Spirochete Diseases

Introduction to Spirochetes
• Long, slender, helically tightly coiled bacteria
• Gram-negative
• Microaerophilic or anaerobic .
• Corkscrew motility
Ø Have axial filaments, which are otherwise similar to bacterial flagella
Ø Filaments enable movement of bacterium by rotating in place
• Can be free living or parasitic
• Best-known are those which cause disease: Syphilis and Lyme’s disease
 Spirochetes

Treponema pallidum Borrelia burgdorferi Leptospira interrogans

causes syphilis causes Lyme disease causes leptospirosis
 Spirochete Diseases

• Localized skin infection disseminates to other

organs.

• Latent stage, no signs/symptoms apparent

• Cardiac and neurological involvement in

untreated cases
 Treponema species
• Most commonly acquired spirochete disease in the U.S.

• Complex sexually transmitted disease that has a highly

variable clinical course.

• The two treponemal species :

Ø Treponema pallidum: with three subspecies: pallidium

(venereal disease), endemicum, pertenue and Treponema
carateum (non venereal disease)
 Morphology
• Spiral shaped and motile due to periplasmic flagella.
• Variable length.
• Non cultivable
 Treponema pallidium epidemiology

• Syphilis is found worldwide and is the third most common

sexually transmitted bacterial disease in the United States

• Natural syphilis is exclusive to humans and has no other

known natural hosts

• Transmission: Sexually
Ø The risk of contracting the disease after a single sexual
contact is estimated to be 30%

• Congenital transmission from mother to fetus can occur

 Stages of clinical disease

• Primary: Chancres
• Secondary
• Latent
• Tertiary
• Congenital Syphilis
 Primary Syphilis

ØOrganism enters directly through skin or

through mucosal tissue.

ØCarried by blood throughout the body.

ØOrganisms remaining at the site begin to

multiply.
 Primary Syphilis - Chancre
• Variable incubation period of 10 days to several
months, a primary lesion, chancre, forms at the
entrance site.

• Chancre begins as a small, usually singular nodule;

as it enlarges, the overlying epithelial tissues
begins to necrose, resulting in a relatively painless
ulcer.

• Unlike other bacterial infections, there is no

formation of pus unless a secondary bacterial
infection sets in.
• Chancre is most frequently seen on the external
genitalia

Ø In women the lesions may form in the vagina or on

the cervix.

Ø In men it may be inside the urethra, resulting in a

serous discharge.

• The lesion heals spontaneously after 1-5 weeks.

• Serologic appearance (1 to 3 weeks)

Primary Syphilis - Chancre
Primary Syphilis - Chancre
 Secondary Syphilis
• Occurs 6-8 weeks after initial chancre

• systemic, patient highly infectious.

• Characterized by localized or diffuse maculopapuar (copper colored lesions), rash,

diffuse, includes palms and soles, patchy alopecia

• Often with generalized lymphadenopathy.

• Candulomata lata: flat wartlike perianal an mucous membrane lesions: highly

infectious.

• Primary chancre may still be present.

• Secondary lesions subside in about 2-6 weeks.

• Serology tests nearly 100% positive.

Skin rashes and/or sores in the mouth, vagina,
or anus (also called mucous membrane
lesions )

This stage usually starts with a rash on one or

more areas of the body.

§ rash may appear as rough, red, or reddish

brown spots both on the palms of the
hands and/or the bottoms of the feet.

§ Large, raised, gray or white lesions may

develop in warm, moist areas such as the
mouth, underarm or groin region.

Ø Other symptoms of secondary syphilis include

fever, swollen lymph glands, sore throat,
patchy hair loss, headaches, weight loss,
muscle aches, and fatigue.

Candulomata lata
 Latent Syphilis

• Stage of infection in which organisms persist in the

body of the infected person without causing
symptoms or signs (asymptomatic).

• This stage may last for years.

• One-third of untreated latent stage individuals

develop signs of tertiary syphilis.
 Latent Syphilis
• This stage may be further subdivided.

Ø Early latent, initial infection occurred within previous 24 months.

Ø Late latent, initial infection occurred greater than 24 months.

– In the late stages of syphilis, the disease damages the internal

organs, including the brain, nerves, eyes, heart, blood vessels,
liver, bones, and joints. This damage can result in death.

Ø Symptoms of the late stage of syphilis include difficulty coordinating

muscle movements, paralysis, numbness, gradual blindness, and
dementia

Ø Serology positive
 Tertiary Syphilis
• Tertiary syphilis may occur approximately 3 to 15 years after
the initial infection, and may be divided into three different
forms:

– Gummatous syphilis (skin, bone and liver).

– Cardiovascular syphilis

– Neurosyphilis (granuloma lesions in the CNS)

Ø Devastating destruction of virtually any organ or tissue

 Tertiary Syphilis - Gummatous

• Gummas are localized areas of granulomatous inflammation

found on bones, skin and subcutaneous tissue.

• Cutaneous gummas may be single or multiple, generally

asymmetric and grouped together.

• Visceral lesions often cause local destruction of the affected

organ.
Tertiary Syphilis Buboe of Neck
Tertiary Syphilis
Tertiary Syphilis - Gumma
 Tertiary - Cardiovascular
• This condition appears 20 or more years post-infection.

• Usually involves the aorta.

• Over many years, the inflammatory scarring weakens

the aortic wall, leading to aneurysm formation
 Neurosyphilis
• Caused by invasion of organisms into the
CNS.
• Manifests as an insidious but progressive
loss of mental and physical functions and
is accompanied by mood alterations.

• General symptoms of the insane:

– forgetful,
– personality change,
– psychiatric symptoms.

• Onset usually 10-20 years after primary

infection.

• Treatment may not improve symptoms.

 Congenital Syphilis

• Transmitted from mother to fetus.

• Fetus affected during second or third trimester.

• Forty percent result in syphilitic stillbirth-fetal death that

occurs after a 20 week gestation and the mother had
untreated or inadequately treated syphilis at delivery.
 Congenital Syphilis symptoms
• Bone deformities
• Blindness
• Deafness
• Deformed faces
• Dental deformities
• Skin rashes
• Neonatal death
• Notched teeth

Mulbary molars

Hutchinson teeth
• Live-born infants show no signs during first few weeks.

– 60 to 90 % develop clear or hemorrhagic rhinitis.

– skin eruptions (rash) especially around mouth, palms of hands
and soles of feet.

• Other signs: general lymphadenopathy, hepatosplenomegaly,

jaundice, anemia, painful limbs, and bone abnormalities.
 Diagnosis of Syphilis

• Evaluation based on three factors:

– Clinical findings.
– Demonstration of spirochetes in clinical specimen.
– Present of antibodies in blood or cerebrospinal fluid.

• More than one test should be performed.

• Direct examination of clinical specimen by
dark-field microscopy or fluorescent
antibody testing of sample.

• Non-specific or non-treponemal
serological test to detect reagin, utilized
as screening test only.

• Specific Treponemal antibody tests are

used as a confirmatory test for a positive
reagin test.
 Nontreponemal Reagin Tests

• Non-specific or non-treponemal serological

test to detect reagin, utilized as screening test
only

– Reagin is an antibody formed against

cardiolipin (antigen which consists of
cardiolipin, cholesterol and lecithin) derived
from beef heart

– Found in sera of patients with syphilis as well

as other diseases.

– Non treponemal tests become positive 1 to 4

weeks after appearance of primary chancre.
Venereal Disease Research Laboratory - VDRL

• Flocculation test, antigen consists of very fine particles

that precipitate out in the presence of reagin.

• Serum must be heated to 56 C for 30 minutes to inhibit

complements activity which may cause false positive, if
serum is not tested within 4 hours must be reheated for
10 minutes.
 VDRL
• Performing the test:

– 0.05 mL of serum added to circle on a slide and spread.

– Add one calibrated drop of antigen to each circle.
– Rotate at 180 rpms for 4 minutes.
– Read and grade reaction if positive.

• VDRL used primarily to screen cerebral spinal fluid.

 VDRL

• Each preparation of antigen suspension should first be examined by

testing with known positive or negative serum controls.
• The antigen particles appear as short rod forms at magnification of
about 100x. Aggregation of these particles into large or small clumps
is interpreted as degrees of positivity
• Reactive on left, non-reactive on right
 Unheated Serum Reagin Test - USR

• Modified VDRL antigen, uses choline chloride/EDTA to stabilize

antigen.

• Microscopic flocculation test.

• Reagent is ready-to-use and no serum heating is required.

• Chelating agents are added to neutralize the interference due to

complements.

• Several types of USR tests are available.

 Reagin Screen Test - RST

• Modified VDRL antigen with Sudan Black to make flocculation

reaction macroscopically visible.

• The sensitivity and specificity of the RST are essentially the same as
those of the VDRL test.

• The specimen of serum does not have to be inactivated by heat.

• The RST antigen is ready to use and it is stable for at least two years.
 Rapid Plasma Reagin Test - RPR

• General screening test

• CANNOT be performed on CSF.
• Antigen
– cardiolipin antigen is modified with choline chloride to make
it more stable
– attached to charcoal particles to allow macroscopic reading
– antigen comes prepared and is very stable.
• Serum or plasma may be used for testing, serum is not heated.
 Specific Treponemal Tests

• Fluorescent treponemal antibody absorption test

• Treponema pallidum hemagglutination

• ELISA
 FTA-ABS Step 1
• Teponema pallidum, the known antigen, is fixed to a microscope slide.
 FTA-ABS – Step 2
• If there are antibodies against Treponema pallidum in the patient's serum,
they will bind to the spirochete.

• All other antibodies are washed from the slide.

 FTA-ABS- Step 3
• Fluorescent anti-human gamma globulin (anti-HGG) is added to the well.

• The anti-HGG will bind with human IgG antibodies bound to the Treponema
pallidum on the slide.

• All unbound anti-HGG is washed from the slide.

• Viewed with a fluorescent microscope, the spirochetes will fluoresce

Positive FTA Test for Syphilis Viewed
with a Flourescent Microscope
Treponema pallidum Hemagglutination (TPHA)
Treponema pallidum Hemagglutination (TPHA)
 ELISA
• Microtitration wells coated with T.pallidum antigens are exposed to test
specimens which may contain specific antibodies.

• After an incubation period, unbound components in the test sample are

washed away.

• Specifically-bound IgG reacts with an anti-human IgG antibody bound with

horseradish peroxidase during a second incubation period.

• Following a second wash cycle, specifically-bound enzyme conjugate is

detected by reaction with hydrogen peroxide and the chromogen.

• The color reaction is measured spectrophotometrically to indicate the

presence or absence of IgG treponemal antibodies.
 Serology analysis

• Positive reactions with the nontreponemal tests develop late during the
first phase of disease

• The serologic findings are negative in many patients who initially have
chancres.

• Serologic results are positive within 3 months in all patients and

remain positive in untreated patients with secondary syphilis.

• The antibody titers decrease slowly in patients with untreated syphilis,

and serologic results are negative in approximately 25% to 30% of
patients with late syphilis.

Ø Therefore, in the nontreponemal tests, there is reduced sensitivity

in early primary disease and late syphilis
 Treatment/Prevention

Penicillin

Control veneral diseases

 Treponema pallidum
Celebrities who had suffered from syphilis: Hitler, Mussolini, Ivan the terrible
and Al Capone.

L. TAWK
 Other Treponemes
• Three other pathogens in the group:
Treponema which are morphologically
and antigenically similar to T. Pallidum

• Differences are in:

– characteristics of lesions,
– Amount of systemic involvement and
– course of the disease.
 T. pertenue
• Found in tropics, causes disease Yaws.

• Non-venereal transmission, transmitted by

direct contact.

• Disease of bone and skin, rarely viscera

• Persistent lesions, wart-like, occur primarily in

children, causes and ulcerative necrosis, scar
formation, disfiguring.

• Untreated disease not as severe as syphilis,

but lesions are more persistent.

• Treat with penicillin

• Serologic syphilis test will be reactive.

T. Pertenue - Lesions
 T. endemicum
• Causes non-venereal syphilis known as bejel or endemic
syphilis

• Typically spread among children, most commonly in the

Middle East and the southern Sahara desert regions.

• Bejel affects the skin, bones, and mucous membranes of

the mouth.

• Transmission is by direct contact, with broken skin or

contaminated hands, or indirectly by sharing drinking vessels
and eating utensils.

• Symptoms begin with a slimy patch on the inside of the mouth

followed by blisters on the trunk, arms, and legs.
Ø Bone infection develops later, mainly in the legs.
Ø Also in later stages, soft, gummy lumps may appear in the
nose and on the roof of the mouth (soft palate)

• Bejel is completely curable with penicillin.

• Serologic syphilis test will be reactive.
 Borrelia species
species causing human disease

• B. burgdorferi (USA/Europe)
• Borrelia garinii (Europe/Japan)
• Borrelia afzelii (Europe/Japan)
• B. recurrentis (Ethiopia, Rwanda)

• North America Central and South

• B. Hermsii America
• B.Parkerii • Mediterranean
• B.turicatae • Central Asia
• Africa.
 Characterization
• Gram negative spirochetes
• Motile
• Spiral shape bacterium
• Microaerophilic
• Transmitted by Ixodes ticks
B. Recurrentis

B. Hermsii
B.Parkerii
B.turicatae

B. burgdorferi
Borrelia garinii
Borrelia afzelii
Clinical diagnosis: Relapsing fever

• Relapsing fever is bacterial infection characterized by recurring

episodes of fever, headache, muscle and joint aches, and nausea.

• It is caused by certain species of Borrelia spirochetes.

• There are two types of relapsing fever:

1. Tick-borne relapsing fever (TBRF)-endemic tick-borne

2. Louse-borne relapsing fever (LBRF)-epidemic louse-borne
• Shaking chills, fever, muscle aches, and headache

• Splenomegaly and hepatomegaly

• A single relapse is characteristic of epidemic louse-borne disease, and

as many as 10 relapses occur in endemic tick-borne disease.

• Mortality with endemic disease is less than 5% but can be as high as 40% in
louse-borne epidemic disease.

• Deaths are caused by cardiac failure, hepatic necrosis, or cerebral

hemorrhage.
Clinical disease: Lyme disease
A-Early localized stage (3-30 days post-tick bite)

• Red, expanding rash called erythema migrans (EM)

• Fatigue, chills, fever, headache, muscle and joint aches, and

swollen lymph nodes.

• These symptoms last for an average of 4 weeks.

 Erythema migrans (EM) or "bull's-eye" rash

• Rash occurs in approximately 70-

80% of infected persons and begins
at the site of a tick bite after a delay of
3-30 days (average is about 7 days).

• Rash gradually expands over a

period of several days, and can reach
up to 12 inches (30 cm) across.

• Parts of the rash may clear as it

enlarges, resulting in a “bull's-eye”
appearance.

• Rash usually feels warm to the touch

but is rarely itchy or painful.

• EM lesions may appear on any area

of the body.
B-Early disseminated stage (days to weeks
post-tick bite)

• Untreated, the infection may spread from the

site of the bite to other parts of the body,
producing an array of specific symptoms that
may come and go, including:

• Additional EM lesions in other areas of the

body
• Facial or Bell's palsy (loss of muscle tone on
one or both sides of the face)
• Severe headaches and neck stiffness due to
meningitis (inflammation of the spinal cord)
• Pain and swelling in the large joints (such as
knees)
• Shooting pains that may interfere with sleep
• Heart palpitations and dizziness due to
changes in heartbeat
C- Late disseminated stage (months-to-years
post-tick bite)

• Approximately 60% of patients with untreated

infection may begin to have intermittent bouts
of arthritis, with severe joint pain and swelling.

• Large joints are most often affected,

particularly the knees

• Up to 5% of untreated patients may develop

chronic neurological complaints months to
years after infection.

Ø These include shooting pains, numbness or

tingling in the hands or feet, and problems with
short-term memory.

acrodermatitis chronica atrophicans

 Diagnosis
q Borreliae that cause relapsing fever can be seen during the febrile period on
Giemsa- or Wright-stained preparation of blood

q Limited success with the culture of B. burgdorferi.

q Nucleic acid amplification techniques (varying sensitivity)

q Serologic tests

Ø Not useful in the diagnosis of relapsing fever but is the diagnostic test of
choice for patients with suspected Lyme disease (late detection of
antibodies)

Ø False positivity with treponema

Spirochetes in Blood
 Treatment, Prevention, and Control

• Relapsing fever has been treated most effectively with tetracyclines

or penicillins

• The early manifestations of Lyme disease are managed effectively

with orally administered amoxicillin, doxycycline, or cefuroxime

Prevention of tick-borne Borrelia diseases includes

• Avoiding ticks and their natural habitats, wearing protective clothing

apply insect repellents.

• Rodent control is also important in the prevention of endemic

relapsing fever.
 Spirochete cont’d: Leptospirosis
• Leptospirosis is a bacterial disease that affects humans and animal.
• Leptospires are thin, coiled spirochetes with a hook at one or both pointed end
• Motile
• Obligate aerobic

Epidemiology:
Reservoirs: Rodents (asymptomatic)
• Most human infections result from recreational exposure to contaminated water or
occupational exposure to infected animals.
• Infection can be introduced through skin abrasions or the conjunctiva.
• The disease often occurs in summer (warm months)
• No person to person transmission
• Farmers, mine workers, slaughter, house workers, veterinarians and animal
caretakers, fish workers dairy farmers military personnel
Penetratiion through mucous membranes
via vunerable areas such as damaged
skin, eyes, nose or the mouth
 Clinical disease
• Incubation period: 1 to 2 weeks

• Initial phase of symptoms:

First : flu like symptoms: fever and myalgia

Second : Headache, Chills, Muscle aches, Vomiting Jaundice
(yellow skin and eyes), Red eyes, Abdominal Pain, Diarrhea,
Rash.

Complication: vascular collapse, thrombocytopenia,

hemorrhage and hepatic and renal dysfunction. Meningitis
may occur.

Weil syndrome: hepatic involvement with jaundice (icteric

disease)
Weil syndrome
 Diagnosis
• Serology: Microscopic agglutination test (MAT):
detection of leptospire antigens

• leptospires are present in blood (or CSF) during the first

10 days of infection and in urine after the first week and
for as long as 3 months.

• Grow on special media but Slow growing (up to 4

months)

• PCR ??
 Treatment and Prevention

• Leptospirosis is treated with antibiotics, such as

doxycycline or penicillin, which should be given early in
the course of the disease.

• Prevention: The risk of acquiring leptospirosis can be

greatly reduced by not swimming or wading in water that
might be contaminated with animal urine, or eliminating
contact with potentially infected animals.