SYPHILIS

Liezle A. Gargoles BSN-3B

Presentation Overview
Other Terms of Syphilis Definition Epidemiology Causative Agent Morphology Mode of Transmission Stages of Syphilis Incubation Period Risk Factors and Pathophysiology Clinical Manifestations

Complications Diagnostic Tests and Expected Results Treatment Nursing Diagnoses Nursing Interventions

Prevention
Patient Education Prognosis Recent Study Related to Syphilis Related videos

Also termed as:

Sy

Bad Blood

The Pox

Syphilis
It is an acute and chronic sexually transmitted disease that causes various symptoms at different stages of infection. If left untreated, syphilis can have many serious complications.

Causative Agent
t Spirochete

Treponema Pallidum

Morphology
Spiraled organism with helical shape resembling a spring or corkscrew; have flagella for organism motility.

Epidemiology

Worldwide ~ 12 million new syphilis cases/year

>90% in the developing world In the US the rate of primary and secondary

syphilis infection decreased through the 1990s to lowest recorded rate in 2000. However, there was a 29% increased annual rate of primary and secondary syphilis in 2004 (2.7 per 100,000) from 2000 (2.1 per 100,000) Nearly all of the increase is in men MSM account for most of the increase One study in Chicago reported transmission via oral sex may constitute as much as 13.7% of contagion

Mode of

Transmissio n

 Direct contact with infectious

sore

Sexual contact, oral genital, or genital anal contact, close body contact and kissing.

Perinatal

4 Stages of Syphilis
Primary Stage Secondary Stage Latency Tertiary Stage

Incubation Period

Primary stage: 10 90 days (~3 months) with

average of 21 days
Secondary stage: 6 weeks after primary lesion

occurs
Latency: 4-12 weeks after beginning of stage 2
Tertiary Stage: 1 year to a lifetime after

secondary lesions occur

Risk Factors

 Any sexually active

person is at risk for syphilis during sexual contact with an infected person or a person whose syphilis status is not known but risk of contracting the disease increases if you: engage in unprotected sexual activity, have multiple sex partners, engage in male to male sexual intercourse. Babies born to infected women are also at risk.

Pathophysiolog y

spirochete Treponema pallidum

gaining access to subcutaneous tissues invading the subcutaneous tissue

establishes the chancre

establish infection in regional lymph nodes during early local replication

Clinical Manifestions

Primary Stage
Small red papule changes to small ulcer, then

to hard chancre at site of entry, lymphadenopathy Chancre begins as a small papule within 3 7 days. Without treatment chancre disappears within 6 weeks but microorganisms spreads. Chancre on genitalia, mouth, or anus. Serous drainage from chancre. Enlarged lymph nodes.

Secondary Stage

Develop 6 weeks to 6 months. Subsided in 4 12 weeks without treatment. Systemic disease. Skin rash on palms and soles of feet. Erosions of oral mucous membrane. Alopecia. Enlarged lymph nodes. Fever.

Latency
Asymptomatic

Tertiary Stage
Gummas, cardiovascular lesions,

neurosyphilis Occurs after a highly variable period from 4 20 years. Benign lesion (gummas) of the skin, mucous membrane and bones. Neurosyphilis causes CNS problem Cardiovascular changes. Personality changes. Ataxia. Stroke.

Congenital syphilis: prematurity, IUGR,

hepatosplenomegaly, bone marrow depression, bone and skin lesions, retinal inflammation, glaucoma, blood dyscrasias, nephrotic syndrome, CNS involvement

Complications

 If treated promptly, syphilis can be cured without causing

any serious health complications. However, if left untreated, syphilis can become a very dangerous illness. The syphilis bacteria will begin to attack all areas of the body, including the joints and muscles, heart and lungs, spinal cord and brain. People with long-term syphilis are at risk for: * blindness * deafness * muscle control problems * seizures * dementia Because of the sores associated with syphilis, those infected with the disease are also at increased risk for contracting HIV, the virus that causes AIDS. Pregnant women infected with syphilis are also at increased risk for miscarriage, preterm labor, and stillbirth.

Syphilis and HIV

HIV and syphilis are prevalent in the same risk groups:

men who have sex with men, injection drug users, and individuals engaging in sex in exchange for drugs or money. Both infections have been reported to enhance the acquisition and transmission of each other

SYPHILIS and pregnancy

Women suffering from syphilis during pregnancy show similar symptoms to that of other women but they are facing additional risk of infecting newborns. Women with syphilis can have miscarriages, stillbirths and even premature births. If active syphilis is not treated during pregnancy, mother will pass the infection to her unborn child. About 25% of these pregnancies result in stillbirth or neonatal death. About 40-70% of such pregnancies will yield a syphilis-infected infant.

 Some infants with congenital syphilis could have

symptoms at birth, but most develop symptoms between two weeks and three months later. These symptoms may include skin sores, rashes, fever, weakened or hoarse crying sounds, swollen liver and spleen, yellowish skin (jaundice), anemia, and various deformities. Care must be taken in handling an infant with congenital syphilis because the moist sores are infectious.

 Rarely, the symptoms of syphilis go undetected in

infants. As infected infants become older children and teenagers, they may develop the symptoms of latestage syphilis including damage to their bones, teeth, eyes, ears, and brain. Babies with congenital syphilis could experience the following symptoms: Skin sores Seizures Fever Swollen liver and spleen Jaundice Anemia Slow development Death due to severe damage done by the disease.

Diagnostic Tests

Darkfield examination and direct

fluorescent antibody
Serologic tests Cerebrospinal fluid evaluation

Diagnostic Evaluation
Darkfield examination and direct

fluorescent antibody Darkfield examination and direct fluorescent antibody (DFA) testing of a sample from suspicious genital or anal chancres or moist dermatologic lesions (not oral lesions) are definitive tests for syphilis, although these are not available in most clinical settings.

Serologic tests

Nontreponemal tests (RPR or VDRL) are most sensitive in primary and secondary syphilis when titers are high, though the response may be delayed in HIV-infected patients (nontreponemal test results typically are positive within 3 months after infection). Because falsepositive results may occur, particularly in the setting of HIV infection, positive nontreponemal test results must be confirmed with a treponemal test. Titers may be used to follow response to treatment; a fourfold change in titer is considered a significant change. Note that the same nontreponemal test should be used consistently for a single patient; RPR titers cannot be compared with VDRL titers.

Treponemal antibody tests (TP-PA [T. pallidum particle agglutination] or FTA-ABS [fluorescent treponemal antibody absorption]) confirm a positive nontreponemal test. As an alternative, many laboratories have begun to use a treponemal test, e.g., an enzyme immunoassay (EIA) as an initial screen for syphilis infection, followed by a nontreponemal test for confirmation, to reduce the workload from the titration required for nontreponemal titers.

A false-negative RPR or VDRL result may occur, usually when the test is performed in early infection, before a sufficient antibody response has developed. Another possible cause of a false-negative nontreponemal result is the prozone phenomenon, seen when antibody concentrations are very high (usually in secondary syphilis) and the specimen is not diluted sufficiently. If serologic test results are negative and suspicion of syphilis is high, perform other diagnostic tests (e.g., biopsy) or request that the laboratory perform additional dilutions on nontreponemal test specimens.

 Cerebrospinal fluid evaluation

HIV-infected patients with neurologic or ocular signs or symptoms of syphilis, late latent syphilis, syphilis of unknown duration, or tertiary syphilis should undergo lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis. CSF evaluation also is indicated for patients in whom treatment for early syphilis fails. Routine CSF evaluation is not indicated for HIV-infected patients who have early syphilis without neurologic or ophthalmic signs or symptoms. CSF analysis should include the following: CSF-VDRL: This test is specific but not very sensitive; a positive result is diagnostic but a negative result does not rule out neurosyphilis. Leukocytes: Elevated white blood cell count (>10 cells/L) is suggestive but not specific. Note that mononuclear pleocytosis (up to 5-20 cells/L) is not uncommon in patients with HIV infection, particularly those with higher CD4 cell counts. Some recommend checking CSF FTA-ABS. This is very

Nursing Diagnosis

Deficient knowledge related to: new diagnosis of STD Information, misinformation, or misinterpretation of diagnosis Lack of exposure Fear of AIDS Embarassment about topic Infection related to: Inadequate body defenses Tissue destruction Extension of infection Sexual exposure Disturbed body image related to: Lesions Urethral discharge Odiferous discharge

Nursing Interventions
Review basic hygiene before topical

administration of drugs (e.g. Wash lesions with soap and water, keep area dry, wear loose-fitting cotton undergarments). Rationale: Basic hygiene of lesions helps prevent further contamination. Cotton products decrease perspiration

 Discuss the importance of notifying all sexual

partners. Rationale: This decrease the chance of spread of the disease. In most states, STDs are reportable diseases. Public health workers will contact sexual partners for testing and treatment.

 Instruct the patient about scheduling

appointments and treatments Rationale: Follow-up testing is necessary to prove eradication of disease

 Instruct the patients to avoid:

kissing touching mutual masturbation oral sex with latex condom Rationale: To prevent the transmission of the disease to sexual partners

 Instruct in use of latex male condom

Rationale: Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of infection

 Discuss the benefits of monogamous

relationships. Rationale: The surest way to avoid transmission of STDs is to abstain from sexual contact, or to be in a longterm mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Treatment

 Early syphilis is a reportable disease and should be

brought to the attention of the department of public health T. pallidum remains highly sensitive to penicillin and no resistance has been reported to date despite several decades of use

 Standard therapy for primary, secondary, or early latent

syphilis is benzathene penicillin G (one dose 2.4 million units IM) If the patient has had syphilis of greater than 1 year duration or if duration is unknown, treatment should be benzathene penicillin G 2.4 million units IM x 3 doses, 1 week apart. For penicillin allergic patients Early syphilis: Doxycyline 100mg BID x 14 days, or tetracycline 500mg QID x 14 days. Ceftriaxone and azithromycin have both been studied but are not currently recommended. Gummatous syphilis: Doxycycline 100mg BID for 28 days. Cardiovascular syphilis: Ceftriaxone 1g daily for 10-14 days (if history of mild PCN allergy) Neurosyphilis: Patients should undergo desensitization and treatment with PCN

Prevention

The following advices can prevent thousands of cases of syphilis: Know your sex partners well. Do not have sex with anyone who has genital sores. Patients with infectious syphilis should abstain from sexual activity until rendered noninfectious by antibiotic therapy. Use condoms - latex condoms used consistently and correctly are an effective means for preventing syphilis.

 Syphilis cannot be prevented

by washing the genitals, urinating, or douching after sex. Any unusual discharge, sore, or rash, especially in the groin area, should be a signal to stop having sex and to seek health care right away. Notify all sex partners immediately so that they can seek care, too. If you are pregnant, get a prenatal blood test. Because untreated syphilis in a pregnant woman can infect and possibly kill her developing baby, every pregnant woman should have

Patient Teaching

 Instruct patients to go to clinic for treatment at the

intervals recommended. If patients are given oral antibiotics (penicillin-allergic individuals), instruct them to take their medications exactly as prescribed.
Warn patients about the possibility of a Jarisch-

Herxheimer reaction and advise them about selfmanagement of associated symptoms (e.g., acetaminophen or aspirin at usual doses, fluids, and rest).
Instruct patients about the required follow-up

laboratory and clinical evaluations necessary to document adequate treatment. Emphasize the need for regular evaluation of treatment efficacy.

Sex partners from the previous 3-6 months

(sometimes longer, depending on the stage of syphilis) need to be evaluated and treated as soon as possible, even if they have no symptoms. Advise patients to inform their partners that they need to be tested and treated. Syphilis is a reportable communicable disease in the United States. Patients will be contacted to assist with partner tracing and to ensure appropriate treatment. Provide education about sexual risk reduction. Review sexual practices and support patients in using condoms with every sexual contact to

Prognosis

After treatment of first episode primary or

secondary syphilis the VDRL titer declines, becoming negative by 12 months in 40-75% in primary and 20-40% in secondary cases.
Re-treatment should be considered if serologic

responses are not adequate or if clinical signs persist or recur.

CSF should be examined in patients with

suspected treatment failure, and if abnormal the patient should be treated for neurosyphilis.

Patients with late latent syphilis may not have a

dramatic drop in antibody titers but should not be retreated unless titers rise or symptoms recur.
Most patients with ocular syphilis will have

improvement in vision, but not necessarily to baseline. Even delayed treatment can improve vision. Prolonged disease can ultimately result in eye destruction.
Monitor response to treatment using RPR or

VDRL titers

Recent Article

Syphilis Rates Rising Among Men Who Have Sex with Men - Jamaluddin Moloo, MD, MPH Published in Journal Watch General Medicine August 23, 2011 The steepest relative increases were among Hispanic and black teenagers. In the 1990s, U.S. syphilis rates were highest among heterosexual men and women in racial and ethnic minority groups. In a recent epidemiologic shift, the rate of primary and secondary syphilis has been highest among men who have sex with men (MSM) 62% of cases in 2003. To evaluate trends in primary and secondary syphilis among MSM, researchers

From 2005 through 2008, the rate of increase in primary and secondary syphilis was greatest among black MSM (from 11.2 to 18.9 cases per 100,000 males), relative to Hispanic MSM (4.7 to 7.3 per 100,000) and white MSM (3.4 to 4.0 per 100,000). The steepest relative increases in rates were among Hispanic and black MSM teens (248% and 180% increases, respectively). The epidemiology of primary and secondary syphilis has shifted a disease that once primarily affected heterosexual people in racial and ethnic minorities is increasingly common among minority men who have sex with men. The rapid increase among teenaged MSM is particularly alarming.

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