Spirochete Infections

negative

Spirochetes are gram positive/negative bacteria

Spirochaetota

Phylum that consists of spirochetes

spiral; loose coils; rigid corkscrew

Spirochetes have a __________ morphology ranging from _____________ to a ____________ shape

Lyme disease and syphilis

What are a couple human diseases caused by spirochetes?

Lyme disease

Most common vector borne infection in US

Ixodes tick ("blacklegged tick")

Vector that transmits lyme disease

Borrelia burgdorferi

Microbe that causes lyme disease

>24-36 hours

How long do ticks need to feed to transmit and infection?

Northeast and central

Where are lyme disease cases concentrated at in the US?

Rhode Island, Vermont, and Maine

3 states with highest concentration of lyme disease cases

Late spring and summer months

When do most lyme disease cases occur?

Erythema migrans ("bulls-eye" rash)

Cutaneous symptom associated with lyme disease

1-2 week after tick bite

When does erythema migrans develop?

gradually

The erythema migrans lesion rapidly/gradually expands over several days

Areas of tight clothing

Where is erythema migrans most likely to develop?

10-20%

What % of individuals don't have a classic "bulls-eye" rash from lyme disease?

viral-like

When erythema migrans is present, lyme disease acts as a _____________ illness

Stage 1/Early localized lyme disease

What does the patient have? Patient presents with single erythema migrans without extracutaneous manifestations

Stage 2/Early disseminated lyme disease

What does the patient have? Patient presents with multiple erythema migrans lesions or objective manifestations of neurologic symptoms and carditis days to weeks later

50-60

Stage 2 or early disseminated lyme disease develops in about _______________%

Stage 3/Late persistent lyme disease

What does the patient have? Patient presents with arthritis and rare neurologic manifestations or acrodermatitis chronica atrophicans (skin condition)

Neurologic, musculoskeletal, and cardiac

What are some different types of extracutaneous manifestations of lyme disease?

Cranial neuropathies (esp. peripheral CNVII, facial)

What is/are some early neurologic symptom(s) of lyme disease?

Encephalomyelitis, peripheral neuropathy (affects hands and feet or "stocking glove distribution"), and encephalopathy

What is/are some late neurologic symptom(s) of lyme disease?

Monoarticular (1 joint) or oligoarticular (2-3 joints) arthritis

What are musculoskeletal symptoms of lyme disease?

6 months after onset

When do musculoskeletal symptoms of lyme disease arise?

a few weeks to several months

Musculoskeletal symptoms of lyme disease can persist for _______________ as intermittent attacks

Large; knee

______________ joints, especially the _________ joint, is affected by lyme disease

weeks to months

Cardiac symptoms of lyme disease occur _________________ after infection

skin

With lyme disease, it is important to do a complete ___________ examination

Erythema migrans and acrodermatitis chronicum atrophicans

What are you looking for in a skin examination for lyme disease?

Acrodermatitis chronicum atrophicans

Late manifestation of lyme disease characterized by bluish-red discoloration and swelling on extensor surface of hands/feet

Complete neurologic examination

In addition to a skin examination, what other examination should be performed with an individual that has lyme disease?

1. Presence of erythema migrans and recent exposure (via travel)

2. One late manifestation plus lab confirmation of infection

Criteria determine by CDC for a lyme disease diagnosis (each are adequate alone to make diagnosis)

negative; antibody titers

During the initial infection phase, serologic tests for lyme disease are frequently _____________, so patients are retested with _________________

4x increase in antibody titers

What results on a lab test indicate recent infection with lyme disease?

False (can often get false positives)

T/F? Conduct lab tests if there are no objective signs of Lyme disease

ELISA, and if positive, IgM and IgG Western immunoblot to confirm

What lab test(s) is/are used to confirm a late manifestation of lyme disease in the absence of erythema migrans?

1. Elevated ESR and mildly elevated LFTs

2. CSF analysis if worried about lyme disease encephalitis

3. Joint aspiration and PCR if lyme arthritis

What other labs can aid in the diagnosis of lyme disease?

1. Doxycycline 100 mg 2x daily

2. Amoxicillin 500 mg 3x daily

3. Cefuroxime 500 mg 2x daily

All for 14-21 days

What are the options for oral antibiotic therapy for lyme disease?

Severe cardiac cases, arthritis, and neurologic disease

When is IV therapy recommended for lyme disease?

Ceftriaxone 2g for 2-4 weeks

What is the typical IV therapy used for lyme disease?

excellent

Treatment when erythema migrans present = ______________ lyme disease prognosis

No

Is a vaccine available for lyme disease?

prophylactic

In certain cases, a 200 mg dose of doxycycline can be used as a _____________ treatment to prevent lyme disease

Alpha-gal syndrome/allergy

Type of acquired food allergy to mammalian red meats (cow, pig, lamb, or goat meat) associated with tick bites

Production of antibodies against alpha-gal (galactose-alpha-1,3-galactose) and antibodies responding to antigen on ingested meats

What causes alpha-gal syndrome after a tick bite?

Treponema pallidum

What spirochete causes syphilis?

almost any organ or tissue

Syphilis can infect...

1. Sexual contact where direct exposure to infectious lesions occurs

2. Congenital syphilis via transplacental route

3. Needle sharing, blood transfusion, and examining lesions without gloves

How can one contract syphilis?

Men who have sex with men

What population is syphilis most common in?

Meth use, acquiring partners via social media, and HIV+

What other factors can increase ones chances of getting a syphilis infection?

25-34 y/o men and black individuals

What other populations are at risk for syphilis?

Early and late syphilis

Stages of syphilis

Weeks to months after infection

When does early syphilis occur?

Primary and secondary syphilis

What is included in early syphilis?

25-40%

What % of untreated individual progress to late syphilis?

1-30 years after initial infection

When does late syphilis occur?

Latent and tertiary syphilis

What does late syphilis include?

Chancre

Typical lesion with primary syphilis

Painless, clean based, and indurated ulcer at initial site of infection 3-4 weeks after exposure

Characteristics of a chancre lesion

Anogenital region and sometimes oropharygeal region

Where are chancres typically found?

spontaneously; 3-6

Chancres heal _______________ after ____________ weeks with no treatment

systematically

If left untreated as chancres heal, syphilis will spread...

regional (inguinal) lymphadenopathy

Primary syphilis can be associated with...

Weeks to months after initial infection

When does secondary syphilis arise?

About 25%

What % of individuals with primary move on to secondary syphilis?

Rash, systemic symptoms, lymphadenopathy, alopecia, and hepatitis

Common symptoms with secondary syphilis

widespread

A rash developing with secondary syphilis is usually ____________ and symmetrical macular or papular involving the trunk and extremities and palms and soles

Condylomata lata (weeping papules)

Rash that occurs with secondary syphilis in moist warm areas and is infectious

Latent syphilis

Phase of syphilis with no physical signs of disease (no primary or secondary lesions) but positive serologic tests

Early and late latent

Stages of latent syphilis

< 1 year

Early latent syphilis is when an individual has been infected for...

Relapse into secondary syphilis if not treated and be infectious

What can occur during early latent syphilis?

> 1 year

Late latent syphilis occurs in individuals that have be infected for...

No (absence of lesions)

Are patients infectious during the late latent stage of syphilis?

In late syphilis stage and have gummatous disease, CV problems, or nervous system problems

What symptoms determine that someone is in the tertiary syphilis stage?

rare; skin, eyes, or deeper visceral organs/bones

Gummatous disease due to tertiary syphilis is common/rare today and involves lesions of the...

Arteritis of ascending thoracic aorta causing aortic aneurysm and/or aortic regurgitation

What cardiovascular symptomatic manifestations can occur with tertiary syphilis?

20-30 years after initial infection

When do cardiovascular symptoms of tertiary syphilis arise?

Tabes dorsalis and general paresis

What are some tertiary forms of neurosyphilis (nervous system symptoms of tertiary syphilis)?

Argyll Robertson pupils

What indicates tabes dorsalis due to tertiary syphilis?

Asymptomatic neuroinvasion, meningovascular syphilis, tabes dorsalis, and general paresis

What are the different types of neurosyphilis?

Any stage of infection

When can neurosyphilis occur?

Asymptomatic neuroinvasion

Type of neurosyphilis that can occur early on with positive findings on CSF analysis

Meningovascular syphilis

Type of neurosyphilis occurring months to years after infection and characterized by acute or chronic meningitis (headache/irritability), cranial nerve palsies, unequal reflexes, and irregular pupil responses

Tabes dorsalis

Type of neurosyphilis occurring usually 20-30 years after infection and characterized by chronic, progressive degeneration of the brain parenchyma and structures, impaired proprioception/vibratory sense, Argyll Robertson pupils, muscular hypotonia and hyporeflexia, and sharp recurrent "lightning" pain in muscles/legs

General paresis

Type of neurosyphilis that occurs 10-25 years after infection characterized by decreased concentration, memory loss/dementia, dysarthria, tremor of lips/fingers, irritability, and personality changes

Congenital syphilis

Type of syphilis that can occur if infections in a pregnant female remain untreated and cause stillbirth, prematurity, and/or cognitive deficits

transplacentally; poor/no prenatal care

Syphilis can be passed from mother to child ______________, usually due to...

Screen for it in mom and treatment if positive

What is the prenatal standard of care for syphilis?

early; late

Congenital syphilis has both _____________ and _______________ manifestations

Skin rash resembling secondary syphilis, rhinitis, hepatosplenomegaly, hemolytic anemia, and jaundice

Early manifestations of congenital syphilis

Sensorineural hearing loss, interstitial keratitis, frontal bossing, saber shin deformity, and hutchinson teeth

Late manifestations of congenital syphilis (occur >2 years after birth)

Culturing

What cannot be done with Treponema pallidum in the lab?

Microscopic examination or serologic testing

How is syphilis diagnosed?

early

Microscopic examination can only be used to diagnose ______________ syphilis

moist lesions/lymph node aspiration; darkfield

With microscopic examination of syphilis, spirochetes are directly visualized from ___________________ on _______________ microscopy

No

Is it common to use microscopic examination to diagnose syphilis today?

Serologic testing

What is the main way syphilis is diagnosed?