The Resurgence of Syphilis

English: Syphilis. False shame and fear may de...
(Photocredit: Wikipedia)

Syphilis is a bacterial disease caused by the spirochete Treponema palladium. While this may be something that most of us have (thankfully!) never encountered there have been multiple reports of this disease in the news and a recent resurgence in infection rates around the globe.

During the month of July and August there was a moratorium in the California pornography community due to an outbreak of syphilis that began with one infected performer1 who forged his most recent test results after it returned positive. This actor then went back to work after treatment but while he was still highly contagious; subsequently infecting nine individuals2. Since this outbreak was discovered all involved persons have been treated and the further spread of this disease has been prevented. However, this outbreak this raises two significant questions about syphilis and what it means to be infected:

  1. What exactly is syphilis?
  2. Why is the appearance of syphilis so significant that it required the shutdown of an entire industry?

Read on to find these answers and more…

What causes syphilis? Syphilis is caused by the bacterial spirochete Treponema palladium. The term spirochete refers to the very distinct corkscrew-like morphology of these organisms when observed at very high magnification. The name Treponema itself is a derivation of this morphology: trepo means “turn” and nema means “thread”, hence “turning thread” or a corkscrew.

Electron Micrograph of Treponema palladium. Photo Credit: Wikipedia

This bacteria is found throughout the human population across the globe. In the United States it currently ranks as the third most common bacterial sexually transmitted infection (STI). Humans are the only known host of T. palladium. It is a very vulnerable organism susceptible to drying and detergents, so the only way to contract the bacteria is through sexual contact or congenitally from mother to child. You cannot get it from fomites (contaminated surfaces) because the bacteria cannot remain viable outside of the host.

Why is syphilis important? Most people are only familiar with syphilis as an STI, but this disease is actually the most dangerous in its manifestations at other sites in the body that occur years after the primary infection. In fact, syphilis is divided into three distinct phases of disease progression: primary, secondary, and tertiary. In addition, there is also congenital syphilis that affects children born to infected mothers.

Primary: This initial stage of infection is marked by the appearance of a chancre (lesion) where the spirochete first breaches the skin. This will appear roughly 10 to 90 days after the initial infection. It begins as a harmless papule (a small solid pimple) and soon progresses to an open ulcer with raised edges. This ulcer will then heal within the next two months. I haven’t included an image on the page because there are just some things you can’t un-see. For the brave or clinically minded among you, go and search “primary syphilis chancre” I’ll be waiting right here.

…We’re back? Okay. These chancres are not painful unless they become subsequently infected by another pathogenic bacteria. They are also highly infectious and a direct route of transmission between sexual partners as T. palladium can breach both intact mucous membranes as well as damaged skin.  Due to this ability chancres may appear on any susceptible location exposed to sufficient numbers of this bacteria, not just the genitalia.

Secondary: If left untreated syphilis can progress to the secondary stage of infection. At this point the bacteria has disseminated throughout an infected person’s body and they would be considered bacteremic. Symptoms of this stage usually include a flu-like syndrome characterized by sore throat, fever, headache, and muscle pain. The most notable symptom of this phase is the appearance of a rash that covers the entire surface of the body, even the palms of hands and the bottoms of the feet. These lesions are also highly contagious just like the primary chancre. After the rash disappears the patient enters the latent phase where disease symptoms may not appear for years but the individual will remain bacteremic for up to 8 more years. Women who have children during this bacteremic phase are at risk of passing the bacteria to their fetus, resulting in congenital syphilis.

Reddish papules and nodules over much of the b...
Reddish papules and nodules over much of the body due to secondary syphilis (Photo credit: Wikipedia)

Tertiary: Of those who are infected and untreated roughly one third of those people will progress to the third stage of syphilis. This stage can take years to decades to develop without any signs of the disease during latency. However, this is the stage of the disease that is the most damaging, as diffuse, chronic inflammation can develop and subsequently lead to the destruction of affected tissues. At this point the patient may develop granulomatous lesions known as gummas. These gummas may develop in the bone, skin, or other parts of the body. See the image below for a casting of the face on an individual with highly advanced  gummatous syphilis.  Furthermore, this spirochete can invade the nervous system and cause what is known as “neurosyphilis.” This can be fatal or result in significant impairment of neurological function with manifestations as diverse as blindness, dementia, the inability to walk, visual disturbances, and seizures3.

English: Head of a patient with tertiary syphi...
English: Head of a patient with tertiary syphilis. Museé de l’Homme, Trocadéro, Paris. (Photo credit: Wikipedia)

Congenital Syphilis: This form of syphilis results when an infected mother becomes pregnant and passes the disease to her fetus. This can result in a 40% miscarriage rate in untreated infected women and severe complications for those infants who do survive. Complications associated with congenital syphilis include death soon after birth, physical deformities, and neurological abnormalities that can result in significant impairment of quality of life. These complications were widely visible before the introduction of antibiotics to treat syphilis in the 1940s. The portrait below shows an individual born with facial deformities due to congenital syphilis that eventually led to his blindness.

Portrait of Gerard de Lairesse
Portrait of Gerard de Lairesse (Photo credit: Wikipedia)

Treatment & Outlook: The severity of tertiary syphilis and the potential complicatons of congenital syphilis are both  driving reasons behind the shutdown of the San Fernando pornography industry. Add the fact that those infected with syphilis are more susceptible to infection with HIV4 and it becomes clear as to why this was such a serious event.

Thankfully, if this disease is caught early and treated these complications and negative outcomes can be entirely avoided. Penicillin is a commonly used antibiotic for treating this infection and is highly effective in most cases. Awareness of these symptoms and regular screening for this disease in vulnerable populations such as men who have sex with men, young black males4, and sex workers2 can help limit the spread of this disease.

There is no vaccine for syphilis making prevention and detection critical to stopping its spread. Safer-sex practices such as monogamy and the proper use of condoms can help to break the transmission cycle and prevent new infections. Regular testing and antibiotic treatment can prevent the development of serious complications due to later forms of the disease. As T. palladium has no hosts outside of humans it stands to reason that if we can successfully identify and treat infected individuals in conjunction with breaking the transmission cycle of this disease we may be able to eradicate it in the coming decades.

References:

1: http://www.huffingtonpost.com/2012/08/23/mr-marcus-admits-porn-syphilis-scare-alter-test_n_1826003.html

2: http://www.dailynews.com/ci_21421042/nine-porn-actors-test-positive-syphilis-san-fernando?source=most_viewed

3: http://www.ncbi.nlm.nih.gov/pubedhealth/PMH0001722/

4: http://www.cdc.gov/std/stats10/trends.htm

Medical Microbiology: 6th Edition by Murray, Rosenthal, and Paller. Printed by Mosby Elsevier

5 thoughts on “The Resurgence of Syphilis”

  1. Very thorough information – thanks! Syphilis is one of the many things I have to study for my upcoming exams. We still see a lot of syphilis here in South Africa, I’ve notably seen some neurosyphilis recently. Fortunately incidence of congenital syphilis has been reduced here due to antenatal screening programs finally being instituted correctly.

    1. I’m glad to hear that congenital syphilis rates are going down there. I’d forgotten about that complication until I started researching this article. It’s really an incredible disease. I’m so thankful that we can effectively treat it still.

      Not to break patient confidentiality, but is the clinical presentation of neurosyphilis as dramatic in person as the text books make it sound? Can you treat a patient successfully if they’ve progressed all the way to tertiary neurosyphilis? It seems as though it would be difficult to resolve after progressing so far and causing so much damage.

      1. Well, at my level of training we do four-week rotations at a time, so I’ve never been able to follow-up a neurosyphilis patient. A lot of them have come in with pretty subtle signs, but there were a few who presented with gross abnormalities and delirium. By the time I left a specific patient in question, their delirium had seemed to improve. Unfortunately I’ve never been on a rotation for long enough to see just how much the patients can recover, so I’m not entirely sure.

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