A young woman presents to the office with a total body rash for one week (Figure 181-1). She denies other symptoms and the rash does not itch. Upon examination, tattoos on her hands are visible and she does admit to experimenting with crack and IV heroine. The physician suspects that she may have secondary syphilis and she admits to many sexual partners especially while using drugs. She is given a shot of 2.4 million units of benzathine penicillin IM in the office and her blood is drawn for an RPR and an HIV test. The RPR and HIV tests come back positive along with a treponemal specific confirmatory test. The patient is called to return to the office for some serious counseling and a referral to an infectious disease specialist. The ID specialist is called on the phone to see if he wants to admit her for a lumbar puncture or if he will do this as an outpatient. She needs investigation for neurosyphilis due to her positive HIV status.

Syphilis, caused by Treponema pallidum, is a systemic disease characterized by multiple overlapping stages: primary syphilis (ulcer), secondary syphilis (skin rash, mucocutaneous lesions, or lymphadenopathy), tertiary syphilis (cardiac or gummatous lesions), and early or late latent syphilis (positive serology without clinical manifestations). Neurosyphilis can occur at any stage. Diagnosis is made using treponemal and nontreponemal tests. Treatment is penicillin; the dose and duration depend on the stage.

Lues is another word for syphilis.

Nontreponemal Tests

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  VDRL—Venereal Disease Research Laboratory.

  
  
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  RPR—Rapid Plasma Reagin.

Treponemal Tests

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  EIA—Enzyme immunoassay.

  
  
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  TPPA—T. pallidum particle agglutination.

  
  
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  FTA-ABS—Fluorescent treponemal antibody absorption.

  
  
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  MHA-TP—Microhemagglutination assay for T. pallidum.

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  Primary and secondary (P&S) syphilis cases reported to CDC increased from 11,466 in 2007 to 13,970 in 2011, an increase of 22 percent.¹ The rate of P&S syphilis in the US in 2011 (4.5 cases per 100,000 population) was 2.2 percent lower than the rate in 2009 (4.6 cases). This is the first overall decrease in P&S syphilis in 10 years.¹

  
  
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  The prevalence of P&S syphilis per 100,000 population is extremely low in ages 0 to 4 (0.0), 5 to 9 (0.0), and 10 to 14 (0.1) year olds, with only 25 reported cases in 2011.¹

  
  
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  The prevalence of P&S syphilis per 100,000 between the ages of 15 and 19 is 3.9, and is higher in males (5.4) than females (2.4).¹

  
  
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  Syphilis in persons ages 15 to 19 differs by races/ethnicities. In 2011, prevalence per 100,000 was 16.7 in black, 2.5 in Hispanic, and 0.9 in white persons.¹

  
  
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  In 2008, 63 percent of the reported cases of P&S (adolescents and adults combined) were in men who have sex with men (MSM).²

  
  
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  HIV-infected patients were found to have syphilis rates of 62.3 per 1000 compared to 0.8 per 1000 in HIV-uninfected patients in a population study of adults in California.³

  
  
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  In 2011, there were 362 reported cases of congenital syphilis, 8.4 per 100,000 live births.¹

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  Syphilis is caused by the spirochete T. pallidum and contracted through direct sexual contact with primary or secondary lesions.

  
  
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  Congenital syphilis can be contracted across the placenta. Seventy-five percent to 95 percent of fetuses are infected when untreated maternal syphilis was contracted within 2 years. Thirty-five percent of fetuses are infected when maternal syphilis was contracted more than 2 years before pregnancy.

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  Sexual contact with a person with primary or secondary syphilis.

  
  
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  Gay males.

  
  
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  Prostitution.

  
  
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  Sex for drugs.

  
  
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  HIV/AIDS.

Clinical Features

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  Primary syphilis is associated with a chancre—Usually a nonpainful ulcer (Figures 181-2 and 181-4). The presence of pain does not rule out syphilis, and the patient with a painful genital ulcer should be tested for both syphilis and herpes.

  
  
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  Secondary syphilis occurs when the spirochetes become systemic and may present as a rash with protean morphologies, condyloma lata, and/or mucous patches (Figures 181-5 to 181-7).

  
  
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  Tertiary syphilis may be visualized with gummas on the skin, but many of the manifestations are internal such as the cardiac and neurologic diseases that occur (e.g., aortitis, tabes dorsalis, and iritis). As tertiary syphilis takes years to develop and penicillin treatment is readily available, it is unlikely to ever see this in a child.

  
  
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  Neurosyphilis can occur at any stage. Clinical symptoms include cognitive dysfunction, vision or hearing loss, uveitis or iritis, motor or sensory abnormalities, cranial nerve palsies, or symptoms of meningitis.

  
  
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  Congenital syphilis.

  
  
  
  
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    Early manifestations (within 2 years, typically by 2 to 3 months) include rhinitis, mucocutaneous lesions, bone changes, hepatosplenomegaly, lymphadenopathy, anemia and jaundice (Figures 181-8 and 181-9).

    
    
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    Late manifestations (after 2 years of age, without treatment) include interstitial keratitis, eight-nerve deafness, recurrent arthropathy, saber shins, saddle nose, tooth abnormalities, and neurosyphilis (Figures 181-10 to 181-12).