Transcript Slide 1

SYPHILIS
Jayne Howard
Clinical Coordinator
HIV Ambulatory Care
The Alfred
Current situation / epidemic
Source: Victorian Infectious Diseases Bulletin, DHS, June 2007.
Syphilis serology - Alfred
Syphilis serology Alfred Hospital
1,800
1,600
1,400
Number of Tests
1,200
1,000
Series1
800
600
400
200
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2004-2005
2005-2006
2006-2007
Financial Year
Courtesy Jenny (micro) and Denis Spelman.
Syphilis serology - Alfred
110
100
Number positive
90
80
70
60
50
40
30
20
10
0
2000
2001
2002
2003
2004
2005
2006
2007*
Year
Courtesy Denis Spelman and VIDRL. *2007 to end July
A bacteria
A member of the
spirochete family
Treponema Pallidum
www.cdc.gov/phil/home.asp
Transmission
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Direct contact with infectious lesions of skin and mucous
membranes
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Most commonly occurs during sexual activity
 Unprotected vaginal, anal or oral intercourse
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Rarely occurs during non sexual activity
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Blood transfusions
Vertical transmission from mother to child during pregnancy
Direct contact with an infectious lesion
Clinical stages of syphilis
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Primary Syphilis
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Chancre (sore) develops
between 10-90 days after
exposure (3 weeks) at the
site of infection
Most are painless
Can often go undetected
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Usually heals within few
weeks(3-6 weeks)
Occasionally more than 1
sore may develop
(HIV +ve individuals)
Lymphadenopathy (swollen
glands)
Infectious period
Fairfield Hospital and MSHC
Photo Collection.
Secondary syphilis
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Infection spreads through the blood and lymph system
Usually between 2-6 week weeks after the chancre
Common symptoms include
Fever and a rash
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Rash
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Also lymphadenopathy, headache, malaise, anorexia
Lesions in mucous membranes e.g. mouth,vagina
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dark pink or copper coloured
palms of hands
Soles of the feet
Abdomen
snail track ulcers and condyloma lata
Chancre may still be present
Secondary syphilis
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Less common symptoms include Hair loss (alopecia) with a moth eaten appearance
 Hepatitis, GI ulceration
 Arthritis and joint problems
 Renal symptoms
 Neurologic abnormalities, headaches,memory loss
(common in HIV+ve individuals)
 Eye and ear abnormalities
Symptoms usually resolve around 3-12 weeks
25% of symptoms will recur in the 1st year (some up to 4 years)
Infectious period
Secondary syphilis
Fairfield Photo Collection, Up to
Date, MSHC collection
Latent and Tertiary Syphilis
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Latent
 Asymptomatic infection, no clinical signs of illness with positive
serology (blood tests)
 Divided into Early latent: Within the first 2 years from transmission
 Based on possibility of relapses, potentially infectious
 Late Latent: Greater than 2 years duration
 (US Public Health Service, CDC: > 1 year)
 Non infectious period, however transmission from mother to
child can occur up to 4 years
Tertiary
 Non infectious period. 2-30 years
 1/3 patients will develop cardiovascular involvement, neurosyphilis,
gummatous syphilis
Acquisition
(~30%)
Clinical stages of syphilis
1o
2o
2o
3o
2 years
Incubation period
10-90 days
(average 21 days)
Weeks to few months
Episodes may recur
(occurs in 25%)
Early syphilis
(infectious)
1 to 30 years:
If untreated
occurs in
40%, 25%
clinically
recognisable
Late syphilis
(non-infectious)
Syphilis and HIV
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Similar mode of transmission
Often more than 1 chancre (up to 70%)
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HIV +ve individuals may present with both primary
and secondary lesions (approx 25%)
Transient increase in HIV viral load and decrease in
CD4 count
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May be larger and deeper
Resolves after the infection is treated
Neurological symptoms are more common in the
early stages of syphilis in HIV+ve individuals
Zetola and Klausner. Syphilis and HIV Infection: An Update. CID 2007;44:1222-1228.
Syphilis and HIV
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Presence of one is risk factor for acquiring the
other
Presence of one increases the risk of transmission
of the other
All patients with syphilis should have a HIV test
All patients with HIV infection should have syphilis
testing
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upon entry to care / diagnosis
annually
more often if risk factors
STIGMA GUIDELINES NSW,2005
Diagnosis and Testing
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Syphilis is known as the “Great Mimicker”
Good sexual history and examination
Identification of the bacteria (treponeme) from infectious
lesion(ability to recognize from other spirochetes)
Most cases rely on specific blood tests
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Serological testing
 VDRL=Venereal Disease Research Laboratory
 RPR=Rapid Plasma Reagin
Beware of false positive results from other illness
+ve in 75% primary
100% secondary
Diagnosis and Testing
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Specific treponemal tests
 FTA Antibody-Fluorescent treponemal antibody absorption
 TPHA test- Treponemal pallidum haemagglutination assay
 TPPA test- Treponemal pallidum particle agglutination assay
 Treponemal 1gG EIA- Recombinant based IgG & IgM EIA
Beware of false positive results
Treponemal tests do not differentiate between other treponeme
species
Neurosyphilis testing includes Positive serology (blood tests)
 Clinical neurological symptoms (headache, confusion, memory loss)
 +/- findings in the cerebrospinal fluid (CSF) following lumbar puncture
Decisions to perform a lumbar puncture may vary between specialists
Treatment recommendations – Early syphilis
(Primary, Secondary, Early Latent)
•
Sexual Health Guidelines – Royal
Australasian College Physicians,
Sexual Health Chapter, 2004
•
Therapeutic Guidelines, 2006
•
MSHC Treatment Guidelines, 2005
Treatment recommendations – Late syphilis
(syphilis > 2 years or unknown duration)
•
Sexual Health Guidelines – Royal
Australasian College Physicians,
Sexual Health Chapter, 2004
•
Therapeutic Guidelines, 2006
•
MSHC Treatment Guidelines, 2005
Treatment recommendations – Neurosyphilis
•
Sexual Health Guidelines – Royal
Australasian College Physicians,
Sexual Health Chapter, 2004
•
Therapeutic Guidelines, 2006
•
MSHC Treatment Guidelines, 2005
“Seek Specialist Advice”
Penicillin treatment issues
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Penicillin is the treatment of choice
Jarisch-Herxheimer
reaction
An acute reaction to penicillin treatment (not an allergy )
fever, headache, myalgia and other symptoms
Usually occurs within 24 hours (6-12 hours) of
therapy for syphilis
Resolves
after 24 hours
Prednisolone
may be used to reduce the likelihood
of a reaction
Penicillin
allergy
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A potential risk
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Desensitization to penicillin can be undertaken
Clinical follow-up
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All patients should return to the clinic at 3, 6 and 12 months. Up to 24
months for HIV+ve individuals
Repeat blood tests and a clinical examination will be performed
 RPR should drop 4 fold by 6 months(Test of cure)
 Will become negative in approx 70% primary 55% secondary
Re-treatment may be necessary (re-infection must be excluded)
Health education and safe sex counselling
Neurosyphilis
 Seek specialist advice
 CSF abnormalities may persist for longer in HIV+ individuals
Management of contacts
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Syphilis is a notifiable infection
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Contact tracing (partner notification) should be undertaken
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Treatment of contacts
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Notify all sexual contacts for the past 3 months for patients with primary
syphilis
Patients with secondary syphilis should notify all contacts within the last 2
years
Treat all sexual contacts of patients with primary and secondary syphilis
(infectious period) even if the blood test is negative
Sexual contacts greater than 12 months ago require treatment if their
blood test is positive for syphilis
Health education and safe sex counselling
Case 1
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45yo MSM
HIV June 2006
CD4 495, 24%. HIV VL 1600
Feb 2007, visited his GP for HIV monitoring
and sexual health screen
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No clinical signs of illness
Syphilis blood tests positive,EIA +, RPR 1024
Last recorded syphilis test was neg, June 06
Case 1
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Single dose of benzathine penicillin was given
intramuscular (IM)
Repeat blood tests were performed at 3,6 months
(test of cure)
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May 07, RPR 16
August 07, RPR 16
Treatment successful to date..
Case 2
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50 yo train driver, MSM
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HIV diagnosed Oct 05
CD4 count 510, 25%. HIV VL >100,000
Syphilis testing performed, EIA +, RPR 64
No clinical signs or symptoms
Treated with a single dose of benzathine penicillin IM
Lost to follow up
October 2006 patient referred to Alfred
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12 month history multiple non-tender genital ulcers
4 month history of bilateral hearing impairment
4 week history of mouth ulcers
S.J.Aitchison, K.M. Watson, A.M. Mijch. IAS Poster
Case 2
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Syphilis testing repeated
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EIA +, RPR 512
Lumbar puncture was performed
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Swabs from penile and oral lesions
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CSF Syphilis serology was positive
Negative
Treated with intravenous (iv) benzylpenicillin and oral
prednisolone
Following treatment
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Hearing improved
Ulcers healing
Unfortunately was lost to follow up. Unable to perform test of
cure
S.J.Aitchison, K.M. Watson, A.M. Mijch. IAS Poster
Conclusion
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HIV and syphilis
 Both conditions increasing
in incidence
 Often occur together
 Variety of clinical
presentations
In general
 diagnosis and treatment
similar as in HIVuninfected patients
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Penicillin best treatment
 no resistance
 allergy
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Alternate treatments
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Azithromycin
Ceftriaxone
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resistance
Acknowledgements
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Dr Jonathan Darby, Infectious Diseases
Registrar at The Alfred
HIV Data Team at The Alfred
Further reading:
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Sexual Health Medicine, 2005
Australasian Contact Tracing Manual 3rd Ed, 2006
National Management Guidelines for Sexually
Transmissible Infections, 2002