Syphilis
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SYPHILIS
Syphilis is a disease caused by the Spirochetal bacterium Treponema pallidum. The route of transmission of syphilis is almost always through sexual contact, although there are examples of congenital syphilis via transmission from mother to child in utero.
History: While working at the Rockefeller University in 1913, Hideyo Noguchi, a Japanese scientist, demonstrated the presence of the spirochete Treponema pallidum in the brain of a progressive paralysis patient, proving that Treponema pallidum was the cause of the disease. Prior to Noguchi's discovery, syphilis had been a burden to humanity in many lands, sometimes misdiagnosed. European outbreak -- The first well-recorded European outbreak of what is now known as syphilis occurred in 1494 when it broke out among French troops, from here the disease swept across Europe. Researchers concluded that syphilis was carried from the New World to Europe after Columbus' voyages. The findings suggested Europeans could have carried the non venereal tropical bacteria home, where the organisms may have mutated into a more deadly form in the different conditions of Europe. Syphilis was a major killer in Europe during the Renaissance. Pathogenecity: There are two strains of T. Pallidum the Pathogenic and Non- Pathogenic. Pathogenic: •
These are known as NICHOLS Strain.
•
They do not grow on artificial media, they grow on LIVE TISSUE or on EGG.
•
These are motile and are maintained in Virulent form in the testicles of rabbit.
Non- Pathogenic: •
These are known as REITER strain.
•
These can be cultured on Artificial media.
Resistance: •
T. Pallidum is very delicate and could die if the temperature is increased, it takes only 1 hour at 41-42*C or 0-4* C for 3-4 days to kill the pathogen. Therefore INDUCED FEVER THERAPY is usually applied to kill T.pallidum.
•
The cultures are maintained at 70*C but at this temp the moisture evaporates and so Glycerol is added.
•
The pathogen gets inactivated if it comes in contact with D.water, Oxygen, or Soap.
Syphilis infection Different manifestations occur depending on the stage of the disease:
Primary
• • • • • •
syphilis:
Primary syphilis is typically acquired via direct sexual contact with the infectious lesions of a person with syphilis. Approximately 10-90 days after the initial exposure (average 21 days), a skin lesion appears at the point of contact, which is usually the genitalia, but can be anywhere on the body. This lesion, called a chancre, is a firm, painless skin ulceration localized at the point of initial exposure to the spirochete, often on the penis, vagina or rectum. The lesion may persist for 4 to 6 weeks and usually heals spontaneously. Local lymph node swelling can occur. During the initial incubation period, individuals are otherwise asymptomatic. As a result, many patients do not seek medical care immediately.
NOTE : Syphilis can not be contracted through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing. Secondary syphilis
• • • • • • • •
Secondary syphilis occurs approximately 1-6 months (commonly 6 to 8 weeks) after the primary infection. There are many different manifestations of secondary disease. There may be a symmetrical reddish-pink non-itchy rash on the trunk and extremities. The rash can involve the palms of the hands and the soles of the feet. In moist areas of the body, the rash becomes flat broad whitish lesions known as condylomata lata. Mucous patches may also appear on the genitals or in the mouth. All of these lesions are infectious and harbor active treponeme organisms so, patient with syphilis is most contagious when he or she has secondary syphilis. Other symptoms common at this stage include fever, sore throat, malaise, weight loss, headache, meningismus, and enlarged lymph nodes. Rare manifestations include an acute meningitis that occurs in about 2% of patients, hepatitis, renal disease, hypertrophic gastritis.
Latent syphilis
• • • •
• •
Latent syphilis is defined as having serologic proof of infection without signs or symptoms of disease. Latent syphilis is further described as either early or late. Early latent syphilis is defined as having syphilis for two years or less from the time of initial infection without signs or symptoms of disease. Late latent syphilis is infection for greater than two years but without clinical evidence of disease. The distinction is important for both therapy and risk for transmission. In the real-world, the timing of infection is often not known and should be presumed to be late for the purpose of therapy. Early latent syphilis may be treated with a single intramuscular injection of a long-acting penicillin. Late latent syphilis, however, requires three weekly injections.
Tertiary syphilis
• • • • •
Tertiary syphilis usually occurs 1-10 years after the initial infection. This stage is characterized by the formation of gummas which are soft, tumor-like balls of inflammation known as granulomas. The gummas produce a chronic inflammatory state in the body with masseffects upon the local anatomy. Other characteristics of untreated tertiary syphilis include neuropathic joint disease. The more severe manifestations include Neuro syphilis and cardiovascular syphilis
Neuro syphilis Neuro syphilis refers to a site of infection involving the central nervous system (CNS). Neurosyphilis may occur at any stage of syphilis. it was typically seen in 2535% of patients with syphilis. LAB DIAGNOSIS OF SYPHILIS •
Usually phase contrast microscope with a negative dye is used to visualize the presence of T. pallidum.
•
The lisions are cleaned with Guaze and then soaked in luke warm water, gentle pressure is applied to obtain fluids
Serological Tests: Serotypes are classified based upon the type of Antigens. Various tests available are STS(standard tests for syphilis): •
It was designed by Wassermanns, Neisser, and Burk in 1906.
•
They designed a complement fixing treponeme using syphilitic live as a source for treponeme.
•
Here patients blood serum is obtained and is deactivated by subjecting it to 56*C for 30 Min. to destroy the complement.
•
Now this serum is added to OX heart extract(containing alcohol extract from OX heart to which Lecitin and Cholestrol are added)and then the complement is added from Gunea pig.
•
If Heamolysis occurs then the test is Negative which indicates the presence of Free complement.
•
If Heamolysis does not occurs then the test is Positive which indicates the presence of Fixed complement.
THE KAHN TEST: •
It is carried in Tube Floccule.
•
0.15 ml of Serum is taken in 3 test tubes
•
First tube is added with 0.05ml antigen, second is added with 0.025ml antigen and the third is added with o.0125ml antigen
•
No the tubes are shaken vigorously and placed in an agitator called KAHN Shaker which can underge 280 occilations/min.
•
If there is a formation of Uniform Opalascence then the test is negative.
•
If there is a formation of Floccules the test is possitieve.
•
The result is accurate at 37*C
VDRL(Veneral Disease Research Laboratory): •
It is an advanced test which is simple and Rapid. This test is also called RPR(Rapid Plasma regain test)
•
Here the concentrations required of both Antigens and Antibody are lowest
•
VDRL slide is taken and 0.05ml inactivated serum is taken and spreaded on slide and a drop of antigen is added and rotated for 8 Min.
•
Now Floccules are observed under microscope, as the whole test solution is white in color a coloring agent is added to see the floccules.
Current treatment
•
• •
Syphilis can generally be treated with antibiotics, including penicillin. One of the oldest and still the most effective method is an intramuscular injection of benzathine penicillin. If left untreated, syphilis can damage the heart, aorta, brain, eyes, and bones. The first-choice treatment for all manifestations of syphilis remains penicillin in the form of penicillin G. The effect of penicillin on syphilis was widely known as a result, Parenteral penicillin G is the only therapy with documented effect during pregnancy. For early syphilis, one dose of penicillin is sufficient.
• • • •
Non-pregnant individuals who have severe allergic reactions to penicillin (e.g., anaphylaxis) may be effectively treated with oral tetracycline or doxycycline although data to support this is limited. Ceftriaxone may be considered as an alternative therapy, although the optimal dose is not yet defined. However, cross-reactions in penicillin-allergic patients with cephalosporins such as ceftriaxone are possible. Azithromycin was suggested as an alternative. However, there have been reports of treatment failure due to resistance in some areas. Azithromycin has been used to treat syphilis in the past because of easy once-only dosing. However, in one study in San Francisco, azithromycinresistance rates in syphilis, which were 0% in 2000, were 56% by 2004.
Prevention
• • •
While abstinence from any sexual activity is very effective at helping prevent syphilis, it should be noted that T. pallidum readily crosses intact mucosa and cut skin, including areas not covered by a condom. Individuals sexually exposed to a person with primary, secondary, or early latent syphilis within 90 days preceding the diagnosis should be assumed to be infected and treated for syphilis, even if they are currently seronegative. Patient education is important as well.
Syphilis is a disease caused by the Spirochetal bacterium Treponema pallidum. The route of transmission of syphilis is almost always through sexual contact, although there are examples of congenital syphilis via transmission from mother to child in utero.
History: While working at the Rockefeller University in 1913, Hideyo Noguchi, a Japanese scientist, demonstrated the presence of the spirochete Treponema pallidum in the brain of a progressive paralysis patient, proving that Treponema pallidum was the cause of the disease. Prior to Noguchi's discovery, syphilis had been a burden to humanity in many lands, sometimes misdiagnosed. European outbreak -- The first well-recorded European outbreak of what is now known as syphilis occurred in 1494 when it broke out among French troops, from here the disease swept across Europe. Researchers concluded that syphilis was carried from the New World to Europe after Columbus' voyages. The findings suggested Europeans could have carried the non venereal tropical bacteria home, where the organisms may have mutated into a more deadly form in the different conditions of Europe. Syphilis was a major killer in Europe during the Renaissance. Pathogenecity: There are two strains of T. Pallidum the Pathogenic and Non- Pathogenic. Pathogenic: •
These are known as NICHOLS Strain.
•
They do not grow on artificial media, they grow on LIVE TISSUE or on EGG.
•
These are motile and are maintained in Virulent form in the testicles of rabbit.
Non- Pathogenic: •
These are known as REITER strain.
•
These can be cultured on Artificial media.
Resistance: •
T. Pallidum is very delicate and could die if the temperature is increased, it takes only 1 hour at 41-42*C or 0-4* C for 3-4 days to kill the pathogen. Therefore INDUCED FEVER THERAPY is usually applied to kill T.pallidum.
•
The cultures are maintained at 70*C but at this temp the moisture evaporates and so Glycerol is added.
•
The pathogen gets inactivated if it comes in contact with D.water, Oxygen, or Soap.
Syphilis infection Different manifestations occur depending on the stage of the disease:
Primary
• • • • • •
syphilis:
Primary syphilis is typically acquired via direct sexual contact with the infectious lesions of a person with syphilis. Approximately 10-90 days after the initial exposure (average 21 days), a skin lesion appears at the point of contact, which is usually the genitalia, but can be anywhere on the body. This lesion, called a chancre, is a firm, painless skin ulceration localized at the point of initial exposure to the spirochete, often on the penis, vagina or rectum. The lesion may persist for 4 to 6 weeks and usually heals spontaneously. Local lymph node swelling can occur. During the initial incubation period, individuals are otherwise asymptomatic. As a result, many patients do not seek medical care immediately.
NOTE : Syphilis can not be contracted through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing. Secondary syphilis
• • • • • • • •
Secondary syphilis occurs approximately 1-6 months (commonly 6 to 8 weeks) after the primary infection. There are many different manifestations of secondary disease. There may be a symmetrical reddish-pink non-itchy rash on the trunk and extremities. The rash can involve the palms of the hands and the soles of the feet. In moist areas of the body, the rash becomes flat broad whitish lesions known as condylomata lata. Mucous patches may also appear on the genitals or in the mouth. All of these lesions are infectious and harbor active treponeme organisms so, patient with syphilis is most contagious when he or she has secondary syphilis. Other symptoms common at this stage include fever, sore throat, malaise, weight loss, headache, meningismus, and enlarged lymph nodes. Rare manifestations include an acute meningitis that occurs in about 2% of patients, hepatitis, renal disease, hypertrophic gastritis.
Latent syphilis
• • • •
• •
Latent syphilis is defined as having serologic proof of infection without signs or symptoms of disease. Latent syphilis is further described as either early or late. Early latent syphilis is defined as having syphilis for two years or less from the time of initial infection without signs or symptoms of disease. Late latent syphilis is infection for greater than two years but without clinical evidence of disease. The distinction is important for both therapy and risk for transmission. In the real-world, the timing of infection is often not known and should be presumed to be late for the purpose of therapy. Early latent syphilis may be treated with a single intramuscular injection of a long-acting penicillin. Late latent syphilis, however, requires three weekly injections.
Tertiary syphilis
• • • • •
Tertiary syphilis usually occurs 1-10 years after the initial infection. This stage is characterized by the formation of gummas which are soft, tumor-like balls of inflammation known as granulomas. The gummas produce a chronic inflammatory state in the body with masseffects upon the local anatomy. Other characteristics of untreated tertiary syphilis include neuropathic joint disease. The more severe manifestations include Neuro syphilis and cardiovascular syphilis
Neuro syphilis Neuro syphilis refers to a site of infection involving the central nervous system (CNS). Neurosyphilis may occur at any stage of syphilis. it was typically seen in 2535% of patients with syphilis. LAB DIAGNOSIS OF SYPHILIS •
Usually phase contrast microscope with a negative dye is used to visualize the presence of T. pallidum.
•
The lisions are cleaned with Guaze and then soaked in luke warm water, gentle pressure is applied to obtain fluids
Serological Tests: Serotypes are classified based upon the type of Antigens. Various tests available are STS(standard tests for syphilis): •
It was designed by Wassermanns, Neisser, and Burk in 1906.
•
They designed a complement fixing treponeme using syphilitic live as a source for treponeme.
•
Here patients blood serum is obtained and is deactivated by subjecting it to 56*C for 30 Min. to destroy the complement.
•
Now this serum is added to OX heart extract(containing alcohol extract from OX heart to which Lecitin and Cholestrol are added)and then the complement is added from Gunea pig.
•
If Heamolysis occurs then the test is Negative which indicates the presence of Free complement.
•
If Heamolysis does not occurs then the test is Positive which indicates the presence of Fixed complement.
THE KAHN TEST: •
It is carried in Tube Floccule.
•
0.15 ml of Serum is taken in 3 test tubes
•
First tube is added with 0.05ml antigen, second is added with 0.025ml antigen and the third is added with o.0125ml antigen
•
No the tubes are shaken vigorously and placed in an agitator called KAHN Shaker which can underge 280 occilations/min.
•
If there is a formation of Uniform Opalascence then the test is negative.
•
If there is a formation of Floccules the test is possitieve.
•
The result is accurate at 37*C
VDRL(Veneral Disease Research Laboratory): •
It is an advanced test which is simple and Rapid. This test is also called RPR(Rapid Plasma regain test)
•
Here the concentrations required of both Antigens and Antibody are lowest
•
VDRL slide is taken and 0.05ml inactivated serum is taken and spreaded on slide and a drop of antigen is added and rotated for 8 Min.
•
Now Floccules are observed under microscope, as the whole test solution is white in color a coloring agent is added to see the floccules.
Current treatment
•
• •
Syphilis can generally be treated with antibiotics, including penicillin. One of the oldest and still the most effective method is an intramuscular injection of benzathine penicillin. If left untreated, syphilis can damage the heart, aorta, brain, eyes, and bones. The first-choice treatment for all manifestations of syphilis remains penicillin in the form of penicillin G. The effect of penicillin on syphilis was widely known as a result, Parenteral penicillin G is the only therapy with documented effect during pregnancy. For early syphilis, one dose of penicillin is sufficient.
• • • •
Non-pregnant individuals who have severe allergic reactions to penicillin (e.g., anaphylaxis) may be effectively treated with oral tetracycline or doxycycline although data to support this is limited. Ceftriaxone may be considered as an alternative therapy, although the optimal dose is not yet defined. However, cross-reactions in penicillin-allergic patients with cephalosporins such as ceftriaxone are possible. Azithromycin was suggested as an alternative. However, there have been reports of treatment failure due to resistance in some areas. Azithromycin has been used to treat syphilis in the past because of easy once-only dosing. However, in one study in San Francisco, azithromycinresistance rates in syphilis, which were 0% in 2000, were 56% by 2004.
Prevention
• • •
While abstinence from any sexual activity is very effective at helping prevent syphilis, it should be noted that T. pallidum readily crosses intact mucosa and cut skin, including areas not covered by a condom. Individuals sexually exposed to a person with primary, secondary, or early latent syphilis within 90 days preceding the diagnosis should be assumed to be infected and treated for syphilis, even if they are currently seronegative. Patient education is important as well.
