The Positive Side

Spring/Summer 2004 

The Story of Syphilis

Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. Left untreated, syphilis is a serious chronic disease.

By Gilles Lambert, Benoît Côté and Elizabeth Lacombe

How is syphilis transmitted?

Infection occurs when the bacteria found in syphilis lesions penetrate a mucous membrane (anus, vagina, penis head, mouth) or a cut in the skin anywhere on the body. The lesions can be very discrete or not visible at all.

Syphilis is spread during sexual activities: oral sex (mainly mouth-penis and also, possibly, mouth-vulva or mouth-anus), penetration (penis-vagina or penis-anus) and, rarely, frottage (rubbing against each other’s naked skin).

A pregnant woman can spread syphilis to her unborn baby, which can cause severe birth defects. In rare cases, syphilis can be spread if contaminated materials are used to inject drugs.

Syphilis is infectious (able to be passed from one person to another) in the first year to two years after infection, unless successfully treated. At some point, it goes into a dormant, or non-infectious, state and is no longer able to be transmitted. The bacteria that cause syphilis can be transmitted even if the infected person has no apparent symptoms.

Signs and symptoms of syphilis

Not all people with syphilis develop symptoms.

Syphilis evolves in 3 stages:

Stage 1 (or “primary” syphilis): One or more lesions (usually painless) appear at the spot where the bacteria entered the body. At first, pimples appear and evolve into ulcers (large lesions causing the loss of the surface layer of the skin or mucous membrane). These ulcers are called syphilitic sores, or chancres. Lesions appear between 9 and 90 days after having sex with an infected partner. In most cases, the lesions are on the penis or vulva, and inside the mouth, vagina or anus. Lesions inside the vagina or anus can easily go unnoticed. These chancres last for 1 to 5 weeks and heal on their own, but the bacteria remain in the body. You are especially infectious when you have a chancre.

To help you distinguish between syphilis and other common STDs: Syphilis sores aren’t usually sensitive (lesions in the mouth, anus or vagina wouldn’t necessarily prevent a person from having sex because of pain) as herpes sores tend to be. Genital warts usually do not form ulcers.

Stage 2 (or “secondary” syphilis): Flu-like symptoms (fatigue, fever, swollen glands, muscle and joint pain) may appear anywhere from 6 weeks to 6 months after the initial infection. An outbreak of rashes may appear on the palms of hands, soles of feet or elsewhere on the body. When the rash is present, you are highly infectious. These symptoms may last from 2 to 6 weeks. As in stage 1, they may disappear on their own, but the bacteria continue to evolve inside the body.

Note: After stage 2 and before stage 3, syphilis goes “latent.” During this time, the amount of syphilis in the blood often drops, but the syphilis still remains in your system. Though you’re generally not infectious at this point, you are at risk for the organ damage that can occur in stage 3.

Stage 3 (or “tertiary” syphilis): If left untreated for years, syphilis can cause serious damage to the heart, brain, bones or skin. It can cause blindness and even death.

Syphilis and HIV

People with syphilis can become infected with HIV more easily.

People with syphilis and HIV transmit the HIV virus more easily.

In some people with HIV/AIDS (PHAs), syphilis can advance to stages 2 and 3 more rapidly and can be more difficult to treat than in HIV negative people.

PHAs, especially those with lower CD4 counts, may need more intense treatment to successfully get rid of syphilis. They also need more rigorous follow-up, as the risk for treatment failure is greater among PHAs than HIV negative people.

PHAs who may have had syphilis for a longer period of time, and/or have a poor treatment response, and/or have very few CD4 cells should have a spinal tap to rule out neurosyphilis (syphilis in the central nervous system). If the test is positive, IV (intravenous) antibiotics are required to successfully get rid of syphilis.

Getting tested

Testing for syphilis requires a blood test. However, it can take from 6 to 12 weeks after the initial infection before a positive result can be obtained. The test must therefore be repeated eventually. Sometimes a sample can be taken from the chancre itself, if present, and examined under a microscope. In some cases, a spinal tap must be performed in order to check for damage to the nervous system.

Screening is recommended for: partners with a known case of syphilis, men who have sex with men, injection drug users, sex trade workers and their clients/partners, pregnant women who may have been exposed, those with sexual contacts in or partners from endemic areas. People who have multiple sex partners should be tested every 3 to 6 months.

Getting treated

Syphilis is treated with antibiotics, usually high-dose penicillin given by IM (inter-muscular) injection. People with advanced syphilis may require IV treatment. The duration of the treatment varies according to the stage of the disease. Penicillin usually doesn’t interfere with anti-HIV drugs and is well tolerated most of the time. Other antibiotics are available for people allergic to penicillin. Once treatment is complete, the person’s blood is monitored to ensure that it worked.

Treatment cures the infection and prevents further damage from occurring, but it can’t repair any damage (stage 3) that’s already been done.

It is possible to contract syphilis more than once.

Sexual partners must also be tested and treated. If the disease is in stage 1, sex partners from the three months before the onset of symptoms should be notified; if in stage 2, sex partners from the previous six to 12 months should be informed; in the case of stage 3 syphilis, only certain long-term partners need to be told. It’s helpful to discuss with a health care professional which specific partners should be notified and how it’ll be done. It can be difficult to tell your sex partners. In most of Canada, a public health STD team is available to help you with notifying your partners.

How to be syphilis-free

Syphilis can be prevented by:

  • using a condom for all sexual activities (including oral sex). Condoms don’t offer complete protection because a syphilis lesion may be in an area not covered by the condom (like at the base of the penis).
  • reducing the number of sexual partners
  • not sharing injection equipment
  • having regular screening tests (including testing early in pregnancy to prevent congenital syphilis in infants)
  • treating people early in the course of the infection
  • ensuring that partners of infected individuals are notified, tested and treated.
Gilles Lambert is a medical officer with the Montreal Public Health Department.
Benoît Côté, MD, is a dermatologist at Hôpital St-Luc in Montreal.
Élizabeth Lacombe is a health promotion agent with the Montreal Public Health Department.
REVIEWED BY EVAN COLLINS, MD.

Image from the "Syphilis Is Back" campaign, sponsored by the AIDS Committee of Ottawa and Pink Triangle Services in partnership with the AIDS Committee of Toronto and Action Séro Zéro. Created and produced by Boomstone Entertainment Inc.

Syphilis Strikes Back

During the past five years, several outbreaks of syphilis have been reported in large urban centres in Canada, the U.S. and Europe. In Canada, rates of contagious-stage syphilis tripled between 1996 and 2002. Here’s a look at syphilis in urban centres across the country:

Montreal: 11 cases declared in 2001, 37 cases in 2002 and 103 in 2003; up to 90% of cases occurred in MSM.

Ottawa: 8 cases declared in 2001 and 16 cases in 2002; 75% of all cases occurred in MSM.

Toronto: 30 cases declared in 2001, 179 cases in 2002, 243 in 2003; the majority of cases occurred in men, 91% of whom had sex with other men.

Vancouver: 127 cases declared in 1999, 186 cases in 2002 and an estimated 250 cases in 2003. Those primarily affected are injection drug users and sex trade workers; during recent months, the outbreak has picked up speed among MSM.

Winnipeg: In early 2003, an outbreak of 15 cases of infectious primary and secondary syphilis occurred in 8 women and 7 heterosexual men aged 30 to 60. Two cases and two of the sexual partners were linked to the sex trade.

In most of these outbreaks, 40% or more of MSM with syphilis were also infected with HIV.

(Source: Recent abstracts and communiqués from the public health authorities of the cities and countries concerned.)