Syphilis

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introducedon :

  • Syphilis is sexually transmitted infection (IS), bacterial, caused by a spirochete, the Treponema pallidum
  • It appeared at the end of the 15th century and continues to arouse great interest after more than five centuries.
  • It is currently on the rise (VIH…)
  • The natural history of the disease is stereotyped with a three-phase course : primary (chancre),  secondary (treponemal sepsis)  and tertiary (neurological and cardiovascular complications)
  • Serologies allow an indirect approach, their interpretation is not always easy
  • The therapeutic management is generally well codified (Penicillin G retard +++)

Historic :

  • In the Barcelona of 1494 appeared an epidemic characterized by the occurrence of sexually transmitted genital lesions
  • During the Italian wars (1494-1559), the epidemic was spreading in Italy, in France, in Switzerland and Germany
  • During its expansion in Europe, syphilis successively took the name of "Spanish disease", "Bad French", "Neapolitan evil" ...
  • In 1530, the publication of a poem by Italian humanist Giroloma Fracastoro, describing the evil with which the shepherd Syphilus was afflicted, definitively endorsed the name of the disease
  • Sixteenth-Century Authors Cited American Origin of Syphilis, imported by the crews of Christopher Columbus, without formal evidence being able to be established

Microbiology :

  • It's about Treponema pallidum (TP), spiral cosmopolitan bacteria, mobile, belonging to the order of Spirochaetales
  • Identified in 1905 by Schaudinn and Hoffman, the T. pallidum is a helical bacillus, with regular turns and tapered ends. It belongs to the genre Treponema which includes other species :  pathogens (responsible for endemic treponematoses :  soon,  login status,  surface)  or commensals
  • Measuring 5-15 µm de long, T. pallidum is driven by a double movement : Firstly, a rotation around its longitudinal axis, d & rsquo; other, a ripple propagating from one end to the other
  • The division time of Treponema pallidum is long, from 33h in early syphilis to several days in late syphilis
  • Au microscope standard, we can only see it on a black background, coloring being difficult
  • Dark field microscope examination shows a moving germ (he moves majestically in the field of the microscope) and rigid (he does not fold in on himself)
  • Treponema pallidum is not cultivable in vitro, its metabolism is therefore little known and it is impossible to establish an antibiogram and, unlike other bacteria, to assess sensitivity to antibiotics in vitro
  • No resistance to Penicillin has yet been reported, Treponema pallidum is sensitive to all β-lactams, cyclins and, to a lesser extent, macrolides
  • Its morphological characteristics make it possible to identify the genus Treponema by direct examination under a dark field microscope or after silver staining, however, this examination does not make it possible to distinguish the different species (pathogenic or commensal) from Treponema
  • Finally, it should be noted the existence of commensal species of Treponema in the oral cavity, making direct examination of this location uninterpretable

Mode from transmission :

  • Transmission sexual : the most frequent,  PT spreads after contact with contagious lesions, it penetrates through a genital epithelium that is the site of micro-lesions during minor trauma occurring during sexual intercourse, sexual practices explain that a chancre can be located elsewhere than on the external genitalia
  • Transmission maternalfetal :  is done during pregnancy by transplacental passage of the Treponema from the 4th month of pregnancy, this justifies routine screening and treatment for any active syphilis in the first trimester of pregnancy. The possibility of contamination of the infant during childbirth from a maternal genital chancre is possible
  • Transmission sanguine :  is exceptionally involved since the systematic treponemal screening of donated blood. Syringe sharing among intravenous drug users remains a hypothetical mode of transmission
  • Transmission professional : only possible if the examination of the syphilitic subject is done with the bare hand, mucosal and genital lesions are the most contagious, because they are most often eroded, bringing the treponemes contained in the dermis to the surface. On the other hand, skin lesions are usually not very contagious because they are covered with a more or less intact non-eroded epidermis
  • The incubation period varies, depending on the size of the inoculum, from 10 at 90 days, on average 3 weeks

classifiedion :

There are several classifications which partially overlap :

  • Classification clinique : distinguishes different successive stages : primary syphilis, secondary, asymptomatic latent, tertiary
  • Classification therapeutic : because of a similarity of care, degree of contagiousness and neurological risk, it is customary to group the different phases of syphilis into 2 categories :

Syphilis recent (precocious) : groups primary forms, secondary and latent less than one year (discovery of positive syphilitic serology without clinical injury, less than a year old),  characterized by high contagiousness and low risk of neurological sequelae

Syphilis late : groups together forms of late latent syphilis over one year (non-datable or more than a year old) and tertiary, having in common a low contagiousness but a high risk of neurological sequelae

CLinique :

  • Syphilis primary : is associated with locoregional lymphatic bacterial diffusion, the incubation is of variable duration (on average : 3 weeks). Primary syphilis is characterized by :

Chancre syphilitic (point d’inoculation) : the chancre is typically an exulceration (or erosion) or more rarely a well-circumscribed mucosal ulceration, from 5-15 mm diameter on average, unique, more rarely multiple, clean background, rosé, indurated base on protected palpation (this is the only truly evocative semiological character, it results in the inability to wrinkle, between two fingers, the surface of the ulceration which becomes a block with the underlying induration), painless. Dwarf canker has been described, giants, painful and inflammatory (surinfection), mixed ...

  • Seat :

In the man : is quite electively in the balano-preputial sulcus, more rarely on the glans or on the sheath

In the women : is most often on the outer part of the vulva (small lips, big lips, fork), more rarely vaginal and since it is painless, he then willingly goes unnoticed

In the of them sexes : the chancre may sit on the oral or pharyngeal mucosa (fellatio), the anorectal mucosa

lymphadenopathy satellite : appears 4-7 days after the chancre, the chancre is accompanied by a non-inflammatory satellite lymphadenopathy, most often unilateral, they are multiple ganglia, small and tough, sometimes centered by a larger ganglion (the “prefect” of the groin in the groin), mobiles, indolores, without periadenitis, that does not fistulate the skin. In certain locations (cervix, rectum) lymphadenopathy is not clinically visible

Evolution :

  • The chancre heals in 10-14 days under treatment, in 3-6 weeks without treatment, without sequelae (sometimes, residual pigmentation)
  • In the absence of treatment,  lymphadenopathy persists for several months,  processed,  she disappears after the chancre
  • If the patient is not treated, he will apparently be cured but his condition may change towards the later stages of syphilis
  • Syphilis secondary : PT sepsis dissemination phase, appears approximately 6 weeks after the chancre (or roughly 2 months after contagion), it can coexist with the inoculation chancre (we then speak of "primary-secondary syphilis"),  it is marked by several rashes, interspersed with asymptomatic phases of a few weeks or months. With these "blooms" are associated general and sometimes visceral signs of varying intensity. It is marked by a polymorphic rash "the great simulator"

Manifestations  skin :  the rash evolves into two more or less intricate phases :

  • Roseola syphilitic (first bloom) : marks the start of the secondary phase, it occurs between the 7th and 10th week, can therefore be associated with the canker, it goes away in 7-10 days or lasts 1-2 months. The rash is made up of pinkish erythematous macules,  5-15 mm in diameter,  without relief or infiltration, scattered over the trunk and root of the limbs,  I-junction,  non- CASTROTHEODORICIENS, non-squameuses. The pale pink color (peach blossom), the absence of functional signs and spontaneous regression explain why the rash usually goes unnoticed. Spontaneous regression without desquamation except at the base of the neck (venus necklace)
  • Syphilides papuleuses (second flowering) : syphilides occur from the 2nd to the 4th month, can therefore coexist with roseola and last from 1 at 6 month, recurrences are possible. Papular syphilids are polymorphic,  but the elementary lesion is almost always a copper-red papule, non-prurigineuse, painless,  a few millimeters in diameter,  I-junction,  symmetrically arranged (on the trunk, limbs and face), sometimes covered with a fine scale or surrounded by a circular peeling peri-lesion (nor constant, neither specific) : Biett collar. Palmoplantar location, the most characteristic, is fickle

Syphilides palmoplantaires : are not papular but infiltrated, they sit astride the palmar or plantar folds, which makes it possible to distinguish them from physiological hyper-pigmented spots in blacks

Sure the face : papules may clump together, drawing circinations, S, especially on the cheeks and chin (elegant syphilides from Brocq), the involvement of the nasolabial folds suggests seborrheic dermatitis and that of the chin an acne

Syphilides perineal and genital : multiples, indolores, non-prurigineuses, soft papulo-erosive, often macerated, giving rise to a vegetative appearance (condyloma lata) highly contagious. The folds are easily erosive

✓ The clinical polymorphism is important and the lesion can present in the form of scales, crusts, ulcerations or necrosis but we always find, below, papule and never vesicles

Manifestations mucous : mucosal damage produces mucous plaques, these are maculopapular lesions, rounded, with clear limits, indolores, which can become erosive or vegetative depending on the location, they are contemporaneous with roseola and papular syphilides, they are very contagious and can last for several months, they touch the tongue ("Forked plates" because the taste buds are abraded there as if mown), pharynx and larynx (hoarseness of voice), the labial commissure (false perlèche with paracommissural papule split in two and not a simple crack without relief at the bottom of the fold), the external genitalia

Manifestations phanériennes : damage to the integuments is classic but rare

  • Alopecia in clearing : occurs in the 3rd-6th month, she has hair loss in patches, incompletely unstacked, circumscribed by 2-4 cm, temporo-occipital on an intact scalp. Diffuse alopecia is very rare, eyebrows, eyelashes and beard can also be affected
  • Peri-onyxis : with involvement of the nail rim, is possible

signs general : they reflect the spread of infection, they are most often discreet but can be severe : fever (the most 38-38.5 ° C up to 39-39.5 ° C), headaches (which are not synonymous with neuro-meningeal disease), meningeal syndrome, poly- adénopathies, hépato-splénomégalie (with cytolytic or cholestatic biological hepatitis), poly-arthralgies, stabbing "bone" pains, variable deterioration in general condition, ophthalmic manifestations (papillitis,  uvéite,  optic neuritis,  justifying a systematic ophthalmologic examination during secondary syphilis, their presence would modify the treatment in the same way as neurological damage and would require treatment with IV Penicillin G)

  • Syphilis latent : an asymptomatic latent phase, long term, follows the secondary phase. The CDC (Center for Disease Control) defines early latent syphilis (contagious) as evolving for less than a year and late latent syphilis as evolving for more than a year, on the other hand, WHO sets the bar at 2 years. The CDC classifies latent syphilis as "early latent" if any of the following events are observed in the 12 previous months : seroconversion or ascent 4x the VDRL titer, history of untreated primary or secondary syphilis, sexual contact with a person with confirmed or suspected early syphilis. If none of these criteria are met, latent syphilis is classified as "late latent" or of undetermined duration
  • Syphilis thirdire :  associate,  to varying degrees,  skin lesions,  bone, cardiovascular and neurological ; these last two making all the seriousness of the disease. These lesions, associating destruction and sclerosis, more suggestive of a delayed hypersensitivity reaction and are non-contagious, most are granulomatous lesions destruction and fibrosis. The transition from early secondary syphilis to late secondary syphilis and then to tertiary syphilis is characterized by a decrease in the number of lesions (which become annular), the appearance of a granulomatous infiltrate, the decrease in the number of PTs and an increasingly low contagiousness

Manifestations skin :

  • Tubers cutaneous : are painless dermal nodules, non-prurigineux, copper red in color, from 5-30 mm, arranged on the back, to make, arms. They progress to sagging or ulceration and then central atrophy. Skin lesions may cluster together and assume an arcuate configuration, circinate or serpiginous
  • gums syphilitic : multiple locations, genital gum can cause an ulceration called "redux chancre", they evolve in 4 stages :

Stade  nodular :  are hypodermic nodules,  farms,  mobiles, indolores, non-prurigineux, 2-10 cm diameter, unique or few

Stade from softening : in a few weeks, the nodule softens and becomes fluctuating, it adheres to the skin which becomes inflammatory

Stade ulceration : the skin opens in the form of a fistulous path which will enlarge to produce a perfectly rounded ulceration (as drawn with a compass), a few centimeters in diameter and regular edges, the bottom of this ulceration quickly becomes clean after evacuation of cellular debris

Stade from healing : in a few months, the skin closes, making a rounded scar, with a whitish atrophic center, depressed on the outskirts, pigmented

Reaching from the mucous mouth : in particular the palatal vault and the uvula, which will achieve a nasal voice and may result, in association with nasal osteochondritis lesions, to a collapse of the nasal structures with a "pot foot" nose

Manifestations visceral :

  • Gums and fibrosis can be seen in many organs : foie, pancreas, stomach, intestine, heart, lung, parotid glands, testicles ...
  • Syphilis cardiovascular : it affects the aorta and becomes more complicated, in descending order, aortic insufficiency, calcified aneurysm of the thoracic aorta and coronary artery disease. Histologiquement, it is a panarteritis with fibrous adventitia and a site of miliary gums, "eggshell" calcification of the intima
  • lesions bone : performing osteochondritis of long bones (warm in «saber lick», clavicular involvement), gummy osteitis of the flat bones (cranial vault), sclerotic osteitis (ivory bone), we also describe : arthritis, bursite, synovite, juxta-articular fibrous nodules
  • Neurosyphilis : the fact that contamination of the central nervous system is, in fact, present at all stages of the disease justifies neurosyphilis to be treated apart from tertiary syphilis, to which it is classically attached, can be divided into several tables :

Neurosyphilis asymptomatic : the presence of cerebrospinal fluid abnormalities is a risk factor for the subsequent development of symptomatic neurosyphilis

Neurosyphilis symptomatic : classically, on distingue :

  • Meningitis acute
  • Syphilis vascular brain : occurs, on average, between 1 and 5 years after primary syphilis, it is endarteritis of the cerebral vessels, it manifests as ischemic strokes :  hemiplegia,  aphasia,  convulsions, impaired pupillary reflexes
  • Neurosyphilis parenchymal :

Paralysis General :  dominated by disorders of higher functions, the abolition of reflexes, psychiatric manifestations (dementia)

Tabes (progressive locomotor ataxia) : occurs on average between 15 and 20 years after syphilis,  it is the consequence of sclerosis of the posterior cords of the spinal cord, it manifests itself by : pupillary abnormalities, loss of achilles and patellar reflexes, shooting pains, romberg sign, sign of Argyll-Robertson,  deep sensitivity disorders,  ataxie,  bladder disorders, paresthésies, optic atrophy, faecal incontinence, superficial sensitivity disorders (pain, to touch), plantar perforating ailments

gums of SNC : are rare and manifest as tumor syndrome

  • Syphilis congenital : is the consequence of the transplacental passage of TP, passage which becomes possible during the last two quarters (from the 4th month) of pregnancy, the risk of infection is even higher as the maternal syphilis is recent and close to childbirth, there are many tables :

Syphilis congenital precocious : is revealed from birth to 2 years, it is the congenital equivalent of secondary syphilis, it combines, in the same way, mucocutaneous signs, bony, meningeal and various visceral disorders

Syphilis congenital late : is revealed after the age of 2 years, it is the congenital equivalent of tertiary syphilis

Stigmata : are the sequelae of lesions observed during congenital syphilis, the most characteristic are rhagades and dental anomalies

Diagnostic organic :

Treponema not cultivating in vitro, the diagnosis of syphilis can only be made by the demonstration of treponema itself under a dark field microscope or indirectly by the demonstration of the specific antibody response

  • Exam at microscope at fond noir : should be performed on erosive lesions (primary syphilis chancre, mucous erosive syphilides), sensitivity to the chancre is 50%, it has no oral value due to the possibility of false positives (spirochètes saprophytes)
  • Immunofluorescence direct : what a test, performed on tissue or exudate, requires heavier equipment and is used less
  • Serodiagnostics : is well standardized, inexpensive and reliable. In the majority of cases, the combination of a specific test for treponematosis (TPHA) and a non-specific test (VDRL) is sufficient to confirm or deny a diagnosis of syphilis. There is no serological test to differentiate the antibodies of syphilis from those of endemic non-venereal treponematoses

Tests nontreponismics (non-specific or anti-cardiolipidic) : use a ubiquitous cardio-lipid antigen

  • Venereal Disease Research Laboratory (VDRL) :

Goal :

❖ It highlights, in the patient's serum, anti antibodies- cardiolipids,  the cardiolipid antigen used as a target is present in all pathogenic treponemes but also in many animal or plant cells

❖ VDRL is not a specific reaction of treponematoses (+++), false positive syphilitic serology (VDRL positive and TPHA negative) seen in dysimmune diseases, especially during lupus and anti-phospholipid antibody syndrome

❖ The VDRL puts in the presence of the patient's serum a cardio antigen- lipid marketed previously fixed on its cholesterol crystals. In the presence of antibodies, complexes are formed which agglutinate the cholesterol crystals which form more or less large aggregates, it is the size of these aggregates that defines positivity, who goes from + at +++

Kinetic :

❖ Only VDRL is positive, on average, 15 days after the onset of the chancre

❖ The title increases, ensuite, quickly to reach a plateau during the secondary phase, variable depending on the patient, generally located between 256 and 1024 The

❖ The VDRL therefore remains very positive throughout the secondary phase

❖ The biological monitoring of the effectiveness of the treatment is done on the quantitative VDRL (+++), treatment is considered to be effective when the titer of VDRL is divided by 4 (two dilutions) 6 months after treatment

❖ In the absence of a decrease of this type, treatment must be resumed,  Conversely,  syphilitic recontamination (the disease is not immunizing) can be diagnosed not only on the clinic but also on the significant rise in quantitative VDRL (title multiplied by at least 4)

False serologies from the syphilis

(non-treponemal causes of positive VRDL)

Causes infectious

Causes noninfectious

  • bacterial : Meadow, tuberculosis, pneumococcal disease, leptospirosis, borreliosis, scarlatine
  • viral : varicella, mumps, infectious mononucleosis, viral hepatitis, measles, VIH
  • Parasitic : malaria
Pregnancy, intravenous drug addiction, chronic liver disease, gammapathie monoclonal, systemic lupus erythematosus, anti-phospholipid syndrome, cancers
  • Rapid Plasma Reagin (RPR) : also non-specific, less used than VDRL

Tests  treponemal (specific) :  use a treponemal antigen,  they are more sensitive and more specific than reaginic tests. TPHA is inexpensive and is used routinely, on the other hand, the FTA is expensive. They are positive a little before the reaginic tests

  • Treponema   Pallidum   Hemagglutination   Assay   (TPHA) :   it is an agglutination reaction obtained by putting, in the presence of the patient's serum, an ultrasound of pale treponemes previously fixed on animal red blood cells, the presence of anti-treponemal antibodies forms a complex which agglutinates the red blood cells. The advantages of this technique are its simplicity, its sensitivity and very good specificity. It does not make it possible to differentiate syphilitic antibodies from antibodies directed against endemic treponematoses

Kinetic :

❖ TPHA is positive around the 8th-10th days of the chancre, the intensity of the reaction is marked as a cross, he quickly reaches +++ and, in the absence of treatment, will stay +++ until the end of life, he is therefore at +++ during secondary syphilis and after the 8th-10th day of chancre

❖ The TPHA is negative only very inconsistently if the treatment was well conducted and if it was instituted early. Beyond this time limit, the TPHA will remain positive

❖ The quantitative TPHA titre is not a good marker of disease progression, nor the response to treatment, because it varies significantly from one examination to another for the same patient

  • Fluorescent Treponemal Antibody (FTA) and FTA absorbed : East, like TPHA, a specific reaction of treponematoses. It is an indirect immunofluorescence test,  he puts,  in the presence of the patient's diluted serum,  a suspension of killed pale treponemes, Nichols strain, the reaction being revealed by the addition of an animal serum anti-human immunoglobulin labeled with fluorescein. Reading is done under a UV microscope and requires a well-equipped laboratory

Kinetic :

❖ The FTA is positive around the 5th day of the chancre, so this is the first test to be positive, a few days before the VDRL and the TPHA

❖ In the absence of treatment, ETS remains positive at a high titer throughout the primary-secondary phase

❖ Its interest is limited to serological diagnosis in the newborn in case of suspected transmission during pregnancy (IgM FTA) and in primary syphilis at the very beginning of the chancre if the 2 TPHA and VDRL tests are negative

❖ To increase the sensitivity of the test, it is first possible to absorb the patient's serum on an ultrasound of Reiter's saprophytic treponemes which neutralizes the parasitic antibodies : this is the FTA absorbed

  • Test Immobilization of Treponema (IPT or Nelson's test) : he is abandoned, it requires the manipulation of live treponemes, not becoming positive until the end of the primary phase, and does not make it possible to judge the failure or effectiveness of the treatment

Other tests :

  • Enzyme   Linked   Immuno-Sorbent   Assay   (ELISA) :   enzyme immunoassay, purified or recombinant treponemal antigens, its place in the serodiagnosis of syphilis is not yet definitively established
  • Test  d’immunotransfer  (Western-blot) :  TP proteins,  separated by electrophoresis, are transferred to a nitrocellulose membrane which is incubated with the serum : specific bands (15.5, 17 and 47 KDa), Western blot could be a good diagnostic test for congenital syphilis, even more sensitive and specific than the absorbed ATF
  • Reaction d’amplification genomics : the genome of TP being known, targets amplification can be used to test for bacteria
  TPHA (+) TPHA (-)
VDRL (+) Non-venereal treponematosis (endemic area)   or venereal, treated or not, healed or not False positive
VDRL (-) – Serological sequela of non-venereal treponematosis
– Syphilis, priori, cured
– Primary syphilis in 10-15 days following the chancre
– Absence of treponematosis
– Syphilis in incubation
– Primary syphilis in 10 days following the chancre

Syphilis 1Histologie :

The histology of syphilis is not very specific, the image the characteristic of secondary syphilis associates a more or less dense inflammatory infiltrate of the dermis where lymphocytes and plasma cells predominate with damage to the vessels. The most common epidermal involvement is exocytosis

Diagnostic differential :

  • Syphilis primary : at the chancre stage, the differential diagnosis is that of other causes of genital ulceration,  syphilis should always be mentioned before any mucous ulceration, genital, anal or buccopharyngeal
  • Syphilis secondary : secondary syphilis is the "great simulator" and must be mentioned before any maculopapular rash, fleeting or persistent : roseola can evoke a virus disease, drug eruption (exanthème maculeux), in the face, she can mimic seborrheic dermatitis, acne, a psoriasis. Papular lesions can mimic psoriasis (erythematous-squamous), a lichen plan, eczema

Traitement :

  • But : prevent transmission and prevent the onset of late complications of syphilis, break the chain of contamination this justifies the screening and treatment of multiple partners
  • Recommandations General : these are those of the World Health Organization : before any genital ulceration, do not wait for the result of TPHA-VDRL to treat (+++), the same, examination under a dark field microscope should not delay the start of treatment

➢ If the diagnosis of early syphilis is mentioned : perform a careful clinical examination (look for neurological signs in particular), look for another STI (gonocoque, C. trachomatis, VIH, Hepatitis B…), make a prescription for TPHA-VDRL :

  • Either deal immediately (probabilistic approach) : which is often the case with mucosal ulceration and seeing the patient with the TPHA-VDRL result
  • Or review the patient with the TPHA-VDRL result (especially if secondary syphilis)

➢ Do not hesitate to contact a specialist in certain delicate situations : pregnant woman, HIV positive subject, allergy to Penicillin

➢ Systematically perform an ophthalmological examination in case of secondary syphilis : possible ophthalmological damage would modify the therapeutic management in the same way as neurological damage

  • Syphilis early (primary, secondary and early latent) : the diagnosis of early latent syphilis is acceptable only if the patient can provide a negative syphilitic serology less than one year old, before the discovery of a positive serology when he is asymptomatic

Diagram  therapeutic  recommended :  is the same for all 3 situations (primary, secondary, early latent), in the absence of allergy to Penicillin and contraindications to intramuscular injections :  a single intramuscular injection of 2.4 MUI of Benzathine Benzyl-Penicillin G (Extencilline®)

  • In case of penicillin allergy in a patient with early syphilis, we can replace the injection (s)(s) through 14 days of Doxycycline (100 mg, per the, morning and evening) or Tetracycline hydrochloride (2 g / d during 15 days) except in pregnant women and HIV-positive patients (indication of tolerance induction) or Erythromycin (2 g / d during 15 days)

Followed  of  traitement :  the efficacy of the treatment should be monitored clinically and biologically at 6, 12 and 24 month, biological monitoring is done on the quantitative VDRL (title divided by 4 (2 dilutions) at 6 month), if it's not the case, the opinion of a specialist is justified. The VDRL must be negative one year after treatment for primary syphilis and within 2 years after treatment for secondary syphilis

  • Syphilis late : 3 intramuscular injections of 2.4 MUI of Extencillin® one week apart, in case of penicillin allergy, induction of tolerance. An alternative is Doxycycline (200 mg / j) or Tetracycline (2 g/j) pendant 4 weeks or Erythromycin (2 g/j) pendant 30 days. Clinical and serological monitoring must be very close
  • Neurosyphilis : penicillin G (12-24 MUI / j) intravenously during 10-14 days or intramuscular penicillin procaine (2-4 MUI) associated with oral probenecid (2 g/j), otherwise desensitization
  • Syphilis in the women pregnant : the risk is that of congenital syphilis, the treatment of syphilis is identical, for the same stage of the disease as that recommended in women who are not- pregnant, some authors recommend a 2nd injection on D8, clinical and biological monitoring is monthly, ultrasound monitoring is essential to look for very suggestive signs of fetal disease. In case of penicillin allergy, most often an induction of tolerance will be necessary, cyclins are contraindicated, macrolides can be used because they cross the placental barrier poorly and there is clinically and microbiologically documented resistance
  • Syphilis withgenital : a child is at risk of congenital syphilis if born to a mother with syphilitic serology (treponemal and non-treponemal tests) is positive and if it presented one of the following situations : absence of treatment, treatment less than a month before childbirth, treatment that does not include Penicillin, no significant decrease in the titer of non-treponemal tests after treatment, treatment for which the exact modalities are unknown, insufficient serological monitoring after treatment. The treatment is based on Benzyl- Aqueous crystalline penicillin (100.000-150.000 IU / kg / day divided into 2-3 daily infusions of 50.000 UI) or procaine-Penicillin (50.000 IU / kg / d by intramuscular injection) pendant 10-14 days. Interrupting a single day of treatment requires restarting the treatment
  • Syphilis of the HIV-positive subject : the standard treatment with Penicillin is the same in the case of primary or secondary syphilis of the HIV-positive subject. A study of the CSF prior to treatment is not justified except in cases of obvious neurological or ophthalmological manifestations (as in HIV negative subjects), which would require treatment with IV Penicillin G : 20 MUI / d during 10-15 days
  • Topics contacts sexual : the ideal is to be able to examine clinically and to make a serology in all the subjects sexual contacts while remembering that if the contact is recent (up to a month), the serology may still be negative, this is not always possible. It may be necessary to propose a systematic treatment of the contact subjects by an injection of 2.4 MUI d’Extencilline®

Prevention from the reaction from Jarisch-Herxheimer :

  • This reaction consists of an aggravation of clinical manifestations with headache, myalgies, high fever and is dose independent and occurs after injection with Penicillin
  • Its pathophysiology is still unknown (lyse massive de TP ?), it is common in early syphilis, it is benign except in pregnant women
  • She can be warned, in part, by co-administration of Prednisolone (0.5 mg/kg/j) the day before and 3 first days of treatment

Conclusion :

Even though the diagnosis of syphilis and its treatment have become much simpler and more reliable in recent decades, it continues to generate great interest after more than five centuries