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dark field illumination microscopy for point-of-care syphilis diagnosis

syphilis is a sexually transmitted disease caused by the spirochetal bacterium Treponema pallidum subspecies pallidum. Globally, an estimated 12 million cases of syphilis occur annually. In the United States, 13,997 cases of primary and secondary (infectious) syphilis were reported to the Centers for Disease Control and Prevention (CDC) in 2009, a 3.7% increase from 2008 and a 134% increase from 2000, when a post-war low of 5,979 primary and secondary syphilis cases was reported. Men who have sex with men (MSM) — especially those who are HIV infected — and blacks are disproportionately affected by syphilis. Geographically, urban areas and the Southeastern region of the United States have the highest rates.

Syphilis is most commonly transmitted by skin-to-skin (or mucous membrane) contact. Following exposure, the infection passes through the following stages:

Primary syphilis, characterized by a painless ulcer, called a chancre, usually develops three weeks after exposure (range 10 days to 90 days) at the site of inoculation. The chancre heals spontaneously after several weeks.

Secondary syphilis is most often characterized by a generalized rash that also resolves without treatment. Rash on the palms and soles can also occur, as can systemic manifestations such as fever, malaise, and lymphadenopathy. Given the widely variable nature of the rash and other manifestations of the disease, syphilis has acquired the moniker “The Great Imitator.”

Early (one year) latent syphilis, defined by the absence of signs or symptoms of disease and diagnosed by serologic evidence of infection.

Tertiary syphilis, which affects about a third of untreated patients and manifests with cutaneous, cardiovascular, or neurologic disease.

Syphilis can also be acquired in utero at any stage of pregnancy and lead to congenital syphilis. Routine syphilis screening and treatment in pregnant women has made congenital syphilis rare in the United States.

Approaches to syphilis diagnosis

Because T pallidum is too fragile an organism to be cultured in the clinical setting, diagnostic testing relies on two approaches: direct detection of the organism and indirect evidence of infection.
Syphilis – Treponema pallidum on darkfield.

Direct methods include darkfield microscopy, molecular assays to detect T pallidum DNA, and histopathologic examination of biopsies of skin or mucous membranes (which can also provide indirect evidence of infection, on the basis of patterns of inflammation in the tissue). Direct methods have the advantage, in some cases, of detecting infection before a patient has mounted a measurable antibody response that results in a reactive serologic test result.

dark field illumination microscopy allows visualization of live treponemes obtained from a variety of cutaneous or mucous membrane lesions, as follows.

In primary syphilis, the chancre teems with treponemes that can be seen with darkfield microscopy. The sensitivity of darkfield microscopy for the diagnosis of primary syphilis is approximately 80%. Darkfield sensitivity declines over time and can also decrease if the patient has applied topical antibiotics to the lesion(s). Of note, the mouth harbors normal non-pathogenic treponemes that are indistinguishable microscopically from T pallidum. Therefore, oral specimens cannot be used for darkfield microscopy because of the possibility of false-positive test results.

In secondary syphilis, mucous patches (as long as not oral) and condyloma lata (found in moist areas between body folds) are appropriate specimens for darkfield microscopy. Dry skin lesions usually do not contain sufficient organisms for darkfield testing.

In congenital syphilis, moist discharge from the nose (snuffles) and vesiculobullous lesions of the skin are high-yield specimen sources for darkfield testing.

Indirect methods of diagnosis include serologic testing of blood or cerebrospinal fluid (CSF) and detection of CSF abnormalities (elevated white blood cell count or protein) consistent with neurosyphilis. Serologic testing of blood involves demonstration of host antibody to either endogenous antigens (non-treponemal tests) or to antigens of T pallidum (treponemal tests). Non-treponemal tests, including the rapid plasma reagin test and the venereal disease research laboratory test, have historically been used as the initial screening tests for the serologic diagnosis of syphilis. If a patient’s non-treponemal test is reactive, confirmatory testing with a treponemal test is performed, using either the T pallidum particle agglutination test, the fluorescent treponemal antibody-absorbed test, or another treponemal test. A reactive treponemal test confirms the diagnosis of a new or previously treated case of syphilis. If the treponemal test is non-reactive, the positive non-treponemal test result is considered a biologic false-positive that is not diagnostic of syphilis. A newer algorithm that is gaini

dark field illumination microscopy

What Principles of dark field illumination microscopy?

To view a specimen in dark field, an opaque disc is placed underneath the condenser lens, so that only light that is scattered by objects on the slide can reach the eye. Instead of coming up through the specimen, the light is reflected by particles on the slide. Everything is visible regardless of color, usually bright white against a dark background.

Pigmented objects are often seen in “false colors,” that is, the reflected light is of a color different than the color of the object. Better resolution can be obtained using dark as opposed to bright field viewing.

Sophisticated equipment is not necessary to get a dark field effect, but you do need a higher intensity light, since you are seeing only reflected light. At low magnification (up to 100x) any decent optical instrument can be set up so that light is reflected toward the viewer rather than passing through the object directly toward the viewer.

dark field illumination microscopy

How to made the dark field illumination microscopy?

How to made the dark field illumination microscopy ?

It is very easy to make dark field illumination microscopy yourself. What you have to do is place an opaque round stop in the condenser. An easy way is to cut a piece of black paper and put it on a filter in your filterholder. You can put the stop on a piece of clear acetate sheet. You can even try to draw the stop on it with black paint. The most important thing is to have it big enough to stop all light going directly into the objective. Only the light that is reflected by the objects in the sample reaches the objective then. Stronger objectives are more difficult because their NA is often too high. The NA of your condenser should always be higher then the NA of the objective. If patch-stops of 8, 10, 12 and 15mm are made you can’t go wrong really. For objectives of around x10 the middle sizes prove best.If you like to make the patchstop as precise as possible: The best way is to set up as normal (brightfield), remove the eyepiece and close/open the substage iris until it is *just* visible. Then, either bending your neck over double, or carefully removing the condenser, measure the diameter of the iris diaphragm as it is now set. A pair of calipers is useful here. This diameter is that for the patch stop. Very often, to be on the safe side it is best to add about 10% to this figure, this avoids leakage, especially if you have no means of centering the stop in the filter holder. If you have a phase contrast condenser, the largest phase contrast annuli often make excellent patch stops for darkfield!The real connoisseurs must have recognized the skills of Klaus Kemp in the arranged (cleaned) diatom slide photographed by Mike Samworth.

dark field illumination microscopy

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