Laboratory diagnosis of

Syphilis
Dr Debashis Roy,MD
Assistant Professor
Dept of Microbiology
AGMC &GBP Hospital
Lesson plan
1.Introduction 2 min
2.Sample collection3 min
3.Enumeration of tests available for detectin of syphilis 3 min
4.Principles of various non trepnemal tests 15 min
5.Principles of various treponemal test 15 min
6.Diagnostic algorithm for diagnosis of syphilis and interpretation of serological
tests for syphilis5 min
7.Lab diagnosis at various stages of syphilis10 min
8 Feedback 7 min
Introduction(Review article Yuting luo et al,clinical microbiology,2021)
• Syphilis is a multistage disease caused by Treponema pallidum subsp. Pallidum.
• It is primaririly transmitted sexually or vertically during pregnancy.
• Public health problem in Africa,South East Asia,Western Europe,Russia and
China.
• Increase in incidence in MSM (mainly HIV+ve cases).
• To control spread of syphilis effectively ,an accurate diagnostic tool is necessary.
• Diagnosis relies on history,physical examination,and interpretation of laboratory
tests.
• Culture:rabbit infectivity test(in vivo)
• Research is on for detection of T.pallidum in a cell culture system
using modified medium in microaerophilic environment(in vitro).
• Currently,diagnosis depends on serologic test (secondary &early latent with
high sensitivity& specificity).
Clinical stages:primary syphilis(hard chancre)
Secondary syphilis:
Skin rash Condylomata lata Mucosal patch
Late syphilis
Sample collection:
• 1. From ulcer- exudate should be collected with care (highly infectious)
• 2.Blood-collected for serology
• 3.CSF-to investigate tertiary stage(neurosyphilis)
Tests available for detecting Syphilis

Direct identification of T.pallidum Serological tests to detect IgG/IgM antibodies

Dark field microscopy(DFM) Non Treponemal tests for determining disease

activity(standard tests for syphilis)

Direct antigen detection by staining Treponemal tests for disease confirmation

T.pallidum(DFA-TP)
Silver impregnation method:Fontana stain
Levadity stain
Nucleoside amplification technique(PCR) Detection of Treponemal IgM antibodies to
detect early infection
Dark Field Microscopy:
• This method is traditionally used to demonstrate T.pallidum in the exudate from
mucocutaneous lesion in early acquired and early conjenital syphilis.

• One of the most specific and easiest method for diagnosis of infectious syphilis
when lesions are present.
Figure:comparison of light pathways of brightfield and dark field microscopy
Procedure:
• Clean the lesion with saline soaked gauze and squeeze it between the index
finger and the thumb to produce a serous exudate (avoid contamination with
blood)
• Exudate is transferred onto a glass slide by directly pressing it on the lesion.
• Normal saline can be added to exudate to make the material homogenous.
• Specimen should immediately be examined as delay in examination reduces
motility of treponemes.
 Results:
T.pallidum in dark field microscopy is identified by typical morphology and characteristic
movement.
T.pallidum differentiates from other treponemes by tightness of spirals and characteristic cork
screw movement
T.pallidum Other non pathogenic treponemes

Has 6-14 regularly wounded coils Irregularly wounded coils

Shows a slow ,deliberate forward and Lack a characteristic motility

backward movement,rotating on its long
axis,soft bending and twisting from side to side
Diagram of dark ground microscopy
Dark field microscopy cont…
Advantages Disadvantages

Easy to do Time consuming

Most specific method to confirm diagnosis in Needs operator expertise

early syphilis
Needs well maintained specialist equipment
Can not differentiate T.pallidum from other
pathogenic treponemes

Not recommended for oral cavity lesions

 Direct Fluorescent antibody-T.pallidum(DFA-TP)
It is a practical alternative to dark field examination.
Advantages Disadvantages

More sensitive and specific than dark field This test can not differentiate T.pallidum sub
microscopy species pallidum from other subspecies of
T.pallidum
Samples from oral mucosa can also be
examined

Slides need not be examined immediately

Method of Direct Fluorescent Antibody –Treponema pallidum(DFA-TP):
• Specimen collection is same as Dark Field Microscopy

• Slide is air dried and fixed with acetone for 10 min or100% methanolx10 sec.

• Smear is stained with fluorescein –labeled anti T.pallidum globulin and examined
under fluorescent microscope.
Silver impregnation method:
• Thickness of organisms are increased due to deposition of metalic silver over
organisms.
Polymerase chain reaction:
• It increasingly becoming the investigation of choice for identifying T.pallidum
from early lesion of early syphilis.

• A number of well- presrved DNA sequnces have been identified that are specific
for T.pallidum ,do not found in other treponemes.

• Based on these primers have been shown to be sensitive &specific in diagnosis

of early syphilis.
Serological Tests(Serodiagnosis)
• Useful in latent stage of disease as treponemes are not readily sustainable in
culture and lesions are usually absent.
• An ideal serological test-
1.Should have high specificity and sensitivity.
2.Should be suitable for treatment monitoring.
3.Should give a negative result on successful therapy to give a clear cut diagnosis
of re infection.
However,using different but complementary characteristics of various specific
and non specific treponemal tests,a diagnosis of syphilis and serological assesment
of disease activity ,treatment response and reinfection can be made.
Principle of serological tests:
• T.pallidum infection produces antibodies antibodies to >20 different
polypeptide antigens.
• Two types of antibodies:
• Non secific antibodies(regains)-directed against lipoidal antigen of T.pallidum
as well as mitochondrial and nuclear membranes of human cells.
• Specific anti Treponemal antibodies –directed against T.pallidum.
• Specfic anti treponemal IgM antibodies develop during 2nd week of infection
• IgG antibody response begins around 4th week after infection and persists.
• Treatments causes generalized loss of antibodies but IgG ab may persists at low
detectable level.
Non treponemal tests measure anti lipoidal IgM and IgG antibodies .
• These tests used for initial screening and for followup after treatment.
• They can be performed as a
1. qualitative test to check for presence or absence of antibodies
2.Quantitative tests to check amount of ab present in serum.
Except VDRL/RPR tests,most lipoidal antigen tests are not used.
 VDRL
• Veneral Disease Research Laboratory(VDRL) test is a slide flocculation test
employed in diagnosis of syphilis.
• As the antigen used in this test is cardiolipin ,which is a lipoidal extract from
beef heart ,it is not a specific test.
• Antibodies reacting with cardiolipin antigen have traditionally termed ‘regain’.
VDRL-Principle
• Patients suffering from syphilis produce antibodies that react with
cardiolipin antigen in a slide flocculation test,which are read using a
microscope .
• It is not known if the antibodies that react with cardiolipin are
produced against some lipid component of Treponema pallidum or
as result of tissue injury following infection.
VDRL –test requirements:
• Patient’s serum,waterbath,freshly prepared cardiolipin antigen,VDRL
slide,mechanical rotator,pipette,hypodermic syringe with unbeveled needle and
microscope.Known reactive and non reactive serum controls also needed.
• VDRL antigen:Cardiolipin antigen is an alcoholic solution composed of
0.03%cardiolipin,0.21%lecithin,0.9%cholesterol.Cardiolipin antigen must be
freshly prepared each day of test.Working antigen is a buffered saline
suspension of cardiolipin.
• VDRL slide:It is a glass slide measuring 2x3 inch with 12 concave depression
,each measuring 16mm in diameter and 1.75mm deep.
VDRL test slide
VDRL reagent
Procedure:Patient’s serum is inactivated at 56 degC water bath for 30 min to remove
non specific inhibitors(complement).The test can be performed both qualitatively and
quantitatively.Those tests are reactive by qualitative test are subjected to quatitative
test to determine the antibody titre.
Qualitative test:

1)0.05ml of inactivated serum is taken into a well.

2)1/6th ml(or 1 drop from 18 gauge needle )of cardiolipin antigen is then added
with help of unbeveled syringe to well and rotated 180rpmx4min.
3)Every test is accompanied with known reactive and non reactive controls.
4)Slide is then examined under 10x low power objective for flocculation.
Depending on size ,results are graded weakly reactive or reactive.
5)Reactive samples are subjected to quantitative test.
Quantitative VDRL test:
• This is performed to determine the antibody titre
1.Serum is doubly diluted in saline from 1in 2 to1:256 or more.
2)0.05ml of each dilution is taken in the well and 1/60 ml of antigen is added to
each dilution and rotated in a rotator.
1. The results are then checked under microscope.
2. Highest dilution showing flocculation is considered as reactive titre.
3. If clinical findings are strongly suggestive of syphilis,a quantitative test may be
directly performed on serum sample.
serial double dilution of serum (Quantitative estimation)
VDRL for CSF:
• VDRL test may also be performed on CSF samples in diagnosis of neurosyphilis.
• Quantitative VDRL is the test of choice
• Antigen is diluted with equal vol of saline ,CSF must not be heated,vol of antigen
solution is 0.01 ml (1 dropfrom21 gauge needle) and rotation time 8 min.
• Rest procedure is same as RPR.
Reporting of results:
• Results of the test are reported as:
1.Reactive:past/present infection with pathogenic T.pallidum ,which is either
treated or untreated or a false +ve reaction.
2.Non reactive:no current infection or effectively treated infection, but does not
rule out syphilis which can be in its incubation period.
3.Weakly reactive
A.VDRL slide and B:VDRL test result
A four fold rise in titre→Infection
Reinfection
Treatment failure
• A four fold decrease in titre→effective therapy
• When a non treponemal test shows a persistent reactivity with no sign of
decline in titre after 6 month of adequqte therapy or fails to show a four fold
decrease of an initial high titre within 1 year ,it is considered as seroresistant.
Disadvantages of Non –treponemal test:
1.Prozone phenomenon:false negative reaction
• Undiluted serum specimens having a high quantity of regain antibodies
occasionally will give false negative reaction ,but on further dilution ,it becomes
+ve.
• Incidence of prozone phenomenon in general population is low(0.4%).
• It may attain clinical significans in cases of certain groups of patients:
1.Patients on continuous immunosuppressive therapy
2.HIV sero+ve patients
2.False +ve reactions:
• 1. Technical false +ve reaction
• 2.Variation in the normal:there may be excess production of regain antibodies in
some normal individuals.
Biological false+ve(BFP) reaction: can occur in1% of normal sera.
syphilitic infection absent
No technical fault
BFP ab usually IgM type,regain Ab in syphilis is mainly IgG.
Polyclonal antiphospholipid antibodies produced against lipoidial antigens
present in normal tissue and in conditions that destroy cell nuclei are responsible
for this reactions.
Types of Biological false+ve reactions:

Transient acute reaction Chronic reaction

Lasts less than 6 months Lasts more than 6 months

Due to various associated infections,narcotic Idiopathic,Leprosy,old age,auto immune and

abuse,immunization procedure,pregnancy other connective tissue
disorders,malignancy,malaria.
Variants of VDRL test
• Unheated serum regain (USR)test
• Rapid plasma regain (RPR) test
• Reagin screen test
• Automated regain test(ART)
• Toludin red unheated serum test(TRUST)
RPR test reagent
Difference between VDRL and RPR
VDRL test RPR test

Results read microscopically(10x Results read macroscopically,large clumps

objective),small clumps formed formed
Antigen once reconstituted,to be used EDTA (stabilizer) used, stored upto6 month at
within24hrs 4-10 degC
Pre-heating of serum to remove complement Choline chloride used,complement is removed

Plasma,serum and CSF can be used Plasma and serum but not CSF

Rotation of slide for 4 min Rotation of slide for 8 min

Sensitivity in primary syphilis 78% Sensitivity in primary syphilis is 86%

Cheaper,250 test can be done from one Expensive than VDRL,used in low sample load
vial,field study,antenatal screening
Treponemal Tests(specific test):
• Here entire T.pallidum or its fragments used as antigen to detect antibodies
directed against treponemal cellular component.
• These tests are used for confirmation of disease activity.
• Treponemal tests become reactive before non treponemal tests but unlike non
treponemal tests they remain+ve for many years after adequate therapy.
Commonly used Treponemal tests:
• Treponema pallidum immobilization test(TPI) : not used nowadays
• Fluorescent treponemal antibody absorption test(FTA-Abs)
• Treponema pallidum Haemagglutination Assay(TPHA).
• Treponema pallidum particulate agglutination test(TPPA).
• Treponemal enzyme Immunoassay(EIA).
• Chemiluminescence Immunoassay(CIA)
Fluorescent Treponemal antibody absorption(FTA-Abs) test: sample serum,CSF
• It is an indirect immunofluorescence antibody test.

Serum for testing is diluted in sorbent(containing extract of Reiter Treponemal culture)

to absorb non specific antibody.
↓

Serum is placed on a microscopic slide to which the antigen (a suspension of T.pallidum

organism) is fixed. ↓

Conjugated fluorescein labeled anti human globulin is added.

Intensity of fluorescence is reported as REACTIVE,NON REACTIVE
False+ve or –ve may occur
It is the most sensitive serological test in early stage of syphilis

Advantage Disadvantage

1. High sensitivity and specificity 1.Expensive

2. Can detect recent infection 1-2 weeks 2.Time consuming
before other assays 3. Reading the test is tiresome
4.Well trained personnel is required
Fluorescencent Treponemal Antibody Absorption Test(T.pallidum showing
apple green fluorescence staining reaction)
Treponema pallidum haemagglutination assay(TPHA):samples are serum,CSF

• A qualitative haemagglutination test using tanned formalized sheep RBCs as

carrier for T.pallidum antigen(sensitized cells).
• Patients serum is diluted in absorbing diluent which contains:
1.Sonicated sheep&bovine cell stroma
2.Normal rabbit testicular extract
3.Reiter treponemal sonicate
4.Normal rabbit serum
5.Stabilizer
 Reporting
• Reactive:if agglutination occur in a dilution of 1:80 or more as per kit used in our
hospital
• Titre as high as 1:5,120 or more is common in secondary syphilis.
• Reactivity is+ve around 4th -5th week of infection.
• False +ve may be due to heteroagglutination ,group specific antibodies.
Advantages Disadvantages
1.Less expensive 1.Less sensitive in primary syphilis
2.Basic equipment
3.Simply trained staff
Patient serum sample
TPHA reagent kit
TPHA reagent Kit:Test cells,control cells,diluent,+vecontrol,-ve control
Reagent of TPHA
Test cells Contains suspension of avian RBC coated with antigens of
T.pallidum,bovine serum albumin

Control cells Contains suspension of avian RBC,bovine albumin serum

Diluent: Saline solution containing rabbit serum

Positive control Human serum containing antibodies to T.pallidum in phosphate buffer

Negative control Rabbit serum in phosphate buffer

Microtitre plate contains 96 wells
After incubation result is read macroscopically:D=diluent site,T=test cells,C=control cells site
-ve reaction:cells settled to a compact button and control cells negative button.
+ve reaction:Full cell pattern covering bottom of well indicating agglutination of RBC and control cells
negative button,
 Variants of TPHA
• Micro hemagglutination with T.pallidum antigen(MHA-TP)

• Automated microhaemagglutination assay with T.pallidum antigen (AMHA-TP)

• Haemagglutination treponemal test for syphilis (HATTS)

• Finger prick MHA-TP

Treponama pallidum Particle agglutination (TPPA)

• Passive agglutination test for detection of antibody toT.pallidum.

• Similar in Principle to TPHA

• But sheep erythrocytes are not used

• Sonicated T.pallidum subsp.pallidum antigen(Nichol strain) are coated onto

gelatin particle.
• These agglutinate with antibodies to T.pallidum in patient’s serum.
• A mat of agglutination particles form in the well of microdilution tray.
Treponema pallidum particle agglutination (TPPA)Test
Enzyme Immunoassay(EIA)
• Serum is added to microwells coated with treponemal antigen.

• An enzyme labeled antihuman immunoglobulin conjugate and enzyme

substrate are added to detect Ag-Ab reaction after incubation.

• Recent studies suggest that EIA used as single test is an alternative to combined
VDRL/RPR+TPHA test.

• It has advantage of higher specificity than FTA-Abs and

automated/semiautomated processing and objective reading of results.
Traditional algorithm which designed to detect active infection ,starts with a non treponemal screening
test (RPR) while reverse algorithm starts with a treponemal specific antibody test (EIA orCIA)
[CDC guideline]
Published in Indian Journal of Sexually transmitted
infections and AIDS 2019
Interpretation of serological tests for syphilis
1. Reagin antibodies appears in serum only abour four weeks after acquiring
infection.So,FTA-ABS test is reactive earlier than VDRL test.
2.In primary chancre ,test for regain are reactive only in 70% of cases .
Antibody level maximum during secondary stage.Next several yrs Antibody titres
decline.
3.Non-treponemal tests become negative or show decline with effective
treatment while treponemal tests usually remain+ve aftercomplete treatment.
VDRL or RPR is more useful for assessment of cure after treatment.
4.Conjenital syphilis:repeat test shows rise in Ab titre in maternal syphilis&fall in
neonate.Demonstration of IgM Ab in newborn is indicative of active infection.
FTA-ABS test to demonstrate IgM Ab confirm conjenital infection.
 Lab diagnosis of syphilis at various stages
• Primary syphilis:a presumptive diagnosis of syphilis can be made based on presence of
chancre and a preeceding history of sexual contact within last 3 months.

• During this period;dark field microscopy(DFM)or PCR or DFA-TP can be used for confirmation.

• Humoral antibody response can be detected by treponemal or non-treponemal tests 1-4

weeks after chancre has formed.
• Sensitivity of various tests during this stage:
1)VDRL/RPR: 70-90%
2)TPPA: 94%
 Secondary syphilis:
• All serological tests are positive in this stage and sensitivity approaches 100%
• Treponemes can be identified in lesions by dark field microscopy or PCR
Presumptive diagnosis
Presence of a typical rash ↓
↓
...…………………………………………………………………………………………………………
↓ ↓
• Reactive non-treponemal tests with a titre=/>1:8 ReactiveNTT with fourfold
(without any past history of syphilis) rise in titre(past history+)
 If non-trepomemal test titre<1:8
↓
……………………………………………………………………………………………............................
↓ ↓
Repeat the test after1-2weeks Perform a treponemal test
↘ ↙
If both are +ve
↓
Confirmation of diagnosis
 Latent syphilis
• As the lesions are not present in this stage,definitive diagnosis for treponemes
can not be done.

• All serological tests are reactive in early latency.

• But reactivity to non-treponemal tests decreases with increased duration of

latency(about 30% patients with latent syphilis are VDRL /RPR non Reactive).

• Sensitivity of treponemal tests in latent syphilis varies from 97-100%.

• Most of patients with latent syphilis are diagnosed presumptively on the basis of
reactive syphilis serology during screening
 Diagnosis of Neurosyphilis
• C S F examination is done in:
1.Patients with neurosyphilis

2.In patients with syphilis of more than 2 years duration to exclude asymptomatic
neurosyphilis.

3.Before treatment of patients who have had relapse after any form of treatment

4. As a followup procedure for patients who have been treated for neurosyphilis

5.As a baseline measure in all patients with syphilis for whom non-penicillin regimens are
prescribed.
6.In all infants suspected of prenatal syphilis
Diagnosis of neurosyphilis cont…
• CSF sample is taken and a cell count is made
• It is further checked for protein abnormalities and subjected to VDRL test
• Diagnosis of neurosyphilis is indicated by increase
cellcount(>10lymphocyte/cumm of CSF),increased protein(>40mg% in CSF) and
a REACTIVE VDRL test
• Serum VDRL test is reactive in about two thirds of the cases.
Diagnosis of Cardiovascular syphilis:
• Non treponemal tests are reactive in most of the patients
Diagnosis of Syphilis in Pregnancy:
• All women should be screened serologically for syphilis during the early stages
of pregnancy.
• Antepartum screening by non treponemal antibody testing is typical ,but in some
setting ,treponemal antibody testing is being used.
• For patients at high risk,serological testing should be done twice during 3rd
trimester,at 28 week-32 weeks gestation and at delivery.
• Expectant mother should be treated when non-treponemal &treponemal tests
are reactive( thorough evaluation cause of possible false+ve result can not be
ensured).
• Post natal screening for pre natal syphilis in infants born to high risk mothers at
4-8 weeks of age is appropriate.
 Diagnosis of Syphilis in HIV
• Unusual serological responses have been observed among HIV infected persons who
have syphilis.

• Majority of reports show titres higher than expected,but false negative serological test
and delayed appearance of seroreactivity also reported.

• However,both treponemal and non treponemal serological tests for syphilis can be
interpreted in the usual manner for majority ofT.pallidum-HIV coinfection.

• When clinical findings are suggestive of syphilis but serological tests are non reactive
,alternative tests like biopsy of lesion,dark field examination ,DFA staing of lesion
material might be useful for diagnosis.
• Neurosyphilis should be considered in the differential diagnosis of neurological
disease in HIV infected persons.
Diagnosis of congenital syphilis
• Based on laboratory criteria of both mother& infant.
• Serology play crucial role as no specific sign of infection at birth.
• IgM antibody of infant at birth (FTA-abs IgM Ab )and VDRL/RPR test in mother.
• Western blot-it is an immunoblot technique to detect IgM&IgG antibody in
congenital syphilis
Clinical case presentation
• A 25 yr old man presented with painless ulcer with hard base on penis He is
having history of multiple sex parters.On examination,inguinal lymphnodes are
enlarged ,discrete,nontender and rubbery.
Q1.What is the clinical diagnosis?
2.What is the causative agent?
3. Write pathogenesis of the disease condition.
4.Laboratory diagnosis of this condition
5.Name the various causes of genital ulcers.
Explain:Non treponemal serological test is more sensitive in secondary syphilis
than primary syphilis
Short note:Non Treponemal serological test for syphilis
Difference between VDRL and RPR test
Case1.Negative Treponemal test and negative
non-treponemal test
• 1.Absence of syphilis
• 2.very early syphilis before seroconversion
• Both treponemal and non –treponemal tests take about 2-4 weeks to
seroconvert in the setting of a new infection.
• Repeat the test after few weeks if indicated.
Case2.+ve non-treponemal test and +ve treponemal
test
• 1.Active infection
• 2.Recently treated syphilis with titres not yet decreased.
• 3.Inadequqte treatment/failure to respond treatment
***successful treatment is 4-fold decrease in titre(1:32 to 1:8 orlessthan that)
Case3.+vetreponemal test and negative non-treponemal
test
• 1.History of syphilis that was treated
• 2.Untreated syphilis
• If no h/o syphilis ,check second treponemal test that targets a different
antigen.
• If +ve ,treat
• 3.False+ve treponemal test
Case4.+ve non –treponemal test and negative
treponemal test
1.False+ve non-treponemal test .
If no possible recent exposure to syphilis
Evaluate for cause of false+ve test result by ruling out other underlying disease.
Clinical problem based question:
• A 23 yrs old women comes to STI clinic for a followup examination.Two weeks
ago ,serologic testing was +ve,a rapid plasma regain(RPR) test was reactive at
1:8 and FTA-ABS test was negative.Physician determines that pt does not have
syphilis.Which of the following is the likely rationale for sequential screening
tests in this patient?
A)High +ve predictive value of RPR and high negative predictive value ofFTA-ABS
B)High sensitivity and low specificity of RPR and FTA-ABS
C)High sensitivity of RPR and high specificity of FTA-ABS
D)High specificity of RPR and high sensitivity of of FTA-ABS
We should go with test having high sensitivity,then to confirm do test with
Questionnaire
• Interpretation of serological test for syphilis.
• MCQ
1.Which of the following serological tests is employed for diagnosis of conjenital
syphilis?
a)FTA-ABS test,b)IgM FTA-ABS test,c)TPHA test,d)Reitre protein complement
fixation test
2.Hard chancre is characteristic of
a)Primary syphilis,b)secondary syphilis,c)Tertiary syphilis,d)None of above
3.Motility of spirochetes may be due to a)flextion and extension,b)cork-screw like
rotatory movement,c)translatory movement,d)All of the above
4.Which of the following methods can be used to demonstrate Treponema
pallidum?a)Dark ground microscopy,b)Silver impregnation
method,c)Immunofluorescence staining,d)All of the above.
Questionnaire
• Q5.Which of the following disease/s is/are transmitted non-
venerally?
a)Yaws,b)Pinta,c)Endemic syphilis,d) All of the above
Q6.The causative agent of yaws is:a)Treponema pallidum subspecies
pertenue ,b)T.pallidum subspecies endemicum,c)T.carateum,d)None
Q7.Causative agent of pinta is a)Treponema pallidum subspecies
pertenue ,b)T.pallidum subspecies endemicum,c)T.carateum,d)None
Ans:
• 1.(b)
• 2.(a)
• 3.(d)
• 4(d)
• 5(d)
• Q6.(a)
• Q7(C)
• Viva question:causes of painless genital ulcer:treponema
pallidum(syphilis),Chlamydia trachomatis(LGV),Klebsiella
granulomatis(Donovanosis)
• Causes of painful genital ulcers:Haemophilus ducreyi(chancroid),Herpes simplex
virus(Herpes genitalis)type2&1
Thank

You
Diagnosis of Cardiovascular syphilis:
• Non treponemal tests are reactive in most of the patients
Reactivity of serological tests in untreated syphilis:Ref CP Beveja seventh Edition)

Test Primary Secondary Latent

stage(%+ve) stage(%+ve) stage(%+ve)
VDRL 78% 100% 70%

RPR 86% 100% 70%

FTA-ABS 80% 100% 95%

TPHA 65% 100% 95%