1. Syphilis – Clinical Aspects of Primary Syphilis
Thad Zajdowicz, MD, MPH
Medical Director, STD/HIV Program
Chicago Dept of Public Health
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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 treatable disease, 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 primary syphilis.

4. Objectives To review the pathogenesis of primary syphilis
To demonstrate the clinical features of primary syphilis
To illustrate clinical variants of primary syphilis

5. Clinical Stages
Syphilis is conventionally divided into several stages:
Primary
Secondary
Latent
Late, or tertiary
This lecture will focus on primary 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. Treponema pallidum
The picture of Treponema pallidum is from the U.S. Navy Environmental Health Center. T. pallidum is a motile spirochete that is closely related to the organisms causing yaws, pinta, and bejel. It is slender and tightly coiled, measuring 5 to 15 µm long by 0.09 to 0.18µm wide. They have a characteristic motility on dark field microscopy. T. pallidum has not been cultured in vivo.

7. Pathogenesis Infectious dose unknown in humans
In rabbits, experimental infection induced with as few as 4 spirochetes
Estimated average inoculum in humans
Inoculation may occur at any body site
Eternal genitalia most frequent
Mouth, anus, cervix quite common
Other sites also well described
While only a few spirochetes may initiate infection, studies have suggested the risk of contracting syphilis after a single exposure to a person with infectious syphilis (primary or secondary disease) is about 1 in 3. As this lecture demonstrates, chancres may occur virtually anywhere on or in the body.

8. Pathogenesis T. pallidum divides every 30-33 hrs Incubation period
Primary syphilis – median 21 days, range 3-90 days
The most prominent histopathological findings are arteritis and periarteritis in affected tissues

9. Primary syphilis - chancre
This is a primary syphilis chancre on the penis. It has some, but not all, of the characteristics of a typical chancre noted in the following slide.

10. Chancre characteristics
Indolent, “punched out” appearance
Indurated
Painless
Raised border
Red, smooth base
Scant serous secretions
These are the typical characteristics of a primary syphilis chancre. The lesion tends to be indolent and “punched out”; the rim is indurated. To appreciate the consistency of the chancre’s rim, touch your nose with a gloved finger – this approximates the feel of a typical chancre. (Never touch lesions of infectious syphilis, primary or secondary, without gloves!). Chancres tend to be painless, but slightly tender upon palpation. The lesion is generally “clean” in appearance; there is serous fluid present, but no blood or exudate unless secondary infection is present. The blood in the previous picture may represent an overly vigorous scraping for dark field examination.

11. Chancre characteristics
Chancre usually solitary, but multiple lesions can occur
May occur at any site in the genital tract:
coronal sulcus, glans, frenum, prepuce, shaft of penis, anorectal area, fourchette, vulva, cervix
May occur in the oropharyngeal area:
lip, tongue, tonsil
And may occur wherever treponemes are inoculated
While solitary chancres are the rule, multiple chancres are common, especially in those who are HIV-infected. While the genital areas and oropharynx are the most common sites to find syphilitic chancres, they may occur anywhere that Treponema pallidum has been inoculated. Inquiry into sexual practices is essential when evaluating lesions as possible primary syphilis.
It is very important to remember that atypical lesions may occur in as many as 60% of cases. On occasion, primary syphilis may occur without a primary lesion present, or with a lesion so atypical it is never considered as syphilitic.
Regional lymphadenopathy accompanies chancres; beginning unilaterally, it may become bilateral if treatment is delayed. The nodes are discrete, rubbery, nontender, and nonerythematous.

12. Penile Chancre
This is an excellent illustration from the Cornell University Medical College website with a fairly typical penile chancre. The edges are rolled and indurated, the chancre’s base is clean, and the entire lesion has a “punched out” appearance. Click on the picture to link to this excellent website.

13. Penile Chancre
This chancre is quite small. It could be overlooked if only size were considered.

14. Penile Chancre
The “punched out” character of a syphilitic chancre is quite apparent in this photograph.

15. Rolled Edges
This slide illustrates the rolled edges of a primary chancre very nicely.

16. Crusted Chancre

17. Chancres – 18th Century
This woodcut from an 18th Century medical text shows primary syphilis with “kissing lesions” on the left (probable inoculation of treponemes into an adjacent area from the original lesion); what appears to be a secondarily-infected chancre in the middle drawing; and multiple chancres in the illustration on the right.

18. Multiple Chancres

19. Primary Chancre - Labial
This chancre on the external female genitalia shows how the lesion may follow natural cleavage lines, and perhaps be missed without thorough examination. It has most of the characteristics of primary syphilitic chancres.

20. “Kissing” Chancres
This picture shows a “kissing” lesion, where apposition of an uninfected area leads to autoinoculation of treponemes from a primary chancre, producing a mirroring lesion. This is common in females and in perianal lesions.

21. “Kissing” Chancres
Another example of “kissing” lesions in a female, this time in the frontal rather than the sagittal plane.

22. Perianal Chancre
This picture shows a perianal chancre. It is atypical in that the lesion follows the lines of cleavage and is therefore elongated. Perianal chancres are seen in people who practice anal intercourse, males and females. It is always important not to assume types of sexual practices when confronted with lesions in atypical locations.

23. Chancre of the Tongue
Chancres may occur anywhere within the oropharynx. They may be misdiagnosed as neoplastic, or as other inflammatory lesions unless syphilis is included in the differential diagnosis.

24. Oral Chancre - Lip
Example of an primary oral chancre of syphilis in a 61 year old man (click the picture to link to the paper in the British Dental Journal).

25. Chancre of Hard Palate
Clicking the picture links to the paper in the British Dental Journal with the case history of this patient – a young homosexual male who acquired this lesion after unprotected oral sex.

26. Chancre of the Lip

27. Facial Chancre

28. Facial Chancre
Facial chancres may easily become secondarily infected, obscuring the underlying problem.

29. Digital Chancre
Chancres may be seen on the hands and fingers, dependent upon sexual practices. Chancres of the breasts, buttocks, and thighs are also well described.

30. Conclusions
The typical primary syphilitic chancre is solitary, indurated, and painless, but many clinical variants occur
Most chancres are genital, oral, or perianal, but may occur anywhere T. pallidum is inoculated
The primary histopathology seen in syphilis is arteritis and periarteritis

31. 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 Assoc
Virtual Naval Hospital