SYPHILIS SEXUAL TRANSMITTED INFECTIONS

3. SYPHILIS SEXUAL TRANSMITTED INFECTIONS

The cause of syphilis and epidemiology:
Syphilis is an acute and chronic, contagious, venereal granulomatous infection due to Treponema pallidum, Since almost any disease may be mimicked by syphilis in one of its 3 clinical stages. Although infection usually occurs during intercourse, transfer of treponema pallidum by infected blood and plasma, and passage from the mother to the fetus through the placenta [congenital syphilis], and blood transfusion are possible. Extra-genital infection such as tongue, lips, breast may also occur.
The organism cannot survive outside the body tissues and fluids, and infection other than through direct personal contact or through blood products is
One-half of sexual contacts of persons with infectious syphilis become infected.
Symptoms and signs depend on the stages of syphilis:
• Primary syphilis: History of contact with an infected individual 1-4 weeks prior to appearance of primary lesion. Primary lesion: chancre at site of inoculation [labia, cervix, anal canal, rectum, mouth or penis in men] may be single or multiple .Regional lymph nodes on one or both sides are often rubbery, discrete, and non-tender.
• Secondary syphilis: Usually occurs 7-10 weeks after exposure to the disease. There is often evidence of systemic involvement with fever, generalized lymphadenitis, non-pruritic maculopapular dermatitis, naso-pharyngitis, laryngitis conjunctivitis, arthralgia, and mucous patches. Primary chancre may still be present. Lesions are widely distributed over the trunk and extremities, including the palms and soles. In most intertriginous areas, papules can enlarge and erode to produce broad, highly infectious lesions called condylomata lata.
• Latent syphilis: Often follows inadequate or improper therapy. Early latent, less than 4 years; late latent, more than 4 years. An intermediate phase after secondary lesions have disappeared and while tertiary symptoms are not yet evident. Latent syphilis offers no clinical evidence of signs other than the positive syphilis serology test. Only latent syphilis develops after the first year of infection. However, women with latent syphilis can infect the fetus in uterus.
• Tertiary Late syphilis: Involvement may be diffuse, may be confined to certain organ systems or localized as discrete lesions [gummata] in any and all tissues.
1. Muco-cutaneous: Gummatous lesions of the skin and mucous membranes.
2. Osseous: Diffuse lesions of bones and joints with periostitis, arthritis, synovitis,
and osteomyelitis.
3. Ocular: Conjunctivitis, iritis, uveitis, keratitis and retinitis.
4. Cardiovascular: Uncomplicated aortitis, aortic regurgitation, and aneurism.
5. Central nervous system disease a continuum throughout syphilis. Meningeal
findings, including headache, nausea, vomiting change in mental status and
neck stiffness present within one year of infection. Tabes dorsalis with clinical
signs: ataxia, pains of varying character and location, visual disturbance,
sphincter and sexual disturbances, hyporeflexia, diminution of vibration and
position sense.
6. Late benign syphilis [gumma]: usually solitary lesions showing granulomatous inflammation with central necrosis are found most often in the skin and skeletal system, mouth, upper respiratory tract, liver and stomach.

Diagnosis
• Dark-field microscopy of lesions exudates or direct fluorescent antibody t.reponema pallidum[DFA-TP] test in fixed smears from suspect lesions.
• Treponemal serologic tests: agglutination assay and the fluorescent treponemal antibody-absorbed test.Result remain positive even after successful treatment.
• Patients with syphilis should be evaluated for HIV disease.

Treatment:
• Primary, secondary, or early latent: Repository penicillin 600 000 units IM daily for ten days, or penicllin G benzathine [single dose of 2.4 million Unit IM]. Patients with confirmed Penicillin Allergy: Tetracycline hydrochloride [500 mg per oral 4 times daily] or Doxycycline [100 mg per oral twice daily] for 2 weeks.
• Late latent, cardiovascular or benign tertiary : Lumbar puncture, if cerebrospinal fluid [CSP] normal : Penicillin G benzathine [2.4 million Unit IM weekly for 3 weeks. CSV abnormal: Treat as neurosyphilis.
• Neuro-syphilis : Aqueous penicillin G [18-24 million Unit IV, given as 3-4 million Unit every 4 hours or continuous infusion] for 10-14 days.
• Syphilis in pregnancy: According to stage; desensitization and treatment with penicillin.

Prevention:
• Avoidance of illicit sexual contact is the surest of all preventive methods.
• The standard rubber condom is effective but protects covered parts only. The exposed parts should be washed with soap and water as soon after contact as possible. This applies to both sexes.
• If there is known exposure to infectious syphilis, abortive penicillin therapy may be used. Give 1.2 million units of repository penicillin IM in one dose, or penicillin G 1-2 million units IV.