SYPHILIS

Why syphilis?

BACKGROUND Treponema pallidum (spiralled spirochaete) First epidemic in Europe in 15 century Incubation – days (average 21 days) Recent outbreaks in MSM communities in Manchester and London (sauna + cruising) Often associated with HIV infection

Transmission Sexual – (primary) 30-50% infection rate Accidental inoculation Blood-borne – needle sharing, blood transfusion rare (screened, organisms die hours at 4 degrees) Transpacental (from 9/40) – more common in early syphilis

Classification Acquired Early - <2 years Primary, secondary and early latent Late - >2 years Late latent and tertiary Congenital Early - <2 years Late - >2 years

Classification Primary – anogenital ulcer is syphilitic until proven otherwise (chancre) Secondary – multisystem involvement within 2 years of infection Early latent - <2 years. Positive serology with no clinical evidence Late latent - >2 years. Positive serology with no clinical evidence Tertiary – neurosyphilis, cardiovascular syphilis, gummatous syphilis

Classification Neurosyphilis – dorsal column loss (tabes dorsalis), dementia (general paralysis of the insane) or meningovascular involvement. Cardiovascular – aortic regurgitation, aortic aneurism and angina Gummatous – inflammatory nodules/ plaques that may be locally destructive

DIAGNOSIS RPR TPPA CLINICAL DIAGNOSIS ELISA EIA IgM/IgG PCR

DIAGNOSIS Dark ground – for suspicious ulcers where empirical treatment not given – dark ground for 3 consecutive days PCR – of swab if chancre in oropharynx or where dark ground unsuccessful ELISA (IgG/IgM/IgA) – if positive then further testing needed TPPA - specific treponal test to confirm ELISA RPR – non specific test to aid staging of infection + monitor response to treatment If suspect recent infection – ELISA IgM positive in those previously uneffected Does not differentiate between other treponemal infection Repeat all tests a week following positive results

DIAGNOSIS EIA IgM/IgGTPPARPR Primary chancre+++1:32 Secondary++++1:128 Early latent+++1:8 Late latent++1:2/neat +/neg Tertiary++1:2/neat +/neg Past treated++1:2/neat +/neg False positive+-neg False positive-- +

TREATMENT Benzathine penicillin 2.4 MU IM x 1 STAT Amoxicillin 500mg TDS + Probenecid 500mg QDS PO for 14/7 Penicillin allergy! Consider desensitisation Doxycycline 100mg BD x 21/7

Partner notification Primary – partners within last 3/12 Secondary – partners within last 6/12 Early latent – partners within last 2 years Late – as many as you can remember! Epidemiological treatments – all primary, secondary and early latent contacts. Serological testing at initial visit, 6/52 and 3/12

BASICALLY, IT’S COMPLICATED DON’T BE AFRAID TO CONTACT YOUR FRIENDLY LOCAL GUM CONSULTANT