THE EARLY DIAGNOSIS OF SYPHILIS
Major. M.P.Vora, M.B.B.S., I.M.S. (Rtd.), Bombay
Indian Medical Record
A monthly journal of Public Health, Tropical Medicine and Surgery etc .
Volume LXXXVI, Number-5 of May 1966
This article was solely contributed to Indian Medical Record
Importance of speedy diagnosis of early syphilis, its manifold advantages and serious consequences of the failure to do so, are not sufficiently appreciated. Whenever a patient complains of genital lesion, one is naturally tempted to think at once of a venereal sore. Such a high index of suspicion is praiseworthy, but not so commendable is the subsequent procedure often adopted by some physicians. In the practice of venereology, the tendency, to administer treatment for a genital ulcer without first ascertaining the exact diagnosis is very regrettable. A physician is often misled by the clinical appearance of the genital ulcer: he takes it for granted as a chancre or chancroid and institutes specific treatment, without first confirming its diagnosis by laboratory tests. Such a step no doubt is prompted by the desire to give immediate relief to the patient, but is dangerous and at times disastrous. Chancre or chancroid is by no means the only cause of a genital ulcer. If the physician, dealing with these cases, desires that his management of patients be scientific, efficient and responsible, he must have recourse to the laboratory aid. There are no short-cuts to the early and accurate diagnosis of a venereal sore.
If the diagnosis of the case turns out to be different from the original assumption, one has only to imagine its effects on the mind of the patient, the health of the community and the slur on the professional ability of the physician concerned. Any presumption based merely on clinical impression or spot diagnosis to the total neglect of modern scientific diagnostic procedures, is quite unjustifiable and amounts to professional negligence. It is not uncommon to come across a patient with frank secondary manifestations of syphilis even though he was treated of course indecisively a few weeks ago. Such a procedure is reprehensible and must stop forthwith.
Experience has proved beyond any doubt that early diagnosis and treatment of syphilis appreciably increases the possibility of a complete cure in the shortest time with least inconvenience to the patient and decreases the opportunity for dissemination of infection both in the individual and in the community. The best prognosis can be expected in the case in which the diagnosis of syphilis is made on the detection of Treponema pallidum in the primary lesion, before the antibody titre rises high enough to show a positive serologic test or syphilis. No treatment however perfect it may be which is given after the passing away of the early primary stage, is an absolute guarantee of a cure. This demands early diagnosis of the primary syphilis, which in turn will help to reduce the chances of the involvement of the cardiovascular or nervous system in the individual and the spread of infection in the community.
The time after infection at which the diagnosis of syphilis is made and the treatment begun, is of major importance in the ultimate outcome; for, the cure of the early syphilis is much more readily obtained provided the treatment is instituted within the first few days of the appearance of the chancre than when it is delayed until the development of the seropositivity or the onset of the frank secondary syphilis. This observation holds good even today in spite of the introduction of penicillin in syphilotherapy.
According to Moore 4 the possibility of the cure is at least about 18 % better in the sero-negative primary stage than in the sero-positive primary stage and 21 % better than after the appearance of secondary syphilis.
The Committee on the Medical Research of the Office of Scientific Research and Development and U.S. Public Health Service 3, while reviewing 11,589 patients with early syphilis, treated with from 0.6 to 2.4 mega units of penicillin G in 4 to 15 days, notes, “There was a close correlation between the failure rate and the duration of the infection. Cases of secondary syphilis had a cumulative failure rate of 32% while the cases of sero-negative primary syphilis had a failure rate of only 14% at the end of 11months.”The high rate of failure of the treatment is obviously due to the early experimental nature of schedules of treatment employed. However, the results show the effects of delayed diagnosis of syphilis on the ultimate outcome.
While evaluating the result of treatment in 31,000 patients with early syphilis, Alshuler 1 and his associates’ state, “the incidence of failure rate was 8.73% in the sero-negative primary syphilis and 18.62% in the sero-positive primary syphilis.” The dose of 2.4 mega units of penicillin in 7 ½ days was used and this could be responsible for the rate of failure noticed.
Employing 4.8 mega units of penicillin G in 10 days in cases of primary syphilis, Chargin 2 and others obtained satisfactory results 100% in the sero-negative primary syphilis, 92% in the sero-positive primary syphilis, and 74.4% percent in the secondary syphilis.
This proves beyond doubt that the treatment of syphilis in the first few days of infection i.e. in the sero-negative primary syphilis, results in complete cure in practically every case, and that a delay of a few days in arriving at a diagnosis of early syphilis may decrease the patient’s chance of a favourable outcome by 15 to 25%. This clearly justifies the insistence of modern venereologists on the early diagnosis of syphilis. Besides, such a step will help to reduce the incidence of syphilis in the population: for, the danger of direct transmission of syphilis to others is greatest during the early syphilis.
The way to achieve this objective speedily is to make the intelligent use of the dark-field microscopy in every case with a genital ulcer. The dark-field microscopy examination of Tr. pallidum is the most valuable means of diagnosing syphilis in its very early stages and has brought about the total collapse of the clinical criteria of the chancre or a revolution in the diagnostic procedure for the early syphilis. The results of this test are very accurate, fool proof and overwhelmingly surpass those of other diagnostic procedures, in the diagnosis of early syphilis. In fact, the results of no other diagnostic procedure are better than those of the dark-field examination in the primary stage of syphilis. This fact is well illustrated by the results of the investigations undertaken by the writer 5. 68.7% cases of venereal sores could be diagnosed as syphilitic by this test in the first week as against 13.4% in the second week and a total of 40.7% at the end of three weeks, by the help of the serologic test for syphilis. This shows the great superiority of the dark-field examination over the customary procedure of blood test for early syphilis. Unfortunately, the dark-field microscopy for Tr.pallidum is most neglected of all examinations for the diagnosis of early syphilis. Even some of the teaching hospitals, it is no secret; blatantly ignore this valuable diagnostic procedure. By this examination, it is possible to diagnose syphilis several weeks before the blood test for syphilis attains positivity. The tendency to delay the diagnosis of syphilis till the serologic test for syphilis becomes positive or secondary manifestations appear must be therefore discarded; for, it invariably sacrifices the patient’s chance of a complete cure by 20 to 25 percent and accentuates the chances of late crippling disabilities in the individual, and spread of infection in the society.
The negative serologic test for syphilis obtained during the observation period does not exclude the presence of early syphilis, but as the follow-up continues from week to week, the significance of negative serologic test for syphilis is steadily increased, and the chances that the patient is developing syphilis becomes increasingly remote. The introduction of penicillin in the treatment of gonorrhoea has increased the risk of concomittent syphilis going unrecognised. The small dose of penicillin which is used to cure gonorrhoea, may suppress or modify syphilis or its early manifestations, as double infection is not uncommon. Hence one would prefer to treat gonorrhoea, as far as possible, with sulpha drugs which do not prevent syphilis from declaring itself. When penicillin is given the follow-up of such a case should extend to six months.
Syphilis is caused by Treponema pallidum and the chancre is the first visible lesion to attract attention. It begins at the point of inoculation of Tr.pallidum and serves as a land mark of the portal of entry of the infection. A peculiar feature of the early syphilis is that it usually produces no other visible signs or symptoms or constitutional disturbances. There is nothing fundamentally characteristic about the appearance of the chancre in the first week of its existence. Any or all the so-called characteristics of the chancre are likely to be modified by the duration of infection, location of the lesion and the presence of the secondary infection; hence no typical picture or feature except the presence of Treponema pallidum in the lesion is consistently available for an inference. Hence the early diagnosis can only be established by the demonstration of specific germs in the lesion. The classical picture of the chancre i.e. 3 to 4 weeks’ incubation period, single, indurated circular, well defined margin, pink areola, painless and indolent with the proximal lymph nodes enlarged, painless, indurated and freely movable under the skin, is very impressive for the purpose of acquainting the medical student with the course of the earlier manifestations of the disease; but there is no further object in going for its details. The earlier the primary sore is seen, the less typical are its clinical features, and less likely are the chances of arriving at an accurate diagnosis on the clinical impressions alone. Clinically, there is no outstanding feature which is not subject to fallacy. It merely helps to convey the presumptive evidence of syphilis, and could not be always treated. The possibility that syphilis may be engrafted at times on the banal genital lesion, obvious on sight, must never be forgotten. The chief question raised by any genital lesion, therefore, should be, “Is it syphilitic?” The incubation period and painlessness may be wholly misleading; indurations a classical sign but it demands a particular site and certain duration. Indolence or prolonged course is characteristic. The typical spotty lymphadenitis of the proximal nodes is the most constant feature and should help to locate hidden chancre. The most trustworthy and reliable evidence is the presence of Treponema pallidum in the sore.
The diagnosis of the chancre is thus no more clinical but a laboratory problem. There is no way to identify chancre in its early stage except by dark-field examination for Tr.pallidum. The demonstration of active Tr.pallidum in the serum from the sore is pathognomonic of syphilis. With such a notion one would serve the cause of public health and syphilotherapy far better than with the antiquated notions of the appearance of the chancre, and would make a valuable contribution towards the control of V.D. This means literally the collapse of clinical criteria, brought about by the dark-field microscopy of the material from the genital ulcers.
It will be seen therefore, that the diagnosis of the primary syphilis must be made as early as possible, and is mainly dependent at present on three procedures: - (1) repeated dark-field examination of the serum from the lesion, (2) repeated serologic test for syphilis, preferably quantitative, and (3) repeated close physical examination of the patient.
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