Syphilis

Presentors:
Anne Franceleen U. Dalura
Daniel Abidin

Reference
Immunology and Serology in
Laboratory Management: 4th
Edition
By: Mary Louise Turgeon

Internet

Objectives

To be able to know how the

characteristics of syphilis
To be able to know the s/s of the
different stage of syphilis
To be able to know the different lab.
tests involved for syphilis
determination

Table of Contents
I.
II.
III.
IV.

Introduction ----------------------------- 5
Etiology------------------------------------ 6
Epidemiology----------------------------7
Signs and Symptoms----------------- 11

Syphilis

The disease syphilis was reported in the

literature as early as 1495.
In 1905 it was discovered that syphilis was
caused by a spirochete type of bacteria,
Treponema pallidum (originally called
Spirochaeta pallida).
Wassermann test, the first diagnostic
blood test and was developed in 1906.
Penicillin, drug of choice in the treatment
of this disease.

Etiology
Spirochaetales and Treponemataceae
(family order) (family) Treponema
(genus)
T. Pallidum T. Pertenue T. Carateum
( 3 clinically significant/pathogenic)

Direct examination with darkfield microscopy

Appear as: fine, spiral (8-24 coils), approximately 615 um long, have trilaminar outer membrane
Remain viable for up to 5 days in tissue specimen

Epidemiology

Pathogenic treponemes are transmitted

almost uniformly by direct contact.
Three treponematoses:
Yaws, Pinta and Bejel are rarely
seen in the United States but are
prevalent in other countries.
Yaws, pinta, and bejel
- are diseases caused by bacteria
closely related to T. Pallidum.

In these infections the skin or oral lesions

contain many spirochetes that may be
transmitted by personal, but not necessarily
venereal, contact.
These infections are generally acquired
during childhood.
The risk of acquiring syphilis from a single
sexual exposure to an infected partner is
unknown
A high percentage of partners do seek
medical treatment within 90 days of contact.
The incidence of syphilis is highest in women
age 20 to 29 years and in men 30-39 years.

Syphilis can be acquired by kissing a person

with active oral lesions
Very few cases of transfusion-acquired
syphilis have been reported.
During the first half of the twentieth century,
however, syphilis was a major blood-borne
infectious disease easily transmitted through
the prevailing method o direct donor-topatient blood transfusion.
Cases have been reported of children who
have acquired syphilis by sharing a bed with
an infected parent.
Syphilis may be transmitted transplacentally
to the fetus.

Treponema-Associated Diseases in
Humans

BACTERIA
1. Treponema pallidum
2. T. Pallidum (variant)
3. T. Pertenue
4. T. carateum

ASSOCIATED
DISEASE
-Syphilis
-Bejel
-Yaws
-Pinta

Signs and Symptoms

The progression of untreated syphilis is
generally divided into stages:
Initially, T. Pallidum penetrates intact
mucous membranes or enters the body
through tiny defects in the epithelium.
Patients are said to be incubating
syphilis. The incubation period usually
lasts about 3 weeks but can range from
10-90 days.

Primary Syphilis
At the end of the incubation period, a
patient develops a characteristic primary
inflammatory lesion called chancre.
The chancre begins as a papule and erodes
to form a gradually enlarging ulcer with a
clean base and indurate edge. Generally, it
is relatively painless.
In most cases, only a single lesion is
present, but multiple chancres are not rare.
Chancres are typically located around the
genitalia, but in about 10% of cases, lesions
may appear almost anywhere else on the
body (throat, lip, hands).

In males, spirochetes are present in the

lesion on the penis or discharged from
deeper sites with semen.
In females, infected lesions are usually
located in the perineal region or on the
labia, vaginal wall, or cervix.
If the lesion is located inside the
urethra, the only symptom may be a
scanty, serous urethral discharge.
The primary chancre will persists for 15 weeks and will heal completely in
about 4-6 weeks, even without
treatment.

Secondary syphilis
Secondary stage is characterized by a
generalized illness that usually begins with
symptoms suggesting a viral infection:
headache, sore throat, low grade fever,
and occasionally a nasal discharge.
Blood tests reveal a moderate increase in
leukocytes with a relative increase in
lymphocytes.
The disease progresses with the
development of lymphadenopathy and
lesions of the skin and mucous
membranes.

Patients may also develop

condylomata lata, flat lesions
resembling warts in moist areas of the
body (around anus, vagina).
Secondary syphilis usually resolves
within 2-6 weeks, even without
therapy.

Latent syphilis
After resolution of untreated secondary
syphilis, the patient enters a latent
noninfectious state in which diagnosis can
be made only by serologic metods.
During the first 2-4 years of infection, one
fourth of patients will have one or more
mucocutaneous relapses in which the
manifestation of secondary syphilis
reappears.
During these relapses, patients are
infectious, and the underlying spirocetemia
may be passed transplacentally to the
fetus.

Late (tertiary) syphilis

The first manifestations of late syphilis are
usually seen from 3-10 years after primary
infection.
About 15% of untreated syphilitic
individuals eventually develop late benign
syphilis, characterized by the presence of
destructive granulomas.
Of untreated patients, 10% develop
cardiovascular manifestations.
In about 8% of untreated patients, late
syphilis the CNS. Initially, CNS disease is
asymptomatic and can be detected only by
examination of CSF.

Meningovascular syphilis usually

manifests as a seizure or
cerebrovascular (stroke).

Congenital syphilis
congenital syphilis is caused by
maternal spirochetemia and
transplacental transmission of the
microorganism. The typing of
congenital syphilis is according to age
at diagnosis.
The early stage is seen in children
under 2 years old who are untreated.
Symptoms of the untreated early age
can include rash, condyloma latum,
bone changes, hepatosplenomegaly,
jaundice, or anemia.

The late stage is seen in children over

2 yrs old who are untreated. Symptoms
of the untreated late stage include
eighth nerve deafness, keratitis, and
Hutchinsons teeth, as well as
arthropathy and neurosyphilis.

Immunological
Manifestations
Two classes of antigen have been
recognized in treponemes:
1. Antigens restricted to one or a few species
2. Antigens shared by many different
spirochetes.
. Specific and nonspecific antibodies are
produced in the immunocompetent host.
. Specific antibodies against T. Palidum and
nonspecific antibodies against the protein
antigen group common to patohgenic
spirochetes are formed.

Specific antitreponemal antibodies in

early or untreated early latent syphilis
are predominantly Igm antibodies.
The early immune response to infection
is rapidly followed by the appearance of
IgG antibodies, which soon become
predominant. The greater elevation in
IgG concentration is seen in secondary
syphilis.
Nontreponemal antibodies, often
called reagin antibodies, are produced
by infected patients against components
of their own or other mammalian cells.

Classic serological methods for syphilis

measure the presence of the following
two types of antibodies:
1. Nontreponemal mtds.
- Rapid Plasma Reagin (RPR) test
2. Treponemal mtds.
- Fluorescent treponemal antibody
adsorption (FTA-ABS) test
- Microhemaggutination for Treponema
allidum (MHA-TP) test.

Darkfield microscopy
- the test of choice for patients with
primary syphilis
- a darkfield examination is also suggested
for immediate results in cases of secondary
syphilis, with a titer follow-up test.
Nontreponemal mtds.
- RPR is the most widely used
nontreponemal serologic procedure.
-RPR test can be performed on unheated
serum or plasma using a modified VDRL
antigen suspension of choline chloride with
EDTA.

- RPR card test antigen also contains charcoal

for macroscopic reading.
Treponemal mtds
FTA-ABS and MHA-TP represent treonemal
methods. The T. Pallidum immobilization (TPI)
test is obsolete.
These 2 specific trepnemal antigen tests can
confirm reactive (Positive) reagin tests but
should not be used as primary screening
methods.
FTA-ABS and MHA-TP can be used to confirm
that a positive nontreonemal test result has
been caused by syphilis rather than other
biologic conditions that can produce a positive
serologic result.

These tests also can determine

quantitative titers of antibody, which is
used for following response to therapy.
An ELISA for syphilis antibody is
available, but it is not widely used at
present.
The ELISA method, however, does offer
a sensitive and specific alternative to
existing methods.

Sensitivity of common serologic tests

for syphilis

Tests

Primary stage

Secondary
stage

Late

Nontreponemal(
reagin tests)
- RPR
80%
- automated
reagin test(ART)

99%

1%
0%

Specific
treponemal
tests
- FTA-ABS
- TP-HA; MHATP

100%
100%

95%
95%

85%
65%

Rapid Plasma Reagin Card test

Principle:
- RPR test is designed to detect reagin, an antibodylike substance present in serum.
Specimen collection and preparation
- patient must be positively identified when the
specimen is collected.
- specimen is to be labelled at bedside and must
include the patients full name, date of collection,
patients hospital identification number. The
phlebotomists initials should also appear on the label.
- blood should be drawn aseptic technique.
- (specimen) minimum of 2 ml of clotted blood (red-top
evacuated tube). After allowing the blood to clot,
centrifuge the specimen and allow the serum to
remain in the original tube.

Fluorescent Treponemal antibody

Absorption test
Principle:
FTA-ABS test is a direct method of observation.
. Not recommended for screening, it is the most
sensitive serologic procedure in the detection
of primary syphilis.

Specimen collection and

preparation
- patient must be positively identified when
the specimen is collected. specimen is to
be labelled at bedside and must include
the patients full name, date of collection,
patients hospital identification number.
The phlebotomists initials should also
appear on the label.
- blood should be drawn aseptic technique.
- required specimen is a minimum of 2ml of
clotted blood (red-top evacuated tube).

- the specimen should be centrifuged

and the serum removed from the clot.
- before testing the serum should be
heated at 56C for 30 minutes if never
inactivated, or 10 minutes at 56C if
inactivated more than 4 hours before
testing.