Syphilis overview
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Syphilis is a curable sexually transmitted disease caused by the Treponema pallidum spirochete. The route of transmission of syphilis is almost always by sexual contact, although there are examples of congenital syphilis via transmission from mother to child in utero. The signs and symptoms of syphilis are numerous; before the advent of serological testing, precise diagnosis was very difficult. In fact, the disease was dubbed the "Great Imitator" because it was often confused with other diseases, particularly in its tertiary stage. Syphilis (unless antibiotic-resistant) can be easily treated with antibiotics including penicillin. The oldest and still most effective method is an intramuscular injection of benzathine penicillin. If not treated, syphilis can cause serious effects such as damage to the heart, aorta, brain, eyes, and bones. In some cases these effects can be fatal. In 1998, the complete genetic sequence of T. pallidum was published which may aid understanding of the pathogenesis of syphilis.
Historical Perspective
The name "syphilis" was coined by the Italian physician and poet Girolamo Fracastoro in his epic noted poem, written in Latin, entitled Syphilis sive morbus gallicus (Latin for "Syphilis or The French Disease") in 1530. The protagonist of the poem is a shepherd named Syphilus (perhaps a variant spelling of Sipylus, a character in Ovid's Metamorphoses). Syphilus is presented as the first man to contract the disease, sent by the god Apollo as punishment for the defiance that Syphilus and his followers had shown him. From this character Fracastoro derived a new name for the disease, which he also used in his medical text De Contagionibus ("On Contagious Diseases"). Until that time, as Fracastoro notes, syphilis had been called the "French disease" in Italy and Germany, and the "Italian disease" in France. In addition, the Dutch called it the "Spanish disease", the Russians called it the "Polish disease", the Turks called it the "Christian disease" or "Frank disease" (frengi) and the Tahitians called it the "British disease". These 'national' names are due to the disease often being present among invading armies or sea crews, due to their high amount of unprotected sexual contacts with prostitutes. It's interesting to notice how the invaders named it after the invaded country and vice versa. It was also called "Great pox" in the 16th century to distinguish it from smallpox. In its early stages, the Great pox produced a rash similar to smallpox (also known as variola). However, the name is misleading, as smallpox was a far more deadly disease. The terms "Lues" (or Lues venerea, Latin for "venereal plague") and "Cupid's disease" have also been used to refer to syphilis. In Scotland, Syphilis was referred to as the Grandgore. It was also called The Black Lion.
Classification
Syphilis can be congenital or acquired and is classified as primary, secondary, latent and tertiary.
Pathophysiology
Syphilis is caused by a spirochete, treponema pallidum. It has an incubation period of 3 - 12 weeks. Spirochete penetrates intact mucous membrane or microscopic dermal abrasions and rapidly enters systemic circulation with the central nervous system being invaded during the early phase of infection. The meninges and blood vessels are initially involved with the brain parenchyma and spinal cord being involved in the later stages of the disease. The histopathological hallmark findings are endarteritis and plasma cell-rich infiltrates reflecting a delayed-type of hypersensitivity to the spirochete.
Causes
Syphilis is caused by a spirochete, treponema pallidum. The spirochete rapidly penetrates via intact mucosal membranes or microscopic dermal abrasions. It is spread through intimate sexual contact, blood transfusion or vertical transmission from infected mother to fetus.
Differentiating Syphilis from other Diseases
Syphilis is a curable sexually transmitted disease caused by the Treponema pallidum spirochete. The route of transmission of syphilis is almost always by sexual contact, although there are examples of congenital syphilis via transmission from mother to child in utero. In fact, the disease was dubbed the "Great Imitator" because it was often confused with other diseases, particularly in its tertiary stage. Hence, patients with tertiary syphilis should also be tested for other sexually transmitted diseases such as chlamydia, gonorrhea, trichomoniasis, bacterial vaginosis and HIV infection.
Epidemiology and Demographics
The rate of primary and secondary syphilis reported in the United States decreased during the 1990s; in 2000, the rate was the lowest since reporting began in 1941. The low rate of infectious syphilis and the concentration of the majority of syphilis cases in a small number of geographic areas in the United States led to the development of the CDCs National Plan to Eliminate Syphilis, which was announced by Surgeon General David Satcher in October 1999 and revised in May 2006.2
Although the rate of primary and secondary syphilis in the United States declined 89.7% between 1990 and 2000, the rate of primary and secondary syphilis increased annually between 2001 and 2007. Overall increases in rates between 2001 and 2007 were observed primarily among men (from 3.0 cases per 100,000 population to 6.6 cases per 100,000 population). After persistent declines from 1992 to 2003, the rate of primary and secondary syphilis among women increased from 0.8 cases per 100,000 population in 2004 to 0.9 cases per 100,000 population in 2005 to 1.0 case per 100,000 population in 2006, to 1.1 case per 100,000 population in 2007.
Syphilis remains an important problem in the South and in urban areas in other regions of the country. Increases in cases among MSM have occurred and have been characterized by high rates of HIV co-infection and high-risk sexual behavior.3-7 The estimated proportion of primary and secondary syphilis cases attributable to MSM increased from 4% in 2000 to 62% in 2004. In 2005, CDC requested that all state health departments report sex of sex partners for persons with syphilis. In 2007, 65% of those primary and secondary syphilis cases in 44 states and Washington D.C. with available information were among MSM. Of reported male cases with primary and secondary syphilis, sex of partner information in 2007 was available for 79%.
Syphilis, a genital ulcerative disease, causes significant complications if untreated and facilitates the transmission of HIV. Untreated early syphilis in pregnant women results in perinatal death in up to 40% of cases and, if acquired during the four years preceding pregnancy, may lead to infection of the fetus in 80% of cases.[1]
Risk Factors
Risk factors of syphilis include unprotected sex, IV drug abuse and occupational risk for health care professionals.
Screening
Syphilis screening tests, such as the Rapid Plasma Reagin (RPR) and Venereal Disease Research Laboratory (VDRL) tests are cheap and fast but not completely specific, as many other conditions can cause a positive result.
Natural History, Complications and Prognosis
The morbidity of syphilis varies with the stage of the disease. The primary stage of infection is often asymptomatic with systemic infection observed in patients with secondary stage and tertiary syphilis being a latent disease that persists for years has shown to be associated with severe neurological and cardiovascular complications.
Treatment
Medical Therapy
Penicillin G, administered parenterally, is the preferred drug for treating all stages of syphilis. If allergic, then tetracycline or doxycycline may also be used. During pregnancy, parenteral penicillin G is the only therapy with documented efficacy for syphilis.
Management of Primary and Secondary Stages
Parenteral penicillin G has been used effectively for more than 50 years to achieve clinical resolution (i.e., the healing of lesions and prevention of sexual transmission) and to prevent late sequelae. However, no comparative trials have been adequately conducted to guide the selection of an optimal penicillin regimen (i.e., the dose, duration, and preparation). Substantially fewer data are available for non-penicillin regimens.
Tertiary Syphilis
Tertiary syphilis refers to gumma and cardiovascular syphilis but not to all neurosyphilis. Patients who are not allergic to penicillin and have no evidence of neurosyphilis should be treated with the following regimen.
Neurosyphilis
CNS involvement can occur during any stage of syphilis. However, CSF laboratory abnormalities are common in persons with early syphilis, even in the absence of clinical neurological findings. No evidence exists to support variation from recommended treatment for early syphilis for patients found to have such abnormalities. If clinical evidence of neurologic involvement is observed (e.g., cognitive dysfunction, motor or sensory deficits, ophthalmic or auditory symptoms, cranial nerve palsies, and symptoms or signs of meningitis), a CSF examination should be performed. Syphilitic uveitis or other ocular manifestations frequently are associated with neurosyphilis and should be managed according to the treatment recommendations for neurosyphilis. Patients who have neurosyphilis or syphilitic eye disease (e.g., uveitis, neuroretinitis, and optic neuritis) should be treated with the recommended regimen for neurosyphilis; those with eye disease should be managed in collaboration with an ophthalmologist. A CSF examination should be performed for all patients with syphilitic eye disease to identify those with abnormalities; patients found to have abnormal CSF test results should be provided follow-up CSF examinations to assess treatment response.
Primary Prevention
As of 2010, there is no vaccine effective for prevention.[2]
Secondary Prevention
While abstinence from intimate physical contact with an infected person is very effective at reducing the transmission of syphilis, it should be noted that T. pallidum readily crosses intact mucosa and cut skin, including areas not covered by a condom. Proper and consistent use of a latex condom can reduce, but not eliminate, the spread of syphilis.[2]
References
- ↑ INGRAHAM NR (1950). "The value of penicillin alone in the prevention and treatment of congenital syphilis". Acta Dermato-venereologica. Supplementum. 31 (Suppl. 24): 60–87. PMID 14829195.
|access-date=requires|url=(help) - ↑ Stamm LV (2010). "Global challenge of antibiotic-resistant Treponema pallidum". Antimicrobial Agents and Chemotherapy. 54 (2): 583–9. doi:10.1128/AAC.01095-09. PMC 2812177. PMID 19805553. Retrieved 2012-02-21. Unknown parameter
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