Cause
- By spirochete Treponema pallidum
Stages
Primary syphilis
- <3 weeks
- Localized disease presenting with painless chancre.
- Use fluorescent or dark-field microscopy to visualize treponemes in fluid from chancre.
- VDRL positive in ~80%.
Secondary syphilis
- Disseminated disease (secondary: systemic)
- Constitutional symptoms
- Maculopapular rash (including palms and soles)
- Condylomata lata (smooth, painless, wartlike white lesions on genitals)
- Lymphadenopathy
- Patchy hair loss
- Evaluation
- Dark field microscopy
- Serologic testing: VDRL/RPR (nonspecific)
- Latent syphilis (positive serology without symptoms) may follow.
- Confirm diagnosis with specific test (eg, FTA-ABS).
Tertiary syphilis
- (Chronic inflammation) (>3 yrs)
- Signs & symptoms
- Gummas (chronic granulomas)
- Cardiovascular syphilis
- Aortitis (vasa vasorum destruction)
- Neurosyphilis (25% of cases)
- Occurs after 7 years
- Characterized by
- Subacute or chronic meningitis with perivascular lymphocytes,
- Huebner arteritis with intimal proliferation and vessel obliteration,
- Multiple ischemic strokes @
- Basal ganglia
- MCA territory
- A slowly progressive parenchymatous degenerative disease of the dorsal column and dorsal root of the spinal cord as a result of syphilis
- Occurs after 15–20 years
- Characterized by
- Myelopathy from meningeal fibrosis.
- There is mainly dorsal root and posterior column involvement,
- W-shaped demyelination in the thoracic and lumbar spinal cord from the posterior horns inward
- Signs & symptoms
- Lightning-like pains
- Sensory ataxia
- Urinary incontinence
- Decreased lower limb deep tendon reflexes
- Decreased proprioception
- Dec. vibratory sense
- Positive Romberg test
- Argyll Robertson pupil (90%, constricts with accommodation but is not reactive to light).
- Ptosis
- Optic atrophy
- Charcot joints of the hip, knee, and ankle
- Occurs after 15 years
- Characterized by
- Invasion into the parenchyma with chronic encephalitis, atrophy, and gummas with nonsuppurative necrotic debris,
- Progressive physical and mental deterioration
- Argyll Robertson pupils.
Meningovascular syphilis (lues)
Tabes dorsalis
General paresis of the insane
Congenital syphilis
- Presents with facial abnormalities
- Rhagades (linear scars at angle of mouth, black arrow in F)
- Snuffles (nasal discharge, red arrow in F)
- Saddle nose
- Hutchinson triad of
- Notched teeth
- CN VIII deafness
- Interstitial keratitis
- Mulberry molars
- Short maxilla
- Saber shins
- To prevent, treat patient early in pregnancy, as placental transmission typically occurs after first trimester.
- Associated with meningovascular syphilis.
See Neurosyphilis
Diagnostic
- VDRL and RPR detects nonspecific antibody that reacts with beef cardiolipin. Quantitative, inexpensive, and widely available test for syphilis (sensitive but not specific).
- Nontreponemal tests (VDRL, RPR) revert to negative after treatment. Direct treponemal test results will remain positive.
- False-positive results on VDRL with
- Pregnancy
- Viral infection (eg, EBV, hepatitis)
- Drugs (eg, chlorpromazine, procainamide)
- Rheumatic fever (rare)
- Lupus (anticardiolipin antibody) and Leprosy
Treatment
- Penicillin G
Q&A
- What is the usual initial event in neurosyphillis?
Meningitis. Within 2 years of primary infection, 25% of all untreated patients develop acute symptomatic meningitis. Symptomatic meningitis responds to penicillin. Spinal syphilis presents as progressive paraplegia, radicular pain, and upper limb atrophy. CSF shows a lymphocytosis, increased protein, increased gammaglobulin, and a positive syphilis serology.
- What are the major symptoms and signs of tabes dorsalis?
The major symptoms are ataxia, lightning pains, and urinary incontinence; the chief signs are absent tendon reflexes at the knee and ankle, impaired vibratory and position sense in the legs and feet, and a positive Romberg sign. An Argyll-Robertson pupil is found in 90% of cases.
- What is Hutchinson triad (congenital syphilis)?
Notched teeth, deafness, and interstitial keratitis.
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