The stage of syphilis determines the symptoms observed in the patients. Symptoms of syphilis vary greatly with the stage of the disease. In some cases, the patient may be infected but never noticed the symptoms for years [5].

Primary syphilis: Chancre is the first sign of syphilis. It appears as a small sore on the skin and is the point from where the bacterium has entered the body. It develops after 3-4 weeks after exposure and is painful, so often goes unnoticed. The chancre heals within six weeks, on its own.

Secondary syphilis: There can be a rash on the trunk or sometimes the entire body, even within a few weeks after the original chancre healing. The rash is not itchy or may be accompanied by wart-like sores in the mouth as well as the genital areas.

Latent syphilis: If syphilis is not treated, the disease moves from secondary to latent stages. This stage can last for several years.

Tertiary (late) syphilis: The complications of the tertiary (late) syphilis can develop if the disease is not treated on time. About 15-30% of the patients not treated for syphilis may graduate to this stage. Damage to the brain, nerves, eyes, brain, blood vessels, liver, joints, and bones is observed in such patients.

Congenital syphilis: Babies born to infected mothers gets the infection through the placenta or even during birth. These children may be asymptomatic or show symptoms that often go unnoticed such as a rash on the palms of the hands and soles of feet. As the disease progresses, congenital syphilis manifests as deafness, teeth deformities, and saddle nose.

Diagnosis of syphilis can be done by performing the tests on the samples of blood, fluids from the sore and the cerebral spinal fluid.

Performing the blood tests confirm the presence of antibodies in the body. Antibodies are produced when the body is exposed to an infection. A positive result of the test indicates that the person is infected with syphilis. Antibodies remain in the body for many years, even if the disease has been treated. A negative result, however, does not necessarily mean the patient is not infected with syphilis as the antibodies are not detected for up to three months after the infection. In that case, the patient is advised to take the test again after 3 months.

The sores that form the hallmark of syphilis are scraped and a small sample of the cells from this sore is analyzed under the microscope in the laboratory. This test is performed only in the primary and secondary syphilis when the sores are present. When analyzed in the laboratory, it can show the presence of bacteria in the scrapings, thus confirming syphilis [7].

Analysis of the cerebrospinal fluid is performed to diagnose CNS involvement. For this, the sample of cerebrospinal fluid is collected through a lumbar puncture, and the fluid is tested in the laboratory.

Penicillin is the preferred drug for the management of syphilis. Guidelines for the dosage regimen of the penicillin for different stages of syphilis are present, with later stages requiring a long course of treatment because of the slow rate of replication of bacteria. Penicillin is the only drug used widely for managing neurosyphilis, and congenital syphilis. The common penicillin used to manage syphilis is Benzathine penicillin G. In patients with syphilis, penicillin allergy skin test must be performed [6].

In patients who are allergic to penicillin, tetracyclines, erythromycin, ceftriaxone have shown anti-treponemal activity. Doxycycline and azithromycin are also good options to manage syphilis. Studies have shown the efficacy of these two drugs [8].

Monitoring syphilis in patients ensures that the treatment is done adequately. Inpatient care is reserved for late-stage patients with syphilis. For patients who were successfully treated for must perform the follow-up visits at 3, 6 and 12-month interval. HIV patients who are treated with non-penicillin regimen must be monitored for life. After 24 months of therapy, patients with neurosyphilis must be reevaluated.

Treatment is said to have failed if the symptoms of syphilis return. The reappearance of symptoms is called “relapse”. Adequate treatment must be initiated in cases of relapse. Pregnant patients with syphilis should go for venereal disease research laboratory (VDRL) testing every month for the duration of pregnancy.

Though the cure of syphilis at the early stages is easy (penicillin), in the later stages damage done to the organs cannot be reversed. Secondary syphilis is cured, if detected early, and is completely treated.

Treatment can last from within weeks to almost a year, in some cases. In the absence of treatment, up to one-third of the patients will develop complications of syphilis. Late syphilis can cause permanent disability and can also lead to death in some cases.

Complications

• If not treated properly, syphilis can cause damage to the entire body. It also increases the risk of HIV by several-fold. A syphilis lesion can bleed easily allowing easy passage of the virus.
• Gummas are small bumps that develop on the patient’s skin, liver and bones. This generally occurs in the later stages of syphilis. Administration of antibiotics can cause these gummas to disappear.
• Neurological problems such as stroke, deafness, meningitis, dementia and visual problems are common among patients with syphilis.
• Cardiovascular problems in syphilis can occur when there is bulging and inflammation of the large vessel, aorta, and other blood vessels.
• Pregnancy: Syphilis can pass from the infected mother to her baby. Congenital syphilis increases the chances of miscarriage and stillbirth in this group of the population.

The pathogen that causes the syphilis infection is the spirochete, T pallidum. This is a human pathogen and does not occur naturally in any other species. Transmission of this spirochete occurs when it penetrates the mucosal membranes or abrasions on the epithelial surfaces. The most common mode of spread of the disease is through sexual contact [2]. T palladium cannot survive dryness or exposure to disinfectant.

Risk factors for transmission of syphilis:

1. Unprotected sex
2. Intravenous drug use
3. Promiscuous sex
4. Healthcare providers or workers are at the occupational risk

Region

The prevalence of syphilis varies from region to region. Developing countries and some areas of America, and Eastern Europe have a greater prevalence of syphilis. The highest reports of the occurrence of syphilis are from South and Southeast Asia. In 1999, Siberia reported a prevalence of syphilis as 1300 per 100,000 populations [3].

Age distribution

The highest frequency of syphilis is observed in years of peak sexual activity. Syphilis is more common in men and women in the age group of 15-40 years.

Sex distribution

Men are more frequently affected by syphilis (primary and secondary) than women.

Ethnicity

Non-Hispanic Blacks are at a greater risk of syphilis than non-Hispanic whites. Since 2005, the incidence of both primary and secondary syphilis has increased in all the races and ethnicities.

Primary syphilis is characterized by ulceration due to the migration of mononuclear leukocyte infiltration, lymphocytes, and macrophages. It generally heals spontaneously. Secondary syphilis, however, is caused by the spread of infection and causes widespread vasculitis. The lesions of secondary syphilis contain treponemes. Though the reasons for the secondary syphilis are still not clear, it is believed to be related to cell-mediated immunity.

The progression of latent syphilis to late syphilis occurs in only about 40% of the patients. Neurosyphilis is seen in about 10% of the patients with untreated syphilis, and it can occur at any stage. It is characterized by inflammation (chronic) of the meninges, caused by the invasion of the bacteria in the CNS by treponemes. When the treponemes cause occlusion of the aorta, the condition is called cardiovascular syphilis [4]. When there is a long-term inflammation of the walls of the vessel, it can cause an aneurysm and weakening of the aortic walls.

Till date there has been no vaccine developed to prevent syphilis. However, safe sex practices, including use of condoms can help reduce the chances of syphilis several-fold [10]. It is advisable to wash or douche the genitals after the sexual act. Treating the infected mother early in the pregnancy can prevent neonatal syphilis [9].

Syphilis is an infectious disease which is caused by the spirochete Treponema pallidum. It is contracted by sexual contact with the infectious lesions, from the mother to the fetus through the blood transfusion and sometimes through the breaks of the skin, which comes in contact with the infected lesions.

Syphilis mimic the presentation of several other infections and immune-mediated processes in advanced stages, hence also called,” the great imposter”.

The disease starts off as a painless sore in and around the genitals, rectum, and mouth, and spread from one person to another via the skin or mucous membrane. The bacteria remain dormant after initial infection for decades, before it becomes active again.

Early detection of the disease can help treat the condition even with a single injection of penicillin [1]. If not treated early, syphilis can damage the heart, brain or other organs and emerge as a life-threatening disease. There are four stages of syphilis: Primary, secondary, latent and tertiary.

The first presentation of syphilis is a small and painless sore or ulcer, which is known as chancre on the skin, rectum, and genitals. The lymph nodes are also enlarged around the sore area. These symptoms characterize primary syphilis. Skin rash, patches around the vagina, penis, and mouth, general ill feeling, loss of appetite, joint and muscle pain, changes in the vision and hair loss are some of the other presentations of syphilis observed in patients.

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