Snapshot A 30-year-old man presents to your clinic with a generalized rash and patchy hair loss. He feels he may be "allergic to something." Drug history is unremarkable. Sexual history reveals patient has regular unprotected sex with both male and female partners. His last unprotected sexual encounter was two months ago. He has been treated for gonorrhoea six months previously. Physical exam reveals a diffuse, erythematous maculopauplar rash on the patient's torso, back, and thighs. On the scalp, there is moth-eaten alopecia. There are also warty growths on the base of the penis, with bilateral inguinal lymphadenopathy. An STD panel was carried out. Dark field microscopy revealed motile spirochetes in one of the warty growths. VDRL and FTA-ABS were positive. Introduction Syphilis has 3 stages (detailed in later sections) the primary and secondary stages are more common incidence has been increasing risk factors include men who have sex with men HIV infection commercial sex workers incarcerated individuals note congenital form is distinct see Syphilis (Pediatric) Primary Syphillis Painless genital ulceration (chancre) appears in 2-10 weeks heals in 3-9 weeks found near area of contact Bilateral inguinal lymphadenopathy Secondary Syphilis Appear 1-3 months after primary infection Presents with low grade fever epitrochlear adenopathy patchy hair loss "moth-eaten" maculopapular rash on palms and soles headache generalized lyphadenopathy condylomata lata (moist lesions on the genitals which are highly infectious) Latent Syphilis No symptoms Positive or negative serology > 1 year of infection 1/3 progress to tertiary syphilis Tertiary Syphilis Findings include aortic aneurysm and aortic regurgitation granulomatous gummas of the CNS, heart and great vessels Argyll-Robertson pupil pathognomonic for tertiary syphilis pupils constrict with accommodation do not constrict to direct light stimulation Evaluation Dark field microscopy identifies motile spirochetes but only on primary or secondary lesions VDRL/RPR is a rapid but nonspecific screening test 60-75% sensitive reverts to negative with treatment 30% of latent or late cases will also revert to negative without treatment FTA-ABS is sensitive and specific and positive for life with infection diagnostic gold standard Differential Infectious (more common) genital herpes simplex chancroid lymphogranuloma venerum Non-infectious sexual trauma fixed drug eruption Behcet syndrome Treatment Benzathine penicillin G may precipitate a Jarisch-Herxheimer reaction an acute febrile reaction within 24 hours after initiation of treatment for a spirochete infection due to release of endotoxin-like substance from dead micro-organisms no preventive therapy is known Latent syphilis is treated with intramuscular pencillin for 3 weeks After treatment, titers should be tested at 3 months (primary and secondary) 6 months (latent or CNS) intervals to document response Give doxycycline/tetracycline in penicilin allergy Pregnant women should be desensitized, then given penicillin Prognosis, Prevention, and Complications Prognosis good if treated early complications of late syphilis can not be cured Prevention avoid sexual contact use of condoms screening of at-risk groups sexual partners of infected patients pregnant women commercial sex workers men who have sex with men Complications seen in tertiary syphilis uncommon with the widespread use of antibiotics and screening tests aortic insufficiency general paresis of the insane tabes dorsalis