Syphilis

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Overview

Syphilis is a disease / sexually transmitted infection, which untreated can cause major complications. Infection has alternating periods of activity and inactivity (latency period). Symptoms occur during periods of activity; in the latency periods there are no symptoms, but the patient is still infected. Whoever comes in contact with a person infected with syphilis can get sick. Intercourse is not necessary to be transmitted infection, this can be achieved by mere contact with the mouth, rectum or genitals of an infected person.
 


Causes

Syphilis is an infection caused by bacteria called Treponema pallidum.


Mode of transmission

Transmission of bacteria is usually done during vaginal intercourse, anal or oral. The bacterium that causes syphilis is transmitted from person to person by direct contact with:
- Open lesion (canker) that occurs during the primary stage
- Mucous membranes or other types of injuries that occur during the second stage and sometimes in latent syphilis.

Lesions usually appear on the external genitals, vagina, anus or rectum. Damage can sometimes occur on the lips or around the lips. The bacteria enters the body, usually through the mucous membranes, most frequently around the genitals and urinary tract. Rarely, the bacteria enter the body through the skin continuity solutions, such as cuts, or by kissing if the infected person has a lesion in the mouth or lips. Syphilis can be transmitted by using a needle previously used for / by an infected person.

Another way of transmission is through blood transfusions, but this way is very rare because blood collected for transfusion is tested for sexually transmitted diseases and bacteria that causes syphilis do not last more than 24-48 hours in conditions in which the blood for transfusion is stored.
If you are pregnant and infected with syphilis, the bacteria can cross the placenta and infect the fetus at any stage of pregnancy or birth (congenital syphilis).
Syphilis is not transmitted through casual contact with toilet seats, door handles, the water in pools, bathtubs, the clothes or dishes. An infection with Treponema pallidum in the past, do not protect the individual for a new infection, although, in rare cases may occur resistance to the disease that protects the individual against a new infection.

The incubation period
The incubation period is the period between the exposure to infection and the moment when symptoms appear. A skin lesion called canker, is the first symptom of sexually transmitted syphilis. Canker occurs in a period of 10-90 days from time of infection, the range is usually 21 days.

Period of infectivity

A person with syphilis can transmit the disease (is contagious) to the partners, when are present lesions that are primary or secondary. The infected person can be contagious intermittently for years and is always contagious when there are open lesions or rash caused by syphilis.

Symptoms

Syphilis has an evolution in four stages, each stage having distinct symptoms.

Primary syphilis

In the primary stage a canker usually painless, occurs at penetration of bacteria in the body. This usually occurs within 3 weeks of exposure (the margins are 10-90 days). The infected person is contagious during the primary stage. In men canker appears frequently in the genital area, usually but not always, on the penis. These lesions are usually painless. In women canker may appear at the external genitalia or internal. Canker may go unnoticed when it occurs in the vagina or lower part of the uterus (cervix) because they are painful and hard to visualize. Increase in volume of the lymph-nodes (adenopathy) is usually found near the area where the canker. Canker may occur on other body parts also. When this occurs, the canker is usually inflamed and produces pus. Canker lasts 28-42 days, then goes away without treatment, leaving a thin scar. If the canker has healed does not mean that a person has been cured or is no longer contagious.

Secondary syphilis

Secondary syphilis is characterized by a rash that occurs at 4-10 weeks after appearance of canker, sometimes before it is cured. And other symptoms may appear that shows that the infection has spread in the body. The person is highly contagious in the second stage of syphilis. The rash appears on the entire body including palms and plants. The lesions are reddish-brown, small, elevated or not, and have less than 2 cm. They can be confused with other skin lesions. Wounds, small, can be present in the mucosa. These lesions may contain pus. Moist lesions are visually distinct, being called “condiloma wide”. In people with dark skin, lesions may have a lighter color than surrounding skin. Rash heals without treatment and without leaving scars in 2 to 12 weeks. After healing, skin may remain slightly discolored. The healing of the rash does not mean that the person has healed or is no longer contagious.

Syphilis latent (hidden)

Left untreated, a person infected with syphilis will go into dormant stage (hidden) of the disease. Latent stage comes one year after the onset of infection. After the eruption of the second stage disappears, the infected person is asymptomatic for a time (latent period). Latency period may be one year but can stretch between 5 and 40 years. Usually, at this stage, a diagnosis can be made only on blood tests, history of illness or birth of a child with congenital syphilis. A person is contagious during the first half of the latent stage and may be contagious in the second part of this range.

Relapses. About 20-30% of those infected with syphilis presents latent stage of disease relapses. Relapse means that in a person who was asymptomatic, symptoms begin to show again. Relapses can occur several times. When relapses do not occur, the patient no longer transmit the disease through contact. A pregnant woman found in dormant stage, can transmit the disease to the fetus (congenital syphilis), can have an abortion or a baby born dead.

Tertiary syphilis (late stage)

This is the most destructive stage of the disease. He may begin one year after infection or at any time in the life of people infected with syphilis and not treated. A person infected with syphilis may never reach the tertiary stage. At this stage, the disease can cause serious diseases of blood vessels and heart, mental disorders, blindness, nervous system disorders and even death. Symptoms of tertiary syphilis depend on the complications that arise.
Complications of this stage include:
- Syphilitic accumulated gummas, which are large lesions located on skin or inside the body
- Cardiovascular syphilis, which affects the heart and blood vessels
- Neuro-syphilis, which affects the brain and meninges.

Overview

Congenital syphilis
Congenital syphilis refers to the disease transmitted by the mother during pregnancy or birth. It is recommended that every pregnant woman be tested for syphilis because of severe consequences of the disease to the fetus.
Testing will be done:
- At the pregnant woman’s first prenatal visit
- In the early third trimester and again at birth, for women at risk of being infected.

Congenital syphilis increases the risk of fetal death and complications in the newborn. Bacteria enter the bloodstream of the fetus through the placenta, causing infection of the newborn or fetal death.
Symptoms of congenital syphilis include:
- Rhinorrhea (discharge of secretions from the nose) aqueous, highly contagious
- Painful inflammation of the periosteum (outer layer of bone)
- Contagious rash that commonly occurs in the plants and palms
- Anemia (shortage of red blood cells)
- Increase in volume of liver and spleen (hepato-splenomegaly)
- Growth in lymph nodes (lymph glands)
- Retardation in growth and development.

Because there are other diseases with similar symptoms, the correct diagnosis is important in treatment.
 

Physiopathogenic mechanism

In about three weeks (although the range lies between 10 and 90 days) after infection, an injury occurs (canker) which is usually painless in the genitals. Usually, the chancre heals without treatment in 28-42 days. This stage is called primary syphilis. If untreated reach the second stage (secondary syphilis). At this stage there is an eruption about two months after the appearance of the canker, which disappears without treatment in 1-2 weeks. After the disappearance of the rash, the infected person may have an asymptomatic period. This is called latent syphilis.

Although the symptoms disappear, the bacteria that cause syphilis remains in the body and attack internal organs. Latency period may be one year, the average being 5 to 20 years. The infected person is contagious during the primary syphilis, secondary and the first part of the latent stage. Meanwhile, symptoms of secondary syphilis may recur several times (relapse). If not diagnosed and treated, it can reach the tertiary stage of syphilis, which is the most destructive stage of the disease. At this stage, the disease can cause diseases of blood vessels and heart, mental illness (including dementia), blindness, nervous system disorders and even death. Tertiary syphilis may begin one year after infection or at any time in the life of the people infected with syphilis and not treated. Approximately one third of those infected develop tertiary syphilis complications.

Risk Factors

Risk factors for infection with Treponema pallidum are:
- Unprotected sex (sex without a condom or incorrect use of condoms), especially among gay
- Multiple sexual partners, especially in areas where the disease is widespread
- Sexual contact with an infected person
- Sexual contact with someone who has multiple sex partners
- Prostitution
- HIV infection.

A person is contagious if you have wounds or rashes in the case of disease. The risk of being infected with syphilis after a single sexual contact with an infected partner is approximately 3-10%. Syphilis infection increases a person’s risk of being infected with HIV. Syphilis causes open lesions on the genitals that allow HIV to enter the body. Syphilis is most common among people who are infected with HIV.

Specialist’s consult

The consult of a specialist is needed when:
- Appear lesions, rashes, blisters or bumps around the genitals, anal area or in any part of the body, if there is suspicion of sexually transmitted disease
- The possibility that the person is exposed to STDs.

Watchful waiting

Watchful waiting, which is a follow-up attitude is not recommended in case of exposure to the bacterium that causes syphilis or in other sexually transmitted diseases. Any symptom or amendment suggests syphilis or another sexually transmitted disease should be evaluated by a physician. Early treatment reduces the complications of the disease and prevents infecting other people. If there is suspicion of sexually transmitted diseases, sexual contact should be avoided until consulting a doctor. If a person is diagnosed with syphilis, the partner should be treated too.

Recommended medical specialists

Usually, the general practician can diagnose and treat syphilis. Other doctors who can do this are:
-Physician
-Gynecologist-obstetrician
-Dermatologist

Complications of tertiary syphilis are treated by a physician in infectious diseases.

Investigations

The first step in the diagnosis of syphilis is a detailed history of symptoms and sexual activity and physical examination. Diagnosis of syphilis is confirmed by blood tests. They are necessary, especially if lesions are not characteristic. If lesions are present, the liquid in one of them is examined under a microscope to highlight the disease-causing bacteria (examination by dark field). A careful examination of the skin and mouth, is made to search for the existence of a rash or other changes. For women, a pelvic examination is necessary to look for signs of syphilis. Are searched the abnormal lesions of the vagina, vulva, labia, genital area. These lesions occur in primary syphilis. Investigations are recommended for pregnant women screening for syphilis infection, because of the risk for the fetus.

Screening is done:
- At the pregnant woman’s first prenatal visit
- In the early third trimester and again at birth for women at risk of being infected
A genital examination is performed in men, in order to detect signs of syphilis. For infants, the initial evaluation for congenital syphilis begins with an assessment of the health of the mother and her testing for syphilis. Your doctor will examine both mother and newborn. In primary and secondary syphilis diagnosis is sometimes required a lumbar puncture.
This is necessary in adults when:
- There are signs of tertiary syphilis (aneurysm (dilation) of the aorta, accumulated gummas, irritation (inflammation of the eye called the iris anatomy) or neuro-syphilis
- Recommended penicillin or other antibiotics can not be used to treat syphilis latent in this situation it is necessary to determine if the spinal cord and brain fluid (cerebrospinal fluid – CSF) is infected, because that requires specific methods of treatment of CSF infection
- Person is infected with HIV
- Is necessary to verify the healing neuro-syphilis

Newborn and infant lumbar puncture is performed when:
- There are signs of congenital syphilis
- The mother had syphilis and was not treated or were treated after the 20th week of pregnancy
- Mother was treated with another antibiotic than penicillin.

There has to be carried out other tests to determine if there are other STDs, especially chlamydia, gonorrhea or HIV infection, people infected with syphilis are more likely to acquire HIV infection.
Syphilis diagnosis can be delayed or complicated because its symptoms are similar to many other diseases. Syphilis is known as the great imitator.


Early diagnosis

Sceening the syphilis is recommended for pregnant women and for people at high risk of infection.

People at risk of being infected are those who:
- Have unprotected sex (sex without a condom or incorrect use of condoms), especially among gay
- Have multiple sexual partners, especially in areas where the disease is widespread
- Have sex with an infected person
- Have sex with someone who has multiple sex partners
- Prostitute
- Who are infected with HIV.

Investigations are recommended for pregnant women screening for syphilis infection, because of the risk for the fetus.
Screening is done:
- At the pregnant woman’s first prenatal visit
- In the early third trimester and again at birth for women at risk of being infected
Remember!
Syphilis diagnosis can be delayed or complicated because its symptoms are similar to many other diseases. Syphilis is known as the great imitator.


Treatment – General

Prompt treatment of syphilis is necessary to cure, prevent complications and transmission to others. Antibiotics are an effective treatment at any stage. Antibiotic treatment can not cure complications already occurred, but may prevent onset of new complications. After treatment are needed some dynamic tests to make sure that the treatment was successful. Exposed life partners, must be examined, tested and treated. Penicillin is the antibiotic of choice for treatment of syphilis. Although penicillin is the standard treatment for neuro-syphilis, congenital syphilis or syphilis acquired or detected during pregnancy, other antibiotics such as ceftriaxone, can be considered. If the patient is allergic to penicillin, treatment is possible, but your doctor should choose the best treatment option.

Remember!
Antibiotics can cure syphilis and prevent complications. Complications occurred in tertiary syphilis an in the congenital one can be irreversible, but progression can be stopped. Penicillin is the preferred antibiotic treatment of syphilis. Although penicillin is the standard treatment in neuro-syphilis, congenital syphilis and syphilis in pregnant women, other antibiotics (e.g. ceftriaxone) may be considered. Penicillin is the only antibiotic with a certain effect in the treatment of neuro-syphilis, congenital syphilis and syphilis of pregnant women. When using other antibiotics, careful follow-up is required after treatment. Penicillin given to the mother comes in small quantities in milk. But these amounts are not harmful to the nursing infant.
Instead doxycycline and tetracycline, which also pass into breast milk can impair the child’s teeth and bones. During breastfeeding, self-medication of any kind is prohibited. For any drug should be required a specialist’s opinion. After treatment, examinations and blood tests will be performed at 6 and 12 months and 24 months for latent syphilis to confirm healing. If present a co-infection with HIV, further examinations and tests will be performed at 3, 6, 9, 12 and 24 months. These tests are necessary because sometimes the first treatment does not cure the disease and additional doses are required.

Overview

Prophylaxis
Avoiding exposure to risk factors effectively prevent infection or reinfection with the bacterium that causes syphilis.
Prevention includes:

- Protected sex: it is recommended that the number of sexual partners not to be high and when the partner is involved in sexual risk behaviors, to use condoms
- Proper use of condoms: condom expiration date should be checked before use, the condom is applied to the erect penis before starting sex and the condom is removed by pressing the base (near the pubic hair line insertion); the condom must be removed at the end of sex , when the penis is still erect
- Buying condoms that meet safety standards: they should be protected until use
- Use diaphragm (female condom): is a plastic tube, soft, closed at one end, which can be inserted into the vagina up to 8 hours before sex; not to be used with the ordinary condom

Home treatment

It is important that people suffering from syphilis to receive specialized treatment. Is not recommended an empirical treatment. Syphilis should be diagnosed accurately and treated with drugs, with antibiotics prescribed by a doctor. Once diagnosed and prescribed the treatment, prophylaxis can prevent reinfection or acquisition of other STDs.

Drug treatment

Treatment of syphilis and other sexually transmitted diseases is complex. Treatment with penicillin cured syphilis in most cases if performed as indicated by the doctor. If the disease reached the stage of secondary syphilis, antibiotic treatment will prevent further complications, but not cure the damage already occurring. Prompt antibiotic treatment decreases the rate of complications and prevent the spread of infection. Sexual partners exposed to infection should be treated. Because the syphilitic canker may facilitate HIV infection, we recommend simultaneous testing for syphilis and HIV.

Medication Choices

Antibiotics are always used in the treatment of syphilis. Penicillin is the antibiotic most commonly used to treat syphilis. Usually is injected. If the patient is allergic to penicillin, your doctor may prescribe another antibiotic such as doxycycline, tetracycline, ceftriaxone or azithromycin. These antibiotics are prescribed, especially in early stage disease. In advanced stages of disease, treatment with penicillin is required. Penicillin is the only antibiotic used during pregnancy. Pregnant women allergic to penicillin need a specialist’s medical consult. Antibiotics kill the bacteria that causes syphilis. Antibiotics are indicated when syphilis is detected by routine blood test or when are present symptoms suggestive of syphilis. Sexual partners of infected persons and infants of infected mothers, also require treatment.

Amount of antibiotic used and the dosing interval is determined by stage of disease. For example, if neuro-syphilis is present, is currently recommended antibiotics for 10-14 days. Treatment with penicillin cured syphilis in most cases, if performed as directed by the doctor. If the disease reached the stage of secondary syphilis, antibiotic treatment will prevent further complications but not cure damage already occurring. After treatment, examinations and blood tests will be performed at 6 months and 12 months, and in case of latent syphilis at 24 months too, to confirm healing. If present a co-infection with HIV, further examinations and tests will be performed at 3, 6, 9, 12 and 24 months. Congenital syphilis can be prevented if infected pregnant women are treated before 16-18 weeks of pregnancy. After this period, the treatment will cure the infection and stop the evolution of damage, but damage already incurred will not involute.

Side effects

Jarisch-Herxheimer reaction occurs after antibiotic treatment of syphilis and include fever and cephalea (headache). It can occur in a period of up to 8 hours after starting the treatment of the early stages of syphilis. To prevent this reaction, before antibiotics are administered oral corticosteroids such as prednisone, or nonsteroidal anti-inflammatory. Many experts do not recommend this method as Jarisch-Herxheimer reaction time is small and light. Jarisch-Herxheimer reaction occurs in approximately 50-75% of patients with primary syphilis treated with antibiotics. The cause of this reaction is unknown but is assumed to be caused by toxins released from bacteria destroyed during treatment with antibiotics. Jarisch-Herxheimer reaction is an allergic reaction to penicillin. Pregnant women in the second quarter, showing Jarisch-Herxheimer reaction are at increased risk for preterm delivery and fetal distress. Despite this they should be treated, because congenital syphilis is frequently associated with fetal death.

Surgical treatment

There is no surgical treatment for syphilis.

Other treatments

There are not other forms of treatment for syphilis.

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