Syphilis
Introduction: This sexually transmitted disease
has been around for thousands of years and was for a long time the major venereal
disease transmitted through prostitutes. The underlying infectious agent is called
Treponema pallidum, which is a spirally shaped bacterium. It can be seen utilizing
a darkfield microscope. Alternatively a fluorescent technique can be used to demonstrate
its presence. It is difficult to culture in a Petri dish in the lab. It
is transmitted through intimate skin contact and quickly invades the body via
the lymphatic and circulatory systems. There are four characteristic stages. 1.The primary stage is the stage of the syphilis
lesion. It is a skin sore that enlarges and then breaks open, called
"chancre". This is a reddish
pimple, which clears in the center, but leaks some serum containing lots
of syphilis bacteria. Untreated this takes about 4 to 8 weeks to heal. The chancre
does not hurt. The regional lymph glands get enlarged, but do not hurt. Characteristic
locations of chancre sores are on the penis, the vaginal entrance, the skin between
the vagina and the rectum in women (=perineum), and also in the anal and rectal
area of homosexual men. 2. The secondary stage of syphilis
consists of a skin rash,
which occurs about 6 to 12 weeks after the original infection. This
is the time when syphilis is blood born and reaches the lymph glands in the whole
body, the spleen, the bones, joints, the kidneys, the eyes (called "uveitis")
and the membranes around the brain (syphilitic meningitis). Syphilis has been
called the "great imitator".
This
is because the rash can come in different shades and shapes on the same person
and look like eczema, but then have a pustular appearance and again in another
area look more like plaques. Any unknown rash should be looked at by a dermatologist
as this specialist knows most about rashes and would not overlook a syphilitic
rash. A special form of skin lesions, called condyloma lata, which are soft elevated
waxy skin formations with dark pink color, appear on moist skin such as the penis
shaft or the labia of a woman. They also can occur inside the lips or nose
and in the rectal mucosa. There are myriads of syphilis bacteria (Treponema pallidum)
in the condyloma lata making contact with it very contagious. 3.
The latent stage of syphilis is an in-between stage where the immune
system has contained the infection, but it is still active, just dormant and waiting
for the immune system to weaken, so it can flare up. In about 1/3 of untreated
latent stage develop the tertiary stage of syphilis. But the majority after several
years of the latent stage in development countries will experience a "spontaneous
cure". This is likely not by chance at all, but due to a fortuitous treatment
of a cold with antibiotics, which happen to have covered the patient for syphilis
in the latent stage as well. 4. Tertiary stage of syphilis
: This late
stage of syphilis is quite varied like a chameleon as it can be a more
benign course affecting bone, internal organs and skin. But it can be more dangerous
when if affects the cardiovascular system, such as the aorta, or the Central Nervous
System (=neurosyphilis). The incubation time for tertiary syphilis is about
3 to 10 years from the beginning of the infection. The characteristic lesion for
tertiary syphilis is the "gumma", which consists of central necrotic
tissue and a surrounding granulation tissue. This is histologically very characteristic
of syphilis and served in the past (before the modern antibody tests) as identification
of the disease. These gumma lesions are found in all of the affected body organs
and lead to scarring and destruction of support tissue. When these lesions are
incorporated in the aortic wall, the aorta can rupture and the patient die instantly.
In the brain they can cause serious neurological, stroke like symptoms including
paranoia. In a bone there might be a sudden pathological fracture and the surgeon
may first think it would be a cancerous lesion, but the pathology,cultures and
other tests are telling the physician otherwise.
Signs
and Symptoms: The symptoms have been largely described above already
and will not be repeated here. As in the western world antibiotics are frequently
given for colds, pneumonia, ear infections and urinary infections, it is rare
to see untreated latent stage or tertiary stage syphilis (point 3 and 4 above).
However, it is common that a patient does not have primary or secondary stage
syphilis treated and the disease can then spread as explained under point 1 and
2 above. It is therefore important to stress that any skin ulceration or red lesion
around the genital area that does not hurt (possibly a chancre ) should be brought
to the attention of a physician. Appropriate tests need to be done at this stage
as in this stage the spirochetes (=the spiral shape Treponema pallidum) are easily
detected with darkfield microscopy. In the secondary stage of syphilis the symptoms
can be very misleading. If the joints are involved, there would be swelling of
the joints and symptoms are similar to arthritis with joint stiffness and joint
pains. With bone marrow involvement there can be a pronounced anemia, which
makes the patient feel fatigued. Spleen and liver are enlarged, the appetite is
diminished, the patient feels sick, looses weight, might get jaundiced. If meningitis
is present, there are headaches, neck stiffness, hearing loss might occur and
the eye movements may be abnormal resulting in double vision. The physician may
see edema of the optic nerve(=papilledema) when the eye is examined with an ophthalmoscope.
The important point to remember is to see a physician and to tell all of
these symptoms and insist to be thoroughly examined and if necessary have the
appropriate blood tests done. If syphilis is not detected at this stage, it will
relentlessly go on to the latent or the tertiary stage and gumma in the aorta
or in the brain could form, possibly killing the patient. If the bone gets infected
and gummas are formed there, sudden pathological fractures can occur. This means
that there is a pathological process that softens up the bone and the body's weight
or a force from moving an arm of leg can suddenly lead to a fracture of the bone.
Diagnostic
Tests: In primary syphilis the serous discharge from the primary
lesion (the chancre) is examined under the dark
field microscope and Treponema pallidum can be directly identified.
Chancres can also occur outside the genital area and the physician must remember
to think about the possibility of syphilis. Secondary syphilis may be recognized
when there is a rash, but this may also be mistaken for other skin rashes. The
serological tests for syphilis are usually positive at this stage (one common
one is called "VDRL", which stands for Venereal Disease Research Laboratory).
In the latent and in the tertiary stage of syphilis other tests need to be done
and it depends somewhat on the clinical presentation. Neurosyphilis needs to be
ruled out by lumbar puncture and analysis of the cerebrospinal fluid. Bone scans
may be needed to look for gummas in the skeleton. MRI scans, CT scans and ultrasounds
investigations can be useful to look for aortic lesions, cardiovascular syphilis
involving heart valves or lesions in the spinal cord or Central Nervous System.
The physician will have to individualize the investigations depending on the clinical
presentation.
Treatment
of Syphilis: For most patients the treatment of choice is penicillin
G by injection (except for those allergic to penicillin). This is given as 1.2
million units of benzathine penicillin G (brand name: Bicillin LA) intramuscularly
into each buttock. This provides for a good blood level of penicillin G
for about 2 weeks. For patients who are allergic to penicillin ceftriaxone (brand
name: Rocephin) is given intramuscularly at a dosage of 1 gram every 3 days for
4 doses. Alternatively erythromycin , tetracycline or doxycycline can be given
by mouth. However, there is a big problem with taking the oral medicine regularly
and for a complete course of 15 days. Part of the treatment is to examine and
treat all sexual contacts of the syphilis patient over the past 12 months as well.
There should be no sexual relations until the present partner is also treated
in order to avoid cross infection. All stages except the tertiary
stage are treated as outlined above. In tertiary
syphilis the dosages might be higher and the treatment lasts longer.
Also the period of careful follow-up is longer than with the more simple cases.
A dosage of 2.4 million units of Bicillin LA in intervals of 7 days for
a total of three injections (total of 7.2 million units) is standard for tertiary
syphilis. The antibody titres fro Treponema pallidum should show a fall of at
least 4-fold by 3 months from the treatment start. In the case of neurosyphilis
lumbar puncture and analysis of the CSF (=cerebrospinal fluid) should be done.
Also, at the end of the treatment protocol a repeat lumbar puncture should be
done to demonstrate that the therapy has been successful. About 6 to 12 hours
after the antibiotic injection half of the patients will have an expected reaction,
called Jarish-Herxheimer reaction. This is a generalized reaction to the massive
kill of the Treponema pallidum (see table). | 
