Decoding the Syphilis threat

Syphilis is a sexually transmitted infection caused by a bacteria called Treponema Pallidum. The infection gets transmitted from an infected person to other people through direct sexual contact of any kind or through broken skin and mucosal surfaces.

The disease is slowly progressive and tends to remain symptomatic for a very long time or may only present with generalized and vague symptoms. So an infected person may pass on the disease to others without even knowing about it. The best way to remain protected from contracting syphilis is to practice safe sex, use barrier methods like condoms, and have fewer sexual partners.

Transmission of syphilis

Syphilis is a sexually transmitted infection (STI) and is transmitted by sexual contact. However, it does not spread by casual contact of an infected person with things of daily use like door handles, tables, books, toilets, etc. Following is some important information regarding transmission of syphilis:

• Any form of unprotected sexual intercourse, whether penetrative or non-penetrative, can transmit the infection. This includes vaginal, oral, and anal sex, and even kissing.
• Vertical transmission from an infected mother to the baby can occur in the uterus through the placenta or during childbirth. It can also spread with breastfeeding.
• The disease is contagious in it’s primary and secondary stages and during these stages, the infected person may pass on the disease to their partner. (see stages of syphilis below)

Risk factors for syphilis

• Unprotected sexual intercourse
• More number of sexual partners
• History of sexual intercourse with an infected person
• History of presence of other STDs like chlamydia, gonorrhea etc increases the risk of getting syphilis.
• HIV infection increases the risk of getting syphilis.

Stages of  Syphilis

Before going into the details of the stages of syphilis, let us have a broad understanding of these stages:

• There are four stages of syphilis – primary, secondary, latent and tertiary.
• The primary and secondary stages are infective to others and last for up to 2 years.
• The latent stage is the quiet or hidden phase and persists from 2 to 20 years.
• The tertiary stage is the stage of complications where the organs are affected.

Primary syphilis

This is the first stage of syphilis and is characterized by a lesion called Chancre and enlarged inguinal lymph nodes.

• The Chancre is a small, painless ulcer that may be present on the penis, in the vagina, cervix, anus, or nipples. Being small and painless, it usually remains hidden except on the penis and nipples where it is easily visible. It is usually a solitary lesion, but multiple chancres may be seen in some patients. It appears about 2 – 4 weeks after contracting the infection and heals spontaneously in 1 to 8 weeks, leaving a scar behind.
• Lymph nodes: Painless and enlarged inguinal lymph nodes are also seen in primary syphilis.
• Primary syphilis does not affect the fallopian tubes or cause infertility.
• The disease can be treated at this stage with injectable antibiotics called Penicillins. If treatment is not taken in this stage, the disease moves on to the next stage called secondary syphilis.
• This stage is infective and the patient can infect their partners through sexual intercourse.

Secondary syphilis

• Develop 6 weeks to 6 months after the onset of primary syphilis.
• The characteristic lesion of secondary syphilis is called Condyloma Lata.
• Other systemic features like fever, rash, sore throat, enlarged lymph nodes, excessive fatigability, weight loss and hair loss also seen.
• Condyloma Lata are the pathognomic lesions of secondary syphilis. They look like coarse, flat-topped greyish-white skin plaques on the genitals or anus. They are usually painless and have a moist and necrotic appearance. These lesions are highly infectious and are the main source of infection to the partners of infected individuals.
• The rash of secondary syphilis is a faint, reddish-brown, maculopapular rash. This means that the rash may look like flat, discolored areas on the skin or small, raised bumps. It is non-itchy and is seen on the chest, back, stomach, pelvis, palms and soles. Like the primary stage, this stage also resolves on its own in a few weeks.
• If it does not resolve completely, it enters the next phase called the Latent Phase.
• This stage can also be treated with injectable antibiotics called Penicillins. If untreated, the patient remains contagious and can infect their sexual partners.

Latent syphilis

• If syphilis is not fully treated in the secondary stage, the disease becomes quiescent and can remain in the body without producing any symptoms for up to 20 years.
• This quiet or hidden phase of the disease is called the latent phase.
• The patient is usually not infective to others in this phase.
• Again the treatment in this stage is injectable Penicillin.
• If not treated, the disease moves on to the last stage called the tertiary stage.

Tertiary syphilis (Late syphilis)

When latent syphilis does not resolve completely or remains untreated, then about one third of such patients progress on to tertiary syphilis. This final stage of syphilis is the stage of complications as the bacteria cause damage to multiple organs of the body like the brain, heart, liver, eyes, ears, nerves, blood vessels etc.

The characteristic lesion of the tertiary stage is called Gumma. Gummas present as bumpy growths or deep, painless ulcers with rolled-out margins on the affected organs.

The various organs that can be affected along with their symptoms are:

• Central nervous system:
  • The brain, spinal cord, or meninges may be affected leading to headaches, confusion, stroke, paralysis, seizures, meningitis, and loss of bladder or bowel control.
  • The cranial nerves may be affected leading to palsies of cranial nerves with their resultant effects on the organs supplied by them.
  • Syphilis can also cause a neurodegenerative disease of the spinal cord called Tabes Dorsalis, characterized by an unstable gait,  weakness, loss of bladder control, and shooting pain along the nerve roots. This condition is also called locomotor ataxia.
• Heart: Tertiary syphilis can cause damage to valves of the heart. These valves act as one-way doors from one chamber of the heart to the other. Damage to these valves affects the proper flow of blood from one chamber to the other.
• Aorta: Aorta is the biggest blood vessel of our body which arises from the heart and supplies oxygenated blood to all parts of our body. Syphilis can cause thinning out and bulging of the wall of the aorta. This is called aortic aneurysm. It is extremely dangerous as an aneurysm can rupture anytime, causing life threatening hemorrhage.
• Eye: When it affects the eye, it is called Ocular syphilis.  It can cause partial loss of vision, blindness, redness or pain in the eye.
• Ear: When it affects the ear, it is called Otosyphilis. It can cause impaired hearing or hearing loss, deafness, vertigo (dizziness) and tinnitus (a feeling of ringing in the ear).
• Increased incidence of other sexually transmitted diseases (STDs): As explained before, the lesions in primary and secondary syphilis are contagious. These lesions can bleed easily and increase chances of transmission of other STDs like HIV during intercourse.

Congenital syphilis

Pregnant patients with syphilis can sometimes pass the disease to their babies through their placenta when the baby is still inside the uterus or during childbirth. This condition is called Congenital syphilis.

Congenital syphilis can lead to many obstetric complications like premature delivery, low birth weight baby, miscarriage, stillbirth or neonatal death.

When the baby is born to a syphilitic mother, it may be asymptomatic or may develop symptoms like fever, skin rash, anemia, jaundice, enlarged lymph nodes, deafness, teeth problems or saddle nose deformity (collapsed bridge of nose).

Diagnosis of syphilis

• The diagnosis is based on a through history, clinical examination and tests conducted by your healthcare provider.
• Your doctor will ask you about your number of sexual partners, whether you have protected or unprotected intercourse, or a history of exposure to an infected partner. This history is very important and no facts should be concealed from your doctor.
• History of recent onset of fever along with the above history and examination findings (below).
• Examination may show characteristic lesions like chancre, condyloma lata, gumma or skin rash.
• Lab – Direct visual inspection (dark field microscopy) of a smear from a lesion.
• Screening tests: VDRL (Venereal Disease Research Laboratory), Rapid Plasma Reagent (RPR) tests
• Confirmatory tests: FTA-abs (Fluorescent Treponemal Antibody Absorption) test and TPHA (Treponema Pallidum Particle Agglutination Assay) test.

Treatment of syphilis

• The mainstay of treatment of syphilis is with antibiotics called Penicillins. These are administered as intramuscular injections. The dose and frequency of administration depend on the stage and severity of the disease.
• In case of allergy to injectable penicillin, doxycycline or tetracycline are given orally as alternatives.
• It is very important to adhere to the treatment regime as early stages of infection are completely treatable without any residual damage. Treatment can resolve then disease in late stages too, but the damage to organs that has already occurred, can not be reversed.
• After completion of treatment, your doctor will send some blood tests again to confirm that the disease has been completely treated.
• It is also important to understand that successful treatment does not mean life-long immunity. You can again contract syphilis if you practice unprotected intercourse. So you must improve your sexual habits, use condoms, and have fewer sexual partners.

How can I prevent syphilis?

Like any other STD, syphilis is easily preventable by using certain basic principles and by having healthy sexual habits. For example:

• Prefer a monogamous relationship or have fewer sexual partners.
• Do not engage in any kind of intimate contact if your partner is known to have any sexually transmitted infection like chlamydia, gonorrhea, herpes, HIV, or syphilis.
• Always use condoms during sexual intercourse, unless you are planning a pregnancy.

Is there any vaccine for syphilis?

No, currently there is no vaccine available for syphilis.

Carry home message

Syphilis is a sexually transmitted infection caused by a bacteria called Treponema Pallidum. It is a slowly progressive disease that, if left untreated, can cause damage to various organs of the body like the brain, heart, liver, eye, ear, nerves, blood vessels etc. There is no vaccine for syphilis but it is easily preventable by adopting healthy sexual habits like monogamous relationship or fewer sexual partners, using condoms, and avoiding intimate relationships with infected people. Treatment is with intramuscular antibiotics called Penicillins. Practice safe sex and stay healthy.

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