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Syphilis new.pptx [repaired]

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Ashish Jitendranath
Ashish Jitendranath

A 29-year-old man presented to an STD clinic complaining of multiple papules on his genitals. Examination revealed indurated papules that were painless. Tests determined it was a case of primary syphilis caused by the bacterium Treponema pallidum.

1 of 55
A 29 year old man came to the STD clinic complaining of multiple papules in his gentials. These papules quickly eroded and become tough. He later admitted to having unprotected sex with as ex worker
There was regional lymphadenopathy with moderately enlarged, firm, non suppurative, painless lymph nodes or satellite buboes. O/E we noticed papules which were indurated. It was painless.
So from the above case what can we assume Its an STD
There after various tests It was found to be a case of Primary Syphilis Syphilis comes under
Treponema-I Dr Ashish Jitendranath Associate Professor, Dept of Microbiology
Introduction Classification is
Organism
Ultrastructure Lipid rich outer membrane- Increased susceptibility to detergents Show hardly any antigenic variations Saprophytic spirochetes are generally coarser. Endoflagella lie inside outer membrane and inserted at tapering portion
Syphilis new.pptx [repaired]
Motility
Cannot be grown in artificial culture media Cannot determine metabolic, physical and pathogenic features. Non pathogenic trep is Reiter strain and Noguchi strain. Virulent strains(eg. Nichols strain) has been maintained by serial passages in rabbit testicles Recently grown in tissue cultures of rabbit epithelial cells
Epidemiology Modes of transmission Sexual contact Placenta Kissing Close contact Contaminated fresh blood Fantastic history of syphilis with exact source not known. All known contacts post diagnosis needs to be considered.
Blood vessel and lymphatics Enters blood and dissipates to various organs in the body Pathogenesis Untreated Syphilis- Progress from 1. Primary 2. Secondary 3. Latent 4. Tertiary stages
Clinical features ( contd ) Veneral syphilis Organism divides 30-33 hours. Generally incubation period a month. Early spirochetemia inevitably develops during this phase Left untreated at least 2/3 spontaneously clear 1/3 progress
Those that progress after 3 weeks Bacteria multiply at initial entry site and progress to form a chancre on the genital. Painless chancre Usually single except immunocompromised patients Superficial Ulcer has clean appearance and no exudate. Painless or slightly tender to touch
Primary syphilis Indurated and superficially ulcerated Base usually smooth, borders raised and firm and cartilaginous consistency. Known as Hard chancre Most common site penis, cervix or labia and anal canal, rectum or mouth Regional lymphadenopathy consisting of enlarged, firm, non suppurative, painless lymph nodes or satellite buboes accompanies primary lesion Chancre heals within 3-6 weeks and 2-12 weeks later the symptoms of secondary syphilis develops
Secondary syphilis Clinically most florid stage of infection Involves skin Multiplication and wide dissemination of spirochete and last until sufficient host response develops to exert some immune control. Begins 2-8 weeks after appearance of chancre.
Secondary syphilis Nonpruritic macular, maculopapular, papular or pustular lesions. Begin on the trunk and proximal extremities. Any surface area becomes involved. Macules evolve to papules. Other sites palms, soles, hair follicles.
Secondary syphilis Warm, moist intertriginous areas ( perianal area, vulva, scrotum, inner aspects of thigh, skin under breast) papules enlarge, coalesce and erode to produce painless, broad, moist, gray- white to erythematous highly infectious plaques termed condylomata lata
Syphilis new.pptx [repaired]
Secondary syphilis Constitutional symptoms are seen CNS involved in 40 % of patients. ( Headache and meningismus). Any organ involved, eg with Renal involements, syphilitis hepatis proctitis, Git Panuveitis ostieits, and otosyphilis.
Latent syphilis Period of quiescence. No clinical manifestation Serological tests. Individuals with late latent syphilis are not considered infectious. May still transmit infection. Early latent syphlis is when clinical relapse occurs. Diagnosis during this period using serological tests.
Late syphilis Slowly progressive destructive inflammatory disease that can affect any organ in body to produce clinical illness 5-30 or more years after initial infection. Neurosyphilis Cardiovascular syphilis Gummatous- rare granulomatous lesion of skeleton, skin and mucocutaneous tissues
Congenital syphilis Women with early syphilis can infect her fetus much more commonly(75-90%) than with syphilis over 2yrs duration(35%) Lesions of congenital- develop 4th month of gestation when fetal immune competence starts appearing (suggests pathogenesis requires immune response from fetus) Congenital syphilis prevent if given adequate treatment Abortions normal.
NON-VENEREAL SYPHILIS Occupationally in doctors or nurses the natural evolution is as in venereal syphilis, except that the chancre is extragenital, usually on fingers In syphilis transmitted by blood transfusion,1 chancre does not occur Transplacental transmission-any stage of pregnancy
Lab Diagnosis
Specimen Collected with care. Lesion cleared with a guaze soaked in warm saline & the margins gently scraped Gentle pressure applied to the base of lesion & serum that exudes is collected Blood also is taken Serous transudate from moist lesions- Primary chancre, condyloma latum or mucous patch
Direct examination Primary, secondary and early congenital syphilis- Immunostaining, PCR, darkfield examination Wet film prepared by exudate examined under dark ground microscope Needs to be differentiated from saprophytes Not specific and requires 104 per ml of spirochetes.
In case lesions is cleaned with antiseptic-Direct immunofluorescent antibody staining and immunohistochemical staining better. Best observed from chancre, condyloma and mucous patches. 3 negatives before final.
Biopsy specimen Warthin starry stain. Levaditi and Fontaina method are silver staining methods. Preferred methods of staining is immunohistochemical staining.
MAJOR SEROLOGICAL TESTS FOR SYPHILIS A.Non-specific(Reagin Ab) tests using cardiolipin Ag (STANDARD TESTS FOR SYPHILIS) oWasserman complement fixation reaction oKahn flocculation test oVDRL test oRapid plasma reagin(RPR) oAutomated RPR oVDRL-ELISA test B. Group specific test using cultivable treponemal(Reiter strain) Ag oReiter protein complement fixation(RPCF) test
C.Specific tests using pathogenic treponemes(T. Pallidum) Treponema pallidum Immobilisation(TPI) test Fluorescent Treponemal Antibody-Absorption(FTA-ABS) Treponema Pallidum Haemagglutination Assay(TPHA) Treponema Pallidum Enzyme Immunoassay(TP-EIA)
VDRL TEST FOR SYPHILIS Type of slide flocculation test In this inactivated serum(heated at 56c for 30 mins) is mixed with cardiolipin Ag on a special slide & rotated for 4 mins Cardiolipin forms visible clumps on combining with reagin Ab Reaction read under low power microscope as reactive, weak or non. Monitor patients response to therapy
RPR Common test in labs now. Employs carbon particles and read macroscopically. Black carbon particles are bound to caridolipin, when mixed with positive serum on disposable card. Agglutination is easily observed. Prozone phenomenon in upto 2% of cases especially in secondary and pregnancy
Vdrl testpositive negative
RPR Advantages Enables the result to be read by eye Useful in field studies RPR done with unheated serum or plasma Fingerprick sample is sufficient Dis advantages Cant test CSF
Trust-Toloudine red unheated serum test. Instead of carbon particle we use toloudine red Automated reagin antibody test-
4 fold change in titre important. Highest prevalence during secondary syphilis. Quantitative test should become non reactive 1 year after treatment in primary and 5 years in secondary.
BIOLOGICAL FALSE POSITIVE(BFP) REACTIONS As cardiolipin Ag is present both in T.Pallidum and in mammalian tissues, reagin Abs may be induced by treponemal or host tissue antigens which accounts for BIOLOGICAL FALSE POSITIVE(BFP) BFP defined as positive reactions obtained in cardiolipin tests, with negative results in specific treponemal tests, in the absence of past or present treponemal infections and not by technical faults They represent non-treponemal cardiolipin antibody responses
BFP Ab is usually IgM while Reagin Ab in syphilis is IgG Represent non treponemal cardiolipin Ab responses Clinically BFP reactions classified as acute & chronic Acute BFP-last only for weeks or months, associated acute infections, injuries or inflammatory conditions Chronic BFP-persist longer than 6 months, seen in SLE & other collagen diseases Other conditions associated BFP reactions r leprosy, malaria, relapsing fever, infectious mononucleosis, hepatitis & tropical eosinophilia
To avoid BFP reactions, tests using cultivable treponemes(REITER STRAIN) as Ags were developed Most common-Reiter Protein Complement Fixation(RPCF) using lipopolysaccharide-protein complex Ag derived fron treponeme Sensitivity & specificity- lower than tests using T. Pallidum RPCF-generally free from BFP but gave false positive reactions GROUP SPECIFIC TREPONEMAL TESTS
Specific test- Nichols strain TPI- Historical concept Ability of Antibody + complement to immobilize live T. pallidum visualized under darkground microscope. Flurescent treponemal antibody- Indirect Immunofluorescence test using smears prepared on slides with Nichols strain of T.Pallidum
FTA- Absorption- Patients serum first absorbed with non pathogenic trep antigen ( sorbent ) to remove low titer, natural cross reacting antibodies Difficult to standardize hence Particulate agglutination test is preferred.
Syphilis new.pptx [repaired]
T.PALLIDUM HAEMAGGLUTINATION ASSAY(TPHA) Uses tanned ethrocytes sensitized with a sonicated extact of T.Pallidum as Ag Test sera for TPHA are absorbed with a diluent containing components of the Reiter treponeme,rabbit testis & sheep erythrocytes Sera screened at initial dilution of 1:80 but titres of 5120 or more-common in 2stage TPHA-as specific as FTA-ABS, almost sensitive except in 1 These advantages have made TPHA-Standard Confirmatory Test
FREQUENCY OF REACTIVE SEROLOGICAL TESTS IN UNTREATED SYPHILIS(%) Stage VDRL/RPR FTA-ABS TPHA Primary 70-80 85-100 65-85 Secondary 100 100 100 Latent/Late 60-70 95-100 95-100
Other tests Enzyme immunoassays Rapid agglutinationa test Western blotting
Congenital syphilis IgM immunoblotting- presence of IgM in neonates confirm diagnosis. Best way of monitoring is with serial quantitative non treponemal tests. Most reliable is test mother at time of birth
Neurosyphilis VDRL is preferred reagin test Confirmed with TPHA
Molecular techniques New age treatment with molecular techniques like PCR have made it more specific.
Treatment
TREATMENT Single inj. Of 2.4 million units of benzathine penicilliin G-adequate in early cases For latent syphilis-this amt repeated weekly for 3 wks Pts allergic to penicillin-doxycyline used Ceftriaxone-effective in neurosyphilis Penicillin treatment sometimes induces-JARISCH-HERXHEIMER REACTION-consisting of fever, malaise & exacerbation of symptoms(due to liberation of toxic products like TNF from the destruction of treponemes or due to hypersensitivity) Harmless in 1 & 2 & managed bed rest & aspirin Dangerous in gummatous,CV or neurosyphilis
Nonvenereal treponematoses ENDEMIC SYPHILIS Common in young children Primary chancre is not seen, except sometimes on nipples of mothers infected by their children Usually seen with manifestation of secondary syphilis ,such as mucous patches &skin eruptions Disease progresses to tertiary lesions ,particularly gummatous Lab diagnosis &treatment same as venereal syphilis
Yaws Causative agent is T.pallidum subspecies pertenue The primary lesion(mother jaw) is an extra genital papule which enlarges & breaks down to form ulcerating granuloma As in syphilis 2 & 3 manifestations follow Destructive gummatous lesions of the bones are common Infection by direct contact, flies may act as mechanical vectors Lab diagnosis & treatment are same as for venereal syphilis
PINTA Causative agent is T.carateum The primary lesion is an extra genital papule which does not ulcerate but develops into a lichenoid/psoriaform patch Secondary skin lesions are charecterized by hyperpigmentation/hypopigmentation Tissues other than skin are seldom effected

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Syphilis new.pptx [repaired]

  • 1. A 29 year old man came to the STD clinic complaining of multiple papules in his gentials. These papules quickly eroded and become tough. He later admitted to having unprotected sex with as ex worker
  • 2. There was regional lymphadenopathy with moderately enlarged, firm, non suppurative, painless lymph nodes or satellite buboes. O/E we noticed papules which were indurated. It was painless.
  • 3. So from the above case what can we assume Its an STD
  • 4. There after various tests It was found to be a case of Primary Syphilis Syphilis comes under
  • 5. Treponema-I Dr Ashish Jitendranath Associate Professor, Dept of Microbiology
  • 8. Ultrastructure Lipid rich outer membrane- Increased susceptibility to detergents Show hardly any antigenic variations Saprophytic spirochetes are generally coarser. Endoflagella lie inside outer membrane and inserted at tapering portion
  • 11. Cannot be grown in artificial culture media Cannot determine metabolic, physical and pathogenic features. Non pathogenic trep is Reiter strain and Noguchi strain. Virulent strains(eg. Nichols strain) has been maintained by serial passages in rabbit testicles Recently grown in tissue cultures of rabbit epithelial cells
  • 12. Epidemiology Modes of transmission Sexual contact Placenta Kissing Close contact Contaminated fresh blood Fantastic history of syphilis with exact source not known. All known contacts post diagnosis needs to be considered.
  • 13. Blood vessel and lymphatics Enters blood and dissipates to various organs in the body Pathogenesis Untreated Syphilis- Progress from 1. Primary 2. Secondary 3. Latent 4. Tertiary stages
  • 14. Clinical features ( contd ) Veneral syphilis Organism divides 30-33 hours. Generally incubation period a month. Early spirochetemia inevitably develops during this phase Left untreated at least 2/3 spontaneously clear 1/3 progress
  • 15. Those that progress after 3 weeks Bacteria multiply at initial entry site and progress to form a chancre on the genital. Painless chancre Usually single except immunocompromised patients Superficial Ulcer has clean appearance and no exudate. Painless or slightly tender to touch
  • 16. Primary syphilis Indurated and superficially ulcerated Base usually smooth, borders raised and firm and cartilaginous consistency. Known as Hard chancre Most common site penis, cervix or labia and anal canal, rectum or mouth Regional lymphadenopathy consisting of enlarged, firm, non suppurative, painless lymph nodes or satellite buboes accompanies primary lesion Chancre heals within 3-6 weeks and 2-12 weeks later the symptoms of secondary syphilis develops
  • 17. Secondary syphilis Clinically most florid stage of infection Involves skin Multiplication and wide dissemination of spirochete and last until sufficient host response develops to exert some immune control. Begins 2-8 weeks after appearance of chancre.
  • 18. Secondary syphilis Nonpruritic macular, maculopapular, papular or pustular lesions. Begin on the trunk and proximal extremities. Any surface area becomes involved. Macules evolve to papules. Other sites palms, soles, hair follicles.
  • 19. Secondary syphilis Warm, moist intertriginous areas ( perianal area, vulva, scrotum, inner aspects of thigh, skin under breast) papules enlarge, coalesce and erode to produce painless, broad, moist, gray- white to erythematous highly infectious plaques termed condylomata lata
  • 21. Secondary syphilis Constitutional symptoms are seen CNS involved in 40 % of patients. ( Headache and meningismus). Any organ involved, eg with Renal involements, syphilitis hepatis proctitis, Git Panuveitis ostieits, and otosyphilis.
  • 22. Latent syphilis Period of quiescence. No clinical manifestation Serological tests. Individuals with late latent syphilis are not considered infectious. May still transmit infection. Early latent syphlis is when clinical relapse occurs. Diagnosis during this period using serological tests.
  • 23. Late syphilis Slowly progressive destructive inflammatory disease that can affect any organ in body to produce clinical illness 5-30 or more years after initial infection. Neurosyphilis Cardiovascular syphilis Gummatous- rare granulomatous lesion of skeleton, skin and mucocutaneous tissues
  • 24. Congenital syphilis Women with early syphilis can infect her fetus much more commonly(75-90%) than with syphilis over 2yrs duration(35%) Lesions of congenital- develop 4th month of gestation when fetal immune competence starts appearing (suggests pathogenesis requires immune response from fetus) Congenital syphilis prevent if given adequate treatment Abortions normal.
  • 25. NON-VENEREAL SYPHILIS Occupationally in doctors or nurses the natural evolution is as in venereal syphilis, except that the chancre is extragenital, usually on fingers In syphilis transmitted by blood transfusion,1 chancre does not occur Transplacental transmission-any stage of pregnancy
  • 27. Specimen Collected with care. Lesion cleared with a guaze soaked in warm saline & the margins gently scraped Gentle pressure applied to the base of lesion & serum that exudes is collected Blood also is taken Serous transudate from moist lesions- Primary chancre, condyloma latum or mucous patch
  • 28. Direct examination Primary, secondary and early congenital syphilis- Immunostaining, PCR, darkfield examination Wet film prepared by exudate examined under dark ground microscope Needs to be differentiated from saprophytes Not specific and requires 104 per ml of spirochetes.
  • 29. In case lesions is cleaned with antiseptic-Direct immunofluorescent antibody staining and immunohistochemical staining better. Best observed from chancre, condyloma and mucous patches. 3 negatives before final.
  • 30. Biopsy specimen Warthin starry stain. Levaditi and Fontaina method are silver staining methods. Preferred methods of staining is immunohistochemical staining.
  • 31. MAJOR SEROLOGICAL TESTS FOR SYPHILIS A.Non-specific(Reagin Ab) tests using cardiolipin Ag (STANDARD TESTS FOR SYPHILIS) oWasserman complement fixation reaction oKahn flocculation test oVDRL test oRapid plasma reagin(RPR) oAutomated RPR oVDRL-ELISA test B. Group specific test using cultivable treponemal(Reiter strain) Ag oReiter protein complement fixation(RPCF) test
  • 32. C.Specific tests using pathogenic treponemes(T. Pallidum) Treponema pallidum Immobilisation(TPI) test Fluorescent Treponemal Antibody-Absorption(FTA-ABS) Treponema Pallidum Haemagglutination Assay(TPHA) Treponema Pallidum Enzyme Immunoassay(TP-EIA)
  • 33. VDRL TEST FOR SYPHILIS Type of slide flocculation test In this inactivated serum(heated at 56c for 30 mins) is mixed with cardiolipin Ag on a special slide & rotated for 4 mins Cardiolipin forms visible clumps on combining with reagin Ab Reaction read under low power microscope as reactive, weak or non. Monitor patients response to therapy
  • 34. RPR Common test in labs now. Employs carbon particles and read macroscopically. Black carbon particles are bound to caridolipin, when mixed with positive serum on disposable card. Agglutination is easily observed. Prozone phenomenon in upto 2% of cases especially in secondary and pregnancy
  • 36. RPR Advantages Enables the result to be read by eye Useful in field studies RPR done with unheated serum or plasma Fingerprick sample is sufficient Dis advantages Cant test CSF
  • 37. Trust-Toloudine red unheated serum test. Instead of carbon particle we use toloudine red Automated reagin antibody test-
  • 38. 4 fold change in titre important. Highest prevalence during secondary syphilis. Quantitative test should become non reactive 1 year after treatment in primary and 5 years in secondary.
  • 39. BIOLOGICAL FALSE POSITIVE(BFP) REACTIONS As cardiolipin Ag is present both in T.Pallidum and in mammalian tissues, reagin Abs may be induced by treponemal or host tissue antigens which accounts for BIOLOGICAL FALSE POSITIVE(BFP) BFP defined as positive reactions obtained in cardiolipin tests, with negative results in specific treponemal tests, in the absence of past or present treponemal infections and not by technical faults They represent non-treponemal cardiolipin antibody responses
  • 40. BFP Ab is usually IgM while Reagin Ab in syphilis is IgG Represent non treponemal cardiolipin Ab responses Clinically BFP reactions classified as acute & chronic Acute BFP-last only for weeks or months, associated acute infections, injuries or inflammatory conditions Chronic BFP-persist longer than 6 months, seen in SLE & other collagen diseases Other conditions associated BFP reactions r leprosy, malaria, relapsing fever, infectious mononucleosis, hepatitis & tropical eosinophilia
  • 41. To avoid BFP reactions, tests using cultivable treponemes(REITER STRAIN) as Ags were developed Most common-Reiter Protein Complement Fixation(RPCF) using lipopolysaccharide-protein complex Ag derived fron treponeme Sensitivity & specificity- lower than tests using T. Pallidum RPCF-generally free from BFP but gave false positive reactions GROUP SPECIFIC TREPONEMAL TESTS
  • 42. Specific test- Nichols strain TPI- Historical concept Ability of Antibody + complement to immobilize live T. pallidum visualized under darkground microscope. Flurescent treponemal antibody- Indirect Immunofluorescence test using smears prepared on slides with Nichols strain of T.Pallidum
  • 43. FTA- Absorption- Patients serum first absorbed with non pathogenic trep antigen ( sorbent ) to remove low titer, natural cross reacting antibodies Difficult to standardize hence Particulate agglutination test is preferred.
  • 45. T.PALLIDUM HAEMAGGLUTINATION ASSAY(TPHA) Uses tanned ethrocytes sensitized with a sonicated extact of T.Pallidum as Ag Test sera for TPHA are absorbed with a diluent containing components of the Reiter treponeme,rabbit testis & sheep erythrocytes Sera screened at initial dilution of 1:80 but titres of 5120 or more-common in 2stage TPHA-as specific as FTA-ABS, almost sensitive except in 1 These advantages have made TPHA-Standard Confirmatory Test
  • 46. FREQUENCY OF REACTIVE SEROLOGICAL TESTS IN UNTREATED SYPHILIS(%) Stage VDRL/RPR FTA-ABS TPHA Primary 70-80 85-100 65-85 Secondary 100 100 100 Latent/Late 60-70 95-100 95-100
  • 47. Other tests Enzyme immunoassays Rapid agglutinationa test Western blotting
  • 48. Congenital syphilis IgM immunoblotting- presence of IgM in neonates confirm diagnosis. Best way of monitoring is with serial quantitative non treponemal tests. Most reliable is test mother at time of birth
  • 49. Neurosyphilis VDRL is preferred reagin test Confirmed with TPHA
  • 50. Molecular techniques New age treatment with molecular techniques like PCR have made it more specific.
  • 52. TREATMENT Single inj. Of 2.4 million units of benzathine penicilliin G-adequate in early cases For latent syphilis-this amt repeated weekly for 3 wks Pts allergic to penicillin-doxycyline used Ceftriaxone-effective in neurosyphilis Penicillin treatment sometimes induces-JARISCH-HERXHEIMER REACTION-consisting of fever, malaise & exacerbation of symptoms(due to liberation of toxic products like TNF from the destruction of treponemes or due to hypersensitivity) Harmless in 1 & 2 & managed bed rest & aspirin Dangerous in gummatous,CV or neurosyphilis
  • 53. Nonvenereal treponematoses ENDEMIC SYPHILIS Common in young children Primary chancre is not seen, except sometimes on nipples of mothers infected by their children Usually seen with manifestation of secondary syphilis ,such as mucous patches &skin eruptions Disease progresses to tertiary lesions ,particularly gummatous Lab diagnosis &treatment same as venereal syphilis
  • 54. Yaws Causative agent is T.pallidum subspecies pertenue The primary lesion(mother jaw) is an extra genital papule which enlarges & breaks down to form ulcerating granuloma As in syphilis 2 & 3 manifestations follow Destructive gummatous lesions of the bones are common Infection by direct contact, flies may act as mechanical vectors Lab diagnosis & treatment are same as for venereal syphilis
  • 55. PINTA Causative agent is T.carateum The primary lesion is an extra genital papule which does not ulcerate but develops into a lichenoid/psoriaform patch Secondary skin lesions are charecterized by hyperpigmentation/hypopigmentation Tissues other than skin are seldom effected

Editor's Notes

  1. First case 1905 John Hunters unfortunate self-inoculation with urethral pus containing both Neisseria gonorrhoeae and T. pallidum only served to prolong misconception s, because the two diseases were considered the same for some time thereafter. However, by the mid-19th century, the cause, epidemiology, and clinical manifestations of syphilis were well known
  2. Outer membrane is lipid rich This has led to the hypothesis that this microorganism acts as a stealth organism by minimizing the number of surface membranebound targets for the hosts immune system to recognize until a sufficient number of spirochetes are present.
  3. The genome consists of a single circular chromosome of approximately 1,138,006 base pairs, which places it close to the lowest end of the range for bacteria. Unlike most pathogenic bacteria, its genome lacks apparent transposable elements, suggesting that the genome is extremely conserved and stable
  4. 11
  5. 14
  6. Unless secondarilyinfected, the ulcer has a clean appearance and no exudate; it is painless or slightly tender to the touch, a conspicuous aspect of the ulcerative
  7. The secondary or disseminated stage becomes evident 2 to 12 weeks (mean, 6 weeks) after contact. This generalized condition with parenchymal, constitutional, and mucocutaneous manifestations occurs when the greatest number of treponemes (high antigen load) is present in the body, particularly in the bloodstream The classic and most commonly recognized lesions involve the skin. Nonpruritic macular, maculopapular, papular, or pustular lesions, and combinations and variations thereof, all occur.
  8. After the secondary stage subsides, the untreated patient enters a latent period, during which the diagnosis can be made only by obtaining a positive serologic test response for syphilis. Because relapses of secondary syphilis in immunocompetent persons can occur up to 4 years after contracting syphilis, this period is divided into early latent (relapses possible) and late latent (relapses very unlikely) stages; 75% of relapses occur within the frst year and are likely a consequence of waning immunity.
  9. 21
  10. 22
  11. Cardiovascular syphilis Consist of lesions including aneurysms, chronic granulomata and meningovascular manifestation. Gummatous syphis Rare granulomatous lesion of skeleton, skin or mucocutaneous tissues. Neurosyphilis Neurological manifestation such as tabes dorsalis or general paralysis
  12. 24
  13. Direct diagnostic methods include the detection of T pallidum by microscopic examination of fluid or smears from lesions, histological examination of tissues or nucleic acid amplification methods such as polymerase chain reaction (PCR). Indirect diagnosis is based on serological tests for the detection of antibodies. Serological tests fall into two categories: nontreponemal tests for screening, and treponemal tests for confirmation
  14. 29