Syphilis

The disease, also known by names such as "frengi" and lues, is one of the oldest diseases, but it was only noticed and described in the 16th century because of the epidemic it caused in Europe. In our country, the disease was first mentioned in 1505 by the surgeon İbrahim Abdullah. Today syphilis continues to be one of the major health problems. It is estimated that about 12 million new cases of infectious syphilis occur each year.

Aetiology

The causative agent of syphilis is Treponema pallidum, a microaerophilic spirochaete. This microorganism, which is very mobile especially under dark-field microscopy, has 3 characteristic movements: corkscrew rotation, undulation, and lengthening and shortening. It stains pale pink with Giemsa stain and can also be stained with India ink and silver staining. To date it has not been possible to culture it in tissue cultures or on non-living media. It is a very delicate microorganism: it cannot withstand drying, and it becomes immobile and dies under the effect of salt water and glycerine. In blood it dies within 2–3 days.

Classification

1) Acquired: early syphilis (1st and 2nd stages), latent syphilis, late syphilis (3rd stage)

2) Congenital: early congenital, late congenital

Stage 1

After an incubation period of about 1 month (10–90 days), a lesion called the syphilitic chancre appears at the site where the microorganism entered. One week after the sore appears, bilateral regional lymphadenopathy develops; the nodes are soft, mobile and not attached to the underlying tissues. The syphilitic chancre is bright red and shiny and is characteristically painless. In 95% of cases it is located in the genital area. Although rare, it can be seen in other areas such as the tongue, lips, cheeks, neck, earlobes and fingers. This stage lasts about 6–8 weeks, and even if the patient is not treated, the chancre heals on its own without scarring. The base of the chancre is hard and indurated. This feature is important in distinguishing syphilis from ulcus molle (chancroid), in which the base of the ulcer is irregular and uneven and the floor is soft.

Stage 2

This stage can appear immediately after stage 1 or 2–6 months later, depending on the patient's immune system. At this stage the microorganism can spread to all organs via the blood and lymph. This is the stage in which symptoms appear most. Fever, tiredness, malaise, weakness and muscle pain are common. It is the most contagious stage of the disease, and high numbers of Treponema pallidum are found in all tissues.

The most important skin sign is roseola syphilitica, a widespread erythema usually seen on the trunk and arms. The roseolar lesions can be confused with viral exanthems. As a papular sign, syphilis papulosa miliaris is located on the trunk and is a non-itchy, firm, copper-red papule the size of a pinhead. Another, syphilis papulosa lenticularis, is located on the trunk and limbs and appears as lentil-sized, copper-red papules. The particular arrangements of these lesions are important for diagnosis; for example, those arranged linearly along the forehead hairline are called "Corona Veneris". Those located side by side along the edges of the nasal folds and covered with greasy scales are called "Certificat de Vérole". Syphilis papulosa nummularis is larger than the lenticular papules, pink-red, round or oval, and sometimes covered with hard scales; for this reason it is also called papulosquamous or psoriasiform syphilis. Erosions may sometimes develop on those located in the genital area; if they become hypertrophic and vegetative, they are called "condylomata lata". Condylomata lata are skin-coloured or slightly pigmented, flat-topped, moist, weeping, macerated lesions and are contagious. Sometimes the papules may be covered with cauliflower-like vegetations.

The skin signs of secondary syphilis heal without scarring within 1–2 weeks even without treatment. Lesions on the neck that heal leaving hypopigmentation are called leucoderma colli or the "necklace of Venus". The tongue and oral mucosa are frequently affected. When an angina specific to syphilis develops on the oral mucosa, it is called "Angina Syphilitica sive Specifica". The tonsils are oedematous and hard, red around the edges and covered with a grey-yellowish purulent coating.

Syphilis lesions can settle on the epiglottis and cause hoarseness. Lesions in the mouth should be distinguished in particular from leukoplakia, lichen planus, hairy leukoplakia and candidiasis. Pustular lesions are rare in syphilis. Small pustules on the face and trunk are called syphilitic acne. Large pustules are called variola syphilitica because they closely resemble variola or varicella.

Alopecia may develop in 3–7% of patients, and it heals completely once the syphilis has been treated. The outer parts of the eyebrows may fall out; this is called the omnibus sign. Complete loss of hair in syphilis is called "Alopecia specifica diffusa". Syphilis can cause nail breakage, raised nails, pitting, fissures, dystrophy and onycholysis; these disorders are called "Onychia syphilitica". Because of the septicaemia caused by syphilis, the development of generalised lymphadenopathy is inevitable and can occur in the neck, armpits, nape and behind the ears; symmetrical enlargement of the epitrochlear lymph nodes in particular is typical of syphilis.

Congenital Syphilis

Treponema pallidum can easily cross the placenta and infect the foetus. The microorganism can be transmitted to the foetus or newborn across the placenta and during birth. If the mother is treated early in pregnancy, the disease can be prevented. Spirochaetes can cross the placenta and infect the foetus from the 14th week of pregnancy, and this risk increases with gestational age. In 25% of mothers with untreated primary and secondary syphilis, the foetus is lost before birth. Early infections after the 18th week of pregnancy usually end in spontaneous abortion. Congenital syphilis is divided into two periods: early (first 2 years) and late (after 2 years).