Syphylis Dan Flashcards
What is the organism responsible for syphylis?
Treponema (genus) pallidum (species) pallidum (subspecies)
T/F
T. pallidum is a protoza
False
A spirochete
T/F
T. pallidum is microaerophilic
True
needs a small amount of O2, not too much
T/F
T. pallidum can be cultured in vitro
False
Cannot be cultured in vitro
Cannot survive outside an animal host
T/F
T. pallidum is slow growing
True
What is the organism responsible for endemic syphylis?
treponema pallidum endemicum
T/F
Syphylis is the main cause of genital ulcers in low income countries
True
In Australia what populations are most at risk of syphylis?
most new cases are in MSM
with possible exception of in NT where still high rates of indigenous syphylis
What is syphylis d’emblee
syphylis acquired by deep innoculation e.g. via needlestick - rare
Is usuallly through contact with through mucous membranes or abraded skin
T/F
All stages of Syphylis are equally infective
False
primary and secondary more than tertiery
T/F
After innoculation treponemes disseminate to local lymph nodes and internal organs within hours
True
T/F
Replication time for T pallidum is about 3 days
False
30 hours
What proportion of infected pts develop secondary syphylis?
almost 100%
What proportion of those with secondary syphylis clear spontaneously?
1/3 clear
2/3 progress to latent disease
T/F
25% of pts in latent phase syphylis have relapses of symptoms of secondary syphylis
True
What is the fate of pts with untreated latent syphylis?
1/3 Asymptomatic with negative RPR but positive specific serology (may be self cured or in RPR-ve latent phase)
1/3 Asymptomatic with positive RPR and positive specific serology (ongoing latent disease)
1/3 develop tertiary syphilis – mucocutaneous>CVS>neurosyphylis
T/F
tertiery syphylis has a mortality of 10%
False
up to 50% if untreated
How long is the latent period after contracting syphylis until symptoms of primary syphylis appear?
9-90 days
average 3 weeks
What are the features of primary syphylis?
Chancre is characteristic lesion
Painless, firm, indurated, circumscribed round/oval ulcer
sometimes >1
with non-tender rubbery regional lymphadenopathy
Typically ulcer at 3 wks, unilat LNs at 4 wks, bilat LNs at 5 wks
resolves in 1-3 months, sometimes scars
How is primary syphylis diagnosed?
Chancre is full of treponemes esp at edge - swab and dark ground microscopy is traditional but rarely performed
Can swab for fluorescence microscopy or for PCR
Usually diagnosed by serology - RPR and specific tests
- if serology negative repeat in 2 weeks
T/F
80% of primary syphylis cases will be positive for RPR
True
T/F
40% of primary syphylis cases will be positive for specific serology tests
False
90% positive
T/F
Dark field miscroscopy can be reliably performed on chancre swabs from the mouth
False
There are resident spirochetes on mucosal surfaces
can only be performe don skin chancre swabs
T/F
Dark field miscroscopy is the most sensitive and specific diagnostic test in primary syphylis
True
but rarely performed
T/F
More than one test is essential for reliable diagnosis of syphylis
True
T/F
On dark field miscroscopy T pallidum spirals around on its long axis and moves forward and backward in a characteristic way. It also bends itself into acute or obtuse angles
True
T/F
fluroesence staining of smears from swabs is an alternative to dark field microscopy
True
T/F
syphylis can be confirmed with one positive serological test
False
need either one +ve specific and one non-specific test
Or 2 +ve specific tests
Labs routinely do second test automatically if first is positive
What is the sequence of serological testing in Australia?
In Aus usually do a modern serology assay first;
EIA (enzyme immunoassay) or
CLIA (chemiluminesence immunoassay)
and if +ve lab will proceed to a conventional serology test
V. sensitive but high risk false positives (not that specific)
If +ve do conventional test;
TPPA (T. Pallidum Particle Agglutination test) or
FTA-abs (Fluorescent Treponemal Ab–absorption test)
RPR may be requested specifically
T/F
The first line diagnostic serology test for syphylis is the VDRL or RPR
False
VDRL not done anymore
RPR not used for diagnosis but can be requested in confirmed cases
What is the RPR test?
Rapid plasma reagin test for IgG and IgM antibodies to cardiolipin-lecithin-cholesterol antigen
(syphilis infection triggers the formation of anticardiolipin and other related antibodies)
T/F - regarding RPR serology;
4x decrease indicates successful treatment
True
T/F - regarding RPR serology;
A 6x increase indicates reinfection
False
4x increase indicates re-infection
T/F - regarding RPR serology;
Test becomes negative if early effective treatment received
True
In what circumstances is RPR negative and specific serology positive?
- False positive serology test or false negative RPR
- Early effective treatment of syphylis
- pt has cleared the disease spontaneously
- pt has entered an RPR-negative latent phase - possibly self-cleared but still need to treat if untreated
T/F
HIV pts may get false negative RPR test
True
T/F
All specific T. pallidum serology tests measure Abs to T. pallidum surface proteins
False
TPPA does (T Pallidum Particle Agglutination test)
also; TPHA and MHA-TP
In the FTA-abs test, Abs react with whole treponeme forming complexes
T/F
All specific T. pallidum serology tests remian positive lifeling after infection
True
unless very early treatment received
T/F
Specific T. pallidum serology tests cannot differentiate syphilis from non-venereal treponemal infection
True
What are the causes of false positive specific T. pallidum serology tests?
Autoimmune disease HIV Hypogammaglobulinaemia Older age CVS disease Lyme disease Pinta, Yaws, Other STDs (HSV)
What dilution constitutes a positive result for RPR?
In the context of a clinical suspicion of syphilis, RPR of 1:8 or above confirms the diagnosis
T/F
The papule is the classic lesion of secondary syphylis
True
What are the 3 common features of the eruptions of secondary syphylis?
They are NOT itchy
They are coppery-red
They are symmetrically distributed
T/F
secondary syphylis is a systemic illness
True
T/F
secondary syphylis occurs by dissemination of treponemes in the blood and lymphatics
True
T/F
secondary syphylis cannot occur while the primary chancre is still present
False
time from the same time as the primary lesion up to 6 months later
most commonly 3-10 wks after infection
T/F
The early latent phase is the asymptomatic period which may occur between resoultion of primary syphylis and onset of clinical signs of secondary syphylis
True
T/F
secondary syphylis affects a minority of infected individuals
False
almost all get secodnary syphylis
T/F
Circulating immune complexes are responsible for some of the clinical features of secondary syphylis
True
The prodrome of secondary syphylis involves
Fever, malaise, sore throat and generalised lymphadenopathy
True
may also be weight loss, headache (meningeal irritation), conjunctivitis, arthralgia (from periostitis), mylagia, hepatosplenomegally, mild hepatitis
o Symptoms often worse at night
T/F
generalised papulosquamous rash is the most common clinical feature of secondary syphylis
True
80%
What are the features of the rash of secondary syphylis?
rash often starts about 8 wks after infection
usually generalised papulosquamous but initially macular and become papular by 3 months
- lesions can be from 1-2mm up to 1-2 cm
- often copper-coloured
macular phase called macular syphylide
papular phase called papular syphylide
Can be polymorphic, corymbose arrangement of satellite papules around a larger central lesion
Some get a morbiliform or roseola-like (pityriasiform) eruption which is not as widespread
But always coppery-red, symmetrical and non-pruritic
Apart from the rash on the trunk and linbs what are the other skin findings of secondary syphylis?
papules/plaques on palms and soles with collarete of scale
syphylitic paronychia
Annular plaques on face or elsewhere w/ central hyperpigmentation
Moth eaten, patchy, non-scarring alopecia (5%); can also get telogen effluvium
Corona veneris – rash along hairline
Fissured papules at oral commissures
Hypopigmentred macules on neck – ‘necklace of venus’
What is lues maligna?
Rare variant of of secondary syphylis w/ disseminated necrotic ulcers resembling chancres, pt ofen systemically unwell
What are the mucosal findings in secondary syphylis?
small ulcers
Chancre redux
condylomata lata (flat toped warty papules) in anogenital area – often around 6/12 (10-20%)
mucous patches in oropharyx – superficial grey erosions which can coalesce to look like snail tracks (in up to 30%)
syphilitic sore throat – whole throat inflamed, erosions, hoarseness
T/F
about 1/3 of pts with secondary syphylis get mucosal signs
True
What is ‘Chancre redux’?
recurrence of the primary chancre at its original site in secondary syphylis
What are the systemic findings in secondary syphylis?
LNs - 50-90% get generalised lymphadenopathy
Neurological–headache, hearing loss, cranial neuropathy/ focal neurology
Eyes - photophobia, visual disturbance, uveitis
Abnormal liver enzymes
Rarely – hepatitis, gastritis, glomerulonephritis, myocarditis, joint effusions, periostitis
T/F
spirochetes may be seen in skin biopsies in secondary syphylis
True
treponemal immunostain
T/F
Pts with secondary syphylis must be assessed for occular and neurological signs
True
If present refer to ID for LP and send off CSF - nb in reality you get ID inout for every case
T/F
Should always do HIV test in pts with syphylis
True
o Also always check for HepC in MSM
T/F
HIV pts have increased risk of neurosyphylis in the secondary stage
True
esp if low CD4 count and high RPR titre
T/F
Spirochaetes are detected by gram stain on microscopy
False
T/F
The primary genital sores are first detected at 5 weeks after exposure
False
3 weeks is typical
T/F
The rash of secondary syphilis is itchy
False
T/F
Skin lesions are frequently seen in latent syphilis
False
T/F
Skin lesions of tertiary syphilis usually manifest within 1-2 years after infection
False
T/F
Tubercular syphilide lesions usually present as grouped papules or nodules
True
T/F
In congenital syphylis Wimberger’s sign manifests as facial palsy
False
bilateral destruction of the metaphyses of the proximal tibias seen on Xrays – pathognomonic for congenital syphilis
T/F
In congenital syphylis hepatosplenomegaly is associated with jaundice
True
T/F
In congenital syphylis T. pallidum is not present in the nasal discharge
False
Can isolate treponemes from discharge
What is latent syphylis?
Period between healing of lesions of secondary syphilis and manifestations of tertiary (late) syphilis
• Early latent phase is up to 2 years after infection
• Late latent phase is after 2 years
T/F
there are no clinical signs in latent syphylis
True
but serology positive
what is the outcome of pts who enter latent stage?
1/3 Asymptomatic with negative RPR but positive specific serology (essentially cured)
1/3 remain asymptomatic with positive RPR and positive specific serology
1/3 as above but will develop tertiary syphylis
How long does latent syphylis last?
months to years – typically 2-20 years
T/F
Positive serology in an asymptomatic pt is definitive for diagnosis of latent syphylis
False
could be false positive tests
Ideally should be history of primary and secondary syphilis features to confirm latent stage
Negative RPR with +ve specific test indicates either sucessfully treated syphylis, self cleared syphylis or an RPR-ve latent phase
If no clear Hx still treat as latent syphylis but may not be
• Successful treatment of latent disease indicated by decline in RPR
T/F
Pts in the latent phase are never infective
False
Can be infective at varying times in latent phase depending on if there are treponemes in blood stream but usually low risk of transmission
T/F
A pregnant mother in latent phase can still infect foetus
True
T/F
Early latent syphylis can include both the period between primary and secondary syphylis and the latent phase following secondary syphylis
True
What is the WHO classification of early and late syphylis?
Early syphylis
Any manifestation or latent phase in the first 2 years after infection
Late syphylis
Any manifestation or latent phase after the first 2 years after infection
T/F
Some authorities refer to tertiery syphylis as early syphylis
False
some call tertiery syphylis late syphylis
In this terminology both primary and secondary stages are called early syphylis
T/F
In latent syphylis the patient carries a large number of organisms
False
small number of organisms but a high immune response to these
T/F
In latent syphylis symptoms are due to the delayed hypersesnitivity to treponemes in different organ systems
True
T/F
Gummata are the most common feature of tertiary syphilis
True
which organ systems are affected in tertiery syphylis?
mainly affects skin bones CNS (25%) heart & great vessels (25%)
T/F
the RPR typically rises as symptoms of tertiery syphylis develop following a period of latency
True
T/F
An LP is mandatory in cases of confirmed or suspected tertiery syphylis
True
T/F in tertiery syphylis;
Gummata are indurrated plaques which develop central necrosis forminga punched out shallow ulcer
True
in tertiery syphylis;
where are gummata found?
Any part of skin esp limbs
also;
oral cavity, tongue, upper resp tract, liver, GIT and CNS and bones
T/F in tertiery syphylis;
Primary gummata of the bones are less common than of the skin
False
same frequency as those of skin
Cause osteitis and periostitis
Present w/ pain, swelling and reduced ROM
What is the natural history of a gumma?
If untreated persist for weeks or months then involute with tissue-paper scaring
If treated they heal completely
what are the main other skin lesions apart from gummata in tertiery syphylis?
Nodular or tubercular syphilide:
Lesions are protruding, firm, coppery red nodules
Appear in groups and forming circinate or serpiginous pattern
Located on extensors of limbs, back and the face
Some lesions may have surface scaling resulting in psoriasiform appearance
Histo same as secondary syphylis
What are the 3 classifications of neurosyphylis based on disease timing?
Asymptomatic - 10% of pts in late latent phase
Clinical early neurosyphylis - within a few years of infection. 10% during secondary syphylis
Late neurosyphylis - rare
T/F
neurosyphylis can occur at any stage of the disease?
True
but most often in tertiery syphylis
T/F
asymptomatic form accounts for over half of all cases of neurosyphylis
False
1/3 of cases
70% remit spontaneously
T/F
Dementia caused by tertiary neurosyphylis does not improve after treatment for syphilis
True
What are the features of Clinical early neurosyphylis?
Acute syphilitic meningitis (meningeal neurosyphylis) meningovascular syphilis (stroke) CNVIII palsy (vestibulocochlear n) ocular syphilis (esp uveitis)
Headache, neck stiffness, aphasia, delerium, papilloedema
hearing loss, cranial neuropathy
photophobia, visual disturbance
hemiparesis, seizures
T/F
Tabes dorsalis is the most common form of neurosyphylis
True
What are the features of Clinical late neurosyphylis?
Tabes dorsalis
Parenchymatous syphilis
Gummatous neurosyphylis
Ataxia, dysuria, areflexia, Argyll-Robertson pupil, Charcot joints, neuropathic ulcers
dementia, psychosis
general paresis, ocular palsies and uveitis
Whata re the signs and symptoms of tabes dorsalis?
DORSALIS Dysuria Orthopaedic pain (charcot's joints) Reflexes (deep tendon) are reduced Shooting pain (‘lightening’ pains) Argyll-Robertson pupil + Ataxia Leg ulcers (neuropathic) Impaired proprioception + vibration sense Spinal disease - dorsal column degeneration
What is an Argyll-robertson pupil?
Small and non reactive pupil
– constricts to accomodation but not to light
– caused by any lesion of Edinger-Westphal nucleus
What are the CSF findings in neurosyphylis?
increased pressure
high protein
high Ig level
mononuclear increased WCC
specific anti-treponemal antibodies (their presence is necessary for but not proof of neurosyphylis - Sin qua non but not pathognomonic)
NB Negative CSF FTA-Abs test excludes neurosyphylis (high sensitivity for anti-teponemal Abs - gold standard)
T/F
Cardiovascular syphylis affects up to 10% of untreated pts usually >10 years after infection
True
T/F
Cardiovascular syphylis always has late onset after 10 years
True
T/F
Cardiovascular syphylis classicially causes Aortitis of the abdominal aorta
False
Aortitis of the ascending aorta is classical
also; aortic calcification aortic valve incompetence anaeurysm LVF
T/F
Pts with cardiovascular syphylis rarely have neurosyphylis
False
often have neurosyphylis
T/F
HIV pts are at hgher risk of getting neurosyphylis
controversial
Books say true but speaker at 2015 ASM says false
T/F
RNA amplification is better for detecting syphylis than PCR
True
T/F
swabs from a primary chancre are usually sent for PCR these days
True
What are common features of biopsies of skin in syphylis?
often plasma cells and lymphocytes + histiocytes
often endarteritis
Do syphilis immunostain to see treponemes
T/F
older secondary syphylis skin elsions may be granulomatous
True
T/F
spirochetes may be visualised in the majority of skin biopsies of secondary syphylis
False
only 1/3
T/F
Warthin-starry stain is routinely performed to look for treponemes
False
No longer used
T/F
tertiery syphylis lesions ahve tuberculoid granulomas with or without caseation
True
T/F
asymptomatic patients with +ve serology but negative RPR do not need to be treated for syphylis
False
If history of treated syphylis no need to treat
If no Hx rpt test and treat if still the same
Approach to management of syphylis (not drug teratment)
Establish diagnosis and stage of disease
RPR level for Rx monitoring
Provide clear pt information and education
test for HIV, HepC and B
Consider transmission to/from index case - ?vertical transmission (congenital syph, pregnant pt), contact tracing
Lab notifies DoH as notifiable disease
Advise; No sex at all for 7 days after treatment; cannot have sex with partners of the last 3 months (if primary Dx) or 6 months (if secondary Dx) until they have been tested also
Monitor high risk pts (promiscuous MSM) for re-infection - ID or sexual health clinic does this
ID team usually treat syphylis - must check RPR post Rx to ensure 4x drop in titre
What is drug Rx of syphylis?
1.8g Benzathine penicillin (long acting penicillin G) IM
– no resistance
Early syphilis needs single dose
Late syphilis needs weekly dose for 3 weeks
Dont use ordinary benzyl penicillin as too short acting
Dont use macrolides as resistance high in Aus
Tetracyclines also effective – Doxy or tetra –cycline
Can use ceftriaxone for penicillin allergic pregnant women but some advocate penicillin desensitization then treat with penicillin – need ID and Obs input
How is treatment of syphylis different in HIV+ve pts?
No different
What is Jarisch-Herxeimer reaction?
Classicially get Jarisch-Herxeimer reaction when treating early (primary and secondary) syphilis (common)
- Sepsis like picture after starting antibiotics due to release of endotoxin-like products from dead micro-organisms causing a massive inflammatory response
– acute fever, headache, myalgia
T/F Regarding congenital syphylis;
The longer mum has had syphilis, the less likely she is to transmit it
True
T/F Regarding congenital syphylis;
Public health measures should prevent any cases of congenital syphilis occurring in Aus
True
syphylis serology usually performed at booking along with HIV, HepB and C and rubella Abs
T/F
congenital syphylis does not occur if mother contracts syphylis in the last 6 weeks of pregnancy
True
But baby at risk of neonatal syphylis by acquisition of primary syphylis during delivery
T/F Regarding congenital syphylis;
transmission risk is reduced to 50% if infection was >2 years pre-pregnancy
True
What are the consequences of transplacental transmission of syphylis?
40% have healthy baby – syphilis not established in child
20% have child born with congenital syphilis - often prem and/or low birth weight
20% early neonatal death
10% spontaneous abortion in 2nd or 3rd trimester
10% stillbirth
T/F Regarding congenital syphylis;
The risk of transmission is low for infection acquired after the 5th month of gestation
False
low if acquired from 7th months onwards
What are early and late congenital syphylis?
Early congenital syphylis;
clinical features presenting from birth to age 2 years
Late congenital syphylis;
clinical features presenting after age 2 years - often presents at ages 5-16
T/F Regarding congenital syphylis;
Pts usuallly present at birth
False
often normal at birth - present in first few months
rarely dont present until late congenital stage
T/F
‘snuffles’ are the most frequent and important sign in early congenital syphylis
True
copious purulent or serosanguinous discharge from nose
can cause nasal bone and cartilage destruction
Can isolate treponemes from discharge
T/F Regarding congenital syphylis;
skin is affected in 80%
False
40-50%
what are the skin features of early congenital syphylis?
Can be coppery red skin lesions similar to acquired secondary syphilis
Or vesiculobullous eruption
Or – ‘pemphigus syphyliticus’ large bullae on inflamed skin on palms and soles
Fissures - perioral, perianal and around nose – heal with scars (rhagades)
Often get paronychia
what are the non-skin features of early congenital syphylis?
snuffles
cachexia
LNs
HSM often with jaundice
bone lesions esp distal tib and fib;
Wimberger’s sign (bilateral destruction of the metaphyses of the proximal tibias seen on Xrays – pathognomonic for congenital syphilis)
Pseudoparalysis of Parrot is when the infant doesn’t move the limb as too painful due to bone lesion
Pneumonia alba (syphylitic pneumonitis)
Nephritic syndrome/ nephropathy
Congenital neurosyphylis – meningitis, meningoencephalitis, neck stiffness, bulging fontanelle, hydrocephalus. Can result in severe intellectual impairment
Anaemia, low platelets
T/F Regarding congenital syphylis;
Late congenital syphylis is easily distinguished from late acquired syphilis
False
hard to tell as if syphylis acquired neonataly/intrapartum can look the same
What are ‘stigmata of congenital syphylis’
scars and deformities caused by characteristic early and late disease
List the stigmata of congenital syphylis
Rhagades Hutchinson’s teeth Mulberry molars Dental caries to defective enamel Saddle nose deformity after snuffles Frontal bossing Hypoplastic maxilla – makes jaw look prominent – ‘dish face’ High arch palate – may be perforated Thickened medial clavicle Scaphoid scapulae Saber shins – anterior tibial bowing Hutchinson’s triad is combination of; - Interstitial keratitis (scarred corneas) - 8th nerve defaness - Hutchinson’s teeth
What is the most serious lesion of late congenital syphylis?
Interstitial keratitis
most common and most serious late lesion
There is clouding of the cornea and blindness can develop
Pts need treatment under ophthal with steroid drops and/or injections
Doesnt respond to antisyphylis antibiotics
T/F Regarding late congenital syphylis;
Interstitial keratitis responds to antisyphilis antibiotics
false
need steroid drops
What are the features of late congenital syphylis?
Interstitial keratitis
Bones – periostitis of long bones esp tibia, gumma and perforation of hard palate
Joints – Clutton’s joints – painless synovitis of knees. Resolves in months. Not improved by antisyphylis antibiotics
Cardiovascular syphilis – v.v. rare
Neurosyphylis – can be juvenile general paralysis or rarely tabes dorsalis
Mucocutaneous gummata
Stigmata
What is Hutchinson’s triad?
HI8
- Interstitial keratitis
- 8th nerve defaness
- Hutchinson’s teeth
What are Hutchinson’s teeth?
Permanent teeth are peg-shaped with notches in the free edge
What are Mulberry molars?
Rounded (flattened) cusps on the permanent 1st molars
What are Rhagades?
radial scars from old fissures around mouth, nose, eyes and anus
How is the diagnosis of congenital syphylis made?
antibodies identified on serology which cannot be from mother (Not IgG)
PCR test on blood for spirochaetaemia
RPR not diagnostic but can be supportive
In late congenital cases diagnosis based on clinical features, positive serology and ideally on assessment of mother and siblings
T/F Regarding congenital syphylis;
If child’s RPR is 4x greater than mothers very suggestive of infection
True
T/F
An asymptomatic neonate born to a mother with treated syphilis should always be treated
False
should be treated only if mothers disease was diagnosed during pregnancy
No need if mother had confirmed successful treatment before conception
T/F
spirochetes are gram positive helically coiled bacteria with a double membrane
False
gram negative
all else true
What organism families are types of spirochetes?
Treponemes
Borrelia
Leptospira
when your weight spirals out of control you go on The Biggest Loser
T/F
Yaws, Pinta and endemic syphylis are caused by treponemes which are identical morphologically and antigenically to treponema pallidum pallidum (venereal syphylis)
True
microscopy and serology cannot distinguish
T/F
Benzathine penicillin is the treatment for all treponemal disease
True
T/F
Yaws is caused by Treponema Carateum
False
Yaws caused by T pallidum pertenue
Pinta is caused by T carateum
T/F
Both Yaws and Pinta mainly affect children
False
Yaws and endemic syphylis mainly in kids
Pinta affects all ages equally
T/F
Yaws consists of a mother yaw at the site of innoculation - an ulcerated papule with orange-yellow crust followed by daughter yaws at periorificial sites (secondary yaws)
True
both types of lesions contain many treponemes
T/F
Pinta only occurs in warm dry parts of central and south america
Yaws occurs in tropical pacific islands
endemic syphylis occurs in N Africa, asia and middle east
True
T/F
Endemic syphylis consists of primary, secondary and tertiery disease with clinical features similar to those of venereal syphylis
True
T/F
Pinta causes macules or papules on the shins with red halos followed by psoriasiform plaques which turn grey-black in colour
True
