Sexually Transmitted Infections: Syphilis

Syphilis is a sexually transmitted bacterial infection (STI) that initially causes genital ulcers (sores).  If untreated, these ulcers can then lead to more serious symptoms of infection.

Although syphilis rates in the United States declined by almost 90 percent from 1990 to 2000, the number of cases rose from 5,979 in 2000 to 7,980 in 2004.  In a single year, from 2003 to 2004, the number of syphilis cases jumped 8 percent.

There also was a dramatic change in whom the disease affects.  Between 2002 and 2003, the number of cases in men increased 13.5 percent, reflecting an increase in syphilis in men who have sex with men.  During the same time, the number of cases in women declined by 27.3 percent.

Syphilis also disproportionately affects African Americans, who represent 41 percent of all cases reported to the Centers for Disease Control and Prevention (CDC).

HIV infection and syphilis are linked.  Having syphilis increases the risk of transmitting as well as getting infected with HIV.

Cause
Syphilis is caused by a bacterium called Treponema pallidum.

Transmission
The most common way to get syphilis is by having sexual contact with an infected person.  If you get infected, you can pass the bacteria from infected skin or mucous membranes, usually your genital area, lips, mouth, or anus, to the mucous membranes or skin of your sexual partner.

Syphilis can be passed from mother to infant during pregnancy, causing a disease called congenital syphilis.

The bacteria that cause syphilis are fragile; you can't get them from eating utensils or through using spas, pools, or toilets.

Symptoms
Syphilis is sometimes called "the great imitator" because it has so many possible symptoms, and its symptoms are similar to those of many other diseases.  Having HIV infection at the same time can change the symptoms and course of syphilis.  Syphilis (other than congenital syphilis) occurs in four stages that sometimes overlap.

Primary Syphilis
The first symptom of primary syphilis is often a small, round, firm ulcer called a chancre ("shanker") at the place where the bacteria entered your body.  This place is usually the penis, vulva, or vagina, but chancres also can develop on the cervix, tongue, lips, or other parts of the body.  Usually there is only one chancre, but sometimes there are many. Nearby lymph glands are often swollen.  (Lymph glands, or nodes, are small bean-shaped organs of your immune system containing cells that help fight off infections.  They are found throughout the body.)  The chancre usually appears about 3 weeks after you are infected with the bacteria, but it can occur any time from 9 to 90 days after exposure.

Because a chancre is usually painless and can appear inside your body, you might not notice it.  The chancre disappears in about three to six weeks whether or not you are treated.  Therefore, you can have primary syphilis without symptoms or with only brief symptoms that could be overlooked.  If primary syphilis is not treated, the infection moves to the secondary stage.

Secondary syphilis
Most people with secondary syphilis have a non-itchy skin rash.  Although the rash is usually on the palms of your hands and soles of your feet, it may cover your whole body or appear only in a few areas.  The rash appears two to ten weeks after the chancre, generally when the chancre is healing or already healed.  Other common symptoms include:

• Sore throat
• Tiredness
• Headache
• Swollen lymph glands

Less frequent symptoms include fever, aches, weight loss, hair loss, aching joints, or lesions (sores) in the mouth or genital area.

Your symptoms may be mild.  The sores of secondary syphilis contain many bacteria, and anyone who has contact with them can get syphilis.  As with primary syphilis, secondary syphilis will disappear even without treatment.  Without treatment, secondary syphilis will move to the next stages.

You may have recurrences of secondary syphilis.

Latent syphilis
The latent (hidden) stage of syphilis begins when symptoms of secondary syphilis are over.

In early latent syphilis, you might not notice signs and symptoms, but the infection remains in your body.  When you are in this stage, you can still infect a sexual partner.

In late latent syphilis, the infection is quiet and the risk of infecting a sexual partner is low or absent. If you do not get treated for latent syphilis, you will progress to tertiary syphilis, the most serious stage of the disease.

Tertiary syphilis
Even without treatment, only a small number of infected people develop the dreaded complications known as tertiary, or late, syphilis.  In this stage, the bacteria will damage your heart, eyes, brain, nervous system, bones, joints, or almost any other part of your body.  This damage can happen years or even decades after the primary stage.

Late syphilis can result in mental illness, blindness, deafness, memory loss or other neurological problems, heart disease, and death.  Late neurosyphilis (brain or spinal cord damage) is one of the most severe signs of this stage.

Diagnosis
It can be very difficult for your health care provider to diagnose syphilis based on symptoms.  This is because symptoms and signs of the disease might be absent, go away without treatment, or be confused with those of other diseases.  Because syphilis can be hard to diagnose, you should:

• Visit your health care provider if you have a lesion (sore) in your genital area or a widespread rash.
• Get tested periodically for syphilis if your sexual behaviors put you at risk for STIs.
• Get tested to be sure you do not also have syphilis if you have been treated for another STI such as gonorrhea or HIV infection.

Your health care provider can diagnose early syphilis by seeing a chancre or rash and then confirming the diagnosis with laboratory tests.  Because latent syphilis has no symptoms, it is diagnosed only by laboratory tests.

• There are two laboratory methods for making the diagnosis:
• Identifying the bacteria under a microscope in a sample taken from a lesion
• Performing a blood test for syphilis

If your doctor thinks you might have neurosyphilis, your spinal fluid will be tested as well.

Treatment
Syphilis is easy to cure in its early stages.  Penicillin, an antibiotic, injected into the muscle is the best treatment for syphilis.  If you are allergic to penicillin, your health care provider may give you another antibiotic to take by mouth.

If you have neurosyphilis, you may need to receive daily doses of penicillin intravenously (in the vein) and may need to be treated in the hospital.

If you have late syphilis, damage done to your body organs cannot be reversed.

While you are being treated, you should abstain from sex until your sores are completely healed.  You should also notify your sex partners so they can be tested for syphilis and treated if necessary.

Complications

With Pregnancy
Untreated syphilis results in a high-risk pregnancy.  There are an estimated 8,000 pregnant women with syphilis in the United States.  Untreated early syphilis results in death of the unborn baby in up to 40 percent of cases.  Studies show that if a woman contracts syphilis during the 4 years before her pregnancy, untreated early syphilis may lead to infection of her unborn baby in more than 70 percent of cases.  Therefore, if you are pregnant, you should be tested for syphilis.

Syphilis can cause miscarriages, premature births, stillbirths, or death of newborn babies.  Some infants with congenital syphilis have symptoms at birth, but most develop symptoms later.

Untreated babies with congenital syphilis can have deformities, delays in development, or seizures along with many other problems such as rash, fever, swollen liver and spleen, anemia, and jaundice.  Sores on infected babies are infectious.  Rarely, the symptoms of syphilis go unseen in infants so that they later develop the symptoms of late-stage syphilis, including damage to their bones, teeth, eyes, ears, and brains.

With HIV Infection
There is an estimated two- to five-fold increased risk of getting infected with HIV when you have syphilis.  Substantial biological evidence shows the increased likelihood that getting and transmitting HIV is linked to the presence of sexually transmitted infections (STIs).  You should discuss this and other STIs with your health care provider.

Prevention
The surest way to avoid getting or transmitting sexually transmitted infections (STIs) is to abstain from sex.  Another safe option is to have a faithful spouse who is not infected and to have sex with that person only. 

To prevent getting syphilis, you must avoid contact with infected tissue and body fluids of an infected person.  Usually syphilis is transmitted from people who have no visible sores or rashes and who do not know they are infected, however.

If you choose to have sex with someone other than your spouse, using condoms properly and consistently during sexual intercourse reduces but does not eliminate the risk of getting syphilis.

Washing or douching after sex will not prevent syphilis.  Even if you have been treated for syphilis and cured, you can be re-infected by having sex with an infected partner.

The risk of a mother transmitting syphilis to her unborn baby during pregnancy declines with time but persists during latent syphilis.  To prevent passing congenital syphilis to her unborn baby, all pregnant women should be tested for syphilis.

The content of this posting is based on information from the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.

Get info.  Get tested.  Get treated.  Be safe.

Share the health.

Deborah White, MD, MBA