logging in or signing up syphilis d_talreja Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1236 Category: Education License: All Rights Reserved Like it (8) Dislike it (0) Added: August 18, 2010 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: orhandemirer (13 month(s) ago) i'LL take it.its very nice Saving..... Post Reply Close Saving..... Edit Comment Close By: orhandemirer (13 month(s) ago) i'LL take it.its very nice Saving..... Post Reply Close Saving..... Edit Comment Close By: priyanka1980 (15 month(s) ago) nice....wud like to download Saving..... Post Reply Close Saving..... Edit Comment Close By: priyanka1980 (15 month(s) ago) nice....wud like to download Saving..... Post Reply Close Saving..... Edit Comment Close By: dr.prakruthibv (15 month(s) ago) nice presentation...... i would like to download it Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Syphilis : Syphilis By: Dr. Deepak Kumar Introduction : Introduction An infectious disease caused by Treponema pallidum Syphilis may present as Sexually acquired Contagious disease Congenitally acquired WHO estimates Annual global incidence 12.2 million cases. Causative organism : Causative organism Spirochaete, Treponema pallidum Ssp. Pallidum Cannot be cultured Dark-field microscopy A Pale, White, Fine, Corkscrew Organism With Coils Contains flagellum And is motile Stages of syphilis : Stages of syphilis Histopathology : Histopathology Perivascular infiltration Lymphocytes and plasma cells, Intimal proliferation Arteries and veins (endarteritis obliterans) Early lesions Organisms in walls of Capillaries and lymphatics Late lesions Granulation tissue with Histiocytes, fibroblasts and epithelioid cells Spirochaetes not demonstrable Acquired Primary syphilis : Acquired Primary syphilis Primary chancre At site of treponemal invasion Usually on external genitalia Extra genital sites Typical primary sore Regular edge Smooth base Hard and button-like ulceration Up to a centimetre in diameter Acquired Primary syphilis : Acquired Primary syphilis Only single chancre (frequently) Followed by swelling of lymph nodes Heals spontaneously In 3–8 weeks Acquired Primary syphilis : Acquired Primary syphilis Acquired Primary syphilis : Acquired Primary syphilis Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Chancroid Lymphogranuloma venereum Genital herpes Erythroplasia of Queyrat Bowen’s disease Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Chancroid (Haemophilus ducreyi) A small, red papule Ulcer Rounded or oval Ragged, undermined edge, surrounded by red areola Tender and painful But not indurated Satellite ulcers Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (female) Chancroid Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Lymphogranuloma venereum (Chlamydia trachomatis) A papulovesicle develops On genitalia Chancre heals rapidly Often unnoticed. Regional lymph nodes Enlarge in 1 - 4 weeks Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Genital herpes Grouped vesicles Ulcers Preceded by malaise Painful Last for 2–3 weeks Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Erythroplasia of Queyrat Red shiny patches Mucosal penis Acquired Secondary syphilis : Acquired Secondary syphilis First appear around 8 weeks. Constitutional symptoms Fever Headache Bone Joint pains Acquired Secondary syphilis : Acquired Secondary syphilis Generalized manifestations On skin and mucous membranes Serology always positive Three common features Do not itch Coppery red Symmetrically distributed Acquired Secondary syphilis : Acquired Secondary syphilis Macular syphilide (roseolar rash) Round and oval spots Symmetrical Coppery red Depigmented spots on hyperpigmented background Leukoderma syphiliticum Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Papular syphilide Firm and round Early papules are shiny Gradually scale forms (Papulosquamous syphilide) Acquired Secondary syphilis : Acquired Secondary syphilis On moist surfaces Weeping papules with hypertrophy Face is often affected If greasy skin Palms and soles Hyperkeratotic lesions Condylomata lata Coalesced papules in perineum Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Micropapular Eruptions Corymbose syphilide Large central papule Surrounded by small satellite papules Acquired Secondary syphilis : Acquired Secondary syphilis Syphilitic Alopecia Moth-eaten patches Eyebrows and beard May be affected Acquired Secondary syphilis : Acquired Secondary syphilis Mucosal Lesions Epithelium turns grey Forms round mucous patches Coalesce to form Snail-track ulcers Acquired Secondary syphilis : Acquired Secondary syphilis Generalized lymphadenopathy Neurological involvement Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(Macular) Measles Rubella Pityriasis rosea Drug eruptions Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(Macular) Pityriasis Rosea First manifestation Herald patch In 5 -15 days Eruption in crops Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(Macular) Rubella Rash first on face Spreads to trunk and limbs Second day Face begins to clear Third day trunk cleared Fourth day Eruption on limbs fades Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (Macular) Measles Prodromal symptoms Fever, malaise Upper respiratory catarrh Conjunctivae injected Koplik’s spots Rash starts from face (4th day) Spread to other areas 6th to 10th day rash fades Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(papular) Psoriasis Lichen planus Seborrhoeic dermatitis Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(papular) Seborrhoeic dermatitis Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(papular) Psoriasis Psoriasiform lesions of syphilis condylomas mucosal lesions Are usually found Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(papular) Lichen planus Occasional cases of LP Without itching Mimic secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (condylomata lata) Haemorrhoids Condylomata acuminata Genital herpes Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (condylomata lata) Condylomata acuminata Pointed Condylomata lata Flatter Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (micropapular) keratosis pilaris Lichen scrofulosorum Trichophytide Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (micropapular) Lichen scrofulosorum Symptomless 0.5–3 mm Grouped lichenoid papules Positive tuberculin Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (micropapular) keratosis pilaris Small grey–white plugs Of keratin obstruct follicles Perifollicular erythema Often present Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (palms + soles) Psoriasis Mycoses Differential diagnosis (oral) Aphthous ulcers Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (palms + soles) Mycoses Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (palms + soles) Psoriasis Acquired Latent syphilis : Acquired Latent syphilis Vertical transmission occur Sexual transmission less likely Criteria Absent C/F Early, late or congenital syphilis Normal CSF Chest X-ray Positive serological tests Acquired Tertiary syphilis : Acquired Tertiary syphilis After latency of 20 years Late syphilis can occur Two types: Superficial or nodular syphilide Deeper gummatous syphilide Acquired Tertiary syphilis : Acquired Tertiary syphilis Superficial or nodular syphilide Lesions are protruding Firm Coppery red nodules In circinate arrangement Acquired Tertiary syphilis : Acquired Tertiary syphilis Superficial or nodular syphilide Sites Arms Back Face Symptomless Cigarette paper scarring Smooth, soft, finely wrinkled Acquired Tertiary syphilis : Acquired Tertiary syphilis Gummata (granuloma) Cutaneous plaques Central ulceration Peripheral healing Painless Tissue paper scarring Site Scalp Forehead Buttocks Pretibial Acquired Tertiary syphilis : Acquired Tertiary syphilis Multiple gummata coalesce Punched out ulcers Acquired Tertiary syphilis : Acquired Tertiary syphilis Late mucous membrane lesions Gummata attack Palate Perforation Tongue Interstitial glossitis Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis (face) Lupus vulgaris Bowen’s disease Midline granuloma Sycosis barbae Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis(trunk and limbs) Circinate psoriasis Leukaemic infiltrations Mycosis fungoides Differential diagnosis(legs) Venous ulcer Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis (trunk and limbs) Mycosis fungoides Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis(legs) Venous ulcer Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis(tongue) Scrotal tongue Acquired Cardiovascular syphilis : Acquired Cardiovascular syphilis Aortitis Asymptomatic Dilatation of ascending aorta on CXR Aortic regurgitation Left ventricular failure/Aneurysm Acquired Neurosyphilis : Acquired Neurosyphilis Asymptomatic neurosyphilis Meningeal neurosyphilis During secondary disease Meningovascular syphilis 4 to 7 years after infection Gummatous neurosyphilis Space-occupying lesion Acquired Neurosyphilis : Acquired Neurosyphilis Parenchymatous syphilis Rare Deterioration in cognitive function Psychiatric symptoms Tabetic neurosyphilis Lightning pains in lower limbs Paraesthesiae Progressive ataxia Bowel and bladder dysfunction Congenital syphilis : Congenital syphilis A woman in early contagious stage Infect her fetus Through placenta Common outcome Abortion Stillbirth or Early neonatal death Congenital syphilis : Congenital syphilis Early Late The stigmata Scars and deformities Early Congenital syphilis : Early Congenital syphilis Asymptomatic at birth Inflammation of Umbilical cord (funisitis) Syphilitic Rhinitis With discharge (T. Pallidum) Most important and frequent sign Severe nasal cartilage and bone destruction Early Congenital syphilis : Early Congenital syphilis Skin lesions Coppery red On extremities, especially Palms and soles On face Fissured (‘split’) papules at Angles of the mouth or external nares Anal condylomas Pemphigus syphiliticus Bullae on red infiltrated palms and soles Early Congenital syphilis : Early Congenital syphilis Early Congenital syphilis : Early Congenital syphilis Bone involvement Osteochondritis Lower end of tibia and fibula Very tender, painful swelling Parrot’s pseudoparalysis Disappear within the first year Syphilitic dactylitis Late Congenital syphilis : Late Congenital syphilis Characteristic facies Eruptions of skin and mucousa Like those of late acquired syphilis Skeletal developmental defects Late Congenital syphilis : Late Congenital syphilis Interstitial keratitis Commonest and most serious Clouding of the cornea Vision is affected Photophobia and pain Treatment Corticosteroid eye drops Late Congenital syphilis : Late Congenital syphilis Bone involvement Periostitis of the long bones Gumma of the palate Perforation of the hard palate Eighth-nerve deafness Common complication Often bilateral Corticosteroids Late Congenital syphilis : Late Congenital syphilis Neurosyphilis Juvenile general paralysis Between 6 and 21 years Congenital syphilisStigmata : Congenital syphilisStigmata The teeth Hutchinson’s teeth Incisors Conical Barrel shape Screwdriver teeth Congenital syphilis : Congenital syphilis Hutchinson’s triad Interstitial keratitis Hutchinson’s teeth Eighth nerve deafness Tests for syphilis : Tests for syphilis Dark-field microscopy Treponema pallidum identified from Primary Secondary Early congenital syphilis Method Sore cleaned with saline Dry and crusted lesions Scrape with currete Clear serum obtained (no red cells) Microscopy Serological tests : Serological tests Two types Non-treponemal tests Specific treponemal tests Serological tests : Serological tests Non-treponemal tests Ab to lipoidal material Response to treatment Venereal disease research laboratory (VDRL) Unheated serum reagin (USR) test Rapid plasma reagin (RPR) test Toluidine red unheated serum test (TRUST) VDRL Test : VDRL Test Basis: Flocculation test The patient’s serum mixed in Colloidal solution of cholesterol, lecithin, and cardiolipin If antibodies present Precipitate occurs After treatment Titer will drop over months Indications Screening and monitoring of therapy Evaluation Highly sensitive test 100% positive in secondary syphilis VDRL Test : VDRL Test Disadvantages 10–20% false-positive results positive test must be confirmed False-positive reactions: Diabetes mellitus cirrhosis Autoimmune diseases (lupus erythematosus, systemic sclerosis, rheumatoid arthritis), viral diseases (HIV, measles, mumps, even herpes genitalis) Pregnancy Serological tests : Serological tests Treponemal antigen tests Confirmatory Detect antibodies to Epitope of treponemes Once positive, remain positive for life T. pallidum immobilization (TPI) test Fluorescent treponemal antibody absorption test (FTA-ABS) Treponema pallidum haemagglutination assay (TPHA) Enzyme immunoassay (EIA) TPI test : TPI test Basis Serum containing ab In the presence of complement Inhibits movements of T. Pallidum Observed by dark-field microscopy Gold standard Due to high specificity TPHA test : TPHA test Basis: Sheep erythrocytes coated with Treponema pallidum antigens Incubated with patient serum If antibodies present Red cells agglutinate Indications: Screening. Evaluation: Highly specific; False positive under 0.1% Becomes positive in third week Remains positive for life of patient Screening : Screening Screening either EIA VDRL/TPHA If positive Confirm with specific test Examination of CSF : Examination of CSF Indications Neurological Treatment failure HIV infection CSF findings of neurosyphilis Mononuclear pleiocytosis Elevated total protein Positive CSF VDRL Evaluation of neonates : Evaluation of neonates Born to seropositive mothers Examination for stigmata X-ray long bones for periostitis CSF examination Management : Management Penicillin Most effective Inexpensive Excellent in all forms and stages Injectable preferred to oral Management : Management Management : Management Penicillin reactions Jarisch–Herxheimer reaction Within 24 h Acute febrile reaction Headache Myalgia Bone pains Exacerbation of skin lesions Prognosis : Prognosis Early syphilis Cure rate=95% Relapse Retreatment with double penicillin doses is recommended Thank you : Thank you FTA–ABS Test : FTA–ABS Test Basis: A slide is coated with Treponema pallidum. Patient’s serum is absorbed with nonpathogenic treponemes and then applied to slide. Antibodies bound to Treponema pallidum are identified with immunofluorescence. Indications: Confirmatory. Evaluation: Becomes positive in fourth week and remains so forever. Advantages: Very sensitive and specific. Disadvantages: Standardized reagents not available so reproducibility varies. IgM–FTA–ABS Test : IgM–FTA–ABS Test Basis: Same as FTA–ABS test, but only labeled anti-IgM antibodies are used to determine if patient has IgM antibodies against Treponema pallidum. Indications: Early diagnosis: IgM antibodies are the first to be produced; they can be found at 2weeks, before a chancre appears. Assessing disease activity: IgM production continues as long as living Treponema pallidum are present in body, so one can determine if latent phase is present or not. Evaluating therapy: The IgM–FTA–ABS test usually turns negative 1month after therapy; always within 1year IgM–FTA–ABS Test : IgM–FTA–ABS Test Diagnosis of congenital syphilis: IgM cannot cross the placenta, so if the infant has IgM antibodies, Treponema pallidum has crossed the placenta. Recognition of second infection: Increase in IgM antibodies coupled with VDRL titer increase suggests second infection without clinical signs. Advantages: Very sensitive and specific. False-positive reactions: Rheumatoid factor is an IgM antibody whose Fc portion is directed against IgG. If the patient has a positive rheumatoid factor and treated syphilis, then persistent IgG antibodies will bind to treponemes on the slide; rheumatoid factor molecules bind to them and are identified by the labeled anti-IgM. 19S–IgM–FTA–ABS Test : 19S–IgM–FTA–ABS Test Basis: If a patient has a large amount of IgG antibodies against Treponema pallidum and only a small amount of IgM, then the IgG can block the test treponemes on the slide, giving a false-negative test for IgM. To correct this, the 19S fraction of serum where IgM is found is separated out and only this portion used for testing. Indications: Negative IgM–FTA–ABS test but appropriate history. Evaluation of Serologic Tests : Evaluation of Serologic Tests Confirmation of infection with Treponema pallidum: Two positive tests with Treponema pallidum-specific tests. Blood should be re-drawn for the confirmatory testing. An endemic treponematosis must be excluded. Assessing degree of activity: IgM–FTA–ABS becomes negative when Treponema pallidum has been eliminated. VDRL titer 1:64 also suggests active disease. Second infection: Newappearance of IgM antibodies, and rapid increase in VDRL titer by 2 dilutions or more. Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis (face) Lupus vulgaris You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
syphilis d_talreja Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 1236 Category: Education License: All Rights Reserved Like it (8) Dislike it (0) Added: August 18, 2010 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: orhandemirer (13 month(s) ago) i'LL take it.its very nice Saving..... Post Reply Close Saving..... Edit Comment Close By: orhandemirer (13 month(s) ago) i'LL take it.its very nice Saving..... Post Reply Close Saving..... Edit Comment Close By: priyanka1980 (15 month(s) ago) nice....wud like to download Saving..... Post Reply Close Saving..... Edit Comment Close By: priyanka1980 (15 month(s) ago) nice....wud like to download Saving..... Post Reply Close Saving..... Edit Comment Close By: dr.prakruthibv (15 month(s) ago) nice presentation...... i would like to download it Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Syphilis : Syphilis By: Dr. Deepak Kumar Introduction : Introduction An infectious disease caused by Treponema pallidum Syphilis may present as Sexually acquired Contagious disease Congenitally acquired WHO estimates Annual global incidence 12.2 million cases. Causative organism : Causative organism Spirochaete, Treponema pallidum Ssp. Pallidum Cannot be cultured Dark-field microscopy A Pale, White, Fine, Corkscrew Organism With Coils Contains flagellum And is motile Stages of syphilis : Stages of syphilis Histopathology : Histopathology Perivascular infiltration Lymphocytes and plasma cells, Intimal proliferation Arteries and veins (endarteritis obliterans) Early lesions Organisms in walls of Capillaries and lymphatics Late lesions Granulation tissue with Histiocytes, fibroblasts and epithelioid cells Spirochaetes not demonstrable Acquired Primary syphilis : Acquired Primary syphilis Primary chancre At site of treponemal invasion Usually on external genitalia Extra genital sites Typical primary sore Regular edge Smooth base Hard and button-like ulceration Up to a centimetre in diameter Acquired Primary syphilis : Acquired Primary syphilis Only single chancre (frequently) Followed by swelling of lymph nodes Heals spontaneously In 3–8 weeks Acquired Primary syphilis : Acquired Primary syphilis Acquired Primary syphilis : Acquired Primary syphilis Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Chancroid Lymphogranuloma venereum Genital herpes Erythroplasia of Queyrat Bowen’s disease Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Chancroid (Haemophilus ducreyi) A small, red papule Ulcer Rounded or oval Ragged, undermined edge, surrounded by red areola Tender and painful But not indurated Satellite ulcers Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (female) Chancroid Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Lymphogranuloma venereum (Chlamydia trachomatis) A papulovesicle develops On genitalia Chancre heals rapidly Often unnoticed. Regional lymph nodes Enlarge in 1 - 4 weeks Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Genital herpes Grouped vesicles Ulcers Preceded by malaise Painful Last for 2–3 weeks Acquired Primary syphilis : Acquired Primary syphilis Differential diagnosis (male) Erythroplasia of Queyrat Red shiny patches Mucosal penis Acquired Secondary syphilis : Acquired Secondary syphilis First appear around 8 weeks. Constitutional symptoms Fever Headache Bone Joint pains Acquired Secondary syphilis : Acquired Secondary syphilis Generalized manifestations On skin and mucous membranes Serology always positive Three common features Do not itch Coppery red Symmetrically distributed Acquired Secondary syphilis : Acquired Secondary syphilis Macular syphilide (roseolar rash) Round and oval spots Symmetrical Coppery red Depigmented spots on hyperpigmented background Leukoderma syphiliticum Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Papular syphilide Firm and round Early papules are shiny Gradually scale forms (Papulosquamous syphilide) Acquired Secondary syphilis : Acquired Secondary syphilis On moist surfaces Weeping papules with hypertrophy Face is often affected If greasy skin Palms and soles Hyperkeratotic lesions Condylomata lata Coalesced papules in perineum Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Micropapular Eruptions Corymbose syphilide Large central papule Surrounded by small satellite papules Acquired Secondary syphilis : Acquired Secondary syphilis Syphilitic Alopecia Moth-eaten patches Eyebrows and beard May be affected Acquired Secondary syphilis : Acquired Secondary syphilis Mucosal Lesions Epithelium turns grey Forms round mucous patches Coalesce to form Snail-track ulcers Acquired Secondary syphilis : Acquired Secondary syphilis Generalized lymphadenopathy Neurological involvement Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(Macular) Measles Rubella Pityriasis rosea Drug eruptions Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(Macular) Pityriasis Rosea First manifestation Herald patch In 5 -15 days Eruption in crops Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(Macular) Rubella Rash first on face Spreads to trunk and limbs Second day Face begins to clear Third day trunk cleared Fourth day Eruption on limbs fades Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (Macular) Measles Prodromal symptoms Fever, malaise Upper respiratory catarrh Conjunctivae injected Koplik’s spots Rash starts from face (4th day) Spread to other areas 6th to 10th day rash fades Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(papular) Psoriasis Lichen planus Seborrhoeic dermatitis Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(papular) Seborrhoeic dermatitis Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(papular) Psoriasis Psoriasiform lesions of syphilis condylomas mucosal lesions Are usually found Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis(papular) Lichen planus Occasional cases of LP Without itching Mimic secondary syphilis Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (condylomata lata) Haemorrhoids Condylomata acuminata Genital herpes Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (condylomata lata) Condylomata acuminata Pointed Condylomata lata Flatter Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (micropapular) keratosis pilaris Lichen scrofulosorum Trichophytide Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (micropapular) Lichen scrofulosorum Symptomless 0.5–3 mm Grouped lichenoid papules Positive tuberculin Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (micropapular) keratosis pilaris Small grey–white plugs Of keratin obstruct follicles Perifollicular erythema Often present Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (palms + soles) Psoriasis Mycoses Differential diagnosis (oral) Aphthous ulcers Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (palms + soles) Mycoses Acquired Secondary syphilis : Acquired Secondary syphilis Differential diagnosis (palms + soles) Psoriasis Acquired Latent syphilis : Acquired Latent syphilis Vertical transmission occur Sexual transmission less likely Criteria Absent C/F Early, late or congenital syphilis Normal CSF Chest X-ray Positive serological tests Acquired Tertiary syphilis : Acquired Tertiary syphilis After latency of 20 years Late syphilis can occur Two types: Superficial or nodular syphilide Deeper gummatous syphilide Acquired Tertiary syphilis : Acquired Tertiary syphilis Superficial or nodular syphilide Lesions are protruding Firm Coppery red nodules In circinate arrangement Acquired Tertiary syphilis : Acquired Tertiary syphilis Superficial or nodular syphilide Sites Arms Back Face Symptomless Cigarette paper scarring Smooth, soft, finely wrinkled Acquired Tertiary syphilis : Acquired Tertiary syphilis Gummata (granuloma) Cutaneous plaques Central ulceration Peripheral healing Painless Tissue paper scarring Site Scalp Forehead Buttocks Pretibial Acquired Tertiary syphilis : Acquired Tertiary syphilis Multiple gummata coalesce Punched out ulcers Acquired Tertiary syphilis : Acquired Tertiary syphilis Late mucous membrane lesions Gummata attack Palate Perforation Tongue Interstitial glossitis Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis (face) Lupus vulgaris Bowen’s disease Midline granuloma Sycosis barbae Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis(trunk and limbs) Circinate psoriasis Leukaemic infiltrations Mycosis fungoides Differential diagnosis(legs) Venous ulcer Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis (trunk and limbs) Mycosis fungoides Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis(legs) Venous ulcer Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis(tongue) Scrotal tongue Acquired Cardiovascular syphilis : Acquired Cardiovascular syphilis Aortitis Asymptomatic Dilatation of ascending aorta on CXR Aortic regurgitation Left ventricular failure/Aneurysm Acquired Neurosyphilis : Acquired Neurosyphilis Asymptomatic neurosyphilis Meningeal neurosyphilis During secondary disease Meningovascular syphilis 4 to 7 years after infection Gummatous neurosyphilis Space-occupying lesion Acquired Neurosyphilis : Acquired Neurosyphilis Parenchymatous syphilis Rare Deterioration in cognitive function Psychiatric symptoms Tabetic neurosyphilis Lightning pains in lower limbs Paraesthesiae Progressive ataxia Bowel and bladder dysfunction Congenital syphilis : Congenital syphilis A woman in early contagious stage Infect her fetus Through placenta Common outcome Abortion Stillbirth or Early neonatal death Congenital syphilis : Congenital syphilis Early Late The stigmata Scars and deformities Early Congenital syphilis : Early Congenital syphilis Asymptomatic at birth Inflammation of Umbilical cord (funisitis) Syphilitic Rhinitis With discharge (T. Pallidum) Most important and frequent sign Severe nasal cartilage and bone destruction Early Congenital syphilis : Early Congenital syphilis Skin lesions Coppery red On extremities, especially Palms and soles On face Fissured (‘split’) papules at Angles of the mouth or external nares Anal condylomas Pemphigus syphiliticus Bullae on red infiltrated palms and soles Early Congenital syphilis : Early Congenital syphilis Early Congenital syphilis : Early Congenital syphilis Bone involvement Osteochondritis Lower end of tibia and fibula Very tender, painful swelling Parrot’s pseudoparalysis Disappear within the first year Syphilitic dactylitis Late Congenital syphilis : Late Congenital syphilis Characteristic facies Eruptions of skin and mucousa Like those of late acquired syphilis Skeletal developmental defects Late Congenital syphilis : Late Congenital syphilis Interstitial keratitis Commonest and most serious Clouding of the cornea Vision is affected Photophobia and pain Treatment Corticosteroid eye drops Late Congenital syphilis : Late Congenital syphilis Bone involvement Periostitis of the long bones Gumma of the palate Perforation of the hard palate Eighth-nerve deafness Common complication Often bilateral Corticosteroids Late Congenital syphilis : Late Congenital syphilis Neurosyphilis Juvenile general paralysis Between 6 and 21 years Congenital syphilisStigmata : Congenital syphilisStigmata The teeth Hutchinson’s teeth Incisors Conical Barrel shape Screwdriver teeth Congenital syphilis : Congenital syphilis Hutchinson’s triad Interstitial keratitis Hutchinson’s teeth Eighth nerve deafness Tests for syphilis : Tests for syphilis Dark-field microscopy Treponema pallidum identified from Primary Secondary Early congenital syphilis Method Sore cleaned with saline Dry and crusted lesions Scrape with currete Clear serum obtained (no red cells) Microscopy Serological tests : Serological tests Two types Non-treponemal tests Specific treponemal tests Serological tests : Serological tests Non-treponemal tests Ab to lipoidal material Response to treatment Venereal disease research laboratory (VDRL) Unheated serum reagin (USR) test Rapid plasma reagin (RPR) test Toluidine red unheated serum test (TRUST) VDRL Test : VDRL Test Basis: Flocculation test The patient’s serum mixed in Colloidal solution of cholesterol, lecithin, and cardiolipin If antibodies present Precipitate occurs After treatment Titer will drop over months Indications Screening and monitoring of therapy Evaluation Highly sensitive test 100% positive in secondary syphilis VDRL Test : VDRL Test Disadvantages 10–20% false-positive results positive test must be confirmed False-positive reactions: Diabetes mellitus cirrhosis Autoimmune diseases (lupus erythematosus, systemic sclerosis, rheumatoid arthritis), viral diseases (HIV, measles, mumps, even herpes genitalis) Pregnancy Serological tests : Serological tests Treponemal antigen tests Confirmatory Detect antibodies to Epitope of treponemes Once positive, remain positive for life T. pallidum immobilization (TPI) test Fluorescent treponemal antibody absorption test (FTA-ABS) Treponema pallidum haemagglutination assay (TPHA) Enzyme immunoassay (EIA) TPI test : TPI test Basis Serum containing ab In the presence of complement Inhibits movements of T. Pallidum Observed by dark-field microscopy Gold standard Due to high specificity TPHA test : TPHA test Basis: Sheep erythrocytes coated with Treponema pallidum antigens Incubated with patient serum If antibodies present Red cells agglutinate Indications: Screening. Evaluation: Highly specific; False positive under 0.1% Becomes positive in third week Remains positive for life of patient Screening : Screening Screening either EIA VDRL/TPHA If positive Confirm with specific test Examination of CSF : Examination of CSF Indications Neurological Treatment failure HIV infection CSF findings of neurosyphilis Mononuclear pleiocytosis Elevated total protein Positive CSF VDRL Evaluation of neonates : Evaluation of neonates Born to seropositive mothers Examination for stigmata X-ray long bones for periostitis CSF examination Management : Management Penicillin Most effective Inexpensive Excellent in all forms and stages Injectable preferred to oral Management : Management Management : Management Penicillin reactions Jarisch–Herxheimer reaction Within 24 h Acute febrile reaction Headache Myalgia Bone pains Exacerbation of skin lesions Prognosis : Prognosis Early syphilis Cure rate=95% Relapse Retreatment with double penicillin doses is recommended Thank you : Thank you FTA–ABS Test : FTA–ABS Test Basis: A slide is coated with Treponema pallidum. Patient’s serum is absorbed with nonpathogenic treponemes and then applied to slide. Antibodies bound to Treponema pallidum are identified with immunofluorescence. Indications: Confirmatory. Evaluation: Becomes positive in fourth week and remains so forever. Advantages: Very sensitive and specific. Disadvantages: Standardized reagents not available so reproducibility varies. IgM–FTA–ABS Test : IgM–FTA–ABS Test Basis: Same as FTA–ABS test, but only labeled anti-IgM antibodies are used to determine if patient has IgM antibodies against Treponema pallidum. Indications: Early diagnosis: IgM antibodies are the first to be produced; they can be found at 2weeks, before a chancre appears. Assessing disease activity: IgM production continues as long as living Treponema pallidum are present in body, so one can determine if latent phase is present or not. Evaluating therapy: The IgM–FTA–ABS test usually turns negative 1month after therapy; always within 1year IgM–FTA–ABS Test : IgM–FTA–ABS Test Diagnosis of congenital syphilis: IgM cannot cross the placenta, so if the infant has IgM antibodies, Treponema pallidum has crossed the placenta. Recognition of second infection: Increase in IgM antibodies coupled with VDRL titer increase suggests second infection without clinical signs. Advantages: Very sensitive and specific. False-positive reactions: Rheumatoid factor is an IgM antibody whose Fc portion is directed against IgG. If the patient has a positive rheumatoid factor and treated syphilis, then persistent IgG antibodies will bind to treponemes on the slide; rheumatoid factor molecules bind to them and are identified by the labeled anti-IgM. 19S–IgM–FTA–ABS Test : 19S–IgM–FTA–ABS Test Basis: If a patient has a large amount of IgG antibodies against Treponema pallidum and only a small amount of IgM, then the IgG can block the test treponemes on the slide, giving a false-negative test for IgM. To correct this, the 19S fraction of serum where IgM is found is separated out and only this portion used for testing. Indications: Negative IgM–FTA–ABS test but appropriate history. Evaluation of Serologic Tests : Evaluation of Serologic Tests Confirmation of infection with Treponema pallidum: Two positive tests with Treponema pallidum-specific tests. Blood should be re-drawn for the confirmatory testing. An endemic treponematosis must be excluded. Assessing degree of activity: IgM–FTA–ABS becomes negative when Treponema pallidum has been eliminated. VDRL titer 1:64 also suggests active disease. Second infection: Newappearance of IgM antibodies, and rapid increase in VDRL titer by 2 dilutions or more. Acquired Tertiary syphilis : Acquired Tertiary syphilis Differential diagnosis (face) Lupus vulgaris