Syphilis

Syphilis
Treponema pallidum.jpg
Electron micrograph of Treponema pallidum
SpecialtyInfectious disease
SymptomsFirm, painless, non-itchy skin ulcer[1]
CausesTreponema pallidum usually spread by sex[1]
Diagnostic methodBlood tests, dark field microscopy of infected fluid[1][2]
Differential diagnosisMany other diseases[1]
PreventionCondoms, not having sex[1]
TreatmentAntibiotics[3]
Frequency45.4 million / 0.6% (2015)[4]
Deaths107,000 (2015)[5]

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum subspecies pallidum.[3] The signs and symptoms of syphilis vary depending in which of the four stages it presents (primary, secondary, latent, and tertiary).[1] The primary stage classically presents with a single chancre (a firm, painless, non-itchy skin ulceration usually between 1 cm and 2 cm in diameter) though 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] 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), neurological problems, or heart symptoms.[2] Syphilis has been known as "the great imitator" as it may cause symptoms similar to many other diseases.[1][2]

Syphilis is most commonly spread through sexual activity.[1] It may also be transmitted from mother to baby during pregnancy or at birth, resulting in congenital syphilis.[1][6] Other diseases caused by the Treponema bacteria include yaws (subspecies pertenue), pinta (subspecies carateum), and nonvenereal endemic syphilis (subspecies endemicum).[2] These three diseases are not typically sexually transmitted.[7] Diagnosis is usually made by using blood tests; the bacteria can also be detected using dark field microscopy.[1] The Centers for Disease Control and Prevention (U.S.) recommend all pregnant women be tested.[1]

The risk of sexual transmission of syphilis can be reduced by using a latex or polyurethane condom.[1] Syphilis can be effectively treated with antibiotics.[3] The preferred antibiotic for most cases is benzathine benzylpenicillin injected into a muscle.[3] In those who have a severe penicillin allergy, doxycycline or tetracycline may be used.[3] In those with neurosyphilis, intravenous benzylpenicillin or ceftriaxone is recommended.[3] During treatment people may develop fever, headache, and muscle pains, a reaction known as Jarisch-Herxheimer.[3]

In 2015, about 45.4 million people were infected with syphilis,[4] with 6 million new cases.[8] During 2015, it caused about 107,000 deaths, down from 202,000 in 1990.[5][9] After decreasing dramatically with the availability of penicillin in the 1940s, rates of infection have increased since the turn of the millennium in many countries, often in combination with human immunodeficiency virus (HIV).[2][10] This is believed to be partly due to increased promiscuity, prostitution, decreasing use of condoms, and unsafe sexual practices among men who have sex with men.[11][12][13] In 2015, Cuba became the first country to eliminate mother-to-child transmission of syphilis.[14]

Signs and symptoms

Syphilis can present in one of four different stages: primary, secondary, latent, and tertiary,[2] and may also occur congenitally.[15] It was referred to as "the great imitator" by Sir William Osler due to its varied presentations.[2][16]

Primary

Primary chancre of syphilis at the site of infection on the penis

Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person.[17] Approximately 3 to 90 days after the initial exposure (average 21 days) a skin lesion, called a chancre, appears at the point of contact. This is classically (40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders approximately 0.3–3.0 cm in size.[2] The lesion may take on almost any form. In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer.[18] Occasionally, multiple lesions may be present (~40%),[2] with multiple lesions being more common when coinfected with HIV. Lesions may be painful or tender (30%), and they may occur in places other than the genitals (2–7%). The most common location in women is the cervix (44%), the penis in heterosexual men (99%), and anally and rectally in men who have sex with men (34%).[18] Lymph node enlargement frequently (80%) occurs around the area of infection,[2] occurring seven to 10 days after chancre formation.[18] The lesion may persist for three to six weeks if left untreated.[2]

Secondary

Typical presentation of secondary syphilis with a rash on the palms of the hands
Reddish papules and nodules over much of the body due to secondary syphilis

Secondary syphilis occurs approximately four to ten weeks after the primary infection.[2] While secondary disease is known for the many different ways it can manifest, symptoms most commonly involve the skin, mucous membranes, and lymph nodes.[19] There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles.[2][20] The rash may become maculopapular or pustular. It may form flat, broad, whitish, wart-like lesions on mucous membranes, known as condyloma latum. All of these lesions harbor bacteria and are infectious. Other symptoms may include fever, sore throat, malaise, weight loss, hair loss, and headache.[2] Rare manifestations include liver inflammation, kidney disease, joint inflammation, periostitis, inflammation of the optic nerve, uveitis, and interstitial keratitis.[2][21] The acute symptoms usually resolve after three to six weeks;[21] about 25% of people may present with a recurrence of secondary symptoms. Many people who present with secondary syphilis (40–85% of women, 20–65% of men) do not report previously having had the classical chancre of primary syphilis.[19]

Latent

Latent syphilis is defined as having serologic proof of infection without symptoms of disease.[17] It is further described as either early (less than 1 year after secondary syphilis) or late (more than 1 year after secondary syphilis) in the United States.[21] The United Kingdom uses a cut-off of two years for early and late latent syphilis.[18] Early latent syphilis may have a relapse of symptoms. Late latent syphilis is asymptomatic, and not as contagious as early latent syphilis.[21]

Tertiary

Model of a head of a person with tertiary (gummatous) syphilis, Musée de l'Homme, Paris.

Tertiary syphilis may occur approximately 3 to 15 years after the initial infection, and may be divided into three different forms: gummatous syphilis (15%), late neurosyphilis (6.5%), and cardiovascular syphilis (10%).[2][21] Without treatment, a third of infected people develop tertiary disease.[21] People with tertiary syphilis are not infectious.[2]

Gummatous syphilis or late benign syphilis usually occurs 1 to 46 years after the initial infection, with an average of 15 years. This stage is characterized by the formation of chronic gummas, which are soft, tumor-like balls of inflammation which may vary considerably in size. They typically affect the skin, bone, and liver, but can occur anywhere.[2]

Neurosyphilis refers to an infection involving the central nervous system. It may occur early, being either asymptomatic or in the form of syphilitic meningitis, or late as meningovascular syphilis, general paresis, or tabes dorsalis, which is associated with poor balance and lightning pains in the lower extremities. Late neurosyphilis typically occurs 4 to 25 years after the initial infection. Meningovascular syphilis typically presents with apathy and seizures, and general paresis with dementia and tabes dorsalis.[2] Also, there may be Argyll Robertson pupils, which are bilateral small pupils that constrict when the person focuses on near objects (accommodation reflex) but do not constrict when exposed to bright light (pupillary reflex).

Cardiovascular syphilis usually occurs 10–30 years after the initial infection. The most common complication is syphilitic aortitis, which may result in aortic aneurysm formation.[2]

Congenital

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.[6] Infection during pregnancy is also associated with miscarriage.[22] The three main dental defects in congenital syphilis are Hutchinson's incisors (screwdriver shaped incisors), Moon's molars or bud molars, and Fournier's molars or mulberry molars (molars with abnormal occlusal anatomy resembling a mulberry).[23]

Other Languages
Afrikaans: Sifilis
አማርኛ: ቂጥኝ
العربية: زهري (مرض)
অসমীয়া: চিফিলিছ
asturianu: Sífilis
azərbaycanca: Sifilis
বাংলা: সিফিলিস
Bân-lâm-gú: Mûi-to̍k
беларуская: Сіфіліс
беларуская (тарашкевіца)‎: Сыфіліс
български: Сифилис
Boarisch: Syphilis
bosanski: Sifilis
brezhoneg: Kleñved Naplez
català: Sífilis
čeština: Syfilis
Cymraeg: Syffilis
dansk: Syfilis
Deutsch: Syphilis
ދިވެހިބަސް: ސިފިލިސް
eesti: Süüfilis
Ελληνικά: Σύφιλη
español: Sífilis
Esperanto: Sifiliso
euskara: Sifili
فارسی: سیفلیس
français: Syphilis
Gaeilge: Sifilis
galego: Sífilis
ગુજરાતી: ઉપદંશ
한국어: 매독
հայերեն: Սիֆիլիս
हिन्दी: उपदंश
hrvatski: Sifilis
Bahasa Indonesia: Sifilis
íslenska: Sárasótt
italiano: Sifilide
עברית: עגבת
ಕನ್ನಡ: ಸಿಫಿಲಿಸ್
ქართული: სიფილისი
қазақша: Мерез
Kiswahili: Kaswende
Кыргызча: Котон жара
Latina: Syphilis
latviešu: Sifiliss
lietuvių: Sifilis
Limburgs: Syfilis
magyar: Szifilisz
македонски: Сифилис
მარგალური: სიფილისი
Bahasa Melayu: Siflis
монгол: Тэмбүү
မြန်မာဘာသာ: ကာလသားရောဂါ
Nederlands: Syfilis
नेपाली: भिरिङ्गी
日本語: 梅毒
norsk: Syfilis
norsk nynorsk: Syfilis
occitan: Sifilis
ଓଡ଼ିଆ: ସିଫିଲିସ୍
oʻzbekcha/ўзбекча: Zaxm
ਪੰਜਾਬੀ: ਆਤਸ਼ਕ
پښتو: باو
Patois: Sifilis
polski: Kiła
português: Sífilis
Ripoarisch: Syphilis
română: Sifilis
Runa Simi: Wanthi unquy
русский: Сифилис
shqip: Sifilizi
සිංහල: Syphilis
Simple English: Syphilis
slovenčina: Syfilis
slovenščina: Sifilis
српски / srpski: Сифилис
srpskohrvatski / српскохрватски: Sifilis
Basa Sunda: Sifilis
suomi: Kuppa
svenska: Syfilis
Tagalog: Sipilis
தமிழ்: சிபிலிசு
татарча/tatarça: Сифилис
Türkçe: Frengi
Türkmençe: Merezýel
тыва дыл: Паш (аарыг)
українська: Сифіліс
Tiếng Việt: Giang mai
Winaray: Sipilis
粵語: 梅毒
中文: 梅毒