Nursing Diagnoses

Risk for injury to patient and others related to the disease process.

If not properly treated, the patient will be at risk of the syphilis progressing into the other phases, which can have serious consequences for the individual. The patient is also at risk of transmitting the infection to others if not properly being treated and/or if not using safe sex practices to protect any sexual partners.

Interrupted family processes related to the effects of the diagnosis on a couple.

Receiving a diagnosis of syphilis can cause some strain and tension within a relationship especially if it agreed to be a closed relationship and neither partner originally had syphilis. Open and casual relationships can also be affected. Patient education should include talking to any sex partners the patient may have to let them know so they can get checked as well to see if they have the infection as well.

Anxiety related to the diagnosis.

Discovering you have a sexually transmitted infection, like syphilis, can create a lot of anxiety for an individual. The person may become anxious about how long he/she has had it, who it was contracted from, and how many people the person may have transmitted it to. Having to tell sex partners you have syphilis can induce anxiety. If a woman is pregnant she may worry about what effect the infection may have on the fetus.

Nursing Care

Patient education

Patient education for a patient with syphilis is critical for the individual to recover and prevent the spread of the infection. The patient needs to understand that syphilis is caused by a bacteria and therefore will be treated by using antibiotics. It is imperative that the patient understands he/she needs to finish the entire course of antibiotics even if the symptoms are resolved before the treatment is complete. 

It is important to explain to the patient that he/she should refrain from any sexual activities during the treatment as the infection can still be transmitted to others. Counseling and testing for HIV infection is also encouraged as well as discussing safe sex practices.

The patient will need to be informed that he/she will need to come in for repeat testing in six and twelve months to verify the infection has been cleared.

References

Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Sexually Transmitted Infections. In Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed., pp. 1264-1265). St. Louis, Missouri: El Sevier.

Treatment

The first choice of treatment for syphilis is the long-acting benzathine penicillin G given through an intramuscular (IM) injection. For individuals who have penicillin allergies there are other antibiotics that can be used to treat the infection such as doxycycline and tetracycline. The chart below explains the recommended treatment based on which phase of syphilis the patient is in. For more information on the treatment of syphilis in different phases and for the treatment of other sexually transmitted infections check out this article.

Phase	Treatment	Treatment outcomes
Primary	One-time IM injection of long-acting benzathine penicillin G, 2.4 million units	Treat T. pallidum infection before progresses to other phases
Secondary	One-time IM injection of long-acting benzathine penicillin G, 2.4 million units	Treat T. pallidum infection before progresses to other phases; will not repair damage already done
Early Latent	One-time IM injection of long-acting benzathine penicillin G, 2.4 million units	Treat T. pallidum infection before progresses to tertiary phase; will not repair damage already done
Late Latent/Latent of unknown duration	Three IM injections of long-acting benzathine penicillin G, 7.2 million units total, given at weekly intervals	Treat T. pallidum infection before progresses to tertiary phase; will not repair damage already done
Tertiary	Three IM injections of long-acting benzathine penicillin G, 7.2 million units total, given at weekly intervals	Treat T. pallidum infection; will not repair damage already done

References:

1:  Syphilis Treatment and Care. (2015, April 17). Retrieved May 6, 2015, from http://www.cdc.gov/std/syphilis/treatment.htm

2:  Diseases Characterized by Genital, Anal, or Perianal Ulcers. (2014, August 15). Retrieved May 6, 2015, from http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm

Uh oh! What's that?

Signs and symptoms

As mentioned in previous posts, syphilis is broken up into four different stages: primary, secondary, latent, and tertiary syphilis. Each stage has it's own unique signs and symptoms.

Primary Syphilis

Primary syphilis is characterized by swollen nodes and the presence of a sore where the bacteria entered the body that appears generally a few weeks after the transmission occurred. This sore is known as a chancre and is not painless and may go unnoticed depending on location. In addition to it being painless, the sore will resolve itself in three to six weeks with or without treatment. If the individual infected does not seek treatment, the sore will heal, but the bacteria will continue to multiply within the body, which then leads to the second phase of syphilis.1,2

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Secondary Syphilis

Secondary syphilis may present immediately after the chancre is healed, or it may present several weeks after. This second phase is characterized by a rash that appears on various areas of the body including in the mouth, vagina, and anus. Very commonly the rash appears on the palm of the hands and the torso of the body. Other characteristics of secondary syphilis that appear in concurrence with the rash are symptoms of the flu like swollen lymph nodes, muscles aches, sore throat and fatigue. During this phase the bacteria is still in the body and can be treated.1

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Latent Phase

The latent phase of syphilis is just what it sounds like - the absence of any signs or symptoms - even though the person is still infected. The latent phase can last for several years to several decades, and many will remain indefinitely in the latent phase without advancing to the final phase.1

Tertiary Syphilis

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The final phase of syphilis is characterized by the presence of a gumma, or a soft growth similar to a granuloma made of dead and swollen fibrous tissue. The gumma most often will form on the liver, but can also form on the brain, skin, heart, and even the eyes.3 Of course having a tumor-like growth on an organ will inhibit or alter the function of the given organ resulting in problematic symptoms depending on the location of the gumma. Symptoms can include numbness in parts of the body, blindness, dementia, decreased muscle coordination, and paralysis.1


References:

1:  Syphilis - CDC Fact Sheet. (2014, July 8). Retrieved May 4, 2015, from http://www.cdc.gov/std/syphilis/stdfact-syphilis.htm

2:  Syphilis - primary: MedlinePlus Medical Encyclopedia. Retrieved May 4, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000861.htm

3:  Gumma. Retrieved May 4, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000859.htm

4: Andrade, P., Mariano, A., & Figueiredo, A. (2010). Solitary frontal ulcer: A syphilitic gumma. Dermatology Online Journal 16(9). Retrieved from: https://escholarship.org/uc/item/5gs4q6wz

Diagnosing Cupid's Disease

Since syphilis is caused by a bacteria, the way to know if someone has syphilis is to identify the bacteria that causes it, Treponema pallidum. However, this bacteria cannot be grown in a culture so other tests have to be used to identify the microbe. There are both direct and indirect ways to verify if someone is infected with T. pallidum.

Direct methods, as you might have guessed, look directly for the bacteria itself. Samples may be taken from exudate from a chancre, a histological exam of tissue from the patient, or through nucleic acid amplification.1

Indirect methods of identifying T. pallidum is through tests that could reveal antibodies known as serological tests. The first serological test that would be done is a nontreponemal test analyzing immunoglobulin G and M antibodies, which are made by a person's immune system in response to a bacteria or virus. If this test were positive, then the second serological test would be done, a treponemal test. The treponemal test detects the specific antibodies made in response to a T. pallidum infection.

Even if a person has been tested and it has been found that he/she is infected with syphilis, the test cannot verify whether the person is in the first or second stage of the disease process. This is when it is important to talk to the patient about the signs and symptoms he/she has been experiencing, which is what I will be discussing next week.



For more information on diagnosing syphilis you can read this paper from the Canadian Journal of Infectious Diseases and Medical Microbiology.

References:

Ratnam, S. (2005). The laboratory diagnosis of syphilis. Canadian Journal of Infectious Diseases and Medical Microbiology, 16(1), 45-51. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095002/

Contraction and Infection

How is syphilis contracted?

Syphilis has various ways that it can be transmitted from person to person. One way is transmission from a pregnant woman to the fetus known as congenital syphilis; however the most common form of transmission and contraction of this infection is through contact with a chancre.

What is a chancre? A chancre is a sore caused by the contraction of T. pallidum. It can be located on the external genitals, inside the vagina, inside the anus or rectum, and in the mouth and lips.1 The bacteria is then passed on when another person comes in contact with the chancre whether it be through vaginal, anal, or oral sex.

Chancre on a lip (3)

Chancre on a penis (2)

In the 1990s syphilis was more common among heterosexual men and women, but now the population predominantly infected with syphilis is men who have sex with men ages 30-39 according to the CDC.1

When T. pallidum enters the body the bacteria is engulfed by antigen presenting cells, which then puts in motion an immune response resulting in the production of antibodies. This is generally what happens with any infection, yet with syphilis the antibodies produced by the immune system end up attacking normal tissues within the body.1,4

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References:

1: Syphilis - CDC Fact Sheet. (2014, December 16). Retrieved April 23, 2015, from http://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm

2: EponymsH | Our Dermatology Online journal. (n.d.). Retrieved April 23, 2015, from http://www.odermatol.com/issue-in-html/2013-1-33-eponymsh/

3: Canadian Medical Association Journal. (n.d.). Retrieved April 23, 2015, from http://www.cmaj.ca/content/183/17/2015.figures-only

4: LEPROSY & SYPHILIS. (n.d.). Retrieved April 23, 2015, from http://nursingstudentinprogress.blogspot.com/

Who has it and where?

CDC Reporting

The Division of Sexually Transmitted Disease Prevention, a division of the Centers for Disease Control and Prevention (CDC), came up with a plan in 1999 that was aimed at eliminating syphilis from the United States with specific goals to reduce the number of primary and secondary cases to less than 1000 and increasing the number of syphilis-free counties to 90 percent by 2005.1 After several years of this project being implemented the CDC noticed problems with the ways in which new cases were being reported and revamped the project again in 2006 with the slogan "Together We Can SEE: Syphilis Elimination Effort."2 The report can be found here. While all states have laws mandating physicians to report all cases of syphilis, often it is the labs that end up doing the reporting. The report found here goes into great detail about how the US can improve our reporting system to better track cases of syphilis around the country.

Where do people have syphilis?

It may not come as much surprise that in general there are higher rates of syphilis where there are more people living. Take a look at these two maps. The first one shows syphilis cases by county in blue from 2013, and the map beneath shows population density in red taken from the 2010 census.

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Because there is mandatory reporting of every syphilis case, there is plenty of information on the infection from the race/ethnicity of people with the infection, the sex and sexual orientation of the people, and the number of people with syphilis in individual states. The next graph represent the number of syphilis cases per 100,000 in the state of Washington broken up by county followed by a chart with similar information, but including previous years and the number of congenital cases.

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Finally, the graph below shows the numbers of people reported to have syphilis in 2013 broken up race, by sex, and then further broken up for males into men who have sex with women (MSW) and men who have sex with men (MSM).

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More information on syphilis cases in other states and territories can be found here.

References:

1: Centers for Disease Control and Prevention. (2003). Recommendations for Public Health Surveillance of Syphilis in the United States. Atlanta, GA: U.S. Department of Health and Human Services.

2: Centers for Disease Control and Prevention. (2006). Together we can: The National Plan to Eliminate Syphilis from the United States. Atlanta, GA: U.S. Department of Health and Human Services.

3: Syphilis Statistics. (2015, February 9). Retrieved April 9, 2015, from http://www.cdc.gov/std/syphilis/stats.htm

4: US census maps – demographics. Retrieved April 12, 2015, from http://ecpmlangues.u-strasbg.fr/civilization/geography/US-census-maps-demographics.html

What is syphilis?

Girolamo Fracastoro (3)

The History

Syphilis is a sexually transmitted infection (STI) that has been infecting people for many years and has had interesting cultural effects around the world. While evidence of the STI has been found in human bones at least 2000 years old in both the "old world" and "new world," it first took to the literary stage in 1530 when an Italian man named Girolamo Fracastoro wrote a poem entitled "Syphilis Sive Morbus Gallicus," which translated to English means "Syphilis or the French Disease."1,2 This poem is about a Shepherd named Syphilis who makes the Greek god, Apollo, angry and in return Apollo gives the man syphilis.2 The title is important to note as this man was Italian and referred to the infection as a French disease. Syphilis had many different nicknames and all were meant to insult as it was viewed as a cultural embarrassment. A few of the other nicknames were "the Neapolitan sickness," "the Castillian sickness," and "the Chinese ulcer."1 

The Bacteria

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Syphilis is caused by the bacteria Treponema pallidum. This bacteria is a spirochete, which means it has a spiral shape and is flexible. T. pallidum is a very fragile bacteria and does not do well when exposed outside of the human body. It is easily destroyed when it comes in contact with heat, if it becomes dry, or if it is washed.5

The Infection

T. pallidum enters the body through breaks in the skin or mucous membranes, and the most common delivery of the bacteria is through the mucous membranes of the genitalia as sexual intercourse causes minor abrasions through which the bacteria can enter. This is why it has earned itself the nickname of Cupid's Disease.5

Syphilis is broken up into four stages. I will be going into greater depth of each stage later so for now I will give a quick explanation. The primary phase usually occurs a couple weeks after transmission and appears in the form of a chancre, which is not very pretty to look at, but it painless. There is also usually lymphadenopathy in the genital area. The secondary phase is systemic and comes a few weeks after the appearance of the chancre. The person will usually have flu-like symptoms. The latent phase is next and can last several years. This is when the person has no symptoms and eventually will no longer by infectious. The final phase is late, or tertiary, syphilis and is characterized by the presence of a gumma. This is a chronic lesion that can affect any organ and, depending on where it is, can have serious consequences for the person.5

References:
1: Rothschild, B. (2005). History Of Syphilis. Clinical Infectious Diseases, 40(10), 1454-1463. doi: 10.1086/429626


2: Intagliata, C. (2011, May 27). Science Diction: The Origin Of The Word "Syphilis" Retrieved April 5, 2015, from http://www.sciencefriday.com/segment/05/27/2011/science-diction-the-origin-of-the-word-syphilis.html

3: Banque d'images et de portraits. (n.d.). Retrieved April 5, 2015, from http://www2.biusante.parisdescartes.fr/img/?refbiogr=6399&mod=s

4: SPIROCHETES, Syphilis Lecture Notes. (2011, April 27). Retrieved April 5, 2015, from http://www.nursing-help.com/2011/04/spirochetes-syphilis-lecture-notes.html

5: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Sexually Transmitted Infections. In Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed., pp. 1264-1265). St. Louis, Missouri: El Sevier.