Assessment of syphilis

Syphilis is caused by Treponema pallidum. The incidence of syphilis in Australia is highest in gay, bisexual and other men who have sex with men, and transgender women and in some Aboriginal and Torres Strait Islander communities (particularly in remote locations)Ong, 2023. Prevalence is increasing in the general population, particularly in females1 of reproductive ageOng, 2023.

Health outcomes are significantly impacted by geographical, historical, socioeconomic, spiritual, emotional and cultural determinants. In Aboriginal and Torres Strait Islander peoples, the incidence of infection and increased risk of poor health outcomes can be linked to complex socioeconomic factors, including poverty, reduced access to health services, incarceration, discrimination and intergenerational trauma. A shared strengths–based approach to healthcare that recognises each patient's unique cultural determinants and circumstances is essential.

Syphilis diagnosis is based on a combination of history, clinical assessment and laboratory investigationsOng, 2023.

Syphilis has 3 clinical stages – early syphilis, late latent syphilis and tertiary syphilis. See Features of the clinical stages of syphilis for key features of each stage.
Central nervous system, eye or ear involvement can occur at any stage of syphilisWorkowski, 2021; assess all patients for neurological, ocular and otological features (see Clinical presentation of neurosyphilis, ocular syphilis and otosyphilis).
Figure 1. Features of the clinical stages of syphilis.

[NB1]

Ong, 2023Workowski, 2021

Early syphilis is syphilis of less than 2 years duration and is subdivided into 3 subcategories:

  • Primary syphilis often presents with genital, anal or oral lesions (chancre); these lesions are often indurated, may not be painful and may be accompanied by lymphoedema.
  • Secondary syphilis should be considered in patients with psoriatic rashes or warty lesions; patients may also have systemic features (eg fever, malaise, lymphadenopathy, headache) and early neurosyphilis (which often presents with ocular or otologic symptoms).
  • Early latent syphilis is asymptomatic.

Late latent syphilis is asymptomatic syphilis of longer than 2 years duration, or of unknown duration.

Tertiary syphilis is syphilis of longer than 2 years duration, or of unknown duration, with cardiovascular, central nervous system or skin and bone (gummatous syphilis) involvement.

Note:
NB1: Central nervous system, eye or ear involvement can occur at any stage of syphilis; assess all patients for neurological, ocular and otological features (see Clinical presentation of neurosyphilis, ocular syphilis and otosyphilis).
Table 1. Clinical presentation of neurosyphilis, ocular syphilis and otosyphilis

Hamill, 2024Workowski, 2021

Syphilis subtype

Clinical presentation

Neurosyphilis [NB1]

  • visual changes
  • photophobia
  • tinnitus
  • hearing loss
  • cranial nerve palsies
  • headache
  • dizziness
  • meningitis
  • cognitive dysfunction
  • altered mental state
  • motor and/or sensory deficits
  • stroke

Ocular syphilis [NB1]

  • neuroretinitis
  • optic neuritis
  • uveitis
  • visual changes – blurred vision, vision loss, flashing lights

Otosyphilis [NB1]

  • sudden onset sensorineural hearing loss
  • tinnitus
  • vertigo
Note:

NB1: Ocular and otological symptoms can occur on their own or in association with neurosyphilis.

1 In this topic, the term ‘female’ is used to include all people presumed female at birth.Return