Syphilis: why the disease is more insidious in women
Alessandra Grazziottin1,2 – , Elena Boero1 –
1 – Alessandra Graziottin Foundation for the treatment of pain in women – Onlus
2 – Gynecology and Medical Sexology Center, H. San Raffaele Resnati, Milan
Corresponding author: Alessandra Graziottin
Why should syphilis be reconsidered in gynecological clinical practice? Why are women more vulnerable to late diagnosis? What are the key points for timely and effective diagnosis and treatment? What are the avoidable consequences of diagnostic and therapeutic delays? Syphilis is caused by the sexually and vertically transmitted bacterium Treponema pallidum. Syphilis, wrongly considered outdated, is making an aggressive comeback worldwide. From a medical point of view, diagnostic timeliness is hampered by: a lack of familiarity with this re-emerging disease and a consequent lack of consideration in the anamnestic picture and differential diagnosis; complex course, which alternates insidious and variable symptomatic phases, with periods of clinical latency, while the disease continues its pro-inflammatory and destructive action at the subclinical level. The late or missed diagnosis of syphilis leads to a prolonged infection, with permanent and at times fatal outcomes. The danger of a delay in diagnosis also results in persistent infectivity of the patients, who continue to infect their sexual partners, and the fetus, if pregnant. The aim of the work is: to identify the key points for timely and effective diagnosis and therapy of syphilis in gynecology, with a focus on vulvar and vaginal vulnerability; to analyze the reasons for its insidious hidden diffusibility; to discuss the diagnostic difficulties, the limited availability of the most effective drug, penicillin, the current lack of a vaccine and finally why it is difficult to follow the course of the disease and its therapy through laboratory diagnostics. The final goal is to enhance the diagnostic effectiveness of the gynecologist.
Keywords: syphilis; primary chancre; secondary syphilis; treponema pallidum; penicillin; vulva.
Available in LRIOG Nr.1 – 2021
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Vulvar herpes: clinics and therapy
Stefano Astorino –
Operational unit of dermatology and stds – “Celio” Military Polyclinic, Rome
Most young people with erosive-ulcerative-genital lesions (“Genital Ulcer Disease”) have genital herpes (prevalence 5-40%), sometimes associated with syphilis or other sexually transmitted diseases, with a significant risk of co-infection with HIV.
Also transmissible in asymptomatic (virus shedding) or “undiagnosed” due to mild, atypical symptoms (fissures, erythema, neuralgia), or hidden localizations, the primary infection of vulvar herpes (HSV2-1) has classic acute manifestations: pain, burning (sometimes sciatica, cruralgia, antalgic urinary retention), cluster vesicle- pustules on erythematous-edematous areas that evolve into confluent-polycyclic erosions, often ulcerative-aphthous-like; satellite lymphadenitis, fever sometimes high. In 1-3 weeks they heal (completely the erosions; ulcers with scars); after weeks or months of latency the secondary herpes relapses on average 5-6 times a year, with variable duration (on average 1 week). Relapsing symptoms and signs, similar to primary-Herpes, are more localized and attenuated, except in immunosuppressed, who manifest chronic, severe-ulcerative, disabling, hypertrophic-pseudo-tumor, generalized-varicelliform forms. Possible cause of fetal malformations, neonatal morbidity and lethality, herpes in pregnancy is effectively treated with systemic acyclovir. Sometimes it justifies caesarean-section. According to European-guidelines (2017), the diagnosis is clinical (when possible supported by PCR); topical antiviral-therapy offers few advantages (except foscarnet 1% in case of resistance and imiquimod 5% effective in HIV-associated pseudotumoral-forms) compared to local soothing-antiseptic and anti-inflammatory (including cortisone) therapy. Acyclovir (ACV), since its discovery (Elion_G.B.1978) the best systemic antiherpetic, is effective both with “episodic-therapy” (average adult dose: ACV tbl 200-800mg 3t./die for 7-10 days in primary-Herpes, for 2-5 days at each relapse) both with “continuous-suppressive-therapy” (if>6 relapses a year a.a.d.:ACV400mg 2t./die or similar: Famciclovir FCV 250mg 2t./die, Valaciclovir VLC 500mg 1t./die; replaceable in case of resistance with Foscarnet 40mg / kgI.V./8-12h.).
Keywords: vulvar herpes; HSV2-1; genital herpes; systemic antiviral therapy; topical therapy; guidelines.
Available in LRIOG Nr.1 – 2021
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