Introduction

Syphilis is a chronic venereal disease (i.e. transmitted by sexual contact), caused by a spirochete Treponema pallidum subspecies pallidum. Because the bacteria are extremely vulnerable to drying, successful disease transmission usually requires intimate sexual contact. It can also be transmitted trans-placentally, by kissing, across abraded skin or through infected blood. The disease may remain latent throughout life or it may characteristically proceed through different stages.

Stages of Syphilis
Primary Stage It is characterized by development of a papular lesion - initially at the site of infection. Later on it ulcerates to produce, what is called a chancre. Chancre is usually seen on moist areas of external genitalia but it may also occur at extra genital sites. Chancre develops approximately 3 weeks after initial contact with the diseased person. During the primary stage, bacteria disseminates throughout the body. The chancre heals with or without therapy within 3 to 6 weeks.

Stages of Syphilis (cont)

Secondary stage Two to 10 weeks after appearance of the chancre, lesions develop on skin in form of macules, papules, scales or pustules. Elevated plaques called condyloma lata may also develop on moist areas of the skin. All these lesions may erode and then they become highly infectious. Secondary syphilis lasts for several weeks. Subsequently, the disease enters a latent phase that can last up to 30 years.

Tertiary Stage
If the patient is not treated adequately during early stages of the disease, tertiary syphilis can develop subsequently. Now a days, however it is rarely seen because of administration of early treatment. Three types of manifestations occur in tertiary syphilis:
Cardiovascular Neurosyphilis Benign tertiary syphilis.

Cardiovascular syphilis
It manifests as aortic regurgitation and aneurysm formation.

Neurosyphilis
shows up as cranial nerve palsies, tabes dorsalis and general paralysis of insane.

Benign tertiary syphilis

Appearances of gummas (a form of chronic granulomatous inflammation) characterize benign tertiary syphilis. Gummas can be seen in any organ but are found more commonly in bone, skin and mucous membrane of respiratory tract and mouth.

Aorta is the most frequently involved organ in tertiary syphilis (80 %to 85 % of cases). Involvement of CNS occurs in 5 % to 10% of cases. Less frequently, liver, bones and testes may be involved.

Congenital Syphilis
Congenital syphilis occurs most commonly when the mother is suffering from primary or secondary syphilis at the time of conception. It occurs rarely if the disease has been present for more than 5 years. If not treated, congenital syphilis may cause fetal death in ~ 50% of cases. Initially, if the fetus survives, disease manifestations can appear during infancy (infantile syphilis) or in later life (tardive syphilis). Infantile syphilis is characterized by nasal discharge, desquamative rashes on skin, hepatomegaly or skeletal abnormalities. Tardive syphilis manifests as Hutchinson triad notched central incisors, interstitial keratitis and 8th nerve deafness. Skeletal, neurological and facial abnormalities also occur.

Pathology
Mechanism of infectivity is not known exactly. Although antibodies are formed readily against the bacteria, they are not protective. The organism is not opsonised easily. TH1 responses help to control the infection to a certain extent. Proliferative endarteritis is responsible for many of the pathological changes seen in this disease. Non-gummatous lesions of syphilis are characterized by intense infiltration by plasma cells and endarteritis. Treponema can be easily demonstrated in such lesions by silver stains. Gumma shows central coagulative necrosis, which is surrounded by macrophages, plasma cells and fibroblasts.

Diagnosis
Serology remains the most commonly employed means for diagnosis. Various tests have been developed for detection of treponemal and non-treponemal antibodies. Non treponemal tests are used as a screening method. They are also used to follow the response to therapy. Demonstration of the bacteria by dark field microscopy is useful in active exudative lesions. In oral cavity, commensals like T. microdentium, T. macrodentium and T. mucosum can pose problems in diagnosis. In such cases, specific immuno-fluorescence is useful for differentiation.

Oral Manifestations
Primary Stage: Chancres can form on lips, tongue, palate, gingiva and tonsils. Secondary stage: Red maculopapular rashes occur. In addition, a white colored lesion called mucous patch can be seen on tongue, lip, buccal mucosa and palate. Condyloma latum resembling viral papilloma may occur. Lues maligna is a widely necrotic lesion of syphilis and is also seen in oral cavity, more often in patients with HIV. Tertiary stage: Gummas occur. When seen on palate, they can produce perforation. On tongue, gumma produces interstitial glossitis or leutic glossitis. Many authorities regard oral syphilis as a premalignant disorder. Congenital syphilis: Hutchinson triad is seen. Hutchison teeth consist of mulberry molars, Fourniers molar and Moons molar, in addition to Hutchinsons incisors.

Sabre Tibia

Investigations for Syphilis

Direct demonstration of T. pallidum in exudate collected from chancre or from moist eroded lesions of secondary syphilis by dark field microscopy, direct fluorescent antibody test or PCR. Spirochetes can be demonstrated in tissue specimens by silver staining methods. Non-treponemal tests: Used fro screening, non-specific tests VDRL test Rapid plasma reagin test Treponemal antibody tests: Specific and confirmatory tests. Treponemal Ag based EIA for IgG and IgM Treponema pallidum hemagglutination assay (TPHA) Fluorescent treponemal antibody absorbed test (FTA-ABS)

Treponema pallidum - silver stain