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Syphilis - Symptoms, Tests And Syphilis Treatment

A chronic, infectious, sexually transmitted disease, syphilis begins in the mucous membranes and quickly becomes systemic, spreading to nearby lymph nodes and the bloodstream. This disease. when untreated, is characterized by progressive stages: primary, secondary, latent, and late (formerly called tertiary). About 34.000 cases of syphilis, in primary and secondary stages, are reported annually in the United States. Incidence is highest among urban populations, especially in people between ages 15 and 39, drug users, and those infected with the human immunodeficiency virus (HIV). Untreated syphilis leads to crippling or death but the prognosis is excellent with early treatment.

Moreover, women who contract syphilis during pregnancy or who leave their syphilis untreated during pregnancy may infect their infants either during the pregnancy or during delivery, potentially causing the infant to suffer neurologic impairment. seizures, and even death. Prenatal syphilis is 32 times higher in Blacks than in Whites.

What causes Syphilis?

Syphilis is caused by infection with the spirochete Treponema pallidum. A spirochete is a wormlike, spiral bacterial organism that infects a person by burrowing into the mucous membranes of the mouth or genitals and causing chancres. transmission occurs primarily through sexual contact during the primary, secondary, and early latent stages of infection. Prenatal transmission from an infected mother to her fetus via the placenta is also possible.

Signs and symptoms of Syphilis

Syphilis has three stages: the first stage is the formation of the chancre; the second stage is more severe and may include hair loss; sore throat; skin rash; white patches on the nose,mouth, and vagina; fever; headaches; and wart like lesions. The third stage begins when the disease has progressed so far it involves the brain, heart, and other internal organs. Primary syphilis develops after an incubation period that generally lasts about 3 weeks. Initially, one or more chancres (small, fluid filled lesions) erupt on the genitalia; others may erupt on the anus, fingers,lips, tongue, nipples, tonsils, or eyelids. These chancres, which are usually painless, start as papules and then erode; they have indurated, raised edges and clear bases. At the time of their eruption, they are highly contagious. Chancres typically disappear after 3 to 6 weeks, even when untreated. They are usually associated with regional lymphadenopathy (unilateral or bilateral). In females, chancres are commonly overlooked because they usually develop on internal structures - the cervix or the vaginal wall.

Secondary syphilis is characterized by the onset of synunetrical mucocutaneous lesions and general lymphadenopathy, which may develop within a few days or up to 8 weeks after onset of initial chancres. The rash of secondary syphilis can be macular, papular, pustular, or nodular. Lesions are of uniform size, well-defined, and generalized. Macules commonly erupt between rolls of fat on the trunk and, proximally, on the anus, palms, soles, face, and scalp. In warm, moist areas (perineum, scrotum, vulva, and between rolls of fat), the lesions enlarge and erode, producing highly contagious, pink or grayish white lesions (condylomata lata). The rash and the wart like lesions are highly contagious and may be transmitted by casual contact. This stage may last from 4 to 6 weeks.

Mild constitutional symptoms of syphilis appear in the second stage and may include headache, malaise, anorexia, weight loss, nausea, vomiting, sore throat, and possibly, slight fever. Alopecia may occur, with or without treatment, and is usually temporary. Nails become brittle and pitted.

Latent syphilis is characterized by an absence of clinical symptoms but a reactive serologic test for syphilis. Because infectious mucocutaneous lesions may reappear when infection has lasted less than 4 years, early latent syphilis is considered contagious. Approximately two-thirds of patients remain asymptomatic through the late stage of latent syphilis and death. The rest develop characteristic late stage symptoms.

Late syphilis is the final, destructive but noninfectious and non contagious stage of the disease. It has three subtypes, any or all of which may affect the patient: late benign syphilis, cardiovascular syphilis, and neurosyphilis. The lesions of late benign syphilis develop between 1 and 10 years after infection on the skin, bones, mucous membranes, upper respiratory tract, liver, or stomach. The typical lesion is a gumma - a chronic, superficial nodule or deep, granulomatous lesion that's solitary, asymmetrical, painless, and indurated. Gummas can be found on any bone particularly the long bones of the legs - and in any organ. If late syphilis involves the liver, it can cause epigastric pain, tenderness, enlarged spleen, and anemia; if it involves the upper respiratory tract, it may cause perforation of the nasal septum or the palate. In severe cases, late benign syphilis results in destruction of bones or organs, which eventually causes death.

Cardiovascular syphilis develops about 10 years after the initial infection in approximately 10% of patients with late, untreated syphilis. It causes fibrosis of elastic tissue of the aorta and leads to aortitis, most commonly in the ascending and transverse sections of the aortic arch. Cardiovascular syphilis may be asymptomatic or may cause aortic insufficiency or aneurysm.

Symptoms of neurosyphilis develop in about 8% of patients with late. untreated syphilis and appear from 5 to 35 years after infection. These clinical effects consist of meningitis and widespread central nervous system damage that may include general paresis, personality changes, and arm and leg wealmess.

Syphilis rates in females were higher in the 20-24 age group, while male rates were higher in the 30 to 39 age group. 
Diagnosis tests information

Identifying T. pallidum from a lesion on dark-field examination confirms the diagnosis of syphilis. This method is most effective when moist lesions are present, as in primary. secondary. and prenatal syphilis.

The fluorescent treponemal antibody-absorption test identifies antigens of T. pallidum in tissue. ocular fluid. cerebrospinal fluid (CSF), tracheobronchial secretions. and exudates from lesions. This is the most sensitive test available for detecting syphilis in all stages. Once reactive. it remains so permanently.

Other appropriate procedures include the following:

  • Venereal Disease Research Laboratory (VDRL) slide test and rapid plasma reagin (RPR) test detect nonspecific antibodies. Both tests, if positive. become reactive within 1 to 2 weeks after the primary lesion appears or 4 to 5 weeks after the infection begins.
  • CSF examination identifies neurosyphilis when the total protein level is above 40 mg/dl. the VDRL slide test is reactive. and the cell count exceeds 5 mononuclear cells/ul.

Treatment of Syphilis

Treatment of choice for syphilis is administration of penicillin I. M. For early syphilis, treatment may consist of a single injection of penicillin G benzathine I.M. (2.4 million units). Syphilis of more than 1 year's duration should be treated with penicillin G benzathine I. M. (2.4 million units/ week for 3 weeks). Non pregnant patients who are allergic to penicillin may be treated with oral tetracycline or doxycycline for 15 days for early syphilis; 30 days for late infections. Non penicillin therapy for latent or late syphilis should be used only after neurosyphilis has been excluded. Tetracycline is contraindicated in pregnant women because it causes discoloration of the infant's teeth. If a pregnant woman with syphilis is allergic to penicillin, desensitization is recommended to permit the use of penicillin. If syphilis isn't treated in a pregnant patient, it can cause blindness or death of the infant.

Special considerations and Prevention

Stress the importance of completing the full course of antibiotic therapy even after symptoms subside.

  • Check for a history of drug sensitivity before administering the first dose.
  • A pregnant woman can avoid passing syphilis on to her unborn child by getting tested and treated for the disease during pregnancy.
  • In secondary syphilis, keep lesions clean and dry. If they're draining, dispose of contaminated materials properly.
  • In late syphilis. provide symptomatic care during prolonged treatment.
  • In cardiovascular syphilis. check for signs of decreased cardiac output (decreased urine output, hypoxia and decreased sensorium) and pubnonary congestion.
  • In neurosyphilis, regularly check level of consciousness, mood and coherence. Watch for signs of ataxia.
  • Urge patients to seek VDRL testing after 3, 6, 12 and 24 months to detect possible relapse. Patients treated for latent or late syphilis should receive blood tests at 6-month intervals for 2 years.
  • Be sure to report all cases of syphilis to local public health authorities. Urge the patient to inform sexual partners of her infection so they can also receive treatment.
  • Refer the patient and her sexual partners for HIV testing.

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