Introduction to Sexually

Transmitted Infections (STIs);

Syphilis
 Definition

The sexually transmitted infections (STIs; earlier k/a

STDs or VDs) are a group of communicable
infections / diseases that are transmitted by sexual
contact & caused by a wide range of bacterial, viral,
protozoal, fungal agents & ectoparasites
 Transformation in STIs

• List of pathogens which are sexually transmitted has

expanded from ‘5 classical’ venereal diseases (VDs)
to include more than 20 agents including viral
infections
• Shift to clinical syndromes associated with STIs
 Classification of STI agents
1. Bacterial Agents
• Treponema pallidum - Syphilis
• Haemophilus ducreyi - Chancroid
• Calymmatobacterium granulomatis - Donovanosis
• Bacterial Vaginosis - caused by various microbial
agents
• Neisseria gonorrhoea - Gonococcal Urethritis and
other manifestations
• Chlamydia trachomatis – Non-Gonococcal Urethritis
(NGU)
• Mycoplasma hominis - NGU
• Ureaplasma urealyticum - NGU
 Classification of STI agents
2. Viral Agents
• Herpes simplex virus 2 or 1 (HSV 2 & 1) - Herpes
genitalis
• Hepatitis B virus
• Human Papilloma Virus - Warts
• Molluscum Contagiosum Virus- Molluscum
Contagiosum
• Human Immunodeficiency Virus (HIV) - AIDS
 Classification of STI agents
3. Protozoal agents
• Entamoeba histolytica – Amoebiasis
• Giardia lamblia – Giardiasis
• Trichomonas vaginalis – Vaginitis
 Classification of STI agents
4. Fungal agents
• Candida albicans - Candidal Vaginitis
5. Ectoparasites
• Phthirus pubis - Pediculosis
• Sarcoptes scabiei - Scabies
 History
• General history (Demography)
• Contact of an STI
• Onset, character, periodicity, duration & relation to
sexual intercourse & urination
• Anogenital discharge / dysuria / hematuria

• Dyspareunia / pelvic pain

• Ulcers, lumps, rashes or itching

 History
• Past medical and STI history
• Medications, allergies (emphasise antibiotics) &
contraception
• Any STI in sexual partner(s)
• Last menstrual period
• Vaccination history
• Obstetric history (h / o abortions)
• Any history of injecting drug abuse, what drug, how
often
• Any history of tattooing or blood product exposure
 Sexual History

• Number of exposure (Single, multiple)

• Number of sexual partner(s)

• Date of last sexual exposure

• Sex of partner(s) and history of male to male

contact (MSM)
• Type of intercourse – oral, vaginal, anal

• Protected / unprotected exposure

 History for HIV

• H/o Recurrent diarrhoea

• H/o Fever

• H/o Loss of weight

• H/o Genital ulcer disease

• H/o Blood transfusion

• H/o Herpes zoster

• H/o Opportunistic infections

 Examination

• Exposure of abdomen, genitals and thighs is

required

Inspect for:
• Rashes

• Lumps

• Ulcers

• Discharge

• Smell
 Examination

Inspect for:
• Pubic hair for lice & nits

• Skin of the face, trunk, forearms, palms & the oral

mucosa
• Palpate: Lymph nodes
 Examination - Men
Inspection:
• Penis
• External meatus
• Retracted foreskin
• Perianal area
• Lymph nodes examination
• Per-rectal (P / R) examination
• Palpation of scrotum & expression of any discharge
from the urethra.
• Proctoscopy
 Examination - Women
Inspection:
• External genitalia
• Perineum
• Perianal area
• Lymph nodes examination
• Speculum examination of vagina & cervix
• Bimanual pelvic examination
• Oral cavity
 Systemic Examination
• Cardiovascular
• Respiratory
• Gastrointestinal (liver, spleen)
• Central Nervous
• Urinary
• Musculoskeletal
 Syphilis
• Caused by Treponema pallidum subsp. pallidum
• T. pallidum - a fine, motile, spiral organism,
measuring 6-15 μm in length & 0.09 to 0.18 μm in
thickness with characteristic motility
• It has regular spirals which helps in differentiating
from other non-pathogenic treponemes
• Cannot be grown on culture media
 Transmission
Moderate to high probability of transmission:
• Sexual contact
• Infected blood
• Trans-placental route
• Accidental to medical personnel
 Pathogenesis
Infection
↓
Attachment to host cells
↓
Corkscrew movement & travel to lymph nodes
↓
In perivascular lymphatics cause endarteritis obliterans
↓
Loss of blood supply
↓
Genital ulcer
 Primary syphilis
• Stage from infection to the healing of the chancre

• Incubation period- 9-90 days

After this time there is ulcer formation

 Primary syphilis
• Single, painless, well-defined, ‘Hunterian’ ulcer with
clean looking granulation tissue on floor

• Indurated, button-like

• Hard chancre - heals with scar even without

treatment
 Primary syphilis
Sites of ulcer
• Genital (90-95%)
Coronal sulcus, glans, frenulum, prepuce, shaft of
penis in male
Cervix, labia, vulva, urethral orifice in females
• Extra-genital (5-10%):
Commonest site is the lips
 Diagnosis
Combination of clinical & Laboratory investigation

• DGI-serum from ulcer / aspirate from lymph node

• VDRL / RPR- Negative till one week after appearance of

ulcer.

Positive by 4 weeks
 Natural History
Gjestland (1955)- a follow-up study of 1147 cases (the Oslo
study)
• 24% -mucocutaneous relapses
• 11% died of syphilis
• 16% - benign late manifestations (usually cutaneous) nodules
or gummata
• 10% cardiovascular syphilitic lesions
• 6% - neurosyphilis.
• Conclusion: Long before penicillin was introduced, at least
60% of people with syphilis lived & died without developing
serious symptoms (Rook’s 2010)
 Secondary Syphilis
• 6-8 weeks after appearance of primary chancre

•Systemic disease

•Constitutional features like sore throat, malaise, fever

& joint pain may accompany the lesions
 Secondary Syphilis
• Common signs are:
- Skin rash (75-100%)
- Lymphadenopathy (50-86%)
- Mucosal lesions (6-30%)
 Secondary Syphilis
Cutaneous:
• Non-itchy lesions generally
•Macular, papular, nodular, pustular, annular lesions
may occur
• Condyloma lata
• Split papules at angles of mouth
• Corona veneris
• Moth eaten alopecia
•Mucosal lesions - mucous patches (snail-track ulcers)
•The ‘great-imitator’
 Diagnosis
• VDRL / RPR - Almost always positive
- False negative (in some cases)
- False positive (in some cases)
• Specific tests: TPHA / TPPA may remain reactive
throughout the life
 Latent syphilis
• Persistent seropositivity with clinical latency
• Following resolution of primary or secondary stage
latency occurs & continues as such in 60-70% of
patients
• Less than 2 years: Early
• More than 2 years: Late
 Tertiary Syphilis
• After a period of latency of up to 20 years,
manifestations of late syphilis can occur

Cutaneous
Characteristic lesion is the gumma
• A deep granulomatous process involving the
epidermis secondarily
• Causes punched out ulcerative lesions with white
necrotic slough on the floor
• On lower leg, scalp, face, sternal area
 Tertiary Syphilis
Cardio-vascular:
Develops 10-30 years after infection - so in middle / old
age; more in men
• Aortitis (ascending aorta)
• Aortic aneurysm  sudden death due to rupture
• Coronary ostial stenosis
 Tertiary Syphilis
Neuro-syphilis:
• In any patient with syphilis, CSF lymphocytosis, an
elevated CSF protein level or a reactive VDRL test
would suggest neuro-syphilis & must be treated
• Asymptomatic neurosyphilis
• Meningeal neurosyphilis -usually has its onset during
secondary disease; characterized by symptoms of
headache, confusion, nausea & vomiting, neck
stiffness & photophobia. Cranial nerve palsies cause
unilateral or bilateral facial weakness &
sensorineural deafness
• Meningovascular syphilis - occurs most frequently
between 4 and 7 years after infection. The clinical
features of hemiparesis, seizures & aphasia reflect
multiple areas of infarction from diffuse arteritis.
• Gummatous neurosyphilis - results in features typical of a
intracranial space-occupying lesion.
• Parenchymatous syphilis : general paralysis (GPI) from
parenchymatous disease of the brain used to occur 10–
20 years after infection. The onset is insidious with
subtle deterioration in cognitive function & psychiatric
symptoms that mimic those of other mental disorders.
• Tabetic neurosyphilis was the most common form of
neurosyphilis in the pre-antibiotic era, with an onset 15–
25 years after primary infection. The most characteristic
symptom is of lightning pains- sudden paroxysms of
lancinating pain affecting the lower limbs.
• Other early symptoms include paraesthesia, progressive
ataxia, & bowel & bladder dysfunction.
 Treatment of Syphilis & STIs

• CDC guidelines: updated regularly and reviewed

thoroughly every 4 years
• Others:
 WHO
 NACO
 Syphilis treatment
Primary, Secondary, Early Latent
• Recommended regimen (CDC)
Inj. Benzathine Penicillin G,
2.4 million units IM stat after test dose
 Treatment
Late Latent Syphilis
• Recommended regimen
Inj. Benzathine penicillin G 2.4 million units IM AST at
one week intervals x 3 doses
 Neurosyphilis
• Recommended regimen
Aqueous crystalline penicillin G, 18-24 million units
daily administered as 3-4 million units IV every 4
hours for 10-14 days
 Alternative regimen for penicillin
allergic patients
• Doxycycline (100 mg) BD
• Erythromycin (500mg) QDS
• Tetracycline (500mg) QDS

Duration of treatment
• Early syphilis : 15 days
• Late syphilis : 30 days
• Pregnancy: Only penicillin G
• If patient allergic: desensitize
• CDC: Guidelines (Dr G. O. Wendel, Jr., et al. N Engl J
Med. 1985)
 The Jarisch-Herxheimer reaction

• The Jarisch-Herxheimer reaction is an acute febrile

reaction frequently accompanied by headache, myalgia,
fever, & other symptoms that can occur within the first
24 hours after the initiation of any therapy for syphilis.
• Antipyretics can be used to manage symptoms
• The reaction might induce early labor or cause fetal
distress in pregnant women, but this should not prevent
or delay therapy
Thank you