Introduction

This is caused by the spirochaete bacterium – treponema pallidum.
Transmission is either by sexual contact, or congenital via spread from the mother in utero.
It can cause many complications, and death.
All genital ulcers are syphilis until proven otherwise!

Epidemiology

The number of cases in the UK is on the increase. In recent years there have been particular outbreaks in certain cities in the UK.
Over the last 5 years, rates have increased by:

  • 200% in heterosexual men
  • 1500% in gay men
  • 25% in women

Infection

The bacterium enters through any abrasion or graze in squamous or columnar epithelium.
Infection of non-genital sites is rare, but possible.

Presentation

Primary syphilis – Usually, a painless, solitary ulcer

  • All genital ulcers are syphilis until proven otherwise!

Secondary syphilis – a rash which typically affects the trunk, face, palms and soles
Tertiary / Late syphilis – the solitary ‘gumma nodule’

  • This is a non-cancerous granuloma, whch can occur in any tissue of the body, typically, skin, bones, testes, mucosa.

Stages of syphilis

Primary syphilis

An ulcer at the site of the original infection. This is usually the genitals (typically, penis, vagina, or rectum), but can be any point of contact.

  • The incubation period is 9-90 days
  • Often beings as a painless hard macule, and develops into an ulcer
  • The ulcer will heal into a painless hard lump known as a chancre
  • Typically persists for 4-6 weeks before healing
  • Usually also involves a local painless lymphadenopathy
  • Often otherwise asymptomatic.
  • EXTREMELY INFECTIOUS!

Secondary syphilis

Occurs 4-8 weeks after the chancre has healed (can be up to 6 months later). Consists of a rash of the trunk, palms, soles and sometimes face. The rash and any papules present are highly infectious. There may also be:

  • Malaise / fever
  • Sore throat
  • Arthralgia
  • Lymphadenopathy
  • Alopecia
  • Condylomata lata
    • These are number moist papules found around the genital region
  • Ulcers of the palate and buccal region
  • Snail track ulcers – found in the mouth and genitalia.
  • Rare:
    • Meningism
    • Nephrosis
    • Uveitis
  • Secondary syphilis is the most infectious phase!

Latent syphilis

A state of being infected with treponema pallidum but without clinical signs or symptoms. It occurs after the signs of primary and secondary syphilis have subsided (or were not noticed). Patients are not infective during this period.

  • Early latent syphilis – two years since the initial infection
  • Late latent syphilis – >2 years since the initial infection

The differentiation between early and late syphilis is important, as it has implications for treatment. Those with early latent syphilis can be treated with a single IM dose of penicillin, those with late latent syphilis require more doses of therapy.
o   In real-life situations, knowing when the initial infection occurred can be difficult, and thus in these cases it should be assumed that the disease Is late latent syphilis.

Tertiary syphilis

Usually occurs after a latency period of >2 years. Typically it occurs several years after the primary infection, but it can be 10+ years later.
There is the appearance of gummas

  • Soft granulomas. Affect any tissue.
  • The result of the inability of the immune system to clear the infection
  • The gummas induce a state of chronic inflammation

 

Quaternary syphilis

Late stage syphilis. Can result in many complications:

  • Cardiovascular:
  • Neurosyphilis:
    • Meningovascular
  • Cranial nerve palsies
  • Stroke
    • General Paresis of insane (GPI)
  • Dementia
  • Psychoses – can be fatal if untreated, can be reversed with treatment
    • Tabes dorsalis
  • Degeneration of sensory neurons
  • Sensory ataxia
  • Sensory loss – legs, nose, chest
  • Lightning pains
  • Gastric crisis
  • Loss of reflexes
  • Argyll – Robertson Pupils – bilateral, pupils constrict excessively when accommodating (focussing on near object), but DO NOT constrict in response to bright light.
    • Aka Prostitiues pupils – like prostitutes, they accommodate, but they don’t react!

 

Investigations

Cardiolipin antibody

  • Not very specific
  • Easiest to detect in primary syphilis, levels decrease as disease progresses
  • Test will be negative after treatment

 

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