pencegahan sifilis dari ibu ke anak

PENCEGAHAN PENCEGAHAN SIFILIS DARI IBU KE SIFILIS DARI IBU KE

ANAKANAK

Dr. Nor Azah bt Mohamad NawiDr. Nor Azah bt Mohamad NawiPakar Perubatan Keluarga UD54Pakar Perubatan Keluarga UD54

Klinik Kesihatan Bakar ArangKlinik Kesihatan Bakar Arang

VDRL dan RPRVDRL 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.

DiagnosisDiagnosis1. Dark ground

field microscopy: Treponema pallidum sphirochaette

2. Serum VDRL3. Serum TPHA4. FTA abs

TPHA/TPPA?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

SENSITIVITY OF SEROLOGICAL SENSITIVITY OF SEROLOGICAL TESTS FOR SYPHILISTESTS FOR SYPHILIS

Tests 1o 2o Latent

FTA-Abs 85% 100% 97%

TPHA 60-70% 100% 97%

VDRL 75% 100% 70%

Interpretasi Ujian DarahInterpretasi Ujian Darah

SEJARAH PENDEDAHAN PENYAKIT PENTING

SyphilisSyphilis• 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

Natural history of syphilis (Course of untreated syphilis)

9 - 90 days 6 wks - 6mths First 2 years 2 years to a lifetime

Primarysyphilis

Secondarysyphilis

Earlylatent Late latent syphilis(30%)

Gumma(14%)

Neuro-syphilis(12%)

Cardiovascular(14%)

Spontaneouscure (30%)

Exposure

Acquired SyphilisAcquired SyphilisEarly Syphilis: 1st 2 years

1. Primary• IP 9 – 90 days• Chancre (ulcer) and

lympadenopathy2. Secondary: stage

bacteraemia• IP: 6 wk – 6/12• Generalised non-

irritating skin lesion, condylomata lata , mucucutaneous lesion and patchy alopecia

3. Early latent: Positive serology without Sn n Sx

Late Syphilis:After 2 years

1. Late Latent- Tiada gejala

2. Tertiary Benign - 1 – 45 (15) years later- Benign gumma of skin, bones

3. Cardiovascular- 15 – 30 years later- Aortic aneurysm

4. Neurosyphilis- Bila-bila masaBerlaku lebih awal di kalangan

RVD positive

TYPES OF

GENITAL ULCERS

Early : Primary syphilisEarly : 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

Primary syphilis (9 – 90 days)

Chancre

Early: Secondary syphilisEarly: 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

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

Early: Secondary syphilisEarly: Secondary syphilis

Malignant syphilis – widespread necrotic papulopustules and ulcers with severe systemic symptoms

Maculo-papular syphilide

Diagnosis of Secondary Diagnosis of Secondary SyphilisSyphilis

• 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

Early Latent SyphilisEarly Latent Syphilis

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

LATE SYPHILIS: > 2 yearsLATE 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

Tertiary syphilis (3 – 12 years later)

Necrotic nodules or plaques

Gummas on lower limb

Late: Benign Tertiary syphilisLate: Benign Tertiary syphilis

Gummatous Syphilis• Nodules on skin,

bones, • Can also involve

the kidney, heart, brain and respiratory

Late: 3. Cardiovascular SyphilisLate: 3. Cardiovascular Syphilis

• Aortitis (Proximal aorta)– Aortic incompetence

causing Heart failure– Coronary ostial stenosis– Aortic medial necrosis

causing aortic aneurysm

Late: 4. NeurosyphilisLate: 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

Parenchymatous syphilisParenchymatous 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.

Serology interpretationSerology interpretation

• 34 years old female G3P2 at 12 weeks came for booking. Below the serology finding

•

• Interpretasi?

VDRL Reactive 1:2 titre

TPHA negative

FTABs negative

Serology interpretationSerology interpretation

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

VDRL NR

TPHA positive

FTAabs positive

Serology InterpretationSerology 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?

VDRL negative

TPHA negative

FTA abs negative

TreatmentTreatment

1. Early Syphilis

- IM Benzathine Penicillin 2.4 mega units single dose or

- IM Procaine Penicillin G 600,000 daily x 10/7

Early Syphilis: For patients Early Syphilis: For patients allergic to penicillin:allergic to penicillin:

1. T. Doxycycline 100 mg bd x 14/7: (contraindicated in pregnancy)

2. T. Erythromycin 500 mg qid x 14/73. T. Erythromycin ES 800 mg qid x 14/74. IM Ceftriaxone 250 mg daily x 10/75. 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.

Penicillin allergy in Pregnant WomenPenicillin 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.

MANAGEMENT OF PATIENTS WITH MANAGEMENT OF PATIENTS WITH HISTORY OF PENICILLIN ALLERGYHISTORY OF PENICILLIN ALLERGY

• Desensitisation should 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.

– 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)

Jarisch-Herxheimer reactionJarisch-Herxheimer reaction

Jarisch-Herxheimer reactionJarisch-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.

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.

Incubating/ Epidemiological Rx: Incubating/ Epidemiological Rx: PartnerPartner

• 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

F/UP for TPHA Positive in F/UP for TPHA Positive in PregnancyPregnancy

• 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.

TreatmentTreatment

2. Late Latent Syphilis• Inj. Benzathine Penicillin 2.4 millionunit

i.m once a week for 3/52 i.e. 3 dosesGap between doses: < 14/7.If missed< repeat whole cycle of Rx.

• Or IM Procaine penicillin G 600,000 units for 17 days

For patients allergic to For patients allergic to penicillin: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

Follow-up of Late SyphilisFollow-up of Late Syphilis

Examine and 6 monthly VDRL x 2 years then yearly until seronegative or low titre (1:4 or less)

Syphilis: Syphilis: Rx Failure and Re-RxRx 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

Syphilis: Persistent ReactorSyphilis: 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.

REMINDERREMINDER

• 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

Pengendalian Bayi Pengendalian Bayi dari Ibu TPPA dari Ibu TPPA

PositifPositif

Dr Nor Azah Mohamad NawiDr Nor Azah Mohamad NawiPakar Perubatan Keluarga UD54Pakar Perubatan Keluarga UD54

Klinik Kesihatan Bakar ArangKlinik Kesihatan Bakar Arang

Congenital SyphilisCongenital Syphilis

• 50-80% of exposed neonates.

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

Congenital SyphilisCongenital Syphilis

Untreated Syphilis in Untreated Syphilis in PregnancyPregnancy

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.

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 transplacental spirochetemia 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.

Congenital SyphilisCongenital Syphilis

Early-onset congenital syphilis Early-onset congenital syphilis (before or at age 2 y)(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)

Maculopapular rash, may involve palms and soles.

In contrast to acquired

syphilis, a vesicular rash and bullae (pemphigus syphiliticus) may develop - highly contagious.

Mucosal involvement may present as rhinitis ("snuffles") – poor feeding.

Nasal secretions are highly contagious.

Early-onset congenital syphilis Early-onset congenital syphilis (before or at age 2 y)(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.

Early-onset congenital syphilis Early-onset congenital syphilis (before or at age 2 y)(before or at age 2 y)

Late Onset ManifestationsLate Onset Manifestations

Neurosyphilis and involvement of the teeth, bones, eyes, and the eighth cranial nerve, as follows: Bone involvement - Saber shins, saddle nose, short

maxillae, protruding mandible, swollen knees Higoumenakis sign, enlargement of the sternal end

of clavicle in late congenital syphilis. Teeth involvement - Notched, peg-shaped incisors

(Hutchinson teeth) Pigmentary involvement - Linear scars (rhagades) at

the corners of the mouth and nose result from bacterial infection of skin lesions.

Interstitial keratitis - Presents in the 1st or 2nd decade of life

Sensory-neural hearing loss (eighth cranial nerve deafness) - Presents between age 10 and 40 years.

Classic Hutchinson triadClassic Hutchinson triad

Defective incisors, interstitial keratitis, eighth cranial nerve deafness

Infants should be evaluated if they Infants should be evaluated if they were born to sero +ve women who:were born to sero +ve women who:

• Have untreated syphilis• Were treated for syphilis less than 1

month before delivery• Were treated for syphilis during

pregnancy with a non - penicillin regimen• Did not have the expected decrease in

RPR titre after treatment• Were treated but had insufficient serologic

follow-up during pregnancy to assess disease activity

EVALUATION OF INFANTEVALUATION OF INFANT

• A thorough physical examination• RPR (compare with mother’s titre) /

EIA • FTA-Abs• CSF analysis for cells, protein and

CSF-VDRL test• Long bones X-ray • Chest X-ray

Treat if they have:Treat if they have:Any evidence of active diseaseA reactive CSF-VDRL / FTA-AbsAn abnormal CSF finding ( WBC > 5/ mm3 or

protein > 50 mg / dl ) regardless of CSF serology

Serum RPR titre that are at least 4 times higher than their mother's.

Positive EIA-IgM antibody

* Treatment (with penicillin) before the development of late symptoms is essential

RxRx• Aqueous Cystalline Penicillin G: 50,000 units/kg/dose 12

hourly for first 7 days then 8 hourly for the following 3-7 days OR

• Procaine Penicillin, 50,000 units/kg daily IM for 10 - 14 days OR

• *IV/IM Ceftriaxone 75 mg/kg (< 30 days old) or 100 mg/kg (>30 days old)

• *If more than a day of treatment is missed, the whole course should be restarted

• Infants who should be evaluated but whose follow-up cannot be assured should be treated with a single dose of Benzathine Penicillin, 50,000 units/kg IM.

•  

F/up and MonitoringF/up and Monitoring

Sero-positive untreated infants must be closely monitored at 1, 2, 3, 6, and 12 months of age. RPR should decrease by 3/12 of age and

usually disappear by 6/12 of age. Treat (with the same regimen as above) if:

Symptoms and signs persist or recur RPR titre increase fourfold or more by 3/12 of

age RPR still positive by 6/12 of age TPHA still positive by 1 year of age

Treated InfantsTreated Infants• Monitored clinically and serologically

at 1, 3, 6, 12, 18, and 24 months. Lumbar puncture should be repeated 6 monthly till normal.

THERAPY OF OLDER INFANTS AND THERAPY OF OLDER INFANTS AND CHILDRENCHILDREN

• After the newborn period, children discovered to have syphilis should have a CSF analysis to rule out congenital syphilis.

• Any child with congenital syphilis or with neurologic involvement should be treated with – Aqueous Cystalline Penicillin, 200,000-

300,000 units/kg/day administered as 50,000 units/kg/dose 4-6 hourly for 10 to 14 days (B, III)

THANK YOU