Syphilis: Clinical Aspects

Abstract

Syphilis is a common sexually transmitted disease which, if left untreated, can result in a multiorgan infection. The causative organism is the spirochaete (from the Greek ‘spiral hairs’) Treponema pallidum. Other subspecies cause similar diseases such as yaws and pinta but these tend to be less severe and do not cause multisystem morbidity. Syphilis is a classic biphasic illness characterised by an initial skin infection which may be followed years later by involvement of the central nervous system (CNS), skeletal and cardiovascular systems with the great vessel the aorta at particular risk. Congenital transmission can occur and a range of clinical features can afflict the baby. Severe deformities, and even intrauterine death, are associated with transmission late in the pregnancy. Early and appropriate antimicrobial treatment of syphilis in all its guises is therefore of critical importance. Newer imaging techniques have become a useful adjunct in aiding diagnosis, which still relies heavily on serological assays and clinical acumen.

Key Concepts:

  • Enhancement of infectivity of syphilis and of early syphilitic lesions, in patients with concomitant HIV.

  • The relapsing nature of syphilis, both in early stages and in the late congenital disease, as in interstitial keratitis and Clutton's joints.

  • Primary form of syphilis is an early localised primary lesion. The secondary phase is manifested by a systemic disease, whereas the later stages are again localised.

  • Similarly, early congenital lesions tend to be disseminated, whereas late lesions are localised.

  • Newer imaging techniques are useful both in diagnosis and for monitoring treatment, especially in those patients with brain and cardiovascular syphilis.

Keywords: clinical syphilis; HIV; rash; syphilis of heart; syphilis of nervous system; treatment

Figure 1.

Bone scan of syphilitic periostitis using a 99mTc radioisotope. Reproduced from Teng‐Teng et al. with permission from BMJ Publishing Group Ltd.

Figure 2.

Experimental T. pallidum infection in rabbits. Ulcerative rash on the shaved surface of a rabbit inoculated intravenously with T. pallidum showing diffuse symmetrical distribution of the lesions.

Figure 3.

Right eye of patient at presentation: (a) colour fundus photograph showing the raised creamy yellow choroidal lesion and retinal haemorrhages; (b) early and (c) late phase of the FFA showing early hyper‐ and hypofluorescence and late leak; (d) ICG of the right eye showing hyperfluorescent spots nasal to the disc; and (e) Optical Coherence Imaging (OCT) demonstrating the presence of subretinal fluid. Reproduced from Joseph et al. with permission from Nature Publishing Group.

Figure 4.

Charcot knee showing subluxation of the joint with shortening. Patient presented with swelling and mild nocturnal joint pain.

Figure 5.

(a and b) Angiography showed critical obstruction from both right and left main coronary ostia. (c) Biopsy revealed nonspecific aortitis characterised by lymphocyte and plasma cell infiltrate adjacent to small vessels in the adventitia. (d) Contrast‐enhanced multidetector computed tomography confirmed the ostial coronary obstructions. (e) Three‐dimensional surface reconstruction showing clearly near‐obstruction of both right and left coronary ostia, as well as the three surgical bypass grafts (arrowheads, from left to right: saphenous vein to right coronary; left internal thoracic to left anterior descending; saphenous vein to marginal branch of the circumflex coronary arteries, respectively). Aortitis (the basic lesion of cardiovascular syphilis), aortic aneurysms and aortic regurgitation may all be detected by angiography, although such conditions may be primarily identified on echocardiography in the first instance. However an interesting case report published in 2009, shows the full role angiography and imaging can play in syphilitic aortitis. Reproduced from Vianna et al. with permission from Oxford University Press.

Figure 6.

Congenital syphilitic liver showing massive infiltrate of T. pallidum. The architecture of the liver is well preserved (Warthin and Starrey stain; original magnification ×900).

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Further Reading

Baughn RE and Musher D (2005) Secondary syphilitic lesions. Clinical Microbiology Reviews 18: 205–216.

Hira SK, Bhat GJ, Patel JB et al. (1985) Early congenital syphilis: clinico‐radiologic features in 202 patients. Sexually Transmitted Diseases 12: 177–183.

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Tramont EC (2010) Treponema pallidum (Syphilis). In: Mandel GL, Bennett JE and Dolin R (eds) Principles and Practice of Infectious Disease, 7th edn, vol. 2, chap. 238, pp. 3035–3053. New York: Elsevier Churchill Livingstone.

Wiedmann A (Ed.) (1962) Syphilis and Ulcus Molle. Heidelberg: Springer (German).

Worster‐Drought C (1940) Neurosyphilis (Syphilis of the Nervous System). London: John Bale.

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Wright, David J, Norris, Steven J, Dhillon, Rishi H‐P, and Edmondson, Diane G(Jan 2012) Syphilis: Clinical Aspects. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0002245.pub3]