A Case Of Syphilis

A 39-year-old woman presents with a non healing ulcer over her upper lip (picture shown below) for 1 week and a new-onset rash on her trunk .
The ulcer on her upper lip was misdiagnosed as herpes simplex by the previous physician. Sexual history revealed that the patient had oral sex with a boyfriend who had a lesion on his penis and she suspected that he had been having sex with other women.

The examining physician recognized the nonpainful ulcer and rash as a combination of primary and secondary (P&S) syphilis. An RPR (rapid plasma reagin) was drawn and the patient was treated immediately with IM benzathine penicillin. The RPR came back as 1:128 and the ulcer was healed within 1 week.

Case Discussion:

Syphillis: 
Syphilis, caused by Treponema pallidum, is a systemic disease characterized by multiple overlapping stages:

• primary syphilis (ulcer), 
• secondary syphilis (skin rash, mucocutaneous lesions or lymphadenopathy),
• tertiary syphilis (cardiac or gummatous lesions), and 
• early or late latent syphilis (positive serology without clinical manifestations).
• Neurosyphilis can occur at any stage. 

Etiology: Syphilis is caused by the spirochete T. pallidum and contracted through direct sexual contact with primary or secondary lesions. Congenital syphilis can be contracted across the placenta.

Risk Factors: include:
• Sexual contact with a person with primary or secondary syphilis.
• Multiple Sexual Partners.
• Prostitution.
• Sex for drugs.
• HIV/AIDS

Clinical Features:
• Primary syphilis is associated with a chancre—Usually a nonpainful ulcer . The presence of pain does not rule out syphilis, and the patient with a painful genital ulcer should be tested for both syphilis and herpes.

• Secondary syphilis occurs when the spirochetes become systemic and may present as a rash with protean morphologies, condyloma lata, and/or mucous patches.

• Tertiary syphilis may be visualized with gummas on the skin, but many of the manifestations are internal such as the cardiac and neurologic diseases that occur (e.g., aortitis, tabes dorsalis, and iritis).
shows a gumma of the scrotum.

• Neurosyphilis can occur at any stage. Clinical symptoms include cognitive dysfunction, vision or hearing loss, uveitis or iritis, motor or sensory abnormalities, cranial nerve palsies, or symptoms of meningitis.

Diagnosis: 
• Serologic tests are either nontreponemal (RPR or VDRL), which measure anticardiolipin antibodies, or treponemal (EIA, TPPA, FTA-ABS, or MHA-TP), which measure antibodies to T. pallidum.
• There are two algorithms for laboratory testing currently in use around the world:
1. Start with a low-cost nontreponemal test and confirm a positive result with a treponemal test.
2. Start with the EIA treponemal test, followed by a nontreponemal test for confirmation.
• In 2008, the Centers for Disease Control and Prevention (CDC) recommended a treponemal EIA initially, with positive results followed by a nontreponemal test for confirmation, a strategy that detected an additional 3% of positive samples not identified in the nontreponemal–treponemal sequence.
• A nontreponemal test is required for confirmation, as a treponemal EIA indicates exposure but not active infection.
• A positive EIA with a negative RPR can be a previous treated or untreated infection, a false positive, or early primary syphilis. In this case, retest with a second treponemal test.
• Dark-field microscopy is useful in evaluating moist cutaneous lesions, such as chancre, mucous patches, and condyloma lata
• Test all patients with syphilis for HIV
• Patients with syphilis who have any signs or symptoms suggesting neurologic disease including vision or hearing need a cerebrospinal fluid (CSF) exam, a slit-lamp ophthalmologic examination, and an otologic examination to determine if neurosyphilis is present.

Treatment:  is penicillin; the dose and duration depend on the stage.