0071643192.pdf

OBSTETRICS AND GYNECOLOGY

DIFFERENTIAL

Syphilis must be ruled out.

DIAGNOSIS

Clinical diagnosis is necessary because smears and cultures are not reliable in
isolating the organism.

TREATMENT

■ Azithromycin 1 g PO ×1 dose or
■ Ceftriaxone 250 mg IM ×1 dose or
■ Ciprofloxicin 500 mg PO BID ×3 days

SYPHILIS

Syphilis is caused by Treponema pallidumand is transmitted by direct contact
with an infectious moist lesion.

SYMPTOMS/EXAM

■ Primary syphilis: This painless genital sore (chancre) is a firm, papule or
ulcer with a raised border. It occurs on the labia, vulva, vagina, cervix, or
anus. Painless, rubbery regional, and then general lymphadenopathy fol-
lows. Serologic tests are positive 70% of the time.
■ Secondary syphilis: This systemic infection becomes evident with diffuse
lymphadenopathy, a “viral syndrome,” and a bilateral, symmetric rash appears
that is papulosquamous and involves the palms and soles. Moist papules
(condyloma lata) are seen in the perineum. Serologic tests are almost always
positive.
■ Tertiary syphilis: This stage is characterized by “gummas,” soft, tumorlike
growths seen in the skin and mucous membranes. Other characteristics of
untreated syphilis include Charcot joints (a degeneration of joint surfaces
resulting from loss of proprioception), and Clutton joints (bilateral knee
effusions). The more severe manifestations include neurosyphilis and car-
diovascular syphilis.

DIAGNOSIS

■ Diagnosis depends on a series of tests with definitive diagnosis being made
only by direct visualization of spirochetes from cutaneous lesions using
darkfield microscopy.
■ VDRL is a nontreponemal test that will become positive 3–6 weeks after
infection. The VDRL test is only about 80% sensitive in primary syphilis
but 100% sensitive in secondary syphilis.
■ VDRL may be used to exclude the disease in patients with a rash possibly
consistent with secondary syphilis.
■ The florescent treponemal antibody absorption (FTA-ABS) test and micro-
hemagglutination assay for T. pallidum(MHA-TP) detect antibodies to
Treponema spirochetes.

TREATMENT

■ Treat primary, secondary, and early latent syphilis with Benzathine peni-
cillin G, 2.4 million units IM ×one dose.
■ Late syphilis should be treated with Benzathine penicillin G 2.4 million
units IM weekly ×3 consecutive weeks.
■ The initial treatment of neurosyphilis requires intravenous penicillin every
4 hours.

The three human diseases

caused by spirochetes are

treated similarly:

Syphilis →penicillin or

doxycycline.

Lyme disease →doxycycline

or amoxicillin.

Leptospirosis →doxycycline

or amoxicillin.

VDRL false-positives may

occur with HIV, malaria, Lyme

disease, and lupus.

Because of its high sensitivity

in patients with 2∞syphilis,

VDRL is the test of choice to

exclude syphilis in patients

presenting with a rash.