Treponematosis (Endemic Syphilis) Workup
- Author: Steven Fine, MD, PhD; Chief Editor: Mark R Wallace, MD, FACP, FIDSA more...
Treponematosis 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.
Tests for endemic treponematosis are the same as for syphilis. 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 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. See the image below.
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.
These include the nontreponemal rapid plasma reagin (RPR) test and the Venereal Disease Research Laboratory (VDRL) test. These tests usually become positive within 2-4 weeks of the appearance of the primary lesion. They can be used as tests of cure because they usually become negative after treatment.
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.
The confirmatory treponemal tests are the fluorescent treponemal antibody absorption (FTA-ABS) test, T pallidum hemagglutination assay (TPHA), and T pallidum particle agglutination assay (TPPA). These tests use 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.
New rapid point-of-care tests are currently being evaluated.
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.
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.
Smajs D, Norris SJ, Weinstock GM. Genetic diversity in Treponema pallidum: Implications for pathogenesis, evolution and molecular diagnostics of syphilis and yaws. Infect Genet Evol. 2011 Dec 15. [Medline].
Mikalová L, Strouhal M, Cejková D, Zobaníková M, Pospíšilová P, Norris SJ, et al. Genome analysis of Treponema pallidum subsp. pallidum and subsp. pertenue strains: most of the genetic differences are localized in six regions. PLoS One. 2010 Dec 29. 5(12):e15713. [Medline]. [Full Text].
Centers for Disease Control and Prevention. Notice to readers: Recommendations regarding screening of refugee children for treponemal infection. MMWR Morb Mortal Wkly Rep. 2005. 54(37):933-4. [Full Text].
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].
World Health Organization. Yaws, Fact sheet no. 316, Updated February 2014. World Health Organization. Available at http://www.who.int/mediacentre/factsheets/fs316/en/. Accessed: June 4, 2014.
Maurice J. WHO plans new yaws eradication campaign. Lancet. 2012 Apr 14. 379(9824):1377-8. [Medline].
Tabbara KF, al Kaff AS, Fadel T. Ocular manifestations of endemic syphilis (bejel). Ophthalmology. 1989 Jul. 96(7):1087-91. [Medline].
Marks M, Mitjà O, Solomon AW, Asiedu KB, Mabey DC. Yaws. Br Med Bull. 2015 Mar. 113 (1):91-100. [Medline].
Backhouse JL, Hudson BJ, Hamilton PA. Failure of penicillin treatment of yaws on Karkar Island, Papua New Guinea. Am J Trop Med Hyg. 1998 Sep. 59(3):388-92. [Medline].
Kazura JW. Yaws eradication--a goal finally within reach. N Engl J Med. 2015 Feb 19. 372 (8):693-5. [Medline].
Mitjà O, Hays R, Ipai A, Gubaila D, Lelngei F, Kiara M, et al. Outcome predictors in treatment of yaws. Emerg Infect Dis. 2011 Jun. 17(6):1083-5. [Medline].
Agadzi VK, Aboagye-Atta Y, Nelson JW. Resurgence of yaws in Ghana. Lancet. 1983 Aug 13. 2(8346):389-90. [Medline].
Anselmi M, Araujo E, Narvaez A. Yaws in Ecuador: impact of control measures on the disease in the Province of Esmeraldas. Genitourin Med. 1995 Dec. 71(6):343-6. [Medline].
Chulay JD. Treponema species (Yaws, Pinta, Bejel). Long SS, Pickering LK, Prober CG, eds. Principles and Practice of Infectious Diseases. New York, NY: Churchill Livingston; 2000. 2490-4.
Engelkens HJ, Judanarso J, Oranje AP. Endemic treponematoses. Part I. Yaws. Int J Dermatol. 1991 Feb. 30(2):77-83. [Medline].
Farnsworth N, Rosen T. Endemic treponematosis: review and update. Clin Dermatol. 2006 May-Jun. 24(3):181-90. [Medline].
Kim SC, Guerrero R, Gonzalez R. A 23-year-old pregnant woman with left-foot and left-ankle ulceration. Clin Infect Dis. 2004 Jul 1. 39(1):81-2, 136-7. [Medline].
Koff AB, Rosen T. Nonvenereal treponematoses: yaws, endemic syphilis, and pinta. J Am Acad Dermatol. 1993 Oct. 29(4):519-35; quiz 536-8. [Medline].
Oriol Mitjà, Kingsley Asiedu, David Mabey. Published OnlineSeminar. Yaws February 13, 2013http://dx.doi.org/10.1016/S0140-6736(12)62130-8.
Perine PL, Hopkins DR, Niemel PLA. Handbook of Endemic Treponematoses: Yaws, Endemic Syphilis, and Pinta. WHO Publications Centre, USA: World Health Organization; 1984.
Second International Conference on Control of Yaws. Report of Second International Conference on Control of Yaws: Nigeria, 1955. II. J Trop Med Hyg. 1957 Mar. 60(3):62-73. [Medline].
Vabres P, Roose B, Berdah S. [Bejel: an unusual cause of stomatitis in the child]. Ann Dermatol Venereol. 1999 Jan. 126(1):49-50. [Medline].
Walker DH, Guerrant RL, Weller PF. Treponemal infections. Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases: Principles, Pathogens, and Practice. New York, NY: Churchill Livingstone; 1999. 527-34.
Walker SL, Hay RJ. Yaws-a review of the last 50 years. Int J Dermatol. 2000 Apr. 39(4):258-60. [Medline].
World Health Organization. 1998 World Health Report: Health in the 21st Century: A Vision for All. 1998.
World Health Organization. WHO Expert Committee on Venereal Infections. Report on the third session. Vol 13. 1950.
Marks M, Lebari D, Solomon AW, Higgins SP. Yaws. Int J STD AIDS. 2015 Sep. 26 (10):696-703. [Medline].