皮肤性病学教案及讲稿华皮肤病与授课专年级课程名称2006级留学生皮肤性病学性病业授课方职称讲师学时2教师肖异珠大课示教式梅毒题目章节作者教材名称《Dermatovenereology》Liu TongDean's officeof Xi'anJiaotong University版次出版社FirstNovember2004教学目掌握梅毒的病原学、临床表现、实验室检查及治疗原则。的要求教学1、二期梅毒的皮损特点。难2、实验室检查。点各期梅毒的临床表现特点。1、教2、梅毒血清学检查的意义。学各期梅毒及新生儿梅毒的治疗原则。3、重点外语全英语教学要求教学方法PPT幻灯教学手段参考安德鲁斯皮肤病学资料教研室意见教学组长：单葵教研室主任：李惠2009年9月17日
皮肤性病学教案及讲稿 课程名称 皮肤病与 性病 年级 2006 级留学生 授课专 业 皮肤性病学 教 师 肖异珠 职称 讲师 授课方 式 大课 示教 学时 2 题目章节 梅毒 教材名称 《Dermatovenereology》 作者 Liu Tong 出 版 社 Dean’s office of Xi’an Jiaotong University November 2004 版次 First 教 学 目 的 要 求 掌握梅毒的病原学、临床表现、实验室检查及治疗原则。 教 学 难 点 1、 二期梅毒的皮损特点。 2、 实验室检查。 教 学 重 点 1、 各期梅毒的临床表现特点。 2、 梅毒血清学检查的意义。 3、 各期梅毒及新生儿梅毒的治疗原则。 外语 要求 全英语教学 教学 方法 手段 PPT 幻灯教学 参考 资料 安德鲁斯皮肤病学 教研 室意 见 教学组长：单葵 教研室主任：李惠 2009 年 9 月 17 日
辅助手段教学内容时间分配Definition of sexually transmitted diseases (STDs)-STDs are a group of infectious diseases transmitted through human sexualbehavior(WHO)Classification of STDsThe common STDs includes:Nongonococcal urethritis-Gonorrhea·Condylomata acuminata·Syphilis5min-Genital herpesOrigins of Syphilis·Syphilis was a shepherd boy's name of ancient Greece.·Debate about the origins of syphilis has continued for nearly 500 years, ever sinceearly sixteenth-century Europeans blamed each other, referring to it variously asthe Venetian, Naples, or French disease. One hypothesis assumes a New Worldorigin, and holds that sailors who accompanied Columbus and other explorersbrought the disease back to EuropeEtiology and pathogenesis of syphilis5min·The organism: spirochete Treponema pallidumthe spirochete enters through the skin or mucous membrans, on which the primarymanifestations are seen.-In congenital syphilis the treponeme crosses the placenta and infects the fetus.·Direct infectionSexual intercourse(95%)>Moist kissing>Sexual touchingIndirect infectioneating-utensils, drinking vessels, pipes or moist towels, etc.·Blood infectionpuncture with needle, syphilitic patients-health people.otransplacental ,mother-fetusAcquired syphilis·Early stage:.Primary stage.Secondary stageoEarly latent syphilisLate stage:.Tertiary stageoLate latent syphilisCongenital syphilis·Primary syphilis---chancreincubation period: 2~4w. occurs on the penis or scrotum of 70% of men with syphilis and on the vulva,cervix, or perineum ofmore than 50%ofwomen with syphilis.Extragenital chancres occur most commonly above the neck,typically affectingthe lips or oralcavity.The primary lesion usually is a single ulcerated lesion with a surrounding redareola. The edge and base of the ulcer have a cartilaginous (buttonlike) consistencyon palpation..The iesion is highly infectious; when abraded, it exudes a clear serum containingnumerousTpallidum30minorganisms
教学内容 辅助手段 时间分配 Definition of sexually transmitted diseases (STDs) •STDs are a group of infectious diseases transmitted through human sexual behavior (WHO) Classification of STDs The common STDs includes: •Nongonococcal urethritis •Gonorrhea •Condylomata acuminata •Syphilis •Genital herpes Origins of Syphilis •Syphilis was a shepherd boy`s name of ancient Greece. •Debate about the origins of syphilis has continued for nearly 500 years, ever since early sixteenth-century Europeans blamed each other, referring to it variously as the Venetian, Naples, or French disease. One hypothesis assumes a New World origin, and holds that sailors who accompanied Columbus and other explorers brought the disease back to Europe. Etiology and pathogenesis of syphilis •The organism: spirochete Treponema pallidum. •the spirochete enters through the skin or mucous membrans, on which the primary manifestations are seen. •In congenital syphilis the treponeme crosses the placenta and infects the fetus. •Direct infection Sexual intercourse(95%)>Moist kissing>Sexual touching. •Indirect infection eating-utensils, drinking vessels, pipes or moist towels, etc. •Blood infection ⚫puncture with needle, syphilitic patients-health people. ⚫transplacental , mother-fetus Acquired syphilis •Early stage: ⚫Primary stage ⚫Secondary stage ⚫Early latent syphilis •Late stage: ⚫Tertiary stage ⚫Late latent syphilis Congenital syphilis •Primary syphilis-chancre ⚫incubation period: 2~4w. ⚫ occurs on the penis or scrotum of 70% of men with syphilis and on the vulva, cervix, or perineum of more than 50% of women with syphilis. ⚫Extragenital chancres occur most commonly above the neck, typically affecting the lips or oral cavity. ⚫The primary lesion usually is a single ulcerated lesion with a surrounding red areola. The edge and base of the ulcer have a cartilaginous (buttonlike) consistency on palpation. ⚫The lesion is highly infectious; when abraded, it exudes a clear serum containing numerous T pallidum organisms. 5min 5min 30min
Chancres areusuallypainless.The regional lymph nodes usually enlarge painlessly and are firm, discrete, andnontender.Chancre will heals slowly over 2 to 8 weeks if untreated.Secondarysyphilis.The manifestations of the secondary stage are extremely variable and usuallyinclude localized ordiffuse symmetric mucocutaneouslesions.The rashes aire generally widespread, frequentinvolvementofthepalmsand soles.The cutaneous eruption may consist of macular, papular papulosquamous, orfollicular lesion.Tiny papular follicular syphilids involving hair follicles may result in patchyalopecia. In addition to the classic moth-eaten alopecia.Condyloma lataIn 10% of patients, highly infectious papules develop at the mucocutaneousjunctions and, in moist intertriginous skin, become hypertrophic and dull pink orgray.10moLess common findings include periostitis, arthralgias, meningitis, nephritis,hepatitis,and ulcerative colitis·Tertiary syphilisGummatous syphilis.Cardiovascular syphilisoNeurosyphilis.Congenital syphilisEarly manifestationsEarly signs and symptoms include development of a diffuse rash, characterized5mby extensive sloughing oftheepithelium,particularly on thepalms, soles,and skinaround themouth and anus..A compilation of early clinical presentations of congenital syphilis includedabnormal bone radiographs, hepatomegaly, splenomegaly, petechiae, other skinrashes,anemia,lymphadenopathy,jaundice,pseudoparalysis, and snuffles.A classic mucocutaneous sign is depressed linear scars radiating from the orificeof the mouth and termed rhagades (Parrot lines).LatemanifestationsoLate signs and symptoms are rare and, if encountered, usually involvecomplications including interstitial keratitis, cranial nerve Vill deafness, cornealopacities,and/orrecurrentarthropathyDental abnormalities may be evident, such as centrally notched and widelyspaced, peg-shaped, upper central incisors (Hutchinson teeth) and sixth-year molars15mwith multiplepoorly developed cusps(mulberrymolars)oln latent syphilis, there are no clinical signs or symptioms of the disease, and itpresence is detectable only by serologic testingLaboratoryexamination·Darkfield examinationDarkfieldmicroscopy is essential in evaluating moist cutaneous lesions, suchas the chancre of primary syphilis or the condyloma lata of secondary syphilis·When dark-field microscopy is not available,direct immunofluorescence staining
⚫Chancres are usually painless. ⚫The regional lymph nodes usually enlarge painlessly and are firm, discrete, and nontender ⚫Chancre will heals slowly over 2 to 8 weeks if untreated. Secondary syphilis •The manifestations of the secondary stage are extremely variable and usually include localized or diffuse symmetric mucocutaneous lesions. ⚫The rashes aire generally widespread, frequent involvement of the palms and soles. •The cutaneous eruption may consist of macular, papular papulosquamous, or follicular lesion. Tiny papular follicular syphilids involving hair follicles may result in patchy alopecia. In addition to the classic moth-eaten alopecia. Condyloma lata : In 10% of patients, highly infectious papules develop at the mucocutaneous junctions and, in moist intertriginous skin, become hypertrophic and dull pink or gray. ⚫Less common findings include periostitis, arthralgias, meningitis, nephritis, hepatitis, and ulcerative colitis •Tertiary syphilis ⚫Gummatous syphilis ⚫Cardiovascular syphilis ⚫Neurosyphilis •Congenital syphilis Early manifestations ⚫Early signs and symptoms include development of a diffuse rash, characterized by extensive sloughing of the epithelium, particularly on the palms, soles, and skin around the mouth and anus. ⚫A compilation of early clinical presentations of congenital syphilis included abnormal bone radiographs, hepatomegaly, splenomegaly, petechiae, other skin rashes, anemia, lymphadenopathy, jaundice, pseudoparalysis, and snuffles. ⚫A classic mucocutaneous sign is depressed linear scars radiating from the orifice of the mouth and termed rhagades (Parrot lines). Late manifestations ⚫Late signs and symptoms are rare and, if encountered, usually involve complications including interstitial keratitis, cranial nerve VIII deafness, corneal opacities, and/or recurrent arthropathy. ⚫Dental abnormalities may be evident, such as centrally notched and widely spaced, peg-shaped, upper central incisors (Hutchinson teeth) and sixth-year molars with multiple poorly developed cusps (mulberry molars). ⚫In latent syphilis, there are no clinical signs or symptioms of the disease, and it presence is detectable only by serologic testing. Laboratory examination •Darkfield examination Darkfield microscopy is essential in evaluating moist cutaneous lesions, such as the chancre of primary syphilis or the condyloma lata of secondary syphilis. •When dark-field microscopy is not available, direct immunofluorescence staining 10m 5m 15m
of fixed smears (direct fluorescent antibody Treponema pallidum [DFA-TP) is anoption: Both procedures detect the causative organism at a rate of approximately 85-92%.·Serologic tests·Nontreponemal tests.Measure nonspecific antibodies (reagins).Employ cardiolipin antigen.Screening and diagnostic tests.Response to therapy·RPR, VDRL, TRUST-Treponemal tests.Specific antibodies15minconfirmatorytests·FTA-ABS,TPHA,MHA-TP, TPIGenital Ulcer Evaluation·Diagnosis based on medical history and physical examination often inaccurate·Serologic test for syphilis·Culture/antigentestforherpessimplex·Haemophilus ducreyi culture in settings where chancroid is prevalent·Biopsy may be usefulDiagnosis?Disease history·Clinical manifestation·Laboratory dataoPrimary syphilis: chancre + darkfield ecaminationSecondary syphilis: skin lesions + serological teststreatmentPenicillin remains the mainstay of treatment.·Penicillin use is the only therapy used widely for neurosyphilis, congenitalsyphilis, or syphilis during pregnancy. Rarely, T pallidum has been found to persistfollowing adequate penicillin therapy; however, there is no indication that theorganism has acquired resistance to penicillin.treatmentIn patients with allergy to penicillin, skin testing and desensitization arerecommended. Make every effort to document penicillin allergy before choosingan alternative treatment because the efficacy ofalternative regimens is questionablein all stages of syphilis. Many treatment failures havebeen reported.treatment5min·Tetracycline, doxycycline and ceftriaxone have shown antitreponemal activity inclinical trials; however, they currently are recommended only as alternativetreatment regimens in patients allergicto penicillin.treatmentPrimary and Secondary Syphilis Treatment15min·RecommendedRegimen forAdults(CDC)-Benzathine penicillin G 2.4 million units IM in a single dose.-RecommendedRegimenforChildren(CDC)Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 millionunits in a single dose
of fixed smears (direct fluorescent antibody Treponema pallidum [DFA-TP]) is an option. • Both procedures detect the causative organism at a rate of approximately 85- 92%. •Serologic tests •Nontreponemal tests ⚫Measure nonspecific antibodies (reagins) ⚫Employ cardiolipin antigen ⚫Screening and diagnostic tests ⚫Response to therapy ⚫RPR, VDRL, TRUST •Treponemal tests ⚫Specific antibodies ⚫confirmatory tests ⚫FTA-ABS, TPHA,MHA-TP, TPI Genital Ulcer Evaluation •Diagnosis based on medical history and physical examination often inaccurate •Serologic test for syphilis •Culture/antigen test for herpes simplex •Haemophilus ducreyi culture in settings where chancroid is prevalent •Biopsy may be useful Diagnosis •Disease history •Clinical manifestation •Laboratory data ⚫Primary syphilis: chancre + darkfield ecamination ⚫Secondary syphilis: skin lesions + serological tests treatment •Penicillin remains the mainstay of treatment. •Penicillin use is the only therapy used widely for neurosyphilis, congenital syphilis, or syphilis during pregnancy. Rarely, T pallidum has been found to persist following adequate penicillin therapy; however, there is no indication that the organism has acquired resistance to penicillin. treatment •In patients with allergy to penicillin, skin testing and desensitization are recommended. Make every effort to document penicillin allergy before choosing an alternative treatment because the efficacy of alternative regimens is questionable in all stages of syphilis. Many treatment failures have been reported. treatment •Tetracycline, doxycycline and ceftriaxone have shown antitreponemal activity in clinical trials; however, they currently are recommended only as alternative treatment regimens in patients allergic to penicillin. treatment Primary and Secondary Syphilis Treatment •Recommended Regimen for Adults(CDC) •Benzathine penicillin G 2.4 million units IM in a single dose. •Recommended Regimen for Children(CDC) Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose. 15min 5min 15min
.PenicillinAllergyDoxycycline 100mg orally twice dailyfor14 days.Tetracycline500mgfour timesdailyfor14days.Cefriaxone 1 gram daily either IM or IV for 8--10 days.Azithromycina single oral dose of2 grams.Treatment in Pregnancy-Screen for syphilis at first prenatal visit: repeat RPR third trimester/delivery forthoseat highrisk orhighprevalence areas-Treat for the appropriate stage of syphilis2.4mu IM after·Someexpertsrecommend additional benzathinepenicillinthe initial dose for primary, secondary,or early latent syphilis-Management and counseling may be facilitated by sonographic fetal evaluation forcongenitalsyphilisinthesecondhalfofpregnancy.Pregnant patients who are allergic to penicillin should be desensitized and treatedwith penicillin or receive the recommended total dose oferythromycin; tetracyclineshould not be usedLatent SyphilisRecommended regimenBenzathinepenicillinG2.4millionunitsIMatoneweek intervalsx3dosesPenicillin allergyDoxycycline 100 mg orally twice dailyorTetracycline 500 mg orally four times dailyDuration of therapy 28 days; close clinical and serologic follow-up;data to support alternatives to pcn are limitedFollow-Up-Treatment failure can occur with any regimen. However, assessing response totreatment often is difficult, and definitive criteria for cure or failure have not beenestablished. Nontreponemal test titers may decline more slowly for patients whopreviously had syphilis. Patients should be reexamined clinically and serologicallyat 3 month intervals in the first year and then at 6 month intervals tor 2 to 3 yearsafter treatment.·Patients who have signs or symptoms that persist or recur or who have a sustainedfourfold increase in nontreponemal test titer (i.e., compared with the maximum orbaselinetiteratthetimeoftreatment)probablyfailedtreatment orwerereinfectedThese patients should be re-treated.Case 1A male, 45 years old, complained of nontender genital erosion. Physicalexamination revealed inguinal adenophthy. His serologic test for syphilis (RPR)was positive at a titer of 1:64. Three months after Benzathine penicillin G 2.4million units IM in a single dose the RPR titerdropped to 1:1.Case 2A 30-year-old man was evaluated for a rash of2 weeks duration on his, handsand feetrapidly spreadingto invovehistrunk andface.Healsohad a chancreonhispeniswithpainlessregionallymphadenopathywhichhedevelopedaCase3few weeks prior to the eruption. Other than the skin rash his physicalexamination was normal. Screening for sexually transmitted diseases revealedpositive Venereal Disease Research Laboratory (VDRL)and rapid plasmareagin(RPR) tests
•Penicillin Allergy Doxycycline 100 mg orally twice daily for 14 days. Tetracycline 500 mg four times daily for 14 days. Ceftriaxone 1 gram daily either IM or IV for 8-10 days. Azithromycin a single oral dose of 2 grams. Treatment in Pregnancy •Screen for syphilis at first prenatal visit; repeat RPR third trimester/delivery for those at high risk or high prevalence areas •Treat for the appropriate stage of syphilis •Some experts recommend additional benzathine penicillin 2.4 mu IM after the initial dose for primary, secondary, or early latent syphilis •Management and counseling may be facilitated by sonographic fetal evaluation for congenital syphilis in the second half of pregnancy •Pregnant patients who are allergic to penicillin should be desensitized and treated with penicillin or receive the recommended total dose of erythromycin; tetracycline should not be used Latent Syphilis Recommended regimen Benzathine penicillin G 2.4 million units IM at one week intervals x 3 doses Penicillin allergy Doxycycline 100 mg orally twice daily or Tetracycline 500 mg orally four times daily Duration of therapy 28 days; close clinical and serologic follow-up; data to support alternatives to pcn are limited Follow-Up •Treatment failure can occur with any regimen. However, assessing response to treatment often is difficult, and definitive criteria for cure or failure have not been established. Nontreponemal test titers may decline more slowly for patients who previously had syphilis. Patients should be reexamined clinically and serologically at 3 month intervals in the first year and then at 6 month intervals tor 2 to 3 years after treatment. •Patients who have signs or symptoms that persist or recur or who have a sustained fourfold increase in nontreponemal test titer (i.e., compared with the maximum or baseline titer at the time of treatment) probably failed treatment or were reinfected. These patients should be re-treated. Case 1 A male, 45 years old, complained of nontender genital erosion. Physical examination revealed inguinal adenophthy. His serologic test for syphilis (RPR) was positive at a titer of 1:64. Three months after Benzathine penicillin G 2.4 million units IM in a single dose the RPR titer dropped to 1:1. Case 2 A 30-year-old man was evaluated for a rash of 2 weeks duration on his, hands and feet rapidly spreading to invove his trunk and face. He also had a chancre on his penis with painless regional lymph adenopathy which he developed a Case 3 few weeks prior to the eruption. Other than the skin rash his physical examination was normal. Screening for sexually transmitted diseases revealed positive Venereal Disease Research Laboratory (VDRL)and rapid plasma reagin(RPR) tests