Syphilis: The International Challenge of the Great Imitator

doi:10.1016/j.det.2007.12.001

Dermatologic Clinics

Volume 26, Issue 2, April 2008, Pages 191-202

https://doi.org/10.1016/j.det.2007.12.001 Get rights and content

Syphilis is a systemic disease caused by the spirochete Treponema pallidum. The name of this ancient but pervasive infection is proverbial to health care providers. The worldwide recognition of this term, however, argues with the intricacy of the disease in addition to the diagnostic and therapeutic challenges that persistently affect the global control of syphilis up to the present. This article focuses on the varied presentations of the infection, earning the title the “great imitator.” The article also tackles other significant concerns regarding this malady.

Section snippets

The many faces of syphilis

During the secondary stage, there is rapid reproduction and spread of the spirochetes consequential to intensive clinical manifestations. Patients may experience a range of constitutional symptoms, such as malaise, appetite loss, fever, headache, stiff neck, lacrimation, myalgias, arthralgias, nasal discharge, and depression. There is multiorgan involvement of the skin, oral cavity, genitalia, central nervous system, eyes, and visceral organs. Among these symptoms, skin eruptions proved to be

Diagnostic and serologic tests

Darkfield examination and a direct fluorescent antibody test of lesion exudates or tissue are the definitive methods for diagnosing early syphilis. A presumptive diagnosis is made with the use of two types of serologic tests: nontreponemal tests (eg, Venereal Disease Research Laboratory [VDRL] and rapid plasma reagin [RPR]), and treponemal tests (eg, fluorescent treponemal antibody absorbed and T. pallidum particle agglutination). The use of only one type of serologic test is insufficient for

Therapeutic options

Syphilis is a disease of considerable health magnitude and has devastating untoward health effects if left untreated. It is avoidable. It is treatable with the use of effective antibiotics.

The design challenge for syphilis elimination is not only to efficiently pursue the riddance of T. pallidum. There should be an intense call for a clinical network of physicians and other sexual health service providers to be at the center of syphilis and sexually transmitted infection (STI) surveillance to

Follow-up guidelines

The Centers for Disease Control has set up guidelines regarding follow-up of patients in different stages of syphilis (Table 2).

Management of sex partners

Persons exposed sexually to a patient who has syphilis in any stage should be evaluated clinically and serologically. They should be treated with a regimen based on the following recommendations [10]:

•
Persons who were exposed within 90 days preceding the diagnosis of primary, secondary, or early latent syphilis in a sexual partner who might be infected even if seronegative; therefore, such persons should be treated presumptively.
•
Persons who were exposed more than 90 days before the diagnosis of

Summary

Syphilis has been a source of social stigma, morbidity, and mortality for centuries. Although the introduction of penicillin in the 1940's contributed much to the decrease in epidemiology, statistics show that it is still a menace to our society.

Syphilis is a rare occurrence in children; therefore, a diagnosis of syphilis in a child warrants an investigation of sexual abuse. Emphasis that this disease is as damaging to the soul as it is to the body, especially in the case of a minor, is vital.

Acknowledgment

The authors thank Dr. Gertrude P. Chan, Section Head of Dermatology at the Research Institute for Tropical Medicine–Department of Health, Philippines and the resident physicians for the assistance with photograph collection.

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Cited by (38)

Histologic features of secondary syphilis: A multicenter retrospective review
2015, Journal of the American Academy of Dermatology
Secondary syphilis has a wide spectrum of clinical and histologic manifestations.
We sought to determine the frequency of histopathological features characterizing secondary syphilis, and which are most common in specimens displaying few diagnostic findings.
In a multicenter, retrospective analysis of biopsy-proven secondary syphilis, cases were subcategorized by the number of histologic characteristics present.
The 106 cases mostly had 5 to 7 of the features studied. Many features were scarcer in cases with 5 or fewer features, including endothelial swelling (87.7% overall vs 72.4% ≤5 features), plasma cells (69.8% vs 48.3%), and elongated rete ridges (75.5% vs 27.6%). Specimens with 5 or fewer features were more likely to be truncal (61.1% vs 34.4% overall), demonstrate rete ridge effacement (44.8% vs 19.8%), and have pityriasis rosea (33.3% vs 17.2%) or drug eruption (33.3% vs 10.9%) in the clinical differential. An interstitial inflammatory pattern was the most common characteristic of specimens with 5 or fewer features (75.9%).
This was a retrospective review.
The independent value of many histologic features of syphilis may be overestimated. Combinations of endothelial swelling, interstitial inflammation, irregular acanthosis, and elongated rete ridges should raise the possibility of syphilis, along with the presence of vacuolar interface dermatitis with a lymphocyte in nearly every vacuole and lymphocytes with visible cytoplasm.
Oral syphilis: Report of three cases and characterization of the inflammatory cells
2015, Annals of Diagnostic Pathology
Citation Excerpt :
In the present study, the efficacy of this drug was demonstrated by the administration of a weekly dose of 2.4 million units (IM) and the observation of complete remission of the lesions after the first dose. However, the patients should be followed up by serologic testing at 6 and 12 months posttreatment [11]. Syphilis has important implications for clinicians because manifestations can occur in the mouth and perioral region and primary and secondary lesions are highly contagious.
Syphilis is a sexually transmitted infectious disease caused by Treponema pallidum. This study reports 3 cases of syphilis and highlights the importance of identifying oral lesions for its final diagnosis. Case 1: a 48-year-old male patient presented with a bleeding ulcer in the lower lip. Overall clinical examination revealed patchy alopecia and skin target lesions. Case 2: a 61-year-old male patient presented with white spots on the lateral tongue and nodules on the dorsum of the tongue. Overall clinical examination showed erythematous target lesions on the abdomen, forearm, palms of the hand, and soles of the feet. Case 3: a 17-year-old male patient presented with an ulcerated lesion on the tongue and lymph node involvement. The following serologic tests were requested: Venereal Disease Research Laboratory, fluorescent treponemal antibody–absorption, anti–HIV-1 and anti–HIV-2, and anti–hepatitis C virus. An incisional biopsy revealed epithelial hyperplasia associated with intense and diffuse mononuclear inflammatory cell infiltration consisting mainly of plasma cells, in a perivascular and perineural distribution. The final diagnosis in the 3 patients was syphilis. Treatment consisted of 1 weekly dose of penicillin (2.4 million units, intramuscular) for 2 or 3 weeks. Immunohistochemical reactions for XIIIa, CD3, CD20, CD68, CD163, S100, CD1a, CD11c, CD83, CD138, and CD208 were performed. Clinicians should be familiarized with oral syphilis lesions in order to be able to diagnose this emerging infectious disease of variable clinical presentation.
Clavi syphilitici-an unusual presentation of syphilis
2014, Journal of the American Academy of Dermatology
Papular Acneform Eruption With Mucositis
2023, Cutis
Syphilis, the Great Imitator—Clinical and Dermoscopic Features of a Rare Presentation of Secondary Syphilis
2023, International Journal of Environmental Research and Public Health
Performance of Molecular Tests in the Diagnosis of Syphilis from 2009 to 2019: A Systematic Review and Meta-Analysis
2022, Sexually Transmitted Diseases

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Syphilis: The International Challenge of the Great Imitator

Section snippets

The many faces of syphilis

Diagnostic and serologic tests

Therapeutic options

Follow-up guidelines

Management of sex partners

Summary

Acknowledgment

Chest

Lancet

Syphilis and the shepherd of Atlantis – renaissance poem about syphilis attempts to explain its origin; genetic map revealed in 1998

Nat Hist

Multiple annular plaques on the face of a middle-aged woman

Arch Dermatol

Papular and nodular lesions of the scalp, face, and neck

Arch Dermatol

Syphilis

BMJ

Multiple painful oral ulcerations

Arch Dermatol

Anterior nodular scleritis secondary to syphilis

Archives of Ophthalmology

Secondary syphilis with pulmonary involvement

West J Med

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006

MMWR Recomm Rep

Elimination of syphilis in the United States

Science

Sexually transmitted disease: easier screening tests, single-dose therapies

J Fam Pract

Syphilis in pregnancy

Sex Transm Infect

U.S. Centers for Disease Control and Prevention guidelines for the treatment of sexually transmitted diseases: an opportunity to unify clinical and public health practice

Ann Intern Med

Pilot study of azithromycin for treatment of primary and secondary syphilis

Clin Infect Dis

Azithromycin compared with penicillin G benzathine for treatment of incubating syphilis

Ann Intern Med