WHAT IS SYPHILIS ?

INTRODUCTION :

The Nationally Notifiable Diseases Surveillance system is a national passive surveillance
system comprising 52 infectious diseases designated as reportable to CDC. Based on the
reported nationally notifiable diseases for 1995, sexually transmitted diseases (STD's)
predominated and were reported among all age groups.

The 10 most frequently reported nationally notifiable infectious diseases in the United States for 1995 were, in descending order, chlamydia, gonorrhea, acquired immunodeficiency syndrome (AIDS), salmonellosis, hepatitis A, shigellosis, tuberculosis, primary and secondary syphilis, Lyme disease, and hepatitis B. The STDs of chlamydia, gonorrhea, AIDS, primary and secondary syphilis, and hepatitis B accounted for 87% of cases reported for these 10 diseases.

DEFINITION :

Syphilis is one type of sexually transmitted disease. Syphilis is the result of a bacterial
infection of the genital tract by the bacterium Treponema pallidum. Syphilis is passed from
one person to another during direct sexual contact with a syphilis lesion that involves
vaginal, oral, or anal sex. Syphilis can also be passed from an infected mother to her baby
during pregnancy and result in stillbirth or serious birth defects.




INCIDENCE :

• In 2008, 63% of the reported primary and secondary (P&S) syphilis cases were among men who have sex with men (MSM).
• During 2004–2008, rates of P&S syphilis increased the most among 15–24 year-old men and women.

ETIOLOGY :

• Syphilis is almost always passed through sexual contact. It also can be passed from an infected mother to her baby during pregnancy. 
• It may also be possible to catch syphilis if one is an injecting drug user and shares a needle with somebody who is infected.
• Pregnant women can pass the condition on to their unborn babies, which can cause stillbirth or death of the baby shortly after labor.
• It is extremely rare for syphilis to be spread through blood transfusions as almost all blood transfusions are routinely screened for syphilis.
• Syphilis is caused by bacteria called Treponema pallidum. The bacteria can enter the body if you have close contact with an infected sore, normally during vaginal, anal or oral sex or by sharing sex toys.

PATHOPHYSIOLOGY :

Treponema pallidum enters the body through intact mucous membrane abraded skin, almost exscluessively by direct sexual contact. After entery, the organism multiply locally and disseminate systemically through the blood stream and lymphatic. The infection can also be passed transplacentally from an untreated pregnant woman to her fetus during any stage of the disease ( congenital syphilis).

In rare instances, syphilis has been contracted through nonsexual personal contact, excidental inoculation, or blood transfusion from a syphilitic donor. Syphilis can progress to irrevisible blindness, mental illness, paralysis, heart disease and death.

CLINICAL MANIFESTATIONS :

Syphilis can manifest in three stages:

1. which occurs within a few weeks to months after infection.
2. which presents after a few months up to a year.  
3. which presents years to decades after primary infection.

PRIMARY SYPHILIS 

This appears 9 to 90 days after the organism gains entry via direct inoculation through the thin skin or mucosa of the anogenital tract or mouth during sexual exposure. 

The resulting lesion is typically a painless ulcer or ‘chancre’, sometimes indurated, that appears at the site of inoculation and is associated with regional lymphadenopathy; chancres can be multiple and atypical.

SECONDARY SYPHILIS

Occurs 3 to 6 weeks after the appearance of the chancre, with manifestations :

• including fever.
• malaise.
• mucocutaneous lesions (rash, condyloma lata, mucous patches).
• generalized lymphadenopathy.
• visceral disease (uncommon).

LATENT SYPHILIS

The lesions of both primary and secondary syphilis may wax and wane, but they eventually resolve. There are no signs or symptoms of active syphilis, but serological tests are positive for T. pallidum.

TERTIARY SYPHILIS

Affects around one-third of infected people following a variable period of latent infection, with manifestations including :

1) neurosyphilis—aseptic meningitis, with variable features, e.g. focal neurological deficits, cranial nerve palsies, hydrocephalus or psychiatric symptoms.

2) Gummatous syphilis—destructive granulomatous lesions most commonly present on skin, mucosal surfaces or in bone.

3) Cardiovascular syphilis—most commonly asymptomatic aortitis, aortic incompetence, aortic aneurysm, and coronary ostial stenosis.

Cardiovascular syphilis - narrowing of coronary ostia in aortus

Neurosyphilis - spirochetes in neural tissue

EXAMINATIONS :

The physical exam may include :

• Assess the skin and mouth to look for any rash or other abnormalities.
• For women, a pelvic examination to look for signs of syphilis. During the pelvic examination, doctor look for abnormal sores in the vagina or on the vulva, labia, rectal area and inner thighs. These sores occur during the primary stage of syphilis.
• For men, a genital examination to look for signs syphilis.
• For newborns, an examination of both the newborn and the mother for symptoms. The evaluation for congenital syphilis begins with a review of the mother’s health and testing the mother for syphilis.

INVESTIGATIONS :

The transient nature of the lesions and the spirochetaemia limit the role of direct detection of T. pallidum, hence diagnosis usually relies on serology, with tests being :

• Rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL) tests detect phospholipid cardiolipin as an antigen generally sensitive in early infection but tend to decline over the next several years without treatment; able to quantify disease activity and hence used for follow-up after treatment.

• T. pallidum haemagglutination assay (TPHA) use T. pallidum as the antigen may become positive shortly before the nonspecific tests typically remain reactive for life after successful treatment and therefore have no role in assessing stage of infection, ‘cure,’ or reinfection.

• Immunoglobulin (IgM) - tests measure both immunoglobulin (Ig) G and IgM antiphospholipid antibodies formed by the host in response to lipoidal material released by damaged host cells early in infection and lipid from the cell surfaces of the treponeme itself. 

• Fluorescent treponemal antibody absorption ( FTAABS) - It is the most specific test for the diagnosis of syphilis when lesions are present. This test uses fluorescein isothiocyanate-labelled antibody specific to pathogenic treponemes, and therefore is suitable for the examination of specimens from oral and rectal lesions.

TREATMENT :

1.Early infections :

• The first-choice treatment for uncomplicated syphilis remains a single dose of intramuscular penicillin G or a single dose of oral azithromycin. Doxycycline and tetracycline are alternative choices; however, due to the risk of birth defects these are not recommended for pregnant women.
• Antibiotic resistance has developed to a number of agents, including macrolides, clindamycin, and rifampin. Ceftriaxone, a third-generation cephalosporin antibiotic, may be as effective as penicillin-based treatment.

2. Late infections :

• For neurosyphilis, due to the poor penetration of penicillin G into the central nervous system, those affected are recommended to be given large doses of intravenous penicillin for a minimum of 10 days.
• If a person is allergic, ceftriaxone may be used or penicillin desensitization attempted. Other late presentations may be treated with once-weekly intramuscular penicillin G for three weeks. If allergic, as in the case of early disease, doxycycline or tetracycline may be used, albeit for a longer duration. 

Treatment at this stage limits further progression, but has only slight effect on damage which has already occurred.

3. Jarisch-Herxheimer reaction :

• One of the potential side effects of treatment is the Jarisch-Herxheimer reaction. It frequently starts within one hour and lasts for 24 hours, with symptoms of fever, muscles pains, headache, and tachycardia. 
• It is caused by cytokines released by the immune system in response to lipoproteins released from rupturing syphilis bacteria.

STAGE	TYPE OF PENICILIN	OTHERS ANTIBIOTICS
Early syphilis (primary, secondary and early latent)	2.4 million U IM of penicillin G benzathine (Bicilin) in a single dose.	Doxycycline( vibramycin) 100mg orally twice a day for 2 weeks , or tetracycline 500mg orally four times a day for 2 weeks.
Re-treatment, if needed	7.2 million U of Bicilin total, given as three doses of 2.4 million U IM of Bicilin each at 1 weeks intervals.	-
Late latent syphilis	7.2 million U total of Bicilin gives as three doses of 2.4 million U IM of Bicilin each at 1 week intervals.	Doxycycline or tetracycline given for 4 week at same dasage/routes as early syphilis.
Tertiary syphilis Gumma , Cardiovascular Neurosyphilis	Same as for re-treatment and late latent stage Aqueous crystalline penicillin G 18-24 U IV daily , given as 3-4 million U every 4 hour for 10-14 days.	Same as for late latent stage Procaine penicillin G 2.4 million U Im once daily plus probenecid (Benemid) 500 mg orally four times a day both drugs given for 10-14 days.

COMPLICATIONS :

1. Cardiovascular complications ( aortitis and aneurysms)
2. Destructive sore of skin and bone (gumms)
3. Neurosyphilis
4. Syphilitic myelopathy – a complication that involves muscle weakness and abnormal sensation.
5. Untreated secondary syphilis during pregnancy may spread the disease to the developing baby. This is called congenital syphilis.

PROGNOSIS :

• Syphilis can be cured if it is diagnosed early and completely treated.
• Secondary syphilis can be cured if it is diagnosed early and treated effectively although it usually goes away within weeks , in some cases it may last for up to 1 year. Without treatment , up to one third of patients will have late complications of syphilis.
• Late syphilis may be permanently disabling, and it may lead to death.

PREVENTIONS :

• Prevention measures include seeking regular medical care throughout a lifetime. To allows a health care professional to best evaluate a person's individual risks of catching syphilis and curing syphilis in its earliest stage before serious complications occur.
• Abstaining from sexual activity or having sex with partner is infected with syphilis or another sexually transmitted disease. Latex condoms also provide some protection when used properly.
• Prevention of congenital infection and serious outcomes such as stillbirth and neonatal death rely on routine antenatal screening early in the pregnancy, with prompt treatment of infected mothers. 

NURSING CARE :

1. Chronic pain related to a lesion in body tissue.

Goal: Pain disappeared and comfort are met.

Nursing Intervention:

• Assess the history of pain and response to pain.
• Assess the needs that can reduce pain and explain the technique reduces pain and causes pain.
• Collaboration with physicians in providing analgesic to reduce pain.

2. Hyperthermia related to the infection process.

Goal: Clients will have a normal body temperature.

Nursing Intervention:

• Observation of general condition of the client with vital signs every 2 hours to detect any abnormal reading.
• Give antipyretics as recommended by your doctor and monitor the effectiveness of 30-60 minutes later to reduce the hyperthermia.
• Recommend that clients use a thin and loose clothing to encourage heat loss.
• Give client a lot of water to prevent dehydration.

3. Anxiety related to the disease process.

Goal: Anxiety is reduced or lost.

Nursing Intervention:

• Tell clients about the disease and actions to be carried out simply.
• Teach the couple about the importance of treatment to their infant.
• Discuss the importance of abstaining from sexual activity until he and his partners are cured and of using condoms to prevent reinfection.

CONCLUSION :

Syphilis represented a unique public health challenge because it carried with it a huge stigma and because it was transmitted by sexual contact. It was a disease that no one wanted to have or discuss. Yet it probably afflicted 10 percent of the population, with a greater incidence in males than in females, and some methods of prevention, control, and treatment were imperative if the disease was ever to be eradicated.


VIDEO : 

REFERENCE :

• Sheila S.S & Cynthia M.T (2009) Nursing Diagnosis Reference Manual , Ed 9^th , Philadelphia : Lippincort Williams & wilkins.
• LeMone & Burke & Bauldoff (2011) Medical-Surgical Nursing : Critical Thinking In Patient Care , Ed 5th , United States of America : Pearson.
• Leslie.H & Rick.D (2012) Contemporary Medical-Surgical Nursing , Ed 2nd , Unitede States of America : Delmar Gengage Learning.
• Priscilla.L.M & Karen.B (2008) Medical-Surgical Nursing : Critical Thinking In Client Care , Ed 4th ,  United States of America : Pearson International Edition.
• http://www.channel4embarrassingillnesses.com/men-in-white-coats/syphilis/introduction/

WHAT IS LEPROSY ?

INTRODUCTION :

Leprosy is a granulomatous infectious disease caused by Mycobacterium leprae.Leprosy is most commonly found in the developing world in developed countries, most cases are found among immigrants.The World Health Organization reported a global registered leprosy prevalence of 212,802 at the start of 2008.M.leprae is slow to proliferate and there may be a several year latency between the initial infection and apparent disease.It is probably spread through respiratory secretions, though most of the population is not susceptible to leprosy.









DEFINITION :

Leprosy also called Hansen's Disease , is a chronic infectious disease that primarily affects the skin , the peripheral nerves , the mucosa of the upper respiratory tract and the eyes. Leprosy can lead to progressive permanent damage of these structures and resulting devasting disfigurement and disability has led to the historical social stigma and isolation (leper colonies) of those affected by the disease.

INCIDENCE : 

Every year between two and three hundred thousand people are diagnosed with it and an estimated two to three million people around the world are disabled because of it. Leprosy is a mildly infectious disease caused by a bacillus called Mycobacterium leprae  (a relative of TB).

It is most common in places of poverty – dirty water, poor nutrition and low standards of living mean people’s immune systems are not strong and they are unable to fight the disease.

HOW IS LEPROSY SPREAD ?

Leprosy is spread through contact with mucous of infected person, usually when he or she sneezes or coughs. The disease is not highly contagious. Close, frequent contact with an untreated person is required to contract leprosy. The bacteria responsible for leprosy multiply very slowly. 

ETIOLOGY :

• Leprosy is caused by a slow-growing type of bacteria called Mycobacterium leprae (M. leprae). Leprosy is also known as Hansen's disease, after the scientist who discovered M.leprae in 1873.

• Leprosy is caused mainly by Mycobacterium leprae, a rod-shaped bacillus that is an obligate intracellular (only grows inside of certain human and animal cells) bacterium.

• M. leprae is termed an "acid fast" bacterium because of its chemical characteristics.

RISK FACTORS :

• People at highest risk are those who live in the areas where leprosy is endemic (parts of India, China, Japan, Nepal, Egypt, and other areas) and especially those people in constant physical contact with infected people.

• There is some evidence that genetic defects in the immune system may cause certain people to be more likely to become infected (region q25 on chromosome 6).

• People who handle certain animals that are known to carry the bacteria (for example, armadillos, African chimpanzee, sooty mangabey, and cynomolgus macaque) are at risk of getting the bacteria from the animals, especially if they do not wear gloves while handling the animals.

PATHOPHYSIOLOGY :

TYPES :

WHO categorizes the disease based on the type and number of skin areas
affected. They are:


1. paucibacillary—five or fewer lesions with no bacteria detected in the skin smear (sample taken from the area)

•intermediate leprosy—a few flat lesions that sometimes heal by themselves and can progress to a more severe type.

• tuberculoid leprosy—a few flat lesions, some large and numb; some nerve involvement, can heal on its own, persist, or may progress to a more severe form.

•borderline tuberculoid leprosy—lesions like tuberculoid but small and more numerous; less nerve enlargement, may persist, revert to tuberculoid, or advance to another form.

2. multibacillary—more than five lesions or bacteria is detected in the skin smear, or both.

• mid-borderline leprosy—reddish plaques, moderate numbness, swollen lymph glands; may regress, persist, or progress to other forms.

• borderline lepromatous leprosy—many lesions with flat lesions, raised bumps, plaques, and nodules, sometimes numb; may persist, regress, or progress.

• lepromatous leprosy—many lesions with bacteria; hair loss; nerve involvement; limb weakness , disfigurement , does not regress.

CLINICAL MANIFESTATIONS :

Painless skin patch accompanied by loss of sensation but not itchiness (Loss of sensation is 

a feature of tuberculoid leprosy, unlike lepromatous leprosy, in which sensation is

preserved.) 

Chronic insensate patch due to leprosy infection. Ho Chi Minh City, Vietnam. (Courtesy of D. Scott Smith, MD)

• Loss of sensation or paresthesias where the affected peripheral nerves are distributed.

• Wasting and muscle weakness.

• Foot drop or clawed hands (may result from neuritic pain and rapid peripheral nerve damage; as seen in the image below) 

 

• Ulcerations on hands or feet. 

• Lagophthalmos, iridocyclitis, corneal ulceration, and/or secondary cataract due to nerve damage and direct bacillary skin or eye invasion.

• Sudden onset of skin redness and new lesions.

• Erythem nodosum leprosum [ENL]; as seen in the image below).

Patient with erythema nodosum leprosum type 2 reaction several weeks after initiation of drug therapy. This photograph was taken after tendon release. Redwood City, California. (Courtesy of D. Scott Smith, MD)

It usually takes about 3 to 5 years for symptoms to appear after coming into contact with the leprosy-causing bacteria. 

Some people do not develop symptoms until 20 years later. The time between contact with the bacteria and the appearance of symptoms is called the incubation period. Leprosy's long incubation period makes it very difficult for doctors to determine when and where a person with leprosy got infected.



EXAMINATIONS :

Physical examination should include the following:

1. Evaluation of skin lesions.
2. Careful sensory and motor examination.
3. Palpation of peripheral nerves for pain or enlargement, with particular attention paid to the following locations:

• Elbows - Ulnar nerve.
• Wrist - Superficial radial cutaneous and median nerves.
• Popliteal fossa - Common peroneal nerve.
• Neck - Great auricular nerve.

 4. Skin smears or biopsy -material that show acid-fast bacilli with the Ziehl-Neelsen stain or the Fite stain (biopsy) can diagnose multibacillary leprosy, or if bacteria are absent, diagnose paucibacillary leprosy. 

5. Other tests can be done, but most of these are done by specialized labs and may help a clinician to place the patient in the more detailed Ridley-Jopling classification and are not routinely done (lepromin test, phenolic glycolipid-1 test, PCR, lymphocyte migration inhibition test or LMIT). 

6. CBC test, liver function tests, creatinine test, or a nerve biopsy may be done to help determine if other organ systems have been affected.

TREATMENT :

1.Systemic antibiotic therapy to prevent deep infection. 

2.Topical antibacterial therapy ex: mupirocin..the medication must be applied to the lession several times daily for week.     
               
 Mupirocin ( Muprin)

Indication : Bacterial skin infections.
Dosage : Adult and children apply one TDS for up to ten days.
Special precaution : Not for ophth or intranasal use. Avoid contact with eyes. Moderate                                              to severe renal impairment.
Side effect : Burning , stinging and itching of the skin.

3.Multidrug therapy is the accepted method as it cures patients, reduces the reservoir of infection and interrupts transmission. It also prevents disability as patients are cured before the disease progresses. Leprosy is divided into two types for treatment (World Heath Organization, 2005):

• - Paucibacillary, involving one to five skin lesions. Rifampicin and dapsone are given for six months.

Rimactane ( Rifampicin)

Indication : Combination with other antibiotic / chemotheraphy agents in all forms of Tb                             and Leprosy .

Dosage : 450mg to 600mg per day (adult).

                  10-20 mg / kg per day . maximum 600mg per day (children) .

Side effect : Reddish brown discolouration of body fluid , gastrointestinal disturbance ,                                  hepatic toxicity and  renal failure .

Contraindication : hypersensitivity , jaundice .

Special precaution : Liver disease , pregnancy , premature and newborn infant.

• - Multibacillary, involving more than five skin lesions. Rifampicin, clofazimine and dapsone are given for 12 months.

Dapsone 

Indication : Primary treatment for dermatitis herpetiformis. It is an antibacterial drug for                           susceptible cases of leprosy. 
Dosage : 25mg and 100mg for oral use (tablet).
Side effect : Liver problem or fetal blood.
Special precaution : G6PD , severe heart disease , liver disease , severe lung disease and                                           serious infections.
Contraindication : Hypersensitivity and pregnancy.






PROGNOSIS : 

The prognosis of leprosy varies with the stage of the disease when first diagnosed and treated. For example, early diagnosis and treatment limits or prevents tissue damage so the person has a good outcome. However, if the patient's disease has progressed to more advanced disease, the complications listed below can markedly affect the patient's lifestyle, and thus the condition has a fair to poor prognosis.




 

PREVENTION :

Prevention of contact with droplets from nasal and other secretions from patient with untreated M.Leprae infection currently is a a way recommended to avoid the disease.




COMPLICATIONS :

The complications of leprosy depend on how quickly the disease is diagnosed and effectively treated. 

• Sensory loss (usually begins in extremities).

• Permanent nerve damage (usually in extremities).

• Muscle weakness.

• Progressive disfigurement (for example, eyebrows lost, disfigurement of the toes, fingers, and nose).

In addition, the sensory loss causes people to injure body parts without the individual being aware that there is an injury; this can lead to additional problems such as infections and poor wound healing.

NURSING CARE :

 1.  Impaired skin intergrity related to disease process.

Goal : patient will exhibit improved or healed lesions or wounds.

Nursing Interventions :

• Inspect patient’s skin every 8 hours, describe and document skin condition and report changes to provide evidence of thr effectiveness of skin care regimen.
• Provide supportive measures as include :
• -Assist with general hygiene and comfort measures to promote comfort and general sense of well being.
• Encourage patient to express his feeling about their skin condition to enhance coping.

2.  Disturbed body image related to disease process.

Goal : Patient express positive feelings about self.

Nursing Intervention:

• Encourage patient to participate in self-care and and as appropriate to reduce their concern about body image.
• Help patient to identify positive aspect of their appearance to improve self-esteem.
• Encourage patient to participate in a support group with other patient who have been diagnosed witn the same diagnosed with them to express feeling and obtain support who can understand their concerns.

3.Anxiety related to disease process.

Goal : Patient is able to be calm and peaceful.

Nursing Intervention:

• Teach client regarding disease process to reduce their anxiety.
• Explain the care and ask them question to measure patient level of understanding.
• Introduce the client to hospital environment to  comfort the patient.

CONCLUSION :

Leprosy is a horrible disease. It is disheartening to know that even in this day and age people diagnosed with this disease are still frowned upon and shunned from their communities. Maybe one day this will be a disease that no longer exists only mentioned in medical history book.

VIDEO :

REFERENCE : 

• Sheila S.S & Cynthia M.T (2009) Nursing Diagnosis Reference Manual , Ed 9^th , Philadelphia : Lippincort Williams & wilkins.
• http://www.nlm.nih.gov/medlineplus/ency/article/001347.htm
• http://www.webmd.com/skin-problems-and-treatments/guide/leprosy-symptoms-treatments-history?page=2
• http://www.slideshare.net/yousrydermatology/my-lecture-on-atopy