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Syphilis

Syphilis. -Spiral shaped spirochete (Treponema pallidum) -gram negative, but does not have lipopolysaccharide (LPS) -helical, thin (0.1 to 0.2 um), and long -flagella are inserted into the periplasm and give it motility -sensitive to drying, chemicals, and heat (as low as 42 degrees celsius).

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Syphilis

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  1. Syphilis

  2. -Spiral shaped spirochete (Treponema pallidum) -gram negative, but does not have lipopolysaccharide (LPS) -helical, thin (0.1 to 0.2 um), and long -flagella are inserted into the periplasm and give it motility -sensitive to drying, chemicals, and heat (as low as 42 degrees celsius) Bacteriology of Syphilis

  3. Epidemiology of syphilis How common?3rd most common STD 2006: > 36,000 cases of syphilis Incidence of 1° & 2° syphilis highest in women aged 20-24 and men aged 35-39 2008: 63% of 1° & 2° syphilis infections involved MSM 2004-2008: syphilis rates increased greatest among men & women 15-24 y/o

  4. More on Syphilis How do we spread it?Sexual contact: vaginal, oral, or anal Spreads P-to-P via direct contact with a sore Sore locations: external genitals, vagina, anus, rectum, lips, & mouth Also, congenital infxn via transplacental transmission Usually any time >20wks gestation Spirochetes are capable of crossing placenta The culprit?Treponema pallidum

  5. In case you were wondering...... NOT transmitted through contact with: Toilet seats Doorknobs Swimming pools Hot tubs or bathtubs Shared clothing Eating utensils

  6. Pathogenesis of Syphilis

  7. Pathogenesis of Syphilis

  8. Virulence Factors of Syphilis • Induces inflammatory response • Adherence via membrane proteins • Coats itself with fibronectin • Secretes hyaluronidase • Motility & corkscrew shape

  9. Clinical Manifestations- Syphillis Primary Syphillis presents with a PAINLESS CHANCRE! http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-229461-152.jpg

  10. Painless Chancre of Syphillis Photo: http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-1641801-229461-1949497.jpg

  11. Clinical Manifestations- Syphillis • Secondary Syphilis • Presents with Disseminated Disease with constitutional symptoms, maculopapular rash (that includes the PALMS and SOLES), condylomatalata. • Many treponemes are present in the condylomatalata of Secondary Syphilis (Treponemes and may be visualized through DARKFIELD MICROSCOPY. • “Teeming with spirochetes!” • Remember: • “Secondary Syphillis = Systemic” • Question: What other Disease presents with rash that includes the hands and feet?

  12. Secondary Syphillis- Disseminated Disease http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-229461-293.jpg

  13. Disseminated Rash (maculopapular) of Secondary Syphillis http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-1641801-229461-1949512.jpg

  14. Rash on Palms and Feet- Secondary Syphilis http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-229461-549.jpg

  15. Tertiary Syphillis • Gummas (chronic granulomas), aortitis (vasa vasorum destruction), neurosyphilis (tabes dorsalis), Argyll Robertson pupil. • NEUROSYPHILLIS has many manifestations • Signs: broad-based ataxia, positive Romberg, Charcot joint, stroke without hypertension.

  16. Gummas of Tertiary Syphilis http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-229461-389.jpg

  17. Argyll Robertson Pupil- Associated with Tertiary Syphilis. • Argyll Robertson is the pupil that constricts with accommodation, but is not reactive to light. • aka “Prostitute’s pupil- it accommodates but does not react.” http://1.bp.blogspot.com/_o3UvLBdaDQc/TGZa6gZOhsI/AAAAAAAAAAc/3GnIcWzYpaw/s1600/argyll+robertson+pupil-762395.jpg

  18. Congenital Syphillis • Babies born with syphillis (infected in utero). • Saber shins, saddle nose, CN VIII Deafness, Hutchinson’s teeth, mulbery molars. http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-229461-594.jpg

  19. Hutchinson Teeth of Congenital Syphillis (note notching). http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-229461-611.jpg

  20. Diagnosis • Will not grow in culture • Microscopy of exudates to look for organisms • Darkfield • Direct fluorescent antibody staining

  21. Diagnosis • Serology • To detect antibodies to cardiolipin (nonspecific) • VDRL- (Venereal Disease Research Laboratory Test) • RPR- (Rapid Plasma Reagin) Test • Then test for treponemal antibodies • FTA-ABS (fluorescent treponemal antibody absorption) • MHA-TP- (microhemagglutination assay for treponema)

  22. Treatment • DOC is Penicillin G • Can also use Ceftriaxone • If allergic to penicillin, can use Erythromycin or Doxycycline • Follow up at 3, 6, and 12 months with VDRL or RPR

  23. Chlamydia

  24. -Obligate intracellular gram-negative bacteria -pleomorphic and non-motile -small in size (0.25 to 0.8 um in diameter), and have small chromosomes (1 – 1.2 megabases) -”Energy Parasites”: Auxotropic for amino acids, and use host cell’s ATP -Cell wall is unusual in that it lacks muramic acid -Cannot be cultured in nutrient broth media or on agar plates Bacteriology of Chlamydia

  25. Epidemiology of Chlamydia How common?#1 reported STD in U.S. Highest infxn rates in Native & African Americans 2010: 1,307,893 reported infxns from 50 states Many unreported cases d/t lack of sxs in many individuals An estimated 2.8 million infxns occur in U.S. per year Worldwide, an estimated 90 million new cases each year Esp high infxn risk for sexually active teen girls d/t immaturity of cervix being more susceptible to infxn

  26. Epidemiology Cont'd How do I get it?Vaginal, oral, or anal sex Also transmitted during childbirth More sexual partners = higher risk Urethra = most common site for infxn in both men & women Chlamydia trachomatis = MCC of acute urethral syndrome in women & MCC of nonspecific urethritis (NSU) in men The leading preventable cause of infertility worldwide N. gonorrhoeae coexists in 45% of cases

  27. Pathogenesis of Chlamydia

  28. Virulence Factors of Chlamydia • Intracellular organism • Downregulates MHC-I • LPS • Prevent fusion of endosome with lysosome • Able to go into a persistent state • Nutrient up-take • Type 3 secretion system

  29. Chlamydia manifestations • Chalamydia trachomatis causes reactive arthritis, conjunctivitis, nongonoccocal urethritis, and pelvic inflammatory disease (PID). http://mshc.org.au/dnn/Portals/6/images/making_diag/urethral_discharge/ngu_discharge/chlamydial_urethritis.jpg

  30. Chlamydia in men • Urethritis • Painful urination • Burning sensation upon urination • Discharge from penis • Red, inflamed urethra • Chlamydia is picked up easier in men because it is more noticeable.

  31. Chlamydia manifestations in Women http://www.sharinginhealth.ca/images/Chlamydia_trachomatis_speculum_SOA_Amsterdam.jpg & http://www.mdguidelines.com/images/Illustrations/pel_in_d.jpg

  32. Diagnosis and Treatment • Doesn’t gram stain well but can gram stain urethral discharge to rule out gonorrhea • Fluorescent stained smear • Positive leukocyte esterase test on first-void urine • NAAT • Treatment- • Azithromycin (single dose) or Doxycycline (costs less, twice daily for 1 week)

  33. Neisseria Gonorrhea

  34. -a facultative intracellular gram-negative diplococci, -humans are the only reservoir -Ferment glucose, but do not ferment maltose -No polysaccharide capsule -produce IgA proteases Bacteriology for N. Gonorrhea

  35. Epidemiology of Gonorrhea How common? 2nd most common venereal disease 2009: 301,174 reported cases However, in U.S., it's estimated that >700,000 new infxns occur each year Highest rates in sexually active teens, young adults, MSM, Hispanics & AAs Worldwide, an estimated 62 million new cases each year W/highest rates in sub-Saharan Africa, southeast Asia, the Caribbean, & Latin America

  36. More Gonorrhea Epidemiology How are we spreading it?Contact w/infected penis, vagina, mouth, or anus Pregnant female can transmit infxn to baby during delivery as well Bacteria multiplies easily in warm, moist areas Urethra = MC site for gonococcal infxn in both men & women N. gonorrhoeae = MCC of septic arthritis in urban populations Can lead to disseminated gonococcemia More common in young women d/t C6-C9 deficiency

  37. Pathogenesis of N. Gonorrhea

  38. Virulence Factors of N. Gonorrhea • Pili • Opa proteins • Antigen variation/antigen phase variation • Porins • LOS • IgA protease

  39. Clinical Manifestations- N. gonorrhoeae • Causes • The STD Gonorrhea • aka “The Clap” • Septic Arthritis • Neonatal Conjunctivitis • PID • Fitz-Hugh-Curtis Syndrome

  40. Gonorrhea Clinical Manifestations • Burning and pain while urinating • Increased urinary frequency or urgency • Discharge from the penis (white, yellow, or green in color) • Red or swollen opening of penis (urethra) • Tender or swollen testicles • Sore throat (gonococcal pharyngitis) http://images.icanhascheezburger.com/completestore/2009/5/23/128875824687097628.jpg

  41. Gonorrhea Clinical Manifestations http://stdpictures.org/_wp/wp-content/gallery/gonorrhea/male-gonorrhea.jpg http://t0.gstatic.com/images?q=tbn:ANd9GcSMM3PMnX_rpuhUHUD4bg_Z6Ed3h9yqwh5W8jB53wNOJzDtwNPTioEo01TC

  42. Fitz-Hugh-Curtis Syndrome • Fitz-Hugh-Curtis Syndrome is a complication of Pelvic Inflammatory Disease and can occur due to both Chlamydia and Gonorrhea • Note “Violin-String” appearance of chronic adhesions/fibrosis http://img.medscape.com/pi/emed/ckb/obstetrics_gynecology/252558-1336972-256448-1810608.jpg

  43. Diagnosis • Nucleic acid amplification test (NAAT)- most sensitive • Culture on Thayer-Martin agar or chocolate agar • Gram stain male urethral specimens-shows intracellular gram negative diplococci

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