Symptoms

Syphilis develops in four stages, each with a different set of symptoms.

Primary stage

During the primary stage of syphilis, a sore (chancre) that is usually painless develops at the site where the bacteria entered the body. This commonly occurs within 3 weeks of exposure but can range from 10 to 90 days. A person is highly contagious during the primary stage.

• In men, a chancre often appears in the genital area, usually (but not always) on the penis. These sores are often painless.
• In women, chancres can develop on the outer genitals or on the inner part of the vagina. A chancre may go unnoticed if it occurs inside the vagina or at the opening to the uterus (cervix). The sores are usually painless and are not easily seen.
• Swelling of the lymph nodes may occur near the area of the chancre.
• A chancre may also occur in an area of the body other than the genitals.
• The chancre usually lasts for 3 to 6 weeks, heals without treatment, and may leave a thin scar. But even though the chancre has healed, syphilis is still present and a person can still pass the infection to others.¹

Secondary stage

Secondary syphilis is characterized by a rash that appears 2 to 8 weeks after the chancre develops and sometimes before it heals. Other symptoms may also occur, which means that the infection has spread throughout the body. A person is highly contagious during the secondary stage.

A rash often develops over the body and commonly includes the palms of the hands and the soles of the feet.

• The rash usually consists of reddish brown, small, solid, flat or raised skin sores that are less than 2 cm (0.8 in.) across. But the rash may look like other more common skin problems.
• Small, open sores may be present on mucous membranes. The sores may contain pus. Or moist sores that look like warts (called condyloma lata) may be present.
• In dark-skinned people, the sores may be a lighter color than the surrounding skin.

The skin rash usually heals within 2 months. on its own without scarring. After healing, skin discoloration may occur. But even though the skin rash has healed, syphilis is still present and a person can still pass the infection to others.¹

When syphilis has spread throughout the body, the person may have:

• A fever of usually less than 101°F (38.3°C).
• A sore throat.
• A vague feeling of weakness or discomfort throughout the body.
• Weight loss.
• Patchy hair loss, especially in the eyebrows, eyelashes, and scalp hair.
• Swelling of the lymph nodes.
• Nervous system symptoms of secondary syphilis, which can include neck stiffness, headaches, irritability, paralysis, unequal reflexes, and irregular pupils.

Latent (hidden) stage

If untreated, an infected person will progress to the latent (hidden) stage of syphilis. The latent stage is defined as the year after a person becomes infected. After the secondary-stage rash goes away, the person will not have any symptoms for a time (latent period). The latent period may be as brief as 1 year or range from 5 to 20 years.

Often during this stage, an accurate diagnosis can only be made through blood testing, the person's history, or the birth of a child with congenital syphilis.

A person is contagious during the early part of the latent stage and may be contagious during the latent period when no symptoms are present.

Relapses

About 20 to 30 out of 100 people with syphilis have a relapse of the infection during its latent stage.² A relapse means the person was symptom-free but then started having symptoms again. Relapses can occur several times.

When relapses no longer occur, a person is not contagious through contact. But a woman in the latent stage of syphilis may still pass the infection to her developing baby and may have a miscarriage or a stillbirth or give birth to a baby infected with congenital syphilis.

Tertiary (late) stage

This is the most destructive stage of syphilis. If untreated, the tertiary stage may begin as early as 1 year after infection or at any time during a person's lifetime. A person with syphilis may never experience this stage of the illness.

During this stage, syphilis may cause serious blood vessel and heart problems, mental disorders, blindness, nerve system problems, and even death. The symptoms of tertiary (late) syphilis depend on the complications that develop. Complications of this stage include:

• Gummata, which are large sores inside the body or on the skin.
• Cardiovascular syphilis, which affects the heart and blood vessels.
• Neurosyphilis, which affects the nervous system.

Congenital syphilis

Congenital syphilis refers to syphilis passed from a mother to her baby during pregnancy or during labor and delivery. The U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force strongly recommend that all pregnant women be screened for syphilis because of the severe consequences of being pregnant while infected or having a child born with congenital syphilis. Screening should be done:^{3, 4}

• At the first prenatal visit for all pregnant women.
• At the beginning of the third trimester of pregnancy and again at delivery for women who are at high risk for syphilis.

Congenital syphilis increases the risk of fetal death and medical complications in newborns. Syphilis enters the fetal blood system through the placenta, causing infection in the newborn or death of the fetus. Symptoms of congenital syphilis include:

• A highly contagious watery discharge from the nose.
• Painful inflammation of the bone coverings.
• Contagious rash that frequently appears over the palms of the hands and soles of the feet.
• Reduced red blood cells in the blood (anemia).
• Enlarged liver and spleen.
• Swelling of the lymph nodes.
• Failure to grow and develop normally (failure to thrive).

Because there are other conditions with similar symptoms, an accurate diagnosis is important for treatment.