Endemic treponematoses

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     Endemic treponematoses are bacterial infections caused by 3 different types of treponema (other than Treponema pallidum). Human-to-human transmission may be direct or indirect.

    The 3 endemic treponematoses result in positive syphilis serology (TPHA-VDRL), but these tests are not necessary as diagnosis is clinical. There is no laboratory test that can distinguish between the different treponematoses.

    For the diagnosis and treatment of syphilis, see Genital infections, Chapter 9.

    Clinical features

     

    Yaws

    Pinta

    Bejel

    Pathogen

    Treponema pertenue

    Treponema carateum

    Treponema pallidum type M

    Geographic distribution

    Tropical and humid forests

    Tropical zones of Latin America

    Arid areas, semi-desert of the Middle East and Africa

    Population

    Children between 4 and 14 years

    Children and adults

    Nomadic populations, particularly children

    First stage

    Yaws chancre: skin coloured lesion, non- indurated, itchy, on the lower limbs in 95% of cases, with peripheral adenopathy.
    Spontaneous healing or development of a large yaw surrounded by smaller yaws.

    Annular, erythematous, scaly plaques, usually on uncovered body parts (face, extremities), resemble dermatophytes. Lesions heal sponta- neously leaving scars.

    Discrete chancre: moist papule, most commonly on the mucous membranes or in dermal folds, with peripheral adenopathy.

    Second stage

    Lesions appear 3 weeks after the initial chancre, occur in crops and heal spontaneously:
    • Frambesioma (papillomatous lesion, vegetal, very contagious)
    • Isolated or associated with yaws (round, squamous papules, not very contagious)
    • Osteoperiostitis of the long bones (phalanges, nasal process of the maxilla, tibia)

    Pintids: plaques of various colours (bluish, reddish, whitish). May occur anywhere on the body.

    • Mucous patches of the mouth common: very contagious ulcerated, round in form, indurated, with white coating, bleed easily, usually occur on the inside of the lips, cheek and tongue or labial folds
    • Condyloma in the anogenital region (rare)
    • Cutaneous lesions are rare: vegetal aspect, in dermal folds
    • Bone destruction identical to that of yaws, in the legs and forearms

    Late stage

    After some years of latency:
    • Periostitis; painful, debilitating osteitis
    • Ulcerating and disfiguring rhinopharyngitis
    • Juxta-articular nodules

    Symmetrical white patches on the limbs. The depigmentation is permanent, remaining after treatment.

    After several years of latency:
    • Gummatous lesions of skin and long bones
    • Plantar and palmar keratosis
    • Juxta-articular nodules
    • Hyper- and hypo-pigmented patches (as in pinta)

     

    Treatment

    Yaws

    azithromycin PO [1] Citation 1. World Health Organization (‎2012)‎. Yaws: recognition booklet for communities. Reprinted with changes, 2014. 
    http://www.who.int/iris/handle/10665/75360 [Accessed 15 May 2018]
    Children and adults: 30 mg/kg single dose (max. 2 g)
    or, if not available,
    benzathine benzylpenicillin IM [2] Citation 2. Oriol Mitjà, David Mabey. Yaws, bejel, and pinta (last updated. May 07, 2018). UpToDate [Accessed 15 May 2018]. [3] Citation 3. Michael Marks, Anthony W Solomon, David C Mabey. Endemic treponemal diseases. Transactions of The Royal Society of Tropical Medicine and Hygiene, Volume 108, Issue 10, 1 October 2014, Pages 601–607.
    https://doi.org/10.1093/trstmh/tru128 [Accessed 15 May 2018]
    Children under 10 years: 1.2 MIU single dose
    Children 10 years and over and adults: 2.4 MIU single dose

    Pinta and bejel

    benzathine benzylpenicillin IM.
    As for yaws.

     

    For patients allergic to penicillin:
    doxycycline PO (except in children under 8 years and pregnant or lactating women)
    Children 8 years and over: 50 mg 2 times daily for 14 days
    Adults: 100 mg 2 times daily for 14 days

     

    Notes:

    • Antibiotic treatment will cure early stage cases and may relieve the pain of osteitis. It may be ineffective for late stage infections.
    • Syphilis serology will remain positive despite clinical cure.

    Treatment of contacts and latent cases

    The same treatment should be administered to all symptomatic and asymptomatic contacts and to all latent cases (asymptomatic individuals with positive serologic test for syphilis) in endemic zones. 

     

    References
    • 1.World Health Organization (‎2012)‎. Yaws: recognition booklet for communities. Reprinted with changes, 2014. 
      http://www.who.int/iris/handle/10665/75360 [Accessed 15 May 2018]
    • 2.Oriol Mitjà, David Mabey. Yaws, bejel, and pinta (last updated. May 07, 2018). UpToDate [Accessed 15 May 2018].
    • 3.Michael Marks, Anthony W Solomon, David C Mabey. Endemic treponemal diseases. Transactions of The Royal Society of Tropical Medicine and Hygiene, Volume 108, Issue 10, 1 October 2014, Pages 601–607.
      https://doi.org/10.1093/trstmh/tru128 [Accessed 15 May 2018]
    Path