# Syphilis

Syphilis is a sexually transmitted infection (STI) caused by the spirochete bacterium Treponema pallidum. This disease can be passed to another person through kissing or close physical contact. The infected person is often unaware of the disease and unknowingly passes it on to his or her sexual partner.

## Stages of Disease

The symptoms of syphilis develop in three stages, which are 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 develop. These symptoms may disappear within a few weeks, after which a person may 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 2 (Secondary syphilis): Secondary symptoms, such as a skin rash and sore throat develop. These symptoms may disappear within a few weeks, after which a person may experience a latent (hidden) phase with no symptoms, which can last for years. After this, syphilis can progress to its third, most dangerous stage.

The symptoms of syphilis are the same for men and women. Also, symptoms are mild and thus can be difficult to recognize. The symptoms develop in three stages:

## Syphilis stages

1. Primary syphilis
2. Secondary syphilis
3. Tertiary syphilis

### Primary Syphilis

The initial symptoms of syphilis can appear any time from 10 days to three months after one has been exposed to the infection.

The most common symptom is the appearance of a small, painless sore or ulcer (called a chancre). The sore will appear on the part of the body where the infection was transmitted, typically the penis, vagina, anus, rectum, tongue, or lips. Most people only have one sore, but some people can have more.

The sores are painless and may be overlooked, so the condition can be spread without realizing that have an infection.

The sore will then disappear within two to six weeks and, if the condition is not treated, syphilis will move into its second stage.

### Secondary Syphilis

The symptoms of secondary syphilis will begin a few weeks after the disappearance of the sore. Common symptoms include:

• A non-itchy skin rash appearing anywhere on the body, but commonly on the palms of the hands or soles of the feet,
• Tiredness,
• Swollen lymph glands,

Less common symptoms include:

• Fever,
• Weight loss,
• Patchy hair loss,
• Joint pains.

These symptoms may disappear within a few weeks, or come and go over a period of months.

#### Latent Phase:

Syphilis will then move into its latent (hidden) phase, where one will experience no symptoms, even though the person remains infected. Latent syphilis can still be passed on during the first year of this stage of the condition, usually through sexual or close physical contact. However, after a couple of years, one cannot pass the infection to others, even though he/she remain infected.

The latent stage can continue for many years (even decades) after a person has first become infected.

Without treatment, there is a risk that latent syphilis will move on to the most dangerous stage – tertiary syphilis.

### Tertiary Syphilis

The symptoms of tertiary syphilis can begin years or even decades after initial infection. Around one-third of people who are not treated for syphilis develop serious symptoms at this stage.

## Pathophysiology

The understanding of T. pallidum pathophysiology is impeded by the inability to grow the organism in culture. Thus, knowledge of the growth characteristics and metabolism of this bacterium is quite limited.

Early local infection: Treponema pallidum initiates infection when it gains access to subcutaneous tissues via microscopic abrasions that occur during sexual intercourse. Despite a slow estimated dividing time of 30 hours, the spirochete evades early host immune responses and establishes the initial ulcerative lesion, the chancre (picture 1). During the period of early local replication, some organisms establish infection in regional draining lymph nodes, with subsequent dissemination.

Immune response: Treponema pallidum elicits innate and adaptive cellular immune responses in skin and blood. The host immune response begins with lesional infiltration of polymorphonuclear leukocytes, which are soon replaced by T lymphocytes. In some respects, the immune response to T. pallidum is paradoxical. On one hand, the various immune responses during early infection appear to be efficacious, since they coincide with the resolution of the primary chancre, even in the absence of therapy. Despite this apparent immune control, however, widespread dissemination of spirochetes occurs at the same time, leading to subsequent clinical manifestations of secondary or tertiary syphilis in untreated patients.

After the acquisition of T. pallidum, humoral immune responses are generated, leading to the development of a variety of antibodies that can be detected relatively early in the course of syphilis.

### Causes

• Syphilis is caused by the bacteria Treponema pallidum.
• The bacteria can enter one’s body if he/she has close contact with an infected sore, normally during vaginal, anal, or oral sex or by sharing sex toys.

### Diagnosis

Physical examination: Syphilis is diagnosed by examining the genitals. For men, it involves examining the penis, foreskin, and urethra (the hole at the end of the penis where urine comes out). For women, it involves an internal examination of the vagina. Both men and women may also have their anus examined.

Blood tests: If one is infected with syphilis, then his/ her body produces antibodies (proteins released as part of the immune response) against the syphilis bacteria. Therefore, one way to determine whether one has syphilis is to have a sample of blood tested for the presence of these antibodies. A positive result (antibodies present) indicates that one can either have the infection or used to have it (because the antibodies can remain in the body for years, even after a previous infection was successfully treated).

A negative result does not necessarily mean that one does not have syphilis as the antibodies may not be detectable for three months after infection. The person may be advised to repeat the test in three months’ time.

Every pregnant woman should have a blood test for syphilis as the infection can kill unborn or newborn babies. The blood test is usually done during an antenatal appointment at weeks 11–20 of pregnancy. If the test is positive, treatment for both the mother and baby can begin.

Venereal Disease Research Laboratory test (VDRL): The VDRL test is a screening test for syphilis. It measures substances, called antibodies that the body may produce if a person comes in contact with the bacteria that causes syphilis. This bacteria is called Treponema pallidum.

Swab test: If sores are present, a swab (like a cotton bud) will be used to take a small sample of fluid from the sore. This is then either looked at under a microscope in the clinic or sent to a laboratory for examination.

### Treatment

Effective antibiotic treatment is available. Treatment needs to be supervised carefully and long-term follow-up is required, particularly for patients with late-stage syphilis infection. Treatment of the mother during pregnancy may be sufficient to prevent fetal infection. Sometimes babies require an additional course of antibiotics after birth.

Primary Option: Penicillin G Benzathine 2.4 million units intramuscularly as a single dose.

Secondary Option: Doxycycline 100 mg orally twice daily and Prednisone 40-60 mg orally once daily for 3 days; start 24 hours before penicillin.

## Prevention

• Protected physical contact through the use of condoms reduces the risk of infection.
• Promoting sex education among teenagers.
• Providing awareness among the population about their sexual health, especially in high risks population (high risks population involves sex workers and their partners, Intravenous drug users, truck drivers, labor migrants, refugees, and prisoners).
• People with syphilis should refrain from any sexual contact for at least 1 week after completing treatment or until the lesions of early syphilis (if they were present) are fully healed.
• People with syphilis should also refrain from any sexual contact until sexual partners have been contacted, tested, and if indicated treated.
• Follow-up blood tests must be done to make sure that treatment has cleared the infection.
• Pregnant women are screened for syphilis in early pregnancy and again in late pregnancy if they are at increased risk of acquiring syphilis.

Testing to exclude other sexually transmitted infections is advisable.

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