Syphilis: Symptoms, Transmission

Syphilis (lues venerea) is one of the most well-known venereal diseases. It is also sometimes called the disease of the famous, as it was suffered by famous rulers, painters, artists or noblemen.

While in the past the disease had a very acute form and a rapid course, today it is rather chronic with multiple phases.

Syphilis is a sexually transmitted disease caused by the bacteria Treponema pallidum. It can be reinfected as it does not leave lifelong immunity.

The incubation time of the disease (the time from the entry of the infectious agent into the body to the appearance of the first symptoms) is usually 3 weeks (between 9-90 days).

The period of contagiousness lasts during the 1st and 2nd stages of the disease, in untreated syphilis it can be as long as 2-4 years.

The disease is transmitted from person to person:

• via saliva,
• via ejaculate (semen),
• via vaginal discharge,
• via blood,
• via skin disease.

How does syphilis arise? What is its mechanism of occurrence?

1. The syphilis bacterium enters the body through the skin or mucous membranes, through minor injuries.
2. It travels to the nearest lymph nodes and spreads further through the blood, damaging the blood vessels themselves.
3. If left untreated, the bacteria also move outside the bloodstream, most commonly to the skin, bones and, in the final stages, the nervous system.

Specific risk factors:

• Promiscuous behaviour (frequent changing of sexual partners).
• Failure to adhere to safer sex principles, i.e. not using barrier contraception (condom).
• Contaminated (dirty) objects used by the syphilis patient at the time when the bacterium is excreted from his/her body (toothbrush, cutlery, crockery, towels, clothes ...).
• Low level of hygiene in the household where the sick person lives.
• From an infected mother to the fetus during pregnancy (congenital syphilis).

Syphilis occurs in the form of acquired or congenital. Acquired syphilis is further divided into early and late.

Early syphilis (according to the World Health Organization - WHO it is syphilis acquired less than 2 years ago) includes:

• primary syphilis
• secondary (secondary, subsequent) syphilis
• early latent (hidden) syphilis

Late syphilis (according to the WHO, syphilis acquired more than 2 years ago) includes:

• late latent (hidden) syphilis
• tertiary (gum syphilis, cardiovascular and neurosyphilis).

Congenital syphilis (syphilis congenita)

Congenital syphilis can be passed from mother to fetus during pregnancy if the infected woman refuses to be treated. Such babies have severely damaged hearts, brains and eyes. A quarter of infected babies are stillborn or die shortly after birth.

As a result of prevention from fetal problems, a blood test for the presence of syphilis in the body is usually performed on each pregnant woman.

Most often, the transmission itself occurs between the 2nd and 5th month of pregnancy.

It is proven that a syphilitic child can only be born from a syphilitic mother. The father's infection is not decisive in terms of possible transmission to the fetus.

The damage to the fetus or the baby depends largely on what stage of the disease the mother was in during pregnancy. Transmission can occur at any time during gestation, although the risk of infection is likely to increase with the length of pregnancy.

The earlier in the pregnancy the fetus comes into contact with the infection, the higher the risk of damage to the fetus. In the early stages of the mother's illness, the likelihood of transmission of infection is highest and the degree of its involvement most severe.

The severity of the manifestations of congenital syphilis is extremely variable and can range from the most severe forms with extensive involvement of many organ systems to minimal laboratory or radiological abnormalities in otherwise asymptomatic newborns.

The fate of the fetus and the baby also depends on whether the mother was sufficiently treated during pregnancy.

According to the activity of the mother's disease may occur:

• abortion/miscarriage
• premature birth
• stillbirth
• live birth of a newborn with active syphilis
• giving birth to an apparently healthy baby
• giving birth to a healthy baby without syphilis.

Transmission to the fetus occurs most commonly transplacentally after the 16th week to the 20th week of intrauterine life.

Transplacental (transmission through the placenta) transmission is the most common, while intrapartum transmission is rare and only occurs if the mother is infected in the late weeks of pregnancy or just before delivery.

Such syphilis in a child is not congenital, but acquired and proceeds as acquired syphilis. The fetus does not have a sufficiently functionally mature immune system.

Treponemes multiply in the body and cause in the body:

• inflammation,
• abscess,
• necrosis,
• toxic damage to the organs of the developing fetus, again causing disturbances in overall development and abnormalities in the formation of the growing organs.

This also damages the baby gland - the thymus (located behind the sternum), therefore the immune system is permanently damaged.

As a consequence of the above-mentioned processes and a characteristic feature of congenital syphilis in the postnatal periods, three types of changes may occur, viz:

• non-specific changes − similar to secondary manifestations of syphilis
• specific manifestations − similar to tertiary syphilis
• stigmas − permanent damage and developmental anomalies.

Fetal syphilis (prenatal syphilis)

Starting from the 16th week of intrauterine life, when treponemes cross the placenta, fetal syphilis is often the cause of premature births and stillbirths in the sixth and seventh months of pregnancy, although the placenta is already passable for treponemes earlier.

Tissue treponemes are the causative agents of massive disseminated (scattered) infections in tissues; they are also found in the umbilical cord and placenta.

Typical manifestations are:

• infiltration of organs (penetration of foreign elements),
• fetal maceration (shedding of fetal skin in utero),
• syphilitic osteochondritis (inflammation of bone and cartilage at the same time),
• hepatitis (viral inflammation of the liver),
• pneumonia alba (pneumonia typical of syphilis),
• miliary abscesses (multiple foci - cavities bordered by a membrane and filled with pus) and
• bounded infiltrates.

Children with congenital (inborn) syphilis:

• are born prematurely,
• are dehydrated,
• have a low birth weight,
• the skin has an aged look,
• yellowish coloration.
• have so-called syphilitic wheals - more extensive infiltrates of light red with a smooth shiny surface of varying intensity and are one of the decisive manifestations,
• infiltrates around the mouth and scar formation as permanent stigmata - Parrot's furrows and scars

Late congenital syphilis is characterized by typical stigmata (signs) after the second year of the child's life:

Hutchinson Triad

• tooth decay – Typical barrel-shaped incisors with incisal surfaces, crescentic wear, excavated, separated by a slit, Moon's bumps on molars, discoloration of teeth.
• interstitial keratitis to blindness
• deafness

On the basis of the above disorders, the typical habitus in late congenital syphilis may be described as follows: the patients are conspicuous by retarded stature, absence of secondary sexual characteristics.

The forehead is raised with prominent lateral bumps (Olympic forehead). Hydrocephalus of moderate degree is indicated, irregularities of the cranial bones result in skull deformities (articulated skull).

Acquired syphilis

Probably the most well-known symptom of syphilis is a hard ulcer, and this is at the point of entry of the infection. After some time, however, the disease spreads to the whole body, so that the rash appears on the mucous membranes in the mouth, but also on the skin.

The early phase of the disease is later replaced by an asymptomatic period, leading to the mistaken belief that the disease has passed.

If left untreated, syphilis will spread gradually to all parts of the body, so that it becomes a systemic disease. It attacks not only the skin and mucous membranes, but also the heart, bones, brain and spinal cord.

In the last stage, it will go into progressive paralysis, which will also affect mental health.

Syphilis has 4 stages:

Stage 1: The primary stage occurs on average within 3 weeks of infection and is characterised by the appearance of a hard ulcer at the site of entry.

Most often, this ulcer appears on the genitals or in the oral cavity, either on the mucous membrane or on the lips. Later, there is also redness and painless swelling of the lymph nodes.

Stage 2: After a while, the hard ulcer disappears and the second stage comes, which can appear within about two years from the first symptoms.

The infection spreads through the bloodstream into the body, ulcers appear on the skin, sometimes red, sometimes covered with scales. Later, there is loss of facial hair, especially eyebrows and, in men, beards.

Stage 3: This stage is called non-infectious and can occur after several years. 

During this phase, there are manifestations on the skin in the form of various bumps, neurological manifestations are associated, chronic inflammations and infections of the kidneys, musculoskeletal system, eyes, liver, and especially the brain and central nervous system begin to arise.

Stage 4: The last fourth stage can occur in untreated disease within 10 to 20 years; it is very individual for each person.

At this stage, degenerative changes in the nervous system and brain, paralysis, disappearance of reflexes and later mental problems at the level of dementia occur. Towards the end of this stage, death occurs.

Table: places of occurrence and manifestations of the disease.

4. In the final stage of syphilis, a person goes blind, loses all reflexes, suffers from leakage of urine and stool, is completely demented. The disease ends in death.

What makes it easier to spread the disease?

Critical to the prevalence of syphilis in communities is whether risk behaviours that promote the spread of syphilis are practiced once the disease is introduced into the community. 

The spread of the disease accelerates:

• Casual, accidental unprotected sex with a partner (without a condom) whose health and previous sexual behaviour are unknown to us. A person can also become infected through vaginal, anal or oral intercourse.
• Frequent change of sexual partners, prostitution.
• Sex without protection (without a condom). Infection can be contracted through the genitals, anus, mouth.
• Injecting drug use - the administration of drugs using a used needle, syringe or by sharing a drug solution with another person.
• Tattooing or piercing the skin using needles and objects that were not sterile before the skin was injured.

The initial suspicion of syphilis is based on the presence of external manifestations and symptoms. Diagnosis is divided into direct and indirect, in principle, several forms of diagnostic tests and examinations are used.

As an infectious sexually transmitted disease, syphilis is also reportable to government authorities.

The most common procedure:

• medical history – The basis of diagnosis is anamnesis and clinical picture, when the presence of external symptoms, involvement of the cranial nerves or the condition of the pupils is detected.
• serological test – Indirect diagnostics include serological tests, non-treponemal and treponemal tests or the presence of specific IgG substances.
• laboratory tests – As part of the direct diagnosis, microscopic and laboratory examinations as well as direct immunofluorescence antigen detection are performed.
• further examinations – In addition to the aforementioned tests, cerebrospinal fluid examinations, tests to exclude neurosyphilis and TPHA index detection are also performed.

At the first stage, dermatovenerological examinations (examinations of skin and venereal diseases) and microscopic tests of tissue obtained from a hard ulcer, which is one of the typical symptoms, are made.

Further specific tests in the later stages of the disease must be done in highly specialised laboratories.

The tests are time-limited, roughly 4 weeks after infection, in terms of serological and laboratory tests.

Is it possible to take a syphilis test at home?

Yes, the home syphilis test is also sold in our pharmacies
and its approximate price is between 10 and 17 €. 

Testing at home may be an acceptable alternative to having to see a specialist for many people, but it should be said that these tests are only indicative, and a doctor should be sought if symptoms occur.

The home test involves testing a drop of blood into a test cartridge to detect the presence of the body's antibodies to the syphilis bacteria and one or two coloured bands will appear, depending on the type of test.

As such, a negative result does not necessarily rule out infection, given that it takes time for the body to build up sufficient antibodies that can also be detected in the blood.

However, the advantage is the relatively quick detection of a possible infection, because if the test detects antibodies in the blood, it is necessary to go to the doctor.

In some cases, it is better to repeat the test with a certain time interval.

Example:

If the first test does not show the presence of syphilis, but a person observes signs and symptoms on himself anyway. In this case, antibodies may not yet have been formed in the body in sufficient quantities to show up in the blood when the first test is taken.

Is there a prevention of syphilis? How to protect yourself from syphilis?

• The basics are fidelity of sexual partners and adherence to the principles of safe sex, i.e. the use of barrier contraception (condom).
• Dôslednejší výber sexuálnych partnerov.
• All pregnant women must see a gynaecologist during pregnancy and receive treatment if they are found to have syphilis.
• The bacterium causing this disease is sensitive to commonly available disinfectants, which effectively destroy it, so hygiene in the home, the use of disinfectants when cleaning, washing in the home of the sick person is important.

There is NO vaccination (inoculation) against syphilis!

All we've got is PREVENTION!

History of the disease and interesting facts about syphilis

Syphilis, also called lues, came to Europe thanks to the importation of the disease by the crew of Christopher Columbus' ship as early as 1493.

Consequently, it spread massively in the following years, with the disease manifesting itself in disfigurement of the affected person's appearance, and many times in the primary stages, death was already occurring, as the untreated disease attacks virtually the entire organism, most often the skin, bones, heart, brain, and spinal cord.

Sometimes it can also lead to other mental disorders.

The disease was called differently in each part of Europe, for example in Germany it was a syphilitic lesion or rash, France called the disease Neapolitan in the 16th century, after the year 1494, when the French King Charles VIII laid siege to Naples, but had to call off his attack because of the massive spread of syphilis in his army.

This case is also the oldest and first documented case of a syphilis epidemic on our continent, and certainly not the last.

Interestingly, the Poles called syphilis a German disease and the Russians called it a Polish disease, given where the disease came to them from.

The period of the Renaissance, which followed the introduction of syphilis into Europe, was thus directly linked to the disease, and many rulers, artists or other well-known personalities did not escape it.

For example, Francis I, Henry VIII, Ivan IV had syphilis. Terrible, Cardinal Richelieu, Catherine the Great, Peter the Great, and, although it is rumoured, the leader of the Bolshevik Revolution, Lenin, did not die of syphilis, although he too was afflicted with it.