Syphilis

The symptoms of syphilis are common for both men and women. It is usually unrecognizable for some time and can be passed to others without knowing it. The symptoms of syphilis change with time and stage. Generally, syphilis can be categorized into three stages:

• Primary syphilis
• Secondary syphilis
• Tertiary syphilis

1. Primary Syphilis

The first symptoms of syphilis usually develop 2 to 6 weeks after exposure to the bacterium. The most common symptom is the appearance of a small, painless sore called a primary chancre. These sores are painless, which can lead to them being overlooked. The sore is typically found on the penis, vagina, or around the anus, and sometimes appears on the mouth and lips. Usually, a single painless lesion occurs, but multiple lesions can be seen in a minority of patients. Regional lymph node swelling accompanies the primary syphilitic lesions. The nodes are firm, painless, and appear within 1 week of the onset of the lesion. Inguinal lymphadenopathy (swollen lymph nodes in the groin or lower extremities) is bilateral and may occur with anal as well as genital chancres. These sores disappear after two to six weeks, but lymphadenopathy may persist for months. If untreated, the condition progresses to the second stage.

2. Secondary Syphilis

These symptoms develop a few weeks after the initial symptoms have passed. The secondary stage usually includes lesions involving the skin and mucous membranes along with generalized non-tender lymphadenopathy. The healing primary chancre may still persist in some cases, more frequently in individuals with concurrent HIV infection. The symptoms of secondary syphilis include:

• A blotchy red rash that develops anywhere on the body, usually on the palms of the hands and soles of the feet
• White patches in the mouth
• Severe necrotic lesions, more commonly in HIV-infected individuals
• Swollen glands
• Headache, tiredness, and joint pain
• Patchy alopecia (hair loss) of scalp hair, eyebrows, or beard due to involvement of hair follicles

Signs and symptoms that may accompany or precede secondary syphilis include sore throat, fever, weight loss, malaise, anorexia, headache, and meningismus (symptoms similar to meningitis without inflammation of the membranes lining the brain). Eye symptoms may include pupillary abnormalities, optic neuritis, and uveitis. These symptoms may disappear within a few weeks and can recur after some time. Secondary syphilis is often mistaken for other conditions such as:

• Pityriasis rosea
• Lichen planus
• Psoriasis

Note: Because the symptoms of syphilis can be nonspecific, individuals may ignore them. For this reason, syphilis is known as the “great imitator.”

Latent Phase

During the latent phase, a person experiences no symptoms, even though they are infected. Early latent syphilis is limited to the first year after infection, whereas late latent syphilis is defined as lasting more than one year or of unknown duration. During the first year, the infection can be transmitted to a partner through close physical contact. However, after a couple of years, transmission is no longer possible. Without treatment, the disease can progress to the most dangerous stage, known as the tertiary stage.

Tertiary Stage

The symptoms of tertiary syphilis appear years after the initial infection. The symptoms manifest based on the part of the body affected, such as the brain, nerves, eyes, and heart. Individuals with tertiary syphilis may experience:

• Vision problems or blindness
• Meningitis
• Stroke
• Dementia
• Heart problems
• Coordination problems

Syphilis is still treatable at this stage, but the damage caused cannot be reversed.

Congenital Syphilis

Babies born to women who have syphilis can become infected during pregnancy or birth. Most newborns with congenital syphilis have no symptoms; however, some may show a rash on the palms of their hands and the soles of their feet. Later signs and symptoms may include deafness, dental deformities, and saddle nose, where the bridge of the nose collapses.

Neurosyphilis

At any stage of infection, syphilis can invade the nervous system, known as neurosyphilis. Signs and symptoms of neurosyphilis can include:

• Severe headache
• Trouble with muscle movements
• Muscle weakness or paralysis (inability to move certain body parts)
• Numbness
• Changes in mental status (difficulty focusing, confusion, and personality changes)
• Dementia (problems with memory, thinking, and/or decision-making)

Syphilis is caused by a bacterium called Treponema pallidum. The only known natural hosts for T. pallidum are humans. Routes of transmission of syphilis include:

• The most common route of transmission is through sexual contact with an infected person.
• It can also enter the body through minor cuts in the skin or mucous membranes or through direct unprotected contact with an active lesion.
• Infected mothers can pass it to their babies during pregnancy or childbirth.
• Less common modes of transmission include blood transfusion and organ transplantation.

• Engage in unprotected sex.
• Have sex with multiple partners.
• Have human immunodeficiency virus (HIV) infection.
• Have sexual contact with someone who has syphilis.
• Engage in sexual activity with someone from a region with high prevalence of syphilis.

Note: The risk of infection increases if a man has unprotected sexual contact with other men.

The doctor will ask about your symptoms and health history. A physical examination is performed to confirm certain risks that increase the likelihood of infection.

1. Physical examination
   The doctor will examine the genitals. For men, this includes examining the penis, foreskin, and urethra. For women, it involves an internal examination of the vagina. Other parts of the body are also examined for any rashes.
2. Blood tests
   If someone is diagnosed with syphilis, their body produces antibodies against the syphilis bacteria. Serological tests for syphilis can be classified into two types: treponemal and nontreponemal. The treponemal test is useful for detecting an antigen or antibody of the T. pallidum bacterium and includes the fluorescent treponemal antibody absorbed test (FTA-ABS) and the T. pallidum particle agglutination test (TPPA). Both tests are more sensitive for primary syphilis than non-treponemal tests. A positive result may indicate an active infection or a past infection. A negative result does not always confirm that the person is free of infection, as antibodies may not be detectable after three months of infection. The non-treponemal test, or lipoidal tests, look for indirect signs of infection, such as cardiolipin, which is released when treponema damages cells. The presence of cardiolipin in the sample indicates an active infection.
3. Venereal Disease Research Laboratory (VDRL) test
   This is a screening test for syphilis that measures antibodies produced by the body at the time of infection. This test, combined with specific antibody testing, checks whether the person has an active infection, minimizing the risk of complications and the spread of the disease.
4. Direct testing of chancre
   The following tests can be performed directly from a chancre:
   • Dark field microscopy
   • Direct fluorescent antibody (DFA)
   • Polymerase chain reaction (PCR)
   DFA uses antibodies tagged with fluorescein that attach to specific syphilis proteins, while PCR uses techniques to detect the presence of specific syphilis genes. These tests are not time-sensitive, as they do not require living bacteria for diagnosis.
5. Cerebrospinal fluid (CSF) evaluation
   The diagnosis of neurosyphilis depends on a combination of CSF tests, such as CSF cell count, protein, or reactive CSF-VDRL, in the presence of reactive serologic tests (nontreponemal and treponemal). Get tested if you are sexually active or have come in contact with an infected person with our sexually transmitted diseases panel.

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There is no vaccine for syphilis. However, to prevent the spread of syphilis, the following measures can be adopted:

• Having protected physical contact by using condoms. Condoms can reduce the risk of contracting syphilis only if they cover the sores.
• Promoting sex education among the population, particularly among teenagers and high-risk groups such as laborers, truck drivers, and migrants.
• Avoiding recreational drugs and alcohol, which can inhibit safe sexual practices.
• Abstaining from sexual contact or being in a mutually monogamous relationship with a tested partner who does not have any infections.

The treatment of syphilis depends on the stage of the disease.

Early syphilis

• Penicillin G benzathine is the most widely used agent for the treatment of early syphilis.
• Preventive treatment is also recommended for individuals who have been exposed to infectious syphilis within the previous three months.
• Penicillin G benzathine cures >95% of the cases of early syphilis, although clinical relapse can occur, especially in HIV-infected patients.

Secondary or tertiary syphilis

• If the CSF examination is normal or not examined, the recommended treatment is Penicillin G benzathine.
• If CSF abnormalities are found, they should be treated as a case of neurosyphilis.
• The same treatment option applies for late syphilis or syphilis of unknown duration.

Neurosyphilis

• Penicillin G benzathine, even at high doses, does not kill the treponema concentrations in CSF and should not be used for the treatment of neurosyphilis.
• Both symptomatic and asymptomatic neurosyphilis should be treated with aqueous penicillin.

Pregnancy

• Parenteral penicillin G is the recommended therapy for syphilis during pregnancy.
• Pregnant women with syphilis at any stage who report penicillin allergy should be desensitized and treated with penicillin.

Syphilis in penicillin-allergic patients

• A 2-week course of therapy may be considered with doxycycline or tetracycline for early syphilis.
• A 4-week course may be considered for late syphilis.
• Ceftriaxone has also been found to be effective for early syphilis.

Jarisch-Herxheimer reaction

• The Jarisch-Herxheimer reaction is an acute febrile reaction frequently accompanied by headache, myalgia, and fever that can occur within the first 24 hours after the initiation of any syphilis therapy.
• It is a reaction to treatment and not an allergic reaction to penicillin.
• Patients should be informed about this possible adverse reaction and how to manage it if it occurs.
• The Jarisch-Herxheimer reaction occurs most frequently among persons who have early syphilis, presumably because bacterial loads are higher during these stages.
• Antipyretics can be used to manage symptoms; however, they have not been proven to prevent this reaction.
• The Jarisch-Herxheimer reaction might induce early labor or cause fetal distress in pregnant women; however, this should not prevent or delay therapy.

Management of sex partners

• Persons who have had sexual contact with someone diagnosed with primary, secondary, or early latent syphilis <90 days before the diagnosis should be treated presumptively for early syphilis, even if serologic test results are negative.
• Persons who have had sexual contact with someone diagnosed with primary, secondary, or early latent syphilis >90 days before the diagnosis should be treated presumptively for early syphilis if serologic test results are not immediately available and the opportunity for follow-up is uncertain.
• If serologic tests are negative, no treatment is needed. If serologic tests are positive, treatment is based on evaluation and stage of syphilis.
• Long-term sexual partners of people with late latent syphilis should be evaluated for syphilis and treated based on the findings.

1. Talk and understand the situation

Understanding the condition of the person is the first step in managing the disease. Caring can involve several skills such as emotional support, dealing with medical equipment, and recognizing the warning signs if the disease worsens. Caring for someone with syphilis involves different aspects depending on the infection.

2. Take medication

When syphilis is treated in the early stages, it is easy to cure. Assist the patient in establishing routines and adhering to the treatment.

3. Encourage treatment

If an individual is diagnosed with syphilis, ensure they have periodic blood tests and follow-ups. Confirm that the person is responding to the penicillin treatment.

4. Support the patient

Finding out you have syphilis can be upsetting. Listen to your loved ones and reassure them that it is a manageable health condition.

5. Eat a balanced diet

To recover from the condition and mitigate side effects related to the medications, a healthy diet is beneficial, along with adequate rest to cope with stress.

Syphilis causes damage to internal organs during the latent and tertiary stages. Tertiary syphilis can lead to various complications, including:

• Mental disorders
• Loss of vision
• Bone damage
• Liver damage
• Nervous system breakdown
• Sores on the skin
• Increased risk of contracting HIV due to the presence of open sores
• Birth defects such as mental retardation, stillbirths, and premature death if the infection spreads from mother to the unborn child during pregnancy
• Late-stage syphilis, if left untreated, can be life-threatening