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Syphilis

DR. Noormartany, dr; SpPK-K; MSi


• Syphilis is caused by the spiroquete Treponema pallidum.

• Syphilis is primarily acquired through sexual contact,though


approximately 1000 cases of vertically acquired congenital
infections occur each year in the United States.

• Antepartum syphilis can profoundly affect pregnancy outcome


by causing

• preterm labor, fetal death, and neonatal infection by


transplacental or perinatal

• infection [8,9]. Fortunately, of the many congenital infections,


syphilis is not

• only the most readily prevented but also the most susceptible to
therapy.
Spirochetes &Other Spiral Microorganisms
Large heterogeneous group of spiral motile bacteria. Two families
1- Spirochaetaceae: Three free living genera.
2- Treponemataceae: Three human pathogens – Treponema, Borrelia,
Leptospira.
Treponema pallidum
Morphology & Identification
Slender spirals o.2um wide & 5-15um length. Motile.
Culture & Growth Characteristics
Pathogenesis, Pathology, & Clinical Findings
A- Acquired Syphilis: Primary, secondary, & tertiary.
B- Congenital Syphilis
DIAGNOSIS
 Diagnostic testing involves a two-step process, beginning with a nonspecific test and
concluding with a treponeme-specific test for patients screening positive.

 The non-treponemal screening tests include the VDRL (Venereal Disease Research
Laboratory), RPR (rapid plasma reagin), or ART (automated reagin test).
Nontreponemal test antibody titers usually correlate with disease activity and should
be reported with a quantitative titer.
On the other hand, other disease states or physiologic states, such as pregnancy,
can yield false-positive results.
Because the current incidence of syphilis is so low, the majority of positive screening
tests are not due to treponemal infection.

 Treponemal-specific tests including fluorescent treponemal antibody absorption test


(FTA-ABS) or Treponema pallidum particle agglutination (TP-PA) are necessary to
confirm the diagnosis of syphilis after a positive nontreponemal test. These tests are
specific for T pallidum antigens and are reported as positive or negative.

 Nontreponemal screening during pregnancy is recommended at the first prenatal


visit, and again in the third trimester, particularly in high-risk populations
Primary syphilis Secondary syphilis

Papules Tertiary syphilis


Hutchinson's teeth - peg-shaped upper
incisors

Frontal bosses and saddle nose

Late congenital syphilis Gumma - thin,


atrophic scar from a previous gumma
WHO clinical classification of syphilis
Classification of Syphilis
Stage Description Symptoms and Signs
Acquired
Primary Contagious Chancre (a small, usually painless skin sore ),
regional lymphadenopathy
Secondary Contagious Rashes (which may be confused with those due to
Occurs weeks to several other disorders), sores on mucous
months after the membranes, hair loss, fever, many other symptoms
primary stage
Latent Asymptomatic; not Early latent syphilis (infection < 1 yr duration ),
contagious sometimes with recurrence of infectious lesionsLate
May persist indefinitely latent syphilis (infection > 1 yr duration ), rarely with
or be followed by late- recurrences; positive serologic tests
stage disease
Late or tertiary Symptomatic; not Clinically classified as benign tertiary syphilis,
contagious cardiovascular syphilis, and neurosyphilis (eg,
asymptomatic, meningovascular, or parenchymatous
neurosyphilis; tabes dorsalis)
Congenital*
Early Symptomatic Overt disease
Occurring up to age 2
yr
Late Symptomatic Hutchinson's teeth, eye or bone abnormalities
Occurring later in life
*Can also exist in a permanently latent (asymptomatic) state.
Why Is Syphilis Important?
Epidemiology of Syphilis
• In the 1940s: Syphilis was distributed widely
throughout the U.S.
• 1986-90: 85% increase in the incidence of
primary and secondary syphilis –Why?
• After 1990, reported cases of syphilis decreased
approximately 15% per year to an all-time low in
2000
Epidemiology of Syphilis
(continued)

• Late 1990s: syphilis elimination a feasible


goal
• Rates remain high in:
– Some urban areas throughout the U.S.;
– Rural areas in the South;
– Some minority populations who suffer
from poverty, lack of access to health
care, and breakdown of stable
community and personal relationships.
• Recent outbreaks have been associated in
men who have sex with men (MSM)
Syphilis
Syphilis is sometimes called:
• “bad blood”,
• pox, or
• a “zipper cut”
Syphilis Is:
• A Bacterial Infection that can be chronic
and systemic
• Infectious During Specific Time Frames
related to Stage
• Sexually Transmitted (oral, vaginal, anal)
• Curable
• Many persons (including physicians) are
unaware that we are currently seeing an
increase in the number of syphilis infections
• Syphilis can increase the risk for
transmission of HIV (if co-infected) by 3-5x
• Having HIV can make someone more
susceptible to an infection with syphilis, if
exposed
• Syphilis increases HIV viral load and
decreases CD4 cell counts in HIV-infected
persons with new syphilis infections
Taxonomy

Domain: Bacteria
Phylum: Spirochaetes
Order: Spirochetales
Family:
Spirochaetaceae
Genus: Treponema
Species: pallidum
Characteristics
• Helical, tightly coiled, mobile
• 5-20 um in length, 0.1-0.4 um in diameter
• Pathogenic treponemes associated with 4
diseases
–Venereal syphilis (pallidum)
– Yaws (perfenue)
– Endemic (endemicum)
– Pinta (carateum)
• Obligate parasites of humans
Syphilis – Treponema pallidum
Method of infection
• Viable bacteria from a chancre enters
through a fissure or mucus membrane
• Bacteria multiply locally and causes a
painless chancre
• Spreads via blood stream or lymphatic
system
• Can infect almost any organ or tissue
• Continuous in vitro culture has yet to be
achieved
How is Syphilis Transmitted?
• Sexual contact with infectious lesion
• In utero and intrapartum
• Sharing needles (extremely rare)
Symptoms

some have no symptoms for years


• 3 stages
– Primary
– Secondary
– Late or latent

• Congenital (passed from a mother to her


unborn child)
Primary stage
• Appearance of a single sore or chancre
(about 21 days after infection)
• Chancre lasts 3-6 weeks and heals w/o
treatment
• If untreated, disease progresses to next
stage
So what Does Syphilis
Look Like?
Syphilis has Several Stages
with different signs/symptoms

Incubation Stage

10 - 90 Days
Average 21 Days
Not infectious to others during this stage
No signs/symptoms are present
Blood tests are negative
Common Symptoms of Syphilis
Primary Stage
• Occurs in males and females
• A painless sore called a chancre develops
where the spirochete entered the body
• The sore may be located on the genitals, lips,
anus, or other area of direct contact
• The chancre will last 1-5 weeks (on average 3
weeks) and heal without treatment
• The person can transmit the infection very
easily during this stage
Clinical Manifestations- Primary
Syphilis
• Chancre
– Clean based, painless, indurated ulcer with
smooth firm borders
– Unnoticed in 15-30% of patients often
because of the location and because it is
painless
– Resolves in 1-5 weeks
– HIGHLY INFECTIOUS
Blood tests may not show infection for up to
7 days after the chancre develops
Primary syphilis-chancre
Primary Syphilis- chancre

Source: Florida STD/HIV Prevention Training Center


Primary syphilis - chancre
Primary syphilis - chancre
Primary syphilis –
chancre of anus
Primary syphilis - chancre
1996 CDC Case Definitions
Syphilis, primary
Clinical description: A stage of infection with Treponema pallidum
characterized by one or more chancres (ulcers); chancres might differ
considerably in clinical appearance.
Laboratory criteria for diagnosis: Demonstration of T. pallidum in
clinical specimens by darkfield microscopy, direct fluorescent antibody
(DFA-TP), or equivalent methods.
Case classification:
Probable: a clinically compatible case with one or more ulcers (chancres)
consistent with primary syphilis and a reactive serologic test
(nontreponemal: Venereal Disease Research Laboratory [VDRL] or rapid
plasma reagin [RPR]; treponemal: fluorescent treponemal antibody
absorbed [FTA-ABS] or microhemagglutination assay for antibody to T.
pallidum [MHA-TP])
Confirmed: a clinically compatible case that is laboratory confirmed
Syphilis – Treponema pallidum
on darkfield examination
Syphilis, secondary
Clinical description:
A stage of infection caused by T. pallidum and characterized by
localized or diffuse mucocutaneous lesions, often with generalized
lymphadenopathy. The primary chancre may still be present.

Laboratory criteria for diagnosis:


Demonstration of T. pallidum in clinical specimens by darkfield
microscopy, DFA-TP, or equivalent methods

Case classification:
Probable: a clinically compatible case with a nontreponemal
(VDRL or RPR) titer greater than or equal to 4
Confirmed: a clinically compatible case that is laboratory confirmed
Syphilis, latent
Clinical description:
A stage of infection caused by T. pallidum in which organisms persist
in the body of the infected person without causing symptoms or signs.
Latent syphilis is subdivided into early, late, and unknown categories
based on the duration of infection.

Case classification:
Probable: no clinical signs or symptoms of syphilis and the presence
of one of the following:
No past diagnosis of syphilis, a reactive nontreponemal test (i.e.,
VDRL or RPR), and a reactive treponemal test (i.e., FTA-ABS or
MHA-TP)
A past history of syphilis therapy and a current nontreponemal test
titer demonstrating fourfold or greater increase from the last
nontreponemal test titer
Syphilis, early latent
Clinical description:
A subcategory of latent syphilis. When initial infection has occurred
within the previous 12 months, latent syphilis is classified as early latent.

Case classification:
Probable: latent syphilis in a person who has evidence of having
acquired the infection within the previous 12 months based on one or
more of the following criteria:
Documented seroconversion or fourfold or greater increase in titer of a
nontreponemal test during the previous 12 months
A history of symptoms consistent with primary or secondary syphilis
during the previous 12 months
A history of sexual exposure to a partner who had confirmed or
probable primary or secondary syphilis or probable early latent syphilis
(documented independently as duration less than 1 year)
Reactive nontreponemal and treponemal tests from a person whose
only possible exposure occurred within the preceding 12 months
Syphilis, late latent
Clinical description:
A subcategory of latent syphilis. When initial infection has occurred greater than 1
year previously, latent syphilis is classified as late latent.

Case classification:
Probable: latent syphilis (see Syphilis, latent) in a patient who has no evidence of
having acquired the disease within the preceding 12 months (see Syphilis, early
latent) and whose age and titer do not meet the criteria specified for latent syphilis
of unknown duration.

Syphilis, latent, of unknown duration


Clinical description: A subcategory of latent syphilis. When the date of initial
infection cannot be established as having occurred within the previous year and the
patient's age and titer meet criteria described below, latent syphilis is classified as
latent syphilis of unknown duration.

Case classification:
Probable: latent syphilis (see Syphilis, latent) that does not meet the criteria for
early latent syphilis, and the patient is aged 13-35 years and has a nontreponemal
titer greater than or equal to 32
Neurosyphilis
Clinical description:
Evidence of central nervous system infection with T. pallidum

Laboratory criteria for diagnosis:


A reactive serologic test for syphilis and reactive VDRL in cerebrospinal fluid
(CSF)

Case classification:
Probable: syphilis of any stage, a negative VDRL in CSF, and both the following:
Elevated CSF protein or leukocyte count in the absence of other known
causes of these abnormalities
Clinical symptoms or signs consistent with neurosyphilis without other
known causes for these clinical abnormalities
Confirmed:
syphilis of any stage that meets the laboratory criteria for neurosyphilis
Syphilitic Stillbirth
Clinical case definition: A fetal death that occurs after a 20-week gestation
or in which the fetus weighs greater than 500 g and the mother had
untreated or inadequately treated* syphilis at delivery

Comment: For reporting purposes, syphilitic stillbirths should be reported as


cases of congenital syphilis.
*Inadequate treatment consists of any non-penicillin therapy or penicillin
given less than 30 days before delivery.
Syphilis, late, with clinical manifestations other
than neurosyphilis (late benign syphilis and
cardiovascular syphilis)
Clinical description: Clinical manifestations of late syphilis other than neurosyphilis
may include inflammatory lesions of the cardiovascular system,
skin, and bone. Rarely, other structures (e.g., the upper and lower
respiratory tracts, mouth, eye, abdominal organs, reproductive
organs, lymph nodes, and skeletal muscle) may be involved. Late
syphilis usually becomes clinically manifest only after a period of
15-30 years of untreated infection.
Laboratory criteria for diagnosis: Demonstration of T. pallidum in late lesions by
fluorescent antibody or special stains (although
organisms are rarely visualized in late lesions)
Case classification:
Probable: characteristic abnormalities or lesions of the cardiovascular system, skin,
bone, or other structures with a reactive treponemal test, in the absence of
other known causes of these abnormalities, and without CSF abnormalities
and clinical symptoms or signs consistent with neurosyphilis
Confirmed: a clinically compatible case that is laboratory confirmed
Comment: Analysis of CSF for evidence of neurosyphilis is necessary in the evaluation
of late syphilis with clinical manifestations.
Congenital Syphilis (CS)
• Syphilis is a chronic infection caused by
the spirochete Treponema pallidum,
which is of particular concern during
pregnancy because of the risk of
transplacental infection of the fetus.
• Congenital infection is associated with
several adverse outcomes, including:
-Perinatal death
-Premature delivery
-Low birth weight
-Congenital anomalies
Modes of Transmission:

• Sexual contact.
• Trans-placental passage from
infected mother.
• Contact with lesion at the time of
delivery.
• The risk of developing syphilis
after exposure is about 40%.
Risk Factors for CS
• Lack of or inadequate prenatal care.
• Maternal substance abuse.
 Failure to repeat a serological test for
syphilis in the third trimester.
 Treatment failure.
 Inadequate access to Sexually
Transmitted Diseases (STD) clinics
and STD outreach activities.
Epidemiology of CS

• Incidence of CS reflects the rate of


syphilis in women of childbearing
age.
• Peaks in CS occur one year after
peaks in P&S syphilis in women.
Congenital syphilis — Rates for infants <1
year of age: US, 1981–2002 and the
Healthy People 2010 objective
Rate (per 100,000 live births)

125 Cong. Syphilis


2010 Objective
100

75

50

25

0
2001
1981 83 85 87 89 91 93 95 97 99

Note: The Healthy People 2010 objective for congenital syphilis is 1.0 case per 100,000 live
births. The surveillance case definition for congenital syphilis changed in 1988.
Congenital syphilis — Reported cases for
infants <1 year of age and rates of P &S
syphilis among women: US, 1970–2002
P&S rate (per 100,000 population) CS cases (in thousands)
20 7.5

16 Kaufman Criteria 6.0


CDC Surveillance
12 Definition 4.5

8 P&S Syphilis 3.0

4 Congenital 1.5
Syphilis
0 0.0
1970 75 80 85 90 95 2000
Note: The surveillance case definition for congenital syphilis
changed in 1988.
Epidemiology

The CS rate peaked in 1991 at 107.3 cases per 100,000 live births, and declined by 90.5%
to 10.2 cases/per 100,000 live births in 2002. The HP2010 objective for CS is 1.0 case per
100,000 live births. In 2002, 27 states, the District of Columbia, and one outlying area had rates
higher than this objective.
Adapted from CDC
CDC surveillance

• Before 1989 reported cases of CS were defined and


classified on the basis of clinical and serological features
known as the Kaufman criteria. The Kaufman criteria
were not designed for use as a surveillance case
definition.

• In 1988 CDC developed a surveillance case definition for


CS. This surveillance case definition differs from the
clinical diagnosis of CS in several ways. All infants born
to mothers who have untreated or inadequately treated
for syphilis are considered potentially infected.
Asymptomatic infants and stillbirths are included in the
case definition.
Maternal treatment history among 451 infants with
CS in US in 2002
Syphilis in Newborns
• Two-thirds of live-born neonates with CS
are asymptomatic at births.
• Overt infection can manifest in the fetus,
the newborn, or later in childhood.
• The infant may have many or even no signs
until 6-8 weeks of life (delayed form).
• Clinical manifestations after birth are
divided arbitrarily into:
- Early CS (<=2 years of age) and
- Late CS ( >2 years of age)
Syphilis in newborns
Congenital syphilis:
- Transplacental:
beginning 9 - 10 weeks
analogous to secondary adquired syphilis
affects bone, brain, liver, lung
placenta: large and thickened, hypercellular villi,
UC abscess-like necrotic foci

- Vertical transmission:
more freq. primary and secondary dz.

Risk diminishes with after 4 years of infection


Case definitions for CS
1. CONFIRMED OR DEFINITE CS

a. infant lesions
b. placenta
c. ummbilical cord
d. amniotic fluid
e. autopsy material
Case definitions for CS
2. PRESUMPTIVE OR PROBABLE,
if mother had:
a. untreated syphilis
b. no documentation of treatment
c. non penicillin therapy
d. penicillin <30 days before delivery

if baby has a reactive treponemal test and any of:


a. any evidence of CS on clinical exam
b. any evidence of CS on long bone radiograph
c. positive VDRL in CSF
d. abnormal CSF without any other cause
e. quantitative nontreponemal test titer >4 fold higher than maternal
titer
f. reactive treponemal antibody test beyond 15 months.
Case definitions for CS
3. POSSIBLE in asymptomatic infants when:

a. reactive treponemal or nontreponemal test


b. maternal tx during pregnancy s/ post-treatment fall
in titers
c. maternal tx before pregnancy s/ adequate follow up

“infants whose mothers were treated>1mo before


delivery AND had a documented fourfold decline in
titers AND have no evidence of reinfection or relapse,
are UNLIKELY to have the infection.”
Evaluation of neonates with
Suspected or Confirmed CS
1. Detailed physical examination
2. Quantitative nontrep. Test on infant
3. Specimens for testing for the presence of
spirochetes form mucocutaneous lesions
4. CBC to assess for anemia or
thrombocytopenia
5. CSF analysis
6. Long bone radiographs unless the diagnosis
has been confirmed otherwise
7. Pathologic examination of the placenta or UC.
Risk factors for Congenital Syphilis
• Lack or inadequate PNC
• Maternal substance abuse
• Failure to repeat a serologic test for
syphilis during the third trimester
• Treatment failure
• Inadequate access to STD’s clinics and
outreach activities
• Syphilis is a chronic infection caused by the
spirochete T. pallidum, which is of particular
concern during pregnancy because of the risk of
transplacental infection of the fetus
• Congenital infection is associated with severe
adverse outcomes:
-perinatal death
-premature delivery
-Low birth weigth
-congenital anomalies
PATHOGENESIS/PATHOLOGY
Clinical manifestations of late onset
• Hutchinson’s triad (63%):
– Hutchinson teeth (blunted upper incisors)
– Interstitial keratitis
– VII nerve deafness
• Frontal bossae (bony prominence of the forehead) 83%
• Saddle nose 74%
• Defect of hard pallate
• Clutton’s joint (bilateral painless swelling of the knees)
• Saber chins
• Short maxillas
• Protruding mandible
Clinical Manifestations
of Early CS
• Condyloma Lata
• Maculopapular rash
• Hepatosplenomegaly
• Jaundice due to the
hepatitis
• Anemia
• Osteochondritis
• Snuffles
• Pseudoparalysis
• Lymphadenopathy
• Mucous patches
Congenital syphilis
Early
Runny nose (rhinitis) known as snuffles, a macular rash and

mucus patches
Clinical manifestations of early CS
• The earliest sign of CS is nasal discharge (snuffles) that
occurs 1-2 weeks before the onset of the rash.
Treponemes abound in the discharge, providing a
definitive means of diagnosis.
• Secondary lesions on face; they first appeared during
the fourth postnatal week.
• The vesiculobullous eruption, known as pemphigus
syphiliticus, is highly distinctive when present. When the
bullae rupture, they leave a macerated, dusky red
surface that readily dries and crusts
• Other stigmata seen before the age of 2
years include maculopapular rash,
hepatosplenomegaly and jaundice.
Congenital syphilis. Diaphysitis with abundant callus formation
secondary to pathologic fractures through the metaphyseal
lesions. The lesions healed, and there were no sequelae
Clinical Manifestations
of Late CS
• Hutchinson’s triad (63%): • Saddle nose (74%)
-Hutchinson’s teeth • Defect of hard pallet
(blunted upper incisors) • Clutton’s joints
-Interstitial keratitis (bilateral painless
-VII nerve deafness swelling of knees)
• Frontal bossae (bony • Saber chins
prominences of the • Short maxillas
forehead) (87%) • Protruding mandible
Congenital Syphilis

Hutchinson’s Triad (late congenital syphilis):


1. Interstitial keratitis
2. Teeth abnormalities
3. Deafness
Sabre Shins
Maternal Treatment
• Penicillin is the gold standard for the
treatment of syphilis.
• Pregnant women with syphilis should be
treated with the appropriate penicillin
regimen according to their stage of
disease.
Follow-up evaluation
• Non-treponemal antibody serologic
testing should be checked at 1, 3, 6,
12 and 24 months following
treatment.
• Titers should decrease four-fold by 6
months post therapy and become
non-reactive by 12 to 24 months.
• Titers that show a four-fold rise or do
not decrease suggest either
treatment failure or re-infection.
Laboratory Diagnosis
• Direct visualization
- Darkfield examination of exudate
- Direct fluorescent antibody to T. pallidum
• Serologic testing
- Nontreponemal Antibody tests (VDRL test and
RPR test)
- Treponemal Antibody tests (FTA-ABS and MHA-TP)
Serologic Testing
1. The non-treponemal screening tests:
 VDRL (Venereal Disease Research Laboratory),
 RPR (rapid plasma reagin),
 ART (automated reagin test).
 usually correlate with dz activity, in titers
 On the other hand, other disease states or
physiologic states, such as pregnancy, can yield
false-positive results.
Serologic Testing
2. Treponemal-specific tests:
Fluorescent treponemal antibody absorption test (FTA-ABS)
or Treponema pallidum particle agglutination (TP-PA) are
necessary to confirm the diagnosis of syphilis after a positive
nontreponemal test.
Nontreponemal screening during pregnancy is
recommended at the first prenatal visit, and again in the third
trimester, particularly in high-risk populations
• Adapted from Sexually Transmitted Diseases, by Holmes, Sparling, Mardh, et al.
Treatment
1. Definitive or probable CS
a) IV aqueous crystalline penicillin G x 10-
14 days 50 000UI/kg q 12hr (1-7 dol) and
q 8hr (8-30dol)
b) IM procaine penicillin G 50 000U/kg/dose
q day for 10 to 14 days
Treatment
2. Infants with probable syphilis, BUT who are
asymptomatic and c/ normal evaluation
a) If f/u is certain a single dose IM benzathine
penicillin G may be adequate
b) Some experts will prefer a 10-14 day full
course if any part of the evaluation is
abnormal or uninterpretable.
3. Asymp. Infants with possible CS.
a) single dose of benzathine penicillin
Follow up
1. Re-evaluation after treatment at 1, 2, 3, 6 and 12
months of age.
2. Nontreponemal tests should be repeated every 2 to 3
months until they have become nonreactive or
diminished four-fold.
3. Maternal origin Ab (nontreponemal) titers become
negative within 3 mo, and should become negative at 6
mo.
4. Treponemal-specific Ab of maternal origin persist for 12
to 15 mo IN 15% of uninfected infants from seropositive
mothers.
5. Congenital neurosyphilis should be evaluated (clinical
and CSF) every 6 months until CSF clears.
Follow up evaluation
• Non treponemal antibody serologic testing
should be checked at 1,3,6, 12 and 24
months following the treatmetn
• Titers should decrease by four fold by 6
months of therapy and became non
reactive by 12 or 24 months
• Titers that show a four fold rise or do not
decrease suggest either failure of
treatment or reinfection
• Sexually transmitted infections remain a major public health concern
in the
• United States. An estimated 19 million infections occur each year
• Sexually transmitted infections are relatively common during
pregnancy, especially
• in indigent, urban populations effected by drug abuse and
prostitution.
• Education, screening, treatment, and prevention are important
components of
• prenatal care for women at increased risk for these infections.
Treatment of these
• sexually transmitted infections is clearly associated with improved
pregnancy
• outcome and reductions in perinatal mortality
TREATMENT
• Penicillin G, in benzathine, aqueous procaine, or
aqueous crystalline form, is the drug of choice for
treatment of all stages of syphilis, and is the only
effective treatment for the prevention of congenital
syphilis in pregnancy.
• Erythromycin may be curative in the mother, but may not
prevent congenital syphilis because of the variability of
transplacental passage of the antibiotic.
• Ceftriaxone may prove useful in adults as an alternative
regimen for patients who have penicillin allergy;
however, there is insufficient information on its use in
pregnancy
• The efficacy of azithromycin in the penicillin-allergic
pregnant woman has not been adequately evaluated.
A recommended dosage regimen for pregnant women is as follows:
• Primary, secondary, or early latent stage: benzathine penicillin G,
2.4 million units intramuscularly (IM) in a single dose
• Late latent stage or syphilis of unknown duration: benzathine
penicillin G, 2.4 million units IM once a week for 3 consecutive
weeks
• Neurosyphilis: aqueous crystalline penicillin G, 3–4 million units
intravenously (IV) every 4 hours, or 18–24 million units daily as
continuous infusion, for 10–14 days
• The rate of treatment failure may be increased in pregnant patients
who have secondary syphilis, therefore some experts recommend
the use of a second injection of benzathine penicillin G 2.4 million
units IM 1 week after the first to treat early syphilis in pregnancy
• Within hours after treatment, patients can develop an acute
complication called the Jarisch-Herxheimer reaction. Symptoms
include fever, chills, myalgias, headache, tachycardia,
hyperventilation, vasodilation, and mild hypotension. Uterine
contractions and fetal heart rate decelerations may occur.
• Although the reaction occurs in 10% to 25% of patients overall, it is
most common in the treatment of early syphilis. A recent report [20]
noted an incidence of 40% among treated pregnant women.
Symptoms last for 12 to 24 hours and are usually self-limiting.
Patients can be treated symptomatically with antipyretics. Routine
hospitalization is not recommended for treatment during pregnancy,
though this has not been systematically evaluated [16].
Evaluation of treatment
• Consideration should be given to ultrasound evaluation of the fetus before
• therapy when syphilis is diagnosed after 24 weeks. Ultrasound abnormalities
• associated with syphilis include polyhydramnios, hepatosplenomegaly, ascites,
• and hydrops [21]. Fetuses that have physical evidence of severe disease discovered
• on ultrasound have also been shown to have biochemical evidence
• of severe disease. Treatment failure and other complications are more common
• among these fetuses [22]. When the fetal ultrasound is abnormal, consultation
• with specialists in maternal-fetal medicine and neonatology should occur.
Complications
• such as preterm labor, preterm premature rupture of the membranes,
• fetal heart rate decelerations, and stillbirth may be precipitated by treatment.
• In the severely affected fetus, particularly with preexisting fetal heart rate
• abnormalities, consideration may be given to an untreated preterm or term
• delivery followed by neonatal treatment [16,23]. Despite the advantages of
• ultrasound assessment, maternal treatment should not be delayed unduly to obtain
• imaging.
Laboratory Diagnosis
of Infection
Outline
• Clinical assessment
• Collecting and transporting specimens
• Microscopy
• Culture
• Sensitivity
• Non-cultural diagnostic methods
• Virological diagnosis
• Interactions between humans and microbes
• Normal flora
Diagnostic Laboratory Tests
A- Specimens
B- Darkfield examination
C- Immunofluorescence
D- Serology
Diagnosis of Bacterial Infection

Patient Clinical Non-microbiological


diagnosis investigations

Radiology

Haematology
Biochemistry

Sample Take the correct specimen


Take the specimen correctly
Label & package the
specimen up correctly
Appropriate transport &
storage of specimen
A proper clinical assessment is essential for
optimal use of laboratory services!

Garbage in

Laboratory

Garbage out
Is your investigation worthwhile?

Do you know what no


information you want?

yes

Is the information
already available?
yes stop!
no think
Does it affect patient
again
no
management?
yes
Can the lab provide this
no
information?
yes

Contact the lab for info on Give the lab all relevant clinical
Best test information
Type of sample e. g. antibiotic treatment
Timing of sample recent travel
Transport of sample special risks etc
Interpretation of results

Happy Happy Happy Happy


clinician microbiologist patient manager
Collecting the correct specimen
• Endocervical swabs for GC
• Pernasal swabs for pertussis
• whole EMU for TB
• Sputum , not saliva
• Blood culture bottles, not clotted blood
• Correctly timed Gentamicin assays
• Pus, not swabs
Getting the specimen to the lab
• Problems in delay or inappropriate storage• delay in
dignosis & treatment
– pathogens die
– contaminants overgrow
• Blood cultures directly into incubator
– not refigerator!
• CSF straight to lab
• Don't put an entire surgical specimen into formalin!
– Send a portion to microbiology in a sterile container
Collecting the specimen

correctly
Take an mid-stream urine
– avoids contamination with perineal flora
• CSF
– Avoid contamination
– Avoid bloody tap
• Throat swab
– Make the patient gag!
• Blood cultures
– Avoid contamination with skin organisms
Specimens & Infection Control
• Please be considerate to lab staff!!
– Label hazardous specimens
• Don't send specimens to the lab without
proper packing
– Leaking or blood-stained specimens are not
acceptable!!!
Factors limiting usefulness of
bacteriological investigations
• wrong sample
– e.g. saliva instead of sputum
• delay in transport / inappropriate storage
– e.g. CSF
• overgrowth by contaminants
– e.g. blood cultures
• insufficient sample / sampling error
– e.g.in mycobacterial disease
• patient has received antibiotics
Diagnosis of Bacterial
Infection
microscopy unstained or stained with e.g.
Gram stain

Stain Decolorise Counterstain

culture identification by biochemical or


serological tests on pure growth
from single colony

on plates or in broth

sensitivities by disc diffusion


methods,
breakpoints or
MICs Serodiagnosis DNA technologies
Microscopy
Unstained preparations
• “Wet prep”
• Dark-ground
illumination for syphilis
Microscopy
Stained preparations
• Gram-stain
• Acid-fast stain
– Ziehl-Neelsen
• Fluorescence
– Direct, e.g. auramine
– Immunofluorescence
Culture of Bacteria
• Solid media
– Agar plates
• For Identification
• For Enumeration
– Slopes
– For safe long-term
culture, e.g. Lowenstein-
Jensen media for TB
• Liquid media (broth)
– For enrichment or
maximum sensitivity
Advantages of Solid
Media
• isolation of single clonal
colonies
– get bacterium in pure
culture
• identify by colonial
morphology
• quantification by colony-
forming units
Identification of Bacteria
• Morphology
• Growth requirements
• Biochemistry
• Enzymes
• Antigens
Non-cultural diagnostic methods
• Antigen detection
– e.g. latex agglutination
• Antibody detection
– e. g. agglutination tests, complement fixation
tests, indirect immunofluorescence
• Molecular methods
– Polymerase Chain Reaction
Sensitivity
tests
no zone around disc =
resistant
• on solid media clear zone
– disc diffusion around disc =
sensitive
technique
• in liquid media bacterium

– minimum inhibitory
concentration
(MIC) test
• Breakpoint methods
• E-test 8mg/ 4mg/ 2mg/ 1mg/ 0.5m 0.25
L L L L g/L mg/L

cloudiness means
amount of bacteria can grow at
antibiotic that concentration of
antibiotic
MIC=2mg/L
Diagnosis of Viral
Infection
• Electron microscopy
• Antigen detection
• Antibody detection
• Virus culture
– Detect cytopathic effect
or antigen
• Molecular methods
– Polymerase Chain
Reaction
– Sequencing (e.g. for
sensitivities)
Microbes and humans

Very few microbes are


always pathogenic

Many microbes are


potentially pathogenic

Most microbes are


never pathogenic
Microbes and humans
Disease can come about in several overlapping ways
1. Some bacteria are entirely adapted to the pathogenic way of life in
humans. They are never part of the normal flora but may cause
subclinical infection, e.g. M . tuberculosis
2. Some bacteria which are part of the normal flora acquire extra virulence
factors making them pathogenic, e.g. E. coli
3. Some bacteria which are part of the normal flora can cause disease if
they gain access to deep tissues by trauma, surgery, lines, e.g. S.
epidermidis
4. In immunocompromised patients many free-living bacteria and
components of the normal flora can cause disease, especially if
introduced into deep tissues, e.g. Acinetobacter
How do we know that a given
pathogen causes a specific disease?
• Koch's postulates
– the pathogen must be present in every case of the disease
– the pathogen must be isolated from the diseased host & grown
in pure culture
– the specific disease must be reproduced when a pure culture of
the pathogen is inoculated into a healthy susceptible host
– the pathogen must be recoverable from the experimentally
infected host
The iceberg concept of infectious disease

poliomyelitis in a child
0.1-1% of infections are
clinically apparent classical
clinical disease
less severe
disease

rubella
50% of infections are
clinically apparent

Spectrum of asymptomatic infection


virulence

rabies
100% of infections
are clinically apparent
How do we know that a given pathogen causes a
specific disease?

Diagnosis and effective treatment of infection


depends not just on isolating an organism, but Recognised syndromes
in establishing a plausible link between the
laboratory findings, recognised syndromes
and the patient's clinical condition e.g.
septicaemia, endocarditis,
osteomyelitis meningitis,
UTI, pneumonia
pharyngitis

patient's clinical
potential pathogen condition
isolated from or
detected in clinical
samples
Microbes and humans
• Evidence for a potential pathogen being clinical
significant (particularly for bacteria)
– Isolated in abundance
– Isolated in pure culture
– Isolated on more than one occasion
– Isolated from deep tissues
– Evidence of local inflammation
– Evidence of immune response to pathogen
– Fits with clinical picture
Normal flora
• All body surfaces possess a rich normal bacterial flora,
especially the mouth, nose, gingival crevice, large bowel, skin
– This can be a nuisance in that
• it can contaminate specimens
• it can cause disease
– This is beneficial in that
• it can protect against infection by preventing pathogens colonising
epithelial surfaces (colonisation resistance)
• removal of the normal flora with antibiotics can cause superinfection,
usually with resistant microbes
• Endogenous viruses reside in the human genome
– worries about similar pig viruses in xenografts
Outline
• Clinical assessment
• Collecting and transporting specimens
• Microscopy
• Culture
• Sensitivity
• Non-cultural diagnostic methods
• Virological diagnosis
• Interactions between humans and microbes
• Normal flora