What is the duration and location of lesions in the body during a syphilis infection?

Duration and Location of Syphilis Lesions

Syphilis lesions appear at different locations on the body and have varying durations depending on the stage of infection, with primary lesions typically appearing as painless chancres at the site of infection, secondary lesions manifesting as widespread rash including on palms and soles, and tertiary lesions potentially affecting multiple organ systems after years of untreated infection. 1, 2

Primary Syphilis

• Primary syphilis is characterized by one or more painless chancres (ulcers) that appear at the site of infection, typically the genitals, rectum, or mouth 1, 2
• The primary chancre usually develops approximately 3 weeks after infection (range: 10-90 days) 3
• These lesions are typically painless, indurated (firm), and accompanied by regional lymphadenopathy 2, 3
• Primary chancres spontaneously heal within 3-6 weeks, even without treatment 3, 4
• In HIV-infected individuals, multiple or atypical chancres may occur, and primary lesions might be absent or missed 1, 2

Secondary Syphilis

• Secondary syphilis typically develops 2-8 weeks after the primary stage, sometimes overlapping with the healing of the primary chancre 1, 4
• Lesions of secondary syphilis involve virtually all organ systems and include: 1, 2
  • Macular, maculopapular, papulosquamous, or pustular skin rash, often beginning on the trunk and spreading peripherally
  • Characteristic involvement of palms and soles
  • Condyloma lata (moist, flat, papular lesions) in warm intertrigenous regions
  • Mucous patches in the oral cavity
• These lesions are accompanied by generalized lymphadenopathy, fever, malaise, anorexia, arthralgias, and headache 1
• Secondary lesions can persist from a few days to several weeks before resolving spontaneously 1, 3
• Multiple relapses of secondary syphilis can occur, with decreasing intensity of symptoms in each episode 3

Latent Syphilis

• During latent syphilis, there are no visible lesions, but serologic tests remain positive 1, 2
• Early latent syphilis occurs within the first year after infection 1, 2
• Late latent syphilis occurs more than one year after infection 1, 2
• The latent period typically lasts 3-12 years before either spontaneous resolution (75% of cases) or progression to tertiary syphilis (25% of cases) 3, 4

Tertiary Syphilis

• Tertiary syphilis develops in approximately 25% of untreated patients after 3-12 years of latency 2, 3
• Lesions in tertiary syphilis include: 1, 2, 3
  • Gummatous lesions: granulomatous inflammatory lesions that can affect any organ system
  • Cardiovascular manifestations: primarily affecting the aorta
  • Neurologic involvement (neurosyphilis): can occur at any stage but is more common in tertiary syphilis
• Specific skin manifestations include superficial nodular syphilids and deeper gummas 3
• Late syphilis usually becomes clinically manifest only after 15-30 years of untreated infection 1, 3

Special Considerations

• HIV co-infection may modify the clinical presentation of syphilis: 1, 2
  • Clinical lesions may be more apparent
  • Disease progression may be accelerated
  • Multiple or atypical chancres are more common
  • Neurologic involvement may occur earlier
• Congenital syphilis presents with various manifestations including hepatosplenomegaly, rash, condyloma lata, jaundice, and other systemic symptoms 1

Clinical Pitfalls and Caveats

• Secondary syphilis can mimic acute primary HIV infection with constitutional symptoms and CSF abnormalities, leading to potential misdiagnosis 1, 2
• The absence of lesions does not rule out syphilis, as patients may be in the latent phase 1, 2
• Lesions of primary syphilis might be missed, especially if they occur in hidden locations such as the cervix, rectum, or oral cavity 1, 2
• Without treatment, syphilis can progress to cause severe morbidity and mortality through cardiovascular and neurological complications 3, 4