Syphilis Diagnostic Techniques during Treponema pallidum Life Cycle and Syphilis Stages:

False Negatives and Positives

Introduction. Treponema pallidum pallidum is a motile spirochaete bacteria that
causes syphilis. It is acquired by close sexual contact (chafed skin/mucous
membranes) or transmitted to a fetus via transplacental passage. It moves in a
corkscrew motion through the mucus and gains access to host lymph and blood
through tissue and mucous membranes. It is not seen on a gram stain because
too thin. There is no vaccine for syphillis as T. pallidum does not have enough
surface proteins for an antibody to be effective. The diagnostic tests for syphilis
vary in reliability. The stage of syphilis (primary, secondary, latent, tertiary)
significantly affects the likelihood of receiving a correct +/- syphilis tests. The
incidence of syphilis has drastically decreased with the introduction of penicillin,
but also rose again with HIV. Outbreaks of syphilis have been reported in men
who have sex with men, and in the United States syphilis is most prevalent in the
South, urban areas, men, and blacks. Syphilis shares many clinical manifestations
with other treponemal and nontreponemal diseases and in some stages is
asymptomatic. Clinical diagnosis then must be supported by lab tests.
FALSE POSITIVE REACTIONS
The frequency of a false positive reaction is dependent upon the following factors:
(1) Individual immunological response: the immune mechanisms are very labile and altered easily by stimuli such as upper respiratory infections,
pneumonia, smallpox vaccinations, causing serological reactivity; (2) the type of serological test: the more crude the lipodial antigen the more fasle
positive reactions; (3) the more serological tests and the frequency of these tests for syphilis performed on an individual will increase the frequency of
false positive reactions; (4) the stage of the disease.
Between 1930 and 1942 approximately 190 instances of positive Wasserman/Eagle flocculation tests were reported. In most of these instance nine
weeks later the false positive reactions turned to normal reactions. Individuals in the pre and post penicillin era were treated erroneously for syphilis
after receiving a non-specific reaction.
TALK ABOUT HOW STUDY RELATES TO STAGES AND HOW IT
EFFECTED THE PEOPLE OF ALABAMA. MORE ABOUT FIGURE CAPTIOn

Life Cycle of T. Pallidum is very complex, as observed in pathogenic T. pallidum as in syphilitic rabbits testis. The
method of division is called “Transverse Fission:” the organism about to divide bends rapidly at one point to form a sharp
angle on itself, lashes back and forth, break appears at this point, rests for a while, new motion is begun in which both
parts rotate in opposite directions, twist themselves apart. Gemmae or buds are produced that turn into unispirochetal
cysts within each of which single spirochetes, then a tangled mass or cord of adult spirochetes subsequently emerges
from the cyst.

DeLamater, M.D., Wiggall, Richter H, M.D., Haanes, Merle, M.D. “Studies on the Life Cycle of Spirochetes.” Department of Dematology and Syphilology,
University of Pennsylvania Medical School. (1950).

STAGES OF THE DISEASE

•PRIMARY: 10-90 days after exposure
–enlarged groin lymph nodes, chancre (painless sore) where entered body
•SECONDARY: 2 weeks-2 1/5 months after chancre
–Fever, swollen lymph nodes, sore throat
–Systems affected include the renal system, liver (hepatitis), CNS (headache, meningitis), and musculoskeletal system (arthritis)
–Rough rashes on palms of hands, soles of feet
–Wart-like sores called condyloma latum present in moist areas Brown, David L. MAJ, MC, USA, Frank, Jennifer E. CPT, MC, USA. American Family Physician. “Diagnosis and Management of Syphilis. (2003) 15 July; 68
(2): 283-290. <http://www.aafp.org/afp/2003/0715/p283.html>.
•LATENT (DORMANT)
–May have no symptoms for years
–Either never show symptoms again or enter tertiary
•TERTIARY (LATE) The T. pallidum specific IgM haemagglutination test (TP-IgM-HA) uses red blood cells sensitized with antiserum to human IgM to separate IgM from
–Bacteria attack important organs: heart, eyes, brain. Leads to dementia, paralysis, blindness IgG in serum. IgM is specific anti-treponemal and is captured by adding a second reagent that has red blood cells sensitized to T pallodum antigen.
–Classified into gummatous, cardiovascular, or neurosyphilis 82 serum sample from 82 patients with untreated syphilis, 521 samples from 73 patients with treated syphilis, and 1872 samples form people who
–Complications lead to death did not have syphilis were examined. The sensitivity of the TP-IgM-HA test on patients with untreated primary and secondary syphilis was 97% and
it was 99% specific.
**Neurosyphilis can occur at any stage of the disease There are several tests that cannot differentiate between patients with active syphilis and those who have been adequately treated. Several of these
serological tests must be performed to monitor the effect of treatment and diagnose syphilis. These tests are not standaradised and have non
uniform performance. For these reasons, the treponemal 19S (IgM) diagnostic tests on syphilitic patients is very important. This test is easy to
perform.
DIAGNOSTIC METHODS
Methods
DARK-FIELD MICROSCOPY is a very specific technique used when there is an active chancre or condyloma latum
Results show that four healthy people ecamined by the TP-IgM-HA method gave positive results at a dilution of 1.5, lending a false positive rate of
(only with secondary syphilis) present. It is limited by the number of live treponemes in the lesion and the present of
0-23%. A false negative may occur by competitive inhibition between excess treponemal IgG and deficient treponemal IgM T pallidum’s surface.
non-pathologic treponemes in the lesions. The lesion is cleansed, then abraded with a pad, collected on a glass slide
Excess treponemal IgG disturbs the attachment of the treponemal IgM to the surface of the T pallidum antigen so that a false negative may occur in
and examined under a microscope with a dark-field condenser. It is identifited by its corkscrew morphology. This
reinfected patients. In conclusion, the TP-IgM-HA test can detect treponemal IgM in a short time, has high specificity and sensibility, and is the current most effective tool in
process must be repeated on three different days for confirmation of negative/positive. Primary Stage chancres are obtaining information and monitoring syphilis treatment.
similar to genital herpes, chancroid, furuncle (boil), traumatic ulcers, and venereal warts which may also impede
diagnosis. T. pallidum also has a very complex morphology. The organism easily contorts or bends itself and distorts is
characteristic coils. Positive findings on dark-field examination permit an immediate syphilis diagnosis and this method
detects primary syphilis several days or weeks prior to the appearance of a reactive serologic tests. The lesion may be
altered by some sort of topical or systemic treatment or the lesion could be in the healing stage, preventing the dark-
field sample from being satisfactory.
NONTREPONEMAL TESTS include tests called VDRL and rapid plasma reagin. Syphilis infection leads to non-specific
antibody production that reacts to cardiolipin. False positives occur due to pregnancy, HIV, and other infections. Limited
by decreased sensitivity in early primary syphilis and late. During this time up to 1/3 of patients are nonreactive. After
treatment of syphilis, these tests becomes ‘nonreactive,’ but even with treatment some patients show a low-level
positive nontreponemal tests called a ‘serofast reaction.’ CSF is tested for white blood cell county, protein level, and
reactivity with CSF CDRL tests REFERENCES
TREPONEMAL-SPECIFIC TESTS detect antibodies to the antigenic T.pallidum components. Used to confirm a reactive Sato, T. Kubo, E. Yokota, M. Kayashima, T. Tomizawa. “Treponema pallidum specific IgM haemagglutination test for seriodiagnosis of syphilis. Br
nontreponemal tests. However, the enzyme immunoassay (EIA) test for anti-treponemal IgG are used for screening. J Vener Dis (1984( 60: 364-370.
More difficult, expensive, and often have false positives if individuals have lupus or Lyme disease. These tests remain Kostant, George H. M.D. Biologically False Positive Reaction to Serological Tests for Syphilis. (1956) Vol 14, 325-247. Bulletin of World Health
reactive for life and is not a useful test for assessing treatment efficacy. Organization.
Brown, David L. MAJ, MC, USA, Frank, Jennifer E. CPT, MC, USA. American Family Physician. “Diagnosis and Management of Syphilis. (2003)
15 July; 68 (2): 283-290. <http://www.aafp.org/afp/2003/0715/p283.html>.
DeLamater, Edward D, M.D., Wiggall, Richter H. M.D., Haanes, Merle, M.D. “Studies on the Life Cycle of Spirochetes.” Plates 11 to 14. (1950).
239-246.