Publichealthworks.ca
Syphilis – A Review
Barbara Romanowski MD, FRCPC
Clinical Professor
Faculty of Medicine & Dentistry
University of Alberta
September 16, 2008
Association Between Genital Ulcers
•
Any genital ulceration is associated with
an increased risk of HIV acquisition and
transmission
•
HIV can be cultured from lesion exudate
•
Therefore, HIV serology for all patients
with genital ulcers and vice versa
Reported Infectious Syphilis Rates in
Alberta and Canada, 1994 to 2007
Note: National rates for 2006 and 2007 are preliminary.
Source: Surveillance and Epidemiology Section, Centre for Communicable Disease and Infection Control, Public
Health Agency of Canada 2008; http://www.phac-aspc.gc.ca/std-mts/stdcases casmts/index.html) and Alberta
Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted
Infections Databases as of June 11, 2008
Infectious and Congenital Syphilis Cases
in Alberta 2007 (n=255)
* 4 of the 7 symptomatic CNS cases were ocular
Source: Alberta Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted Infections Databases as of June 11, 2008
Gender-Specific Age Distribution of Infectious Syphilis
Cases in Alberta, 2007
Age (yrs)
Source: Alberta Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted Infections Databases as of June 11, 2008
Male Infectious Syphilis Cases in Alberta
by Sexual Preference, 2003-2007
Source: Alberta Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted Infections Databases as of June 11, 2008
Infectious Syphilis – HIV Status in Regions 3 and 6, Alberta, 2007
Calgary Health (Region 3)
Capital Health (Region 6)
n=100 cases
n=106 cases
Unknown,
Unknown, 16,
Positive, 9,
Positive,
24, 24%
Negative,
Negative, 81,
Note: In 2007, there was one HIV positive infectious syphilis case outside of Capital and Calgary Health Region.
Source: Alberta Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted Infections Databases as of June 11, 2008
Sexual Contact
3-4 weeks
Infectious
Primary Syphilis
6-8 weeks
Secondary Syphilis
lymphadenopathy
Latent Syphilis
Early <2 years
Late > 2 years
Spontaneous Cure
Tertiary
Static positive serology
Primary Syphilis
Incubation 9-90 days (average
•
Chancre
•
Regional lymphadenopathy
Secondary Syphilis
•
Mucocutaneous eruption
•
Generalized
lymphadenopathy
•
Constitutional symptoms
Latent Syphilis
•
asymptomatic
•
positive serology
< 2 years – early latent
infectious
25% relapse to secondary
> 2 years – late latent
non-infectious
Tertiary Syphilis
•
3-30 years after primary infection
•
Non-infectious
•
Types late benign – skin,
bone, viscera
Cardiovascular –
aorta, heart
Neurosyphilis –
meninges, brain
Outcome of Pregnancy in Relation to
Stage of Untreated Maternal Syphilis
Primary or
Late Normal
Secondary
Prematurity
Perinatal death
Congenital syphilis
Healthy child
Congenital Syphilis
Early < 2 years of age
Late > 2 years of age
•
mucocutaneous &
•
interstitial keratitis
bony lesions
•
mulberry molars
•
hepatosplenomegaly
•
Hutchinson’s teeth
•
meningitis
•
saddle nose
•
perforation of hard
Summary of Congenital Syphilis Cases,
Alberta, 2005 to 2007
•
All 14 cases were born in Edmonton to 13 mothers (1 set
of twins)
•
5 neonatal deaths
•
Ethnicity: 8 First Nations, 4 Caucasian, 1 Asian
•
Marital status: 6 married/common-law
•
5 sex trade workers
•
8 mothers did not access antenatal care and were not
tested for syphilis until delivery; 1 mother was tested in the
second trimester but could not be located and the
remaining 4 tested negative for syphilis early in pregnancy
Source: Communicable Disease Reporting System: Notifiable Diseases and Sexually
Transmitted Infections Databases as of June 11, 2008
Diagnosis of Syphilis
1. History
2. Physical Examination
3. Laboratory Investigations
A) Darkfield examination / DFA
B) Serology
Serologic Tests for Syphilis
•
Non-treponemal test
RPR
VDRL
ART
EIA
RST
•
Treponemal test
MHA-TP / TP-PA
FTA-Abs
Serologic Tests for Syphilis
•
EIA – treponema specific test – detects
•
improved sensitivity / specificity
•
has replaced RPR, TPPA, FTA-Abs
•
cannot differentiate venereal from non-
venereal treponemal infection i.e. yaws /
pinta
INNO-LIA®
•
measures antibodies to T pallidum
antigens
•
will remain positive for life
•
will be only run initially to confirm EIA
Interpretation of Syphilis EIA
•
EIA -ve - no syphilis or incubating.
Consider repeating in 2 – 4 weeks
•
EIA +ve - syphilis. RPR will be done to
determine titres
•
EIA +ve / RPR –ve / LIA +ve – syphilis
False Positive Reactions
NON-TREPONEMAL
TREPONEMAL
•
viral infections
•
autoimmune
•
pregnancy
•
malaria
•
genital herpes
•
leprosy
•
elderly
•
pinta
•
injection drug abuse
•
cirrhosis
•
autoimmune
Indications for CSF Examination
•
any neurological abnormalities
•
before re-treatment of patients
who have had a relapse
•
in all infants
•
in the investigation of patients
with late latent syphilis and an
RPR ≥ 16
Diagnosis of Congenital Syphilis
•
physical examination
•
serology
if maternal transfer – titre should
gradually decrease & disappear by 6-12
months.
if congenital infection – titre will increase
•
CSF examination
•
long bone x-rays
Treatment of Syphilis
“A night on Venus, but a month on Mercury”
Primary, secondary, early latent
•
Benzathine penicillin 2.4 mu IM STAT
•
Doxycycline 100 mg bid x 14 days
Latent > 1 year duration
•
Benzathine penicillin 2.4 mu IM weekly for 3
successive weeks
•
Doxycycline 100 mg bid x 28 days
Treatment of Syphilis in Pregnancy
•
All women not previously treated should receive
penicillin appropriate to their stage of disease
•
Some experts suggest that pregnant women with
early syphilis received 4.8 mu benzathine
penicillin
•
Retreatment during pregnancy is unnecessary
unless there is clinical or serologic evidence of
new infection
•
When penicillin allergy is reported,
desensitization should be attempted
Syphilis Screening during Pregnancy
•
All pregnant women should have
syphilis serology undertaken at their 1st
pre-natal visit
•
Serology should be repeated at 28 – 32
weeks gestation
•
For “high-risk’ women serology should
again be repeated at term
Congenital Syphilis
Neonates should be treated at birth if:
•
They demonstrate symptoms/signs of
congenital syphilis
•
Maternal treatment was inadequate
•
Maternal treatment is unknown
•
Maternal treatment was with drugs other
than penicillin
RPR Titre Decrease After Treatment of
Infectious Syphilis
PRIMARY
2 tube decrease at 6 months
3 and 4 tube decrease at 12 and 24 months
SECONDARY
3 and 4 tube decrease at 6 and 12 months
EARLY LATENT
2 tube decrease at 12 months
Source: Romanowski B. Annals Int Med 1991;114:1005
Source: http://www.publichealthworks.ca/archive/2008/2008_09_Romanowski_Syphylis.pdf
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