A Brief Synopsis of AFPs "Syphilis: A Reemerging Infection"

A brief synopsis of "Syphilis: A Reemerging Infection"
PETER L. MATTEI, MD, 87th Medical Group, Joint Base McGuire-Dix-Lakehurst, New Jersey, THOMAS M. BEACHKOFSKY, MD, 8th Medical Group, Kunsan Air Base, Republic of Korea, ROBERT T. GILSON, MD, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, OLIVER J. WISCO, DO, Harvard Medical School, Boston, Massachusetts
http://www.aafp.org/afp/2012/0901/p433.pdf
Am Fam Physician. 2012 Sep 1;86(5):433-440.

     Syphilis has been on the rise over the last decade, especially in men who have sex with men. It is spread by the transmission of Treponema pallidum through sexual contact. Primary syphilis is characterized by a single painless genital chancre, which develops about a week after infection.  Sometimes, (if the syphilis didn't read the micro book in disease school) the chancre may show up in the mouth, fingers, or nipple. There are times when more than one chancre appears (the nerve of that bug!).It is possible for the chancre to go undetected. 
     Secondary syphilis will occur 6-8 weeks after primary syphilis. Pinkish red macules and papules will appear on the face, trunk, mouth, and extremities. The patient may also develop syphilitic alopecia, which presents as "moth eaten"  hair. Occasionally the alopecia is the only symptom. Cutaneous mucosal papules can become macerated, warm, moist, flat and ulcerated. A sample from these cutaneous manifestations can reveal treponema under dark-field microscopy.
     Untreated secondary syphilis can progress to a latent stage, where the patient will appear symptomatic.  If the patient is in the latent stage for more than a year, it is classified as late latent, less than a year being classified as early latent. In the early latent phase, the patient can still infect others, whereas in the late phase, it appears that the patient cannot. 
     About a third of latent staged patients will progress to tertiary syphilis. It can present as either neurosyphilis, cardiovascular syphilis, or late benign syphilis. Neurosyphilis occurs when the treponema crossed the blood brain barrier. It can cause paresis, memory defects, or a cerebrovascular accident. It can cause changes in the posterior column of the spinal cord, causing tabes dorsalis (sensory ataxia of the legs). Patients infected with HIV have a greater risk of getting neurosyphilis.  Cardiovascular syphilis can affect the ascending aorta or similar vessels. Late benign syphilis occurs in about half of all patients with tertiary syphilis. It appears as granulomas, gummas, and psoriasiform plaques. 
     Transplacental transmission or direct contact with lesions during birth can cause congential syphilis. Two thirds of infected babies are symptomatic at birth.  Early signs (by age 4 years) are hepatosplenomegaly  fever, rash, seizures, a bulging fontanelle, or cranial nerve palsies. Common late signs (age 4-20 years) are hutchinson teeth (peg shaped upper central incisors), higoumenakis sign (unilateral enlargement of the proximal clavicle), mulberry moles (additional cusps on first molar), saddle nose (diminished nasal cartilage), or olympian brow(frontal bossing of forehead).
     Screening for syphilis is done with VDRL and RPR (nontreponemal serologic)  tests. They detect antibodies to cardiolipin in the blood. The test will not be positive until about a month after being infected.  IgM antibodies can be detected 2-3 weeks after being infected. Dark field microscopy can be used to directly visualize the pathogen within the lesion.  Patients who are positively screened should have a confirmatory test, such as the fluorescent treponemal antibody absorption assay or the T.pallidum particle agglutination test. If the screening test is negative, but there is strong clinical indication, a screen can be repeated in 2 weeks. Patients found to have syphilis should also be tested for HIV. Male patients who have sex with men should be tested for syphilis annually. 
     Treatment has not changed. In primary, secondary, and early latent syphilis, a single injection of penicillin G benzathine is given. Late latent or tertiary syphilis patients can be treated with three injections, one per week. Neurosyphilis requires IV aqueous crystalline penicillin G every four hours for up to two weeks.
     Within the first day of treatment, the patient can develop a Jarisch-Herxheimer reaction. The reaction is a acute fever in result of an increase of inflammatory cytokines from the pathogen lysis. within 3-6 months, the RPR/VDRL titer should decrease by fourfold. The pate will eventually seroconvert but if they don't it is called a serofast reaction.