-40yrs
1. Neurosyphilis - brain, spinal cord
2. Cardio-syphilis - heart, blood vessels
3. Liver
4. Bones and joints
*Risk of vertical transmission negligible

Question 3

Neuro syphilis

Answer 3

At any stage of syphilis infection
Symptoms:
1. meningitis
2. cranial nerve palsies
3. change in vision
4. change in hearing
5. difficulty coordinating muscle movements
6. paralysis, numbness
7. dementia
8. psychosis
9. death

Question 4

Syphilis serology

Answer 4

1. EIA reactive (enzyme immuno assay)
2. TPPA, FTA-abs
   Above indicate exposure to syphilis, active status cannot be tested
3. RPR (rapid plasma reagent)
   -active status
   -response to treatment
   -reinfection
4. POCT (point of care testing)
   -Treponemal antibody test
   -active/inactive/treated
5. VDRL

Question 5

Diagnosis of syphilis

Answer 5

DNA PCR and Serology
●PCR swabs from ulcers in primary and secondary syphilis
●Serology in latent syphilis

Question 6

USG findings for congenital syphilis

Answer 6

1. Hepatomegaly
2. Placentomegaly
3. Polyhydramnios
4. Ascites
5. Abnormal middle cerebral arterial doppler assessment
6. Fetal hydrops
7. Bent, thickened or shortened fetal long bones

Question 7

Jarisch-Herxheimer reaction

Answer 7

1. 2-24hrs after high dose Penicillin in Syphilis <2yrs
2. Transient inflammatory reaction to death of spirochetes
3. fever, chills, headache, myalgias, and exacerbation of cutaneous lesions
4. <20wks gestation, pptn uterine contractions, decreased fetal movements, abnormal fetal heart rate
   (FHR), preterm birth, still birth
5. Continue syphilis rx
6. Symptomatic mx: PCM, tocolytics

Question 8

Mx of primary, secondary, early latent syphilis

Answer 8

1. Benzyl penicillin - single dose
   2.4 Million units (1.8g)
   IM
   -1.2million units on each buttock
2. Second dose same as above in
   a. T3 syphilis+
   b. >20wks, signs of congenital syphilis on USG
3. RPR: disease activity
   -on the day of rx (peak RPR)
   -monthly
   -at birth
4. Avoid sex until 7days after rx
   Rx sexual partners
5. F/u 4wks after rx - clinical exam, ensure no sex happened

Question 9

Mx of late latent syphilis

Answer 9

Benzyl penicillin 2.4million units IM
-3 doses at 0, 7, 14 days

*if one dose delayed by >24hrs, restart rx with 3 doses

RPR on first dose day

Question 10

Mx of tertiary syphilis

Answer 10

*IV Benzyl penicillin 2.4million units
-intravenous
-every 4hrs
-for 15 days

Refer to specialist

Question 11

True penicillin allergy in syphilis

Answer 11

1. Try desensitisation

if not possible

2. Doxy
   100mg BD x14days - pri/sec/early latent
   100mg BD x28days - late latent syphilis
3. If preg, Doxy till 18wks only
   *>18wks use causes
   a. Teeth discolouration
   b. Enamel hypoplasia
   c. Inhibition of bone growth
4. Monthly RPR

Question 12

Successful rx of syphilis established by what test

Answer 12

RPR - 4 fold drop
●Within 1yr in pri/sec/early latent
●Within 2 yrs in late latent

Question 13

Syphilis in pregnancy

Answer 13

*1. Rx before 28wks or at least 30 days before delivery

2. Causes:
    Miscarriage
    Stillbirth
    Prematurity and low birth weight
    Perinatal death
    Born with signs of congenital syphilis
    Born as a healthy-looking baby, showing clinical signs of congenital syphilis later
    Healthy non-infected baby if mother adequately treated at least 30 days before birth.

Question 14

Syphilis+, can the baby be breast fed.
What if a chancre is present on breast

Answer 14

1. Baby can be fed as spirochetes do no enter breastmilk
2. If chancre present on breast or axilla,
   discard milk for 7days post rx
   and lesion os healed

Question 15

Congenital syphilis test, rx

Answer 15

Presentation:
Early - <2yrs
Late - >2yrs

1. RPR, IgM
2. Placental serology, histopathology
3. PCR
4. CSF, Xray long bones, auditory exam

Rx:
●Benzylpenicillin 50 mg/ kg body wt
IV every 12 hrs x first 7 days of life
every 8 hours thereafter for a total of 10 days

OR

●Procaine penicillin G 50mg/ kg IM daily
x 10 days