Test for syphilis in all patients presenting with a genital ulcer. The ulcer (chancre) is characteristically a single indurated painless ulcer which can occur in the genital region or elsewhere on the body.
Particularly in endemic communities, consider syphilis if a patient presents with characteristic signs of secondary syphilis, e.g. hair loss, rashes on hands and feet, and painless enlarged lymph nodes.
- In Australia, syphilis usually presents either as a primary chancre, clinical manifestations of secondary syphilis or through the chance finding of positive serology.
- Congenital syphilis is rare if there is general screening of antenatal patients.
- Tertiary syphilis is rarely seen.
- Careful physical examination of the relevant areas, and awareness of its likely presence in endemic communities is crucial to establishing an accurate diagnosis of syphilis.
- Untreated, early clinical syphilis usually resolves spontaneously, leading to latent disease, which may proceed to late, destructive lesions.
Staging of syphilis
The appropriate course of treatment can only be decided after the clinical stage of the disease has been determined. This requires examination and serological testing. The stages are:
- Primary syphilis: the signs are an ulcer (chancre) at the site of infection that is typically solitary, indurated and painless.
- Secondary syphilis: manifestations are a rash that is typically bilaterally symmetrical and non-itchy; ulcers of the mouth, nasal cavity or vulva; enlarged lymph nodes and condylomata lata. Hair loss involves scalp and eyebrows. Cranial nerve palsies and other neurosyphilis manifestations may develop.
- Latent syphilis: presence of T. pallidum in the body without symptoms or signs. Latent syphilis can be either early (within 24 months of primary infection) or late (more than 24 months since primary infection).
- Tertiary syphilis: progression of syphilis to involve the heart, nervous system, eye, ear or the development of gummata (granulomatous lesions). The first lesions of tertiary syphilis are usually seen five to 20 years after primary infection, but asymptomatic neurosyphilis may occur within five years.
Presentation of latent syphilis
Positive serology in a patient without symptoms or signs of disease is the most common presentation of syphilis in Australia today.
- The duration of latency influences potential infectivity of the patient and the treatment required.
- The problem, with a finding of positive syphilis serology without clinical symptoms or signs, is to distinguish adequately treated syphilis from untreated disease.
- The duration of latency must be determined by:
- identifying the occurrence of primary or secondary lesions, if possible
- asking about previous syphilis serology at the time of blood donations, previous STI diagnosis or pregnancy
- checking the records of Community Health, PHUs, ACCHS, PathWest, or other medical practitioners.
Note: A clue can also be gained from the RPR titre. Titres of less than 8 are likely to reflect latent syphilis (two years or more from infection) and titres greater than 8 reflect active syphilis, with a proviso that if acute disease is suspected do a repeat blood test in two weeks.
Presentation of tertiary syphilis
Tertiary syphilis should be excluded in any patient with the following conditions:
- aortic incompetence
- aneurysm of the ascending arch of the aorta
- personality change
- multifocal neurological disorders
- nerve deafness
- pupillary abnormalities
- retinal disease or uveitis.
If tertiary syphilis is suspected, referral to a specialist should occur. Contact details of specialists with appropriate experience are provided on contacts for specialist advice on STIs and HIV.
Cases of suspected tertiary syphilis need to be discussed with specialists because managing patients with tertiary syphilis can be very complex. Such complexities are beyond the scope of these guidelines.
- Practitioners should maintain an awareness of the possibility of tertiary syphilis.
- Tertiary manifestations of syphilis may be 'benign', with development of gummata in almost any organ, or more serious, with cardiovascular or central nervous system involvement. Benign gummatous disease is rare. Cardiovascular disease and neurosyphilis occasionally occur from five to 35 years after exposure.
Exclude other STIs
Investigate all patients presenting with possible syphilis for other STIs, including chlamydia, gonorrhoea, HIV, HBV, hepatitis A (HAV) (if symptomatic or if there is any history of male-to-male and/or oro-anal sex and vaccination is contemplated), and HCV (if there is a history of injecting drug use), as coinfection is likely.
In patients with primary syphilis and at risk for HIV, retesting for HIV should occur after three months. The presence of herpes, donovanosis and warts may be detected during clinical examination