Syphilis: symptoms, infection, cause, treatment

Syphilis: symptoms, infection, cause, treatment

Syphilis is an infectious disease. It is triggered by a bacterium and is mainly transmitted during unprotected sexual intercourse. Typical first symptoms are ulcers on the genitals and swelling of the lymph nodes. As the disease progresses, the bacteria can cause severe organ damage and even lead to death. Read all important information about symptoms, ways of infection, treatment and chances of cure of syphilis!

Brief overview

  • What is syphilis? A bacterial infectious disease that is almost exclusively sexually transmitted. It is also called lues, lues venera, hard chancre or “French disease” (Maladie française).
  • Frequency: The number of syphilis cases has fallen sharply since the late 1970s, before starting to rise again from 2001. Most of the patients are men: in 2012, more than ten out of 100,000 men contracted syphilis. Among women, less than one in 100,000 was affected.
  • Symptoms: very variable and dependent on the stage of the disease; initially painless ulcers at the site of entry of the pathogen as well as swollen lymph nodes; in stage 2 diverse skin symptoms; in stage 3 infestation of the internal organs; in stage 4 inflammation of the central nervous system (brain and spinal cord).
  • Infection: mostly through unprotected sex, less frequently through direct contact with infected blood (for example, when sharing drug paraphernalia). In addition, infected pregnant women can transmit the pathogen to the child (congenital syphilis).
  • Treatment: antibiotics (preferably penicillin)
  • Prognosis: Early stages of syphilis can usually be cured with antibiotics. Without therapy the disease sometimes heals on its own. However, it can also be chronic and cause severe organ damage or even death.
  • Attention: Even after a healed infection you can still be infected with syphilis bacteria!

Syphilis: Symptoms

An infection with syphilis (syphilis, hard chancre) is “asymptomatic” in about half of all patients. This means that the infected persons do not develop any symptoms. The other half of those infected show symptoms of syphilis. These can be very different and vary from patient to patient.

Syphilis is a diagnostic chameleon. The complaints can manifest themselves in skin or organ changes. In addition, syphilis is generally rare, so it is not necessarily the first thing you think of. Mostly skin changes or open spots lead genital or in the mouth on the right track. If there is any suspicion, a blood test is carried out. By the way, pregnant women are routinely tested because they can transmit syphilis to the unborn child.

Syphilis is untreated if it does not heal spontaneously, a very serious disease. It can cause severe permanent damage in all organ systems – for example, the eyes, heart and central nervous system. Especially in the early stages of the disease, however, the infection can be treated well with penicillin.

In the majority of cases a complete healing is possible. Provided that the disease is treated in time and does not occur together with other serious diseases, for example HIV. But even those who have been successfully treated should have a blood test once a year for life, as syphilis does not lead to immunity and renewed infections are possible.

Syphilis symptoms in men and women

Basically, syphilis symptoms can affect women and men equally. Only the site where the first sign of the infection develops varies: a painless, fluid-secreting nodule. The small ulcer develops at the entry point of the syphilis pathogen. In men this is usually on the penis (preferably on the glans) and in women very often on the labia.

Another possible gender difference concerns hair loss, which can occur in later stages of the disease. There is evidence that it is more common in men than in women.

Apart from this, syphilis generally runs in four stages in both sexes. The first two stages are also called early syphilis, the last two late syphilis. The time interval between the individual stages and their characteristics can vary greatly from patient to patient. It can also happen that individual stages of syphilis are barely noticeable or even absent.

Syphilis symptoms in stage 1

The first sign of syphilis appears on average three weeks after infection: a small, coarse ulcer forms at the point of entry of the pathogen. It is called “Ulcus durum” or “primary effect”. As mentioned above, the small nodule is usually found on the penis in men and on the labia or even in the vagina in women. In these places it causes little or no pain.

In people who contract syphilis through oral sex, the ulcer often develops on the lips, in the oral cavity or in the throat. In the case of an infection via anal intercourse, it forms on the anus or in the rectum. These syphilis nodules outside the genital region can be painful.

In the beginning the nodule is a small reddish spot. Within one to two weeks it develops into a sharply defined, flat ulcer. It is yellowish in colour and has a rough edge wall. It often secretes a colorless liquid that contains a large number of syphilis pathogens. So she’s highly contagious.

In the course of the following weeks the lymph nodes around the ulcer swell. They do not hurt and feel hard.

The ulcer at the entry point of the syphilis pathogen heals spontaneously (on its own) within four to six weeks. The lymph node swelling can remain for months. Without treatment, the first stage of syphilis (primary stage) can move on to the next stage.

Syphilis symptoms in stage 2

About four to ten weeks after infection, the second stage of syphilis (secondary stage) may occur. This happens when the pathogen spreads through the blood and lymph channels in the body.

Initial syphilis symptoms at this stage are flu-like symptoms such as fever, fatigue, headache, muscle and joint pain. Further hard lymph node swellings develop.

In the further course of the disease, a skin rash (exanthema) develops, which can be very variable: Typically, slightly reddish, non-itching spots appear first, mainly on the trunk. After a few days the spots can turn into rough nodules (papules). Like ulcers, they can open up and start to wet themselves. Again, the escaping liquid is highly infectious.

At the base of the neck, the colour pigments of the skin can disappear after the skin symptoms have healed (depigmentation). What remains is the pale “collar of Venus“.

Possible syphilis symptoms in this second stage of the disease are also changes in the mucous membranes of the oral cavity: various plaques can form here (red, furrowed, whitish, etc.). In addition, the almonds may swell.

Flat, lobed tissue growths sometimes form in the anal region.

In many patients the hair begins to fall out in places. Doctors call this alopecia syphilitica.

Although syphilis in the 2nd stage is mainly noticeable in the skin and mucous membranes, all organ systems are affected by the disease! This can manifest itself for example in anaemia, swelling of the liver and headaches.

Syphilis symptoms of the second stage (secondary stage) can subside after a few weeks without leaving any traces (such as scars). However, they can recur several times. The symptoms are less pronounced each time, and the skin symptoms are increasingly restricted to a smaller area.

Resting phase (latency)

After the second stage of syphilis, the disease can come to a prolonged standstill. This can last up to ten years (on average three to four years). During this time there are no syphilis symptoms at all. However, the pathogen is still present in the body, so there is still a risk of infection. At some point, syphilis can break out again – now as so-called late syphilis (3rd and 4th stage).

Syphilis symptoms in stage 3

The third or tertiary stage is characterized by symptoms of syphilis, which can affect not only the skin and mucous membranes but also internal organs (such as the skeleton, nervous system, eyes, etc.). All over the body so-called gums can now appear. These are slowly growing nodes that can break open and form one or more ulcers. The tissue in the ulcer usually dies off (necrosis).

The name “gums” comes from the fact that the tissue nodes contain a thin, thread-like (rubber-like) and inflammatory secretion.

It becomes particularly dangerous when syphilis damages the wall of the main artery (aorta). Doctors call this “Mesaortitis luica”. A wall sacculation (aneurysm) may form. At this point the aortic wall is very thin and can easily burst. Then there is danger to life! The aorta carries a lot of blood. If it tears open, you can bleed to death internally within a short time. This can happen even decades after infection with syphilis.

Syphilis symptoms in stage 4

If syphilis is not treated, inflammation of the central nervous system (brain and spinal cord) can develop about ten to twenty years after infection. Then one speaks of neurolues or neurosyphilis. The syphilis symptoms that occur depend on which part of the brain and/or spinal cord is affected.

For example, if the dorsal marrow is affected, reflexes may fail and the coordination of movement may be impaired. Other possible symptoms are false sensations (such as skin tingling), stabbing pain in the lower abdomen and legs and impotence. Many patients are also unable to control the emptying of the bladder and bowel.

Some syphilis patients develop meningitis with damage to the cranial nerves. This is what doctors call “syphilitic meningitis”. Possible consequences are, for example, deafness, dizziness, paralysis of the eye muscles and impaired vision.

If the syphilis pathogens attack the brain, the result is a chronically progressive encephalitis. It is called progressive paralysis and can cause a variety of symptoms. For example, those affected show changes in their personality, develop concentration and memory disorders and gradually become demented. Paralysis is just as possible as epileptic seizures, delusions and depression. Without treatment, progressive paralysis leads to death within four to five years.

Congenital Syphilis: Symptoms

Many children infected with syphilis in the womb die during pregnancy (miscarriage, stillbirth) or shortly after birth. Others are born prematurely (premature birth).

Infected newborns are often inconspicuous at first. Only rarely do symptoms of syphilis occur immediately after birth, such as breathing problems (respiratory distress syndrome of the newborn), tissue swelling (edema), an enlarged liver and spleen, jaundice, anaemia and skin symptoms.

Many of the young patients only show signs of syphilis from the 3rd to 10th week of life. These include, among others:

  • Fever and swollen lymph nodes
  • variable skin changes (mostly on the palms of the hands and soles of the feet) and mucous membrane ulcers
  • broad-based, warty skin elevations (Condylomata lata), especially in the skin folds (anal and genital region, armpits etc.)
  • Tissue swelling (edema)
  • Enlargement of the liver
  • Enlargement of the spleen
  • Jaundice
  • Paleness
  • punctiform skin bleeding (petechiae)
  • Inflammation of the nasal mucous membrane (rhinitis, “cold”)
  • Enteritis (inflammation of the bowels)
  • Laryngitis (inflammation of the larynx)
  • abstinence from breast or bottle drinking

Meningitis (inflammation of the meninges) as a result of congenital syphilis (syphilis connata or lues connata) usually becomes noticeable between the 3rd and 6th month of life (refusal to drink, crying or whimpering, breathing disorder, etc.) Other signs that syphilis has affected the central nervous system include seizures andhydrocephalus” (hydrocephalus).

All these syphilis symptoms in newborns and infants are summarized under the term “Lues connata precox“. Without treatment, the disease sooner or later moves on to the next phase of the disease after the second year of life (“Lues connata tarda“):

Syphilis signs now appear on various organs. Some examples:

  • “saddle nose” as well as changes in the palate, forehead and shins, swelling of the knee joints
  • Corneal inflammation of the eyes (with photophobia, eye pain and vision problems up to blindness)
  • Hearing loss or deafness
  • Malformations of the teeth (“barrel teeth”)
  • small cracks in skin and mucous membrane (rhagades), such as torn corners of the mouth
  • Seizures, loss of cranial nerves etc. when the nervous system is affected

In this phase the syphilis patients are no longer contagious.

Syphilis: infection & causes

The trigger of the so-called French disease is the bacterium Treponema pallidum. It is mainly transmitted from one infected person to another during unprotected sexual intercourse. Syphilis infection is also possible through oral and anal sex. People with frequently changing sexual partners are particularly at risk.

The syphilis bacterium can also be transmitted by mere kissing. This can happen if the patient has a small blister/ulcer in the oral cavity and the partner has a tiny injury in the mucous membrane.

Syphilis may also be transmitted by contaminated blood during a blood transfusion. All blood samples are subjected to a syphilis test before they are administered to a patient. In Western countries there is no danger of infection in this way.

Drug addicts have another possibility of infection: they can become infected with syphilis when they share injecting equipment (such as needles) with infected persons and thus come into direct contact with infected blood.

There is also a congenital form of syphilis (syphilis connata or connatal syphilis): pregnant women infected with syphilis can transmit the pathogen to the unborn child from the 5th month of pregnancy. This risk is particularly high in early stages of the disease. If a woman becomes infected even during pregnancy, the pathogen almost always passes on to the unborn child.

Syphilis and HIV often occur together. This is due to the fact that skin ulcers in early stages of syphilis are easy entry points for the AIDS pathogen. Both diseases can negatively influence each other in their course.

Syphilis: incubation period

The incubation period is the time interval between infection with a pathogen and the appearance of the first symptoms. In the case of syphilis, this period can be between ten and 90 days. On average, however, the disease breaks out within two to three weeks.

Duration of contagiousness

First-stage patients are highly contagious. The risk of infection is somewhat lower in the second stage of syphilis. From the 3rd disease stage onwards, there is no longer any risk of patients infecting other people with the syphilis pathogen.

Syphilis: treatment

Syphilis therapy can often be done on an outpatient basis. Sometimes, however, inpatient treatment in hospital is necessary. This is especially true for neurolues (neurosyphilis) and congenital syphilis.

Syphilis is usually treated with penicillin (benzathine benzylpenicillin). The pathogen reacts very sensitively to this antibiotic and has not yet become resistant (insensitive) to it. The duration and dosage of antibiotic treatment depends on the stage of the disease:

In the case of early syphilis (first and second stage of the disease) the doctor usually injects the patient with a single dose of penicillin. Those who cannot tolerate the active substance are given another antibiotic. For example, tablets containing doxycycline or erythromycin are often prescribed. They must be taken daily for two weeks. Alternatively, in these early stages of syphilis, the antibiotic ceftriaxone can be administered as a short infusion, once daily for ten days.

Late syphilis (except neurosyphilis) is also treated with penicillin. But then three penicillin injections are necessary, each at an interval of several days. Here, too, another antibiotic (doxycycline, erythromycin, ceftriaxone) can be used in case of intolerance. The duration of treatment is then longer than for early syphilis (e.g. doxycycline tablets for 28 days).

Neurosyphilis requires even higher doses of antibiotics and hospital treatment. Patients are usually given high-dose penicillin daily for two weeks directly into a vein. In case of penicillin intolerance, ceftriaxone (as an infusion) or doxycycline (in tablet form) can be given.

In addition, individual symptoms of neurosyphilis are specifically treated. For example, the doctor can relieve epileptic seizures with antispasmodic drugs (antiepileptic drugs).

In some patients it can be proven that the syphilis pathogen has affected the central nervous system, but no symptoms occur. However, this asymptomatic neurosyphilis is treated in the same way as one that causes symptoms.

Side effect of the therapy

From the second syphilis stage onwards, patients receive a cortisone preparation once before the first antibiotic administration. From this stage on, the number of syphilis pathogens in the body is so high that antibiotic therapy can trigger the so-called Jarisch-Herxheimer reaction:

Due to the antibiotic treatment, large quantities of syphilis bacteria decay in a short time. The body can react very violently to the bacterial toxins released in this process. Within two to eight hours after administration of the antibiotic, those affected develop fever, chills and headaches. In addition, new rashes may appear and existing rashes may worsen.

This Jarisch-Herxheimer reaction only occurs with the first administration of penicillin. It can be prevented if cortisone is given half an hour or an hour before the antibiotic.

Regular check-ups

The success of the syphilis treatment is checked in several follow-up examinations. At certain intervals (every few months) the attending physician will examine the patient’s blood for the type and amount of antibodies against the syphilis pathogen. In the case of neurosyphilis, the cerebrospinal fluid (liquor) must also be examined. Patients can find out from their doctor how often and at what intervals check-ups are advisable in individual cases.

Treating partners as well

Until the 3rd stage of the disease, syphilis patients can infect other people, especially during sexual intercourse. In patients in the first stage of syphilis, all sexual partners of the previous three months should therefore be advised, examined and – if necessary – treated with antibiotics by a doctor. In case of syphilis in stage 2 or in the early resting phase (latency phase), the same is recommended for all sexual partners of the past two years.

Syphilis therapy for pregnant women

In all stages of the disease, syphilis in pregnancy should be treated with penicillin.

If the woman has a penicillin allergy, doctors recommend a specific immunotherapy (hyposensitization): the patient is given gradually increasing amounts of penicillin (starting with a very small dose). This should help her hypersensitive immune system to slowly get used to it.

Many other antibiotics used to treat syphilis are unsuitable during pregnancy. Some can endanger the unborn child (such as doxycycline), others can damage the liver and trigger a gestosis (“pregnancy poisoning”) (erythromycin estolate). In exceptional cases, syphilis in pregnancy can be treated with the antibiotic ceftriaxone.

Therapy of congenital syphilis

Newborns born with syphilis receive penicillin directly into a vein for two weeks. If the baby is also infected with HIV, the antibiotic may be administered for a longer period.

Syphilis: examinations and diagnosis

If syphilis is suspected, the doctor first takes the patient’s medical history (anamnesis). Among other things, he can describe exactly the symptoms that occur, ask how long they have existed and whether there are any pre-existing or underlying diseases (such as HIV infection). The doctor also inquires about the patient’s sex life. As unpleasant as such questions may be to some people affected by the disease, the doctor needs the information to be able to make the right diagnosis as quickly as possible.

In the next step, the doctor tries to detect the syphilis pathogen directly or indirectly:

At an early stage, the bacteria can be detected in large numbers in the liquid secretion of the skin ulcers. A special microscopy technique is used (dark field microscopy).

Specific antibodies in the blood can be detected after the pathogen has entered the bloodstream. Various test procedures are used for this screening test, for example the Treponema pallidum haemagglutination test (TPHA). It shows a positive result two to three weeks after infection, which usually lasts for a lifetime. Then the patient most likely does indeed have syphilis.

Syphilis rapid tests are also suitable as screening tests for specific antibodies against the pathogen.

However, the result of addiction tests is not one hundred percent certain. Therefore, even if it is positive, a confirmatory test using another method is necessary (e.g. a fluorescent responseema antibody absorption test, FTA-ABS test).

Once the diagnosis of “syphilis” has been established, the doctor still has to find out whether it is an old infection or an active infection requiring treatment. The VDRL test (Veneral Disease Research Laboratory Test) is suitable for this purpose. It detects antibodies that the immune system produces in syphilis, but also in other diseases (such as malaria, HIV). A positive test result is thus generally an indication of tissue destruction and inflammatory processes. If syphilis is confirmed, the test can say something about the disease activity.

A syphilis infection can become active again after a long symptom-free rest phase (latency phase) and cause symptoms (reactivation). On the other hand, after a successfully healed infection, one can become infected with syphilis again (reinfection). It is not possible to tell from the results of the antibody determination whether it is a reactivation or a reinfection.

If neurosyphilis is suspected, the doctor will also take a sample of the cerebrospinal fluid (cerebrospinal fluid puncture). It is examined in the laboratory for specific antibodies against lues bacteria.

The doctor often carries out further examinations. Among other things, they serve to exclude concomitant diseases. For example, some syphilis patients also suffer from other sexually transmitted diseases such as HIV, hepatitis B or chlamydia.

Syphilis is notifiable

Doctors must report any evidence of the syphilis pathogen to the responsible health authority. This applies to both direct detection (smear of skin ulcers) and indirect detection (specific antibodies against syphilis bacteria). However, the name of the patient is not given to the public health department.

Syphilis: course of disease and prognosis

Antibiotics are very effective for syphilis: thanks to these drugs, the first two stages of the disease are almost 100 percent curable. Even in the third stage, penicillin therapy can heal the infection in most cases. However, already existing organ damage can generally not be reversed.

Without treatment, syphilis heals spontaneously in about every 3rd patient (early stages). In the others the disease progresses and becomes chronic. In advanced stages, organs are permanently damaged. About one in 10 patients dies of untreated syphilis.

Syphilis in HIV patients is often atypical and more severe than in HIV-negative patients. They also develop neurosyphilis more frequently.

Syphilis: Prevention

You can prevent syphilis above all with safer sex: always use condoms during sexual intercourse. For oral sex, licking cloths are recommended to protect against syphilis and other venereal diseases.

Such protective measures are particularly important if someone changes sexual partners frequently. They can significantly reduce the risk of syphilis, but not eliminate it completely. The syphilis pathogen can also be transmitted when kissing or just touching, for example if the infected person has ulcers in the mouth and the partner has tiny skin or mucous membrane injuries.

Caution should also be exercised with articles and materials that have been in contact with the blood or infectious rash of early stage syphilis patients. This would include syringes, towels and bandages. They should not be reused. However, no special precautions (disinfection etc.) are necessary for normal social contacts – syphilis patients do not have to be avoided!

As part of prenatal care, the blood of the expectant mother is tested for syphilis, among other things. If the test is positive, the pregnant woman should be treated with penicillin immediately. The antibiotic also reaches the child via the placenta. It is therefore also treated. This can prevent or at least contain a childhood infection.

The blood of blood donors is also subjected to a syphilis test to prevent transmission through blood transfusions.


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