Updated: 8/15/2020

Treponema pallidum / Syphilis

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Snapshot

chancre of primary syphilis
  • A 35-year-old man presents to the clinic after noticing an ulcer on his penis. He is unsure how long the ulcer has been present, as he has not felt pain in the area. He denies any symptoms of discharge, rash, or dysuria. Sexual history is notable for unprotected sexual intercourse with multiple partners over the past year. On physical examination, there is a 1-cm ulcer on the underside of the penis and bilateral inguinal lymphadenopathy. Dark-field microscopy reveals motile, spiral-shaped organisms.
Introduction
  • Classification
    • Treponema pallidum
      • spirochete
  • Epidemiology
    • demographics
      • most common during years of peak sexual activity
        • most new cases in men and women aged 20-29 years
      • recent rise in syphilis cases among MSM community
    • co-infection of syphilis with HIV is high
    • location
      • genitourinary tract
    • risk factors 
      • unprotected sex
      • IV drug use and needle-sharing
  • Pathogenesis
    • mechanism
      • T. pallidum rapidly penetrates intact mucus membranes or dermal abrasions and enters the lymphatics and blood to cause systemic infection
    • transmission
      • intimate contact with infectious lesions (most common)
      • blood transfusion
      • transplacentally from infected mother to fetus
  • Associated conditions
    • cardiovascular syphilis
      • aneurysm formation
    • neurosyphilis
  • Prognosis
    • favorable prognosis for patients diagnosed with either primary or secondary syphilis
    • 20% of untreated patients with tertiary syphilis die of the disease
      • prognosis for tertiary syphilis depends on extent of scarring and tissue damage
      • with adequate treatment, 90% of patients with neurosyphilis have a favorable clinical recovery
Presentation
  • Primary syphilis
    • painless chancre  
      • indurated edge
      • can visualize treponemes in fluid from chancre using dark-field microscopy
  • Secondary syphilis
    • disseminated disease
    • diffuse, maculopapular rash that involves the palms and soles
    • condylomata lata
      • smooth, painless, wart-like white lesions on genitals
    • lymphadenopathy
    • patchy alopecia
  • Tertiary syphilis  
    • gummas 
      • chronic granulomas
    • aortitis
      • from destruction of the vasa vasorum
    • neurosyphilis
      • tabes dorsalis 
        • Affects spinal dorsal column and dorsal root ganglia resulting in loss of proprioception and vibratory sensation below the level of the lesion
    • Argyll Robertson pupil
      • pupil constricts with accommodation but is not reactive to light
    • other symptoms
      • broad-based ataxia
      • positive Romberg
      • stroke without hypertension
  • Congenital syphilis
    • facial abnormalities
      • rhagades (linear scars at angle of mouth)
      • nasal discharge
      • saddle nose
      • notched Hutchinson teeth
      • mulberry molars
      • short maxilla
    • saber shins
    • sensorineural deafness
Studies
  • Labs
    • Nonspecific serologic testing
      • VDRL (Venereal Disease Research Laboratory)
      • RPR (rapid plasma reagent)
    • Specific serologic testing
      • FTA-ABS (fluorescent treponemal antibody-absorption) 
        • use to confirm diagnosis
  • Microscopy
    • dark-field microscopy
      • visualize motile spirochetes 
VDRL FTA Interpretation
+
+
  • Active infection
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-
  • Probably false positive
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+
  • Successfully treated

Differential
  • Herpes simplex virus
    • painful genital vesicles and ulcers
  • Haemophilus ducreyi
    • painful genital ulcer with exudate
  • Lymphogranuloma venereum
    • buboes
  • Klebsiella granulomatis
    • beefy red ulcer that bleeds on contact
Treatment
  • Medical
    • penicillin
      • IM penicillin for primary or secondary syphilis and early latent syphilis
      • IV penicillin G for late latent syphilis
    • doxycycline
      • an alternative for treating early and late latent syphilis 
Complications
  • Jarisch-Herxheimer reaction
    • flu-like syndrome after starting treatment for syphilis
      • due to toxins released by killed T. pallidum
  • complications of tertiary syphilis
    • aortic insufficiency
    • tabes dorsalis
    • general paresis
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Questions (6)
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(M1.MC.13.6) A 51-year-old man presents complaining of decreased vibratory sense in his lower limbs. Physical exam reveals a widened pulse pressure and a decrescendo murmur occurring after the S2 heart sound. After further questioning, he also reports he experienced a maculopapular rash over his trunk, palms and soles many years ago that resolved on its own. In order to evaluate the suspected diagnosis, the physician FIRST tested for which of the following? Tested Concept

QID: 101465
1

Agglutination of antibodies with beef cardiolipin

56%

(19/34)

2

Indirect immunofluoresence of the patient’s serum and killed T. palladium

29%

(10/34)

3

Cytoplasmic inclusions on Giemsa stain

9%

(3/34)

4

Agglutination of patients serum with Proteus O antigens

6%

(2/34)

5

Gram negative, oxidase positive, comma shaped bacteria growing at 42 degrees C

0%

(0/34)

M 1 D

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Evidence (4)
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