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UBC Theses and Dissertations

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Tim : Thank you, Lisa. Good evening and welcome everyone. It is nice to see so many people attending. We have got just on over attendees tonight, so very warm welcome and thank you for spending time with us tonight. It is a pleasure to have our two guests, firstly Dr Donna Mak, welcome.

Tim : Very well, thank you and doing your best to project as loudly as possible which is wonderful. Tim : Thank you, Donna. And then welcome, Ben. Tim : I am a GP from Perth, and that is my title tonight. So, okay, so let us get started with an overview. Donna, would you like to kick off? Donna : Yes, sure. So, we are going to talk firstly about some clinical features of syphilis and how you would test and treat for syphilis.

Then we will look at the epidemiology of syphilis, starting broadly with Australia and international, and then we will be talking about the three epidemics or outbreaks of syphilis that we are currently seeing in Australia in remote Aboriginal communities, in men who have sex with men and the emerging trend in heterosexual people sort of in mainstream Australia.

Sexually acquired syphilis and congenital syphilis

And then I am going to hand over to Ben to talk about three vignettes, which I think typify the issues and some of the difficulties that as public health physicians and as GPs you might have in dealing with patients with syphilis and then we will move onto, well what are the implications for clinical and public health practice. And there will be time for questions. But I thought before we start, it would be really interesting for us here to see how many cases of syphilis each of you have seen in the last say five years. Tim : So we are going to open that up as a poll. In the text box, if you could send us a text through the question box and we will wait for your answers.

We will give that about a minute. Maybe less than a minute. Everyone is answering very promptly which is fantastic. Tim : Okay, so the numbers that we are seeing are by and large numbers of zero to three. A few are outliers and we were talking earlier about these trends that we see with notifications, Ben, where you see the majority of people who notify are notifying say one case a year and then a handful of sort of specialised clinics are perhaps where they are doing this a lot.

Ben : Yes absolutely. So in Perth it is in clinics that are sort of specialising in a service for men who have sex with men primarily. Or I think perhaps other places that have specialist services for Aboriginal people also tend to see more syphilis. Tim : Yes, and I guess that is why it is such an important topic to go through, that this is not something that run of the mill GPs are seeing routinely.

It would be normal to not feel particularly familiar or certain and to really need to call out and ask for help with it. So it is great to get this education out there. If you have not seen many cases of syphilis throughout your clinic, you are probably the norm. So that is probably the important message. Donna : Yes, the important message is to be aware of it. So we might move on to the next slide now.

So syphilis is caused by a spirochaete bacteria, Treponema pallidum and it has an incubation period of nine to 90 days, approximately 30 on average. The typical chancre which appears at the site of sexual contact is a painless, bloodless, well-defined ulcer. It is caused by an endarteritis. So syphilis is actually a systemic disease from the get-go.

And what a lot of people do not realise is that we are now seeing more early neurosyphilis. So this is not tertiary syphilis, this is early neurosyphilis in the primary and secondary stages and presenting in quite strange ways that you would not normally associate with syphilis. So, uveitis, cranial nerve palsy, meningitis, stroke or seizure. And you can imagine that those could be referred to any sort of a specialist apart from a sexual health physician or an infectious diseases physician.

So it is important to keep that in the back our minds. And especially patients who are HIV positive, they might be more likely to present this way. Tim : Donna, just to clarify one point. So that slide out in the right hand side is a tongue?

Tim : I was wondering what that was earlier. They are not the greatest pictures, so our apologies. And that is a chancre on the left-hand side. Donna : Yes. So we have got a chancre on the penis, a chancre on the labia, a chancre in the perianal area.

But I thought it was really important to show chancres on the tongue and the lips because there is a lot of oral sex going on. I do not know any patients who use condoms for oral sex, and syphilis spreads very well with oral sex. So, we need to be aware of that. Tim : Yes. And I guess the other important thing that we covered before was this idea that chancre is not perhaps, well it is the classic presentation but it is not the common presentation.

Donna : No, and a lot of people will go through the stage of primary syphilis without having a chancre or without having a chancre that they know is there. Because if you think about that chancre on the labia, someone might not know it is there. And it will go away by itself in a few weeks. So, yes, a lot of people just will not know. And it could be inside the mouth and you do not know it is there because it is not painful.

Tim : And the other thing that struck me just going through these slides, was now very occasionally I would see say a cranial nerve palsy but I would not routinely test for syphilis, so it is just something else to think about with these sorts of interesting neurological presentations. Yes, and I am not saying you need to test everyone for syphilis with everything, but it is just something to keep in the back of your mind.

Donna : Yes, so then without any treatment, syphilis will apparently go away but then it can come back as secondary syphilis, so typically six to 24 months afterwards and this is when people get quite systemic symptoms, flu-like symptoms, fever, muscle aches and pains, but they have the classical rash and you can see there the classical rash on the hands and the soles of the feet.

We all know that. We remember that from med school. And we might also remember the condylomata lata which you can see quite a florid example of there.

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Now, unfortunately I have heard from various colleagues that sometimes that gets treated as genital warts and they get burnt off which might get rid of them, but certainly does not get rid of the syphilis. Sometimes the rash presents in strange ways in different parts of the body and you know, that rash there on the face, and I have personally seen that a long time ago when I was a young doctor, and it took me some weeks to figure out what that was, so the patient went and merrily spread that for a while.

And then the typical moth-eaten appearance of the hair loss, and also people can lose their eyebrows as well. Tim : So just a point you made earlier. The condylomata are sort of much more moist looking than a classical genital wart. Donna : Yes, and they are swarming with spirochetes, so if you see them put on your gloves. Then we have tertiary syphilis which we very rarely see these days thank goodness.

It is rare. Now that does not mean we should not take syphilis seriously in its infectious stages, but this is not something that we see commonly. Tim : Oh hang on, I just clicked on the link there.

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We can continue on. We are not changing slides though Lisa sorry. Just bear with us. Apologies everyone, we are just getting our technology sorted. Donna : Okay so now we are moving onto congenital syphilis and for me as a public health physician, this is really the pointy end of syphilis, because infectious syphilis is a curable condition. It usually does not make people terribly sick. But congenital syphilis, the way I see it is probably a failure of our health care system.

This is totally preventable. Unfortunately, we are not there at the moment and when we get to the part about the epidemiology of it I will talk more about that. But this is what we need to be preventing, and not to be seeing.