Thursday, March 11, 2010

Syphilis

Syphilis - Acute
Rahul Soman, M. Pharm


 

Definition  

A sexually transmitted disease cause by the spirochete Treponema pallidum


 

Medical History  

* Substance Abuse

* Imprisonment

* Prostitution

* Sexual intercourse


 

Findings  

* Abdominal pain - Acute

* Abnormal vision

* Argyll-Robertson pupil

* Arthralgia

* Bone pain

* Chancroid - anogenital ulcer

* Chancroid - Acute

* Condyloma latum

* Female genital ulcers

* Fever

* Genital ulcer

* Headache

* Hematochezia

* Hepatosplenomegaly

* Loss of appetite

* Lymphadenopathy - Acute

* Malaise

* Myalgia

* Nuchal rigidity

* Pain in throat

* Pain of eye structure

* Personality change

* Pruritus of skin

* Rash - Acute

* Rectal pain

* Secondary syphilis of mucous membrane

* Secondary syphilis of tonsil

* Seizure

* Sensorineural hearing loss, bilateral

* Syphilitic chancre of face

* Syphilitic chancre of oral mucous membranes

* Vomiting

* Weight loss


 

Tests  


 

Screening, diagnosis, and therapy response in patients with known or suspected syphilis  

* VDRL titer measurement, Serum: A four-fold or greater rise in antibody titer is presumptive of syphilis but requires confirmatory treponemal testing .


 

Suspected and known syphilis .  

* Rapid plasma reagin test: A fourfold or greater rise in antibody titer is presumptive of syphilis but requires confirmatory treponemal testing .


 

Suspected or known congenital syphilis .  

* Rapid plasma reagin test: A fourfold or greater rise in antibody titer is presumptive of syphilis but requires confirmatory treponemal testing .


 

Suspected syphilis  

* Fluorescent treponemal antibody absorption test: A positive nontreponemal test followed by a positive FTA-ABS is suggestive of syphilis .


 

Suspected congenital syphilis  

* Fluorescent treponemal antibody absorption test: For infants born to syphilitic mothers, a positive fluorescent treponemal antibody absorption (FTA-ABS) test confirming a reactive nontreponemal test is suggestive of congenital syphilis .


 

Suspected syphilis  

* Microhemagglutination test for antibody to syphilis: A positive nontreponemal test followed by a positive microhemagglutination test is suggestive of syphilis .


 

Suspected syphilis  

* Dark field microscopy: Identification of Treponema pallidum by darkfield microscopy can confirm the diagnosis of early syphilis and congenital syphilis (in neonates) .


 

Suspected syphilis  

* Direct fluorescent antibody test for syphilis: Detection of the presence of T pallidum by direct fluorescent antibody microscopy is considered diagnostic for early and congenital syphilis .


 

Suspected HIV infection  

* HIV-1 and HIV-2 antibody, single assay: The first time a person is found to be seropositive, the initial reactive (positive) result must prompt a repeat screening test.


 

Suspected and known neurosyphilis and patients with a high risk of developing neurosyphilis  

* Cerebrospinal fluid examination: The cerebrospinal fluid reflects both the presence of the neurosyphilitic process and disease activity.


 

Monitoring disease activity in neurosyphilis  

* White blood cell count, automated, cerebrospinal fluid: A cerebrospinal fluid cell count greater than 5/mm3 and specific serology findings for Treponema pallidum may be diagnostic of active neurosyphilis .


 

Suspected neurosyphilis  

* Cerebrospinal fluid protein: An elevated cerebrospinal fluid (CSF) protein level may suggest neurosyphilis in the presence of other criteria .


 

Suspected neurosyphilis in the presence of a positive serum treponemal test, and known neurosyphilis to monitor therapy response  

* VDRL titer measurement, Cerebrospinal fluid: A positive VDRL-CSF is considered diagnostic for neurosyphilis in the absence of sample contamination .


 

Suspected neurosyphilis  

* Fluorescent treponemal antibody absorption test, Cerebrospinal fluid: A negative cerebrospinal fluid fluorescent treponemal antibody absorption test may rule out a diagnosis of neurosyphilis .


 

Suspected meningovascular syphilis in the tertiary stage  

* CT of head: Head CT findings in patients with meningovascular syphilis suggest vasculitis and consist of small infarcts affecting both the gray and white matter .


 

Detection of bone lesions in patients with suspected secondary or tertiary (late) syphilis  

* Radioisotope scan of bone: In tertiary syphilis, periostitis is shown as increased cortical activity, osteomyelitis as focal hot spots, and gummas as photopenic or "cold" defects


 

Differential Diagnosis  

* Primary syphilis

* Chancroid - Acute

* Secondary syphilis

* Genital herpes simplex

* Latent syphilis with positive serology

* Cardiovascular syphilis

* Congenital syphilis

* Granuloma inguinale

* HIV infection

* Fixed drug eruption

* Latent early syphilis

* Late syphilis

* Neurosyphilis

* Syphilitic retrobulbar neuritis

* Meningovascular syphilis - quaternary stage

* Lymphogranuloma venereum

* Secondary syphilitic uveitis

* Optic neuritis

* Syphilitic meningitis

* Tabes dorsalis

* Condyloma acuminatum

* Infectious mononucleosis - Acute

* Late latent syphilis

* Secondary syphilis of liver

* Secondary syphilitic periostitis

* Asymptomatic neurosyphilis

* Latent syphilis unspecified

* Syphilitic bursitis

* General paresis - neurosyphilis

* Jarisch Herxheimer reaction

* Gastric syphilis


 

Treatment  


 

Drug Therapy  


 


 

Suspected and known primary or secondary syphilis  


 

PENICILLIN G BENZATHINE  

Adults: 2.4 million units IM in a single dose

Pediatrics: 50,000 units/kg (maximum 2.4 million units) IM in a single dose


 


 

Suspected and known early latent syphilis  


 

PENICILLIN G BENZATHINE  

Adults: 2.4 million units IM in a single dose

Pediatrics: 50,000 units/kg IM (maximum 2.4 million units) IM in a single dose


 


 

Suspected and known late latent syphilis or latent syphilis of unknown duration  


 

PENICILLIN G BENZATHINE  

Adults: 2.4 million IM once weekly for 3 weeks for a total of 7.2 million units

Pediatrics: 50,000 units/kg (maximum 2.4 million units) IM once weekly for 3 weeks for a total of 150,000 units/kg (total maximum 7.2 million units)


 


 

Suspected and known tertiary syphilis in the absence of neurosyphilis  


 

PENICILLIN G BENZATHINE  

Adults: 2.4 million IM once weekly for 3 weeks for a total of 7.2 million units


 


 

Suspected and known neurosyphilis  


 

PENICILLIN G POTASSIUM  

Adults: 18 to 24 million units/day, administered as 3 to 4 million units IV every 4 hours or continuous infusion, for 10 to 14 days


 

PENICILLIN G PROCAINE - PROBENECID (Related toxicological information in PROBENECID)  

Adults: Procaine penicillin 2.4 million units IM once daily AND probenecid 500 mg orally 4 times daily, both for 10 to 14 days


 


 

Suspected and known congenital syphilis in children older than 1 month of age  


 

PENICILLIN G POTASSIUM  

Pediatrics (>1 month): 200,000 to 300,000 units/kg/day IV, administered as 50,000 units/kg every 4 to 6 hours for 10 days


 


 

Suspected and known congenital syphilis in neonates  


 

PENICILLIN G POTASSIUM  

Neonates: 100,000 to 150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter, for a total of 10 days. If more than 1 day of therapy is missed, restart the entire regimen


 

PENICILLIN G PROCAINE  

Neonates: 50,000 units/kg/dose IM in a single daily dose for 10 days. If more than 1 day of therapy is missed, restart the entire regimen


 

Procedural Therapy  


 

Reportable infectious diseases  

* Infectious disease notification: In the United States, specific infectious diseases must be reported to the state or local public health department .


 

Sexual contacts of patients with a sexually transmitted disease  

* Sexual partner notification: Patients with certain sexually transmitted diseases need to refer their partners for evaluation and treatment .


 

At risk for sexually transmitted disease  

* Infection prevention education: Patient education and counseling is one of the essential strategies for the prevention and control of sexually transmitted diseases (STDs) .


 

Non-Procedural Therapy  


 

Syphilis  

* Patient Education


 

 
 

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SYSTEM BASED CLASSIFICATION OF DISEASES

SYSTEM BASED CLASSIFICATION OF DISEASES

Bone and Joint Diseases

  1. Gout and Hyperurecemia
  2. Osteoarthritis
  3. Rheumatoid Arthritis
  4. Acute coronary Syndroms

Cardiovascular Diseases

  1. Arrhymias
  2. Cardiopulmanary Resuscitation
  3. Heart Failure
  4. Hypertension
  5. Hyperlipidemia
  6. Ischemic Heart Diseases
  7. Shock
  8. Stroke
  9. Venous Thromboembolism

Dermatrologic Diseases

  1. Acne
  2. Psoriasis
  3. Skin Disorders and Cutaneous Drug Eruptions

Endocrine Diseases

  1. Cirrhosis
  2. Portal Hypertension

Gastrointestinal Diseases

  1. Irritable Bowel Syndrome
  2. Constipation
  3. Diarrhea
  4. Gastroesophagal Reflux Disease
  5. Hepatitis, Viral
    1. Hepatitis A
    2. Hepatitis B
    3. Hepatitis C
  6. Nausea and Vomiting
  7. Pancreatitis
  8. Peptic Ulcer disease

Gynecologic and Obstetric Diseases

  1. Contraception
  2. Hormone therapy

Hematologic Diseases

  1. Anemia
    1. Megaloblastic Anemia

i. Megaloblastic Anemia due to Folate Deficiency

ii. Megaloblastic Anemia due to Vitamine B12 Deficiency

    1. Sickle Cell anemia
    2. Hemolytic Anemia
    3. Iron Deficiency Anemia
    4. Aplastic Anemia
    5. Iron Deficiency Anemia

Infectious Diseases

  1. Central Nervous System infections
  2. Endocarditis
  3. Fungal infections, Invasive
  4. Gastrointestinal Infection
  5. HIV / AIDS
  6. Intra-Abdominal Infection
  7. Respiratory Tract infections, Lower
  8. Respiratory Tract infections, Upper
  9. Sepsis and Septic Shock
  10. Sexually transmited Diseases (STD)
  11. Skin and soft tissue infection
  12. Tuberculosis
  13. Urinary tract infection and prostatitis

Neurologic Diseases

  1. Epilepsy
  2. Headache
    1. Migraine
    2. Cluster Headache
  3. Pain management
  4. Parkinson’s Diseases
  5. Status epilepticus

Nutritional Diseases

  1. Enteral Nutrition
  2. Obesity
  3. Parentaral Nutrition

Onchologic Diseases

  1. Breast cancer
  2. Colorectal Cancer
  3. Lung cancer
  4. Lymphomas
  5. Prostate cancer
  6. Cervical Cancer
  7. Esophageal Cancer
  8. Gastric Cancer
  9. Head and Neck Cancer
  10. Lung Cancer
  11. Ovarian Cancer
  12. Pancreatic Cancer
  13. Primary bone Cancer
  14. Primary Brain cancer
  15. Testicular Cancer
  16. Thyroid Gland Cancer
  17. Urinar Bladder cancer
  18. Uterine Cancer

Ophtalmic Diseases

  1. Glaucoma

Psychiatric Diseases

  1. Alzhimer’s Diseases
  2. Anxiety Disease
  3. Bipolar Diseases
  4. Depressive diseases
  5. Schizophrenia
  6. Sleep Diseases
  7. Substance-Related Diseases

Renal Diseases

  1. Acid base Diseases
  2. Acute renal Failure
  3. Chronic Renal Failure
  4. Drug Dosing in renal insufficiency
  5. Electrolyte Homeostasis

Respiratory Diseases

  1. Allergic Rhinitis
  2. Asthma
  3. Chronic Obstructive Pulmonary Diseases

Urologic Diseases

  1. Benign Prostatic, Hyperplasia
  2. Erectile Dysfunction
  3. Urinary Incontinence