Source: Finnish Medical Society Duodecim. Syphilis. Helsinki, Finland:
	Duodecim Medical Publications Ltd.; 2001 Nov 22.

	Syphilis

	EBMG
	22.11.2001

	Contents

	   * Aims 
	   * Aetiology and transmission 
	   * Clinical picture 
	   * Differential diagnosis 
	   * Diagnosis 
	   * Treatment 
	   * Follow-up and identification of partners 
	   * Related evidence 
	   * Bibliography 

	This guideline has been extensively revised

	Aims

	   * Suspected syphilis should be verified with the appropriate
	     clinical and serological tests and the patient should be treated
	     with the most efficient antibiotics.
	   * Syphilis is a dangerous infectious disease that should be
	     prevented and treated effectively.

	Aetiology and transmission

	   * The pathogen is the spirochete Treponema pallidum.
	   * Easily transmitted by sexual intercourse and also from the mother
	     to the foetus.
	   * Contagiousness is highest (30 - 60%) in the primary and secondary
	     phases. After 2 years, the patient ceases to spread the disease.

	Clinical picture

	   * Asymptomatic incubation period lasts for 3 - 4 weeks after which
	     two thirds of the patients (not all!) have visible symptoms
          	1. Primary symptoms (local infection)
                       * An ulcer, the "primary lesion", with a clean, hard
                         base (See Figure 1 of the corresponding full text
                         guideline available on the EBM Web site) appears in
                         the genital region, sometimes also in anus or the oral
                         region.
                       * There is local lymphadenopathy without tenderness. 
          	2. Secondary stage 6 - 8 weeks after exposure (general infection).
                       * General symptoms include indisposition, fever and
                         enlarged lymph nodes.
                       * Roseola eczema (See Figure 2 of the corresponding full
                         text guideline available on the EBM Web site)
                         resembles widely spread viral eczema or drug eruption.
                            * Syphilids, i.e. formations of papules are found
                              in the hands and feet or spread all over the
                              body. May be large, cauliflower-like formations
                              (condylomata latum) around the anus or necrotic
                              in patients with a poor immune response (e.g. HIV).
                       * Alopecia syphilitica, typical "moth-eaten" spotty
                         baldness in some patients.
          	3. Late symptoms occur in about one third of untreated patients
                   in 10 - 30 years. The most important are neurological
                   (atypical psychosis, paralytic dementia) and vascular
                   symptoms (aortic aneurysm, valvular regurgitation).

	Differential diagnosis

	   * Primary syphilis
          	* Genital herpes. Incubation time is short in primary
                  infection, lesions occur in groups and they are painful.
                  Lymphadenopathy is less pronounced, however, the nodes are
                  tender.
          	* Ulcus molle (soft chancre)
          	* Infected coital or other traumas.
                       * Secondary syphilis
          	* Roseola may resemble pityriasis rosea, drug eruption,
                  measles (rubeola), German measles (rubella) or scarlet fever
                  (scarlatina).
          	* Syphilids may resemble papular lichen ruber planus,
                  psoriasis, scabies or infectious eczema of the feet (e.g.
                  tinea). Condyloma latum may resemble condyloma acuminata.

	Diagnosis

	   1. History of exposure (unprotected sex) and/or clinical picture.
	   2. Plain specimen. A dark field microscope may reveal spirochetes in
	      lesion discharge and confirm the diagnosis.
	   3. Serology
          	* The cardiolipin test becomes positive 3 - 4 weeks after
                  infection. It is the primary test for screening. High titres
                  (>16) are almost always specific. A low titre is in many
                  cases a false positive result (pregnancy, connective tissue
                  disease, infection) or a serological scar of an earlier
                  treated infection or latent syphilis.
          	* TPHA (Treponema pallidum haemagglutination test) is the test
                  of choice for verifying syphilis. The result becomes
                  positive slightly later than that of the cardiolipin test,
                  but it is specific (almost 100%) and suitable for following
                  up response to treatment.
          	* FTA-abs (fluorescence test) is a specific syphilis test used
                  in special cases (neurosyphilis, suspicion of neonatal
                  syphilis) as it detects also IgM antibodies.

	   * Gene amplification methods are already being used for screening.

	Treatment

	   * Procaine penicillin 800 000 IU x 1 i.m. for 12 - 15 days (primary,
	     secondary and latent syphilis), in neurosyphilis i.v. penicillin.
	   * Ceftriaxone (1 g/day) injection is an alternative to penicillin.
	     Doxicyclin is no longer recommended.

	Follow-up and identification of partners

	   * After antibiotic therapy the cardiolipin and TPHA tests are
	     performed at 3 and 6 months and one year. In primary stage
	     infection the tests become negative in most cases, in other recent
	     infections the titre falls by at least two dilutions when the
	     treatment has be successful.
	   * All sexual partners who have been exposed to infection should be
	     screened with the cardiolipin test. If the result is negative, the
	     test should be repeated after 3 months.

	Related evidence

	   * Patient assistance at facilitating patient referral and provider
	     referral may increase partner notification for sexually
	     transmitted diseases (Level of Evidence = C; Evidence Summary
	     available on the EBM Web site).
	   * Penicillin is effective in the treatment of syphilis in pregnancy
	     and in the prevention of congenital syphilis (Level of Evidence =
	     B; Evidence Summary available on the EBM Web site).
	   * References^1, 2, 3, 4

	Bibliography

	   1. Hernandez-Aguado I, Bolumar F, Moreno R, Pardo FJ, Torres N, Belda
	      J, Espacio A. False-positive tests for syphilis associated with
	      human immunodeficiency virus and hepatitis B virus infection among
	      intravenous drug abusers. Valencian Study Group on HIV
	      Epidemiology. Eur J Clin Microbiol Infect Dis 1998; 17: 784-787
	   2. Morse SA, Trees DL, Htun Y ym. Comparison of clinical diagnosis
	      and standard laboratory and molecular methods for the diagnosis of
	      genital ulcer disease in Lesotho. J Infect Dis 1997; 175: 583-589
	   3. Gerbase AC, Rowley JT, Heymann DH, Berkley SF, Piot P. Global
	      prevalence and incidence estimates of selected curable STDs. Sex
	      Transm Infect 1998; 74 Suppl 1: S12-16
	   4. The Database of Abstracts of Reviews of Effectiveness (University
	      of York), Database no.: DARE-945071. In: The Cochrane Library,
	      Issue 4, 1999. Oxford: Update Software
	   5. Walker GJA. Antibiotics for syphilis during pregnancy. The
	      Cochrane Database of Systematic Reviews, Cochrane Library number:
	      CD001143. In: The Cochrane Library, Issue 2, 2002. Oxford: Update
	      Software. Updated frequently
	   6. Oxman AD, Scott EA, Sellors JW, Clarke JH, Millson ME, Rasooly I,
	      Frank JW, Naus M, Goldblatt D. Partner notification for sexually
	      transmitted diseases: an overview of the evidence. Can J Publ
	      Health 1994;85(suppl 1):41-47

	Author(s): Timo Reunala
	Article ID: P12012 (012.003)
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