Syphilis. Overview. Clinical classification. Stages of syphilis
Primary syphilis - clinical features of the chancre, diagnostic approach, typical and unusual
ulcus primaria, complications, differential diagnosis.
Secondary syphilis. Clinical features, variations, mucosal lesions, other systemic changes,
diagnostic approach, tyreatment.
Congenital syphilis. Symptoms of early and late congenital syphilis. Serology. Stigmata
Serologic test for syphilis in screening, diagnosis and follow-up.
Maintenance of serological test in untreated syphilis.
Biologically false-positive serological tests during the diagnosis of syphilis.
- Syphilis “Lues” – chronic infection by Treponema pallidum. Early stages are primarily
cutaneous & mucocutaneous, after decades, untreated
syphilis affects CV & CNS.
- Overview:
▪ Pathogenesis: spirochete Treponema pallidum transmission
is by close tissue contact with entry thg minor injury points.
- Clinical classification:
▪ Early syphilis – manifestations & latent period, first 1 year
▪ Primary syphilis – 3-8w after infection, inflammation in inoculation site & regional
LNs
▪ Secondary syphilis – 9w after infection, bacteraemia, generalized exanthem,
systemic signs, antibodies production.
▪ Latent syphilis – symptom-free period (only recognized by serology). OBS do not
confuse latent syphilis with (+) seroreactions
▪ Late syphilis – after 1 year from infection. Granulomatous inflammation & marked cell
response, in skin, bones, CV & CNS (Tertiary, Quaternary & Latent Syphilis (-) seroneg)
▪ Congenital syphilis “Syphilis connata” – after transplacental transmission of Trep.
Pallidum
- Primary Syphilis
▪ Clinical manifestations:
▪ Dark red nodule at entry site 3w after contact, becomes eroded & ulcerated.
▪ Typical Chancre “Ulcus durum” – firm 1cm, circumscribed ulcer, base is ham-colored
& periphery is more red. On palpation, firm (like small coin). Heals spontaneously ∼ 3-
8w. Painless (OBS ulcer in syphilis is painless, other ulcers are painful)
▪ OBS any location is possible, generally asymptomatic. Sometimes mixed infections.
◦ Men: prepuce, glans, sulcus, shaft (perianal or rectum in gay)
◦ Women: vagina or cervix, labia, clitoris, posterior commissure, perianal or rectum
◦ Extragenital: lips, tongue, palate, finger
▪ Atypical primary chancre: pleural/copy/twin, abortive, huge, syphilis
balanitis, syphilitic vulvovaginitis, gangrenous, coexisting with HSV…
▪ Regional lymphadenopathy – ∼ 1-2w after chancre, unilateral, nontender
▪ Diagnostic approaches: darkfield microscopy, serology (FTA-IgM ∼ 2w)
▪ Differential diagnosis: HSV2, traumatic ulcers, chancroid (H. Ducreyi),
lymphogranuloma venereum (Chlamydia), erythroplasia of Queyrat
, - Secondary Syphilis – early eruptions (9-16w) & recurrence eruptions (16w-1y)
▪ Clinical manifestations: many exanthems & enanthems possible (“great imitator”).
Rashes are known as “syphilids”. OBS rashes of secondary syphilis do not itch & are
rarely bullous, anything else is possible.
▪ Macular syphilid – most common* finding. Pale irregular pink macules “syphilic
roseola” on side of chest, later spreading to trunk, palms & soles with typical red-
brown color. Variations:
◦ Papular syphilid – firm red-brown papule. Multiple small papules “lenticular
syphilid”
◦ Annular “circinate” syphilid – spread of papules with central clearing & peripheral
growth
◦ Corymbose syphilid – many small papules surrounding single large lesion
◦ Corona venerea “Venus crown”– papules along anterior hair line
◦ Palmoplantar syphilid – papules on palms & soles with red-brown color & scale
“clavi syphilitici”. OBS always suspect syphilis
when confronted with acute palmoplantar rash.
◦ Lichen syphiliticus – tiny follicular papules
(resemble milia), rare.
◦ Malignant syphilid (ulcerated) or rupial syphilis
(crusted) – larger lesions in HIV
◦ Syphilitic leukoderma “Necklace of Venus” – any
secondary lesion can heal with hypopigmentation.
On nape
◦ Condyloma lata – eroded genital papules,
teeming with spirochetes
◦ Syphilitic “Motch-eaten alopecia” – ⬆ typical
moth-eaten hair loss in scalp
▪ Mucosal changes:
◦ Mucous plaques – small papules on oral mucosa, become eroded
◦ Opaline plaques – later stage with glossy gray membranous cover
◦ Plaques fouée – dark red plaques on tongue
◦ Syphilitic angina – tonsils involvement with swelling & dusky erythema, unilateral.
▪ Other systemic changes:
◦ Generalized lymphadenopathy – painless firm lymphadenopathy in antecubital,
axillary, nuchal, preauricular nodes. Most regular* feature. “Syphilitic handshake”
(“father-in-law check”) doctor slides hand up pt’s arm to palpate pts antecubital
nodes
◦ Acute hepatitis
◦ Acute Glomerulonephritis with Ig deposition
◦ Splenomegaly
◦ Meningitis or meningoencephalitis
▪ Musculoskeletal
◦ Periostitis – tibia, sternum, clavicle. Pain worse at night
◦ Polyarthritis
◦ Tenosynovitis
▪ Diagnostic approaches: serology (100%), dark field of eroded
lesions (not very accurate due to false negative results)
▪ Prognosis: even without treatment, all lesions resolve
Primary syphilis - clinical features of the chancre, diagnostic approach, typical and unusual
ulcus primaria, complications, differential diagnosis.
Secondary syphilis. Clinical features, variations, mucosal lesions, other systemic changes,
diagnostic approach, tyreatment.
Congenital syphilis. Symptoms of early and late congenital syphilis. Serology. Stigmata
Serologic test for syphilis in screening, diagnosis and follow-up.
Maintenance of serological test in untreated syphilis.
Biologically false-positive serological tests during the diagnosis of syphilis.
- Syphilis “Lues” – chronic infection by Treponema pallidum. Early stages are primarily
cutaneous & mucocutaneous, after decades, untreated
syphilis affects CV & CNS.
- Overview:
▪ Pathogenesis: spirochete Treponema pallidum transmission
is by close tissue contact with entry thg minor injury points.
- Clinical classification:
▪ Early syphilis – manifestations & latent period, first 1 year
▪ Primary syphilis – 3-8w after infection, inflammation in inoculation site & regional
LNs
▪ Secondary syphilis – 9w after infection, bacteraemia, generalized exanthem,
systemic signs, antibodies production.
▪ Latent syphilis – symptom-free period (only recognized by serology). OBS do not
confuse latent syphilis with (+) seroreactions
▪ Late syphilis – after 1 year from infection. Granulomatous inflammation & marked cell
response, in skin, bones, CV & CNS (Tertiary, Quaternary & Latent Syphilis (-) seroneg)
▪ Congenital syphilis “Syphilis connata” – after transplacental transmission of Trep.
Pallidum
- Primary Syphilis
▪ Clinical manifestations:
▪ Dark red nodule at entry site 3w after contact, becomes eroded & ulcerated.
▪ Typical Chancre “Ulcus durum” – firm 1cm, circumscribed ulcer, base is ham-colored
& periphery is more red. On palpation, firm (like small coin). Heals spontaneously ∼ 3-
8w. Painless (OBS ulcer in syphilis is painless, other ulcers are painful)
▪ OBS any location is possible, generally asymptomatic. Sometimes mixed infections.
◦ Men: prepuce, glans, sulcus, shaft (perianal or rectum in gay)
◦ Women: vagina or cervix, labia, clitoris, posterior commissure, perianal or rectum
◦ Extragenital: lips, tongue, palate, finger
▪ Atypical primary chancre: pleural/copy/twin, abortive, huge, syphilis
balanitis, syphilitic vulvovaginitis, gangrenous, coexisting with HSV…
▪ Regional lymphadenopathy – ∼ 1-2w after chancre, unilateral, nontender
▪ Diagnostic approaches: darkfield microscopy, serology (FTA-IgM ∼ 2w)
▪ Differential diagnosis: HSV2, traumatic ulcers, chancroid (H. Ducreyi),
lymphogranuloma venereum (Chlamydia), erythroplasia of Queyrat
, - Secondary Syphilis – early eruptions (9-16w) & recurrence eruptions (16w-1y)
▪ Clinical manifestations: many exanthems & enanthems possible (“great imitator”).
Rashes are known as “syphilids”. OBS rashes of secondary syphilis do not itch & are
rarely bullous, anything else is possible.
▪ Macular syphilid – most common* finding. Pale irregular pink macules “syphilic
roseola” on side of chest, later spreading to trunk, palms & soles with typical red-
brown color. Variations:
◦ Papular syphilid – firm red-brown papule. Multiple small papules “lenticular
syphilid”
◦ Annular “circinate” syphilid – spread of papules with central clearing & peripheral
growth
◦ Corymbose syphilid – many small papules surrounding single large lesion
◦ Corona venerea “Venus crown”– papules along anterior hair line
◦ Palmoplantar syphilid – papules on palms & soles with red-brown color & scale
“clavi syphilitici”. OBS always suspect syphilis
when confronted with acute palmoplantar rash.
◦ Lichen syphiliticus – tiny follicular papules
(resemble milia), rare.
◦ Malignant syphilid (ulcerated) or rupial syphilis
(crusted) – larger lesions in HIV
◦ Syphilitic leukoderma “Necklace of Venus” – any
secondary lesion can heal with hypopigmentation.
On nape
◦ Condyloma lata – eroded genital papules,
teeming with spirochetes
◦ Syphilitic “Motch-eaten alopecia” – ⬆ typical
moth-eaten hair loss in scalp
▪ Mucosal changes:
◦ Mucous plaques – small papules on oral mucosa, become eroded
◦ Opaline plaques – later stage with glossy gray membranous cover
◦ Plaques fouée – dark red plaques on tongue
◦ Syphilitic angina – tonsils involvement with swelling & dusky erythema, unilateral.
▪ Other systemic changes:
◦ Generalized lymphadenopathy – painless firm lymphadenopathy in antecubital,
axillary, nuchal, preauricular nodes. Most regular* feature. “Syphilitic handshake”
(“father-in-law check”) doctor slides hand up pt’s arm to palpate pts antecubital
nodes
◦ Acute hepatitis
◦ Acute Glomerulonephritis with Ig deposition
◦ Splenomegaly
◦ Meningitis or meningoencephalitis
▪ Musculoskeletal
◦ Periostitis – tibia, sternum, clavicle. Pain worse at night
◦ Polyarthritis
◦ Tenosynovitis
▪ Diagnostic approaches: serology (100%), dark field of eroded
lesions (not very accurate due to false negative results)
▪ Prognosis: even without treatment, all lesions resolve
