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Syphilis is a bacterial infection caused by the Treponema pallidum spirochete (a spirochete is a type of bacterium that is thin, long, and coiled in shape). Called the great pretender or great imitator, syphilis has a number of signs and symptoms that may mimic those of other conditions.

Syphilis is a sexually transmitted disease/sexually transmitted infection that most commonly occurs in people aged twenty to twenty-nine. Women aged twenty to twenty-four and men aged thirty-five to thirty-nine are the most likely groups to be diagnosed with syphilis. In the early years of the twenty-first century, the majority of syphilis cases have occurred in men who have sex with men.

T. pallidum uses minor cuts or abrasions to enter the body, and the infection is typically contracted by direct contact with a syphilis sore, which is called a chancre. Infection can occur with oral, vaginal, or anal sex. In addition, women who are pregnant can transmit the disease to their fetuses (called congenital syphilis). Sores are most commonly found on the external sex organs, vagina, rectum, or anus; they can occur, however, in other places (e.g., in the mouth, on the lips).

Less likely means of transmission include transfusions of infected blood, direct intimate contact with an infected partner's chancre (e.g., through kissing), or a transfer to a health-care provider during an examination or procedure. Transmission via blood transfusion is extremely unlikely because the spirochetes cannot survive long in stored blood and the blood supply is screened for syphilis. Syphilis is not spread through casual contact (e.g., commodes, pools, clothing, kitchen utensils), likely because T. pallidum is highly sensitive to light, air, and temperature fluctuations.

Infections of syphilis may progress through four stages. The infection may be spread during the primary, secondary, and early latent stages as well as from a pregnant woman to a fetus. In the primary stage the infection is usually evidenced by one sore, although there may be more than one, at the site where syphilis entered the person's body. Most often the point of entry is the penis, vagina, or vulva, but it could be another spot (e.g., lips, tongue, cervix). Typically, there is an average of twentyone days (range ten to ninety days) between infection and evidence of a sore.

Chancres are normally small, hard, painless, and round. Chancres are usually present for three to six weeks and then heal. In approximately two-thirds of cases, lymph glands in the area will be swollen. Because chancres are often small, painless, and inside the body, they can easily be overlooked. Without satisfactory treatment, however, syphilis continues into the secondary stage. In the secondary stage, common symptoms are rashes on the skin and lesions in mucous membranes. This stage usually begins with a skin rash, often one without itching, which may appear red or reddish brown in color. The rash typically emerges two to ten weeks after the chancre, following or during the healing of this sore. Although the rash may appear on one or more places on the body, frequently, such rashes appear on the palms of the hands and soles of the feet. Rashes may be light, challenging to see, and mimic those associated with other conditions. Other symptoms may occur during this stage of syphilis, including sore throat, fever, fatigue, aches, hair or weight loss, swollen lymph glands, and headaches. Regardless of whether treatment is administered, these symptoms will fade; without satisfactory treatment, however, disease progression may continue.

A third stage of the disease is the latent stage, which begins with the end of the symptoms of secondary syphilis. Early in the latent stage an individual may have no symptoms; however, one can infect others. When in late latent syphilis the risk of infecting others diminishes; without treatment, however, progression to the tertiary stage, a relapse into secondary-stage symptoms, or transmission of the disease to a fetus by a pregnant woman can occur. It is also possible that the signs and symptoms of syphilis may disappear and never return.

The final stage of syphilis is the tertiary stage, which is sometimes referred to as late syphilis. In this stage a subset of people receiving no treatment will develop serious health complications. After entering the body syphilis moves through the bloodstream, attaching to cells and damaging internal organs as time passes. By this late stage of the infection, damage to the body's internal organs (e.g., brain, heart, eyes, liver, joints) may have occurred. Although this damage takes place over time, it may not be evident for several years. In fact, individuals may have syphilis and not exhibit symptoms for a considerable period of time; nevertheless, they may still be subject to late-stage complications. Symptoms of this stage include coordination difficulties, blindness, and dementia. The damage incurred may even cause death.

Syphilis can be transmitted to a fetus at any stage of pregnancy. Estimates suggest that more than half of pregnant women with untreated syphilis may infect their fetuses, and that nearly half of babies with congenital syphilis will die. Passing syphilis to a fetus increases the likelihood of miscarriage, premature birth, stillbirth, and newborn death. Babies who are infected with syphilis may not exhibit any signs of the disease, but prompt medical treatment is needed or health conditions may worsen. If untreated, babies with syphilis may experience slower development, seizures, or death. Other health conditions in babies born with syphilis include sight and hearing problems, bone irregularities, joint swelling, and misshapen teeth (i.e., screwdriver-shaped teeth, called Hutchinson's teeth).

Because it shares symptoms with so many other diseases, may have no symptoms, or may have symptoms that disappear, syphilis can be challenging to diagnose. In the early twenty-first century, there are two methods for diagnosing syphilis--examination of material from a chancre under a dark-field microscope, which can detect syphilis bacteria, or via a blood test, which will detect syphilis antibodies. All pregnant women should have this blood test to avoid the complications of infecting the fetus. If diagnosed with syphilis pregnant women should be treated immediately. During the second and third trimesters of pregnancy, infected fetuses may be cured by treatment.

If treated during the initial stages, syphilis is easy to cure. A penicillin injection is the typical treatment for individuals who have had syphilis for less than one year. For those who have been infected for more than a year, additional doses are needed. For individuals with penicillin allergies, other antibiotics (such as doxycycline and tetracycline) can be used. Penicillin treatment is more effective when used early rather than as the infection progresses. It is important to note that treatment stops the infection but does not repair previous damage. Also, persons can be reinfected. Although no effective alternative treatments exist for syphilis, rest, reduction of stress, and appropriate exercise can aid the results of taking antibiotics.

The availability of penicillin in the 1940s led to a dramatic decline in syphilis. Prior to penicillin arsenic- or bismuth-based treatments yielded some effectiveness. Early ineffective treatments included guaiacum (a wood gum) and mercury, which was inhaled, swallowed, or rubbed into the skin. Even malaria was used as a treatment, especially for tertiary syphilis, because some individuals with high fevers seemed to recover from syphilis, and then the malaria could be treated with quinine.

In the early twenty-first century, the Centers for Disease Control and Prevention (CDC) recommends screenings for individuals at risk. Further, individuals treated for syphilis should refrain from sexual contact until sores have healed and inform sexual partners so that they can be tested. The majority of syphilis transmission occurs from people who are undiagnosed. Because sores can be hidden (e.g., in the mouth, vagina, or rectum) and symptoms absent or difficult to diagnosis, one may not know a partner is infected. Also, chancres increase the likelihood of contracting and transmitting HIV.

The origin of syphilis has been debated for several centuries. Three hypotheses now predominate. One hypothesis suggests that syphilis began in the New World and was taken back to Europe by sailors traveling with explorers, such as Christopher Columbus (1451-1506). This theory is also referred to as the Columbian explanation or Columbian exchange perspective. A second is that syphilis existed in the Old World but was confused with leprosy until medical diagnosis allowed practitioners to distinguish between the two illnesses. This perspective is also called the pre-Columbian view. The third suggests that syphilis emerged on both continents evolving from yaws and bejel, diseases caused by other bacteria in the genus with T. pallidum. Recent work in paleopathology favors the New World as the source.

References:

Centers for Disease Control and Prevention. ''Syphilis: CDC Fact Sheet.'' www.cdc.gov/std/Syphilis/STDFact-Syphilis.htm.

Centers for Disease Control and Prevention. 2006. Sexually Transmitted Disease Surveillance, 2005. Atlanta, GA: U.S. Department of Health and Human Services.

Mayo Clinic. ''Syphilis.'' www.mayoclinic.com/health/syphilis/DS00374.

National Institutes of Health. National Institute of Allergy and Infectious Diseases. ''Syphilis.'' www.niaid.nih.gov/topics/syphilis/Pages/default.aspx.

Rothschild, Bruce M. 2005. ''History of Syphilis.'' Clinical Infectious Diseases 40(10): 1454-1463.

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