Language selection

Government of Canada / Gouvernement du Canada

Search

Staging a syphilis infection in adolescents and adults: Selected physical exam findings according to stage of disease

Download in PDF format
(1.1 MB, 8 pages)

Organization: Public Health Agency of Canada

Date published: 2024-06-14

March 2024

The clinical manifestations of syphilis are usually described according to stage of disease: primary, secondary, latent and tertiary syphilis. Early and late neurosyphilis can also occur.Footnote a

Nervous system (neurosyphilis)

Lymphatic system

Skin

Head and neck

Cardiovascular

Anogenital

Staging a syphilis infection in adults and adolescents: signs and symptomsFootnote b

Primary syphilis

Timing:

Usually occurs 3 weeks after infection, but can occur anywhere from 3 to 90 days post-infection.

Signs & symptoms:

Painless lesion (chancre), regional lymphadenopathy.

(1.1) Oral chancreFootnote 1

Image: Oral chancre

figure 1.1

The image shows a single, round, well-demarcated, ulceration on the centre of the tongue.

Source: Centers for Disease Control and Prevention

(1.2) Vaginal chancreFootnote 2

Image: Vaginal chancre

figure 1.2

The image shows a single, round, well-demarcated, erythematous ulceration at the vaginal introitus.

Source: Centers for Disease Control and Prevention

(1.3) Penile chancreFootnote 3

Image: Penile chancre

figure 1.3

The images shows a single, round, well-demarcated, erythematous ulceration on the ventral shaft of the penis.

Source: Centers for Disease Control and Prevention

(1.4) Inguinal lymphadenopathyFootnote 4

Image: Inguinal lymphadenopathy

figure 1.4

The male groin is shown, with swelling evident in the left inguinal area.

Source: Centers for Disease Control and Prevention

Secondary syphilis

Timing:

Usually occurs from 2 to 12 weeks after infection, but can occur up to 6 months post-infection.

Signs & symptoms:

Rash, fever, malaise, mucosal lesions, condylomata lata, lymphadenopathy, patchy or diffuse alopecia.

(2.1) Mucosal lesions on tongueFootnote 5

Image: Mucosal lesions on tongue

figure 2.1

The image shows white mucosal patches on the tongue.

Source: Centers for Disease Control and Prevention

(2.2) Secondary syphilis rash on bodyFootnote 6

Image: Secondary syphilis rash on body

figure 2.2

The image shows a diffuse, erythematous, maculopapular rash covering the back and arms.

Source: Centers for Disease Control and Prevention

(2.3) Secondary syphilis palmar rashFootnote 7

Image: Secondary syphilis palmar rash

figure 2.3

Reddish-brown macules on the palms of the hands are depicted.

Source: Centers for Disease Control and Prevention

(2.4) Vaginal condylomata lataFootnote 8

Image: Vaginal condylomata lata

figure 2.4

Multiple grey-white raised labial and perianal lesions are depicted.

Source: Centers for Disease Control and Prevention

Latent syphilis

Timing:

Early latent syphilis is an asymptomatic infection of less than 1 year duration. It is considered infectious because of the 25% chance of relapse to the secondary stage.

Latent syphilis of unknown duration is an asymptomatic infection where the duration cannot be confirmed (i.e. no serologic testing within the prior 12 months).

Late latent syphilis is an asymptomatic infection of more than 1 year duration.

Signs & symptoms:

All latent syphilis infections are present without signs or symptoms.

Neurosyphilis

Timing:

Early neurosyphilis occurs within the first year after infection.

Late neurosyphilis occurs more than 1 year after infection.

Note that HIV alters the natural course of syphilis and sometimes results in a more rapid progression to neurosyphilis with more aggressive and atypical signs of infection.

Signs & symptoms:

Early neurosyphilis: Meningitis (e.g. headache, nuchal rigidity), uveitis/retinitis (e.g. blurred vision, red eye, flashers, floaters), otic signs and symptoms (e.g. hearing loss, tinnitus).

Late neurosyphilis: General paresis (e.g. personality and cognitive changes), tabes dorsalis (e.g. Argyll Robertson pupils, ataxia, sensory changes, abnormal reflexes).

Tertiary Syphilis

Timing:

Late neurosyphilis, cardiovascular syphilis, or syphilitic gumma can develop years to decades after infection.

Signs & symptoms:

Cardiovascular syphilis: Aortic aneurysm, aortic regurgitation, coronary artery ostial stenosis.

Syphilitic gumma: Gummatous lesions causing tissue damage, with clinical manifestation depending on the site involved.

Late neurosyphilis: General paresis (e.g. personality and cognitive changes), tabes dorsalis (e.g. Argyll Robertson pupils, ataxia, sensory changes, abnormal reflexes).

(3.1) Argyll Robertson pupils, indicative of late neurosyphilisFootnote 9

Image: Argyll Robertson pupils, indicative of late neurosyphilis

figure 3.1

The image depicts pupils that do not react to bright light, but constrict in response to a near object.

Source: The New England Journal of Medicine

(3.2) Intraoral gummatous lesion of the soft palateFootnote 10

Image: Intraoral gummatous lesion of the soft palate

figure 3.2

The image shows a large, raised mass with an irregular surface on the soft palate.

Source: Centers for Disease Control and Prevention

(3.3) Cutaneous ulcerative lesion on the forearmFootnote 11

Image: Cutaneous ulcerative lesion on the forearm

figure 3.3

A large, erythematousulceration on the forearm is depicted.

Source: Centers for Disease Control and Prevention

(3.4) Syphilitic gumma of the testicleFootnote 12

Image: Syphilitic gumma of the testicle

figure 3.4

Significant scrotal swelling is depicted.

Source: Centers for Disease Control and Prevention

Congenital syphilis: signs and symptomsFootnote c

Early Congenital Syphilis

Timing:

Presentation before 2 years of age.

Signs & ysmptoms:

More than half of liveborn infants with congenital syphilis are asymptomatic at birth.Footnote 13 If present, signs and symptoms may include mucocutaneous lesions (e.g. maculopapular rash, desquamation), hepatosplenomegaly, anemia, fulminant disseminated infection.

(4.1) Papular rash on the chin and lips and darkly pigmented spots on the feetFootnote 14

Image: Papular rash on the chin and lips and darkly pigmented spots on the feet

figure 4.1

A papular rash is visible on the chin and lips of an infant. Hyperpigmented lesions are shown on the soles.

Source: Centers for Disease Control and Prevention

(4.2) Rhinitis (snuffles)Footnote 15

Image: Rhinitis (snuffles)

figure 4.2

The image shows a newborn with copious nasal discharge.

Source: Centers for Disease Control and Prevention

(4.3) Typical desquamating and maculopapular skin lesionsFootnote 16

Image: Typical desquamating and maculopapular skin lesions

figure 4.3

Images depict desquamating and maculopapular lesions on the forehead, ears, and palms and soles an infant.

Source: Centers for Disease Control and Prevention

(4.4) Copper coloured palmar rashFootnote 17

Image: Copper coloured palmar rash

figure 4.4

Copper-colored lesions on the palm of an infant are shown.

Source: Centers for Disease Control and Prevention

Late Congenital Syphilis

Timing:

Presentation after 2 years of age.

Signs & symptoms:

Musculoskeletal involvement (e.g. osteoperiostitis, saddle nose), interstitial keratitis, eighth nerve deafness, dental abnormalities (e.g. Hutchinson’s teeth, mulberry molars).

(5.1) Interstitial keratitisFootnote 18

Image: Interstitial keratitis

figure 5.1

A close-up of an eye showing cloudy spots in the cornea.

Source: Centers for Disease Control and Prevention

(5.2) Hutchinson’s teethFootnote 19

Image: Hutchinson’s teeth

figure 5.2

Irregularly-shaped and widely-spaced teeth are shown with notched incisors.

Source: Centers for Disease Control and Prevention

(5.3) Mulberry molar (rounded enamel cusps on the permanent first lower molars)Footnote 20

Image: Mulberry molar (rounded enamel cusps on the permanent first lower molars)

figure 5.3

Molars withrounded surfaces that resemble the surface of a mulberry are shown.

Source: Centers for Disease Control and Prevention

(5.4) Osteoperiostitis of the tibia leading to characteristic sabre shinsFootnote 21

Image: Osteoperiostitis of the tibia leading to characteristic sabre shins

figure 5.4

The image shows child’s shins with pronounced curvature of the tibia.

Source: Centers for Disease Control and Prevention

References

Footnote 1

CDC. Sumpter RE. Circular lesion diagnosed as a primary syphilitic chancre [internet]. 1967 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=12623

Return to footnote 1 referrer

Footnote 2

CDC. Syphilis images [internet]. 2016 [cited 2024 January 3]. Available from: https://www.cdc.gov/std/syphilis/images.htm

Return to footnote 2 referrer

Footnote 3

CDC. Fiumara NJ. Penile chancre diagnosed as a primary syphilitic infection [internet]. 1976 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=6760

Return to footnote 3 referrer

Footnote 4

CDC. Lindsley S. Inguinal lymphadenopathy due to a case of primary syphilis [internet]. 1977 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=3477

Return to footnote 4 referrer

Footnote 5

CDC. Syphilis images [internet]. 2016 [cited 2024 January 3]. Available from: https://www.cdc.gov/std/syphilis/images.htm

Return to footnote 5 referrer

Footnote 6

CDC. Hart G. Papulosquamous rash that proved to be a case of secondary syphilis [internet]. n.d. [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=17838

Return to footnote 6 referrer

Footnote 7

CDC. Papulosquamous rash of secondary syphilitic lesions on the palmar surface of both hands [internet]. 1970 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=16749

Return to footnote 7 referrer

Footnote 8

CDC. Ayers J. Condylomata lata lesions atop the labia and perianal region [internet]. 1968 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=17052

Return to footnote 8 referrer

Footnote 9

The New England Journal of Medicine. Osman C, Clark TW, Tabes dorsalis and Argyll Robertson pupils, 375;20, e40. Copyright © 2016 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. Available from: https://www.nejm.org/doi/full/10.1056/NEJMicm1507564

Return to footnote 9 referrer

Footnote 10

CDC. Intraoral gummatous lesion of the soft palate, due to tertiary syphilis infection [internet]. n.d. [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=16762

Return to footnote 10 referrer

Footnote 11

CDC. Cutaneous lesion on the left forearm, diagnosed as tertiary syphilis [internet]. n.d. [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=17837

Return to footnote 11 referrer

Footnote 12

CDC. Lindsley S. Syphilitic gumma of the testicle [internet]. 1976 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=6754

Return to footnote 12 referrer

Footnote 13

The Lancet Infectious Diseases. Keuning MW, Kamp GA, Schonenberg-Meintema D, Dorigo-Zetsma JW, van Zuidan JM, Pajkrt D. Congenital syphilis, the great imitator—case report and review. 2020 Jul;20(7):e173-e179.

Return to footnote 13 referrer

Footnote 14

CDC. Lindsley S. Female infant born with congenital syphilis, with a papular rash on the chin and lips and darkly pigmented spots on the soles of the feet [internet]. 1973 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=16743

Return to footnote 14 referrer

Footnote 15

CDC. Cole N. Pathologic morphology indicative of congenital syphilis [internet]. 1963 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=2246

Return to footnote 15 referrer

Footnote 16

CDC. Ballard R. Congenital syphilis [internet]. 2021 [cited 2024 January 3]. Available from: https://www.cdc.gov/ncbddd/birthdefects/surveillancemanual/quick-reference-handbook/congenital-syphilis.html

Return to footnote 16 referrer

Footnote 17

CDC. Copper-coloured rash characteristic of congenital syphilis. 1970 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=16746

Return to footnote 17 referrer

Footnote 18

CDC. Lindsley S. Interstitial keratitis, the result of late congenital syphilis [internet]. 1973 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=4149

Return to footnote 18 referrer

Footnote 19

CDC. Sumpter R. Hutchinson’s teeth, developed as a result of congenital syphilis [internet]. 1967 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=12599

Return to footnote 19 referrer

Footnote 20

CDC. Sumpter R. Mulberry molars, developed as a result of congenital syphilis [internet]. 1967 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=2386

Return to footnote 20 referrer

Footnote 21

CDC. Sumpter R. Sabre shin of the right lower leg, due to congenital syphilis [internet]. 1967 [cited 2024 January 3]. Available from: https://phil.cdc.gov/Details.aspx?pid=2387

Return to footnote 21 referrer

Footnotes

Footnote a

Not an exhaustive list.

Return to footnote a referrer

Footnote b

See the Syphilis Guide for Health Professionals for more information. https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis/risk-factors-clinical-manifestation.html

Return to footnote b referrer

Footnote c

See the Syphilis Guide for Health Professionals and the Canadian Pediatric Society’s Position Statement for more information.

Return to footnote c referrer

Page details

Date modified: