2. Classification of sexually transmitted diseases. Primary syphilis. Diagnostic tests for syphilis. Lector: M. Shkilna

3. CONTENT Causative organism of STD. Causative organism of STD. Clinical presentation of syphilis. Clinical presentation of syphilis. Characteristics of Treponema pallidum. Characteristics of Treponema pallidum. The mode of transmission. The mode of transmission. Pathogenesis of T. pallidum. syphilis. Classification of syphilis. Chard chancre and lymphadehopathy. Chard chancre and lymphadehopathy. Complications of hard chancre. Complications of hard chancre. Atypical forms of chancre. Atypical forms of chancre. Diagnosis and differential diagnosis of syphilis. Diagnosis and differential diagnosis of syphilis. Diagnostic tests for syphilis. Sensitivity & specificity of serologic tests for syphilis.

4. Common STDs Bacterial diseases Bacterial diseases Chlamydia (CT)Chlamydia (CT) Gonorrhea (GC)Gonorrhea (GC) SyphilisSyphilis Trichomoniasis (Trich)Trichomoniasis (Trich) Viral diseases Viral diseases Human Papillomavirus (HPV)Human Papillomavirus (HPV) Genital herpes (HSV-2 or HSV-1)Genital herpes (HSV-2 or HSV-1) Hepatitis BHepatitis B HIVHIV

5. Sexually Transmitted Diseases Diseases Causative organism Syphilis Treponema pallidum Chancroid Heamophilus ducreyi Donovanosis Calymmatobacterium granulo- matis Lymphogranuloma venereum Chlamidia trachomatis Gonorrhea Neisseria gonorrhoeae Non-gonococcus genital infection Chlamidia trachomatis; Ureaplasma urealyticum; Trichomonas vaginalis

6. Sexually Transmitted Diseases Genital ulcers Herpes Herpes Syphilis Syphilis Chancroid. Chancroid. Urethritis and Cervicitis Gonococcal infection Gonococcal infection Nongonococcal urethritis ( Chlamidia, etc.). Nongonococcal urethritis ( Chlamidia, etc.). Vaginal discharge Trichomoniasis Trichomoniasis Candidiasis Candidiasis Bacterial vaginosis ( Mycoplasma hominis, anaerobic bacteria- Prevotella sp.,Gardnerella vaginalis). Bacterial vaginosis ( Mycoplasma hominis, anaerobic bacteria- Prevotella sp.,Gardnerella vaginalis).Papules Warts Warts Molluscum contagiosum. Molluscum contagiosum.

7. Clinical Presentation PrimarySecondary Tertiary Acquired Congenital Syphilis

8. SYPHILIS is a sexually transmitted disease caused by the bacterium Treponema pallidum. Can be: early and late. Treponema pallidum may infect any organ ( skin, mucous membrane, lymphatic nodes, inner organs), causing an infinite number of clinical presentations; thus the old adage, Treponema pallidum may infect any organ ( skin, mucous membrane, lymphatic nodes, inner organs), causing an infinite number of clinical presentations; thus the old adage, ’’ he who knows syphilis knows medicine.’’

9. Treponema pallidum corkscrew shaped, 0,25 micron in diameter; corkscrew shaped, 0,25 micron in diameter; can be observed only by dark-field microscopy as a shining, silver corkscrew, against a dark background, with characteristic movements of propulsion, rotation on its own axis and angulations; can be observed only by dark-field microscopy as a shining, silver corkscrew, against a dark background, with characteristic movements of propulsion, rotation on its own axis and angulations; reproductive time is estimated to be 30 to33hours (in contest to most bacteria, which replicate every 30 minutes); reproductive time is estimated to be 30 to33hours (in contest to most bacteria, which replicate every 30 minutes); the Gram stain cannot be used, and growing the bacteria is difficult; the Gram stain cannot be used, and growing the bacteria is difficult; is not stable in outside; is not stable in outside; it is very sensitive to dehumidification; it is very sensitive to dehumidification; it is very sensitive to boiling; it is very sensitive to boiling; it is very sensitive to disinfectants; it is very sensitive to disinfectants; usually enter the body through minute abrasions in the body, either on the skin or mucous membrane. usually enter the body through minute abrasions in the body, either on the skin or mucous membrane.

10. The mode of transmission can be: Sexual, which is the most important mode of infection. Sexual, which is the most important mode of infection. Kissing the genitalia can produce extra- genital chancres on the lips, fingers and nipples. Kissing the genitalia can produce extra- genital chancres on the lips, fingers and nipples. Sexual perversion( homosexual and orogenital contacts ). Sexual perversion( homosexual and orogenital contacts ). Accidental inoculation. Accidental inoculation. Through contaminated blood. Through contaminated blood. Transplacental infection, from an infected mother to the fetus. Transplacental infection, from an infected mother to the fetus. During delivery as the baby passes through an infected canal. During delivery as the baby passes through an infected canal.

11. Pathogenesis of T. pallidum  Tissue destruction and lesions are primarily a consequence of patient’s immune response  Syphilis is a disease of blood vessels and of the perivascular areas  In spite of a vigorous host immune response the organisms are capable of persisting for decades Infection is neither fully controlled nor eradicated In early stages, there is an inhibition of cell-mediated immunity

12. Pathogenesis of T. pallidum

13. Syphilis Penis, anus, vagina, mouth, breasts Penis, anus, vagina, mouth, breasts PRIMARY SPHYHILIS PRIMARY SPHYHILIS Chancre 3 weeks, red bumpChancre 3 weeks, red bump Bump breaks, depression heals, no painBump breaks, depression heals, no pain SECONDARY SYPHILIS SECONDARY SYPHILIS Rash on body, feet and palms, painlessRash on body, feet and palms, painless TERTIARY SYPHILIS TERTIARY SYPHILIS 3-40 years3-40 years Heart failure, liver damage, blindnessHeart failure, liver damage, blindness Ruptured blood vesselsRuptured blood vessels

14. Early syphilis A-Primary syphilis: Primary syphilis of genital organs. Primary syphilis of genital organs. Primary syphilis of anal zone ( zone of rectum). Primary syphilis of anal zone ( zone of rectum). Primary syphilis of other localization. Primary syphilis of other localization. B-Secondary syphilis: Secondary syphilis of the skin and the mucous membranes. Secondary syphilis of the skin and the mucous membranes. Other forms of Secondary syphilis. Other forms of Secondary syphilis. C-Early latent syphilis:

15. LATE SYPHILIS 1. Cardio-vascular syphilis. 1. Cardio-vascular syphilis. 2. Neuro- syphilis. 2. Neuro- syphilis. 3. Late latent syphilis. 3. Late latent syphilis. 4. Late muco -cutaneous damage. 4. Late muco -cutaneous damage.

16. CONGENITAL SYPHILIS Early congenital syphilis: occur before the age of 1 year; occur before the age of 1 year; occur in children from 1 to 4 year. occur in children from 1 to 4 year. Late congenital syphilis: a) late syphilitic ophtalmopathy (involvement of the eyes); a) late syphilitic ophtalmopathy (involvement of the eyes); b) other forms of the late congenital syphilis (involvement of the skin, mucous membrane, nervous system, latent syphilis). b) other forms of the late congenital syphilis (involvement of the skin, mucous membrane, nervous system, latent syphilis).

17.  Primary disease process involves invasion of mucus membranes, rapid multiplication & wide dissemination through perivascular lymphatics and systemic circulation Occurs prior to development of the primary lesion  10-90 days (usually 3-4 weeks) after initial contact the host mounts an inflammatory response at the site of inoculation resulting in the hallmark syphilitic lesion, called the chancre (usually painless) Chancre changes from hard to ulcerative with profuse shedding of spirochetes Swelling of capillary walls & regional lymph nodes w/ draining Pathogenesis of T. pallidum (cont.) Primary Syphilis

18. PRIMARY SYPHILIS PRIMARY SYPHILIS THE MAIN SYMPTOMS ARE: HARD CHANCRE HARD CHANCRE LYMPHADENOPATHY LYMPHADENOPATHY

19. HARD CHANCRE Begins as a single, painless, well defined, regular or indurate (button-like) red brown papule plaque, from 0,3-to 2,0 cm, which may ulcerate. The ulcer has a clean floor which oozes clear serum on pressing, with a firm indurate border. Begins as a single, painless, well defined, regular or indurate (button-like) red brown papule plaque, from 0,3-to 2,0 cm, which may ulcerate. The ulcer has a clean floor which oozes clear serum on pressing, with a firm indurate border. The base is clean, with a scant, yellow, serous discharge and pink areola. The base is clean, with a scant, yellow, serous discharge and pink areola. Painful ulcers, multiple ulcers, secondarily infected ulcers, and non-indurate ulcers are variations of the classic chancre. Painful ulcers, multiple ulcers, secondarily infected ulcers, and non-indurate ulcers are variations of the classic chancre.

20. “Kissing chancres”

21. Primary syphilis - chancre

22. Facial Chancre

23. Multiple Chancres

24. Primary Chancre - Labial

25. Chancre of the Tongue

26. Chancre of Hard Palate

27. Chancre of the Lip

28. PRIMARY SYPHILIS CHANCRE

29. LYMPHADENOPATHY Spotty (small and rubbery firm, like lead shots). Spotty (small and rubbery firm, like lead shots). It is develops in 50- 85% of patients approximately 1 week after the appearance of the primary ulcer. It is develops in 50- 85% of patients approximately 1 week after the appearance of the primary ulcer. Супутній бубон

30. Atypical forms of chancre Amygdalate Indurate edema Panarhicium

31. Complications of hard chancre ( in cases of non-rational therapy) 1. Balanitis. 1. Balanitis. 2. Phimosis. 2. Phimosis. 3. Paraphimosis. 3. Paraphimosis. 4. Gangrene. 4. Gangrene. 5. Phagedenism. 5. Phagedenism.

32. Complications of hard chancre Balanitis

33. Balanopostatis

34. Phimosis

35. Paraphimosis

36. Gangrene

37. Phagedenism

38. Course of primary syphilis Sero-negative, when V.D.R.L is negative (3-4 weeks). Sero-negative, when V.D.R.L is negative (3-4 weeks). Sero-positive, when V.D.R.L is positive (next 3-4 weeks). Sero-positive, when V.D.R.L is positive (next 3-4 weeks).

39. Diagnosis is based upon : Diagnosis is based upon : Clinical features : Incubation period of 9-90 days, following high- risk sexual behavior. Incubation period of 9-90 days, following high- risk sexual behavior. Single, indurate (button-like ), painless clean- looking ulcer. Single, indurate (button-like ), painless clean- looking ulcer. Regional lymphadenopathy with discrete, rubbery nodes. Regional lymphadenopathy with discrete, rubbery nodes.Investigations: Demonstration of T. Pallidum on DGI. Demonstration of T. Pallidum on DGI. The fluorescent antibody test ( F.T.A) The fluorescent antibody test ( F.T.A) Positive V.D.R.L. after 2-4 weeks after the onset of primary chancre. Positive V.D.R.L. after 2-4 weeks after the onset of primary chancre.

40. Differential Diagnosis 1- Chancroid: (Haemophilus Ducreyi) 1- Chancroid: (Haemophilus Ducreyi) Soft chancre, painful, multiple, bleed easily, L.N. painful and may suppurate.Soft chancre, painful, multiple, bleed easily, L.N. painful and may suppurate. Short IP (2-5 days).Short IP (2-5 days). 2- LGV: (Chlamydia trachomatis) 2- LGV: (Chlamydia trachomatis) Ulcer transient, rapidly disappearUlcer transient, rapidly disappear LN enlarged, painful, matted may fistulateLN enlarged, painful, matted may fistulate 3- Genital herpes: 3- Genital herpes: Recurrent, shallow and painful ulcers.Recurrent, shallow and painful ulcers. LN: may enlarged and tender.LN: may enlarged and tender. 4- Other ulcers: 4- Other ulcers: Traumatic ulcer, tumors, pyogenic ulcers.Traumatic ulcer, tumors, pyogenic ulcers.

41. Diagnostic Tests for Syphilis NOTE: Treponemal antigen tests indicate experience with a treponemal infection, but cross-react with antigens other than T. pallidum ssp. pallidum. (Original Wasserman Test)

44. Dark field Microscopy of Treponema pallidum

45. Syphilis Serology Non-treponemal tests Non-treponemal tests VDRL (Venereal Disease Research Laboratory)VDRL (Venereal Disease Research Laboratory) RPR (Rapid Plasma Reagin)RPR (Rapid Plasma Reagin) TRUST (Toluidine Red Unheated Serum Test)TRUST (Toluidine Red Unheated Serum Test) USR (Unheated Serum Reagin)USR (Unheated Serum Reagin) Treponemal tests Treponemal tests TP-PA (Treponema Pallidum Particle Agglutination) FTA-abs (Fluorescent Treponemal Antibody - Absorbed) EIA (Enzyme Immunoassay)

47. Sensitivity & Specificity of Serologic Tests for Syphilis

48. Conditions Associated with False Positive Serological Tests for Syphilis

49. THANKS – QUESTIONS?