Editing Syphilis (section)

==Signs and symptoms==
[[File:Primary stage syphilis sore (chancre) on the surface of a tongue-CDC.jpg|thumb|Primary syphilis on a tongue]]

Syphilis can [[Presentation (medical)|present]] in one of four different stages: primary, secondary, latent, and tertiary, and may also occur [[congenital]]ly.<ref name=Ferri202>{{cite book |last=Ferri |first=Fred F. |title=Ferri's Clinical Advisor 2022 |date=2022 |publisher=Elsevier |location=Philadelphia, PA |isbn=978-0-323-75571-9 |page=1452 |chapter-url=https://books.google.com/books?id=VW4yEAAAQBAJ&pg=PA1452 |chapter=Syphilis}}</ref> There may be [[asymptomatic|no symptoms]].<ref name=WHO21May2024>{{cite web |title=Syphilis |url=https://www.who.int/news-room/fact-sheets/detail/syphilis |website=www.who.int |publisher=World Health Organization |access-date=16 August 2024 |language=en |date=21 May 2024}}</ref> It was referred to as "the great imitator" by [[Sir William Osler]] due to its varied presentations.<ref name=Kent08/><ref name=TUS00>{{cite journal |last=White |first=RM |title=Unraveling the Tuskegee Study of Untreated Syphilis|journal=Archives of Internal Medicine|date=13 March 2000 |volume=160 |issue=5 |pages=585–598 |pmid=10724044 |doi=10.1001/archinte.160.5.585}}</ref><ref>{{cite web |title=Revisiting the Great Imitator, Part I: The Origin and History of Syphilis |url=https://www.asm.org/Articles/2019/June/Revisiting-the-Great-Imitator,-Part-I-The-Origin-a |website=www.asm.org |access-date=29 July 2019 |archive-date=28 July 2019 |archive-url=https://web.archive.org/web/20190728221602/https://www.asm.org/Articles/2019/June/Revisiting-the-Great-Imitator,-Part-I-The-Origin-a |url-status=live}}</ref>

===Primary===
[[File:Chancres on the penile shaft due to a primary syphilitic infection caused by Treponema pallidum 6803 lores.jpg|thumb|Chancre on a penis due to primary syphilis, 1978]]
Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person.<ref name=RedBookSyphilis>{{cite book|author=Committee on Infectious Diseases |editor= Larry K. Pickering |title=Red book 2006 Report of the Committee on Infectious Diseases|year=2006 |pages=631–44|publisher=American Academy of Pediatrics|location=Elk Grove Village, IL|isbn=978-1-58110-207-9|edition=27th}}</ref> Approximately 2–6 weeks after contact (with a range of 10–90 days) a skin lesion, called a [[chancre]], appears at the site and this contains infectious bacteria.<ref>{{cite web |title=STD Facts - Syphilis (Detailed) |url=https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm |website=www.cdc.gov |language=en-us |date=23 September 2019 |access-date=15 September 2017 |archive-date=30 July 2018 |archive-url=https://web.archive.org/web/20180730092959/https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm |url-status=live }}</ref><ref name=NEJM2020>{{cite journal |last1=Campion |first1=Edward W. |last2=Ghanem |first2=Khalil G. |last3=Ram |first3=Sanjay |last4=Rice |first4=Peter A. |title=The Modern Epidemic of Syphilis |journal=New England Journal of Medicine |date=27 February 2020 |volume=382 |issue=9 |pages=845–54 |doi=10.1056/NEJMra1901593|pmid=32101666 |s2cid=211537893 }}</ref> This is classically (40% of the time) a single, firm, painless, non-itchy [[skin ulceration]] with a clean base and sharp borders approximately 0.3–3.0&nbsp;cm in size.<ref name=Kent08/> The lesion may take on almost any form.<ref name=Pri2008/> In the classic form, it evolves from a [[macule]] to a [[papule]] and finally to an [[erosion (dermatopathology)#Primary lesions|erosion]] or [[ulcer (dermatology)|ulcer]].<ref name=Pri2008>{{cite journal |last=Eccleston|first=K|author2=Collins, L |author3=Higgins, SP |title=Primary syphilis|journal=International Journal of STD & AIDS|date=March 2008|volume=19|issue=3|pages=145–51|pmid=18397550|doi=10.1258/ijsa.2007.007258|s2cid=19931104}}</ref> Occasionally, multiple lesions may be present (~40%),<ref name=Kent08/> with multiple lesions being more common when coinfected with HIV.<ref name=Pri2008/> Lesions may be painful or tender (30%), and they may occur in places other than the genitals (2–7%).<ref name=Pri2008/> The most common location in women is the [[cervix]] (44%), the [[Human penis|penis]] in heterosexual men (99%), and [[Human anus|anally]] and [[rectal]]ly in [[men who have sex with men]] (34%).<ref name=Pri2008/> [[Lymphadenopathy|Lymph node enlargement]] frequently (80%) occurs around the area of infection,<ref name=Kent08/> occurring seven to 10&nbsp;days after chancre formation.<ref name=Pri2008/> The [[lesion]] may persist for three to six weeks if left untreated.<ref name=Kent08/>

===Secondary===
[[Image:Secondary Syphilis on palms CDC 6809 lores.rsh.jpg|thumb|upright=1.4|Typical presentation of secondary syphilis with a rash on the palms of the hands, 1967]]
[[image:Syphilis second state 2.jpg|thumb|upright=1.4|Reddish [[papules]] and [[nodule (dermatology)#Primary lesions|nodules]] over much of the body due to secondary syphilis]]
Secondary syphilis occurs approximately four to ten weeks after the primary infection.<ref name=Kent08/> While secondary disease is known for the many different ways it can manifest, symptoms most commonly involve the [[Human skin|skin]], [[mucous membranes]], and [[lymph nodes]].<ref name=Sec2010/> There may be a symmetrical, reddish-pink, non-itchy [[rash]] on the trunk and extremities, including the palms and soles.<ref name=Kent08/><ref name=2darySyphilis>{{cite journal |vauthors=Dylewski J, Duong M |title=The rash of secondary syphilis |journal=Canadian Medical Association Journal |date= 2 January 2007 |volume=176 |issue=1 |pages=33–35 |doi= 10.1503/cmaj.060665 |pmid=17200385 |pmc=1764588}}</ref> The rash may become [[maculopapular]] or [[abscess|pustular]].<ref name=Kent08/> It may form flat, broad, whitish, wart-like lesions on mucous membranes, known as [[condyloma latum]].<ref name=Kent08/> All of these lesions harbor bacteria and are infectious.<ref name=Kent08/> Other symptoms may include [[fever]], [[sore throat]], [[malaise]], [[weight loss]], [[hair loss]], and [[headache]].<ref name=Kent08/> Rare manifestations include [[hepatitis|liver inflammation]], [[kidney]] disease, [[arthritis|joint inflammation]], [[periostitis]], [[optic neuritis|inflammation of the optic nerve]], [[uveitis]], and [[interstitial keratitis]].<ref name=Kent08/><ref name=Eye07/> The acute symptoms usually resolve after three to six weeks;<ref name=Eye07/> about 25% of people may present with a recurrence of secondary symptoms.<ref name=Sec2010/><ref>{{cite journal |last1=Baughn |first1=R. E. |last2=Musher |first2=D. M. |title=Secondary Syphilitic Lesions |journal=Clinical Microbiology Reviews |date=14 January 2005 |volume=18 |issue=1 |pages=205–16 |doi=10.1128/CMR.18.1.205-216.2005|pmid=15653827 |pmc=544174 }}</ref> Many people who present with secondary syphilis (40–85% of women, 20–65% of men) do not report previously having had the classical chancre of primary syphilis.<ref name=Sec2010>{{cite journal |last=Mullooly|first=C|author2=Higgins, SP |title=Secondary syphilis: the classical triad of skin rash, mucosal ulceration and lymphadenopathy|journal=International Journal of STD & AIDS|date=August 2010|volume=21|issue=8|pages=537–45|pmid=20975084|doi=10.1258/ijsa.2010.010243|s2cid=207198662}}</ref>

===Latent===
Latent syphilis is defined as having [[serology|serologic]] proof of infection without symptoms of disease.<ref name=RedBookSyphilis/> It develops after secondary syphilis and is divided into early latent and late latent stages.<ref name="O'Byrne"/> Early latent syphilis is defined by the [[World Health Organization]] as less than 2 years after original infection.<ref name="O'Byrne">{{cite journal |last1=O'Byrne |first1=Patrick |last2=MacPherson |first2=Paul |title=Syphilis |journal=BMJ |date=28 June 2019 |volume=365 |pages=l4159 |doi=10.1136/bmj.l4159|pmid=31253629 |pmc=6598465 }}</ref> Early latent syphilis is infectious as up to 25% of people can develop a recurrent secondary infection (during which bacteria are actively replicating and are infectious).<ref name="O'Byrne" /> Two years after the original infection the person will enter late latent syphilis and is not as infectious as in the early phase.<ref name=Eye07/><ref>{{cite web |title=Ward 86 Practice Recommendations: Syphilis |url=http://hivinsite.ucsf.edu/InSite?page=md-ward86-syphilis |website=hivinsite.ucsf.edu |access-date=29 July 2019 |archive-date=29 April 2019 |archive-url=https://web.archive.org/web/20190429161518/http://hivinsite.ucsf.edu/InSite?page=md-ward86-syphilis |url-status=dead }}</ref> The latent phase of syphilis can last many years after which, without treatment, approximately 15–40% of people can develop tertiary syphilis.<ref>{{cite journal |last1=Peeling |first1=Rosanna W. |last2=Mabey |first2=David |last3=Kamb |first3=Mary L. |last4=Chen |first4=Xiang-Sheng |last5=Radolf |first5=Justin D. |last6=Benzaken |first6=Adele S. |title=Syphilis |journal=Nature Reviews Disease Primers |date=12 October 2017 |volume=3 |issue=1 |pages=17073 |doi=10.1038/nrdp.2017.73|pmid=29022569 |pmc=5809176 }}</ref>

===Tertiary===
[[File:Tertiary syphilis head.JPG|thumb|left|upright=1.2|Model of a head of a person with tertiary (gummatous) syphilis, [[Musée de l'Homme]], Paris]]
Tertiary syphilis may occur approximately 3 to 15 years after the initial infection and may be divided into three different forms: gummatous syphilis (15%), late [[neurosyphilis]] (6.5%), and cardiovascular syphilis (10%).<ref name=Kent08/><ref name=Eye07/> Without treatment, a third of infected people develop tertiary disease.<ref name=Eye07/> People with tertiary syphilis are not infectious.<ref name=Kent08/>

Gummatous syphilis or late [[benignity|benign]] syphilis usually occurs 1 to 46 years after the initial infection, with an average of 15&nbsp;years.<ref name=Kent08/> This stage is characterized by the formation of chronic [[gumma (pathology)|gummas]], which are soft, tumor-like balls of inflammation which may vary considerably in size.<ref name=Kent08/> They typically affect the skin, bone, and liver, but can occur anywhere.<ref name=Kent08/>

Cardiovascular syphilis usually occurs 10–30&nbsp;years after the initial infection.<ref name=Kent08/> The most common complication is [[syphilitic aortitis]], which may result in [[aortic aneurysm]] formation.<ref name=Kent08/>

[[Neurosyphilis]] refers to an infection involving the [[central nervous system]]. Involvement of the central nervous system in syphilis (either asymptomatic or symptomatic) can occur at any stage of the infection.<ref name=NEJM2020/> It may occur early, being either asymptomatic or in the form of [[Meningeal syphilis|syphilitic meningitis]]; or late as meningovascular syphilis, manifesting as [[general paresis]] or [[tabes dorsalis]].<ref name=Kent08/>

Meningovascular syphilis involves inflammation of the small and medium arteries of the central nervous system. It can present between 1–10 years after the initial infection. Meningovascular syphilis is characterized by stroke, cranial nerve palsies and [[myelopathy|spinal cord inflammation]].<ref name=autogenerated1>{{cite journal |last1=Longo |first1=Dan L. |last2=Ropper |first2=Allan H. |title=Neurosyphilis |journal=New England Journal of Medicine |date=3 October 2019 |volume=381 |issue=14 |pages=1358–63 |doi=10.1056/NEJMra1906228|pmid=31577877 |s2cid=242487360 }}</ref> Late symptomatic neurosyphilis can develop decades after the original infection and includes 2 types; general paresis and tabes dorsalis. General paresis presents with dementia, personality changes, delusions, seizures, psychosis and depression.<ref name=autogenerated1 /> Tabes dorsalis is characterized by gait instability, sharp pains in the trunk and limbs, impaired positional sensation of the limbs as well as having a positive [[Romberg's sign]].<ref name=autogenerated1 /> Both tabes dorsalis and general paresis may present with [[Argyll Robertson pupil]] which are pupils that constrict when the person focuses on near objects ([[accommodation reflex]]) but do not constrict when exposed to bright light ([[Light reflex|pupillary reflex]]).

===Congenital===
{{main|Congenital syphilis}}
Congenital syphilis is that which is transmitted during pregnancy or during birth.<ref name=Wood09/> Two-thirds of syphilitic infants are born without symptoms.<ref name=Wood09/> Common symptoms that develop over the first couple of years of life include [[hepatosplenomegaly|enlargement of the liver and spleen]] (70%), rash (70%), fever (40%), neurosyphilis (20%), and [[pneumonitis|lung inflammation]] (20%).<ref name=Wood09/> If untreated, [[late congenital syphilis]] may occur in 40%, including [[saddle nose]] deformation, [[Higouménakis' sign]], [[saber shin]], or [[Clutton's joints]] among others.<ref name=Wood09/> Infection during pregnancy is also associated with [[miscarriage]].<ref name="Will2013">{{cite book|title=Williams Obstetrics|last=Cunningham|first=F, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS|publisher=McGraw-Hill|year=2013|pages=5|chapter=Abortion}}</ref> The main dental defects seen in congenital syphilis are the peg-shaped, notched incisors known as [[Hutchinson's teeth]] and so-called [[mulberry molars]] (also known as Moon or Fournier molars), defective permanent molars with rounded, deformed crowns resembling a [[mulberry]].<ref name="Phillips">{{cite journal |author1=Nissanka-Jayasuriya EH |author2=Odell EW |author3=Phillips C |date=September 2016 |title=Dental Stigmata of Congenital Syphilis: A Historic Review With Present Day Relevance. |journal=Head Neck Pathol |volume=10 |issue=3 |pages=327–331 |pmid=26897633|pmc=4972761 |doi=10.1007/s12105-016-0703-z}}</ref>