• Camelia Brande

Syphilis - an STI on the rise, again

April is STD Awareness Month and we believe it is time to focus on this important topic. According to the WHO (World Health Organization) around 1 million STIs are acquired every day worldwide.

In the previous weeks, we talked about STIs, STDs and VDs and the differences between them and about some of the most common STIs, Chlamydia and Gonorrhea.


Now we are sharing some very interesting facts about another common STI, that unfortunately is making its way back, the one and only Syphilis.

What is Syphilis and what are the symptoms? Let’s find out!


Syphilis is a sexually transmitted disease acquired through an infection with the bacterium Treponema pallidum, and it affects only humans. It was first discovered in the 15th century in Europe and was a mystery to many. Only four centuries later was it medically identified. Throughout history, many public figures, such as politicians, musicians and literature writers got infected with this bacteria. Thankfully, with the discovery of penicillin and effective public measures, syphilis had a decline in the United States and Europe.


Syphilis still remains a public health concern as in the last decades, in Western Europe, the USA and China cases of syphilis have shown an increase in MSM (men who have sex with men), while in low and middle-income countries syphilis has remained an endemic (commonly spread disease that is present in specific regions). In 2018, men accounted for almost 90% of syphilis cases. More than half of them reported having sex with men and approx. 40% of them were infected with HIV (Human Immunodeficiency Virus), as syphilis increases the risk of infection with HIV through the open wounds that develop. Besides HIV, syphilis can be accompanied by other STIs as well.


Each year, around 11 million new cases of syphilis develop in people aged 15 to 49 years worldwide. With a high transmission rate, up to 30% of individuals that have sexual contact with an infected person acquire the infection as well. The spread of syphilis can be controlled but it is dependent on the early diagnosis and treatment.


Transmission

  • Skin to skin contact during sexual activity (vaginal, anal and oral sex)

  • From mothers to babies, during the pregnancy in the uterus or during birth

  • Through blood transfusions (rare)

  • Organ donors (rare)

  • Occupational exposure (via accidental injury, transmission through blood)

  • Through human bite in both sexual and non-sexual circumstances

  • Through mouth-to-mouth feeding of infants with pre-chewed food from infected relatives


Risk categories where diagnosis and screening is difficult due to stigma and social constructs

  • MSM (men who have sex with men); MSM are reported to have a riskier sexual life.

  • People that have multiple sex partners

  • Sex workers

  • Transgender women

  • People that used injectable drugs or that had sex with a person who injected drugs


Syphilis symptoms


Syphilis is a chronic disease that presents different stages, which develop over multiple years, even decades if left untreated. The different stages are characterized by periods of active disease, interrupted by periods of latency. Left untreated, its development process has the following stages: infection with T. pallidum → primary syphilis → secondary syphilis → latent syphilis -> tertiary syphilis/no further development. From latent syphilis, 70% of cases do not develop further while the rest can develop into tertiary syphilis. Primary and secondary syphilis have the highest risk of transmitting the infection to other people.


Primary syphilis

  • It presents itself as a chancre (a painless ulcer- open wound) in the genital area

  • In heterosexual men, the chancre develops usually on the penis, while in MSM (men who have sex with men) 30% of cases appear in other regions as well, such as the anal or oral area

  • In women, the chancre develops on the labia (the folds of skin around the vaginal opening) or cervix (a cylinder-shaped neck of tissue that connects the uterus and the vaginal canal)

  • Because the chancre does not present any pain and it is usually in hidden regions, sometimes it is difficult to be diagnosed

  • After acquiring the infection, the bacteria multiply at the site of infection in a period of up 90 days and the symptoms may appear after 3 weeks of getting infected

  • Left untreated, the chancre usually heals spontaneously within 4 to 6 weeks, without showing any symptoms


Secondary syphilis

  • During the evolution of primary syphilis, the bacteria spreads into other tissues and organs

  • Symptoms appear usually after 3 months of the initial infection and are hard to diagnose as they are not very specific

  • Symptoms are: sore throat, muscle pain, weight loss, malaise (general feeling of discomfort), low-grade fever

  • The most common symptom of secondary syphilis is disseminated mucocutaneous rash (rash extended on a large surface of the body) that is usually found on the palms of the hands and the soles of the feet

  • Up to 11% of patients present an infection with T. pallidum in the hair follicles, leading to alopecia (spot baldness), facial and body hair loss

  • In this stage of secondary syphilis, up to 10% of patients develop condylomata lata (similar to genital warts) in the genital area, that are highly infectious; these warts-like forms can appear on the tongue as well

  • Secondary syphilis can cause complications such as gastric (stomach) problems, hepatitis and kidney damage

  • Left untreated, symptoms can resolve spontaneously within 3 months of appearance


Latent syphilis

  • Appears after a period of not having any symptoms after the secondary syphilis heals spontaneously

  • It represent the inactive period between the secondary syphilis and the tertiary syphilis

  • It can be classified into early latent syphilis and late latent syphilis

  • Early latent syphilis is considered as the period of the first year after the infection, when 25% of patients can again develop symptoms of secondary syphilis

  • Late latent syphilis is defined as the infection without symptoms that has a duration longer than a year and can last up to 30 years after the initial infection; meaning that in this period patients are tested positive for syphilis but the sexual transmission is very unlikely

  • Even though sexual transmission is unlikely, pregnant women in this phase can pass the infection through blood to the fetus inside the uterus

  • Latent syphilis ends when treatment is provided or when it develops into tertiary syphilis


Tertiary syphilis

  • Around one-third of patients with latent syphilis develop tertiary syphilis

  • This was more common in the past, in the pre-antibiotic area. Nowadays it is very rare, as most patients receive treatment during the primary or secondary syphilis

  • The symptoms usually appear after 20 up to 40 years after the initial infection and develop into the following syndromes (a group of symptoms that are correlated with each other)

  • gumma (a tumor-like growth that degrades the skin and bones) appears in 15% of patients with untreated syphilis

  • Cardiovascular syphilis: aortic insufficiency (when the heart can’t keep the normal blood flow) or aneurysm (when the wall of the blood vessel that goes to the heart gets weak and creates a balloon shape form that can burst and lead to internal bleeding) appears in 10% of untreated patients

  • Neurological syphilis: insomnia (sleep disorder characterized by the difficulty of falling or staying asleep), personality changes, loss of consciousness, seizures, memory loss, hallucinations, loss of temperature and deep pain sensations, blindness, dementia, paranoia, hearing loss, tinnitus (experiencing ringing or other sounds in the ears); appear in 6.5% of untreated patients


Congenital (present from birth) syphilis

  • pregnant women with untreated syphilis can pass the infection through blood to the fetus inside the uterus (studies show that this is the case with untreated syphilis acquired even 4 years before giving birth)

  • It can result in miscarriage, stillbirth (birth of a deceased fetus), fetal death, fetal damage, birth of an infected infant, premature delivery

  • Infants that are born with the infection can present low weight, severe hepatitis (inflammatory disease of the liver) and pulmonary hemorrhage (bleeding from the lungs)

  • Prevention is possible by early prenatal (before birth) screening and treatment of the pregnant woman

  • All women should be screened for syphilis early in pregnancy and those at high risk should be screened again at 28 weeks of pregnancy and at delivery


Screening

  • Physical examination of wounds or rashes that can appear in the genital area or other body parts exposed to infection; it is done in a clinical setting by a doctor

  • Blood test: the blood test can show if you currently have syphilis or had it in the past

  • Swab test: a swab can be used to collect fluid from wounds and rashes and later tested for syphilis


Treatment

  • Syphilis can be treated easily with antibiotics, if detected in time

  • Partner treatment is essential in order to manage syphilis outbreaks

  • There have been many attempts to develop a vaccine against syphilis but none resulted in being effective

  • Studies show that humans can be re-infected with syphilis after they received treatment


Strategies

  • In 2016 WHO (World Health Organization) released a new strategy to combat and prevent STIs that aims to have a 90% reduction in syphilis incidence globally by 2030

  • Strengthening the public health infrastructure such as improving testing and screening, providing sex education, promoting condom use, providing medication supply, providing treatment for infected patients, encouraging partner treatment and developing preventive medicine and vaccines are strategies that will ultimately decrease the incidence of syphilis


In the meantime, let’s stay safe and test ourselves.


Be smart. Be (c)LIT. Fly with us!🌺🐝

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360276/

https://pubmed.ncbi.nlm.nih.gov/30116697/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5354565/

https://pubmed.ncbi.nlm.nih.gov/32101666/

https://pubmed.ncbi.nlm.nih.gov/25702043/

https://www.cdc.gov/std/stats/archive/STD-Surveillance-2015-print.pdf

https://www.nhs.uk/conditions/syphilis/diagnosis/