What are the signs and symptoms of syphilis?

Signs and Symptoms of Syphilis

Syphilis presents with distinct clinical manifestations that vary by stage: primary syphilis features a painless chancre at the infection site, secondary syphilis displays a characteristic diffuse rash involving palms and soles with systemic symptoms, latent syphilis remains asymptomatic with positive serology, and tertiary syphilis causes destructive cardiovascular, neurologic, and gummatous lesions. 1

Primary Syphilis

The hallmark is a painless ulcer (chancre) at the site of inoculation, typically accompanied by regional lymphadenopathy. 1

• The chancre is characteristically painless and indurated, appearing at the contact site where Treponema pallidum entered the body 2
• Regional lymph node swelling is typically indolent and accompanies the primary chancre 2
• In HIV-infected individuals, multiple or atypical chancres may occur, and primary lesions might be absent or missed entirely 1
• The primary lesion heals spontaneously after several weeks, even without treatment 2

Secondary Syphilis

This stage is characterized by disseminated mucocutaneous lesions with generalized lymphadenopathy, often while the primary chancre is still present. 3

Cutaneous Manifestations

• A polymorphic rash that is typically maculopapular, starting on the trunk and spreading peripherally 4
• Involvement of palms and soles is a characteristic hallmark of secondary syphilis 4
• The rash is typically non-pruritic and transient 2
• Lesions may be macular, maculopapular, or pustular in appearance 4
• Condylomata lata (moist, wart-like lesions) appear in genital or intertriginous areas 4, 2
• Mucous patches may appear in the oral cavity, causing a specific angina 2

Systemic Manifestations

• Constitutional symptoms including fever, malaise, and anorexia 4
• Generalized lymphadenopathy 4, 2
• Arthralgias and headache 4
• Secondary syphilis can mimic acute primary HIV infection with constitutional symptoms and CSF abnormalities 1
• Acute syphilitic meningitis can occur during this stage 4
• Symptoms may last from several days to weeks before spontaneously resolving 4

Latent Syphilis

This stage is characterized by positive serologic tests without any clinical signs or symptoms. 1

Early Latent Syphilis

• Infection acquired within the previous 12 months 3
• Still potentially infectious to sexual partners 4
• May experience relapses of secondary manifestations, most commonly within the first 1-4 years after infection 4

Late Latent Syphilis

• Infection acquired more than 1 year previously 3
• Asymptomatic period lasting 3-12 years before potential progression to tertiary disease 2

Tertiary (Late) Syphilis

Tertiary syphilis occurs in approximately 25% of untreated patients after 3-12 years of latency, with manifestations including gummatous lesions, cardiovascular syphilis, and neurologic involvement. 1

Gummatous Syphilis

• Granulomatous lesions (gummas) that can affect skin, bones, and internal organs 4
• May involve respiratory tract, eyes, abdominal organs (including liver), reproductive organs, lymph nodes, and skeletal muscles 4

Cardiovascular Syphilis

• Inflammatory lesions affecting the cardiovascular system 4
• Typically becomes clinically apparent 15-30 years after untreated infection 4

Skeletal Involvement

• Bone lesions affecting the skeletal system 4

Neurosyphilis

Neurosyphilis can occur at any stage of infection and is characterized by CNS involvement by T. pallidum. 1

Asymptomatic Neurosyphilis

• No clinical symptoms but CSF abnormalities present (elevated protein, lymphocytic infiltration, or positive serologic tests) 4

Symptomatic Neurosyphilis

• May present as meningitis, meningovascular disease, or parenchymal disease 4
• Can cause hearing loss, uveitis, or stroke 5
• Uveitis and meningitis occurring together may be more common in HIV-infected patients 4
• Late manifestations (10-30 years post-infection) include tabes dorsalis and progressive paralysis 2

Congenital Syphilis

Congenital syphilis results from in-utero infection with T. pallidum, with up to 40% of exposed fetuses being stillborn or dying from infection during infancy. 5

Early Manifestations (Infants and Children <2 Years)

• Hepatosplenomegaly, rash, condylomata lata 4
• Snuffles (rhinitis), jaundice, pseudoparalysis 4
• Anemia and edema 4

Late Manifestations (Older Children)

• Stigmata including keratitis interstitialis, nerve deafness 4
• Skeletal abnormalities: anterior bowing of tibia, frontal bossing 4
• Dental abnormalities: mulberry molars, Hutchinson teeth 4
• Saddle nose, rhagades, Clutton joints 4

Special Considerations in HIV-Infected Patients

HIV-infected patients may have more apparent clinical lesions and accelerated progression of syphilitic disease. 1

• Multiple or atypical chancres are more common 1
• More rapid disease progression may occur 6
• Atypical presentations, including orchitis, are more likely 6
• All patients with syphilis should be tested for HIV 1

Gastrointestinal Manifestations (Rare)

T. pallidum can seed any part of the GI tract, causing:

• Esophagitis with painless ulcers and dysphagia 7
• Gastritis with nausea, vomiting, and early satiety 7
• Hepatitis and pancreatitis 7
• Proctocolitis with diarrhea, melena, hematochezia, or anorectal ulcers 7