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60 Cards in this Set
- Front
- Back
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When did syphilis first arise? Where did it arise?
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1500s, port cities in Southern Europe
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What was syphilis assocaited with when it first arose?
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Large pox lesions on the skin. It was known to be a sexually transmitted disease and thus a was viewed negatively.
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What family of bacteria causes Syphilis?
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Family: Spirochaetaeceae
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What diseases are causes by members of the Spirochaetaceae family?
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Lyme disease, Leptospirosis, Syphilis
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What Genus of bacteria causes Syphilis?
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Treponema
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What species of bacteria causes Syphilis?
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Treponema pallidum subsp. pallidum
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What diseases are causes by bacteria of the treponema pallidum species?
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Yaws: Treponema pallidum subsp. pertenue
Bejel, endemic syphilis: Treponema pallidum subsp. endemicum Pinta: Treponema pallidum subsp. carateum Syphilis: Treponema pallidum subsp. pallidum |
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Which treponema pallidum subspecies are transmitted sexually?
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Only Treponema pallidum subsp. pallidum
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What is yaws?
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It is a disease that causes disfiguring infection of the skin and soft tissue around the joints of the upper extremities. It is uncommon in general and still exists in the Caribbean.
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When was syphilis linked to Treponema pallidum subsp. pallidum?
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1905 by Fritz Schaudinn
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What are some ideas on the origin of syphilis?
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One idea is that syphilis existed in the New World and when sailors went traveling around the world in the 1400s and 1500s they brought it back with them on their boats. Another thought was that the trepodema pallidum was a bacteria that existed in Europe for ages and then something happened around the 1400s that is mutated in a different way, became more virulent, and started to cause syphilis. The last idea was that there was a disease in the New World that changed in its virulence or pathogenicity and became syphilis.
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What organism has 100% genetic homology with T. pallidum pallidum?
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T. pallidum pertunae
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What was the basis for the early attempts to treat syphilis? What was the treatment?
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Galen's humors
Pox diseases were associated with phlegm, so the treatments promoted spitting and sweating. Treatments involved: -Mercury -Arsenic -Bismuth (Pepto-Bismol) -Malaria |
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What is the current treatment for syphilis?
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Antibiotics, specifically penicillin
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Describe syphilis in WWI
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It was the most common cause for rejection from service. Up to 10% of European theater allied soldiers had it.
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Describe syphilis in WWII
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Most penicillin available was used not to treat infected wounds but to treat syphilis (so that soldiers could return to the front)
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What caused the mini-epidemic in the US in the late 80s to early 90s? Describe this mini-epidemic
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The AIDS epidemic. This cause case rates that were higher than any time since the introduction of penicillin
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Where in the US is syphilis concentrated?
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The south and urban areas
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Is syphilis more common in men, women, or equal? Why?
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It is more common in men due to increases in cases among men who have sex with men.
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What is the relationship between syphilis and HIV?
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Primary syphilis lesions increase the risk of transmission of HIV 2-5 fold. The risk group with the highest incidence rates were HIV-infected MSM.
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Describe the structure of the T. pallidum pallidum bacteria
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-It is small, long and thin and difficult to see under brightfield microscopy.
-It is tightly coiled and helical. -It has an undulating movement about its center (flexuose) that distinguishes it from nonpathogenic treponemes under darkfield microscopy. -It cannot be cultured in vivo (only in the testicles of live rabbits) -Unlike other pathogenic bacteria, the genome lacts apparent transposable element |
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What are the consequences of the lack of transposable elements in T. pallidum pallidum?
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-It has always been sensitive to penicillin
-It is a scavenger due to the paucity of genes involved in biosynthesis of nutrients or energy production. |
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What are the special risk groups for syphilis?
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-MSM
-HIV patients |
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Describe the transmission of syphilis
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Transmission of T. pallidum can occur via sexual contact, vertical transmission,
kissing/close contact with active lesions, transfusions, or accidental injection. The disease is most infectious early on during primary and secondary syphilis when patient’s have chancres, mucous patches, condyloma latum and other lesions which are highly infectious. An immunologically intact person cannot, essentially, spread disease sexually after 4 years. The USPHS, CDC and local health departments, therefore, focus their efforts on identifying and treating primary, secondary and early latent cases of syphilis. |
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Describe primary syphilis
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It is usually small, painless, and usually on the genitals, though it can be anywhere on the skin. Treated or untreated, that usually goes away in a few weeks to months and you start to have symptoms of secondary syphilis.
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When is syphilis infectious?
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In its primary and secondary stages
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How many organisms are needed to infect with syphilis?
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60
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What is the incubation period for primary syphilis?
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21 days (3-90 days is the range)
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What are the clinical manifestations of primary syphilis?
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-Papule develops into classic chancre lesion at the site of inoculation
-Clean based ulcer -Indurated and painless -Heals spontaneously in 3-6 weeks -Wide dissemination of spirochetes occurs |
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Describe the early pathophysiology of T. pallidum pallidum
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-Infection is initiated when T. pallidum gains access to subcutaneous tissues via microscopic abrasions
-It evades early host immune responses and establishes the initial ulcerative lesion. Some organisms establish infection in regional draining lymph nodes -There is widespread dissemination of spirochetes despite apparent effective immune control (i.e. resolution of chancre) -Early lesional infiltration of PMNs which get replaced by T lymphocytes. -There is a humoral immune response that leads to the development of a variety of antibodies that can be detected relatively early in the course of syphilis |
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Why does syphilis increase the risk of HIV spread?
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The secondary syphilis lesional fluid is enriched for CD4+ and CD8+ T cells and dendritic cells. These contain the CCR5 receptor which is an HIV coreceptor.
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What are the clinical manifestations of secondary syphilis?
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-Systemic illness a few months after chancre
-Rash -Any type except vesicular -Classically is symmetric macular or papular -Discrete red or reddish-brown lesions 0.5 to 2cm in diameter -Palms and soles involvement is an important clue to the diagnosis of secondary syphilis. -Other rashes (condyloma lata, mucous patches) -Systemic symptoms -Lymphadenopathy -Alopecia -Protean manifestations -Hepatitis -GI, MS, Renal abnormalities -Neurological manifestations -Ocular manifestations |
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What is inside the mucous patches on the lips?
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Plasma cytoid cells
Lots of spirochetes |
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What is condyloma lata?
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This occurs in the peroneal region. It resembles genital warts, but its whitish appearance which HPV associated genital warks lacks indicates that this may be some other kind of skin disease (syphilis)
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What are the clinical manifestations of late syphilis?
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-Gummatous syphilis
-Visceral granulomas -The Great pox -uncommon nowadays -Cardiovascular syphilis -Ascending thoracic aorta resulting in a dilated aorta and aortic valve regurgitation. -Syphilis of the CNS |
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Describe cardiovascular syphilis
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The small vessel s that feed the connective tissue, arteries, and nerves of your veins can be affected. It can cause a vasculitis anywhere, especially the aorta. This occurring in the aorta will lead to an inflammatory respnse which can result in thrombosis to the vessel which leads to the lack of oxygen to the muscle and connective tissue, causing muscle necrosis, connective tissue disintegration, and a weakening of the wall of the aorta. This can lead to an aortic aneurism.
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How do you diagnose primary syphilis?
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-Darkfield microscopy of chancre scrapings
-corkscrew-shaped organisms with tightly wound spirals -forward and backward motion with rotation -Soft side-to-side bending and twisting -Specific but not sensitive -Direct fluorescent antibody test of specimen (DFA-TP) -Not widely used |
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What is the gold standard for the diagnosis of syphilis?
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Culture of T. pallidum by in vivo intra-testicular inoculation of rabbits. This is not routinely done.
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Describe non-treponemal serologic tests for syphilis
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-Venereal Disease Research Laboratory (VDRL) test (less commonly used except on CSF)
-Rapid Plasma Reagin (RPR) test These are test for auto-antibodies to cardiolipid, a tissue lipid -Easy and cheap, used for screening -Report as a titer -Used to follow treatment -Sensitive except in late syphilis, specific |
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Describe treponemal serologic tests for syphilis
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-Fluorescent treponemal antibody absorption (FTA-ABS) test
-Microhemagglutination test for antibodies to Treponema pallidum (MHA-TP) -Treponema pallidum particle agglutination assay (TPPA) -Mose sensitive and more specific, even in late syphilis -Reported as a + or a - |
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What can cause acute false positives with non-treponemal tests?
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Pneumococcal pneumonia
TB HIV Measles Infection mononucleosis Viral hepatitis Pregnancy |
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What can cause chronic false posives in non-treponemal tests?
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Chronic liver disease
Malignancy Injection drug use Connective tissue disease |
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What can cause false positives with the treponemal test?
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Lyme borreliosis
Malaria Infectious mononucleosis Leptospirosis Systemic lupus erythematosis |
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What are the risk factors in screening for syphilis?
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-MSM who engage in high risk behaviors
-CSWs (sex workers) -Persons who exchange sex for drugs -Adult correctional facilites -HIV |
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What is the two step process in syphilis screening?
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Non-treponemal test followed by a confirmatory treponemal test if positive
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Describe the general treatment of syphilis
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-Prolonged antibiotics neccesary since T pallidum divides slowly
-one doubling in vivo per day -Long-acting preparations -Highly sensitive to penicillin Penicillin only works when the bacteria are dividing. Usually they are given a penicillin injection in the deltoid or gluteous that will cause them to have penicillin in their system for a week. |
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What is the treatment for early syphilis?
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Benzathin penicillin G 2.4 million units intramuscularly x1
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What is the treatment for late latent syphilis or latent syphilis of unknown duration?
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Benzathine penicillin G 2.4 million units intramuscularly every week for 3 weeks
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What other antibiotics are useful for syphilis? What should you do with someone who can not tolerate penicillin?
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Doxycycline
Azithromycin Ceftriaxone People who cant tolerate penicillin and have late stage syphilis should be desensitized and then treated with penicillin. |
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What is the Jarisch-Herxheimer Reaction?
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-Acute febrile reaction during first 24 hrs of therapy
-Headache and myalgias -Most common among patients with early syphilis -Antipyretics can be used for symptomatic treatment This is something you can expect people to have when they are treated with syphilis. Because of the killing of organisms which have a high burden in the body there is a release of different kinds of antigens. The immune system reacts by producing cytokines. People can feel very lousy. It usually only lasts a day or two and is related to the killing of the organism, so you should not stop treatment. Other spirochete diseases can have similar reactions, one of them being lyme disease. |
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How do you monitor response to treatment with syphilus?
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-Monitor changes in the titer of reagin antibodies
-Use the same testing method (RPR, VDRL) -Patients with primary and secondary syphilis -Expect a fourfold decline by six months -Expect as eightfold decline by 12 months -Slower rate of decline among patients with early latent syphilis -Expect fourfold decline by 12 months -If expected change does not occur, test for HIV. |
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When do you look for neurosyphilis?
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You want to examine the CSF if there is latent syphilis and any of the following:
-Ophthalmic signs and symptoms -Evidence of active late syphilis -Treatment failure (including failure of nontreponemal tests to fall appropriately) -HIV infection with late syphilis or syphilis of unknown duration. |
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What do you look for in the CSF in a patient with neurosyphilis? What do you expect?
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CSF analysis:
-cell count -protein concentration -CSF-VDRL titer Expect: -moderate mononuclear pleocytosis -elevated protein concentration -Positive CSF-VDRL -very specific, not sensitive |
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What are the symptoms of neurosyphilis?
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Early
-Transient or persistent asymptomatic meninitis Early symptomatic (weeks to years) -Symptomatic meningitis -Ocular findings -Stroke Late symptomatic meningitis (years to decades) -Paresis -Dementia -Personality change -Tabes Dorsalis |
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Describe the general paresis of neurosyphilis
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Personality
Affect Reflexes Eyes Sensorium Intellect Speech |
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What is the treatment for neurosyphilis?
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Penicillin G 3 to 4 million units IV every four hours or 24 million units continuous IV infusion for 10 to 14 days.
-Neurologic examination and lumbar puncture -three to six months after treatment -every six months thereafter -CSF WBC count should normalize and CSF VDRL should become nonreactive by 2 years after treatment. -Failure to respond or a worsening of CSF WBC should prompt re-treatment |
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Describe syphilis serolysis in HIV
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-More false positive non-treponemal tests
-Higher non-treponemal titers than non-HIV infected -Loss of reactivity in late HIV disease -Slower decline of titers on treatment |
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Describe syphilis in pregnancy
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-Untreated early syphilis in pregnant women results in perinatal death in up to 40% of cases
-if acquired during the four years preceding pregnancy, fetal infection may occur in up to 80% of cases -Sequelae of congenital infection -perinatal death -premature delivery -low birth weight -congenital anomalies -active congenital syphilis in the neonate All pregnant women are screened for syphilis as part of routine prenatal care. |
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What is Tabes dorsalis?
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Locomotor ataxia
-Less common in antibiotic era -Disease of the posterior columns of the spinal cord and dorsal roots -Ataxia and lancinating pains -Pupillary irregularities -Argyll-Robertson pupil |
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What is the Argyll-Robertson pupil?
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-Small
-Does not respond to light -Contracts normally to accommodation and convergence -Dilates imperfectly to mydriatics -Dilate in response to painful stimuli |
