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SWIPE LEFT ON SYPHILIS IN PA
Swipe Left on Syphilis
In Pa!
BY YVONNE KINGON, SHERI HILT AND TOM BRODHEAD
DISEASE INTERVENTION SPECIALISTS OF THE ALLENTOWN HEALTH BUREAU
If syphilis filled out a dating app profile, its relationship status would have to be: “It’s complicated.” But that hasn’t stopped it from getting around. During calendar year 2020, Pennsylvania (exclusive of Philadelphia) reported the highest number of primary and secondary (P&S) syphilis cases in almost 30 years. This mimics national trends: according to the CDC, the number of reported P&S cases in 2019 represented a 63% increase from 2015 and the highest reported number of cases since 1991. The numbers have been trending upward since 2010, but while the increase in cases from 2010 to 2017 was primarily driven by men who have sex with men, since 2017 the rise was driven by increases among women and men who have sex with women. The surge in cases among women has led to a particularly tragic consequence: nationally, from 2013 to 2019, congenital syphilis, which can cause stillbirth and infant death, increased by an astonishing 417%. On the dating app, syphilis definitely has a preference for everyone.
Further complicating the matter, depending on a wide range of factors including symptoms (or lack thereof), prior history of syphilis, and the date and results of prior tests, syphilis can be classified as primary, secondary, early latent, late latent, and tertiary. And if that weren’t enough, neurosyphilis, ocular, and otic syphilis can occur at any stage at all, even if there are no other symptoms.
How does syphilis announce itself? Primary syphilis, which is typically one to three weeks after inoculation, is characterized by the development of a painless ulcerated sore, called a chancre, at the location of exposure, which includes but is not limited to the genitals, rectum, mouth, and throat. Being painless and located in anatomic areas not frequently observed by the patient, this chancre will often go undetected. This means many patients who contract syphilis will never be aware they have it in this early, highly infectious stage, making primary syphilis a significant missed opportunity for prevention.
The chancre will resolve on its own, causing the patient much relief (if they ever noticed it at all) and leading to the assumption that all is well. But this is far from the case. Four to ten weeks after initial infection, the symptoms of secondary syphilis appear. There are a few hallmark symptoms of secondary syphilis, but they are notoriously unreliable – syphilis’s wide variability in presentation has earned itself the moniker “the great imitator” for good reason. Unlike the chancre, these symptoms are more likely to get the patient’s attention. They include a body rash that generally is not itchy, and which often involves the palms and soles. Other symptoms include sore throat and swollen lymph nodes, fatigue, muscle ache, and fever, all of which occur in many common infections. Some patients may notice oral lesions, wart-like clusters in skin folds, or patchy hair loss, but these are present in a minority of patients. These symptoms often resolve spontaneously, and if the earlier hallmark chancre went unnoticed, syphilis may not appear on the differential should these patients seek care.
Unfortunately, once again, the waning of symptoms does not mean the infection has resolved. Syphilis is the toxic partner you can’t break up with. Untreated, it can lie dormant for years, only to re-emerge with an array of sometimes devastating and irreversible manifestations. The asymptomatic phase, called latent syphilis, can be early latent (an infection of less than one year of duration) or late latent (an infection of greater than one year). Latent syphilis is not infectious, but if untreated, approximately 30% of patients will progress to the tertiary stage, which can manifest two to 50 years after the original infection. Among the complications of this stage are cardiovascular syphilis which can cause ascending aortic aneurysm, aortic valve insufficiency, and coronary artery disease; and late neurosyphilis, which can result in a range of symptoms including dementia. (Neurosyphilis, including ocular and otic syphilis, can occur during any stage of infection.)
The good news is that syphilis is treatable at any stage of infection, primarily with penicillin given via intramuscular injection. The treatment regimen varies depending on the stage, which is why some detective work may be necessary. For example, knowing if a currently asymptomatic patient tested negative for syphilis within the past twelve months can help determine the stage of latency, which in turn determines treatment. If you aren’t sure what stage your patient is in or how to treat them, contact your local health department for assistance with staging, lab interpretation, and treatment guidance. It is never too late to treat syphilis and prevent potential medical catastrophe down the road.
Why is syphilis suddenly so prevalent? Lack of testing is the first hurdle. Public funding of STD clinics has not kept up with the need for decades. The COVID pandemic further reduced services by fostering the elimination of both walk-in and by-appointment STD testing clinics. Other contributing factors include a general increase in the number of lifetime sex partners; lack of comprehensive sex education; and the rise of dating apps. Insurance also plays a role; the uninsured have few resources and even some patients with insurance find the treatment is not covered or carries a high copayment. This gap in services leads to infected persons not being able to be tested and continuing to spread the disease. In addition to offering partner services, guidance and support, your local health department can provide treatment for those who are un- and underinsured.
Communication is going to be key as health professionals strive to gain control of this surge. Improved screening will help drive down cases. The PA DOH now recommends that all pregnant females be offered a test for syphilis at the first prenatal visit, the third trimester of pregnancy, the delivery of a child, or at the delivery of a stillborn child. Annual screening is recommended for men who have sex with men, with more frequent screening (every 3 to 6 months) for MSM who have an ongoing increased risk for acquiring syphilis (e.g., multiple partners, anonymous partners, and concurrent partners). Routine syphilis screening is not recommended for men who have sex with women, nonpregnant women who have sex with men, and nonpregnant women who have sex with women, but for these groups, syphilis screening may be indicated if the individual has increased risk for acquiring syphilis. Taking a thorough, nonjudgment sexual history, talking honestly with patients about risk, and screening and treating appropriately will be key to lowering the rates – and consequences – of this dangerous disease.
