Syphilis%20is%20still%20with%20us%20%20Paul%20R.%20Earl%20%20Facultad%20de%20Ciencias%20Biol

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Syphilis is still with us Paul R. Earl
Facultad de Ciencias BiológicasUniversidad
Autónoma de Nuevo LeónSan Nicolás, NL, Mexico
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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.
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Primary syphilis involves chancre and regional
lymphadenitis. Secondary syphilis usually
involves generalized rash, mucous patches and
condylomata lata. These 2 stages last about 12-20
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.
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Primary and secondary syphilis rates, by year -
US, 1970-1997
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HEALTH MINIMUMS INCLUDEAppropriate
antibiotic therapy such as penicillin GCareful
screening for other sexually-transmitted 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
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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.
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IS THERE A HAPPY ENDING TO THE SYPHILIS
STORY ? WILL NORWAY, CANADA AND THE US
BECOME MILESTONES ON THE ROAD TOGLOBAL
ERADICATION?
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DiscoveryEverything 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
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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.
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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.
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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.
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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 novelsin any wayrelate 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.
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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.
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ProgressIs 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.
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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?
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SYMPTOMSPrimary syphilisThe
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.
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Secondary syphilisA 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
contactsexual or nonsexualwith the broken skin
of an infected person may spread the infection at
this stage. The rash heals within several weeks
or months.
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Latent syphilisIf 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 syphilisAbout
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.
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NeurosyphilisYears 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.
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DIRECT SMEARSDarkfield microscopyDarkfield
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 antibody
to T. pallidum.
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SEROLOGICAL TESTSNontreponemal 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.
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Treponemal TestsPrologue now! Treponemas can be
cultured with mammalian cells (Infect. Immun. 32
908915, 1981 36 437439, 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.
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TreatmentIf the patient has a
reactive RPR or VDRL, a nonreactive
confirmatory test,such as fluorescent treponemal
antibody absorption (FTA-ABS),microhemagglutinati
on assay for antibodies to Treponema pallidum
(MHA-TP),or enzyme immunoassay (EIA), and no
clinical or epidemiologic evidence ofsyphilis,
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.
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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.
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Is it true that for every doctor preferring
parental therapy theres 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 one-dose in
a cocktail that eliminates all bacterial STD
agents is simple to attain. Or useperhapsjust a
FEW oral doses. Wake up America !
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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.