Syphilis
Syphilis: Excerpt from Handbook of Diseases
A chronic, infectious, sexually transmitted disease, syphilis begins in the mucous membranes and quickly becomes systemic, spreading to nearby lymph nodes and the bloodstream. This disease, when untreated, is characterized by progressive stages: primary, secondary, latent, and late (formerly called tertiary).
The primary and secondary stages of syphilis have a high incidence among urban populations, especially in persons between ages 15 and 39, drug users, and those infected with the human immunodeficiency virus (HIV).
Untreated syphilis leads to crippling or death, but the prognosis is excellent with early treatment.
Causes
Infection from the spirochete Treponema pallidum causes syphilis. Transmission occurs primarily through sexual contact during the primary, secondary, and early latent stages of infection. Prenatal transmission from an infected mother to her fetus is also possible. (See Prenatal syphilis.)
Signs and symptoms
Each stage produces distinctive signs and symptoms.
Primary syphilis
After an incubation period that generally lasts about 3 weeks, symptoms of primary syphilis develop.
Initially, one or more chancres (small, fluid-filled lesions) erupt on the genitalia; others may erupt on the anus, fingers, lips, tongue, nipples, tonsils, or eyelids. These chancres, which are usually painless, start as papules and then erode; they have indurated, raised edges and clear bases.
Chancres typically disappear after 3 to 6 weeks, even when untreated. They are usually associated with regional lymphadenopathy (unilateral or bilateral). In women, chancres are frequently overlooked because they often develop on internal structures — the cervix or the vaginal wall.
Secondary syphilis
The development of symmetrical mucocutaneous lesions and general lymphadenopathy signals the onset of secondary syphilis, which may develop within a few days or up to 8 weeks after the onset of initial chancres.
The rash of secondary syphilis can be macular, papular, pustular, or nodular. Lesions are of uniform size, well defined, and generalized. Macules often erupt between rolls of fat on the trunk and on the arms, palms, soles, face, and scalp. In warm, moist areas (perineum, scrotum, vulva, between rolls of fat), the lesions enlarge and erode, producing highly contagious, pink or grayish white lesions (condylomata lata). Even without treatment, rashes clear up on their own.
Mild constitutional symptoms of syphilis appear in the second stage and may include headache, malaise, anorexia, weight loss, nausea, vomiting, sore throat and, possibly, slight fever. Alopecia may occur, with or without treatment, and is usually temporary. Nails become brittle and pitted.
Latent syphilis
Although no clinical symptoms occur in latent syphilis, it produces a reactive serologic test for syphilis. Because infectious mucocutaneous lesions may reappear when infection is of less than 4 years’duration, early latent syphilis is considered contagious.
Approximately two-thirds of patients remain asymptomatic in the late latent stage until death. The rest develop characteristic late-stage symptoms.
Late syphilis
The final, destructive, but noninfectious stage of the disease, late syphilis has three subtypes, any or all of which may affect the patient: late benign syphilis, cardiovascular syphilis, and neurosyphilis.
The lesions of late benign syphilis develop between 1 and 10 years after infection. They may appear on the skin, bones, mucous membranes, upper respiratory tract, liver, or stomach.
The typical lesion is a gumma — a chronic, superficial nodule or deep, granulomatous lesion that’s solitary, asymmetrical, painless, and indurated. Gummas can be found on any bone, particularly the long bones of the legs, and in any organ.
If late syphilis involves the liver, it can cause epigastric pain, tenderness, enlarged spleen, and anemia; if it involves the upper respiratory tract, it may cause perforation of the nasal septum or the palate. In severe cases, late benign syphilis results in destruction of bones or organs, which eventually causes death.
Cardiovascular syphilis develops about 10 years after the initial infection in approximately 10% of patients with late, untreated syphilis. It causes fibrosis of elastic tissue of the aorta and leads to aortitis, most often in the ascending and transverse sections of the aortic arch. Cardiovascular syphilis may be asymptomatic or may cause aortic regurgitation or aneurysm.
Symptoms of neurosyphilis develop in about 8% of patients with late, untreated syphilis and appear from 5 to 35 years after infection. These clinical effects consist of meningitis and widespread central nervous system damage that may include general paresis, personality changes, and arm and leg weakness.
Diagnosis
Identifying T. pallidum from a lesion on a dark-field examination provides immediate diagnosis of syphilis. This method is most effective when moist lesions are present, as in primary, secondary, and prenatal syphilis.
The fluorescent treponemal antibody-absorption test identifies antigens of T. pallidum tissue, ocular fluid, cerebrospinal fluid (CSF), tracheobronchial secretions, and exudates from lesions. This is the most sensitive test available for detecting syphilis in all stages. After it becomes reactive, it remains so permanently.
Other appropriate procedures include the following:
❑ Venereal Disease Research Laboratory (VDRL) slide test and rapid plasma reagin test detect nonspecific antibodies. Both tests, if positive, become reactive within 1 to 2 weeks after the primary lesion appears or 4 to 5 weeks after the infection begins.
❑ CSF examination identifies neurosyphilis when the total protein level is above 40 mg/100 ml, VDRL slide test is reactive, and CSF cell count exceeds five mononuclear cells/µl.
Treatment
Administration of penicillin I.M. is the treatment of choice. For early syphilis, treatment may consist of a single injection of penicillin G benzathine I.M. (2.4 million units). Syphilis of more than 1 year’s duration should be treated with penicillin G benzathine I.M. (2.4 million units/week for 3 weeks).
Nonpregnant patients who are allergic to penicillin may be treated with oral tetracycline or doxycycline for 15 days for early syphilis and for 30 days for late infections. Nonpenicillin therapy for latent or late syphilis should be used only after neurosyphilis has been excluded. Tetracycline is contraindicated in pregnant women. Patients who receive treatment must abstain from sexual contact until the syphilis sores are completely healed.
CLINICAL TIP: Rashes from secondary syphilis will clear up without treatment.
Special considerations
❑ Stress the importance of completing the course of therapy even after symptoms subside. Instruct those infected to inform their partners that they should be tested and, if necessary, treated.
❑ Check for a history of drug sensitivity before administering the first dose.
❑ Practice standard precautions.
❑ In secondary syphilis, keep lesions clean and dry. If they’re draining, dispose of contaminated materials properly.
❑ In late syphilis, provide symptomatic care during prolonged treatment.
❑ In cardiovascular syphilis, check for signs of decreased cardiac output (decreased urine output, hypoxia, and decreased sensorium) and pulmonary congestion.
❑ In neurosyphilis, regularly check level of consciousness, mood, and coherence. Watch for signs of ataxia.
❑ Urge patients to seek VDRL testing after 3, 6, 12, and 24 months to detect possible relapse. Patients treated for latent or late syphilis should receive blood tests at 6-month intervals for 2 years.
❑ Be sure to report all cases of syphilis to local public health authorities. Urge the patient to inform sexual partners of his infection so that they can receive treatment also.
❑ Refer the patient and his sexual partners for HIV testing.
Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Medical Books Excerpts
- Syphilis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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