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Syphilis – A Review
Barbara Romanowski MD, FRCPC
Clinical Professor
Faculty of Medicine & Dentistry
University of Alberta
September 16, 2008
Association Between Genital Ulcers
• Any genital ulceration is associated with
an increased risk of HIV acquisition and
transmission
• HIV can be cultured from lesion exudate
• Therefore, HIV serology for all patients
with genital ulcers and vice versa
Reported Infectious Syphilis Rates in
Alberta and Canada, 1994 to 2007
Note: National rates for 2006 and 2007 are preliminary.
Source: Surveillance and Epidemiology Section, Centre for Communicable Disease and Infection Control, Public
Health Agency of Canada 2008; http://www.phac-aspc.gc.ca/std-mts/stdcases casmts/index.html) and Alberta
Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted
Infections Databases as of June 11, 2008
Infectious and Congenital Syphilis Cases
in Alberta 2007 (n=255)
* 4 of the 7 symptomatic CNS cases were ocular Source: Alberta Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted Infections Databases as of June 11, 2008 Gender-Specific Age Distribution of Infectious Syphilis
Cases in Alberta, 2007
Age (yrs)
Source: Alberta Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted Infections Databases as of June 11, 2008 Male Infectious Syphilis Cases in Alberta
by Sexual Preference, 2003-2007
Source: Alberta Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted Infections Databases as of June 11, 2008 Infectious Syphilis – HIV Status in Regions 3 and 6, Alberta, 2007
Calgary Health (Region 3)
Capital Health (Region 6)
n=100 cases
n=106 cases
Unknown,
Unknown, 16,
Positive, 9,
Positive,
24, 24%
Negative,
Negative, 81,
Note: In 2007, there was one HIV positive infectious syphilis case outside of Capital and Calgary Health Region.
Source: Alberta Health and Wellness Communicable Disease Reporting System: Notifiable Diseases and Sexually Transmitted Infections Databases as of June 11, 2008 Sexual Contact
3-4 weeks
Infectious
Primary Syphilis
6-8 weeks
Secondary Syphilis
lymphadenopathy
Latent Syphilis
Early <2 years
Late > 2 years
Spontaneous Cure
Tertiary
Static positive serology
Primary Syphilis
Incubation 9-90 days (average
• Chancre
• Regional lymphadenopathy
Secondary Syphilis
• Mucocutaneous eruption
• Generalized
lymphadenopathy
• Constitutional symptoms
Latent Syphilis
• asymptomatic
• positive serology
< 2 years – early latent
infectious
25% relapse to secondary
> 2 years – late latent
non-infectious
Tertiary Syphilis
• 3-30 years after primary infection
• Non-infectious
• Types late benign – skin,
bone, viscera
Cardiovascular –
aorta, heart
Neurosyphilis –
meninges, brain
Outcome of Pregnancy in Relation to
Stage of Untreated Maternal Syphilis
Primary or
Late Normal
Secondary
Prematurity
Perinatal death
Congenital syphilis
Healthy child
Congenital Syphilis
Early < 2 years of age
Late > 2 years of age
• mucocutaneous &
• interstitial keratitis
bony lesions
• mulberry molars
• hepatosplenomegaly
• Hutchinson’s teeth
• meningitis
• saddle nose
• perforation of hard
Summary of Congenital Syphilis Cases,
Alberta, 2005 to 2007
• All 14 cases were born in Edmonton to 13 mothers (1 set
of twins)
• 5 neonatal deaths
• Ethnicity: 8 First Nations, 4 Caucasian, 1 Asian
• Marital status: 6 married/common-law
• 5 sex trade workers
• 8 mothers did not access antenatal care and were not
tested for syphilis until delivery; 1 mother was tested in the
second trimester but could not be located and the
remaining 4 tested negative for syphilis early in pregnancy
Source: Communicable Disease Reporting System: Notifiable Diseases and Sexually
Transmitted Infections Databases as of June 11, 2008
Diagnosis of Syphilis
1. History
2. Physical Examination
3. Laboratory Investigations
A) Darkfield examination / DFA
B) Serology
Serologic Tests for Syphilis
• Non-treponemal test
ƒ RPR
ƒ VDRL
ƒ ART
ƒ EIA
ƒ RST
• Treponemal test
ƒ MHA-TP / TP-PA
ƒ FTA-Abs
Serologic Tests for Syphilis
• EIA – treponema specific test – detects
• improved sensitivity / specificity
• has replaced RPR, TPPA, FTA-Abs
• cannot differentiate venereal from non-
venereal treponemal infection i.e. yaws /
pinta
INNO-LIA®
• measures antibodies to T pallidum
antigens
• will remain positive for life
• will be only run initially to confirm EIA
Interpretation of Syphilis EIA
• EIA -ve - no syphilis or incubating.
Consider repeating in 2 – 4 weeks
• EIA +ve - syphilis. RPR will be done to
determine titres
• EIA +ve / RPR –ve / LIA +ve – syphilis
False Positive Reactions
NON-TREPONEMAL
TREPONEMAL
• viral infections
• autoimmune
• pregnancy
• malaria
• genital herpes
• leprosy
• elderly
• pinta
• injection drug abuse
• cirrhosis
• autoimmune
Indications for CSF Examination
• any neurological abnormalities
• before re-treatment of patients
who have had a relapse
• in all infants
• in the investigation of patients
with late latent syphilis and an
RPR ≥ 16
Diagnosis of Congenital Syphilis
• physical examination
• serology
ƒ if maternal transfer – titre should
gradually decrease & disappear by 6-12
months.
ƒ if congenital infection – titre will increase
• CSF examination
• long bone x-rays
Treatment of Syphilis
“A night on Venus, but a month on Mercury”
Primary, secondary, early latent
• Benzathine penicillin 2.4 mu IM STAT
• Doxycycline 100 mg bid x 14 days
Latent > 1 year duration
• Benzathine penicillin 2.4 mu IM weekly for 3
successive weeks
• Doxycycline 100 mg bid x 28 days
Treatment of Syphilis in Pregnancy
• All women not previously treated should receive
penicillin appropriate to their stage of disease
• Some experts suggest that pregnant women with
early syphilis received 4.8 mu benzathine
penicillin
• Retreatment during pregnancy is unnecessary
unless there is clinical or serologic evidence of
new infection
• When penicillin allergy is reported,
desensitization should be attempted
Syphilis Screening during Pregnancy
• All pregnant women should have
syphilis serology undertaken at their 1st
pre-natal visit
• Serology should be repeated at 28 – 32
weeks gestation
• For “high-risk’ women serology should
again be repeated at term
Congenital Syphilis
Neonates should be treated at birth if:
• They demonstrate symptoms/signs of
congenital syphilis
• Maternal treatment was inadequate
• Maternal treatment is unknown
• Maternal treatment was with drugs other
than penicillin
RPR Titre Decrease After Treatment of
Infectious Syphilis
PRIMARY
ƒ 2 tube decrease at 6 months
ƒ 3 and 4 tube decrease at 12 and 24 months
SECONDARY
ƒ 3 and 4 tube decrease at 6 and 12 months
EARLY LATENT
ƒ 2 tube decrease at 12 months
Source: Romanowski B. Annals Int Med 1991;114:1005

Source: http://www.publichealthworks.ca/archive/2008/2008_09_Romanowski_Syphylis.pdf