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  • Syphilis is caused by the spirochete Treponema pallidum.
  • Usually sexually transmitted
  • Causes a wide range of systemic manifestations that are characterized by episodes of active disease interrupted by periods of latency
  • Approximately 30% of asymptomatic contacts examined within 30 days of exposure have infection


  • Spirochetes penetrate intact mucous membranes or microscopic dermal abrasions.
  • Transmission through sexual contact with infectious lesions, infection in utero, blood transfusion, and organ transplantation
  • Blood from a patient with incubating or early syphilis is infectious.
  • Characterized by multiple stages separated by periods of latency: primary, secondary, latent and tertiary

Clinical Features

Primary Syphilis

  • Primary lesion appears after an incubation of 2-6 weeks
    • Single painless papule that becomes eroded and indurated, cartilaginous consistency on palpation
    • Minority of patients can have multiple lesions or atypical appearance
    • Occurs at point of contact: penis, rectum, mouth, external genitalia, cervix, or labia
    • Heals in 4-6 weeks
  • Regional lymphadenopathy that is painless and firm

Secondary Syphilis

  • Characterized by generalized mucocutaneous lesions and lymphadenopathy but can also be found in other tissues[1]
  • Skin lesions are usually maculopapular, pale red or pink, non-pruritic, discrete, and distributed on the trunk and proximal extremities. They may be subtle.
  • They progress to more wide spread papular lesions that frequently involve the palms and soles.
    • Appears 6-8 weeks after the chancre heals and subsides within 2-6 weeks
    • Healing chancre may still be present in ~15% of cases. The stages may overlap more frequently in HIV patients. [2]
    • In intertriginous areas, papules can enlarge to produce broad, moist, pink or gray-white infectious lesions called condylomata lata
  • CSF abnormalities are detected in as many as 40% during this stage. CNS involvement can be symptomatic or asymptomatic.
  • Constitutional symptoms may accompany or precede secondary syphilis. Can include: sore throat, fever, weight loss, malaise, anorexia, headache, and meningismus
  • Less common complications include: hepatitis, nephropathy, gastritis, proctitis, rectosigmoid mass arthritis, periositis, optic neuritis, iritis, uveitis, pupillary abnormalities

Differential Diagnosis


Treatment requires antimicrobial therapy. Advanced stages require a prolonged course due to the slow growth time of T. pallidum.


Early Stage

This is classified as primary, secondary, and early latent syphilis less than one year. Treatment Options:

  • Penicillin G Benzathine 2.4 million units IM x 1
    • Repeat dose after 7 days for pregnant patients and HIV infection
  • Doxycycline 100mg oral twice daily for 14 days as alternative

Late Stage

Late stage is greater than one year duration, presence of gummas, or cardiovascular disease Treatment Options:


There are 3 Major options with none showing greater efficacy than others:

  • Penicillin G 3-4 million units IV every 4 hours x 10-14 days
  • Penicillin G 24 million units continuous IV infusion x 10-14 days
  • Penicillin G Procaine2.4 million units IM daily + probenecid 500mg oral every 6 hours for 10-14 days.
  • Alternative:
  • Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)


See Also


  • Emedicine
  1. Chapel TA. The signs and symptoms of secondary syphilis. Sex Transm Dis. 1980;7(4):161–164.1.
  2. Chesson HW, Heffelfinger JD, Voigt RF, Collins D. Estimates of primary and secondary syphilis rates in persons with HIV in the United States, 2002. Sex Transm Dis 2005; 32:265.