eMedicine Specialties > Infectious Diseases > Bacterial Infections

Treponematosis (Endemic Syphilis): Differential Diagnoses & Workup

Author: Steven Fine, MD, PhD, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, University of Rochester School of Medicine
Coauthor(s): Lynn S Fine, PhD, MPH, Manager of Clinical Microbiology Laboratory, ACM Medical Laboratories; Adjunct Professor, Department of Biology, St John Fisher College and Nazareth College
Contributor Information and Disclosures

Updated: Apr 30, 2009

Differential Diagnoses

Blastomycosis
Sickle Cell Anemia
Leishmaniasis
Syphilis
Leprosy
Tuberculosis
Pinta
Yaws

Other Problems to Be Considered

Pyoderma
Cutaneous leishmaniasis
Tropical ulcer
Neurodermatitis
Tinea versicolor
Chloasma
Vitiligo

Workup

Laboratory Studies

Endemic syphilis should be suspected in persons with appropriate clinical findings (eg, chronic skin or bone lesions) who live in or are from endemic areas. As with other treponeme diseases, confirmation of the diagnosis depends on dark-field examination, if available, or serologic testing. The epidemiologic setting is vital because the nonvenereal treponemes cannot be distinguished from T pallidum pallidum (the cause of venereal syphilis) with laboratory studies.

Because treponemes cannot be easily and readily cultured, use other laboratory methods of identifying infection. The current tests for syphilis fall into the following 3 categories: direct microscopic identification when lesions are present, nontreponemal tests used for screening, and treponemal tests used for confirmation.

  • Direct microscopy
    • Direct microscopic identification of treponemes from lesion fluids by either dark-field microscopy or direct fluorescent antibody should be the initial step in diagnosing a treponemal infection. This is most helpful during the primary stage of infection because treponemal antibodies do not usually appear until 1-4 weeks after the lesion has formed.

      Photomicrograph (540X) of <EM>Treponema carateum<...

      Photomicrograph (540X) of Treponema carateum obtained from an early pinta lesion. Courtesy of the CDC.

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      Photomicrograph (540X) of <EM>Treponema carateum<...

      Photomicrograph (540X) of Treponema carateum obtained from an early pinta lesion. Courtesy of the CDC.

    • A negative dark-field finding does not exclude the diagnosis of treponematosis because the organisms may be too few if the lesion is in the healing stage or if the infection has been altered by treatment.
  • Nontreponemal tests
    • These include the nontreponemal rapid plasma reagin (RPR) test and the Venereal Disease Research Laboratory (VDRL) test.
    • RPR is inexpensive and rapid and is convenient for screening large numbers of sera specimens.
    • The standard nontreponemal test is the VDRL slide test, in which serum is tested for its ability to flocculate a suspension of cardiolipin-cholesterol-lecithin antigen. This test is based on the observation that antibodies elicited against treponemal surface antigens cross-react with cardiolipin.
  • Treponemal tests
    • The principal confirmatory treponemal antibody test is the fluorescent treponemal antibody absorption (FTA-ABS) test. This is an indirect immunofluorescent antibody test that uses T pallidum organisms as the antigen. The patient's serum is first absorbed to remove any naturally occurring cross-reacting antibody; it is then reacted with the organism.
    • Because of the nonstandardized, qualitative, and subjective nature of this test, its principal use is to confirm any positive VDRL or RPR test result.

Imaging Studies

Imaging studies are generally not used in the diagnosis or treatment of endemic treponematosis, although changes to bone periosteum and cartilage may be observed on radiography in late-stage yaws or endemic syphilis.

Histologic Findings

Dark-field microscopy of material from cutaneous lesions often yields treponemes. However, this technique may not be available in endemic areas, and pathologic diagnosis is not considered necessary. In yaws and pinta, granulomatous inflammation resembles that of syphilis. Endarteritis is a feature of late yaws lesions.

More on Treponematosis (Endemic Syphilis)

Overview: Treponematosis (Endemic Syphilis)
Differential Diagnoses & Workup: Treponematosis (Endemic Syphilis)
Treatment & Medication: Treponematosis (Endemic Syphilis)
Follow-up: Treponematosis (Endemic Syphilis)
Multimedia: Treponematosis (Endemic Syphilis)
References
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References

  1. Julvez J, Michault A, Kerdelhue V. [Serologic studies of non-venereal treponematoses in infants in Niamey, Niger]. Med Trop (Mars). 1998;58(1):38-40. [Medline].

  2. Tabbara KF, al Kaff AS, Fadel T. Ocular manifestations of endemic syphilis (bejel). Ophthalmology. Jul 1989;96(7):1087-91. [Medline].

  3. Backhouse JL, Hudson BJ, Hamilton PA. Failure of penicillin treatment of yaws on Karkar Island, Papua New Guinea. Am J Trop Med Hyg. Sep 1998;59(3):388-92. [Medline].

  4. Agadzi VK, Aboagye-Atta Y, Nelson JW. Resurgence of yaws in Ghana. Lancet. Aug 13 1983;2(8346):389-90. [Medline].

  5. Anselmi M, Araujo E, Narvaez A. Yaws in Ecuador: impact of control measures on the disease in the Province of Esmeraldas. Genitourin Med. Dec 1995;71(6):343-6. [Medline].

  6. Chulay JD. Treponema species (Yaws, Pinta, Bejel). In: Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Infectious Diseases. New York, NY: Churchill Livingston; 2000:2490-4.

  7. Engelkens HJ, Judanarso J, Oranje AP. Endemic treponematoses. Part I. Yaws. Int J Dermatol. Feb 1991;30(2):77-83. [Medline].

  8. Farnsworth N, Rosen T. Endemic treponematosis: review and update. Clin Dermatol. May-Jun 2006;24(3):181-90. [Medline].

  9. Kim SC, Guerrero R, Gonzalez R. A 23-year-old pregnant woman with left-foot and left-ankle ulceration. Clin Infect Dis. Jul 1 2004;39(1):81-2, 136-7. [Medline].

  10. Koff AB, Rosen T. Nonvenereal treponematoses: yaws, endemic syphilis, and pinta. J Am Acad Dermatol. Oct 1993;29(4):519-35; quiz 536-8. [Medline].

  11. Perine PL, Hopkins DR, Niemel PLA. Handbook of Endemic Treponematoses: Yaws, Endemic Syphilis, and Pinta. WHO Publications Centre, USA: World Health Organization; 1984.

  12. Second International Conference on Control of Yaws. Report of Second International Conference on Control of Yaws: Nigeria, 1955. II. J Trop Med Hyg. Mar 1957;60(3):62-73. [Medline].

  13. Vabres P, Roose B, Berdah S. [Bejel: an unusual cause of stomatitis in the child]. Ann Dermatol Venereol. Jan 1999;126(1):49-50. [Medline].

  14. Walker DH, Guerrant RL, Weller PF. Treponemal infections. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases: Principles, Pathogens, and Practice. New York, NY: Churchill Livingstone; 1999:527-34.

  15. Walker SL, Hay RJ. Yaws-a review of the last 50 years. Int J Dermatol. Apr 2000;39(4):258-60. [Medline].

  16. World Health Organization. 1998 World Health Report: Health in the 21st Century: A Vision for All. 1998.

  17. World Health Organization. WHO Expert Committee on Venereal Infections. Report on the third session. Vol 13. 1950.

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Further Reading

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Keywords

treponematosis, endemic syphilis, treponemiasis, nonvenereal syphilis, yaws, pinta, non-venereal syphilis, pian, bouba, frambesia, bejel, sibbens, radesyge, dichuchwa, njovera, skerljevoj, mal de pinto, carate, azul, purupuru, Treponema pallidum, Treponema pertenue, Treponema endemicum, Treponema carateum, T pallidum, T pertenue, T endemicum, T carateum

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Contributor Information and Disclosures

Author

Steven Fine, MD, PhD, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, University of Rochester School of Medicine
Steven Fine, MD, PhD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Lynn S Fine, PhD, MPH, Manager of Clinical Microbiology Laboratory, ACM Medical Laboratories; Adjunct Professor, Department of Biology, St John Fisher College and Nazareth College
Lynn S Fine, PhD, MPH is a member of the following medical societies: American Public Health Association and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey M Zaks, MD, Clinical Associate Professor of Medicine, Wayne State University School of Medicine; Vice President, Medical Affairs, Chief Medical Officer, Department of Internal Medicine, Providence Hospital
Jeffrey M Zaks, MD is a member of the following medical societies: American College of Cardiology, American College of Healthcare Executives, American College of Physician Executives, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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