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Clinical, (Histo-) Pathological and Laboratory Studies SYPHILIS AND THE ENDEMIC TREPONEMATOSES CLINICAL, (HISTO-) PATHOLOGICAL AND LABORATORY STUDIES SYPHILIS AND THE ENDEMIC TREPONEMATOSES Clinical, (Risto-) Pathological and Laboratory Studies SYFILIS EN DE ENDEMISCHE TREPONEMATOSEN Klinische, (Risto-) Pathologische en Laboratorinm Studies PROEFSCIIRIFT ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de Rector Magnificus Prof.Dr.C.J.Rijnvos en volgens besluit van het College van Dekanen. De openbare verdediging zal plaatsvinden op woensdag 17 maart 1993 om 13.45 uur door HERMAN JAN HENK ENGELKENS geboren op 16 maart 1963 te Rotterdam ~0 -RUKKE(tU •• PROMOTIECOMMJSSIE: Promotor: Prof.Dr. E. Stolz Copromotor: Dr. J .J. van der Sluis Overige !eden: Prof.Dr. H.G. van Eijk Prof.Dr. A. Meheus Prof.Dr. F.J.W. ten Kate Ajbeelding omslag: uit: Hermans EH. Humor in de Geneeskunde. T.weede dee!. Uitgeverij Het Wereldvenster N. V. te Baarn, 1962. Foto omslag: Medische Faculteit, Erasmus Universiteit Rotterdam (H.J.H.E.) CIP-GEGEVENS KONINKLDKE BIBLIOTHEEK, DEN HAAG Engelkens, Herman Jan Henk Syphilis and the endemic treponematoses: clinical, (histo-) pathological and laboratory studies I Herman Jan Henk Engelkens.·[S.I.:s.n.] (Rotterdam: Universiteitsdrukkerij Erasmus Universiteit). -ill. Proefschrift Rotterdam.-Met lit.opg., reg.- Met samenvatting in het Nederlands. ISBN 90-9005819-2 NUGI 742 Trefw.: treponematosen I geslachtsziekten 4 "We see the light at the end of the tunnel" Apollo Victoria Theatre, London, 1984 aan: B.A. Engelkens, M. Engelkens-Deumens en J osee 5 The printing of this thesis was financially supported by: Boehringer Ingelheim B. V., Alkmaar Brocades Pharma Nederland B.V., Leiderdorp Glaxo B. V., Zeist Leo Pharmaceutical Products B.V., Weesp Pfizer B.V., Rotterdam Schering Nederland B.V., Weesp Schering-Plough B.V., Amstelveen CONTENTS Chapter 1. General introduction 1.1 Treponematoses, important to mankind. 11 1.2 Venereal syphilis. 17 1.3 Syphilis in. the AIDS era. 31 1.4 Endemic treponematoses. Part I. Yaws. 37 1.5 The resurgence of yaws. World-wide consequences. 47 1.6 Endemic treponematoses. Part II. Pinta and endemic syphilis. 53 1. 7 Aspects of Treponema pallidum research. 63 Chapter 2. Purposes of study 75 Chapter 3. Clinical aspects of syphilis and yaws 3.1 Recent epidemiological aspects of syphilis. 77 3.2 Yaws in West Sumatra, Indonesia: clinical manifestations, serological findings and characterisation of new Treponema isolates by DNA probes. 85 3.3 Early yaws, imported in The Netherlands. 95 7 Chapter 4. Light microscopy: syphilis and yaws (patient material) 4.1 Early yaws: a light microscopic study. 101 4.2 Primary and secondary syphilis: a histopathological study. 107 4.3 The localisation of treponemes and characterisation of the inflammatory infiltrate in skin biopsies from patients with primary or secondary syphilis, or early infectious yaws. 115 Chapter 5. Experimental treponemal infection (syphili.s and yaws) 5.1 Rapid in vitro immobilisation of purified Treponema pallidum (Nichols strain), and protection by extraction fluids from rabbit testes. 131 5.2 The influence of different sera on the in vitro immobilisation of Percoll purified Treponema pallidum, Nichols strain. 141 5.3 The importance of different components of normal human serum and lysozyme in the rapid immobilisation of purified Treponema pallidum, Nichols strain. 149 5.4 Ultrastructural aspects of infection with Treponema pallidum subspecies penem.te (Pariaman strain). 165 8 Chapter 6. Discussion 173 Chapter 7. Summary 181 Chapter 8. Samenvatting 189 List of publications 198 Acknowledgements 203 Dankwoord 205 Curriculum vitae 207 9 CHAPTER 1. GENERAL INTRODUCTION TREPONEMATOSES, IMPORTANT TO MANKIND Herman Jan H. Engelkens M.D., and Ernst Stolz M.D. Submitted for publication II CHAPTER 1. GENERAL INTRODUCTION 1.1. TREPONEMATOSES, IMPORTANT TO MANKIND Treponemal diseases important to mankind are sexually transmitted syphilis and the endemic nonvenereally transmitted treponematoses (yaws, pinta, and endemic syphilis). Historically, the most important disease caused by treponemes is syphilis. During the last few decades, yaws, endemic syphilis and pinta have been largely ignored. These diseases, however, have not been eradicated (1-10). The causative agents of these chronic bacterial diseases belong to the order Spirochaewles, the family Treponemataceae and the genus Treponema. The order Spirochaetales comprises the families Treponemataceae and Spirochaetaceae. The Treponemataceae can be subdivided in: the genus Treponema (pathogenic, saprophytic, and special strains, for example the Nichols strain), the genus Borrelia and the genus Leptospira, respectively (11). Species pathogenic for humans are enumerated in Table !. Hitherto, it has not been possible to cultivate these species in artificial media or in tissue culture, which greatly hampers research (12, 13). Moreover, it has not been possible to distinguish the causative agents of venereal syphilis and the endemic treponematoses routinely by morphological or immunological criteria or by DNA hybridisation studies. DNA homology studies (14) appear to support the view that syphilis and yaws are possibly caused by the same organism (''unitarian" theory) (15). Shared antigens give rise to cross-reactive antibodies common to all treponema! diseases, which so far precludes a differential diagnosis on the basis of serological tests. However, clinical and geographical differences between the treponematoses do exist. T.pallidum, a Gram-negative bacterium, is a microaerophile, which requires low concentrations of oxygen for optimal in vitro survival. This slender, close-coiled, regular spiral-shaped organism, 6-15 micrometer in length, with an average breadth of 0.15 micrometer, with a variable number of regular coils, has a wavelength of approximately 1 micrometer and an amplitude of 0.2 to 0.3 micrometer (13). At each end of the protoplasmic cylinder, periplasmic flagella (axial filaments, axial fibrils, endoflagella) are present within the outer membrane, which are assumed to play a part in locomotion. Cytoplasmic fibrils (microtubules) extend along the inner layer of the cytoplasmic membrane, below the 13 periplasmic flagella. The outer membrane resembles the outer membrane of Gram-negative bacteria. A rotary motion with flexion and back-and-forth motion is considered characteristic. The best method to visualise the microorganism is with darkground illumination or phase contrast microscopy (13,16-18). In the following paragraphs some aspects of the clinical manifestations and research of venereal syphilis are described. Separately some of the current problems with venereal syphilis due to the AIDS epidemic are mentioned. After this paragraph the endemic treponematoses are reviewed, with special emphasis on the current resurgence of yaws. Table 1 Causative organisms and names of treponematoses important to mankind. Treponema pallidum subspecies pallidum syphilis, sifilis, lues, lues venerea, Great pox, Morbus Gallicus Treponema pallidum subspecies penenue yaws, framboesia tropica, pian, bouba, buba, paru, parangi Treponema pallidum subspecies endemicum endemic syphilis, nonvenereal syphilis, bejel, fujal, loath, radesyge, button scurvy, sibbens, dichuchwa, njovera, skerljevo, rewan, frenjak Treponema carateum pinta, carate, azul, mal del pinto, cute, cativa 14 References 1. Perine PL, Hopkins DR, Niemel PLA, St.John RK, Causse G, Antal GM. Handbook of Endemic Treponematoses: Yaws, Endemic Syphilis and Pinta. World Health Organization, Geneva, 1984. 2. Programme for the Control of the Endemic Trepnnematoses. World Health Organization. VDT/EXBUD/87.1; August 1987. 3. Luger A, Meheus A. Drastische Ausbreitung endemischer Treponematosen. Alarming spread of endemic treponematoses. Z Hautkr 1988;63:463-464. 4. Meheus A, Schryver A de. Les treponematoses endemiques: un danger resurgissant. Ann Soc Beige Mect Trop 1988;68:281-284. 5. Engelkens HJH, Stolz E. Framboesia tropica en andere endemische treponematosen. In: Import Dermatologie. Faber WR, Naafs B (eds). Hoofdstuk 6. Nieuwegein: Glaxo, 1991. pp 107-112. 6. Engelkens HJH, Jubianto Judanarso, Oranje AP, Vuzevski VD, Niemel PLA, Sluis JJ van der, Stolz E. Endemic Treponematoses. Part L Yaws. Int J Dermatol 1991;30:77-83. 7. Engelkens HJH, Niemel PLA, Sluis JJ van der, Stolz E. The resurgence of yaws. World-wide consequences. Int J Dermatoll991;30:99-101. 8. Engelkens HJH, Niemel PLA, Sluis JJ van der, Stolz E. Framboesia tropica, terug van weggeweest. Ned Tijdschr Dermatol Venereol 1991;1:14-20. 9. Engelkens HJH, Niemel PLA, Sluis JJ van der, Stolz E. Endemic Treponematoses. Part II. Pinta and endemic syphilis. Int J Dermatol 1991;30:231-238. 10. Engelkens HJH, Niemel PLA, StolzE, Meheus A. Klinische aspecten van framboesia tropica, endemische syfilis en pinta. Ned Tijdschr Dermatol Venereol 1992;2:115-121. 11. Smibert RM. Genus III Treponema Schaudinn 1905, 1728~. In: Bergey's Manual of Systematic Bacteriology. (Krieg NR, Holt JG, eds). Baltimore: Williams & Wilkins, 1984;49-52. 12. Turner TB, Hollander DH. Biology of the Treponematoses. WHO Monograph Series, no. 35. World Health Organization, Geneva, 1957. 15 13. Musher DM. Biology of Treponema pallidum. Chapter 18. In: Sexually Transmitted Diseases. Holmes KK, M:l.rdh PA, Sparling PF, Wiesner PJ (eds). Second edition. New York: McGraw-Hill, 1990, pp 205-211. 14. Miao RM, Fieldsteel AH. Genetic relationship between Treponema pallidum and Treponema pertenue, two noncultivable human pathogens. J Bacteriol
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