Syphilis is a chronic, systemic sexually transmitted disease (STD) caused by Treponema pallidum. The vast majority of cases are transmitted through sexual contact. The clinical manifestations of syphilis include primary syphilis, secondary syphilis, tertiary syphilis, and latent syphilis. It is listed as a Class B infectious disease under the "Law of the People's Republic of China on the Prevention and Treatment of Infectious Diseases."
1. Clinical Manifestations of Acquired Manifest Syphilis
1.1 Clinical Manifestations of Primary Syphilis: The hallmark clinical feature is the chancre.
Common sites include: penis, glans, coronal sulcus, prepuce, urethral opening; labia majora and minora, clitoris, cervix; anus, anal canal, etc. Chancres can also appear on the lips, tongue, and breasts.
Characteristics of chancres: They appear 7-60 days after infection with T. pallidum. Most patients have a single, painless, non-itchy, round or oval ulcer with clear borders that protrudes above the skin surface. The sore is relatively clean, though secondary infections may produce more secretions. It feels like cartilage when touched. The duration is 4-6 weeks, and it can heal spontaneously. Chancres can coexist with secondary syphilis and need to be differentiated from local ulcerative lesions such as soft chancres, genital herpes, and fixed drug eruptions.
Syphilitic bubo: 1-2 weeks after the appearance of a chancre, some patients develop inguinal or sentinel lymph node swelling. It can be solitary or multiple, varying in size, hard, non-adherent, non-ulcerated, and painless. This is called syphilitic bubo.
1.2 Clinical Manifestations of Secondary Syphilis: Characterized by secondary syphilis rash, accompanied by systemic symptoms, which occur or overlap after the disappearance of chancres.
T. pallidum spreads via the bloodstream, causing damage to multiple areas and various lesions. It affects the skin, mucous membranes, bones, internal organs, cardiovascular system, and nervous system. When syphilis enters its second stage, all laboratory diagnostic tests for syphilis are positive.
Systemic symptoms occur before the appearance of rashes, including fever, headache, bone and joint pain, hepatosplenomegaly, and lymphadenopathy. In males, the incidence is about 25%; in females, it is approximately 50%. Symptoms improve within 3-5 days. Subsequently, syphilis rash appears, characterized by recurrence.
1.2.1 Skin Syphilis Rash: Occurs in 80-95% of patients. Features include diverse rash types, recurrence, extensive and symmetrical distribution, no pain or itching, minimal scarring after healing, rapid resolution with anti-syphilis treatment, and high concentration of T. pallidum in the rash. Major rash types include macular, papular, pustular syphilis rash, and flat condyloma, palmoplantar syphilis rash, etc.
1.2.2 Recurrent Syphilis Rash: After the spontaneous resolution of primary syphilis rash, about 20% of secondary syphilis patients will relapse within one year. Any symptom of secondary syphilis can reappear, with annular papules being the most common.
1.2.3 Mucosal Damage: About 50% of patients experience mucosal damage. It occurs on the lips, oral cavity, tonsils, and throat, manifesting as mucosal patches or mucositis, with exudate or gray-white membrane and redness and swelling of the mucosa.
1.2.4 Syphilitic Alopecia: Accounts for about 10% of patients. Mostly sparse, with unclear boundaries, resembling insect erosion; a few are diffuse.
1.2.5 Bone and Joint Damage: Periostitis, osteitis, osteomyelitis, and arthritis, accompanied by pain.
1.2.6 Clinical Manifestations of Secondary Ocular Syphilis: Includes syphilitic iritis, iridocyclitis, choroiditis, retinitis, etc., often bilateral.
1.2.7 Clinical Manifestations of Secondary Neurosyphilis: Often asymptomatic, with abnormal cerebrospinal fluid (CSF) and positive CSF RPR. Meningitis symptoms may occur.
1.2.8 Clinical Manifestations of Secondary Relapsing Syphilis: Commonly seen are recurrent syphilis rash and mucosal damage, with possible other damages but milder symptoms.
1.2.9 Generalized Superficial Lymphadenopathy
1.3 Clinical Manifestations of Tertiary Syphilis: One-third of overt T. pallidum infections progress to tertiary syphilis. Among them, 15% are benign late syphilis, and 15-20% are malignant late syphilis.
1.3.1 Skin and Mucosal Damage: Nodular syphilis rash commonly occurs on the scalp, shoulder blades, back, and extensor surfaces of the limbs. Gummatous swelling often happens on the lower legs, forming deep ulcers and atrophic scars; when occurring on the upper jaw, tissue necrosis and perforation occur; nasal septum involvement leads to bone destruction, resulting in saddle nose; tongue involvement presents as burrowing ulcers; vaginal damage manifests as ulcers, possibly leading to vesicovaginal fistula or rectovaginal fistula.
1.3.2 Periarticular Nodules: Slow-growing subcutaneous fibrous nodules due to syphilitic fibroma, symmetrically distributed, varying in size, firm, immobile, non-ulcerated, with normal epidermis, no inflammation, painless, and capable of spontaneous regression.
1.3.3 Cardiovascular Syphilis: Primarily affects the aortic arch, leading to aortic valve insufficiency, i.e., syphilitic heart disease.
1.3.4 Clinical Manifestations of Neurosyphilis: Incidence is about 10%, often occurring 10-20 years after T. pallidum infection. Can be asymptomatic or present with syphilitic meningitis, cerebral vascular syphilis, meningeal gumma, paralytic dementia. Meningeal gumma involves lesions under the cortex of one cerebral hemisphere, leading to increased intracranial pressure, headaches, and localized brain compression symptoms. Substantive neurosyphilis refers to substantial lesions in the brain or spinal cord; the former results in paralytic dementia, while the latter shows degeneration of the posterior roots and posterior columns of the spinal cord, sensory abnormalities, ataxia, among other symptoms, known as tabes dorsalis.
2. Clinical Manifestations of Acquired Latent Syphilis
After congenital infection with T. pallidum without developing manifest syphilis or after a certain active period of manifest syphilis where symptoms temporarily subside, syphilis serological tests are positive, and CSF examination is normal, this is referred to as acquired latent syphilis. If the infection occurs within 2 years, it is called early latent syphilis; if over 2 years, it is termed late latent syphilis.
3. Clinical Manifestations of Syphilis During Pregnancy
When manifest or latent syphilis occurs during pregnancy, it is called gestational syphilis. In gestational syphilis, T. pallidum can be transmitted to the fetus via the placenta or umbilical vein, leading to congenital syphilis in the newborn. Pregnant women suffering from small artery inflammation leading to placental tissue necrosis may cause miscarriage, premature birth, stillbirth, but nearly 1/6 of these pregnant women can give birth to healthy babies.
4. Clinical Manifestations of Congenital Manifest Syphilis
4.1 Early Congenital Syphilis: Infants are born underweight, and symptoms appear around 3 weeks after birth. There is generalized lymphadenopathy, non-adherent, painless, and hard. Many infants have syphilitic rhinitis. Around 6 weeks after birth, skin lesions appear, presenting as bullous-vesicular type lesions (syphilitic pemphigus) or maculopapular and papulosquamous lesions. Osteochondritis and periostitis may occur. Hepatosplenomegaly, thrombocytopenia, and anemia are common. Neurosyphilis is rare, and the absence of chancres is one of the characteristics of congenital syphilis.
4.2 Late Congenital Syphilis Clinical Manifestations: Usually occur after 2 years of age. One category includes permanent damage to bones, teeth, eyes, nerves, and skin caused by early lesions, such as saddle nose, Hutchinson's teeth, etc., without activity. Another category involves clinical manifestations due to active damage, such as keratitis, neurosensory deafness, abnormal neurological signs, changes in CSF, hepatosplenomegaly, nasal or palatal gumma, joint effusion, periostitis, dactylitis, and skin and mucosal damage.
5. Clinical Manifestations of Congenital Latent Syphilis
Without treatment, there are no clinical symptoms, but serological reactions are positive. If the age is less than 2 years, it is classified as early congenital latent syphilis; if greater than 2 years, it is termed late congenital latent syphilis.
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