Syphilis

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This is a venereal disease transmitted by sexual contact with infectious lesions, from mother to foetus in utero, via blood transfusion, and breaks in skin that come in contact with infectious lesions.

Causes

  • Treponema pallidum

Symptoms

Signs

Primary syphilis

 

Primary syphilis (3-4wks after exposure)

Painless chancre, punched-out base and rolled edges on penis, vulva or cervix, anus, fingers, tongue, nipples etc.

Secondary syphilis

Tiredness, headache, anorexia, nausea, aching pains in the bones.

Syphilitic (aseptic) meningitis (in a few cases) presents with headache, neck stiffness, facial numbness and weakness; deafness.

Hepatitis

Secondary syphilis (4-8 weeks after chancre has healed)

Painless, gray-white lesions in warm, moist sites.

Reddish brown maculopapular rash over entire body (palms, soles, oral mucosae)

Swollen lymph nodes

Loss of hair on scalp and face, including eyebrows

Latent syphilis (< 1 year in duration): Asymptomatic

If untreated, progresses to tertiary syphilis

Latent syphilis (< 1 year in duration): Positive serological test result in the absence of clinical signs

Tertiary syphilis (up to 40 years after primary infection)

Impaired balance; sensation of pins and needles at extremities; incontinence and impotence

Hearing problems and vision loss

Dementia

Chest pain, back pain

Headache, dizziness, mood disturbance; weakness and wasting

Tertiary syphilis (up to 40 years later after primary infection)

Necrotic tissue (gummas) in liver, testes, bones or any organ; cardiovascular syphilis; neurosyphilis

Differential diagnosis

  • Other causes of genital ulcers
  • Chancroid, herpes, lymphogranuloma venerum, granuloma inguinale, trauma, Behhcet’s disease, tuberculous ulcer; cancer

Investigations

  • Dark- field microscopy (definitive diagnostic test)
  • Serologic testing using the Venereal Disease Research Laboratory (VDRL)

Note: VDRL test turns positive 1-2 weeks after chancre formation.

  • Pregnant females should be screened for syphilis at first prenatal visit
  • Screen all patients for HIV infection
  • Histology

Treatment objectives

  • Manage symptoms
  • Eradicate infection
  • Prevent transmission of the disease

Non-pharmacological treatment

  • Advise on the importance of using condoms
  • Advise to abstain from sex during treatment
  • Encourage partner testing

Pharmacological treatment

A. Patient with no penicillin allergy

1st line treatment

Adult:

Primary or secondary

Early latent syphilis (<2 years duration)

  • Benzathine benzyl penicillin G 2.4 million IU, IM in a single dose

OR

  • Procaine benzyl penicillin 1 million IU, IM, every 24 hours for 10 days

Late latent syphilis or late syphilis (other than neurosyphilis)

  • Benzathine benzylpenicillin G 2.4 million IU, IM, weekly for 3 weeks.

Pregnancy:

Give treatment appropriate to the stage of syphilis as recommended above (2.4 million units IM every week x 2 doses. Pregnant patients must repeat full course of therapy.

If HIV positive: 2.4 Mega units IM every week x 3 doses.

OR

  • Procaine Penicillin, 1 million IU, IM every 24 hours for 3 weeks.

B. Patient with penicillin allergy 

1st line treatment

Doxycycline, oral

Adult:            

100 mg every 12 hours for 30 days 

Note

Pregnancy

It should not be used in a pregnant woman unless, in judgement of physician

 

Child with no allergy to penicillin (congenital syphilis)

1st line treatment

Benzathine penicillin G

Child:

  • Children >2 years: Benzyl penicillin 200,000-300,000 IU/Kg (maximum 2.4million IU) IV or IM weekly in divided doses for 2weeks
  • Children ≤ 2years: Benzyl penicillin 25,000IU/kg (maximum 1.5million IU) IV or IM, every 12 hours for 10days

OR

  • Procaine benzylpenicillin

Child:

 Congenital Syphilis: 50,000 IU/kg (maximum 1.5million IU) IM, every 24 hours for 10 days

Primary, secondary, and latent (aged 12 years or older): as adults, 600,000 units IM per day for 8 days.

Child with penicillin allergy

Doxycycline, oral

Child:

<or equal to 8 years not recommended for middle to moderate infections

>8 years: 2mg/kg; maximum 100mg) orally every 12 hours for 30 days

2nd line treatment

Tetracycline, oral

Adult:

Early syphilis

500 mg every 6 hours for 15 days

Late Syphilis

500 mg every 6 hours for 30 days 

OR

Erythromycin, oral

Adult:

Primary syphilis

Erythromycin 500 mg orally every 6 hours for 15 days

 

 

 

2nd line treatment

Tetracycline

Note: Avoid

in pregnancy

Give pregnant women adult erythromycin dose under supervision

2nd Line Treatment

Tetracycline

Child:

> 8 years   25-50 mg/kg/day orally divided every 6 hours, not to exceed 3g/day

Up to 8 years: not recommended

 

OR

Erythromycin, oral

Neonates:

< 1.2 kg:  20 mg/kg/day divided every 12 hours

1.2 kg or more; 0-7 days old:   20 mg/kg/day in divided every 12 hours

1.2 kg or more, 7 days or older:   30 mg/kg/day  divided every 8 hours

Child:

Mild to moderate infections: 30-50 mg/kg/day in divided every 6-12 hours

Severe infection 60-100 mg/kg/day in divided doses every 6-12 hours

7.5-12 mg/kg; maximum 250 mg orally every 6 hours for 15 days

Prevention

  • Limit spread of infection (counsel on safe sex practices and avoidance of sharing of sharp objects)
  • Notification and treatment of sexual partners and exposed drug partners
  • Educate health care workers to use standard precautions when treating all patients.
  • Empiric treatment is recommended in all patients who have had contact with an infected person.

Referral

  • Refer to a specialist if complications arise, especially tertiary syphilis