SYPHILIS
ETIOLOGY: Treponema pallidum
Spirochetales
lenght: 5-20
thickness: 0,09-0,18
number of coil: 6-20
elegant movements
Giemsa staining (weak)
Silver staining
Direct IF with monoclonal antibody
SYPHILIS
Dark field microscopy
SYPHILIS
Non pathogenic treponemes
1. T.macrodentium
2. T. microdentium
3. T. genitalis
✓ morphology
✓ Movements
SYPHILIS
Contagion
Someone is naturally resistent
Relevant factors for the infection:
bacterial load
skin lesions rich in bacteria
blood, sperm, milk
Transplacental after the 4° month
Professional
SYPHILIS
Contagion
Sexually transmitted (95%)
SYPHILIS
Contagion
SYPHILIS
Acquired I, II latent, III
recent late
Congenital early late
(connatalis)
SYPHILIS
Natural history without therapy
Incubatione: 15-25 days(1 week.-30 days)
syphiloma
Primary complex
adenopathy
In few days serological tests become
positive
PRIMARY SYPHILIS
Syphiloma
Nodule 0,5-1 cm
Red in colour, ulcered
Firm, cartilaginous
Painless
Regional lymphadenopathy
hard, movable, painless nodes
Not inflammed
Multiple
PRIMARY SYPHILIS
PRIMARY SYPHILIS
PRIMARY SYPHILIS
PRIMARY SYPHILIS
PRIMARY SYPHILIS
PRIMARY SYPHILIS
PRIMARY SYPHILIS
SIFILIDE SECONDARIA
50-80 giorni dal contagio
Cute, mucose, annessi, linfonodi
Disseminazione ematica spirochete
Sierologia fortemente positiva
Sintomatologia d’organo
Malessere, cefalea, febbricola
Sifilide “decapitata”
SECONDARY SYPHILIS
Syphiloderma + micropolyadenopatihy
▪ roseolar
▪ papular
▪ papular-nodular
▪ papular-psoriasiform
▪ papular-pustular
▪ discromico
Alopecia areolaris syphilitica
Condylomata lata
Mucous patches
SECONDARY SYPHILIS
roseolar rash
The earliest
rash: trunk and proximal part of arms
and legs
Coppery red, round and oval spots, 1 cm
Duration: 20-40 days
SECONDARY SYPHILIS
roseolar rash
SECONDARY SYPHILIS
roseolar rash
SECONDARY SYPHILIS
Papular syphilide
Typical, characteristic
Lenticular, coppery red papule
Central scale
Biett’s collarette
Sites:
Palmo-plantar!!!
face
skinfolds
Ano-genital (condylomata lata)
SECONDARY SYPHILIS
Papular syphilide
SECONDARY SYPHILIS
Papular syphilide
SECONDARY SYPHILIS
Papular syphilide
SECONDARY SYPHILIS
SECONDARY SYPHILIS
Condylomata lata
SECONDARY SYPHILIS
Papular-nodular syphilide
SECONDARY SYPHILIS
Alopecia areolaris
Distal eyebrow loss
LATE SYPHILIS
Latent: asymptomatic seropositive
•Variable duration (years)
•Vertical transmission of infection may still occur,
but sexual transmission is less likely in the absence
of mucocutaneous lesions.
•Rule out the possibility of asymptomatic
neurosyphilis or aortitis
Tertiary (1/3 of the cases, after 5-15 years)
✓Cutaneous-mucous (gumma, ulcerative)
✓Neurological (tabe dorsalis, progressive paralysis)
✓Visceral (cardiovascular, epatic)
CARDIOVASCULAR
SYPHILIS
Appears 15-30 years after syphilis I
26-40% of patients that undergo to autopsy
Infrequent since the penicillin discover.
Aortic aneurysm (40%)
Aortic regurgitation (29%)
Coronary ostial stenosis (26%)
Therapy
Penicillin
Cardiac symptomatic therapy
Surgery (damaged cardiac valves)
TERTIARY SYPHILIS
TERTIARY SYPHILIS
CONGENITAL SYPHILIS
(CONNATAL)
Transplacental transfer of spirochetes
Active and untreated disease of the mother
Trnsmitted from the 4° month
1. late abortion al 4°-5° mese
2. Premature birth with dead fetus
3. Newborn with early congenital syphilis
4. Healthy newborn late congenital
syphilis
CONGENITAL SYPHILIS
EARLY (like acquired secondary syphilis)
Low birth weight, old appearance
palmo-plantar papular-bollous lesions
rhinitis
Parrot's pseudoparalysis
LATE CONGENITAL
SYPHILIS
Nodules and gummata like those of the
acquired tertiary syphilis
LATE CONGENITAL
SYPHILIS
Stigmata (result of early congenital
syphilis)
Hitchinson’s triad
1. The incisors are conical or barrel shaped, with a
degree of notching at the free edge. They may be
well separated and converge or diverge
2. eighth-nerve deafness
3. Interstitial keratitis
Saddle nose, olympian forehead, peribuccal radiated
scars, sabre tibiae
LATE CONGENITAL
SYPHILIS
SYPHILIS
Diagnosi microbiologica
•Asciugare la lesione
•Grattare il fondo con bisturi
•Poggiare su vetrino portaoggetto con
soluzione fisiologica
•Vetrino coprioggetto
•Visualizzare al M.P in campo oscuro
NON TREPONEMAL TESTS
Non specific (IgM, IgG)
Lipoid Antigen : Cardiolipin
VDRL (microflocculation)
Reactivity to these tests does not develop until 1–
4 weeks after the chancre appears in primary
syphilis
100% sensibility in secondary syphilis (high titre)
Low sensibility in late syphilis
Usefull for therapy follow-up, not for the dignosis
If the titre decrease 4 fold in 6 months:
therapeutic success
NON TREPONEMAL TESTS
False positive reactions (1-20%)
Titre < 1:8
Negative confirmation tests
Acute false positive (< 6 month)
Infections: mononucleosis, varicella, measles,
malaria, brucellosis
Chronic false positive (> 6 month)
autoimmune disease, chronic inflammatory
disease
Old age, pregnancy, alcool
HIV: 10-30% of false positive
NON TREPONEMAL TESTS
False negative
Frequent in the early and late phase
Unusual in secondary syphilis with high titre
“prozone” phenomenon (2% of the cases)
undiluted sera give negative results because of
antibody excess
Frequent in HIV and pregnancy
Dilute serum >1:16
TREPONEMAL TESTS
Specific
TPI Immobilizzation
FTA-ABS Immunofluorescence
TPHA Hemoagglutination
SPHA Solid phase adsorption
ELISA Immunoenzymatic
Confirmation tests
IgG e IgM (19S)
TPHA for screening too
TREPONEMAL TESTS
Specific
FTA-ABS
Titre non correlated with diseas activity
tend to remain positive for life, irrespective
of treatment
High sensibility e specificity
Rare false negative and false positive
reactions
quali-quantitative IgM and IgG determination
Serological tests:
STAGING
VDRL quantitative
+
FTA-ABS IgM
Useful for staging and terapia monitoring
IgM last for 3-9 months after treatment of recent S
IgM last for 12-18 months after treatment of late S
IgM 19S disappear with healing
Impossible with serology tests to distinguish
reinfection from reactivation
Reinfection: sudden increase of TPHA lipoid tests
titre
Syphilis and AIDS
Atypical incubation
Atypical clinical features
Atypical serology
False negative
False positive (> 11%)
“prozone” phenomenon
CONNATALIS SYPHILIS
Maternal IgG pass the placenta
Measurable in the newborn
Eliminated in few weeks
IgM useful for diagnosis
FTA-ABS
ELISA IgM 19S
TPHA
If negative IgM:
Ripete after few weeks
control progressive decrease of maternal IgG
THERAPY
Benzathine penicillin
a)Recent syphilis : 1,2 MU every 3-5 days x10 (1
cycle)
b)Late syphilis: 2 cycles repeat second cycle after
30 days
acquired and congenital
c)Syphilis in pregnant: dipends on the clinical
phase
d)Early ongenital syphilis: 50.000 U.I./kg single
dose i.m
THERAPY
Benzathine penicillin
New therapeutic strategies
Recent syphilis: 2.400.000 U.I. single dose
Tertiary syphilis: 2.400.000 U.I. weekly x 3
Penicillin allergy
Doxycycline Erythromycin
THERAPY
Jarisch-Herxheimer reaction
2-12 hours after penicillin therapy
Fever 40 °C
exacerbation of skin lesions
Frequent secondary syphilis
reaction to endotoxin-like products released by
the death of microorganisms
Avoid in:
early congenital syphilis
cardiovascular syphilis (ruptured aneurysm)
Give bacteriostatic antibiotics penicillin (es.
erytromicyn)
