Syphilis is a sexually transmitted disease (STD) caused by an infection with spirochete bacteria known as Treponema pallidum. Like other STDs, syphilis can be spread by any type of sexual contact. Syphilis can also be spread from an infected mother to the fetus during pregnancy or to the baby at the time of birth. The signs and symptoms of syphilis vary depending in which of the four stages it presents (primary, secondary, latent, and tertiary)

1. 1
SYPHILIS
Urinary system Module
HUMAM OMER ABDUL-LATEEF
STAGEND2
UNIVERSITY OF BAGHDAD
COLLEGE OF MEDICINE

2. 2
Contents:
1.Introduction ……………..…………………...……... 3
2.Search board and Discussion
 Definition and transmission ……………..…...... 5
 History ……………………………………...…... 6
 Etiology …………………………………………. 9
 Signs and symptoms ………………………….. 10
 Diagnosis ……………………………………..... 11
 Treatment …………………………………...… 14
 Epidemiology and prognosis …………………. 16
 Prevention …………...………………………... 17
3.Summary ……………………………………...…… 18
4.References …………………………………….…… 19
5.Figures' references …………………………..……. 21

3. 3
Introduction
Syphilis is a sexually transmitted disease (STD) caused by an infection with spirochete
bacteria known as Treponema pallidum.
Like other STDs, syphilis can be spread by any type of sexual contact. Syphilis can also be
spread from an infected mother to the fetus during pregnancy or to the baby at the time of
birth.
The signs and symptoms of syphilis vary depending in which of the four stages it presents
(primary, secondary, latent, and tertiary). [38]
The primary stage classically presents with a single chancre (a firm, painless, non-itchy
skin ulceration) but there may be multiple sores. [1]
In secondary syphilis a diffuse rash occurs, which frequently involves the palms of the
hands and soles of the feet. [1,2]
There may also be sores in the mouth or vagina. [1]
In latent syphilis, which can last for
years, there are few or no symptoms. [1]
In tertiary syphilis there are gummas (soft non-cancerous growths Syphilis has been
described for centuries. It can cause long-term damage to different organs if not properly
treated).
Figure 1: Chancre on glans and vagina is one of the signs of Syphilis disease.

4. 4
Definition and Transmission Ways
A chronic infectious disease caused by Treponema pallidum, either transmitted by direct
contact, usually in sexual intercourse, or passed from mother to child in utero, and
progressing through three stages characterized respectively by local formation of chancres,
ulcerous skin eruptions, and systemic infection that leads to general paresis. [2]
Syphilis has both acute and chronic forms that produce a wide variety of symptoms
affecting most of the body's organ systems. The range of symptoms makes it easy to
confuse syphilis with less serious diseases and ignore its early signs. Acquired syphilis has
four stages (primary, secondary, latent, and tertiary) and can be spread by sexual contact
during the first three of these four stages.
Syphilis, which is also called lues (from a Latin word meaning plague), has been a major
public health problem since the sixteenth century. The disease was treated with mercury or
other ineffective remedies until World War I, when effective treatments based on arsenic
or bismuth were introduced. These were succeeded by antibiotics after World War II. At
that time, the number of cases in the general population decreased, partly because of
aggressive public health measures. This temporary decrease, combined with the greater
amount of attention given to AIDS in recent years, leads some people to think that syphilis
is no longer a serious problem. In actual fact, the number of cases of syphilis in the United
States has risen since 1980. This increase affects both sexes, all races, all parts of the
nation, and all age groups, including adults over 60. The number of women of
childbearing age with syphilis is the highest that has been recorded since the 1940s. About
25,000 cases of infectious syphilis in adults are reported annually in the United States. It is
estimated, however, that 400,000 people in the United States need treatment for syphilis
every year, and that the annual worldwide total is 50 million persons.
In 1999, the Centers for Disease Control and Prevention (CDC) joined several other
federal agencies in announcing the "National Plan to Eliminate Syphilis in the United
States." Eliminating the disease was defined as the absence of transmission of the disease;
that is, no transmission after 90 days following the report of an imported index case. The
national goals for eliminating syphilis include bringing the annual number of reported
cases in the United States below 1000, and increasing the number of syphilis-free counties
to 90% by 2005. In November 2002, the CDC released figures for 2000–2001, which
indicate that the number of reported cases of primary and secondary syphilis rose slightly.
This rise, however, occurred only among men who have sex with other men. The CDC
also stated that the number of new cases of syphilis has actually declined among women as
well as among non-Hispanic blacks. [3]
The increased incidence of syphilis since the 1970s is associated with drug abuse as well
as changes in sexual behavior. The connections between drug abuse and syphilis include
needle sharing and exchanging sex for drugs. In addition, people using drugs are more
likely to engage in risky sexual practices. As of 2002, the risk of contracting syphilis is
particularly high among those who abuse crack cocaine.
With respect to changing patterns of conduct, a sharp increase in the number of people
having sex with multiple partners makes it more difficult for public health doctors to trace
the contacts of infected persons. Women are not necessarily protected by having sex only

5. 5
with other women; in the past few years, several cases have been reported of female-to-
female transmission of syphilis through oral-genital contact. In addition, the incidence of
syphilis among men who have sex with other men continues to rise. Several studies in
Latin America as well as in the United States reported in late 2002 that unprotected sexual
intercourse is on the increase among gay and bisexual men.
Changing patterns of sexual behavior have led to a striking increase in the number of cases
of syphilis in eastern Europe since the collapse of the Soviet Union; Slovenia reported an
18-fold increase in reported cases of syphilis just between 1993 and 1994. Over half of the
new cases were linked to a source of infection in another European country. [4]
In general, high-risk groups for syphilis in the United States and Canada include:
 sexually active teenagers
 people infected with another sexually transmitted disease (STD), including AIDS
 sexually abused children
 women of childbearing age
 prostitutes of either sex and their customers
 prisoners
 persons who abuse drugs or alcohol
 The chances of contracting syphilis from an infected person in the early stages of
the disease during unprotected sex are between 30-50%.
Figure 2: The ways of syphilis's transmission

6. 6
History
The first known case of syphilis was documented by Dr. Pintor in 1493 in Rome. He
called it the Morbus Gallicus (The French Disease), and assumed that it had been carried
to Italy by the French Army. When the French began to notice it, they called it mal de
Naples (the sickness of Naples). Emperor Maximilian officially referred to it as malum
franciscum in 1495, but soon it was known by an altogether simpler name: The Pox.
It was called this because of the noticeable effects the disease had on the skin of the
afflicted, leaving lesions and decaying soft tissues that were sometimes mistaken for
leprosy. The name syphilis comes from a Greek legend about a peasant Apollo had
punished with poor health and lesions all over his body: the peasant’s name was Syphilus,
and he could only be cured (rather chillingly) by Mercury. [5]
It is generally believed that Columbus had brought the disease back with him from the
Americas. It existed in the Americas before Columbus arrived, and the timing certainly
was convenient. Some Renaissance thinkers suspected it had something to do with
astrology (see right and above left), while others thought it was derived from leprosy.
Francis Bacon believed that it was a result of cannibalism. [5]
The oldest artistic representation of syphilis is considered one on a Peruvian jug dating
back to VIth
century, depicting a mother suffering from syphilis holding a child in her
arms; the mother shows a saddle nose and superior incisive teeth with notches on their free
margins. The piece belongs to a collection of jugs also encompassing two jugs illustrating
leprosy and leishmaniasis. [6]
Albrecht Dürer, a German artist, depicts in woodcuts, for the first time in Europe, in 1496,
the image of a mercenary whose skin bears sores of multiple chancres (Fig. 3). Next to the
image lays written a text by physician Theodorus Ulsenius warning on the new disease,
also describing its signs and symptoms, mentioning that the illness is not curable and
establishing a direct link between the epidemic and the grand astrological conjuction in
1484 [6,7]
Figure 3: A mercenary whose skin presents multiple chancres, woodcut
by Albrecht Dürer, 1496 –published in a Romanian book in 1933

7. 7
From the very beginning numerous theories on the origin of syphilis existed, most of
which linking initially syphilis and leprosy together. According to several fables of the
early XVI th century, syphilis was the result of a sexual relation between a Spanish
prostitute and a leper. The prostitute also infected the soldiers of Charles VIII. Paracelsus
(1493-1541) considered that syphilis was the result of a sexual intercourse between a
prostitute suffering from gonorrhea and a French leper. In compliance to other theories of
the time, the disease might have been the outcome of the relationship of a prostitute having
a uterine abscess with a leper or the result of poisoning the wine with blood coming from a
leper [8]
.
Sexual transmitted diseases were seen as a single disease for many centuries. The
differentiation between gonorrhea, cancroids and syphilis as distinct maladies was
achieved no earlier than XIXth century. In the beginning of XVIIIth century there were
several doctors who treated syphilis and gonorrhea as separate entities. However, in 1767
John Hunter a famous physician of venereal diseases at that time (1728-1793) conducted
an experiment consisting of an inoculation of the urethral secretion of a gonorrhea patient
in the prepuce of a healthy patient, the last developing syphilis shortly afterwards.
Consequently, his experiment proved that syphilis resulted from gonorrhea. What Hunter
has missed out was that the patient from whom the urethral secretion was taken had both
syphilis and gonorrhea. However, his experiment, widely acknowledged in his époque,
delayed the differential diagnosis of the two diseases with a few decades [9,10]
.
In 1831 Ricord has designed a larger study on syphilis and gonorrhoea and succeeded to
show that the last occurs only after contact with gonorrohea patients, whilst the former –
only after contact with syphilis patients [9]
.
It was not earlier than 1905 that Schaudinn (1871-1906) and Hoffman (1868 – 1959) have
discovered the etiologic agent of syphilis, whom they have named Spirochaeta pallida, on
various syhilis lesions, proving its existence in both fresh and Giemsa coloured specimens.
It was them who changed the name of the bacterium subsequently to Treponema pallidum
[9,11,12]
.
In 1906 Landsteiner introduced the use of the dark-field microscopy method for the
detection of the spirochete of syphilis. In 1910 the German bacteriologist August
Wasserman (1866-1925) came with the first serologic test for syphilis and in 1949 Nelson
and Mayer have conceived Treponema pallidum immobilization test (TPI), the first
specific test for T. pallidum [11,13]
. Their discoveries had a very important role in detecting
the disease in patients who were suspected of syphilis, as well as in other healthy
individuals, and in monitoring syphilis response to treatment.
Syphilis treatments along the history
Initially, the treatment of syphilis included less efficient methods that were accompanied
by pain and multiple adverse reactions [11]
. Taking into consideration that the disease was
associated with the discovery of the American continent, numerous treatments included
plants brought from the New World, such as the guaiac tree (lat. Guaiacum Officinale),

8. 8
known also as sasafras or willow (Salix), which led to the widest recognition at the time
(Fig. 4). These plants acted as purgative agents, lead to sudoration, diarrhea and the
increase in urinary debt and were believed to be “blood cleansers” [9]
. One of the main
supporters of the guaiac tree utilisation in the treatment of syphilis, and in the same time
an ardupus opponent of mercury treatment, was Ulrich von Hutten (1488-1523), a former
priest who described in a detail the manifestations of the disease as well the simptoms of
mercury intoxication, based on his own experience as a sufferrer from the disease [14,15]
.
From the guaiac tree a decoction was made, the resulted potion was boiled and the patient
was assumed to consume the mixture daily for 30 days. Before drinking the potion, the
patient was covered in blankets in order to induce perspiration, and a mild purgative was
also administered [14]
.
German scientist Paul Ehrlich (1854-1915) received Nobel Prize in Physiology and
Medicine in 1908 for his discovery of arsphenamine (Salvarsan). The scientist discovered
the compound that acted like an antibiotic by accident, while working on finding a cure for
Trypanosoma brucei. Ehrlich’s desire was to discover a “magical bullet”- a drug able to
specifically bind to a bacterium and kill it, without affecting human cells. Salvarsan was
also denominated as “Compound 606”, as it was discovered after 606 failed experiments
(Fig. 5) [9]
. The safer novel drug that superseded the more toxic and less water-soluble
salvarsan as a treatment for syphilis was Neosalvarsan, also an arsenic compound. Both
Salvarsand and Neosalvarsan were replaced in the treatment of syphilis by Penicillin, after
1940.
Figure 4: Guaiacum officinale (guaiac tree), used widely for the
treatment of syphilis
Figure 5: The laboratory in which famous 606 compound was
invented

9. 9
Etiology
The cause of syphilis is infection with the spirochete T pallidum.T pallidum is solely a
human pathogen and does not naturally occur in other species. T pallidum has, however,
been cloned in Escherichia coli and has been used experimentally in rabbits.
Transmission of T pallidum occurs via penetration of the spirochetes through mucosal
membranes and abrasions on epithelial surfaces. It is primarily spread through sexual
contact but can be spread by exposure to blood products and transferred in utero. T
pallidum is a labile organism that cannot survive drying or exposure to disinfectants; thus,
fomite transmission (eg, from toilet seats) is virtually impossible.
Unprotected sex is the major risk factor for the acquisition of syphilis, especially among
men who have sex with men (MSM), who accounted for 83.7% of all syphilis cases in the
United States. [16]
There are two causes for syphilis disease which are:
Bacteriology
Treponema pallidum subspecies pallidum is a spiral-shaped, Gram-negative, highly
mobile bacterium. [17]
Three other human diseases are caused by related Treponema
pallidum subspecies, including yaws (subspecies pertenue), pinta (subspecies carateum)
and bejel (subspecies endemicum). Unlike subtype pallidum, they do not cause
neurological disease. Humans are the only known natural reservoir for subspecies
pallidum. It is unable to survive more than a few days without a host. This is due to its
small genome (1.14 Mbp) failing to encode the metabolic pathways necessary to make
most of its macronutrients. It has a slow doubling time of greater than 30 hours. [17]
Transmission
Syphilis is transmitted primarily by sexual contact or during pregnancy from a mother to
her fetus; the spirochete is able to pass through intact mucous membranes or compromised
skin. [18]
It is thus transmissible by kissing near a lesion, as well as oral, vaginal, and anal
sex. Approximately 30% to 60% of those exposed to primary or secondary syphilis will
get the disease. Its infectivity is exemplified by the fact that an individual inoculated with
only 57 organisms has a 50% chance of being infected. [17]
Most (60%) of new cases in the
United States occur in men who have sex with men. Syphilis can be transmitted by blood
products, but the risk is low due to blood testing in many countries. The risk of
transmission from sharing needles appears limited.
It is not generally possible to contract syphilis through toilet seats, daily activities, hot
tubs, or sharing eating utensils or clothing. This is mainly because the bacteria die very
quickly outside of the body, making transmission by objects extremely difficult. [19]

10. 10
Signs and symptoms
The first symptoms of syphilis can take 10 days to 3 weeks to appear after infection. The
most common symptom is a painless sore that appears where the virus was transmitted -
normally on the penis, vagina or anus. Your lymph glands (in the neck, groin or armpit)
may also swell. [38]
The sore will disappear in 2-6 weeks. However, if the infection itself is not treated, it will
move to the second stage.
You can't diagnose syphilis by looking at pictures because symptoms vary from person to
person. If you think you have syphilis, see your doctor or healthcare worker as soon as
possible. [20]
Symptoms of secondary syphilis begin a few weeks after the disappearance of the sore and
include:
 a non-itchy skin rash
 small skin growths on the vulva (in women) and around the anus (in both men and
women)
 flu-like symptoms such as tiredness, headaches, joint pains and fever
 swollen lymph glands
 weight loss
 hair loss.
These symptoms may disappear within a few weeks, or come and go over a period of
months.
Without treatment, syphilis becomes 'latent' whereby you do not experience any symptoms
even though you remain infected. This stage can happen for years, even decades and there
is a danger of moving onto the most dangerous stage - tertiary syphilis. [21]
A third of people who are not treated for syphilis develop serious symptoms at this stage
including: Fig (6): A maculopapular rash is pre- sent on the palm
 stroke
 dementia
 loss of co-ordination
 numbness
 paralysis
 blindness
 deafness
 heart disease
 skin rashes.
 At this stage, syphilis can also cause death.
This is why it is important to see a healthcare professional and get tested and treated in the
early stages of syphilis. [21]

11. 11
Diagnosis
Patient history and physical diagnosis
The diagnosis of syphilis is often delayed because of the variety of early symptoms, the
varying length of the incubation period, and the possibility of not noticing the initial
chancre. Patients do not always connect their symptoms with recent sexual contact. They
may go to a dermatologist when they develop the skin rash of secondary syphilis rather
than to their primary care doctor. Women may be diagnosed in the course of a
gynecological checkup. Because of the long-term risks of untreated syphilis, certain
groups of people are now routinely screened for the disease: [39]
 pregnant women
 sexual contacts or partners of patients diagnosed with syphilis
 children born to mothers with syphilis
 patients with HIV infection
 persons applying for marriage licenses
When the doctor takes the patient's history, he or she will ask about recent sexual contacts
in order to determine whether the patient falls into a high-risk group. Other symptoms,
such as skin rashes or swollen lymph nodes, will be noted with respect to the dates of the
patient's sexual contacts. Definite diagnosis, however, depends on the results of laboratory
blood tests. [22]
Blood tests
There are several types of blood tests for syphilis presently used in the United States.
Some are used in follow-up monitoring of patients as well as diagnosis.
NONTREPONEMAL ANTIGEN TESTS. Nontreponemal antigen tests are used as
screeners. They measure the presence of reagin, which is an antibody formed in reaction to
syphilis. In the venereal disease research laboratory (VDRL) test, a sample of the patient's
blood is mixed with cardiolipin and cholesterol. If the mixture forms clumps or masses of
matter, the test is considered reactive or positive. The serum sample can be diluted several
times to determine the concentration of reagin in the patient's blood.
The rapid plasma reagin (RPR) test works on the same principle as the VDRL. It is
available as a kit. The patient's serum is mixed with cardiolipin on a plastic-coated card
that can be examined with the naked eye.
Nontreponemal antigen tests require a doctor's interpretation and sometimes further
testing. They can yield both false-negative and false-positive results. False-positive results
can be caused by other infectious diseases, including mononucleosis, malaria, leprosy,
rheumatoid arthritis, and lupus. HIV patients have a particularly high rate (4%, compared
to 0.8% of HIV-negative patients) of false-positive results on reagin tests. False-negatives
can occur when patients are tested too soon after exposure to syphilis; it takes about 14-21
days after infection for the blood to become reactive.
TREPONEMAL ANTIBODY TESTS. Treponemal antibody tests are used to rule out
false-positive results on reagin tests. They measure the presence of antibodies that are
specific for T. pallidum. The most commonly used tests are the microhemagglutination-T.
pallidum (MHA-TP) and the fluorescent treponemal antibody absorption (FTA-ABS)

12. 12
tests. In the FTA-ABS, the patient's blood serum is mixed with a preparation that prevents
interference from antibodies to other treponemal infections. The test serum is added to a
slide containing T. pallidum. In a positive reaction, syphilitic antibodies in the blood coat
the spirochetes on the slide. The slide is then stained with fluorescein, which causes the
coated spirochetes to fluoresce when the slide is viewed under ultraviolet (UV) light. In
the MHA-TP test, red blood cells from sheep are coated with T. pallidum antigen. The
cells will clump if the patient's blood contains antibodies for syphilis.
Treponemal antibody tests are more expensive and more difficult to perform than
nontreponemal tests. They are therefore used to confirm the diagnosis of syphilis rather
than to screen large groups of people. These tests are, however, very specific and very
sensitive; false-positive results are relatively unusual.
INVESTIGATIONAL BLOOD TESTS. Currently, ELISA, Western blot, and PCR testing
are being studied as additional diagnostic tests, particularly for congenital syphilis and
neurosyphilis. [23]
Other laboratory tests
MICROSCOPE STUDIES. The diagnosis of syphilis can also be confirmed by identifying
spirochetes in samples of tissue or lymphatic fluid. Fresh samples can be made into slides
and studied under darkfield illumination. A newer method involves preparing slides from
dried fluid smears and staining them with fluorescein for viewing under UV light. This
method is replacing darkfield examination because the slides can be mailed to professional
laboratories.
SPINAL FLUID TESTS. Testing of cerebrospinal fluid (CSF) is an important part of
patient monitoring as well as a diagnostic test. The VDRL and FTA-ABS tests can be
performed on CSF as well as on blood. An abnormally high white cell count and elevated
protein levels in the CSF, together with positive VDRL results, suggest a possible
diagnosis of neurosyphilis. CSF testing is not used for routine screening. It is used most
frequently for infants with congenital syphilis, HIV-positive patients, and patients of any
age who are not responding to penicillin treatment. [24]
Figure 7

13. 13
Table 1: Presentations and features of the phases of syphilis [25]
Stage Features
Primary syphilis (10-
90 days afterinitial in
fection)
Skin: papule develops at site of initial infection; undergoes
ulceration to form apainless, firm chancre
Lymphatics: painless regional lymphadenopathy
Duration: lesion heals spontaneously in 2-3 weeks
Comment: cervical and rectal lesions may go unnoticed
Secondary syphilis (4
-
10 weeks afterappea
rance of primary lesi
on)
Constitutional illness: fever, sore throat, malaise and arthral
gia; inflammation of manyorgans, e.g. hepatitis, nephritis, a
rthritis
Skin: generalized papular, non-
itchy rash involving plantar and palmar skin, butexcluding t
he face; condylomata lata; oral and genital snail track ulcers
Lymphatics: generalized lymphadenopathy
Duration: signs subside in 3-
12 weeks, but 20% of cases show recurrent symptomsover 1
-2 years
Tertiary syphilis (3-
30 years aftersecond
ary stage has passed)
Widely varying signs and symptoms
Skin: granulomatous and ulcerating lesions (gumma) often
developing at sites oftrauma
Bone: gumma-
like lesions develop in any bone causing local pain and path
ologicalfracture
Viscera: gumma-
like lesions of the gastrointestinal tract, especially in the liv
er, withresultant dysfunction
Cardiovascular: aortitis and aortic aneurysm
Neurosyphilis: aseptic meningitis, tabes dorsalis, general pa
ralysis of the insane;Argyll Robertson pupils
Congenital syphilis Early signs show at age 2-6 weeks, and include:
Skin: chronic catarrhal inflammation of mucous membranes
Failure to thrive
Late signs show at 2+ years and include:
Skin eruptions
Corneal keratitis (corneal deposits)
Tooth deformity: peg (Hutchinson) incisors, multicusped (m
ulberry) molars
Collapse of nasal cartilage (saddle nose)
Bone deformity
Neurosyphilis

14. 14
Treatment
Approach Considerations
Key principles for the treatment of syphilis include the following: [26]
Penicillin is the drug of choice to treat syphilis.
Doxycycline is the best alternative for treating early and late latent syphilis. Syphilis
associated with HIV infection does not require any enhanced antimicrobial therapy.
In the treatment of late syphilis by weekly injections, missing a dose of penicillin for a
period of 10-14 days does not require restarting the entire course of injections.
The exception to this is in the case of pregnant women in whom there is no latitude for
missing a dose of penicillin.
There is evidence that an interval of 7-9 days between doses may produce better results.
CSF testing to detect neurosyphilis is strongly recommended in patients with tertiary
syphilis or with neurological signs or symptoms consistent with neurosyphilis and in
patients without symptoms whose serologic titers do not decline appropriately after being
treated with recommended therapy.
Reinfection rates among MSM are high, so frequent serological testing in this group is
recommended.
CDC recommends the use of the RPR-based screening algorithm. When there is a low
epidemiologic risk or clinical probability of syphilis, the positive predictive value of an
isolated unconfirmed reactive treponemal chemoluminescence test or enzyme
immunoassay is low.
Antibiotic Therapy
 Penicillin
Penicillin was established as an effective treatment for syphilis before the widespread use
of randomized clinical trials. [26] The treatment guidelines published by the CDC (see
current CDC recommendations) are based largely on uncontrolled trials and expert
opinion. Guidelines are based on staging, with later stages requiring longer courses of
treatment due to the slower rate of bacterial replication. [27]
Penicillin remains the mainstay of treatment and the standard by which other modes of
therapy are judged. [28] The 2015 CDC STD treatment guidelines support the use of
penicillin as the preferred drug for treating all stages of syphilis. [19] Penicillin is the only
recommended therapy for neurosyphilis, congenital syphilis, or syphilis during pregnancy.
Rarely, T pallidum has been found to persist following adequate penicillin therapy;
however, there is no indication that the organism has acquired resistance to penicillin.
The following regimens are recommended for penicillin treatment:
 Primary or secondary syphilis - Benzathine penicillin G 2.4 million units
intramuscularly (IM) in a single dose
 Early latent syphilis - Benzathine penicillin G 2.4 million units IM in a single dose
 Late latent syphilis or latent syphilis of unknown duration - Benzathine penicillin G 7.2
million units total, administered as 3 doses of 2.4 million units IM each at 1-week
intervals

15. 15
 Pregnancy - Treatment appropriate to the stage of syphilis is recommended.
Clinicians should be aware that only benzathine penicillin product (Bicillin L-A) should be
used, not benzathine-procaine penicillin (Bicillin C-R). In addition, oral penicillin is never
appropriate for the treatment of syphilis.
If the patient arrives late for subsequent doses, clinical experience suggests that an interval
of 10-14 days between doses of benzathine penicillin for latent syphilis might be
acceptable before restarting the sequence of injections; however, according to
pharmacokinetics/pharmacodynamics, an interval of 7-9 days between doses is more
optimal. [29, 30, 31]
In pregnancy, missed doses are not acceptable. Pregnant patients must
repeat the full course of therapy. [28]
In patients with a history of penicillin allergy, desensitization may be necessary in cases of
pregnancy, neurosyphilis, congenital syphilis, or tertiary syphilis.
According to the 2015 CDC STD guidelines, no treatment regimens for syphilis have been
shown to be more effective in preventing neurosyphilis in patients who are HIV positive
than the syphilis regimens recommended for patients who are HIV negative. Careful
monitoring after therapy is required, as patients with HIV infection are at higher risk for
reinfection and have a slower serologic response than patients without HIV infection. [32]
Alternatives to penicillin
As stated in the 2015 CDC guidelines, several therapies exist that might be effective in
nonpregnant, penicillin-allergic patients with primary or secondary syphilis. [32]
Surgical Care
Surgical care is reserved for treating the complications of tertiary syphilis (eg, aortic valve
replacement).
Table 2

16. 16
Epidemiology and Prognosis
In 2012, about 0.5% of adults were infected with syphilis, with 6 million new cases. In
1999 it is believed to have infected 12 million additional people, with greater than 90% of
cases in the developing world. It affects between 700,000 and 1.6 million pregnancies a
year, resulting in spontaneous abortions, stillbirths, and congenital syphilis. During 2010,
it caused about 113,000 deaths, down from 202,000 in 1990. In sub-Saharan Africa,
syphilis contributes to approximately 20% of perinatal deaths. Rates are proportionally
higher among intravenous drug users, those who are infected with HIV, and men who have
sex with men. In the United States, rates of syphilis as of 2007 were six times greater in
men than women; they were nearly equal in 1997. African Americans accounted for
almost half of all cases in 2010. As of 2014, syphilis infections continue to increase in the
United States. [33]
Syphilis was very common in Europe during the 18th and 19th centuries. Flaubert found it
universal among nineteenth-century Egyptian prostitutes. In the developed world during
the early 20th century, infections declined rapidly with the widespread use of antibiotics,
until the 1980s and 1990s. Since 2000, rates of syphilis have been increasing in the USA,
Canada, the UK, Australia and Europe, primarily among men who have sex with men.
Rates of syphilis among American women have remained stable during this time, while
rates among UK women have increased, but at a rate less than that of men. Increased rates
among heterosexuals have occurred in China and Russia since the 1990s. This has been
attributed to unsafe sexual practices, such as sexual promiscuity, prostitution, and
decreasing use of barrier protection. [33]
Untreated, it has a mortality rate of 8% to 58%, with a greater death rate in males. The
symptoms of syphilis have become less severe over the 19th and 20th centuries, in part
due to widespread availability of effective treatment, and partly due to virulence of the
spirochaete. With early treatment, few complications result. Syphilis increases the risk of
HIV transmission by two to five times, and coinfection is common (30–60% in some
urban centers). In 2015, Cuba became the first country in the world to eradicate mother to
child transmission of syphilis.
Figure 8

17. 17
Prevention
Syphilis is an infectious disease but it is preventable to a large extent. The best and the
most certain method of prevention of this infection is to avoid sexual contact or only to
maintain sexual contact with one faithful partner who has been tested and is not infected.
Some of the tips to prevent transmission of syphilis include the safe sex measures. [34]
Safer sex
Safer sex measures include:
Having sex with a single faithful, tested and non-infected partner. Sexual penetration or
ejaculation does not need to take place for syphilis to spread. Condoms can be used to
reduce the risk of catching syphilis, but cannot prevent it altogether. Some risk remains via
exposure to the mouth (those having oral sex) or via anus (those having anal intercourse).
It is important to use a condom during vaginal, oral and anal sex. Other forms of barriers
like use of a dental dam (square of plastic) when having oral sex or when the mouth of an
uninfected individual makes contact with partner's vagina or anus. This also prevents
transmission of sexually transmitted infection (STI). Sex toys that have been used by
another individual (possibly infected) should not be shared. For people who wish to use
them can wash them after each use and use a fresh condom over them. [35]
Syphilis and injection drug users
Syphilis can also spread by sharing injection drug users. Injection drug users should avoid
sharing needles. They can opt for needle-exchange programmes that are offered by many
pharmacies and local authorities. In these used needles can be exchanged for new
disposable clean ones. [36]
Treatment of sexual partner
Transmission needs to be prevented by routine testing and, if positive, treatment of sexual
partners of infected individuals.
The infected individuals are counselled regarding prevention of spread to their sexual
partners. Individuals sexually exposed to a person with primary, secondary, or early latent
syphilis within 90 days preceding the diagnosis should be assumed to be infected.
All sexual partners of the infected person in the recent past need to be identified, notified
and rapidly referred for medical
evaluation and treatment. Long-
term sex partners of patients
with late syphilis should be
evaluated clinically and
serologically and treated
appropriately. All patients with
syphilis should be tested for
HIV. Patient and partner
education is important. [37]
Figure 9

18. 18
Summary
Treponema pallidum infection in men not only provoked a disease that represented a threat
to humans for many centuries, but it also had a tumultuous history. From examining it, one
could learn how easy was to place stigma not only on individuals affected by the disease,
but on entire nations, as countries were blamed along the history for the spread of the
disease. Throughout the centuries, syphilis has affected individuals of various origins,
from monarchs, painters and philosophers to low income people, mainly due to
promiscuity. Various treatments to cure the disease were tried along the centuries;
nowadays, penicillin and prevention programs control the disease.
Syphilis is difficult to diagnose clinically early in its presentation. Confirmation is either
via blood tests or direct visual inspection using microscopy. Blood tests are more
commonly used, as they are easier to perform. Diagnostic tests are unable to distinguish
between the stages of the disease.
Congenital syphilis is that which is transmitted during pregnancy or during birth. Two-
thirds of syphilitic infants are born without symptoms. Common symptoms that develop
over the first couple of years of life include enlargement of the liver and spleen (70%),
rash (70%), fever (40%), neurosyphilis (20%), and lung inflammation (20%). If untreated,
late congenital syphilis may occur in 40%, including saddle nose deformation,
Higoumenakis sign, saber shin, or Clutton's joints among others. Infection during
pregnancy is also associated with miscarriage.
The signs and symptoms of syphilis vary depending in which of the four stages it presents
(primary, secondary, latent, and tertiary). The primary stage classically presents with a
single chancre (a firm, painless, non-itchy skin ulceration) but there may be multiple sores.
In secondary syphilis a diffuse rash occurs, which frequently involves the palms of the
hands and soles of the feet. There may also be sores in the mouth or vagina. In latent
syphilis, which can last for years, there are few or no symptoms. In tertiary syphilis there
are gummas (soft non-cancerous growths), neurological, or heart symptoms. Syphilis has
been known as "the great imitator" as it may cause symptoms similar to many other
diseases.
Syphilis can be cured with the right antibiotics. However, treatment will not undo any
damage that the infection has already caused.

19. 19
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