Summary
Overview
Syphilis is a systemic, sexually transmitted infection caused by the spirochete Treponema pallidum. It can be either acquired (via sexual contact or blood exposure) or congenital (transplacental or perinatal transmission). Untreated infection progresses through distinct stages with systemic, neurologic, and cardiovascular complications. Despite effective treatment with penicillin, syphilis incidence is rising, particularly among high-risk groups such as men who have sex with men (MSM) and patients with HIV.
Epidemiology
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Increasing global incidence; >5,000 UK cases reported in 2015.
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High-risk groups: MSM, HIV-positive patients, those with multiple sexual partners.
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Congenital syphilis: ∼23 cases per 100,000 live births in the U.S.
Etiology and Pathophysiology
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Pathogen: Treponema pallidum (motile spirochete).
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Transmission: Sexual contact, transplacental, perinatal, and rarely blood transfusion.
- Pathogenesis: Entry via mucous membranes → local chancre formation (primary stage). Persistent infection may cause obliterative endarteritis leading to ischemic tissue damage and multi-organ involvement in late disease.
Classification
Acquired Syphilis
|
Stage |
Clinical Features |
Key Points |
|---|---|---|
|
Primary (3–6 wks post-infection) |
Painless hard chancre at genital, anal, or oral sites; regional painless lymphadenopathy |
Heals spontaneously within 4–6 weeks |
|
Secondary (6–12 wks) |
Maculopapular rash (palms/soles), condylomata lata, mucous patches, systemic symptoms, widespread lymphadenopathy |
Represents disseminated disease |
|
Latent |
No symptoms, positive serology |
Early (<2 yrs) vs. Late (>2 yrs) |
|
Tertiary (years later in ~40% untreated) |
Gummas, cardiovascular syphilis (aortitis, aneurysm), neurosyphilis (tabes dorsalis, paresis, Argyll Robertson pupil) |
Non-infectious, destructive lesions |
Congenital Syphilis
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Universal antenatal screening recommended.
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Untreated maternal syphilis → miscarriage, stillbirth, preterm birth, or congenital infection.
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Penicillin I.M is safe and highly effective in preventing congenital transmission.
|
Timing |
Clinical Features |
|
In utero |
Miscarriage, stillbirth, hydrops fetalis |
|
Early (<2 yrs) |
Snuffles (bloody nasal discharge), hepatosplenomegaly, jaundice, maculopapular or bullous rash, periostitis, lymphadenopathy |
|
Late (>2 yrs) |
Hutchinson triad (interstitial keratitis, sensorineural deafness, Hutchinson teeth), mulberry molars, saddle nose, rhagades, saber shins, frontal bossing |
Clinical Features
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Primary: Single painless chancre, painless lymphadenopathy.
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Secondary: Rash (palms/soles), condylomata lata, systemic symptoms.
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Latent: Asymptomatic, positive serology only.
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Tertiary: Gummas, neurosyphilis (ataxia, Charcot joints, Argyll Robertson pupil), cardiovascular lesions.
- Congenital: Facial dysmorphism, skeletal deformities, hearing loss, interstitial keratitis.
Diagnosis
|
Test |
Purpose |
Notes |
|
Non-treponemal tests (VDRL, RPR) |
Screening, monitoring treatment |
False positives in pregnancy, viral infections, lupus, leprosy |
|
Treponemal tests (FTA-ABS, TPPA, MHA-TP) |
Confirmatory, remain positive for life |
|
|
Dark-field microscopy |
Direct visualization of spirochetes in chancre |
Diagnostic in primary stage |
|
CSF analysis |
Suspected neurosyphilis |
VDRL-CSF, cell count, protein |
Management
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First-line: Penicillin G (benzathine or IV depending on stage).
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Early syphilis: Benzathine penicillin 2.4 MU IM × 1.
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Late syphilis: Benzathine penicillin 2.4 MU IM weekly × 3.
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Neurosyphilis: IV benzylpenicillin for 14 days.
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Congenital syphilis (neonates): IV penicillin G × 10 days.
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Penicillin allergy: Doxycycline (except in pregnancy). Pregnant women require penicillin desensitization.
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Follow-up: Repeat RPR/VDRL at 6–12 months; a 4-fold decline indicates adequate response.
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Jarisch-Herxheimer reaction: Acute flu-like reaction within 24 hrs of therapy; self-limiting but may need steroids in neurosyphilis or cardiovascular disease.
Key Clinical Notes
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Coinfections are common: screen for HIV, gonorrhea, chlamydia, hepatitis B.
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All recent sexual partners should be traced and tested.
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Education on safe sex practices is essential for prevention.
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