Syphilis - S Abraham
Syphilis - S Abraham
Syphilis - S Abraham
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CASE PRESENTATION<br />
S. <strong>Abraham</strong>
A.Y, 53yr Indian Male<br />
Hx: Hx:<br />
one day history<br />
Typical chest pain<br />
Grade NYHA 3-4 3<br />
3 pillow orthopnoea<br />
Class 2-3 2 3 angina and Grade 2 NYHA dyspnoea<br />
for past 2years<br />
PMHx:<br />
Previous anteroseptal MI with left ventricular<br />
dysfunction(EF 18) and L parietal CVA<br />
secondary to intracardiac thrombus in 2006.On<br />
Warfarin.<br />
Aortic regurgitation diagnosed 2006
History cont..<br />
PSHx: PSHx:<br />
nil<br />
Allergies:Nil<br />
Allergies:Nil<br />
Social Hx : Smoking history 60pack years<br />
Never consumed alcohol or other<br />
drugs<br />
self-employed self employed businessman<br />
Family history-No history No history IHD
Examination<br />
Well looking middle aged male<br />
Conscious and co-operative<br />
co operative<br />
Distressed<br />
No pallor, cyanosis, oedema<br />
No skin lesions
Examination cont..<br />
BP: 131/54, equal in all limbs<br />
Pulse: 76/min, regular, low volume, all<br />
pulses equal and palpable<br />
RESP: RESP<br />
RR 28/min<br />
Increased AP diameter<br />
Hyperinflated,liver dullness 7 th ICS<br />
Bibasal crepitations
CVS<br />
JVP raised 5cm<br />
Examination cont…. cont<br />
Apex 6 th ICS AAL,hypodynamic<br />
L parasternal heave present<br />
EDM 2/4 aortic area,loudest left sternal<br />
border<br />
Loud P2
Examination cont… cont<br />
ABD: ABD<br />
Soft ,non tender<br />
Shifting dullness present<br />
CNS: CNS:<br />
normal higher mental function<br />
no meningism<br />
no focal motor,sensory ,motor or<br />
cerebellar signs
ECG
Summary<br />
52 year old male with background of CAD<br />
and LV dysfunction and strong smoking<br />
history<br />
Congestive cardiac failure in the setting of<br />
ACS<br />
COPD<br />
Aortic regurgitation for further investigation
Valvular<br />
Rheumatic heart Disease(unlikely)<br />
Disease(unlikely<br />
<strong>Syphilis</strong><br />
Rheumatoid spondylosis<br />
Infective endocarditis<br />
Aortic root<br />
HPT<br />
Artherosclerosis<br />
<strong>Syphilis</strong><br />
Collagen vascular ds-Takayasus<br />
ds Takayasus<br />
Rheumatoid Ankylosing spondylosis
Investigations<br />
FBC: WCC 6.7/Hb 13.8/MCV 93/Plts 173<br />
U&E: Na 137/K 4.6/Cl 108/CO2 24/U 24/<br />
12.5/Creat 129<br />
Clotting profile :INR : INR 5.32<br />
Cardiac enzymes: Trop I >100,CK 894<br />
LFTs: LFTs:<br />
ALP 49/Tbil 15/TP 61/Alb 36/GGT<br />
32/ALT 49<br />
Lipid profile:Tg 1.03/Chol 4.5/HDL<br />
0.68/LDL 3.4
Investigations cont… cont<br />
HIV negative<br />
RPR positive(Titre 1:64)<br />
Lung function tests<br />
FEV1/FVC-(1.47/2.09)<br />
FEV1/FVC (1.47/2.09) 70 70 % with no<br />
reversibility
CXR
E<br />
C<br />
H<br />
O<br />
:<br />
Echo<br />
MV<br />
Ao V<br />
LV<br />
LA<br />
PV<br />
RV<br />
RA<br />
TV<br />
Peric<br />
Minimal thickening, trace<br />
MR<br />
Min thickening, mod AR,<br />
Syst peak flow1.5m/s,Ao<br />
root 30mm<br />
Dilated, EF 40,EDD 89,<br />
ESD 70, FS 18<br />
Dilated 60mm<br />
N<br />
Dilated<br />
Mildly dilated<br />
N,PAS 34<br />
N
Management and progress<br />
Managed as Non ST elevation Myocardial<br />
infarction`and diuresis optimised. optimised<br />
Subsequent angiogram showed normal<br />
coronaries with global hypokinesis<br />
TPHA positive and treated with<br />
Benzathine Penicillin 2.4 MU weekly for 3<br />
weeks
LP done –normal normal<br />
Polys nil/ Lymp nil/TP 0.26/Globulin no<br />
increase/Glu<br />
increase/ Glu 3.26/ VDRL and<br />
FTA-AB FTA AB pending<br />
Presented to IALCH for AVRnot AVR not for<br />
surgery
52 year old male with Tertiary <strong>Syphilis</strong><br />
with Cardiovascular complications<br />
Aortic regurgitation<br />
Coronary artery involvement<br />
COPD
TERTIARY SYPHILIS
SYPHILIS<br />
Chronic infectious disease caused by<br />
Treponema pallidum<br />
Management is based on 3 stages of disease:<br />
EARLY: primary/ secondary/latent<br />
LATE OR TERTIARY:<br />
- Cardiovascular<br />
- Gummatous syphilis<br />
- Neurosyphilis
EPIDEMIOLOGY<br />
Common in preantibiotic era in 20-30% 20 30% of<br />
pts with syphilis<br />
Currently common in patients with HIV -<br />
often have early neurosyphilis, neurosyphilis,<br />
most<br />
commonly asymptomatic and symptomatic<br />
meningitis, with ocular disease
PATHOGENESIS<br />
Cellular immunity plays a role<br />
Waning immunity with age allows reactivation of<br />
the spirochete that have sequestered in these<br />
sites.<br />
Alternatively re infection occurs in a partially<br />
immune hypersensitive host leading to a chronic<br />
inflammatory response.(gummas)<br />
response.(gummas<br />
Small vessel vasculitis
GUMMATOUS SYPHILIS<br />
Skin, bones, or internal organs<br />
Range from small to very large<br />
Visceral gummas may present as a mass<br />
lesion
CARDIOVASCULAR SYPHILIS<br />
Small vessel vasculitis affecting vasa vasorum<br />
Usually involves ascending thoracic aorta- aorta Aortic<br />
aneurysm( aneurysm( rarely dissection)<br />
Aortic valve regurgitation<br />
Coronary arteries<br />
- involvement<br />
involvement<br />
- narrowing &<br />
- thrombosis
CVS cont…. cont<br />
Most present with asymptomatic murmur,<br />
or left heart failure<br />
Occur 15-30 15 30 yrs from initial Ix<br />
CXR CXR calcification ascending arch of<br />
aorta (not seen with arterosclerosis)<br />
arterosclerosis<br />
Coronary ostial stenosis may be found on<br />
catheterization
NEUROSYPHILIS<br />
Can occur any time after initial infection<br />
Early disease involves: CSF, meninges, meninges,<br />
and<br />
vasculature<br />
- Asymptomatic meningitis<br />
- Symptomatic meningitis<br />
- Meningovascular disease<br />
Late disease involves brain and spinal cord<br />
- General paresis of insane<br />
- Tabes dorsalis
Asymptomatic Meningitis<br />
No symptoms or signs of CNS<br />
Can occur within wks – months after Ix,<br />
uncommonly >2yrs after Ix<br />
CSF: lymphocytic pleocytosis >20cells<br />
/ul ul, , protein (0.46-1), (0.46 1), positive VDRL
Symptomatic meningitis<br />
Often occurs within 1 st yr after Ix<br />
uncommonly yrs later<br />
Symptoms: headache, confusion, N & V,<br />
and stiff neck<br />
Uveitis, Uveitis,<br />
retinitis, or optic neuritis<br />
Leptomeningitis,Gumma<br />
Cranial neuropathy common: CNII, CNVII,<br />
CNVIII<br />
Hydrocephalus
Arteritis of small,medium or large vessels<br />
Seizures<br />
Uncommonly affects Spinal Cord:<br />
meningomyelitis,<br />
meningomyelitis,<br />
polyradiculopathy,<br />
polyradiculopathy,<br />
hyperplastic<br />
pachymeningitis<br />
CSF AbN: AbN:<br />
lymphocyte 200-400, 200 400, protein <br />
100-200mg/dl, 100 200mg/dl, VDRL always +<br />
Imaging: features of meningitis &/or gummas
Meningovascular syphilis<br />
Infectious arteritis-> arteritis > thrombi & infarcts<br />
Onset any time from 1sr months- months 1 st few years,<br />
average 7yrs<br />
May be seen as stroke in young person<br />
Prodromal symptoms present<br />
Acute or chronic stroke usually of MCA branches,<br />
rarely Ant spinal A.-> A. > SC infarct<br />
CSF abN: abN:<br />
lymphocyte pleocytosis 10-100 10 100 &<br />
protein 100-200, 100 200, VDRL usually positive<br />
CSF
General paresis<br />
Progressive dementing illness<br />
usually 10-25 10 25 yrs after Ix<br />
chronic progressive frontotemporal<br />
meningoencephalitis with loss of<br />
cortical function<br />
early stage: forgetfulness<br />
late stage : severe dementia
P – personality<br />
A – affect<br />
R – reflexes (brisk)<br />
E – eye (Argyll Robertson pupil)<br />
S – sensorium (illusions, delusions)<br />
I – intellect (memory, calculation,<br />
orientation, judgement, judgement,<br />
insight)<br />
S – Speech (dysarthric ( dysarthric)
MRI:<br />
frontocortical atrophy, frontal high-signal high signal<br />
lesions, cerebral atrophy<br />
mesiotemporal T2 hyperintensity<br />
ventriculomegaly<br />
pathological T2 hypointensity of Basal<br />
ganglia & thalamus<br />
diffuse white matter T2 hyperintensity
Tabes dorsalis<br />
Disease of the posterior columns of the spinal<br />
cord and the dorsal roots.<br />
Longest latent period average 20 yrs.<br />
<br />
CSF : normal/mild lymphocytic pleocytosis with<br />
10 to 50 cells/µL cells/ L and protein concentrations of<br />
0.45 to 0.75 .1/4 cases VDRL non reactive.
Triad of Symptoms<br />
- Lancinating pains<br />
- Bladder incontinence / sexual dysfunction<br />
- Ataxia<br />
Triad of Signs<br />
- Argyll Robertson pupil<br />
- Loss of reflexes<br />
- Loss of proprioception, proprioception,<br />
vibration sense
Diagnosis<br />
Darkfield microscopy (3x),DFA-TP<br />
(3x),DFA TP<br />
Serological<br />
Non-specific<br />
Non specific – titres reflect disease activity<br />
RPR/VDRL(positive<br />
RPR/ VDRL(positive titres>1:32)<br />
titres>1:32)<br />
Specific<br />
– confirm non-specific non specific tests<br />
FT-ABs,MHA<br />
FT ABs,MHA<br />
CSF-VDRL,FTA CSF VDRL,FTA AB
Treatment<br />
Aimto Aim to prevent progression of disease<br />
Gummatous<br />
Benzathine penicillin 2.4 MU once wkly x 3<br />
Alternatives: Doxycycline,Ceftriaxone<br />
Cardiovascular<br />
Benzathine Penicillin<br />
Alternatives:Ceftriaxone
Treatment cont… cont<br />
Neurosyphilis<br />
IV Penicillin G 10-14 10 14 days<br />
Alternatives(not recommended)<br />
- Procaine penicillin plus Probenecid<br />
- Amoxycillin plus probenecid<br />
- Doxycycline<br />
Same regimen for ocular/auditory
Followup …<br />
Serum VDRL at 3 and 6 months,thereafter<br />
6 monthly for 2 years<br />
Drop in titres fourfold serum VDRL<br />
CSF 6monthly until cell count normalises<br />
All sexual contacts should be treated
Harrison 16 th edit<br />
Up to date<br />
References