■ Clinical Manifestations
Maternal Syphilis and Definitions
This is staged according to clinical features and disease duration.
• Primary syphilis is diagnosed by its characteristic chancre, which develops at the inoculation site. Typically, a solitary, painless lesion has a raised, firm border and a red, smooth ulcerated base without significant pus (Fig. 68-1). Nonsuppurative lymphadenopathy may develop. A chancre usually resolves spontaneously in 2 to 8 weeks, even if untreated. Multiple lesions, if found, are predominantly in women with HIV co-infection.
• Secondary syphilis stems from spirochete dissemination to multiple organ systems. Manifestations develop 4 to 10 weeks after the chancre appears and include dermatological abnormalities in up to 90 percent. A diffuse macular rash, plantar and palmar circular lesions, patchy alopecia, and mucous patches may be seen (Fig. 68-2). Condylomata lata are fresh-colored fat nodules found on the perineum and perianus. Mucosal lesions teem with spirochetes and are highly infectious. Women may have constitutional symptoms such as fever, headache, and myalgias. Hepatitis, nephropathy, ocular changes, anterior uveitis, and periostitis are less common findings. Manifestations of secondary syphilis resolve without treatment after 1 to 6 months, despite incomplete clearance of organisms by the immune system.
• With latent syphilis, clinical manifestations of primary or secondary syphilis either have resolved or were never recognized, but infection persists and is identified by serological testing. Early latent syphilis is subclinical disease acquired within the preceding 12 months. Timing of infection is determined by laboratory seroconversion results, clearly described symptoms consistent with primary or secondary syphilis within the prior 12 months, or exposure to a sexual partner in the previous 12 months with primary, secondary, or early latent syphilis. If the duration of infection is either unclear or beyond 12 months, the term is latent syphilis, unknown duration or late.
• Tertiary syphilis is a slowly progressive disease that affects any organ system but is rarely seen in reproductive-aged women. Early-stage syphilis includes primary, secondary, and early latent syphilis. These are associated with high spirochete loads, and partner transmission rates range from 30 to 60 percent (Garnett, 1997; Singh, 1999). Late-stage syphilis includes latent syphilis, unknown duration or late and tertiary syphilis. In these, transmission rates decline because of smaller inoculum sizes.
■ Congenital Syphilis
Without screening and treatment, approximately 70 percent of infected women will have an adverse pregnancy outcome
FIGURE 68-1 Primary syphilis. Chancres show a raised, firm border and smooth base and may be singular or multiple, as seen here. Arrows point to two reciprocal or “kissing” lesions, which develop as infection on one side spreads to the other when tissues are apposed. (Reproduced with permission from Dr. Allison J. Tracy, MD.)
FIGURE 68-2 Secondary syphilis. A. Condyloma lata. (Reproduced with permission from Dr. Ralynn Brann.) B. Target lesions on the palms. C. Diffuse maculopapular rash.1208 Medical and Surgical Complications Section 12 (Hawkes, 2011).
Maternal infection can lead to congenital infection, preterm labor, low birthweight, and fetal or neonatal death (Qin, 2014). Because of its immune incompetence prior to midpregnancy, the fetus is less likely to manifest the immunological inflammatory response characteristic of congenital infection before this time (Silverstein, 1962). However, congenital infection is still presumed in all cases, and thus treatment is imperative.
When vertical transmission occurs, severe congenital syphilis progresses along a continuum. Hepatic abnormalities are followed by anemia, thrombocytopenia, and then ascites and hydrops. Stillbirth remains a major complication (Centers for Disease Control and Prevention, 2021b). The newborn may have jaundice with petechiae or purpuric skin lesions, lymphadenopathy, rhinitis, pneumonia, myocarditis, nephrosis, or long-bone involvement (Fig. 68-3).
With syphilitic infection, the placenta becomes large and pale. Microscopically, villi lose their characteristic arborization, and blood vessels diminish or are obliterated as a result of endarteritis and stromal cell proliferation. Shefeld and colleagues (2002c) described these villi in more than 60 percent of placentas from women with untreated syphilis at delivery. Examination of the umbilical cord may reveal necrotizing funisitis, and spirochetes may be microscopically seen after immunohistochemical staining (Adhikari, 2020)
FIGURE 68-3 Congenital syphilis. A. A desquamating skin rash known as pemphigus syphiliticus may be seen. B. Neonatal lower-extremity long-bone radiographs show a “moth-eaten” appearance (arrows). C. Enlarged hydropic placenta of a syphilis-infected pregnancy.
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