introduction

• >100 people diagnosed/yr in NZ

• most infectious in earlier stages

• incidence increased dramatically over last decade

• caused by spiral shaped spirochete treponema pallidum

• highly infectious 1ary and 2ary stages

  • able to pass through intact mucous membranes and compromised skin

  • transmissible via kissing and vaginal, oral and anal sex

  • consistent condom use reduces but doens’t elimate risk of syphilis infection

  • rate of transmisison = 30% in primary / secondary

symptoms

Primary

• time between infection and initial symptoms average 21d (10-90)

• appearance of single chancre (although multiple lesions may occur)

  • firm, painless and can vary in size up to \~3cm

  • appears at site of disease transmission

    • therefore may not be noticed

  • non tender lymphadenopathy may develop near site of chancre

• usually resolves wihin 4-8 weeks and doesn’t required localised treatment

• antibiotic treatment to prevent syphilis infection from progression

• atypical presentation:

  • multiple or painful ulcers

Secondary

• develops 3w - 3m after appearance of primary syphilis

  • if left untreated

• characterised by skin rashes and mucous membrane lesions

  • typcial rash

  • widespread

  • symmetrical eruption

    • slighly scaly

    • reddish brown plaques

    • occur palms and soles

  • rashes non specific

  • may resemble pityriasis rosea for example

  • may be faint so not noticed

• Comdylomata lata may aloso be present

  • moist

  • grey, pink or white

  • raised wart-like lesions/plaques

  • highly infectious areas of concentrated spirochete particulates

  • occur penis,vulva,rectum,mouth,throat,larynx,innerthighs,armpits, under breasts

• Other symptoms;

  • flu-like

  • lymphadenopathy

  • triedness

  • heaache

  • sore throat

  • fever

  • weight loss

• rashes and lesions usually resolve within 2-6w

• antibiotic treatmetn reduces duration of symptoms and prevents progression

Tertiary

• following aymptomatic latent period

  • may last > decade

• infectivity waning

• 1/3 of untreated will devleop 3ary syphilis

• infection identifiable on serological testing

• 3-10yr after first contracted

  • can appear up to 40 yrs later

• Neurological

  • Neurosyphilis

    • numbness in arms, legs, face

    • paralysis

    • gradual blindness

    • changes in mental state

    • dementia

• Cardiovascualr

  • chornic inflmamation of aorta

    • aneurysm formation

    • aortic valve incometence

    • CHF

  • Granulomatous lesions (gummas)

    • painless rubbery nodules seen skin, mouth,throat

    • may ulcerate

    • form as lesions in long bones

    • bone pain @ night

Congential syphilis

• infection passed vertically from mother to infant

• risk \~ 75-95%

  • in mother with 1ary syphilis

• risk of mother passing infection remains up to 7 years psot infection ifuntreated

• doens’t need to be symptomatic to pass on

• serology testing for syphilis included in first antentaal screen

• should be repeated @ 28w and prior to delivery with high risk of syphilis infection

  • recent immigrants from high risk countries

Testing

• two types of serology

  • non-specific (non-treponemal)

    • RPR, VDRL

      • high false positive

      • esp in women who are pregnant, cancer, autoimmune, co-morbid viral infections, older people and in people who use illicit drugs

  • specific (treponemal)

    • low false positive

    • enzyme immunoassay first

      • if posiive then

      • TTPA

        • treponemal pallidum particle agglutination

  • disease activity determined using RPR

• “syphillis serology”

Intepretation:

| EIA | TPPA | RPR | Intepretation |

| === | ===| ===|===|

| NR | Not tested | not tested | no evidence of syphilis, too early, retest 1/12 |

| R | NR | NR | Possible early primary, latent or false pos; retest 1/12 |

| R | NR | R | Probable early primary, false + possible but unlikely; retest 2w |

| R | R | NR | evidence of past infection/possible latent infection |

| R | R | R | current syphilis |

| R = reactive, NR = Non reactive |\|\|\|

Management

• all patients with suspected syphilis referred to, or discussed with, specialist sexual health service

• Benzathine benzylpenicillin = first line treatment

• macrolides/cephalosporin alternative

• Effective treatment usually results in decline in RPR titres

• return to pre0infective levels may take years

• Jarisch-Herxheimer reaction

  • worsening of rash and fever, headahce, malaise, myalgia after administration of abx

  • not important unless:

    • neurological/opthalmic involvment

    • occurs in pregnancy

    • common secondary syphilis

    • release of endotoxins from dying spirochaetes