10 Minute Clinical Podacst on Syphilis

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum that can have serious health consequences if left untreated. The infection spreads primarily through direct contact with syphilitic sores, which typically occur on the genital, anal, or oral areas. Though syphilis was once thought to be largely under control, its prevalence has increased in recent years. This 10-minute clinic podcast discusses the new syphilis guidelines issued by the British Association for Sexual Health and HIV (BASHH) and how these impact those of us working in primary care.

Take-home points

Syphilis is caused by infection with the spirochete bacterium Treponema pallidum and is transmitted by direct contact with an infectious lesion, or by mother-to-child transmission via the placenta during pregnancy
Approximately one-third of sexual contacts of individuals with infectious syphilis will subsequently develop the disease
It may be categorised as early (primary), secondary and late (tertiary), with a latent stage following secondary syphilis.
Primary syphilis refers to local infection with a typical incubation period of 2-3 weeks
Secondary syphilis is a generalised infection, with an incubation period of 6-12 weeks
Following secondary syphilis, there is a latent stage.
Early latent syphilis refers to asymptomatic syphilis of less than two years’ duration
Late latent syphilis is syphilis that is asymptomatic for longer than two years
Tertiary (late symptomatic) syphilis can be split into cardiovascular syphilis, neurosyphilis and gummatous syphilis.
Early congenital syphilis occurs within the first two years of life.
Late congenital syphilis occurs in children older than 2 years.
Investigations should include a screen for all sexually transmitted infections (including HIV) as well as an investigation for other possible diagnoses.
All patients with neurological signs or symptoms and those who fail treatment should have a lumbar puncture and neurological imaging if appropriate.
Serology testing should be performed in all patients with signs or symptoms of syphilis.
The usual approach is a treponemal test as the initial serological test, followed by a non-treponemal test if the treponemal test is positive.
Treponemal tests include Treponemal enzyme immunoassay (EIA), T. pallidum haemagglutination assay (TPHA), fluorescent antibody absorption (FTA-ABS) and immunocapture assay (ICA).
The Treponema pallidum particle agglutination (TPPA) assay was withdrawn from the UK in 2022
Following a positive treponemal test, a non-treponemal test should always be undertaken to confirm the diagnosis and to provide evidence of active disease or reinfection.
Non-treponemal tests include the RPR test and the VDRL test
Treponemal-specific tests remain reactive lifelong and so are unable to differentiate between active and past infections, or monitor response to treatment.
Treatment should be within a sexual health clinic, along with enquiries about sexual contacts
The treatment of syphilis infection is curative with appropriate antibiotics.
Parenteral benzylpenicillin is the first-line drug treatment for all stages of syphilis
When using antibiotics in syphilis, the Jarisch-Herxheimer reaction must always be remembered as a possible effect in many people.
Treatment failure is characterised by a four-fold or greater increase in non-treponemal test titre, recurrence of signs or symptoms and exclusion of re-infection