A PLEA FOR EARLY DIAGNOSIS OF SYPHILIS

by M. P. Vora

Indian Journal of Medical Sciences

Volume No – 5, Number – 12 of December 1951.

Page No. 732 to 737.

The complaint of a genital ulcer by the patient suggests at once a venereal sore. Such a high index of suspicion is commendable, but not so praiseworthy is the consequent procedure often adopted by some qualified practitioners. The tendency to administer treatment without first attempting to ascertain the exact diagnosis is very deplorable. Too often the physician is led astray by the clinical appearance; he takes for granted that it is the case of either chancre or a chancroid and starts specific treatment without first attempting bacteriological confirmation. Such a step, no doubt, is promoted by a desire to cure the patient as quickly as possible, but it is dangerous and at times disastrous. A chancre or chancroid is by no means the only cause of genital lesion.

There are also other aspects to be kept in mind such as the effects of wrong diagnosis on the mind of the patient, its effects on the health of the community and the slur on the profession and the doctor, if the diagnosis of the case turns out to be different from the previous assumption. Any presumption based merely on clinical impression to the total neglect of modern diagnostic procedures is quite unjustifiable and amounts to negligence. How often one is pained to see a patient with frank secondary syphilis, who was treated a few weeks earlier as a case of chancroid? How often does one come across a case of mucocutaneous relapse of syphilis, a very infectious condition indeed, simply because it was treated indecisively a few days earlier? Such a procedure is objectionable and must cease forthwith.

Early diagnosis and treatment of syphilis appreciably increases the possibility of a complete cure. The earlier the diagnosis is made and the treatment started, the greater the hope of a ‘cure’. The best prognosis can be given in cases where a diagnosis of syphilis is made on the finding of T. pallidum in the primary lesion before the antibody titre has risen high enough to show a positive serologic reaction. No treatment however perfect it may be, which is begun after the commencement of generalization of the disease, is an absolute guarantee of a cure. For cure to be guaranteed, treatment must be prescribed before such a stage. This necessitaies early diagnosis of the primary lesion, which, in turn, helps to reduce the possibility of cardiovascular and nervous involvement. In addition, it decreases the opportunity for dissemination of infection, both in the individual and in the community.

The period after infection, at which the diagnosis of syphilis is made and the treatment started, is of major importance in the ultimate outcome, for the cure of early syphilis is much more readily obtainable provided the treatment is instituted within the first few days of the infection, than when it is delayed until the onset of frank secondary manifestations or the development of a positive blood Wassermann reaction. This observation holds good inspite of the introduction of antibiotics (penicillin) in syphilotherapy. This is well illustrated by the study of the following.

Moore gives the following table of the results of treatment with arsenic and bismuth in various stages of syphilis.

TABLE – I – Results of Treatment at Various Stages.

The possibility of cure is at least about 18 per cent better in seronegative primary stage than in the seropositive primary stage and 21 per cent better than after the appearance of secondary syphilis. “Cure” measured by the criterion of re-infection is more than twice as frequent in the seronegative primary syphilis as in early secondary syphilis.

Reviewing the results of a nationwide study participated in by 4 I cooperating clinics, employing 26 different penicillin treatment schedules, varying in dose factor from 0.6 to 2.4 mega units of crystalline penicillin sodium and at a time factor extending from 4 to 15 days, in II,589 patients with early syphilis, the Committee on Medical Research of the Office of Scientific Research and Development and the U.S. Public Health Service remarks:- There was progressive increase in the failure rate with the smaller doses, and increasing the doses resulted in progressively fewer failures. 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 per cent while the cases of seronegative primary syphilis had a failure rate of only I4 per cent at the end of II months.

Altshuler and others used 60 consecutive intramuscular injections of 40,000 units of aqueous amorphous penicillin at 3 hourly intervals for 7½ days (total dose of 2.4 mega units). Evaluating the results in 3I,000 soldiers with early syphilis, the authors state that the incidence of failure rate was 8.73 per cent (lowest) in the seronegative primary syphilis and I8.62 per cent (higher) in the seropositive primary syphilis.

Chargin and others tried a 16 day schedule employing a total dose of 4.8 mega units of penicillin in oil-wax in I53 cases, and extended their observations over 8-I4 months. Results were I00 per cent satisfactory in primary seronegative syphilis, 92 per cent satisfactory in the seropositive primary syphilis, and 74.4 per cent satisfactory in secondary syphilis. (Diagnosis and treatment of syphilis in the first few days i.e., seronegative primary stage resulted in complete cure in practically every case).

This means factually 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 per cent. The instance of modern syphilologists on early diagnosis is thus thoroughly justified.

The requisite speed in the diagnosis of early syphilis implies the intelligent use of a dark field microscope. Dark field examination is the most valuable means of diagnosing syphilis in its early stage and has revolutionized the diagnostic procedure. To get oneself familiarized with its precise technic and the identifying characteristics of T. pallidum is not at all difficult. One can master it in a short time. The results of this examination are very accurate, fool-proof and compare most favourably with the results of other diagnostic procedures. In fact, the results of no other diagnostic procedure are better than those of a dark field examination in the early stage of syphilis. This fact is well illustrated by the results of investigations undertaken by the writer at the J. J. Hospital, Bombay in 1939-1940. Out of 115 cases of venereal sore, 78 cases (68.7 per cent) could be diagnosed by the help of a dark field examination in the first week, as against 15 cases (13.4 per cent) in the second week, and a total of 46 cases (40.7 per cent) at the end of three weeks by the help of blood Wassermann reaction. These figures demonstrate beyond doubt the great efficiency of the dark field examination over the customary procedure of blood Wassermann reaction in the early stages of syphilis. Unfortunately, the dark filed procedure is probably the most neglected of all examinations for the diagnosis of syphilis. It is possible, as is obvious from the above results, to make the diagnosis of syphilis by means of this examination several weeks before the blood test becomes positive or the threshold amount of antibody becomes demonstrable. Therefore, the practice to delay the diagnosis till blood tests for syphilis become positive or secondary rash develops must be discarded, for it deliberately sacrifices the patient’s chance of a complete cure, at least in one case out of every four or five.

The negative serologic tests obtained during the course of the period of observation do not exclude the presence of early syphilis but as the follow-up continues from week to week, the significance of negative serologic test is steadily increased and the chance that the individual is developing syphilis becomes increasingly remote.

The treatment of gonorrhoea with penicillin has increased the risk that the concomitant syphilis may go unrecognised. The small dose of penicillin which cures acute gonorrhoea may suppress or modify syphilis or its early manifestations. Double infection is not uncommon, and whenever it is suspected, gonorrhoea should be treated not with penicillin but with sulphathiazole or sulphadiazine, which do not prevent syphilis from declaring itself. The significance of fever early in the course of penicillin therapy either for gonorrhoea or any other condition should make one suspect the possibility of a dual infection, and one must look carefully for further developments. Reekie quotes three cases, in which manifestations of syphilis were appreciably masked by penicillin therapy for gonorrhoea and repeated serological examinations for syphilis had belied the condition. However, dark field examinations alone proved of value in arriving at a correct early diagnosis. His cases demonstrate the importance of the dark field procedure.

Syphilis is caused by the T. pallidum and the chancre or the primary sore is the first recognizable syphilitic lesion. It begins usually at the point of inoculation and serves as a landmark of the portal of entry of the infection. An unique feature of the early syphilitic infection is that it is usually unaccompanied by symptoms and constitutional disturbances. The classical description of its appearance – i.e., an incubation period of 2 weeks to 3 months, a single, indurated lesion, circular in shape, with a well defined edge, pink areola, painless, and indolent, the proximal lymph nodes, enlarged, indurated, painless and freely moveable under the skin, is very impressive for the purpose of acquainting the student with the course of the earlier manifestations of the disease; but there is no further object in describing its appearance in detail. The earlier the primary sore is seen, the less typical are its manifestations and the less likelihood is there of reaching an accurate diagnosis on clinical grounds alone. Clinically, there is no outstanding feature of a genital lesion which is not subjected to fallacy. It merely helps to convey presumptive evidence of syphilis and cannot be trusted to eliminate it. The possibility that syphilis may be engrafted at times on the genital lesion, obvious on sight, must never be forgotten. The main question raised by any genital lesion, therefore, should be ‘Has the patient syphilis’? The incubation period and painlessness may be wholly deceptive; induration is a classical sign but it entails duration and particular site. Indolence or obstinacy and a prolonged course are characteristic of the chancre. The typical lymphadenitis of the nodes nearest to the lesion is the most constant feature of a chancre and should help to locate hidden chancres such as intraurethral in the male and the genital chancre in the female. “Syphilis d’emblee” or syphilis without chancre is a feasibility but a rare event in syphilological accidents. The fact that generalised syphilis may develop without local reaction at the site of inoculation should not discourage the clinician from making the most rigorous search into any out-of-the-way corner of the body for the site of a primary reaction to the infection.

The diagnosis of the chancre is thus no longer clinical but a laboratory problem. One must understand that there is no way to identify a genital lesion except by a dark field examination, no matter how experienced the clinician is or how characteristic the lesion. The demonstration of active T. pallidum in the serum from the lesion or the neighbouring lymph node is pathognomonic. With such a notion in mind, one would serve the cause of syphilotherapy for better than with the antiquated notions of the appearance of the chancre, and would make a valuable contribution towards the relief of syphilitics. This means literally the collapse of clinical criteria which has been brought about by the dark field examination of the genital lesions, and by the local Wassermann reaction i.e., blood Wassermann reaction on the fluid of the suspected sore. The “local” Wassermann reaction often yields a positive result fairly long before the blood becomes positive and secondary stage becomes established.

It will be seen, therefore, that the diagnosis of the primary lesion of syphilis is mainly dependent, at the present day, on three procedures.

• repeated dark field examination of the serum from the lesion or aspirated lymph from the adjacent enlarged lymph nodes,
• the local Wassermann reaction performed on the serum obtained from the lesion, and
• repeated blood serologic tests or “Wassermann follow-up”, preferably quantitative.

Other points of importance in the diagnosis of early syphilis are worthy of consideration. It is common clinical experience that the infectivity of syphilis is closely related to the duration of infection, the danger of direct transmission to others being greatest in early syphilis. It must be remembered that the reduction in the incidence of syphilitic infection in the general population, and the prevention of the spread of infection by the patient, to a great extent, depends on early recognition and the adequate treatment of early syphilis.

SUMMARY

• A presumptive diagnosis of syphilis or chancroid of any genital lesion based merely on clinical impressions should not be made. It is dangerous and at times disastrous.
• The diagnosis of syphilis should be established at the earliest moment and certainly long before the advent of a positive Wassermann reaction or secondary manifestations.
• This can only be done with certainty by the intelligent use of a dark field examination in every case of a genital lesion, and later on by the finding of consistently positive serologic tests for syphilis.

ACKNOWLEDGMENT

My thanks are due to Dr. V. V. Gupte and Dr. F. C. D’Souza, Bombay, for their kind help and suggestions.

REFERENCES

• Altshuler, L., Karpenos,B.D. and others: Efficiency of Penicillin Treatment of Early Syphilis in Army, Am. J. Syphilis, Gon. And Ven. Dis., 33: I0I-200, I949.
• Chargin, L., Sobel, N, Rein C, and Rosenthel, T.: Treatment of Early Syphilis with Penicillin in Oil-wax, Archives of Dermatology and Syphilology, 59: 595-680, 1949.
• The Committee on Medical Research of the Scientific Research and Development and the U.S. Public Health Service, J.A.M.A. 131: 265-271, 1946.
• Moore, J. E.: The Modern Treatment of Syphilis, Treatment of Early Syphilis, page 177, Baltimore, Charles Thomas, 1933.
• Reekie, A. A. M.: The Danger of Penicillin Therapy in Gonorrhoea, The Lancet, 328, 1951.
• Vora M. P.: Importance of Dark field Examination in Early Diagnosis of Syphilis, The Med. Bull. 8: 40-42, 1940.