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Updated: Jan 30 2022

Syphilis (Adult)

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  • Snapshot
    • A 41-year-old man presents to the clinic complaining of an intensely pruritic rash over his torso, back, and arms including his palms. He also describes being concerned about patchy hair loss on his scalp as well as the presence of warty growths on his penis. His sexual history is notable for frequent sexual encounters with both male and female partners without the use of condoms. Physical exam is significant for a diffuse, erythematous maculopapular rash, patchy alopecia on his scalp, wart-like white lesions on the base of his penis, and bilateral inguinal lymphadenopathy. VDRL and FTA-ABS were positive.
  • Introduction
    • Classification
      • Treponema pallidum
        • spirochete
    • Associated conditions
      • cardiovascular syphilis
        • aneurysm formation
      • neurosyphilis
  • Epidemiology
    • Demographics
      • most common during years of peak sexual activity
        • most new cases occur in men and women aged 20-29 years
      • recent rise in syphilis cases among men who have sex with men (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 mucous 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
  • 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
      • 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)
          • can test in CSF with neurologic or otologic involvement of syphilis
        • RPR (rapid plasma reagent)
      • specific serologic testing
        • FTA-ABS (fluorescent treponemal antibody-absorption)
          • use to confirm diagnosis
    • Microscopy
      • dark-field microscopy
        • visualize motile spirochetes
  • 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
          • if allergic to penicillin, patient should be desensitized
        • if patient is pregnant and allergic to penicillin, patient should be desensitized
          • high risk of stillbirth, neonatal death, and mental retardation
      • doxycycline
        • an alternative for treating syphilis in pencillin-allergic patients
      • ceftriaxone
        • an alternative for tertiary syphilis in penicillin-allergic patients
      • densensitization to penicillin
        • can be attempted for tertiary syphilis but typically done in the intensive care setting under supervision of an allergy specialist
  • Complications
    • Jarisch-Herxheimer reaction
      • flu-like syndrome after starting treatment for syphilis
        • due to toxins released by killed T. pallidum
          • symptomatic treatment (NSAIDs and acetaminophen)
    • Complications of tertiary syphilis
      • aortic insufficiency
      • tabes dorsalis
      • general paresis
  • 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 the extent of scarring and tissue damage
      • with adequate treatment, 90% of patients with neurosyphilis have a favorable clinical recovery
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