syphilis

23 Jul

Syphilis is a sexually transmitted disease caused by the bacteria, Treponema Pallidum. It can be categorised into stages based on the clinical presentations seen in patients- primary, secondary and tertiary. Contact with others, sexual intercourse and through birth can transfer syphilis to others.

- The WHO estimated that patients between 15-49 years, there were 5.6 million new cases of syphilis
- The highest prevalence was found in the WHO African region [1]
- In 2021, 46.5% of all male primary and secondary syphilis cases affected men who had sex with men (MSM) [2]
- Between 2019 to 2021 the annual number of syphilis diagnoses from 8010 to 7506
- In the UK in 2021, the rate of infectious syphilis diagnoses per 100,000 is highest among people from Black-Caribbean background [3]
- Treponema pallidum (bacteria)
- Sexual intercourse with an infected person
- Can infect someone through the anus, vagina, penis, mouth or broken skin (wounds, cuts etc)
- Contact with a sore from syphilis can infect people (eg. kissing) [4]
Medical Students
- Causative Organism
  - Treponema pallidum: spirochete visible only on darkfield microscopy
  - Fragile organism; does not survive long outside the body
- Clinical Stages
  - Primary Syphilis
    Typically presents as a single, non-tender genital chancre
    May have multiple lesions at various contact sites
    Often accompanied by regional lymphadenopathy
  - Secondary Syphilis
    Occurs if untreated
    Features include rash, generalised lymphadenopathy, headache, and other systemic symptoms
  - Latent Syphilis
    Follows resolution of primary/secondary lesions
    Asymptomatic, but serology remains positive
  - Tertiary Syphilis
    Occurs in some untreated patients
    Includes:
    Cardiovascular syphilis
    Neurosyphilis
    Late benign syphilis (e.g., gummatous lesions)
Patients
- What Causes It
  - Caused by a tiny germ called Treponema, seen only under special microscopes
  - It cannot survive outside the human body for long
- Stages of Infection
  - Primary Stage
    Usually starts as a painless sore on the genitals or mouth
    There may be more than one sore
    Nearby lymph nodes (glands) may swell
  - Secondary Stage
    If not treated, the infection spreads
    Can cause rash, swollen glands, headache, and feeling unwell
  - Latent Stage
    Symptoms go away, but the infection stays in the body
    Can still be found with a blood test
  - Tertiary Stage
    May develop years later in untreated people
    Can affect the heart, brain, or cause skin lumps (gummas) [5]
- Unprotected sexual activity
- Sexual intercourse with an infected person
- History of syphilis, HIV or other STIs
- Born from a mother with syphilis
- Substance abuse and anonymous sexual intercourse are social factors that increase the risk of infection [6]
- Chancre- sore that oozes fluid [7]
- Sores found on the penis, vagina and anus- painless
- Sores found on the mouth, lips, hands and bottom
- White/grey growths in a wart-like shape found on the genital regions
- Rashes found on the palms and soles
- White patches in the mouth
- Temperature, headaches, tiredness
- Swollen glands
- Hair loss in patch like patterns of the head, beard and eyebrows [8]
  - Neurological conditions;
    Stroke
    Dementia
    Loss of co-ordination
    Numbness
    Paralysis
- Blindness
- Deafness [9]
- Clinical assessment of the appearance with symptoms, and take a history about risk factors and past medical conditions
- Examine the person for genital, skin, neurological and eye conditions with the addition of cardiovascular problems in late stage disease
- Referral to specialist for lab testing including microscopy, blood tests and a full sexual health screening to rule out differential diagnosis and diagnosis syphilis [1]
- Primary
  - Genital herpes
  - Chlamydia
  - Genital cancer
  - Anal fissures
  - Crohns disease
  - Anal cancer
  - Cervical herpes
  - Cervical cancer
  - Cervical erosions
  - Infectious and systemic diseases cause inflammation of the lymph nodes
- Secondary
  - HIV
  - Rubella
  - Scabies
  - Measles
  - HPV
  - Molluscum contagiosum
  - Haemorrhoids (anal lumps)
  - Alopecia
  - Ringworm
  - Oral cancer
  - Mouth ulcers
- Tertiary
  - Dementia
  - Systemic symptoms;
  - Tuberculosis
  - Sarcoidosis
  - Leprosy [1]
Medical Students
- Refer all suspected cases to a specialist sexual health clinic due to complexity in diagnosis and follow-up.
- Preventative advice
  - Promote condom use
  - Avoid substance use during sex
  - Provide risk-reduction counselling
  - Recommend regular screening for high-risk individuals
- Abstain from sex until diagnosis is excluded or treatment is completed, especially if lesions are present.
- If patients decline specialist referral, offer testing in primary care and refer to GUM clinic if tests are positive.
  - Early syphilis (primary, secondary, early latent): Single IM dose of Benzathine penicillin G.
  - Late latent syphilis or unknown duration: Three weekly IM doses of Benzathine penicillin G.
- Direct testing: use dark-field microscopy or PCR on primary lesions.
- Serological testing: perform treponemal and non-treponemal tests for screening, staging, and monitoring.
- Repeat testing may be needed to confirm treatment response or detect reinfection.
- Neurosyphilis/ocular syphilis: requires CSF analysis via lumbar puncture.
Patients
- You should be referred to a specialist sexual health clinic if syphilis is suspected – it's a complex infection to diagnose and treat.
- How to prevent syphilis:
  - Always use condoms during sex.
  - Avoid alcohol or drugs when having sex, as they increase risk.
  - Talk to a healthcare provider about ways to reduce your risk.
  - If you're at higher risk, get regular check-ups and blood tests.
- If you might have syphilis:
  - Do not have sex until you're tested and treated.
  - If you don’t want to go to a specialist clinic, your GP can offer testing and refer you if needed.
- Treatment:
  - Early syphilis (first few stages): a single antibiotic injection (Benzathine penicillin G) can cure it.
  - Later syphilis or if it's been there a long time: three injections over three weeks are needed.
- Tests used to confirm syphilis:
  - Swabs from sores can be tested using special tools (dark-field microscope or PCR).
  - Blood tests check for antibodies linked to syphilis.
- You may need repeat blood tests to make sure the treatment has worked.
- If syphilis spreads to the brain or eyes, a test called a lumbar puncture (spinal tap) may be needed.
- Heart complications;
  - Aortic aneurysm- bursting of the aortic artery
  - Angina- chest pain
  - Heart failure
- Neurological complications;
  - Dementia
  - Personality changes
  - Seizures
- Nervous complications;
  - Pains
  - Pins and needles
  - Joint pain
  - Complication can affect the bones, liver, testicles and other organs [8]
- Syphilis can be easily noticed on a patient
- Having syphilis protects you for getting it again
- Syphilis only impacts people who have sexual intercourse with multiple partners [11]
- How can I protect others from syphilis?
- Who do I contact if my condition gets worse?
- How can I stage my syphilis in a clinic?
- How long does treatment take to be effective?
- Terrance Higgins Trust
- SH:24
- NHS Inform
[1] https://cks.nice.org.uk/topics/syphilis/background-information/prevalence/
[2] https://www.cdc.gov/std/statistics/2021/overview.htm#Syphilis
[3] https://www.gov.uk/government/publications/syphilis-quarterly-data-for-england/syphilis-in-england-2019-to-2021#epidemiology
[4] https://my.clevelandclinic.org/health/diseases/4622-syphilis#symptoms-and-causes
[5] https://www.ncbi.nlm.nih.gov/books/NBK534780/
[6] https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis/risk-factors-clinical-manifestation.html#a1
[7]https://www.health.state.mn.us/diseases/syphilis/hcp/diagnosis.html#:~:text=Usually%2C%20a%20single%20ulcer%20
[8] https://www.nhs.uk/conditions/syphilis/
[9] https://www.nhsinform.scot/illnesses-and-conditions/sexual-and-reproductive/syphilis
[10] https://cks.nice.org.uk/topics/syphilis/management/management-of-suspected-syphilis/
[11] https://share.upmc.com/2019/09/myths-and-facts-about-syphilis/