Secondary Syphilis- The Great Imitator and Pretentious Rash

Where does syphilis come from?

Syphilis tends to affect various organs and presents a wide range of symptoms thus earning the distinction of being called “the great mimicker”[1]. Recent evidence indicates that this venereal disease was contracted during Christopher Columbus’ voyage to North and South America, subsequently spreading the pathogen to the European region [2].

What is syphilis?

To understand secondary syphilis, one must first understand syphilis as a disease by itself. Syphilis is a bacterial infection that is caused by spirochete Treponema pallidum [3]. 

It is a type of sexually transmitted infection (STI) which is passed on through: 

• Vaginal, anogenital (anus and genital), and orogenital (oral stimulation of genitalia) intercourse
• Skin-to-skin transfer (rare)
• Blood-borne transmission (from needle sharing or blood transfusion)
• Mother to child (also known as congenital syphilis)

Syphilis has been one of the main public health concerns worldwide, affecting millions of people throughout the world. The level of concern is justified as this disease can result in significant morbidity and affect various organs of the body including the nervous system, cardiovascular system, and even the eyes. 

In some developing countries, syphilis is common in those with lower socioeconomic status and those with limited access to healthcare services [4]. Syphilis is also more common in people with multiple partners[4]. 

Is syphilis re-emerging?

The short answer is, yes. Initially, the spread of syphilis was identified particularly among men who have sex with men (MSM) [5], regardless of socioeconomic background. However, recently, concern was heightened when reports of syphilis resurgence were noted among heterosexual men and women in the USA [6], Australia [7], and Japan [8]. Even more concerning was the sudden rise of syphilis among women of childbearing age increasing the risk of transmission of syphilis from mother to child. 

What is secondary syphilis?

Syphilis occurs in three stages; 1,2 and 3 [10]. Before diving into secondary syphilis, let’s first review the symptoms of primary syphilis. The typical characteristic of primary syphilis is individual painless nodules and lesions known as a chancre which typically manifests over the genital region, fingers, nipple, mouth, or back of the throat (tonsils). 

When the lesions are left untreated, the syphilitic infection remains in the body resulting in eventual dissemination throughout the bloodstream. The dissemination subsequently leads to the graduation of secondary syphilis. 

In secondary syphilis, the clinical manifestations tend to be more florid and dramatic. Secondary syphilis symptoms affect multiple organs and have various presentations, thus earning the infamous title of being the ‘great imitator’. If both primary and secondary syphilis is left alone without treatment, the patient can progress into a latent phase of syphilis infection; the tertiary syphilitic stage which progresses over 10-30 years. 

The third stage of syphilis can be devastating and debilitating. It even increases the risk of morbidity. Often, third-stage syphilis is accompanied by cardiovascular and nervous system involvement.

Prompt treatment and symptom resolution are achievable in secondary syphilis, hence avoid further delay and do seek medical attention if you have any symptoms to suggest syphilis infection.

What are the signs and symptoms of secondary syphilis?

The signs and symptoms of secondary syphilis are evident and blatant. Typically, there are signs manifesting on the skin with occasional involvement of other organs. 

Signs include: 

• Widespread scaly red spots (papules) on the palms and soles, some over the body
• Large greyish/whitish lesions over the mucosal region such as the mouth, groin region, and armpit (condylomata)
• Patch hair loss
• Presence of swollen lymph node
• Weight loss
• Headache
• Viral-like symptoms such as fever, lethargy, sore throat

If you are not sure about the presentation of your symptoms, it is always better to be safe than sorry. Consult your doctor on your concerns, and evaluate further with the appropriate tests to screen for syphilis.

How did I get secondary syphilis?

Syphilis is passed on from one person to another via direct contact with a syphilitic sore. This happens frequently during sexual activity. Secondary syphilis specifically occurs when a person, during the initial infective stage (primary syphilis), missed the treatment window period, allowing the bacteria to progress to the second stage with haematogenous spread.

When should I screen for syphilis?

You should consider screening for syphilis if you are:

• experiencing symptoms to suggest syphilis
• known to have a sexual partner/positive contact who has recently been diagnosed with syphilis
• pregnant
• sexually active MSM
• HIV-positive and sexually active
• Taking HIV prophylaxis medication

What should I expect when I see my doctor for syphilis?

Given that there is an array of signs and symptoms for syphilis, there are sequential steps to diagnosing and obtaining treatment for syphilis. 

Step 1 : Diagnosing syphilis in Singapore  

Your doctor will first collect your medical history and lifestyle information on top of conducting a primary physical examination.  

The information collected will include:

• Sexual history
• Progress of symptoms
• Timeline of exposure risk
• Previous STI/STD infections
• Physical examination of the skin, cardiovascular, nervous system, and genital/mucosal examination

Step 2: Screening for syphilis in Singapore 

If suspected of syphilis, your doctor will order specific blood tests as screening measures. You would also be ordered to conduct these tests if suspected of risk of transmitting syphilis to others without any overt signs and symptoms of syphilis.

Step 3: Monitoring treatment response of syphilis

Blood tests will be repeated within a certain time frame to monitor syphilis activity in blood during and after treatment of the condition.

What are the tests available for testing for syphilis?

There are a few types of syphilis tests in the current market, mainly looking at antibodies against syphilis- which is a protein that the immune system produces upon contract of syphilis.

These tests include:

• Non-treponemal antibody tests: ( RPR Test, VDRL Test)- used to detect and monitor the activities of syphilis.
• Treponemal antibody tests: (TPPA, Syphilis-EIA): detect antibodies that one produces upon being infected by syphilis– can be detected even earlier than non-treponemal antibodies and will remain positive lifelong even after treatment.  
• Darkfield microscopy: smear a fluid/sample from the sores and analyse it under a microscope to look for treponema pallidum bacteria that will light up against a dark background.
• PCR testing: to detect treponema pallidum DNA.

During your consultation, your doctor will guide you on further tests for evaluation of your symptoms or concerns of syphilis.

Is there a treatment for secondary syphilis?

The treatment for syphilis (including secondary syphilis) includes a benzathine penicillin injection. In patients with penicillin allergies, you can discuss with your doctor regarding other alternative medications such as doxycycline, tetracycline, or even ceftriaxone for treatment. 

Your doctor will work closely with you during the treatment of syphilis. You will be counselled on the medication indications, side effects, and followed-up closely with subsequent blood tests to ensure there is an appropriate serological response following treatment.

Is syphilis curable?

Yes, syphilis is a curable and treatable condition. Prompt treatment and early detection will provide you with the best chance of recovery.   

Can I acquire syphilis again after successful treatment?

Unfortunately, the answer is yes. If you have a new exposure risk to syphilis, even with successful treatment of syphilis, you are not immune towards the disease. Occasionally, a person after treatment of syphilis may have a recurrence of infection due to reinfection or treatment failure. If you have a higher risk of exposure, you are advised to consider regular screening for syphilis or other STIs. You can discuss with your doctor about the risk of exposure and appropriate measures for monitoring. 

How do I ensure syphilis infection does not recur?

It is imperative to follow-up with your doctor after the completion of the treatment of syphilis. Your doctor will follow-up with you periodically to monitor for signs and symptoms of recurrence and offer you regular serological/laboratory blood tests to monitor the syphilis titre value for any possibilities of recurrence of infection. Preventative measures such as condom use and maintaining monogamous relationships will aid in avoiding recurrence. 

How long do I have to abstain from sex after treatment for syphilis?

You are advised to abstain for at least 7-10 days and until the sores/symptoms have resolved after treatment of syphilis. Discuss with your doctor about individual presentation and response to medication as different patients may have different responses against treatment. Some may need a longer time of abstinence until symptoms/conditions resolve.

What is the link between syphilis and HIV?

A person with untreated syphilis has an increased chance of acquiring HIV infection. Active syphilis with genital open sores presentation predisposes a person to transmission and acquisition of HIV infection. The presence of syphilis or other forms of STIs is suggestive of a person’s lifestyle and exposure risk, placing a person with a higher possibility of contracting HIV. 

Bottomline…

• Syphilis is becoming more common than one may perceive. 
• Syphilis can be a debilitating condition both physically and mentally with the associated social stigma, but it is treatable.
• Syphilis can present in various forms, hence having a rash- may not necessarily be as simple as eczema or psoriasis. It is important to book an appointment with your doctor and have symptoms assessed. 

References

1. Peeling, R.W. et al. (2017) Syphilis, Nature reviews. Disease primers. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809176/ (Accessed: 17 May 2023). 

2. Stein, L. (2008) Did Columbus bring syphilis to Europe?, Scientific American. Available at: https://www.scientificamerican.com/article/did-columbus-bring-syphilis-to-europe/ (Accessed: 17 May 2023).

3. Radolf, J.D. et al. (2016) Treponema pallidum, the syphilis spirochete: Making a living as a stealth pathogen, Nature News. Available at: https://www.nature.com/articles/nrmicro.2016.141 (Accessed: 17 May 2023).
   
4. Tudor ME, Al Aboud AM, Leslie SW, et al. Syphilis (Nursing) [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568808/

5. Tsuboi, M., Evans, J., Davies, E.P., Rowley, J., Korenromp, E.L., Clayton, T., Taylor, M.M., Mabey, D. and Chico, R.M., 2021. Prevalence of syphilis among men who have sex with men: a global systematic review and meta-analysis from 2000–20. The Lancet Global Health, 9(8), pp.e1110-e1118.
   
6. Schmidt, R., Carson, P.J. and Jansen, R.J., 2019. Resurgence of syphilis in the United States: an assessment of contributing factors. Infectious Diseases: Research and Treatment, 12, p.1178633719883282.
   
7. Carter, A., McManus, H., Ward, J.S., Vickers, T., Asselin, J., Baillie, G., Chow, E.P., Chen, M.Y., Fairley, C.K., Bourne, C. and McNulty, A., 2023. Infectious syphilis in women and heterosexual men in major Australian cities: sentinel surveillance data, 2011–2019. Medical Journal of Australia.
   
8. Ukai, T., Kakimoto, K., Kawahata, T., Miyama, T., Iritani, N. and Motomura, K., 2023. Resurgence of syphilis in 2022 amongst heterosexual men and women in Osaka, Japan. Clinical Microbiology and Infection, 29(3), pp.396-397.
   
9. Goodman, B. and McPhillips, D. (2023) Rates of congenital syphilis are skyrocketing in the US. here’s why, CNN. Available at: https://edition.cnn.com/2023/03/01/health/congenital-syphilis-alarming-rise/index.html#:~: (Accessed: 17 May 2023).
   
10. Syphilis: Symptoms, cause and treatments (no date) Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/diseases/4622-syphilis (Accessed: 17 May 2023).