Introduction
Syphilis is a sexually transmitted infection caused by the spirochete bacterium (Treponema Pallidium) subspecies palladium. The primary route of transmission is through sexual contact however, it may also be transmitted from mother to foetus during pregnancy or at birth, resulting in congenital syphilis. other human disease caused by related Treponema Pallidum include yaws (subspecies pertenue), pinta (subspecies carateum) and bejel (subspecies endomecum), (Geo et al., 2009).
The signs and symptoms of syphilis vary depending on which of the four stage its present (primary, secondary, latent and tertiary), the primary stage classically presents with a single chance (a firm, painless, non itchy skin ulceration), secondary syphilis with a diffuse rash which frequently involves the palm of the hands and soles of the feet, latent syphilis is with little to no symptoms, tertiary syphilis with gummas neurological or cardiac symptoms. It has however, been known as the great “imitator” due to its frequent typical presentation (Goe et al., 2009). Diagnosis is usually through blood tests. However, the bacteria can also visualize under a microscope. Syphilis can be affectively treated with antibiotic, specifically the preferred intramuscular (penicillin G given intravenously for neurosyphilis) or ceftriaxone and those who have a severe penicillin allergy, oral doxycycline or azithromycin.
Syphilis is believed to have infected 12 million people worldwide in 1999, with greater than 90% of cases in the developing world after decreasing dramatically since the wide spread availability of penicillin in the 1940, rates of infection have increased since the turn of the millennium in many countries, often in combination with human immunodeficiency virus (HIV). This has been attributed partly to unsafe sexual practice among men who have sex with men, increase promiscuity, prostitution and decreasing use of barrier protection (Coffin et al., 2010). Sexual transmission is probably by inoculation into tiny abrasions from sexual trauma causing a local response resulting in an erosion then ulcer. This is followed by spread of the treponemes to the regional lymph nodes and haematogenous dissemination to other parts of the body, while the local immunity lead to ulcer healing, system dissemination results in immune response to the deposited treponemes leading to secondary syphilis.
Circulating immune complexes formed may be deposited in organs such immune complexes formed may be deposited in organs such as kidney, contributing to the systemic manifestation, this is often followed by a latent phase and if untreated, about 40% of patient will go on to the tertiary stage which is characterize by gummatous, cardiovascular and neurological involvement. The latter which are also classified as quarternary syphilis. The basic pathology in all stages is vasculities.
Genital ulceration disease (GUD), involving syphilis increases the risk of transmission of HIV (Fleming and Wasserheit, 2004). In addition, HIV infection may cause more severe manifestation of early syphilis or more rapid progression of late syphilis.
Conceptual framework
Sexually transmitted diseases (STD) are major global cause of infertility, long term disability and death with severe medical and psychological consequences for millions of men, women and infants (WHO, 2001).
Syphilis caused by Treponema Pallidum bacteria is a major STD which remains an important cause of morbidity and is associated, like other ulcerative sexually transmitted infection with enhanced sexual transmission of human immunodeficiency virus (HIV) (Cohen, 2002). While syphilis is largely under control in affluent part of the world, it continues to be a tragic and substantial problem in many developing countries including Nigeria.
Furthermore, through its association, syphilis has acquired a new potential for morbidity and mortality (Zeltser and Kurban, 2004). The interaction of syphilis and HIV infection is reportedly complex (Tramount, 2005). Isolated cases reports have suggested that co-existent HIV infection may alter the natural history of syphilis and the dosage or duration of treatment required to cure syphilis (John, Tierneg and Felsenstein, 2002) these report have led to the hypothesis that in patient with HIV and T. Pallidum cutaneous lesions may be more severe symptomatic neurosyphilis may be more likely to develop the latency period before the development of meningo vascular syphilis may be shorter and the efficacy of standard therapy for early syphilis may be reduced (Bolan, 2001) furthermore, the genital ulceration and inflammation caused by syphilis are implicated as co-factors making infected individual three to five time more likely to acquire HIV exposed to the virus through sexual contact (Wasserheit, 2002).
Unless prompt diagnosis and treatment of syphilis are performed serious complication including male and female infertility may result
Etiology of syphilis
Although given various names following its discovery the causative organism of syphilis was finally named treponema because of resemblance to a twisted and pallidum because of it pale Colour (Quinn, 2005).
- Pallidum is a member of the order spirochatales, family spirochacteceage and genus treponema, which include four human pathogens and at least six human non pathogens. The pathogenic species are T.Pallidum subspecies pallidum which causes venereal syphilis are T. Pallidum subspecies endomecum, which causes endemic syphilis, T. Pallidum subspecies pertenue which causes yaws and T.Carateum which is the etiological agents for pinta. Initial studies indicated that these four agents were morphologically indistinguishable with 95% DNA homology.
- Pallidum is a spirochete varying from 0.10 to 0.18um in diameter and from 6 to 20um in length, making it visible by light microscopy (Norris and Larsen, 2005; Wilcox and Guthe, 2005). The bacterium exhibit characteristics, corkscrew motility due to endoflagella with rapid rotation about the longitudinal axis and flexing, bending and snapping about the full length (Norris et al., 2005).
Epidemiology prevalence of syphilis
Prevalence of syphilis in the tropics comes from studies of GUD (genital ulcerative disease) and serelogical test screening syphilis is usually the second or third commonest causes of genital ulcers either chancoid or genital herpes being common, using polymerase chain reaction (PCR), GUD was caused by syphilis in 14 % of affected people in Dar es salaam, Tanzania (Ahmed et al, 2003) 10% in Peru 5% in the Dominican Republic (Sanchez et al., 2002), 42% in positive men and 10.6% in HIV negative men in South Africa (Ballard et al., 2002). And 10% in Peru, India (Risbud et al, 2002). In the latter co-infection with chancoid, herpes or both occur in 4% in hong kong, prevalence of 2% was obtained by Abdullah, Fieldiry and Hedley (2002). For woman in Nairobi, Kenya was 6.0% (Fonk et al., 2002) And 15. 1% in Mumbai, India (Divakar et al., 2000). And 2.3% was found among student in Harare, Zimbabwe (Gwanzura et al., 2001). And 113% among young adults in Lesothe (Calvin and Sharp, 2002), 2.2% for men and 9.7% for women in the Gambia (Shaw et al., 2001).
In Nigeria however, the study of Uneke, Ogbu and Alo (2006) reported a prevalence of 2.0%. This is because HIV destroys cell mediated and humoral humanity which could lead to limits to the host defence against syphilis invasion. Syphilis has a prevalence of 15% in female and 12.7% in males (Uneke et al., 2006). And found mostly among the age range of 41-50 years in Ibadan and Irag, syphilis prevalence were found to be 0.1% each (Gharbani, Mohamadi and Estahan, 2009).
Clinical presentation
During the primary stage of syphilis, a sore (chancre) that is usually painless develops at the site where the bacterial entered the body. This commonly occurs within three (3) weeks of exposure but can range from 10 to 90 day. The person is highly contagious during the primary stage.
In male, a chancre often appear in the genital area, usually (but not always) on the penis. These sores are often painless. In female, chancre can develop on the outer genitals or on the inner part of the virginal. A chancre may go unnoticed if it occurs inside the vagina or at the opening of the uterus (cervix). The sore are usually painless and are not easily seen, swelling of the lymph nodes may occur near the area of chancre. A chancre usually lasts for 3-6 weeks, heals without treatment, and may leave a thin scar but even though the chancre has healed syphilis is still present and the person can still pass the infection to other (Tremont, 2010).
Secondary stage of syphilis is characterized by rash that appear 2 to 8 weeks after the chancre develops and sometimes before it heals, other symptom may occur, which means that the infection has spread throughout the body. One is highly contagious during the secondary stage. A rash often develops over the body and commonly includes the palm of the hands and the soles of the feet. The rash usually consists of the reddish brown small, solid flat or raised skin sores that are less than 2cm (0.8in) across. But the rash may look more like other common skin problem small, open sores may be present on mucous membranes; the sores may contain pus or moist sores that look like warts (called condylomalata) may be present.
In dark skinned people, the sores may be the skin rain usually heal within 2 months on its own without scarring, after healing skin discolouration may occur but even though the skin rash has healed syphilis is present and the person can still pass the infection to other (Tremont, 2010). When syphilis has spread throughout the body, the person may have
- A fever
- A sore throat
- A vague feeling of weakness or discomfort throughout the body
- Weight loss
- Patchy hair loss, especially in the eyebrows, eyelashes and scalp hair, swelling of the lymph nodes.
- Nervous system of symptoms of secondary syphilis which can include neck stiffness, headaches, irritability, paralysis, unequal reflexes and irregular pupils
Structure of syphilis
Treponema Pallidum is a spiral shaped, gram-negative spirochaete bacterium with subspecies that cause treponemal disease such as syphilis, bejel, pinta and yaws. The treponemes have a cytoplasmic and outer membrane using (light microscope). Treponemes are only visible using dark field illumination.
Transmission of syphilis
Syphilis is transmitted primarily by sexual contact or during pregnancy from a mother to her foetus, the spirochete is able to pass through intact mucous membranes or compromised skin (Kent and Romanelli, 2008; Stamm, 2010). It is thus transmissible by kissing or oral vagina and anal sex (Kent et al., 2008). Approximately 30 to 60% of those exposed to primary or secondary syphilis will get the disease (Bhatti, 2007) its infectivity is exemplified by the fact that an individual inoculated with only 57 organisms has a 50% chance of being infected (Eccleston et al., 2008).
It can be transmitted through blood product. However it is tested for many countries and thus the risk is low. The risk of transmission from sharing needles appears limited (Kent et al., 2008). Syphilis cannot be contacted through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing.
History of syphilis
The exact origin of syphilis is unknown (Kent et al., 2008). There are two hypotheses one proposes syphilis was carried to Europe by the returning crewmen from Christopher Columbus, voyage to the (Americas), the other proposes syphilis existed in Europe previously, but went unrecognized. These are referred to as the “Columbian” and “pre-Columbian” hypotheses respectively (Farhi and Dupin, 2010). The Columbia hypothesis is best supported by the available evidence (Rothschild, 2008).
The first written record of an outbreak of syphilis in Europe occurred in 1494/1495 in Naples, Haly during a French invasion (Frazen 2008; Farhi et al., 2010). Due to its being spread by returning French troops, it was initially known as the “French disease” as it still traditionally referred. in 1930 the name “syphilis” was first used by the Italian physician and poet (Girolamofracastoro) as the title of his Latin poem in dactylic hexameter describing the ravages of the disease in Italy. It was also known historically as the “Great Pox” (Dayan, 2005; Knell, 2004). The causative organism, Treponema Pallidum, was first identified by Fritz, Schaudinn and Erich Hoffmann in 1905 (Frazen, 2008). The first effective treatment (salvarsan) was developed in 1910 by Paul Ehrlich, which was followed by trials of penicillin and confirmation of its effectiveness in 1943 (Franzen, 2008 Dayan et al., 2005). Before the advent of effective treatment mercury and isolation were commonly used with treatment often worse the disease (Dayan et al, 2005) many famous historical figures including franz Schubert, Arthur schopenhaure, edouardmanent, including (Frazen , 2008) and Adolf Hittler (Hitler, 2003) were believed to have had the disease.
Pathogenesis of syphilis
Most of the information on the pathogenesis of syphilis is derived from animal models because of the limited information available from human studies (Musher 2005; Magnuson et al., 2007). Researcher were able to demonstrate that two organisms inoculated intracutaneously in rabbits produced a dark field positive lesion in 47% of cases (Magnuson et al., 2007). The increase to 71 and 100% when 20 and 200, 000 organism were inoculated, respectively on intracutanous, inoculation, the incubation period varied with the size of the inoculums, so that with a large inoculums e.g. 107 organism a chancre appeared in 5 to 7 days an inoculation study in human volunteers, which would be considered unethical by today’s standard showed similar findings.
Animals studies have shown that the organism appear within minutes in lymph nodes and disseminate widely within hours although the exact mechanism by which T. Pallidum enter cell is not known, it has been shown to attach to mammalian cells in vitro attachment may occur by specific attachment ligands. Invasion appear to be a critical virulence factor for T. Pallidum, as demonstrated by its ability to penetrate endothelial cell mononolayers and intact membranes (Rivere et al., 2007).
Prognosis of syphilis
The prognosis is good for the early stage of syphilis if the patient is treated promptly and given sufficiently large dose of antibiotics Treatment failures can occur and patient can be reinfected. There are no definite criteria for cure for patient with primary and secondary syphilis, although patients who are symptoms free and have had negative blood tests for two years after treatment are usually considered cured patient should be followed up with blood tests at one, three six and twelve months after treatment or until the result are negative CSF should be examined after one year, patient with recurrences during the latency period should be tested for Reinfection. The prognosis for patients with untreated syphilis is spontaneous remission for about 30%, lifelong latency for another 30% and potentially fatal tertiary forms of the disease in 40% (Rivere et al).
HIV co-infection with syphilis
Many region in the tropic have high prevalence of both HIV infection and syphilis. syphilis can mimic HIV infection and vice versa. chancre versus chronic mucocutaneous anogental herpes in AIDS, secondary syphilis versus primary HIV infection, nerosyphilis versus neurological complication of HIV infection. HIV infection can lead to larger or more numerous chancre (Rampalo et al., 2001).
Rampalo et al. (2001) found that HIV positive patient were more likely to present with multiple ulcers deeper ulcer, or concomitant primary and secondary lesions with regard to treatment of syphilis in HIV infected patient, there are no new data to contradict previous recommendation that HIV infected individuals should receive the same treatment regimens as person without HIV- infection. Browning (2000) found no difference in the responses to treatment of ocular syphilis between HIV – positive and HIV- negative patient finally, recent studies suggest that acquisition of syphilis by infected individual causes an increase in the serum HIV load but there is improvement with standard syphilis treatment (Kofoed, 2006, Buchacz, et al., 2004).
Diagnosis of syphilis
Syphilis is difficult to diagnose clinically, early in its presentation, confirmation is either through blood test or direct visual inspection using microscopy. Blood test are more commonly used, as they are easier to perform, diagnostic test are however, unable to distinguish between the stages of the disease (Farhi et al., 2010).
Blood test
Blood tests are divided into nontroponemal and treponemal test (Eccieston et al., 2008). Nontreponemal test are used initially, and include veneral disease research laboratory (VDRL) and rapid plasma reagin tests however, as these tests are occasionally false positive confirmation is required with a treponemal test, such as treponemal pallidum particle agglutination (TPAA) or fluorescent treponemal antibody absorption test (FTA-ABS). (Kent et al., 2008). False positive on the nontreponemal test can occur with some viral infection such as varicella and measles, as well as with lymphoma tuberculosis malaria, enclocarditis, connective tissue disease and pregnancy (Larry and Pickering, 2006). Treponemal antibody test usually, become positive two to five weeks after the initial infection.
Direct testing of syphilis
Dark ground microscopy of serious fluid from a chancre may be used to make an immediate diagnosis, however, hospitals do not always have equipment or experienced staff members, where as testing must be done within 10 minutes of acquiring the sample sensitivity has been reported to be nearly 80% thus can only be used conform a diagnosis but not rule one out two other tests can be carried out on a sample from the chancre. Direct fluorescent antibody testing and nucleic acid amplification tests Direct fluorescent testing use antibodies tagged with fluorescein which attaches to specific syphilis protein, while nucleic acid amplification uses techniques such as the polymerase chain reaction, to detect the presence of specific genes. These test are not as time sensitive as they do not require living bacteria to make the diagnosis
Prevention of syphilis
As of 2010 there is no vaccine affective for prevention of syphilis (Stamm, 2010). Abstinence from intimate physical contact with an infected person is effective at reducing the transmission of syphilis as is the proper use of a latex condom, Condom use. however does not completely eliminate the risk (Koss et al., 2009). Thus the Center for Disease Control and Prevention recommends a long term, mutually monogamous relationship with an uninfected partner and the avoidance of substances such as alcohol and other drugs that increase risky sexual behaviour.
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