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Syphilis is still with us
Paul R. Earl
Facultad de Ciencias Biológicas
Universidad Autónoma de Nuevo León
San Nicolás, NL, Mexico
Syphilis is caused by the 5-15 micron
spiral spirochete Treponema pallidum and
is sexually transmitted. The bacterium
spreads from the initial ulcer or chancre
(shanker) of an infected person to the skin
or mucous membranes of the genital area,
mouth or anus of an uninfected sexual
partner. In addition, a pregnant woman with
syphilis can pass it to her unborn child,
who may be born with serious mental and
physical problems as a result of this
infection: congenital syphilis.
Primary syphilis involves chancre and regional
lymphadenitis. Secondary syphilis usually
involves generalized rash, mucous patches and
condylomata lata. These 2 stages last about 1220 weeks and then syphilis becomes latent.
During the first 2 years, the disease is called
early syphilis.
Pregnant women in hospital for maternity should
be screened for syphilis, so that the result can
be made available while they are still confined,
and treatment can be provided if a positive
diagnosis (seroreactive) is made. Their newborn
infants should never be discharged from care
until the mother's syphilis status is known.
Primary and secondary syphilis rates*,
by year - US, 1970-1997
HEALTH MINIMUMS INCLUDE:
·Appropriate antibiotic therapy such as
penicillin G
·Careful screening for other sexuallytransmitted diseases (STD)
·Referral of partner(s) to a sexual health
service for diagnosis, treatment and
contact-tracing
·Instructions to refrain from sexual activity
during treatment
·Regular follow up of immunological testing
to ensure that titers steadily decline to low
levels
Elimination plans for sexualy
transmissable diseases (STDs) have
at least 5 strategies:
- Increase surveillance.
- Strengthen community involvement and
partnerships.
- Rapidly respond to outbreaks.
- Improve and increase health promotion.
- Expand clinical and laboratory services.
IS THERE A HAPPY ENDING
TO THE SYPHILIS STORY ?
WILL NORWAY, CANADA AND
THE US BECOME
MILESTONES ON THE ROAD
TOGLOBAL ERADICATION?
Discovery
“Everything” happened mostly
in Germany from 1905 to 1910 !
With a short life of 35 years,
Fritz Schaudinn (1871-1906) and
Paul E. Hoffmann (1868-1959)
discovered Treponema pallidum
in serum in 1905.
Paul Ehrlich,
father of
immunochemistry
and his assistent Hati.
Fritz
Schaudinn
In 1903, Elie Metchnikoff (1849-1916) and
Pierre Roux (1853-1937) found that syphilus can
be transferred from man to chimpanzee and
from one chimpanzee to another.
In 1905, Aldo Castellani (1878-1971)
discovered tropical yaws in children.
August von Wassermann (1866-1925) and
coworker Albert Neisser (1855-1916)
devised a complement fixation test in
1906, and Paul Ehrich (1854-1915) found
a cure in 1909. The arsenical Salvarsan,
the magic bullet, worked. Metchnikoff
shared the Nobel prize with Ehrlich in
1905.
The social past
Europe learned about syphilis from Christopher
Columbus (Cristóbal Colon) in the 16th century.
By the 19th century it was riddled with syphilis
from King Henry the 8th and his sterile wives and
lovers, to the writers Edgar Allan Poe, Oscar
Wilde and Guy Demaupassant, to painters Paul
Gauguin and Vincent VanGough, through to the
composers Ludwig von Beethoven and Robert
Schumann. Insanity, tales of terror and bizarre
acts connected these men. Once infected, the
victim was infected for life before Salvarsan and
more pointedly before penicillin by 1946.
Syphilis was used by feminists in fictional form in
the 'New Woman' novels of the 1890s and earlier
in England. These revolutionary novels for their
day dealt with the burning issues of the women's
movement such as marriage and motherhood.
Do these novels—in any way—relate to the AIDS
TV novels in South Africa?
The corruption at the heart of highly desirable
marriage was central to feminist novelists'
messages. Syphilis in these novels acts as a
powerful metaphor for the dangers to which
unknowing women were exposed when pursuing
what they were told should be their prime aim:
a good marriage.
The New Women writers proposed that if a
woman was informed of what to look for, she
could protect herself against the predatory male
with or without disease. Dorian Gray by Oscar
Wilde is characterized as that syphilitic man,
although of course never explicitly admitted for
Dorian or Oscar.
The Ladies's National Association for the Repeal
of the Contagious Diseases Acts came forth
against the assumptions on male sexuality and
female guilt which underlay those Acts that
punished women under the banner of medical
necessity while ignoring the role of men, at least
in the 1860s.
Progress
Is syphilis now replaced by AIDS? Of course, not.
What is new and different? Antibiotics for one.
Antibiotics on the one hand have radically reduced
infant and child mortality, while on the other AIDS
has raised it. AIDS is in the no-cure position
syphilis was in for centuries. Still, untreated
syphilis is also sometimes selfcures.
We must ask: Why is syphilis not eradicated?
Even when the technology is effective, it may not
be taken proper advantage of. Lack of
determination or plain ignorance can cause failure
to eradicate both of these diseases and all the
other STDs as well.
Many knowlegable communities or counties
not paying the mandatory public health cost
believe that they can sleep through
epidemics that are well hidden. Again: If the
public does not feel the threat, it will not
demand the protection. Those not at risk, as
always, do not want to pay taxes for diseases
that do not concern them, except for the
altruistic ultrarich. Does it follow these
assertions that syphilitic rates are much
higher in blacks than in whites? Yes. Is less
public health money in poor districts? Yes.
How does poverty relate to syphilis?
SYMPTOMS
Primary syphilis
The first symptom of primary
syphilis is an ulcer called a
chancre. It can appear within
10 days to 3 months after exposure generally
appearing within 2-6 weeks. However as it is
painless, the infected person might not notice it. It
usually is found on the part of the body exposed to
the infected partner's ulcer, such as the penis,
vulva or vagina. A chancre also can develop on the
cervix, tongue, lips or other parts of the body. It
disappears within a few weeks treated or not. If not
treated during the primary stage, about 1/3 of
people will go on to the chronic stages.
Secondary syphilis
A skin rash as in the illustration or with
brown sores, often marks this chronic stage.
The rash appears anywhere from 3-6 weeks
after the chancre appears. The rash may
cover the whole or part of the body and is
almost always on the palms of the hands and
soles of the feet.
Since active spirochetes are present in such
sores, any physical contact—sexual or
nonsexual—with the broken skin of an
infected person may spread the infection at
this stage. The rash heals within several
weeks or months.
Latent syphilis
If untreated, syphilis may enter the latent stage
when no longer contagious and no symptoms
are present. Many people who are not treated
will suffer from no further signs and symptoms
of the disease.
Tertiary syphilis
About 1/3 of people who have had secondary
syphilis go on to develop the complications of
late, or tertiary syphilis, in which the bacteria
damage the heart, eyes, brain, nervous system,
bones, joints, or almost any other part of the
body. This stage can last for years, or even for
decades.
Neurosyphilis
Years after infection, neurosyphilis can be
permanent, progressively destructive and life
threatening, occurring in 4 forms:
1/asymptomatic, 2/ meningovascular, 3/ tabes
dorsalis and 4/ general paresis of the insane. In
meningovascular neurosyphilis, cranial nerve
palsies and pupil abnormalities may be among a
wide variety of symptoms. This may also cause
damage to blood vessels resulting in stroke. In
tabes dorsalis, progressive degeneration of the
spinal cord occurs causing lameness. In general
paresis, paralysis, tremors, seizures and mental
deterioration occur as a result of damage to
brain cells.
DIRECT SMEARS
Darkfield microscopy
Darkfield microscopy is used to demonstrate
Treponema pallidum in material from lesions or
lymph nodes. The presence of T. pallidum
constitutes a definitive diagnosis of syphilis.
Since T. pallidum is identified by characteristic
spiral morphology and its motility, the
preparation must be fresh and the organisms
actively motile.
Direct fluorescent antibody (DFA-TP)
As an alternative to darkfield microscopy, fixed
smears from lesions, serous fluid or lymph node
aspirates may be sent to reference laboratories
for staining with fluorescein-conjugated
SEROLOGICAL TESTS
Nontreponemal or reagin tests
This group of common nontreponemal tests
initiated by the Wassermann test measure
antibody to a nonspecific cardiolipin lecithin
antigen. The tests are moderately specific
for syphilis (false-positives occur often), but
highly sensitive.Because they are easily
performed, the nontreponemal tests are
useful screening tools. The tests can be
quantitated to obtain a titer and, thus, are
useful in monitoring patient response to
therapy.
Treponemal Tests
Prologue now! Treponemas can be cultured
with mammalian cells (Infect. Immun. 32:
908–915, 1981 &36: 437–439, 1982), but most
grievously such cultivation is little studied.
Tissue culture (cell culture) could be a
prominent source of antigens. Vaccine
development is NOT a motive, because the
risk is very low. Titration of antitreponema
effects in vitro, cheaper than in rabbits is a
challenge. The titration of antibiotics and
other drugs is the MOTIVE for developing
cultures.
Treatment
If the patient has a reactive RPR or VDRL,
a nonreactive confirmatory test,
such as fluorescent treponemal antibody
absorption (FTA-ABS),
microhemagglutination assay for antibodies
to Treponema pallidum (MHA-TP),
or enzyme immunoassay (EIA), and no
clinical or epidemiologic evidence of
syphilis, no treatment is necessary. If
clinical or serologic evidence of syphilis is
found, or if diagnosis of syphilis cannot be
excluded with reasonable certainty, the
patient should be treated.
Intramuscular (IM) penicillin G is the drug of
choice, despite some unfounded fears of
resistant treponemal strains and possible
anaphylaxis. Other applicable antibiotics are:
a) Doxycycline 100 mg twice daily (BD) x 14
days, b) Erythromycin 500 mg 4 times daily
(QDS) x 14 days, c) Azithromycin 500 mg daily
x 10 days, d) IM Ceftriaxone 500mg daily x 10
days (if no anaphylaxis to penicillin), and e)
Amoxycillin 500 mg 4 times daily plus
Probenecid 500 mg 4 times daily x 14 days.
Is it true that for every doctor preferring
parental therapy there’s a patient preferring
oral therapy? The recommended IM penicillin G
is the same as oral penicillin G and has 17
synonyms, e. g., ampicillin = amoxycillin. Many
other medications, e. g., tetra-cycline, are
effective against syphilis and others. Even
though penicillen is supreme, perhaps onedose in a cocktail that eliminates all bacterial
STD agents is simple to attain. Or use—
perhaps—just a FEW oral doses. Wake up
America !
Some penicillin dosages are: primary,
secondary and latent with a negative spinal
fluid in adults and children over 12 years of
age: 600,000 units daily for 8 days-total
4,800,000 units. Late (tertiary, neurosyphilis
and latent syphilis with positive spinal fluid
examination or no spinal fluid examination):
600,000 units daily for 10-15 days-total 6-9
million units. Congenital syphilis under 30
kg body weight: use 50,000 units/kg/day for
10 days.
Has penicillin been adequately titered ?? No.