Syphilis, like many sexually transmitted diseases, is quite prevalent and a public health threat. It is a bacterial infection by treponema pallidum and can be very difficult to diagnose and treat but has very serious health consequences. Patients should understand what the disease is, how it is transmitted, how to prevent it and the best treatment options. The best option is to prevent infection in the first place.
The disease can present in different stages and can be difficult to recognize as it can mimic many other conditions. The stages include primary, secondary, latent and tertiary. When the patient is initially infected a lesion, or chancre, will appear on the body at the entry point of infection and this is usually on the genitals. It is possible to transmit the disease by direct contact with this chancre. The chancre will disappear within three to six weeks but, if not treated, can progress into secondary syphilis with a rash that spreads to multiple areas of the body. If not treated, the infection becomes latent or hidden and can lie dormant for years with no signs or symptoms but still be present in the body. If the patient has still not been treated, the disease progresses to tertiary syphilis which can cause problems with multiple organs in the body, including the heart, liver, joints, nerves and brain and lead to severe complications. Once the brain is involved, it can lead to dementia, paralysis, headaches, alternation of thought and neurologic compromise. The infection is quite severe and needs to be recognized and treated.
Syphilis is transmitted through direct contact with someone who is infected with syphilis. Commonly, contact is through sex and exposure to a chancre. Any type of sexual intercourse can lead to infection: anal, oral or vaginal. The chancres can be small and difficult to see, therefore testing and protection are key to avoiding syphilis. Of note, syphilis can be passed from mother to unborn child, so it is particularly worrisome in pregnant women and can lead to birth defects in the fetus and even death. While condoms are of great importance to prevent the transmission of syphilis, it is still possible to become infected if exposed to a chancre that is not covered by the condom. The best way to prevent syphilis is to make sure you and your partner are tested and both negative. Not being exposed to the disease is the best way to prevent the disease.
If syphilis is suspected or the patient is at risk for infection, then testing needs to be done. Risk includes being sexually active, especially if the partners’ status is unknown or if certain other conditions, like HIV are present. Multiple tests exist for syphilis with confirmatory tests being available. The protocols can be quite complicated, but a brief overview will be addressed to allow for basic understanding. The blood tests will be considered non-treponemal or treponemal. The non-treponemal tests are those that are not specific for syphilis and can have false positives but are easy to run as initial screening tests. The RPR (rapid plasma reagin) and VDRL (venereal disease research lab) are the two common initial tests in the classic algorithm. They can be used to measure response to treatment. The treponemal tests are usually antibody tests that react to the body’s response to infection and tend to stay positive even after successful treatment. The tests are FTA-ABS (fluorescent treponemal antibody-absorption) and TP-PA (treponemal pallidum-particle agglutination). Diagnosing the presence of syphilis and the stage is critical to proper treatment. The mainstay of treatment is an injection with Benzathine Penicillin G 2.4 million units in a single dose for primary, secondary and early latent syphilis but weekly injections of 2.4 million units for three weeks for latent or unknown duration syphilis. If it has progressed to neuro syphilis or ocular syphilis, then a continuous IV infusion is needed. Regardless, treatment may not heal the damage that has been done by the disease but can prevent further damage. In addition, the patient should abstain from sexual activity until the lesions are healed and inform the partner so testing and treatment can be done.
In summary, syphilis is a complex disease with severe consequences in the untreated patient. Testing and treatment should be done under the guidance of trained physicians who understand the indications and testing options available as well as familiarity with current treatment guidelines. The first step to prevention is abstaining from sex with an infected individual, but if the status is not known then condoms must be used. Through proper testing, and treatment, the spread of syphilis can be curtailed, but it will take the effort for sexually active people to be responsible.
Jason M. Goldman, MD, FACP
