SYPHIILIIS

 

SYPHIILIIS

SYPHILIS IS :

a sexual transmitted disease caused by spirochetal bacterium Treponema pallidum ,a motile anaerobic.

Transmission of syphilis is almost always through sexual contact or congenitally through the placenta to a fetus or at birth from an infected mother.

Different manifestations occur depending on the stage of the disease

 

• Primary Syphilis:

it’s the first stage after infection

3.painless & localized ulcer with rolled edge (chancres).

4.single or multiple.

5.appear 2-3 weeks after contact.

6.most common site are cervix, vagina,vulva , anus and mouth.

7.regional L.N become enlarged.

 

PRIMARY SYPHILIS(The Chancre)

 Incubation period 9-90 days, usually ~21 days.

 Develops at site of contact/inoculation.

 Classically: single, painless, clean-based, indurated ulcer, with firm, raised borders. Atypical presentations may occur.

 Mostly anogenital, but may occur at any site (tongue,pharynx, lips, fingers, nipples, etc...)

 Non-tender regional adenopathy

 Very infectious.

 May be darkfield positive but serologically negative.

 Untreated, heals in several weeks, leaving a faint scar.

 

SECONDARY SYPHILIS

 The skin rash:

◦ Diffuse,

◦ often with a superficial scale (papulosquamous).

◦ May leave residual pigmentation or depigmentation.

 Condylomata Lata:

◦ Formed by coalescence of large, pale, flat-topped papules.

◦ Occur in warm, moist areas such as the perineum.

◦ Highly infectious.

 Mucosal lesions:

~ 30% of secondary syphilis patients develop mucous patch (slightly raised, oval area covered by a grayish white membrane,with a pink base that does not bleed).

◦ Highly infectious

 

 Secondary Syphilis:

2. Systemic

3. 1-6 months after contact

4. fever, malaise, general adenopathy and nonitchy maculopapular skin rash “money spot” .

5. involve the palms of the hands and the solesof the feet.

6. Mucous patches and linear (snail track) ulcers are seen on the mucosal surfaces.

SECONDARY SYPHILIS

 Seen 6 wks to 6 mos after primary chancre

 Usually w diffuse non-pruritic, indurated rash, including palms & soles.

 May also cause:

◦ Fever, malaise, headache, sore throat, myalgia, arthralgia, generalized lymphadenopathy

◦ Hepatitis (10%)

◦ Renal: an immune complex type of nephropathy with transient nephrotic syndrome

◦ Iritis or an anterior uveitis

◦ Bone: periostitis

◦ CSF pleocytosis in 10 - 30% (but, symptomatic meningitis is seen in <1%)

 

Differential diagnosis

 The rash may be confused with

◦ Pityriasis rosea (usually has a herald patch and lesions seen along lines of skin cleavage)

◦ Drug eruptions

◦ Acute febrile exanthems

◦ Psoriasis

◦ Lichen planus

◦ Scabies

 The mucous patch may be confused with oral thrush.

 Malaise, sore throat, generalized adenopathy, hepatitis,

& rash may be confused with infectious mononucleosis.

 Fortunately, the serologic tests for syphilis are positive in 99% of

secondary syphilis pts.

 

LATENT SYPHILIS

Positive syphilis serology without clinical signs of syphilis (& has normal CSF).

◦ It begins with the end of secondary syphilis and may last for a lifetime.

◦ Pt may or may not have a h/o primary or secondarysyphilis.

◦ Diseases known to cause occasional false-positive nontreponemal test reactions for syphilis, such as systemic lupus erythematosus (SLE), and congenital syphilis must be excluded before the diagnosis of latent syphilis can be made.

 Is divided into early and late latency.

LATENT SYPHILIS

 Early latent:

◦ The first year after the resolution of primary or secondary lesions, or

◦ A reactive serologic test for syphilis in an asymptomatic individual who has had a negative serologic test within the preceding year.

◦ Infectious.

2. Late latent:

◦ Usually not infectious, except for the pregnant woman, who may transmit infection to her fetus.

 

LATENT SYPHILIS

‘Tertiary Syphilis’

 Is the destructive stage of the disease.

 Lesions develop in skin, bone, & visceral organs (any organ).

 The main types are:

◦ Late benign (gummatous)

◦ Cardiovascular &

◦ Neurosyphilis

 Can be crippling and life threatening

 Blindness, deafness, deformity, lack of coordination, paralysis, dementia may occur

 It is usually very slowly progressive, barring certain neurologic syndromes which may develop suddenly due to endarteritis and thrombosis in the CNS

 Late syphilis is noninfectious.

 

LATENT SYPHILIS

Positive syphilis serology without clinical signs of syphilis (& has normal CSF).

◦ It begins with the end of secondary syphilis and may last for a lifetime.

◦ Pt may or may not have a h/o primary or secondary syphilis.

◦ Diseases known to cause occasional false-positive nontreponemal test reactions for syphilis, such as systemic lupus erythematosus (SLE), and congenital syphilis must be excluded before the diagnosis of latent syphilis can be made.

 Is divided into early and late latency.

Latent syphilis

Absent of symptoms or physical finding.

1\3 proceed to tertiary.

 

Tertiary syphilis

6. Ocurre 1-10 years after infection

7. gummas: ulcerative nodule in the skin, bone and nervous system as a result of hypersensitivity reactions.

8. Systemic manifestation: CVS, CNS and bone

 

Congenital Syphilis

 Mode of transmission:

-trans placental passage from infected mother

- at birth

 

 Congenital infection is associated with several adverse outcomes including:

-low birth wt

-congenital anomalies

-premature birth

-miscarriages or death of baby

 

Congenital Syphilis

 Early:

-skin lesions ,

maculopapular tissue

-Lymphadenopathy

-Hepatosplenomegaly

-failure to thrive

-jaundice , anemia

- osteochondritis

 

 Late:

-gummatous ulcers

-bony prominence of forehead

-Saddle nose

-Short maxilla

-keratitis, 8 nerve deafness and dentaldeformities

 

Treatment

The first-choice treatment for all manifestations of syphilis is penicillin.

Parenteral penicillin G is the only therapy with documented effect during pregnancy.

Non-pregnant individuals who have severe allergic reactions to penicillin

may be effectively treated with oral tetracycline or doxycycline

physcological disorders

 

physcological disorders 

Normal sexual behavior

 It achieves three major functions for human beings.

They are:

 1. Procreation (reproduction)

 2. Pastime, pleasure

 3. Object relation, it is an expression of relatedness, and preserves bonds between human beings (families). This is the most important function.

Brain and Sexual Behavior

 The limbic system is directly involved with elements of sexual functioning. In all mammals the limbic system is involved in behavior required for self-preservation and the preservation of the species.

Brain and Sexual Behavior

 Brain neurotransmitters are related to sexual function.

 For example, an increase in dopamine is presumed to increase libido.

 Serotonin (upper pons and midbrain) is presumed to have an inhibitory effect on sexual function.

 Erection is mediated by cholinergic innervation.

 Ejaculation is mediated by alpha-1 adrenergic fibers.

 The uterus receives both adrenergic and cholinergic fibers.

Factors in Normal or abnormal sexuality

 There are three interrelated factors:

1. Sexual identity

2. Gender identity

 It is formed by the age of 2-3 years, and may be earlier.

 It is usually congruent with the sexual identity.

 Abnormality in this domain causes Transsexualism.

3. Sexual behavior: It is a series of psychological and physiological responses that represent the sexual cycle. Abnormalities in this domain cause Sexual

Dysfunctions.

The Sexual Cycle

 The sexual cycle (response) is a true psychophysiological experience.

 Four phases are recognized in the human sexual cycle.

 Phase I: Desire

 Phase II: Excitement

 Phase Ill; Orgasm

 Phase IV: Resolution

 

 

Sexual Dysfunctions

 They include:

 1. Lack or loss of sexual desire.

 2. Disorders in sexual arousal that include impotence in males and failure of genital response in females.

 3. Orgasm disorders (inhibited male or female orgasm).

 4. Sexual pain disorders in which pain occurs before, during or after intercourse recurrently or persistently in either the man or the woman.

Erectile dysfunction (impotence)

 It is the persistent inability to obtain an erection sufficient for vaginal insertion, or to maintain it until completion of the sexual activity.

 It may be due to organic or psychological causes or a combination of both.

 A good history is of primary importance in determining the cause of the dysfunction.

Erectile dysfunction (impotence)

 If a man reports having spontaneous erections at times when he does not plan to have intercourse, having morning erections, etc..., the organic causes of his

impotence can be considered negligible, and costly diagnostic procedures can be avoided.

 The condition may accompany some other psychiatric disorders e.g. depression and schizophrenia or may occur due to a pharmacological substance or psychoactive substance abuse.

Female orgasmic disorder

 Inhibited female orgasm or anorgasmia is manifested by the recurrent delay in, or absence of, orgasm after a normal sexual excitement phase judged to be adequate in focus, intensity, and duration.

 Numerous psychological factors arc associated with female orgasmic disorder.

 They include fear or guilt concerning sexual impulses, fear of rejection by a sex partner, or hostility toward men.

Premature Ejaculation

 The man recurrently achieves orgasm and ejaculates before he wishes to do so.

 There is no definite time frame within which to define the dysfunction.

 The diagnosis is made when the man regularly ejaculates before or immediately after entering the vagina or following minimal sexual stimulation.

 That definition assumes that the female partner is capable of an orgasmic response.

 

Dyspareunia

 It refers to recurrent and persistent pain related to intercourse. It is usually a disorder of women. The dysfunction is usually related to vaginismus. Vaginismus is an involuntary and persistent constriction of the outer one third of the vagina that prevents penile insertion and intercourse. The complaint is more common in women who have anxiety about sexual intercourse, and in those with a history of rape or childhood sexual abuse.

 

Abnormal sexuality

 It is defined as: "sexual behavior that is destructive to self or to others; that is not directed towards a partner; or that excludes stimulation of the genitalia.

 

Paraphilias

 Paraphilias are diagnosed if the deviant behaviour replaces normal sexual behavior or becomes an integral part of a normal sexual behavior, without

it, sexual behavior is not performed.

 This a group of sexual deviations in which sexual urges and sexually arousing fantasies involve:

1. nonhuman objects; or

2. children or other non-consenting persons; or

3. suffering or humiliation of oneself or one's partner

 

Paraphilias

They include the following examples:

 1. Fetishism

 2. Exhibitionism

 3. Voyeurism

 4. Frotteurism

 5. Sexual Sadism

 6. Sexual Masochism

 7. Pedophilia

 Other sexual disorder: Homosexuality (disorder in sexual orientation)

Management of Psychosexual Disorders

 1. Proper diagnosis:

 2. Psychotherapy:

 Different psychotherapeutic methods are used.

 Behavioral and cognitive behavioral psychotherapies are the most widely used techniques.

 3. Pharmacological treatment:

 • Sildenafil (Viagra) for erectile dysfunction

 • Local anesthetic sprays for premature ejaculation

 • SSRIs are used for premature ejaculations, no controlled studies are available

 • Pharmacological treatment of any underlying psychiatric disorders: depression, generalized anxiety, phobia

OSTEOPOROSIS

 

OSTEOPOROSIS

 

 Osteon is bone and porosis is hole in Greek.

 Osteoporosis is a “ Systemic skeletal  disorder “ characterized by “ Low bone mass “ , microarchitectural deterioration of  bone tissue leading to bone fragility , and consequent increase in fracture risk .

 It leads to abnormally porous bone that is compressible , like a sponge.

 The spine , hips and wrists are common areas of bone fractures from osteoporosis.

 

Prevalence :-

 Osteoporosis is the most prevalent bone disease in the world.

 According to the International Osteoporosis Foundation, 1 in 3 women over 50 will experienced osteoporotic fractures, as will 1 in 5 men .

 Female to male ratio 1 : 6 .

 

Types of osteoporosis :-

2 types :-

a) Primary osteoporosis

I. Type-1 : Postmenopausal osteoporosis

II. Type-2 : Age – associated osteoporosis

b) Secondary osteoporosis

Loss of bone is caused by an identifiable agent or disease process such as inflammatory disorder , bone marrow cellularity disorder and corticosteroid use.

 

Clinical signs and symptoms :-

 Fractures caused by osteoporosis are often painful. Osteoporosis is often called the ‘Silent disease’ or ‘Silent thief’ as many people don’t recognize they have it until a fracture occurs.

 Back pain: Episodic, acute , low thoracic/high lumbar pain

 Compression fracture of the spine

 Bone fractures

 Decrease in height

 Kyphosis

 Dowager’s hump

 Decreased activity tolerance

 Early satiety

 

Causes :-

 Hereditary , congenital :-

·         Osteogenesis imperfecta

·         Neurologic disturbances

·         Gonadal dysgenesis

 

 Acquired ( Primary & secondary )

 Generalized :

Primary

Idiopathic

Postmenopausal

Age related

 

Secondary

Nutrition

Sedentary lifestyle ,

immobility , smoking

Gastrointestinal diseases

Malignancy

Drugs

Endocrine disorder

 

 Localized

 Inflammatory arthritis

 Fractures and immobilization in cast

 

Risk factors :-

[ National Osteoporosis Foundation Physician guidelines for risk factors for osteoporotic fracture. ]

 Current cigarette smoking

 Low body weight (<127 pounds)

 Alcoholism

 Estrogen deficiency

 Prolonged amenorrhea (>1 year)

 Early menopause (<45 year) or bilateral ovariectomy

 Lifelong low calcium intake

 Recurrent falls

 Poor health / fragility

 Inadequate physical activity

 Family history of osteoporosis

 

Physical examination :-

Osteoporosis

• Height loss

• Body weight

• Kyphosis

• Humped back

• Tooth loss

• Skinfold thickness

• Grip strength

 

Vertebral fracture

• Arm span-height difference

• Wall- occiput distance

• Rib-pelvis distance

 

No single maneuver is sufficient to rule in or rule out osteoporosis or vertebral fracture without

further testing.

 

Diagnosis :-

 Bone Mineral Density (BMD) test :-

 The most common test.

 Results are reported using T-scores.

 T-scores are relative to how much higher or lower your bone density is compared to that of a

healthy adult.

 T-score :- It is the number of standard deviation (SD) above or below a reference value.

 

Category T-score

Normal -1.0 or Above

Osteopenia(Low bone mass) -1.0 to -2.5

Osteoporosis -2.5 or Less

Severe osteoporosis -2.5 or Less with one or more fragility fracture

 

 

Laboratory Tests :-

• Blood Calcium levels

• 24-hour urine calcium measurement

• Thyroid function tests

• Parathyroid hormone levels

• Testosterone levels in men

• 25-hydroxyvitamin D test to determine whether the body has enough vitamin D

• Biochemical marker tests

 

Pharmacological option in osteoporosis :-

Antiresorption :-

 Act on osteoclasts and stabilize bone

 Calcium

 Estrogen

 Calcitonin

 Bisphosphonates

 Selective estrogen receptor modulators

 Thiazide diuretics

Formation :-

 Act on osteoblasts and increase bone formation

 Vitamin D

 Anabolic steroids

 Parathyroid hormone

 Growth factors (investigation)

 Fluoride (investigation)