What you need to know about Syphilis.

Syphilis.

Syphilis is one of the infections that cause genital ulcers but it is different from chancroid in that it follows serious disease stages as it advances. Also the mode of transmission is slightly different, although the main mode is sexual contact.

Causative Organisms.

A spirochete organism called treponema pallidum causes syphilis. As you already know, the most common mode of transmission is sexual contact. However, it can also be transmitted from the mother to the unborn baby. This is known as vertical transmission and may lead to congenital syphilis. It also can be acquired by coming into physical contact with a patient in the secondary stage of infection that has mucosal or cutaneous lesions and through blood transfusion.

Syphilis can be transmitted through:

·         Sexual contact

·         Blood transfusion

·         Vertical transmission

·         Physical contact

The clinical features will depend on the stage of infection the patient presents himself or herself in. As mentioned earlier, there are four stages of syphilis namely primary, secondary, latent
and tertiary.

The stages of infection will be addressed individually.

Primary Syphilis.

After an incubation period of 10 to 90 days, a primary chancre develops at the site of inoculation. The chancre is typically painless, indurated with a clean base and raised edges and does not bleed on contact, although it oozes clear fluids containing Treponema pallidum. At this stage there is usually one lesion. In a female the chancre is on the cervix or the vulva, while in the male the lesion is most commonly on the gland penis, the foreskin, and the coronal sulcus or on the penile shaft. The primary chancre resolves spontaneously if left untreated over several weeks but disease progresses to the secondary stage.

Secondary Syphilis.

This stage follows a few weeks or months after the appearance of the primary chancre. It is during this stage that the micro-organisms begin to affect other systems in the body. Also, it is at this stage that signs and symptoms become manifest. These include skin rashes that take different forms like papular, macular or pustular. In moist areas of the body, soft, raised condylomata lata may be seen. These condylomata lata do not itch.

There may also be patches on the mucous or oral ulceration, sometimes referred to as snail track ulcer. Also, in addition to its cutaneous manifestation, secondary syphilis may present with fever and general malaise as a result of systemic illness. There could also be generalized lymphadenopathy, nephritis, hepatitis, meningitis or uveitis. These lesions generally resolve after several weeks but the disease progresses to the next stage.

Latent Syphilis.

In the absence of adequate treatment, the disease enters in latent stage. At this stage there are no clinical manifestations but there is history of syphilis and a blood test will give positive serological evidence. This patient is liable to develop tertiary syphilis in the future.

Tertiary Syphilis.

This is the last stage and it accounts for the morbidity and mortality of syphilis. It begins during the third to fifth year of disease and sometimes it takes an extended period of time to manifest. Lesions of tertiary syphilis fall into three categories, namely, gamma, cardiovascular disease, and central nervous system disease.

Gamma Lesions.

The gamma lesions are painless ulcers with little or no inflammation, which sometimes affect bones, making them fragile.

Cardiovascular lesions.      

The lesions affect the aorta and may cause aortitis or aortic valve disease. They also cause coronary ostial occlusion.

Neurological lesions.

The micro-organisms cross the blood brain barrier to reach the cerebrospinal fluid (CSF) and cause symptomatic neurosyphilis, presenting as epilepsy, hydrocephalus, general paralysis of the insane, syphilitic meningo-encephalitis, cranial nerve palsy or dementia.
There could also be asymptomatic neutrosyphilis where the patient is clinically normal, yet the cerebral spinal fluid (CSF) shows the presence of treponema pallidum.

Congenital Syphilis.

As mentioned earlier if an infected pregnant woman is not treated, she is likely to pass the infection to the foetus in utero through the placenta barrier and therefore, the baby will be born already infected. This type of disease is referred to as congenital syphilis and is acquired through vertical transmission. Signs of congenital syphilis in a neonate include syphilitic pemphigus, (which is highly contagious) anaemia, jaundice, hepatospleenomegaly, cleft lip and cleft palate. In addition, there may be ulcers of the nasoperiosteum leading to watery nasal discharge.

The babies are born small and they do not thrive well. At birth the baby might appear normal but later develops the characteristic rash affecting the soles and palms, then persistent nasal discharge, which is sometimes blood stained. This progresses to anaemia, jaundice and hepatospleenomegaly. The prognosis is poor but the few who live longer or reach adolescent age develop late congenital syphilis, which is like tertiary syphilis in adults. Those who reach this stage, manifest in bone and dental abnormalities, and inflammatory lesions of the cornea (interstitial keratitis).

Diagnosis.

This will start with the history given by the patient. It is followed by a physical examination. This may reveal an ulcer in the genital region suggestive of syphilis but clinically it could be impossible to distinguish syphilitic primary chancre from other genital ulcers. This is why you should use the NASCOP Syndromic Flow Chart for Genital Ulcer Disease to treat all genital ulcer diseases. However, if there is no improvement, you should refer the patient for further investigation. In serological diagnosis, that is, blood tests, you may receive positive results, which are normally reported as VDRL, which is Venereal Disease Research Laboratory Test. This will indicate the presence of treponema antibody, but in vertical transmission, a positive maternal test gives sufficient reason to start the neonate on treatment.

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