Question

History and Physical Examination

A 25-year-old female comes to an ambulatory centre with pain in the right side of her pelvis and a slight temperature. She has a history of two episodes of Chlamydia cervicitis and herpes simplex vulvitis.

On physical examination, she is found to have abundant mucopurulent cervical discharge and painless genital lesion. She also has some swelling of her inguinal lymph glands.

Laboratory Data: A stat pregnancy test is order. It is positive.

Questions:

1. What other laboratory tests would you expect to be ordered?

2. Could this patient have syphilis?

3. If syphilis is suspected, what tests should be ordered?

4. Is there risk of congenital infection in this woman’s unborn child

Answer 1

1.Syphilis accelerates the course of HIV infection in pregnant woman. Lab investigation include

• Serological test
• A positive VDRL test has to be confirmed by fluorescent treponemal antibody absorption test (FTA-ABS) and Treponemal pallidum microhemagglutination (MHA-TP) test which are specific.
• Detection of spirochetes from the cutaneous lesion if any, by dark field examination.
• Fetal infection could be diagnosed by polymerase chakn reaction (PCR) of T. pallidum in amniotic fluid, fetal serum or spinal fluid.

2.Syphilis has a variety of signs and symptoms that can mimic a number of diseases. Consequently, compared with other STDs it is more difficult to recognize syphilis.if it is not treated, specific clinical stages are characteristic of the progression of disease. In the primary stage of the bacterial invasion, chancres appear. These are painless indurated lesions on the vulva. They frequently occur 10 to 90 days after inoculation. The chancre lasts 3 to 6 weeks, eventually healing on its own. Genital ulcers may also be present. Without treatment the infection progresses to the secondary stage. The secondary stage is systemic. The stage begins a few weeks after the chancres are first seen and blood-borne bacteria spread to all major organ systems. Manifestations characteristic of second stage can include flu-loke symptoms, such as fever, sore throat, headaches, fatigue, and generalized adenopathy. Cutaneous eruptions can also occur and include a bilateral, symmetric rash that typically begins on the trunk and also involve the palms snd soles;mucus patches in the mouth, tongue or cervix and condylomata lats in the anal and genital area.

3.The presence of spirovhetes on dark-field microscopy and direct fluorescent antibody tests of lesion exudate or tisdue can confirm a clinical diagnosis of syphilis. Nonspecific antitreponemal antibodies can be detected by tests such as the VERY test and the RPR test. The fluorescent treponemal antibody absorption test and the T. pallidum particle agglutination test detect specific antitreponemal antibodies and are suitable for confirming the diagnosis. A false-negative result maybe obtained during primary syphilis if the test is done before the individual has had time to produce antibodies. 4.Congenital infection results from transplacental migration of spirocgete to the fetus. Cobgenital disease occurs with all stages of maternal infection and at any gestational age. The basic pathology is obliterative endarteritis. Depending upon the intensity and time of occurence of the infiltration, the fate of fetus will be as follows

• Abortion
• Preterm birth
• Intrauterine deaths leading to either a macerated or a fresh still birth.
• Non-immune fetal hydrops.
• Delivery of a highly infected baby with early neonatal death.
• Survival with congenital syphilis.