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Sexually Transmitted Diseases (STDs)
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Syphillis

Syphilis, once a cause of devastating epidemics, now can be effectively controlled with antibiotic therapy. Yet, in many cities of the United States both adult and congenital syphilis are on the rise. In 1990, about 134,000 cases were reported to the U.S. Public Health Service. Although treatment is available, the early symptoms of syphilis can be very mild, and many people do not seek treatment when they first become infected. Of increasing concern is the fact that a person with syphilis sores who has sex with someone infected with HIV (the virus that causes AIDS) is at high risk for developing HIV infection.

Syphilis is a sexually transmitted disease (STD) caused by a bacterium called Treponema pallidum. The bacterium can move throughout the body, damaging many organs over time. Medical experts describe the course of the disease by dividing it into four stages--primary, secondary, latent, and tertiary (late). An infected person who does not get treatment may infect others during the first two stages and during the early latent stage, which usually lasts 1 to 2 years. In its late stages, untreated syphilis, although not contagious, can cause serious heart abnormalities, mental disorders, blindness, other neurological problems, and death.

The bacterium spreads from the sores of an infected person to the mucous membranes of the genital area, the mouth, or the anus of a sexual partner. It also can pass through broken skin on other parts of the body. The syphilis bacterium is very fragile, and the infection is rarely, if ever, spread by contact with objects such as toilet seats or towels. A pregnant woman with syphilis can pass the bacterium to her unborn child, who may be born with serious mental and physical problems as a result of this infection.

The most common way to get syphilis is to have sex with someone who has an active infection. People at increased risk for syphilis, like those at high risk for other STDs, are those who have had multiple sex partners, have sexual relations with an infected partner, have a history of STDs, and do not use condoms (rubbers).

Symptoms

The first symptom of primary syphilis is a sore called a chancre ("shan-ker"). The chancre can appear within 10 days to 3 months after exposure, but it generally appears within 2 to 6 weeks. Because the chancre is ordinarily painless and sometimes occurs inside the body, it may go unnoticed. It is usually found on the part of the body exposed to the bacteria, such as the penis, the vulva, or the vagina. A chancre can also develop on the cervix, tongue, lips, or other parts of the body. The chancre disappears within a few weeks whether or not treatment is obtained. If not treated during the primary stage, the disease may progress through three other stages.

Secondary syphilis is marked by a skin rash that appears anywhere from 3 to 6 weeks after the chancre appears. The rash may cover the whole body or appear only in a few areas, such as the palms of the hands or soles of the feet. Because active bacteria are present in these sores, any physical contact--sexual or nonsexual--with the broken skin of an infected person may spread the infection at this stage. The rash usually heals within several weeks or months. Other symptoms may also occur, such as mild fever, fatigue, headache, sore throat, as well as patchy hair loss, and swollen lymph glands throughout the body. These symptoms may be very mild and, like the chancre of primary syphilis, will disappear without treatment. The signs of secondary syphilis may come and go over the next 1 to 2 years.

If untreated, syphilis then lapses into a latent stage during which the disease is no longer contagious and no symptoms are present. Many people who are not treated will suffer no further consequences of the disease. However, approximately one-third of those infected go on to develop the complications of late, or tertiary, syphilis, in which the bacteria damage the heart, eyes, brain, nervous system, bones, joints, or almost any other part of the body. This stage can last for years, or even for decades. Late syphilis, the final stage, can result in mental illness, blindness, other neurological problems, heart disease, and death.

Neurosyphilis: The syphilis bacterium frequently invades the nervous system during the early stages of infection, and approximately 3-7 percent of persons with untreated syphilis develop neurosyphilis. Some persons with neurosyphilis never develop any symptoms. Others may have headache, stiff neck, and fever that result from an inflammation of the lining of the brain. Some persons develop seizures. In those whose blood vessels are affected, symptoms of stroke can occur with resulting numbness, weakness, or visual complaints. In some instances, the time from infection to the development of neurosyphilis may be up to 20 years. Neurosyphilis may be more difficult to treat, and its course may be different, in people with HIV infection.
Diagnosis
Syphilis has sometimes been called "the great imitator" because its early symptoms are similar to those of many other diseases. People who have more than one sex partner should consult a doctor about any suspicious rash or sore in the genital area. Those who have been treated for another STD such as gonorrhea should be tested to be sure they have not also acquired syphilis.

There are three ways to diagnose syphilis: a doctor's recognition of its signs and symptoms, microscopic identification of syphilis bacteria, and blood tests. These approaches are usually used together to detect syphilis and decide upon the stage of infection.

To diagnose syphilis by identifying the bacteria, the doctor takes a specimen from a chancre and examines it under a special "darkfield" microscope to detect the organism itself. Blood tests also provide evidence of infection, although they may give false negative results (not show signs of infection despite its presence) for up to 3 months after infection. Interpretation of blood tests for syphilis can be difficult, and repeated tests are sometimes necessary to confirm the diagnosis.

The blood-screening tests most often used to detect evidence of syphilis are the VDRL (Venereal Disease Research Laboratory) test and the rapid plasma reagin (RPR) test. These tests can result in false-positive results (show signs of infection when it is not present) in people with autoimmune disorders, certain viral infections, and other conditions.

Confirmatory blood tests are, therefore, used when the initial test is positive. These tests include the fluorescent treponemal antibody-absorption (FTA-ABS) test that can accurately detect 70 to 90 percent of cases. Another specific test is the T. pallidum hemagglutination assay (TPHA). These tests detect syphilis antibodies (proteins made by a person's immune system to fight infection). They are not useful for diagnosing a new case of syphilis in patients who have had the disease previously, because once antibodies are formed, they remain in the body for many years. These antibodies do not, however, protect against a new syphilis infection. In some patients with syphilis (especially in the latent or late stages), a lumbar puncture (spinal tap) must be done to check for infection of the nervous system.

Treatment

Syphilis is usually treated with penicillin, administered by injection. Other antibiotics can be used for patients allergic to penicillin. A person usually can no longer transmit syphilis 24 hours after beginning therapy. However, some people do not respond to the usual doses of penicillin. Therefore, it is important that people being treated for syphilis have periodic blood tests to check that the infectious agent has been completely destroyed. Persons with neurosyphilis may need to be retested for up to 2 years after treatment. In all stages of syphilis, proper treatment will cure the disease, but in late syphilis, damage already done to body organs cannot be reversed.
Effects of Syphilis in Pregnant Women
It is likely that a pregnant woman with active syphilis who is not treated will pass the infection to her unborn child. About 25 percent of these pregnancies result in stillbirth or neonatal death. Between 40 and 70 percent of such pregnancies will yield a syphilitic infant.

Some infants with congenital syphilis may have symptoms at birth, but most develop symptoms between 2 weeks and 3 months later. These symptoms may include skin sores, rashes, fever, weakened or hoarse crying sounds, swollen liver and spleen, yellowish skin (jaundice), anemia, and various deformities. Care must be taken in handling an infant with congenital syphilis because the moist sores are infectious.

Often the symptoms of syphilis go undetected in infants. As infected infants become older children and teenagers, they may develop the symptoms of late-stage syphilis including damage to their bones, teeth, eyes, ears, and brain.
Prevention
The open sores of syphilis may be visible and infectious during the active stages of infection. Any contact with these infectious sores and other infected tissues and body fluids must be avoided to prevent spread of the disease. As with many other sexually transmitted diseases, methods of prevention include limiting the number of sex partners and use of condoms during sexual intercourse. Testing and treatment early in pregnancy is the best way to prevent syphilis in infants and should be a routine part of prenatal care.

Research

Developing better ways to diagnose and treat syphilis is an important research goal of scientists supported by the National Institute of Allergy and Infectious Diseases (NIAID). New tests are being developed that may provide better ways to diagnose syphilis and define the stage of infection.

Tissue culture systems are being used as models to determine how the syphilis bacterium infects tissues--whether it moves through or between cells. NIAID-supported scientists have found the syphilis organisms to be very mobile, able to slip through tight junctions between cells. Learning how the bacteria enter tissues may lead to effective ways to block that mechanism and limit the spread of syphilis in the body.

Scientists are also learning about the body's natural defenses against syphilis. Important disease-fighting cells called macrophages have the ability to engulf and destroy syphilis organisms. Scientists are exploring how this mechanism works in hopes of boosting the ability of these immune system cells to combat the bacterium.

In an effort to stem the spread of syphilis, vaccine research is under way. Molecular biologists are learning more about the various surface components of the syphilis bacterium that stimulate the immune system to respond to the invading organism. This knowledge will pave the way for development of an effective vaccine that can ultimately prevent this age-old sexually transmitted disease.

NIAID, a component of the National Institutes of Health, supports research on AIDS, tuberculosis and other infectious diseases as well as allergies and immunology.

Prepared by:
Office of Communications
National Institute of Allergy and Infectious Diseases
National Institutes of Health
Bethesda, MD 20892
Public Health Service
U.S. Department of Health and Human Services
August 1992

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