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Bejel, pinta, and yaws (endemic treponematoses) are chronic, tropical, nonvenereal spirochetal infections spread by body contact. Symptoms of bejel are mucous-membrane and cutaneous lesions, followed by bone and skin gummas. Yaws causes periostitis and dermal lesions. Pinta lesions are confined to the dermis. Diagnosis is clinical and epidemiologic. Treatment is with penicillin.
The causative agents, Treponema pallidum subsp endemicum (bejel), T. pallidum subsp pertenue (yaws), and T. carateum (pinta), are morphologically and serologically indistinguishable from the agent of syphilis, T. pallidum subsp pallidum. As in syphilis, the typical course is an initial mucocutaneous lesion followed by diffuse secondary lesions, a latent period, and late destructive disease.
Transmission is by close skin contact—sexual or not—primarily between children living in conditions of poor hygiene. Bejel (endemic syphilis) occurs mainly in arid countries of the eastern Mediterranean and West Africa (Sahel). Transmission results from mouth-to-mouth contact or sharing eating and drinking utensils. Yaws (frambesia) occurs in humid equatorial countries where transmission is favored by scanty clothing and skin trauma. Pinta occurs among the natives of Mexico, Central America, and South America and is not very contagious. Transmission probably requires contact with broken skin.
Symptoms and Signs
Bejel begins in childhood as a mucous patch (usually on the buccal mucosa), which may go unnoticed; it is followed by papulosquamous and erosive papular lesions of the trunk and extremities that are similar to yaws. Periostitis of the leg bones is common. Later, gummatous lesions of the nose and soft palate develop.
Yaws, after an incubation period of several weeks, begins at the site of inoculation as a red papule that enlarges, erodes, and ulcerates. The surface resembles a strawberry, and the exudate is rich in spirochetes. The lesion heals but is followed after months to a year by successive generalized eruptions that resemble the primary lesion. These lesions often develop in moist areas of the axillae, skinfolds, and mucosal surfaces; they heal slowly and may recur. Keratotic lesions may develop on the palms and soles, causing painful ulcerations (crab yaws). Five to 10 yr later, destructive lesions may develop; they include periostitis (particularly of the tibia), proliferative exostoses of the nasal portion of the maxillary bone (goundou), juxta-articular nodules, gummatous skin lesions, and, ultimately, mutilating facial ulcers, particularly around the nose (gangosa).
Pinta lesions are confined to the dermis. They begin at the inoculation site as a small papule that enlarges and becomes hyperkeratotic; they develop mainly on the extremities, face, and neck. After 3 to 9 mo, further thickened and flat lesions (pintids) appear all over the body and over bony prominences. Still later, some lesions become slate blue or depigmented, resembling vitiligo.
Diagnosis
Diagnosis is based on the typical appearance of lesions in people from endemic areas. Serologic tests for syphilis (the Venereal Disease Research Laboratory [VDRL] and fluorescent treponemal antibody absorption tests) are positive; thus, differentiation from venereal syphilis is clinical. Early lesions are often darkfield-positive for spirochetes and are indistinguishable from T. pallidum subsp pallidum.
Treatment
Active disease is treated with 1 dose of penicillin benzathine 1.2 million units IM. Children < 45 kg should receive 600,000 units IM. Public health control includes active case finding and treatment of family and close contacts with penicillin benzathine.
Last full review/revision August 2009 by Burke A. Cunha, MD
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