II. Epidemiology

  1. Resurgence of Syphilis since HIV epidemic onset in 1980s
  2. Syphilis Incidence in U.S. (primary and secondary) is increasing
    1. 2000: 2.1 cases per 100,000 persons (5979 new cases in U.S.)
    2. 2005: 2.9 cases per 100,000 persons (8724 new cases in U.S.)
    3. 2010: 4.5 cases per 100,000 persons (13,774 new cases in U.S.)
    4. 2014: 6.3 cases per 100,000 persons (19,999 new cases in U.S.)
      1. Men account for 91% of cases, of whom 83% are Gay Men)

III. Etiology

  1. Caused by Spirochete Treponema pallidum
  2. In addition to Syphilis, Treponema pallidum also causes yaws and pinta

IV. Pathophysiology

  1. Transmission via mucous membranes, non-intact skin, transfusions, and vertical transmission (transplacental)

V. Risk factors: Cohorts with highest Prevalence in U.S.

  1. Homosexual men
  2. Males
  3. Southern and urban centers
  4. African americans

VI. Stages

  1. Primary Syphilis
    1. Solitary Chancre (hallmark of Primary Syphilis) - genital lesion in 95% of cases
    2. Nonsuppurative Regional Lymphadenopathy (uncommon)
  2. Secondary Syphilis
    1. Nickel and dime-size pale, pink to red discrete round, ScalingMacular to papular lesions over trunk, flexors, palms, soles
    2. Condyloma Lata (painless, wart-like lesions) on mouth, genitalia and intertriginous areas (perineum, axilla, between toes)
    3. Syphilitic Alopecia (Alopecia with moth-eaten appearance)
  3. Latent Syphilis
    1. Latent, asymptomatic period of 3-20 years
    2. Infectious only in pregnancy and Blood Transfusion
    3. One third will progress to Tertiary Syphilis
  4. Tertiary Syphilis
    1. Syphilitic Gumma (granulomas and Psoriasis-like Plaques)
    2. Cardiovascular Syphilis (thoracic aneurysm)
    3. Neurosyphilis (Tabes Dorsalis, Meningitis, Dementia)

VII. Signs

  1. See Neurosyphilis
  2. Chancre (ulcer in Primary Syphilis)
    1. Single, painless, well-demarcated ulcer
    2. Clean base
    3. Indurated border
  3. Gumma (lesion in Tertiary Syphilis)
    1. Diffusely distributed soft ulcerative lesions, with firm necotic center
  4. Lymph
    1. Mildly tender inguinal lyphadenopathy (Secondary Syphilis)

VIII. Differential Diagnosis: Syphilis Chancre or condyloma

IX. Diagnosis

X. Precautions

  1. Syphilis requires a high index of suspicion
    1. Widely variable presentations
    2. Resurgence in the last 10 years
    3. Insidious and delayed onset with painless primary lesions that may easily be missed

XI. Management

  1. Incubation stage (Post-exposure Prophylaxis)
    1. Ceftriaxone 250 mg IM and
    2. Doxycycline 100 mg for 14 days
    3. Azithromycin (Zithromax) 1 gram orally for 1 dose
  2. Primary, secondary, early latent (under one year)
    1. Benzathine Penicillin G
      1. Adult: 2.4 MU IM for 1 dose
      2. Child: 50,000 units/kg IM for 1 dose (max: 2.4 MU)
    2. Aqueous Procaine Penicillin G 0.6 MU IM qd for 8 days
    3. Jarisch-Herxheimer Reaction may occur
      1. Acute febrile reaction (due to Spirochete lysis) in first 24 hours of Syphilis treatment
      2. Manifests as fever, Headache, rash exacerbation
    4. If Penicillin allergic
      1. Ceftriaxone 1 gram IM or IV for 10-14 days
      2. Tetracycline 500 mg orally four times daily for 14 days
      3. Doxycycline 100 mg orally twice daily for 14 days
      4. Avoid Azithromycin
        1. Previously dosed at Azithromycin 2 grams orally once
        2. High risk of resistance (esp. pregnancy, Men who have Sex with Men)
        3. Was used only in Penicillin allergic patients who can not take doxycyline, Minocycline or Ceftriaxone
  3. Late latent, Cardiovascular Syphilis (duration over 1 year)
    1. Benzathine Penicillin G 2.4 MU IM qWeek for 3 weeks
    2. If Penicillin allergic
      1. Tetracycline 500 mg PO qid for 4 weeks
      2. Doxycycline 100 mg PO bid for 4 weeks
  4. Neurosyphilis
    1. See Neurosyphilis
  5. Pregnancy
    1. Treat with Penicillin as above
    2. If Penicillin allergic, admit, desensitize and treat with Penicillin
  6. Congenital Syphilis
    1. CDC STD management booklet
      1. http://www.cdc.gov/mmwr/pdf/rr/rr5912.pdf
  7. Sexual partners
    1. Treat all sexual contacts from prior 90 days

XII. Follow-up: 6 months after treatment (Stage 1-2)

  1. Repeat quantitative nontreponemal test titers at 6 and 12 months after treatment (all patients)
    1. Expect a four-fold decrease in RPR or VDRL titers over subsequent 3-6 months following treatment
    2. Four-fold increase in titers over prior level suggests recurrent Syphilis and these patients should be re-treated
    3. Decrease in titers may be slower in patients who have had more than one Syphilis infection
    4. Seronegative conversion may occur if original titers were low or in cases treated early (stage 1-2)
  2. Repeat clinical evaluation
    1. Persistent symptoms and signs despite treatment should prompt Syphilis re-treatment

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Ontology: Syphilis (C0039128)

Definition (MEDLINEPLUS)

Syphilis is a sexually transmitted disease caused by bacteria. It infects the genital area, lips, mouth, or anus of both men and women. You usually get syphilis from sexual contact with someone who has it. It can also pass from mother to baby during pregnancy.

The early stage of syphilis usually causes a single, small, painless sore. Sometimes it causes swelling in nearby lymph nodes. If you do not treat it, syphilis usually causes a non-itchy skin rash, often on your hands and feet. Many people do not notice symptoms for years. Symptoms can go away and come back.

The sores caused by syphilis make it easier to get or give someone HIV during sex. If you are pregnant, syphilis can cause birth defects, or you could lose your baby. In rare cases, syphilis causes serious health problems and even death.

Syphilis is easy to cure with antibiotics if you catch it early. Correct usage of latex condoms greatly reduces, but does not completely eliminate, the risk of catching or spreading syphilis.

NIH: National Institute of Allergy and Infectious Diseases

Definition (MSHCZE) Chronicky probíhající infekční onemocnění způsobené anaerobní spirochetou Treponema pallidum, která je velmi citlivá na vyschnutí a na kyslík. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) A contagious bacterial infection caused by the spirochete Treponema pallidum. It is a sexually transmitted disorder, although it can also be transmitted from the mother to the fetus in utero. Typically, it is initially manifested with a single sore which heals without treatment. If the infection is left untreated, the initial stage is followed by skin rash and mucous membrane lesions. A late stage follows, which is characterized by damage of the internal organs, including the nervous system.
Definition (MSH) A contagious venereal disease caused by the spirochete TREPONEMA PALLIDUM.
Definition (CSP) subacute to chronic infectious venereal disease caused by the spirochete treponema pallidum.
Concepts Disease or Syndrome (T047)
MSH D013587
ICD9 097.9
ICD10 A53.9
SnomedCT 154379007, 186907007, 187359001, 186904000, 76272004
LNC LA17003-7
English Syphilis, Syphilis NOS, Syphilis, unspecified, [X]Syphilis, unspecified, syphilis, syphilis (diagnosis), Treponema pallidum infection, Syphilis [Disease/Finding], lues, luetic disease, Syphilis NOS (disorder), [X]Syphilis, unspecified (disorder), Lues, Infection by Treponema pallidum, Luetic disease, Syphilis (disorder), Treponema pallidum; infection, Syphilis, NOS, Syphilis, stage unspecified, Great Pox, Pox, Great
Dutch syfilis NAO, syfilis, niet-gespecificeerd, lues, Treponema pallidum-infectie, Treponema pallidum; infectie, Syfilis, niet gespecificeerd, syfilis, Lues, Syfilis
French Luès, Syphilis SAI, Infection à Treponema pallidum, Syphilis, non précisée, Grosse vérole, Syphilis
German Syphilis NNB, Treponema pallidum-Infektion, Syphilis, unspezifisch, Syphilis, nicht naeher bezeichnet, Harter Schanker, Lues, Schaudinn-Krankheit, Syphilis
Italian Sifilide NAS, Sifilide non specificata, Infezione da treponema pallidum, Lue, Sifilide
Portuguese Sífilis NE, Infecção por Treponema pallidum, Sifílis, Sífilis
Spanish Lúes, Sífilis NEOM, Sífilis no especificada, Infección por Treponema pallidum, sífilis, SAI (trastorno), sífilis, SAI, [X]sífilis, no especificada (trastorno), [X]sífilis, no especificada, infección por Treponema pallidum, lúes, sífilis (trastorno), sífilis, Sífilis
Japanese 梅毒、詳細不明, 梅毒NOS, 梅毒トレポネーマ感染, バイドクトレポネーマカンセン, バイドク, バイドクNOS, バイドクショウサイフメイ, 梅毒
Swedish Syfilis
Czech příjice, lues, syfilis, Lues, Syfilis, blíže neurčená, Syfilis, Syfilis NOS, Infekce Treponema pallidum
Finnish Kuppa
Russian SIFILIS, СИФИЛИС
Korean 상세불명의 매독
Croatian LUES
Polish Zakażenie Treponema pallidum, Kiła, Syfilis
Hungarian syphilis, nem meghatározott, Vérbaj, Treponema pallidum fertőzés, syphilis, syphilis k.m.n.
Norwegian Lues, Syfilis

Ontology: Treponema pallidum (bacteria) (C0040840)

Definition (NCI_CDISC) Any bacterial organism that can be assigned to the species Treponema pallidum.
Definition (NCI) A species of anaerobic, Gram indeterminate, spiral shaped bacteria assigned to the phylum Spirochaetes. This species is motile, NADH oxidase positive, ferments glucose and is an obligate parasite. T. pallidum is the causative agent of syphilis and at least 3 other subspecies are also human pathogens.
Definition (MSH) The causative agent of venereal and non-venereal syphilis as well as yaws.
Definition (CSP) species in the genus Treponema, the causative agent of venereal and non-venereal syphilis as well as yaws.
Concepts Bacterium (T007)
MSH D014210
SnomedCT 72904005
LNC LP14042-3, MTHU013914
English Treponema pallidum, T. palidum, Treponema palidum, Treponema pallidum (bacteria), Treponema pallidum (Schaudinn and Hoffmann 1905) Schaudinn 1905, pallidum treponema, treponema pallidum, Microspironema pallidum, Spirillum pallidum, Spironema pallidum, TREPONEMA PALLIDUM, Treponema Pallidum, Spirochaeta pallida, TP - Treponema pallidum, Treponema pallidum (organism)
Swedish Treponema pallidum
Czech Treponema pallidum
Finnish Treponema pallidum
Russian BLEDNAIA TREPONEMA, SPIROKHETA BLEDNAIA, SIFILIS, VOZBUDITEL', БЛЕДНАЯ ТРЕПОНЕМА, СИФИЛИС, ВОЗБУДИТЕЛЬ, СПИРОХЕТА БЛЕДНАЯ
Croatian TREPONEMA PALLIDUM
Polish Krętki blade, Treponema pallidum
Norwegian Treponema pallidum
Spanish Treponema pallidum (organismo), Treponema pallidum
French Treponema pallidum
German Spirochaeta pallida, Treponema pallidum
Italian Treponema pallidum
Dutch Treponema pallidum
Portuguese Treponema pallidum