Syphilis and the Mucocutaneous Venereal Diseases

Syphilis "He who knows syphilis knows all of medicine." –Sir William Osler

a.k.a. lues venera (lues=plague, venera= from Venus, the Goddess of love)
caused by infection with the Spirochete Treponema pallidum. It is unclear how often T. pallidum replicates in humans with long standing infections. Consequently it is unknown exactly how long to treat patients with antibiotics that kill during cell division.
Incidence is currently on the rise in the U.S.
Heating and desiccation kill T. pallidum, however freezing and thawing do not. Chemicals may immobilize them.
Natural infections occur only in man; rabbits are used for culturing. Can be caught off wet toilet seats.

Key Features of Syphilis:

(1) secondary syphilis can look like every Dermatologic disease (it is the great imitator)
(2) two shots of benzathine penicillin given a week apart is necessary to treat syphilis
(3) three to five percent of patients with secondary syphilis display the prozone phenomenon, which complicates diagnosis (too much antibody causes a false negative)

Primary Syphilis

a relatively painless chancre appears at the site of contact 2 – 6 wks after any part of the body comes in contact with syphilis. The chancre has a rolled up firm border and heals without treatment in 3-6 weeks. Diagnosis of early syphilis by Darkfield microscopy is the only definite diagnosis.

Secondary Syphilis

begins 2-10 wks after the chancre appears and is characterized by a diffuse rash, particularly on the palms and soles, that may be accompanied by white oral lesions, fever, lymphadenopathy, headache, and arthritis.

Lesions – contain enormous amounts of treponemes(very contagious). Usually heal without scars in another 2-10 weeks.

Macules (roseola syphilitica) are non-pruritic, non-scaling oval spots on the trunk, palms, and soles.

Papules are the most frequently seen. They may assume a psoriasiform appearance.

Follicular lesions are pinhead sized and erythematous, occurring in crops on the trunk and extremities.

Lenticular papules are pinhead to bean size with brown/red color. Occur on the forehead and face.

Moist papules (Condyloma lata) highly infectious papules that develop in anogenital areas.

Annular lesions at the corner of the mouth one should think of Sarcoidosis and Syphilis!

All serological tests for syphilis are reactive during the secondary stage except for 3% of patients who demonstrate a PROZONE.

the prozone phenomenon – too much antibody to diagnose; an excess of antibody in the serum causes a false negative. Dilutions of sera will be positive.

Latent Syphilis

no clinical signs or symptoms of disease, only a positive serological test for syphilis.

Tertiary Syphilis

develops years later (except in co-infection with HIV where the course of both diseases is accelerated) and results in systemic problems

Syphilitic Gummas occur in most organs, particularly the skin, subcutaneous tissue, bone, and joints

Neurosyphilis results in Tabes dorsalis

Opthalmologic: Argyll Robertson pupil, optic nerve atrophy, and blindness

Cardiovascular syphilis: aortic aneurysm and aortic insufficiency.

Congenital Syphilis

most severe when the mother’s infection is recent

Treponemes do not invade the placenta until the 5^th month of pregnancy so treatment before the 5^th month will almost always prevent syphilis in the newborn

If the mother has had syphilis for more than 2 years there is little risk to the fetus

Early pre-natal syphilis (perinatal form; symptoms before 2 years old) – presents like secondary syphilis. Copper-red macule on palms and soles, vesicles, macules, and papules, condyloma, and mucous patches. All lesions are infectious. The baby may have Snuffles, laryngitis, painful bony involvement (pesudoparalysis of Parrot), hepatosplenomegaly, renal, and CNS involvement. May result in blindness.

Late pre-natal syphilis (infantile form) – distinctive for the triad of Interstitial keratitis, Hutchinson teeth, and eighth nerve deafness. Eye changes consist of interstitial keratitis and choroditis with a spotted retina. Dental changes involve he incisor teeth which are peg shaped and notched. 8^th nerve deafness and optic nerve atrophy develop secondary to meningovascular syphilis.

Diagnosis – Darkfield provides absolute diagnosis, especially in early primary syphilis when the other tests are negative

VDRL, RPR, RST – test non-specific antibodies to lipoidal antigens of T. pallidum. Positive 5-6 wks after infection through the secondary phase. Revert back to normal after 1 year after therapy. High antibody titers will demonstrate the prozone phenomenon.
FTA-ABS – Treponemal antigen tests become + early and remain so, even after treatment. Confirmation test.

Chancroid

caused by Hemophilus ducreyi

more common in the Gulf states

a very painful chancre with soft borders and "kissing lesions" (lesions that occur where the primary lesion has touched)

Lymphogranuloma venereum

caused by Chlamydia trachamatis types L1-L3

lymphadenopathy plus a small painless lesion on genitals

often the lymphadenopathy is the presenting symptom, not the lesion

Granuloma inguinale

caused by Calymmatobacterium granulomatis

the only VD without lymphadenopathy

Beefy red ulcers with centers resembling granulation tissue gave rise to its name.

Herpes simplex

type 1 is fever blisters, type 2 is genital

painful, shallow erosions that may be recurrent

it is possible to get herpes from inanimate objects (e.g. the locker-room bench)