English
What do composer Franz Schubert,1 President Abraham Lincoln,2 author James Joyce,2 and gangster Al Capone3 all have in common? If you guessed that they were all infected with syphilis, you’d be correct.
Syphilis, a major public health threat, may have faded from the forefront of public consciousness, but it remains a persistent and significant concern. Globally, syphilis has significantly increased over the last 25 years.4 In 2022 alone, the World Health Organization (WHO) estimated that 8 million adults (age 15-49) acquired syphilis.5 In the United States, syphilis cases increased 76% between 2013 and 2017.4
Caused by the bacterium Treponema pallidum, syphilis has the potential to cause severe complications, including neurological and cardiovascular damage, underscoring the importance of awareness and early detection.
A Brief History of Syphilis
The first recorded outbreak of syphilis in Europe occurred in 1495 in Naples, Italy, during the French invasion. The disease spread rapidly across Europe, earning the name "French disease" before the term "syphilis" was coined by Italian physician Girolamo Fracastoro in 1530.6
‘One night with Venus, a lifetime with Mercury’7
As a sexually transmitted disease, syphilis ran rampant through brothels and those that visited them. Mercury was first used to treat syphilis in the late 1400s by Giorgio Sommariva.7 Although somewhat effective, mercury was dangerous, with many people dying from mercury poisoning. Over the years, many other remedies were tried, but with limited success. In the 19th century, salvarsan, an arsenic compound that interferes with bacterial metabolism, was identified by Paul Ehrlich to treat syphilis. Salvarsan was only available as an injection and caused serious side effects including fever, chills, vomiting, and kidney damage. It was also known to cause a painful reaction at the injection site.4
The introduction of penicillin for clinical use in 1943 revolutionized the treatment of syphilis, drastically reducing its prevalence and severity. Treatment with penicillin is now the standard of care7—for the allergic population, ceftriaxone may be an alternative.
Disease transmission
Syphilis is primarily transmitted through direct contact with a chancre—a painless sore on the genitals, rectum, or mouth, where the bacteria entered the body—during vaginal, anal, or oral sex. Chancre sores can appear on the external genitals, anus, rectum, lips, or inside the mouth. As the sores are usually painless, the individual may not realize they are infected. Syphilis can also be transmitted from a pregnant mother to her unborn child, leading to congenital syphilis. As a result, both the CDC and the WHO recommend that pregnant women are screened for syphilis at least during the first prenatal care visit to prevent vertical transmission and fetal complications such as bone deformities and brain involvement.8,9 Though rare, transmission can also occur through blood transfusions or sharing needles—however, drug use is associated with an increase in high-risk sexual behaviors that may lead to disease transmission. Practicing safe sex, including the use of condoms, and avoiding the sharing of needles may reduce the risk of syphilis transmission.10
Disease progression
With its variable clinical manifestations that can mimic other diseases, syphilis is often called “the great imitator.” Syphilis has four phases—primary, secondary, latency, and tertiary. Symptoms of primary syphilis include a chancre. Fortunately and unfortunately, the chancre is usually small and painless, meaning that it is often not noticed during this highly infectious stage. The chancre usually appears within 3 weeks of exposure and heals in 3 to 6 weeks, but the bacteria remain in the body. Six to 12 weeks after the initial chancre resolves, secondary syphilis develops. With secondary syphilis, a rash may appear somewhere on the body accompanied by flu-like symptoms and hair loss. People are still highly contagious, and lesions appear at the site of the chancre. Symptoms of secondary syphilis resolve without treatment. Between Secondary and Tertiary syphilis, there is a period of often asymptomatic and mostly non-contagious latency that may last for years or even decades. While most infected individuals do not develop tertiary syphilis, 25-40% of those individuals with untreated syphilis will.11 Tertiary syphilis can appear years after secondary syphilis has resolved. Tertiary syphilis is the late stage of syphilis infection, occurring when the body’s immune system fails to control the infection. Symptoms of tertiary syphilis can range from skin lesions to dementia-like symptoms to cardiovascular problems and beyond. Syphilis in the tertiary stage can cause death.12
Syphilis remains a significant public health concern, despite advances in diagnostics and treatment. Public health efforts must continue to focus on education, regular screening, and prompt treatment to prevent the resurgence of syphilis infection. Synergizing public health efforts to reduce syphilis spread by addressing barriers to care, increasing access to testing and treatment, and promoting stigma reduction can help to improve equitable access to healthcare services. Understanding its history and the evolution of diagnostic methods highlights the importance of early detection and treatment. Modern diagnostic techniques, combined with historical knowledge, continue to play a role in managing and preventing the spread of syphilis.
The Tuskegee Syphilis Study
While beyond the scope of this blog, no overview of syphilis is complete without at least mentioning the horrors of the Tuskegee Syphilis Study. The Tuskegee Syphilis study was a deeply unethical and inhumane experiment conducted by the U.S. Public Health Service from 1932 to 1972. Black American men with syphilis were deliberately misled and subsequently left untreated—even after penicillin became available—so that physicians could study the progression of the disease. This atrocious behavior led to significant harm including unnecessary suffering and death, infection of the men’s wives, and congenital infection of their children, and highlighted severe racial and ethical violations in medical research.13,14
After prompting by the Tuskegee Legacy Committee,13 President Bill Clinton issued a formal apology for the Tuskegee Syphilis Study on May 16, 1997, acknowledging the unethical nature of the study and the suffering it caused to both the men involved and to their families. Learn more about the Tuskegee Syphilis Study here: https://www.tuskegee.edu/about-us/centers-of-excellence/bioethics-center/about-the-usphs-syphilis-study
