Syphilis

There is one thing about syphilis worth knowing above all others: it responds beautifully to treatment, but it never clears up on its own. The sore heals without any treatment at all, the rash fades and goes, and it is easy to assume you got away with it. What has actually happened is that the infection has withdrawn inwards and carries on living in the body for years, still infectious and slowly damaging the blood vessels, the heart and the nervous system. All it takes to prevent that is a blood test and a course of antibiotics. The only thing standing in the way is the belief that if the symptoms have gone, so has the illness.

The first sign: a sore that does not hurt

Three or four weeks after infection (sometimes ten days, sometimes three months) a small ulcer appears where the infection entered: the chancre.

• There is usually just one, round, with a firm base and clean edges, anywhere from a few millimetres to a centimetre across.
• It is painless, and that is its defining feature. It is precisely why it gets missed: a sore that does not hurt does not read as a warning.
• It sits wherever contact happened: on the penis, on the vulva and inside the vagina, around the anus, but also on the lips, tongue, throat or fingers. Inside the vagina, the rectum or the throat it simply cannot be seen.
• Nearby glands often swell, in the groin or the neck, and they too are firm and painless.

The sore heals by itself in three to six weeks, often without a trace. That is not recovery. It is the end of the first stage, and everything that was in the body is still there.

The second wave: a rash on the palms and soles

Weeks or months after the sore heals, the infection spreads through the whole body and the second stage begins. Its features vary enormously, and doctors do not call syphilis the great imitator for nothing: it can look like a great many other illnesses.

• A rash that does not itch, made up of pale pink or coppery-red spots and small bumps. Its most recognisable feature is lesions on the palms of the hands and the soles of the feet, where an ordinary allergic rash almost never appears.
• Swollen glands in several places at once: neck, armpits, groin.
• A general unwellness like a cold that will not end: tiredness, a mild temperature, sore throat, headache and aching muscles, poor appetite.
• Soft moist growths in the skin folds and around the anus, whitish patches in the mouth, a hoarse voice.
• Patchy hair loss on the scalp, eyebrows or beard, with a moth-eaten look.

All of this also settles by itself, over weeks or months. And that too is not recovery. In some people the second stage returns in waves during the first year or two.

The latent stage: a silence that misleads

Once the rash fades, the latent stage begins. There are no symptoms at all, sometimes for decades. The person looks well, feels well, and the only way to know about the infection during that time is a blood test.

Meanwhile, without treatment, about a third of people go on to develop late syphilis. It arrives after many years — five, ten, thirty — and the damage it leaves cannot be undone: antibiotics kill the organism, but they do not rebuild destroyed tissue.

• Heart and blood vessels: inflammation of the aortic wall, widening and tearing of the aorta, damage to the aortic valve, narrowing of the heart's own arteries.
• Nervous system: unsteady walking and poor coordination, shooting pains, loss of sensation in the legs, incontinence, changes in personality, failing memory, dementia.
• Gummas: nodules that destroy the tissue where they form, whether in the skin, bones, liver or palate.

That list is the reason to have the test. Late syphilis today is almost always the consequence of someone once deciding that, since everything had settled, there was no need to be treated.

Nervous system, eyes and ears: not only "years later"

There is a widespread misconception that the nervous system is only affected decades on. It is not so. The organism can reach the nervous system, the eye and the inner ear at any stage, including in the first months after infection.

So some signs call for urgent assessment rather than a routine appointment:

• loss or blurring of vision, eye pain, a red eye, discomfort in bright light, floaters, double vision;
• sudden loss of hearing in one or both ears, ringing or buzzing, vertigo with loss of balance;
• severe headache, a stiff neck, weakness or numbness in the limbs, changed speech, seizures.

Eye and ear involvement in syphilis responds well if treatment starts quickly, and leaves permanent loss if it is put off for weeks. If you have been diagnosed with syphilis or it is a possibility, and your sight or hearing has worsened, say so plainly and do not wait for a routine slot.

How the diagnosis is made

Testing is simple, widely available and reliable.

A blood test is the mainstay at every stage. Usually two tests are done: one shows whether there has ever been contact with the organism, the other how active the infection is now, and it is the second that is later used to judge whether treatment has worked. One important detail: in the first weeks after infection the test can still be negative. If the exposure was recent, your doctor will arrange a repeat a few weeks later, and that repeat matters.

Testing material from the sore. If an ulcer is present, a sample is taken from it, and this confirms the diagnosis straight away, before antibodies have even appeared.

Beyond that, a sample of spinal fluid may be needed if nervous system involvement is suspected, along with an eye examination and a hearing test. And you will almost always be offered testing for other sexually transmitted infections at the same time, HIV included: they often travel together, and syphilis also makes catching HIV easier.

It is worth being tested if: you or a partner have any of the signs described; a partner has told you they have syphilis or another infection; you have had sex without a condom with a new partner; you are pregnant or planning to be; you have shared a needle.

Treatment and the checks that follow

Syphilis is treated with antibiotics, and it is one of those uncommon cases where treatment genuinely cures. The mainstay is the penicillin group, usually by injection; where there is allergy, there are alternatives. The number of doses and the length of the course depend on the stage: early disease is treated briefly, while late disease and nervous system involvement need longer courses, usually given in hospital. A doctor sets the regimen; self-treating here is pointless and dangerous, because a partly treated infection simply moves into the latent stage.

What to expect from treatment:

• In the first day after the first injection a reaction is possible: shivering, a temperature, headache and aching muscles, a rash that flares. It is the body responding to the mass die-off of the organism, it lasts a few hours and it settles by itself. There is no need to be alarmed, but it is worth being warned in advance, particularly in pregnancy.
• Sex is off the table until treatment is complete and the follow-up test confirms it has worked; otherwise a partner will be infected, or will reinfect you.
• Follow-up blood tests are not optional. Blood is checked a few months after treatment and then over the following year or two, to make sure the numbers are falling as they should. In many people one of the tests stays positive for life: that is the footprint of a past infection, not a sign that treatment failed, and your doctor will explain it.

Syphilis and pregnancy

This is the part that gives everything above its practical point. Syphilis passes from mother to baby during pregnancy, and that is entirely preventable.

Untreated, the infection causes miscarriage, premature birth, stillbirth, or congenital syphilis in the baby: damage to the bones, liver, skin, eyes, hearing and nervous system, some of it permanent. That is why a syphilis blood test is part of antenatal care and is offered to every pregnant woman without exception, whatever her age, her circumstances or how unlikely the situation seems. Where there is a risk of infection during the pregnancy, the test is repeated.

Treatment in pregnancy is always given, using penicillin-group medicines, which are safe for the baby. The earlier it starts, the more likely the baby is to be born healthy, and started early the odds are very good indeed. After delivery the baby is tested and followed up. Turning down treatment out of fear of antibiotics in pregnancy is the gravest mistake in this whole subject: the risk from the untreated infection is incomparably greater.

Partners, reinfection and protection

Infection passes on through contact with the sore or the skin lesions, during vaginal, anal and oral sex, and occasionally through close skin contact with an affected area. A person is most infectious during the first year of the illness. It also passes through shared needles and from mother to baby.

What matters here:

• Partners need testing and treatment. That means a current partner and anyone there was contact with in the preceding months; your doctor will say how far back to go, based on the stage. Partners are often treated even when their own test is still negative, because the infection may not have declared itself yet. They can be notified anonymously, without your name being given.
• Having had syphilis gives no immunity. Once cured you can catch it again, even a month later, and repeat infections are not rare. It is not a relapse, it is a new infection, and it is treated from scratch.
• Condoms lower the risk but do not remove it: they protect only what they cover, and lesions can lie outside that area. For oral sex, use a condom or a latex square.
• Do not share needles or lend your own; sex toys do not go from one person to another without being washed and re-covered.
• With changing partners, regular sexual health testing is worth doing even with no symptoms. That is how syphilis is most often caught in time.

Online consultation

A subject that is hard to raise is exactly where a remote appointment earns its keep: you can ask calmly, with no waiting room. The doctor will go through your situation properly: whether there was a risk, how long ago, when a test will be reliable and which tests specifically to ask for. They will help you read a result you already have, since a report with two different tests and titres is nearly impossible to interpret alone, and explain what a lingering positive from an old, treated infection means. They will suggest how to approach the conversation with a partner and how far back the contact period should reach. They will work through the pregnancy questions: when to test, what happens if it is positive, how treatment and the baby's follow-up are handled. And they will flag separately the eye, ear and neurological signs where the answer is not to message a doctor but to be seen urgently.

This material is for information only and does not replace medical advice.