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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
What are the two periods of latent syphilis?
Early - less than 2 years of infection Late - more than 2 years of infection
26
What are the three types of late (or tertiary) syphilis?
Neurosyphilis Cardiovascular syphilis Gummatous syphilis
27
What percentage of untreated individuals with latent syphilis go on to develop neurological lesions?
10%
28
What percentage of untreated individuals with latent syphilis go on to develop cardiovascular lesions?
10%
29
What percentage of untreated individuals with latent syphilis go on to develop gummatous lesions?
15%
30
What are the three classifications of neurosyphilis?
Asymptomatic Meningovascular Parenchymatous
31
What is asymptomatic syphilis?
This is based purely on positive test results in serum and cerebrospinal fluid
32
What are the features of meningovascular tertiary neurosyphilis?
Headache Signs of meningitis Third, sixth and eighth cranial nerve involvement - Argyll Robertson pupils Papilloedema Homonymous hemianopia - rare Hemiplegia - rare
33
What are the two presenting formats of parenchymatous tertiary neurosyphilis?
General paresis Tabes dorsalis
34
What are the early symptoms of general paresis?
Irritability Fatiguability Personality changes Headaches Impaired memory Tremors
35
What are the later symptoms of general paresis?
Lack of insight Depression or euphoria Confusion and disorientation Delusions Seizures Transient paralysis and aphasia
36
What are the signs of general paresis on examination?
Expressionless facies Tremor of lips, tongue and hands Dysarthria Impairment of handwriting Hyperactive tendon reflexes Pupillary abnormalities Optic atrophy Convulsions Extensor plantar responses
37
How long after the original primary syphilis infection does general paresis occur?
10-20 years
38
What are the key features of tabes dorsalis, a type of tertiary neurosyphilis?
Increasing ataxia Failing vision Sphincter disturbances Attacks of severe pain - mostly in the legs
39
What term is used to describe the attacks of severe pain in tabes dorsalis, a type of tertiary neurosyphilis?
Lightening pains because they occur so acutely
40
What are the symptoms of tabes dorsalis, a type of tertiary neurosyphilis??
Lightening pains Ataxia Bladder disturbance Paraesthesia Tabetic crises Visual loss Rectal incontinence Deafness Impotence
41
What are the signs of tabes dorsalis, a type of tertiary neurosyphilis?
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
What is the majority of the signs of tabes dorsalis due to in terms of pathophysiology?
Degeneration of the posterior column
43
What is most commonly affected in cardiovascular tertiary syphilis?
The large vessels, particularly the aorta.
44
How is the aorta affected in tertiary syphilis?
Aortitis - with or without coronary ostial stenosis Aneurysm of ascending part Aortic incompetence
45
What is gummatous syphilis?
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
What are the features of skin gummata associated with tertiary syphilis?
Found in small groups Painless lesions Indolent Firm Coppery red 0.5 - 1 cm diameter
47
What investigations can be used to confirm a diagnosis of syphilis?
PCR and NAATs Dark ground microscopy Serology Examination of CSF Radiology
48
What are the direct tests used to diagnose syphilis infection?
PRC of ulcer swab Dark ground microscopy - rarely used nowadays
49
How many samples need to be taken for dark ground microscopy diagnosis of syphilis?
Normally 3 separate specimens from the lesions, often on 3 separate days
50
What are the non-specific serological tests used in the diagnosis of syphilis?
Rapid plasma reagin (RPR) Venereal disease reference laboratory (VDRL)
51
What are the specific serological tests used in the diagnosis of syphilis?
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
What are specific serological tests for syphilis useful for?
Confirming diagnosis particularly at first presentation, however, these tests usually remain positive throughout a patient's life even after successful treatment.
53
What are non-specific tests for syphilis useful for?
Monitoring response to treatment and the diagnosis of reinfection of syphilis. However, they have a high false positive rate.
54
What is the window period for the specific EIA syphilis test?
14-21 days
55
What is the window period for the specific TPPA syphilis test?
21-28 days
56
What is the window period for the non-specific RPR syphilis test?
28 days (range of 3-5 weeks)
57
Other than syphilis, what can cause a rise in RPR?
Pregnancy Acute and chronic infections (eg herpes, measles and mumps) Autoimmune conditions such as SLE and rheumatoid arthritis
58
What is the diagnostic criteria in terms of RPR for re-infection of syphilis?
4 fold increase - remember RPR gives you a titre.
59
What would the following serology results indicate with regard to syphilis infection? PRC - positive EIA - negative TPPA - negative RPR - negative
Primary syphilis
60
What would the following serology results indicate with regard to syphilis infection? EIA - positive TPPA - positive RPR - negative
Previously treated syphilis OR New syphilis still within window period for RPR OR Untreated late or latent syphilis
61
What would the following serology results indicate with regard to syphilis infection? EIA - positive TPPA - negative RPR - negative
Early primary syphilis OR False positive
62
What would the following serology results indicate with regard to syphilis infection? EIA - positive TPPA - negative RPR - positive
Primary syphilis if ulcer present
63
What would the following serology results indicate with regard to syphilis infection? EIA - negative TPPA - negative RPR - positive
False positive
64
What will CSF tests show in someone with neurosyphilis?
WCC - More than 5 x 10^6/L Protein - more than 40g/L
65
What syphilis diagnostic tests can be done on CSF?
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
Which syphilis patients should be offered a chest x-ray?
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
What is the treatment of primary, secondary or early latent syphilis?
Benzathine penicillin 2.4 mega units IM as single dose OR Aqueous procaine penicillin 600 000 units IM OD for 10 days
68
What is the treatment of primary, secondary or early latent syphilis in someone who is allergic to penicillin?
Doxycycline 100 mg BD for 14 days
69
What is the treatment of late latent, cardiovascular or gummatous syphilis?
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
What is the treatment of late latent, cardiovascular or gummatous syphilis who is allergic to penicillin?
Doxycycline 100 mg BD for 28 days
71
What is the treatment of neurosyphilis?
Aqueous procaine penicillin 1.8-2.4 mega units IM OD for 17 days AND Probenecid 500mg QDS for 17 days
72
What is the treatment of neurosyphilis who is allergic to penicillin?
Doxycycline 100 mg BD for 28 days
73
What is the name of the reaction to syphilis treatment?
Jarisch-Herxheimer reaction
74
What are the features of the Jarisch-Herxheimer reaction to syphilis treatment?
Fever Flu-like symptoms Occasionally chancre or skin lesions enlarge or become more widespread
75
How long after initiation of treatment for syphilis does the Jarisch-Herxheimer reaction tend to occur?
3-12 hours after the injection of penicillin
76
How do we treat the Jarisch-Herxheimer reaction to syphilis treatment?
Reassurance Antipyretics
77
How far back must you go in terms of contact tracing for someone diagnosed with infectious syphilis?
Early infectious syphilis: 3-6 months Late syphilis patient is no longer infectious so only practical to test current regular partners
78
What are the differences seen in someone with syphilis who is HIV positive versus someone who is HIV negative?
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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