SEXUAL TRANSMITTED DISEASES
Syphilis:- is a human infectious disease caused by the bacterium Treponema Pallidum .the disease is transmitted by( contact with lesion during primary or secondary stage, in uterus by placental route, or during delivery as the baby passes through an infected canal, and rarely through blood transfusion). Treponema pallidum may infect any organ causing infinite number of presentations.Stages
Untreated syphilis may pass through three stages.Syphilis begins with the infectious cutaneous primary and secondary stages that may terminate without further sequelle or may evolve into alatent stage ,marked by the appearance of cardiovascular,neurologic,and deep cutaneous complication.The stages as follows: 1.Infectious syphilis : -includes the primary ,secondary and early latent syphlis of less than 1 year. 2.Latent syphilis :-( ie, those lacking clinical manifestations) are detected by serologic testing .Latent syphilis is divided into early latent of less than 1 year duration &early latent of greater than 1 year duration .3.Late latent disease of 4 yrs duration & longer.Risk of transmission:-
#The greatest risk of transmission during the primary, secondary, and early latent stages of disease. #The patient is most infectious during the first 1-2 year of infection. # Patients with secondary syphilis are the most contagious because of the large number of lesions. #The risk of acquiring syphilis from infected partner is 10% to 60%. #One third of persons with single exposure to early syphilis will become infected.Treponema pallidum:-
The organism responsible for syphilis ,is very small,microaerophilic spiral bacterium(spirochete) whose form and corkscrew rotation motility can be obesvered only by darkfield micrscopically.The reproductive time is estimated to be 30-33 hours ,in contrast to most bacterium which replicate 30 minutes.Serologic Tests:-
Serologic tests for syphilis(STS) reveals the individual immunological status but not (unless in rising titer) whether the patient is currently infected. Non –Treponemal antigen tests using lipoidal antigens rather than T.pallidum or components of it.The most widely used rapid plasma reagin(RPR) and venereal disease research laboratary tests ( VDRL ) tests. These tests yield apositive result as arule 5-6 weeks after infection shortly before the chancre heals. Tests are strongly positive through out the secondary phase except in patients with AIDS. In primary infection the titer may be only 1:2 ,in secondary syphilis itis regularly high 1:32 to 1:256 or higher, in late syphlis much lower as arule perhaps 1: 4or 1:8. The rise of titer in early infection is of great diagnostic value. Patients with very high antibody titer as occur in secondary syphilis may have false negative result when undiluted serum tested called prozon phenmenon#Tests using specific Treponemal antigen are the:- microhemagglutination assay for T.pallidum(MHA-TP) and fluorescent treponemal antibody absorpent test(FTA-ABS). #All positive non-trponemal test results should be confirmed with aspecific treponemal test. #The treponemal tests become positive early ,before non-treponemal tests and may be useful in confirming primary syphilis. They usually remain positive for life and are therefore not useful in diagnosing other than the initial episode of syphilis. #Because non- treponemal tests become negative in late syphilis,the specific treponemal tests are useful in diagnosing late syphilis.
Primary syphilis:-
Characterised by cutaneous ulcer ,is acquired by direct contact with an infectious lesion of the skin or the moist surface of the mouth ,anus,or vagina.From 10-90 days (average 21days) after exposure. Clinical picture :- aprimary lesion(chancre) develops at the site of initial contact .male(glans,coronal sulcus&foreskin.in female.cervix,lab majora.labia minora). chancre are usually solitary but multiple chancres may occur and extragenital chancres account for 6% of all chancres and most occur on the lips and in the oral cavity and are transmitted by kissing &orogenital sex. The lesion begin as apapule that undergoes ischemic necrosis and erodes forming 0.3-2cm painless to tender,hard indurated ulcer,the base is clean,with scant yellow,serous discharge. The borders of the ulcer is raised rubbery,smooth,and sharply defined. Painless, hard,discrete regional lymphadenopathy occurs in 1-2 weeks,without treatment ,the chancre heals without scarring in 3-6 weeeks.painless vaginal and anal lesions may never be detected.If untreated 25% of infections progress directly to the secondary stage the other 75% enter latency.Diagnosis:-
In apatient present with acute genital ulceration, darkfield examination should be performed if this investigation is available. #An alternative method to darkfield examination is the Direct flourescent antibody test(DFAT_TP)for identification of treponema pallidum. # Multiple (PCR) is also an accurate and reproducible method for diagnosing genital ulcerations. #The results for serologic tests for syphilis are positive in 50%(non treponemal) tests, and 90% ( treponemal tests) of a patient with primary syphilis.Different ial Diagnosis of Primar y Syphilis
INFECTIOUS H erpes simplex Chancroid G ranuloma inguinale Vaccinia Lymphogranuloma venereum Aphthous ulcer Erosive candidal vulvitis or balanitis NON-INFECTIOUS Traumatic erosion or ulcer Behcet disease Squamous cell carcinoma Basal cell carcinoma Fixed-drug eruptionDifferential Diagnosis:-
1-Chaceroid :- which has ashort incubation priod 4-7 days , the ulcer is acutely inflammed,is extremely painful ,and has assurrounding inflammatory zone ,the ulcer edge is undemined & extend in the dermis&lymphadenopathy (unilateral ,tender,,&may suppurate). 2-Granuloma Inguinale :- It begins as indurated nodule that erodes to produce hypertrophic vegetative granulation tissue,it is soft beefy red & bleeds readily.Asmear of granulation tissue from the lesion stained with Wrights or Giemsa stain reveals Donovan bodies ,in cytoplasm of macrophages 3-Lymphgranuloma venerium LGV:- Is usually small painless or superficial non indurated ulcer. 4-Herpes simplex:- Begins with agrouped vesicles,often accompanied or preceded by burning pain.After rupture of vesicles of , irregular,tender soft erosions form.SECONDARY SYPHILIS
Is characterized by mucocutaneous lesions, aflulike syndrome,and generalized adenopathy.Asymptomatic dissemination of T.pallidum to all organs occurs as the chancre heals,and the disease then resolves in 75% of cases, in the remaining 25% the clinical signs of secondary stage begins approximately 6 weeks( range 2weeks to 6 months) after the chancre appears and last for 2-10 wks.Cutaneous lesions preceded by flulike syndrome(sore throat ,headaches,muscle ache,meningismus, and loss of appetite) and generalized painless lymphadenopathy. Cutaneous lesions :- #Thereis little or no fever at first. #Lesions are non-inflammatory, develop slowly,and may persist for weeks or months. #Pain or itching is minimal or abscent. #There is marked tendency with polymorphism, with various types of lesions presenting simultaneously, the color is characteristc is having coppery tint &lesions assumes various shapes including round, elliptic or annular. The types of lesions in approximate order of frequency are maculopapular, papular,macular, annular, papulopustular, psoriasiform and follicular. #Lesions occur on the palms and soles in most patients with secondary syphilis . # Temporary irregular (moth eaten) alopecia of the beard, scalp, or eyelashes may occur.Secondary syphilis
Moth eaten alopecea-macular rash
Moist ,anal,wartlike papules(condylomata lata) are highly infectious lesions may appear on any mucous membrane.All cutaneous lesions of secondary syphilis are highly infectious therefore if you don’t know it, don’t touch it.Approximately25% of untreated sycondary syphilis may experience relapse, most of them(90%) during the first year.Mucous membrane lesions are present in one third of patients with secondary syphilis.The most common mucosal lesion in the early phase is the syphilitic sore throat,diffuse pharyngitis that may be associated with tonsillitis or laryngitis.Hoarsness and sometimes complete aphonia may be present.On the the tongue small or large & smooth well defined patches devoid of pappilae may be seen.Ulceration may occur on the tongue & lipsMucous patches can be present elsewhere in the oralcavity, on other mucous membranes, or at the corners ofthe mouth, where they appear as “split papules,” withan erosion traversing the cente.Mucous patches-condyloma lata
Systemic involvementLymaphatic system:-the lymph nodes most frequently affected are the inguinal,posterior cervical, post-auricular & epitrochlear.The nodes are shotty,firm,slightly enlarged,non tender& discrete. Acute glomerulonephritis, gastritis, or gastric ulceration,proctitis, hepatitis, acute meningitis,sensorineural hearing loss, iritis,anterior uveitis, optic neuritis,Bells palsy,periostitis, osteomyelitis,polyarthritis,or tenosynovitis may all be seen in secondary syphilis.
Diagnosis & Differential Diagnosis
The non-treponemal serologic tests for syphilis are almost strongly reactive in secondary syphilis.Identification of spirochetes by darkfield examination or histologic examination of affected tissues may be used to confirm the diagnosis.DDx:- syphilis has long been known as the (great imitator) because the varios cutaneous manifestion may simulate any cutaneous or systemic diseasePityriasis rosea-Drug eruptions-Lichen planus-psoriasis-Sarcoidosis.DDx of mucous membrane lesion of secondary syphilis-Infectious mononucleosis –Geographic tongue –Recurrent aphthus ulceration.Latent Syphilis
Is defined as syphilis characterized by seroreactivity without other evidence of the disease.Patients who have latent syphilis and who acquired syphilis within the preceding year are classified As having early latent syphilis.So after the lesions of secondary syphilis have involuted alatent period occurs,this may last for months or continue for the remainder of infected patients life.Tertiary Cutaneous Syphilis
Approximately one-third of patients of untreated latent syphilis develop tertiary syphilis. Most often occurs 3-5 yrs after infection.Treponema are usually not found by silver stains or darkfield examination but may be demonstrated by PCR.The three principal presentations during this stage are late benign syphilis,cardiovascular disease,and neurosyphilis. Diagnosis of Late Syphilis:- Diagnosis relays on serologic tests for syphilis.The non treponemal tests such as RPR &VDRL are positive in 75%of cases .The treponemal tests such as FTA-ABS & MHA-TP are positive in 100% of patients.Late benign syphilis(Tertiary)
Include any symptomatic manifestations after the secondary and relapsing stages. The more commonly involved organs are the skin,mucous membranes ,and bones. Tertiary skin lesions can be divided into three types(granulomatous nodules,psorisiform granulomatous plaques and gummas).Nodular and noduloulcerative tertiary lesions are superficial, firm,painless,dull-red,shiny,flat cutaneous nodules. Gummas are non-tender pink to dusky-red nodules or plaques.They favor sites of previous trauma and may arise anywhere in the body but are more common on the scalp,forehead,buttocks,and presternal,supraclvicular,or pretibial areas. Discrete gummas may involve mucous membranes the lesions ulcerate and are disfiguring.
Different ial Diagnosis of Tertiary Syphilis
SarcoidMetastatic carcinomaSarcomasLymphomasG ranulomatosis with polyangiitis (Wegener’s)LeishmaniasisVasculitisDeep fungal infectionsLupus vulgarisPsoriasisGumma
Cardiovascular syphilisIn early syphilis ,cardiovascular disease is rare and limited to conduction defects,but it is common in tertiary syphilis. The most common complication of cardiovascular syphilis are aortitis,aortic aneurysim,aortic valve incomptence.
Neurosyphilis
Hematogenous invasion of the meninges by T.pallidum occurs early in syphilis. Meningeal(acute meningitis,spinal pachymeningitis). Meningovascular(heiplalegia,hemiparesis) Parenchymatous(general paresis,Tabes dorsalis,optic atrophy)Congenital Syphilis:-
Is aproblem in parts of the world where women donot receive prenatal care . T. pallidum can be transmitted by an infected mother to the fetus in utero ,in untreated cases stillbirth or infants dies shortly after birth. Infection through the placenta usually does not occur before the fourth month, so treatment of the mother before this time will almost always prevent infection. Early Congenital Syphilis:- Is defined as syphilis acquired in utero that becomes symptomatic during the first 2yrs of life. It usually appears in the first week of life.The fetal stigmata seen before the age of 2yrs include eruptions characteristic of secondary syphilis.there are influnza like respiratory symptoms in 20-50%, with hepatospleenmegaly & lymphadenopathy in 50-75%& mucocutaneous changes. Maculopapular rash &desquamating erythema of the palms &soles.Deep fissures of the angles of the mouth . Ahighly infectious hemorrhagic nasal discharge.Snuffles is characteristic early sign.Bone and joint symptoms are cmmon. A vesicocobullous variant(pemphigus syphiliticus) may occur.Early cong.syphlis
Late Congenital syphilisSymptoms and signs of late congenital syphilis become evident after age of 5 years. The most important signs are:- Frontal bossae (bony prominences of the forehead). Saddle nose- short maxilla-high arched palate. Mulberry molars(more than four small cusps on anarrow first lower molar of the second dentition). Hutchinson teeth( peg shaped upper central incisers of the permanent dentition that appear after the age of 6 years). Rhagades (linear scars radiating from the angle of the eyes,nose ,mouth and anus). Hutchinson triad(hutchinson teeth,interstitial keratitis,and cranial nerve 8 deafness) is considered pathognomonic of late congenital syphlils
Hutchinson teeth
DiagnosisInfants of women who meet the following criteria should be evaluated for congenital syphilis:- 1-Maternal untreated syphilis, inadequate treatment,or no documentation of adequate treatment. 2-Treatment of maternal syphilis with erythromicin. 3-Treatment less than 1 month before delivery. 4-Inadequate maternal response to treatment. 5-appropriate treatment before pregnancy, but insufficient serologic follow up to document adequacy of therapy.
Treatment
# penicillin remains the drug of choice for treatment of all stages of syphilis. # Erythromicin is not recommended for treatment of any stage or form of syphilis. # HIV testing is recommended in all patients with syphilis. # Patients with( primary,secondary ,or early latent syphilis known to be less than 1 year duration) can be treated with asingle intramuscular injection of 2,4 Mu of benzathin pencillin G. The addition of second dose sometimes used 1 week later. # In non- pregnant, pencillin allergic, HIV-negative patients, tetracycline 500 mg orally four times aday or doxycycline 100mg orally twice aday for 2 weeks is recommended. # The recommended treatment for late or late latent syphilis of more than 1 year in duration in HIV- negative patient is benzathin pencillin G 2,4 Mu intramuscularly once aweek for 3 weeks.# In pencillin allergic, non-pregnant,HIV-negative patient:- tetracycline 500mg orally four times aday or doxycycline 100mg orally twice aday for 30 days is recommended. Recommended treatment for neurosyphilis:- Include penicillin G crystalline, 3-4Mu IV every 4 hours for 10-14 days,or penicillin G procain,2,4 Mu\ day intramuscularly plus probencid 500 mg orally four times aday both for 10-14 days. These regieme are shorter than those for late syphilis so they followed by benzathine pencillin.G,2.4 Mu intramuscularly once aweek for 3 weeks. # Patients allergic to penicillin should have their allergy confirmed by skin testing. If allergy exists desenstization and treatment with penicillin are recommended.
Treatment for congenital syphilis:- Therapy should be undertaken under consultation with pediatric infectious disease specialist. Treatment with aqueous crystalline penicillin G 200.000-300.000 U\Kg\day intravenously or intramuscularly (50.000 U every 4-6 hours) for 10-14 days. Pregnant wommen with syphilis:-should be treated with penicillin in doses appropriate for the stage of syphilis. Sonographic evaluation of the fetus in the second half of the pregnancy for signs of congenital infection may facilitate management and counseling. Pregnant women who are allergic to penicillin should be skin tested and desensitized if skin results are positive.