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Syphilis is an acute and chronic infectious disease caused by the spirochete Treponema pallidum. It is acquired through sexual contact or may be congenital in origin.
In the untreated person, the course of syphilis can be divided into three stages: primary, secondary, and tertiary. These stages reflect the time from infection and the clinical manifestations observed in that period, and are the basis for treatment decisions.
Primary syphilis occurs 2 to 3 weeks after initial inoculationwith the organism. A painless lesion at the site of infection is called a chancre. Untreated, these lesions usually resolve sponta-neously within about 2 months.
Secondary syphilis occurs when the hematogenous spread of or-ganisms from the original chancre leads to generalized infection. The rash of secondary syphilis generally occurs about 2 to 8 weeks after the chancre and involves the trunk and the extremities, in-cluding the palms of the hands and the soles of the feet. Transmis-sion of the organism can occur through contact with these lesions. Generalized signs of infection may include lymphadenopathy, arthritis, meningitis, hair loss, fever, malaise, and weight loss.
After the secondary stage, there is a period of latency, during which the infected person has no signs or symptoms of syphilis. Latency can be interrupted by a recurrence of secondary syphilis.
Tertiary syphilis is the final stage in the natural history of thedisease. It is estimated that between 20% and 40% of those in-fected do not exhibit signs and symptoms of this final stage. In this stage, syphilis presents as a slowly progressive, inflammatory dis-ease with the potential to affect multiple organs. The most com-mon manifestations at this level are aortitis and neurosyphilis, as evidenced by dementia, psychosis, paresis, stroke, or meningitis.
Because syphilis shares symptoms with many diseases, clinical his-tory and laboratory evaluation are important. The conclusive di-agnosis of syphilis can be made by direct identification of the spirochete obtained from the chancre lesions of primary syphilis. Serologic tests used in the diagnosis of secondary and tertiary syphilis require clinical correlation in interpretation. The sero-logic tests are summarized as follows:
Nontreponemal or reagin tests, such as the Venereal DiseaseResearch Laboratory (VDRL) or the rapid plasma reagin circle card test (RPR-CT), are generally used for screening and diagnosis. After adequate therapy, the test result is ex-pected to decrease quantitatively until it is read as negative, usually about 2 years after therapy is completed.
Treponemal tests, such as the fluorescent treponemal anti-body absorption test (FTA-ABS) and the microhemag-glutination test (MHA-TP), are used to verify that the screening test did not represent a false-positive result. Posi-tive results usually are positive for life and therefore are not appropriate to determine therapeutic effectiveness.
Treatment of all stages of syphilis is administration of antibiotics. Penicillin G benzathine is the medication of choice for early syphilis or latent syphilis of less than 1 yearâ€™s duration. It is ad-ministered by intramuscular injection at a single session. The same therapy is recommended for patients with early latent syphilis. Patients with late latent or latent syphilis of unknown duration should receive three injections at 1-week intervals. Patients who are allergic to penicillin are usually treated with doxycycline. The patient treated with penicillin is monitored for 30 minutes after the injection to observe for a possible allergic reaction.
Treatment guidelines established by the CDC are updated on a regular basis. Recommendations provide special guidelines for treat-ment in the setting of pregnancy, allergy, HIV infection, pediatric infection, congenital infection, and neurosyphilis (CDC, 2002d).
Syphilis is a reportable communicable disease. In any health care facility, a mechanism should be in place to ensure that all patients who are diagnosed are reported to the state or local public health department to ensure community follow-up. The public health department is responsible for interviewing the patient to deter-mine sexual contacts, so that contact notification and screening can be initiated.
Lesions of primary and secondary syphilis may be highly in-fective. Gloves are worn when having direct contact with lesions, and hands are washed after gloves are removed. Isolation in a pri-vate room is not required (Chart 70-4).
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