3. History
Fritz Schaudinn (1871-1906) and Paul E.
Hoffmann (1868-1959) discovered Treponema
pallidum in serum in 1905.
4. Recent Years
Scientist sequenced the
genome of the bacteria
Treponema Pallidum in
1998.
From this information
scientist hoped to
advance their ability
to diagnose, treat, and
prevent Syphilis
5. Introduction
Morpholgy
Thin delicate spirochete with tapering ends
length: 4-14µm
width: 0.1-0.2µm
has 10 spirals
actively motile
Genus Axial filament Insertion disk
Treponema 6-10 1
Borrelia 30-40 2
Leptospira 2 3-5
6. Resistance
Delicate and inactivated by drying or by heat(41-
42ºC in 1hr)
Fever therapy for syphilis
killed in 1-3 days at 0- 4ºC
inactivated by soap, arsenicals, common
antiseptic agents
7. Antigenic structure
complex antigenic structure
Treponema infection induces
3 types of antibody
1st is reagin antibody
2nd is group antigen
3rd is polysaccharide in nature
and is species specific
8. Pathogenesis
Organism entry(Sexual contact)
by penetrating the intact mucous membrane or
entering through breaks in the skin
Invade the blood stream and spreads to other
body sites
endarteritis
Progressive tissue destruction
9. Syphilis
Origin not definitely known
widely spread disease in Europe in 15th century
Types
Early Syphilis
Late Syphilis
Neuro Syphilis
Cardiovascular Syphilis
Late “Benigin” Syphilis
Congenital Syphilis
10.
11. Primary Syphilis
Primary lesion or "chancre" develops at the
site of inoculation after 18- 21 days
Chancre:
Progresses from macule to papule to ulcer
Typically painless, indurated, and has a clean base
Highly infectious
Cartilage-like consistency
Heals spontaneously within 1 to 6 weeks
25% present with multiple lesions
chancre also can develop on the cervix, tongue, lips or
other parts of the body
Regional lymphadenopathy
12. Primary lesion in penile
region Primary lesion in tongue
Serologic tests for syphilis may not be
positive during early primary syphilis
13. Secondary Syphilis
Secondary lesions occur 3 to 6 weeks after the
primary chancre appears
may persist for weeks to months
Primary and secondary stages may overlap
Mucocutaneous lesions most common
Symptoms:
fever
swollen lymph glands
sore throat
patchy hair loss
headaches
weight loss
muscle aches
fatigue
15. Latent Syphilis
Host suppresses infection-no lesions are
clinically apparent
Only evidence is positive serologic test
May occur between
primary and secondary stages
secondary relapses
after secondary stage
Categories:
Early latent: <1 year duration
Late latent: 1 year duration
16. Late Syphilis
Approximately 30% of untreated patients
progress to the tertiary stage within 1 to 20
years
Rare because of the widespread availability
and use of antibiotics
Manifestations
Gummatous lesions
Cardiovascular syphilis
Neurosyphilis
17. Late “Benign” Syphilis
characterized by formation of non specific
granulomatous lesion called gumma
most common complication
15% of untreated patients
indicates fully active
cellular immune response
Destory surrounding
tissue as it enlarge
18. Cardiovascular Syphilis
10% of untreated patients
inflammation of the small vessel that feed
aorta and affect primarily the ascending aorta
Complications
Aortic aneurysm
dilation of aortic ring
19. Neuro Syhilis
May be symptomatic or asymptomatic
asymptomatic disease is characterized by
CSF abnormalities
symptomatic infection is either
meningovascular or parenchymatous
In meningovascular syphilis any cranial
nerve may be inflammed and deafness and
visual impairement may occur
Parenchymatous disease may involve the
neurons of cerebrum or the spinal cord
20. Congenital Syphilis
Occurs when T. pallidum is transmitted from a
pregnant woman to her fetus
May lead to
stillbirth &neonatal death
infant disorders such as deafness
neurologic impairment and bone deformities
Transmission can occur during any stage of
syphilis
risk is much higher during primary and
secondary syphilis
Fetal infection can occur during any trimester
of pregnancy
22. Laboratory Diagnosis
Identification of Treponema pallidum in lesions
Darkfield microscopy
Direct fluorescent antibody - T. pallidum
(DFA-TP)
PCR
Serologic tests
Nontreponemal test
Treponemal tests
23. Darkfield Microscopy
Sample collection
Clean the area around the lesion with gauze pad
moistened in saline
surface of ulcer is abraded until some blood is
expressed
blott the lesion until no futher bleeding
squeeze the area until serous fluid is expressed
expressed fluid is aspirated with sterile pipette
What to look for?
T. pallidum morphology and motility
8-10µm long, conists 8-14 tightly coiled even
spirals,
24. Advantage:
Definitive immediate diagnosis
easiest method of diagnosis
Disadvantages:
Requires specialized equipment and an experienced
microscopist
Possible confusion with other
pathogenic and nonpathogenic
spirochetes
Must be performed immediately
Generally not recommended on
oral lesions
Possibility of false-negatives
25. Direct fluorescent antibody test
Identifies T. pallidum in direct lesion smear by
immunofluorescence
smear are stained flourescein-isothyocyanide
labelled anti-T.pallidum globulin
Advantages:
Commercially available
detects and differentiate pathogenic
treponemes from non pathogenic
applicable to the sample of oral, rectal,
intestinal lesion
Disadvantages:
Turnaround time 1-2 days
28. Complement fixation test
(Wassermann reaction)
Formerly used for serodiagnosis of Syphilis
consist of 2 steps
Inactivated serum + (wassermann antigen + 2 unit
of guinea pig complement) incubate for 1hr at 37ºC
2nd step addition of sensitized sheep red cell and
incubate at 37ºC for 30 min
No lysis--- Posituve
Lysis----- Negative
29. Flocculation test
Soluble antigen + antibody---- antigen-antibody
complex form remain suspended as floccules
Khan test is the first flocculation test and has been
replaced by VDRL test
VDRL test can be used for CSF but not for plasma
Modification of VDRL test is RPR
which uses the VDRL antigen containing carbon
particles
RPR test can be done in unheated serum but not
CSF
Automated RPR is also available
Automated VDRL-ELISA test is also developed
31. Sensitivity & Specificity of non treponemal
test
% Sensitivity %
Specificity
Test Primary Secondary Latent Late Non-
Syphilis
VDRL 78 100 95 71 98
RPR 86 100 98 73 98
USR 80 100 95 99
TRUST 85 100 98 99
32. Treponemal tests
Treponema pallidum Immoblisation
Test serum is incubated with complement and
T.pallidum maintained in a complex medium
anaerobically
If antibody is present the treponemas are
immobilized i.e. non-motile when observed under
dark ground ilumination
Complex procedure
33. Fluorescent treponemal antibody
Indirect immunofluorescent test using as antigen,
smears prepared on slides with Nichol`s strain
Currently used modification is FTA-absorption
(FTA-ABS)
test serum is pre-absorbed with sorbent (heat
extract from cultures of non pathogenic Reiter
strain) to eliminate group specific reactions
serum is layered on slide to which T.pallidum is
fixed
FITC-labelled anti human immunolobulin is added
and combine with patient antibodies adhering to
T.pallidum, resulting in FITC stained spirochetes
34. Modification of FTA-ABS is the FTA-ABS double
stain
Conjugate used is rhodamine isothiocyanate-
labeled antihuman globulin and counterstain FITC-
labeled anti T.pallidum conjugate
35. Hemagglutination methods
TPHA uses tanned erythrocytes sensitised with
sonicated extract of T.pallidum as antigen
presence of treponemal antibodies in patient serum
was detected by indirect agglutination of sensitized
erythocytes
The procedure now employed is MHA-TP which can be
automated
simpler to perform than flourescent antibody tests
36. Particle agglutination methods
MHA test has been modified to use gelatin
particles rather than erythocytes as the antigen
carrier creating T.pallidum particle agglutination
removal of preabsorption process
procedure similar to MHA-TP
Sensitivity and specificity similar to that of the
FTA-ABS test
37. Latex agglutination methods
In 1985 1st report of latex agglutination was
publish
use cloned T. pallidum antigens bound to latex
particles
easy to perform, fast and require less than 30
min for result
38. Enzyme immunoassay
First applied in 1975 as a serology test for syphilis
2 types of EIA tests are available
one uses sonicated T.pallidum as anitgen
one uses cloned antigen
Advantage of EIA are capability to automate the
test and run large number of samples in relatively
short time
39. Immunoblotting
Used to detect IgG or IgM
to prepare the strips for T.pallidum immuno-blotting,
intially boiled sodium dodecyl sulphate (SDS) extract
of organism is electrophoresed through a gradient gel
After electrophoresis a sheet of nitrocellulose is
placed on the top of gel & the protein immuno-
determinants are electrophoretically transfer to blot
The blot is cut into strips and incubated with the
patient serum
after incubation strips with patient serum are detected
using enzyme and substrate lebeled antibody
IgM western blot is most sensitive to diagnose the
congenital syphilis
40. Sensitivites and Specifites of treponemal
test
%
Sensitivity Specificity
Test Primary Secondary Latent Non- Syphilis
FTA-ABS 84 100 100 97
TP-PA 88 100 100 98
FTA-ABS DS 86 100 100 98
EIA 90 100 100 98
Western blot 90 100 100 98
41. Therapy for Primary, Secondary, and Early
Latent Syphilis
Benzathine penicillin G 2.4 million units IM in
a single dose (Bicillin L-A®)
If penicillin allergic:
Doxycycline 100 mg orally
twice daily for 14 days,
or
Tetracycline 500 mg orally
4 times daily for 14 days
Source: Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2006. MMWR 2006;55 (No. RR-11).
42. Latent Syphilis of Unknown Duration
Benzathine penicillin G 7.2 million units total,
administered as 3 doses of 2.4 million units
IM each at 1-week intervals
If penicillin allergic:
Doxycycline 100 mg orally twice daily for
28 days OR
Tetracycline 500 mg orally 4 times daily for
28 days
Source: Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2006. MMWR 2006;55 (No. RR-11).
43. Therapy for Neurosyphilis
Aqueous crystalline penicillin G 18-24
million units per day, administered as 3-4
million units IV every 4 hours or continuous
infusion for 10-14 days IV
Alternative regimen (if compliance can be
ensured):
Procaine penicillin 2.4 million units IM once
daily PLUS Probenecid 500 mg orally 4
times a day, both for 10-14 days
44. Follow-Up
Primary or secondary syphilis
Re-examine at 6 and 12 months
Follow-up titers should be compared to the
maximum or baseline nontreponemal titer
obtained on day of treatment.
Latent syphilis
Re-examine at 6, 12, 18, and 24 months
HIV-infected patients
3, 6, 9, and 12 months for primary or secondary
syphilis
6, 12, 18, and 24 months for latent syphilis
Neurosyphilis
Serologic testing as above
Repeat CSF examination at 6-month intervals until
normal
45. Prevention
Refraining from sexual contact with a individual
infected with Syphilis will prevent spreading.
Using a condom will also help prevent transmission
46. References
Koneman`s Color Atlas and Textbook of
Diagnostic Microbiology
Ananthanarayan and Paniker`s Textbook of
Microbiology
Bailey & Scott`s Diagnostic Microbiology
Topley`s and Wilson
