In the 4th phase, or tertiary syphilis, there are usually lesions and changes in the skin, bones, cardiovascular and neurological systems. The condition is severe and, especially when it affects the nervous system, can lead to death.
STD or STD?
Syphilis is an STI, or Sexually Transmitted Infection. Before, the terminology STD (Sexually Transmitted Disease) was used.
Currently, the terminology infection is adopted, as the patient may be a carrier of the infectious agent, and may transmit the infection, but not manifest symptoms (that is, not characterizing a clinically active disease).
Syphilis is triggered by contact with the bacterium Treponema pallidum , which can occur when the healthy person has sexual contact (vaginal, anal or oral) with a patient with the bacterium.
It can also be transmitted to the baby during pregnancy or delivery (called vertical transmission), when the mother is infected.
Discovered in 1905, the bacterium Treponema pallidum looks like a thin spiral (similar to those in a notebook), approximately 8 micrometers in length.
The agent is not very resistant outside the body and, therefore, when it is expelled from the body, it quickly dries out and dies. In addition, in contact with disinfectants, soap and cleaning products, T. pallidum has high sensitivity and survives for a short time.
If it is deposited in damp places or objects, its life is approximately 10 hours.
Having sex without a condom is the most common cause of contagion and transmission of the syphilis bacteria.
Although there has been greater awareness in recent years about the importance of using condoms during sex, the problem still lies in the fact that many people consider sexual contact only when penetration occurs.
This false belief makes oral sex one of the most frequent routes of contamination by syphilis, according to statistics from the Emílio Ribas Institute (reference center for sexually transmitted diseases at Hospital das Clínicas de São Paulo).
Between 2014 and 2015, Brazil experienced an outbreak of infection, in which contagion rates rose by more than 32%.
According to the World Health Organization (WHO), the most common forms of syphilis transmission are unprotected sex (including any sexual act, even without penetration) and vertical transmission (at birth or during pregnancy, between mother and baby) .
Contagion is favored in the early stages of infection. That is, the longer the person has the infection, the less the chances of transmitting it.
In addition to unprotected sexual contact, the bacteria can infect the healthy person through minor injuries, wounds or cuts in the oral cavity.
Therefore, every sexual relationship needs the use of male or female condoms, even if penetration does not occur .
It is also possible that the patient has been infected with syphilis through blood transfusion or organ transplantation. These cases are quite rare, as soon as blood and organs are previously evaluated and analyzed.
Transmission cases due to contact with fluids in the environment, shared syringes and kissing (if there are sores or microlesions in the mouth) can also occur. However, they are less common, since the bacterium does not survive for a long time in these conditions.
It is worth remembering that syphilis is a non-immunizing disease, that is, even those who have already contracted the bacteria can be infected again.
According to the 2017 Ministry of Health bulletin on syphilis, Brazil has experienced a steady and significant increase in cases of the disease in the past 5 years.
The higher incidence of congenital and acquired cases is attributed to factors such as greater access to free and rapid tests, poor information from society, in addition to the lack of distribution of penicillin to health posts and units.
On the other hand, it is important to emphasize that the neglect regarding the use of condoms, whether in stable relationships or not, is one of the factors that can have an impact on the increase in rates.
In 2016, more than 87 thousand cases of acquired syphilis, more than 37 thousand in pregnant women and more than 20 thousand congenital were reported, resulting in 185 deaths.
It is important to note that the states with the highest infection rates are Espírito Santo, Rio de Janeiro, Rio Grande do Sul and Mato Grosso do Sul, and are not among the regions with the lowest HDI.
In 2016, there were 87,593 notifications of acquired syphilis, of which 53.5% occurred in the Southeast, 24.2% in the South, 11.6% in the Northeast, 6.1% in the Midwest and 4.5% in the North.
Considering that the southeastern and southern regions have a high HDI, concentrate the highest schooling rates and have urban reference centers, it is possible to note that syphilis has increased in all social classes.
The southeastern region has one of the highest HDIs for education and income, being considered a high human development band, pointing out that the increase in syphilis cases is not linked to socioeconomic factors.
The south also has a high index of MHDI, with more than 37% of the municipalities in the south region above the Brazilian average for education and, according to the Ministry of Health, had the second highest increase in syphilis cases in 2016.
The drop in condom use is pointed out as one of the main causes, especially among young people, since most of the recent diagnoses were in the age group between 20 and 39 years, that is, young adults.
Risk behaviors, such as unprotected sex, are among the biggest concerns and, therefore, have been the target of awareness campaigns aimed mainly at the public of this age.
Therefore, syphilis has been shown to be an alarming disease that extends to everyone, not limited to social, regional, economic or educational factors.
Anyone who has practiced or maintains unprotected sex is subject to infection, so the groups and risk factors for STI contagion are:
- Patients whose partner was recently diagnosed (either by primary, secondary or latent syphilis);
- HIV-infected patients;
- Patients exposed to unprotected sexual intercourse (either in isolated or recurrent cases, regardless of the number of partners).
The guidelines for attending to syphilis treatment recommend that syphilis tests be performed on the following patients:
- Sexual partner (s) of an individual diagnosed with STD;
- Patient with genital lesion;
- Patient with skin rash;
- Young patient with ischemic stroke;
- Patient of any age with dementia;
- Pregnant women;
- HIV infected patient with active sex life.
Stages and symptoms
Syphilis can be divided into 4 phases: primary, secondary, latent and tertiary.
The evolution of the disease is slow and can present symptomatic and asymptomatic periods. The infected patient, if not treated after reaching secondary syphilis, has 2 latency periods, which are the recent (less than 2 years of the disease) and the late (more than 2 years).
After the person is infected with T. pallidum , there is a period when the agent is in the body but does not show symptoms, called the incubation period, which can be between 10 and 90 days after the infection.
In general, the first and most obvious sign of contagion is the appearance of a lesion in the mouth or close to the place where the bacteria invaded the body (mouth, penis, vulva, vagina, anus or other parts of the skin).
This lesion, called a hard cancer or protosyphiloma, is usually isolated (there are no other wounds on the body) and does not itch, burn or hurt. The wound base is hardened and appears to contain a serous secretion that is full of bacteria.
In addition, small lumps (lumps) may appear in the groin. In a short time, usually between 2 and 6 weeks, the manifestations improve and disappear spontaneously.
If it is not diagnosed and treated in the primary phase, syphilis progresses to the secondary phase, in which the agent invades the body’s organs and fluids.
Between 6 weeks and 6 months after the first wound appeared and healed spontaneously, the patient may have spots along the body, including the soles of the feet and the palms of the hands.
Like the initial wound, there is no pain or itching, but more intense symptoms of fever , malaise, headaches, nausea, vomiting and lumps may occur .
The skin then presents spots and changes, such as macules and papules, which have a reddish appearance, which can be broad and concentrated (macules) or isolated, as small spots distributed over the skin (papules).
These lesions or spots can form plaques on the skin, that is, manifest themselves in close places and occupy all or a large part of the skin surface.
Stains can also occur on the entire body, especially on the palms of the hands and soles.
Usually, these manifestations occur between the 6th week and the 6th month after the first injury (hard cancer) and can last for an average of 1 to 3 months.
Some patients may even experience symptoms such as:
- Skin peeling;
- Muscle pain;
- Sore throat;
- Tingling in the arms and legs;
- Changes in vision and hearing;
- Mild fever, usually below 38 ºC;
- Lack of appetite;
- Capillary fall;
- Memory loss;
- Neurological dysfunctions;
- Weight loss.
Once they appear, these manifestations tend to improve quickly as well, similar to the stage of primary syphilis. But, even if the signs disappear, the infectious agent remains in the body and the disease has not been cured .
When the patient who reaches secondary syphilis, does not undergo treatment and the signs disappear, the latent period of infection begins. This phase is divided between recent (up to the 2nd year) and late (after 2 years of infection).
It is important to note that at this stage, syphilis does not present any symptoms or clinical manifestation, but in a few patients it can be interrupted or crossed by specific manifestations characteristic of the third phase of the disease.
Approximately 15% to 30% of untreated infected people reach the tertiary stage of the disease. In some cases, the patient may not go through the latent stage, going directly to tertiary syphilis.
The manifestation of tertiary syphilis can take long periods to occur. In general, the average time for this phase to start is between 2 and 4 years after infection, but it can take more than 20 years.
When it occurs, it usually manifests itself through inflammation and destruction of body tissues, in which the patient presents lesions on the skin surface, in the bones, cardiovascular and neurological alterations and dysfunctions.
In addition, there may be consequences related to these changes (such as arrhythmia, heart problems, memory difficulties and concentration). The stage is severe and can lead to death when left untreated.
In addition to the signs on the body, usually after long years without treatment (between 10 and 30 years), the tertiary phase can be accompanied by:
- Nausea and vomiting;
- Neck stiffness, with difficulty in moving the head;
- Hearing Loss;
- Exaggerated reflexes;
- Dilated pupils.
Some neurological changes can occur and cause delusions, hallucinations, reduced memory, difficulties in orientation and spatial location, in addition to affecting speech and locomotion.
Neurosyphilis is characterized when the central nervous system (CNS) is affected by the bacterium Treponema and can occur in any period of the disease.
Its characterization is quite complex (clinically and theoretically), as soon as the condition in which Treponema pallidum reaches the CNS can be named as neurosyphilis , triggering different reactions.
Due to this multiplicity of symptoms, neurosyphilis is called an “mimicking disease” as soon as its symptoms resemble several other conditions.
Neurosyphilis is classified according to the time of early infection (up to 1 year of infection) or late (more than 1 year) – or according to the presence of symptoms – symptomatic or asymptomatic.
On average, 40% of patients have neurosyphilis in the 1st or 2nd stage of syphilis, with spontaneous resolution. In other words, the organism itself manages to combat and neutralize the damage caused by the invasion.
Approximately 10% of patients who are not treated with neurosyphilis in the 1st or 2nd stage develop the infection later.
When the condition does not resolve spontaneously, neurosyphilis may remain asymptomatic for long periods or gradually manifest.
Among the most frequent signs of the disease are:
- Intense headaches;
- Nausea and vomiting;
- Cervical stiffness;
- Alteration of movements or reflexes;
- Eye pain;
- Paralysis of the limbs;
- Reduced muscle control;
- Numbness or tingling in the limbs;
- Cognitive and concentration decrease.
Congenital syphilis (in pregnancy)
Congenital syphilis is when the infection reaches the fetus during pregnancy (when the bacteria pass through the placenta) or during delivery. In general, the more recent the mother’s infection and when there is no treatment, the more severe the manifestation will be in the baby.
When pregnant women have syphilis, the risks of miscarriage, premature birth or birth followed by death are higher.
In general, up to 40% of children born with syphilis do not survive, but if the mother’s diagnosis and treatment are carried out, the risks to the child are greatly reduced.
The therapeutic referral of congenital syphilis depends on the mother’s clinical history. When the woman has not received or undergone appropriate treatment, the child must undergo examinations and evaluations in order to investigate the impairment of health. So it is essential that pregnant women follow prenatal care correctly.
Among the possible referrals are the collection and blood tests, neurological evaluation, bone examination (radiography), evaluation of the health of the eyes and hearing, and hospitalization may be necessary.
The baby may show symptoms from the first moments of life or take up to 2 years to manifest them. In general, they are quite similar to primary and secondary syphilis lesions, also involving:
- Rounded patches of pale red or pink color on the skin, including the palms of the hands and the soles of the feet;
- Easy irritability;
- Loss of appetite and energy to play;
- Bone and teeth problems;
- Hearing loss;
- Mental disability.
Ocular syphilis is characterized by inflammation in the eyes or changes in vision resulting from complications or worsening of syphilis. That is, it is not that the contact and contagion occurred in the eyes.
Recently, data on ocular syphilis have been increasing in Brazil, and until 2012, only 1 person per year was diagnosed, but as of 2013 this number has risen to 8 patients.
Although it can manifest itself at any stage of the infection, ocular syphilis tends to predominate in the secondary phase, when the disease is not treated.
Among the most frequent signs are redness of the eyes, pain, reduction or difficulty in focusing on vision, blurring, sensitivity to light and a considerable decrease in vision.
In addition to these symptoms that indicate impaired vision, the patient may contract other infections, such as:
- Anterior uveitis : irritation and inflammation of the iris;
- Posterior uveitis : ocular inflammation that reaches the choroid, retina and nerve of the eyes;
- Neuroretinitis : inflammation of the nerve and retina;
- Keratitis : inflammation of the cornea, which is the outermost layer of the eyes;
- Scleritis : intense inflammation of the sclera, the white part of the eyes;
- Episcleritis : usually recurrent inflammation that affects one layer of the eye, episclera;
- Neuritis : inflammation or degeneration of the eye nerve;
- Argyll Robertson’s syphilitic pupil : when the pupil reacts badly to light.
In general, if the patient is swiftly and properly treated, ocular syphilis – like other syphilis symptoms – tends to gradually improve until complete remission.
However, if there is no adequate therapeutic intervention, where the infection continues to weaken the organism, vision can be irreversibly affected.
How is the diagnosis made?
The doctors most suitable for making the diagnosis and monitoring the patient are the gynecologist, urologist, infectious disease and general practitioner . Initially, the doctor will perform a physical assessment and survey the patient’s personal history.
As the symptoms and signs are very mild and similar to other diseases, it is important that any risky situation (such as having unprotected sex) is reported to the professional.
But, in addition, it is necessary to perform the detection of antigens or antibodies through tests and laboratory exams. Only then can the diagnosis of syphilis be confirmed or ruled out.
In cases of suspected syphilis, laboratory tests must be performed so that the diagnosis is effectively made or ruled out. Among the procedures adopted are:
Through a normal blood collection it is possible to count blood cells and check for changes. Altered values in cell numbers can be an indication of infection and that the body is trying to fight it.
Through samples of body secretions, usually collected from a wound or injury, it is possible to assess the presence of bacteria. When they appear, skin lesions are rich in the infectious agent of syphilis and, therefore, the culture of bacteria is quite effective in confirming the diagnosis.
Examination in dark field
The test is effective for both primary and secondary syphilis lesions. Small samples of the lesions or wounds are collected. The test has a sensitivity between 74% and 97% for the diagnosis.
The variety also occurs because the identification of the bacteria depends on the experience of the professional who evaluates the sample.
Despite being a very effective and accessible test, being widely used in the diagnosis of syphilis, it is not the most suitable for lesions of the mouth (because the oral cavity is inhabited by several bacteria that can mix and make specification difficult).
Direct search of colored material
The test has a lower sensitivity compared to the effectiveness of the dark field test, however, it is one of the alternatives to the diagnosis. A sample of the lesions is collected and reagent dyes are applied, analyzing the results.
VDRL (Venereal Disease Research Laboratory)
The VDRL is an immunological test and one of the most used and used tests for the diagnosis of syphilis. Through blood collection, the material begins to be diluted and analyzed.
The dilution ends when the bacteria can no longer be identified in the sample. Therefore, results like 1/8 mean that the blood has been diluted 8 times until the antibodies are no longer detected.
But it should be noted that the test can also indicate a false positive if there is infection by other diseases, such as lupus , rheumatoid arthritis or liver disease.
Immunological tests can vary according to the patient, as they depend on the appearance of antibodies against the bacteria. But in most cases, a concrete and safe result is possible 10 days after the appearance of the first lesion (hard cancer).
FTA-ABS or TPHA (Treponemic Antigens)
The test can be more specific and sensitive than the VDRL and show a positive result more quickly when the patient is infected.
The analyzes allow the detection of specific antibodies to the treponemas, through the application of reagents that will leave the antibodies with fluorescent apple-green tones.
In cases of infection, the FTA-ABS values remain positive for the rest of life, even if the patient is treated and cured of syphilis.
Rapid test (TR) of syphilis
To facilitate and speed up the diagnosis of syphilis, there is an exam that has been widely used, especially in public health services (SUS). The advantage is its ease and speed in showing the results, needing a few minutes.
It is possible to buy the kit at pharmacies, but SUS care units and screening and counseling centers (CTA) offer the exam free of charge to the entire population.
The TR is made with a small sample of blood, taken from the tip of the finger (the amount is 20uL, which corresponds to a drop ). The blood is deposited in the meter (a device that will read the sample) and a liquid is applied to dilute the blood.
After 5 to 20 minutes the result is obtained by the appearance of 1 or 2 scratches on the meter. If only 1 line appears, the test is negative or non-reactive, but if 2 lines are formed, the test is reactive to syphilis.
Patients who have a positive RT should be referred for confirmatory exams.
The lumbar puncture exam is indicated as a complementary exam when there are suspicions of neurological complications resulting from syphilis. In it, samples of the cerebrospinal fluid are collected to be analyzed in the laboratory.
Is there a cure?
-Yeah . Once diagnosed, syphilis has a simple and very effective treatment, in which the cure reaches 95% of cases, even in the tertiary phase. However, it is important to note that the earlier the diagnosis and treatment, the less damage to the organism.
In cases of late diagnosis, complications from syphilis can be irreversible, even if the disease is cured.
What is the treatment?
Currently, primary, secondary and latent syphilis (with up to 1 year of evolution) are treated with the application of Penicillin G Benzatin , in a single dose of 2.4 million IU, usually dividing the amount in 1.2 million in each gluteus .
Patients who cannot receive penicillin are recommended to use 100mg Doxycycline every 12 hours for 15 days.
In cases of late latent syphilis (more than 1 year of evolution) or tertiary syphilis, treatment consists of applying 2.4 million IU of Penicillin G Benzathine once a week for 3 weeks (totaling 7.2 million IU ).
The alternative to Penicillin is 100mg Doxycycline, every 12 hours for 30 days.
It is worth remembering that each case must be previously evaluated by a doctor.
It should also be noted that the dosage can manifest side effects, called the Jarisch-Herxheimer reaction, such as fever, chills, headaches, joint pain and nausea, but which tend to be well supported.
In addition to the injections, constant examinations are necessary to assess the patient’s condition. In general, it is necessary to maintain control for up to 24 months after treatment.
If the patient is allergic to penicillin, it is possible to resort to desensitization of the medication, preventing the occurrence of angioedema (swelling), urticaria and anaphylaxis in response to treatment.
In cases of suspicion or knowledge of penicillin sensitivity, you should inform your doctor and perform the allergy test.
For patients with neurosyphilis, treatment consists of the intravenous application of between 18,000,000 and 24,000,000 IU penicillin, in fractional doses. On average, the patient receives about 4,000,000 IU every 4 hours, for up to 14 days, according to medical advice.
But the tables are quite variable and the dosages can be adjusted according to each case. In general, there is an improvement and reduction in the neurological symptoms resulting from neurosyphilis, but it is often that there is no full recovery even after curing.
The Benzetacil is currently the most widely used drug in the treatment of syphilis, but in cases of allergy, sensitivity or need for other medications, can also be used:
- Bepeben ;
- Clordox ;
- Doxycycline ;
- Erythromycin .
NEVER self-medicate or stop using a medication without first consulting a doctor. Only he will be able to tell which medication, dosage and duration of treatment is the most suitable for his specific case. The information contained on this site is only intended to inform, not in any way intended to replace the guidance of a specialist or serve as a recommendation for any type of treatment. Always follow the instructions on the package insert and, if symptoms persist, seek medical or pharmaceutical advice.
After the positive result for syphilis, correct and well-guided treatment is essential. After the weeks of medication are over, syphilis is cured by the disappearance of symptoms and the reduction of infectious values, which is measured by the results of the VDRL exam:
- VDRL was 1/32 and after treatment it dropped to 1/8.
- VDRL was 1/64 and after treatment it dropped to 1/16.
- VDRL was 1/128 and after treatment it dropped to 1/32.
In general, the more recent the infection, the faster the VDRL values drop, but it is not necessary to reach zero or negative values to certify the cure.
Still, the patient needs to maintain a routine of examinations and follow-up to assess the conditions of the organism. In the first year after treatment, the VDRL exam must be done every 3 months and, in the second year, every 6 months, to monitor the disease titles.
It is important to know that even using a condom, the patient diagnosed with syphilis should avoid having sex during treatment until the results show that the infection has been cured .
After the cure is confirmed, the patient returns to a normal life and must maintain the necessary care for the entire population, such as protection in the sexual act and the non-sharing of intimate objects.
It is also important to note that late diagnoses can cause the patient to have positive titers, even if quite low, for the rest of his life. Thus, even with the disease cured, VDRL tests may indicate ¼ or less.
If syphilis is diagnosed in the early stages (primary, secondary and until the beginning of the latent stage) the prognosis is generally excellent as long as the treatment is done properly.
In tertiary syphilis, the fight against infection may have an effect, but there are greater risks of permanent consequences of the disease, such as irreversible neurological changes. If left untreated, the infection can lead to death.
If not properly diagnosed or treated, syphilis can compromise various functions and systems of the body, weakening the patient, such as:
Swelling of organs and tissues
The disease can cause swelling in different organs and tissues in the body. In general, treatment reduces and inhibits edema, but in the absence of treatment, the condition can progress to organ dysfunction and even tumors.
Syphilis can cause neurological changes of various intensities, such as strokes, meningitis , deafness, changes in vision, dementia, motor changes and reduced sensitivity, numbness in the hands and feet, in addition to reduced muscle control and balance.
Treatment usually improves and relieves symptoms, but if the patient takes too long to start, the symptoms can be persistent.
Syphilis can cause changes in cardiovascular function due to inflammation mainly from the aorta. Cellular infiltration of heart tissues, closure and decreased elasticity of blood vessels and consequent tissue necrosis may arise.
Aortic insufficiency, reduced resistance of the heart walls and formation of aneurysms can occur.
Risk of pregnancy and congenital syphilis
Syphilis increases the risk of miscarriage, premature birth and birth followed by death. Babies are at risk of having congenital syphilis, which can cause malformation, delays in neuromotor development, seizures , skin rashes, fever, enlarged liver, anemia , irritation and other symptoms related to syphilis.
Undiagnosed children can develop late complications, affecting the eyes, bones, heart, the auditory, neurological and cardiac systems.
Easier transmission of HIV
As syphilis causes lesions on the skin surface, the body is more sensitive and susceptible to contamination by infectious agents. But it is not only due to the vulnerability of the organism that the risk of contracting HIV is increased, because when the infectious agent of syphilis combines with that of HIV, there is a greater ease of transmission.
It is as if the syphilis virus potentiates the capacity for HIV infection, increasing the risk of contamination by these diseases.
In addition, if the patient with syphilis contracts the HIV virus, the disease tends to undergo changes in its symptomatic course. That is, common symptoms of the primary, secondary and tertiary phases may appear together.
How to prevent syphilis?
The easiest way to prevent syphilis and other STIs is to use condoms at all times.
Although the patient may present wounds and injuries in areas not covered by condoms, it is due to unprotected sex that the vast majority of contamination occurs.
Female or male condoms can be found in pharmacies or health units (including, distributed free of charge), being a viable and accessible option, recommended by the Ministry of Health as a preventive measure for STIs.
To prevent and reduce cases of congenital syphilis, pregnant women should undergo prenatal and necessary follow-up examinations. It is worth remembering that the children of infected mothers should also receive clinical follow-up.
If the partner is diagnosed with syphilis, it is important to avoid sexual intercourse until treatment is completed and the cure is confirmed.
If I use a condom, can I have sex during treatment?
No. The most recommended is that there is no intimate contact or sharing of objects until the cure is confirmed. Even with the use of condoms, there are wounds that can manifest in places that are difficult to identify (such as in the mouth).
To avoid the risk of contaminating other people, the ideal is to finish the entire treatment and make sure that the infection has been cured.
Does kissing on the mouth transmit syphilis?
-Yeah . If the patient has lesions in the mouth, the infectious agent can be transmitted during the kiss.
Can you get syphilis by the toothbrush?
It’s difficult, but not impossible. Bacteria need moist places to live, so it is necessary that the patient has an injury to the mouth and that the brush is shared in a short time so that there is the potential for contagion.
Is it possible to catch syphilis more than once?
-Yeah . Even if the patient performs the treatment correctly, the body does not create immunity to the disease. Therefore, if it is exposed to the agent again, it could be infected.