Syphilis crisis in the United States: Syphilis and congenital syphilis cases have been surging nationwide, with an 80% increase in total syphilis cases between 2018 and 2022. Serologic testing is the primary means of diagnosing, staging, and managing syphilis. Testing should be done for any sexually active patient in whom syphilis is suspected or who has new, unexplained symptoms. Prompt diagnosis and treatment of syphilis can prevent systemic complications, including ocular involvement and permanent blindness.

Secondary syphilis is the second stage of the infection caused by the spirochete Treponema pallidum. Although syphilis (also known as lues) is seen worldwide, it is especially problematic in developing countries. It should be considered within the differential diagnosis of any oral mucosal patch, erythema, or erosion in those at risk.

Secondary syphilis typically occurs 3-10 weeks after the appearance of the primary syphilitic chancre and results from hematologic or lymphatic dissemination of the treponemes. There may be mucocutaneous as well as systemic disease.

Secondary syphilis can present with varied manifestations. Patients generally develop constitutional symptoms including malaise, appetite loss, fever, headache, stiff neck, myalgias, pharyngitis, and flu-like symptoms. Generalized lymphadenopathy is typically present. Cutaneous manifestations of secondary syphilis may include a generalized rash that includes the palms and soles. Patchy alopecia or telogen effluvium can be present. Gastric ulcers may occur. Ocular symptoms may include lacrimation, photophobia, and red, painful eyes.

Oral lesions of secondary syphilis can take the form of mucous patches and "snail-track" ulcers. The latter are confluent mucous patches that form a serpiginous outline. The median age of patients with acquired oral syphilis is in the third and fourth decades of life (aged 20s-30s). The oral locations involved may include the tongue, palate, lips, buccal mucosa, and labial commissure. Condylomata lata (gray, flat, moist papules and plaques) may be seen in moist anogenital locations or in the mouth. They are teeming with spirochetes and are, therefore, extremely infectious.

The lesions of secondary syphilis resolve in 3-12 weeks, with or without treatment. If left untreated, up to 25% of patients will relapse within the first 2 years.

Immunocompromised patient considerations: HIV infection can alter the clinical presentation of syphilis. Manifestations include multiple chancres, atypical cutaneous eruptions, increased severity of organ involvement (such as hepatitis and glomerulonephritis), and rapidly developing arteritis and neurosyphilis. Neurosyphilis can occur at any stage of syphilis.

Related topics: primary syphilis, tertiary syphilis, early congenital syphilis, late congenital syphilis, ocular syphilis