Pathophysiology

Syphilis is a complex sexually transmitted disease (STD) that can become systemic and cause serious complications, including death. The causative organism is a spirochete called Treponema pallidum. Although the organism can be seen only with a darkfield microscope, several serologic tests may be used to screen for the presence of syphilis antibody. T. pallidum is damaged by dry air or any known disinfectant. The organisms die within hours at temperatures of 105.8° to 107.6° F (41° to 42° C) and are not airborne. The infection is usually transmitted by sexual contact and blood exposure, but transmission can occur through close body contact such as kissing.

Syphilis progresses through four stages: primary, secondary, latent, and tertiary. The appearance of an ulcer called a chancre is the first sign of primary syphilis. It develops at the site of entry (inoculation) of the organism from 10 to 90 days after exposure (3 weeks is average). Chancres may be found on any area of the skin or mucous membranes but occur most often on the genitalia, lips, nipples, and hands and in the mouth, anus, and rectum.

During this highly infectious stage, the chancre begins as a small papule. Within 3 to 7 days, it breaks down into its typical appearance: a painless, indurated (hard), smooth, weeping lesion. Regional lymph nodes enlarge, feel firm, and are not painful. Without treatment, the chancre usually disappears within 6 weeks. However, the organism spreads throughout the body and the patient is still infectious.

Secondary syphilis develops 6 weeks to 6 months after the onset of primary syphilis. During this stage, syphilis is a systemic disease because the spirochetes circulate throughout the bloodstream. Common manifestations include:

These symptoms are often mistaken for those of influenza. The rash, the most commonly presenting symptom, usually involves the palms and soles of the feet. Although it has no typical appearance, the rash tends to change from papules to squamous papules to pustules. Other skin lesions include psoriasis-like rashes (Fig. 76-1), wartlike lesions (condylomata lata), and mucous patches. These lesions are highly contagious and should not be touched without gloves. The rash subsides without treatment in 4 to 12 weeks.

FIG. 76-1 Palmar and plantar secondary syphilis.

After the second stage of syphilis, there is a period of latency. Early latent syphilis occurs during the first year after infection, and infectious lesions can recur. Late latent syphilis is a disease of more than 1 year’s duration after infection. This stage is not infectious except to the fetus of a pregnant woman. Patients with latent syphilis may or may not have reactive serologic test (e.g., Venereal Disease Research Laboratory [VDRL]) findings.

Tertiary, or late, syphilis occurs after a highly variable period, from 4 to 20 years. This stage develops in untreated cases and can mimic other conditions because any organ system can be affected. Manifestations of late syphilis include:

Because of strong U.S. public health efforts between 1990 and 1996, there was a 90% decrease in syphilis cases to an all-time low in 2000. Since 2001, there has been a steady increase in cases of primary and secondary syphilis with the majority among men having sex with men (MSM) (CDC, 2009).

Health Promotion and Maintenance

One of the Healthy People 2020 objectives is to completely eliminate syphilis in the United States (U.S. Department of Health and Human Services [USDHHS], 2010) (Table 76-3). The most important tool for prevention of sexually transmitted diseases (STDs), including syphilis, is education. All people, regardless of age, gender, ethnicity, socioeconomic status, education, or sexual orientation, are susceptible to these diseases. STDs are largely preventable through safer sex practices. Do not assume that a person is not sexually active because of his or her age, education, marital status, profession, or religion. Discuss prevention methods, including safe sex, with all patients who are or may become sexually active.

TABLE 76-3 MEETING HEALTHY PEOPLE 2020 OBJECTIVES AND TARGETS FOR IMPROVEMENT: SEXUALLY TRANSMITTED DISEASES

Safe sex practices are those that reduce the risk for nonintact skin or mucous membranes coming in contact with infected body fluids and blood. These practices include using:

Abstinence, mutual monogamy, and decreasing the number of sexual partners also decrease the risk for acquiring an STD.

Assessment

Assessment of the patient who has manifestations of syphilis begins with a history to gather information about any ulcers or rash. Take a sexual history and conduct a risk assessment to include whether previous testing or treatment for syphilis or other STDs has ever been done (Chart 76-1). Ask about allergic reactions to drugs, especially penicillin. A woman may report inguinal lymph node enlargement resulting from a chancre in the vagina or cervix that is not easily visible to her. She may state a history of sexual contact with a male partner who had an ulcer that she noticed during the encounter. Men usually discover the chancre on the penis or scrotum.

Conduct a physical examination, including inspection and palpation, to identify manifestations of syphilis. Wear gloves while palpating any lesions because of the highly contagious treponemes that are present. Observe for and document rashes of any type because of the variable presentation of secondary syphilis.

After the physical examination, the health care provider obtains a specimen of the chancre for examination under a darkfield microscope. Diagnosis of primary or secondary syphilis is confirmed if T. pallidum is present.

Blood tests are also used to diagnose syphilis. The usual screening and/or diagnostic nontreponemal tests are the Venereal Disease Research Laboratory (VDRL) serum test and the more sensitive rapid plasma reagin (RPR). These tests are based on an antibody-antigen reaction that determines the presence and amount of antibodies produced by the body in response to an infection by T. pallidum. They become reactive 2 to 6 weeks after infection. VDRL titers are also used to monitor treatment effectiveness. The antibodies are not specific to T. pallidum, and false-positive reactions often occur from such conditions as viral infections, hepatitis, and systemic lupus erythematosus (SLE) (Pagana & Pagana, 2010).

If a VDRL result is positive, the health care provider requests or the laboratory may automatically perform a more specific treponemal test, such as the fluorescent treponemal antibody absorption (FTA-ABS) test or the microhemagglutination assay for T. palladium (MHA-TP), to confirm the infection. These tests are more sensitive for all stages of syphilis, although false-positive results may still occur. Patients who have a reactive test will have this positive result for their entire life, even after sufficient treatment. This poses a challenge when receiving a positive result for a patient who denies a history of or does not know he or she had syphilis.

Interventions

Patient-centered collaborative care includes drug therapy and health teaching to resolve the infection and prevent infection transmission to others.

Pathophysiology

Genital herpes (GH) is an acute, recurring, incurable viral disease. It is the most common STD in the United States, with 16.2% of Americans currently infected with herpes simplex virus type 2 (HSV-2). The prevalence among African Americans is 39.2%, disproportionately affecting African-American women (48.0%) (CDC, 2010b). These rates are based on the presence of HSV-2 antibodies in the blood of those tested, the majority of whom have had no symptoms and most have never received a diagnosis of GH infection (CDC, 2010b).

Two serotypes of herpes simplex virus (HSV) affect the genitalia: type 1 (HSV-1) and type 2 (HSV-2). Most nongenital lesions such as cold sores are caused by HSV-1. Historically, HSV-2 caused most of the genital lesions. However, this distinction is academic because the transmission, symptoms, diagnosis, and treatment are nearly identical for the two types. Either type can produce oral or genital lesions through oral-genital contact with an infected person. HSV-2 has been thought to cause the majority of the primary episodes of GH, though up to one-third are caused by HSV-1 (Drugge & Allen, 2008). HSV-2 recurs and sheds asymptomatically more often than HSV-1. Most people with GH have not been diagnosed because they have mild symptoms and shed virus intermittently (CDC, 2010a).

The incubation period of genital herpes is 2 to 20 days, with the average period being 1 week. Many people do not have symptoms during the primary outbreak. When outbreaks occur, they are usually more severe than in recurrent outbreaks and occasionally require hospitalization.

Recurrences are not caused by re-infection. Additional episodes are usually less severe and of shorter duration than the primary infection episode. Some patients have no symptoms at all during recurrence or viral reactivation. However, there is viral shedding and the patient is infectious. Long-term complications of GH include the risk for neonatal transmission and an increased risk for acquiring HIV infection.