Diagnosis of Syphilis: Clinical and Laboratory Problems Syphilisdiagnostik: Klinische Und Labormedizinische Problematik
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1058 Academy DOI: 10.1111/j.1610-0387.2006.06072.x CME Diagnosis of syphilis: Clinical and laboratory problems Syphilisdiagnostik: Klinische und labormedizinische Problematik Stephan Lautenschlager Department of Dermatology, City Hospital Triemli, Zurich, Switzerland Section Editor Prof. Dr. Michael Landthaler, Regensburg Introduction Due to HIV prevention campaigns there was a sharp decline in the incidence of classical sexually transmitted diseases in many Western European nations at the end of the 1980s and beginning of the 1990s. Also, the initially high mortality of AIDS contributed to the reduction of syphilis cases. After a dramatic increase of syphilis in the countries of the former Soviet Union since 1994, outbreaks have been registered in Great Britain, Ireland, France, Holland and Norway [1]. Similar trends can be observed in Germany and Switzerland [2–4]. The increase in syphilis observed for years continued in 2004 [2, 4] with 3,345 newly diagnosed cases being reported in Germany, an incidence rate of 4.1 cases per 100,000 population, a 14 % increase compared to 2003 [2]. Syphilis in Europe is observed mainly in large cities among young adults. Homosexual males in particular are affected, many of whom have known HIV infections [5]. The HIV co-infection rate varies greatly depending on country but ranges up to 50 %. Most recent trends also show a rise in syphilis among heterosexual men [2]. Particularly worrisome is that the rise in syphilis correlates with the renewed increase of sexually acquired HIV infection, which has risen by 20 % between 1995 and 2000 [1]. The return of syphilis presents a diagnostic challenge for young physicians who are often not familiar with the clinical presentation, diagnostic approach or treatment. We must re-familiarize ourselves with the diverse clinical features of syphilis [6] and the complex diagnostic approach to this disease [7, 8]. It is especially crucial to recognize the diverse clinical symptoms of each individual stage and to keep them in mind in considering differential diagnoses. The key to diagnosis is examination of the entire skin surface and its appendages, the anogenital region, the oral mucosa and regional lymph nodes while considering possible general and neurologic symptoms. The peculiarities in simultaneous HIV To stop the current spread of syphilis, co-infection must especially be considered. To stop the current spread of syphilis, we we must once more become familiar must once more become familiar with the complex clinical presentation and diagnostic with the complex clinical presenta- approach. Rapid diagnosis and treatment are essential to prevent further spread, late tion and diagnostic approach. complications, transfer to the newborn and may represent a key to reducing new sexually acquired HIV infections. Definition of the stages of syphilis The course of syphilis – caused by Treponema pallidum – is characterized by stages, where symptomatic periods are interrupted by sometimes very long asymptomatic phases (latent syphilis). Early syphilis comprises primary and secondary syphilis as well as early latent syphilis with a latency of < 1 year (definition of the Centers for Disease Control (CDC), Atlanta) or < 2 years (definition of the WHO) after infection. Late syphilis consists of late latent, tertiary and – depending on nomenclature – qua- ternary syphilis or metalues (Table 1). This classification in stages is a simplification which is not always applicable to the diverse clinical presentation. JDDG |12˙2006 (Band 4) © The Authors • Journal compilation © Blackwell Verlag, Berlin • JDDG • 1610-0379/2006/0412-1058 Academy 1059 Table 1: Definition of the stages of syphilis. Stage Duration Manifestations Incubation period 3 weeks (9–90 days) Ulcer at the site of Primary syphilis 6 weeks inoculation, regional infection Syphilids, general symptoms, Secondary syphilis Months further organ manifestations, hematogenous dissemination Early latency: < 1 year (CDC) < 2 years (WHO) Seropositivity, no clinical Latent syphilis Late latency: symptoms, spontaneous > 1 year (CDC) healing (two-thirds) > 2 years (WHO) Tuberoserpiginous syphilids, gummas in multiple organs, Tertiary syphilis Years cellular reaction in face of few pathogens Metasyphilis, quaternary syphilis Years Tabes dorsalis, general paresis Meningovascular syphilis (symptomatic/asymptomatic), Years, possible in stage basilar meningitis, acute Neurosyphilis II-IV transverse dorsal myelitis, cerebral gummas, general paresis, tabes dorsalis Early latent syphilis is defined as < 1 year according to the CDC and < 2 years Early latent syphilis is defined as according to the WHO. < 1 year according to the CDC and < 2 years according to the WHO. Clinical problems in syphilis diagnosis Primary syphilis The incubation period is 3 weeks, but can be as long as 3 months. After an average The incubation period is 3 weeks, but incubation period of 3 weeks (9–90 days) a dark red macule or papule develops at the can be as long as 3 months. site of inoculation and rapidly progresses to an erosion (Figure 1). Size and depth of the defect increase over the course of one to two weeks until a typical, indolent, well-circumscribed, flat ulcer with a yellow coated base and an indurated, non-undermined wall results [9]. This is followed by edema and bilateral asymptomatic lymphadenopathy. Classically, the chancre is located in the coronal sulcus in males and on the labia minora in females. Principally, primary syphilis may present with atypical morphology, symptoms and locations causing diagnostic difficulties, so that only 30 to 40 % of patients in the primary stage are diagnosed [4, 10]. Only 30 to 40 % of cases are Only 30 to 40 % of cases are diagnosed in the primary stage of syphilis. diagnosed in the primary stage of syphilis. a) Atypical morphology and symptoms The clinical diagnosis of syphilis in its primary stage is unreliable because of possible The clinical diagnosis of syphilis in its atypical presentations. DiCarlo and Martin [11] demonstrated that in 446 males with primary stage is unreliable because genital ulcer the classical, indurated and indolent syphilitic chancre was present in of possible atypical presentations. only 31% and that clinical features in the majority could not be differentiated from herpetic ulcers or from chancroid [11]. In a recent outbreak in Manchester, many JDDG |12˙2006 (Band 4) 1060 Academy Figure 1: Early eroded papule in primary syphilis. In industrialized lands, differentiation patients exhibited multiple, painful genital ulcers resembling genital herpes [12]. In from genital herpes is most important. industrialized lands, differentiation from genital herpes is important. Sometimes the chancre is totally absent or multiple ulcers occur or simply a nodular lesion is present. Examination of lymph nodes does not always aid clinical diagnosis, as the lympha- denopathy may be painful as in other infections [11]. The most important differen- tial diagnoses of genital ulcers are listed in Table 2. b) Atypical location Just as clinical presentation can be non-specific, so can the location of the chancre cause it to be overlooked. This is especially true for anal or rectal ulcers in homosexual Atypical locations as well as hidden males and vaginal or cervical ulcers in females. Atypical locations as well as hidden chancres (cervical or rectal forms) chancres (cervical or rectal forms) complicate diagnosis in primary syphilis. In rectal complicate diagnosis in primary ulcers, lymphadenopathy occurs in para-aortal and not in inguinal nodes, so that it is syphilis. not noticed. In a recent study in England, 20 % of homosexual patients with syphilis had an anal chancre [13]. The anal chancre tended to be located towards the peri- neum. Sometimes only swelling, induration (edema indurativum) (Figure 2) or fissu- res are present, making differentiation from hemorrhoids, anal fissures and other infections, e.g. herpes simple, necessary [14]. Examination of the anal canal – preferably with a proctoscope – should be part of the work-up for sexually transmit- Proctoscopy should be a routine part ted infections. Extragenital chancres are most frequent at anal or oral sites, but can of the work-up for sexually transmitted principally occur at any muco-cutaneous site coming into contact with an infectious infections. lesion. The incidence of extragenital chancres is reported at 5–14 % [6, 15–17]. Ab- out two-thirds occur in or around the mouth after unprotected oral sex. Among ho- mosexual syphilis patients, 12.5 % of chancres are oral [13]. Due to the increasing popularity of oral sex in recent years – in part because it supposedly is a safer-sex prac- Two-thirds of extragenital chancres tice – an increase of oral chancres has been observed. Case reports describe syphilitic are oral or perioral. chancres of fingers, mammillae, eyelid, arm, toe or presternal region (Figure 3) [6, 15, 18–20]. Decades ago extragenital chancres were no rarity; Fournier describes 642 from head to toe in his textbook [21]. Any indurated ulcer with regional lymphadenopathy An ulcer with lymphadenopathy should lead one to consider syphilis. An ulcer with lymphadenopathy should, regard- should, regardless of site, make one less of site, make one think of syphilis. Differential diagnosis of extragenital lesions think of syphilis. includes tularemia, cat scratch disease, sporotrichosis, mycobacteriosis, leishmaniosis, staphylococcal lymphangitis and neoplasia. A clinical diagnosis in primary syphilis is not reliable due to