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Syphilis

Syphilis

Definition

Syphilis is an infectious systemic disease that may be either congenital or acquired through sexual contact or contaminated needles.

Description

Syphilis has both acute and chronic forms that produce a wide variety of symptoms affecting most of the body's organ systems. The range of symptoms makes it easy to confuse syphilis with less serious diseases and ignore its early signs. Acquired syphilis has four stages (primary, secondary, latent, and tertiary) and can be spread by sexual contact during the first three of these four stages.

Syphilis, which is also called lues (from a Latin word meaning "plague"), has been a major public health problem since the sixteenth century. The disease was treated with mercury or other ineffective remedies until World War I, when effective treatments based on arsenic or bismuth were introduced. These were succeeded by antibiotics

after World War II. At that time, the number of cases in the general population decreased, partly because of aggressive public health measures. This temporary decrease, combined with the greater amount of attention given to AIDS in recent years, leads some people to think that syphilis is no longer a serious problem. In fact, the number of cases of syphilis in the United States rose between 1980 and 2001. This increase affected both sexes, all races, all parts of the nation, and all age groups, including adults over 60. The number of women of childbearing age with syphilis is the highest that has been recorded since the 1940s. About 25,000 cases of infectious syphilis in adults are reported annually in the United States. It is estimated, however, that 400,000 people in the United States need treatment for syphilis every year, and that the annual worldwide total is 50 million persons.

In 1999, the Centers for Disease Control and Prevention (CDC) joined several other federal agencies in announcing the "National Plan to Eliminate Syphilis in the United States." Eliminating the disease was defined as the absence of transmission of the disease; that is, no transmission after 90 days following the report of an imported index case. The national goals for eliminating syphilis include bringing the annual number of reported cases in the United States below 1000, and increasing the number of syphilis-free counties to 90% by 2005. In November 2002, the CDC released figures for 20002001, which indicate that the number of reported cases of primary and secondary syphilis rose slightly. This rise, however, occurred only among men who have sex with other men. The CDC also stated that the number of new cases of syphilis has actually declined among women as well as among non-Hispanic blacks.

The increased incidence of syphilis since the 1970s is associated with drug abuse as well as changes in sexual behavior. The connections between drug abuse and syphilis include needle sharing and exchanging sex for drugs. In addition, people using drugs are more likely to engage in risky sexual practices. As of 2002, the risk of contracting syphilis is particularly high among those who abuse crack cocaine.

With respect to changing patterns of conduct, a sharp increase in the number of people having sex with multiple partners makes it more difficult for public health doctors to trace the contacts of infected persons. Women are not necessarily protected by having sex only with other women; in the past few years, several cases have been reported of female-to-female transmission of syphilis through oral-genital contact. In addition, the incidence of syphilis among men who have sex with other men continues to rise. Several studies in Latin America as well as in the United States reported in late 2002 that unprotected sexual intercourse is on the increase among gay and bisexual men.

Changing patterns of sexual behavior have led to a striking increase in the number of cases of syphilis in eastern Europe since the collapse of the Soviet Union; Slovenia reported an 18-fold increase in reported cases of syphilis just between 1993 and 1994. Over half of the new cases were linked to a source of infection in another European country.

In general, high-risk groups for syphilis in the United States and Canada include:

  • sexually active teenagers
  • people infected with another sexually transmitted disease (STD), including AIDS, herpes, and gonorrhea
  • sexually abused children
  • women of childbearing age
  • prostitutes of either sex and their customers
  • prisoners
  • persons who abuse drugs or alcohol

The chances of contracting syphilis from an infected person in the early stages of the disease during unprotected sex range from 3050%.

Causes & symptoms

Syphilis is caused by a spirochete, Treponema pallidum. A spirochete is a thin spiral- or coil-shaped bacterium that enters the body through the mucous membranes or breaks in the skin. In 90% of cases, the spiro-chete is transmitted by sexual contact. Transmission by blood transfusion is possible but rare, not only because blood products are screened for the disease, but also because the spirochetes die within 24 hours in stored blood. Other methods of transmission are highly unlikely because T. pallidum is easily killed by heat and drying.

Primary syphilis

Primary syphilis is the stage of the organism's entry into the body. The first signs of infection are not always noticed. After an incubation period ranging from 1090 days, the patient develops a chancre, which is a small blister-like sore about 0.5 in (13 mm) in size. Most chancres are on the genitals, but may also develop in or on the mouth or on the breasts. Rectal chancres are common in male homosexuals. Chancres in women are sometimes overlooked if they develop in the vagina or on the cervix. The chancres are not painful and disappear in three to six weeks even without treatment. They resemble the ulcers of lymphogranuloma venereum, herpes simplex virus, or skin tumors.

About 70% of patients with primary syphilis also develop swollen lymph nodes near the chancre. The nodes may have a firm or rubbery feel when the doctor touches them but are not usually painful.

Secondary syphilis

Syphilis enters its secondary stage ranging from six to eight weeks to six months after the infection begins. Chancres may still be present but are usually healing. Secondary syphilis is a systemic infection marked by the eruption of skin rashes and ulcers in the mucous membranes. The skin rash may mimic a number of other skin disorders such as drug reactions, rubella ringworm, mononucleosis , and pityriasis rosea . Characteristics that point to syphilis include:

  • a coppery color
  • absence of pain or itching
  • occurrence on the palms of hands and soles of feet

The skin eruption may resolve in a few weeks or last as long as a year. The patient may also develop condylomata lata, which are weepy pinkish or gray areas of flattened skin in the moist areas of the body. The skin rashes, mouth and genital ulcers, and condylomata lata are all highly infectious.

About 50% of patients with secondary syphilis develop swollen lymph nodes in the armpits, groin, and neck areas; about 10% develop inflammations of the eyes, kidney, liver, spleen, bones, joints, or the meninges (membranes covering the brain and spinal cord). They may also have a flulike general illness with a low fever, chills , loss of appetite, headaches, runny nose, sore throat , and aching joints.

Latent syphilis

Latent syphilis is a phase of the disease characterized by relative absence of external symptoms. The term latent does not mean that the disease is not progressing or that the patient cannot infect others. For example, pregnant women can transmit syphilis to their unborn children during the latency period.

The latent phase is sometimes divided into early latency (less than two years after infection) and late latency. During early latency, patients are at risk for spontaneous relapses marked by recurrence of the ulcers and skin rashes of secondary syphilis. In late latency, these recurrences are much less likely. Late latency may either resolve spontaneously or continue for the rest of the patient's life.

Tertiary syphilis

Untreated syphilis progresses to a third or tertiary stage in about 3540% of patients (only those who go untreated). Patients with tertiary syphilis cannot infect others with the disease. It is thought that the symptoms of this stage are a delayed immune hypersensitivity reaction to the spirochetes. Some patients develop so-called benign late syphilis, which begins between three and 10 years after infection and is characterized by the development of gummas. Gummas are rubbery tumor-like growths that are most likely to involve the skin or long bones but may also develop in the eyes, mucous membranes, throat, liver, or stomach lining. Gummas are increasingly uncommon since the introduction of antibiotics for treating syphilis. Benign late syphilis is usually rapid in onset and responds well to treatment.

CARDIOVASCULAR SYPHILIS. Cardiovascular syphilis occurs in 1015% of patients who have progressed to tertiary syphilis. It develops between 10 and 25 years after infection and often occurs together with neurosyphilis. Cardiovascular syphilis usually begins as an inflammation of the arteries leading from the heart and heart attacks, scarring of the aortic valves, congestive heart failure, or the formation of an aortic aneurysm.

NEUROSYPHILIS. About 8% of patients with untreated syphilis will develop symptoms in the central nervous system that include both physical and psychiatric symptoms. Neurosyphilis can appear at any time from five to 35 years after the onset of primary syphilis. It affects men more frequently than women and Caucasians more frequently than African Americans.

Neurosyphilis is classified into four types:

  • Asymptomatic. In this form of neurosyphilis, the patient's spinal fluid gives abnormal test results but there are no symptoms affecting the central nervous system.
  • Meningovascular. This type of neurosyphilis is marked by changes in the blood vessels of the brain or inflammation of the meninges (the tissue layers covering the brain and spinal cord). The patient develops headaches, irritability, and visual problems. If the spinal cord is involved, the patient may experience weakness of the shoulder and upper arm muscles.
  • Tabes dorsalis. Tabes dorsalis is a progressive degeneration of the spinal cord and nerve roots. Patients lose their sense of perception of body position and orientation in space (proprioception), resulting in difficulties walking and loss of muscle reflexes. They may also have shooting pains in the legs and periodic episodes of pain in the abdomen, throat, bladder, or rectum. Tabes dorsalis is sometimes called locomotor ataxia.
  • General paresis. General paresis refers to the effects of neurosyphilis on the cortex of the brain. The patient has a slow but progressive loss of memory, decreased ability to concentrate, and less interest in self-care. Personality changes may include irresponsible behavior, depression , delusions of grandeur, or complete psychosis. General paresis is sometimes called dementia paralytica, and is most common in patients over 40.

Special populations

NEWBORNS. Congenital syphilis has increased at a rate of 400500% over the past decade, on the basis of criteria introduced by the Centers for Disease Control (CDC) in 1990. In 1994, more than 2,200 cases of congenital syphilis were reported in the United States. The prognosis for early congenital syphilis is poor: about 54% of infected fetuses die before or shortly after birth. Those who survive may look normal at birth but show signs of infection between three and eight weeks later.

Infants with early congenital syphilis have systemic symptoms that resemble those of adults with secondary syphilis. There is a 4060% chance that the child's central nervous system will be infected. These infants may have symptoms ranging from jaundice , enlargement of the spleen and liver, and anemia to skin rashes, condylomata lata, certain congenital bone abnormalities, inflammation of the lungs, "snuffles" (a persistent runny nose), and swollen lymph nodes.

CHILDREN. Children who develop symptoms after the age of two years are said to have late congenital syphilis. The characteristic symptoms include facial deformities (saddle nose), Hutchinson's teeth (abnormal upper incisors), saber shins, dislocated joints, deafness, mental retardation, paralysis, and seizure disorders.

PREGNANT WOMEN. Syphilis can be transmitted from the mother to the fetus through the placenta at any time during pregnancy , or through the child's contact with syphilitic ulcers during the birth process. The chances of infection are related to the stage of the mother's disease. Almost all infants of mothers with untreated primary or secondary syphilis will be infected, whereas the infection rate drops to 40% if the mother is in the early latent stage and 614% if she has late latent syphilis.

Pregnancy does not affect the progression of syphilis in the mother; however, pregnant women should not be treated with tetracyclines.

HIV PATIENTS. Syphilis has been closely associated with HIV infection since the late 1980s. Syphilis sometimes mimics the symptoms of AIDS. Conversely, AIDS appears to increase the severity of syphilis in patients suffering from both diseases, and to speed up the development or appearance of neurosyphilis. Patients with HIV are also more likely to develop lues maligna, a skin disease that sometimes occurs in secondary syphilis. Lues maligna is characterized by areas of ulcerated and dying tissue. In addition, HIV patients have a higher rate of treatment failure with penicillin than patients without HIV.

ADULT MALES. A recent study indicates that infection with syphilis increases a man's risk of developing prostate cancer in later life. It is thought that infection may represent one mechanism among several through which prostate cancer may develop.

Diagnosis

Patient history and physical diagnosis

The diagnosis of syphilis is often delayed because of the variety of early symptoms, the varying length of the incubation period, and the possibility of not noticing the initial chancre. Patients do not always connect their symptoms with recent sexual contact. They may go to a dermatologist when they develop the skin rash of secondary syphilis rather than to their primary care doctor. Women may be diagnosed in the course of a gynecological checkup. Because of the long-term risks of untreated syphilis, certain groups of people are now routinely screened for the disease:

  • pregnant women
  • sexual contacts or partners of patients diagnosed with syphilis
  • children born to mothers with syphilis
  • patients with HIV infection
  • persons applying for marriage licenses

When the doctor takes the patient's history, he or she will ask about recent sexual contacts in order to determine whether the patient falls into a high-risk group. Other symptoms, such as skin rashes or swollen lymph nodes, will be noted with respect to the dates of the patient's sexual contacts. Definite diagnosis, however, depends on the results of laboratory blood tests.

Blood tests

There are several types of blood tests for syphilis presently used in the United States. Some are used in follow-up monitoring of patients as well as diagnosis.

NONTREPONEMAL ANTIGEN TESTS. Nontreponemal antigen tests are used as screeners. They measure the presence of reagin, which is an antibody formed in reaction to syphilis. In the Venereal Disease Research Laboratory (VDRL) test, a sample of the patient's blood is mixed with cardiolipin and cholesterol . If the mixture forms clumps or masses of matter, the test is considered reactive or positive. The serum sample can be diluted several times to determine the concentration of reagin in the patient's blood.

The rapid plasma reagin (RPR) test works on the same principle as the VDRL. It is available as a kit. The patient's serum is mixed with cardiolipin on a plastic-coated card that can be examined with the naked eye.

Nontreponemal antigen tests require a doctor's interpretation and sometimes further testing. They can yield both false-negative and false-positive results. False-positive results (test shows a positive result when the patient does not have the disease) can be caused by other infectious diseases, including mononucleosis, malaria , leprosy, rheumatoid arthritis , and lupus. HIV patients have a particularly high rate (4%, compared to 0.8% of HIV-negative patients) of false-positive results on reagin tests. False negative results (patient does have the disease, but test comes back negative) can occur when patients are tested too soon after exposure to syphilis; it takes about 1421 days after infection for the blood to become reactive.

TREPONEMAL ANTIBODY TESTS. Treponemal anti-body tests are used to rule out false-positive results on reagin tests. They measure the presence of antibodies that are specific for T. pallidum. The most commonly used tests are the microhemagglutination-T. pallidum (MHA-TP) and the fluorescent treponemal antibody absorption (FTA-ABS) tests. In the FTA-ABS, the patient's blood serum is mixed with a preparation that prevents interference from antibodies to other treponemal infections . The test serum is added to a slide containing T. pallidum. In a positive reaction, syphilitic antibodies in the blood coat the spirochetes on the slide. The slide is then stained with fluorescein, which causes the coated spirochetes to fluoresce when the slide is viewed under ultraviolet (UV) light. In the MHA-TP test, red blood cells from sheep are coated with T. pallidum antigen. The cells will clump if the patient's blood contains anti-bodies for syphilis.

A newer treponemal antibody test developed in Belgium, the INNO-LIA, uses recombinant and peptide antigens derived from T. pallidum proteins. Preliminary testing in Europe indicates that the INNO-LIA is the most accurate of the available treponemal antibody tests for syphilis.

Treponemal antibody tests are more expensive and more difficult to perform than nontreponemal tests. They are therefore used to confirm the diagnosis of syphilis rather than to screen large groups of people. These tests are, however, very specific and very sensitive; false-positive results are relatively unusual.

INVESTIGATIONAL BLOOD TESTS. As of 1998, ELISA, Western blot, and PCR testing are being studied as additional diagnostic tests, particularly for congenital syphilis and neurosyphilis.

Other laboratory tests

MICROSCOPE STUDIES. The diagnosis of syphilis can also be confirmed by identifying spirochetes in samples of tissue or lymphatic fluid. Fresh samples can be made into slides and studied under darkfield illumination. A newer method involves preparing slides from dried fluid smears and staining them with fluorescein for viewing under UV light. This method is replacing dark-field examination because the slides can be mailed to professional laboratories.

SPINAL FLUID TESTS. Testing of cerebrospinal fluid (CSF) is an important part of patient monitoring as well as a diagnostic test. The VDRL and FTA-ABS tests can be performed on CSF as well as on blood. An abnormally high white cell count and elevated protein levels in the CSF, together with positive VDRL results, suggest a possible diagnosis of neurosyphilis. CSF testing is not used for routine screening. It is used most frequently for infants with congenital syphilis, HIV-positive patients, and patients of any age who are not responding to penicillin treatment.

Treatment

It is difficult to obtain information about alternative treatments for syphilis. The disease has a high profile as a public health issue and few alternative practitioners want to risk accusations of minimizing its dangers. One respected resource for alternative therapies states bluntly, "Syphilis should not be treated only with natural therapies." Most naturopathic practitioners agree that antibiotics are essential for the treatment of syphilis. Others would add that recovery from the disease can be assisted by dietary changes, sleep, exercise , and stress reduction, and immune support measures.

Homeopathy

Homeopathic practitioners are forbidden by law in the United States to claim that homeopathic treatment can cure syphilis. Given the high rate of syphilis in HIV-positive patients, however, some alternative practitioners who are treating AIDS patients with homeopathic remedies maintain that they are beneficial for syphilis as well. The remedies suggested most frequently are Medorrhinum, Syphilinum, Mercurius vivus, and Aurum. The use of Mercurius vivus as a homeopathic remedy reflects the past use of mercury to treat syphilis prior to the discovery of penicillin. Syphilinum represents a class of homeopathic remedy called nosodes. A nosode is a homeopathic medicine made from diseased material, such as bacteria, viruses, or pus. Its effect is based on the homeopathic law of similars, in which a substance that causes a specific set of symptoms in a healthy person is determined curative when given to a sick person with the same symptoms. Syphilinum is a nosode made from a dilution of killed Treponema pallidum. The historical link between homeopathy and syphilis is Hahnemann's theory of miasms, which he defined as fundamental predispositions toward disease that were transmitted from one generation to the next. He thought that the syphilitic miasm was the second oldest cause of constitutional weakness in humans.

Other

Traditional Chinese medicine (TCM) and other alternative methods emphasize the mental aspects of conditions and diseases such as syphilis. Mind-body medicine, guided imagery and affirmations are often used to help support a person through such a disease. New thought holds that humans can control physical as well as mental or spiritual events through the power of thinking itself. Some alternative therapies reflect new thought beliefs by maintaining that humans make themselves ill through harmful thought patterns, and that they can heal themselves by affirming positive beliefs. The affirmation suggested for healing syphilis is "I decide to be me." Most alternative practitioners would recommend this or similar new thought affirmations only as adjuncts to conventional medical treatment for syphilis.

One interesting recent historical development is that outdated or discredited treatments for syphilis have resurfaced as alternative treatments for AIDS or cancer. One study of alternative treatments for HIV infection notes that hyperthermia , which involves treating a disease by giving the patient a fever, originated as a treatment for syphilis. Syphilis patients were given malaria in the belief that the resultant fever would kill the spiro-chetes that cause syphilis.

Another example is the so-called Hoxsey treatment for cancer, which was started in the 1920s by an Illinois practitioner named Harry Hoxsey. The treatment is no longer legally available in the United States but is offered through a clinic in Tijuana, Mexico. The treatment consists of several chemical mixtures applied externally and a formula of nine herbs taken internally. The Hoxsey herbal formula is almost identical to a remedy that was listed in the 1926 and 1936 editions of the United States National Formulary called "Compound Fluidextract of Trifolium." It was recommended as a treatment for secondary and tertiary syphilis. One of the external Hoxsey compounds contains both arsenic and antimony, which were used to treat syphilis before the use of antibiotics. The internal formula includes Phytolacca americana, or pokeweed, which was used by Native Americans to treat syphilitic chancres; and Stillingia sylvatica, or queens-root, which has also been used to treat syphilis. There is no demonstrated data to support the therapy's effectiveness for syphilis.

It should be noted that many alternative medicine therapies that claim to help such infectious diseases as syphilis have little data supporting their effectiveness.

Allopathic treatment

Medications

Syphilis is treated with antibiotics given either intramuscularly (benzathine penicillin G or ceftriaxone) or orally (doxycycline, minocycline, tetracycline, or azithromycin). Neurosyphilis is treated with a combination of aqueous crystalline penicillin G, benzathine penicillin G, or doxycycline. It is important to keep the levels of penicillin in the patient's tissues at sufficiently high levels over a period of days or weeks because the spiro-chetes have a relatively long reproduction time. Penicillin is more effective in treating the early stages of syphilis than the later stages.

In the fall of 2000, the CDC convened a group of medical advisors to discuss backup medications for treating syphilis. Although none of the newer drugs will displace penicillin as the primary drug, the doctors recommended azithromycin and ceftriaxone as medications that should have a larger role in the treatment of syphilis than they presently do.

Doctors do not usually prescribe separate medications for the skin rashes or ulcers of secondary syphilis. The patient is advised to keep them clean and dry, and to avoid exposing others to fluid or discharges from condylomata lata.

Pregnant women should be treated as early in pregnancy as possible. Infected fetuses can be cured if the mother is treated during the second and third trimesters of pregnancy. Infants with proven or suspected congenital syphilis are treated with either aqueous crystalline penicillin G or aqueous procaine penicillin G. Children who acquire syphilis after birth are treated with benzathine penicillin G.

Jarisch-Herxheimer reaction

The Jarisch-Herxheimer reaction, first described in 1895, is a reaction to penicillin treatment that may occur during the late primary, secondary, or early latent stages. The patient develops chills, fever, headache , and muscle pains within two to six hours after the penicillin is injected. The chancre or rash gets temporarily worse. The Jarisch-Herxheimer reaction, which lasts about a day, is thought to be an allergic reaction to toxins released when the penicillin kills massive numbers of spirochetes.

Expected results

The expected results of alternative therapies used as adjuncts to conventional antibiotic treatment, for stress reduction or similar purposes, would include improvements in the patient's emotional and spiritual quality of life. The effectiveness of homeopathic treatment for syphilis has not been evaluated in clinical trials, although there are anecdotal reports of successful treatment of syphilis by homeopathic methods.

Analysis of the Hoxsey formulae, however, indicate that they should not be used to treat syphilis or other venereal diseases. Two ingredients in the internal formula have toxic effects: queensroot contains an irritant that can cause inflammation or swelling of the skin and mucous membranes, while pokeweed can cause potentially fatal respiratory paralysis. In addition, the arsenic and antimony in the external formula could potentially cause heavy metal toxicity.

Prevention

Immunity

Patients with syphilis do not acquire lasting immunity against the disease. As of 2002, no effective vaccine for syphilis has been developed even though the genome of T. pallidum was completely sequenced in 1998. The sequencing may, however, speed up the process of developing an effective vaccine. Prevention depends on a combination of personal and public health measures.

Lifestyle choices

The only reliable methods for preventing transmission of syphilis are sexual abstinence or monogamous relationships between uninfected partners. Condoms offer some protection but protect only the covered parts of the body.

Public health measures

CONTACT TRACING. United States law requires reporting of syphilis cases to public health agencies. Sexual contacts of patients diagnosed with syphilis are traced and tested for the disease. Tracing includes all contacts for the past three months in cases of primary syphilis and for the past year in cases of secondary disease. Neither the patients nor their contacts should have sex with anyone until they have been tested and treated.

Because of the rising incidence of syphilis abroad, a growing number of public health physicians are recommending routine screening of immigrants, refugees, and international adoptees for syphilis as of late 2002.

All patients who test positive for syphilis should be tested for HIV infection at the time of diagnosis.

PRENATAL TESTING OF PREGNANT WOMEN. Pregnant women should be tested for syphilis at the time of their first visit for prenatal care, and again shortly before delivery. Proper treatment of secondary syphilis in the mother reduces the risk of congenital syphilis in the infant from 90% to less than 2%.

As of late 2002, many obstetricians and gynecologists are recommending routine screening of nonpregnant as well as pregnant women for syphilis. At present, only about half of obstetricians and gynecologists in the United States screen nonpregnant women for chlamydia and gonorrhea, while fewer than a third screen them for syphilis.

EDUCATION AND INFORMATION. Patients diagnosed with syphilis should be given information about the disease and counseling regarding sexual behavior and the importance of completing antibiotic treatment. It is also important to inform the general public about the transmission and early symptoms of syphilis, and provide adequate health facilities for testing and treatment.

Resources

BOOKS

Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Fife, WA: Future Medicine Publishing, Inc., 1995.

Fiumara, Nicholas J. "Syphilis." In Conn's Current Therapy, edited by Robert E. Rakel. Philadelphia: W.B. Saunders Company, 1998.

Jacobs, Richard A. "Infectious Diseases: Spirochetal." In Current Medical Diagnosis & Treatment 1998, edited by Lawrence M. Tierney Jr. et al. Stamford, CT: Appleton & Lange, 1998.

Ramin, Susan M., et al. "Sexually Transmitted Diseases and Pelvic Infections." In Current Obstetric & Gynecologic Diagnosis & Treatment, edited by Alan H. DeCherney and Martin L. Pernoll. Norwalk, CT: Appleton & Lange, 1994.

Sigel, Eric J. "Sexually Transmitted Diseases." In Current Pediatric Diagnosis & Treatment, edited by William W. Hay Jr., et al. Stamford, CT: Appleton & Lange, 1997.

"Syphilis." Section 13, Chapter 164 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Wolf, Judith E. "Syphilis." In Current Diagnosis 9, edited by Rex B. Conn, et al. Philadelphia: W.B. Saunders Company, 1997.

PERIODICALS

Augenbraun, M. H. "Treatment of Syphilis 2001: Nonpregnant Adults." Clinical Infectious Diseases 35 (October 15, 2002) (Suppl. 2): S187S190.

Campos-Outcalt, D., and S. Hurwitz." Female-to-Female Transmission of Syphilis: A Case Report." Sexually Transmitted Diseases 29 (February 2002): 119120.

Centers for Disease Control. "Primary and Secondary SyphilisUnited States, 2000-2001." Morbidity and Mortality Weekly Report 51 (November 1, 2002): 971973.

Dennis, L. K., and D. V. Dawson. "Meta-Analysis of Measures of Sexual Activity and Prostate Cancer." Epidemiology 13 (January 2002): 7279.

Gibbs, R. S. "The Origins of Stillbirth: Infectious Diseases." Seminars in Perinatology 26 (February 2002): 7578.

Grgic-Vitek, M., I Klavs, M. Potocnik, and M. Rogl-Butina. "Syphilis Epidemic in Slovenia Influenced by Syphilis Epidemic in the Russian Federation and Other Newly Independent States." International Journal of STD and AIDS 13 (December 2002) (Suppl. 2): 24.

Hagedorn, H. J., A. Kraminer-Hagedorn, K. de Bosschere, et al. "Evaluation of INNO-LIA Syphilis Assay as a Confirmatory Test for Syphilis." Journal of Clinical Microbiology 40 (March 2002): 973978.

Hogben, M., J. S. Lawrence, D. Kasprzyk, et al. "Sexually Transmitted Disease Screening by United States Obstetricians and Gynecologists." Obstetrics and Gynecology 100 (October 2002): 801807.

Kolivras, A., J. de Maubeuge, M. Song, et al. "A Case of Early Congenital Syphilis." Dermatology 204 (2002): 338340.

Pao, D., B. T. Goh, and J. S. Bingham. "Management Issues in Syphilis." Drugs 62 (2002): 14471461.

Ross, M. W., L. Y. Hwang, C. Zack, et al. "Sexual Risk Behaviours and STIs in Drug Abuse Treatment Populations Whose Drug of Choice is Crack Cocaine." International Journal of STD and AIDS 13 (November 2002): 769774.

Stauffer, W. M., D. Kamat, and P. F. Walker. "Screening of International Immigrants, Refugees, and Adoptees." Primary Care 29 (December 2002): 879905.

Sutmoller, F., T. L. Penna, C. T. de Souza, et al. "Human Immunodeficiency Virus Incidence and Risk Behavior in the 'Projeto Rio': Results of the First 5 Years of the Rio de Janeiro Open Cohort of Homosexual and Bisexual Men, 199498." International Journal of Infectious Diseases 6 (December 2002): 259265.

Whittington, W. L., T. Collis, C. Dithmer-Schreck, et al. "Sexually Transmitted Diseases and Human Immunodeficiency Virus-Discordant Partnerships Among Men Who Have Sex With Men." Clinical Infectious Diseases 35 (October 15, 2002): 10101017.

ORGANIZATIONS

Centers for Disease Control and Prevention. 1600 Clifton Road NE, Atlanta, GA, 30333. (404) 639-3534.

Rebecca J. Frey, PhD

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Syphilis

Syphilis

Definition

Syphilis is an infectious systemic disease that may be either congenital or acquired through sexual contact or contaminated needles.

Description

Syphilis has both acute and chronic forms that produce a wide variety of symptoms affecting most of the body's organ systems. The range of symptoms makes it easy to confuse syphilis with less serious diseases and ignore its early signs. Acquired syphilis has four stages (primary, secondary, latent, and tertiary) and can be spread by sexual contact during the first three of these four stages.

Syphilis, which is also called lues (from a Latin word meaning plague ), has been a major public health problem since the sixteenth century. The disease was treated with mercury or other ineffective remedies until World War I, when effective treatments based on arsenic or bismuth were introduced. These were succeeded by antibiotics after World War II. At that time, the number of cases in the general population decreased, partly because of aggressive public health measures. This temporary decrease, combined with the greater amount of attention given to AIDS in recent years, leads some people to think that syphilis is no longer a serious problem. In actual fact, the number of cases of syphilis in the United States has risen since 1980. This increase affects both sexes, all races, all parts of the nation, and all age groups, including adults over 60. The number of women of childbearing age with syphilis is the highest that has been recorded since the 1940s. About 25,000 cases of infectious syphilis in adults are reported annually in the United States. It is estimated, however, that 400,000 people in the United States need treatment for syphilis every year, and that the annual worldwide total is 50 million persons.

In 1999, the Centers for Disease Control and Prevention (CDC) joined several other federal agencies in announcing the "National Plan to Eliminate Syphilis in the United States." Eliminating the disease was defined as the absence of transmission of the disease; that is, no transmission after 90 days following the report of an imported index case. The national goals for eliminating syphilis include bringing the annual number of reported cases in the United States below 1000, and increasing the number of syphilis-free counties to 90% by 2005. In November 2002, the CDC released figures for 20002001, which indicate that the number of reported cases of primary and secondary syphilis rose slightly. This rise, however, occurred only among men who have sex with other men. The CDC also stated that the number of new cases of syphilis has actually declined among women as well as among non-Hispanic blacks.

The increased incidence of syphilis since the 1970s is associated with drug abuse as well as changes in sexual behavior. The connections between drug abuse and syphilis include needle sharing and exchanging sex for drugs. In addition, people using drugs are more likely to engage in risky sexual practices. As of 2002, the risk of contracting syphilis is particularly high among those who abuse crack cocaine.

With respect to changing patterns of conduct, a sharp increase in the number of people having sex with multiple partners makes it more difficult for public health doctors to trace the contacts of infected persons. Women are not necessarily protected by having sex only with other women; in the past few years, several cases have been reported of female-to-female transmission of syphilis through oral-genital contact. In addition, the incidence of syphilis among men who have sex with other men continues to rise. Several studies in Latin America as well as in the United States reported in late 2002 that unprotected sexual intercourse is on the increase among gay and bisexual men.

Changing patterns of sexual behavior have led to a striking increase in the number of cases of syphilis in eastern Europe since the collapse of the Soviet Union; Slovenia reported an 18-fold increase in reported cases of syphilis just between 1993 and 1994. Over half of the new cases were linked to a source of infection in another European country.

In general, high-risk groups for syphilis in the United States and Canada include:

  • sexually active teenagers
  • people infected with another sexually transmitted disease (STD), including AIDS
  • sexually abused children
  • women of childbearing age
  • prostitutes of either sex and their customers
  • prisoners
  • persons who abuse drugs or alcohol

The chances of contracting syphilis from an infected person in the early stages of the disease during unprotected sex are between 30-50%.

Causes and symptoms

Syphilis is caused by a spirochete, Treponema pallidum. A spirochete is a thin spiralor coil-shaped bacterium that enters the body through the mucous membranes or breaks in the skin. In 90% of cases, the spirochete is transmitted by sexual contact. Transmission by blood transfusion is possible but rare; not only because blood products are screened for the disease, but also because the spirochetes die within 24 hours in stored blood. Other methods of transmission are highly unlikely because T. pallidum is easily killed by heat and drying.

Primary syphilis

Primary syphilis is the stage of the organism's entry into the body. The first signs of infection are not always noticed. After an incubation period ranging between 10 and 90 days, the patient develops a chancre, which is a small blister-like sore about 0.5 in (13 mm) in size. Most chancres are on the genitals, but may also develop in or on the mouth or on the breasts. Rectal chancres are common in male homosexuals. Chancres in women are sometimes overlooked if they develop in the vagina or on the cervix. The chancres are not painful and disappear in three to six weeks even without treatment. They resemble the ulcers of lymphogranuloma venereum, herpes simplex virus, or skin tumors.

About 70% of patients with primary syphilis also develop swollen lymph nodes near the chancre. The nodes may have a firm or rubbery feel when the doctor touches them but are not usually painful.

Secondary syphilis

Syphilis enters its secondary stage between six to eight weeks and six months after the infection begins. Chancres may still be present but are usually healing. Secondary syphilis is a systemic infection marked by the eruption of skin rashes and ulcers in the mucous membranes. The skin rash may mimic a number of other skin disorders such as drug reactions, rubella, ringworm, mononucleosis, and pityriasis rosea. Characteristics that point to syphilis include:

  • a coppery color
  • absence of pain or itching
  • occurrence on the palms of hands and soles of feet

The skin eruption may resolve in a few weeks or last as long as a year. The patient may also develop condylomata lata, which are weepy pinkish or grey areas of flattened skin in the moist areas of the body. The skin rashes, mouth and genital ulcers, and condylomata lata are all highly infectious.

About 50% of patients with secondary syphilis develop swollen lymph nodes in the armpits, groin, and neck areas; about 10% develop inflammations of the eyes, kidney, liver, spleen, bones, joints, or the meninges (membranes covering the brain and spinal cord). They may also have a flulike general illness with a low fever, chills, loss of appetite, headaches, runny nose, sore throat, and aching joints.

Latent syphilis

Latent syphilis is a phase of the disease characterized by relative absence of external symptoms. The term latent does not mean that the disease is not progressing or that the patient cannot infect others. For example, pregnant women can transmit syphilis to their unborn children during the latency period.

The latent phase is sometimes divided into early latency (less than two years after infection) and late latency. During early latency, patients are at risk for spontaneous relapses marked by recurrence of the ulcers and skin rashes of secondary syphilis. In late latency, these recurrences are much less likely. Late latency may either resolve spontaneously or continue for the rest of the patient's life.

Tertiary syphilis

Untreated syphilis progresses to a third or tertiary stage in about 35-40% of patients. Patients with tertiary syphilis cannot infect others with the disease. It is thought that the symptoms of this stage are a delayed hypersensitivity reaction to the spirochetes. Some patients develop so-called benign late syphilis, which begins between three and 10 years after infection and is characterized by the development of gummas. Gummas are rubbery tumor-like growths that are most likely to involve the skin or long bones but may also develop in the eyes, mucous membranes, throat, liver, or stomach lining. Gummas are increasingly uncommon since the introduction of antibiotics for treating syphilis. Benign late syphilis is usually rapid in onset and responds well to treatment.

CARDIOVASCULAR SYPHILIS. Cardiovascular syphilis occurs in 10-15% of patients who have progressed to tertiary syphilis. It develops between 10 and 25 years after infection and often occurs together with neurosyphilis. Cardiovascular syphilis usually begins as an inflammation of the arteries leading from the heart and causes heart attacks, scarring of the aortic valves, congestive heart failure, or the formation of an aortic aneurysm.

NEUROSYPHILIS. About 8% of patients with untreated syphilis will develop symptoms in the central nervous system that include both physical and psychiatric symptoms. Neurosyphilis can appear at any time, from 5-35 years after the onset of primary syphilis. It affects men more frequently than women and Caucasians more frequently than African Americans.

Neurosyphilis is classified into four types:

  • Asymptomatic. In this form of neurosyphilis, the patient's spinal fluid gives abnormal test results but there are no symptoms affecting the central nervous system.
  • Meningovascular. This type of neurosyphilis is marked by changes in the blood vessels of the brain or inflammation of the meninges (the tissue layers covering the brain and spinal cord). The patient develops headaches, irritability, and visual problems. If the spinal cord is involved, the patient may experience weakness of the shoulder and upper arm muscles.
  • Tabes dorsalis. Tabes dorsalis is a progressive degeneration of the spinal cord and nerve roots. Patients lose their sense of perception of one's body position and orientation in space (proprioception), resulting in difficulties walking and loss of muscle reflexes. They may also have shooting pains in the legs and periodic episodes of pain in the abdomen, throat, bladder, or rectum. Tabes dorsalis is sometimes called locomotor ataxia.
  • General paresis. General paresis refers to the effects of neurosyphilis on the cortex of the brain. The patient has a slow but progressive loss of memory, ability to concentrate, and interest in self-care. Personality changes may include irresponsible behavior, depression, delusions of grandeur, or complete psychosis. General paresis is sometimes called dementia paralytica, and is most common in patients over 40.

Special populations

CONGENITAL SYPHILIS. Congenital syphilis has increased at a rate of 400-500% over the past decade, on the basis of criteria introduced by the Centers for Disease Control (CDC) in 1990. In 1994, over 2,200 cases of congenital syphilis were reported in the United States. The prognosis for early congenital syphilis is poor: about 54% of infected fetuses die before or shortly after birth. Those who survive may look normal at birth but show signs of infection between three and eight weeks later.

Infants with early congenital syphilis have systemic symptoms that resemble those of adults with secondary syphilis. There is a 40-60% chance that the child's central nervous system will be infected. These infants may have symptoms ranging from jaundice, enlargement of the spleen and liver, and anemia to skin rashes, condylomata lata, inflammation of the lungs, "snuffles" (a persistent runny nose), and swollen lymph nodes.

CHILDREN. Children who develop symptoms after the age of two years are said to have late congenital syphilis. The characteristic symptoms include facial deformities (saddle nose), Hutchinson's teeth (abnormal upper incisors), saber shins, dislocated joints, deafness, mental retardation, paralysis, and seizure disorders.

PREGNANT WOMEN. Syphilis can be transmitted from the mother to the fetus through the placenta at any time during pregnancy, or through the child's contact with syphilitic ulcers during the birth process. The chances of infection are related to the stage of the mother's disease. Almost all infants of mothers with untreated primary or secondary syphilis will be infected, whereas the infection rate drops to 40% if the mother is in the early latent stage and 6-14% if she has late latent syphilis.

Pregnancy does not affect the progression of syphilis in the mother; however, pregnant women should not be treated with tetracyclines.

HIV PATIENTS. Syphilis has been closely associated with HIV infection since the late 1980s. Syphilis sometimes mimics the symptoms of AIDS. Conversely, AIDS appears to increase the severity of syphilis in patients suffering from both diseases, and to speed up the development or appearance of neurosyphilis. Patients with HIV are also more likely to develop lues maligna, a skin disease that sometimes occurs in secondary syphilis. Lues maligna is characterized by areas of ulcerated and dying tissue. In addition, HIV patients have a higher rate of treatment failure with penicillin than patients without HIV.

Diagnosis

Patient history and physical diagnosis

The diagnosis of syphilis is often delayed because of the variety of early symptoms, the varying length of the incubation period, and the possibility of not noticing the initial chancre. Patients do not always connect their symptoms with recent sexual contact. They may go to a dermatologist when they develop the skin rash of secondary syphilis rather than to their primary care doctor. Women may be diagnosed in the course of a gynecological checkup. Because of the long-term risks of untreated syphilis, certain groups of people are now routinely screened for the disease:

  • pregnant women
  • sexual contacts or partners of patients diagnosed with syphilis
  • children born to mothers with syphilis
  • patients with HIV infection
  • persons applying for marriage licenses

When the doctor takes the patient's history, he or she will ask about recent sexual contacts in order to determine whether the patient falls into a high-risk group. Other symptoms, such as skin rashes or swollen lymph nodes, will be noted with respect to the dates of the patient's sexual contacts. Definite diagnosis, however, depends on the results of laboratory blood tests.

Blood tests

There are several types of blood tests for syphilis presently used in the United States. Some are used in follow-up monitoring of patients as well as diagnosis.

NONTREPONEMAL ANTIGEN TESTS. Nontreponemal antigen tests are used as screeners. They measure the presence of reagin, which is an antibody formed in reaction to syphilis. In the venereal disease research laboratory (VDRL) test, a sample of the patient's blood is mixed with cardiolipin and cholesterol. If the mixture forms clumps or masses of matter, the test is considered reactive or positive. The serum sample can be diluted several times to determine the concentration of reagin in the patient's blood.

The rapid plasma reagin (RPR) test works on the same principle as the VDRL. It is available as a kit. The patient's serum is mixed with cardiolipin on a plastic-coated card that can be examined with the naked eye.

Nontreponemal antigen tests require a doctor's interpretation and sometimes further testing. They can yield both false-negative and false-positive results. False-positive results can be caused by other infectious diseases, including mononucleosis, malaria, leprosy, rheumatoid arthritis, and lupus. HIV patients have a particularly high rate (4%, compared to 0.8% of HIV-negative patients) of false-positive results on reagin tests. False-negatives can occur when patients are tested too soon after exposure to syphilis; it takes about 14-21 days after infection for the blood to become reactive.

TREPONEMAL ANTIBODY TESTS. Treponemal antibody tests are used to rule out false-positive results on reagin tests. They measure the presence of antibodies that are specific for T. pallidum. The most commonly used tests are the microhemagglutination-T. pallidum (MHA-TP) and the fluorescent treponemal antibody absorption (FTA-ABS) tests. In the FTA-ABS, the patient's blood serum is mixed with a preparation that prevents interference from antibodies to other treponemal infections. The test serum is added to a slide containing T. pallidum. In a positive reaction, syphilitic antibodies in the blood coat the spirochetes on the slide. The slide is then stained with fluorescein, which causes the coated spirochetes to fluoresce when the slide is viewed under ultraviolet (UV) light. In the MHA-TP test, red blood cells from sheep are coated with T. pallidum antigen. The cells will clump if the patient's blood contains antibodies for syphilis.

Treponemal antibody tests are more expensive and more difficult to perform than nontreponemal tests. They are therefore used to confirm the diagnosis of syphilis rather than to screen large groups of people. These tests are, however, very specific and very sensitive; false-positive results are relatively unusual.

INVESTIGATIONAL BLOOD TESTS. Currently, ELISA, Western blot, and PCR testing are being studied as additional diagnostic tests, particularly for congenital syphilis and neurosyphilis.

Other laboratory tests

MICROSCOPE STUDIES. The diagnosis of syphilis can also be confirmed by identifying spirochetes in samples of tissue or lymphatic fluid. Fresh samples can be made into slides and studied under darkfield illumination. A newer method involves preparing slides from dried fluid smears and staining them with fluorescein for viewing under UV light. This method is replacing darkfield examination because the slides can be mailed to professional laboratories.

SPINAL FLUID TESTS. Testing of cerebrospinal fluid (CSF) is an important part of patient monitoring as well as a diagnostic test. The VDRL and FTA-ABS tests can be performed on CSF as well as on blood. An abnormally high white cell count and elevated protein levels in the CSF, together with positive VDRL results, suggest a possible diagnosis of neurosyphilis. CSF testing is not used for routine screening. It is used most frequently for infants with congenital syphilis, HIV-positive patients, and patients of any age who are not responding to penicillin treatment.

Treatment

Medications

Syphilis is treated with antibiotics given either intramuscularly (benzathine penicillin G or ceftriaxone) or orally (doxycycline, minocycline, tetracycline, or azithromycin). Neurosyphilis is treated with a combination of aqueous crystalline penicillin G, benzathine penicillin G, or doxycycline. It is important to keep the levels of penicillin in the patient's tissues at sufficiently high levels over a period of days or weeks because the spirochetes have a relatively long reproduction time. Penicillin is more effective in treating the early stages of syphilis than the later stages.

In the fall of 2000, the CDC convened a group of medical advisors to discuss backup medications for treating syphilis. Although none of the newer drugs will displace penicillin as the primary drug, the doctors recommended azithromycin and ceftriaxone as medications that should have a larger role in the treatment of syphilis than they presently do.

Doctors do not usually prescribe separate medications for the skin rashes or ulcers of secondary syphilis. The patient is advised to keep them clean and dry, and to avoid exposing others to fluid or discharges from condylomata lata.

Pregnant women should be treated as early in pregnancy as possible. Infected fetuses can be cured if the mother is treated during the second and third trimesters of pregnancy. Infants with proven or suspected congenital syphilis are treated with either aqueous crystalline penicillin G or aqueous procaine penicillin G. Children who acquire syphilis after birth are treated with benzathine penicillin G.

Jarisch-Herxheimer reaction

The Jarisch-Herxheimer reaction, first described in 1895, is a reaction to penicillin treatment that may occur during the late primary, secondary, or early latent stages. The patient develops chills, fever, headache, and muscle pains within two to six hours after the penicillin is injected. The chancre or rash gets temporarily worse. The Jarisch-Herxheimer reaction, which lasts about a day, is thought to be an allergic reaction to toxins released when the penicillin kills massive numbers of spirochetes.

Alternative treatment

Antibiotics are essential for the treatment of syphilis. Recovery from the disease can be assisted by dietary changes, sleep, exercise, and stress reduction.

Homeopathy

Homeopathic practitioners are forbidden by law in the United States to claim that homeopathic treatment can cure syphilis. Given the high rate of syphilis in HIV-positive patients, however, some alternative practitioners who are treating AIDS patients with homeopathic remedies maintain that they are beneficial for syphilis as well. The remedies suggested most frequently are Medorrhinum, Syphilinum, Mercurius vivus, and Aurum. The historical link between homeopathy and syphilis is Hahnemann's theory of miasms. He thought that the syphilitic miasm was the second oldest cause of constitutional weakness in humans.

Prognosis

The prognosis is good for the early stages of syphilis if the patient is treated promptly and given sufficiently large doses of antibiotics. Treatment failures can occur and patients can be reinfected. There are no definite criteria for cure for patients with primary and secondary syphilis, although patients who are symptom-free and have had negative blood tests for two years after treatment are usually considered cured. Patients should be followed up with blood tests at one, three, six, and 12 months after treatment, or until the results are negative. CSF should be examined after one year. Patients with recurrences during the latency period should be tested for reinfection.

The prognosis for patients with untreated syphilis is spontaneous remission for about 30%; lifelong latency for another 30%; and potentially fatal tertiary forms of the disease in 40%.

Prevention

Immunity

Patients with syphilis do not acquire lasting immunity against the disease. Currently, no effective vaccine for syphilis has been developed. Prevention depends on a combination of personal and public health measures.

Lifestyle choices

The only reliable methods for preventing transmission of syphilis are sexual abstinence or monogamous relationships between uninfected partners. Condoms offer some protection but protect only the covered parts of the body.

Public health measures

CONTACT TRACING. The law requires reporting of syphilis cases to public health agencies. Sexual contacts of patients diagnosed with syphilis are traced and tested for the disease. This includes all contacts for the past three months in cases of primary syphilis and for the past year in cases of secondary disease. Neither the patients nor their contacts should have sex with anyone until they have been tested and treated.

Because of the rising incidence of syphilis abroad, a growing number of public health physicians are recommending routine screening of immigrants, refugees, and international adoptees for syphilis as of late 2002.

All patients who test positive for syphilis should be tested for HIV infection at the time of diagnosis.

PRENATAL TESTING OF PREGNANT WOMEN. Pregnant women should be tested for syphilis at the time of their first visit for prenatal care, and again shortly before delivery. Proper treatment of secondary syphilis in the mother reduces the risk of congenital syphilis in the infant from 90% to less than 2%.

As of late 2005, many obstetricians and gynecologists are recommending routine screening of nonpregnant as well as pregnant women for syphilis. At present, only about half of obstetricians and gynecologists in the United States screen nonpregnant women for chlamydia and gonorrhea, while fewer than a third screen them for syphilis.

EDUCATION AND INFORMATION. Patients diagnosed with syphilis should be given information about the disease and counseling regarding sexual behavior and the importance of completing antibiotic treatment. It is also important to inform the general public about the transmission and early symptoms of syphilis, and provide adequate health facilities for testing and treatment.

KEY TERMS

Chancre The initial skin ulcer of primary syphilis, consisting of an open sore with a firm or hard base.

Condylomata lata Highly infectious patches of weepy pink or gray skin that appear in the moist areas of the body during secondary syphilis.

Darkfield A technique of microscope examination in which light is directed at an oblique angle through the slide so that organisms look bright against a dark background.

General paresis A form of neurosyphilis in which the patient's personality, as well as his or her control of movement, is affected. The patient may develop convulsions or partial paralysis.

Gumma A symptom that is sometimes seen in tertiary syphilis, characterized by a rubbery swelling or tumor that heals slowly and leaves a scar.

Index case The first case of a contagious disease in a group or population that serves to call attention to the presence of the disease.

Jarisch-Herxheimer reaction A temporary reaction to penicillin treatment for syphilis that includes fever, chills, and worsening of the skin rash or chancre.

Lues maligna A skin disorder of secondary syphilis in which areas of ulcerated and dying tissue are formed. It occurs most frequently in HIV-positive patients.

Spirochete A type of bacterium with a long, slender, coiled shape. Syphilis is caused by a spirochete.

Tabes dorsalis A progressive deterioration of the spinal cord and spinal nerves associated with tertiary syphilis.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Syphilis." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Augenbraun, M. H. "Treatment of Syphilis 2001: Nonpregnant Adults." Clinical Infectious Diseases 35, Supplement 2 (October 15, 2002): S187-S190.

Campos-Outcalt, D., and S. Hurwitz. "Female-to-Female Transmission of Syphilis: A Case Report." Sexually Transmitted Diseases 29 (February 2002): 119-120.

Centers for Disease Control. "Primary and Secondary SyphilisUnited States, 20002001." Morbidity and Mortality Weekly Report 51 (November 1, 2002): 971-973.

Dennis, L. K., and D. V. Dawson. "Meta-Analysis of Measures of Sexual Activity and Prostate Cancer." Epidemiology 13 (January 2002): 72-79.

Gibbs, R. S. "The Origins of Stillbirth: Infectious Diseases." Seminars in Perinatology 26 (February 2002): 75-78.

Grgic-Vitek, M., I Klavs, M. Potocnik, and M. Rogl-Butina. "Syphilis Epidemic in Slovenia Influenced by Syphilis Epidemic in the Russian Federation and Other Newly Independent States." International Journal of STD and AIDS 13, Supplement 2 (December 2002): 2-4.

Hagedorn, H. J., A. Kraminer-Hagedorn, K. de Bosschere, et al. "Evaluation of INNO-LIA Syphilis Assay as a Confirmatory Test for Syphilis." Journal of Clinical Microbiology 40 (March 2002): 973-978.

Hogben, M., J. S. Lawrence, D. Kasprzyk, et al. "Sexually Transmitted Disease Screening by United States Obstetricians and Gynecologists." Obstetrics and Gynecology 100 (October 2002): 801-807.

Kolivras, A., J. de Maubeuge, M. Song, et al. "A Case of Early Congenital Syphilis." Dermatology 204 (2002): 338-340.

Pao, D., B. T. Goh, and J. S. Bingham. "Management Issues in Syphilis." Drugs 62 (2002): 1447-1461.

Ross, M. W., L. Y. Hwang, C. Zack, et al. "Sexual Risk Behaviours and STIs in Drug Abuse Treatment Populations Whose Drug of Choice is Crack Cocaine." International Journal of STD and AIDS 13 (November 2002): 769-774.

Stauffer, W. M., D. Kamat, and P. F. Walker. "Screening of International Immigrants, Refugees, and Adoptees." Primary Care 29 (December 2002): 879-905.

Sutmoller, F., T. L. Penna, C. T. de Souza, et al. "Human Immunodeficiency Virus Incidence and Risk Behavior in the 'Projeto Rio': Results of the First 5 Years of the Rio de Janeiro Open Cohort of Homosexual and Bisexual Men, 199498." International Journal of Infectious Diseases 6 (December 2002): 259-265.

Whittington, W. L., T. Collis, C. Dithmer-Schreck, et al. "Sexually Transmitted Diseases and Human Immunodeficiency Virus-Discordant Partnerships Among Men Who Have Sex With Men." Clinical Infectious Diseases 35 (October 15, 2002): 1010-1017.

ORGANIZATIONS

Centers for Disease Control and Prevention. 1600 Clifton Rd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311. http://www.cdc.gov.

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Syphilis

Syphilis

Syphilis is a chronic, degenerative, sexually transmitted disease caused by the bacterium Treponema pallidum. Although modern treatments now control the disease, its incidence remains high worldwide, making it a global public health concern. Spread by sexual contact, syphilis begins as a small, hard, painless swelling, called a primary (or Hunter's) chancre. The disease is very contagious in the early stages. The initial sore will usually pass away in about eight weeks, but the disease will then spread through the body and lodge in the lymph nodes, causing a skin rash to appear in two to four months along with fever and headaches. This second stage can last two to six weeks. After a latent period, which can extend for years, the disease can appear in various bodily organs and it can be spread to others.

The earliest records of syphilis are those of Spanish physician Rodrigo Ruiz de Isla, who wrote that he treated syphilis patients in Barcelona in 1493. He further claimed that the soldiers of explorer Christopher Columbus contracted the disease in the Caribbean and brought it back to Europe in 1492. However, others challenge this position. Some medical historians believe that syphilis has been present from ancient times but was often mislabeled or misdiagnosed. Italian physician and writer Girolamo Fracastoro gave the disease its name in his poem "Syphilis sive morbus Gallicus" (Syphilis or the French Disease), published in 1530, during the height of a European epidemic. However, for centuries, the disease was called pox or the great pox. At that time, the treatment was mercury, used in vapor baths, as an ointment, or taken orally. The mercury increased the flow of saliva and phlegm to wash out the poisons, but it also caused discomfort, such as loss of hair and teeth, abdominal pains, and mouth sores. Through the centuries, a milder form of the disease evolved and often became confused with gonorrhea . In 1767, physician John Hunter infected himself with fluid from a patient who had gonorrhea to prove these were two different diseases. Unknown to Hunter, the patient also had syphilis. Hunter developed the sore indicative of syphilis that now bears his name.

The distinction between the two diseases was made clear in 1879, when German bacteriologist Albert Neisser isolated the bacterium responsible for gonorrhea. In 1903, Russian biologist Elie Metchnikoff and French scientist Pierre-Paul-Emile Roux demonstrated that syphilis could be transmitted to monkeys and then studied in the laboratory. They also showed that mercury ointment was an effective treatment in the early stages. Two years later, German zoologist Fritz Schaudinn and his assistant Erich Hoffmann discovered the bacterium responsible for syphilis, the spiral-shaped spirochete Treponema pallidum. The following year, German physician August von Wassermann (18661925) developed the first diagnostic test for syphilis based on new findings in immunology . The test involved checking for the syphilis antibody in a sample of blood. One drawback was that the test would take two days to complete.

In 1904, German research physician Paul Ehrlich began focusing on a safe, effective treatment for syphilis. Ehrlich had spent many years studying the effect of dyes on biological tissues and treatments for tropical diseases. His work in the emerging field of immunology earned him a Nobel Prize in 1908. Ehrlich began working with the arsenic-based compound atoxyl as a possible treatment for syphilis. Japanese bacteriologist Sahachiro Hata came to study syphilis with Ehrlich. Hata tested hundreds of derivatives of atoxyl and finally found one that worked, number 606. Ehrlich called it Salvarsan. Following clinical trials, in 1911 Ehrlich and Hata announced the drug was an effective cure for syphilis. The drug attacked the disease germs but did not harm healthy cells; thus, Salvarsan ushered in the new field of chemotherapy . Ehrlich went on to develop two safer forms of the drug, including neosalvarsan in 1912 and sodium salvarsan in 1913.

Penicillin came into widespread use in treating bacterial diseases during World War II. It was first used to against syphilis in 1943 by New York physician John F. Mahoney, and it remains the treatment of choice today. Other antibiotics are also effective. Meanwhile, Russian-American researcher Reuben Leon Kahn (18871979) developed a modified test for syphilis in 1923 that took only a few minutes to complete. Another test was developed by researchers William A. Hinton (18831959) and J. A. V. Davies. Today fluorescent antibody tests are used for detection. Although there is no inoculation for syphilis, the disease can be controlled through education, safe sexual practices, and proper medical treatment.

See also Sexually transmitted diseases

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Syphilis Test

Syphilis test

Syphilis was once a disease of epidemic proportions. Today, it is effectively treated with penicillin and other antibiotics. Because there is no known immunization to protect against contracting syphilis, accurate testing has become a key determinant for quick and successful treatment.

Discovery of the Bacteria

In 1903 Russian biologist Elie Metchnikoff (1845-1916) and French scientist Pierre-Paul-Emile Roux demonstrated that syphilis could be transmitted to monkeys. With this capability, the disease could be studied in the laboratory. Two years later, German zoologist Fritz Schaudinn and his assistant Erich Hoffmann isolated the bacterium that causes syphilis. Schaudinn and Hoffmann showed it to be a spiral-shaped spirochete called Treponema pallidum.

Salvarsan

In 1904 German researcher Paul Ehrlich (1854-1915) and Japanese bacteriologist Sahachiro Hata began looking for a safe, effective treatment for syphilis. They tested hundreds of derivatives of atoxyl, eventually discovering one that worked. Ehrlich called the derivative "Salvarsan." Following trials of the substance on humans, Ehrlich and Hata announced in 1911 that the drug was an effective cure for syphilis. The drug attacked the bacteria without harming healthy cells.

Wassermann Test

The first effective test for syphilis was developed in 1906 by German physician and bacteriologist August von Wassermann (1866-1925). Wassermann was influenced by Ehrlich's work. Wassermann's exam consisted of testing a patient's blood sample for the syphilis bacterium antibody. If antibodies were present, the test was positive. If the antibodies disappeared after treatment, the test was negative. The Wassermann test proved successful in diagnosing syphilis in 95 percent of cases.

Kahn Test

Unfortunately, the Wassermann test required a two-day incubation period. Reuben Leon Kahn (1887-1979), a Russian-born American immunologist, developed a faster and simpler syphilis test in 1923. This modified test used an extract from beef heart to detect syphilis antibodies. More sensitive than the Wassermann test, the Kahn test could be completed in a matter of minutes. The Kahn tests, however, could also be inaccurate. It could show false positive or false negative reports.

Davies-Hinton Test

Another effective syphilis test was developed by William A. Hinton (1883-1959). Hinton was an African-American physician who became a leading expert on venereal disease. Hinton worked out of Harvard Medical School, collaborating with J. A. V. Davies on the Davies-Hinton test.

Syphilis

Syphilis is a serious disease transmitted through sexual activity. Although modern treatments can control the disease, the number of people suffering from syphilis remains high. It is a public health concern around the world.

Syphilis can be cured through doses of penicillin, yet many people remain untreated. The first stage appears between one and eight weeks after infection occurs. The symptom is a small, hard, painless swelling, called a primary chancre (pronounced "shanker"). The sore usually heals in one to five weeks. However, during this period, disease bacteria circulate throughout the body via the bloodstream.

The second stage appears about six weeks after the sore disappears. Symptoms include a general feeling of being ill, fever, headache, and a loss of appetite. Glands may swell in the groin or neck, and a skin rash may develop. This second stage can last two to six weeks.

The third stage is called latent or late syphilis. It can last for years. While no symptoms may be present for some time, a special blood test will show the presence of the disease. During this stage, the disease will eventually flare up without warning. Syphilis affects both the brain and heart. At this point, the disease is no longer treatable. Symptoms of third stage syphilis include blindness, sterility, and insanity.

VDRL Test

Several other syphilis tests have been developed. One of most widely used tests today is the VDRL test, designed by the Venereal Disease Research Laboratory. Other diagnostic tools include a fluorescent antibody test to reveal the syphilis bacterium.

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syphilis

syphilis (sĬf´əlĬs), contagious sexually transmitted disease caused by the spirochete Treponema pallidum (described by Fritz Schaudinn and Erich Hoffmann in 1905). Syphilis was not widely recognized until an epidemic in Europe at the end of the 15th cent. Some medical historians have proposed that syphilis first appeared in Spain among sailors who had returned from the New World in 1493, while others have concluded from archaeological evidence that it probably originated in the Old World but may have been confused with leprosy. A study (pub. 2008) that examined the evolutionary relationships among Treponema bacteria supported the idea that the spirochete originated in the New World, with some researchers suggesting it may have mutated into a sexually transmitted disease in Europe.

Transmission

The most prevalent mode of transmission is by sexual contact; infection by other means is possible, but its occurrence depends upon an open wound or lesion to permit invasion of the organisms. A person with syphilitic sores has an increased chance of contracting AIDS from an infected partner. An infected mother can transmit the disease to her fetus; 25% of such pregnancies end in stillbirth or death of the infant, and another 40% to 70% will result in a baby with congenital syphilis, which, if untreated, can progress to late-stage syphilis and cause serious damage to the brain and other organs.

Symptoms

The development of syphilis occurs in four stages. The primary stage is the appearance of a painless chancre at the site of infection (often internal) about 10 days to 3 months after contact. There are no other symptoms, and the chancre disappears with or without treatment.

The secondary stage usually begins 3 to 6 weeks after the chancre with a rash over all or part of the body. Active bacteria are present in the sores of the rash. Headache, fever, fatigue, sore throat, patchy hair loss, and enlarged lymph nodes may be present. The signs of the secondary stage will disappear with or without treatment, but may reappear over the next 1 to 2 years.

Untreated syphilis then goes into a noncontagious latent period. Some people will have no more symptoms, but about one third will progress to tertiary syphilis, with widespread damage to the heart, brain, eyes, nervous system, bones, and joints. Late syphilis can result in mental illness, blindness, severe damage to the heart and aorta, and death.

Neurosyphilis, infection of the nervous system, frequently occurs in the early stages in untreated patients. There may be no symptoms, mild headache, or severe consequences such as seizures and stroke. Its treatment and course are complicated by concomitant HIV infection.

Diagnosis and Treatment

Diagnosis is made by symptoms, blood tests (required by many states before issuing marriage licenses), and microscopic identification of the bacterium. Until the advent of penicillin in the 1940s, treatment for syphilis was with mercury, arsenic, and bismuth. Penicillin is the antibiotic of choice for all stages of syphilis treatment, but penicillin-resistant organisms have complicated treatment of the disease. Even late-stage syphilis can be cured, but damage that has already occurred cannot be reversed. Despite available treatment, the incidence of syphilis in the United States was on the rise until 1990, when it began declining significantly; since 2000, it has risen again.

See also Ehrlich, Paul.

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Syphilis

SYPHILIS

Syphilis is a sexually transmitted disease (STD) caused by Treponema pallidum, a spirochete that can be transmitted during vaginal, anal, or oral sex. An estimated 70,000 syphilis cases occur in the United States annually.

Without treatment, syphilis in adults progresses through four stages: primary, secondary, latent, and tertiary. Persons with syphilis are most infectious during the primary and secondary stages. Primary syphilis is marked by an infectious sore (chancre) that resolves on its own. Without treatment, syphilis bacteria spread through the bloodstream and lead to the secondary stage, which is characterized by a skin rash and systemic symptoms. These symptoms can come and go over one to two years, during which an infected person can infect others. If untreated, the infection progresses to a latent stage. Symptoms disappear, and the disease is no longer infectious, but the bacteria remain in the body and can damage vital organs. In about a third of untreated persons, the results of the internal damage show up years later in the tertiary stage. Symptoms include paralysis, blindness, dementia, impotence, joint damage, heart problems, tumors, and deep sores. The damage can be serious enough to cause death. An untreated pregnant woman in an infectious stage of syphilis can pass the infection to her developing fetus.

Syphilis bacteria can be detected by laboratory examination of material from infectious sores. A safe, accurate, and inexpensive blood screening test is also available. Syphilis is treatable with penicillin. Persons who engage in sexual behaviors that place them at risk of STDs should use latex or polyurethane condoms every time they have sex and limit the number of sex partners. Pregnant women should be screened for syphilis. Infected persons should notify all sex partners so they can receive treatment.

Allison L. Greenspan

Joel R. Greenspan

(see also: Sexually Transmitted Diseases )

Bibliography

Centers for Disease Control and Prevention (1998). "1998 Guidelines for Treatment of Sexually Transmitted Diseases." Morbidity and Mortality Weekly Report 47(RR-1):2841.

Sparling, P. F. (1999). "Natural History of Syphilis." In Sexually Transmitted Diseases, 3rd edition. eds. K. Holmes, P. Mardh, P. Sparling et al. New York: McGraw-Hill.

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syphilis

syphilis a chronic bacterial disease that is contracted chiefly by infection during sexual intercourse, but also congenitally by infection of a developing fetus. The word is recorded in English from the early 18th century, and is modern Latin, originally from the title of a poem, Syphilis, sive Morbus Gallicus, published 1530 by Girolamo Fracastoro or Hieronymus Fracastorius (1483–1553), a physician, astronomer, and poet of Verona; it was translated by Nahum Tate in 1686 with the title ‘Syphilis: or, a Poetical History of the French Disease’. The illness was known from the early 16th century as the great pox, to distinguish it from smallpox.

Syphilis was used as the name of the disease in the poem itself; the subject is the shepherd ‘Syphilus’, the first sufferer from the illness. (The ultimate origin of his name is disputed; it has been suggested that it is a corrupt medieval form of Sipylus, a son of Niobe.)

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syphilis

syphilis (sif-i-lis) n. a sexually transmitted disease caused by the bacterium Treponema pallidum. Bacteria usually enter the body during sexual intercourse; they may also pass from an infected pregnant woman across the placenta to the developing fetus, resulting in the disease being present at birth (congenital s.). The primary symptom is a hard painless ulcer (chancre) at the site of infection. Secondary stage symptoms include fever, malaise, general enlargement of lymph nodes, and a faint red rash on the chest. After months, or even years, the disease enters its tertiary stage with widespread formation of tumour-like masses (gummas). Tertiary syphilis may cause serious damage to the heart and blood vessels (cardiovascular s.) or to the brain and spinal cord (neurosyphilis), resulting in tabes dorsalis, blindness, and general paralysis of the insane. See also bejel.
syphilitic (sif-i-lit-ik) adj.

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syphilis

syphilis Sexually transmitted disease caused by the spiral-shaped bacterium (spirochete) Treponema pallidum. Untreated, it runs its course in three stages. The first symptom is often a hard, painless sore on the genitals, appearing usually within a month of infection. Months later, the second stage features a skin rash and fever. The third stage, often many years later, brings the formation of growths and serious involvement of the heart, brain and spinal cord, leading eventually to blindness, insanity and death. The disease is treated with antibiotics.

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Syphilis

Syphilis

What Is Syphilis?

How Common Is Syphilis?

Is Syphilis Contagious?

What Are the Signs and Symptoms of Infection?

How Is the Diagnosis of Syphilis Made?

How Is Syphilis Treated?

How Long Does Infection Last?

Does the Disease Have Complications?

Can Syphilis Be Prevented?

Resources

Syphilis (SIH-fih-lis) is a sexually transmitted disease that, if untreated, can lead to serious lifelong problems throughout the body, including blindness and paralysis*.

*paralysis
(pah-RAH-luh-sis) is the loss or impairment of the ability to move some part of the body.

KEYWORDS

for searching the Internet and other reference sources

Chancre

Congenital infections

Sexually transmitted disease (STD)

Treponema pallidum

What Is Syphilis?

Syphilis is a disease that is caused by the bacterium Treponema pallidum (treh-puh-NEE-muh PAL-ih-dum). The disease develops in three distinct phases. The first, or primary, stage is marked by a chancre*. In the secondary stage, a rash develops. By the third, or tertiary, stage the disease can cause widespread damage to the body, affecting the brain, nerves, bones, joints, eyes, and heart and other organs. Syphilis does not advance to this point in all infected people, and it does so only if it has not been treated adequately during either of the two earlier stages.

*chancre
(SHANG-ker) is a usually painless sore or ulcer that forms where a disease-causing germ enters the body, such as with syphilis.

Without treatment, syphilis can be fatal. It also can have serious consequences for babies who become infected in the womb, before birth. If a pregnant woman has syphilis, she can pass it to her fetus*, a condition known as congenital* syphilis. Because the immune system of a baby is not developed fully until the infant is well into the first year of life, infection with syphilis bacteria can lead to severe complications. If pregnant women who are infected are not treated, more than a third of their infants may die before or shortly after birth.

*fetus
(FEE-tus) is the term for an unborn human after it is an embryo, from 9 weeks after fertilization until childbirth.
*congenital
(kon-JEH-nih-tul) means present at birth.

How Common Is Syphilis?

Before the introduction of the antibiotic penicillin in the 1940s, syphilis was rampant in the United States. Although the disease is still relatively common, the number of cases today is far below the high rate of infection early in the twentieth century. According to the U.S. Centers for Disease Control and Prevention (CDC), 31,575 cases (or about 12 per 100,000 people) were reported in 2000 (although the number of actual infections is likely higher, because many cases go unnoticed at first). Of those, 529 were cases of congenital syphilis. Compare that with 485,560 cases overall (or 368 per 100,000 people) in 1941, the first year that the government began tracking syphilis rates.

Is Syphilis Contagious?

Syphilis is a sexually transmitted disease that spreads from person to person through vaginal*, oral*, or anal* intercourse. A pregnant female also can pass the disease to her fetus. People are most contagious during the second stage of the infection.

*vaginal
(VAH-jih-nul) refers to the vagina, the canal in a woman that leads from the uterus to the outside of the body.
*oral
means by mouth or referring to the mouth.
*anal
refers to the anus, the opening at the end of the digestive system through which waste leaves the body.

What Are the Signs and Symptoms of Infection?

Syphilis has been called the great imitator, because its symptoms can resemble those of many other diseases. Not all people have obvious symptoms, but in those who do, signs of disease appear 10 to 90 days after being infected. The first symptom is a small, usually painless sore known as

How Syphilis Changed The FAce Of Medical Research

Just a few decades ago syphilis was the subject of the most infamous public health study ever carried out in the United States. From 1932 to 1972 the U.S. Public Health Service conducted a study in Macon County, Alabama, to learn more about the long-term consequences of the disease. Six hundred poor African-American men, 399 infected with syphilis, participated in the study in exchange for free medical exams, free meals, and burial insurance.

The Tuskegee Syphilis Study became notorious because local doctors who participated in the study were instructed not to treat the mens infections, even after an easy cure with penicillin became widely available in 1947. Although the men had agreed to be part of the project, they were never told they would not be treated fully for their condition. They were simply told that they were part of a study of bad blood, a local term used for several illnesses.

Public outrage erupted in 1972 when it became known that men with syphilis in the study had been allowed to remain untreated so that doctors could investigate the progression of the disease, and the project was stopped. But that came too late for the men; many were disabled permanently or had died. In the wake of the study, the government moved quickly to adopt policies that protect people who take part in research programs. In 1974, a new law created a national commission to set basic ethical standards for research. New rules also required that participants in government-funded studies be made fully aware of how a study will proceed and voluntarily agree to take part in it. Any study that involves humans also is reviewed before it begins to ensure that it meets ethical standards.

Of course, these changes could not reverse the physical and emotional harm done to the men in the Tuskegee Syphilis Study and to their families. In recognition of that harm, in 1997, President Bill Clinton offered an apology to the survivors, families, and descendants of those men on behalf of the U.S. government.

a chancre that appears where the syphilis bacterium entered the body, such as on the penis or the lips of the vagina*. Without treatment, chancres will heal on their own within 6 weeks. A person who is infected may never even notice a chancre, especially if it is inside the vagina or the rectum*.

*vagina
(vah-JY-nah) is the canal, or passageway, in a woman that leads from the uterus to the outside of the body.
*rectum
is the final portion of the large intestine, connecting the colon to the anus.

When the chancre fades, the disease moves to its second stage 1 to 2 months later. In this phase, a rash of rough reddish or brownish spots appears on the body, including the soles of the feet and the palms of the hands. The rash may be so faint that it is barely noticeable. Second-stage symptoms of syphilis also may include fever, headache, extreme tiredness, sore throat, muscle aches, swollen lymph nodes*, weight loss, hair loss, and ulcers* on mucous membranes* in the mouth and on the genitals*. Wartlike lesions* may appear on the vagina or anus. This stage of the infection also disappears on its own, fooling many people into thinking that they have had a common viral illness.

*lymph
(LIMF) nodes are small, bean-shaped masses of tissue that contain immune system cells that fight harmful microorganisms. Lymph nodes may swell during infections.
*ulcers
are open sores on the skin or the lining of a hollow body organ, such as the stomach or intestine. They may or may not be painful.
*mucous membranes
are the moist linings of the mouth, nose, eyes, and throat.
*genitals
(JEH-nih-tuls) are the external sexual organs.
*lesions
(LEE-zhuns) is a general term referring to sores or damaged or irregular areas of tissue.

After the second-stage symptoms clear up, the disease enters a latent, or hidden, period in which there are no signs of illness. The latent period can last for many years, and in some infected people the bacteria do no further damage. In about one-third of people who reach the latent period, the disease progresses to its final stage. This phase has no symptoms at first, but as the bacteria invade and damage nerves, bones, and the heart and other organs, the patient may experience dizziness, headaches, seizures*, dementia*, loss of coordination, numbness, increasing blindness, and paralysis. The disease also can eat away at tissue in the mouth and nose, disfiguring the face. This last stage of the disease can begin 2 to 40 years after a person is first infected.

*seizures
(SEE-zhurs) are sudden bursts of disorganized electrical activity that interrupt the normal functioning of the brain, often leading to uncontrolled movements in the body and sometimes a temporary change in consciousness.
*dementia
(dih-MEN-sha) is a loss of mental abilities, including memory, understanding, and judgment.

Babies who are born with syphilis may have symptoms right away or may show signs of the disease within a few weeks or months. Those symptoms include failure to thrive*, irritability, fever, rash, a nose without a bridge (known as saddle nose), bloody fluid from the nose, and a rash on the palms, soles, or face. As these children grow older, they may become blind and deaf and have notched teeth (called Hutchinson teeth). Bone lesions may arise, and lesions and scarring may appear around the mouth, genitals, and anus.

*failure to thrive
is a condition in which an infant fails to gain weight and grow at the expected rate.

How Is the Diagnosis of Syphilis Made?

If a patient has a chancre or other lesion, the doctor collects a sample of fluid from the sore to examine under a special microscope. Syphilis bacteria in the fluid are visible under magnification. The doctor also may take a blood sample to look for antibodies* to the bacterium. If neurosyphilis (nur-o-SIH-fih-lis, syphilis that has progressed to the point that it affects the brain, spinal cord, and nerves) is suspected, the spinal fluid also may be tested for antibodies. Pregnant women are screened for syphilis during routine prenatal care.

*antibodies
(AN-tih-bah-deez) are protein molecules produced by the bodys immune system to help fight specific infections caused by microorganisms, such as bacteria and viruses.

How Is Syphilis Treated?

Even though visible signs of the infection will clear up on their own, patients with syphilis are treated to prevent the disease from progressing to the late, potentially much more harmful stage, or to prevent a pregnant womans infant from being damaged by the infection. Early-stage syphilis is treated easily with antibiotics. People who are infected with syphilis are advised to notify all their recent sexual partners so that they, too, can be tested for the disease. Patients with advanced cases of the disease often need to be hospitalized. They also receive antibiotics, although medications cannot reverse damage already done to the body.

How Long Does Infection Last?

A single dose of antibiotics can clear up syphilis infections that are less than a year old. Longer-term cases require longer courses of treatment. Congenital syphilis also needs a longer course of treatment. Without treatment, the disease can last for years or even decades.

Does the Disease Have Complications?

Untreated cases of syphilis can lead to destructive tissue lesions known as gummas on the skin, bones, and organs; seizures; damage to the spine that can result in paralysis; heart problems; damage to blood vessels that can lead to stroke*; and death. According to the CDC, a person with syphilis has a two to five times greater risk of acquiring human immunodeficiency (ih-myoo-no-dih-FIH-shen-see) virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), an infection that weakens the immune system. The reason for this increased risk is that open sores make it easier for HIV to enter the body during sexual contact. Also, people infected with HIV are more likely to experience neurological* complications of syphilis. In infants, syphilis can lead to hearing loss, blindness, neurological problems, and death.

*stroke
is a brain-damaging event usually caused by interference with blood flow to the brain. A stroke may occur when a blood vessel supplying the brain becomes clogged or bursts, depriving brain tissue of oxygen. As a result, nerve cells in the affected area of the brain, and the specific body parts they control, do not properly function.
*neurological
refers to the nervous system, which includes the brain, spinal cord, and the nerves that control the senses, movement, and organ functions throughout the body.

Can Syphilis Be Prevented?

Using latex condoms or not having sex, especially with someone who is known to be infected, can prevent the spread of syphilis and other sexually transmitted diseases. To be effective, the condom has to cover all syphilis sores. Contact with sores in the mouth or on areas such as the rectum that may not be covered by a condom can spread the disease. Doctors advise pregnant women to be tested and, if needed, treated for syphilis to minimize the risk of passing it to the developing fetus.

See also

AIDS and HIV Infection

Congenital Infections

Sexually Transmitted Diseases

Resources

Organizations

American Social Health Association, P.O. Box 13827, Research Triangle Park, NC 27709. The American Social Health Association has information and fact sheets concerning sexually transmitted diseases, including syphilis, at its website.

Telephone 919-361-8400 http://www.ashastd.org

U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333. The CDC provides fact sheets and other information on syphilis at its website.

Telephone 800-311-3435 http://www.cdc.gov

Website

KidsHealth.org. KidsHealth is a website created by the medical experts of the Nemours Foundation and is devoted to issues of childrens health. It contains articles on a variety of health topics, including syphilis.

http://www.KidsHealth.org

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syphilis

syph·i·lis / ˈsifəlis/ • n. a chronic bacterial disease caused by the spirochete Treponema pallidum. It is contracted chiefly by infection during sexual intercourse, but also congenitally by infection of a developing fetus. DERIVATIVES: syph·i·lit·ic / ˌsifəˈlitik/ adj. & n.

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syphilis

syphilis XVIII. — modL. Syphilis title of a poem, in full ‘Syphilis sive Morbus Gallicus’ (syphilis or the French disease), 1530, by Girolamo Fracastoro, physician, astronomer, and poet, of Verona; the poem is the story of a shepherd Syphilus, represented as the first sufferer.
Hence syphilitic XVIII.

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syphilis

syphilis See sexually transmitted disease.

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syphilis

syphilisAlice, chalice, challis, malice, palace, Tallis •aurora australis •Ellis, trellis •necklace •aurora borealis, Baylis, digitalis, Fidelis, rayless •ageless • aimless • keyless •amaryllis, cilice, Dilys, fillis, Phyllis •ribless • lidless • rimless •kinless, sinless, winless •lipless • witless • annus mirabilis •annus horribilis • syphilis •eyeless, skyless, tieless •polis, solace, Wallace •joyless •Dulles, portcullis •accomplice •Annapolis, Indianapolis, Minneapolis •Persepolis •acropolis, cosmopolis, Heliopolis, megalopolis, metropolis, necropolis •chrysalis • surplice • amice • premise •airmiss • Amis • in extremis • Artemis •promise •pomace, pumice •Salamis •dermis, epidermis, kermis

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Syphilis

Syphilis

Definition

Syphilis is an infectious systemic disease that may be either congenital or acquired through sexual contact or by exposure to contaminated needles.

Description

Syphilis has both acute and chronic forms that produce a wide variety of symptoms affecting most of the body's organ systems. Acquired syphilis has four stages, including primary, secondary, latent, and tertiary, and can be spread by sexual contact during the first three of these four stages.

Syphilis has been a major public health problem since the sixteenth century. The disease was treated with mercury or other unsuccessful remedies until World War I, when effective treatments based on arsenic or bismuth were introduced. Antibiotics were introduced after World War II. At that time, the number of syphilis cases in the general population decreased, partly due to public health measures. But since 1980, the number of cases of syphilis in the United States has risen steadily. This increase includes men and women, all races, all parts of the nation, and all age groups, including adults over age 60. The number of women of childbearing age with syphilis is the highest that has been recorded since the 1940s. About 25,000 cases of infectious syphilis in adults are reported annually in the United States. It is estimated, however, that 400,000 people in the United States need treatment for syphilis every year, and that the annual worldwide total of persons infected with syphilis is 50 million.

The increased incidence of syphilis in recent years is associated with drug abuse as well as changes in sexual behavior. The connections between drug abuse and syphilis include needle sharing and exchanging sex for drugs. In addition, people using drugs are more likely to engage in risky sexual practices. With respect to changing patterns of conduct, a sharp increase in the number of people having sex with multiple partners makes it more difficult for public health professionals to trace the contacts of infected individuals. High-risk groups for syphilis include:

  • sexually active teenagers
  • people infected with another sexually transmitted disease (STD), including AIDS
  • sexually abused children
  • women of childbearing age
  • prostitutes of either gender and their customers
  • prisoners
  • people who abuse drugs or alcohol

The chances of contracting syphilis from an infected person in the early stages of the disease during unprotected sex are 30-50%.

Causes and symptoms

Syphilis is caused by Treponema pallidum, a spirochete, which is a thin spiral- or coil-shaped bacterium that enters the body through the mucous membranes or breaks in the skin. In 90% of cases, the spirochete is transmitted by sexual contact.

Primary syphilis

Primary syphilis refers to the initial stage of the organism's entry into the body. The first signs of infection are not always noticed. After an incubation period ranging between 10 and 90 days, an individual develops a chancre, which is a small blister-like sore about 0.5 inches (13 mm) in size. Most chancres are on the genitals, but they may also develop in or on the mouth or on the breasts. Rectal chancres are common among male homosexuals. Chancres in women are sometimes overlooked if they develop in the vagina or on the cervix. The chancres are not painful and disappear in three to six weeks, with or without treatment. They resemble the ulcers of Lymphogranuloma venereum, herpes simplex virus, or skin tumors.

About 70% of people with primary syphilis also develop swollen lymph nodes near the chancre. The nodes may have a firm or rubbery feel, but they are not usually painful.

Secondary syphilis

Syphilis enters its secondary stage between six to eight weeks and six months after the initial infection begins. Chancres may still be present but are usually healing. Secondary syphilis is a systemic infection marked by the eruption of skin rashes and ulcers in the mucous membranes. The skin rash may mimic a number of other skin disorders such as drug reactions, rubella (German measles), ringworm, mononucleosis, and pityriasis rosea. Characteristics of the rash that point to syphilis include:

  • a coppery color
  • absence of pain or itching
  • occurrence on the palms of hands and soles of feet

The skin eruption may resolve in a few weeks or last as long as a year. A person may also develop condylomata lata, which are watery pink or gray areas of flattened skin in the moist areas of the body. The skin rashes, mouth and genital ulcers, and condylomata lata are all highly infectious.

About 50% of people with secondary syphilis develop swollen lymph nodes in the armpits, groin, and neck areas; about 10% develop inflammations of the eyes, kidney, liver, spleen, bones, joints, or the meninges (membranes covering the brain and spinal cord ). They may also have a flu-like general illness with a low fever, chills, loss of appetite, headaches, runny nose, sore throat, and aching joints.

Latent syphilis

Latent syphilis is a phase of the disease characterized by relative absence of external symptoms. The latent phase is sometimes divided into early latency (less than two years after infection) and late latency. During early latency, people are at risk for spontaneous relapses marked by recurrence of the ulcers and skin rashes of secondary syphilis. In late latency, these recurrences are much less likely. Late latency may either resolve spontaneously or continue for the rest of the person's life.

Tertiary syphilis

Untreated syphilis progresses to a third, or tertiary, stage in about 35-40% of people. Individuals with tertiary syphilis cannot infect others with the disease. It is thought that the symptoms of this stage are a delayed hypersensitivity reaction to spirochetes. Some people develop so-called benign late syphilis, which begins between three and 10 years after initial infection and is characterized by the development of gummas. Gummas are rubbery tumor-like growths that are most likely to involve the skin or long bones but may also develop in the eyes, mucous membranes, throat, liver, or stomach lining. Gummas are increasingly uncommon since the introduction of antibiotics for treating syphilis. Benign late syphilis is usually rapid in onset and responds well to treatment.

CARDIOVASCULAR SYPHILIS. Cardiovascular syphilis occurs in 10-15% of people who have progressed to tertiary syphilis. It develops between 10 and 25 years after initial infection and often occurs together with neurosyphilis. Cardiovascular syphilis usually begins as an inflammation of the arteries leading from the heart and causes heart attacks, scarring of the aortic valves, congestive heart failure, or the formation of an aortic aneurysm.

NEUROSYPHILIS. About 8% of persons with untreated syphilis will develop problems in the central nervous system that include both physical and psychiatric symptoms. Neurosyphilis can appear at any time, from five to 35 years after the onset of primary syphilis. It affects men more frequently than women and Caucasians more frequently than African Americans.

Neurosyphilis is classified into four types:

  • Asymptomatic: In this form, the person's spinal fluid gives abnormal test results, but there are no symptoms affecting the central nervous system.
  • Meningovascular: This type is marked by changes in the blood vessels of the brain or inflammation of the meninges. A person develops headaches, irritability, and visual problems. If the spinal cord is involved, an individual may experience weakness of the shoulder and upper arm muscles.
  • Tabes dorsalis: This type causes a progressive degeneration of the spinal cord and nerve roots. People lose their sense of perception of their body position and orientation in space (proprioception), resulting in difficulties with walking and the loss of muscle reflexes. They may also have shooting pains in the legs and periodic episodes of pain in the abdomen, throat, bladder, or rectum. Tabes dorsalis is sometimes called locomotor ataxia.
  • General paresis: This type refers to the effects of neurosyphilis on the cortex of the brain. A person experiences slow but progressive losses of memory, ability to concentrate, and interest in self-care. Personality changes may include irresponsible behavior, depression, delusions of grandeur, or complete psychosis. General paresis is sometimes called dementia paralytica, and is most common among people over age 40.

Special populations

CONGENITAL SYPHILIS. Congenital syphilis has increased at a rate of 400-500% over the past decade, on the basis of criteria introduced by the Centers for Disease Control (CDC) in 1990. In 1994, more than 2,200 cases of congenital syphilis were reported in the United States. The prognosis for early congenital syphilis is poor: about 54% of infected fetuses die before or shortly after birth. Those which survive may look normal at birth but show signs of infection between three and eight weeks later.

Infants with early congenital syphilis have systemic symptoms that resemble those of adults with secondary syphilis. There is a 40-60% chance that a child's central nervous system will be infected. These infants may have symptoms ranging from jaundice, enlargement of the spleen and liver, and anemia to skin rashes, condylomata lata, inflammation of the lungs, a persistent runny nose, and swollen lymph nodes.

CHILDREN. Children who develop symptoms after the age of two years are said to have late congenital syphilis. The characteristic symptoms include facial deformities (saddle nose), Hutchinson's teeth (abnormal upper incisors), saber shins, dislocated joints, deafness, mental retardation, paralysis, and seizure disorders.

PREGNANT WOMEN. Syphilis can be transmitted from a mother to her fetus through the placenta at any time during pregnancy, or through the child's contact with syphilitic ulcers during the birth process. The chances of infection are related to the stage of the mother's disease. Almost all infants of mothers with untreated primary or secondary syphilis will be infected, whereas the infection rate drops to 40% if the mother is in the early latent stage, and 6-14% if she has late latent syphilis.

Pregnancy does not affect the progression of syphilis in the mother. However, pregnant women should not be treated with tetracyclines as this drug will discolor the teeth of her infant.

PEOPLE WITH HIV. Syphilis has been closely associated with HIV infection since the late 1980s. Syphilis sometimes mimics the symptoms of AIDS. Conversely, AIDS appears to increase the severity of syphilis in people suffering from both diseases, and to speed up the development or appearance of neurosyphilis. People with HIV are also more likely to develop lues maligna, a skin disease that sometimes occurs in secondary syphilis. In addition, people with HIV have a higher rate of treatment failure with penicillin than those without HIV.

Diagnosis

Personal history and physical diagnosis

Because of the long-term risks of untreated syphilis, certain groups of people are now routinely screened for the disease, including:

  • pregnant women
  • sexual contacts or partners of people diagnosed with syphilis
  • children born to mothers with syphilis
  • individuals with HIV infection
  • persons applying for marriage licenses

When a physician takes a person's history, there will be questions about recent sexual contacts to determine whether the person falls into a high-risk group. Symptoms such as skin rashes or swollen lymph nodes will be noted with respect to the dates of the person's sexual contacts. Definite diagnosis, however, depends on the results of laboratory blood tests.

Blood tests

There are several types of blood tests for syphilis presently used in the United States. Some are used in follow-up monitoring of infected people as well as diagnosis.

NON-TREPONEMAL ANTIGEN TESTS. Non-treponemal antigen tests are used with initial screening. They measure the presence of reagin, which is an antibody formed in reaction to syphilis. In the venereal disease research laboratory (VDRL) test, a sample of a person's blood is mixed with cardiolipin and cholesterol. If the mixture forms clumps or masses of matter, the test is considered reactive, or positive.

The rapid plasma reagin (RPR) test, which is available as a kit, works on the same principle as the VDRL. A person's serum is mixed with cardiolipin on a plastic-coated card that can be examined with the naked eye.

Non-treponemal antigen tests require a physician's interpretation and sometimes further testing. They can yield both false-negative and false-positive results. False-positive results can be caused by other infectious diseases, including mononucleosis, malaria, leprosy, rheumatoid arthritis, and lupus. People with HIV have a particularly high rate (4%, compared to 0.8% of people who are HIV-negative) of false-positive results on reagin tests. False-negatives can occur when individuals are tested too soon after exposure to syphilis; it takes about 14-21 days after infection for the blood to become reactive.

TREPONEMAL ANTIBODY TESTS. Treponemal antibody tests are used to rule out false-positive results on reagin tests. They measure the presence of antibodies that are specific for T. pallidum. The most commonly used tests are the microhemagglutination-T. pallidum (MHA-TP) and the fluorescent treponemal antibody absorption (FTA-ABS) tests. In the FTA-ABS test, a person's blood serum is mixed with a preparation that prevents interference from antibodies to other treponemal infections. In a positive reaction, syphilitic antibodies in the blood coat the spirochetes on the slide. In the MHA-TP test, red blood cells from sheep are coated with T. pallidum antigen. The cells will clump if the person's blood contains antibodies for syphilis.

Treponemal antibody tests are more expensive and more difficult to perform than non-treponemal tests. They are therefore used to confirm the diagnosis of syphilis rather than to screen large groups of people. These tests are, however, very specific and very sensitive; false-positive results are relatively unusual.

Other laboratory tests

MICROSCOPE STUDIES. The diagnosis of syphilis can also be confirmed by identifying spirochetes in samples of tissue or lymphatic fluid.

SPINAL FLUID TESTS. Testing of cerebrospinal fluid (CSF) is an important part of monitoring programs as well as being a diagnostic test. The VDRL and FTA-ABS tests can be performed on CSF as well as on blood. An abnormally high white cell count and elevated protein levels in the CSF, together with positive VDRL results, suggest a possible diagnosis of neurosyphilis. CSF testing is not used for routine screening. It is most frequently used for infants with congenital syphilis, people who are HIV-positive, and individuals of any age who are not responding to penicillin treatment.

Treatment

Medications

Syphilis is treated with antibiotics given either intramuscularly (benzathine penicillin G or ceftriaxone) or orally (doxycycline, minocycline, tetracycline, or azithromycin). Neurosyphilis is treated with a combination of aqueous crystalline penicillin G, benzathine penicillin G, or doxycycline. It is important to keep the levels of penicillin in the person's tissues at sufficiently high levels over a period of days or weeks because the spirochetes have a relatively long reproduction time. Penicillin is more effective in treating the early stages of syphilis than the later stages.

Physicians do not usually prescribe separate medications for the skin rashes or ulcers of secondary syphilis. A person is advised to keep the rashes clean and dry, and to avoid exposing others to fluid or discharges from condylomata lata.

Pregnant women should be treated as early in pregnancy as possible. Infected fetuses can be cured if the mother is treated during the second and third trimesters of pregnancy. Infants with proven or suspected congenital syphilis are treated with either aqueous crystalline penicillin G or aqueous procaine penicillin G. Children who acquire syphilis after birth are treated with benzathine penicillin G.

Jarisch-Herxheimer reaction

The Jarisch-Herxheimer reaction, first described in 1895, is a reaction to penicillin treatment that may occur during the late primary, secondary, or early latent stages. A person develops chills, fever, headache, and muscle pains within two to six hours after the penicillin is injected. The chancre or rash temporarily gets worse. The Jarisch-Herxheimer reaction, which lasts about a day, is thought to be an allergic reaction to toxins released when the penicillin kills massive numbers of spirochetes.

Alternative treatment

Antibiotics are essential for the treatment of syphilis. Recovery from the disease can be assisted by dietary changes, changes in sexual practices, sleep, exercise, and stress reduction.

HOMEOPATHY. Homeopathic practitioners are forbidden by law in the United States to claim that homeopathic treatment can cure syphilis. The remedies most frequently recommended by alternative practitioners who treat people with syphilis are Medorrhinum, Syphilinum, Mercurius vivus, and Aurum.

Prognosis

The prognosis is good for the early stages of syphilis if a person is treated promptly and given sufficiently large doses of antibiotics. There are no definite criteria for cure for individuals with primary and secondary syphilis, although people who are symptom-free and have had negative blood tests for two years after treatment are usually considered to be free of syphilis. Treated people should follow up with blood tests at one, three, six, and 12 months after treatment, or until the results are negative. CSF should be examined after one year. People with recurrences during the latency period should be tested for re-infection.

The prognosis for people with untreated syphilis is spontaneous remission for about 30%, lifelong latency for another 30%, and potentially fatal tertiary forms of the disease in 40%.

Health care team roles

Trained lay people often take medical and personal histories. Phlebotomists draw blood for testing. A pathologist often interprets the results of specialized tests. A physician may also administer and check test results and provide treatment. Psychiatrists or other counselors may treat psychiatric symptoms.

Prevention

Immunity

People with syphilis do not acquire lasting immunity against the disease. No effective vaccine for syphilis has been developed. Prevention depends on a combination of personal and public health measures.

Lifestyle choices

The only reliable methods for preventing transmission of syphilis are sexual abstinence or monogamous relationships between uninfected partners. Latex condoms offer some protection but protect only the covered parts of the body.

Public health measures

CONTACT TRACING The law requires reporting of syphilis cases to public health agencies. Sexual contacts of people diagnosed with syphilis are traced and tested for the disease. This includes all contacts for the past three months in cases of primary syphilis, and for the past year in cases of secondary disease. Neither the affected people nor their contacts should have sex with anyone until they have been tested and treated.

All people who test positive for syphilis should be tested for HIV infection at the time of initial diagnosis.

PRENATAL TESTING OF PREGNANTWOMEN. Pregnant women should be tested for syphilis at the time of their first visit for prenatal care, and again shortly before delivery. Proper treatment of secondary syphilis in the mother reduces the risk of congenital syphilis in the infant from 90% to less than 2%.

EDUCATION AND INFORMATION. People diagnosed with syphilis should be given information about the disease and counseling regarding sexual behavior and the importance of completing antibiotic treatment. It is also important to inform the general public about the transmission and early symptoms of syphilis, and provide adequate health facilities for testing and treatment.

KEY TERMS

Chancre— The initial skin ulcer of primary syphilis, consisting of an open sore with a firm or hard base.

Condylomata lata— Highly infectious patches of watery pink or gray skin that appear in the moist areas of the body during secondary syphilis.

General paresis— A form of neurosyphilis in which a person's personality, as well as the control of movement, is affected.

Gumma— A symptom that is sometimes seen in tertiary syphilis, characterized by a rubbery swelling or tumor that heals slowly and leaves a scar.

Jarisch-Herxheimer reaction— A temporary reaction to penicillin treatment for syphilis that includes fever, chills, and worsening of the skin rash or chancre.

Lues maligna— A skin disorder of secondary syphilis in which areas of ulcerated and dying tissue are formed.

Spirochete— A type of bacterium with a long, slender, coiled shape.

Tabes dorsalis— A progressive deterioration of the spinal cord and spinal nerves associated with tertiary syphilis.

Resources

BOOKS

Larsen, Sandra A., Victoria Pope, and Robert E. Johnson. Syphilis: A Manual of Tests and Supplement. Washington, DC: American Public Health Association, 1999.

Lukehart, Shiela A., and King Holmes. "Syphilis." In Harrison's Principles of Internal Medicine, 14th ed., edited by Anthony S. Fauci et al. New York: McGraw-Hill, 1998.

Reverby, Susan. Tuskegee's Truths: Rethinking the Tuskegee Syphilis Study. Chapel Hill, NC: University of North Carolina Press, 2000.

PERIODICALS

Finelli, L., W. C. Levine, J. Valentine, and M. E. St. Louis. "Syphilis Outbreak Assessment." Sexually Transmitted Disease 28 no. 3 (2001): 131-35.

Gayle, H. D., and G. W. Counts. "Syphilis Elimination: A Unique Time in History." Journal of the American Medical Womens Association 56 no. 1 (2001): 2-3.

Patel, A., D. Moodley, and J. Moodley. "An Evaluation of On-Site Testing for Syphilis." Tropical Doctor 31 no. 2 (2001): 79-82.

Polsky, I., and S. C. Samuels. "Neurosyphilis. Screening Does Sometimes Reveal an Infectious Cause of Dementia." Geriatrics 56 no. 3 (2001): 60-2.

Warner, L., et al. "Missed Opportunities for Congenital Syphilis Prevention in an Urban Southeastern Hospital." Sexually Transmitted Disease 28 no. 2 (2001): 92-8.

ORGANIZATIONS

American Society of Clinical Pathologists. 2100 West Harrison Street, Chicago, IL 60612. (312) 738-1336. 〈http://www.ascp.org/index.asp〉. [email protected]

OTHER

Centers for Disease Control and Prevention. 〈http://www.cdc.gov/nchstp/dstd/Fact_Sheets/Syphilis_Facts.htm〉.

Columbia Presbyterian Medical Center. 〈http://cpmcnet.columbia.edu/texts/gcps/gcps0036.html〉.

National Institute of Allergy and Infectious Disease. 〈http://www.niaid.nih.gov/factsheets/stdsyph.htm〉.

University of Virginia Health System. 〈http://hsc.virginia.edu/hs-library/historical/apology/〉.

Vanderbilt University Medical Center. 〈http://www.mc.vanderbilt.edu/peds/pidl/infect/congsyph.htm〉.

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Syphilis

Syphilis

Syphilis is a bacterial infection caused by the Treponema pallidum spirochete (a spirochete is a type of bacterium that is thin, long, and coiled in shape). Called the great pretender or great imitator, syphilis has a number of signs and symptoms that may mimic those of other conditions.

Syphilis is a sexually transmitted disease/sexually transmitted infection that most commonly occurs in people aged twenty to twenty-nine. Women aged twenty to twenty-four and men aged thirty-five to thirty-nine are the most likely groups to be diagnosed with syphilis. In the early years of the twenty-first century, the majority of syphilis cases have occurred in men who have sex with men.

T. pallidum uses minor cuts or abrasions to enter the body, and the infection is typically contracted by direct contact with a syphilis sore, which is called a chancre. Infection can occur with oral, vaginal, or anal sex. In addition, women who are pregnant can transmit the disease to their fetuses (called congenital syphilis). Sores are most commonly found on the external sex organs, vagina, rectum, or anus; they can occur, however, in other places (e.g., in the mouth, on the lips).

Less likely means of transmission include transfusions of infected blood, direct intimate contact with an infected partner's chancre (e.g., through kissing), or a transfer to a health-care provider during an examination or procedure. Transmission via blood transfusion is extremely unlikely because the spirochetes cannot survive long in stored blood and the blood supply is screened for syphilis. Syphilis is not spread through casual contact (e.g., commodes, pools, clothing, kitchen utensils), likely because T. pallidum is highly sensitive to light, air, and temperature fluctuations.

STAGES

Infections of syphilis may progress through four stages. The infection may be spread during the primary, secondary, and early latent stages as well as from a pregnant woman to a fetus. In the primary stage the infection is usually evidenced by one sore, although there may be more than one, at the site where syphilis entered the person's body. Most often the point of entry is the penis, vagina, or vulva, but it could be another spot (e.g., lips, tongue, cervix). Typically, there is an average of twenty-one days (range ten to ninety days) between infection and evidence of a sore.

Chancres are normally small, hard, painless, and round. Chancres are usually present for three to six weeks and then heal. In approximately two-thirds of cases, lymph glands in the area will be swollen. Because chancres are often small, painless, and inside the body, they can easily be overlooked. Without satisfactory treatment, however, syphilis continues into the secondary stage.

In the secondary stage, common symptoms are rashes on the skin and lesions in mucous membranes. This stage usually begins with a skin rash, often one without itching, which may appear red or reddish brown in color. The rash typically emerges two to ten weeks after the chancre, following or during the healing of this sore. Although the rash may appear on one or more places on the body, frequently, such rashes appear on the palms of the hands and soles of the feet. Rashes may be light, challenging to see, and mimic those associated with other conditions. Other symptoms may occur during this stage of syphilis, including sore throat, fever, fatigue, aches, hair or weight loss, swollen lymph glands, and headaches. Regardless of whether treatment is administered, these symptoms will fade; without satisfactory treatment, however, disease progression may continue.

A third stage of the disease is the latent stage, which begins with the end of the symptoms of secondary syphilis. Early in the latent stage an individual may have no symptoms; however, one can infect others. When in late latent syphilis the risk of infecting others diminishes; without treatment, however, progression to the tertiary stage, a relapse into secondary-stage symptoms, or transmission of the disease to a fetus by a pregnant woman can occur. It is also possible that the signs and symptoms of syphilis may disappear and never return.

The final stage of syphilis is the tertiary stage, which is sometimes referred to as late syphilis. In this stage a subset of people receiving no treatment will develop serious health complications. After entering the body syphilis moves through the bloodstream, attaching to cells and damaging internal organs as time passes. By this late stage of the infection, damage to the body's internal organs (e.g., brain, heart, eyes, liver, joints) may have occurred. Although this damage takes place over time, it may not be evident for several years. In fact, individuals may have syphilis and not exhibit symptoms for a considerable period of time; nevertheless, they may still be subject to late-stage complications. Symptoms of this stage include coordination difficulties, blindness, and dementia. The damage incurred may even cause death.

CONGENITAL SYPHILIS

Syphilis can be transmitted to a fetus at any stage of pregnancy. Estimates suggest that more than half of pregnant women with untreated syphilis may infect their fetuses, and that nearly half of babies with congenital syphilis will die. Passing syphilis to a fetus increases the likelihood of miscarriage, premature birth, stillbirth, and newborn death. Babies who are infected with syphilis may not exhibit any signs of the disease, but prompt medical treatment is needed or health conditions may worsen. If untreated, babies with syphilis may experience slower development, seizures, or death. Other health conditions in babies born with syphilis include sight and hearing problems, bone irregularities, joint swelling, and misshapen teeth (i.e., screwdriver-shaped teeth, called Hutchinson's teeth).

DIAGNOSIS AND TREATMENT

Because it shares symptoms with so many other diseases, may have no symptoms, or may have symptoms that disappear, syphilis can be challenging to diagnose. In the early twenty-first century, there are two methods for diagnosing syphilis—examination of material from a chancre under a dark-field microscope, which can detect syphilis bacteria, or via a blood test, which will detect syphilis antibodies. All pregnant women should have this blood test to avoid the complications of infecting the fetus. If diagnosed with syphilis pregnant women should be treated immediately. During the second and third trimesters of pregnancy, infected fetuses may be cured by treatment.

If treated during the initial stages, syphilis is easy to cure. A penicillin injection is the typical treatment for individuals who have had syphilis for less than one year. For those who have been infected for more than a year, additional doses are needed. For individuals with penicillin allergies, other antibiotics (such as doxycycline and tetracycline) can be used. Penicillin treatment is more effective when used early rather than as the infection progresses. It is important to note that treatment stops the infection but does not repair previous damage. Also, persons can be reinfected. Although no effective alternative treatments exist for syphilis, rest, reduction of stress, and appropriate exercise can aid the results of taking antibiotics.

The availability of penicillin in the 1940s led to a dramatic decline in syphilis. Prior to penicillin arsenic- or bismuth-based treatments yielded some effectiveness. Early ineffective treatments included guaiacum (a wood gum) and mercury, which was inhaled, swallowed, or rubbed into the skin. Even malaria was used as a treatment, especially for tertiary syphilis, because some individuals with high fevers seemed to recover from syphilis, and then the malaria could be treated with quinine.

In the early twenty-first century, the Centers for Disease Control and Prevention (CDC) recommends screenings for individuals at risk. Further, individuals treated for syphilis should refrain from sexual contact until sores have healed and inform sexual partners so that they can be tested. The majority of syphilis transmission occurs from people who are undiagnosed. Because sores can be hidden (e.g., in the mouth, vagina, or rectum) and symptoms absent or difficult to diagnosis, one may not know a partner is infected. Also, chancres increase the likelihood of contracting and transmitting HIV.

ORIGINS

The origin of syphilis has been debated for several centuries. Three hypotheses now predominate. One hypothesis suggests that syphilis began in the New World and was taken back to Europe by sailors traveling with explorers, such as Christopher Columbus (1451–1506). This theory is also referred to as the Columbian explanation or Columbian exchange perspective. A second is that syphilis existed in the Old World but was confused with leprosy until medical diagnosis allowed practitioners to distinguish between the two illnesses. This perspective is also called the pre-Columbian view. The third suggests that syphilis emerged on both continents evolving from yaws and bejel, diseases caused by other bacteria in the genus with T. pallidum. Recent work in paleopathology favors the New World as the source.

see also Sexually Transmitted Diseases.

BIBLIOGRAPHY

Centers for Disease Control and Prevention. "Syphilis: CDC Fact Sheet." Available from http://www.cdc.gov/std/Syphilis/STDFact-Syphilis.htm.

Centers for Disease Control and Prevention. 2006. Sexually Transmitted Disease Surveillance, 2005. Atlanta, GA: U.S. Department of Health and Human Services.

Mayo Clinic. "Syphilis." Available from http://www.mayoclinic.com/health/syphilis/DS00374.

National Institutes of Health. National Institute of Allergy and Infectious Diseases. "Syphilis." Available from http://www.niaid.nih.gov/factsheets/stdsyph.htm.

Rothschild, Bruce M. 2005. "History of Syphilis." Clinical Infectious Diseases 40(10): 1454-1463.

Rothschild, Bruce M., and Christine Rothschild. 1996. "Treponemal Disease in the New World." Current Anthropology 37(3): 555-561.

                                                  Joy L. Hart

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Syphilis

Syphilis

Introduction

Disease History, Characteristics, and Transmission

Scope and Distribution

Treatment and Prevention

Impacts and Issues

BIBLIOGRAPHY

Introduction

Syphilis is one of the most significant of the sexually transmitted diseases (STDs) with an estimated 12 million new infections occurring each year worldwide. It is a deceptive condition, starting with a single, painless sore which may not even be detected but which may progress over a period of years to potentially fatal complications such as heart damage, dementia, and paralysis. Syphilis is very infectious, and most cases are caused by sexual contact with people who may not even be aware that they have themselves contracted the disease.

Syphilis is caused by the bacterium Treponema pallidum and the advent of penicillin in the late 1940s led to a dramatic decrease in the number of cases. However, syphilis has been on the increase again in recent years in the United States and in other countries, so there is a great need to treat the disease at an early stage and to educate people about the risks.

Disease History, Characteristics, and Transmission

Syphilis is caused by T. pallidum, which belongs to the spirochaete class of fine, spiral, highly motile bacteria. Its incubation time is from nine to 90 days and the disease progresses through an infectious and a non-infectious stage. The infectious stage lasts for a few months, during which time symptoms may cause little, or no, illness. The non-infectious stage, which follows if syphilis is not treated early on, may also be without symptoms—or it may be accompanied by major heart or neurological damage.

Infectious syphilis is divided into two stages. The primary stage is characterized by the appearance of a single sore, known as a chancre, either on or inside the genitals or elsewhere on the body, such as on the eyelid or lip. Typically, the chancre is firm, round, small and painless. It appears at the site of entry of T. pallidum into the body. The chancre, which those affected may be completely unaware of, lasts for three to six weeks and heals without treatment. However, if treatment is not administered, the infection will progress to the secondary stage.

A skin rash and mucous membrane lesions are the prime symptoms of the secondary stage. A non-itching rash develops, either while the chancre is healing or several weeks afterwards. This might appear as rough red or reddish-brown spots on the palms of the hands and the soles of the feet. However, a rash might appear on some other part of the body and resemble that from some other disease—especially if the primary stage has not been identified.

Sometimes the rash from secondary syphilis is so faint as to be unnoticeable. There may be other symptoms such as fever, swollen glands, weight loss, headaches, loss of appetite, and fatigue. However, this stage also resolves within a few weeks without any treatment.

Latent syphilis is untreated disease past the primary and secondary stage. It has no obvious symptoms and is known as early or late, depending on whether it develops earlier or later than two years after the first infection. This is an arbitrary cut-off time that refers to whether or not the disease is likely to still be infectious.

Late latent syphilis may lead to complications of the nervous system. Ten percent of people with latent syphilis will develop neurosyphilis, of which there are various types, depending on which part of the brain and nervous system is affected. Neurosyphilis produces early symptoms such as personality change, tremor, and impaired memory, often followed by paralysis, delusions and seizures. Another form of neurosyphilis, tabes doralis, is accompanied by sharp pains in the legs and an absence of normal reflexes. The meningovascular type of neurosyphilis is an inflammation of the covering of the brain, and headache is usually a major symptom. Neurosyphilis may not have any symptoms at all, but evidence of infection can still be found in the cerebrospinal fluid.

Another ten percent of those with late disease will develop cardiovascular syphilis, which affects the aorta— the main vessel leaving the heart to supply the rest of the body with oxygenated blood. The disease leads to aneurysm, which is a weakness in the artery, which may lead to a potentially fatal rupture. Finally, gummatous syphilis affects 15 percent of those with later disease and leads to the presence of sores on the skin and mucous membranes, many years after the primary infection.

WORDS TO KNOW

ANTIBIOTIC: A drug, such as penicillin, used to fight infections caused by bacteria. Antibiotics act only on bacteria and are not effective against viruses.

SEXUALLY TRANSMITTED DISEASE (STD): Sexually transmitted diseases (STDs) vary in their susceptibility to treatment, their signs and symptoms, and the consequences if they are left untreated. Some are caused by bacteria. These usually can be treated and cured. Others are caused by viruses and can typically be treated but not cured. More than 15 million new cases of STD are diagnosed annually in the United States.

VENEREAL DISEASE: Venereal diseases are diseases that are transmitted by sexual contact. They are named after Venus, the Roman goddess of female sexuality.

A pregnant woman with syphilis might pass the disease on to her unborn child. Congenital syphilis leads to stillbirth, death shortly after birth, physical deformity, or neurological problems. Increasing awareness of the dangers of syphilis can decrease the risk of all these complications, by treating cases at the earliest possible stage with antibiotics.

Transmission of syphilis is by direct contact with a chancre, which usually occurs through sexual contact. Since the sore may be inside the body—on the cervix, for instance—it is possible that neither person will realize the danger of infection. It is also possible to become reinfected with syphilis at some later stage—unlike with some other infectious diseases, one infection does not confer lifelong immunity.

Scope and Distribution

According to the World Health Organization, there are around 12 million new syphilis infections each year. South and Southeast Asia account for about four million, sub-Saharan Africa for another four million. Other areas where syphilis is a significant health problem include Eastern Europe and the United States.

IN CONTEXT: SCIENTIFIC, POLITICAL, AND ETHICAL ISSUES

In 1932, the U.S. Public Health Service (USPHS). Venereal Disease Division began an experiment in Macon County, Alabama, to determine the natural course of untreated, latent syphilis in African American men. The experiment, known as the Tuskegee Syphilis Study, involved 400 men with syphilis, as well as 200 uninfected men who served as controls. The men were told that they were ill with “bad blood,” a rural Southern colloquialism for syphilis and anemia, but were never informed that they were participants in a study. The USPHS was investigating the possibility that anti-syphilitic treatment was unnecessary.

Despite the fact that major medical textbooks in 1932 advocated treating syphilis at the latent stage, the USPHS actively prevented the men enrolled in the study from receiving treatment. They were never given a clear diagnosis. In 1934, the USPHS advised local black hospitals not to treat the study subjects, and when the Alabama Health Department took a mobile venereal disease unit into Macon County in the early 1940s, the USPHS advised the health officials to deny treatment to the test subjects. At the start of World War II (1941–1945), several of the men were drafted for military service and were told by the Army to begin anti-syphilitic treatment. Concerned about the continuation of the experiment, the USPHS gave the names of 256 study members to the Alabama state draft board and asked that they not be drafted and, thus, receive treatment in the military. The draft board complied with the request. When penicillin became widely available by the early 1950s as a cure for syphilis, the men enrolled in the study did not receive treatment.

No effort was made by the USPHS to protect the wives and families of the diseased men from syphilis. The officials in charge of the experiment presumed that syphilis existed naturally in the black community, presumed that African American men were promiscuous, and presumed they would not seek or continue treatment even if given the choice.

The first published report of the Tuskegee Syphilis Study appeared in 1936, with subsequent papers issued every four to six years throughout the 1960s. Each report noted the ravages of untreated syphilis. In 1969, a committee from the Centers for Disease Control decided that the study should be continued. However, by this time, some of the test subjects had received antibiotics for other illnesses, thereby compromising the syphilis study. Only in July 1972, when the Associated Press reported the story, did the Department of Health, Education, and Welfare (HEW) halt the experiment amid great public outrage. At that time, 74 of the test subjects were still alive. Many of the subjects had died from untreated syphilis with estimates of the dead ranging from twenty-eight to one hundred men. In August 1972, HEW appointed an investigatory panel, which subsequently found the study to be “ethically unjustified.” HEW declared that penicillin should have been provided to the men. None of the physicians who participated in the study were ever prosecuted for any crimes, although the United States did settle a lawsuit brought by the survivors and their families for $10 million.

The Tuskegee Syphilis Study led to new standards for experiments that employ human subjects. In U.S. Senate hearings on human experimentation held in the wake of publicity about the study, physicians were reminded that the goal of human experimentation must always be to advance the human condition and to improve the situation of the subjects of the study. Institutional review boards were established to guarantee that studies are grounded in scientific principles and that the rights of study participants are protected.

In May 1997, President Bill Clinton issued a formal apology for the Tuskegee Syphilis Study on behalf of the United States government.

According to the Centers for Disease Control and Prevention (CDC), where data on syphilis infection is collected, the disease fell to an all-time low in 2000 but has been increasing since then. Accordingly, there were 7,940 reported cases of primary and secondary syphilis in 2004 and 8,724 in 2005. But there has been a decrease in congenital syphilis during that time period from 9.1 to 8.0 per 100,000 births.

Treatment and Prevention

Penicillin is still the mainstay of treatment for syphilis. Doxycycline and erythromycin are alternatives for those who are allergic to penicillin. Early cases can be treated by a single injection of penicillin but the more the disease progresses, the longer the duration of treatment must be. Treatment is effective and it halts progression to the later stages of syphilis and its progression.

Prevention of the disease includes the tracing of the sexual contacts of those in the infectious stages of syphilis. If they are found to be infected, they should be treated promptly. Sexual abstinence, or having monogamous sexual contact with a partner known not to be infected, are the most effective way of avoiding infection with syphilis.

Impacts and Issues

During World War I (1914–1918), many involved nations launched public campaigns to combat the spread of sexually transmitted diseases (then commonly called venereal disease or VD) that often rose dramatically during and immediately after wartime. Posters and pamphlets warned soldiers of contracting venereal disease from prostitutes and transmitting venereal disease to wives back home. Syphilis was the focus of most anti-VD campaigns since it then was the most devastating and difficult to treat venereal disease. Anti-VD, and especially anti-syphilis campaigns were again launched during World War II (1939–1945), but the advent of antibiotics shifted their focus to one of wartime rationing and conservation—saving precious antibiotics for those most in need by reducing the risk of exposure to venereal disease.

The Tuskegee Syphilis Study (1932–1972) documented the effects of untreated syphilis in approximately 400 African-Americans living near Tuskegee, Alabama. Most of the subjects of the study were poor and had scant access to health care. Many were illiterate, or had little formal education. The study was kept secret for almost four decades, with minimal concern for the welfare of participants. Individuals who volunteered for the study were told they would receive free meals and medical care for their “bad blood.” The families of participants who died were eligible to receive $35 for funeral expenses. When the Tuskegee Syphilis Study began in 1932, antibiotic penicillin had been discovered but was not yet commonly available for medical use. Standard treatments for syphilis were neither effective of safe, many involved toxic substances that damaged the liver, kidneys, and nervous system.

The originators of the Tuskegee Syphilis Study claimed that it might be more beneficial for patients to receive no treatment at all than to be subjected to the syphilis remedies then available. However, the Study continued long after penicillin became commonly available after World War II (1939–1945), and patients were denied antibiotics or information about antibiotic treatments. Participants were never fully informed that they had syphilis or that treatment was available. Throughout the course of the study, participants were subjected to repeated injections of non-medicinal solution, routine examinations, and medical testing. Many participants suffered painful symptoms for many years; many died from complications related to untreated syphilis. The experiment terminated abruptly in 1972 after information about the Tuskegee Study was leaked to the press.

While incidence of syphilis in the United States, especially in young adults, reached a new low in the 1990s, an isolated outbreak in 1996 garnered national media attention when public health officials documented 17 cases of syphilis in teenagers in a suburban county near Atlanta, Georgia. Health officials asserted that as many as 250 teens may have been exposed to syphilis. Testing and disease tracking found that many of the teens routinely engaged in high-risk sexual behaviors including having multiple partners, group sex, and unprotected sex.

Much of the increase in syphilis cases in recent years has occurred among men who have sex with men who now account for nearly half of all cases. There has also been an increase in syphilis cases among women, for the first time in more than ten years, and among African-Americans.

Syphilis infection is a major risk for those who already have HIV infection. The presence of the chancre makes it easier for the virus to enter the body. Studies have shown that the risk of HIV transmission is two to five times higher among those who already have syphilis. The symptoms of HIV and syphilis tend to overlap one another, which may confuse the diagnosis. Also, people who are HIV positive might progress quicker to the complications of syphilis. For these reasons, those who are diagnosed with syphilis are recommended to have an HIV test and those who are HIV positive should be tested for syphilis, so treatment can be given as soon as possible.

Primary Source Connection

In the aftermath of the Tuskegee Experiment revelations, calls for government investigations, reparations, and apologies were met with Congressional hearings. The Henderson Act of 1943 had required that all forms of venereal disease be documented and treated; the U.S. Surgeon General had sent letters of commendation to men enrolled in the study on its twenty-fifth anniversary in 1957; and the study violated the 1964 World Health Organization's Declaration of Helsinki, in which informed consent is required. All of these events pointed to a level of government involvement and neglect that led the National Association for the Advancement of Colored People (NAACP) to file a 1973 class-action lawsuit that resulted in a financial settlement.

President William Jefferson Clinton's apology was part of an effort on the part of the Clinton administration to further correct the omission of an apology from the federal government. In 1997, when President Clinton issued his apology, only 8 of the 399 study participants who had syphilis were still alive.

President William Jefferson Clinton's apology on behalf of the United States of America

The East Room.

2:26 P.M. EDT.

THE PRESIDENT: Ladies and gentlemen, on Sunday, Mr. Shaw will celebrate his 95th birthday. I would like to recognize the other survivors who are here today and their families: Mr. Charlie Pollard is here. Mr. Carter Howard. Mr. Fred Simmons. Mr. Simmons just took his first airplane ride, and he reckons he's about 110 years old, so I think it's time for him to take a chance or two. I'm glad he did. And Mr. Frederick Moss, thank you, sir.

I would also like to ask three family representatives who are here—Sam Doner is represented by his daughter, Gwendolyn Cox. Thank you, Gwendolyn. Ernest Hendon, who is watching in Tuskegee, is represented by his brother, North Hendon. Thank you, sir, for being here. And George Key is represented by his grandson, Christopher Monroe. Thank you, Chris.

I also acknowledge the families, community leaders, teachers and students watching today by satellite from Tuskegee. The White House is the people's house; we are glad to have all of you here today. I thank Dr. David Satcher for his role in this. I thank Congresswoman Waters and Congressman Hilliard, Congressman Stokes, the entire Congressional Black Caucus. Dr. Satcher, members of the Cabinet who are here, Secretary Herman, Secretary Slater, members of the Cabinet who are here, Secretary Herman, Secretary Slater. A great friend of freedom, Fred Gray, thank you for fighting this long battle all these long years.

The eight men who are survivors of the syphilis study at Tuskegee are a living link to a time not so very long ago that many Americans would prefer not to remember, but we dare not forget. It was a time when our nation failed to live up to its ideals, when our nation broke the trust with our people that is the very foundation of our democracy. It is not only in remembering that shameful past that we can make amends and repair our nation, but it is in remembering that past that we can build a better present and a better future. And without remembering it, we cannot make amends and we cannot go forward.

So today America does remember the hundreds of men used in research without their knowledge and consent. We remember them and their family members. Men who were poor and African American, without resources and with few alternatives, they belived they had found hope when they were offered free medical care by the United States Public Health Service.

They were betrayed.

Medical people are supposed to help when we need care but even once a cure was discovered, they were denied help, and they were lied to by their government. Our government is supposed to protect the rights of its citizens; their rights were trampled upon. Forty years, hundreds of men betrayed, along with their wives and children, along with the community in Macon County, Alabama, the City of Tuskegee, the fine university there, and the larger African American community.

The United States government did something that was wrong—deeply, profoundly, morally wrong. It was an outrage to our commitment to integrity and equality for all our citizens.

To the survivors, to the wives and family members, the children and the grandchildren, I say what you know: No power on Earth can give you back the lives lost, the pain suffered, the years of internal torment and anguish. What was done cannot be undone. But we can end the silence. We can stop turning our heads away. We can look at you in the eye and finally say on behalf of the American people, what the United States government did was shameful, and I am sorry.

The American people are sorry—for the loss, for the years of hurt. You did nothing wrong, but you were grievously wronged. I apologize and I am sorry that this apology has been so long in coming.

To Macon County, to Tuskegee, to the doctors who have been wrongly associated with the events there, you have our apology, as well. To our African American citizens, I am sorry that your federal government orchestrated a study so clearly racist. That can never be allowed to happen again. It is against everything our country stands for and what we must stand against is what it was.

So let us resolve to hold forever in our hearts and minds the memory of a time not long ago in Macon County, Alabama, so that we can always see how adrift we can become when the rights of any citizens are neglected, ignored and betrayed. And let us resolve here and now to move forward together.

The legacy of the study at Tuskegee has reached far and deep, in ways that hurt our progress and divide our nation. We cannot be one America when a whole segment of our nation has no trust in America. An apology is the first step, and we take it with a commitment to rebuild that broken trust. We can begin by making sure there is never again another episode like this one. We need to do more to ensure that medical research practices are sound and ethical, and that researchers work more closely with communities.

Today I would like to announce several steps to help us achieve these goals. First, we will help to build that lasting memorial at Tuskegee. (Applause.) The school founded by Booker T. Washington, distinguished by the renowned scientist George Washington Carver and so many others who advanced the health and well-being of African Americans and all Americans, is a fitting site. The Department of Health and Human Services will award a planning grant so the school can pursue establishing a center for bioethics in research and health care. The center will serve as a museum of the study and support efforts to address its legacy and strengthen bioethics training.

Second, we commit to increase our community involvement so that we may begin restoring lost trust. The study at Tuskegee served to sow distrust of our medical institutions, especially where research is involved. Since the study was halted, abuses have been checked by making informed consent and local review mandatory in federally-funded and mandated research.

Still, 25 years later, many medical studies have little African American participation and African American organ donors are few. This impedes efforts to conduct promising research and to provide the best health care to all our people, including African Americans. So today, I'm directing the Secretary of Health and Human Services, Donna Shalala, to issue a report in 180 days about how we can best involve communities, especially minority communities, in research and health care. You must—every American group must be involved in medical research in ways that are positive. We have put the curse behind us; now we must bring the benefits to all Americans.

Third, we commit to strengthen researchers’ training in bioethics. We are constantly working on making breakthroughs in protecting the health of our people and in vanquishing diseases. But all our people must be assured that their rights and dignity will be respected as new drugs, treatments and therapies are tested and used. So I am directing Secretary Shalala to work in partnership with higher education to prepare training materials for medical researchers. They will be available in a year. They will help researchers build on core ethical principles of respect for individuals, justice and informed consent, and advise them on how to use these principles effectively in diverse populations.

Fourth, to increase and broaden our understanding of ethical issues and clinical research, we commit to providing postgraduate fellowships to train bioethicists especially among African Americans and other minority groups. HHS will offer these fellowships beginning in September of 1998 to promising students enrolled in bioethics graduate programs.

And, finally, by executive order I am also today extending the charter of the National Bioethics Advisory Commission to October of 1999. The need for this commission is clear. We must be able to call on the thoughtful, collective wisdom of experts and community representatives to find ways to further strengthen our protections for subjects in human research.

We face a challenge in our time. Science and technology are rapidly changing our lives with the promise of making us much healthier, much more productive and more prosperous. But with these changes we must work harder to see that as we advance we don't leave behind our conscience. No ground is gained and, indeed, much is lost if we lose our moral bearings in the name of progress.

The people who ran the study at Tuskegee diminished the stature of man by abandoning the most basic ethical precepts. They forgot their pledge to heal and repair. They had the power to heal the survivors and all the others and they did not. Today, all we can do is apologize. But you have the power, for only you—Mr. Shaw, the others who are here, the family members who are with us in Tuskegee—only you have the power to forgive. Your presence here shows us that you have chosen a better path than your government did so long ago. You have not withheld the power to forgive. I hope today and tomorrow every American will remember your lesson and live by it.

Thank you, and God bless you.

CLINTON, WILLIAM J. APOLOGY FOR STUDY DONE IN TUSKEGEE. WHITE HOUSE OFFICE OF PRESS SECRETARY,1997.

See AlsoSexually Transmitted Diseases.

BIBLIOGRAPHY

Books

Adler, Michael, et al. ABC of Sexually Transmitted Diseases. London: BMJ, 2004.

Web Sites

Centers for Disease Control and Prevention (CDC). “Trends in reportable sexually transmitted diseases in the United States, 2005.” December 2006 <http://www.cdc.gov/std/stats/trends2005.htm#trendssyphilis> (accessed May 1, 2007).

World Health Organization. “Sexually Transmitted Infections.” <http://www.who.int/reproductive-health/stis/docs/sti_factsheet_2004.pdf> (accessed May 1, 2007).

Susan Aldridge

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Syphilis

SYPHILIS

syphilis in nineteenth-century europe
toward a new regulation of syphilis
bibliography

As is the case with many diseases that afflicted (and continue to afflict) European populations, the early names of syphilis reflected contemporary understandings of the origins of the disease. The disease has been traced back to French military campaigns in Italian lands, and more specifically to the Neapolitan excursions of Charles VIII (r. 1483–1498) in 1495. The subsequent demobilization of mercenaries facilitated the rapid spread of the disease throughout Europe. Dynastic loyalties influenced whether one referred to it as the "French" or "Neapolitan" disease. In the early sixteenth century a controversy arose as to whether the introduction of syphilis in Europe should be regarded as one of the major consequences of the Spanish conquest of the Americas; thus, occasionally, it was described as the "American" disease. Still others referred to syphilis simply as the "pox," conjuring up the physical manifestations of the disease that began on the genitals and that eventually spread over the entire body.

No matter how they named it, syphilis inspired fear and dread among sixteenth-century Europeans. They considered it worse than leprosy and the plague. Although they understood the link between sexual activity and infection, and developed therapies (a combination of mercury and the wood extract guaiac, applied either as an ointment or through friction) aimed at alleviating symptoms, Europeans often resorted to draconian measures. The city of Paris forbade the treatment of syphilis at the centrally located Hôtel Dieu; the stricken homeless population was driven out of Paris, and the poor were placed in barns located in outlying areas of the city. After the initial and rapid spread of syphilis in sixteenth-century Europe, rates of infection appear to have abated, which may account (in part) for a waning interest in the disease among medical authorities until the end of the eighteenth century. In this space created by medical neglect, charlatans and quacks arrived with their various remedies, eagerly embraced by Europeans searching for a quick and effective cure.

syphilis in nineteenth-century europe

More surprising is the notable absence of syphilis in the medical advances that characterized nineteenth-century Europe. Apart from the important work of Philippe Ricord (1800–1889), who distinguished gonorrhea from syphilis, few doctors placed syphilis at the center of their research, and medical curricula largely ignored it. By contrast, syphilis figured prominently in a European social imagination—a veritable "bourgeois obsession"—that gave expression to a growing anxiety about the vexed relationship between individual liberty and social order. That obsession drew upon purported links between sex, prostitution, and the spread of syphilis. The prostitute, who lived outside the regulated contexts of marriage and family, and who separated sexual pleasure from the social functions of procreation, was seen as exercising an excessive and dangerous freedom. She lured unsuspecting single men away from the strictures of duty, risked the fortunes amassed by married men, and in doing so threatened the very institutions and values of society. In ways both figurative and material, syphilis embodied these dangers posed by the prostitute. It was she who spread the disease to unsuspecting men, in turn threatening the lives of innocent fiancées, moral wives and mothers, and future unborn generations.

The social imaginary of syphilis developed most precociously in France. Its influence was felt afar, made evident in the international recognition accorded to the work of the French social observer and hygienist Alexandre Parent-Duchâtelet (1790–1836). In his 1836 study De la prostitution dans la ville de Paris Parent-Duchâtelet set out in excruciating (although far from convincing) detail the characteristics of prostitutes that defined them a "race apart" and a veritable "counter society": their distaste for work, their love of luxury, and their unfortunate family origins. He also described the peculiar regulation of prostitution adopted by French authorities. Recognizing the limitations of recourse to individual liberty or legislative pronouncement as effective strategies for addressing the problems posed by individual freedom, the French devised an extralegal regulatory system drawing on the cooperation of police and doctors. Prostitutes associated with "tolerated" houses were subject to weekly brothel medical examinations for syphilis. If infected, they were sent to Saint-Lazare, an institution that served as a prison and a hospital, and which combined curing and physical as well as moral discipline in the "treatment" of prostitutes supposedly suffering from syphilis. Prostitutes who were registered with the police authorities but who worked independently of tolerated houses were required to seek out the services of municipal dispensaries; they carried a card detailing their medical histories, while medical information pertaining to women associated with the tolerated houses was maintained by the brothel-keeper.

The British dealt with the problem of the relationship between syphilis and prostitution in slightly different ways. Defending (and defensive of) their time-honored commitment to individual liberty, British officials and social observers deplored the French toleration of brothels, which in their view recognized prostitution and thus perpetuated (rather than prevented) the demoralization of women. They also criticized the association of dispensaries and hospitals with prisons, because (in their view) it addressed the social problems involved in the spread of syphilis at the expense of depriving women of their civil rights. But prostitutes had been treated in British "lock hospitals" since the 1770s, and new hospitals were created during the first three decades of the nineteenth century. Like their French counterparts, these hospitals confined prostitutes to specific sections, restricted their mobility and access to visitors, required them to stay until "cured" or at least until no longer contagious, and wedded medical care to disciplinary and moralizing activities. Between 1864 and 1869 the government passed three Contagious Diseases Acts. Originally designed as exceptional legislation to deal with the problem of syphilis affecting soldiers in military districts in England and Ireland, the purview of the Acts was soon after extended to other areas. A rigorous and coercive regulation of syphilis in British colonial territories such as India and Hong Kong predated the passage of the CD Acts and persisted long after their repeal in the 1870s and 1880s. In those territories, the social anxieties conjured up by the interrelated problems of syphilis and prostitution dealt, above all, with the colonial prostitute and the threat she posed to the British soldier, settler, and "race."

toward a new regulation of syphilis

The repeal of the CD Acts in England between 1870 and 1886 reflected the influence of the protest mounted against the regulation of prostitution and syphilis there by moral and Christian reformers such as Josephine Butler (1828–1906). Butler's criticisms gained attention in France as well, although French interest in reform was due in large part to the Republican ascendancy beginning in the 1870s and 1880s. French politicians, doctors, and social observers focused on the problem of regulating syphilis and prostitution as part of a larger criticism of the abuses perpetuated by the authoritarian Second Empire. They debated the relative merits of two alternatives: abolishing regulation altogether, and replacing it with new, more individualistic initiatives aimed at moral education and the promotion of early marriage, or elaborating a "neoregulationism" devoid of the abusive intrusions of police authority and carefully restricted to the medical question of diagnosing and treating syphilis. Neoregulationism emerged victorious.

The French medical community supported the alternative of neoregulationism. Indeed, that alternative owed much to the enhanced status of syphilis in French medicine at the end of the nineteenth century: the recognition of syphilology as a medical specialty and its inclusion in departments of dermatology, advances in understanding the different stages of syphilis and its connection to general paralysis, the "humanization" of syphilis treatment through its integration into general hospital care, and the creation of national leagues and international studies devoted to the problem of the disease. Many of these accomplishments became associated with the work of Alfred-Jean Fournier, "the new pope of syphilography." For all of Fournier's scientific preoccupation with syphilis, however,


his work and the efforts of other neoregulationists more generally betray a deep reservoir of social anxiety that shaped the contours of interest in syphilis in fin-de-siècle France.

Fournier's articulation of the venereal peril was informed by an entirely new configuration of social concerns at the turn of the century, most importantly the influence of social Darwinism, worries about declining birth rates, and growing fears about the degeneration of the French "race." In the face of these threats, the specter of syphilis loomed even larger than it had in the 1830s and 1840s. Failing to distinguish between the possibility of hereditary and congenital syphilis, Fournier highlighted the deleterious consequences for babies born of sexual relations between prostitutes and their unsuspecting clients. Of more serious import, Fournier did not limit the effects of syphilis to sexual activity. Glassblowing, tattooing, and improperly cleaned medical instruments all provided conduits for the non-venereal transmission of syphilis, although both forms of the diseases contributed to the "peril." (The Russian venereologist Veniamin Tarnovsky [1839–1906] likewise distinguished between venereal and non-venereal syphilis, but in this case the distinction appears to have emphasized the dangers of illicit sexual relations—and social relations more generally—that characterized the industrial and urban centers of liberalizing Imperial Russia.) Despite their avowed commitment to reducing the role of police in the regulation of syphilis, Fournier and other neoregulationists retained their focus on the social threats posed by prostitutes, now with a new (and perhaps more insidious) twist: the objective was no longer to protect society by excluding or marginalizing the prostitute, but rather to "normalize" her, with the support of medical knowledge and according to the needs and dictates of society.

The twentieth century set the stage for many of the discoveries that we now associate with the scientific diagnosis and treatment of syphilis: the identification of its cause (Treponema pallidum) by Erich Hoffmann and Fritz Schaudinn in 1905, the recognition of the diagnostic value of the Wassermann Test in 1906, and the introduction of penicillin in the 1950s. The benefits of these discoveries notwithstanding, an understanding of the problem of syphilis has continued to be refracted through the prism of social issues. Vichy France linked syphilis to the problem of Jews and "aliens"; in the early twenty-first century, syphilis conjures up the dangers of international tourism and promiscuity. In this regard, syphilis offers a telling instance of the difficulty encountered in separating the scientific understanding of disease from the elaboration of social values. As such, syphilis also represents the important and enduring role for historical scholarship in understanding the contours of disease and societal responses to it.

See alsoButler, Josephine; Prostitution; Public Health; Science and Technology; Sexuality.

bibliography

Aisenberg, Andrew. "Syphilis and Prostitution: A Regulatory Couplet in Nineteenth-Century France." In Sex, Sin, and Suffering: Venereal Disease and European Society, since 1870, edited by Roger Davidson and Lesley A. Hall, 15–28. London and New York, 2001.

Corbin, Alain. Women for Hire: Prostitution and Sexuality in France after 1850. Translated by Alan Sheridan. Cambridge, Mass., 1990.

Engelstein, Laura. The Keys to Happiness: Sex and the Search for Modernity in Fin-de-Siècle Russia. Ithaca, N.Y., 1992.

Levine, Philippa. Prostitution, Race, and Politics: Policing Venereal Disease in the British Empire. New York, 2003.

Quétel, Claude. The History of Syphilis. Translated by Judith Braddock and Brian Pike. Baltimore, Md., 1990.

Walkowitz, Judith R. Prostitution and Victorian Society: Women, Class, and the State. Cambridge, U.K., and New York, 1980.

Andrew Aisenberg

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