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syphilis Flashcards

1
Q

How is syphilis transmitted?

A

Sexual transmission: early syphilis increased risk (no sexual transmission in late latent)
transplacental
transmission by blood eg PWID / transfusion is rare

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2
Q

incubation time for syphilis

A

9-90d

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3
Q

How long does a chancre last

A

3-8 weeks (can be longer in PLWH)

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4
Q

Describe the lymphadenopathy with 1y syphilis

A

regional, unilateral or bilateral, painless, rubbery

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5
Q

How long after infection does secondary syphilis occur?

A

6w - 6m, commonly 3m
and it lasts 3-12w

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6
Q

what is the classic triad of symptoms in secondary syphilis

A

Rash
mucosal patches/ulceration
generalised lymphadenopathy

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7
Q

What is early latent syphilis

A

<2y after infection, asymptomatic

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8
Q

what is Lues Maligna?

A

Nasty ulcerating skin rash in 2y syphilis, more common in PLWH, JH reaction more likely

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9
Q

What proportion of patients may have a relapse of 2y syphilis symptoms in the first 2 years

A

25%

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10
Q

What is late latent syphilis

A

asymptomatic >2y after infection

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11
Q

Gummatous syphilis - what % untreated go on to develop this and describe

A

15%,
granulomas destroy skin/viscera/bones/brain/mucosa

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12
Q

cardiovascular syphilis - what % untreated go on to develop this and describe

A

10%
gummas -> conduction problems eg stokes adams intermittent heart block and drop attacks
Aortitis ->
* proximal aortic aneurysm, can cause pressure effect on mediastinal structures
* Aortic regurg
coronary ostial stenosis ->
* angina
* MI

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13
Q

Neurosyphilis- at what stage of syphilis does it occur

A

Can occur at any stage, 10% untreated develop late neurosyphilis

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14
Q

What is the pathological process behind early neurosyphilis

A

meningeal inflammation (first 2 years)
* meningitis
* cranial nerve palsies, commonly 8th
also general confusion, reduced concentration, N+V and fatigue

meningovascular (2-5y): inflammation of meninges and meningeal arteritis =>thrombosis and infarction
* headache, N+V, dizziness, vertigo, mood lability, insomnia
* stroke syndrome, commonly MCA, maybe preceeded by prodromal symptoms
* meningomyelitis (spastic weakness and sensory loss)

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15
Q

What is the pathological process behind late neurosyphilis >10y

A

General paresis = loss of brain parenchyma: white matter
* general dementia features, seizures, paralysis
* hyperreflexia/extensor plantars, abnormal pupils, optic atrophy
Tabes dorsalis = demyelination/degeneration of the dorsal columns
* lightening pains/paraesthesia/sensory ataxia
* bladder disturbance / ED
* charcot’s joints
* romberg +ve, hyporeflexia, reduced vibration, reduced joint position sense
* argyll robertson pupil (react to accomodation not light)

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16
Q

Describe ocular syphilis

A

can occur at any stage of syphilis,
with or without symptoms of neurosyphilis
typically posterior or pan uveitis
can cause retinal vasculitis

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17
Q

what is the sensitivity for dark ground testing from a penile ulcer

A

85% sensitivity, specificity higher

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18
Q

what is the sensitivity for PCR syphilis testing

A

93%

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19
Q

Syphilis serology: what can cause false positive in trep tests

A

endemic trep will show +ve
can have false positives if older patient, PWID, autoimmune disease

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20
Q

Syphilis serology: what can cause false negative in trep tests

A

testing too soon
immunodeficiency
tests can become negative after treatment for syphilis in people with HIV

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21
Q

causes of false positive RPR

A

biological false positives
temporary <6m: preg, post MI, fever, post imms
persistent >6m:autoimmune / connective tissue / chronic liver disease, leprosy, TB, chagas, malaria, HCV, PWID, malignancy, older people

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22
Q

cause of false negative RPR

A

testing too early
prozone reaction

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23
Q

What level of RPR is indicative of active disease

A

1:16, but lower titres don’t exclude active disease

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24
Q

What does serofast mean?

A

RPR stays the same or only 2 fold (1 increment) reduction following syphilis treatment by 1y

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25
What could account for the finding of 2x positive trep tests with a negative RPR
latent untreated syphilis previously treated syphilis late congenital syphilis endomemic trep very early (might expect symptoms though) (False pos - possible but less likely if 2x trep test postive)
26
What could account for the finding of 1 trep test positive RPR negative
false positive early infection previously treated for infection with loss of antibody response REPEAT AFTER 2 WEEKS
27
What is likely to account for persistent reactivity in only 1 serological test in an asymptomatic patient
false positive
28
What management should be offered if a patient who has spent time in a country with endemic trep has positive syphilis serology?
Unless previous adequate syphilis treatment, treat for syphilis as a precaution
29
What are the indications for LP in syphilis
suspected neurosyphilis failure to achieve 4x reduction in RPR (or could just pragmatically treat for neurosyphilis) ## Footnote Insufficient evidence to support using syphilis pcr testing on CSF
30
What is the significance of a +ve RPR when testing CSF in the absence of blood staining
supports a diagnosis of neurosyphilis also TPPA >1:320 protein >0.45g/L WCC >5microL (6-20 HIV treated, >20 HIV untreated)
31
If RPR and TPHA are negative in CSF what is the significance
excludes neurosyphilis
32
Is LP useful for otosyphilis or opthalmic syphilis
No
33
what is the replication time for trep pallidum, and why is this relevant?
30-33h, need prolonged treatment with antibiotics to cover several replication cycles, particularly in latent disease when treps replicate slowly
34
What blood level of Penicillin is considered treponemocidal
0.018mg/L
35
Benzathine penicillin should be avoided with which allergies?
Penicillin, soya and peanut ## Footnote Procaine Penicillin can be used with soya and peanut allergy, Ceftriaxone can be use unless history of anaphylaxis to penicillin
36
Why is Benzathine penicillin not used for neurosyphilis
It doesn't achieve treponemocidal levels in CSF
37
Why are macrolides not used to treat syphilis
High levels of macrolide resistance due to 23SrRNA mutations
38
What is a particular concern with the JH reaction?
Can cause acute deterioration of neuro, CVS, eye and laryngeal symptoms ## Footnote Give 3d prednisolone 40-60mg starting 1d prior to antibiotics in these situations
39
What is Hoigne's syndrome
Procaine reaction
40
What is the antibiotic management of early syphilis
recommended: Benzathine Benzyl Penicillin 2.4mu im x1 alternate: procaine penicillin 600,000 units im 10d doxycycline 100mg bd 14d ceftriaxone 500mg - 1g im/iv 10d amoxicillin 500mg **QDS** and probenecid 500mg qds 14d ## Footnote Benzathine penicillin with lidocaine is now licensed for syphilis and is the preferred treatment 2024 BASHH
41
what is the antibiotic management of late syphilis
recommended: benzathine pen 2.4mu im once a week for 3w alternative doxycycline 100mg bd 28d amoxicillin 2g tds plus probenecid 500mg qds 28d ceftriaxone 2g im/iv 10-14d ## Footnote additional dose of benzathine Pen not needed if dose received within 2w of previous dose
42
what is the antibiotic management of neurosyphilis
Recommended: Procaine penicillin 1.8-2.4mu im od PLUS probenecid 500mg qds for 14 days (benzyl penicillin 1-8-2.4g 4hrly for 14d) Alternate: ceftriazone 2g im/iv 10-14d doxycycline 200mg bd 28d amoxicillin 2g tds plus probenecid 500mg qds 28d ## Footnote if treatment interrupted >24h restart
43
Prednisolone 40-60mg od for 3d starting 1d before antibiotics is needed for:
neurosyphilis otosyphylis opthalmic syphilis laryngeal gumma Cardiovascular syphilis ## Footnote for interstitial keratitis use steroid eye drops
44
Routine syphilis follow up timescale
3,6,12m then 6 mnthly until RPR neg or serofast continue annually if person with HIV
45
define treatment success
4 fold decrease in RPR, with resolution of symptoms ## Footnote usually within 6m, longer if re-infection or HIV
46
define treatment failure
4 fold increase in RPR recurrence of symptoms exclusion of re-infection
47
PN for early syphilis
1y syphilis = 3m 2y/early latent/relapse = 2y for asymptomatic partners offer epidemiological treatment or rescreen 12w after exposure
48
PN for late syphilis
Can the date of infection be worked out? partners from 2y on from dx at particular risk AND all children (inc risk vertical transmission) - offer screening otherwise all previous partners and children of females should be offered screening
49
Which service is responsible for syphilis screening in pregnancy
infections diseases in pregnancy screening IDPS
50
When should syphilis screening be offered in pregnancy?
at the first appointment, don't defer urgently if late booking / present in labour offer repeat testing if * change of partner * PWID * CSW * partner with HBV HIV * pt or partner has other partners * pt or partner dx with STI
51
What happens if a screening test is positive in pregnancy?
IDPS midwife will discuss the result with the pregnant person within 5d and refer to GUM, urgently if >20/40
52
What to do if a syphilis screenign test in pregnancy shows just 1 trep test positive?
Reassure the pregnant person, explain the result is likely a false positive arrange repeat in 2 weeks.
53
What to do if a syphilis screening test in pregnancy is negative
'Negative now' safe sex advice and advice on when to seek retesting
54
which teams are involved in caring for pregnant people with syphilis in pregnancy
GUM Obs neonates screening team/midwife micro/virology (Fetal med if >26/40 to scan for signs of congenital syphilis) | BIRTH PLAN IS IMPORTANT ## Footnote co-ordinated at multidisciplinary team meetings, sometimes the same MDT as HIV in pregnancy
55
% transplacental transmission in pregnancy with 1y syphilis
70-100% | nearly all
56
% transplacental transmission in pregnancy with early latent syphilis
approx 40% | nearly half
57
% transplacental transmission in pregnancy with late latent syphilis
10% | rare >4y after infection
58
What RPR level is associated with transplacental syphilis transmission
1:8 or higher
59
Adverse pregnancy outcomes with syphilis?
miscarriage, prematurity, stillbirth IUGR, polyhydramnios fetal anaemia / hydrops placentomegaly hepatomegaly/hepatic calcifications
60
which medications has good evidence of effectiveness for treatment of syphilis in pregnancy
penicillin ## Footnote can use ceftriaxone but less evidence
61
What treatment side effect is important to discuss prior to starting antibiotics to treat syphilis in pregnancy?
JH reaction - can cause uterine contractions and fetal heart rate abnormalities, theoretical risk of prem and pregnancy loss. Risk greater >20/40. No evidence for steroids to reduce risk. risk benefit in favour of treatment as syphilis can also cause pregnancy loss as well as congenital syphilis risk
62
which pregnant women need treating for syphilis?
* active syphilis at any stage * +ve trep serology and uncertain history of treatment / treatment response ## Footnote treatment is not required if false positive or confirmed adequate treatment prior to pregnancy
63
treatment of early syphilis in pregnancy
recommended: benzathine pen 2.4mu im x1 (extra dose 1 wk later in 3rd trimester) alternative: procaine pen 2.4mu od 10d ceftriaxone 2g im/iv 10-14 | BIRTH PLAN IS IMPORTANT
64
treatment of late syphilis in pregnancy
recommended: benzathine pen 2.4mu im once a week for 3 weeks alternative: ceftriaxone 2g im/iv 10-14d procaine ? 600,000 mu im daily for 10d | BIRTH PLAN IS IMPORTANT ## Footnote doses must be weekly in pregnnacy, can't be late due to pharmocokinetics in pregnancy
65
follow up after treatment for syphilis in pregnancy
frequency as per non pregnant eg 3,6,12m more frequent follow up if risk of reinfection may not demonstrate treatment response prior to delivery PN safe sex advice
66
definition of early and late congital syphilis
early <2y, late >2y
67
symptoms of early congenital syphilis
2/3 asymptomatic at birth usually have signs by 5w haemorrhagic rhinitis perioral fissures rash hepatosplenomegaly skeletal problems eye problems ## Footnote vasculitis => fibrosis and necrosis
68
symptoms of late congenital syphilis
60% asymptomatic - diagnosed on serology symptoms often appear in puberty hutchinson's triad = hutchinson's incisors, interstitial keratitis, sensorineural deafness frontal bossing, high arched palate, saddle nose, protruberant mandible, sabre tibia, clutton's joints (bilateral knee effusions) neurosyphilis / cranial nerve palsies / learning disability cold haemoglobinuria | kearatitis is most common late symptom ## Footnote Inflammatory manifestations and malformations
69
Diagnosing congenital syphilis can be tricky, which tests in the child support a diagnosis of congenital syphilis?
Direct tests eg dark ground or PCR showing spirochaetes IgM, confirmed on repeat (IgM doesn't cross placenta) RPR +ve in the CSF RPR >4X mother's RPR increases x4 within 3m child >12-18m with any +ve trep test
70
How long can placental transfer account for +ve RPR in the infant?
maternal transfer usually reverts by 6m
71
How long can placental transfer of IgG account for +ve trep tests in the infant?
12-18m
72
Apart from syphilis serology, what other tests can be abnormal in infants with congenital syphilis?
FBC: anaemia, cytopenias, raised WCC LFTs: hepatitis U+E: raised urea long bone x-rays: osteochondritis, periostosis, osteomyelitis
73
Which factors increase the risk of congenital syphilis?
partial / no treamtent not treated with Pen or cef Rx <30d prior to delivery 1y/early maternal syphilis 4x decrease in RPR not achieved prior to delivery ## Footnote BIRTH PLAN IS IMPORTANT
74
In mums with positive syphilis serology, which babies are NOT at risk of congenital syphilis?
Mother treated prior to pregnancy, evidence of good treatment response, no risk of reinfection | Normal postnatal care ## Footnote BIRTH PLAN IS IMPORTANT
75
For mum's treated for syphilis in pregnancy which babies are considered low risk? And how are they managed?
Mum treated in pregnancy with Pen or Cef >30d prior to delivery, no relapse, no re-infection Normal neonatal examination Discharge with plan for follow up at 3m: * if 3m RPR and IgM are negative: no further follow up * if 3m RPR is decreasing, repeat at 6m * if RPR same/increasing or +ve IgM, refer to paeds for Rx ## Footnote BIRTH PLAN IS IMPORTANT
76
Which babies are considered high risk for congenital syphilis
Inadequate maternal treatment / not treated with Pen or Cef / treated <30d prior to delivery. ## Footnote Ix with paired serology, DG/PCR if lesions, +/-CSF
77
What is the treatment of congenital syphilis?
Benzyl penicillin 25mg/kg iv for 10d <7d 12hrly 7-28d 8 hrly >28d old 6 hrly Ceftriaxone <1y 75mg/kg od >1y 100mg/kg od ## Footnote if doses >24h late, restart treatment course
78
Confirmed congenital syphilis =
*inadequate treatment reactive RPR Plus one of * features of congenital syphilis on examination * evidence on long bone XRs * CSF RPR +ve * RPR >4x mum* PLUS T pallidum on direct test or IgM +ve ## Footnote italics = probable case, confirmed by direct test or IgM
79
follow up of congenital syphilis
* RPR 3,6,12m can discharge if good treatment response * if initial CSF abnormal, repeat at 6m ISOSS notification screen family: parents and siblings breast feeding is OK after treatment report as a serious incident
80
how are endemic trepanomatoses acquired?
Direct contact Bejel also via eating/cooking utensils - lesions on mouth | No sexual or vertical transmission
81
How are endemic trepanomatoses differentiated from sexually acquired sypilis
Differentiation is clinical Both trep and non trep tests can be positiive, dark ground from lesions showes treponemes, and there are no widely available PCRs to differentiate
82
What are the clinical features of endemic syphilis
1y: ulcer 2y: skin/mucosal lesions and lymphadenopathy 3y: Gummas affecting skin, bone and cartilage (just skin changes with pinta) | similar to sexually transmitted syphillis ## Footnote No CVS or neuro involvement
83
Endemic areas for Pinta? T carateum
Central and south america
84
Endemic areas for Yaws? T pertenue
carribean, central africa, indonesia, polynesia | Humid equatorial regions
85
Endemic areas for Bejel
Middle East, West Africa | Arid regions
86
Treatment of endemic trepanematosis
1x Benzathine penicillin 1.2mu im >10y old (or doxy/azith) If unsure if endemic or sexually acquired, treat for sexually acquired t oavoid complications of tertiary syphilis ## Footnote Individuals could have both endemic and sexually acquired syphilis

DipGUM 2025 (7 decks)

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