SYPHILIS
Why syphilis?
BACKGROUND
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•
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Treponema pallidum (spiralled spirochaete)
First epidemic in Europe in 15 century
Incubation – 10-90 days (average 21 days)
Recent outbreaks in MSM communities in
Manchester and London (sauna + cruising)
• Often associated with HIV infection
Transmission
• Sexual – (primary) 30-50% infection rate
• Accidental inoculation
• Blood-borne – needle sharing, blood
transfusion rare (screened, organisms die 90120 hours at 4 degrees)
• Transpacental (from 9/40) – more common in
early syphilis
Classification
Acquired
• Early - <2 years
Primary, secondary and early latent
• Late - >2 years
Late latent and tertiary
Congenital
• Early - <2 years
• Late - >2 years
Classification
• Primary – anogenital ulcer is syphilitic until
proven otherwise (chancre)
• Secondary – multisystem involvement within 2
years of infection
• Early latent - <2 years. Positive serology with no
clinical evidence
• Late latent - >2 years. Positive serology with no
clinical evidence
• Tertiary – neurosyphilis, cardiovascular syphilis,
gummatous syphilis
Classification
• Neurosyphilis – dorsal column loss (tabes
dorsalis), dementia (general paralysis of the
insane) or meningovascular involvement.
• Cardiovascular – aortic regurgitation, aortic
aneurism and angina
• Gummatous – inflammatory nodules/ plaques
that may be locally destructive
DIAGNOSIS
RPR
TPPA
EIA
IgM/IgG
PCR
CLINICAL
DIAGNOSIS
ELISA
DIAGNOSIS
• Dark ground – for suspicious ulcers where empirical treatment not
given – dark ground for 3 consecutive days
• PCR – of swab if chancre in oropharynx or where dark ground
unsuccessful
• ELISA (IgG/IgM/IgA) – if positive then further testing needed
• TPPA - specific treponal test to confirm ELISA
• RPR – non specific test to aid staging of infection + monitor
response to treatment
• If suspect recent infection – ELISA IgM positive in those previously
uneffected
• Does not differentiate between other treponemal infection
• Repeat all tests a week following positive results
DIAGNOSIS
EIA IgM/IgG
TPPA
RPR
Primary chancre
+
++
1:32
Secondary
+
+++
1:128
Early latent
+
++
1:8
Late latent
+
+
1:2/neat +/neg
Tertiary
+
+
1:2/neat +/neg
Past treated
+
+
1:2/neat +/neg
False positive
+
-
neg
False positive
-
-
+
TREATMENT
• Benzathine penicillin 2.4 MU IM x 1 STAT
• Amoxicillin 500mg TDS + Probenecid 500mg
QDS PO for 14/7
• Penicillin allergy!
Consider desensitisation
Doxycycline 100mg BD x 21/7
Partner notification
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Primary – partners within last 3/12
Secondary – partners within last 6/12
Early latent – partners within last 2 years
Late – as many as you can remember!
Epidemiological treatments – all primary,
secondary and early latent contacts.
Serological testing at initial visit, 6/52 and
3/12
BASICALLY, IT’S COMPLICATED
DON’T BE AFRAID TO CONTACT YOUR FRIENDLY
LOCAL GUM CONSULTANT