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How is syphilis transmitted ? Transmission occurs most commonly through sexual contact . Congenital transmission is also possible . The T . pallidum bacterium can pass through intact mucous membranes , therefore it can be transmitted orally ( via kissing or oral sex ) on contact with an infectious lesion . There is limited evidence for transmission via needles . Syphilis is not transmitted via general social contact , sharing eating utensils or toilet seats . The bacteria die quickly outside the body .
What are the symptoms ? Syphilis often follows three specific stages , at which different symptoms may occur . However , the infection is known as ‘ the great mimicker ’ as symptoms can be absent , vague , occur in different orders , or completely diverge from the typical presentations . As a result , it is recommended that syphilis be included in a patient ’ s differential diagnosis for a variety of symptoms unless ruled out . ⁶
The typical stages of syphilis⁷ are set out below .
Primary infection ( nine to 90 days after exposure ) A painless shallow ulcer , known as a chancre , appears at the site of infection . The chancre contains infectious T . pallidum spirochaetes . The classic presentation of a chancre is a firm , painless , indurated ulcer , between 0.5cm and 3cm in size . However , chancres can also be multiple ( especially in people living with HIV ), itchy or painful . Typically , lesions will appear at the site of inoculation – often in the genital area , but some may be located elsewhere .
As chancres are often painless , they can easily be missed if not in an easily visible location , and can appear on the cervix , throat or rectum . Lymph node enlargement is common but will often be delayed by up to 10 days after chancre formation . Chancres generally resolve without treatment within three to eight weeks , although the active syphilis infection remains .
Secondary infection ( four to 10 weeks after chancre formation ) Secondary syphilis can manifest in a number of different ways ; a typical presentation involves the skin , mucous membranes or lymph nodes . A characteristic syphilis rash is symmetrical , pink and not itchy . It often occurs on the trunk and extremities but may also appear as a palmar-plantar rash , or as wart-like lesions known as condylomata lata . Patients may also present with a fever , flu-like symptoms and malaise .
Although these are typical symptoms , secondary syphilis can also present with weight loss , alopecia , hepatitis and neurological symptoms , among many other presentations . Again , these symptoms may resolve within three to six weeks even without treatment .
Latent phase Three to 12 weeks after secondary infection , syphilis typically enters a latent , asymptomatic phase . Some patients may then experience a recurrence of secondary infection symptoms .
Tertiary ( late latent ) infection Late infection occurs up to 40 years after initial infection . Due to the use of penicillin , many of the most severe sequelae of syphilis are thankfully rare , but may still occur in the absence of treatment .
Cardiovascular symptoms may include aneurysm , aortic regurgitation , coronary stenosis and angina .
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References 1 Farhi D , Dupin N . Origins of syphilis and management in the immunocompetent patient : facts and controversies . Clin Dermatol 2010 ; 28 ( 5 ): 533-38 2 Szreter S , Siena Kevin . The pox in Boswell ’ s London : an estimate of the extent of syphilis infection in the metropolis in the 1770s . Econ Hist Rev 2020 ; 74 ( 2 ): 372-99 3 Mahoney J , Arnold R , Harris A . Penicillin treatment of early syphilis . Amer J Pub Health 1943 ; 33 ( 12 ): 1387-91 4 Rayment M , Sullivan A . ‘ He who knows syphilis knows medicine ’ – the return of an old friend . Br J Cardiol 2011 ; 18:56-58 5 Public Health England . Tracking the syphilis epidemic in England : 2010-2019 . 2021 6 Rockwood N , Nwokolo N . Syphilis the great pretender : when is cancer not cancer ? SexTransm Infect 2018 ; 94:192-193 7 British Association of Sexual Health and HIV . BASHH Guidelines on syphilis . 2015 . bit . ly / 3LgRgnp
Jodie Crossman is nurse team leader at Brighton Sexual Health and Contraception Service , chair of the British Association of Sexual Health and HIV Nurses and Health Adviser group , and co-chair of the Sexually Transmitted Infections Foundation
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Gummatous symptoms develop very late after syphilis infection and manifest as granulomatous destructive lesions . They can occur anywhere in the body but will typically affect bones or skin . Gummas are the commonly pictured disfiguring lesions associated with the pre-penicillin treatment era .
Neurosyphilis ( infection of the central nervous system ) can occur at any stage of infection but is most often linked to tertiary syphilis . In earlier stages it may be asymptomatic but later it can manifest as paresis , including symptoms similar to dementia , or tabes dorsalis , seizures and paralysis .
Congenital syphilis Syphilis can be transmitted during pregnancy or birth . Not all babies born with syphilis will show symptoms . Early symptoms of congenital syphilis ( developing within two years of birth ) include hepatosplenomegaly , rash , fever , lymphadenopathy or skeletal abnormalities . If untreated , later symptoms can include facial and dental abnormalities , deafness and neurological symptoms . In order to ameliorate the negative effects of syphilis in the young , routine screening is offered to everyone seeking antenatal care in the UK .
How is syphilis diagnosed ? Syphilis may be treated presumptively in sexual health clinics based on history and examination . Clinics may offer dark-field microscopy , which can isolate treponemes from a chancre . Neurosyphilis is diagnosed by sampling cerebrospinal fluid . More commonly , however , syphilis is identified through a serological sample . If initial screening tests are positive , more detailed tests are conducted which , in combination with a thorough history , determine which stage the patient is at and how the infection should be treated .
As interpretation of test results can be complex , it is essential to seek guidance or referral to genitourinary medicine specialists in the event of a positive syphilis diagnostic test result .
What treatment is available ? Patients diagnosed with syphilis should be referred to a sexual health clinic for management , partner notification and screening for other STIs ( if not already conducted ). First-line treatment involves intramuscular injection of benzathine penicillin . This may be a single dose , or three doses spaced apart by seven days , depending on the stage of the infection . Treatment with doxycycline or ceftriaxone may be given in the event of the patient having penicillin allergy . For neurosyphilis , steroid treatment is given alongside daily penicillin treatment for 14 days .
Patients receiving syphilis treatment may experience a response known as the Jarisch-Herxheimer reaction . This is an acute febrile illness with headache , myalgia , chills and rigors . It is self-limiting and usually resolves within 24 hours .
Patients should be advised to abstain from sex for 14 days and inform any sexual partners of their diagnosis – epidemiological treatment may be given based on history . Follow-up serology should be conducted at three , six and 12 months to ensure treatment has been effective . Once positive , a patient ’ s EIA ( enzyme immunoassay ) result will always remain positive , but this does not imply active infection . However , if in doubt about a patient ’ s previous treatment history , advice should always be taken from a sexual health specialist clinician .
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