Syphilis Flashcards
What is syphilis?
An STI caused by Treponema pallidum
What type of organism is Treponema pallidum?
Spiochete gram-negative bacteria
How many cases of syphilis were diagnosed in the UK in 2015?
5,000
What is happening to the incidence of syphilis?
Increasing
What groups is incidence of syphilis markedly increasing in?
High risk groups e.g. MSM
What other conditions can be caused by other types of Treponemes?
- Bejel
- Yaws
- Pinta
What is Bejel?
A chronic skin and tissues disease
What is Yaws?
A disease of the bones and joints
What is Pinta?
A skin disease
How are other Treponeme diseases spread?
Any close contact but not mother to foetus
What does the increasing rates of syphilis in MSM suggest?
They still have high rates of condomless sex
How can syphilis be transmitted?
- Sexual transmission
- Mother to foetus via placenta
- Infected blood products
What is it called if a foetus gets syphilis across the placenta?
Congenital syphilis
How does Treponema pallidum enter the host?
Through breaks in the skin or intact mucous membranes
What forms at the site of contact in syphilis after an incubation period of 2-3 weeks?
Infectious hard ulcer (chancre)
What is the chancre in syphilis an indicator of?
The first stage of acquired symptomatic syphilis - Primary syphilis
What can happen if syphilis is left untreated?
T. pallidum can persist and cause systemic damage via obliterating arteritis
What is obliterating arteritis?
Where the endothelial cells of the vessels excessively proliferate causing lumen of the vessels to narrow
What can occur as a result of obliterating arteritis?
Ischaemia at the tissues supplied by the arteries which leads to symptoms associated with syphilis
What are the risk factors for syphilis?
- Unprotected sex
- Multiple partners
- MSM
- HIV infection
What are the two types of syphilis?
- Acquired
- Congenital
What are the forms of acquired syphilis?
- Asymptomatic (latent)
- Symptomatic
What are the stages of symptomatic syphilis?
- Primary
- Secondary
- Tertiary
What forms the basis of primary syphilis?
Chancre formation
How does the chancre form in primary syphilis?
A papule forms at the inoculation site which will ulcerate into a chancre
What is a chancre?
A painless ulcer that is usually singular, hard and non-itchy
When does a chancre develop after inoculation with syphilis?
9-90 days post infection
Where does the syphilis chancre present?
- Penis
- Scrotum
- Anus
- Rectum
- Labia
- Cervix
What is an atypical syphilis chancre?
- One that appears on unusual sites e.g. oral
- Multiple
- Painful
When do syphilis chancres typically heal?
Within 3-10 weeks with or without symptoms but can persist into secondary syphilis
When does secondary syphilis typically develop?
3 months post infection
What are the signs and symptoms of secondary syphilis?
- Skin rash
- Fever
- Malaise
- Arthralgia
- Headaches
- Condylomata lata
- Painless lymphadenopathy
- Silvery-grey mucous membrane lesions
What sort of skin rash develops in secondary syphilis?
Painless and non-itchy rash usually on the hands or soles of feet
What is condylomata lata?
Elevated plaque like warts on moist areas of the skin e.g. inner thighs, anogenital region and axillae
Where do secondary syphilis mucous membrane lesions form?
- Oral
- Pharyngeal
- Genital
What are some other manifestations of secondary syphilis?
Affecting kidneys or brain and many other sites
What happens after secondary syphilis?
The disease enters a latent asymptomatic phase
What is tertiary syphilis?
Syphilis that presents many years after the initial infection
How can tertiary syphilis be classified?
- Gummatous syphilis
- Neurosyphilis
- Cardiovascular syphilis
What happens in gummatous syphilis?
Granulomas can form in the bone, skin, mucous membranes of the upper respiratory tract, mouth and viscera or connective tissue
Are patients with gummatous syphilis infectious?
No
What can result from neurosyphilis?
- Tabes dorsalis
- Dementia
- Meningovascular complications
- Argyll Robertson pupil
What is tabes dorsalis?
- Ataxia
- Numb legs
- Absence of deep tendon reflexes
- Lightning pains
- Loss of pain and temperature sensation
- Skin and joint damage
What can be caused by syphilis dementia?
- Cognitive impairment
- Mood alterations
- Psychosis
What are the meningovascular complications of tertiary syphilis?
- Cranial nerve palsies
- Stroke
- Cerebral gummas
What is an Argyll Roberston pupil?
- Constricted
- Unreactive to light
- Reactive to accommodaiton
What can happen in cardiovascular syphilis?
- Aortic regurgitation
- Angina
- Dilation and calcification of the ascending aorta
What causes aortic regurgitation in cardiovascular syphilis?
Aortic vasculitis
What causes angina in cardiovascular syphilis?
Stenosis of the coronary ostia
What are the differentials for primary syphilis?
- Herpetic ulcers
- Chancroid
- Lymphogranuloma venereum
- Donovanosis
What are the differentials for the rash seen in secondary syphilis?
- Pityriasis rosea
- Viral exanthema
Why are the differentials for tertiary syphilis so variable?
The presentation is so variable
Who should tertiary syphilis be considered in?
Anyone with neurological or cardiac signs or symptoms
What tests are available for syphilis?
- Dark ground microscopy of chancre fluid
- PCR testing of swab from active lesion
- Serology
- Lumbar puncture
What does dark ground microscopy look for?
Spirochaete in primary syphilis
What serology tests can be used to look for syphilis?
- Treponemal tests
- Non-treponemal tests
What do treponemal serology tests do?
Assess for exposure to treponemes (not necessarily syphilis)
What are the treponemal tests used to look for syphilis?
- Treponemal ELISA
- TPPA or TPHA
What are the non-treponemal serology tests for syphilis?
RPR/VDRL
When are RPR/VDRL tests for syphilis highest?
In early disease
When can RPR/VDRL tests for syphilis results fall?
In successful treatment or advanced disease
When can false positive RPR/VDRL tests for syphilis results occur?
- Inflammatory diseases
- Pregnancy
Why may LP be useful for assessing for syphilis?
CSF antibodies are present in neurosyphilis
What drug is the treatment of choice for syphilis?
Penicillin
What should be considered in patients with syphilis and penicillin allergy?
Desensitisation
What is the first line regimen for early syphilis?
Benzathine penicillin 2.4 MU IM single dose
What is the first line regimen for late syphilis?
Benzathine penicillin 2.4 MU IM 3 doses at weekly intervals
How is neurosyphilis treated?
Procaine penicillin plus probenecid for 14 days
What additional management steps are required in syphilis?
- Advise to avoid any sex until treated
- Screen for other STIs
- Patient education
- Contact tracing
- Follow-up serology
What is the Jarisch Herxheimer reaction?
An inflammatory response to death of treponemes and results in a flu-like illness within 24 hours of treatment for syphilis
How is Jarisch Herxheimer reaction managed?
Supportive care and oral steroids in cardiovascular or neurosyphilis
How is syphilis detected in pregnancy?
Screening alongside HIV and Hep B at first antenatal appointment
Why is it important to screen for syphilis in pregnancy?
T. pallidum can cross the placenta or infect the baby during delivery
Why should women with syphilis in pregnancy be treated ASAP?
To reduce the risk of adverse outcomes
What are the risks of untreated syphilis in pregnancy?
- Miscarriage
- Stillbirth
- Pre-term labour
- Congenital syphilis
How severe is congenital?
Usually severe and debilitating
What can congenital syphilis present with?
- Saddle nose
- Rashes
- Fever
- Failure to gain weight
