FEW CASES OF MARETNAL SYPHILIS
DR. IRESH JAYAWEERA (VENEREOLOGY DIPLOMA TRAINEE)
CASE HISTORY-01 Mrs. T 30 years old pregnant female with a Period of Amenorrhea of 19/52 referred from OPD of base hospital Homagama to STD clinic Kalubowila on 02nd of May 2014. Presenting complaint: Warty lesions on the vulva for four months duration
• History of presenting complaint • Patient noticed small wart like lesions on the vulval area four months ago. • She went to the Outpatient department of Homagama base hospital where she was referred to STD clinic Kalubowila.
Past Medical History :Not significant Obstetric and Gynecological History: G4P4C3 C1- 12years old male C2- 9 years old Male C3- 6 years old Female
Current pregnancy: • Unplanned • POA 19/52. • Booking visit at 8/52 weeks of POA
Sexual History: Coitarche at 18 years with the first marital partner. Regular partner for last 6 Years. Last sexual exposure unprotected penovaginal intercourse with the regular partner 3 days ago. Life time 2 partners
Social History: She is a house wife. Educated up to G C E O/L. MP1=Driver Married at 18 years. Separated from him 5 years ago due to marital disharmony with alcohol dependence. She had the first two children from him.
MP-2 Lorry driver . He is a 37 y male who also got separated from the first wife. He is working from home doing short trips daily. He is a regular consumer of moderate amounts of alcohol. She is financially dependent on the regular partner. She has never gone abroad.
Examination findings: General Examination: She was a healthy looking female with an average built. No generalized lymphadenopathy No skin rashes..
Cardio vascular and respiratory system: Unremarkable. Abdomen: Unremarkable. Central Nervous system examination: Unremarkable.
Genital examination: There were multiple painless, nonkeratinized fleshy looking lesions dull pink in color over the labia minora and the left labia majora. The lesion over the left labia majora was 2 x 1 cm in size and had a rounded out line.
• Speculum Examination: • There were no intra-vaginal lesions. Cervix was normal.
Summary 30 y female with a POA 19/52 presented with wart like lesions on the vulva for 4/12. On examination there were raised dull pink colored non keratinized flesh looking lesions involving the Labia minora and a prominent large lesion on the Left Labium majora.
• Differential diagnosis: • Genital Warts • Secondary syphilis
Investigations • Dark ground microscopy: Negative • VDRL- R 16 • TPPA-2+ • HIV screening-Negative • Cervical smear-Negative
Diagnosis
Secondary Syphilis complicating Pregna
Management B.Penicilin Safe sex counseling done Partner notification done Health education about the disease Referral letter given to VOG Follow up with VDRL
Important points • Initial VDRL was negative? Prozoan phenominon • Lab errorDone at private sector. Rapid test/strip test.
Response to the treatment
8 Weeks after the treatment. Large lesion also became smaller
VDRL follow up • 1 month- R 8 • 2 month- R 4 • Defaulted
Final Outcome • Patient was referred back by the Obstetrician at term. • Apparently healthy Full term Baby was delivered on 22nd of September at BHHomagama • Baby- VDRL- R4 TPPA-2+ Epi Rx given Mother’s VDRL at delivery – R4
Problems..
• Partner never showed up for screening.? Important for Epi-Rx, staging, Prevent reinfection • Tried best to bring the partner but all the efforts were failed. • Patient defaulted after 2 months.
CASE HISTORY-02
• 23 years old pregnant female from Mt.Lavinia referred from the Local Antenatal Clinic following positive VDRL test for furthe investigations and Management.
She was asymptomatic and had a POA o 18/52 weeks in July 2014 EDD 24/12/2014
Sexual history: • Coitarche at the age of 16 years with Married Partner. • LSE: Had unprotected peno-vaginal intercourse with Living in (regular) partner10 days ago. Denies any EMSE Past Medical History: Not significant
Social History : House wife First marriage: Married at 16 years of age and continued for 5 years, separated 2 years ago. One child – 7 years male
Second marriage : Married a three wheel driver 3/12 ago. He is a 28 years old male. He is a smoker and a occasional alcoholic. There is no history of substance abuse.
Examination findings General Examination: There were copper colored macular lesions on her palms and soles. Some lesions were scaly.
No other skin lesions involving the trunk and limbs.
Cardio vascular and respiratory system examination: Unremarkable Abdomen: Unremarkable Central Nervous system examination: Unremarkable
Genital examination: There was a 1*4 cm size grey colored elevated soft lesion over the left labia majora. There were enlarged inguinal lymph nodes but their sizes were < 1cm in diameter. Lymph nodes were rubbery in consistency.
Examination findings
â&#x20AC;˘ Speculum Examination: There were no intra-vaginal lesions Cervix was normal
Summary â&#x20AC;˘ 23 years old female with a POA 18/52 presented with a copper colored macular rash involving palms and soles and a grayish soft lesion over the left labia majora.
Summary Investigations • VDRL R(64) • TPPA 2+ • HIV-Negative
Diagnosis â&#x20AC;˘ Secondary Syphilis complicating pregnancy
• Partner: Had multiple exposures with casual male and female partners. He was asymptomatic. • VDRL R(8) • TPPA 2+ • HIV-Negative
Response to Rx 1 week after Rx with BP
Labial lesions were disappeared
Problems… • Defaulted after treatment. • Reason for late presentation?? • Booking visit 6/52VDRL at 12/52 reports and referral at 19/52 • Even though there were new rashes appeared on the body during past 1 month, patient did not take it as significant. No health seeking behavior.
CASE HISTORY-03
18 years old pregnant female with a POA of 29/52+5days from Borupana. She was referred by the VOG of Colombo South teaching Hospital following a Positive VDRL Report done at MOH clinic of Rathmalana. She had no complains with regard to her health.
• Obstetric and Gynecological History:
• G3P3C0 • P1- Second Trimester Miscarriage • P2-First trimester Miscarriage P3-Planned pregnancy POA29/52+5days. Preconception folic acid was taken. • Antenatal booking visit was at 6/52 of PO • Cervical cerclage done • VDRL was done at private sectorR4 • VDRL was done at
• Past Medical History : • Not significant
Sexual History: Coitarche at the age of 16 years with the married partner. LSEď&#x192; 28/52 ago unprotected penovaginal intercourse. No history of other sexual exposures other than the marital partner during her life time.
â&#x20AC;˘ Social History: House wife. Never been abroad Husband is a mason/contractor. He is an occasional consumer of alcohol. No other substance abuse.
Examination findings
General Examination: She was a healthy looking female with an average built. No skin rashes or lymphadenopathy
Cardio vascular system examination Unremarkable Respiratory system: Unremarkable Central Nervous system examination Unremarkable Abdomen:Unremarkable
Genital examination: There were no ulcers/rashes/lumps in the vulva and the urethral meatus was normal. There was no inguinal lymphadenopathy.
• Speculum Examination: • Speculum examination not done. • Consent was not given due to worry about miscarriage.
Summary â&#x20AC;˘ 18 years asymptomatic female with a past history of recurrent miscarriages presented at POA 29/52+ with a Positive VDRL report. â&#x20AC;˘ No significant examination findings.
Blood Investigations • VDRL- R 8 • TPPA- 2+ • HIV- Negative
Diagnosis Syphilis of Unknown duration
Follow up Ix • VDRL -1st Month – R4
Out come • Uncomplicated vaginal delivery at Term • Apparently healthy baby was delivered on 13/08/2014. • No stigmata of congenital syphilis found. • Baby- VDRL- R (4) • Mothers VDRL at delivery – R4
Laps in the health care delivery • Even though this was a planned pregnancy with a past history of M/Cs • She had her first visit/booking visit at 6/52 • VDRL was done at 20/50 at MOH • Private lab VDRL was done-- early report?? was R4. Was not taken in to consideration. • Patient came to STD clinic at 29+/52 with the referral.
Other important points â&#x20AC;˘ Past Miscarriages due to syphilis? â&#x20AC;˘ MP ran away from the clinic on the first day and never turned up to undergo screening despite several requests.
Thank you