Syphilis often masquerades as something else, doctor says

Holly came to the emergency department with a counselor from the drug treatment center where she was currently undergoing treatment for drug abuse.

She had dealt with drug abuse for the past several years and had relapsed a few months ago. She had recently witnessed her best friend die of an overdose and decided that she needed to get help and was admitted to a drug treatment center about a week prior to her emergency department visit.

In attempts to get her life back together, she had also gone to a health department clinic to be tested for sexually transmitted diseases, and she was notified while at the drug treatment facility that she had a positive test.

They called her the day she visited the emergency department to let her know that she had tested positive for syphilis and needed treatment immediately. She wasn’t sure if it was related or not, but for the past several days she had noticed that she was having blurry and at times double vision.

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Syphilis can cause serious health problems. It is spread by direct contact with a syphilis sore during sexual intercourse or can be passed from a mother to her baby during pregnancy or childbirth.

There are specific stages of syphilis infection that each have different signs and symptoms. The first sign of syphilis is a small sore —called a chancre— that appears at the spot where the bacteria enters the body. This chancre is frequently not noticed by the patient because it is painless; it heals on its own within 3 to 6 weeks.

Within a few weeks of the chancre healing, the patient can develop a rash that begins on the trunk and spreads to the rest of the body, including the soles of the feet and palms of the hands. Some patients also experience muscle aches, fever, sore throat, and swollen lymph nodes.

These relatively nonspecific signs and symptoms of secondary syphilis can disappear within a few weeks and can recur intermittently for as long as a year. If left untreated, syphilis can progress to the latent or hidden stage where the patient may have no symptoms at all.

Symptoms can progress from the latent stage to the tertiary stage. Fifteen to thirty percent of patients with syphilis who are not treated develop tertiary syphilis, which can result in damage to the brain, eyes, nerves, heart, liver, bones, and joints. These issues can develop many years after the original infection.

Babies who are born to women who have syphilis can become infected through the placenta or during birth. Most newborns with congenital syphilis do not have symptoms but can develop symptoms later that include deafness, deformities of their teeth and deformity to the bridge of the nose. Some babies infected with syphilis during pregnancy can die in the womb, be born prematurely or die shortly after birth.

Unfortunately, rates of syphilis have been increasing in recent years. In 2021 there were over 176,000 reported cases of all stages of syphilis in the US. After historic low numbers in 2000 and 2001, rates of infection have been increasing almost every year, including an increase of nearly 29% from 2020 to 2021. Even more disturbing is data that 2,855 cases of congenital syphilis were reported in 2021, including 220 congenital syphilis related stillbirths and infant deaths.

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When I examined Holly, I paid special attention to her neurological exam because of her visual complaints. I also carefully examined her skin looking for a rash. I didn’t find anything unusual in her physical exam.

She had brought the paperwork that included the lab testing with her positive syphilis test result. I had the nurse get blood from Holly and a urine sample and I ordered a pregnancy test to make sure she wasn’t pregnant.

Holly had never been tested for syphilis before this and didn’t recall any symptoms of her initial infection. She had no idea how long she may have been infected.

I was worried that her visual complaints were related to her syphilis infection and discussed the appropriate antibiotic therapy with a pharmacist. I ordered Holly IV penicillin and admitted her to the hospital to undergo further evaluation for ocular syphilis and to continue antibiotics that she would need every 4 hours.

While in the hospital, Holly underwent multiple tests including a lumbar puncture, where a needle is placed in the low back to acquire spinal fluid for analysis. This spinal fluid is the fluid that surrounds the brain and spinal cord.

This spinal fluid was sent for analysis for syphilis infection. Holly ultimately was diagnosed with ocular syphilis and was in the hospital for 10 days receiving her penicillin infusions.

Ocular syphilis can occur at any stage of syphilis infection and can involve any structure in the eye. The expected prognosis is good with appropriate antibiotic treatment.

Syphilis is frequently referred to as the “great masquerader” because it can present with a variety of clinical symptoms and mimics other diseases, making diagnosis very challenging. Anyone who is sexually active is at risk for syphilis infection and with any signs or symptoms that are suggestive of syphilis, should be tested.

Anyone with a sexual partner who tests positive for syphilis should also receive testing. Patients at higher risk for syphilis should be tested routinely.

Particularly important is the screening of pregnant women to prevent transmission of infection to their fetus. It is recommended that all pregnant women are tested at their first prenatal visit, and some receive a second test during the third trimester and at birth.

I discussed with Holly that she needed to inform her sexual partners of her diagnosis so that they could seek evaluation and be tested as well. I also told her how glad I was that she went to get tested and was able to quickly get treatment for her syphilis infection with hopes that treatment would solve her vision problems and prevent any further complications for her down the road.

Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.

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