From the Guidelines
Syphilis progresses through four distinct stages, each with specific characteristics, including primary, secondary, latent, and tertiary syphilis, with treatment and management depending on the stage and patient's HIV status, as outlined in the guidelines by the Centers for Disease Control and Prevention 1, 2, 3. The four stages of syphilis are characterized as follows:
- Primary syphilis: a painless sore called a chancre appears at the site of infection, typically on the genitals, rectum, or mouth, about 3-4 weeks after exposure, and heals on its own within 3-6 weeks.
- Secondary syphilis: develops 2-8 weeks after the chancre appears, featuring a non-itchy rash that often affects the palms and soles, along with flu-like symptoms including fever, sore throat, headaches, and fatigue.
- Latent syphilis: follows with no visible symptoms but positive blood tests, divided into early latent (less than one year after infection) and late latent (more than one year), with early latent syphilis defined as syphilis acquired within the preceding year 4, 1.
- Tertiary syphilis: can occur 10-30 years after initial infection, causing severe damage to multiple organ systems, including the heart, brain, nerves, eyes, blood vessels, liver, bones, and joints. Treatment typically involves penicillin G benzathine injections, with dosage and duration depending on the stage: a single injection of 2.4 million units for primary, secondary, or early latent syphilis, and three weekly injections for late latent or tertiary syphilis, with alternatives for penicillin-allergic patients, such as doxycycline 100 mg twice daily for 14 days (early stages) or 28 days (late stages) 5, 6, 7. Key considerations in management include:
- HIV-infected patients with early latent syphilis should be managed and treated according to the recommendations for HIV-negative patients with primary and secondary syphilis 3.
- HIV-infected patients with late latent syphilis or syphilis of unknown duration should have a CSF examination before treatment 3.
- All patients with syphilis should be tested for HIV infection 1, 7. Regular follow-up testing is essential to ensure treatment success.
From the Research
Characteristics of Syphilis Stages
The four stages of syphilis are primary, secondary, latent, and tertiary syphilis. Each stage has distinct characteristics, including:
- Primary syphilis: characterized by a distinct painless and indurated ulcer at the contact site, known as the primary chancre, and indolent regional lymph node swelling 8
- Secondary syphilis: marked by common symptoms like fever and malaise, generalized lymphadenopathy, and a broad variety of lesions of the skin and mucosal membranes, including non-pruritic transient exanthems, condylomata lata, and a specific angina with mucous patches of the oral cavity 8, 9, 10
- Latent syphilis: a period of decreased re-occurrence of secondary stage manifestations, with an absence of symptoms, lasting 3-12 years 8, 10
- Tertiary syphilis: characterized by granulomatous skin reactions, including superficial nodular syphilids and gummas, and potential involvement of the bones, cardiovascular, and central nervous system 8, 10
Clinical Manifestations
The clinical manifestations of syphilis can vary widely, and may include:
- Ocular involvement, which can occur at any stage of syphilis, and may present with diverse manifestations, including uveitis and syphilitic posterior placoid chorioretinitis 11
- Unusual manifestations, such as nodular lesions and periostitis, which can be mistaken for other conditions, such as lymphoma or osteoma 12
- Systemic symptoms, such as fever, malaise, and generalized lymphadenopathy, which can occur during the secondary stage of syphilis 8, 9, 10
Diagnosis and Treatment
Diagnosis of syphilis is typically made through serological testing, including treponemal and nontreponemal tests 8, 10, 11, 12. Treatment of syphilis usually involves the use of benzathine penicillin G, which is effective against all stages of the disease 8, 9, 10, 11, 12.