Syphilis in Adolescents

00:01 In this lecture, we’re going to review syphilis which is actually on the rise in our adolescent population in the United States. So, syphilis is an STD or a sexually transmitted disease that leads to a systemic disease.

00:15 There are certain risk factors, high risk sexual behavior, living in an urban area or being in the southeastern United States. Generally, males have this disease more than females because it’s most common in men who have sex with men. The cause is Treponema pallidum which is a motile spirochete.

00:36 It’s transmitted through direct sexual contact with ulcerative lesions. The spread is via the lymph and the blood. It’s also transmitted transplacentally from the mother to the fetus.

00:49 Generally, there are four stages and I’m going to go through these one at a time. There is the primary, the secondary, then the latent stage, and then the tertiary stage. Let’s talk about the primary stage.

01:01 Primary syphilis primarily presents as a chancre. That is a very mildly painful or not at all painful or touchy lesion that’s at the point of inoculation usually on the external genitalia. It usually happens three to nine weeks after incubation. It’s often asymptomatic. It heals spontaneously in one to six weeks.

01:26 Patients may have inguinal lymphadenopathy but 25% of these patients then later develop these other stages of syphilis. So, let’s move on to those other stages with the secondary stage.

01:40 The secondary stage typically happens 4-10 weeks after the chancre has appeared. This comes out as a rash which is somewhat looking like a Christmas tree which in little tiny children may appear like pityriasis rosea but involves the hands and the feet. So, let me be clear. Pityriasis rosea happens in small children and could be a Christmas tree like rash. In infants who are exposed to syphilis in utero, their secondary syphilis may appear at the same age as when kids show up with pityriasis rosea.

02:18 So, that’s on your differential. Patients will also develop a hepatitis and they may develop synovitis, osteitis, and a periostitis. They may develop the nephrotic syndrome. They may develop meningitis or rarely, you can see ocular syphilis which can cause blindness. Let’ s talk about the latent period very briefly.

02:44 The latent period is an asymptomatic phase that may last for years after the secondary phase.

02:52 But it leads to the tertiary phase which is life threatening. In tertiary syphilis, this happens to 30% of untreated patients usually 2-20 years after they first acquired the syphilis. What’s clear is they can have something called a gumma formation. You can see a picture of that right here.

03:15 This is a granulomatous lesion with a centralized tissue necrosis. It has a rubbery texture to it.

03:23 It’s found in skin, bone, or in viscera. This is very rare. But it may come more common if we don’t get a handle on our current syphilis epidemic. Patients can also develop cardiovascular involvement.

03:38 That’s one of the things we really worry about. They can have an ascending aortic aneurysm from their syphilis getting into the wall of the lining of the aorta. They can also develop an AV valve regurgitation from that dilatation. So, neurosyphilis is also tertiary syphilis. Here, Treponema pallidum invades the CNS. This can concur at any stage. And it can also present as acute syphilitic meningitis.

04:12 These patients may have cranial nerve palsies. They may develop meningovascular syphilis.

04:18 These patients also can develop tabes dorsalis which is damage to the posterior columns of the spinal cord resulting in impaired vibration and proprioceptive sensation. They can have a wide based gait as a result of their difficulty with proprioception. They may also have the Argyll Robertson pupil which is known because it does not react to light but it reacts to accommodation.

04:50 So, how do we make a diagnosis of syphilis. Well first, we may do dark field microscopy and visualize the corkscrew shaped Treponema pallidum. Without microscopy, you can do serologic tests.

05:07 This include the RPR and the VDRL. These treponemal serological tests are generally antibodies directed against Treponema pallidum agents, the highly specific test used to confirm diagnosis after a positive non-treponemal screening test. So first, we’ll do the RPR or the VDRL.

05:29 If it’s positive then we’ll do the serologic testing. Also, we would do a CSF analysis to rule out acute meningitis. How do we treat syphilis? It’s still pretty simple. Penicillin is the antibiotic of choice.

05:46 If they’re allergic, we can use doxycycline. The dose and duration depends on the stage of the disease.

05:53 Usually, we’ll do one dose intramuscularly for early disease or if otherwise healthy patient.

06:00 We may do it weekly for three weeks for tertiary disease. What’s key is that we should re-examine these patients and perform another non-treponemal test. We’re going to repeat this test every three months. We have to ensure that these titers are falling. We expect to see a fourfold increase in the titer within six months. If we see a patient with syphilis, it’s important that we report this to public health authorities. We’re trying to control this outbreak. It’s important to evaluate and treat any sexual partners of that patient. When we treat them, keep an eye out for the Jarisch–Herxheimer reaction.

06:40 Remember, that’s a febrile, acute episode that happens soon after initiation of therapy.

06:46 We shouldn’t stop the therapy if we don’t have to. The prognosis of these patients depends on their stage of illness. If they’re early in disease, the prognosis is usually outstanding.

06:58 Later on, they can have problems certainly with aortic aneurysms or neurosyphilis.

07:03 So, that’s my review of syphilis in adolescent medicine. Thanks for your time.