1. Syphilis – Clinical Aspects of Secondary Syphilis
Thad Zajdowicz, MD, MPH
Medical Director, STD/HIV Program
Chicago Dept of Public Health

2. I am the Medical Director for the STD/HIV Program of the Chicago Department of Public Health. Chicago is dealing with a multi-year outbreak of syphilis. Control of syphilis is possible only through a thorough understanding of its epidemiology, clinical manifestations, and links with other sexually transmitted diseases, such as HIV.

3. Why a lecture on syphilis?
Although syphilis is an eminently treatabledisease, its continuing occurrence illustrates that our control efforts still need to be improved The disease remains elusive clinically even today, and unless thought of and sought for can silently cause disease as it has for centuries. Further, control of syphilis is vital because of its interactions with HIV. This lecture will focus on secondary syphilis.
The presence of infectious syphilis (primary and secondary) is associated with a 2 to 5 fold increase in transmission of HIV.

4. Objectives To review the pathogenesis of secondary syphilis
To demonstrate the clinical features of secondary syphilis
To describe nondermatologic features of secondary syphilis

5. Clinical Stages
Syphilis is conventionally divided into several stages:
Primary
Secondary
Latent
Late, or tertiary
This lecture will focus on secondary syphilis
It is important to remember that syphilitic infection is a true continuum. Overlaps between primary and secondary syphilis are well recognized. Staging is a clinical exercise with prognostic and therapeutic implications. This lecture will focus on recognition of primary syphilis.

6. Natural History of Untreated Syphilis
It is important to understand the natural history of untreated syphilis. All patients with primary disease will progress to secondary disease; about a quarter will then recover spontaneously. Of the remaining patients who go on to latent syphilis, about 40% will have a relapse of secondary syphilis, generally within the first year. Over years, about 60% will continue to be latently infected and about 40% will go on to develop late manifestations of syphilis. Those late manifestations will cause incapacity and death in about 1/3 of those who were infected to begin with.

7. Progression Into Secondary Syphilis
Secondary syphilis is the most florid stage of syphilis
Systemic infection
Dermatologic findings are most common
However, treponemes infect virtually all tissues
Resolves when host immune response overcomes infection
Secondary syphilis occurs with widespread dissemination of Treponema pallidum. While the skin manifestations are most characteristic, constitutional symptoms are common, as well as symptoms referable to the CNS, kidneys, GI tract, and musculoskeletal system.

8. Histopathology
The basic lesions seen on histopathological examination in secondary syphilis are a perivascular infiltrate of mononuclear cells, including lymphocytes, monocytes, and plasma cells. This is accompanied by endothelial proliferation, leading to an obliterative enderarteritis.

9. Secondary Syphilis
Generalized maculopapular rash of the trunk (from the excellent Cornell web site,

10. Secondary Syphilis
The rash of secondary syphilis may be psoriasiform, as here on the palms of the hands.

11. Secondary Syphilis An example of lesions of secondary syphilis on the
foot, including the sole.

12. Secondary Syphilis
Click on the picture for a link to a nice case presentation of secondary syphilis on the Medscape web site. This is a typical papulosquamous eruption of secondary syphilis in a dark-skinned individual. The case history is also illustrative in that the patient denied having contact with STDs, but had a spontaneously healing “spider bite” on the penis some weeks before.

13. Secondary Syphilis
An example of the papulopustular form of syphilis (from

14. Secondary Syphilis
Patchy alopecia is common in secondary syphilis. This may include loss of the outer third of the eyebrows.

15. Condyloma Lata
Condyloma lata are described as large, grayis lesions found in moist areas. They may not be true manifestations of secondary syphilis, as they are frequently contiguous with a chancre and tend to precede the development of other skin lesions in secondary syphilis. They are also teeming with spirochetes and are dark-field positive.

16. Mucous Patch
The arrows show a common oral finding in secondary syphilis – mucous patches. These are usually painless and are teeming with treponemes.

17. Renal, GI, Rheumatologic
Syphilis - Secondary
Manifestation
Percent of cases
Skin 90
Constitutional 70
Mouth & throat 35
Genital lesions 20
CNS
8-40
Renal, GI, Rheumatologic
Unusual
Secondary syphilis is truly a systemic disease. While dermatologic findings dominate the picture, the majority of patients show systemic symptoms. In some studies as many as 40% had neurologic symptoms, and although renal, gastrointestinal, and rheumatologic findings are less common, their occurrence contributes to the protean presentations seen with secondary syphilis.

18. Constitutional Symptoms
Malaise
Sore throat
Headache
Myalgias
Pruritis
The patient is likely to present with a constellation of symptoms. Pruritis may be severe.

19. Constitutional Signs Fever (low-grade) Weight loss Lymphadenopathy
Inguinal most common
May be generalized
Periosteal involvement
Hepatitis
Immune complex disease
Lymphadenopathy is frequently generalized in secondary syphilis. Symptomatic periosteal involvement was common in the pre-penicillin era but is rare today, although technetium bone scanning frequently reveals lesions. About 20% of cases have elevated liver enzymes, though symptomatic hepatitis is rare. Deposition of immune complexes may cause arthritis, anterior uveitis, iritis, and glomerulonephritis. In the absence of HIV disease, upwards of 40% of patients may have abnormal cerebrospinal fluid, although only a few percent will have meningismus.

20. Conclusions
Secondary syphilis is a systemic disease and is typically florid
Constitutional symptoms and signs are common and may cause diagnostic confusion
Dermatologic findings are typically multiple and florid
The basic pathology is obliterative endarteritis

21. Sources of Information
The following sites are useful if more information on syphilis is sought:
Centers for Disease Control
World Health Organization
American Social
Hygiene Association
Virtual Naval Hospital