1. Syphilis – Clinical Aspects of Primary Syphilis Thad Zajdowicz, MD, MPH Medical Director, STD/HIV Program Chicago Dept of Public Health

3. Why a lecture on syphilis? Why a lecture on syphilis? Although syphilis is an eminently treatable disease, its continuing occurrence illustrates that our control efforts still need to be improved. The disease remains elusive clinically even today, and unless thought of and sought for can silently cause disease as it has for centuries. Further, control of syphilis is vital because of its interactions with HIV. This lecture will focus on primary syphilis.

4. Objectives To review the pathogenesis of primary syphilisTo review the pathogenesis of primary syphilis To demonstrate the clinical features of primary syphilisTo demonstrate the clinical features of primary syphilis To illustrate clinical variants of primary syphilisTo illustrate clinical variants of primary syphilis

5. Clinical Stages Syphilis is conventionally divided into several stages:Syphilis is conventionally divided into several stages: –Primary –Secondary –Latent –Late, or tertiary This lecture will focus on primary syphilisThis lecture will focus on primary syphilis

6. Treponema pallidum

7. Pathogenesis Infectious dose unknown in humansInfectious dose unknown in humans –In rabbits, experimental infection induced with as few as 4 spirochetes –Estimated average inoculum 500- 1000 in humans Inoculation may occur at any body siteInoculation may occur at any body site –Eternal genitalia most frequent –Mouth, anus, cervix quite common –Other sites also well described

8. Pathogenesis T. pallidum divides every 30-33 hrsT. pallidum divides every 30-33 hrs Incubation periodIncubation period –Primary syphilis – median 21 days, range 3-90 days The most prominent histopathological findings are arteritis and periarteritis in affected tissuesThe most prominent histopathological findings are arteritis and periarteritis in affected tissues

9. Primary syphilis - chancre

10. Chancre characteristics Indolent, “punched out” appearanceIndolent, “punched out” appearance InduratedIndurated PainlessPainless Raised borderRaised border Red, smooth baseRed, smooth base Scant serous secretionsScant serous secretions

11. Chancre characteristics Chancre usually solitary, but multiple lesions can occurChancre usually solitary, but multiple lesions can occur May occur at any site in the genital tract:May occur at any site in the genital tract: –coronal sulcus, glans, frenum, prepuce, shaft of penis, anorectal area, fourchette, vulva, cervix May occur in the oropharyngeal area:May occur in the oropharyngeal area: –lip, tongue, tonsil And may occur wherever treponemes are inoculatedAnd may occur wherever treponemes are inoculated

12. Penile Chancre

15. Rolled Edges

16. Crusted Chancre

17. Chancres – 18 th Century

18. Multiple Chancres

19. Primary Chancre - Labial

20. “Kissing” Chancres

22. Perianal Chancre

23. Chancre of the Tongue

24. Oral Chancre - Lip

25. Chancre of Hard Palate

26. Chancre of the Lip

27. Facial Chancre

29. Digital Chancre

30. Conclusions The typical primary syphilitic chancre is solitary, indurated, and painless, but many clinical variants occurThe typical primary syphilitic chancre is solitary, indurated, and painless, but many clinical variants occurmany clinical variantsmany clinical variants Most chancres are genital, oral, or perianal, but may occur anywhere T. pallidum is inoculatedMost chancres are genital, oral, or perianal, but may occur anywhere T. pallidum is inoculated The primary histopathology seen in syphilis is arteritis and periarteritisThe primary histopathology seen in syphilis is arteritis and periarteritis

31. Sources of Information The following sites are useful if more information on syphilis is sought: www.cdc.govwww.cdc.govCenters for Disease Control www.cdc.gov www.who.intwww.who.intWorld Health Organization www.who.int www.ashastd.orgwww.ashastd.org American Social Hygiene Assoc www.ashastd.org www.vnh.orgwww.vnh.orgVirtual Naval Hospital www.vnh.org