Endemic treponematoses


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 PO1
Children and adults: 30 mg/kg single dose (max. 2 g)
or, if not available,
benzathine benzylpenicillin IM2,3
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 for children under 8 years and pregnant and lactating women)
Children over 8 years: 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]