Dr.

Violeta Melinte
Objectives
To learn which are the endemic treponematosis and
their etiology
To have an idea about their distribution and
prevalence
To recognize the diseases by their symptoms
To be able to treat the patients and contacts
Introduction
Treponematoses
Caused by treponemes (“trepo”= turn;
“nema”= thread)
 Belong to the Spirochetaceae
 Cause 4 different, chronic, exclusively human

diseases
 There is no animal reservoir
Introduction
Treponemes
 Cannot be cultivated in vitro (exc. T. pallidum)
 Morphologically they cannot be distinguished one from

another – all give positive results on serological tests

 Sensitive to penicillin
Classification of Human Treponema
Non-pathogenic Pathogenic
 T. denticola  T.pallidum pallidum
 T. macrodenticum (syphilis)
 T. orale  T.pallidum endemicum

Conditionally (bejel)
 T.pallidum pertenue (yaws)
pathogenic
 T.carateum (pinta)
 T. vincentii
Endemic treponematosis
1. Non-venereal syphilis or Bejel. (T.p. endemicum)
2. Framboesia or Yaws or Pian (T.p. pertenue)
3. Pinta (T. carateum)
Non-venereal Syphilis, Bejel, Njovera
or Treponarid
Caused by T. endemicum
Occurs in foci (dry, hot climates) in sub-Saharan
Africa, in the Middle East, Australia and in Asia
At present the disease has become rare
Turkey
Syria
Iran
Iraq
Saudi Arabia
Niger
Mali
Senegal Burkina
Transmission
NOT via sexual intercourse, but through human-
to-human contact or contaminated objects
As a rule: non-venereal or
endemic syphilis occurs in
childhood
The oral mucosa = the most
important source of infection
Children probably acquire immunity against T.
pallidum before puberty and are protected
against later venereal syphilis
Pathogenesis
We know little about it!
Chronic bacterial infection
Early in the course of infection – spread
hematogenously – w/o Rx → secondary and late
manifestations (rare)
 Regional lymphadenopathy occurs
Little if any evidence of cardiovascular
involvement in late infection, neurologic
sequelae or transmission to children born to
infected, untreated mothers!
Symptoms
Early stage = 5 years
Incubation period = 9-50 days
Oral mucosal lesions (primary white ulcers)
Skin lesions (intermittently)
Osteitis/ periosteitis
Symptoms
Delayed lesions (rare cases)
“Gangosa”= destruction of the nose, lip and palate, and
lead to severe mutilation
 Framboesia or Yaws or Pian
Caused by T. pallidum pertenue
Occurs in (warm, humid, tropical areas) Africa,
Central and South America, some islands in
Southeast Asia, in poor isolated rural communities
Indonesia
Papua New
Solomon
Guinea
Islands

Gana Central African

Togo Republic
Cote d’ivoire
Cameroon

Congo
 Framboesia or Yaws or Pian
  Yaws is believed to have originated in
tropical areas of Africa, and spread to other
tropical areas of the world via immigration
and the slave trade.
 The latter is likely the way it was introduced
to Europe from Africa in the 15th century.
 The first unambiguous description of yaws
was made by the Dutch physician Willem
Piso (1611-1678).
 Yaws was clearly described in 1679 among
African slaves by Thomas Sydenham (1624-
1689) in his epistle on venereal diseases,
although he thought that it was the same
disease as syphilis.
 The causative agent of yaws was discovered
in 1905 by  Aldo Castellani in ulcers of
patients from  Ceylon.
 (wikipedia)
Symptoms – primary lesion
Skin and skeleton affected
Wart-like skin lesions with the appearance of
strawberries (yaw = strawberry)
Primary lesion – extragenital
An initial “parent” lesion with various satellite lesions
If the hypertrophic epidermis is removed, an exudate
with a crust forms
Heal w/o scars
Residual skin discoloration
There is no deep ulceration
Swollen lymph nodes
Symptoms – secondary lesions
w/o Rx secondary widespread
lesions (macular/
papillomatous) form
Flare-ups which last wk/mo or 3-
5 years (w/o Rx)
Malaise
Joint pain
Fever
On the palmes and soles –
hyperkeratotic and itchy skin →
painful fissures → “crab gait”
Secondary lesions
Nodules – mainly around the joints
Hard, loose from the skin and the deep
tissue
Elbow, wrists, ankles, sacrum
DD: onchocerciasis
Gumma ~ subcutaneous cold abscess
Gangosa
Caused by gumma
DD: mucocutaneous leishmaniasis;
deep mycosis; leprosy
Secondary lesions
• Sometimes – involvement of the skeleton
• Chronic inflammation of the bones of the fingers ≠
acute dactylitis in sickle cell anaemia

Chronic inflammation Acute inflammation

With Rx few lesions or
limited hyperkeratosis
Symptoms – late-onset framboesia
Occurs in 10% of patients (after
> 5 years)
Sporadic “gummata” = deep
crater-like ulcer,
Heal with the formation of
scars covered by a thin skin
Treponemes = rare, therefore
not particularly infectious
Contracture of the affected
limb
Chronic osteitis and periostitis
→ bent legs ( sabre tibiae)
 Pinta
Caused by Treponema carateum
Limited to a few foci in Central America,
Colombia, Mexico.
Less frequent
Symptoms
Only skin affected

Primary lesion = scaling papule,

often itchy
Appears ten days after exposure
Increase in size over the following 2-
3months to a flat scaly plaque
A few months – years later = mild,
itchy, maculopapular rash develops
The spots – random distributed
Abnormal, changing pigmantation
(blue → purplish → brown)
Symptoms
These lesions still contains treponemes
Later – atrophic and fade
Discoloration remains after treatment is administered
Main problem = cosmetic
There are no ulcers or bone lessions
DD: vitiligo

Pinta does not protect against the other

treponematoses!
Overview
Diagnosis
T. pallidum treponemes cannot be cultured on
synthetic media

Direct methods
Dark-field microscopy on
a wet preparation of
material obtained from
early lesions
Fluorescent antibody tests
– distinguish pathogenic
from saprophyte
treponemes
Low sensitivity
Diagnosis
Biopsy specimen – skin pathology using silver
impregnation technique
Cannot differentiate them by their shape
Early Bejel: granulomas may be present
Yaws: epidermal hyperplasia, with collection of
neutrophils and typical plasmocytic dermal infiltrate
Pinta: no ulcer formation;
 Early lesion – loss of melanin in basal cells;
 late – stage – epidermal atrophy and melanophages in dermis
Diagnosis
Molecular methods (PCR)
Distinguish nonvenereal T. pallidum
subspecies
Indirect methods
Serological tests
Cannot distinguish between
endemic treponematoses and
syphilis
The antibody response is often
detectable after one – 3 wk of
infection
Clinical identification of ET has important implications
regarding diagnostic approach, case management and
prevention strategies.
Differential diagnosis
Treatment
Benzathine penicilin
Single IM adm of 1.2 or 2.4 million units
Three weekly adm – better in the late stage
Cure rates = 97%
Tetracyclines, doxycycline,
erythromycin for 14 days = alternatives

Plastic reconstructive surgery – often

needed to repair mutilations
Prevention

All individuals who have been in contact with

the patient should be treated
2012 – one dose of oral azithromycin in areas
known to harbour yaws
Resurveyes every 6 moths

The eradication of yaws has been followed by

an increase in veneral syphylis!
Overview
Yaws Bejel Pinta
Exercises
1. Togo. A patchy depigmentation, following a
wart-like lesion, over the tibia is suggestive for:
A. Bejel
B. Yaws
C. Pinta
D. Onchocerciasis
Exercises
2. Ghana. A 9-year-old girl has several papulo-
squamous skin lesions on her arm. Darkfield
microscopy reveals numerous treponemes and
the serology for syphilis is positive. Radiography
of the fibula and tibia reveal periostitis. Her
mother is negative for syphilis. Is this report
compatible with:
A. Yaws
B. Pinta
C. Syphilis
D. None of the above
Exercises
3. Sudan. A hypopigmentation skin spot suggest:
A. Pinta
B. Vitiligo
C. Tinea versicolor
D. None of the above
Exercises

4. Iraq. A 9-years old boy presents with an white

ulcer on his oral mucosa and a transitory rash.
This is suggesting for:
A. Yaws
B. Bejel
C. Oral herpes ulcer
D. Aphtous ulcer
Exercises
5. Kenya. A child of 3 years of age suddenly has
painfully swollen hands and feet. You think that
could be:
A. Yaws
B. Pinta
C. Acute dactylitis in sickle cell anaemia
D. None of the above
Exercises
6. Guyana. A 25-year-old man complains of
persistent painful fissures on his hand and feet.
The skin is thickened and chapped. You think
this could be:
A. Yaws – primary lesions
B. Bejel
C. Yaws – secondary lesions
D. Pinta