Early syphilis

Syphilis is a chronic sexually transmitted infection disease caused by the bacterium Treponema pallidum. Early syphilis encompasses the primary, secondary and early latent stages of the disease. These stages occur within the first two years of infection and, if untreated, can progress through disease to late syphilis. Early syphilis is the period of highest transmissibility and fast diagnosis and treatment are critical in preventing disease spread.

Etiology and Epidemiology of Early Syphilis

The causative agent of syphilis, Treponema pallidum, is a spiral-shaped motile bacterium. Bacterium enters the body through mucosal surfaces or skin small cracks during sexual contact. It can also be transmitted transplacentally from mother to fetus, causing congenital syphilis. Early syphilis is associated with risk factors such as unprotected sexual intercourse, multiple sexual partners and the presence of other sexually transmitted infections like risk.

Syphilis is prevalent worldwide, particularly in low- and middle-income countries. In recent years, an increase in syphilis cases has also been observed in some developed countries. This rise is especially pronounced among men who have sex with men (MSM). Early diagnosis and treatment play a major importance in preventing disease transmission and reducing complications.

Clinical Findings and Symptoms

Early syphilis consists of the primary, secondary and early latent stages. Each stage is characterized by distinct clinical findings.

Primary Syphilis

Primary syphilis is the first stage of infection and typically appears 10 to 90 day after the bacterium enters the body. The hallmark lesion of this stage is a painless ulcer known as a chancre. The chancre most commonly occurs in the genital area (penis, vulva, vagina) but may also appear in the mouth, anus or other sites. It is a lesion with firm borders, a clean base and no surrounding erythema. If untreated, the lesion heals spontaneously within 3 to 6 week, but this does not indicate resolution of the infection.

Secondary Syphilis

Secondary syphilis develops 4 to 10 weeks after the primary stage and is characterized by a systemic infectious syndrome. Key findings include:

• Dermatological rashes: Maculopapular rashes may be prominent on the palms and soles. Rashes are typically non-pruritic.
• Mucosal lesions: Superficial ulcers (mucous patches) may occur in the mouth and genital area.
• Systemic symptoms: Fever, malaise, headache, lymphadenopathy (swollen lymph nodes) and weight loss may accompany the rash.
• Condyloma lata: Broad, flat, gray-white lesions occurring in moist areas such as the genital region and anus.

Signs of secondary syphilis may resolve spontaneously within weeks if untreated, but this does not indicate cure of the disease situation.

Early Latent Syphilis

Early latent syphilis begins after the resolution of secondary syphilis symptoms and occurs within the first year of infection. During this stage, no clinical signs are present, but serological tests remain positive. Early latent syphilis is a period of continued transmissibility.

Diagnostic Methods

The diagnosis of early syphilis is based on clinical findings and laboratory tests. The following methods are used:

• Direct microscopy: Treponema pallidum can be visualized in specimens from lesions such as chancres or condyloma lata using dark-field microscopy or fluorescent antibody tests.
• Serological tests: Non-treponemal tests (VDRL, RPR) and treponemal tests (FTA-ABS, TPHA) are used for diagnosis. Non-treponemal tests are used to monitor treatment response, while treponemal tests provide specific confirmation.
• Polymerase Chain Reaction (PCR): Used to detect Treponema pallidum DNA, particularly in atypical cases.

Treatment Approaches

In the treatment of early syphilis, parenteral penicillin (benzathine penicillin) is the first-line step drug. A single dose of benzathine penicillin G (2.4 million units, intramuscular) is sufficient for primary, secondary and early latent syphilis. In patients with penicillin allergy, alternative medications such as doxycycline or ceftriaxone may be used.

During treatment, a Jarisch-Herxheimer reaction (fire, chills and hypotension) may occur. This reaction is more common in patients with secondary syphilis. Follow-up with serological testing after treatment is essential. A decline in non-treponemal test titers is used to assess treatment response.