QuestionSBA
QuestionChoice
The MMR vaccine protects against measles, mumps, and rubella. Congenital rubella syndrome is a good differential as this can cause sensorineural deafness. However, there is no mention of the other features of CRS such as cataracts, a blueberry muffin rash, or heart defects (typically pulmonary stenosis).
10017307
b
MMR Vaccine
QuestionChoice
Ganciclovir or aciclovir may be used in maternal HSV infection.
10017310
e
Ganciclovir
QuestionChoice
This is used in the treatment of toxoplasmosis in pregnancy. Toxoplasmosis causes chorioretinitis, intracranial calcifications, and hydrocephalus. Treatment for toxoplasmosis in neonates includes sulfadiazine, pyrimethamine, and folate.
10017309
d
Spiramycin treatment
QuestionChoice
The diagnosis is congenital syphilis, presenting with sensorineural deafness and a desquamating rash. Other features include Hutchinson's teeth, interstitial keratitis, and ostrochondritis visible on x-ray.
10017306
a
Benzathine benzylpenicillin
QuestionChoice
This is advice prevent neonatal listeriosis, as listeria can be present in raw (unpausturised) milk. The main presentations are neonatal sepsis and meningitis.
10017308
c
Avoidance of unpasturised dairy
QuestionComment
I swear I knew more in 3rd year than now 3 days out of my y5 finals
37597
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you got this! these questions r just shit xx
38407
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evieeee
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Epidermis Flutter
QuestionComment
Why can't this be congenital varicella 
48462
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yes this is what I thought too!
50932
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Suture Myopathy
QuestionComment
palmoplantar rash
58003
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MC
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Edema Dominant
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a point gained rather than 2 dropped on this one for me

61437
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Gabriel Magalhaes
Concept
Chapter
# Summary
  
  
Syphilis is a sexually transmitted infection that occurs in three distinct stages: primary, secondary, and tertiary. The primary stage presents with painless solitary lesions often located in the genital or perianal region. Secondary syphilis typically features a symmetrical maculopapular rash, and lymphadenopathy. Tertiary syphilis, occurring in about a third of untreated patients, may present with gummatous disease, cardiovascular complications, and neurological implications. Diagnosis often involves serological testing, and management primarily includes penicillin-based therapy.
  
  
# Definition
  
  
Syphilis is a sexually transmitted infection caused by the spirochete bacterium Treponema pallidum. It is primarily transmitted through direct contact with syphilis sores or rash during vaginal, anal, or oral sex. 
  
  
# Epidemiology
  
  
Syphilis has a global prevalence with varied incidence based on geographical regions and specific population subsets. High-risk populations include men who have sex with men, sex workers, and individuals with multiple sexual partners.
  
  
# Aetiology
  
  
Syphilis is caused by the bacterium *Treponema pallidum*, which is transmitted through direct contact with syphilis sores during sexual activity. It can also be transmitted from an infected mother to her unborn child, resulting in congenital syphilis.
  
  
# Signs and Symptoms
  
  
- Primary syphilis: Characterised by the appearance of a single painless lesion, known as a chancre, typically at the site of inoculation. The lesion is round, with an indurated base, and heals spontaneously within 3-8 weeks. Painless regional lymphadenopathy may also be present.
  
- Secondary syphilis: Manifests 4-10 weeks post-primary infection with a symmetrical maculopapular rash, often involving the palms, soles, and face. Mucosal ulcers and lymphadenopathy are common, and some patients may experience malaise, fever, hepatitis, glomerulonephritis and neurological complications.
  
- Tertiary syphilis: This stage may occur 20-40 years after the primary infection in untreated patients. It presents with gummatous disease, cardiovascular complications (aortitis, arteritis, aortic valve regurgitation), and neurological complications (meningovascular syphilis, paresis, dementia, tabes dorsalis, Argyll-Robertson pupil).
  
- Congenital syphilis: Resulting from the transmission of the Treponema pallidum bacterium from an infected mother to her fetus during pregnancy, presents shortly after birth or later in infancy with a rash on the palms/soles of feet, mucous patches/lesions in the mouth/nose/genitals, fever, hepatosplenomegaly, anaemia, bone developmental abnormalities ('saber shins'), neurological sequalae (seizures, developmental delay).
  
# Differential diagnosis
  
Differential diagnoses for **primary syphilis** include:
  
- Chancre (initial lesion): genital herpes, lymphogranuloma venereum, malignancy, Behcet's syndrome
- lymphadenopathy: infection, systemic diseases, malignancy
  
Differential diagnoses for **secondary syphilis** include:
  
- Rash: primary HIV infection, viral exanthem, drug eruptions
- Lesions on oral mucosa: malignancy, infectious mononucleosis, aphthous ulcers
  
Differential diagnosis for **tertiary syphilis**:
  
- Dementia
- Psychiatric conditions
- Diseases affecting mobility
- Chronic granulomatous lesions
  
# Investigations
  
**Dark field microscopy** is used to directly observe *T. pallidum* in samples from primary lesions or secondary rash. However, it should not be used for oral lesions due to the presence of commensal treponemes which may cause a false positive result.
  
**PCR** testing is used for oral lesions. This detects genetic material, so can differentiate between *T. pallidum* and other commensals.
  
**Serological tests** can be used for screening, diagnosis confirmation and treatment monitoring.
  
- **Treponemal** tests such as enzyme immunoassays (EIA) and chemiluminescent assays (CLIA) detect treponemal IgG and IgM. It is most sensitive for secondary, early latent and late latent stages, and are the recommended **screening tests**. These tests **remain positive even after treatment** so cannot be used for monitoring or re-infection.
  
- **Non-treponemal tests** such as Venereal Diseases Research Laboratory (VDRL) also have higher sensitivity for secondary and early latent stages of syphilis, but is less sensitive in late stage disease. Titres decline with effective treatment, so it is useful for **monitoring treatment efficacy**.
  
  
- **False negatives** may occur early in the disease, and non-treponemal tests may be negative in late-stage disease, or with HIV co-infection.
  
- **False positives** can occur with non-treponemal tests due to viral infections, malignancy, autoimmunity, older age, IVDU and pregnancy.
  
To diagnose syphilis from screening serology, a repeat test must be performed using a different method.
  
Additional investigations to consider are:
  
- **Virology** swabs of lesions to exclude HSV
  
- Screening for other **STI's**
  
- **CSF** examination: Should be considered in tertiary syphilis to evaluate for CNS involvement.
  
  
# Management
  
  
Syphilis is primarily managed with antibiotics:
  
  
- Primary, secondary, and early latent syphilis: A single dose of intramuscular penicillin G (benzathine benzylpenicillin) is the first-line therapy.
  
- Tertiary and late latent syphilis or syphilis of unknown duration: Requires a longer course of intramuscular penicillin G for 2-3 weeks.
  
- Neurosyphilis: Treated with intravenous penicillin G for 10-14 days.
Patients allergic to penicillin may be given doxycycline or tetracycline.
  
A Jarisch-Herxheimer reaction may occur on treatment initiation. This is an acute febrile illness which is self-resolving within 24 hours. Generally, patients can be reassured and given antipyretics for the fever. In late syphilis or during pregnancy, specialist advice should be sought.
  
Patients should be referred to a GUM clinic for partner notification and screening for other STIs.
  
 

# NICE guidelines
  
[NICE CKS guidelines on syphilis](https://cks.nice.org.uk/topics/syphilis/)
  
# References
  
[Patient.info: Syphilis](https://patient.info/doctor/syphilis-pro#syphilis-treatment-and-management)
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Syphilis
Topic
58
Infectious Diseases
16005
Benzathine benzylpenicillin is the first-line treatment for congenital syphilis
A neonate is found to have a hearing impairment after being referred for an auditory brainstem response test. There is a desquamating rash on the feet and palms.

Which intervention would have prevented the vertical transmission of the infective agent causing these symptoms?
a