Download MBBS Dermatology PPT 14 Introduction Stis Syphilis Lecture Notes

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Syphilis

Definition

The sexual y transmitted infections (STIs; earlier k/a

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STDs or VDs) are a group of communicable infections /
diseases that are transmitted by sexual contact &
caused by a wide range of bacterial, viral, protozoal,
fungal agents & ectoparasites
Transformation in STIs

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? List of pathogens which are sexual y transmitted has

expanded from `5 classical' venereal diseases (VDs)
to include more than 20 agents including viral

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infections

? Shift to clinical syndromes associated with STIs

Classification of STI agents

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1. Bacterial Agents
? Treponema pal idum - Syphilis
? Haemophilus ducreyi - Chancroid
? Calymmatobacterium granulomatis - Donovanosis

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? Bacterial Vaginosis - caused by various microbial

agents

? Neisseria gonorrhoea - Gonococcal Urethritis and

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other manifestations

? Chlamydia trachomatis ? Non-Gonococcal Urethritis

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(NGU)

? Mycoplasma hominis - NGU
? Ureaplasma urealyticum - NGU
Classification of STI agents

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2. Viral Agents
? Herpes simplex virus 2 or 1 (HSV 2 & 1) - Herpes

genitalis

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? Hepatitis B virus
? Human Papil oma Virus - Warts
? Molluscum Contagiosum Virus- Mol uscum

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Contagiosum

? Human Immunodeficiency Virus (HIV) - AIDS

Classification of STI agents

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3. Protozoal agents
? Entamoeba histolytica ? Amoebiasis
? Giardia lamblia ? Giardiasis
? Trichomonas vaginalis ? Vaginitis

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Classification of STI agents

4. Fungal agents
? Candida albicans - Candidal Vaginitis
5. Ectoparasites

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? Phthirus pubis - Pediculosis
? Sarcoptes scabiei - Scabies

History

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? General history (Demography)
? Contact of an STI
? Onset, character, periodicity, duration & relation to

sexual intercourse & urination

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? Anogenital discharge / dysuria / hematuria
? Dyspareunia / pelvic pain
? Ulcers, lumps, rashes or itching
History

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? Past medical and STI history
? Medications, al ergies (emphasise antibiotics) &

contraception

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? Any STI in sexual partner(s)
? Last menstrual period
? Vaccination history
? Obstetric history (h / o abortions)

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? Any history of injecting drug abuse, what drug, how

often

? Any history of tattooing or blood product exposure

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Sexual History

? Number of exposure (Single, multiple)
? Number of sexual partner(s)

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? Date of last sexual exposure
? Sex of partner(s) and history of male to male

contact (MSM)

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? Type of intercourse ? oral, vaginal, anal
? Protected / unprotected exposure
History for HIV

? H/o Recurrent diarrhoea

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? H/o Fever
? H/o Loss of weight
? H/o Genital ulcer disease
? H/o Blood transfusion
? H/o Herpes zoster

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? H/o Opportunistic infections

Examination

? Exposure of abdomen, genitals and thighs is

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required

Inspect for:

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? Rashes
? Lumps
? Ulcers
? Discharge
? Smel

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Examination

Inspect for:

? Pubic hair for lice & nits

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? Skin of the face, trunk, forearms, palms & the oral

mucosa

? Palpate: Lymph nodes

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Examination - Men

Inspection:
? Penis

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? External meatus
? Retracted foreskin
? Perianal area
? Lymph nodes examination
? Per-rectal (P / R) examination

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? Palpation of scrotum & expression of any discharge

from the urethra.

? Proctoscopy

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Examination - Women

Inspection:
? External genitalia
? Perineum

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? Perianal area
? Lymph nodes examination
? Speculum examination of vagina & cervix
? Bimanual pelvic examination
? Oral cavity

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Systemic Examination

? Cardiovascular

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? Respiratory

? Gastrointestinal (liver, spleen)

? Central Nervous

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? Urinary

? Musculoskeletal
Syphilis

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? Caused by Treponema pal idum subsp. pal idum
? T. pal idum - a fine, motile, spiral organism,

measuring 6-15 m in length & 0.09 to 0.18 m in

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thickness with characteristic motility

? It has regular spirals which helps in differentiating

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from other non-pathogenic treponemes

? Cannot be grown on culture media

Transmission

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Moderate to high probability of transmission:
? Sexual contact
? Infected blood
? Trans-placental route

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? Accidental to medical personnel
Pathogenesis

Infection

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Attachment to host cel s

Corkscrew movement & travel to lymph nodes

In perivascular lymphatics cause endarteritis obliterans

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Loss of blood supply

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Genital ulcer

Primary syphilis

? Stage from infection to the healing of the chancre

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? Incubation period- 9-90 days

After this time there is ulcer formation
Primary syphilis

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? Single, painless, wel -defined, `Hunterian' ulcer with

clean looking granulation tissue on floor

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? Indurated, button-like

? Hard chancre - heals with scar even without

treatment

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Primary syphilis

Sites of ulcer
? Genital (90-95%)

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Coronal sulcus, glans, frenulum, prepuce, shaft of

penis in male
Cervix, labia, vulva, urethral orifice in females

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? Extra-genital (5-10%):
Commonest site is the lips
Diagnosis

Combination of clinical & Laboratory investigation

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? DGI-serum from ulcer / aspirate from lymph node

? VDRL / RPR- Negative til one week after appearance

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of ulcer.

Positive by 4 weeks

Natural History

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Gjestland (1955)- a fol ow-up study of 1147 cases (the Oslo

study)

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? 24% -mucocutaneous relapses
? 11% died of syphilis
? 16% - benign late manifestations (usual y cutaneous)

nodules or gummata

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? 10% cardiovascular syphilitic lesions
? 6% - neurosyphilis.
? Conclusion: Long before penicil in was introduced, at

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least 60% of people with syphilis lived & died without

developing serious symptoms (Rook's 2010)
Secondary Syphilis

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? 6-8 weeks after appearance of primary chancre

? Systemic disease

? Constitutional features like sore throat, malaise, fever

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& joint pain may accompany the lesions

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Secondary Syphilis

? Common signs are:
- Skin rash (75-100%)
- Lymphadenopathy (50-86%)

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- Mucosal lesions (6-30%)

Secondary Syphilis

Cutaneous:

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? Non-itchy lesions general y
? Macular, papular, nodular, pustular, annular lesions

may occur

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? Condyloma lata
? Split papules at angles of mouth
? Corona veneris
? Moth eaten alopecia
? Mucosal lesions - mucous patches (snail-track ulcers)

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? The `great-imitator'

Diagnosis

? VDRL / RPR - Almost always positive

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- False negative (in some cases)
- False positive (in some cases)
? Specific tests: TPHA / TPPA may remain reactive

throughout the life

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Latent syphilis

? Persistent seropositivity with clinical latency
? Fol owing resolution of primary or secondary stage

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latency occurs & continues as such in 60-70% of

patients

? Less than 2 years: Early

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? More than 2 years: Late

Tertiary Syphilis

? After a period of latency of up to 20 years,

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manifestations of late syphilis can occur

Cutaneous
Characteristic lesion is the gumma

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? A deep granulomatous process involving the

epidermis secondarily

? Causes punched out ulcerative lesions with white

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necrotic slough on the floor

? On lower leg, scalp, face, sternal area
Tertiary Syphilis

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Cardio-vascular:
Develops 10-30 years after infection - so in middle / old

age; more in men

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? Aortitis (ascending aorta)
? Aortic aneurysm sudden death due to rupture
? Coronary ostial stenosis

Tertiary Syphilis

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Neuro-syphilis:
? In any patient with syphilis, CSF lymphocytosis, an

elevated CSF protein level or a reactive VDRL test

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would suggest neuro-syphilis & must be treated

? Asymptomatic neurosyphilis
? Meningeal neurosyphilis -usual y has its onset during

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secondary disease; characterized by symptoms of

headache, confusion, nausea & vomiting, neck

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stiffness & photophobia. Cranial nerve palsies cause

unilateral or bilateral facial weakness &

sensorineural deafness

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? Meningovascular syphilis - occurs most frequently

between 4 and 7 years after infection. The clinical

features of hemiparesis, seizures & aphasia reflect

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multiple areas of infarction from diffuse arteritis.

? Gummatous neurosyphilis - results in features typical of a

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intracranial space-occupying lesion.

? Parenchymatous syphilis : general paralysis (GPI) from

parenchymatous disease of the brain used to occur 10?

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20 years after infection. The onset is insidious with subtle

deterioration in cognitive function & psychiatric

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symptoms that mimic those of other mental disorders.
? Tabetic neurosyphilis was the most common form of

neurosyphilis in the pre-antibiotic era, with an onset 15?

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25 years after primary infection. The most characteristic

symptom is of lightning pains- sudden paroxysms of

lancinating pain affecting the lower limbs.

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? Other early symptoms include paraesthesia, progressive

ataxia, & bowel & bladder dysfunction.

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Treatment of Syphilis & STIs

? CDC guidelines: updated regularly and reviewed

thoroughly every 4 years

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? Others:
? WHO
? NACO
Syphilis treatment

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Primary, Secondary, Early Latent
? Recommended regimen (CDC)

Inj. Benzathine Penicil in G,

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2.4 mil ion units IM stat after test dose

Treatment

Late Latent Syphilis

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? Recommended regimen
Inj. Benzathine penicil in G 2.4 mil ion units IM AST at

one week intervals x 3 doses

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Neurosyphilis

? Recommended regimen
Aqueous crystal ine penicil in G, 18-24 mil ion units

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daily administered as 3-4 mil ion units IV every 4 hours

for 10-14 days

Alternative regimen for penicillin

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allergic patients

? Doxycycline (100 mg) BD

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? Erythromycin (500mg) QDS

? Tetracycline (500mg) QDS

Duration of treatment

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? Early syphilis : 15 days

? Late syphilis : 30 days
? Pregnancy: Only penicil in G

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? If patient al ergic: desensitize

? CDC: Guidelines (Dr G. O. Wendel, Jr., et al. N Engl J

Med. 1985)

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The Jarisch-Herxheimer reaction

? The Jarisch-Herxheimer reaction is an acute febrile

reaction frequently accompanied by headache, myalgia,

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fever, & other symptoms that can occur within the first

24 hours after the initiation of any therapy for syphilis.

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? Antipyretics can be used to manage symptoms
? The reaction might induce early labor or cause fetal

distress in pregnant women, but this should not prevent

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or delay therapy



Thank you

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