Acute primary syphilitic infection in a Caucasian male
Acute primary syphilitic infection in a Caucasian male |
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Key words: primary syphilis, diagnosis, epidemiology, and treatment.
Introduction
Sexually acquired syphilitic infection is caused by the spirochaete bacteria Treponaema pallidum. There are reports of recent increases of infectious syphilis in the United Kingdom (1). Between 1991 and 2001, infectious syphilis increased by 204% in England, Wales and Northern Ireland (2). The increase has been in both the homosexual and heterosexual sex groups. There have also been reports of outbreaks in various cities in the United Kingdom - Bristol (3), Manchester (4) and Brighton (5). The various outbreaks have been associated with crack cocaine use, commercial sex workers and men who have sex with men (2). The natural history of the infection can be classified into primary, secondary, latent (early and late) and tertiary (6).
Case Report
A 43-year-old man presented at the Genito-Urinary Medicine Clinic with a painless penile ulcer. Past history revealed that he was treated for gonococcal urethritis about one year earlier. At that time, his serological tests for syphilis were negative. He smoked 20 cigarettes a day and drank about 55 units of alcohol in a week. He did not use any drugs. The last time he had sexual intercourse was 3 weeks ago in Thailand with a prostitute prior to attending the clinic.
Physical examination revealed that the chest and abdomen were normal and genital examination showed a small penile ulcer of about _cm diameter was present (fig 1). The ulcer had indurated edges and was non-tender.
Screening for other sexually transmitted infections - gonorrhoea and chlamydia revealed negative results. Serology for HIV was reported negative. Syphilis serology was positive with VDRL at 1:4, TPHA at less than 1:80 with positive IgM ELISA and FTA Abs. A diagnosis of primary syphilis was made. He was treated with a course of Bicillin injections. Although regular follow-up appointments were arranged, he moved to another area of the country.
Figure 1: Primary chancre
Discussion
The incidence and prevalence of syphilis varies in different parts of the world, the highest being in developing countries (see table). The consequences of untreated acute infection in men may result in syphilitic orchitis and sterility. However the consequences in women especially in pregnancy include abortion, premature delivery, stillbirths and neonatal deaths. In the surviving children, there may be stunted growth; snuffles and stigma of congenital syphilis like Hutchinson's teeth or depressed nasal septum. In order to decrease such devastating effects, serological tests for syphilis have been incorporated as part of antenatal care. This routine practice has been calculated and was found to be cost effective (7).
Syphilitic infection is classified into primary, secondary, latent (early and late) and tertiary. The natural history of this infection is variable. Classification into types depends on time interval since acquisition of infection - early or late. The early types (within two years): primary, secondary and early latent, are infectious while the late types: late latent and tertiary are not infectious (6). This patient was diagnosed with primary syphilis.
The diagnosis of syphilis can be made from a detailed sexual history and clinical examination. Unprotected sexual intercourse with a prostitute in
an area with high prevalence of syphilis is strongly suggestive especially in a person who then develops a painless genital ulcer. Also dark ground microscopy of serum from the ulcer may reveal spirochetes. More commonly, the diagnosis is made by serology. Serological tests for syphilis are divided into treponaemal and non-treponaemal tests.
Following a diagnosis it is necessary to start treatment with appropriate antibiotics. Penicillin by intramuscular injections is often the first choice in people who are not allergic to this medicine. There are other alternatives that can be taken by the oral route. It is also important to trace the sexual contacts of the index patient.
Syphilis is an old disease that is still present (8) despite past predictions of its demise! Although the prevalence is low in the UK, travels to several parts of the world on holidays or business may expose travellers to this infection especially if they participate in unsafe sexual practices. Vigilance is the watchword.
References
1. Fenton K, Nicoll A, Kinghorn G. Resurgence of syphilis in England: time for more radical and nationally co-ordinated approaches. Sex Transm Inf 2001; 77: 309-10.
2. PHLS, DHSS&PS and the Scottish ISD (D)5 Collaborative Group. Sexually Transmitted Infections in the UK: New episodes seen at Genitourinary Medicine Clinics, 1991 to 2001. London: Public Health Laboratory Service, 2002.
3. CDSC. Syphilis in Bristol 1997-8: an update. CDR Wkly. 1998; 8:413.
4. Lacey HB, Higgins SP, Graham D. An outbreak of early syphilis: cases from North Manchester General Hospital. Sex Transm Inf. 2001; 77: 311-313.
5. Poulton M, Dean GL, Williams DI, Carter P, Iversen A, Fisher M. Surfing with spirochaetes: an ongoing syphilis outbreak in Brighton. Sex Transm Inf 2001; 77: 319-21.
6. Egglestone SI, Turner AJL (PHLS Syphilis Serology Working Group). Serological diagnosis of syphilis. Commun Dis Public Health 2000; 3: 158-62.
7.Connor N, Roberts J, Nicoll A. Strategic options for antenatal screening for syphilis in the United Kingdom: a cost effectiveness analysis. J. Med. Screen 200; 7: 7-13.
8. Doherty L, Fenton KA, Jones J et al. Syphilis: old problem, new strategy. BMJ 2002; 325: 153-6.
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