Syphilis

 What you need to know
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 Incidence rates of syphilis have increased substantially around theworld, mostly affecting men who have sex with men and people infectedwith HIV•

Have a high index of suspicion for syphilis in any sexually active patientwith genital lesions or rashes•

Primary syphilis classically presents as a single, painless, induratedgenital ulcer (chancre), but this presentation is only 31% sensitive;lesions can be painful, multiple, and extra-genital•

Diagnosis is usually based on serology, using a combination oftreponemal and non-treponemal tests. Syphilis remains sensitive tobenzathine penicillin G•

Staging syphilis is important because it is the basis of management(treatment, expected treatment response, follow-up periods, and partnerfollow-up)•

Patients with syphilis should be screened for HIV, gonorrhoea, andchlamydia


Syphilis is a contagious STD caused by bacteria that can cause serious complications. Syphilis is spread by having direct contact with a syphilis sore (also called a chancre) during vaginal, anal, or oral sex. The sores can occur on or around the penis, vagina, and anus. They can also appear on the lips, in the mouth, or in the rectum. In the early stages, the sores are usually painless, so people with syphilis may not notice them or know they have syphilis.

Pregnant women with syphilis can pass the infection to their unborn baby during pregnancy or childbirth.

What symptoms should alert me to thisdiagnosis? 

the diagnosisshould be considered in any sexually active patient with genitallesions or with rashes Primary syphilis—Patients with primary syphilis  havea chancre at the site of inoculation—classically a solitary,painless, indurated, non-exudative ulcer .17 19 While oftenon the glans, corona, labia, fourchette, or perineum, it may occurin the mouth (fig 3), rectum, or vagina.17 Chancres can beinconspicuous  and resolve in 3-10 weeks, possiblyexplaining why 60% of patients do not recall this lesion.Chancres may be multiple, painful, or atypical due to coinfectionwith other bacteria or herpesvirus.20 Depending on inoculumsize, chancres appear 10-90 days after exposure (mean 21days).17 Localised painless adenopathy may occur.17Secondary syphilis—Secondary syphilis is a manifestation ofbacterial dissemination and classically presents as a diffuse,symmetric, copper, maculopapular, possibly pruritic rash of anymorphology except vesicular17 20 21 A rash on the palmsor soles is common (11-70%, fig 6). Mucus lesions (fig 7),patchy alopecia, fever, headaches, and generalised painlessadenopathy may also occur.17-21 Early neurosyphilis developsin 25-60% of people 17-22 Secondary symptoms appear2-24 weeks after infection, concurrently with or up to eightweeks after chancres, and disappear spontaneously after severalweeks with or without marking.17 19Latent syphilis—Syphilis then becomes latent, althoughsymptoms of secondary syphilis recur in 25% of people, mostly(90%) within one year of acquiring the infection.17 Latentsyphilis has early and late stages.17 Early latent disease includesthe period of potential symptom relapse, classified by the WHO14and European15 guidelines as <2 years since inoculation and as<1 year by US,11 UK,12 and Canadian13 guidelines. As symptomrelapse indicates bacterial replication, early latent disease canbe infectious. Late latent syphilis occurs >1-2 years afteracquisition and is non-infectious (.Tertiary syphilis—Without treatment, 14-40% of people withsyphilis progress to tertiary disease—irreversible damage toany organ—within 1-46 years. The damage is primarilyneurologic, cardiovascular, or gummatous (necroticgranulomatous lesions pathognomonic of tertiary syphilis

The RPR test may remain non-reactive for up to four weeksafter the chancre, so it is often negative in primary syphilis, butit is 98-100% sensitive in secondary syphilis. However, becausethe RPR is a test of non-specific tissue damage, it may bepositive for reasons other than syphilis.15In the absence of treatment, a negative non-treponemal test threemonths after potential exposure effectively rules out a newsyphilis infection.Note that treponemal tests cannot distinguish active from treatedinfections and generally remain positive for life

 in pregnant women

Pregnant women should get tested for syphilis at their first prenatal visit. Women who are at high risk for getting syphilis, live in an areas where the syphilis rate is high, have not been tested for syphilis, or who tested positive for syphilis during the first trimester should be screened during the third trimester (28 to 32 weeks) and again at the time of delivery.

Without treatment, syphilis can cause complications for the unborn baby during and after pregnancy. These include:

    Miscarriage, giving birth to a stillborn baby, or having a baby who dies soon after being born.
    Passing the infection to the baby, which can lead to permanent delays in development, seizures, and sometimes death if the baby is not treated immediately. Babies may develop other health problems such as fever, skin sores, and swelling in the liver and spleen.

Talk with your healthcare provider about what is best for you and your unborn baby.

Staging of syphili 

Staging of syphilis cannot be done based on laboratory resultsalone, and requires history and examination. Primary andsecondary syphilis are symptomatic; early and late latent syphilisare generally asymptomatic. Careful examination to identifyany symptoms not noticed by the patient is important and shouldinclude thorough anogenital and dermatologic inspection.21The staging criteria for early latent syphilis are given in box 2.Asymptomatic patients with positive serology who do not fulfilthe criteria of early latent syphilis could be staged as latentsyphilis or as having syphilis of unknown duration. 

Box 2: Staging criteria for early latent syphilis 

atients with early latent syphilis are asymptomatic, with one of the following:•New positive serology with a documented negative test within previous12* or 24† months•

≥4-fold increase in the RPR titre relative to a previous test done within12* or 24† months•

Unequivocal symptoms of primary or secondary syphilis within theprevious 12* or 24† months•

Only one possible exposure, which occurred within previous 12* or 24†months*According to US,11 UK,12 and Canadian13 guidelines†According to World Health Organization14 and European15 guidelines 

What should I do with inconclusiveresults?

Generally, inconclusive results arise in early infection or fromwaning antibody levels in late infection. The most commoncombinations are:•

A positive RPR with negative treponemal screening(EIA/CLIA) and confirmatory tests (TPPA) suggests theRPR result is a false positive•

A positive screen (EIA/CLIA) with negative confirmatorytest (TPPA) and negative RPR is likely a false positive butcould indicate early infection•

A positive screen (EIA/CLIA) with indeterminantconfirmatory test (TPPA) and negative RPR could representwaning antibody levels after a previous, treated infectionor a new infection.When results are inconclusive, clinicians should inquire aboutprevious syphilis infection and treatment, and, if early syphilisis possible, retest in two to four weeks.13 If results areunchanged, interpretation is based on history—consider thepossibility of late untreated infection, treated infection, ornon-venereal treponemal disease in adults from endemiccountries in South and Central America, South-East Asia, andAfrica. 

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