Syphilis: Difference between revisions

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<section begin="dermatology" />* Sometimes called ''lues''
<section begin="dermatology" />Syphilis is an STD which is sometimes called lues. It’s caused by infection of the spirochete Treponema pallidum. It’s a very rare disease nowadays. Mostly only the primary stage is seen nowadays.
* Treponema pallidum
 
* Risk factors
=== Risk factors ===
** Men who have sex with men
 
** Promiscuity
* Men who have sex with men
** Unprotected sex
* Promiscuity
* Incubation period 10 – 90 days (average 21)
* Unprotected sex
* Has 4 characteristic stages
 
** Primary syphilis
=== Clinical features ===
*** Characterised by a special lesion called a ''chancre''
Incubation period can last from 10 – 90 days (average 21). Syphilis has 4 characteristic stages
*** Chancres occur at the site where the bacterium enters the body
 
*** It’s a painless, firm ulcer with indurated borders and a smooth base
* Primary syphilis
*** Chancres resolve spontaneously without scarring after 3 – 6 weeks
** Characterised by a special lesion called a chancre
** Secondary syphilis
** Chancres occur at the site where the bacterium enters the body
*** Known as the “great imitator” as its skin symptoms resemble those of many other skin diseases
** It’s a painless, firm ulcer with indurated borders and a smooth base
*** Both systemic and mucocutaneous lesions
** Chancres resolve spontaneously without scarring after 3 – 6 weeks
*** Begins 8 – 12 weeks after primary infection
* Secondary syphilis
*** Lasts 2 – 6 weeks
** Known as the “great imitator” as its skin symptoms resemble those of many other skin diseases
*** Disseminated, symmetric rash
** Begins 8 – 12 weeks after primary infection
**** Polymorphic, i.e. can take on many appearances
** Lasts 2 – 6 weeks
**** Typically nonpruritic macular or papular rash
** Condyloma lata
**** Reddish-brown
*** Broad-based, wart-like papular erosions
**** Roseola syphilitica = macules on trunk and flexor aspects of the extremities
*** In anogenital region, intertriginous folds, oral mucosa
**** Corona veneris
** Disseminated, polymorphic, symmetric rash
***** Maculopapular lesions
** Mucous patches (White patches on mucous membranes)
***** On forehead or back of neck
** Patchy alopecia
**** Clavus syphiliticus = maculopapular lesions on palms and soles
** Necklace of Venus = hypopigmentation around the neck
*** Mucous patches
* Latent syphilis
**** White patches on mucous membranes
** The patient is seropositive but there are no symptoms
*** Condyloma lata
** Can last months, years or the rest of the patient’s life
**** Broad-based, wart-like papular erosions
** There are four outcomes:
**** In anogenital region, intertriginous folds, oral mucosa
*** The disease resolves and the patient becomes healthy
*** Patchy alopecia
*** The disease reactivates as secondary syphilis
*** Leucoderma syphiliticum
*** The disease progresses into tertiary syphilis
**** Hypopigmentation
*** The patient dies before any of these outcomes occur
**** Necklace of Venus = hypopigmentation around the neck
* Tertiary syphilis
**** Differential diagnosis: pityriasis versicolor
** Occur in approx. 30% of untreated patients in the latent stage
*** Non-cutaneous and non-mucosal symptoms
** Gummas (Destructive and ulcerative granulomatous lesions with necrotic centre)
**** Pharyngitis
*** Can occur anywhere on or in the body, even on organs and bones
**** Iritis
** Nodules
**** Hepatitis
** Psoriasiform granulomatous lesions
**** Generalized nontender lymphadenopathy
** Cardiovascular syphilis
**** Meningitis
*** Aortitis with resulting aneurysm of the aorta
** Latent syphilis
*** Dilated aortic root
*** The patient is seropositive but there are no symptoms
** Neurosyphilis
*** Can last months, years or the rest of the patient’s life
*** Meningitis
*** There are four outcomes
*** Stroke
**** The disease resolves and the patient becomes healthy
*** Tabes dorsalis (broad-based sensory ataxia)
**** The disease reactivates as secondary syphilis
*** Dysesthesia
**** The disease progresses into tertiary syphilis
*** General paresis
**** The patient dies before any of these outcomes occur
*** Widespread cerebellar atrophy
** Tertiary syphilis
*** Dementia
*** Occur in approx. 30% of untreated patients in the latent stage
*** Argyll Robertson pupil (Bilateral miosis, pupils don’t react to light)
*** Late benign syphilis
 
**** Gummas
=== Diagnosis and evaluation ===
***** Destructive and ulcerative granulomatous lesions with necrotic centre
A specimen is taken from a lesion. Nontreponemal tests like RPR and VDRL are used for screening. These are sensitive but not specific tests. Treponemal tests are used for confirming the diagnosis. These are highly specific.
***** Can occur anywhere on or in the body, even on organs and bones
 
**** Nodules
Direct visualization of treponema is also possible, and may be useful in the primary stage, when the serological tests below can be negative. The bacteria are visible by darkfield microscopy.
**** Psoriasiform granulomatous lesions
 
*** Cardiovascular syphilis
=== Treatment ===
**** Aortitis with resulting aneurysm of the aorta
 
**** Dilated aortic root
* For prevention, primary, secondary, and early latent syphilis: 2,4 million units of benzathine penicillin G intramuscularly – single dose (one 1,2 mill IU vial in each gluteus)
*** Neurosyphilis
* For tertiary (except neurosyphilis) and late latent syphilis: 2,4 million units of benzathine penicillin G IM – once weekly for three weeks
**** Early neurosyphilis
* For neurosyphilis: IV penicillin G for 10 to 14 days
***** Meningitis
 
***** Stroke
Jarisch-Herxheimer reaction may occur after treatment is initiated. It's a systemic reaction to bacterial endotoxins. It is usually self-limiting.<section end="dermatology" />
**** Late neurosyphilis
***** Tabes dorsalis
****** Demyelination of the dorsal column and dorsal root ganglia
****** Causes a broad-based ataxia
***** Dysesthesia
***** General paresis
***** Widespread cerebellar atrophy
***** Dementia
***** Argyll Robertson pupil (Bilateral miosis, pupils don’t react to light)
** Diagnosis
*** Direct visualization of treponema
**** In the primary stage, when the serological tests below can be negative
**** Darkfield microscopy
**** Specimen from a lesion
*** Nontreponemal tests – for screening
**** RPR
**** VDRL
**** Sensitive, not specific
*** Treponemal test – for confirming the diagnosis
**** TPPA
**** FTA-ABS
**** Specific, not sensitive
** Treatment
*** For prevention, primary, secondary and early latent syphilis
**** 2,4 million units of benzathine penicillin G intramuscularly – single dose (one 1,2 mill IU vial in each gluteus)
*** For tertiary (except neurosyphilis) and late latent syphilis
**** 2,4 million units of benzathine penicillin G IM – once weekly for three weeks
*** For neurosyphilis
**** IV penicillin G for 10 to 14 days
*** Jarisch-Herxheimer reaction may occur
**** Systemic reaction to bacterial endotoxins
**** Is usually self-limiting
*** In case of penicillin allergy
**** Doxycycline
**** Desensitization to penicillin, then use penicillin as normal<section end="dermatology" />


[[Category:Dermatology]]
[[Category:Dermatology]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]