Page 204 - The Netter Collection of Medical Illustrations - Integumentary System_ Volume 4 ( PDFDrive )

Plate 6-29 Integumentary System

SYPHILIS IN PREGNANCY

SYPHILIS (Continued)

and tabes dorsalis. Tabes dorsalis results from degenera-
tion of the posterior columns of the spinal cord. The
posterior columns are critical for proper sensation, and Macerated
patients with tabes dorsalis develop gait disorders, erosions,
diminished reflexes, proprioception abnormalities, sloughed
pain, paresthesias, and a host of other neurological skin, failure
symptoms. If neurosyphilis remains untreated, the to thrive.
patient dies of the disease. Therefore, any patient who Approx-
exhibits signs or symptoms of neurosyphilis should imately
undergo a spinal tap to evaluate the cerebrospinal fluid Large, pale, 1/3 of neo-
for involvement with T. pallidum. boggy placenta nates will
Congenital syphilis occurs as the result of vertical die from
transmission from an infected mother to her unborn congenital
fetus. Up to one third of infected neonates die of the syphilis.
disease. In neonates who survive, the disease manifests
in many ways. Neonates may present with macerated
erosions associated with cachexia and failure to thrive. Macerated fetus
“Snuffles” is the term used to describe the chronic
runny nose with a bloody purulent discharge. Rhagades
are one of the most common signs seen in congenital
syphilis; they appear as scarring around the mouth and
eyes. Many bony abnormalities have been reported,
including a saddle-nose deformity, the Higoumenakis
sign (medial clavicular thickening), saber shins, and
Clutton’s joints. Teeth abnormalities include Hutchin-
son’s teeth (notched incisors) and, less frequently, mul-
berry molars.
Histology: Skin biopsies of syphilis that are evaluated
with routine hematoxylin and eosin (H&E) staining
show varying features depending on the stage and form
of disease being biopsied. A universal finding in all
forms is the presence of numerous plasma cells within
the inflammatory infiltrate. Ulceration, granulomas,
and vasculitis are often encountered. The spirochetes
cannot be appreciated with routine H&E staining;
special staining techniques are required. The Steiner Spirochetes
stain and the Warthin-Starry stain are the two most in fetal tissue
commonly used stains. Immunohistochemical stains (Levaditi stain).
can also be used, and they have been shown to be highly T. pallidum
sensitive and specific.
Pathogenesis: Syphilis is caused by the spirochete, T.
pallidum pallidum. This bacteria is highly infective and
is predominantly spread by sexual contact and by trans-
mission from an infected mother to her unborn child. penicillin for at least 2 weeks. Most patients who are the rash of secondary syphilis appear worse for a period
Treatment: The T. pallidum organism has very little treated for syphilis develop the Jarisch-Herxheimer of time. This reaction is not specific to T. pallidum and
antibiotic resistance, and the therapy of choice is still reaction. This reaction is the result of the decimation has been reported with other infectious agents. It is
penicillin. A single intramuscular dose of 2.4 million IU of the T. pallidum organisms due to therapy with peni- critical to follow patients long enough after therapy
of benzathine penicillin G is recommended, and some cillin. As the scores of bacteria are killed, the dead ensure adequate treatment as measured by titers on
now recommend a follow-up dose—the same as the spirochetes induce an inflammatory reaction. This rapid plasma reagin (RPR) or venereal disease research
initial dose—at 1 or 2 weeks. Patients who develop reaction may manifest as fever, chills, fatigue, malaise, laboratory (VDRL) testing. All patients with syphillis
neurosyphilis need to be treated with intravenous and rashes of varying morphology. It can often make should be tested for HIV.

190 THE NETTER COLLECTION OF MEDICAL ILLUSTRATIONS