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). Untreated syphilis leads to long-term health problems, but the prognosis is excellent with early treatment.
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.)
Incidence is highest in people ages 20 to 29.
Primary syphilis develops after an incubation period that generally lasts about 3 weeks. 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’re usually associated with regional lymphadenopathy (unilateral or bilateral). In females, chancres are commonly overlooked because they usually develop on internal structures — the cervix or the vaginal wall.
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 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 typically erupt between rolls of fat on the trunk and, proximally, on the arms, palms, soles, face, and scalp. In warm, moist areas (perineum, scrotum, vulva, and between rolls of fat), the lesions enlarge and erode, producing highly contagious, pink or grayish white lesions (condylomata lata).
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 is characterized by an absence of clinical symptoms but 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; the rest develop characteristic late-stage symptoms.
Late syphilis is the final, destructive but noninfectious stage of the disease. It 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 on the skin, bones, mucous membranes, upper respiratory tract, liver, or stomach between 1 and 10 years after infection. 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 can 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, usually in the ascending and transverse sections of the aortic arch. Cardiovascular syphilis may be asymptomatic or may cause aortic insufficiency 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.
The fluorescent treponemal antibody-absorption test identifies antigens of T. pallidum in 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. Once reactive, it remains so permanently.
Other appropriate procedures include the following:
❑ Venereal Disease Research Laboratory (VDRL) slide test and rapid plasma reagin test (RPR) 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/dl, the VDRL slide test is reactive, and the cell count exceeds five mononuclear cells/µl.
Treatment of choice is administration of penicillin I.M. or I.V. depending on the infection’s stage. After therapy, follow-up RPR tests are usually done to check for adequacy of treatment. The nonpregnant patient who is allergic to penicillin may be treated with tetracycline or doxycycline. Nonpenicillin therapy for latent or late syphilis should be used only after neurosyphilis has been excluded. Tetracycline is contraindicated in the pregnant woman because it causes discoloration of the infant’s teeth. If a pregnant woman with syphilis is allergic to penicillin, desensitization is recommended to permit the use of penicillin.
❑ Stress the importance of completing the full course of antibiotic therapy even after symptoms subside.
❑ Check for a history of drug sensitivity before administering the first dose.
❑ 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 and monitor vital signs. Watch for signs of ataxia.
❑ Urge the patient to seek testing after treatment to determine the treatment’s effectiveness. A patient treated for latent or late syphilis should be encouraged to continue follow-up care after treatment to determine its effectiveness.
❑ Be sure to report all cases of syphilis to local public health authorities. Urge the patient to inform sex partners of his infection so that they can also receive treatment.
❑ Remind the patient that safer sex practices and consistent condom use are important measures in syphilis prevention.
❑ Screen patients who are pregnant for syphilis to reduce the risk that the disease will be passed on to the fetus.
❑ Refer the patient and his sex partners for human immunodeficiency virus testing as appropriate.
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Title: Professional Guide to Diseases (Eighth Edition)
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2005
ISBN: 1-58255-370-X
» Next page: Syphilis (Handbook of Diseases)
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