In latent syphilis there are little to no symptoms which can last for years.

In tertiary syphilis there are gummas (soft non-cancerous growths), neurological, or heart symptoms.

Syphilis has been known as "the great imitator" as it may cause symptoms similar to many other diseases.


Physical Exam

The primary stage classically presents with a single chancre (a firm, painless, non-itchy skin ulceration) but there may be multiple sores.


Indurated, relatively clean base; heals spontaneously   Firm, rubbery, discrete nodes; not tender

Primary: chancre

Secondary: rash, mucocutaneous lesions, lymphadenopathy

Tertiary: cardiac, ophthalmic, auditory, central nervous system lesions

  1. Primary syphilis is diagnosed by the characteristic chancre, which develops at the inoculation site. It is usually painless, with a raised, red, firm border and a smooth base (Fig. 65-1). Nonsuppurative lymphadenopathy may develop. A chancre will usually resolve spontaneously in 2 to 8 weeks, even if untreated. Multiple lesions may be found, predominantly in HIV-1 co-infected women.

    Primary syphilis. Photograph of a chancre with a raised, firm border and smooth, red base.

    Image not available.


  2. Secondary syphilis is diagnosed when the spirochete is disseminated and affects multiple organ systems. Manifestations develop 4 to 10 weeks after the chancre appears and include dermatological abnormalities in up to 90 percent of women. A diffuse macular rash, plantar and palmar targetlike lesions, patchy alopecia, and mucous patches may be seen (Figs. 65-2 and 65-3). Condylomata lata are flesh-colored papules and nodules found on the perineum and perianal area. They are teeming with spirochetes and are highly infectious. Most women with secondary syphilis will also express constitutional symptoms such as fever, malaise, anorexia, headache, myalgias, and arthralgias. Up to 40 percent will have cerebrospinal fluid abnormalities, although only 1 to 2 percent will develop clinically apparent aseptic meningitis. Hepatitis, nephropathy, ocular changes, anterior uveitis, and periostitis may also develop.

    Target lesions on the palms of a pregnant woman with secondary syphilis.

    Image not available.
  3. Mucous patches around the mouth of a pregnant woman with secondary syphilis.

    Image not available.
  4. Latent syphilis develops when primary or secondary syphilis is not treated. It is characterized by reactive serological ­testing, but resolved clinical manifestations.Early latent syphilis is latent disease acquired within the preceding 12 months. Disease diagnosed beyond 12 months is either late latent syphilis or latent syphilis of unknown duration.

  5. Tertiary or late syphilis is a slowly progressive disease affecting any organ system but is rarely seen in reproductive-aged women.

Maternal syphilis can cause preterm labor, fetal death, fetal-growth restriction, and neonatal infection (Krakauer, 2012Saloojee, 2004). Any stage of maternal syphilis may result in fetal infection, but risk is directly related to maternal spirochete load (Fiumara, 1952Golden, 2003). Maternal syphilis is staged according to clinical features and disease duration:


Laboratory Tests



The application and limitations of diagnostic tests in different stages of syphilis

Stage Recommended tests Comments
Primary syphilis Direct examination, Nontreponemal tests, Treponemal tests Detection of Treponema pallidum in lesions is definitive evidence of syphilis but a negative result does not ruleout syphilis. PCR-based tests have a high reliability. In the first two to three weeks, serology may not be positive in most cases, and in early primary syphilis, treponemal tests are recommended. The presence of a genital ulcer and a positive nontreponemal test may not indicate primary syphilis. Repeat serology over a two to 12 week period to rule out syphilis
Secondary syphilis Direct examination, Nontreponemal tests, Treponemal tests T pallidum can be detected in skin and mucosal lesions, and PCR-based tests may be useful in atypical lesions. Serological tests have nearly 100% sensitivity. In persons with a history of syphilis, a fourfold increase in titre provides presumptive diagnosis of secondary syphilis.
Latent syphilis Nontreponemal tests, Treponemal tests Nontreponemal tests are reactive in early latent syphilis but the sensitivity declines over time. In low prevalence populations, false-positive results are common with both types of tests. Reactive treponemal tests in the absence of a reactive nontreponemal test require confirmation.
Tertiary syphilis Nontreponemal tests, Treponemal tests Up to 30% may not be reactive in nontreponemal tests, whereas treponemal tests are almost always reactive.Therefore, treponemal tests should always be considered. Lesions are not suitable for direct microscopic examination.
Neurosyphilis Nontreponemal tests, Treponemal tests Diagnosis requires a combination of tests. VDRL-CSF, the standard serological test for CSF, is highly specific but insensitive. Therefore, a negative VDRL-CSF result does not rule out neurosyphilis. In addition to a reactive VDRL-CSF, diagnosis depends on reactive serological tests and CSF abnormalities. FTA-ABS is more sensitive than VDRL-CSF but less specific. Therefore, the CSF FTA-ABS test may be useful to exclude neurosyphilis. PCR-based tests have a high reliability.
Congenital syphilis Direct examination, Nontreponemal tests Diagnosis requires a combination of tests. Venous blood from both the mother and the child should be tested. Serological tests on infant serum can be nonreactive if the mother has a low titre or was infected late in pregnancy. Immunoglobulin M-specific tests are useful for neonatal serum, but negative results may not rule out congenital syphilis. T pallidum can be detected by direct examination of a variety of specimens from the neonate, and PCR-based tests have a high reliability. Asymptomatic congenital syphilis requires a comprehensive approach.

CSF Cerebrospinal fluid; FTA-ABS Fluorescent treponemal antibody absorption; PCR Polymerase chain reaction; VDRL Venereal Disease Research Laboratory






Submit blood for serologic test for Syphylis

VDrl, etc


Negative Positive


Diagnostic Criteria

1. Treponema found on darkfiled microscopy (video)




Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum subspecies pallidum.


The causative agent for syphilis is Treponema pallidum. Minute abrasions on the vaginal mucosa provide an entry portal for the spirochete, and cervical eversion, hyperemia, and friability increase the transmission risk. Spirochetes replicate and then disseminate through lymphatic channels within hours to days. The incubation period averages 3 weeks—3 to 90 days—depending on host factors and inoculum size. The early stages of syphilis include primary, secondary, and early latent syphilis. These are associated with the highest spirochete loads and transmission rates of up to 30 to 50 percent. In late-stage disease, transmission rates are much lower because of smaller inoculum sizes.

The fetus acquires syphilis by several routes. Spirochetes readily cross the placenta to cause congenital infection. Because of immune incompetence prior to midpregnancy, the fetus generally does not manifest the immunological inflammatory response characteristic of clinical disease before this time (Silverstein, 1962). Although transplacental transmission is the most common route, neonatal infection may follow after contact with spirochetes through lesions at delivery or across the placental membranes. Increased maternal syphilis rates have been linked to substance abuse, especially crack cocaine; inadequate prenatal care and screening; and treatment failures and reinfection (Johnson, 2007Lago, 2004Trepka, 2006Warner, 2001Wilson, 2007). A report from Maricopa County, Arizona, also cited minority race or ethnicity as a risk factor (Kirkcaldy, 2011).

What proportion of sexual contacts of persons with infectious syphilis become infected?

Next Question
You will be able to view all answers at the end of your quiz.

The correct answer is C. You answered B.

The answer is C. (Chap 206) Early syphilis describes syphilis acquired within the first year and includes primary syphilis, secondary syphilis, and early latent syphilis. In contrast to late latent syphilis, patients with early syphilis are generally infectious, and their identification and treatment represent an important public health activity to interrupt the transmission of syphilis. Nearly all syphilis is transmitted by sexual contact with infectious lesions. The mucocutaneous lesions of syphilis, especially the primary chancre and condyloma lata, are teeming with spirochetes and are highly infective. The infective dose is approximately 57 organisms, and the concentration of organisms in a chancre is approximately 107organisms per gram of tissue. One-third to one-half of sexual contacts of persons with infectious syphilis become infected.


The primary and secondary syphilis rate among women in 2012 was 0.9 case per 100,000 persons, which is a 9-percent decrease from 2010. Congenital syphilis rates also decreased in 2012, mirroring the decline in primary and secondary syphilis rates among women since 2008. However, syphilis remains a significant global health problem, with many countries reporting high numbers of new infections.1





Physical Exam


Laboratory Tests



Essentail Criteria to Establish Diagnosis



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Content 11

A 22-year-old man presents to the emergency department complaining of generalized malaise and rash. The patient has a history of illicit drug use with intranasal heroin and cocaine. He admits to engaging in unprotected sexual intercourse with men in exchange for drugs. He was negative for the HIV virus 8 weeks previously. He has a prior history of syphilis and gonorrhea that were treated appropriately 2 years previously. Following treatment, his rapid plasma reagin test fell to a titer of 1:8 from a high of 1:128 after 12 months. On physical examination, the patient has normal vital signs without fever. He is well developed and has no wasting. Diffuse lymphadenopathy measuring up to 2.5 cm is palpable in the cervical, axillary, and femoral areas. Genital examination shows no ulcerations or lesions. The rash is shown in Figure XII-12. Which test is most likely to yield the appropriate diagnosis in this patient?

Image not available.





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