Classification of sexually transmitted diseases. General scheme of syphilis motion and laboratory investigation.

Lector: M. Shkilna

STI General Overview

What is an STI (Sexually Transmitted Infection)?

A serious infection of the reproductive organs acquired during sexual contact. They may cause painful localized symptoms such as burning and itching or a more generalized illness affecting the entire body, such as infertility, blindness or even death.

Sexually Transmitted Diseases

Diseases Syphilis Causative organism Treponema pallidum

Chancroid
Donovanosis Lymphogranuloma venereum Gonorrhea

Heamophilus ducreyi
Calymmatobacterium granulomatis Chlamidia trachomatis Neisseria gonorrhoeae

Non-gonococcus genital Chlamidia trachomatis; infection Ureaplasma urealyticum; Trichomonas vaginalis

Sexually Transmitted Diseases

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

Clinical Presentation

Syphilis
Acquired Congenital

Primary

Secondary

Tertiary

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,

he who knows syphilis knows medicine.

Spirochaetales
~~~~~~~~~~~~~~~~~~

Treponema Borrelia & Leptospira

Treponema pallidum

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; reproductive time is estimated to be 30 to33 hours (in contest to most bacteria, which replicate every 30 minutes); the Gram stain cannot be used, and growing the bacteria is difficult; is not stable in outside; it is very sensitive to dehumidification; it is very sensitive to boiling; it is very sensitive to disinfectants; usually enter the body through minute abrasions in the body, either on the skin or mucous membrane.

The mode of transmission can be:

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

Pathogenesis of T. pallidum
Tissue destruction and lesions are primarily a consequence of patients 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

Pathogenesis of T. pallidum

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

Syphilis

Penis, anus, vagina, mouth, breasts PRIMARY SPHYHILIS

Chancre 3 weeks, red bump Bump breaks, depression heals, no pain

SECONDARY SYPHILIS
Rash on body, feet and palms, painless

TERTIARY SYPHILIS
3-40 years Heart failure, liver damage, blindness Ruptured blood vessels

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

CONGENITAL SYPHILIS
Early congenital syphilis: occur before the age of 1 year; occur in children from 1 to 4 year. Late congenital syphilis: 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).

Pathogenesis of T. pallidum (cont.) Primary Syphilis

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

PRIMARY SYPHILIS

THE MAIN SYMPTOMS ARE:

HARD CHANCRE LYMPHADENOPATHY

HARD CHANCRE
Usually occurs on the genitalia (about 95%): the coronal sulcus, prepuce, frenulum, meatus (in the male). the cervix, labia major and minor, urethra, clitoris (in the female). Extragenital chancre occur in 5% of all cases of primary syphilis. the lip, which is associated with oral sex and anus, which is associated with anal intercourse. Other reported sites include: the tongue, tonsil, finger, eyelid, chin, nipple, umbilicus, axilla, and even the lower limb.

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. 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.

Kissing chancres

Primary syphilis - chancre

Facial Chancre

Multiple Chancres

Primary Chancre - Labial

Chancre of the Tongue

Chancre of Hard Palate

Chancre of the Lip

PRIMARY SYPHILIS CHANCRE

LYMPHADENOPATHY

Spotty (small and rubbery firm, like lead shots). It is develops in 5085% of patients approximately 1 week after the appearance of the primary ulcer.

Atypical forms of chancre

Amygdalate

Panarhicium

Indurate edema

Complications of hard chancre ( in cases of non-rational therapy)

1. 2. 3. 4. 5.

Balanitis. Phimosis. Paraphimosis. Gangrene. Phagedenism.

Complications of hard chancre

Balanitis

Complications of hard chancre

Balanopostatis

Complications of hard chancre

Phimosis

Complications of hard chancre

Paraphimosis

Complications of hard chancre

Gangrene

Complications of hard chancre

Phagedenism

Course of primary syphilis

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).

Diagnosis is based upon :

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

Differential Diagnosis

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

Diagnostic Tests for Syphilis

(Original Wasserman Test)

NOTE: Treponemal antigen tests indicate experience with a treponemal infection, but cross-react with antigens other than T. pallidum ssp. pallidum.

Darkfield Microscopy of Treponema pallidum

Syphilis Serology

Non-treponemal tests
VDRL (Venereal Disease Research Laboratory) RPR (Rapid Plasma Reagin) TRUST (Toluidine Red Unheated Serum Test) USR (Unheated Serum Reagin)

Treponemal tests
TP-PA (Treponema Pallidum Particle Agglutination) FTA-abs (Fluorescent Treponemal Antibody Absorbed) EIA (Enzyme Immunoassay)

Sensitivity & Specificity of Serologic Tests for Syphilis

Conditions Associated with False Positive Serological Tests for Syphilis

Questions?

THANKS QUESTIONS?

Garcia 99