Syphilis

Incidence and Prevalence: The number of new syphilis cases in the US has waxed and waned over the last decades; the increases have been attributed to unsafe sex practices and use of drugs; the decreases possibly are due to increased awareness about the disease, education about safer sexual practices, and more aggressive testing for STDs. Current US rates are about 5.3 cases for every 100,000 individuals ("Primary and Secondary"). Tertiary syphilis is now rare in the US.

History: The incubation period is 10 days to 3 months (on average, 3 weeks). Syphilis occurs in four stages. Individuals with the primary stage may have a painless chancre (a usually single papule that rapidly ulcerates and becomes indurated) at the site of infection. Ten percent of sores occur in areas other than the genitals (anus, oropharynx, tongue, nipples, fingers) (Euerle). Individuals may report that the sores heal rapidly. Individuals may also report swollen lymph glands (lymphadenopathy). A complete social history aids diagnosis. There may be a history of sexual contact with an infected individual or sharing of needles among substance abusers. Individuals may report unprotected sex with many partners.

The secondary stage begins 6 to 24 weeks after infection, and lasts for 2 or more years. Individuals may report symptoms of a non-itchy, symmetrical, usually macular rash (however, it may also be pustular) that can cover any part of the body (most likely the palms of the hands and the soles of the feet). Fever, a vague feeling of bodily discomfort (malaise), loss of appetite (anorexia), nausea, sore throat, fatigue, headache, lymphadenopathy, condylomata lata, and hair loss (patchy alopecia) may also occur. Inflammation of the liver (hepatitis), joints (arthritis), bone (periostitis), eye (retinitis or uveitis), or the membranes that envelop the brain and spinal cord (meningitis) can also occur during this stage. This stage can recur at any time and with any severity in about 25% of individuals.

Individuals usually enter the latent stage 1 to 2 years after initial infection. This stage lasts for months to a lifetime. Individuals are not contagious, have no symptoms during this time, and may believe they are cured.

About 15% to 30% of individuals with untreated latent syphilis develop tertiary (late) syphilis, a slowly progressive stage that usually develops within 3 to 10 years of infection and can affect any organ. The most common manifestations of tertiary disease are coalescent granulomatous lesions (gummas) that may involve any organ (but particularly the skin and bones); ascending aortic aneurysm with possible pressure on the left laryngeal nerve and the trachea that may produce hoarseness and respiratory distress (cardiovascular syphilis); and invasion of the nervous system by the bacteria which may result in meningitis, paralysis, mental illness, and degeneration of the spinal nerves (neurosyphilis). Today this stage is seen mainly in HIV-infected individuals, who may have atypical or accelerated disease.

Physical exam: In the early stages of syphilis, chancre may be identified on the penis or cervix. Swollen, but not tender, lymph glands may be identifiable during the first two stages. The late stages of syphilis may reveal tumors (gummas) in the organs, neurological conditions, visual disturbances, or dementia.

Tests: Two types of serologic tests for syphilis are available, nontreponemal and treponemal. The well-known venereal disease research laboratory test (VDRL test), and rapid plasma reagin (RPR) (sensitivity of both, 78% to 86%), are reaginic nontreponemal tests that measure serum antibodies (IgG and IgM) and are used for screening, diagnosis, assessment of clinical syphilis activity, or monitoring the response to treatment. Serologic treponemal tests used for confirmation of positive VDRL or RPR test findings include the fluorescent treponemal antibody-absorbed (FTA-ABS) test, and the T. pallidum particle agglutination (TPPA) test, for antibodies to T. pallidum.

An increasing number of enzyme immunoassays (EIAs) for detecting syphilis antibodies have also become available.

A spinal tap may also be done in later stages of the disease to diagnose infection of the nervous system. Individuals with tertiary syphilis may need chest x-rays, computed tomography (CT) scans, and magnetic resonance imaging (MRIs) to determine involvement of other organs in the body.

Individuals diagnosed with syphilis should also be tested for other STDs, including HIV infection. Pregnant women should be tested for syphilis to prevent transmission of the disease to their children.

Risk: Individuals with the open sores found during the first two stages of syphilis should be kept away from other employees, because the sores are highly contagious and the infection may be transmitted by nonsexual skin contact. Lifestyle factors including education on safe sex practices may need to be initiated to prevent disease spread and recurrence.

Capacity: Capacity is dependent on the extent and anatomic locations affected by the infection and the stage of disease. Individuals in early stages of the disease with skin ulcers on the fingers may need to wear protective gloves to prevent local secondary bacterial infection and to protect coworkers. Individuals with retinitis or uveitis may have difficulty with prolonged computer work, and those with meningitis may require a temporary leave of absence.

Tolerance: In the first two stages of syphilis, tolerance may be affected by symptoms of malaise, headache, and fever. Individuals with untreated latent syphilis will have reduced tolerance dependent on the extent and location of organ system involvement.