disease risk factors investigation management of syphilis : classification
Differential diagnosis ofa genital ulcer:
Genital herpes:
Primary syphilis: location: usually multiple, painful, superficial,and if seen early, vesicular. Atypical
Initial lesions are papular but rapidly ulcerate, occur presentationsmay be indistinguishable from a syphilitic chancre.
1)In men: the chancre usually occurs on Prepuce,
on any skin or mucous membrane ,usually situated Chancroid:
glans, sulcus, less often shaft.
on the external genitalia usually painful, often multiple,frequently exudative, non-
In homosexually acquired syphilis, the anus and
( regular lyedged, regularly based, hard and button- indurated.Lymphogranuloma venereum: a small, papularlesion associated
rectum may be sites of primary infection
like ulceration measuring up to 1 cm in diameter) with a regional adenopathy.
*Note: Any location is possible
*As a rule, it heals spontane-ously in 3–8 weeks.it Other conditions: granuloma inguinale, drugeruptions, carcinoma,
leaves atrophic scar. 2)In women: Vagina or cervix (often
superficial fungal infections,traumatic lesions, lichen planus.
-genital and perianal chancre is followed by swelling overlooked),labia majora or minora, clitoris, posterior
chancre on the lip, the most importantdifferential diagnosis is facial
of the inguinal lymph nodes ,enlarged glands are commissure, perianal region, rectum.
herpes simplex,traumatic lesion, Behçet’s syndrome.
(discrete, rubbery and free from fixation to skin or -Extragenital chancres may be found on the lips,
underlying tissues) ,appears1–2weeks after chancre tongue and tonsil , nipple, the ear, neck or arm
In general, the diagnosis of syphilis should beconsidered in all patients
with ulcerativelesions in the genital ar
Secondary syphilis: secondary syphilis manifestations:
is the stage generalized manifestations occur on the Recommended treatment regimens for early syphilis:
•Syphilitic alopecia: Patchy hair loss ischaracteristic first line
skin and mucous membranes
of syphilis. The hair fallsleaving small, scattered, • Benzathine penicillin G 2.4 MU i.m. single doseor ×2 (day 1 and 8)
•Rashes in secondary syphilis have three common
irregularly thinned,‘moth- eaten’ patches of semi- • Procaine penicillin G 600 000 U i.m. daily ×10
features: Differential diagnosis:
baldness. -Penicillin allergy:
1) they do not itch 1- macular rash (drugeruptions, Measles and rubella, pityriasis rosea )
•Lesions of the mucous membranes: may coalesce to • Doxycycline 100 mg twice daily orally for 14days
2) they are coppery red 2- papular eruptions (seborrhoeic dermatitis ,psoriasis , Lichen planus,
causative agent form ‘snail-track’ ulcer. • Erythromycin 500 mg four times daily orally for14 days
3) the lesions are symmetrically distributed leprosy or tuberculosisif the face is affected)
*caused by thespirochete treponema pallidum •Generalized lymphadenopathy :Occurs in 50%of • Azithromycin 500 mg daily orally for 10 days
subspecies pallidum Initial Evaluation: secondary syphilis cases the nodes arepainless,
Evaluation of the patient with suspected •first appear at around 8 weeks. Rashes arethe Differential Diagnosis of SecondarySyphilis • Ceftriaxone 500 mg daily i.m. for 10 days (if noanaphylaxis to
The spirochete enters through the skin discrete, mobile, rubbery and vary insize from about penicillin)
syphilisrequires:-- -Complete physical commonest feature They are initially macular and -Guttate Psoriasis
ormucous membranes
(treponema pallidum bacteria 🦠 ) examination(mucosae,genitals ,
lymphadenopathy)
Therapy first after diagnosis is
become papular by 3 months.
•Constitutional symptoms consist of fever,headache,
0.5 to 2 cm.
•Neurological involvement:- central nervous
system may be invaded, Less often, serological tests
-Pityriasis Rosea
-viral exanthems
completelyconfirmed (identification and bone and joint pains thatare more pronounced -drug eruption
-medical and sexual history including HIV status are positive in the CSF. The patient maycomplain of
Transmission: ofTreponema pallidumor confirmatory at nigh -lichen plan
1)Transmission occurs almost exclusively during serological testing). 1) Acquired: headache only.
Tests for syphilis • Macular syphilide (roseolar rash):This is the -In the anogenital region, condylo-mata latahave been diagnosed as
-unprotected sex sexual intercourse, including by oro-genital
1)Darkfield microscopy:
-Syphilis is a reportable disease in most Early infectious(first 2 years): earliest generalized syphilide. It appears as
-meningitis may present as paralysis of one ormore
haemorrhoids ,condylomata acuminata
contact countries a. Primary stage ( chancre) cranial nerves
-having multiple sexual partners -Quickest and most direct method symmetrical, coppery red, round and oval spots of -The lesions of secondary syphilis
-oral lesions: aphthae ,infectious mononucleos
2)can be by blood transfusion -HIV serology b. secondary stage
-participating in the sex trade 3)by accidental puncture with a needle
-Primary and secondary syphilis
-Examination of sexual partners; then treatment c. Early latent(serological test +ve)
no substance. do not scale or itch. resolvespontaneously in a variable time periodand
-Direct visualization of spirochetefrom moist •a leukoderma syphiliticum is most commonly
-In the USA, approximately 58.1% of (syphilisd’emblee.)
lesions
or follow-up. late non infectious ( over 2 years): located on the back or sides of the neck and
most patients enter the latency stage within the first
reported caseswere among men who 4)Congenital syphilis is acquired by -No sexual contacts until treatment is a. Late latent (30% + ve) year of infection
-Requires experienced lab tech andproper wasformerly known as ‘the necklace of Venus
placentaltransmission of infection from the completed b. Tertiary stage
have sex with men(MSM) mother.
equipment be readilyavailable
c. CVS , neurosyphilis
-Negative results do not excludedisease.Rarely
-almost exclusively transmittedduring sexual
Syphilis used in practice
sexually
contact of an infectious lesion Jarisch–Herxheimer reaction: Early latent syphilis (first 2 years)
“The Great imitater" -incubation period from 10–90 days.
Available diagnostic laboratory testing:-
an acute febrile reaction that occurs in The patient is infectious and can pass the infection
-The primary chancre is located at the placeof manypatients within 24 h of commencing
also known as lues 1) Non-treponemal tests: on to a partner.Usually normal,i.e. no signs on clinical Subtopic 1
transmitted
the pathogen inoculation treatment examination. Continued infection found by positive
-Rapid plasma reagin (RPR) -Headache, myalgia, bone pains and an
-Venereal disease research laboratory (VDRL) treponemal antibody test
exacerbation of skin lesions may accompany
Syphilis and HIV infection: -Toluidine red unheated serum test (TRUST)
diseases
the fever.
2)Treponemal tests
-Syphilis increases the risk of HIV -Fluorescent treponemal antibodyabsorption
-Many clinicians advocate a short course
prevention: ofcorticosteroids to lessen its effects in these Late latent syphilis (afte 2 years)
acquisition andonward transmission. (FTA-ABS) Patient is non-infectious.Usually normal,i.e. no signs
Early recognition and treatment aretherefore patients
-HIV infection may alter the natural key to preventing progression ofdisease and its
-Microhemagglutination assay (MHA-TP) on clinical examination Subtopic 1
-Treponemal specific enzymeimmunoassays Continued infection found by positive treponemal
history of syphil irreversible complication (TP-EIA) -T.pallidum particle agglutination (TP-
Can syphilis be cured completely?Yes,
syphilis can be cured with the right antibiotics antibody tests. Recommended treatment regimens for late andcardiovascular
PA) However, treatment might not undo anydamage syphilis.:
Histopathology: First-line therapies:
They occur in and around blood vessels in the that the infection has already done
*once infection is confirmed, non-treponemal • Benzathine penicillin G 2.4 MU i.m. weekly ×3(day 1, 8 and 15)
form of a perivascularinfiltration of test titers can be checked regularly to measure Tertiary syphilis Manifestations:
• Procaine penicillin G 600 000 units i.m. daily ×17
lymphocytes and plasma cells,accompanied by disease activity tomonitor for new infection and -Gummas nodular lesions of skins and
Second-line therapies
intimal proliferation inboth arteries and veins todetermine treatment response. bones(Tumor-like growths)
• Doxycycline 200 mg twice daily orally for 28days (if penicillin
(endarteritis obliterans). -Gumma of the palate. This is a favouredsite for such
Tertiary syphilis lesions in both acquired and congenital syphilis.
allergic)
This leads to ischaemia andulceration • Amoxicillin 2 g three times daily orally plusprobenecid 500 mg four
may develop 3 to 10 years after initial infectiono .Gummas may develop in internal organs aswell (skin, Differential Diagnosis of TertiarySyphilis times daily orally for 28days
ccurs in approximately one-third of untreated bones, liver, heart, testis, brain,respiratory tract, and -Sarcoidosis
patients within months to years after initial infection. others). -CutaneousTP
-cutaneous, neurological, or neurosyphilis:- may include meningitis, cranialnerve -Leishmaniasis
cardiovascularinvolvement may occur during this involvement, stroke, general paresis,and tabes -mycosis fungoides
stage dorsalis. -SLE
-cutaneous lesions of tertiary syphilis include: cardiovascular syphilis :-Aortic aneurysm of the
ulcers, nodules or plaques (gummas) thorax, aortic regurgitation and stenosis ofcoronary
ostia Common sexually transmitted diseases:
-saddl nose Syphilis
HIV/AIDS
Gonorrhea
Candidal balanitis and vulvovaginitis
Chlamydia infections
Early congenital syphilis Condylomata acuminata
-including marasmic syphilis, a rash similar to Chancroid
secondary syphilis, bloody or purulent mucinous Herpes genitalis
Congenital Syphilis manifestations:
nasal discharge , perioral and perianal fissures, - Lymphogranuloma venereum
2) Congenital 1)Hutchinson’s Teeth Cytomegalovirus
lymphadenopathy,hepatosplenomegaly, Congenital syphilis can be confirmed by the direct visualization of T.
a. Early ( infectious first years) Smaller Widely spaced Central notches on biting pallidum in the placenta, umbilicalcord, amniotic fluid, or fetal tissue Granuloma inguinale
osteochondritis,anemia, ,
b. Late (non- infectious after 2 years) surface Peg-shaped incisors via PCR, dark field microscopy, or skin biops Hepatitis B and hepatitis C
pneumonitis,hepatitis,neurosyphilis
c. stigmata including scars and deformities Hutchinson triad:is a combination of interstitial Bacterial vaginosis
-Rash tends to be more bullous and erosive as
compared to adults. keratitis, neuraldeafness, and Hutchinson teet Pediculosis
-Late congenital syphilis is the equivalent of tertiary pubisScabies
syphilis in adults
characterized clinically: The incubation period:
Initial Treatment
-is typically 3–10 days
-by a painful, genital ulcer associated First Steps
-Gram stain seen school fish
-Azithromycin 1 g orally as a single dose.
with inguinal adenitis. caused by the fastidious gram-negative rod -The diagnosis is typically made clinicallyas
CHANCROID -In some developing countries, Haemophilus ducreyi. confirmatory culture or PCR tests are not
Alternative Steps
1)Ceftriaxone 250 mg IM in a single dose.
widely available
chancroid is themost common cause -screening for other sexually transmitted
2)Ciprofloxacin 500 mg twice daily for 3 days.
3)Erythromycin 500 mg 3 times daily for 7
of sexually transmittedgenital ulcers diseases should be performed concurrently
by fatema okoff
Differential diagnosis ofa genital ulcer:
Genital herpes:
Primary syphilis: location: usually multiple, painful, superficial,and if seen early, vesicular. Atypical
Initial lesions are papular but rapidly ulcerate, occur presentationsmay be indistinguishable from a syphilitic chancre.
1)In men: the chancre usually occurs on Prepuce,
on any skin or mucous membrane ,usually situated Chancroid:
glans, sulcus, less often shaft.
on the external genitalia usually painful, often multiple,frequently exudative, non-
In homosexually acquired syphilis, the anus and
( regular lyedged, regularly based, hard and button- indurated.Lymphogranuloma venereum: a small, papularlesion associated
rectum may be sites of primary infection
like ulceration measuring up to 1 cm in diameter) with a regional adenopathy.
*Note: Any location is possible
*As a rule, it heals spontane-ously in 3–8 weeks.it Other conditions: granuloma inguinale, drugeruptions, carcinoma,
leaves atrophic scar. 2)In women: Vagina or cervix (often
superficial fungal infections,traumatic lesions, lichen planus.
-genital and perianal chancre is followed by swelling overlooked),labia majora or minora, clitoris, posterior
chancre on the lip, the most importantdifferential diagnosis is facial
of the inguinal lymph nodes ,enlarged glands are commissure, perianal region, rectum.
herpes simplex,traumatic lesion, Behçet’s syndrome.
(discrete, rubbery and free from fixation to skin or -Extragenital chancres may be found on the lips,
underlying tissues) ,appears1–2weeks after chancre tongue and tonsil , nipple, the ear, neck or arm
In general, the diagnosis of syphilis should beconsidered in all patients
with ulcerativelesions in the genital ar
Secondary syphilis: secondary syphilis manifestations:
is the stage generalized manifestations occur on the Recommended treatment regimens for early syphilis:
•Syphilitic alopecia: Patchy hair loss ischaracteristic first line
skin and mucous membranes
of syphilis. The hair fallsleaving small, scattered, • Benzathine penicillin G 2.4 MU i.m. single doseor ×2 (day 1 and 8)
•Rashes in secondary syphilis have three common
irregularly thinned,‘moth- eaten’ patches of semi- • Procaine penicillin G 600 000 U i.m. daily ×10
features: Differential diagnosis:
baldness. -Penicillin allergy:
1) they do not itch 1- macular rash (drugeruptions, Measles and rubella, pityriasis rosea )
•Lesions of the mucous membranes: may coalesce to • Doxycycline 100 mg twice daily orally for 14days
2) they are coppery red 2- papular eruptions (seborrhoeic dermatitis ,psoriasis , Lichen planus,
causative agent form ‘snail-track’ ulcer. • Erythromycin 500 mg four times daily orally for14 days
3) the lesions are symmetrically distributed leprosy or tuberculosisif the face is affected)
*caused by thespirochete treponema pallidum •Generalized lymphadenopathy :Occurs in 50%of • Azithromycin 500 mg daily orally for 10 days
subspecies pallidum Initial Evaluation: secondary syphilis cases the nodes arepainless,
Evaluation of the patient with suspected •first appear at around 8 weeks. Rashes arethe Differential Diagnosis of SecondarySyphilis • Ceftriaxone 500 mg daily i.m. for 10 days (if noanaphylaxis to
The spirochete enters through the skin discrete, mobile, rubbery and vary insize from about penicillin)
syphilisrequires:-- -Complete physical commonest feature They are initially macular and -Guttate Psoriasis
ormucous membranes
(treponema pallidum bacteria 🦠 ) examination(mucosae,genitals ,
lymphadenopathy)
Therapy first after diagnosis is
become papular by 3 months.
•Constitutional symptoms consist of fever,headache,
0.5 to 2 cm.
•Neurological involvement:- central nervous
system may be invaded, Less often, serological tests
-Pityriasis Rosea
-viral exanthems
completelyconfirmed (identification and bone and joint pains thatare more pronounced -drug eruption
-medical and sexual history including HIV status are positive in the CSF. The patient maycomplain of
Transmission: ofTreponema pallidumor confirmatory at nigh -lichen plan
1)Transmission occurs almost exclusively during serological testing). 1) Acquired: headache only.
Tests for syphilis • Macular syphilide (roseolar rash):This is the -In the anogenital region, condylo-mata latahave been diagnosed as
-unprotected sex sexual intercourse, including by oro-genital
1)Darkfield microscopy:
-Syphilis is a reportable disease in most Early infectious(first 2 years): earliest generalized syphilide. It appears as
-meningitis may present as paralysis of one ormore
haemorrhoids ,condylomata acuminata
contact countries a. Primary stage ( chancre) cranial nerves
-having multiple sexual partners -Quickest and most direct method symmetrical, coppery red, round and oval spots of -The lesions of secondary syphilis
-oral lesions: aphthae ,infectious mononucleos
2)can be by blood transfusion -HIV serology b. secondary stage
-participating in the sex trade 3)by accidental puncture with a needle
-Primary and secondary syphilis
-Examination of sexual partners; then treatment c. Early latent(serological test +ve)
no substance. do not scale or itch. resolvespontaneously in a variable time periodand
-Direct visualization of spirochetefrom moist •a leukoderma syphiliticum is most commonly
-In the USA, approximately 58.1% of (syphilisd’emblee.)
lesions
or follow-up. late non infectious ( over 2 years): located on the back or sides of the neck and
most patients enter the latency stage within the first
reported caseswere among men who 4)Congenital syphilis is acquired by -No sexual contacts until treatment is a. Late latent (30% + ve) year of infection
-Requires experienced lab tech andproper wasformerly known as ‘the necklace of Venus
placentaltransmission of infection from the completed b. Tertiary stage
have sex with men(MSM) mother.
equipment be readilyavailable
c. CVS , neurosyphilis
-Negative results do not excludedisease.Rarely
-almost exclusively transmittedduring sexual
Syphilis used in practice
sexually
contact of an infectious lesion Jarisch–Herxheimer reaction: Early latent syphilis (first 2 years)
“The Great imitater" -incubation period from 10–90 days.
Available diagnostic laboratory testing:-
an acute febrile reaction that occurs in The patient is infectious and can pass the infection
-The primary chancre is located at the placeof manypatients within 24 h of commencing
also known as lues 1) Non-treponemal tests: on to a partner.Usually normal,i.e. no signs on clinical Subtopic 1
transmitted
the pathogen inoculation treatment examination. Continued infection found by positive
-Rapid plasma reagin (RPR) -Headache, myalgia, bone pains and an
-Venereal disease research laboratory (VDRL) treponemal antibody test
exacerbation of skin lesions may accompany
Syphilis and HIV infection: -Toluidine red unheated serum test (TRUST)
diseases
the fever.
2)Treponemal tests
-Syphilis increases the risk of HIV -Fluorescent treponemal antibodyabsorption
-Many clinicians advocate a short course
prevention: ofcorticosteroids to lessen its effects in these Late latent syphilis (afte 2 years)
acquisition andonward transmission. (FTA-ABS) Patient is non-infectious.Usually normal,i.e. no signs
Early recognition and treatment aretherefore patients
-HIV infection may alter the natural key to preventing progression ofdisease and its
-Microhemagglutination assay (MHA-TP) on clinical examination Subtopic 1
-Treponemal specific enzymeimmunoassays Continued infection found by positive treponemal
history of syphil irreversible complication (TP-EIA) -T.pallidum particle agglutination (TP-
Can syphilis be cured completely?Yes,
syphilis can be cured with the right antibiotics antibody tests. Recommended treatment regimens for late andcardiovascular
PA) However, treatment might not undo anydamage syphilis.:
Histopathology: First-line therapies:
They occur in and around blood vessels in the that the infection has already done
*once infection is confirmed, non-treponemal • Benzathine penicillin G 2.4 MU i.m. weekly ×3(day 1, 8 and 15)
form of a perivascularinfiltration of test titers can be checked regularly to measure Tertiary syphilis Manifestations:
• Procaine penicillin G 600 000 units i.m. daily ×17
lymphocytes and plasma cells,accompanied by disease activity tomonitor for new infection and -Gummas nodular lesions of skins and
Second-line therapies
intimal proliferation inboth arteries and veins todetermine treatment response. bones(Tumor-like growths)
• Doxycycline 200 mg twice daily orally for 28days (if penicillin
(endarteritis obliterans). -Gumma of the palate. This is a favouredsite for such
Tertiary syphilis lesions in both acquired and congenital syphilis.
allergic)
This leads to ischaemia andulceration • Amoxicillin 2 g three times daily orally plusprobenecid 500 mg four
may develop 3 to 10 years after initial infectiono .Gummas may develop in internal organs aswell (skin, Differential Diagnosis of TertiarySyphilis times daily orally for 28days
ccurs in approximately one-third of untreated bones, liver, heart, testis, brain,respiratory tract, and -Sarcoidosis
patients within months to years after initial infection. others). -CutaneousTP
-cutaneous, neurological, or neurosyphilis:- may include meningitis, cranialnerve -Leishmaniasis
cardiovascularinvolvement may occur during this involvement, stroke, general paresis,and tabes -mycosis fungoides
stage dorsalis. -SLE
-cutaneous lesions of tertiary syphilis include: cardiovascular syphilis :-Aortic aneurysm of the
ulcers, nodules or plaques (gummas) thorax, aortic regurgitation and stenosis ofcoronary
ostia Common sexually transmitted diseases:
-saddl nose Syphilis
HIV/AIDS
Gonorrhea
Candidal balanitis and vulvovaginitis
Chlamydia infections
Early congenital syphilis Condylomata acuminata
-including marasmic syphilis, a rash similar to Chancroid
secondary syphilis, bloody or purulent mucinous Herpes genitalis
Congenital Syphilis manifestations:
nasal discharge , perioral and perianal fissures, - Lymphogranuloma venereum
2) Congenital 1)Hutchinson’s Teeth Cytomegalovirus
lymphadenopathy,hepatosplenomegaly, Congenital syphilis can be confirmed by the direct visualization of T.
a. Early ( infectious first years) Smaller Widely spaced Central notches on biting pallidum in the placenta, umbilicalcord, amniotic fluid, or fetal tissue Granuloma inguinale
osteochondritis,anemia, ,
b. Late (non- infectious after 2 years) surface Peg-shaped incisors via PCR, dark field microscopy, or skin biops Hepatitis B and hepatitis C
pneumonitis,hepatitis,neurosyphilis
c. stigmata including scars and deformities Hutchinson triad:is a combination of interstitial Bacterial vaginosis
-Rash tends to be more bullous and erosive as
compared to adults. keratitis, neuraldeafness, and Hutchinson teet Pediculosis
-Late congenital syphilis is the equivalent of tertiary pubisScabies
syphilis in adults
characterized clinically: The incubation period:
Initial Treatment
-is typically 3–10 days
-by a painful, genital ulcer associated First Steps
-Gram stain seen school fish
-Azithromycin 1 g orally as a single dose.
with inguinal adenitis. caused by the fastidious gram-negative rod -The diagnosis is typically made clinicallyas
CHANCROID -In some developing countries, Haemophilus ducreyi. confirmatory culture or PCR tests are not
Alternative Steps
1)Ceftriaxone 250 mg IM in a single dose.
widely available
chancroid is themost common cause -screening for other sexually transmitted
2)Ciprofloxacin 500 mg twice daily for 3 days.
3)Erythromycin 500 mg 3 times daily for 7
of sexually transmittedgenital ulcers diseases should be performed concurrently
by fatema okoff
