syphilis
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.
Epidemiology
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]
Source: DermNetNZ.org
Syphilis
Rash of secondary syphilis on the trunk
Causes [4]
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)
Pathophysiology [5]
Medical Students
Treponema is a tiny organism visible only on darkfield microscopy and does not survive long outside the body.
Primary syphilis typically presents as a single non-tender genital chancre, but multiple chancres can occur at various sites of direct contact with the infected lesion, accompanied by lymphadenopathy.
If untreated, primary syphilis can progress to secondary syphilis, which manifests with various clinical features like rash, lymphadenopathy, headache, etc.
Both primary and secondary lesions resolve without treatment, leading to an early or latent phase where no clinical signs are present, but the infection can be detected through serological testing.
Some patients progress to the tertiary stage, characterized by cardiovascular syphilis, neurosyphilis, and late benign syphilis.
The incubation period is 20 to 90 days, and the organism invades the central nervous system early, but symptoms appear late.
Patients
Treponema is a tiny organism visible only on darkfield microscopy (device used to view the biological specimens with increased clarity) and does not survive long outside the body.
Primary syphilis typically presents as a single non-tender genital chancre, but multiple chancres can occur at various sites of direct contact with the infected lesion, accompanied by lymphadenopathy.
If untreated, primary syphilis can progress to secondary syphilis, which can be seen with with various clinical features like rash, lymphadenopathy (swelling of the lymph nodes) headache, etc.
Both primary and secondary lesions resolve without treatment, leading to an early or latent phase where no clinical signs are present, but the infection can be detected through serological testing (a laboratory test that checks for the presence of antibodies or other substances in a blood sample).
Some patients progress to the tertiary stage, characterised by cardiovascular syphilis, neurosyphilis, and late benign syphilis.
The incubation period (the period between exposure to an infection and the appearance of the first symptoms) is 20 to 90 days, and the organism invades the central nervous system (network that controls the activities of the body) early, but symptoms appear late.
Source: DermNetNZ.org
Syphilis
Rash caused by secondary syphilis on the trunk and arms
Risk factors [6]
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
Presentation
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]
Source: DermNetNZ.org
Syphilis
Healing multi-papular rash on the upper chest in tertiary syphilis
Source: DermNetNZ.org
Syphilis
Large sores seen on the scalp
Source: DermNetNZ.org
Syphilis
One sided facial swelling, purple discolouration and raised lesion
Investigations [1]
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
Differential diagnosis [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
Source: DermNetNZ.org
Syphilis
Ulcer seen on the penis
Source: DermNetNZ.org
Syphilis
Primary chancre seen on the penis in primary syphilis
Management [10]
Medical students
Refer all individuals with suspected syphilis to a specialist sexual health service due to the complexity of diagnosis, treatment, and monitoring.
Preventative measures include condom use, avoiding drugs and alcohol during sex, risk-reduction counselling, and regular syphilis screening for high-risk individuals.
Advise suspected syphilis patients to avoid sexual contact and exposure of active lesions until diagnosis is excluded or successful treatment is confirmed.
For those declining referral to a specialist, discuss testing options in primary care and consider referral to a GUM clinic if any test results are positive.
A single injection of long-acting Benzathine penicillin G can cure the early stages of syphilis. This includes primary, secondary, or early latent syphilis. The Centre of Disease Control and Prevention recommends three doses of long-acting Benzathine penicillin G at weekly intervals for late latent syphilis or latent syphilis of unknown duration. [2]
Laboratory diagnosis involves direct tests (dark-field microscopy and PCR) for primary lesions and serological tests (treponemal and non-treponemal) for screening.
Repeat testing may be necessary, and examination of cerebrospinal fluid is required for diagnosing neurosyphilis or ocular syphilis.
Patients
Refer all individuals with suspected syphilis to a specialist sexual health service due to the complexity of diagnosis, treatment, and monitoring.
Preventative measures include condom use, avoiding drugs and alcohol during sex, risk-reduction counselling, and regular syphilis screening for high-risk individuals.
Advise suspected syphilis patients to avoid sexual contact and exposure of active lesions until diagnosis is excluded or successful treatment is confirmed.
For those declining referral to a specialist, discuss testing options in primary care and consider referral to a GUM (genital-urinary) clinic if any test results are positive.
A single injection of long-acting Benzathine penicillin G can cure the early stages of syphilis. This includes primary, secondary, or early latent syphilis. The Centre of Disease Control and Prevention recommends three doses of long-acting Benzathine penicillin G at weekly intervals for late latent syphilis or latent syphilis of unknown duration. [2]
Laboratory diagnosis involves direct tests (such as microscope usage and chain reactions) for primary lesions and serological tests (testing a blood sample for antibodies and antigens) for screening.
Repeat testing may be necessary, and examination of cerebrospinal fluid is required for diagnosing neurosyphilis or ocular syphilis.
Complications [8]
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
Myths [11]
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
Questions to ask your doctor
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?
Support
Terrance Higgins Trust
SH:24
NHS Inform
Bibliography
[1] https://cks.nice.org.uk/topics/syphilis/background-information/prevalence/
[2] https://www.cdc.gov/std/statistics/2021/overview.htm#Syphilis
[4] https://my.clevelandclinic.org/health/diseases/4622-syphilis#symptoms-and-causes
[5] https://www.ncbi.nlm.nih.gov/books/NBK534780/
[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/
