Syphilis history and symptoms

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Aysha Anwar, M.B.B.S[2]Nate Michalak, B.A. Maha Jaffar Azhar, M.D. Muhammad Saad, M.B.B.S.[3]

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## Overview

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The history and symptoms of syphilis depends on stage of disease. The hallmark of syphilis infection is painless chancre. A positive history of painless chancre on genitalia, and presence of risk factors such as unprotected sex, multiple sexual partners, residence in highly prevalent area and previous history of sexually transmitted infections may be suggestive of syphilis infection. The most common symptoms of syphilis infection include painless chancre which progresses to ulcer with regional lymphadenopathy in primary syphilis. Secondary syphilis is characterized by rash and constitutional symptoms. Syphilis infection in tertiary syphilis can involve any organ system, hence named the "Great Imitator".[1][2][3]

## History and symptoms

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The history and symptoms of syphilis according to the stage of disease are described below:[1][2][3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]

Stage of syphilis | History and symptoms

|

Primary syphilis |

* History of risk factors (MSM, unprotected sex, multiple sex partners)
* Onset within 3 weeks of contact

* Chancre:

* Single painless firm raised papule
* Rapidly progresses to an ulcerated lesion
* Usually located on the glans penis, cervix, labia, anal canal, rectum or oral cavity

* Nontender regional lymphadenopathy

* Heals spontaneously within 4-6 weeks; however, regional lymphadenopathy may persist for longer periods

Secondary syphilis |

* Develops 6-8 weeks after the appearance of primary chancre
* Generalized systemic symptoms such as malaise, fatigue, headache and fever may be present
* Nephrotic syndrome and syphilitic hepatitis
* Skin eruptions may be subtle and asymptomatic
* Classic:

* Non-pruritic bilateral symmetrical mucocutaneous rash
* Non-tender regional lymphadenopathy
* Condylomata lata
* Patchy alopecia

Early latent syphilis | No symptoms or findings on examination with a reactive serologic test for syphilis plus

* (1)a documented non reactive serologic test or sustained 4-fold or greater increase in titer of a nontreponemal test during the prior year,

* (2)unequivocal symptoms of primary or secondary syphilis, or

* (3)a sex partner documented to have primary, secondary, or early latent syphilis during the prior year

Late latent syphilis  |

* Asymptomatic

Tertiary (late) syphilis  | Clinical manifestation of this stage depends on organ system involved:

Symptomatic late neurosyphilis Cardiovascular syphilis

* Aortic Regurgitation

* Dyspnea on exertion
* Orthopnea
* Paroxysmal nocturnal dyspnea
* Palpitations (due to compensatory tachycardia)
* Chest pain (if left ventricular end diastolic pressure compromises coronary perfusion)

* Congestive heart failure

* Dyspnea on ordinary exertion
* Fainting
* Fatigue
* Hemoptysis or frothy sputum
* Nocturia or urination during the night
* Nocturnal cough
* Orthopnea or sleeping on pillows
* Palpitations or extra heart beats
* Paroxysmal nocturnal dyspnea
* Shortness of breath

Gummatous lesions

* Presents with any organ system involved.
* Nodular papular lesions in case of cutaneous gumma.

Symptomatic early neurosyphilis  | Meningitis:

* headache,
* blurred vision,
* nausea/vomiting Cranial nerve dysfunction: III, VII, VIIII

Symptomatic late neurosyphillis | General paresis:

* personality or mood changes,
* dementia,
* cognitive decline,
* and behavioral defects

Tabes dorsalis:

* sharp stabbing pain in limbs or abdomen;
* bladder disturbances, rectal incontinence;
* loss of deep tendon reflexes, proprioception, touch, pain, and vibratory sensation;
* positive Romberg sign;
* and gait disturbances

Ocular and otic syphilis | Ocular syphilis can present as

* conjunctivitis,
* scleritis,
* episcleritis,
* uveitis,
* chorioretinitis,
* retinitis
* vasculitis

Otosyphilis can present as

* sensorineural hearing loss,
* tinnitus,
* vertigo and
* may include osteitis of temporal bone; patient may report haring loss, ringing in ears, and dizziness/vertigo

## References

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1. ↑ 1.0 1.1 Singh AE, Romanowski B (1999). "Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features". Clin Microbiol Rev. 12 (2): 187–209. PMC 88914. PMID 10194456.
2. ↑ 2.0 2.1 Carlson JA, Dabiri G, Cribier B, Sell S (2011). "The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity". Am J Dermatopathol. 33 (5): 433–60. doi:10.1097/DAD.0b013e3181e8b587. PMC 3690623. PMID 21694502.CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 Wöhrl S, Geusau A (2007). "Clinical update: syphilis in adults". Lancet. 369 (9577): 1912–4. doi:10.1016/S0140-6736(07)60895-2. PMID 17560432.
4. ↑ Peterman TA, Kidd SE (January 2019). "Trends in Deaths Due to Syphilis, United States, 1968-2015". Sex Transm Dis. 46 (1): 37–40. doi:10.1097/OLQ.0000000000000899. PMC 6743072 Check `|pmc=` value (help). PMID 30044338.
5. ↑ Ropper AH (October 2019). "Neurosyphilis". N Engl J Med. 381 (14): 1358–1363. doi:10.1056/NEJMra1906228. PMID 31577877.
6. ↑ Hamill MM, Ghanem KG, Tuddenham S (May 2024). "State-of-the-Art Review: Neurosyphilis". Clin Infect Dis. 78 (5): e57–e68. doi:10.1093/cid/ciad437. PMID 37593890 Check `|pmid=` value (help).
7. ↑ Maghsoudlou P, Epps SJ, Guly CM, Dick AD (August 2025). "Uveitis in Adults: A Review". JAMA. 334 (5): 419–434. doi:10.1001/jama.2025.4358. PMID 40434762 Check `|pmid=` value (help).
8. ↑ Ramchandani MS, Litvack JR, Marra CM (May 2020). "Otosyphilis: A Review of the Literature". Sex Transm Dis. 47 (5): 296–300. doi:10.1097/OLQ.0000000000001155. PMC 8530448 Check `|pmc=` value (help). PMID 32149965 Check `|pmid=` value (help).
9. ↑ Jenkins DC (May 1968). "Observations on the early migration of the larvae of Ascaris suum Goeze, 1782 in white mice". Parasitology. 58 (2): 431–40. doi:10.1017/s0031182000069456. PMID 5740484.
10. ↑ Madonna MJ, Zhu YF, Lampen JO (February 1987). "Nucleotide sequence of the beta-lactamase I gene of Bacillus cereus strains 569/H and 5/B". Nucleic Acids Res. 15 (4): 1877. doi:10.1093/nar/15.4.1877. PMC 340593. PMID 3103105.
11. ↑ "The Modern Epidemic of Syphilis | New England Journal of Medicine".
12. ↑ "Primary and secondary syphilis, 20 years' experience. 2. Clinical features. | Sexually Transmitted Infections".
13. ↑ Forrestel AK, Kovarik CL, Katz KA (January 2020). "Sexually acquired syphilis: Laboratory diagnosis, management, and prevention". J Am Acad Dermatol. 82 (1): 17–28. doi:10.1016/j.jaad.2019.02.074. PMID 30986474.
14. ↑ "Syphilitic hepatitis".
15. ↑ "Renal manifestations of syphilis - Shettigar - 2021 - Internal Medicine Journal - Wiley Online Library".

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