Condylomata lata ; mucous patches snail track ulcers.

· Syphilis is a chronic systemic infection caused by Treponema pallidum, and is usually sexually transmitted. Most cases are acquired by sexual contact withinfectious lisions – i.e. the chance , mucous patch, skin rash or conylomate lata. It maybe transmitted through non-sexual modes also - i.e. transfusion or infection in utero

· Treponema pallidum can rapidly penetrate intact mucous membranes or abraded skin, Within a few gours they enter the lymphatics and blood stream to produce systemic infrection . The primary lesion appears at the site or inculation. The generalized parenchmal, constitutional and mucocutaneous manifectations or secondary syphilis usually appear about 6 – 8 weeks after healing of the chancre.

Classification

Acquired syphilis Congenital syphilis

· Primary syphilis Early

· Secondary syphilis Late

· Latent syphilis Stigmata

· Late syphilis (tertiary,quaternary)

Primary syphilis

· Primary chancre begins as a single painless papule which rapidly becomes an uncerated and indurated lesion (‘hard chancre’). The chancre is usually locatedon the penis in heterosexual mateds. In homosexual males it may be seen in the anal canal, rectumor within the mouth. Infemales the common primary sites are the cervix and the labia.

· Regional lymphadenopathy usually accompanies the primary lesion, appearing within I week of the onset of the lesion. The nodes are firm , rubbery, non-suppurative, painless and non-tender , External genital and anal chancres produce bilateral inguinal lymphadenopathy. Chancres of cervix and vagina result in iliac or perirectal adenopathy.

· The primarychancre usually heals within 4 – 6 weeks (even without treatment), but the lymphadenopathy may persists for month.

Secondary syphilis

· Secondary syphilis develops 6 – 8 weeks after the appearance of the primary chancre . It starts with symptoms of generalized infectionlike malaise , headache and low-grade fever. The four cardinal signs of secondary syphilis are:

1. Skin rashes (75%).

2. Generalised lymphadenopathy (50%).

3. Condylomata lata (10%).

4. Mucous patches (30%).

· Skin rashes start as madular lesions on the trunk and proximal limbs, progressing to a generalized popular rash. These lesions may progress to nerotic uncers, which frequently involve the palms and soles.

· Generalised , firm non – tender lymphadenopathy occurs in about 50% of cases.

· In worm, moist, intertriginous areas, including the peranal area, vulva, scrotum and inner thighsm papules enlarge and become eroded, to produce broad , moist , pink or grey – white highly infection lesions called condylomata lata.

· Mucous patches occur in the lips, tongue, palate pharynx, vulva , vagina or glans penis. The typical mucous patch is a superficial mucosal erosion surrounded by a red serpigenous perpheryand is usually painless. Sometimes they may coalesce to form ‘snail track’ ulcers.

· Other less common manifestations of secondary syphilis include meningitis, hepatitis , nephropathy (proteinuria,nephroticc syndrome or haemorrhagic glomerulonephritis), gastrointestinal involvement, ovular involvement (anterior uveitis, chroidits m intersititial keratitis, retinal vasculitis, retinitis, optic nuritis, dacryoadenitis or scleritis), arthritis, and periostitis.

· After several months, the secondary syphilis resolved to be followed by a latent period

Latent syphilis

· Early latent’syphilis encompasses the Ist year after infection, while ‘late latent’s syphilis, begins 1 year after infection. A diagnosis of latent syphilis is established based on:

· Positive specific treponemal antibody test for syphilis.

· Normal CSF examination

· Absence of clinical manifestations of syphilis on physical ecamination and chest film.

· History of primary or secondary lesions.

· History of expolsure to syphilis.

· Pregnant females with latent syphilis may infect the foetus in utero

· About 70% of untreated patients never develop features of late syphilis; rest 30% or cases go on to deveolop late syphilis.

Late syphilis

Asymptomatic late neurosyphilis

· The patients does not have any symptoms or signs.

· The CSF shows mononuclear pleocytosis and increased protein.

· VDRL is positive.

· Patients are at risk of developing symptomatic neurosyphilis and therefore , thiscondition requires treatment.

Tertiary (benign gummatous) syphilis

· This takes 10 or more years to develop and affects skin, subcutaneous tissues, mucous members , submucosa and bones. The characteristic feature is a granulomatous lesion called a gumma.

Quaternary syphilis

· Quaternary syphilis includes cardiovascular syphilis and neurosyphilis.

· The manifestations of cardiovascular syphilis are discussed under ‘Diseases of the Cardiovascular system’, and of neurosyphilis under ‘Diseases of the nervous System’.

Congenital syphilis

Early congenital syphilis

· Manifestations appear within first 2 year of life , most often between 2 and 10 weeks of age. They resemble features of secondary syphilis.

· Rhinitis or ‘snuffles.

· Mucocutaneous lesions including bullae, vesicles , mucous patches and condyloma lata.

· Bone involvement in the form of osteochondritis, soteitis and periostitis.

· Hepatosplenomegalu, lymphadenopathy,anaimia, jaundice, thrombocytopenia.

Late congenital syphilis

· Occurs after two years of age.

· Remains subclinical in 50 – 60% cases.

· Interstitial dermatitis , deafness , Clutton’s joints , neurosyphilis , gummatous periostitis , destruction of palate and nasal septum.

· Cardiovascular involvement is rare.

Stigmata of congenital syphilis

· Hutchinson’s teeth (centrally notched, widely spaced upper central incisors), mulberry molars, frontal bossing , saddle nose, saber chin(anterior tibial bowing).

Diagnosis

· In primary and secondary stages, T. Pallidum maybe demonstrable in the infectious lesions by dark-field microscopy.

· Direct fluorescent antibody T. pallidum (DFA-TP) test can detect T. pallidum in fixed smears prepared from suspect lesions.

· Demonstration of T. pallidum in tissues by appropriate stains.

Serologic test

Non-treponemal tests

· Non-trponemal test antibody titers usually correlate with disease activity , and results shoud be reported quantitatively. A four-foldchange intitre is considered necessary to demonstrate a clinically significant difference between two non-trponemal test results that were obtained using the same serologic test.

· Non-treponemal tests usually become non-reactive with timeafter treatment; however in some patients, non –treponemal antibodies can persist at a low titre for a long period of time.

· The test are:

1. Venereal Disease Research Laboratory (VDRL) test.

2. Rapid plasma regain(RPR) test.

Treponemal test

· Most patients who have reactive treponemal tests will have reactive test for the remainder of their lives, regardless of treatment or disease activity. However,15 – 25% of patients treated during the primary stage revert to non-reactive after 2-3 years.

· Treponemal test antibody titers correlate poorly with disease activity and should not be used to assess treatment response.

· Various tests are:

1. Fluorescent treponemal antibody-absorption(FTA-ABS) test.

2. T. pallidum haemagglutination (TPHA).

3. T. pallidum immobilization(TPI) test.

Management

Stage Drug Regimen

· Primery Procaine 600,000 units IM once daily for

12 days

Oxytetracycline 500 mg orally four times daily

For 15 days.

Doxycycline 100 mg orally two times daily

for 15days

Benzathine penciline 2.4 million units IM single

dose(1.2 million units in each

· Secondary Procaine penicillin 600,000 units IM once daily for

15 days

Benzathin penicillin 2.4 million units IM single dose

· Latent/tertiary Benzathin penicillin 2.4 million units IM weekly for

3 weeks

· Cardiovascular Benzathin penicillin 2.4million units IM weekly for

3 weeks

· Neurosyphilis Crystalline penicillin 18-24 million units/day for

10-14 days

Procaine pencillin PLUS- 2.4 million units /day IM for

10-14 PLUS

Probenecid 500 mg QID for 10-14 days

Jarisch-Herxheimer reaction

· It is an acute febrile reaction frequently accompanied by headache, myalgia and other symptoms that usually occurs within the first 24 hours after any therapy for syphilis.

· The Jarisch-Heerxheimer reaction occurs most often among patients who have early syphilis.

· Antipiretics may be used, but they have not been proven to prevent this reaction.

· It may induce early labor or cause foetal distress in pregnant females. This concern should not prevent or delay therapy.

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