Download syphilis: clinical Manifestations, Diagnosis, and Management

Infectious Diseases Board Review Manual
Syphilis: Clinical Manifestations,
Diagnosis, and Management
Kokila B. Nagendran, MBBS, and Jose A. Bazan, DO
INTRODUCTION
After a substantial decline in the number of
syphilis cases since reporting began in 1941, a
resurgence of syphilis in the United States over
the past decade has made this disease a major
public health concern once again.1 The number
and rates of primary and secondary syphilis cases
reported each year in the United States increased
from 8724 to 16,663 cases and from 2.9 to 5.3
cases per 100,000 population, respectively, between 2005 and 2013. Furthermore, the incidence
of early syphilis has increased across the country
among men, especially men who have sex with
men (MSM). The proportion of cases of primary
and secondary syphilis diagnosed in MSM increased from 77% (6366 cases) in 2009 to 83.9%
(8701 cases) in 2012.2
Also of great public health concern is the fact
that syphilis increases the likelihood of acquiring
and transmitting HIV.3,4 According to the Centers
for Disease Control and Prevention (CDC), the
median proportion of MSM with primary and secondary syphilis who were also infected with HIV in
2013 was 45.5% (range 15.8%–47.4%).5 High HIV
seroconversion rates have been reported following
primary and secondary syphilis infection.6 The current syphilis epidemic has been characterized by
a high number of early-stage syphilis cases.7,8 The
reemergence of syphilis in modern times makes
it imperative that all health care providers be able
to recognize the signs and symptoms of syphilis,
conduct risk assessments, screen vulnerable and
at-risk populations, treat promptly to prevent shortand long-term complications, and appropriately
manage exposed sex partners.9
NATURAL HISTORY AND DIAGNOSIS
Case Patient 1
A 32-year-old African American man presents
with a rash that involves his body as well as the
palms of his hands and soles of his feet. He also
complains of mouth sores and reports experiencing generalized malaise for the past 4 weeks
(Figure 1). He was last tested for HIV 3 years ago
and tested negative at that time. He reports having
had 8 male sex partners in the past 6 months and
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Infectious Diseases Volume 16, Part 6 1
Syphilis: Clinical Manifestations, Diagnosis, and Management
A
C
B
Figure 1. Manifestations of secondary syphilis observed in Case Patient 1:
(A) oral mucous patches, (B) macular rash, and (C) palmoplantar rash.
(Images courtesy of Dr. Jose A. Bazan/Columbus Public Health.)
engaging in unprotected receptive anal intercourse
and receptive oral intercourse. He also reports that
he uses the Internet to find anonymous sex partners and uses methamphetamines during some
sexual encounters. Given the physical exam findings, the physician is concerned about the possibility of syphilis infection.
• What is the natural history of syphilis infection?
Syphilis, also known as the “Great Imitator,”
is a sexually transmitted infection caused by the
spirochete Treponema pallidum. The natural history of syphilis infection is characterized by periods of symptomatic disease and long periods
2 Hospital Physician Board Review Manual
of asymptomatic infection, or latency.8 Clinical
manifestations of symptomatic infection include
primary syphilis, secondary syphilis, certain forms
of neurosyphilis, tertiary syphilis, and congenital
syphilis (result of vertical transmission).8–11 The
asymptomatic stages include early latent (infection
of less than 1 year’s duration) and late latent syphilis (infection of more than 1 year’s duration).8,9 Primary, secondary, and early latent syphilis are collectively referred to as “early syphilis” and represent
the stages of infection with the highest probability
of transmission to exposed individuals.9 In fact, up
to 30% of individuals who have come in contact
with active mucocutaneous lesions (as seen in the
primary and secondary stages) within the previous
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