AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Syphilis is a venereal disease that can also be acquired by exposure to infected blood. The organism can cross the placenta and infect the unborn child.

Untreated syphilis progresses through 4 stages: primary, secondary, latent, and tertiary stages. Known as a great imitator, patients with syphilis can be a diagnostic challenge because of their wide-ranging clinical presentations.

Pathophysiology

Three genera of spirochetes cause human infection: (1) Treponema, which causes syphilis, yaws, and pinta; (2) Borrelia, which causes Lyme disease and relapsing fever; and (3) Leptospira, which causes leptospirosis.

Transmission occurs by penetration of the spirochetes through mucosal membranes and abrasions on epithelial surfaces. Incubation time from exposure to development of primary lesions averages 3 weeks but can range from 10-90 days. Lesions develop at the primary site of inoculation. Pathologically, the primary lesion of syphilis is a focal endarteritis and periarteritis. Rabbit studies show that spirochetes can be found in the lymphatic system as early as 30 minutes after primary inoculation, suggesting that syphilis is a systemic disease from the outset.

The primary lesion of syphilis is the chancre. Histologically, it is characterized by mononuclear leukocytic infiltration, macrophages, and lymphocytes. The inflammatory reaction causes an obliterative endarteritis. In this stage, the spirochete can be isolated from the surface of the ulceration or the overlying exudate of the chancre. Whether treated or not, healing occurs within 3-12 weeks, with considerable residual fibrosis.

Secondary syphilis lesions are quite variable in their manifestation. Widespread mucocutaneous lesions are observed over the entire body. Most often, lesions are macular, discrete, reddish brown, and 5 mm or less in diameter; however, they can be pustular, annular, or scaling. All lesions contain treponemes. Of these, wet mucous patches are the most contagious. Histologically, the inflammatory reaction is similar to but less intense than that of the primary chancre.

Currently, late syphilitic disease is rare. It mainly affects the cardiovascular system (80-85%) and the CNS (5-10%). The pathognomonic lesion of tertiary syphilis is the gumma, which is characterized by a center of necrotic tissue with a rubbery texture. Gummas principally form in the liver, bones, and testes. Histological examination shows palisaded macrophages and fibroblasts as well as plasma cells surrounding the margins. Treponemes are rarely visualized or recovered from these lesions.

Frequency

United States

During most of the 20th century, the incidence declined. A dramatic decrease occurred during the 1940s, following the advent of penicillin therapy; however, during the mid 1980s, the trend reversed. Increases in the use of IV drugs and crack cocaine, the exchange of sex for drugs, indiscriminate or anonymous sex, and the number of people with multiple sexual partners contributed to the turnaround. From 1986-1990, the rate of syphilis nearly doubled, reaching a peak of 53.8 cases per 100,000 population in 1990.

After 1990, the incidence decreased; in 2000, the number of cases reported was at an all-time low. Increased awareness, aggressive screening, and emphasis on primary prevention contributed to the decrease.

Recently, the number of cases in the United States has slightly increased. The Centers for Disease Control and Prevention (CDC) reported that, from 2003-2004, the rate of primary and secondary syphilis increased 8%, from 2.5 to 2.7 cases per 100,000 population. The number of cases increased from 7,177 in 2003 to 7,980 in 2004.

Mortality/Morbidity

• The morbidity of syphilis ranges from the relatively minor symptoms of the primary stages of infection to the more significant constitutional systemic symptoms of secondary syphilis and the significant neurological and cardiovascular consequences of tertiary disease.
• Twenty percent of untreated patients with tertiary syphilis die of the disease.
• Since latent syphilis can persist for years or decades, the manifestations of tertiary syphilis often occur much later in life, causing significant morbidity.

Race

Non-Hispanic blacks are at higher risk for syphilis than non-Hispanic whites. In 1997, non-Hispanic blacks had a case report rate of 22 cases per 100,000 population. This was 44 times higher than the rate for non-Hispanic whites. This ratio had declined to 8:1 by 2002, after implementation of a national plan to eliminate syphilis in the United States.

In 2004, the primary and secondary syphilis rate in blacks increased from 7.7 cases per 100,000 in 2003 to 9 cases per 100,000 in 2004 (a 16.9% increase). Mirroring overall trends, this increase was primarily due to a 22.6% increase specifically among black men (from 11.5 cases per 100,000 to 14.1 cases per 100,000).

Sex

Male-to-female ratios of primary and secondary syphilis infection increased from 1.6:1 in 1965 to nearly 3:1 in 1985. Since then, the ratio has decreased, reaching a nadir in 1994-95. From 2000-2002, the ratio has increased to 1985 levels.

Studies of patients diagnosed with sexually transmitted diseases (STDs) demonstrate that men are screened for syphilis in emergency departments and health clinics more often than women. Despite this, the primary and secondary syphilis rate among men increased 11.9% from 2003-2004 (4.2 cases per 100,000 to 4.7 cases per 100,000) and 81% since 2000 (2.6 cases per 100,000 to 4.7 cases per 100,000). Although surveillance data based on risk behavior are not available, a separate CDC analysis suggests that approximately 64% of all adult primary and secondary syphilis cases in 2004 were among men who have sex with men, up from an estimated 5% in 1999.

Between 1999 and 2004, the overall rates among women have decreased 55% (2 to 0.9 cases per 100,000).

Age

Syphilis is most common during the years of peak sexual activity. Most new cases occur in men and women aged 15-40 years. The highest infection rates occur in people aged 20-29 years.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

The presentation of patients with syphilis is variable. A high index of suspicion is needed for prompt diagnosis. Rigorous attention to the time course of symptoms is required for proper staging.

• Obtain a thorough sexual and social history, including number of partners, condom use, history of STDs in the patient and their partners, IV drug use, and exposure to blood products.
• For children and infants, seek a maternal history, history of exposure to syphilitic individuals or blood products, and history of sexual abuse.
• Primary syphilis
• • Primary syphilis manifests mainly on the glans penis of males and on the vulva or cervix of females. Regional nontender lymphadenopathy follows invasion.
  • Ten percent of lesions are found on the anus, fingers, oropharynx, tongue, nipples, fingers, or other extragenital sites.
  • Lesions (chancres) are usually solitary, raised, firm papules that can be several centimeters in diameter. The chancre erodes to create an ulcerative crater within the papule, with slightly elevated edges around the central ulcer.
• Secondary syphilis
• • Secondary syphilis manifests in various ways. It usually includes a localized or diffuse mucocutaneous rash and generalized, nontender lymphadenopathy.
  • Constitutional symptoms of secondary syphilis include malaise, sore throat, headache, fever, anorexia, and meningismus (rarely).
  • Other less common manifestations include GI involvement, hepatitis, nephropathy, proctitis, arthritis, and optic neuritis.
• Latent syphilis
• • Syphilis primarily spreads during the first year after infection.
  • Patients may recall symptoms of primary and secondary syphilis.
  • They are asymptomatic during the latent phase, and the disease is detected only by serologic tests.
  • Latency may last from a few years to as many as 25 years before the destructive lesions of tertiary syphilis manifest.
  • Latent syphilis is divided into early latent and late latent. The distinction is important because treatment for each is different.
  • • The early latent period is the first year after the resolution of primary or secondary syphilis. Asymptomatic patients who have a newly active serologic test after having a serologically negative test result within 1 year are also considered to be in the early latent period.
    • Late latency syphilis is not infectious; however, women in this stage can spread the disease in utero.
• Tertiary syphilis
• • Late syphilis is slowly progressive and may affect any organ.
  • The disease is generally not thought to be infectious at this stage.
• Congenital syphilis
• • Early congenital syphilis occurs within the first 2 years of life.
  • Late congenital syphilis emerges in children older than 2 years.

Physical

• Primary syphilis
• • Classic chancres are not painful and are associated with regional lymphadenopathy. They can become painful if suprainfected with bacteria.
  • The patient is typically afebrile.
  • Symmetric rash is typical; however, the presence of overlying superinfection, scratching, or scaling may make the presentation atypical.
• Secondary syphilis
• • The rash may be macular, papular, pustular, or mixed.
  • Early lesions are typically round, discrete, reddish brown macules, and are usually distributed on the trunk and extremities. These measure approximately 5 mm in diameter. The rash is nonpruritic, and the macules are symmetric.
  • Red papular lesions may appear on the palms, soles, face, and scalp and may become necrotic. The lesions can cross the lifelines of the palms and soles. Alopecia may also occur.
  • Reddish brown papular lesions on the penis or anogenital area can coalesce into large elevated plaques (condylomata lata) up to 2-3 cm in diameter. These can be confused with condylomata acuminata or venereal warts.
  • Superficial painless mucous patches may develop on the tongue, oral mucosa, lips, penis, and vulva. These erosions harbor treponemes and can transmit disease.
  • Thirty percent of patients have recurring symptoms after the primary or secondary stage. Lesions are fewer and are still infectious.
• Tertiary syphilis
• • Tertiary syphilis (gummatous syphilis) manifests cutaneously or may involve visceral organs.
  • Cutaneous gummas may be single or multiple. They are generally asymmetric and grouped together. The lesions may mimic other granulomatous ulcerative lesions and may be histologically indistinguishable from them. Visceral lesions often cause local destruction of the affected organ.
  • The liver and skeleton are commonly affected.
  • Fever, jaundice, anemia, and nighttime skeletal pain are characteristic.
  • Cardiovascular syphilis usually involves the aorta. Invading treponemes cause scarring of the tunica media. Over many years, the inflammatory scarring weakens the aortic wall, leading to aneurysm formation, which causes incompetence of the aortic valve and narrowing of the coronary ostia.
  • Neurosyphilis manifests as an insidious but progressive loss of mental and physical functions and is accompanied by mood alterations. It is caused by invasion of organisms into the CNS. Neurosyphilis chiefly manifests as the 3 following entities:
  • 1. Meningovascular syphilis is characterized by obliterative endarteritis and perivascular inflammation in the brain.
    2. Paretic syphilis is the result of widespread parenchymal invasion that causes individual cell death and brain atrophy.
    3. Tabes dorsalis is the result of damage to the sensory nerves in dorsal roots, producing ataxia and loss of pain sensation, proprioception, and deep tendon reflexes in joints.
• Congenital syphilis
• • Clinical evidence of early congenital syphilis is similar to that of secondary syphilis in adults. The rash has a higher probability of being atypical and can be vesicular or bullous instead of the characteristic reddish brown macular rash.
  • Additional symptoms of early congenital syphilis
  • • Hemorrhagic rhinitis
    • Periostitis
    • Pseudoparalysis, often from pain secondary to osteochondritis
    • Mucous patches
    • Perioral fissures
    • Hepatosplenomegaly
    • Generalized lymphadenopathy
    • Hydrops
    • Glomerulonephritis
    • Thrombocytopenia
    • Neurologic
    • Ocular involvement
  • Late congenital syphilis mainly manifests with neurologic symptoms. Cardiovascular abnormalities are rare. Symptoms include the following:
  • • Prominent frontal bones, depression of nasal bridge, abnormal maxilla development, anterior tibial bowing
    • Clutton joints (arthritis of both knees)
    • Interstitial keratitis
    • Hutchinson incisors
    • Mulberry molars
    • Deafness
    • Paroxysmal cold hemoglobinuria
    • Gummatous involvement

Causes

Syphilis is caused by the spirochete T pallidum, a thin helical cell approximately 0.15 µm X 6-50 µm. T pallidum is a labile organism that cannot survive drying or exposure to disinfectants; thus, fomite transmission (eg, from toilet seats) is virtually impossible. It is solely a human pathogen and does not naturally occur in other species. T pallidum has, however, been cloned in Escherichia coli and has been used experimentally in rabbits. Transmission occurs by penetration of the spirochetes through mucosal membranes and abrasions on epithelial surfaces. It is primarily spread through sexual contact but can be spread by exposure to blood products and transferred in utero.

• Risk factors
• • Unprotected sex, promiscuous sex, and IV drug use are the major risk factors.
  • Health care workers are at occupational risk.
  • See Frequency, Race, Sex, and Age sections.

DIFFERENTIALS

Section 4 of 11  

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• Clinical
• Differentials
• Workup
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• Follow-up
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• Multimedia
• References

Other Problems to be Considered

Primary

Genital herpes
Chancroid
Lymphogranuloma venereum
Granuloma inguinale
Drug eruptions
Carcinoma
Lichen planus
Superficial fungal infections
Psoriasis
Trauma

Secondary

Hepatitis
Infectious mononucleosis
Drug eruptions
Viral exanthemas (eg, pityriasis rosea)
Febrile exanthemas
Scabies
Lichen planus
Psoriasis
Oral candidiasis
Condylomata acuminata

Tertiary

Tuberculosis
Sarcoid
Leprosy
Deep fungal infections
Carcinoma
Lymphoma
Congestive heart failure
Myocardial infarction
HIV
Stroke
Multiple sclerosis
Seizures
Brain tumors
Other CNS infections

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Immunofluorescence staining of mucocutaneous lesions or dock-filled microscopy demonstrates the spirochete in primary, secondary, and early congenital disease.
• Serologic reaginic tests
• • Screening tests include the rapid plasma reagin (RPR) test and the VDRL test.
  • Sensitivities are 70-80% for patients with primary syphilis and approach 99-100% for patients with secondary syphilis. These tests have high false-positive rates. Other factors (eg, lupus, concomitant viral or bacterial infection, recent immunization, pregnancy) may give false-positive readings.
  • Serological tests cannot differentiate the different species of the treponeme family (eg, yaws).
  • Use VDRL titers to follow efficacy of treatment.
  • The VDRL test turns positive 1-2 weeks after chancre formation. After a positive VDRL test finding, follow up with a more specific test.
  • A small percentage of adequately treated individuals have persistently positive VDRL test findings. See Further Outpatient Care for more information.
• The fluorescent treponemal antibody absorption (FTA-ABS) test is reactive in 85% of primary cases, in 99-100% of secondary cases, and in 95% of latent or late cases. It should be used as a confirmatory test for positive VDRL or RPR test findings.
• The T pallidum hemagglutination (TPHA) test and the T pallidum particle agglutination (TPPA) test are generally used for screening.
• Treponemal enzyme immunoassay (EIA/immunoglobulin G [IgG], immunoglobulin M [IgM]) tests may be performed.
• Testing must be performed more than once in patients diagnosed with latent syphilis in order to exclude laboratory error.
• Infants with congenital syphilis and positive VDRL or FTA-ABS test results can have an IgM FTA-ABS test (maternal IgM is not passed to the fetus in utero). A 35% false-negative rate and a 10% false-positive rate still exist. See the Congenital syphilis testing section in Special Concerns for more information.

Imaging Studies

• Obtain a chest radiograph for patients with tertiary syphilis to screen for aortic dilation.
• CT scan and MRI of the head and body may be employed to document the complications of tertiary syphilis.

Other Tests

• Slit-lamp examination and ophthalmic assessment can differentiate between acquired and congenital syphilis (presence of interstitial keratitis) in patients with latent infection of uncertain duration.

Procedures

• Lumbar puncture
• • CNS invasion by treponemes occurs in 30-40% of patients with primary or secondary syphilis; however, no studies show this to be a predictor of poor neurologic outcome.
  • Lumbar puncture (LP) is not indicated for patients with early syphilis. Current guidelines in clinical infectious diseases state that physicians should evaluate cerebrospinal fluid (CSF) in individuals with latent syphilis of unknown duration or with late latent syphilis if (1) treatment fails, (2) neurologic or ocular symptoms are present; or (3) the patient has underlying HIV infection. Patients with high titers on serological tests (³1:32) have only a relative indication for performing an LP.
  • Examination of the CSF should include the VDRL test, cell count, and protein level. Abnormalities of any of these measurements combined with a suggestive history and examination strongly indicate the presence of neurosyphilis. Derangements of these values are consistently found in neurosyphilis. The presence of a positive VDRL test result is indicative of active disease. A positive polymerase chain reaction (PCR) test finding is sensitive in detecting past invasion of the CNS but does establish whether the organisms are still alive.

Histologic Findings

The primary lesion of syphilis is a chancre. Histologically, it is characterized by mononuclear leukocytic infiltration, macrophages, and lymphocytes.

The inflammatory reaction of secondary syphilis is histologically similar to that of the primary chancre but is less intense.

In tertiary syphilis, histological examination shows palisaded macrophages and fibroblasts as well as plasma cells surrounding the margins. Treponemes are rare in these lesions and typically cannot be cultured or visualized.

TREATMENT

Section 6 of 11  

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• Follow-up
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• References

Medical Care

• Clinical and serologic conversions are the endpoints of medical treatment.
• Obtain follow-up VDRL test levels to document treatment efficacy.

Surgical Care

• Surgical care is reserved for treating the complications of tertiary syphilis (eg, aortic valve replacement).

Consultations

• Infectious disease consultation may be required for difficult or complex cases.
• Consult dermatology, vascular surgery, ophthalmology, and neurology to assist with the variable presentations.

MEDICATION

Section 7 of 11  

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The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Penicillin is the DOC for treating syphilis.

Researchers are studying the efficacy of ceftriaxone and azithromycin in treating syphilis. CNS penetration and its similarity to penicillin support the use of ceftriaxone in the treatment of syphilis. Studies are presently inconclusive, and Centers for Disease Control and Prevention (CDC) guidelines neither support nor refute its use. Given the limited data available to support its efficacy, prudence dictates a 5- to 7-day course of treatment for early syphilis.

The long half-life of azithromycin and its clinical efficacy in vitro against syphilis support its use in treating early syphilis; however, clinical data are currently insufficient to recommend its use.

No good evidence indicates that the non–beta-lactam antibiotics, which are used as alternatives to penicillin, are clinically effective.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

FOLLOW-UP

Section 8 of 11  

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• Introduction
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Inpatient Care

• Inpatient care is generally reserved for complications of late syphilis.

Further Outpatient Care

• The Clinical Effectiveness Group notes that follow-up visits should be performed at 3-, 6-, and 12-month intervals.
• Monitor patients who have neurosyphilis with physical examinations, CSF testing, and serologic testing every 6 months for at least 3 years.
• Patients with HIV or patients treated with a nonpenicillin regimen should be followed for life.
• Clearly defined criteria regarding failure of treatment are lacking. In their literature review, Augenbraun and Rolfs found that 15-25% of patients treated for syphilis do not have a 4-fold decrease in titers over a 3-month period, and some do not have a decrease for 6 months or longer. Information is lacking on whether these patients are at higher risk for progression. Currently accepted guidelines are as follows:
• • Any reappearance of symptoms is defined as a relapse.
  • More than a double-dilution increase (ie, a 4-fold titer increase) in serologic tests is a relapse.
  • Patients with latent syphilis who have initially high titers (³1:32) and fail to have a double-dilution decrease (4-fold titer decline) 12-24 months after therapy should be reevaluated for neurosyphilis and possible retreatment.
  • Some treponemal test results may remain positive for life despite effective treatment. Individuals in this circumstance require proper documentation to avoid unnecessary retreatment.
  • Supervise retreatment to ensure compliance.

In/Out Patient Meds

• See Medication.

Deterrence/Prevention

• The primary goal of prevention is to limit the spread of disease. This entails counseling patients to use safe sex practices and advising patients who abuse IV drugs to never share needles and to use clean needles.
• Educate health care workers to use universal precautions when treating all patients.
• Studies of primary screening for syphilis in clinics and emergency departments are favorable for screening of high-risk, inner-city populations. Routine screening is advocated for all at-risk mothers.
• Notification and treatment of sexual partners and exposed drug partners are of paramount importance.

Complications

• Jarisch-Herxheimer reaction
• • Following treatment, temporary intensification of existing lesions may occur, with symptoms of fever, malaise, chills, headache, and myalgias. The reaction is quite common, develops within several hours after beginning antibiotic treatment, and clears within 24 hours.
  • The etiology of the reaction is unclear, although it may be due to an immunological reaction to the rupture of spirochetes.
  • Treatment often involves symptomatic management and observation. In pregnant women, treatment may induce early labor or cause fetal distress.
• Procaine toxicity
• • Some patients experience severe anxiety and other psychological disturbances after the administration of procaine penicillin.
  • Fever, hallucinations, hyperventilation, and convulsions characterize the reaction.
  • Circulatory collapse is occasionally reported.
  • Resuscitation and supportive care are necessary in severe cases; however, most reactions are mild, requiring only reassurance or symptomatic relief.
  • Symptoms usually dissipate in 30 minutes.
• Untreated syphilis leads to the complications of tertiary syphilis, which include cardiovascular or aortic disease, CNS abnormalities, end organ damage, and disfigurement by gummas.

Prognosis

• Treatment of primary and secondary syphilis has a high cure rate. No treponemal resistance to penicillin is documented.
• Untreated primary or secondary syphilis has a 1-in-3 chance of progressing to tertiary syphilis.
• With adequate treatment, 90% of patients with neurosyphilis have a clinical response.

Patient Education

• See Deterrence/Prevention.
• Advise patients who abuse IV drugs to avoid sharing needles and to use clean needles. Needle exchange programs are in place in some areas; however, the establishment and existence of these programs remain controversial in many communities.
• Stress to patients the importance of compliance with their entire antibiotic course and follow-up visits.
• Counsel patients to use safe sex practices.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center and Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Sexually Transmitted Diseases, Syphilis, Birth Control Overview, and Birth Control FAQs.

MISCELLANEOUS

Section 9 of 11  

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• Miscellaneous
• Multimedia
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Medical/Legal Pitfalls

• Syphilis, a reportable disease, is tracked by the CDC.
• Test patients diagnosed with syphilis for other STDs, including infections with Chlamydia, gonococcus, Trichomonas, bacterial vaginosis, and HIV.
• When making a primary diagnosis of a generalized rash or of an STD, always include syphilis in the differential because of its varying manifestations. Consider prophylactic treatment or serologic studies for syphilis.
• Consider congenital syphilis and sexual abuse in all children who present with syphilis.
• Counsel patients to notify their partners of infection and to inform them of the need to be treated.
• Track patients to ensure adequacy of treatment.

Special Concerns

• Pregnancy
• • Routinely screen all pregnant women. Repeat tests for high-risk mothers and patients who live in high-risk areas for syphilis (eg, inner city) before delivery. The rate of stillbirths in untreated syphilitic mothers is as high as 33%.
  • For pregnant patients who have positive VDRL test results, perform monthly VDRL tests for the duration of the pregnancy.
  • For pregnant patients who are allergic to penicillin, current CDC recommendations are for desensitization and subsequent treatment with penicillin. Erythromycin has also been used in penicillin-allergic pregnant patients even though it is less effective than other treatment regimens.
  • Penicillin is safe to use while breastfeeding.
  • Ceftriaxone has been used for the treatment of syphilis, but data are limited regarding efficacy.
• Congenital syphilis testing
• • Most infants with syphilis at birth are born to mothers either (1) not treated in pregnancy or (2) treated too late during pregnancy.
  • Mothers infected with T pallidum deliver infants with positive VDRL and FTA-ABS test results secondary to passive transfer of IgG antibodies, which react with the reagents in these tests.
  • Most infants are born without any clinical evidence of syphilis. Because infants may develop serious disease up to several weeks after delivery, it is important to follow the care of these patients with serial serological tests. If the mother has been adequately treated for syphilis during pregnancy and the infant has no symptoms, serial VRDL tests for 2 months are adequate. A rising titer over a 2-month course is evidence of active disease, whereas falling titers indicate passive maternal antibody transfer.
  • Some clinicians empirically treat infants who have positive serologic tests with penicillin to avoid the inconvenience of serial testing and the risk of no follow-up care.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Syphilis. These photographs depict the characteristic chancre observed in primary syphilis. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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Media file 2:  Syphilis. These photographs show the disseminated rash observed in secondary syphilis. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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Media file 3:  Syphilis. These photographs show close-up images of gummas observed in tertiary syphilis. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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Media file 4:  Syphilis. This is a dark-field micrograph of spirochetes. Used with permission from Murray P et al. Medical Microbiology. 2nd ed. Mosby; 1994.
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Media file 5:  Syphilis. This photograph depicts primary syphilis "kissing" lesions. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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Media file 6:  Syphilis. Palmar lesions observed in secondary syphilis. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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Media file 7:  These photographs illustrate examples of condylomata lata. The lesions resemble genital warts (condylomata acuminata). Fluids exuding from these lesions are highly infectious. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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Media file 8:  Syphilis. These photographs illustrate typical facies of congenital syphilis. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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Media file 9:  Syphilis. This photograph shows an example of Hutchinson teeth in congenital syphilis. Note notching. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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Media file 10:  Syphilis. This photograph illustrates chorioretinitis of congenital syphilis. Used with permission from Wisdom A. Color Atlas of Sexually Transmitted Diseases. Year Book Medical Publishers Inc; 1989.
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REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Augenbraun M, Workowski K. Ceftriaxone therapy for syphilis: report from the emerging infections network. Clin Infect Dis. Nov 1999;29(5):1337-8. [Medline].
• Augenbraun MH, Rolfs R. Treatment of syphilis, 1998: nonpregnant adults. Clin Infect Dis. Jan 1999;28 Suppl 1:S21-8. [Medline].
• Bennett JC, Plum F. Cecil Textbook of Medicine. 20th ed. WB Saunders Company;. 1996:1705-1713.
• Bordon J, Martinez-Vazquez C, de la Fuente-Aguado J. Response to standard syphilis treatment in patients infected with the human immunodeficiency virus. Eur J Clin Microbiol Infect Dis. Oct 1999;18(10):729-32. [Medline].
• CDC. Congenital syphilis, United States, 1998. MMWR Morb Mortal Wkly Rep. 1999;48(34):757-760. [Medline].
• CDC. Primary and secondary syphilis, United States, 1998. MMWR Morb Mortal Wkly Rep. 1999;48(39):873-8. [Medline].
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Article Last Updated: Aug 1, 2006