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SYPHILIS
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Contents
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� Characteristics
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� Incidence
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� Primary Syphilis
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� Secondary Syphilis
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� Latent Syphilis
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� Late Syphilis
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� Syphilis in Pregnancy
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� Congenital Syphilis
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� Laboratory Methods
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� Syphilis Treatment
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� Course of Infection
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Characteristics
Syphilis is caused by a corkscrew-shaped bacterium called Treponema pallidum. It does not live or cause disease outside the human body; it is spread directly from person to person. It is transmitted through direct contact with an infectious lesion. The spirochetes pass through intact mucous membranes and abraded skin; they are then carried by the blood stream to every organ in the body.
Incidence
More than 50,000 cases of primary and secondary syphilis were reported to CDC in1990. In addition to these cases, more than 55,000 cases of early latent syphilis and more than 25,000 cases of late and late latent syphilis were reported. Of these cases,52 percent occurred in men. In 1990, men and women aged 20-24 years had the highest rates for primary and secondary syphilis.In 1988, a total of 741 cases of congenital syphilis (<1 year of age) were reported to CDC. 1,809 cases of congenital syphilis were reported in 1989. The case definition for congenital syphilis was changed in 1989 to include births to women with untreated syphilis. In 1989, approximately 1,000 (57%) of the reported cases would not have been included under the old case definition. In 1990, a total of 3,288 cases, or approximately 70 cases per 100,000 live births, were reported. A substantial increase in congenital syphilis occurred, regardless of the new case definition.
Primary Syphilis
Primary syphilis is the most infectious stage of the disease. The first clinical sign is the chancre, or lesion. This sore develops at the original site of infection 10 to 90 days after inoculation (21 days average). The three most important epidemiologic points to remember about a primary lesion are 1) the lesion appears at the site of inoculation, 2) it is highly infectious, and 3) it resolves without treatment. Chancres are normally single lesions, but multiple lesions sometimes occur. The lesion is usually an eroded papule that is indurated (firm). The surface may be crusted or ulcerated. The size ranges from a few millimeters to 1 or 2 centimeters in diameter. The border surrounding the lesion is frequently raised and firm. When free of other infectious agents, the chancre is painless. Lymph nodes draining the involved area are frequently enlarged, hard, and painless (satellite bubo). In males, genital lesions due to syphilis will usually show bilateral lymphadenopathy. Genital chancres are observed much less frequently in women because they are commonly located within the vagina or on the cervix, although some chancres may be seen on the labia. On the cervix, the appearance may range from an erosion to a deep ulceration resembling carcinoma. Primary lesions are not confined to the genital area; they may be seen on the lips, tongue, tonsil, nipple, fingers, and anus. Without treatment, the chancre will heal completely within 1 to 5 weeks (3 weeks average). The longer the chancre has been present, the greater the likelihood that serologic tests will be reactive. If the lesion has been present a month, nearly all serologic tests will be reactive.
Secondary Syphilis
The diagnosis of secondary syphilis is suspected primarily on the basis of the skin and mucous membrane lesions. The skin lesions are bilaterally symmetrical and may be macular, papular, follicular, papulosquamous, or pustular. They are seldom pruritic and are usually dry. "Moth-eaten" scalp alopecia beginning in the back of the head is characteristic. Loss of the eyelashes and the lateral third of the eyebrows may occur. Moist papules occur most frequently in the anogenital region (condylomata lata) and the mouth. Lesions of the mouth, the throat, and the cervix (mucous patches) frequently occur in secondary syphilis, as does generalized lymphadenopathy. Occasionally, secondary syphilis lesions occur while the chancre of primary syphilis is still present. Symptoms of secondary syphilis may last 2 to 6 weeks (4 weeks average) and may recur. These symptoms may include the following:
� macular rash (a flat spot of skin discoloration)
� palmer/plantar rash (a macular or papular rash on the hands or feet)
� papular rash (a raised or coned rash)
� squamous rash (a scaly rash)
� annular rash (a ring or circular skin discoloration)
� nickel/dime lesions (occur typically on the face)
� split papules (infectious, usually found at a crease in the skin around the mouth or
genital areas)
� mucous patches (highly infectious lesions occurring in the mouth or the genital area)
� condylomata lata (highly infectious wet, rounded, raised, wart-like rashes usually in
the genital area)
� alopecia (temporary loss of patches of hair)
� malaise (a tired, listless feeling)
Syphilis has been called the great imitator because so many of the signs and symptoms are indistinguishable from those of other diseases. Because this is particularly true of secondary syphilis, serologic tests and darkfield microscopy are necessary to establish accurate diagnosis. Serologic tests during the secondary stage of syphilis are nearly 100 percent reactive; this fact makes diagnosis fairly reliable. Relapsing lesions of the skin or the mucous membranes may occur in untreated or inadequately treated patients. Secondary lesions during a relapse are often nodularand larger than the early secondary lesions and are usually darker red. Relapses after inadequate therapy were quite common before penicillin became available, but they are infrequent today. Most relapses appear near the end of the first year of infection and are rare after 2 years of infection. After 4 years, relapses are not believed to occur.
Latent Syphilis
Latent syphilis is the stage in which no observable clinical signs or symptoms are present to suggest infection, yet the serologic tests for syphilis (STS) are reactive. All cases of syphilis are latent at some time during the course of an untreated infection. A clinical diagnosis of latent syphilis does not preclude the possibility that the patient may be infectious or that gummatous lesions, cardiovascular abnormalities, or neurosyphilis may develop. Latent simply means "without symptoms." The early latent stage of syphilis is defined as latent disease within the first year after infection. These periods can occur between the primary and secondary stages, between secondary relapses, and after the secondary stage. There can be 0-10 weeks (4 weeks average) of latent syphilis between the disappearance of the primary lesion and the onset of secondary symptoms. In early syphilis, any period during which primary or secondary symptoms are absent is classified as latent. Note that these latent periods should not be confused with the early latent interview period, which is the year preceding the date of diagnosis. When more than a year has passed since the patient became infected and there are no signs of disease, we define this period as the late latent stage. The reason for separating latent stages into early and late is that secondary relapses generally do not occur following the first year and that early latent disease is treated with a single dose of benzathine penicillin (vs. three doses for late latent disease). The diagnosis of latent syphilis is made on the basis of a confirmed positive serologic test. An infection that has persisted for more than 4 years is rarely communicable. The exception is an untreated pregnant woman who may transmit syphilis to the fetus regardless of the duration of her disease; transmission is more likely in primary, secondary, and early latent disease than in late latent.
Late Syphilis
In untreated late syphilis, signs and symptoms range from inapparent to symptoms that indicate severe damage to one or more body systems. Late syphilis, also referred to astertiary syphilis, can be classified as neurosyphilis, cardiovascular syphilis, and late benign syphilis. About one third of persons with untreated syphilis develop late syphilis.
Neurosyphilis
Although neurosyphilis is often thought of as a late complication of syphilis, it can occur any time after infection, especially during secondary syphilis. Neurosyphilis that occurs during early infection is usually acute syphilitic meningitis. Neurosyphilis is divided into the following groups, depending on the type and the degree of central nervous systempathology:
� asymptomatic: The patient is usually seen because of a reactive serologic test forsyphilis. There are no signs or symptoms indicative of central nervous system involvement, yet results of an examination of the cerebrospinal fluid (CSF) are abnormal. The most reliable single test on CSF is a positive Venereal Disease Research Laboratory (VDRL) test result.
� meningovascular: There are definite signs and symptoms of central nervous system damage resulting from blood vessel occlusion. Damage differs according to the size and location of the lesion. The cerebrospinal fluid is abnormal, and the result of the CSF VDRL is usually reactive.
� parenchymatous: This type of neurosyphilis appears as paresis or tabes dorsalis. The signs and symptoms of paresis are always indicative of widespread parenchymatous damage. Personality changes range from minor to psychotic. Focal neurologic signs are common. The CSF is invariably abnormal, and the VDRL is reactive.
The primary signs and symptoms of tabes dorsalis are posterior column degeneration of the spinal cord, with ataxia, areflexia, paresthesia, bladder disturbances, impotency, and lancinating pain (lightning pains). The spinal fluid findings are abnormal in 90 percent of cases; the serology is reactive in 75 percent. A gastric or abdominal crisis frequently begins with vomiting and severe abdominal pain. Persistent vomiting may cause serious electrolyte imbalance. Trophic joint disease (Charcot's joints) results from the loss or impairment of the sensation of pain. Syphilitic optic atrophy is a serious complication of neurosyphilis and every patient should be checked for this condition. It is most frequently associated with tabes dorsalis. The signs and symptoms of both paresis and tabes dorsalis are frequently found in the same patient.
Cardiovascular Syphilis
This form of late syphilis is usually caused by necrosis of the wall of the aorta at its junction with the heart. The signs of cardiovascular syphilis are aortic insufficiency, coronary insufficiency, or an aneurysm (ballooning) of the thoracic aorta. When fully developed, these conditions are not difficult to detect by physical exam and chest x-ray. Serologic tests for syphilis are usually reactive at this point.
Late Benign Syphilis
Late benign syphilis seldom results in physical incapacity or death. The lesion of late benign syphilis is the gumma. The term benign is misleading; gummas in the brain or other vital organs could cause death. Gummas are probably the result of hypersensitivity reactions to treponemes. The most common sites are soft tissues (e.g.,skin, liver) and bone, but practically any organ may be involved. Skin lesions may be solitary or multiple, tend to form circles or segments of circles, are destructive and chronic, and tend to heal centrally and extend peripherally. Bone lesions are usually marked by pain, swelling, and bony tumor. The most common sites are the cranial bones, tibia, and clavicle. The serologic tests are nearly always reactive, and usually titers are high.
Syphilis in Pregnancy
Kassowitz' law states that the longer the duration of untreated infection before pregnancy, the less likely the fetus will be stillborn or infected. Thus, infants born to mothers in the secondary stage of infection are almost always infected, and stillbirths are common. Conversely, infants born to women with late syphilis may be uninfected. If the mother becomes infected late in the pregnancy, she may show no signs before delivery, and the infected newborn may also appear normal at birth. Unfortunately, this is common, so if a woman has untreated syphilis at delivery, it must be assumed that the infant is infected and must be treated. Stillbirths, although common, are only reported as such after a 20-week gestation.
Adequate treatment for the mother early in pregnancy prevents infection of the fetus. Because penicillin crosses the placenta in adequate amounts, treating the mother later in pregnancy may also cure the infected fetus. Women who say that they are allergic to penicillin should have a skin test. If the skin test result is negative, they can be safely treated with penicillin. A woman who is truly allergic to penicillin should be desensitized and then treated with penicillin. Once the woman has been adequately treated and quantitative serologic test results show no evidence of re-infection, she does not need to be retreated at each pregnancy. If the mother's titers do not respond as expected before the infant is born, the therapy may not have effectively treated the fetus.
Congenital Syphilis
Congenital syphilis is divided into stages much like those in the classification of acquired syphilis. However, since the treponeme is introduced directly into the fetal circulation, there is no primary stage. A chancre appears on the newborn only if the mother has a chancre in the birth canal at the time of delivery.
Early Congenital Syphilis
The early stage is characterized by the appearance of signs and symptoms before the age of 2. These signs and symptoms, which resemble those of secondary syphilis in an adult, usually appear 2 or more weeks after an infant's birth. An early onset, in the first few weeks of life, usually results in a poor prognosis. The signs and symptoms may include the following.
� cutaneous lesions: The skin lesions seen shortly after birth are frequently vesicular or bullous, and progress to superficial crusted erosions. Skin lesions seen in later weeks are frequently papulosquamous with a generalized symmetric distribution like that of acquired syphilis and may form typical condylomata lata.
� maculopapular eruptions: These lesions are large with a wide base and a pustular eruption in the center.
� mucous membrane lesions: The mucous membranes of the nose and pharynx are frequently involved and produce a heavy mucoid discharge referred to as snuffles. A hemorrhagic nasal discharge in the newborn is characteristic of syphilis. Mucous patches occur in the mouth, nose, and throat; they cause a hoarse cry and are highly infectious. Because both the skin and the mucous membrane lesions are teeming with spirochetes, the lesions and their secretions are extremely infectious.
� bone involvement: This usually takes the form of an osteochondritis of the long bones. Although only 15 percent of newborns show clinical signs, almost 100 percent show radiologic signs of bone involvement after the first month of life.
� anemia: Most infected newborns have a self-limited hemolytic anemia.
� hepatosplenomegaly: This enlargement of the spleen and the liver causes anemia, edema, jaundice, or a potbelly.
� lymphadenopathy: The swelling and inflammation of the lymph nodes.
� central nervous system: Up to 50 percent of infected newborns have abnormal CSF findings; however, the incidence of clinical manifestations is much lower than 50 percent.
Late Congenital Syphilis
This stage of congenital syphilis has persisted beyond 2 years of age. In about 60 percent of cases, the disease is latent. The titers of serologic tests in untreated congenital syphilis may fluctuate greatly. Late congenital syphilis is not infectious. The signs of late syphilis (see following list) usually do not appear in an infant who was treated at birth.
� interstitial keratitis: The cornea develops a ground glass appearance with vascularization of the adjacent sclera. These signs usually appear near puberty and eventually become bilateral.
� Mulberry or Moon's molars: The first molars may show maldevelopment of the cusps.
� Hutchinson's teeth: Because of poor development of the middle denticle, the permanent upper (occasionally the lower) central incisors develop a barrel shaped, notched appearance; smaller than normal, these teeth are more widely spaced than is usual.
� eighth nerve deafness: This is an unusual manifestation that more commonly begins near puberty but may be delayed until middle age.
� neurosyphilis: Tabes dorsalis is much less common in late congenital syphilis than in acquired syphilis; paresis is more frequent than in the adult. Juvenile paresis may result in the gradual loss of the use of the lower extremities.
� bone involvement: This may produce saber shin, an abnormal development which results in a very thin and fragile tibia, or gummas, which most frequently affect the nasal septum (saddle nose) or the hard palate. Perforation of the palate is very suggestive of congenital syphilis, although any part of the skeletal system may be involved.
� cutaneous involvement: Rarely seen, rhagades (cracks or fissures about the mouth or nose) may result from infantile syphilitic rhinitis. Gummas may involve any portion of the skin or other organ system as in acquired syphilis.
� Clutton's joints: Painless swelling of the joints, usually of the knees. Clutton's joints, interstitial keratitis, and eighth nerve deafness all begin near puberty and are commonly associated with each other. None of these three responds well to penicillin treatment alone. Recent evidence suggests that T. pallidum, despite systemic therapy, may persist for many years in the aqueous humor in patients who have interstitial keratitis.
Laboratory Methods
Infection with T. pallidum provokes a complex antibody response. The detection of these antibodies is the basis of serologic testing. The ideal test would be performed easily and quickly, it would be highly sensitive and specific, and the results would be readily reproducible in different laboratories. At present, no ideal test is available. The sensitivity of a test is its ability to be reactive in the presence of disease; specificity is the ability of a test to be nonreactive when disease is absent. Highly sensitive tests are particularly suited for screening purposes; tests that are highly specific are better suited to confirming the positive results of screening tests. Serologic tests are a definite aid in the diagnosis in any stage, and they are the basis for the diagnosis of latent syphilis. The results of qualitative tests for syphilis are customarily reported as reactive (or positive), weakly reactive (or weakly positive), or nonreactive (negative). Quantitative results are obtained by geometric dilution (progressively diluting the amount of serum by half while keeping the antigen constant) until antibody becomes so diluted that the results finally become negative. The titer is usually expressed as the highest dilution in which the test is fully reactive. For example, if a test is reactive at 1:2, 1:4, 1:8, and 1:16, but is nonreactive at 1:32, the test results are reported as 1:16. The excessive production of antibody (particularly in the secondary stage of syphilis) occasionally
results in the prozone phenomenon because of an excess of antibodies. Undiluted (1:1) specimens produce a nonreactive or a weakly reactive test result; testing at higher dilutions gives highly reactive test results Two types of syphilis tests have been developed. The first are nontreponemal tests, which are based on detecting reaginic antibody. This antibody is not formed directly against T. pallidum but is directed against the cardiolipin antigen found in blood vessel walls. The second type of tests is treponemal tests, which detect antibody directed specifically against T. pallidum.
Nontreponemal Antigen Tests: Nontreponemal antigen tests are practical to perform, widely available, and the findings are indicative of infection. They offer a diagnostic clue in latent syphilis, they are an effective tool for detecting cases in epidemiologic investigations, and they are superior to treponemal tests in follow-up of the response to therapy. These tests have been developed for the rapid screening of sera. The two tests you will most commonly use are the Rapid Plasma Reagin (RPR) test and the Venereal Disease Research Laboratory (VDRL) test. Reagin is detected in the serum about 4-6 weeks after infection, or 1-3 weeks after the chancre appears. The VDRL is not necessarily reactive in primary syphilis; it usually does not become reactive until at least one week after the appearance of the chancre. Because the RPR and the VDRL are quantitative tests, their use reveals a dynamic process. A rising titer may indicate a recent infection, a reinfection in a previously treated patient, or a relapse in an inadequately treated patient. The adequate treatment of early syphilis produces a decline in titer. Titers should become nonreactive in 6 to 12 months after treatment for primary syphilis and in 12 to 18 months after treatment for secondary syphilis, but they may remain reactive at a low titer (serofast). The treatment of a late infection usually has little or no effect on the titer, and it should not be used to gauge the adequacy of treatment. If ever the titer rises persistently (by at least two tube dilutions, e.g., 1:8 to 1:32), it must be concluded that the disease remains active, and re-treatment must be initiated. A one-tube variation up or down in quantitative titer is not considered significant because it is within the limits of laboratory error. Careful attention must be paid to every reactive or weakly reactive serologic result. Many cases of untreated late latent or late syphilis produce only weakly reactive results with undiluted serum. On the other hand, the titer is invariably high (16 dilutions or greater) in secondary syphilis. A high titer does not necessarily mean early syphilis (or even syphilis), but it is much less likely to represent a biologic false-positive test. A reactive VDRL performed on a sample of cerebrospinal fluid is important in establishing the diagnosis of neuro-syphilis.
Treponemal Antigen Tests: Since the nontreponemal antigen tests are not entirely specific for T. pallidum infection, antigens for testing have also been prepared from treponemes. Treponemal tests are used to confirm positive nontreponemal test results. Some of these tests are tedious and expensive to perform and lack the sensitivity of nontreponemal tests. The Fluorescent Treponemal Antibody-Absorption (FTA-ABS) test has been shown to be more sensitive than nontreponemal tests. The FTA-ABS test is now widely available; because of its excellent sensitivity and specificity, it is used as a preferred confirmatory test. The Microhemagglutination for Treponema pallidum (MHA-TP) is a less expensive and equally effective test (although not as sensitive in primary syphilis and possibly late latent disease) that has come into wide use in the past few years. The Hemagglutination Treponemal Test for Syphilis (HATTS) is similar to the MHA-TP. Like the MHA-TP, the HATTS is less sensitive than the FTA-ABS in the early primary stage of syphilis. Both the HATTS and the MHA-TP provide a convenient confirmatory test for syphilis in laboratories that are not equipped for fluorescent procedures.
Darkfield Examination: It is preferable to diagnose both primary and secondary syphilis on the basis of a positive darkfield and a reactive serologic test for syphilis. As a rule, T. pallidum can be obtained from the fluid in any mucous or cutaneous lesion. Failure to demonstrate T. pallidum in lesions, however, does not rule out the diagnosis of syphilis. Poor specimen collection, drying lesions, imperfect darkfield microscopy, the patient's use of topical antibiotic or other creams, local antiseptics, soaps, or systemic antibiotics may result in failure to identify organisms. T. pallidum can usually be demonstrated in lesions only during the early stages of syphilis. However, it is essential that a search for T. pallidum be made whenever there is any suspicion that a given lesion, whether of the genitalia, skin, or mucous membrane, may be syphilitic. If the initial examination is negative, highly suggestive lesions should have repeated darkfield examinations on successive days before syphilis can be ruled out. Serologic tests should be taken at the time of the initial darkfield examination and repeated weekly for a month or more until syphilis or a different diagnosis is established. When collecting specimens for examination, the examiner should wear plastic or rubber gloves for protection against accidental infection. The examiner should clean the surface of the suspected lesion carefully with physiologic saline, dry it, and then gently abrade it to the point of bleeding. Gentle pressure should be maintained upon the lesion until only clear serum exudes. To increase the exudation of serum, the base of the lesion may be squeezed gently, or suction may be applied. The examiner should then pick up a drop of the serum directly on the surface of a glass slide and a cover slip and examine the serum under a properly adjusted darkfield microscope. T. pallidum can be identified by its morphologic characteristics and by its characteristic motions. These motions consist of a slow forward and backward movement, rotation about the long axis like a corkscrew, and a slight bending, twisting, or undulation from side to side. Care must be exercised in interpreting positive darkfield examinations of specimens from the mouth or anorectal areas since saprophytic spirochetes from these areas may be morphologically identical to T. pallidum. Failure to demonstrate the organisms from a suspected lesion may mean that: 1) the lesion is not syphilitic, 2) the patient has received systemic or local treatment, 3) too much time has elapsed since the lesion appeared, 4) the lesion may be a late manifestation of syphilis or, 5) the specimen collection technique or the person examining the specimen is ineffective.
Spinal Fluid Examination: The only means of diagnosing neurosyphilis accurately and evaluating the treatment of it is by spinal fluid examination. Commonly, neurosyphilis can be demonstrated months or years before the subjective or objective neurologic evidence of the disease develops.
False-Positive Reactors: Repeatedly reactive nontreponemal tests accompanied by nonreactive treponemal tests characterize the false-positive reactor. The duration of reagin reactivity arbitrarily determines whether the false-positive reaction is acute (less than 6 months) or chronic (6 months or longer). Acute false-positive reactions are found in persons who are suffering from many viral and bacterial infections or who have had certain vaccinations and immunizations. Titers are generally less than 1:8; the reaction lasts a few weeks to a few months. Many times, no preexisting illness or specific cause can be recognized. Chronic false-positive reactions are generally less common than acute false-positive reactions. Some findings are suggestive of collagen disease. Lepromatous leprosy, heroin addiction, and, occasionally, malaria are associated with chronic false-positive nontreponemal test results for syphilis.
Relapse and Reinfection
Relapse refers to the persistence or the reappearance of clinical or laboratory evidence of disease after treatment. Distinguishing relapse from reinfection may be difficult. The possibility of relapse is very small because of the extreme efficacy of modern antibiotic treatment, particularly penicillin. In early syphilis, lesions disappear, and the serologic reagin titer decreases rapidly and regularly after adequate treatment. Failure to do so indicates reinfection or that the earlier treatment was inadequate. Reinfection may be difficult to prove, but it is indicated by a new primary lesion at a site different from the initial primary lesion, a serologic pattern of new infection, or a history of new exposure. Both relapse and reinfection require retreatment and also renewed disease intervention efforts.
Serology in Pregnancy and the Newborn
Both nontreponemal and treponemal antibodies (including the antibodies responsible for a false-positive reaction) cross the placenta; therefore, if the mother has a reactive serologic test for syphilis, one may also expect the newborn's serologic test to be reactive. If the mother has a high titer, the infant may have a high titer because of the passive transfer of antibody from mother to infant. However, the child's titer usually does not exceed that of the mother's. A reactive serologic test for the newborn that is due to passive transfer should revert to nonreactive in 6 months for nontreponemal tests and in 12-15 months for treponemal tests. If the test does not become nonreactive, active infection of the newborn is strongly suggested. If the mother is infected late in pregnancy, both the mother and the newborn may have a nonreactive serologic test for syphilis at the time of delivery. In such a case, clinical signs and a rising titer in the ensuing weeks will confirm the diagnosis.
Syphilis Treatment
Early Syphilis:
For primary, secondary, or early latent less than one year: Benzathine penicillin G, 2.4 million units IM, once For patients who are allergic to penicillin: Doxycycline 100 mg orally 2 times a day for 2 weeks or Tetracycline 500 mg orally 4 times a day for 2 weeks
Syphilis of More Than One Year's Duration
For late latent syphilis of more than one year's duration, gummas, and cardiovascular syphilis: Benzathine penicillin G, 7.2 million units total, administered as 3 doses of 2.4 million units IM, given 1 week apart for 3 consecutive weeks For patients who are allergic to penicillin: Doxycycline 100 mg orally 2 times a day for 4 weeks or Tetracycline 500 mg orally 4 times a day for 4 weeks.
Neurosyphilis
Aqueous crystalline penicillin G, IV 12-24 million units administered daily, 2-4 million units every 4 hours for 10-14 days
Syphilis in Pregnancy
For patients at all stages of pregnancy who are not allergic, penicillin should be used in dosage schedules appropriate for the stage of syphilis as recommended for the treatment of non-pregnant patients. Tetracycline and doxycycline are contraindicated in pregnancy. Erythromycin should not be used because of the high risk of failure to cure infection in the fetus. Pregnant women with histories of penicillin allergy should first be questioned carefully about the validity of the history. If necessary, they should be skin tested and either treated with penicillin or referred for desensitization.
Congenital Syphilis
Aqueous crystalline penicillin G, 100,000-150,000 units/kg daily administered as 50,000 units/kg IV every 8-12 hours for 10-14 days or Procaine penicillin G, 50,000 units/kg daily administered once IM for 10-14 days.
Follow-Up and Retreatment
All patients treated for early syphilis should be reexamined at 3 months and 6 months. If nontreponemal antibody titers have not declined fourfold 3 months after treatment of primary or secondary syphilis, or 6 months after treatment of early latent syphilis, or if signs or symptoms persist and reinfection has been ruled out, the CSF should be examined and the patients retreated appropriately. If the patient is pregnant, monthly followup is mandatory so that retreatment can be given if needed. Seropositive untreated infants must be observed closely at 1, 2, 3, 6, and 12 months of age. In the absence of infection, nontreponemal antibody titers should begin to decrease by 3 months of age and should have disappeared by 6 months of age. If these titers are found to be stable or increasing, the child should be reevaluated and fully treated.
Preventive Treatment
Patients who have been exposed to infectious syphilis within the preceding 3 months and other patients who are at high risk for early syphilis should be treated as for early syphilis. Every effort should be made to establish a diagnosis in these cases.
Adverse Reactions to Penicillin
According to published reports, about 3,000 of every 100,000 persons receiving penicillin have an adverse reaction. Of these 3,000 persons, about 40 experience anaphylaxis and two die from the reaction. This estimate of the death rate agrees well with the finding in STD clinics of one fatal penicillin reaction in 94,655 treated patients.
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anaphylaxis: An allergic reaction to penicillin, usually occurring within one hour. The clinical presentation may include urticaria, bronchospasm, laryngeal edema, and hypotension. Death can result.
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procaine reaction: A nonallergic, self-limited neuropsychiatric syndrome that follows, within minutes, the IM administration of procaine penicillin. This occurs in about 0.1 percent to 0.3 percent of patient receiving procaine penicillin.
�
Jarisch-Herxheimer reaction: A self-limited febrile reaction. Most researchers believe that the reaction is caused by a toxin released by the dying spirochete after therapy. This reaction appears as a fever beginning several hours after therapy and subsiding within 24 hours. Headache and an increase of rashes are common. The reaction is seen in at least 50 percent of primary and secondary syphilis patients. Pregnant patients should be warned that early labor may occur.In addition to the penicillin reactions, some patients experience side effects when given tetracycline, including nausea, vomiting, diarrhea, predisposition to candida, and phototoxic skin eruptions. Tetracycline should not be given to pregnant patients and should not be taken with meals or dairy products.
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