د· حسين عباس السلطاني
Genital Ulcer
Differential Diagnosis:
ST causes: herpes genitalis, chancre (primary syphilis), chancroid, lymphogranuloma venereum (LGV), granuloma inguinale (donovanosis).
Non ST causes: Behcet disease, fixed drug eruption, trauma, malignancy as SCC, chronic infection as TB.
Diagnosis:
History:
1. Lesion history: prodrome, initial presentation, duration of lesion, pain, any history of similar lesion in the past or in the partner.
2. Sexual history: history of illegal sexual contact and its date, gender of partner, number of partners, partners with known STIs or with signs and symptoms of STIs.
3. Medical history: HIV status, skin conditions, drug history.
Physical exam:
1. Lesion: appearance, distribution, number, size, induration, depth, and tenderness.
2. Genital exam: examine genital and perianal area for other lesions.
3. Lymph node(s): number and location of enlarged nodes, size, tenderness.
4. General exam: thorough examination of the skin, oral cavity, palms and soles, and neurologic exam.
Investigation:
Accordingly (smear, culture, serology, biopsy, or PCR).
Syphilis
Definition:
syphilis is a STI caused by a spirochetal bacterium Treponema pallidum, also called "Lues" or "cubid s disease".
Mode of Transmission:
The infection is usually acquired through sexual contact with infected lesions or body fluids; less commonly, transplacentally; and rarely through blood transfusion, or inoculation with contaminated instruments (as tattooing or IV drug users).
Microbiology:
Syphilis is caused by T. pallidumpallidum, which is a very small, fragile, spiral bacterium (spirochete) with a corkscrew rotation motility. It can be observed only by dark-field microscope. The reproductive time is estimated to be 30 hours, while most other bacteria replicate every 30 minutes.
In addition to syphilis, T. pallidum can cause the following diseases:
Bejel (endemic syphilis): caused by T. pallidumendemicum. Transmitted non sexually, and has features of secondary syphilis without presence of the primary stage. Bejel is endemic in some areas in Saudi Arabia, Iraq, and Syria.
Yaws: caused by T. pallidumpertenue. It is a tropical disease characterized by an infection of the skin, bones, and joints.
Pinta: caused by T. pallidumcarateum (vitiligo-like presentation).
Treponema may be saprophytic and present as normal oral flora (T. buccalis).
Classification and Stages:
There are two types of syphilis congenital and acquired. The congenital is subdivided into early and late. The Acquired Syphilis passes through four distinct clinical stages:
primary stage (chancre), secondary stage (skin and mucous membrane eruption), a latent stage (history of syphilis, absence of signs and symptoms, and reactive serologic tests), and a tertiary stage (skin, mucous membrane, and visceral).
Primary, secondary, and early latent stages regarded as early syphilis (within the first 2 years of infection, infectious). Late latent and tertiary regarded as late syphilis (after 2 years, less infectious).
Acquired Syphilis:
Primary Syphilis:The syphilitic ulcer (the chancre) appear in the genital area after 9-90 days (21 days in 50%) after exposure to infected partner at the site of initial contact (in 50% of exposed persons). Extragenital chancre accrue in 5% of cases. Chancre is usually solitary, painless, hard, and indurated; the base is clean with a scant yellow serous discharge. The chancre usually heals with scarring after 3-6 weeks. Typical chancre occur in 50% of patients. Painless, hard, discrete regional lymphadenopathy occurs in 1-2 weeks; which never coalesce or suppurate unless there is mixed infection. 50% of primary syphilis develops into secondary syphilis.
Secondary Syphilis: Cutaneous Findings: They are preceded by a flulike symptom and generalized painless lymphadenopathy in about 50%. Most eruptions are macular and/or papular; nodular, follicular, and pustular eruptions occur infrequently; but vesiculo-bollous lesions are seen only in congenital suphilis. The skin changes of syphilis can mimic many other skin diseases "great imitator". The lesions of secondary syphilis have certain characteristics that differentiate them from other cutaneous diseases:
1. There is little or no fever at onset.
2. Pain or itching is minimum or absent.
3. Lesions are non inflammatory, develop slowly.
4. There is a marked tendency to polymorphism, and the lesions may assume a variety of shapes, including round, elliptic, or annular
Usually bilateral symmetrical, with characteristic palms and soles involvement.
6. The color is characteristic, resembling a "clean-cut ham" (coppery tint).
Malignant syphilis present with wide spread papulopustules or nodules that become necrotic and break down into ulcers. The eruption is associated with toxicity, fever, arthralgia, and occasionally hepatitis. Most patients are immunocompromised.
Hair loss the most characteristic type consists of small irregular patches of non-scarring alopecia throughout the scalp ("moth eaten" alopecia).
Mucous Membrane Findings: are extremely infectious, including: codylomata lata (smooth, papillated , or covered with cauliflower-like vegetations), oral mucous patches, pharyngitis and laryngeal involvement which may produce hoarseness .
Systemic Findings:
Ophthalmologic: iritis, is the most common eye complication.
Auditory: sensorineural hearing loss.
Musculoskeletal: back pain, arthralgias, arthritis, tenosynovitis, and bursitis.
Haematologic: anaemia, leukocytosis, relative lymphopenia, and elevated ESR.
Renal: acute membranous glomerulonephritis.
Neurological: asymptomatic or symptomatic (headache and meningeal irritation).
Hepatic and gastric.
Differential Diagnosis of Secondary Syphilis:
Skin eruption: pityriasis rosea, guttate psoriasis, lichen planus, pityriasis versicolor, exanthematous drug eruptions, and viral eruptions.
Condylomata lata: genital warts, haemorrhoids.
Oral lesions: aphthous ulcers, candidiasis.
"Moth eaten" alopecia: alopecia areata, tinea capitis.
Latent Syphilis:
The secondary stage may be followed by latent stage which may remain indefinitely (1/3), be interrupted by relapse of secondary syphilis (1/3), or progress to the tertiary stage (1/3). The latent stage is divided into early latent (less than one year) and late latent (1 year or longer).
Tertiary Syphilis:
Cutaneous Lesions: are few, asymmetrical, slowly growing, destructive and heals with scar. The microorganisms are few within these lesions (in opposite to the secondary syphilis). They can be divided into 2 types:
1. Nodular and noduloulcerative lesions: may be psoriasiform.
2. Gummas (a form of granuloma): are non-tender pink to dusky-red nodules or plaques. They favor sites of previous trauma and may arise anywhere in the body but are more common on the scalp, and forehead.
Mucous Membranes Lesions: Discrete gummas or diffuse gummatous infiltration may involve mucous membranes, especially the palate, nasal mucosa, tongue, tonsils, and pharynx. The lesions ulcerate and are disfiguring. Destruction of the nasal cartilage and bone (saddle nose) are the disease hallmark. Oral leukoplakia may occur, and may progress to SCC in 50% of cases.
Visceral: cardiovascular syphilis and neurosyphilis {asymptomatic or symptomatic (headache, fever, stiff neck, confusion, and seizures)}.
Congenital Syphilis:
T.pallidum can be transmitted to the fetus in utero from an infected mother (usually with early syphilis), this transmission usually occurs after the forth month of gestation. The ability of the mother to infect the fetus diminishes with further pregnancies.
Approximately 25% of infants from mothers with untreated primary or secondary syphilis die in utero. Of those infants born (75%), almost one-half develop the disease, another one-forth are seropositive without clinical manifestations, and one-forth are not infected.
Congenital syphilis divided into:
Early: presenting within the first 2 years of life (usually after the third week).
Late: presented after the age of 2 years.
Stigmata of Congenital Syphilis: The destructive effect of syphilis in children often leaves scars or defects called stigmata which persist throughout the life, include:
1. Ophthalmic: corneal clouding.
2. Oral: Hutchinson teeth (small, notched, peg-shaped upper incisors) and high-arched palate.
3. Nose: saddle nose.
4. Orthopedic: frontal bossing, saber shin, and thickened medial clavicle.
5. Neurologic: 8th cranial nerve palsy.
6. Positive serology for syphilis.
Diagnosis of Syphilis:
1. History and examination.
2. Dark-field microscopy: mostly useful in early disease when the serological tests still negative.
3. Serological tests.
4. PCR.
5. Biopsy: rarely needed.
Syphilis Serology: classified into two main groups:
A- Non-Specific (Lipoidal or Non Treponemal) Tests: These tests are directed against the phospholipids in the microorganisms cell wall, including two important tests, venereal disease research laboratory (VDRL) and rapid plasma regain (RPR) tests. These tests become positive 3-6 weeks after infection (after 3 weeks in 50%), remain strongly positive throughout the secondary phase, and usually become negative after treatment, so can be used to monitor response to therapy. They are used for screening purposes and have a high degree of sensitivity but relatively low specificity.
These tests give quantitative as well as qualitative results, so all reactive samples are titrated to determine the highest reactive dilution. A fourfold change in titer, is considered significant clinically.
False-Positive Reactions (positive non-treponemal test with negative specific test), may occur with collagen vascular disease, advancing age, narcotic drug use, chronic liver disease, several chronic infections such as TB, and several acute infections such as herpes. False-negative results may occur if the patient has been used topical or systemic antibiotics.
When these tests are positive, verification is done by the specific tests.
B- Specific (Treponemal) Tests: directed against the treponaeml antigens, include :
1. T. pallidum haemagglutination test (TPHA): available in Iraq.
2. Reiter protein complement fixation test.
3. Fluorescent treponemal antibody absorption test (FTA/ABS).
4. T. pallidum immobilization test (TPI).
These tests become positive earlier than the non specific tests. A patient who has a reactive treponemal test usually will have a reactive test for a life time, regardless of treatment or disease activity, so these tests should not be used to asses response to treatment.
Treatment of Syphilis:
Penicillin remain the treatment of choice for all stages of syphilis.
Early syphilis:
Single IM injection of 2.4 MU benzathin penicillin G, if penicillin allergic, doxycycline 100 mg orally twice daily for 2 weeks.
Late syphilis:
IM injection of 2.4 MU benzathin penicillin G once a week for 3 weeks, if penicillin allergic, doxycycline 100 mg orally twice daily for one month.
Congenital syphilis:
Crystalline penicillin G 200 000 U/Kg/d IV or 50 000 U/6h IM for 10-14 days.
Sexual partner: should be treated.
No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, HIV infected patient, or pregnant patient. These patients should be skin tested and desensitized if the test is positive.
Jarisch-Herxheimer Reaction: a complex allergic response to antigens released from dead microorganism can complicate the treatment of syphilis. A transient acute febrile reaction with head ache and myalgia may develop within 24 hours of therapy. It occurs in of 50% of patients with early syphilis.
Follow Up :
All patient should be followed after treatment, this done by clinical examination and by measuring the VDRL titer, as follows:
Early syphilis: every 3 months in the 1st year, every 6 months in the 2nd year, yearly thereafter.
Late syphilis: yearly.
Neurosyphilis: every 6 months by measuring the blood and CSF level.
A 4 fold decrease in titer suspected after 6 months of therapy.
Signs of relapse: {clinical, serological (4 fold increase), transplacental infection, and infection of the partner}.
Chancroid
It is a common and endemic in many of the world s poorest regions such as areas of Africa, and Asia, but it is rare in Iraq. It is caused by haemophilus ducreyi which is short gram negative bacillus.
Clinical Features:
The ulcer of chancroid is painful, tender, deep, soft, bleed easily with purulent base. It has a short IP (3-5 days). Usually heal with scarring after months. Multiple ulcers appear on the genitalia from autoinoculation (highly infectious ulcer). Unilateral or bilateral painful inguinal lymphadenopathy (which may matted together) develops in about 50% of patients.
Investigation:
Smear: the gram negative bacilli are usually found in small clusters or parallel chains of two or three organisms (the "school-of-fish" pattern).
Culture: using modified Muller-Hinton agar.
Treatment:Single dose of azithromycin 1 gm orally, or cefriaxone 250 mg IM, or ciprofloxacin 500 mg orally twice daily for 3 days, or erythromycin 500 mg orally four times daily for 7 days.
Lymphogranuloma Venereum (LGV)
It is a rare STI, caused by chlamydia trachomitis, characterized by transient small ulcer on the genital area followed in one to two months by painful swelling of inguinal and perirectal LN, which is often accompanied by mild constitutional symptoms. The inguinal ligament often form a cleft between the enlarged inguinal LN "groove sign". Early treatment with doxycycline is curable.
Granuloma Inguinale (Donovanosis)
Iit is a rare STI, caused by Klebsiella granulomatis (gram-negative bacillus), characterized by intracellular inclusions in macrophages referred to as Donovan bodies. It usually affects the skin and mucous membranes in the genital region, results in nodular lesions that evolve into ulcers. This disease is treated by azithromycine, doxycycline, or metheprim. Untreated ulcers do not resolve spontaneously, on the contrary, they tend to worsen with time.
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