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Spirochetal Infections
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given, about one-third of people infected with syphilis will undergo spontaneous cure, about one-third will remain in the latent phase throughout life, and about one-third will suffer from serious late lesions (See Table 34 3)
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CLINICAL STAGES OF SYPHILIS 1 Primary Syphilis
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History of sexual contact (often unreliable) Painless ulcer on genitalia, perianal area, rectum, pharynx, tongue, lip, or elsewhere 2 6 weeks after exposure Nontender enlargement of regional lymph nodes Fluid expressed from lesion contains T pallidum by immunofluorescence or darkfield microscopy Serologic test for syphilis may be positive
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This is the stage of invasion and may pass unrecognized The typical lesion is the chancre at the site or sites of inoculation, most frequently located on the penis, labia, cervix, or anorectal region Anorectal lesions are especially common among men who have sex with men Chancres also occur occasionally in the oropharynx (lip, tongue, or tonsil) and rarely on the breast or finger An initial small erosion 10 90 days (average, 3 4 weeks) after inoculation then rapidly develops into a painless superficial ulcer with a clean base and firm, indurated margins, which is associated with enlargement of regional lymph nodes, which are rubbery, discrete, and nontender Bacterial infection of the chancre may occur and may lead to pain Healing occurs without treatment, but a scar may form, especially with secondary bacterial infection Multiple chancres may be present, particularly in HIV-positive patients
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The lesions associated with primary and secondary syphilis are self-limiting and resolve with few or no residua Late syphilis may be highly destructive and permanently disabling and may lead to death In broad terms, if no treatment is
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Spirochetal Infections
CMDT 2008
B Laboratory Findings
Table 34 1 Stages of syphilis and common clinical manifestations
Primary syphilis Genital ulcer: painless ulcer with clean base and firm indurated borders Regional lymphadenopathy Secondary syphilis Skin and mucous membranes Rash: diffuse (including palms and soles), macular, papular, pustular, and combinations Condylomata lata Mucous patches: painless, silvery ulcerations of mucous membrane with surrounding erythema Generalized lymphadenopathy Constitutional symptoms Fever, usually low-grade Malaise Anorexia Arthralgias and myalgias Central nervous system Asymptomatic Symptomatic Headache Meningitis Cranial neuropathies (II VIII) Ocular Iritis Iridocyclitis Other Renal: glomerulonephritis, nephrotic syndrome Liver: hepatitis Bone and joint: arthritis, periostitis Late syphilis Late benign (gummatous): granulomatous lesion usually involving skin, mucous membranes and bones, but any organ can be involved Cardiovascular Aortic insufficiency Coronary ostial stenosis Aortic aneurysm Neurosyphilis Asymptomatic Meningovascular Seizures Hemiparesis or hemiplegia Tabes dorsalis Impaired proprioception and vibratory sensation Argyll Robertson pupil Shooting pains Ataxia Romberg s sign Urinary and fecal incontinence Charcot joint Cranial nerve involvement (II VIII) General paresis Personality changes Hyperactive reflexes Argyll Robertson pupil Decreased memory Slurred speech Optic atrophy
The serologic tests for syphilis are discussed below; rising titers are especially significant when there is a history of previous infection Immunofluorescence or darkfield microscopy shows treponemes in at least 95% of chancres Cerebrospinal fluid pleocytosis has been reported in 10 20% of patients with primary syphilis 1 Serologic tests for syphilis (Table 34 2) There are two general categories of serologic tests for syphilis: (1) Nontreponemal tests detect antibodies to lipoidal antigens present in either the host or in T pallidum The original antigens used to measure these nonspecific antibodies (reagin) were crude extracts of beef heart or liver and resulted in significant numbers of false-positive reactions The cardiolipin cholesterol lecithin preparation presently used is much purer and gives fewer false-positive reactions (2) Treponemal tests use live or killed T pallidum as antigen to detect antibodies specific for pathogenic treponemes a Nontreponemal antigen tests The most commonly used nontreponemal antigen tests are the Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR), which measure the ability of heated serum to flocculate a suspension of cardiolipin cholesterol lecithin The flocculation tests are inexpensive, rapid, and easy to perform and are therefore used primarily for routine screening Quantitative expression of the reactivity of the serum, based on titration of dilutions of serum, is valuable in establishing the diagnosis and in evaluating the efficacy of treatment, since titers usually correlate with disease activity Nontreponemal tests generally become positive 4 6 weeks after infection or 1 3 weeks after the appearance of a primary lesion; they are almost invariably positive in the secondary stage, with titers 1:32 In the late stages, titers tend to be lower (< 1:4) These serologic tests are not highly specific and must be closely correlated with other clinical and laboratory findings The tests are positive in patients with non sexually transmitted treponematoses (see below) More important, false-positive serologic reactions are frequently encountered in a wide variety of nontreponemal states, including connective tissue diseases, infectious mononucleosis, malaria, febrile diseases, leprosy, injection drug use, infective endocarditis, old age, hepatitis C viral infection, and pregnancy False-positive tests also occur more commonly in HIV-seropositive patients (4%) than in HIV-seronegative patients (08%) False-positive
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