SEXUALLY TRANSMITED DISEASES SYPHILIS ( LUES )

1. SEXUALLY TRANSMITED DISEASES SYPHILIS ( LUES ) Dr D. Tenea Department of Dermatology University of Pretoria

2. INTRODUCTION History • Venereal disease = old term • STD – infections transmitted by sexual contact • Sexually transmissible infections – caused by pathogens • for which non-sexual routes of transmission predominate

3. SEXUALLY TRANSMITTED AND TRANSMISSIBLE PATHOGENS History • Bacteria : Neisseria gonorrhoea– Gonorrhoea • Treponema Pallidum– Syphilis • Haemophilus Ducreyi– Chancroid • Chlamidia Trachomatis– LGV • Mycoplasma Hominis / Ureaplasma urealyticum • Viruses : HIV , HSV , CMV , HPV , MC , HTLV-1, -2, HAV, HBV, HCV • Protozoa : Trichomonas vaginalis , Giardia Lamblia , E. Histolytica • Fungi : Candida Albicans • Ectoparasites : Phthirus pubis , Sarcoptes scabies

4. SYPHILIS ( Lues ) History • Sexually acquired chronic, systemic infection / congenital infection • Progresses through active and latent stages • Caused by genus Treponema pallidum – order Spirochaetales • Leading cause of genital ulcer • Worldwide distribution • Higher incidence : men ( Blacks, Hispanics ) homosexuals, prostitutes

5. Laboratory Dx. of Syphilis History • Direct detection of Treponemes by darkfield microscopy • Serologic tests for Ab. response ( treponemal tests : TPHA and non-treponemal tests : VDRL , RPR ) • T. pallidum cannot be routinely cultured in vitro • PCR—molecular biological detection of treponemal DNA – not as a • routine test ( used in dx. of Neurosyphilis ) • Histology : H&E + special stains ( Warthin-Starry stain for identification • of Spirochetes in the tissues )

6. NATURAL HISTORY OF UNTREATED SYPHILIS History • Inoculation + penetration – mucosa and abraded skin • Incubation : 14 – 21 days • Primary Syphilis : painless chancre + regional lymphadenopathy • VDRL / RPR / TPHA +ve in 80% cases • Haematogeneous and lymphatic dissemination 3-8 wks. later • Secondary Syphilis : • - constitutional symptoms ( systemic manifestations ) • - generalised lymphadenopathy • - mucocutaneous manifestations • - positive syphilis serology ( 100% ) • - lesions disappear spontaneously ( 25% relapse in the first year )

7. NATURAL HISTORY – Ctd. History • Latent Syphilis : Early latent stage ( < 1 year ) • Late latent stage ( > 2 years ) – may last 2-20 years • Absence of any clinical signs and positive serology • 1/3 patients – clinical symptoms of tertiary syphilis • Tertiary Syphilis : • - superficial nodular syphilides ( confined to the skin ) • - gummatous syphilides of the skin , bones , liver • - cardiovascular syphilis • - neurosyphilis • - syphilitic hepatic cirrhosis • - reactive blood + presence of anti-treponema Ab. in CSF

8. CONGENITAL SYPHILIS History • Mother-to-child transmission risk : • - Infection of the mother from contraception to 7th. month of pregnancy • transmission 100% - abortion, stillbirth, IUD, severe Cong. Syphilis • - Infection 2 years before pregnancy or earlier : 50% risk • - Infection after 7th month of pregnancy : reduced risk of transmission • - Infection 3-6 weeks before labor : no placental transmission ; risk of • perinatal transmission

9. EARLY CONGENITAL SYPHILIS History • Symptoms apparent during perinatal period –first 3months after birth • Symptoms similar to acquired secondary Syphilis : • - annular skin lesions / bullous disease with erosions • - periorificial fissures ( perioral + perianal ) • - snuffles ( bloody or purulent mucinous nasal discharge ) • - lymphadenopathy • - osteochondritis – painful (Parrot pseudoparalysis ) • Skin manifestations are accompanied by constitutional symptoms • ( fever, malaise, myalgia, arthralgia ) ; underweight , senile features

10. LATE CONGENITAL SYPHILIS History • Child / adolescent • Corresponds to tertiary Syphilis in the adult • Is not infectious • Stigmata : • - keratitis • - Hutchinson`s teeth • - neural deafness • - Hutchinson`s triad

11. SYPHILIS AND HIV History • Syphilis / any other genital ulcers add to an increased risk • for acquisition of HIV • Syphilis manifestations are altered in HIV+ve patients • Neurological manifestations are observed more often • ( neurosyphilis is common in HIV ) • Higher incidence of ulcerative lesions of secondary Syphilis • in HIV + ve patients

12. Treatment recommendations for Syphilis History • Penicillin G is still the treatment of choice for all stages of Syphilis • No tendency toward Penicillin resistance found in T. Pallidum • Tetracyclines are used as a 2nd line therapy ( allergy / intolerance) • Follow-up examinations ( VDRL, TPHA ) – every 3-6 months for 2 years • for Early Syphilis and 3 years for Late Syphilis • Evaluation of sexual partners + reporting are mandatory in many countries • Primary , Secondary , Early latent Syphilis – a single dose 2.4 MU Benzanthine Penicillin • Latent Syphilis > 1 year duration + Late Syphilis : 3 weekly IM. Inj. of • 2.4 MU Penicillin

13. TREATMENT – Ctd. History • Neurosyphilis ( persistent high titres of VDRL /TPHA ) – 24 million units • IV. Pen. G in 6 divided doses for 14 days • Pregnancy : Benzanthine Penicillin 2.4 MU given IM. Weekly X 3 • Procaine Penicillin 50 000 units IM daily for 14-21 days • Congenital : Benzanthine Penicillin 2.4 MU given IM. Weekly X 3 or • Procaine Penicillin 50 000 u / kg IM daily for 14 days • HIV infection : Benzanthine Penicillin 2.4 MU given IM weekly X 3 or • Pen. G 2.4 MU adm. IV every 4 h. ( 12-14 mil. Dly for 14/7) • Alternative regimens for Penicillin allergies : Doxycycline 200mg/d -14/7 • Tetracycline 500mg 6hr. -14/7 • Erythromycin 2g/dly – 14/7