Syphilis

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Complex chronic bacterial infection affecting a variety of organs and with multiple manifestations.

Cause

• Treponema pallidum
• Transmitted sexually and from mother to foetus, rarely through blood transfusion or non sexual contact

Clinical features

The disease has several stages

• Primary syphilis: 10-90 days following inoculation, characterized by a painless genital ulcer with clean base and indurated margins, regional lymphadenopathy. It can heal spontaneously but the disease will progress to secondary lesions
• Secondary syphilis: few weeks to months (max 6 months) from primary lesions, characterised by:
  • Generalised maculopapular rash
  • Mucous membranes lesions (patches and ulcers)
  • Weeping papules (condyloma alata) in moist skin areas
  • Generalized non tender lymphadenopathy
  • Fever, meningitis, hepatitis, osteitis, arthritis, iritis
• Early latent syphilis (<1 year in duration): clinically quiescent but possible relapse of secondary syphilis
• Late latent syphilis: clinically quiescent, not very infectious (but possible maternal foetal transmission)
• Late (tertiary) syphilis: at any time after secondary syphilis (even many years):
  • Infiltrative tumour of skin, bones, liver
  • Aortitis, aneurysms, aortic regurgitation
  • Central nervous system disorders (neurosyphilis): meningo vascular syphilis, hemiparesis, seizures, progressive degeneration with paraesthesias, shooting pains, dementia, psychosis

Investigations

• Non-treponemal antibody tests (VDRL and RPR)
  • Positive 4-6 weeks after infection
  • Used as screening test
  • Possibility of false positive
  • Remains positive 6-12 months after treatment
• Treponemal antibody tests (TPHA): very sensitive, used to confirm a positive non-treponemal test. Remains positive for long even after treatment so its positivity may not indicate active disease.

Management

Treatment	LOC
Primary, secondary and early latent syphilis Benzathine penicillin 2.4 million IU IM stat, half in each buttock or Doxycycline 100 mg every 12 hours for 14 days Late latent or uncertain duration, or tertiary without neurosyphilis Benzathine penicillin 2.4 million IU IM weekly for 3 weeks Or Doxycycline 100 mg every 12 hours for 28 days	HC3
Neurosyphilis Benzylpenicillin 4 million IU IV every 4 hours or Ceftriaxone 2 g IV or IM daily for 10-14 days	HC2 HC3
Followed by Benzathine penicillin 2.4 million IU IM weekly for 3 weeks Treat partner(s), abstain from sex during treatment and 10 days after	HC3