Sex Transm Infect 2005;81:448-452 doi:10.1136/sti.2005.

015875
Tropical medicine
Syphilis in adults
1. B T Goh
1. Correspondence to: Beng T Goh The Ambrose King Centre, The Royal London Hospital,
Whitechapel, London E1 1BB, UK; [Link]@[Link]
Accepted 30 March 2005
Abstract
Syphilis is a sexually transmitted disease with protean manifestations resulting from infection
by Treponema pallidum. It is systemic early from the outset, the primary pathology being vasculitis.
Acquired syphilis can be divided into primary, secondary, latent, and tertiary stages. The infection
can also be transmitted vertically resulting in congenital syphilis, and occasionally by blood
transfusion and non-sexual contact. Diagnosis is mainly by dark field microscopy in early syphilis
and by serological tests. The management in the tropics depends on the diagnostic facilities
available: in resource poor countries, primary syphilis is managed syndromically as for anogenital
ulcer. The introduction of rapid desktop serological tests may simplify and promote widespread
screening for syphilis. The mainstay of treatment is with long acting penicillin. Syphilis promotes the
transmission of HIV and both infections can simulate and interact with each other. Treponemes may
persist despite effective treatment and may have a role in reactivation in immunosuppressed patients.
Partner notification, health education, and screening in high risk populations and pregnant women to
prevent congenital syphilis are essential aspects in controlling the infection.
Syphilis is caused by the bacterium Treponema pallidum and is acquired by sexual intercourse or
transmitted vertically from mother to baby. Sexual transmission is probably by inoculation into tiny
abrasions from sexual trauma causing a local response resulting in an erosion, then an ulcer. This is
followed by spread of the treponemes to the regional lymph nodes and haematogenous dissemination
to other parts of the body.
While the local immunity leads to ulcer healing, systemic dissemination results in immune response
to the deposited treponemes leading to secondary syphilis. Circulating immune complexes formed
may be deposited in organs such as kidney, contributing to the systemic manifestations. This is then
followed by a latent phase and, if untreated, about 40% of patients will go on to the tertiary stage,
which is characterised by gummatous, cardiovascular, and neurological involvement
1
; the latter two
are also classified as quaternary syphilis. Infected pregnant women can result in stillbirth, premature
birth or a baby with congenital syphilis. The basic pathology in all stages is vasculitis.
Genital ulcerative diseases (GUD), including syphilis, increase the risk of transmission of HIV.
2,3
In
addition, HIV infection may cause more severe manifestations of early syphilis or more rapid
progression to late syphilis.
4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25

EPIDEMIOLOGY
Prevalence of syphilis in the tropics comes from studies of GUD and serological tests screening.
Syphilis is usually the second or third commonest cause of genital ulcers, either chancroid or genital
herpes being commoner. Using polymerase chain reaction (PCR), GUD was caused by syphilis in
14% of affected people in Dar es Salaam, Tanzania,
26
10% in Peru, 5% in the Dominican
Republic,
27
4.2% in HIV positive men and 10.6% in HIV negative men in South Africa,
28
and 10%
in Pune, India.
29
In the latter, co-infection with chancroid, herpes, or both occurs in 4%. Serological
screening for syphilis in antenatal patients and different population groups showed a variable
prevalence. For example, in antenatal clinics, the prevalence was 3% in both Vitoria, Brazil
30
and
Nairobi, Kenya,
31
6.3% in HIV positives and 3.7% in HIV negative women in Kigali, Rwanda,
32
and
13.7% in Ethiopia.
33
In other population groups, the prevalence in STD clinics was 2% in Hong
Kong
34
and for women attenders it was 6% in Nairobi, Kenya
35
and 15.1% in Mumbai, India.
36
The
prevalence in sex workers was 7.211.6% in Singapore
37
and 32% in Papua New Guinea
38
; 13.3% in
long distance truck drivers in south India
39
; 2.3% in factory workers in Harare, Zimbabwe
40
; and in
the rural community the prevalence was 11.3% in Lesotho
41
and 2.2% for men and 9.7% for women
in the Gambia.
42

CLINICAL PRESENTATION
The primary lesion, chancre, presents as an anogenital ulcer that appears 990 days after exposure
(fig 1). The chancre may not be apparent or not recognised by the patient. The ulcer is classically
indurated and painless but may commonly be atypical (painful, soft, multiple). Painful chancre can
also results from co-infection with chancroid or genital herpes. Extra-anogenital sites include lip,
tongue, and tonsils from oral sex and kissing, nipple from kissing or wet nursing of infected babies,
and finger with minor abrasion from touching infectious lesions. Regional lymphadenopathy results
in moderately enlarged rubbery lymph nodes.

Figure 1
Penile chancre.
Secondary syphilis presents with generalised rash affecting the palms and soles (fig 2), generalised
lymphadenopathy, oro-genital mucosal lesions (fig 3), including snail tract ulcers and condylomata
lata (fig 4). The rash which begins as macules becoming papules is usually non-itchy but pruritus
may be present, particularly in dark skinned patients. It may be polymorphic, indolent, or transient
but is not vesicular or bullous. Less common presentations include patchy alopecia, anterior uveitis,
retinitis, cranial nerve involvement, meningitis, laryngitis, gastritis, hepatosplenomegaly including
hepatitis, glomerulonephritis, and periosteitis.

Figure 2
Secondary syphi lis affecting palms and soles.

Figure 3
Mucosal lesions of the penis in secondary syphilis.

Figure 4
Condylomata lata of vulva.
Tertiary syphilis includes gummatous, cardiovascular, and neurological involvement. Gummatous
syphilis (sometimes known as benign tertiary syphilis) can involve the organs or supporting structure
and can result in infiltrative or destructive lesions leading to granulomatous lesions or ulcers (for
example, skin) or perforation/collapse of structure (for example, palate, nasal septum) or
organomegaly. Gumma of the tongue may be prone to leucoplakia leading to malignant change. Late
neurosyphilis can cause meningovascular syphilis leading to stroke syndromes, parenchymal
involvement leading to general paresis and tabes dorsalis. Cardiovascular syphilis involves the aortic
arch which can lead to angina from coronary ostitis, aortic incompetence, and aortic aneurysm.
DIAGNOSIS
The diagnosis is by identification of treponemes using dark field microscopy (DFM) or direct
fluorescent antibody stain (DFA), staining of treponemes in histology specimen, and by serological
tests. In DFM, the treponemes are identified by the morphology and characteristic movements. PCR
singly or as part of multiplex testing for T pallidum in genital ulcer is available mainly as a research
tool. Serological tests are treponemal antigen based such as treponemal enzyme immunoassay
(EIA), T pallidum particle agglutination (TPPA) or haemagglutination (TPHA) and fluorescent
antibody absorption (FTA-abs) tests or non-treponemal cardiolipin based tests such as the
Venereal Disease Research Laboratory (VDRL) or rapid plasma reagin (RPR) tests.
43

In primary syphilis, the diagnosis is by DFM or DFA stain of serum from the ulcer or lymph node
aspirates. DFM and DFA staining have sensitivities of 7486% and 73100% and specificities of
85100% and 89100%, respectively. The serological tests may initially be negative and the first
tests to be positive are the EIA IgM or FTA-19S IgM tests, with a sensitivity of 86.593% and 90%,
respectively, while the sensitivity of EIA is 4877%, VDRL 4476%, TPHA 5083%, and FTA-abs
is 7592% for primary syphilis.
4452

The diagnosis of secondary syphilis can be made by DFM of condylomata lata, genital mucosal
lesions, skin papules and lymph node aspirate, and/or by serological tests, which are invariably
positive, except for prozone phenomenon in the cardiolipin tests
53
and occasional delayed
seroreactivity or false negative in HIV co-infection.
Latent syphilis is diagnosed by the presence of positive serological tests in the absence of clinical
evidence of syphilis, and if acquired within the first 2 years is classified as early latent and after 2
years as late. In late latent syphilis the treponemal tests are all positive while the VDRL tests are
positive in about 77%. The serological tests do not differentiate the different treponematoses. In
regions where non-venereal treponematoses such as yaws, pinta, and bejel are endemic, the
serological tests should be interpreted with care and patients should also be evaluated for such
conditions. However, the treponemes causing the different treponematoses can now be differentiated
using genomic tests.
54

Neurosyphilis is diagnosed clinically and by abnormal cerebrospinal fluid (CSF), the presence of a
positive VDRL/RPR, and a raised TPHA (or TPPA) index in the CSF indicates neurological
involvement.
55
Non-specific indicators such as raised lymphocyte count and protein level in the CSF
are commonly present but may also occur in patients with concomitant HIV infection. If the intention
is to treat as for neurosyphilis, it may not be necessary to perform a lumbar puncture unless it is to
rule out other causes of the neurological problem, particularly in HIV positive patients.
The cost effectiveness of screening tests for syphilis will depend on the prevalence in the population
and risk groups. While the VDRL or RPR test alone is useful for screening infectious syphilis, it will
fail to diagnose many primary and late latent/late syphilis as the sensitivity is 4476% and 7073%,
respectively. Biological false positive for VDRL/RPR and prozone phenomenon in secondary
syphilis causing false negative using undiluted serum can occur; both may be more common in HIV
infection.
40,5659
However, VDRL/RPR is still commonly used as screening test as it is cheap and
easy to perform. If a single test is to be used, the TPPA/TPHA or treponemal EIA is preferable to the
RPR/VDRL as it will diagnose almost all stages of syphilis except for primary syphilis. For
screening, the sensitivities of EIA and TPHA/TPPA are 82100% and 85100% with specificity of
97100% and 98100%, respectively. Antenatal screening will be cost effective as screening enables
treatment in pregnant women and prevents adverse pregnancy outcome. Decentralised antenatal
screening in Haiti over 2 years has reduced the incidence of congenital syphilis by 75%.
60
The
availability of new RPR/VDRL reagents that can be stored at room temperature, solar powered
rotators as well as rapid desktop treponemal tests using whole blood, serum, or plasma may
simplify screening in resource poor countries. All positive tests, whether cardiolipin or treponemal
antigen based, should preferably be confirmed with a different method from the initial test. Where
confirmatory tests are not easily available, treatment should be initiated as delay in treatment is much
more deleterious than not getting confirmation of tests. If syndromic treatment is not given,
suspected chancre should have repeated DFM on three consecutive occasions and a repeat
serological test at 3 months if initial tests were negative.
HIV CO-INFECTION
Many regions in the tropics have high prevalence of both HIV infection and syphilis. Syphilis can
mimic HIV infection and vice versa: chancre versus chronic mucocutaneous anogenital herpes in
AIDS, secondary syphilis versus primary HIV infection, neurosyphilis versus neurological
complications of HIV infection. HIV infection can lead to larger or more numerous
chancres,
4,5
accelerated ulcerating secondary syphilis,
6
frequent ocular syphilis, faster progression to
late syphilis such as neurosyphilis and gummatous syphilis; the former have been reported mainly in
those treated for early syphilis with single dose benzathine penicillin.
925
Although serological tests
in HIV positive patients generally perform in the same way as in immunocompetent patients, it can
occasionally behave unpredictablyfor example, delayed positive serological tests in secondary
syphilis. Biological false positives for cardiolipin tests (VDRL, RPR) and prozone phenomenon can
also occur in HIV infection.
5659

TREATMENT
Treatment guidelines for syphilis from the World Health Organization (WHO),
61
Europe,
62
United
States,
63
and United Kingdom
64
have been published. Intramuscular benzathine penicillin 2.4
megaunits either as a single dose or weekly in two to three doses is the mainstay of treatment in
developing countries. In patients allergic to penicillin, oral doxycycline 100 mg twice daily for 2
weeks is given or tetracycline 500 mg four times daily for 2 weeks or azithromycin 500 mg daily for
1 week. A recent study suggest that azithromycin 2 g as a single dose or as two doses 1 week apart
may be as good as benzathine penicillin for the treatment of early syphilis.
65
However, the
emergence of azithromycin/macrolide resistant T pallidum is cause for concern.
66

There are controversies surrounding treatments of pregnant women with a single dose of benzathine
penicillin as failures has been reported.
6769
Although a single dose may be effective,
70,71
some prefer
to treat pregnant women with two to three doses of benzathine penicillin at weekly intervals.
68
In one
study treatment of pregnant women using a single dose benzathine penicillin improved pregnancy
outcome but the risk of adverse outcome remained high when compared with uninfected
mothers,
31
but these result were not found in another study.
70

In HIV positive patients, single dose benzathine penicillin for early syphilis is effective with up to 1
year follow up.
72
However, in that study, the dropout rate was high with a serological relapse of 17%
and the follow up is not sufficiently long enough to decide whether neurosyphilis could be prevented.
A study using benzathine penicillin 2.4 megaunits weekly for three injections among HIV positive
and HIV negative women showed similar serological response to conventional therapy for
syphilis.
73
As treponemes persist despite clinical cure
74
together with the numerous report of
progression to neurosyphilis following treatment of single dose of benzathine penicillin, it might be
preferable to treat with three doses of benzathine penicillin 2.4 megaunits at weekly intervals. Should
neurological signs appear in HIV positive patients, neurosyphilis should be considered in the
differential diagnoses. Neurosyphilis should be treated with intravenous benzyl penicillin G 1224
megaunits daily (24 megaunits 4 hourly) for 14 days, intramuscular procaine penicillin G 1.8
megaunits daily together with oral probenecid 500 mg 6 hourly for 17 days, or doxycycline 200 mg
twice daily for 4 weeks.
Patients should be warned of the Jarisch-Herxheimer reaction that causes a flu-like illness within 24
hours of starting treatment. This can be serious in patients with neuro/oculo/cardiovascular syphilis
and may be ameliorated by prednisolone 1020 mg three times a day for 3 days starting 24 hours
before giving antitreponemal treatment.
SYNDROMIC MANAGEMENT
GUD can have multifactorial causes. In regions where there are no diagnostic facilities or where the
costs of diagnostic tests are prohibitive, syndromic management of GUD to cover common causes
such as chancroid and syphilis is recommended. If there is a history of genital blisters suggestive of
genital herpes or in a region endemic for lymphogranuloma venereum or donovanosis, treatment
should also cover for these organisms. This usually consists of a single dose of benzathine penicillin
for syphilis, and a single dose of ciprofloxacin for chancroid. Syndromic algorithms for GUD were
most effective in identifying syphilis and chancroid.
75
Adding a RPR test to the algorithm for better
detection of syphilis may disadvantage chancroid management. A positive RPR test may lead to
treatment of syphilis only, and treatment for chancroid is missed in patients with dual infection. It is
recommended that patients with a positive RPR should also be treated for chancroid.
76

Syndromic management for GUD, besides covering all causes, may also need to cover other STDs,
as shown by a recent study,
28
where urethritis commonly coexists with GUD. Of 186 mine workers
with GUD in South Africa, 53% had urethritis, of whom 45% had gonorrhoea and 20% had
chlamydial or mycoplasmal infection; 64.5% were HIV positive. These illustrate the principle that
the presence of one STD indicates that other STDs may also be present and should be screened for,
otherwise syndromic management for other STDs should be considered.
It is recommended that azithromycin 1 g or erythromycin 500 mg four times daily for 7 days be
included to cover non-gonococcal urethritis caused by Chlamydia trachomatis and Mycoplasma
genitalium. The protocol for syndromic management should be modified accordingly as determined
by the main causes of genital ulcers and concomitant STDs in each country. One of the major
challenges is partner notification and provision of epidemiological treatment to sexual partners,
otherwise public health control will fail.
CONCLUSIONS
Syphilis continues to be a major problem in the tropics causing anogenital ulcers and systemic
manifestations. Primary syphilis is best treated using syndromic management algorithms tailored to
suit the individual country. There is a need for simple reliable on-site test for syphilis so that results
are available immediately for treatment to commence and partner notification to take place. The
control of syphilis is important for the control of HIV as well as for avoiding adverse interactions
between the two infections. There is a need also for simple and effective oral treatment and
azithromycin should be evaluated further. The genome of T pallidum has been sequenced with the
potential of research into pathogenesis, novel tests, and a vaccine.
77

Footnotes
Series editor: David Lewis
REFERENCES
[Link]


Syphilis
January 2011
Background
Syphilis is a sexually transmitted infection (STI) caused by the spirochete Treponema pallidum. It is
a complex disease with protean variations that can mimic many common infections or illnesses. HIV
infection may alter the natural history and management of syphilis, causing a more rapid course of
illness, higher risk of neurologic complications, and potentially greater risk of treatment failure with
standard regimens. Because many individuals with syphilis have no symptoms, or have symptoms
that subside without treatment, sexually active individuals at risk of syphilis should receive regular
screening for syphilis, as well as for other STIs. Many clinicians strongly recommend routine
syphilis testing every 3-6 months for patients at risk of syphilis.
There has been a resurgence of syphilis in metropolitan areas of the United States and western
Europe. This trend is concerning, because syphilis can have major health consequences if it is
undetected and untreated, and because it is associated with increased risk of new HIV infections.
Risk assessment should be conducted at each patient visit for unprotected sex (including oral sex),
multiple sex partners, and use of recreational drugs (methamphetamine and cocaine, in particular, are
associated with high-risk sexual practices among men who have sex with men [MSM]).
Asymptomatic persons at risk of acquiring syphilis should be screened at regular intervals (with
rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL] testing, as discussed
below), depending on their risk factors. MSM with multiple partners should be tested every 3-6
months.
The natural history of untreated syphilis infection is divided into stages based on length of infection.
Primary Syphilis
Primary syphilis usually manifests after an incubation period of 1-3 weeks from exposure and is
characterized by a painless self-limiting ulcer (chancre) at the site of sexual contact. HIV-infected
individuals may have multiple or atypical chancres that could be misidentified. Some patients have
no primary lesion, or have a primary lesion that is not visible. Associated regional lymphadenopathy
can occur. HIV-infected individuals sometimes have a chancre concurrently with rash typical of
secondary syphilis.
Secondary Syphilis
Secondary syphilis usually develops 2-8 weeks after initial infection and is caused by ongoing
replication of the spirochete, with disseminated infection that may involve multiple systems. Rash is
the most common presenting symptom; skin lesions may be macular, maculopapular, papular, or
pustular, or they may appear as condyloma lata (which may look like the condyloma of
papillomavirus). The rash often appears on the trunk and extremities and may involve the palms and
soles of feet. Constitutional symptoms, lymphadenopathy, arthralgias, and myalgias are common,
and neurologic or other symptoms may occur. In the absence of treatment, the manifestations of
secondary syphilis last days to weeks, then usually resolve to the latent stages.
Latent Syphilis
Latent syphilis follows resolution of secondary syphilis. As in HIV-uninfected individuals, latent
syphilis is asymptomatic and the diagnosis is determined by positive serologic tests. Latent syphilis
is further classified as "early latent" if the infection is known to be <1 year in duration, "late latent" if
the infection is known to be >1 year in duration, or "latent syphilis of unknown duration" if the
duration of infection is not known.
Late or Tertiary Syphilis
Late or tertiary syphilis is caused by chronic infection with progressive disease in any system
causing serious illness and death in untreated patients. The most common manifestations include
neurosyphilis, cardiovascular syphilis, and gummatous syphilis.
Neurosyphilis
Neurosyphilis can occur at any time after initial infection, owing to spread of the spirochete to the
central nervous system (CNS). In HIV-infected individuals, neurosyphilis may occur more
commonly early in the course of infection, during secondary or latent syphilis. It is associated with
neurologic symptoms, including cranial nerve abnormalities (particularly extraocular or facial
muscle palsies, tinnitus, and hearing loss) or symptoms of meningitis. Uveitis and other eye disease
may occur in conjunction with neurosyphilis.
S: Subjective
Symptoms depend on the site of initial infection, the stage of disease, and whether neurosyphilis is
present. Symptoms are not present in all patients.
If symptoms are present, the patient may experience the following:
Painless sore(s) or ulcer(s) in the genital area, vagina, anus, or oral cavity
New rash, usually on the trunk, often on extremities, soles of the feet, or palms; patchy hair
loss
Fever, malaise, swollen glands, arthralgias, myalgias
Altered mental status, weakness, paralysis
Neurosyphilis: vision changes, eye pain, tinnitus, hearing loss, headaches, dizziness,
generalized weakness, seizures, confusion, changes in personality or affect
Conduct a targeted history, asking the patient about symptoms listed above, including duration;
inquire about other or associated symptoms. Ascertain the following:
Previous diagnosis of syphilis
New sex partners in past 90 days (for primary or secondary syphilis)
Unprotected sex (oral, vaginal, anal)
Date of last syphilis test
Possibility of pregnancy
O: Objective
Check for fever, document other vital signs.
Perform a complete examination including the following:
Skin and mucosal areas (including the genitals, palm, and soles): rash, gummas, granulomas,
patchy hair loss
Oropharynx: chancres, mucous patches, condyloma lata
Lymph nodes
Heart: murmurs
Ophthalmic examination
Neurologic examination (mental status, cranial nerves [including visual acuity], sensory,
motor, reflexes, coordination, gait): abnormal mental status, visual acuity changes,
extraocular movement abnormalities, neurosensory hearing loss, facial palsy, paraesthesias,
paralysis, hemiplegia, hyperactive reflexes, ataxia
A: Assessment
Because syphilis has a wide range of manifestations, the differential diagnosis is broad. It is
important to consider syphilis as a possible cause of many presenting illnesses. A partial differential
diagnosis includes the following:
Other causes of maculopapular rashes: pityriasis, drug eruption, condyloma, folliculitis,
psoriasis, acute HIV infection
Other causes of genital ulcerative disease: herpes simplex virus (HSV), chancroid
Other causes of ocular disease; glaucoma, cytomegalovirus (CMV) retinitis, CMV immune
reconstitution uveitis, HSV keratitis
Other causes of neurologic disease: stroke, Bell palsy, CNS lymphoma, toxoplasmosis,
meningitis
Other causes of cardiac murmurs: bacterial endocarditis, congenital abnormalities
Other causes of systemic symptoms (e.g., fever, malaise, adenopathy): acute HIV infection,
acute hepatitis, other infections or malignancies
P: Plan
Diagnostic Evaluation
Darkfield examination and direct fluorescent antibody
Darkfield examination and direct fluorescent antibody (DFA) testing of a sample from suspicious
genital or anal chancres or moist dermatologic lesions (not oral lesions) are definitive tests for
syphilis, although these are not available in most clinic settings.
Serologic tests
Nontreponemal tests (RPR or VDRL) are most sensitive in primary and secondary syphilis when
titers are high, though the response may be delayed in HIV-infected patients (nontreponemal test
results typically are positive within 3 months after infection). Because false-positive results may
occur, particularly in the setting of HIV infection, positive nontreponemal test results must be
confirmed with a treponemal test. Titers may be used to follow response to treatment; a fourfold
change in titer is considered a significant change. Note that the same nontreponemal test should be
used consistently for a single patient; RPR titers cannot be compared with VDRL titers.
Treponemal antibody tests (TP-PA [T. pallidum particle agglutination] or FTA-ABS [fluorescent
treponemal antibody absorption]) confirm a positive nontreponemal test. As an alternative, many
laboratories have begun to use a treponemal test, e.g., an enzyme immunoassay (EIA) as an initial
screen for syphilis infection, followed by a nontreponemal test for confirmation, to reduce the
workload from the titration required for nontreponemal titers.
A false-negative RPR or VDRL result may occur, usually when the test is performed in early
infection, before a sufficient antibody response has developed. Another possible cause of a false-
negative nontreponemal result is the prozone phenomenon, seen when antibody concentrations are
very high (usually in secondary syphilis) and the specimen is not diluted sufficiently. If serologic test
results are negative and suspicion of syphilis is high, perform other diagnostic tests (e.g., biopsy) or
request that the laboratory perform additional dilutions on nontreponemal test specimens.
Cerebrospinal fluid evaluation
HIV-infected patients with neurologic or ocular signs or symptoms of syphilis, late latent syphilis,
syphilis of unknown duration, or tertiary syphilis should undergo lumbar puncture (LP) and
cerebrospinal fluid (CSF) analysis. CSF evaluation also is indicated for patients in whom treatment
for early syphilis fails (see below). Routine CSF evaluation is not indicated for HIV-infected patients
who have early syphilis without neurologic or ophthalmic signs or symptoms. CSF analysis should
include the following:
CSF-VDRL: This test is specific but not very sensitive; a positive result is diagnostic but a
negative result does not rule out neurosyphilis.
Leukocytes: Elevated white blood cell count (>10 cells/L) is suggestive but not specific.
Note that mononuclear pleocytosis (up to 5-20 cells/L) is not uncommon in patients with
HIV infection, particularly those with higher CD4 cell counts.
Some recommend checking CSF FTA-ABS. This is very sensitive but not very specific; a
negative result indicates that neurosyphilis is highly unlikely.
Other testing
All patients who test positive for syphilis should be tested for gonorrhea and chlamydia, with
sampling sites based on sexual practices and exposures (oropharyngeal, urethral, vaginal, or
anorectal testing). Patients not known to be HIV infected also should be tested for HIV.
Treatment
Treatment of syphilis in HIV-infected individuals essentially is the same as in HIV-uninfected
individuals, and depends on stage and the presence or absence of neurosyphilis. It is important to
follow patients closely to assure the success of treatment. For further information, see the Centers for
Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines (see
"References," below).
An RPR or VDRL test should be sent on the day of treatment; the titer will be the reference point for
assessing treatment efficacy (see "Follow-Up," below).
Early syphilis
(<1 year in duration [i.e., primary, secondary, and early latent]); nonneurologic)
Recommended: benzathine penicillin G, 2.4 million units IM (single dose)
Alternatives: note that penicillin is strongly preferred; consider allergy testing and
desensitization to penicillin; in penicillin-allergic, nonpregnant patients, consider the
following; note that these therapies are not as well proven in HIV-infected individuals; close
monitoring for treatment response is recommended.
o Doxycycline, 100 mg PO BID for 14 days
o Tetracycline, 500 mg PO QID for 14 days
o Ceftriaxone, 1 g IM or IV once daily for 10-14 days
o High rates of treatment failure have been reported in patients treated with
azithromycin (2 g, single dose); this regimen should be used only if other options are
contraindicated and close follow-up is possible
Late latent syphilis
(>1 year in duration or of unknown duration; no evidence of neurologic disease)
CSF examination to rule out neurosyphilis should be done on all patients with a history of
syphilis >1 year in duration or of unknown duration.
If CSF examination result is negative, treat with benzathine penicillin G, 2.4 million units IM
weekly for 3 consecutive weeks (7.2 million units in total).
In penicillin-allergic clients, refer for desensitization to penicillin. As an alternative, some
specialists consider doxycycline 100 mg PO BID for 28 days. Referral to infectious disease
specialist and close clinical monitoring are required, as treatment efficacy is not proven in
HIV-infected individuals.
Tertiary syphilis
Consult with specialists.
Neurosyphilis
(syphilis at any stage with neurologic or ocular symptoms or CSF findings of neurosyphilis)
Ideally, patients should be hospitalized and given 2 weeks of penicillin IV under close observation.
Penicillin-allergic patients should be referred for desensitization, if possible.
Recommended: aqueous crystalline penicillin G, 18-24 million units IV per day (3-4 million
units Q4H [or continuous infusion] for 10-14 days).
Alternatives (require strict adherence with therapy):
o Procaine penicillin 2.4 million units IM per day, plus probenecid 500 mg PO QID,
both for 10-14 days
o Some experts consider use of ceftriaxone 2 g IM or IV once daily for 10-14 days with
close clinical monitoring
o Some experts recommend administration of benzathine penicillin, 2.4 million units
IM weekly for 3 weeks, after completion of the standard 10- to 14-day course of
therapy for neurosyphilis.
o Recheck CSF leukocyte count every 6 months until the cell count normalizes (if CSF
pleocytosis was present at initial evaluation). If the leukocyte count is not lower at 6
months, consider retreatment (consult with a specialist).
Note that a Jarisch-Herxheimer reaction may occur after initial syphilis treatment, especially in
primary, secondary, or even latent syphilis. This self-limited treatment effect should not be confused
with an allergic reaction to penicillin. It usually begins 2-8 hours after the first dose of penicillin and
consists of fever, chills, arthralgias, malaise, tender lymphadenopathy, and intensification of rash. It
resolves within 24 hours and is best treated with rest and acetaminophen. Patients should be warned
about the possibility of a Jarisch-Herxheimer reaction.
Pregnancy
Pregnant women should be treated with penicillin, if possible, using a regimen appropriate for the
stage of infection (see above). Additional treatment may be indicated; consult with a specialist.
Penicillin-allergic pregnant women should be referred for desensitization to penicillin. Doxycycline
and tetracycline may cause fetal toxicity and should not be used during pregnancy; erythromycin is
not sufficiently effective in treating syphilis in the fetus. Azithromycin and erythromycin do not have
adequate efficacy in treating pregnant women or their fetuses and should not be used. The efficacy of
ceftriaxone during pregnancyhas not been studied adequately.
Women treated during the second half of pregnancy are at risk of contractions, early labor, and fetal
distress if they develop a Jarisch-Herxheimer reaction; thus, they should be monitored carefully.
Sex partners
Syphilis is transmitted sexually only when mucocutaneous lesions of syphilis are present; this is
uncommon after the first year of infection. Nevertheless, sex partners of a patient who has syphilis in
any stage should be evaluated.
Persons exposed within 90 days preceding the diagnosis of primary, secondary, or early latent
syphilis should be treated presumptively, as they may be infected with syphilis even if they
are seronegative.
Persons exposed more than 90 days before the diagnosis of primary, secondary, or early
latent syphilis should be treated presumptively if serologic test results are not available
immediately and their follow-up is in doubt. Otherwise, they should receive serologic testing
and be treated appropriately if the test result is positive. Note that some specialists
recommend presumptive treatment of all persons potentially exposed to syphilis. For patients
with primary syphilis, that means partners within the previous 3 months; for secondary,
within 6 months; for early latent, within 1 year.
Follow-Up
All HIV-infected patients treated for syphilis should be evaluated clinically and serologically at 3, 6,
9, 12, and 24 months (at 6, 12, 18, and 24 months for latent syphilis) to rule out treatment failure.
Treatment success is determined by a fourfold decrease in RPR or VDRL titer by 6-12 months (for
primary and secondary syphilis) or 12-24 months (for latent syphilis) of treatment. Patients whose
titers do not decrease appropriately probably either experienced treatment failure or were reinfected.
Any patient with apparent treatment failure should undergo an LP for CSF analysis and be re-treated
as appropriate. If at any time symptoms develop or nontreponemal test titers increase fourfold, CSF
examination should be performed and appropriate treatment should be given.
Some patients retain reactive (low-titer) nontreponemal test results after successful treatment for
syphilis. In these "serofast" individuals, reinfection with syphilis is indicated by a rise in test titer of
at least fourfold.
Risk-reduction counseling
All patients with syphilis should receive risk evaluation and risk-reduction counseling. Evaluate each
patient's sexual practices with regard to risk of acquiring STIs and of transmitting HIV. Work with
the patient to reduce sexual risks.
Patient Education
Instruct patients to go to clinic for treatment at the intervals recommended. If patients are
given oral antibiotics (penicillin-allergic individuals), instruct them to take their medications
exactly as prescribed.
Warn patients about the possibility of a Jarisch-Herxheimer reaction and advise them about
self-management of associated symptoms (e.g., acetaminophen or aspirin at usual doses,
fluids, and rest).
Instruct patients about the required follow-up laboratory and clinical evaluations necessary to
document adequate treatment. Emphasize the need for regular evaluation of treatment
efficacy.
Sex partners from the previous 3-6 months (sometimes longer, depending on the stage of
syphilis) need to be evaluated and treated as soon as possible, even if they have no symptoms.
Advise patients to inform their partners that they need to be tested and treated.
Syphilis is a reportable communicable disease in the United States. Patients will be contacted
to assist with partner tracing and to ensure appropriate treatment.
Provide education about sexual risk reduction. Review sexual practices and support patients
in using condoms with every sexual contact to prevent becoming reinfected with syphilis or
infected with other STIs, and to prevent passing HIV to sex partners.
References
[Link]


Syphilis is a bacterial infection that is usually caught by having sex
with someone who is infected.
The bacteria that cause syphilis are called Treponema pallidum. They can enter your body if you
have close contact with an infected sore, normally during vaginal, anal or oral sex or by sharing sex
toys with someone who is infected.
Pregnant women can pass the condition on to their unborn baby, which can cause stillbirth or death
of the baby shortly after labour. It may also be possible to catch syphilis if you are an injecting drug
user and you share a needle with somebody who is infected.
It is extremely rare for syphilis to be spread through blood transfusions, as all blood transfusions in
the UK are tested for syphilis.
Syphilis also cannot be spread by using the same toilet, clothing, cutlery or bathroom as an infected
person, as the bacteria cannot survive for long outside the human body.
Three stages of disease
The symptoms of syphilis develop in three stages, described below.
Stage 1 (primary syphilis) Symptoms of syphilis begin with a painless but highly
infectious sore on the genitals or sometimes around the mouth. If somebody else
comes into close contact with the sore, typically during sexual contact, they can also
become infected. The sore lasts two to six weeks before disappearing.
Stage 2 (secondary syphilis) Secondary symptoms, such as a skin rash and sore
throat, then develop. These symptoms may disappear within a few weeks, after which
you experience a latent (hidden) phase with no symptoms, which can last for years.
After this, syphilis can progress to its third, most dangerous stage.
Stage 3 (tertiary syphilis) Around a third of people who are not treated for syphilis
will develop tertiary syphilis. At this stage, it can cause serious damage to the body.
The primary and secondary stages are when you are most infectious to other people. In the latent
phase (and usually around two years after becoming infected), syphilis cannot be passed on to others.
Tertiary syphilis is rare in the UK.
Read more detailed information about the symptoms of syphilis.
What to do
If you suspect you have syphilis, visit a genitourinary medicine (GUM) clinic, sexual health clinic or
your GP as soon as possible. The earlier syphilis is treated, the less chance there is of serious
complications. Find your nearest sexual health clinic by searching by postcode or town.
Read more information about how syphilis is diagnosed.
How common is it?
The number of diagnoses of syphilis has risen substantially in the past decade in the UK. There have
been several local outbreaks across England, the largest of which was in London between 2001 and
2004. Rates are highest among men who have sex with men.
However, syphilis is still one of the less common sexually transmitted infections in the UK. Between
2011 and 2012, there were 2,978 cases of syphilis diagnosed in the UK.
Treating syphilis
If diagnosed early, syphilis can be easily treated withantibiotics, usually penicillin injections.
Read more information about treating syphilis.
However, if it is not treated, syphilis can progress to a more dangerous form of the disease and cause
serious conditions such as stroke, paralysis, blindness or even death.
Complications
It is estimated that people with syphilis are three to five times more likely to catch HIV. This is
because the genital sores caused by syphilis can bleed easily, making it easier for the HIV virus to
enter the blood during sexual activity.
Infection with both HIV and syphilis can be serious because syphilis can progress much more rapidly
than normal.
Preventing syphilis
The only guaranteed way to prevent a syphilis infection is to avoid sexual contact or to have sexual
contact only with a faithful partner who has been tested and does not have the infection.
You can reduce your risk of catching syphilis and other sexually transmitted infections (STIs) by:
using a male condom or female condom during vaginal, oral and anal sex
using a dental dam (square of plastic) during oral sex
avoiding sharing sex toys
Page last reviewed: 10/01/2014
Next review due: 10/01/2016
[Link]


Syphilis - primary
Syphilis is bacteria infection that is most often spread through sexual contact.
Causes
Syphilis is a sexually transmitted, infectious disease caused by the spirochete Treponema pallidum.
This bacterium causes infection when it gets into broken skin or mucus membranes, usually of the
genitals. Syphilis is most often transmitted through sexual contact, although it also can be transmitted
in other ways.
Syphilis occurs worldwide. Syphilis is more common in urban areas, and the number of cases is
rising fastest in men who have sex with men. Young adults ages 15 - 25 are the highest-risk
population. People have no natural resistance to syphilis.
Because people may be unaware that they are infected with syphilis, many states require tests for
syphilis before marriage. All pregnant women who receive prenatal care should be screened for
syphilis to prevent the infection from passing to their newborn (congenital syphilis).
Syphilis has three stages:
Primary syphilis
Secondary syphilis
Tertiary syphilis (the late phase of the illness)
Secondary syphilis, tertiary syphilis, and congenital syphilis are not seen as often in the United States
as they were in the past because of the availability of:
Free, government-sponsored sexually transmitted infection (STI) clinics
Screening tests for syphilis
Public education about STIs
Prenatal screening
Symptoms
Symptoms of primary syphilis are:
Small, painless open sore or ulcer (called a chancre) on the genitals, mouth, skin, or rectum
that heals by itself in 3 - 6 weeks
Enlarged lymph nodes in the area of the sore
The bacteria continue to grow in the body, but there are few symptoms until the second stage.
Secondary syphilis symptoms may include:
Skin rash, usually on the palms of the hands and soles of the feet
Sores called mucous patches in or around the mouth, vagina, or penis
Moist, warty patches (called condylomata lata) in the genitals or skin folds
Fever
General ill feeling
Loss of appetite
Muscle aches
Joint pain
Swollen lymph nodes
Vision changes
Hair loss
Symptoms of tertiary syphilis depend on which organs have been affected. They vary widely and are
difficult to diagnose. Symptoms include:
Damage to the heart, causing aneurysms or valve disease
Central nervous system disorders (neurosyphilis)
Tumors of skin, bones, or liver
Exams and Tests
The doctor or nurse will examine you. Tests that may be done include:
Examination of fluid from sore
Echocardiogram, aortic angiogram, and cardiac catheterization to look at the major blood
vessels and the heart
Blood tests to screen for syphillis bacteria (RPR or VDRL)-- if positive, one of the following
tests will be needed to confirm the diagnosis:
o FTA-ABS (fluorescent treponemal antibody test)
o MHA-TP
Spinal tap, and examination of spinal fluid
Treatment
Syphilis can be treated with antibiotics, such as penicillin G benzathine, doxycycline, or tetracycline
(for patients who are allergic to penicillin). Length of treatment depends on how severe the syphilis
is, and factors such as the patient's overall health.
For treating syphilis during pregnancy, penicillin is the drug of choice. Tetracycline cannot be used
because it is dangerous to the unborn baby. Erythromycin may not prevent congenital syphilis in the
baby. People who are allergic to penicillin should ideally be desensitized to it, and then treated with
penicillin.
Several hours after getting treatment for the early stages of syphilis, people may experience Jarish-
Herxheimer reaction. This is caused by an immune reaction to the breakdown products of the
infection.
Symptoms and signs of this reaction include:
Chills
Fever
General feeling of being ill (malaise)
Headache
Joint aches
Muscle aches
Nausea
Rash
These symptoms usually disappear within 24 hours.
Follow-up blood tests must be done at 3, 6, 12, and 24 months to ensure that the infection is gone.
Avoid sexual contact when the chancre is present, and use condoms until two follow-up tests have
indicated that the infection has been cured.
All sexual partners of the person with syphilis should also be treated. Syphilis is extremely
contagious in the primary and secondary stages.
Outlook (Prognosis)
Syphilis can be cured if it is diagnosed early and completely treated.
Secondary syphilis can be cured if it is diagnosed early and treated effectively. Although it usually
goes away within weeks, in some cases it may last for up to 1 year. Without treatment, up to one-
third of patients will have late complications of syphilis.
Late syphilis may be permanently disabling, and it may lead to death.
Possible Complications
Cardiovascular complications (aortitis and aneurysms)
Destructive sores of skin and bones (gummas)
Neurosyphilis
Syphilitic myelopathy - a complication that involves muscle weakness and abnormal
sensations
Syphilitic meningitis
In addition, untreated secondary syphilis during pregnancy may spread the disease to the developing
baby. This is called congenital syphilis.
[Link]

Symptoms
By Mayo Clinic Staff
Syphilis develops in stages, and symptoms vary with each stage. But the stages may overlap, and
symptoms don't always occur in the same order. You may be infected with syphilis and not notice
any symptoms for years.
Primary syphilis
The first sign of syphilis is a small sore, called a chancre (SHANG-kur). The sore appears at the spot
where the bacteria entered your body. While most people infected with syphilis develop only one
chancre, some people develop several of them. The chancre usually develops about three weeks after
exposure. Many people who have syphilis don't notice the chancre because it's usually painless, and
it may be hidden within the vagina or rectum. The chancre will heal on its own within six weeks.
Secondary syphilis
Within a few weeks of the original chancre healing, you may experience a rash that begins on your
trunk but eventually covers your entire body even the palms of your hands and the soles of your
feet. This rash is usually not itchy and may be accompanied by wart-like sores in the mouth or
genital area. Some people also experience muscle aches, fever, sore throat and swollen lymph nodes.
These signs and symptoms may disappear within a few weeks or repeatedly come and go for as long
as a year.
Latent syphilis
If you aren't treated for syphilis, the disease moves from the secondary to the latent (hidden) stage,
when you have no symptoms. The latent stage can last for years. Signs and symptoms may never
return, or the disease may progress to the tertiary (third) stage.
Tertiary (late) syphilis
About 15 to 30 percent of people infected with syphilis who don't get treatment will develop
complications known as tertiary (late) syphilis. In the late stages, the disease may damage your brain,
nerves, eyes, heart, blood vessels, liver, bones and joints. These problems may occur many years
after the original, untreated infection.
Congenital syphilis
Babies born to women who have syphilis can become infected through the placenta or during birth.
Most newborns with congenital syphilis have no symptoms, although some experience a rash on the
palms of their hands and the soles of their feet. Later symptoms may include deafness, teeth
deformities and saddle nose where the bridge of the nose collapses.
When to see a doctor
Call your doctor if you or your child experiences any unusual discharge, sore or rash particularly
if it occurs in the groin area
The cause of syphilis is a bacterium called Treponema pallidum. The most common route of
transmission is through contact with an infected person's sore during sexual activity. The bacteria
enter your body through minor cuts or abrasions in your skin or mucous membranes. Syphilis is
contagious during its primary and secondary stages, and sometimes in the early latent period.
Less commonly, syphilis may spread through direct unprotected close contact with an active lesion
(such as during kissing) or through an infected mother to her baby during pregnancy or childbirth
(congenital syphilis).
Syphilis can't be spread by using the same toilet, bathtub, clothing or eating utensils, or from
doorknobs, swimming pools or hot tubs.
Once cured, syphilis doesn't recur. However, you can become reinfected if you have contact with
someone's syphilis sore.
You face an increased risk of acquiring syphilis if you:
Engage in unprotected sex
Have sex with multiple partners
Are a man who has sex with men
Are infected with HIV, the virus that causes AIDS
Without treatment, syphilis can lead to damage throughout your body. Syphilis also increases the risk
of HIV infection and, for women, can cause problems during pregnancy. Treatment can help prevent
future damage but can't repair or reverse damage that's already occurred.
Small bumps or tumors
Called gummas, these bumps can develop on your skin, bones, liver or any other organ in the late
stage of syphilis. Gummas usually disappear after treatment with antibiotics.
Neurological problems
Syphilis can cause a number of problems with your nervous system, including:
Stroke
Meningitis
Deafness
Visual problems
Dementia
Cardiovascular problems
These may include bulging (aneurysm) and inflammation of the aorta your body's major artery
and of other blood vessels. Syphilis may also damage heart valves.
HIV infection
Adults with sexually transmitted syphilis or other genital ulcers have an estimated two- to fivefold
increased risk of contracting HIV. A syphilis sore can bleed easily, providing an easy way for HIV to
enter your bloodstream during sexual activity.
Pregnancy and childbirth complications
If you're pregnant, you may pass syphilis to your unborn baby. Congenital syphilis greatly increases
the risk of miscarriage, stillbirth or your newborn's death within a few days after birth.
Syphilis can be diagnosed by testing samples of:
Blood. Blood tests can confirm the presence of antibodies that the body produces to fight
infection. The antibodies to the bacteria that cause syphilis remain in your body for years, so the
test can be used to determine a current or past infection.
Fluid from sores. Your doctor may scrape a small sample of cells from a sore to be analyzed by
microscope in a lab. This test can be done only during primary or secondary syphilis, when sores
are present. The scraping can reveal the presence of bacteria that cause syphilis.
Cerebral spinal fluid. If it's suspected that you have nervous system complications of syphilis,
your doctor may also suggest collecting a sample of cerebrospinal fluid through a procedure
called a lumbar puncture (spinal tap).
Through the Centers for Disease Control and Prevention, your local health department offers partner
services, which will help you notify your sexual partners that they may be infected. That way, your
partners can be tested and treated and the spread of syphilis can be curtailed.
When diagnosed and treated in its early stages, syphilis is easy to cure. The preferred treatment at all
stages is penicillin, an antibiotic medication that can kill the organism that causes syphilis. If you're
allergic to penicillin, your doctor will suggest another antibiotic.
A single injection of penicillin can stop the disease from progressing if you've been infected for less
than a year. If you've had syphilis for longer than a year, you may need additional doses.
Penicillin is the only recommended treatment for pregnant women with syphilis. Women who are
allergic to penicillin can undergo a desensitization process that may allow them to take penicillin.
Even if you're treated for syphilis during your pregnancy, your newborn child should also receive
antibiotic treatment.
The first day you receive treatment you may experience what's known as the Jarisch-Herxheimer
reaction. Signs and symptoms include fever, chills, nausea, achy pain and headache. This reaction
usually doesn't last more than one day.
Treatment follow-up
After you're treated for syphilis, your doctor will ask you to:
Have periodic blood tests and exams to make sure you're responding to the usual dosage of
penicillin
Avoid sexual contact until the treatment is completed and blood tests indicate the infection has
been cured
Notify your sex partners so that they can be tested and get treatment if necessary
Be tested for HIV infection
To help prevent the spread of syphilis, follow these suggestions:
Abstain or be monogamous. The only certain way to avoid syphilis is to forgo having sex. The
next-best option is to have mutually monogamous sex with one partner who is uninfected.
Use a latex condom. Condoms can reduce your risk of contracting syphilis, but only if the
condom covers the syphilis sores.
Avoid recreational drugs. Excessive use of alcohol or other drugs can cloud your judgment and
lead to unsafe sexual practices.
Screening for pregnant women
People can be infected with syphilis and not know it. In light of the often deadly effects syphilis can
have on unborn children, health officials recommend that all pregnant women be screened for the
disease.
[Link]


What is syphilis?
Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. It has
often been called "the great imitator" because so many of the signs and symptoms are
indistinguishable from those of other diseases.
How common is syphilis?
In the United States, health officials reported 49,903 cases of syphilis in 2012, including 15,667
cases of primary and secondary (P&S) syphilis. In 2012, half of all P&S syphilis cases were reported
from 26 counties and 2 cities. The incidence of P&S syphilis was highest in women 20 to 24 years of
age and in men 20 to 24 years of age. Reported cases of congenital syphilis in newborns decreased
from 2011 to 2012, with 360 new cases reported in 2011 compared to 322 cases in 2012.
Between 2011 and 2012, the number of reported P&S syphilis cases increased 12.1 percent. In 2012,
75% of the reported P&S syphilis cases were among men who have sex with men (MSM).
How do people get syphilis?
Syphilis is passed from person to person through direct contact with a syphilis sore. Sores occur
mainly on the external genitals, vagina, anus, or in the rectum. Sores also can occur on the lips and in
the mouth. Transmission of the organism occurs during vaginal, anal, or oral [Link]
women with the disease can pass it to the babies they are carrying. Syphilis cannot be spread through
contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating
utensils.
What are the signs and symptoms in adults?
Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late
complications if they are not treated. Although transmission occurs from persons with sores who are
in the primary or secondary stage, many of these sores are unrecognized. Thus, transmission may
occur from persons who are unaware of their infection.
Primary Stage
The primary stage of syphilis is usually marked by the appearance of a single sore (called a chancre),
but there may be multiple sores. The time between infection with syphilis and the start of the first
symptom can range from 10 to 90 days (average 21 days). The chancre is usually firm, round, small,
and painless. It appears at the spot where syphilis entered the body. The chancre lasts 3 to 6 weeks,
and it heals without treatment. However, if adequate treatment is not administered, the infection
progresses to the secondary stage.
Secondary Stage
Skin rash and mucous membrane lesions characterize the secondary stage. This stage typically starts
with the development of a rash on one or more areas of the body. The rash usually does not cause
itching. Rashes associated with secondary syphilis can appear as the chancre is healing or several
weeks after the chancre has healed. The characteristic rash of secondary syphilis may appear as
rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet.
However, rashes with a different appearance may occur on other parts of the body, sometimes
resembling rashes caused by other diseases. Sometimes rashes associated with secondary syphilis are
so faint that they are not noticed. In addition to rashes, symptoms of secondary syphilis may include
fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and
fatigue. The signs and symptoms of secondary syphilis will resolve with or without treatment, but
without treatment, the infection will progress to the latent and possibly late stages of disease.
Latent and Late Stages
The latent (hidden) stage of syphilis begins when primary and secondary symptoms disappear.
Without treatment, the infected person will continue to have syphilis even though there are no signs
or symptoms; infection remains in the body. This latent stage can last for years. The late stages of
syphilis can develop in about 15% of people who have not been treated for syphilis, and can appear
10-20 years after infection was first acquired. In the late stages of syphilis, the disease may damage
the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints.
Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle movements,
paralysis, numbness, gradual blindness, and dementia. This damage may be serious enough to cause
death.
Why should MSM be concerned about syphilis?
Over the past several years, increases in syphilis among MSM have been reported in various cities
and areas, including Chicago, Seattle, San Francisco, Southern California, Miami, and New York
City. In the recent outbreaks, high rates of HIV co-infection were documented, ranging from 20
percent to 70 percent. While the health problems caused by syphilis in adults are serious in their own
right, it is now known that the genital sores caused by syphilis in adults also make it easier to
transmit and acquire HIV infection sexually.
How is syphilis diagnosed?
Some health care providers can diagnose syphilis by examining material from a chancre (infectious
sore) using a special microscope called a dark-field microscope. If syphilis bacteria are present in the
sore, they will show up when observed through the microscope.
A blood test is another way to determine whether someone has syphilis. Shortly after infection
occurs, the body produces syphilis antibodies that can be detected by an accurate, safe, and
inexpensive blood test. A low level of antibodies will likely stay in the blood for months or years
even after the disease has been successfully treated.
HIV/AIDS & STDs
What is the link between syphilis and HIV?
Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV infection
sexually. There is an estimated 2- to 5-fold increased risk of acquiring HIV if exposed to that
infection when syphilis is present.
Ulcerative STDs that cause sores, ulcers, or breaks in the skin or mucous membranes, such as
syphilis, disrupt barriers that provide protection against infections. The genital ulcers caused by
syphilis can bleed easily, and when they come into contact with oral and rectal mucosa during sex,
increase the infectiousness of and susceptibility to HIV. Having other STDs is also an important
predictor for becoming HIV infected because STDs are a marker for behaviors associated with HIV
transmission.
What is the treatment for syphilis?
Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an antibiotic,
will cure a person who has had syphilis for less than a year. Additional doses are needed to treat
someone who has had syphilis for longer than a year. For people who are allergic to penicillin, other
antibiotics are available to treat syphilis. There are no home remedies or over-the-counter drugs that
will cure syphilis. Treatment will kill the syphilis bacterium and prevent further damage, but it will
not repair damage already done.
Because effective treatment is available, it is important that persons be screened for syphilis on an
on-going basis if their sexual behaviors put them at risk for STDs.
Persons who receive syphilis treatment must abstain from sexual contact with new partners until the
syphilis sores are completely healed. Persons with syphilis must notify their sex partners so that they
also can be tested and receive treatment if necessary.
Will syphilis recur?
Having syphilis once does not protect a person from getting it again. Following successful treatment,
people can still be susceptible to re-infection. Only laboratory tests can confirm whether someone
has syphilis. Because syphilis sores can be hidden in the vagina, rectum, or mouth, it may not be
obvious that a sex partner has syphilis. Talking with a health care provider will help to determine the
need to be re-tested for syphilis after being treated.
How can syphilis be prevented?
The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to
abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner
who has been tested and is known to be uninfected.
Avoiding alcohol and drug use may also help prevent transmission of syphilis because these
activities may lead to risky sexual behavior. It is important that sex partners talk to each other about
their HIV status and history of other STDs so that preventive action can be taken.
Genital ulcer diseases, like syphilis, can occur in both male and female genital areas that are covered
or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of
latex condoms can reduce the risk of syphilis, as well as genital herpes and chancroid, only when the
infected area or site of potential exposure is protected.
Condoms lubricated with spermicides (especially Nonoxynol-9 or N-9) are no more effective than
other lubricated condoms in protecting against the transmission of STDs. Use of condoms lubricated
with N-9 is not recommended for STD/HIV prevention. Transmission of an STD, including syphilis
cannot be prevented by washing the genitals, urinating, and or douching after sex. Any unusual
discharge, sore, or rash, particularly in the groin area, should be a signal to refrain from having sex
and to see a doctor immediately.
The CDCs 2006 Sexually Transmitted Disease Treatment Guidelines recommend that MSM who
are at risk for STDs be tested for syphilis annually.
[Link]


Stages of Syphilis
Syphilis is often called "the great imitator" because it has varying symptoms and these symptoms
usually resemble those of many other diseases. The bacteria usually follows a four stage pattern that
at times can overlap.
Primary Syphilis (Stage One)
The first symptom of syphilis is a small, round firm ulcer known as a chancre that usually develops
at the site of infection where the bacteria has entered the body.
Nearby Lymph Glands are often swollen due to the immunological response towards infection.
Chancres will often appear about three weeks after infection but can present themselves within 9 to
90 days after initial exposure to the bacteria. During this primary stage of syphilis, the infected
person is highly contagious. Chancres are usually painless and can occur inside the body which often
leaves these chancres to go undetected or unnoticed. The chancres will disappear in about three to six
weeks even without the treatment of the bacteria or infection. If the infection is not treated however,
then it is enevitable that the infection will progress to secondary stage.

Secondary Syphilis (Stage Two)
The secondary stage of syphilis brings about a non-itchy skin rash that appears in the infected area of
the body as well as more commonly found on the palms, hands, and soles of the feet. However, the
skin rash could in fact cover the entire body or in a few areas. The rash appears two to ten weeks
after the chancre developed and disappeared. The rash will appear generally where the chancre is
healing or already healed. The rash contains reddish brown, small, solid, flat or raised skin sores that
are only a couple of centimeters in length. One problem is that the syphilis rash can take on the form
and look of many other common skin problems. Small, open sores can develop on the mucous
membranes and may contain pus or moist sores that are wart-like.
Some common syptoms with secondary syphilis are sore throat, fatigue, weakness or discomfort of
the body, swollen lymph glands, weight loss and patchy hair loss. Some less frequent symptoms that
can occur are fever, aches, severe weight loss, aching joints, or lessions in/around the mouth and
genital region. Nervous system symptoms of secondary syphilis include headaches, irritability,
paralysis, unequal reflexes, and irregular sized pupils. After infection, skin discoloration will occur
where the rash and sores were spotted.
This stage of syphilis is highly contagious as well. Secondary syphilis will too disappear without
treatment during a period of two to twelve weeks. This does not mean that the syphilis bacteria has
been irradicated. Without treatment the bacteria will go on to the next stage of syphilis. There may
be recurrences of secondary syphilis for a one to two year period.

Latent Syphilis (Stage Three)
Latent syphilis is known as the "hidden" stage of syphilis.
This usually is marked by completeing an entire year of infection. After the secondary syphilis rash
disappears the infected will undergo a latent stage. This is where one will experience no symptoms at
all yet the bacteria is still inside the body. The latent period can be brief and last up to a year or can
be long and drawn out and last anywhere from five to twenty years. Because no symptoms are
present, accurate diagnosis can only be made through blood tests. One is only contagious in the
earlier part of the latent stage. This however is misleading because you can still infect your partner
through sexual contact.
If you do not get treatment during the latent stage you will develop the next stage of infection which
is the most serious stage of the disease.
Tertiary Syphilis (Stage Four)
This is the most destructive and devestating stage of the disease. Only a small percentage of those
infected who do not undergo treatment will develop the terrible complications that accompany
tertiary (or late) syphilis. If untreated, Tertiary syphilis can develop from as early as one year after
infection to decades into the disease.
Tertiary syphilis causes damage to the heart, eyes, brain, nervous system, bones, joints, and many
other areas of the body. This late stage can result in mental illness, blindness, deafness, memory loss,
heart disease, neurological issues, and even death. One serious development during this stage would
that be of neurosyphilis which causes extreme brain and spinal chord damage.

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