Syphilis and other STDs

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Syphilis and other STDs

• DH Duckworth
• ID Class

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Common Features of All STDs

• Human only
• Transmission
• Virulence Mechanism
• Inapparent Infection
• Prevention
• Abstinance
• Monogamy
• Epidemics
• Sexual Promiscuity

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Two Major Presentations

• Drips
• Urethritis or Cervicitis
• Gonorrhea
• Non-gonoccal urethritis
• Vaginitis
• Trichomoniasis

• Bumps
• Warts
• Swollen lymph glands
• AIDS
• Chancroid
• LGV
• Genital ulcer disease
• Herpes
• Syphilis
• Chancroid
• LGV

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Most Common STDs

• Non-gonococcal urethritis
• Gonorrhea
• Genital herpes
• Genital warts
• Trichomoniasis

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Less Common STDs

• Common
• AIDS
• Syphilis

• Uncommon
• Chancroid
• LGV

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Gonorrhea

• Causative agent Neisseria gonorrhoea
• Major Symptoms
• Many asymptomatic
• Male urethritis with painful urination,
  purulent discharge proctitis
• Female cervicitis, urethritis, both
  asymptomatic or with minor discharge
  salpingitis PID
• Both sexes pharyngitis, septic arthritis
• Disseminated gonococcal infection (DGI)
• Pustular skin lesions
• Septic arthritis
• Newborns conjunctivitis, opthalmia neonatorum

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Gonorrhea

• Diagnosis
• intracellular Gram negative diplococci in
  discharge
• growth on selective media, oxidase positive
  colonies
• flourescent antibody
• Treatment
• Penicillin, ciprofloxacin, ceftriaxone,
  tetracycline for probable association of C.
  trachomatis

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Gram-negative Intracellular Diplococci
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Gonorrhea -- Pathogenesis

• Encounter from other humans only
• Entry genital contact NOT fomites
• Spread can spread hematogenously and also
  through the uterus to Fallopian tubes and pelvic
  cavity
• Multiplication can multiply extracellularly or
  intracellularly
• Avoid Host Immune Response adhesins, antigenic
  variation, phase variation, sialation of LOS,
  IgA-ase
• Damage -- inflammation
• Transmission sexual contact vertical (mother
  to newborn)

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Non-gonococcal Urethritis

• Infectious agents
• Chlamydia trachomatis
• Ureaplasma urealyticum
• Symptoms of Chlamydial infection
• Often inapparent in men
• Watery or mucopurulent discharge
• Dysuria
• In women, mucopurulent cervicitis, salpingitis,
  premature labor
• In newborns may cause conjunctivitis or pneumonia

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Chlamydial Life Cycle
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Non-gonococcal urethritis (Chlamydia)

• Pathogenesis
• Encounter from infected humans
• Entry direct sexual contact NOT fomites
• Spread
• Multiplication intracellular in columnar
  epithelial cells elementary body is infectious
  form, reticulate body is replicative form
• Avoid Host Immune Response prevents
  phagolysozome fusion by hijacking membrane
  trafficking system grows intracellularly
• Damage -- inflammation
• Transmission

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Non-gonococcal urethritis (Chlamydia)

• Diagnosis
• grow in fibroblasts, detect with
  flourescein-labeled antibody
• PCR
• Treatment
• tetracycline
• doxycycline
• erythromycin

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Other Common STDs

• Genital herpes
• Caused by HHV 1
• Causes painful ulcers and (with a primary
  infection) asceptic meningitis
• Can be treated with acyclovir
• Genital warts
• Caused by papilloma virus
• May cause cervical cancer
• Trichomoniasis
• Caused by Trichomonas vaginalis
• Asymptomatic in men
• Causes severe vaginal itching and a blood-tinged
  discharge in women
• Treated with metronidazole

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Less Common STDs

• Aids
• Syphilis
• Chancroid
• Lymphogranuloma venereum

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Syphilis
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Treponema pallidumDark Field
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Treponema pallidum EM
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Stages of Syphilis
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Symptoms of Syphilis

• Primary
• Single, painless, genital ulcer
• Regional lymphadenopathy (swollen lymph nodes)
• Secondary
• Headache
• Fever
• Whole-body rash
• Generalized lymphadenophathy
• Tertiary
• Neurological damage
• Heart damage
• Bone and joint damage
• Congenital
• Fetal death
• Birth defects

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Primary Syphilis -- chancre
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Secondary Syphilis -- rash
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Syphilis -- Pathogenesis

• Encounter humans only
• Entry horizontal, sexual contact NOT fomites
• Entry vertical, acquired in utero
• Spread to virtually any organ
• Multiplication multiplies very rapidly
  extracellularly
• Avoid Host Immunity -- ?
• Damage inflammation, cell death, autoimmunity
  (?)
• Transmission

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SyphilisNote

• Only infection that is
• Bacterial
• STD
• Congenital
• Causes bone changes

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Syphilis

• Diagnosis
• VDRL
• Dark-field microscopy
• Anti-treponemal tests
• Treatment
• Penicillin
• Mercury (before penicillin)

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Other Diseases Caused by T. pallidum

• Bejel or endemic syphilis
• Affects the skin and bones.
• Begins with ulcer on the leg
• The sore heals, but soft nodules of tissue
  (granulomas) erupt on the face, arms, legs, and
  buttocks.
• Painful open sores may develop on the soles of
  the feet (crab yaws).
• Areas of the shinbones may be destroyed, and
  other disfiguring growths, especially around the
  nose, may develop.
• Occurs in arid countries of the eastern
  Mediterranean and West Africa.

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Other Diseases Caused by T. pallidum, ctd.

• Yaws
• Transmitted by skin contact, mainly between
  children
• Begins with a slimy patch in the mouth
• Followed by blisters on the trunk, arms, and
  legs.
• Bone infection develops later, mainly in the
  legs.
• Occurs in humid equatorial countries.
• Pinta
• Involves only the skin
• Skin loses pigmentation in patches
• Occurs in Mexico, South and Central America

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Other Diseases Caused by T. pallidum

• All caused by organisms that cannot be
  distinguished
• By antibodies
• By DNA hybridization
• DNA sequence?????

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HISTORY OF SYPHILIS
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HISTORY OF SYPHILISFacts

• 1495 Severe epidemic of (possibly) new disease
• Starts in Naples, Italy, during siege of city
• Ends war due to illness of soldiers
• Soldiers return to all countries of Europe
• Disease had no name called French or Spanish or
  German or Polish diseasenoteNOT called Indian
  disease
• Disease turns up in far flung places
• Aberdeen, Scotland, 1497 For protection of
  disease from France and strange parts all
  prostitutes cease work or be branded with hot
  poker
• Edinburgh, Scotland, 1498 Individuals with
  French disease banished to Island of Inchkeith
• 1539 Spanish doctor says Columbus men returned
  from America with the disease

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HISTORY OF SYPHILISFacts

• Evidence of epidemic from
• Letters
• Legal documents
• Literary and art works
• Medical treatises
• Evidence that Columbus started the epidemic
• None
• Nada
• Zilch

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Were Indians afflicted?

• Conflicting Evidence
• Strictest criteria in bones (caries sicca)
• none in 12,000
• 6 in 4500
• Looser criteria some bone changes

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If not Columbus.where?

• Subacute,smoldering disease in Europe
• Not much evidence from bones
• Was leprosy really syphilis?
• Evolved from Yaws or Bejel after being brought
  from Africa

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Bones rewrite syphilis history 2001

• The remains of a medieval woman found in Essex
  could change medical history by disproving the
  theory that Christopher Columbus brought syphilis
  to Europe.
• Experts estimate the bones, which show signs of
  syphilis, are aged between 1296 and 1445
• The roughness of the bones and the pitted surface
  indicate she had syphilis. (?)
• Work including DNA tests will now continue on
  this and related specimens.

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Did Syphilis Exist in Europe before 1492?

• China, 2000BC ms claims ulcer may happen if a
  woman meets a man whose blood has the virus.
  This virus will then spread throughout the entire
  volume of blood. Mercury is treatment.
• Japan 808 AD. After ulcer (of genital tract)
  has been cured there is fever and the bones and
  joints become painful.
• Vedic books of the Hindus Disease transmitted
  by copulation causes destruction of the nose,
  affects the blood and contaminates the seed.
  Called leprosy!
• Vedic books of the Hindusshameful disease cause
  ulcers on the soles of the feet and palms of the
  hands

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Was leprosy really syphilis?

• Lepers very feared even though leprosy not very
  contagious
• Leprosy is not congenital but ancient references
  refer to it as such
• Leprosy described (14th cent) as a disease that
  will break forth in him who lies with a woman
  who has lain with a leper
• Mercury thought to be a cure for leprosy
• 1321 English cardinal bought a brothel as an
  investment for the church to protect against
  great pox
• Woodcut from14th cent pictures leper with spots
  on hands and dragging one leg as people with
  tertiary syphilis sometimes do.

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Unitarian Hypothesis

• Syphilis, yaws, bejel, pinta are all same disease
• Yaws originated in Sub-Saharan Africa
• Spread around the world and adapted to different
  climates
• Slave trade brought disease to Europe
• Superior hygiene.eliminated opportunities for
  transmission between children

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EMERGING DISEASES

• CAUSED BY A CHANGEto
• pathogen
• reservoir
• vector
• host
• EXAMPLES
• acquisition of new gene (pathogen changed)
• diseases migrating to new areas (reservoir moved)
• diseases caused by human technologies (new
  vectors)
• diseases caused by disruption of animal habitats
  ( reservoir or vector moved)
• immune deficiency diseases (host changed)

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SOLUTION

• Will come from DNA studies to show differences
  between the four treponematoses (done)
• Will be able to show whether syphilis was in New
  World before 1492 or in the Old World prior to
  then (maybe)