SYPHILIS (LUES) Pidha

Universitas Lambung Mangkurat

DEFINITION
Syphilis is a systemic disease caused by Treponema pallidum that is sexual transmiitted
sexually or by other intimate contact; could also from pregnant woman to her fetus
in utero or contact directly with maternal lesion.

Sifilis adalah penyakit yang disebabkan oleh infeksi bakteri Treponema pallidum
yang bersifat akut dan kronis ditandai dengan lesi primer diikuti dengan erupsi
sekunder pada kulit dan selaput lendir, kemudian masuk ke dalam periode laten
diikuti dengan lesi pada kulit, lesi pada tulang, saluran pencernaan, sistem saraf
pusat dan sistem kardiovaskuler.
PATHOGENIC TREPONEMAS
* Bentuk spiral helix (spirochete)
* Panjang: 6-15 m; lebar: 0,1-0,2 m, Diameter 5-15 m
Punya membran luar (OM) yg dikelilingi
- flagela periplasmik,
- Kompleks membran peptidoglikan-sitoplasmik
- Silinder protoplasmik
OM sangat berbeda dengan bakteri gram (-) lain yang dimana :
1. LPS tidak ada , 2. Porin tidak ada, 3. Sangat sedikit protein dalam membrannya
* Multiplikasi dg pembelahan biner
* Tdk dpt dikultur in-vitro dan gram stain
* sangat sedikit antigen di permukaannya, sehingga membuatnya memiliki peralatan yg tersembunyi
oleh sistem imun kita
 ABOUT TREPONEMA
•Bakteri motil, gram negatif

•Gerakannya berupa rotasi sepanjang aksis dan

maju gerakan pembuka botol

•Penularan sifilis dapat melalui hubungan seksual,

dapat terjadi secara vertikal dari ibu kepada janin
dalam kandungan atau saat kelahiran, melalui
poduk darah atau transfer jaringan yang telah
tercemar, dan kadang-kadang dapat ditularkan
melalui alat kesehatan
 Syphilis Yaws Bejel Pinta

Organism T.P subs pallidum T.P subs pertenue T.P subs endemicum T. carateum

Transmission Sexual contact Skin contact Skin contact oral Skin contact

Lesion type
Primary Chancre (durum) Crusted papules Oral mucosal lesion Crusted papules and
paques

Secondary Macular or Papillomatous and Mucous patches and Scaly plaques

papulosuamous scarring condyloma lata

Tertiary Gummata and Gummata of bone and Gummata of catilage, Dyschromia

endarteritis skin bone, and skin
KLASIFIKASI
1. Sifilis Akuisita
 S.dini S.Primer
S. Sekunder
S. Laten dini
 Lanjut  S. Laten lanjut
S. Tersier
S. Kardiovaskuler
Neurosifilis
2. Sifilis Kongenital
SIFILIS STAD. PRIMER
3 mgg setelah CS
papula- erosi, keras, permukaan tertutup krusta
ulkus di daerah genital eksternadurum (tidak nyeri)
tunggal/multipel, uk 1-2 cm
- tepi meninggi, keras
- pembesaran lln. Inguinal bilateral
- sembuh spontan 4-6 mgg (30 hr)
SIFILIS STAD. SEKUNDER
Lesi-lesi skunder yg menyerupai
penyakit kulit lain, seperti ruam
makulopapuler merah di seluruh kulit,
dan papula pucat basah (kondiloma)
pada daerah anogenital, ketiak, dan
mulut.
S II umumnya tidak gatal disertai
limfadenitis generalisata. Lesi
skunder juga sembuh secara spontan.
lesi kulit simetris, makula, papula, folikulitis, papuloskuamosa,pustula
papula basah daerah lembab: kondilomata lata
lesi pd mukosa mulut, kerongkongan, serviks: plakat
alopesia : moth-eaten alopecia --> oksipital
SIFILIS STAD. LATEN AWAL
-Disebut juga Sifilis Laten Asimtomatik
-6 bulan setelah stadium sekunder
-Ditandai dengan serologi positif namun tidak ada
manifestasi klinis dari sifilis
 EARLY SYPHILIS
Persisten selama 4-10 mgg setelah Stadium latent
Primary Infection Syphillis

Syphilis

Syphilis
Secondary Infection

Early Latent Infection

4-6 minggu fase primer & asimptomatis
setelah kontak persisten sampai 6 bulan setelah
Ulkus durum 24 bulan stadium sekunder
(soliter, dasar Lesi Serologi (+)
bersih, indurari, mucocutaneous, asimptomatis
tidak nyeri) berhubungan
dengan end
artery
Moth eaten
alopecia
 EARLY SYPHILIS
Primary Infection Syphilis Secondary Infection Syphilis EARLY LATENT INFECTION SYPHILIS

ASIMPTOMATIK !
BUT SEROLOGY (+)
 PATHOGENESIS OF SYPHILIS
stage of disease signs and symptoms
initial contact
2-10 weeks (depends on primary chancre at site of
Inoculum size) infection
primary syphilis enlarged inguinal nodes
spontaneous healing
1-3 months
secondary syphilis flu-like illness
4-6 weeks myalgia, headache, fever
mucocutaneous rash
spontaneous resolution
latent syphilis
3-30years
tertiary syphilis neurosyphilis;
general paralysis of the
insane, tabes dorsalis
cardiovascular syphilis;
aortic lesions, heart failure
progressive destructive
disease
pathogenesis
multiplication of treponemes at
site of infection; associated host
response
proliferation of treponemes in
regional lymph nodes
multiplication and production of
lesions in lymph nodes, liver
joints, muscles, skin and mucous
membranes
treponemes dormant in liver and
spleen
re-awakening and
multiplication of treponemes
further dissemination and invasion
and host response (cell-mediated
hypersensitivity)
gummas in skin, bone, testis
 6 weeks Approx Approx
To 6 month 18 month 18 month

Infection

Primary Secondary Latent Syphilis

Tertiary
(Chancre) (Rash) (No sign of disease)

Incubation Benign gummatous

Period 9-90 Cardio-vascular
days syphilis
Neurosyphilis

1-2 years Many years

To a lifetime

Early Syphilis Late Syphilis

PATHOGENESIS
Masa inkubasi ± 2-10 minggu rata-rata 3 minggu
Primary lesion dihubungkan dengan lymphadenophaty
Secundary (Bacterimic) stage dihubungkan dengan general mucocutaneus
lesion.
Tertiary stage charakteristik dengan progressive destructive, mucocutaneus
musculoskletal atau parenchymeal lesion, aortitis, atau symptomatic
central nervous system disease.
LATE SYPHILIS
The late manifestations of syphilis fall into three main types : cardiovascular, benign
gummatous, and neurosyphilis. The common underlying pathophysiology event
appears to be an endarteritis and periarteritis of small and medium sized vessels.

 Hyperplastic endothelial cells

 Lymphocytes infiltrating media and
adventitia
 Eccentric internal Hyperplasia
LATE SYPHILIS
A. Cardiovascular Syphilis
This form of late syphilis is uncommon today, it has been estimated to occur in
approximately 10% of cases of untreated syphilis
The major pathologic changes in cardiovascular syphilis are dilatation of aortic ring with
incompetence of valve, LVH, Aortic dilatation with aneurysm formation, stenosis coronary
artery.
B. Benign Gummatous Syphilis
This is probably represent a severe inflamatory response to treponemal antigens. Skin
and bones are affected most commonly. Skin lesion maybe nodular( multiple, groups,
asymetric), noduloulcerative or gummatous. They are chronic, painless, and slowly
progressive and are found most often on the face, trunk, and extremities.
LATE SYPHILIS
C. Neurosyphilis
T.Palidum invades meninges and neural tissue during secondary stage of disease.
Spirochetes maybe seen in CSF, and in ocular and middle ear fluid.
A chronic, low grade meningitis with lymphocytic infiltration of the meninges. An
endarteritis of small vessels of the brain and spinal cord
diagnostic criteria of Asymptomatic neurosyphilis are :
1. Reactive CSF VDRL
2. Ractive Serum treponemal test
3. Five or more lymphocytes/ mm3 CSF
4. CSF total protein ≥ 45 mg/dL
DIAGNOSIS
1. Spesimen :
• Eksudat lesi
• Darah
2. Darkfield Examination
3. Immunofluorescence
4. Serologic Test for Syphilis (STS)
COLLECTION OF SPECIMENS
Specimens for dark field microscopy can be collected from primary chancre, moist
secondary lesion or from lymph nodes
Specimens for the direct immunofluorescent antibody test for T.Palidum can be
collected from oral and anal lesion. The idel specimen is serous fluid with minimal
RBC.
 DARKFIELD EXAMINATION
Pengecatan :
a. Impregnasi perak
b. Negatif
Paling baik : dengan mikroskop lapangan gelap
 kuman yang hidup
Terdiri dari 3 gerakan :
 Undulasi
 Cork-screw (pembuka botol)
 Maju mundur
 DIRECT FLUORESCENT ANTIBODY TEST
DFAT-TP is used to diagnose late stage
adult or congenital syphilis, or to
distinguish skin lesion or secondary or
late syphilis from those lyme disease, or
primary lesion herpes and chancroid
SEROLOGIC TEST FOR SYPHILIS
Infeksi treponemal pallidum menghasilkan 2 tipe antibodi :
1.Spesifik antibodi  polipeptida dari bakteri.
2.Nonspesifik antibodi (reagin antibodi)  non-treponemal antigen disebut
cardiolipin.
SEROLOGIC TEST FOR SYPHILIS (STS)
Non treponemal and Treponemal
A. Non Treponemal Serologic Test
Detect IgM and IgG antibodies to lipoidal material released from damaged host
cells, as well as to cardiolipin like material released from treponeme. All non
treponemal test will occasionally give false-positive (Titer less than 8). Diulang 1
minggu, 1 bulan dan 3 bulan (jika non reactive “BUKAN SYPHILIS”)
1. Venereal Disease Research Laboratory (VDRL) – Microscopic Test
2. Unheated Serum Reagen (USR) – Microscopic Test
3. Rapid Plasma Reagen (RPR) – Macroscopic Test
4. Toluidine Red Unheated Serum Test(TRUST) – Macroscopic Test
SEROLOGIC TEST FOR SYPHILIS (STS)
B. Treponemal Serologic Test
Test konfirmatif setelah tanda2 klinis yang nampak/ RPD dan hasil yang reaktif
pada serologi non-treponemal. They are qualitative procedure, which therefore they
cannot be used to monitor efficiacy of treatment.
1. Fluorescent Treponemal Antibody Absorption (FTA-ABS) & FTA-ABS DS(Double
Strain)
Initial Test Repeat Test Interpretation of Fluorescent report
2+ to 4+ .... Reactive
1+ >1+ Reactive
1+ =1+ Reactive minimal*
<1+ Non-Reactive
SEROLOGIC TEST FOR SYPHILIS (STS)
2. T.Palidum Hemagglutination Assay (TPHA) & TP-PA (Passive Particle Agglutination
Assay)
A reactive test at a titer of 1:80 is considered positive.
3. Treponemal Enzyme Immunoassays (EIA)
4. Treponamal Rapid Test
TREATMENT
A. Primary and Secondary Syphilis
Benzathine Penicilin G 2,4 juta unit I.M SD (Dewasa)
Benzathine Penicilin G 50.000 Unit/KgBB I.M
Clinical and serologic evaluation should be performed at 6 and 12 months after treatment; more
frequent evaluation might be prudent if follow-up is uncertain or if repeat infection is a concern.
B. Late Syphilis
Benzathine penicillin G 2.4 million units IM in a single dose (Early in adults)
Benzathine penicillin G 7.2 million units total (Late in adults) bagi 3 dosis interval 1 minggu
Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 m units in SD (child)
Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 m units in SD (child) x3
TREATMENT
Tertiary Syphilis
Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million
units IM each at 1-week intervals
Neurosyphilis & Occular Syphilis
Aqueous crystalline penicillin G 18–24 million units per hari, masukkan 3–4 juta unit
I.V setiap 4 jam atau infus selama 10–14 days.
Alternative : (BOTH)
Procaine penicillin G 2.4 million units IM once daily
Probenecid 500 mg orally four times a day, both for 10–14 days
SPECIAL CONSIDERATION
A. Penicilin Allergy
Doxycycline 100mg 2x (14 hari) + tetracycline 500mg 4x (14 hari)
Although limited clinical studies, along with biologic and pharmacologic evidence,
suggest that ceftriaxone (1–2 g daily either IM or IV for 10–14 days)
Azithromycin as a single 2 g
B. Pregnancy
Pregnant women should be treated with the penicillin regimen appropriate for their
stage of infection.
CONGENITAL SYPHILIS
Screening terbaik saat kunjungan prenatal pertama kali ! Uji serologic tambahan
saat usia gestasi 28 wks dan saat kelahiran.
The diagnosis of congenital syphilis can be difficult, as maternal nontreponemal
and treponemal IgG antibodies can be transferred through the placenta to the
fetus, complicating the interpretation of reactive serologic tests for syphilis in
neonates.
All neonates born to mothers who have reactive nontreponemal and treponemal test
results should be evaluated with a quantitative nontreponemal serologic test (RPR or
VDRL) performed on the neonate’s serum.
SIGN OF CONGENITAL SYPHILIS
1.Keratitis interstitialis
2.Gigi Hutchinson
3.Gigi Mullberry
4.Gangguan syaraf pusat VIII (ketulian)
5.Neurosifilis
6.Kelainan pada tulang
7.Kelainan pada kulit
8.Lesi kardiovaskuler (aortitis)
9.Gambaran muka menunjukkan saddlenose
SCENARIO 1: PROVEN OR HIGHLY PROBABLE
CONGENITAL SYPHILIS
Any neonate with:
1. an abnormal physical examination that is consistent with congenital syphilis; OR
2. a serum quantitative nontreponemal serologic titer that is fourfold higher than the
mother’s titer; OR*
3. a positive darkfield test or PCR of lesions or body fluids.
SCENARIO 2: POSSIBLE CONGENITAL SYPHILIS
Any neonate who has a normal physical examination and a serum quantitative
nontreponemal serologic titer equal to or less than fourfold the maternal titer and
one of the following:
1. mother was not treated, inadequately treated, or has no documentation of having
received treatment; OR
2. mother was treated with erythromycin or a regimen other than those recommended
in these guidelines (i.e., a nonpenicillin G regimen); †† OR
3. mother received recommended treatment <4 weeks before delivery.
SCENARIO 3: CONGENITAL SYPHILIS LESS LIKELY
Any neonate who has a normal physical examination and a serum quantitative
nontreponemal serologic titer equal to or less than fourfold the maternal titer and
both of the following are true:
1. mother was treated during pregnancy, treatment was appropriate for the stage of
infection, and treatment was administered >4 weeks before delivery and
2. mother has no evidence of reinfection or relapse.
SCENARIO 4: CONGENITAL SYPHILIS UNLIKELY
Any neonate who has a normal physical examination and a serum quantitative
nontreponemal serologic titer equal to or less than fourfold the maternal titer and
both of the following are true:
1. mother’s treatment was adequate before pregnancy and
2. mother’s nontreponemal serologic titer remained low and stable (i.e., serofast)
before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4).
RECOMMENDED EVALUATION
Only needed for Proven-Possible syphilis !

• CSF analysis for VDRL, cell count, and protein**

• Complete blood count (CBC) and differential and platelet count
• Other tests as clinically indicated (e.g., long-bone radiographs, chest radiograph,
liver-function tests, neuroimaging, ophthalmologic examination, and auditory brain
stem response).
TREATMENT
Aqueous crystalline penicillin G 100,000–150,000 units/kg/day, administered as
50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8
hours thereafter for a total of 10 days OR
Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days
OR
Benzathine penicillin G 50,000 units/kg/dose IM in a single dose
THANK YOU