Diagnostic Tests Definitive: darkfield microscopy or DFA DFA- from scraping of lesions Darkfield not readily available High false negative Presumptive diagnosis with treponemal and nontreponemal tests Must use BOTH Nontreponemal test for screening Treponemal test to establish presumptive dx

Nontreponemal Tests VDRL Venereal Disease Research Lab RPR Rapid Plasma Reagin ART Automated Reagin Test Inexpensive, rapid, quantitative results (Ab titer) Monitor response to therapy Must confirm positives with treponemal test Attributed to Albrecht Dürer (1496). It is possible that this could be an early work of Durer, or just as likely the work of his master, Wolgemut. The 1484 refers to a planetary conjunction, not the date of the print. The appearance of Scorpio indicates that the author of the medical tract of which this is an illustration regarded the disease as the product of unfavourable planetary alignment. They didn't call it syphilis then, referring to it as the 'French' or 'Neopolitan' disease. The two coats of arms to the left and the right are those of the city of Nürnberg

Nontreponemal Tests False Positives: viral infections, lymphoma, TB, endocarditis, connective tissue dz, pregnancy, IV drug use, Wharton jelly contamination of cord. Do not delay treatment awaiting confirmation Adequate treatment: 4 fold titer decrease by 6mos Negative by 1yr (congenital 2yrs) Relapse: 4 fold increase in titer

Nontreponemal Tests Low-titer false-positive nontreponemal test may be seen in pregnancy Persistently negative treponemal test confirms false positive

Treponemal Tests FTA-ABS Fluorescent Treponemal Antibody Absorption TP-PA T pallidum particle agglutination Most pts remain positive for life Correlate poorly with dz activity False positives with other spirochetal diseases Differentiate by using VDRL Yaws, pinta, leptospirosis, rat-bite fever, relapsing fever, Lyme dz

CSF Evaluation VDRL test of choice Highly specific, but insensitive Negative result does not R/O neurosyphilis Reactive test may be result of antibodies crossing blood-brain barrier Elevate CSF WBC and protein Treatment of congenital syphilis nearly always necessitates treatment of CNS involvement*

All patients who have syphilis should be tested for: HIV

Screening During Pregnancy VDRL or RPR early and again at delivery In areas of high prevalence screen also at 28WGA Any woman delivering stillborn >20WGA

Treatment of pregnant woman PCN G 2.4 million Units IM weekly X3wks Treated 4wks prior to delivery 4fold decrease in 6mos There were originally no effective treatments for syphilis. The Spanish priest Francisco Delicado wrote El modo de adoperare el legno de India (Rome, 1525) about the use of Guaiacum in the treatment of syphilis. He himself suffered from syphilis.[citation needed] Nicholas Culpeper recommended the use of heartsease (wild pansy), an herb with antimicrobial activities.[37][not in citation given] Another common remedy was mercury: the use of which gave rise to the saying "A night in the arms of Venus leads to a lifetime on Mercury".

Treatment of Newborn Followup Aqueous Penicillin G For neurosyphilis 50,000 U/kg IV q12 X10 days For neurosyphilis Add 3 weekly doses IM Nontreponemal test q2mos until decreases 4 fold If increasing or perisitently stable titers 6-12mos after treatment Reevaluate including CSF, 10-days penicillin Followup

Hutchinson's triad is named after Sir Jonathan Hutchinson (1828–1913) Hutchinson's triad is named after Sir Jonathan Hutchinson (1828–1913). It is a common pattern of presentation for congenital syphilis, and consists of three phenomena: interstitial keratitis , Hutchinson incisors, and eighth nerve deafness.[1]

Image 128_07. Syphilis Newborn with congenital syphilis Image 128_07. Syphilis Newborn with congenital syphilis. Note the marked generalized desquamation. Red Book Online Visual Library, 2009. Image 128_07. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_11. Syphilis Newborn with congenital syphilis with cutaneous ulceration (luetic gumma). These lesions are highly infectious. Red Book Online Visual Library, 2009. Image 128_11. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_21. Syphilis Congenital syphilis in a 2-week-old infant boy with marked hepatosplenomegaly. The infant kept his upper extremities in a flail-like position because of painful periostitis. Red Book Online Visual Library, 2009. Image 128_21. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_42. Syphilis The face of a newborn infant displaying pathologic morphology indicative of "Congenital Syphilis" with striking mucous membrane involvement. Red Book Online Visual Library, 2009. Image 128_42. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_04. Syphilis Newborn with congenital syphilis with bleeding from the nares and tender swelling of the wrists and elbows secondary to Luetic periostitis. Red Book Online Visual Library, 2009. Image 128_04. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_13. Syphilis Neonate with congenital syphilis with metaphyseal osteomyelitis. Note radiolucent distal radius and ulna with cupping of the distal ulna. Red Book Online Visual Library, 2009. Image 128_13. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_30. Syphilis This photograph depicts the presence of a diffuse stromal haze in the cornea of a female patient, known as interstitial keratitis (IK), which was due to her late-staged congenital syphilitic condition. Interstitial keratitis, which is an inflammation of the cornea's connective tissue elements, and usually affects both eyes, can occur as a complication brought on by congenital, or acquired syphilis. IK usually occurs in children older than two years of age. Red Book Online Visual Library, 2009. Image 128_30. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_06. Syphilis A 3-day-old neonate with severe Luetic pneumonia. Red Book Online Visual Library, 2009. Image 128_06. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_16. Syphilis Congenital syphilis with a pathologic fracture of the proximal humerus and the distal femur. Red Book Online Visual Library, 2009. Image 128_16. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_33. Syphilis A photograph of Hutchinson's Teeth resulting from congenital syphilis. Hutchinson's Teeth is a congenital anomaly in which the permanent incisor teeth are narrow and notched. Note the notched edges and "screwdriver" shape of the central incisors. Red Book Online Visual Library, 2009. Image 128_33. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Fig 3.6. Algorithm for evaluation and treatment of infants born to mothers with reactive serologic tests for syphilis. Red Book Online Visual Library, 2009. Image FIGURE3F. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics

Image 128_47. Syphilis Primary Secondary Syphilis Incidence by State - 2006 Red Book Online Visual Library, 2009. Image 128_47. Available at: http://aapredbook.aappublications.org/visual. Copyright ©2009 American Academy of Pediatrics