syphillis

[독고구검]

- syphillis non-treponemal tests 원리?  — Nontreponemal tests (also known as tests for reagin antibodies). reactive test

- syphillis non-treponemal tests 종류 3개?

1) Venereal Disease Research Laboratory (VDRL)

2) Rapid Plasma Reagin (RPR)

3) Toludine Red Unheated Serum Test (TRUST)

- Syphillis treponemal test 원리?                           more complex and expensive to perform;  used as confirm‎atory tests.

- Syphillis treponemal test 4 개 ?

1) Fluorescent treponemal antibody absorption (FTA-ABS)

2) Micro-hemagglutination test for antibodies to Treponema pallidum 

   (MHA-TP)

3) Treponema pallidum particle agglutination assay (TP-PA)

4) Treponema pallidum enzyme immunoassay (TP-EIA ) 

1. PRIMARY SYPHILIS란 ?(특징)                                  an initial local infection, chancre ( genital painless ulcer )

— Following acquisition of T. pallidum, the initial clinical manifestations are termed primary syphilis and usually consist of a chancre at the site of inoculation.

The chancre( painless ulcer ) represents an initial local infection.

- genital painless ulcer 질환?                               Syphilis
- Genital painful ulcer 질환 2개?                            hemophilus ducreyi,     genital HSV ( multiple ulcer)

2. SECONDARY SYPHILIS의미 ?                 ( systemic infection)

 — Weeks to a few months later, approximately 25 percent of individuals with untreated infection develop a systemic illness that represents secondary syphilis

2.1. 2ndary syphillis 증상 6개 (  m/c)

- A rash (the most characteristic finding)

- Fever

- Headache

- Malaise

- Anorexia

- Diffuse lymphadenopathy

3. LATENT SYPHILIS(잠복 매독)의미 ?                                                       균감염상 양성이지만 . no symptoms

— Latent syphilis refers to the period during which patients infected with T. pallidum have no symptoms but have infection demonstrable by serologic testing.

3. latent syphilis의 m/c manifestation 3개?                                    CNS syphils( neurosyphilis )

Cardiovascular syphilis (especially aortitis)

Gummatous syphilis 

1) Central nervous system involvement (neurosyphilis, particularly general paresis and tabes dorsalis)

2) Cardiovascular syphilis (especially aortitis)

3) Gummatous syphilis (granulomatous, nodular lesions which can occur in a variety of organs, most commonly skin and bones )

1) CNS syphillis( Neurosyphilis )?                            infection of the (CNS) by T. pallidum.

★ CNS syphilis 증상 3개? 

(뇌) Meningovascular syphilis

(눈) Ocular syphilis

(귀) Otosyphilis

(1) Meningovascular syphilis 증상          - brain or spinal cord의 artery내에  arteritis, thrombosis -> ischemia -> infarction

— As with other bacterial meningitides, syphilitic meningitis can cause an infectious arteritis that may affect any vessel in the subarachnoid space surrounding the brain or spinal cord and result in thrombosis, ischemia, and infarction.

(2) Ocular syphilis 증상                           - 눈의  posterior uveitis

— Ocular syphilis can involve almost any eye structure, but posterior uveitis is most common and presents with diminished visual acuity.

(3) Otosyphilis 증상                               - 청신경 손상으로  Hearing loss with or without tinnitus

— Hearing loss, with or without tinnitus, should be considered as part of the neurologic symptoms or signs of neurosyphilis.

2) Cardiovascular syphilis (especially aortitis) : Aoric valve dilatation, AR,   Aortic aneurysm/dissection

- Cardiovascular syphilis classically involves the ascending thoracic aorta resulting in a dilated aorta and aortic valve regurgitation

- Syphilitic aneurysms rarely lead to dissection.

3) gummatous syphilis

- Gummas may occur anywhere, including skin, bones, or internal organs. 

On the skin, gummas may present as ulcers or heaped up granulomatous lesions with a round, irregular or serpiginous shape.

4.1. Neurosyphilis Tx. 2개?                       

- Aqueous crystalline Penicillin G 3 to 4 million units IV every four hours or 

   24 million units continuous IV infusion for 10 to 14 days.

- procaine Penicillin G 2.4 million units IM daily 

   plus probenecid 500 mg four times daily oral,  both for 10 to 14 days

4.2. Cardiovascular Tx.                 — Benzathine penicillin G (2.4 million units IM )once weekly for three weeks.

4.3. Gummas Tx.                         — Benzathine penicillin G (2.4 million units IM) once weekly for three weeks.

Treatment options for syphilis

Early (primary, secondary, or latent less than one year)

Drugs of choice

Penicillin G benzathine 2.4 million units IM once*

Alternatives

Doxycycline• 100 mg oral twice daily for 14 days

Late (more than one year's duration, cardiovascular, gumma, late-onset)

Drugs of choice

Penicillin G benzathine 2.4 million units IM weekly for three weeks

Alternatives

Doxycycline• 100 mg oral twice daily for four weeks

NeurosyphilisΔ

Drugs of choice

Penicillin G 3 to 4 million units IV every four hours or 24 million units continuous IV infusion for 10 to 14 days OR

Penicillin G procaine 2.4 million units IM daily plus probenecid 500 mg four times daily oral, both for 10 to 14 days

Alternatives

Ceftriaxone 2 g IV once daily for 10 to 14 days

Congenital

Drugs of choice

Penicillin G 50,000 units/kg every 8 to 12 hours for 10 to 14 days OR

Penicillin G procaine 50,000 units/kg IM daily for 10 to 14 days

* Some experts recommend a repeat dose after seven days, especially in patients with HIV infection or pregnant women.
• Not recommended in pregnancy.
Δ Patients allergic to penicillin should be desensitized and treated with penicillin.

Adapted from: Drugs for sexually transmitted diseases. Treat Guidel Med Lett 2004; 2:67.

Graphic 50435 Version 2.0

5.  Neurosyphils 진단 알고리즘

- Neurosyphilis 진단 법?                                          CSF-VDRL, CSF FTA-ABS

Algorithm for diagnosis of neurosyphilis in a patient without HIV infection

CSF: cerebrospinal fluid; EIA: syphilis enzyme immunoassay; FTA-ABS: fluorescent treponemal antibody-absorbed test; HIV: human immunodeficiency virus; LP: lumbar puncture; NS: neurosyphilis; RPR: rapid plasma reagin test; TPPA: treponema pallidum particle agglutination test; VDRL: Venereal Disease Research Laboratory test; WBC: white blood cell count.
* A reactive serum EIA should be confirmed with a reactive serum FTA-ABS or TPPA.

Algorithm for the diagnosis of neurosyphilis in a patient with HIV infection

ARV: antiretroviral drugs; CD4: cluster determinant 4 T lymphocyte; CSF: cerebrospinal fluid; EIA: syphilis enzyme immunoassay; FTA-ABS: fluorescent treponemal antibody-absorbed test; HIV: human immunodeficiency virus; LP: lumbar puncture; NS: neurosyphilis; RNA: ribonucleic acid; RPR: rapid plasma reagin test; TPPA: treponema pallidum particle agglutination test; VDRL: Venereal Disease Research Laboratory test; WBC: white blood cell count.
* A reactive serum EIA should be confirmed with a reactive serum FTA-ABS or TPPA.

Courtesy of Christina M Marra, MD.

★ HIV infection(-)인,  Neurosyphilis환자의 CSF Leukocyte 수 ?                                  > 5 cells/microL

★ HIV infection(+)인,  Neurosyphilis환자의 CSF Leukocyte 수 ?                                  >20 cells/microL      

 As noted earlier, in patients with neurosyphilis who are seronegative for HIV infection, the CSF leukocyte count is usually elevated to >5 cells/microL. This contrasts with patients who have HIV coinfection, where a CSF leukocyte count of >20 cells/microL is considered to be consistent with neurosyphilis.

1) HIV 감염된 사람이 anti-retroviral drug치료 안할 때 CSF

One study found that an HIV-induced CSF pleocytosis was independently and significantly associated with three factors [27]:

• Lack of current antiretroviral use (OR 5.9, 95% CI 1.8-18.6)
• CD4 count >200/microL (OR 23.4, 95% CI 3.1-177.3)
• Detectable plasma HIV RNA (OR 3.3, 95% CI 1.1-9.4)

2) HIV 감염된 사람이 anti-retroviral drug치료 중일 때 CSF

- CD4 counts ≤200 cells/microL

- an undetectable plasma HIV RNA viral load

(In HIV-infected patients who are taking antiretroviral agents, have CD4 counts ≤200 cells/microL, or have an undetectable plasma HIV RNA viral load.)