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Patients who have been sexually exposed to infectious syphilis within the preceding 3 months may be infected but seronegative and thus should be treated as for early syphilis Persons exposed more than 90 days previously should be treated based on serologic results If their partners are unavailable for testing or unreliable for follow-up, empiric therapy is indicated Others at high risk either for infection (ie, those with other sexually transmitted diseases and those infected with HIV) or its consequences (ie, pregnant women) should undergo serologic tests for syphilis The present recommended therapy for gonorrhea (single-dose ceftriaxone or cefpodoxime) may not be effective in treating incubating syphilis Therefore, patients with gonorrhea and a known exposure to syphilis should be treated with separate regimens effective against both diseases
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Generalized maculopapular skin rash Mucous membrane lesions, including patches and ulcers Weeping papules (condylomas) in moist skin areas Generalized nontender lymphadenopathy Fever Meningitis, hepatitis, osteitis, arthritis, iritis Many treponemes in scrapings of mucous membrane or skin lesions by immunofluorescence or darkfield microscopy Serologic tests for syphilis always positive
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The Jarisch Herxheimer reaction is ascribed to the sudden massive destruction of spirochetes by drugs and release of toxic products and is manifested by fever and aggravation of the existing clinical picture It is most likely to occur in early syphilis It usually begins within the first 24 hours and subsides spontaneously within the next 24 hours of penicillin treatment Treatment should not be discontinued unless the symptoms become severe or threaten to be fatal or unless syphilitic laryngitis, auditory neuritis, or labyrinthitis is present, where the reaction may cause irreversible damage The reaction may be prevented or modified by simultaneous administration of antipyretics, although no proved method of prevention exists
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The secondary stage of syphilis usually appears a few weeks (or up to 6 months) after development of the chancre, when sufficient dissemination of T pallidum has occurred to produce systemic signs (fever, lymphadenopathy) or infectious lesions at sites distant from the site of inoculation The most common manifestations are skin and mucosal lesions The skin lesions are nonpruritic, macular, papular, pustular, or follicular (or combinations of any of these types, but not vesicular), though the maculopapular rash is the most common The skin lesions usually are generalized; involvement of
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Table 34 3 Natural course of untreated syphilis in immunocompetent individuals
Stage of Disease Latent Late Benign (gummatous) Cardiovascular Neurosyphilis Early symptomatic 15% 10% 65% 5% Seen 1 46 years postinfection Many patients have more than one late manifestation Seen only in persons in whom syphilis develops after 15 years of age Onset 20 30 years postinfection Asymptomatic neurosyphilis has been reported in 8 40% Occurs weeks to years after infection; can coexist with primary and secondary disease; manifests as meningitis, cranial neuritis, ocular involvement, meningovascular disease (stroke) 2 50 years after primary infection; tabes or general paresis Likelihood of Developing Clinical Manifestations 24% Comment 90% of relapses occur in first year after infection
Late (tertiary)
5 10%
the palms and soles is especially suspicious Annular lesions simulating ringworm may be observed in dark-skinned individuals Mucous membrane lesions range from ulcers and papules of the lips, mouth, throat, genitalia, and anus ( mucous patches ) to a diffuse redness of the pharynx Both skin and mucous membrane lesions are highly infectious at this stage Specific lesions condylomata lata are fused, weeping papules on the moist areas of the skin and mucous membranes Meningeal (aseptic meningitis or acute basilar meningitis), hepatic, renal, bone, and joint invasion may occur, with resulting cranial nerve palsies, jaundice, nephrotic syndrome, and periostitis Alopecia (moth-eaten appearance) and uveitis may also occur The serologic tests for syphilis are positive in almost all cases (see Primary Syphilis, above) The moist cutaneous and mucous membrane lesions often show T pallidum on darkfield microscopic examination A transient cerebrospinal fluid pleocytosis is seen in 30 70% of patients with secondary syphilis, though only 5% have positive serologic cerebrospinal fluid reactions There may be evidence of hepatitis or nephritis (immune complex type) Circulating immune complexes exist in the blood and are deposited in blood vessel walls Skin lesions may be confused with the infectious exanthems, pityriasis rosea, and drug eruptions Visceral lesions may suggest nephritis or hepatitis due to other causes The diffusely red throat may mimic other forms of pharyngitis Treatment is as for primary syphilis unless central nervous system or ocular disease is present, in which case a lumbar puncture should be performed and, if positive, treatment is as for neurosyphilis (see below) Isolation of the patient is important See Primary Syphilis for follow-up care
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