Another Public Health Epidemic in the U.S.

Last week, the CDC issued a media release (U.S. Syphilis Cases in Newborns Continue to Increase: A 10-Times Increase Over a Decade | CDC Online Newsroom | CDC) warning of a 10-fold increase in the numbers of congenital syphilis cases resulting from the rapidly accelerating epidemic of sexually transmitted diseases (specifically, gonorrhea and syphilis) in the U.S. (though this problem is not limited to the U.S.).

What causes syphilis and how is the infection transmitted?

Syphilis is a disease that results from infection with a bacterium called Treponema Pallidum. Most often, transmission of this infection occurs with sexual activity, regardless of whether homosexual or heterosexual in nature. Generally, transmission results from direct contact with a chancre, which is a syphilitic sore oftentimes resembling a superficial ulcer. The chancre is typically painless; however, exceptions occur such as when the chancre is located on the anus.

Chancres typically appear on the penis, vagina, anus, rectum, lips or mouth. However, the person who is the source of the infection is not always aware that they have a chancre, and the person who becomes infected may not notice the chancre, especially when it is located inside the sex partner’s mouth, vagina or rectum. Thus, transmission most often occurs during oral sex, vaginal intercourse or anal-receptive sex and the chancre develops at the site where the bacteria (often referred to as spirochetes because of their corkscrew-like appearance under the microscope) are inoculated – i.e, on the lips or in the mouth with oral sex, on the penis with intercourse, on the labia or in the vagina with vaginal intercourse, and on the anus or in the rectum with anal-receptive sex. Of great concern is the potential for a pregnant mother to infect their unborn fetus through placental transfer of the bacteria (see below).

Syphilis can be successfully treated with antibiotics.

What is the natural course of infection if left untreated?

After exposure to Treponema Pallidum from sexual contact with someone who is infected, the incubation period (the time period between exposure and subsequent infection until the disease becomes manifest) can range from 10 days to 3 months, but on average is 3 weeks. The resulting disease is referred to as primary syphilis and is generally recognizable by the development of one or more chancres (multiple chancres are more common in HIV-positive individuals). At this point, the patient is contagious and may remain infectious to others for up to a year if untreated. The patient may have enlarged lymph nodes (which most often are not tender) in the area near the chancre. If a woman becomes infected and is not treated, she can transmit the infection to her unborn baby if she becomes pregnant up to four years later.

Even without treatment, the chancre tends to resolve on its own over the course of 3 – 6 weeks, with or without leaving a small scar behind. However, when the patient is not treated for syphilis, the disease most often progresses to secondary syphilis.

Secondary syphilis occurs between 4 and 10 weeks after the initial chancre of primary syphilis. It is difficult to identify secondary syphilis other than by performing a screening blood test based on the patient being at risk due to unknown or multiple sexual partners or suspicion when a wide range of possible rashes appear.

The classic rash of secondary syphilis is one that does not cause itching and appears on the palms of both hands. The other place I always check is the bottom of the feet. The rash can be very faint, so one has to look closely. Secondary syphilis is the great masquerader and may present with rash over the back, areas of hair loss, a patch on the tongue, or condylomas (wart-like skin lesions) over the genital areas (though they can occur in the mouth) that are typically white or gray in color. These rashes can easily be confused with other diseases and conditions.

Some patients will have symptoms during secondary syphilis, such as fever, headache, muscle aches, fatigue, and even weight loss. However, many patients do not report symptoms. The symptoms will resolve with or without treatment. However, if not treated, the disease will most often then progress to latent syphilis, and in some cases, to tertiary syphilis.

Latent syphilis can only be detected with a blood test. There are no rashes or symptoms to suggest that infection is present. The latent stage can last many years.

The dreaded consequences of untreated syphilis are the potential for transmission to an unborn child and the development of the next phase of syphilis called tertiary syphilis. Tertiary syphilis can affect the brain (severe headaches, confusion, dementia, weakness, paralysis), nerves (numbness and loss of sensation), eyes (pain, redness, blurred vision or even loss of vision), heart, blood vessels, liver, bones and/or joints. It also can be fatal.

What is congenital syphilis?

An infected pregnant mother can transmit the infection to the developing fetus with potentially severe consequences to the baby. Therefore, testing for syphilis is recommended in all pregnant moms at their first prenatal visit, especially since physical signs of syphilis are often not evident. If the mom has risk factors for acquiring syphilis (drug use, sex worker, multiple sex partners, homelessness, incarceration or sexual partner has been incarcerated), then repeat testing in the third trimester is indicated.

Untreated syphilis during pregnancy sadly can cause the baby to be stillborn (often after 20 weeks) or tragically, to die shortly after birth in as much as 40 percent of pregnancies.

Babies who survive to be delivered can appear to be normal, but then deteriorate several weeks later. Even if the baby survives, developmental delays and seizures may result. Babies can also have wide-ranging signs of congenital syphilis including rashes, bleeding from the nose, anemia, liver enlargement or jaundice, lung and/or kidney problems, among others. These problems tend to manifest within the first two years of life, whereas toddlers with congenital syphilis can develop a number of deformities and loss of hearing after the age of 2 years.

Unfortunately, more than 3,700 babies were born with congenital syphilis in 2022, more than 10 times the number just a decade ago. It is estimated that 90 percent of these cases could have been avoided with early and proper prenatal care and prompt treatment.

If you have unknown or multiple sex partners, please get testing on a regular basis. If you are concerned about anonymity, contact your local health department for confidential STI (sexually transmitted infections) screenings and testing. Keep in mind, you can have more than one STI. My personal record as a physician is diagnosing a patient with 5 STIs at the same time.

If you become pregnant, be sure to get prenatal care right away and on a regular basis.