Syphilis

A famous historical STD with many different manifestations and symptoms, caused by the spirochete bacteria Treponema pallidum.ย  Diagnostic tests are a bit complex, many clinicians don’t understand them well.ย  We’ll try to be simple here (for an in-depth discussion, see Syphilis — Blood Tests).ย  The disease is easily passed by any kind of sex.ย  There are 4 stages (time frames are approximate):

Primary Syphilis:  Occurs 4-8 weeks after getting infected.  A painless ulcer called a “chancre” with firm edges develops at point of contagion, mainly seen on the penis.  If it’s inside the vagina, mouth, rectum, or under the foreskin, it won’t be noticed.  It lasts around 3-6 weeks and goes away on its own.  The chancre has lots of bacteria, is very contagious.

Blood tests are all negative.ย  The diagnosis can be made from the chancre by a special microscope (darkfield), only available at a few STD clinics, and isnโ€™t useful if it’s from the mouth.ย  So if we see something that looks like a chancre, & the person had sex recently, we simply assume the diagnosis, and treat with one high dose of long-acting injected penicillin [if not allergic].

Secondary Syphilis:ย  Begins as the chancre disappears, around 2-4 months after getting infected.ย  This stage lasts 1-2 years, goes away on its own.ย  Some people have symptoms, others just few or even none.ย  Symptoms may come & go, the most common include:

  • Fevers and achiness
  • Swollen lymph nodes (“swollen glands”), not just in the neck
  • Sore throat
  • Rash: Red spots that don’t itch or hurt, often also on the palms / soles
  • Gray patches in the mouth, vagina, or anus
  • Hair loss in patches

Blood tests for syphilis antibodies (VDRL & RPR) are 100% accurate at this stage.ย  Treatment is a single high dose of long-acting injected penicillin [if not allergic].

Late Latent Syphilis:  A silent phase, defined as beginning 1 year after all symptoms have gone away (usually begins 2 years after becoming infected).  There are no symptoms.  Blood tests are usually positive at first, but as time goes on, they may become false-negative.  At this stage, transmission isn’t very likely.  Treatment is a high dose of long-acting injected penicillin, every week for 3 doses [if not allergic].

Tertiary Syphilis:  May cause any of three complications: 1) Heart valve damage; 2) Gummas (growths or ulcers on skin/bone/internal organs; or 3) Nervous System disease (“Neurosyphilis”), mainly Brain or Eyes.

Heart:ย  Occurs 15-30 years after infection.ย  Damage to the aortic valve, which can cause heart failure.ย  Main sign is a murmur.ย  Can also cause aneurysm of ascending aorta in chest, which doesn’t usually rupture.ย  Blood tests usually positive.ย  Treatment is a high dose of long-acting injected penicillin every week for 3 doses [if not allergic].

Gummas:  Very rare.  Destructive tumors maybe mistaken for cancer.  Blood tests usually positive.  Treatment is a high dose of long-acting injected penicillin every week for 3 doses [if not allergic].

Early Neurosyphilis:  Occurs soon after infection (first year, or a few years).  Bad headache, stroke symptoms.  Might cause eye pain and/or visual loss.  Mostly occurs among patients with HIV.  Blood tests almost always positive.  Treatment is IV penicillin for 10 days (if allergic, given in ICU to start).

Late Neurosyphilis:ย  Occurs 25-30 years after infection.ย  Causes dementia (maybe with psychosis), loss of balance, deafness.ย  Before penicillin was invented (late 1940s), 1/3 of patients in mental hospitals were there for syphilis.ย  The common blood test (RPR or VDRL) is positive only 75% of time; should order “treponemal antibody” also, to be sure.ย  Diagnosis by spinal tap.ย  Treatment with IV penicillin (in ICU if allergic).

Congenital Syphilis:ย  Babies who don’t die in pregnancy begin with constant runny nose (sometimes bloody) during their first 1-2 weeks.ย  There’s nose destruction later on, liver damage, rashes, swollen lymph nodes, and eventually damage to many organs.ย  Treatment is IV penicillin.ย  Prevention is by testing pregnant women, and treating with IV penicillin (if allergic, given in ICU to start).

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