Spirochete- a spiral-shaped bacterium

E.g., Borrelia [bor re' ;e ah], Treponema (T.)

Non-pathogenic - normal flora of intestinal tract, oral cavity, genital tract

?T. calligyrum- smegma
T. genitalis
?T. macrodentium
T. microdentium
?T. mucosum -> pyorrhea alveolaris

5 types of pathogenic treponemes [treponema]

never cultured in vitro
no nonhuman reservoirs

Central and South America
Skin- usually hands, feet, and scalp

Depigmentation

Usually children and adolescents
Nonsexual contact- not highly contagious

Humid tropics- Africa, South America, India, Indonesia, Pacific Islands- about 50 million cases
Rural
Skin and bone
In endemic areas, 75% contract before age 20

Arid and warm- Middle East, Central & South Africa
Lesions similar to yaws- skin and skeleton
Usually acquired in childhood
~ Poor hygiene
Penicillin

Any climate
Any tissue
Stages

Primary- infection at entry

Chancre [shang' ker]

Secondary- spread to other tissues
Tertiary- highly destructive lesions

Fatalities

80% cardiovascular (aortitis, aneurysm)
20% neurologic

Oslo study- 2000 untreated for 40-60 years

25% developed secondary
13% developed tertiary
11% fatalities <- syphilis
? developed immunity

Venereal Syphilis

• AKA: Neapolitan disease, French d., Spanish sheep herder's d., etc.
• 1530 Girolamo Fracastoro- Syphilis Sive Morbus Gallicus
• 1902 Germany: A cure would lead to “a moral syphilisation even worse than that of the body.” (Rene Dubos 1959 Mirage of Health, P.202)
• 
  Columbian Theory

Guaiac wood
Epidemics 1495->

“Venereal leprosy”
“Saracen ointment”- contained mercury

1450- Moveable type
1490 & 1505- Order of St. Lazarus asylums disbanded by the pope
1492- Jews expelled from Spain

Moors in Spain- slaves imported from areas of yaws and endemic syphilis

1495- French army at Naples disbanded

?placental transmission only in venereal syphilis
Partial cross-immunity
Strains

Living conditions: hygiene & crowding
Climate- treponeme susceptible to oxygen & dessication

84% attack rate- from infected mother's placenta
50% aborted or stillborn

Metaphysitis (osteochondritis) -> increased calcification

May -> “saw-toothed” metaphysis
Spongy bone decreases
May cause displacement of the epiphysis

Also in TB & pyogenic osteomyelitis

Periostitis- in about 9% of cases
Diaphyseal osteomyelitis in about 50% of cases

Wimberger's sign- medial proximal on both tibae

Also may be seen in osteomyelitis, hyperparathyroidism, & infantile generalized fibromatosis

Skull involvement in 5-10% of cases

Osteitis -> necrosis
Hypertrophic periostitis (bossing) rare

<- rickets, anemia

Rickets often ~ congenital syphilis

50-75% of cases- bone changes are slight or heal

Late Congenital Syphilis- 5-15 years old

Only 7.2% have bone lesions

Chronic- latent infection & persistent deformities

Tibia- most commonly affected bone

Ulna, skull, & femur next

Hyperplastic osteoperiostitis may ->

Skull  -> frontal bossing

Sternocleidomastoid part of clavicle -> Higoumenaki's sign (swelling)

Tibia -> saber shin 43% of cases

• Subperiosteal apposition of woven bone on anterior tibia

• ~ Narrowing of the medullary cavity
• Porous bone tends to become sclerotic
• Unaffected fibula & accelerated tibial growth -> bowing
• Rickets -> lateral bowing <- weight

Gummatous osteomyelitis

-> dense, irregular trabeculae
Sequestrum rare

“Saddle nose”- 17-30% of cases- non-specific

<- maxilla fails to grow normally <- rhinitis

Dental stigmata ~ 50% of cases with bone lesions

Not diagnostic without bone lesions

Deciduous molars and permanent teeth

Hutchinson's teeth- notched, narrowed, & barrel-shaped incisors

 

Mulberry molar- smaller, 1st lower molar with rough occlusal surface

Diagnostic:

1. Hutchinson's triad-

Hutchinson's teeth,

Interstitial keratitis (photophobia & blurred vision),

and 8th nerve deafness,

2. Mulberry molars, or
3. Cluttons joint- hydrarthrosis

<- synovial membrane infection

1943- penicillin

10-20% have bone lesions- tertiary

Bones that may be affected: tibia, frontal, frontal, parietal, nasal-palatal region, sternum, clavicle, vertebrae [slight, usually cervical body], femur, fibula, humerus, ulna, radius

Cranial lesions- highly diagnostic
Subperiosteal lesions may be secondary
Periostitis

Hematogenic/ trauma
Lifting periosteum, especially in metaphysis of tibia, fibula, clavicle, radius, ulna

Osteitis and osteoperiostitis

<- periostitis

Medullary cavity narrows
Radial pattern spiculation- new bone at right angles to shaft

~ Osteosarcoma

Gummatous osteomyelitis

Soft tissue gummas- skin, liver, etc.

Gumma <- thrombosed vessels [restricts blood flow] + treponemal toxins -> hyperimmune reaction
Resorption <- leukocytes and macrophages
Sequestra rare

Cranial involvement from soft tissue infection
Joints involved in 12% of osseous syphilis cases

Charcot joints- tabes dorsalis

Usually knee

Due to nerve damage and loss of feeling

Gummatous arthritis

~ Acquired syphilis

From metaphysis to epiphysis to articular cartilage

Endemic (nonvenereal) syphilis

(Bejel [Bej' el])

~ Poor hygiene

At one time in Ireland, Scotland, Scandinavia, Greece, Russia

Bone lesions similar to those of acquired syphilis in 3-4% of cases
Rarely involves cranium and joints
Absent- dental stigmata & osteochondritis <- no fetal infection
Saber shin
“Gangosa”

Destruction of nose, paranasal tissues & palate

Deep gummas

Localized subperiosteal apposition

Rare outside of the 20th parallels
Childhood & adolescent disease (may persist)
Bone lesions in about 10% of cases

Long bones of legs & forearms & hands & feet

Saber shin in 40%
15% of all cases of tertiary yaws
Dactylitis- rare in syphilis

Subperiosteal apposition

Absent- dental stigmata & osteochondritis <- no fetal infection

Gangosa [nasal destruction]- in 1% of all yaws

Also in leishmaniasis, leprosy

Goundou [goon' doo]- “large nose”

Hypertrophic osteitis of maxilla

Localized gummatous osteomyelitis

Cranial rare & does not penetrate inner table

©2007 by Steve Savage