Please enable JavaScript.
Coggle requires JavaScript to display documents.
Syphilis (Risk factors (UPSI, Sex work, Multiple partners, Previous STI,…
Syphilis
Risk factors
UPSI
Sex work
Multiple partners
Previous STI
MSM
Epidemiology
Commonly MSM
Increasing prevalence in UK
M>>F
Young adults (F 20-24y, M 25-34y)
Clinical
presentation
Secondary
Skin
Maculopapular rash (non-itchy, involving palms/soles)
Condylomata lata (wart lesions in skin creases)
Snail tract oral lesions (patchy oral mucosa)
Patchy alopecia ('moth eaten' appearance)
Other
General:
fever, malaise, LNs
Ocular:
uveitis, iritis
ENT:
hearing loss (otosyphilis)
Neuro:
CN palsy, meningitis
Renal:
haematuria (nephrotic syndrome/GN)
Tertiary
Neurosyphilis
Dementia:
reduced cognition/judgement/insight, memory loss
CN palsies:
visual disturbance etc.
Stroke:
paraplegia, sensory loss, dysphagia
Tables dorsalis:
altered gait, numbness, lightning pains, foot deformity
Cardiovascular syphilis
AR/CVD:
syncope, chest pain, SOB
Heart failure:
SOB, ankle swelling
Gummatous
Inflammatory, fibrous nodules and plaques
Often skin, bone or liver
Primary
Chancre
At point of contact (usually genital)
Typical: single, firm, painless, indurated, clear discharge
Atypical: multiple, painful, purulent, destructive, extragenital (oral, hands)
Lymphadenopathy
Regional or generalised
Painless, rubbery
Congenital
Early (2-6w)
Nasal discharge
Skin/mucosal lesions
Failure to thrive
2y
Late syphilis signs
Sabre tibia
Hutchinson's teeth
Stillborn
Pathophysiology
Transmission
Direct contact with infectious lesions (sexual, rectal, oral)
Vertical transmission from mother to child
Blood-blood (e.g. IVDU)
Natural history
Early
<2 y post-infection
Primary
Initial infection, highly infectious
Symptomatic after 9-90d, usually 14-21d
Get painless chancre at point of contact (usually genitals),
may have LNs
Secondary
Highly infectious
Symptomatic 6-12 wk after primary (multisystem involvement)
Early latent
Asymptomatic period, but +ve serology
Infectious/non-infectious
Late
2+y post-infection
Late latent
Asymptomatic period, but +ve serology
Non infectious
Tertiary
Non-infectious, occurs 1-10y after infection, symptomatic
Gummatous - inflammatory granulation tissue, destructive, non-contageous
Neuro - infection of brain causing dementia (general paralysis of the insane GPI), CN palsies, tabes dorsalis (dorsal column loss)
Cardio - aneurysms, AR, HF, CVD
Agent
Spirochete gram -ve bacterium Treponema pallidum
Diagnosis
Examination
Neurological
Meningeal signs (fever, photophobia, neck stiff, reduced GCS)
CN palsy, focal signs, broad-based gait, Romberg's +ve
ENT
Snail track oral lesions
Reduced hearing (sensorineural)
Lymphadenopathy
Derm
Chancre, maculopapular rash,
condylomata lata, gummas
Abdominal
Hepatomegaly/tender liver, splenomegaly,
peripheral oedema (nephrotic syndrome), LNs,
expansile abdominal pulse (AAA)
Cardiovascular
Diastolic murmur (AR), fine crackles (HF),
peripheral oedema (HF)
Fundoscopy
Iritis, uveitis
Investigations
Swabs/samples
Chancre:
dark ground microscopy (treponemes),
DNA PCR (HSV/syphilis combo test)
Genital/oral/rectal:
swabs/FPU for CT/NG NAAT
:CSF:
microscopy, ELIZA (?neurosyphilis)
Bloods
Syphilis tests
Cardiolipin Abs:
VDRL/RPR, detects active disease
(-ve early primary or treated; +ve in secondary/tertiary);
false +ve in inflamm conditions e.g. pregnancy, infection, SLE
Treponeme Abs:
specific for treponema, +ve active and post-tx;
ELIZA/haemaggluttination test/fluorescent Ab test
BBV screen
HIV, HBV, HCV
Others
FBC, CRP, U+Es (may be deranged),
LFTs (may be deranged), BNP (HF)
Bedside
Obs (may have low-grade fever)
Imaging
CT/MRI: extra-dermal gummas
Urinalysis
Dipstick (protein, blood if GN/nephrotic syndrome)
History
PMH
Previous STIs, treatment
Reproductive history
Gynae: menses, bleeding, contraception, smears
Obs: gravity/parity, delivery, complications
PC/HPC
Painless ulcer, LNs, skin lesions,
generalised malaise/fatigue, maculopapular rash
DH
Current meds, abx
allergies
SH
Partners (casual/regular, gender, origin, age)
Type of sex (vaginal, anal, oral, active/passive)
Partners (last 3m, last 12m, last 10y if needed)
BBV risk (MSM, paid for sex, IVDU, blood transfusions)
Complications
Secondary disease
Uveitis, iritis, otosyphilis, hepatitis,
splenomegaly, meningitis, CN palsy,
periosteitis, GN, nephrotic syndrome
Tertiary disease
Neurosyphilis (meningitis, stroke, dementia, tables dorsalis)
Cardiovascular syphilis (aortitis, aneurysms, CAD, AR)
Gummatous syphilis (skin, bone, liver; complications of mass effects at these sites)
Jarisch-Herxheimer reaction
Pathophysiology:
abx treatment of secondary syphilis causes mass death of bacteria, releasing endotoxins and subsequent excessive inflammatory response
Presentation:
malaise, fever, headache, tachycardia
Management:
steroids and microbiology input
Prognosis
Treatment can be curative
If untreated, 1/3 get tertiary disease
Patients with HIV at higher risk of complications
Management
Medical
Abx
Indication: all stages of syphilis
E.g. benzylpenicillin IM 3 doses OR procaine penicillin IM OD 10d (early/late disease);doxy 28d if pen allergic, erythromycin if pregnant;
ceftriazone 14d (neurosyphilis)
MOA: penicillin destroys treponema pallidum
SEs: Jarisch-Herxheimer reaction, GIT upset, rashes
Conservative
Information and advice
Information on syphilis, transmission, complications
Avoid SI until successful treatment completed
Legal implications of not being treated and infecting others (battery)
Follow up
Repeat testing at 6 and 12w if -ve (incubation period)
If +ve, repeat serology in 1y
Referral
GUM clinic for specialist care
(testing, treatment, contact tracing, STI screening)
Contact tracing
Primary: 3m
Secondary: 2y
Tertiary: many years!
Definition
Sexually transmitted infection caused
by bacterium Treponema pallidum
