Chapter 17: Infectious Diseases 219
areusuallynoclinical signs orsymptoms,and infection
mayalsogoundiagnosed.
Tertiarysyphiliscandevelopwhenlatentsyphilisisleft
untreated. Virtually any organ system may be involved.
Whenthecardiovascularsystembecomesinvolved,theout-
comecanbefatal.Lesionsmaydevelopontheaorta,result-
inginaneurysm.Ifneurologicmanifestationsarepresent,
neurosyphilisshouldberuledout.
Syphilis during pregnancy most commonly results in
spontaneous abortion. Successfully completed pregnancies
arecomplicatedbyprematurityorintrauterinegrowthretar-
dation. Early congenitalsyphilismay present withrhinitis,
pneumonia,orfailuretothrive,usuallybeginningwithinthe
rst3months.Nasaldischargebecomesthickandevenhem-
orrhagic. Like adult syphilis, congenital syphilis can affect
multipleorgansystems.
Thediagnosisofsyphiliscanbe made througheither
thetestingoflesionexudateorserologicaltesting.Testing
of the lesion exudates (primary or secondary stage)can
be doneeither throughdark eld examination or direct
uorescentantibodytoestablishthediagnosis.
Twotypesofserologictestsareused.Thersttypeis
referredtoasnontreponemaltests.TheyareVenerealDis-
ease Research Laboratories (VDRL) and rapid plasma
reagin (RPR). Either one of these tests can be used for
screeningortodeterminediseaseactivityaftertreatment
andwilltypicallybecomepositive4–6weeksafterinfec-
tion.Thesecondtypeoftestsarethetreponemalantibody
tests (uorescent treponemal antibody absorption) and
Treponema pallidum particle agglutination. Any of these
testsareusedtoconrmthediagnosis.
7,9
Whenadiagnosisofsyphilishasbeenestablishedand
treatmentisundertaken,titersfromeitherVDRLorRPR
should be consistently used to ascertain a therapeutic
responsereectedbydecreasingtiters.Typicallytitertest-
ingisdoneoveraperiodof12months,butinsomecases,
suchasinlatesyphilisorinthesettingofHIVinfection,
titertesting may berequired foralonger period oftime.
Thegoaloftitertestingisthedevelopmentofanonreactive
titer,buttypicallyasignicantdecrease(fourfoldoreight-
folddropfrombaseline)ismorecommonlyencountered.
Incertaincasesalowtitermaypersistindenitely.
7,9
Ifneurosyphilisissuspected,alumbarpunctureshould
be performed. Indirecttesting of the cerebrospinal uid
(CSF) by VDRL should be ordered in conjunction with
serologytestingtoconrmthediagnosis.
Management
Themanagement of syphilisclearlydepends on staging.
Primary,secondary,orearlylatentsyphilisoflessthan1
yeardurationrequiresasingleintramuscularinjectionof
penicillinG.Inlatelatentsyphilisorsyphilisofunknown
duration,threeweeklyinjectionsofintramuscularpenicil-
linGarerequired(Table17–2).Inthesettingof neuro-
syphilisandtertiary syphilis, intravenous(IV)penicillin
isrequired.
Treatmentofneurosyphilisandtertiarysyphilisinpen-
icillin-allergicpatientsrequiresclinicalexpertiseineither
alternative regimens or in desensitization to penicillin.
Additionally, treatment of syphilis in pregnant patients,
children,orneonatesalsorequiresclinicalexpertise.Non-
treponemal testing with either VDRL or RPR should be
performedatmonths3,6,and12tomeasuretherapeutic
responseinadults.
7,9
Genital Herpes
General Characteristics
Herpesvirusesincludeherpessimplexvirus(HSV),varicella-
zostervirus(VZV),EBV,andcytomegalovirus(CMV).HSV
causesgenitalherpesandcanbedifferentiatedintoHSV1
andHSV2.HSV1acquisitiontendstooccurinchildhood
andisthecauseoffeverblisters,butitcanalsocausegenital
herpesandbeacquiredinadulthood.
HSV2 acquisitiontends to occuras aresultofsexual
activity and is often a cause of recurrent genital herpes
outbreaks. Infection with both HSV 1 and 2 is possible.
Althoughtheincubationperiodrangesfrom2to20days
afterexposure,aprimaryoutbreakwithvesiclesdoesnot
alwaysoccur.Infact,oftenpatientswillbeasymptomatic
during this initial infection period. Patients may remain
asymptomaticthroughoutlife,developrecurrentoutbreaks,
ordeveloptheirrstcaseofgenitalherpesmanyyearsafter
theinitialinfection.Ofnoteisthefactthattransmissionof
HSVispossibleevenwhenapatientisasymptomatic.HSV
maynotonlyaffectthelips,oralcavity,orgenitalarea,but
alsotheeyesormeninges,oritmaybedisseminatedbeyond
these areas.
7,10
Signs, Symptoms, and Diagnosis
IfaninitialinfectionwithHSVleadstosymptoms,fever,
headache, malaise, myalgia, arthralgia, and inguinal
lymphadenopathy may develop.The lesionsmay appear
asgroupsofvesiclesonanerythematousbase,whichmay
evolveintopustulesandeventuallyulcerate(Figure 17–2).
Thelesionstendtobepainful,andoftenminimaledema
Figure 17–2 Genital herps of the penis.
Source: Courtesy of Dr. N. J. Flumara and Dr. Gavin Hart/CDC.

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