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Primary syphilis
| • | chancre: clean, well made, rolled border, painless |
| • | serology becomes positive » 3 weeks after chancre (4-6 weeks after infection) |
| • | therefore diagnose primary syphilis by dark field examination |
| • | generally heals within 4 to 6 weeks |
Secondary syphilis
| • | 6 weeks to 6 months after contact |
Manifestations
| • | healing primary chancre is still present in 15% of cases |
| • | generalized non-tender lymphadenopathy (cervical, epitrochlear, inguinal) |
Dermatologic:
| • | often PR or guttate psoriasis appearing lesions; non-pruritic |
| • | moth eaten alopecia (eyebrows also) |
| • | check for mucous patches: |
| • | ddx: white sponge nevus, LP, SCC, oral hairy leukoplakia, thrush, leukoplakia, blistering disease |
| • | dark-field exam useless in specimens from the mouth (because of nonpathogenic spirochetes) |
| • | split papules (commisures of lips, side of nose, post-auricular) |
| • | when the papular lesions occur in most intertriginous areas, they are known as condyloma lata same lesions in the mouth = mucous patches etc... |
DISTINCT PRESENTATIONS
| • | rupioid = “dirty”; secondary syphilis |
| • | heaped up, ostraceous (oyster shell) scale |
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| • | classically: black patient, face |
| • | “nickels and dimes” on face of patient with secondary syphilis |
| • | histology: lichenoid and granulomatous with plasma cells |
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TREATMENT: primary or secondary (non-HIV) syphilis pencillin G 2.4 million units IM X 1
Prozone phenomenon:
| • | cause of false negativity in RPR, VDRL etc… |
| • | titer of antibody is too high, and therefore no flocculation will occur until higher dilutions |
Jarcisch – Herxheimer Reaction:
| • | flu-like symptoms occurring 2-6 hours after treatment with PCN (most often seen in secondary syphilis) |
| • | symptoms are controlled with NSAID's or aspirin |
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| • | 4 to 20 years after infection |
| • | 1/3 of untreated cases progress to tertiary syphilis |
| • | tertiary syphilis can be mucocutaneous, osseous, visceral or neural |
| • | tertiary lesions are caused by obliterative small-vessel endarteritis (usually involves the vasa vasorum of the ascending aorta and, less often the CNS) |
Neurosyphilis
Meningovascular:
| • | invasion of the CNS by T. pallidum occurs during the first weeks or months of infection |
| • | syphilitic meningitis is therefore seen in secondary syphilis; presenting as an aseptic meningitis |
| • | meningovascular syphilis is an endarteritis with focal neurologic signs |
Parenchymatous:
| • | a result of the arteritis that occurs in tertiary syphilis |
| • | these are late complications of late untreated neurosyphilis |
Tabes dorsalis
| • | dorsal columns and posterior roots affected (particularly affecting the lower extremities) |
| • | dorsal columns = proprioception and stereognosis |
| • | posterior roots = peripheral sensory nerves entering spinal cord |
| • | posterior root irritation à shooting or lightening pains |
| • | paresthesia à secondary injuries and infection: Charcot’s joints (from trauma) |
General paresis
| • | parenchymatous degeneration of brain substance |
| • | Argyll Robertson pupils (+ accommodate, (-) light; i.e. like a prostitute, they accommodate but do not react) |
gumma
| • | starts as a deep firm swelling that eventually breaks down to form an ulcer |
| • | destructive, hypersensitivity reaction |
cardiovascular disease
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Congenital syphilis:
| • | early – until 2 years (snuffles, diaper dermatitis, peri-orificial inflammation, palms and soles, blisters this is the only time that syphilis is vesicular) |
| • | “snuffles” (syphilitic rhinitis) – purulent/ hemorrhagic nasal discharge |
| • | late – after 2 years (stigmata) |
| • | Hutchinson’s teeth – upper incisors that are peg shaped and notched |
| • | Mulberry molars – dome shaped molars with numerous cusps |
| • | Higoumenakis sign – unilateral irregular enlargement of the clavicle (secondary to previous periostitis) |
| • | Saber shins – anterior bowing and thickening of midportion of the tibia (secondary to previous periostitis) |
| • | Rhagades – depressed linear lines that radiate form the orifice like spokes of a wheel |
| • | diagnosis: IgM FTA-ABS (all other tests measure IgG) |
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