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SEXUAL HEALTH AND HIV > SYPHILIS > Flashcards

SYPHILIS Flashcards

1
Q

What is the bacteria that is responsible for syphilis?

A

Treponema pallidum

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2
Q

What type of bacteria is T. pallidum?

A

Coiled motile spirochaete bacterium

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3
Q

What are the two way in which T. pallidum can be transmitted?

A

Sexually transmitted

Vertical transmission - can cross the placenta easily

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4
Q

What other animals are known to contract T. pallidum?

A

No others. Humans are the only natural host.

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5
Q

What is the relationship between syphilis and HIV?

A

Ulcerative lesions of primary and secondary syphilis are a facilitator for HIV transmission.

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6
Q

What is the incubation period for the primary stage of syphilis?

A

14-21 days (range of 9 - 90 days)

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7
Q

What is the most common extragenital site to be inoculated with syphilis?

A

Mouth

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8
Q

What are the clinical features of primary syphilis?

A

Normally a solitary, painless lesion (however, can be multiple and can sometimes be painful)

Develops initially as a red macule which then becomes a papule and then eventually an ulcer.

Round clean ulcer

Indurated (hardened) base

Defined edges

Local lymph nodes are moderately enlarged, rubbery, painless and discrete

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9
Q

What do we call the ulcerated lesion associated with syphilis?

A

Chancre

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10
Q

How long do the primary lesions (chancres) take to heal?

A

3 - 10 weeks

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11
Q

How long after the appearance of the primary lesion does secondary syphilis develop?

A

4-8 weeks

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12
Q

In which percentage of patients will the primary chancre still be present when they develop secondary syphilis?

A

1/3rd of cases

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13
Q

What are the clinical features of secondary syphilis?

A

Skin lesions (80%)

Generalised lymphadenopathy (60%)

Mucous membrane erosions (30%)

Malaise, fever (15%)

Hepatitis

Glomerulonephritis and nephritic syndrome

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14
Q

What are the different skin lesions associated with secondary syphilis?

A

Macular or papular

Condylomata lata

Papulosquamous

Pustular

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15
Q

How big are the macular and papular lesions associated with secondary syphilis?

A

0.5 cm to 1 cm

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16
Q

Where do the lesions associated with secondary syphilis usually appear?

A

Trunk

Palms

Arms

Legs

Soles

Face

Genitalia

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17
Q

What are condylomata lata?

A

Areas of secondary syphilis lesions where papular lesions have enlarged and coalesced to form large fleshy masses.

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18
Q

Where do condylomata lata tend to form?

A

Warm, opposed areas of the body such as the anus or labia.

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19
Q

How are papulosquamous lesions formed in secondary syphilis?

A

When scaling of the papules occurs

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20
Q

What is the term used to describe papulosquamous lesions of secondary syphilis when they occur on the palms or soles?

A

Psoriasiform

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21
Q

How are pustular lesions formed in secondary syphilis?

A

This is when the papular lesions undergo central necrosis

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22
Q

What is the term used to describe the mucosal erosions that often occur in secondary syphilis?

A

Snail track ulcers

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23
Q

What percentage of untreated patients have recurrent episodes of secondary syphilis?

A

25% - however this is rare after the first year of infection

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24
Q

What do we call the phase of syphilis in an untreated individual who has no symptoms or signs of infection?

A

Latent syphilis

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25
Q

What are the two periods of latent syphilis?

A

Early - less than 2 years of infection

Late - more than 2 years of infection

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26
Q

What are the three types of late (or tertiary) syphilis?

A

Neurosyphilis

Cardiovascular syphilis

Gummatous syphilis

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27
Q

What percentage of untreated individuals with latent syphilis go on to develop neurological lesions?

A

10%

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28
Q

What percentage of untreated individuals with latent syphilis go on to develop cardiovascular lesions?

A

10%

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29
Q

What percentage of untreated individuals with latent syphilis go on to develop gummatous lesions?

A

15%

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30
Q

What are the three classifications of neurosyphilis?

A

Asymptomatic

Meningovascular

Parenchymatous

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31
Q

What is asymptomatic syphilis?

A

This is based purely on positive test results in serum and cerebrospinal fluid

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32
Q

What are the features of meningovascular tertiary neurosyphilis?

A

Headache

Signs of meningitis

Third, sixth and eighth cranial nerve involvement - Argyll Robertson pupils

Papilloedema

Homonymous hemianopia - rare

Hemiplegia - rare

33
Q

What are the two presenting formats of parenchymatous tertiary neurosyphilis?

A

General paresis

Tabes dorsalis

34
Q

What are the early symptoms of general paresis?

A

Irritability

Fatiguability

Personality changes

Headaches

Impaired memory

Tremors

35
Q

What are the later symptoms of general paresis?

A

Lack of insight

Depression or euphoria

Confusion and disorientation

Delusions

Seizures

Transient paralysis and aphasia

36
Q

What are the signs of general paresis on examination?

A

Expressionless facies

Tremor of lips, tongue and hands

Dysarthria

Impairment of handwriting

Hyperactive tendon reflexes

Pupillary abnormalities

Optic atrophy

Convulsions

Extensor plantar responses

37
Q

How long after the original primary syphilis infection does general paresis occur?

A

10-20 years

38
Q

What are the key features of tabes dorsalis, a type of tertiary neurosyphilis?

A

Increasing ataxia

Failing vision

Sphincter disturbances

Attacks of severe pain - mostly in the legs

39
Q

What term is used to describe the attacks of severe pain in tabes dorsalis, a type of tertiary neurosyphilis?

A

Lightening pains because they occur so acutely

40
Q

What are the symptoms of tabes dorsalis, a type of tertiary neurosyphilis??

A

Lightening pains

Ataxia

Bladder disturbance

Paraesthesia

Tabetic crises

Visual loss

Rectal incontinence

Deafness

Impotence

41
Q

What are the signs of tabes dorsalis, a type of tertiary neurosyphilis?

A

Argyll Robertson pupils

Absent ankle reflexes

Absent knee reflexes

Absent biceps and triceps reflexes

Romberg’s sign

Impaired vibration sense

Impaired proprioception

Impaired sense of touch and pain

Optic atrophy

Ocular palsis

Charcot’s joints

42
Q

What is the majority of the signs of tabes dorsalis due to in terms of pathophysiology?

A

Degeneration of the posterior column

43
Q

What is most commonly affected in cardiovascular tertiary syphilis?

A

The large vessels, particularly the aorta.

44
Q

How is the aorta affected in tertiary syphilis?

A

Aortitis - with or without coronary ostial stenosis

Aneurysm of ascending part

Aortic incompetence

45
Q

What is gummatous syphilis?

A

These are granulomatous lesions or necrotic nodules that develop 3-12 years after primary infection. Gummata may occur pretty much anywhere - skin, mucous membranes, bones or viscera.

46
Q

What are the features of skin gummata associated with tertiary syphilis?

A

Found in small groups

Painless lesions

Indolent

Firm

Coppery red

0.5 - 1 cm diameter

47
Q

What investigations can be used to confirm a diagnosis of syphilis?

A

PCR and NAATs

Dark ground microscopy

Serology

Examination of CSF

Radiology

48
Q

What are the direct tests used to diagnose syphilis infection?

A

PRC of ulcer swab

Dark ground microscopy - rarely used nowadays

49
Q

How many samples need to be taken for dark ground microscopy diagnosis of syphilis?

A

Normally 3 separate specimens from the lesions, often on 3 separate days

50
Q

What are the non-specific serological tests used in the diagnosis of syphilis?

A

Rapid plasma reagin (RPR)

Venereal disease reference laboratory (VDRL)

51
Q

What are the specific serological tests used in the diagnosis of syphilis?

A

T. pallidum enzyme immunoassay (EIA)

T. pallidum particle agglutination (TPPA)

Chemiluminescent microparticle immunoassay (CMIA)

Absorbed fluorescent treponemal antibody (FTA)

T. pallidum haemagglutination assay (TPHA)

52
Q

What are specific serological tests for syphilis useful for?

A

Confirming diagnosis particularly at first presentation, however, these tests usually remain positive throughout a patient’s life even after successful treatment.

53
Q

What are non-specific tests for syphilis useful for?

A

Monitoring response to treatment and the diagnosis of reinfection of syphilis. However, they have a high false positive rate.

54
Q

What is the window period for the specific EIA syphilis test?

A

14-21 days

55
Q

What is the window period for the specific TPPA syphilis test?

A

21-28 days

56
Q

What is the window period for the non-specific RPR syphilis test?

A

28 days (range of 3-5 weeks)

57
Q

Other than syphilis, what can cause a rise in RPR?

A

Pregnancy

Acute and chronic infections (eg herpes, measles and mumps)

Autoimmune conditions such as SLE and rheumatoid arthritis

58
Q

What is the diagnostic criteria in terms of RPR for re-infection of syphilis?

A

4 fold increase - remember RPR gives you a titre.

59
Q

What would the following serology results indicate with regard to syphilis infection?

PRC - positive

EIA - negative

TPPA - negative

RPR - negative

A

Primary syphilis

60
Q

What would the following serology results indicate with regard to syphilis infection?

EIA - positive

TPPA - positive

RPR - negative

A

Previously treated syphilis

OR

New syphilis still within window period for RPR

OR

Untreated late or latent syphilis

61
Q

What would the following serology results indicate with regard to syphilis infection?

EIA - positive

TPPA - negative

RPR - negative

A

Early primary syphilis

OR

False positive

62
Q

What would the following serology results indicate with regard to syphilis infection?

EIA - positive

TPPA - negative

RPR - positive

A

Primary syphilis if ulcer present

63
Q

What would the following serology results indicate with regard to syphilis infection?

EIA - negative

TPPA - negative

RPR - positive

A

False positive

64
Q

What will CSF tests show in someone with neurosyphilis?

A

WCC - More than 5 x 10^6/L

Protein - more than 40g/L

65
Q

What syphilis diagnostic tests can be done on CSF?

A

All the specific and non-specific serological tests. Positive RPR will usually indicate neurosyphilis, as long as sample is not contaminated with macroscopic blood.

66
Q

Which syphilis patients should be offered a chest x-ray?

A

All those who may have had infection for more than 20 years.

Chest x-ray needs to show the arch of the aorta to screen for aortic dilatation.

67
Q

What is the treatment of primary, secondary or early latent syphilis?

A

Benzathine penicillin 2.4 mega units IM as single dose

OR

Aqueous procaine penicillin 600 000 units IM OD for 10 days

68
Q

What is the treatment of primary, secondary or early latent syphilis in someone who is allergic to penicillin?

A

Doxycycline 100 mg BD for 14 days

69
Q

What is the treatment of late latent, cardiovascular or gummatous syphilis?

A

Benzathine penicillin 2.4 mega units IM weekly over 2 weeks (3 injections)

OR

Aqueous procaine penicillin 600 000 units IM OD for 17 days

70
Q

What is the treatment of late latent, cardiovascular or gummatous syphilis who is allergic to penicillin?

A

Doxycycline 100 mg BD for 28 days

71
Q

What is the treatment of neurosyphilis?

A

Aqueous procaine penicillin 1.8-2.4 mega units IM OD for 17 days

AND

Probenecid 500mg QDS for 17 days

72
Q

What is the treatment of neurosyphilis who is allergic to penicillin?

A

Doxycycline 100 mg BD for 28 days

73
Q

What is the name of the reaction to syphilis treatment?

A

Jarisch-Herxheimer reaction

74
Q

What are the features of the Jarisch-Herxheimer reaction to syphilis treatment?

A

Fever

Flu-like symptoms

Occasionally chancre or skin lesions enlarge or become more widespread

75
Q

How long after initiation of treatment for syphilis does the Jarisch-Herxheimer reaction tend to occur?

A

3-12 hours after the injection of penicillin

76
Q

How do we treat the Jarisch-Herxheimer reaction to syphilis treatment?

A

Reassurance

Antipyretics

77
Q

How far back must you go in terms of contact tracing for someone diagnosed with infectious syphilis?

A

Early infectious syphilis: 3-6 months

Late syphilis patient is no longer infectious so only practical to test current regular partners

78
Q

What are the differences seen in someone with syphilis who is HIV positive versus someone who is HIV negative?

A

Primary syphilis: larger, painful, multiple ulcers

Secondary syphilis: genital ulcers (slow healing of primary ulcers), higher titres of RPR

Possibly more rapid progression to neurosyphilis

SEXUAL HEALTH AND HIV (13 decks)

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