PENCEGAHAN SIFILIS DARI IBU KE ANAK

1. PENCEGAHAN SIFILIS DARI IBU KE ANAK Dr. Nor AzahbtMohamadNawi PakarPerubatanKeluarga UD54 KlinikKesihatanBakarArang

2. VDRL dan RPR • Venereal Diseases Research Laboratory • Juga dikenali sebagai non-treponemal test. • RPR: Rapid Plasma Reagin • Ujian saringan untuk sifilis. • False positive: kehamilan, yaws, malaria, Connective tissue disease, HIV, leprosy etc. • Untuk diagnos sebagai sifilis, perlu sahkan dgn ujian pengesahan: • TPHA, TPPA, dark-ground microscopy, FTA-Abs, ELISA, EIA, atau PCR.

3. Diagnosis • Dark ground field microscopy: Treponema pallidum sphirochaette 2. Serum VDRL 3. Serum TPHA 4. FTA abs

4. TPHA/TPPA? • TPHA: Treponema pallidum haemagglutination assay • Bound to erthrocytes • TPPA: Treponema pallidum particle agglutination • Bound to gelatin • Baru dan lebih mudah dari TPHA • Kedua-duanya mengesan antibodi • Dilakukan bila RPR/VDRL reactive

5. SENSITIVITY OF SEROLOGICAL TESTS FOR SYPHILIS

6. InterpretasiUjianDarah SEJARAH PENDEDAHAN PENYAKIT PENTING

7. Syphilis Cause: Treponema pallidum A sphirochaette 50% pesakit ada tanda-2 klasikal Screening : at booking and 28/52 POA. Cara Jangkitan: Diperolehi/Acquired Early Late Kongenital Early, < 2 years Late, > 2 years

8. Natural history of syphilis (Course of untreated syphilis) Spontaneous cure (30%) Primary syphilis Exposure Secondary syphilis Early latent Late latent syphilis(30%) Neuro- syphilis (12%) Cardio vascular (14%) Gumma (14%)

9. Acquired Syphilis Early Syphilis: 1st 2 years Late Syphilis: After 2 years Late Latent - Tiada gejala Tertiary Benign 1 – 45 (15) years later Benign gumma of skin, bones 3. Cardiovascular 15 – 30 years later Aortic aneurysm 4. Neurosyphilis - Bila-bila masa Berlaku lebih awal di kalangan RVD positive • Primary • IP 9 – 90 days • Chancre (ulcer) and lympadenopathy 2. Secondary: stage bacteraemia • IP: 6 wk – 6/12 • Generalised non-irritating skin lesion, condylomatalata , mucucutaneous lesion and patchy alopecia 3. Early latent: Positive serology without Sn n Sx

10. TYPES OF GENITAL ULCERS

11. Early : Primary syphilis IP: 1-3 weeks Usually Painless single papule then became ulcer, round/oval Well circumscribed, clean floor, no exudate Usually no vesicle Regional lymphadenopathy Any anogenital ulcer should be considered to be due to syphilis unless proven otherwise. 90% genital ulcer, 10% extragenital

12. Primary syphilis (9 – 90 days) Chancre

13. Early: Secondary syphilis • 6 weeks to 6 months • Stage of bacteremia • May cause uveitis, cranial nerve palsies, hepatitis and splenomegaly • The most common features • fever, • lymphadenopathy, • diffuse non irritating rash • condyloma lata

14. Patchy alopecia of secondary syphilis.  Hair loss also occurs commonly from the lateral third of the eyebrows.

15. Early: Secondary syphilis Malignant syphilis – widespread necrotic papulopustules and ulcers with severe systemic symptoms

16. Maculo-papular syphilide

17. Diagnosis of Secondary Syphilis • All serological tests for syphilis are expected to be positive in secondary syphilis • RPR/ VDRL titres in untreated cases are often > 1:8 (VDRL) and > 1: 16 (RPR) • If a specific treponemal test is used for diagnosis and is found to be positive, use the VDRL/ RPR test to determine disease activity, and to monitor response to therapy

18. Early Latent Syphilis • Diagnosed by a POSITIVE SEROLOGY without symptoms and signs in a person known to be sero-negative in the previous 2 years

19. LATE SYPHILIS: > 2 years • Late latent: Asx • Benign Tertiary Syphilis (Gumma) • 1 – 45 (average 15) years after infection, • destructive granulomatous lesions on skin, bones • Cardiovascular Syphilis • 15 – 30 yrs • Neurosyphilis: at any stage of syphilis, earlier in HIV patient

20. Tertiary syphilis (3 – 12 years later) Necrotic nodules or plaques Gummas on lower limb

21. Late: Benign Tertiary syphilis Gummatous Syphilis • Nodules on skin, bones, • Can also involve the kidney, heart, brain and respiratory

22. Late: 3. Cardiovascular Syphilis • Aortitis (Proximal aorta) • Aortic incompetence causing Heart failure • Coronary ostial stenosis • Aortic medial necrosis causing aortic aneurysm

23. Late: 4. Neurosyphilis Involves Central Nervous System Meningovascular (MV) or parenchymatous syphilis Sx of MV syphilis: Headache, vertigo and CN palsy Parenchymatous: General paresis of insane

24. Parenchymatous syphilis • GPI: gradual personality change, ataxia, stroke, opthalmic involvement and tabes dorsalis (lightning pain, sensory impairment and mobility problem) • Rx: Admit for Ix (LP) and IM/IV antibiotic.

25. Serology interpretation 34 years old female G3P2 at 12 weeks came for booking. Below the serology finding Interpretasi?

26. Serology interpretation 42 years old Malay male, asymptomatic came for VDRL screening as his pregnant partner was treated for syphilis. Below his serology result.

27. Serology Interpretation 23 years old Male history of painless penis ulcer for 5 days. History of visit to Thai border recently Below the serology result Next step?

28. Treatment • Early Syphilis - IM Benzathine Penicillin 2.4 mega units single dose or - IM Procaine Penicillin G 600,000 daily x 10/7

29. Early Syphilis: For patients allergic to penicillin: • T. Doxycycline 100 mg bd x 14/7: (contraindicated in pregnancy) • T. Erythromycin 500 mg qid x 14/7 • T. Erythromycin ES 800 mg qid x 14/7 • IM Ceftriaxone 250 mg daily x 10/7 • T. Azithromycin 2 G single dose • Erythromycin should not be used because of the high risk of failure to cure the foetus. • If erythromycin is used, paediatricians must be alerted and babies have to be treated prophylactically with penicillin and monitored.

30. Penicillin allergy in Pregnant Women • Should be meticulously interviewed regarding the validity of the history. • Currently, no proven alternative therapies to penicillin are available for treating neurosyphilis, congenital syphilis or syphilis in pregnancy. • Therefore, skin testing, with desensitisation, if indicated, should be done for these patients.

31. MANAGEMENT OF PATIENTS WITH HISTORY OF PENICILLIN ALLERGY • Desensitisationshould be done in a hospital setting because serious IgE-mediated allergic reactions may occur. • A protocol is recommended (refer STI guideline). • Oral penicillin in increasing concentration is administered every 15 minutes. Sensitisation is completed within 4 hours with a cumulative dose of 1.3 million units of penicillin V.

32. Jarisch-Herxheimer reaction • An acute febrile illness with headache, myalgia, chills and rigors and resolving within 24 hours. • This is common in early syphilis but is usually not important unless • neurological or ophthalmic involvement or • in pregnancy when it may cause fetal distress and premature labour (second half of pregnancy)

33. Jarisch-Herxheimer reaction • It is uncommon in late syphilis but can potentially be life threatening if there is involvement of strategic sites (coronary ostia, larynx, nervous system). • Prednisolone can reduce the reaction. Recommendation • In early syphilis : Treat with Paracetamol • In Neurosyphilis, Cardiovascular, certain cases of benign tertiary and late latent syphilis: • Treat with Prednisolone 40-60mg daily for 3 days: begin 24 hours before treatment and for 2 days after starting treatment.

34. ADVICE • Abstain from sex until 1 week after they and their partner(s) have completed treatment. CONTACT TRACING • Examine and investigate all sex partners and treat epidemiologically. • Primary syphilis, notify sexual partners within the past 3/12. • Secondary syphilis with clinical relapse or in early latent syphilis: 2 years   • All patients should be offered patient and provider referral as a method of contacting any sexual partner. The method agreed upon with the patient should be clearly documented. • Epidemiological treatment for asymptomatic contacts of early syphilis is recommended.

35. Incubating/ Epidemiological Rx: Partner • IM B. Penicillin 2.4 mega units single dose or • T. Doxycycline 100 mg bd x 14/7 or • T. Azithromycin 1 G single dose

36. F/UP for TPHA Positive in Pregnancy • Repeat VDRL/RPR titre • 1/12 after last dose • then monthly until delivered and then • 3/12ly – 6/12ly as non-pregnant women until seronegative or at low titre.

37. Treatment 2. Late Latent Syphilis • Inj. Benzathine Penicillin 2.4 millionunit i.m once a week for 3/52 i.e. 3 doses Gap between doses: < 14/7. If missed< repeat whole cycle of Rx. • Or IM Procaine penicillin G 600,000 units for 17 days

38. For patients allergic to penicillin: • T. Doxycycline 100 mg oral bd x 28/7 (c/i in pregnancy) or • Erythromycin 500mg q.i.d P.O for 28 days • Erythromycin ES 800mg q.i.d P.O for 28 days

39. Follow-up of Late Syphilis Examine and 6 monthly VDRL x 2 years then yearly until seronegative or low titre (1:4 or less)

40. Syphilis: Rx Failure and Re-Rx • Clinical Sx persist • Initial High titre VDRL failed to decreased fourfold by 1 year • Sustained four fold increase of VDRL titre

41. Syphilis: Persistent Reactor Titre VDRL persistently > 1:4 despite retreatment with B. Penicillin and trial of treatment with Doxycycline for 28 days when she was not pregnant.

42. REMINDER • For all pregnant lady and partner with TPHA positive, don’t forget to screen for other STIs i.e: • HIV Ab, HCV, HBsAg • GC smear • TV wet smear

43. PengendalianBayidariIbu TPPA Positif Dr Nor AzahMohamadNawi PakarPerubatanKeluarga UD54 KlinikKesihatanBakarArang

44. Congenital Syphilis 50-80% of exposed neonates.

45. Congenital Syphilis • Caused by transplacental transmission of spirochetes; the transmission rate approaches 90% if the mother has untreated primary or secondary syphilis. • The child is at greatest risk of contracting syphilis when the mother is in the early stages of infection • A woman in the secondary stage of syphilis decreases her child's risk of developing congenital syphilis by 98% if she receives treatment before the last month of pregnancy

46. Untreated Syphilis in Pregnancy • Fetal infection can develop at any time during gestation. • Because inflammatory changes do not occur in the fetus until after the first trimester of pregnancy, organogenesis is unaffected. • All organ systems may be involved. • Can cause: • Miscarriages, • Premature birth • Stillbirths • Death of newborn babies: pulmonary haemorrhage.

47. Congenital Syphilis • Manifestations are defined as • Early if they appear in the first 2 years of life • Late: develop after age 2 years. • Early-onset disease, • result from transplacentalspirochetemia and are analogous to the secondary stage of acquired syphilis. (Congenital syphilis does not have a primary stage) • Late-onset disease (>2 years) is considered contagious.

48. Early-onset congenital syphilis (before or at age 2 y) • 60% are asymptomatic at birth. • Sx develop within the first 2/12 of life. Almost 100% has hepatomegaly; biochemical evidence of liver dysfunction is usually observed. • Common Sn: skeletal abnormalities, rash, and generalized lymphadenopathy. • Radiographic abnormalities, periostitis or osteitis, involve multiple bones. Sometimes, the lesion is painful and an infant will favor an extremity (pseudopalsy)

49. Early-onset congenital syphilis (before or at age 2 y) • Maculopapular rash, may involve palms and soles. • In contrast to acquired syphilis, a vesicular rash and bullae (pemphigussyphiliticus) may develop - highly contagious. • Mucosal involvement may present as rhinitis ("snuffles") – poor feeding. • Nasal secretions are highly contagious.

50. Early-onset congenital syphilis (before or at age 2 y) • Hematological abnormalities include anemia and thrombocytopenia. Some have leukocytosis. • Abnormal CSF examination • Seen in a half of symptomatic infants, • 10% of asymptomatic baby.