Syphilis

Last Updated: 2021-11-19

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Leonicenus, 1497

Lues, lues venerea, hard chancre, French disease, Schaudinn's disease.

  • Sexually transmitted disease caused by treponema pallidum. The infection can occur through sexual intercourse (syphilis acquisita) or through the birth process (syphilis connata).

Transmission occurs through smear infection, especially during sexual intercourse.

  • Stage I (early syphilis)
    • Incubation period: 2-3 weeks
    • Primary effect: Erythematous, indolent papule or ulcer (ulcus durum) in the area of the infection site
    • Indolent, bilateral lymphadenopathy (bubo)
    • Primary effect + bubo = primary complex
    • CAVE: in some cases, primary effect may also occur extragenitally, e.g. during oral sexual intercourse
  • Syphilis II (stage of generalised spirochetosis)
    • Approximately 25% of sufferers progress to stage II after 7-8 weeks after initial infection
    • ↓ general condition, fever, generalised lymphadenopathy, fatigue, arthralgias, myalgias
    • Maculopapular exanthema (roseolae) also with palmoplantar involvement
      • These exanthems are infectious!
      • Healing with de- or hyperpigmentation is possible
    • Lues maligna: Ulceration may occur with immunosuppression
    • Papular syphilid: erythematous, dermal, sometimes painful, symmetrical papules
    • Psoriasiform syphilid: arises from the papular syphilid, is often localised at the hairline. Characterised by scaling
    • Pustular syphilid: in the area of the papules, there is additional formation of pustules
    • Plaques muqueuses: Plaques in the area of the mucous membrane, especially on the hard and soft palate, erythematous macules appear
    • Plaques opalines: Formation of inflammatory, oedematous plaques in the area of the oral mucosa
    • Angina specifica: inflammatory induration of the tonsils with consequent dysphagia and difficulty swallowing
    • Hair loss (alopecia syphilitica): patchy, moth-eaten alopecia
    • Infestation of internal organs is possible: e.g. eye, kidney, liver
    • Recurrences (exanthema) are possible over 2-3 years. Without therapy, healing at approx. 60%
  • Stage III (late syphillis)
    • 2-5 years after infection
    • Development of granulomatous abscesses (gummata)
    • Asymmetrical arrangement
    • Low infectivity
    • Skin: Erythematous, partly brownish nodules.
    • Gums: Painful nodules, so-called gummata, which may also perforate. These can occur subcutaneously, on the muscles, bones, eyes, heart, liver, lungs, spleen and GI tract
    • Neurosyphilis
      • Tabes doralis: demyelination of the hindbrain with disturbance of the sense of movement as well as the sense of vibration
      • Paralysis progressiva: cephalgia, dementia, depression, personality changes
  • Anamnesis
  • Clinical picture
  • In stage I: collection of irritant secretions and dark-field microscopic search for spirochetes
  • PCR very sensitive, can replace dark-field microscopy
  • Laboratory
    • Screening tests:
      • TPHA serology
      • VDRL test
  • If negative and clinical suspicion continues, repeat serology after 3-6 months
  • Confirmatory reaction:
    • FTA test
    • FTA Abs test
  • Biopsy
  • Control and, if necessary, therapy of the partner!
  • Neurological consult (stage III).
  • Chest x-ray (assessment of the aorta e.g. of Gummen)
  • Prophylaxis of Jarisch-Herzxheimer reaction
    • Prednisolone p.o.25-50 mg

 

Early syphilis

  • Benzathine penicillin 2.4 million IU i.m. 1 time

Late syphilis

  • Benzathine penicillin i.m. 2.4 million IU at weeks 0.1 and 2

Neurosyphilis

  • Benzylpenicillin sodium i.v. 2-4 million IU 4-6x daily for up to 3 weeks

 

In case of penicillin allergy:

  • Doxycycline p.o. 100mg 2xtgl. for 14 days (early syphilis), for late syphilis for 28 days
  • Ceftriaxone i.v./i.m. 1000 mg over 10-14 days (insufficient data regarding dosage, treatment duration and failure rate)
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