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Syphilis

Syphilis, a chronic systemic infection caused by Treponema pallidum, is usually sexually transmitted and is characterized by episodes of active disease interrupted by periods of latency. About 20,000 cases of primary and secondary syphilis and 32,000 cases of early latent syphilis are

Clinical Evaluation

Primary Syphilis

The incubation period for syphilis is 10-90 days; 21 days is average.

The lesion begins as a painless, solitary nodule that becomes an indurated ulceration (chancre) with a ham-colored, eroded surface, and a serous discharge. Ninety five percent of primary lesions are found on or near the genitalia. Atypical lesions are frequent and may take the form of small multiple syfilis, siphilis

The chancre is usually accompanied by painless, enlarged

Untreated lesions heal in

The diagnosis is made by the clinical appearance and a positive darkfield examination; the serologic test (VDRL, RPR) is often negative in early disease.

Secondary Syphilis

Twenty five percent of untreated patients progress to secondary syphilis 2-6 months after exposure. Secondary syphilis lasts for 4-6 weeks.

Bilateral, symmetrical, macular, papular, or papulosquamous skin lesions become widespread. The lesions are non-pruritic and frequently involve the palms, soles, and face, in addition to the trunk and extremities. Condyloma lata consists of rash and moist lesions. Secondary syphilis is highly infectious.

Mucous membranes are often involved, appearing as white patches in the mouth, nose, vagina, and rectum.

Generalized nontender lymphadenopathy and patchy alopecia sometimes occur. A small percentage of patients have iritis, hepatitis, meningitis, fever, and headache.

The serologic test (VDRL. RPR) is positive in >99% of cases; the test may be falsely negative because of the prozone phenomenon caused by high antigen titers. Retesting of a diluted blood sample may be positive. No culture test is available.

Latent consists of the interval between secondary and late. Patients have no signs or symptoms, only positive serological tests.

Late is characterized by destruction of tissue, organs, and organ systems.

Late Benign. Gummas occur in skin or bone.

Cardiovascular. Medial necrosis of the aorta with dilation of the ascending aorta may lead to aortic insufficiency or saccular aneurysms of the thoracic aorta.

Neurosyphilis

Spinal fluid shows elevated WBCs, increased total protein, and positive serology.

Pupillary changes are common; The Argyll Robertson pupil accommodates but does not react to light.

Neurosyphilis may cause general paresis or tabes dorsalis--degeneration of the ascending sensory neurons in the posterior syphilis columns of the spinal cord.

Serology

Nontreponemal Tests

Complement fixation tests (VDRL or RPR) are used for screening; they become positive 4-6 weeks after infection. The tests start in low titer and, over several weeks, may reach 1:32 or higher. After adequate treatment of primary syphilis, the titer falls and, in most cases, becomes nonreactive within 9-18 months.

False positive tests occur in hepatitis, mononucleosis, viral pneumonia,malaria, varicella, autoimmune diseases, diseases associated with increased globulins, narcotic addicts, leprosy, and old age.

Treponemal Tests

Treponemal tests include the FTA-ABS test, TPI test, and microhemagglutination assay for T. pallidum (MHA-TP). A treponemal test should be used to confirm a positive VDRL or RPR.

Treponemal tests are specific to treponema antibodies and will remain positive after treatment.

All patients with syphilis should be tested for HIV.

Treatment of Primary or Secondary Syphilis